final report outpatient gi endoscopy realignment and best ... · hospital sites in the region that...

FINAL REPORT

Outpatient GI Endoscopy Realignment and Best Practice Implementation Project

February 25, 2015

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Table of Contents

Introduction .......................................................................................................................... 3

Executive Summary ............................................................................................................... 4

Recommendations and Implementation Plan ......................................................................... 5

Site Scorecards – Key Performance Indicators ........................................................................ 9

Regional Investment ............................................................................................................ 10

Project Activity and Key Milestones ..................................................................................... 11

Methods for Data Collection and Information Gathering ...................................................... 13

Conclusion ............................................................................................................................15

References ...........................................................................................................................16

Appendix A - Site Scorecards ................................................................................................ 17

Appendix B - Current State Survey ....................................................................................... 61

Appendix C - Efficiency Committee Briefing Document ....................................................... 131

Appendix D - Health Equity Impact Assessment .................................................................. 134

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Introduction This report will summarize the findings of the Outpatient GI Endoscopy Realignment and Best Practice Implementation Project (”the Project”) in the South West Local Health Integration Network (South West LHIN) with a project completion date of March 31, 2015. The information contained in the following sections serves as closure to the project with recommendations noted and a high-level Implementation Plan included to guide the future work and collaborations which will be led by the South West Regional Cancer Program. The aim of the project is: By 2016, decrease the variation of wait times and volumes and implement best practices in the GI Endoscopy services delivered in the South West LHIN.

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Executive Summary Beginning in November of 2013, the South West LHIN, together with the South West Regional Cancer Program and hospital sites in the region that perform outpatient GI Endoscopy, established an objective to identify, evaluate, and improve the way outpatient Endoscopy services and follow-up care is to be delivered across the region, and launched the Outpatient GI Endoscopy Realignment and Best Practice Implementation Project. Through the development of key performance indicators, the implementation of best practice guidelines according to the Guideline for Colonoscopy Quality Assurance in Ontario (Tinmouth, 2013) and the GI Endoscopy Quality Based Procedure Clinical Handbook (Cancer Care Ontario & Ministry of Health and Long Term Care, Province of Ontario, 2013), a framework for ongoing quality measurement in the South West region has been developed, and baseline scorecards have been circulated for Q1 2015 evaluation.

Facility and provider recommendations have been formulated and a comprehensive plan has been established utilizing the following four work streams:

1) Patient Safety Checklist and Key Performance Indicator (KPI) implementation 2) Data provision, analysis and report generation 3) Program accountability and quality improvement 4) Patient flow and system optimization

A comprehensive clinical services review has been developed by the SW LHIN and all project outcomes as identified in this review for GI Endoscopy have been achieved. A LHIN-wide quality measurement improvement strategy that is supported by a robust reporting and quality management structure will be implemented following the completion of the project on March 31, 2015.

The development of a LHIN wide approach to GI Endoscopy ensures that local service delivery needs and programs within regional hospitals are aligned to the South West LHIN’s Integrated Health Service Plan, and services within the South West are delivered at the right time, in the right place, by the right provider.

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Recommendations and Implementation Plan As stated above, the recommendations for this project have been categorized to reflect the following four work streams: 1) Patient Safety Checklist and Key Performance Indicator (KPI) implementation 2) Data provision, analysis, and report generation 3) Program accountability and quality improvement 4) Patient flow and system optimization

1. Patient Safety Checklist and Key Performance Indicator (KPI) implementation

Patient Safety Checklist It is recommended that:

• Critical patient safety indicators are identified and in place at all Endoscopy program sites by January 1, 2016.

Implementation: Ensure partner sites are meeting best practices and/or present a clear action plan to achieve best practice. Within 60 days from the time recommendations are accepted by the LHIN Board, partner sites are required to respond in one of the two following ways: a) In cases when the patient safety standards identified in the KPI scorecard are not met and the organization decides not to proceed with the program, a transition plan describing how existing patient activity will be re-distributed is presented to the Regional Vice President, Cancer Care Ontario. b) In cases when the patient safety standards identified in the KPI scorecard are not met and the organization decides to proceed with the program, a remediation plan identifying steps to meet the standard is presented to the Regional Vice President, Cancer Care Ontario. Key Steps:

1) Validate safety indicator compliance with each site - by February 28, 2015 – South West Regional Cancer Program 2) Issue compliance/non-compliance communication to each site - by March 15, 2015 - Project Sponsors/Co-Chairs 3) Non-complaint hospitals will submit a remediation plan to South West Regional Cancer Program by May 31, 2015 for review by SW Endoscopy QI Committee (see 2.3) 4) Adopt/refine submitted remediation plans - by July 15, 2015 - Hospital Site & SW Endoscopy QI Committee 5) Hospital will implement transition/remediation strategy by December 31, 2015 – Hospital Site and SW Endoscopy QI Committee

All sites to be fully compliant by January 1, 2016

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All Key Performance Indicators (KPI) are implemented at all GI Endoscopy program sites It is recommended that: All hospitals providing GI Endoscopy services meet the criteria/benchmarks established in the Guideline for Colonoscopy Quality Assurance and complete the GI Endoscopy scorecard quarterly as part of an ongoing quality management program for cancer services at the site. Implementation: Project team completes KPI scorecard for submission to LHIN Board for acceptance. Key Steps:

1) South West Regional Cancer Program data team completes revisions for all scorecards by February 6, 2015 – South West Regional Cancer Program

2) Updated scorecards shared with project team by February 13, 2015 – South West Regional Cancer Program

3) Site specific scorecards shared with Executive Leaders and identified Endoscopic Site Leads by February 20, 2015 – South West Regional Cancer Program

4) Scorecards submitted as part of final recommendations/implementation plan to LHIN board March 17, 2015 – South West LHIN and South West Regional Cancer Program

2. Data provision, analysis, and report generation

Program data collection, analysis and report generation is standardized. It is recommended that: All Hospitals to immediately begin to collect and submit all required ColonCancerCheck (CCC) data fields and patient postal codes using a common data collection tool. Implementation: Working with CCO and South West LHIN, the South West Regional Cancer Program will complete the development for program performance measurement. The KPI scorecard will provide the basis for regional program data collection. Analysis and reporting for program performance will align with CCO reporting requirements and time lines. Key Steps:

1) Work with CCO to ensure participating sites are appropriately identified as ColonCancerCheck sites by March 1, 2015 – South West Regional Cancer Program

2) Develop and provide an education program for sites not familiar with providing data by March 30, 2015 – South West Regional Cancer Program

3) All program sites remit data using the standardized tool (CIRT), as well as any supplemental data to the South West Regional Cancer Program beginning April 2015 – South West Regional Cancer Program

4) Align Endoscopy reporting to program sites with CCO reporting timelines by Q1 2015 – South West Regional Cancer Program

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3. Program accountability and quality improvement

Program Accountability Through system funding reform the South West Regional Cancer Program (SWRCP) as an agent of Cancer Care Ontario, has overall accountability for the program. It is recommended that:

a. The SWRCP develop infrastructure and processes to ensure the ongoing support of QBP implementation.

b. Cancer Care Ontario’s performance management processes be used as an accountability tool to ensure that current and future quality standards and associated funding requirements are met.

c. A regional Quality Improvement Committee (QIC) be established to ensure ongoing performance monitoring and quality improvement.

Implementation: Key Steps:

1) Resolve steering committee and all project teams - March 30, 2015 2) Advocate for current and future state funding requirements – ongoing – CCO Regional Vice

President 3) Define small hospitals in future CCO funding agreements/contracts - December 2015 – CCO

Regional Vice President 4) Draft SW Endoscopy Quality Improvement Committee Terms of Reference - March 1, 2015 –

CCO Regional Vice President and CCO Regional Endoscopy Lead 5) Membership of the QIC to reflect the hospital diverse regional geography, site size, and care

environments as well as providing for clinical, administrative and patient perspectives - CCO Regional Vice President and CCO Regional Endoscopy Lead

6) Launch South West Endoscopy Quality Improvement Committee - June 30, 2015 (to be operational by the end of Q2 2015-16) - CCO Regional Endoscopy Lead

Quality Improvement It is recommended that:

a. All hospitals, regardless of size participate in efficiency and costing work. b. The specific issues facing hospitals providing endoscopic training be considered in planning and that

these organizations be supported in the delivery of their academic and care missions. c. A combination of minimum procedural volume and other quality metrics are used to assess quality of

services provided and this aligns with the Quality Management Partnership of CPSO and CCO. d. The SWRCP GI Endoscopy Lead ensure that a comprehensive physician education program be

developed for consistent application and understanding of quality metrics as well as QBP funding requirements.

e. Patient experience performance measures be developed and implemented as part of the scorecard requirements.

Implementation: The Quality Improvement Committee chaired by the CCO Regional Endoscopy Lead will be responsible for ensuring these quality improvements are implemented and aligned with HEIA and the South West LHIN Aboriginal Care Unit. Key Steps:

1) Include quality improvements in the Regional Endoscopy Lead work plan 2015-16 – CCO Regional Vice President and CCO Regional Endoscopy Lead

2) South West Regional Cancer Program to support implementation of quality initiatives through Regional Endoscopy Program-– South West Regional Cancer Program

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4. Patient flow and system optimization

Patient Flow It is recommended that:

a. As Health System Funding Reform is implemented, that emergency and advanced therapeutic endoscopy procedures continue to be provided, even when annual funding targets have been achieved.

b. Ensure endoscopy procedure access is available and expanded for marginalized populations in the region, in alignment with formal Health Equity Impact Analysis methodologies.

Implementation: South West Regional Cancer Program executive leadership will advocate for maintaining patient service ongoing – South West Regional Cancer Program. System optimization It is recommended that:

a) Standard data collection and reporting criterion is used for all GI endoscopies performed. b) Where applicable, in order to improve timeliness of access, coordinated access models for endoscopy

procedures be considered at all levels to reduce variability in access to GI Endoscopy procedures and ensure timely, continued safe, effective and efficient care. Potential models should include:

• Patient preference/ informed decision making • Patient satisfaction • Ensure continued safe care delivery • Potential differences in scope of practice between Gastroenterologists and General

Surgeons • Real time data collection, intervention and analysis

c) Wait list management practices be adopted at the local level. Implementation: Delegated by the Regional Vice President, the Quality Improvement Committee chaired by the CCO Regional Endoscopy Lead will be responsible for implementing these quality improvements. Key Steps:

1) SW Endoscopy Quality Improvement Committee reviews immediate and long term quality improvements making recommendations annually to Regional Vice President by March 1, 2015 and ongoing - CCO Regional Endoscopy Lead

2) Include quality improvements as part of the Regional Endoscopy Lead future work plan – CCO Regional Vice President and CCO Regional Endoscopy Lead

3) South West Regional Cancer Program advocates for future state funding requirements – ongoing – CCO Regional Vice President

4) South West Regional Cancer Program to support implementation of quality initiatives through Regional Endoscopy Program - South West Regional Cancer Program

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Site Scorecards – Key Performance Indicators Site Scorecards have been developed for each site providing GI Endoscopy services in our region. This will serve as a baseline for data, operational and clinical measurements moving into the implementation phase beginning April 1, 2015, and will be executed and monitored by the South West Regional Cancer Program. (See Appendix A)

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Regional Investment Under the leadership of the Project Sponsors, supported by the South West LHIN and the South West Regional Cancer Program, the following committees were developed to advise and provide direction to the project.

2013 2014 2015 Project Structures/Resources J F M A M J J A S O N D J F M A M J J A S O N D J F M

Steering Committee (December 2013-March 2015) Senior Leadership representatives from each hospital site

Physician Advisory Committee (December 2013-March 2015) Endoscopists representing seven sites in the region (large and small hospitals)

Core Project Team (December 2013-August 2014, January 2015) Operational Managers/Directors representing each site

Efficiency Committee (October 2014-December 2014) Fusion of finance, data and operational management representing each site

Project Team (December 2013-March 2015) South West Regional Cancer Program (Director, Project Lead, data and administrative support)

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Project Activity and Key Milestones (September 2013-April 2015) September 13, 2013 South West LHIN CCAC/CEO Leadership Committee commissioned a clinical

services planning strategy to focus on Stroke, Cataract, and GI Endoscopy services in the region.

December 16, 2013 The GI Endoscopy Realignment and Best Practice Implementation Project launched. Administrative and clinical leadership came together in a half day session to brainstorm ideas for data analysis and project delivery. From this work, a Steering Committee, Physician Advisory Committee, and Core Project Team were established. Included in the membership of these groups were representatives of all publicly funded organizations involved in the delivery of outpatient GI Endoscopy services.

January - March 2014 Steering Committee was formulated and approved the Project Charter.

February - May 2014 Core Project Team members completed two comprehensive data collection surveys to establish a common data set that measures the quality and current service offerings (Appendix A). Survey responses were used to identify current practices, operational planning parameters, staffing, and regional demographics for each of the sites. Each site’s ability to respond to the survey questions varied due to a lack of common data collection, reporting requirements, and resource allocations to support this work. A synopsis of the data reported from the survey is included in this report as Appendix B.

June 16, 2014 A Current State Workshop was held to review the submitted information. Final revisions were made in July and final site responses were complete by August 31, 2014.

August 27, 2014 A recommendation was adopted by the Project Steering Committee to focus the project on the following quality dimensions:

• Access • Efficiency • Effectiveness

The intent of this recommendation was to provide a common set of expectations from which to build key performance indicators. Furthermore, it was identified that without a common methodology for data collection and reporting there were gaps in the understanding of basic quality measures such as wait times, required interventions, initial patient outcome measures, etc. CCO’s ColonCancerCheck program was adopted as the proxy for data collection methodology.

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September 28, 2014 CCO released the interim QBP pricing.

October 29, 2014 The Current State Report was approved by Steering Committee; future state work continued.

October - December 2014 As a result of CCO’s release of interim pricing, an Efficiency Committee was established to develop directional indicators related to efficiency.

October 29, 2014 Project evaluation and key performance indicators were approved.

October 22 - November 21, 2014 Site visits were conducted by Kelly Simpson (South West LHIN) and Brenda Fleming (South West Regional Cancer Program) to review project and draft scorecards.

December 9, 2014 Project Team presented project at Ministry meetings.

January 6, 2015 CCO communicated to Regional Vice President’s the MOHLTC’s Amendments to the Application for Licensing under the Independent Health Act.

January 20-28, 2015 Each site responded to minimum quality standards performance indicators questionnaire.

January 26, 2015 Steering Committee reviewed and approved Recommendations and Implementation Plan.

January 30, 2015 Project Team presented recommendations to CCAC/CEO Leadership Forum.

February 25, 2015 Final Report & Recommendations and Implementation Plan was approved by Steering Committee.

March 17, 2015 Project Team presented Recommendations and Implementation Plan to South West LHIN Board of Directors.

April 1, 2015 South West Regional Cancer Program initiates and manages Project Implementation Plan and QBP roll-out.

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Methods for Data Collection and Information Gathering Overall, the following tools were used in the Project:

Current State Survey and QBP Quality Standards Survey

Since project inception, the ability to collect consistent data sets across all sites was an identified risk to the project’s success. A comprehensive survey (CS Report), followed by a QBP quality standards survey was circulated in February of 2014 to start to collect baseline data sets. Due to variability in infrastructure or the ability of some sites to obtain this information, the results of the survey could not be compiled for analysis until April 2014. A workshop was held on June 16, 2014 to validate the regional current state. From this work, the project’s Current State Report was approved (Appendix B) and the progression to future state began.

From the information gathered in the two surveys, the Steering Committee endorsed the foci of the project: access, effectiveness, and efficiency. In addition, the AIM statement was adopted.

Site Scorecards – Key Performance Indicators

Using the framework identified above, key performance indicators from the 2013 Guidelines, and the 2014 QBP Handbook, a regional scorecard was created. In October and November of 2014, site visits conducted by the South West Regional Cancer Program and South West LHIN took place and utilized the scorecard to frame and guide future state recommendations.

Process Mapping and Costing Template

In response to the release of the CCO QBP interim pricing in September 2014, an Efficiency Committee was established, and the group developed and completed a process map (which formed baseline process) and a case draft costing template (utilizing efforts and resources from other regional QBP work streams). As a result of the analysis of the most significant variances across the sites, the development of the five directional key performance indicators for efficiency was developed.

Minimum Standards Questionnaire

The Project Team recommended that in order to initiate the implementation plan beginning April 1, 2015, a minimum quality standard scorecard should be developed for the region. Sites responded to a questionnaire and the results are listed in the chart below.

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Sout West LHIN: Minimun Quality Standards Outpatient Endoscopy

HPHA S

HPHA ST M

HPHA C WGH MHA S

MHA FC TDMH

GBHS OS

GBHS MA

GBHS ME

GBHS S

GBHS W STEGH

LHSC VH

LHSC UH

SBGHC L

SBGHC W

LWHA L

LWHA W SJHC HDH AMGH

IndicatorNumber of AER per basin (1/1800)

X Endowasher

X X X X X X X X X X X X X X X X X X X X

Use of automated machine reprocessors X X X X X X X X X X X X X X X X X X X X X X

Available complete resuscitation equipment(defibrillator, endotracheal tubes, airw ays, laryngoscope, oxygen sources w ith positive pressure capabilities, emergency drugs and oxygen tanks)

X X X X X X X X X X X X X X X X X X X X X X

Equipment to remove polyps and manage related complications (hemoclips, injectors, snares, biopsy, forceps, electrocautery equipment, tattooing ink)

X

No (esopha

gus only)

X X X X X X X X X X X X X X X X X X X X

Supplies onsite (intravenous f luid, setup, supplies and suction systems


Percent of all nurses involved in sedation monitoring that receive special training/certif ication in sedation

X X X X X X X X X X X X X X X X X X

All nurses must have BCLS training in the procedure room


> 2 ACLS certif ied persons site X X X X X X X X X X X X X X X X X X X X

Training of all the staff involved w ith endoscope care &maintenance w ith a clear chain of accountability for endo processing procedures.


Minimum Quality Standards Checklist

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Standard not met as of January 31, 2015

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Conclusion Given the established aim to,”by 2016, decrease the variation of wait times and volumes and implement best practices in the GI Endoscopy services delivered in the South West LHIN”, there is now a defined path to decrease the variances of these services. The release and further implementation of GI Endoscopy QBP in the province will continue to enhance the current structure and will frame future modeling to ensure full alignment with quality based practices and guidelines. The South West Regional Cancer Program is circulating agreements with each hospital site that performs outpatient Endoscopy in the region to establish a data and quality reporting structure beginning April 1, 2015.

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References Cancer Care Ontario & Ministry of Health and Long Term Care, Pvince of Ontario. (2013, September).

Retrieved 2014, from Ontario Ministry of Health and Long Term Care: http://health.gov.on.ca/en/pro/programs/ecfa/docs/qbp_gi.pdf

Cancer Care Ontario Prevention and Cancer Planning and Control. (2010). Retrieved 2014, from Cancer Care Ontario: https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=156747

South West Local Health Integration Network. (2014). South West Local Health Integration Network (LHIN). Retrieved 2014, from South West LHIN: http://www.southwestlhin.on.ca/SiteContent/PublicCommunity/IntegratedHealthServicePlan/2013IHSP/PA-ClinicalServicesPlanning.aspx

South West Regional Cancer Program. (2014). Partners in Care| South West Regonal Cancer Program. Retrieved 2014, from South West Regional Cancer Program: http://www.southwestcancer.ca/about-swrcp/partners-care

Tinmouth, J. K. (2013). Guideline for Colonoscopy Quality Assurance in Ontario. Toronto: Cancer Care Ontario Program in Evidence-based Care.

Not available Yes Not available NA NA Annual

90% 92% 85% 75% Quarterly

100% 100% 87% 80% Quarterly

106 days 77 days 312 days No target Quarterly



77% 73% 83% 90% Quarterly

Not availableRecord and monitor

April 1, 2015Not available Not available 90% Quarterly


April 1, 2015Not available Not available 100% Annual



Not available 100% Not available 100% 100% Quarterly






Not available Yes Not available NAOne AER/basin for every

1800 procedures per yearAnnual


Not available Yes Not available NAAs per manufacturer

specificationsAnnual




Meeting or within 2% of target.

Not meeting target, but improving from the previous quarter.

Not meeting target.

Equipment to remove polyps and manage

related complications (hemoclips,

injectors, snares, biopsy, forceps,

electrocautery equipment, tattooing ink)

Supplies onsite (intravenous fluid, setup,

supplies and suction systems)

Available complete resuscitation

equipment

Percent of procedures where patient is

offered sedation

Percent of sedated patients where

patient's vitals are monitored and captured

before, during and after sedation

Deep sedation monitoring: dedicated

nurse with no other responsibilities if

patient is under deep sedation

Readiness for discharge scoring system

i.e. Aldrete score or PADS

Site audit processes are in place to

monitor physician's use of sedation

Equipment Quality

Maintenance and inservicing up-to-date

Ability to capture video/photo

documentation

Number of AER per basin

Use of automated machine reprocessors

Number of times scope is used per year

Use of Sedation

Accreditation

Accreditation Status

Timely Access to Quality GI Endoscopy

Percent of procedures completed within

priority target (8 weeks) - Positive FOBT


priority target (26 weeks) - Family History

90th Percentile Wait Time - Other

Screening

90th Percentile Wait Time - Surveillance

for Colorectal Neoplasm

90th Percentile Wait Time - Symptomatic

or Abnormal Lab Test

Increase Success of Bowel Preparation

Percent of procedures where bowel

preparation was good (mucosa seen

throughout)

Percent of cases where split dosing is

used

2013/14 Outpatient Endoscopy Indicators - Woodstock Hospital

Indicator

Woodstock

2012/13

Performance

Woodstock

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency

Increase of 5% or more from

the previous period

Decrease of 5% or more from

the previous period

Within 5% compared to

previous period

No trend data

Prepared by: SWRCP Decision Support Page 1 of 2

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Appendix A

2013/14 Outpatient Endoscopy Indicators - Woodstock Hospital

Not available 100% Not available 82% 100% Annual






0.00% 0.00% 0.02% 0.05% Every 6 months

93% 92% 95% 95% Every 6 months

36% 36% 38% 35% Every 6 months

Total 2,054 procedures

Avg = 342/phys


Avg = 190/phys

Total 14,218

Avg = 263/phys>200/year Every 6 months

Not available Begin April 1, 2015 Not available Not available +/-10% Annual

Not available Begin April 1, 2015 Not available Not available 150 mins Annual



93% 92% 95% 95% Annual



Not meeting target.

Notes:

Wait Times: The wait time in days from referral to procedure. Only includes cases with Scheduled Recall = No.

Cecal Intubation Rate: Percent of cases in which the cecum was intubated.

Perforation Rate: Rate of large bowel perforation at time of procedure.

SWRCP Overall Performance: Some indicators are for CIRT hospitals only.

Data may be different than CCO reports depending on data source.

Source: CIRT outpatient cases for CCC hospitals only (wait times, bowel preparation, standardized physician quality)

Self-reported (accreditation, sedation, equipment quality, physician/nurse training)

Determine an acceptable range of time for

outpatient admission from registration to

discharge

Record overall Cecal Intubation Rate

Polyp Detection Rate

Volume

Optimize Cost/Efficiency of Service Delivery

Establish cost per procedure

Determine the nursing hours per

procedure

Itemize the consumable supplies per

procedure

Cecal Intubation Rate

SWRCP

2013/14

Performance

TargetReporting

Frequency

Physician/Nurse Training

Percent of all nurses involved in sedation

monitoring that receive special

training/certification in sedation

All nurses must have BCLS training in the

procedure room

Trend

> 2 ACLS certified persons on site

Minimum training requirements met for all

physician trainees (>300 procedures, CIR

>85%, cognitive proficiency)

Training of all the staff involved with

endoscope care and maintenance with a

clear chain of accountability for endo

processing procedures

Standardized Physician Quality (All Physicians at Site)

Large Bowel Perforation Rate

Indicator

Woodstock

2012/13

Performance

Woodstock

2013/14

Performance


the previous period


the previous period


previous period

No trend data



Not available Not available Not available 85% 75% Quarterly


Not available Not available Not available 312 days No target Quarterly


























Not meeting target.

2013/14 Outpatient Endoscopy Indicators - Wingham and District Hospital

Indicator

Wingham

2012/13

Performance

Wingham

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency

Use of Sedation

Accreditation








Screening








throughout)


used


equipment


offered sedation











Equipment Quality



documentation











the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - Wingham and District Hospital







Not available Not available Not available 0.02% 0.05% Every 6 months

Not available Not available Not available 95% 95% Every 6 months


Not available Not available Not availableTotal 14,218






Not available Not available Not available 95% 95% Annual



Not meeting target.

Notes:







Indicator

Wingham

2012/13

Performance

Wingham

2013/14

Performance


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend













discharge



Volume




procedure


procedure


the previous period


the previous period


previous period

No trend data



86% 79% 85% 75% Quarterly

65% 64% 87% 80% Quarterly




94% 96% 83% 90% Quarterly























Not meeting target.








equipment


offered sedation











Equipment Quality



documentation




Use of Sedation

Accreditation








Screening








throughout)


used

2013/14 Outpatient Endoscopy Indicators - Wiarton Hospital

Indicator

Wiarton

2012/13

Performance

Wiarton

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency


the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - Wiarton Hospital







0.00% 0.00% 0.02% 0.05% Every 6 months

94% 94% 95% 95% Every 6 months

36% 40% 38% 35% Every 6 months

Total 431 procedures

Avg = 596/phys*


Avg = 579/phys*

Total 14,218






94% 94% 95% 95% Annual



Not meeting target.

Notes:






* Total procedures is per facility, but average procedures by physician is by corporation.





discharge



Volume




procedure


procedure


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend











Indicator

Wiarton

2012/13

Performance

Wiarton

2013/14

Performance


the previous period


the previous period


previous period

No trend data


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Grey Bruce Health Services offers endoscopy services at 4 rural sites ( Meaford, Markdale, Wiarton and Southampton) as well at Owen Sound and perform in excess of 4000 procedures per year. We have 5 physicians in total providing endoscopy, (5 general surgeons and 1 gastroenterologist). Our innovative roaming scope program includes an SPD technician who rotates across the rural sites, and ensures consistent quality (e.g. adherence to reprocessing standards) as well as an efficient use of scoping resources.

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Not meeting target.

2013/14 Outpatient Endoscopy Indicators - South Bruce Grey Health Centre - Walkerton

Indicator

Walkerton

2012/13

Performance

Walkerton

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency

Use of Sedation

Accreditation








Screening








throughout)


used


equipment


offered sedation











Equipment Quality



documentation











the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - South Bruce Grey Health Centre - Walkerton



















Not meeting target.

Notes:







Indicator

Walkerton

2012/13

Performance

Walkerton

2013/14

Performance


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend













discharge



Volume




procedure


procedure


the previous period


the previous period


previous period

No trend data































Not meeting target.

2013/14 Outpatient Endoscopy Indicators - LHSC - Victoria Hospital

Indicator

Victoria

2012/13

Performance

Victoria

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency

Use of Sedation

Accreditation








Screening








throughout)


used


equipment


offered sedation











Equipment Quality



documentation











the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - LHSC - Victoria Hospital



















Not meeting target.

Notes:







Indicator

Victoria

2012/13

Performance

Victoria

2013/14

Performance


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend













discharge



Volume




procedure


procedure


the previous period


the previous period


previous period

No trend data































Not meeting target.

2013/14 Outpatient Endoscopy Indicators - LHSC - University Hospital

Indicator

University

2012/13

Performance

University

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency

Use of Sedation

Accreditation








Screening








throughout)


used


equipment


offered sedation











Equipment Quality



documentation











the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - LHSC - University Hospital



















Not meeting target.

Notes:







Indicator

University

2012/13

Performance

University

2013/14

Performance


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend













discharge



Volume




procedure


procedure


the previous period


the previous period


previous period

No trend data



60% 86% 85% 75% Quarterly

67% 76% 87% 80% Quarterly




69% 68% 83% 90% Quarterly























Not meeting target.








equipment


offered sedation











Equipment Quality



documentation




Use of Sedation

Accreditation








Screening








throughout)


used

2013/14 Outpatient Endoscopy Indicators - Tillsonburg District Memorial Hospital

Indicator

Tillsonburg

2012/13

Performance

Tillsonburg

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency


the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - Tillsonburg District Memorial Hospital







0.00% 0.00% 0.02% 0.05% Every 6 months

93% 96% 95% 95% Every 6 months

32% 36% 38% 35% Every 6 months


Avg = 328/phys


Avg = 298/phys

Total 14,218






93% 96% 95% 95% Annual



Not meeting target.

Notes:










discharge



Volume




procedure


procedure


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend











Indicator

Tillsonburg

2012/13

Performance

Tillsonburg

2013/14

Performance


the previous period


the previous period


previous period

No trend data































Not meeting target.

2013/14 Outpatient Endoscopy Indicators - Strathroy Middlesex General Hospital

Indicator

Strathroy

2012/13

Performance

Strathroy

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency

Use of Sedation

Accreditation








Screening








throughout)


used


equipment


offered sedation











Equipment Quality



documentation











the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - Strathroy Middlesex General Hospital



















Not meeting target.

Notes:







Indicator

Strathroy

2012/13

Performance

Strathroy

2013/14

Performance


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend













discharge



Volume




procedure


procedure


the previous period


the previous period


previous period

No trend data



73% 66% 85% 75% Quarterly

93% 92% 87% 80% Quarterly


Volume less than 10 No volume 364 days No target Quarterly


80% 75% 83% 90% Quarterly























Not meeting target.








equipment


offered sedation











Equipment Quality



documentation




Use of Sedation

Accreditation








Screening








throughout)


used

2013/14 Outpatient Endoscopy Indicators - Stratford General Hospital

Indicator

Stratford

2012/13

Performance

Stratford

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency


the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - Stratford General Hospital







0.00% 0.05% 0.02% 0.05% Every 6 months

94% 96% 95% 95% Every 6 months

29% 36% 38% 35% Every 6 months


Avg = 322/phys*


Avg = 304/phys*

Total 14,218






94% 96% 95% 95% Annual



Not meeting target.

Notes:











discharge



Volume




procedure


procedure


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend











Indicator

Stratford

2012/13

Performance

Stratford

2013/14

Performance


the previous period


the previous period


previous period

No trend data































Not meeting target.

2013/14 Outpatient Endoscopy Indicators - St. Thomas Elgin General Hospital

Indicator

STEGH

2012/13

Performance

STEGH

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency

Use of Sedation

Accreditation








Screening








throughout)


used


equipment


offered sedation











Equipment Quality



documentation











the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - St. Thomas Elgin General Hospital



















Not meeting target.

Notes:







Indicator

STEGH

2012/13

Performance

STEGH

2013/14

Performance


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend













discharge



Volume




procedure


procedure


the previous period


the previous period


previous period

No trend data



























Not available No Not available NA NA Annual




Not meeting target.

2013/14 Outpatient Endoscopy Indicators - St Marys Memorial Hospital

Indicator

St Marys

2012/13

Performance

St Marys

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency

Use of Sedation

Accreditation








Screening








throughout)


used


equipment


offered sedation











Equipment Quality



documentation











the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - St Marys Memorial Hospital



















Not meeting target.

Notes:







Indicator

St Marys

2012/13

Performance

St Marys

2013/14

Performance


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend













discharge



Volume




procedure


procedure


the previous period


the previous period


previous period

No trend data



50% 88% 85% 75% Quarterly

100% 95% 87% 80% Quarterly




96% 91% 83% 90% Quarterly























Not meeting target.








equipment


offered sedation











Equipment Quality



documentation




Use of Sedation

Accreditation








Screening








throughout)


used

2013/14 Outpatient Endoscopy Indicators - Southampton Hospital

Indicator

Southampton

2012/13

Performance

Southampton

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency


the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - Southampton Hospital







0.00% 0.00% 0.02% 0.05% Every 6 months

99% 97% 95% 95% Every 6 months

45% 44% 38% 35% Every 6 months


Avg = 596/phys*


Avg = 579/phys*

Total 14,218






99% 97% 95% 95% Annual



Not meeting target.

Notes:











discharge



Volume




procedure


procedure


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend











Indicator

Southampton

2012/13

Performance

Southampton

2013/14

Performance


the previous period


the previous period


previous period

No trend data


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87% 93% 85% 75% Quarterly

71% 85% 87% 80% Quarterly




85% 84% 83% 90% Quarterly























Not meeting target.




equipment

Reporting

Frequency





Use of Sedation



throughout)


used

Indicator

SWRCP

2013/14

Performance

Target

SJHC

2012/13

Performance

SJHC

2013/14

Performance

Trend



2013/14 Outpatient Endoscopy Indicators - St. Joseph's Healthcare, London

Accreditation



offered sedation





Screening







Equipment Quality


documentation















the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - St. Joseph's Healthcare, London







0.00% 0.04% 0.02% 0.05% Every 6 months

96% 96% 95% 95% Every 6 months

44% 46% 38% 35% Every 6 months


Avg = 188/phys


Avg = 190/phys

Total 14,218






96% 96% 95% 95% Annual



Not meeting target.

Notes:











TargetReporting

Frequency


Indicator

SJHC

2012/13

Performance

SJHC

2013/14

Performance

Trend

SWRCP

2013/14

Performance








procedure


procedure



discharge










Volume


procedure room


the previous period


the previous period


previous period

No trend data



89% 88% 85% 75% Quarterly

90% 82% 87% 80% Quarterly




91% 92% 83% 90% Quarterly























Not meeting target.








equipment


offered sedation











Equipment Quality



documentation




Use of Sedation

Accreditation








Screening








throughout)


used

2013/14 Outpatient Endoscopy Indicators - Owen Sound Hospital

Indicator

Owen Sound

2012/13

Performance

Owen Sound

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency


the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - Owen Sound Hospital







0.04% 0.00% 0.02% 0.05% Every 6 months

95% 96% 95% 95% Every 6 months

31% 26% 38% 35% Every 6 months


Avg = 596/phys*


Avg = 579/phys*

Total 14,218






95% 96% 95% 95% Annual



Not meeting target.

Notes:











discharge



Volume




procedure


procedure


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend











Indicator

Owen Sound

2012/13

Performance

Owen Sound

2013/14

Performance


the previous period


the previous period


previous period

No trend data


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77% 64% 85% 75% Quarterly

85% 90% 87% 80% Quarterly




96% 96% 83% 90% Quarterly























Not meeting target.








equipment


offered sedation











Equipment Quality



documentation




Use of Sedation

Accreditation








Screening








throughout)


used

2013/14 Outpatient Endoscopy Indicators - Meaford Hospital

Indicator

Meaford

2012/13

Performance

Meaford

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency


the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - Meaford Hospital







0.00% 0.00% 0.02% 0.05% Every 6 months

94% 94% 95% 95% Every 6 months

28% 35% 38% 35% Every 6 months


Avg = 596/phys*


Avg = 579/phys*

Total 14,218






94% 94% 95% 95% Annual



Not meeting target.

Notes:











discharge



Volume




procedure


procedure


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend











Indicator

Meaford

2012/13

Performance

Meaford

2013/14

Performance


the previous period


the previous period


previous period

No trend data


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100% 100% 85% 75% Quarterly

100% 100% 87% 80% Quarterly


Volume less than 10 Volume less than 10 364 days No target Quarterly


96% 96% 83% 90% Quarterly























Not meeting target.








equipment


offered sedation











Equipment Quality



documentation




Use of Sedation

Accreditation








Screening








throughout)


used

2013/14 Outpatient Endoscopy Indicators - Markdale Hospital

Indicator

Markdale

2012/13

Performance

Markdale

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency


the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - Markdale Hospital







0.00% 0.00% 0.02% 0.05% Every 6 months

92% 95% 95% 95% Every 6 months

24% 32% 38% 35% Every 6 months


Avg = 596/phys*


Avg = 579/phys*

Total 14,218






92% 95% 95% 95% Annual



Not meeting target.

Notes:











discharge



Volume




procedure


procedure


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend











Indicator

Markdale

2012/13

Performance

Markdale

2013/14

Performance


the previous period


the previous period


previous period

No trend data


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Not meeting target.

2013/14 Outpatient Endoscopy Indicators - Listowel Memorial Hospital

Indicator

Listowel

2012/13

Performance

Listowel

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency

Use of Sedation

Accreditation








Screening








throughout)


used


equipment


offered sedation











Equipment Quality



documentation











the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - Listowel Memorial Hospital



















Not meeting target.

Notes:







Indicator

Listowel

2012/13

Performance

Listowel

2013/14

Performance


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend













discharge



Volume




procedure


procedure


the previous period


the previous period


previous period

No trend data































Not meeting target.

2013/14 Outpatient Endoscopy Indicators - South Bruce Grey Health Centre - Kincardine

Indicator

Kincardine

2012/13

Performance

Kincardine

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency

Use of Sedation

Accreditation








Screening








throughout)


used


equipment


offered sedation











Equipment Quality



documentation











the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - South Bruce Grey Health Centre - Kincardine



















Not meeting target.

Notes:







Indicator

Kincardine

2012/13

Performance

Kincardine

2013/14

Performance


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend













discharge



Volume




procedure


procedure


the previous period


the previous period


previous period

No trend data































Not meeting target.

2013/14 Outpatient Endoscopy Indicators - Hanover and District Hospital

Indicator

Hanover

2012/13

Performance

Hanover

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency

Use of Sedation

Accreditation








Screening








throughout)


used


equipment


offered sedation











Equipment Quality



documentation











the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - Hanover and District Hospital



















Not meeting target.

Notes:







Indicator

Hanover

2012/13

Performance

Hanover

2013/14

Performance


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend













discharge



Volume




procedure


procedure


the previous period


the previous period


previous period

No trend data































Not meeting target.

2013/14 Outpatient Endoscopy Indicators - Four Counties Health Services

Indicator

Four Counties

2012/13

Performance

Four Counties

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency

Use of Sedation

Accreditation








Screening








throughout)


used


equipment


offered sedation











Equipment Quality



documentation











the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - Four Counties Health Services



















Not meeting target.

Notes:







Indicator

Four Counties

2012/13

Performance

Four Counties

2013/14

Performance


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend













discharge



Volume




procedure


procedure


the previous period


the previous period


previous period

No trend data



59% 38% 85% 75% Quarterly

100% 89% 87% 80% Quarterly


Volume less than 10 No volume 364 days No target Quarterly


98% 96% 83% 90% Quarterly























Not meeting target.








equipment


offered sedation











Equipment Quality



documentation




Use of Sedation

Accreditation








Screening








throughout)


used

2013/14 Outpatient Endoscopy Indicators - Clinton Public Hospital

Indicator

Clinton

2012/13

Performance

Clinton

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency


the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - Clinton Public Hospital







0.00% 0.00% 0.02% 0.05% Every 6 months

96% 99% 95% 95% Every 6 months

29% 42% 38% 35% Every 6 months


Avg = 322/phys*


Avg = 304/phys*

Total 14,218






96% 99% 95% 95% Annual



Not meeting target.

Notes:











discharge



Volume




procedure


procedure


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend











Indicator

Clinton

2012/13

Performance

Clinton

2013/14

Performance


the previous period


the previous period


previous period

No trend data































Not meeting target.

2013/14 Outpatient Endoscopy Indicators - Alexandra Marine & General Hospital

Indicator

AMGH

2012/13

Performance

AMGH

2013/14

Performance

Trend

SWRCP

2013/14

Performance

TargetReporting

Frequency

Use of Sedation

Accreditation








Screening








throughout)


used


equipment


offered sedation











Equipment Quality



documentation











the previous period


the previous period


previous period

No trend data


2013/14 Outpatient Endoscopy Indicators - Alexandra Marine & General Hospital



















Not meeting target.

Notes:







Indicator

AMGH

2012/13

Performance

AMGH

2013/14

Performance


SWRCP

2013/14

Performance

TargetReporting

Frequency






procedure room

Trend













discharge



Volume




procedure


procedure


the previous period


the previous period


previous period

No trend data


Current State of Outpatient GI Endoscopy Services in the South West Region November 1, 2014

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Appendix B

2

Table of Contents

Introduction .......................................................................................................................... 3

Project Overview ................................................................................................................... 3

Background & Actions to Date ............................................................................................... 4 Demographics of the South West LHIN ............................................................................................5 Outpatient Demographics – Who Uses GI Endoscopy Services? .......................................................6 Where Do South West Patients Go For GI Endoscopy Care? .............................................................7

Current State – Access and Availability of Services ................................................................. 9 Referral and Patient Choice Patterns ............................................................................................ 11 Wait Times ................................................................................................................................... 12 Cancellations and Capacity ........................................................................................................... 13

Endoscopy Quality Measures ............................................................................................... 14 Best Practices and Standards of Care ............................................................................................ 14 QBP Quality Standards Survey ...................................................................................................... 14 Enhancing Patient Care ................................................................................................................. 15

Efficiency ............................................................................................................................. 16 Defining Cost of Procedures .......................................................................................................... 16 Key Factors Affecting the Ability for Site Level Cost Comparisons................................................... 16

Cancer Care Ontario QBP Roll-out South West LHIN ............................................................. 18 Hospital Corporations Subject to Carve-Out .................................................................................. 18

Looking to the Future .......................................................................................................... 19 Future Demand for Endoscopy Procedures .................................................................................... 19

Conclusion ........................................................................................................................... 22

References .......................................................................................................................... 23

Appendix A – Current State Survey Questions ...................................................................... 24

Appendix B – Survey Responses by Site................................................................................ 28

Appendix C – Patient Referral Patterns ................................................................................69

3

Introduction This report describes the current state of outpatient GI Endoscopy services in the South West region as of October 2014. The information contained in the following sections serves as a baseline/starting point for the Outpatient GI Endoscopy - Realignment and Best Practice Implementation Project, which is intended to improve the quality of outpatient GI Endoscopy services in South West region.

Project Overview The South West LHIN is working together with the South West Regional Cancer Program and 28 hospital sites in the region to identify, evaluate and improve the way outpatient endoscopy services and follow-up care is delivered across the South West. The aim of the project is: By 2016, decrease the variation of wait times and volumes and implement best practices in the GI Endoscopy services delivered in the South West LHIN. This will be accomplished through a detailed examination and review of the location, organization and service delivery variation in outpatient GI Endoscopy services across the region. Key drivers of this work include:

• Clinical services planning • Continuous quality improvement • Implementation of Health System Funding Reform (HSFR) • Quality based procedures for key health care services

This project includes implementation of best practice guidelines according to the Guideline for Colonoscopy Quality Assurance in Ontario (Tinmouth, 2013) and the GI Endoscopy Quality Based Procedure Clinical Handbook (Cancer Care Ontario & Ministry of Health and Long Term Care, Province of Ontario, 2013), a capacity assessment, and identification of key enablers to meet project goals and maximize the use of system resources.

The development of a LHIN wide approach to GI Endoscopy will ensure local service delivery needs and programs within regional hospitals are aligned to the South West LHIN’s Integrated Health Service Plan, and will ensure that services within the South West are delivered at the right time, in the right place and by the right provider.

4

Background & Actions to Date On September 13, 2013 the South West LHIN CCAC/CEO Leadership Committee commissioned a clinical services planning strategy to focus on Stroke, Cataract and GI Endoscopy services in the region.

On December 16, 2013 the GI Endoscopy Realignment and Best Practice Implementation Project was launched. Administrative and clinical leadership came together in a half day session to brainstorm ideas for data analysis and project delivery. From this work, a Steering Committee, Physician Advisory Committee and Core Project Team were established. Included in the membership of these groups were representatives of all publicly funded organizations involved in the delivery of outpatient GI Endoscopy services.

From February through May of 2014, the Core Project Team members individually completed a comprehensive data collection tool to establish a common data set that measures the quality of the current service offering. Data was collected through a detailed survey questionnaire (see Appendix A). Survey responses were used to identify current practices, operational planning parameters, staffing and regional demographics for each of the sites. Each sites’ ability to respond to the survey questions varied due to a lack of common data collection, reporting requirements and resource allocations to support this work. A synopsis of the data reported from the survey is included in this report as Appendix B.

On August 27, 2014 a recommendation was adopted by the Project Steering Committee to focus the project on the following quality dimensions:

• Access • Efficiency • Effectiveness

The intent of this recommendation was to provide a common set of expectations from which to build future state recommendations.

Furthermore, it was identified that without a common methodology for data collection and reporting there were gaps in the understanding of basic quality measures such as wait times, required interventions, initial patient outcome measures, etc.

In response to this concern, the Steering Committee asserted that the ColonCancerCheck data collection methodology as developed by Cancer Care Ontario (Cancer Care Ontario Prevention and Cancer Planning and Control, 2010) would be initiated for all GI Endoscopy work identified within the scope of the project.

5

Demographics of the South West LHIN The South West LHIN is 21,639 square kilometres and covers a portion of Southwestern Ontario from Lake Erie to the Bruce Peninsula. The South West LHIN includes the counties of Bruce, Elgin, Grey*, Huron, Middlesex, Norfolk*1, Oxford and Perth. It has a population of approximately 969,970 people and is a mixture of large and small urban areas, small towns and rural communities. Overall, the population of the South West LHIN is not growing quickly, but the proportion of people over the age of 50 is increasing which has implications for future needs of endoscopy services.

By 2018, the population in the South West LHIN is estimated to grow to 999,223 while approximately 40 percent of the total population will be over the age of 50. This number will continue to increase. As a whole, the South West LHIN has a higher percentage of seniors compared to the provincial average and most seniors live in the central and north parts of the LHIN.2

All counties in the South West LHIN are expected to have more people over the age of 50 in 2018 with the LHIN as a whole seeing a growth rate of 9.3% for people over the age of 50 compared to just 3.0% growth for all ages. Huron and Perth counties are both estimated to have a negative growth rate from 2013 to 2018 with -1.0% and -0.5%, respectively; however, the number of people over 50 is still expected to increase by 5.0% in Huron County and 8.0% in Perth County. Elgin and Middlesex counties have the highest growth rate from 2013 to 2018 with Elgin County growing by 2.5% and Middlesex County by 5.2% and the number of people over the age of 50 also increasing by 9.7% in Elgin and 11.4% in Middlesex. Additionally, Grey and Bruce counties have the biggest proportion of people over 50 with almost half of their population being over the age of 50 in 2018 (48.4% for Grey and 48.9% for Bruce).3

1 The eastern part of Grey County is part of another LHIN and the western part of Norfolk County is part of the South West LHIN. 2 Population Projections County (Statistics Canada, ON Ministry of Finance), MOHLTC, IntelliHEALTH Ontario 3 Population Projections County (Statistics Canada, ON Ministry of Finance), MOHLTC, IntelliHEALTH Ontario

6

Table 1 - South West LHIN Population Projections by County 2013 and 2018

County

2013 2018

Population (All Ages)

Population Age 50+

Percent of Population

Age 50+

Population (All Ages)

Growth Rate

(All Ages)

Population Age 50+

Growth Rate

(Age 50+)

Percent of Population

Age 50+

Grey 96,743 44,350 45.8% 98,516 1.8% 47,640 7.4% 48.4% Bruce 67,599 31,697 46.9% 68,118 0.8% 33,278 5.0% 48.9% Huron 60,335 25,977 43.1% 59,704 -1.0% 27,279 5.0% 45.7% Perth 76,866 29,648 38.6% 76,465 -0.5% 32,023 8.0% 41.9% Oxford 109,146 41,689 38.2% 110,442 1.2% 45,737 9.7% 41.4% Elgin 91,418 33,787 37.0% 93,687 2.5% 37,068 9.7% 39.6% Middlesex 467,863 164,061 35.1% 492,291 5.2% 182,840 11.4% 37.1%

Total 969,970 371,209 38.3% 999,223 3.0% 405,865 9.3% 40.6%

Source: Population Projections County (Statistics Canada, ON Ministry of Finance), MOHLTC, IntelliHEALTH Ontario

Outpatient Demographics – Who Uses GI Endoscopy Services? In the South West LHIN, people over the age of 50 are the highest users of endoscopy services, accounting for 77% of all procedures in FY2013/14. The ColonCancerCheck program recommends that all individuals between the age of 50-74 screen using a Fecal Occult Blood Test (FOBT). If the test is positive or the individual has a family history of colon cancer, the recommended screening test is a colonoscopy.

Figure 1 - Age Distribution for Outpatient Endoscopy Procedures per 100,000 population in the South West LHIN

Source: (NACRS, CIHI), MOHLTC, IntelliHEALTH Ontario

0

2000

4000

6000

8000

10000

12000

Proc

edur

es p

er 1

00,0

00 P

eopl

e

Age Group

7

Where Do South West Patients Go For GI Endoscopy Care? Very few people travel outside of the South West LHIN for GI Endoscopy services. Overall, only five percent of all South West LHIN residents receive their care elsewhere. If South West residents do travel for care, it is most often to the neighbouring LHINs of Waterloo Wellington and Hamilton Niagara Haldimand Brant.

Table 2 –Patient Flow of South West LHIN Residents

Endoscopy Procedures for South West LHIN Patients LHIN of Endoscopy Number of Procedures Percent

Erie St. Clair 76 0.2% South West 38,249 94.7% Waterloo Wellington 725 1.8% HNHB 672 1.7% Central West 60 0.1% Mississauga Halton 81 0.2% Toronto Central 222 0.5% Central 67 0.2% Central East 25 0.1% South East 3 0.0% Champlain 5 0.0% North Simcoe Muskoka 193 0.5% North East 9 0.0% North West 1 0.0% Total 40,388 100%


8

The patient inflow to the South West LHIN suggests that hospitals in the region primarily serve South West residents; only nine percent of endoscopy procedures scheduled were for patients residing outside the South West LHIN. Most people who traveled to sites within the South West LHIN for endoscopy care were from neighbouring LHINs – 5.1% from Erie St. Clair, 1.7% from Waterloo Wellington and 0.7% from Hamilton Niagara Haldimand Brant.

Table 3 - Patient Inflow to the South West LHIN

Endoscopy Procedures at SW LHIN Hospitals Patient Home LHIN Number of Procedures Percent Erie St. Clair 2,158 5.1% South West 38,288 91.0% Waterloo Wellington 721 1.7% HNHB 283 0.7% Central West 14 0.0% Mississauga Halton 17 0.0% Toronto Central 26 0.1% Central 16 0.0% Central East 27 0.1% South East 7 0.0% Champlain 10 0.0% North Simcoe Muskoka 88 0.2% North East 66 0.2% North West 15 0.0% No Region Listed 357 0.8% Total 42,093 100%


9

Current State – Access and Availability of Services

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The map as part of the November 2014 version has been removed.

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Typewritten Text

10

As of September 30, 2014, there are 20 sites within 14 different hospital corporations that provide outpatient endoscopy services. Of these organizations, only five (10 sites) are registered with the ColonCancerCheck program and are currently collecting and reporting operational level endoscopy quality metrics. Out of Hospital Premises (OHPs) have not been included as part of the current state analysis completed to date. Both OHPs in the South West LHIN are located in London, Ontario within approximately five kilometers of London Health Sciences Centre’s Victoria Hospital. At this time neither site has met the clinical quality benchmarks for endoscopy care established for OHPs by the Province, nor have they indicated a willingness to participate in the clinical services planning work or the planned quality improvements.

Corporations (Sites) ColonCancerCheck Program

Grey Bruce Health Services (Owen Sound, Meaford, Markdale, Wiarton, Southampton)

Yes

Huron Perth Healthcare Alliance (Stratford, St. Marys, Clinton, Seaforth) Yes

London Health Sciences Centre (Victoria , University) No

St. Joseph’s Heath Care London Yes

South Bruce Grey Health Centre (Kincardine, Walkerton) No

Tillsonburg District Memorial Hospital Yes

Alexandra Hospital No

Woodstock Hospital Yes

Alexandra Marine and General Hospital No

St. Thomas Elgin General Hospital No

Strathroy Middlesex Hospital No

Four Counties Hospital No

Listowel Memorial Hospital No

Wingham & District Hospital No

11

Referral and Patient Choice Patterns There is not a centralized referral process in the SW LHIN for endoscopy procedures. Patients are free to choose where to access this service. Factors to explain why a patient may have a procedure performed at a specific site include:

• Existing relationships with a hospital or surgeon • Short wait time • Family and other system supports

Using patient postal code analysis, the project team has identified that patients access services from sites other than their “home” community hospital. In the northern area of the region this is particularly evident and may be attributed to an influx of residents during cottage season (See Appendix C). These trends will be examined further as part of the future state recommendation phase of the project. Findings may indicate a willingness or ability for patients to travel further to access endoscopy care than was initially assumed at the onset of the project.

12

Wait Times Currently, only the hospitals participating in the ColonCancerCheck (CCC) program are actively measuring and monitoring wait times for colonoscopies. The established target measure for screening colonoscopy based on a positive FOBT result or a first degree family relative is 9 out of 10 patients in each category receiving the procedure within 8 weeks and 26 weeks respectively. As stated earlier in the report there are currently ten sites that record and monitor wait times under this program.

An identified weakness of data collection under the CCC methodology is the inability to record patient requested delays in care or “Dates Affecting Readiness to Treat (DARTs)”. This is inconsistent with wait times data collection under the established surgical wait times program and does cause confusion and some misrepresentation of data at the site level. The ability to record these patient requested delays is a key success factor in adequately measuring wait times within our future state service delivery model.

For the sites that were able to report current wait time data (CCC sites) this data is outlined below:

Figure 2 - Percent within Target by Indication in FY2013/14 for CCC Program Hospitals

0%10%20%30%40%50%60%70%80%90%

100%

Perc

ent w

ithin

Tar

get

First Degree Positive FOBT Target FD Target PF

13

Cancellations and Capacity In FY2012/13, only seven sites were able to report and record cancellations (due to patient or provider circumstances). Of those reported, the range of total cancelled procedures was from <1% - 6.4%.

The maximum number of outpatient endoscopy spaces reported per week in the survey ranged from zero spaces to 183, with an average of 63 slots being cancelled and not rescheduled. This indicates potential lost capacity across the system that should be considered as part of the future state recommendations and desire for system efficiency.

14

Endoscopy Quality Measures

Best Practices and Standards of Care The 2013 Guidelines for Colonoscopy Quality Assurance in Ontario (Tinmouth, 2013) are to be implemented at all sites performing GI Endoscopy services within the South West LHIN.

Sites were surveyed regarding their current practices, operational planning, and quality standards. The 2013 Guideline was referenced during this survey as the required minimum standard for quality endoscopy care.

Survey responses indicate significant variation in practice and compliance to the published standards, with inadequate data reporting abilities at some sites to access compliance. .

QBP Quality Standards Survey DRAFT – Quality Standards Sites Survey Responses

Must have full Canadian Physician & Surgeons of Ontario “Pass” status

All yes

Must have and use automated machine reprocessors All yes

Must have and use oxygen, oxygen systems and supplies

All yes

Must have and use suction systems and supplies All yes

Must have IV fluid, setup, and supplies and use where appropriate

All yes

Must be equipped with picture-taking capabilities. Both analog and digital units are acceptable at this time though considerations for digital imaging requirements are being explored

No – 2 sites

Must meet Nurse Staff Complement All yes

Must have acceptable infection control processes in place (minimum standard)

All yes

Must be able to meet all data submission deadlines All yes

Must maintain the ability to offer sedation(recovery room, monitoring devices)

All yes

Endoscopes must be used for less than or equal to 300 procedures per year

No -7 sites

Must have at least one AER/basin for every 1800 procedures per year

No –1 site

Must use approved endoscopes All yes

15

Consistent treatment offerings for patients with regards to sedation and bowel preparation are also required as part of the published standard. Survey results indicate inconsistent practices in place at some of the sites.

For example, of the sites that reported the types of preparation offered, there exists great variation in the consensus and consistency of bowel preparation options: 72% offer Pico Salax, 33% Lytely and Fleet and 17% Peg Solution and Citromag. Other offerings include: Purg-Odan, Simethoecone, Klean Prep, Tap Water Enema, and Castor Oil.

Standardization of both the use of sedation and bowel preparation is seen as an opportunity for improvement in the project recommendations.

Enhancing Patient Care To achieve an optimal patient experience while striving to meet quality standards, the following best practices were identified as currently being in place:

• Personal pre-procedure education (telephone and/or in-hospital screen) • Photo-documentation • Patient satisfaction metrics • Roaming scope initiative in place at some rural sites. The scopes are assigned to weekly blocks

at each hospital, along with a Sterile Processing Technician • One-on-one consult with surgeon, prior to discharge

It is important to note these key quality processes and ensure that they are sustained as future state recommendations are developed.

16

Efficiency

Defining Cost of Procedures The ability to calculate actual costs per procedure at each of the hospital sites varies greatly. Some organizations have formal case costing methodologies in place and are better positioned to understand their current cost structure. These organizations are:

• Huron Perth Healthcare Alliance • London Health Sciences Centre • Grey Bruce Health Services • St Thomas Elgin General Hospital

Significant additional work is required to understand the QBP funding methodologies within Health System Funding Reform as well as cost drivers and other efficiency measures to be implemented at the remaining hospital sites.

Key Factors Affecting the Ability for Site Level Cost Comparisons

Equipment: Each site has autonomy over which equipment is purchased. Sites have indicated that it is usually done in consultation with physician’s preference and input. Also, some have signed multi-year leases for equipment and others have purchased through their capital equipment process. This affects the cost per unit as well as the ability to realize efficiencies through bulk ordering. Leasing costs vs amortization costs can vary amongst and even within the sites. Location of Procedure: Currently, nine sites have dedicated endoscopy suites. For all others, outpatient endoscopy procedures are completed in an Operating Room, usually within the day surgery unit. This impacts the ability to isolate and control direct costs of endoscopy specifically at these sites. Staffing Complement: Neither the 2013 Guidelines for Colonoscopy Quality Assurance in Ontario, nor the QBP Clinical Handbook for GI Endoscopy specify the required number of nurses or nursing assistants present during GI endoscopy procedures. There are various models in place, all at differing costs. Furthermore, some sites have realized staffing efficiencies, for example, Woodstock Hospital has initiated and trained select nursing staff to perform flexible sigmoidoscopy.

17

Anesthesia Support: The process by which a patient is offered sedation is typically determined during the bedside consultation pre-procedure with a physician. The opportunity to offer full sedation is influenced by whether or not a site has access to an Anesthetist. An Anesthetist is not currently available at all sites and co-ordination of such offering must be done in advance or as an emergent response. The presence of the resource in the procedure also impacts the overall costs of the procedure and has a direct impact on the overall experience for the patient.

18

Cancer Care Ontario QBP Roll-out South West LHIN

Hospital Corporations Subject to Carve-Out On September 29th, 2014, Cancer Care Ontario released its endoscopy carve-out files and interim funding rates for QBP. Most hospitals received this information with the following exceptions: Four Counties Health Services Alexandra Marine & General Hospital Hanover District Hospital Listowel Memorial Hospital Tillsonburg District Memorial Hospital Wingham & District Hospital Each of these sites is defined as a “small hospital” under Health System Funding Reform and as such is not subject to the funding considerations of the other sites. Within the scope of the SW LHIN project however, these sites are being included and will mirror the cost and efficiency targets established as part of the QBP work to ensure consistent quality of service throughout the LHIN. A high level analysis of the range of costs identified in these funding carve out files is identified below:

BAND Average Cost per weighted case Range A – Endoscopy Suite $194.09 $134.53-$290.21 B – OR Procedure Room $189.44 $175.25-$216.29 C – Small Hospital $191.89 $170.95-$255.63

In-Scope Procedure Combinations for QBP GI Endoscopy Services 1a. Colonoscopy Inspections 1b. Colonoscopy Inspections with Excisions and/or Biopsies 2a. Colonoscopy Inspection and Gastroscopy 2b. Colonoscopy Inspections with Excision and/or Biopsy and Gastroscopy 3a. Colonoscopy Inspections and Other 3b. Colonoscopy Inspections with Excisions and/or Biopsies and Other 4a. Gastroscopies alone 4b. Gastroscopies and Other 5a. Colonoscopy Inspection and Gastroscopy and Other 5b. Colonoscopy Inspections with Excision and/or Biopsy and Gastroscopy and Other

19

Looking to the Future An important consideration in reviewing the current state of endoscopy services in the region is to consider future needs in the context of equality and access to required health care services for all of the residents of the SWLHIN. The future need for endoscopy services in relation to population growth and cancer screening programs must be considered, as well as the unique and distinct needs of urban and rural hospitals within the South West LHIN.

Future Demand for Endoscopy Procedures From 2013 to 2018, the overall growth in resident population in the South West LHIN is expected to be relatively modest. Given the expected increase in the number of people over the age of 50 living in the South West LHIN, the volume of endoscopies is expected to grow 6.9% by 2018.

Age Group 2013 Population

Number of Endoscopy Procedures FY2013/14

2018 Population

Crude expected cases*

% change

Population Age 50+ 371,209 32,222 405,865 35,230 9.3%

Population Under 50 598,761 9,871 593,358 9,782 -0.9% Total Population (All Ages) 969,970 42,093 999,223 45,012 6.9%

*proportion of current cases/population applied to future population, no adjustments Source: Intellihealth – NACRS; Population Projections (Statistics Canada, ON Ministry of Finance), MOHLTC, IntelliHEALTH Ontario

20

Next Steps A comprehensive engagement strategy that addresses the current and future state of regional endoscopy services has been established and incorporates input from physicians, local hospital leadership, and hospital boards. To support this strategy, a communication/community engagement plan has been developed and approved, and is ready for implementation. Time lines have been established to engage with stakeholders and final recommendations will be presented to the LHIN Board in March, 2015. Details for engagement include:

Physician input – Drs. Kevin Lefebvre and Nitin Khanna are co-chairing a regional Advisory Committee comprised of Surgeons and Endoscopists from each regional hospital where endoscopy services are performed. Recommendations from this Advisory Committee with regards to clinical quality performance will be presented at the Steering Committee meeting on October 29, 2014.

Local leadership input- During the months of October and November, site visits and interviews are taking place at each participating hospital site. Discussions are occurring with physicians and senior/operational leaders about current state, key performance indicators, and future planning. Preliminary findings from the site visits will be presented on October 29 to the Steering Committee.

Endoscopy Regional Site Visits/Interview Schedule

Tuesday, October 7 12:00 – 1:30 GBHS

Tuesday, October 7 3:00 – 4:30 Hanover

Wednesday, October 8 8:30 – 10:00 Walkerton

Wednesday, October 8 3:00 – 4:30 Listowel

Friday, October 10 8:30 – 9:45 Tillsonburg

Thursday, October 23 9:00 – 10:00 LHSC

Thursday, October 23 10:30 – 12:00 SJHC

Thursday, October 23 3:00 – 4:30 Woodstock

Thursday, October 30 9:00 – 10:30 Goderich

Thursday, November 13 3:30 – 5:00 STEGH

Tuesday, November 18 10:30-12:00 Stratford

Friday, November 14 11:30-1:00 Strathroy

21

Senior Executive and Hospital Board engagement – On November 26th, a presentation will be made to the Regional Leadership Forum that outlines current state and highlights recommendations to address gaps and move toward a preferred future state. It is anticipated that following this meeting individual hospital boards will review and respond to recommendations.

Community engagement - A plan has been developed and approved by the Steering Committee to describe and define the proposed community engagement and communication strategy for the Endoscopy Outpatient/Ambulatory Realignment & Best Practice Implementation Project. The plan identifies internal and external audiences, key messages and a tactical outline.

Key Messaging: • In September 2013, the South West LHIN Hospital/CCAC Leadership Forum prioritized that LHIN-

wide clinical services planning be done focusing on Cataracts, Stroke and Endoscopy to ensure the system is ready for the implementation of HSFR and can ensure continued access to high-quality health services

• The impact of the Quality Based Procedure (QBP) component of Health System Funding Reform (HSFR) is the impetus for this project to make sure that hospital sites delivering this service are ready to implement these new provincial directions

• In an effort to ensure best practices and high-quality endoscopy services, health service providers in the South West LHIN are working to ensure a sustainable model of delivery to best serve the patients in the LHIN

• The ultimate goal of this project is to ensure people receive the same quality of endoscopy care at the right time, regardless of where they live. This will be achieved by:

o Assessing current quality and best practice implementation for endoscopy services in hospitals

o Ensuring best clinical practice in endoscopy services is applied throughout the South West LHIN

• Recommendations will align with the clinical services planning work stream across the South West LHIN

• Realignment of services could be considered as a solution for issues uncovered as current state data and quality data is analyzed as hospitals prepare for the implementation of HSFR

The timing for communication to local communities/external stakeholders will be directed by each hospital and is expected to take place between December 2014 and February 2015. LHIN Board – Final recommendations for implementation will be presented to the LHIN Board by March 31, 2015.

22

Conclusion Based on the extensive investigation of the current state of outpatient endoscopy services in the South West region, hospitals and physicians are well on their way to developing future state recommendations that will ensure reduced variability in access, effectiveness and improved efficiency in all GI Endoscopy services performed in the South West by 2016.

23

References Cancer Care Ontario & Ministry of Health and Long Term Care, Province of Ontario. (2013, September).

Retrieved 2014, from Ontario Ministry of Health and Long Term Care: http://health.gov.on.ca/en/pro/programs/ecfa/docs/qbp_gi.pdf

Cancer Care Ontario Prevention and Cancer Planning and Control. (2010). Retrieved 2014, from Cancer Care Ontario: https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=156747

Health Quality Ontario. (2014). Quality Improvement: Health Quality Ontario. Retrieved 2014, from Health Quality Ontario: http://www.hqontario.ca/quality-improvement

Ministry of Health and Long Term Care. (2014). Excellent Care for All - Health System Funding Reform. Retrieved 2014, from Ministry of Health and Long Term Care: http://www.health.gov.on.ca/en/pro/programs/ecfa/funding/hs_funding.aspx

South West Local Health Integration Network. (2014). South West Local Health Integration Network (LHIN). Retrieved 2014, from South West LHIN: http://www.southwestlhin.on.ca/SiteContent/PublicCommunity/IntegratedHealthServicePlan/2013IHSP/PA-ClinicalServicesPlanning.aspx

South West Regional Cancer Program. (2014). Partners in Care| South West Regonal Cancer Program. Retrieved 2014, from South West Regional Cancer Program: http://www.southwestcancer.ca/about-swrcp/partners-care

Tinmouth, J. K. (2013). Guideline for Colonoscopy Quality Assurance in Ontario. Toronto: Cancer Care Ontario Program in Evidence-based Care.

24

Appendix A – Current State Survey Questions

Endoscopy Realignment and Best Practices Implementation

Current State Survey

Location:

Current Practice

1. What was the total number of cases by procedures in FY12/13? Colonoscopy #

ERCP #

Gastroscopy #

Flexible Sigmoidoscopy #

EBUS #

2. What type of room/facility are the outpatient procedures performed?

Endoscopy Suite # Operating Room # Other

Type, #

3. Does the centre provide after hours endoscopy coverage?

Y/N If so, where are these procedures performed? Example: Bedside, OR

Insert Answer

4. Are there after hours dedicated endoscopy nursing support? Y/N

5.On a weekly basis, what is the maximum total number of endoscopy slots available? # Insert Answer

6. Has the facility undertaken a case costing analysis? Y/N If yes, can results be provided?

Insert Answer

25

7. When was this completed? Eg. January 1, 2013 Insert Answer

8. Are you able to gather endoscopy wait time information for ‘12/13? Y/N If so, what are the wait time for the following:

Colonoscopy Choose one of the following Gastroscopy Choose one of the following

9. What are the limits to wait times? Eg. Space, access, staffing, demand Insert Answer

10. What is the distribution of appointment type by providers specialty? Gastroenterolgist #

General Surgeon # Other # Please specify

11. Please list all Physicians performing endoscopy services in your hospital.

Name: Specialty:

*insert more columns if needed

12. Are nurses performing flex sigs at your hospitals? Y/N If so, how many? #

13. How many nurses work in the unit?

#

14. How many anesthesia assistants?

# 15. How many people are assigned to clean scopes? # 16. Are there other roles that assist with the preparation or clean-up of the room?

Insert Answer 17. If this is a teaching hospital,( Are you able to determine) how many cases were performed by Residents? Y/N

If yes, how many? #

26

18. In fiscal '12/13, how many appointments were cancelled?

By patient # By provider # By no shows #

19. If financial resources existed to expand, what would the major barriers be to be able to increase the number of procedures/slots? Eg. Space, MD availability, nursing staff, # of scopes, demand. Insert Answer

Operational Planning

20. Are there any physical plant/redevelopment considerations underway? Y/N If yes, please specify.

Insert Answer

21. If so, will (is) there be post construction operating plan (PCOP) funding available? Insert Answer

22. How many scopes does the facility utilize? Include both adult and pediatric scopes. Colonoscope #

Gastroscope # Duodenoscope # Flexible Sigmoidoscopy # Other #

23. What is the approximate age of the scope/equipment? Example: Purchased in 2011

Colonoscope yr(s) Gastroscope yr Duodenoscope yr Flexible Sigmoidoscopy yr Other yr

24. Has the centre formally implemented the 2007 CCO Standards for Colonoscopy? Y/N

25. Is there a plan to implement the 2013 CCO Standards/ QBP Clinical Handbook? Y/N

Explain

26. Are there Physician HR gaps? Insert Answer

27

27. Are there Nursing HR gaps? Insert Answer

28. Is there a recruitment or succession plan?

Y/N If yes, please explain.

Insert Answer

29. Do you offer anesthesia to your patients? Y/N If yes, for what procedure(s)?

Insert Answer

30. What are the pathology turnaround times? (based on 90th percentile days):

# Days

31. Can any innovative methods that have enhanced current practice be shared? Eg. Info pamphlets, post-procedure phone calls, provider/procedural quality metrics, photo documentation Insert Answer

32. Are any advanced endoscopy techniques performed? Eg. EMR, capsule, banding Insert Answer

33. What type of endoscopy reporting systems is currently utilized? Electronic Y/N indicate type

Template Y/N indicate type Dictation Y/N

34. Is there capability to do photo documentation?

Y/N

If you should have any questions regarding the questions or project, please contact: Sara Folias, Project Manager @ (519) 685-8500 ext 77037 or [email protected]

Endoscopy Realignment and Best Practice Implementation

SW LHIN Current State September 30 2014

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Appendix B - Survey Responses by Site

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SW LHIN Current State 1. Current Practice

2. Operational Planning

3. Quality Standards

4. SW LHIN Regional Focus

2

1. Current Practice

•Volumes

•Capacity

•Wait Times

•Prep

• Education

•Quality Measures 3

Current Practice: Volume Total Cases F12/13

4

Alexandra Marine & General, 516

Alexandra Hospital, 659

Four Counties, 196 GBHS -

Markdale, 305

GBHS - Meaford, 719

GBHS - Owen Sound, 2618

GBHS - Southampton, 373

GBHS - Wiarton, 495

Hanover, 1373

HPHA - Clinton, 490

HPHA - St. Marys, 137

HPHA - Stratford, 3654

LHSC - University, 7051

LHSC - Victoria, 7053

Listowel, 424 South Bruce - Kincardine, 894

South Bruce - Walkerton, 463

St. Joseph's, 6651

St. Thomas, 4007

Strathroy, 2125

Tillsonburg, 1558

Wingham, 1058 Woodstock,

3029

Current Practice: Volume Number of Cases by Procedure F12/13

5

0

1000

2000

3000

4000

5000

6000

7000

Other

Flexible Sigmoidoscopy

Cystoscopy

Gastroscopy

Colonoscopy

Current Practice: Capacity

6

Maximum number of outpatient endoscopy slots available/week/facility

0

50

12

125

50

28 35

169

4

100 100

50 45

169

183

28

75


7

In which type of room/facility are the outpatient procedures performed?

Other

Operating Room

Endoscopy Suite


8

Does the centre provide endoscopy coverage after regular business hours?

If yes, where are these procedures performed?

Un

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Unspecified

No

Yes

OperatingRoom

EndoscopySuite

ICU (on-callbasis)

Pt Bedside(after hours)

Woodstock

Wingham

Victoria

University

Tillsonburg

Strathroy

Stratford

St. Thomas

St. Marys

St. Joseph's

Listowel

Hanover

Grey Bruce

Clinton

Alexandra Marine & General


9

After regular business hours, is there dedicated endoscopy nursing support?

No

Yes


10

Is Wait Time Data Available for FY12-13?

Wait Times/Procedure/Facility

188

146 146 146

90

55 48

37

126

64

Colonoscopy

Gastroscopy

Clin

ton

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St. J

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St. M

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Yes

No


• Wait days from referral date to date of procedure. DARTS (dates affecting readiness to treat) are not captured in data sent to CCO

• WT's pulled from iPort access

• No formal program to capture data, informal paper process

• Budget, space, staffing, physician availability

• Referrals go directly to physician

• Not a WT hospital, limitation with endo wait time data

• Not mandatory to report procedures performed in Endo Suite, does not capture wait times for endo procedures

• Staffing, and only 2 surgeons serving the community

11

What are the limits to wait times?

Current Practice Distribution of

Appointment Type by Provider

12

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Other

General Surgeon

Gastroenterologist

Current Practice: Capacity Staffing Complements

Nurses in Unit Anesthesia

Assistants in Unit

Assigned Cleaning Staff

Alexandra Marine &

General 1 0 1

Clinton 1 0 1

Four Counties 3 0 1

Grey Bruce 4 - 5 0 1 - 2

Hanover 6 0 4

Listowel 2 - 3 0 2

St. Joseph's 9 2 2

St. Marys 1 1

St. Thomas 1 + 1 relief 1 + 1 relief

South Bruce 4 1

Stratford 1 1

Strathroy 5 5

Tillsonburg 3 1

University 8 2

Victoria 9/day 1/case 2/day

Wingham 4 1

Woodstock 3 2

• At Woodstock Hospital, nurses perform Flexible Sigmoidoscopies

• Survey results indicate that Flexible Sigmoidoscopies are not performed by nurses at any of the remaining sites 13

Current Practice Number of Appointments Cancelled in F12/13

14

133

30 17

34

4

157

22

15

50

3 4

257

159

0

50

100

150

200

250

By patient By provider No Shows Total

Current Practice: Prep Offerings by Facility

15

Woodstock

Wingham

Victoria

University

Tillsonburg

Strathroy

Stratford

South Bruce

St. Thomas

St. Marys

St. Joseph's

Listowel

Hanover

Grey Bruce

Four Counties

Clinton

Alexandra Marine & General

Current Practice: Prep Anesthesia

16

AMGH: Determined by surgeon offering procedure. Typically neurolept and/or IV sedation.

Colonoscopy

Gastroscopy

Flexible Sigmoidoscopy

Current Practice Innovative Methods that have Enhanced Care

17

• Pre- & post-procedure education and patient information pamphlets are provided

• Personal pre-procedure education (telephone and/or in-hospital screen)

• Photo-documentation

• Patient satisfaction metrics

• Roaming scope initiative in place at rural sites. The scopes are assigned to weekly blocks at each hospital, along with an SPD tech

• One-on-one consult with surgeon, prior to discharge

• EMR, banding, pancreatic cyst drainage through EUS

• Banding, injecting, blue spot tattooing for marking and gold probe for GI bleeds

• Banding, liver biopsy, paracentesis

• ERCP, EUS, EBUS, luminal GI (capsule endoscopy, balloon endoscopy, stenting, EMR (Endomucosal Resection), RFA (Radiofrequency Ablation), BPT (Broncothermoplasty)

• Botox injections indicated for anal fissures

18

Current Practice: Advanced Endoscopy Techniques Performed

2. Operational Planning

• Equipment

•Physical Plant

• Technology

•Medical HR

•Quality Standards

19

Operational Planning: Equipment Number of Scopes (including Adult/Pediatric)

Colonoscope Gastroscope Duodenoscope Flexible

Sigmoidoscopy Other

Alexandra Marine & General 4 2

Clinton 4 2 2

Four Counties 2 1

Grey Bruce 14 10 2 3

Hanover 5 3 1

Listowel 4 3

St. Joseph's 18 7 8

St. Marys 2 4 2

St. Thomas 9 5 2

South Bruce 6 4 5

Stratford 10 4 1 1

Strathroy 6 3 2 4

Tillsonburg 6 4 1 1

University 17 13 5

Victoria 16 15 4 1 9

Wingham 5 3 1

Woodstock 10 4

20

Operational Planning: Equipment Age

21

Colonoscope Gastroscope Duodenoscope Flexible

Sigmoidoscopy Other

Alexandra Marine & General 2009, 2010, 2011 2010 & 2013

Clinton 2013 2013 2009

Four Counties 2009, 2012 2005, 2012 2008

Grey Bruce

Hanover 2013 2013 2013

Listowel 2009, 2010, 2012 2003, 2009, 2013

St. Joseph's 2009 2009 2009

St. Marys 2009 2009

St. Thomas 2006, 2007, 2008,

2011, 2012, 2014

South Bruce 2009 2010

Stratford 2013 2013 2013 2009

Strathroy 2007, 2010, 2011,

2012 2004, 2007, 2011 2011

Tillsonburg 2013 2013 2013 2011

University 2009, 2012, 2013 2009, 2012 2013 2008, 2009, 2013

Victoria 2009, 2012, 2013 2009, 2012 2013 2008, 2009, 2013

Wingham 2008 2008

Woodstock 2009 2009

Operational Planning: Physical Plant

• Alexandra Marine & General: Ideally would like to build a dedicated Endoscopy Suite. Availability of capital is a barrier.

• Hanover: New OR build with separate procedure suite for Endo.

• South Bruce: Refurbishment of endoscopy cleaning area.

• St Thomas: Build separate procedure suite for Endo.

• University: Retrofitting the Sterile Processing Unit.

• Wingham: Ministry project for redevelopment.

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Yes

No

Unspecified

23

Operational Planning: Technology

Endoscopy Reporting Systems Utilized

Electronic Template/EMR Endoscopic Reporting (EndoPro, etc) Dictation

Operational Planning: Technology

24

Capability for Photo Documentation

Yes

No

Operational Planning: Medical HR

25

Nursing HR Gaps

Yes

No

Unspecified

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mas

Stra

tfo

rd

Stra

thro

y

Tills

on

bu

rg

Win

gham

Wo

od

sto

ck

Clin

ton

St. M

arys

Physician HR Gaps

Yes

No

Unspecified

There is a Recruitment or Succession Plan in Place

Yes

No

Unspecified

Operational Planning: Medical HR

Recruitment Succession Planning

• Business Innovation & Recruitment Specialist employed by facility (Alexandra Marine & General)

• Additional General Surgeon recruited for June 2015 (Hanover)

• Younger nurses are being hired and trained for the OR as senior OR nurses will be retiring in the next 5 – 10 years. (Listowel & Wingham)

• FT Staff RN has been recruited to Team Leader role as current Team Leader moves to retirement (SJHC)

• Recruitment plan for upcoming vacancies due to retirements (STEGH)

• New model implementation, using RPNs (TDMH)

• Recruitment is ongoing (LHSC) 26

Operational Planning: Pathology Turnaround Times (based on 90th percentile days)

27

Days

Alexandra Marine & General 7

Clinton 3

Four Counties N/A

Grey Bruce 6.4

Hanover 2 - 3

Listowel 3 – 7

St. Joseph's 4

St. Marys 3

St. Thomas 10

South Bruce 30

Stratford 3

Strathroy N/A

Tillsonburg 3 – 7

University 2 – 3

Victoria 2 – 3

Wingham 7 – 10

Woodstock 2 - 3

28

Operational Planning: Quality Standards

Gre

y B

ruce

List

ow

el

St. T

ho

mas

Stra

tfo

rd

Tills

on

bu

rg

Un

iver

sity

Vic

tori

a

Win

gham

Wo

od

sto

ck

Clin

ton

Han

ove

r

Sou

th B

ruce

Fou

r C

ou

nti

es

Stra

thro

y

St. J

ose

ph

's

Ale

xan

dra

Mar

ine

& G

ene

ral

St. M

arys

There is a Plan to Implement the 2013 CCO Standards/QBP

Clinical Handbook

Yes

No

Unspecified

Gre

y B

ruce

Han

ove

r

List

ow

el

Stra

tfo

rd

Stra

thro

y

Tills

on

bu

rg

Wo

od

sto

ck

Clin

ton

St. J

ose

ph

's

Sou

th B

ruce

Un

iver

sity

Vic

tori

a

Win

gham

St. T

ho

mas

Ale

xan

dra

Mar

ine

& G

ene

ral

St. M

arys

The 2007 CCO Standards for Colonoscopy have been Formally

Implemented

Yes

No

Unspecified

3. QBP - Quality Standards Checklist

29

The following sites completed the Quality Standards Checklist: • Strathroy Middlesex General Hospital • Hanover and District Hospital • Alexandra Marine & General Hospital, Goderich • St. Joseph's Hospital London • Wingham District Hospital • Listowel Memorial Hospital • HPHA • LHSC (University and Victoria Hospital) • Walkerton/Kincardine • Woodstock Hospital • St. Thomas Elgin General Hospital • Alexandra Hospital, Ingersoll • Grey Bruce Health Services

30

QBP - Quality Standards Checklist

• Listowel does not currently have the capability; however, these have been placed on the capital list for purchase this year, pending Board approval.

• HPHA Stratford site ONLY

Note: Both analog and digital units are acceptable at this time though considerations for digital imaging requirements are being explored

Must be equipped with picture taking capabilities

Yes

No

31

• STEGH continues to monitor and track volumes to determine additional capital purchases to add to the fleet.

• GBHS scopes are used for 400-500 or greater per year.

• LHSC: The manufacturer's suggestion in yearly usage should be followed (may be slightly higher or lower depending on manufacturer)

Endoscopes must be used for less than or equal to 300 procedures per year



32

• STEGH is on the cusp and will continue to monitor volumes to determine if there is a need for additional washers.

• GBHS follows PDAC standards as well as the manufacturers cleaning guidelines. Scopes are manually cleaned with hand pumps and then put through the Medivators and/or Steris reprocessing units.

• LHSC: The manufacturer's suggestion in yearly usage should be followed (may be slightly higher or lower depending on manufacturer)

Must have at least one AER/basin for every 1800 procedures per year

Regional Focus

•Demographics

•Catchment Patterns

•Referral Patterns

33

Population Projections by County

34

CYear 2013 2013 2014 2014 2015 2015 2016 2016 2017 2017 2018 2018 2019 2019 2020 2020

Measures Level

# People %

Annual Growth

# People %

Annual Growth

# People %

Annual Growth

# People %

Annual Growth

# People

% Annual Growt

h

# People %

Annual Growth

# People %

Annual Growth

# People %

Annual Growth

County/Reg. Municip

BRUCE 67,599 0.15% 67,694 0.14% 67,786 0.14% 67,888 0.15% 68,002 0.17% 68,118 0.17% 68,238 0.18% 68,359 0.18%

ELGIN 91,418 0.31% 91,760 0.37% 92,159 0.43% 92,625 0.51% 93,159 0.58% 93,687 0.57% 94,210 0.56% 94,729 0.55%

GREY 96,743 0.23% 97,013 0.28% 97,331 0.33% 97,694 0.37% 98,103 0.42% 98,516 0.42% 98,933 0.42% 99,357 0.43%

HALDIMAND & NORFOLK 110,782 -0.22% 110,553 -0.21% 110,343 -0.19% 110,162 -0.16% 110,015 -0.13% 109,868 -0.13% 109,722 -0.13% 109,579 -0.13%

HURON 60,335 -0.27% 60,185 -0.25% 60,049 -0.23% 59,925 -0.21% 59,813 -0.19% 59,704 -0.18% 59,600 -0.17% 59,500 -0.17%

MIDDLESEX 467,863 0.90% 472,235 0.93% 476,834 0.97% 481,740 1.03% 486,945 1.08% 492,291 1.10% 497,771 1.11% 503,379 1.13%

OXFORD 109,146 0.33% 109,467 0.29% 109,753 0.26% 110,002 0.23% 110,222 0.20% 110,442 0.20% 110,665 0.20% 110,891 0.20%

PERTH 76,866 -0.22% 76,727 -0.18% 76,617 -0.14% 76,541 -0.10% 76,501 -0.05% 76,465 -0.05% 76,435 -0.04% 76,411 -0.03%

Prepared by: Harpreet Brar

Data source: Population Projections County (Statistics Canada, ON Ministry of Finance), MOHLTC, IntelliHEALTH Ontario, extracted Friday, March 7, 2014 11:35:05 AM EST

Data source description: Ministry of Finance Population Projections by County from 2012−2036, based on the 2006 Census

Endoscopic Procedures by Patient Residence: Bruce County

35

97%

1%

1% 1%

0%

South Bruce Grey Health Centre - Kincardine

Bruce County

Grey County

Huron County

Other LHIN

98%

1% 1% 0%

Grey Bruce Health Services - Southampton

Bruce County

Grey County

LHIN 4

Middlesex County

77%

22%

1%

Grey Bruce Health Services - Wiarton

Bruce County

Grey County

Other LHIN

2013 Population 67,599

2022 Population (Projected) 68,584

Population Growth Rate Increasing

% Annual Growth 0.16%

Population Density 16.9/km2

% of population over 50 years in 2013 47%


South Bruce Grey Health Centre - Chesley

South Bruce Grey Health Centre - Kincardine

Bruce County: Quick Facts

Hospitals:

Grey Bruce Health Services - Lions Head

Grey Bruce Health Services - Wiarton

Grey Bruce Health Services - Southampton

South Bruce Grey Health Centre - Walkerton

Endoscopic Procedures by Patient Residence: Grey County

36 66%

32%

2% 0%

Grey Bruce Health Services, Owen Sound

Grey County

Bruce County

Other LHIN

SW LHIN - Other

92%

4%

2% 1% 1%

Grey Bruce Health Services, Markdale

Grey County Bruce County LHIN 5 LHIN 3 LHIN 1

94%

4% 2% 0%

0%

Grey Bruce Health Services, Meaford

Grey County

Bruce County

LHIN 12

LHIN 3

LHIN 4

72%

25%

2% 1% 0%

Hanover and District Hospital

Grey County

BruceCounty

LHIN 3

SW LHIN -Other

Other LHIN








South Bruce Grey Health Centre - Durham

Hanover and District Hospital

Grey County: Quick Facts

Hospitals:

Grey Bruce Health Services - Owen Sound

Grey Bruce Health Services - Meaford

Grey Bruce Health Services - Markdale

Endoscopic Procedures by Patient Residence: Huron County

37

95%

3% 1% 1%

Alexandra Marine and General Hospital, Goderich

HuronCounty

BruceCounty

OtherLHIN

SW LHIN- Other

87%

12%

1%

Seaforth Community Hospital

HuronCounty

PerthCounty

MiddlesexCounty

87%

7%

2% 2%

1%

1% 0% 0%

Clinton Public Hospital

HuronCountyLHIN 1

Bruce County

Perth County

MiddlesexCountyGrey County

64%

29%

2%

2% 1% 1% 1%

0%

Wingham and District Hospital

Huron County

Bruce County

Grey County

LHIN 3

MiddlesexCountySW LHIN -OtherLHIN 1

Huron County: Quick Facts



Population Growth Rate Declining

% Annual Growth -0.20%

Population Density 17.4 /km2



Hospitals:

Alexandra Marine and General Hospital

Clinton Public Hospital

Seaforth Community Hospital

Wingham and District Hospital

South Huron Hospital Association - Exeter

Endoscopic Procedures by Patient Residence: Perth County

38 74%

20%

3% 2% 1%

St. Marys Memorial Hospital

Perth County

Middlesex County

Oxford County

SW LHIN - Other

LHIN 4

65%

16%

14%

3% 1% 1%

Listowel Memorial Hospital

Perth County

LHIN 3

Huron County

Bruce County

Grey County

LHIN 13

61% 15%

9%

7%

4% 3%

1% 0%

Stratford General Hospital

Perth County

Huron County

Middlesex County

Oxford County

LHIN 3

LHIN 1

SW LHIN - Other

Other LHIN








Stratford General Hospital

St. Marys Memorial Hospital

Perth County: Quick Facts

Hospitals:

Listowel Memorial Hospital

Endoscopic Procedures by Patient Residence: Oxford County

39

88%

9%

1%

1%

1%

0%

0%

0%

Woodstock General Hospital

Oxford County

Middlesex County

LHIN 4

Norfolk County

Elgin County

Other LHIN

LHIN 3

SW LHIN - Other

80%

10%

4% 3%

3%

0%

Alexandra Hospital, Ingersoll

Oxford County

Middlesex County

Elgin County

Other LHIN

Norfolk County

SW LHIN - Other62%

18%

14%

4%

2% 0%

Tillsonburg District Memorial Hospital

Oxford County

Norfolk County

Elgin County

MiddlesexCountyOther LHIN

SW LHIN - Other








Hospitals:

Alexandra Hospital

Woodstock General Hospital

Oxford County: Quick Facts

Tillsonburg District Memorial Hospital

Endoscopic Procedures by Patient Residence: Middlesex & Elgin Counties

40

40%

38%

22%

Four Counties Health Services, Newbury

LHIN 1 Middlesex County Elgin County

79%

18%

2% 1%

0%

Strathroy Middlesex General Hospital

Middlesex County

LHIN 1

Elgin County

SW LHIN - Other

Other LHIN

85%

12%

1%

1%

1%

0%

St. Thomas Elgin General Hospital

Elgin County

Middlesex County

Oxford County

Other LHIN

Norfolk County

SW LHIN - Other








Hospitals:

Four Counties Health Services

Middlesex County: Quick Facts

St. Joseph's Health Care, London

LHSC - University Hospital

LHSC - Victoria Hospital









Hospitals:

Elgin County: Quick Facts

St. Thomas Elgin General Hospital

Endoscopic Procedures by Patient Residence: City of London

41

55%

14%

7%

6%

6%

3%

2%

2% 2%

1%

1%

1%


Middlesex County - London only

LHIN 1

Middlesex County (excl London)

Oxford County

Elgin County

Perth County

Huron County

LHIN 3

Other LHIN

Bruce County

Grey County

Norfolk County

71%

8%

7%

4%

3%

2% 1%

1% 1% 1%

1%

St. Joseph's Health Care

Middlesex County - London only

Middlesex County - excl London

LHIN 1

Elgin County

Oxford County

Huron County

LHIN 3

Perth County

Other SW LHIN

Bruce County

Other LHIN

69%

9%

8%

4%

2% 2%

2% 2% 1%

1%


Middlesex County - LondononlyMiddlesex County - exclLondonLHIN 1

Elgin County

Oxford County

SW LHIN - Other

Other LHIN








Hospitals:

Four Counties Health Services

Middlesex County: Quick Facts

St. Joseph's Health Care, London








Population Density NA



Hospitals:

None in the SW LHIN

Haldimand & Norfolk: Quick Facts

69

Appendix C – Patient Referral Pattern

s

BRIEFING NOTE - Status of Efficiency Committee Prepared by: Sara Folias, Efficiency Committee Co-chair Prepared for: Steering Committee Date: January 23, 2015 Background

In spring of 2014, a case costing group comprised of two (clinical) members from the core project team and two finance specialists from case costing hospitals was developed to help advise and define the costing of GI endoscopy procedures in the South West LHIN. Due to a lack of information regarding the impending roll-out of QBP as well as the continuing development of the project aim statement, it was recommended that this group would cease to meet until further advancement and direction for the project was released.

On September 27, 2014, Cancer Care Ontario (CCO) released interim funding methodologies for QBP.

Commencing October 22nd, 2014, various members representing each site were asked to participate in a formally established Efficiency Committee for the GI Endoscopy Realignment and Best Practice Implementation Project (“the project”). The Committee met bi-weekly and included representation from CCO, as well as finance, data and clinical backgrounds (Appendix 1). Roles and responsibilities of the Committee are:

• Identify standard process/cost drivers and attain consensus from all sites (by November 19, 2014)

• Develop *draft* key indicators related to efficiency (by November 26, 2014) • Share *draft* costing by site (by November 26, 2014) • Complete efficiency assessment/current state (by January 14, 2015) • Share final efficiency indicators, costing, and recommendations with Steering Committee (by

February 25, 2015) • Champion activities related to project at individual sites

Activities to date/Current Status

October, 2014

• Established Focus/Secondary Driver “Optimize cost and efficiency of service delivery” • Developed draft cost and process templates

November, 2014

• Completed site visits and reviewed responses to cost and process templates • Developed*draft*baseline process map

henriksj

Typewritten Text

Appendix C

December, 2014

• Endorsed baseline process map • Developed *draft* directional indicators and received endorsed from Committee to present to

Steering Committee

Tools Utilized

1) Process Template (Appendix 2a) 2) Costing Template (Appendix 2b)

Summary of results

1) Baseline Process Map – Excluding site responses (Appendix 3a) 2) Initial Costing Summary (Appendix 3b)

Recommendations for Key Performance Indicators Related to Efficiency

As a result of the information compiled through Appendices 1, 2 &3, an analysis of the largest and most significant variances was completed. The analysis helped to guide and frame the development of the Directional Indicators:

1) Establish cost per procedure 2) Itemize the consumable supplies per procedure 3) Determine nursing hours/minutes per procedure 4) Determine acceptable range of time for outpatient admission from:

• Time of registration to time in room • Time of procedure (pt in room to discharge) • Time of discharge- room readiness for next patient

5) Record overall Cecal Intubation Rate

Next Steps

These draft indicators will be presented to the Steering Committee on January 28th If approved, the efficiency indicators (along with the others) will be incorporated into the Project Workplan in early 2015.

Appendix 1

Endoscopy Efficiency Membership Name Organization Sara Folias South West Regional Cancer Program

London Health Sciences Centre

Nancy Campbell South West Regional Cancer Program London Health Sciences Centre

Julia Monakova Cancer Care Ontario Irene Blais Cancer Care Ontario Samantha Marsh Alexandra Marine and General Hospital

Michele Turcotte Grey Bruce Health Services

Marnie Ferguson Hanover and District Hospital

Esther Millar Hanover and District Hospital

Iris Malig Huron Perth Health Alliance

Terry Pitt Middlesex Hospital Alliance

Sandra Albrecht Listowel & Wingham Hospital Alliance Angela Stanley Listowel & Wingham Hospital Alliance

Tim Lewis Listowel & Wingham Hospital Alliance

Mike Berta London Health Sciences Centre

Gus Baziotis London Health Sciences Centre

Chris Cartwright South Bruce Grey Health Centre Mary Rae South Bruce Grey Health Centre Debbie Marshall St. Joseph's Health Care, London

Shannon Tabor St. Thomas Elgin General Hospital Betty Wang South West LHIN Jana Fear South West LHIN Katie Dedrick Tillsonburg District Memorial Hospital Tim Rice Tillsonburg District Memorial Hospital Lynn Stern Woodstock Hospital

of 6 © Queen’s Printer for Ontario, 2012

HEIA is a flexible and practical assessment tool that can be used to identify and address potential unintended health impacts (positive or negative) of a policy, program, or initiative on specific population groups. NOTE: The HEIA Template is designed to be used alongside the accompanying HEIA Workbook, which provides definitions, examples, and more detailed instructions to help you complete this template.

Date: October 27, 2014

Organization: South West Regional Cancer Program

Name and contact information for the individual or team that completed the HEIA: Sara Folias Regional Program Specialist South West Regional Cancer Program [email protected] (519) 685-8500 ext 77037

Project Name: GI Endoscopy Realignment and Best Practice Implementation

Project Summary: The South West LHIN is working together with the South West Regional Cancer Program and 28 hospital sites in the region to identify, evaluate and improve the way outpatient endoscopy services and follow-up care is delivered across the South West. The aim of the project is: By 2016, decrease the variation of wait times and volumes and implement best practices in the GI Endoscopy services delivered in the South West LHIN. This will be accomplished through a detailed examination and review of the location, organization and service delivery variation in outpatient GI Endoscopy services across the region. Key drivers of this work include:

• Clinical services planning • Continuous quality improvement • Implementation of Health System Funding Reform (HSFR) • Quality based procedures for key health care services

This project includes implementation of best practice guidelines according to the Guideline for Colonoscopy Quality Assurance in Ontario (Tinmouth, 2013) and the GI Endoscopy Quality Based Procedure Clinical Handbook (Cancer Care Ontario & Ministry of Health and Long Term Care, Province of Ontario, 2013), a capacity assessment, and identification of key enablers to meet project goals and maximize the use of system resources.

Objective for Completing the HEIA: The objective for completing this document is to ensure the successful development of a LHIN wide approach to GI Endoscopy that will ensure local service delivery needs. Also, ensure that programs within regional hospitals are aligned to the South West LHIN’s Integrated Health Service Plan, and that services within the South West are delivered at the right time, in the right place and by the right provider. Three areas of focus are:

• Access • Effectiveness • Efficiency

mailto:[email protected]

henriksj

Typewritten Text

Appendix D

of 6 © Queen’s Printer for Ontario, 2012

NOTE: This section to be filled in after completing the following HEIA template. Conclusions: (e.g. what decisions were made following completion of the HEIA tool?) The Quality Improvement Committee chaired by the CCO Regional Endoscopy Lead will be responsible for ensuring quality improvements are implemented and aligned with HEIA and the South West LHIN Aboriginal Care Unit, with considerations also made to Ethno Racial Communities, Homeless , Religious/Faith Communities, and Remote/Rural or Inner Urban Populations within our region.

HEIA Template

Page 3 of 3 © Queen’s Printer for Ontario, 2012

The numbered steps in this template correspond with sections in the HEIA Workbook. The workbook with step-by-step instructions is available at www.ontario.ca/healthequity.

Step 1. SCOPING

Step 2. POTENTIAL IMPACTS

Step 3. MITIGATION

Step 4. MONITORING

Step 5. DISSEMINATION

a) Populations* Using evidence, identify which populations may experience significant unintended health impacts (positive or negative) as a result of the planned policy, program or initiative.

b) Determinants of Health Identify determinants and health inequities to be considered alongside the populations you identify.

Unintended Positive Impacts.

Unintended Negative Impacts.

More Information

Needed.

Identify ways to reduce potential negative impacts and amplify the positive impacts.

Identify ways to measure success for each mitigation strategy identified.

Identify ways to share results and recommendations to address equity.

Aboriginal peoples (e.g., First Nations, Inuit, Métis, etc.) Resources : Mikkonen, J., & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management. https://www.cancercare.on.ca/pcs/screening/coloscreening https://www.cancercare.on.ca/cms/one.aspx?objectId=37272&contextId=1377

Limited access, low socio-economic status/income, education and awareness, social isolation

1)Maintaining access and manage increase of screening rate 2) Reveal co-morbidities, other health conditions

Fear Identified Resources : 1.Regional Aboriginal Lead – SWRCP 2. Aboriginal Patient Navigator - SWRCP 3. Aboriginal Lead –SW LHIN Focused Awareness Campaigns : CCO Aboriginal Cancer Strategy (Let’s take a stand against…colorectal cancer!)

1)Increase in screening rates 2) Increase in awareness (participants in CCO Aboriginal Cancer Strategy) 3) Screening rates to sub-population given to Aborginnal Lead - SWRCP

Refer to Community Engagement Strategy document

Age-related groups (e.g., children, youth, seniors, etc.) Resources: Mikkonen, J., & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management. https://www.cancercare.on.ca/pcs/screening/coloscreening

Disabilities, low income, access (transportation)

1) Maintain access while managing increase of screening rate 2) ) Reveal co-morbidities, other health conditions

Increase stress due to procedure process

Identified Resources: 1)Regional Primary Care Lead – SWRCP 2)ColonCancerCheck Program (Screening for Life!)

1)Increase in screening rates (CCC Program) 2) SAR - CCO


http://www.ontario.ca/healthequity

https://www.cancercare.on.ca/pcs/screening/coloscreening

https://www.cancercare.on.ca/cms/one.aspx?objectId=37272&contextId=1377

https://www.cancercare.on.ca/cms/one.aspx?objectId=37272&contextId=1377


HEIA Template


Step 1. SCOPING


Step 3. MITIGATION

Step 4. MONITORING






More Information

Needed.




Disability (e.g., physical, D/deaf, deafened or hard of hearing, visual, intellectual/developmental, learning, mental illness, addictions/substance use, etc.)

Ethno-racial communities (e.g., racial/racialized or cultural minorities, immigrants and refugees, etc.) Resources: Mikkonen, J., & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management. https://www.cancercare.on.ca/pcs/screening/coloscreening

Language barrier, education and awareness/stigma, low socio-economic status, access,

1)Maintaining access and manage increase of screening rate 2) Reveal co-morbidities, other health conditions

Identified Resources: 1)Education sessions (CCS, PH, SWRCP) 2)Peer Health Educators (CCS) 3) Translators (Sites) 4.Education materials in various languages 5. Regional Primary Care Lead – SWRCP 6. ColonCancerCheck Program (Screening for Life!)

1)Increase in screening rate 2)GIS Mapping 3)SAR - CCO


Francophone (including new immigrant francophones, deaf communities using LSQ/LSF, etc.)

Homeless (including marginally or under-housed, etc.) Resouces: Mikkonen, J., & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts.

Access, low socio-economic status, education and awareness

1)Maintaining access and manage increase of screening rate

Results do not find their way back to patient

Identified Resources: ColonCancerCheck Program (Screening for Life!)



HEIA Template


Step 1. SCOPING


Step 3. MITIGATION

Step 4. MONITORING






More Information

Needed.




Toronto: York University School of Health Policy and Management. https://www.cancercare.on.ca/pcs/screening/coloscreening

2) Reveal co-morbidities, other health conditions

Linguistic communities (e.g., uncomfortable using English or French, literacy affects communication, etc.).

Low income (e.g., unemployed, underemployed, etc.) Religious/faith communities Resources: Mikkonen, J., & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management. https://www.cancercare.on.ca/pcs/screening/coloscreening

education and awareness/stigma,



Rural/remote or inner-urban populations (e.g., geographic or social isolation, under-serviced areas, etc.) Resources: Mikkonen, J., & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management. https://www.cancercare.on.ca/pcs/screening/coloscreening

Access, social isolation, farming calendar


Identified Resources: 1)Primary Care Lead – SWRCP 2)Education and awareness opportunities (pamphlets, booth at Plowing match) – CCS, PH, SWRCP

1)GIS Mapping 2)SAR – CCO 3) FOBT Screening rates





HEIA Template


Step 1. SCOPING


Step 3. MITIGATION

Step 4. MONITORING






More Information

Needed.




3)ColonCancerCheck Program (Screening for Life!)

Sex/gender (e.g., male, female, women, men, trans, transsexual, transgendered, two-spirited, etc.)

Sexual orientation, (e.g., lesbian, gay, bisexual, etc.) Other: please describe the population here. * NOTE: The terminology listed here may or may not be preferred by members of the communities in question and there may be other populations you wish to add. Also consider intersecting populations (i.e. Aboriginal women).

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