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AHW RHA Efficiency Review
Aspen Regional Health Authority
Governance and Accountability Overview Final Report
July 14, 2006

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

Property of Alberta Health and Wellness 2006 Deloitte Inc.

Governance and Accountability Overview
Key Components of Governance and Accountability
The province of Alberta uses a four part accountability framework that includes: 1) a three year Health Plan; 2) Annual Business Plans; 3) Quarterly Performance Reports; and 4) Annual Reports. This framework is to promote:
Governance and management of the health region Accountability to the Minister Keeping the public informed

For this assessment, Deloitte has focused on the three year health plan and the most recent Annual Business Plan to assess the degree to which there is demonstrable evidence that the direction is cascading to the operational level. In addition, Deloitte has applied a high level assessment of the Board's role related to:
Responsibilities and mandate Structure and organization Processes and information Performance assessment and accountability Organizational culture
Performance Assessment and Accountability Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

ARHA Three-Year and Annual Plan

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Three Year Plan
Strategy Mapping AH&W Goals & Legislated Responsibility
Deloitte's review of Aspen's strategies (2005 2008) mapped to health system goals and legislated responsibilities provides the following observations.
Health System Goal 1 Albertans Choose Healthier Lifestyles Legislated Responsibility 1 Promote and protect the health of the population in the health region and work towards the prevention of disease and injury

Three corresponding strategies identified:
1.1 Healthy Living (8 areas of focus: employees; eating; tobacco free; reduction of alcohol during pregnancy; injury prevention; mental health; immunizations; and prevention and management of chronic diseases)

Deloitte Observation at the Operational Level

Generally, expected outcomes are qualitative in nature in spite of concrete performance measures and targets. Community Health Services consultation indicated substantial efforts although staffing is limited. Consultation process identified that the chronic disease initiative remains in the planning process. Dialysis program in two communities (funded by Capital Health) is noted and emerging Diabetes and Asthma programs. We did not see strong emphasis yet in terms of service standardization or coordination. Initial CDM focus will be Diabetes and Stroke Management to build on past work.

1.2 Regional Plan for Environmental Health.
This process was evidenced through consultation. Lack of information system across region is a limitation.

1.3 Health Living campaign for Aspen staff.
Consultation process did demonstrate organizational efforts on this strategy.
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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Three Year Plan
Strategy Mapping AH&W Goals & Legislated Responsibility
Deloitte's review of Aspen's strategies (2005 2008) mapped to health system goals and legislated responsibilities provides the following observations.
Health System Goal 2 Albertans' Health is Protected Legislated Responsibility 2 Assess on an ongoing basis the health needs of the region.

Six corresponding strategies identified:
2.1 Continual feedback from public. 2.2 Service response based on client need.
Region does demonstrate high effort to serve clients equitably, however, care settings are not always appropriate because of the lack of assisted living, transitional care, dedicated psych beds, outpatient services or community supports.

Deloitte Observation at the Operational Level

2.3 Ongoing stakeholder collaboration to reduce injuries/deaths from traffic incidents.
Strategy and metrics appears heavily weighted to seatbelt usage only.

2.4 Promote safe working environments.
Occupational Health and Safety is taking lead here. Limited resources constrain implementation.

2.5 Strengthen community capacity to prevent/reduce youth injuries and deaths from traffic incidents.
Appears to have strong overlap with strategy 2.3.

2.6 Enhance regional response for pandemic influenza.
Initiatives are underway.

Overall, strategy and performance measures / targets in this area are focused on service delivery. Reliance on community needs data appears somewhat limited.
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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Three Year Plan
Strategy Mapping AH&W Goals & Legislated Responsibility
Deloitte's review of Aspen's strategies (2005 2008) mapped to health system goals and legislated responsibilities provides the following observations.
Health System Goal 3 Improve Access to Health Services Legislated Responsibility 3 Reasonable access to quality health services is provided in and through the health region.

Ten corresponding strategies identified:
3.1 Selected services within established standards.
Region working toward implementation of standards across the acute and community service sectors. (CTAS, MORE, Community Care service model).

3.2 Continual update to Continuing Care plans.

Deloitte Observation at the Operational Level

Renewal plans evident. Degree of consistency across region is variable. Gains related to placement wait are noted.

3.3 Accurate wait list data.
In process.

3.4 Attend major recruitment opportunities. Continued effort on regional workforce plan and reporting system.
The success of this strategy and the cascade to operational level appears minimal. Acute sites in particular struggle with recruitment and retention and associated workload related to securing staff. Work effort is repeated by each manager role.

3.5 Increase culturally sensitive delivery.
Community Health Councils are good vehicle to assess success. CHC devoted to M tis Settlement is very effective. Some effectiveness challenges in other CHC's. Aboriginal Liaison role effective way to integrate community specific input and service.
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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Three Year Plan
Strategy Mapping AH&W Goals & Legislated Responsibility
Health System Goal 3 (continued) Improve Access to Health Services Legislated Responsibility 3 (continued) Reasonable access to quality health services is provided in and through the health region.

3.6 Strengthened mental health access.
Reported at community level. Access is reported be an issue in select areas. Admission to active care is commonplace due to the lack of outpatient supports. Intervention through day clinics and home care appear limited. Access to dedicated beds in region an issue. Select sites have on site access of mental health resources where they are co-located which can be helpful. Stronger integration of mental health resources within continuum is suggested.

3.7 Enhance access to diabetes care services.
While in place appears to have limited coordination or standardization across region.

Deloitte Observation at the Operational Level

3.8 Consistent process for telehealth scheduling.
Work has been reported on this and improvements noted. Increased use of clinical telehealth is beginning. Mental health appears to be the most common clinical application. Region should consider increased use.

3.9 Continued support for LPCI (Local Primary Care Initiatives).
Initiatives reported as underway. Our consultation suggests that physicians do not completely understand the concept.

3.10 Increased sexual health services for "at risk" groups.
Reported as underway by Population Health as part of Core Service delivery, however, limited resources impact implementation.

The Project Team recognizes that the Aspen strategy to maintain basic and primary services and expand select services. Aspen needs to ensure that expansion does not occur at the cost of other services, unless this is the plan. For example, the lack of full costing for Ortho Program has brought pressures elsewhere.
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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Three Year Plan
Strategy Mapping AH&W Goals & Legislated Responsibility
Deloitte's review of Aspen's strategies (2005 2008) mapped to health system goals and legislated responsibilities provides the following observations.
Health System Goal 4 Improve Health Services Outcomes Legislated Responsibility 4 Activities and strategies to improve program and facility quality.

Six corresponding strategies identified:
4.1 Enhance quality of care, improve public and client satisfaction and maintain standards; maintain accreditation status; utilize data from current sources in above.

Deloitte Observation at the Operational Level

Evidence of quality development processes underway, however largely in plan mode. Aspen will be challenged to cascade required changes at the operational level (particularly in care facility setting given the lack of implementation resources). Much activity ramping up for Accreditation (May 06). Some evidence of program rationalization (no elective deliveries in a few sites). The review team believe that re-assessing clinical service role for select care facilities is warranted and could yield operating efficiencies. Any service rationalization needs to done with access considerations.

4.2 Enhance quality of care for mental health and adhere to standards.
Given the integration of mental health services in regional delivery framework, there has been lots of change and integration challenges. The extent to which service standardization is in place is unknown.

4.3 Develop Regional Quality Improvement Framework for continuum (regional indicators, performance indicators and best practices).
This is an important need for the region and there is much work to do here. Consistent approaches have not yet cascaded across the region. Again, implementation support is important for implementation success. Quality Improvement Teams are well in place.
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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Three Year Plan
Strategy Mapping AH&W Goals & Legislated Responsibility
Deloitte's review of Aspen's strategies (2005 2008) mapped to health system goals and legislated responsibilities provides the following observations.
Health System Goal 4 (cont'd) Improve Health Services Outcomes Legislated Responsibility 4 (cont'd) Activities and strategies to improve program and facility quality.

4.4 Implement quality improvement process to improve resident care in Continuing Care.
Another important area for the region which is in its early stage. Relationship with Extendicare should be utilized related to metrics adoption and measurement.

Deloitte Observation at the Operational Level

4.5 Promote awareness of ethics and related decision-making.
Consultation findings identified that the region has undertaken an awareness creation strategy related to ethics.

4.6 Implement community care quality improvement process.
Much of the service and process standardization appears to have begun with some achievements already made. Community Health Services appear to have made earlier gains and achievement related to regional integration (for example: shared staffing between communities, resource allocation to enhance service or address gaps). Population Health programming provides the required range of Core Services (mandated) as well as programs for specified communities (Seniors Wellness, Aboriginal Liaison, Show Me, Diabetes Management and Education). Targeted programs can be provided for specific populations based on need. Again, resourcing remains a challenge for service delivery beyond core.

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Three Year Plan
Strategy Mapping AH&W Goals & Legislated Responsibility
Deloitte's review of Aspen's strategies (2005 2008) mapped to health system goals and legislated responsibilities provides the following observations.
Health System Goal 5 Health System Sustainability Legislated Responsibility 5 Determine priorities in the provision of health services in the health region and allocate resources accordingly.

Two corresponding strategies identified: Deloitte Observation at the Operational Level
5.1 Determine strategic priorities. Develop Specialty Centres. Consult with key stakeholders to identify service need.
Consistently, across the region, timely decision-making was identified as a concern. Clearly specialty centres are part of the region's approach to service access.

5.2 Provide support and education opportunities for employees.
While the region has a regional education program, there are insufficient staff for this program to have the traction required to create a strong regional approach. The region is without necessary implementation support resources for change initiatives. Moreover, the limited decision-making at the manager level is a serious impediment to both timely and evidence-based decision-making at Aspen.

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Three Year Plan
Strategy Mapping AH&W Goals & Legislated Responsibility
Deloitte's review of Aspen's strategies (2005 2008) mapped to health system goals and legislated responsibilities provides the following observations.
Health System Goal 6 Legislated Responsibility 6 Promote the provision of health services in a manner that is responsive to the needs of individuals and communities and supports the integration of services and facilities in the health region.

Create Organizational Excellence

Eleven corresponding strategies identified:
6.1 Support implementation of provincial electronic health record. 6.2 Support implementation of RSHIP - Regional Shared Health Information System

Deloitte Observation at the Operational Level

6.3 Maintain and support information technology infrastructure across Region. 6.4 Work with relevant stakeholders, to integrate ground ambulance services. 6.5 Reflect changes in scope of practice for all disciplines. 6.6 Appropriate staff mixes will be established. 6.7 Support the attraction and retention of physicians. 6.8 Enhance awareness of privacy and security issues. 6.9 Improve employee satisfaction. 6.10 Optimize effectiveness of Region. 6.11 Develop strategic communication tools.

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Three Year Plan
Strategy Mapping AH&W Goals & Legislated Responsibility
Deloitte's review of Aspen's strategies (2005 2008) mapped to health system goals and legislated responsibilities provides the following observations.
Health System Goal 6 (cont'd) Legislated Responsibility 6 (cont'd) Promote the provision of health services in a manner that is responsive to the needs of individuals and communities and supports the integration of services and facilities in the health region.

Create Organizational Excellence

Given the developmental nature of these strategies, we will comment on them as an aggregate.

Deloitte Observation at the Operational Level

The strategies and intended outcomes are all appropriate. To some degree, there is evidence of work taking place already (e.g., EHR, RSHIP, PACS, Technology Infrastructure). Given the large scale planning and implementation for some, Aspen needs to seriously assess its ability to implement. Increased technology applications (PACS, EMR, Telehealth) require stronger implementation to support rural service environment and associated challenges. For some of these strategies, Aspen should assess its current strategy and determine the degree to which it is on target (for example: attract/recruit physicians to which staff should be added). Currently, Aspen appears to face implementation challenges post regionalization and integration. Given the degree of diversity across the region at present, this is a compounding variable for future change.

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Three Year Plan
Challenges and Opportunities Section
Deloitte's review of Aspen's Three Year Plan (2005-2008) provides the following observations. Concur with the identified challenges and opportunities related to:
Information and Technology; Cost of Services Sustainability; Wellness and Healthy Living; Access to Services; Mental Health; Quality of Services; Primary Care; Information Access and Privacy; Continuing Care; Diagnostic Services; and Workforce.

Our consultation findings indicates that:
Many of the opportunities identified are well underway, particularly related to Information and Technology, Access to Services, Mental Health, Diagnostic Services areas. Many of the opportunities have not yet received the attention or achieved results required to alleviate many of the current operating challenges. These include: Cost of Services Sustainability; Quality of Services; Continuing Care; and Workforce.
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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Annual Plan
Observations
Deloitte's review of Aspen's Annual Business Plan (2005 2006) provides the following observations related to the extent to which annual direction and activities align to broader strategy.
Annual Business Plan (2005-06) does align and support the 3 Year Plan through the development of Tactical Approaches (TA). Tactical Approaches do provide high level activity description of the planned activity to support strategy achievement. While the Annual Plan reflects a more focused plan to cascade strategy to the operational level, our earlier observation that highlights resource limitations to effectively implement change remain.

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

ARHA Governance Assessment

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

ARHA Governance Assessment
Assessment Areas and Indicators
The high level assessment of the five areas of governance responsibility included:
Responsibilities and mandate Structure and organization Processes and information Performance assessment and accountability Organizational culture
Responsibilities and Mandate Performance Assessment and Accountability Organizational Culture Processes and Information Structure and Organization

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

ARHA Governance Assessment
Responsibilities and Mandate
Performance Assessment and Accountability Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization

Understanding of scope, authority and responsibilities (the difference between stewardship and management and setting policy vs. implementing policy)

Areas of Assessment

Involvement in multi-year strategic planning; Involvement in annual planning and budgeting Involvement in establishing risk management process and aware of procedures to mitigate risk Ensuring management effectiveness and succession Communication with key stakeholders Board self reports a good level of involvement in key areas of responsibility; Board also reports that it has worked to overcome its initial area-specific focus (former Regions) to develop a renewed "Aspen" perspective Board receives regular reports from Community Health Councils through CHC documented minutes and CEO; Board endeavors to have a member assigned per CHC Board devotes substantial time to annual planning and update process; relies on analyst reports; reviews the export/import data to assess needs and changing priorities Board may want to ensure stronger efforts are applied to management succession planning given the ever-present and increasing need to secure good talented managers, and the expected management retirement in Aspen.

Deloitte Observations

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

ARHA Governance Assessment
Structure and Organization
Performance Assessment and Accountability Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization

Appropriate number of members and meetings

Areas of Assessment

Appropriate representation of communities Committee structure Self assessment Board understanding of responsibilities Currently, one vacancy on Board Board self reports effective working structure for board and that board members have a good understanding of their responsibility

Deloitte Observations

Board has a focused committee structure and participates in broader regional committee structure (Regional Quality Council, Information Management, Accreditation) Board meets regularly over the course of year (monthly schedule) Board reports regular staff presentation to Board meeting (monthly basis) Board may want to consider stronger representation of senior management as regular participants at Board meetings.

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

ARHA Governance Assessment
Process and Information
Performance Assessment and Accountability Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization

Board identification of information needs and receives required reporting Board meetings considered to be appropriate structured (length, frequency, advance circulation of materials, attendance, management ability to respond to enquiry)

Areas of Assessment

Documentation of meetings Identification of required skill sets/competencies for board members Formal orientation; ongoing education/development Board related policies (roles/responsibility; code of conduct; conflict of interest)

Board self reports good information flow between management and Board

Deloitte Observations

Board receives in-depth monthly CEO report Formal orientation process for new Board Members Ongoing development opportunities for Board Members Board specific policy in place to direct board management

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

ARHA Governance Assessment
Performance Assessment and Accountability
Responsibilities and Mandate Performance Assessment and Accountability Organizational Culture Processes and Information Structure and Organization

Process to assess and monitor organization performance related to financial management, operations, people management, risk and safety

Areas of Assessment

Process to monitor achievement of strategic directions Self assessment of board performance Board understanding of liability issues Process to routinely assess performance of CEO/President Board compliant with required reporting Annual review process in place for CEO Board reports annual self assessment Strong financial reporting and control mechanisms in place

Deloitte Observations

Other areas of reporting largely through CEO report. Board may want to consider adopting established metrics for tracking and reporting related to other key areas of reporting (people, operations). Board may want to consider increased attention and focus on developing a comprehensive HR plan (that includes attraction, recruitment, development, retention, and evaluation) given the growing pressure points in terms of staffing and people management.

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

ARHA Governance Assessment
Organizational Culture
Performance Assessment and Accountability Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization

Board involvement in setting organization's values and philosophies

Areas of Assessment

Diverse representation from communities within region Board serving role as policy advocates with government and key stakeholders Fosters effective board / management relations Board self reports significant involvement in value setting and strong relationship with management Board has secured diverse representation through its 6 Community Health Councils including a focus on both M tis Settlements and First Nations. The strongest focus of regionalization appears to be related to the financial management and control component.

Deloitte Observations

The decision-making processes and accountability structure within management roles is not optimal. Given the elapsed time since re-regionalization, the incoming CEO and management team may want to review current role structure, decision-making and accountabilities within organization. Given the three year time factor since Aspen was formed, it may be time to apply increased energy and effort in other areas of regional structure and requirements (Human Resource Planning and Support, Clinical Care Standardization, Alternative Service Delivery Approaches)

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Key Conclusions
Strengths to build on include... Strengths to build on include...
Regional roles to support Regional roles to support standardization of service delivery standardization of service delivery and program development and program development Seasoned staff and managers Seasoned staff and managers A strategic direction that aligns to A strategic direction that aligns to provincial requirements provincial requirements Commitment to serve residents Commitment to serve residents close to home close to home

However, some challenges do However, some challenges do exist. Aspen should assess: exist. Aspen should assess:
Number of strategic priorities it can Number of strategic priorities it can undertake undertake Resources to support Resources to support implementation implementation Business case development process Business case development process for program development/ for program development/ expansion expansion Commitment to serve close to home Commitment to serve close to home should be within quality parameters should be within quality parameters Service standardization, quality Service standardization, quality monitoring, risk management in monitoring, risk management in relation to access and relation to access and rationalization rationalization Management organization structure, Management organization structure, roles and decision-making processes roles and decision-making processes

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Deloitte & Touche LLP and affiliated entities. Deloitte, one of Canada's leading professional services firms, provides audit, tax, consulting, and financial advisory services through more than 6,100 people in 47 offices. Deloitte operates in Qu bec as Samson B lair/Deloitte & Touche s.e.n.c.r.l. The firm is dedicated to helping its clients and its people excel. Deloitte is the Canadian member firm of Deloitte Touche Tohmatsu. Deloitte refers to one or more of Deloitte Touche Tohmatsu, a Swiss Verein, its member firms, and their respective subsidiaries and affiliates. As a Swiss Verein (association), neither Deloitte Touche Tohmatsu nor any of its member firms has any liability for each other's acts or omissions. Each of the member firms is a separate and independent legal entity operating under the names "Deloitte," "Deloitte & Touche," "Deloitte Touche Tohmatsu," or other related names. Services are provided by the member firms or their subsidiaries or affiliates and not by the Deloitte Touche Tohmatsu Verein. 22
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AHW RHA Efficiency Review
Aspen Regional Health Authority
Findings and Opportunities Final Report
July 14, 2006
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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

Property of Alberta Health2006 Deloitte Inc. and Wellness

Table of Contents
Project Overview Clinical Resource Management Acute Care Continuing Care Community Health Services Physician Findings and Opportunities Clinical Support and Allied Health Corporate and Support Services Operational Trending and Key Metrics Human Resources Infrastructure Cluster 1 Opportunities Moving Forward: Opportunity Prioritization and Mapping
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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Project Overview

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Project Overview
Scope, Objectives and Business Drivers
Scope: Alberta Health and Wellness is undertaking an RHA Efficiency Review to identify potential efficiencies and opportunities for improvement within each of the RHAs in the province. To achieve this purpose, this Review is focusing its scope on improvements to deployment across five key dimensions:
Increases to productivity Improvements to patient flow Improvements to patient outcomes Improvements to financial stewardship Exploration of province-wide opportunities

The review does include voluntary organizations, but will not be reporting to the voluntary boards. Project Objectives There are three primary objectives that direct the activities of this Review:
Identify performance improvement issues and opportunities. Identify productivity and performance improvement strategies and solutions. Provide recommendations to optimize: available resources, operational efficiency, service delivery, safety and quality.
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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Project Overview
Approach and Timelines
The diagram below outlines the project approach, and key activities of the review. The review started in December 2005, and was completed in June 2006.
AH&W Launch
Phase 0:
AH&W Contract Management and Risk/Benefit Assessment

RHA Cluster Efficiency Review Activities by Phase
Phase 1:
Project Launch

AH&W Closure
Phase 6
Project Evaluation and Go-Forward Risk/Benefit Assessment with AH&W

Phase 2:
Global High Level Review

Phase 3:
Opportunity Identification and Preliminary Reporting

Phase 4:
Opportunity Prioritization Support

Phase 5:
Recommendations and Final Report

Administrative and Support Services Allied Health and Clinical Support Services Clinical Nursing Services Clinical Resource Management Governance and Performance Management Technology

Workstreams

Scope Definition, Workplan and Information Collection

Project KickOff Meeting with Steering Committee

Qualitative Analysis, Profile Review, Data Analysis Consultation On-Site Consultation Integrated Collect Data Review to and Develop Information Comprehensive Regional Findings Conduct Risk Assessment Quantitative Analysis and Benchmarking Comparison

Region Assessment Overview

Opportunities Prioritized

Insights from Phases 2 and 3

Final Report and Recommendations

Opportunity Identification Workshops

Working Session with each RHA to Identify Priorities for Action

Final Report

AH&W Project Evaluation and GoForward Risk Assessment Workshop

Infrastructure

RHA Cluster Observations

Opportunity Prioritization from Phase 4

Deliverables

Project Management, Quality and Risk Management, Knowledge Management and Transfer, Stakeholder Engagement and Communication

Project Scope Project Contract Risk/Benefit Assessment Project Workplan Stakeholder Consultation Plan

Current State Assessment Governance Performance Management Diagnostic Technology Assessment

RHA High-Level Opportunities RHA Cluster HighLevel Opportunities

Project Evaluation Prioritized Opportunities Final Report with Recommendations Go-Forward Risk/Benefit Assessment

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Project Overview
Reporting


This report presents the findings and opportunities identified through the region's review. Findings and opportunities are organized into 10 categories of reporting:
1. 2. 3. 4. 5. 6. 7. 8. 9.



Clinical Resource Management Acute Care Continuing Care Community Health Services Physician Findings and Opportunities Clinical Support and Allied Health Corporate and Support Services Operational Trending and Key Metrics Human Resources

10. Infrastructure



Following the identification and validation of findings and opportunities for each region, two additional activities were completed for this review, which are summarized in the final two sections of the report:

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Identification of opportunities at a cluster / provincial level. An opportunity prioritization and mapping exercise to support regional planning and goforward monitoring.
2006 Deloitte Inc.

AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

Clinical Resource Management

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Clinical Resource Management
Overview Clinical resource management analysis includes CIHI analysis (internal trending of complexity and utilization data and external comparison of utilization data for each program) and the results of the MCAP review. In conducting an internal review of the complexity and utilization data, a drilldown approach is used to understand changes in utilization efficiency (volume, complexity and utilization efficiency).
Analysis is based on 2003-04 and 2004-05 data.

In conducting an external comparison of utilization data, the goal is to identify potential opportunities to improve utilization in relation to CIHI ELOS and peer performance.
A drill-down approach is utilized, which begins with a "gross" assessment of utilization and potentially "conservable days" opportunities by comparing Sunrise's acute ALOS by CMG to the CIHI acute ELOS. The analysis is based on the 2004-05 data. This analysis is then fine tuned to determine the more realistic opportunities related to improved utilization management. A filter is applied that specifies the number of cases required and the minimum variance in ALOS required before an opportunity can be considered realistic. For example, if there were fewer than 10 cases or the conservable days for the CMG are less than .5, it is not considered to be a realistic opportunity.

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Top 10 Patient Services (2003-04 to 2004-05)
CIHI Abstract Data (Region) The Top 10 Patient Services represent 99% of the region's Total Patient Services.
General Medicine represents almost 64% and Obstetrics/Newborns almost 21%. It is expected that General Surgery and Orthopaedic Surgery have a stronger proportion given service expansion in these areas.
Patient Service General Medicine Obs Delivered Newborn Paediatric Medicine General Surgery Obs Antepartum Psychiatry Palliative Care Alternate Level of Care Obs Aborted Top 10 Patient Services Total Other Patient Services Total Region Patient Services Total
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2003-04 11,375 1,673 1,646 1,178 770 415 354 205 167 89 17,872 79 17,951

2004-05 11,582 1,687 1,685 1,041 834 432 380 170 110 82 18,003 116 18,119

Two-Year Variance 2% 1% 2% -12% 8% 4% 7% -17% -34% -8% 1% 47% 1%
2006 Deloitte Inc.

AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

Patient Volume, Weighted Cases and Patient Acuity
Region Wide
18000 15000 12000 9000 6000 3000 0

2003-04 2004-05

18000 15000 12000 9000 6000 3000 0 Weighted Cases

2003-04 2004-05

Patient Volume

1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 Patient Acuity

Regional volume has increased slightly (0.9%).

2003-04 2004-05

Both acuity and weighted cases have remained stable. Essentially volumes, patient acuity and weighted cases are flat line. Due to unavailability of the 2005-06 data, this analysis is missing the impact of Orthopedics and other clinical program changes in this fiscal year.

Source: Alberta Health & Wellness CIHI DAD, 2003-04 and 2004-05 9
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

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Patient Volume, Weighted Cases and Patient Acuity
by Plx (Region)
13000 11500 10000 8500 7000 5500 4000 2500 1000 -500 Plx Level I/II

Cases by Plx
2003-04 2004-05

12000 10000 8000 6000 4000 2000 0

Weighted Cases by Plx
2003-04 2004-05

Plx Level III/IV

Plx Level IX

Plx Level I/II

Plx Level III/IV

Plx Level IX

Acuity by Plx
3.5 3 2.5 2 1.5 1 0.5 0
Plx Level I/II Plx Level III/IV Plx Level IX

The majority of patients for the region are Plx level I/II and Plx IX.
2003-04 2004-05

Volumes increased across Plx III/IV and IX levels. Only Plx III/IV had acuity increases (9%). Plx IX had decreased acuity of 3%. While the weighted cases for Plx III/IV have risen dramatically (13.3%), the relatively low volume compared to other groupings has not had an impact on weighted cases overall.
Note: Plx further refines case mix groups to reflect additional diagnoses that influence a patient's overall medical condition. These co-morbid conditions may be present at time of admission, or may arise during the hospital stay. Cases are assigned to one of four Plx Levels. Level 1 denotes the absence of co-morbid conditions, while Level 4 denotes the presence of co-morbid conditions that may be potentially life threatening. Level 9 indicates no complexity overlay.
2006 Deloitte Inc.

Source: Alberta Health & Wellness CIHI DAD, 2003-04 and 2004-05 10

AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

CRM Import/Exports for ARHA
By Complexity for 2003-04 and 2004-05
As a % of total Cases for each Plx % Imports % Exports 2003-04 Plx I/II 6% 33% Plx III/IV 2% 65% Plx IV 6% 35% Plx I/II 7% 34% 2004-05 Plx III/IV 5% 60% Plx IV 5% 34%

Overall, 6% of patients are imported into Aspen Health Region in both 2003-04 and 200405
In 2004-05: 34% of total imported patients are from Capital Health Region and 38% are from other regions.

Overall, 35% of patients are exported from Aspen Health Region in both 2003-04 and 2004-05
In 2004-05: 92% of exports are sent to Capital Health Region

Observations
Imports/Exports as a percentage of total cases has not changed for ARHA in 2003-04 and 2004-05 The relative proportion of patients at each Plx Level (as a % of total patients at each Plx for Aspen) being exported has remained relatively constant - it is noted that the proportion of Plx III/IV patient exports decreased by 5% for the same period.

Source: Alberta Health & Wellness CIHI DAD, 2003-04 and 2004-05 11
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Average Length of Stay vs. Expected Length of Stay
as a Region
Aspen Regional Health Authority 7 6 5 4 3 2 1 0 2003-04 Average ALOS 2004-05 Average ELOS

ARHA's average length of stay (ALOS) is higher than the CIHI expected length of stay (ELOS). The gap between average and expected length of stay has stayed relatively constant over the two year period. The chart below shows the that Plx Levels I/II and III/IV are driving the ALOS to ELOS gap.
Plx Level III/IV Plx Level IX

Plx Level I/II Fiscal Year ALOS ELOS

ALOS

ELOS

ALOS

ELOS

2003-04 2004-05

5.1 5.0

4.0 4.0

14.8 15.1

12.8 12.8

3.4 3.1

3.4 3.5

Source: Alberta Health & Wellness CIHI DAD, 2003-04 and 2004-05 12
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Average Length of Stay vs. Expected Length of Stay
By Site
7 6 5 4 3 2 1 0 Swan Hills Bonnyville Elk Point Lac La Biche Whitecourt Slave Lake Barrhead Westlock Cold Lake Mayerthorpe Smoky Lake Athabasca Wabasca St. Paul Hinton Jasper Edson Boyle

2004-05

West 1

West 2

East 3

East 4

Average ALOS

Average ELOS

The facilities driving overall regional ALOS to ELOS gap are: Greater than 1 day gap:
Westlock (gap of 1.7) Athabasca (gap of 1.6) Mayerthorpe (gap of 1.4) St. Paul (gap of 1.2)

Greater than 0.5 day and less than 1 day:
Barrhead (gap of 0.8) Boyle (gap of 0.8) Lac La Biche (gap of 0.8)

Only Swan Hills and Wabasca demonstrate an ALOS < ELOS, suggesting patients are transported out. Source: Alberta Health & Wellness CIHI DAD, 2003-04 and 2004-05
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Top 10 CMGs by Potential Days Savable in 2004-05
as a Region
CMG
851 847 841 222 483 279 485

CMG Description
OTH FACTORS CAUSE HOSPITALIZ OTHER SPECIFIED AFTERCARE REHABILITATION HEART FAILURE DIABETES DIGESTIVE SYSTEM MALIGNANCY NUTRITIONAL AND MISCELLANEOUS METABOLIC DISORDERS DEMENTIA WITH OR WITHOUT DELIRIUM WITH AXIS III DIAGNOSIS RESPIRATORY NEOPLASMS CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Total Cases
931 212 112 374 301 42 209

Total Acute Days
9221 3405 2661 2970 1915 726 1237

Average Length of Stay
9.9 16.1 23.8 7.9 6.4 17.3 5.9

CIHI Expected Length of Stay
5.2 9.1 16.9 6.1 4.8 6.7 4.1

ALOS Potential ELOS Gap Days Savable
4.7 7.0 6.8 1.9 1.5 10.6 1.8 4,345 1,473 763 707 447 443 379

772 138 140

30 64 224 2,499 15,620 18,119

798 781 1680 25,394 59,313 84,707

26.6 12.2 7.5 133.5 1,800.6 1,934.1

15.3 7.9 6.5 82.7 1,639.4 1,722.1

11.3 4.3 1.0 50.8 151.2 212.0

338 276 235 9,406 3,892 13,298

Top 10 Region CMGs Total Other 284 Region CMGs Total

Total Region CMGs

The leading CMG for savable days is "Other Factors". Coding improvements are required to identify appropriate strategies for length of stay. Given the occurrence of CMG's related to Heart Failure, Diabetes, and Chronic Obstruction Pulmonary Disease suggests stronger chronic disease management strategies.
The savable days calculation includes only those cases where the gap between actual length of stay was greater than 0.5 of a day, and the number of cases per CMG was greater than 10.
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Source: Alberta Health & Wellness CIHI DAD, 2003-04 and 2004-05; CIHI CHAP Reports 2006 Deloitte Inc.

Top 10 CMGs by Potential Days Savable in 2004-05
West 1 Breakdown
CMG CMG Description Total Cases Total Acute Days Average Length of Stay CIHI Expected Length of Stay ALOS - ELOS Gap Potential Days Savable

851

Other Factors Causing Hospitalization Nutritional and Miscellaneous Metabolic Disorders Other Specified Aftercare Rehabilitation Orthopaedic Aftercare Psychoactive Substance Dependence Respiratory Neoplasms Heart Failure Chronic Bronchitis Cellulitis

144

892

6.2

4.3

1.9

277

485

38

398

10.5

4.0

6.5

246

847 841 399 783 138 222 142 447

45 24 13 18 14 53 58 31 438

625 567 231 194 225 394 438 234 4,198

13.9 23.6 17.8 10.8 16.1 7.4 7.6 7.5

8.5 16.2 7.2 4.4 8.4 5.6 5.9 5.0

5.4 7.4 10.6 6.4 7.7 1.8 1.7 2.6

243 179 138 115 108 97 97 81 1,579

Top 10 West 1 CMGs Total

The leading CMG for savable days is "Other Factors Causing Hospitalization". Coding improvements are required to identify appropriate strategies for length of stay. The next highest CMG cluster is Nutritional and Miscellaneous Metabolic Disorders.
Note: The savable days calculation includes only those cases where the gap between actual length of stay was greater than 0.5 of a day, and the number of cases per CMG was greater than 10.
Source: Alberta Health & Wellness CIHI DAD, 2003-04 and 2004-05; CIHI CHAP Reports 15
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Top 10 CMGs by Potential Days Savable in 2004-05
West 2 Breakdown
CMG CMG Description Total Cases Total Acute Days Average Length of Stay CIHI Expected Length of Stay ALOS - ELOS Gap Potential Days Savable

851 847 222 772

Other Factors Causing Hospitalization Other Specified Aftercare Heart Failure Dementia with or without Delirium with Axis III Diagnosis Chronic Obstructive Pulmonary Disease (COPD) Signs and Symptoms Chronic Bronchitis Diabetes Simple Pneumonia and Pleurisy Back Pain (MNRH)

322 74 100 14

3,548 1,290 896 468

11.0 17.4 9.0 33.4

6.2 9.4 5.8 15.3

4.8 8.1 3.1 18.1

1,536 596 312 254

140 842 142 483 143 409

48 35 106 69 134 34 936

471 333 751 464 837 247 9,305

9.8 9.5 7.1 6.7 6.2 7.3

7.0 5.7 6.0 5.2 5.5 4.7

2.9 3.8 1.1 1.5 0.7 2.5

137 134 114 105 95 86 3,368

Top 10 West 2 CMGs Total

The leading CMG for savable days is "Other Factors Causing Hospitalization" and "Other Specified Aftercare". Coding improvements are required to identify appropriate strategies for length of stay.
Note: The savable days calculation includes only those cases where the gap between actual length of stay was greater than 0.5 of a day, and the number of cases per CMG was greater than 10.
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Source: Alberta Health & Wellness CIHI DAD, 2003-04 and 2004-05; CIHI CHAP Reports 16 2006 Deloitte Inc.

Top 10 CMGs by Potential Days Savable in 2004-05
East 3 Breakdown
CMG CMG Description Total Cases Total Acute Days Average Length of Stay CIHI Expected Length of Stay ALOS - ELOS Gap Potential Days Savable

851 841 483 680 279 536 485 773 208 846

Other Factors Causing Hospitalization Rehabilitation Diabetes Femur or Pelvic Fractures and Dislocations Digestive System Malignancy Urinary Obstruction (MNRH) Nutritional and Miscellaneous Metabolic Disorders Dementia with or without Delirium without Axis III Diagnosis AMI without Cardiac Cath without Specified Cardiac Conditions Aftercare following Surgery or treatment

208 25 124 19 13 51 78 13 18 14 563

2,581 844 898 396 301 224 409 239 185 155 2,363

12.4 33.8 7.2 20.8 23.2 4.4 5.2 18.4 10.3 11.1

4.3 16.1 4.9 8.2 5.9 1.8 4.0 10.8 5.7 6.2

8.1 17.7 2.3 12.7 17.2 2.6 1.3 7.6 4.6 4.9

1,687 442 291 241 224 130 99 99 83 68 3,363

Top 10 East 3 CMGs Total

The leading CMG for savable days is "Other Factors Causing Hospitalization" and "Rehab". Coding improvements are required to identify appropriate strategies for length of stay.
Note: The savable days calculation includes only those cases where the gap between actual length of stay was greater than 0.5 of a day, and the number of cases per CMG was greater than 10.
Source: Alberta Health & Wellness CIHI DAD, 2003-04 and 2004-05; CIHI CHAP Reports 17
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Top 10 CMGs by Potential Days Savable in 2004-05
East 4 Breakdown
CMG CMG Description Total Cases Total Acute Days Average Length of Stay
8.6

CIHI Expected ALOS - ELOS Potential Days Length of Stay Gap Savable

851 847 222 841 783 138 483 791 398 102

Other Factors Causing Hospitalization Other Specified Aftercare Heart Failure Rehabilitation Psychoactive Substance Dependence Respiratory Neoplasms Diabetes Anxiety Disorders (MNRH) Other Inflammatory Arthritis Dysequilibrium

257

2,200

5.3

3.3

845

58 155 45

1,142 1,270 985

19.7 8.2 21.9

9.7 6.4 18.0

9.9 1.8 3.9

577 278 175

69

433

6.3

4.6

1.7

119

21 62 22 12 46

260 380 177 131 190

12.4 6.1 8.0 10.9 4.1

7.8 4.9 5.1 5.5 2.9

4.6 1.3 3.0 5.4 1.2

97 78 65 65 57

Top 10 East 4 CMGs Total

747

7,168

2,354

The leading CMG for savable days is "Other Factors Causing Hospitalization" and "Other Specified Aftercare". Coding improvements are required to identify appropriate strategies for length of stay.
Note: The savable days calculation includes only those cases where the gap between actual length of stay was greater than 0.5 of a day, and the number of cases per CMG was greater than 10.
Source: Alberta Health & Wellness CIHI DAD, 2003-04 and 2004-05; CIHI CHAP Reports 18
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Beds Savable in 2004-05
as a Region
Potential Beds Savable
60 55 50 45 40 35 30 25 20 15 10 5 0 CIHI Comparison With Filter Peer Comparison Without Filter CIHI Comparison Without Filter Peer Comparison With Filter
11 31 32 59

Comparison of ALOS to CIHI expected length of stay suggests that the region could save as many as 31 beds. When compared to peers, using the same filter process, the region can save 11 beds.
Given the small bed size of sites, and that many sites have potential bed savings of less than 1, just over half of this opportunity is feasible. Next slide identifies where bed opportunity is greatest.

Note: The filter excludes cases where the gap between actual length of stay was less than 0.5 of a day, and the number of cases per CMG was less than 10. Estimated bed savings are based on 100% occupancy.
Source: Alberta Health & Wellness CIHI DAD, 2003-04 and 2004-05; CIHI CHAP Reports 19
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Beds Savable in 2004-05
By Site
Sub-Region Site
Edson Healthcare Centre West 1 Hinton Healthcare Centre Seton - Jasper Healthcare Centre Whitecourt Healthcare Centre Barrhead Health Care Centre West 2 Mayerthorpe Healthcare Centre Swan Hills Healthcare Centre Westlock Healthcare Centre Athabasca Health Care Centre Boyle Health Care Centre Slave Lake Healthcare Centre East 3 Wabasca/Desmarais Healthcare Centre William J. Cadzow - Lac La Biche Healthcare Centre Bonnyville Healthcare Centre Cold Lake Healthcare Centre Elk Point Healthcare Centre East 4 George McDougall - Smoky Lake Healthcare Centre St. Therese - St. Paul Healthcare Centre

CIHI Comparison CIHI Comparison Peer Comparison Peer Comparison Without Filter With Filter Without Filter With Filter
2.3 3.2 0.9 3.7 5.0 4.0 0.1 8.3 6.1 3.4 2.4 0.7 4.8 2.8 2.5 0.7 1.0 6.9 1.0 1.6 0.2 1.7 3.2 2.4 4.6 3.5 1.8 1.0 0.1 3.0 1.5 0.9 0.6 4.3 1.0 1.6 0.7 2.6 1.5 1.9 0.1 4.3 2.6 2.7 0.7 0.4 2.3 1.7 1.0 0.5 0.4 5.7 0.1 0.4 0.1 1.0 0.4 0.6 1.4 0.8 1.4 1.0 0.5 0.2 0.1 3.5

Grand Total
20

58.9

31.4

31.8

11.4
2006 Deloitte Inc.

Source: Alberta Health & Wellness CIHI DAD, 2003-04 and 2004-05; CIHI CHAP Reports
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

MCAP Overview
Process
An MCAP review was conducted to:
Gain a better understanding of patients' required levels of care and their specific care needs and the impact these needs have on inpatient bed utilization. Identify system issues why patients are not at appropriate level of care.

MCAP is a utilization management tool that uses rigorous scientifically researched and validated criteria to review the intensity of services required for any given patient and determine the appropriate level of care required. The tool uses a "service-driven methodology" and focuses on the treatment plan/services ordered for that day. By avoiding the placement of patients at too high or low of a care level, health care managers can be assured that patients will receive the highest possible quality of care and will move through the health care system in the shortest possible time. The review was conducted by Registered Nurses certified in MCAP . They reviewed the charts of all admitted inpatients in the Acute Care settings between February 6 - 16, 2006. Using MCAP criteria, the following three key questions were asked of each admitted patient:
Does the patient require the level of care (i.e. Long Term Care, Acute Care, Intensive Care, etc.) they are receiving? If not, what level of care does the patient require? Why is the patient not at the level of care they require?

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Patient Profile
RHA Acute Care
190 patients were reviewed at selected acute care sites within Aspen RHA, which represents 72% of the total acute care bed capacity (267 beds) across the sites reviewed.
The average patient age was 64 years; 56% of patients were female and 44% were male.

Site Athabasca HCC Barrhead HCC Bonnyville HCC Cold Lake HCC Edson HCC Hinton HCC Mayerthorpe HCC Slave Lake HCC St. Paul HCC Westlock HCC Grand Total
22

Total Number of Beds 26 34 23 22 19 21 24 14 40 45 267

Number of Beds Reviewed 12 22 18 21 15 12 14 14 32 30 190
Mayerthorpe 7%

Westlock 16%

Athabasca 6%

Barrhead 12%

St. Paul 18%

Bonnyville 9%

Cold Lake 11%

Slave Lake Hinton 7% 6%

Edson 8%

AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

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Patient Service Profile
by Site
Site Patient Service Combined Medical/Surgical Combined Medical/Surgical Combined Medical/Surgical Combined Medical/Surgical/ Obstetrics Combined Medical/Surgical Combined Medical/Surgical Combined Medical/Surgical Number of Beds Reviewed 12 22 18 St. Paul HCC 21 Site Patient Service Number of Beds Reviewed 14 14 25 7 32 13

Athabasca HCC Barrhead HCC Bonnyville HCC

Slave Lake HCC

Combined Medical/Surgical

Slave Lake HCC Total Combined Medical/Surgical Psychiatry St. Paul HCC Total

Cold Lake HCC

Edson HCC

15

Combined Medical/Surgical Westlock HCC Combined Medical/Surgical/ Obstetrics

Hinton HCC Mayerthorpe HCC

12

17

14 Westlock HCC Total Grand Total 30 190
2006 Deloitte Inc.

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Patients with Insufficient Physician Documentation
ARHA Acute Care
Westlock St. Paul Slave Lake Mayerthorpe Hinton Edson Cold Lake Bonnyville Barrhead Athabasca 0 5 12 10 15 20 25 30 35 11 11 13 20 18 18 4 1 2 1 14 3 26 29 4 3

Site

Percent with Insufficient Documentation 0% 18% 0% 5% 13% 8% 21% 0% 9% 13% 9%
2006 Deloitte Inc.

Athabasca HCC Barrhead HCC Bonnyville HCC Cold Lake HCC Edson HCC Hinton HCC Mayerthorpe HCC Slave Lake HCC St. Paul HCC Westlock HCC Total

Sufficient Documentation

Insufficient Documentation

Overall, 18 out of the 190 reviewed patients (or 9%) had insufficient physician documentation. In these situations, our clinical team is unable to appropriately determine if the patient meets clinical criteria for admission. This percentage of patients with insufficient physician documentation suggests an opportunity for improvement in charting.

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Patients Who Meet Clinical Criteria for Admission
ARHA Acute Care
Westlock St. Paul Slave Lake Mayerthorpe Hinton Edson Cold Lake Bonnyville Barrhead Athabasca 0 7 5 15 14 5 10 15 20 25 30 35 6 10 9 18 3 4 8 5 1 4 2 15 6 18 7 8

Site 7 Athabasca HCC Barrhead HCC Bonnyville HCC Cold Lake HCC Edson HCC Hinton HCC

Percent at Appropriate Level 58% 78% 83% 90% 69% 91% 55%

Meet Criteria Do Not Meet Criteria Psychiatric Patients Who Do Not Meet Criteria

For patients with sufficient documentation, the clinical team Mayerthorpe HCC determined that 120 out of 172 patients reviewed (or 70%) met clinical criteria for admission to the service they were on. As shown in table (upper right), there is a significant percentage range by site. In comparing these results to our experience with other regions and hospitals in Canada, Aspen is in line with peers.
Our observed average for patients in the most appropriate care setting ranges between 65-75%. Slave Lake HCC St. Paul HCC Westlock HCC Total
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57% 52% 69% 70%
2006 Deloitte Inc.

Patients Identified - Requiring Different Level of Care
ARHA Acute Care
Westlock St. Paul - Psych St. Paul (No Psych) Slave Lake Mayerthorpe Hinton Edson Cold Lake Bonnyville Barrhead Athabasca
7 2 5 5 5 1 3 1 1 4 1 3 3 1 1 1 5 2 1

Site

Percent Identified as Requiring a Different Level of Care 80% 25% 100% 50% 75% 100% 100% 83% 50% 29% 88% 71%
2006 Deloitte Inc.

Athabasca HCC Barrhead HCC Bonnyville HCC Cold Lake HCC

0

2

4 Identified

6

8

10

Edson HCC Hinton HCC Mayerthorpe HCC Slave Lake HCC St. Paul No Psych

Not Identified

Of the 52 patients who did not meet clinical criteria, 37 (71%) were already identified by the facility as requiring a different level of care.

This indicates an opportunity for improvement in the early identification of those patients require a different St. Paul Psych level of care and applies to about 29% of patients who Westlock HCC did not meet criteria.
Total
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Required Level of Care
ARHA Acute Care
For 52 patients who did not meet clinical criteria for admission, the most frequently identified care level was Continuing Care, Rehabilitation and Outpatient (related to Psychiatry).
Required Level Cold Mayer- Slave Athabasca Barrhead Bonnyville Edson Hinton of Care Lake thorpe Lake St. Paul

Westlock

Total

Rehab

1

1

1

1

1

2

2

9

Palliative Continuing Care Lodge Home Care Outpatient Home Total 5 1 4

1 3 1 1 2 1 2 7 2 4 3 2 4 1 1 5 6 2 14 1 3 4 1

1 5

2 22 1 6 7 5

8

52

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Reasons Patients Did Not Meet Clinical Criteria
ARHA Acute Care
Of these same 52 patients who did not meet clinical criteria, 27 (or 52%) were due to challenges in accessing different levels of care or resources available within the region.

Westlock St. Paul - Psych St. Paul (No Psych) Slave Lake Myerthorpe Hinton Edson Cold Lake Bonnyville Barrhead Athabasca 0

7 7 2 5 2 1 2 1 1 3 1 3 3 2 1 1 2 1 4 1 1

1

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Access to Internal RHA Resources Inappropriate Admission Treatment Unavilable as Outpatient
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Delay in Discharge Planning Sociodemographic

2006 Deloitte Inc.

Acute Care Profile Summary: February 6 16, 2006
Met Clinical Criteria for Admission Rehab

9

120
Beds Reviewed Continuing Care

190
Did Not Meet Clinical Criteria for Admission

22

Homecare

52
Sites Reviewed: Acute Care Bed Capacity

6

Outpatient Insufficient MD Documentation

267

7

18

Home

5
Beds Not Reviewed Other

77

3

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Clinical Resource Management Opportunities
Opportunities
1. Ensure alignment of resources to support increased acuity

Findings
Cases and Weighted cases for Plx Level III/IV patients have increased between 2003-04 and 2004-05. Exports of Plx Level III/IV patients have decreased for the same period These findings support the anecdotal evidence that higher acuity patients are being repatriated to ARHA. Analysis identified CMG 851 (Other Factors Causing Hospitalization) and CMG 847 (Other Specified Aftercare) as having the highest potential days savable. The high presence of these CMGs suggest additional coding and abstracting focus is required to help the region more discreetly identify and manage this patient volume. The MCAP review found 9% of inpatient charts could not be not assessed for eligibility for admission due to insufficient physician documentation.

2.

Improvements to Regional Coding and Abstracting

3.

Improve MD Documentation in Inpatient Charts

Where this occurs, there is a heavy requirement and reliance on verbal communication between the physician and the team to support care management. The heavy reliance on verbal communication has potential risk issues for patient outcome, and potential for increased length of stay without clear discharge direction.

4.

Refocus Mental Health planning on broader continuum of care

CRM analysis shows that on MCAP assessment day, most of unqualified admissions would have benefited from outpatient service. Examination of mental health programming to ensure non-bedded health services are accessible as viable alternatives to service. Mental Health Plan and approved innovations projects may support alternative settings and services. 2 FTE Placement Coordinators exist to support single point of entry placement. However, consulting team believes there is limited dedicated resources within inpatient facilities to support inpatient discharge and planning processes in acute care setting. Inpatient discharge function for acute care patients largely falls to the Nursing Supervisor. Region reports plans to augment the Social Work complement to a total of 4 across the region. The plan is to allocate 1 FTE of Social Work support to each area. The roles will follow the other discipline reporting model and report through Community Health Services. Improved awareness of and education on admission/discharge leading practices to staff will support realization of reduced length of stay.

5.

Examine regional admission/ discharge process and role creation to support patient flow process

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Clinical Resource Management Opportunities
Opportunities Findings
Clinical Resource Management findings show a need within ARHA for alternative levels of care settings to support patient flow, maximize use of acute resources, and support leading practice. ARHA's future planning does reflect movement to alternative care settings, however, increased attention in this area appears warranted.
For 42% of patients who were not at the required level of care, the required level of care identified through the MCAP process was related to Continuing Care. Of the 52 patients who did not meet clinical criteria for admission to the service they were on, 52% were due to challenges in accessing different levels of care or resources available within the region. Limited use of Adult Day Care Programming for Senior population.

6.

Expand functional planning to include alternative service settings and non-acute service delivery and link to the Community Health Needs Assessment

Admittedly, the Region will continue to struggle to attract private LTC operators which further supports its need to assess its own internal capacity to deal with this need. 7. Support policy development that enables the availability of incremental levels of continuing care for residents living in the community

The MCAP review suggested that a high proportion of the patients reviewed who required a different level of care best fit the needs of a continuing care setting. Increasingly, continuing care is not a static concept and is evolving to align and support individual and family need and desires. This creates challenges for the region in determining what the need is and how resources should be deployed.

8.

Assess feasibility of shifting acute beds to Several facilities experiencing LOS challenges due to long inpatient stays while patients wait continuing care status where there is low acute for Continuing Care placement. occupancy coupled with lengthy placement waits. Targeted assessment of CMG's driving Approximately 2.8% (11 beds) of acute bed capacity could be saved if ARHA's ALOS by CMG conservable beds was in line with the peer ALOS. analysis with a focus on Several of the LOS opportunities relate to the chronic disease conditions (Heart Failure, using CDM to divert Diabetes, COPD) suggesting renewed emphasis and direction for CDM. admissions related to AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness 2006 Deloitte Inc. chronic disease

9.

31

Acute Care Sites Review

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Acute Care Sites Review
Process Overview
Our review of acute care sites included:
Site consultation according the sites agreed upon with Senior Management and AH&W Profile review and follow-up Nursing staff comparison

Key site findings, associated opportunities and staffing comparison results are provided for all acute care sites by areas:
West 1 West 2 East 3 East 4

Findings and opportunities are identified from consultation, utilization and staffing analysis. Given the similar operating models, strengths and challenges seen across facilities, we are grouping findings and opportunities into two categories:
Site specific opportunities including potential staffing efficiency or investment Cross regional opportunities

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Nursing Staffing Comparison and Consultation
Process Overview
The relative efficiency of patient/resident care services was assessed based on a comparative analysis of staffing levels and skill mix for each inpatient care unit using three key inputs:
GRASP Systems International Database (using the Canadian section of the database) Deloitte Peer Database Unit Staffing Schedule/Pattern

As an indicator of variance from the benchmark, the difference in hours per patient day (HPPD) is reflected using an FTE estimate for illustrative purposes. To gain an understanding of the clinical requirements and environment on each unit, profiles were completed and consultation was conducted with clinical leadership. For each patient care unit, the following analysis was then conducted:
Total nursing unit producing personnel (UPP) worked hours per patient day/visit (HPPD). Nursing UPP Worked Hours include direct patient care hours provided by RNs, LPNs, and certain percentage of Health Care Aides. UPP hours include regular worked, relief, and overtime, and exclude benefit hours (i.e., vacation and absenteeism). HPPD were calculated using actual worked hours (not budgeted) for 2004-05 and 2005-06 YTD, and then compared to comparable peer units based on the profiles completed by each program/unit. All units are shown at the 50th percentile. In some units, adjustments have been made to better reflect patient mix/care requirements.

Staffing opportunities are identified based on comparative analysis and the clinical team's understanding of minimum staffing requirements. Staffing opportunities are not stand alone, and need to be considered in the context of other opportunities identified for each clinical area.
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West 1
- Acute Care

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Peer Staffing Comparative Analysis
Edson Healthcare Centre
Opportunities
1. There is opportunity for significant investment in the acute and ER/OPD departments at Edson, however this needs to be reviewed in conjunction with primary care physician coverage in the community. Staffing investments should be considered with respect to the planned redevelopment of the site.

Findings
Projected increase in patient days and visits to the ER/OPD as a large increase in population over the past few years due to increased activity in the oil and gas sector. Limited information on the nature of the ER/OPD visits Acute care staff provide support to the Continuing Care. There are usually 2 or more patients waiting for placement in LTC at any given time. The average wait for a Lodge bed is between 4 - 6 months, resulting in extended waits in Acute Care until a bed is available in LTC. There has been an increase in the number of surgical cases from visiting specialists. Staffing comparison suggests potential investment in Acute Units and ER and some efficiency in surgical day care/OR. See opportunity comment.

2.

Unit/Area Description

Actual FTEs 2004-05

Actual FTEs 2005-06 YTD

Actual HPPD 2005-06 YTD

Recom'd HPPD

Recom'd FTE (Effic.)/ Re-Invest. 05-06 YTD

Acute Nursing Emergency / OPD Surgical Day Care Operating Room

19.0 4.2 1.5 0.3

20.0 3.8 1.5 0.3

5.2 0.3 9.2 12.2

5.5 0.9 4.9 4.1

1.2 6.6 (0.7) (0.2)

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 36
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Hinton Healthcare Centre
Opportunities
1. An efficiency opportunity exists in the combined OR, recovery room and surgical day care. At this time the efficiency target is equivalent to 3.8 FTE and indicates an opportunity to increase OR/SDC volumes within the current staffing complement. The potential investment opportunity in ambulatory needs to be reviewed in conjunction with primary care physician coverage in the community.

Findings
Strong Alberta economy in oil and gas in Hinton. In 2004 there were 4000 persons living in camps. This increased to 7000 persons in 2005. Strong Maternal Newborn Program with trained facility nurses and Physicians specialized in epidural anesthesia and caesarian sections with an increasing maternity catchment area. This accounts for the 24.8% increase in newborns over 2004. All RNs are cross-trained and are required to work in all areas of Acute Care. Staffing efficiency findings suggest up to 3.8 FTE in the OR/Surgical Day Care areas. A potential investment of 1.3 FTE is noted in Ambulatory care.

2.

Unit/Area Description

Actual FTEs 2004-05

Actual FTEs 2005-06 YTD

Actual HPPD 2004-05

Recom'd HPPD

Recom'd FTE (Effic.)/ Re-Invest. 2004-05

Acute Nursing Emergency Operating Room Surgical Day Care Ambulatory Care

22.2 2.7 3.7 2.0 1.2

22.7 1.0 3.2 1.9 1.7

7.3 0.4 14.7 14.4 0.6

6.3 0.9 4.9 4.1 1.2

(3.0) 3.1 (2.4) (1.4) 1.3

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 37
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Other Rural Sites Not Visited
Actual FTEs 2005-06 YTD Recom'd FTE (Effic.)/ Re-Invest. 2004-05

Site

Unit/Area Description

Actual FTEs 2004-05

Actual HPPD 2004-05

Recom'd HPPD

Acute Nursing Jasper Seton Hospital Emergency

11.0

10.4

11.4

5.1

(2.4)

4.4

4.4

0.9

0.9

0.0

Comments

Profile reports combined staffing for acute, ER/OPD and RN supports for Continuing Care as needed. Minimum staffing requirement negates full staffing efficiency. Potential savings of up to 2.4 FTE where at times the facility can work at 2 RN over 24 hour coverage model. This is dependant on seasonal fluctuations and the ability to manage peaks in workload. Acute Nursing 14.9 14.9 5.6 6.0 1.7

Emergency Whitecourt Surgical Day Care

7.3

7.3

0.6

0.9

4.0

0.9

0.9

3.6

4.3

0.2

Operating Room

0.1

0.1

4.0

4.1

0.0

Comments

Physician shortage in community drives ER volume and the staffing investment should be seen in the light of many of the ER visits being low acuity clinic visits.

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 38
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

West 2
- Acute Care

39

AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Barrhead Healthcare Centre
Opportunities
1. Staffing investment of 4.9 FTE in acute care and ER/OPD should be considered related to ER/OPD volumes, and in light of proposed facility redevelopment and functional planning.

Findings
Acute Nursing and ER requirement drives increase in staffing. 34 Acute beds, 2 LDRP with 134 deliveries. Anecdotally it is reported that the busiest time is between 1700 hrs and 2200 hrs as patients are sent to ER for tests, with X-ray volume perpetuating a lot of overtime. Transfers to Edmonton require on occasion an RN to accompany as there is only 1 ACLS EMS in the town This site has been marked for redevelopment. In light of physician resource issues in this area of the region, there is an opportunity to review the consolidation of certain patient services between Westlock and Barrhead. Inefficient layout as the ER/OPD is a long way from acute units making it more of a challenge to provide cross-coverage. Acute skill mix is 67% and LPNs are not yet practicing at full scope related to administration of medications, however there is a plan in place to address this.





Unit/Area Description

Actual FTEs 2004-05

Actual FTEs 2005-06 YTD

Actual HPPD 2004-05

Recom'd HPPD

Recom'd FTE (Effic.)/ Re-Invest. 2004-05

Acute Nursing Emergency Surgical Day Care Operating Room Ambulatory Care
40

22.6 5.2 2.3 1.4 1.3

22.8 5.4 2.2 1.4 1.2

4.1 0.7 10.2 2.3 1.7

4.7 0.9 4.9 4.1 1.2

3.0 1.9 (1.2) 1.1 (0.4)
2006 Deloitte Inc.

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

Peer Staffing Comparative Analysis
Mayerthorpe Healthcare Centre
Opportunities


Findings
Farming community with an increasing aging population and seasonal variations in ER volumes. Limited obstetrics at this site. 25 acute bed facility with an average 55% occupancy. Staff in acute support the ER in the evening, who reportedly run evening clinics 1600 1800 hrs, and 1930 2200 hrs appointments in evening walk-in clinics. ER is staffed on the day shift for 4 hours but relies on the acute unit staffing on the evening and night shift. Night shift RN covers acute and ER services.

1.

There is a staffing investment equivalent to 4.1 FTE in ER/OPD that is driven by the increase in volumes, however this needs to be reviewed in conjunction with primary care physician coverage in the community.



Unit/Area Description

Actual FTEs 2004-05

Actual FTEs 2005-06 YTD

Actual HPPD 2004-05

Recom'd HPPD

Recom'd FTE (Effic.)/ Re-Invest. 2004-05

Acute Nursing Emergency / OPD Surgical Day Care

14.1 4.2 0.3

14.7 4.0 0.3

4.6 0.5 6.3

4.8 0.9 4.9

0.6 4.1 (0.1)

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 41
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Westlock Healthcare Centre
Opportunities
1. Consider staffing investment equivalent to 5.0 FTEs to support ER/OPD visits, however this needs to be reviewed in conjunction with primary care physician coverage in the community. There is an efficiency opportunity in Surgical Day Care that is equivalent to 1.6 FTE due to the potential for additional capacity. This indicates that there is an opportunity to further increase surgical cases within the current staffing complement.

Findings
Poorly designed department with no triage function so there is a need to review the workflow in this area. There is a mix of patient services in a very congested area making it difficult to determine staffing requirements of these patient. Need to review the location of Orthopaedics that is currently adjacent to the OPD department in the former Palliative care rooms. A 21% projected increase in ER/OPD volumes for 2005-06. Orthopaedic cases account for 25% of all cases for 2004-05. There has been a significant investment in staffing in acute care, OR and SDC to support the Orthopaedic program. It is recommended that staffing levels remain constant given anticipated volume increases for orthopedics with a review at year end.

2.

Actual FTEs Unit/Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HPPD 2005-06 YTD

Recom'd HPPD

Recom'd FTE (Effic.)/ Re-Invest. 05-06 YTD

Acute Nursing Emergency / OPD Surgical Day Care

30.3 5.1 3.8

37.7 5.3 5.7

5.1 0.5 6.9

5.1 1.0 4.9

0.0 5.0 (1.6)

Operating Room
42

0.9

1.5

4.1

4.1

0.0
2006 Deloitte Inc.

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

Peer Staffing Comparative Analysis
Other Rural Sites Not Visited
Actual FTEs 2004-05 Actual FTEs 2005-06 YTD Actual HPPD 2004-05 Recom'd FTE (Effic.)/ Re-Invest. 2004-05
12.1 4.8 (1.7) See Below (4.7) See Below

Site

Unit/Area Description

Recom'd HPPD

Acute Nursing Swan Hills Emergency

3.0

3.0

7.1

7.1

2.8

0.9

Minimum staffing requirement for the services provided negates staffing efficiency due to low occupancy. Comments Swan Hills should undergo a facility role review although the Region reports that this has been done. Region identifies that only significant savings available through closure which is not an acceptable solution given access requirements.

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 43
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

East 3
- Acute Care

44

AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Athabasca Healthcare Centre
Opportunities
1. Strengthen discharge planning and utilization management procedures and improve linkages between the hospital and home care staff. Any recommendation around investments in this facility needs to be considered in light of the recommendation that the region complete a review of this facility's role. Any staffing investment opportunity needs to be considered in the context of an adjusted HPPD to reflect the number of patients awaiting placement in the community.

Findings
Home care nurse generally links with hospital staff once a week to discuss patients who are ready for discharge, unless asked to go mid-week. Delays in initiating discharge planning can result in longer acute length of stays, which is supported by MCAP review and analysis of ALOS vs. ELOS.

2.

Facility is underutilized
Approximately half of the available space in the acute care facility is in use for patient care. 70% occupancy in staffed acute beds. Low surgical and obstetrical volumes.

3.

Consultation findings indicated that a substantial volume of inpatient days are related to "awaiting placement", and are supported by MCAP findings on day of visit.

Unit/Area Description

Actual FTEs 2004-05

Actual FTEs 2005-06 YTD

Actual HPPD 2004-05

Recom'd HPPD

Recom'd FTE (Effic.)/ Re-Invest. 05-06 YTD

Acute Nursing Emergency

17.7 5.0

18.2 5.3

4.3 1.2

4.8 0.9

2.1 (1.3)

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 45
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Slave Lake Healthcare Centre
Opportunities Findings
Anecdotally it is reported that there is limited access to after hours physician clinic appointments in the community which is driving ER volume. Data collection around time seen in the ER/OPD would assist the facility in better understanding the workload issues in the ER in light of any potential staffing investments or alternative delivery models. Substantial number of acute patients waiting for Continuing Care (seen in MCAP ). Continuing Care provides 4 hours of recreation therapy activities to acute care patients waiting placement. Currently operating at 15 of the 25 acute beds open with the addition of 2 SDC beds, 2 L&D rooms and a Palliative care room. This additional bed capacity suggests an opportunity to look at a different service model to utilize additional physical capacity. Consultation findings indicate that staffing was not reduced for unused acute care beds although Region indicates that bed reduction was undertaken given staff shortages and that staffing now aligns to safe staffing levels.

1. Explore alternative service setting for clinic visits seen in the ER.

2. Consider reallocation of acute beds funding to meet longstanding Continuing Care needs in the community. 3. There is a small efficiency opportunity in the OR/SDC, equivalent to 0.9 FTE, which suggests that there is an opportunity to increase volume capacity in the OR with the current staffing complement.

Unit/Area Description

Actual FTEs 2004-05

Actual FTEs 2005-06 YTD

Actual HPPD 2004-05

Recom'd HPPD

Recom'd FTE (Effic.)/ Re-Invest. 200405 (1.8) 1.8 (0.7) (0.2)
2006 Deloitte Inc.

Acute Nursing Emergency Surgical Day Care Operating Room
46

18.0 6.2 1.0 0.2

17.9 6.7 1.0 0.3

5.8 0.8 14.3 14.7

5.2 0.9 4.9 4.1

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

Peer Staffing Comparative Analysis
Other Rural Sites Not Visited
Unit/Area Description Actual FTEs 2004-05 Actual FTEs 2005-06 YTD 10.4 2.6 Actual HPPD 2005-06 YTD 4.5 0.8 Recom'd HPPD Recom'd FTE (Effic.)/ Re-Invest. 2005-06 YTD 4.8 0.9 0.8 0.2

Site

Acute Nursing Boyle Emergency Comments

9.8 2.4

There is a potential staffing investment of 1.0 for the acute care services in Boyle, however as this site was not reviewed, the appropriate utilization of the acute beds is not known. Acute Nursing Emergency 19.3 8.6 20.2 8.9 4.6 0.8 5.0 0.9 1.6 1.7

Lac La Biche

Surgical Day Care

0.8

0.6

12.0

4.9

(0.4)

Operating Room

0.3

0.3

9.3

4.1

(0.2)

Comments

Anecdotally, it is reported that there are between 3-5 patients at any given time awaiting placement. Consider reallocation of acute beds to continuing care beds to resolve bed blocking issue.

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 47
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Other Rural Sites Not Visited
Unit/Area Description Actual FTEs 2004-05 Actual FTEs 2005-06 YTD 7.8 Actual HPPD 2005-06 YTD 9.9 Recom'd HPPD Recom'd FTE (Effic.)/ Re-Invest. 2005-06 YTD

Site

Wabasca Desmarais

Acute Nursing

8.2

5.4

(3.5)

Emergency

3.0

4.2

0.6

0.9

1.8

Remote northern community with unique challenges. Most of the professional staff have spouses who are working for other service sectors such as the RCMP and teachers. The average of stay is approximately 2 years. Comments Facility currently staffed 2 RNs and 1 LPN providing coverage for 16 hours a day during the busier day and evening times. In addition the evening RN shift is used to offset replacement costs. Average daily census is 5 patients. Staff savings not feasible given minimum staffing requirements and inability to find casual relief for this facility.

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 48
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

East 4
- Acute Care

49

AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Bonnyville Healthcare Centre (St. Paul)
Opportunities Findings
High volume ER/OPD, and obstetrics. There is a projected 10% growth in patient and ER/OPD visits. 1. There is a considerable staffing investment opportunity in the acute and ER areas, however this needs to be reviewed in conjunction with primary care physician coverage in the community. This staffing investment should be considered in line with a clinical service role review. ICU/CCU patients from Cold Lake are sent to Bonnyville when Cold Lake has no capacity. It is anticipated that there will be an increase in the number of physicians in the community with admitting privileges. An orthopaedic surgeon is currently shared between Bonnyville and Cold Lake with an approximate annual caseload of 210 and further expansion planned. Facility redevelopment is well underway with master plan development completed, however some concerns remain, related to not allocating appropriate Triage space and functionality in the plan. At times there are acute admissions waiting for Continuing Care placement (supported by MCAP ) and this should be considered in light of any staffing investment in acute care.

2.

Unit/Area Description

Actual FTEs 2004-05 20.4 10.6 1.8 0.6 3.0

Actual FTEs 2005-06 YTD 21.8 10.7 2.4 0.8 3.4

Actual HPPD 2005-06 YTD 4.3 0.6 5.2 6.5 1.1

Recom'd HPPD

Recom'd FTE (Effic.)/ Re-Invest. 2005-06 YTD

Acute Nursing Emergency Surgical Day Care Operating Room Ambulatory Care

5.2 0.9 4.9 4.1 1.2

4.8 5.1 (0.1) (0.3) 0.4

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 50
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Cold Lake Healthcare Centre
Opportunities
1. Staffing in acute care needs to be monitored as activity and volumes increase, given the trend is towards higher worked hours.

Findings
Consultation findings indicate that the repatriation of patients back to Saskatchewan is a challenge and increases LOS. Acuity is high in the acute care units and the number of obstetrical deliveries is increasing. There has been an increase in the number of worked hours for 2005-06 which is likely due to the introduction of the orthopaedic program. The location of ER relative to acute care negates any ability to have staff from acute support the ER. This is an issue especially at night when there is one RN on staff in the ER. There is no clerical support in the ER increasing the non-nursing duties performed by nurses. ER physical capacity has been exceeded by the increase in the number of patients. There is a projected 17% increase in ER/OPD volumes for 2005-06. CFB Cold Lake Physicians do not take call after 1700 hrs, which drives after hour, weekend and holiday workload at hospital.

2.

There is a significant investment in the ER/OPD to address volume and workload. Increase senior management dialogue with CFB Cold Lake to create stronger alignment and integration with CFB physician resources.

3.

Unit/Area Description

Actual FTEs 2004-05

Actual FTEs 2005-06 YTD

Actual HPPD 2004-05

Recom'd HPPD

Recom'd FTE (Effic.)/ Re-Invest. 2005-06 YTD 0.0 7.2 (0.6) (0.6)
2006 Deloitte Inc.

Acute Nursing Emergency Surgical Day Care Operating Room
51

20.1 9.9 1.6 1.0

20.1 11.6 1.6 1.1

5.4 0.7 7.6 8.3

5.4 1.1 4.9 4.1

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

Peer Staffing Comparative Analysis
St. Therese Healthcare Centre (St. Paul)
Opportunities
1. Functional and master plan study required. There is a staffing investment opportunity in acute care equivalent to 1.9 FTE. This might be offset by the number of patients at St. Therese's who require an alternative level of care.

Findings
Functional planning required for inpatient facility given outdated and inappropriate facility design for current inpatient use. Acute care had medically managed detoxification patients that are not accepted in the psychiatric unit. There are always between 2-3 patients awaiting placement in continuing care. The wait list for the LTC unit at St. Paul's is currently at 15. Estimated waiting time for placement is between 6 weeks to 3 months. (Supported by MCAP review).

2.

Unit/Area Description

Actual FTEs 2004-05

Actual FTEs 2005-06 YTD

Actual HPPD 2005-06 YTD

Recom'd HPPD

Recom'd FTE (Effic.)/ Re-Invest. 2005-06 YTD

Acute Nursing Psychiatry Emergency Surgical Day Care Operating Room

25.3 9.1 8.2 1.6 0.3

24.6 9.5 8.1 1.4 0.3

4.6 5.3 0.8 4.9 3.9

5.0 5.1 0.9 4.9 4.1

1.9 (0.4) 1.1 -

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 52
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Other Rural Sites Not Visited
Actual FTEs 2004-05 Actual FTEs 2005-06 YTD Actual HPPD 2005-06 YTD Recom'd FTE (Effic.)/ Re-Invest. 2005-06 YTD

Site

Unit/Area Description

Recom'd HPPD

Acute Nursing Elk Point Emergency

10.7

10.5

6.1

5.3

(1.4)

1.6

1.6

0.5

0.9

1.2

Comments

No staffing opportunity at Elk point. (2.0) See Below (0.1) See below

Acute Nursing Smoky Lake Emergency

9.6

9.8

6.0

5.0

2.3

2.3

1.0

0.9

Comments

Minimum staffing requirements negates staffing opportunity.

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 53
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Cross Region Opportunities

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

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Cross Region Opportunities
Opportunities 1. Conduct a clinical service role review to determine the feasibility of the delivery of services by cluster:
Conduct a Community Needs Assessment; Assess current programming, hours of operation, capacity, critical mass, and patient safety issues at both the area and regional levels; Identify centres of excellence (Hinton and Cold Lake); Conduct master and functional planning exercises based outcomes of clinical service role review.

Findings

Low surgical volumes in certain sites. Proximity of some facilities suggests assessment of critical mass and potential service rationalization/re-alignment. Low occupancy is a challenge in achieving staffing efficiencies. High percentage of acute admissions waiting for continuing care (supported by MCAP ). Some facilities have surplus bed capacity to support additional continuing care requirements. Region's feedback is that it has worked since its inception to balance service rationalization with political factors and access.

2. Conduct regional assessment of CTAS used in the ER Department to determine resources, capital investment, education support, and policies/procedures required to standardize its use as a risk/management tool.

Triage data is not fully appreciated as a risk management tool. The majority of sites do not yet triage patients and where Triage is performed there are issues around coding practice. Triage space inadequate in most facilities. Master planning exercises conducted in some facilities do not appear to support triage function in new facility design.

55

AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

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Cross Region Opportunities
Opportunities 3. Conduct a regional assessment of the ER volumes and the required staffing. 4. A Community Needs Assessment will assist the region in identifying the challenges in accessing primary care within the region and the resulting impact to ER departments. 5. The Region needs to reassess the impact analysis and business case development process to ensure that it is grounded in Community Needs Assessment data and sufficient cost impact data in both acute and community sectors Findings When reviewing staffing opportunities in the ER/OPD departments, it appears that there is a total investment of 42.8 FTEs across the region. Lack of Triage data and the associated workload compounds the ability of the region to fully understand the type of patients being seen and the required resource allocation. Staffing workload between ER and acute care units is often blurred and therefore may influence the findings of the comparative staffing analysis.

Orthopaedic cost impact analysis reported to have had significant impact on resources (beds, staff). Impact analysis did not deal with the service complexity involved. Increased staffing to respond to Orthopaedic program development, primarily in acute setting.

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Cross Region Opportunities
Opportunities Findings Accessing mental health services is problematic for all facilities in the region. Different service models for mental health services exist within the region: West patients go to Ponoka, despite the existence of a regional facility located in St. Paul. The decision-making process around citing Mental Health beds at St. Therese was incomplete and did not factor in challenges around human resources, geography and physical plant capabilities. The expansion to increase to a 20 bed unit is underway. Rationale for bedded expansion vs. other service models is unclear. The Region relies on inpatient capacity as its primary service response given lack of other resources. Psychiatry is serviced by 1 Psychiatrist with plans for future recruitment of an additional resource. No concrete plans are in place to secure additional qualified staff for the new unit. None of the inpatients reviewed through MCAP were qualified for acute admission and could have benefited from outpatient services. Access to community-based mental health programs appears to be limited and stronger linkage to outpatient support post discharge appears required. Region reports recent addition of funding to address need to increase outpatient service (Crisis Intervention Team).

6. Reassess value of psychiatry inpatient bed expansion vs. other service models across the region. 7. Conduct service model and caseload review for Mental Health Therapists to explore stronger linkages and support to the inpatient service.







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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

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Cross Region Opportunities
Opportunities Findings Region indicates that HR strategy is a corporate priority, however staffing resources to enable occurrence appear limited. 8. Increase support to enable Human Resources strategy and programming to fulfill its status as a corporate priority. (See HR section later in Report.) High complement of senior staff. Limited succession planning demonstrated in region. Limited coordinated recruitment strategies for key clinical roles. Difficulty recruiting staff to select areas given housing challenges, especially in Hinton and Edson, which requires a heightened regional response. High casualization of the workforce in the acute sites (full time complement is low: 6 acute sites are less than 20%, 6 acute sites are between 21 and 30%, and 10 acute sites are between 31% and 40%). Span of control varies across the region. 9. Explore concept of establishing rural academic centres in Aspen (Cold Lake for East and Hinton for West) with increased relationship with rural training streams (physicians) and nursing schools in the North. Hinton reports stronger physician relationships and resourcing through its strong academic relationships. Active teaching program with rural family medicine programs, which provides three residents most of the time and provides a steady stream of both permanent staff and locums. Serves as a good model for regional expansion. Region reports that its data indicates that Aspen is largest participant in rural training program and that it has well established relationship with nursing program.

Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 58
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Cross Region Opportunities
Opportunities Findings Somewhat premature placement in continuing care given lack of alternative levels of care such as assisted living care environments. 10. Explore alternative service models to support patient flow and access to care. Anecdotal reporting of increased hours of home care provided in lodge settings to maintain residents in place. No transitional care beds available within region. Limited use of adult day program for medical or mental health needs. Increased use of telehealth for clinical applications is on the rise but slow . 11. Need for stronger discharge planning focus and support in acute care across the region Exceedingly limited Social Work resources to support discharge planning. Discharge planning function is primarily performed by nursing staff. Varied interface with community home care staff and the hospitals. Current plan and reported approval to augment Social Work complement in region by 2.5 FTE. Clear role responsibility will be required. Reported mismatch between some community offices in terms of caseload and FTE. Assess homecare practice variation as driver of caseload.

12. Homecare Caseload Review

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

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Continuing Care

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

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Continuing Care Activity Analysis
ARHA Weighted Cases by Classification
Classification Spring 2005 Continuing Care Weighted Cases 278 2,679 3,163 9,084 12,092 39,420 9,613 76,329 Spring 2005 Proportion of Total Cases 0% 4% 4% 12% 16% 51% 13% 100% Proportion Variance Fall 2002 to Spring 2005 200% 17% -17% 2% 9% -7% 7% -2%
F 51%
Source: Alberta Health & Wellness LTC Database

Proportion of Weighted Cases by Classification
G 13% A 0% B 4% C 4% D 12%

A B C D E F G ARHA Total

E 16%

80% of ARHA's continuing care weighted cases are distributed across classifications E, F and G as of Spring 2005.
Overall, proportion of weighted cases across all classification have remained relatively constant. The proportion of F weighted cases have decreased the greatest from 55%in Fall 2002 to 52% in Spring 2005. The decrease in weighted cases in C and F have been the primary drivers of an overall decrease in weighted cases of 2%.
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Peer Staffing Comparative Analysis
Aspen Summary All Continuing Care Facilities Opportunities


Findings
Actual Hour Per Resident Day (HPRD) does not reflect the level of rehabilitation support provided by Physiotherapy, Occupational Therapy or Recreational Therapy. Reported data for residential rehabilitation indicates varied levels of discipline support:
West 1: OT is 10% and PT is 18% West 2: OT is 78% and PT is 45% East 3: OT is 25% and PT is 24% East 4: OT is 38% and PT is 29%

1. Identify the total HPRD for all care roles involved in continuing care (PT, OT, Recreation, Social Work) to determine true gap before any potential staffing adjustments are made.



Where roles like Rehab Assistants (PT or OT) and Recreation Aides have a blended function with Health Care Aides/Nursing Aides, this combination is not factored in the actual HPRD value and should be considered as part of 3.4 HPRD target pursuit. Potential staffing adjustments must consider the model of care and roles of all disciplines.



Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 62 AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Aspen Summary All Continuing Care Facilities Opportunities
2. Examine staffing allocations across continuing care facilities with respect to recent AHW target of 3.4 HPRD, and in the context of continuing care HR plan.

Findings
In West 1, Edson and Seton facilities demonstrate relatively consistent levels of staffing. In West 2, Westlock has higher HPRD than Keir CCC or Mayerthorpe In East 3, Slave Lake has higher HPRD than Athabasca and Lac La Biche In East 4, all facilities are relatively close, with Radway having the highest HPRD of all sites. In terms of resident classification in Levels E, F and G:
West 1 has 78% of residents across Levels E, F and G West 2 has 80% of residents across Levels E, F and G East 3 has 89% of residents across Levels E, F and G East 4 has 80% of residents across Levels E, F and G



This resident classification system suggests the target of 3.4 HPRD of combined nursing and personal care staffing is appropriate. Continuing care has had difficulty in attracting and retaining aide staff, as salaries are no longer competitive relative to other market opportunities for staff.

3. Develop a targeted HR plan for continuing care, as part of the broader regional HR strategy



Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 63 AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

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Peer Staffing Comparative Analysis
Aspen Summary All Continuing Care Facilities
Actual FTEs 2005-06 29.0 10.1 71.5 19.4 68.1 14.9 15.6 29.1 18.1 19.8 20.3 34.4 17.9 19.2 Actual Total Paid HPRD 2005-06 3.4 3.6 3.4 3.5 3.6 3.5 4.4 3.8 3.3 3.4 3.7 3.4 5.0 3.5 AHW Recom'd 3.4 HPRD @ 100 CMI 3.1 2.3 3.0 3.3 3.5 2.9 3.2 3.2 3.7 3.1 3.0 3.3 3.5 3.0 Recom'd FTE Effic.)/ ReInvest. 2005-06 (2.7) (3.5) (8.2) (1.4) (1.1) (2.5) (4.1) (4.2) 2.3 (1.7) (3.5) (1.1) (5.3) (3.0)

Area

Site

West 1

Edson Healthcare Centre Seton Hospital - Jasper Dr. Keir Continuing Care Centre

West 2

Mayerthorpe Healthcare Centre Westlock Long Term Care Centre Athabasca Healthcare Centre

East 3

Slave Lake Healthcare Centre Lac La Biche Healthcare Centre Bonnyville Healthcare Centre Cold Lake Healthcare Centre Elk Point Healthcare Centre

East 4

George McDougall Smoky Lake Healthcare Centre Radway Continuing Care Centre St. Therese Healthcare Centre

*Note: Full Year 2005-06 data was provided by the region for FTEs and HPRD calculations. The AHW Recom'd 3.4 HPRD @ 100 CMI is calculated using the Spring 2005 CMI for each facility. Source: ARHA 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database 64
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Community Health Services

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Mental Health

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West 1
- Mental Health

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Mental Health Outpatient Activity
West 1
West 1 Enrolments decreased by 2% between 2002-03 and 2004-05, while Events decreased by 3% for the same period, driven by a decline in volumes for Edson Mental Health Clinic. This decrease is offset by significant increases for Whitecourt and Hinton Mental Health Clinics of roughly 20%.

Enrolments Clinics 2002-03 Edson Mental Health Clinic Hinton Mental Health Clinic Jasper Mental Health Clinic Whitecourt MH Clinic Grand Total 590 420 54 435 1,499 2004-05 493 423 65 486 1,467 3-Year Variance -16% 1% 20% 12% -2% 2002-03 4,337 2,884 684 2,662 10,567

Events 2004-05 3,121 3,491 483 3,187 10,282 3-Year Variance -28% 21% -29% 20% -3%

Source: ARMHIS Database 2002-03 to 2004-05 68
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Mental Health Outpatient Activity
West 1 Events by Type
Type of Event Type of Activity Assessment Face-to-Face Consultation Therapeutic Intervention Face-to-Face Total Telephone Videoconference Not Specified Grand Total 2002-03 1,406 544 6,528 8,478 740 1,349 10,567 2003-04 1,257 391 6,117 7,765 351 15 1,244 9,375 2004-05 1,328 584 6,845 8,757 309 26 1,190 10,282 3-Year Variance -6% 7% 5% 3% -58% n/a -12% -3%

As demonstrated above, outpatient mental health activity in West 1 has been decreasing over the past three years by 3% - driven primarily by reductions in telephone-based events. The apparent absence of group interventions as a common service response strategy is noted. It is unknown if this is a coding issue. The observed 12% decline in Events that are "Not Specified" indicates that the accuracy for event coding in this sub-region has increased.
Source: ARMHIS Database 2002-03 to 2004-05 69
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Mental Health Outpatient Activity
West 1 - Top 10 Referral Sources
Top 10 referral sources for ARHA mental health enrolments represent almost 98% of total. Self-Referral, at 35% in 2004-05 is the most common referral source.
West 1 - Top 10 Enrolment Referral Sources
Child and Family Services Other Agency 1% 3% RHA Hospital 5% RHA Community and Outpatient Services 5% Educational Facility 10%

Legal System 1%

Self 35%

Significant Other 17% Physician / Psychiatrist 23%
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Source: ARMHIS Database 2002-03 to 2004-05 70

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West 2
- Mental Health

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Mental Health Outpatient Activity
West 2
West 2 Enrolments increased by 16% between 2002-03 and 2004-05, while Events decreased by 13% for the same period. Increases in Enrolment volumes have been driven by the top 3 clinics while declines in Event volumes have been driven by Westlock, Barrhead and Onoway respectively; Swan Hills Mental Health Clinic has shown the greatest decline in Events on a 3-year % variance basis. Given the substantive decline, the issue of data capture and consistency is raised.

Enrolments Clinics Barrhead Mental Health Clinic Mayerthorpe Mental Health Clinic Onoway Mental Health Swan Hills Mental Health Clinic Westlock Mental Health Clinic Grand Total

Events

3-Year 3-Year 2002-03 2004-05 2002-03 2004-05 Variance Variance 379 202 216 46 320 1,163 430 259 225 55 383 1,352 13% 28% 4% 20% 20% 16% 3,496 1,380 1,538 464 2,847 9,725 3,278 1,195 1,325 296 2,390 8,484 -6% -13% -14% -36% -16% -13%

Source: ARMHIS Database 2002-03 to 2004-05 72
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Mental Health Outpatient Activity
West 2 Events by Type
Type of Event Type of Activity Assessment Face-to-Face Consultation Group Work Therapeutic Intervention Face-to-Face Total Telephone Videoconference Not Specified Grand Total 2002-03 1,167 1,164 14 5,373 7,718 1,007 1,000 9,725 5,989 7,999 610 1 534 9,144 5,538 7,634 456 3 391 8,484 2003-04 818 1,192 2004-05 901 1,195 3-Year Variance -23% 3% n/a 3% -1% -55% n/a -61% -13%

As demonstrated above, outpatient mental health activity in West 2 has decreased over three years by 13% - driven primarily by reductions in telephone-based events. The absence of group intervention volumes also requires further investigation to determine if this service doesn't exist, or if there is a reporting anomaly. A significant decline in Events that are "Not Specified" indicates that the accuracy for event coding in this sub-region has increased, notwithstanding the query related to group work.
Source: ARMHIS Database 2002-03 to 2004-05 73
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Mental Health Outpatient Activity
West 2 - Top 10 Referral Sources
Top 10 referral sources for ARHA mental health enrolments represent almost 98% of total. Physician/Psychiatrist is the highest referral source, followed by self-referral at 31% in 2004-05.
West 2 - Top 10 Enrolment Referral Sources
Educational Child and Facility Other Agency Family Services Other 2% 2% 2% Government RHA 1% Community and Outpatient Services 4% RHA Hospital 5% Self 31%

Significant Other 19%

Source: ARMHIS Database 2002-03 to 2004-05 74
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Physician / Psychiatrist 34%
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East 3
- Mental Health

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Mental Health Outpatient Activity
East 3
East 3 Enrolments increased by 4% between 2002-03 and 2004-05, while Events increased by 1% for the same period. Increased Enrolments and event volumes have been driven by Lac La Biche mental health clinic.

Enrolments Clinics 2002-03 2004-05 Athabasca Mental Health Clinic Lac La Biche Mental Health Clinic Slave Lake Mental Health Clinic Grand Total 372 376 87 835 360 404 107 871

Events

3-Year 3-Year 2002-03 2004-05 Variance Variance -3% 7% 23% 4% 3,480 3,724 722 7,926 2,909 4,548 509 7,966 -16% 22% -30% 1%

Source: ARMHIS Database 2002-03 to 2004-05 76
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Mental Health Outpatient Activity
East 3 Events by Type
Type of Event Type of Activity Assessment Face-to-Face Consultation Group Work Therapeutic Intervention Face-to-Face Total Telephone Videoconference Not Specified Grand Total 2002-03 680 327 25 3,431 4,463 657 2,806 7,926 3,330 4,313 663 9 2,079 7,064 2003-04 689 294 2004-05 743 344 5 3,780 4,872 657 10 2,427 7,966 3-Year Variance 9% 5% -80% 10% 9% 0% n/a -14% 1%

As demonstrated above, outpatient mental health activity in East 3 increased slightly over the past three years by 1%, driven primarily by an increase in therapeutic intervention-based events. The absence of group intervention volumes also requires further investigation to determine if this service doesn't exist, or if there is a reporting anomaly. The observed 14% decline in Events that are "Not Specified" indicates that the accuracy for event coding in this sub-region has increased.
Source: ARMHIS Database 2002-03 to 2004-05 77
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Mental Health Outpatient Activity
East 3 - Top 10 Referral Sources

Top 10 referral sources for ARHA mental health enrolments represent almost 98% of total. Self-Referral, at 28% in 2004-05 is the most common referral source.

East 3 - Top 10 Enrolment Referral Sources
Legal System 3% RHA Community and Outpatient Services 6% Educational Facility 8% Child and Family Services Other Agency 2% 2%

Self 28%

RHA Hospital 12% Significant Other 17%
Source: ARMHIS Database 2002-03 to 2004-05 78
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Physician / Psychiatrist 22%

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East 4
- Mental Health

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Mental Health Outpatient Activity
East 4
East 4 Enrolments increased by 16% between 2002-03 and 2004-05, while Event volumes were flat for the same period Enrolment and Event volumes were driven primarily by increased volumes for St. Paul Mental Health Clinic. Bonnyville and Cold Lake Event volumes have declined for the same period

Enrolments

Events

Clinics 2002-03 2004-05 Bonnyville Mental Health Clinic Cold Lake MH Clinic St. Paul Mental Health Clinic Grand Total 584 484 572 1,640 631 551 715 1,897

3-Year 3-Year 2002-03 2004-05 Variance Variance 8% 14% 25% 16% 8,872 5,336 3,743 17,951 7,970 5,208 4,722 17,900 -10% -2% 26% 0%

Source: ARMHIS Database 2002-03 to 2004-05 80
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Mental Health Outpatient Activity
Events by Type East 4
Type of Event Type of Activity Assessment Consultation Face-to-Face Group Work Therapeutic Intervention Face-to-Face Total Telephone Not Specified Grand Total 119 4,712 7,992 1,476 8,483 17,951 112 5,589 8,473 1,103 10,712 20,288 2 5,112 7,894 1,011 8,995 17,900 -98% 8% -1% -32% 6% 0% 2002-03 1,333 1,828 2003-04 1,235 1,537 2004-05 1,139 1,641 3-Year Variance -15% -10%

East 4 outpatient mental health activity has been flat over the past three years. The absence of group intervention volumes also requires further investigation to determine if this service doesn't exist, or if there is a reporting anomaly. The observed 6% increase in Events that are "Not Specified" implies an opportunity to examine the accuracy of event coding. There is a notable jump in activity during 2003-04, also driven by Events that are "Not Specified.
Source: ARMHIS Database 2002-03 to 2004-05 81
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Mental Health Outpatient Activity
East 4 - Top 10 Referral Sources
Top 10 referral sources for ARHA mental health enrolments represent almost 98% of total. Self-Referral, at 32% in 2004-05 is the most common referral source.

East 4 - Top 10 Enrolment Referral Sources RHA Community Other and Outpatient Government Child and Services 1% Family Services 2% 1%
Other Agency 5% RHA Hospital 8% Educational Facility 10% Self 32%

Physician / Psychiatrist 20%

Significant Other 21%

Source: ARMHIS Database 2002-03 to 2004-05 82
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Mental Health Staff Trending and Opportunities
Area Description Region-wide West 1 West 2 East 3 East 4
Source: ARHA Payroll Data

Actual FTEs 2003-04 79.6 21.8 15.1 18.7 24.0

Actual FTEs 2004-05 79.3 22.3 17.0 18.5 21.6

Actual FTEs 2004-05 projected 78.3 20.8 17.4 18.3 21.8

% Change -1.7% -4.3% 15.2% -2.6% -9.2%

Opportunities
1. Conduct a comprehensive review of regional mental health services to determine the most appropriate alignment of resources across the continuum to meet client needs. Develop a targeted mental health resource strategy to address current and anticipated capacity, staffing, physician and education requirements for expanded service at St. Therese's.

Findings

Region reports that Mental Health plan does identify continuum of care considerations. The inpatient psychiatry, located at St. Therese Hospital in St. Paul, is currently under renovation to expand beds. Our MCAP assessment of this unit indicated that none of the admitted patients (7) were qualified for inpatient admission. Discussion with the Psychiatrist and staff indicates no outpatient service is available and that there are limited mental health community services. The inpatient unit then becomes the "default" provider. Given the far east location of psychiatric beds, West 1 and 2 will likely continue to access services in Edmonton or Ponoka before traveling further east to St. Paul. Mental Health does appear to one of the most common clinical user groups for Telehealth. The Mental Health Program is threatened by a lack of staff to serve the expanded capacity.
Psychiatrists, as there is currently only 1 psychiatrist at St. Therese, however there is a indication that an additional psychiatrist may be on staff within a year. The same concern exists for nursing.

2.

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Home Care

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Home Care Services Findings and Opportunities
Area Description Region-wide West 1 West 2 East 3 East 4
Source: Payroll Data ARHA

Actual FTEs 2003-04 198.6 41.0 46.9 33.4 77.3

Actual FTEs 2004-05 211.9 41.3 53.9 35.2 81.4

Actual HPPD 2005-06 % Change 218.9 41.8 58.0 36.6 82.4 10% 2% 24% 10% 7%

Opportunities
1. Develop and implement workload measurement, and caseload tracking and reporting for home care to enable management decision making.

Findings
Consultation findings suggests that there is limited monitoring of activity or volume of Home Care services which is supported by a lack of available data from the region. This lack of information is resulting in management challenges with respect to resource management, planning and program development. Reports of mismatch between caseload/FTE assignments. Caseload auditing may suggest practice differences across the region.

2.

Develop a targeted recruitment Similar to continuing care, home care is faced with a significant challenge in attracting and and retention plan for PCAs, that retaining PCAs due to market competition and low salaries. Although this finding was is integrated into the broader noted in our interviews, Human Resource reports that postings have not yet shown this regional HR strategy. concern. Develop standardized discharge and process across region. Expand alternative service model like Adult Day Programs and other transitional supports. Assess the required investments to enable success, such as transportation. Home care role in discharge planning and placement coordination is reported to vary throughout the region, which can have a negative impact on resource management and care delivery. Adult Day Programs, where they are implemented, have been reported to be a very successful strategy to support elderly in home. There has been limited uptake in this alternative service model across region. Available and accessible transportation is a necessary enabler for client attendance. Given the cross-jurisdictional nature of transportation, RHA should continue its advocacy role related to transportation.
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3.

4.

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Population Health

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Population Health Staff Trending and Opportunities
Area Description Region-wide West 1 West 2 East 3 East 4
Source: Payroll Data ARHA

Actual FTEs 2003-04 89.8 24.3 16.5 28.7 20.4

Actual FTEs 2004-05 85.7 21.3 15.7 28.1 20.7

Actual FTEs 2004-05 projected 84.3 20.1 16.6 27.7 19.9

% Change -6% -17% 1% -3% -2%

Opportunities
1. Explore options for increased use of telehealth in service delivery, with impact assessment of the relative costs/benefits to align resources to this service delivery model.

Findings
Population Health programming is divided between core services, programs in specified communities, targeted programs for high risk/need. All regions have population elements that are hard to reach and hard to serve. Project based funding creates challenges for service sustainability. Population Health leadership is largely focused at Regional Coordinator role. Other roles that have a leadership part to play have many other areas of focus (VP's with very large responsibility and similar scenario for CHS Managers and Supervisors). Some concern about matrix model limiting program development and innovation at community office level. Analysis indicates that there are over 80 FTEs dedicated to population health, but in the absence of workload/activity data or a community health needs assessment, the appropriateness of this level of resourcing is difficult to determine.
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2.

Assess service standardization across Region, in alignment with a regional community health needs assessment.

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Environmental Health

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Environmental Health Staff Trending
Area Description Region-wide
Source: Payroll Data ARHA

Actual FTEs 2003-04 13.3

Actual FTEs 2004-05 13.1

Actual HPPD 2005-06 14.2

% Change 7%

Opportunities

Findings
Service not integrated within broader Community Health Services given the high regulatory requirements. Transient work force and camps across region increase workload for PHI staff. Manual reporting lack of information system to support reporting and trending.

1.

Assess staffing need in Environmental Health to ensure appropriate staffing levels.

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Physician Findings and Opportunities

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Physician Findings and Opportunities
Introduction The review process incorporated several direct consultations with physicians, which have yielded a number of findings and opportunities. Physician-related findings and opportunities have been clustered into the following five key areas, which also have linkage to opportunities identified across other areas of the region:

Physician Governance and Leadership Physician Human Resources Planning and Management

Quality, Risk and Performance Management

Physician Findings and Opportunities

Program Review and Organization

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Physician Findings and Opportunities
Governance and Leadership
Findings
Consultation findings suggest there are gaps in physician accountability related to adherence with bylaws and medical policies/procedures. These gaps contribute to challenges in overall physician governance and leadership in the region. In consultation, Chiefs did not consistently identify their role definition and accountability framework, however, the Region reports that chief roles have been defined are reported in MAC minutes and are reflected in medical staff bylaws. Variation in leadership roles and definitions suggests a need for greater alignment between current physician leadership structures/supports and requirements of the region. Consultation identified a sense of apathy among the physician group. The Region acknowledges that physician shortages play a role in securing physician engagement.

Opportunities
1. 2. 3. Conduct an externally led review of MAC governance structure/mechanisms with specific attention to by-law adherence/alignment. Identify physician leadership requirements and conduct an alignment exercise to determine gaps. Create a medical leadership accountability framework which includes examining current organizational and reporting structures, and current/potential roles and responsibilities for Chiefs in the management and decision making process at a program, site, and regional level.

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Physician Findings and Opportunities
Physician Human Resources
Findings
The region is facing several physician recruitment/retention issues and current staffing shortages. A broader physician HR strategy is lacking. Areas of focus should be alignment of physician skill mix with care and service delivery priorities for the region, and exploration of alternative remuneration strategies to attract and retain physicians. Limited education structure to facilitate advanced physician training and maintenance of certification. Physician recruitment and service expansion is reported to occur without full consideration of physician impact on other clinical services (i.e. nursing, allied health, community health), space availability, bed capacity, equipment requirements, IT/IS requirements, etc. Strong IMG population. Region is addressing this issue, however, consultation suggests continued efforts are required to continue to address and support cross-cultural considerations.

Opportunities
1. Continue to develop a regional Physician Human Resource Strategy that links to the HR and regional strategy, and is focused on Physician resource gaps, skills management and education, alignment/realignment of current resources to core service delivery needs, recruitment/retention. 2. Continue to explore alternative payment models for physicians in the region, with an objective to improve resourcing, and linkage to care/service delivery model. As part of this opportunity, explore alternate staffing models in the consideration of physician AFP options e.g. APN/NP model in ER and community health clinics. 3. Continue to develop a regional, comprehensive Physician Impact Assessment process for physician recruitment needs planning, and in assessment when new physicians are being considered and when services are being expanded or developed. This assessment needs to be linked to the region's strategic directions for its clinical programs, and needs to consider broad programming impacts (human resources, infrastructure, funding, etc.) Physician Impact Assessments should be considered in the context of a regional needs assessment.
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Physician Findings and Opportunities
Quality, Risk, and Performance Management
Findings
Substantial efforts made over the last few years in this area. Region reports gains made in patient safety, incident reporting, QI teams. Lacking an assessment framework for MD quality, performance, or competencies; which is compounded by a lack of required funding or resources available to maintain education and certification. Recognize preliminary efforts underway by the region on standardized protocols or care paths, and the goal to continue these efforts. Consultation findings suggest limited physician support of established standardized protocols or paths, and a need for greater physician accountability for developing and maintaining consistent standards of practice across region. Also, no standardized utilization tools. There is need for a physician risk management framework to assess and proactively manage physicianrelated issues and risks at the service, site, community and regional levels. Significant apathy is apparent among the physician group, reducing their engagement, support and buyin to quality and risk management issues.

Opportunities
1. Create an accountability framework with evaluation and quality/risk/performance management tools for Physicians, which is integrated into the broader regional framework.
Continued and significant education is required at all levels of the organization to promote a quality culture. While the region has undertaken substantial effort in this regard, it must continue its emphasis in this regard.

2.

Develop a regional approach and support for CME, based on a sustainable business model, and integrated with the physician recruitment and retention strategy and broader regional education function.
Given proximity to academic centre, CME credits should be mandatory to maintain privilege.

3.
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Develop a clinical adoption strategy for standardized, peer reviewed protocols and care maps for key conditions (e.g. pneumonia, cellulitis, congestive heart failure, and MI management).
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Physician Findings and Opportunities
Clinical Program Frameworks and Review
Findings
Varied adoption of leading practices within Maternal/Child, Orthopedics, and General Surgery services. CTAS implementation inconsistent across the region (which has quality of care and efficiency issues as well). Requirement to examine laboratory services regionally focusing on testing menu, resource duplication, supporting IT/IS, quality and performance management, and procurement. Observed inconsistencies were also noted with respect to the pharmaceutical formulary, and inventory control across the region. Need for increased attention and review of critical mass for select clinical areas supports need for Clinical Service Role review, particularly in communities of relatively close proximity.

Opportunities
Alignment diagnostic along leading practices for Maternal/Child, Orthopedics, and General Surgery services - requirement for alignment with centres of excellence models. 2. CTAS strategy requirement that considers space configuration, human resources, and training/education needed to ensure region-wide adoption.
Triage needs to be fully implemented and supported with properly trained resources. Rural modifiers may need to be considered especially in centres with volumes of less than 15,000 ER visits (not to include booked patients). Space should be configured to accommodate Triage in a standardized and functional manner.

1.

3. 4.

Regional laboratory review: standardized menu, consolidation of resources, LIS, group purchasing, quality monitoring, repatriation Regional pharmacy review to examine opportunities for formulary standardization, stricter inventory management and control, and PIXIS
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Clinical Support and Allied Health

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Peer Staffing Comparative Analysis
Process Overview
To understand the relative efficiency of the Clinical Support and Allied Health services, we conducted a comparative analysis with a number of comparable health regions from Alberta, British Columbia, Manitoba, and Saskatchewan Fiscal 2004-05 data for ARHA was used for peer comparison, as this represents a full year of staffing, but reference to observed 2005-06 YTD staffing levels are also provided The efficiency analysis assessed peer staffing based on a comparison of actual total paid hours per adjusted patient day (HAPD) for each "discipline" within the organization (based on MIS functional centre alignment).
Although many of the allied health disciplines in the region are aligned to clinical programs, an MISbased alignment for comparison was used to ensure an `apples-to-apples' comparison to peers.

The adjustment factor increases the base of inpatient clinical activity to better reflect the span of inpatient, outpatient, continuing care and community clinical activity. The results across the comparator group were considered with the following "rules" applied at the departmental level:
Values among the comparator group that were well outside the range (e.g. outliers) were eliminated from the analysis. For Clinical Support and Allied Health Services, the FTE efficiency opportunity was identified compared to the 50th percentile to reflect a more realistic level of clinical resourcing to support patient care needs.

Staffing opportunities are identified based on comparative analysis and the team's understanding of minimum staffing requirements. Staffing opportunities are not stand alone, however, and need to be considered in the context of other opportunities identified for each area. The benchmarking information should be used as input to management decision-making, rather than as a decision in and of itself.
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Peer Staffing Comparative Analysis
Clinical Support Services Areas Reviewed

MIS Code 71410 71415 71435 71440 71445 71450 71455 71460 71470 71485 Clinical Laboratory Diagnostic Imaging Respiratory Therapy Pharmacy Clinical Nutrition Physiotherapy Occupational Therapy

MIS Description

Audiology And Speech/Language Pathology Social Work Recreation

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 98
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Peer Staffing Comparative Analysis
Clinical Laboratory
Opportunities Findings
Legacy lab operations still in place; limited evidence of regional programming in place; levels of staffing varied across region. Single lab site not appropriate. More could be done in cluster model. 1. Review and assess benefit in adopting a regional laboratory management model that organizes lab service by cluster. Comparative analysis shows that Aspen has considerably more staffing than peers; hence the potential benefit in exploring different regional model. Labs indicated staffing challenges in terms of vacancies, attraction and recruitment 2. 3.


Develop standardized regional menu Conduct a Targeted Lab Review in Region to support stronger centralization of lab function.
Focus of review should include: required service levels, staffing (including CLXT impact and requirements), hours of operation and enabler requirements related to Information Technology and equipment.

Lab menu varied by site continued evidence of legacy operations.

Regional gains and efficiencies not yet achieved in lab operations. Many Labs across region have inadequate space. Equipment issues.

4.

Develop staffing plan based on regional model to address potential staff savings (identified as up to 18 FTE's at the midpoint comparison level).

Staffing comparison suggests current lab operating model is not efficient. Given the region's size, there are limitations to efficiency. Service organization and delivery by cluster may yield efficiencies. FTE savings is not achievable in the current operating model.

Area Description

Actual FTEs 2004-05

Actual FTEs 2005-06 YTD
125.7

Actual HAPD 2004-05

Alberta Peer HAPD MIN
0.03

Alberta Peer HAPD MAX
0.82

National Peer 50th Percentile HAPD
0.37

Potential FTE (Effic.)/ Re-Invest.
See above (18.0)
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Clinical Laboratory

118

0.44

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 99 AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

Peer Staffing Comparative Analysis
Diagnostic Imaging
Opportunities Findings
Legacy DI operations are still in place. Department indicated staffing challenges in terms of vacancies, attraction and recruitment. For example, Ultrasound Clinical Lead role is largely functioning in a staff capacity. 1. Review and assess benefit in adopting a regional Diagnostic Imaging management model that plans, organizes and provides DI service by cluster. Equipment and facility (space) issues across region. Region is too broad for single role (Area 3 Director) providing regional leadership in addition to her Area 3 role related to facilities and community health services. Same concern applies to the practice support roles across the region. Reported extended hours of operation will put DI over benchmark performance in terms of staffing efficiency. 2. Assess future operating savings related to film and staffing with fuller adoption of PACS across Region. Limited PACS installation does not enable operating efficiencies related to supply cost (film) and staffing.

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest.

Diagnostic Imaging

70.7

79.5

0.26

0.09

0.35

0.26

-

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 100
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2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Respiratory Therapy
Opportunities Findings
Respiratory Therapy is primarily community-based service, which is appropriate for types of facilities and service across Region. Staffing by Area (1 through 4) is varied suggesting some legacy operations holdover. Aspen's comparison against peer set produces high staff investment result of 10.8. This result is largely driven by critical care presence in other regions. Hence, there is no investment opportunity in Respiratory Therapy at this time. Where internal medicine increases presence and a site assumes key / lead role, Aspen should consider investment at that time.

1.

Ensure consistent range of services supported by Respiratory Therapy available across Region.

2.

No FTE investment opportunity at this time.

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest.
See above 10.8

Respiratory Therapy

5.8

6.8

0.02

0.01

0.12

0.06

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 101
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2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Pharmacy
Opportunities Findings
Legacy Pharmacy operations still in place; limited evidence of regional programming in place; levels of staffing varied across region. Single pharmacy location not appropriate, however more could be done in cluster model. This may mean limited function at select sites and enhanced function at others and potential for regional management role. Department indicated staffing challenges in terms of vacancies, attraction and recruitment. Equipment and facility (space) issues across region. Some sites in very small cramped locations. IS / IT investment for stronger regional model is significant. Region is too broad for single role (Area 3 Director) providing regional leadership in addition to her Area 3 role related to facilities and community health services. Same concern applies to the practice support roles across the region. Staffing comparison suggests some staff savings may be possible, however efficiencies not possible until service model realigned. Highly variant practice across region. Staffing comparison suggests current operating model is very close to mid point level of staffing performance (small opportunity of 2 FTE savings). Given size of region, there are limitations to efficiency, however service organization and delivery by cluster should yield efficiencies. FTE savings not achievable in current operating model.

1.

Review and assess benefit in adopting a regional pharmacy management model that organizes pharmacy service by cluster:
Develop standardized formulary Develop standardized procedures for inventory control

2.

Develop staffing plan based on regional service model.

Area Description

Actual FTEs 2004-05

Actual FTEs 2005-06 YTD
29.5

Actual HAPD 2004-05
0.12

Alberta Peer HAPD MIN
0.07

Alberta Peer HAPD MAX
0.20

National Peer 50th Percentile HAPD
0.12

Potential FTE (Effic.)/ Re-Invest.
See above (2.0)
2006 Deloitte Inc.

Pharmacy

28.9

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 102 AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

Peer Staffing Comparative Analysis
Clinical Nutrition
Opportunities
1. Review and assess benefit in adopting a regional Clinical Nutrition management model that organizes service by cluster:
Region should assess the greatest area of need for staffing investment based on the varied staffing levels within Region.

Findings
Clinical Nutrition is primarily community-based service, which is appropriate for types of facilities and service across Region. Services are provided for continuing care and acute care facilities, as required. Staffing is somewhat varied by Area (1 through 4) suggesting some legacy operations holdover.

Staffing comparison against peer midpoint suggests required staffing investment of approximately 3 FTE. 2. Develop staffing plan based on regional service model. Additional staffing should be assessed in light of regional model and value in resources to support community and Chronic Disease Management programming. FTE investment should be considered to support future service delivery.

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest.
See above 3.1

Clinical Nutrition

9.4

9.5

0.03

0.01

0.06

0.05

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 103
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Peer Staffing Comparative Analysis
Physiotherapy
Opportunities
1. Conduct a Targeted Rehab Review in Region to determine if current level of investment is desirable and contributes to the desired patient flow and continuum of care needs.
Focus of review should include: required service levels (current and future), model of care, staffing (including mix and potential re-allocation if appropriate), hours of operation, and professional practice. Assess staffing requirements in light of further review

Findings
Physiotherapy function and discipline is housed in Community Health Services. Staff are deployed to the continuum (acute care, continuing care, and community care). Reported data suggests that Physiotherapy provides approximately 33% of its work effort to residential care, 50% for community and outpatient and 17% for inpatient. Physiotherapy operates with a staff split of approximately 55% professional staff and 45% assistant staff. Mixed reaction among care facilities at the management model which does not have on-site staff reporting to Facility Managers. Staffing appears highest in West 2, followed by East 4 suggesting the impact of ortho and possible legacy staffing. However, crude comparison of FTE to visits suggest that West 1 and 2 are working at lower levels of throughput than the East 3 and 4. Staffing comparison suggests current operating model is well above midpoint level of staffing performance (high opportunity of 20 FTE savings). Data shows that there are 0 FTE within staffing numbers related to SHIP. Targeted review of Rehab is required before staffing adjustments made particularly in light of reported challenges to serve orthopaedic and emerging initiatives such as Regional Stroke.



Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HAPD 2004-05

Alberta Peer HAPD MIN 0.09

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest.

Physiotherapy

63.6

59.0

0.24

0.30

0.16

See above (20.6)
2006 Deloitte Inc.

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 104 AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

Peer Staffing Comparative Analysis
Occupational Therapy
Opportunities
1. Conduct a Targeted Rehab Review in Region to support if current level of investment is desirable and contributes to the desired patient flow and continuum of care needs.
Focus of review should include: required service levels (current and future), model of care, staffing (including mix and potential re-allocation if appropriate), hours of operation, and professional practice. Assess staffing requirements in light of further review

Findings
Occupational Therapy function and discipline is housed in Community Health Services. Staff are deployed to the continuum (acute care, continuing care, and community care). Reported data suggests that Physiotherapy provides approximately 52% of its work effort to residential care, 41% for community and outpatient and 7% for inpatient. Occupational Therapy operates with a staff split of approximately 75% professional staff and 25% assistant staff.. Mixed reaction among care facilities at the management model which does not have on-site staff reporting to Facility Managers. Staffing levels appear highest in West 2 and East 4 suggesting the impact of ortho and possible legacy staffing. Staffing comparison suggests current operating model is well above midpoint level of staffing performance (high opportunity of 13.8 FTE savings). Data shows that 9.8 FTE within staffing numbers include 9.8 FTE for SHIP. Targeted review of Rehab is required before staffing adjustments made particularly in light of reported challenges to serve orthopaedic and emerging initiatives such as Regional Stroke.



Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest. See above (13.8)

Occupational Therapy

40.1

43.0

0.15

0.07

0.17

0.10

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 105
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Peer Staffing Comparative Analysis
Audiology & Speech Language Pathology
Opportunities Findings
Speech and Language Therapy and Audiology functions and disciplines are housed in Community Health Services. Staff are deployed to the continuum (acute care, continuing care, and community care). 1. Conduct a Targeted Rehab Review in Region to support if current level of investment is desirable and contributes to the desired patient flow and continuum of care needs.
Focus of review should include: required service levels (current and future), model of care, staffing (including mix and potential reallocation if appropriate), hours of operation, and professional practice.

One community has used Telehealth to support SLP delivery. Staffing in Area 4 is highest, probably driven the Audiology program. Speech and Language Practice Lead is vacant. Region is too broad for single role to provide practice support across region. Staffing comparison suggests current operating model is well above midpoint level of staffing performance (high opportunity of 7.6 FTE savings). Data shows that 6.3 FTE within staffing numbers include 9.8 FTE for SHIP. Targeted review of Rehab is required before staffing adjustments made particularly in light of recruitment and retention challenges.

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest. See above (7.6)

Audiology & Speech Language Pathology

32.0

36.7

0.13

0.04

0.21

0.10

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 106
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Peer Staffing Comparative Analysis
Social Work
Opportunities
1. Determine a region wide process and structure to support patient flow and discharge planning 2. Reassess the planned upward adjustment to Social Work or similar roles (in light of reported investment opportunity) to support patient flow and discharge requirements.

Findings
Staffing comparison suggests staffing investment of approximately 6 FTE is required. Social Work currently work only in Area 1 and provide a blend of both acute inpatient and community based service support. Existence of two Placement Coordinators in Region are available resources for placement and other support as required. Limited dedicated resources to support inpatient discharge and planning processes in acute care setting. Discharge function for acute care patients largely falls to the Nursing Supervisor. Region reports plans to augment the Social Work complement to a total of 4 across region. The plan is to allocate 1FTE of Social Work support to each area. The roles will follow the other discipline reporting model and report through Community Health Services.
This reporting structure raises concerns about role focus in terms of patient flow.

3. Reassess organizational placement and reporting model for dedicated patient flow and discharge support roles.

The primary function and role for Social Work was unclear although most expect the role is to focus on patient flow, care planning and discharge.

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest. See above 6.3

Social Work

1.5

1.4

0.1

0.003

0.04

0.03

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 107
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Recreation
Opportunities Findings
Recreation roles are primarily supporting continuing care residents. Recreation staff will also support long stay patients in acute care who are waiting placement. 1. No opportunity at regional level. Given the increased emphasis on continuing care delivery, staffing efficiencies are not warranted in this group. Ensure the recreation staffing contribution is included in the Hour Per Resident Day determination against the provincial target (see Continuing Care section of this report).

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest. See above (3.7)

Recreation

29.6

31.2

0.11

0.03

0.11

0.10

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 108
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Corporate and Support Services

109

AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Process Overview
To understand the relative efficiency of the Corporate and Support Services, we conducted a comparative analysis with a number of comparable health regions from Alberta, British Columbia, Manitoba, and Saskatchewan Fiscal 2004-05 data for ARHA was used for peer comparison, as this represents a full year of staffing, but reference to observed 2005-06 YTD staffing levels are also provided The efficiency analysis assessed peer staffing based on a comparison of actual total paid hours per adjusted patient day (HAPD) for each "department" within the organization (based on MIS functional centre alignment). The adjustment factor increases the base of inpatient clinical activity to better reflect the span of inpatient, outpatient, continuing care and community clinical activity. The results across the comparator group were considered with the following "rules" applied at the departmental level:
Values among the comparator group that were well outside the range (e.g. outliers) were eliminated from the analysis. Given the northern geographic challenges faced by the region, the FTE efficiency opportunity for all Corporate, Support, Clinical Support and Allied Health Services was identified compared to the peer 50th percentile level of staffing performance.

Staffing opportunities are identified based on comparative analysis and the team's understanding of minimum staffing requirements. Staffing opportunities are not stand alone, however, and need to be considered in the context of other opportunities identified for each area. The benchmarking information should be used as input to management decision-making, rather than as a decision in and of itself.
110
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

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Peer Staffing Comparative Analysis
Administrative and Non-Clinical Support Services Areas Reviewed
MIS Code 71105 71110 71205 71170 71305 71505 71115 71120 71125 71135 71145 MIS Description General Admin Administration Nursing Admin - Acute Nursing Admin Nursing Admin - Ambulatory Community Svcs Admin Finance Human Resources/Personnel Systems Support Materiel Management Housekeeping MIS Code 71150 71153 71155 71165 71175 71180 71130 71190 71195 71910 MIS Description Laundry And Linen Plant Admin Plant Operation Plant Maintenance Bio-Medical Engineering/Medical Physics Registration Communications Health Records Patient/Resident Food Services Non-Patient Food

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 111
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Peer Staffing Comparative Analysis
General and Nursing Administration Combined Areas
Opportunities
1.


Findings
Matrix model is a heavier management model, which is exacerbated by the size of the Region. High degree of role overlap between a number of roles:
Regional Coordinators, Clinical Leads, Community Health Services Manager, Community Health Supervisors on community side Area Directors, Facility Managers, Community Health Service Managers, Regional Coordinators

Review matrix model in terms of:
Management roles and responsibilities Role overlap Accountability framework for decision-making Span of control for Director roles (who have site and regional responsibility) Establishing corporate critical mass

2.

Increase support for regional implementation initiatives that allow change to cascade to the operational level Review / restructure Medical / Legal / Quality portfolio to create two roles (1 for Medical and 1 for Performance Management (Quality, Risk, Legal)
Do not replace the current Medical Director vacancy (in light of the above reorganization)

3.

4.

Review span of control across region for both clinical and operating support areas. Review need and allocation of practice support roles for Nursing.

Area focus appears to be reasonable method to drive operations. Area Director role have very broad responsibilities (facility and community oversight and regional responsibilities) with significant travel requirements Very low level of staff resource investment to support implementation particularly evident at the facility level (both acute and continuing care). Very low number of "out of scope" roles. Very low level of organizational investment in areas such as decision support, quality, performance and risk management. Lack of standardized staff ratio to supervisor requirements Number of out of scope vs. in scope supervisors varies across region appears related to legacy operations The corporate structure also follows a decentralized model, which creates challenges for direction setting and maintaining critical mass. Where the region considers further centralization of corporate resources, investment in facilities may be required. Limited dedicated professional practice support roles for Nursing

5.

Area Description General & Nursing Admin. Combined
112

Actual FTEs 2004-05 76.8

Actual FTEs 2005-06 YTD 78.3

Actual HAPD 2004-05 0.33

Alberta Peer HAPD MIN 0.09

Alberta Peer HAPD MAX 0.44

National Peer 50th Percentile HAPD 0.39

Potential FTE (Effic.)/ Re-Invest. See above 15.2

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05
AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Peer Staffing Comparative Analysis
Finance
Opportunities Findings
Staffing comparison shows no staff savings opportunity. Finance Department quite focused on transactional activities (Accounts Payable/Receivable, Budget Development). Region wide policies and procedures are in place. 1. Shift accountability to management for budget development, thereby enabling Finance to play stronger consultative / advisor / decision support role. Do provide peer review data quarterly to Managers. Unsure the extent to which data is used. Financial reporting in community side is rolled up by community thereby making variance tracking by service stream difficult. Finance runs additional report to sort out variance. Consultation indicated that budget development is done by Finance with limited management involvement at the cost centre level. This may contribute to limited accountability. Organization appears heavily oriented to centralized control of financial management as evidenced by middle manager level having little involvement, responsibility and accountability.

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest.

Finance

38.4

38.8

0.14

0.05

0.19

0.14

-

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 113
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Peer Staffing Comparative Analysis
Human Resources
Opportunities
1. Re-assess the predominantly decentralized approach to HR management. 2. Provide additional investment of at least 3 FTE in HR to support stronger centralized roles and strategic focus on recruitment, workforce planning, external partnerships, and developing innovative models at both the staff and physician level. 3. Increase support and work effort with local communities and physicians to strengthen recruitment and retention. 4. Assess partnership potential with other Northern Regions.

Findings
Staffing comparison shows an investment opportunity of approximately 3 FTEs to bring staffing in line with mid point. Decentralized approach has been adopted to support various areas by providing closer local support, however, it negates any potential for broader HR critical mass and requires a stronger generalist function. Currently outsource disability management with plans to bring back in. Human Resources requires much stronger profile and role if it is to support the escalating and critical people needs in ARHA and begin to adopt a strategic role vs. transactional. While the department is under-resourced to support managers in areas such as recruitment, the workload downloaded to the Manager level is high. The result is inconsistent HR practices across the Region. Moreover, the lack of centralized resources to support recruitment creates substantial duplication of work effort among Managers who are recruiting roles from a very limited pool. Physician recruitment is missing as is a workforce plan with key demographics, skills inventory, and location. Given the pressing HR issues, the organization may want to resource it above the midpoint level (for example at or near the 75th percentile).

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD 17.7

Actual HAPD 2004-05 0.06

Alberta Peer HAPD MIN 0.03

Alberta Peer HAPD MAX 0.13

National Peer 50th Percentile HAPD 0.07

Potential FTE (Effic.)/ Re-Invest. See above 3.0
2006 Deloitte Inc.

Human Resources

15.9

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 114
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Peer Staffing Comparative Analysis
Education
Opportunities Findings
Staffing comparison against peer midpoint suggests required staffing investment of approximately 3.7 FTEs. Finding supports the reported low level of education resource availability for training and development Education resources are focused on the planning, programming and coordinating function, which is understandable given their resourcing. Education delivery at the operational level is downloaded to the managers and select staff, which creates risk in terms of standard delivery or delivery at all.

1.

Determine most critical areas for staff training investment.

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest. See above 3.7

Education

6.5

8.9

0.02

0.01

0.06

0.04

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 115
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Peer Staffing Comparative Analysis
Systems Support (IS/IT)

Opportunities

Findings
Staffing comparison against peer midpoint suggests some staff savings opportunity. However, in light of increasing work effort related to IS / IT requirements, staff reduction is not advisable. ARHA still struggling with legacy systems and lack of integrated data. RSHIP initiative has and will continue to require large amount of work effort across region. Proposed reconfiguration of staffing to support Technology Applications vs. Projects. This plan will prevent project requirements cannibalizing the day to day operational support requirements.

1. 2. 3.

No staff savings opportunity ARHA should expand collaborative initiatives with other Regions particularly in North. Stronger regional interface and collaboration related to IT prioritization and implementation support.

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest. See above (2.5)

Systems Support

18.8

19.9

0.07

0.04

0.17

0.06

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 116
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Peer Staffing Comparative Analysis
Materiel Management
Opportunities Findings
Staffing comparison shows no staff savings opportunity. Department has moved to regionalize across the former 4 entities:
Purchasing is consolidated at Westlock Use of regional forms

1.

Where region adopts stronger regional management model for Food Services, explore Materials Management supporting consolidation of purchase for these areas.

Regionalized contracting out Use of regional hubs for inventory (hub and spoke such as Slave Lake)

Reported progress on: controlled inventory, inventory backlog. Do not purchase for Food, Pharmacy. Maintenance does some of own purchase (parts and oxygen). Director reports untapped opportunity related to Laundry, Food Services and Maintenance.

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest.

Materiel Management

50.4

52.0

0.19

0.06

0.43

0.19

-

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 117
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Peer Staffing Comparative Analysis
Housekeeping
Opportunities
1. Review and assess benefit in adopting a regional housekeeping management model that focuses on standardization across region.

Findings
Limited regional management approach to staffing, standards, procedures Facilities visited were very clean, clear of hallway obstacles and in excellent condition (regardless of facility age).

2.

Assess span of control across region.

Wide variation in staff supervision across sites where supervision occurs by:
Facility Manager Out of Scope Supervisor for various areas (Housekeeping, Laundry, Plant) In Scope Supervisor (Housekeeping, Laundry, Plant)

3.

No staffing investment opportunity

Housekeeping's comparison against peer set is problematic given the large number of Aspen sites that are either leased or located in provincial buildings. Non-Aspen housekeeping sites are not provided in this comparison, hence Aspen staffing appears artificially low.

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest.

Housekeeping

135.0

133.6

0.5

0.24

0.62

0.59

No investment

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 118
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Peer Staffing Comparative Analysis
Laundry & Linen
Opportunities
1. Review and assess benefit in adopting a regional laundry management model that organizes laundry service by cluster:
Consider alternative service model for laundry that creates regional laundry centres following cluster / area framework (Athabasca model). Avoid future capital cost requirements to replace laundry units at each site.

Findings
Generally, all sites visited provide laundry service with the exception of Slave Lake that receives laundry service from Athabasca. Frequent role blending between Laundry and Central Sterilizing and Distribution functions. However, equivalent FTE's reported in Laundry is 57.6 across Region. Generally, laundry equipment across sites visited appeared in good working order.



2.

Assess staffing saving potential through adoption of alternative service model (above).

Staffing comparison analysis indicates a potential staff savings of approximately 7.4 FTE.

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest. See above (7.4)

Laundry & Linen

57.7

59.5

0.21

0.07

0.21

0.19

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 119
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Peer Staffing Comparative Analysis
Health Records, Telecom and Patient Registration Combined

Opportunities

Findings
Created blended area for staffing comparison based on role blending across facilities and regions. State of health records departments widely varied across region (from extremely well organized in well designed space to remarkably cramped in very poor space) Continued progress on the Electronic Health Record will dramatically change service function and staffing requirements. No savings identified in staffing comparison analysis. Note: the blend of Health Records with Patient Registration and Telecommunications may offset required investment in Heath Records to support decisionsupport functionality.

1.

Assess investment required as ARHA adopts stronger Decision Support function.

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD 171.0

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest.

Health Rec., Telecom Pt Reg. Combined

168.2

0.44

0.14

0.49

0.44

-

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 120
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Peer Staffing Comparative Analysis
Plant Operations, Maintenance and Biomedical Engineering Combined

Opportunities

Findings
Facilities visited, regardless of age, were well maintained and appeared in good condition. Wide variation in staff supervision across sites where supervision occurs by:
Facility Manager Out of Scope Supervisor for various areas (Housekeeping, Laundry, Plant) In Scope Supervisor (Housekeeping, Laundry, Plant)

1.

Review and assess benefit in adopting a regional Plant Maintenance and Operations management model that manages by cluster:
Consider alternative service model for staffing, workload planning that incorporate both demand and preventative maintainence.

Reported wide variation in staffing across Regions (FTE / square metre space) All sites visited had on-site maintenance support. Degree of area management (Areas 1, 2, 3, 4) varied. Legacy Plant Maintenance / Operations still in place; limited evidence of regional management / programming in place. More could be done in cluster model.

Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD 67.2

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest.

Plant Ops, Main., and Biomed.

68.9

0.26

0.21

0.42

0.26

2.0

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 121
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Peer Staffing Comparative Analysis
Patient and Non-Patient Food Services Combined

Opportunities
1. Review and assess benefit in adopting a regional food services management model that manages by cluster:
Consider alternative service model for food that creates regional food production centres following cluster / area framework. Requires food production changes to include rethermalization. Avoid future capital cost requirements to replace food production capacity at each site.

Findings
All sites visited provide on site food production. Wabasca and Slave Lake are noted as an exception in that it uses contract management. Duplication of administrative support function across region (purchasing, menu development). Commonly Food Services Department does patient food, retail food, and Meals on Wheels support. Staffing comparison analysis does not suggest any staff savings opportunity. Legacy Food operations still in place; limited evidence of regional programming in place. Single food production location not appropriate, however more could be done in cluster model.



Actual FTEs Area Description 2004-05

Actual FTEs 2005-06 YTD 157.5

Actual HAPD 2004-05

Alberta Peer HAPD MIN

Alberta Peer HAPD MAX

National Peer 50th Percentile HAPD

Potential FTE (Effic.)/ Re-Invest.

Pt. & Non-Pt. Food Services Combined

174.7

0.65

0.36

0.79

0.65

-

Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, ARHA Payroll Data 2004-05 122
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Operational Trending and Analysis

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Operational Trending and Key Metrics
- Overview Through the peer staffing comparison, this review has already explored opportunities for efficiency and effectiveness across 70% of the organization's operational spending. Other key cost drivers for consideration include:
Sick and Overtime premium costs Non-Salary Discretionary Supplies and Sundries Medical/Surgical Supply Costs Drugs and Medical Gas Supply Costs Food Supply Costs

Further examination of each of these costs will be presented over the following slides. In addition, an overall review of where the region is investing its operating dollars across the continuum of care will be presented relative to peers.

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Sick Time and Overtime Summary
Service Area Administration & Support Services Nursing Allied Health Community & Social Services Total FTEs 2004-05 758 1,031 468 485 Sick Time % Sick Time % Potential of Total Paid of Total Paid FTE Savings 2004-05 2005-06 2004-05 3.5% 3.7% 2.4% 2.9% 3.5% 3.6% 2.9% 3.7% 7.1 6.3 3.1 2.2 By examining the internal sick and overtime averages by service area, opportunities for improvement can be realized by shifting departments to perform at the area-specific sick and overtime averages. Analysis suggests:
Potential improvement in over 8.0 FTEs of reduced sick time hours, and Approximately $676,655 in overtime premium cost savings. Both of these issues need to be explored within a broader HR framework for change.

Sick time and overtime rates remained relatively constant from 2004-05 to 2005-06.

Service Area Administration & Support Services Nursing Allied Health Community & Social Services

Total FTEs 2004-05 759 1,031 468 485

Overtime % Overtime % of Total Paid of Total Paid 2004-05 2005-06 0.6% 2.4% 0.9% 0.8% 0.8% 3.1% 0.9% 1.0%

Potential $ Savings 2004-05 $84,773 $439,670 $137,905 $14,307

Source: ARHA Payroll 2004-05, 2005-06 Oct ytd. 125
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Non-Salary Discretionary Supplies and Sundries
An analysis of non-salary discretionary accounts was conducted to identify spending variations as well as to understand the large increase in sundry expenses. Discretionary accounts are identified as those non-salary costs that are not directly related to patient care, and over which management is able to exert some degree of control. Overall, 2005-06 Projected data suggests that non-salary discretionary costs may increase by as much as $1.7 million, or 13%, between 2003-04 and 2005-06 Projected.
The main drivers of the increase include Travel Expenses, Professional Fees and Departmental Sundries for the same period.

Continued management monitoring of these costs to compare year-end 2005-06 actuals to projected numbers is suggested. Where year-end actual costs demonstrate similar spend levels, the organization will need to evaluate the balance of non-salary discretionary spending relative to core service delivery. Variance 2003-04 to 2005-06 Projected 19% 6% 9% 15% 7% 83%

Account

2003-04

2004-05

2005-06 Projected $7,270,674 $1,653,189 $1,615,439 $1,513,333 $958,505 $624,921

Travel Expenses Rental - Land/Buildings Office & General Supplies Departmental Sundries Insurance Professional Fees

$6,105,963 $1,560,870 $1,477,314 $1,311,994 $894,330 $342,184

$7,020,515 $1,595,180 $1,594,628 $1,501,369 $977,962 $491,233

Source: ARHA General Ledger 2003-04, 2004-05, 2005-06 Oct ytd. 126
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Med/Surg, Drugs and Food Supply Costs
Medical/Surgical, Drugs and Food Supply expenses were examined relative to adjusted patient days for ARHA and other rural RHAs in Alberta. ARHA is at the lower end of the spectrum with respect to Medical / Surgical supply costs (per adjusted patient day). In comparison to peers, ARHA was found to be midrange among the rural Alberta RHAs for Food and Dietary Supply costs/APD and Drug and Medical Gas costs/APD in 2004-05.

Supply Costs as a % of Total Expenses Medical/Surgical Supplies Drugs and Medical Gases Food and Dietary Supplies

2004-05 Actual Expenses $3,761,260 $3,672,295 $2,999,834

2004-05 Expense/APD $12.56 $12.26 $10.0

Alberta Peers Expense/APD MIN $10.11 $5.13 $5.23

Alberta Peers Expense/APD MAX $29.32 $19.92 $14.35

Source: AHW MIS Database 2004-05 127
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Financial Profile Across the Care Continuum
A financial profile of ARHA relative to other regions in Alberta is presented below, which examines the % of total expenses currently allocated across different dimensions of the organization. As observed through this analysis, ARHA has one of the higher % of total operating expenses Allied Health, which supports the staffing comparison findings of potential opportunities for savings in these areas. Conversely, ARHA is currently spending the lowest % of total operating expenses on Corporate Services, Acute Nursing, and Telehealth relative to other rural RHAs in Alberta. Components of Regional Operational Expenses Corporate Services Support Services Acute Nursing Residential Nursing Emergency, Day and Ambulatory Services Telehealth Allied Health Community Health Services Marketed Services Undistributed
Source: AHW MIS Database 2004-05 128
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2004-05 % of Total Expenses 6.3% 22.2% 14.9% 13.2% 8.2% 0.0% 17.5% 15.0% 0.5% 2.3%

Alberta Peers % of Total Operating Expenses MIN 6.3% 15.6% 14.9% 4.6% 4.4% 0.0% 13.8% 10.9% 0.0% 2.1%

Alberta Peers % of Total Operating Expenses MAX 12.4% 22.2% 26.2% 18.2% 8.2% 0.3% 17.8% 15.9% 1.2% 5.6%

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Human Resource Strategy and Management

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Human Resources Strategy and Management
Overview
Our findings are based on a review of relevant documentation and consultation. From these, we will identify opportunities for Regions to consider. Our model for review, findings reporting and opportunity identification follows a four part framework: Human Resources Re-focus efforts to enhance
HR capacity and capability to support service and management priorities of the Region.

Talent Management the integration of processes,
Re fo HR cu si ng

programs, technologies and staff to Develop, Deploy and Connect workforce. Develop builds employees' capabilities as required by organization either currently or for the future. Deploy ensures candidates are attracted, and recruited to roles and that recruitment is well aligned to strategic and operational needs. Connect cultivates high quality work relationships and culture that fosters engagement, productivity and innovation.

HR Transformation Strategy Process
y R g H olo n ch Te

Human Resources Technology focuses on the
extent to which technology supports the HR capacity and consistency in practice across Region.

Healthy Work Environment encompasses the
physical and psychosocial work environment. Healthy work environment practices exist where culture and practices converge to create improvements for staff that cascade to the patient and community level.
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Human Resources Strategy and Management
HR Refocusing
Findings HR department is insufficiently resourced to support strategic function. Hence, Department is largely transactional in nature. Decentralized HR staffing model requires a generalist focus and prevents critical mass of HR expertise. HR does function according to regional standards and processes. Client stakeholders report need for increased HR support. Limited external partnerships and alliances to support strategic initiatives.

R

ef HR oc us in g

HR Transformation Strategy Process
c Te y R g H olo hn

H En W eal vi o thy ro rk nm en t

Opportunities 1. Refocus Human Resources strategy and programming to support its performance and outcomes as a corporate priority. Shift HR from current decentralized model to stronger centralized, strategic oriented resource. HR to play stronger role directing its people management to support the business requirements. 2. Develop an evaluation strategy with metrics, KPI's, and scorecards to assess effectiveness. 3. Establish or increase external partnerships and alliances to support strategic initiatives. 4. Where substantial external focus is required, collaborate with AH&W and other Northern Regions to jointly create a "Northern Solution".
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H En W e a vi o lth ro rk y nm en t
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M

t n t en le m Ta ge a an

M

nt n le me Ta ge a an t

Human Resources Strategy and Management
Talent Management
Findings
M nt n le me Ta ge a an ef HR oc us in g

HR Transformation Strategy Process
c Te y R g H olo hn

ARHA is not well positioned to compete or attract scarce health care resources; limited HR capacity to support recruitment. Limited education infrastructure (resources and roles) to support staff and management development. No formal succession planning yet significant number of staff and management roles will exit organization in foreseeable future. Legacy cultures very evident. Quality/performance management culture or mindsets not strong. High casualization of workforce threatens service delivery.

R

Develop Deploy

H En W eal vi o thy ro rk nm en t

1. Identify critical workforce elements required to actualize ARHA strategy and developed focused workforce recruitment and development on these roles (physicians, RN's, rehabilitation professionals) 2. Assess the Region's current talent quotient, required competencies, and market availability of required talent. Develop internal and external strategy to grow or secure talent. 3. Explore concept of establishing rural academic centres in Aspen (two locations Cold Lake for East and Hinton for West) with more formal relationship with rural training streams (physicians) and nursing school in North. 4. Ensure that Region is sufficiently resourced to manage people issues at community level and that middle management possess required competencies. 5. Increase focus on culture, front-line supervisory skills, workforce communities, and communications to establish a stronger "connectivity" between workforce and Region as a whole.
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Human Resources Strategy and Management
HR Technology

t

Connect

Opportunities

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R

ef HR oc us in g

Findings Region is growing technology applications to leverage and support stronger centralization model. Limited technology application for staff development HR management issues related to staffing, recruitment, absenteeism are currently manual. Region continues to explore increased applications.

HR Transformation Strategy Process
c Te y R g H olo hn

H En W eal vi o thy ro rk nm en t

1. Continue efforts to use HRIS to support management and staff development 2. Increased E-learning and online development for staff particularly for mandatory annual training 3. On line Performance Management processes for staff

M

nt n le me Ta ge a an t

Opportunities

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Human Resources Strategy and Management
Health Work Environment
Findings Employ outsourced contract to provide disability management which is under review to bring in-house. ARHA needs to be certain that it can replicate expertise HR Department / OH&S does support awareness campaigns for staff related to healthy work environment. Given the breadth of the Region, healthy workplace initiatives need to cascade to the site and community office level. As stated earlier, the middle management level do not have capacity to implement. Limited OH&S presence in Region. Levels of staff satisfaction is reported low but reliant on anecdotal reporting as no staff satisfaction done since new Aspen. One now underway.
M nt n le me Ta ge a an ef HR oc us in g R

t

HR Transformation Strategy Process
c Te y R g H olo hn

H En W eal vi o thy ro rk nm en t

Opportunities 1. Re-assess the current plan to bring disability management in-house. 2. Involve OH&S in broader organizational risk management approach to identify workplace safety risks to patients and staff, and in developing related mitigation strategies. 3. Continue effort to assess staff satisfaction with implementation process to act on findings 4. Continued effort to involve front line staff in healthy workplace initiatives
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Infrastructure

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Regional Infrastructure Alignment
Overview
Our review of regional infrastructure is intended as a high level assessment of how well infrastructure is aligned to support operations. Where there are opportunities for improvement to infrastructure, these opportunities will be identified for the region's consideration. The review has focused on the key high level opportunities across two dimensions of regional infrastructure, with findings and opportunities based on consultation, document review and related analysis:

Facilities and Equipment Technology

Regional Infrastructure Findings and Opportunities

Alignment to Support Operations

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Facilities and Equipment

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Facilities and Equipment
High-level consultation findings, on-site observations, and analysis of availability Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities
1. Facility renewal plans should be linked to outcomes of clinical service role review for region and be done at the Area Level at a minimum. 2. Assess feasibility of colocating community health services in or adjacent to health centres during time of HCC redevelopment.

Findings
Many facilities have master plans and / or are in process of functional programming. Potential risk is that facility renewal follow a site based approach vs. a broader area-wide or region-wide plan. Limited application of alternative settings of care to support patient flow (transitional care, day programs, ...)

Facilities that have community health services co-located report improved communication, facilitated patient flow.

3. Redevelopment of ER Departments to support triage function and effective patient flow.

Many sites have inadequate waiting space that does not offer line-of-sight to Triage Desk Exposed, cramped triage areas for patient information exchange Difficult access routes in many facilities Undersized space for use in many facilities

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Facilities and Equipment
High-level consultation findings, on-site observations, and analysis of availability Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities
4. Explore options to partner with physicians in co-locating physicians' clinics to hospital sites or adjacent locations as part of overall physician recruitment and retention planning. 5. Engage clinical stakeholders to develop a regional strategy and resource plan to further leverage use of telehealth in clinical service delivery. 6. Reassess need for additional inpatient beds vs. outpatient services psychiatry at St. Therese's (St. Paul)

Findings

Numerous sites have high ER volume as a result of limited access to physicians in community

Several opportunities have been identified for increased use of telehealth in clinical service delivery. The region is currently lacking physician champions to drive increased use of telehealth in clinical service delivery.

Utilization findings for psychiatry unit at St. Therese's (St. Paul) suggest higher need for outpatient services

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Facilities and Equipment
High-level consultation findings, on-site observations, and analysis of availability Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities
8. Reassess bed replacement policy and practice in Region.

Findings
Condition of patient / resident beds are poor in many facilities Reported policy that bed replacement is a facility / community fundraising responsibility is out of line with equipment replacement practice. Current equipment use largely reflects a site-based approach. A stronger regional service delivery approach may identify different needs. Area of focus should include:
Beds and Lifts Monitors Diagnostic Imaging Laboratory Pharmacy Telehealth

9. Equipment acquisition plans should align with clinical service role review and regional management models across clinical support departments.

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Technology

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Leveraging the Value of Information Technology through IT Governance
Information and the Technology that supports it often represent the most valuable but least understood asset in an organization. The essential elements of IT governance are to ensure that value is received from spending on technology and then to control and safeguard information. The purpose of an IT governance framework is to institutionalize good practices that ensure an organizations IT investment supports business objectives. These objectives are identified through the Aspen Health Region's mission statement To provide accessible and sustainable health services to Aspen citizens.
And involves: ensuring senior management and frontline providers are involved in determining the direction and goals of the IT department evaluation of service delivery from two perspectives, the total cost of technology operations and monitoring of project outcomes ongoing support and maintenance intended to safeguard the value of existing assets and knowledge in the regional facilities.

Available IT resources, including infrastructure, applications, information and people, should be optimized to the organization's mission. Organizations need to satisfy the quality, fiduciary and security requirements of IT information and infrastructure as for all other assets. To discharge these responsibilities, as well as to achieve objectives, the status of the evolving enterprise architecture must be known.
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What is IT Governance?
IT governance consists of leadership, organizational structures and processes that are designed to support an organization's strategies and objectives to increase stakeholder value. Clear responsibility for the direction of IT requirements is necessary to successfully deliver services that support the enterprise's strategy. Monitoring success in delivering against business requirements, requires that management put a framework in place to measure achievements against goals. IT governance transforms business goals into IT objectives through consideration of value, risk and control.

Value IT Objectives
IT Governance

Business Goals ...

Risk

Control

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Determination of IT Activities
Align Business Goal and IT Objectives
Organizational Strategic Plan
Defines

Define IT Strategy
Translate IT objectives into specific initiatives

Business Priorities for IT
Defines

Assess resource suitability and gaps

IT Objectives

Identify IT Resources
Infrastructure Applications Information People
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Determine ability to fill gaps through acquisition, training, realignment etc. Determine extent to which business priorities for IT can be met

Communicate results and manage expectations

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Technology
Findings and observations for the technology workstream are intended to identify the degree to which IT investments and resulting initiatives support the goals of the region, and the degree to which they are executed efficiently and effectively. The following key documents were reviewed in support of the Technology review for ARHA:
Facility Profiles Aspen Facilities Facility Profiles Aspen IT Consultation Findings Aspen Health Plan Information Template Information Services IT Organization Chart

Information has been summarized in five key focus areas: Technology Categories Strategic Alignment Key Questions Is the IT strategy aligned to support the business? Is there a clear understanding of how IT is supporting the RHA's business objectives? Is the RHA achieving optimum use of its IT resources? Is the RHA investing in the appropriate IT resources? Does the RHA perceive value from their IT investments? Is IT delivering the promised benefits? Are IT risks understood and being managed? Is the quality of IT systems appropriate for business needs? Is there a framework within which to measure the achievement of IT goals?
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Resource Alignment Value Delivery Risk Management Quality Management

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1. Strategic Alignment
Leading Practice Attributes The organization focuses on ensuring the linkage of business and IT plans; on defining, maintaining and validating the IT value proposition; and on aligning IT operations with enterprise operations.
Aspen has drafted a business plan for the Information Systems department that outlines key strategies, tactical approaches, targets and measures, expected outcomes/objectives and timeline to achieve objectives.

Deloitte Findings and Observations

The draft plan is an important and promising milestone for the region, as it clearly outlines the key IT priorities required to align to the region's business objectives. Business users across the organization report a high level of awareness of IT initiatives, with specific focus on the RSHIP Meditech implementation. Further consideration of physician clinic IT integration into the new Meditech implementation will be important for alignment to broader stakeholder needs to meet care delivery requirements. 1. When finalizing the IT strategic planning to support the alignment of business goals and requirements with realistic IT initiatives, consider the following: Involve relevant stakeholders in the identification of IT objectives and in the prioritization of IT initiatives Ensure that the strategic plan is in sufficient detail to support tactical IT plans and to allow for the evaluation of performance against the plan. Ensure that the plans considers IT staffing levels and skill sets aligned to the proposed IT initiatives. Revisit the strategic plan annually to adjust for changes in the focus and direction of service delivery in the region.
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Potential Opportunities



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2. Resource Alignment
Leading Practice Attributes The organization is focused on the optimal investment in, and the proper management of, critical IT resources: applications, information, infrastructure and people including the optimization of knowledge and infrastructure.
Aspen has 12 FTEs, some of which are on secondment in the Regional IS Department to support 20 geographically dispersed sites. With the large number of new IT initiatives there is an increasing demand on IT services. A proposal has been made to restructure the IS department, and Aspen is proposing to add 5 more FTEs. Several different departments in the region have asked for an intranet to streamline inter- and intra-department communications. The quality of the help desk phone system has been raised as impacting the ability of the help desk to deliver service. Concern over available training to support Meditech users has been raised by some facilities. IT is currently reviewing its departmental organization structure to determine allocation of staff across implementation efforts and ongoing operations requirements. 1. 2. 3. Investigate the benefit of procuring new remote support tools, including software/patch deployment and network monitoring to increase the efficiency of the help desk. Explore the possibilities and options to replace the existing helpdesk phone system. Investigate the use of basic collaboration tools and SuperNet to satisfy the initial need for an intranet. Evaluate the effectiveness of existing training plans. Communicate the training plan to users across the region to support their resource planning and comfort with pending technology changes. Continue review of departmental organization structure to ensure appropriate alignment of resources to maintain ongoing operations and support implementation initiatives.
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Deloitte Findings and Observations

Potential Opportunities 4.
5. 6.
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3. Value Delivery
Leading Practice Attributes The organization executes the value proposition throughout the delivery cycle, ensuring that IT delivers the promised benefits against the strategy, concentrating on optimising costs and proving the intrinsic value of IT.
Business users are seeing value from being involved in the Meditech implementation. This involvement has increased confidence in achieving value upon full roll out. The region reports that challenges with respect to organization awareness of IT initiatives, such as the Meditech implementation, include limited training resources to support business users.

Deloitte Findings and Observations

Some stakeholders report challenges with insufficient hardware to support business activities e.g. some sites do not have adequate computers for users. Inadequate business user hardware to support IT initiatives will impede the ability of some sites to benefit from these initiatives. The region reports a recent infrastructure upgrade, which should address some of these challenges. The region reports the need for region-wide reporting functionality to generate meaningful reports to track and improve service delivery. Satisfaction with the current regional IT support service has been reported. 1. Continue to upgrade IT hardware infrastructure to support business user's access to IT capabilities in the region.

Potential Opportunities 2. Review Meditech's reporting capacity and assess its ability to meet stated reporting

needs. Where requirements have been determined to be valid, determine the path and prioritization for meeting the requirements of users with regard to reporting.

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4. Risk Management
Leading Practice Attributes The organization requires risk awareness by senior corporate officers, a clear understanding of the enterprise's appetite for risk, understanding of compliance requirements, transparency about the significant risks to the enterprise, and embedding of risk management responsibilities into the organization.
Many applications used daily are simple and basic. Some users have limited access to the computers at work or still work on paper. There is no measure of the computer proficiency level of the users, which is a potential risk to end-user uptake during implementation.

Deloitte Findings and Observations

IT training and education is noted as one of the greatest risks for ARHA, where there is limited support to provide training and education to business users for the Meditech implementation, and for general project management skills within IT. There are no mitigation strategies in place yet for the region. Many parts of ARHA are reported to have a very high expectation of Meditech. There was no indication of any assessment of the impact that the Meditech implementation may have on overall region information management or operational process. 1. 2. Perform a risk assessment on the impact of the Meditech implementation(s), including a plan for mitigating the identified risks. Explore opportunity to create a dedicated Change Management group for the ARHA implementation to support end-user change management, communications, and training, which are linked closely to a broader regional education strategy and infrastructure. Assess the skill level of potential users within the facilities to ensure that each site will respond to training and transition to new systems, thus avoiding a negative impact on service delivery.
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Potential Opportunities
3.

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5. Quality Management
Leading Practice Attributes The organization utilizes a system of performance measurement to track and monitor strategy implementation, project completion, resource usage, process performance and service delivery, using, for example, balanced scorecards that translate strategy into action to achieve goals measurable beyond conventional accounting.
Aspen reports the recent development of a quality improvement framework for information management, but the need for enhanced ability to measure performance of its IT function was identified, which is needed to support the high level implementation and operations activities.

Deloitte Findings and Observations

Continued enhancement of quality and performance management processes will support the region in identifying, achieving buy-in to, and achieving potential benefits from IT initiatives. This is especially important to consider given the current Meditech implementation, as limited development of a benefits realization framework through RSHIP has been identified resulting in the region needing to develop this framework through its own initiative. 1. Continue to develop and enhance a quality improvement framework and associated processes, which will provide:

Potential Opportunities

Development of a benefits realization framework that defines the cost, benefits, strategy, policies, and service levels of each IT initiative. Ability to measure objectively the satisfaction of management, the users, and other stakeholders. A clear path to further improvement of IT service to ARHA.

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Cluster 1 Opportunities

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Cluster 1 Opportunities
Introduction
Having reviewed three regional health authorities concurrently, we have identified opportunities that are common across the three regions. We have identified common opportunities as `Cluster Opportunities', and they are based on of the following three criteria:


Where the opportunity requires a solution larger than 1 Region's capacity (as it may require cross-region collaboration, provincial collaboration or investment). ` Where a cross region collaboration and solution development will deliver greater value (either qualitative or quantitative) than if pursued by 1 Region independently. Where individual regions are without the current resources or talent and/or will have challenge attracting and recruiting individuals or securing resources independently.





Further, Cluster Opportunities may become `Provincial Opportunities', where the opportunities will have application to more than the three northern regions. These Cluster Opportunities have been accepted by AHW, although a timeline for moving forward has yet to be determined by the province.

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Cluster 1 Opportunities
Reporting Framework
Cluster 1 Opportunities are identified in five key areas of reporting, which have been aligned to the project workstreams, as shown below:
Leadership, Governance, Accountability and Performance Management

Governance and Performance Management

Administrative and Support Services Allied Health and Clinical Support Services Clinical Nursing Services Clinical Resource Management Infrastructure (Technology and Equipment) Resource Optimization

Human Resources Strategy and Management Physician Leadership and Management Risk and Quality Management
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Cluster 1 Opportunities
Resource Optimization
I. Develop strategy to promote expanded clinical application and adoption of Telehealth to respond to growing clinical needs (strategy to include sourcing clinical expertise external to regions to support Telehealth delivery). Adopt a stronger standardized approach to Chronic Disease Management, supported by clinical expertise and links to Telehealth, which can be customized within Regions.

II.

III. Explore shared service model for core corporate services as a strategy to enhance effectiveness, avoid cost, and achieve efficiency: Finance and Decision Support Human Resources (includes physician issues) Information Systems and Support Supply Chain Services Management and Leadership Training IV. Develop and implement workload measurement and caseload tracking and reporting for home care to enable management decision-making and cross-regional comparisons. V. Develop and implement workload measurement and reporting for Population Health and Environmental Health to enable management decision-making and cross-regional comparisons.
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Cluster 1 Opportunities
Leadership, Governance, Accountability and Performance Management
I. Strengthen capability and resource allocation to position Health Human Resource (HHR) Strategy and Management as top priority for organization. (See next section.)

II. Collaborate in the development or procurement of leadership and management development and training based on identified need or gaps. III. Increase attention and effort to creating board awareness and education on responsibilities and liabilities. IV. Enhance broad regional reporting requirements to include ongoing monitoring of IT strategic initiatives, to ensure ongoing alignment of IT to business priorities and objectives. V. Develop a Northern Response Strategy for the three Regions that includes:
Increasing effort on building and growing external partnerships, primarily focused on industry and academia, focused on attraction, recruitment, retention, housing and reimbursement. Reviewing the accountability framework and interface requirements between regional governance model and appropriate operational structure given the size and geography of Northern Regions. Developing alternative funding mechanisms that attracts and retains critical workforce segments (physicians, registered nurses, pharmacists, ...) and high talent management pool. Determining the appropriate funding / resource support for the growing service delivery pressures in the North as well as the impact of rapid industry growth (high population growth, transient and shadow population). Support for the more frequent requirement to conduct a community health needs assessment to be able to respond to the dynamic and growing challenges in the North.
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Cluster 1 Opportunities
Human Resources Strategy and Management
I. Explore northern collaboration for comprehensive Health Human Resources (HHR) strategy development that includes HR refocus, talent management, HR technology and a focus on healthy work environments. Ensure that HHR strategy, management and implementation includes the physician component and is focused on: Workforce/resource gaps, skills management and education; Alignment/realignment of current resources to core service delivery needs; Attraction/recruitment/retention of a talent workforce; and Enhanced business case approach to cost impact analysis related to physician recruitment and service repatriation. III. Define talent strategy to ensure effective leadership in place (from governance to front line delivery) to support change in complex environment. IV. Review current agreement language and requirements in the AHW-AMA-RHA Agreement and staffing union labour agreements, which limit the Regions' ability to provide service in an increasingly challenged environment. V. Explore concept of establishing stronger rural academic centres across the three Northern regions as a mechanism to ensure steady human resource stream (includes physicians, nurses and other health care disciplines).
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Cluster 1 Opportunities
Physician Leadership and Management
Our observations and identified opportunities reflect common and emerging physician practice across the country. Where these five opportunities are seen as desirable by AHW, the province will have to explore different remuneration models that support and lever physician behaviour and desired change. I. II. Review MAC governance structure and mechanisms with specific attention to by-law adherence and alignment. Develop a medical leadership accountability framework and leadership requirements (which includes examining current organizational and reporting structures, and current /potential roles and responsibilities for Chiefs in the management and decision-making process at the site and regional levels).

III. Create a Physician accountability framework with evaluation and quality/risk/performance management tools for Physicians which is integrated into the broader regional performance management framework. IV. Explore alternative payment models for physicians with the objective to improve resourcing and linkage to care/service delivery model. (As part of this opportunity, explore alternate staffing models in consideration of physician AFT options e.g., APN/NP model in ER and other primary care models.) V. Develop a comprehensive Physician Impact Assessment process for physician recruitment related to needs planning and service expansion.
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Cluster 1 Opportunities
Risk and Quality Management
I. Increase awareness, commitment and focus on risk management as a key requirement for operations and decision-making across clinical and non-clinical service areas. Sample areas of focus include: II. Evaluation/quality/risk/performance management tools for physicians Regular community heath needs assessment Stronger and consistent adoption of CTAS Increased education for Board members

Develop a benefits realization approach for RSHIP to ensure investments are aligned to intended outcomes.

III. Increase collaboration and partnership with industry to address increasing environmental health workload and associated risks.

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Regional Opportunity Map and Reference Guide

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Regional Opportunity Map and Reference Guide
Introduction
A reference guide has been developed for the opportunities identified in the region's report. Opportunities have been filtered to facilitate discussion and planning. Filter 1: The overlap of cluster and regional opportunities is one filter. Cluster-Related Opportunities
Cluster Opportunities will be driven by a separate process through a collaboration of AHW and the Cluster 1 regions, and so have not been prioritized in the region's opportunity map. Where Cluster and regional opportunities overlap, the cluster-related regional opportunities have been identified in this reference guide, but not included in the prioritization and sequencing process.

Regional Opportunities

Opportunity Consolidation

Filter 2: Like / related opportunities have been consolidated to facilitate planning and action. Opportunities for Prioritization
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Opportunity consolidation is based on interdependencies and linkages, which are highlighted in the reference guide.
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Regional Opportunity Map and Reference Guide
Opportunity Alignment
To facilitate prioritization, opportunities are aligned across five areas, shown in framework below.
Regional Initiatives

This framework will be referenced to facilitate an understanding of the different types of opportunities for prioritization. Also important will be an understanding of how broader system goals and initiatives, and other regional initiatives impact opportunity prioritization.

Cluster-Related Cluster-Related Strategy, Partnerships and Planning Strategy, Partnerships and Planning

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure
He alt h Go Syst als em

m ste Sy th tives al He nitia I
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Cluster-Related Regional Opportunities

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

The following regional opportunities are directly related to cluster opportunities.
Resource Optimization Opportunity Name Opportunity Description Homecare Workload Measurement Continuing Care Staffing Target Homecare Caseload Review HR FTE Investment Procurement Service Consolidation
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Develop and implement workload measurement, and caseload tracking and reporting for home care to enable management decision making.

Examine staffing allocations across continuing care facilities with respect to recent AHW target of 3.4 HPRD, and in context of continuing care HR plan.

Homecare Caseload Review.

Provide additional investment of at least 3 FTE in HR to support stronger centralized roles and strategic focus on recruitment, workforce planning, external partnerships, and developing innovative models at both the staff and physician level. Where Region adopts stronger regional management model for Food Services and Materials Management, explore Materials Management supporting consolidation of purchase for these areas.

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Cluster-Related Regional Opportunities

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

The following regional opportunities are directly related to cluster opportunities.
Resource Optimization (continued) Opportunity Name Opportunity Description
Engage clinical stakeholders to develop a regional strategy and resource plan to further leverage use of telehealth in clinical service delivery.

Telehealth Service Strategy Explore options for increased use of telehealth in service delivery, with
impact assessment of the relative costs/benefits to align resources to this service delivery model. Stronger regional interface and collaboration related to IT prioritization and implementation support. Investigate the benefit of procuring new remote support tools, including software/patch deployment and network monitoring to increase the efficiency of the help desk. Explore the possibilities and options to replace the existing helpdesk phone system. Assess the skill level of potential users within the facilities to ensure that each site will respond to training and transition to new systems, thus avoiding a negative impact on service delivery.

Regional IT Services

Systems Support Regional ARHA should expand collaborative initiatives with other Regions particularly in North. Information Management
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Cluster-Related Regional Opportunities

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

The following regional opportunities are directly related to cluster opportunities.
Leadership, Governance, Accountability and Performance Management Opportunity Name Opportunity Description
Explore concept of establishing rural academic centres in Aspen (Cold Lake for East and Hinton for West) with increased relationship with rural training streams (physicians) and nursing schools in the North. Shift accountability to management for budget development, thereby enabling Finance to play stronger consultative / advisor / decision support role.

Rural Academic Centres

Budget Management Accountability

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Cluster-Related Regional Opportunities

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

The following regional opportunities are directly related to cluster opportunities.
Human Resources Strategy and Management Opportunity Name Opportunity Description
Re-assess the current plan to bring disability management in-house. Involve OH&S in broader organizational risk management approach to identify workplace safety risks to patients and staff, and in developing related mitigation strategies. Continue effort to assess staff satisfaction with implementation process to act on findings. Continued effort to involve front line staff in healthy workplace initiatives.

Healthy Work Environment

Increased Increase support and work effort with local communities and physicians to strengthen Recruitment and recruitment and retention. Retention Support

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Cluster-Related Regional Opportunities

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

The following regional opportunities are directly related to cluster opportunities.
Human Resources Strategy and Management (continued) Opportunity Name Opportunity Description
Continue efforts to use HRIS to support management and staff development Increased E-learning and online development for staff particularly for mandatory annual training.

Human Resources Technology

Online Performance Management processes for staff.

Human Resources Re-focus

Recalibrate Human Resources strategy and programming and lever to become corporate priority. Shift HR from current decentralized model to stronger centralized, strategic oriented resource. HR to play stronger role directing its people management

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Cluster-Related Regional Opportunities

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

The following regional opportunities are directly related to cluster opportunities.
Human Resources Strategy and Management (continued) Opportunity Name Opportunity Description
Identify critical workforce elements required to actualize ARHA strategy and developed focused workforce recruitment and development on these roles (physicians, RN's, rehabilitation professionals). Assess the Region's current talent quotient, required competencies, and market availability of required talent. Develop internal and external strategy to grow or secure talent.

Talent Management

Explore concept of establishing rural academic centres in Aspen (two locations Cold Lake for East and Hinton for West) with more formal relationship with rural training streams (physicians) and nursing school in North. Ensure that Region is sufficiently resourced to manage people issues at community level and that middle management possess required competencies. Increase focus on culture, front-line supervisory skills, workforce communities, and communications to establish a stronger "connectivity" between workforce and Region as a whole.

PCA Recruitment & Retention Plan Regional HR Strategy Support
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Develop a targeted recruitment and retention plan for PCAs, that is integrated into the broader regional HR strategy. Increase support to enable Human Resources strategy and programming to fulfill its status as a corporate priority.
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Regional Opportunity Map and Reference Guide
Cluster-Related Regional Opportunities

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

The following regional opportunities are directly related to cluster opportunities.
Physician Leadership and Management Opportunity Name Opportunity Description
CTAS strategy requirement that considers space configuration, human resources, and training/education needed to ensure region-wide adoption. Triage needs to be fully implemented and supported with properly trained resources. Rural modifiers may need to be considered especially in centres with volumes of less than 15,000 ER visits (not to include booked patients). Space should be configured to accommodate Triage in a standardized and functional manner.

Clinical Program Frameworks and Review

Conduct an externally led review of MAC governance structure/mechanisms with specific attention to by-law adherence/alignment.

Governance & Leadership

Identify physician leadership requirements and conduct an alignment exercise to determine gaps. Create a medical leadership accountability framework which includes examining current organizational and reporting structures, and current/potential roles and responsibilities for Chiefs in the management and decision making process at a program, site, and regional level.

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Cluster-Related Regional Opportunities

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

The following regional opportunities are directly related to cluster opportunities.
Physician Leadership and Management (continued) Opportunity Name Opportunity Description
Continue to develop a regional Physician Human Resource Strategy that links to the HR and regional strategy, and is focused on Physician resource gaps, skills management and education, alignment/realignment of current resources to core service delivery needs, recruitment/retention. Continue to explore alternative payment models for physicians in the region, with an objective to improve resourcing, and linkage to care/service delivery model.

Physician Human Resources

-As part of this opportunity, explore alternate staffing models in the consideration of physician AFP options e.g. APN/NP model in ER and community health clinics. Continue to develop a regional, comprehensive Physician Impact Assessment process for physician recruitment needs planning, and in assessment when new physicians are being considered and when services are being expanded or developed. This assessment needs to be linked to the region's strategic directions for its clinical programs, and needs to consider broad programming impacts (human resources, infrastructure, funding, etc.) -Physician Impact Assessments should be considered in the context of a regional needs assessment.

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Cluster-Related Regional Opportunities

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

The following regional opportunities are directly related to cluster opportunities.
Physician Leadership and Management (continued) Opportunity Name Opportunity Description
Create an accountability framework with evaluation and quality/risk/performance management tools for Physicians, which is integrated into the broader regional framework.

Quality, Risk, & Performance Management

-Continued and significant education is required at all levels of the organization to promote a quality culture. While the region has undertaken substantial effort in this regard, it must continue its emphasis in this regard. Develop a regional approach and support for CME, based on a sustainable business model, and integrated with the physician recruitment and retention strategy and broader regional education function. -Given proximity to academic centre, CME credits should be mandatory to maintain privilege.

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Cluster-Related Regional Opportunities

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

The following regional opportunities are directly related to cluster opportunities.
Risk and Quality Management Opportunity Name Opportunity Description
Continue to develop and enhance a quality improvement framework and associated processes, including:

Technology Quality and Risk Management

-Development of a benefits realization framework that defines the cost, benefits, strategy, policies, and service levels of each IT initiative Perform a risk assessment on the impact of the Meditech implementation(s), including a plan for mitigating the identified risks. Conduct regional assessment of CTAS use in ER Department to determine resources, capital investment, education support, and policies/procedures required to standardize its use as a risk/management tool.

Regional CTAS Assessment

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Strategy, Partnerships, and Planning
Opportunity Name VP Medical / Legal / Quality Portfolio Review CFB / Cold Lake Physician Relations Equipment Replacement Policy Opportunity Description

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

Review / restructure Medical / Legal / Quality portfolio to create two roles (1 for Medical and 1 for Performance Management (Quality, Risk, Legal) Do not replace the current Medical Director vacancy (in light of the above reorganization) Increase senior management dialogue with CFB Cold Lake to create stronger alignment and integration with CFB physician resources. Deloitte identified the opportunity to `Reassess bed replacement policy and practice in Region.' The region has identified the preference for review of its broader equipment replacement policy, which is represented by the title of this opportunity. Determine most critical areas for investment in change / implementation support throughout the region (based on finding that the Region lacks resources to support and cascade change.)

Implementation Support

Explore opportunity to create a dedicated Change Management group for the ARHA implementation to support end-user change management, communications, and training, which are linked closely to a broader regional education strategy and infrastructure. Support policy development that enables the availability of incremental levels of continuing care for residents living in the community.
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Continuing Care Capacity Planning
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Strategy, Partnerships, and Planning (continued)
Opportunity Name Opportunity Description
Review matrix model in terms of: Management roles and responsibilities Role overlap Accountability framework for decision-making

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

Span of control for Director roles (who have site and regional responsibility) Re-assess the predominantly decentralized approach to HR management.

Review Matrix Model
Review span of control across region for both clinical and operating support areas.

Increase support for regional implementation initiatives that allow change to cascade to the operational level.

Review need and allocation of practice support roles for Nursing.

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Service Delivery Model
Opportunity Name Opportunity Description

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

Conduct a clinical service role review to determine the feasibility of the delivery of services by cluster: Conduct a Community Needs Assessment; Assess current programming, hours of operation, capacity, critical mass, and patient safety issues at both the area and regional levels; Identify centres of excellence; and Conduct master and functional planning exercises based outcomes of clinical service role review Equipment acquisition plans should align with clinical service role review and regional management models across clinical support departments. Swan Hills should undergo a facility role review although the Region reports that this has been done. Region identifies that only significant savings available through closure which is not an acceptable solution given access requirements. Any recommendation around investments in this facility needs to be considered in light of the recommendation that the region completed a review of this facility's role. Edson staffing investments should be considered with respect to the planned redevelopment of the site. Bonnyville staffing investment should be considered should be considered in line with clinical service role review. Functional and master plan study required.
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Service Delivery Model (continued)
Opportunity Name Population Health Service Standardization Opportunity Description

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

Assess service standardization across Region, in alignment with a regional community health needs assessment. Refocus Mental Health planning on broader continuum of care. Conduct a comprehensive review of regional mental health services to determine the most appropriate alignment of resources across the continuum to meet client needs. Reassess value of psychiatry inpatient bed expansion vs. other service models across the region. Reassess need for additional inpatient beds vs. outpatient services psychiatry at St. Theresa's (St. Paul).

Regional Mental Health Program Alignment Review

Regional ER CTAS Utilization Respiratory Therapist Role Review

Conduct regional assessment of CTAS used in the ER Department to determine resources, capital investment, education support, and policies/procedures required to standardize its use as a risk/management tool. Ensure consistent range of services supported by Respiratory Therapy available across Region.

Alternative Level Of Care Expand alternative service model like Adult Day Programs and other transitional supports. Assess the required investments to enable success, such Setting Review as transportation.
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Service Delivery Model (continued)
Opportunity Name Opportunity Description

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

A Community Needs Assessment will assist the region in identifying the challenges in accessing primary care within the region and the resulting impact to ER departments. Explore alternative service models to support patient flow and access to care. There is a considerable investment staffing opportunity in the acute and ER areas, however this needs to be reviewed in conjunction with primary care physician coverage in the community.

Primary Care Model & Access Review

There is a small efficiency opportunity in the OR/SDC, equivalent to 0.9 FTE, which suggests that there is an opportunity to increase volume capacity in the OR with the current staffing complement. Expand functional planning to include alternative service settings and non-acute service delivery. Explore alternative service setting for clinic visits seen in the ER. Assess feasibility of co-locating community health services in or adjacent to health centres during time of HCC redevelopment.

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Service Delivery Model (continued)
Opportunity Name Opportunity Description

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

Alignment diagnostic along leading practices for Maternal/Child, Orthopedics, and General Surgery services - requirement for alignment with centres of excellence models.

Regional DI Alignment Review

Review and assess benefit in adopting a regional Diagnostic Imaging management model that plans, organizes and provides DI service by cluster. Assess information and equipment needs for enhanced regional management model in high cost and high tech areas like laboratory, Diagnostic Imaging and Pharmacy. Review and assess benefit in adopting a regional Clinical Nutrition management model that organizes service by cluster: Region should assess the greatest area of need for staffing investment based on the varied staffing levels within Region. Conduct a Targeted Rehab Review in Region to determine if current level of investment is desirable and contributes to the desired patient flow and continuum of care needs. Focus of review should include: required service levels (current and future), model of care, staffing (including mix and potential re-allocation if appropriate), hours of operation, and professional practice. Assess staffing requirements in light of further review

Regional Clinical Nutrition Review

Rehabilitation Review

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Service Delivery Model (continued)
Opportunity Name Opportunity Description

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

Regional laboratory review: standardized menu, consolidation of resources, LIS, group purchasing, quality monitoring, repatriation. Review and assess benefit in adopting a regional laboratory management model that organizes lab service by cluster. Develop standardized regional menu.

Regional Clinical Lab Review

Conduct a targeted Lab review in region to support stronger centralization of lab function Focus of review should include: required service levels, staffing (including CLXT impact and requirements), hours of operation and enabler requirements related to Information Technology and equipment. Assess information and equipment needs for enhanced regional management model in high cost and high tech areas like laboratory, Diagnostic Imaging and Pharmacy. Regional pharmacy review to examine opportunities for formulary standardization, stricter inventory management and control, and PIXIS.

Regional Pharmacy Review

Review and assess benefit in adopting a regional pharmacy management model that organizes pharmacy service by cluster: Develop standardized formulary; Develop standardized procedures for inventory control Assess information and equipment needs for enhanced regional management model in high cost and high tech areas like laboratory, Diagnostic Imaging and Pharmacy.

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Service Delivery Model (continued)
Opportunity Name Opportunity Description

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

Review and assess benefit in adopting a regional laundry management model that organizes laundry service by cluster:

Laundry Service Model

-Consider alternative service model for laundry that creates regional laundry centres following cluster / area framework (Athabasca model). -Avoid future capital cost requirements to replace laundry units at each site. Assess staffing saving potential through adoption of alternative service model (above). Review and assess benefit in adopting a regional Plant Maintenance and Operations management model that manages by cluster: -Consider alternative service model for staffing, workload planning that incorporate both demand and preventative maintenance. Review and assess benefit in adopting a regional food services management model that manages by cluster: Consider alternative service model for food that creates regional food production centres following cluster / area framework; Requires food production changes to include rethermalization; Avoid future capital cost requirements to replace food production capacity at each site. Review and assess benefit in adopting a regional housekeeping management model that focuses on standardization across region. Assess span of control across region.

Plant Operations Service Model

Food Service Model

Housekeeping Service Model
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Clinical Resource Management and Practice
Opportunity Name Opportunity Description

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

Assess feasibility of shifting acute beds to continuing care status where there is low acute occupancy coupled with lengthy placement waits.

Reallocation of Acute Beds to Continuing Care

Consider reallocation of acute beds funding to meet longstanding Continuing Care needs in the community. Consider reallocation of acute beds to continuing care beds to resolve bed blocking issue. Determine a region wide process and structure to support patient flow and discharge planning. Reassess organizational placement and reporting model for dedicated patient flow and discharge support roles. Examine regional admission/ discharge process and role creation to support patient flow process.

Regional Discharge Need for stronger discharge planning focus and support in acute care across the Planning Process & region. Patient Flow Reassess the planned upward adjustment to Social Work or similar roles (in light of
reported investment opportunity) to support patient flow and discharge requirements. Strengthen discharge planning and utilization management procedures and improve linkages between the hospital and home care staff. Develop standardized discharge and process across region.
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Clinical Resource Management and Practice (continued)
Opportunity Name Opportunity Description

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

Coding/Abstracting Improvements to Regional Coding and Abstracting Enhancements

MD Documentation

Improve MD Documentation in Inpatient Charts

Clinical Protocol Adoption Targeted CMG Assessment with CDM Focus

Develop a clinical adoption strategy for standardized, peer reviewed protocols and care maps for key conditions (e.g. pneumonia, cellulitis, congestive heart failure, and MI management).

Targeted assessment of CMG's driving beds savable with a focus on CDM to divert admissions related to chronic disease.

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Resource Alignment
Opportunity Name Opportunity Description

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

Mental Health Service HR Planning

Develop a targeted mental health resource strategy to address current and anticipated capacity, staffing, physician and education requirements for expanded service at St. Theresa's. Conduct service model and caseload review for current Mental Health Therapists to explore stronger linkage and support to the inpatient service. Identify the total HPRD for all care roles involved in continuing care (PT, OT, Recreation, Social Work) to determine true gap before any potential staffing adjustments are made. Develop a targeted HR plan for Continuing Care, as part of the broader regional HR strategy.

Continuing Care HR & Staffing Plan Any staffing investment opportunity needs to be considered in Athabasca, in the

context of an adjusted HPPD to reflect the number of patients awaiting placement in the community. There is a staffing investment opportunity in St. Theresa in acute care equivalent to 1.9 FTE. This might be offset by the number of patients at St. Theresa's who require an Alternative Level of Care.

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Resource Alignment (continued)
Opportunity Name Opportunity Description

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

There is opportunity for significant investment in the acute and ER/OPD departments at Edson, however this needs to be reviewed in conjunction with primary care physician coverage in the community. The potential investment opportunity in Hinton ambulatory needs to be reviewed in conjunction with primary care physician coverage in the community. Physician shortage in community drives ER volume and the staffing investment should be seen in the light of many of the ER visits being low acuity clinic visits. (Whitecourt)

ER / OPD Staffing Plan

Staffing investment of 9 FTE in acute care and ER/OPD should be considered related to ER/OPD volumes, and in light of proposed facility redevelopment and functional planning. (Barrhead) There is a staffing investment equivalent to 1 FTE in ER/OPD that is driven by the increase in volumes, however this needs to be reviewed in conjunction with primary care physician coverage in the community. (Mayerthorpe) Consider staffing investment equivalent to 5.0 FTEs to support ER/OPD visits, however this needs to be reviewed in conjunction with primary care physician coverage in the community. (Westlock) There is a significant investment in the ER/OPD to address volume and workload. (Cold Lake)

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Resource Alignment (continued)
Opportunity Name Westlock Surgical Day Care Capacity Hinton Perioperative Services Capacity DI Staffing Plan Opportunity Description

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

There is an efficiency opportunity in Surgical Day Care that is equivalent to 6 FTE due to potential for additional capacity. This indicates that there is an opportunity to further increase surgical cases within the current staffing complement. An efficiency opportunity exists in the combined OR, recovery room and surgical day care. At this time the efficiency target is equivalent to 8 FTE and indicates an opportunity to increase OR/SDC volumes within the current staffing complement. Assess future operating savings related to film and staffing with fuller adoption of PACS across Region.

Clinical Lab Staffing Develop staffing plan based on regional model to address potential staff savings (identified as up to 18 FTEs at the midpoint comparison level). Plan Clinical Nutrition Staffing Plan Pharmacy Staffing Plan Corporate Services Staffing Plan
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Develop staffing plan based on regional service model.

Develop staffing plan based on regional service model.

Assess investment required as ARHA adopts stronger Decision Support function.
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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

Cluster-Related Cluster-Related Strategy, Partnerships and Planning Strategy, Partnerships and Planning

Regional Opportunity Map and Reference Guide
Infrastructure
Opportunity Name Facility Renewal Plans Opportunity Description

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure

Facility renewal plans should be linked to outcomes of clinical service role review for region and be done at the Area Level at a minimum.

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Regional Opportunity Prioritization

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Regional Opportunity Prioritization
Introduction
Based on a facilitated working session with the Region's Senior Management Team, the Project Team have developed an Opportunity Sequence Map. Opportunity prioritization has focused on sequencing, using four key factors:
Opportunity Inter-Dependencies Resource Requirements (Leadership, People, Financial, External Support) Identified Risks Timeline Feasibility Priority Level to the Region

The opportunity mapping (timeline) has four phases of effort:
Phase 1: 0-6 months Phase 2: 6-12 months Phase 3: 12-18 months Phase 4: 18-24 months

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Regional Opportunity Prioritization
Introduction (continued)
During the working session with the region's Senior Management Team, opportunities were reviewed by phase of effort to discuss the appropriateness and feasibility of the preliminary prioritization. Throughout the discussion, a "go forward determination" was also assigned to each opportunity to establish if phasing needs to be changed, deferred and / or not pursued: Priority Opportunities that are considered priorities for achievement by the region over a two year period. Deferred Opportunities which must be deferred at this stage, but which will be re-considered for pursuit in the future. Not Pursued Opportunities which are not considered as regional priorities, and so will not be pursued. The following slide presents the opportunity prioritization map, based on those opportunities identified as priorities by the region. Supporting this opportunity map is an overview of the regional lead, required resources, and priority assignment for each regional opportunity.
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Regional Opportunity Prioritization Map
Regional Initiatives

Cluster-Related Cluster-Related Strategy, Partnerships and Planning Strategy, Partnerships and Planning

Service Service Delivery Delivery Model Model

Clinical Clinical Resource Resource Management Management and Practice and Practice

Resource Resource Alignment Alignment

Infrastructure Infrastructure
He alt h Go Sy als ste m

m ste Sy es alth iativ He it In

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Regional Opportunity Prioritization
Phase 1 Senior Leads and Resources
Project Resources Opportunity Name Responsible Senior Lead Andrew Will Andrew Will Andrew Will / Yolanda Lackie Andrew Will / Yolanda Lackie / Cliff Cottingham Andrew Will / Cliff Cottingham Prioritization
Not Pursued Additional External Internal Financial Resource Priority Deferred Resources Support Support

Review Matrix Model Implementation Support VP Medical / Legal / Quality Portfolio Review Primary Care Model and Access Review Clinical Services Role Review

Alternative Level of Cliff Cottingham Care Settings Review Regional Mental Health Program Alignment Review Continuing Care Capacity Planning
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Cliff Cottingham

Cliff Cottingham
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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

Regional Opportunity Prioritization
Phase 1 Senior Leads and Resources (continued)
Project Resources Opportunity Name Responsible Senior Lead Prioritization
Not Pursued Additional External Internal Financial Resource Priority Deferred Resources Support Support

Population Health Service Standardization Equipment Replacement Policy

Cliff Cottingham

Shelly Pusch

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Regional Opportunity Prioritization
Phase 2 Senior Leads and Resources
Project Resources Opportunity Name Responsible Senior Lead Andrew Will / Shelly Pusch Cliff Cottingham / Yolanda Lackie Cliff Cottingham / Yolanda Lackie Cliff Cottingham Cliff Cottingham Prioritization
Not Pursued Additional External Internal Financial Resource Priority Deferred Resources Support Support

Corporate Services Staffing Plan Regional Discharge Planning Process & Patient Flow Regional ER CTAS Utilization Westlock Surgical Day Care Capacity Hinton Perioperative Services Capacity

Mental Health Service Cliff Cottingham HR Planning Reallocation of Acute Cliff Cottingham Beds to Continuing Care

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Regional Opportunity Prioritization
Phase 3 Senior Leads and Resources
Project Resources Opportunity Name Responsible Senior Lead Cliff Cottingham / Yolanda Lackie Yolanda Lackie / Cliff Cottingham Yolanda Lackie / Cliff Cottingham Cliff Cottingham Cliff Cottingham Cliff Cottingham Cliff Cottingham Cliff Cottingham Prioritization
Not Pursued Additional External Internal Financial Resource Priority Deferred Resources Support Support

Coding/Abstracting Enhancements MD Documentation Clinical Protocol Adoption Acute Staffing Plan ER/OPD Staffing Plan Continuing Care HR & Staffing Plan Rehabilitation Review Regional DI Alignment Review

Regional Clinical Lab Cliff Cottingham Review
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Regional Opportunity Prioritization
Phase 3 Senior Leads and Resources (continued)
Project Resources Opportunity Name Responsible Senior Lead Prioritization
Not Pursued

Additional External Internal Financial Resource Priority Deferred Resources Support Support

Regional Pharmacy Review Regional Clinical Nutrition Review Laundry Services Model Review

Cliff Cottingham Cliff Cottingham Cliff Cottingham / Shelly Pusch

Food Services Model Cliff Cottingham Review / Shelly Pusch Plant Services Model Cliff Cottingham Review / Shelly Pusch Housekeeping Services Model Review Cliff Cottingham / Shelly Pusch

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Regional Opportunity Prioritization
Phase 4 Senior Leads and Resources
Project Resources Opportunity Name Responsible Senior Lead Prioritization
Additional External Internal Not Financial Resource Priority Deferred Resources Pursued Support Support

Targeted CMG Assessment with CDM Focus DI Staffing Plan Clinical Lab Staffing Plan

Cliff Cottingham / Yolanda Lackie Cliff Cottingham Cliff Cottingham

Pharmacy Staffing Plan Cliff Cottingham Clinical Nutrition Staffing Plan Facility Renewal Plans Cliff Cottingham Andrew Will

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Deloitte & Touche LLP and affiliated entities. Deloitte, one of Canada's leading professional services firms, provides audit, tax, consulting, and financial advisory services through more than 6,100 people in 47 offices. Deloitte operates in Qu bec as Samson B lair/Deloitte & Touche s.e.n.c.r.l. The firm is dedicated to helping its clients and its people excel. Deloitte is the Canadian member firm of Deloitte Touche Tohmatsu. Deloitte refers to one or more of Deloitte Touche Tohmatsu, a Swiss Verein, its member firms, and their respective subsidiaries and affiliates. As a Swiss Verein (association), neither Deloitte Touche Tohmatsu nor any of its member firms has any liability for each other's acts or omissions. Each of the member firms is a separate and independent legal entity operating under the names "Deloitte," "Deloitte & Touche," "Deloitte Touche Tohmatsu," or other related names. Services are provided by the member firms or their subsidiaries or affiliates and not by the Deloitte Touche Tohmatsu Verein.

Member of Deloitte Touche Tohmatsu

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AHW RHA Efficiency Review
Aspen Regional Health Authority
Performance Management Overview Final Report
July 14, 2006

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Performance Management Overview
Key Components of Performance Management
The framework below is used to assess performance management alignment. There are seven components used in this assessment.

Leadership
Vision and Strategy

Organization Structure People Infrastructure

Measurement

Operating Processes

Opportunities

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1. Leadership
Leading Practice Attributes
Visible leadership; vision and strategy focused; Role mentorship and succession planning; Systems thinking and planning; Multi-stakeholder relationships management Transparent and timely management processes related to decision-making; Demonstrated commitment to standardization;

Findings
Documentation Review
3 Year Health Plan; Annual Business Plan; Annual Report Organization Charts Accreditation Overview (4 Regions) Performance Management Profile

Stakeholder Feedback
Stakeholders recognize the potential for change at Aspen (new CEO VP East). Individuals commented on the slow decision-making process through the Issue for Decision requirement. Although the process can be swift for emergent /urgent issues. Management at various levels identified frustration with limited function and authority related to their roles. Matrix model and organizational structure deliberately selected to address wide geographical coverage and challenges that traditional program management model would have had with geographical constraints.

Multiple regional initiatives are in planning mode, however there is limited implementation support. Need for stronger performance management processes a long standing issue (in early Accreditation recommendations); limited standardization in place. Significant work is underway related to quality reporting at both Board level and within management team. Many of the leadership roles are overly large and don't allow appropriate time to lead initiatives (Director roles fragmented between site, community, regional responsibilities). Leadership acknowledges the struggle with balancing consultation, communication and decision-making.
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Deloitte Observations

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2. Vision and Strategy
Clearly articulated Mission, Vision, and Value Statements (or Guiding Principles)

Leading Practice Attributes

Current Strategic Plan with supportive structure and processes to cascade to operational level; prioritization process to focus organizational initiatives and decision-making Performance management processes and structure aligned to support strategy; Focused on direction Cross RHA collaboration; integration mindset

Findings
Documentation Review
3 Year Health Plan; Annual Business Plan; Annual Report, Performance Management Profile

Stakeholder Feedback
RHA continues to undertake substantial planning related to regionalization; a time-consuming process Relatively young as new regional entity (3 years) Multiple initiatives and priorities may create limited traction (too fragmented) Multiple roles responsible for initiative planning; limited roles responsible for implementation

Deloitte Observations

3 year plan and annual business plan show alignment; however, many of the strategic initiatives are in planning or early implementation stage. Limited implementation resources available to cascade change at the operational level is noted. Region does not appear sufficiently resourced in terms of implementation resources to affect strategy and change initiatives.

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3. Organization Structure
Organizational structure reflects unique requirements of organization, service delivery; supports changing service and people requirements;

Leading Practice Attributes

Supports timely decision-making and efficient work flow; role accountability and communication Minimizes role duplication and confusion Strategic portfolios instead of service management ones

Findings
Documentation Review
Organization Structure / Charts Role descriptions (select management roles) Policy: Issue for Decision Performance Management Profile

Stakeholder Feedback
Multiple roles involved in planning (Regional Coordinators, CHS Managers, Facility Managers, Directors) Matrix structure (area and regional responsibilities) creates very large role responsibilities substantive travel suggested up to 50% Shift to matrix structure has taken some time for management team to gain comfort level and understanding of required communication Shift of Recreation Therapy to Facility Manager endorsed Mix reaction on rehab staff serving facility reporting to community

Matrix organization and role structure require substantial role consultation, travel. Lack of clear role differentiation between number of roles (CHS Managers and Supervisors, Area Director and Facility Managers). Regional gains appear stronger in community health services side vs. facility. Variable spans of control across region Organization may want to consider aligning select functions (such as: education, quality, research, Telehealth, information/privacy) within one senior management portfolio.
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4. People
Current Human Resources Strategic Plan; HR planning and management from a regional perspective (move from local to central)

Leading Practice Attributes

Standardized performance review process with regular application Identified competencies for roles particularly at leadership level Sufficient HR staffing support across organization to support management and staff Supportive staff development and education program / process in place; career paths / laddering opportunities

Findings
Documentation Review
Role descriptions HR Strategic Plan Organization structure

Stakeholder Feedback
Most individuals believe HR is under-resourced Managers identify that performance review compliance is inconsistent Limited education delivery support available Recruitment process is decentralized

Need for comprehensive HR strategy and implementation plan; staff performance management processes appear weak and increased efforts across region related to recruitment. Limited HR support within recruitment efforts at the area level creates work duplication between areas (all after the same limited number of potential candidates). Deloitte Observations Limited education / training support for transition. Span of control across region requires review. Senior Management report that significant amount of work and development of HR strategies has occurred as part of overall regional plan and specific to program plans. Middle level management did not comment on this work effort.
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5. Infrastructure
Leading Practice Attributes
Current and integrated information management, technology and facility plans Sufficient and appropriate technology to support efficient and effective operations Capital replacement plan (current and integrated); Facility development processes and plans to support care requirements and efficient operations Metrics to assess value of investment (economic and social value, linking service to infrastructure) Assessment of new business models to enable infrastructure investment

Findings
Documentation Review Stakeholder Feedback
IT structure reflects organization working through updating and managing legacy systems. Re-regionalization to Aspen disbanded some legacy systems but left areas without replacement or a better system (for example Environmental Health). Region has committed to align its IT initiatives with RSHIP initiative. Capital redevelopment in place or planned in numerous sites across region; many work around solutions given poor or inappropriate design. Where community and facility services are co-located, individuals report good information and work flow.

IT plan Capital Redevelopment Submissions

Deloitte Region has many individual redevelopment processes underway and would benefit from a Observations consolidated assessment across region, an overall plan at least at the area level, and
clearly identified priorities.
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ER design in most facilities requires review; many facilities suffer cramped space (DI, Lab, Pharmacy).

2006 Deloitte Inc.

6. Measurement
Existence of a comprehensive performance management system in place (people, financial, operations, satisfaction, and other key processes)

Leading Practice Attributes

Development of performance metrics and targets to manage care and service; linkage of measurement to action and communication Consistent, standardized measures Performance measurement linked to quality and risk management

Findings
Documentation Review
3 Year Health Plan; Annual Business Plan; Annual Report, Accreditation Annual Reports

Stakeholder Feedback
Currently, much work effort devoted to upcoming Accreditation Continued efforts related to building and implementing quality management across region Managers appeared without quality or risk management resources to problem solve

Support the continued effort to build and implement performance management processes across region

Deloitte Observations

Potential benefit of region adopting a scorecard for internal management Indicator development process may require improvement process Insufficient resources to give related initiatives traction across region The region has demonstrated a steady work effort in this area, however continued effort is required to cascade processes to operational level.

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7. Operational Processes
A formal, organization-wide risk identification and management process is in place; Established processes in place to support standardization and development of practice

Leading Practice Attributes

Established processes, initiatives to support standardization of care and service Established resources to support initiative implementation and monitoring Assessment of new or different business models to support service delivery and integration Management processes that support accountability

Findings
Documentation Review
Annual Business Plan Accreditation Report Care documentation (charts) Policy/Procedure

Stakeholder Feedback
"New" Aspen still forging its new identity; Managers identify wide variation in practice across sites, staffing and processes across region Low signing authority, often decisions through Issue For Decision process can be slow, Matrix responsibilities of area and regional programming is time-consuming and compounds decision-making; although matrix viewed favourably

Deloitte Observations

Aspen is still a region in formation mode; organization structure should be re-assessed for effectiveness and efficiency in terms of management decision making and the span of control for region-wide roles Management accountability needs to strengthened at middle management level, and span of control should be reviewed The region continues to work through the process of regional standardization. Clinical care and management processes are largely site-based.

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Summary Remarks
Strengths to build on include... Strengths to build on include...
Strong leadership at the Strong leadership at the corporate level corporate level A defined strategic direction A defined strategic direction Matrix organization structure Matrix organization structure that supports both regional that supports both regional service planning and areaservice planning and areaspecific delivery specific delivery Senior management and staff Senior management and staff RSHIP Initiatives RSHIP Initiatives General awareness about General awareness about performance measurement and performance measurement and senior leadership commitment senior leadership commitment Reported improvements within Reported improvements within community health services community health services continuum continuum

There are, however, some There are, however, some challenges. Aspen needs to: challenges. Aspen needs to:
Enable middle management Enable middle management decision-making decision-making Assess the number of priorities Assess the number of priorities it undertakes and ensure there it undertakes and ensure there is adequate implementation is adequate implementation support support Reassess the feasibility of Reassess the feasibility of select roles within its matrix select roles within its matrix organization model organization model Focus on a regional approach to Focus on a regional approach to HR planning and management, HR planning and management, and include support for and include support for physicians physicians More aggressively support More aggressively support regionalized care standards regionalized care standards

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

2006 Deloitte Inc.

Deloitte & Touche LLP and affiliated entities. Deloitte, one of Canada's leading professional services firms, provides audit, tax, consulting, and financial advisory services through more than 6,100 people in 47 offices. Deloitte operates in Qu bec as Samson B lair/Deloitte & Touche s.e.n.c.r.l. The firm is dedicated to helping its clients and its people excel. Deloitte is the Canadian member firm of Deloitte Touche Tohmatsu. Deloitte refers to one or more of Deloitte Touche Tohmatsu, a Swiss Verein, its member firms, and their respective subsidiaries and affiliates. As a Swiss Verein (association), neither Deloitte Touche Tohmatsu nor any of its member firms has any liability for each other's acts or omissions. Each of the member firms is a separate and independent legal entity operating under the names "Deloitte," "Deloitte & Touche," "Deloitte Touche Tohmatsu," or other related names. Services are provided by the member firms or their subsidiaries or affiliates and not by the Deloitte Touche Tohmatsu Verein.

Member of Deloitte Touche Tohmatsu

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AHW RHA Efficiency Review Aspen Regional Health Authority Property of Alberta Health and Wellness

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