LEADING FOR PATIENTS
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LEADING

FOR PATIENTS

Community Roundtable: Service Clubs, Ratepayers, Neighbourhood Organizations – Scarborough

7:00 – 9:00pm

Facilitator TSH: Cara Flemming

Facilitator RVHS: Cheryl Williams

Transcript

With teaching, it’s one of the things we talk about that we could do more of. Teaching is remunerated through the funding formula now, and it is one of the things that is funded. If we did teaching, we could get a share of that money. In the old formula, there was a global base of money; now, we need to compete in this realm to get our fair share.

Community Member:

Is there a funding difference between teaching and regular hospitals?

Facilitator:

In the new funding formula, the funding follows the patient. In the old system, the hospitals would get a lump sum, which wasn’t really based on the number of patients you saw. The new funding formula is based on the number of patients you see, and how well you provide their care. People in our community generally go downtown because it’s easy; but if we can provide the same level of care, close to home, this is where patients will go.

Facilitator:

There is also something called “Centres of Excellence”. RVHS sees more cardiac procedure patients than the downtown single hospitals do. It’s a big program, and well recognized, so people will go here rather than try to find services downtown. We have world class services here, and we need to get patients in to take advantage of that.

 Engagement Exercise

Facilitator:

The purpose of tonight is not for us to talk at you, but in order to get your input. We have some questions we want to ask you. We are interested in your feedback on four areas: what do you perceive are the benefits/risks of merger. For the risks, how could we resolve the issues? How could the hospitals work together to improve patient care and accessibility? What additional concerns or questions do you have?

Community Member:

I am extremely familiar with the website. Leading for Patients is outstanding, I haven’t seen transparency like that in a long time. The fourteen workbooks are in there, and they are large working groups dealing with the subjects.

Facilitator:

The working groups have gone through due diligence in looking at the benefits and risks of the merger from 11 clinical functions and four back office functions. Those groups have been working, and all of their work is on the website. As new versions of their workbooks get completed, they get put on the website.

Community Member:

I encourage everyone to go on the website and look at these workbooks. They are very in-depth; there is a definite disciplined process there, and it’s the right way of doing it. I applaud this.

I do also have some concerns about the future with this merger. If 24 people are involved in just one workbook, and another 24 involved in another workbook, and there are fourteen working groups – that is an awful lot of people involved in the merger process. We need to be sure that people remain focused on patient care. I don’t care about what the LHIN says – everything is superficial compared to having access to health care.

Community Member:

I just did research online and pulled out a statement issued by both CEOs of TSH and RVHS. They started saying that the layoffs would likely be a part of the merger, and that the closure of an ER could also be in the offing.

Facilitator:

We have definitely said since then, no ERs will close. That was early on in the process.

Community Member:

He also emphasized that no merger is decided; but given the numbers you have been discussing, we need to cut the funding. How will cutting the funding in a hospital affect the patient coming in? Will we have enough nurses looking after patients? I had a medical crisis a few years ago, and RougeValley did an outstanding job providing care. One night, I was transferred from RougeValley to General. In the night, my wound started bleeding; and the nurse didn’t do anything to help me. I had to stay one more day. What I’m saying is that the quality between one hospital and another is very different. If you cut funds, how will it affect care?

Facilitator:

The funding issues will continue whether we merge or not.  We spend 80% of our funding on labour.  If our funding continues to be zero but salaries, wages and benefits increase, there may be layoffs. My question for you to think about is, does the merger provide any opportunities to mitigate funding issues? Funding issues will continue even if we don’t merge, so the status quo won’t be an option.

Community Member:

I think a merger will cut down administrative costs – one board, one CEO. At the end of the day, there will be one authority deciding the whole thing; and the funding will be divided equally between the hospitals. That will be a benefit of the merger. The one concern I have is that, whether the hospitals stay separate or combined, will patient care remain high quality?

Facilitator:

There is some evidence that you can be efficient and improve quality of care.

Community Member:

There were some mergers in early 2000s. Did you do any studies on how those unfolded? Are those hospitals working in a better position or at the same level of care?

Facilitator:

Probably both. There have been examples of mergers that have been successful and others that have been failures – even ones which ended up ‘divorcing’.

Community Member:

You’re talking about Sunnybrook and Women’s College. They amalgamated then separated.

Facilitator:

They did identify a few different things that would help to determine if a merger is a good thing. One identifier is whether the hospitals share a focus and similar services. RVHS and TSH offer very similar services. Sunnybrook has since partnered with St. John’s, and that partnership is going well because they have similar business lines and values. That is important.

Community Member:

Mergers raise the cost of care by 2%, and sometimes more. A study in 2012 showed that hospital mergers result in declined financial performance; increased waiting times; and no evidence of increased quality.

 

 

Facilitator:

Those might be some risks. That is why we are going through this process now.

Community Member:

The issue is that Canada has never conducted any studies on whether mergers help costs or quality of care.

Facilitator:

I suppose the question is, have RougeValley and ScarboroughHospital looked back on their own mergers – because we are both already merged organizations. Have we benefited from a quality or fiscal standpoint?

Community Member:

We had success stories within some departments – Emergency, for instance – at the General and Birchmount. They have similar standards and good leadership in that sense, so we have access to great services. So that is a success story. On the other hand, there are departments which have maintained silos.

Community Member:

When BMO merged, they provided better services. Mergers, in a way, help because you become a bigger corporation in a business sense. Loblaws and Shoppers merged and it was a good thing. With hospitals, you have to look beyond the fiscal considerations – will quality of care be improved?

Community Member:

Do you have any strategies to engage Scarborough Newcomers organizations? Particularly given the language barriers?

Facilitator:

We have had several roundtables with leaders from religious organizations and from organizations that do represent community agencies for newcomers. We have translations on the LeadingforPatients.ca website in Tamil and Chinese, and if someone wanted translation in an additional language, we employ interpreters at the hospital. It is difficult – we don’t do it perfectly, especially with a process that is moving this quickly. But we have made an effort to deliver communications in English, Tamil and Chinese, which hits 75% of the population [Correction:  with translations in Chinese and Tamil, we will hit over “90% of the population].

Community Member:

It is crucial to engage with those organizations.

Facilitator:

We have also put stories in other language community newspapers. Our CEOs did an interview with Omni last week.

We are in one of the most diverse multicultural areas in Canada. It’s a daily experience for us, and we need to find other ways to engage our diverse community. People don’t necessarily participate in forums such as this.

If we wanted to talk about the risks of the merger, is it fair to say that a risk might be that we don’t adequately engage those who don’t have English as their first language?

Community Member:

I think that is a risk, yes. Just think about the percentage of the newcomers in Toronto. The Local Immigration Partnership is a CIC funded body in East Scarborough – you should look at engaging with them. (Local Immigration East). They work with ambassadors in different cultural groups, the informal groups that are hard to reach.

Facilitator:

Last week we had a telephone town hall. Did anyone participate?

[Yes]

Community Member:

And there is a link on the website where you can listen to the entire thing.

Community Member:

What are the key benefits of a merger for Scarborough residents? I really want to know from you – what do you see as the benefits of a merger and why it would work?

Community Member:

If you think about how the hospital is fighting to get dollars, as has happened at the General campus, it’s crazy. When you are a small hospital, it is difficult. By merging, we would become 7th largest hospital in Ontario, and we would have the largest number of ER visits. This would lead to increased funding. By being bigger, you are stronger.

Facilitator:

Slide 9 discusses that – it gives us a framework to discuss the rationale for merger. I talked about competition, and being bigger and attracting patients does now give you more money under the new funding model. We believe we can be more competitive. By being more competitive, we can retain and grow services in our community. How can we deliver services in the Scarborough cluster, at home, to our patients, rather than having them have to go downtown for services? The services might move within the community, but there will still be high quality services within the community. We also think we can be more efficient with the dollars.

More important is the ability to integrate services. If patients are going between campuses, or between the hospital and the community organization, we would be better positioned to communicate on patient care.

Community Member:

That is great.

Facilitator:

Rather than competing against each other, we would be working together. The new funding introduces this notion of competition.

Community Member:

There is an opportunity there to have funding strategies. But I still feel this will impact direct patient care at the end of the day, because the focus will be on merger, rather than patient care.

Facilitator:

So the risk is that we take our eye off the ball, and get too wrapped up in a merger and neglect to think about patient care?

Community Member:

Exactly.

Facilitator:

For example, you could read in the workbook on post acute care for strokes that now, you get taken by ambulance to a downtown teaching hospital (a regional stroke centre) if you have a stroke. They do your assessment and give you medication at these regional stroke centres, then you get taken back to Scarborough. But we could do that here – if we had enough neurologists, we would work together to make this a real viable service. If we merged, we would create a larger pool of neurology experts to support this service – meaning that we could provide that stroke care and medication here. So the care would get to the patients faster, which is critical for strokes. Right now for a stroke, you go downtown.

Community Member:

I moved near Birchmount campus because I thought it was strategically important to live near a hospital – and I’m glad I’ve done that. But there is so much focus on the merger right now that it is overwhelming. I used to work for the Foundation, but right now I can’t – I’m not at ease asking for funds for the hospital when I don’t know where those funds will go. Will the money I raise for Birchmount go towards care at General? The siting of this is important. They don’t have time to decide the siting of it, but the siting is the important thing that will affect the community. People will be very upset if the siting changes and they can’t give birth at the site of their choice. We went through that at The Scarborough Hospital, and it became a very bad issue to the point where there was a political intervention.

Facilitator:

So people are tied to the site?

Community Member:

Would a merger impact direct services for maternal and newborn care?

Facilitator:

We don’t know yet.

Community Member:

I read the entire maternal/newborn workbook this morning. One of the four recommendations is to create a Centre of Excellence for women’s health, but without the site chosen. So the merger is to go ahead without the siting discussion, which would happen later. We went through something like this with surgery, which was to be centralized at General – but people threw up a fuss. That is what I would love to see indicated as a risk of the merger: that we need emergencies that are well equipped with quality surgeons and anesthetists so that I don’t get carried all around Scarborough if I have a medical emergency in the middle of the night.

Community Member:

Last month, my son got food poisoning. In the night, he started vomiting. We got to the hospital at 3:30 AM; there was only one doctor in the whole emergency, and there were 12 patients sitting there. It’s too much load on one doctor, and the patients are waiting in pain. If there is any possibility with a merger to get more than one doctor on the night shift in the ER, that would be excellent. It took four hours for him to be seen.

Facilitator:

That is a specific issue. So your question is, would a merger improve that?

Community Member:

Yes. Would it improve emergency, so that it has more than one doctor?

Community Member:

What that comes down to is standardization. If you have a chief of emergency for the four sites, they should have the same procedures and same approach – the doctors will do the rotations so they know each other. This is amazing – the doctors are the same guys at the different sites, at Birchmount and General. The same thing is happening with Rouge, the doctors are rotating between the hospitals. When you have singular leadership, it makes a huge difference.

Community Member:

I know that you are going to have the review done by November. Are you planning to have any other consultations with stakeholders about direct impacts on services?

Facilitator:

That is something that would happen in the future. We could put that down as an opportunity to discuss sizing and siting in the future. While there can be supported principles for the merger, the community should have an opportunity to be re-engaged when we have that opportunity.

Community Member:

Definitely. A key risk for newcomers is transportation. We would want to be engaged in a conversation on sizing and siting.

Community Member:

If there were good communications that outlined where patients could go for care, would that mitigate it? It’s not like we can have a hospital in everyone’s backyard.

Community Member:

It’s not just about the language – it’s about the cost of transportation. Sometimes it is not possible for newcomers to afford transportation costs.

Community Member:

But it’s not like they would be going to the hospital every week, unless they had a very serious issue.

Facilitator:

If we think about transportation as a risk, how could we mitigate it?

Community Member:

Shuttle buses. We could have shuttle buses from community centres to the hospitals several times a day, or between the hospitals. That would definitely help.

Facilitator:

That’s a great idea.

Community Member:

What if we merged more gradually? Rather than an immediate merge.

Facilitator:

If a decision is made to merge, it is a ‘go/no go decision’. Regardless of what happens you could implement clinical changes on a slower basis.

Community Member:

Yes. Like, if one hospital has good quality of care, they can help pull up the other through best practices. But don’t try to change everything all at once.

Community Member:

The administrative cuts will create money in other areas, so there is a definite opportunity to create other services which are much needed.

Community Member:

Any major change like this needs a disciplined management system in order to implement the change. It should be a ‘management of change’, so that you don’t just do it all at once, without outlining all of the responsibilities needed. Be slow; make sure you cover all the angles before, particularly for critical patient care services.

Community Member:

Specialization is also a key. If you did all of the knee surgeries at one site, you would get very good at them. So it could become the centre of excellence, which is not only good for care, but also good for branding.

Community Member:

The people doing the workbooks are looking at the benefits. For example, mental health care for children. It’s difficult to provide children’s care. Children are overstressed with social issues, you hear about suicides and nervous breakdowns that they have – and this area could be improved by merging, mental health for children’s care. There are some benefits, but there are also stresses on people. People will be affected because they will lose their jobs or have to work somewhere else

Facilitator:

That will happen regardless. The dollars are shrinking, whether we are working together or apart. Job loss shouldn’t be a key issue, because it will happen anyways.

Community Member:

Are there any plans for partnering with other community healthcare partners to provide services more efficiently?

Facilitator:

Yes. We recently partnered with a community agency, which runs a mental health group home. We have a really excellent sexual assault program, and we said we would do the acute part of it, but it’s better for women to get the continuing care in the community. Do you think that could be a benefit, that we could better work with community?

Community Member:

I think there should be increased focus on that – how we can move services out of the hospitals and into the community.

Community Member:

That’s actually part of the Action Plan for Healthcare. They say that they want acute care only at the hospitals, and that other services should be moved out. The diabetic clinic, for example, you don’t need to get that care at a hospital.

Community Member:

In terms of the community clinics – I recently received care at a community agency. Getting a gastroscopy done at the hospital takes two or three weeks. When I scheduled it in the community, it was next day. Those are specialized clinics. If you have more of that – colonoscopies, gastroscopies – in the community, that’s a great thing.

Funding based on the quality and the quantity that you do makes sense.

Community Member:

In the end, whether it will be successful or not, depends on the staff buy-in. With all of the staff, from the top to the bottom. If they give it their all, it will be successful. The community will adapt, as long as the service is good, the service is positive. Patients will follow quality of care. If you want to get an operation, you say ‘where can I get the best service?’ and you go there, regardless of if it’s downtown or here. It’s about the quality of care – the patients will follow.

Facilitator:

Are there any other benefits or risks that we need to capture?

Community Member:

When you get a surgery, one of the things that you get is home care check-up within five days. I know keeping a patient in the hospital is more expensive – but do we have enough people to cover that? There needs to be adequate community and home care support if a merger happens.

Community Member:

An example of that is the CCAC IV Clinic — very positive. This is the future of healthcare. You may not necessarily see a doctor, but you will get the care you need.

There are things in the plans which will drastically improve the quality of care in the community.

Facilitator:

Are there any questions you feel like we haven’t answered?

Community Member:

Has it ever been considered to close down a facility?

Facilitator:

Not completely. We did evaluate consolidation of some services at The Scarborough Hospital, but no hospital is large enough to entirely absorb the capacity of another one. You need a certain number of operating rooms, the size of the ER – the physical size of the hospitals are not big enough to allow that. Some other groups have said one of the benefits might be that we could lobby for a new mega-hospital, but other are worried that you couldn’t have them everywhere.

Facilitator:

There has been talk about a super-hospital, but that would be far down the road. We would be better positioned to achieve that together.

Community Member:

I think we have the opportunity to be Mt. Sinai in Scarborough.

Community Member:

We don’t need the hospital to be padded with the bells and whistles – as long as we have quality of care, that’s what matters.

Facilitator:

And that’s what we want to compete with the downtown hospitals for. The quality of care, and the quality of surgeons.

Facilitator:

Any more comments?

Community Member:

When I ask around, the answers I get from the community are all the same: they say, I don’t care. If I need a surgery, give me the best surgeon and I will go there. Without exception, that is the answer I get. The details are not as important, as long as the service and quality is good. Another concern is the possibility and frequency of hospital acquired infections.

Community Member:

I think it would be more beneficial than risky – especially if we incorporate moving services to community based centres. It’s too early to know what the risks and benefits are if you don’t have a detailed plan, though.

Community Member:

One of the most important things is that we have to deliver the operating efficiencies of this year. There is a risk that people are so involved with the merger, that they don’t deliver on efficiencies. If they don’t deliver, the deficit of the hospital goes up.

Facilitator:

A question for you – what would you need to see, or like to see, to get the assurances from the hospital that we aren’t taking the eye off the ball, and that we are paying attention to quality care and fiscal restraint?

Community Member:

Measurements. Our community hospital is extremely important, and we don’t want it to be in a deficit mode. Given the fiscal problems, we need to deliver on balancing the budget, and I don’t want that to slip while testing the merger. The merger exploration is costing a lot of money – it’s not some little thing that is being done on the side. It’s $1.1 million. The momentum is so big, I can’t see how the train will be stopped, particularly with the LHIN mandate. We will be hard pressed to deliver the efficiencies as soon as the merger is realized, I expect this will come faster than we want.

Community Member:

A merger is good, but you have to market it in the community. You have to create confidence in the community that the hospital is good, has high quality care, and that the merger makes sense. One risk is the perception that if you go to a teaching hospital, they will cut you open because it benefits the students. I prefer my Scarborough hospital, rather than St. Mikes where I will get cut open needlessly. Create confidence in the people that there is better care available in Scarborough.

Community Member:

One more thing. Hospital parking is very expensive.

Facilitator:

We absolutely hear that, but we depend on that revenue to buy equipment.

Another thing we are doing is looking at ways to move services into the community. We are partnering with community and recreation centres to provide care in the community.

Community Member:

You should be publishing success stories.

Facilitator:

True; but it is sometimes difficult to get good news stories picked up. People are more interested in bad news stories.

Community Member:

The cook at Scarborough hospital is making news, because the food is so good. During my surgery, I spent four days in the hospital and I was looking forward to my meals. Now there is fear that they will lose that fresh farm food from TSH. I was really pleased with the food. It’s such a little thing, but the quality of food for the patient improves the morale of the patient – which improves the healing process.

Community Member:

Some of the nurses are excellent as well.

 

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