Quality of Care

Nursing Care

There are insufficient numbers of adequately trained individuals to monitor patients' progress, change bed clothing, assist with ADL's, perform dressing changes, turn patients, supervise intravenous therapy, and provide suitable post-operative or convalescent nursing care. Nurses are also so rushed that they cannot document their activities adequately. This means that physicians are inadequately informed of their patients' progress.

E.g., a lady with a tibia-fibula fracture received no change of bed clothes or help with personal hygiene for a week. E.g., a man in a wheelchair with a fractured spine received no assistance with bowel habits. E.g., a patient was found in bed with a respiratory rate of 8 by his doctor. E.g., an inpatient lay bleeding and in shock for two days after surgery, losing 50% of his blood volume. E.g. a patient developed compartment syndrome of the leg overnight, which was not noticed and led to severe disability. E.g., falls by the elderly and infirm are more frequent; there are no staff to supervise them. E.g., more patients are turning up with bedsores and contractures because they are not turned.

Most of the patient-submitted complaints and disasters related to this issue of the shortage of nursing care. The long term costs here are high: post-operative contractures, falls, nosocomial infections, medication errors (as high as 20% on at least one ward), and increased incidents in general. A number of detailed and carefully documented cases of inadequate care were submitted by patients' families and by physicians.

In the 34 weeks ending May 24, 1996 the Alberta Association of Registered Nurses (AARN) received twice the number of complaints relating to patient safety concerns as they received in the preceding 34 week period. 2/3 of the complaints related to the CHA. Prior to regionalization the AARN

received very few complaints . From January 1 to June 30, 1995, nurses submitted 53 Professional Responsibility Committee (PRC) claims to management documenting their professional concerns. For the same period in 1996, 232 PRC claims were submitted, an increase of 340%.

Medical Supplies

There is a shortage of supplies which are essential to proper patient care. E.g., nurses on the wards are unable to obtain the basic supplies which they need. E.g., eggcrate mattresses (to prevent decubitus ulcers) are hard or impossible to find. E.g., there are not enough IV poles or pumps available at RAH emergency. E.g., at times there are no litre bags of saline available. E.g., there are problems with indwelling catheter kits and at times broviac catheter kits are not available. E.g., a drain was ordered but unavailable for a patient undergoing neurosurgery; the patient had to be resuscitated, then reanesthetized to complete the operation after a drain was finally found.

Treatments

Some treatments are not available or restricted. E.g., low molecular weight heparin (blood thinner) is not on the formulary. E.g., there is difficulty in obtaining FFP and cryoprecipitate (hematology). Some essential new drugs are not available because they are not affordable. E.g., there is no money for Desferal, interferon, or growth factors. E.g., there is no money for Sevoflurane (inhalant anesthetic). E.g., there is a need to cover the increased costs of transplant drugs and AIDS drugs.

Laboratory Services

The laboratory budget for Region 10 was reduced from $77.8 million to $47.1 million, a reduction of 40%. 500 workers were cut. The number of lab technicians in April 1995 was 379; the number projected for December 1996 is 214, a decrease of 44%. Staff are "run off their feet" trying to keep up with demand. The new $12 million state-of-the-art lab at RAH has been closed for all but emergency tests.

A new lab information system was put in place but there was a failure to implement a backup system and a refusal to have a gradual or trial period of switching over to the new system. Meanwhile, the volume of requisitions for laboratory services continues to increase, which is overwhelming the capacity of the present system and the personnel who use it.

In view of the massive cuts which were made, those responsible for the reorganization of lab services were given an almost impossible task. There are numerous documented problems reported pertaining to laboratory services. All result in delays for patients and poor patient treatment, with potential for serious problems.

1. Accessibility.

Lab facilities are less accessible. E.g., the closure of over 125 collection sites has created more difficult access, especially for the infirm. E.g., UAH lab collection services on 2E2 have been closed. E.g., Grey Nuns collections discontinue after 6 PM, except for children, hard to collects, and the medicine floor. E.g., sometimes 50 patients are waiting at once for service. E.g., patients are waiting up to 1 1/2 hours in the lab to have blood taken. E.g., doctors are not allowed to take urine samples of handicapped patients on their premises. E.g., a patient with abdominal pain was sent

to emergency because lab service was unavailable. E.g., the lab refused to screen bottled breast milk fed to a baby for cocaine because the baby's mother was not a patient in the hospital.

2. Collection.

Collection of samples by inexperienced and inadequately trained individuals results in distress for patients. There are long waiting times and line-ups. Sometimes technician phlebotomists are too busy to get blood samples.

3. Care.

Lab workers are pressed for time and cannot take the care they should in performing their duties. If they are too busy, lab staff have to eliminate recalibration from some testing protocols. Cultures are not handled with the same care they were in the past and the consequences for patient care decisions can be catastrophic.

4. Lost Specimens.

The loss of or incorrect labelling of specimens is not at all uncommon. Physicians, nurses, and ward clerks are spending valuable time pursuing lost samples. Some are never recovered. Mail is lost; test reports are sent that never reach the physician. E.g., a node biopsy for suspected lymphoma was still not received after three weeks. E.g., one physician reported 8 missing results in one week. E.g., 130 specimens were not found from April to July 96.

5. Delays.

Lab results are taking too long to be returned. Physicians are labelling less urgent tests as STAT to get results within a reasonable period of time. E.g., one patient who waited four days for results of a thyroid test was in the prep room for surgery when the results finally arrived. E.g., lab results for a psoriasis patient on Soriatane who needed monitoring due to abnormal liver function took two weeks; his ALT (alanine amino transferase) test was 734 units per liter, with normal limits from 5-30. E.g., specialized tests for bleeding and thrombotic disorders take too long. E.g., routine tests now take a week instead of 24 hours. E.g., test results which once took 1 or 2 days now take 13-14 days. E.g., there are delays in radioisotope reports.

There are major bottlenecks collecting and processing STAT results and increasing unavailability of STAT results. E.g., STAT tests can take four hours plus. E.g., there is a 2 hour wait for emergency blood tests (used to be 20-30 minutes). E.g., a STAT blood test on a baby with neutropenia (abnormally small number of neutrophil cells in the blood) was not available at the end of the day because it had to be sent to the central lab. E.g., the time from a critical NA test result to notice on the ward was about 8 hours. E.g., a STAT test for a patient with critical hyperkalemia (excess potassium in the blood) took about 1 1/2 hours.

6. Reporting.

The quality of lab results is questionable. E.g., there is inconsistency in indicating that tests are underway or pending. E.g., there is inconsistency in highlighting results as above or below references. Incorrect results are being sent. E.g., an erroneous report was sent that a baby had meningitis and the baby was treated unnecessarily. E.g., an erroneous report was sent of coli septicemia in a pediatric case. E.g., an erroneous report was sent of non-candida yeast septicemia in a geriatric case. Orders are dropped off the sheet and not done. Physician requests for tests are returned marked "cancelled" with no explanation.

7. Waste.

Multiple reports are produced on the same tests of individual patients. E.g., nine unwanted sheets were received on one patient. Some physicians receive two copies of the same report two days apart, one with slightly more information.

8. Communication.

Results are not being sent to the appropriate physicians. E.g., the result of a biopsy from a lesion on a patient's temple was sent to the GP and to Cross Cancer but not to the dermatologist, which delayed treatment. It is difficult to get through on the helpline to try to resolve problems.

9. Tests.

Some tests cannot be done, for example, Bence Jones protein for diagnosis of monoclonal gammopathies including multiple myeloma or erythropoietin assays for diagnosing polycythemia. There are long delays or inadequate resources to initiate new tests such as APC resistance assay

for management of patients with hypercoagulable states, anti-Factor Xa levels needed for management of some patients with "heparin resistance", or quantitative homocysteine and methylmalonic acid assays.

10. Information

Community physicians cannot access the central computer directly to collect lab information on behalf of their patients. This results in costly delays and often duplication of tests for patients who have received care from another physician in the region.

11. Process

The Quality Committee formed for laboratory services keeps all information completely confidential, not even sharing it with the directors of the laboratories. Individual laboratory physicians have been unable to voice their concerns in any manner which is significant in modifying the process. There is no Program Council for Laboratory Medicine and Pathology physicians.

Radiology and Diagnostic Imaging

Access to magnetic resonance imaging (MRI) is severely limited, with a long waiting list. 745 were waiting in September. Elective MRI patients are waiting 12-20 weeks. Some physicians are deciding not to refer patients at all because of wait lists, e.g., orthopedics. Too long waits will result in increased costs later as patients are not investigated in a timely manner, for example, if a malignancy is not diagnosed at a treatable stage.

Staff can do virtually no chest, cardiac, or abdominal MRI, except in exceptional circumstances, due to inadequate resources. There is an inability to provide timely access for acute orthopedic conditions or to do screening MR angiography of carotids. Attempting to develop and implement new techniques such as MRCP is nearly impossible and existing technology is falling behind advances.

Only one CT scanner is available at RAH. CT scans are delayed. E.g., one patient spent 4 days in bed in pain awaiting a scan and 6 more days to get a report, then was told he needed surgery. The Misericordia is having to decrease its volume of CT scans from 4500 to 4000 due to budgetary restrictions.

There is an increase of about 50% over last year of minor injuries to diagnostic imaging and radiology patients at UAH. They usually occur during transfer from wheelchair to table or stretcher to table. Also, more of these patients are falling or fainting.

Tissue Biopsy, EKG

Some tissue biopsy results take up to two weeks to return. Some electrocardiogram (EKG) results are not getting to the patient's physician and, as well, copies are not being made.

Nosocomial Infections

Nosocomial (hospital-acquired) infections are on the rise. Primary bloodstream infections have risen. E.g., in the NICU at RAH, bacteremias per 1000 patient days have increased from .3 in 1994 to 3.6 in the second quarter of 1996 (1100% increase). E.g., hemodialysis-related blood stream infections at UAH have tripled by comparison to historical trends.

Antibiotic resistant bacteria infections have risen. E.g., aminoglycoside resistant enterococci are increasing in frequency, from .3 per 1000 admissions in May-June 92 to almost 6 in Jan-Mar 96 (1900% increase). E.g., there was a major outbreak of gentamicin-resistant enterococci at one hospital in 1995. E.g., 4 enterococcal bacteremias occurred in one three week period in one hospital, resulting in two fatalities. E.g., elderly patients were found to be infected with methicillin-resistant staphylococcus aureus (MRSA).

Other infections have arisen or appeared for the first time, for example, the first incidences of nosocomial Rhizopus in pediatrics oncology since 1991. Nosocomial Rhizopus has also appeared in adult hematology patients and in a lung transplant recipient.

Work Environments

Cluttered work environments due to reduced housekeeping services are causing reduced access to sinks and increasing nosocomial infections, with disastrous results for patients and increased care costs. This is particularly true of infections of methicillin-resistant staphylococcus aureus, antibiotic resistant enterococci, and clostridium difficile.

Meals

Patient food is of poor quality. Meals arrive late, cold, frozen, unpalatable, or incorrect meal for that individual. Diabetic diets are not on time or not attended to. Patients are kept fasting long after their procedure is done or canceled. Many trays are returned with food uneaten. E.g., a patient who did not eat following mental illness because of poor food quality was referred to a psychiatrist to investigate why he was not eating.

Food choices are reduced or nonexistent. It is difficult to order special items, e.g., salty foods for the treatment of hyponatremia. There is no extra menu for long stay patients, e.g., hematology patients.

Almost daily complaints about food are received from patients. Regional patient food satisfaction surveys of UAH, RAH, Misericordia, Grey Nuns, and Sturgeon show a decline in food satisfaction at four hospitals comparing the first seven months of 1996 to the last three months of 1995. The biggest decline was in the three hospitals using the new centralized food system, which also have the lowest overall ratings -- all below 60%. The Sturgeon declined 27%, UAH declined 15%, and RAH declined 13%. The Misericordia declined only 5%, while at the Grey Nuns patient satisfaction increased 1%.

Similarly, the percentage of patients surveyed who stated they were either dissatisfied or very dissatisfied with their food has markedly increased at the hospitals using the centralized system but has decreased at the two hospitals using conventional kitchens. Dissatisfaction increased 29% at the Sturgeon, 13% at UAH, and 4% at RAH. Dissatisfaction decreased at the Misericordia and at Grey Nuns.

Therapy

Access to speech therapy or rehabilitation therapy is difficult. There are related costs due to reduced productivity and long term management.

Physiotherapy is more difficult to access. Patients are either going without or are paying privately, sometimes to avoid waiting. Patients are only allowed nine treatments, then must either pay or wait two months. The result of patients not accessing physiotherapy is increased morbidity and often increased costs in the long run.

Homecare

There are insufficient resources for the increased volumes in home care services. The handoff from active to home care is inefficient. Home care often makes their own assessment only after the patient is discharged. Staff are not properly trained. Home parenteral therapy intravenous (IV) lines and connectors do not match hospital connectors. Continuity and constancy of care is disrupted in homecare because providers may change daily.

Home care visits do not occur often enough to fulfil patient needs. E.g., a man in his late seventies caring for his wife with late-stage colon cancer plus complications, had weekly homecare reduced from 27 hours to 4 within a two month period due to cutbacks. E.g., patients with joint replacements receive home care physiotherapy once a week or even once every two weeks even though hospital staff have identified they need two to three visits per week or daily service.

Seniors' Group Homes

There is a lack of standards, lack of supervision, lack of monitoring, and lack of licensing for some group homes which care for three or fewer seniors. Without accountability, these homes may provide a dubious standard of care.

Disabled Adult Transportation Service (DATS)

There are heavy strains on DATS services. The number of transportation disabled adults in 1995 was estimated to be about 17,500. The number of DATS users with cognitive impairment has increased by about 45% since 1991. This group utilizes 28% of all DATS trips.

DATS has only obtained funding for 745,800 trips in 1996, with 801,600 trips estimated. This is a shortfall of 55,800 trips. More people are being discharged from hospitals into the community and to community programs, and medical services are being dispersed to different sites. The steadily increasing demand for transportation, estimated to be over 4% per year, exceeds the supply. DATS is unable to meet this demand with its present resources.

More and more people cannot obtain necessary transportation to work, medical services, educational programs, and leisure programs, which negatively impacts their quality of life and is a cost to the society. The DATS boundary is Edmonton but the Northwest Regional Zone covers both Edmonton and St Albert, which means that many people within Region 10 cannot access DATS services at all.

Staffing

Physicians

Physicians are leaving the region to work elsewhere. E.g., doctors moving to Saudi Arabia. E.g, doctors moving to the U.S. E.g., retinal surgeons have moved to Calgary and the U.S. E.g., lab physicians have left the province. E.g., pediatricians have left. E.g., as of January 1, 1996, 227 physicians out of 4500 (5%) were planning to leave the province, according to the Alberta Medical Association (AMA).

The recruitment of new physicians into Region 10 is being negatively impacted. One highly qualified Canadian who recently decided not to further pursue consideration of a position in Region 10 stated: "...in the current political environment, the preservation and development of the clinical service is a daunting task. I believe in rising to challenges, but in this case I perceive the control of essential basic resources lies at a level which I could not realistically influence."

Surgeons

There is a lack of definitive roles, sites, and vision, and a lack of identification with specialty, site, region or program. The surgical program lacks direction and unity. There is poor downward communication in the program and a lack of consultation. The high-low intensity plan is proving unworkable. There are critical subspecialty manpower shortages. There is an increased demand on time for non-productive work, e.g., driving between sites. Surgeons have little time for teaching.

Nurses

Inadequate qualified RN presence on wards was an extremely important complaint of many patients and physicians. The severity of illness has greatly increased on our wards, however, the number of trained, experienced RN's to deal with this problem has dropped dramatically. Working teams of specially trained nurses in specialties and sub-specialties have been seriously disrupted by lay-offs.

According to Alberta Health, 19,033 RN's were employed in Alberta in 1992. In 1995, 10,758 were employed. This is a decrease of 43%. Over the same period of time, the number of licensed practical nurses (LPN's) employed in Alberta has also decreased by about the same percentage. In Region 10, the number of RN's employed has decreased from 5305 to 3114, a decrease of 41%. 24,580 nurses were registered in Alberta in 1993. This number decreased to 21,434 in 1996, of which 6048, or almost 30%, are currently unemployed or only casually employed.

Because of inadequate staffing, nurses are too hurried to provide basic care such as the correct administration of medications, IV therapies, and routine nursing care, much less provide information, comfort or compassionate care. The physical results are contractures, decubitus ulcers, falls, lacerations, and infectious diseases. Other results are medication errors and the psychological consequences of negative care experiences.

Staff Displacements

Because of staff cuts, experienced RN's and other staff have to be displaced by staff with seniority but less experience in key positions. Repeated lay-offs as a result of cutbacks have led to activation and reactivation of collective agreement recall articles to a degree never anticipated. These articles were originally drafted under the assumption that layoffs in health care would be few and occasional.

The loss of thousands of experienced RN's through massive layoffs and subsequent displacement of other RN's through the layoff process has been disruptive, costly, and potentially unncessary. RN's "bumped" into areas they are unfamiliar with have to be retrained, placing an additional burden on experienced staff who are already overworked. The Oberg report estimates "conservatively" that the approximately 3000 bumps between April 1993 and January 1996 cost $1.8 million in formal orientation time alone.

Staff Workload

Overall, health care staff in Region 10 have been reduced by 4300 employees over the past three years. From April 1993 to January 1996, the CHA laid off, retired, or reduced hours for 3923 staff. In some departments entire shifts have been deleted. There is increased workload on all staff. A survey by the CHA and Caritas in January and February revealed that about 70% of staff responded "fair" or "poor" when asked if staffing was sufficient to accomplish tasks without overloading employees.

Staff are working through breaks, putting in increasing overtime (paid and unpaid), double shifting, and having difficulty getting their vacation and days off. E.g., overtime costs for the CHA were estimated by the Oberg Report to be $5.5 million a year.

Radiology and Diagnostic Imaging

Workload has increased about 18% at UAH and 8% elsewhere. Staff are dealing with more patients and higher acuity of care; patients require more intervention and help. Backlogs occur, especially in Emergency, Plaster Room, and Out-Patients Clinics, as well as on weekends.

The nursing workloads and examinations per technologist are very high compared to other hospitals. E.g., Vancouver General Hospital (VGH) has 11 nursing FTE's to cope with critically ill patients going through the department; UAH department has 2.5. E.g., VGH is completing 1,349 CT exams per FTE; UAH is completing 3,385, or 2 1/2 times as many as VGH.

There is a shortage of porters at the UAH site. There are no porters available on Evenings or Nights. Technologists and nurses are portering patients.

Pathologists

There are inadequate numbers of tissue and clinical pathologists for the population. Edmonton pathologists have been cut by over 10% since December 1994. Pathologist manpower is now only 67% of ratio recommended by Canadian Medical Association and the Royal College of Physicians and Surgeons of Canada in their Validation Study of June 17, 1988.

Child Psychology

The child psychology program at Glenrose is understaffed and not able to deliver proper service. The program needs more psychologists, 2 FTE nurses, and more clerical support.

Respiratory Therapists

An increased patient workload is being handled by fewer staff. E.g., there is inability to give consistent care to ENT patients with tracheostomies and to airway patients, due to workload. There is no central staffing schedule, resulting in inconsistent staffing and scheduling.

Dietary Personnel

According to Alberta Health, dietary personnel in Region 10 were reduced from 905 in 1994 to 779 in 1995. This is a decrease of 14%.

Staff Training

As care becomes increasingly compartmentalized according to programs and diseases the staff becomes less able to identify and manage unexpected complications and situations. This greatly increases the risks to our patients.

E.g., gynecology ward mismanages ruptured appendix, septicemia, or cardiac complication. E.g., nursing home evening and night staff are often not adequately trained to properly assess situations; one nurse reported to a physician she was the only RN on evening shift in a nursing home with 180 patients. E.g., there is minimal orientation or training for new staff or staff whose responsibilities change.

Medical Records

Due to staff shortages, charts do not return to physicians' cubicles until one or two weekdays before the cutoff date. This is nearly one month after discharge. Some records are inconsistent, incomplete. E.g., the Misericordia health records staff has been reduced by 25%, clerical by 34%, coding by 21%, and transcription by 15%, resulting in a backlog of charts to be processed and records to be transcribed.

Housekeeping

Housekeeping is not being done thoroughly enough because of inadequate staffing. E.g., housekeeping staff on the afternoon shift at the Misericordia now clean as many as 36 beds on a shift. In the day surgery unit, staff clean eight washrooms, upwards of 30 beds and stretchers, and perform other duties in one shift. This allows less than 10 minutes at the bedside to terminal (discharge) clean a bed which involves stripping, remaking, and thoroughly washing environmental surfaces. A few years ago the standard was 13 terminal cleans per shift.

Letters of complaint from the public have a theme of uncleanliness. E.g., dirty carpets in the lobby of the Misericordia. This is both dangerous and unaesthetic and is unacceptable to citizens using our hospitals. A high standard of housekeeping is important in ensuring cleanliness and infection control, as well as in giving patients confidence in the quality of their care. E.g., studies show that a 5 second clean does not kill bacteria on environmental surfaces and that a superficial and quick cleaning can result in the development of germicidal-resistant bacteria (Noskin et al, 1995).

Back-up Staff

There is a lack of back-up staff to handle work in the event of full-time staff taking sick leave, maternity leave, or vacation. One result is increased overtime for already overworked full-time staff.

Equipment

Funds for the region are not adequate to cover our present activities and therefore do not provide funds for recapitalization. The Oberg Report states that recapitalization of equipment is a significant issue in the region.

Insufficient Equipment

Insufficient equipment is available. E.g., recently on a general surgical ward at UAH suture removal scissors for emergency removal of neck wound sutures were unobtainable. E.g., there are only two sets of tonsil equipment at the Misericordia so surgeons are borrowing equipment from RAH. E.g., when endoscopes fail gastroenterologists often take equipment from one hospital to another. E.g., more respiratory equipment is needed at UAH site.

Procedures are increasing but resources remain the same or are decreasing. E.g., there is a 31% increase in pulmonary function laboratory activities at UAH from July 1995 to April 1996, but fewer resources.

Outdated Equipment

Much equipment is becoming out-dated and there are no funds for it to be renewed. E.g., new surgical drills and headlights are needed (some headlights are 20 years old, held together with tape). E.g., the UAH angiography equipment is outdated. E.g., laparascopic surgical equipment needs continuous upgrading. E.g., an estimated 35% of imaging equipment in the region is obsolete. E.g., the electrophysiology lab at UAH is over 20 years old and there are no available replacement parts. E.g., anesthesia needs to replace 20 oximeter/capnograph/EKG devices soon. E.g., anesthesia gas monitors are aging. E.g., there are deficiencies in otolaryngology instruments. E.g., physiologic monitoring equipment in critical care units at UAH is outdated and does not meet current standards. E.g., pulmonary equipment at UAH is over ten years old.

New Equipment

New equipment is needed, both to provide adequate care and to stay up-to-date in order to give best care. E.g., a laser bronchoscopy system is needed at UAH for lung cancer patients. E.g., a gait analysis lab needs to be developed at the Glenrose for children with motor disabilities. E.g., equipment is needed to address chronic pain; 350 of 5000 patients surveyed were dissatisfied with their pain management. E.g., another MRI is needed and another CT scanner is needed.

Education

Health Science Faculties

The CHA Business Plan was developed without considering the needs of the educational programs of the Health Sciences Faculty, including the Faculty of Medicine. There has been a significantly adverse effect on the postgraduate, undergraduate, and continuing medical education programs of the Faculty of Medicine.

Of the 40 active postgraduate training programs, all currently enjoy full accreditation by the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada. There is concern that many of these programs might have difficulty in maintaining full accreditation status if subjected to an on-site accreditation visit at the present time. These concerns are based on comprehensive formal internal reviews of the four surgical programs plus substantial informal feedback about others. The surgical programs were reviewed initially because of the anticipated adverse effects of restructuring.

The principal adverse effects on educational programs result from two generic factors. These are the consequences of fragmentation of care into so-called low intensity (community health centres) and high intensity (referral hospital system) venues and poor morale among teaching faculty.

Experience

Students and residents are unable to experience adequate continuity of care in their patients. E.g., fewer beds are available for general pulmonary patients whose presence is critical to the pulmonary medicine training program. E.g., there is difficulty in larger surgical programs in exposing residents to a multitude of disease entities.

Residents are not seeing patients pre or post-operatively and are being exposed very little to their work other than in the operating room. There is very sporadic resident coverage and assistance. Surgeons have little time to teach because of the pressure of completing very long operating lists and the reduction in access to OR -- residents operating takes more time.

Mix of Cases

A poor mix of cases in a given rotation occurs regardless of whether a student or resident is assigned to a low intensity CHC or a high intensity referral hospital.

Non-Educational Activities

There is increased involvement of residents in non-educational but time-consuming activities, such as finding beds, arranging transfers, and dealing with patients and their families who are understandably frustrated with prolonged emergency room waits, transfers between hospitals, decreased levels of service on the wards, etc.

Travel

The need for faculty (particularly in surgical specialties) and to a lesser extent residents, to travel between hospitals results in less time for teaching and further aggravates the continuity of care issue. It also leads to an excessive reliance on the resident staff, often beyond their capabilities and training.

Morale

Poor staff morale is a matter of increasing concern among residents and students. The increasing complexity and time consumed by clinical faculty in dealing with their own professional, educational, research, and administrative responsibilities has led to a decreased enthusiasm for teaching, particularly among the very large numbers of voluntary faculty whose contribution to our teaching programs is significant and essential.

Performance

In the past, University of Alberta graduating medical students have consistently rated first or second in Canada in the results of the Medical Council of Canada Qualifying Exam. The performance of our most recent graduating class (1996) was less satisfactory. Failures on the LMCC's (Licensure by the Medical Council of Canada) were the highest since the 1980's, e.g., 7/115 or 6%. Given the consistent high level performance in the past, we are concerned that the abrupt change may reflect students being caught in the system deficiencies and faculty morale changes referred to above.

Role Modeling

One of the most important features of strong education programs is role-modelling. It is no longer possible to demonstrate to future physicians an efficient, collaborative, and compassionate health care delivery system. Physicians are increasingly forced to role model generic, itinerant, or fragmented care which does not involve functional health care teams or primary care physicians. This discourages the pursuit of excellence and professional pride and satisfaction.

There is concern that residency programs may have difficulty in continuing to attract the best and brightest of medical school graduates. Since a substantial segment of our skilled specialist community comes from graduates of local residency programs the long term consequences of these changes will result in a decreased quality of health care delivery in the region. This will be further aggravated by a continuing exodus of teaching physicians and recruiting difficulties.

Programs and Facilities

Cuts have been made to small division teaching programs. Many teaching services have reduced rosters to 2 week blocks instead of the usual 4 week blocks. Classrooms are being converted into other functions.

Evaluation by Preceptors

In-patient loads exceed 18/preceptor. This makes it very difficult for a preceptor to provide a comprehensive evaluation of a candidate's competency.

Continuing Education

Continuing education is being reduced. There is a lack of teaching personnel, resources, and time. E.g., the IV team was eliminated at RAH and there is no longer a manual describing IV starts or process to enable an RN to learn how to start an IV. E.g., there is no formal process to help staff gain new skills when they commence caring for patients with new problems an RN may not have seen before, such as chest tubes or a TURP (transurethral resection prostate) case.

Patient Education

Medical staff have found it necessary to reduce their commitment to participate in providing education to patients, for example, asthma education. Patient education can improve quality of life and be a major cost-saving. One example is diabetic education. Assal et al (1993) concluded that education and training of diabetes mellitus patients resulted in a marked decrease in lower extremity amputations: 12 times less above knee amputations, reduction by half of below knee amputations, and a four fold decrease of toe amputations.

Off-Loading of Costs

There is substantial offloading of costs occurring within and out of the Region 10 health care system, which calls into question the notion that the cuts to health care are "saving" money.

Many of these offloaded costs are difficult to track, due to lack of data or difficulties in placing a monetary value on them. For example, it is hard to calculate the costs in terms of lost work when family members must be cared for at home, the costs to providers when they must spend time travelling to multiple sites, or the social costs when people cannot access disabled transportation to get to work and to education programs.

There are also the "hidden costs" of restructuring which are not taken into account and which, again, are difficult to track and to place a value on. These include the costs of inadequate care, the costs of not accessing new treatments, the costs of wasted human resources through lay-offs, the costs of improper education of the next generation of health care providers, and the costs of neglecting to obtain new, improved equipment which can provide better and more cost effective diagnosis and treatment. All of these "hidden" costs are offloaded onto the society as a whole.

The report has conceptualized five main areas of offloading of healthcare costs, all of which bear further, systematic investigation. A brief description and examples are provided for each area.

Offloading of Costs to Patients

Cost shifting to the patient means health care costs which are "saved" are borne by the patient and the patient's family and friends.

Length of stay in hospitals is being shortened and patients are being discharged to home sooner, in order to reduce hospital costs. Average length of stay has decreased from 7.2 days in 1993/94 to 5.6 days in 1995/96, a reduction of 22.2%. Patients who would formerly be in hospital must be cared for at home, often with inadequate hours of homecare. Patients and families must pay for more care and/or provide care themselves. This may involve missing work, buying drugs, buying medical supplies, etc.

Care of chronically ill children at home involves parents doing procedures which were previously done in hospitals. One example is changing feeding tubes. The tubes, which range from $60 to $300, become the financial responsibility of the family.

Care of terminally ill patients at home can require expenses such as oxygen, medical supplies and equipment, special nutrition, drugs to control pain, etc. Terminally ill patients who are admitted to long-term care facilities must pay about $25 per day for room and board plus charges for laundry and other items.

It has been suggested that the UAH sleep laboratory should be privatized. The lab can now do the tests done at the private clinic in Calgary for 50-60% of what is being levied to the public in Calgary. Privatization of the UAH lab would drastically raise costs to the public.

The lack of timely access to public health services causes patients to purchase such services privately. For example, long waiting lists for MRI exams encourages patients to pay to be seen at a private MRI facility which can be accessed sooner, but which costs in the range of $750 per exam.

Offloading of Costs to Providers

Cost shifting to the provider means health care costs which are "saved" are borne by the provider, e.g., family practitioners, specialists, etc.

Physicians are having increased hours of non-productive travel time in order to attend to patients who have been dispersed to multiple sites. For example, many surgeons are now operating at multiple sites. As well, physicians are having increased hours of travel and consult time in order to attend to the greater numbers of patients being cared for in the community, for example in homecare and in nursing homes.

Physicians are spending additional time trying to access scarce resources for their patients and trying to sort out the numerous problems which arise in the process of trying to provide proper care. Office staff must spend increased time dealing with the complexities of getting patients attended to in a timely manner.

Offloading of Costs Intra-regionally

Cost shifting intra-regionally means health care costs which are "saved" are borne by the same region in a different way.

The UAH psychiatric Walk-In clinic staff have been reduced by 30% over last two or three years. Due to reduced access, patients are being turned away. They go to Emergency for treatment instead. Cost is shifted from the clinic to Emergency.

Delays in getting written pathology reports and radiology support have lengthened investigation of pulmonary conditions at UAH. These delays result in increased length of stay, the cost of which is borne by the Medicine Program.

There is a shortage of porters for transporting patents to radiology and diagnostic imaging at UAH. Higher paid technologists and nurses are portering patients instead.

Patients are not taking physiotherapy because they either have to wait for treatment or else have to pay privately. The result of patients not accessing the necessary therapy services is increased morbidity, more visits to their physician, and often increased costs in the long run.

There may be closure of the psychiatric eating disorders program at UAH, which is not officially recognized. This is the only program in the province so patients would have to be sent out of province for treatment, which would be more expensive and still paid for by the province.

Offloading of Costs Inter-regionally

Cost shifting intra-regionally means health care costs which are "saved" are borne by a different region. When a service is difficult to obtain or is unavailable in one region the patient may go to another region for that service.

As providers, services, and resources diminish in surrounding regions, there will be added pressure on Region 10 resources. E.g., the endoscope in Hinton broke and, as there was no budget to fix it, patients are now being sent to Edmonton.

With long waiting lists in Region 10, patients are making appointments in other Regions in order to "jump the queue" and get their needs attended to sooner. Some regions are actively recruiting Region 10 physicians.

Offloading of Costs From the Province

Cost shifting from the province means health care costs which are "saved" are "unofficially" shifted from the province, often by default, to a department, program, or staff, which performs the service as an extra duty.

Transport programs were not developed by the province to access the pediatric intensive care unit (PICU) despite 65% of PICU patients coming from outside Region 10. This transportation function fell to the staff of the PICU. As they will experience an increase in patients served from 700 to over 1000 this year they no longer have the staff or resources to perform this function.

Morale

General Morale

There is low morale and lack of job satisfaction among staff due to job losses, threats of more job losses, threats of roll-backs, staff shortages, lack of basic supplies, lack of facilities, increased workload, working through breaks, increasing overtime, double shifting, and difficult getting vacation and days off. A survey by the CHA and Caritas in January and February revealed that 36% of staff rated their morale as only fair or poor. 48% rated their job security as poor.

Institutions are no longer a focus of professional pride for caregivers. Staff are "going the extra mile" but feel they cannot do their job properly and provide the excellent care that they want to. Staff feel stressed, rushed, burned out, devalued by the system. E.g., there is increased stress leave.

There is increasing sick time averaging about 20 days per FTE per annum at the UAH, RAH, and Glenrose. There is a correlation between shortages and sick leave as evidenced by the fact that higher sick leave exists where there are higher staff shortages (according to the John Crothall Hospital Consultant Report). Further, there is a difference of 4.5 sick days per year in sick leave between the Glenrose, currently best staffed, and the UAH, currently worst staffed.

Many specific examples of low morale have been reported. Statements have been made, for example, about low morale of psychiatrists at Grey Nuns, anesthetists, clinical teachers at UAH, radiology staff, laboratory technologists, nursing staff at all sites, and support staff at all sites.

Physicians

Physician perception that change is proceeding without meaningful input from medical staff has caused lingering resentment. This has been demoralizing particularly as they experience daily struggles providing care in the downsized system. Unending change creates a perception of tinkering, particularly when little change results in improved care or satisfaction for those responsible for care.

The WMC Medical Staff Executive physician survey, conducted in summer 1996, shows the majority of responders feel the situation in health care is deteriorating in comparison to one year ago, as well as the quality of work life. Mean responses to the questions on these two topics were 4.1 and 4.2 on a 5 point scale, with 5 being the lowest response. A recent Canadian Medical Association survey of four provinces found that in Alberta 62.6% of doctors surveyed thought quality of care had been reduced since regionalization. This was the highest percentage for any of the four provinces.

Family Physicians

The virtual exclusion of family physicians from acute care medicine has been a great loss of professional opportunities for education, teaching, and satisfaction. Studies show poorer practice patterns when family physicians do not have hospital privileges.

Surgical Suite

Within the surgical suite there is perceived lack of leadership or direction, feelings of lack of control over change, too many conflicting patient responsibilities, uncertainty about the future, loss of identity, and the stress of working at different hospital sites. OR time is being wasted due to the loss of flexibility when surgeons are booked at different sites.

Length of the working day has increased. There is increased on call load for anesthetists, too many meetings, and physical fatigue. Permanent staff are laid off then rehired casual, with a commensurate loss of pride. Staff no longer feel valued. Many are now refusing to be available for short-notice work and call-backs.

Psychiatry

Staff at all levels are very stressed, feel they are survivors, are disheartened in the face of constant changes, are exhausted. There is an increase in patient assaults and assaults on staff by patients, a greater incidence of staff injury, and an increase in staff sick time.

Radiology and Diagnostic Imaging

Staff are overworked and stressed. They feel they cannot give excellent patient care and cannot give patients full attention. Sick leave is slowly increasing. Two resignations occurred in August from the CT technology staff.

SUMMARY

The report represents a summary of only those problems which were sent to the committee. It is not meant to be systematic or all-encompassing. It is acknowledged that due to the nature of the report, the way that the data was gathered, and the short time frame within which it was produced, some programs have detailed commentary while others are limited with regard to the insights provided about them.

The data which was gathered was subjected to a verification process. This included careful checking by committee members and review by other physicians and by healthcare administrators. Information which was questioned was sent back to the original source for further checking. Judgment was used in resolving competing claims. When possible, new information was gathered to substantiate claims. Statements proven to be erroneous were deleted from the document.

It is noted that a large proportion of the report focuses on the university site. This is partially due to the detailed and comprehensive reports submitted to the committee by a number of the clinical program directors. It may also be a reflection of the size of the site and/or the magnitude of its problems. No doubt there are numerous additional, undocumented problems at other sites.

The committee recognizes that this report is only the first step in the ongoing process of identifying the main problems with the health care system, determining the underlying causes of the problems, and developing solutions. As previously stated, our ultimate goal is to participate in designing a sustainable healthcare system based on sound principles and effective processes, which meets the needs of the citizens of our region.

STUDIES

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