LEADING FOR PATIENTS
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LEADING

FOR PATIENTS

Medical Advisory Committee (MAC) Rouge Valley Health System Roundtable

September 27, 2013. 10:00-11:00

Facilitators: Rik Ganderton & Naresh Mohan

Benefits of a merger:

  • Increased human resources, raises quality of care and workforce numbers.
  • Access to certain specialties.
  • Augment SVC to community.
  • Supports the patient’s (Pt’s) best interests.
  • Integration of skill.
  • Focus is on the patient, not MD.
  • Better continuity of care.
  • Efficiency.
  • Create centers of excellence.
  • Build expertise and reduce fears of community.
  • Can take advantage of technology advancements and virtual applications.
  • Improve linkages with educational partners.
  • Greater influence and lobbying power with government to bring SVC to Scarborough.
  • Tertiary SVCs – more specialization within groups.
  • Financial flexibility for resources.

Risks of a merger:

  • Critical mass can’t be exceeded – can’t grow too big.
  • Community perception can hurt reputation.
  • Access can be impaired for PTs, especially for those that can’t or aren’t able to be as easily mobile.
  • Feeling of unintended neglect of MDs.
  • Disillusionment, risk of disengagement.
  • Potential for growing mistrust between MDs, administration, and the Board.
  • Resistance from Ajax.
  • Perception that this may not be a merger of equals.
  • Will cultural differences of all four sites create more risks for a merger organization?

 Transcript

Slide 7: Integration Options

Facilitator:

  • Some form of integration has to happen, it was mandated.
  • To be able to fully explore, look at merger as the endpoint; could work back based on less integration.
  • LHIN has reaffirmed maternal, newborn and geriatrics have to come up with an integrated plan by March.

MAC Member:

  • Does that sound like a smart suggestion? Look at a merger, yet start with looking at one section (pediatrics, geriatrics, etc.).

Facilitator:

  • If the hospitals report to the LHIN that a merger is the best option, the merger is the next step, and the LHIN will give you a pass on the maternal timeframe.
  • If you can’t do a merger, we need some action and a plan on maternal.

MAC Member:

  • Why is LHIN concerned about maternal?

Facilitator:

  • Reflection of the frustration that the 2009 LHIN-wide clinical services plan identified integration of maternal as a priority.
  • High risk, pediatric unit, to be located in Scarborough . Despite multiple attempts and forums, it has been impossible to get the physicians, OBS and geriatric, to have any form of reasonable conversation about this whatsoever.  There has been a lot of pushback from Scarborough.

MAC Member:

  • TSH and RVHS are communicating in a much more civil way than you have in the last 15 years, our previous CEOs when the initial mergers occurred, that was warfare.  That was extremely disruptive and created a lot of distrust between the two organizations.  Made strides to improve things which are great.
  • If we can communicate and realize we’re doing the same thing, we don’t necessarily need to get married but it can work

MAC Member:

  • I work in both institutions, and I experienced the attempted merger of Scarborough hospital which has been a failure in terms of how the sides cooperate, there is a very predatory aspect. Over the years and in the 90s when this started, there was a lot of acrimony and the same attitude still prevails, there is very little integration, functions separate except for emergency, medicine, etc.
  • I can understand the rationale of a merger at a corporate level in terms of funding, but these hospitals are going to continue to function as they always have functioned, with very little shift of physicians to different sites.

MAC Member:

  • We must work together for change, rather than having two organizations work separately to change.
  • In radiology we have tried to merge with other sites, but have a different business model.  It hasn’t been that successful.

Facilitator:

  • We aren’t sure if there will be a merger at this point in time.

MAC Member:

  • If you look at a potential merger, if you look at size alone Scarborough is bigger than us.  There is a concern that they will want a bigger share.
  • If you look at different reasons for merger, in the UK they talk about failing trusts when one organization takes over another.
  • KPMG talks about due diligence – have we looked about financial status of both ? Heard rumours they were in the black, now they are in the red.
  • Are we the ones that should be running the show because we are financially stronger? Is this a merger of equals, or unequals?

Facilitator:

  • From a financial perspective the two organizations are more similar than dissimilar.
  • Scarborough Hospital has struggled over the last few years financially more than we have.
  • Their working capital situation is substantially worse than ours, although they did break even and make a small surplus last year.  They are apparently anticipating breaking even this year.
  • The commentary would be that they do not see opportunities for efficiencies without reducing services going forward.
  • Our position would be that our working capital is improving and continues to improve, we have substantial amount of cash in the bank so not drawing on credit lines, and I believe that at least for next year we can go through another round of cost-reduction without impacting the scope or quantity of service that we are providing. I can’t see beyond that.
  • If we do not merge, may have to start having discussions about how we deliver our services, and where we deliver them.

MAC Member:

  • This would be the same position of any hospital in Ontario. The delivery model is broken, and there is no politician willing to break their own neck by saying Ontario needs an entirely new model for healthcare.

Facilitator:

  • The issue is that government has tip-toed on communications, and is trying to make it this change grassroots and come from the bottom up.
  • These mergers aren’t going to provide huge huge savings in the system.  If it improves the current services available, or helps maintain access, it’s worth it.

Facilitator:

  • In terms of function versus dysfunction, we have to look to see what they say and feel. Greater deal of dysfunction between The Birchmount and General Campuses, than there is within our organizations.  Don’t think that is a statement you can make across the board.
  • Between Ajax and Centenary, there are differences, however there is less fighting

MAC Member:

  • There are certain minor cultural differences which are historic, right now this is is not affecting delivery of services, and emergency in both are functioning at a high level given the volumes we are dealing with.

Facilitator:

  • General and Birchmount thinks ED is functioning very well.  There are still challenges with radiology, as well as between maternal and newborn.
  • There are some surface issues, but these are not systemic.

MAC Member:

  • Perhaps this is something that will go away over time, the younger generation may not have this predatory effect of a merger.

Facilitator:

  • The two hospitals are quite unified in their distrust of admin and dislike of the Board.  That contention is quite significant.

MAC Member:

  • Between Centenary and Ajax, have some differences, some unified and working as a team, some trying to share visions and opinion, some are completely separate and can’t talk to each other.
  • For example, with internal medicine the two hospitals have two different processes, and bringing them together is a challenge.
  • Between them there are a number of sub-specialties, many that are not available at Ajax.

Facilitator:

  • We have some of the same issues; however there is less open warfare.
  • Ajax is being built up, more of a feeling of security because they know they are not being picked on.  However a feeling of distrust still exists towards their “bigger brother”.

MAC Member:

  • Back in 1998, when the mergers did occur, the mergers were essentially takeovers, two hospitals were unequal in size and so on, and the CEOs dictated what was going to occur.  Wasn’t an amicable relationship at all. What’s happened now is that there is a big difference in the attitude.
  • Everyone feels that the Board, admin, and CEOs are being fair, looking at them in a local manor, not biased or influenced by other things.
  • Everyone feels comfortable that decisions being made are in the best interests of the community.
  • Probably true now with Scarborough hospital in last few years, animosity is gone.  Mergers are about providing services for the community.
  • The Scarborough community, if you provide a service, they don’t care if they go to General or Centenary, as long as service is provided for the community.

Facilitator:

  • There is a little bit of twist around that, as the community around Birchmount has a loyalty focused on that campus.
  • When you get south of the 401, it is much more homogeneous.

MAC Member:

  • Out of curiosity, does the Scarborough hospital hold joint sessions like we do?

Facilitator:

  • No, they have not.

MAC Member:

  • We have an open culture of openness amongst the senior members that gets disseminated amongst the ranks; this could be a good thing.

Questions

What are the benefits of a merger?

MAC Member:

  • Improved patient access.

MAC Member:

  • Larger corporation, so increased clout with the government in terms of funding and other issues.  Focus has to be a Scarborough issue and a Durham issue. Have to deal with integration in those areas

MAC Member:

  • We have experienced a merger on two sites.  We see it as a benefit in terms of the service that we provide because it allows us to bring on more radiologists; this means more information, more intellectual property.
  • In terms of numbers, we have more opportunity to interact and share information.   This in turn raises the quality of care

 

MAC Member:

  • Access to certain emergency services such as dialysis would be huge, could pick up the phone and could call doctor and we would be part of the same organization, work together and are on call for that service , so know patient would be receiving greater care.
  • Ability to introduce increased specialty services. Could be opportunities to regionalize and even augment services we are providing in terms of having all of these services accessible to every one of the four institutions very seamlessly.

 

MAC Member:

  • Nothing to do with what doctors think, going to be about patients.  A merger would provide much easier access to clinical notes and clinical services.
  • Doctors have to say it is not about them anymore. Only what is in the patient’s best interest.

Facilitator:

  • What does this mean for the caring doctor?

MAC Member:

  • A patient arrives at emergency at Centenary, patient has integration of services so doctors can see their history of services form the other hospitals.
  • All this info is available to me immediately.
  • Integration of services is best for the patient.

MAC Member:

  • Patients are the most ones suffering currently, not doctors.
  • Two weeks ago there was patient flown to our emerg, progressive chronic kidney disease, that hasn’t been referred before, and was admitted and I took over.  Patient was having dialysis but not urgent.  Called general, said have patient needing dialysis, few days nothing happens, hasn’t heard anything about this and contacts someone else in the department, hadn’t heard about it.
  • Shows a complete lack of communication between the hospitals.
  • Took 5 days, 5 hours on the phone to get this patient to the hospital.   I still don’t fully know what happened to the patient.

MAC Member:

  • Comes down to what patient hears and perceives.  They want to hear that we are cooperating, not fighting, integrating and working together.
  • Don’t care which site it is, just want to know that this is “team healthcare”, it is beneficial if we work together. If we are talking and communicating we can work with that.
  • I am unsure if the changes involved with a merger would be financially beneficial at all.

 Facilitator:

  • There are many mergers that have been financially successful throughout history.

MAC Member:

  • A merger would need a strong PR campaign, this would have to be the doctors who are trained and on-side because they are the ones who are going to talk to their patients.

MAC Member:

  • Potential for centers of excellence.  If could combine specialists into one center, could provide drastically improved services.
  • Machines that are expensive could be used more efficiently.
  • Sites could have something they claim around their own expertise.
  • Decreased fear of being eliminated, may be preventative for LHIN due to a LHIN-wide center of expertise in our hospitals.

Facilitator:

  • Yes, with sub-specialization, if we can find a way to bring them together, sum of the whole is better than the sum of the parts.

MAC Member:

  • Do not see any short term gains.  Do like to think of this as a compartmental exercise.
  • Within admin, clinical services and access, there is some opportunity here that a merger would assist.
  • Merger is a long and challenging process, clinical groups would have to work together which would be difficult as it is all very territorial.
  • See in GTA what is happening is terms of access to technology – we have not done that, even at Rouge Valley.
  • Increased access through utilization of technology.   Huge leaps that are going to occur in this area.
  • Other area is that if a merger goes ahead, there will be opportunity to have better liaison with the educational programs, and with that this will result in better recruitment, improved physician services.  The opportunity we have as a merged cluster gives us more pull than if we are individual organizations.

MAC Member:

  • Way we should look at this is by asking ourselves if it is more likely in a merged environment to achieve a goal than as different institutions.
  • Both hospitals may agree a certain goal should occur for patients, but it is better or more financially possible in a merged environment?
  • If you view last decade as living experiment, we have had a lot of difficulty as two separate corporations
  • Beyond that, think the key benefits are based on extending corporation into areas that are high capital, tertiary in nature.
  • With regards to bread and butter stuff in a merged environment, there is a small incremental benefit in terms of efficiency.
  • Financial flexibility; with pooled resources have flexibility to achieve things you can’t do alone.

Facilitator:

  • What do you see as having changed in the environment that hasn’t happened in the last 20+ years?

MAC Member:

  • No question that if we merge, we would see increased cooperation from everyone, going to be able to put the services where they are needed without too much hassle, integration can go along much smoother, centers of excellence can be put where they are needed or best suited.
  • Why the integration didn’t work years ago is because whenever there is a merger, everyone was more concentrated about the benefits of their own corporation that they were previously attached to.
  • Now, focus is on the patient, when you have the merger now everyone is concerned about providing the services in x area; everyone is onside and all working together.

MAC Member:

  • I disagree.  I go between hospitals and right now there is no integration between the areas.

What are the risks of a merger?

MAC Member:

  • Have to look at historical perspective; failed merger with Toronto East hospital, was about to implement it when had heads chopped off.
  • They are in a defensive position – very jaded.
  • How do you engage jaded physician leaders? How can we amalgamate a medical staff when one side is hostile, p-o’ed, have no trust in their administration or their board, or any trust with each other.

MAC Member:

  • Possibility of applied resistance to the Ajax site.
  • Because TSH is a bit bigger, might have attitude where they look at us as potential prey.
  • Question of whether this is a merger of equals?

Facilitator:

  • When we look at numbers  our hospitals are a lot closer than people think we are.
  • They do more inpatient surgery, we do more outpatient surgery.
  • If exclude cataracts, we do quite a bit more outpatient cases.

MAC Member:

  • Do they have a different way of practicing?

Facilitator:

  • There is a much higher tendency to admit from emergency than we do.  They are admitting at a 33% higher rate than we are.

MAC Member:

  • This is dependent in part on the population you are dealing with – if it’s heart failure then the patient needs to come in.
  • See more ambulatory patients at Centenary.
  • Ajax has developed over years a coping strategy as we have been under-bedded based on size and volume,
  • Do coping strategies to do admittance avoidance in safe situations.

MAC Member:

  • If we are to merge and we are supposed to have a similar culture, and the whole discussion about quality is having a similar high quality benchmark to all organizations, if we do something in a certain way or at a certain rate at one site, and they traditionally or culturally have done this a different way, that would cause a lot of difficulty at the staff level.
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