1

Improving System Performance: Making the Most of our Resources at

Vancouver Coastal Health

Quality Forum 2013

Duncan Campbell C.F.O. and V.P. Systems Development &

Performance

February 28, 2013

2

Making Most of Our Resources Agenda

• Just imagine if….. • Vision • Background and context • Fiscal crisis in 2008 • Workforce optimization • Results • Where to from here

3

Just Imagine if…. • You know how many patients you will receive each and

every minute of the day • You know what staffing is required to perform on straight

time • Your staff can plan their lives outside work, without the

risk of being called back • You have the correct number and mix of staff to safely

support the workload demand. • You could use information to reduce adverse drug

events • You can use information to optimize OR’s, staffing

surgeon availability and beds to drive down wait times

4

Vision: Create Agile Financial And Operation Processes

1. Real time information updated every 15 minutes – ED visits and Pay for Performance metrics, census and bed maps, staff scheduling and availability, discharges and targets.

2. Forecasting and scheduling software that predicts census, volume mix, physician and clinical staffing, operating room and acuity

3. Using analytics to make decisions in real time e.g. whether to flex beds up or down, use overtime understanding PFF revenue and costs.

4. Very little time spent wondering what happened as part of decisions when they did happen

5. Have sufficient notice based on forecasts to staff plan at straight time

…to support quality care

5

Vision: Create Agile Financial And Operation Processes

1. Manage wait times through complex scenario analysis

– Real time based on forecast models and simulation the optimum balance of scheduled and unscheduled surgeries against wait time targets, bed capacity, physician and clinical staffing, and diagnostics

2. Forecasting revenue based on RIW, Volumes, and capacity constraints

3. Budgeting is simple – driven by forecasts, revenue, staffing and efficiency assumptions

4. Pay for Performance agency pays for all growth (could be subject to a cap)

– Block funding becomes a smaller and smaller part of funding

6

Fiscal Crisis in 2008 $42m Operating deficit •95% of funding received committed to collective bargaining •Cash less than 1 weeks payroll - $10m •High admin and support costs (15%) •Staff growth higher than volume growth

$1 Billion Infrastructure Deficit (excluding hospitals)

Outdated technology – on fire pc’s Obsolete equipment Aging and not well maintained facilty

•$50m capital projects in flight without a funding source •ED congestion and hallway patients •Long wait times, and cancelled elective surgery

7

Turnaround Plan • Take control of cash and stop in flight projects • Get admin and support costs into line – $26m and 200 staff

reduction –reduce from 13% to 9.2% • Invest in ED Pay for Performance • Get control over headcount – Senior team approves all new hires

and replacements • Focus on workforce optimization to get control over the biggest cost

item –over 70% • Invest in staff scheduling, forecasting,decision support tools and

portals • Invest in Greencare sustainability initiatives

I will focus my discussions today on workforce and resource

optimization and developing agile financial processes

8

Key Elements of Our Resource Optimization Journey

Scheduling Deploy staff effectively

Data Warehouse Standardized data

increased data quality for decision making

Care Management Understand patient acuity

and care needs

Bed Management Maximize utilization of beds

Business Intelligence Integrated portal improves and Simplifies reporting capabilities

Forecasting Project demand and staffing requirements

Resource Optimization

9

Average Variable StaffingGFS Rehab MedicineOct 03-Nov 13, 2008

0

5

10

15

20

25

30

35

40

F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T

3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13

Ave

rag

e N

um

ber

of

Sta

ff

52

54

56

58

60

62

64

66

68

70

72

Cen

sus

RN LPNAide CensusBudget

Staff Forecasting and Staff Scheduling

• Lower fixed levels of staffing and increase flexibility of variable staffing

Average Variable Staffing

Staff Forecasting Solution will allow the

ability to forecast demand & the

associated staff requirements

Optimizing Variable Staffing Levels

Staff Scheduling Efficient & effective deployment of staff to match expected

activity patterns

10

Pre-Cap Plan: Decision in real time

24

1 2 3 4 5 6 7

6

*

Overtime

Day

Open additional beds

7

28

Beds FTEs

24

6

11

Utilizing Cap Plan to make decision 3 days in advance

1 2 3 4 5 6 7

*

Straight time

Open additional beds 28

7

Beds FTEs

Day

6

24 * Decision

24

6

12

Utilizing Cap Plan to Create Capacity and plan ahead to exceed discharge targets

1 2 3 4 5 6 7

24

6

Baseline staffing

No additional beds 28

7

Beds FTEs

Day

28

7

13

CapPlan Dashboard

• Updated every 15 minutes

• Provides web-based real-time daily visibility

• Worm graph shows 3 days of information – retrospectively, today and tomorrow

• Displays key metrics with applicable traffic light on the current status within the hospital

• Can display the details of each nursing unit under each planning group

14

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2011

-01

2011

-02

2011

-03

2011

-04

2011

-05

2011

-06

2011

-07

2011

-08

2011

- 09

2011

-10

2011

-11

2011

-12

2011

-13

2012

-01

2012

-02

2012

-03

2012

-04

2012

-05

2012

-06

2012

-07

2012

-08

2012

-09

2012

-10

2012

-11

2012

-12

2012

-13

2013

-01

2013

-02

2013

-03

2013

-04

2013

-05

2013

-06

2013

-07

2013

-08

2013

-09

2013

-10

2013

-11

Perc

ent o

f 4-h

our s

hift

s

Staffing Implications Example - Richmond 2 West Psychiatry

Elevated (>1 over)

Balanced (-1 to 1)

Insufficient (<-1 under)

15

ED Performance

16

Results

17

Hand Hygiene Up

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

08/09Q4

09/10Q1

09/10Q2

09/10Q3

09/10Q4

10/11Q1

10/11Q2

10/11Q3

10/11Q4

11/12Q1

11/12Q2

11/12Q3

11/12Q4

12/13Q1

12/13Q2

12/13Q3

Hand Hygiene Percent Compliance (VGH, LGH and RH for consistent four-year trend)

18

MRSA Down

0.00

2.00

4.00

6.00

8.00

10.00

12.00

MRSA Rate per 10,000 Acute Patient Days (in VCH facilities excluding PHC for consistent long term trend)

19

Workforce Optimization Efforts

FTE' Analysis

1600017000180001900020000

FTE'

s

Actual Projected

Actual 16083 16683 17452 18043 17932 17932

Projected 16083 16683 17452 18063 18695 19349

2005/6 2006/7 2007/8 2008/9 2009/10 2010/11

20

Improvements in Insufficient Notice

Key Findings:

Year over year reductions in insufficient notice are projecting annualized savings of $724k in 2011/12

Insufficient Notice Premiums

$-

$100,000$200,000

$300,000$400,000

$500,000

$600,000$700,000

$800,000$900,000

$1,000,000

2008 2009 2010 2011 2012

Insu

ffic

ien

t N

oti

ce (

$)

Pilot, A and B

• Reduced scheduling errors

• Shift to proactive scheduling processes

• Standard Interpretation of Insufficient notice contract language

21

The Bottom Line • Quality improved and costs reduced

– Improved quality, Mortality, Infection, wait times and access, Adverse drug events etc

• Reinvested operating surpluses in infrastructure to support front line staff – bed –pan decontaminators, replaced 10000 pc’s, invested in quality initiatives

• $120m turnaround –now $70m surplus • Set aside $100m for Clinical Systems transformation across

continuum, including decision support • Increased cash from $10m to $250m • Paid off all long term debt including $50m to Health Benefit trust

liabilities • Investment in decision support tools less than $15m • Real productivity gains 2% volume growth with the same level of

staffing – previously staff growth twice volume growth

22

Where to From Here?

23

Real Time ED Dashboard

INTERNAL DASHBOARD BCAmbulance DASHBOARD

PUBLIC WEBSITE

24

Data Linkages across the Patient Continuum

24

http://www.information-management.com/news/Vancouver-Coastal-Healths-Patient-Continuum-Increases-Insights-10023644-1.html

What is a Patient Continuum? • Facilitates longitudinal patient tracking across the

entire health authority according to criteria and measurements such as time, space, visits, facilities and type of care.

Why Build a Patient Continuum? • Standardizes joins between fact tables • Provides a means of analyzing patient movement • Improves data quality • Enables easier data mining Award • Winner of the 2012 Innovation Solution Award for

BI/Analytics

25

Agile Processes: Armour vs. Fly by Wire

26

Questions?

http://www.vch.ca

Thank You

27

Appendix: Full Deck

28

About Vancouver Coastal Health

VCH delivers acute, residential and community healthcare services directly to more than one million residents

• $3.0 billion annual funding • 22,000 staff • 2,500 physicians • 5,000 volunteers • 556 locations including: – 13 hospitals – 3 diagnostic and treatment centres – 15 community health centres

• 3 million+ patient days of care • 308,000+ annual emergency department visits • 640,000+ annual clinic visits • 116,000+ annual surgeries • 79,000+ inpatient discharges • 2.3 million+ residential care days • 1.9 million+ home support hours • 199,000+ home nursing visits

29

About Vancouver Coastal Health

Geographic area:

• 54,165 square kms • Richmond • Vancouver • North Shore • Sunshine Coast • Powell River • Sea to Sky • Bella Bella/Bella Coola

One of BC’s top 55 employers

30

Who we serve at VCH Vancouver

• Urban centre with inner city challenges • Highest and lowest socio-economic status in

one geographic area • 40% of our patients in acute care are from

outside Vancouver • 640,000 Vancouver residents:

– 1 in 4 live in poverty – 1 in 5 are under 19 – 1 in 8 are 65+ – 1 in 3 live alone – 1 in 6 families annual income below $20,000 – 1 in 2 speak English at home

31

32

Innovate For Sustainability

Workforce Optimization Initiatives

Program Budget Marginal Analysis, Pay for Performance

Food Waste and Recycling Programs

33

Fiscal Crisis in 2008

34

Fiscal Crisis in 2008 $42m Operating deficit •95% of funding received committed to collective bargaining •Cash less than 1 weeks payroll - $10m •ED congestion and hallway patients •High admin and support costs (15%) •Staff growth higher than volume growth

$1 Billion Infrastructure Deficit (excluding hospitals)

Outdated technology – on fire pc’s Obsolete equipment Aging and not well maintained facilty

•$50m capital projects in flight without a funding source

35

Turnaround Plan • Take control of cash and stop in flight projects • Get admin and support costs into line – $26m and 200 staff

reduction –reduce from 13% to 9.2% • Invest in ED Pay for Performance • Get control over headcount – Senior team approves all new hires

and replacements • Focus on workforce optimization to get control over the biggest cost

item –over 70% • Invest in staff scheduling, forecasting,decision support tools and

portals

I will focus my discussions today on workforce and resource optimization and developing agile financial processes

36

Key Elements of Our Resource Optimization Journey

Scheduling Deploy staff effectively

Data Warehouse Standardized data

increased data quality for decision making

Care Management Understand patient acuity

and care needs

Bed Management Maximize utilization of beds

Business Intelligence Integrated portal improves and Simplifies reporting capabilities

Forecasting Project demand and staffing requirements

Resource Optimization

37

Workforce Optimization Objectives

• Optimize resource utilization through alignment of staffing to predicted

patient volumes / activities:

– Reduce productive hours per patient day

– Reduce cost per patient day

– Optimize variable staffing

• Improve patient flow:

– Optimize discharges to create capacity

– Decrease ALOS

38

LGH Pilot LGH, VC, VA

VGH/VC

Scope & Timeline: Staff Scheduling and Staff Forecasting

Jun 2009

Oct 2009

Mar 2010

RHS and Community

Jun 2010

Jan 2011

PHC Upgrade

Feb 2011

May 2011

PR, Corp, Regional

Feb 2012

VA Amb, HR, MI, Comms

LMI – MI July 2012 VC, Corp,

NS Com

STS and SC

Dec 2012

RH Pilot

Apr 2009

RH & LGH

Feb 2011

SP & MSJ

Jun 2011

VGH & UBCH

Mar 2012

2009 Apr

2009 Jun

2009 Oct

2010 Mar

2010 Jun

2011 Jan - Feb

2011 May - Jun

2012 Feb - Mar

2012 Jul

2012 Dec

Staff Scheduling

Staff Forecasting

39

Average Variable StaffingGFS Rehab MedicineOct 03-Nov 13, 2008

0

5

10

15

20

25

30

35

40

F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T

3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13

Ave

rag

e N

um

ber

of

Sta

ff

52

54

56

58

60

62

64

66

68

70

72

Cen

sus

RN LPNAide CensusBudget

Staff Forecasting and Staff Scheduling

• Lower fixed levels of staffing and increase flexibility of variable staffing

Average Variable Staffing

Staff Forecasting Solution will allow the

ability to forecast demand & the

associated staff requirements

Optimizing Variable Staffing Levels

Staff Scheduling Efficient & effective deployment of staff to match expected

activity patterns

40

Predicting Demand An integrated approach to optimal resource utilization

..and

How will I know… How will I know…

CapPlan

..and

How many patients can I expect? How many staff will I need?

What beds are available to place patients?

(Access and Flow)

What staff are available to fill shifts?

(Staffing Service) Beds Staff

Patient Volume

41

Workforce Optimization through Capacity Planning

Capacity Planning for Hospital Care (CapPlan), an operational management system and a toolkit for decision-making:

• Providing integrated information • Enabling staffing and bed utilization decisions on long-term and short-

term basis • With an easily accessible and visual web-based dashboard displaying

key performance indicators (i.e., discharges, occupancy) • Matching staffing levels to patient volumes:

– Optimize productive hours per patient day – Reduce overtime by planning for fluctuations in demand – Optimize relief staffing – Optimize bed utilization and flow

42

Workforce Optimization through Electronic Staff Scheduling & Timekeeping Maximizing workforce capacity and effectively deploying clinical staff through the provision of efficient scheduling tools and real time staffing data for managers:

• Improved consistency and efficiency in workforce productivity • A regional view of staff resources • Real-time data access for analysis • Improved decision making • More effective deployment of staff to baseline • Decreased overtime, insufficient notice premiums and payroll errors • Significant reduction in hours per patient day • Improved daily and weekly planning • Standardized processes and procedures • Increased support for frontline and operations staff with improved

reporting processes made available through online reporting portals

43

Bed Management - TeleTracking™ Capacity Management

TeleTracking™ enables patient placement and flow management redesign through:

• Pre-Admit Tracking • Bed Tracking • Transport Tracking

Successes – Technology and Process Redesign • Enhanced ability to create and manage capacity and throughput • Automated processes to improve efficiency • Reduction in “idle” bed time • Enhanced ability for proactive vs. reactive decision-making • Accurate and real-time reporting

44

Managing Patient Flow through Effective Bed Utilization

• Enhanced ability to create and manage capacity

and throughput

• Enhanced ability for proactive vs. reactive

decision-making

• Automated processes to improve efficiency

• Accurate and real-time reporting

• Reduction in “idle” bed time

45

Management Reporting Through Portals (SharePoint)

Online Portals Provide: • A “one stop shop”

• Managers with real-time

tools and data to guide

decisions

• Improved productivity

• Improved data quality

• Increased accessibility,

usability, and accountability

46

CapPlan Dashboard

• Provides web-based real-time daily visibility

• Worm graph shows 3 days of information – retrospectively, today and tomorrow

• Displays key metrics with applicable traffic light on the current status within the hospital

• Can display the details of each nursing unit under each planning group

47

Pre-Cap Plan: Decision in real time

24

1 2 3 4 5 6 7

6

*

Overtime

Day

Open additional beds

7

28

Beds FTEs

24

6

48

Utilizing Cap Plan to make decision 3 days in advance

1 2 3 4 5 6 7

*

Straight time

Open additional beds 28

7

Beds FTEs

Day

6

24 * Decision

24

6

49

Utilizing Cap Plan to Create Capacity and plan ahead to exceed discharge targets

1 2 3 4 5 6 7

24

6

Baseline staffing

No additional beds 28

7

Beds FTEs

Day

28

7

50

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2011

-01

2011

-02

2011

-03

2011

-04

2011

-05

2011

-06

2011

-07

2011

-08

2011

- 09

2011

-10

2011

-11

2011

-12

2011

-13

2012

-01

2012

-02

2012

-03

2012

-04

2012

-05

2012

-06

2012

-07

2012

-08

2012

-09

2012

-10

2012

-11

2012

-12

2012

-13

2013

-01

2013

-02

2013

-03

2013

-04

2013

-05

2013

-06

2013

-07

2013

-08

2013

-09

2013

-10

2013

-11

Perc

ent o

f 4-h

our s

hift

s

Staffing Implications Example - Richmond 2 West Psychiatry

Elevated (>1 over)

Balanced (-1 to 1)

Insufficient (<-1 under)

51

Supporting Systems

Home Care

Home ED Home

Residential

Acute

Community

Real time decision support tools for agile decisions • Forecasting – staffing, census, Operating Rooms • Kronos Scheduling and timekeeping • Acuity • ED Performance monitoring • Bed management • Portals and decision support metrics • Management practices and bed meetings

52

Results

53

Hand Hygiene Up

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

08/09Q4

09/10Q1

09/10Q2

09/10Q3

09/10Q4

10/11Q1

10/11Q2

10/11Q3

10/11Q4

11/12Q1

11/12Q2

11/12Q3

11/12Q4

12/13Q1

12/13Q2

12/13Q3

Hand Hygiene Percent Compliance (VGH, LGH and RH for consistent four-year trend)

54

MRSA Down

0.00

2.00

4.00

6.00

8.00

10.00

12.00

MRSA Rate per 10,000 Acute Patient Days (in VCH facilities excluding PHC for consistent long term trend)

55

Workforce Optimization Efforts

FTE' Analysis

1600017000180001900020000

FTE'

s

Actual Projected

Actual 16083 16683 17452 18043 17932 17932

Projected 16083 16683 17452 18063 18695 19349

2005/6 2006/7 2007/8 2008/9 2009/10 2010/11

56

Improvements in Insufficient Notice

Key Findings:

Year over year reductions in insufficient notice are projecting annualized savings of $724k in 2011/12

Insufficient Notice Premiums

$-

$100,000$200,000

$300,000$400,000

$500,000

$600,000$700,000

$800,000$900,000

$1,000,000

2008 2009 2010 2011 2012

Insu

ffic

ien

t N

oti

ce (

$)

Pilot, A and B

• Reduced scheduling errors

• Shift to proactive scheduling processes

• Standard Interpretation of Insufficient notice contract language

57

The Bottom Line • $120m turnaround • $10m to $250m in cash • Investment in decision support tools less than

$15m • Invest in infrastructure out of operating funds • Improved quality, Mortality, Infection, wait times

and access, Adverse drug events • Real productivity gains 2% volume growth with

the same level of staffing

58

Where to From Here?

59

Real Time ED Dashboard

INTERNAL DASHBOARD BCAmbulance DASHBOARD

PUBLIC WEBSITE

60

Data Linkages across the Patient Continuum

60

http://www.information-management.com/news/Vancouver-Coastal-Healths-Patient-Continuum-Increases-Insights-10023644-1.html

What is a Patient Continuum? • Facilitates longitudinal patient tracking across the

entire health authority according to criteria and measurements such as time, space, visits, facilities and type of care.

Why Build a Patient Continuum? • Standardizes joins between fact tables • Provides a means of analyzing patient movement • Improves data quality • Enables easier data mining Award • Winner of the 2012 Innovation Solution Award for

BI/Analytics

61

Agile Processes: Armour vs. Fly by Wire

62

Questions?

http://www.vch.ca

Thank You