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IndependentAssessmentCommitteeReport

ConstitutedunderArticle8.01ofthe

CollectiveAgreement

Between

SouthlakeRegionalHealthCentre

And

OntarioNurses’Association

October9,2017

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October9,2017Ms.SusanBlairProfessionalPracticeSpecialistOntarioNurses'Association85GrenvilleStreet,Suite400Toronto,Ontario,M5S3A2Ms.AnnetteJonesVicePresidentPatientExperiencesandChiefNursingOfficerSouthlakeRegionalHealthCentre596DavisDr.Newmarket,ON,L3Y2P9DearMs.BlairandMs.Jones,ThemembersoftheIndependentAssessmentCommitteehaveconcludedourreviewandrespectfullysubmittheReportoftheIndependentAssessmentCommitteethatwasconstitutedunderArticle8.01ofthecollectiveagreementbetweenSouthlakeRegionalHealthCentreandtheOntarioNurses’Association.ThisreportcontainstheIndependentAssessmentCommittee’sfindingsandrecommendationsregardingtheProfessionalWorkloadComplaintsubmittedbyRegisteredNursesfromtheEmergencyDepartmentatSouthlakeRegionalHealthCentre.TheprocessundertakenthroughanIndependentAssessmentCommitteeprovidesauniqueopportunityfordiscussionanddialoguebetweenallthepartiesregardingthecomplexissuesandconditionsthatunderlieaProfessionalWorkloadComplaint.TheCommitteehasmade28recommendationsinfiveareasregardingissuesthatimpacttheworkloadofRegisteredNurses.TheMembersoftheIndependentAssessmentCommitteeunanimouslysupportallrecommendationsinthisreport.TheCommitteehopesthattherecommendationswillassisttheHospitalandtheAssociationtofindmutuallyagreeableresolutionswithregardtonursingworkloadissuesintheEmergencyDepartment.

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TableofContents

1. Introduction.....................................................................................................................................................61.1. OrganizationoftheIndependentAssessmentCommitteeReport.......................................61.2. ReferraltotheIndependentAssessmentCommittee...............................................................61.3. JurisdictionoftheIndependentAssessmentCommittee........................................................71.4. ProceedingsoftheIndependentAssessmentCommittee....................................................11

Pre-Hearing.......................................................................................................................................................................11Hearing...............................................................................................................................................................................12PostClosureofHearing.................................................................................................................................................14

2. PresentationoftheProfessionalResponsibilityWorkloadComplaint...............................................152.1 InformationonSouthlakeRegionalHealthCentreandtheEmergencyDepartment.152.2 CurrentStaffingintheEmergencyDepartment......................................................................172.3 WorkloadConcernsofRegisteredNursesandDiscussionsattheHospitalAssociationCommittee.......................................................................................................................................................192.4 MeetingsbetweenAssociationandHospitalPriortoIAC....................................................29

3 Discussion,Analysis,andRecommendations...........................................................................................313.1 BaseRegisteredNurseStaffingintheED...................................................................................313.2 RecruitmentandRetention..................................................................................................................333.3 NurseStaffinginVariousAreasoftheEmergencyDepartment.........................................343.4 PhysicianNavigators.............................................................................................................................383.5 PhysicalEnvironment............................................................................................................................39

4 Recommendations........................................................................................................................................40

5. Conclusion.....................................................................................................................................................43

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AppendicesAppendix1:LetterfromAssociationMay2,2017.Appendix2:LetterfromHospitaltoAssociationMay30,2017Appendix3:ConfirmationofInvitationtoChairAppendix4:InformationRequestAppendix5:AgendaforIACAppendix6:AttendeesattheIAC

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1. Introduction

1.1. OrganizationoftheIndependentAssessmentCommitteeReport

TheIndependentAssessmentCommittee(IAC)Reportispresentedinfiveparts:

1. IntroductionThis section outlines the referral of the ProfessionalWorkload Complaint to the IAC,reviewsthe IAC’s jurisdictionasoutlined intheCollectiveAgreement,andsummarizesthePre-Hearing,HearingandPost-Hearingprocesses.

2. PresentationoftheProfessionalResponsibilityWorkloadComplaint

This section presents the context of practice relating to the professional workloadcomplaint in the Emergency Department at Southlake Regional Health Centre;summarizes the relevant history leading to the referral of the professional workloadcomplainttotheIAC;andreviewsthepresentationsbytheOntarioNurses’Association(‘theAssociation’),SouthlakeRegionalHealthCentre(‘theHospital’)attheIACmeeting.

3. Discussion,Analysis,andRecommendations4. SummaryandConclusions5. ReferencesandAppendices

ThesubmissionsandexhibitsoftheOntarioNurses’AssociationandSouthlakeRegionalHealthCentreareonfilewithbothparties.

1.2. ReferraltotheIndependentAssessmentCommittee

ThisReportaddressestheprofessionalworkloadcomplaintsofRegisteredNursesfromtheEmergencyDepartment at Southlake Regional Health Centre. The Association stated the following in their pre-hearingsubmission:

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“TheRNscontinuetostruggletomeettheirobligationtoprovidesafe,qualitypatientcareasaresultofthesehighpatientvolumesandthehospital’scontinuousstateofovercapacity.Thisissupportedby104ProfessionalResponsibilityWorkloadReportForms(PRWRFs)completedfromJanuary2016topresent.”1

1.3. JurisdictionoftheIndependentAssessmentCommittee

The IAC is convenedunder the authority ofArticle 8.01onProfessional Responsibility in theHospitalCentralHospitalAgreementwiththeOntarioNurses’Association.Article8.01states:2

8.01 The parties agree that patient care is enhanced if concerns relating to professional practice,

patient acuity, fluctuating workloads and fluctuating staffing are resolved in a timely andeffectivemanner.Thisprovisionisintendedtoappropriatelyaddressemployeeconcernsrelativeto their workload in the context of their professional responsibility. In particular the partiesencourage nurses to raise any issues that negatively impact their workload or patient care,includingbutnotlimitedto:• Gapsincontinuityofcare• Balanceofstaffmix• Accesstocontingencystaff• Appropriatenumberofnursingstaff.IntheeventthattheHospitalassignsanumberofpatientsoraworkloadtoanindividualnurseorgroupofnurses such that theyhave cause tobelieve that theyarebeingasked toperformmoreworkthanisconsistentwithproperpatientcare,theyshall

i. Atthetimetheworkload issueoccurs,discussthe issuewithintheunit/programtodevelop

strategiestomeetpatientcareneedsusingcurrentresources

1SubmissiontotheIndependentAssessmentCommitteebyOntarioNurses’Association,2017,p.52CollectiveAgreementBetweentheHospitalandOntarioNurses’Association,Article8–Professional

2CollectiveAgreementBetweentheHospitalandOntarioNurses’Association,Article8–ProfessionalResponsibility,March31,2018,p.19-21.

(a)

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ii. If necessary, using established lines of communication as identified by the hospital, seekimmediateassistancefromanindividual(s)(whocouldbewithinthebargainingunit)whohasresponsibilityfortimelyresolutionofworkloadissues.

iii. Failingresolutionoftheworkloadissueatthetimeofoccurrenceoriftheissueisongoingthenurse(s)willdiscusstheissuewithherorhisManagerordesignateonthenextdaythattheManager (or designate) and the nurse are both working or within ten (10) calendar dayswhichever is sooner. When meeting with the manager, the nurse(s) may request theassistanceofaUnionrepresentativetosupport/assisther/himatthemeeting.

iv. CompletetheONA/HospitalprofessionalResponsibilityWorkloadReportForm.Themanager(ordesignate)willprovideawrittenresponseontheONA/HospitalProfessionalResponsibilityWorkloadReport Form to thenurse(s)within ten (10) calendardays of receipt of the formwithacopytotheBargainingUnitPresident,ChiefNursingExecutiveandtheSeniorClinicalLeader (if applicable). When meeting with the manager, the nurse(s) may request theassistanceofaUnionrepresentativetosupport/assisther/himatthemeeting.

v. Everyeffortwillbemadetoresolveworkloadissuesattheunitlevel.AUnionrepresentativeshallbe involved inany resolutiondiscussionsat theunit level. Thediscussionsandactionswillbedocumented.

vi. Failing resolution at the unit level, submit the ONA/Hospital Professional ResponsibilityWorkload Report Form to the Hospital-Association Committeewithin twenty (20) calendardays fromthedateof theManager’s responseorwhensheorheought tohaverespondedunder(iv)above.

vii. The Chair of the Hospital-Association Committee shall convene ameeting of the Hospital-Association Committee within fifteen (15) calendar days of the filing of the ONA/HospitalProfessionalResponsibilityWorkloadReportForm.TheCommitteeshallhearandattempttoresolvetheissue(s)tothesatisfactionofbothpartiesandreporttheoutcometothenurse(s)using the Workload/Professional Responsibility Review Tool to develop jointrecommendation).

viii. AnysettlementarrivedatunderArticle8.01(a)iii),v),orvi)shallbesignedbytheparties.ix. Failing resolution of the issue(s) within fifteen (15) calendar days of the meeting of the

Hospital-Association Committee the issue(s) shall be forwarded to an IndependentAssessmentCommittee.

x. Failingdevelopmentof joint recommendation(s)andprior to the issuesbeing forwarded totheIndependentAssessmentCommittee,theUnionwillforwardawrittenreportoutliningtheissue(s)andrecommendationstotheChiefNursingExecutive.

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xi. ForprofessionalsregulatedbytheRHPAotherthannurses,theUnionmayforwardawrittenreport outlining the issue(s) and recommendations to the appropriate senior executive asdesignatedbytheHospital.

xii. TheIndependentAssessmentCommitteeiscomposedofthree(3)registerednurses;onechosenbytheOntarioNurses'Association,onechosenbytheHospitalandonechosenfromapanelofindependentregisterednurseswhoarewellrespectedwithintheprofession.ThememberoftheCommitteechosenfromthepanelofindependentregisterednursesshallactasChair.Ifoneofthepartiesfailstoappointitsnomineewithinaperiodofthirty(30)calendardaysofgivingnoticetoproceedtotheIndependentAssessmentCommittee,theprocesswillproceed.ThiswillnotprecludeeitherpartyfromappointingtheirnomineepriortothecommencementoftheIndependentAssessmentCommitteehearing.

xiii. TheAssessmentCommitteeshallsetadatetoconductahearingintotheissue(s)withinfourteen(14)calendardaysofitsappointmentandshallbeempoweredtoinvestigateasisnecessaryandmakewhatfindingsasareappropriateinthecircumstances.TheAssessmentCommitteeshallrenderitsdecision,inwriting,tothepartieswithinforty-five(45)calendardaysfollowingcompletionofitshearing.

xiv. ItisunderstoodandagreedthatrepresentativesoftheOntarioNurses'Association,includingtheLabourRelationsOfficer(s),mayattendmeetingsheldbetweentheHospitalandtheUnionunderthisprovision.

xv. Anyissue(s)lodgedunderthisprovisionshallbeontheformsetoutinAppendix6.Alternately,thelocalpartiesmayagreetoanelectronicversionoftheformandaprocessforsigning.

xvi. TheChiefNursingExecutive,BargainingUnitPresidentandtheHospital-AssociationCommitteewilljointlyreviewtherecommendationsoftheIndependentAssessmentCommitteewithinthirty(30)calendardaysofthereleaseoftheIACrecommendationsanddevelopanimplementationplanformutuallyagreedchanges.SuchmeetingswillbebookedpriortoleavingtheIndependentAssessmentCommittee.

b)i. ThelistofAssessmentCommitteeChairsisattachedasAppendix2.Duringthetermofthis

Agreement,thecentralpartiesshallmeetasnecessarytoreviewandamendbyagreementthelistofchairsofProfessionalResponsibilityAssessmentCommittees.ThepartiesagreethatshouldaChairberequired,theOntarioHospitalAssociationandtheOntarioNurses'Associationwillbecontacted.TheywillprovidethenameofthepersontobeutilizedonthealphabeticallistingofChairs.

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ThenametobeprovidedwillbethetopnameonthelistofChairswhohasnotbeenpreviouslyassigned.ShouldtheChairwhoisscheduledtoservedeclinewhenrequested,oritbecomesobviousthatsheorhewouldnotbesuitableduetoconnectionswiththeHospitalorcommunity,thenextpersononthelistwillbeapproachedtoactasChair.

ii. EachpartywillbearthecostofitsownnomineeandwillshareequallythefeeoftheChairandwhateverotherexpensesareincurredbytheAssessmentCommitteeintheperformanceofitsresponsibilitiesassetoutherein.

TheIAC’sjurisdictionthusrelatestowhetherregisterednursesarebeingrequestedand/orrequiredtoassumemoreworkthanisconsistentwiththeprovisionofproperpatientcare.Workloadisinfluencedbybothdirectfactors(e.g.nurse-patientratio,patientacuity/complexityofcarerequirements,patientvolume) and indirect factors (e.g. roles and responsibilities of other care providers, physicalenvironment of practice, standards of practice, and systems of care). The IAC is responsible forexamining factors impactingworkload, and formaking recommendations to addressworkload issues.ConcernsoutsideofworkloadarebeyondthejurisdictionoftheIAC.TheIAC’sjurisdictionceaseswithsubmissionofitswrittenReport.Thefindingsandrecommendationsofthe IAC provide an independent external perspective to assist the Association and the Hospital toachievemutuallyagreeableresolutionstoworkloadissues.TheIACisnotanadjudicativepanel,anditsrecommendations are not binding. In accordance with Professional Responsibility Article 8 of theCollectiveAgreement,theIACwascomprisedofthreeRegisteredNurses.ThemembersoftheIndependentAssessmentCommitteewere:ChairpersonLeslieVincentFortheAssociationCindyGabrielliFortheHospitalDerekMcNally

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1.4. ProceedingsoftheIndependentAssessmentCommittee

Pre-Hearing

OnMay2,2017theAssociationnotifiedtheHospitalinaletterthattheAssociationwasforwardingthecomplainttotheIndependentAssessmentCommittee;andconfirmingtheirnomineeasCindyGabrielli(Appendix1).OnMay30,2017theHospitalnotifiedtheAssociationthattheirnomineewouldbeDerekMcNally(Appendix2).OnMay9,2017,LeslieVincentagreedtobetheIACChair.ThiswasconfirmedinwritingonJune1,2017(Appendix3).On July27, 2017 the IACproposed to theHospital and theAssociation that the IACbe scheduled forSeptember 27-29, 2017. The chair also informed both parties on July 27,2017 that due to otherobligationsinOctober,thefinalreportmightbedelayedbeyondtheprescribed45dayperiodspecifiedinthecollectiveagreement.BothpartiesagreedtothedatesfortheIAC.OnAugust13,2017,theIACChairrequestedthatthesubmissionbriefsfrombothpartiesbereceivedbySeptember8,2017.TheIACmembersmetbyteleconferenceonAugust16,2017anddiscussedthefollowingissues:

• OverviewoftheIACprocessandtimeframes;• AgendafortheIAC;• InformationrequirementsforthecommitteetoassistintheIAC’sprocessanddeliberations.

OnAugust16,2017 the IACchair sentan information request to theHospitalandrequested that theinformationbeprovidedwiththeirbriefsubmission(Appendix4).OnSeptember12,2017theIACchairsenttheagendafortheIAC(Appendix5).TheIACalsorequestedatouroftheEmergencyDepartmentonthefirstdayoftheIAC.ThefollowinggroundrulesforconductduringtheIACwereprovided:• Adheretotheagendaandthetimeframesforpresentation.• Opportunitywillbegiventoaskquestionsforclarityattheendofeachpresentation.Ifeitherparty

hasaquestion,pleaseindicatethistotheChair.• Pleasespeakfromyourownperspectiveandexperience.• Donotraiseissuesrelatedtoindividuals;theIACisnotconvenedtoaddressanyconcernsregarding

individualperformance.• Theproceedingsofthehearingareconfidentialandnottobediscussedoutsidethehearingexcept

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forthepurposeofpreparingoftheIACmeeting.• Thebriefs,presentations,discussionandanydistributeddocumentsinthishearingarenottobe

sharedwithotherparties.

OnSeptember18,2017theIACmetbyteleconferenceinpreparationfortheIACmeetingandtoreviewthebriefssubmittedbybothparties.On September 22, 2107 the Hospital provided a copy of the Emergency DepartmentModel of CareReportsubmittedbytheProfessionalPracticeDepartmentatSouthlakeRegionalHealthCareCentre.OnSeptember25,2017theHospitalprovidedasupplementarybriefoutliningthehospital’sobjectiontotheIACtakingjurisdictionofthePhysicianNavigatordisputebetweentheparties.OnSeptember25,2017theAssociationprovidedanadditionalsubmissionregardingtheirresponsetothePhysicianNavigatorissue.Priortothehearing,bothpartiesconfirmedwhowouldbeinattendanceatthehearing.

Hearing

Wednesday,September27,2017TheIACmetattheHospitalat0830hoursonSeptember27,2017andweregreetedbyrepresentativesoftheHospitalandmembersoftheAssociation.TheIACwasprovidedwithanextensivetouroftheEmergencyDepartment(ED).ThetourservedtofamiliarizetheIACwiththeworkenvironmentandphysicallayoutoftheunit.MarleneWheaton-Chaston,ManageroftheEmergencyDepartmentfacilitatedthetour.ThefollowingindividualsfromtheAssociationwereonthetour:

• SusanBlair,ProfessionalPracticeSpecialist• DJSanderson,BargainingUnitPresident,Local124

Followingabreak,TheIAChearingconvenedat1300houraspertheagenda(Appendix4).ParticipantsandobserversontherespectivehearingdatesarelistedinAppendix6.

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Following introductionoftheIACCommitteemembersandrepresentativesoftheAssociationandtheHospital,theIACChairreviewedthejurisdictionalscopeoftheIAC,includingthepurposeoftheIAC;andthegroundrulesfortheHearingprocedureincludingconfirmationthatallparticipantsunderstoodandagreed.TheChairof the IAC responded to theHospital’s request that the IACdecline to consider theallegedworkloadcomplaintsregardingPhysicianNavigatorsbecauseofagrievancefiledbytheAssociationonthe issue in July. The IAC panel discussed the issue and decided that the IAC would consider anyworkloadcomplaintsrelatedtothePhysicianNavigators,astheissueisgermanetotheinvestigationoftheworkloadissuesintheED.At the request of the IAC panel, the Hospital provided a detailed description of the daily staffingscheduleintheEmergencyDepartment.TheAssociationagreedthatthedescriptionwasaccurate.Theagreeduponstaffingisprovidedinsection2.2.Ms. Susan Blair, Professional Practice Specialist (PPS), presented on behalf of the Association. TheAssociation’spresentationwasbasedontheirwrittenpre-hearingsubmissionandsupportingexhibitsaswell as a summaryof104ProfessionalResponsibilityWorkloadReport Forms (PRWRFs) submittedbytheRegisteredNursesoftheEmergencyDepartmentbetween2016andthepresent.Anadditional16PRWRFs completed between September 4 and September 26, 2017 was provided during thepresentation.Kim Storey, Director of the Emergency Department and Patient Flow; Annette Jones, Vice PresidentPatientExperiencesandMarleneWheaton-Chaston,ManageroftheEmergencyDepartmentpresentedonbehalfoftheHospital.TheHospital’spresentationwasbasedontheirpre-hearingsubmission,andadditionalinformation:

• Theorganizationalapproachtoemergencycareincludingnotbelievinginhavingpatientsinanexternal waiting room, ‘keeping patients upright’ by utilizing chairs and exam tables asappropriate,andanengineeredphysicianschedulingsystembasedonvolumeandflexiblestartendtimesforshifts.

• TheEDthatwasdesignedtocarefor70,000patientsannually,butitisestimatedthattheunitwill care for120,000patients this year. Thehospital stated their concerns regarding infectioncontrolinthedepartmentandhascommissionedareviewbyDr.KevinKatz.

• TheHospitalstatedtheyagreedthattheHospitalneededtoaddadditionalstafftotheEDandprovidedthemostrecentinvestmentsinstaffing.

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• TheHospitalacknowledgedtheneedtoimproveEDaccesstocriticalcarebeds.• ArecruitmentplanforEDregisterednurses.• PlanstoreduceagencyandovertimebyMarch2018.

Thursday,September28,2017TheIACChairresumedtheHearingat0900hours.Dr.StevenBeatty,ChiefofStaff,MarleneWheaton-Chaston, Kim Storey, and Annette Jones provided the Hospital’s response to the Association’ssubmission.MembersoftheHospitalparticipatedinthesubsequentdiscussion.Ms.BlairprovidedtheAssociation’sresponsetotheHospital’ssubmission.OthermembersoftheAssociationalsoparticipatedin the subsequent discussion. Following adjournment of the Hearing, the IAC met to review andsynthesize the information provided, and to identify key issues requiring additional clarification andtheirrespectivequestionsforthefinaldayofthehearing.Friday,September29,2017TheIACchairresumedthemeetingat0900hr.MembersoftheIACaskedfurtherquestionsinordertounderstanda rangeof issues inmoredetailandgaining furtherclarityof the issuesarising frombothparties’presentations.TheIACChairconcludedthehearingbythankingMs.CindyGabrielli,AssociationNomineeandMr.DerekMcNally,HospitalNominee;aswellasalltheparticipantsfortheirengagementandcontributions in theHearingprocess.The IACChairalsocommunicated thehope that thepartieswill be able to move forward to seek resolution to the issues. The IAC Chair closed the Hearing atapproximately1200hours.

PostClosureofHearing

The IACmetby teleconferenceonOctober5,2017.At thismeeting, the IAChadextensivediscussionandreviewedthedraftreportandanalysis.Followingthemeeting,allIACmemberscontributedtothenext versionof the reportand recommendations.The IACmetby teleconferenceonOctober7,2017andfinalizedthereportonOctober9,2017.

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2. PresentationoftheProfessionalResponsibilityWorkloadComplaint

2.1 InformationonSouthlakeRegionalHealthCentreandtheEmergencyDepartment

The Emergency Department at Southlake Regional Health Centre is located in Newmarket, Ontario.SouthlakeRegionalHealthCentreisalarge,regionalfullservicehospitalandservesacatchmentareaofmorethan1,000,000peopleinYorkRegion,SimcoeCountyandasfarnorthasMuskoka.The hospital has approximately 384 beds, approximately 3,227 employees, a medical staff ofapproximately 589, and approximately 854 volunteers. There are 1092 Registered Nurses (RNs)employedbySouthlake,and265RegisteredPracticalNurses(RPNs).3TheEmergencyDepartmentisthethirdbusiestEDinOntario,anditisestimatedthattheEDwillserve120,000bytheendofthecurrentfiscalyear.TheEDisdividedintoseveralareas:

• TriageandRegistration:Thisarea isadjacent to theexternalwaiting roomat theentranceoftheED.Ambulatorypatientsenterbythemaindoorandifavailable,aremetbythePre-Triagenursewhocompletestheinfectioncontrolscreening.Patientsthentakeanumberandaseatintheexternalwaitingroom.Patientsarethencalledtothetriagedesk.TheTriageRNperformstriage according to the Canadian Triage and Acuity Scale (CTAS) utilizing an electronic triagesystemthencallsthepatient.Registrationclerkscompleteallpatientregistrations.Patientsarethensentdirectlytotheassignedcarearea.Themainhospitalsecurityofficeisadjacenttotheexternalwaitingroomandisstaffed24/7.

• AcuteArea:o EMSTriage/TransitionStretchers:EMSpatientsarrivedirectly throughtheambulance

bay that isadjacent to theacutearea. A triagenursewill triage thepatientand ifnoappropriatespaceorbedisavailable,thepatientwillbeplacedononeoffourtransitionstretchersinthehallway.EMSremainswithanypatientrequiringcardiacmonitoringifamonitoredstretcherisnotavailable.Thehospitalgoalistooffloadallpatientswithin30minutesofarrival.ThisareaisstaffedbyRN.

o CardiacMonitored Stretchers: Sixteenprivate stretchered rooms including7negativepressurerooms,and3resuscitationrooms(oneofwhichisequippedforpediatriccare).CTAS 1 and 2 patients are seen in this area. All rooms are equipped with cardiacmonitoring.ThisareaisstaffedbyRNs.

3SubmissionsonBehalfofSouthlakeRegionalHealthCareCentre,Volume1,p.8.

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o RedZoneTelemetry:Anambulatoryareawithreclinerchairsthatcanprovidetelemetryforupto6patients.Theareaalsoincludestwostretchersusedforpatientassessmentandconscioussedationandisopen12hoursadayfrom1100-2300.CTAS2patientsareseeninthisareaandreassessmentpatientswhohavebeentransferredfromtheacutearea.ThisareaisstaffedbyanRN.

• Sub-Acute/Ambulatory:ThisareautilizesanRN/RPNmodelofcare.Thearea is separated into twoareas–FastTrackandSub-Acute.Thereare2waitingareas.The InternalWaitingRoom (IWR) isutilized for theSub-Acutepatients,andtheotherforFastTrack.Bothwaitingareasarelocatedinhallways.

o FastTrack:ThepatientssenttothisareaareCTAS4and5patientswithpresentationssuch as orthopaedic injuries, integumentary complaints such as lacerations, rashes,minor burns, cellulitis and patients who are returning for care such as CT scans,ultrasoundandcellulitisassessment.TheFasttrackisopen12hoursadayandstaffedbyRPNs.

o Sub-acute: The patients sent to this area are CTAS 2,3,4 and 5 patients with acutepresentations includingbutnot limited tomedical,gynaecologicalandsurgicalnature.There are 5 podswith an exam roomadjacent to a roomwith 6 chairs. Patients aretakenfromtheinternalwaitingroom(IWR)tooneofthepods. Ifallthepodsarefull,thenpatientswillcontinuetowaitintheIWR.ThereisalsoaccesstooneENTroomaswellasanotherprivateroomwithawashroom.ThisareaisstaffedbyRNs.

• YellowZone:Thisareacanholdupto14consultedoradmittedpatients.Telemetryisavailable.Fourofthespacescanbedividedintosemisbycurtains.ThisareaisstaffedbyRNs.

• MentalHealthandWellnessArea(MHWA):A 5 stretcher area that is separate from all other areas and accessed through a badge swipesystem and is monitored by CCTV. The area includes two separation rooms. There areinclusion/exclusioncriteriaforpatiententry.Thenursingstation isadjacentbutseparatefromthecareareas.Theareaprovidescaretoadultmentalhealthpatients.4ThisareaisstaffedbyRNs and Psychiatric Emergency Nurses (PENs). The PENs are assigned to the MHWA by thepsychiatricunitandarenotpartoftheEDbudget.Thereisalsoasecurityguard24hoursadaystationedintheunit.

4SubmissionsonBehalfofSouthlakeRegionalHealthCentre,Volume1,p.8-11.

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2.2 CurrentStaffingintheEmergencyDepartment

CurrentlytheEDisstaffedby:• OneManagerwhoworksMondaytoFriday.OnePermanentChargeNurseondaysandoneon

nights.OneClinicalCoordinatorwhoworks4-10hoursshiftsaweekonweekdays.• RegisteredNurses,RegisteredPracticalNursesandPsychiatricEmergencyNurses(PEN),whoall

work11.25hoursshiftsondays,eveningsornights.Thenursingstaffisallocatedtoaspecificfunctionorareaortotheroleoffloatnurse.Thedayshiftisnormally0730-1930.Theeveningshiftisnormally1100-2300.Thenightshiftis1930-2330.Thereareafeweveningshiftsthatstartatdifferenttimes.

• Staffing was increased in 2016 because of an increase of $950,000 to the ED budget. Theincreaseinbudgetwasutilizedfor:

o Two 11.25 RN shifts: 1 evening shift for EMS offload/hallway, and 1 shift in the sub-acutearea.

o One11.25RPNshift infasttracktoreplaceanRN,andtheRNshiftwasreallocatedtotheinternalwaitingroomandreassessmentpodinthesub-acutearea.

o Two11.25clericalstaff:oneevening/nightinsub-acuteareaandoneintheYellowZone(admits/consults).

• OnSeptember11,2017aphlebotomistwasaddedtothestaffingtodothemorningbloodworkonalladmittedpatientsintheED;

• Infiscal2018-19,anadditional$450,000willbeaddedtothebudgetfor:o OneRPN24/7intheyellowzone,whichwillincreasenursestaffingintheyellowzoneto

3nursespershiftandfreeupanRNshifttobereallocatedtotheinternalwaitingroominthesub-acutearea.

• Pharmacytechnicianhourswereincreasedto7daysaweek,ondaysandevenings.• The hospital also utilizes agency nurses and nurses from the hospital’s Virtual Nursing Team

(VNT)toreplaceshiftsthatarevacant,sickcallsandforsurge.• ED physicians employ Physician Navigators (PN) to work with them on their shift. Physician

Navigatorsassistphysicianswithnon-clinical tasksandarenottobeengaged indirectpatientcareortotouchpatients.PNsareutilizedinordertoincreasephysicianefficiency.

• Currentlythereare38RNand2RPNshiftsperday.TheallocationofshiftsisshowninTable1.

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Table1:AllocationofNursingandClericalShiftsina24-hourperiod.Assignment Days Evenings Nights Notes

ChargeNurse 1 1 Float 0.5 1400-1930ClericalFloat 1 Triage 1 1 1 Pre-Triage 1 0900-2100EMSTriage/Transition 2 1 Acute1-3;ResusB 1 1 Acute4-6;ResusC 1 1 Acute9-12 1 1 Acute13-15;ResusA 1 1 AcuteFloats 2 RedZone 1 ClericalforAcute 1 1 SubAcuteReassessandIWR

1 1000-2200

SAPod17/18 1 1 SAPod19/20 1 1 SAPod21/22 1 1 SAPod27 1 SAFloat 2 0.5 1930-0200SAFastTrack 1RPN 1RPN Dshift1000-2200ClericalforSub-Acute/FT 1 1 YellowConsult/Admit 2 1 2 ClericalforYellow 1 1 Daysis0900-2100MHWA 1 1 Plus1PENDays&NightsMHWASecurity 1 1 TotalRNShifts 15.0 9.5 13.5 TotalRPNShifts 1 1 TotalSecurity 1 1 TotalClerical 3 1 3

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2.3 WorkloadConcernsofRegisteredNursesandDiscussionsattheHospitalAssociationCommitteeTherehavebeen120ProfessionalResponsibilityWorkloadResponsibilityForms(PRWRFs)submittedbetweenJanuary2016andSeptember26,2017.During thepresentation, theAssociationstated that thenursingworkloadproblemsareasa resultofeight issues – the primary issue being a lack of adequate RN staffing resulting in the significantchallengesfortheRNstomeettheCollegeofNursesofOntariopracticestandardsforRNs,andspecialtystandardssetbytheNationalEmergencyNurseAssociation.5Theeightissuesare:• SkillmixofRNsandRPNsinthesub-acute/fasttrackarea.• InsufficientRNstaffinginthesub-acute/internalwaitingroom• InsufficientRNstaffingintheacutearea/redzone• InsufficientRNstaffingintheyellowzone/consult/admit• InsufficientRNstaffinginthetriage/EMSoffloadarea• MixofPENsandEDRNsintheMHWA• Roleandresponsibilitiesofphysiciannavigators• Frequent use of agency RNs, vacant shifts on the posted baseline schedule, communicationwith

management

TheAssociationprovidedthefollowingrecommendations:• Skillmixinfasttrackarea:

o AlthoughCTAS4and5patientsarecaredforinthisarea,theAssociationstatesthatCTASisbased on the chief complaint, and does not preclude that the patient can haveunpredictable and complex needs. Conscious sedation is also conducted in this area,requiring thatanRNprovide care, and thereforeanRNmustbe reassigned fromanotherareaforaperiodoftime.IfanRPNdeterminesthataclientistoocomplex,theyconsultanRNandthismayresultinatransferofcare,usuallyrequiringthatthepatientbemovedtosub-acute.

o ThereforetheAssociationrecommendsthat:! TheRPNsarereplacedwithRNs.! Thefasttrackremainsopen24hours/day,anincreaseof11hoursaday.

• InsufficientRNstaffinginthesub-acute/internalwaitingroom(IWR)5SubmissiontotheIndependentAssessmentCommitteebyOntarioNurses’Association,p.9.

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o TheSub-acute/IWRarea seesa largenumberofpatientsperday, and isopen24hoursaday.Theareaisoftencongestedwithpatientsandfamilymembers.TheReassessmentpodandtheadjacenthallwayservesastheIWR,andisstaffedbetween1000-2200byaRNwhois also managing the reassessment pod. When fast track closes at 2300, any remainingpatientsmustbecaredfor,andoftenaremovedtosub-acuteifthereisnoothernursethatcanbereassignedtofasttrack.Thenursesstatethatthisoccursfrequentlyalthoughthereisnodataavailabletoassessthefrequencyofoccurrence.

o Fifty-one (51) of the PRWRFs were related to workload issues in this area related toexcessivenursepatientratios,delays incare,concernsregarding lackofmonitoringoftheIWRandthereassessmentpod.

o ThereforetheAssociationrecommends:! AnadditionalRNinPod27atnight! AnadditionalRNintheIWRtoprovide24/7coverage.! AnadditionalfloatRNintheevening.! Asurgeprotocol forthe IWRwhencensus is>10,to includeadditionalRNstaffing

andhousekeeping.• InsufficientRNstaffingintheacutearea/redzone

o The Association stated that the acuity of patients in this area warrants a decrease inpatient/nurse ratio to 3:1 from 4:1. Due to the challenges in accessing critical care beds,patientsmaybeheldintheERformanyhoursbeforetransfer.

o Twenty-nine of the PRWRFs were related to workload issues in the acute area/red zonerelated topatientacuity, caredelays, thecareof ICUpatients,patientvolume,and triageoverload.

o TheAssociationthereforerecommends:! IncreasingtheRNstaffto5ondaysandnightsfromthecurrentlevelof4.! Keepingtheredzoneopen24hoursaday,anincreaseof12hoursaday.

• InsufficientRNstaffingintheyellowzone/consult/admito The yellow zone is staffedwith twonurses ondays andnights andoneon evenings. The

desiredpatient/nurseratiois5:1ratio.Onaregularbasisthecensusintheareaexceeds10,andtheEDpolicyistoaddanursewhenthecensusisover10.

o Approximately 17 of the PWRFs were generated from the yellow zone related to highvolumesofpatients,delaysincare,andworkingshortofstaff.

o TheassociationacknowledgedthatrecentchangesmadebytheHospitalhaveimprovedthesituation;

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! A pharmacy technician completes the BestMedication Reconciliation Records forpatients.

! AnauditofthemostcommonmedicationsresultedinanupdatingoftheAccudosemedicationdispenser,allowingtheRNstogivemedicationinatimeliermanner.

! Anadditionalwardclerkwasassignedtotheareaonthenightshift.! AsofSeptember11,2017,phlebotomistisdoingallregularbloodworkfrom0600-

0900onalladmittedpatientsintheED.o TheAssociationthereforerecommends:

! AddinganadditionalRNonDaysandNightstoensuresufficientstafftomaintainapatient/nurseratioof5:1.

• InsufficientRNstaffinginthetriage/EMSoffloadareao Approximately 12 PWRFs were generated from the triage/EMS area related to delays in

patientcareandpatientvolumes.Frequentdelaysintriageweredocumented.o TheAssociationthereforerecommends:

! AddinganadditionalRNtoEMSoffloadonthedayshift.• MixofPENsandEDRNsintheMHWA

o TheMHWAisstaffedbyoneERRNandonePENondaysandnights,plusasecurityguard.o Therewere11PWRFsgeneratedfromtheMHWAin2017relatedtoviolence,patientswith

exclusioncriteriabeingplacedintheMHWA,useofVNTstaffintheunittoreplacethePEN.o Theassociationthereforerecommends:

! ReplacingtheEDRNwithaPENondaysandnights.• RoleandresponsibilitiesofPhysicianNavigators

o PNswere introduced to theER in2012 to increasephysicianefficiency andarenot tobeengagedindirectpatientcare.

o Five PRWRFs were completed related to PNs functioning outside the scope of the role;communicationissuesthatcauseandremovingpatientsfromthepatienttrackerwhentheRN still has care to provide causing confusion as to the location of the patient and thepatientrecord.

o On July 14, 2017 the Association filed a grievance regarding the PNs with regard to theinappropriatelycontractingouttheworkofRNstounregulatedpersons.6

o TheAssociationthereforerecommends:

6SupplementalBriefonBehalfofSouthlakeRegionalHealthCentre:ObjectiontoPhysicianNavigatorIssue.p.3.

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! EnsuringthatPNsdonotengageinpatientcare! Ensuring that physicians are communicating directly with RNs on patient care

matters.• FrequentuseofagencyRNs,vacantshiftsonthepostedbaselineschedule,communicationwith

managemento The Association stated that there is frequently insufficient staffing in the ED because of

vacant shifts in the schedule, therefore not meeting baseline requirements, which mayresultinworkingshortorbeingreplacedwithagencyorVNT.TheassociationisconcernedthatthemajorityofagencyandVNTnursesarenotEDtrainednurses,thereforeimpactingonqualityofcareandtheworkloadoftheEDnursingstaff.

o TheAssociationthereforerecommends:! EnsuringtheEDisstaffedwithEDtrainednursesatalltimes.! IncreasingthebaselineRNstaffing! IncreasetheEDRNpool.! EnsuringallEDRNshaveAdvancedCardiacLifeSupport(ACLS);PediatricAdvanced

Life Support (PALS); Trauma Nursing Core Courses (TNCC); Canadian Triage andAcuityScale-CombinedAdult/PediatricComponentEducationalProgram

! FinanciallysupportRNcontinuingeducationinEmergencyNursingPediatricCourse(ENPC); Course on Advanced Trauma Nursing (CATN II); Emergency NursingCertificationCanada(ENCC).

TheAssociationstatedthattheincreasingpatientworkloadrequiresRegisteredNurses(RNs)toperformmore work than is consistent with proper patient care. During and following the presentation, theAssociationrespondedtoquestionsofclarificationfromboththeHospitalandIAC.Kim Storey, Director of the Emergency Department and Patient Flow; Annette Jones, Vice PresidentPatientExperiencesandMarleneWheaton-Chaston,ManageroftheEmergencyDepartmentpresentedon behalf of the Hospital. The Hospital’s presentation was based on their written pre-hearingsubmissions. The presentation addressed ED performance, innovations and approach to care, thecurrentlimitationsofthephysicalenvironment,staffingintheED,accesstocriticalcarebeds,modelofcare,reductionofagencyandovertime,recruitment,andreplacementofRNsintheEDandforsurge,educationofstaff,andphysiciannavigators.

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• Performance,innovationandapproachtocareintheED:o The hospital takes pride in being a top performer in ER care in Ontario, and having

developednovelapproachestoEDcare.Theorganizationalapproachtoemergencycareis based on not keeping patients in an external waiting room, but sending patientsdirectly to theappropriate careareaafterbeing triaged, ‘keepingpatientsupright’byutilizing chairs and exam tables as appropriate, and on an engineered physicianschedulingsystembasedonvolumeandflexiblestartendtimesforshifts.

o The average lengthof stay for non-admittedhigh acuity patients is 6.7 hours and3.5hoursfornon-admittedlowacuitypatients.7

o Theaveragetimetoseeaphysicianis40min.,and1.2hoursatthe90thpercentile.o Thepercentageofpatientswho leavewithoutbeingseenYTD is0.6%,wellbelowthe

provincialaverageof3.2%,andotherEDsintheCentralLHINat2.0%.o The hospital has reviewed return visits to EMS as per the Health Quality Ontario

requirementthathospitalsmonitorreturnvisitsasanefficientwaytoidentifyadverseeventsandqualityissues.Theindicatorsare:

! NumberandpercentageofEDreturnvisitswithin72hoursofdischargefromtheinitialEDnon-admitvisit,tothesameoradifferenthospital,andresultinginanadmissiontoaninpatientunitonthesecondvisit.8

• Southlakerateis0.89%,Ontarioaverageis0.98%! NumberandpercentageofEDreturnvisitswithin7daysofdischargefromthe

initialEDnon-admitvisit,tothesameoradifferenthospital,resultinginanadmissiontoaninpatientunitinthesecondvisitwithasentineldiagnosis(subarachnoidhemorrhage[SAH],acutemyocardialinfarction[AMI],andpaediatricsepsis)andwitharelevantdiagnosisdocumentedintheinitialEDnon-admitvisit.8

• Southlakerateis.86%,Ontarioaverageis0.98%.

7SubmissionsonBehalfofSouthlakeRegionalHealthCentre,Volume1,p.11.

8TheEDReturnVisitQualityProgram:HowtoConductandAudit,HealthQualityOntario,April2017,RevisedAugust2017.P.2.

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o There was a recent implementation of process changes in EMS offload based on arecentLEANinitiativetoreducethetransferofcaretime.

o TheHospitalStandardizedMortalityRatiois71.• Limitationsofthephysicalenvironment:

o The current ED was originally designed to care for 70,000 patients annually. It isexpectedthatthisyeartheEDwillserve120,000patients.

o The hospital stated their concerns regarding the limitations on clinical space andinfectioncontrolrelatedtoovercrowdinginthedepartmentandhascommissionedanIPACreviewbyDr.KevinKatz.

• StaffingintheEDo ThehospitalstatedthattheyagreedthattheyneededtoaddadditionalstafftotheED

and provided themost recent investments in staffingwhich are provided in detail insection2.2.

o Thereare131positionsintheEDforRNs,butnotallarefilled.Thecurrentheadcountis115.Thedistributionofthe131positionsisoutlinedinTable2.Table2:DistributionofRNpositionsbyFT,PTandCasualStatus

Position NumberFT 91(3arejobsharepositions)PT 21Casual 19Total 131

o Thehospitaldoesnotagreewiththeamountofincreaseinstaffrecommendedbythe

Association.o Thehospitalprovidedtheirrationaleforstaffingineacharea.

! EMSOffload:ThehospitalstatesthatEMSpatientvolumesarerelativelystableandnot increasing at the same rate as ambulatorypatients, and therefore anadditionalEMSoffloadnurseisnotnecessary.EMSvolumesforthepast3yearsare:

• 2014-2015:16,077• 2015-2016:16,834• 2016-2017:16,508

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• 2017-2018:YTD9,008(annualizedvolumeestimateof13,512)! ThehospitalstatedthattheybelievetheprojectedreductioninEMStransfersis

due to improvements beingmadeby EMS and partners to reduce emergencytransferstohospitals.

! AcuteArea:Thehospitaldoesnotagreethatadditionalnursesarerequiredtocareforcriticallyillpatients,statingthatinthelastyeartherewere510patientswho were admitted to critical care from the ED, an average of 1.4 per day.Additionally, therehavebeen89critically illpatientswhowere transferredbyCriticallfromtheEDsinceApril1,2017.Basedon89patientsin5months,theestimated annual volume of Criticall patients is 213. Therefore there areapproximately723critically illpatientsayear.This isanaverageof2perday.Thehospitalagreesthatitneedstoimproveaccesstocriticalcarebeds.

! Red Zone: Thehospital does not see a need to keep this area open formorethan12hoursadaybasedonthedecreaseinpatientvolumesduringthenighthours.Thespace isutilizedforadmittedpatientswhentheYellowZone is full,andtheywilluseVNTstafftocareforthepatientsiftheydonothavesufficientEDnursingstaff.

! Fast Track: The hospital states that 98% of fast track patients are dischargedhome,andconcedesthatitfrequentlystaysopenuntil0100or0200,butdoesnot think that there is sufficient patient volume to keep the area open 24/7.AlthoughconscioussedationdoestakeplaceinthisareaandrequiresanRN,theChargeNursethediscretiontodecideonthetimingoftheproceduresbasedonavailabilityofstaffandtheacuityofthepatient.

! Sub-Acute/IWR: The hospital acknowledges the concerns of the nurses, andplanstoreallocateone11.25hournursingshifttotheIWRwhentheRPNsarehiredtoworkintheYellowzone.

! MHWA:OnePENand1 ERRN currently staff theMHWA.Thehospital statedthatthepsychiatryunitiscurrentlystrugglingtostafftheunitwithPENnursesduetochallengesinrecruitmentandretention.Theyhavebeensupplementingthe staffing with VNT staff that has additional training in mental health. ThehospitalstatedthattheybelieveitissaferforpatientcaretohavethemixofaPENandERRN.ThetotalnumberofCodeWhiteintheEDyeartodateis21,12ofwhichwere in theMHWA.Given the current staffing challengeswith PENsandthepreferencetomaintainthe1PEN/1EDRNmodel,thehospitaldoesnotagreewithmovingtoanallPENmodelofcare.

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! YellowZone/AdmittedPatients:TheEDadmitsanaverageof30patientsaday.The hospital monitors the number of admitted patients in the ED and this isreportedatseveraldatapointsduringthe24-hourperiod.ThehospitalprovideddataonadmissionsintheEDat0800forthelastfewmonths(Table3).Table3:AveragenumberofadmittedpatientsintheEDat0800

Timeframe NumberofAdmitsat0800ApriltoJune2017 12AprilYTD 16Last7days 27

• Accesstocriticalcarebeds.

o ThehospitalstatedtheneedtoimproveaccesstocriticalcarebedsfromtheED.o CurrentlytheaveragetimeforanadmittedcriticalcarepatientintheEDis10.03hours,

and24.06hoursatthe90thpercentile.Thegoalistoreducethe90thpercentiletimeto8hours.

o Theaveragetimefromdecisiontoadmittoadmissiontoacriticalcareunit is6hours,and18.13hoursatthe90thpercentile.

o The average time from triage to decision to admit is 4.03 hours and 5.93 at the 90thpercentile.

o The hospital provided the current initiatives to improve access through processimprovements:

! ChangingthecurrentreferralprocesstoremovetheGeneralInternalMedicineconsultbeforeconsultinganintensivist(onlypossibleindayshift)

! Addinganadditionalbedinthemedical/surgicalICUforatotalof14beds! Changingthepracticeofholdingabedopenincaseofacardiacarrest.! HavingtheChargeNursesinEDandICUworktogethertoimprovethetransfer

processbetweenunits.• Accesstoinpatientbeds

o ThehospitalhasseveralinitiativesinprocesstotryandimproveaccesstoinpatientbedsandreducethenumberofadmittedpatientsintheED.

o BedoptimizationatSouthlake:theHospital iscurrentlyrealigningbedsbyrepatriating10-12patientroomscurrentlybeingutilizedasloungesoroffices

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o TheHospital isseekingapprovaltoopenanadditional66bedsbyDecember including30 sub acute beds at the Southlake Residential Care Village and 30 beds at the oldHumberHospitalFinchsite.

o TenhospicebedswillopeninNovember2017.• Modelofcare

o RPNswereintroducedtotheEDin2009inasupportroleintheyellowzone.In2011aprofessionalpractice reviewwas conductedon themodelof care in thehospital. Thegoalsof the reviewwere tomaximize the scopeofpracticeofnursesand to increase“hands-oncareofpatients”.

o In2013,RPNsstartedtoworktofullscopeofpracticeinfasttrackincollaborationwithanRN.

o InMarch2017,aRPNonlymodelinfasttrackwasinitiated.o Thehospital’sview is thataCTAS4-5patient isappropriatelycared forbyaRPN,and

thatRNsareavailableintheadjacentacuteareaforconsultationand/ortransferofcareifnecessary.

o The Professional Practice Department conducted a model of care review over thesummerof2017andsubmittedareportinSeptember2017.Anumberofopportunitieswereidentifiedinthereportincluding:

! Reviewofthechargenurserole.Thecompetingchallengesoftherolemaybelimitingtheabilityorthechargenursetobearesourcetonovicestaff.

! Revising the RN position guide to include Coronary Care II as a preferredrequirement to hire given that performance of a 12 lead EKG is a basiccompetencyforanEDnurse.

! ReviewtheRPNroletoconsiderexpandingtheroleintotheconsult/assessmentarea to provide care to admitted patients as the unit generally hasmedicineadmittedpatients,andtheinpatientunitsutilizeaRN/RPNmodelofcare.9

• PlanstoreduceagencyandovertimebyMarch2018.o The year to date utilization of agency (Apr-Aug) is 2,925 hours and overtime is 4,765

hours.Thisannualizesto18,456hoursor9.5FTEs.o The Hospital is focused on eliminating the use of agency nurses by March 2018,

primarilythroughtherecruitmentofmorenurses.

9NursingModelofCareReviewEmergencyDepartment,SouthlakeRegionalHealthCareProfessionalPracticeDepartment,p.26-27.

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o Thehospitalplanstoreduceunplannedovertimeby50%byMarch31,2019.o Thehospital is also increasing the size of theVNT in an effort to offset overtime and

agency.Trainingincardiac,ER,andintensivecareisbeingoffered.• ReplacementofRNsintheEmergencyDepartmentandsurge

o Thehospital utilizes casual/part time staff, overtime,VNT, and agency to replaceRNsandtorespondtosurge.

o VNTstaffaresupposedtocareforadmittedpatients.• RecruitmentplanforEDRegisteredNurses.

o The ED does not have sufficient baseline staffing (as shownby the number of vacantpositions),resultingintheutilizationofhighlevelsofagency,overtimeandVNT.10

o Turnover isapproximately8%. Inthelastyeartherehavebeenatotalof6departuresfrom the ED: 5 resignations (3 located outside of the geographic area), 1 for familyreasons,1unknown)and1termination.Therewere7transfersoutoftheunit:threetocriticalcare, tworeturnedtotheirpreviousunit,onenewgraduatetookapermanentposition in Medicine, and one took an advanced practice position. There were noretirements.

o TheEDhascreated10additionalRegularPartTime(RPT)positions.o The Hospital has held career fairs and the Manager of the ED has conducted 75

interviews.Thecorporateeffortshaveresultedin45RNsbeinghiredtothehospital,butonlyonetotheED.

o AnincentiveprogramisplannedtoprovideamonetaryrewardifanurseishiredbasedonthereferralofanursealreadyemployedatSouthlake.

o HistoricallythehospitalhasreliedonbeingabletohireexperiencedEDnurses,butarenowunabletohiresufficientexperiencedRNstomeetthestaffingneeds.

o Thehospital hasdevelopedaGraduatedDevelopmentPlan to support the trainingofnoviceEDnurses.Theplanwillprovidenewnurseswiththeorientationandtrainingtofacilitate their successful transition from novice to competent ER RN. The programincludes360hoursoforientationand62hoursofeducation+/-CC2.Todatethereare5FTRNsenrolledinthisprogram.11

10SubmissionsonBehalfofSouthlakeRegionalHealthCentre,Volume1,p.20

11SubmissionsonBehalfofSouthlakeRegionalHealthCentre,Volume1,p.20.

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o Previously, there was an Internship Program to support the training of RNs whotransferredtotheEDfromotherunitsinthehospital,buttheprogramwasnotfoundtobe successful, and most of the nurses eventually transferred back to their previousdepartment.

• OrientationandeducationofRNso TheEDhasafulltimeeducator.o All ED nurses receive 1 paid education day per year. The day focuses on topics the

nurses wish to learn about and any additional training considered necessary by thehospital.Itisofferedoncepermonthexceptduringthesummer.SeventyonepercentoftheEDnurseshaveattendedtheeducationdaythisyear.

o Any training consideredmandatory is paid for by the hospital. e.g. Non Violent CrisisIntervention(NVCI).

o Nurses may also access up to $1,200 per year for other courses from a professionaldevelopmentfund.

• PhysicianNavigatorso Dr. Steven Beatty, Chief of Staff at Southlake Regional Health Centre, addressed the

issueofphysiciannavigatorsduring theSeptember28meeting.Dr.Beatty stated thatwhenthePNrolewasapprovedattheMedicalAdvisoryCommittee,asetofregulationsandaroledescriptionweredeveloped.PNsmustdeclareinwritingthattheywilladhereto the role. In addition, references and a criminal check are conducted. PNs sign aconfidentialityagreement.Dr.Beattystatedthatheisawareoftheconcernsraisedbynurses including PNs functioning outside the role description, and perceived as beingobstructive.HestatedthatheaskedDr.Duic,(PhysicianHeadintheED)toreviewthePNroleandtoensurethattherewasnorolecreeporobstructivebehavioroccurring.

2.4 MeetingsbetweenAssociationandHospitalPriortoIAC

TheHospitalAssociationCommittee(HAC)istheforumwherePWRFsarediscussed.Foraperiodoftimetherewasasub-HACtoaddresstheEDissues,butthiswasdissolvedafterestablishingaLabourManagementCommitteetodiscusspolicyissues;thereforeallowingtheHACtofocusonworkloadissues.TheminutesofHACmeetingsthataddressedERissueswereprovidedtotheIACpanel.Themeetingstookplaceon:

• October4,2016• November1,2016• December6,2016

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• January10,2017• February7,2017:• March7,2017• April4,2017• April18,2017• May2,2017• June6,2017• June20,2017

ByFebruary2017,anactiontrackerdocumentfortheEDhadbeendevelopedandthisformedthebasisforfurtherdiscussionregardingissuesandresolutionsatsubsequentmeetings.IntheminutesoftheApril18,2017meeting,itwasnotedthatoneightofthesixteenissuesrelatedtotheED,thepartieshadeitherreachedagreement,hadaworkinprogressortherewereopportunitiesforjointrecommendationsandcollaboration.12IntheminutesoftheJune6,2017meeting,itwasnotedthattheAssociationhadinformedtheHospitalthattheworkloadissuesintheEDwerebeingreferredtoanIndependentAssessmentCommittee.InthemeetingtheHospitalcommentedthatitwouldbehelpfulfortheHospitaltohavea“clearerpictureofwhichitemshavegonetosettlementandwhichwouldproceedtotheIAC.’13InthemeetingONAagreedtocreateaseparatedocumenttoclearlyidentifytheitemsinAgreement.IntheJune20,2017meetinga“comprehensive,collaborativediscussionregardingeachitemintheEDActionTemplatedocumentoccurred.Strategies,datesandtimelinesaredocumentedintheEDActiontemplateasattached.”ItwasfurtherstatedintheJune20minutesthattheAssociationandtheHospitalwouldmeettoupdatethedocumentaccordinglyandbringitforwardforreviewandapprovalatthenextmeeting.14TheHospitalwasalsoaskedabouttheirinterestinmediation.13TheHospitaldeclinedmediation.

12HospitalAssociationCommittee(HAC)Minutes,April18,2017.DataRequestsfromtheIAC,Tab6.

13HospitalAssociationCommittee(HAC)Minutes,June6,2016,DataRequestsfromtheIAC,Tab6.

14AllminutesweremarkedasApprovedwiththeexceptionoftheminutesfromJune6and20,2017.

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3 Discussion,AnalysisandRecommendations

FiveissuesthatimpactonnursingworkloadintheEmergencyDepartmentwereidentifiedbytheIAC.Theissuesare:

1. BaseRegisteredNurseStaffingintheED2. RecruitmentandRetention3. NurseStaffinginSpecificAreasoftheED4. PhysicianNavigators5. PhysicalEnvironment

3.1 BaseRegisteredNurseStaffingintheEDAdequatenursestaffingisanessentialcomponenttoensurepatientsafetyandqualityofcare.Ongoingevaluationofnursestaffingandoutcomesrelatedtopatientsafetyandqualityisessential.Thecurrentbasenumberofpositionsis131(91FT,21RPTofwhich9arecurrentlyvacant,and19casual),designedtomeetaneedfor38shiftsperday.Thecurrentheadcountofnursesis115.TheutilizationofnursestaffinginthelasttwoyearsisasperTable4.15

Table4:RNUtilization

2016-2017 2017-2018YTDJuly 2017-2018Annualized

Hours FTEs Hours FTEs FTE

Fulltime 152,264 78.08 59,714 30.62 91.86

RegularParttime

29,754 15.26 9,576 4.91 14.73

Casual 11,421 5.85 1,135 0.58 1.75

Agency 7,557 3.87 2,295 1.17 3.53

Total 200,996 103.07 72,720 37.29 111.87

15TotalPaidHoursinFTESforFullTime,PartTime,Casual,AgencyRNsforYTD17/18,IACDataRequest,Item3b

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• Thereisexcessiveuseofovertimeshiftstofillstaffingrequirements.Theuseofovertimehasincreasedeveryyearsince2015(Table5).

Table5:OvertimeUtilization2015-2017

Year OvertimeHours FTEequivalent

2015 6,382 3.3

2016 10,508 5.4

2017YTD 13,671 7.0

• VNTstaffUtilizationforApriltoAugust2017,is3,659.08hours.Thiswouldannualizeto8,781hours

or4.5FTEsoranaverageof2.1VNTshiftsperdayintheED.

• Sicktimehasalsoincreasedoverthesametimeperiod(Table6)

Table6:SickTimeUtilization2015-2017

Year SicktimeHours FTEEquivalent

2015 7,109 3.6

2016 10,910 5.6

2017YTD 11,513 5.9

• TheHospitalprovideddataonweeklystaffingfortheperiodsofJanuary1toApril12017,andJune

25toSeptember232017.Thesummariesprovideadailybreakdownonthenumberofshiftsofvacation,vacanciesonthepostedschedule,sicktime,emergencyLOA,noshows,regulartimerelief,VNT,overtime,agency,andactualstaffing.Althoughtheplannedstaffingisnow38RNshiftsperday(itwas36duringtheJan-Apriltimeperiod),thereweremanydayswhentheunitstaffingexceededthisnumber.Presumablytheadditionalstaffwasinresponsetopatientvolumes,patientacuityandorsurgerequirements,astherewasconsistentsicktime,vacation,andEMLOAsthroughouttheperiodthatwouldnothavebeenifpatientcaredemandswerenotanissue.

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• DuringtheJan-Aprilperiodwhenthebaselinestaffingwas36,theaverageactualstaffingonmostweekswas37-40,andoneweekwas43.

• DuringtheJunetoSeptemberperiod,whenthebaselinestaffingwas38,theaveragewas39-40,withoneweekat37,andoneweekat43.

• DuringtheperiodofJanuarytoApril,therewere38dayswhentherewasavacancyontheschedule,andatotal122shifts.

• DuringtheperiodofJunetoSeptember,therewere60dayswhentherewasavacancyontheschedule,andatotalof269shifts.

• Throughoutbothtimeperiods,therewasconsistentuseofVNT,overtimeandagencytoreplaceshifts,andduringthesummermonths,torespondtoworkloadincrease.DuringtheJunetoSeptemberperiod,therewere75daysand187shiftswhenadditionalstaffwasutilizedtorespondtoworkloadincreases.

Basedonthecurrentstaffingof38shiftsaday,theunitrequiresaminimumofapproximately100FTEs(assumingreplacementof20daysofvacation,12statutoryholidaysand7sickdays).Thesicktimethatexceeds7daysayear/FTE,andthereareadditionalreplacementrequirementsforpaideducationtime,otherreplacementsneeds(e.g.longtermillness)andtheconstantneedtosurge.ThereareaninsufficientnumberofnursesemployedintheEDatSouthlakeRegionalHealthCentretoensuretheunitisstaffedonaregularbasiswithEDnurses.ThereisanimmediateneedtostabilizethenursestaffingintheED,particularlyinlightoftheconstantlyincreasingpatientvolumes,workloadlevels,andexcessiverelianceonovertime,agencyandVNT.

3.2 RecruitmentandRetention

TheEDhashistoricallybeenabletorecruitexperiencedEDnurses,butisnowexperiencingsignificantchallenges.Theunithashadlimitedexperienceinhiring,orientingandretainingnewgraduatesandornurseswhoarenotEDtrained.TheunithasbeenunsuccessfulinretainingnurseswhotransferfromotherunitstotheED.AccordingtothedataprovidedtotheIAC,thereareonlyTemporaryFullTime(TFT)andRegularPartTime(RPT)positionsposted.16GiventhecompetitivelabourmarketthattheHospitalnowfindsitselfin,itwouldseemprudenttooffermorepermanentfulltimepositionsrather

16NumberandTypeofNursePositionsPostedintheCurrentYear,IACDataRequest,Item3d.

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thanparttimeortemporary.Theriskofthisstrategyislowgiventheconstantgrowthinvolumeandtheregularturnoverthatisnormalinanyunit.Staffnursesarenotcurrentlyengagedinrecruitmentefforts.

ThehospitalrecognizesthatanewrecruitmentandretentionapproachisnecessaryandhastakenstepstoincreaserecruitmenteffortsandbydesigninganeworientationprogramtosupportthehiringofnurseswithoutEDexperience.GiventhattheunithashistoricallyhiredfewnoviceEDnurses,itisadvisedthatthosewhowillbepreceptors/mentorshaveeducationineffectivementoringandcoachingpractices.Theengagementoftheseniorstaffinretainingnewhireswillbecritical.Bothmanagementandstaffneedtocommitthemselvestocollaboratingonthisimportanttask.

3.3 NurseStaffinginVariousAreasoftheEmergencyDepartment

HospitalDataonERFunctioningandPatientVolumes/AcuityThehospitalhasdataontheusualEDmeasuressuchasvolume,acuity,admissions,qualityoutcomesandsoforth.Acorporatedashboardofkeyindicatorsissentoutseveraltimesaday,butnotablynotatnight.ItwastheobservationoftheIACpanel,thatwhilemanagementhasaccesstoconsiderabledatatoassistindecisionmaking,itlacksinformationoninformationtomeasuretheimpactonnursingworkloadintheEDparticularlyduringthenightperiod,suchasthevolumeofpatientsinspecificareasandhowlongsomeareasareopenpastplannedclosuretimes.Inaddition,theredidnotseemtobedatacollectedonimportantaspectsofnursingworkloadsuchasnumbersoftransfersofcarebetweenRPNsandRNs,numberoftimesthereareconcurrentcriticallyillpatientsrequiringcare,timespentonmovingpatientsfromoneareatoanothertoprovidecare,averageadmitsduringthenight,orhowoftenRNsarebeingreassignedfromoneareatoanothertorespondtocareneeds.NurseSchedulingNursesarescheduledtostartshiftsat0730,1100,or1930.Therearethreeshiftswithotherstarttimes,oneat0900intriage,oneat1000insub-acute,andoneat1400thatisasplitshiftbetweenfloatingandsub-acute.TheRPNsstartat1000and1100infasttrack.Thepurposeoftheeveningshiftstartingat1100istoensureadequaterelieffordayandeveningstaffforbreaks,aswellastomatchstaffingtothepatientvolumethroughoutthe24-hourperiod;however,thismeansthatthestaffingislowestduringthenightperiodof2300-0730.TherewasfrequentmentioninthePWRFsandintheIACmeetingofthelateclosureproblemsinfasttrackandredzoneduringtheperiodof2300-0200,plusthebuildupofadmittedpatientsinthedepartment.Thereforeconsiderationmightbegiventowhetherthestarttimesonsomeeveningshiftsshouldbelaterthan1130,andwhetherthereissufficientnightstaffing.

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Triage/EMSOffloadTheEmergencyDepartmentisexpectingtosee120,000patientsthisyear.Thisisanaverageof328patientsadaywhomustbetriagedbyanurse.Thepatternofregistrantsbyhoursshowsthatthenumberofpatientsarrivingislowestaftermidnight,andclimbsquicklystartingat0900andremainssteadyuntil2100,beforedroppingagainduringthenightperiod.Thispatternisconsistentoverthelast3years.17BasedonthispatternthetriageandEMSstaffingisstaggeredtopeakduringtheafternoonandeveninghours,leavingonenursetotriagebetween0730-0900,andfrom2300-0730.Oneshiftisdesignatedto“pre-triage”,butinrealitytheshiftisusuallyallocatedtotriage.ThereisalsoamorningreductioninstaffingintheEMStriage/offload,oftenrequiringtheChargeNursetocoverinthisarea,asthelonetriagenursecannoteffectivelycoverbothareas.Duringthelatterpartoftheeveningshift,therecanbeupto6nursesbetweenthetwoareas.RecentdatawouldindicatethattheremightbeasignificantdecreaseinEMSvolumeinthecurrentyear.Thetimetotriageapatientisminimally5minutes,andcancertainlytakelongergivenanycomplexities,communicationchallenges,interruptionsandsoforth.Thereforeitcanbeestimatedthattheminimalamountoftriagetimefornursesbasedon120,000patientsis600,000minutesor10,000hoursayearoranaverageof27.39hoursperday.Giventhatnursesreceive90minutesofpaidandunpaidbreak,theavailabledirectnursingtimeforcareis10.5hoursper12-hourshift.Thereforetheavailabletriagenursingtimeonanygivendayis4shiftsx10.5hoursor42hours.Thereforeitwouldseemthatthepressurepointsthestaffareexperiencingintriage/EMSoffloadmaybemorerelatedtothedistributionofstaffover24hours,ratherthantheabsolutenumberofstaffassignedonadailybasistothearea.Thismaybecompoundedbythefactthattheoverallnumberofstaffislowestduringthe2300-0730period,whichresultsinreducedcapacitytorespondtosurgesinworkloaddemandinthevariousareasoftheEDbyreassignmentofstaff.However,giventhesteadyannualincreaseinpatientvolume,anddespiteaprojecteddecreaseinEMSvolume,itistheopinionoftheIACthatthisareawillrequireclosemonitoringregardingnurseworkloadoverthenextyeartodeterminewhenadditionaltriageRNresourcesshouldbeadded.

17YearoveryearRegistrationsbyHourofDayandDayofWeek(Year14/15,15/16,16/17,DataRequestsfromIACPanel,Item1a.

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FastTrackStartinginMarch2017,themodelofcareinthefasttrackareawaschangedtobeRPNonly.AttheIAC,thenursesidentifiedthattheutilizationofanRPNmodelinfasttrackwastheirbiggestconcern.ThehospitalissupportingtheautonomousfunctioningofRPNsinthisarea,supportedbyRNswhoworkintheadjacentsub-acutearea.Butitshouldalsobenotedthattherewasonly1PWRFthatdirectlystatedaconcernoverRPNstaffing.OtherPRWFssubmittedfromthesub-acuteareadidspeaktothefasttracknotclosingontime,conscioussedationneeds,orthemovementofpatientsfromfasttracktosub-acute.Theonlyformalevaluationofthismodelchangewastheprofessionalpracticereviewcompletedoverthesummer,whichexaminedselecteddata/informationonunitfunctioning,staffinterviews,and16hoursofjobshadowing.Datacollectedandassessedaspartofthereviewincluded:

• Unitprofileassessmenttool(adaptedforpopulation)• Reviewofdailyaccessreportingtool(DART)• Reviewofpositionguides• Reviewofpatientoutcomedataincludingincidentreportsandpatientsatisfaction• Reviewofdailystaffingcomplement• Reviewofovertime/agencyusedata• Humanresourcedatavacancy/positing/demographics

GiventherecentestablishmentofanallRPNmodelinthearea,andthelevelofconcernbyRNsaboutthecurrentutilizationofRPNsinthearea,itisadvisedthatamoreindepthevaluationofthepracticeofRPNsandRNsinthefasttrack/sub-acuteareabeconducted.WhileRPNscanfunctionautonomously,theydonotfunctioninisolation.TheCollegeofNursesofOntarioPracticeGuidelineonRNandRPNPractice:theClient,theNurseandtheEnvironment18utilizesthreefactors(theclient,theenvironmentandthenurse)toguidedecisionmakingoncare-providerassignmentsandtheneedforconsultationandcollaboration.EffectiveandtimelyconsultationandcollaborationbetweenRNsandRPNsisessentialintheprovisionofsafecare.RNsmustcareforthosepatientswhoarelessstable,lesspredictableandathigherriskofnegativeoutcomes.TheRNsviewtheRPNsastheircolleaguesandunderstandtheirprofessionalaccountabilityandresponsibilitytosupporttheRPNSthroughconsultation,collaborationand/ortransferof

18CollegeofNursesofOntario.RNandRPNPractice:theClient,theNurseandtheEnvironment,2014

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accountability.ThiswasdescribedbytheRNsaschallenginggiventhehighvolumeofpatientsbeingseeninboththefasttrackandsub-acuteareas,andthefactthatconscioussedationcanoccurinthefasttrackareathatrequiresthepresenceofanRN.ThepracticeofconscioussedationinanareaonlystaffedbyRPNsnecessitatesthatanRNprovidecare.TheHospitalshouldevaluatethecurrentpracticeofconductingconscioussedationinfasttrackwithregardtopatientsafetyandnursingworkload,andwhetheritisfeasible/desirabletoonlyperformconscioussedationinareasnormallystaffedbyRNs.

BasedondiscussionattheIAC,itwasclearthattheRPNsdoconsultRNs,buttherehasbeennoevaluationofthedegree/frequencyofconsultation/collaborationormonitoringoftransferofaccountability.WhiletheProfessionalPracticeReviewdidexaminethefasttrackarea,itwasnotafulsomeevaluationofRPN/RNfunctioningsincethemajorchangeinmodelofcare.

Inaddition,itwasreportedinthePWRFsandacknowledgedbythehospitalthatthefasttrackareafrequentlydoesnotcloseontimeat2300,necessitatingthatanRN(s)takeoverthecareofthesepatientsinadditiontoher/hiscurrentpatientassignment(s).

Sub-AcuteArea

Thesub-acuteareaisaverybusyareaoftheEDandisfrequentlycongestedwithpatientsandfamilymembers.DuringtheIAC,thenurseswereaskediftherewasone‘missioncritical’areawheretheywouldincreasestaffing,theresponsewassub-acute.ThehospitalhascommittedtoaddingoneadditionalshifttotheIWR,assoonastheRPNsarehiredtoworkintheYellowZone.Thenursesinthesub-acuteareaarealsotheclosestsupporttofasttrack,andthereforearethemostlikelytobeconsultedandtoassistwithanyadditionalcarerequirementsinthisarea.Theefficientfunctioningofthesub-acuteareaiscriticaltomaintainflowinthisEDforthelessacute/ambulatorypopulationofpatients.ThecurrentcomplementofstaffdoesnotallowfortheeffectivemanagementofpatientsintheIWR,thereassessmentarea,andpod27.

YellowZone

Theyellowzonecensushasbeenconsistentlyat14patientsforsometime,requiringadditionalnursingstaff.ThehospitalplanstointroduceoneRPNshiftaroundtheclockinthenearfuture,tomeetthecurrentstaffingrequirementsof3nursespershift.Thiswillbeanadditionalshiftabovethecurrentallocationof2nursesondaysandnights.One12-hourRNshiftistobereallocatedtothesub-acutearea.GiventhattheYellowZonehasprimarilyadmittedpatients,theHospitalshouldconsiderwhetherinpatientmedicaland/orsurgicalunitscouldstaffthisarearatherthanutilizingEDnurses.

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AcuteArea

Themainpressurepointintheacuteareaistheunpredictablecareneedsofcriticallyillpatientsanddelaysinthedispositionofcriticallyillpatientstoaninpatientarea.Othercriticalcarenursingresourcesinthehospital,suchastheCCRT,arenotcalledupontoassistwithcare.ThehospitalismakingconsiderableeffortstoimproveaccesstocriticalcarebedsandtoreducetheLOSintheER.TherelationshipbetweenthenursesintheEDandnursesincriticalcareislessthanideal,andthereislittleevidentcollaboration.Whilemanagementcanimproveaccessandpoliciesofcare,onlythestaffnursescanimprovethecurrentworkingrelationships.

MentalHealthWellnessArea

ThehospitalstatedthattheybelievethemodelofonePENandoneEDRNisoptimalgiventhepatientpopulationandtheirviewthatthereareoccasionswhentheknowledgeandskilloftheEDRNisimportantbecausechangesinthepatient’snon-mentalhealthstatus.ItwasnotcleartotheIACwhethertheERnurses,despitethedirectionfrommanagementtodoso,consistentlyfollowtheinclusion/exclusioncriteriabecauseofvolumepressuresthroughoutthedepartment.ManagementisalsoconcernedaboutthechallengesthepsychiatryunitiscurrentlyhavinginrecruitingandretainingPENs.However,itistheviewoftheIACthatmovingtoanallPENmodelwouldbeoptimal,giventhecapacityofthepsychiatryunittoimproverecruitmentandretention.ThiswouldfreeuptheEDRNscurrentlyassignedtoworkinthisarea,tomovebackintothepoolofnursesfortherestoftheED(butnottoincreasedailystaffing).

OverallEDStaffingBeyondtheincrementalstaffingrecommendedinspecificareas,theIACseriouslyconsideredwhetheranadditionalshiftshouldbeaddedinordertorespondtowhicheverareamightbeexperiencinganincreaseinpatientvolumeand/orworkload.IftheplannedmeasurestoincreaseflowtoinpatientbedsdonotsignificantlydecreasethevolumeofadmittedpatientsintheEDwithin6months,thentheHospitalneedstoensuresufficientstaffingforpatientvolumesandmaintainanappropriateratioofadmittedpatientstonurse.(i.e.fivetoone).

3.4 PhysicianNavigatorsTherewereasmallnumberofPWRFsrelatedtotheissuesofphysiciannavigators.ThenurseshaveidentifiedconcernsthatsomePNsarefunctioningoutsidetheirroledescription,aswellasconcernsaboutcommunicationchallengesbetweenPNs,RNsandphysiciansregardingpatientcareissues.TheviewoftheIACisthatissuesregardingPNsarenotsomuchaworkloadissue;butareratherissuesof

39

roleclarityandcommunication.WhiletherehavebeenevaluationsofthepositiveimpactofthePNonphysicianefficiency19,itwasnotedthatnoneofthe3studiesevaluatedtheimpactontheefficiencyorworkloadofotherteamprofessionalssuchasRNs.Managementseemstofunctionasthe‘go-between’betweenphysiciansandnurseswhenissuesareraised.WhileitwasimportantfortheChiefofStafftocometotheIACtodirectlyaddressPNissues,itwouldseemthatmoredirectcommunicationandcollaborationbetweennurse,physiciansandPNsattheunitlevelarenecessary.

3.5 PhysicalEnvironment

TheEDiscurrentlyprovidingcareto120,000patientsayear(andtheirfamilies/careproviders)inaspacedesignedfor70,000.Themultidisciplinarystaffistobecomplimentedontheexcellentqualityofcarebeingprovidedtopatientsinthisconstrainedenvironment.Whilealongtermredevelopmentplanisunderway,theEDismanyyearsawayfromhavingasignificantlargerspacesuitedtothecurrentvolumes.Thereforeanyintermediateopportunitiestoexpandclinicalspaceareessential.

19Leung,A.K,Puri,G.,Chen,BE,Gong,Z.,Chan,E.,Feng,E.&Duic,M.(2017).ImpactofphysiciannavigatorsonproductivityindicatorsintheED.EmergMed,(0),1-7.

Whatley,S.D.,Leung,A.K.&Duic,M.(2016).Processimprovementstoreformpatientflowintheemergencydepartment.HealthcareQuarterly,19(1),29-35.

Leung,A.K.,Whatley,S.D,Gao,D.&Duic,M.(2017).Impactofprocessimprovementsonmeasuresofemergencydepartmentefficiency.CanadianJournalofEmergencyMedicine,19(2),96-105.

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4 Recommendations

TheIndependentAssessmentCommitteemakesthefollowingrecommendationsregardingworkloadissuesintheEmergencyDepartmentatSouthlakeRegionalHealthCentre.

RelatedtoBaselineStaffingandScheduling1. Createaminimumoffive(5)permanentfulltimepositionsinordertoincreasetheunit’scapacityto

effectivelyrespondtoreliefrequirementsandanyincreasedworkload,andtherebydecreasingthedependencyonagency,overtimeandVNT.Thisaugmentationinpositionsisnotmeanttoincreasethedailyminimumcomplement(currentlysetat38),buttoprovidealargerpoolofnursestomeetthedailyminimumstaffing.

2. ContinuetheeffortstoreduceovertimeandagencythroughhiringadditionalEDstaff,ensuringthatthedepartmentisprimarilystaffedbyEDNurses.

RelatedtoRecruitmentandRetention3. Increasethenumberofpermanentfulltimepositionsratherthantryingtohiretemporary,

permanentparttimeorcasualpositions.4. Engagethenursingstaffinrecruitmenteffortssuchasattendingthejobfairswithmanagementand

interviewingcandidates.5. Establishamentorshipprogramandoffereducationtothenursesinpreceptorship/mentorshipin

ordertosupporttheirimportantroleinteachingandsupportingnovicenursesinthedepartment.RelatedtoNurseStaffing6. Reviewthecurrentstaggeringofeveningshiftsandconsiderwhethermoreshiftsshouldstartafter

1100inordertoincreasenursingstaffduringthe2300-0200timeperiod.e.g.aneveningshiftfrom1500-0300.

7. IftheplannedmeasurestoincreaseflowtoinpatientbedsdonotsignificantlydecreasethevolumeofadmittedpatientsintheEDwithin6months,thentheHospitalneedstoensuresufficientstaffingforpatientvolumesandmaintainanappropriateratioofadmittedpatientstonurse.(i.e.fivetoone).IntheTriage/EMSOffloadarea:

8. Ifthefunctionofpre-triageisdesired,considerwhetheranon-healthcarepersoncouldconducttheinfectioncontrolscreeninginthewaitingroom.

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9. RealigntheshiftsintriageandEMSoffloadtothreeondays,3onnights,and1onevenings(1000-2200or1100-2300)toprovidemoreevencoverageacrossthe24-hourperiod.

10. Giventhesteadyannualincreaseinpatientvolume,theHospitalmustcloselymonitorconditionsforwhenanadditionaltriageRNresourcesshouldbeaddedtodailystaffing.

IntheFasttrackarea:

11. HaveanindependentevaluationoftheRPNS/RNmodelofcareinfasttrack/sub-acuteconductedwithin6monthstoevaluatewhetherthecurrentRPNonlymodelisadequatetomeetpatientneeds.Theevaluationtominimallyinclude:

a. WhetherRPNsarefunctioningwithintheirscopeofpracticeandconsistentwiththe3-factorframework.

b. HowoftenRNsareconsultedbyRPNsandifthereareanytimeswhentheyshouldhavebeenbutwerenot.

c. NumberofoccasionsoftransferofcarefromRNtoRPNorviceversa.d. Numberofoccasionsthatapatientassignedbytriagetofasttrackisfoundonfurther

assessmentnottobeappropriateforthisarea.e. Numberofconscioussedationsbeingconducted.

12. Evaluatethefrequencyofthefollowingissuesinfasttrackbymeasuringoccurrenceonadailybasisforaminimumofonemonth:

a. Howoftenfasttrackremainsopenpasttheplannedclosuretimeof2300.b. Ifitremainsopen,thenwhotakesovercareofthepatientsandforwhatperiodoftime.

Howmanypatientsarestillinfasttrackatclosingtime.Dotheyremaininfasttrackoraretheymovedtoanotherareafortheirremainingcare.

c. Howoftenisconscioussedationperformedinthearea,andwheredoestheRNcomesfromtoprovidecare,andforhowlong.

13. Evaluatethecurrentpracticeofconductingconscioussedationinthisareaintermsofpatientsafetyandnursingworkloadandwhetheritisfeasible/desirabletoonlyperformconscioussedationinotherareasnormallystaffedbyRNs.

14. AttheendoftheperiodofevaluationandtheindependentreviewwhetherthereshouldbeaRPNmodelatall,orwhetherreturningtoaRN/RPNmodelinfasttrackiswarranted.

15. Keepthefasttrackopenfrom2300-0300andaddanadditional4hoursofstaffingtothedailycomplement.

16. Continuewithcurrentoperationalplanstofindalternativecareoptionsforpatientsreturningforissuessuchasdiagnosticimagingandintravenousmedications.

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IntheSub-Acutearea:17. Inadditiontothe11.25hourstobere-allocatedfromtheYellowZone,itisrecommendedtoadd

another11.25hoursofRNcare(foratotalof22.5hours)toprovideforthecarerequirementsintheSub-AcuteareaandensuringcoverageforIWR.

IntheYellowzone:

18. TheIACsupportstheadditionofanRPNshifttothisarea24/7,andthereallocationofone11.25hourRNshifttothesub-acutearea.

19. ThechangetoRN/RPNstaffingmixintheareashouldbeevaluatedusingthe3-factorframeworkwithina6-monthtimeframetoevaluatewhetherRPNsarefunctioningeffectivelyinthisareaandbeingassignedappropriatepatients.

20. WhenthechangeismadetoanRN/RPNmodelintheYellowZone,ensurethatreplacementofRNsisbyRNs,andRPNsbyRPNs.

21. GiventhattheYellowZonehasprimarilyadmittedpatients,theHospitalshouldconsiderwhetherinpatientmedicaland/orsurgicalunitscouldstaffthisarearatherthanutilizingEDnurses.

IntheAcuteArea:

22. TheIACsupportseffortstoincreaseaccesstocriticalcarebedsbyopeningofa14thICUbed,processimprovementsinmedical/intensivistconsultation,andeliminatingthecodebedhold.

23. Implementasolutiontoresolvethesurgerequirementsfor1:1careissuesthroughoptionssuchas:a. IfthepatientistobeadmittedtoaSouthlakeintensivecarearea,additionalcriticalcare

staffsupportsaresenttotheERtomanagethesepatientssuchastheCCRToracriticalcarenurseifsufficientresourcesarenotavailableintheER.

b. Considerestablishinganon-callsystemintheEDforcriticalcaresurgerequirements.

IntheMentalHealthandWellnessArea:24. EstablishaPENonlynursingmodelintheMHWA.RelatedtoPhysicianNavigators25. Conductaprospectiveauditonphysiciannavigatorfunctioningtoevaluatewhethertheyare

consistentlyfunctioningwithintheirroledescription.26. ImmediatelyestablishatimelimitedworkingcommitteebetweenRNs,PNsandphysicianstowork

onimprovingcommunicationandcollaboration.

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RelatedtothePhysicalEnvironment27. AnyadministrativespacewithinorcontiguoustotheEDshouldbeconvertedtoadditionalclinical

space.28. ConductaLEANeventontheEDUnitfocusingonamount,type,utility,storageofequipmentand

supplies,inordertostandardizesuchmaterials,inordertoreducecongestion,clutterandunnecessarymaterials.

5. Conclusion

ThisreportcontainstheIndependentAssessmentCommittee’sfindingsandrecommendationsregardingProfessionalWorkloadComplaintsubmittedbyNursesfromtheEmergencyDepartmentatSouthlakeRegionalHealthCentre.TheprocessundertakenthroughanIndependentAssessmentCommitteeprovidesauniqueopportunityfordiscussionanddialoguebetweenallthepartiesregardingthecomplexissuesandconditionsthatunderlieaProfessionalWorkloadComplaint.TheCommitteehasmade28recommendationsinfiveareasregardingissuesthatimpacttheworkloadofRegisteredNurses.TheMembersoftheIndependentAssessmentCommitteeunanimouslysupportallrecommendationsinthisreport.TheCommitteehopesthattherecommendationswillassisttheHospitalandtheAssociationtofindmutuallyagreeableresolutionswithregardtonursingworkloadissuesintheEmergencyDepartment.

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Appendix1:LetterfromtheAssociationMay2,2017.

45

Annette Jones/May 2, 2017 Page 2Professional Practice and Workload Issues at the Southlake Regional Health Centre ED

Please provide written confirmation concerning the name, mailing address, home or cell and officephone number, fax number and e-mail address of your nominee

I have contacted David McCoy of Ontario Hospital Association to determine the next IAC Chairrotation in accordance with Appendix 2 will be Leslie Vincent. I will confirm with Ms. Vincent thatshe is available to Chair this hearing and will document this by a separate letter to her.

The parties have collaborated and attained resolutions to address some of the practice andworkload issues in the ED. The Union is open to continue to work with the Hospital to furtherresolve the outstanding issues and believe that many dollars spent on the IAC could be betterutilized to improve the practice and workplace environment for our members and patients.

Sincerely,

ONTARIO NURSES’ ASSOCIATION

jlA4 £gwSusie BlairProfessional Practice Specialist

C: DJ Sanderson LCIBUPSilvanna Petersen Servicing LRODr. Dave Williams President and CEO, Southlake Regional Health CentreLinda Haslam-Stroud ONA PresidentVicki Mckenna ONA Vice-PresidentAndy Summers ONA Regional VP

46

Appendix2:LetterfromHospitaltoAssociationMay30,2017

47

48

Appendix3:ConfirmationofInvitationtoChair

M Ontario Nurses’ Association85 Grenville Street, Suite 400, Toronto1 Ontario M55 3A2

TEL: (416)g64-8833 FAX: (416)964-8864www.ona.org

June 112017

Leslie Vincent716 Windermere Ave.Toronto, ON, M6S 3M1

Dear Leslie Vincent,

Re: Southiake Emergency IAC Hearing - Confirmation of Invitation to Chair

Thank you for accepting the nomination to chair an Independent Assessment Committee (IAC)investigating a Professional Responsibility Complaint in the Emergency Department atSouthlake Regional Heath Centre. I have consulted with Mr. David McCoy, at the OntarioHospital Association and both parties have agreed to you chairing this IAC..

In order to move forward on resoMng workload issues DNA is requesting that a date be set foran IAC investigation and hearing. ONA remains committed to working with the Employer untilsuch time as a date is set for the AC. The contact details for DNA’s nominee are as follows:

Cynthia Gabrielli6285 McMicking Street Niagara Falls, ON L2J 1W7Tel: 905-357-6276 (home) Tel: 905-329-3597 (cell)Email: cgabrieIIicogeco .ca

Please feel free to contact our Nominee directly for dates in proceeding. Furthermore, shouldyou have any additional questions please do not hesitate to contact me by telephone or email.

Sincerely,

ONTARIO NURSES’ ASSOCIATION

J_tt€2-i__} &tWS

Susan BlairProfessional Practice Specialist

C: Linda Haslam-Stroud, RN, President, ONAVicki McKenna, RN, First Vice-President, DNAAndy Summers, RN, Region 3 Vice President, DNADJ Sanderson, DNA Local Coordinator and Bargaining Unit President, DNATodd Davis, Labour Relations Officer, ONAAthena Brown, Manager, ONACynthia Gabrielli, ONA nomineeDr. Dave Williams, President and CEO, Southlake Regional Health CentreAnnette Jones, Chief Nursing Officer, Southlake General Hospital

Provincial Office: TorontoRegional Offices: Ottawa Hamilton . Kingston LondonOrillia Sudbury . Thunder Bay .Timmins Windsor

49

Appendix4:InformationRequest

1. PatientInformation(forpast2fiscalyears)a. Volumes;byyear,dayofweekandbyhourofdayb. DistributionbyCTASlevel;byyear,bydayofweekc. Ambulancevolumesandoffloadtimesd. AdmissionsbyCTASlevel(includingadmissionrate)e. NumberofAdmitswithnobed,byhourofdayf. Performanceindicatorsg. EDLOSbydayofweek

2. UnitOrganization/Functioning

a. Organizationalchartfornursinginemergencydepartmentb. DescriptionofhowERisorganized;zonesandfunctions.c. JobdescriptionsforRegisteredNurse,TeamLeader/ChargeNurseandTriageNursed. CopyoftypicalchartformatforEmergencyDepartmente. Chartingguidelinesand/orpoliciesforEDf. Policiesregardinggridlock/overcapacityintheERandactionstobetakenif

volumes/admissionsexceedscapacity;includinganyprocedures/policiesregardingcallinginadditionalstaffbecauseofhighvolumes/admissions

g. ChangesorinitiativesthathaveimpactedERinlasttwoyears:i. Externalissuesthatimpactpatientflow/volumesinERii. Majorprocesschanges,modelofcarechanges,technologyimplementations,special

projectsinER

3. Staffingdata(for2016-2017and2017-2018)

a. BudgetedFTEsforallstaffcategoriesintheERb. TotalpaidhoursinFTEsforfulltime,parttime,casual,agencyRNs(YTDfor17/18)c. NumberofFT,PT,CasualRNs(i.e.headcount)d. NumberandtypeofRNpositionspostedinthecurrentfiscalyear;e. Sicktime,overtimeinFTEsforRNs(YTD);andacomparisonforthelast3yearsf. CurrentvacanciesforRNs;g. TurnoverrateRNs;h. Experienceprofile-AverageyearsofexperienceinER;numberofjuniorstaff(lessthan2

yearsexperience)i. Numberofnursingstaffonmodifiedwork;orhavepermanentaccommodationsj. Copyoflocalcollectiveagreement;k. MasterSchedule;copyoflasttwopostedschedules;copyofadailyassignmentsheet

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l. AllocationofAlliedHealthbydisciplinetoER(Physiotherapy,OccupationalTherapy,SocialWork,ClinicalNutrition,Pharmacists,PhysicianAssistants.

m. NumberofEducators,AdvancedPracticeNurses,NursePractitionerswhoworkinERn. IfutilizedforER:sizeandutilizationoforganizationalfloatpool

4. BudgetandPerformanceIndicators(forlast3years)

a. TotalplannedandexpendedbudgetforER–labour,suppliesetc.b. PFRperformanceandallocationforERc. P4Rindicatorsandresults

5. QualityofCare/PerformanceIndicators

a. Patientsatisfactionresultsforlasttwofiscalyearsb. NumberoftypeofcriticalincidentsinERforlasttwofiscalyearsc. Resultsoftriageauditsforlastyeard. Programqualityminutesorprogramminutesrelatedtostaffingandchangeprocesse. Reportsonanyotherindicatorsbeingutilizedtoevaluateefficiencyandeffectivenessofthe

ER.

6. HACagendasandminutesfrom2016,2017andanyotheragendas/minutesofmeetingsregardingworkloadcomplaintsinER

7. Staffmeetingminutesforthelastyear

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Appendix5:AgendaforIAC

Agenda

ParkInnbyRadisson555CochraneDrive,Markham,ON,L3R8E3

Wednesday,September27,201

Time Item Participants

08:30–11:00 TourofEmergencyDepartment IAC, SRHC and

ONA

11:00—13:00 TransittoParkInn,LunchandIACPanelMeeting IAC

13:00—13:15 IntroductionandReviewofProceedingsbyChairperson IACChair

13:00—14:30 OntarioNurses’AssociationSubmissionPresentation

Responsetoquestionsofclarificationfrom:• IndependentAssessmentCommittee• SouthlakeRegionalHealthCentre

IAC, SHRC and

ONA

14:30—14:45 Break All

15:15—16:45 SouthlakeRegionalHealthCentre

SubmissionPresentation

Responsetoquestionsofclarificationfrom• IndependentAssessmentCommittee• OntarioNurses’Association

IAC, SRHC and

ONA

16:45—17:00 ReviewofProcessforThursday,September28,2017

IACChair

17:00 AdjournmentofHearing

IACChair

52

Agenda

Thursday,September28,2017

Time Item Participants

09:00-12:00 SouthlakeRegionalHealthCentre

Responseto

OntarioNurses’AssociationSubmission

Responsetoquestionsfrom• IndependentAssessmentCommittee• OntarioNurses’Association• Discussion

IAC, SRHC and

ONA

12:00-13:00 Lunch All

13:00-16:00 Ontario Nurses’ Association Response to Southlake Regional

HealthCentre

Responsetoquestionsfrom• IndependentAssessmentCommittee• SouthlakeRegionalHealthCentre• Discussion

IAC, SHRC and

ONA

16:00–16:15 ReviewofProcessforFriday,September29,2017

IACChair

16:15 AdjournmentofHearing

IACChair

16:15onwards IndependentAssessmentCommitteeMeeting

IAC

53

Agenda

Friday,September29,2017

Time Item Participants

09:00—12:00 Questions to both Parties by Independent AssessmentCommittee

IAC, SRHC andONA

12:00—12:30 ClosingRemarksandIdentificationofNextStepsbyChairperson IACChair

12:30 ClosureofHearing All

12:30—14:00 IndependentAssessmentCommitteeMeeting IAC

54

Appendix6:AttendeesattheIAC

AssociationAttendees:SusanBlair,ProfessionalPracticeSpecialist,OntarioNurses’AssociationLorrieDaniels,ProfessionalPracticeSpecialist,OntarioNurses’AssociationKellyFarrugia,ManagerII/ProfessionalPractice,OntarioNurses’AssociationCathrynHoy,VicePresident,OntarioNurses’AssociationBoardNicoleButt,LegalCounsel,OntarioNurses’AssociationJillMoore,StaffNurse,SouthlakeRegionalHealthCentre DJSanderson,BargainingUnitPresident,Local124 RebeccaSanderson,StaffNurse,SouthlakeRegionalHealthCentre AdamCastelliStaffNurse,SouthlakeRegionalHealthCentre LoriMellett,StaffNurse,SouthlakeRegionalHealthCentre KatieAnneNorris,StaffNurse,SouthlakeRegionalHealthCentre HospitalAttendees:

AnnetteJonesVicePresident,PatientExperiencesandChiefNursingOfficerMarleneWheaton-Chaston,Manager,EmergencyDepartmentKimStorey,Director,EmergencyDepartmentandPatientFlowHelenaHutton,ExecutiveVicePresident,andChiefOperatingOfficerSandraSmith,VicePresident,OurPeopleandCorporateServicesandChiefHumanResourcesOfficerLeahMartusculli,Director,HumanResourcesLorrieReynolds,Director,MaternalChildandProfessionalPractice,DeputyChiefNursingOfficerDr.StevenBeatty,ChiefofStaff,SouthlakeRegionalHealthCentre