Overview Who we are What are the pressures What we have done What - - PDF document

SLIDE 1

Eastern Health Volume 72 Page 001

CIHRT Exhibit P-0700 Page 1

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"Excellence in Health Care"

On behalf of the Board of Trustees, the staff and physicians of the Health Care Corporation of 81. John's, I would like to thank you for this

• pportunity to speak to you about our ongoing efforts to effectively

utilize our resources to provide quality care to the people of this

• province. The Hea/th Care Corporation of 81. John's (HCC8J)

appreciates the financial challenges facing Government and to that end, assures you of our continued commitment to work with you to seek out ways and means of providing appropriate/eve/s of service while keeping our costs to a minimum. 1

SLIDE 2

Eastern Health Volume 72 Page 002

CIHRT Exhibit P-0700 Page 2

Overview

• Who we are
• What are the pressures
• What we have done
• What does this mean
• What we face
• Where to from here

During the next several minutes I want to highlight the aspects of our

• rganization that make us unique in this province's health care system.

I will describe some of the challenges we currently face and identify new pressures associated with offering care and treatment at a tertiary care level. I will also show you how we have successfully responded to those challenges while making our system more effective and efficient. In addition, I will outline for you the difficulties that we currently face and discuss implications of service reductions. 2

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Eastern Health Volume 72 Page 003

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Uniqueness in Service Delivery

• One-of-a-kind services (tertiary)

i.e. Cardiac, Neurosurgery, Vascular, High Risk Obstetrics, Nephrology, Haemolotogy, Oncology

• Patient complexity
• Technology
• Staff skill sets
• Patient flow
• Supports to other centres
• Size

It is important to remember that the HCCSJ functions differently from

• ther health organizations in the province. As an academic teaching

hospital, a significant portion of the services we provide are one of a

• kind. Also we differ in the complexity of patients we care for. These

elements significantly impact patient flow both into and out of our hospitals,.it affects the technology we required to diagnose and treat these patients, and the skill sets required from a variety of health professionals to deliver the necessary care. In addition, our role means that we interact with a variety of external partners in intricate and multifaceted ways. Within the HCCSJ are the provincial perinatal program, kidney program, genetics and the organ donor program. Our education service offers regional and provincial training in clinical and leadership areas. With MUN, we have a growing research portfolio which is offering new innovations to clinicians and the public. 4

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Eastern Health Volume 72 Page 004

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Provincial Portion of all Inpatient and SDC Services Provided by HCCSJ

• HCC 01 SL John's

Avalon Board Peninsulas Board

Cenlral East Board Cenlral West Board

Western Board

Grenf~!!I-Board

II

Health Labrador

The HCCSJ provides a substantial portion of the total services delivered to residents of other regions. This graph shows the provincial portion of all inpatient separations and SOC services provided by the HCCSJ in 2000-01, the most recent data available. Most notably we provide 55.2% of the total inpatient separations and SDC services used by the residents of the Avalon region .... And 47.4% for the residents of the Peninsulas Health region. As this map clearly indicates we also provide a significant portion of the total services to all of the other regions. Provincially, the HCCSJ provides almost one-half of the total inpatient separations and two-thirds of the SOC cases. National measures show that the HCCSJ has the highest net inflow of "out of region" patients in the country. 5

SLIDE 5

Eastern Health Volume 72 Page 005

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What we have done- Operational

Streamlined Administrative cost Improved efficiency

• HR, Materiels Mgmt, Finance

Site closures Investments in Staff

• Recruitment, Employee Wellness, Labour

Relations, Attrition, Stabilization

Investments & New technology

• e.g. Central Kitchen, CNS, Energy Efficiency,

Renovations, PACS, Decision Support Tools

Regional planning

Since lhe regionalization in 1996, aggressive steps have been taken to consolidate and streamline our structure and administrative cost which has resulted in the reductiDn of 236 management positions. In addition we have closed 3 sites and financed the new Janeway Dut of these savings. The Drganization has participated in a number of external reviews that have helped us eliminate unnecessary overhead. Some of these reports included the HayGroup Operational Review ( Net Savings of $16.5M), Hewett Associates Review Df HR and the Atlantic Management Consultants review of

• Pharmacy. Many areas of the organization have found ways to improve the

delivery of services. HR has shifted tD a service centre model, while Materials Management cDmbined inventory on two primary sites, and both fODd and laundry services have centralized their entire operations Dn off site centres. In addition, we ensured that these operations are scalable tD accDmmodate growth and additional volumes. We also invested in Dur staff by recognizing the importance of our unique training needs, increasing recDgnitiDn activities and enhancing our wellness

• strategies. We have made technolDgy investments, giving Dur staff better tools

to work with and improving their decision-making capabilities. Human reSDurce initiatives and investments have improved staff attendance, decreased staff turnDver and increased pride amDngst our health care

• professionals. We have been active participants and catalysts in regiDnal and

prDvincial planning We have reduced the level Df debt by Dver $5 million over the last three years.

6

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Operational Efficiency - Corporate Services HCCSJ and Canadian Teaching Hospitals

7.00%

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• HCCSJ

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6.00%

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• National Benchmarks

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5.00%

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1.00% 0.00% All Depts Info Systems Mat Mgmt HAY Group Benchmarking Study 2001 & Operational Review

National comparisons and operational reviews have confirmed that our corporate % of operating costs compares very favourably with national

• peers. From the Hay Benchmarking study and operational reviews we

know that our administrative cost structure is lower then our peers. In 2001 our Corporate Departments cost 5.7 % of net operating cost compared to 6.7% average nationally. (This is 15% less) Since 2001 further improvements have been made by combining departments and reducing managers. For examples: Consolidation of Finance & Budgeting, Audiology, Quality Initiatives and Management Engineering.

7

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Sick Leave Analysis Average Sick Leave Days /PTE

• -+- HCCSJ
• -- WHee
• tr-Other lnst. Boards

22 20

18 16 14

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1997 1998 1999 2000 2001 2002 2003 2004 P

Throughout the organization we have improved the management of our human resources. In the area of attendance management the

• rganization has decreased the average sick leave days per FTE from

15.8 to 13.1 and targeting 12.3 days per FTE this year. This is all the more impressive given that the average usage for all Institutional Health Boards in the province has risen during the same period of time. This is an area where we have worked hard to achieve improvements and it is an area where our investments and creative solutions have shown a positive return. We believe that it is extremely important that we continue to focus on attendance management. While we also identify new initiatives in Employee Health and Wellness, Occupational Health and Safety and Employee and Family Assistance. The HCCSH has received international recognition for its Human Resource initiatives with our IPMA award in 2004.

8

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Eastern Health Volume 72 Page 008

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Turnover Rate Comparison

14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% 11.90%

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2000-01 2001-02 2002·03 2003-04 2004-05 ytd

In addition, the Turnover rate for our organization has declined from 11.9% in 2000-01 to 5.4% in 2003-04 . Nationally, in 2004 the weighted Turnover rate in the Health sector is 10.0%. 9

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Eastern Health Volume 72 Page 009

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What we have done - Clinical

• More evidenced-based
• Investments in technology,

physicians, ambulatory services

• SDC Cases, Ambulatory Treatment

Units

• Targeted inpatient bed efficiency
• Facilitated improved flow through,

LOS reductions, and Inpatient bed reductions

Over the past couple of years our organization has made a number of strategic investments that have certainly enhanced our ability to deliver health care services to people throughout the province and in the process we have positioned ourselves as a leader in Canada. We have invested in our clinical services, as is our evident by improved clinical efficiency. 'Our LOS has decreased in major clinical program areas such as Medicine and Surgery. 'We are doing a better job of identifying ALC days. ·The incidence of cases that are considered MNRH (May not Require Hospitalization) has decreased. We have expanded and enhanced our Ambulatory Services. We shortened lengths of inpatient stay and delivered more services on an ambulatory basis. 'Surgical Day Care Cases have increased on average of 10% annually. 'And the Ambulatory Treatment Unit has increased by 95% since 2001. We have been successful in recruiting specialized physicians and enhancing our medical technology. Often such recruitment begins 5 or more years in advance. ( Provincial Medical Human Resources Plan)

These investments have allowed us oyer the past three years to accolllmodate more patients (l5% overall increase) despite eliminating ten (100/0) percent of our inpatient bed capacity. And in areas were we have conducted Patient Satisfaction the vast majority of people (90%) indicate that they are satisfied with the services they receive.

10

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Surgical Care Analysis

• Inpatient OR Cases

50,000

• Surgical Day Care
• +-Total

45,000 f~~~~~~~~~i~~s~~ 36997 36728 43000

40,000 35,000

30,000 +---"""'-,-------'~"---­

25,000 20,000 15,000 10,000 5,000

• 2000-01

Surgical procedures have also witnessed a shift in the manner in which they are delivered. Inpatient OR cases (the pale blue columns) have declined consistently with the shift to an ambulatory delivery of services. At the same time the SDC component of services (dark blue) has increased at a more rapid rate leading to a significant total increase in services delivered. (red line). This trend is also a national and international trend and it reflects a change in practices that is driven by new techniques, new equipment and a less invasive approach to many different procedures and

• treatments. For example - Gall Bladder surgery which use to be a 4 - 5

day inpatient stay is now done by a far less invasive procedure on a

• utpatient basis.

(INFO for ref - Surgical Day Care includes outpatient surgery, endoscopy, cardiac catheterization and ambulatory ECT. It does not include major cost drivers such as dialysis and interventional

• radiography. Including these would make the net service even greater.)

11

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Beds Operated Profile

1300

1249

1250

1199

1200

1161

1150

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1050 1000 950 900

96-97 97·98 98-99 99·00 2000- 2001- 2002- 2003· 2004· 01 02 03 04 05

Since the formation of the HCCSJ, the number of inpatient beds has declined steadily. This represents a 274 bed reduction or a 22% reduction. 12

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FTE Profile (Excludes Salaried MD's)

5700

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5300 5200 5100 5000

2000/01 2001/02 2002/03 2003/04 2004/05

Since 2000-01 we have reduced our FTE complement from 5662 FTE's to 5474 FTE's.. This is a reduction of 188 FTE's or 3.3%. (2004- 05 numbers are YTD numbers) Noteworthy: In this time period we have closed 77 beds. 13

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What does this mean?

• Delivered Balanced Budgets
• Reduced debt load
• Freed up operation~l

funding for uncontrollable growth areas

• Provided for a significant increase ih

the nUtnber ofpatient encounters

• Created organizational stability

Our efforts during the past several years tell an important success

• story. The main elements of this story include

That we have controlled our Operational costs and reduced our debt load

• ver the past 3 years.

In 2000-01 we had $28.0M of debt (combination of accumulated deficits and working capital deficits) and we have reduced this to $ 21.4M

We have significantly increased the number ofpatient encounters and have accommodated these through efficiency initiatives We have improved patient accessibility And we continue to experience increased financial pressures from high- cost services

14

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Cost Increases (excluding salary increases) vs. Funding

I_ Cost Increases rm i"tlndingj

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Actual Increases over the past 3 years: 2002-03 $ 1.0 M of the $5.0M 2003-04 $1.0 M of the $4.5M 2004-05

• $1.4 M Block reduction

This represents net cost increases of $18.1 Million with net funding increases of $0.6M. 15

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Patient Encounters Apr-Mar

!OAml.mlatory Encounters 0 SDC 0 ER Visits lID Admissions I 950,000

930,000

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600,000 2000/01 2001/02 2002/03 2003/04

And it is not only in the administrative areas that we are seeing significant change. In Clinical areas we have successfully managed the transition from an inpatient to an ambulatory service, Collectively, patient encounters have increased from approximately 810,000 in 00-01 to 930,000 in 03-04. In this stacked graph you will see that each column is comprised of the number of ambulatory encounters, SOC cases, ER visits and inpatient admissions. While inpatient admissions and ER visits have remained relatively consistent during this period the most significant growth has been in ambulatory encounters and SOC cases. This reflects the shift to ambulatory care adopted by the HCCSJ which is consistent with best practice across the country. (INFO for ref- This also reflects the new MO's and allied health staff recruited as well as better reporting practices) 16

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()

Acute Cate Volume Change 02-03 to 03-04

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Total

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DllYS Tre:ltmellT

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Service delivery has changed with a shift to ambulatory care. Most noteworthy is that inpatient volumes (shown in column one) have remained almost constant while patient days (column two) have declined. Ambulatory volumes through ATU and SOC continue to increase - e.g., ATU 25.1% and SOC 9.5%. Net overall service volumes (combination of admissions, SOC and ATU) delivered continue to rise (9.5%).AS can be seen from this chart ICO insertion continues to grow at a significant rate and Dialysis continues to grow at approx 8% to 9 % per year. 17

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Eastern Health Volume 72 Page 017

CIHRT Exhibit P-0700 Page 17

Provincial Funding (1997$) and % of Provincial Wt Cases

___ HeCS) Pro,,'Fllmling

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Hec %o(I'ro\,WI Cases

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295.5 281.7

273.6 15% 260.2

317.0 249.4 253.4 70% 264 65% 226 : 60'1:

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189 191 59.9% 59.7% 58.6% 55% 168 56.1% 53.6% 5'%

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35% 199&·97 1S97·98 1998.99 1999·2000 2000.(11 2001.02 2002-C3 2003.()4

All of these clinical pressures have been accommodated within a shrinking portion of the provincial hospital expenditures. This slide shows that the HCCSJ in comparison to the rest of the province's portion of Hospital Provincial funding (source - CIHI NHEX database and HCCSJ General Ledger). The dollars shown are 1997 constant dollars.... The right axis shows the portion of weighted cases delivered by the HCCSJ and the rest of the province. Itis clear that the HCCSJ is delivering a greater portion of the clinical services with a diminishing portion of the Hospital resources. (Source: NLCHI and CIHI) NACRS - (National Amb Care Reporting System) HCCSJ still does not include Weighted cases for Interventional Radiography, Ambulatory Treatment and Dialysis. Reason for the increase over last couple of years ......Rest of province has probably improved reporting. Point to be made: Teaching Hospitals cost per weighted case is higher than non-teaching.

18

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What we face

• Patient growth
• Shifting demographics
• Rising health care delivery costs
• Accessibility delays e.g. waitlists,

ALC patients, expectations

• Condition of physical plants/

space pressures

Internally there are also pressures that we must rnanage.

Significant growth in patient volmues ilnpacts accessibility, wait tUnes, and wait

• lists. The current wait list for cardiac surgery is over 320 patients and 345 patients

for the cardiac catherization suite. The wait time for non-urgent MRI is nine

111011th5 and four 111011ths for non-urgent ultra-sound investigation.

High numbers of "Alternative level of care patients" means d,at beds can not be used as efficiently as possible and that patients are delayed in receiving the most appropriate care in d,e most appropriate environment. ALe is directly related access to home care, Long Term Care and internal resources such as DI, OR's, ICU's and Rehab, Increasing attentlon on Infection Control is leading to demands for special processes and increasing cost for supplies. Many of our facilities 'are old and need significant work. The increasing maintenance cost associated with these physical plants results in difficult choices

bet\veen costly repairs and clinical services

Human Resources (stability, recruitlnent, retention)

19

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CIHRT Exhibit P-0700 Page 19

n 1

What we face (cont'd)

• Patient Safety
• Infection control
• Health Planning
• Primary health care
• Mental health
• Long term care
• National Standards/Clinical

Practice guidelines

• Privacy Legislation

External Forces continued ... In addition there are Patient Safety, Privacy legislation, and initiatives from our Regional Health planning process. For example an analysis of the impact of the pending Privacy Legislation identified that our organization will incur additional extra cost associated with the implementation of this new legislation. Anticipating the overall effect of many of these elements is difficult but the overall effect has been an increasing cost for the health care system.

20

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Eastern Health Volume 72 Page 020

CIHRT Exhibit P-0700 Page 20

Measures implemented in 2004-05

1. Position Elimination/Realignment 2. Bed Closures 3. Freezing Volumes at 03-04 levels 4. Reinvestment of strike savings 5. Debt payment deferral $ 0.75 M $ 0.55 M $2.00 M $ 5.00 M $2.20 M $10.5 M We proceeded with initiatives to balance our budget in 2004-05.

21

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Unavoidable Service Delivery Pressures

• Clinical- Current Activity Levels
• Drugs
• Dialysis, OR's, Intervelltional Radiography, etc
• New Services, Technology and Drugs
• e.g. Neuta coiling and visudyne
• Administrative/Support

Fuel Electricity Service Contracts It is important to recognize that the delivery of health services is dynamic not static. We are constantly facing pressures in clinical and administrative areas that are difficult to control. For example, in the area of drugs, there is a nationally recognized inflation

• f 9.9%. We have done well by controlling our expenses in the range of 5 - 6% during

the last 3 years. In clinical areas there is growth that can not be avoided. How de we say no to the patient needing dialysis. Waiting is not an option. Treatment must be provided. In the area of Interventional Radiography, we are experiencing significant growth. In the past three years the number of procedures have grown from 2900 to 5100. Why such significant growth? The answer is simple. It is to provide the patient with the recognized, acceptable standard of care. Even with this growth we are still not meeting the need. For the patient needing chemotherapy, timely access to an interventional radiography is often the difference between starting or delaying their treatment. For the patient with a vascular blockage in their leg, access may mean the difference between saving their leg or having an amputation. We all recognized the concerns about delays in service, waits for diagnostic testing, waits for surgeries and waits for LTC. But at the same time there is increasing pressure in administrative areas that are forcing us to divert funds to non-clinical

• areas. For example, the three non-clinical areas are causing a $1.0 million dollar

issue - 'Our fuel will increase 639,000 'Electricity 'Service contracts 152,000 190,000

22

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CIHRT Exhibit P-0700 Page 22

Unavoidable Financial Challenges 2005-06

Opening Adjusted Deficit position

One-time sttike savings (5.0M) 2004-05 ptojected deficit (1.0M)

Unavoidable Cost Increases

Drugs Medical/surgical supplies Unavoidable volume increases Fuel, Electricity and insurance

Shortfall

$ 6.0 M $ 5.7 M

$11.7 M We have examined this issue in great depth. Our budget planning process has been comprehensive and very consultative throughout the

• rganization. Meetings have been held with clinical directors and

Clinical chiefs to investigate the issues associated with the clinical delivery of services. The magnitude of the pressures is such that additional funding as the

• nly alternative to significant curtailment in service levels.

In summary, our current financial challenges for 05 - 06 are as follows: Opening Adjusted Deficit 6.0 Unavoidable Cost Increases Shortfall

11.7 23

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Measures to Eliminate 2005-06 Deficit

1.

Annualization of position eliminated $0.25 M in 2004-05 2. Annualization of Bed Closures $0.85 M in 2004-05 3. Elimination of Prior Year Debt Repayment $0.60 M' Total $1.70 M Projected Remaining Deficit ($10.0 M) Annualization of initiatives in 2004-05 will result in an unmet gap of $1 0.0 M. However remember that over the past three years we have absorbed $1 7.7M of cost increases. 24

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Eastern Health Volume 72 Page 024

CIHRT Exhibit P-0700 Page 24

Where to from here?

Concerns:

• Further efficiency options minimal
• Too few beds???
• Major accessibility problem

We are routinely running occupancies of greater than 90% in the surgery inpatient

• units. The current Same Day Admission rate is 92%- 94%. To sustain this level,
• ccupancy rates will have to be cioser to 85%.

Furthermore the reduced number of beds provides a much smaller pool to accommodate the significant Emergency volumes, especially at the General Site. With fewer beds there is much less flexibility to accommodate sudden spikes in Emergency demand while still maintaining appropriate elective access, Projections for 2005-06 indicate that an additional 8 beds will be required to more appropriately and efficiently operate the surgery inpatient units.

25

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Average LOS for Admitted Patients inER General Site for 2003-04 vs. 2004-05

!-+-WaitTimc 2004/05 -

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This report provides the wait times in Emergency for admitted patients (hours). Average LOS at the General site is increasing and even though a number of policies and processes to improve wait times have been established i.e. Code 111, access to ambulatory services and further education on discharge planning, the average LOS continues to

• increase. The high surgery inpatient occupancy rate exacerbates this

problem.

26

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LOS Profile 2000-01 to 2004-05 ytd I.......surg LOS Variance %

• {]- Med LOS Variance %1

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30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00%

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Substantial improvements in LOS were achieved between 2000-01 and 2003-04. The current year has seen increasing difficulties in accessing Emergency OR time, as a consequence some patients are waiting more than 2 days for their urgent and/or emergent surgery after

• admission. This has increased the LOS for the first two quarters

slightly. 27

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MNRH Profile

2000-01 to 2004-05 ytd

1+,Surg MNRH %Cases -G-Med MNRH %CasesI

16% 14% 12% 10% 8% 6% 4%

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2000/01 2001/02 2002/03 2003/04 2004/05

The May not require hospitalization % of total cases has declined year

• ver year to national benchmark levels. This has been accomplished

by the transfer of patients to ambulatory services. As a result, the profile of current inpatients has greater acuity and more resource requirements.

.

28

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Left with Undesirable Choices

• OR closures ($0.7M/OR)

$2.1 M Diagnostic Imaging reductions $1.0 M (MRI,CT,Ultrasound, Mammography)

• Other Service Reductions

$6.9M

Service reduction options had also been identified as possible options to balance the budget in 2004-05. To achieve the necessary shortfall in 2005-06 even greater service reductions would be required. The closure of one adult OR would mean a reduction of services to 900 patients annually and an associated savings of $700,000 . Implications:

• access delays, including increased length of inpatient stays
• deteriorating patient health status
• loss of OR staff expertise ie. surgeon/anaesthesiologist
• increased system inefficiency
• increase in emergency Operating Room booking

·priority would be on more acute/expensive cases

• public criticism

Service reductions in DI would result in 1.0 million dollar savings. These reductions would lead to significant increases in waiting lists and waiting times. Our current wait time for MRI is 9-11 months, Ultrasound (key for pregnancy and other conditions) 4 months, Mammography urgent 5 weeks. Guaranteed timely access to health care and diagnostic services is a growing concern in the public forum. The current national election campaign rhetoric has brought even greater emphasis to this issue. Reducing access to the Operating Rooms, treatment and diagnostic services of the HCCSJ will be a backward step in this context and

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SLIDE 29

Eastern Health Volume 72 Page 029

CIHRT Exhibit P-0700 Page 29

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Impacts of OR Closures on Surgery Wait Lists (Elimination of 900 cases per OR)

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,

'"!'"

Dec-04 1 OR Closed 2 OR Closed 3 OR Closed

Estimated Median months waiting with the closure of OR's: Dec -04 6.0 1 OR Closed 8.5 2 OR Closed 10.9 3 OR Closed 13.4 Impact on Patients 1. Patients will have an increased waiting time for surgery. 2. Surgeons will prioritize higher acuity patients, and as these surgeries are more expensive, the predicted cost savings will not be realized. 3. Patients with cancer will wait longer for surgery, which has a very emotional impact on patients and their families. 4. Patient complaints will increase because of access issues. 5. There will be more pressure on the after hours' emergency list, and the General Site cannot absorb more emergency patients. This will also impact the budget. 6. Patients for elective procedures, which impact their quality of life, e.g., incontinence procedures, will have an even longer wait for surgery.

30

SLIDE 30

Eastern Health Volume 72 Page 030

CIHRT Exhibit P-0700 Page 30

Waiting Time Impact of Reduction of Diagnostic Imaging on Non-utgent Outpatients

IOCurrent .20%Less lID 40% Less 050% less j

70.,,----------------,

60

g' 50

'"

~ 40

~

30

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~

20 10

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CJA..

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,:>,~.:::,'\ 0'<;

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cl

A budget reduction in the 01 service will radically increase waiting times for Non-urgent Outpatients diagnostics. Urgent and Emergent patients will continue to access these services however there will be considerably fewer resources available to service the non-urgent patients. 31

j

SLIDE 31

Eastern Health Volume 72 Page 031

CIHRT Exhibit P-0700 Page 31

Health Accord Issues

• Cancer
• Heart
• Diagnostic Imaging Procedures
• Joint Replacements
• Sight Restoration

Now we will address the "Five for Five" Categories of: 'Cancer 'Cardiac 'Diagnostics 'Joints 'Sight

32

SLIDE 32

Eastern Health Volume 72 Page 032

CIHRT Exhibit P-0700 Page 32

Improved Access for Cancer Care 2005-06

/

..)

,1

Operating Costs:

• Operating Rooms

Acute Inpatient Beds

• Ambulatory Services

Capital Cost:

• Capital Equipment

$1.80 M $2.50 M $0.35M $4.65 M $0.9M

The general practice by most surgeons is to utilize the OR time to meet the highest priority cases. When cancer cases are moved to a higher priority it means that other non-cancer cases are delayed. To provide appropriate access for Cancer surgery we require increased OR time, inpatient beds and outpatient clinics at an operational cost of $4.65M. Additionally, a capital equipment outlay of $900,000 (OR equipment and Instruments)

33

SLIDE 33

Eastern Health Volume 72 Page 033

CIHRT Exhibit P-0700 Page 33

Improved Access for Cardiac Services 2005-06

Operating Cost:

• Operating Rooms
• Echocardiography
• Cardiac Catheterization

Capital Cost:

• Capital Renovations/

Equipment $1.25 M

$ 0.09M

$1.80 M

$ 3.14 M $ 9.1M

\Xle all recognize d,at Newfoundland and Labrador has d,e highest level of

Cardiac disease in Canada. The l-Jealth Accord funding provides an opportunity to move toward national access standards. The costs for 2005-06 have been calculated 011 the basis of lTIO\r1ng fron1 SL'(teen to t\venty cases per week.

'New operating costs of $1.25 m are projected for OR staff and supplies for the

additional 192 cases.

• Additional staffmg costs of $90,000 are reqnired for echocardiography.
• Cardiac catheterization services are integral to the diagnosis and tteat.1ncnt of

cardiac disease including angiography, angioplasty, rCD and pacemaker insertion. New costs are calculated to meet growing demands and changing clinical guidelines. 'Capital investments are reguired for cardiac smgery, cardiac catheterization equipment, for a total of $9.1 m. Additional renovation andlor construction for additional cardiac surgery operating rOom is required. No estimate is available as yet.

34

SLIDE 34

Eastern Health Volume 72 Page 034

CIHRT Exhibit P-0700 Page 34

Improved Access for Diagnostic Imaging 2005-06

Operating Costs:

• Ultrasound
• Mammography
• Other Diagnostics

Capital Costs: Capital Renovations / Equipment $0.40 M $O.12M $O.12M $0.64 M $14.4 M

In Diagnostic Imaging there are significant wait list and waiting times for necessary diagnostic procedures such as MRI, Mammography, Ultrasound and Nuclear

• Medicine. Delays in diagnostics contribute to delays in treatment and discharge.

The access document identified the areas where improvements are needed: MRI, Ultrasound, Mammography" Nuclear Medicine, CT, EEG, PFT, EMG. In addition we have outlined the need for new funding to enable us to initiate new service for neuro coiling. In DI we require additional operating costs in:

• Ultrasound

$OAM

• Mammography

$0.12M

• Other Diagnostics

$0.12M Capital costs for 2005-06 are $14A M 'To accommodate a second MRI $2.5 M is required for equipment and approx. $1.5 M for construction/renovation.

'Two new CT scanners are required - $3 M. 'Two new ultrasound machines are required - $0.5 M.

'Additional mammography equipment - $0.24 M and renovations/construction of $0.85M . 'Patients are being sent out of province for neurocoiling treatment Implementation of this service requires $2.8 M in capital expenses for 05-06. 'Replacement nuclear medicine cameras are required - $3.0 M. Total needs for 05-06 are $14A M. This significant investment is needed for the infrastructure to accommodate the increased service levels to improve access.

35

SLIDE 35

Eastern Health Volume 72 Page 035

CIHRT Exhibit P-0700 Page 35

Improved Access for

Joint Replacement 2005-06

Operating Costs:

• Operating Rooms
• Acute Inpatient Beds
• Ambulatory Services

Capital Costs:

• Capital Renovations/

Equipment $1.50 M $1.80 M $0.05M $3.35 M $0.6M

Access to Joint Replacement in Newfoundland & Labrador should be comparable to the national averages ... 'Knee Replacement Cdn Std - 70.5 per 100,000

• Sf. John's Region 34.2 per 100,000

'Hip Replacement Cdn Std 56.9 per 100,000

• Sf. John's Region_ 38.9 per 100,000

To reach the Canadian Standard for these services will require increased OR time, inpatient days and outpatient clinic time. Additionally, renovations to the surgical Day Care of $500,000 and $100,000 of Instruments are required in 2005-06. 36

SLIDE 36

Eastern Health Volume 72 Page 036

CIHRT Exhibit P-0700 Page 36

Improved Access for Sight Restoration 2005-06

Operating Costs: Operating Rooms

• Visudyne

Capital Costs: Capital Renovations/ Equipment

Cataract surgery demand will grow by 3% per year.

$0.70 M $0.35 M $1.05 M $ 0.06 M

1

.J

Clinical guidelines recommend that we change to a soft lens at higher cost. Additional OR time will be required for the additional volume. Visudyne is a treatment for age-related macular degeneration funded in most provinces. Treatment is proposed for the fastest growing form of macular degeneration, the number one cause of vision loss and legal blindness in adults over 60. Operating cost Capital renovations $0.06 M $1.05 M

37

SLIDE 37

Eastern Health Volume 72 Page 037

CIHRT Exhibit P-0700 Page 37

.Improved Access Support Costs 2005-06

• Clinical Support

$2.40M

(Laboratory, Pharmacy, QS&I, CEU, Nursing Services, Allied Health Development, Respiratory Therapy)

Non-Clinical Support $2.05M

(Environmental Services, Dietary Services,Facilities Management, H.calth Records, Admissions Management, Materiels Managemerit,-Financc, Human Resources, Organizational Development, Communication and Administration)

During the extensive process to develop a budget submission for 2005

• 2006 for the Department of Health and Community Services, additional

efforts were made to define the cascade effect of the proposed changes

• n clinical support and non clinical support departments.

The clinical support costs represent increased demands on: Laboratory, Pharmacy, OS&I, CEU, Nursing Services, Allied Health Development, Respiratory Therapy The non-clinical support costs cover areas such as: Environmental Services, Dietary Services, Facilities Management, Health Records, Admissions Management, Materiels Management, Finance, Human Resources, Organizational Development, Communication and Administration

38

SLIDE 38

Eastern Health Volume 72 Page 038

CIHRT Exhibit P-0700 Page 38

Improved Access -Summary 05-06 (Millions $)

I

0 Operating

II Capital

16.00 14.00 12.00

1k-----

10.00 1--+--= 8.00 l-+nr.------ 6.00

IA6'~::":":'"

4.00 2.00 0.00

In summary this is the price tag for improved access.

39

)

SLIDE 39

Eastern Health Volume 72 Page 039

CIHRT Exhibit P-0700 Page 39

Summary

• Significant pressures on operations both

in terms of demand and cost

• Numerous efficiency measures

implemented,(previous operational reviews)

• Unprecedented efforts and achievements
• Clear value for money
• Workforce stability
• Further fiscal restraint will result in

service curtailment

Our organization has faced significant pressures over the past couple of years both in terms of demand and cost and we have responded with numerous efficiency measures. We have made a number of strategic investments

• in our clinical services .... because of new physicians recruited, new

equipment attained, and new services established, particularly those of an ambulatory nature;

• investments in our staff.... because of increased training, an attrition as
• pposed to layoff policy, renewed emphasis on employee recognition and

employee wellness, as well as successful recruitment/retention strategies;

• investments in our infrastructure .... because of improvements to our

physical plants, and enhancements to our information systems to improve our decision making capacity Previous reviews have helped us provide health care services to the people of the province while keeping our costs to a minimum. Despite all of our previous efforts, we now we find ourselves in a position where we are not able to accommodate the cost pressures currently facing our

• rganization without making significant and severe curtailments in some of the

services we offer. We have prepared projections of cost to improve access to national consensus levels beginning in 05-06. Clearly, these efforts are contingent on

• ur maintaining our current services at current levels. Service reductions to

address the budget shortfall identified will preclude any advancement toward improved access.

40

SLIDE 40

Eastern Health Volume 72 Page 040

CIHRT Exhibit P-0700 Page 40

Thank you

41

SLIDE 41

Eastern Health Volume 72 Page 041

CIHRT Exhibit P-0700 Page 41

% MNRH Cases

10 Medicine. SurgeryI

O.IHl% 4.lJO% 6.00% 2.00% 8.II(JI'/o 12.00% IIJ.{JO%

14.00%-/0---------------

200n-OJ 2001-(}2 2002-03 qI 03-04 q2lJ3-04 q3113-04

The efforts toward improved clinical efficiency have produced a significant decline in cases admitted that MAY not require

• hospitalization. A certain number of this patient group will always have

to be admitted due to their clinical condition. The availability of community resources will also influence the number of people that will

have to be admitted.

42

SLIDE 42

Eastern Health Volume 72 Page 042

CIHRT Exhibit P-0700 Page 42

Patient Days and Admissions Apr-Mar

350,000

W!1l Patit:nl Day.,

....... i\d1l1i~~i(Jn~ 29.000

345,000 340,000

28,500

335,000 28,000

330,000

325,000

27,500

320,000 315;000

27,000 :310;000 26;500 0305-,000

300,000 26,000

2000-01 2001·02 2002-03 2003·04

Focusing for a minute on our use of beds we see an interesting story emerging. Consistent with national practice and in response to financial pressures, we reduced the total number of beds from 1072 in 2000 - 01 to 988 in 2003 - 04. During the initial years total patient days and admissions decreased as the beds were reduced, but in 2002-03 we began to see admissions once again increasing while the numbers of total patient days continued to decrease. This change reflects the improved clinical efficiency in acute service delivery. On the inpatient side of our operation we are doing more with less. 43

SLIDE 43

Eastern Health Volume 72 Page 043

CIHRT Exhibit P-0700 Page 43

National Comparison - Clinical Efficiency l\mbulatory Provision of Senrice 3Q 03-04

,.:tiS

• n. .:1/0 clUlnge Wlu

move mese LO me

JW yua ,he

I

,

r

.

50% 45% 40% 35% 30% 25% 20% 15% 10%

5% 0% Best performance

3rd quartile

Lower than 3rd Quartile

Screened inpatient-outpatient case comparisons provide a measure of how well the organization is providing appropriate ambulatory procedural services. The HCSCJ results for 30 03-04 (most recent available) show that almost 50% are at best practice (at or better than 75 percentile) almost one-third in the third quartile and little improvement to bring the remaining cases into the third quartile.

44

SLIDE 44

Eastern Health Volume 72 Page 044

CIHRT Exhibit P-0700 Page 44

)

Average RIW Comparison 2000-01

• Hces" • Others in Province I
• l- I-

M

1=

~

i

E

1:

ci5

t

::>

co::

~

;.,

(j (j NLCHI 2000-0 I Data 3.5 3 2.5

2

1.5 I 0.5

• For services that are available throughout the province, this slide shows

that greater complexity of patients treated by the HCCSJ. The average RIW value is a measure of the average cost (and volume) of clinical resources required to treat the average patient treated by the provider

• type. For example, the orthopedic patients treated by the HCCSJ

require about one-third more clinical resources compared to those treated by other orthopedic services throughout the province. 45

SLIDE 45

Eastern Health Volume 72 Page 045

CIHRT Exhibit P-0700 Page 45

Average RIW Comparison 2001-02

10 HCC$J • others in Province I

H-

i

• l

l Ii£

0.5

• eO

.V~

~

0'

~ _\~

~ ,~

• ~('~

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NLCHI 2001-02 Data 3

2.5

2

1.5

For services that are available throughout the province, this slide shows that greater complexity of patients treated by the HCCSJ. The average RIW value is a measure of the average cost (and volume) of clinical resources required to treat the average patient treated by the provider

• type. For example, the orthopedic patients treated by the HCCSJ

require about 50% more clinical resources compared to those treated by other orthopedic services throughout the province.

46