Cambridge Memorial Hospital Appendix B Environmental Scan · Cambridge Memorial Hospital Appendix B...

Cambridge Memorial Hospital Appendix B Environmental Scan

Background for Strategic Planning Retreat – May 28, 2014

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2 © 2013 Hay Group. All rights reserved

Purpose of this document

Helping retreat participants prepare for the strategic planning session by: Reviewing a summary of what the data say

about what we do and who we serve Learning what our stakeholders think about

CMH and what the hospital should consider as it plans for the future


Material presented in this document is based on:

Environmental scan and identification of key integration priorities for Waterloo region hospitals

Focused current state data analysis for CMH Input from 37 internal (Board, Senior team,

medical and program leadership) and external stakeholders. − 6 individual interviews − 13 focus groups


Contents

1.0 Current state: Understanding who we are • What is CMH doing now? • How well is CMH doing what it does? • Who is CMH serving? • How dependent is the population on CMH? • Who else is providing hospital care to the CMH community? • How well is the Cambridge population served? • Growing need for hospital care into the future

2.0 The context in which CMH operates 3.0 Considering the future role of CMH 4.0 Summary of stakeholder feedback

1.0 Current State: Understanding who we are

13

What is

Cambridge Memorial Hospital

doing now?


Data used for analysis

The full fiscal year (2012/13) was used to examine patterns of utilization of hospital services in Waterloo and at the 3 Waterloo hospitals. A number of databases were: − DAD (acute inpatient) − NACRS (ED and day surgery) − OMHRS (adult mental health) − NRS (rehab) − RAI MDS (CCC)

Acute data includes categorization of cases by “program cluster category” (PCC). The PCC is a way to group data by physician specialty in relation to the specialty that would ‘typically’ provide that type of care.


CMH beds and occupancy rates – 2013/14 YTD Average

109 acute care beds (excluding mental health*) at 89% occupancy

156 total inpatient beds and bassinets

Bed Type Beds

(2013/ 14)

Average Occupancy (2013/14)

Medical 57 102%Surgical 28 77%ICU 7 87%Obs. 10 75%Paeds 7 57%Total (Acute Care) 109 89%Level 1 Bassinets 13 62%Adult Mental Health 20 87%IP Rehabilitation 14 98%

Total 156 87%* For the past several years adult mental health has been measured separately from other acute care activity. in Ontario


Volume of emergency department activity at CMH in 2012/13 by Triage score

CTAS Level Visits % of All Visits

1 - Resuscitation 221 0.4%2 - Emergent 6,642 12.4%3 - Urgent 28,551 53.1%4 - Semi-Urgent 17,155 31.9%5 - Non-Urgent 1,164 2.2%Total 53,733 100.0%


Volume of inpatient care activity at CMH in 2012/13 by program

Program 2012/13 IP Cases Program 2012/13

IP Cases Obstetrics 1,531 Endocrinology 225 Neonatology 1,517 Rehabilitation 222 Pulmonary 885 Otolaryngology 152 Orthopaedics 690 Haematology 126 Cardiology 688 Other Reasons 97 Gastro/Hepatobiliary 684 Nephrology 55 Psychiatry 678 Neurosurgery 33 Other Internal Medicine 620 Plastic Surgery 13 General Surgery 561 Ophthalmology 10 Neurology 313 Dental/Oral Surgery 3 Urology 287 Thoracic Surgery 2 Non-Acute 274 Vascular Surgery 2 Gynaecology 238 Total IP Cases 9,906


Distribution of 2012/13 inpatient acute care activity among Waterloo hospitals

Shows rationalization of inpatient services between 2 Kitchener hospitals

Shows size of CMH activity relative to Kitchener hospitals


Grand River Hospital

St. Mary's General, Kitchener

Grand Total

Cardiac Surgery - - 749 749 Cardiology 688 286 2,090 3,064 Dental/Oral Surgery 3 1 6 10 Endocrinology 225 234 163 622 Gastro/Hepatobiliary 684 999 513 2,196 General Surgery 561 1,577 424 2,562 Gynaecology 238 664 3 905 Haematology 126 366 85 577 Neonatology 1,517 4,427 - 5,944 Nephrology 55 128 92 275 Neurology 313 845 133 1,291 Neurosurgery 33 65 15 113 Non-Acute 274 390 271 935 Obstetrics 1,531 4,551 4 6,086 Ophthalmology 10 6 6 22 Orthopaedics 690 1,947 16 2,653 Other Internal Medicine 620 1,006 551 2,177 Other Reasons 97 193 67 357 Otolaryngology 152 177 186 515 Plastic Surgery 13 45 8 66 Psychiatry 678 2,141 25 851 Pulmonary 885 586 1,188 2,659 Thoracic Surgery 2 4 191 197 Urology 287 303 240 830 Vascular Surgery 2 23 1 26 Grand Total 9,087 19,568 7,027 35,682

PCC

2012/13 IP Cases


Useful Definitions

Primary admitted via ED or birthing or very minor surgery, usually at closest hospital

Secondary not usually available at small or rural hospitals, includes most surgery

Tertiary requires specialized supports, usually consolidated in single provider within a LHIN

Quaternary highly specialized, demonstrated volume/outcome relationship, usually consolidated in academic health science centres

Levels of Hospital Inpatient Care:

RIW Weighted Cases: Resource Intensity Weights (RIWs) are measures of the relative cost of the resources used in providing inpatient acute care. RIWs are assigned by CIHI based on cost data collected from hospitals across Canada. For CMH, the estimated average cost per RIW is about $5,400 (i.e. every RIW is "worth" about $5,400)


92% of CMH inpatient weighted cases are for ‘Primary’ or ‘Secondary’ level hospital care

Hay Level of Care

Grand River

Hospital

St. Mary's General,

Kitchener


Grand Total

P 7,307 3,715 4,163 15,185S 10,660 3,704 4,336 18,700T 3,013 5,118 514 8,644Q 1,573 1,450 284 3,306Grand Total 22,552 13,986 9,297 45,835P 32% 27% 45% 33%S 47% 26% 47% 41%T 13% 37% 6% 19%Q 7% 10% 3% 7%T/Q 20% 47% 9% 26%

Distribution of RIW Weighted Cases by Hospital Level of Care


93% of CMH medicine weighted cases are primary or secondary level hospital care

Hay Level of Care

Grand River

Hospital

St. Mary's General,

Kitchener


Grand Total

P 4,067 3,596 3,277 10,940S 2,720 2,418 1,474 6,612T 1,444 1,720 275 3,438Q 647 426 123 1,195Grand Tota 8,878 8,159 5,149 22,186P 46% 44% 64% 49%S 31% 30% 29% 30%T 16% 21% 5% 15%Q 7% 5% 2% 5%T/Q 24% 26% 8% 21%

RIW Weighted Cases - Medicine


86% of CMH surgery weighted cases are primary or secondary level hospital care

Hay Level of Care

Grand River

Hospital

St. Mary's General,

Kitchener


Grand Total

P 644 95 225 964S 5,409 1,282 2,079 8,770T 1,524 3,393 216 5,133Q 899 1,024 149 2,072Grand Total 8,476 5,793 2,669 16,939P 8% 2% 8% 6%S 64% 22% 78% 52%T 18% 59% 8% 30%Q 11% 18% 6% 12%T/Q 29% 76% 14% 43%

RIW Weighted Cases - Surgery


2012/13 IP Quality Based Procedures in Waterloo Hospitals


Grand River

Hospital


Total

CHFHigh 29 9 44 82 CHFMedium 163 50 392 605 COPDHigh 39 13 35 87 COPDMedium 231 35 406 672 Hip Fracture 89 280 3 372 Hip Replacement 148 353 - 501 Knee Replacement 288 553 - 841 Stroke Hemorrhage 8 25 5 38 Stroke Ischemic 58 312 12 382 Stroke TIA 26 115 13 154 Stroke Unspecified 22 3 6 31 Grand Total 1,101 1,748 916 3,765

Quality Based Procedure Group

Inpatient CasesHealth System Funding Reform in Ontario is increasingly focusing on funding for patient volume. Funding is being provided at a set rate for selected procedures, Quality Based Procedures. The funding rate for these procedures is moving from the current average cost to the cost for ‘quality’ care.


2012/13 Quality Based Procedures- average length of stay for inpatient cases

Although current QBP prices (and carve out) are based on costs per weighted case, it is anticipated that prices will shift to true case payment (independent of weighting) based on ‘quality’ care. Quality care will likely include targeted ‘best practice’ lengths of stay.

Profitable performance will require LOS reduction to achieve the targeted lengths of stay. (e.g. Current target of 5 day stay for ischemic strokes)

Targeted lengths of stay will likely include ALC days; − reduction in LOS may require

reduction in ALC days; − reduction in ALC days may require

investments in post-acute services Lengths of Stay in accompanying

table include both acute and ALC days.

Except for Ischemic Strokes, CMH ALOS performance compares well with provincial averages.


Grand River

Hospital


Total

CHFHigh 7.1 19.0 11.0 10.5 10.5 9.6 CHFMedium 8.0 15.0 8.7 9.1 8.3 7.1 COPDHigh 6.6 6.5 14.1 9.6 11.3 10.2 COPDMedium 5.3 9.1 6.3 6.1 6.7 5.9 Hip Fracture 8.5 13.3 2.3 12.1 12.2 8.7 Hip Replacement 3.5 4.4 4.1 4.4 4.1 Knee Replacement 3.1 4.0 3.7 3.8 3.7 Stroke Hemorrhage 6.1 8.5 9.6 8.2 13.1 8.8 Stroke Ischemic 12.8 9.6 14.8 10.2 11.9 8.3 Stroke TIA 2.3 4.4 4.2 4.0 4.1 3.6 Stroke Unspecified 21.4 6.0 4.7 16.6 9.3 6.9

Quality Based Procedure Group

Average Total Length of StayOntario Average

Ontario Avg. Excl.

ALC Days


Highest volume day surgery procedures in 2012/13 by Program

Program Cluster Category


Grand River

Hospital


Grand Total % CMH

Grand Total 9,427 10,672 21,596 41,695 23%Gastro/Hepatobiliary 3,433 5,927 6,024 15,384 22%Ophthalmology 1,351 33 3,688 5,072 27%Urology 1,206 268 5,782 7,256 17%Orthopaedics 1,156 514 1,036 2,706 43%General Surgery 837 809 1,072 2,718 31%Otolaryngology 641 849 788 2,278 28%Obstetrics 315 847 1,162 27%Plastic Surgery 168 296 149 613 27%Dental/Oral Surgery 120 138 213 471 25%Gynaecology 76 275 1 352 22%Pulmonary 54 1 218 273 20%Vascular Surgery 32 99 20 151 21%Neurosurgery 26 96 1 123 21%Haematology 12 4 56 72 17%Cardiology 2,548 2,548 0%


Highest volume day surgery procedures in 2012/13 by ambulatory group (CACS)

CACSCambridge Memorial Hospital

Grand River Hospital


Grand Total % CMH

Grand Total 9,427 10,672 21,596 41,695 23%(C060) Cataract Removal/Lens Insertion 1,333 3,376 4,709 28%(C254) Partial Excision Anus, Rectum, Intestine 1,111 2,328 1,987 5,426 20%(C259) Biopsy Lower Digestive System 906 1,045 1,316 3,267 28%(C251) Inspection Digestive Tract 805 1,650 1,709 4,164 19%(C457) Cystoscopy (Bladder Inspection) 733 5 3,931 4,669 16%(C260) Biopsy Esophagus, Stomach 456 548 614 1,618 28%(C253) Hernia Repair, Open Approach 332 211 320 863 38%(C303) Other Lower Limb Intervention 324 61 273 658 49%(C282) Cholecystectomy 316 239 335 890 36%(C105) Myringotomy With Tubes 270 357 58 685 39%(C466) Dilation/Curettage And Endometrial Ablation 245 645 890 28%(C302) Other Knee Intervention, Excluding Cruciate Repair 232 65 222 519 45%(C101) Tonsillectomy/Adenoidectomy 213 383 154 750 28%(C305) Shoulder Intervention 194 21 83 298 65%(C310) Open Fixation/Fusion Without Graft 144 174 71 389 37%(C109) Dental/Peridontal Intervention 120 138 198 456 26%(C455) Lower Urinary Tract Intervention 119 76 328 523 23%(C456) Other Minor Lower Urinary Tract Intervention 104 24 752 880 12%(C351) Complete And Partial Mastectomy 80 127 90 297 27%(C602) Open Lymph Node Excision/Biopsy, Except Extremity 74 148 179 401 18%


Adult mental health cases in 2012/13

CMH sees higher % of mood disorder patients, and lower % of schizophrenia patients

CMH GRH CMH GRH(25) Acute Unit 597 1,308 9.9 15.2 (99) Other Longer Term - 60 138.4 (96) Longer Term Geriatric Unit - 26 178.9 Grand Total 597 1,394 9.9 23.5

Type of Unit IP Discharges Average LOS

CMH GRH CMH GRHMood disorders 282 463 48% 35%Short Stay assessments 163 410 28% 31%Schizophrenia and other psychotic disorders 94 309 16% 23%Other disorders 22 43 4% 3%Cognitive disorders 7 49 1% 4%Substance related disorders 8 47 1% 4%Personality disorders 10 10 2% 1%Grand Total 586 1,331 100% 100%

Patient Group # of Assessments % Dist. By Group


2012/13 Inpatient rehabilitation discharges from Waterloo hospitals

CMH rehabilitation patients admitted with lower functioning at CMH (FIM score of 77) and make significantly larger functional improvements than at GRH

CMH GRH CMH GRH CMH GRH CMH GRHOther Disabilities 68 70 78 90 100 106 22 16 Fracture of Lower Extremity 58 34 74 88 104 105 30 17 Stroke 35 130 73 78 98 101 25 24 Replacement of Lower Extremity 12 33 78 90 111 108 33 18 Pain 9 5 84 97 108 110 24 13 Maj Mult Trauma, Oth Mult Trauma & Maj Mult Frac 8 8 75 92 106 112 31 20 Cardiac 6 20 94 91 115 109 22 18 Other Orthopedic 6 8 74 83 98 101 24 18 Traumatic Brain Injury 6 5 82 88 99 106 18 18 Neurological 5 9 77 86 110 103 33 17 Non-Traumatic Brain Injury 4 2 67 95 97 112 30 18 Non-Traumatic Spinal Cord Injury 2 16 101 83 112 105 11 22 Amputation, Lower Extremity 2 14 97 90 119 101 23 11 Traumatic Spinal Cord Injury 1 2 59 56 70 82 11 27 Pulmonary - 16 94 106 12 Rheumatoid Arthritis and Other Arthritis - 3 89 104 16 Grand Total 222 375 77 85 103 104 26 19

Rehabilitation Group 2012/13 Discharges Average Admit FIM Average Disch FIM Avg. FIM Chg


Diagnostic activity at CMH

Imaging Functional Centre 2008/ 2009

2009/ 2010

2010/ 2011

2011/ 2012 2012/ 2013

MI Radiography 51,139 50,144 50,476 49,245 49,673 MI Mammography 5,768 3,203 3,922 4,374 4,022 MI Computed Tomography 12,313 13,834 14,186 14,074 13,737 MI Diagnostic Ultrasound 14,686 14,478 18,283 18,000 19,232 MI Nuclear Medicine - Gamma Cameras 5,075 4,543 5,210 4,848 4,421

Lab Functional Centre 2008/ 2009

2009/ 2010

2010/ 2011

2011/ 2012

2012/ 2013

LAB Combined/Multi Functions (Core Lab) 902,080 891,811 882,180 950,196 1,160,245 LAB Anatomical Pathology 104,862 109,084 114,754 130,866 125,422 LAB Pre/Post Analysis 66,739 68,171 64,446 72,343 98,842 LAB Clinical Microbiology 38,007 33,725 33,055 35,248 35,264

Imaging Exams by Type

Laboratory Procedures by Type


Outpatient Clinic activity at CMH

Ambulatory Functional Centre 2008/ 2009

2009/ 2010

2010/ 2011

2011/ 2012

2012/ 2013

AC Emergency 46,079 46,916 52,814 55,285 53,982 AC Day/Night Care - Oncology 10,111 10,230 9,176 9,612 12,478 Day Surgery Pre and Post Operative Care 10,306 10,813 11,552 10,965 17,445 AC Clinic Surgical 9,607 9,723 9,328 9,331 8,182 AC Clinic Orthopedic 8,493 8,686 9,192 9,568 10,131 AC Clinic Obstetrics 7,303 4,333 3,711 3,852 3,983 AC Clinic Metabolic 2,490 4,274 3,983 3,463 2,893 AC Clinic Mental Health - Acute Psychiatry 4,736 3,315 1,854 1,729 1,762 AC Clinic Pediatric 2,116 2,117 2,008 2,247 2,446 AC Clinic - Medical 211 69 345 669 2,404

Ambulatory Activity and Clinics at Cambridge Memorial Hospital

How well is CMH doing

what it does now?


Clinical efficiency: Limited additional opportunity to shift IP surgical cases to day surgery

Only elective inpatient cases with LOS 3 days or less considered as candidates for conversion from IP to day surgery

CMH already has a very high % of cases as day surgery Benchmarks identify a very small number of additional inpatient cases to shift

to day surgery (and very small number of associated days) based on comparison to performance of large Ontario hospitals

Less than 1 bed to save @ CMH via more aggressive shift to day surgery

Non-Admitted

Qual. Day Surgery

Candidate IP Cases

% Day Surgery

Best Practice

Best Quartile

Best Practice

Best Quartile

Cambridge Memorial Hospital 9,328 789 92% 199 96 286 115 Grand River Hospital 10,523 1,506 87% 418 211 649 298 St. Mary's General, Kitchener 20,174 363 98% 155 80 187 94 Grand Total 40,025 2,658 94% 772 387 1,122 507

Hospital

2012/13 Actual Cases to Shift @ Target

Days to Save @ Target


Clinical efficiency: Some additional opportunity to reduce inpatient lengths of stay

At “best practice” CMH could save 10.4% of inpatient acute (i.e. excluding ALC) medicine days and 10.6% of surgery days

At “best quartile” CMH, the days to save drop to 7.0% for medicine, and 3.4% for surgery

IP Cases

Acute Days

Avg. LOS

Best Practice

Best Quartile

Best Practice

Best Quartile

Cambridge Memorial Hospital 4,256 19,837 4.66 2,070 1,380 10.4% 7.0%Grand River Hospital 5,399 34,388 6.37 3,521 2,462 10.2% 7.2%St. Mary's General, Kitchener 5,365 29,129 5.43 3,824 2,479 13.1% 8.5%Grand Total 15,020 83,354 5.55 9,415 6,321 11.3% 7.6%

Program: Medicine

Hospital2012/13 Actual Activity Days to Save @

Targets% of Total Acute

Days to Save @ Tgt.

IP Cases

Acute Days

Avg. LOS

Best Practice

Best Quartile

Best Practice

Best Quartile

Cambridge Memorial Hospital 1,702 6,961 4.09 736 236 10.6% 3.4%Grand River Hospital 4,446 24,324 5.47 3,081 1,404 12.7% 5.8%St. Mary's General, Kitchener 1,633 13,548 8.30 1,135 1,002 8.4% 7.4%Grand Total 7,781 44,833 5.76 4,952 2,641 11.0% 5.9%

Program: Surgery

Hospital2012/13 Actual Activity Days to Save @

Targets% of Total Acute

Days to Save @ Tgt.


Operating efficiency: opportunity to reduce cost of care

CMH costs are above what is expected for acute and rehabilitation, but below expected for emergency care

Under Health System Funding Reform these high costs will be a problem for both HBAM funding and the ‘Carve – Out’ for QBP funding

Actual HBAM Expected

Actual Over

ExpectedActual HBAM

Expected

Actual Over

ExpectedCambridge Memorial Hospital $5,478 $5,239 105% $4,962 $5,222 95%St. Mary's General, Kitchener $5,035 $5,523 91% $5,815 $5,357 109%Grand River Hospital $5,396 $5,419 100% $6,747 $5,281 128%Guelph General Hospital $5,130 $5,379 95% $5,142 $5,159 100%

Mental Health

Actual HBAM Expected

Actual Over

ExpectedActual HBAM

Expected

Actual Over

ExpectedActual

Cambridge Memorial Hospital $13,374 $12,048 111% $554Grand River Hospital $13,414 $12,207 110% $542 $521 104% $583St. Joseph's HC, Guelph $13,339 $15,184 88% $520 $504 103%

Facility Name

Facility Name

Acute Inpatient and Day Surgery ER

Rehab CCC


Very high percentage of medicine days recorded as ALC days at CMH

26% of CMH medicine days recorded as ALC − Higher than other WW hospitals − But shorter acute ALOS; are patients being designated ALC earlier? − Reducing ALC days will reduce costs, reduce congestion & improve quality of care

Similar rates of referral of medicine patients to home care across WW large community hospitals − Access to home care does not appear to be the issue creating the ALC days at

CMH

Cases Days LOS % ALC

Home - No

Suppt.

Home w/

Suppt.Cases LOS %

ALC Cases LOS % ALC

Cambridge Memorial Hospital 4,256 26,738 6.3 26% 58% 16% 2,457 3.4 3% 691 7.9 15%Grand River Hospital 5,399 42,952 8.0 20% 54% 17% 2,922 4.4 3% 911 9.7 11%St. Mary's General, Kitchener 5,365 34,093 6.4 15% 57% 15% 3,077 4.1 2% 794 9.6 15%Guelph General Hospital 5,457 33,042 6.1 17% 55% 18% 2,975 3.6 2% 962 7.5 11%Grand Total 20,477 136,825 6.7 19% 56% 16% 11,431 3.9 2% 3,358 8.7 13%

Broad Program: Medicine, PCC: (All), Age Group: (All)

Hospital

2012/13 IP Activity % Cases to Disposition

Home - No Suppt. Home - w/ Suppt.


Only 10% of CMH surgical days are recorded as ALC

Only 10% of CMH surgical days are recorded as ALC − Relatively small % of days, but reducing ALC days will help to reduce costs, reduce

congestion and improve quality of care 37% of CMH surgery patients are referred to home care

− Higher than other WW hospitals − Access to home care does not appear to be the issue


Home - No

Suppt.

Home w/

Suppt.Cases LOS %

ALC Cases LOS % ALC

Cambridge Memorial Hospital 1,702 7,734 4.5 10% 54% 37% 912 3.1 1% 624 4.8 2%Grand River Hospital 4,446 27,500 6.2 12% 64% 24% 2,825 3.8 2% 1,083 6.5 6%St. Mary's General, Kitchener 1,633 14,005 8.6 3% 73% 16% 1,189 6.7 0% 259 11.3 3%Guelph General Hospital 3,441 16,479 4.8 10% 63% 23% 2,185 3.0 1% 799 5.7 2%Grand Total 11,222 65,718 5.9 9% 63% 25% 7,111 4.0 1% 2,765 6.3 4%

Broad Program: Surgery, PCC: (All), Age Group: (All)

Hospital




CMH has highest % ALC days (33%) for elderly patient in WW hospitals

CMH has highest % ALC days (33%) for elderly patient in WW hospitals − Reducing ALC days will reduce costs, reduce congestion and improve quality of care

CMH also has highest referral of elderly patients to home care (27%) − Access to home care does not appear to be the issue


Home - No

Suppt.

Home w/

Suppt.Cases LOS %

ALC Cases LOS % ALC

Cambridge Memorial Hospital 1,863 16,095 8.6 33% 34% 27% 628 4.3 5% 495 7.1 15%Grand River Hospital 2,626 27,769 10.6 26% 33% 23% 865 5.9 4% 606 9.3 17%St. Mary's General, Kitchener 2,734 23,105 8.5 15% 42% 22% 1,142 5.6 1% 605 10.4 15%Guelph General Hospital 3,211 24,701 7.7 22% 34% 26% 1,099 4.4 2% 828 7.2 11%Grand Total 10,434 91,670 8.8 23% 36% 24% 3,734 5.1 3% 2,534 8.4 15%

Broad Program: (All), PCC: (All), Age Group: 75+

Hospital




Quality of care: ED length of stay for admitted patients


Quality of care: ED wait times for non-admit CTAS 4 & 5 patients


Quality of care: Wait times for cancer surgery


Quality of care: patient satisfaction

CMH patient satisfaction score are declining. CMH scores now in or approaching worst quartile in

province

Dimensions 2010/11 2011/12 2012/13

Score Percentile Rank



Inpatient Overall Rating of Care 90.6% 29th 92.6% 45th 91.2% 27th ↓

Would You Recommend 63.2% 17th 66.4% 37th 60.2% 17th↓

Emergency Department

Overall Rating of Care 87.2% 70th 87.5% 66th 83.7% 25th↓

Would You Recommend 48.5%

31st 51.3% 40th 45.1% 18th↓

Who is CMH serving?


Patients served by CMH

CMH serves the community of Cambridge − The majority of CMH patients

(84 %) of CMH patients come from 6 postal code areas

− This is the primary catchment area/population for CMH

Based on DAD; does not include mental health patients only recorded in OMHRS

Program CMH IP Cases

% from Selected

FSAsBirthing 3,048 82%Medicine 4,256 90%Surgery 1,702 74%Grand Total 9,006 84%Paediatric 761 83%


Population characteristics: Considering Determinants of Health

“Pampalon Index” based on Statistics Canada census data used to examine socio-economic characteristics of Waterloo population*

“Pampalon Index” creates 5 level measure of each of Material Deprivation and Social Deprivation − Measure of deprivation of socio-economic status discrepancies based on 2006

Census data − Material deprivation based on well-recognized variations in education,

employment and income and, to a lesser degree, single-parent families − Social deprivation is more prevalent with single-parent families, with people living

alone, and with those who are separated, divorced or widowed. − Material and social deprivation have been shown to be related to health status

and use of health services Waterloo population not homogenous with respect to socio-economic

status Rural areas have mix of low and high material deprivation with generally

low levels of social deprivation

* Data not available for Cambridge by itself


Material deprivation

Measure of Material deprivation based on 2006 Census data

Light blue areas have no data

1 Least Deprived2345 Most Deprived

No data available


Social deprivation

Measure of Social deprivation based on 2006 Census data

Light blue areas have no data

1 Least Deprived2345 Most Deprived

How much

does Cambridge community

depend on CMH for care?


Market share/ population dependence on a hospital for care

Percent of hospitalizations of residents is provided by hospital

Inpatient records assigned to “forward sortation areas” (1st 3 characters of postal code)


Population of Cambridge is very dependent on CMH for their hospital care.

Residents of CMH primary catchment area receive 73% of their inpatient hospital care from CMH: − 87% of ED care − 82% of primary inpatient hospital care − 71% of secondary inpatient hospital Care

Only receive 25% of tertiary/quaternary inpatient hospital care from CMH


Percentage of population receiving care at CMH - medicine

Very dependent on CMH for inpatient medicine


Percentage of population receiving care at CMH - general surgery

Less Dependent on CMH for inpatient surgery


Percentage of population receiving care at CMH - orthopaedics

But greater dependence on CMH for orthopaedics

Who else

is providing hospital care for

Cambridge community?


Outflow from communities that are usually dependent on CMH

Are there local residents who are hospitalized for primary/secondary care outside Waterloo Wellington region who might, in the future, access care closer to home?

Examined flow of Cambridge residents for primary/ secondary care outside CMH catchment area (i.e. In the “forward sortation areas” where CMH has high % capture)

High percentages or volumes of outflow may represent opportunity for expanded service in CMH


Hospitals providing care for people who live in CMH community – all levels of care

CMH provides 73% of care

GRH/SMGH provides 11%

Guelph General provides 3%

Most of remainder provided by academic health science centres

Hospital Providing Care for Cambridge Residents

# of Cases

% of Total

Cambridge Memorial Hospital 7,649 73%Grand River Hospital 696 7%St. Mary's General, Kitchener 375 4%Guelph General Hospital 350 3%Hamilton HSC - McMaster 333 3%Hamilton HSC - General 189 2%London HSC - University Hosp 118 1%St. Joseph's HCS, Hamilton 109 1%Hamilton HSC - Henderson 94 1%University Health Network 71 1%

All Others 482 5%


% of primary care hospitalizations of Cambridge residents outside CMH

Programs where Cambridge residents tend to travel to other hospitals for primary level hospital care: − Child and adolescent

psychiatry - 58% outside CMH*

− General surgery – 32% − Neurology – 26% − Nephrology – 25% − Obstetrics – 23% *Note: Adult Psychiatry not available in DAD; only in OMHRS data base

ProgramIP Cases for Cambridge Residents

# @ CMH

# @ Other Hosp.

% @ Other Hosp.

Neonatology 1,343 1,079 264 20%Obstetrics 662 511 151 23%Gastro/Hepatobiliary 617 537 80 13%Pulmonary 574 534 40 7%Cardiology 481 399 82 17%Other Internal Medicine 323 293 30 9%Neurology 246 183 63 26%Non-Acute 219 188 31 14%Endocrinology 181 159 22 12%Urology 132 119 13 10%Psychiatry 125 52 73 58%Other Reasons 120 80 40 33%Orthopaedics 70 65 5 7%Otolaryngology 64 54 10 16%Haematology 63 55 8 13%Nephrology 49 37 12 24%General Surgery 47 32 15 32%Neurosurgery 23 22 1 4%Gynaecology 13 9 4 31%Ophthalmology 9 9 - 0%Grand Total 5,361 4,417 944 18%


Types of case that Cambridge residents get in hospitals other than CMH –primary level cases

10 highest volume primary CMGs for Cambridge residents where >30% of their hospitalizations are not in CMH

Case Mix Group

IP Cases for Cambridge Residents

# @ CMH

# @ Other Hosp.

% @ Other Hosp.

563 Vag Birth w Anaes. w/o Non-Major Interv 238 165 73 31%557 Antepartum Diagnosis treated Medically 84 57 27 32%693-Depressive Episode without ECT 36 6 30 83%038-Neoplasm Central Nervous Sys 31 21 10 32%587-NB/Neo 2000-2499 gm, 35-36 Wks 27 17 10 37%040-Seizure Disorder exc. Stat. Epil. 26 18 8 31%209-Other/Misc Cardiac Disorder 18 8 10 56%484-Symptom/Sign Urinary System 16 10 6 38%687-Stress Reaction/Adjust Disord 15 0 15 100%553 Postpartum Diagnosis treated Medically 15 5 10 67%


% of secondary hospitalizations of Cambridge residents outside CMH

Programs where Cambridge residents tend to travel to other hospitals for secondary level hospital care: − Vascular, thoracic, neuro,

and cardiac surgery − Nephrology 59% − Haematology 56% − Otolaryngology 47% − Urology 34%

ProgramIP Cases for Cambridge Residents

# @ CMH

# @ Other Hosp.

% @ Other Hosp.

Obstetrics 937 748 189 20%General Surgery 570 408 162 28%Orthopaedics 470 365 105 22%Pulmonary 323 257 66 20%Other Internal Medicine 289 240 49 17%Cardiology 289 207 82 28%Neonatology 226 150 76 34%Gynaecology 215 159 56 26%Urology 151 99 52 34%Otolaryngology 116 61 55 47%Haematology 99 44 55 56%Neurology 92 70 22 24%Gastro/Hepatobiliary 87 66 21 24%Non-Acute 86 58 28 33%Vascular Surgery 50 1 49 98%Endocrinology 48 37 11 23%Thoracic Surgery 42 1 41 98%Neurosurgery 34 - 34 100%Nephrology 27 11 16 59%Psychiatry 24 14 10 42%Plastic Surgery 20 8 12 60%Other Reasons 17 6 11 65%Cardiac Surgery 8 - 8 100%Ophthalmology 3 1 2 67%Grand Total 4,223 3,011 1,212 29%


Types of case that Cambridge residents get in hospitals other than CMH – secondary level cases

10 highest volumes for Cambridge residents where >25% of their hospitalizations are not in CMH

Case Mix Group

IP Cases for Cambridge Residents

# @ CMH

# @ Other Hosp.

% @ Other Hosp.

559 Primary Caesarean Section, no induction 183 136 47 26%806-Convalescence 79 57 22 28%228-Complex Hernia Repair 56 18 38 68%193-MI/Shock/Arrest w Coronary Angiogram 51 38 13 25%221-Colostomy/Enterostomy 47 34 13 28%424-Thyr/Parathyr/Thymus Gl Intv 42 18 24 57%463-Partial Excision Prostate OA 41 30 11 27%209-Other/Misc Cardiac Disorder 37 22 15 41%226-Non-Maj Excis/Rep Upp GI,Plnd 33 18 15 45%456-Min Intv Upp Urin Trct Ext/ PO 29 21 8 28%


Other Hospitals providing primary / secondary care for people who live in CMH community –

GRH provides 7%

Guelph General provides 3%

SMGH provides 2%

Most of remainder provided in Hamilton or London

Hospital Providing Care for Cambridge Residents

# of Cases

% of Total

Cambridge Memorial Hospital 7,428 78%Grand River Hospital 643 7%Guelph General Hospital 279 3%Hamilton HSC - McMaster 258 3%St. Mary's General, Kitchener 225 2%Hamilton HSC - General 92 1%London HSC - University Hosp 85 1%St. Joseph's HCS, Hamilton 73 1%Hamilton HSC - Henderson 72 1%Brant CHS - Brantford 39 0%

All Others 390 4%


Most primary/secondary cases for Cambridge residents treated in other hospitals are obstetrics cases

Case Mix GroupCambridge Memorial Hospital

Grand River

Hospital

Guelph General Hospital

Hamilton HSC -

McMaster


Hamilton HSC -

GeneralAll Others Total

Grand Total 7,428 643 279 258 225 92 659 9,584 576-Normal Newborn Sing Vag Deliv 479 64 19 11 - - 27 600 563 Vag Birth w Anaes. w/o Non-Major Interv 165 32 13 11 - - 17 238 562 Vag Birth w Anaes. and Non-Major Interv 237 27 10 13 - - 16 303 577-Normal NB Mult/C-Sect Deliv 151 17 8 12 - - 15 203 601-NB/Neo 2500+, Oth Min Prob 310 21 9 14 - - 6 360 559 Primary Caesarean Section, no induction 137 20 3 21 - - 3 184 565 Vag Birth w/o Anaes w/o Non-Maj Interv 278 21 9 3 - - 5 316 806-Convalescence 101 2 9 2 11 1 13 139 228-Complex Hernia Repair 18 - 3 - 1 - 34 56 560 Caes. Section w uterine scar, no induction 134 12 3 9 - - 10 168 693-Depressive Episode without ECT 10 30 - 1 - - - 41 321-Unilateral Knee Replacement 176 15 2 - - - 12 205 194-MI/Shock/Arrst wo Coronary Angiogram 135 3 - - 24 - 2 164 196 Heart Failure without Coronary Angiogram 175 7 3 - 14 - 4 203 502-Hysterectomy w Non Mal Dx 119 14 3 2 - - 9 147 557 Antepartum Diagnosis treated Medically 57 6 1 15 - - 6 85 320-Unilateral Hip Replacement 82 18 3 - - - 6 109 815-Cancelled Intervention 5 1 1 1 5 4 15 32 209-Other/Misc Cardiac Disorder 30 6 3 1 8 2 5 55 182-Bypass/Extract Vein/Art Limb - - 24 - - - 1 25

Should CMH

try to repatriate

service volumes?

Is the

population adequately served

by CMH et al?


Hospital ED utilization: why is the rate so low for residents of Waterloo Wellington?

0 2,000 4,000 6,000 8,000 10,000

CentralMississauga Halton

Central WestToronto Central

Waterloo WellingtonCentral East

OntarioChamplain

Hamilton Niagara …Erie St. Clair

North Simcoe MuskokaSouth WestSouth EastNorth East

North West

1 - Resusc.

2 - Emergent

3 - Urgent

4 - Semi-Urgent

5 - Non-Urgent

9 - Missing


CMH 2012/13 ED visits by diagnosis group and CTAS

1 - Resusc.

2 - Emerg.

3 - Urgent

4 - Semi-Urgent

5 - Non-Urgent

Un-known Total

Abdominal Pain 1 197 1,768 344 10 - 2,320 Chest Pain 3 698 1,258 144 7 - 2,110 Injuries to Wrist and Hand 2 62 560 1,419 65 - 2,108 Acute Upper Respiratory Infections 2 144 976 811 30 - 1,963 Dorsalgia (incl. Lower Back Pain) - 49 801 397 19 - 1,266 Influenza and Pneumonia 7 202 816 189 1 - 1,215 Use of Health Services for Other Factors - 22 348 701 115 - 1,186 Chemotherapy 1 4 213 849 102 - 1,169 Urinary Tract Infection 2 68 617 427 8 - 1,122 Other Viral Diseases 1 60 608 402 13 - 1,084 Open Wound of Head 1 37 430 568 1 - 1,037 Intestinal Infectious Disease - 67 641 168 3 - 879 Injuries to Ankle and Foot - 7 213 559 22 - 801 Headache - 116 574 82 3 - 775 Syncope/Dizziness 5 95 595 63 4 - 762 Other Injuries To The Head 3 68 427 187 2 - 687 Cellulitis - 16 318 338 8 - 680 Other Arthropathies - 17 273 351 26 - 667 Abnormalities of Breathing 3 81 368 176 2 - 630 Injuries to Knee and Lower Leg 1 13 208 358 10 - 590 All Other Diagnosis Groups 189 4,619 16,539 8,622 713 1 30,683

Total 221 6,642 28,551 17,155 1,164 1 53,734 % Distribution by CTAS 0.4% 12.4% 53.1% 31.9% 2.2% 0.0% 100.0%

Visits by CTAS Level

Diagnosis Group


Age/Gender standardized acute care discharges per 10,000 population

Residents of Waterloo have lowest rate of utilization of inpatient acute care (cases) among peer counties, and 3rd lowest rate in Ontario

Why is rate so low for residents of Waterloo County? Is this because: − population is healthy? − have access to other types of care? − there are barriers to accessing hospital care?

-

100

200

300

400

500

600

700

800

900

1,000

Waterloo Essex Halton Frontenac Middlesex Wellington


Age/Gender standardized acute care inpatient days per 10,000 population

Residents of Waterloo also have the lowest rate of utilization of inpatient acute care (days) among peer counties

-

1,000

2,000

3,000

4,000

5,000

6,000



Age/Gender standardized utilization (Cases) by program cluster category (PCC)

Waterloo resident inpatient utilization is relatively low for: − Cardiology − Gastro/Hepatobiliary − Orthopaedics

Is this because: − Difficulty in accessing

inpatient care? − Greater access to

ambulatory services? − Lower need? − Other?

Waterloo Essex Halton Frontenac Middlesex WellingtonCardiac Surgery 9 10 9 13 9 9 Cardiology 54 77 81 73 62 78 Dental/Oral Surgery 1 3 1 1 2 0 Endocrinology 13 15 14 20 17 14 Gastro/Hepatobiliary 47 61 57 64 61 65 General Surgery 60 66 68 76 67 67 Gynaecology 20 19 15 19 20 23 Haematology 14 16 14 16 15 19 Neonatology 108 101 102 111 105 115 Nephrology 6 8 6 5 8 6 Neurology 29 26 27 29 28 31 Neurosurgery 9 13 9 13 10 9 Non-Acute 20 16 14 11 16 25 Obstetrics 113 113 114 97 104 116 Ophthalmology 1 1 1 1 2 2 Orthopaedics 57 72 61 63 71 65 Other Internal Medicine 46 46 43 45 52 57 Other Reasons 9 12 13 9 17 13 Otolaryngology 15 15 19 11 18 18 Plastic Surgery 2 4 4 4 7 4 Psychiatry 15 9 12 13 11 14 Pulmonary 56 65 54 75 68 71 Thoracic Surgery 4 3 3 5 4 4 Ungroupable 0 0 0 0 0 0 Urology 22 45 31 32 35 30 Vascular Surgery 7 5 5 7 6 7 Total 735 820 779 814 814 865

IP Cases PCC


Low rate of admission of CMH ED patients to inpatient care

Comparison of actual & expected admissions to inpatient care from ED by CTAS for CMH

“Expected” rates calculated for every combination of ED diagnosis, CTAS, and patient age, based on Ontario hospital average admission rate − Transfers to other acute hospitals are counted as admissions

Overall CMH admission rate is lower than expected, but above expected for CTAS 1 and 2

Actual Expected Actual Expected1 221 178 166 80.5% 75.2% 1.07 12 2 6,642 2,095 1,974 31.5% 29.7% 1.06 121 3 28,551 2,928 3,229 10.3% 11.3% 0.91 - 4 17,155 210 262 1.2% 1.5% 0.80 - 5 1,164 11 10 0.9% 0.8% 1.11 1 9 1 - 0 0.0% 19.8% - -

Grand Total 53,734 5,422 5,642 10.1% 10.5% 0.96 -

CTAS Total VisitsAdmissions to Acute

CareAcute Care Admit

RateRatio of Actual to Expected

Excess Admits


Comparison of actual & expected admissions to inpatient care from ED for CMH by age

CMH average rate of admission of ED patients by patient age is above expected only for paediatric patients

Actual Expected Actual Expected00-17 11,188 581 563 5.2% 5.0% 1.03 18 18-49 24,512 1,386 1,479 5.7% 6.0% 0.94 - 50-74 12,808 1,856 1,958 14.5% 15.3% 0.95 - 75+ 5,226 1,599 1,642 30.6% 31.4% 0.97 - Grand Total 53,734 5,422 5,642 10.1% 10.5% 0.96 18

Age Group Total Visits

Admissions to Acute Care

Acute Care Admit Rate

Ratio of Actual to Expected

Excess Admits


Comparison of actual and expected admits to inpatient care from ED for CMH by diagnosis

While overall CMH admission from ED rate is lower than expected, there are excess admissions for selected diagnoses

Actual Expected Actual ExpectedInfluenza and Pneumonia 1,215 304 291 25.0% 24.0% 1.04 13 COPD 505 233 213 46.1% 42.3% 1.09 20 Congestive Heart Failure 258 179 169 69.4% 65.6% 1.06 10 Other Diseases Of Intestines 502 161 157 32.1% 31.2% 1.03 4 Appendicitis 191 145 150 75.9% 78.6% 0.97 - Stroke and Other Cerebrovascular Disease 198 126 149 63.6% 75.2% 0.85 - Poisoning by Drugs/Medicaments/Biolog. Subst. 338 166 136 49.1% 40.1% 1.22 30 Abdominal Pain 2,320 57 131 2.5% 5.7% 0.43 - Depressive Episode 395 145 130 36.7% 33.0% 1.11 15 Ischaemic Heart Diseases 149 72 112 48.3% 75.2% 0.64 - Schizophrenia 181 117 110 64.6% 61.0% 1.06 7 Urinary Tract Infection 1,122 127 110 11.3% 9.8% 1.15 17 Other Endocrine and Metabolic 226 112 109 49.6% 48.4% 1.02 3 Malignant Neoplasm 200 114 108 57.0% 54.2% 1.05 6 Diabetes 296 125 107 42.2% 36.2% 1.17 18 All Other Diagnoses 45,638 3,239 3,458 7.1% 7.6% 0.94 248 Total 53,734 5,422 5,642 10.1% 10.5% 0.96 390

ED Visit Diagnosis Total VisitsAdmissions to Acute

CareAcute Care Admit

RateRatio of Actual to Expected

Excess Admits


Waterloo has 3rd highest rate of ALC days among peer counties

− Age/Gender standardized ALC days per 10,000 population − Age/gender standardized to take into account differences in demographics of

populations across counties − May be impacted by variation in supply of post-acute services across counties − Is there a difficulty in accessing post-acute care in Waterloo?

-

100

200

300

400

500

600

700

800

900


Is there a need to further improve primary care in

Cambridge? Would this further reduce need for /

use of hospital care?


2012/13 Waterloo hospital ED visits by CTAS

34% of ED visits at CMH are CTAS 4/5 Is large number of CTAS 4/5 visits because of

difficulty in accessing primary care?

1 - Resusc.

2 - Emerg.

3 - Urgent

4 - Semi-Urgent

5 - Non-Urgent

9 - Other Total % CTAS

4/5Cambridge Memorial Hospital 221 6,642 28,551 17,155 1,164 1 53,734 34%Grand River Hospital 270 12,646 31,978 14,190 573 - 59,657 25%St. Mary's General, Kitchener 149 6,390 25,677 13,311 513 - 46,040 30%Grand Total 640 25,678 86,206 44,656 2,250 1 159,431 29%

HospitalED Visits by CTAS Level


ED visits for family practice sensitive conditions at CMH

Family Practice Sensitive Conditions: − Percent of ED or UCC

visits for health conditions that may be appropriately managed at a family physician’s office

High compared to other high volume EDs in urban settings

Higher than provincial average

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

St. Joseph's HC, TorontoCambridge Memorial Hospital

Guelph General HospitalLondon HSC - Victoria Hosp

Royal Victoria Hospital BarrieSouthlake Regional HC

St. Mary's General, KitchenerSt. Michael's HospitalGrand River Hospital

Hotel-Dieu Grace, WindsorMount Sinai Hospital

Lakeridge Hlth -OshawaRouge Valley HS - Centenary

North York GeneralTrillium Health - CVHToronto East General

William Osler HC - CivicScarb. Hosp. - General

Windsor Reg. - MetropolitanOttawa Hospital - General

University Health - WesternHamilton HSC - General

Trillium Health - MissisaugaSt. Joseph's HCS, HamiltonHamilton HSC - HendersonKingston General Hospital

Ottawa Hospital - CivicLondon HSC - University Hosp

University Health -GeneralNiagara HS - St. Cath. Gen

Sunnybrook HSCProvincial Average


But, ED data suggests high % of CMH patients have access to primary care

Each hospital indicates whether ED patients have regular access to primary care

Only 6.4% of CMH ED patients do not have regular access to primary care

Hospital ED Visits% No Prim. Care

Grand River Hospital Corp - Waterloo Site 59,705 22.0%Cambridge Memorial Hospital 53,784 6.4%St. Mary's General Hospital 46,094 9.6%

Grand Total 159,583 13.2%


CMH ED patients without access to primary care by CTAS and Age

CMH CTAS 5 (non-urgent) and CTAS 1 (resuscitation) ED patients most likely to have no regular access to primary care

CMH ED patients aged 18 to 49 least likely to have regular access to primary care; Almost 99% of CMH elderly ED patients have regular access to primary care

CTAS ED Visits% No Prim. Care

1 256 9.9%2 6,650 5.5%3 28,558 5.6%4 17,155 7.7%5 1,164 14.4%9 1 0.0%


Patient Age ED Visits% No Prim. Care

00-17 11,191 3.4%18-49 24,519 10.1%50-74 12,827 4.1%75+ 5,247 1.2%



% of Waterloo ED patients without access to primary care

Rural Waterloo residents more likely to have regular access to primary care

Cambridge residents more likely than K-W residents to be reported as having regular access to primary care

Legend

0-6%6-9%9-12%12-17%>17%


CMH ED patient least and most likely to have access to primary care by diagnosis

CMH ED patients with mental health diagnoses least likely to have access to primary care

Patients with common chronic diseases (e.g. COPD, diabetes) do have access

Diagnosis Group ED Visits% No Prim. Care

Psychoactive Substance Use 478 16.6%Other Neurotic, Stress-Related & Somatoform Disorder 397 12.8%Other Dermatologic Conditions 354 10.8%Diseases Of Oral Cavity, Salivary Glands And Jaws 330 12.5%Injuries to Shoulder and Upper Arm 231 10.8%Attention to Surgical Dressings & Sutures 214 12.7%Dis. Of Pulp & Periapical Tissues 194 14.9%Schizophrenia 181 12.2%Gastro-Oesophageal Reflux Disease 151 10.6%Other Mood [Affective] Disorders 116 12.3%Prescription Repeat 115 36.6%Local Swelling Mass & Lump of Skin 98 13.5%Fracture of Skull and Facial Bones 97 11.5%Gastritis and Duodenitis 85 11.9%Disorders Of Eyeliod, Lacrimal System And Orbit 82 12.3%

Diagnosis Group ED Visits% No Prim. Care

Chest Pain 2,111 5.0%Influenza and Pneumonia 1,215 4.6%Chemotherapy 1,169 4.9%Urinary Tract Infection 1,122 4.6%Syncope/Dizziness 762 4.2%Calculus/Renal Colic 517 4.3%Other Acute Lower Respiratory Infections 511 4.9%COPD 506 2.6%Other Childbirth 444 4.5%Fever 441 3.4%Complications of Surgical & Medical Care 432 2.3%Closed Fracture - Elbow/Forearm 420 4.3%Cholelithiasis 351 4.0%Constipation 323 4.0%Diabetes 296 4.4%


Definition: Ambulatory care sensitive conditions (ACSCs)

ACSCs are conditions that likely would not require acute inpatient care if they were well managed/cared for in the community.

In this analysis, the following conditions are considered to be ACSCs − Grand mal status and other epileptic convulsions − Chronic obstructive pulmonary diseases (COPD) − Asthma − Diabetes − Heart failure and pulmonary edema – excludes those where

there was a cardiac procedure − Hypertension- excludes those where there was a cardiac

procedure − Angina- excludes those where there was a cardiac procedure


Waterloo has relatively low rate of IP admits for Ambulatory Care Sensitive Conditions

Considering IP Admits for Ambulatory Care Sensitive Conditions per 10,000 pop’n − Waterloo is 2nd lowest among peer communities − Suggests that residents of Waterloo County with Chronic Disease are receiving relatively

good primary care and chronic disease management.

Should CMH do something to further

reduce need for / use of ED and/or

inpatient care in its community?

There will be a growing need for hospital care into

the future


Projected change in Waterloo population to 2019 and 2024

Ministry of Finance population projections show 7.1% increase in Waterloo total population from 2014 to 2019, and 14.7% from 2014 to 2024

Graphs below show change in population will be greater for elderly

-10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

00-0

405

-09

10-1

415

-19

20-2

425

-29

30-3

435

-39

40-4

445

-49

50-5

455

-59

60-6

465

-69

70-7

475

-79

80-8

485

-89

90+

Female

Male

-10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

00-0

405

-09

10-1

415

-19

20-2

425

-29

30-3

435

-39

40-4

445

-49

50-5

455

-59

60-6

465

-69

70-7

475

-79

80-8

485

-89

90+

Female

Male

2014 to 2019 2014 to 2024


Aging will have dramatic impact on demand for hospital services – inpatient cases


Aging will have even more dramatic impact on demand for inpatient days


Projected growth for CMH by Broad Groups

If no changes except size and age of population served, projected % increase of 29% for inpatient cases, 39% for inpatient days, and 40% for acute beds (i.e. excluding adult mental health and rehab)

Approximately 50 more beds would be required to accommodate the projected change in population

IP Cases IP Days

IP Beds/ Bass.

IP Cases IP Days Beds/

Bass.IP

CasesIP

DaysBeds/ Bass.

Birthing 3,048 7,057 26 3,461 8,026 29 14% 14% 14%Medicine (incl. Paeds, ICU) 4,256 26,738 71 5,898 38,934 107 39% 46% 50%Mental Health (Adol.) 81 502 2 100 647 2 23% 29% 29%Surgery 1,702 7,734 28 2,273 10,831 39 34% 40% 40%Grand Total 9,087 42,031 126 11,732 58,438 177 29% 39% 40%

Program Cluster

2012/13 Actual 2024 Projection % Growth from 12/13 to 2024


Projected growth for CMH by programs

Greatest increases for: − Cardiology − Haematology − Pulmonary − Neurology − Urology

Smallest increases for: − Obstetrics − Neonatology − Gynaecology − Plastic Surgery

IP Cases

IP Days

IP Cases IP Days IP

Cases IP Days IP Cases

IP Days

Pulmonary 885 5,207 1,071 6,422 1,245 7,614 41% 46%Other Internal Medicine 620 5,079 731 6,186 830 7,244 34% 43%Cardiology 688 4,093 853 5,162 1,001 6,210 46% 52%General Surgery 561 3,312 656 4,009 734 4,632 31% 40%Gastro/Hepatobiliary 684 3,286 803 3,967 906 4,563 32% 39%Neonatology 1,517 3,889 1,630 4,174 1,758 4,501 16% 16%Neurology 313 2,861 380 3,581 438 4,204 40% 47%Orthopaedics 690 2,870 846 3,571 963 4,117 40% 43%Obstetrics 1,531 3,168 1,657 3,426 1,703 3,525 11% 11%Non-Acute 274 1,799 335 2,242 387 2,635 41% 46%Urology 287 1,173 350 1,462 406 1,739 41% 48%Other Reasons 97 1,004 117 1,240 136 1,478 41% 47%Endocrinology 225 996 264 1,201 301 1,402 34% 41%Haematology 126 908 154 1,164 180 1,389 43% 53%Psychiatry 81 502 92 586 100 647 23% 29%Otolaryngology 152 474 174 560 196 639 29% 35%Nephrology 55 415 70 526 82 624 49% 50%Gynaecology 238 535 259 580 280 624 17% 17%Neurosurgery 33 208 41 278 48 343 45% 65%Vascular Surgery 2 95 2 102 3 120 33% 26%Thoracic Surgery 2 74 2 89 2 89 17% 21%Plastic Surgery 13 54 14 57 15 61 18% 13%Ophthalmology 10 25 12 30 14 35 40% 39%Dental/Oral Surgery 3 4 3 4 3 4 -3% -3%Grand Total 9,087 42,031 10,517 50,618 11,732 58,438 29% 39%

2012/13 Actual 2019 Projection 2024 Projection % Growth from 12/13 to 2024

Program Cluster


But this growth is similar to rest of province

Other communities are projected to also have large increases in population (particularly in the Greater Toronto Area and Ottawa)

1.1%

7.3%

9.2%

11.8%

12.7%

13.6%

17.0%

17.8%

20.1%

20.2%

20.2%

23.3%

30.3%

Essex

Niagara

Hamilton

Wellington

Toronto

Middlesex

Simcoe

Waterloo

Durham

Ottawa

Peel

York

Halton

Projected % Change in Population from 2012 to 2024

2.0 The context in which CMH operates

91


Ontario’s Action Plan (2012): provincial priorities identified

“Obsessively Patient

Centred”

Keeping Ontario Healthy •Childhood Obesity Strategy •Smoke Free Ontario •Online Cancer Risk Profile and Expanded Screening

Access and Links to Family Health Care • At the Centre of our System •Faster Access • House Calls •Integration of Family Health Care

•Quality in Family Health Care

Right Care, Right Time, Right Place: • High Quality •Timely and Proactive •Close to Home •Seniors Strategy •Procedures in the Community

•Local Integration Reform •Funding Reform


WW LHIN priorities identified in their health services plan (2013-2016)

Quality of Care

Co’ord & Integration

Access

Focus on Best Practices: -Tx of stroke patients on designated stroke units - Creation of regional programs (e.g. success of regional cardiac and cancer care programs

Focus on: -High system users - Individuals with chronic conditions

Focus on: - Avoidable ED visits - Ambulatory care sensitive conditions -Integration and Coordination of primary care - 30 day readmissions


Health Quality Ontario’s strategic roadmap (2012)

A healthcare system that is sustainable, improves continually and uses evidence to optimize population

health and provide excellent care for all Ontarians Common Quality Agenda • Establish

priorities, goals and targets;

• Mobilize leadership around a common agenda

Evidence and Knowledge • Leverage

evidence and knowledge to provide quality care and improve health;

• Align funding with quality

Broker Improvement • Develop tools &

support to drive evidence based practice

• Develop QI capacity in system

Catalyze Spread • Guide, support

and collaborate to spread knowledge

• Embed best practices into standards

Evaluate Progress • Accountability

through health system monitoring, measurement and reporting


Waterloo region hospitals

CMH, SMGH, GRH have: Established Collaborative Council to do joint planning,

pursue clinical integration opportunities Committed to identifying a vision for shared decision

making and planning for the region…moving towards shared governance

Identified engagement of physician as critical success factor for integration

Identified support structures for integration (IT, back office, etc) and new delivery models (ambulatory clinics) as clinical integration priorities that should be evaluated

And, CMH is building a new hospital!


Perspectives of key stakeholders about the current health care context

Recognized need to continue to find efficiencies at CMH, and to organize care in new ways, including regionally (with other hospitals) and with other parts of the continuum of care

May need to acknowledge / embrace integration as deliberate strategy

But results of election may

change everything!

3.0 Considering future role of CMH

98

What does

all this mean for our

future?


Strategic issues for CMH

Need to prepare for growth in demand − May be able to partner with primary care to better manage chronic disease in community; avoid admissions

and readmissions − May be able to partner with primary care to reduce reliance on ED − Need to develop approaches to reduce ALC days

Need to prepare for HSFR − CMH services are relatively expensive; high costs put CMH is at risk with advent of HBAM and QBP funding − Need to improve operating and clinical efficiency; need to reduce costs

CMH is a Primary/Secondary Care hospital − Is this the appropriate continuing role for CMH − Cambridge community is well served for primary and secondary hospital care. But many services being

provided by other hospitals. − Should CMH focus on repatriating some of these services

CMH provides relatively few Tertiary/Quaternary services − Should CMH consider developing these types of services − Community currently has good access to these services

Is integration an opportunity or a threat − Integration of administrative and support services for economies and/or qualities of scale − Integration of clinical services for qualities of scale; improved access for community

Patient satisfaction is declining − Will this be a problem for funding raising for future capital requirement − Will this be a problem in maintaining/replenishing health professionals? − Will this be a problem for gaining support for program development/expansion

What is desired future role

for CMH?

What should

focus for future

development be?

4.0 Summary of stakeholder feedback

103


Stakeholder engagement

To inform the strategic planning process, key internal and external stakeholders were interviewed about the following: − Strategic intent − Organizational capabilities/challenges (leadership, culture,

work organizations & processes, capabilities, rewards, meeting patient needs)

− Unmet health needs − Mitigating demand for services − Future state of hospital/system − Clinical opportunities − Decision making criteria

The following is a summary of the key themes collected from the stakeholder interviews.


Key messages from stakeholders

Strong senior leadership has made a difference at CMH in last several years

Opportunity to promote stronger leadership from medical staff and mid-level leaders

Culture and morale may have suffered as result of attention to “value and affordability” direction in last strategic cycle. There is a need to attend to supporting people to deliver exceptional care

Multiple unmet needs both within hospital and community were identified

Concern over future of CMH − Concern over financial viability of some programs under new funding models − Debate over maintaining community hospital role or adding /developing a niche

clinical service − Multiple potential clinical niches/centres of excellence have been identified


Strategic intent

Senior team has done excellent job of leading initiatives to ensuring strategy is in place and people are aware of the strategy. Very good progress made in last 5 years. Still in early phases organizationally.

Generally the strategic directions (“3 pillars”) are well understood. People are aware of the “WIGs”.

Strategic directions/priorities are more meaningful at administrative leadership level than at line staff or medical staff level in guiding every day activity and decision making − Maybe not as detailed or “meaty” as it needs to be to really guide day to day actions − Perception that medical staff at organizational level not always consistent in living M,V,V − Front line and mid-level managers feel efforts have been biased toward value and

affordability pillar There is agreement that the current strategic pillars are relevant. Opportunity

to discuss the need to: − change the priority areas under each pillar during this planning cycle − always have quality as a strategic pillar − place less emphasis on Value and Affordability (because people are already “stretched”)

and more emphasis on supporting people to deliver excellent care in this cycle − consider a bigger focus on the patient experience − consider new directions, such as Innovation, Integration, Clinical Focus, Ensuring Access


Organizational assessment

Leadership Strong leadership from senior team has resulted in the

organization achieving “real improvements in the last 5 years”

Continue to develop and grow capacity in mid-level leaders (managers, directors) throughout the organization

Opportunities to improve medical/clinical leadership and engagement. Need a stronger medical voice: − Rely primarily on Chief of Staff − more than 1 physician representative/champion may be needed on

senior team − consider a program management structure − integration agenda needs to be clinically led

Greater “courage” is needed at all levels. Hospital can be reactive, predictable, cautious.



Culture People are committed to this organization and want to serve our

community. Many staff have been here a long time, and this might contribute to a

sense that the organization can be “stuck in an old mindset” at times. Organizationally, change is hard. Sometimes people feel like there is

much talk but little action. “South of the 401” “Woe is me” mindset. We want to be different and are fearful of “losing” services to other

hospitals. We have a desire to be known for something. We like “firefighting”. We are happiest and most effective when we

are in crisis mode. Concern that ongoing sense of “batten down the hatches” and “making

ends meet” has had a detrimental impact on staff morale and commitment.

Interest was expressed in establishing a metric to assess culture.



Organization of work We have tendency to work in silos: clinical vs.

corporate, medical vs. other. We need a way to think across the patient

journey.



Processes to support work Big gains in supporting processes in the last several years.

Opportunities still exist. Some staff feel that leadership has only been interested in efficiencies,

and haven’t recognize the impact of cuts on remaining staff. Staff feel “piled on” and that it is hard to do their jobs well given the many “ripple effects” of cuts and changes.

Hospital is building clinical supports. Still need for better clinical resource management and ways of allocating patient resources.

IT infrastructure/support is an ongoing challenge; lack of capacity in decision support results in difficulty accessing timely information.

Physicians could be more involved in identifying opportunities in work processes and efficiencies. Some indicate concern that physicians are not overly willing to engage.



Capacity of people to do their jobs Continued leadership competency development for mid-

level leaders is important. Turn over of hospitalists is a challenge; need to evolve to

first generation hospitalist model to improve continuity of care.

Would like to build a culture of accountability for individual performance excellence in line with corporate strategy.

Hospital does a lot of “rapid change cycles” and has many projects on the go. Too much rapid change becomes unhealthy, and contributes to a unpredictable and unfocused work environment for people.


Organizational Assessment

Rewards and recognition Almost universal acknowledgement that

significant efforts have been made to formally recognize and reward good performance in this organization.

On a day to day basis, the sense is that staff is not shown sufficient respect and the “little things” become annoyances.



Ability to meet needs of our patients Patients generally get good care when they come to

CMH Low NRC Picker scores for recommending this

hospital suggest that front line staff are under-resourced and have difficulty meeting patient needs on units.

Size of our hospital is a constraint for many programs. We have less capacity than other hospitals in the region to work on systems change.

There may be some services that patients currently get sent out for the could be access here (e.g. neurology, specialized urology, dialysis).


Unmet needs identified

Concern that there is a "bleed" of non-tertiary cases to GRH - need to do a better job of meeting local needs

Concern over losing general surgery, hips and knees Need to move acuity “up” in organization

− are we doing too much chronic care rather than an acute cute? − Is there a need for more low level tertiary to remain in community?

Need better connections with primary care Need better preventative care for our community Mental health and addiction services are lacking in our community Aging patients with behavioural issues are becoming an increased challenge

for us to care for (particularly on medicine units) Dialysis is available in Guelph; could it be provided at CMH? High musculoskeletal and neuro DI consults suggest growing need Non-hospital resources for chronically ventilated patients are needed in our

area We lack general internists Neurology/neurosurgery is not available locally More dieticians and social workers are needed at CMH


Mitigating future demand for hospital services

We still have efficiencies to find We need better IT resources to support decision

making about the services that we provide We need mechanisms to allow us to work more

effectively with our partners and other hospitals in the region. Need to eliminate “politicking” and “horse trading” that occurs presently in the region to ensure needs of our population are really being met.

CCAC needs more resources to increase its capacity to manage patients in the community

Have urged LHIN to be bold; sense is that so far it has not been.


Clinical changes predicted in next 5 to 10 years

Shift more services from hospital to ambulatory or private clinics

Mobile communications technologies will allow people to do more for themselves

Will possibly see less routine maternal care in hospital, as a move toward different models increases

Focus on improved management of high end/high cost users of the system

Focus on clinical standardization, reducing practice variation

More interdisciplinary models (NPs, PAs, physician alternatives, advanced practice allied health)


Regional changes predicted in next 5 to 10 years

Hospitals and providers will work together as a region to ensure necessary services are available in Waterloo region

LHIN wide back office integration that has been spoken about for years needs to happen

Could see regional centres in orthopedics, eye care and/or stroke

Need to include integration (clinical and otherwise) as part of strategy to ensure we are committed and it is achieved


Strategic partnerships in next 5 to 10 years

Predict a move to shared leadership and/or governance in the region. For example, CEO and CNE at Guelph hospital are retiring…this may be an opportunity

Need for rebranding area hospitals as a single system for the region

Further integration of DI services in the region Hospital and family docs will work together and

access new structures (such as step down clinics) so that family docs are supported to handle more complex patients discharged earlier from hospital


Opportunity to establish niche clinical role?

Primary role should be to continue to be a good community hospital

Some feel that a “raison d'être” is needed beyond this However, many feel that strategy should focus on

building strength as acute community hospital and strengthening connections with family physicians in community

Focus should be on building core set of services needed in a community hospital

Sense that the Board has not listened to suggestions of physicians and continues to seek a “niche”


Areas for clinical focus

If a “niche” is needed, the following were suggested as potential centres of excellence: Full range of team capability for obstetrics. Could work on improving perception in community to

reduce loss of market share - opportunity to focus on the birthing experience and involvement of family

Focus on women's health with specialty gyne offerings not available elsewhere in region Have capacity to provide plastics, specifically hands and breast reconstruction Opportunity to provide continuum of service offerings for Musculoskeletal

− nice opportunity to brand − include OP rehab for growing hand surgery − Access to acute/urgent case time for fractured hips

Opportunity to build DI and cardiac diagnostics Urology demand growing; opportunity to recruit more surgical skills in urology; interdisciplinary

cancer rounds sets basis to develop centre of excellence ERCP - would it be cheaper to do at CMH than the costs of sending out Pediatrics is a small program, seeing seasonal increases in occupancy Nov-March and the

community growing with young families. Pediatrician shave no problem with coverage or acute consults and are willing to support fundraising/foundation. Could build a focus on urgent pediatric service in conjunction with inpatient service and provide pediatric friendly environment and skill sets not available in ED

Moving to a closed ICU will allow for intensivist to deliver Critical Care


Criteria that should be used for decision making

The following should be used to guide decisions about clinical service for the future Will it help better serve the needs of our population? Will it improve access (decrease wait times, referral times,

meet guidelines)? Does it provide for what we are not serving now –

opportunity to repatriate? Does it create a critical mass to ensure sustainability and

quality Is it an appropriate clinical fit with existing programs? Does it support clinical excellence in a program(s) that can

be marketed by foundation? There should be a commitment to teaching only if it fits Does the LHIN support it?


Other themes from stakeholders

Innovation − We tend to follow instead of lead. We could be

recognized as an innovative leader in providing community care

Our new hospital − We have space already designated and are increasing

capacity. This should factor into planning. Teaching/academic role

− We could strengthen our academic mandate and train early physician learners (non-specialized).

− Physicians are not in full support of this and not all want a teaching role.

Cambridge Memorial Hospital Appendix B Environmental Scan · Cambridge Memorial Hospital Appendix B...

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