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Ontario Wait Time Strategy
Visit to South East LHIN
May 26, 2008
Alan R. Hudson, OC, FRCSC
2
Cataract Surgery 90th Percentile Wait Time Trend
0
50
100
150
200
250
300
350
Aug
-Sep
05
Oct
-Nov
05
Dec
-Jan
06
Feb-
Mar
06
Apr
-May
06
Jun-
Jul 0
6
Aug
-Sep
06
Oct
-Nov
06
Dec
-Jan
07
Feb-
Mar
07
Apr
-May
07
Jun-
Jul 0
7
Aug
07
Sep
07
Oct
07
Nov
07
Dec
07
Jan
08
Feb
08
Mar
08
Apr
-08
Wai
t Day
s
trendline
Priority 4 Target - 182 days
3
Cataract Surgery - Histogram
4
Cataract Surgery Wait Times – LHIN Variation
5
Cancer Surgery 90th Percentile Wait Time Trend
0
10
20
30
40
50
60
70
80
90
100
Aug
-Sep
05
Dec
-Jan
06
Apr
-May
06
Aug
-Sep
06
Dec
-Jan
07
Apr
-May
07
Aug
07
Oct
07
Dec
07
Feb
08
Apr
08
Wai
t Day
s
trendline
Priority 4 Target - 84 days
6
Hip Replacement 90th Percentile Wait Time Trend
0
50
100
150
200
250
300
350
400
Aug
-Sep
05
Oct
-Nov
05
Dec
-Jan
06
Feb-
Mar
06
Apr
-May
06
Jun-
Jul 0
6
Aug
-Sep
06
Oct
-Nov
06
Dec
-Jan
07
Feb-
Mar
07
Apr
-May
07
Jun-
Jul 0
7
Aug
07
Sep
07
Oct
07
Nov
07
Dec
07
Jan
08
Feb
08
Mar
08
Apr
08
Wai
t Day
s
trendline
Priority 4 Target - 182 days
7
Knee Replacement 90th Percentile Wait Time Trend
0
50
100
150
200
250
300
350
400
450
500
Aug
-Sep
05
Dec
-Jan
06
Apr
-May
06
Aug
-Sep
06
Dec
-Jan
07
Apr
-May
07
Aug
07
Oct
07
Dec
07
Feb
08
Apr
08
Wai
t Day
s
trendline
Priority 4 Target - 182 days
8
MRI 90th Percentile Wait Time Trend
0
20
40
60
80
100
120
140
Aug
-Sep
05
Oct
-Nov
05
Dec
-Jan
06
Feb-
Mar
06
Apr
-May
06
Jun-
Jul 0
6
Aug
-Sep
06
Oct
-Nov
06
Dec
-Jan
07
Feb-
Mar
07
Apr
-May
07
Jun-
Jul 0
7
Aug
07
Sep
07
Oct
07
Nov
07
Dec
07
Jan
08
Feb
08
Mar
08
Apr
08
Wai
t Day
s
trendline
Priority 4 Target - 28 days
9
CT 90th Percentile Wait Time Trend
0
10
20
30
40
50
60
70
80
90
Aug
-Sep
05
Dec
-Jan
06
Apr
-May
06
Aug
-Sep
06
Dec
-Jan
07
Apr
-May
07
Aug
07
Oct
07
Dec
07
Feb
08
Apr
08
Wai
t Day
s
trendline
Priority 4 Target - 28 days
10
Progress to Date
11Note: Based on priority level 4 targets.
Current State (Apr 2008) - % of cases completed within target
83%
94%
100%
96%
89%84%
54%0%
100%
Cancer Surgery
Bypass Surgery
Cataract Surgery
Hip ReplacementKnee Replacement
MRI
CT
Target Actual
12
June 2007
Cardiac
Cancer
Hip and Knee Replacements
Cataract
MRI and CT Scans
March 2008
Ophthalmic Surgery
Orthopaedic Surgery
General Surgery
Paediatric Surgery PilotPaediatric Surgery Pilot
2008/09
Neurosurgery
Vascular Surgery
Otolaryngic Surgery
Ob/Gyn Surgery
Thoracic Surgery
Urologic Surgery
Plastics/Reconstruction
Oral Surgery
Paediatric SurgeryPaediatric Surgery
WTIS Phase 1-3
• 81 WT funded hospitals
• Surgeons: 1,700
• Total cases 2006/07: 1,301,069
• Total MRI and CT scans (2006/07): 1.2 million
WTIS Adult Group 2 Expansion
• ~74 WT funded hospitals (surgery only)
• Cumulative surgeons: ~3,350
• Total cumulative cases 2008/09: ~2,225,000
IMPLE
MENTED
IMPLE
MENTED
WTIS Adult Group 1 Expansion
• 74 WT funded hospitals (surgery only)
• Cumulative surgeons: 2,600
• Total cumulative cases 2007/08: 1,610,000
Paediatric (Pilot)
• London Health Sciences Centre and St. Joseph’s Health Care (London)
• All paediatric surgical procedures
All Surgery Adult & Paediatric Scope
13
South East LHIN Wait Time Trend Analysis April 2008 Data
14
South East LHIN Monthly Trend
Hip Replacement
Knee Replacement
Cataract Surgery
15
South East LHIN Hospital Performance April 2008 data
16
South East LHIN Priority Analysis – April 08 data
17
LHIN #10 – South EastImpact of Concurrent ATC Hospital Implementation Activities
Impl
emen
tatio
n Ac
tiviti
es
Q2 (07/08) Q3 (07/08) Q4 (07/08) Q1 (08/09) Q2 (08/09) Q3 (08/09)
Q2 (07/08) Q3 (07/08) Q4 (07/08) Q1 (08/09) Q2 (08/09) Q3 (08/09)
Implementation Activities By Hospital in LHIN #10
WTIS – Expansion Group 1
CCIS Phase 3: Specialty ICUs
WTIS-ExpansionCardiac Module (WTIS-CCN)
SET Program Phase 2
CCIS Phase 3: (Wave 4)Specialty ICUs
WTIS-ExpansionCardiac Module (WTIS-CCN)
SET Program Phase 2
EDRS
CCIS Phase 3: (Wave 4)Specialty ICUs
SET Program Phase 2
EDRS WTIS – ExpansionGroup 2 & All Paed Sites
CCIS Phase 3: (Wave 5) Specialty ICUs
SET Program
EDRS(TBD)
CCIS Roll-out to all MSICUs
SET Program Phase 1
CCIS Roll-out to all MSICUs
WTIS – ExpansionGroup 1
CCIS ROLL-OUTKingston General Hospital
Quinte Healthcare Corporation*
Hotel-Dieu KingstonKingston General Hospital
SETP PHASE 1
Perth and Smith Falls District Hospital
CCIS ROLL-OUTBrockville General HospitalQuinte Healtcare Corporation
Quinte Healthcare Corporation
Lennox and Addington County General
CCIS ROLL-OUTKingston General Hospital
EDRSTBD
TBDWTIS-EXPANSION
SETP
Quinte Healthcare Corporation
Brockvill General HospitalHotel-Dieu Kingston
WTIS-EXPANSION
Lennox and Addington County General
CCIS ROLL-OUTBrockville General HospitalQuinte Healtcare Corporation
Quinte Healthcare Corporation
Kingston General Hospital
Kingston General HospitalCCIS ROLL-OUT
Focus Groups/Design Sessions Underway
Kingston General Hospital
Brockville General HospitalHotel-Dieu Kingston
SETP PHASE 2
Lennox and Addington County General
Quinte Healthcare Corporation*Perth and Smith Falls District Hospital
Kingston General Hospital
WTIS-CCN
Brockville General HospitalHotel-Dieu Kingston
WTIS-EXPANSION
Lennox and Addington County GeneralQuinte Healthcare Corporation
Kingston General Hospital
EDRSHotel-Dieu KingstonPerth and Smith Falls District HospitalQuinte Healthcare Corporation
CCIS ROLL-OUT
WTIS-CCNKingston General Hospital
Brockville General HospitalHotel-Dieu Kingston
SETP PHASE 2
Lennox and Addington County General
Quinte Healthcare Corporation*Perth and Smith Falls District Hospital
Kingston General Hospital
Brockville General HospitalHotel-Dieu KingstonKingston General HospitalLennox and Addington County General
Quinte Healthcare CorporationPerth and Smith Falls District Hospital
EDRS
EDRS
Perth and Smith Falls District Hospital
Hotel-Dieu KingstonKingston General HospitalLennox and Addington County General
SETP PHASE 2Brockville General Hospital
Quinte Healthcare Corporation*Perth and Smith Falls District Hospital
Hotel-Dieu KingstonKingston General HospitalLennox and Addington County General
Brockville General Hospital
* Belleville General, Trenton Memorial, and Prince Edward County Memorial only.
Brockville General HospitalHotel-Dieu KingstonKingston General HospitalLennox and Addington County General
Quinte Healthcare CorporationPerth and Smith Falls District Hospital
EDRS
18
The infrastructure and resources to reduce demand and increase supply cannot be put in place overnight, therefore, efforts must start early and will take time to show results
The ER Strategy calls for System-wide Improvements
Increasing Supply of ServicesImproving Processes within the ERReducing Demand for Services
OR
HH
EREDER HomeHome
RehabilitationRehabilitation
Long Term Care
Long Term Care
Alternate Levels of Care
HomeCommunityand home-based services
RehabilitationRehabilitation
Long Term Care
Long TermCare
Alternate Levels of Care
Complex and Continuing
Care
Reducing ER Wait Times and Improving Public Satisfaction can only be achieved by making improvements across the entire system
Therefore, accountability for improvement must rest with Hospital Boards and CEOs, LHIN Boards and CEOs and community partners such as
CCACs
• Aging at Home• Family Health Care for All• Chronic Disease Prevention and
Management (Diabetes)• Mental Health and Addiction
• Aging at Home (ALC)• High Growth Hospital Funding
• Emergency Room Strategy• HHR - Emergency Department
Coverage
20
21
22
Number of Patients in Emergency Waiting for an In-patient BedBy LHIN (at any given point in time)
26
28
28
31
31
42
45
49
55
71
82
104
121
136
Central West
North Simcoe Muskoka
North West
Erie St. Clair
South East
North East
Waterloo Wellington
Champlain
South West
Central East
Mississauga Halton
Central
Toronto Central
Hamilton Niagara Haldimand Brant
Ontario = 849
Source: OHA April 2008 ALC Survey Results
23
Number of Patients in Emergency Waiting for an In-patient BedSince December 2007 (at any given point in time)
723
791
819
849
700
720
740
760
780
800
820
840
860
Dec-07 Jan-08 Feb-08 Mar-08 Apr-08
ALC Survey Results – December 2007 to April 2008
17% increaseSource: OHA April 2008 ALC Survey Results
24
0%
5%
10%
15%
20%
25%
1999 2000 2001 2002 2003 2004 2005 2006
% A
LC D
ays
Erie St. Clair South West Waterloo Wellington HNHBCentral West Mississauga Halton Toronto Central CentralCentral East South East Champlain North SimcoeNorth-East North-West
% ALC days in hospitals by LHIN
Most LHINs are experiencing their highest levels of ALC days in recent years
Data source: Inpatient Discharges Table, Ontario Provincial Health Planning Database (PHPDB), V. 17.07
25
Percent of Acute Care Beds Occupied by ALC PatientsBy LHIN
19%
11%
12%
12%
12%
15%
15%
16%
17%
19%
20%
22%
25%
29%
33%
Ontario
Erie St. Clair
Toronto Central
Central West
South East
South West
North Simcoe Muskoka
Mississauga Halton
Central
Central East
Champlain
North West
Hamilton Niagara Haldimand Brant
Waterloo Wellington
North East
Percent of Acute Care Beds Occupied by ALC Patients = Number of patients in an acute care bed waiting for an ALC
Total acute care beds
Source: OHA April 2008 ALC Survey Results
About 2,900 patients are waiting daily in acute care for ALC
26
South East LHINPercentage ALC Days per Quarter
0.00
5.00
10.00
15.00
20.00
25.00
South EastLHIN
14.80 17.43 21.48 20.28 16.89 16.59 14.11
Provincial 10.73 11.37 12.57 13.72 12.64 12.96 14.28
Q1 Q2 Q3 Q4 Q1 Q2 Q3
2006-07 2007-08
27
ALC
15,587 IP Acute Beds (*)
81.43% IP Acute Beds 18.57% IP Acute Beds
5,216,000 visits/year (***)
12.1% admissions/year (**)
Rehabilitation
Complex Continuing Care
unit
Palliative care unit or hospice
Other
Long-Term Care Home
Community / Home care
Sub-acute or convalescent
care
13.71%
7.39%
5.35%
3.39%
2.18%
1.24% Home
57.89%
8.84%
ED
(*) “Alternate Level of Care ALC”, OHA ALC Survey Results, Feb 2008(**) “Review of ED Services in Waterloo Wellington”, Waterloo Wellington LHIN, Dec 2006(***) “Hospital Report : Emergency Department Care”, HRRC 2007.
28
ER visits in FY2006
11%
38%
40%
11%CTAS 2
CTAS 3
CTAS 4
CTAS 5
Figure 3: Number of ED visits by age group
1,293,34725%
1,407,29427%
1,323,18025%
859,21716%
364,3007%
000-019020-039040-059060-079080+
1 visit per year (63%)
2 visits per year (20%)
3 visits per year (8%)
4 visits per year (4%)
5 or more visits per year(5%)
Figure 3: Number of times Ontarians visit ER per year
Figure 1: Number of ER visits in FY2006 by CTAS Figure 2: Number of ER visits by age group
Total number of unique visitors – 2,860,598
Total visits in FY2006 = 5,247,338
29
Emergency Department Lengths of Stay in FY2006
ED LOS Distribution
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
000-0
3003
1-060
061-0
9009
1-120
121-1
5015
1-180
181-21
0211
-240
241-2
7027
1-300
301-3
3033
1-360
361-3
9039
1-420
421-4
5045
1-480
OVER 480
Time spent in ED (minutes)
Num
ber o
f vis
its
Source: NACRS, 2006
30
Distribution of ED Lengths of Stay in FY2006, by CTAS level
ED LOS Distribution, CTAS 1
0
500
1,000
1,500
2,000
2,500
3,000
3,500
000-0
3003
1-060
061-0
9009
1-120
121-1
5015
1-180
181-2
1021
1-240
241-2
7027
1-300
301-3
3033
1-360
361-3
9039
1-420
421-4
5045
1-480
OVER 480
Time spent in ED (minutes)
Num
ber o
f vis
its
Source: NACRS, 2006
ED LOS Distribution, CTAS 2
0
20,000
40,000
60,000
80,000
100,000
120,000
000-0
3003
1-060
061-0
9009
1-120
121-1
5015
1-180
181-2
1021
1-240
241-2
7027
1-300
301-3
3033
1-360
361-3
9039
1-420
421-4
5045
1-480
OVER 480
Time spent in ED (minutes)
Num
ber o
f vis
its
Source: NACRS, 2006
ED LOS Distribution, CTAS 3
0
50,000
100,000
150,000
200,000
250,000
000-0
3003
1-060
061-0
9009
1-120
121-1
5015
1-180
181-2
1021
1-240
241-2
7027
1-300
301-3
3033
1-360
361-3
9039
1-420
421-4
5045
1-480
OVER 480
Time spent in ED (minutes)
Num
ber o
f vis
its
Source: NACRS, 2006
ED LOS Distribution, CTAS 4
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,00000
0-030
031-0
6006
1-090
091-1
2012
1-150
151-1
8018
1-210
211-2
4024
1-270
271-3
0030
1-330
331-3
6036
1-390
391-4
2042
1-450
451-4
80OVER 48
0
Time spent in ED (minutes)
Num
ber o
f vis
its
Source: NACRS, 2006
31
ED LOS Distribution, CTAS 5
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
000-0
3003
1-060
061-0
9009
1-120
121-1
5015
1-180
181-2
1021
1-240
241-2
7027
1-300
301-3
3033
1-360
361-3
9039
1-420
421-4
5045
1-480
OVER 480
Time spent in ED (minutes)
Num
ber o
f vis
its
Source: NACRS, 2006
Distribution of ED Lengths of Stay in FY2600, by CTAS level (cont’d)
32
Academic centres and large community hospitals have the worst ER-Length of Stay across all urgency (triage) levels
* Recommended LOS Goals per ER Expert Panel, JPPC ER-LOS Goals: CTAS I/II – within 8 hours
CTAS III – within 6 hoursCTAS IV/V – within 4 hours
0
10
20
30
40
50
60
70
<70%
70-90%
>90%
<70%
70-90%
>90%
<70%
70-90%
>90%
<70%
70-90%
>90%
All Patients Resuscitation-Emergent
Urgent Less/Non-Urgent
Triage Level / Percentage Within ER-LOS goal
Num
ber o
f ED
s (T
otal
N=1
00)
Percentage of patients meeting ER-LOS goals* by triage level Best performing hospitals (>=95% of patients are treated within LOS goals)
• Carleton Place and District Memorial Hospital
• Glengarry Memorial Hospital• Haldimand War Memorial Hospital• Niagara Health System – Port Colborne Site• Perth & Smiths Falls District – Perth Site• Perth & Smiths Falls District – Smiths Falls• Quinte Healthcare Corporation – Picton• Renfrew Victoria Hospital• Sensenbrenner Hospital• Stevenson Memorial Hospital Alliston• Temiskaming Hospital• West Parry Sound Health Centre
Worst performing hospitals (<70% of patients are treated within LOS goals)
• Grand River Hospital Corp – Waterloo• Hopital Montfort• Humber River Regional Hospital – Humber
Memorial• Humber River Regional Hospital – York-
Finch• Mount Sinai Hospital• North York General Hospital• Ottawa Hospital – Civic Site• St Joseph’s Health Care System – Hamilton• St Michael’s Hospital• Sunnybrook Health Sciences• Toronto East General Hospital• University Health Network – General• University Health Network – Western
All ERs with Annual Volumes >= 20,000, Ontario, NACRS 2006-07
CTAS I/II CTAS III CTAS IV/VAll Patients
33
EDRS Indicators – Process Flow Diagram
34
EDRS Implementation Timeline
All Hospitals submitting data to EDRS
Beta Wave 1 Wave 2
% of EDRS hospitals 6% 55% 26%
Q2 07/08 Q3 07/08 Q4 07/08 Q1 08/09 Q2 08/09 Q3 08/09 Q4 08/09
Public Reporting of ED Wait Times
Technical Development
Beta Testing
Hospital Training
Wave 1 and Wave 2 Implementation
35
Patient Satisfaction SurveyOntario Emergency Department by Hospital Location in LHIN
Source: National Ambulatory Care Reporting System 2005-2006, CIHI
Overall Impressions – Patients’ assessments, overall, of their hospital stays. 74.4
Communication – Patients’ assessments of how well information was communicated to them or family during ER stay. 66.9
Consideration – Patients’ assessments of whether they were treated with respect and courtesy by doctors, nurses and other staff during their stays in the ED.
72.8
Responsiveness – Patients’ assessments of the amount of time they waited to see doctors and nurses and receive test results; assessments of pain management; assessments of team work; and the staff’s responsiveness to their needs.
65.4
Survey Results Summary (2005-2006):
36
Proposed ER Strategy Timeline
January2008
July2008
January2009
January2010
January2011
July2009
July 2010
July2011
January2012
Provincial election(Oct. 2011)
Readiness to announce multi-year ER-LOS targets (Dec. 2008)
Premier commits to reduce ER wait times (Oct. 2007)
ER wait time goals achieved (Jul. 2011)
Pay-for-Results Y1 allocation (Jul. 2008)
ER wait times publicly reported (Feb. 2009)Pay-for-Results Y2 allocation including expanded list of hospitals (Mar. 2009)
Pay-for-Results Y3 allocation (Apr. 2010)
Pay-for-Results Y4allocation (Apr.2011)
Hospitals submit public satisfaction survey results (Jan. 2009 and quarterly from Jul. 2009)
Increase ER/CCAC resources (Apr. 2009)
CCAC demonstration projects for ER diversion begin (Jul. 2008)
Expand CCAC/ER diversion demonstration projects (Jul. 2009)
ER HHR plan complete, implementation begins (Nov. 2008)Online ED patient flow Toolkit and expert program launched (Nov. 2008)
Hospitals selected for Expert Teams (Apr. 2009)
Hospitals selected forExpert Teams (Apr. 2011)
Hospitals selected for Expert Teams (Apr. 2010)
Public awareness campaign begins (Aug. 2008-Jul. 2009)
Target Communication to key stakeholders (Jul. 2008-Jan.2009)
Hospitals selected for Expert Teams (Oct. 2008)
Minister announces ER/ALC policy changes to public and stakeholders (Apr. 2008)
Preliminary EDIS results available; re-calibrate ER Strategy (Oct. 2008)
37
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