Physician Access Heading in the Right Direction, ED Waits Encouraging — Alternative Level of Care and Long-Term Care Waits Need Major Improvement

TORONTO, June 2, 2011 /CNW/ - This year, Quality Monitor, Health Quality Ontario's (HQO's) annual report, finds there are far too many patients occupying alternative level of care (ALC) beds in the province's hospitals and wait times for long-term care are still very high. The report on the province's health system also identified many significant achievements, including improvements in primary care access, reductions in wait times for many surgeries and CT scans, as well as better patient outcomes for coronary artery disease and declining smoking rates. Emergency department wait times are also going down, which is encouraging, but they are still far from ideal.

"While we are seeing positive news around primary care access and wait times in hospital emergency departments, too many patients are not being treated in appropriate settings," said Lyn McLeod, HQO Chair. "The province's ALC rate and waits to get into long-term care, while remaining steady compared to last year, are still too high, which has a ripple effect throughout the healthcare system."

One in six people in hospital are ALC, which means that they are occupying a bed in hospital when they could be better served elsewhere. This problem has not been improving as of 2009/10, and represents a major inefficiency in the system. The ALC issue delays new hospital admissions and can contribute to increased emergency department wait times.

"Tackling the root causes of ALC needs to be one of the most urgent priorities for the Government of Ontario," said Dr. Ben Chan, President and CEO, HQO. "Hospital care is very expensive, and there are ways we can serve people more effectively and efficiently in the community."

Health Quality Ontario's mandate is to improve the province's healthcare system through public reporting and accelerating evidence-based quality initiatives.

"Many healthcare organizations are pioneers in quality improvement across the province. We need to learn from their innovative ideas, celebrate their successes and continue fostering a culture of quality improvement provincially," said Chan.

The report features several examples of quality improvement initiatives that are achieving positive results for the health system. A full list of success stories is available by clicking on this link or in chapter 12 of the report. Ideas for improvement are listed in the accompanying backgrounder.

Broadly speaking, this report identifies three system areas that need to be addressed to improve the quality of Ontario's healthcare system: access to healthcare, chronic disease management and keeping the population healthy. Below are some of the key findings within those areas.

Access to Healthcare

  • About 6.5 per cent of Ontarians are without a regular family doctor. There has been steady improvement in this area since 2005, and Ontario now ranks among the best in Canada. However, fewer than half of Ontarians who were sick were able to book time with their doctor on the same or next day.

  • Half the people who are referred to a specialist wait four weeks or longer for an appointment. Canada's and Ontario's standings are the worst among 10 major developed countries.

  • Over the past two years emergency department wait times have decreased by two hours for complex patients and by 30 minutes for less complex patients with minor complaints. This is encouraging, but targets have still not been met. Complex patients spend 12 hours in the ED, while the target is eight hours. Less complex patients spend 4.3 hours in the ED, while the target is four hours.

  • The average wait time to long-term care (LTC) placement is 3.5 months. LTC wait times are still far too high, although they have stopped increasing for the first time since 2005.

  • Approximately one in six hospital beds in Ontario are filled with patients who should be cared for somewhere else. Most are waiting for placement into long-term care.

  • Wait times for hip and knee replacements, cataract surgeries and CT scans have been cut by more than half since 2005.

  • One-third of urgent cancer surgery patients are not getting their surgery within the recommended two-week timeframe. MRI wait times have remained unchanged since 2005, despite a nearly threefold increase in the number of scans.

Chronic Disease Management

  • Heart attack mortality has been decreasing steadily over the past seven years, and rates of readmission to hospital for heart attacks have decreased by almost one-half.

  • Hospitalizations and readmissions for many chronic conditions, such as heart failure and emphysema, are still common. There is huge room for improvement.

  • There is still room to improve the use of life-saving medications for patients with heart disease and diabetes. Also, many patients with diabetes are not being monitored regularly enough (e.g., with eye exams).

Population Health

  • Ontario has seen a 25 per cent decrease in smoking rates and a steady decline in exposure to second-hand smoke over the past six years. Ontario is now among the best-performing provinces in Canada on these indicators. However, 19 per cent of people still smoke and smoking rates remain highest among those with low income and education and in rural areas.

  • The rate of obesity increased from 16 per cent to 18 per cent over the past eight years. Just one in two Ontarians get enough exercise, and this number has remained the same since 2007.

  • Less than half the population gets the recommended five or more servings of fruits or vegetables every day, with no major improvement since 2003.

Backgrounder
Key Indicator Findings and Considerations

Topic Area Key Facts Ideas for Improvement
Primary Care/Specialist Access
  • About 6.5 per cent of Ontarians are without a regular family doctor. This represents steady improvement and ranks among the best in Canada. However, fewer than half of Ontarians who were sick could book an appointment with a physician on the same or next day
  • Half the people referred to a specialist wait four weeks or longer for an appointment
  • Are we using advanced access, the system of scheduling
    appointments and managing patient flow to reduce or eliminate wait times for appointments?
  • Could we reduce unnecessary repeat visits to free up more time to serve people better (e.g., by giving lab results over the phone instead of requiring a visit)?
  • Are we working in a team? What tasks could be shifted from one team member to another, to be more efficient?
Emergency Department (ED) Wait Times
  • The maximum time nine in 10 patients spend in an ED decreased in the last two years by two hours for high complexity patients (from 14 to 12 hours), and by half an hour for low complexity patients (from 4.8 to 4.3 hours). However, the target is eight and four hours, respectively 
  • Are we moving patients who do not need to be receiving care in the hospital to the right place as quickly as possible?
  • Have we considered all the different ideas for improving patient flow within the ED, such as a fast track area for less serious cases or flexible staff scheduling to respond to peaks in demand?
  • Have we looked at ways of diverting less serious cases away from the ED to other settings?
Long-Term Care (LTC) Wait Times
  • The median wait time is 3.5 months (103 days), which is nearly three times higher than in the spring of 2005. For those waiting in the community, the wait is over five months; for those waiting in hospital, it is just under two months
  • What alternatives to LTC need to be considered or developed for those who do not need the full range of LTC services? More home care services? Assisted living or supportive housing options?
  • Are there bottlenecks that delay the admission of residents to a home? How can the admission intake process be redesigned to make it more efficient?
Alternative Level of Care (ALC)
  • Approximately one in six hospital beds in Ontario are filled with patients who should be cared for somewhere else. This problem has not improved in the last year (FY 2009/10). This represents a major inefficiency in the healthcare system
  • Are we working with community care access centres (CCACs) to apply the Home First approach, where frail individuals admitted to hospital go home with the necessary home care support, where they can then make a decision about whether they need to be in a LTC home?
  • Are we working with CCACs and local health integration networks (LHINs) to promote supportive housing models or similar options for frail individuals?
Surgical and CT/MRI Wait Times
  • The 90th percentile wait for hip or knee replacement is just under seven months; for cataracts, four months; and for CT scans, one month. Waits are less than half of what they were in 2005
  • One-third of urgent cancer surgery patients are not getting their surgery within the recommended two-weeks
  • The 90th percentile wait for MRIs is four months — the same as it was in 2005, despite nearly a threefold increase in the number of scans being done
  • Are there poor hand-offs, poor communication or lack of standardized processes that contribute to delays?
  • Do we have appropriate criteria to ensure that patients truly require surgery or tests?
  • Can we ensure at least some excess capacity for services associated with surgery (such as space in the intensive care unit)?
  • Have we considered centralized booking systems to connect patients to places with the shortest wait time?
  • Do we monitor key process metrics (e.g., on-time case starts and downtime) so we can maximize our efficiency and increase our capacity?
  • Do we measure demand and supply and do we know if they are in balance? Have we ever done queue-clearing blitzes — for example, temporarily increasing the rate of procedures done until backlog is eliminated?
Readmissions
  • About one in five patients with congestive heart failure or chronic obstructive pulmonary disorder (COPD) are readmitted within a month, for any cause. There is huge room to improve these rates
  • Readmissions over the past seven years have decreased by almost half for heart attack, which is good news
  • To reduce readmissions, are we making sure patients have all the information they need when they are sent home?
  • Do patients at high risk for readmission have a follow-up home care visit immediately after discharge and an appointment with their doctor soon after discharge (e.g., within a week)?
  • How quickly are we transferring discharge summaries to family physicians?
Chronic Disease Management
  • The use of effective drugs (angiotensin-converting enzyme inhibitors [ACEIs]/angiotensin-receptor blockers [ARBs]) and statins for cholesterol) is increasing among elderly people with diabetes, but there is still room to improve since only half of people are getting both these drugs
  • Only half of diabetes patients get regular eye exams
  • Are primary care providers using methods such as flow sheets to remind themselves of all the best practices?
  • Have we set up electronic medical records (EMRs) so they remind providers when patients need tests or follow-up?
  • Have patients identified their own goals for improving their health (e.g., personal targets for weight reduction)? Have they all been connected with a chronic disease management program?
Population Health
  • Smoking rates have decreased by 25 per cent over the past eight years. However, 19 per cent of people still smoke and smoking rates remain highest among those with low income and education and in rural areas
  • 18 per cent of Ontarians are obese, half the population do not get enough physical activity, and more than half do not eat enough fruits and vegetables 
  • Have we considered ways to improve access to smoking cessation programs and make it easier for people to use nicotine replacement therapies?
  • Do we have outreach programs for people in high-risk groups? Have we made sure they know how to access them?
  • Other places in the world have banned junk food from schools, have better labelling of caloric and sodium content (e.g., in restaurants) or promote better exercise and diet in the workplace. Are these options that Ontario should consider?


Examples of Success

Reducing ED waits

THE CHALLENGE:
Over the past two years emergency department wait times have decreased by two hours for complex patients and by 30 minutes for patients with minor complaints. This is encouraging but still doesn't meet targets of eight hours for complex patients and four hours for minor complaints.

SOLUTIONS:
By improving teamwork and handoffs, and creating special zones to handle certain types of patients Mount Sinai Hospital, Oakville-Trafalgar Memorial Hospital and Georgetown Hospital achieved major reductions in emergency department (ED) waits between April 2008 and October 2010. Nine in 10 low acuity patients now wait two hours less in Mount Sinai's ED and one hour less in the EDs of the other two hospitals. Meanwhile, nine in 10 high acuity patients now wait 7.1 hours less at Mount Sinai, 2.1 hours less at Oakville-Trafalgar and 1.4 hours less at Georgetown.

Primary care

THE CHALLENGE:
About 6.5 per cent of Ontarians are without a regular family doctor. There has been steady improvement in this area since 2005, and now Ontario ranks among the best in Canada. However, fewer than half of Ontarians who were sick were able to book time with their doctor on the same or next day.

SOLUTIONS:
Doctors at the North York Family Health Team (FHT) and Smithville Medical Centre FHT who implemented ideas to improve scheduling and efficiency were able to reduce their wait for appointments to zero or close to zero days. This allowed patients to maximize their time with a healthcare provider during an office visit.  Further improvement ideas include better teamwork, making appointments available on days when patient requests are highest and using electronic medical records to reduce time used finding information.

Surgical wait times

THE CHALLENGE:
Wait times for hip replacements, knee replacements and cataract surgeries have been cut by more than half since 2005. Wait times for cancer surgeries decreased from 2005 to 2008, but there has been no improvement in the past two years. There is room for improvement.

SOLUTIONS:
North York General Hospital tackled the challenge of reducing wait times for hip and knee replacement, cataract, general and cancer surgery by hiring a dedicated wait times strategy co-ordinator and developing both an online booking system and a comprehensive bed management system, among other initiatives. Today, the hospital ensures that 100 per cent of patients in all priority categories and all types of surgery are served within the provincially recommended timeframe.

MRI wait times

THE CHALLENGE:
MRI wait times have remained unchanged at about four months (113 days in 2010) since 2005. This is despite a nearly threefold increase in the number of scans; however, there is room for improvement.

SOLUTIONS:
Windsor Regional Hospital cut the time nine in 10 people wait for MRIs by more than one-half and St. Joseph's Health Care, London cut the same indicator by more than two-thirds between January 2008 and December 2010. In both cases, Lean methods helped to point out inefficiencies so the teams could implement effective strategies, such as streamlined booking processes and consistent coding of priority levels.

Chronic disease management

THE CHALLENGE:
Use of statins and angiotensin-converting enzyme inhibitors (ACEIs)/ angiotensin-receptor blockers (ARBs) has improved among elderly people with diabetes; however, when it comes to ongoing management, there has been no improvement in the percentage of people with diabetes who had an eye exam in the past 12 months. This number is stagnant at one in two.

SOLUTIONS:
Petawawa Centennial Family Health Team (FHT) and Timmins FHT implemented changes to follow patients with diabetes more closely. With strategies such as using an electronic medical record (EMR) and diabetes patient registry, instituting a system to remind patients when they are due for follow-up and promoting self-management, the two teams achieved measurable improvements in markers that show diabetes is under better control.

Congestive heart failure readmissions

THE CHALLENGE:
There has been only very slight improvement in readmission rates for people with congestive heart failure. There is huge room for improvement.

SOLUTIONS:
Ottawa Heart Institute achieved a 24 per cent reduction in readmissions for congestive heart failure between FY 2008/09 and FY 2009/10. Their efforts focused on improving transitions from acute to primary care and ensuring that people receive follow-up in the community. Today, congestive heart failure patients receive written discharge checklists and symptom monitoring through tele-homecare and interactive voice response systems. Meanwhile, primary care providers get the medical information they need to better manage their patients' health through electronic health records.

Ventilator-associated pneumonia, central line infection and C. difficile infection

THE CHALLENGE:
Hospital-acquired infections can cause unnecessary deaths, longer hospital stays, more hospital costs, more disability and more psychological effects. While ventilator-associated pneumonia (VAP) and central line infection (CLI) cases have been decreasing over the past two years, and C. difficile rates were stable throughout 2010, there is room for improvement.

SOLUTIONS:
Collingwood General and Marine Hospital achieved at least 15 consecutive months with zero VAP and CLI cases. Collingwood's C. difficile rate has declined steadily since 2009. Improvement initiatives included campaigns to promote hand hygiene, developing protocols and checklists, and consistently applying best practices. They also developed a strong culture of patient safety including launching an initiative called the Single Safety System.

Alternative level of care (ALC)

THE CHALLENGE:
Approximately one in six hospital beds in Ontario are filled with patients who should be cared for somewhere else — these are known as alternative level of care (ALC) beds.

SOLUTIONS:
The University Hospital site of London Health Sciences Centre created a new unit to provide short-term in-patient care as patients prepare to transition back into the community. Oakville-Trafalgar Memorial Hospital introduced a joint discharge operations group to review ALC patients, discuss discharge options and ensure that every patient has a clear discharge plan. St. Thomas Elgin General Hospital uses an electronic bed board to obtain real-time data on bed availability throughout the organization and monitors patients daily to find out whether they should be receiving acute, home or community care. All three hospitals have reduced their ALC bed days — the last two by more than 50 per cent.

More details on each of these Examples of Success are available in chapter 12 of Quality Monitor

 

 

SOURCE Health Quality Council

For further information:

Ivan Langrish
Senior Advisor, Public Affairs
Health Quality Ontario
416-323-6868, ext 288 (office)
416-938-9871 (cell)

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