Section Title

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Welcome Address

• Sue Smith - Conference Chair
• Director, Clinical Support Services,
• Hamilton Health Sciences

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Agenda

• 845 Health Care Structure Health Care Funding
• 1030 Break
• 1045 Health Care System Responsiveness
• 1200 Lunch
• 100 Health Care Business Technology
  Movement Towards Integration
  Standardization
• 205 Break
• 215 Health Care Business Technology
  Innovation Development Assessment
• 315 The Outcomes of Collaboration, Cultivation,
  Celebration
• 345 Conference Close

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Opening Address

• Jeff Lozon
• President and CEO,
• St. Michaels Hospital

6

• Video Wound Care

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Health Care Structure Local Health Integrated
Networks

• John King - Moderator
• Executive Vice President, Hospital Services
• Chief Administrative Officer,
• St. Michaels Hospital

9
Transformation Journey So Far

• Hugh MacLeod
• Associate Deputy Minister Executive Lead of the
  Health Results Team,
• Ontario Ministry of Health and Long-Term Care

10

Single Goal Improve Access and Quality

• The future is not what it used to be.
• Rapid change is possible in a large, politically
  sensitive, financial stressed, publicly
  administered healthcare system.
• Improved quality, better service, and reduced
  cost can all be achieved at the same time.

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TransformationFraming the Play

• First Principle. Treat health care reform
  organically rather than structurally or
  fiscally
• Second Principle. Apply the principle of
  momentum.
• Third Principle. Apply the leverage

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Build On Lessons from the Business World

• Build a quality Product
• Get your price point as low as possible
• Explore alternate distribution systems
• Pay attention to customer service

13
Improving the Ontario Healthcare System

• Building Blocks Access, Accountability,
  Performance, Quality, Patient Centred Care
• The New Building Blocks Now Drive.New
  Conversations
• Out of the new conversations, we are now seeing
  examples of System Helping System
• Key element of the play is the Democratization
  of Access to Information (Transparency)
• Next Wave Performance Improvement (Quality
  Safety)

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Update on Local Health Integration Networks

• Presented by
• Pat Mandy, CEO, Hamilton Niagara Haldimand Brant
  LHIN
• Barry Monaghan, CEO, Toronto Central LHIN
• June 21, 2006

15
LEGISLATION principles values
Ministry of Health Long-Term Care Provincial
standards, policy strategic direction

• 10-year strategic plan and provincial
  priorities
• Standards and directives
• Ministry-LHIN accountability agreements
• Funding models and LHIN funding envelope

Local Health Integration Networks (LHINs) Local
planning, accountability, funding allocation
COMMUNITY ENGAGEMENT
COMMUNITY ENGAGEMENT

• Integrated Health Services Plan (3-year
  plan)
• LHIN-provider accountability agreements
• Integration directions
• Service planning, funding and allocation

Service Providers Delivery of services programs
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LHIN Activities

• Community Engagement
• Integrated Health Services Plan (IHSP)
• Best Practice Initiatives

17
Overview Toronto Central LHIN Joint Health and
Disease Management ProgramPresentation to
Building Common Ground Conference

• Presented by
• Barry Monaghan, CEO
• Toronto Central LHIN

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Overall Gap Cases Completed within Target
Source Interim wait times database, Wait Times
Information Office
June 2006
Note Priority 4 targets used in absence of
priority-level data
Target April 2007
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Joint Health and Disease Management Program Goals

• Program Goals
• To improve joint health in the TC LHIN by
• Improving access to services
• Integrating components of care including Primary
  Care, Specialist Care, Rehabilitation, Community
  support services, Education and the determinants
  of Health for joint disease
• Objectives
• Improve access, and reduce wait times for hip and
  knee replacement surgery
• Increase cost-effectiveness and efficiencies as a
  result of an integrated model of care and
  surgical room efficiencies
• Improve quality of care for patients, through the
  development and implementation of best practice
  guidelines

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Joint Health and Disease Management Program Key
Principles

• Initial focus is on increased access to hip and
  knee replacement surgery and will therefore have
  a positive impact on the Ministrys goal of
  improved access and reduced wait times
• Scope of the program is LHIN-wide and therefore
  contributes to the Ministrys transformation
  agenda
• Current facility-specific joint health
  initiatives within the LHIN are being
  incorporated and folded into the program to
  facilitate the system helping the system
• Program designed around an integrated model of
  care and improved patient flow
• Focus is on arthritis care using a chronic
  disease management framework

21
Project Governance Structure
22
TC LHIN Wait Times for Hip and Knee Replacements
TC LHIN wait times for hip and knee replacements
have generally decreased over the past 8 months
Goal is to achieve the 90th percentile of
Priority 4 Access Targets by March 2007
Hip Replacement
Knee Replacement
Median wait time
P4 Access Target
90th percentile wait time
Data Source MOHLTC Wait Times

• Wait times for hip and knee replacement surgery
  are improving
• Patients generally waiting 96 days less for hip
  replacements than 8 months ago
• Patients generally waiting 178 days less for
  knee replacements than 8 months ago

Data collection started in July 2005 N4 does
not support a statistically significant trend
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TC LHIN Must Address System and Hospital-Level
Efficiencies

• Appropriate surgical consultation using standard
  assessment referral process
• Distribution of patients across LHIN based on
  capacity, throughput quality outcomes
• Hip and Knee health education early in the
  disease process
• Coordination of post-operative community services
  prior to surgery

• Unequal distribution of wait times
• One facility performing majority of hip knee
  surgeries
• Inappropriate non-surgical patient referrals
• Variability in amount type of hip knee
  education for patients
• Majority of referrals from outside TC LHIN
• Delays in discharge from hospitals

Implications for maximizing patient throughput

• Single, Centralized Intake/Referral Centre
• Standard assessment process
• Appropriate referrals to surgeons
• Early education programs for hip knee health

• Customized patient care plans
• Post-operative service planning prior to surgery
• Centralized OR booking process
• IM/IT solution

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Proposed TC LHIN Joint Health and Disease
Management Model
Population Health Strategies to influence
lifestyle behaviours that affect joint health
(e.g., healthy weights, healthy activity, injury
prevention), awareness programs for early
detection of arthritis
Referring Physician
TC LHIN Joint Health Disease Mgmt Program
Triage
Medical Candidate
Surgical Candidate
Medical Model(Osteo-Arthritis Disease Mgmt)
Surgical Model(Intake Assessment Centre)
Clinical Guidelines, Education Tools Care
Pathways
Hip Knee Assessment Team
OA Mgmt Education Centres

• Assessment for surgery by Hip Knee Assessment
  Team
• Patient choice of surgeon or shortest wait list

• Education Support
• Rehabilitation
• Medication Pain Mgmt

Standards Quality
Information Management Support
Human Resources, Education Training
Research Program Evaluation
Surgical Team Assessment Care Planning at
Pre-Admit Clinics

• Book OR
• Coordinate Post-OP services
• Pre-OP Preparation

H
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Next Steps

• Present recommendations at June 26th Steering
  Committee
• Final approval of the Proposed Joint Health
  System Model
• Decisions on configuration will be made post June
  30th
• Present Progress Report to Alan Hudson and Hugh
  MacLeod including
• recommendations for additional hip and knee cases
  in 06/07 and
• recommended next steps for implementation of the
  Joint Health System Model

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Health Care Funding

• John King Moderator
• Executive Vice President, Hospital Services
  Chief Administrative Officer,
• St. Michaels Hospital

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New Funding Model
Maureen Adamson Assistant Deputy Minister,
Corporate Services and Organizational
Development, Ontario Ministry of Health and
Long-Term Care
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Collaborate. Cultivate. Celebrate.
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Celebrate

• Passion
• Purpose
• Vision

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Cultivate

• Awareness
• Choice
• Mastery
• Learning
• Global
• Home Grown

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Cultivate - More

• Courage
• Determination
• Humility

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Collaborate

• Relationships
• Trust
• Alignment

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Commitment

• Hearts Minds
• Listening to Divergent Voices
• From Answers to Questions

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Thank You!
36
Health Care Funding

• Ontarios Wait Times Strategy

Peter Glynn, Ph.D. Senior Advisor Access to
Services and Wait Times Strategy, Health Results
Team, Ontario Ministry of Health and Long-Term
Care
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Access and Wait TimesRight Care at the Right
Time in the Right Place

• Goal
• A comprehensive system that ensures Ontarians
  receive timely and appropriate access to health
  services by Dec 2006.
• Scope
• Wait time reduction in five areas cancer,
  cataract, hipknee joint replacement, cardiac
  procedures and MRI exams.

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Strategy Elements

• Accountability hospitals responsible for
• Wait times and access management
• Equity of access for patients and for
  information about access
• Access Management
• Consistent method of prioritizing patients
• Provincial registry for the five key services
• Capacity
• Improved efficiency in hospitals as a result of
  maximizing existing resources
• Increased capacity and volumes in hospitals
• Evaluation
• Measurement of rates of procedures,
  appropriateness, wait times, patient outcomes,
  and quality of care
• Communication
• Public reporting of wait times on website

Data Information Knowledge
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Transformation

• Authority
• Responsibility
• Accountability

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Transformation and Change Management Model

• Supports
• Development of registry
• Audit of allocated volumes
• Targets for wait times
• Sign backs for volumes to enhance accountability
• Implementation of best practices
• A provincial approach to Information Management
  and Information Technology

• Hospital Agreement on
• Price
• Quality
• Information
• Accountability

Wait Time Strategy Volume increases for 5 key
services

• Aligned Tactics
• Efficiency Fund - knowledge transfer
• Expert Panel on Surgical Process Analysis and
  Improvement-Coaching teams

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The expert panel reports

• A key strategy to provide advice on how to
  address the profound problems of timely and
  appropriate access
• Cancer Surgery
• Hip and knee joint replacement
• Cataract Surgery
• Surgical process Improvement
• MRI and CT
• Wait time Information Strategy
• Have provided advice on many aspects of managing
  access
• We are already moving ahead with many of the
  recommendations
• All reports are available on the Ministry of
  Health Web site under the Wait Time Strategy
  section

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Increasing Capacity
Additional
Increase 2006/07 vs. 2003/04 Cardiac procedures
11 Hip Knee 37 Cataract
32 Cancer surgery 11 MRI Scans 44
Global
Purchased Service with Conditionality
43
The Price!

• Cataract Surgery
• 750
• Hip and knee Surgery
• Community Hospitals Primary 6,882
                                            Revision
  8,796
• Teaching Hospitals              Primary
  8,930                                            
  Revision 10,776
• MRI
• 385/Hour

Note Prices for surgery were developed by JPPC
in 2005
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The Price!

• Cancer Surgery

Note Prices for surgery were developed by JPPC
in 2005
45
Better Information, Better DecisionsWait Time
Information System
WTIS High Level Information Flows
4
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WTIS/EMPI Implementation Timeline

• Phase 1 5 hospitals by March 06
• UHN
• Hamilton Health Sciences
• Grey Bruce Health Services
• Grand River Regional
• Southlake Regional
• Phase 2 50 hospitals by Dec 06
• Phase 3 77 hospitals by June 07

All Hospitals
Phase 3 Hospitals WTIS Implemented June/07
Phase 2 Hospitals WTIS Implemented Dec/06
Phase 1 Hospitals 5 Hospitals WTIS by Mar/06 18
of cases
Implementation of WTIS and EMPI in Phase 2
hospitals will begin immediately following Phase
1, with preparation activities occurring before
March 2006
50 Hospitals 80 of funded cases
77 Hospitals 100 of Funded Cases
100 Hospitals
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The WTIS will incorporate Targets and Priority
Classification Systems

• Priority Rating Tools can be used to ensure that
  all patients with similar clinical need are
  treated in the same timeframe, irrespective of
  their surgeon, hospital, or geographic location.
• Targets can be used to give patients a sense of
  how quickly they should be receiving treatment.
• Targets can also be used to measure how well our
  health system is performing However, targets
  can only be used in this fashion if we have wait
  time data to measure against these targets!

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Ontario Targets and Priorities
50
The Data to make Decisions
Patient and primary care provider make informed
decisions about where to be treated
Hospital board make informed decisions about
where to put its resources
Wait Times Web Site Data by hospital, Oct. 05
www.ontariowaittimes.com
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HOW ARE WE DOING?
52
cases completed within targetFebruary/March
2006
Note Priority 4 targets used in absence of
priority-level data
Source Interim wait times database, Wait Times
Information Office
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Reasons for Variation are Complex!

• Important to remember that this isnt about good
  and bad
• Data now provides the facts for hospitals (and
  LHINs) to
• Understand waiting
• Understand how they compare with others
• Analyze the multiple causes
• Consider program design or redesign
• To work in partnership with physicians to meet
  the needs of patients
• In other words, take charge of patient access to
  needed care

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Summary!

• Access Management
• Organized Care
• Patient Centered
• Quality
• Efficiency
• Effectiveness
• ACCOUNTABILITY

59
www.ontariowaittimes.com
THANK YOU
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Structure Funding Moderated Q A
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Break
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Health Care System Responsiveness

• Sue Smith Moderator
• Conference Chair
• Director, Clinical Support Services,
• Hamilton Health Sciences

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Provincial Responsiveness Planning Pandemic
Planning In Ontario

• Mark Breen
• Acting Senior Manager, Emergency Management Unit,
  
• Ontario Ministry of Health and Long-Term Care

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Provincial Responsiveness PlanningPandemic
Planning In Ontario
Mark Breen Acting Manager Emergency Management
Unit June 21, 2006
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The World View
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Characteristics of an Influenza Pandemic

• Requirements
• Introduction of a novel (new) influenza virus
• Highly contagious human to human transmission
  happens easily
• New virus causes serious illness and/or death
• Population has little/no immunity
• Occurs roughly three times a century and
  international impact
• Usually starts in southeast Asia

• Current Status
• New virus
• Limited spread to humans
• Limited transmission to date
• Avian flu with 50 mortality
• In place
• Overdue
• Began in southeast Asia (recently to Africa,
  Asia, Europe)

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World Health Organization Pandemic Phases
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Important Reminders

• Influenza Pandemic ? Seasonal Influenza
• Influenza Pandemic ? SARS
• Influenza Pandemic ? Avian Influenza
• BUT
• Important Lessons to be Learned from Each

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Ontario Perspective
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Ontario Health Plan for an Influenza Pandemic
(OHPIP) Overview

• Goals
• Minimize serious illness and overall deaths
  through appropriate management of Ontarios
  health care system
• Minimize societal disruption in Ontario as a
  result of influenza pandemic
• Strategic Approach
• Be ready establish comprehensive contingency
  plans at provincial and local level
• Be watchful practice active screening and
  monitor emerging epidemiological and clinical
  information
• Be decisive act quickly and effectively to
  manage the epidemic
• Be transparent communicate with health care
  providers and Ontarians

74
Updates in OHPIP 2006

• Antiviral strategy
• Stockpile to treat 25 of the population
• Prophylaxis strategy to be developed nationally
• Clinical care pathway for acute care including
  triage and critical care
• Occupational health and safety chapter
• Surgical masks for patient care N95 respirator
  for aerosol-based procedures hierarchy of
  controls
• Public health measures
• Pandemic Lab Manual tests available
  recommended tests etc
• Community strategy
• Surge capacity for health care workers
• Communications manual
• Pandemic Plan for Long-Term Care Homes
• Paediatric chapter
• First Nations chapter

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OHPIP Supplies and Equipment

• Templates for stockpiles by health care sector
• Organizations stockpile for 4 weeks, MOHLTC
  stockpile for 4 weeks
• Resources in place for MOHLTC to begin
  stockpiling Personal Protective Equipment
• Gloves, gowns, surgical masks, eye protection,
  alcohol-based hand rinse
• Challenges during a pandemic
• Market overwhelmed
• Supply chain business continuity
• Potential border restrictions

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Command and Control in an Influenza Pandemic

• Use IMS structure
• Legislative framework
• Emergency Management Act Bill 56 passed third
  reading
• Health Protection and Promotion Act
• Chief Medical Officer of Health responsible
• Role of Commissioner of Emergency Management/EMO
  to support lead ministry
• Ministry Emergency Operations Centre/EMU
  operational direction
• LHINs not engaged at this time

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Emergency Response in the Ministry

• EEMC Executive Emergency Management Committee
• PEOC Provincial Emergency Operations Centre

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Information Cycle
79
Important Health Notice
Highlights text box public health and
infection control measures Details of outbreak
case definition, number of cases, detailed
control measures Signed by CMOH, EMU
80
http//www.health.gov.on.ca/pandemic
Launched May 8, 2006
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Lets Get Personal
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Personal Preparedness

• Be informed
• Stay healthy
• Hand washing
• Cough/sneeze etiquette cover mouth and nose
  dispose of tissues wash hands
• Avoid overcrowding when possible, particularly
  challenging with multi-generational families and
  housing shortage
• Identify contingency plans
• Daycare unavailable
• Food shortages
• Limited fuel
• Caring for the ill at home
• Reach out
• Support of neighbours, friends and family who may
  have difficulty managing in a pandemic

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Resources

• Emergency Management Unit
• http//www.health.gov.on.ca/pandemic
• WSIB
• http//www.wsib.on.ca/wsib/wsibsite.nsf/public/fl
  u_resources
• CDC
• http//pandemicflu.gov/plan/pdf/businesschecklist
  .pdf

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Contacts

• For questions, contact
  Emergency Management
  Unit staff at
• 1 866 212-2272 Healthcare Providers Hotline
• 1 866 331-0339 Employers Health Hotline
• Email emergencymanagement_at_moh.gov.on.ca

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Hospital Planning for Pandemic Influenza

• John King - Co-Chair TAHSN Pandemic Taskforce
  Steering Comm.
• Executive Vice President Chief Administrative
  Officer,
• St. Michaels Hospital

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Outline

• Toronto Academic Health Sciences Network
  Taskforce
• Key messages
• Next steps

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TAHSN taskforce

• Co-chaired with Dr. Michael Gardam
• Attempt to coordinate planning efforts in the
  absence of regionalization
• Minimize duplication
• Minimize staff confusion
• Learn from SARS experience
• The TAHSN Pandemic Planning Task Force consists
  of

• Baycrest
• CAMH
• Hospital Business Services
• Hospital for Sick Children
• MOHLTC
• Mount Sinai Hospital
• St. Michaels Hospital
• St. Josephs Hospital

• Sunnybrook Health Sciences Centre
• Toronto East General
• Toronto Medical Laboratories
• Toronto Public Health
• Toronto Rehabilitation Institute
• University Health Network
• University of Toronto
• Womens College Hospital

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TAHSN tasks

• Communication
• Staff safety and support
• Triage
• Lab/IT
• Human resources
• Physicians
• Linkages with other plans

89
Communication

• Common plan
• Transparency, frequent communication
• Staged approach matching WHO phases
• We must emphasize that you cannot over
  communicate during this stressful period

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Staff safety issues
Of course this unknown flu that you and everyone
else has caught is harmless, Mr. Bell.
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Protective equipment

• A hotly debated issue that is not going away
• Droplet/contact versus Airborne precautions
• ONA, OPSEU position
• Can we secure enough supplies to protect our
  staff for duration of flu period?
• Hospitals and agencies 4 weeks of supplies,
  MOHLTC 4 weeks of supplies
• Can the suppliers provide the necessary supplies?
• Alternate storage arrangements must be planned

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Antiviral prophylaxis

• Who will look after patients if we are sick?
• Mathematical models typically assume unlimited
  healthcare resources
• Healthcare worker prophylaxis has a large impact
  on societal morbidity and mortality
• This is our only insurance policy
• Our decision was to purchase anti-viral
  prophylaxis for all staff, physicians and
  volunteers for a 56 day course
• Planning is now underway for security, storage
  and distribution of anti-virals
• Need to involve various decision makers when
  determining distribution (how much, how often?)

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Triage

• Where will flu patients be seen?
• What will happen with outpatient clinics?
• Which inpatient programs will be scaled back?
• Logistical considerations
• How does this fit into local plans?
• Need to work with Public Health and the provinces
  on assurance of assessment centres

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Human Resources issues

• Proactively discuss
• Update unions regularly
• Proactively discuss how to deal with
  pandemic-related grievances
• Staff working in more than one facility
• Staff refusing to work

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Ethical issues

• Decisions will be made that will tip the ethical
  scale
• Which patients will receive treatment?
• Treatment of patients in less then ideal
  conditions
• Forcing staff to work
• Who will receive scarce resources?

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Coping mechanisms

• Develop arrangement with employee assistance
  program for staff support
• Have crisis management program
• Education of staff to fully understand the risks

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Redeployment Centre

• HR to manage operation of centre
• Develop a generic framework for a centre
  (provided in TAHSN plan)
• principles and guidelines
• Redeployment will require clinical expertise
• Requires ability to track all staff
• Will our staff be asked to work and provide
  support in the community?

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Volunteers

• Determine how volunteers are going to be used
• Proactively discuss with volunteers their
  possible roles
• If may be asked to fill union roles, discuss with
  unions proactively

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Staff medical concerns

• Proactively discuss possible redeployment of
  pregnant staff
• OHS will make individual decisions regarding
  staff with high risk medical conditions
• Who will care for ill staff?
• Can they safely go home?

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Child care/Elder care

• Staff should proactively discuss with their
  families, their roles during a pandemic
• Healthcare workers must be considered the
  essential worker in the family
• Duty to care will certainly be challenged with
  family illnesses

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What can you do?
Prepare like you would for any emergency

• Waterless hand wash
• Non-prescription medications
• Knife, can opener etc..
• Learn about your work and community plan

• Food and water
• Batteries, flashlights
• Radio
• Contact information
• Alternate child care/elder care arrangements

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Key messages

• Planning is not wasted
• Human resources and communications issues will
  make or break you
• Protective measures, antiviral prophylaxis are
  hot topics
• Determine what is planned for you in your region
• Security arrangements to protect supplies and
  antivirals in a chaotic period needs attention
• How do we distribute anti-viral medications?
• Still questions related to who will take charge
  during a pandemic
• BE PREPARED!
• The TAHSN Pandemic Influenza Planning Guidelines
  can be obtained from www.tahsn.ca

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Post traumatic stress or lessons learned?
104
Thank you
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Perioperative Services Environmental Control
Operating Room CRISIS

• Valerie Zellermeyer, RN, MHSc, CPN (C),
• Program Director Perioperative Services,
• St. Michaels Hospital

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• Video OR Rain Forest

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Perioperative Services Environmental Control
Failure

• Chronology (July 18, 2005)
• 0615 hrs Honeywell and flow control
  commissioning Valve closed after losing signal
  caused a fitting to leak in the chiller water
  system. Engineering shut off water
• 0630 hrs OR 13 Nursing Staff notice increase
  temperature
• 0640 hrs Fire Alarms going off

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Perioperative Services Environmental Control
Failure

• Chronology (July 18, 2005)
• 0705 hrs ORs Humidity, ORs postponed.
• Project Manager OR, noticed change, pulled
  equipment out, paged Engineering paged Medical
  Director. Nurses reported the rooms were
  extremely humid. Case packs were damp. All
  cases were put on hold. OR 17 implants packaging
  surfaces were wet with condensation film.
  Supplies damp. Manager Engineering notified
  through locating STAT - with immediate response
• 0715 hrs All OR Fire alarms going off
• 0730 hrs Chief, Surgery, Exc. VP, CMO and
  covering Program Director, Infection Control and
  Housekeeping notified

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Perioperative Services Environmental Control
Failure

• Chronology (July 18, 2005)
• 0800 hrs Engineering paged again Security
  contacted to find Engineering for room
  temperature and humidity readings
• 0815 hrs 2 chillers started. Eng. Manager came
  up to the OR and notified that Engineering was
  fixing the problem. Asked to get humidity and
  temperature readings
• 0830 hrs Emergency and Trauma Leader notified.
  Closed to Trauma and EMS/Criticall. All surgeons
  notified. ORs closed to noon. Prioritize
  patients. Patients in OR notified delay

111

• Chronology (July 18, 2005)
• 0845 hrs Implants checked and were dry in OR 17
  (Storage)
• 0905 hrs Administrator on Call notified
  Organized stakeholder meeting. Notified Finance
• 0915 hrs Eng. Manager notified that the
  humidity was greater than 60 standard. All
  morning cases put on hold. Surgeons notified to
  prioritize their OR cases

112

• Chronology (July 18, 2005)
• 1000 hrs Director of Perioperative Services
  notified
• 1100 hrs Status Meeting Stakeholders, Command
  Centre activated and Action Planning with OR,
  Vendor Administration, Logistics, CPD,
  Housekeeping, Infection Control, Engineering for
  recovery. Cancelled afternoon cases. Surgeons
  and patients notified. MOHLTC notified (Irv
  Mapa) (1330)
• Action Plan Quarantine Products, monitor
  temperature, humidity. Decant OR and Sterile
  Corridor, purchase replacement products, Project
  Clean, Equipment Check, Restock

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Perioperative Services Environmental Control
Failure

• Chronology (July 18, 2005)
• 1530 hrs Status Meeting Stakeholders and Action
  Planning.
• All scheduled cases were cancelled for July 19,
  20, 2005. Surgeons, Patients and Staff notified.
  Criticall, Trauma, EMS remained closed until
  0800 hrs July 19, 2005. Receiving held open
  until 700 PM
• 1600 hrs 1 OR opened, available for emergency
  surgery
• 2000 hrs Status Meeting in Command Centre. OR
  1 5 opened for surgery
• 2200 hrs The Sterile Core was decanted, product
  counted and quarantined and moved to 4 Shuter
  (old CVICU). OR day staff sent home

114
Perioperative Services Environmental Control
Failure

• Chronology (July 19, 2005)
• 0100 hrs Command Centre closed. Marriott Hotel
  Accommodations for Manager on Call and
  Administrator on Call, Manager of Engineering and
  key staff
• 0430 hrs In house emergency case (perforated
  bowel). Case completed, MSICU patient stable.
  ICP tracking and ENCON form completed
• 0730 hrs Command Centre opened. Team meeting
  and status updated. OR s 1, 2, 5, 7 are ready
  and cleaned. ORs were prioritized based on
  humidity readings. Assessed EMS/Trauma status
  committed to noon target

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Perioperative Services Environmental Control
Failure

• Chronology (July 19, 2005)
• 1200 hrs All humidity readings within normal
  range (lt 60). OR s 1, 2, 3, 5, 7, 9, 10, 11
  12 ready and cleaned. Decision made to open to
  trauma and EMS and Medical Director Emergency
  notified and Trauma Team Leader and MOHLTC (Irv
  Mapa) updated
• 1600 hrs select team members meet. Supplier
  status review and equipment review. Review of
  chronology documentation
• 2000 hrs Command Centre closed

116
Technical Explanation
Excessive humidity was allowed to go in to the
OR because the saturation dew point was 94 which
meant that the air hits a cold surface and
condenses. The relative humidity in the OR at
that time before the incident would have been
below 55 and the surfaces would be 18 C causing
excessive condensation.
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Patient Management

• Cases cancelled
• Scheduled
• Monday 41
• Tuesday 47
• Emergency/Urgent 6
• Personal contact to patient by surgeon or
  management
• Letter explaining situation and apology and
  referred to Patient Affairs
• Case Recovery Plan in Process

126
Staff Support

• This incident required significant extended hours
  of staff overtime and dependent on the good will
  of staff as no code orange was called.
• Operating Room, CPD, Day Surgery, PACU,
  Perioperative Leadership Team, Vendor Admin,
  Logistics, Periop Pharmacy RT, Admin Support,
  Medical Leadership, Engineering, Housekeeping,
  Biomedical Engineering, Public Affairs, Infection
  Control, Security Catering
• Actions taken included Team meetings, Internal
  and External communications through Public
  Affairs. Hydration measures to cope with
  significant heat and humidity. Catering to
  sustain energy. Other measures after hours
  accommodation, taxi chits. Recognition to staff
• Crisis assistance to Labour and Birth by
  Perioperative staff team

127
Risk Management Environment

• Engineering
• July 18, 2005 Humidity and temperature monitoring
  
• ORs (hourly)
• Sterile Corridor (hourly)
• Ambulatory ORs
• Recovery
• Housekeeping
• Staffing scheduled to project clean
• CVICU, cleaning for quarantine

128
Risk Management Supplies

• Relevant suppliers alerted. Confirmation of
  product integrity from Vendor and manufacturer
  recommendations as to Sterility, Functionality
  and Safety
• Team decision to Quarantine supplies and
  quarantine location confirmed
• Sourcing Direct and Hamilton Health Sciences
  Warehouse extended hours and additional
  shipments. Processes began on July 18th at 1330
  and completed by 0400 on July 19th (16 hours)
• Scheduling location and cart builds for
  replacement OR TPL Supplies
• Extended hours in Receiving
• July 19th 0800 to 2000 back order management and
  contingency backorders - product of 20.
  Clinical team will assess critical product gaps
  and Vendor Admin mitigate
• TPL Carts built for ORs and Ambulatory ORs on
  July 19th. Approximately 12 carts
• Drugs assessed and affected drugs were
  quarantined and replaced
• Financial liability documentation products,
  drugs
• Anaesthetic carts re-stocked
• Suture carousels are contaminated and will be
  ordered for replacement.
• Supplies Management required deployment of
  approximately 130 OR Staff to expedite the
  decanting process and facilitate the entire
  recovery process

129
Risk Management Equipment

• Equipment assessed for humidity damage,
  functionality and safety
• Equipment Suppliers were called in for validation
  and corrective action
• Equipment was tested to ensure operational
  integrity
• Equipment failure 1 (monitor)
• Equipment missing in action dopplers
  (temporarily)
• Biomedical team worked with OR/RT team and
  suppliers
• Documentation completed on each piece of
  equipment by Perioperative Biomedical Engineering

130
Successes

• Handled in house emergency in 21 hours
• Open for emergency cases in 30 hours
• Open for scheduled cases in 48 hours
• OR was completely cleaned
• Teams worked in harmony and were mutually
  supportive
• Tracked supplies for insurance and recovery

131
Action Plans

• Recommend
• Monitoring plan for humidity and temperature and
  early alarm system
• Emergency Action Plan associated with alarm
• Procedures have been established in the OR for
  product protection (covers, storage)
• Review of Environmental issues in the OR
• Develop after hours supplier contact list
• Complete Supply Chain project for Consignment
• Note If the Supply Chain re-design had not
  occurred this incident would have potentially
  closed down the ORs for 2 weeks. (7,000 items)
• Note Expedite supply storage for consignment in
  a warehouse safe environment
• Emergency contacts for equipment suppliers
  supply manufacturers
• Establish critical reference values which trigger
  actions
• Insurance Recovery and tracking for all out of
  pocket costs Documentation binder assembly

132
Action Plans

• 1) Reduce impact of outdoor conditions
• Air recirculation capability, automatically
  controlled by outdoor/indoor RH
• Variable Speed Fan Control (Slower speed allows
  for greater dehumidification)

133
Action Plans

• 2) Minimize disruption of air supply due to
  maintenance, unexpected failure and repairson
  Supply Air Handling Units
• Redundant Supply Air Handling Units and Variable
  Speed Fan Control (Run all units at 50)

134
Action Plans

• 3) Maintain lower humidity levels in Operating
  Rooms during summer
• Raised temperature space set-point from 18C to
  20C
• Installation of Humidity monitoring system

135
Accomplishments

• Humidity monitoring system installed in December
  2005
• New AHU craned into place end of April
• Core ORs scheduled for completion end of June
• Ambulatory ORs scheduled for completion end of
  July

136
Questions For Discussion

• What is the root cause of this failure?
• Could it have been prevented?
• If not, then what safety precautions and
  processes should be put in place to minimize risk
  i.e. timing and scheduling of work, advanced
  communication and notification on-site
  management.
• Was there anything else we could have done
  differently?

137
Health Care System Responsiveness Moderated Q A
138
Health Care System Responsiveness Moderated Q A

• Alcon Canada
• Baxter Corp
• Boston Scientific
• Cardinal Health
• Carl Zeiss Canada
• Coherent AMT INC
• Datex-OHMEDA (Canada) INC
• Edwards Lifesciences Canada INC
• Logihedron

• Johnson and Johnson
• Karl Stortz
• Medtronic of Canada LTD.
• Smith Nephew
• Sorin Group
• St. Jude Medical
• Stryker Canada
• Wright Medical Technology
• Zimmer Canada
• Hamilton Health Sciences

139
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140
Lunch
141
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142
Health Care Business Technology Movement Towards
Integration and Standardization

• Paul Faguy - Moderator
• Integrated Vice President, Clinical Support
  Hospital Services, Hamilton Health Sciences and
  St. Josephs Healthcare Hamilton

143

• Video - Standardization

144

• Strategy without tactics is the slowest route to
  victory.
• Tactics without strategy is
• the noise before defeat.
• Sun Tzu

145
Standardization and Integration

• Adds value by lowering costs of acquisition and
  actual cost of products
• Improving the service to the end users by
  implementing best practice
• Creating economies of scale
• Accelerating quality improvement through focus on
  patient safety, communications and information
  sharing

146
Inevitability of Progress

• USA IDNs
• Great Britain - CPHs

147
There is nothing more difficult to take in
hand, more perilous to conduct, or more
uncertain in its success, than to take the lead
in the introduction of a new order of things.
Niccolo Machiavelli

148
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149
Moderate Expert Panel Integration and
Standardization

• E-Commerce New Contracting Platform
• Rick Cochrane President and CEO, Medbuy
  Corporation

150
Moderate Expert Panel Integration and
Standardization

• E-Commerce New Contracting Platform
• Rick Cochrane President and CEO, Medbuy
  Corporation
• Distribution Standardization
• Keith Whorley Senior Consultant, Logihedron Inc.

151
Moderate Expert Panel Integration and
Standardization

• E-Commerce New Contracting Platform
• Rick Cochrane President and CEO, Medbuy
  Corporation
• Distribution Standardization
• Keith Whorley Senior Consultant, Logihedron
  Inc.
• Product Standardization
• Patrick Smith Manager, Purchasing, Hamilton
  Health Sciences

152
Moderate Expert Panel Integration and
Standardization

• E-Commerce New Contracting Platform
• Rick Cochrane President and CEO, Medbuy
  Corporation
• Distribution Standardization
• Keith Whorley Senior Consultant, Logihedron
  Inc.
• Product Standardization
• Patrick Smith Manager, Purchasing, Hamilton
  Health Sciences
• Clinical Practice Standardization
• Dr. Michael Marcaccio Chief of Surgery,
  Hamilton Health Sciences

153
Moderate Expert Panel Integration and
Standardization

• E-Commerce New Contracting Platform
• Rick Cochrane President and CEO, Medbuy
  Corporation
• Distribution Standardization
• Keith Whorley Senior Consultant, Logihedron
  Inc.
• Product Standardization
• Patrick Smith Manager, Purchasing, Hamilton
  Health Sciences
• Clinical Practice Standardization
• Dr. Michael Marcaccio Chief of Surgery,
  Hamilton Health Sciences
• Information Metrics Clinical Networking
• Bala Kathiresan Hamilton Niagara Haldimand
  Brant LHIN Integrated Vice President Chief
  Information Officer

154
Moderate Expert Panel Integration and
Standardization

• E-Commerce New Contracting Platform
• Rick Cochrane President and CEO, Medbuy
  Corporation
• Distribution Standardization
• Keith Whorley Senior Consultant, Logihedron
  Inc.
• Product Standardization
• Patrick Smith Manager, Purchasing, Hamilton
  Health Sciences
• Clinical Practice Standardization
• Dr. Michael Marcaccio Chief of Surgery,
  Hamilton Health Sciences
• Information Metrics Clinical Networking
• Bala Kathiresan Hamilton Niagara Haldimand
  Brant LHIN Integrated Vice President Chief
  Information Officer

155
Health Care Business Technology Movement Towards
Integration and StandardizationModerated Q A
156
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157
Contractual Relationships

• Paul Faguy
• Integrated Vice President, Clinical Support
  Hospital Services, Hamilton Health Sciences and
  St. Josephs Healthcare Hamilton
• Patrick Smith
• Manager, Purchasing,
• Hamilton Health Sciences

158
Focus On Healthcare Supply Chain Integration
159
i-SCM Project - Overview

• The FOHSCI Project is in response to a Ministry
  of Finance initiative.
• OntarioBuys Mission
• To facilitate and accelerate the widespread
  implementation of
• integrated supply chain management (iSCM) leading
  practices in
• Ontarios Broader Public Sector (BPS)
• Role
• Champion iSCM leading practices
• Provide funding of iSCM projects
• Measure and report on iSCM performance against
  benchmarks
• Not a supply chain service provider or project
  implementer
• OntarioBuys works collaboratively with the BPS,
  supporting their iSCM efforts so that they can
  better serve Ontario

160
i-SCM Project - Overview

• FOHSCI Focus on Healthcare Supply Chain
  Integration
• Current Project goal is to examine the
  feasibility of comprehensive shared services for
  a wide range of supply chain services
• 18 hospitals participating in the detailed
  implementation analysis
• Information Technology will be a key enabler to
  efficiencies
• Report to be submitted to the Ministry of Finance
  October, 2006

161
Focus On Healthcare Supply Chain Integration
FOHSCI

• 18 Hospitals
• 3.2 Billion
• 600 Million on Med / Surg and Material Management

162
i-SCM Project Hospital Participants

• Cambridge Memorial Hospital
• Brant Community Healthcare System
• Guelph General Hospital
• Groves Memorial Hospital
• Grand River Hospital
• Hotel Dieu Shaver
• Hamilton Health Sciences
• Joseph Brant Memorial Hospital
• Norfolk General Hospital

• Niagara Health System
• North Wellington Health Care
• St. Joseph's Health Centre Guelph
• St. Joseph's Healthcare Hamilton
• St. Michael's Hospital
• St. Mary's General Hospital
• St. Peter's Hospital
• West Haldimand General Hospital
• West Lincoln Memorial Hospital

163
Focus On Healthcare Supply Chain Integration
FOHSCI

• Individual hospital participation
• Well informed local decision making
• Comprehensive full sharing of information

164
Focus On Healthcare Supply Chain Integration
FOHSCI
Regional
GPO
Group
Local
165
Focus On Healthcare Supply Chain Integration
FOHSCI

• Best value at time
• Cost
• Quality
• Service
• Flexibility
• Transparency for members
• Bias to standardization

166
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167
Break
168
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169
Health Care Technology Innovative Development
and Assessment

• Joan McLaughlin - Moderator
• Director, Supply Chain and Support Services,
• St. Michaels Hospital

170

• Video Guardrails

171
Health Technology Assessment in OntarioFrom
Evidence to Policy

• Dr. Leslie Levin MD FRCPC
• Head Medical Advisory Secretariat,
• Ministry of Health and Long-Term Care

172
Health Technology in Ontario

• One of the most important cost drivers in U.S.
  and Canada accounts for 30 of unsustainable
  medical inflation
• The medical device field has become one of the
  most innovative and profitable segments of the
  economythe medical device market is expected
  to grow by double digits for years to come. New
  York Times January 21, 2006
• Utilization in Ontario (Hay Group, 2003) between
  1996 and 2002 for health technologies accounted
  for
• 117 ? in physician fees vs. 17 for
  non-technology
• 16 ? in procedures in acute care services
• 29 ? in technology dependent same day surgery
• 46 ? in hospital costs for technology-related
  CMGs vs. 23 for non-technology
• 6 ? in utilization rate for
  technology-related CMGs vs. 3? for non-
  technology
• Cost pressures compounding at gt0.5 billion per
  year
• Need to balance expenditure against effectiveness
  
• The most effective way of managing escalating
  health care costs is by developing organized,
  evidence-based health technology assessment
  (Bodenheimer, 2005)

173
THE ONTARIO HEALTH CARE SYSTEM
174
Health Technology Assessment in Ontario
Health Technology Assessment in Ontario
JOINT POLICY PLANNING COMMITTEE (JPPC)
Provincial Guidelines Committee (Dissemination) OM
A OHA CPSO CNO OCFP
DEPUTY MINISTER
ONTARIO HEALTH SYSTEM
INTERDIVISIONAL COMMITTEE
Hospitals, Community Agencies, LHINs,
(Implementation)
Recommendation
Health System Requests
Health Technology Utilization Guidelines of
Ontario (Health TUGO) Steering Committee, Expert
Panels
Professional Feedback Loop
Ontario Health Technology Advisory Committee
(OHTAC)
OHTAC guideline development recommendation
Outcomes Tracked By Health Results Team ,
ICES, etc... Utilization and patient outcomes
UHN Usability Lab
Further Analysis required
OHTAC safety and training recommendation
Cardiac arrhythmia
Urinary Inconti-nence
PET
Expert Panels to integrate technologies around
disease states

• Genetic screening
• Diabetes
• (Pre-OHTAC)

Medical Advisory Secretariat (Evidence-based
Platforms) Experts, industry
Cardiac Imaging
Arthritis
Health Quality Council, MOHLTC, LHINs
OHTAC field evaluation recommendation
Cancer-Remains under CCO
E-Base (ICES, PATH, CHEPA)
Field Evaluation Studies PATH, Experts,
Institutions
175
Point of Inflection Portal of Recommendation
OHTAC Prioritization
Evidence-based analysis (GRADE) on effectiveness
related to patient outcomes and system
efficiencies
Active engagement of provincial experts industry
Ontario specific info on practice patterns,
trends utilization for current other
technologies around the disease state.
MAS HTPA
Economic analysis (MOHLTC budget impact,
comprehensive lit review, Ontario based
cost-effectiveness, downstream costs and savings,
sensitivity analysis, Bayesian and Markov
modeling)
MAS/OHTAC
Ethical, legal, regulatory, societal and human
resource issues
Recommendation to DM 60 days later Disseminate
on Website E-Bulletin
OHTAC Critical Review Determining the strength
of recommendation based on weighing risks
benefits
176
OHTAC Decision and Technology Trajectories
Approval with no Restrictions
Approval with Restrictions
UHN Usability Lab
Health TUGO
PATH
Guideline Development
Safety Human Factors Analysis
Integration of Technologies
Field Evaluation
Opportunity For Revision
Rejected
Professional Feedback Loop
Hospitals Community
Specialists, experts, academic institutions
Expert Panels
MAS/OHTAC
177
Diffusion Curve - Diffusion Phase
Information Management (Health Results Team)
Tracking
ICES
Volume of new and competing
technologies
Health Quality Council
Performance (e.g. patient outcomes, accuracy and
system efficiencies)
178
Field Evaluation Conditional Coverage

• The provision of funding for new health
  technologies to enable data collection for
  determining the clinical and/or economic value of
  a technology and to support a definitive funding
  policy.
• (Summit on Conditional Coverage of New Medical
  Technology, Medical Technology Leadership Forum,
  1999).

179
Conditional Coverage on the Rise

• Conditional Coverage will likely expand
• Fiscally strained health systems and more
  expensive health technologies, will raise
  evidence thresholds for funding decisions.
• Non-drug health technologies not always subject
  to the same standard of proof of effectiveness
  cost-effectiveness as drugs in pre-marketing
  studies. Failure of licensing agencies to apply
  stringent evidence to non-drug technologies will
  fuel demand for conditional coverage.
• Increasing need to improve our understanding of
  the systemic effects of health technologies and
  to use this to develop diffusion strategies
  especially for disruptive technologies (e.g.,
  multi-slice CT, endocardial ablative techniques,
  PET).
• Concerns regarding safety.

180
Examples of Conditional Coverage

• United States
• Australia
• Ontario, Canada

181
Field Evaluation Studies

• Considered if the health technology seems
  effective, is
• likely to have an important impact on patient
  outcomes but
• Cost/volume/systems impact justifies test of
  generalisability (efficacy vs. effectiveness)
• Quality of evidence is too questionable to
  justify a multimillion dollar multi-year
  investment
• Concerns re off-label diffusion
• NNT and per unit cost are unacceptably high
• Technology is potentially disruptive
• Available follow-up data insufficient
• Unresolved patient safety issues
• Conducted mainly by PATH (Also OCOG, UHN more
  recently)
• arms length
• design, execute with experts AHSC etc, analysis
  and reporting
• 3 Million (4 year agreement, 10 projects) plus
  the cost of devices

182
Example 1. Field Evaluation of PET

• In 1999, nuclear medicine recommended funding for
  40,000 PET scans phased in, based on evidence of
  effectiveness.
• 2001 ICES systematic review concluded -
  insufficient evidence on the clinical utility of
  PET, and its impact on patient outcomes.
• FDG used in PET scanning only approved for
  clinical trial application by Health Canada
• In 2002, MOHLTC funded PET evaluations through
  the Ontario Clinical Oncology Group on the advice
  of a newly appointed PET Steering Committee to
  advise MOHLTC on uptake and diffusion of PET.
• Currently 3 RCTs, 2 observational trials and 4
  registry studies for additional 4 cancer
  indications

183
Provincial PET Steering Committee
MOHLTC
5 Trial Steering Committees
Clinical Centres Investigators
External Safety Efficacy Monitoring Committee
FDG Suppliers
PET Quality Assurance Subcommittee
Health Canada
PET Scan Readers Subcommittee
184
Example 2. Drug Eluting Stent (DES)

• MAS HTPA in 2002 confirmed potential diffusion
  pressure and effectiveness of DES for low risk
  patients
• Initial RCTs reported restenosis rates fell from
  23 to lt5 for lower risk patients (Arteries with
  shorter and wider stenosis and without diabetes)
  -anticipated spread to include all patients
• DES costs 1,200 more than the bare metal stent
  with projected incremental cost gt 10 million and
  rising
• Policy required to handle diffusion of this
  promising technology
• Funding for D