LEADING FOR PATIENTS
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LEADING

FOR PATIENTS

RVHS MSS (Medical Staff Society) Roundtable

6:00 – 8:30 PM 

Facilitator: Rik Ganderton

Transcript

Facilitator:

Many of you have been involved in the workbook process – there were ten workbooks, plus a special stream for surgery, because it was so large.

We had some 100 physicians involved in the workbook process over the last 6 to 8 weeks. Despite a few hiccups, the output from the workbooks has been remarkable. The level of engagement that people have entered into has been remarkable as well. As we start to look at the output, it is beginning to show that if we focus on working as a system, as opposed to working as a series of silos (internally or between organizations) there are huge opportunities to deliver significantly enhanced patient care, from a quality point of view, an access point of view (in terms of our patients being able to access services on a timely basis) and on a cost performance point of view that is sustainable into the future. If we can work together more effectively, we can truly provide more services for less money, and deliver better care to our patients.

Focusing on the workbooks, there are tremendous opportunities. They won’t be immediate, nor will the benefits be seen tomorrow, but if we look at the medium to long term there are real opportunities.

The workbook process is beginning to close down and the results are being posted on the website for public viewing. The draft report is in progress. We have a meeting tomorrow night to receive the first draft that the ILC has seen of the draft report. It remains to be seen what that story will be coming out of that report. I can assure you that no decisions have been made yet – tomorrow night will tell. We have tried very hard to engage with our various communities, and we have been relatively successful engaging with the docs/medical staff as a community and with the internal staff as a whole. We have tried some different methods for engaging with the general public, patients and their families. We’ve had, I think, very positive engagement. The telephone town halls that we’ve held with the community reached almost 16,000 people. The roundtables with community and stakeholder leaders in Ajax Pickering and Scarborough have been relatively well represented. We got a balanced view of the opportunities. We have tried to focus not only on what the benefits are, but also to understand the risks. We do recognize that there are significant risks to individuals, communities and patients in this process, and we will have to weigh very carefully exactly what we recommend coming out of this, because it won’t be a slam dunk.

The pivotal meeting is at the end of October – the final ILC meeting where we have to frame our recommendation. The recommendation then goes from the ILC to the two hospital boards. The two hospital boards (RVHS and TSH) meet on November 12 independently. They are open Board meetings, so feel free to show up.  Once the boards have come to a conclusion, they will make a recommendation to the LHIN. IF that recommendation were to be a merger, the LHIN would have to consider that and they would be required to make a recommendation under the Local Health Integration Network Act, which would then require approval from the Minister of Health. The LHIN board meets Nov 27th. I have no idea how to predict when or how the Minister would make a decision. The next 6 weeks will be pivotal in terms of where we will spend time and effort over the next little while.

Questions?

Medical Staff:

Can you expand a bit on the position of our administration with respect on preserving a full service emergency at Centenary?

Facilitator:

We have committed at all four hospital sites to continue providing a full service Emergency Department at all sites, 24/7. We have had this debate at Rouge over the years in other discussions, and one thing we did in 2007 was to try and come up with a definition of what the core services are needed to support an Emergency Department. We did that – it’s articulated in our Strategic Plan, and it covers things like access to general surgery; 24/7 anesthesia coverage; access to diagnostic and support services; to community-level obstetrics and a few others (crisis intervention for mental health). Those are important for us to continue to commit to our communities – and the reality is that physically we couldn’t close an Emergency Department anyways. There is not the physical capacity to absorb the patient numbers from one hospital into another. The only way we could close any would be to build a new hospital altogether.

Medical Staff:

We understand a lot of the benefits of merging. Could you list three or four of the risks that a merger would pose to Rouge Valley?

Facilitator:

I’m not really going to make these specific to Rouge, because they apply regardless of the organization. One of the biggest risks is around attitudes. That is: can you as Rouge Valley physicians, find a way to work effectively with your mirror counterparts at the other organization? That is a fundamentally big question: whether there are ways you can align your interests to make this of mutual benefit. If that can’t be done, it will potentially doom this discussion to failure. I’m encouraged by the work I’ve seen coming out of the working groups – of course there have been tensions and turf issues, but that is natural in any of these situations. I would say that at the end of the day, those working groups have been able to articulate a common ground. That is encouraging, but it is still a risk. That risk translates into the community, because if the Doctors aren’t happy, the first people you will get unhappy as well, are patients and their families. We need to make sure you are happy, because if we keep you happy, we can keep patients and families happy.

Operationally, if we can get over those perceptual issues, the biggest risk is having the governance and leadership to make this work. You need to have the right Board of Directors, the right representatives from the medical staff on that board, and you need the right CEO and Chief of Staff to manage that implementation.

Another risk is that, given where we are in the political climate, we have a minority government eight months away from having to be at the polls. That is the biggest risk of all, because they will worry about being reelected, and they will worry whether there will be political noise about changing the system.

Medical Staff:

I think Mr. Hudak is on record saying that if he is elected, he will get rid of the LHINs. So the implication is that this whole thing could be down the drain.

Facilitator:

Yes – he has said that. He is going to create another organization to replace the LHINs. First of all, you need to understand that Ontario is behind all the other provinces in terms of reorganizing delivery of healthcare services from a structural standpoint. The way our system is organized is so siloed that patients have trouble accessing services. The two main political parties – the Liberals and Conservatives – have proposed essentially the same solution, but wrapped in a different set of rhetoric. The Liberals tool is the LHIN; and the Tories have taken a different approach and said we need to drive this through ‘regional hospital corporations’ which will force things through. They suggest 40 regional hospital corporations which would run the system, which would replace the Liberal approach of having 14 LHINs. No particular political stripe will produce a fundamentally different result. This is being driven by the financial situation in the province, not politics – and it will be driven by federal finances by the time we get to 2018’s federal transfer payments.

The province has decided that they need to cap growth of healthcare expenditures, which they have done for the past two years. Hospitals have been flat-lined for funding for the past two years, and will continue to be flat-lined till 2017-2018. That works from a political point of view, but growth in demand through aging and immigration is running at 2% a year – plus, we are dealing with 3-5% of inflation on salaries and wages and supplies and expenses. So we have flat-lining revenue and increasing costs – so we have to change the way we deliver services to be more cost effective.

Medical Staff:

Can you say anything with respect to job security for physicians, support workers, administrators?

Facilitator:

There is no issue of job security for physicians. There is more work available than we have physicians currently on staff to take care of. We under-service our community as it is. I would suggest over the next few years that physician employment will actually increase, and that will include further sub-specialization as we round out the range of services available in our community.

From a staff perspective, there will be ongoing changes, and you have to look to the collective agreements that we have to operate under with our unions as to how that will play out. Our collective agreements give us a set of rules we have to follow when we are making choices in terms of who is doing what, when. We as management don’t have the flexibility to redeploy Nurse X to a different job. If we have a vacancy in one site, and we make a job in another site redundant, we can’t send Nurse X to the site with the job. If that happens, Nurse X has the right to look through every job in their bargaining unit that is held by someone less senior, and can ‘bump’ them. You can imagine that process and the complexity that it creates when everyone bumps; and frankly the disruption it creates on a personal level for everyone in those bargaining units. The more senior you are, the more chance you have to bump, but the more junior you are the better chances are that you will be bumped. Over the last seven years, less than five unionized employees have left RVHS involuntarily.

For sure, the ongoing process, whether we merge or not, will continue to display those disrupting characteristics.

Medical Staff:

What about administration, in terms of job security?

Facilitator:

The mortality rate for CEOs is between 50 and 100 percent. That’s the same for any administrator or manager – it’s a very uncomfortable position for people to be in, particularly our line managers. I would say that we have a fantastic management team which does tremendous work and has great relationships with their colleagues.

Medical Staff:

You articulated the importance in the potential risk to leadership. You also articulated that some of the working groups had views which are not conducive to integration being a successful strategy. Who will lay down the leadership requirements for selection so that the integration process is not sabotaged? If both Boards agree that integration is the way to go, but those in the new governance positions don’t agree with it, they could pose a risk to a successful integration.

Facilitator:

That comes back to the risk around implementation and how to do it effectively. Clearly if we go down the merger route, we have to create a Board of Directors that is capable of setting that appropriate tone to guide the organization. I don’t know how that will work right now, and that will have to be determined over the next couple of months. When the Board is established, its first job will be to hire the CEO and Chief of Staff. That is their challenge, and that will determine the tone of integration.

Medical Staff:

Is that a LHIN decision – how to select the Board?

Facilitator:

No – that will be the decision of the ILC advising the hospital Boards. The individual Boards will recommend an approach to deal with that. If there were to be a merger, the Boards could reject that advice; but there would be at least a path that the future board could follow.

Medical Staff:

There’s no question that Centenary has the least vocal community support among the three sites. Do you think that might play a role in the final decision – and would we end up with the short stick?

Facilitator:

I don’t think I agree with that proposition. We have two communities with strong and public allegiance to the campus (Birchmount and Ajax Pickering); but I think there is a common undifferentiated community support for General and Centenary. Other than if you lived next door to one or the other, I think the loyalty is more amorphous to those facilities. It’s almost a single community with two hospitals. You certainly don’t see the feedback being expressed in the same way as Ajax Pickering or Birchmount. And I don’t think that’s necessarily a bad thing either. It’s interesting that the two physically larger facilities have been perceived to have more indifference in their communities.

Medical Staff:

Can you discuss the timing of your departure with regards to the integration?

Facilitator:

I announced to the Board of Directors that I won’t be continuing as the CEO of Rouge or hold myself out as the potential CEO of a merged organization should that occur. I will stay around at least till the end of January through the transition process, and potentially part time in Feb and March if necessary to get through to the point of transition.

Medical Staff:

Where does the money come from to maintain the physical hospital sites?

Facilitator:

That comes directly out of our hospital budget. There is no separate funding stream for maintaining physical infrastructure at individual sites.

Medical Staff:

I can’t envision the community having one hospital for the whole community. If we had an infectious outbreak and had to close critical portions of the hospital, it would be devastating.

Medical Staff:

With current practice styles, if we move towards the bed needs for acute care in the Scarborough community that would give us some perspective. The number was a lot lower than you would think.

Facilitator:

We looked at high level assumptions, inpatient beds, population growth five, ten, fifteen and twenty years out, and made an assumption that there would be 90% occupancy across the board. The number of beds that we are seeing is a number that is over 1500, collectively.

Medical Staff:

And that assumes present day practices?

Facilitator:

Yes – no efficiencies built into it.

Facilitator:

If you think about that, the value of efficiencies that we’ve had out of the system over the last 20 years have primarily been driven from a surgical perspective. We’ve shifted tremendous volumes to an outpatient basis, and are running 82-85% of our surgeries on an outpatient basis.  On a provincial system, we are starting to look at ways of driving down bed utilization for that other 15to 20% of surgical activity. There we run into the law of diminishing returns from a care perspective. We need to look at the changes in medicine that will impact bed and bed utilization – and the freight train coming is aging of the population. Unless we find the ‘magic bullet’ for some of these chronic diseases, it will be very hard to justify reducing space numbers for non-surgical medical care over the next few years. The bed demands will continue to rise.

Medical Staff:

I believe that. I understand the value of building a large new infrastructure, but there are caveats. We don’t know the size that will work before managing something so big is problematic. Somewhere two bigger new hospitals for Scarborough and Ajax could make more sense.

Facilitator:

You couldn’t have a super-hospital that would cover both West Durham and Scarborough. Its not feasible from a size or community perspective.

Medical Staff:

The biggest problem is that no one has defined what we mean by ‘merger’. Does it mean we will all be one hospital? Does it mean we would merge the same way that we merged with AP where we are really two separate sites?

Facilitator:

We had that discussion, and in essence the slate was open to a number of different levels of integration: cooperation, some degree of integration of some programs across hospitals; and at the other end of the spectrum, full merger. It was decided collectively that we should focus the discussion on the full merger: merger of governance, board, finances and departments/program delivery. But that does not preclude having multiple sites.

Medical Staff:

If you look at the way cardiology works at Rouge, it is one infrastructure that covers both sites. We cross cover, but you don’t have to physically have one plant other than for the high cost/high tech components. The human resources are moved to where they are needed. The chief of the department decides how much service is provided at which site.

Facilitator:

There is no magic definition of merger. If you look at Rouge, we have a single board and single administrative management structure, and we have a hybrid model of medical leadership. We have some departments that are cross-site (diagnostic imaging, for instance) entities, and some that aren’t (medicine, surgery, ob-gyn) which are site-specific organization. That kind of model is not problematic. To increase the chance of getting the benefits out of a merger, you need to have a single governance administrative management and medical leadership structure – and I’m not defining what the medical leadership structure would look like. That’s what we’ve said around merger. What that will mean at an individual department level has to evolve. Cardiology evolved to a cross-site model for Rouge. Things can evolve over time.

Medical Staff:

At the same time, our policies and procedures are harmonized across the sites. The sites need to have a common vision, and common way of doing things – best practices – but we don’t necessarily need a single style across the sites. There needs to be synergies – common purposes around quality agenda, accountability, but not necessarily culture. To think of it as a homogenous group moving forward is limiting. You can allow the cultures to be different, but there is an overall corporate culture which governs behavior.

Facilitator:

The actual work around governance structure has yet to be done.

Medical Staff:

If you follow up that model, I’m still confused as to how it will save money. If we are maintaining everything at all three sites, it won’t save money.

Facilitator:

We have not said we will maintaining everything at all three sites. We need to provide a level of support services to maintain 24/7 ER at all sites. That does not pre-suppose all services are available at all site – that isn’t even the case today. We have consolidated certain subspecialties, which would likely continue. If you look at obs-gyn, there are good models elsewhere in the province and country that have an obs-gyn model that does not have inpatient access on every ER site. There are many models where sub-specialty surgery is consolidated at a single site or where in-patient medical services such as stroke are on a single site. I think there are all sorts of opportunities moving forward, and we will have to work through them, but I don’t think we can pre-suppose that nothing will change.

Medical Staff:

One thing that needs clarification is that you look at an integration scenario, there is top down where management tells programs how to run, and there’s bottom up, where physicians are collaborating, which is the workbook structure. We have pushed and I think we will have more bottom-up workbook sessions to work through integrative opportunities for the future. To get true buy-in, you have to work together and there are differences that need to be recognized. That’s something we’ve lobbied for.

I didn’t bring a lot of these things to upset the apple cart. It needs to be discussed – these are important points. I still think there are many things patients will benefit from with integration. The system right now is not good. I really feel strongly that there are opportunities for patients and physicians. We can improve efficiency, bring cost down and get patients more access. There are things which are more difficult to achieve, but we are committed to maintaining the quality and improving it, and it can be done.

 

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