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REPORT FROM ABC WORKING

GROUP

April 15, 2014

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1.0 Background

On November 1, 2013, Minister Terry Lake initiated a strategic and operational review of Fraser Health (the Fraser Health Review) to address ongoing service and fiscal challenges in the health authority.

As part of the review, the Minister directed the Fraser Health (FH) board to submit by spring 2014 a new strategic and operational plan to cover a three-year period beginning fiscal 2014/15. The plan which must be approved by the Minister will identify service targets, operational and financial objectives and outline how Fraser Health’s programming and structure can best support achieving these objectives.

The Board was directed to prepare the plan with the assistance of and based upon the findings and recommendations of a Ministerial appointed Review Committee. The Minister appointed 10 individuals to the Committee and charged them with examining the health authority’s current operational practices and identifying priority action areas to address service and fiscal challenges. Section 4(2) of the Order specifically outlined eight key areas to be taken into consideration during the review process.

Given the limited timelines for this work the Committee divided itself into three working groups each of which concentrated on a particular aspect of the Regulation section 4(2). This report constitutes the body of work for the first working group. It is the result of a region-wide and site-specific review undertaken by Ms. Cathy Ulrich, Chief Executive Officer for NH, Dr. Jeremy Etherington, Vice-President Medicine and Quality for Interior Health (IH) and Ms. Christina Krause, Executive Director of the BC Patient Safety and Quality Council. The section and its recommendations are meant to inform the Fraser Health Board of key opportunities related to clinical care, quality improvement, productivity, and cost, some requiring urgent attention, to be considered in the development of the Board’s strategic and operational plan.

The main findings of the first working group clustered into four key themes:

1. Recommendations on clinical service delivery issues: right place, right time, right provider, right care, right resources;

2. Recommendations to address culture and key quality indicators, including patient safety; 3. Recommendations on primary and community care integration and primary care access; and 4. Recommendations on Health Human Resources based on HR indicators

The first part of this document presents analyses related to definition of community need. The second presents general regional and health-service-delivery- area (HSDA) findings for each of the four themes and makes recommendations for further analysis and action based on a broad review of available data, key aspects of which are included in the report. The third section comprises a series of ‘narratives’ that provide more specific analysis of improvement opportunities by site.

1. 1 Limitations of the Analysis

There are several limitations to the analysis of quality indicators that should be noted. First, the timeliness of data prevented a full and more rigorous analysis, resulting in “flagged” areas

being suggested for further exploration. Second, there was a lack of specific site-based data related to

understanding workplace culture, which is known to influence clinical outcomes, (PSLS data over time,

PCQO information and Gallup data). Finally, the most recent data provided were usually 2012-13 CIHI

data, with more recent information being provided by Fraser Health (which covered only three fiscal

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periods at a site level). For certain indicators, 2011/12 was the most recent year available from CIHI,

which is often the only source of comparable pan-Canadian points of reference.

The limitations in the quality-indicator data provided means that our analysis can only provide an

overview of site-specific and regional issues, many of which still require further investigation by Fraser

Health.

1.2 Fraser Health Overview Fraser Health Populations Fraser Health is divided into three Health Service Delivery Areas (HSDAs). As of 2012 Fraser South was

the largest HSDA, with 738,107 people, 45% of the Fraser Health total. Fraser North is the second

largest, with 623,357 people (38%). Fraser East is less than half the size of either of the other two HSDAs

with 288,598 people (17%). Since this report addresses specific issues by HSDA and hospital site, Table 1

is included to identify the distribution of Fraser Health hospitals by HSDA.

Table 1: Fraser Health Hospital Distribution by HSDA

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2.0 Examination of ‘Need’ within Fraser Health

One of the areas of examination defined by the Regulation was ‘community need’ within FH. All BC

Health Authorities have self-defining outlooks built around unique circumstances in their respective

operating environments. Fraser Health is most likely to communicate its position as “BC’s largest and

fastest growing health authority” not only as a source of pressure and frustration, but also as a source of

opportunity and pride. And there is much to support these contentions:

Since inception of the current health authority structure in 2001/02, Fraser Health has had both the largest population base and fastest growing population of any health authority.

55% of the projected growth in BC’s population from 2013 to 2032 will occur in Fraser Health (BC STATS' PEOPLE 2013).

Looking 20 years ahead, 40% of the projected growth in BC’s population aged 65 or older will occur in Fraser Health (BC STATS' PEOPLE 2013). It is this older population group which best correlates with overall growth in need for service.

Fraser Health now has the largest share of the funding allocation for BC health authorities, rising from 19% below the largest region in 2001/02 to 5% above the second largest region (VCHA) in 2013/14 (BC Ministry of Health).

From 2001/02 to 2012/13 the Fraser Health share of the total HA funding lift was 32.6% and in the current cycle (2013/14 to 2015/16) the share of growth will exceed 40% (BC Ministry of Health).

Fraser Health has advanced to become BC’s largest employer of nursing staff, and is certainly one of the top ten (and perhaps top five) employers of nurses in Canada, confirming the FH status as “biggest and fastest growing” not only in population served, but also in the capacity for care.

2.1. Fraser Health Status Compared to Rest of BC

Table 2 confirms that Fraser Health generally has modestly higher prevalence rates for selected chronic

conditions than BC averages. The conditions identified in Table 2 are those where Fraser Health exceeds

provincial norms. In other areas, Fraser Health has better than average health status. The Northern

Health Authority and Vancouver Coastal prevalence rates are introduced as additional comparisons.

Rates are based on the three year average of both the prevalence markers (counts) and of the

population cohorts drawn from PEOPLE 2013, the most recent projection available.

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Table 2: Selected Chronic Conditions Prevalent in Fraser Health

(3 Year Moving Average)

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2.1.2 Variation in Health Status within FH Table 3 extends the prevalence rates analysis examining the three separate HSDAs within Fraser Health;

Fraser North has the best health status within Fraser Health with only two of the measures (angina and

diabetes) exceeding the provincial average prevalence rate. Amongst the three FH delivery areas, Fraser

East has the highest calculated prevalence of AMI, cardiovascular disease, asthma and COPD.

These prevalence rates are captured on a secure Ministry of Health system driven by encounters with

the acute care, physician service and pharmaceutical sectors. An example of how the registry is

constituted is set out below:

Angina Pectoris

Rules: One hospitalization with angina diagnosis, or one specialist visit with angina diagnosis and one prescription for nitrates within 365 days, or two GP visits with an angina diagnosis and one prescription for nitrates in 365 days.

Diagnostic Codes:

ICD-9 413 Angina pectoris

ICD-10 I20 Angina pectoris

Medications - Nitrates

Similar rules apply to other conditions in the registry dataset. It should be noted that rates may be under

represented in locations with high percentages of patents, residents and clients who receive full or

partial coverage at the federal level, for example aboriginal peoples on reserve. The Northern Health

diabetes rate is almost certainly understated.

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Table 3: Chronic condition Prevalence Rates within Fraser Health

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2.1.3 Self-Reported Perceptions An examination of self-reported perceptions of health status, and self-reported health behaviours

augments the chronic condition prevalence conceptualization of population health set out in Tables 2

and 3. Table 4 compares Canadian Community Health Survey (CCHS) results for Fraser South to Fraser

Health overall. Both measures are presented with reference to provincial averages.

Surveyed perceptions from South Fraser (orange dots) are generally more positive than those of Fraser

Health overall (green dots). Both sets of survey results are portrayed relative to the provincial average

adjusted for age. Perceived health is better than the BC average in both the Fraser South and Fraser

Health populations.

Table 4: CCHS Findings within Fraser Health

Table 5, which juxtaposes the South Fraser and Richmond HSDAs relative to provincial average levels, is

also instructive, as just one of many such comparisons which could be made. Richmond was selected

with reference to its close geographic proximity and comparable socio-economic status.

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Table 5: CCHS Findings for Fraser South HSDA Compared to Richmond HSDA

The self-reported CCHS data have more self-reported pain and arthritis for Richmond residents and

more diabetes recorded for South Fraser Residents. Life-style related factors (smoking, excess alcohol

consumption, exercise levels) are not greatly different overall for both HSDAs, although Richmond

residents are more likely to report more than 5 drinks per day at least once a month and less likely to

report a regular smoking habit. Moderately active or active physical activity is reported at below

provincial norms in both HSDAs. Richmond residents are less likely to report health status as good or

excellent and more likely to report health status as fair or poor. Richmond residents are more likely to

report access to a regular medical doctor, but residents of both HSDAs self-reported physician access

rates above the surveyed provincial average level.

2.1.4 Health status impacts arising from multi-cultural populations A major Canadian study with a significant BC representation in the surveyed population concluded that,

after adjustment for socio-demographic characteristics and other factors identified in the research

design, diabetes and hypertension were significantly more prevalent among South Asian respondents,

Filipino or South East Asian respondents than among white respondents.

Members of visible minorities, with the exception of Arab or West Asian respondents, were less likely

than white respondents to smoke. Compared with white respondents, Chinese, Japanese or Korean,

South Asian, and Filipino or South East Asian respondents were less likely to be obese, and Chinese,

South Asian or Filipino, South East Asian, black and Arab or West Asian respondents were more likely to

be physically inactive. (Cardiovascular risk factors in ethnic populations within Canada: results from

national cross-sectional surveys. Richard Liu et al, Open Medicine, Vol. 4, No 3, 2010).

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The observation from Fraser Health that the growing South Asian population has diabetes prevalence

rates doubling the rate found in the general population accruing appreciatively higher rates of

cardiovascular illness and kidney dialysis is confirmed by additional Canadian based research, also drawn

from self-reported survey data. A counterpart study from Ontario, published with reference to

population research studies between 1996 and 2007 reported similar findings identifying the two fold

diabetes rate and the associated cardiac risk factors. (Comparison of cardiovascular risk profiles among

ethnic groups using population health surveys between 1996 and 2007, Maria Chiu et al Canadian

Medical Association Journal, May 18, 2010 vol. 182 no. 8).

The South Asian population comprises approximately 15 % of the population of Fraser Health, as

compared to 3% of the overall population of the province. Over the past decade, more than 90% of the

growth in the South Asian population of British Columbia occurred in Fraser Health.

Table 6 rounds out the picture, positioning South Fraser against Fraser Health overall, with the provincial

rates as a backdrop. As expected interventions for diseases and disorders of the circulatory system are

somewhat higher in SF than FH overall (as the SF rates are embedded in the FH rates, the difference is

more than it appears). Overall age standardized utilization rates are higher than the provincial rates, but

not as distinctly higher as those recorded for the circulatory group.

Table 6: South Fraser Compared to Fraser Overall

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2.1.4 Health status impact arising from Aboriginal populations Fraser Health is home to approximately 40,000 Aboriginal individuals. There are 32 bands with the

majority of individuals living in urban settings. Approximately 3% of Fraser Health residents self-

reported as Aboriginal in the 2006 census, this is lower than the provincial counterpart figure of 4.7%. In

2006, Fraser Health was home to 19.4 per cent of the total provincial Aboriginal population. As a

proportion of the total population, Fraser Health had the second lowest percentage of Aboriginal people

in the province, behind Northern Health (17.5 per cent), Interior Health (6.7 per cent) and Vancouver

Island Health (5.8 per cent). As a percentage of the total population, the Aboriginal population in Fraser

East accounted for 5.7 per cent of the total, compared to 2.1 per cent of Fraser South and 1.9 per cent

of Fraser North. These estimates may be understated for both FH and BC overall, real numbers are

generally thought to be higher than census records suggest.

The following observations are from “ Profile of aboriginal people in the Fraser Health Region, 2010,” an

extensive, well documented compilation pulled together by Fraser Health, the provincial health officer

aboriginal leaders and the broader aboriginal community:

• First Nations people account for 56 per cent of the Fraser Health Aboriginal population and

Métis 40 per cent.

• 12 per cent or 4,590 reside on reserves while 88 per cent or 33,515 live off reserve.

• The Aboriginal population is much younger and has higher birth rates than the non-Aboriginal

population.

• Mortality trends show decreasing rates for everyone in Fraser Health including Status Indians.

• Approximately 8 out of every 10 Status Indian deaths are premature (deaths before age 75)

while only 4 out of 10 non-Status deaths are premature.

• Injury and suicide account for a much higher proportion of total deaths (27 per cent) in Status

Indians than in other residents (6 per cent).

• Two specific injury-related causes – motor vehicle collisions and accidental poisonings – result in

much higher mortality rates in Status Indians than in other residents.

• Suicide rates among Status Indian youth are approximately four to five times higher than among

non-Status Indian youth.

• Prevalence of diabetes among Status Indians (6.9 per cent in 2006/07) continues to increase

steadily, and remains higher than among other residents.

• Approximately 56 per cent of Aboriginal people are overweight or obese, the largest proportion

among major ethnic groups in Canada. Compared to other health authorities,

• Fraser Health’s Aboriginal population has the highest rates of mammogram and cervical cancer

screening (83 per cent).

• Status Indians have lower rates of Medical Services Plan utilization in Fraser Health and across

the province, including physician, laboratory and other diagnostic services.

• Status Indians are more likely to be hospitalized than non-Status Indians.

• A Status Indian person is less likely to receive follow-up for mental health condition(s) within 30-

days of discharge from hospital compared with a non-Status person.

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The most recent update on the First Nations Health Authority website provides that:

“Working closely with Fraser Health, Integrated Health Teams are being established in each First

Nation community or within groups of First Nations in the region to create closer linkages between

community members and their health services. These team members include health staff,

leadership, service providers, and staff of the FNHA and Fraser Health. There has also been

collaboration on MSP Project Boards to determine various regional projects for MSP funding. The

Fraser Salish Partnership Accord implementation is well underway.... The partner organizations are

also working together to develop measurable health indicators for the region.... Other plans include

the Aboriginal Health Operations Committee developing a strategy to enhance Indigenous Cultural

Competency Training for review at a future Aboriginal Health Steering Committee meeting.”

Currently, the Fraser Salish First Nations are developing a Fraser Salish Regional Health & Wellness Plan

(RHWP) which will be the foundation for collaborative action on First Nations and Aboriginal health in

the Fraser Region. The RHWP covers off goals and priorities in a number of specified areas.

Fraser Health has a dedicated program – Aboriginal Health (AH), which has been in place for many years

with a Director and a small team who provide planning, direct service to patients for navigation,

advocacy and partnership building. The Program works closely with other Fraser Health programs and

Divisions of Family Practice to ensure AH needs are understood, supported and where possible services

provided. Fraser Health has undertaken positive efforts in the area of Aboriginal health planning in the

region; the 2007-2010 Aboriginal Health Plan was developed based on engagement with Aboriginal

peoples in the region, and endorsed by many key First Nations and Aboriginal groups. Many specific

action plans are underway which will focus efforts while building capacity for change. The extensive

effort to involve partners and communities in the planning, delivery and alignment of services is

noteworthy.

The implementation of these planning and partnership efforts holds significant promise for service

improvements and continued advances in First Nations and aboriginal health status.

2.2 Conclusions and Considerations arising from Population Health Indicators

Using the most measured and accepted indicator of health status, life expectancy (LE), FH is the second

healthiest region in British Columbia at present, with a LE of 82.3 years compared to provincial LE OF

82.0 years for both genders combined. Over the past decade, FH LE gained 2.2 years in exact consistency

with the provincial gain in LE. Only the residents of Vancouver Coastal live longer, 83.7 years at present,

80.3 years a decade past. FH is healthier than Island Health with 0.8 extra years of LE now, compared to

0.5 years of added LE a decade ago. Both the North and Interior lag on LE at 78.9 and 80.9 years

respectively (all LE measures from BC Vital Statistics).

FHA’s standardized mortality ratio (SMR) for all causes is somewhat better than BC’s average (0.98),

the second best rate among the geographic based authorities. Of the major causes of death,

circulatory diseases (1.01) and respiratory diseases (1.07) have slightly higher (poorer) standardized

mortality ratios (SMR’s), while the cancer ratio (0.97) is better than BC. Cerebrovascular disease

(strokes) and diseases of the digestive system have lower (better) than average SMR’s. All of the

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external causes of death (accidents, suicides, drug induced deaths, etc.) are better than BC’s average

rate. These standardized ratios for the time period 2007 to 2011 have all improved relative to the

province since 2004 to 2008 time interval. Fraser Health’s potential years of life lost before age 75 (PYLL)

rate is 0.93, the second best behind Vancouver Coastal. Amongst the Health Authorities, Interior,

Northern and Island Health all have higher than average PYLL rates. The infant death rate is also the

second best, exceeded only by Interior Health (all SMR, PYLL and infant death measures from BC Vital

Statistics).

Fraser Health is large in population and growing fast. Within this rapidly growing population conditions

related to diabetes and circulatory disorders are more prevalent than the BC average. Other factors such

as arthritis are less prevalent. Table 7 references chronic conditions where measured Fraser Health

prevalence is lower than average for BC based upon the PEOPLE 2013 population estimate.

On balance, there is little evidence to suggest that Fraser Health residents are less physically healthy

than their counterparts in similar age and gender cohorts across the province. Life expectancy profiles

are suggestive of a slightly healthier population on average. When compared to the provincial

population, fewer Fraser residents perceive themselves to be in only a poor or fair state of mental

health and a small portion of the population perceives itself to be in “quite a lot” of life stress.

The social dimension of health which addresses the complex interactions among people, their personal

characteristics and the environment is harder to describe than the physical and mental dimensions; it

often refers to the capacity to establish and maintain social bonds and to interact successfully with

others. The sense of community belonging reported in the CCHS for Fraser Health is somewhat below

but reasonably close to provincial norms given the rapid rate of community growth and expansion.

Examining all of the dimensions of health (physical, mental and social) helps to specify the desirable

focus for future planning in Fraser Health. The analysis completed for this review did not, however,

uncover marked deficiencies in general population health status.

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Table 7 Additional Fraser Health Comparisons

Although averages within cohorts are important to funding models and generic needs assessment, it is

the unique risk factor profiles of different populations groups which warrant consideration in the design

of health promotion and disease response activities. For example, aggressive programs for the

prevention, early detection and control of diabetes and hypertension may be needed to target South

Asian, and Filipino populations throughout BC. The South Asian Health Institute launched by Fraser

Health in 2013 is dedicated to the advancement of evidence based practice in support of this

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population. The South Asian Health Centre in Surrey is considered the best example of an early

accomplishment of this institute, a model for community and provider collaboration.

Similarly, Fraser Health has made good progress on aboriginal health issues, working constructively with

a range of partners including the communities and particular populations directly involved. Continued

efforts should deliver strong and responsive undertakings, most particularly with the First Nation Health

Authority.

It is anticipated that Fraser Health will augment and extend the scope of these and similar programs as

an organizational priority intended to address larger percentages of the population at risk within a

generally good and generally improving baseline health status.

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3.0 Profile of Service Use by FH Residents Need for health service, as examined in the preceding sections, is a function of the illness burden of a defined population. It is the conceptual sum of all heart conditions, strokes, cancers, arthritis, trauma, dementia and other forms of human morbidity in a population. Demand for service, on the other hand, originates with a request of the patient, resident or client (or a request of a physician responsible for care or of a family member) for intervention and follow up. Demand is related to, but independent of need. Need can manifest at a higher rate than demand (for vaccinations as one example) and demand can be higher than need as for diagnostic services where the diagnosis will not alter underlying health status. As a product of supply and demand, observed utilization is yet a further step removed from underlying need. Nonetheless utilization comparisons between and among different geographic areas and different sectors of the system over time can help augment an understanding of system, provider, family and consumer (patient/resident/client) priorities. Table 8 portrays utilization for Fraser Health residents for 2012/13 against the utilization experience of the Vancouver Coastal region. The vertical centre line represents the provincial average rate of use. The admission rate for all acute care clinical categories is higher for FH residents than for VCH residents. The largest discrepancies are for circulatory system diseases/disorders and for diseases/disorders of the kidney, urinary tract and male reproductive systems. The circulatory system age standardized rate of acute care use (weighted caseload) for FH residents was 44% higher than that for VCH residents in 2012/13; the kidney, urinary tract and male reproductive system rate was 102% higher. Over the entire spectrum of acute care, the admission rate (weighted caseload) for FH residents was 30% higher than that for VCH residents in 2012/13. Use is a function of capacity and demand. Demand is related to but not always fully aligned with need. For circulatory system disorders and kidney disease higher rates of utilization in FH should be expected based on the established profile of underlying need. The degree of expected elevation in use is impossible to quantify in a review of the current type (high level findings, snapshot in time). The overall rate of utilization compared to the immediately adjacent health authority sharing the lower mainland geography and population in arguably higher than that expected by a reasonable specification of the needs and pertinent preconditions for acute care.

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Table 8: Age Standardized Rates for Selected Services

Conversely, the age standardized utilization rate for home and community services is at a lower age standardized rate per 1000 for FH residents than for VCH residents. Public sector residential care is 6 to 7% lower, home support hours are 4% lower and assisted living is 29% lower(The VCH rate is considerably higher than the provincial average rate). In 2012/13 home support hours in Fraser Health were modestly lower than the provincial average level adjusted for age. In 2008/09, home support utilization was 4 per cent higher than the provincial age adjusted rate of use. The MSP fee for service data on encounters per 1000 closely follows the acute care trajectory, with FH use exceeding VCH use per 1000. It is important to note that VCH has a higher percentage of non-fee-for- service physicians, and that encounter based data rates every encounter the same, this can be a distorting factor.

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Table 9 compares the two largest population cohorts within FH to each other. Based on underlying

chronic disease prevalence an expected pattern presents for the acute care response to circulatory

conditions: the, South Fraser case usage rate is 19 % higher than North Fraser. The kidney, urinary tract

and male reproductive system rate is 14 % higher for South Fraser residents than for North Fraser

Residents. Over all acute care admissions are 5 % higher in the North compared to the South.

Cardiac surgery for Fraser North exceeds the provincial rate by 29%; Fraser South exceeds the province

by 37% after adjustment for age. The AMI hospitalization experience in Fraser Health is near the average

level for BC. Acute myocardial infarction (AMI) hospitalization is often used as a marker for coronary

artery disease in a population. The ratio of AMI to cardiac surgery is an identified reference point. The

Fraser Health rate exceeds the BC intervention rate; BC exceeds the national average rate of

intervention.

Table 9: South Fraser Compared to North Fraser

Residential care in South Fraser is 9 % lower than North Fraser. History and demographic makeup of the

population are factors in addition to age and gender which influence population health use. The

difference between South and North Fraser residents in the overall use of continuing care services is less

than the difference between Fraser Health overall and Vancouver Coastal. Once again, MSP encounters

follow the acute care trajectory

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Table 10 addresses the rate of acute weighted cases, inpatient and outpatient combined, for surgical

and medical patients from FHA compared to VCHA and VIHA. Population cohorts over and below age 70

are each standardized by age within the larger age spans. .

Table 10: Acute Care Use Profile

The tables above are colour coded in a “heat map” style where the progression from darkest green to

darkest red differentiates rates relative to the provincial average. The actual ratio relative to the

provincial rate of use is set out in the various cells of the table. It is clear that the utilization experience

for the age 70 plus population is notably higher in FH when compared to Vancouver, particularly for

medical (as opposed to surgical) patients. FH medical patient use over age 70 is 40% higher than that of

Island Health residents, while surgical use is only 4% higher (the Island has long had a heavy “surgical

footprint” coupled with high rates of mental health admissions) FH Surgical patient use over age 70 is

12 % higher than the rate of use by Vancouver Coastal Health residents. Under age 70 uses by FH

residents is very close to Island Health (4% lower on surgery, 3% higher for medical cases). Compared to

Vancouver Coastal residents, under age 70 use by FH residents is 18% and 27% higher for medical and

surgical patients respectively. Table 11 introduces a comparison between 2012/13 and 2007/08

utilization profiles for Vancouver, Fraser North and Fraser South. With a smaller population size, Fraser

East has more year to year variation and is not as well displayed in this particular presentation format.

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Table 11: Acute Care Use Profile and Trend

Over the five year time interval, Fraser North medical utilization by residents advanced from 16% over

provincial norms to 23% higher. Again for the over 70 population group, Fraser South moved from 7%

higher than the provincial average to 13% higher for medical care. Surgical care utilization for over 70

residents advanced from 5% over the provincial average to 8% higher. Age standardized utilization for

under age 70 population cohorts is in line with the province overall. The focus on over age 70

populations stems from the exceptionally high rates of growth expected for this group over the next two

decades.

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Table 12 tracks age standardized home support hour use in Fraser Health and its sub regional

components over a 10 year plus period. As can be seen home support use has consistently declined

when standardized for age, even over the recent years when acute care rates of use by FH residents

were increasing.

Table 12: Fraser Health Home Support Hour Use

3.1 Conclusions Concerning Observed Utilization Trends

Utilization statistics have been introduced as a tool to assist in appreciation of underlying population

health status and need for service. For previously identified reasons, use is always a rough proxy, a

function of supply and demand, and not necessarily a true reflection of baseline need. Nonetheless,

several conclusions are offered for consideration with reference to population health needs:

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Vital statistics including life expectancy, standardized mortality, infant death rate and potential years of life lost prior to age 75 all position Fraser Health as the second healthiest health authority, healthier on average than the province overall.

There is no evidence of declining acute care use by Fraser Health residents, particularly for medical patients and for patients 70 years of age or older where utilization rates are increasing relative to provincial norms.

Conversely, the age adjusted use of home support hour hours has declined significantly in recent years, particularly in Fraser South and Fraser North.

. Fraser Health residents over age 70 use 22% more weighted patient cases, 20% more cases and 16% more admissions per 1000 than the average of Vancouver Coastal and VIHA. FH utilization norms for the under 70 population are comparable to other urban regions of the province, but much higher than Vancouver which has historically had BC’s lowest admission rates for patients under age 70.

Cardiac conditions are treated at significantly higher levels in FH than elsewhere. The rate of revascularization to admitted heart attacks is significantly higher in FH than elsewhere in BC or Canada.

The overall rate of acute care service use in 2012/13 appears higher than the measured underlying health conditions would warrant. Acute care use is intensified by the lack of options in the primary and continuing care sectors.

3.2 The Intersection of FH Need, Utilization and Funding

Standardized for age, Fraser Health residents experience greater rates of admission, patient days use,

and weighted patient day use than their counterparts elsewhere in urban British Columbia. Over the

past decade the opening of new capacity has kept up with the ageing and growth of the population, yet

acute care occupancy pressures persist in this large and fast growing health authority.

Although all authorities are unique in some way, exceptional status in the extent of population growth

and aging is the most likely underlying demographic circumstance to be captured by contemporary

regional health funding models. Other important determinants of need are also addressed in existing BC

funding models including remoteness, case complexity, and to a limited extent, health status. The

following determinants are issues of concern across all health authorities to differing degrees:

underlying morbidity and mortality trends across the population age spectrum

economic and social vulnerability

First Nations and aboriginal health issues,

housing,

education,

Immigrant and ethnic status demographics.

Since Fraser Health’s projected deficit for 2013-14 played a significant role leading up to Ministerial

Order M-282, operating-budget consistency warrants some discussion. From the Canadian perspective,

health-care expenditure by province changed significantly between 2002 and 2011. In 2002, BC had the

third-highest expenditure per capita on health care; by 2011, however, BC dropped to the second lowest

(Figure 1).

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Figure 1:

3.2.1 BC Ministry Funding The Ministry provides annual funding allocations to health authorities at the beginning of the three year budget cycle. Funding in the current year is confirmed, the two out years are notional and subject to change. In practice to date, the notional funding level in the two out years is either confirmed or increased in the subsequent budget cycles. Base funding adjustments made during the course of the current fiscal year are reflected in the subsequent budget cycle. Onetime adjustments are also made available as circumstances warrant.

The Ministry funds HAs with a mixed approach, using its Population Needs-Based Funding (PNBF)

model, supplemented by a targeted funding approach (capital substitution needed for public private

partnerships among other things) and activity-based funding used to provide specific incentives in

support of expected outputs from the system. Raw per capita funding comparisons are not

particularly helpful in the Fraser Health context:

Ignores inter-regional flows (e.g. patient referral patterns between FHA – VCHA)

Insufficient recognition of the cost of complex services (e.g. patient referrals to VGH or SPH)

Ignores factors such as remoteness, underlying health status, the cost of remote care

delivery, and age make-up of the population served

The PNBF model is a tool for allocating available funding. PNBF helps determine a HA’s share of

funds – but it is not the sole factor in determining this. PNBF does NOT determine available funding,

i.e. the size of the pie to be allocated.

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PNBF allocations among HAs are based on:

Population’s estimated need for services

Population size, age structure, health status

Where services are delivered (model adjusts for ‘inter-regional flows’ where HAs provide

services to residents of other HAs)

Cost adjustment factors for remoteness / small size facilities and complexity / tertiary care

facilities

PNBF models have been developed and implemented for Acute Care and Home & Community Care

(residential and community services)

Figure 2 illustrates how the PNBF system works in practice.

Figure 2: Overview of BC Funding Model

Figure 3 establishes the impact of various funding adjustments on the Fraser Health allocation. The

adjustment for age and gender reduces the FH allocation by approximately 3 % reflecting a younger

population than the BC average. A further half percent reduction occurs in recognition of the relatively

better than average health status as measured by chronic disease prevalence and associated treatment

cost proxies. A 10.4% drop occurs in recognition of net workload transfers, predominately to Vancouver

Coastal. Remoteness funds are top sliced from the model and reallocated, reducing FH funding by a

further 4% (only the Interior and Northern Health authorities have a net gain from the remoteness

allocation). Complexity decreases FH funding by almost an additional 3% again reflecting the macro

patterns of service allocation in the lower mainland. In this context, what appears as a reasonable

distribution of complex tertiary costs from the provincial perspective may be a subject of concern to FH

which has been expanding its baseline tertiary service commitment.

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Figure 3: Impact of Various Steps in the PNBF Allocation Process

3.2.2 Population Health Need and Implications for Funding Each HA’s current year funding allocation is determined using the Ministry’s established approach (e.g.

allocating targeted funding for provincial priorities, then adding the PNBF allocation). To test the

“reasonableness” of the allocation, Ministry staff compare the communicated funding against what each

HA might have received if all available funding was run through just the PNBF model (no interventions).If

an HA’s communicated allocation is moving away from its “notional PNBF allocation”, the Ministry may

intervene with additional funds to the affected HA. FHA’s communicated allocation in the various

funding letters is consistently close to its notional PNBF allocation (plus or minus one percent).

Adding the one time provisions allocated to Fraser Health over the past confirms that Fraser Health

funding made available consistently slightly exceeds the articulated PNBF model allocation for the past

several years.

Each year the Ministry’s PNBF model is up-dated for the latest demographic, inter-regional flow and

utilization data that is available. FHA’s PNBF share and relative ranking has steadily increased in

recognition of its expanding population and changing demographics, moving FH from the second largest

funding allocation in 2010/11 to the largest since 2011/12 and beyond. The 2015/16allocation forecast

would position FH with 30.5% of funding, compared to 26.8% for Vancouver Coastal (the second largest

allocation).

.

IHA FHA VCHA VIHA NHA

Distribution by Pop only 16.1% 35.8% 25.1% 16.6% 6.3%

2: After Demographics 17.7% 34.7% 23.8% 18.3% 5.5%

3: After adding Health Status 19.0% 34.5% 21.5% 18.7% 6.3%

4: After Interregional Flows 17.6% 30.9% 27.8% 18.9% 4.8%

5: After Remoteness 18.2% 29.7% 26.9% 18.5% 6.8%

6: After Complexity 16.8% 28.9% 28.8% 19.2% 6.4%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

HA PNBF Share of Acute Care 2013/14

26

When new facilities are brought on stream, the incremental cost exposure to Fraser Health have been reviewed by the Ministry and funded concurrently (or even in advance). Fraser Health residents have relatively high rates of use. These higher rates have been accommodated through the existing funding model. Population growth and population aging, the two factors best l recognized in PNBF generate incremental funding contributions which can often (though not always) be implemented locally for a marginal cost increment (economies of scale, fixed costs spread over a larger volume of activity, etc.). As previously illustrated, Fraser Health patient days for the population over age 70 were substantially higher than the Island Health and Vancouver Coastal average in 2012/13 .(. This ongoing patient day experience points to the futility of adding acute care bed capacity in Fraser Health as the unilateral or even primary response to population aging. There is no guarantee and indeed there is limited likelihood that existing site congestion problems can be fixed by dollars alone or dollars as the primary lever. The funding model starts with age standardized volumes of weighted cases; utilization beyond provincial norms in acute care restricts funding opportunities in primary care and continuing care. Moderating over age 70 acute care use through the development of well-considered options has to be a priority for Fraser Health in the years ahead.

The funding system recognizes the cost exposure associated with chronic conditions. Accordingly, a measure of support is included for the above average rates of diabetes and heart disease, but this is offset by lower observed prevalence rates for other costly conditions such as dementia and arthritis which are less in evidence in FH.

All health authorities have areas of lesser or greater than average intervention, reflecting local need, demand and supply conditions. The factoring of regional priorities under PNBF funding is a responsibility of the local governing Board. All health Authorities have issues with the PNBF model which are of concern from a local perspective. For example, FH may well argue for a larger share of the complexity funding while questioning the degree of support for remoteness. The Interior and North may well have decidedly different views. The provincial role is to address these competing expectations with a transparent system which stands the test of time. On balance Fraser Health has funding consistent with provincial policy, given the age structure of the population, chronic disease prevalence and cross regional patent flow dynamics. A change in any one of these circumstances or a change in the weighting allocated to various inputs in the formula could be consequential if the funding system fails to adjust over time. Analysis of the funding allocations since 2010/11 confirms a rate of growth in funding exceeding that of all other Health Authorities, recognizing the pressures of population growth and aging. At present, Fraser Health receives its full share of PNBF and a very small bit more through onetime adjustments.

3.2.3 Deployment of Regional funds In Health Service Plans, developed by Health Authorities within a Ministry framework, annual operating expenditures are reported by sector, specified as: Acute Care; Residential Care; Community Care; Mental Health and Substance Use (MHSU); Population Health and Wellness (PHW); and Corporate. Table

27

13 provides a comparison of expenditure percentages. The percentages have remained very consistent since 2007/08 with sector coding changes over time as expenditure definitions have been refined in a joint Ministry/HA effort to reach consistency.

Table 13: Regional Health Authority Sector Expenditures 2012/13

FHA % IHA % NHA % VCHA % VIHA

Acute Care 1,693.1 57% 1,014.5 55% 430.8 59% 2,047.5 60% 1,092.2

Residential Care 521.5 18% 356.7 19% 95.9 13% 442.8 13% 343.4

Community Care 258.6 9% 183.6 10% 49.2 7% 240.9 7% 227.1

MHSU 209.8 7% 107.8 6% 50.6 7% 282.8 8% 143.2

PHW 73.6 2% 54.5 3% 37.2 5% 99.9 3% 55.5

Corporate 201.8 7% 131.2 7% 61.4 8% 289.6 9% 131.3

Total 2,958.5 100% 1,848.2 100% 725.0 100% 3,403.5 100% 1,992.7

On the surface, the FH expenditure distribution appears reasonably comparable to the pattern of other Health Authorities, but here the use of Vancouver Coastal services by Fraser Health residents becomes a material consideration. If the Vancouver Coastal cost exposure associated with Fraser Health residents (now funded by the Ministry outside of FH) was conceptually repositioned back into the FH envelope with the appropriate offsets for counter flow from VCHA:

The acute care percentage would increase to just under 60%, while the Vancouver Coastal allocation would shrink, placing FH with the highest percentage of acute care investment despite a younger than average population;

The FH Residential care would shrink to 17% as a result of the fully costed acute care funding; baseline and the larger conceptualized total HA expenditure;

The aggregate of Community Care, MHSU and PHW would shrink to 17%, the lowest amongst the health authorities

Recommendation 1: The MoH should continue to advance its detailed examination of PNBF

methodology and outputs to ensure funding system consistency and responsiveness.

Recommendation 2: FH should examine its sector allocation strategy, seeking opportunities to reinvest

outside of the acute care sector.

28

4.0 Theme One: “Right Place, Right Time, Right Provider, Right Care, Right Resources”

4.1 Access and Flow

It is well recognized that hospital overcrowding creates inefficient processes of care and often

compromises clinical care, which in turn leads to decreased morale and poor staff engagement. A

disengaged staff is less productive and less improvement-focused. In an environment of overcrowding it

is almost impossible for care providers to shift their focus from day-to-day stress at work to

implementing sustainable strategies to improve access and flow. Several factors have exacerbated

hospital overcrowding in Fraser Health including a perceived lack of sufficient acute beds (right

resources), longer than expected lengths of stay (right place, right time), beds blocked by ALC patients

(right place, right providers), and unexpected readmissions (right care).

There are only four main solutions to the current overcrowding problem: open more acute-care beds,

decrease ALOS/ELOS, expedite the movement of ALC patients out of the acute-care setting, or admit

fewer patients.

4.1.1 Acute-Care Beds per 1,000 population Based on People 2013 data, 1.65 million people reside in the Fraser Health region. Ministry of Health

data from 2012-13 show that Fraser Health had 1.5 beds per 1,000 populations during the same period

(Table 14). At first blush, this raises the question of whether Fraser Health is under-bedded compared to

other HAs, but the number of hospital beds that are needed to serve a population depends on four main

factors:

1. Age structure of the population: A population with a large proportion of seniors would generally

require more beds per capita than an area with a small proportion of seniors. As we noted in the

previous section FH has one of the lowest proportion of seniors.

2. Health status of the population: A healthier population would generally require fewer beds per

capita than a population of people with poorer health. As noted previously FH has a population

with generally higher health status than do the other HAs

3. Location of tertiary services: Tertiary services generally require highly specialized personnel and

equipment: Also, tertiary services are generally centralized in a single location, such as the BC

Children’s Hospital, to provide care to all BC residents.

4. Isolation of the population: Because of the distance between communities, a region with

isolated communities would require more hospital beds per capita than urban regions.

29

Table 14: Beds per 1,000 Population

By health authority, a beds per population measure is not meaningful. Since many of the tertiary and

provincial services are provided in Vancouver Coastal Health or the Provincial Health Services Authority

(PHSA) facilities, the bed per population rate would overstate the number of beds for Vancouver Coastal

Health residents and understate the beds per population for other HAs such as Fraser Health.

A more appropriate measure for comparing regional bed rates is beds per catchment area population,

adjusted for age. Although health authorities are responsible for hospitals in their region, British

Columbians can be hospitalized anywhere in the province. Especially in the Lower Mainland, a

significant proportion of residents are hospitalized outside their local Health Service Delivery Area or

even their Health Authority. As will be discussed in Section 3 there are many reasons for this, including

convenience for the patient, where their physician has admitting privileges, or where the specialized

services are available. Because BC residents can, and do, use hospital services outside their health

authority, the calculation of bed rates should be based on the catchment area populations, which take

inter-regional flows into consideration.

4.1.2 Occupancy rates For fiscal years 2008-09 to 2012-13, Fraser Health had the highest occupancy rates of all HAs, whether

ALC patients were included in, or excluded from the analysis. With the exception of the Abbotsford

Regional Hospital, the larger Fraser Health hospitals (RCH, Burnaby, SMH and Delta Hospital) spent

almost these entire five years with occupancy rates above 100%. The data for 2011-12 and 2012-13 are

particularly compelling (Table 15).

IHA FHA VCHA VIHA NHA BC

Beds per 1,000 population (NOT age adjusted) 1.8 1.5 1.8 2.0 1.7 1.8

Beds per 1,000 catchment population (adjusted for age structure and

inter-regional flows including to PHSA) 1.7 1.9 1.6 1.8 2.5 1.8

Source: DAD 2012/2013 and PEOPLE2013, (excludes NICU beds and population under 1 year old)

30

Table 15:

Source: Provincial Scorecard of the Innovation and Change Agenda: 2012/13 Year End Performance Report

In the context of the time it takes to improve prolonged admit times from the emergency department

(ED) and the stress overcrowding places on the system, long lengths of stay, significant ALC days,

patients boarded in inappropriate hospital locations and hospital occupancy rates at most major sites

regularly exceeding 100%, this issue warrants urgent attention and improvement.

4.1.3 Alternate Level of Care (ALC) rates Through fiscal years 2008-09 to 2012-13, Fraser Health was not unusual compared to other HAs for ALC

days as a percentage of total in-patient days, even though Fraser Health under-reported about 50,000

ALC days per annum up to and including 2011-12 (this was rectified from 2012-13 onward).

For the same time period, however, Fraser Health had the second highest number amongst all HAs for

ALC days ≥ 30 days (where the first 29 days of an ALC stay are not counted), second only to Island

Health. This may suggest a regional shortage of difficult-to-place ALC-patient beds. For further

discussion on ALC, see Theme 3.

31

4.1.4 Actual Length of Stay vs Expected Length of Stay (ALOS/ELOS) Comparing 2010-11 baseline data to 2012-13 actual performance, Fraser Health had the lowest

percentage of all HAs for cases where ALOS ≤ ELOS. Although Fraser Health met its assigned target in

2012-13, more than 35% of admissions exceeded ELOS (Figure 4). This is significant in that a 35%

reduction of cases where ALOS ≥ ELOS would contribute significantly to increased acute in-patient bed

capacity

Figure 4:

Source: Provincial Scorecard of the Innovation and Change Agenda: 2012/13 Year End Performance Report

ALOS/ELOS data for medical cases, however, is much more compelling. For the five-year period between

2008-09 and 2012-13, Fraser Health had the lowest percentage among all HAs of medical cases where

ALOS was ≤ ELOS (Figure 5).

32

Figure 5:

Source: Provincial Scorecard of the Innovation and Change Agenda: 2012/13 Year End Performance Report

Data from the five fiscal years 2008-09 to 2012-13 also show that Fraser Health has among the highest

ALOS/ELOS in BC for patients with chronic medical conditions. Key outliers include:

- Patients with heart failure (second highest in BC)

- Patients with stroke (second highest in BC)

- Patients with COPD (highest in BC)

- Patients with sepsis (highest in BC)

Since the majority of medical patients and, specifically, patients with chronic medical conditions in

Fraser Health are admitted under hospitalists, we hypothesized a cause-effect relationship between a

hospitalist being the most responsible physician (MRP) (or actively involved in patient care) and

increased ALOS/ELOS.

Appendix B confirms this relationship (see data highlighted in red). From this perspective, Burnaby,

Royal Columbian and Surrey Memorial Hospitals are major outliers because patients admitted under

hospitalists or who have hospitalists involved in their care at these sites have actual lengths of stay far in

excess of those for patients admitted under other members of the medical staff. For further analysis

please see Site Specific Analysis Appendix A.

33

While we are noting the correlation further analysis needs to be undertaken by the Fraser Board to

understand the underlying drivers which could include factors related to models of payment,

engagement etc. We are aware of the positive impact of the use of hospitalists in other jurisdictions.

4.1.5 Delays in Admitting Patients from the Emergency Department (ED) to In-Patient Beds Figure 6 provides further evidence of the extent to which overcrowding in Fraser Health is contributing

to poor access and flow. Data from the five years 2008-09 to 2012-13 show that timely flow from the ED

to in-patient beds is significantly below that of the other geographical HAs.

Figure 6:

Source: Provincial Scorecard of the Innovation and Change Agenda: 2012/13 Year End Performance Report

Recommendation 3: A retrospective five-year analysis of acute occupancy rates should be conducted

comparing sites to identify overcapacity trends and assess whether acute bed capacity is equitably

distributed within Fraser Health. Given current practices, Fraser Health has insufficient acute beds to

meet current demand. A short-term increase in acute bed capacity, distributed appropriately, could

then be implemented to allow administrators and health-care providers to focus less on acute

operational stressors and more on decongestion strategies. Any temporary increase in acute bed

capacity must be tied to an organizational imperative to focus on the development of sustainable

strategies to reduce ALOS/ELOS, prevent unnecessary readmissions, implement chronic-disease

pathways that reduce hospital admissions, address ambulatory-care sensitive-condition rates and

develop more effective and timely ALC patient placement mechanisms.

34

Recommendation 4: Fraser Health should implement a prospective ALOS/ELOS analysis methodology in

all its chronically overcrowded sites to provide real-time data that can be acted on immediately. Current

ALOS/ELOS data provided by CIHI is at least one to two years out of date.

Recommendation 5: Fraser Health should undertake an urgent review of the care provided by

hospitalists in its major sites to determine why hospitalist-associated patients continue to have

chronically high ALOS/ELOS rates. Fraser Health should then take decisive steps to correct this problem.

This action alone would have a major positive impact on acute-bed capacity. To effect significant

change, key performance deliverables should be linked to remuneration in future hospitalist contracts.

Recommendation 6: Fraser Health should address ED factors contributing to ED overcrowding. Whereas

ED overcrowding is often the result of acute inpatient over-capacity, this is not always the case. Timely

implementation of Recommendations 1 and 2 above will only resolve those problems that are not ED-

specific. Curtailing practices such as bringing patients back to the ED for follow-up, repeat IV antibiotics

or suture removal requires a change in emergency-physician culture and practice, development of

better relationships with primary-care physicians and community specialists, and often the

establishment of appropriately-resourced outpatient facilities to manage this non-ED workload.

Especially in the large EDs, discontinuation of the fee-for-service model of emergency-physician

remuneration should be explored, since the FFS model encourages physicians to bring back quick or

relatively simple cases to the ED when treatment could be easily provided elsewhere.

35

5.0 Theme 2: Key Quality Indicators and Culture

5.1 HSDA-Based Analysis: Patient Safety

5.1.1 Hospital Standardized Mortality Rate (HSMR) Analysis by HSDA Overall, Fraser Health’s HSMR is very near the BC average of 85 and well below the national average of

100, which is excellent (Table 16). While not yet a trend, Fraser Health has demonstrated consistent

improvement in this measure since 2008-09. Examining HSMR data more granularly by HSDA, however,

reveals opportunities for more focused improvement, particularly for those Health Service Delivery

Areas (HSDA) whose HSMR data falls in the second decile above the national average (Table 17).

Table 16:

HSMR in BC HAs

36

Table 17:

HSMR by Fraser Health Service Delivery Area (HSDA)

HSMR Parameter HSMR = 100-109

(1st

decile above mean)

HSMR = 110-119

(2nd

decile above mean)

30-Day In-Hospital

Stroke Mortality Fraser East

30-Day In-Hospital

AMI Mortality

Fraser North Fraser East

HSMR Surgical Cases

Fraser North Fraser South

Fraser East

HSMR ICU Cases

Fraser North

5.1.2 Readmission Rate by HSDA As will be discussed later acute inpatient bed capacity can be improved by several measures, including

reducing hospital readmissions. Low 30-day hospital readmission rates serve as a proxy for either good

initial care in-hospital or better outpatient follow-up to prevent readmissions.

Whereas 30-day readmission rates do not show that Fraser Health is an outlier when reviewing

aggregated data, improvement opportunities still exist for specific health conditions in specific HSDAs

(Table 18).

37

Table 18:

Readmission Rate (RR) by Fraser Health Service Delivery Area (HSDA)

Readmission Rate

(risk-adjusted)

RR = 100-109

(1st

decile above

mean)

RR = 110-119

(2nd

decile above

mean)

RR = 120-129

(3rd

decile above

mean)

30-Day Surgical RR

Fraser East

30-Day Obstetric

RR Fraser North Fraser East

30-Day AMI RR

Fraser North Fraser East

30-Day Surgical RR

Fraser East

30-Day Mental

Health RR Fraser East

The upcoming site specific analysis will further our understanding of which sites are contributing to high

HSMR.

Recommendation 7: Fraser Health should undertake an urgent review of service delivery in each HSDA

where HSMR falls above the national mean establish root causes and implement changes to improve

outcomes, based on the following priorities:

Priority 1 – sites where performance falls in the 2nd decile above the mean

Priority 2 – sites where performance falls in the 1st decile above the mean

38

Recommendation 8: Fraser Health should review 30-day readmission data in specific hospitals in each HSDA where rates are above the mean, establish root causes and develop an action place to reduce these readmissions. Priority 1 – Hospitals where readmission rates are in the third decile above the mean: In Fraser East: Abbotsford Regional Hospital for obstetric readmissions Chilliwack Regional Hospital for acute myocardial infarction (AMI) readmissions Priority 2 - Hospitals where readmission rates are in the second decile above the mean: In Fraser East: Abbotsford Regional Hospital for surgical readmissions Chilliwack Regional Hospital for surgical readmissions In Fraser North: Burnaby Hospital for surgical, AMI and obstetric readmissions Royal Columbian Hospital for surgical and obstetric readmissions Eagle Ridge Hospital for AMI readmissions Ridge Meadows Hospital for obstetric readmissions

5.1.3 Nursing-Sensitive Adverse Events Several Fraser Health hospitals perform very poorly when their nursing-sensitive adverse event rates are

compared to those within their Canadian peer hospitals. For nursing-sensitive adverse events for

surgical and medical patients in large community hospitals, Burnaby Hospital was the worst in Canada

for two consecutive years (100% of peer hospitals performed better in 2010-11 and 2011-12).

Surrey Memorial Hospital performed worse than 98% of peer hospitals for each of the same years on

nursing-sensitive adverse events for surgical patients. Royal Columbian Hospital fared only slightly less

unfavorably, with 92% of peer hospitals performing better in 2010-11 and 83% performing better in

2011-12 (Table 19). These outcomes are particularly concerning, considering that the majority of

surgeries that occur in Fraser Health are performed in these three hospitals. Peace Arch Hospital also

performed significantly poorer on this parameter in 2011-12 than in the previous year (51% of peer

hospitals performed better in 2010-11 and 88% performing better in 2011-12).

For nursing-sensitive adverse events for surgical patients in medium community hospitals, Ridge

Meadows Hospital performed in the bottom 5th percentile, with 99% of peer hospitals performing better

in 2010-11 and 96% performing better in 2011-12.

39

Table 19:

Performance Against Peer Group Hospitals: Nursing-Sensitive Adverse Events

for Surgical Patients

40

Figure 7 expresses surgical nursing-sensitive adverse events for these five hospitals from a different

perspective, as a rate per 1,000 surgical patients.

Figure 7:

Medical patients are equally prone to suffering an unusually high rate of nursing-sensitive adverse

events at Burnaby, Surrey Memorial and Ridge Meadows Hospitals, and to a lesser extent at Royal

Columbian Hospital (Figure 8).

Figure 8:

41

Table 20 combines performance information on nursing-sensitive adverse events for both medical and

surgical patients, compared to peer hospitals.

Table 20:

Nursing-Sensitive Adverse Events: % of Hospitals Performing Better in Peer Group

Medical Surgical

10/11 11/12 10/11 11/12

ARH 34 26 3 18

BH 100 100 100 100

CGH 45 49 55 38

LMH 62 65 68 60

PAH 40 63 51 88

RCH 82 94 92 83

SMH 97 98 98 98

DH 78 75 53 25

ERH 84 88 61 42

RMH 100 99 99 96

= worse than 90% of Canadian peer hospitals

= worse than 80-89% of Canadian peer hospitals

= worse than 65-79% of Canadian peer hospitals

= near or better than the median of Canadian peer hospitals

Recommendation 9: Fraser Health should undertake an immediate review of nursing-sensitive adverse

events at Burnaby, Peace Arch, Royal Columbian, Surrey Memorial and Ridge Meadows Hospitals to

identify root causes for significantly poor performance, by site, and take urgent steps to rectify this

problem. This is an urgent patient-safety issue.

5.2 Satisfaction Survey Results

5.2.1 Acute Care Survey Fraser Health's percent positive score for the overall quality of care received at acute care facilities was

89% in 2011-12, compared with the provincial average of 92% (Figure 8). Fraser Health received slightly

lower scores than other health authorities in all dimensions, including Access to Care, Continuity and

Transition, Coordination of Care, Emotional Support, Information and Education, Involvement of Family,

Physical Comfort, and Respect for Patient Preferences. Although 89% is not a significantly different

number from that of the other HAs, it is important to note that this is a drop in performance between

the 2005 and 2008 survey results.

42

Figure 9:

5.2.2 Emergency Department Survey Fraser Health's percent positive score for overall quality of care received in its EDs was 83% in 2012-13,

4% below the provincial average of 87% (Figure 10). Fraser Canyon and Delta Hospitals received the

highest scores in Fraser Health, 92% and 90% respectively in 2012-13, whereas Langley Memorial and

Surrey Memorial Hospitals received the lowest scores, each with an overall quality-of-care score of 76%.

Viewing the data from another perspective, Langley Memorial and Surrey Memorial Hospitals were both

double (24%) the provincial average (12.6%) for the percentage of patients responding “poor” or “fair”

(Figure 11). The proportion of patients reporting poor in comparison to fair was also higher in these

sites compared to other Fraser Health sites. Only one site, Delta Hospital, had a lower fair/poor score

(10.4%) than the provincial average. Physical comfort, emotional support, access and coordination, and

information and education were the dimensions that provided Fraser Health the most challenges, all

receiving positive scores under 60%.

43

Figure 10:

Figure 11:

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

FH Emergency Department Patient Satisfaction Survey

Fair

Poor

44

5.2.3 Mental Health and Substance Use Survey Fraser Health scored at the provincial average for patients reporting a positive experience in mental-

health and substance-use settings (Figure 12).

Figure 12:

Recommendation 10: Fraser Health should dedicate quality-improvement resources to focus on

improving patient satisfaction in its Emergency Departments. Surrey Memorial and Langley Memorial

Hospitals require the most urgent attention. Mission, Burnaby, Chilliwack and Ridge Meadows Hospitals

should also be addressed.

5.3 Patient Care Quality Office (PCQO) Function

An increasing number of clients writing into the MoH have complained that they have not received a

timely response to their concerns from the Fraser Health PCQO. The MoH has subsequently challenged

Fraser Health to meet its requirements under the Patient Care Quality Review Board Act. There is

concern at the Ministry that the Fraser Health PCQO is understaffed and therefore not able to manage

complaints according to legislated timelines and processes.

Fiscal year 2012-13 saw significant slippage on legislated timelines and response requirements by the

Fraser Health PCQO, as well as an increase in complaints escalating to the Patient Care Quality Review

Board (PCQRB). In the past year the Fraser Health PCQRB has made three recommendations to Fraser

Health to ensure that the PCQO is adequately staffed to meet legislated timelines, the only HA to

receive such recommendations.

During 2012-13 Fraser Health had the highest number of Board reviews completed (35), as well as

receiving the highest number of recommendations (54% of BC total). The top five subjects of concern

45

brought forward to the Fraser Health PCQO in 2012-13 were, in descending order:

1. Care

2. Attitude/conduct

3. Accessibility

4. Communication and

5. Discharge arrangements.

Over 75% of quality improvement recommendations to Fraser Health in 2012-13 are within the

dimensions of acceptability and safety. Two specific issues of note, highlighted through review board

decisions, are the use of the emergency departments for planned follow up care, and understanding

patient rights in relation to the Mental Health Act, particularly in the emergency departments.

Recommendation 11: Fraser Health should implement appropriate staffing and staff-training in its PCQO

to ensure it can meet Ministerial and PCQRB requirements.

46

6.0 Theme 3: Integration of Primary and Community Care

It has been shown that longitudinal and comprehensive primary and community care delivered by an

integrated multidisciplinary team improves health outcomes for patients living with one or more chronic

conditions, mental health and substance use issues and for the frail elderly.

This type of integrated care has been demonstrated to reduce utilization of emergency-department

services and hospital services, and delay the need for higher levels of care. Shifting care from the

hospital to the community and primary-care setting is a focus for the health authorities and part of the

strategic priorities described in the opening to this Report. Fraser Health has undertaken a number of

initiatives that are beginning to shift care away from the hospital. These efforts need to be spread and

scaled up in partnership with the Divisions of Family Practice across the region.

Fraser Health has developed a comprehensive set of population health profiles at the Local Health Area

(LHA) level1. These describe the health status and population health needs evident in each of the LHAs.

Although there are some consistencies in many of the population characteristics across LHAs, there is

also significant variability in the population profile and the associated health needs. These population

profiles provide meaningful direction for service providers as they focus their efforts to meet the needs

of particular communities.

As discussed earlier in this document Fraser Health’s population tends to be younger than the BC

average with an age distribution of 23% less than 20, 35% between the ages of 20 – 44, 28% between

the ages of 45 – 64, and 14% over age 65. The number of seniors in Fraser Health is expected to increase

rapidly over the next two decades and by 2032, the population age 65 and older is projected to increase

from 14% to 22%. Although the prevalence of chronic disease in Fraser Health is at or below the

provincial average, with the exception of diabetes, the incidence of chronic disease is likely to increase

as the proportion of those over age 65 increases.

The Ministry of Health’s Blue Matrix 4.0 provides an analysis of the population of BC’s utilization of

health care services funded by government. When the Blue Matrix is applied to Fraser Health’s

population using 2009-10 data, a picture of the number and percent of the population with certain

health states emerges. Table 21 outlines the percent of the population and number of people accessing

services with low, medium, and high complexity conditions or who are frail and living in the community.

This matrix suggests that there are over 650,000 people who require comprehensive, longitudinal

primary and community care services.

1 Source: Fraser Health, Population Health Profiles by LHA, 2010

47

Table 21:

MoH Blue Matrix 4.0, 2009-10 data applied to FRASER HEALTH population

Population Thousands Total Health Care

Cost

Low complex conditions 28% 439.2 14%

Medium complex conditions 7% 114.7 10%

Maternal and healthy newborn 3% 43.5 5%

Frail Population living in community 0% 4.0 3%

High complex chronic condition 4% 60.4 19%

Earlier in this section we described the struggles Fraser Health hospitals are experiencing with

overcapacity and quality of care issues. Shifting health services away from acute care, wherever it is

appropriate, represents one solution to pressures at the higher levels of care.

Further analysis of Ambulatory Care Sensitive Conditions (ACSC), Alternate Level of Care (ALC), actual

length of stay versus expected length of stay (ALOS/ELOS), readmissions, and emergency-department

utilization point to the opportunities that exist for health authorities and primary care practitioners to

partner in providing care in the community to reduce the utilization of higher-level hospital services.

ACSC is a measure of conditions that can be managed in community settings and should not require

admission to acute care. This measure includes the following conditions: chronic obstructive pulmonary

disease (COPD), asthma, diabetes, heart failure, epilepsy, hypertension, angina, and pulmonary edema.

Over the years 2008-09 to 2013-14 (partial year), the rate of ACSC admissions in Fraser Health has

improved. However, for every 100 Fraser Health ACSC admissions over age 75 in 2012-13, Vancouver

Coastal Health had proportionately 82 and Island Health had 90. Similarly, for every 100 ACSC

admissions under age 75 in Fraser Health in 2012/13, Vancouver Coastal Health had 75 and Island

Health had 85.2

If Fraser Health were to achieve an ACSC admission rate consistent with the other urban regions (Island

Health and Vancouver Coastal Health) for those over age 75 and under age 75, approximately 520 and

680 admissions could be saved respectively. If we assume conservatively that each admission has an

average length of stay of 3.0 days, 3600 inpatient days per year (about 10 bed-years) could be avoided.3

These calculations are made with reference to the acute and rehabilitation activity in Fraser Health

facilities. As Fraser Health has higher than average admission and patient day volumes, achievable

savings should be larger than those noted.

2 Source: MoH, ACSC Inpatient Cases %, by Health Authority and Year 3 Note that actual average lengths of stay for admitted ACSC patients range from 6.8 to 11 days.

48

ALC patients are those patients admitted to hospital who no longer require acute-care services but are

waiting for discharge to a setting with an appropriate level of care. Fraser Health’s ALC days as a

percentage of total inpatient days were underreported from 2009-10 to 2011-12 but were estimated to

range between 13 and 17%. In 2012-13, the ALC rate in Fraser Health was 13% and ranged from 5% at

RCH and 7% at SMH to 18% at Mission Memorial Hospital. During the same period, Vancouver Coastal

Health’s rate was 8% while the other Health Authorities’ ranged between 16 and 17%.4 The provincial

average of 12.7% was fractionally lower than that for Fraser Health at 13.1%.

Fraser Health’s ALC inpatient days have continued to decline into the first half of 2013-14. If this

downward trend were sustainable and progressive and if Fraser Health is able to reduce its facility ALC

days from 13% to 10%, 36,700 inpatient days could be avoided. This represents approximately 100 bed-

years. If ALC days were reduced to 8%, a further 18,300 days or 50 bed-years would be avoided.

As noted earlier in this document, for age groups over age 70 in Fraser Health, patient-day utilization,

weighted cases, and admissions were higher than those of Island Health and Vancouver Coastal Health.

This points to the importance of focusing on options other than acute care for those over age 70 and the

futility of adding acute care capacity as a primary response to the aging of the population.

ALOS for 35% of in-patient admissions in Fraser Health exceeded ELOS. Fraser Health experiences the

highest ALOS/ELOS for patients with chronic medical conditions of all the health authorities. If ALOS for

these patients were reduced to ELOS, utilization of acute care beds would be reduced.5

Readmissions to hospital for-all causes within 30 days of discharge represent another opportunity to

free up acute-care beds. The health authorities’ readmission rate ranged between 10% and 10.8% in

2012-13. Fraser Health’s readmission rate ranged from 9.1% in 2008-09 to 10.2% in 2012-13. While

Fraser Health’s rate is consistent with that of the other health authorities, readmissions to hospital often

can be prevented with intentional discharge planning and community follow up.6

Emergency-department utilization provides a picture of the effectiveness of the community and primary

care service delivery system as well as the effectiveness of patient flow inside the hospital. Over the

period from 2008-09 to 2012-13, Fraser Health experienced the poorest health-authority performance

in terms of the percent of patients who presented to the emergency department and waited less than

10 hours from the decision to admit to an inpatient bed. Over this same period, Fraser Health’s

performance has consistently been the poorest at Chilliwack, Abbotsford, Ridge Meadows, Langley,

Surrey Memorial, Peace Arch, and Delta Hospitals. Improvement was noted at Royal Columbian,

Burnaby, Mission, and Eagle Ridge Hospitals. Overall, 56% of patients in Fraser Health waited less than

10 hours in 2012-13. This indicator is an issue for all of the health authorities and no health authority is

meeting its target.

When patients present at emergency departments they are triaged using the Canadian Triage

Assessment Scale (CTAS). CTAS data for Abbotsford Regional, Burnaby, Royal Columbian, and Surrey

Memorial Hospitals is presented in Table 22.

4 Source: MoH, ALC days as a percentage of total inpatient days 5 Source: MoH, Provincial Scorecard of the Innovation and Change Agenda: 2012/13 Year End Performance Report

and 2013/14 Q1 Progress Report 6 Source: MoH, Readmission rates, unplanned/emergency readmissions within 30 days, all causes

49

Table 22:

Percent of visits by CTAS triage level

2012/13 2013/14

CTAS level 1 2 3 4 5 1 2 3 4 5

Hospital

Abbotsford Regional 0.5 16.7 45.3 31.4 6.0 0.5 16.8 46.6 31.0 4.2

Burnaby 0.2 10.7 41.9 44.4 2.7 0.3 11.7 45.0 41.3 1.3

Royal Columbian 1.2 12.2 54.1 28.6 3.7 1.6 14.1 57.4 24.1 2.3

Surrey Memorial 0.42 12.6 55.4 28.4 2.4 0.4 15.9 54.9 25.5 1.5

Patients triaged as level 4 and 5 generally could receive their care in a primary or community care

setting. Although patients triaged as CTAS 3 present to the emergency department with more complex

needs, a proportion of the care needs of this group could be provided in the community with intentional

care coordination through a primary care home and a multidisciplinary team. In particular, those with

co-morbid chronic conditions, the frail elderly, and those with mental health and substance use issues

often fall into this group. Rapid response, deployment of community services, self-management

strategies, and support for caregivers are critical components of care planning and care coordination

that have been shown to prevent utilization of emergency department services and ultimately hospital

admission. The percent of visits triaged as CTAS levels 3, 4, and 5 in Fraser Health’s hospitals in 2013-14

are outlined in Table 23.

Table 23:

Percent of CTAS 3, 4, and 5 visits in 2013/14 to FRASER HEALTH Hospitals

CTAS level CTAS 3 CTAS 4 & 5 CTAS 3 CTAS 4 & 5

Hospital Hospital

Abbotsford 46.6 35.2 Chilliwack 42.0 48.4

Burnaby 45.0 42.6 Delta 45.3 34.2

Eagle Ridge 56.5 28.5 Fraser Canyon 22.9 69.7

Langley 45.0 36.5 Mission 43.2 42.8

Peace Arch 38.9 49.2 Ridge Meadows 38.3 55.2

Royal Columbian 57.4 26.4 Surrey Memorial 54.9 27.0

50

In summary, there are compelling reasons to focus the efforts of the health authorities on improving the

partnership with primary care practitioners to deliver comprehensive, longitudinal and multidisciplinary

care for those people whose health condition would benefit from such coordinated care. The evidence

suggests that both acute-care and emergency-department utilization could be affected by refocusing the

system of services to the community sector.

Fraser Health has embarked on a number of initiatives and strategies to begin such a shift. Many of

these initiatives are in the very early stages of implementation and have not been fully evaluated, nor

have they yet had the opportunity to fully inform system change. The next section outlines what is

known about the status of the work underway.

6.1 Status of Primary and Community Care Strategies

6.1.1 Divisions of Family Practice There are ten Divisions of Family Practice in the Fraser Health region, which is the most comprehensive

coverage of the population by Divisions of Family Practice in the province. Each Division has a

Collaborative Services Committee (CSC), and senior staff representatives from Fraser Health participate

actively on these committees. Fraser Health receives funding from the Doctors of BC (BCMA) for the

Physician Support Program and is working to reorganize its primary care and physician-support-program

team to better align with the Divisions. A business plan has been submitted to increase resources in the

Physician Support Program.

There is a growing partnership between the Divisions and Fraser Health to implement initiatives that

improve outcomes for people living with chronic disease and mental health conditions, the frail elderly,

and the perinatal population, such as the Surrey Diabetes Collaborative, South Asian Health Centre,

Global Family Care Clinic, and the Chilliwack Primary Care and Seniors Clinic. Fraser Health documents

shared with this Working Group state that approximately 8,000 patients or 7.45% of the population that

needs to be targeted with such initiatives have received new or revised services. Spread and up scaling

of these initiatives and using the results of these initiatives to inform the system shift away from

hospitals to community and primary care represent future work for Fraser Health.

6.1.2 Attachment to Primary Care – GP4Me, NP4Me The Ministry of Health estimates that 27.3% (440,697) of Fraser Health residents remain unattached to a

family practice physician and that 15.5% (250,237) remain unattached to a primary care practice (also

identified as “group attachment”). Twenty nurse-practitioner positions have been added in 2012/13 to

Fraser Health from the NP4Me program.

Table 24 establishes the relative position of Fraser South (orange) and Fraser North (green) relative to

the BC average rate of GP attachment and group attachment over the five year 2007/08 to 2011/12

time interval. GP attachment is a subset of group attachment, identified when more than 50% of visits

are to a single GP within a group. In 2012/13 FH had an estimated 77.9% of its population associated

with a group, and 66.3% associated with a particular GP, very near the provincial average levels.

Unattached plus attached rates do not add to 100% as individuals with less than 3 visits in 10 years are

assigned to an “other” category which constitutes approximately 7% of the population in BC. As

displayed below Fraser North and Fraser South have moderately better rates of attachment than the

provincial average.

51

Table 24: Attachment Rates for Fraser South and Fraser North

Table 25 investigates the attachment rate in Fraser East relative to Central Vancouver Island as a

comparator. Fraser East attachment levels are below the provincial average, and the ratio is moderately

deteriorating with time.

Table 25: Attachment Rates for Fraser East

Table 26 sets out attachment rates for frail elderly and mental health and substance use populations as

described in the Ministry’s “blue matrix”. The community based frail elderly group is more likely to be

attached to a primary care physician than the population overall, an encouraging sign, although the

orange dots designating the Fraser South HSDA show a record of increasing unattached status for the

frail elderly in recent years. The record for mental and substance use clientele is not as positive with

more than 30% not having an identified GP, though “unattachment” to a primary care practice was in

the 20% range, with unattached status increasing with time. Green dots represent the Richmond HSDA

where the record is generally better for both population groups. Blue dots in the background indicate

the rates for other HSDAs, and the potential for increasing attachment rates in the years ahead.

52

Table 26: Attachment Rates for Selected Conditions

53

Figure 13 investigates the relationship between GP attachment and the ratio of Ambulatory Care

Sensitive Admissions (ACSCs) to overall admissions. Although the expected inverse relationship

between increasing attachment to GP care and a decreasing ACSC admit ratio is displayed at the HA

(orange line) and HSDA (green line) levels, the statistical association is very weak. Moreover a similar

scatterplot of attachment to a GP group shows a flat line with no inverse relationship whatsoever.

Figure 13

“Attachment” is a precondition to a transformation in acute care admission staging and general system

effectiveness. A strong attachment coefficient will be bettered with credible model building, relationship

building with both the provider and patient communities, capable project management and responsive

change management strategies. To address the attachment issues evident across the region, Fraser

Health and the Divisions of Family Practice have partnered to establish Rapid Access Clinics focused on

mental health and substance use in White Rock, Langley, Abbotsford, Chilliwack, Langley, and Burnaby,

with plans underway to implement in Surrey, New Westminster, and the Tri-Cities. A number of primary

care clinics have been established in partnership with the Divisions, such as the Global Family Care Clinic

in Burnaby, Primary Care Seniors’ Clinic in Chilliwack, and the South Asian Health Centre in Surrey. These

are relatively new initiatives with implementation occurring throughout 2013. The degree of partnership

established varies from Division to Division and is dependent on both Fraser Health leadership capacity

and the leadership in place at the Division level. Fraser East warrants particular attention in the years

ahead.

54

6.1.3 Accelerated Integrated Primary and Community Care Funding In 2012-13, Fraser Health received $14,417,051 to support initiatives targeted at improving health

outcomes for those living with mental health conditions, one or more chronic conditions, and the frail

elderly. In addition, Fraser Health received a one-time allocation of $2.5M in 2012-13. The projects

underway include:

a. BreatheWell (COPD) – served 450 patients

b. Psychosis Treatment Optimization Program (PTOP) – served 248 patients

c. Home First – served 419 patients

d. End of Life Care – served 345 patients

e. Community REDi (Community Reintegration and Rehab Services) – served 350 patients

An evaluation has been undertaken to take an early look at the impact of the PTOP, Home First and

BreatheWell initiatives on acute-care utilization. The evaluation suggests that all three projects have an

impact on acute care utilization. The BreatheWell project was found to not have an immediate impact,

but rather the impact became more evident over time. In terms of the spread of these initiatives beyond

the project phase, Fraser Health is implementing the BreatheWell initiative into residential care facilities

across the region. Early indicators suggest that the Community REDi project is not having the same

expected impact on hospital utilization.

Although it is early in the system design and implementation process, how Fraser Health intends to use

the learnings from these projects to inform system level change is not yet clear. There are learnings that

will be helpful to the next phases of work in Fraser Health, which could also inform work in other HAs.

6.1.4 Home and Community Care Services From 2007-08 to 2011-12, Fraser Health experienced the lowest client rates in the province for home

support, adult day services, home nursing care, and rehabilitation services for clients age 75 and older.

Home nursing care client rates have decreased steadily year over year for the past decade. Fraser Health

spends approximately 16% of its budget on mental health and community care services. Approximately

9% is allocated to community care. This funding percentage has remained consistent over the last four

years. The spending of the other health authorities on mental health and community care ranged from

14 to 18% in 2012-13.

Fraser Health implemented a Home-First initiative in 2012-13 that is funded through the accelerated

Integrated Primary and Community Care funds. In addition, there is work underway in Fraser Health’s

Home Health program to establish connections between Case Managers and GPs and to ensure that

Home Health staff are educated in the CARE management approach. Given Fraser Health’s historical

investment in Home Health services, this change in emphasis is critical if people living with chronic

conditions and the frail elderly are to receive their care in community and primary care settings.

55

Recommendation 12: Fraser Health should continue to establish trusting relationships and partnerships

with Divisions of Family Practice in order to integrate services that enable longitudinal-care planning and

care coordination for those living with chronic conditions, mental health and substance use, the frail

elderly, and the perinatal population. The business case developed by Fraser Health’s Primary Care team

outlining the resources required to facilitate this collaborative work should be considered for resourcing.

Recommendation 13: Fraser Health should continue with an intentional focus to redesign care

processes such as care management, care planning, and rapid access in the Home Health and Mental

Health and Substance Use Programs to align with family-practice changes and improvements underway

through the Divisions of Family Practice. Learnings from the initiatives underway in collaboration with

the Divisions of Family Practice and through the accelerated Integrated Primary and Community Care

funding should inform the redesign of Home Health and Mental Health & Substance Use care processes.

The change management required for Fraser Health leaders, physicians and staff to accomplish the

redesign of Home Health and Mental Health and Substance Use services needs to be carefully

considered and appropriately resourced.

Recommendation 14: Fraser Health should consider how its program structure facilitates or hinders the

integration of services between its Home Health, Public Health, and Mental Health & Substance Use

programs and the Fraser Health Primary Care Team and the ten Divisions of Family Practice. Changes in

the structure of Fraser Health’s community programs will be required to enable alignment and

integration of services that need to be positioned to respond to the variation in community and

population-based needs while retaining the consistency of these services across the region.

Recommendation 15: The Fraser Health Board of Directors should continue to advance an organization-

wide vision and strategy for system change focused on primary and community care with clear pathways

to specialist services and higher levels of care. This vision and strategy should be informed by the

excellent projects and initiatives underway across Fraser Health. The groundwork for the development

of such a vision and strategy has been laid through the Community-Based Health-Care-System Strategic

Planning that began in 2013 as a collaborative effort between Fraser Health’s Programs, Primary Care

Team, and Divisions of Family Practice. The Fraser Health Board must hold the organization accountable

for delivering the care processes and structural changes necessary to achieve the vision.

56

7.0 Theme 4: Health Human Resources

Collective agreement tracking information for the Health Authorities and Providence Health Care

confirms that both straight time hours (vacation/other paid leave included) and productive hours have

been growing at a faster pace in Fraser Health than in the province overall. From the mid-point of 2010

to the mid-point of 2013:

Fraser Health was the largest provincial employer of nursing staff by a considerable margin, with over 50% more paid hours than Vancouver Coastal Health, the second largest employer of nurses; Fraser Health nursing hours, including Licensed Practical Nurses (LPNs), grew by 17.4% over the three years up to 2013 while the provincial nursing hours grew by 12.0%;

the health-sciences group of employees (HSA) grew by 10.5% against a provincial rate of 8.5%;

the community-agreement staff grew by 15.1% against a provincial growth rate of 8.6%; and

the facilities-agreement staff grew by 6.1% against a provincial average of 3.2% (LPNs are not included in the facilities-staff comparison).

This collective agreement data is captured by worksite location. Health Shared Services BC (HSSBC) staff

are not included in the above numbers.

Over a longer time period, for which data is available (2008 to 2012 inclusive), non-contract (excluded)

staff grew by 19.1% in Fraser Health. The provincial average growth rate was 18.6% over the same 5

years. Overall, it is evident that Fraser Health has experienced both the opportunities and challenges

associated with an expanding workforce. The productivity of this workforce can be analyzed by

examining overtime, sick time, staff injury, and staff vacancy rates.

7.1 Overtime

Overtime is often the result of temporarily high patient volumes, permanent service demand growth or

inefficient work processes. The overcapacity issues in many Fraser Health sites described earlier in this

report are a likely contributor to the nursing overtime experienced in several sites across Fraser Health.

Despite these growth pressures, Fraser Health made progress on the management of overtime during

the mid-2010 to mid-2013 time period. Figure 14 describes the overtime hours as a percentage of

productive hours for the health authorities. Nursing overtime hours grew by only 2% per FTE, or 30.4

hours per FTE, in mid-2013 compared to a provincial average growth of 31.6 hours per FTE in the same

period. Although nursing overtime is an ongoing challenge for all health authorities, Fraser Health’s

progress in managing nursing overtime between mid-2010 and mid-2013 is commendable, particularly

given the 17.4% increase in nursing hours over the same time frame. Generally, a relatively rapid

expansion of nursing hours coupled with an aging workforce demographic is accompanied with growth

in overtime per FTE.

57

However, by mid-2013, overtime hours began to increase, placing Fraser Health in about the midpoint in

overtime use per FTE among the health authorities. Remedial measures were introduced at Fraser

Health and overtime as a percentage of productive hours again started to decline. As of February 2014,

overtime use in Fraser Health is at 2.29% of productive hours compared to 2.68% for the corresponding

2013 fiscal year to date period.

The Fraser Health nursing overtime percentage is at 3.35% this year, compared to 3.93% last year.

Nursing overtime use at several Fraser Health hospitals exceeded 4% in 2013/14. These sites include

Abbotsford Regional, Eagle Ridge, Langley, Mission, Royal Columbian, and Surrey Memorial Hospitals. All

of these sites, with the exception of Surrey Memorial Hospital, experienced a drop in nursing overtime

in 2013-14 compared to 2012-13. The Royal Columbian Hospital experienced a significant decline, with

nursing overtime dropping from 6.98% to 4.89%.7

7.2. Sick Time

Fraser Health’s sick time hours per regular FTE are constant or nearly constant over the past three years.

Overall, sick time is up 3.5% for nurses, up 1.1% for the facilities bargaining unit, down 9.4% for the

health sciences sector, and up 13.8% for the community bargaining unit. In all cases, Fraser Health is at

or moderately above provincial norms in sick time use. Of interest, sick time for the three-year period

ending a year previously (2012) was somewhat better than that in 2013, with Fraser Health sick time

decreasing modestly for both the one-year and three-year periods ending December 31, 2012.

7 Sources: Fraser Health, Overtime by Locations and Health Employers Association of BC (HEABC), Overtime as a

percentage of productive hours, 2008 to 2013

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

2008 2009 2010 2011 2012

Pe

rce

nt

Figure 14:

Overtime hours as a percent of productive hours

IHA FHA VCHA VIHA NHA PHSA British Columbia

Notes: VCHA includes Providence.

58

Figures 15 and 16 show sick time as a percentage of productive hours for the years 2008 to 2012 and by

quarter in 2012 and 2013.8

8 Source: HEABC, Sick leave as a percentage of productive hours

4.0%

4.5%

5.0%

5.5%

6.0%

6.5%

2008 2009 2010 2011 2012

Pe

rce

nt

Figure 15:

Sick leave as a percent of productive hours

IHA FHA VCHA VIHA NHA PHSA British Columbia

Notes: VCHA includes Providence.

59

Attendance management is an area that requires consistent attention in all of the health authorities and

is not unique to Fraser Health. Information on a site-by-site basis was not made available to us and may

be worthwhile to examine. In addition, there is a growing proportion of the workforce who exhausts

their sick banks and utilizes unpaid sick time. Unpaid sick time is not captured in these workforce

statistics.

7.3 Staff Injury Rate

Using the WorkSafe BC (WSBC) definition of ‘non-health care only’ claims, the Fraser Health staff injury

rate per 100 FTEs increased from 4.3 to 5.3 claims per 100 from 2009 to 2012 inclusive. As outlined in

Figure 17, Fraser Health’s experience is the second-highest rate among the health authorities between

2009 and 2012. At 17.5 claims per 100, the Fraser Health long-term-care experience was the highest

rate of all HAs in 2012.9

In 2013, Fraser Health was able to drop its ‘WSBC claims with cost’ by over 8% from the average of the

previous three years. The long term care experience also declined by 17% over the past three-year

average.10

Claims duration is a particular focus for all Health Authorities. The WSBC rolling average calculation

positioned Fraser Health at 43 days per claim in 2013, the lowest average duration among the HAs. As

9 Source: WSBC, Staff injury rate/100 person years of employment, 2008-2012 10 Source: FH, Fraser Health WSBC Claims History

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2012 2013

Pe

rce

nt

Figure 16:

Sick leave as a percent of productive hours

IHA FHA VCHA VIHA NHA PHSA British ColumbiaNotes: VCHA includes Providence.

60

with overtime control, Fraser Health‘s track record on staff injury duration shows an ability to focus on

results, to identify effective remedial and preventive measures, and to improve organizational

performance.11

7.4 Difficult-to-Fill Vacancies

Difficult-to-fill vacancies are those vacancies that have been posted externally and remain unfilled after

90 days. These vacancies declined steadily in BC from 2008 to 2011 with all HAs experiencing relief from

near-crisis levels. By the third quarter of 2012 the rate had again started to climb, with province-wide

vacancies in the health sciences sector increasing 31% by Quarter 2 in 2013 from Quarter 4 in 2012

(Figure 18). This was offset by a 10% decline in nursing vacancies overall.

Fraser Health is experiencing challenges, though not at 2008 levels, in difficult-to-fill health-sciences

positions, which include such professionals as pharmacists, physiotherapists, occupational therapists,

social workers, and lab and imaging technologists. Difficult-to-fill nursing positions in Fraser Health are

at the provincial average level.12

11 Source: FH, WSBC Claims Duration 12

Source: HEABC, Vacancies in “difficult-to-fill” positions

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

2008 2009 2010 2011 2012

Cla

ims

pe

r 1

00

pe

rso

n-y

ear

s o

f e

mp

loym

en

t Figure 17:

Staff Injury Rate by Health Authority

IHA FHA VCHA2 VIHA NHA PHSA4

2 VCHA does not include Providence 4PHSA does not include EHSC *2012 injury rates are esimates using 2011 payroll

61

7.5 Staff Deployment Opportunities

Overtime use and difficult-to-fill position pressures are influenced by staff mix and the rate of program

growth. Fraser Health, with known population growth and demand pressures, will continue to add staff

in the years ahead. Staffing at the BC median level of productive hours per patient day in Fraser Health

facilities could reduce the demand for nursing positions somewhat, and staffing with a higher ratio of

nursing-support staff could also reduce the potential for difficult-to-fill situations if the lower mainland

pool of available nursing staff continues to tighten. By some estimates, a redesign of care process and

staff mix could redirect as many as 70 nursing positions. This would require significant staff engagement

and an effective redesign process, such as the ‘releasing time to care’ model used by Vancouver Coastal

Health. Health Sciences vacancy management can be an even-more-difficult challenge, suggesting the

need for careful control of the pace of program expansion.

0%

2%

4%

6%

8%

10%

12%

14%

2008 2009 2010 2011 2012

Pe

rce

nt

Figure 18:

Vacancies in “difficult to fill” positions

IHA FHA VCHA VIHA NHA PHSA British Columbia

Notes: VCHA includes Providence.

62

7.6. Hours of Care per Patient Day

Hours of care per patient day provides a picture of the care provided by the nursing-care team, including

front line registered nurses (DC1s), licensed practical nurses (LPNs), and Care Aides. Comprehensive

information was not available regarding the hours of care per patient day but a high level comparison is

provided in Tables 27 and 28.13

Table 27:

Hours of Care per Patient Day and Cost per Patient Day

Year to Date at

Period 11 – 2010

Year to Date at

Period 11 - 2014

Medical

Units

Inpatient Days 239,000 302,000

Worked hours/patient day (RN –

DC1, LPN, Care Aide)

5.23 5.78

Cost per patient day 10.66 13.67

Surgical

Units

Inpatient Days 133,000 138,600

Worked hours/patient day (RN –

DC1, LPN, Care Aide)

6.02 6.42

Cost per patient day 17.45 18.47

Table 28:

Comparison of Hours of Care per Patient Day Year to Date 2014 at 4 Fraser Health Hospitals

Hospital Surgical Units – Hours of Care

per Patient Day

Medical Units – Hours of Care

per Patient Day

Surrey Memorial 6.02 6.02

Royal Columbian 7.16 6.16

Abbotsford Regional 6.59 5.65

Burnaby Hospital 5.08 5.44

13 Source: FH, Financial Performance Report, Period 11, 2014

63

7.7. Staff Engagement

Improving quality of care and services requires attention to three areas: care processes, structures, and

culture. Culture exists at the unit level. A culture focused on quality reflects characteristics such as

feeling safe to speak up about quality issues and a willingness to challenge the status quo, perceptions

of management, and the quality of team relationships. Staff engagement is an important aspect of

building such a culture. Also critical is how the changes necessary to achieve a quality culture are led and

implemented.

The Gallup Q12 engagement survey is one method available to BC health authorities to gain insight into

organizational culture Staff engagement can be directly linked to improved health care performance and

improved patient outcomes in the health sector.

The health authorities have participated in three Gallup Q12 staff engagement surveys. Fraser Health

had a 17% improvement in participation in the 2013 Gallup Q12 survey, with 67% of staff participating

and the grand mean improved by 0.07 to 3.52. Fraser Health grand mean compares favourably with the

other health authorities as outlined in Table 29.14

Table 29:

Grand Mean by Health Authority in 2013

Health Authority Grand Mean Health Authority Grand Mean

PHC 3.58 NH 3.55

VCH 3.54 FRASER HEALTH 3.52

PHSA 3.49 VCH 3.54

IH 3.41 VIHA 3.39

The grand mean for BC health authorities overall in 2013 is 3.49. This represents a small improvement

from 3.44 in 2010. This compares to a grand mean of 4.11 in Gallup’s overall healthcare database. BC

health authorities’ staff-engagement performance is in the bottom 25th percentile. The ratio of engaged

to actively disengaged staff in BC is 0.9 to 1, as compared to 2.3 to 1 in the Gallup Canada database and

4.5 to 1 in the Gallup healthcare database (international). Gallup states that the staff engagement

tipping point occurs at 4.0 engaged to 1 actively disengaged.

14 Source: Gallup, British Columbia Health Authority Overall Presentation of Results, 2013

64

The Gallup survey results for Fraser Health, while not significantly different from the rest of the province

require attention. An overview of the Gallup grand mean by site in Fraser Health is summarized in Table

30. All sites showed improvement in 2013 over the grand mean in 2010 with the exception of Mission. In

Fraser Health overall, two out of ten staff are engaged and six out of 10 are not engaged. There is a

higher percentage of bargaining unit staff who are actively disengaged versus engaged. The survey

results also point out that there was weak follow-through after the 2010 survey.15

Table 30:

Gallup Q12 grand mean by site in 2010 and 2013

Site 2010 2013 Site 2010 2013

Abbotsford 3.46 3.58 Burnaby 3.43 3.49

Chilliwack 3.29 3.39 Delta 3.51 3.55

Eagle Ridge 3.39 3.48 Fraser Canyon 3.30 3.50

Langley 3.28 3.42 Mission 3.47 3.30

Peace Arch 3.29 3.57 Ridge Meadows 3.29 3.46

Royal Columbian 3.36 3.47 Surrey Memorial 3.47 3.58

Fraser Health has developed a draft engagement plan that includes the following four strategies:

Large Scale Cultural Change - Intentional actions across the organization to grow a culture that

fosters interactions to improve the quality of daily work and care

Communication - Communication Plan to inspire and regularly inform all staff about main

actions, progress and celebrations in an innovative and “engaging way”

Recognition - Build a culture of recognition through both formal and informal actions.

Accountability – Fraser Health Employee Survey Gallup Q12 follow up process strengthened by

CEO cascading objective and entry into Performance Link.16

15 Source: FH, 2013 Fraser Health Employee Survey – Gallup Q12, PowerPoint 16 Source: FH, Every Opinion Matters: Fraser Health’s E Plan (draft) 2013-2015

65

Recommendation 16: Fraser Health has undertaken work to manage overtime, sick time, staff injury

rates and duration with demonstrable results. Focused efforts to improve staff productivity need to

continue in Fraser Health as in all health authorities.

Recommendation 17: Fraser Health may benefit from an examination of the deployment of the

workforce and should do so in a manner that engages staff in the process of analysis and redesign.

Recommendation 18: Fraser Health should be commended for the improvement they have experienced

in both their staff engagement scores and the increased staff participation in the 2013 Gallup Q12

survey. As in all BC health authorities, intentional work is required to continue to improve staff

engagement. This work is critical given the degree of change underway in Fraser Health and across the

health system.

Recommendation 19: The Fraser Health Board should explore strategies that foster an improvement

culture, teamwork and communication at the unit and site level to address the significant quality issues

identified. Deliberate strategies for engagement should exist as part of every improvement initiative.

66

8.0 Part Three: Site Level Narratives

Fraser Health has made some significant improvements in quality of care over the past few years, in

particular with regard to taking action on C. difficile infections, HSMR and medical device reprocessing.

While improvements have been made in these areas, they still warrant continued attention and effort to

maintain results and make continued improvements.

Based upon the high-level quality indicators selected for review, there are quality issues spanning the

region that would suggest further investigation and targeted initiatives are required, including hip

fracture procedures within 48 hours. Overall, the trend appears to be going in the wrong direction, with

several Fraser Health sites (Surrey Memorial, Royal Columbian, Burnaby, Abbotsford and Chilliwack

Hospitals) demonstrating poor performance in this area. More recent data from Fraser Health shows

some improvement across these sites (Periods 9 – 11 for 2013-14); however, there is not enough data to

determine whether these are sustained improvements. A theme of high readmission rates across

multiple Fraser Health sites also warrants further investigation

Monitoring outcome data at a regional, or even HSDA level, does not provide understanding of variation

across individual sites, nor does it provide an opportunity to determine where specific interventions

would yield the most significant improvements.

The first Working Group wanted to explore whether there were patterns of poor quality at specific sites.

Our quality-indicators review identified five sites with concerns across multiple parameters. The

methodology underlying this analysis is included in Appendix A. The clustering of issues across specific

sites requires timely intervention by the Board.

67

Figure 19: Quality Concerns by Site

Red – Major Quality Concerns Yellow – Significant Quality Concerns Green – Few Quality Concerns Subsequent to preparation of this report the MOH ran an updated analysis adding more recent data and using a slightly different methodology. For your information this is contained in appendix C. While the colours on the chart change slightly the overall trend and impact remain unchanged.

8.1 Surrey Memorial Hospital (SMH)

Across all quality indicators considered, SMH had flags that warrant deeper investigation. Most striking

is that a pattern of quality issues is consistent across multiple areas, such as infection control, surgical

outcomes, HSMR and patient satisfaction.

While SMH has demonstrated improvements in HSMR overall, the HSMR for ICU cases has remained

continuously high for the past five years at a rate above 120. In addition, SMH has multiple outliers and

“needs-improvement” areas that are highlighted in its NSQIP data. SMH performance on hip fracture

procedures within 48 hours was the worst in Canada, with a rate of 28.33 per 100 that is getting worse

over time.

Nursing-sensitive adverse events (NSAE) also reflect a significant concern, with NSAE for medical

patients (65.28) showing a slight increase over time, and rates of double those of the peer-group

average (29.19). For surgical patients (65.47), there has been no change in rates over the past three

years, which are also significantly high at double the peer-group average (35.99).

HSMRHSMR -

Surgical

HSMR-

Medical

HSMR-

ICU

Surgical

(NSQIP)

NSAE

(Medical)

NSAE

(Surgical)

Re-

admission

Rate

Hip Fracture

Repair 48hrs

Sepsis

Mortality

C.

DifficileMRSA

Hand

Hygiene

Pt-Satis.

Emerg

Surrey

Memorial

Royal

Columbian

Burnaby

Hospital

Abbotsford

Regional

Langley

Memorial

Peace Arch

Chilliwack

General

Eagle

Ridge

Ridge

Meadows

Delta

Hospital

Co

mm

un

ity

Larg

e

Co

mm

un

ity

Me

diu

m

68

Readmission rates at SMH are generally around the national average, with the exception of readmission

of patients aged 19 and younger, with 88% of peer hospitals performing better.

Infection control data at SMH show improvements in CDI rates, with Period 9 – 11 for 2013-14 showing

CDI rates below the Fraser Health target of 7.2 per 10,000 patient days. Rates for 2012-13 showed SMH

to be above the target at 8.2 per 10,000 patient days. The most recent data reviewed is insufficient to

determine if this is a sustained improvement over the previous fiscal year. The MRSA rate of 7.8 per

10,000 patient days in 2012-13 is above the health authority target of 5.6. Hand hygiene compliance is

66 %.

Patient satisfaction data by site was not available for the recent acute and mental health surveys;

however, site based data for patient satisfaction in EDs showed that 24% of patients rated their overall

experience in emergency as fair or poor, which is double the BC average.

8.2 Royal Columbian Hospital (RCH)

RCH has made some notable improvements in quality of care, in particular for in-hospital hip fractures

and HSMR. While HSMR overall, and HSMR for surgical, medical and ICU care is trending downwards

the numbers, in particular for ICU HSMR, are high and warrant continued attention. As well, RCH has

multiple outliers and needs-improvement areas that are highlighted in its NSQIP data, with 41 “Needs

Improvement” designations out of 94 outcomes. RCH performance on hip-fracture procedures within

48 hours is an outlier, with a rate of 58.55 per 100, which has remained stable over time. More recent

data from Periods 9 – 11 in 2013-14 show an average of 80.00 per 100, although there is insufficient

data to know whether this is a sustained improvement.

Readmission rates are notably above national averages for 30-day overall readmission rates (9.45 per

100); 30-day medical (13.97 per 100), surgical (7.12 per 100) and obstetric (2.86 per 100) readmission

rates, as well as for 90-day readmission following hip replacement (7.57 per 100).

Nursing-sensitive adverse events also reflect a significant concern, with NSAE for medical patients

(48.80) showing a slight increase over time. For surgical patients, nursing-sensitive adverse events

(40.47) have shown a slight decrease over time.

Infection-control data at RCH show improvements in CDI rates, with Periods 9 – 11 of 2013-14 showing

CDI rates below the Fraser Health target of 7.2 per 10,000 patient days. Rates for 2012-13 showed RCH

to be above the target at 9.7 per 10,000 patient days. The most recent data provided is insufficient to

determine if this is a sustained improvement over the previous fiscal year. The MRSA rate of 7.0 per

10,000 patient days in 2012-13 is above the health authority target of 5.6. Hand hygiene compliance is

65 %.

69

8.3 Burnaby Hospital (BH)

BH is showing flags in nearly all patient-safety indicators. BH’s overall HSMR has been trending down for

the past five years and showing improvement. The HSMR in ICU and medicine has leveled off at the

national average and warrants continued attention. As well, BH has multiple outliers and needs-

improvement areas highlighted in its NSQIP data (25 “Needs Improvement” designations out of 42

outcomes). BH performance on hip fracture procedures within 48 hours has been trending down over

time, with a most recent rate of 54.43 per 100, and is in the worst 3% of peer hospitals. More recent

data shows some improvements, but is not sufficient to know whether a true improvement has

occurred.

Burnaby Hospital is the worst performer in Canada on nursing-sensitive adverse events for both medical

and surgical patients. Both areas show no improvement over time, with rates for medical patients of

75.02 per 1,000 and 69.23 per 1,000 for surgical patients. Both are double the national average.

Readmission rates are high in almost all areas, with the exception of readmission following AMI, stroke

(demonstrating improvement) and hip and knee replacement.

Infection-control data at BH demonstrate improvements in CDI rates, which is a notable achievement

following significant attention to CDI at this site. While periods 9 – 11 of 2013-14 showed CDI rates to

be close to the Fraser Health target of 7.2 per 10,000 patient days, rates for 2012-13 showed BH to be

above the target at 8.5 per 10,000 patient days. The most recent data provided is insufficient to

determine if this is a sustained improvement over the previous fiscal year. The MRSA rate of 6.2 per

10,000 patient days in 2012-13 is above the health authority target of 5.6. Hand hygiene compliance is

79%.

Patient Satisfaction in the emergency department showed patients rated their overall experiences as

17.4% fair or poor (in comparison to the BC average of 12.6%).

8.4 Ridge Meadows Hospital (RMH)

While RMH is performing well overall on the quality indicators examined, particularly for improvements

in in-hospital fracture rates and in-hospital mortality following AMI, two areas were identified as

warranting further attention.

Readmission rates for stroke rose significantly in 2010-11 and 2011-12. In addition, 30-day overall

readmission rates, as well as medical and obstetrics readmission rates were high. There was also a big

jump in readmission rates following hip replacement in 2011-12 (more recent data are not available to

determine if this is sustained).

Nursing-sensitive adverse events also reflect a significant concern, with NSAE for medical patients

(70.26) showing no improvement over time, currently at double the peer-group average (29.19). For

surgical patients (61.76), there has been a slight decrease in nursing-sensitive adverse events over the

past three years, but these remain significantly high.

70

8.5 Abbotsford Regional Hospital

Across all readmission-rate categories, with the exception of patients aged 19 and younger and

readmission following knee replacement, ARH performed in the bottom 10% of peer hospitals. These

rates have been stable over time and suggest a need for further investigation.

8.6 Specific Focus on Surgical Quality Indicators for Fraser Health NSQIP Sites:

As part of the analysis of quality indicators, we completed a detailed dive into the surgical program area

for sites participating in the National Surgical Quality Improvement Program (NSQIP). Analysis included

the following indicators and data sources:

NSQIP Semi-annual Reports data

HSMR for surgical cases

Re-admission for surgical cases

Nursing-sensitive adverse events for surgical cases

Hip fracture repair within 48 hours.

Overall, the HSMR for surgical cases is trending downwards for the majority of Fraser Health sites,

demonstrating improvement over the past three years. Improvement opportunities exist at Royal

Columbian, Burnaby, Abbotsford and Chilliwack Hospitals for surgical re-admission rates; however,

variation among peer-group sites across the country is low.

Nursing-sensitive adverse events for surgical patients (NSAE-surgical) and hip fracture surgical

procedures performed within 48 hours are concerning for Fraser Health. Not only were NSAE-surgical

rates high in comparison to the percent of hospitals better in peer group for Surrey Memorial, Royal

Columbian, Burnaby, Peace Arch and Ridge Meadows Hospitals; the actual rates were almost double the

national average in Surrey Memorial, Burnaby Hospital and Ridge Meadows Hospitals, with no

demonstrated improvement over the past three years.

Hip fracture repair within 48 hours was a concern for the large community hospitals within Fraser

Health, with six of the seven hospitals in this category performing worse than 80% or more of peer

hospitals. Of particular note is Surrey Memorial Hospital, which is trending downwards over the past

three years, with most recent data showing a rate of 28.33 per 100 patients.

Fraser Health’s three largest sites show consistent concerns in multiple indicators of surgical quality.

While Royal Columbian and Burnaby Hospitals are demonstrating improvement in surgical HSMR data,

these three sites show continued concerns based on NSQIP, readmission, NSAE and hip fracture fixation

with 48 hours. Additionally Peace Arch Hospital NSQIP data highlights potential issues with its surgical

orthopedic program that warrants further investigation.

71

Recommendation 20: Fraser Health should continue participation in the National Surgical Quality

Improvement Program, since it will provide data enabling targeted quality improvement efforts to move

these big dot indicators.

Recommendation 21: The Fraser Health Board should ensure that quality-of-care materials that come to

the Board and Senior Executive Team provide a more fulsome picture of quality across both programs

and sites. The analysis of materials provided to us indicates that a systematic review of site-based

quality information appears to be limited in Fraser Health. This information should also be shown over

time and include sufficient data points to determine trends and understand variation.

Recommendation 22: The Fraser Health Board should seek to understand and take action on two

quality-of-care issues that have been identified across multiple sites: above-average readmission rates;

and hip fracture procedures that should be completed within 48 hours.

Recommendation 23: Fraser Health should undertake focused corrective action at the following four

sites, each of which demonstrate a pattern of quality concerns across multiple dimensions: Surrey

Memorial Hospital, Royal Columbian Hospital, Burnaby Hospital and Ridge Meadows Hospital.

Recommendation 24: The Fraser Health Board should strengthen accountability and site-level

operational leadership that focuses on quality improvement at those sites demonstrating poor

performance on multiple dimensions of quality.

72

Appendix A

FHA High Level Site Analysis Data Sources & Definitions

Abbreviation Quality Indicator Definition Data Source Flagging Rating

HSMR Hospital Standardized

Mortality Ratio

Ratio of the actual number of deaths in a facility to the expected

number of deaths for patients in acute care hospitals.

CIHI, 2013 A ratio of 100 = no difference between

the hospital’s mortality rate and

average rate in baseline year. A ratio

greater than 100 = hospital’s mortality

rate is higher than average rate; less

than 100 = hospital’s mortality rate is

lower than average rate.

Green: HSRM below 100/ trending

down

Yellow: HSMR close to 100/ trending

down

Red: HSMR above 100

HSMR –

Surgical

Hospital Standardized

Mortality Ratio –

Surgical Cases

Ratio of the actual number of surgical case deaths in a facility to the

expected number of surgical case deaths for patients in acute care

hospitals.

CIHI, 2013 As above.

HSMR –

Medical

Hospital Standardized

Mortality Ratio –

Medical Cases

Ratio of the actual number of medical case deaths in a facility to the

expected number of medical case deaths for patients in acute care

hospitals.

CIHI, 2013 As above.

HSMR – ICU Hospital Standardized

Mortality Ratio – ICU

Ratio of the actual number of ICU deaths in a facility to the expected

number of ICU deaths for patients in acute care hospitals.

CIHI, 2013 As above.

NSQIP National Surgical

Quality Improvement

In the NSQIP reports there are three designations for their outcome

reporting: exemplary, as expected and needs improvement.

ACS NSQIP Interim

Semi-annual Report

NSQIP sites identified as flagged have

high ratio of Needs Improvement /

73

Abbreviation Quality Indicator Definition Data Source Flagging Rating

Program (American

College of Surgeons)

Exemplary outcomes are in the top 10% of participating hospitals

and/or are statistically significant high performers. As expected

outcomes are everything that falls between exemplary and needs

improvement. Needs improvement outcomes are in the bottom 10%

of participating hospitals and/or are statistically significant low

performers.

(04/01/2012 - 03/31/2013) Outcomes or have multiple outliers.

NSAE –

Medical

Nursing-Sensitive

Adverse Events for

Medical Conditions (All

Medical Case Mix

Groups) (rate per

1,000)

Four NSAE events: Hospital acquired pneumonia; Hospital acquired

urinary tract infections; In-hospital fractures; and Pressure ulcers.

Unit of analysis: The measuring unit of this indicator is a single

admission. The indicator is expressed as a rate of nursing-sensitive

adverse events per 1,000 medical discharges.

Denominator: Acute care hospitalizations with medical conditions.

Numerator: Cases within the denominator with one or more adverse

events.

Canadian Hospital

Reporting Project,

CIHI, Feb 2013

Factors considered include % of

hospitals better in peer group, trend

over time and rate. Green: More than

75% hospitals better, trend and rate.

Yellow: More than 80% of hospitals

better, trend and rate.

Red: More than 90% of hospitals

better; trend and rate.

NSAE –

Surgical

Nursing-Sensitive

Adverse Events for

Surgical Procedures

(All Surgical Case Mix

Groups) (rate per

1,000)

Four NSAE events: Hospital acquired pneumonia; Hospital acquired

urinary tract infections; In-hospital fractures; and Pressure ulcers.

Unit of analysis: The measuring unit of this indicator is a single

admission. The indicator is expressed as a rate of nursing-sensitive

adverse events per 1,000 surgical discharges.

Denominator: Acute care hospitalizations where a surgical procedure

was performed.

Numerator: Cases within the denominator with one or more adverse

events.

Canadian Hospital

Reporting Project,

CIHI, Feb 2013

As above.

Readmissions High level view of

readmission data

across all of the areas

provided in the CHRP,

– 28-Day Readmission After Acute Myocardial Infarction – 28-Day Readmission After Stroke – 90-Day Readmission after Hip Replacement – 90-Day Readmission after Knee Replacement – 30-Day Overall Readmission – 30-Day Obstetrical Readmission

Canadian Hospital

Reporting Project,

CIHI, Feb 2013

As above.

74

Abbreviation Quality Indicator Definition Data Source Flagging Rating

CIHI. – 30-Day Readmission – Patients Age 19 and younger – 30-Day Surgical Readmission – 30-Day Medical Readmission

Hip Fracture

48 hours

Proportion of hip

fracture surgical

procedures performed

within 48 hours of

initial admission across

facilities.

Unit of analysis: The measuring unit of this indicator is a single

admission or multiple admissions. The indicator is expressed as a rate

of hip fracture procedures performed within

48 hours of admission per 100 hip fracture procedures.

Denominator: Inpatient cases with a pre-admission hip fracture and

hip fracture surgery.

Numerator: Cases within the denominator with hip fracture surgery

performed within 48 hours.

Canadian Hospital

Reporting Project,

CIHI, Feb 2013

As above.

Sepsis

Mortality

30 day sepsis mortality

rate

Denominator: number of unique patients, defined as distinct valid BC

PHNs, with Sepsis.

Numerator: number of unique patients (BC residents with valid PHNs)

who died from natural causes during or within 30 days of their last

hospital admission for Sepsis.

Note: this data does have methodological concerns.

Discharge Abstract

Database, Ministry

of Health, Oct 2013

(Data covering

2008/09 - 2012/13)

Sites with no change or high variation

across quarters that are above BC

average.

C. Difficile

(CDI)

Clostridium difficile

infection is often

related to

antimicrobial therapy

which alters normal

bacteria found in the

gastrointestinal tract.

CDI may be mild

infection or can

present as massive

diarrhea that may be

difficult to control,

Number of new CDI and facility-associated CDI incidence rate by FH

site, 2012/13.

Number of new healthcare-associated CDI attributed to the same FH

acute care site where CDI was most likely acquired and confirmed or

diagnosed (does not account for cases that are transferred between

sites where CDI was acquired vs. where CDI was confirmed or

diagnosed) / total patient days for particular site or FH total * 10,000

Target: 6.0 per 10,000 patient days

FH Board Quality

Performance

Committee

BRIEFING NOTE

(Infection

Prevention &

Control, Annual

Report 2012-13) &

Clinical Capacity

Quality Measures

and Targets

Sites above target.

75

Abbreviation Quality Indicator Definition Data Source Flagging Rating

with potential for toxic

mega-colon, sepsis &

death.

2013/14, FHA

Report: Measures

Fiscal Period 11

(Jan 03, 2014 to Jan

30, 2014)

MRSA Methicillin-resistant

Staphylococcus aureus

(MRSA) are strains of

staphylococci that

have become resistant

to antimicrobial agents

used to treat common

skin and soft tissue

infections.

Number of new MRSA and facility-associated MRSA incidence rate by

FH site, 2012/13.

Number of new healthcare-associated MRSA attributed to the same

Fraser Health acute care site where MRSA was most likely acquired

and

confirmed or diagnosed (does not account for cases that are

transferred between sites where MRSA was acquired vs. where MRSA

was confirmed or diagnosed) / total patient days for particular site or

FH total * 10,000

Target: 5.9 per 10,000 patient days

FH Board Quality

Performance

Committee

BRIEFING NOTE

(Infection

Prevention &

Control, Annual

Report 2012-13) &

Clinical Capacity

Quality Measures

and Targets

2013/14, FHA

Report: Measures

Fiscal Period 11

(Jan 03, 2014 to Jan

30, 2014)

Sites above target.

Hand Hygiene Hand Hygiene

compliance.

Hand hygiene compliance among all staff by FH site, 2012/13

Target = 80%

FH Board Quality

Performance

Committee

BRIEFING NOTE

Date: May 15, 2011

(Infection

Prevention &

Control, Annual

Report 2012-13)

Sites above target.

76

Abbreviation Quality Indicator Definition Data Source Flagging Rating

Pt. Satis.

Emerg

Emergency

Department Patient

Experience

Overall, how would you rate the care you received at the hospital?

Response scale = Poor, Fair, Good, Very Good, Excellent

BC average = 12.6%

Emergency

Department Patient

Experience-All

Dimensions and

Overall Ratings (Apr

1, 2012 - Mar 31,

2013), NRC Picker,

July 2013.

Green: sites similar to or below BC

average of poor/fair rating.

Yellow: sites above BC average but

below 20%

Red: sites above 20%

77

Appendix A: NSQIP Sites – Surgical Quality Indicator Analysis Site NSQIP1

(Needs Improvement2/ Outcomes measured)

HSMR-Surgical3

Re-admission rates for surgical cases4

*Low variation in data

NSAE for surgical patients4

Hip fracture repair within 48 hours4

Surrey Memorial

24 Needs Improvement designations (out of 88 outcomes) – General renal failure & Pneumonia &

Return to OR – Ortho SSI

– Ortho Mortality – All Cases SSI

– Urology SSI

Stable, no significant change over time. Last 2 annual HSMR-surgical of 96 and 103.

48% of hospitals better in peer group. 2009-11 / 2010-11: SMH: 6.19 / 6.15 BC: 7.04 / 7.01 Nat’l: 6.50 / 6.51

98% of hospitals better in peer group. No improvement; almost double national rate. 2009-11 / 2010-11 / 2011-12: SMH: 63.56/ 65.55/ 65.47 BC: 39.63/ 37.60/ 38.57 Nat’l: 35.59/ 36.15/ 35.99

100% of hospitals better in peer group. Trending down. Significant issues in performance – worst in Canada last 2 years. 2009-11 / 2010-11 / 2011-12: SMH: 50.89/ 49.35/ 28.33 BC: 81.27/ 80.92/ 76.76 Nat’l: 78.53/ 80.18/ 80.50

Royal Columbian

41 Needs Improvement designations (out of 94 outcomes) – General pneumonia

– G/V SSI & Morbidity – Colorectal SSI

– Cardiac SSI – Ortho UTI & SSI

– Urology Morbidity & UTI

Demonstrated improvement / trending down with last 2 annual HSMR-surgical of 105 and 102.

82% of hospitals better in peer group. 2009-11 / 2010-11: RCH: 7.21 / 7.12 BC: 7.04 / 7.01 Nat’l: 6.50 / 6.51

83% of hospitals better in peer group. Trending down. 2009-11 / 2010-11 / 2011-12: RCH: 53.58/ 47.55/ 40.75 BC: 39.63/ 37.60/ 38.57 Nat’l: 35.59/ 36.15/ 35.99

94% of hospitals better in peer group. 2009-11 / 2010-11 / 2011-12: RCH: 60.79/ 63.67/ 58.55 BC: 81.27/ 80.92/ 76.76 Nat’l: 78.53/ 80.18/ 80.50

Burnaby 25 Needs Improvement designations (out of 42 outcomes):

– General/Vascular (G/V) pneumonia (also high outlier in the related fields: general pneumonia, all cases pneumonia, all cases morbidity)

– G/V UTI (also general UTI, measures UTI, all cases UTI, all cases morbidity)

– Colorectal LOS

– Ortho UTI – Ortho SSI

Demonstrated improvement /trending down with last 2 annual HSMR-surgical of 89 and 72.

93% of hospitals better in peer group. 2009-11 / 2010-11: BH: 7.14 / 7.52 BC: 7.04 / 7.01 Nat’l: 6.50 / 6.51

100% of hospitals better in peer group. No improvement; worst in Canada; double national rate. 2009-11 / 2010-11 / 2011-12: BH: 72.07/ 67.52/ 69.23 BC: 39.63/ 37.60/ 38.57 Nat’l: 35.59/ 36.15/ 35.99

97% of hospitals better in peer group. Trending down. 2009-11 / 2010-11 / 2011-12: BH: 71.72/ 61.36/ 54.43 BC: 81.27/ 80.92/ 76.76 Nat’l: 78.53/ 80.18/ 80.50

78

Appendix A: NSQIP Sites – Surgical Quality Indicator Analysis Site NSQIP1

(Needs Improvement2/ Outcomes measured)

HSMR-Surgical3

Re-admission rates for surgical cases4

*Low variation in data

NSAE for surgical patients4

Hip fracture repair within 48 hours4

Abbotsford 15 Needs Improvement designations (out of 73 outcomes). – General Mortality & Unplanned

Intubation

– Colorectal Mortality – Ortho Mortality – Deep/Organ Space SSI

Trending down, stable last 3 years. Last 2 annual HSMR-surgical 98 and 94.

98% of hospitals better in peer group. 2009-11 / 2010-11: ARH: 6.70/ 7.98 BC: 7.04 / 7.01 Nat’l: 6.50 / 6.51

18% of hospitals better in peer group. In top 20%. 2009-11 / 2010-11 / 2011-12: ARH: 22.67/ 14.98/ 20.50 BC: 39.63/ 37.60/ 38.57 Nat’l: 35.59/ 36.15/ 35.99

85% of hospitals better in peer group. 2009-11 / 2010-11 / 2011-12: ARH: 74.53/ 68.59/ 70.69 BC: 81.27/ 80.92/ 76.76 Nat’l: 78.53/ 80.18/ 80.50

Langley Memorial

16 Needs Improvement designations (out of 73 outcomes) – Gen pneumonia

– Colorectal LOS – Ortho UTI & SSI

Trending down. Last 2 annual HSMR-surgical of 112 and 70.

31% of hospitals better in peer group. 2009-11 / 2010-11: LMH: 7.68/ 5.81 BC: 7.04 / 7.01 Nat’l: 6.50 / 6.51

60% of hospitals better in peer group. Trending down. 2009-11 / 2010-11 / 2011-12: LMH: 45.69/ 36.27/ 32.97 BC: 39.63/ 37.60/ 38.57 Nat’l: 35.59/ 36.15/ 35.99

39% of hospitals better in peer group. Stable. 2009-11 / 2010-11 / 2011-12: LMH: 83.76/ 74.80/ 84.84 BC: 81.27/ 80.92/ 76.76 Nat’l: 78.53/ 80.18/ 80.50

Peach Arch 17 Needs Improvement designations (out of 40 outcomes) – General pneumonia & SSI

– Colorectal morbidity – Ortho UTI, SSI & Return to OR

Trending down. Last 2 annual HSMR-surgical of 100 and 76.

28% of hospitals better in peer group. 2009-11 / 2010-11: PAH: 5.99/ 5.76 BC: 7.04 / 7.01 Nat’l: 6.50 / 6.51

88% of hospitals better in peer group. 2009-11 / 2010-11 / 2011-12: PAH: 42.4/ 30.15/ 46.99 BC: 39.63/ 37.60/ 38.57 Nat’l: 35.59/ 36.15/ 35.99

81% of hospitals better in peer group. 2009-11 / 2010-11 / 2011-12: PAH: 76.79/ 78.52/ 71.92 BC: 81.27/ 80.92/ 76.76 Nat’l: 78.53/ 80.18/ 80.50

Eagle Ridge 21 Needs Improvement designations (out of 74 outcomes)

– General SSI – Gyne UTI & SSI

– Ortho SSI

Stable with low HSMR-surgical results in last two years of 50 and 45.

31% of hospitals better in peer group. 2009-11 / 2010-11: ERH: 6.10/ 5.65 BC: 7.04 / 7.01 Nat’l: 6.50 / 6.51

42% of hospitals better in peer group. Trending down. 2009-11 / 2010-11 / 2011-12: ERH: 33.83/ 28.02/ 20.89 BC: 39.63/ 37.60/ 38.57 Nat’l: 35.59/ 36.15/ 35.99

34% of hospitals better in peer group (2010-11 data). 2009-11 / 2010-11: ERH: 87.92/ 89.42 BC: 81.27/ 80.92/ 76.76 Nat’l: 78.53/ 80.18/ 80.50

79

Appendix A: NSQIP Sites – Surgical Quality Indicator Analysis Site NSQIP1

(Needs Improvement2/ Outcomes measured)

HSMR-Surgical3

Re-admission rates for surgical cases4

*Low variation in data

NSAE for surgical patients4

Hip fracture repair within 48 hours4

Ridge Meadows

8 Needs Improvement designations (out of 77 outcomes) – Gen pneumonia & Unplanned

Intubation

– Ortho pneumonia

Trending down. Last 2 annual HSMR-surgical of 90 and 42.

45% of hospitals better in peer group. 2009-11 / 2010-11: RMH: 5.59/ 6.11 BC: 7.04 / 7.01 Nat’l: 6.50 / 6.51

96% of hospitals better in peer group. Slight improvement last year; almost double national rate. 2009-11 / 2010-11 / 2011-12: RMH: 71.25/ 71.03/ 61.76 BC: 39.63/ 37.60/ 38.57 Nat’l: 35.59/ 36.15/ 35.99

50% of hospitals better in peer group. Stable. 2009-11 / 2010-11 / 2011-12: RMH: 83.05/ 87.81/ 61.63 BC: 81.27/ 80.92/ 76.76 Nat’l: 78.53/ 80.18/ 80.50

Chilliwack New to NSQIP – July 2013 SAR not complete enough for analysis; should have better data with most recent (Jan 2014) SAR.

Variation across years, overall shift downward. Last 2 annual HSMR-surgical of 49 and 87.

95% of hospitals better in peer group. 2009-11 / 2010-11: CGH: 8.84/ 7.80 BC: 7.04 / 7.01 Nat’l: 6.50 / 6.51

38% of hospitals better in peer group. Trending down. 2009-11 / 2010-11 / 2011-12: CGH: 37.02/ 31.14/ 25.90 BC: 39.63/ 37.60/ 38.57 Nat’l: 35.59/ 36.15/ 35.99

87% of hospitals better in peer group. Trending down. 2009-11 / 2010-11 / 2011-12: CGH: 83.49/ 81.23/ 68.92 BC: 81.27/ 80.92/ 76.76 Nat’l: 78.53/ 80.18/ 80.50

Delta 1 Needs Improvement designations (out of 77 outcomes)

– Ortho SSI

80% of hospitals better in peer group. 2009-11 / 2010-11: DH: 7.73/ 7.64 BC: 7.04 / 7.01 Nat’l: 6.50 / 6.51

25% of hospitals better in peer group. Trending down. 2009-11 / 2010-11 / 2011-12: DH: 28.57/ 25.41/13.10 BC: 39.63/ 37.60/ 38.57 Nat’l: 35.59/ 36.15/ 35.99

No data.

1 ACS NSQIP Interim Semi-annual Report (04/01/2012 - 03/31/2013.

2 NSQIP ‘Needs Improvement’ outcomes are in the bottom 10% of participating hospitals and/or are statistically significant low performers.

3 CIHI, 2013.

4 Canadian Hospital Reporting Project, CIHI, Feb 2013.

80

Appendix B

81

82

83

84

85

86

High Level Facility Assumptions

Page 1

Appendix C

Quality Concerns by Site (MOH Methodology)

Size

Health

Authority

Hospital

HSMR

HSMR ‐

Surgical

HSMR‐

Medical

HSMR‐ICU

NSAE

(Medical)

NSAE

(Surgical)

Re‐

admission

Rate

Hip

Fracture

Repair

48hrs

Sepsis

Mortality

Clostridium

Difficile

Infection

MRSA

Hand

Hygiene

Pt‐Satis.

Emerg

Co

mm

un

ity‐

Larg

e

FHA

Abbotsford Regional

Hospital and Cancer Centre G

Y

G

Y

G

G

R

Y

Y

g

g

Y

Y

FHA

Burnaby Hospital Y

Y

Y

Y

R

R

R

R

Y

y

Y

Y

Y

FHA

Chilliwack General Hospital G

Y

G

G

Y

Y

Y

Y

G

g

g

g

Y

FHA

Langley Memorial Hospital Y

Y

Y

Y

Y

Y

Y

Y

Y

y

G

Y

R

FHA

Peace Arch Hospital G

Y

G

Y

Y

Y

Y

Y

G

y

G

Y

Y

FHA

Royal Columbian Hospital Y

Y

Y

R

R

Y

R

R

Y

y

y

Y

Y

FHA

Surrey Memorial Hospital Y

Y

Y

R

R

R

Y

R

Y

y

y

y

R

Co

mm

un

ity

Me

diu

m

FHA

Delta Hospital G

Y

G

N/A

Y

Y

Y

N/A

G

r

G

Y

G

FHA

Eagle Ridge Hospital G

Y

G

N/A

R

G

R

N/A

Y

G

Y

Y

Y

FHA

Ridge Meadows Hospital

and Health Care Centre G

Y

Y

Y

R

R

R

Y

G

G

G

Y

Y

Colour Coding based on data for: (fiscal year) 2007/2008 to 2012/2013 2011/2012 2010/2011 2011/2012 2012/2013 2011/2012 to 2012/2013 2012/2013

Major Quality Concerns

Significant Quality

Concerns

Few Quality Concerns

High Level Facility Assumptions

Page 2

Notes:

Abbreviation Indicator Definition Data Source Colour Rating

HSMR

Hospital Standardized

Mortality Ratio

Ratio of the actual number of deaths in a facility to

the expected number of deaths for patients in acute

care hospitals.

CIHI, 2013

Data assessed 2007/08 to 2012/13 fiscal year results. A

ratio of 100 = no difference between the hospital’s

mortality rate and Canadian average rate in baseline year.

A ratio greater than 100 = hospital’s mortality rate is

higher than average rate; less than 100 = hospital’s

mortality rate is lower than average rate. Trend data over

the 6 years plus data with Confidence Levels used for

evaluations. Green: if trend is downward and in the last 2

years the upper Confidence Level is below 100

Yellow: if trend is downward for at least last three years

and the rate is 100 or less Red: if rate is greater than 100

and statistically higher than Canada

HSMR – Surgical

Hospital Standardized

Mortality Ratio – Surgical

Cases

Ratio of the actual number of surgical case deaths in

a facility to the expected number of surgical case

deaths for patients in acute care hospitals.

CIHI, 2013

As above.

HSMR – Medical

Hospital Standardized

Mortality Ratio – Medical

Cases

Ratio of the actual number of medical case deaths in

a facility to the expected number of medical case

deaths for patients in acute care hospitals.

CIHI, 2013

As above.

HSMR – ICU

Hospital Standardized

Mortality Ratio – ICU

Ratio of the actual number of ICU deaths in a facility

to the expected number of ICU deaths for patients in

acute care hospitals.

CIHI, 2013

As above.

NSAE – Medical

Nursing‐Sensitive Adverse

Events for Medical

Conditions (All Medical Case

Mix Groups) (rate per 1,000)

Four NSAE events: Hospital acquired pneumonia;

Hospital acquired urinary tract infections; In‐

hospital fractures; and Pressure ulcers. Unit of

analysis: The measuring unit of this indicator is a

single admission. The indicator is expressed as a rate

of nursing‐sensitive adverse events per 1,000

medical discharges. Denominator: Acute care

hospitalizations with medical conditions. Numerator:

Cases within the denominator with one or more

adverse events.

Canadian Hospital

Reporting Project,

CIHI,

Feb 2013

The colours indicate statistically significant relationships to

the Canadian average. We use each hospital's upper/lower

confidence levels (CLs), BC's upper/lower CLs, and the

Canadian national average (no upper/lower CLs available)

to distinguish these relationships, according to CIHI's data

and estimates. Green: significantly better than Canadian

average Yellow: not statistically different than Canadian

average Red: significantly worse than Canadian average

NSAE – Surgical

Nursing‐Sensitive Adverse

Events for Surgical

Procedures (All Surgical

Case Mix Groups) (rate per

1,000)

Four NSAE events: Hospital acquired pneumonia;

Hospital acquired urinary tract infections; In‐

hospital fractures; and Pressure ulcers. Unit of

analysis: The measuring unit of this indicator is a

single admission. The indicator is expressed as a rate

of nursing‐sensitive adverse events per 1,000

surgical discharges. Denominator: Acute care

hospitalizations where a surgical procedure was

performed. Numerator: Cases within the

denominator with one or more adverse events.

Canadian Hospital

Reporting Project,

CIHI,

Feb 2013

As above.

Readmissions

High level view of

readmission data provided

in the CHRP, CIHI.

30‐Day Overall Readmission

Canadian Hospital

Reporting Project,

CIHI,

Feb 2013

As above.

Hip Fracture 48

hours

Proportion of hip fracture

surgical procedures

performed within 48 hours

of initial admission across

facilities.

Unit of analysis: The measuring unit of this indicator

is a single admission or multiple admissions. The

indicator is expressed as a rate of hip fracture

procedures performed within 48 hours of admission

per 100 hip fracture procedures. Denominator:

Inpatient cases with a pre‐admission hip fracture

and hip fracture surgery. Numerator: Cases within

the denominator with hip fracture surgery

performed within 48 hours.

Canadian Hospital

Reporting Project,

CIHI,

Feb 2013

As above.

High Level Facility Assumptions

Page 3

Abbreviation Indicator Definition Data Source Colour Rating

Sepsis Mortality

30 day sepsis mortality rate

Denominator: number of unique patients, defined as

distinct valid BC PHNs, with Sepsis. Numerator:

number of unique patients (BC residents with valid

PHNs) who died from natural causes during or within

30 days of their last hospital admission for Sepsis.

Discharge Abstract

Database, Vital

Information

Statistics (VISTA)

decision support

system, Ministry of

Health, Oct 2013

CERTS Project

2013_0923

Sites with no change or high variation across quarters that

are above BC average. Small volumes makes evaluation of

trending difficult. Green: at or below BC rate or if close to

BC rate and trending down Yellow: above BC rate and

trending up with large volumes Red: above BC rate and

trending up with large volume increase

Clostridium

Difficile Infection

Clostridium difficile infection

is often related to

antimicrobial therapy which

alters normal bacteria found

in the gastrointestinal tract.

CDI may be mild infection or

can present as massive

diarrhea that may be difficult

to control, with potential for

toxic mega‐ colon, sepsis &

death.

Number of new CDI and facility‐associated CDI

incidence rate by FH site, 2011/12 and 2012/13.

Number of new healthcare‐associated CDI

attributed to the same FH acute care site where CDI

was most likely acquired and confirmed or

diagnosed (does not account for cases that are

transferred between sites where CDI was acquired

vs. where CDI was confirmed or diagnosed) / total

patient days for particular site or FH total * 10,000

Fraser Health Target: 6.0 per 10,000 patient days

FH Board Quality

Performance

Committee

BRIEFING NOTE

(Infection

Prevention &

Control, Annual

Report 2012‐13) &

Clinical Capacity

Quality Measures

and Targets

2013/14, FHA

Report: Measures

Fiscal Period 11 (Jan

03, 2014 to Jan 30,

2014)

Green: consistently below target Yellow: at or slightly

above target trending down Red: well above target with

no improvement in past two years

Facilities may get a better rating where there was

substantial improvement between the fiscal years.

MRSA

Methicillin‐resistant

Staphylococcus aureus

(MRSA) are strains of

staphylococci that have

become resistant to

antimicrobial agents used to

treat common skin and soft

tissue infections.

Number of new MRSA and facility‐associated MRSA

incidence rate by FH site, 2011/12 and 2012/13.

Number of new healthcare‐associated MRSA

attributed to the same Fraser Health acute care site

where MRSA was most likely acquired and confirmed

or diagnosed (does not account for cases that are

transferred between sites where MRSA was acquired

vs. where MRSA was confirmed or diagnosed) / total

patient days for particular site or FH total * 10,000

Fraser Health Target: 5.9 per 10,000 patient days

FH Board Quality

Performance

Committee

BRIEFING NOTE

(Infection

Prevention &

Control, Annual

Report 2012‐13) &

Clinical Capacity

Quality Measures

and Targets

2013/14, FHA

Report: Measures

Fiscal Period 11 (Jan

03, 2014 to Jan 30,

2014)

As above

Hand Hygiene

Hand Hygiene compliance.

Hand hygiene compliance among all staff by FH site,

2011/12 and 2012/13

Fraser Health Target = 80%

FH Board Quality

Performance

Committee

BRIEFING NOTE

(Infection

Prevention &

Control, Annual

Report 2012‐13) &

Clinical Capacity

Quality Measures

and Targets

2013/14, FHA

Report: Measures

Fiscal Period 11 (Jan

03, 2014 to Jan 30,

2014)

Green: consistently above target Yellow: at or slightly

below target trending upwards Red: well above target

with no improvement in past two years

Pt Satis Emerg

Patient Satisfaction

Emergency

Overall, how would you rate the care you received

at the hospital? Response scale = Poor, Fair, Good,

Very Good, Excellent

BC Average = 12.6%

Emergency

Department Patient

Experience‐All

Dimensions and

Overall Ratings (Apr

1, 2012 ‐ Mar 31,

2013), NRC Picker,

July 2013.

Sites compared to BC average for fair/poor rating

Green: sites similar to or below BC average

Yellow: sites above BC average but below 20%

Red: sites above 20%