MEDICAL MANAGEMENT CONSULTING - Interior Health€¦ · MEDICAL MANAGEMENT CONSULTING (MMC) 6453 Morrison Street, Suite 103 • Niagara Falls, ON L2E 7H1 Tel: 905‐357‐6644 •

MEDICAL MANAGEMENT CONSULTING (MMC)

6453 Morrison Street, Suite 103 • Niagara Falls, ON L2E 7H1

Tel: 905‐357‐6644 • Fax: 905‐357‐2601 • [email protected]

OPERATIONAL REVIEW

SUMMARY OF RECOMMENDATIONS

VERNON JUBILEE HOSPITAL VERNON, BC

OCTOBER 2009

MEDICAL MANAGEMENT CONSULTING (MMC)

Medical Management Consulting (MMC)

REPORT IN BRIEF

OVERVIEW OF REPORT & SUMMARY LIST OF RECOMMENDATIONS

Background

Vernon Jubilee Hospital (VJH) is undeniably a busy organization and, similar to most hospitals,

it is confronted with a need to respond to demands for service in an environment of constrained

resources. As is common, the tension between the demand for and supply of resources has

given rise to discussions regarding the relative adequacy and/or fairness of the resourcing

levels at VJH. With occupancy levels consistently above 100%, the medical staff at VJH

believes the hospital is under-resourced relative to comparable communities while management

maintains the available data does not support such a conclusion.

Late in 2008, Interior Health (IH) made a decision to expeditiously undertake an operational

review of VJH with individuals external to IH playing a central role. That initiative was ultimately

halted given concerns from the medical staff that the process might not be sufficiently objective.

As a result, a formal Request for Proposals (RFP) was issued in April 2009 and is the genesis

for this report. The RFP clearly established the focus of the review as being an assessment of

the equity of resourcing at VJH relative to other hospitals. It is worth noting at the outset that,

despite the focus as defined by the RFP, it is abundantly clear that the relationship between

IH/local VJH management and the medical staff is at least as critical as the resourcing question.

Objectives and Scope

The RFP clearly focused on resource equity while also identifying the need to address certain

topics (i.e. regional boundaries, referral patterns, utilization rates etc). With regard to project

scope, there is a distinction to be made between questions of resource equity and resource

adequacy. Resource equity questions deal with the outcome of how the pool of available

resources is distributed across facilities or services, while resource adequacy questions deal

with the level of resourcing needed by a facility or service. This review offers an independent

opinion on whether VJH appears to be treated fairly relative to other hospitals in terms of

Overview of Report & Summary List of Recommendations page - 2


resources received. Resource adequacy questions (e.g. what level of resources does VJH

need?) are outside the scope of the review.

Methodology

The selection of the Review Team as well as the planning and execution of the operational

review occurred under the direction of, or relied upon input from, the Operational Review

Steering Committee (ORSC). The ORSC included membership from IH and VJH senior

management, staff, physicians and civic and regional elected officials and/or staff.

Data collection was based on a review of a wide range of documentation including Committee

Minutes, financial and statistical reports, facility audits as well as a site visit and interviews.

Statistical and financial data were drawn from the Discharge Abstract Database (DAD) and

Management Information System (MIS) files, respectively. Demographic data was drawn from

a number of sources.

The site visit and interviews were conducted over a three-day period in June 2009. Semi-

structured individual or focus group interviews were conducted with more than 100 stakeholders

including senior management, frontline staff, union representatives and physicians.

Report Structure

The report is presented in two volumes. The first volume is the main body of the report and

contains the narrative and recommendations flowing from the data collection process. Within

this volume are three sections dealing with the resource equity question, surgical and clinical

services and medical staff leadership/organization. The second volume is a data compendium

with no associated commentary.

SECTION 1 – SUMMARY

Resource Equity

The equity issue at VJH has been framed in an unusual manner. Typically these discussions

are framed in monetary terms but in this case hospital capacity, as expressed in terms of

occupancy, seems to be offered as the principal indicator of inequity. The number of operating



rooms (OR) is also mentioned given a perceived shortage of OR time is seen to be contributing

to the occupancy issues as surgical patients are left occupying beds while they await surgery.

Ultimately, the origins of the equity problem, and the key to its resolution, are portrayed as

resting in how VJH’s catchment population is defined. MRI has also been mentioned in the

equity debate but without reference to specific capacity or access problems.

Key Findings

The Review Team can offer little in the way of comment on the MRI issue. Although IH was

able to produce data regarding the number of MRI exams provided to residents of the North

Okanagan, it was unable to provide any information regarding utilization rates or wait times.

As such, it was impossible to access whether access to MRI is equitable, a possibility even

in the absence of a machine at VJH.

Beginning in 2003-04 and persisting to today, average annual occupancy rates at VJH

appear to have consistently exceeded 100% and, on a fiscal period basis, have reportedly

never dropped below 96%. However, it is clear that for at least 2 ½ years (ending March

31/09) VJH’s occupancy was miscalculated resulting in a routine overstatement of at least

10%. There is some risk that IH’s occupancy calculations are systemically flawed. If this is

the case it is questionable whether IH’s occupancy figures have any utility for comparative

purposes either within or outside the health region. In the end, it remains unclear to what

degree the magnitude of the occupancy problem is greater at VJH, if at all, but it is clear the

frequency of the problem at VJH is only matched by Kelowna General Hospital.

Utilization rates may suggest some potential to ease occupancy problems but the rates do

not raise significant alarms regarding over-utilization; some opportunity may also be

available in relation to surgical cases having potential to be managed as day surgery cases.

These gains will probably prove challenging and will require concerted effort and planning

by clinical and management staff. In a similar vein it is worth noting the ALC days rate for

Vernon has dropped by 60% since 2001-02. The beds used by Vernon residents

designated ALC have dropped from about 17 in 2001-02 to about 11 in 2007-08 (not all of

these beds would necessarily be at VJH). Further elimination of ALC days would likely have

an impact on VJH’s occupancy issues. An important implication flowing from the ALC days

rate is that to the extent VJH bears the burden of these ALC days, the occupancy issue at



VJH is heavily oriented to the throughput of acute patients as opposed to the presence of

‘bed blockers’.

It has been asserted that VJH is underfunded because the funding formula does not fully

recognize VJH’s catchment population. More specifically, VJH’s role in serving the

Revelstoke and Salmon Arm areas is thought not to be recognized. This assertion is false

and is based on a mistaken understanding of how VJH and other IH hospitals are funded.

There has been no misapplication of a funding formula in this case and nor have resources

flowed away from VJH as a result of changes to regional boundaries.

It is not evident that any of the parties closest to the resourcing debate in Vernon actually

have a full picture of the total acute expenditure at VJH. More specifically, local managers

only see those cost centres for which they have responsibility and have no financial

information concerning essential corporate services such as diagnostic imaging, laboratory

etc. The structure of summary financial reports has also inadvertently left even senior

managers believing that Penticton Regional Hospital (PRH) is more richly resourced than

VJH.

For the 3 years reviewed, VJH consistently had the 3rd highest throughput for inpatient

weighted cases and total weighted cases (following Langley Memorial and Peace Arch) but

the 2nd highest net acute and comparable acute expenditure (following LMH). Relative to

PRH, VJH’s expenditures were $2.4 to $7.1 million higher depending on the choice of year

and reference to either net acute or comparable acute expenditures. While there is no

accepted single proxy for the total output of a hospital, were weighted cases (either inpatient

or total) used as such a proxy, VJH would have the highest expenditure per weighted case

in this group of hospitals. To the extent that resource consumption is a proxy for the

resources provided to an organization and organizational workloads are similar, this review

suggests there is no inequity in the manner in which VJH is resourced for the services

delivered.



Recommendations

RECOMMENDATION 1:

IH should take steps to ensure it can respond to public concerns regarding equitable access to MRI and possibly other services. Further, IH should have a public plan indicating how, when and where technologies will be diffused in the region and the decision framework guiding such matters should be transparent.

RECOMMENDATION 2:

IH should review its policies and practices regarding occupancy calculations with a view to conforming to industry norms. Specific attention should be paid to when positive or negative changes to the bed supply should be incorporated in such calculations, regardless of formal budgetary status, as well as to overflow beds located on inpatient units.

RECOMMENDATION 3:

IH should undertake a review and risk assessment of the occupancy issues evident at VJH and possibly other IH hospitals. The acceptability of sustained over-occupancy situations should be assessed as should the adequacy of facility over-capacity protocols. The adequacy of corporate risk mitigation strategies, including bed requirement projections and associated budget planning should be reviewed.

RECOMMENDATION 4:

VJH should review the effectiveness of current occupancy management strategies and further explore opportunities to convert inpatient cases to day procedure cases. In assessing current strategies VJH should systematically address what occupancy level is sustainable in the short and medium term, and consider whether current strategies are sufficient in scope and impact to produce the required result.



RECOMMENDATION 5:

IH should review its plans regarding the bed supply at VJH in the short and medium term and clearly communicate the details of those plans as well as the supporting rationale.

RECOMMENDATION 6:

There is no funding imperative for changing the geographical boundaries of the North Okanagan.

RECOMMENDATION 7:

IH needs to ensure that capital and operational planning processes recognize the population growth patterns in the North Okanagan and the implication these will have for VJH.

RECOMMENDATION 8:

IH should review its practices in terms of the financial data available to senior managers and the perceptions that may be fed by the manner in which data is aggregated.


Surgical & Clinical Services

The surgical program was identified as a priority area of interest within the operational review.

This was reinforced throughout the interviews by the physicians and management staff. Lack of

access to surgical resources was a consistent theme throughout the qualitative review and was

viewed as a priority by the majority of physicians interviewed. Lack of operating room time is

perceived to contribute to hospital over-occupancy and an inability to recruit new surgeons.



Key Findings

The surgical program at VJH has many strengths and in many respects is quite efficient.

Length of stay for surgical patients is generally good, available beds are generally well

utilized and wait times for surgery appear to be, in most cases, the best amongst

comparable hospitals.

Surgical services at VJH have been the subject of previous reviews and in many respects

the findings of those reviews remain relevant and in some instances identical to the current

review. It is noteworthy that there is some indication that some of the recommendations

contained in previous reviews have not been implemented.

Opportunities for increased capacity through improved utilization and efficient use of

resources still reside internally with the surgical program. It is in the best interest of the

surgical team to address these issues prior to looking for resolution externally to VJH.

Fundamental to this is a strong, cohesive co-leadership / co-management team that works

together to achieve the goals of the surgical program. The surgeons, anaesthesiologists,

nursing and support staff have universally expressed a wish to increase and improve the

operative services provided at VJH.

Broadly, the recommendations in Section 2 are related to increasing capacity through

improved utilization and efficient use of resources and include:

− Organization and Infrastructure

Establishment of effective governance structures to assist in the planning,

evaluation and problem-solving of clinical programs

Clarifying lines of communication and decision-making

− Process

Development of systems and processes to support the effective management of

resources

Utilization of best practice in the planning and delivery of clinical services



− People

Effective utilization of available staff and physicians

Provision of support for development of leadership and management skills and

knowledge

Clarification of roles and responsibilities

− Monitoring

Development and/or implementation of monitoring activities

Utilization of data for decision-making and problem-solving

Recommendations

RECOMMENDATION 1:

Review services accessed by Vernon residents at other facilities to determine ability to repatriate.

Review the model for hip and knee replacement surgery to ensure that the funding is associated with where procedures are done.

RECOMMENDATION 2:

Distribute wait time reports to surgeons and incorporate this information into the QA/QI activities of the Hospital.

Complete a review of patients waiting for urological surgery where “cancer is suspected” to determine incidence of cancer and take further action if required.

RECOMMENDATION 3:

Identify and implement initiatives to decrease the number of occurrences of “room running late.”



RECOMMENDATION 4:

Complete a prospective review to determine compliance with IHA Add-On Classification.

Develop a process for concurrent and prospective reviews of emergency (add-on) surgeries to ensure that they comply with the accepted definitions.

Implement process for managing add-on procedures to ensure that only appropriate surgeries are performed outside of “regular” OR hours.

Implement OR Booking Model that accommodates elective and urgent procedures during the day Monday to Friday, e.g. 75/25 slated/add-on allocation where add-on time is left open to accommodate urgent/emergent bookings.

RECOMMENDATION 5:

VJH OR Committee should analyze current OR utilization between 2000 and 2300 hours to identify opportunities for improved utilization of staffed OR time.

Consistently run a daily “long room”, i.e. until 1730 hours. Assign anaesthesiologist coverage to the ORs to facilitate maximum utilization of OR

time and staff. That IHA and VJH form a task group to reexamine whether there is sufficient volume

of added emergency surgery to warrant assigning OR time for this in a more appropriate fashion and to identify options based on the accepted definitions.

VJH OR Committee should implement strategies that support 90% utilization of OR time.

VJH should utilize the Sullivan Report as a framework for improving the utilization of resources for the surgical program.

RECOMMENDATION 6:

VJH OR Committee to design an OR Booking Model that: − Is based on services needs − Is based on surgeon’s practice − Considers surgical classification



− “Levels” wait times − Is based on service, i.e. allocate X hours to General Surgery based on service wait

times − Is based on surgeon, i.e. allocated Y hours of General Surgery hours based on

surgeon wait times − Is based on Surgical classification, i.e. elective, urgent, and emergency surgeries

based on service/surgeon profile − Integrates surgical bed management (bedmapping) − Accommodates add-on cases during the day shift

Review OR utilization quarterly and reallocate OR time based on changing wait times. Revise the methodology of allocating and reallocating OR time based on service and

surgeon wait times; classification of surgery (inpatient/SDC, urgent/elective); bed availability.

RECOMMENDATION 7:

VJH OR Committee to implement strategies to improve “First Case Start Times”, i.e. provide Manager/delegate with responsibility and authority to ensure that cases start on time and to problem-solve barriers to improving First Case Start Times.

VJH OR Committee to monitor reasons for First Case of the Day delays and have as a goal to match performance in other IH ORs.

IHA Surgical Council should confirm that the definition and method of capturing first case starts is standardized and consistent across the health authority.

RECOMMENDATION 8:

Introduce OR LPNs into the operating room as a complimentary role to the RNs.



RECOMMENDATION 9:

Review LOS for services where ALOS is above the VJH average and/or peer averages. Review all surgical procedures that May Not Require Hospitalization and identify

strategies to meet identified targets.

RECOMMENDATION 10:

VJH OR Committee should ensure SDC criteria supports minimizing need for patient admission.

VJH OR Committee should ensure Pre-Admission process supports minimizing need for patient admission.

VJH OR Committee should audit day procedure group classification.

RECOMMENDATION 11:

Complete budget analysis to identify factors contributing to increased cost per weighted case.

RECOMMENDATION 12:

Implement quality improvement initiatives related to monitoring of surgical standards. Establish processes for promoting and ensuring adherence with surgical standards.

RECOMMENDATION 13:

Provide support for the Perioperative Manager to assume responsibility for the OR immediately.

Provide business support, human resources support and mentoring for Perioperative and Surgical Services Managers in fulfilling the full scope of the Manager role including program planning and evaluation, financial decision-making and problem-solving, human resource and labour relation management, and quality improvement.



Ensure that the Health Service Director Acute Services delegates Manager responsibilities for the surgical program to the respective Managers and makes the transition to providing support at the Director level.

Clarify the role of Department Heads of Surgery and Anaesthesia as it relates to providing leadership in planning and problem-solving for their respective services.

Clarify lines of communication and decision-making at all levels, i.e. program, portfolio, site, and IHA-wide.

RECOMMENDATION 14:

Develop a governance structure for the Surgical Program based on a co-management structure (Surgical Leadership Team).

Clarify roles and responsibility of all members of the Surgical Leadership Team. Implement OR Management Committee to provide leadership and decision-making for

the surgical program. Voting members should include Perioperative Manager, Inpatient/PSS Manager, Anaesthesiologist Representative, Surgeon Representative.

Involve representatives from the entire continuum of surgical services in the planning, evaluation, problem-solving and decision-making for the surgical program, i.e. Perioperative Manager, Inpatient Manager, Department Heads of Surgery and Anaesthesia.

IHA should provide support for the surgical team to establish effective governance structures and assist with planning and problem-solving as required.

RECOMMENDATION 15:

Support the role of Manager in the daily monitoring of compliance with OR Booking guidelines including process for add on procedures.

Implement processes to facilitate compliance with OR Booking guidelines, e.g. additional OR time for surgeon’s who comply; loss of OR time for non-compliance.



RECOMMENDATION 16:

Implement a co-leadership model for the PSS involving nursing and anaesthesia consistent with best practice.

Ensure consistent involvement by anaesthesiologists in the PSS.

The Vernon Operational Review Implementation Committee feels that it is important to make an early response to recommendation 16.2, section 2, and is therefore inserting the following comment directly into the report document.

On investigation the Implementation Committee finds that it does not support the validity of recommendation 16.2, section 2.

Implement process for monitoring appropriate rate of referral for anaesthetic consults.

RECOMMENDATION 17:

Schedule ECT and cardioversion in a manner that does not adversely impact access to the OR.

Explore alternative models for providing ECT and cardioversion service. RECOMMENDATION 18:

Inpatient Manager should assume responsibility for managing daily activity related to bed planning and patient flow.

Involve surgical inpatient Manager in planning for surgical services and activity. Clarify lines of communication and decision-making relating to surgical activity. Implement processes to support timely discharge of patients including:

− Guidelines for discharge − Medical leadership support for non-compliance.

Explore the impact of dedicated surgical beds (must include accountabilities for managing patients, beds and surgical slate.)

Develop a bedmap that reflects elective/urgent and emergency surgery patterns and ALOS, e.g. 50 % of beds are routinely used for emergency surgery. These would no longer be available for scheduled procedures. Allocate the remaining beds based on service and ALOS.

Schedule OR cases based on bedmap.



RECOMMENDATION 19:

Head of ICU/CSU and Manager should provide leadership in undertaking a collaborative review, revision (if required) and implementation of admission and continued-stay criteria for ICU that are objective, measurable, and have a common understanding.

Establish a process for evaluation of criteria on a regular basis to ensure appropriate utilization.

Review and implement admission and discharge criteria for telemetry based on best practice.

Explore the impact of consolidating telemetry patients on one unit. Alternately, identify processes based on best practice for managing patients receiving telemetry in multiple areas of the hospital.

RECOMMENDATION 20:

Submit business case for additional funding from Cancer Agency to support increased activity.

RECOMMENDATION 21:

Chief of Staff and the Health Service Administrator should provide leadership and support to the Departments of Obstetrics and Anaesthesia in establishing a forum for collaborative problem-solving regarding epidural services and surgical preparation of the patient for C-Section.

Clearly articulate systems, processes, and support available to staff for conflict resolution.

RECOMMENDATION 22:

Establish standards for physician attendance in the ER. Explore process for management of patients receiving IV antibiotic therapy outside of

the ER based on best practice.



Utilize the LLTO Transfer Algorithm process for receiving critical care patients from other communities.

ER Committee to provide leadership in the development of a process for accepting patients who do not fall within the LLTO Transfer Algorithm that includes all key stakeholders.

RECOMMENDATION 23:

Formalize weekly Manager meeting into organizational structure. Establish formalized meetings between the Manager and Heads of Family Practice and

Internal Medicine to assist in program planning and solution identification. Continue with plan for establishment of an ALC unit with appropriate staff and skill

mix. Review the current admission criteria for community sub-acute and transitional care

beds to determine potential to include medical patients who meet the criteria. Alternately, explore the possibility of establishing medical sub-acute/transitional care beds in the community.

Explore options for the provision of telemetry care and complete a business case including option analysis regarding cohorting telemetry and ICU step-down patients as appropriate.

Review Overcapacity Protocol, revise based on revised bed capacity and implement stages that result in escalating action steps based on increasing patient volumes as originally intended.

Establish protocols for facilitating discharge 7 days per week. Formalize the role of Doctor of the Day to include discharge management of patients.




Medical Staff Leadership/Organization

The medical staff at Vernon Jubilee Hospital is identified as a strong, cohesive body of

physicians and surgeons who are mutually supportive in both their clinical and social roles.

The general practitioners take an active part in providing acute care to patients in the hospital

and their relationship with specialist colleagues appears to be mutually respectful. The same

cannot be said for the relationship between the medical staff and IH management. More

recently, constant over census of acute beds at VJH, perceived inadequacy of OR time, slow

response to renovation of clinical space and inadequate clinical input into planning of a new

hospital tower have been aggravating factors. It is evident that the working relationship

between the medical staff and IH / VJH management is at least as critical as the issue of

resources.

Key Findings

The manner in which VJH physicians view their treatment by IHA senior administration

causes great resentment. From their perspective they are ignored, their efforts and advice

trivialized, their presence at meetings met on occasion with derogatory comments from

senior staff. While there appears to be some validity in their position, it is obvious that their

long-standing frustration brings an angry and confrontational face to their interactions with

IHA which further deepens the rift. The tenor of IHA’s response for the most part seems

measured and reactive in nature; perhaps not as strong and focused a response as called

for by the deterioration of a critical relationship.

All medical staff organizations that function well have strong leadership. Within VJH, the

leadership of the medical staff organization must be improved. The overload of work

experienced by the Senior Medical Director (SMD) of IHA is known and understood.

Vacancy in three of the four Regional Medical Director (RMD) positions has left the SMD

spread very thinly covering almost the entire IHA. The arrival of a new RMD for the

Okanagan HSDA should allow the SMD to refocus efforts in his own portfolio allowing the

new RMD to rebuild relationships with VJH medical staff.



Just as the position of Chief of Medical Staff is filled by default, so it seems, are the

positions of medical department heads. As became clear in the interview process, each

member takes on the role and its responsibilities in turn, typically without enthusiasm and

mostly without vision. Tenure as a department head seldom if ever extends beyond the

minimum term.

The Medical Staff Organization (MSO) as defined in the Medical Staff Bylaws and Rules has

defined duties and responsibilities often fulfilled by way of a committee structure. The

required committee structure is not functioning effectively at VJH. For example, there is no

active OR Utilization Committee to ensure that surgical resources including pre and post-

operative systems are maximized. Such a committee should concern surgeons, including

obstetricians, anaesthetists and nursing. The strongly-felt demands of the doctors involved

in the operating room are not supported be an equally strong Operating Room Committee

with well-defined goals and an effective system of achieving those goals.

The 2009 Fraser Institute Report ranking suggests that VJH doctors deliver good care to

their patients. Nonetheless, some opportunities exist to improve the organization of services

and practices within VJH.

Recommendations

RECOMMENDATION 1:

That the Interior Health Authority and the Medical Staff of Vernon Jubilee Hospital meet for the purpose of improving communication systems and styles with professional facilitation as needed.

RECOMMENDATION 2:

Selection of a new Chief of Medical Staff should be undertaken as soon as possible. The selection process (recruitment, short listing and selection) should include the site

administrator, the current COMS, the SMD, the RMD, the Chair of the LMAC, the President of the Medical Staff, the heads of two medical departments at VJH and one or two physicians selected by the medical staff.



The role of the COMS should be clearly defined and understood by both the incumbent and the medical staff.

IHA must commit to reasonable funding for the COMS position. IHA must commit to appropriate training and mentoring for the new COMS both prior

to the appointment and on an ongoing basis.

RECOMMENDATION 3:

IHA must address the role of the medical staff Department Heads to coincide with the Medical Staff Bylaws and Rules.

IHA should undertake a program to familiarize physicians with the duties and responsibilities of Department Heads.

VJH medical staff must take the role and duties of their Department Heads more seriously with a view to compliance with their Bylaws and Rules and to develop stronger leadership.

IHA should review the compensation provided for Department Heads.

RECOMMENDATION 4:

The LMAC at VJH should review its performance to ensure it is fulfilling its requirements detailed in the Medical Staff Bylaws and Rules.

The LMAC must re-establish an active utilization committee to optimize VJH inpatient and outpatient resources.

The Department Heads of Surgery and Anaesthesia must employ an OR Utilization committee to ensure the best use of operating and anaesthesia time.

RECOMMENDATION 5:

The medical staff must come together as a body and learn to deal with change, possibly with the help of outside expertise in change management.

IHA must help the medical staff in accepting change by supporting efforts to grow past their focus with recent conflicts and take part in the process.



RECOMMENDATION 6:

The senior physicians who have positive relationships with IHA must consciously model a different pattern of behaviour for their younger counterparts to emphasize a more positive attitude within VJH and with administration.

RECOMMENDATION 7:

Physicians at VJH need to make every effort to discharge their patients as soon as possible. Availability, cooperative efforts with colleagues and hospital staff, taking responsibility when on call must be priorities. Serious consideration must be given to either an expanded role for the Doctor of the Day to include patient discharge or to re-appointing a physician to facilitate patient discharges.

RECOMMENDATION 8:

IHA and VJH physicians need to prepare a program for care of orphan and out of town patients if and when the number of general practitioners in the DOD program continues to decline.

RECOMMENDATION 9:

Reassessment of patients started on IV antibiotics in the Emergency Department should be limited to one or two follow up visits in the emergency department with the patient transferred to the home IV program as soon as possible.

The home IV program must be available to accept such patients as a priority.

RECOMMENDATION 10:

Serious consideration should be given to creation of a funded position for an ICU Director with written roles and responsibilities.

The ICU Director should have training in intensive care medicine.



Recruitment for the position should be jointly undertaken by VJH medical staff who use the ICU, VJH administration including the ICU manager, and IHA medical administration.

RECOMMENDATION 11:

The ICU at VJH should be classified as “semi-open” with the ICU Director overseeing patient care by treating physicians.

Standards should be established for physicians who admit and treat patients in ICU. RECOMMENDATION 12:

The Department Heads of Surgery and Anaesthesia should undertake the leadership necessary to create and manage an OR Utilization Committee in a co-management model with Nursing.

The OR Utilization Committee must set appropriate standards of practice for the use of OR time.

RECOMMENDATION 13:

The Department of Anaesthesia needs to address their members’ inconsistency in complying with patient management standards at VJH. This effort must be supported by the Department of Surgery to ensure safe and effective care for their patients and to provide the most efficient use of OR time.

The Vernon Operational Review Implementation Committee feels that it is important to make an early response to recommendation 13, section 3, and is therefore inserting the following comment directly into the report document.

On investigation the Implementation Committee finds that it does not support the validity of recommendation 13, section 3.

RECOMMENDATION 14:

Under no circumstance are patient records to be removed from the facility without administrative approval (Medical Staff Rule 9.1). This includes Emergency Department forms.

To facilitate timely completion of patient records by emergency physicians, adequate dictating equipment and facilities must be present in the Emergency Department.



RECOMMENDATION 15:

Medical Staff representatives from VJH should meet with counterparts from Shuswap Lake and Queen Victoria Hospitals to discuss and resolve inter-site and inter-physician communication issues regarding patient transfer and care.

Conclusions

The challenges confronting VJH are not unique or new to the health system. Ironically, it is the

chronic nature of the challenges that makes relationships so critical. In the absence of a ‘cure’

it is essential that the various players in the system work together to mitigate operational

pressures and to support one another in often difficult work environments. Conflicted

relationships inhibit cooperation, mutual support and lead to protracted decision making

processes.

VJH is a very busy hospital staffed by dedicated physicians and other professionals. IHA and

VJH managers are also dedicated individuals struggling to meet the demands of a large

population with constrained resources. Relationships between some of these parties have

deteriorated to a point that is neither in their interest nor in the community’s interest.

The medical staff and IHA / VJH management need to turn their attention to their relationship

and their ability to work together constructively. The medical staff needs to be more deeply

engaged in the management of VJH and more temperate in some of their communication. IHA

needs to be more communicative and more transparent, and needs to show more leadership on

some issues such as sustained high occupancy. Overall relationships must become more

collegial and more respectful. In those situations when the parties disagree, including those

where the medical staff may feel obligated to voice concerns publicly, the parties need to

separate issues from personalities and act in a manner that preserves essential relationships.



Respectfully Submitted by:

James Murtagh, MHA, CHE, FACHE

Medical Management Consulting (MMC) Associate

Jennifer Clary, RN, Med


Ernest Higgs, MD


Mark Isaacs, MSc


Mona Kines, RN, MSN, CHE, RCC


Michael Stanger, MDCM, FRCSC


Documents

MEDICAL MANAGEMENT CONSULTING - Interior Health€¦ · MEDICAL MANAGEMENT CONSULTING (MMC) 6453 Morrison Street, Suite 103 • Niagara Falls, ON L2E 7H1 Tel: 905‐357‐6644 •