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2. welfare
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4. hospital

Executive Summary
Presented at the Roma Club in Leamington ON, on November
12th, 2014 as part of the Erie St. Clair Local Health Integration
Network “Special” Board Meeting
© 2013 Hay Group. All rights reserved
1
Who are we?
•
•
•
•
•
LDMH is located along Essex County’s South Shore and serves the
communities of:
Leamington
Kingsville
Essex
Wheatley
•
We have nearly 700 ambassadors comprised of staff, physicians, volunteers
and Board of Directors
•
We provide:
Emergency Room with approximately 29,000 – 30,000 ED visits annually
Medical care
In-Patient & Out-patient Surgery
Full suite of Diagnostic services
Restorative Services
We provide a wide range of partnerships to improve Access to Care
•
•
•
•
•
•
© 2013 Hay Group. All rights reserved
2
Need-Based
Clinical Services Plan
Leamington District Memorial Hospital
EXECUTIVE SUMMARY
How did we get here?
Loss of approximately $700k since Health System
Funding Reform has been implemented
•

•
We have remained in a “Balanced” position over the same
time period by reducing Management positions by 25%
•
The Hay Group has found that LDMH performance in
2013/14 makes it one of the most efficient smaller Hospitals
they have worked with
Loss of approximately $1.2M in Assess & Restore
one time Funding at December / 2014
© 2013 Hay Group. All rights reserved
4
We have been working with the ESC LHN to
address Structural issues for 18 – 24 months
•
Funding Reductions have created an approximate $2M
structural issue
•
Collectively, (LDMH & ESC LHIN), we agreed to retain
the Services of a independent third party consultant to
address these issues
© 2013 Hay Group. All rights reserved
5
Project Objective to create a sustainable
Hospital model

What are the needs of the community (ies) served by
LDMH?
and

What is the appropriate role of LDMH in meeting the
needs of this population?
© 2013 Hay Group. All rights reserved
6
Evaluation Criteria
for Selecting future role for LDMH
Health Related Criteria
1.
Addresses identified hospital service need of local community
2.
Maintains ED and inpatient acute care services at LDMH
3.
Ensures access to needed hospital services for local community
Maximizes local access to hospital services for local community
Minimizes impediments to accessing hospital services for local community
Maximizes quality of hospital services accessed by local community
Ensures access to comprehensive set of hospital services for local
community
Enhances quality and accessibility of primary health care
5.
Enhances quality and accessibility of post acute care
6.
Contributes to fiscal strength of LDMH
Socio-Economic Criteria
1.
Maximizes health related economic activity in local community
2.
Maintains economic attractiveness of local community
3.
Maintains social attractiveness of local community
4.
© 2013 Hay Group. All rights reserved
7
Current
LDMH
Services
Current Role of LDMH











Emergency Department (ED)
Inpatient Medicine
Inpatient Surgery
Critical Care: Level 2 Intensive Care Unit (ICU)
Birthing
Outpatient Surgery
Outpatient Clinics
Comprehensive Diagnostics & Therapeutics (D&T)
‘Assess and Restore’
Complex Continuing Care
Palliation
© 2013 Hay Group. All rights reserved
9
Current Service Volumes
Type of Clinical Activity
Emergency Department Visits
Visits / Cases
Patients
Days
29,002
N/A
Outpatient Clinic Visits
9,922
N/A
Outpatient Surgery Cases
3,348
N/A
Inpatient Medical / Surgical Cases
2,673
16,264
IP CCC / A&R Cases
296
4,807
IP OB Cases
303
605
© 2013 Hay Group. All rights reserved
10
2013 /2014 Average LDMH Beds &
Occupancy
2013/14
Beds
Avg
Occupancy
Medicine/Surgery
53
96%
ICU (Level 2)
3
54%
Based on 2 beds = 81%
Obstetrics (LDRP)
8
37%
Based on 3 beds = 55%
Total Acute
64
86%
CCC
5
87%
Bed Type
© 2013 Hay Group. All rights reserved
11
Future
Need for
Hospital
Services
Essex County Projected Change in
Population by Age and Gender

Virtually no projected change in total population
from 2012 to 2020

But, the population aged 65 and older will
increase by 29.4%

Those over 65 years will shift from 15.2% of
population to almost 20%

Need for obstetrical services in catchment
population will decline modestly to 2020
© 2013 Hay Group. All rights reserved
13
Selecting
Future
Clinical Role
for
LDMH
Critical considerations in
evaluating clinical services


ED: Residents of Leamington and Kingsville rely on LDMH for 84% of
their ED visits
IP Care: If ED, then need access to inpatient acute care beds:
Local inpatient medicine (General Internal Medicine) beds.
Local inpatient general surgery and beds.
Access to remote site(s) for subspecialty medicine or surgery inpatient acute care
beds
Access to remote site(s) for inpatient paediatrics
Access to remote site(s) for acute inpatient psychiatry.

ICU: with the continuation of ED and IP care comes the need for an ICU:
Intensive nursing care
Beds with cardiac monitoring.


OP Surgery: Need additional surgical volume to support surgeons and
anesthetists needed for IP surgery which is required to support ED
D&T Services: If ED and IP care, then need onsite access to diagnostic
and therapeutic services
© 2013 Hay Group. All rights reserved
15
ED volumes are expected to rise over
30,000 visits by 2020…
Year
ED Visits
2012
2013
2014
2015
2016
2017
2018
2019
2020
29,034 29,129 29,228 29,341 29,473 29,628 29,804 29,987 30,184
…and we are #1 in the ESC LHIN in ED Wait times
© 2013 Hay Group. All rights reserved
16
Demographic Change will result in
15.7% increase in IP cases by 2020

Projected increases of 15.7% inpatient cases and
23.8% inpatient days
2012/13 Actual
Broad Program
IP
Avg.
IP Days
Cases
LOS
Medicine
1,983 15,956
8.0
Surgery
399
2,969
7.4
Birthing
584
1,107
1.9
Mental Health
10
114
11.4
Grand Total
2,976 20,146
6.8
2020 Projected
IP
Avg.
IP Days
Cases
LOS
2,429
20,302
8.4
437
3,453
7.9
566
1,072
1.9
10
116
11.3
3,442
24,944
7.2
% Change
Cases
22.5%
9.6%
-3.1%
3.5%
15.7%
Days
27.2%
16.3%
-3.2%
2.1%
23.8%
Projected county level changes in population by age/gender group applied to LDMH actual 2012/13 inpatient activity
© 2013 Hay Group. All rights reserved
17
Demographic Change will result in 7.9%
increase in Outpatient Surgery by 2020
Program
Gastro/Hepatobiliary
General Surgery
Neurosurgery
Dental/Oral Surgery
Orthopaedics
Obstetrics
Plastic Surgery
Gynaecology
Other
Total
© 2013 Hay Group. All rights reserved
2012/13
2020
%
Actual Projection Change
2,339
2,577 10.2%
418
433
3.6%
390
430 10.3%
243
254
4.5%
187
192
2.4%
90
86
-4.9%
84
84
0.0%
62
60
-3.2%
59
62
5.1%
3,872
4,177
7.9%
18
Considering Birthing
500

LDMH market share has
increased

Need for obstetrical services in
catchment population will
decline modestly to 2020

Disconnect between volume
and costs

Evaluation suggests that LDMH
should discontinue its birthing
service
400
300
47%
200
51%
55%
100
0
Leamington
Births
250
200
150
100
50
0
LDMH
23%
Kingsville
Births
2011
2012
2013
27%
34%
LDMH
© 2013 Hay Group. All rights reserved
2011
2012
2013
19
Implications of Eliminating Birthing

300 women in catchment population who currently rely
on LDMH for birthing would need to travel to WRH to
deliver their babies
WRH is a more clinically/technologically sophisticated birthing
service

Dislocation for these women could be mitigated if LDMH
(and WRH) made arrangements for pre and post natal
care to be provided in Leamington
This would also be a benefit for some of the women who are
already delivering their babies at WRH

LDMH obstetrician has secured privileges at WRH and
will maintain office at LDMH
© 2013 Hay Group. All rights reserved
20
Considering Post Acute Care

Assess & Restore: MOHLTC guidelines suggest that
A&R is an approach to care not a program
As currently configured A&R at LDMH will soon be an
unfunded element of hospital’s acute care services
LDMH A&R is a very effective and highly valued approach to
care as recognized by the Hay Group

Recommend that:
LDMH continue volume of acute care patients receiving A&R
services
LHIN increase LDMH CCC beds from 5 to 10 to better serve
LDMH catchment population
LDMH provide post acute portion of its A&R service in these
10 CCC beds
© 2013 Hay Group. All rights reserved
21
Transitioning
to
the future
LDMH: Transitioning to the Future
Current Role
 ED
 Inpatient Medicine
 Inpatient Surgery
 Level 2 ICU
 Birthing
 Outpatient Surgery
 Outpatient Clinics
 Comprehensive D&T
 Complex Continuing Care
 ‘Assess and Restore’
 Palliation
© 2013 Hay Group. All rights reserved
Proposed Future Role
 ED
 Inpatient Medicine
 Inpatient Surgery
 Level 2 ICU
 Birthing Clinics
 Outpatient Surgery
 Outpatient Clinics
 Comprehensive D&T
 Complex Continuing Care
 Palliation
23
The resulting Bed configuration
Summary
Program / Service
Actual
Proposed
Current
Medical / Surgical
2015
2020
53
49
62
ICU
3
3
3
OB / Birthing
8
0
0
CCC
5
10
11
Total
69
62
76
© 2013 Hay Group. All rights reserved
24
LDMH Motion
Foundation of motion is to address
Structural Issues

…..due to Funding Reductions, the LDMH Board
of Directors has approved the reconfiguration of
programs and Services to focus on:
Emergency Department
Internal Medicine
In-patient and Out-patient Surgery
Restorative Care

As a result, LDMH will cease offering birthing
services effective March 31, 2015.
© 2013 Hay Group. All rights reserved
26
LDMH
Logo
© 2013 Hay Group. All rights reserved
27
Appendix I – Demographic profile of Essex
County
Essex County Projected Change in
Population by Age and Gender



Virtually no
projected
change in
total
population
from 2012 to
2020
But, the
population
aged 65 and
older will
increase by
29.4%
Those over
65 years will
shift from
15.2% of
population to
almost 20%
Age
Cohort
00-04
05-09
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
90+
Total
65 Plus
% 65 Plus
2012
2020
Female
Male
Total
Female
Male
Total
10,200
11,239
21,439
9,760
10,367
20,127
11,270
12,341
23,611
9,953
10,608
20,561
11,356
11,960
23,316
10,616
11,484
22,100
13,726
14,092
27,818
11,681
12,736
24,417
14,332
15,864
30,196
13,532
14,439
27,971
12,712
13,682
26,394
14,538
14,454
28,992
12,712
11,860
24,572
12,385
13,162
25,547
12,923
12,704
25,627
12,294
11,428
23,722
13,433
14,476
27,909
11,564
11,174
22,738
14,945
15,558
30,503
12,292
12,781
25,073
14,798
15,819
30,617
12,770
13,616
26,386
13,735
13,244
26,979
15,000
15,065
30,065
12,108
11,441
23,549
13,978
14,068
28,046
9,647
9,290
18,937
12,489
11,524
24,013
7,498
6,663
14,161
10,953
9,763
20,716
6,103
4,973
11,076
7,647
6,818
14,465
5,160
3,674
8,834
5,480
4,197
9,677
3,775
2,015
5,790
3,667
2,472
6,139
1,980
646
2,626
3,060
1,396
4,456
202,413 201,541 403,954 203,659 201,552 405,211
34,163
27,261
61,424
43,296
36,170
79,466
16.9%
13.5%
15.2%
21.3%
17.9%
19.6%
© 2013 Hay Group. All rights reserved
% Change
Female Male
-4.3% -7.8%
-11.7% -14.0%
-6.5% -4.0%
-14.9% -9.6%
-5.6% -9.0%
14.4%
5.6%
-2.6% 11.0%
-4.9% -10.0%
-13.9% -22.8%
-17.8% -17.8%
-13.7% -13.9%
9.2% 13.7%
15.4% 23.0%
29.5% 24.0%
46.1% 46.5%
25.3% 37.1%
6.2% 14.2%
-2.9% 22.7%
54.5% 116.1%
0.6%
0.0%
26.7% 32.7%
Total
-6.1%
-12.9%
-5.2%
-12.2%
-7.4%
9.8%
4.0%
-7.4%
-18.5%
-17.8%
-13.8%
11.4%
19.1%
26.8%
46.3%
30.6%
9.5%
6.0%
69.7%
0.3%
29.4%
29
Appendix II – LDMH Efficiency Comparison
LDMH is Among the Most Efficient
Hospitals within its Peer Group





LDMH admits lowest % of ED visits to IP care;
LDMH % day surgery is closest to best practice of all peer
hospitals; only patients needing IP care are being admitted
for surgery.
LDMH length of stay clinical efficiency is 2nd best of all peer
hospitals.
LDMH operating efficiency has been improving for the past 4
years.
In 2013/14 LDMH was the most efficient hospital within its
peer group; it had the smallest % of operating costs that
could be saved from improvements in operating efficiency. In
fact its % opportunity for improvement was among the
smallest of all hospitals studied, not just peer hospitals.
© 2013 Hay Group. All rights reserved
31
Like all organizations,
LDMH has opportunities
to improve efficiency;
but its opportunity is
smaller than most other
similar sized hospitals in
Ontario
Clinical
Efficiency
Among peer hospitals, LDMH is the most
judicious in deciding which ED patients to admit to hospital
LMDH has the lowest ratio of actual to expected admissions to IP Care
Comparison of Actual and Expected Admissions to Inpatient Acute Care from ED for (All) Diagnosis
Group, CTAS (All), and Age Group (All)
Admissions
Hospital
Visits*
Actual
Expected
Admission Rate
Actual
Expect.
Ratio of
Actual to
Expect.
Rank of
Act. To
Expect.
Pembroke Regional
31,447
4,417
2,620
14.0%
8.3%
169%
1
Brockville General Hospital
26,233
3,691
3,268
14.1%
12.5%
113%
2
Stratford General Hospital
24,526
2,978
2,865
12.1%
11.7%
104%
3
Norfolk General Hospital
27,811
3,097
3,009
11.1%
10.8%
103%
4
Collingwood Gen. & Marine
32,044
3,212
3,249
10.0%
10.1%
99%
5
Woodstock General Hospital
34,817
2,908
3,122
8.4%
9.0%
93%
6
Northumberland Hills Hospital
30,721
3,076
3,513
10.0%
11.4%
88%
7
Stevenson Memorial Alliston
29,831
1,916
2,354
6.4%
7.9%
81%
8
Leamington District Memorial
29,002
2,402
3,000
8.3%
10.3%
80%
9
266,432
27,697
27,001
10.4%
10.1%
103%
Grand Total
Expected ED Admission rate is based on average ED admission rate of all Ontario hospitals, standardized for Diagnosis,
CTAS (Acuity) and Age
© 2013 Hay Group. All rights reserved
34
LDMH % day surgery is closest to best practice of all peer
hospitals; only patients needing IP care are being admitted for surgery
Given practice in Ontario hospitals, LDMH can shift very few cases to day surgery



LDMH had only 70 elective short-stay IP surgery cases that might have been provided as same day
surgery (SDS)
To achieve ‘best’ quartile performance of peer hospitals, LDMH would need to shift only 17 of these cases
to day surgery
If all 17 of these cases were shifted to day surgery LDMH would only save a maximum of 28 patient days
at ‘best quartile’ performance of Ontario hospitals
2012/13 Actual
Hospital
Candidate IP Qualifying
Cases
Day Surgery
% Day
Surgery
Cases to Shift % of Candidate
@ Best Q'tile Cases to Shift
Collingwood Gen. & Marine
191
3,536
95%
33
17.5%
Pembroke Regional
369
4,851
93%
85
23.0%
Leamington District Memorial
70
3,315
98%
17
23.7%
Stevenson Memorial Alliston
149
3,446
96%
36
24.1%
Brockville General Hospital
429
7,812
95%
106
24.8%
2,898
45,529
94%
826
28.5%
Stratford General Hospital
991
8,054
89%
302
30.5%
Northumberland Hills Hospital
210
4,115
95%
72
34.1%
60
4,241
99%
21
34.3%
429
6,159
93%
155
36.1%
Peer Group Average
Norfolk General Hospital
Woodstock General Hospital
© 2013 Hay Group. All rights reserved
35
LDMH clinical efficiency related to ALOS
is 2nd best among peer hospitals



As has been seen, LDMH is among most judicious of peer hospitals in deciding
who to admit; as a result its inpatients have relatively long lengths of stay
However, to achieve best quartile performance of all Ontario hospitals, LDMH
would need to reduce the ALOS of its patients by only 7%
This is the second smallest opportunity for improvement in ALOS of its peer
hospitals
% of Total
Acute Days to
Acute Days to
Save @ Best
Save @ Best
Q'tile Targets
Avg. LOS
Q'tile.
2012/13 Actual Activity
Hospital
IP Cases
Acute
Days
Stratford General Hospital
6,908
23,423
3.39
1,331
5.7%
Leamington District Memorial
2,974
18,603
6.26
1,311
7.0%
Brockville General Hospital
4,567
21,354
4.68
1,500
7.0%
Stevenson Memorial Alliston
2,659
10,138
3.81
822
8.1%
Norfolk General Hospital
3,628
21,016
5.79
1,750
8.3%
40,368
187,764
4.65
16,049
8.5%
Northumberland Hills Hospital
4,263
18,561
4.35
1,605
8.6%
Pembroke Regional
5,644
30,809
5.46
3,095
10.0%
Collingwood Gen. & Marine
4,439
19,554
4.41
2,055
10.5%
Woodstock General Hospital
5,286
24,306
4.60
2,580
10.6%
Peer Group Totals/Average
© 2013 Hay Group. All rights reserved
36
Operating
Efficiency
LDMH has been improving its operating
efficiency over the past seven years
Most significant improvement over past 2 years
Savings Opportunity by Year
14.30%
13.80%
11.90%
9.40%
FY2007/08

FY2008/09
FY2012/13
FY2013/14
Metric is the percentage of total net operating cost that might be saved if
the hospital achieved best quartile efficiency (compared to all similar
sized hospitals) in every functional centre of the hospital.
© 2013 Hay Group. All rights reserved
38
LDMH is the most efficient of
similar sized hospitals in Ontario



Metric is the percentage of total net operating cost that might be saved if the hospital achieved best
quartile efficiency (compared to all similar sized hospitals) in every functional centre of the hospital.
This metric has been shown to provide a reasonable measure of the relative efficiency of different
hospitals.
Using this metric, LDMH in 2013/14 (the most recent complete fiscal year) performed better than all
similar sized hospitals for whom the analysis is available.
Estimated Savings Opportunities
WDMH
HDGH
KDH
HSRFH
NHH
QHC
OSMH
NHH
CCH
TDMH
RMH
OSMH
LDMH
0.00%
5.00%
© 2013 Hay Group. All rights reserved
10.00%
15.00%
20.00%
25.00%
39
Methodological
Notes
Peer Hospitals
Used for Comparing Clinical Efficiency
STEVENSON MEMORIAL
 BROCKVILLE GENERAL
 COLLINGWOOD GENERAL
 PEMBROKE GENERAL
 NORFOLK GENERAL
 STRATFORD GENERAL
 WOODSTOCK GENERAL
 NORTHUMBERLAND HILLS

© 2013 Hay Group. All rights reserved
41
Comparisons of Operating EfficiencyMethodology



HCM, who worked with Hay Group in the Clinical Services Planning Study at LDMH, has
conducted similar operational efficiency benchmarking studies for hospitals across Ontario.
Comparison metric is the percentage of total operating cost that might be saved if the
hospital achieved best quartile efficiency (compared to all similar sized hospitals) in every
functional centre of the hospital. Although this level of performance is not realistically
achievable (because of different approaches to organizing work and staffing; inconsistencies
in reporting workload, staffing and costs, etc.) it does provide a reasonable measure of the
relative efficiency of different hospitals.
Using this metric, LDMH in 2013/14 (the most recent complete fiscal year) performed better
than all similar sized hospitals for whom the analysis is available.
Estimated Savings Opportunities
WDMH
HDGH
KDH
HSRFH
NHH
QHC
OSMH
NHH
CCH
TDMH
RMH
OSMH
LDMH
0.00%
© 2013 Hay Group. All rights reserved
5.00%
10.00%
15.00%
20.00%
25.00%
42