Compromised accreditation?

Is the hospital accreditation process compromised by coercion?

In Nova Scotia our health authorities traditionally cherry-pick the results to build a story that everything is fine and our system is maintaining national standards. But these same health executives ignore results that show half (between 48 to 52 percent) of their staff don’t trust, believe or respect them.

I raise the question because I’ve been told that this week Valley Regional Hospital in Kentville is undergoing the accreditation process. In prep for this VRH circulated the accreditation questionnaires and attached management-approved answers. That doesn’t seem in the spirit of fact-based research.

But VRH’s action isn’t the first time I’ve had people in the health care system question the accreditation process. Five years ago a hospital worker told me that their authority would hire extra staff for the accreditation period, call a Code Purple as a way to empty the ER for a day and send patients to another hospital if they were overcrowded.  I was also told of a manager at the Pictou hospital who stood over her staff as they filled out their accreditation questionnaires. My source said this manager claimed it was to prevent errors or confusion. But even this type of passive-aggressive management failed to stop staff from trashing the place. When the health authority published the accreditation results national averages were stripped out so people couldn’t see how poorly they performed against other hospitals.

A former accreditation surveyor says, “ It is difficult, almost impossible, to get objective information about what is happening. Surveyors rarely got to speak with unselected patients or staff except for a few (surveyors) who get off of the beaten track.”

Silencing comment is not unlike the experience provided to a health minister when they visit a hospital. Executives who work off-site are on-the-floor to micromanage every minute of the minister’s time so that he/she never comes in to contact with anyone who hasn’t been prepped on the proper platitudes to present to the politician.

It’s ironic that this arises in the week when women everywhere are posting #metoo on social media to show the scale of sexual harassment in the workplace. That’s wrong. Perhaps the next campaign will be about management coercion and improper pressure. That’s another type of harassment. In the meantime, we are left to wonder about the accuracy of the hospital accreditation process.

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Launching a regional solution for PTSD centre of excellence

A clinical psychologist in Halifax, Dr. John Whalen, is calling for a PTSD centre to be established to service Atlantic Canada. Dr. Whalen would like to see a facility open in Halifax.

Reading headlines from around the region, PTSD seems to almost qualify as an epidemic.

Back in February I privately suggested there was a turn-key solution for the situation. Turn-key in terms of a facility.

A U.S.-based colleague confided that he had spent years dealing with depression. One facility which turned his life around is the Brattleboro Retreat in Vermont. I looked at their website. They have a campus like that of a small college. It looked like a healing place.

This prompted me to think we could have a Brattleboro-like facility by repurposing the Memramcook Institute into a facility treating PTSD and related illnesses. The Institute opened 150 years ago as Collège Saint-Joseph, which became the University of Moncton. It then morphed into a conference centre and was later operated as a four-star resort. The resort failed, but the buildings and campus amenities survive. The Province of New Brunswick owns the facility and spends $5 million a year to maintain it while they try to figure out what to do with the buildings and campus. In 2013 New Brunswick struck a committee to find a new use for the facility. None has been found.

This could be a perfect, almost off-the-shelf, turn-key solution to a problem vexing all four provinces. The institute has the physical structures and facilities of a small university in place. There are bedrooms, classrooms, kitchens, cafeterias and dining halls, recreational facilities, laundry and so forth. The province has been maintaining the facility, so the set-up costs would be for cosmetic fixes, furniture and staffing. There would be no significant capital outlay or construction delays. The biggest challenge is finding the staff.

It could be an unique enough concept to appeal to professionals looking for a change as well as young professionals bored by the grim, traditional options. It might even become affiliated with a medical school to turn it into a teaching facility and a centre of excellence for mental health issues. And, if it served four provinces, perhaps staffing could be managed on a rotation basis, which clinicians, like Dr. Whalen, coming in for defined periods.

The provinces have been discussing cooperation on various files and this could be a solution for the mental health challenges.

The Institute is located in Memramcook between Amherst and Moncton. Its location is central for New Brunswick, Nova Scotia and Prince Edward Island. Patients from all three Maritime provinces could drive or be driven to it. For families in Care Breton it’s not that much farther than Halifax, less inconvenient and probably less expensive than a trip to the city. Islanders only have to zip across the Confederation Bridge. Newfoundland could fly patients to Moncton. Quebec might also consider sending patients from the Magdalen Islands – they take a ferry to Souris, PEI, and drive over. NB is bilingual, so that removes linguistic and other issues for Quebec patients. It might also work for the military since CFB Gagetown, Shearwater, Halifax and Greenwood are less than a three-hour drive.

I doubt there is another facility like it in Canada. Rather than a city-centred hospital that so many mental health facilities are this offers a country campus. It’s quiet and like a resort for troubled souls. A retreat, like Memramcook, may provide the space, distance and a type of positive segregation to help someone regain control of their life. (By positive segregation, I mean they can take treatment, sit in the sun, exercise or do whatever they want to without feeling the pressure of being judged by strangers passing through a hospital corridor.) It could be large enough for families to have multiple day visits to see how the patient deals with the pressure/pleasure of family before returning to their home community.

This would be a quick, tangible and real solution to a growing problem. And could be done at an unimaginably low cost for health care.

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Slow ambulances nothing new

The news today is slow off-loading of ambulance patients at major hospitals in Halifax. The provincial requirement is for patients delivered to hospital in an ambulance be off-loaded within 20 minutes 90 percent of the time.

Halifax’s failure to meet the requirement is nothing new. The last time we learned of this failure in delivery of care was in 2010-2011. A then weak or disinterested health minister allowed the Capital Health Authority to set their time-line for improving performance. It was a five-year to-hell-with-patient-pain-and–suffering solution that also ignored potential catastrophic consequences of delaying ambulances in hospital parking lanes.

This is what I wrote in April 26, 2012:

The province has a target to off-load patients from ambulances in 20 minutes 90% of the time. Capital Health is nowhere near meeting provincial targets. In their fourth quarter report for 2010-2011 they admitted to off-loading patients in 133 minutes. That was up from the 114 minutes it took in the previous quarter. Capital Health promised to improve that by 10% per quarter. At 10% per quarter it will take them until September 2016 to achieve the provincial health department’s targets. That’s not performance. And what if they don’t achieve their own target? Aside from the pain and suffering and inconvenience to patients, what is the impact on executives collecting six-figure incomes? I don’t understand why the Minister and the Premier think it’s acceptable for this health authority to flaunt the regulations this way. Allowing public servants to re-set loose, self-regulating, multi-year soft targets is one more example that this administrative structure is not operating in the public interest.

https://helphealthcare.wordpress.com/2012/04/26/capital-healths-poor-performance/

I brought up slow off-loading on:

January 4, 2012:

https://helphealthcare.wordpress.com/2012/01/04/if-it-happens-in-ontario-is-it-happening-here/

July 30, 2014:

https://helphealthcare.wordpress.com/2014/07/30/health-care-whats-in-a-name/

February 7, 2015:

https://helphealthcare.wordpress.com/2015/02/07/why-arent-ambulances-included-in-universal-care-coverage/

March 16, 2015:

https://helphealthcare.wordpress.com/2015/03/16/a-worrisome-timeline-for-change/

June 12, 2015:

https://helphealthcare.wordpress.com/2015/06/12/how-fast-is-health-care/

and on November 6, 2016 I wrote this:

Another example of this preferred five-to-seven health care timeline arose in the fourth quarter of fiscal 2010-2011. It was a different administration, but it was discovered that Capital Health took up to 133 minutes (two hours +) to offload a patient from an ambulance instead of the provincial criteria to complete this in 20 minutes. Capital Health told the then NDP government they would improve by 10 percent per quarter to achieve the provincial requirement. For some unexplained reason, then Health Minister Maureen MacDonald allowed then Capital Health CEO Chris Powers to dictate to the ministry. Doing the math, this incremental quarterly change meant Capital Health/NSHA wouldn’t meet the provincial requirement for five years. The health authority’s self-imposed deadline was September 2016. In those five years, people in dire enough condition to be delivered to hospital in an ambulance could be left for hours in an ambulance without being seen by hospital staff. Allowing the authority to determine what would happen is insensitive, unresponsive and arrogant.

https://helphealthcare.wordpress.com/2016/11/06/health-cares-five-and-seven-year-timelines/

It is clear that Nova Scotia’s health executives rely on a short public and political memory to get away with continued failure to deliver care. It is time for the Department of Health to dictate to the Nova Scotia Health Authority a time-frame for fixing the problem. And it has to be a short time frame because obviously anything else is merely cover for the executives and not a serious solution.

 

 

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Impediments to practice

We’ve learned that Nova Scotia’s doctors are feeling burnout and stress at greater numbers than ever. This has long been known, but was made “official” with the release of a Doctors Nova Scotia study in September.

Nova Scotia’s doctor shortage is the result of a combination of circumstances: practice-limiting restrictions, poor treatment and low pay.

Practice limitation:

The Nova Scotia Health Authority used a spread sheet to decide where doctors practiced. With an eye on court cases which overturned attempts by other health authorities to restrict where doctors practiced, NSHA introduced credentialing to the equation to decide where doctors practiced. Credentialing is essential for a doctor. Without it a physician can’t order medical tests, write prescriptions or send a patient to hospital. Without those abilities the physician can’t bill for services and patients are left without essential tests, treatments and medications. In essence it is a type of medical rationing they hope withstands a legal challenge.

The idea was to level out where doctors established their practices. For example, Halifax is, statistically, over-doctored. So rather than allow more doctors to establish a practice there, the idea is to encourage doctors to go to rural areas. The caveat is that they go to a rural area to work in a collaborative care centre.

There are several problems with this: while Halifax may statistically be over-run with doctors, many are specialists who don’t provide family practice services. The statistics don’t differentiate the doctors, which is why as many as 20 percent of Haligonians may be without a family physician.

Secondly, this type of geographic limitation to care is old thinking brought forward to a new unified system created to overcome the inefficiencies of the former silo system. Under the old system of nine regional health authorities patients were to be treated within their home health authority and not travel further than 100k for care. A laudable goal, but one that is quickly negated when it compounds and/or prolongs suffering or delay in delivery of care.

Since merging the health authorities we have been able to better utilize some facilities and assets. For example, hundreds of patients have accepted the option of driving to Amherst for knee surgery versus waiting a year or two to have it closer to home.

The NSHA’s current geographic focus overlooks patient mobility and our commuter society. A quick look at commuters driving Highways 101, 102, 103 and 107 would illustrate how many people travel daily to Metro for work. If these rural or non HRM residents had access to a city-based family physician most would not find it inconvenient.

Geographic silos created the backlogs which haunt us today. While some places had sufficient resources for the local population, others had waiting lists, while other authorities’ facilities and professionals were under-utilized.

Physician treatment:

Another issue with practicing medicine in Nova Scotia is how doctors are treated. Nova Scotia is currently divided into five health zones. A doctor told me that the head of their zone “speaks to us like we’re all idiots” and told a roomful of doctors, “If I were you I wouldn’t renew my lease.” His advice was based on population density numbers and the Physician Resource Plan, not actual need seen by doctors in that zone.

The NSHA refers to consultations. That is PR-speak. Their interaction with medical professionals is top-down. Whether written, in a teleconference or face-to-face meeting the conversation is one-way. It has let doctors know what has been decided about how they practice, where they practice, what they practice. Done without input from them.

I was told of a Cape Breton meeting where a roomful of doctors called the NSHA executive speaking to them a liar who should be ashamed of their bold-faced lies.

In December 2015 or January 2016, I’m fuzzy on the date, I was told of a meeting with family medicine residents set to graduate in June 2016, which students left in tears. This meeting changed the work options for both new graduates and practicing doctors.

At another meeting a health executive told a roomful of physicians they were a “privileged elite who had no concept of reality”. Hardly collegial.

The Money:

Finally, there is no financial incentive to practice in Nova Scotia. The Canadian Medical Association says the average income for a general practitioner in Canada is $251,362. In Nova Scotia the average is $214,567. That’s a practice income, not the physician’s take home pay.

https://www.cma.ca/Assets/assets-library/document/en/advocacy/37-avg-gross-ffs-e.pdf

To make ends meet in this province many doctors have been reducing patient appointments to 15 minutes. That production-line like scheduling means a family physician sees four patients per hour, 32 per day, 160 per week and 7,680 per year. Recently, I have learned of some doctors who have shaved appointments down to 10 minutes. Their numbers become: five patients per hour, 40 a day, 200 a week and 9,600 a year! Like a teacher, there’s unpaid evening and weekend work on files. No wonder there’s burnout.

With a combination of career limitations, adversarial workplace and some of the lowest income in Canada, why would physicians flock here?

Ironically, in the 1990s and 2000s Atlantic Canada promoted the concept that lifestyle trumped cash. A number of business voices touted the message that employers could find an educated workforce willing to work for less for the opportunity to stay home or return. Interestingly, while business media, organizations and government adopted that message, governments and health executives took a different tract when it came to hiring for their ranks – and setting their pay. We were told that we had to be aggressive in executive compensation in order to attract the best people for the job. That’s not the way their treat medical professionals.

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Corporate governance, confidence and care

In spite of the scandal involving the IWK’s CEO expenses and role the Chief Financial Officer played in smoothing over the bumpy, uncomfortable details, confidence has been expressed in the IWK.

Confidence is the pro-forma, generic response. In attempting to contain the damage comforting sounds have to be made. It’s PR101. Expressions of confidence are primarily for internal face-saving. Public opinion is messier, more blunt and contrarian.

No one has called into question actual patient care at the IWK. The rot isn’t on the patient floor, but executive suite and board room. Confidence seems to be a flexible word. The previous board chairman told the CBC, and by extension the public, that he and the board had confidence in the CEO, CFO and processes in place. Now the CEO and CFO are the “former CEO”, “former CFO” and the processes are under review by the Auditor General.

To repeat, it’s not the patient care that’s in question it’s the management and corporate governance. It’s going to take a lot of work to convince the people that the board hasn’t been asleep for 27 months.

When this scandal broke, a patient rights group sent me a PDF of the boards of the IWK and Nova Scotia Health Authority. The IWK has a 19-person board for a $250 million budget. The NSHA has a 13-person board for a much bigger budget. The Province of Nova Scotia has a 17-person cabinet to manage a $10.5 billion budget.

Corporate governance is always a challenge. How big is too big, when is a board too small? What are the proper mix of skills, experience and knowledge? Is the IWK board too big to be effective? Or could the NSHA board be too small? And given the problems with governance at the IWK, what is happening at the ultra-secretive NSHA?

Prior to the unfolding of the IWK expense scandal, the complaint was that the NSHA board lacked representation from medical professionals. Whatever is the right size for a health board, what is missing from both is strong patient representation.

The system is unlikely to ever achieve public aspirations until those who have used and experienced the system have a voice. A patient voice represents one of the real measures for effectiveness. We’ve had top-down directives. It hasn’t worked. Patient floor up is what hasn’t been tried.

 

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Imagine there were no doctors

To highlight the depth of Nova Scotia’s doctor shortage I’ve studied the 2016 census figures to provide a geographic perspective and give these statistics a sort of face. Picking up on John Lennon’s theme of imagining, imagine there are no doctors…

If Corporate Research Associate’s recent finding that 13 percent of Nova Scotians, roughly 123,500 people, don’t have access to a family physician is accurate, here’s what that means:

nscounty

Block out counties as you read to grasp the scale of our physician crises.

  • imagine no one in all of Cape Breton having a physician. That’s 122,311 people. Imagine 12 hospitals and health centres without doctors.
  • or imagine no doctor for the residents of nine of our 18 countries: Antigonish, Annapolis, Digby, Guysborough, Inverness, Queens, Shelburne, Victoria, Yarmouth. That’s 124,860 people. That would leave 20 hospitals and health centres without physicians.
  • consider the 132,525 people who live in Kings, Annapolis, Digby, Yarmouth, Shelburne and Queens counties without family physicians. That’s a doctor-less Southwest Nova. Not only that, there would be 16 hospitals and health centres without access to a doctor.

If the actual number of Nova Scotians is the 155,415 orphaned patients suggested by the October 2016 Freedom of Information request, then stretch the imagination to this doctor-less geography:

  • most of Southwest Nova (Kings, Annapolis, Digby, Shelburne, Queens and Lunenburg counties) without a physician. That’s 155,232 residents. That’s the bulk of our agricultural, fishing and forestry sectors at risk.
  • imagine driving from the New Brunswick border by Amherst to Meat Cove on the tip of Cape Breton without crossing any community with a doctor. Cumberland, Colchester, Pictou, Antigonish, Richmond, Inverness and Victoria counties have a population of 156,214 Nova Scotians. They’re home to 18 hospitals and health centres.
  • finally, imagine no doctor for the 156,150 residents of Halifax’s commuter counties: Annapolis, Kings, Hants and Lunenburg.

Imagine driving through county after county without a single physician available. This is how severe our doctor shortage is. It’s more than being down a few physicians here and there.

There aren’t just the current vacancies to fill, there is a rising wave of physicians about to retire, who must be replaced. Our current health care executives are not adequately addressing the issue of physician retention or recruitment.

And given how badly physicians are paid and treated in this province, why would they want to practice here.

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Doctor shortages by the numbers

A new poll by Corporate Research Associates says 13 percent of Nova Scotians (approximately 122,000 people) don’t have a family doctor. That’s probably an optimistic number.

Statistically, Nova Scotia appears to almost qualify as a medical nirvana, with one of the highest doctor-population ratios in Canada.

However, some suggest the ratios are skewed by the medical mix. Of the 177 new hires NSHA claimed between April 1, 2015 and March 20, 2017, 71 are family physicians and 106 are specialists. That leaves a significant portion of the population waiting years for a family physician.

Figures for orphaned patients range from 25,000 to 95,000, but could be well in excess of 150,000.

The 25,000 figure represents the number of people who, in the first five months it was available, called a doctor registry hotline instituted by the Nova Scotia Health Authority (NSHA). Later the NSHA adjusted that to 33,000 people looking for a doctor. Doctors Nova Scotia (DNS) says a freedom of information request filed by the Progressive Conservatives found that a study done in October 2016 “was quite startling. We’ve always run on a premise of as many as 10 per cent of Nova Scotians don’t have a family doctor (95,000). This survey indicated in the Halifax Regional Municipality (HRM) about 20 percent of residents and in rural Nova Scotia about 14 percent (didn’t have a family physician) so both of those numbers are higher than what we expected.”

Using the October percentages, that means 155,415 Nova Scotians (78,019 in HRM and 77,396 rural residents) don’t have a family physician. The orphaned patient numbers grow even worse if the projections from a 2012 Physician Resource Plan are used. The Plan predicts that by 2021, the population health services needs will be equivalent to a population of 1,100,000.

That 1.1 million population figure is based on our current aging population, not an influx of new residents. In other words, it is adding the needs of 60,000 more people to the system. That’s basically the population of Kings County to squeeze into our existing system.

One of the problems in attempting to quantify the doctor shortage is the NSHA’s inability to say how many doctors there are in the province. In April, a NSHA representative said, “Given daily changes with retirements, deaths, relocations, etc. and the complex roles that family doctors play, this number fluctuates regularly. On any given day in Nova Scotia there are more than 1000 doctors seeing patients in a family practice.

“If you include specialists, there are more than 2600 doctors in Nova Scotia.
“The best source for these numbers are CIHI Physician Migration Studies.
https://secure.cihi.ca/estore/productSeries.htm?pc=PCC34

“Family physicians are independent contractors; they are not employees of NSHA. NSHA does maintain a list of vacant positions by zone and positions that are coming vacant when a physician has given notice that they will be leaving or relocating.

“NSHA does not maintain a centralized list of physicians.  We do work with family physicians to better understand when they are planning to retire or leave the province.”

Since the NSHA doesn’t know how many doctors are in practice in the province, they can’t guess at how many Nova Scotians don’t have a doctor.

Physicians complain about the age of data and methodology used to make guestimates. The Physician Resource Plan, which is the guiding document for the NSHA, was published in 2012 using data gathered in 2008. So the Resource Plan was launched with old numbers and five years later relies on what front-line doctors feel are unrealistic numbers.

How can you fix a problem you can’t quantify?

 

 

 

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