QHC board approves revised plans for hospital cuts

Quinte Health Care board of directors has approved revised plans to cut staff and services and meet a projected $10-$15 million deficit for 2013-14.

As for Picton hospital’s concerns, the QHC senior leadership team sought approval of the board for essentially the same nine bed cuts originally proposed but the plan now is to cut four beds this year and three more next year – having separated out the discussion about the two obstetrics beds, of which the fate is unknown at this time.

QHC is no longer considering diversion of CTAS 1 (most urgent) patients from the Picton and Trenton emergency rooms. Instead, QHC will work with ER physicians and EMS to determine appropriate CTAS level 2 and 3 patients who could go directly to BGH instead. These would be patients who are already coming to BGH for treatment (e.g., hip fracture, mental health).

The board was also told additional ideas have led to more than $1 million in savings in the administrative and support areas.

“To address these funding changes, hospitals like ours must focus more on the complex cases, difficult surgeries and most critically ill patients that truly require hospital-based care,” said Mary Clare Egberts, QHC CEO  in a statement. “Other health care providers will perform services that people are accustomed to receiving in a hospital. Over the coming years, we expect to see a dramatic shift in Ontario of where services are provided and how people access care.”

Prince Edward Family Health Team president Elizabeth Christie had hoped the board would demand a more evidence-based and principled approach to cost savings, but said the physicians and PEFHT “will continue to do everything we can to provide the highest quality of health care to the people of Prince Edward County.”

“The physicians of PEC are extremely disappointed,” she said. “Particularly having been asked to provide alternatives, suggestions and input, and having done so at great length, only to have no substantive response or analysis of any of our proposals.”

Christie had written a pointed email last week in anticipation of the meeting between PEC doctors and the senior leadership team Monday in Picton and received no response to questions, in writing, or otherwise.

Christie said a summary of the various suggestions, proposals and ideas from Prince Edward County physicians was provided to the senior leadership team last week after Egberts advised she had heard of no suggestions coming from PEC doctors. (See the PEC suggestions below, following the QHC’s funding gap solutions). This despite public comments on several occasions that “since late-October, QHC management has consulted with hundreds of staff members, volunteers, Foundation partners and community members, with the goal of providing everyone the opportunity to provide input and offer suggested changes to the proposals.”

The next step will be to take the draft proposals to unions partners on March 6 and 8 to officially begin the staff planning process.

Quinte Health Care is governed by a 17-person board of directors, made up of 12 volunteer elected directors and five ex-officio (*non-voting) directors. Members listed on the QHC website are:
Brian Smith, Chair, of Belleville
Tricia Anderson, of Stirling
Karen Baker, of Belleville
Steve Blakely, Vice Chair, RR1 Picton,
Dr. Norma Charriere, Vice President, Professional Staff Association
Mary Clare Egberts*, President and CEO
John Embregts, Treasurer, of Brighton
Les Hanbury, of Carrying Place
Darlene O’Farrell, of Bancroft
Douglas McGregor, of Prince Edward County
David MacKinnon, of Wellington.
John Petrie, of RR1 Carrying Place
Nick Pfeiffer, Stirling
Katherine Stansfield*, Vice President, Patient Services & Chief Nursing Executive
Dr. Margaret Tromp*, President, Professional Staff Association
Stuart Wright, of Carrying Place
Dr. Dick Zoutman*, Chief of Staff
Based on the input, the original proposed funding gap solutions are being amended or augmented as follows:
•       QHC is no longer considering diversion of CTAS 1 patients from the TMH and PECMH ERs. Instead, QHC will work with ER physicians and EMS to determine appropriate CTAS level 2 and 3 patients who could go directly to BGH instead. These would be patients who are already coming to BGH for treatment (e.g., hip fracture, mental health).

•       PECMH bed reductions would be implemented over a longer timeframe. The current proposal is to reduce by four medicine beds in 2013/14. The goal would then be to  have the community and internal supports in place to be able to reduce by another three medicine beds in 2014/15. There will need to be further discussion over the coming weeks to determine how this could impact the maternity services at PECMH.

•       Additional ideas have led to more than $1 million in savings in the administrative and support areas.

•       The Surgery Program will spend more time looking at options for endoscopy services which will broaden consultation to include the Prince Edward County physicians.

•       There will be an extensive plan for bed reductions to ensure internal and community supports are in place before the beds start closing. This includes clinical pathways developed in partnership with staff and physicians.

•       Diagnostic Imaging coverage has been increased compared to original proposals.

•       Diverting CTAS 4s and 5s (less urgent) patients from the ERs will be a longer-term change, once more options are available in the communities.

•       The ER and Medicine physicians will need to help develop clear protocols for appropriate direct admissions to BGH inpatient units from the other ERs, to support patient safety.

•       The implementation planning teams will include further physician engagement and participation.

 Summary of Cost Saving Suggestions for QHC from PEC Physicians

On Tuesday, February 18, 2013, PEC physicians, Drs. Koval (QHC Department of Rural Medicine, Emergency-Primary Care, PEC Division Lead), Cluett, Christie (President, Prince Edward Family Health Team), Colby, and Lett  (Medical Director of Emergency Medicine for QHC),  attended a meeting in Belleville with the QHC Senior Leadership Team, and physician representatives from various divisions and from Trenton.
Following the meeting, CEO Mary Clare Egberts indicated that she was unaware of any cost saving proposals having been presented by PEC physicians, and requested a summary of the suggestions and proposals that have previously been presented by PEC physicians.  Below is this summary.  Given our understanding that all suggestions were being recorded over the past two months, this is not intended to replace previous suggestions, but to provide a summary.

1.  Work with MDs and the rest of the care team and medical records staff to ensure LOS data is accurate – i.e. that all appropriate comorbidities, issues arising in hospital, etc are captured
– the PEC physicians believe that for a variety of reasons, all comorbidities, health events in hospital, etc, are not being recorded, resulting in lower than appropriate LOS assessments.  This in turn results in inacurrately high “conservable days”.  A chart review is currently underway, and early results confirm this hypothesis
– this will enable QHC, the LHIN and MOH to have a more accurate assessment of “conservable days”
– this will require collaboration between medical records, IT, nurses, MDs, nurse managers, etc
– the result will be an increase in funding for QHC to permit ongoing quality inpatient care

2.  Replicate the PEFHT / CCAC palliative care program in Belleville.  This program currently includes the PEFHT Palliative Care Coordinator (RN), a dedicated Palliative Care “Care Coordinator” (RN) with CCAC, and a coordinated 24/7 MD call group
– this will undoubtedly keep palliative care patients out of hospital longer, if not entirely, thereby freeing up beds
– this will require collaboration between QHC, the FHOs and FHTs, CCAC, and likely the LHIN and Health Links
– the PEC palliative care program is currently extremely effective, and it is our belief that there is little room for improved efficiency and reduced hospital admissions

3.  Increase the number of ALC beds in PECMH
– this will reflect the ongoing reality that there are some patients who simply cannot be home until alternative placement is found
– officially permitting ALC patients to stay in PECMH is in keeping with the “right place, right provider” principle, and avoids the cruelty of transferring frail, elderly, often demented patients far from family to TMH
– this will also reflect the reality that despite the ALC beds at TMH being referred as “corporate” beds, these beds are almost always full, and patients from Picton are rarely, if ever, able to be transferred to TMH
– ALC beds are staffed at a lower level, potentially allowing for some reductions in staffing

4.  Increase physiotherapy and discharge planning services at PECMH (and other sites), preferably to 7 days per week
– this would allow QHC to assess the impact of these services on discharges and would undoubtedly reduce LOS for many many patients by at least one day

5.  Admit patients with a PEC physician to PECMH – from TMH or BGH ER, ICU, Surgery, etc
– this will result in shorter length of stay/ lower cost care because their family physician will provide inpatient care and can ensure direct follow up, and PEC admissions are less expensive than other sites

6.  Analyze the CPWC data and figure out why PECMH is less expensive for some of the most common admission diagnoses (ie. COPD)
– knowing where the cost saving is, will likely allow QHC to implement changes to bring the costs of LOS at other sites down
– this will focus on cost savings – which is the point of this entire exercise – rather than a theoretical “conservable days” measure

7.  Make all possible non-clinical cuts before any cuts that will have direct patient care impact – eg. bed cuts.
– SLT has indicated that this is the plan, however, at the Feb 18 meeting it was announced that a final decision to recommend 26 bed cuts has already been made, and now additional cost savings ideas will be used to further reduce the budget in anticipation of future cuts
– this is a directly contradictory approach:  if the goal is to make non-clinical cuts first, then there must be a review of the original proposals in the face of new ideas
– for example, we have been told that rather than the anticipated $500,000 in administrative savings, there has been $1 million found:  this should lead immediately to a change in the bed cuts plans
– cut the nurse education program and spread the job of educating colleagues about new equipment and mentoring new and young nurses amongst senior nurses – this will likely lead to improved morale as senior nurses take on more responsibility for their colleagues and their unit;  this would completely negate the need for any bed cuts at PECMH as roughly the same amount of money would be saved
– redistribute policy development, infection control and other duties now held by full time non-clinical nurses, to a larger number of clinically active nurses

8.  End all RN inter-site transfers except where medically necessary.
– nurses will still periodically be required to travel with patients if there is an assessed medical need, but most cases would not require a nurse
– this would require engaging ER and diagnostic imaging nurses in the care of patients transferred from other sites to BGH for imaging or consultation
– all MDs with QHC privileges can write orders for nurses at any site, so patients requiring ongoing pain control, etc, can travel with orders for the nurses at BGH
– BGH is the one site with the nurse flexibility to provide this care without overtime
– this initiative would save enormous overtime costs

9.  Close outpatient lab at BGH and TMH as has been done at PECMH
– there should still be outpatient services at all sites for care not available at the private labs such as holter monitors, event monitors, blood product tests, etc

10.  Engage Senior nurses at PECMH to help improve morale at other sites
– for example, giving nurses/ unit “head” direct control over scheduling may help (and would reduce need for “staffing office”)
– senior nurses should be given responsibility for educating each other and mentoring younger nurses
– sick time costs for QHC was approximately $1.75 Million last year, and for PEC from April 1, 2012 to present, was $2,518:  clearly the nursing staff at PECMH has a different and more “healthy” culture which should be capitalized upon to assist the other sites

11.  Improve clinical care pathways to reduce unnecessary medication, etc

12.  Implement a hiring freeze and assess cost savings through attrition
– there will be lots of room, for example, if one senior nurse retires, to permit part time nurses to increase their hours at lower cost to QHC (lower wages and no benefits)
– there will be exceptions necessary, but those can be made on a case by case basis
– this is one of the most basic principles applied in most large corporations and government whenever significant budget reductions are made

13.  Insist from MOH on maximum rural funding through HBAM for QHC – or at least for the rural components of QHC

14.  Review when and why patients should be designated ALC and educate nurses and MDs
– there is confusion over ALC – we have been told over the past several years to designate every patient as ALC as early as possible, and now, these designations seem to be leading to bed cuts

15.  Institute a policy requiring patients to take the first available LTC bed
– this would require cooperation / collaboration between CCAC, the LTC facilities and QHC to ensure patients know they will be transferred to their facility of choice

16.  Ensure LTC staff has adequate training and facilities to address and improve care for cognitively challenged patients with behaviour problems
– these patients cannot be “trained” to behave better – they have degenerative illnesses, therefore significant investments in training QHC staff may lead to shorter lengths of stay initially but not over time, and will not change readmission rates
– although QHC staff should know how to best care for these patients to reduce their behaviour issues, it is far more important that LTC staff can provide the right environment and care, and this will lead to fewer transfers to hospital from LTC
– this will require strong collaborative efforts between the LHIN, QHC, various dementia experts at Queen’s, LTC facilities and their medical directors

17.  Review the initial decisions regarding “financial targets” and terms of reference for the various “committees”, as the patient impact information provided by physicians and others has now revealed these to be inappropriate starting points.

18.  Ensure urgent home care can be put in place and / or urgent placement in LTC seven days per week
– this will require collaborative efforts with CCAC

19.  Work with nursing unions to change overtime rules and ensure maximum flexibility for nurses
– at PECMH OT is often avoided because nurses are willing to go home part way through a shift using up flex time, etc
– some rules will be unchangeable but there are likely several avenues that would allow more flexibility – flexibility will also enhance morale, thereby reducing sick days

20.  Look at actual occupancy rates to determine if there are unneeded beds – there are several units where occupancy is quite low – or are there efficiencies re: periods of time when beds are not needed (i.e. are many surgery floor beds empty on the weekends, can staffing model therefore be changed?)

21.  Analyze the data re: reduction in palliative care admissions and reduction in CHF admissions over past several years since these programs have been in place in PECMH to determine how many admissions have been avoided

22.  Increase the number of beds at PECMH and the number of surgical and other procedures performed there to capitalize on the cost-effective, efficient, highly collaborative model of care.
– PECMH provides a model of rural hospital / community collaborative healthcare that should be replicated elsewhere in QHC
– for example, the PEFHT pays full cost rent for space at PECMH through which the PEFHT offers numerous outpatient clinics to the benefit of our patients, and the financial benefit of QHC;  perhaps more outpatient care could be provided this way at other sites
– take advantage of the large number of Family Physicians who provide high quality inpatient care by providing “step-down” care at PECMH for any patients – whether from PEC or not

23.  Review in detail how Ottawa and St. Joseph’s hospitals have found their required cost savings without cutting beds
– recall that Ontario already has a very low number of hospital beds per capita – compared to 32 OECD countries, Ontario is 4th from last;  Canada has roughly half the number of beds per capita than the OECD average;  and Ontario has a potentially dangerously high occupancy rate;  the ideal occupancy rate is 85% to ensure space for patients in need of admission, avoid overcrowding in ER, etc, and QHC sites are all well over 90% occupancy for medicine beds – this risk of cutting medicine beds is very very high

24.  Ensure the PEC physicians are actively involved in any committees examining the issues of obstetrics and endoscopy at PEC, as well as the issue of ER bypass

25.  Cut costs in purchasing.  Anecdotal information indicates that purchasing costs have increased substantially since joining the Kingston group in an effort to reduce costs.  If this is true, reverting to the previous system should be very easy to do quickly with significant potential savings within this year.

26.  Request a much longer “roll-out” period for QHC cuts, particularly in light of the active plans that are in place which may well have an impact on occupancy.

As you can see, the PEC physicians have indeed provided a number of concrete suggestions.  The SLT has indicated that this past month of discussions with physicians has been the source of patient impact information.  In light of the advice from us and others that the proposed bed cuts to medicine beds across QHC poses a significant risk to patients, we urge the SLT to reconsider the order of implementation of cuts.  Focus on non-clinical savings first – and there would certainly appear to be sufficient savings to be had to satisfy the MOH in the first year.

-Respectfully submitted by PECMH Physicians.