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AHW RHA Efficiency Review
Peace Country Health
Governance and Accountability Overview Final Report
July 14, 2006
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Property of Alberta Health DeloitteWellness and Inc 2006
Introduction
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 Peace Country Health Property of Alberta Health and Wellness
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PCH Three-Year and Annual Plan
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
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Three Year Plan
PCH Strategic Priorities
Peace Country's identification of eight strategic priorities provides a focused framework within which strategy is developed, measures defined, and action planned. The eight priorities have good linkage with the provincial direction and requirements for Regional Health Authorities and align well with the Peace Country's 4 Strategic Principles. Strategic Principles Self Health Strategic Priorities 1. Chronic Disease Management 2. Support Healthy Communities 3. Reform Health Care Delivery 4. Healthy Communities 5. Quality of Work Life 6. Staff Development 7. Risk Management and Quality Framework 8. Information Management System
Meeting Community Needs
Team Work
Accountability
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
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Three Year Plan
PCH Strategy Mapping to AH&W Goals
Deloitte's review of Peace Country's strategies (2005 2008) mapped to strategic principles, and health system provides the following observations. Health System Goal Albertans' Health is protected; Albertans choose healthier lifestyles Strategic Principle Peace Country Goal Provide resources and information to help people and communities take responsibility for their health and wellness Priority
1. Self Health
Chronic Disease Management
One corresponding strategy identified: 1.1 Develop and implement a long-term plan for chronic disease management with a focus on prevention and promotion. The region has several chronic disease management efforts underway to support this goal, but stakeholders identify that travel is a challenge for service delivery, given the geographic distribution of the region. To support this goal, the region is exploring the use of telehealth technology as an enabler, and does have some programs in place to support service delivery.
Chronic disease management is a program that has historically been funded through special project grants, however, and so developing an integrated consistent telehealth service into the chronic disease management program has been a challenge.
Deloitte Observation at the Operational Level
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
2006 Deloitte Inc
Three Year Plan
PCH Strategy Mapping to AH&W Goals
Deloitte's review of Peace Country's strategies (2005 2008) mapped to strategic principles, and health system provides the following observations. Health System Goal Albertans' Health is protected; Albertans choose healthier lifestyles Strategic Principle Peace Country Goal Priority
Provide resources and information to help people and 1. Self Health communities take responsibility for their health and wellness
Support Healthy Communities
One corresponding strategy identified: 1.2 Promote, support and expand upon innovative programs and initiatives that support healthy communities. Collaborate with community partners including industry and aboriginal populations.
Deloitte Observation at the Operational Level
The region has several efforts underway to support this goal, but stakeholders identify a number of continuing challenges including: Increased workload associated with `shadow' populations in industry camps throughout the region. Need for improved coordination for service provision to communities or industry camps that border with other regions or provinces. Challenges faced in serving the First Nations and M tis populations included literacy, poverty, access/travel, traditional vs. assimilated cultures, and jurisdictional issues. This suggests the need for external partnerships with Aboriginal Health Liaison Workers to support service delivery to First Nations and M tis populations.
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
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Three Year Plan
PCH Strategy Mapping to AH&W Goals
Deloitte's review of Peace Country's strategies (2005 2008) mapped to strategic principles, and health system provides the following observations. Health System Goal Albertans' Health is protected; Improved access to health services Strategic Principle Peace Country Goal Priority Reform health care delivery
Offer the right programs, in the 2. Meeting community right place, at the right time within our human and financial needs resources
Four corresponding strategies identified: 2.1 Provide broad range of care and residential options (in line with continuing care strategic directions)
PCH has several continuing care facilities in place to support residential care, and has also initiated the development of supportive housing alternatives so that a broader choice of service is available. This goal has been further supported through the investigation and development of private partnerships. Consultation findings suggest the need to continue exploration of the number and types of beds available across continuing care and supportive housing, with focus on enabling/supporting effective patient flow.
Deloitte Observation 2.2 Implement the Region's mental health plan ensuring integration, client focus and increased access at the The region has recently re-crafted its mental health plan, so ongoing monitoring of program development Operational and outcomes should be implemented. A key challenge for this plan is the current physician resources available to support mental health services, as the region currently has only 1 psychiatrist. Level
Inpatient mental health services in the region demonstrate challenges in length of stay, and indicate the need for increased community resources to complement inpatient services. Increased focus on the integration between inpatient and community mental health services is also an area of opportunity. Analysis of outpatient/community mental health activity demonstrated a decline between 2002-03 and 2004-05, so 2005-06 levels should be monitored to determine support for this goal. Strengthening of external partnerships with other mental health service providers (e.g. AADAC) was also identified as an opportunity moving forward. These opportunities are in line with the region's mental health plan, and should continue to be supported.
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Three Year Plan
PCH Strategy Mapping to AH&W Goals
Deloitte's review of Peace Country's strategies (2005 2008) mapped to strategic principles, and health system provides the following observations.
Health System Goal Albertans' Health is protected; Improved access to health services Strategic Principle 2. Meeting community needs Peace Country Goal Priority
Reform health Offer the right programs, in the right place, at the right time within care delivery our human and financial resources (continued)
Four corresponding strategies identified: (continued) 2.3 Reduce waitlists, improve access, enhance specialty service by repatriation, expand technology, and enhance role of facilities
The region has recently completed a surgical and obstetrical service review of the rural sites to explore rural options for service repatriation. The region has also introduced orthopaedic services in QEII, as part of a broader plan to repatriate surgical services from other regions. Capital redevelopment is in planning for a number of sites (e.g. Beaverlodge, QEII), which presents opportunity for the region to consider broader service roles and repatriation opportunities for these facilities to support this goal. Wait lists in some areas are still noted as a challenge (e.g. CT). The region reports it is currently making progress towards these challenges through a focus on increased throughput and the use of technology, and so this is an area for continued monitoring.
Deloitte Observation at the Operational Level
2.4 Partner with external stakeholders to implement alternate primary care programs
Consultation findings suggest that primary care programs are still in development, and should continue to be explored by the region to support this goal.
7 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Three Year Plan
PCH Strategy Mapping to AH&W Goals
Deloitte's review of Peace Country's strategies (2005 2008) mapped to strategic principles, and health system provides the following observations.
Health System Goal Albertans' Health is protected; Improved access to health services Strategic Principle 2. Meeting community needs Peace Country Goal Priority
Offer the right programs, in the Healthy right place, at the right time within Communities our human and financial resources
One corresponding strategy identified:
Deloitte Observation at the Operational Level
2.5 Determine community health needs through assessment to establish baseline for ongoing assessment.
A community health needs assessment is reported as complete in 2005-06, although the ability of the region to re-allocate resources to meet assessed needs could not be determined. From a governance level, the region's Board engages Community Health Councils to provide ongoing input on community health needs. Consultation suggests that there is varied level of engagement from the CHCs, so is an area for continued focus of the region to support this goal.
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
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Three Year Plan
PCH Strategy Mapping to AH&W Goals
Deloitte's review of Peace Country's strategies (2005 2008) mapped to strategic principles, and health system provides the following observations.
Health System Goal Improved access to health services Improved health service outcomes Strategic Principle Peace Country Goal Priority
Build a sustainable workforce Quality of Work 3. Team Work committed to life long learning and Life personal development.
Two corresponding strategies identified: 3.1 Implement a comprehensive workforce plan
The region has developed an HR recruitment and retention plan, but stakeholders identify the need for improvements and re-alignment of the plan to the overall strategic priorities of the organization.
Deloitte Observation at the Operational Level
Succession planning is also underway, but a structured approach is still in development, as the region has had significant management turnover and organization change over its first few years as an organization. Physician workforce plan is in place, but not well communicated, which is risk to the organization in building broad physician buy-in and support of the plan.
3.2 Collaborate with external partners, education institutions and stakeholders to establish innovative workforce plan and strategies.
The region is currently in development of a broader education function and plan that is anticipated to support this goal, however it was not reviewed by the consultants. Limited evidence was observed of partnership development to support this goal, and so it is expected that this is future work of the region.
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
2006 Deloitte Inc
Three Year Plan
PCH Strategy Mapping to AH&W Goals
Deloitte's review of Peace Country's strategies (2005 2008) mapped to strategic principles, and health system provides the following observations.
Health System Goal Improved access to health services Improved health service outcomes Strategic Principle Peace Country Goal Priority
Build a sustainable workforce Staff 3. Team Work committed to life long learning and Development personal development.
Two corresponding strategies identified: 3.3 Encourage learning and personal development and develop supportive tools.
The region currently has a Clinical Affairs department with a role to support nursing clinical education, although stakeholders identify significant challenges with the department's limited on-unit education.
Deloitte Observation at the Operational Level
A broader education function that supports both clinical and non-clinical education does not exist for the region, although planning was underway at the time of review to develop this function through a collaboration of the Human Resources and Clinical Affairs departments. Stakeholders report the need for further education support to build management and leadership competencies, to fund education travel, and to support distance learning.
3.4 Develop innovative ways to create supportive work environment.
The region's HR and OH&S departments have recently re-staffed to full complement and are in progress of developing and implementing several programs to support this goal. Several facilities challenges are noted as impacting the work environment (e.g. QEII ER) Stakeholders also report challenges with cultural differences across foreign-trained physicians, which suggest the need for focused effort in support of this goal.
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
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Three Year Plan
PCH Strategy Mapping to AH&W Goals
Deloitte's review of Peace Country's strategies (2005 2008) mapped to strategic principles, and health system provides the following observations.
Health System Goal Improved health service outcomes Organizational excellence Strategic Principle Peace Country Goal Priority
Demonstrate accountability and Risk Management apply evidence-based information 4. Accountability and Quality to improve the safety and quality Framework of our services.
Two corresponding strategies identified: 4.1 Implement and evaluate the comprehensive risk management framework
The region has developed and implemented an Enterprise Risk Management Framework, although stakeholder reports suggest that this tool is still gaining traction in the organization.
Deloitte Observation at the Operational Level
The region has recently hired a dedicated role to support quality and risk management in the organization to support this goal. Board reporting suggests that quality and risk management indicators need further refinement to flag the organization's top risks in support of Board decision-making.
4.2 Engage communities and staff in strategic planning.
Regional stakeholders report a mixed level of involvement in strategic planning initiatives, although do report good involvement in initiatives once established. Community engagement in strategic planning was not evaluated, although reports that the CHCs have a mixed level of engagement in community health planning suggests that further improvements in this area could be made to support this goal.
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
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Three Year Plan
PCH Strategy Mapping to AH&W Goals
Deloitte's review of Peace Country's strategies (2005 2008) mapped to strategic principles, and health system provides the following observations.
Health System Goal Improved health service outcomes Organizational excellence Strategic Principle Peace Country Goal Priority
Demonstrate accountability and Information apply evidence-based information 4. Accountability Management to improve the safety and quality System of our services.
Two corresponding strategies identified: 4.3 A comprehensive information management system to support evidencebased decision-making
Deloitte Observation at the Operational Level
The region is currently implementing Meditech as part of the collaborative non-metro RSHIP initiative, to support this goal. The region is taking a leadership role in the RSHIP initiative, at both the CEO and CIO levels. This is a multi-year goal that will require several phases of the Meditech implementation to be complete before full decision-making support is available through information systems.
4.4 Implement an electronic health record that supports the continuum of care while maintaining established standards.
The development and implementation of an EHR that follows common standards is underway through the implementation of Meditech, as part of the RSHIP initiative. Although a full EHR will require several phases of implementation before complete, the region is continuing to move forward with select areas of the continuum (e.g. continuing care).
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Three Year Plan
PCH Challenges and Opportunities Section
Deloitte's review of PCH's Three Year Plan (2005-2008) provides the following observations. We concur with the identified challenges and opportunities related to:
Population Profile and Geography (younger, transient population, many ethnic specific communities, rural decline with urban expansion in Grand Prairie) Healthy Choices and Opportunities (high need for health promotion, injury prevention) Technological Advances (recognizes emerging technology as appropriate and feasible response to serve rural setting, also increasingly emphasizing information technology to support regional management) Health Human Resources (aging workforce, hard to recruit and retain disciplines are key drivers, emphasis on corporate culture and staff development are enablers for staff) Risk Management and Quality Improvement (patient care and safety, staff issues and incidents and service access are key areas of focus) Sustainability (funding, service demand, alternative service delivery models are the focus)
Our consultation findings indicates that:
Many of the opportunities identified are well underway, particularly related to Healthy Choices and Opportunities, and Technological Advances. Many of the opportunities have not yet received the attention or achieved results required to alleviate many of the current operating challenges, although preliminary work is underway. These include: Population Profile and Geography, Health Human Resources, Risk Management and Quality Improvement, and Sustainability.
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Annual Plan
Observations
Deloitte's review of Peace Country'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) demonstrates good alignment and support to the Three Year Plan through the development of more supportive activities to support the respective strategies. Supportive activities include a number of specific tactical approaches to support strategy:
Changes to resource allocations Development of external partnerships Identification of where further project work and review are required to determine detailed plans in support of strategy. Established performance metrics to track progress to strategic priorities, where feasible.
While the Annual Plan reflects a more focused plan to cascade strategy to the operational level, the region's projection of an operating deficit for 2005-06 may impact the implementation of these goals.
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PCH Governance Assessment
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PCH 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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PCH Governance Assessment
Responsibilities and Mandate
Performance Assessment and Accountability Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization
Understanding of scope, authority and responsibilities (the difference between stewardship and management and setting policy vs. implementing policy) Involvement in multi-year strategic planning
Areas of Assessment
Involvement in annual planning and budgeting Involvement in establishing risk management process and aware of procedures to mitigate risk Ensuring management effectiveness and succession Communication with key stakeholders Board self reports a good level of involvement in key areas of responsibility, including:
Annual planning and budget approvals
Deloitte Observations
Community Health Council forums Monitoring of risk management framework
Board meets with Auditors at least twice annually Self-reporting suggests that Board members may need additional information and awareness about personal liability of individual members as governors of the region.
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PCH Governance Assessment
Structure and Organization
Performance Assessment and Accountability Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization
Appropriate number of members and meetings
Areas of Assessment
Appropriate representation of communities Committee structure Self assessment The Board currently has 13 members, and self reports to have an effective working structure for board. Changes to the number of Board members is reported to require AHW input and approval. Board members are appointed by AHW, with input from the Chair, and members currently have indefinite terms. The Chair reports a good mix of skills on the Board, with strong financial competencies. Appropriate committee structure in place; Board Committees include:
Deloitte Observations
Executive The board formally has this structure, but it is not currently in use. Finance This is done as an entire board meeting, due to travel requirements of Board Members for other committee meetings. Audit Includes four members of the Board Quality, Risk and Performance Management done by whole Board quarterly Ad hoc committees established as need (Examples reported include: mental health, by-law review, and 3rd way)
Although geography presents a challenge for Board meetings, the Board reports regular monthly meetings - with at least full day meetings held monthly.
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PCH Governance Assessment
Processes and Information
Performance Assessment and Accountability
Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization
Areas of Assessment
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) 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, with primary efforts focused on annual planning and review, and quarterly reporting. In addition, the Board meets for two-day meetings every second month, where staff have opportunity to present information and seek input from the Board. Information is provided in advance of board meeting to enable review and preparation A formal orientation process exists for new Board Members, supported by a Board manual, and meetings with the Chair and CEO to provide orientation both to Board responsibilities and the region. Ongoing development opportunities are reported for Board Members through a mix of region-provided updates and education sessions. Board specific policy in place to direct board management (roles and responsibilities; code of conduct; conflict of interest; board member compensation; terms of reference for board committees). The Board self-reports to be a policy-focused Board, with operations mandate clearly given to the Executive Team.
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Deloitte Observations
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
PCH Governance Assessment
Performance Assessment and Accountability
Responsibilities and Mandate Performance Assessment and Accountability Organizational Culture Processes and Information Structure and Organization
Areas of Assessment
Process to assess and monitor organization performance related to financial management, operations, people management, risk and safety Process to monitor achievement of strategic directions Self assessment of board performance Board understanding of liability issues Process to routinely assess performance of CEO/President The Board is compliant with required reporting from AHW. Quarterly reporting is primary mechanism which is a combination of financials, operational indicators (nursing worked hours, visits, select departmental costs per procedures, and overtime and sick time) at a site / community level. The Board is kept aware of the financial position of the organization, and approves deficit projection where it feels it is required to meet the care needs of its communities. The Board conducts an annual facilitated self-assessment to determine changes required to Board structure, process or objectives. This self-assessment examines the Board as a whole, and does not focus on individual Board member evaluations. For the CEO, the Board conducts an annual performance evaluation of the CEO relative to the strategic directions, goals and activities of the region. Although the Board does receive monthly risk management reports, reporting suggests that further prioritization of risk reporting to Board would support the Board's involvement in risk management. Further, the Board may want to consider moving to indicator reporting that is focused on strategic direction and initiatives to provide an assessment of the operational implementation of strategic directives.
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Deloitte Observations
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
PCH Governance Assessment
Organization Culture
Performance Assessment and Accountability Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization
Board involvement in setting organization's values and philosophies
Areas of Assessment
Diverse representation from communities within Region Board serving role as policy advocates with government and key stakeholders Fosters effective board / management relations Board self reports significant involvement in value setting and strong relationship with management, but prefers to allow organization culture to evolve naturally instead of driving specific efforts. Board has secured diverse representation through its 14 Community Health Councils, where one Board member serves as a liaison on each CHC. The Board itself has representation from across the region, based on where population density is greatest in each of the region's communities. Board also reports a balance of regional vs. local community focused discussions. With respect to physicians, although there are no physicians currently on the Board, the Board Chair reports a close working relationship with the CEO and VP Medical in working collaboratively to meet with physicians or respond to physician requests of the Board.
Deloitte Observations
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Concluding Comments
PCH
Strengths to build on include... Strengths to build on include...
Alignment of three-year plan to Alignment of three-year plan to provincial directions, and provincial directions, and supporting alignment of the supporting alignment of the annual business plan. annual business plan. Development of risk management Development of risk management function and framework. function and framework. Continued revitalization of the Continued revitalization of the organization's information organization's information systems systems Identification of need for new Identification of need for new focus on Health Human Resources focus on Health Human Resources as a strategic priority as a strategic priority
Areas for further development Areas for further development and assessment... and assessment...
Number of goals PCH can Number of goals PCH can undertake in support of its undertake in support of its strategic priorities strategic priorities Overall timing for implementation Overall timing for implementation of three-year plan of three-year plan Strategic approach to resource Strategic approach to resource allocation to meet overall allocation to meet overall implementation timeline, and for implementation timeline, and for ongoing operations post ongoing operations post implementation implementation Ability to leverage experts, Ability to leverage experts, programs, best practices and programs, best practices and lessons learned from other lessons learned from other jurisdictions in Canada jurisdictions in Canada Change management support to Change management support to stakeholders to ensure uptake of stakeholders to ensure uptake of strategic initiatives into strategic initiatives into operations operations
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
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AHW RHA Efficiency Review
Peace Country Health
Findings and Opportunities Final Report July 14, 2006
0 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Property of Alberta Health 2006 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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Project Overview
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Project Overview
Scope, Objectives and Business Drivers
Scope: Alberta Health and Wellness is undertaking an RHA Efficiency Review to identify potential efficiencies and opportunities for improvement within each of the RHAs in the province. To achieve this purpose, this Review is focusing its scope on improvements to deployment across five key dimensions:
Increases to productivity Improvements to patient flow Improvements to patient outcomes Improvements to financial stewardship Exploration of province-wide opportunities
The review does include voluntary organizations, but will not be reporting to the voluntary boards. Project Objectives There are three primary objectives that direct the activities of this Review:
Identify performance improvement issues and opportunities. Identify productivity and performance improvement strategies and solutions. Provide recommendations to optimize: available resources, operational efficiency, service delivery, safety and quality.
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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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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:
Identification of opportunities at a cluster / provincial level. An opportunity prioritization and mapping exercise to support regional planning and goforward monitoring.
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Clinical Resource Management
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Clinical Resource Management
Overview Clinical resource management analysis includes CIHI analysis (internal trending of complexity and utilization data and external comparison of utilization data for each program) and the results of the MCAP review. In conducting an internal review of the complexity and utilization data, a drilldown approach is used to understand changes in utilization efficiency (volume, complexity and utilization efficiency).
Analysis is based on 2003-04, 2004-05 and 2005-06 Q2 data. A straight-line projection on 2005-06 Q2 data was used to project patient volumes.
In conducting an external comparison of utilization data, the goal is to identify potential opportunities to improve utilization in relation to CIHI ELOS and peer performance.
A drill-down approach is utilized, which begins with a "gross" assessment of utilization and potentially "conservable days" opportunities by comparing Peace Country's acute ALOS by CMG to the CIHI acute ELOS. The analysis is based on the 2004-05 data. This analysis is then fine tuned to determine the more realistic opportunities related to improved utilization management. A filter is applied that specifies the number of cases required and the minimum variance in ALOS required before an opportunity can be considered realistic. For example, if there were fewer than 10 cases or the conservable days for the CMG are less than .5, it is not considered to be a realistic opportunity.
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Top 10 Patient Services (2003-04 to 2005-06p) CIHI Abstract Data (Region)
The Top 10 Patient Services account for 98% of the region's total caseload. Comparison over the past three fiscal years suggests a consistent distribution of key patient services:
General Medicine represents almost 50%, Obstetrics/Newborns represents almost 25%, and Paediatrics Medical/Surgical represents 10% of current volume.
Patient Service General Medicine Newborn Obstetrics Delivered Paediatric Medicine Orthopaedic Surgery General Surgery Psychiatry Obstetrics Antepartum Gynaecology Paediatric Surgery Top 10 Patient Services Total Other Patient Services Total Region Patient Services Total
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2003-04 8,751 1,888 1,874 1,630 929 809 752 462 356 131 17,582 307 17,889
2004-05 8,875 1,845 1,829 1,496 942 939 781 379 327 145 17,558 305 17,863
2005-06 Projected 9,006 2,049 2,028 1,770 867 1,053 750 402 288 147 18,360 369 18,729
Three-Year Variance 3% 9% 8% 9% -7% 30% 0% -13% -19% 12% 4% 20% 5%
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Patient Volume, Weighted Cases and Patient Acuity (Region)
18000 15000 12000 9000 6000 3000 0 Patient Volume
2005-06 Projected 2003-04 2004-05
18000 15000 12000 9000 6000 3000 0 Weighted Cases
2003-04 2004-05 2005-06 Projected
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 inpatient volume increased by 5% over the three year spread.
2003-04 2004-05 2005-06 YTD
Note: 2005-06 data is projected.
Overall regional Patient Acuity (RIW) has also increased over this period by 2%, which has resulted in a corresponding 6% increase in Weighted Cases.
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Patient Volume, Weighted Cases and Patient Acuity by Plx (Region)
12000 10500 9000 7500 6000 4500 3000 1500 0 Plx Level I/II Plx Level III/IV Plx Level IX 2004-05 2005-06 Projected
8000 6000 4000 2000 0 Plx Level I/II Plx Level III/IV Plx Level IX 2005-06 Projected
Cases by Plx
12000
Weighted Cases by Plx
2003-04 2004-05
2003-04
10000
Acuity by Plx
4 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 Region's patients are Plx level I/II. However, volumes are increasing across all Plx levels:
2003-04 2004-05 2005-06 YTD
Plx III / IV volumes have the highest rate of increase (15%) with a matching acuity increase (17%). This patient grouping is the key driver of the overall increase in weighted cases (35% for Plx III/IV).
Acuity decreased slightly for Plx I/II (at 1%) and Plx IX 9 (at 4%).
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.
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Import/Export Inpatient Volumes for PCH
By Complexity for 2004-05
As a % of total Cases for each Plx % Imports % Exports 2004-05 Plx I/II 5% 15% Plx III/IV 4% 25% Plx IX 2% 9% Total 4% 14%
In examining the impact of import/export on inpatient volumes for 2004-05, an overall average of 4% of patients were imported into PCH in 2004-05:
Further examination suggests that 51% of imported patients are from Northern Lights Health Region.
Overall, 14% of inpatient volumes were exported from PCH in 2004-05.
Plx III/IV patients demonstrated the highest level of export, at 25%. Further examination suggests that 76% of exported patients are sent to Capital Health Region.
Although not demonstrated here, analysis suggests that imports/exports as a % of total cases has not changed significantly for PCH over 2003-04, 2004-05 and 2005-06 YTD.
Further the proportion of import/export by Plx level and across CMGs has also been comparable over the three-year period.
Source: Alberta Health & Wellness CIHI DAD, 2003-04, 2004-05 and 2005-06 YTD 11 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Average Length of Stay vs. Expected Length of Stay
as a Region
Peace Country Health Region 6 5 4 3 2 1 0 2003-04 Average ALOS 2004-05 2005-06 Q2 Average ELOS
Length of Stay analysis reveals that PCH's average length of stay (ALOS) is consistently higher than the CIHI expected Length of Stay (ELOS) PCH has been working to close the gap, as a decrease in this gap from 0.7 days to 0.6 days is observed for the region. The chart below shows the growing group of Plx III/IV patients drive the gap, particularly in the last two years.
PLx Level I/II Fiscal Year ALOS 2003-04 2004-05 2005-06 Q2 4.8 4.7 4.5 ELOS 3.9 3.8 3.9
Plx Level III/IV ALOS 13.5 15.1 16.4 ELOS 13.6 13.9 15.0
Plx Level IX ALOS 4.4 4.8 4.3 ELOS 3.8 3.9 3.8
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Average Length of Stay vs. Expected Length of Stay
By Site
2004-05 6 5 4 3 2 1 0
Cr ee k
Ri ve r
ie w
he
Q EI I
Be av er lo dg e Ce nt ra lP ea ce
ri e
rt
ni ng
Ca c
Pr ai
irv
ea
an
H ig h
Pe a
ra
Average ALOS
G
Average ELOS
A comparison of the facilities that are driving overall regional ALOS to ELOS gap suggests that this is a region-wide challenge:
Queen Elizabeth II (gap 1.17) Beaverlodge (gap of 1.07) Central Peace, Fairview, Peace River (all have gap of approximately 0.6) High Prairie and Sacred Heart (both have gap of approximately 0.45) Manning (gap of 0.36)
Only Grande Cache demonstrates an ALOS that is in line with ELOS.
13 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Sa
Va lle
Fa
ce
nd e
Fo
cr
ed
x
M
yv
H
ie w
Top 10 CMGs by Potential Days Savable in 2004-05
as a Region
CMG
851 483 847 222 765 609 766 138 840 783
CMG Description
Other Factors Causing Hospitalization Diabetes Other Specified Aftercare Heart Failure Depressive Mood Disorders without ECT with Axis III Diagnosis Vaginal Delivery with Complicating Diagnosis Depressive Mood Disorders without ECT without Axis III Diagnosis Respiratory Neoplasms Other Admissions with Surgery Psychoactive Substance Dependence
Total Cases
645 277 59 238 50 478 164 63 13 114 2,101 17,866 19,967
Total Acute Average CIHI Expected ALOS Days Length of Stay Length of Stay ELOS Gap
Potential Days Savable
2,279 542 500 466 398 335 330 298 257 249 5,652 17,748 23,400
5,339 1,805 1,058 1,932 1,285 1,439 2,799 793 390 769
17,609 73,263 90,872
8.28 6.52 17.93 8.12 25.70 3.01 17.07 12.59 30.00 6.75
4.74 4.56 9.46 6.16 17.74 2.31 15.06 7.86 10.27 4.57
3.53 1.96 8.47 1.96 7.96 0.70 2.01 4.73 19.73 2.18
Top 10 Region CMGs Total Other 333 Region CMGs Total Total Region CMGs
Leading CMG for savable days is "Other Factors". Coding improvements are required to identify appropriate strategy. Next highest CMG cluster is Mental Health related, which may have implications for bed expansion.
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.
14 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Top 10 CMGs by Potential Days Savable in 2004-05
as a Region Further drill down of this ALOS to ELOS potential days savable at a site level indicates:
"Other Factors" (CMG 851) and Other Specific Aftercare (CMG 500) are dispersed across the entire Region. The leading sites are Peace River, High Prairie, Central Peace and QEII. As stated, increased effort on coding can identify the clinical nature of these patient populations. Diabetes (CMG 483) is also dispersed across the Region suggesting a need for stronger regional approach to care management, as diabetes admissions as primary diagnosis are out of line with observation across other organizations. Heart Failure (CMG 222) is seen at about half the sites with QEII having the least potential days savable. Suggests the need for stronger regional approach to care management. Mental Health (CMG's 765, 766 and 783) are concentrated at QEII, although do show some opportunity in the rural sites. The potential improvements in LOS may have implications for bed expansion and / or the need to expand supportive services post discharge.
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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
Comparison of PCH actual ALOS to CIHI ELOS suggests the Region could save as many as 36 beds.
59 37 33 15
When compared to peers, using the same filter process, the region can save 15 beds.
12 of the 15 beds are at QE II. Given the small potential beds savable at the remaining sites, saving these 3 beds is not likely feasible.
CI H
Pe er
H
ith ou m pa t Fi ris lte Co on r m W pa ith ris Fi on Pe lte er W r ith Co ou m pa t Fi ris lte on r W ith Fi lte r Co
Co
m
pa I
ris on
I
W
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.
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CI
AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Top 10 CMGs by Peer Potential Days Savable in 2004-05
at QEII
CMG CMG Description
Depressive Mood Disorders without ECT without Axis III Diagnosis Depressive Mood Disorders without ECT with Axis III Diagnosis Bipolar Mood Disorders, Manic without ECT without Axis III Diagnosis Anxiety Disorders (MNRH) Bipolar Mood Disorders, Manic without ECT with Axis III Diagnosis Major Lower and Upper Extremity Procedures for Trauma Knee Replacement Hip Replacement Schizophrenia and Other Psychotic Disorders w/o ECT or Axis III Diagnosis Psychoactive Substance Abuse
Total Cases
106 41 34 16 13 167 91 100 78 46 692 9,746 10,438
Total Acute Average Days Length of Stay
Peer Average Length of Stay
14.5 18.0 18.1 7.9 24.4 4.0 6.4 7.1 22.0 3.6
ALOS Peer Avg ALOS Gap
7.1 7.8 8.7 13.6 15.9 1.1 1.9 1.6 1.9 3.1
Potential Days Savable
749 318 296 218 207 182 171 162 150 142 2,595 1,740 4,335
766 765 770 791 769 666 354 352 777 784
2,287 1,056 913 344 524 851 756 872 1,868 308
9,779 42,915 52,694
22 26 27 22 40 5 8 9 24 7
Top 10 QEII CMGs Total Other 325 QEII CMGs Total Total QEII CMGs
When QEII CMGs are compared to peers, mental health cases represent the 7 of the top 10 opportunities for potential days savable, equal to over 5.5 beds. This supports earlier observation that PCH should consider opportunities around mental health bed management with respect to the planned mental health bed expansion and / or the need to expand supportive services post discharge.
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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MCAP Review
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MCAP Overview
Process
An MCAP review was conducted to:
Gain a better understanding of patients' required levels of care and their specific care needs and the impact these needs have on inpatient bed utilization Identify system issues why patients are not at appropriate level of care.
MCAP is a utilization management tool that uses rigorous scientifically researched and validated criteria to review the intensity of services required for any given patient and determine the appropriate level of care required. The tool uses a "service-driven methodology" and focuses on the treatment plan/services ordered for that day. By avoiding the placement of patients at too high or low of a care level, health care managers can be assured that patients will receive the highest possible care quality and will move through the health care system in the shortest possible time. The review was conducted by Registered Nurses certified in MCAP. They reviewed the charts of all admitted inpatients in the Acute Care settings between January 23 - 27, 2006. MCAP was completed using patient charts as well as discussions with members of multidisciplinary team. Using the MCAP criteria, the following three key questions were answered for each admitted patient:
Does the patient require the level of care (i.e. Long Term Care, Acute Care, Intensive Care, etc.) they are receiving? If not, what level of care does the patient require? Why is the patient not at the level of care they require?
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Patient Profile by Site
PCH Acute Care
On day of review, Beaverlodge, Grande Cache and High Prairie had low occupancy (50%, 36%, and 60% respectively). Both Peace River and QEII had over 80% occupancy. Average patient age was 54 years. This average age driven is by QEII (with an average of 50 years; other sites had an average age of 63 75 years). 48% were female; 52% were male.
Site Beaverlodge Grande Cache High Prairie Peace River Queen Elizabeth II Grand Total
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Total Number of Beds 18 11 23 30 162 244
Number of Beds Reviewed 9 4 14 25 133 185
QEII 71%
Beaverlodge 5%
Grande Cache 2% High Prairie 8%
Peace River 14%
AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
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Patient Profile by Site and Service
PCH Acute Care
185 out of a possible 244 patients (or 75%) were reviewed at 5 acute care sites in PCH.
Site Patient Service Medicine Palliative Medicine Surgical Medicine Surgical Medicine Peace River Obstetrics Psychiatry Surgical Peace River Total
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Number of Beds Reviewed 8 1 9 3 1 4 12 2 14 20 1 1 3 25
Site
Patient Service ER Observation Intensive Care Medicine NICU
Number of Beds Reviewed 1 5 51 4 8 8 22 6 28 133 185
Beaverlodge Beaverlodge Total Grande Cache
Queen Elizabeth II
Obstetrics Paediatrics Psychiatry Rehabilitation Surgical
Grande Cache Total High Prairie High Prairie Total
Queen Elizabeth II Total Grand Total
AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
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Patients With Insufficient MD Documentation
PCH Acute Care
QEII Peace River High Prairie
25 7 7 114 19
Site
% with Insufficient Documentation 11% 0% 50% 0% 14% 15%
Beaverlodge Grande Cache High Prairie Peace River
20 40 60 80 100 120 140
Grande Cache 4 Beaverlodge
0
81
QEII Total for Region
Sufficient Documentation Insufficient Documentation
Overall, 27 of 185 reviewed patients (or 15%) had insufficient MD documentation. Where insufficient MD documentation exists, our clinical team is unable to appropriately determine if the patient meets clinical criteria for admission. This percentage of patients with insufficient MD documentation suggests opportunity for improvement in physician charting.
22 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Patients Who Meet Clinical Criteria for Admission
PCH Acute Care
Site
QEII Peace River
13 12 86 28
Percent Meeting Clinical Criteria for Admission 38% 75% 57% 52% 75% 69%
Beaverlodge Grande Cache High Prairie Peace River
High Prairie 4 3 Grande Cache 3 1 Beaverlodge 3 5
0 20 40 60 80 100 120
QEII Total for Region
Meet Admission Criteria Do Not Meet Admission Criteria
For patients with sufficient documentation, the clinical team determined that 109 out of 158 patients (or 69%) reviewed met criteria for admission to the service they were on. As shown in table (upper right), there is significant percentage variation by site. In comparing these results to our experience with other regions and hospitals in Canada, PCH is in line with peers, although still has opportunity for additional improvement. The observed average for other Canadian sites is approximately 65-75% of patients in the most appropriate care setting.
23 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Patients Who Meet Clinical Criteria for Admission
Queen Elizabeth II Acute Care
Surgical Rehab-Slow Psychiatry Paediatrics Obstetrics NICU Medicine Intensive Care ER Observation
0
20 5 1 14 6 8 4 24 4 1
5 10 15 20
6
Service
7
Percent Meeting Clinical Criteria for Admission 100% 80% 67% 100% 100% 86% 67% 83% 77% 75%
1
ER Observation Intensive Care
12
Medicine NICU
1
25
30
35
40
Obstetrics Paediatrics Psychiatry Rehab-Slow Surgical Total for QE II
Meet Admission Criteria Do Not Meet Admission Criteria
Focusing this analysis on QEII, 75% of patients reviewed (or 86/114) met clinical criteria for admission to the service they were on. As demonstrated by the chart (at right), Medicine and Psychiatry at QEII demonstrate the lowest percentage of patients who met criteria, which is consistent with other reviews.
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Patients Identified as Requiring a Different Level of Care
PCH Acute Care
Percent Identified as Requiring a Different Level of Care 60% 0% 67% 92% 75% 76%
QEII Peace River High Prairie
2 1 11
21 1
7
Site
Beaverlodge Grande Cache
Grande Cache 1 Beaverlodge 0
3 2
High Prairie Peace River
5
10
15
20
25
30
Queen Elizabeth II Total for Region
Identified
Not Identified
Of the 49 patients who did not meet clinical criteria, 37 (76%) of this group were already identified by the facilities as requiring a different level of care. This suggests an opportunity across the Region to improve in the early identification of patients requiring a different level of care.
More specifically at QEII, early identification focus should be in Medicine, Surgery and Psychiatry.
25 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Required Level of Care for Patients Not Requiring Acute Care PCH Acute Care
For patients who did not meet clinical criteria for admission, the most frequently observed care level required was Continuing Care, followed by Home, Rehabilitation, Outpatient and Home Care. Given the higher proportion of patients requiring discharge "Home" at QE II, this suggests a need to focus on discharge barriers within local and peripheral communities in catchment.
Required Level of Care Acute Sub-Acute Rehabilitation Palliative Continuing Care Group Home / Assisted Living Home Care Outpatient Home Total
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Beaverlodge
Grande Cache
High Prairie
Peace River
QEII 2 1
Total 2 1 8 1
1
3 1
4
3
2
5 1 1
4
14 1
5 4 8
6 7 9 49
2 1 5 1 3
1
12
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Reasons Patients Did Not Meet Clinical Criteria
PCH Acute Care
Of these same 49 patients who did not meet clinical criteria, 25 of the 49 (or 51%) were related to challenges accessing different levels of care or resources in the region. An additional 12 of these 49 (or 27%) did not meet acute admission criteria.
QEII Peace River High Prairie Grande Cache Beaverlodge 0
1 3 2 2 1 9 11 1 8 8 3
5
10
15
20
25
30
Access to Internal RHA Resources Inappropriate Admission
Delay in Discharge Planning Sociodemographic
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Acute Care Profile Summary: January 23 27, 2006
Met Clinical Criteria for Admission Rehabilitation
8
109
Continuing Care Beds Reviewed
14
Did Not Meet Clinical Criteria for Admission
185
Homecare
Acute Care Bed Capacity
49
6
244
Insufficient MD Documentation
Outpatient
7
27
Home
9
Beds Not Reviewed Other
59
5
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Clinical Resource Management Opportunities
Opportunities Findings QEII currently uses swing beds to offset bed availability for ER admits. Based on the CMG analysis, QEII has an opportunity to reduce length of stay across existing services, and thereby reduce occupancy of swing beds.
1.Realize length of stay savings Length of stay savings at QEII are dependent on resource availability / realignment in community and ambulatory care. at QEII
An early patient discharge strategy requires an increased focus on patient / family / caregiver education, and strengthened external partnerships with broader social support resources. 2.Examine Regional Admission/ Discharge Criteria Length of stay savings at QEII are dependent on consistent criteria for discharge to peripheral sites. Based on the potential days savable analysis, the predominance of diabetes, heart failure and mental health suggests the need for implementation of alternative models/settings of care. Improved awareness of and education on admission/discharge best practices to staff will also support the realization of this opportunity. Analysis identified CMG 851 (Other Factors Causing Hospitalization) and CMG 847 (Other Specified Aftercare) as having the highest potential days savable to ELOS. 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.
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3.Improvements to Regional Coding and Abstracting
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Clinical Resource Management Opportunities
Opportunities Findings The MCAP review found 15% of inpatient charts could not be not assessed for eligibility for admission due to insufficient physician documentation. 4.Improve MD Documentation in Inpatient Charts Where this occurs, there is a heavy requirement and reliance on verbal communication between physician and team to support care management. The heavy reliance on verbal communication has potential risk issues for patient outcomes, and potential for increased length of stay without clear discharge direction. Clinical Resource Management analysis shows opportunity for length of stay reduction in Mental Health at QEII. This finding suggest reexamination of planned bed expansion in Mental Health.
5.Continue efforts to re-focus Mental The examination of mental health programming should also include Health planning non-bedded mental health services as viable alternatives service efforts on broader delivery models. continuum of care Management team identifies that much of the Mental Health Program Plan was approved and has moved to implementation phase (since January 06 when the consulting team was on site).
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Clinical Resource Management Opportunities
Opportunities Findings Clinical Resource Management findings show a need within PCH for alternative levels of care and settings to support patient flow, maximize use of acute resources, and adopt leading practice. PCH's future planning needs to fully reflect the continuum of care settings. 6.Continue to expand and re- Specific examples supporting this opportunity include: focus functional planning to Low occupancy at Beaverlodge and its proximity to QEII suggests include non-acute service opportunity to consider a different focus of care for this facility delivery. e.g. urgent care, rehabilitation, palliative care, transitional care.
The region reports support for this alternative role in its current capital planning. Through continued monitoring of required level of patient care, consider the creation of sub-acute, ALC or rehabilitation units where critical mass exists e.g. High Prairie, Peace River. The region reports support for this in its current capital planning.
7.Explore the availability of incremental levels of continuing care and supportive housing 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.
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Clinical Program Review
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Clinical Program Review
Introduction
Our review of the clinical programs and facility-based care across PCH has focused on identifying key findings and opportunities related to service delivery and staffing. Clinical programs and services will be reported on in the following order:
Clinical Programs and Facilities QEII Medicine and Critical Care Services QEII Surgery and Perioperative Services QEII Obstetrics, Neonatal and Paediatric Services QEII Emergency Department Services Regional Mental Health Services Rural Acute Care Facilities Regional Continuing Care Facilities Regional Home Care Services Regional Emergency Medical Services Regional Population Health Services Regional Environmental Health Services
33 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Clinical Program Review
Nursing Staffing Process Overview
The relative efficiency of patient/resident care services was assessed based on a comparative analysis of staffing levels and skill mix for each inpatient care unit using three key inputs:
GRASP Systems International Database (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, RPNs, and certain percentage of Health Care Aides. UPP hours include regular worked, relief, and overtime, and exclude benefit hours (i.e., vacation and absenteeism). HPPD were calculated 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, however, and need to be considered in the context of other opportunities identified for each clinical area
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QEII Medicine and Critical Care
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Peer Staffing Comparative Analysis
QE II - Medicine Opportunities Findings
1. Review the current roles and Transition Coordinators are in place in QEII to manage functions of staff related to discharge discharge planning and utilization management. planning and utilization management Social Work reports increasing role in discharge in the region, as part of the planning, but that it is still an evolving function. development of a regional discharge Consultation findings across the clinical programs planning model that incorporates suggests that challenges exist in the discharge rural site repatriation from QEII, and planning function at QEII, and that there is need for a supports timely discharge to patient's clear framework, policies and procedures, and home community. (Note: this education to support discharge planning and opportunity applies to all clinical utilization management as a regional function. programs) Rehabilitation program beds are underutilized (38%) and are currently being used as additional space for 2. Explore opportunity for staff savings ER overflow. It is expected that this is driving staffing or increased activity in the comparison findings that 5N has a small staff savings Rehabilitation unit in Medicine 5N, in opportunity of 2.2 FTE. alignment with a broader regional Conversely there is an opportunity for increased community health needs assessment. utilization of the rehabilitation beds within the current staffing complement.
Unit/Area Description 5N Medical 3N Medical
36
Actual FTEs 2004-05 28.4 30.9
Actual FTEs 2005-06 YTD 28.3 33.5
Actual HPPD 2004-05 5.3 5.0
Recom'd HPPD 4.9 5.0
Recom'd FTE (Effic.)/ Re-Invest. 2004-05 (2.2) 2006 Deloitte Inc
Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
QE II Critical Care Opportunities
1.Relocate outpatient activity out of the ICU to an ambulatory care setting. 2.Relocate telemetry within the ICU and create a combined ICU/CCU. 3.Create a specialized and dedicated clinical educator to support ICU staff. 4.Examine ICU staff savings opportunity once other opportunities have been achieved, with consideration of crosstraining ICU staff in emergency and recovery room care.
Findings
Cardiology outpatient procedures such as tilt tables and cardioversions are currently performed in the ICU, which is out of line with peer practice and may cause challenges to staff workload and patient care on the unit. ICU staff are remotely monitoring telemetry patients on 3N. ICU staff are trained in CCU. The ICU has over 50% of staff with less than 2 years experience, so has an increased need for targeted education and senior clinical support. The observed staffing ratio to patients is not standard of typical ICUs. Common practice at QEII is to staff ventilated patients 1:1 and cardiac patients 1:2 - Staff/patient ratios but this could be staffed at 1:2 for ventilated patients and 1:3 for Cardiology patients. This is a potential option to consider to achieve identified the staff savings opportunity, but should be considered only once other ICU opportunities have been explored. Analysis suggests that ICU has had a high level of sick and overtime over the past two years. The organization also has opportunity to consider cross-training ICU staff in the emergency and recovery room.
Actual FTEs 2005-06 YTD 25.6 Actual HPPD 2004-05 22.5 Recom'd HPPD 15.6 Recom'd FTE (Effic.)/ Re-Invest. 2004-05 (7.2)
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Unit/Area Description ICU
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Actual FTEs 2004-05 23.6
Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
QEII Surgical and Perioperative Services
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Peer Staffing Comparative Analysis
QE II Perioperative Services Opportunities
1. Develop an action plan that outlines an implementation strategy in response to the QEII and regional surgical services reviews, with consideration of resources required to support rural site surgical service repatriation. (Note: This opportunity applies to both Surgical and Perioperative Services)
Findings
The region recently completed a targeted review of QEII and regional surgical services. Current resourcing, equipment, facilities and ancillary support need to be assessed for impact before the region considers rural site surgical services repatriation. The OP Recovery area is currently being used as ER overflow, which can create challenges to patient care and the overall work environment for staff. The co-location of day surgery to the surgical unit is reported to result in day surgery being used as a `near-unit', suggesting need for further role clarity of this function.
2. Engage stakeholders in clarifying roles and functions of day surgery and recovery areas.
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Peer Staffing Comparative Analysis
QE II Perioperative Services Opportunities
3. Assess instrument inventory in conjunction with OR scheduling review, to determine appropriate inventory to support care delivery. 4. Continue efforts to determine most appropriate organizational alignment of CSR services in the region.
Findings
CSR services in the OR are currently provided by OR staff, separately from the broader regional CSR function. A review is currently underway to determine appropriate alignment of CSR services in the region (please refer to CSR section for related opportunity). Within the OR, a high level of instrument flashing is reported, due to challenges in OR case management and instrument inventory. The corresponding risk to patient safety has been documented through internal incident reports. PAC currently sees about 50% of surgical patients preoperatively.
5. A savings opportunity exists in PAC that relates to the percentage of patients seen in PAC and the use of telephone screening.
The number of patients being screened in PAC can be increased by the use of telephone interviews. Staffing comparison indicates a potential staff savings opportunity for the PAC relative to peers, based on 2004-05 staffing levels. This opportunity should be considered with respect to increasing the % of patients seen in the PAC.
Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 40 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Peer Staffing Comparative Analysis
QE II Perioperative Services Opportunities
6. Examine OR case management practices to address scheduling challenges that prevent sufficient time between cases to allow for correct instrument sterilization practices. 7. Explore identified efficiency opportunity in the combined OR and PACU related to the potential to increase throughput by prompt starts and decreased wait times between cases, within the current staffing complement. Further, in considering this opportunity, the region should examine OR skill mix to continue the use of OR technicians. 8. For O/P Recovery, the region should further examine the identified staffing investment relative to endoscopy volumes, to address current wait list for screening.
Unit/Area Description
Pre-Admission Assessment Clinic Operating Room / PACU O/P Recovery
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Findings
The QEII Sullivan Report raises several concerns about the utilization of OR time, including start, finish and turnover times. Staffing comparison suggests a staff savings opportunity the OR/PACU, and an investment opportunity in O/P Recovery. Efficiency opportunity in the OR/PACU represents an opportunity to increase OR volumes within the current staffing complement. For the O/P Recovery, a high level of endoscopy volumes may further suggest the need for a higher recommended HPPD, but this would require further investigation to determine.
Actual HPPD 2004-05
1.2 6.8 0.3
Actual FTEs 2004-05
2.4 27.9 1.1
Actual FTEs 2005-06 YTD
2.1 30.8 1.1
Recom'd HPPD
0.9 5.4 1.3
Recom'd FTE (Effic.)/ Re-Invest. 2004-05
(0.6) (5.9) See Above 4.0 See Above
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Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
QE II Surgical Care Opportunities Findings
1. Improve access to on-unit clinical The surgery units have a mix of RNs and LPNs. LPNs are moving to full scope of practice, but consultation findings educators as part of broader suggest that additional support is needed. regional refocus on education, with specific focus in surgery on Limited on-unit education is identified as a challenge to supporting LPN scope of practice. clinical practice. Late starts of cases results in some same day surgery patients having to stay overnight. The day/night unit is being staffed longer hours to address cases starting late and additional cases. 2. Explore the 4S/4N staffing investment opportunity through Staffing comparison for surgical care was combined due to further determination of the challenges in availability of separate staffing and activity appropriate alignment of staffing for comparison. Analysis for 2005-06 is presented, due to to the recommended HPPDs and the change in service delivery from 2004-05. the increase in beds related Staffing comparison findings suggest that the combined surgical services repatriation 4S/4N services have a staffing investment opportunity of from Capital Health. 3.9 FTEs. The allocation of these staffing investments across 4S/4N will require further examination by the region, with focus on aligning staffing to the recommended HPPDs for each area.
Unit/Area Description 4S Surgical Unit 4N Surgical Day Care
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Actual FTEs 2005-06 YTD 31.3 19.7
Actual HPPD 2005-06 See Above See Above
Recom'd HPPD 5.5 4.9
Recom'd FTE (Effic.)/ ReInvest. 2005-06 3.9 See Above
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Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
QEII Obstetrics, Neonatal and Pediatrics Services
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Peer Staffing Comparative Analysis
QE II Obstetrics Opportunities Findings
PCH recently had a review of regional obstetrics services. 1.Develop an action plan that The review found a number of opportunities for regional outlines implementation consideration, including the implementation of a single standard of care across facilities, and standardized provider strategies in response to the certification. regional obstetrical services review. Availability of epidural service is reported as a challenge at QEII due to nurse staffing. The unit reports that all staff have completed the 5-day 2.Improve access to on-unit Fundamentals of Obstetrics course and do on-line training clinical educators as part of through the APHP. broader regional refocus on education, centered on Consultation findings indicate that nurses are not all trained in supporting specialized skills Obstetrical Ultrasound and/or Vaginal examinations, which and knowledge in obstetrics. may impact staffing flow. 3.Explore options for obstetrics service delivery model and alignment of outpatient services to inpatient unit. Consultation findings suggest that the region currently has no midwifery program. This is a program that would support broader service delivery options for patients preferring alternate obstetrics services. Obstetrical assessment area is currently off-unit, which may impact ease of patient access to service and staffing efficiency.
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Peer Staffing Comparative Analysis
QE II Obstetrics Opportunities
4.When comparing staffing for both L&D and PP, QEII has a savings opportunity of 5.3 FTE through the reduction of 1 nurse 24/7. This opportunity is contingent upon the adoption of an LDRP model of care with associated infrastructure investments, and that predictable workload from repeat c-sections, assessments and inductions are scheduled appropriately. 5.Conduct a skill mix review in light of efficiency targets and best practice models of care for LDRP.
Unit/Area Description Labour & Delivery Post Partum
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Findings
Obstetrics reports that capturing true workload has been a challenge, and has begun to initiate q4h census to determine frequency of minimum staffing level requirements. Staff in L&D and PP are cross-trained and are reported as functional, but not expert in both areas. Lack of patient portering and support staff were identified in consultation as a challenge. RN skill mix is 100% in L&D and 75% in Post Partum. L&D staffing is currently staffed equivalent to 3 RNs 24/7 and Post Partum is staffed 4 RN 24/7. It is reported that at peak times the unit is unable to meet minimum staffing requirements. Staffing comparison suggest that across these two units there is a staff savings opportunity relative to peers. It is suggested, however, that this potential savings should be considered in context of a model realignment to LDRP, which would also suggest a need for further skill mix review. Shifting to an LDRP staffing model may require some infrastructure investment to improve staffing flow between the two units. Shifting to a full LDRP model for care delivery may require more substantial infrastructure investment, and so infrastructure costs should be considered relative to staffing opportunity.
Actual HPPD 2004-05 20.9 8.8 Recommended HPPD 9.5 3.4 Recom'd FTE (Effic.)/ Re-Invest. 2004-05 (5.3) See Above
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Actual FTEs 2004-05 16.3 20.9
Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
QE II Neonatal and Pediatric Services Opportunities Findings
Nursing staff are oriented to both Pediatrics and Intermediate Nursery and about 50% are cross-trained. 1.Establish a dedicated educator/CNS to enhance Intermediate nursery provides some short-term ventilator support. Ventilator days for 2004-05 are reported to be 28 days. clinical team knowledge in this specialized area, as Consultation findings suggest that LPNs on Pediatrics are not part of broader regional working to full scope of practice, which is impacting the need for refocus on education. higher staffing levels to support care delivery. Scope of practice for RT's is suggested to be an issue. Lack of portering and support staff were identified in consultation 2.Examine staffing as a challenge for Pediatrics and Intermediate Nursery, resulting opportunity with in higher workload for nursing staff. consideration of broader QEII need for patient Staffing comparison suggests that both Pediatrics and portering support, and Intermediate Nursery have opportunity for staff savings. The Pediatrics/Intermediate organization should consider these staff savings opportunities Nursery education support within the context of the above-identified need to shift RNs to full to move RNs to full scope scope of practice, and the broader QEII need for patient portering of practice. support.
Actual FTEs 2004-05 13.9 17.4 Actual FTEs 2005-06 YTD 15.2 16.7 Actual HPPD 2004-05 11.4 10.2 Recom'd FTE (Effic.)/Re-Invest. 2004-05 (4.7) (4.9)
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Unit/Area Description
Recom'd HPPD
Intermediate Nursery Pediatrics
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7.6 7.3
Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
QEII Emergency Services
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Emergency Department Volumes by Triage Level
QEII Volumes
Triage Level 2004-05 Emergency 2004-05 Proportion of Department Visits Total Emergency Visits CTAS National Averages: Weekday 0.4% 9.9% 37.9% 41.9% 9.5% 0% 0.4% CTAS National Averages: Weekend 0.2% 8.5% 38.9% 45.3% 6.7% 0% 0.4%
I II III IV V IX
Resuscitation Emergency Urgent Semi-Urgent Non-Urgent Unavailable
98 1499 17951 17159 5371 262
0
0% 4% 42% 41% 13% 1% 0%
Left Without Being Seen
Source: Alberta Health & Wellness ACCS Database
A review of 2004-05 triage levels suggests that the QEII emergency department visits are in line when compared to national standards. This analysis could not be completed for the other sites in PCH due to a lack of CTAS data reporting.
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Peer Staffing Comparative Analysis
QE II Emergency Department Opportunities
1.Conduct a full review of the QEII ED to determine appropriate alignment of staffing and physician resources, facilities and security, policies and procedures to support care requirements. Please refer to Infrastructure section for additional ED facilities opportunities 2.Create dedicated ED advance practice nurses / educators to support ED staff in knowledge and skills development in emergency and mental health care.
Findings
Consultation findings suggested a number of challenges currently being faced by the QEII Emergency Department:
ED facilities designed for significantly lower volume than current workload Current facilities do not provide appropriate space for increased volume of mental health patients coming to the ED, and present several impediments to patient care Security services in the ED are reported as limited, and a challenge to service delivery Physician coverage in the ED does not meet current demand Limited staffing is impacting ability to meet guidelines for reassessment of waiting room patients. Challenges in discharge planning and patient flow management, in part caused by need for additional portering, challenges in physician availability, and need for improved care responsibility for `unattached' patients
Consultation finding suggest that a number of RNs in the department are not formally trained in emergency or mental health nursing. LPNs are moving to full scope of practice, but consultation findings suggest that additional support is needed. Limited in-department education is identified as a challenge to clinical practice.
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Peer Staffing Comparative Analysis
QE II Emergency Department Opportunities Findings
3.Conduct regional assessment of Anecdotal reporting suggests varied compliance to CTAS CTAS use in the ED to recording, a lack of use of CTAS as a quality/risk determine resources, education management tool in the ED, and the need for increased support, and policies and education. procedures required to Reporting from the rural sites suggests similar challenges standardize use across the with respect to CTAS use in rural site EDs. region.
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Peer Staffing Comparative Analysis
QE II Emergency Department Opportunities
4.There is a significant opportunity for future investment in nursing staff for the QEII Emergency Department based on the trend of increased patient volumes, which needs to be considered in the context of a full ED review. 5.As part of staffing investment opportunity, staffing levels in the ER should be enhanced by 1 RN for every 24 hours to support the triage function of this busy Emergency Department. 6.As part of staffing investment opportunity, there is an opportunity to introduce a support worker role into the ER to provide ancillary support to nursing staff.
Unit/Area Description General ER & Overflow
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Findings
Consultation findings indicate that this is a highly charged and stressful working environment and analysis indicates that the ED has had high overtime usage over the past two years. ER could use dedicated psychiatric nurses to enhance care for patient presenting to the ER with mental illness. Nurses are performing a number of non-nursing duties such as portering, changing and cleaning stretchers, clean instruments, stock patient care areas with supplies, etc The EMS teams accompanying patients from out of region have a limit of a 3-hour wait time, after which additional pressures arise for nursing staff to take over care. The department is not physically designed to meet the needs of the increasing patient volumes. Staffing comparison indicates a significant investment opportunity for the QEII ED. Given current challenges of physical facilities, physician resources and clinical education supports, however, this opportunity needs to be considered in the context of a full review of the ED.
Actual FTEs 2005-06 YTD 31.2 Actual HPPD 2004-05 1.1 Recom'd HPPD 1.6 Recom'd FTE (Effic.)/Re-Invest. 2004-05 14.2
2006 Deloitte Inc
Actual FTEs 2004-05 30.7
Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Regional Mental Health Services
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Mental Health Outpatient Activity
PCH Overview
As presented below, PCH Enrolments increased by 12% between 2002-03 and 2004-05, while Events decreased by 6% for the same period High Prairie Mental Health Clinic showed the greatest growth for these two metrics over the three years analyzed, while Grand Prairie exhibits the highest volumes Although the region provides Adult, Pediatric, Geriatric and Student-focused mental health services, the majority of outpatient service delivery is focused on the Adult population (67%)
Average age for clients is 32 for females and 24 for males for the same period
Enrolments Clinics 2002-03 2004-05 1,254 408 105 84 127 58 2,036 1,292 474 252 103 106 63 2,290 3-Year Variance 3% 16% 140% 23% -17% 9% 12%
Events 2002-03 2004-05 16,782 4,926 1,216 944 1,362 666 25,896 15,395 4,727 1,794 1,078 950 487 24,431 3-Year Variance -8% -4% 48% 14% -30% -27% -6%
Grande Prairie Mental Health Clinic Peace River Mental Health Clinic High Prairie Mental Health Clinic Grande Cache Mental Health Clinic Fairview Mental Health Clinic Valleyview Mental Health Clinic Grand Total
Source: ARMHIS Database 2002-03 to 2004-05 53
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Mental Health Outpatient Activity
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 4,477 25,896 2002-03 1,353 686 699 17,138 19,876 1,543 2003-04 1,253 377 192 15,436 17,258 1,527 2 4,286 23,073 2004-05 1,284 408 55 16,010 17,757 2,048 11 4,615 24,431 3-Year Variance -5% -41% -92% -7% -11% 33% 3% -6%
As demonstrated above, outpatient mental health activity in PCH has been decreasing over the past three years by 6%
Group work shows the greatest decrease (92%), driven primarily by decreases in Grande Prairie and Peace River. This low volume of group work observed as of 2004-05 supports consultation findings that there is opportunity for an increase in mental health group sessions in the region.
Source: ARMHIS Database 2002-03 to 2004-05 54 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Mental Health Outpatient Activity
Top 10 Diagnoses Driving Enrolments Year over Year
Diagnoses Parent-Child Relational Problem Partner Relational Problem Major Depressive Disorder, Recurrent, Moderate Adjustment Disorder With Mixed Anxiety and Depressed Mood Relational Problem NOS Depressive Disorder NOS Phase of Life Problem Schizophrenia, Paranoid Type Adjustment Disorder With Depressed Mood Bereavement Top 10 Diagnoses Total PCH Total 2002-03 347 119 93 67 82 42 37 59 64 34 944 2,036 2003-04 373 157 61 56 85 56 54 63 64 61 913 2,151 2004-05 400 171 87 77 73 65 65 63 60 58 1,119 2,290 3-Year Variance 15% 44% -6% 15% -11% 55% 76% 7% -6% 71% 19% 12%
The top 10 diagnoses driving enrolments have increased by almost 20% over the past three years, and represent approximately 49% of total enrolments.
Source: ARMHIS Database 2002-03 to 2004-05 55 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Mental Health Outpatient Activity
Top 10 Referral Sources
The top 10 referral sources for mental health enrolments in PCH represent almost 99% of total enrolments. From these top 10 sources, the largest referral source for Mental Health enrolments in PCH was Self-Referral, at 29% in 2004-05 Although overall regional average time between referral and intake call for PCH in 2004-05 was 3.7 days, which is a slight increase from 2003-04. Referrals from hospital and AADAC demonstrate a significantly faster intake time, both less than 0.6 days in 2004-05. The time between intake call and initiation of services is not available. Referral source data for this analysis was only available for 2003-04 and 2004-05.
PCHR Top 10 Enrolment Referral Sources
RHA Hospital 3% RHA Community and Outpatient Services 2% Child and Family Services 2% Other Government 1%
Referral Source AADAC RHA Hospital Significant Other Self RHA Community and Outpatient Services Child and Family Services Other Government Educational Facility
Average Days Between Referral & Intake Call 2003-04 0.8 0.8 1.2 4.2 3.0 4.7 8.2 5.9 5.7 5.2 3.4 2004-05 0.3 0.6 1.1 1.3 2.9 4.3 4.6 6.3 6.5 9.1 3.7
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Other Agency 5%
Self 29% Physician / Psychiatrist 19%
Significant Other 18%
Source: ARMHIS Database 2003-04 and 2004-05 56
Educational Facility 21%
Physician / Psychiatrist Other Agency PCH Average
AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Mental Health Findings and Opportunities
Regional Services and QEII Psychiatry Opportunities
1.Continue work in regional mental health services planning to determine the most appropriate alignment of resources across the continuum to meet client needs. 2.Develop a targeted mental health strategy resource strategy to address current and anticipated capacity, staffing, physician and education requirements. 3.Establish formal partnerships with other mental health service providers (e.g. FAC, AADAC) to coordinate service delivery, and to collaboratively engage the community in reducing sociodemographic drivers of mental health illness.
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Findings
The QEII inpatient psychiatry unit has 26 beds but reported issues of overcrowding and staff shortages resulted in fluctuating bed numbers. Reports indicate that occupancy average is 98%, and that there is continuous wait list for admission. Walk-In Clinic Services in GP are not sufficient to meet current needs, resulting in overflow into the Emergency Department. There is a plan to close the Outpatient Clinic when the Day Treatment Program opens, which may further heighten this challenge. The Mental Health Program is threatened by a lack of psychiatrists, as there is currently only 1 psychiatrist at QEII, however GPs do also have admitting privileges. This lack of physician resources represents a significant risk to planned expansion of the mental health program. Consultation findings suggest that there is no single point of entry or coordinated access to community/facility MH services. Each team manages own workload and wait list, and there is limited linkage between inpatient services and community-based mental health. Challenges exist in the coordination of referrals from and discharges to rural sites. Further, rural sites identify challenges in access to services, training for staff, and appropriate facilities. Consultation findings also identified a low level of group services, which is supported through the mental health data analysis. There is no formal connection between FACS and mental health services, and a need for increased partnership and integration with AADAC for broader mental health service delivery in the region. This is needed to align size and resourcing for detox services
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Mental Health Findings and Opportunities
Regional Services and QEII Psychiatry Opportunities Findings
4.Explore increased use of The region currently uses telehealth for geriatric telehealth in mental health psychiatric assessments, and to support forensic mental services across the region, health services. These services are delivered primarily with consideration for both through external regional partnerships. internal service delivery and Broader use of telehealth services for mental health care the potential further delivery is not in place, which may help to alleviate part of expansion of current resource constraint challenges while still providing access external regional to service in the rural sites. partnerships. 5.Develop and communicate formalized admission and discharge criteria for the inpatient psychiatry unit in QEII and other regional mental health services. Admission and discharge criteria for the inpatient psychiatry unit are not formalized, which can cause challenges to access for patients in Grande Prairie, and for rural sites to refer patients to QEII.
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Mental Health Findings and Opportunities
Regional Services and QEII Psychiatry Opportunities
6.Examine future staffing resource alignment for the QEII psychiatry services as part of broader regional mental health services planning.
Findings
Analysis indicates that inpatient psychiatry has had high sick and overtime levels over the past two years. Staffing comparison suggests a small savings opportunity for QEII 5S relative to peers, and that 5S Follow-up is line with peers. Given the need for broader mental health services planning, however, adjustment to staffing is not recommended at this time.
Unit/Area Description 5S Psychiatry 5S Follow-up
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Actual FTEs 20004-05 29.7 1.4
Actual FTEs 2005-06 YTD 30.8 1.5
Actual HPPD 2004-05 5.3 2.5
Recom'd HPPD 4.9 2.5
Recom'd FTE (Effic.)/ Re-Invest. 2004-05 See Above See Above
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Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Rural Acute Care Facilities
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Peer Staffing Comparative Analysis
High Prairie Health Complex Opportunities Findings
1.Explore option to create a dedicated Access to alternative levels of care is reported as a ALC unit in High Prairie, and where challenge in High Prairie. this service delivery model may apply Limited on-site education is identified as a challenge to the remainder of the region's to clinical practice, so the region may consider a shift hospital sites. of High Prairie clinical resources to support on-site 2.Develop education plan for clinical clinical education, as part of broader regional HR and staff, as part of broader regional HR education strategies. and education strategy. Challenges are noted in maintaining perioperative staffing and volumes across Peace River and McLennan. Specifically, limited MD staffing is in place to support anesthesia service for more complex obstetrics cases, which presents a risk to patient safety. Given considerations for service model integration with McLennen, no staffing change is suggested at this point.
Actual HPPD 200405 5.7 0.6 16.7 Recom'd HPPD 5.9 0.9 1.3 Recom'd FTE (Effic.)/ Re-Invest. 2004-05 0.6 2.3 (1.9)
2006 Deloitte Inc
3.Examine options for service model integration across across High Prairie and McLennen, and consider alignment of staffing levels to meet resource requirements of integrated model.
Unit/Area Description Medical / Surgical Unit Emergency Operating Room
61
Actual FTEs 2004-05 20.6 5.0 2.1
Actual FTEs 2005-06 YTD 19.8 5.5 2.0
Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Grande Cache General Hospital Opportunities
1.Continue to monitor staff resource requirements relative to current and anticipated increase in demand due to catchment population. 2.Coordinate need for increased education support to staff as part of broader regional education strategy.
Findings
The Grande Cache community has recently had a resurgence in activity driven by local industry, which has resulted in a significantly increased catchment due to surrounding `shadow' population. Further, there are 7 non-status First Nations communities that have applied for, and are expected to be granted status. Although the current average daily census suggests some flexibility to accommodate additional patients, these changing population dynamics suggest the need for continued monitoring by the region for resource requirements in the community. Consultation findings identified the need for targeted staff development and clinical practice education support. Staffing comparison suggests that Grande Cache has a small opportunity for staff savings. Given education needs, and the anticipated increase in demand for services, however, no staffing change is suggested at this time.
Actual FTEs 2004-05 12.1 Actual FTEs 2005-06 YTD 12.8 Actual HPPD 2004-05 6.8 Recom'd FTE (Effic.)/Re-Invest. 2004-05 (3.7) See Above
Unit/Area Description Medical / Surgical / ER / OPD
Recom'd HPPD 6.0
Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 62 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Peer Staffing Comparative Analysis
Peace River Community Health Centre Opportunities
1.There is an investment opportunity in the combined Medical/Surgical and ER/OPD. This opportunity should be considered in light of the current issue of elderly patients waiting placement in the community. 2.Review options for improved patient flow into the Peace River emergency department, with consideration of associated infrastructure investment requirements. 3.An efficiency opportunity exists in the combined OR and recovery room related to the potential to increase capacity. This efficiency target is equivalent to 1.8 FTE and represents an opportunity to increase OR volumes within the current staffing complement. 4.Review role of Peace River in regional surgical services delivery, and consider staffing levels alignment relative to role.
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Findings
Peace River is the second largest facility in the region providing acute services and surgical and obstetrics programs. Since the closure of Grimshaw acute beds, the acute care services admission numbers have increased. Analysis suggests that length of stay has increased over the past three years. Consultation findings further identified that this may, in part, be due to a lack of continuing care beds in this area of the region which is reducing the availability of the acute care beds. Increasing oil and gas exploration in the community has also made an impact on the number of ER/OPD visits. Emergency patient flow is identified as a challenge due to the distance between patient registration and the emergency entrance. In part, these challenges are also resulting in low CTAS compliance, in line with the earlier identified regional opportunity. Changes to this model will require infrastructure investments. Consultation findings identified that additional capacity exists in the OR, so consideration should be made as to the option for the facility to increase throughput as an alternate approach to achieving efficiency. Given that a regional review of surgical services was recently completed for PCH, the region should consider these findings in determining the most appropriate role for Peace River in surgical service delivery, and align throughput or staffing to this role to target efficiencies in service delivery.
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Peer Staffing Comparative Analysis
Peace River Community Health Centre
*Note: Please refer to related staffing opportunities on the previous page.
Unit/Area Description Medical / Surgical / ER / OPD Operating Room Actual FTEs 2004-05 33.7 3.3 Actual FTEs 2005-06 YTD 34.3 3.2 Actual HPPD 2004-05 5.5 9.1 Recom'd HPPD 6.3 4.1 Recom'd FTE (Effic.)/Re-Invest. 2004-05 4.7 (1.8)
Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database
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Peer Staffing Comparative Analysis
Beaverlodge Acute Care Hospital Opportunities
1.Conduct a role review of Beaverlodge as part of regional care delivery planning, with future alignment of staffing based on role review decisions. (Please refer to Infrastructure section for further opportunity detail).
Findings
Beaverlodge is an old facility that requires replacement. Opportunities exist for a role evaluation of this facility, to complement the services provided in close proximity in Grande Prairie. The region reports support for this role review through its existing capital plans. Although staffing comparison suggests some opportunity for change, given the need to re-examine the overall role of Beaverlodge as part of regional facility-based care delivery, no staffing change is recommended at this point.
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
Medical / Surgical / ER/ OPD
19.1
18.8
5.3
5.7
4.3 See Above
Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 65 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Peer Staffing Comparative Analysis
Grimshaw/Berwyn & District Community Health Centre Opportunities Findings
Grimshaw is currently undergoing capital redevelopment 1. Engage stakeholders in a review and a shift in care delivery roles in the region. The of physician coverage and facility continues to have an ER with 4 ER holdover beds. transfer practices between Challenges are reported in ER services related to mixed Peace River and Grimshaw, to practice for physician coverage and for transfers between standardize practice in support Peace River. As a result some patients are held at of care delivery. Grimshaw longer than expected. Limited on-site education is identified as a challenge to 2. Develop education plan for clinical practice. For example, although the facility has Grimshaw staff to support ER services, not all staff are trained in ACLS. clinical education and shift to LPN full scope of practice, in At this point, the facility reports that LPNs are not alignment with broader regional required to work at full scope of practice, which limits HR and education strategies. flexibility in care delivery models. 3. Consider staffing investment Staffing comparison suggests that Grimshaw has a opportunity as it relates to the staffing investment opportunity of 1.2 FTEs, which is issues with holding patients in driven by the number of patients held in the ER for 24 the ER for longer than expected. hours or longer.
Unit/Area Description Emergency
66
Actual FTEs 2004-05 5.5
Actual FTEs 2005-06 YTD 6.0
Actual HPPD 2004-05 0.8
Recom'd HPPD 0.9
Recom'd FTE (Effic.)/ Re-Invest. 2004-05 1.2
2006 Deloitte Inc
Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Other Rural Sites
Although the consulting team did not visit the remaining rural sites in the region, a comparative peer staffing analysis was conducted. As outlined in the table below, there are several opportunities for resource realignment across the rural sites available for consideration. These opportunities should be explored further in the context of broader regional community health needs, before action is taken. Further, consideration should also be made of where acute and continuing care nursing staff cross-cover these respective areas within facilities, and where minimum staffing requirements exist, before the region takes action on these opportunities.
Actual FTEs 2004-05 Actual FTEs 2005-06 YTD Actual HPPD 2004-05 Recom'd HPPD Recom'd FTE (Effic.)/ Re-Invest. 2004-05
Site
Unit/Area Description
Central Peace Health Complex Fairview Health Complex
Medical / Surgical / ER / OPD Medical / Surgical / ER / OPD Operating Room
14.9 18.9 0.5 10.1 12.9 23.7 1.6 17.9
15.5 18.6 0.2 10.2 14.3 24.0 1.8 17.9
6.5 4.9 5.3 7.3 8.6 5.7 21.4 5.5
5.7 6.4 1.3 6.1 7.6 6.5 4.1 6.4
(2.8) 9.5 (0.3) (5.6) (1.2) 1.8 (1.3) 3.3
Fox Creek Health Centre Manning Community Health Centre Sacred Heart Community Health Centre Valleyview Health Centre
Medical / Surgical / ER / OPD Medical / Surgical / ER / OPD / OR Medical / Surgical / ER / OPD Operating Room Medical / Surgical / ER / OPD
Source: PCH 2004-05, 2005-06 Oct YTD Payroll, Deloitte Database, Grasp Database 67 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Regional Continuing Care Facilities
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Continuing Care Activity Analysis
PCH Weighted Cases by Facility
As depicted below, PCH had 39,602 continuing care weighted cases in Spring 2005, which represents an overall decrease in weighted cases by 10% from Fall 2002.
Regional continuing care beds increased from 447 to 450 over this same period.
12 11 10 9 8 Thousands 7 6 5 4 3 2 1 0 Valleyview Health Centre Grande Prairie Care Centre Manning Community Community Health Centre Fairview Health Complex Queen Elizabeth II Hospital MacKenzie Place J.B. Wood Nursing Home Sacred Heart CommunityHealth Centre Central Peace Health Centre Grimshaw/Berwyn Sutherland Continuing Care Centre Hythe Nursing Home Fall 2003
Source: Alberta Health & Wellness LTC Database 69
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Spring 2005
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Continuing Care Activity Analysis
PCH Weighted Cases by Classification
Fall 2005 Continuing Classification Care Weighted Cases A B C D E F G PCH Total 0 1,037 2,208 4,682 6,270 17,555 7,850 39,602 Fall 2005 Proportion of Total Cases 0% 3% 6% 12% 16% 43% 20% 100% Proportion Variance Fall 2002 to Spring 2005 -100% -27% 16% 22% -16% 1% -35% -10%
F 43%
Source: Alberta Health & Wellness LTC Database
Proportion of Weighted Cases by Classification G 20%
A 0% B 3% C 6% D 12%
E 16%
Almost 80% of PCH's continuing care weighted cases are distributed across classifications E, F and G as of Spring 2005.
Overall proportion of E, F and G weighted cases has decreased from 84% in Fall 2002 to 79% in Spring 2005, although classification F weighted cases have been fairly stable. Although the region has reduced its facility-based residents in classifications A and B, an increase in residents classified as C and D is observed. Combined with the decrease in classifications E and G, this increase in C and D contributes to the overall decline of 10% in total regional continuing care weighted cases.
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Continuing Care Staffing Comparative Analysis
PCH Continuing Care
Opportunities Findings
1.Continue planning and Limited supportive housing / assisted living exists in the region, to implementation efforts bridge the gap between home care and continuing care services. related to regional Plans are in place to create a 60-bed complex through private Continuing Care Plan, to partnership, however evidence of broader regional planning ensure optimal alignment around supportive housing was not observed. of care resources to The region has recently completed a continuing care plan that supportive housing and outlines future planning needs. continuing care needs. Continuing care has had difficulty in attracting and retaining aide staff, as salaries are no longer competitive relative to other market opportunities for staff. 2.Develop a targeted HR Recent temporary closure of beds in Continuing Care have plan for Continuing Care, occurred due to staffing shortages, while patients are reported as part of the broader waiting in acute care for continuing care placement. regional HR strategy The Director currently has regional continuing care, home care and site responsibility for Mackenzie place. This is a fairly large portfolio, and may impact management ability for broader planning and decision-making. PCH facilities demonstrate varied levels of staffing across the 3.Examine staffing region. allocations of total care Recent AHW announcements suggest that regions should target team across continuing an average level of 3.4 hours per resident day of combined care facilities with respect nursing and personal care staffing. to recent AHW target of Given the trend for increasing involvement of rehabilitation and 3.4 HPRD, and in context recreation therapy disciplines in continuing care service delivery, of continuing care HR however, the region should examine total care team staffing planning. levels in determining appropriate alignment to the AHW 3.4 HPRD.
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Peer Staffing Comparative Analysis
PCH Continuing Care
Continuing Care staffing levels are compared to the recent AHW recommendation that residents receive 3.4 Hours per Resident Day (HPRD) of combined Nursing and Personal Care, for facilities with an average CMI of 100. There are several notes for consideration in reviewing this staffing comparison for PCH Continuing Care:
This comparison do not include staffing related to rehabilitation and recreation therapy. Although the consulting team recognizes the presence of units in Peace River and Mackenzie Place West 1 that have a higher CMI than their respective facility average CMI, only the facility average CMIs were available for this comparison. This should be considered in reviewing the identified staffing opportunity for Peace River and Mackenzie Place West 1. Given the current changes at Grimshaw, this facility is not included in this comparison. Site Central Peace Health Centre Fairview Health Complex High Prairie Health Complex Hythe Continuing Care Centre Mackenzie Place - East 1 Mackenzie Place - East 2 Mackenzie Place - West 1 Manning Community Health Centre Peace River Community HC Sacred Heart Community HC Valleyview Health Complex
Source: PCH 2004-05, 2005-06 Oct YTD Payroll 72 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Actual FTEs 2005-06 YTD 11.8 41.8 25.6 24.9 20.4 31.3 35.0 31.9 9.4 32.8 29.7
Actual Total Paid Recom'd FTE AHW Recom'd 3.4 HPRD 2005-06 Effic.)/ Re-Invest. HPRD @ 100 CMI YTD 2005-06 4.1 3.6 3.5 3.9 4.2 3.5 6.9 3.1 4.5 3.4 3.2 2.8 3.1 2.8 3.6 3.5 3.5 3.5 3.2 3.5 3.1 3.2 (3.7) (5.4) (5.1) (1.6) (5.5) 0.1 (15.0) 0.3 (7.5) (2.4) (0.2)
Regional Home Care Services
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Regional Home Care Services
Findings and Opportunities
Opportunities
1. Develop and implement workload measurement 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. Similar to continuing care, home care is faced with a significant challenge in attracting and retaining PCAs due to market competition and low salaries. Recent unionization of PCAs has resulted in further challenges to adjust compensation to market rates. PCA staff are not cross-trained, and are not aligned to individual clients resulting in challenges in resource management and care delivery. 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.
2. Develop a targeted recruitment and retention plan for PCAs, that is integrated into the broader regional HR strategy.
3. Develop standardized discharge/transition planning policies and procedures throughout the region.
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Regional Emergency Medical Services
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Regional Emergency Medical Services
Findings and Opportunities
Opportunities
1.Consider options for multiple levels of patient transport with central coordination as the region continues to develop the EMS program. 2.Develop an EMS human resources plan for staff union amalgamation and future resource needs, as part of broader regional HR strategy. 3.Continue to develop an overall cost assessment for the EMS program that projects cost and resource requirements for the RHA to operate EMS for the region, and identifies a strategy to align resources to identified requirements. Please refer to Infrastructure section for additional opportunities related to EMS facilities and equipment.
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Findings
The region is currently in the process of adopting the EMS program from municipal providers. As a result, full cost of EMS operations have not yet been assumed by the region. Consultation findings for EMS identified several challenges that the region is facing as it integrates this service into regional operations: EMS employees are currently in different unions, the amalgamation of which will likely increase overall staffing costs to the region. The EMS service currently lacks a centralized dispatch, which impacts service coordination. Facilities and equipment are currently a mix of municipal and regional ownership. Some communities have only one ambulance, which can lead to extended wait times. The region is lacking dedicated patient transportation vehicles, which results in extended wait times for inter-facility transfers.
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Regional Population Health Services
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Population Health
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
Travel is identified as a challenge for service delivery, given the geographic distribution of the region. Although the region does use telehealth for some service delivery, opportunity exists for programs to further leverage this technology to improve access to service (e.g. Chronic Disease Management). Community health services report significant workload associated with `shadow' populations in industry camps throughout the region. Stakeholders also identify the need for improved coordination for service provision to communities or industry camps that border with other regions or provinces. Services for First Nations and M tis populations are reported as challenged due to different sociodemographic, cultural and jurisdictional issues, suggesting need for improved linkage with Aboriginal Health Liaison Workers in the region.
2. Explore options for increasing partnerships with other regional, provincial and federal service providers to improve overall community health service delivery in the region.
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Regional Environmental Health Services
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Environmental Health
Opportunities
1.Conduct a regional review of Environmental Health services to align service programming and resources to increasing community health inspections needs and to meet minimum provincial standards. 2.Implement a consistent and standardized workload activity tracking system to enhance resource management and utilization.
Findings
The increasing number of hotels, restaurants, food stores, rental housing and industrial work camps is reported as putting a strain on the ability of the program staff to conduct routine inspections. Given the region's current staffing, Environmental Health reports being unable to meet AHW blue book standards for routine inspections, which is a significant potential risk to the region. An additional 3.5 FTEs have been requested for FY07 (2.0 FTEs based in Grand Prairie, 1.0 FTE in Peace River, with 0.5 FTE clerical support) in order to increase response times to urgent request and manage routine inspections.
- Because workload and activity are not currently tracked for all inspections, however, alignment of resource requests to workload is difficult to determine.
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Physician Findings and Opportunities
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Physician Findings and Opportunities
Introduction
The review process incorporated several direct consultations with physicians, which have yielded a number of findings and opportunities. Physician-related findings and opportunities have been clustered into the following four key areas, which also have linkage to opportunities identified across other areas of the region:
Physician Governance and Leadership Physician Human Resources Planning and Management
Quality, Risk and Performance Management
Physician Findings and Opportunities
Program Review and Organization
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Physician Findings & Opportunities
Governance and Leadership
Findings
Review of the VP Medical portfolio suggested that the portfolio is very extensive given responsibility to manage physician issues as well as clinical support services, with limited direct staff to support the VP. Consultation findings suggest that gaps in physician accountability related to adherence with by-laws and medical policies/procedures currently exist, which are causing challenges in overall physician governance and leadership in the region. Further, variation in leadership roles and definitions suggests a need for greater alignment between current physician leadership structures/supports and requirements of the region, to focus leadership on regional responsibilities and perspective.
Opportunities
1. Conduct an external review of MAC governance structure/mechanisms with specific attention to by-law adherence/alignment. 2. Conduct an alignment diagnostic of the VP Medicine portfolio, to consider overall organization structure and support resources required to support strategic HR focus on physician recruitment and retention. 3. Conduct an alignment review of physician leadership requirements across all services, with further development of the regional focus and responsibility of roles.
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Physician Findings & Opportunities
Physician Human Resources
Findings
The region is facing several physician recruitment/retention issues and staffing shortages. For example, shortages in Internal Medicine in QEII create challenges in providing regional internal medicine support as well as supporting other services. Similarly, primary care shortages results in the service being insufficiently resourced to provide access across the region. A broader physician HR strategy is lacking which ensures alignment of physician skill mix with care and service delivery priorities for the region, and considers alternative remuneration strategies to attract and retain physicians. A supporting education structure to facilitate advanced physician training and maintenance of certification is also lacking in the region. A significant risk issue is evident in resourcing the validation of credentials and maintenance of competence. Physician recruitment is reported as often occurring without consideration of physician impact on other clinical services (i.e. nursing, allied health), space availability & bed capacity, equipment requirements, IT/IS requirements, etc.
Opportunities
1.Engage physicians and regional leadership in the development of a regional Physician Human Resource Strategy that is linked to the broader regional strategy, to address Physician resource gaps, skills management and education, alignment/realignment of current resources to core service delivery needs, remuneration and recruitment/retention. There is a need for a `made in the north solution' a northern human resource stabilization initiative. 2.Explore alternative payment models for physicians in the region, with an objective to improve resources 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.Develop a regional Physician Impact Assessment process that is used for physician recruitment needs planning, and in assessment when new physicians are being considered.
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Physician Findings & Opportunities
Quality, Risk, & Performance Management
Findings
Consultation findings indicate that there are no current CME requirements from a regional perspective; although CME requirements are applied for Canadian-trained physicians, requirements do not currently exist for foreign-trained medical graduates. The region is currently lacking an assessment framework for MD quality, performance, or competencies which is further compounded by a lack of funding or resources available to maintain education and certification. There is a need for greater physician accountability related to developing and maintaining consistent standards of practice throughout the region. Further, there is need for a physician risk management framework to assess and proactively manage physician-related issues and risks at the service, site, community and regional levels.
Opportunities
1. Create an accountability framework with evaluation and quality/risk/performance management tools for Physicians, which is integrated into the broader regional framework. 2. Develop a regional approach and support for CME for both Canadian-trained and foreigntrained medical graduates, based on a sustainable business model, and integrated with the physician recruitment and retention strategy and broader regional education function. 3. 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 & Opportunities
Clinical Program Frameworks and Review
Findings
Consultation suggests that several of the rural facilities and/or clusters of facilities continue to operate in silos based on previous regional configuration or site-specific needs. There is continued effort needed to get buy-in on Regionalization. Further, communication and coordination of services across region continues to be a challenge for select areas, which suggests a need for greater integration region-wide. Observed challenges across the region suggest a need for a greater regional focus across various services to:
Define scope of service for current and future community/regional needs. Ensure congruence of site/regional services with functional planning exercises. Assess and determine current/future capacity requirements/constraints. All of which need to be linked to a recent and comprehensive community needs assessment
Specific clinical program challenges in Emergency, Internal Medicine and Psychiatric services suggest the need for a more in-depth review that examines the role, function and resourcing required of these areas as regional programs.
Opportunities
1. Conduct external reviews of Emergency, Internal Medicine and Psychiatric services as regional programs. 2. Establish program framework for Family Medicine, Surgery, Obstetrics as programs that are provided across the majority of sites throughout the region, which defines scope of service in alignment to community health needs and resource availability. 3. Enhance communication between the rural sites and regional hub in Grande Prairie by leveraging Telehealth technology in a structured approach for coordination of service, information sharing of leading practices, CME and professional support.
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Physician Findings & Opportunities
Summary of Key Issues
The following five key issues summarize the physician findings and opportunities for the region:
1. Risk Management (e.g. single resource specialty, triage, IMGs) 2. Human Resources (e.g. quantity, quality, critical mass, comprehensive planning) 3. Physician Support (e.g. infrastructure, IT/IS, governance) 4. Vision-Mission Alignment with Community Health Needs Assessment 5. Northern Strategies and Resulting Partnerships
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Clinical Support and Allied Health Services
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Clinical Support and Allied Health Services
Peer Staffing Comparison Process Overview
To understand the relative efficiency of the Clinical Support and Allied Health services, we conducted a comparative analysis with a number of comparable health regions from Alberta, British Columbia, Manitoba, and Saskatchewan Fiscal 2004-05 data for PCH 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 MIS-based 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 and Allied Health Services Areas Reviewed
MIS Code 71410 71415 71435 71440 71445 71450 71455 71460 71470 71485 MIS Description Clinical Laboratory Diagnostic Imaging Respiratory Therapy Pharmacy Clinical Nutrition Physiotherapy Occupational Therapy Audiology And Speech/Language Pathology Social Work Recreation Therapy
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 90 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Peer Staffing Comparative Analysis
Clinical Laboratory
Opportunities
1. Continue plan to repatriate specialized testing volume from Peace River and northern sites to QEII, where this is expected to result in cost savings 2. Develop a lab utilization management framework, process and roles to monitor and improve lab service utilization 3. Engage physician, lab and IT stakeholders in developing a plan to integrate Meditech lab results with clinic systems.
Findings
Clinical Labs is a regionalized service with centralized management and the majority of specialized testing in QEII, with charge technologists or CLXTs responsible for the rural sites. Cytology is not available in the region, and so all volume is referred to Edmonton. Peace River and other northern sites refer specialized testing directly to Edmonton, although this volume will be repatriated in May 2006. Labs has moved to standardized equipment where possible, and standardized lot numbers for reagents as a quality control mechanism. Limited physician utilization monitoring or controls for lab services are currently in place, however, which is a likely driver of inefficiencies. Region-wide electronic availability of lab results will be available through Phase 1 of the Meditech implementation. Continued maintenance of the linkage of the Meditech LIS module to physicians' clinic systems (e.g. in Peace River) will be important to maintaining physician efficiencies and care management. Reported challenges include lack of casual staff and increasing workload, which contribute to increased turnaround times also noted as a challenge by the clinical departments. Staffing comparison suggests that Clinical Labs is has a small savings opportunity of 3.6 FTE the 50th percentile. Given plan to repatriate northern volume to the region, and the need for focus on lab utilization management, it is suggested that the region re-examine staffing once repatriation is complete. Actual FTEs 2005-06 YTD 87 Actual HAPD 2004-05 0.39 Alberta Alberta National Peer Potential Peer Peer HAPD 50th Percentile FTE (Effic.)/ HAPD MIN MAX Re-Invest. HAPD 0.03 0.82 0.37 (3.6) See Above
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Area Description
Actual FTEs 2004-05 78.9
Clinical Laboratory
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 91 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Diagnostic Imaging
Opportunities
1.Explore partnership with Health Registry for common transcription staffing and dictation system, to drive part of staffing opportunity. 2.Explore opportunities to increase throughput within existing staff complement, to drive part of staff savings opportunity and increase access to select modalities. 3.Examine opportunities to reduce DI records staff and film costs once regional PACS is in place. 4.Explore options for evergreen equipment contracts as a means of reducing up-front capital costs.
Actual FTEs 2004-05 68.4
Findings
DI is a regional service with primary services at all sites, with CT at Peace River and QEII, and Nuclear Medicine, MRI and Angiography also available at QEII. PACS exists at Peace River and High Prairie, and a mini-PACS is in place for MRI and CT at QEII. Region-wide PACS is pending implementation of the provincial PACS strategy. Between 15-20% of DI equipment is reported as outdated (e.g. QEII CT > 10 years), but limited capital dollars have been made available for replacement since the Medical Equipment Fund. The region is not currently using an evergreen model for equipment. Dictation for DI is done internally, based on a tape-based Dictaphone system, with no current partnering with Health Registry. Report turnaround time is 48-50 hours. Staffing comparison suggests that DI (excluding DI porters) has a 13.9 FTE savings opportunity at the 50th percentile. Staging of this opportunity should be considered relative to future potential savings through implementation of a regional PACS. Further, the region will need to balance potential staffing reductions with the option to instead increase throughput. This may be a targeted strategy for areas that show high waitlists.
Actual FTEs 2005-06 YTD 71.6 Actual HAPD 2004-05 0.33 Alberta Peer HAPD MIN 0.09 Alberta Peer HAPD MAX 0.63 National Peer 50th Percentile HAPD 0.26 Potential FTE (Effic.)/ Re-Invest. (13.9)
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Area Description
Diagnostic Imaging
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Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Respiratory Therapy
Opportunities Findings
Respiratory Therapy overtime usage has increased from 5.6% of total paid hours in 2004-05 to 7.5% in 2005-06 YTD, and is higher than other clinical support and allied health areas in the organization. This suggests opportunity for premium cost savings. Further, consultation findings indicate a shortage of clerical staff, resulting in RTs doing some administrative work in support of clinical delivery. Staffing comparison suggests that Respiratory Therapy has a small staff savings opportunity of 0.6 FTE relative to peers at the 50th percentile. A projected decrease in 2005-06 YTD staffing levels, however, suggests that the region has moved to a staffing level below peers, which may be driving higher overtime levels and increased administrative workload for RTs - and may suggest need for staffing investment if the region continues at the projected 2005-06 staffing level.
Actual FTEs 2005-06 YTD 12.3 Alberta Peer HAPD MIN 0.01 Alberta Peer HAPD MAX 0.12
1. Continue to monitor staffing levels relative to overtime premium use, to determine need to recruit additional staff for service delivery.
Area Description
Actual FTEs 2004-05
Actual HAPD 2004-05 0.07
National Peer 50th Percentile HAPD 0.06
Potential FTE (Effic.)/ Re-Invest. (0.6) See Above
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Respiratory Therapy
13.1
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 93 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Pharmacy
Opportunities Findings 1. Continue focus on drug Pharmacy is a regional program that is centrally managed by one out-of-scope Director, with a mix of Pharmacists, Pharmacy Assistants and Technicians, but utilization through the limited Pharmacists in the rural sites. P&T committee with additional focus on The region is on a central automated unit dose system, where unit dose packs for best practices, the rural sites are prepared and distributed centrally from QEII. Lack of on-site medication errors and Pharmacist presence in several rural sites results in limited medication order review education. for those sites, however, which presents potential risk to patients and the organization. 2. Establish consistent practices around Pharmacy is working with Materials Management to improve pharmaceutical medication order inventory controls and management, and has a shared Pharmacy Assistant position review across the in place to support this collaboration. Although the region will not be on centralized region to mitigate risks drug purchasing until later in the Meditech implementation, in comparison with and improve patient peers, PCH is above drug expenses/APD. care. PCH has started a quality council to begin focus on medication errors, but this is still 3. Examine staffing levels in early stages of development. Although a P&T Committee exists, drug utilization following planned is identified for improvement, which may also be contributing to higher than peer recruitment of vacant drug supply costs. Pharmacist positions, Staffing comparison suggests that Pharmacy has a small staff savings opportunity of and establishment of 3.7 FTE relative to peers at the 50th percentile, but no change is suggested as this standardized difference is likely driven by the need for a higher level of Pharmacy Assistants and medication order Technicians to compensate for a lack of Pharmacists in the rural sites of the region. review across the The region should re-evaluate staffing levels pending planned recruitment of region. additional Pharmacists.
Area Description Pharmacy
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Actual FTEs 2004-05 27.2
Actual FTEs 2005-06 YTD 29.7
Actual HAPD 2004-05 0.13
Alberta Peer HAPD MIN 0.07
Alberta Peer HAPD MAX 0.20
National Peer 50th Percentile HAPD 0.12
Potential FTE (Effic.)/ Re-Invest. (3.7) See Above
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Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Clinical Nutrition
Opportunities
1. Examine opportunities to pursue improved efficiency and effectiveness of service delivery through increased use of telehealth to reduce travel requirements.
Findings
Clinical and Community Nutrition is a regional cross-continuum service that provides traveling service to rural sites. Travel is noted as a challenge, resulting in downtime in service delivery. Opportunity to reduce travel downtime was identified through increased use of telehealth in service delivery. Challenge to this opportunity exists, however, with respect to limited telehealth support resources to support clients receiving service. Staffing comparison suggests Clinical Nutrition has a small staff savings opportunity of 2.1 FTE at the 50th percentile, but given regional travel requirements the suggested focus for change is instead on increasing use of telehealth as a means of improving service efficiency and accessibility.
Area Description
Actual FTEs 2004-05
Actual FTEs 2005-06 YTD 10.9
Actual HAPD 2004-05 0.06
Alberta Peer HAPD MIN 0.01
Alberta Peer HAPD MAX 0.06
National Peer 50th Percentile HAPD 0.05
Potential FTE (Effic.)/ Re-Invest. (2.1) See Above
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Clinical Nutrition
11.4
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 95 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Physiotherapy
Opportunities Findings
Physiotherapy is a regional service, with most communities having PTs that work across the continuum of care. In Grande Prairie, PTs are aligned to support acute, residential or community care. 1. Explore Access to service and increased waitlists are noted as challenges to service opportunity delivery. Where vacancies exists, contract services are used, but are noted for staffing as not being effective in meeting full care delivery needs. savings in context of A high level of PTs in the rural sites are reported to be close to retirement, so broader succession planning with HR is underway. Due to preferences of new grads Physiotherapy for greater work-life balance, the service is now shifting to staff 2 PTs/site to succession maintain current volumes and still meet staffing requirements. planning, Physiotherapy has had increased education workload to support home care support to PCAs, as contract changes resulted in multiple PCAs caring for each client. SHIP, and Staffing comparison suggests that Physiotherapy (including Home Care PT) rehab unit has staff savings opportunity of 8.2 FTE at the 50th percentile. Some of this staffing opportunity is related to PT support of SHIP, however, and so the region requirements. must discount these resources before moving on this opportunity. Further, the presence of a dedicated rehab unit in the region is unique among many national peers, and so likely contributes to higher staffing requirement.
Actual FTEs 2004-05 Actual FTEs 2005-06 YTD 40.3 Actual HAPD 2004-05 0.20 Alberta Peer HAPD MIN 0.09 Alberta Peer HAPD MAX 0.30 National Peer 50th Percentile HAPD 0.16 Potential FTE (Effic.)/ Re-Invest. (8.2) See Above
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Area Description
Physiotherapy
40.9
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 96 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Occupational Therapy
Opportunities
1.Explore opportunity for staffing savings in context of broader Occupational Therapy succession planning, support to SHIP, and rehab unit staffing requirements. 2.Continue to explore opportunities to use telehealth as a means of reducing travel downtime, to contribute to staff savings opportunity.
Findings
Occupational Therapy is a regional service that is centrally managed, but locally coordinated in each of the rural sites. Travel across rural sites is noted as a challenge, but work with schools is expected to transition to a higher level of telehealth once SuperNet is rolled out to the schools. The department has a high level of junior staff, who require ongoing mentoring and support from senior staff. Junior staff also have different work-life balance requirements, with limitations on travel that are driving more local-based services across the rural sites. Staffing comparison suggests that Occupational Therapy (including Home Care OT and SHIP) has a 5.1 FTE savings opportunity at the 50th percentile. Some of this opportunity is related to OT support of SHIP, however, and so the region must discount these resources before moving on this opportunity. Further, the presence of a dedicated rehab unit in the region is unique among many national peers, and so likely contributes to higher staffing requirement. Actual FTEs 2004-05 Actual FTEs 2005-06 YTD 24.8 Actual HAPD 2004-05 0.12 Alberta Peer HAPD MIN 0.07 Alberta National Potential Peer FTE Peer 50th HAPD Percentile (Effic.)/ HAPD Re-Invest. MAX 0.17 0.10 (5.1) See Above
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Area Description
Occupational Therapy
97
24.9
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Audiology & Speech Language Pathology
Opportunities Findings
Audiology and Speech Language Pathology (SLP) are both regional programs that are centrally managed with local coordination. Audiology provides service to the full age continuum, and has implemented a universal newborn screen program. PCH has sound booths in both Grande Prairie and Peace River to support care delivery. SLP provides both adult and pediatric services, and staff are aligned to serve one of these two populations, with an ability to follow clients throughout the continuum of care. Challenges in SLP delivery include travel requirements, especially for widely dispersed adult clients, and several vacancies which are compounding these challenges. Although some contract staff is in use, high cost of these resources limits the scope of services available. Both services have faced recruitment challenges. Staffing comparison suggests Audiology/SLP has a small staffing investment opportunity of 2.1 FTE at the peer 50th percentile. Once current vacancies in Audiology and SLP are filled, it is expected that the combined service will be in line with peers. Actual FTEs 2004-05 19.2 Actual FTEs 2005-06 YTD 18.1 Actual HAPD 2004-05 0.09 Alberta Alberta National Potential Peer Peer Peer 50th FTE (Effic.)/ HAPD HAPD Percentile Re-Invest. MIN MAX HAPD 0.04 0.21 0.10 2.1 See Above
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1. No opportunity identified.
Area Description
Audiology & Speech Language Pathology
98
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Social Work
Opportunities Findings
Social work is a regional service based out of QEII, with some resources based in the rural sites. Travel requirements for Social Workers from QEII to provide service to the rural sites is noted as a challenge, and is a cause of 1. Work with service delivery downtime. The service is increasing use of Transition telehealth where possible to reduce travel-related downtime, and is Coordinators and focusing on increasing locally-based resources. clinical programs to support Social Work works with the Transition Coordinators to support improvements to discharge planning, although the need for improvements to discharge planning consistency in the discharge planning process are noted. process. Staffing comparison suggests that Social Work has a small staff savings opportunity of 2.1 FTE at the peer 50th percentile. Given the suggested focus for region to focus on improving transition coordination, no change to staffing is suggested at this time. Area Description Actual FTEs 2004-05 7.4 Actual FTEs 2005-06 YTD 8.3 Actual HAPD 2004-05 0.04 Alberta Peer HAPD MIN 0.003 Alberta Peer HAPD MAX 0.04 National Potential Peer 50th FTE (Effic.)/ Percentile Re-Invest. HAPD 0.03 (2.1) See Above
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Social Work
99
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Recreation Therapy
Opportunities Findings
Recreation Therapy is focused on continuing care across the region, but also provides support to inpatient mental health services at QEII, and adult day programs in Grande Prairie, Beaverlodge, Hythe and Peace River. Staffing comparison suggests that Recreation has a minor staff investment opportunity of 0.7 FTE at the peer 50th percentile. Once current Recreation vacancies are filled, however, it is expected that the service will be in line with peers.
1.No opportunity identified.
Area Description
Actual FTEs 2004-05 18.8
Actual FTEs 2005-06 YTD 21.3
Actual HAPD 2004-05 0.09
Alberta Peer HAPD MIN 0.03
Alberta Peer HAPD MAX 0.11
National Peer 50th Percentile HAPD 0.10
Potential FTE (Effic.)/ Re-Invest. 0.7 See Above
Recreation
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05
100
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Corporate and Support Services
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Corporate and Support Services
Peer Staffing Comparison Process Overview
To understand the relative efficiency of the Corporate and Support Services, we conducted a comparative analysis with a number of comparable health regions from Alberta, British Columbia, Manitoba, and Saskatchewan Fiscal 2004-05 data for PCH 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.
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Peer Staffing Comparative Analysis
Corporate and Support Services Areas Reviewed
MIS Primary Account 71105, 71110, 71205, 71170, 71305, 71505 71115 71120 71840 71125 71135 71145 71150 71153, 71155, 71165, 71175 71190, 71180, 71130 71195, 71910
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Departments General Administration and Nursing Administration Combined (Combined to ensure comparability to peer reported data) Finance Human Resources/Personnel and Occupational Health & Safety Clinical Affairs and Education Systems Support Regional Information Management Materiel Management (includes all CSR for the region) Housekeeping Laundry And Linen (excluding any CSR staff) Plant Operations, Maintenance and Biomedical Engineering Combined (Combined to ensure comparability to peer reported data) Health Records, Registration and Telecommunications Combined (Combined to ensure comparability to peer reported data) Patient/Resident and Non-Patient Food Services Combined (Combined to ensure comparability to peer reported data)
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AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
General and Nursing Administration Combined
Opportunities
1. Consider staffing investment opportunity with respect to building management capacity for planning and performance management.
Findings
PCH has had a high level of purposeful management turnover and new role creation over the past three years. Anecdotal reporting suggests that management has limited time and capacity for broader planning, program management and development. Quality and risk management are new functions that are developing within the region, but currently have limited staffing to support the functions. As these programs rollout through the region, increased time demands are expected on management. Staffing comparison suggests that General Administration (including Nursing Administration) has an investment opportunity of 2.8 FTEs at the 50th percentile. Actual FTEs 2004-05 Actual FTEs 2005-06 YTD 73.7 Actual HAPD 2004-05 0.37 Alberta Peer HAPD MIN 0.09 Alberta Peer HAPD MAX 0.44 Potential National FTE Peer 50th (Effic.)/ Percentile HAPD Re-Invest. 0.39 2.8
Area Description
General & Nursing Admin. Combined
74.5
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 104 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Peer Staffing Comparative Analysis
Finance
Opportunities
1.Consider opportunity to shift some Finance resources into a regional Decision Support function to support broader analysis and planning. 2.Support initiatives to develop activitybased costing capacity to enable better understanding of activity.
Findings
Finance has recently re-staffed to full complement, and is currently in role re-alignment. The department has a high proportion of junior professional staff, and so several staff are still in a learning mode. Finance reports limited role in broader Decision Support function for the region, but does provide financial analysis. Components of Decision Support as a function are currently provided across Finance, Health Records and Information Management, but improved coordination across these areas is suggested to facilitate planning and management decision-making. Finance further reports limited ability to identify activity costs - which impacts business case development, physician impact assessment, etc. This also impacts ability to capture true costs of the shadow population on service delivery. Staffing comparison suggests that Finance has a 5.7 FTE savings opportunity at the 50th percentile. In part, this may be driven by the need for a higher level of staffing due to a lack of available CA professionals.
Actual FTEs 2005-06 YTD 33.6 Actual HAPD 2004-05 0.17 Alberta Peer HAPD MIN 0.05 Alberta Peer HAPD MAX 0.19 National Peer 50th Percentile HAPD 0.14 Potential FTE (Effic.)/ Re-Invest. (5.7)
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Area Description
Actual FTEs 2004-05
Finance
105
34.4
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Human Resources/Personnel
Opportunities Findings
HR is a regional function, with a dedicated recruitment team, HR Consultants and a `one-stop shopping' Help Desk model, but has no dedicated labour relations resources, and no education function. 1.Consider HR Broader organization departments and clinical programs reported a mixed level and OH&S of support from HR, with respect to recruitment, staff management, staffing levels performance management, education and management training. with respect Staffing comparison suggests that HR (including OH&S) is above peer staffing to broader levels and could have a savings opportunity of 11.1 FTE, however given need regional refor broader regional re-focus on HR strategy and management, no savings focus on HR opportunity is currently identified. The current lack of an HRIS further impacts strategy and work efficiencies, which should be considered with respect to this opportunity. management. OH&S is a separate department from HR, and has had 100% turnover in the Please refer past year, but has been fully staffed since Fall 2005. Many OH&S programs are to HR section in place, but the department is in rebuild mode with respect to service for additional provision and delivery. opportunities Limited OH&S presence over the past few years has resulted in several workplace safety concerns, limited attention to disability management, and limited organization confidence in the department.
Area Description Human Resources / Personnel and OH&S
106
Actual FTEs 2004-05 25.1
Actual FTEs Actual Alberta Alberta National Peer 2005-06 HAPD Peer HAPD Peer HAPD 50th Percentile YTD 2004-05 MIN MAX HAPD 23.8 0.13 0.03 0.13 0.07
Potential FTE (Effic.)/ Re-Invest. (11.1) See Above
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Peer Staffing Comparative Analysis
Clinical Affairs and Education
Opportunities Findings
PCH currently lacks a region-wide organization development and education function, although preliminary planning was in place at the time of review to 1.As part of explore the development of this function. broader Clinical staff education is provided through Clinical Affairs, although the regional HR department's focus on program development vs. delivery has been identified re-focusing, as a significant challenge to effecting staff education and development by the develop a clinical program areas. On-unit educators are identified as a regional need. regional Non-clinical staff currently have no regionally-organized education available, education although some areas do report good education support through their function that department management. supports both From a management development and training perspective, although the clinical and region has some training options available, they are not well communicated non-clinical or understand by department managers. This has resulted in limited education, management training and development, which is a challenge given the recent and includes number of new managers in the organization. management Staffing comparison suggests that Education (including Clinical Affairs) is training and above peer staffing levels and could save 4.9 FTEs, however given need for development. broader regional HR re-focusing, no savings opportunity is currently identified.
Area Description Clinical Affairs and Education
107
Actual FTEs 2004-05 12.5
Actual FTEs 2005-06 YTD N/A
Actual HAPD 2004-05 0.06
Alberta Peer HAPD MIN 0.01
Alberta Peer HAPD MAX 0.06
National Peer 50th Percentile HAPD 0.04
Potential FTE Effic.)/ Re-Invest. (4.9) See Above
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Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Systems Support Regional Information Management
Opportunities
1. Consider IT staffing levels with respect to broader regional IT and RSHIP implementation management. Please refer to Technology section for additional opportunities
Findings
Staffing comparison suggests that IT has a staff savings opportunity at the peer 50th percentile of 6.9 FTEs. Given the current RSHIP initiative and associated resources, however, it is suggested that the region consider broader IT staffing requirements relative to implementation and ongoing operations maintenance and support of the Meditech system before exploring this potential staffing opportunity further.
Area Description
Actual FTEs 2004-05
Actual FTEs 2005-06 YTD 20.5
Actual HAPD 2004-05 0.09
Alberta Peer HAPD MIN 0.04
Alberta Peer HAPD MAX 0.17
National Potential Peer 50th FTE (Effic.)/ Percentile Re-Invest. HAPD 0.06 (6.9) See Above
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Systems Support
19.1
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 108 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Materiel Management
Opportunities
1. Consider potential staff savings opportunity once regional CSR realignment is complete, and with respect to role distribution for laundry and food services distribution.
Findings
MM is a centralized regional function responsible for purchasing, inventory, distribution, regional fleet, and also includes a regional transportation service that distributes supplies, drugs, labs, DI films and linen. PCH participates with other rural RHAs in a GPO through HealthPro, as a means of reducing overall supplies spend, and reports 70% product standardization of medical products. Staff in rural sites are cross-trained to do MM, laundry and CSR work. Staffing comparison suggests that MM (including CSR and CSR function in OR) has a significant savings opportunity at the 50th percentile equivalent to 18.9 FTEs, but this should be considered once CSR re-alignment is complete. The impact of MM roles in laundry and food distribution should also be considered with respect to staffing levels.
2. Explore CSR services in the region are functionally managed and delivered by consolidation of Laundry staff and staff in the OR, although limited coordination and practice the CSR function, standardization across these functions currently exists. and re-consider An operational review of CSR for the region is currently underway, and MM staffing anecdotal reporting suggests good opportunity to consolidate CSR into one opportunity once function for the region. CSR staff are re- Re-alignment of CSR into one function will provide good opportunity for aligned. practice standardization and review of staffing levels. Area Description Materiel Management
109
Actual Actual FTEs Actual Alberta Alberta National Peer Potential FTEs 2005-06 HAPD Peer HAPD Peer HAPD 50th Percentile FTE Effic.)/ 2004-05 YTD 2004-05 MIN MAX Re-Invest. HAPD (19.3) 56.7 56.6 0.28 0.06 0.43 0.19 See Above
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Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Housekeeping
Opportunities Findings
Housekeeping is a regional service, and zones staff at QEII to increase staff competency in specialized areas. Staff challenges have increased due to reported high sick time, and difficulty recruiting given market wage rates. Staffing comparison suggests that Housekeeping has a small FTE savings opportunity of 0.7 FTEs at the 50th percentile for 2004-05, but 2005-06 appears to be tracking at a level that is below the 50th percentile. Need for improved communication with nursing about isolation areas was reported as a current risk to housekeeping staff safety. Risk management in this department and others should be linked into a broader risk management framework for the region. Actual HAPD 2004-05 0.59 Alberta Peer HAPD MIN 0.24 Alberta National Potential Peer Peer 50th FTE (Effic.)/ HAPD Percentile Re-Invest. HAPD MAX 0.62 0.59 (0.7) See Above
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1. Monitor staffing levels for 200607 to determine if alignment of staffing levels relative to peers.
2. Develop structured communication process between Housekeeping and Nursing for isolation area cleaning, with linkage to broader organization risk management framework. Actual FTEs 2004-05 Housekeeping 120.9
Actual FTEs 2005-06 YTD 117.2
Area Description
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 110 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Laundry & Linen
Opportunities
1. Work to reduce overtime as a premium cost driver for Laundry and Linen, with consideration of time requirements to maintain current revenue generation. See CSR opportunity for additional information.
Findings
Laundry is a regional service, with the majority of service centralized at QEII using an automated tunnel, with regular delivery to the rural sites. The laundry service also provides service to clients, generating revenue for the region. Laundry overtime usage has averaged at 3% for 2004-05 and 2005-06 YTD, which is higher than other corporate and support areas in the organization, suggesting opportunity for premium cost savings. This premium cost should be considered with respect to Laundry's revenue-generating role. Staffing comparison found Laundry (excluding CSR) to be in line with peers. Staffing levels should be considered relative to staffing in Materials Management and Food Services, where mixed roles in support staff exists. Actual FTEs Alberta Peer HAPD MIN 0.07 Alberta Peer HAPD MAX 0.21 National Peer 50th Percentile HAPD 0.19 Potential FTE (Effic.)/ Re-Invest. 2006 Deloitte Inc
Area Description
Actual FTEs 2004-05
Actual HAPD
2005-06 2004-05 YTD 36.4 0.19
Laundry & Linen
111
38.0
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Plant Operations, Maintenance and Biomedical Engineering Combined
Opportunities
1.Explore ability to increase focus on preventative maintenance within current staffing complement. 2.Work to reduce overtime as a premium cost driver. Please refer to Infrastructure section for additional opportunities.
Findings
Property Management is a regional service with local service delivery and staffing. Preventative maintenance is reported as a challenge and several years behind schedule. This is a potential significant financial risk to the organization, if a lack of preventative maintenance results in higher cost repairs or replacement. The region is starting an energy service contract to retrofit the building to improve utilities consumption Biomedical Engineering (3 FTEs for the region) and Security (outsourced) are separate functions. Property Management overtime usage has averaged at 3% for 2004-05 and 2005-06 YTD, which is higher than other corporate and support areas in the organization, suggesting opportunity for premium cost savings. Staffing comparison suggests that Property Management (including Biomedical Engineering) has a small savings opportunity of 2.9 FTEs at the 50th percentile, but given high capital project management workload, and minimum staffing requirements in the rural sites, no change is suggested. Actual FTEs 2004-05 55.5 Actual FTEs 2005-06 YTD 56.2 Actual HAPD 2004-05 0.28 Alberta Peer HAPD MIN 0.21 Alberta Peer HAPD MAX 0.42 National Peer 50th Percentile HAPD 0.26 Potential FTE (Effic.)/ Re-Invest. (2.9) See Above
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Area Description Property Mgmt and Biomed.
112
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Health Records, Telecom and Patient Registration Combined
Opportunities
1. Explore staff savings opportunity relative to the transition of Telecomm FTEs to IT, and further investigation of the roles/FTEs split in the smaller sites.
Findings
Health Registry is a regional service with local staffing, but Telecomm has recently been transitioned to IT. Transcription is primarily home-based, but the region does not currently have a region-wide digital dictation system. DI currently completes own transcription, and there is limited coordination with Health Registry for this function. Staffing comparison suggests that Health Registry (including Telecomm, Registration and Health Records) has a 2.2 FTE savings opportunity at the 50th percentile. Before targeting this 2. Consider further level of savings, however, the region needs to consider this coordination with DI for opportunity relative to the transition of Telecom to IT, any transcription as part of associated role re-definition for rural site staff, and minimum staffing opportunity staffing requirements in the rural sites. exploration. Actual FTEs 2004-05 Health Rec., Telecom and Pt. Reg. Combined
113
Area Description
Actual FTEs
Actual HAPD
2005-06 2004-05 YTD 91.1 0.45
Alberta Peer HAPD MIN 0.14
Alberta Peer HAPD MAX 0.49
National Peer 50th Percentile HAPD 0.44
Potential FTE (Effic.)/ Re-Invest. (2.2) See Above
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90.3
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Peer Staffing Comparative Analysis
Patient & Non-Patient Food Services Combined
Opportunities Findings
Food Services is a regionally managed, but locally delivered service. QEII uses chill-cook-freeze with re-therm, but rural sites do raw food 1. Examine production. Food Services is also responsible for meals on wheels, which feasibility of is run out of existing hospital kitchens. moving to a Regionalized food preparation and distribution has not been implemented, regional food in part due to current facilities' ability to support regional food production. preparation and However, facilities support for current operations were also noted as a distribution challenge at several sites. model, in Tray distribution and pick-up are done by both food services staff and coordination nursing a mix of roles across the region. with planned Staffing comparison suggests that Food Services has a staffing investment facilities changes opportunity of 6.2 FTEs at the 50th percentile, however this may, in part, at QEII, before be explained by nursing doing some typical food services work. The considering impact of Materials Management staffing involvement in food services staffing distribution should also be considered with respect to these staffing levels. changes. It is suggested that the region consider regional food service delivery models as a first step before considering any staffing changes. Area Description Patient & Non-Pt. Food Services Combined
114
Actual Actual FTEs FTEs 2005-06 2004-05 YTD 123.4 123.1
Actual HAPD 2004-05 0.62
Alberta Peer HAPD MIN 0.14
Alberta Peer HAPD MAX 0.79
National Peer 50th Percentile HAPD 0.65
Potential FTE (Effic.)/ Re-Invest. 6.2 See Above
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Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Corporate and Support Services
Additional Opportunities
Opportunities
1.Explore creation of dedicated patient porters at QEII, in conjunction with reexamination of Materials Management staff savings or realignment opportunity. 2.Explore creation of a support services staff float pool to support service delivery.
Findings
QEII has several different portering pools across departments (e.g. DI, ER), but no centralized patient porters that would be available to the clinical programs. Consultation findings suggest that this is resulting in increased nursing workload, where nursing does the majority of patient portering. Given the potential opportunity for staff savings or re-alignment across Materials Management, this may suggest an opportunity to re-align resources into a dedicated patient portering pool for the QEII site. A further consideration would be to explore a broader support services float pool that would support a variety of support services currently impacted by challenges in maintaining casual workers.
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PCH Payroll Data 2004-05 115 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Operational Trending and Analysis
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Introduction
Through the peer staffing comparison, this review has already explored opportunities for efficiency and effectiveness across over 70% of the organizations operational spending. Other key cost drivers for consideration include:
Sick and Overtime Premium Costs Non-Salary Discretionary Supplies and Sundries Medical/Surgical Supply Costs Drugs and Medical Gas Supply Costs Food Supply Costs
Further examination of each of these costs will be presented over the following slides. In addition, an overall review of where the region is investing its operating dollars across the continuum of care will be presented relative to peers.
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Sick Time and Overtime Summary
Service Area Administration & Support Services Nursing Allied Health Community & Social Services Sick time rates decreased Sick Time Sick Time Potential or remained relatively Total FTEs % of Total % of Total FTE Savings constant from 2004-05 to 2004-05 Paid Paid 2004-05 2005-06, while overtime 2004-05 2005-06 rates increased across all service areas for the 667 3.6% 2.7% 2.7 same period. 925 3.4% 2.7% 2.5 By examining the region's 337 359 3.6% 4.3% 3.7% 4.1% 1.6 1.6 internal sick and overtime averages by service area, opportunities for improvement can be realized by shifting departments to perform at the area-specific sick and overtime averages. Analysis suggests a potential for up to 8.4 FTEs in sick time improvement, and over $585,000 in overtime premium cost savings, which would need to be explored within a broader HR framework for change.
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Service Area Administration & Support Services Nursing Allied Health Community & Social Services
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Overtime Overtime Total FTEs % of Total % of Total 2004-05 Paid Paid 2004-05 2005-06 655 937 337 359 0.9% 1.2% 1.0% 2.7% 1.0% 1.3% 1.1% 3.6%
Potential $ Savings 2004-05 $87,024 $392,470 $67,012 $38,694
Source: PCH Payroll 2004-05, 2005-06 Oct YTD. AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Non-Salary Discretionary Supplies and Sundries
An analysis of non-salary discretionary accounts was conducted to identify spending variations as well as to understand the large increase in sundry expenses. Discretionary accounts are identified as those non-salary costs that are not directly related to patient care, and over which management is able to exert a degree of control. Overall, 2005-06 Projected data suggests that non-salary discretionary costs may increase by as much as $2.1 million, or 15%, between 2003-04 and 2005-06 Projected.
The main drivers of the increase include Professional Fees, Office & General Supplies and Advertising and PR 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.
Account 2003-04 2004-05 2005-06 Projected $1,920,158 $4,460,658 $1,134,350 $1,294,394 $1,552,270 Variance 2003-04 to 2005-06 Projected 175% 15% 91% 37% 17%
Professional Fees Office & General Supplies Advertising & PR Rent Land or Building (Excl. Equip.) Departmental Sundry
$698,576 $3,865,176 $593,384 $943,311 $1,331,832
$1,038,405 $4,406,284 $724,443 $1,047,814 $1,633,488
Source: PCH General Ledger 2003-04, 2004-05, 2005-06 Oct YTD. 119 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Med/Surg, Drugs and Food Supply Costs
Medical/Surgical, Drugs and Food Supply expenses were examined relative to adjusted patient days for PCH and other rural RHAs in Alberta. In comparison to peers, PCH was found to be at the 50th percentile among the rural Alberta RHAs for Food and Dietary Supply costs in 2004-05. PCH had higher Medical/Surgical and Drug Expenses per adjusted patient days than peers, however, suggesting opportunities for improvement.
For drug expenses, this further supports the need for a drug utilization committee that monitors utilization and best practices, and the need for centralized drug purchasing for the region. Supply Costs as a % of Total Expenses Medical/Surgical Supplies Drugs and Medical Gases Food and Dietary Supplies 2004-05 Actual Expenses $4,365,698 $2,939,945 $2,081,723 2004-05 Expense/APD $19.72 $13.28 $9.40 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 2004-05 120 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness 2006 Deloitte Inc
Financial Profile Across the Care Continuum
A financial profile of PCH relative to other regions in Alberta is presented below, which examines the % of total expenses currently being allocated across different dimensions of the organization. As observed through this analysis, PCH has the second highest % of total operating expenses in its corporate services, which supports the staffing comparison findings of potential opportunities for savings in these areas. Conversely, PCH is currently spending the second lowest % of total operating expenses on community health services, 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
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2004-05 % of Total Expenses 9.5% 18.0% 22.5% 9.5% 7.0% 0.1% 17.1% 12.5% 0.1% 3.8%
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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Source: PCH General Ledger 2003-04, 2004-05, 2005-06 Oct YTD.
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Human Resources Strategy and Management
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Human Resources Strategy and Management
Overview
Talented people or shortage of talented people can make or break any organization's strategy. In the past, health care in general has taken the people and talent issues for granted. Our people plans including plans to hire and / or workforce deployment were tactical issues to be addressed once the business strategy was finalized. This approach can no longer stand up to the growing and increasingly complex demands of the health care workforce. What was once tactical has now become strategic. Coming into this review, Deloitte expected that the Health Regions would share the following common healthcare workforce challenges:
Critical shortage of numerous professional and non-professional roles Retention issues as staff leave health care industry for other better paying opportunities Retention issues as staff go to other healthcare organizations for better pay or perceived better role Aging workforce Increased casualization of the workforce Reliance on foreign graduates and the corresponding need for higher level of organizational support for these individuals Need for incentives to recruit and retain Restrictive labour contracts and requirements
Our goal was to assess the extent to which the Region understands these issues and has developed strategy to respond. Specifically, we are looking to see the degree to which the Human Resource Strategy and roles are well positioned to support the growing complex world of people management.
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Human Resources 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: Talent Management the integration of processes,
programs, technologies and staff to Develop, Deploy and Connect workforce. Develop builds individuals' capabilities as required by organization either currently or for the future.
Connect cultivates high quality work relationships and culture that fosters engagement, productivity and innovation.
Human Resources Re-focus efforts to enhance
HR capacity and capability to support service and management priorities of the Region.
Re fo HR cu si ng
Deploy ensures candidates are attracted, and recruited to roles and that recruitment is well aligned to strategic and operational needs.
HR Transformation Strategy Process
Te gy R H olo n ch
Human Resources Technology focuses on the
extent to which technology supports the HR capacity and consistency in practice across Region.
Healthy Work Environment encompasses the
physical work environment and psychosocial work environment. Healthy work environment practices exist where culture and practices converge to create improvements for staff that cascade to the patient and community level.
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Human Resources Findings and Opportunities
HR Refocusing
Findings
Performance management processes have been developed and are starting to get traction after 1 year of implementation, however are not well understood and in use throughout the organization. Cascading of performance management processes is not yet part of personal evaluation at Executive/Director/ Manager levels for most areas of the organization. Directors/Managers are challenged to complete performance management processes given high workload Challenges in recruiting labour relations expertise into region, so no dedicated labour relations support exists Lack of labour relations expertise expected to be a specific challenge for upcoming UNA bargaining, and ambulance services integration and bargaining Region has several human resources pressures that will drive HR operations focus to support the region.
R ef HR oc us in g
HR Transformation Strategy Process
Opportunities
1. 2. 3. Re-focus regional priorities to recognize and drive Human Resources strategy and initiatives as a top corporate priority, with a focus on supporting individuals to build capacity in the region. Examine need for HR department roles and focus realignment once a new HR Strategy and Plan are developed for the region. Further develop the performance management focus and function in the region to drive increased accountability, monitoring and evaluation, with a clear accountability framework that cascades down to manager and frontline staff levels. Collaborate with other RHAs to develop and maintain labour relations expertise
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Human Resources Findings and Opportunities
Talent Management - Develop
Findings
As noted in previous findings, the region needs a regionwide education function both to mitigate potential risks through lack of knowledge transfer, and to attract, retain and build employee knowledge throughout the organization. Specific education roles for the function could include coordinated orientation, management capacity building, infection control policies and procedures, quality and risk management, and maintenance of certification across staff disciplines. Need for education was also observed in the physician review, and suggests that a coordinated function that supports both organization and physician education would best serve the region. Given the region's current level of investment, increased focus on development will potentially require significant resources, training and change management support.
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1. Develop a coordinated education function that supports the full human resource base of the organization executive, management, staff, and physicians and which incorporates organization-wide learning and training, support for quality and risk management, and support for maintenance of certification across staff and physician disciplines, with associated resources to enable the education strategy and function.
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Human Resources Findings and Opportunities
Talent Management - Deploy
Findings
Market wage rates for unregulated and support service staff are creating significant competition for casual resources. Current union contracts limit region's ability to compete on direct wages, so alternate strategies are required (e.g. rural adjustment, additional monthly stipend, etc.). The region faces similar challenges with respect to physician recruitment and retention, where creative strategies are needed to address physician challenges around geography, facilities, balance of Canadian-trained vs. foreign-trained MDs, alternative funding models.
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HR Transformation Strategy Process
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Develop Deploy
Opportunities
1. The region needs to develop a comprehensive HR Strategy and Plan that is aligned to the business needs and operating realities of the north, and considers a number of key dimensions: significant population growth in the north, high level of market competition for resources and compensation, resourcing strategies and staffing models, partnerships with industry, broader community health focus across care providers. Physician planning needs to be an integrated component of this plan, so that the region has a consolidated plan that focuses its efforts on talent management to support current and future core service delivery. The region needs to explore alternative strategies to HR planning to position the region for success in recruiting and retaining staff in the north. To support broad talent management, the region needs a structure approach to succession planning that is integrated across key human resources - including executives, management, staff, and physicians.
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Human Resources Findings and Opportunities
Talent Management - Connect
Findings
Consultation findings suggest that the regional reorganization over the past three years has resulted in some degree of change fatigue, and fear of further change. To support the development of high quality work relationships, productivity and innovation throughout change, the region needs to create a dedicated change management focus that supports staff and physicians through change. Communication was also noted as a challenge by some stakeholders, further impacting ability for the region to effect change and leverage the benefits of regionalization.
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Develop Deploy
Opportunities
1. Develop clear change management function and support within HR that is linked to the education function, and which provides broad organization support to engage stakeholders in change initiatives. This will be a critical function to enable broader organization opportunities for change and to support ongoing work in regionalization. 2. Develop a communications plan and strategy that promotes the benefits of regionalization, engages stakeholders in change initiatives, increases executive engagement, and reports back on resulting improvements from change initiatives.
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Human Resources Findings and Opportunities
HR Technology
Findings
Finance reports limited incorporation of union contract terms in current scheduling system (e.g. monitoring premium time, flagging potential for premium expense based on staffing pattern), which results in challenges in premium cost management. Analysis of overtime premium costs further suggests that the region has several areas of opportunity to reduce overtime premium costs, but needs a scheduling system to support cost management. A new Meditech HRIS module will be implemented in Summer 2006, which is expected to support broader HR operations. From an education perspective, the region has opportunity to further leverage e-learning as a cost effective resource. Given the telehealth infrastructure in the region, this resource should be further leveraged to provide both regional HR and OH&S support and education opportunities to reduce staff travel requirements.
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Opportunities
1. 2. 3. 4. 5. Develop strategy to address HRIS needs, which aligns HR technology enablers to support the organizations HR re-focus, and is part of the broader regional IT Strategic Plan development. Improve alignment of staff scheduling system to union contract terms as a mechanism to support premium cost management. Examine HR service delivery options to increase use of existing telehealth infrastructure for HR and OH&S support across the region. Explore options for increased e-learning and tele-learning to improve existing education for staff through a cost-efficient mechanism. Develop online performance management processes for management and staff to enable improved performance measurement and management capabilities in the organization.
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Healthy Work Environment
Findings
Limited OH&S presence over the past few years has resulted in several workplace safety concerns, limited attention to disability management, and limited organization confidence in the department. Consultation findings have further indicated several work environment challenges currently being faced by the organization, including: Change fatigue from re-regionalization. Challenges in management capacity for broader planning and change, given turnover in management staffing Relationship challenges across cultural differences of foreigntrained physicians. Disengagement of physician stakeholders from regional operations.
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Opportunities
1. 2. 3. 4. 5.
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Develop a targeted healthy work environment strategy as part of the region's HR re-focus, with corresponding infrastructure, support, and organization alignment (where necessary). Create forums for management, staff and physicians to identify workplace challenges, and contribute to the development of strategies to address challenges. Develop a communication and stakeholder engagement strategy and plan to re-engage management, staff and physicians in regional planning and programs to promote an engaged, healthy work environment. Develop a communication strategy and plan to re-engage management and staff in OH&S programs to promote a health work environment. Continue to increase involvement of OH&S in broader organizational risk management approach to identify workplace safety risks to patients and staff, and in developing related mitigation strategies.
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Infrastructure
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Regional Infrastructure Alignment
Introduction
Our review of regional infrastructure is intended as a high level assessment of how well infrastructure is aligned to support operations. Where there are opportunities for improvement to infrastructure, these opportunities will be identified for the region's consideration. The review has focused on the key high level opportunities across two dimensions of regional infrastructure, with findings and opportunities based on consultation, document review and related analysis:
Facilities and Equipment Technology
Regional Infrastructure Findings and Opportunities
Alignment to Support Operations
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Facilities and Equipment
QEII Emergency Department
High-level consultation findings, on-site observations, and analysis of available Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities Findings
The current QEII Emergency Department was originally designed for significantly lower volumes than current levels, and faces several facilities challenges, including: 1.Explore options for immediate redevelopment of the QEII Emergency Department, and develop capital funding plan to enable redevelopment.
Inadequate waiting room space that does not provide line-of-sight from the Triage Desk; Exposed, small triage area, with limited patient privacy/confidentiality. Privacy/confidentiality concerns in Admitting area. Not properly wheelchair accessible; No line of sight from main desk to trauma rooms; trauma rooms undersized; No seclusion rooms or staff refuge room; Only 6 beds are monitored; Overflow is in another Department adjacent to Emergency.
Although the region is waiting approval for redevelopment of the QEII site, the timeline for approval and then facilities development is sufficiently long enough for the region to focus more immediate attention on the QEII Emergency Department as an interim step. It is anticipated that this may require significant capital funding to effect.
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Facilities and Equipment
QEII Pediatrics and NICU
High-level consultation findings, on-site observations, and analysis of available Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities Findings
The QEII Pediatrics and NICU units face several space challenges: 1.Conduct a facilities needs assessment for Pediatrics and NICU to determine the costs/benefits of space redesign in advance of broader QEII redevelopment. Need permanent, wall-mounted cardiac/physiological monitoring in at least 2 of the isolation rooms, and central monitoring for the unit. The unit is in need of bed replacement. There is a shortage of storage space on the unit, impacting staffing and patient flow. The unit has inadequate admission space. The unit has inadequate procedure space for outpatients. NICU space is very tight and creates staff and patient flow challenges when occupancy is high. These space challenges will need to be considered by the region in context of the potential redevelopment of the QEII site.
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Facilities and Equipment
QEII Central Monitors
High-level consultation findings, on-site observations, and analysis of available Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities
1. Consider options to increase central monitoring capacity in the QEII recovery room to support additional beds, in conjunction with plan to open 5th OR. 2. Investigate business case to implement central monitoring in Pediatrics, as a mechanism of improving care and reducing staffing costs.
Findings
The current QEII recovery room central monitoring is reported to be at capacity. Given current consideration by the organization to open a 5th OR in QEII, this would result in the need for 2 additional recovery room beds. Additional beds would not be on the central monitoring system, which may result in additional staffing being needed to monitor additional patient volume in the recover room. QEII Pediatrics currently has no central monitoring, resulting in 1:1 staffing when patients are on the unit that require monitoring.
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Facilities and Equipment
Regional Triage
High-level consultation findings, on-site observations, and analysis of available Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities Findings
Consultation findings indicate the need for increased CTAS triage use as a care and risk management tool in the rural site emergency departments. 1. Examine infrastructure requirements and costs related to the recommendation for increased use of CTAS triaging in the rural site emergency departments. Where triage exists, CTAS scoring is currently completed manually, which may result in data capture errors. This suggests need for further technology enablement of this function to support improved data capture and decisionmaking. Development of this suggested triage function has a potentially significant facilities infrastructure implication for the rural site emergency rooms not currently using triage, which needs to be examined by the region.
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Facilities and Equipment
Regional Diagnostic Imaging
High-level consultation findings, on-site observations, and analysis of available Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities Findings
Between 15-20% of regional DI equipment is reported as being beyond expected end-of-life, and beyond equipment lifespan standards for DI equipment (e.g. QEII CT > 10 years). The region is currently facing capital expenses of up to $5 million in DI equipment based on replacement of end-of-life inventory. Over the next three years, the region will face up to an additional $5 million in equipment replacement costs as other equipment reaches expected end-of-life. Capital dollar availability is limited, however, so the region is challenged to meet equipment replacement demands for this high cost inventory. The current does not currently use an evergreen leasing model for equipment renewal as an alternate cost and equipment management strategy.
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1. Continue to explore options and business cases for capital replacement of DI equipment. 2. Explore business case for evergreening as a method of enabling DI equipment renewal under a lower capitalintensive cost model.
Facilities and Equipment
Regional EMS Services
High-level consultation findings, on-site observations, and analysis of available Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities Findings
The EMS is a program in transition from municipal operations, and the region is in process of inheriting the program and related facilities and equipment. The region does not currently have responsibility for physical resources (e.g. ambulance bays), and only has partial responsibility for the ambulance fleet. The region does not currently have a central dispatch for EMS services, which impacts ability to coordinate service delivery. Anecdotal reporting suggests that a limited ambulance fleet is impacting ability for region to balance inter-facility patient transfers with emergency workload. Previous work suggests that the facilities and equipment maintenance for EMS services present a potential high risk area to the region.
1. Conduct an external review and cost impact analysis of Regional EMS as the service is transitioned to the region, including an assessment of facilities and equipment infrastructure requirements.
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Facilities and Equipment
Regional Telehealth
High-level consultation findings, on-site observations, and analysis of available Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities
1. Engage clinical stakeholders to develop a regional strategy and resource plan to further leverage use of telehealth in clinical service delivery.
Findings
Several opportunities have been identified for increased use of telehealth in clinical service delivery. Although the region does have several programs currently established, telehealth clinical program development is reported, in part, to have followed specific provincial funding grants available. The region is currently lacking physician champions to drive increased use of telehealth in clinical service delivery.
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Facilities and Equipment
Beaverlodge
High-level consultation findings, on-site observations, and analysis of available Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities Findings
Beaverlodge is an old facility requiring replacement, for which the region is currently working with AHW. IFHIS analysis for Beaverlodge supports this need for replacement, finding that the suitability of department space, buildings and overall site has the lowest rating among regional facilities, and the highest overall degree of deficiencies in the region. The proximity of Beaverlodge to the QEII site in Grande Prairie suggests that opportunity exists to re-examine the future role and service delivery model of the site, to better leverage overall care delivery models available in the region e.g. ER volumes could be shifted to Grande Prairie site, and an alternative level of care could be considered for the future Beaverlodge site. The region reports support for this role review through its existing capital plans.
1. Conduct a role review of Beaverlodge to determine feasibility of alternative service delivery model options for the site.
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Facilities and Equipment
Peace River Physicians' Clinic
High-level consultation findings, on-site observations, and analysis of available Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities
1. Explore options to partner with physicians in co-locating the physicians' clinic to the hospital site in Peace River, as part of overall physician recruitment and retention planning.
Findings
In Peace River, the distance between the new hospital site and the physicians' clinic is a challenge to physician service delivery and call coverage, and a potential physician retention risk for the organization.
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Technology
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Leveraging the Value of Information Technology through IT Governance
Information and the Technology that supports it often represent the most valuable but least understood asset in an organization. The essential elements of IT governance are to ensure that value is received from spending on technology and then to control and safeguard information. The purpose of an IT governance framework is to institutionalize good practices that ensure an organization's IT investment supports business objectives. These objectives are identified through the Peace Country Health's goal of providing "the best possible health care in the best possible work environment."
And involves: ensuring senior management and frontline providers are involved in determining the direction and goals of the IT department evaluation of service delivery from two perspectives, the total cost of technology operations and monitoring of project outcomes ongoing support and maintenance intended to safeguard the value of existing assets and knowledge in the regional facilities.
Available IT resources, including infrastructure, applications, information and people, should be optimized to support goals. Organizations need to satisfy the quality, fiduciary and security requirements of IT information and infrastructure as for all other assets. To discharge these responsibilities, as well as to achieve objectives, the status of evolving enterprise architecture must be known.
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What is IT Governance?
IT governance consists of leadership, organizational structures and processes that are designed to support an organization's strategies and objectives to increase stakeholder value. Clear responsibility for the direction of IT requirements is necessary to successfully deliver services that support the enterprise's strategy. Monitoring success in delivering against business requirements, requires that management put a framework in place to measure achievements against goals. IT governance transforms business goals into IT objectives through consideration of value, risk and control.
Value IT Objectives
IT Governance
Business Goals ...
Risk
Control
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Determination of IT Activities
Align Business Goal and IT Objectives
Organizational Strategic Plan
Defines
Define IT Strategy
Translate IT objectives into specific initiatives
Business Priorities for IT
Defines
Assess resource suitability and gaps
IT Objectives
Identify IT Resources
Infrastructure Applications Information People
Determine ability to fill gaps through acquisition, training, realignment etc. Determine extent to which business priorities for IT can be met
Communicate results and manage expectations
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Technology
Findings and observations for the technology workstream are intended to identify the degree to which IT investments and resulting initiatives support the goals of the region, and the degree to which they are executed efficiently and effectively. The following key documents were reviewed in support of the Technology review for PCH:
Facility Profiles Peace Country Facilities Facility Profiles Peace Country IT Consultation Findings Information Management Plan 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.
PCH developed an Information Management plan in November 2003 that extends until 2009, and IT reports an annual process to confirm alignment of the plan to business strategies and objectives, and to update progress to plan. The "Excellence Framework" process has been in place since 2005 to monitor and keep the IT Plan aligned with business plan. For the RSHIP implementation, business resources have been pulled from operations to support the implementation, to ensure close alignment of the Deloitte Meditech application to end-user needs. Findings and Ongoing communication is reported as a continuing success factor to keeping Observations business users aware of the RSHIP and other implementations. Business users across the organization report a high level of awareness of IT initiatives, with specific focus on the RSHIP Meditech implementation. Awareness of Information Management as a concept is still developing. Physicians report concern about the Meditech implementation, however, noting limited coordination to ensure alignment and integration of new system to existing physicians' clinic systems. 1.Overall, the organization demonstrates a good level of strategic alignment of IT to business objectives and strategy. Continued annual review and realignment of IT to business objectives is suggested. Potential Opportunities 2.Further engagement of community-based physician stakeholders is also suggested to ensure good communication and exploration of options for integration of physician clinic systems with the new Meditech system.
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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. PCH has approximately 20 FTEs in the Regional IM Department, including a mix of Network Analysts, Application Analysts, Helpdesk support, IT Purchasing/Inventory support, and Director. The majority of resources are centralized in Grande Prairie, and 1 Network Analyst and 1 Application Analyst are located in Peace River to support local service delivery to the northern part of the region. For the RSHIP implementation, additional business user resources have been allocated from operations to support the implementation. No official secondments are in place. Network analyst skill sets have been aligned across key components (e.g. server, mail, routers). PCH reports that insufficient network analyst support impacts the ability to support new application deployments.
Deloitte Findings and Observations
1. PCH should ensure an enterprise-wide view of resource allocation to minimize impact of large initiatives on the business unit. 2. The RHA should continue to ensure dedicated business resources are Potential available to support the RSHIP initiative. Opportunities 3. Where business resources continue to support business functions during assignment to IT initiatives, a formal arrangement should be documented to limit conflict.
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2. Resource Alignment (continued)
Leading Practice Attributes The organization is focused on the optimal investment in, and the proper management of critical IT resources: applications, information, infrastructure and people including the optimization of knowledge and infrastructure. The RHA has worked to automate some application deployments through the use of SMS technology in order to `push' applications onto desktops. Through the RSHIP initiative, additional helpdesk and security analyst resources will be available to the region. PCH has further augmented their resource base through outsourcing: Deloitte Findings and Observations
Desktop hardware, imaging and installations, and server infrastructure to Dell Network and related hardware to Cisco Microsoft Licensing to Compugen
Cost reduction efforts are being driven through an IP Telephony pilot, which is expected to rollout across the region over the next 2-3 years, with an anticipated ROI of less than 5 years. There is a general trend towards having non-IT people working as technical support for staff in order to augment the helpdesk support.
Operational staff are being drawn away from their core responsibilities
4. Communicate the value of utilizing the centralized helpdesk function in order to increase reliance on this function by the facilities. Potential Opportunities 5. Provide training to facility staff to improve self reliance in the use of automated systems.
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2. Resource Alignment (continued)
Leading Practice Attributes The organization is focused on the optimal investment in, and the proper management of critical IT resources: applications, information, infrastructure and people including the optimization of knowledge and infrastructure. Problems that are beyond the scope of the on-site ad-hoc resource are referred to the Helpdesk in Grande Prairie. Most regions prefer onsite system support staff.
By bypassing the formal helpdesk facility, IT is potentially losing control over configuration and usage of IT resources.
Deloitte Findings and Observations
Limited ongoing support or maintenance to ensure continued availability and operations of new information systems or technology. All purchasing and inventory management for IT-related purchases are managed by IT, in close coordination with the Materiel Management department. IT currently has 1 FTE in place to support this process, which was implemented to provide more focused supply chain management for IT in the region. PCH is currently exploring opportunities to integrate IT resources with NLHR to maximize IT skill sets, capacity and value to both organizations.
6. During the implementation of the new Meditech functionality ensure cross training for maintenance and functionality occurs between RSHIP support staff and PCH IT staff in order to secure the ongoing viability of automated Potential systems. Opportunities 7. Continue exploration of IT integration with NLHR, with specific assessment of the potential costs, benefits, risks and implementation considerations associated with integration.
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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. Although business users from most areas report good involvement in the Meditech implementation, they also note the challenge of the corresponding strain on their resources available for daily operations. 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. Although the regional Information Management group currently supports Meditech report writing, the region expects to improve the level of information management and analysis support that this group provides to regional business users once the Meditech implementation is completed.
Deloitte Findings and Observations
Potential Opportunities
1. Plan for and execute adequate training to ensure a smooth and complete transition to the new automated tools in order to reduce potential for increased workload on PCH operations, achieve benefits and increase value to service delivery.
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3. Value Delivery (continued)
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. An overall benefits framework is lacking for the RSHIP implementation in PCH. Although business users are engaged in the implementation, and are involved to ensure that the system meets business needs and promotes standardization across regions, where possible, this activity has not resulted in the identification of specific benefits that are expected postimplementation. Consultation with end-users supports this observation, where the majority of business users did not identify specific expectations with regards to improved efficiency or effectiveness to department operations postimplementation. As such the region has opportunity to identify expected qualitative and quantitative benefits for each key department with respect to expected efficiency and effectiveness, and then monitor expected benefits for realization. 2. Establish a benefits realization framework that identifies, promotes, monitors and assesses benefits realization for each key department as the new Meditech system is implemented, rather than focusing on future functionality.
Deloitte Findings and Observations
Potential Opportunities
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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. There is a pervasive shortage of IT experience across the region, which is impacting both the operation and development activities. IT training and education are noted as the greatest risks for PCH. There is limited support to provide training to business users for the Meditech implementation, and for general project management skills within IT. Although some training is provided through a central RSHIP training centre for PCH, the lack of a broader regional education group and infrastructure to provide general training across all disciplines/areas is noted as contributing to this challenge. Mitigation strategies to resolve risks are in development, but have yet to be finalized for the region. PCH also reports a deployment resource challenge with respect to Network Analyst support, and broader IT resource availability to support business user training. These challenges may create risk to IT implementations, and the ability of the organization to achieve full benefit from the systems in a timely manner.
Deloitte Findings and Observations
1. Need to either reduce the expectation for IT achievements or increase resource availability through focused training or recruitment. Potential 2. Explore opportunity to create a dedicated Change Management group for Opportunities the RSHIP implementation to support end-user change management, communications, and training, which is linked closely to a broader regional education strategy and infrastructure.
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4. Risk Management (continued)
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. The region's commitment to the RSHIP initiative, and limited management support has resulted in a compromised business planning cycle:
Business resources are overcommitted to the Meditech implementation, which contributes to a limited capacity to address broader planning and management activities. IT management also reports a high degree of delivery work, which is reported as being due to limited IT staffing in the region.
Deloitte Findings and Observations
Healthcare operations and service efficacy may be compromised by training not being aligned to the functional responsibilities of each intended user.
The stated objective is to have 80% of staff trained. Professional trainers are not being used for training delivery. The organization lacks a region-wide education function to support departmental training, resulting in the default requirement for the business users involved in the Meditech implementation to provide training to their respective departments.
3. Implementation scoping needs to accommodate appropriate levels of training for the entire user population. Potential 4. Enterprise wide resource planning needs to address the risk to both Opportunities business operations and system development and implementation activities when identifying resources to support new initiatives.
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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. The region is starting to use a common system development lifecycle (SDLC).
As a key part of the SDLC, business cases and team-based planning are in place for all initiatives, and a standard phased approach to the SDLC is now in place for all IT-driven initiatives.
Deloitte Findings and Observations
To support implementation, key activities and responsibilities are assigned, and evaluation is conducted post-implementation to confirm success or further change requirements.
From a provincial perspective, PCH works closely with the RSHIP initiative to ensure alignment of the Meditech implementation, and leverage best practices and lessons learned across peer RHAs. Other provincial initiatives in which PCH is also involved include the planned DI Strategy deployment of a province-wide PACS. 1. Complete standardization of a common SDLC for the organization. Once a standard is in place, ensure that all IT resources (technical and functional) are trained in its execution. 2. Expand communication with peer RHA's regarding best practices to other IT initiatives.
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Potential 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 these 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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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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II.
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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. 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).
II.
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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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. Regional Opportunities 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.
Opportunity Consolidation
Opportunities for Prioritization
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Filter 2: Like / related opportunities have been consolidated to facilitate planning and action.
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
Enhance communication between the rural sites and regional hub in Grande Prairie Clinical Program by leveraging Telehealth technology in a structured approach for coordination of Frameworks & Review service, information sharing of leading practices, CME and professional support.
Home Care WL Measurement
Develop and implement workload measurement and reporting for home care to enable management decision making. Engage clinical stakeholders to develop a regional strategy and resource plan to further leverage use of telehealth in clinical service delivery. Examine opportunities to pursue improved efficiency and effectiveness of service delivery through increased use of telehealth to reduce travel requirements. Explore options for increased use of telehealth in service delivery, with impact assessment of the relative costs/benefits to align resources to this SDM. Continue to explore opportunities to use telehealth as a means of reducing travel downtime, to contribute to staff savings opportunity.
Regional Telehealth
Human Resources Staffing Finance and Decision Support Regional Information Management
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Examine HR staffing relative to HR strategy alignment and to exploration of cluster shared services opportunity. Consider opportunity to shift some Finance resources into a regional Decision Support function to support broader analysis and planning. Consider IT staffing levels with respect to broader regional IT and R-SHIP implementation management.
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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.
Human Resources Strategy and Management Opportunity Name Opportunity Description
Develop a targeted healthy work environment strategy as part of the region's HR re-focus, with corresponding infrastructure, support, and organization alignment (where necessary).
Create forums for management, staff and physicians to identify workplace challenges, and contribute to the development of strategies to address challenges.
Healthy Work Environment
Develop a communication and stakeholder engagement strategy and plan to re-engage management, staff and physicians in regional planning and programs to promote an engaged, healthy work environment.
Develop a communication strategy and plan to re-engage management and staff in OH&S programs to promote a health work environment.
Involve OH&S in broader organizational risk management approach to identify workplace safety risks to patients and staff, and in development of related mitigation strategies.
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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.
Human Resources Strategy and Management (continued) Opportunity Name Opportunity Description
Re-focus regional priorities to recognize and drive Human Resources strategy and initiatives as a top corporate priority, with a focus on supporting individuals to build capacity in the region.
Examine need for HR department roles and focus realignment once a new HR Strategy and Plan are developed for the region.
Human Resources Re-Focus
Further develop the performance management focus and function in the region to drive increased accountability, monitoring and evaluation, with a clear accountability framework that cascades down to manager and frontline staff levels.
Collaborate with other RHAs to develop and maintain labour relations expertise.
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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.
Human Resources Strategy and Management (continued) Opportunity Name Opportunity Description
Develop strategy to address HRIS needs, which aligns HR technology enablers to support the organizations HR re-focus, and is part of the broader regional IT Strategic Plan development.
Improve alignment of staff scheduling system to union contract terms as a mechanism to support premium cost management.
Human Resources Examine HR service delivery options to increase use of existing telehealth infrastructure for HR and OH&S support across the region. Technology
Explore options for increased e-learning and tele-learning to improve existing education for staff through a cost-efficient mechanism.
Develop online performance management processes for management and staff to enable improved performance measurement and management capabilities in the organization.
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Cluster-Related Cluster-Related Strategy, Partnerships and Planning Strategy, Partnerships and Planning
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.
Human Resources Strategy and Management (continued) Opportunity Name Opportunity Description
HR Resources/ Consider HR and OH&S staffing levels with respect to broader regional re-focus on HR Personnel and Occ. strategy and management. Health & Safety
The region needs to develop a comprehensive HR Strategy and Plan that is aligned to the business needs and operating realities of the north, and considers a number of key dimensions: significant population growth in the north, high level of market competition for resources and compensation, resourcing strategies and staffing models, partnerships with industry, broader community health focus across care providers. Physician planning needs to be an integrated component of this plan, so that the region has a consolidated plan that focuses its efforts on talent management to support current and future core service delivery. The region needs to explore alternative strategies to HR planning to position the region for success in recruiting and retaining staff in the north. To support broad talent management, the region needs a structure approach to succession planning that is integrated across key human resources - including executives, management, staff, and physicians.
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Talent Management Deploy
Cluster-Related Cluster-Related Strategy, Partnerships and Planning Strategy, Partnerships and Planning
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.
Human Resources Strategy and Management (continued) Opportunity Name Opportunity Description
Develop clear change management function and support within HR that is linked to education function, and which provides broad organization support to engage stakeholders in change initiatives. This will be a critical function to enable broader organization opportunities for change and to support ongoing work in regionalization. Develop a communications plan and strategy that promotes the benefits of regionalization, engages stakeholders in change initiatives, increases executive engagement, and reports back on resulting improvements from change initiatives. Develop a coordinated education function that supports the full human resource base of the organization executive, management, staff, and physicians and which incorporates organization-wide learning and training, support for quality and risk management, and support for maintenance of certification across staff and physician disciplines, with associated resources to enable the education strategy and function.
Talent Management Connect
Talent Management Develop
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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
Engage physicians and regional leadership in the development of a regional Physician Human Resource Strategy that is linked to the broader regional strategy, to address Physician resource gaps, skills management and education, alignment/realignment of current resources to core service delivery needs, remuneration and recruitment/retention. Explore alternative payment models for physicians in the region, with an objective to improve resources 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. Develop a regional Physician Impact Assessment process that is used for physician recruitment needs planning, and in assessment when new physicians are being considered.
MD HR Strategy
Alternative Payment Model Physician Impact Assessment
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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.
Risk and Quality Management Opportunity Name Accountability Framework Regional CME Approach Regional CTAS Assessment Opportunity Description
Create an accountability framework with evaluation and quality/risk/performance management tools for Physicians, which is integrated into the broader regional framework. Develop a regional approach and support for CME for both Canadian-trained and foreign-trained medical graduates, based on a sustainable business model, and integrated with the physician recruitment and retention strategy and broader regional education function. Conduct a regional assessment of CTAS use in the ED to determine resources, education support, and policies/procedures required to standardize use across the region.
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Strategy, Partnerships, and Planning
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
Change Management Function
Develop clear change management function and support within HR that is linked to the broader HR strategy and education function, and which provides broad organization support to engage stakeholders in change initiatives. This will be a critical function to enable broader organization opportunities for change and to support ongoing work in regionalization. Develop a communications plan and strategy that promotes the benefits of regionalization, engages stakeholders in change initiatives, increases executive engagement, and reports back on resulting improvements from change initiatives. Conduct an alignment diagnostic of the VP Medicine portfolio, to consider overall organization structure and support resources required to support strategic HR focus on physician recruitment and retention. Conduct an alignment review of physician leadership requirements across all services, with further development of the regional focus and responsibility of roles. Engage stakeholders in a review of physician coverage and transfer practices between Peace River and Grimshaw, to standardize practice in support of care delivery.
Communications Strategy & Plan VP, Medicine Portfolio MD Leadership Alignment Peace/Grimshaw MD Relations
Preventative Explore ability to increase focus on preventative maintenance within current Maintenance Program staffing complement.
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Regional Opportunity Map and Reference Guide
Service Delivery Model
Opportunity Name External Reviews ED, Medicine, Psychiatry Program Frameworks Family Medicine, Surgery, OBS Surgical Services Review Planning 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 external reviews of Emergency, Internal Medicine and Psychiatric services as regional programs.
Establish program framework for Family Medicine, Surgery, Obstetrics as programs that are provided across the majority of sites throughout the region, which defines scope of service in alignment to community health needs and resource availability. Develop an action plan that outlines an implementation strategy in response to QEII and regional surgical services reviews, with consideration of resources required to support rural site surgical service repatriation. (Note: Applies to both Surgical and Perioperative Services)
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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
Consider options for multiple levels of patient transport with central coordination as the region continues to develop the EMS program. Develop an EMS human resources plan for staff union amalgamation and future resource needs, as part of broader regional HR strategy. Develop an overall cost assessment for the EMS program that projects cost and resource requirements for the RHA to operate EMS for the region, and identifies a strategy to align resources to identified requirements.
EMS Review
Obstetrics Review Planning
Develop an action plan that outlines implementation strategies in response to the regional obstetrical services review.
Conduct a full review of the QEII ED to determine appropriate alignment of staffing and physician resources, facilities and security, and policies and procedures to support care requirements.
QE II ED Review
Explore options for immediate redevelopment of the QEII Emergency Department, and develop capital funding plan to enable redevelopment.
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Service Delivery Model (continued)
Opportunity Name Opportunity Description
Examine Regional Admission/ Discharge Criteria.
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Regional Discharge Planning and Utilization Management
Review the current roles and functions of staff related to discharge planning and utilization management in the region, as part of the development of a regional discharge planning model. This model would incorporate rural site repatriation from QEII, and supports timely discharge to patient's home community. (Note: this opportunity applies to all clinical programs) Develop and communicate formalized admission and discharge criteria the inpatient psychiatry unit in QEII and other regional mental health services. Develop standardized discharge/transition planning policies/ procedures regionwide. Work with Transition Coordinators and clinical programs to support improvements to discharge planning process. Explore option to create a dedicated ALC unit in High Prairie, and where this service delivery model may apply to the remainder of the region's hospital sites. Examine options for service model integration across High Prairie and McLennen, and consider alignment of staffing levels to meet resource requirements of integrated model.
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ALC Strategy High Prairie / McLennan Service Integration
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Service Delivery Model (continued)
Opportunity Name Environmental Health Review Beaverlodge Role Review Regional Surgical Services Review Peace River's Role Revisit PAC Relocation to McKenzie CSR Alignment 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 regional review of Environmental Health services to align service programming and resources to increasing community health inspections needs and to meet minimum provincial standards. Conduct a role review of Beaverlodge to determine feasibility of alternative service delivery model options for the site.
Review role of Peace River in regional surgical services delivery, and consider staffing levels alignment relative to role.
Engage stakeholders to re-examine plan to re-locate PAC to Mackenzie Place, with cost/benefit considerations of related impact on patients, MDs and staff. Continue efforts to determine most appropriate organizational alignment of CSR services in the region.
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Service Delivery Model (continued)
Opportunity Name Regional Food Production & Distribution Model Opportunity Description
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Examine feasibility of moving to a regional food preparation and distribution model, in coordination with planned facilities changes at QEII, before considering staffing changes. Explore creation of dedicated patient porters at QEII, in conjunction with reexamination of Materials Management staff savings or realignment opportunity.
QE II Portering Model & Staffing
Examine staffing opportunity with consideration of broader QEII need for patient portering support, as well as Pediatrics/Intermediate Nursery education support to move RNs to full scope of practice. Explore creation of a support services staff float pool to support service delivery.
Support Service Staffing Pool
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Clinical Resource Management and Practice
Opportunity Name Improve Coding Improve MD Documentation Clinical Lab Utilization Medication Order Review Isolation Cleaning Practice Clinical Protocol Adoption Opportunity Description
Improvements to Regional Coding and Abstracting.
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Improve MD Documentation in Inpatient Charts.
Develop a lab utilization management framework, process and roles to monitor and improve lab service utilization. Establish consistent practices around medication order review across the region to mitigate risks and improve patient care. Develop structured communication process between Housekeeping and Nursing for isolation area cleaning, with linkage to broader organization risk management framework. 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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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
As part of broader regional HR re-focusing, develop a regional education function that supports both clinical and non-clinical education, and includes management training and development. High Prairie: Develop education plan for clinical staff, as part of broader regional HR and education strategy. Grande Cache: Coordinate need for increased education support to staff as part of broader regional education strategy. There is an investment opportunity in the combined Medical/Surgical and ER/OPD. This opportunity should be considered in light of the current issue of elderly patients waiting placement in the community. LPN full scope of practice, in alignment with broader regional HR and education strategies. Improve access to on-unit clinical educators as part of broader regional refocus on education, centered on supporting specialized skills and knowledge in OBS. Surgical Care: Improve access to on-unit clinical educators as part of broader regional refocus on education, with specific focus in surgery on supporting LPN scope of practice. Create a specialized and dedicated clinical educator to support ICU staff.
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Regional Education Strategy Develop education plan for Grimshaw staff to support clinical education and shift to
Cluster-Related Cluster-Related Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Regional Opportunity Map and Reference Guide
Clinical Resource Management and Practice (continued)
Opportunity Name Same Day Surgery & PACU Role Review OR Utilization Management Opportunity Description
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Engage stakeholders in clarifying roles and functions of day surgery and recovery areas. Examine OR case management practices to address scheduling challenges that prevent sufficient time between cases to allow for correct instrument sterilization practices. An efficiency opportunity exists in the combined OR and PACU related to the potential to increase throughput by prompt starts and decreased wait times between cases. This efficiency target is equivalent to 5.9 FTE and represents an opportunity to increase OR volumes within the current staffing complement. Further, in considering this opportunity, the region should examine OR skill mix with respect to the use of OR technicians. When comparing staffing for both L&D and PP, QEII has a savings opportunity of 5.3 FTE through the reduction of 1 nurse 24/7. This opportunity is contingent upon the adoption of an LDRP model of care, and that predictable workload from repeat c-sections, assessments and inductions are scheduled appropriately. Conduct a skill mix review in light of efficiency targets and best practice models of care for LDRP.
Decrease Wait Times
LDRP Skill Mix
PAC Utilization Management Endoscopy Utilization
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A savings opportunity exists in PAC that relates to the percentage of patients seen in PAC and the use of telephone screening. For O/P Recovery, the region should further examine the identified staffing efficiency as an opportunity to increase throughput of endoscopy volumes to address current wait list for screening.
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Resource Alignment
Opportunity Name Surgical Care Staffing Opportunity Description
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Explore the 4S/4N staffing investment opportunity through further determination of the appropriate alignment of staffing to the recommended HPPDs and the increase in beds related surgical services repatriation. There is a significant opportunity for future investment in nursing staff for the QEII Emergency Department based on the trend of increase in patient volumes. This opportunity is however limited at this time due to physical constraints, physician resources and the current level of leadership and clinical supports.
QEII ED Staffing
Staffing levels in the QEII ER should be enhanced by 1 RN for every 24 hours to support the triage function of this busy Emergency Department. There is an opportunity to introduce a support worker role into the QEII ER to provide ancillary support to nursing staff.
Peace River Patient Peace River: There is an investment opportunity in the combined Medical/Surgical and ER/OPD. This opportunity should be considered in light of the current issue of Flow to Community elderly patients waiting placement in the community. QEII OR and Recovery Room Staffing Grimshaw/Berwyn ED Staffing
An efficiency opportunity exists in the combined OR and recovery room related to the potential to increase capacity. This efficiency target is equivalent to 1.8 FTE and represents an opportunity to increase OR volumes within the current staffing complement. Consider staffing opportunity as it relates to the issues with holding patients in the ER for longer than expected.
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Cluster-Related Cluster-Related Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Regional Opportunity Map and Reference Guide
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
Explore opportunities to increase throughput within existing staff complement, to drive part of staff savings opportunity and increase access to select modalities.
DI Staffing
Examine opportunities to reduce DI records staff and film costs once regional PACS is in place. Explore partnership with Health Registry for common transcription staffing and dictation system, to drive part of staffing opportunity.
OT Staffing PT Staffing Lab Staffing Pharmacy Staffing
Explore opportunity for staffing savings in context of broader Physiotherapy succession planning, and support to R-SHIP. Explore opportunity for staffing savings in context of broader Physiotherapy succession planning, and support to R-SHIP. Given plan to repatriate northern volume to the region, and the need for focus on lab utilization management, it is suggested that the region re-examine staffing once repatriation is complete. Examine staffing levels following planned recruitment of vacant Pharmacist positions, and establishment of standardized medication order review across the region.
Acute Medicine and Explore opportunity for staff savings or increased activity in the Rehabilitation unit in Rehabilitation Unit Medicine 5N, in alignment with a broader regional community health needs assessment. Staffing Social Work Staffing
As a result of the Regional Discharge Planning and Utilization Management opportunity, Social Worker staffing will need to be re-examined. Explore options for obstetrics service delivery model and alignment of outpatient
Obstetrics Staffing services to inpatient unit.
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Cluster-Related Cluster-Related Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Regional Opportunity Map and Reference Guide
Resource Alignment (continued)
Opportunity Name General / Nurse Admin. Staffing Opportunity Description
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Consider staffing investment opportunity with respect to building management capacity for planning and performance management. Explore consolidation of the CSR function, and re-consider MM staffing
CSR Function & Staffing opportunity once CSR staff are re-aligned.
Plant Ops/Maintenance/ Work to reduce overtime as a premium cost driver. Biomedical Overtime Health Records & Telecommunication Staffing
Explore staff savings opportunity relative to the transition of Telecomm FTEs to IT, and further investigation of the roles/FTEs split in the smaller sites. Consider further coordination with DI for transcription as part of staffing opportunity exploration. Consider potential staff savings opportunity once regional CSR re-alignment is complete. Explore consolidation of the CSR function, and re-consider MM staffing opportunity once CSR staff are re-aligned.
Materials Management Staffing
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Cluster-Related Cluster-Related Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Regional Opportunity Map and Reference Guide
Infrastructure
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
Explore options for evergreen equipment contracts as a means of reducing up-front capital costs.
DI Equipment Renewal Process
Continue to explore options and business cases for capital replacement of DI equipment. Explore business case for evergreening as a method of enabling DI equipment renewal under a lower capital-intensive cost model.
EMS Infrastructure Requirements Physician Clinic Colocation Peace River ED Patient Flow QE II Paediatrics/NICU Physical Plan
Conduct an external review and cost impact analysis of Regional EMS as the service is transitioned to the region, including an assessment of facilities and equipment infrastructure requirements. Explore options to partner with physicians in co-locating physicians' clinics to hospital sites in Peace River and High Prairie, as part of overall physician recruitment and retention planning. Review options for improved patient flow into the Peace River emergency department. Conduct a facilities needs assessment for Pediatrics and NICU to determine the costs/benefits of space redesign in advance of broader QEII redevelopment
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Cluster-Related Cluster-Related Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Regional Opportunity Map and Reference Guide
Infrastructure (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
Central Monitoring Enhancements PACU & Paediatrics
Consider options to increase central monitoring capacity in the QEII recovery room to support additional beds, in conjunction with plan to open 5th OR. Investigate business case to implement central monitoring in Pediatrics, as a mechanism of improving care and reducing staffing costs. Explore option to shift cardiac telemetry monitoring to Medicine, including consideration of decentralizing monitors and/or display pagers. Assess instrument inventory in conjunction with OR scheduling review to determine appropriate inventory to support care delivery.
Instrument Inventory
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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 Executive 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
Hea lth Go Sys al te s m
em st Sy s lth tive Hea itia In
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Regional Opportunity Prioritization
Phase 1 Senior Leads and Resources
Project Resources Opportunity Name VP, Medicine Portfolio MD Leadership Alignment External Reviews ED, Medicine, Psychiatry Program Frameworks Family Medicine, Surgery, OBS QEII ED Review Peace/Grimshaw MD Relations Improve Coding
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Prioritization
Not Pursued
Responsible Senior Lead Dalton Russell / Dr. Brent Piepgrass Dr. Brent Piepgrass
Additional External Internal Financial Resource Priority Deferred Resources Support Support
Dr. Brent Piepgrass
Dr. Brent Piepgrass
Dr. Brent Piepgrass / Dianne Calvert Simms Dr. Brent Piepgrass / Tim Guest Shawn Terlson
2006 Deloitte Inc
AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Regional Opportunity Prioritization
Phase 1 Senior Leads and Resources
Opportunity Name Grimshaw/ Berwyn ED Staffing Acute Medicine and Rehabilitation Unit Staffing Surgical Services Review Planning Regional Surgical Services Review Peace River's Role High Prairie/McLennan Service Integration Decrease Wait Times Project Resources Prioritization Responsible Senior Additional External Internal Not Lead Financial Resource Priority Deferred
Resources Support Support
Pursued
Tim Guest Dianne Calvert Simms Dianne Calvert Simms / Tim Guest / Dr. Brent Piepgrass Tim Guest
Tim Guest Dianne Calvert Simms / Tim Guest
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Regional Opportunity Prioritization
Phase 1 Senior Leads and Resources (continued)
Opportunity Name OR Utilization Management Same Day Surgery & PACU Role Review PAC Utilization Management Materiel Management Staffing QEII Portering Model & Staffing Project Resources Prioritization Responsible Senior Additional External Internal Not Lead Financial Resource Priority Deferred
Resources Support Support
Pursued
Dianne Calvert Simms Dianne Calvert Simms Dianne Calvert Simms Shawn Terlson Shawn Terlson / Dianne Calvert Simms
Dianne Calvert Obstetrics Simms / Tim Guest / Review Planning Dr. Brent Piepgrass/ Jane Manning
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Regional Opportunity Prioritization
Phase 1 Senior Leads and Resources (continued)
Project Resources Opportunity Name Responsible Senior Lead Dianne Calvert Simms / Tim Guest/ Dr. Brent Piepgrass/ Jane Manning Dianne Calvert Simms / Tim Guest/ Jane Manning Tim Guest Prioritization
Additional External Internal Not Financial Resource Priority Deferred Resources Pursued Support Support
Regional Discharge Planning and Utilization Management
ALC Strategy
Peace River ED Patient Flow Peace River Patient Flow to Community Regional Education Strategy
Tim Guest Jim Sanderson / Tim Guest
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Regional Opportunity Prioritization
Phase 1 Senior Leads and Resources (continued)
Project Resources Opportunity Name Responsible Senior Lead Prioritization
Additional External Internal Not Financial Resource Priority Deferred Resources Pursued Support Support
Health Records & Telecommunications Staffing Beaverlodge Role Review
Shawn Terslon
Dalton Russell
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Regional Opportunity Prioritization
Phase 2 Senior Leads and Resources
Project Resources Opportunity Name Responsible Senior Lead Dianne Calvert Simms Dianne Calvert Simms / Shawn Terslon Dianne Calvert Simms / Shawn Terslon Jane Manning Jane Manning Jane Manning Jane Manning / Dianne Calvert Simms / Tim Guest Tim Guest
2006 Deloitte Inc
Prioritization
Not Pursued
Additional External Internal Financial Resource Priority Deferred Resources Support Support
QEII ED Staffing CSR Alignment CSR Function & Staffing PT Staffing OT Staffing Environmental Health Review Social Work Staffing Peace River Acute Staffing
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Regional Opportunity Prioritization
Phase 3 Senior Leads and Resources
Project Resources Opportunity Name Responsible Senior Lead Prioritization
Not Pursued
Additional External Internal Financial Resource Priority Deferred Resources Support Support
Clinical Lab Utilization Medication Order Review Endoscopy Utilization DI Staffing
Dr. Brent Piepgrass
Dr. Brent Piepgrass Dianne Calvert Simms Dr. Brent Piepgrass
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Regional Opportunity Prioritization
Phase 4 Senior Leads and Resources
Project Resources Opportunity Name Responsible Senior Lead Prioritization
Not Pursued
Additional External Internal Financial Resource Priority Deferred Resources Support Support
Lab Staffing Pharmacy Staffing
Dr. Brent Piepgrass Dr. Brent Piepgrass
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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
Peace Country Health
Performance Management Overview Final Report
July 14, 2006
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Property of Alberta Health DeloitteWellness and Inc 2006
Introduction
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; systems thinking and planning; Transparent and timely management processes related to decision-making; Demonstrated commitment to standardization; Role mentorship and succession planning; Multi-stakeholder relationships management
Findings
Documentation Review Stakeholder Feedback
New leadership in the region has initiated a high level of change across the region, in support of regionalization efforts over the past few years. Senior Leadership visibility is mixed across the region, and some stakeholders report a disconnect between the Director/Manager and Executive Team levels. Management and Senior Management identified the need for more management training to support new leaders in the organization. Succession planning is in place, but is not comprehensively implemented throughout the region. Rehabilitation clinical practice leadership is reported as being strong and well supported, however there are mixed reports on nursing and physician leadership
3 Year Health Plan; Annual Business Plan; Annual Report Organization Charts Accreditation Overview
Deloitte Observations
The region has initiated several instances of purposeful management turnover to establish leadership base moving forward. The region will now need to mentor and support these new directors/managers to further create a sense of `team', and to build capacity and support for broader management and planning of regional operations. Senior Management focus is on region-wide strategy and operations, and this focus has cascaded through to the management levels. There is a need for more focused clinical practice leadership across disciplines, as also noted by accreditation.
2006 Deloitte Inc
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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
Findings
Documentation Review Stakeholder Feedback
Region has a number of initiatives in place, with prioritization driven through Board and Executive Team decision-making. 3 Year Health Plan; Annual Business Plan; Annual Report; Service Plans The region is moving towards increased decentralization of decisionmaking, to improve local autonomy of the rural sites. Cross-RHA collaboration is occurring for multiple areas of the organization, driven in part by the RSHIP initiative, which requires stakeholders to collaborate for standards development.
The region has a clearly articulated mission, vision and principles, which are supported by the three-year plan and annual business plan.
Deloitte Observations
Three-year plan and annual business plan show good alignment, and performance indicators are in place to track progress to plans. Regional service plans also show alignment to key strategic priorities. An overall implementation timeline for the three-year plan is needed, to ensure balanced approach to resource requirements to support each initiative.
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3. Organization Structure
Leading Practice Attributes
Organizational structure reflects unique requirements of organization, service delivery; supports changing service and people requirements; Supports timely decision-making and efficient work flow; role accountability and communication Minimizes role duplication and confusion Strategic portfolios instead of service management ones
Findings
Documentation Review Stakeholder Feedback
Expansion of the number of Directors to support service delivery is reported to have improved portfolio size. Development of COO responsible for regional acute sites has received mixed reports from stakeholders, with some identifying improved visibility of these sites in the regional organization, and others noting continued challenges with rural site representation Develop of Corporate Business Officer role supports broader organization initiatives.
Organization Structure / Charts
Deloitte Observations
The region has focused on organization change and is still in a process of aligning the organization chart to strategic directions. Given Executive Team identification of an intended move to greater local autonomy in the rural sites, further exploration and alignment of the COO portfolio responsible for those sites will need to be considered. Organization structure for some areas still suggest challenges due to large portfolio size (e.g. Director of Continuing Care). The VP Medicine has a large portfolio with limited support infrastructure, given the strategic nature of this portfolio. Alignment of select services to Senior Management portfolios may reduce potential for cross-service operational synergies (e.g. Housekeeping, Property Management, Security and Parking).
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4. People
Leading Practice Attributes
Current Human Resources Strategic Plan; HR planning and management from a regional perspective (move from local to central) 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
Documentation Review
Findings Stakeholder Feedback
Human resources recruitment and retention challenges are reported as significant by many managers. Although the organization has an HR plan, it is reported as being misaligned with the strategic priorities of the organization. Stakeholders report limited support from the HR department, noting that it has only recently reached full complement. The OH&S department has only just re-started operations and is in process of developing programs, but has limited impact in the organization. Clinical Affairs is in place to support clinical education, but many stakeholders report significant challenges with this function. No education function exists for non-clinical staff.
HR Recruitment and Retention Plan Organization structure
The region has identified Health Human Resources as a strategic priority, but still needs further focus to achieve success on this priority. Broader communication of the current physician workforce plan to stakeholders will also help to ensure buy-in and support. The maintenance of a VP HR is a good signal of the organization's commitment to HR. Deloitte Observations HR and OH&S infrastructure is in development, but will need time and concerted efforts to gain credibility in the organization. Broad education and management training are needed to support the region's ability to move through change priorities. As part of this, on-unit expert clinical educators are needed to support clinical service delivery.
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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
IT plan Capital Redevelopment Submissions
Stakeholder Feedback
The region's IT initiatives are resource-intensive but are expected to provide a good information management foundation for operations. Development of business case approach to IT shows good progress. Capital planning involves stakeholders, but delay in approvals impact appropriateness of functional planning. Barriers exist to considering alternative business models for regional sites.
QEII ER requires immediate review for improved patient care delivery and regional risk mitigation. Other key facilities issues exist in relation to QEII, Regional EMS, Regional DI and Physicians' Clinics, as outlined in the report, which require continued regional focus. Deloitte The region is focusing significant efforts on the RSHIP Meditech implementation, which is required for implementation, but may be causing a corresponding strain on resources and Observations management ability to focus on broader regional information management. The region needs to expand its preliminary work on new business models, partnership ventures, and alternative service delivery roles as it works through facility re-development and functional planning to meet community health needs.
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6. Measurement
Leading Practice Attributes
Existence of a comprehensive performance management system in place (people, financial, operations, satisfaction, and other key processes) Development of performance metrics and targets to manage care and service; linkage of measurement to action and communication Performance measurement linked to quality and risk management
Findings
Documentation Review
3 Year Health Plan; Annual Business Plan; Annual Report, Accreditation Summary Annual Reports Risk Management and Quality Framework Service Plans
Stakeholder Feedback
The region has developed an enterprise risk management framework, but its integration into Board and organization culture is still in development. Performance management frameworks and metrics are in place, and service teams develop plans that link operational performance to strategic goals. Individual performance management is conducted irregularly due to management capacity challenges. No physician performance management and accountability framework is in place.
Deloitte Observations
The region has some leading practice areas for performance management that demonstrates clear cascades between regional plans to service plans and individual performance plans, but this is not consistently implemented or embraced throughout the organization. The region has corporately identified the importance of risk management, and has developed an enterprise risk management in support, but still needs to further cascade a risk management culture that extends consistently from Board to staff. Performance management, clinical service utilization, and clear roles, responsibilities and accountabilities for physicians is needed to support regional strategy, operations, care delivery and risk management.
2006 Deloitte Inc
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7. Operational Processes
Leading Practice Attributes
A formal, organization-wide risk identification and management process is in place; Established processes in place to support standardization and development of practice Established processes, initiatives to support standardization of care and service Established resources to support initiative implementation and monitoring Assessment of new or different business models to support service delivery and integration Management processes that support accountability
Findings
Documentation Review
Annual Business Plan Accreditation Report Service Plans Policy/Procedure Risk Management and Quality Framework
Stakeholder Feedback
The region has developed an enterprise risk management framework, but its integration into organization culture is still in development. Several departments report good progress in achieving regional standardization in operational processes. Geography and lack of common technology is a current barrier to standardizing regional processes and information management.
Limited resources are currently focused on quality and risk management in the organization. Stakeholders show mixed level of risk management awareness, and use of risk tools (e.g. enterprise risk management framework, external tools such as CTAS in the ER, etc.) The region is involved in several standardization processes to promote regional focus on Deloitte operations, although this is still in development. Observations Completion of regional IT infrastructure is expected to support standardization and coordination efforts across operations. Physician leadership and involvement in clinical practice standardization is limited. Physician charting is lacking in several areas, which poses a risk to the organization and impacts comprehensive interdisciplinary charting to support care management
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Summary Remarks
Strengths to build on include: Strengths to build on include:
Good alignment between the Good alignment between the three-year plan, annual plan and three-year plan, annual plan and service plans service plans The development of a regional The development of a regional enterprise risk management enterprise risk management framework framework Development of program Development of program frameworks to support the frameworks to support the organization (e.g. performance organization (e.g. performance management, in OH&S, and in HR) management, in OH&S, and in HR) Internal leading practices of Internal leading practices of integrated performance integrated performance management management
Areas for further consideration: Areas for further consideration:
Development of an overall Development of an overall implementation timeline and plan implementation timeline and plan for strategic priorities that links for strategic priorities that links resources and organization resources and organization change capacity change capacity Continued examination of Continued examination of organization structure to ensure organization structure to ensure portfolio balance and alignment portfolio balance and alignment Implementation of developed Implementation of developed programs e.g. cascading of programs e.g. cascading of performance management, risk performance management, risk management and accountability management and accountability culture throughout the culture throughout the organization to move from organization to move from planning to implementation planning to implementation Structured region-wide education Structured region-wide education function that provides direct function that provides direct education to management and education to management and staff at the operational unit level staff at the operational unit level
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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. 10 AHW RHA Efficiency Review Peace Country Health Property of Alberta Health and Wellness
Member of Deloitte Touche Tohmatsu 2006 Deloitte Inc