ministry-lhin performance agreement (mlpa) patient flow …/me… · patient flow report quality...

Ministry-LHIN Performance Agreement

(MLPA)

Patient Flow Report

Quality and Safety Committee

Hamilton Niagara Haldimand Brant (HNHB) Local Health Integration Network (LHIN)

November 21, 2012

Agenda

• 2012-13 MLPA Targets

• First quarter (Q1) Summary of Results

• Alternate Level of Care (ALC)

• Emergency Room (ER) Wait Times

• Wait time from community for Community Care Access Centre (CCAC)

services

• Recap on Public Reporting

2

MLPA (Patient Flow) Targets for 2012-13

• Four of the five targets unchanged from 2011-12

• New target for CCAC wait time indicator, representing a 10% improvement over the

2011-12 year end performance of 29 days

• New for 2012-13 a 10% corridor on targets

3

MLPA Indicator 2011-12 Target 2012-13 Target (10% corridor)

Percent ALC Days 11% 11% (12.1%)

ER Wait Time 90th Percentile

Admitted Patients

28.3 hours 28.3 hours (31.13 hours)


Non -admitted High Acuity



Non-admitted Low Acuity


Wait time for CCAC services

from Community

27 days 26 days (28.6 days)

MLPA – Summary of 2012-13 Performance

MLPA Indicator 2011-12

Year End

2012-13 Target Q1

2012-13

Q2

2012-13

Provincial

Average

Percent ALC Days 15.7% 11% 16.02% *13.31% *13.1%

ER Wait Time 90th

Percentile Admitted

Patients (hours)

35.45 28.3 32.3 33.4 28.4

Q1 & 2

ER Wait Time 90th

Percentile Non -admitted

High Acuity (hours)

7.75 7.5 7.52 7.8 7.2

Q1 & 2

ER Wait Time 90th

Percentile Non-admitted

Low Acuity (hours)

4.87 4.5 4.78 4.8 4.2

Q1 & 2

Wait time for CCAC

services from

Community (days)

29 days 26 days 35 days *26 days *31 days

4

*Reports on April 1 – June 30 2012

Source: MOHLTC MPLA Reports

% ALC Days - Patient Flow vs System Efficiency

• MLPA indicator calculated on number of ALC days patient accumulated during their entire acute

care stay at the time of discharge.

5

Scenario 1 Scenario 2

• 5 patients discharged each collected 400 ALC days =

2000 days.

• 5 beds were not available for other patients over a long

period of time

• Impact on:

• patient – higher risk of decline (functional and

cognitive) and hospital acquired complications

• Patient flow - the overall number of beds available

each day for new patients only decreased by 5

• Costs to the system - assume a daily cost of acute

care bed of $1,034, 2000 days * $1034 = $2,068,000

• ALC rate – LHIN’s ALC rate higher

• 20 patients discharged each collected 30 ALC days = 600

days

• Less beds (20) available for new admissions on a daily

basis

• Impact on:

• patient – lower risk of decline (functional and

cognitive) and hospital acquired complications

• Patient flow - the overall number of beds available each

day for new patients decreased by 20

• Cost to the system- assume a daily cost of acute care

bed of $1,034, 600 days * $1034 = $620,400

• ALC rate – LHIN’s ALC rate lower

Source: Acute care daily bed rate – HNHB LHIN ALC SC Oct 2012

Percent Alternate Level of Care (ALC) Days

Source: MOHLTC MLPA, August 2012 Note: Preliminary data for April – June show the ALC rate

ranging from 10.8% in April to 13.8% in June. In Q1 2012-13,

42 individuals with long waits that together accumulated

6,623 days were discharged. The LHIN expects the ALC rate

will be lower in Q1 2012-13. Source: HNHB LHIN IDS

6

7

• The % ALC Days (closed cases) has shown a steady improvement from a

starting point of 23.24% in Q1 09/10 to a reported low of 12.94% in the first

quarter of 2011-12 (the lowest rate reported since 2007).

• The rise in the % ALC Days through 2011-12 going from 12.94% in Q1 to

16.02% in Q4, was the result of a focused strategy to transition individuals

experiencing long waits to the right level of care.

• This strategy resulted in the successful discharge of 146 individuals with

long waits (>30 days) that accumulated over 27,019 ALC days in Q3 and

Q4.

• Since the implementation of this focused strategy, the number of individuals

with super long waits (>100 days) has decreased from 118 to 52 in 1 year

(Sept. 2011 to Sept. 2012). The major barrier for those individuals

remaining is choice.

Percent Alternate Level of Care (ALC) Days cont’d

UCL 20.69%

CL 16.43%

LCL

12.17%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

% o

f A

LC

Da

ys

(M

LP

A)

(DA

D)

Apr-09 - 12-Jul

Percent ALC Days (MLPA) (DAD)

% of ALC Days(MLAA) (DAD)UCL

+2 Sigma

+1 Sigma

Average

-1 Sigma

-2 Sigma

LCL

UCL = Upper Control Limit and the number of standard deviations above the mean

LCL = Lower Control Limit and the number of standard deviations above the mean

Data Source: HNHB LHIN IDS October 2012

Control Chart Percent ALC Days

Use: Successive decreasing points

suggest trend. This could suggest

impact from bundled strategies and

Home First. The blue dots in

December could reflect impact of

CCAC service cap

8

Percent Alternate Level of Care (ALC) Days 2

2.5

%

23

.1%

21

.8%

20

.6%

18

.5%

17

.1%

16

.1%

14

.8%

15

.2%

14

.8%

14

.1%

14

.3%

13

.2%

13

.3%

13

.3%

15

.4%

15

.6%

15

.3%

14

.8%

16

.5%

15

.2%

15

.2%

14

.2%

12

.6%

13

.2%

13

.0%

13

.2%

14

.6%

15

.4%

14

.4%

14

.4%

14

.1%

14

.2%

15

.7%

14

.0%

13

.3%

12

.8%

14

.0%

13

.5%

13

.2%

12

.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

HNHB LHIN Acute ALC Rate (Internally Monitored) Source: Weekly Hospital ALC Trigger Report

Influences Year to Date:

•Additional AR beds at SJV (September 2011) & at Wellington Park (July 2011)

•Crisis placement status for hospital patients with > 100 days ALC (September 2011)

•CCAC personal support maximum service cap of 56 hours per week (December 2011)

•CCAC re-instated service hours >56 hours (January 2012)

9

• The LHINs Internally monitored % ALC Rate has shown a steady

improvement since January 2012.

• The peak of 15.7% noted in January 2012, was a result of a

CCAC personal support maximum service cap of 56 hours per

week due to financial pressures in December 2011.

• CCAC re-instated service hours of >56 hours in January 2012.

• The LHIN has maintained a % ALC rate of 14.0% or less since

February 2012.

Percent Alternate Level of Care (ALC) Days

10

% Alternate Level of Care (ALC) Days

• The number of individual waiting in hospital

for an ALC steadily decreased from a peak

of 656 reported in January 2010 to 401

reported September 23, 2012.

• The number of individuals waiting in hospital

for LTCH decreased from 396 in January

2010 to 138 reported September 2012.

• The measured success can be attributed to a

bundle of strategies that have been

implemented across the care continuum:

Screening for High Risk Seniors

Home First

Escalation process for individuals designated

ALC-LTC

Intensive Case Management Review Process

and Tool

Restorative Transitional Care Programs -

Assess & Restore

LHIN weekly calls with Hospitals and CCAC

656

391

0

100

200

300

400

500

600

700

1/3

/20

10

3/3

/20

10

5/3

/20

10

7/3

/20

10

9/3

/20

10

11

/3/2

01

0

1/3

/20

11

3/3

/20

11

5/3

/20

11

7/3

/20

11

9/3

/20

11

11

/3/2

01

1

1/3

/20

12

3/3

/20

12

5/3

/20

12

7/3

/20

12

9/3

/20

12

11

/3/2

01

2

Number of Open ALC Cases - ALL Bed Types Source: ALCIS

Home with CCAC Total Long Term Care

Grand Total Linear (Grand Total)

11

Acute ALC Rates by Hospital Corporations:

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Acute ALC Rate - Internally Monitored Source: Weekly Hospital ALC Trigger Report

10% Corridor Target HHSNHS St. Joseph's

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35


10% Corridor Target BCHS JBMH

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35


10% Corridor Target NGH WLMH

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35


10% Corridor Target HWMH WHGH

ALC 2012-13 Action Items

2012-13 ALC Action Plan Activities

ALC Bundled strategies • Continue bundled strategies that demonstrated improvement in 2011-12

Improve Identification of

High Risk Seniors through

screening.

• Roll out the modified interRAI ED Screener across all LHIN hospital ERs

• Expand Primary Care Screening tool to St. Catharines and Hamilton Family Health

Teams

2011-12 High ALC User

population Analysis by

Hospital site.

• In 2011-12, 730 patients identified as the High ALC Users (top 10% of ALC users),

accounting for 51% of the total ALC Days in the HNHB LHIN

• 68% over the age of 75, 83% admitted through the ED and 65 % were not

receiving home care services

• All LHIN hospitals have completed an analysis of their high ALC population to

develop action strategies

Improve Transitions in Care:

• Introduction and rollout of the Rapid Response Transition Team (R2T2).

• Team consists of nurses and nurse practitioner who will: provide a face-to-face

visit with high risk clients within 24 hours of a hospital discharge and visit with

clients currently in the community at risk of an avoidable ED/hospital visit

Implement HQO BestPATH

Discharge Transition Bundle

at two hospital sites

• Pilot and evaluate processes and tools to improve and facilitate transition from

hospital to the community.

• Develop a toolkit for easy adoption by other LHIN hospitals

13

ER Admitted Patients 90th Percentile Wait Time

Baseline

Q 108/09

Q 208/09

Q308/09

Q408/09

Q109/10

Q209/10

Q 309/10

Q409/10

Q110/11

Q210/11

Q3 10/11

Q410/11

Q111/12

Q211/12

Q311/12

Q411/12

Q112/13

Q212/13

HNHB LHIN 45.1 42.6 40.7 43.7 46.8 39.6 31.6 33.3 37.7 35.4 39.9 36.8 42.1 34.6 31.1 34.7 42.0 32.3 33.4

LHIN Target 28.3 28.3 28.3 28.3 28.3 28.3 28.3 28.3 28.3 28.3

Provincial 36.4 33.4 31.5 33.6 37.5 30.9 29.8 30.4 33.3 30.3 30.8 32.2 35.8 30.4 28.9 30.2 33.1 28.4 30.3

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

90th

Per

cen

tile

Wai

t T

ime

Ho

urs

HNHB ER Admitted Patient 90th Percentile Wait Time

Source: ATC-CCO ER Public Reporting and Pay for Results Hospital Comparison Report Sept 2012

14

• The 90th percentile wait time for the Admitted population became

an MLPA indicator in 2010-11.

• Prior to 2010-11 the indicator was the % of visits completed

within recommended wait time.

• The LHIN demonstrated improvement for the 90th percentile wait

time in 2009-10 from the base line year of 2008-09.

• Since then, the LHIN has been challenged to made sustainable

improvements in this indicator.

ER Admitted Patients 90th Percentile Wait Time cont’d

15

Control Chart ER Admitted Patients 90th Percentile

Wait Time

Source: ATC-CCO ER Public Reporting and Pay for Results Hospital Comparison Report March and Sept 2012

16

26.2 20.3

47.7

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

90

th P

erc

en

tile

LO

S H

ou

rs

ED Admitted Patient ED LOS Large Community Hospitals

BCHS NGH JBMH Target

51.1

44.0

45.4

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

90

th P

erc

en

tile

LO

S H

ou

rs

ED Admitted Patient ED LOS - Niagara Health System

NHS GNG NHS St.Catharines NHS Welland Target

37.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

90

th P

erc

en

tile

LO

S H

ou

rs

ED Admitted Patient LOS Small Hospitals

HWMH WLMH Target

17

15.9

21.5

28.3

0.010.020.030.040.050.060.070.080.090.0

100.0

90

th P

erc

en

tile

LO

S H

ou

rs

ED Admitted Patient ED LOS Hamilton Hospitals

HHSC General HHSC McMaster HHSC Juravinski SJHH Target

Source: ATC-CCO ER Public Reporting and Pay for Results Hospital Comparison Report Sept 2012

ER Admitted Patient Wait Time – Drivers and Actions

Drivers Actions

Number of patients admitted

through the ER requiring

isolation protocols

• Select hospitals are reviewing their isolation processes, including

consultation with provincial experts.

• Request to LHIN Hospital Vice President of Clinical Practice to

review isolation protocols/practices across the LHIN.

Percent of ER visits that are

admitted to hospital

• LHIN hospitals with higher percent of ER visits admitted to

hospital requested to review their admission practices.

• Roll out of ED screener for high risk seniors to all LHIN hospitals.

Availability of inpatient beds

• Maintain high emphasis on LHIN patient flow strategies, including

increased funding for Home First and Service Maximums.

Select LHIN hospital ER sites

that report higher wait times

especially in the last quarter

• LHIN meetings with hospitals and the CCAC to identify

opportunities to improve patient flow and reduce number of admit

to no beds in the ER.

Timely access to primary and

specialist care • Implementation and expansion of General Internal Medicine

Rapid Assessment Clinics.

• Hospitals implementing strategies to reduce time for internal

medicine consult.

18

90th Percentile Wait Times for Non-Admitted ER Patients

Source: ATC-CCO ER Public & Pay for Result Hospital Comparison Report Sept 2012

ER LOS – Non-Admitted High Acuity

• Increasing number of ER volumes – Non admitted high

acuity volumes have increased 27.5% since 2008-09

(50,773 in 2008-09 to 69,950 in 2011-12).

• This population often requires diagnostic procedures that

result in longer wait times.

• Hospitals that report longer wait times are Niagara Health

System (NHS) – Welland and St. Catharines sites and

St. Joseph's Healthcare Hamilton.

ER LOS – Non-Admitted Low Acuity

• Low acuity volumes increased by 2,118 in Q2 over Q1

2012-13.

• Wait times for this ER population are impacted by a high

number of patients waiting in the ER for an inpatient bed

and a high volume of non admitted high acuity patients.

• Hospitals that report longer wait times are NHS-Welland

and St. Catharines sites and Brant Community Healthcare

System

Q110/11

Q210/11

Q3 10/11

Q410/11

Q111/12

Q211/12

Q311/12

Q411/12

Q112/13

Q212/13

HNHB LHIN 7.83 7.92 7.93 7.77 7.78 7.73 7.67 7.87 7.52 7.8

Target 7.5 7.5 7.5 7.5 7.5 7.5 7.5 7.5 7.5 7.5

Province 7.62 7.55 7.52 7.62 7.47 7.37 7.2 7.47 7.23 7.2

6.8

7

7.2

7.4

7.6

7.8

8

90

th P

erc

en

tile

Wai

t Ti

me

Ho

urs

ER Non-Admitted Wait Time High Acuity

Q110/11

Q210/11

Q3 10/11

Q410/11

Q111/12

Q211/12

Q311/12

Q411/12

Q112/13

Q212/13

HNHB LHIN 4.8 4.78 4.72 4.95 4.98 4.83 4.78 4.85 4.8 4.8

Target 4.5 4.5 4.5 4.5 4.5 4.5 4.5 4.5 4.5 4.5

Province 4.4 4.38 4.27 4.5 4.35 4.32 4.18 4.43 4.17 4.2

3.6

3.8

4

4.2

4.4

4.6

4.8

5

5.2

90

th P

erc

en

tile

Wai

t Ti

me

Ho

urs

ER Non-Admitted Wait Time Low Acuity

19

90th Percentile Wait Time For CCAC Services

Q 309/1

0

Q409/1

0

Q110/1

1

Q210/1

1

Q310/1

1

Q410/1

1

Q111/1

2

Q211/1

2

Q311/1

2

Q411/1

2

HNHB LHIN 35 53 28 26 25 54 25 25 25 35

Target 29 29 29 29

0

10

20

30

40

50

60

90

th P

erc

en

tile

Wai

t Ti

me

Day

s

90th Percentile Wait Time for CCAC Services from Community Setting

Source: MOHLTC Stocktake Report May 2011 and 2012

• CCAC, in order to support clients with higher care

needs (Home First), traditionally placed clients

determined to have lower care needs on a wait list.

• As funds become available, clients are removed from

the wait list and the wait time in that particular quarter

is impacted and increases.

• Over the past year, CCAC has worked with

Community Support Services to transition low acuity

clients from the wait list.

• CCAC has also implemented a strategy-

Occupational Therapy Independence Pathway (OTIP)

whereby clients would be assessed by an

occupational therapist to determine if any equipment

needs/assistive devices are required before placing

low acuity clients on a wait list.

• Many clients, once assessed and equipment installed,

may no longer require to be wait listed for Personal

Support Worker support.

20

Control Charts – Baseline Comparison

• HNHB LHIN staff have been working with statistical experts at the

Ministry of Health and Long-Term Care (ministry) and Health Quality

Ontario (HQO) on data reporting.

• The Quality and Safety Committee data has been presented with upper

and lower control limits to assess statistically significant variation.

• HNHB LHIN staff are now utilizing control charts with comparison

against a historical baseline.

• The limits (calculated on 2009-10 data) have been extended forward so

we can compare if a process is in control/out of control compared to

2009-10.

• This technique is designed to better assess special and common cause

variation to assist in making intervention decisions.

Cancer Surgery at the HNHB LHIN

Source: “Adult Surgery and DI Hospital Comparison Report”, WTIS, Access to Care, Cancer

Care Ontario

Cardiac By-Pass Surgery at the HNHB LHIN


Care Ontario

Cataract Surgery at the HNHB LHIN


Care Ontario

Hip Replacement Surgery at the HNHB LHIN


Care Ontario

Knee Replacement Surgery at the HNHB LHIN


Care Ontario

MRI Scans at the HNHB LHIN


Care Ontario

CT Scans at the HNHB LHIN


Care Ontario

Recap of Public Indicators

• Coming in November 2012 –

Emergency Department

(ED) and Alternate Levels of

Care (ALC)

• February 2013 – Remaining

MLPA indicators

29

30

Questions?

ministry-lhin performance agreement (mlpa) patient flow …/me… · patient flow report quality...

Documents