Ontario Wait Time Strategy

Ontario Wait Time Strategy Visit to South East LHIN May 26, 2008 Alan R. Hudson, OC, FRCSC

Cataract Surgery 90 th Percentile Wait Time Trend 350 300 250 200 Priority 4 Target - 182 days 150 100 50 0 2 Mar 08 Aug-Sep 05 Oct-Nov 05 Dec-Jan 06 Feb-Mar 06 Apr-May 06 Jun-Jul 06 Aug-Sep 06 Oct-Nov 06 Dec-Jan 07 Feb-Mar 07 Apr-May 07 Jun-Jul 07 Aug 07 Sep 07 Oct 07 Nov 07 Dec 07 Jan 08 Feb 08 Wait Days Apr-08 trendline

Cataract Surgery - Histogram 3

Cataract Surgery Wait Times LHIN Variation 4

Cancer Surgery 90 th Percentile Wait Time Trend 100 90 80 70 60 50 40 30 20 10 0 5 Aug-Sep 05 Dec-Jan 06 Apr-May 06 Aug-Sep 06 Dec-Jan 07 Apr-May 07 Aug 07 Oct 07 Dec 07 Feb 08 Wait Days Apr 08 Priority 4 Target - 84 days trendline

Hip Replacement 90 th Percentile Wait Time Trend 400 350 300 250 200 150 100 50 0 6 Aug-Sep 05 Oct-Nov 05 Dec-Jan 06 Feb-Mar 06 Apr-May 06 Jun-Jul 06 Aug-Sep 06 Oct-Nov 06 Dec-Jan 07 Feb-Mar 07 Apr-May 07 Jun-Jul 07 Aug 07 Sep 07 Oct 07 Nov 07 Dec 07 Wait Days Jan 08 Feb 08 Mar 08 Apr 08 trendline Priority 4 Target - 182 days

Knee Replacement 90 th Percentile Wait Time Trend 500 450 400 350 300 250 Priority 4 Target - 182 days 200 150 100 50 0 7 Aug-Sep 05 Dec-Jan 06 Apr-May 06 Aug-Sep 06 Dec-Jan 07 Apr-May 07 Aug 07 Oct 07 Dec 07 Wait Days Feb 08 Apr 08 trendline

MRI 90 th Percentile Wait Time Trend 140 120 100 80 60 40 20 0 8 Aug-Sep 05 Oct-Nov 05 Dec-Jan 06 Feb-Mar 06 Apr-May 06 Jun-Jul 06 Aug-Sep 06 Oct-Nov 06 Dec-Jan 07 Feb-Mar 07 Apr-May 07 Jun-Jul 07 Wait Days Aug 07 Sep 07 Oct 07 Nov 07 Dec 07 Jan 08 Feb 08 Mar 08 Apr 08 trendline Priority 4 Target - 28 days

CT 90 th Percentile Wait Time Trend 90 80 70 60 50 40 30 20 10 0 9 Aug-Sep 05 Dec-Jan 06 Apr-May 06 Aug-Sep 06 Dec-Jan 07 Apr-May 07 Wait Days Aug 07 Oct 07 Dec 07 Feb 08 Apr 08 trendline Priority 4 Target - 28 days

Progress to Date 10

Current State (Apr 2008) - % of cases completed within target Cancer Surgery 100% 94% CT Bypass Surgery 83% 100% MRI 54% 0% 96% Cataract Surgery 84% 89% Knee Replacement Hip Replacement Target Actual Note: Based on priority level 4 targets. 11

All Surgery Adult & Paediatric Scope June 2007 Cardiac Cancer Hip and Knee Replacements Cataract IMPLEMENTED MRI and CT Scans WTIS Phase 1-3 81 WT funded hospitals Surgeons: 1,700 Total cases 2006/07: 1,301,069 Total MRI and CT scans (2006/07): 1.2 million March 2008 Ophthalmic Surgery Orthopaedic Surgery General Surgery IMPLEMENTED Paediatric Surgery Pilot WTIS Adult Group 1 Expansion 74 WT funded hospitals (surgery only) Cumulative surgeons: 2,600 Total cumulative cases 2007/08: 1,610,000 Paediatric (Pilot) London Health Sciences Centre and St. Joseph s Health Care (London) All paediatric surgical procedures 2008/09 Neurosurgery Vascular Surgery Thoracic Surgery Otolaryngic Surgery Ob/Gyn Surgery Urologic Surgery Plastics/Reconstruction Oral Surgery Paediatric Surgery WTIS Adult Group 2 Expansion ~74 WT funded hospitals (surgery only) Cumulative surgeons: ~3,350 Total cumulative cases 2008/09: ~2,225,000 12

South East LHIN Wait Time Trend Analysis April 2008 Data 13

South East LHIN Monthly Trend Cataract Surgery Hip Replacement Knee Replacement 14

South East LHIN Hospital Performance April 2008 data 15

South East LHIN Priority Analysis April 08 data 16

LHIN #10 South East Impact of Concurrent ATC Hospital Implementation Activities Implementation Activities SET Program Phase 1 WTIS Expansion Group 1 EDRS WTIS-Expansion Cardiac Module (WTIS-CCN) WTIS Expansion Group 1 SET Program Phase 2 EDRS WTIS-Expansion Cardiac Module (WTIS-CCN) SET Program Phase 2 EDRS SET Program Phase 2 EDRS (TBD) WTIS Expansion Group 2 & All Paed Sites SET Program CCIS Roll-out to all MSICUs CCIS Roll-out to all MSICUs CCIS Phase 3: Specialty ICUs CCIS Phase 3: (Wave 4) Specialty ICUs CCIS Phase 3: (Wave 4) Specialty ICUs CCIS Phase 3: (Wave 5) Specialty ICUs Q2 (07/08) Q3 (07/08) Q4 (07/08) Q1 (08/09) Q2 (08/09) Q3 (08/09) Implementation Activities By Hospital in LHIN #10 SETP PHASE 1 Hotel-Dieu Kingston Kingston General Hospital Lennox and Addington County General Perth and Smith Falls District Hospital Quinte Healthcare Corporation CCIS ROLL-OUT Brockville General Hospital Quinte Healtcare Corporation WTIS-EXPANSION Brockvill General Hospital Hotel-Dieu Kingston Kingston General Hospital Lennox and Addington County General Quinte Healthcare Corporation CCIS ROLL-OUT Brockville General Hospital Quinte Healtcare Corporation EDRS Hotel-Dieu Kingston Perth and Smith Falls District Hospital Quinte Healthcare Corporation WTIS-CCN Kingston General Hospital WTIS-EXPANSION Brockville General Hospital Hotel-Dieu Kingston Kingston General Hospital Lennox and Addington County General Quinte Healthcare Corporation SETP PHASE 2 Brockville General Hospital Hotel-Dieu Kingston Kingston General Hospital Lennox and Addington County General Perth and Smith Falls District Hospital Quinte Healthcare Corporation* CCIS ROLL-OUT Focus Groups/Design Sessions Underway EDRS Brockville General Hospital Hotel-Dieu Kingston Kingston General Hospital Lennox and Addington County General Perth and Smith Falls District Hospital Quinte Healthcare Corporation WTIS-CCN Kingston General Hospital SETP PHASE 2 Brockville General Hospital Hotel-Dieu Kingston Kingston General Hospital Lennox and Addington County General Perth and Smith Falls District Hospital Quinte Healthcare Corporation* CCIS ROLL-OUT EDRS Brockville General Hospital Hotel-Dieu Kingston Kingston General Hospital Lennox and Addington County General Perth and Smith Falls District Hospital Quinte Healthcare Corporation SETP PHASE 2 Brockville General Hospital Hotel-Dieu Kingston Kingston General Hospital Lennox and Addington County General Perth and Smith Falls District Hospital Quinte Healthcare Corporation* CCIS ROLL-OUT Kingston General Hospital EDRS TBD WTIS-EXPANSION TBD SETP Brockville General Hospital Hotel-Dieu Kingston Kingston General Hospital Lennox and Addington County General Perth and Smith Falls District Hospital Quinte Healthcare Corporation* CCIS ROLL-OUT Kingston General Hospital Quinte Healthcare Corporation Kingston General Hospital 17 Q2 (07/08) Q3 (07/08) Q4 (07/08) Q1 (08/09) Q2 (08/09) Q3 (08/09) * Belleville General, Trenton Memorial, and Prince Edward County Memorial only.

The ER Strategy calls for System-wide Improvements Reducing ER Wait Times and Improving Public Satisfaction can only be achieved by making improvements across the entire system Reducing Demand for Services Therefore, accountability for improvement must rest with Hospital Boards and CEOs, LHIN Boards and CEOs and community partners such as CCACs Improving Processes within the ER Increasing Supply of Services ED ER OR H Alternate Levels of Care Community and home-based Home services Long Term Care Rehabilitation Complex and Continuing Care Aging at Home Family Health Care for All Chronic Disease Prevention and Management (Diabetes) Mental Health and Addiction Emergency Room Strategy HHR - Emergency Department Coverage Aging at Home (ALC) High Growth Hospital Funding The infrastructure and resources to reduce demand and increase supply cannot be put in place overnight, therefore, efforts must start early and will take time to show results 18

ER Transfer ALC Institution Booked Admission Communities * 19

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Number of Patients in Emergency Waiting for an In-patient Bed By LHIN (at any given point in time) Hamilton Niagara Haldimand Brant Toronto Central Central Mississauga Halton Central East South West Champlain Waterloo Wellington North East South East Erie St. Clair North West North Simcoe Muskoka Central West 31 31 28 28 26 55 49 45 42 121 104 82 71 Ontario = 849 136 Source: OHA April 2008 ALC Survey Results 22

Number of Patients in Emergency Waiting for an In-patient Bed Since December 2007 (at any given point in time) 860 840 820 800 780 760 791 819 849 740 720 700 723 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 17% increase Source: OHA April 2008 ALC Survey Results ALC Survey Results December 2007 to April 2008 23

Most LHINs are experiencing their highest levels of ALC days in recent years 25% % ALC days in hospitals by LHIN 20% % ALC Days 15% 10% 5% 0% 1999 2000 2001 2002 2003 2004 2005 2006 Erie St. Clair South West Waterloo Wellington HNHB Central West Mississauga Halton Toronto Central Central Central East South East Champlain North Simcoe North-East North-West Data source: Inpatient Discharges Table, Ontario Provincial Health Planning Database (PHPDB), V. 17.07 24

Percent of Acute Care Beds Occupied by ALC Patients By LHIN North East Waterloo Wellington Hamilton Niagara Haldimand Brant North West Champlain Central East Central Mississauga Halton North Simcoe Muskoka South West South East Central West Toronto Central Erie St. Clair Ontario 12% 12% 12% 11% 16% 15% 15% 17% 19% 19% 20% 22% 25% 29% 33% About 2,900 patients are waiting daily in acute care for ALC Percent of Acute Care Beds Occupied by ALC Patients = Number of patients in an acute care bed waiting for an ALC Source: OHA April 2008 ALC Survey Results Total acute care beds 25

South East LHIN Percentage ALC Days per Quarter 25.00 20.00 15.00 10.00 5.00 0.00 South East LHIN Q1 Q2 Q3 Q4 Q1 Q2 Q3 2006-07 2007-08 14.80 17.43 21.48 20.28 16.89 16.59 14.11 Provincial 10.73 11.37 12.57 13.72 12.64 12.96 14.28 26

15,587 IP Acute Beds (*) 8.84% Other ALC 81.43% IP Acute Beds 18.57% IP Acute Beds 2.18% 13.71% 7.39% 57.89% Community / Home care Rehabilitation Complex Continuing Care unit Long-Term Care Home 12.1% admissions/year (**) 5.35% 3.39% Palliative care unit or hospice Sub-acute or convalescent care 5,216,000 visits/year (***) 1.24% Home ED (*) Alternate Level of Care ALC, OHA ALC Survey Results, Feb 2008 (**) Review of ED Services in Waterloo Wellington, Waterloo Wellington LHIN, Dec 2006 (***) Hospital Report : Emergency Department 27 Care, HRRC 2007.

ER visits in FY2006 Figure 1: Number of ER visits in FY2006 by CTAS Total visits in FY2006 = 5,247,338 Figure 2: Number of ER visits by age group Figure 3: Number of ED visits by age group 40% 38% 11% 11% CTAS 2 CTAS 3 CTAS 4 CTAS 5 859,217 16% 1,323,180 25% 364,300 7% 1,293,347 25% 1,407,294 27% 000-019 020-039 040-059 060-079 080+ Figure 3: Number of times Ontarians visit ER per year 1 visit per year (63%) 2 visits per year (20%) 3 visits per year (8%) 4 visits per year (4%) 5 or more visits per year (5%) Total number of unique visitors 2,860,598 28

OVER 480 Emergency Department Lengths of Stay in FY2006 ED LOS Distribution 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 29 421-450 451-480 391-420 Number of visits 000-030 031-060 061-090 091-120 121-150 151-180 181-210 211-240 241-270 271-300 301-330 331-360 361-390 Source: NACRS, 2006 Time spent in ED (minutes)

391-420 421-450 451-480 OVER 480 391-420 421-450 451-480 OVER 480 Distribution of ED Lengths of Stay in FY2006, by CTAS level ED LOS Distribution, CTAS 1 ED LOS Distribution, CTAS 2 3,500 120,000 3,000 2,500 2,000 1,500 1,000 500 100,000 80,000 60,000 40,000 20,000 0 30 Number of visits Number of visits 0 000-030 031-060 061-090 091-120 121-150 151-180 181-210 211-240 241-270 271-300 301-330 331-360 361-390 391-420 421-450 451-480 OVER 480 000-030 031-060 061-090 091-120 121-150 151-180 181-210 211-240 241-270 271-300 301-330 331-360 361-390 Source: NACRS, 2006 Time spent in ED (minutes) Source: NACRS, 2006 Time spent in ED (minutes) ED LOS Distribution, CTAS 3 ED LOS Distribution, CTAS 4 250,000 400,000 200,000 150,000 100,000 50,000 350,000 300,000 250,000 200,000 150,000 100,000 50,000 Number of visits Number of visits 0 0 000-030 031-060 061-090 091-120 121-150 151-180 181-210 211-240 241-270 271-300 301-330 331-360 361-390 391-420 421-450 451-480 OVER 480 000-030 031-060 061-090 091-120 121-150 151-180 181-210 211-240 241-270 271-300 301-330 331-360 361-390 Source: NACRS, 2006 Time spent in ED (minutes) Source: NACRS, 2006 Time spent in ED (minutes)

Distribution of ED Lengths of Stay in FY2600, by CTAS level (cont d) ED LOS Distribution, CTAS 5 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0 31 Number of visits 000-030 031-060 061-090 091-120 121-150 151-180 181-210 211-240 241-270 271-300 301-330 331-360 361-390 391-420 421-450 451-480 OVER 480 Source: NACRS, 2006 Time spent in ED (minutes)

Academic centres and large community hospitals have the worst ER-Length of Stay across all urgency (triage) levels Number of EDs (Total N=100) 70 60 50 40 30 20 10 0 Percentage of patients meeting ER-LOS goals* by triage level < 70% 70-90% All Patients > 90% All Patients < 70% 70-90% > 90% Resuscitation- Emergent < 70% * Recommended LOS Goals per ER Expert Panel, JPPC ER-LOS Goals: CTAS I/II within 8 hours CTAS III within 6 hours CTAS IV/V within 4 hours 70-90% Urgent > 90% < 70% Triage Level / Percentage Within ER-LOS goal 70-90% > 90% Less/Non-Urgent CTAS I/II CTAS III CTAS IV/V All ERs with Annual Volumes >= 20,000, Ontario, NACRS 2006-07 Best performing hospitals (>=95% of patients are treated within LOS goals) Carleton Place and District Memorial Hospital Glengarry Memorial Hospital Haldimand War Memorial Hospital Niagara Health System Port Colborne Site Perth & Smiths Falls District Perth Site Perth & Smiths Falls District Smiths Falls Quinte Healthcare Corporation Picton Renfrew Victoria Hospital Sensenbrenner Hospital Stevenson Memorial Hospital Alliston Temiskaming Hospital West Parry Sound Health Centre Worst performing hospitals (<70% of patients are treated within LOS goals) Grand River Hospital Corp Waterloo Hopital Montfort Humber River Regional Hospital Humber Memorial Humber River Regional Hospital York- Finch Mount Sinai Hospital North York General Hospital Ottawa Hospital Civic Site St Joseph s Health Care System Hamilton St Michael s Hospital Sunnybrook Health Sciences Toronto East General Hospital University Health Network General University Health Network Western 32

EDRS Indicators Process Flow Diagram 33

EDRS Implementation Timeline Q2 07/08 Q3 07/08 Q4 07/08 Q1 08/09 Q2 08/09 Q3 08/09 Q4 08/09 Technical Development Beta Testing Hospital Training Wave 1 and Wave 2 Implementation All Hospitals submitting data to EDRS Public Reporting of ED Wait Times Beta Wave 1 Wave 2 % of EDRS hospitals 6% 55% 26% 34

Patient Satisfaction Survey Ontario Emergency Department by Hospital Location in LHIN Source: National Ambulatory Care Reporting System 2005-2006, CIHI Survey Results Summary (2005-2006): Overall Impressions Patients assessments, overall, of their hospital stays. 74.4 Communication Patients assessments of how well information was communicated to them or family during ER stay. 66.9 Consideration Patients assessments of whether they were treated with respect and courtesy by doctors, nurses and other staff during their stays in the ED. Responsiveness Patients assessments of the amount of time they waited to see doctors and nurses and receive test results; assessments of pain management; assessments of team work; and the staff s responsiveness to their needs. 72.8 65.4 35

Proposed ER Strategy Timeline Premier commits to reduce ER wait times (Oct. 2007) Minister announces ER/ALC policy changes to public and stakeholders (Apr. 2008) Pay-for-Results Y1 allocation (Jul. 2008) CCAC demonstration projects for ER diversion begin (Jul. 2008) Target Communication to key stakeholders (Jul. 2008-Jan.2009) Public awareness campaign begins (Aug. 2008-Jul. 2009) Preliminary EDIS results available; re-calibrate ER Strategy (Oct. 2008) Hospitals selected for Expert Teams (Oct. 2008) ER HHR plan complete, implementation begins (Nov. 2008) Online ED patient flow Toolkit and expert program launched (Nov. 2008) Readiness to announce multi-year ER-LOS targets (Dec. 2008) ER wait times publicly reported (Feb. 2009) Pay-for-Results Y2 allocation including expanded list of hospitals (Mar. 2009) Increase ER/CCAC resources (Apr. 2009) Hospitals selected for Expert Teams (Apr. 2009) Expand CCAC/ER diversion demonstration projects (Jul. 2009) Pay-for-Results Y3 allocation (Apr. 2010) Hospitals selected for Expert Teams (Apr. 2010) Hospitals selected for Expert Teams (Apr. 2011) Pay-for-Results Y4 allocation (Apr.2011) ER wait time goals achieved (Jul. 2011) Hospitals submit public satisfaction survey results (Jan. 2009 and quarterly from Jul. 2009) Provincial election (Oct. 2011) January 2008 July 2008 January 2009 July 2009 January 2010 July 2010 January 2011 July 2011 36 January 2012

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