LEADING FOR PATIENTS
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LEADING

FOR PATIENTS

Chinese Community Agencies Roundtable


3 October, 2013 – 5:30-7:30PM

Chinese Community Church

Facilitator TSH: Robert Biron

Facilitator RVHS: Rick Gowrie

General Comments

  • Must communicate changes in service delivery to patients
  • Work with community physicians to get referrals to improve local access
  • Must develop performance metrics for post-merger, to determine whether it was successful or not
  • Consider developing programs to meet the needs of emerging demographics (e.g., seniors)
  • Analyze how services can meet community needs – can tailor services through a merger more effectively
  • Value proposition needs to be demonstrated to the communities
  • Consider intended/unintended consequences of merger on other providers in the system
  • Need to address perceived “loss of trust” in the community

Benefits

  • Can work with community-based organizations to provide care – more access to care in the community
  • Improved communications and integration with community-based healthcare organizations
  • Improved reputation of the hospital
  • Inter-hospital collaboration
  • Possibility to update hospital infrastructure
  • Ability to become a key healthcare provider for culturally appropriate care
  • Possibility of repatriating patients
  • Standardization of care and service delivery
  • Reinvest savings into quality and program improvement

Risks

  • Costs of merging e.g., union negotiations
  • Benefit of the merger not understood by the community-at-large given the lack of metrics regarding success rates of prior hospital mergers
  • Downloading patient volumes and associated fiscal issues onto community-based care organizations without the appropriate level of reinvestment
  • Ease of transportation for seniors and newcomers between sites

Transcript

Facilitator:

Do you have any questions about the content of the presentation?

Community Member:

It looks like the main purpose of the merger is to save money.

Facilitator:

It may feel that way, and saving money certainly is an imperative. When we go back to the Ontario’s Action Plan for Health Care, and look at our circumstances, a big driver is improving access to services and quality. We talked about establishing centres of excellence and regional services to better service our local communities. We need to better serve our immediate communities – we know our market share is low in some of our programs.  As well, the new hospital funding methodology essentially introduces a level of competition – so we need to compete with other communities around Toronto to get our fair share of patients and funding dollars.

Community Member:

Did you find you saved a lot of money when Grace and General merged?

Facilitator:

There were savings, because the back office (administrative) functions and some patient services were consolidated, for example.

Community Member:

Do you know the exact number?

Facilitator:

No – the sites have been merged since 1997 so it has been quite some time since it happened, and there have been a lot of concurrent changes in terms of services and inflation. There have been a lot of integrations between the campuses throughout the years – our palliative care program, inpatient mental health, some of our surgeries – so there are examples of where we looked at programs and brought them together to gain efficiencies. These initiatives did improve access and care.

Community Member:

A merger may not be understood by a community in terms of the benefits it can offer. The first impression I have is that it’s to save money. We need to explain to people that the merger adheres to the four major principles you outlined, such as improving accessibility, and how money saved through merging will be fed into improving accessibility and sustaining programs. If you can communicate that to the community – that savings will lead to an improved quality of care because they can be reinvested in care and programming – that would be a good thing. It’s not about cutting out services; the savings go back into improving quality. That would help people understand the benefits.

Facilitator:

That is what we hope to accomplish by November. The work that we’ve done up to now, in terms of looking at various clinical programs – it’s all posted on our website – and all the information we’re getting is still coming together, but has not been compiled yet into a decision. That work will inform the hospitals on the potential benefits and risks to merging.

Some people are now are saying ‘show me the benefits’ – but this is a work-in-progress and we’re asking our stakeholders to come along and provide their input. Once we’ve completed the engagement activities we can compile the findings and feedback to determine the benefits.

Community Member:

If I put myself in the shoes of a regular person in Scarborough, it doesn’t mean much to me whether all four campuses constitute one hospital or two. I’m used to going to Grace [TSH Birchmount site] – and if that service is still there, whether it bears the Scarborough or Rouge Valley logo, it doesn’t mean all that much, as long as the service is still there. Whether they merge may mean more to us around the table, because we’re involved in community healthcare organizations, but it may not mean much to the general community.

We want to explore the possibility of an expedited pathway to healthcare between community and hospital organizations in order to improve healthcare. If my healthcare organization has to negotiate with two organizations, there may not be consistency in how the process works between my organization and the two hospitals. If there were a merger and some integration in diagnostic services, that would be a great thing in terms of where fellow service providers are concerned. Some form of integration would be attractive in that sense.

From a different perspective, it might become difficult for people to know where to go for services. At an institutional level it might not matter – because if a certain site specializes in a certain clinic, it would just add to the service as it is – but if a service changes campus, that needs to be communicated.

A lot of newcomers have difficulty negotiating public transit, and they may not have access to their own transportation. If they have to go to Grace instead of RVHS Centenary for a particular service, that’s a big change in terms of transportation. If the merger means a consolidation and concentration of resources at particular sites, it may have a negative impact. On the other hand, if you say you may merge but services will stay at the sites, then it would be good for the community but bad in terms of resources.

Community Member:

From a planning perspective, you plan based on whether health services address the needs of the community. From a planning perspective, is there enough analysis on whether there is duplication of services now, and whether any particular duplication of resources between hospitals can be reduced, in terms of services and program utilization? Some sites probably have lower utilization of certain services, because there is a similar local clinic or because that particular clinic is not ‘reputable’ in terms of expertise. My point is that we need to analyze – if we do want to look at better coordination of services, you need all that information to make a decision about whether those services are meeting the community’s needs right now or can be amalgamated.

When we plan, it should not be just because of money. It should be about what are the needs of the population in the community.

Community Member:

I agree with everyone’s comments. On another note, in terms of human resources – with the zero increase of funding, we still need services, and we all know how difficult it could be to get things done with unions, which require two or three percent increases annually. It doesn’t matter whether the hospitals merge or not; there will still be a challenge in terms of limited funding. I’m not sure how the merger can deal with that, and if you merge, you may need to do more in terms of negotiating with the unions – you may need to consider that there could be additional costs associated with merging in that sense.

Facilitator:

So the risk I’m hearing you say is that there may be additional costs in merging – and how would that be paid for.

Community Member:

I have a couple of comments. From the benefit side, no matter what happens, I appreciate the effort of both hospitals for having a dialogue. Giving the opportunity to residents and community stakeholders to talk about how the hospitals can get closer to serve the community is a merit.

The second thing I’m thinking of is, from a service usage point, what are the benefits of merging? Quite often, the community’s anxiety is about the emergency department. You need to ‘sell’ the fact that ERs are staying, much more strongly. People will think that they won’t have access to radiology or other ER services.

I don’t actually know if you will save money in a merger. If you think about things moving forward, the population is growing. In terms of demographics, based on the 2011 census, the population is exploding in Scarborough – particularly in the seniors’ bracket. How does this exercise target programs or departments that will meet these emerging needs? I don’t know how you are building that in.

In terms of investment back to the community, I’m doubtful that will happen. It would be better to have one CEO than two; but for the entire work, they will have to cut payroll.

Community Member:

To maintain quality of services, you can’t cut too many staff.

Community Member:

Even at different sites, I would expect to have a similar quality of services. Going to one ER should be exactly the same as another, so it’s about the standardization of quality of care. If you cut staff, you may not be able to maintain quality of care.

Secondly the hospitals in terms of location are not too close. If someone is a senior, how can they navigate from one campus to another?

Facilitator:

The idea of centres of excellence – it’s not a suggestion that we could do that for every program. That’s not possible. If we kept ERs open at all the hospitals, there would be an envelope of services which would go along with that. There are potentials in other programs where we could work better together – for example, oncology. Right now we are competing with each other to be a centre of excellence for Scarborough, so there is merit in creating a coordinated program. We have cardiologists in every hospital; but the more invasive technical procedures are consolidated right now at RVHS Centenary. The high risk or more advanced specialized services is where you can consolidate, and they can be maintained in the community. The Eye Centre at Birchmount is another example. But we won’t be consolidating absolutely everything.

Facilitator:

The other comment I would offer is that if we look at the number of patients that are actually leaving the community, there is definitely an opportunity to reintegrate those patients.  Whether its quality or access, we have the opportunity to improve upon performance moving forward. Some programs are as low as 30% market share of patients, which is not acceptable. We ought to be serving our immediate community. We don’t know fully why – there might be perception issues, quality issues, or it could be referral – but we can do a better job of serving patients in our immediate community.

Community Member:

Talking about the coming together in a merger, from a practical perspective there are several to talk about: the community partners say ‘what are the benefits for us as community partners?’ the patients and community says ‘what are the benefits for us as service users?”

As community partners, I’d like to say that since provincial policies are really moving towards integration and cooperation, I would like to see the two hospitals integrated so that it’s easier for us to connect with you to provide services. That would enable us to get our messages out quicker to all campuses. For example, the GAIN (Geriatric Assessment Intervention Network) clinics at both hospitals are basically the same; but I have to talk to both hospitals since our clients attend both. The Province wants you to collaborate with community partners, so efficiency-wise it is easier on both ends. There would be only one contact point.

If we look at the end ambition, since the Central East LHIN is pushing out Health Links, if we have to work towards that goal it might as well be easier to look at the infrastructure of the communities – the hospitals working with the community regardless of whether they merger. That would improve efficiency.

For the consumers/service users, they don’t really care whether your logo is TSH or RVHS – as long as they get good services. If you come together, you will provide them with good services. The reason people go downtown is because, somehow, the perception is that the academic affiliation means they have better quality services. For instance, I’d rather go to St Mikes for cardiology services. One of the guiding principles you have is Excellence – you need to focus on that. It’s the name recognition and the reputation of certain programs that you need to build up. That will build up utilization of your good programs.

Your claims need to be evidence-based.

Community Member:

I know your primary focus is right now on potential integration between the hospitals and what it would mean. But I would also urge you to consider the intended or unintended impact it might have on the rest of the community continuum of healthcare. Even if your primary goal is not cost savings, to realize any kind of benefit out of integration there has to be some amount of service rationalization. You have to figure out how to do things more efficiently and effectively. It may involve changing how your services are structured. There may still need to be a primary site with satellite sites, but it may have inadvertent effects. If certain resources are invested in a coordinated site, the other three sites may not be able to do the same amount of work they are doing now. So, some of the demand of the three other sites may be downloaded onto community providers. So it may have an impact on other services, without us actually being partners. Give some consideration to this, and to looking at opportunities to explore with healthcare providers about the possible mitigating measures could be to cushion the blow – sooner rather than later.

Facilitator:

It is a good point that you made.How many of you have been approach in terms of collaborating on the workbooks?

[Three participants acknowledged having input on the workbook exercises.]

So we have eleven clinical areas where we did a deeper dive, which was with the front line staff, physicians and leadership of the programs. Those workbooks are intended to explore opportunities at a high-level, and the teams were expected to go out and engage their stakeholders, including members of the community services. If a change in the hospital has a ripple effect on the community services, it must be coordinated.

Right now, what we’re trying to understand the potential value proposition. Patient services planning would take place at a later, separate phase. It requires a rigor of planning and engagement that would be done after the merger. Our commitment is that we will do that.

Community Member:

I hope that, no matter what the hospitals do, a merger does not affect the staff. The staff have to attend to business as usual, and also have to look at integration activities with the two hospitals – so I hope that a decision is made soon, so the staff can settle and get on with things.

Community Member:

Scarborough presents an opportunity to work with different ethno-cultural communities because it is one of the most diverse communities you can find. If the two hospitals have aspirations to be a diverse healthcare centre, you have a lot more to offer with the resources you can command as one organization to challenge the academic centres. Focus on culturally appropriate or culturally competent care in order to do that. Ethno-cultural healthcare organizations would love to partner with you on this.

Facilitator:

One of the other things worth talking about is that, in Scarborough, we have three hospitals which are of significant ‘vintage’. We know that we have to address our infrastructure. It’s time for Scarborough to step up. The signals that we’re getting informally, and the reality is, that when you have two corporations six kilometres apart competing with each other, how can you really create a master plan for hospital renewal? So the government won’t invest in two corporations – they will invest in one. The Windsor hospitals have essentially gone through a similar process – they have old hospital infrastructure and the two hospital corporations were serving the same community and competing with each other for healthcare dollars. They ended up working together and got a planning grant for a new hospital.

Community Member:

I would like to touch on something about community services. Hospitals also have community outpatient programs, which can be combative with community-based services. Hospitals use up resources here, and we can work together to look at how community agencies can take on those roles. Consumers can have choices between going to a community or a hospital program – a way that you can look at resources and costs for outpatient programs could be considered.

Facilitator:

The Ministry is clear that hospitals need to get out of the business of community care – and rightly so. We have to focus on what’s ours to do – hospitals are only one part of the healthcare system. The model has to change. We just transferred sexual assault counseling to an agency in the community. The benefit of that was that the community provider has outreach in many more locations. The hospital is one location; but the outreach program is much more accessible, and can provide the same quality of services with the same training – and we were able to find savings for the taxpayer. That is an example of where we can improve quality of care the patient and improve access, while decreasing costs. We’re committed to doing this – we will have to do it with or without a merger.

Community Member:

In terms of infrastructure – even after the programs have been streamlined, there should be support and the right information given to the community, such as how the hospital is triaging different people to different specialized units of care; how the EMS support is working with the community. An example is when York Central Hospital integrated their cardiology unit and into Southlake, some of the community did not know that the program no longer existed at York Central. That contributes to a delay of time for patients. If you streamline programs, community education is a big part of the exercise to provide information – what programs are located, where, regardless of whether it’s in the community or the hospital.

Community Member:

In terms of community expectations of the hospitals – the Scarborough community’s expectation for the hospital to be all things to all people is still the same, even while the community itself has changed. That same expectation of that same vision of a community hospital hasn’t changed. That may well have been consistent throughout other transformations and changes that TSH has gone through. Every time there has been a potential for change, the community has resisted.

Facilitator:

There’s no ‘secret agenda’ for shutting down any hospital sites. That’s so important for us, and we have been clear to the community. It’s not feasible for us to close an ER or a site, given the population currently served and projections for the future. Unfortunately past attempts of making service changes has deteriorated trust in the community, which is a shame because there are ways that the hospital can improve services through change. We’ve committed to transparency in this because there will be a change, in some way, and we need to engage the community in how to do it. We need to start building trust in order to do this. I hope we can effect change in a constructive way.

Community Member:

Have you talked to the staff about this exercise?

Facilitator:

Absolutely. All of this process is public. There have been three phases of workbooks over the past month and a half, which included staff input. Staff can also include feedback on the website. The minutes of this meeting will be sent to one or two of you to edit yourselves to give confirmation that the minutes are reflective, and once you’ve approved them, they will be posted on the website. The minutes from the many community roundtables we’ve had already are posted on the website. We try to find common feedback from the meetings and will provide that feedback to the Boards.

Community Member:

All of this engagement is good with staff and community – how about academics? If you want to create Centres of Excellence, you need to integrate the academic community.

Facilitator:

It hasn’t been a necessary focal point. There are ten clinical areas which have looked at opportunities, which may have included academic improvements. To establish an academic centre or affiliation with a university takes a lot of effort. We don’t want to necessarily say that that is the end stake, because the ultimate goal is service to our community.

Facilitator:

Going back to your previous question, both hospitals have also had town halls where we engaged staff. They are videotaped and put on the website, so you can check them out online. Today, for example, I was invited to a nursing unit ‘huddle’ to talk about the merger, which was a good conversation. The entire management team is involved in the review and staff engagement in various ways.

Community Member:

You should let everyone know what the process will be, because the support of your staff is incredibly important.

Facilitator:

Absolutely. The Motion of the Board is to conduct stakeholder engagement first, which set the tone of how we were going to reach out. It’s overwhelming, because you never think you’re doing enough because it’s such a big community. But we’re starting to see common themes emerging.

Facilitator:

Given that it’s a 24/7 operation, it poses some challenges to getting staff input in a timely fashion.

Community Member:

I appreciate that you are taking the time to engage groups like us. It’s clear that you have taken the time to consider who your stakeholders are. Commenting on that, the physicians at large in Scarborough are a big stakeholder group. Have you engaged with them, are they interested?

Facilitator:

We set up town halls in both of our communities – one hasn’t taken place yet, but the other no one showed up. We are going to try again though.

Community Member:

Probably a big piece of this has to do with where physicians are referring their patients to. If they don’t see the Scarborough hospitals as a viable option, they will keep referring their patients’ downtown.

Facilitator:

At The Scarborough Hospital we recognize that we must address some issues relating to our reputation, particularly relating to past issues. There needs to be a concerted effort to reassure the physicians (primary care) and communities that our hospitals provide quality and safe care to its patients. We have work to do to dispel those impressions and myths.

Community Member:

You may look at the patients you have at Birchmount to see if there’s anyone who’s had a good experience at Birchmount, so they can speak to their positive experience. Someone, who really used the services – a patient voice.

Facilitator:

Great suggestion.

Community Member:

I think a benefit would be that the hospitals are working together to see how they are able to do a better job. That in itself is a benefit – the collaboration is there.

Community Member:

At the system level, dealing with one hospital is much simpler than dealing with two – no matter how many sites there are.

Community Member:

Look at the metrics. If this is going to be a collaborative effort between hospitals and community services, you need to start looking at metrics in order to demonstrate the measurable outcomes of it.

Community Member:

When you talk about a merger, there are always bad stories. People think there are going to be fewer services. You need to frame it in terms of that you are going to be adding value.

Community Member:

Beware of the lesson of Sunnybrook and Women’s College – a forced marriage and a divorce.

Facilitator:

We do view this as an integration of equal partners. We are very similar in many ways, in terms of our cultures: our values are similar, we serve the same community. But your point is that a forced merger won’t work, and there’s good evidence of that. Although the Central East LHIN has asked us to look at integration options, they didn’t force a merger. We decided to look at a merger because we believe there are some value to the patient and taxpayer. At the end of the day, we will still have to work together, better anyways.

Facilitator:

Certainly one of the underlying discussions at the beginning of this is the premise of quality costing less. It’s not a ‘cost cutting’ or cost saving exercise – that’s not the key focus.

Community Member:

Given that there may be a change in government come spring, how will that change the process?

Facilitator:

Along this process, we have worked very hard to keep our local politicians fully apprised as to where we are – so they don’t feel anxious about it. What we know is that integration is consistent with the current government’s healthcare policy.

The problem is that a merger is perceived as negative – so we need to demonstrate value at all levels of the system.

From a process point of view, only the Minister of Health can approve a proposed merger.

Facilitators:

The facilitators thanked the participants for taking the time to participate and to provide their insight.

©2013 Leading For Patients
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