June 22, 2011 Michael Barrett, CEO South West Local Health Integration Network 201 Queens Avenue,

Suite 700 London, ON N6A 1J1

Dear Mr. Barrett: Attached please find my review for the London Emergency Departments and Urgent Care Centre. Thank you for the opportunity to better understand the strengths and challenges facing the LHIN and specifically London. The professionalism and candor which we received from all organizations and individuals was exemplary. I would especially like to thank Mr. Mark Brintnell for his thoughtful guidance and knowledge of local issues and overall support. I would also like to sincerely thank my colleague at St. Josephs Health System, Mr. Brian Guest, without whom this report would not have been possible. Should you, your Board or hospital partners have any questions or concerns, I would be only too happy to chat. In closing, I am confident with the implementation of these recommendations, all drawn from local intelligence, the South West LHINs Urgent and Emergent care system will find greater stability and enhanced patient and provider satisfaction. Sincerely,

Dr. Kevin Smith President and CEO St. Joseph's Health System

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External Review of London Emergency Departments and Urgent Care Centre

JUNE, 2011

Background The South West Local Health Integration Network (LHIN) instituted an external review of the St. Josephs Health Care London and London Health Sciences Centre Emergency Departments as a result of a challenge to clinical coverage in Urgent Care. On May 24th, 2011 a series of meetings were held in London with representatives of the Board, Executive Management Teams and Medical Leadership of St. Josephs Health Care London (SJHC) and London Health Sciences Centre (LHSC) as well as the South West LHIN. On June 6, 2011 meetings were held at SJHC and the University and Victoria campuses of LHSC with both the nursing and physician staff who work in the Urgent Care Centre (UCC) and Emergency Departments (ED). In addition, we were fortunate to receive numerous emails from staff who were unable to meet with us during our on-site meetings. Issue While the inability to staff the UCC with qualified ED physician support over the past year has resulted in a gradual erosion of hours of service to the community and most recently the plan to close the UCC for both weekend days commencing in June 2011, the underlying pathology appears to be related to flow issues in the ED. As a result of the inability to offer what physicians and nurses perceive to be high-quality clinical care, the number of those choosing to practice as full time ED physicians has declined and the capacity to cover additional shifts as well as UCC coverage eroded. Though much is being done to address flow issues by both hospital corporations, the sooner planned bed openings might be realized and expanded capacity for Long Term Care created, the more likely the hospitals will be successful in recruiting an adequate complement of physicians to ensure full coverage of all sites. While this review has focused on the London hospitals, the issue of access to urgent and emergent care must increasingly be viewed across the entire LHIN and consideration of how limited human resources may most effectively be deployed to serve the broader population of the South West LHIN.

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Observations It is challenging to arrive at definitive conclusions based on two extended site visits but due to the urgency of this review the following observations form the basis for the recommendations in this report: All parties are committed to finding a solution based on the best interests of the community; There is a very strong and supportive patient-focused bond between the UCC/ED nursing, allied health professionals and physician staff; There is a divergent opinion as to the relevance of urgent care by some physicians. As urgent care serves approximately 50,000 patient visits a year, the possibility of the two busy emergency rooms absorbing even a modest percentage of these visits and improving quality of care and timely access to care is unlikely. The community would be well served by the LHIN and hospital boards making clear the full support for the continuum of urgent and emergent care as soon as possible (copies of statistical profiles of the EDs and UCC are attached and provide context to this review); It is our understanding from SJHC administration and physician leads that in excess of 80% of previously open shifts in the UCC have been assigned and all days have at least one physician confirmed and available. This coupled with the recruitment of, and successful deployment of nurse practitioners gives us confidence that services (7 days/week) will be uninterrupted over the summer months. However these short term solutions will not alleviate ongoing coverage challenges unless the larger systemic flow issues and quality of work life are appropriately addressed and recruitment needs fulfilled; The two separate and distinct payment schemes for ED physicians- Alternate Funding Arrangement (AFA) at LHSC and Fee for Service at the SJHC UCC contributes to the problem in that work is not equally valued. It was noted that other departments (e.g. anaesthesia) have put in place city wide payment schemes in order to assure that all necessary work is appropriately valued regardless of site*; Hospital top-ups to ensure UCC coverage are unsustainable in the current model*; Lack of clarity in administrative management responsibilities are perceived by many individuals within the organizations, perhaps not surprisingly as a number of changes have recently occurred; The ED physician staffing for the UCC was significantly impacted by the recent addition of a total of thirty-two (32) additional monthly shifts awarded to the two LHSC EDs. While a provincial issue, as a broader policy change the MOHLTC should consider additional shifts be funded when appropriate recruitment is in place and in a phased model to ensure that destabilization of the regional system does not occur*;

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Observations (cont.) The UCC coverage issue was noted consistently as but one symptom of overall frustration and discontent by the ED physician group with their quality of work life. Long wait times in the department, shortage of beds for transfer to an in-patient unit , frustration of patients being seen, excessive coverage requirements for working unsociable hours (evenings and weekends), perceived lack of engagement in decision making , etc. were felt to have a greater impact on the current situation. To some degree the current staffing challenges may be as a result of a lack of perceived progress resulting in a line in the sand around continued coverage; LHSC has plans to open 101 additional inpatient beds during the period from November 2010 to December 2011. This should have a significant impact on an improved patient flow in the EDs; In addition to providing urgent care services, the UCC also provides critical access and back up support to SJHC acute care services. This unique role makes apples to apples comparison to stand alone UCCs difficult; There remains varied opinion around the impact of Health Force Ontario and its remuneration rates in nearby communities. The perception is that one can earn more money and do less work- or at a minimum, lower acuity work- and this contributes to the staffing challenges in London*; The reaction to an increased role of specially trained nurse practitioners in UCC and EDs was mixed and the impact on income for UCC physicians noted*; As in every review this reviewer has undertaken, there was consistent concern expressed for the perceived lack of communication and proactive decision making to address patient flow and quality of work life concerns. There was a lack in consistency in how front-line staff perceive they could and should interact with administration; It is our understanding that two physician entities continue to exist in London. The Urgent Care associates, which is made up of a smaller subset of physicians who were very involved in the development of the UCC, and the larger entity of the Emergency Physician Associates, which we understand includes all physicians working in EDs or UCC. Going forward it would be useful to clarify the purpose and need for both entities or if appropriate consolidate into a single physician organization A structural issue which prevents funding from following the patient is especially evident when exploring physician replacement. For example, should nurse practitioners take on work previously done by MDs there is no funding source accessible by the hospital, or capacity to access resources from the physician envelope. In the upcoming MOHLTC/OMA negotiations it is our hope this challenge will be considered*.
*Indicates broader provincial issues which should be considered by the MOHLTC

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RECOMMENDATIONS Recommendations A) The LHIN consider a UCC/ED ad hoc task force to examine the issues across the LHIN and encourage a human resource plan to appropriately address the needs of the broader population. This should include consideration of optimal practices between secondary and tertiary hospitals to maximize flow and coverage i.e. repatriation. B) In addition to the reports recommendations, the implementation of recommendations will be monitored and a follow-up external evaluation will be undertaken in 6 and 12 months. C) In London a city wide implementation group be formed immediately to ensure rapid execution of the following recommendations; Access Recommendations 1. Patient flow from the ED to inpatient units at LHSC is the key to appropriate patient care and coverage at both the UCC and ED in London. Any policy that negatively impacts on ER flow (e.g. No Cancelled Surgery) should be reconsidered such that vital ER services are not threatened. Thresholds to effect scheduled activity should be clear and consistently applied. 2. Additional bed capacity at LHSC must be opened to aid in moving patients out of the ED expeditiously. A total of 107 beds are to be opened by the end of the calendar year. There is additional Long Term Care capacity also scheduled for the LHIN and we encourage rapid deployment of this resource. In addition, the capacity of LHIN partner hospitals to deal with higher levels of acuity and morbidity in local communities impacts the London EDs. Ensuring optimal performance of these hospitals will contribute to improving the situation in London. 3. In the longer term, and subject to an overall review of the role of the UCC in providing service to the community, stable hours of operation by UCC should be targeted as 0800-2000 Monday through Friday and 0800-1800 on weekends and holidays. This should be reexamined should our recommendation of a primary/urgent care review be endorsed and implemented in the broader context of all services and their hours of operation. Should patient volumes overwhelm the UCC a process should be put in place for additional physician coverage at such times. It is recognized that this will not be possible until full staffing is achieved. Responsibility LHIN Time Frame Commence immediately; ongoing

LHIN

Commence immediately; report in 6 months Commence immediately; ongoing

LHSC/SJHC

LHSC

September 2011

LHIN/LHSC/MOHLTC

October 2011

SJHC/LHSC

October 2011

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Recommendations Access Recommendations Continued 4. To address the flow related challenges, and improve the ER/ALC issues, in addition to the new capacity being created at LHSC and via long term care in the community, it is essential that an ambitious Home First Program be concurrently implemented. This would see the CCAC and LHSC partner in minimizing potentially avoidable admissions and ensuring rapid deployment of home based services. Successful programs have been implemented in Hamilton/Niagara/Haldimand/Brant, Mississauga-Halton and Toronto Central LHINs. Coverage Recommendations 5. Working with the MOHLTC, pursue a remuneration model for all sites using the AFA template and consider augmenting with volume tracking for UCC; current hospital top-up of UCC coverage is not sustainable and a new approach must be determined. 6. Ensure adequate infrastructure is in place to pursue recruitment of approximately five full-time equivalent ED physicians with updates provided to the Board of the hospitals at each meeting. 7. In an effort to maximize recruitment success, permit limited recruitment of individuals who choose to work exclusively in ED or UCC, with the majority working in both settings. 8. Specialized ER nurse practitioners have been recruited and deployed at the UCC in response to the current ED physician gaps in coverage. In the future, and as appropriate, considerations should be given to recruit nurse practitioners and physician assistants to LHSC EDs to support flow and create a comprehensive multidisciplinary health team. 9. Resolution as to the role of the UCC physician for Code Blues at SJHC should be realized. The two-tiered model under development should be pursued. This would see the first response by the non-physician members of the team and if required the UCC physician will be requested to attend, or if possible the patient brought to UCC. This should not be perceived by the most responsible physician in any way as diminishing his or her role and responsibility in the care of this patient and they should expect rapid transfer of any patient post Code back to their care as appropriate.

Responsibility LHSC/CCAC

Time Frame December 2011

LHIN/MOHLTC/SJHC

September 2011

LHSC/SJHC

Immediate

LHSC/SJHC

Immediate

LHSC/SJHC/LHIN/ MOHLTC

UCC Immediate LHSC ASAP

SJHC

July 2011

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Communication Recommendations 10. Communications planning is an essential part of addressing stakeholders concerns and confusion. Renewed communications plans for internal and public audiences should be finalized by the Hospitals and LHIN. Such plans should ensure enhanced mechanisms for two-way communications to ensure questions or concerns can be openly addressed. This is especially so for those colleagues who comprise the care teams in UCC and EDs, where social media and web based communications can prove very effective. Continued public education as to the appropriate problems and conditions for presentation to UCC or an ED must be ongoing, and a shared vision by the Boards for the continuum of care, including UCC and ED be part of that communications plan. 11. Ensure clarity with respect to the ED Associates and the UCC Associates, such that all physicians current and future understand the relationship and structure. 12. With the multiple changes in leadership across the city, there is some perception among the staff and physicians interviewed that there is increasing inconsistency between the hospitals. It is incumbent on the Boards to ensure that while two corporations exist, one health system is delivered and staff will be supported to voice concerns. 13. Management must make clear to all, the responsible leaders for Urgent and Emergent Care and ensure this leadership team has clear goals (SMART) and deliverables with timeframes, and ensure all operational management is conducted through the leadership team. Longer Term Strategies 14. Urgent care needs are addressed through primary care, walk in clinics, UCC and ED. A LHIN-led review should be undertaken to access the effectiveness of each component of the system and their collective impact (e.g. whether serving right patients, most effective hours of operation, optimal level of clinical care, maximizing appropriate scope of practice and leaving other patient focused considerations).

LHSC/SJHC

Communications plan to be complete in 1 month; implementation ongoing

LHSC/SJHC/Associate groups LHSC/SJHC Boards

September 2011

September 2011

LHSC/SJHC CEOs

September 2011

LHIN/SJHC/LHSC

April 2012

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Longer Term Strategies Continued 15. A process to ensure that physicians providing service through Health Force Ontario have fully met their home hospital obligations prior to eligibility for HFO shifts must be a priority. While this is not unique to London, London might serve as a model for the province in ensuring compliance with this approach. The MOHLTC working with OHA should ensure a standardized approach is put in place.

MOHLTC

November 2011

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DayofWeek,TimeofDayandCTASLevelTrend SJHCUrgentCareCentre,FY2009/10
700

600

500 NumberofVisits

400

300

200

100

0 7 9 11 13 15 17 19 21 7 1 9 11 13 15 17 19 21 7 2 9 11 13 15 17 19 21 7 3 9 11 13 15 17 19 21 23 8 10 12 14 16 18 20 22 8 10 12 14 16 18 20 22 8 10 12 14 16 18 20 22 4

DayofWeek(Monday=1throughSunday=7)andTimeofDay(0700hto2300h) (1)RESUSCITATION/LIFETHREATENING (2)EMERGENT/POTENTIALLYLIFETHREATENING (3)URGENT/POTENTIALLYSERIOUS (4)LESSURGENT/SEMIURGENT (5)NONURGENT

DayofWeek,TimeofDayandCTASLevelTrend SJHCUrgentCareCentre,Qs13,FY2010/11
600

500

400 NumberofVisits

300

200

100

0 7 9 11 13 15 17 19 21 7 1 9 11 13 15 17 19 21 7 2 9 11 13 15 17 19 21 7 3 9 11 13 15 17 19 21 7 4 9 11 13 15 17 19 21 7 5 9 11 13 15 17 19 21 7 6 9 11 13 15 17 19 21 23 7

DayofWeek(Monday=1throughSunday=7)andTimeofDay(0700hto2300h) (1)RESUSCITATION/LIFETHREATENING (2)EMERGENT/POTENTIALLYLIFETHREATENING (3)URGENT/POTENTIALLYSERIOUS (4)LESSURGENT/SEMIURGENT (5)NONURGENT

FYear

2004 # AM Visits

2005 # AM Visits

2006 # AM Visits

2007 # AM Visits

2008 # AM Visits

2009 # AM Visits

Hospital LHIN

Hospital

Visit Type PATIENT REFERRED AND SEEN BY NONER SERVICE PROVIDER PATIENT REFERRED TO ER SERVICE PROVIDER FOR ASSESSMENT (PRE FY2009)

86

406

20

40

SOUTH WEST

(4255) ST.JOSEPH'S HEALTH CARE,LONDON

92

1,490

1,381

955

953

PLANNED RETURN VISIT OR FOLLOWUP TO ER FOR SAME CLINICAL CONDITION UNPLANNED ER VISIT FOR NEW CLINICAL CONDITION

212

2,512

2,659

3,510

3,834

3,843

4,512

38,715

38,876

41,795

42,157

42,701

UNPLANNED RETURN TO ER FOR SAME CLINICAL CONDITION Total

106

932

1,100

1,320

1,084

1,126

5,008

44,055

44,036

47,620

48,033

47,671