Ontario Wait Time Strategy Visit to Champlain June 25, 2008 Alan R. Hudson, OC, FRCSC

Ontario Wait Time Strategy

Visit to Champlain

June 25, 2008

Alan R. Hudson, OC, FRCSC

2

Cataract Surgery 90th Percentile Wait Time Trend

0

50

100

150

200

250

300

350

Aug

-Se

p 05

Oct

-No

v 05

De

c-Ja

n 0

6

Feb

-Mar

06

Apr

-Ma

y 0

6

Jun

-Ju

l 06

Aug

-Se

p 06

Oct

-No

v 06

De

c-Ja

n 0

7

Feb

-Mar

07

Apr

-Ma

y 0

7

Jun

-Ju

l 07

Aug

07

Sep

07

Oct

07

No

v 0

7

De

c 0

7

Jan

08

Feb

08

Ma

r 0

8

Apr

il 0

8

Ma

y 0

8

Wai

t D

ays

trendline

Priority 4 Target - 182 days

3

Cataract Surgery Wait Times – LHIN Variation

4

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

May

08

Wai

t D

ays

trendline


5

Cancer Surgery 90th Percentile Wait Time Trend

0

10

20

30

40

50

60

70

80

90

100

Au

g-S

ep

05

Oct

-No

v 0

5

De

c-Ja

n 0

6

Fe

b-M

ar

06

Ap

r-M

ay

06

Jun

-Ju

l 06

Au

g-S

ep

06

Oct

-No

v 0

6

De

c-Ja

n 0

7

Fe

b-M

ar

07

Ap

r-M

ay

07

Jun

-Ju

l 07

Au

g 0

7

Se

p 0

7

Oct

07

No

v 0

7

De

c 0

7

Jan

08

Fe

b 0

8

Ma

r 0

8

Ap

r 0

8

Ma

y 0

8

Wa

it D

ays

trendline


6

Champlain LHIN Priority Analysis – May 08 data

7

MRI 90th Percentile Wait Time Trend

0

20

40

60

80

100

120

140

Au

g-S

ep

05

Oct

-No

v 05

De

c-Ja

n 0

6

Fe

b-M

ar

06

Ap

r-M

ay

06

Jun

-Ju

l 06

Au

g-S

ep

06

Oct

-No

v 06

De

c-Ja

n 0

7

Fe

b-M

ar

07

Ap

r-M

ay

07

Jun

-Ju

l 07

Au

g 0

7

Se

p 0

7

Oct

07

No

v 0

7

De

c 0

7

Jan

08

Fe

b 0

8

Ma

r 0

8

Ap

r 0

8

Ma

y 0

8

Wa

it D

ay

s

trendline


8

CT 90th Percentile Wait Time Trend

0

10

20

30

40

50

60

70

80

90

Aug

-Se

p 05

Oct

-No

v 05

De

c-Ja

n 0

6

Feb

-Mar

06

Apr

-Ma

y 0

6

Jun

-Ju

l 06

Aug

-Se

p 06

Oct

-No

v 06

De

c-Ja

n 0

7

Feb

-Mar

07

Apr

-Ma

y 0

7

Jun

-Ju

l 07

Aug

07

Sep

07

Oct

07

No

v 0

7

De

c 0

7

Jan

08

Feb

08

Ma

r 08

Apr

08

Ma

y 0

8

Wa

it D

ay

s

trendline


9

Progress to DateService

Baseline Current

(Aug/ Sept05) (May 08) Net change % change

Cancer surgery 81 61 84 96% -20 -24.7

Angiography 56 23 - -33 -58.9

Angioplasty 28 14 - -14 -50.0

Bypass surgery** 49 55 182 100% 6 12.2

Cataract surgery 311 125 182 96% -186 -59.8

Hip replacement 351 204 182 87% -147 -41.9

Knee replacement 440 248 182 82% -192 -43.6

MRI 120 95 28 51% -25 -20.8

CT 81 38 28 84% -43 -53.1

Paediatric surgery* 273 223 182 85% -50 -18.3

90% Completed Within

Current vs. Baseline% completed within PL4

access target

Priority Level 4 (PL4) access target (days)

*Apr/May06 data used as baseline for paediatric surgery; **bypass surgery wait time includes elective referrals only

10Note: Based on priority level 4 targets.

Current State (May 2008) - % of cases completed within target

84%

96%

100%

96%

87%82%

51%0%

100%

Cancer Surgery

Bypass Surgery

Cataract Surgery

Hip ReplacementKnee Replacement

MRI

CT

Target Actual

11

Champlain LHIN Wait Time Trend Analysis May 2008 Data

12

Knee Replacement Wait Time Trend

0

100

200

300

400

500

600

Au

g-S

ep 0

5

Oct

-Nov

05

De

c-Ja

n 0

6

Fe

b-M

ar

06

Ap

r-M

ay 0

6

Jun-

Jul 0

6

Au

g-S

ep 0

6

Oct

-Nov

06

De

c-Ja

n 0

7

Fe

b-M

ar

07

Ap

r-M

ay 0

7

Jun-

Jul 0

7

Au

g 0

7

Se

p 0

7

Oct

07

No

v 0

7

De

c 0

7

Jan

08

Fe

b 0

8

Ma

r 0

8

Ap

r 08

Ma

y 0

8

Wai

t D

ays

Champlain Province


Champlain LHIN Monthly Trend

Cataract Surgery 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

May

08

Wa

it D

ay

s

Champlain Province


Hip Replacement Wait Time Trend

0

50

100

150

200

250

300

350

400

450

500

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

May

08

Wa

it D

ay

s

Champlain Province


13

Champlain LHIN Hospital Performance – May 2008 data

14

Champlain LHIN Ranking 2007/08Service Area 90th Percentile Wait Time Rank

Cancer Surgery 81 14

Cataract Surgery 229 13

Hip Replacement 348 13

Knee Replacement 412 14

MRI 168 12 (14 in Q4)

CT 63 12

Cardiac Bypass 78 11 (out of 13)

Service Area Current Status Rank

Systemic Therapy ~Median 6 Weeks 12

Radiation 61% completed within 14 days 8

Colonoscopy -6% of Expected Colonoscopy volumes completed 9

Other Provincial Programs

•Champlain LHIN has ranked within the bottom 3 LHINs across the priority wait time service area in 2007/08

15

Champlain LHIN’s current wait time performance is still significantly higher than the Province

Variance between Champlain's 90th percentile wait time vs Provincial Wait Time (April 08)

22%

49%

58%54%

93%

41%

0%

20%

40%

60%

80%

100%

Can

cer

Cat

arac

t

Hip

Kn

ee MR

I

CT

Per

cen

t

16

Other ATC and MLAA Performance and Ranking-2007/08

Other ATC Initiatives Current Status Rank

Surgical Efficiency 92%(Q3 & Q4) 4th

CCIS-Avoidable Days

ICU Occupancy

8.6%(Q4) 6th

85.2% (Q4) 4th

EDRS AWAITING DATA

•Thus far, the Champlain LHIN has had positive performance in the other ATC initiatives

•Other MLAA indicators highlight the fact that ALC (and specifically LTC within the ALC population) continues to be a challenging factor for the LHIN.

MLAA Performance Indicators Current Status Rank

Percentage of ALC Days 18.6% 12

Rates of ED visits for conditions that may be treated in alternative primary care settings

7.4 8

Median Time to Long-Term Care Placement

169 days 14

17

Champlain LHIN makes up approximately 10% of the Provincial volumes for the priority service areas.

Volume Share of Champlain LHIN to Provincial Total (Q4 07- 08 closed cases)

9%

10% 10%10%

11%

9%

0%

2%

4%

6%

8%

10%

12%

Ca

nc

er

Ca

tara

ct

Hip

Kn

ee

MR

I

CT

Pe

rce

nt

•TOH is the only adult tertiary care center

•65% of the adult surgery is provided by TOH

•Second largest provider of cancer surgery in the province

•Largest provider of cataract surgery in the province

18

Significant proportion of patients currently waiting for a priority surgery are in the Champlain LHIN

Volume Share of Champlain LHIN to Provincial Total - Open cases as of May 2008

9%

18% 18%

15%

0%

5%

10%

15%

20%C

ance

r

Cat

arac

t

Hip

Kn

ee

Per

cen

t

•Long waits at the Champlain LHIN are expected to continue

19

Champlain LHIN has not seen a significant reduction in the number of patients waiting compared to the Province.

•This is particularly evident for hip replacements, where the Province has seen an 12% decrease in the number of patients on the wait list since July 2007.

Percent Change in Wait List Queue Province and Champlain LHIN July 07 vs April 08

20%

-8%-12%

-15%

6%

-5%

-1%

-8%

-0.2

-0.15

-0.1

-0.05

0

0.05

0.1

0.15

0.2

0.25

Cancer Cataract Hip KneeNu

mb

er o

f C

ases

Province Champlain

20

Champlain LHIN did not meet their 2007/08 Wait Time Performance Targets for 6 of the 7 service areas.

•Champlain LHIN set some of the highest targets compared to other LHINs for 2007/08

•Significantly higher than the Provincial Targets

•Within performance corridor for 4 of the 7 services

21

For service areas where the Province has seen a significant shift in performance, Champlain LHIN still has a skewed wait time distribution

PROVINCE CHAMPLAIN LHIN

22

Cataract Surgery-Champlain is the only LHIN above the Provincial Target

Cataract Surgery 90th Percentile Wait Time Trend –Provincial

Cataract Surgery 90th Percentile Wait Time by LHIN - April 2008

0

100

200

300

Pro

vinc

e

Erie

St.

Cla

ir

Sou

th W

est

Wat

erlo

o W

ellin

gton

Ham

ilton

Nia

gara

Hal

dim

and

Bra

nt

Cen

tral

Wes

t

Mis

siss

auga

Hal

ton

Tor

onto

Cen

tral

Cen

tral

Cen

tral

Eas

t

Sou

th E

ast

Cha

mpl

ain

Nor

th S

imco

eM

usko

ka

Nor

th E

ast

Nor

th W

est

90th

Per

cen

tile

(day

s)

Priority 4 Target (182 days)

0

50

100

150

200

250

300

350

Au

g-S

ep 0

5

Oct

-No

v 05

Dec

-Jan

06

Feb

-Mar

06

Ap

r-M

ay 0

6

Jun

-Ju

l 06

Au

g-S

ep 0

6

Oct

-No

v 06

Dec

-Jan

07

Feb

-Mar

07

Ap

r-M

ay 0

7

Jun

-Ju

l 07

Au

g 0

7

Sep

07

Oct

07

No

v 07

Dec

07

Jan

08

Feb

08

Mar

08

Ap

r-08

Wa

it D

ays

trendline


Cataract Surgery 90th Percentile Wait Time By LHIN

23

At the Provincial level, less percentage of high priority surgical patients are seen within target. However, this is much more evident in the Champlain LHIN.

PROVINCE CHAMPLAIN LHIN

Hip Replacement Surgery is circled as an example; however, all service areas apply

24

Surgeon Level Variability

25Provincial vs. Champlain LHIN Surgeon Wait Time Variation

Hip Replacement-Q4 2007/08

Significant variation in Surgeon wait times across the Champlain LHIN.

26Provincial vs. Champlain LHIN Surgeon Wait Time VariationKnee Replacement-Q4 2007/08

Significant variation in Surgeon wait times across the Champlain LHIN. (cont’d)

27

Any performance improvements in the Champlain LHIN wait times would improve the Provincial wait times

Provincial Wait Time with and without Champlain (Fiscal Year 07-08)

65

135

216

282

113

5563

119

198

265

108

55

0

50

100

150

200

250

300

Can

cer

Cat

arac

t

Hip

Kn

ee

MR

I

CT

Per

cen

t

with Champlain without Champlain

3%

12%

8%

6%

4%

0%

28

• The Champlain LHIN makes up a large proportion of the Province’s wait time volumes and the current queue for all service areas.

• With a large volume and poor overall performance, the LHIN has a significant impact to the Province’s wait time performance.

• This also applies to other MLAA indicators and other cancer service areas.

• Since the LHIN has a large number of patients currently waiting for surgical and DI services, the trend of poor performance will continue.

• The LHIN is currently below the Provincial target for all service areas and is not meeting the access targets of urgent patients.

• The targets set with the MOHLTC are considerably higher than the targets set by other LHINs.

Summary

29

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

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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

30

Michael Schull, MD – Chair, ER Expert Panel

Kevin Smith, D. Phil – Expert Lead, ALC

Hugh MacLeod, MA – OMA Negotiations

Sarah Kramer, MSc – IM/IT

31

ER

Transfer

Institution Communities

Booked Admission

*****

ALC

32

33

34

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

35

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


36

Number of Patients in Emergency Waiting for an In-patient Bed Since 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% increase


37

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.

38

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-

030

031-

060

061-

090

091-

120

121-

150

151-

180

181-

210

211-

240

241-

270

271-

300

301-

330

331-

360

361-

390

391-

420

421-

450

451-

480

OVER 480

Time spent in ED (minutes)

Nu

mb

er o

f vi

sits

Source: NACRS, 2006


0

20,000

40,000

60,000

80,000

100,000

120,000

000-

030

031-

060

061-

090

091-

120

121-

150

151-

180

181-

210

211-

240

241-

270

271-

300

301-

330

331-

360

361-

390

391-

420

421-

450

451-

480

OVER 480


Nu

mb

er o

f vi

sits

Source: NACRS, 2006


0

50,000

100,000

150,000

200,000

250,000

000-0

30

031-0

60

061-0

90

091-1

20

121-1

50

151-1

80

181-2

10

211-2

40

241-

270

271-3

00

301-

330

331-3

60

361-

390

391-4

20

421-4

50

451-4

80

OVER 480


Nu

mb

er o

f vi

sits

Source: NACRS, 2006


0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

000-

030

031-

060

061-

090

091-

120

121-

150

151-

180

181-

210

211-

240

241-

270

271-

300

301-

330

331-

360

361-

390

391-

420

421-

450

451-

480

OVER 480


Nu

mb

er o

f vi

sits

Source: NACRS, 2006

39


0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

000-

030

031-

060

061-

090

091-

120

121-

150

151-

180

181-

210

211-

240

241-

270

271-

300

301-

330

331-

360

361-

390

391-

420

421-

450

451-

480

OVER 480


Nu

mb

er o

f vi

sits

Source: NACRS, 2006

Distribution of ED Lengths of Stay in FY2600, by CTAS level (cont’d)

40

EDRS Indicators – Process Flow Diagram

41

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

42

Client Registry

WTIS is part of a broader agenda to improve access to care

EDRS

EmergencyRoom

MRI/CT

ORAfter Care(i.e. Rehab, Home Care)

NursingUnit

PrimaryProvider

Specialist

ICU

Other Diagnostic Procedures

Other Specialized Services

(Systemic; Radiation)

Screening

WTIS – Wait 1 pilot

Wait 2 adult & paeds

Neurosurgery

Colon Cancer Screening

SETP

CCIS

Quality/Safety Indicators

ALC

43

Proposed ER Strategy Timeline

January2008

July2008

January 2009

January 2010

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)

44

Patient Satisfaction Survey

Ontario 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):

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$109 ER/ALC

$39.5 23 Hospitals

$38.5 Home Care/CCAC

$22.0 14 LHINs/ALC

$4.5 Nurses/Ambulance Offload

$4.5 LTC Outreach Teams

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Documents

Ontario Wait Time Strategy Visit to Champlain June 25, 2008 Alan R. Hudson, OC, FRCSC