Hamilton Health Sciences
Progress Report
Clinical Appropriateness and Efficiency Initiatives
December 2007
A Balanced and Systems Based Approach
3 Streams of Activity Over Multiple Years
Clinical Appropriateness & Efficiency
Practice
•Drug Utilization
DI Utilization (Cancer
Patients)
Lab Utilization
Appropriateness of Referrals
Appropriateness of Surgical
and Invasive Procedures +/Surgi Centre
Software driven care
management tools
MDU Utilization
Flow & Partnerships
1. Admission Avoidance – Repatriation and Referral
Agreements, Daily reports at site BM meeting of non-HW
patients, Admission Criteria, Increase understanding of 1-2 day
LOS, Admission Avoidance Clinics, Clinic review, Prevention
management and disease management, Walk-in clinic
2. Streamlined Bed Placement Process – Bed Management
Policy, Centralized Bed Assignment Centre
3. Expediting Care Delivery – LOS targets +/- consolidation
with associated reinvestment and adjustment to staffing,
Concurrent Review of select CMG’s, Physician Scorecard,
Admission/Discharge team
4. Earlier Patient Discharge – Patient Discharge Shuttle (see
Elective Patient Transport)
5. Accelerated Post Acute Transfer – Convalescent Care, Rehab
Access, Palliative Care Capacity, Long Stay review team
Providers & Technology
Workload measurement
Scheduling
Therapeutic Beds &
Surfaces
VAC Therapy
Elective Patient Transport
HPPD’s and Staffing
Models
Skill Mix
Compliance with scheduling
guidelines
Simulation Modeling and
Queuing Theory
Prepared By:
1
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Table of Contents
Fast Facts ................................................................................................................. 3
Introduction .............................................................................................................. 4
Making Improvements – Using a Quality Improvement Model ............................. 6
Clinical Appropriateness and Efficiency Activities at Hamilton Health Sciences:
Background, Case for Change and Current Reality .............................................. 7
Flow and Partnerships ...................................................................................................... 7
Practice
................................................................................................................. 12
Providers and Technology............................................................................................... 12
What Are We Trying to Accomplish? Goals and Aims ....................................... 14
Flow and Partnerships .................................................................................................... 14
Practice
................................................................................................................. 14
Providers and Technology............................................................................................... 14
What Changes Could Result in an Improvement? .............................................. 15
Planning and Priority Setting ........................................................................................... 15
2007-08 Flow and Partnerships Stream Initiatives:.......................................................... 17
2007-08 Practice Stream Initiatives: ................................................................................ 25
2007-08 Providers and Technology Initiatives: ................................................................ 28
Appendix 1: Achievement of Length of Stay* ..................................................... 37
Appendix 1a: Access to Care: Local Initiative: Care and Discharge Coordinator * ........ 40
Appendix 1b: Transitional Long Term Care Beds* – Increasing Acute Care Capacity ..... 42
Appendix 2: Henderson Patient Flow Innovation and Learning Site* ............... 44
Appendix 2a: Bed Map Revisions................................................................................... 48
Appendix 2b: Smoothing and Queuing Simulation (OR Smoothing elective
admissions/scheduled care and overall site simulation) ............................ 49
Appendix 2c: Synchronizing Admissions, Discharges and Transfers .............................. 50
Appendix 2d: the Flo Collaborative ................................................................................. 52
Appendix 3: Fracture Clinic Smoothing and Queuing Initiative ........................ 54
Appendix 4: Disease Management Model: Heart Failure* .................................. 55
Appendix 5: Case Costing and Workload Measurement* .................................. 59
Appendix 6: Clinically Appropriate and Efficient Staffing Plans* ..................... 63
2
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Fast Facts








There has been a 38% decrease in conservable beds, from 127.5 beds in 2004-05 to 78.9
beds October 2006 – September 2007
Access to care indicators had been trending favourably until recent months. Since October
2007, however, the impact of changes in interpretation of Long Term Care placement
regulation has had a negative impact:
o Occupancy: The average occupancy rate has been stable at 97% for the past two
years, but monthly values have trended down, from a peak of 103% in October 2006 to a
low of 92.5% in August of 2007.
o ED patient days peaked in January 2007 at 954 and dropped to low of 540 in August
2007
o Surgical cancellations due to no bed (ward or ICU) decreased from 12.0 per 1000
scheduled in 2006-07 to 6.9 per 1000 cases April – September 2007
ALC-LTC:
o HHS opened 41 transitional care beds for HHS patients awaiting interim or permanent
placement at St. Joseph’s Villa (January – November 2007 occupancy rate = 90%)
o The total number of ALC-LTC days tripled between FY 2005-06 and FY 2006-07,
increasing from 6439 to 19175 days.
o The impact of the ALC-LTC increase on access to acute care was reduced with the
introduction of the beds at the Villa. From January to November 2007, 58.2% ALC-LTC
days were at the Villa (12009 of 20626 days).
o In September 2007, there were changes to the interpretation of Long Term Care
placement regulations. This has led to dramatic increases in ALC-LTC days as follows:
 September 2007:
1625 days (54 beds)
 October 2007:
1991 days (64 beds)
 November 2007:
2466 days (82 beds)
The Henderson Site has been designated the “Patient Flow Innovation and Learning Site”
for 2 successive years. While there has been some recent fluctuation given closed beds as
a result of isolation, the positive impact of changes to the bed map was evident in steadily
declining off-service rates (from 14.1% in December 2006 to 4.2% in May 2007).
Improvements to patient flow (matching admissions, discharges and transfers) have been
reflected in the decrease from 30.7 beds to 25.5 conservable beds; % patients admitted
from ED increased from 20.1% in October 2006 to 51.5% in August 2007.
A corporate and site ”Access To Care Monitor” (synthesis of key indicators) was developed
in 2007. Program and unit “Access to Care Monitors” will be developed in 2008.
Wards that piloted the Care and Discharge Coordinator role (H-A3, G-6S, M-4Z) had a 31%
decrease in conservable bed opportunity (from 18.4 beds in 2005-06 to 12.7 beds October –
September 2007).
The Workload Measurement System was “revitalized” across HHS clinical units and
implementation completed in all episodic care areas for both Nursing and Allied Health.
Actual workload data is to be incorporated into Case Costing calculations for HHS effective
April 2008.
Three 3-week audits have been completed (February, May and August 2007) to evaluate
implementation of the Heart Failure clinical pathway. In August:
o 73% patients had preprinted orders and a clinical pathway at least partially completed;
o Weights were completed for 54% of patient days for patients on the pathway compared
to 22% of patient days for those not on the pathway;
o 86% patients on the pathway received education at least once (day 1-5).
3
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Introduction
Hamilton Health Sciences is committed to providing quality care. Dimensions of quality include
accessibility, appropriateness, efficiency, continuity, safety and effectiveness. Hamilton Health
Sciences continues to focus on understanding the underlying issues and executing
improvement initiatives in the realm of access, appropriateness and efficiency. The interrelationship between the quality dimensions of appropriateness, efficiency, accessibility and
safety are apparent. The balance of delivering quality care in a fiscally responsible manner is a
core responsibility of health care providers and leaders.
As delegated by the Executive Team, the Clinical Resource Utilization Management Steering
Team (CRUM) acts as the guiding coalition for activities related to clinical appropriateness and
efficiency. Responsibilities of this senior level team include planning, priority setting, policy,
coordination of multiple improvement initiatives, monitoring, ensuring accountability, advocacy,
sustainability and spread of best clinical utilization practices throughout the organization.
A clinical appropriateness and efficiency framework has been adopted by CRUM to assist in
balancing and coordinating efforts. Three main streams of activity are considered: Practice,
Flow and Partnerships and Providers and Technology. Within the Patient Flow and
Partnerships stream, a process driven approach has been taken in the identification of the five
major steps that occur in the flow of a patient through an acute care hospital. Namely, these
process steps are admission, placement into a bed, care delivery, discharge and/or placement
to another post-acute facility. These major process steps have evolved into five levers of activity
within patient flow and partnerships. Note, many issues and initiatives cross between the
streams and levers within the framework. Examples of issues and actual or future potential
improvement initiatives are portrayed in the figure below:
A Balanced and Systems Based Approach
3 Streams of Activity Over Multiple Years
Clinical Appropriateness & Efficiency
Practice
•Drug Utilization
DI Utilization (Cancer
Patients)
Lab Utilization
Appropriateness of Referrals
Appropriateness of Surgical
and Invasive Procedures +/Surgi Centre
Software driven care
management tools
MDU Utilization
Flow & Partnerships
1. Admission Avoidance – Repatriation and Referral
Agreements, Daily reports at site BM meeting of non-HW
patients, Admission Criteria, Increase understanding of 1-2 day
LOS, Admission Avoidance Clinics, Clinic review, Prevention
management and disease management, Walk-in clinic
2. Streamlined Bed Placement Process – Bed Management
Policy, Centralized Bed Assignment Centre
3. Expediting Care Delivery – LOS targets +/- consolidation
with associated reinvestment and adjustment to staffing,
Concurrent Review of select CMG’s, Physician Scorecard,
Admission/Discharge team
4. Earlier Patient Discharge – Patient Discharge Shuttle (see
Elective Patient Transport)
5. Accelerated Post Acute Transfer – Convalescent Care, Rehab
Access, Palliative Care Capacity, Long Stay review team
Providers & Technology
Workload measurement
Scheduling
Therapeutic Beds &
Surfaces
VAC Therapy
Elective Patient Transport
HPPD’s and Staffing
Models
Skill Mix
Compliance with scheduling
guidelines
Simulation Modeling and
Queuing Theory
4
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Recognizing the scope, breadth, complexity and magnitude of clinical utilization issues related
to Practice, Patient Flow and Partnerships and Providers and Technology is imperative. HHS
recognizes that efforts to improve clinical utilization need to span over multiple years and need
to be coordinated in a single, system wide effort. Key stakeholders need to be informed and,
more importantly involved in making improvements. This includes a commitment and visible
involvement from the senior team, physicians, professional practice chiefs, clinical and clinical
support leaders front-line staff, patients/families and community partners. Real improvement
will only be realized and sustained with a coordinated effort, systems thinking and “all hands on
deck” perspective.
There is a need to acknowledge the magnitude of this effort and impact on workload for all staff.
In part, eliminating non-value added tasks; streamlining workflow and standardizing practice can
assist in managing workload. The means and the end are interlinked. The upfront effort should
eliminate some of the day-to-day “chaos” that currently exists and improve the demand/control
imbalance and positively impact on quality of work life for staff. More importantly, improvements
that are sustained in the operating line will improve the quality of patient care: accessibility,
appropriateness, efficiency, continuity, safety and effectiveness.
The long-term goal is to ensure access to clinically appropriate care that is delivered as
efficiently as possible. Hamilton Health Sciences continuously strives to deliver the right care by
the right care provider at the right time and in the right place.
The report is divided into two parts. The body is intended to give Board Members and
Executive Team Members a high level overview of the external and internal factors driving the
need for change and a brief synopsis of initiatives with progress and pertinent results where
available. The appendices provide more detail about the initiatives and therefore serve as
reference, but may be more pertinent at the operating level.
5
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Making Improvements – Using a Quality Improvement Model
The Institute for Healthcare Improvement (IHI) from Boston, MA endorses the Model for
Improvement developed by Associates in Process Improvement (Langley GL, Nolan KM, Nolan
TW, Norman CL, Provost LP). It is a simple yet powerful tool for accelerating improvement.
Often, this model is used to facilitate clinical appropriateness and efficiency initiatives and
provides a framework for presenting the corporate-wide efforts related to improvement in clinical
utilization. The model for improvement has two parts:
 Three fundamental questions, which can be addressed in any order.
 The Plan-Do-Study-Act (PDSA) cycle (Deming WE. The New Economics for Government,
Industry, Education) to test and implement changes in real work settings. The PDSA
cycle guides the test of a change to determine if the change is an improvement.
Model for Improvement
Background and
Case for Change
How Do We Know We Have a Problem?
Set Aims
1. What are we
trying to
accomplish?
Select
Measures
2. How will we
know that a
change is an
improvement?
Select
Changes
- Test (Is the
change an
improvement?)
- Implement
- Spread
- Sustain
Act
Plan
3. What
changes can we
make that will
result in
improvement?
Study
Do
6
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Clinical Appropriateness and Efficiency Activities at Hamilton Health
Sciences: Background, Case for Change and Current Reality
Flow and Partnerships
Hamilton Health Sciences continues to experience patient flow and bed capacity pressures,
manifested in waits, delays and diversions. Although some improvements have been made, like
most acute care hospitals, we need to continue to address Emergency Department (ED)
overcrowding and diversions, scheduled care deferrals/cancellations, meeting regional program
commitments and downstream problems of high occupancy and off-service rates.
Figure 1 illustrates the trend of acute bed occupancy rates. While occupancy rates peaked in
October 2006 at 103.06%, there has been a downward trend in recent months. Contextually,
the literature would support an average occupancy rate between 85-90% in order to ensure
surge capacity given day-to-day fluctuations in occupancy.
In part, the decrease in occupancy may be attributed to the increase in beds at the Henderson
site that resulted from revisions to the bed map to more appropriately match resources to
utilization. The creation of “virtual capacity” through gains in achieving length of stay targets
has contributed substantially to the reduction in occupancy rates. In addition, in January 2007,
Hamilton Health Sciences partnered with St. Joseph’s Villa to open 41 beds for patients who
were awaiting interim or permanent placement in a long-term care home.
Recent increases in occupancy rates may be attributed to changes (October 2007) in the
interpretation of Long Term Care placement regulation have resulted in an increase in the
number of patients waiting for placement in an acute care bed (increases in Alternate Level of
Care days for Long Term Care (ALC-LTC)). See Figure 8 for details.
Figure1: HHS Acute Bed Occupancy – August 2005 to October 2007
occupancy rate
105%
All Sites - Hamilton Health Sciences
Acute Beds (Adult and Pediatric) Occupancy
100%
95%
90%
Au
g05
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85%
Occupancy
Target 92%
7
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Patient safety, staff satisfaction, and patient satisfaction are all negatively affected when
patients, information, and materials do not move through hospitals in a timely and efficient way.
High downstream occupancy rates result in upstream capacity issues. Quantification of
“boarding” patients in the ED (Figure 2), the length of time that patients admitted through the ED
wait in the ED after a decision to admit to ED departure (Figure 3) and the percentage of
patients meeting the current target of waiting 4 hours or less in the ED post decision to admit
relative to internal improvement targets (Figures 4, 5, 6).
Figure 2: Emergency Department Patient Days (Admitted Patients in ED at midnight) –
September 2005 – November 2007
All Sites - Hamilton Health Sciences
Emergency Department Patient Days (Midnight Census)
1000
Patient Days
800
600
400
ay
-0
7
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l-0
7
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7
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200
Figure 3: Average wait (hours) of admitted patients from admit order to ED departure –
September 2005 – December 2007 by Site
Average w ait (hours) from order to admit to depart ED by Site
Wait time (hours)
25
20
15
10
5
Se
p05
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ar
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0
Target 4 h
General
Henderson
McMaster (adult)
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Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Figure 4: General Site - % of patients admitted through the ED that are transferred to an inpatient unit within 4 hours post decision to admit relative to target (target = 55%)
% Admitted through ED transferred w ithin 4 hours of decision to admit
General Site April 2005 - December 2007
Percent patients
80%
60%
40%
20%
Ap
r-0
5
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Oc
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0%
General Site
Target = 55%
Figure 5: Henderson Site - % of patients admitted through the ED that are transferred to an inpatient unit within 4 hours post decision to admit relative to targets:
% Admitted through ED transferred within 4 hours of decision to admit
Henderson Site April 2005 - December 2007
Percent patients
80%
60%
40%
20%
Ap
r-0
5
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n05
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Oc
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Oc
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0%
Henderson Site
Month/Year
Target = 55%
Figure 6: McMaster Site - % of patients admitted through the ED that are transferred to an inpatient unit within 4 hours post decision to admit relative to target (target = 87%):
% Admitted through ED transferred within 4 hours of decision to admit
McMaster Site (Adult) April 2005 - December 2007
Percent patients
100%
80%
60%
40%
20%
Ap
r-0
5
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6
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c- 0
7
0%
MUMC (Adult)
Month/Year
Target = 87%
9
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Excessively high acute inpatient bed occupancy rates can result in scheduled care deferrals or
cancellations. Figure 7 presents the scheduled surgical cases cancelled due to no bed (ICU or
ward) from April 2005 to September 2007. Although the absolute numbers are not large in
magnitude, the trend is concerning and has been monitored closely. In addition, the inability to
quantify surgical delays as deferrals minimizes the day-to-day attention and effort required to
balance scheduled care admissions with unscheduled care admissions (largely through the ED).
Figure 7: Scheduled Surgical Cases Canceled Due to No Bed (ward and ICU)
30
25
20
15
10
5
Ju
n07
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g07
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r-0
7
6
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5
Cancellations per 1000 surgeries
# Surgeries Canceled due to No Beds (Wards & ICU) per 1000 Surgeries
HHS All Sites Apr-05 to Sept-07
Over the past year, we have seen improvements at the Henderson Site related to an intensive
focused effort under the corporate strategic Patient Flow Innovation and Learning Site initiative.
Likewise, improvements at the General and McMaster Sites can be attributed to ongoing
corporate and local efforts to improve patient flow across HHS. These efforts and initiatives will
be described later in this report.
In the spirit of continuous improvement and knowing that the fundamental issue of access to
care is paramount, HHS recognizes the need to continue with a coordinated systems level
effort. In the absence of this coordination, individual unit/department attempts to optimize their
flow may result in sub optimizing other areas and system flow. Looking upstream and
downstream from "problem" hospital units is essential to making changes that will result in
hospital-wide improvements. Most often, Emergency Departments (ED) divert patients because
hospitals lack the space to move patients forward, and simply increasing capacity in the ED will
not solve flow problems.
One strategy to increase bed capacity is to increase throughput and specifically, increase the
number of bed turns by decreasing length of stay (LOS). Faster throughput will result in
additional beds to accommodate rising demands, maximum return on current labour force,
decrease scheduled care cancellations and ED overcrowding. It creates virtual capacity
(deceasing LOS by hours assists with bed turnover), minimizes the need for actual capacity
expansion, and puts HHS in a favorable position for MOH-LTC funding. When one compares
HHS’ actual length of stay (ALOS) to the expected length of stay (ELOS) given industry
standards, an equivalent conservable bed day opportunity remains. It should be noted that
10
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
significant improvement has occurred over the last two years through system-wide focused
efforts.
Acute LOS Opportunity (conservable bed methodology – no netting)





Fiscal Year 2004/05:
Fiscal Year 2005/06:
Fiscal Year 2006/07:
YTD April – September 2007:
October 2006 – September 2007
127.5 beds
98.3 beds
89.1 beds
80.3 beds
78.9 beds
LOS Opportunity on 26 HAPS CMGs:



Fiscal Year 2005/06:
Fiscal Year 2006/07:
YTD April – September 2007:
14.2 beds
14.0 beds
9.0 beds
Despite considerable gains in bed utilization, one can see that capacity pressures remain an
issue at HHS as previously illustrated in acute bed occupancy rates, ED patient days, ED wait
times and scheduled surgical care cancellations due to no bed.
Concomitant to LOS gains, HHS has experienced a threefold increase in patients in an acute
care bed awaiting placement into a long-term care home (LTCH), increasing from 6439 to
19175 days between FY 2005-06 and FY 2006-07. This upward trend is illustrated in Figure 8.
We have mitigated the impact of this increase through the partnership with St. Joseph’s Villa
and the introduction of 41 transitional beds to cohort patients awaiting placement. From
January to November 2007, 58.2% ALC-LTC days were at the Villa (12009 of 20626). Overall
occupancy rates at the Villa have been 89.8%, but occupancy since October has been 97.7%.
The changes to interpretation in LTC placement in late September have led to dramatic
increases in ALC-LTC days. Consequently, the Villa strategy has been insufficient to offset the
impact of this increase on access to acute care.
Figure 8: HHS Average number of Alternate Level of Care (ALC) patients occupying acute beds
140
120
100
80
60
40
20
-
Ap
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Bed Equivalents
Hamilton Health Sciences ALC-LTC and ALC Total Bed Equivalents
April 2003 - November 2007
ALC-LTC total
ALC Total (all designations)
11
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Understanding variability is key to making improvements in flow through the acute care setting.
The variation inherent in surgery scheduling, for example, challenges hospital staff to find
inpatient beds at varying times of the day.
In addition to reducing variability, establishing partnerships with other community resources
such as long-term care homes, retirement homes and outpatient clinics, is crucial to solving flow
problems. As we move forward, Hamilton Health Sciences needs to leverage the Aging at Home
(AAH) Strategy in alignment with the HNHB LHIN. Ensuring that the patient is receiving the
appropriate level of care in the appropriate setting increases efficiencies in the system as a
whole.
Better models for flow can be found by looking outside of the health care industry. The trucking
and airline industries, for example, have used resource allocation to better serve their
customers, reduce costs, and improve safety.
Practice
At the core of health care is the desire to deliver appropriate, effective and safe care to our
patients. HHS believes that adopting best clinical practice will lead to better patient outcomes
and allow care to be delivered in a more efficient manner. The translation of evidence-based
practice into clinical care remains a challenge. Consequently there is variation in practice as
evidenced by both over and under utilization of pharmaceuticals, diagnostic imaging testing,
laboratory testing and clinical interventions.
Controversy exists about the extent to which economic issues should be factored into any
definition of quality care. However, most health care providers would accept that cost
minimization is desirable provided that health outcomes are not compromised. Therefore, for
process-of-care criteria to be valid, one can reasonably argue that they must have a direct link
to either improving health or to lowering resource use without compromising health outcomes.
Generally, it has been cited that the cost of poor quality can be up to 30% of total expenditures.
Re-directing and re-allocation of health care resources is a tangible outcome of implementing
evidence based practice and appropriate clinical utilization.
Providers and Technology
The most valuable asset in the delivery of health care is our human resources. The supply of
health care providers relative to the demands for care in an aging society with an increasing
prevalence of chronic diseases is an international, national, provincial and local issue for
Hamilton Health Sciences. Over the next 20 years, Ontario’s population is projected to increase
by almost 25 per cent. However, during that same timeframe, the elderly population will expand
by as much as 70 per cent. An aging population will require more health resources.
In parallel to a societal increase in demand for health care services, the supply of health care
providers is at risk of declining given the aging health care provider workforce. Provincial and
local planning is required to deal with the risk of a health care workforce demand/supply
imbalance.
The average age of workers in most health occupations is increasing in Canada. Overall, it rose
from 39.2 years in 1994 to 40.8 years in 2000, and to 41.6 in 2003 (Canada’s Health Care
Providers 2005 Chart book, Canadian Institute for Healthcare Information (CIHI)). Assuming a
12
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
retirement age of 65, Canada can expect to lose 29,746 RN’s aged 50 or older by 2006 –
equivalent to 13% of the 2001-nursing workforce.
The average age of a Canadian Registered Nurse in 1994 was 39.6 years and rose to 42.7
years in 2003. The average age in 2006 of Registered Nurses (RN) at HHS is 42 years old and
9.80% are over the age of 55 years. The average age of a Canadian Registered Practical Nurse
in 1994 was 41.0 years and rose to 42.3 years in 2003. The average age of the 220 Registered
Practical Nurses (RPN) at HHS is 45 years old and 14.82% are over the age of 55 years. The
average age of nurse managers at HHS is 47 years.
The Ontario Medical Association (OMA) in a Position Paper on Physician Workforce Policy and
Planning (April 2002) states in 1995 there were approximately 186 physicians per 100,000
population in Ontario. In 2000 this had declined to approximately 175 physicians per 100,000
Ontarians. They further suggest that the physician shortage is expected to increase to between
2,400 and 3,400 physicians by 2010, depending on the degree of government action. Thus,
Ontario’s current physician shortage is projected to almost double within 10 years.
Compounding the issue is a workforce that is required to operate in environments of increasing
complexity, new technology and dramatic reforms in health care policy and delivery.
The appropriate use of technology and equipment can be leveraged to improve the efficiency
and effectiveness of health care providers enabling them to deliver appropriate care. The
proliferation on new technologies needs to be carefully monitored and managed to ensure
appropriate utilization.
In addition to the need for change driven from health care human resource planning
perspective, one cannot ignore that 70% of the cost per weighted case is driven by staffing. It is
imperative that we utilize scarce and valuable physician, nursing, allied health and un-regulated
support resources in a manner that leverages upon full scopes of practice in a collaborative,
team based environment. The existing and upcoming scarcity of clinical care providers creates
the need for HHS to ensure appropriate and efficient utilization of health care providers to
ensure that patients receive the right care by the right care provider.
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Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
What Are We Trying to Accomplish? Goals and Aims
The long-term goal is to ensure access to clinically appropriate care that is delivered as
efficiently as possible. Hamilton Health Sciences wants to deliver the right care by the right care
provider at the right time and in the right place. To achieve this goal there is a need to deliver
best practice care, create capacity, maximize throughput and utilize the skills and expertise of a
finite supply of health care providers in an appropriate and efficient manner.
Flow and Partnerships
The over-reaching aim for initiatives within the Flow and Partnerships stream of activity include:
 25% reduction in equivalent conservable bed day opportunity
 25% increase in the % of patients waiting in ED for <4 hours from time of decision to admit
to transfer to the ward
 25% reduction in ED patient days
 25% reduction in surgical cancellations due to no bed
 25% reduction in off-service days (exclude ED)
 85-90% ward occupancy rate
Note: Specific and quantifiable goals and objectives are clearly articulated for specific
improvement strategies.
Practice
The goal of practice stream of activities is to ensure that the best clinical care is delivered.
Note: Specific and quantifiable goals and objectives are clearly articulated for specific
improvement strategies.
Providers and Technology
The overall goal of the related activities within the Providers and Technology stream is to ensure
the appropriate utilization of human resources and clinical technology to ensure positive clinical
outcomes. This includes appropriate staffing to meet patient activity and clinical needs and
appropriate use of the right health care providers in a collaborative team based model centred
on the patient needs.
Note: Specific and quantifiable goals and objectives are clearly articulated for specific
improvement strategies.
14
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
What Changes Could Result in an Improvement?
Planning and Priority Setting
In alignment with the corporate strategic and operational planning process, the Clinical
Resource Utilization Management Steering Team reviews best practice, identifies current issues
and makes recommendations to the Executive Team on priorities for improvement initiatives
related to clinical appropriateness and efficiency. Many of these recommendations have been
adopted in the past and current corporate planning cycle and have evolved into corporate
strategic, operational or developmental initiatives. In addition, many initiatives have less
corporate breadth but still require the focus of CRUM and different facets of the organization.
Finally, as stated previously, CRUM has a responsibility to monitor on-going, operational access
to care, clinical appropriateness and efficiency issues and ensure sustainability of previous
gains and spread of best practice throughout the organization. As such, there are many
improvement initiatives and on-going monitoring efforts guided by CRUM related to clinical
appropriateness and efficiency. These initiatives and efforts are outlined in the pages below.
Initiatives
HHS has committed to a multi-year work plan to improve clinical appropriateness and efficiency.
This work began in 2005/06. There were nineteen corporate strategic initiatives related to
access to care and clinical appropriateness. These initiatives are identified in the figure below
according to the most applicable stream of activity.
Clinical Appropriateness & Efficiency
2005/06 Access to Care and Clinical Appropriateness Initiatives
Practice
•Drug Utilization
 DI Utilization (Cancer
Patients)
 Lab Utilization
Flow & Partnerships
1. Admission Avoidance – Increase understanding of 1-2 day
LOS, Heart Failure Management – CHF Clinic, Admission
Criteria
2. Streamlined Bed Placement Process – Bed Management
Policy, Admit/Discharge Team, Simulation Modeling and
Queuing Theory – Cardiac Surgical Population
3. Expediting Care Delivery – LOS targets, Physician
scorecard, Heart Failure Management (repeated)
4. Earlier Patient Discharge – Admit/Discharge Team
(repeated), LOS targets (repeated) with associated work on
discharge planning, Repatriation
5. Accelerated Post Acute Transfer – Rehab Access, Palliative
Care Capacity, Long Stay review team
Providers & Technology
 Workload measurement
 RN Scheduling Metrics
 Therapeutic Bed Surfaces
Some of these initiatives continued to be corporate strategic initiatives in 2006/07, while some of
the suggested changes turned out not to be appropriate in nature or timing given external
decisions (e.g. MOH-LTC decision around workload measurement system) or, after further
exploration, were not deemed to be a change that would result in an improvement by key
stakeholders (e.g. admission/discharge team). This is the nature of continuous improvement.
The philosophy of piloting changes and evaluating effectiveness relative to desired outcomes
prevails.
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Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Most of the initiatives in 2005/06 and 2006/07 did contribute to the overall desired outcomes. It
is important for the organization to ensure gains are sustained within the operating line. Ongoing monitoring remains a focus corporately (via CRUM) and within the operating line. As
such, some of these initiatives remain a focus 2007/08 in addition to corporate strategic,
corporate operational and developmental initiatives.
Related 2007-08 Corporate Strategic and Operational Initiatives:
1.
2.
3.
4.
5.
Achievement of Length of Stay
Henderson Patient Flow Innovation and Learning Site
Disease Management Model: Heart Failure
Case Costing and Workload Measurement
Clinically Appropriate and Efficient Staffing Plans
With the notion of sustainability and alignment to corporate initiatives, the initiatives related to
access to care and clinical appropriateness are identified in the figure below.
Clinical Appropriateness & Efficiency
2007/08 Initiatives (Corporate Strategic, Operational and Developmental + Sustaining 2005/06 & 2006/07
Gains)
Practice
Congestive Heart Failure,
A Disease Management
Approach* (also related to
Flow and Partnerships)
Drug Utilization
Flow & Partnerships
Providers & Technology
1. Admission Avoidance – Role of CCAC Case Manager in ED (in
Implementation of
collaboration with the Hamilton Emergency Services Network (HESN)
Workload Measurement*
and part of Achieve LOS targets*), ICU Admission Criteria and ICU
HPPD’s and Staffing
Admission Avoidance – Critical Care Strategy (Henderson Patient Flow
Models (within Case
Innovation and Learning)
Costing Initiative)
2. Streamlined Bed Placement Process – Daily Site Bed Management,
Elective Patient
ED Early Warning and Response System, Bed Map Methodology,
Transport
Application of Queuing and Smoothing in OR for Joint Replacements
RN Scheduling
(Henderson Patient Flow Innovation and Learning*)
Clinically Appropriate
3. Expediting Care Delivery – Achieve LOS targets*, Joint Replacement
and Efficient Staffing
Program Expansion, Fracture Clinic – Queuing and Smoothing Tools
Plans*
4. Earlier Patient Discharge – Synchronize admissions and discharges
(Henderson Patient Flow Innovation and Learning*), Improve
Discharge Planning Process (Achieve LOS targets*), Implementation of
Care and Discharge Coordinator at Local Level (Achieve LOS
targets*), Repatriation from ICU (Henderson Patient Flow Innovation
and Learning)
5. Accelerated Post Acute Transfer –Improving ALC Designation
Process (Achieve LOS targets), Palliative Care Capacity, Electronic
referral and placement systems with partner organizations (e.g. CCAC),
ALC-LTC Transitional Care Beds, Investigate Alternative Settings for
Long-term Ventilated Patients (In collaboration with SJHH as lead),
Evaluate Convalescent Care Program, Access to CCC (in partnership
with SJHH and SPH
* Denotes current Corporate Strategic, Operational or Developmental Initiative
An overview of initiatives and sub-initiatives is listed below. For a more comprehensive
understanding of select initiatives, please refer to the attached appendices. (Note: Additional
appendices will be added as initiatives unfold throughout the year. An asterisk* denotes a
corporate strategic, operational or developmental initiative).
16
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
2007-08 Flow and Partnerships Stream Initiatives:
Achievement of Length of Stay* (See Appendix 1):
Related Strategic Goals:
 Goal #1. We meet or exceed our communities' expectations.
 Goal #4. We have a sound financial base to sustain our mission and achieve our vision.
 Goal #5. We create a sustainable and aligned system through action and leadership
Executive Sponsor:
Change Initiative Lead:
Brenda Flaherty
Teresa Smith
Background and Case for Change:
 The achievement of length of stay targets will ensure HHS is aligned with industry
expectations in order to improve patient access to care and achieve the HHS targets for
acute inpatient volumes.
 Both system and local level strategies have been implemented over the course of the
past 2 years as part of the ongoing corporate focus on length of stay targets.
 The strategies include access to care, discharge planning and CCAC partnerships.
What are we trying to accomplish?
 Aim: Program targets for 07/08 length of stay and acute inpatient HAPS volumes have
been achieved.
How will we know that a change is an improvement?
 Improving the length of stay will increase capacity and expedite transfer of ED admitted
patients to the ward, reduce surgical cancellation rates and improve regional referral
rates facilitating care closer to home.
 The plan of care will be documented and patients and families will be better prepared for
discharge.
 The staff will have access to discharge specialists to assist with the care plan for long
stay patients.
What changes can we make that will result in an improvement?
 Continue to focus on improving length of stay for applicable cases to enhance
throughput and occupancy rates, reduce wait times in the ED for admitted patients,
improve scheduled surgical cancellation rates and improve cost per case.
 Continue to develop creative solutions with community partners.
 Regular review of access to care indicators by program leadership, discussed monthly at
program and unit based meetings with physicians.
 Documented care plans will include expected date of discharge and documented health
teaching on discharge.
 Access to care and discharge planning strategy program/unit opportunity for
improvement identified and implemented.
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Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Results:
 For the three wards that piloted the Care and Discharge Coordinator role (Henderson
A3, General 6S, MUMC 4Z), the total opportunity decreased from 18.4 beds in 2005-06
to 12.7 beds in YTD October 2006-September 2007 (a total decrease of 31.0%).
 Overall occupancy rate at the Villa between January and November 2007 was 89.8%.
For October and November, occupancy has been 97.7%.
 From January – November 2007, 58.2% ALC-LTC days were managed by cohorting at
the Villa. This created access to 40 acute beds at 92% occupancy.
18
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Henderson Patient Flow Innovation and Learning Site* (See Appendix 2):
Related Strategic Goals:
 Goal #1. We meet or exceed our communities' expectations.
 Goal #4. We have a sound financial base to sustain our mission and achieve our vision.
Executive Sponsor:
Change Initiative Leads:
Dr. Bill Evans
Carol Potvin/Susan Taylor
Background and Case for Change:
 The Henderson General Hospital was experiencing patient flow and bed capacity
pressures, in the face of rising ALC numbers and a planned sharp increase in
inpatient surgical volumes.
 Pressures were manifested in ED waits, delays and diversions, and high rates of offservice patients.
 Significant improvements have been achieved. However, we continue to be
challenged to address patient flow to provide access to care and meet our regional
program commitments. Downstream problems of high occupancy and off-service
rates have been partially resolved.
What are we trying to accomplish?
 25% increase from historic mean in % patients admitted through ED who are
transferred within 4 hours (Target: 46.1%)
 25% decrease from historic mean in the % days where ICU occupancy is 100% at
midnight (Target: 45.6%)
 25% decrease from historic mean in patients booked off-service (Target: 5.8%)
 25% decrease from historic mean in the number of surgeries cancelled due to no bed
per 1000 surgeries performed (Target: 7.9 per 1000)
 Actual separations per budgeted bed fall within the corridor of potential separations
per budgeted bed at 92% and 100% occupancy based on ELOS
How will we know that a change is an improvement?
We are trying to align our resources to better match supply and demand. By doing this we
expect to:
 reduce wait times in the ED,
 achieve occupancy targets,
 reduce off-service rates,
 reduce surgical cancellations,
 eliminate deferred scheduled care for cancer patients,
 move patients from the ED to inpatient beds sooner,
 improve discharge planning through the use of innovative tools,
 collaborate with external partners to improve discharge processes for frail elderly
patients
 analyze and respond to predictable changes in patient flow patterns,
 implement admission avoidance strategies,
 expedite admissions when necessary
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Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
What changes can we make that will result in an improvement?
a. Bed map revisions (see appendix 2a)
 Revisions to the bed map were recommended based on analysis of historical
patterns of demand for beds.
 Implementation of recommended changes started in January 2007 and was
completed in April 2007.
Results:
 Overall, revisions to the bed map have had a positive affect on Henderson Site
indicators. April to October 2007 results in particular, show much improvement when
compared to the previous fiscal year, with indicators at various times exceeding their
25% improvement targets, even in the face of challenges presented by a VRE
outbreak and temporary bed closures.
 May 2007 saw the lowest off-service rate at 5.15% at the Henderson since
September 2005. This rate has remained around the 6% mark for most of this year
(target = 5.8%).
 ED patient days for August 2007 at 167 days were the lowest results seen for the
Henderson Site since September 2005 (F06/07 avg/mth = 305 days).
 August 2007 ED separations were recorded at 25, again, this is lowest number seen
since September of 2005 (F06/07 avg/mth = 59 separations).
 November and December 2007 results are less favourable and this can be linked
back to changes in the application of ALC placement policy that occurred in October
2007 and the increase in ALC patients and patient days at the Henderson Site.
b. Application of queuing and simulation tools to plan OR schedules for Phase 1
(Joint Replacements) and Phase 2 (all services) (see appendix 2b)
 Process map completed (foundation for the model) and associated delays identified.
 Data extraction and analysis for Phase 1 (Orthopedics) model development is
complete, and in progress for Phase 2 (all services).
 Design requirements for simulation model complete.
 Recent challenges with the software have led to delayed testing of scenarios, but
these are being addressed.
Results:
 pending
c. Synchronizing Admissions, Discharges and Transfers (see appendix 2c)
 Sequential brainstorming sessions and tests of change were held with Clinical
Managers as key stakeholders.
 A ‘Bed Assignment Tool’ aimed at inpatient units recognizing and planning given
their historical patterns of unscheduled and emergent admissions, as well as their
scheduled care has been developed, piloted and implemented.
 A “flex bed” protocol has been developed, tested and implemented as a strategy to
expedite transfers to the wards in anticipation of discharges that will occur.
 The role of the Bed Management Chair was reviewed and recommendations
approved by the site Monthly Bed Management Committee.
20
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007


Membership of the Daily and Monthly Bed Management meetings has been
reviewed and augmented to facilitate planning that will enhance patient flow. Each
unit has been asked to review their discharge planning process and use of available
discharge planning tools (i.e. Expected Date of Discharge)
A whiteboard for daily site bed management meetings was tested as a visual trigger
to identify and communicate a comprehensive plan of action for the site for the day.
It is currently being evaluated and decision whether to continue is forthcoming.
Results:
 Bed Assignment Tool (BAT) use at the individual unit level was audited and
produced positive results. The tool was completed for next day discharges
(confirmed and potential with barriers) and next day admissions on 100% of audited
units
 Express-bed-a-day policy audit was undertaken for a 10-day period and resulted in
100% compliancy with this policy. There were some documented challenges
(outside of the audit timeframe) noted, related to the application of the policy at times
of temporary bed closures. However, these challenges were resolved easily and
quickly and overall, the policy has been accepted as routine and useful in decanting
the ED early in the morning.
 A survey was distributed to daily Bed Management attendees related to the
usefulness of a white board as a visual trigger/tool at the daily meetings. Results
suggested that the white board, in some form, was helpful to track patient moves,
decisions and changes occurring in the daily bed management meeting.
 A reduction in the number of daily site bed management meetings was noted in the
first two quarters of Fiscal 2007-08 compared to the last two quarters of Fiscal 200607 and anecdotal feedback from meeting participants indicated that adherence to
newly developed meeting ground rules had positively impacted meeting function.
d. Schedule the Discharge
 This pilot will examine the ability for teams to schedule discharge appointments for
patients. This will be linked back to the Bed Assignment Tool, since scheduled
discharges will be incorporated into the day ahead planning.
 Historical data analysis has been completed to identify potential discharge
appointment slots/times based upon historical unit discharge patterns (by day-ofweek and by time-of-day) and the availability of physicians, staff and support
services required to discharge a patient and prepare the bed for the next admission.
 Process has been developed with stakeholders from pilot units (F3 Hematology, F4
Orthopedic Surgery, F5 Medicine)
 Pilot completed and evaluation underway.
Results:
 pending
e. Early Warning and Response System
 Odds ratio analysis has been completed to identify relationship between potential
leading indicators and corporate intervention. Most likely predictors were ALC>20;
ER arrival >105; Sunday, Saturday, Monday; bed mismatch at 0900 Bed
Management meeting (admissions > discharges)
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Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007


Contingency plans/protocol drafted in response to leading indicators. This will allow
us to identify the actions in response an anticipated mismatch between supply and
demand for beds, both at an individual ward level and hospital wide level.
These responses are scheduled to be tested and evaluated in January 2008.
Results:
 pending
f.
Dedicated Admissions Nurse
 Pilot unit selected (E2 Surgical Oncology)
 Draft role description and recruitment into temporary role completed (with support from
Late Career Entry funding180 hrs (4.8 weeks of 1.0 FTE) Late Career RN Initiative
Funding secured
 Quantitative and qualitative evaluation criteria developed
 Pilot scheduled to begin in January 2008.
Results:
 pending
g. Weekend Support Services
 Preliminary analysis of discharge patterns by day of week completed.
 Site Administrative Coordinators conducting weekend "snap-shots" December 1 to
identify patients expected to be discharged on Mondays or Tuesdays. For those
identified patients, information will be collected regarding tests/results, assessments,
procedures and/or therapies planned (ordered or likely to be ordered) for the
beginning of the week that could have been done on the weekends if resources had
been (more) available, leading to a weekend discharge.
Results:
 pending
h. Admission Avoidance from JCC
 Admission patterns to oncology program reviewed.
 High-level flow map outlining process of admission from JCC to Henderson site
drafted.
 Brainstorming session planned to utilize the expertise of key stakeholders identify
areas of focus
Results:
 pending
i.
Flo Collaborative
 The Ontario Health Performance Initiative (a joint initiative of the Health System
Strategy and Health System Accountability and Performance Divisions of MOH-LTC)
launched the Flo Collaborative in September 2007. The Collaborative has been
designed with a dual aim of improving patient transition from medical units of acute
care hospitals to subsequent care destinations while building capability within the
team members for quality improvement.
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Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007

Hamilton Health Sciences has identified Henderson Ward A3 Medicine as the
collaborative unit and partnered with HNHB CCAC.

Aim:
o
o
o

To decrease the average time of day of discharge by 4 hours (current mean
of 1409h)
25% reduction in the total number of days from identification of patient as no
longer requiring acute care (ALC-LTC) to completion of the placement
package
To decrease the total number of days from identification as ALC-Rehab to
transfer to HHS rehab bed.
Progress to Date:
o Drafted flow map and admission criteria matrix for post-acute destinations in
consultation with stakeholder group.
o Initial testing of visual triggers (Red-Yellow-Green whiteboard) to expedite
and communicate discharge planning.
o Collecting baseline data for CCAC referrals in preparation for evaluation of
utility of CCAC case manager attendance at rounds and flow map drafted for
current placement process for those ALC patients destined for LTC.
o Developing test of 4 rehab beds to be accessible to de-conditioned geriatric
patients who do not meet current rehab admission criteria.
Results:
 pending
23
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Fracture Clinic – Application of Queuing and Smoothing Tools (see appendix XX)
Background and Case for Change
 In 2005/2006 HHS partnered with the University of Toronto (Department of
Engineering) in the development and application of a cardiac surgical queuing and
smoothing simulation model. Results and outcomes have been positive and further
smoothing and queuing initiatives are in progress at Henderson Site as part of the
Innovation and Learning Initiative.
 All the HHS Fracture Clinics experience daily “back-logs” of patients resulting in
considerable waits and delays impacting staff, patients and physicians - the
McMaster Site experiences the most challenges.
What are we trying to accomplish?
 Aim: To reduce the average patient cycle time by 50%.
What changes can we make that will result in an improvement?
 HHS is partnering with the University of Toronto on an additional smoothing and
queuing exercise specific to the Fracture Clinical at the McMaster Site.
 Simulation model has been developed to assist in identifying alternate scheduling
and resource utilization processes that will improve patient throughput in the clinic.
 Focused meetings with surgeons and patient survey have been completed and will
drive further process improvements.
 PDSA cycles have been completed for revised appointment scheduling template
approach. Revised appointment scheduling templates have been developed for all
MUMC Fracture Clinic days/surgeons and the new templates are being integrated
into the processes performed by scheduling clerks.
Results:
 pending
24
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
2007-08 Practice Stream Initiatives:
Disease Management Model: Heart Failure* (see Appendix 4)
Related Strategic Goals:
 Goal # 1. We meet or exceed our communities' expectations.
 Goal # 2. We are internationally recognized for the excellence of our patient-centred
care, research and education.
 Goal # 5. We create a sustainable and aligned system through action and leadership
Executive Sponsors:
Change Initiative Lead:
Charlotte Daniels
Kelly O’Halloran
Background and Case for Change:
 Heart Failure (HF) reduces patients’ quality of life, exercise tolerance and survival.
 Patients experience acute, recurrent episodes of decompensation, leading to repeated
hospitalization.
 The incidence of HF is age dependent: 1 to 5 per 1,000 each year in the total population,
to as high as 30 to 40 per 1,000 each year in people > 75 years old.
 Approximately 40% of patients are readmitted within 1 year of their first hospitalization
for HF.
 In 2001, Canadians spent 1.4 million days in hospital for HF.
 Health Care Professionals have tried to care for HF patients in a health care system that
is not set-up to deal with chronic illness. A paradigm shift was required to change a
health care system that focused on acute and episodic care to a system that integrates
chronic illness management with health promotion and disease prevention, as well as
acute and episodic care.
 Patients living with HF must be involved in the management of their illness because the
majority of chronic illness management is done by the patient/family/ caregiver. Realignment of care must include education and skills management for self-efficacy which
will ultimately enable the patient/family/caregiver to participate in the management of
their chronic illness.
 CDMMs have been shown to be effective in improving the quality of care for patients
living with chronic illnesses such as HF. In 2005, Roccaforte et al conducted a metaanalysis of the effectiveness of disease management programs and reported a 14%
reduction in the rates of all-cause hospital re-admissions, a 31% reduction in total
number of HF-related (re)hospitalizations and a 16% risk reduction in total mortality.
 A systematic review of multidisciplinary strategies for the management of HF conducted
by McAlister et al (2006), reported a 27% reduction in HF hospitalization rates and a
43% reduction in total number of HF hospitalizations.
What are we trying to accomplish?
 The evidenced-based CHF Disease Management approach is fully integrated into all
health care professional clinical practice with increased utilization of evidence based
support and tools.
 Meeting the Canadian Cardiovascular Society’s Quality Indicator targets for HF patients.
 Meeting the agreed upon performance targets for HF, CMG 222 as outlined in the HAPS
and HHA in 2005/2006.
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Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
How will we know that the change is an improvement?
 Patients – Consistent application of evidence-based care will lead to: improved quality of
life of for HF patients, a decrease in mortality, a decrease in length of stay and a
decrease in readmissions.
 Front line staff – Tools such as the Pre-printed Admission Orders, the HF Care Path and
Patient Education Materials have developed utilizing the most recent evidence. This will
assist health professionals with varying levels of knowledge and/or expertise to provide
quality care to HF patients.
 Auditing will continue over the next year in order to monitor the use of the evidencebased tools/model that has been established. Based on the results of the audits, course
corrections will be determined and implemented. A fully integrated CDDM for HF
patients across HHS is the expected outcome.
What changes can we make that will result in an improvement?
 A Chronic Disease Management Model (CDMM) was developed for Heart Failure (HF)
patients admitted to HHS.
 Key elements of a CDMM include: comprehensive care (multiprofessional,
multidisciplinary, acute care, prevention and health promotion); integrated care, care
continuum, coordination of the different components; population oriented; active patient
management tools (health education, empowerment, self-care); evidence-based
guidelines, protocols, care pathways; system solutions; and continuous quality
improvement.
Results:
 Overall 471 of 691 (68%) cases had an acute length of stay less than or equal to the
ELOS, with distribution by site as follows:
 General Site: 244 of 331 (74%)Henderson Site: 99 of 174 (57%)
 McMaster Site: 128 of 186 (69%)
 Audit August 2007 Results:

Preprinted Orders:
 Overall, 23 of 40 (58%) patients appropriate for the cardiology preprinted orders had
orders completed.
 16 of 18 (89%) from the General Site,
 5 of 11 (45%) from the McMaster Site
 2 of 11 (18%) from the Henderson Site

Clinical Pathway:
 16 of 22 (73%) patients had preprinted orders and a clinical pathway at least partially
completed. For 1 patient, orders were completed, but the patient was admitted to
CCU and not appropriate to follow the pathway.
 Outcomes were completed in 67% patient days in August, compared to 49% in May
2007.

Daily Weights:
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Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007

Weights were completed in 32 of 59 (54%) of patient days for patients on the
pathway. By comparison, weights were completed in 17 of 77 (22%) of patient days
for those not on the pathway. In addition to the lower rates of daily weights
completed for patients not on the clinical pathway, we found that the documentation,
when it was completed, was located in different areas of the chart, making it less
likely to be located by the team.

Patient Education:
 A comprehensive patient education package has been developed as part of the
development of the Heart Failure Disease Management Model. This includes four
key elements, which are embedded in the clinical pathway: patient pathway, CHF
booklet, patient reminder and weight diary.
 12 of 14 (86%) patients on the pathway received each component of the education
package at least once (day 1-5). This is an improvement from the May audit, when
12 of 17 (70.6%) patients were documented to have received education at least
once. The rate of introduction of the weight diary has been constant at 50% patients
for the past two audits (May and August 2007). We were unable to locate
documentation of any education for patients who were not on the pathway.

Heart Function Clinic Access:
 The average number of monthly visits has, predictably, increased with the
introduction of this initiative. The average number of monthly visits:
o 2005-2006:
119.2
o 2006-2007:
134.0
o 2007-2008 YTD:
158.0 (April – July)

CCAC Referrals and Visits:
 In order to support our HF patients, CCAC initiated a pilot to provide 5 to 7 nursing
visits to every patient discharged from HHS with the primary diagnosis of HF. The
intent of this pilot was to augment the number of visits to reinforce and continue with
the education started in hospital (e.g. weights, side effects of medications, signs &
symptoms of worsening HF).
 Referral to CCAC is embedded in the clinical pathway. Consequently, the number
and source (by site) of referrals reflects the sites where implementation is more
advanced.
 Between September and June 2007, there were 44 referrals and 213 visits.
27
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
2007-08 Providers and Technology Initiatives:
Case Costing and Workload Measurement* (See Appendix 5):
Related Strategic Goals:
 Goal # 4. We have a sound financial base to sustain our mission and achieve our vision.
Executive Sponsors:
Change Initiative Leads:
Kathy Watts/Nancy Fram
Wendy Gerrie/Sharon Pierson
Background and Case for Change:
 HHS has been selected to be part of the next group of Hospitals to participate in the
Case Costing project. Currently, 11 hospitals contribute to the provincial case-costing
database, among which 5 are academic facilities. Thirty-seven new case costing
hospitals have been accepted to join the initiative of which 4 are teaching hospitals.
 Case costing determines the average cost of care by clinical categories (Case Mix
Groups – CMG’s). The costing data submitted by participating case costing hospitals is
the basis for calculations in turn will inform our funding.
 The existence of accurate, valid nursing and allied health workload data is a necessity to
participate in the provincial case costing initiative.
 Case Costing will be used as a basis for determining funding in addition to targeted
funding (Priority, Wait List etc).
 HHS’ participation is a strategic decision from a planning (provincial and LHIN)
perspective and will enable evidence based, internal resource allocation.
 In addition, HHS will use this information for workforce planning, the annual budgeting
processes, monthly budget monitoring (cost driver), ensuring appropriately matched
budget and actual costs to the clinical needs of patients, assist in relating care delivered
to clinical outcomes, identify opportunities for work-flow improvement and non-value
added tasks and, in future, skill mix decisions.
 HHS will be able to more accurately reflect true costs provided to complex cases versus
average costs as determined by the provincial case-costing database.
 This will identify for the MOH and LHIN’s limitations in case-mix groups that are too
broad to accurately reflect a clinically, homogenous group of patients, demonstrate
uniqueness of the cost of delivering care in tertiary, academic centres and thus explain
variations in costs amongst different hospitals.
 This will enable HHS to appropriately advocate for volume/service expansion and
resource allocation within the LHIN environment.
 Internally, the availability of the specific case costing data will enable
modeling/forecasting and impact analysis for program planning.
 Provide evidence based internal resource allocation related to the annual budgeting
process, identification of potential efficiencies and internal allocation of new, volume
related funding.
What are we trying to accomplish?
 Valid and reliable workload data for both Nursing and Allied Health available on 100% of
all clinical units and episodic care units.
28
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
How will we know that the change is an improvement?
 100% of units will achieve greater than 85% workload compliance
 100% of inpatient units have completed Nursing IRM education.
 100% of AH disciplines completed audit education
 45-70% of review/revise have been scheduled to be completed contingent on Mangers
approval.
 Actual workload data utilized for Case Costing
 Actual workload used to inform staffing decisions and support practice changes
What changes can we make that will result in an improvement?
 All Nursing staff, (including all RN’s, RPN’s and clinical Health Care Aids) for all inpatient
areas and all Allied Health professionals (including all Assistant roles) for both inpatient
and outpatient areas must collect patient specific workload, on every patient, every day
and every shift, to reflect work completed up to and including the time of
discharge/transfer.
Results:
 Compliancy
 25 % of Inpatient Nursing units completed IRM education.
 Planning for Auditing Tool for Allied Health in progress
 Complete schedule for the Review and Revise of Nursing Inpatient workload charts
developed and with 23% complete.
 Review /Revise of the existing Allied Health workload charts in progress
 E-Learning package for ongoing education developed
29
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Clinically Appropriate and Efficient Staffing Plans* (See Appendix 6):
Related Strategic Goals:
 Goal # 3. We have a healthy work environment.
 Goal # 4. We have a sound financial base to sustain our mission and achieve our vision.
Executive Sponsor:
Change Initiative Leads:
Nancy Fram
Kim Alvarado & Teresa Smith
Background and Case for Change:
 Staffing plans are written documents that identify the number and types of healthcare
professionals required to meet patient care needs on a clinical area.
 Staffing plans take into account the specific needs of patients, number of patients, and
activity on the unit as well as the mix of competencies of the health care providers, and
any additional supports available.
 These plans are tailored to be appropriate to individual units and wards. The most
appropriate number and mix of registered nurses and registered practical nurses on a
clinical unit will be determined as part of this initiative.
 The reason this initiative is so important right now is because our workforce is aging,
recruitment of staff is challenging due to shortages, and the educational preparation of
our largest group of care providers, nurses, has changed.
 The decisions required to ensure we deliver this type of care are critical to patient health,
safety, and well-being.
 The Canadian Health Services Research Foundation (CHSRF, 2006) recently published
a synthesis of the evidence on staffing for safety.
 CHSRF suggests that formal staffing plans should be developed and implemented in all
organizations employing nurses. To achieve this goal, we need to review our current
staffing plans and implement appropriate plans that utilize the skills and expertise of a
limited supply of health care providers.
What are we trying to accomplish?
Aim: To staff the clinical units at the accepted HHS standard hours per patient day with the
right care provider while maintaining patient safety, provider sensitive outcomes, and patient
satisfaction and staff satisfaction.
This is a multi-year initiative with the first year concentrating on:
a) Implementing a staffing model/plan that meets an HHS determined standard Hours per
Patient Day (HPPD) for selected “like” patient populations (How many).
b) Implementing the right skill mix of Registered Nurses (RN’s) and Registered Practical
Nurses (RPN’s). (Who)
How will we know that a change is an improvement?
Upon successful implementation of the initiative, HHS will achieve improvements in the
appropriate and efficient utilization of our healthcare resources to ensure that patients receive
the right care by the right provider at the right time and in the right place.
30
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Measures of success for the overall initiative include:
Outcome Indicators:
 Worked hours per patient per day on 80% of the targeted clinical units will match the HHS
established standards
 Actual costs related to staffing in the cost per weighted case are within 2% corridor of
expected costs per weighted case related to staffing
 Staff will verbalize increased satisfaction in the workplace related to practicing within
scope of practice
 25% reduction in unfilled shifts on targeted units
 25% reduction in overtime on targeted units
Process Indicators:
 Staffing plans will be developed in 70% of the targeted clinical units
 100% of clinical units will have assessed the feasibility of introducing RPN’s into their
staffing models with 100% of the units where feasibility is determined implementing skill
mix changes in year 1 (subsequent units in Year 2)
 No change in “nursing sensitive” outcomes indicators related to changes in staffing models
on target units
What changes can we make that will result in an improvement?


Each target clinical unit/ward will review their current staffing patterns and develop a
formal written staffing plan based on patient care requirements, staff competencies,
activity patterns and environmental supports.
The staffing plan will be implemented subsequent to approval from the Clinical Staffing
Plans Steering Team.
Milestones representing measures of success at completion of year-one of the initiative
(September 2008) include:
 HHS staffing plan for select adult medicine and critical care units established
 50% of units in identified population(s) - select adult medicine and critical care - have
completed implementation of HHS standard staffing plan (pending budget availability)
and/or made case for exemption including endorsement from third party observer.
 100% of in-scope units with positive feasibility have begun RPN/RN skill mix
implementation.
Progress to Date (October to December 2007):
 Establishment of the Clinical Staffing Plans Steering Team (formerly HPPD Analysis
Working Group) with new mandate
 Communication and engagement plans implemented related to staffing plans and
integration with skill mix
 In-services related to RN/RPN skill mix scope of practice and collaborative RN/RPN model
to Directors and Managers and Chiefs of Nursing to introduce skill mix changes provided.
 Project plan developed with Managers and Chiefs of Nursing to introduce skill mix changes
 Preliminary work completed to begin skill mix implementation on selected clinical units with
positive feasibility assessment related to RN/RPN skill mix.
31
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Elective Patient Transport
Related Strategic Goals:
 Goal #4. We have a sound financial base to sustain our mission and achieve our vision.
 Goal #5. We create a sustainable and aligned system through action and leadership.
Background and Case for Change:
 Provincially the evolution of patient transportation infrastructures beginning with the
transition of land ambulance services from the province to municipal management in
2001 has contributed to ongoing challenges at all hospitals including HHS with respect
to ensuring safe, appropriate, timely and reliable service for patients while
simultaneously managing facility costs.
 Locally the Hamilton Niagara Haldimand Brant (HNHB) Local Health Integration Network
(LHIN), through its community consultations process, identified lack of affordable,
accessible transportation as a key barrier to accessing health services in both rural and
urban areas.
 The HNHB LHIN’s Aging at Home Directional Plan “ reports early findings that a key
requirement for healthy aging at home is coordinated transportation arrangements within
and across LHIN communities for ease of access to supports and activities of daily
living; affordable, timely, wheelchair accessible, and that support behaviourally and
cognitively impaired persons”.
 While preliminary discussions are beginning at the LHIN level regarding the need to
develop strategies to address transportation issues there is no indication of imminent
provincial or regional direction or coordination for elective patient transport.
 At HHS, elective patient transport costs have escalated since 2001/02 and it is estimated
that the organization will spend in excess of 1.5 million dollars by this fiscal year end
on Ontario Patient Transport (OPT) services. This leads to the need to identify
immediate opportunities to address OPT utilization within HHS.
What are we trying to accomplish?
 To improve utilization of elective patient transport (EPT) services at HHS through
implementation of key strategies that increase coordination and decrease unnecessary
costs associated with OPT services.
What changes can we make?
Progress to date (October to December 2007):
 Updated scan of literature and environment to determine progress in policy development
and to identify current strategies being employed to manage elective patient transport.
 Continued development of concept document with a focus on aligning immediate and
longer-term strategies for improving utilization of EPT.
 Completion of an internal consultation with key stakeholders from the clinical areas at
HHS to validate current issues identified and obtain input regarding potential strategies
for managing OPT utilization and costs at HHS with a focus on immediate opportunities.
Based on outcomes of the internal stakeholder consultation including strong support for the
centralization of the OPT ordering process within HHS, next steps include:
 Development of a draft model for centralization of the OPT ordering process within HHS
32
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007

Design of a decision-making algorithm to support clinical units in selecting from between
alternative patient transportation options that ensures safe, appropriate, timely and
reliable service for HHS patients while simultaneously managing patient transport costs.
33
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
HHS Chronic Ventilated Patients
Background and Case for Change:
 In 2004/05, the Ministry of Health launched a four-year Critical Care Transformation
Strategy and Task Group as part of a broader Access to Services and Wait Times
Strategy. The purpose of the strategy was to improve quality of care and system
performance in adult critical care services in Ontario.
 The Task Group discovered that many intensive care unit (ICU) beds in Ontario were
occupied by chronically ventilated patients who were otherwise medically stable.
Although these patients did not need the critical care services available in an ICU, there
was no adequate alternative setting for these patients.
 It was determined that the demand by this patient population for ICU beds would grow
between 92 and 120% over the next 25 years. The Task Group estimated that between
1,000 and 2,000 additional ICU admissions could be accepted into current facilities if
medically stable chronically ventilated patients were discharged in a more timely fashion
to a more appropriate setting1.
 The number of ventilated patients living in the community, some of whom will eventually
experience an acute episode that brings them to the ICU and, potentially, to long-term
institutional care, is also projected to place an increasing burden on our healthcare
institutions.
 A 2006 HHS internal review of “long-stay” patients (LOS > 26 days) resulted in several
recommendations one of which specifically focused on examining the care processes
related to long-term ventilated patients.
What are we trying to accomplish?
 To determine if opportunity exists for HHS to improve quality of care and system
performance for individuals who require chronic mechanical ventilation.
Progress to date:
 Retrospective chart review to quantify historical volumes of *chronically ventilated
patients (04/05, 06/07, YTD December 2007) (“Chronically ventilated” defined as those
patients ventilated over 21 days)
 Clinical review of 271 cases and categorization of patients according to predefined data
set as “Acute”, “Weaning” or “Chronic/Long Term”
 Physician review of classifications from chart review to validate categorization of patients
completed.
 Volume estimation of HHS Weaning and Chronic Ventilated patients was conducted.
 Conservable bed day analysis completed.
Results:
 A retrospective two-part review of all HHS ventilated patient episodes was completed for
fiscal years 2004/05, 2005/06, and 2006/07 year-to-date July (YTD).
 A “ventilated patient episode” is defined as any admission to an HHS setting that
involves a continuous period of mechanical ventilation. It is important to note that a
patient may have had multiple ventilated episodes during a “unique patient admission”.
34
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007

The following table represents all ventilated patient episodes in each HHS Intensive
Care Unit over this period:
To accurately measure clinical utilization for the population of HHS Long-Term
Ventilated patients, data analysis occurred at the level of “unique patient admission” as
seen in Table 2
Table 1: HHS Long-Term Ventilated Patients ICU and CCU (Ventilated, > 21 days) by Fiscal Year
Average
Cases Average LOS ICU/CCU LOS
100
74.0
47.3
112
72.9
48.0
36
66.4
41.8
Fiscal Year
2004/05
2005/06
2006/07 YTD July
Grand Total





248
72.5
Total ICU/CCU
Days
4734
5374
1503
Average Ventilated
Days
41.4
43.2
36.3
Total Ventilated
Days
4141
4843
1308
11611
41.5
10292
46.8
Analysis of all 248 consisting using InterQual Level of Care Criteria to determine volume
estimation of HHS Ventilated patients and were categorized patients as Acute Medical,
Weaning, or Chronic Ventilated.
14.5% (n=36) were recognized as either Weaning or Chronic Ventilated patient admissions.
HHS Critical Care Physicians analyzed a sample of Long-Term Ventilated patient charts
(n=167) including all 36 Weaning or Chronic patients. Physicians found two cases that were
initially reviewed as “Weaning” which were subsequently changed to “Acute. Physician review
was statistically equivalent for defining Chronic or Weaning ventilated patients (p>0.05).
34 patient cases were “over-serviced” in HHS critical care due to long- term ventilation.
The 34 long-term ventilated episodes contribute only 3.8% of all HHS patient ventilated
episodes, but utilized a significant proportion of overall ICU bed days and ventilation hours.
Table 2: Acute, Chronic and Weaning Long-Term Ventilated Patients by Fiscal Year
Acute
2004/05
2005/06
2006/07 YTD July
Grand Total

Avg Vent.
Cases Avg LOS
Days Cases
87
44.6
39.5
2
95
44.6
39.7
3
32
37.6
32.4
214
43.6
38.5
5
Chronic
Avg Avg Vent.
LOS
Days Cases
35.5
31.9
11
77.0
69.9
14
4
Weaning
Avg Avg Vent.
LOS
Days
70.9
58.2
64.5
61.7
74.8
67.7
60.4
68.3
54.7
29
61.2
Weaning and Chronic
Cas Avg Avg Vent.
es LOS
Days
13 65.5
54.2
17 66.7
63.1
4
74.8
67.7
34
67.2
60.2
To attain an estimate of HHS’s contribution to this increase in critical care capacity, analysis of
the 34 Weaning or Chronically-Ventilated Patient charts was completed to approximate a date
by which transfer to an alternative level of care could have occurred if such an option
existed within the local health system.
Table 3: Conservable Bed Day Estimation for Long-Term Ventilated, (FY 2004/05 to 2006/07 YTD July)
Patient Cases
Conservable Bed
Days
Avg. Conservable Bed
Day / Case
Bed Opportunity @ 85%
Weaning
29
800
27.6
1.29
Chronically-Ventilated
5
271
54.2
0.44
Grand Total
34
1071
31.5
1.73
35
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007

The 1.73 bed opportunity could be an under-estimation of demand. If alternative models
could meet the care requirements of the “acute” population additional “conservable” days
beyond the identified 1.73 may be identified.
Appendices:
Details for Selected Initiatives
36
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Appendix 1: Achievement of Length of Stay*
Background and Case for Change:
The first annual "Ontario Health Quality Council" (OHQC) Report identified nine attributes that
Ontarians have identified as "key attributes" of the health care system including "Efficient",
"Effective", "Accessible" and "Safe".
As per the Ministry of Health and Long-Term Care (MOH-LTC) Hospital Accountability
Agreements (HAA’s), hospital performance relative to patient access and outcomes will be
measured according to LOS.
HHS has experienced a considerable reduction in LOS since 2005/2006. An identified need for
change (127.5 conservable beds), coupled with a corporate commitment to ensuring optimal
and efficient utilization of resources, resulted in the implementation of multiple, coordinated local
and system change initiatives. The cumulative impact of the initiatives contributed to the overall
reduction in LOS. The quantifiable impact was a reduction in conservable beds from 127.5 to
89.1 (March 2007).
Continued reduction in conservable beds is critical if HHS is to achieve provincial wait time
targets, accommodate increase surgical volumes, address emergency department
overcrowding and improve patient flow at HHS.
What are we trying to accomplish?
Achieving length of stay (LOS) benchmarks will, when coupled with other HHS initiatives,
decrease occupancy rates, reduce scheduled care cancellations, improve emergency room
waits, decrease off-service rates, improve surgical wait times and reduce regional referrals
refusal rates.
What changes can we make that will result in an improvement?
Both system and local level strategies have been implemented over the course of the past 2
years as part of the ongoing corporate focus on LOS targets. In 2007/2008 both local and
system efforts will be continued and focused on 3 primary areas:
1. Access to Care Monitoring
In 2005/2006, key “access to care” indicators (scheduled care cancellations, ED wait times,
etc.) were identified. The concept of a monthly “monitor”, a synthesis of all indicators into a
single report, resulted in the development of Corporate and Site “Access to Care” monitors.
In 2006/2007 many Programs/Services created “access to care” monitors specific to their
respective units/areas.
The consolidation of the indicators into a standard format has been valuable and a regularly
reviewed as a standing agenda item at the “Access To Care” Committee. In 2007/2008
efforts must be focused on developing coordinated formal local and system processes to
respond to Site/Program/Unit “access to care” indicators. Specifically mechanisms that will
address and communicate indicator results to stakeholders; determine causation/
contributing factors; identify requirements for intervention; establish stakeholder roles and
accountabilities; and formalize outcome/evaluation processes must be developed by/for
Programs/Services.
2. Discharge Planning
37
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
The objective of the Discharge Planning initiative is two-fold:
i)
Care and Discharge Coordinator Role (C &DC) Review & Recommendations
In 2006/2007 a temporary “Care and Discharge Coordinator” role was introduced on 3
units with above average conservable bed opportunities. The pilot role was
implemented to determine if a role focused primarily on expediting patient flow and
reducing barriers to discharges would improve LOS on identified units. The one-year
pilot will not be completed until March 2008 but anecdotal evidence and preliminary
indicators suggest there have been positive impacts.
Efforts in 2007/2008 will focus on continued role implementation. A trial of “readiness for
discharge” software (Medworxx) on pilot units has been explored and could yield
additional unit/site benefits if HHS experiences outcomes similar to those in user
organizations – improved patient flow, reduced ED wait times, reduction in surgical
cancellations. A C &DC role evaluation and unit impact analysis will also be completed in
2007/2008. Should evaluations reveal significant benefits the need/value of
implementing permanent C &DC roles across Programs/Services will require discussion
and exploration.
ii) Discharge Planning Initiatives
In 2006, a Discharge Planning Audit measuring staff awareness and compliance with the
Corporate Discharge Planning Protocol was completed. The results did not reflect a
noticeable improvement from a 2001 audit and significant opportunity to improve the
discharge planning process at a local level remains. There was recognition at CRUM
that diagnosing issues related to compliance of best practices in discharge planning and
re-educating staff on the same was not, in of itself, enough to affect change. Thus, was
borne the idea of piloting the Discharge and Care Coordinator role (see above).
However, it was also recognized that since discharge planning is inseparable from
proactive care planning, all staff would need to remain accountable for complying with
best practices in discharge planning. To that end, in 2006/2007 corporate-wide
discharge efforts focused on ongoing education forums and networks provided for frontline staff to enable an understanding and sharing of best practice.
In 2007/2008 efforts will focus on the development of local discharge planning
strategies. A preliminary menu/selection of potential strategies has been developed. This
menu/selection is subject to change but may include: implementation of a Unit Discharge
“Expeditor” role; creation of unit based “discharge room”; development of discharge
patient education strategies (i.e. Discharge Passport/Pamphlet); EDD communication
strategies; revisions/modifications of Discharge Round processes including
membership/frequency/documentation tools; creation of local/program discharge
networks; and participation in discharge education sessions. Programs/Services will
select from the menu of strategies those which will best support and assist them in
improving discharge planning processes or alternatively identify other formal means by
which they will address discharge barriers and issues of discharge protocol compliance.
Local improvements will be required but creativity in how this will be achieved will be
allowed and encouraged. The Discharge Planning Audit will repeat in June 2008. In
addition, it is proposed that an automatic referral to the corporate Transitional
38
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Care/Discharge Specialist occur for patients with a LOS greater than 35 days. In
collaboration with the health care team providing care to that patient, creative strategies
will be developed and implemented to expedite discharge or accelerate transfer to a
post-acute facility.
3. CCAC/Partnerships and Networks
Opportunities to enhance CCAC/HHS communications and partnerships exists, as does an
opportunity to develop new LHIN relationships. Collaboration with both groups will facilitate
and support proactive management of HHS LOS and patient flow issues.
CCAC – Several collaborative initiatives were implemented in 2006/2007 including
integration of CCAC data into the Common Clinical Data Warehouse; development of the
transitional care bed unit @ St. Joseph’s Villa; preliminary planning for a CCAC ED Case
Manager role; and the development of strategies to begin an E-referral process. Given
CCAC restructuring in 2006/2007 there have been challenges to moving forward with all
initiatives but efforts have been made to align HHS strategies with CCAC’s annual work
plan.
Efforts in 2007/2008 will include: in conjunction with SJHH, continued work on the
development of common operational approaches to managing transitional care
patients/beds @ St. Joseph’s Villa; development of a MOH-LTC submission for full-cost
funding of transitional care beds; exploration with St. Peters, SJHH, St. Joseph’s Villa other
patient populations potentially suitable for transitional care beds; and the development of a
St. Joseph’s Villa “Quality of Care” Committee for transitional care patients.
HHS/LHIN partnerships will be enhanced and expanded through many of the CCAC/HHS
initiatives in 2007/2008. In addition a LHIN wide ALC Strategy group has been established –
given scope, mandate and direction of the group, HHS will actively participate throughout
2007/2008 to develop regional strategies to address the management of ALC patients.
It must be acknowledged that other creative initiatives and funding opportunities with CCAC
and partners may arise in the 2007/08 planning year and HHS must be responsive to these
opportunities. As such details within this part of the Access to Care/LOS initiative may
change including sequencing and priorities.
How will we know that a change is an improvement?
Overall desired outcomes for many initiatives associated with improving access to care and
improving patient flow include the following:
 25% reduction in conservable beds (8,722 conservable bed days)
 25% reduction in waiting times from ED arrival to decision to admit*
 25% reduction in waiting times from decision to admit in ED to transfer to the ward*
 Occupancy rates of 85 - 90%
 25% reduction in off-service rates*
 25% reduction in surgical cancellations due to no bed*
 10% reduction in Central South regional refusals*
 Achievement of industry identified LOS benchmarks (ELOS) for all HAP’s identified
CMG’s.
39
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Appendix 1a: Access to Care: Local Initiative: Care and Discharge
Coordinator *
Background and Case for Change:
To assist the units in addressing LOS issues a temporary “Care and Discharge Coordinator”
(CDC) role will be introduced on one unit at each of the three acute care sites. The selected
units has been based on continued LOS opportunity (based on FY 2005/2006): MUMC 4Z,
Henderson 497/A3, General 6S.
The CDC will, in collaboration with the leadership team/unit staff/identified stakeholders, focus
on expediting patient flow and reducing barriers to discharges. Specifically the CDC will
assume temporary, primary accountability for the coordination of unit discharge planning
processes. The CDC will work with the team to create a sustainable discharge-planning/patient
flow infrastructure.
What are we trying to accomplish?

To improve and enhance patient flow and discharge planning processes on target units
How will we know that a change is an improvement?








Achievement of conservable bed targets on pilot units
90% of patients on target units have identified and updated EDD
90% of patients included in regular discharge rounds
90% patients have a Discharge Risk Screen Tool completed
90% of patients have a completed Discharge Planning Overview Form
90% of patients have documented plan of care
90% of patients have documentation of health teaching
Greater than 75% of staff able to identify:
 Importance of Discharge Planning processes
 Key elements of Discharge Planning
 Individual and team role(s) in Discharge Planning
 Resources and tools available to assist in Discharge Planning
What changes can we make that will result in an improvement?
 C & DC Role implemented on Pilot units February/March 2007
 C & DC Role pilot period complete at December 2007 for Wards 4Z (MUMC) and A3
(Henderson)
 C& DC Role pilot period will be completed at March 2008 for Ward 6S (General).
 Pilot Tests of Changes in Progress including
 Daily Rounds Process – review and revisal
 EDD Communication Strategies
 Patient Education Material – Discharge Pamphlet
 Staff Newsletters
 Education Forums
 Changes to Lab/Diagnostic times/processes
 Draft of Role/Unit Impact Analysis Completed
40
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007



Review of “Medworxx – Utilization Management System (UMS)” software (concurrent
review) for potential pilot on target units complete.
Medworxx-UMS user training completed.
Implementation of Medworxx-UMS software use on Wards 6S/6W has been initiated.
Results:
 Total 31.0% decrease in conservable bed opportunity for pilot units:
Site/Ward
Opportunity
(FY 2005/06)
Opportunity
Oct 06- Sept 07
Change
Henderson Site: 497/A3
Before C&DC
7.9 beds
After C&DC
5.5 beds
FY 05/06 to
Oct 06 – Sept 07
30.4% decrease
General Site: 6S
5.7 beds
4.8 beds
15.8% decrease
MUMC Site: 4Z
4.8 beds
2.4 beds
50.0% decrease
Total (3 units)
18.4 beds
12.7 beds
31.0% decrease
41
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Appendix 1b: Transitional Long Term Care Beds* – Increasing Acute
Care Capacity
Background and Case for Change:
Hamilton Health Sciences is experiencing significant challenges in meeting the needs of
patients requiring timely access to acute inpatient services. These challenges are manifested in
overcrowding in the Emergency Departments, delayed admission to acute hospital beds and
surgical cancellations. To restore acute care bed capacity at HHS, we must address the
underlying causes of reduced access.
HHS reviewed utilization data for evidence of the contributing factors. The single most
significant factor identified was the tremendous increase in the number of Alternate Level of
Care (ALC) patients awaiting placement to Long Term Care. ALC-LTC days have increased
from an equivalent of 8 beds in September 2005 to a peak of 82 in November 2007. ALC days
related to patients with other ALC designations have remained relatively constant during this
interval.
140
120
100
80
60
40
20
-
Ap
r
Ju -03
nAu 03
g
O -03
ct
D -03
ec
Fe -03
b
Ap -04
r
Ju -04
nAu 04
g
O -04
ct
D -04
ec
Fe -04
b
Ap -05
r
Ju -05
nAu 05
g
O -05
ct
D -05
ec
Fe -05
b
Ap -06
r
Ju -06
nAu 06
g
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ct
D -06
ec
Fe -06
b
Ap -07
r
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nAu 07
g
O -07
ct
D -07
ec
-0
7
Bed Equivalents
Hamilton Health Sciences ALC-LTC and ALC Total Bed Equivalents
April 2003 - November 2007
ALC-LTC total
ALC Total (all designations)
In an effort to address access to inpatient beds, we have improved bed use through
implementation of a number of concerted strategies including:
 Reducing conservable bed days;
 Implementing a broad range of strategies to optimize bed days;
 Collaboration with community partners, and
 Planning toward a long-term system wide solution within the region.
What are we trying to accomplish?
 To reduce the number of ALC-LTC days in acute sites of Hamilton Health Sciences by
60% through the introduction of transitional beds at the Villa (in January 2007 when
these beds were opened, HHS had approximately 60-65 patients in acute sites awaiting
placement to a LTCH.
 To increase access to care and decrease occupancy rates in the acute and rehab sites
of Hamilton Health Sciences.
 To provide an appropriate level of care for patients awaiting placement in a long term
care home – providing the “right care” in the “right place”.
42
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Progress to Date:
 In January 2007, Hamilton Health Sciences, in collaboration with CCAC and St.
Joseph’s Villa, introduced 41 transitional beds for the consolidation of Long Term Care
ALC patients. In April 2007, St. Joseph’s Healthcare Hamilton implemented a
comparable solution, opening 29 transitional beds at the Villa.
 In March 2007, the MOH-LTC approved funding until October 2007 for transitional beds
in Hamilton. A proposal was submitted to the LHIN for continued funding in September
2007.
 Through an Operations Working Group, all partners (HHS, SJHH, SJV and CCAC) are
working together to ensure consistent or comparable processes for managing these
beds.
Results:
 Following the introduction of the transitional beds at the Villa in January 2007, we saw
immediate and dramatic improvements on access to acute beds, reduction in surgical
cancellation rates due to no bed and improved access for patients admitted through the
ED (thereby reducing ED overcrowding).
 Average wait times for patients in the ED from order to admit to depart ED have
decreased from an average of 12.27 hours in 2006-07 to a low of 7.88 hours in August
2007.
 The percentage of patients transferred from ED within 4 hours (all sites) increased by
40%, from 30% in January to 50% in September.
 Surgical cancellations due to no bed peaked at 2.7% in December 2006, and then fell to
1.1% by March 2007 (more current data are being reviewed to incorporate changes to
reporting definitions).
 In May, occupancy rates decreased below 95% for the first time in over a year.
 From January – November 2007, 58.2% ALC-LTC days have been at the Villa. While
this, in essence, meets the original target of cohorting patients to reduce ALC-LTC days
at acute site by 60%, the recent trends (following changes to interpretation of LTC
placement) suggest that this strategy will be insufficient.
HHS Utilization of beds at the Villa:
 Between January 8 and September 30, 2007, a total of 345 patients were transferred
from HHS to the Villa to await interim or permanent placement in a Long Term Care
Home.
 227 of the 304 patients (74.7%) discharged during this time period were discharged to a
permanent or interim Long Term Care Placement. The remainder were discharged to an
alternate location:
 16 of 304 (5.3%) to home/retirement home
 27 of 304 (8.9%) expired
 34 of 304 (11.2%) returned to acute care
 The overall occupancy rate at the Villa from January to November 2007 was 89.9%, with
peak occupancy in October at 98.5%.
43
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Appendix 2: Henderson Patient Flow Innovation and Learning Site*
How will we know that a change is an improvement? Results:

These are the outcome indicators identified for the Henderson Patient Flow Innovation and
Learning Site initiative. All sub-initiatives will contribute to achieving the desired outcomes
as listed below.
Targets:
o Year I baseline for targets was established in March 2006 as 25% improvement from the
mean of data from the 2004-05 and 2005-06 fiscal years
o Year II baseline for targets was based on incremental 25% improvement from the mean
of data from the two year period from April 2005 to March 2007.

I. Access to Care from ED
Percentage of patients admitted through the ED within 4 hours of order to admit
Unlike most other indicators for the site, December results for this indicator did improve slightly
from November results. The percent of admitted patients transferring out of the ED within 4
hours increased from 29.02 to 33.75%. However, the results for both November and December
have slipped to below the historic mean for the first time since improvements were realized over
the summer months.
It is worth noting here that in general, indicators for November and December, both process and
outcome, have worsened with the likely cause being the sharp increase in ALC patients
remaining in acute beds (related to internal policy changes in September 2007).
P e rce nta ge of pa tie nts tra nsfe rre d fro m ED to w a rd w ithin 4 h ou rs o f ord e r to a dm it
B a se lin e 2 0 0 5 -0 6 a n d 2 0 0 6 -0 7 fisca l ye a rs
He n d e rso n S ite : E D A cce ss
80
UCL = 7 1 .7 7
70
% transferred w ithin 4 hours
6
60
Historical Mean
Target
Current (December 07)
36.88%
46.10%
33.75%
6
50
25% im provem ent (46.1%)
_
X = 3 6 .8 8
40
2
30
2
20
10
L CL = 1 .9 9
0
A p r-0 5
J ul-05
Oc t-05
J an -06
A p r-0 6
J ul-06
Oc t-06
J an -0 7
A p r-0 7
J ul-0 7
Oc t-07
M onth
44
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
II. Access to Critical Care
Percentage of days in one month where ICU occupancy is 100% at midnight
This indicator allows us to track access to a Critical Care (ICU) bed at the Henderson Site.
Between April 2005 and March 2007, ICU was full (100% occupancy) at midnight an average of
61% of the time. This has fluctuated, but reached a low of 29% in August 2007. December’s
results have improved somewhat from the new (undesirable) high seen in November (from 86.67
to 74.19), November and December results combined are much worse than other months in this
fiscal year. This worsening is consistent with other indicators for the site.
Percentage of days in one month w here ICU occupancy is 100% at midnight
Baseline 2005-06 and 2006-07 fiscal years
Henderson Site: Critical Care Access
ICU capacity increases from 9 to 10 beds at April 2007
100
% days in one month where ICU occupancy is 100% at midnight
UCL=96.05
90
Historical Mean
Target
Current (December 07)
60.86%
45.64%
74.19%
80
70
_
X=60.86
60
50
25% improvement (45.64%)
40
30
LCL=25.67
20
Apr-05
Jul-05
Oct-05
Jan-06
Apr-06
Jul-06
Oct-06
Jan-07
Apr-07
Jul-07
Oct-07
M onth
III. Access to Acute Care (ward)
Percentage of patients booked off-service
From January to March 2007, the Henderson Site implemented changes to its bed map with the
intention to better match increases in surgical volumes, as well as medicine service demand.
Off-service rates peaked in December of 2006 at 14.1%, with a favourable low point recorded at
May 2007 of 4.2%. Unfortunately, since May, overall trending for this fiscal year has shown a
moderate (unfavourable) increase in the off-service rate. Even though October’s results were
encouraging, November and December’s rates (at 9.02% and 11.54 % of days recorded as offservice) are the highest rates recorded in this fiscal year. Once again, the dramatic rise in ALC
patients remaining in acute beds is the most likely cause.
45
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Off-Service Rate (excluding ED and corrected for doctor service)
Baseline 2005-06 and 2006-07 fiscal years
Henderson Site: Acute Access to Care
15.0
1
12.5
Individual Value
Historical Mean
Target
Current (December 07)
UCL=12.13
2
2
10.0
2
2
2
2
2
2
_
X=7.75
7.5
6
5.0
7.75%
5.81%
11.54%
6
6
6
25% improvement target = 5.81%
6
LCL=3.37
05 l-05 - 05 - 06 -06 l-06 - 06 - 07 -07 l-07 - 07
rt
r
t
r
t
n
n
p
Ju
Ju
Ju
Oc
Ja
Oc
Ja
Oc
A
Ap
Ap
month
IV. Access to Scheduled Care
Number of surgeries cancelled due to no ward/ICU bed per 1000 inpatient surgeries
S ur gica l C ance lla tion R a te due to N o W a r d & N o IC U Be d
Ba se line 2005-06 a nd 2006-07 fisca l ye a rs
He nde rson S ite : A cce ss to S che dule d C a re
60
1
Individual Value
UC L=51.05
5
50
40
Historical Mean
Target
Current (December 07
6
30
20
_
X =15.91
10
25% im provem ent target = 11.93/1000
0
Ap
LB=0
6
r-
05
Ju
5
l- 0
Oc
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5
n
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-0
6
Ap
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15.91
11.93
36.72
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6
Ja
n-
07
Ap
r-
07
Ju
l-0
7
Oc
t- 0
7
mo nt h
46
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
V. Patient Flow/Length of Stay
Rate of Separations per budgeted bed
While conservable bed days are considered the industry standard for comparison of actual
length of stay to the benchmark Expected Length of Stay, there is a delay of several months
before the data are available. This limits its usefulness as evidence of success of the
improvement efforts of this initiative, where we are reliant of rapid results to direct our energies.
In an effort to identify an alternative measure, we have compared actual and potential
separations per bed.
It must be noted, however, that the significant limitation of this calculation is that it does not
reflect each case’s length of stay relative to its expected length of stay. Consequently, a few
patients with an appropriately long, but greater than average, length of stay may result in what
appears to be length of stay creep. Similarly, what may seem to be a month with relatively few
separations may not in the end result in high conservable days if the length of stay related to
ALC days. We need to be cautious in drawing conclusions based on these data alone.
Actual separations per budgeted
bed relative to potential separations
per budgeted bed
Target: Within or above corridor of
potential separations (based on
ELOS) per budgeted bed at 92%
and 100% occupancy
3.63-3.95
(December 2007)
Medicine (497/A3/F5)
Historical
Mean
(2005-06
& 2006-07)
2.75
Current
Ortho/Medicine (385/E4)
2.78
3.08-3.34
1.77
Surgery (498/E2)
5.63
5.71-6.21
5.79
Orthopedics/Rehab (293/F4)
3.83
4.82-5.24
5.09
Oncology (395/E3)
3.67
3.63-3.95
3.82
Hematology (396/F3)
2.88
2.95-3.20
3.14
2.75
47
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Appendix 2a: Bed Map Revisions
Background and Case for Change:
 Medicine patient bed days per month significantly exceeded allotted medicine bed days
per month during every month in Fiscal 2005/06.
 Approximately 27.2% medicine patient days were recorded in ED or in off service beds.
 Off-service patients lead to inefficiencies in care since patients are dispersed across
many units rather than cohorted.
 Delayed, deferred and cancelled surgical and scheduled care was a daily occurrence.
 Bed management meetings were held up to 4 times daily, and surgical case delays and
deferred admissions for cancer care had become a daily occurrence.
What are we trying to accomplish?
 Given achievement of length of stay targets, to appropriately allocate beds by service to
reduce the off-service rate by 25%.
 To ensure proper allocation of acute, inpatient beds so that newly funded joint
replacement surgical volumes are achieved.
What changes can we make that will result in improvement?
 Revisions to the bed map were recommended based on analysis of historical patterns of
demand for beds. Three approaches were used to predict bed/service requirements:
(1) actual historical length of stay, regardless of opportunities for efficiency; (2) the
historical number of cases multiplied by their expected length of stay; and (3) the
historical utilization with reduction based on conservable day methodology.
 In each case, adjustments for anticipated incremental increases in total joint volumes
associated with the wait list strategy were included.
 The methodology assumed no growth other than that associated with the funded
increases in total joint volumes.
 Implementation of recommended changes started in January 2007 and was completed
in April 2007.
How will we know that a change is an improvement? Results:
 Overall, revisions to the bed map have had a positive affect on Henderson Site
indicators. April to October 2007 results in particular, show much improvement when
compared to the previous fiscal year, with indicators at various times exceeding their
25% improvement targets, even in the face of challenges presented by a VRE outbreak
and temporary bed closures.
 May 2007 saw the lowest off-service rate at 5.15% at the Henderson since September
2005. This rate has remained around the 6% mark for most of this year (target = 5.8%).
 ED patient days for August 2007 at 167 days were the lowest results seen for the
Henderson Site since September 2005 (F06/07 avg/mth = 305 days).
 August 2007 ED separations were recorded at 25, again, this is lowest number seen
since September of 2005 (F06/07 avg/mth = 59 separations).
 November and December 2007 results are less favourable and this can be linked back
to changes in the application of ALC placement policy that occurred in October 2007 and
the increase in ALC patients and patient days at the Henderson Site
48
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Appendix 2b: Smoothing and Queuing Simulation (OR Smoothing
elective admissions/scheduled care and overall site simulation)
Background and Case for Change:
 With wait list targets, there was a planned shift to take place in the types and volumes of
specific surgical procedures performed at the Henderson Site – Orthopedic surgery
cases (knee/total joint replacements) increased while other surgeries (ophthalmology)
were relocated elsewhere.
 The initial phase (year 1) of surgical simulation/smoothing focused on OR block
scheduling and inpatient flow for scheduled orthopedic surgical cases. The current
phase (year 2) will simulate all surgical cases at the Henderson site.
 The simulation model will also take into account non-scheduled and medicine cases
(i.e., number of beds each day of week and at what time of day) that compete with the
scheduled surgical cases for ICU and ward beds and therefore impact on surgical
patient flow. The process to be modeled will be the flow of scheduled surgical patients
beginning on the actual day of surgery and ending on the actual day of discharge.
 Based on retrospective data analysis and with feedback from key stakeholders,
suggested changes to improve the OR scheduling process and surgical inpatient
resource utilization will be reflected in the model. The impact of smoothing efforts will be
evaluated using identified output indicators.
 This sub-initiative, along with the bed map revisions, will dovetail with the Total Joint
strategic initiative in the planning to accommodate increased surgical volumes and the
associated inpatient resources required.
What are we trying to accomplish?
 To implement changes to the Henderson OR schedule and surgical inpatient resources
to meet or exceed the targeted number (approximately 2200) of total joint (knee)
replacement procedures within the preoperative and surgical inpatient resources
allocated to those surgical patients.
What changes can we make that will result in improvement? Progress to date:
 Process map completed and associated delays identified.
 Foundation for the simulation model completed.
 Data extraction and analysis for Phase 1 (Orthopedics) model development is complete
and underway for Phase 2 (all services).
 Design requirements for simulation model complete.
 Recent challenges with the software have led to delayed testing of scenarios but these
are being addressed.
49
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Appendix 2c: Synchronizing Admissions, Discharges and Transfers
Background and Case for Change:
 Bed management meetings were held at the Henderson Site up to 4 times daily and
surgical case delays and deferred admissions for cancer care had become a daily
occurrence.
 There was opportunity to shift from the current process of ‘pushing’ patients through the
system (hospital), with pressure at the admitting end, to ‘pulling’ patients according to
timetables of treatment, toward planned or anticipated discharge.
 Clinical managers attending these daily meetings acknowledged that while these
meetings produce positive and necessary results, the process could be improved,
making these meetings more efficient, less stressful, and less time consuming.
 Synchronization of admissions, discharges and transfers is the precursor for the “Early
Warning and Response System” since it allows us to identify when we anticipate a
mismatch between supply (discharges) and demand (admissions) for beds.
 This will allow us to establish hospital wide (not just ED) signals as mechanism for
communicating need for action and options for those actions
What are we trying to accomplish?
 Since historical utilization can be used to predict demand for service, this information will
be used to better plan for:
o Decanting of admitted patients from the ED/ICU/CCU to the inpatient units
o Allowing non-emergency department patients access to beds on their designated
wards (thus decreased medicine off-service)
o The day’s OR cases to move through without delay or cancellation
 Overall better synchronization of admissions, discharges, and transfers
 Fewer, and less stressful daily bed management meetings
What changes can we make that will result in improvement? Progress to date:
 Sequential brainstorming sessions and tests of change were held with Clinical Managers
as key stakeholders.
 A ‘Bed Assignment Tool’ aimed at inpatient units recognizing and planning given their
historical patterns of unscheduled and emergent admissions, as well as their scheduled
care has been developed, piloted and implemented.
 A “flex bed” protocol has been developed, tested and implemented as a strategy to
expedite transfers to the wards in anticipation of discharges that will occur.
 The role of the Bed Management Chair was reviewed and recommendations approved
by the site Monthly Bed Management Committee.
 Membership of the Daily and Monthly Bed Management meetings has been reviewed
and augmented to facilitate planning that will enhance patient flow. Each unit has been
asked to review their discharge planning process and use of available discharge
planning tools (i.e. Expected Date of Discharge)
 A whiteboard for daily site bed management meetings was tested as a visual trigger to
identify and communicate a comprehensive plan of action for the site for the day. It is
currently being evaluated and decision whether to continue is forthcoming.
50
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Results:
 Bed Assignment Tool (BAT) use at the individual unit level was audited and produced
positive results. The tool was completed for next day discharges (confirmed and
potential with barriers) and next day admissions on 100% of audited units
 Express-bed-a-day policy audit was undertaken for a 10-day period and resulted in
100% compliancy with this policy. There were some documented challenges (outside of
the audit timeframe) noted, related to the application of the policy at times of temporary
bed closures. However, these challenges were resolved easily and quickly and overall,
the policy has been accepted as routine and useful in decanting the ED early in the
morning.
 A survey was distributed to daily Bed Management attendees related to the usefulness
of a white board as a visual trigger/tool at the daily meetings. Results suggested that the
white board, in some form, was helpful to track patient moves, decisions and changes
occurring in the daily bed management meeting.
 A reduction in the number of daily site bed management meetings was noted in the first
two quarters of Fiscal 2007-08 compared to the last two quarters of Fiscal 2006-07 and
anecdotal feedback from meeting participants indicated that adherence to newly
developed meeting ground rules had positively impacted meeting function
.
51
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Appendix 2d: the Flo Collaborative
Background
The Ontario Health Performance Initiative (a joint initiative of the Health System Strategy and
Health System Accountability and Performance Divisions of MOH-LTC) launched the Flo
Collaborative in September 2007. The Collaborative has been designed with a dual aim of
improving patient transition from medical units of acute care hospitals to subsequent care
destinations while building capability within the team members for quality improvement.
Provincially there are 29 partners, representing acute care hospitals, Rehab/CCC hospitals and
CCACs. Improvement teams are comprised of physicians, front-line staff, clinical leaders, all
learning to apply leading edge ideas from high performing health systems related to improving
patient flow.
What are we trying to accomplish?
Hamilton Health Sciences has identified Henderson Ward A3 Medicine as the targeted medicine
ward and partnered with HNHB CCAC for the Flo Collaborative. Specific improvements include:
 To streamline the referral process and standardize understanding and communication of
discharge destinations through established admission criteria for discharge destinations
 To facilitate and expedite safe discharge plans and their communication through the use
of commonly defined and understood designations and standardized responses.
 To streamline and expedite process of placement to long term care by:
 Reducing duplication and increasing alignment of roles (e.g. CCAC and HHS staff
meet jointly with patient and family for first meeting to discuss placement);
 Creating and making available virtual tours of LTCH to expedite completion of
choice list
 To standardize understanding and communication of established rehab guidelines and
referral processes to HHS rehab and to optimize selection of appropriate rehab referrals
(including convalescent care, slow-paced rehab).
What changes can we make that will result in improvement?
 To decrease the average time of day of discharge by 4 hours (current mean of 1409h)
 25% reduction in the total number of days from identification of patient as no longer
requiring acute care (ALC-LTC) to completion of the placement package
 To decrease the total number of days from identification as ALC-Rehab to transfer to
HHS rehab bed.
Progress to Date:
 Drafted flow map and admission criteria matrix for post-acute destinations in consultation
with stakeholder group.
 Initial testing of visual triggers (Red-Yellow-Green whiteboard) to expedite and
communicate discharge planning.
 Collecting baseline data for CCAC referrals in preparation for evaluation of utility of
CCAC case manager attendance at rounds and flow map drafted for current placement
process for those ALC patients destined for LTC.

Developing test of 4 rehab beds to be accessible to de-conditioned geriatric patients who
do not meet current rehab admission criteria.
52
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Results: pending
53
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Appendix 3: Fracture Clinic Smoothing and Queuing Initiative
Background and Case for Change:
 In 2005/2006 HHS partnered with the University of Toronto (Department of Engineering) in
the development and application of a cardiac surgical queuing and smoothing simulation
model. Results and outcomes have been positive and further smoothing and queuing
initiatives are in progress at the Henderson Site as part of the Innovation and Learning
Initiative.
 All the HHS Fracture Clinics experience daily “back-logs” of patients resulting in
considerable waits and delays impacting staff, patients and physicians - the McMaster Site
experiences the most challenges
 HHS is partnering with the University of Toronto on an additional smoothing and queuing
exercise specific to the Fracture Clinical at the McMaster Site.
 Development of a simulation model will assist in identifying alternate scheduling and
resource utilization processes that will improve patient throughput in the clinic.
 Using historical data and based on feedback from key stakeholders suggested changes to
improve the processes will be incorporated into the model and presented to key
stakeholders.
What are we trying to accomplish?
 To improve patient flow through the McMaster Site Fracture room to decrease appointment
delays and reduce cancellations, wait times and staff overtime hours.
 To share “best practice” opportunities with other HHS Fracture Clinics. Mapping and
validation of current patient flow at the MUMC Fracture Clinic
What changes can we make that will result in improvement? Progress to Date:
 Retrospective patient data collection complete
 Time studies complete
 Patient Survey to determine potential process/resource changes complete
 Focus meetings with Orthopedic Surgeons to determine process and resource changes
required/suggested
 First draft of model completed with selection of Orthopedic Surgeon for initial test of change
 Current work towards implementation of first tests of change:
 Creation of optimal clinic schedule scenario through use of retrospective patient data and
probability distributions for specific appointment 'types'
 Review of scenario's predicted impact on related ancillary services (i.e. Diagnostic Imaging)
with discussion regarding potential to co-ordinate patient bookings in prospective fashion.
 Examination of current Meditech CWS capability with intent to ensure necessary
modifications to support required patient booking ‘rules’
 Discussion with Orthopedic surgical staff regarding a mechanism to identify patient
appointments appropriate for booking within specified time frames rather than on exact
dates; allowing additional flexibility in assigning appointment types to more closely match
the optimal schedule
 PDSA cycles completed for revised appointment schedule approach. New templates are
being integrated into the processes performed by scheduling clerks.
54
Clinical Appropriateness and Efficiency Initiatives
Performance Monitoring – Board of Directors Sub-committee
Progress Report, December 2007
Appendix 4: Disease Management Model: Heart Failure*
How will we know that a change is an improvement? Results:
Outcome Indicator: Length of Stay
We compared the length of stay using CIHI DAD data with exclusions as for conservable day
methodology, then examined on a case-by-case basis the variance between actual acute length
of stay and the expected length of stay (ELOS).
Overall 471 of 691 (68%) cases had an acute length of stay less than or equal to the ELOS, with
distribution by site as follows:
 General Site: 244 of 331 (74%)
 Henderson Site: 99 of 174 (57%)McMaster Site: 128 of 186 (69%)
These results mirror the progressive implementation by site of the Heart Failure Disease
Management Model, where we have seen the greatest progress at the General Site, followed by
the McMaster and Henderson Sites.
Fiscal Year 2006-2007, CIHI DAD (with exclusions as for Conservable Day Methodology)
Percentage of Cases where Acute LOS <=ELOS
Percentage Cases by Ward
120%
100%
100%
100%
100%
100%
100%
79%
80%
75%
73%
63%
61%
60%
65%
68%
59%
57%
50%
42%
40%
20%
0%
G-4W
n=82
G-8S
n=127
G-8W
n=73
G-CCUG-Off-Service G-ED
n=4
n=17
n=28
H-A3
n=65
H-F5
n=4
H-CCUH-Off-Service H-ED
n=8
n= 75
n=22
M-3X
n=46
M-3Y
n=99
M-CCUM-Off Service M-ED
n=17
n=12
n=12
Balancing Measures: Readmission Rates and Intervals
Despite small numbers over time, we have continued to measure the readmission rate for
patients discharged with CMG 222 Heart Failure as a leading indicator that might suggest overly
aggressive discharge practices and our need to adjust the plan of care either on an inpatient
basis or following discharge (for example, increased readmission might suggest the need for
additional clinic or in home supports).
Num ber of Patient Readm issions for CMG 222 Heart Failure (all
sites, each quarter separately)
number of cases
40
30
20
10
0
Q1
Q2
Q3
Q4
Q1
2005-06
Q2
Q3
Q4
2006-07
Fiscal Year/quarter
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Given the chronic nature of heart failure, we expect readmissions to occur. With the
introduction of patient education aimed at improving the patient’s ability to manage his illness,
supported by CCAC through additional visits to reinforce these teaching and additional clinic
resources to provide this expertise, we hope to extend the time between readmissions.
Consequently, we would expect to see the proportion of readmissions within 7 days decreasing,
while that in 8-28 days and > 28 days is increasing.
Readmission Intervals (readmissions to any site within the quarter)
70%
61%
55%
% readmissions
60%
50%
37%
40%
30%
25%
20%
41%
22%
40% 40%
<=7days
35%
8-28 days
>28 days
20%
20%
10%
4%
0%
April - June 2006
n = 20
July - September 2006
n=27
October - December 2006
n=10
January - March 2007
n=23
Fiscal Year/quarter
Process Indicators:
Process indicators were defined to measure the implementation of the Heart Failure Disease
Management Model. These indicators have been measured through three 3-week audits
(February 2007, May 2007, August 2007) and two 1-day snapshot reviews (March 2007, April
2007).
August 2007 audit results are summarized as follows:
Preprinted Orders:
 Overall, 23 of 40 (58%) patients appropriate for the cardiology preprinted orders had
orders completed.
o 16 of 18 (89%) from the General Site,
o 5 of 11 (45%) from the McMaster Site
o 2 of 11 (18%) from the Henderson Site
Clinical Pathway:
 The clinical pathway is embedded in the preprinted orders, and as such, initiation is
contingent upon their completion.
 16 of 22 (73%) patients had preprinted orders and a clinical pathway at least partially
completed. For 1 patient, orders were completed, but the patient was admitted to CCU and
not appropriate to follow the pathway.
 We saw improvement in the completion of the pathway between the May and August audits.
Outcomes were completed in 67% patient days in August, compared to 49% in May 2007.
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Daily Weights:
 One of the original EFFECT Study quality indicators was daily monitoring of weight for
patients with Heart Failure. Our 2005 baseline measure, based on this study, was 15%,
with a target of 90%.
 When we compared the monitoring of daily weights with the audit, we found that weights
were completed in 32 of 59 (54%) of patient days for patients on the pathway. By
comparison, weights were completed in 17 of 77 (22%) of patient days for those not on the
pathway. In addition to the lower rates of daily weights completed for patients not on the
clinical pathway, we found that the documentation, when it was completed, was located in
different areas of the chart, making it less likely to be located by the team.
Patient Education:
 A comprehensive patient education package has been developed as part of the
development of the Heart Failure Disease Management Model. This includes four key
elements, which are embedded in the clinical pathway: patient pathway, CHF booklet,
patient reminder and weight diary.
 The EFFECT Study advised for counseling on at least one topic for 90% patients. With a
baseline (2005) of 74%, our target was 86% patients to receive education at least once. To
achieve this, patient education was embedded in the clinical pathway.
 In the August audit, 12 of 14 (86%) patients received each component of the education
package at least once (day 1-5). This is an improvement from the May audit, when 12 of 17
(70.6%) patients were documented to have received education at least once. The rate of
introduction of the weight diary has been constant at 50% patients for the past two audits
(May and August 2007). We were unable to locate documentation of any education for
patients who were not on the pathway.
Monitoring Indicators: Heart Function Clinic Access and Wait Times
 To ensure timely access to the outpatient component of care, we have monitored the Heart
Function Clinic volumes.
 The average number of monthly visits has, predictably, increased with the introduction of
this initiative. The average number of monthly visits:
o 2005-2006:
119.2
o 2006-2007:
134.0
o 2007-2008 YTD:
158.0 (April – July)
175
132
123
116
111
146
124
117
124
121
July
May
December
October
2006/2007
November
September
July
August
May
June
April
March
January
February
November
December
October
September
July
August
May
June
2005/2006
April
98
95
March
115
154
133
129
124
January
119
117
151
142
139
February
135
126
117
172
160
155
June
200
180
160
140
120
100
80
60
40
20
0
April
Total Heart Function Clinic Visits
Total Heart Function Clinic Visits
(Community Wide Scheduling Data April 2005 - July 2007)
2007/2008
Month
Heart Function Clinic Wait Times:
Total Heart Function Clinic Visits
 A total of 91 of 174 (52.3%) patients were
referred with a specific time frame requested
(within 7 days, 14 days, 21 days, 30 days, 60 days). Of these patients, 40 of 91 (44%) were
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
seen within the requested time. For the remaining 83 of 174 (47%) patients, no time interval
was specified so we were unable to determine whether the time from referral to visit was
appropriate.
With increasing visits, we are seeing increases in the average wait time from referral to the
first scheduled appointment, from 29 days in January to 71 days in July 2007. Initially we
had introduced both admission and discharge criteria for the clinic, based on New York
Heart Association Classification. Additional evaluation is required to understand whether
there are opportunities to optimize clinic utilization or whether additional capacity must be
added.
Average w ait tim e from Referral to First Scheduled Appointm ent
(Heart Function Clinic Database)
80
69.3
70
71.0
average # days
60
53.6
50
46.6
40
29.0
30
35.9
28.7
20
10
0
January 2007
n=18
February 2007
n=20
M arch 2007
n=27
April 2007
n=38
M ay 2007
n=29
June 2007
n=17
July 2007
n=16
CCAC Referrals and Visits



In order to support our HF patients, CCAC initiated a pilot to provide 5 to 7 nursing visits to
every patient discharged from HHS with the primary diagnosis of HF. The intent of this pilot
was to augment the number of visits to reinforce and continue with the education started in
hospital (e.g. weights, side effects of medications, signs & symptoms of worsening HF).
Referral to CCAC is embedded in the clinical pathway. Consequently, the number and
source (by site) of referrals reflects the sites where implementation is more advanced.
In total, there have been 44 referrals and 213 visits.
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Appendix 5: Case Costing and Workload Measurement*
Background and Case for Change:
Workload
Workload data collected for case costing does not meet reliability and validity standards; there is
limited application and integration of workload data resulting in low compliancy; data is not available
for clinic/outpatient areas; and current workload measurement tool is outdated and not meeting user
requirements.
Case Costing
As HHS progresses into the second year of this initiative a great deal of work has been done getting
ready for Milestone 1 and 2, ensuring the Data Repository was structured and programmed to hold
the required elements and education Programs and Services on the Case Costing Initiative.
Milestone 1 (readiness assessment) was passed in later October 2006 by HHS after audit by
MOHLTC/OCCI. As part of that assessment it was determined that changes needed to be made to a
number of source application to ensure data being collected made the requirements. As such, the
OR system, ORSOS was migrated over the Meditech OR so that high cost supplies could be better
captured at a patient specific level. Feeds from both the HIU system and Nutrition System needed to
be added to the warehouse. An investigation is ongoing to implement additional Meditech ITS
modules in DI to be able to capture high cost supplies in that area. Workload collection also needed
to be improved.
As of June 2007 there has been a delay in the release of the Provincial Software solution selected by
the OCCI RFP Steering Committee and the audit for Milestone 2 has been delayed. HHS has taken
advantage of this delay to improve its data quality and collection in the data repository, and continue
moving forward with the workload data collection improvements, work to educate the Programs and
Services on the Case Costing Methodology and what it means for HHS. Due to the delay in
receiving software, Milestone 2 has now been split into 2 phases. Phase 1 has been tentatively
scheduled for the week of August 13 and involves a number of days for site visits by the
MOHLTC/OCCI auditors to investigate data collections, interview staff, and ensure that HHS
understands and complies with the OCCI methodology. Phase 2 will take place at a later date, after
implementation of the software, as it involves running test data through the software and submitting
to OCCI for audit. The hopes are that this can be accomplished by December 2007. Further testing
with OCCI will take place from January 2008 to March 2008 with a new GO-Live date of April 2008
being proposed.
Initiative Aim/Outcome/Scope/Results/Conclusion: Case Costing
HHS been selected to be part of the next group of Hospitals to be part of the Case Costing
project. Currently, 11 hospitals contribute to the provincial case-costing database, among which
5 are academic facilities. Thirty-seven new case costing hospitals have been accepted to join
the initiative of which 4 are teaching hospitals. All teaching hospitals will now be part of the
provincial initiative except for Kingston and CHEO.
Why is case costing important and why will engagement in this initiative benefit Hamilton
Health Sciences (HHS)?
Case costing determines the average cost of care by CIHI clinical categories (Case Mix Groups
– CMG’s). The costing data submitted by participating case costing hospitals is the basis for
RIW calculations for Provincial weights, which in turn informs funding. In addition, targeted
funding (Priority, Wait List etc) use case costing as a basis for determining funding. HHS’
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participation is a strategic decision from a planning (provincial and LHIN) perspective and will
enable evidence based, internal resource allocation. HHS will be able to more accurately reflect
true costs provided to complex cases versus average costs as determined by the provincial
case-costing database. This will serve as a platform to proactively and strategically identify for
the MOH and LHIN’s limitations in case-mix groups that are too broad to accurately reflect a
clinically, homogenous group of patients, demonstrate specificity and uniqueness of the cost of
delivering care in tertiary, academic centres and thus explain variations in costs amongst
different hospitals. This will enable HHS to appropriately advocate for volume/service expansion
and resource allocation within the LHIN environment.
Internally, the availability of the specific case costing data will enable modeling/forecasting and
impact analysis for program planning. Specific, actual costing for cases can be compared to the
proposed funding thus informing HHS in decisions related to new funding/service opportunities.
Case costing information can serve as the backbone for evidence based internal resource
allocation related to the annual budgeting process, identification of potential efficiencies and
internal allocation of new, volume related funding.
Nursing costs makes up more than 70% of the hospital’s costs. Nursing and Allied Health
(clinical) workload must be captured as a fundamental criterion for participation as a case
costing hospital. Non-compliant hospitals cannot participate as a case costing hospital.
Evidence will be required by the MOH-LTC (including site visits) of accurate, valid clinical
workload data. The MOH-LTC is offering the option of how nursing and allied health workload is
captured. The first methodology is the standard method for collecting nursing workload by
patient. The alternate method is based on “bed history”. An extensive impact analysis on the
potential over/under estimation of actual costs/workload using the alternate method has been
completed by Decision Support Services. The conclusion of this is that the alternate
methodology will result in compression of costs on clinically different patients toward the mean.
The impact for HHS and other centres delivering complex tertiary and quaternary care will be an
underestimation (and potential under funding) of true costs for delivering care to complex
patients, and a concomitant over-estimation of the true costs on less complex patients. The
impact analysis revealed that on highly complex patients, expected versus actual costs could be
underestimated by up to 20%.
Given the mandate and populations served at HHS, this will have an overall negative impact on
the true costs of care (i.e. under-estimation). The existence of accurate, valid nursing and allied
health workload data is a necessity to participate in the provincial case costing initiative. In
addition, HHS will use this information for workforce planning, the annual budgeting processes,
monthly budget monitoring (cost driver), ensuring appropriately matched budget and actual
costs to the clinical needs of patients, assist in relating care delivered to clinical outcomes,
identify opportunities for work-flow improvement and non-value added tasks and in future skill
mix decisions. Workload data can be used for day-to-day, short term scheduling on clinical
units.
Completion of the Milestone documents (readiness assessments) required by the MOHLTC
through the OCCI Project and passing the audit portion of the OCCI requirements by October
2007. Assessment, evaluation and implementation of processes and structures to ensure
accurate costing data (MIS guideline and CIHI compliant data collection, patient specific costing
related to high cost supplies/pharmaceuticals, operating room med/surgical high cost supplies
identified, diagnostic imaging workload, lab workload, case costing software implementation…).
This portion of the initiative relates to but excludes the implementation of nursing and allied
health workload measurement. Decision Support Services will take the lead on this portion of
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the initiative. Original implementation was set for October 2006 but this has been revised due to
the provincial software delays.
Initiative Aim/Outcome/Scope/Results/Conclusion: Workload Measurement
In order to participate as a Case Costing (CCI) Hospital, HHS was required to revitalize and
implement Workload Measurement in 2006/2007. Given the CCI timelines, an accelerated
implementation plan was developed to ensure workload data for Nursing and Allied Health was
available for inpatient units. Interim “proxy’s” estimating workload were developed for the areas
without a measurement system. Continued work is required in 2007/2008 to complete full
implementation of workload and meet outstanding CCI requirements. The 4 areas requiring further
workload focus for 2007/2008 include:
1. Workload Chart Reviews
The MOH-LTC requires CCI hospitals report workload, but also require workload tools (charts) be
*reviewed/updated every 2 years as a means of ensuring data reliability & validity. To meet the
CCI milestones in 06/07 only minor modifications were made to the charts therefore the existing
70 charts require a complete review.
*
Chart reviews require interventions be reviewed to ensure workload values
appropriately reflect changes in staffing, practice and equipment – approximately one
month required to rebuild, educate, pilot and evaluate each reviewed chart.
2. Data Application and Integration
Demonstrated application of workload data is critical to maintaining staff support but given
compliancy issues there has been limited integration. Aside from case costing, workload
information should be used to assist with workforce planning, resource distribution/allocation
practice change decisions, budget planning, monitoring and evaluation. Ongoing sustainability of
workload measurement will require the identification and implementation of formal workload
application and integration strategies at both a Program/Service and Corporate level.
3. Outpatient/Clinic Implementation
In 2007/2008 workload measurement must be implemented in all HHS outpatient areas/clinics.
Given the volume, complexity and uniqueness of clinics structures and processes it is not known
if workload can be introduced into all outpatient areas/clinics in 2007/2008 but a significant
number should be completed with the collective support of stakeholders across multiple
Programs/Services.
4. New Software Solution
“Dataworks” is the current workload measurement system but effective December 2007 it is no
longer vendor supported. The application is becoming increasingly sensitive, time and resource
intensive and difficult to maintain, particularly given the increase volume in use. The tool has
limitations with respect to customizations that would significantly enhance functionality of the
system for users. An alternate tool is required in 2007/2008.
In 2004/2005, as part of the Corporate Annual Objective “Development of a Workload
Implementation Plan”, alternate workload tools were explored. There was senior stakeholder
consensus that the alternative solutions (ex. Sampling, Classification Systems) would not meet
HHS requirements. In addition, in 2006/2007 an extensive impact analysis on the potential
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over/under estimation of actual costs/workload using alternate proxy methodology was
completed. The alternate methodology resulted in compression of costs on clinically different
patients toward the mean and would have resulted in an underestimation (and potentially under
funding) of true costs for delivering care to complex patients and a concomitant over-estimation of
true costs on less complex patients. It is imperative that there is a workload system in place that
is capable of accurately measuring resources requirements.
MistroClef is the latest software solution introduced by GRASP. It has been reviewed @ HHS by
stakeholders and would meet workload requirements and functionality needs. Alternatively,
Meditech may offer a workload solution given full implementation of on-line documentation. An
impact analysis to ensure Meditech is able to provide quality workload data is required for, as
above, inadequate workload data will negatively impact HHS funding.
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Appendix 6: Clinically Appropriate and Efficient Staffing Plans*
Background and Case for Change:
The most valuable asset in the delivery of healthcare is our human resources. Hamilton Health
Sciences wants to deliver the right care by the right care provider at the right time and in the
right place. To achieve this goal there is a need to have clinical programs and units review and
implement appropriate staffing plans that utilize the skills and expertise of a finite supply of
health care providers.
During 2006/07 Hamilton Health Sciences’ programs and units reviewed their staffing numbers
in an HPPD analysis exercise related to the pressures of budget and recruitment and retention.
This process needs a continued focus and will benefit from a continued, coordinated approach
that involves all key stakeholders to ensure efficient and appropriate distribution of our health
human resources.
This is a multi-year initiative with the first year concentrating on:
a) Implementing a staffing model/plan that meets an HHS determined standard HPPD for
like patient populations (How many)
b) Implementing the right skill mix of Registered Nurses (RN’s) and Registered Practical
Nurses (RPN’s). (Who)
Subsequent years will focus on work that may include understanding and managing the impact
of the work environment on workload and skill mix of health care providers outside of nursing.
What changes can we make that will result in improvement?
There were two distinct pieces of work that began in 2006/07 – “HPPD” and “Skill Mix”
1. HPPD:
A review of Hours Per Patient Day (HPPD) began in March 2007. This work was primarily
driven from a financial/budget perspective given that the 2005/2006 actual cost per weighted
case (ACPWC) at HHS exceeded the expected cost per case (ECPWC) by 6%. Cost per
weighted case is the standard indicator of unit costs in the healthcare industry and widely used
in the funding formula and funding decisions. It was recognized that as HHS moves into the
LHIN environment, it is imperative that there is an understanding and control of ACPWC. Since
about 70% of the costs in this indicator are associated with staffing, focused work began in
March 2007 to understand and control direct staffing costs as measured by unit level hours per
patient per day (HPPD).
The work evolved into 3 components: Data Integrity and Analysis, Establishing and
Implementing a “standard” HPPD (# of patients/provider/shift) and Staffing to Demand and
Improving Workflow and the Work Environment.
i) Data Integrity and Analysis
This work included analyzing HPPD performance by units relative to budget, historical
performance, internal like-units and peer benchmarks. It was quickly realized that there was a
need to ensure proper alignment of health care provider hours/dollars to the cost centres where
services were being rendered. Without a true picture of the “real HPPD” it would be difficult to
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compare staffing models between like-units within HHS and outside HHS. A great deal of effort
has continued to date to ensure unit level HPPD’s accurately reflect actual staffing models.
ii) Establishing and Implementing a Standard HPPD or Patient: Provider Ratio
A working group consisting of Program Directors, QPSCRM Clinical Manager, AVP and Chief of
Nursing was established to determine a standard of how to staff a unit. Work by this group was
intended to provide a standard and a comparison the organization would be able to use to
determine appropriate patient: provider ratios as well as fair allocation of resources. This
standard would give clinical programs/units autonomy in staffing plan development.
Though there will be units who indicate, “They are different” there is an opportunity for right
sizing and fair allocation of resources. Thus, third party opinion will be sought from Professional
Practice to assess claims that units and patient populations served are different enough that the
standard staffing ratios do not apply. Staffing plans are not just numbers – they must include
experience of healthcare professionals, types of healthcare professionals, environment, and
patient population. Professional Practice will provide leadership in relation to the determination
of appropriate/different staffing models once the standard is determined.
iii) Staffing to Demand and Improving Workflow and the Work Environment (Note: This
work was completed on the two pilot units but was scoped out of the current initiative for
2007/08 due to capacity issues. Consideration to re-instate the work will occur for 2008/09)
The staffing to demand and improving workflow and the work environment project consisted of 3
areas of improvement activities:
a) Patient Activity – Understanding patterns of patient activity on each clinical unit by day of
week and time of day.
b) Staffing to Demand and Best Practice Scheduling Guidelines- Examination of master
schedules and six-week schedules to ensure matching of staffing resources to
predictable patterns in patient activity and application of HHS RN Scheduling Guidelines.
c) Workload and Workflow- This included the measuring, validation and understanding of
workload as captured in the Integrated Workload Tool (IWT), observation of workflow
with external consultant (Process Engineer) using Lean methodology.
Specific to understanding and improving work flow and the work environment, the working group
determined that an observational review of two units, one adult medical and one adult surgical
unit (3Y MUMC Site and 5 South –General Site) would provide a clearer understanding of the
increased workload reported by health care providers. This work would assist in answering the
question “Busy yes, but busy doing what”. Currently, care providers experience a level of
frustration and sense of “chaos” as they go about their day-to-day activities. It is thought that
this may be due to how the work environment is organized, how workflow processes have been
designed and who is doing what work.
A Process Engineer was hired as a consultant to work with focus groups from each unit and
examine the workload and workflow patterns and assist in determination of improvement
opportunities. This working group successfully completed the pilot on the two medical – surgical
units. However, capacity issues required that further observational studies would be deferred to
subsequent years of this initiative.
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2.
Skill Mix:
The determination of skill mix is an extremely challenging change. To date units and programs
across the organization have been at different stages with respect to initiating work regarding
skill mix. Many units/programs are unfamiliar with Registered Practical Nurses as they have not
traditionally existed in their staffing models. As well as many staff members remain unfamiliar
with the current RPN scope of practice.
The HHS Professional Affairs portfolio developed “Practical Guidelines to Determining and
Implementing Nursing Staff Skill Mix Changes” in February 2007. This change was initiated at
the Henderson site and has been successful in the development and implementation of a
RN/RPN model of a care in a number of medical and surgical inpatient units. This document
has been shared across the organization and has provided a framework for inpatient clinical
programs to review their current RN/RPN skill mix.
The current initiative to develop and implement clinically appropriate and efficient staffing plans
evolved out of this previous work. Membership of the HPPD Analysis Working Group has
continued as the Clinical Staffing Plans Steering Team with a new formal mandate needed to
ensure that the right care is provided by the right care provider at the right time and in the right
place.
How will we know that a change is an improvement?
Success of this corporate strategic initiative will be evidenced by the following measures:
Outcome Indicators:
a) Actual worked hours per patient day on 80% of the targeted clinical units will match HHS
established standard.
b) Actual costs related to staffing in the cost per weighted case are within a 2% corridor of
expected costs per weighted case related to staffing.
c) Staff will verbalize increased satisfaction in workplace related to practicing within scope
of practice (via focus groups).
d) 25% reduction in unfilled shifts on targeted units (given clinical need and activity levels)
within 1 year.
e) 25% reduction in overtime on targeted clinical units.
Process Indicators:
a) Staffing plans will be developed in 80% of the targeted clinical units
b) 100% of clinical units will have assessed feasibility of introducing RPN’s into their
staffing models with 100% of the units where feasibility is determined implementing skill
mix changes in year 1 (subsequent units in Year 2)
c) No change in “nursing sensitive” outcome indicators related to changes in staffing
models on targeted units
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