Non - North East LHIN

Non-Urgentt Patien
nt Tran
nsportation in
n the N
North E
East
LHIN
N:
An Evidenc
E
ce-Base
ed 3rd Party
P
R
Review & Resttructuri
ring
Plan
June 9, 2014
2
Prepared by Performan
nce Concepts
s Consulting Inc.
I
Table off Contents
Pag
ge
Executive
E
Su
ummary
A.
A
i
Ration
nale for Rev
viewing No
on-Urgent
Patient
P
Transportation in
i North Ea
ast LHIN
B.
B
Overviiew
of
Non-Urgent
N
Patient
Transportati
T
ion Across Ontario
C.
C
Review
w
3
3
Method
dology
&
Patient
Centred
C
Prin
nciples
D.
D
Situatiion
Analys
sis
9
9
–
Sta
akeholder
Qualitative
Q
Feedback
F
E.
E
1
12
Situatiion Analysiis - Evidenc
ce Based
Quantitative
Q
Modeling
F.
F
1
1
Situatiion
Analy
ysis
2
25
-
Funding,
Governance
G
& Decision
n-making
4
48
G.
G
Finding
gs & Recom
mmendation
ns
5
53
H.
H
APPEN
NDICES
6
67
Executive Summary
A review
w of non-urge
ent patient transportatio
t
on across N
Northeastern Ontario wa
as begun in June
2013 by the North East
E
Local Health
H
Integration Netwo
onse to conccerns
ork (NE LHIN) in respo
ystem expre
essed by pa
atients, hosspitals and E
Emergency Medical Se
ervice
about the current sy
o
was
s to develop
p a model off transportattion that provides
(EMS) prroviders. The review’s objective
timely, safe and cos
st-effective non-urgent
n
patient
p
transsfers into an
nd out of ho
ospital centrres in
stern Ontario
o, while saffeguarding needed
n
EM S coverage
e in commun
nities across the
Northeas
region.
ew of non-urgent patient transfers had
h been ide
entified as a key project in the NE LH
HIN’s
This revie
2013-201
16 Integrated Health Se
ervice Plan (under the ca
are transitions and coorrdination prio
ority).
Transporrtation is also a key enabler of the care
c
models and pathwa
ays (i.e. flow in and out o
of the
region’s hub hospita
als) identified
d in the LHIN’s Clinica l Services R
Review, com
mpleted in M
March
2014.
A Projec
ct Advisory Committee
e was crea
ated in Jun
ne 2013 to
o oversee tthe review, and
Performa
ance Concep
pts Consulting Inc. was retained (viia RFP) to e
execute the approved prroject
work plan
n.
The map below illustrates the
e relatively long dista
ances betw
ween hospita
als, and sp
parse
populatio
on densities,, associated with non-urrgent inter-fa
acility patien
nt transporta
ation flows accross
the vast North East LHIN
L
geogra
aphy.
i
ii
The revie
ew’s stakeho
older engage
ement and execution
e
pro
ocess consissted of the ffollowing
compone
ents:

1:1 interviews with ma
anagement and frontline
e staff repressenting all 2
25 hospitals a
and
8 EMS prroviders in th
he NE LHIN region, whicch consists o
of five geogrraphic transffer
“hubs”;

unds of hub-w
wide consultations with community and secondary/tertiary
Three rou
hospitals;

Three datta driven non
n-urgent tran
nsfer “summ
mit meetings”” with the 8 E
EMS Chiefs
covering the
t North Ea
ast;

Working session
s
with the 5 Northeastern Onttario Centrall Ambulance
e Communiccation
Centres (CACCs);

P
Advisory Committee evaluattion of findin
ngs and pote
ential
Ongoing Project
restructurring scenario
os;

Final repo
ort with syste
em restructu
uring recomm
mendations provided to the LHIN CE
EO in
June 2014
4.
The revie
ew’s stakeho
older consulttations and EMS data m
modeling werre used to co
onduct a nonurgent tra
ansportation
n situation an
nalysis and construct
c
ap
patient journ
ney “map” – emphasizing
g
current system
s
perfo
ormance prob
blems requirring restruct uring solutio
ons. The sysstem problem
ms
“map” ap
ppears below
w.
iii
s
qualitative fe
eedback, the
e review also
o incorporatted extensive
e quantitativve
Beyond stakeholder
data mod
deling underrtaken by Pe
erformance Concepts
C
ussing the EMS
S Electronic Patient Care
e
Reporting
g system (eP
PCR). Deta
ailed modelin
ng (using 20 12 data) info
ormed the re
eview’s
restructuring recomm
mendations. Modeling re
eports includ
ded the follo
owing:

n-EMS non-u
urgent transffer volume m
mapping of IN/OUT transsfer flows byy
EMS/Non
hospital service
s
delive
ery Hub;

EMS mea
an patient tra
ansfer duratiion (minutess per transfe
er by Hub);

EMS transfer outputs
s (transfer ho
ours delivere
ed by Hub);

EMS 12-h
hour daytime
e “peak” serv
vice busyne ss (utilizatio
on rate by am
mbulance ba
ase);

EMS overrlapping eme
ergency/non
n-urgent call s (by ambulance base/ccoverage zone);

LHIN-wide patient esc
cort costing//potential resstructuring ssavings estim
mates
iv
Highlightts of the tran
nsfer flow data modeling across the LHIN are co
ontained in th
he following
figures. The first figu
ure documen
nts IN/OUT non-urgent
n
ttransfer volu
ume flows byy the five transfer
T second figure
f
sets out “long-hau
ul” vs. “short--haul” duratiion non-urge
ent
hubs in the region. The
transfer hours
h
delivered by hub.
v
Additiona
al data mode
eling and analysis condu
ucted by Perrformance C
Concepts exp
plored key riisk
factors associated with i) EMS sy
ystem “peak
k” busyness (12-hour da
aytime utiliza
ation rates) a
and
ency of overla
apping emergency and non-urgent ccalls within a given amb
bulance base
e’s
ii) freque
coverage
e zone. The
e following ev
vidence-bas
sed modeling
g conclusion
ns are compe
elling:
•
Across
A
the LH
HIN, there is
s a clear sep
paration of no
on-urgent tra
ansfers into “short haul”” &
“long haul” du
uration categ
gories for pu
urposes of syystem restru
ucturing.
•
on-urgent transfers repre
esent significcant Code 4 EMS response risk. Th
he
Long-haul no
esult is erode
ed EMS response times
s & unsustain
nable levels of system b
busyness at
re
ce
ertain ambulance bases
s.
•
Overlapping
O
Code
C
1-2 & 3-4 calls are
e creating fre
equent cove
erage breakd
downs at cerrtain
bases. At the
ese bases, EMS
E
units arre drawn outt of response zones creating a “zero
o
available unitts” problem characterize
c
ed by unacce
eptable resp
ponse times.
•
Short-haul
S
no
on-urgent tra
ansfers do NOT
N
create r isk of drawin
ng EMS unitts out of
re
esponse zon
nes. There is no compelling reason why EMS a
and contracte
ed providerss
ca
annot contin
nue to delive
er these local transfers w
with existing fixed resourrces.
ew’s in-depth
h qualitative stakeholder consultatio
ons and evid
dence-based
d data modelling
The revie
have together delivered a rigorou
us situation analysis tha
at has yielded the followiing overall
p
conclusions
s:
system performance
•
The current non-urgent
n
trransportation
n system is n
able from a p
patient care or
not sustaina
fin
nancial pers
spective for community
c
hospitals.
h
H owever, sign
nificant finan
ncial savingss are
po
ossible with successful restructuring
g.
•
The current non-urgent
n
trransportation
n system is a major prob
blem creatin
ng patient flo
ow
blockages at hub hospitals.
•
The patient escort model of “care and
d control” is not sustaina
able for com
mmunity hosp
pitals
unless transp
portation bec
comes far mo
ore reliable in/out of hub
b hospitals.
•
Non-urgent
N
trransportation
n system reliability impro
oved significcantly when the LHIN pilot
projects were
e implemente
ed in 2013.
•
n
a perm
manent, non-ambulance
e solution forr long-haul trransfers in th
he
The system needs
North
N
East.
vi
System Restructuriing Recomm
mendations
s
The revie
ew’s non-urg
gent transpo
ortation restru
ucturing reco
ommendatio
ons are orga
anized into th
he
following categories:
1. New
N
Operatio
onal Model
2. Hospital-Base
H
ed Business
s Process Im
mprovementss
3. Leadership, Policy
P
& Dec
cision-Making
S
Fund
ding
4. System
5. Stakeholder
S
Communicat
C
tions
1. Ne
ew Operatio
onal Model
New Ope
erational Mo
odel recomm
mendations will
w create tw
wo distinct se
ervice delivery channels for
short-hau
ul versus lon
ng-haul non--urgent trans
sfers. EMS sservices acrross the LHIN, and non--EMS
transfer resources
r
in Sudbury an
nd North Bay
y, will contin ue to deliver short-haul transfers tha
at fall
within the
eir existing coverage
c
zon
nes. Long-h
haul non-urg
gent transferrs will be delivered via a
route-bas
sed model with
w schedule
ed legs serv
viced by multti-patient veh
hicles. The proposed le
egs
and vehic
cle configura
ations are as
s follows (no
ote – these a
are bi-directional routes)):
vii
In two ins
stances (We
est Parry Sound and Cha
apleau) whe
ere dedicated long-haul route-based
d
transfer resources
r
arre not warranted due to volume, con
nsideration sshould be givven to an EM
MS
up-staffin
ng envelope to deliver th
he long-haul patient tran sfers.
w Operationa
al Model will also feature
e the followin
ng:
The New
•
One
O or more CACCs to dispatch
d
long
g haul non-u
urgent transffer vehicles – as well as
trraditional am
mbulance res
sources whe
en appropriatte (i.e. shortt haul EMS, dead head
re
eturns);
•
New
N
informattion technolo
ogy tools to coordinate
c
rride scheduliing with testt/procedure
sc
cheduling.
2. Hospital–
–Based Bus
siness Proce
ess Improv
vements
mendations concerning
c
Hospital–Bas
H
sed Businesss Process Im
mprovementts focus on
Recomm
eliminatin
ng the current system off community
y hospital-fun
nded staff esscorts accom
mpanying no
onurgent pa
atients to hub hospitals for
f tests/procedures (i.e
e. continuity o
of patient ca
are and control).
Leveraging process improvemen
nt insights ga
ained from a 2013-14 No
orth West LH
HIN pilot pro
oject
a the Thund
der Bay Regiional Health Sciences C
Centre, hub h
hospitals in tthe
currently underway at
ast LHIN will phase in sta
affed patientt holding are
eas to provid
de basic care
e to non-urgent
North Ea
patients arriving
a
from
m community
y hospitals. Beginning w
with a pilot project recom
mmended to
occur in 2015,
2
the us
se of commu
unity hospita
al patient esccorts should be reduced
d and then
eliminate
ed over time.. Patient escort savings
s at commun
nity hospitalss will be traccked, and willl be
used to offset
o
hub ho
ospital holdin
ng area costts.
3. Leadersh
hip, Policy & Decision-M
Making
mendations concerning
c
Leadership,
L
Policy
P
& Deccision-Makin
ng Model/Tools focus on
n
Recomm
establish
hing a multi-s
stakeholder, permanent Non-Urgentt Transporta
ation Leadersship Working
g
Group to lead the implementation and oversight of the n ew system a
across the N
North East LHIN.
Recomm
mendations also
a
address the need fo
or improved d
data management practtices/standards
within the
e non-urgent patient tran
nsportation system.
s
Imp roved data m
managemen
nt will, in turn
n,
support recommende
r
ed performance monitorring and targ
get setting to
oolkits.
viii
4. System Funding
F
F
reco
ommendatio
ons would se
ee the creatio
on of a new LHIN-wide non-urgent
System Funding
transporttation funding model deffined as follo
ows:
•
EMS
E
providerrs will contin
nue funding “short-haul”
“
within
non-urgent patient transsportation w
th
heir existing approved bu
udgets;
•
Hub
H hospitals
s that curren
ntly fund non-urgent tran
nsfer services (i.e. HSN a
and NBRHC
C) will
co
ontinue to do
o so for short-haul patient transfers;;
•
New
N
funding will be direc
cted to provid
ders of the n
new scheduled long-hau
ul transfer routes
(likely selecte
ed via RFP). Additional funded vehi cle hours off long-haul p
patient transffer
se
ervice will be
e added to the North Ba
ay transfer ca
ar and the S
Sudbury EMS
S nonambulance co
ommunity flo
ow car. EMS
S up-staffing
g funding is a
also recomm
mended to
su
upport: Parry
y Sound EM
MS predomin
nantly “south
h bound” non
n-urgent tran
nsfer pattern
ns
outside the LHIN; and Ma
anitoulin-Sud
dbury EMS ttransfers in a
and out of T
Timmins from
m
Chapleau.
C
•
Operational
O
savings
s
from
m all affected health care
e partners asssociated witth non-urgen
nt
pa
atient transp
portation res
structuring sh
hould be con
nsidered for reallocation
n/reinvestme
ent
where
w
approp
priate.
5. Stakehold
der Commu
unications
mendations concerning
c
Stakeholder
S
Communica
C
ations will improve stakeholder
Recomm
understanding of the
e review’s ch
hange manag
gement age nda, and se
ecure buy-in to the necesssary
restructuring actions. The recom
mmendations
s outline com
mmunication
ns strategiess/messages that
e implementted for a varriety of key ta
arget audien
nces (e.g. the public, com
mmunity and
d
should be
hub hosp
pital physicia
ans, hospitall administrattive and fron
nt-line staff, E
EMS provide
ers, CACCs,,
ORNGE)).
ix
Impleme
entation of Change/Res
C
structuring
ew sets out a three-yearr critical path
h for impleme
enting change/restructu
uring. The crritical
The revie
path implementation activities arre categorize
ed as Do NO
OW (Year 1), Do SOON (Year 2) and
d Do
LATER (year 3).
W work focuses on establishing the new
n
decision
n-making and
d system ma
anagement u
units
Do NOW
– the Lea
adership Wo
orking Group
p, the Coordinating Centtre, the posssible long-ha
aul transfer
provider RFP, and a dedicated project
p
mana
agement reso
ource to drivve the non-u
urgent
cturing agen
nda forward.
transporttation restruc
e new opera
ational mode
el, including
Do SOON work addrresses the sttart-up challenges of the
phased implementation of transffer legs and execution off capital imp
provements ffor hub hosp
pital
p
holding areas. Budget
B
development, datta managem
ment reformss, and
transfer patient
performa
ance target development
d
t will also falll into this tim
meframe.
The Do LATER
L
perio
od will featurre the final ro
oll-out of hosspital busine
ess process changes aro
ound
staffed patient “care and control”” holding are
eas expected
d to generate significantt savings in
p
escort costs.
community hospital patient
x
A. Ratiionale forr Reviewiing Non-U
Urgent Pa
Patient Tra
ansportation in
Norrth East LHIN
L
ent patient trransportation
n has been a challengin g issue in no
orthern Onta
ario for the p
past
Non-urge
two deca
ades. The trravel distanc
ces between community and hub ho
ospitals creatte a host of
logistics/patient risk challenges
c
(see
(
map on
n next page).. Northern h
hospitals, Em
mergency
Medical Services
S
(EM
MS) providers and local governance
e authorities have all weighed in with
h
ideas to clarify
c
respo
onsibilities, ra
ationalize funding, and i mprove servvice quality. Despite a ra
ange
of review
ws, position papers
p
and local advoca
acy, fundame
ental restruccturing of non-urgent pattient
transporttation in the North has not yet occurrred.
Recently
y the Provinc
ce has indica
ated that a new regulato
ory frameworrk for non-urrgent patientt
transporttation providers will be fo
orthcoming during
d
2014 . The timing
g of the Nortth East Loca
al
Health In
ntegration Ne
etwork’s (NE
E LHIN) 2013
3-14 review dovetails with the Province’s upcom
ming
new regu
ulatory requirements (i.e
e. Highway Traffic
T
Act re
equirements)) and health service provvider
guideline
es aimed at improving tra
ansport safe
ety and patie
ent care.
Non-urge
ent patient trransportation
n restructuring is promin
nently positio
oned in the N
North East
LHIN’s 2013-16 Integ
grated Healtth Services Plan.
P
Non-u
urgent transp
portation resstructuring iss also
quirement off the NE LHIN’s just com
mpleted cliniccal service re
eview. Durin
ng Q2 2013//14
a key req
the North
h East LHIN initiated this
s comprehen
nsive review
w of non-urge
ent patient trransportation
n.
To provid
de ongoing guidance
g
in this
t
review of
o non-urgen
nt patient tra
ansportation in the region
n,
the LHIN
N struck a Pro
oject Adviso
ory Committe
ee with stake
eholder reprresentation d
drawn from tthe
region’s 25
2 hospitals
s, 8 EMS serrvices, the ORNGE
O
air a
ambulance sservice, 5 lan
nd ambulancce
Central Ambulance
A
Communicat
C
tions Centres (CACC) a nd a numbe
er of commun
nity
stakehold
ders. The Ad
dvisory Com
mmittee endo
orsed: a proj ect charter, patient centtred review
principles
s, and a projject work pla
an setting-ou
ut required a
analyses and
d restructurin
ng deliverab
bles.
Performa
ance Concep
pts Consultin
ng Inc. was retained to p
provide evidence-based
d analyses and
execute project work
k plan deliverables. This report’s resstructuring re
ecommendattions are the
e
akeholder drriven review of non-urge
ent patient trransportation
n. Performan
nce
culminatiion of the sta
Concepts
s Consulting
g Inc. is prov
viding this report’s recom
mmendationss to the LHIN
N and its
1
partners for considerration. Perfo
ormance Concepts’ evid
dence-based
d analyses and system
mendations have
h
been th
horoughly re
eviewed and
d supported b
by the Proje
ect
restructuring recomm
his report.
Advisory Committee prior to finalization of th
2
In terms of scope, no
on-urgent tra
ansportation within the ccontext of thiis project reffers to:

Transportatio
T
on for the folllowing patient groups be
etween hosp
pitals, or from
m hospitals tto
Long-Term Care
C
Homes//patient resid
dences:
 Stable me
edical condittion; and
 Requiring
g a stretcher vehicle; or
 Ambulato
ory or semi-a
ambulatory in
npatients/LT
TC residentss; or
 Requiring
g a nursing or
o other health provider e
escort

Transportatio
T
on of Emerge
ency Department patien ts requiring access to a schedule 1 bed
or psychiatric
c assessmen
nt under the Mental Hea lth Act
But not:

Transportatio
T
on for medica
al appointme
ents within a communityy or between
n communitie
es
f
an EMS
S perspectiv
ve, non-urge
ent refers to lower priorityy calls i.e. dispatched ass
Further, from
code 1 and 2 calls. See
S Append
dix #1 for the
e definition o
of pertinent a
ambulance ccall codes in
Ontario.
B. Ove
erview of Non-Urg
gent Patie
ent Transp
portation
n Across Ontario
Restructturing Initia
atives Proviince-wide
ent patient trransportation
n restructuring is being a
actively conssidered, or iss underway,, in
Non-urge
the North
h West LHIN
N, the South West LHIN, and the Sou
uth East LHIN. The solu
utions being
considere
ed across th
hese LHINs vary,
v
but the
e common re
estructuring denominato
or is improve
ed
transporttation reliability for non-u
urgent patien
nts achieved
d without com
mpromising EMS emerg
gency
response
e coverage.
orth West LH
HIN, the key restructuring
g issue is su
upplementarry funding fo
or EMS upIn the No
staffing necessary
n
to
o safeguard emergency
e
coverage
c
wh
hen ambulan
nces at remo
ote bases m
must
execute “long-haul”
“
duration
d
non
n-urgent patient transferss outside the
eir catchmen
nt areas. An
n
alternativ
ve to traditional land amb
bulance prov
vision of non
n-urgent tran
nsfers within
n the higher
volume 225
2 km Keno
ora-Winnipeg corridor is also being a
actively conssidered.
3
In the So
outh West LH
HIN, a hospital funded private
p
secto r contractor model has b
been design
ned
and exec
cuted through an RFP prrocess. Pricing and serrvice levels have been sstandardized
d
across th
he LHIN. A transportatio
t
on selection algorithm ha
as also been
n standardizzed. Hub and
community hospitals can utilize this
t
LHIN-wide private co
ontractor on
n an as-need
ded basis.
ce provider occurs
o
outsid
de the land ambulance CACC syste
em.
Dispatch of the contrracted servic
e provision h
has not been
n eliminated from the me
enu
Howeverr, traditional EMS non-urrgent service
of transp
port options.
In the So
outh East LH
HIN, all hospitals have signed on to a multi-year contract (eff
ffective Janu
uary
2014), as
s the result of
o an RFP prrocess, with a single non
nsfer provide
er. The con
ntract
n-urgent tran
lays out a pricing sch
hedule for un
nits of transffer service (ccases). Priccing varies b
based on
distance,, pre-booked
d calls vs. sa
ame day callls, and single
e vs. multiplle bookings, for example
e.
The conttracted non-u
urgent transportation pro
ovider also ffunctions as the dispatch
h point.
Hospitals
s in the LHIN
N created a joint
j
funding pool based on their pre
evious year’ss costs incurrred
for purch
hasing non-u
urgent transp
portation. Th
he SE LHIN has committted to contributing mode
est
one-time funding ove
er a two-year period to support
s
transsitional costss to the new
w model.
Demogra
raphic Press
sures Intens
sifying
d for a restru
uctured non--urgent patie
ent transporttation modell is becoming
g increasing
gly
The need
acute. The
T aging ba
aby boomer driven
d
demo
ographic servvice deliveryy and funding challengess are
imminentt. The propo
ortion of the North East LHIN popula
ation age 65
5+ is projecte
ed to increasse
from 19%
% to 30% by 2036. The estimated
e
nu
umber of old
der adults (65+) is projeccted to increase
by 72%, from just over 100,000 to
t over 172,0
000 (note th
he provincial average is e
expected to
7%).
increase by about 67
4
The following figure documents
d
the
t forecaste
ed aging of tthe North Ea
ast LHIN pop
pulation.
Regional
R
Hu
ub Model
A portfoliio of large re
egional hosp
pitals anchorrs Ontario’s ssystem of no
on-urgent pa
atient care.
Patients are transporrted to and from
f
these consolidated
c
centres for diagnostic a
and specialtyy
able in smalller commun
nity hospitalss. The regio
onal hub eco
onomies of sscale
procedurres not availa
provide a critical mas
ss of clinical expertise to
o ensure app
propriate serrvice qualityy for patientss.
Consolidation has he
elped to conttrol patient care
c
costs byy creating hiigh utilization locations ffor
ve diagnostic
c/specialty re
esources – thereby
t
leve raging efficient economies of scale..
expensiv
s dispersed portfolio
p
of community
c
hospitals provvides accessible localize
ed care; the
eir
Ontario’s
medical staff
s
act as decision-ma
d
alized servicces
king “triggerrs” to link pattients to the more specia
offered at
a the regiona
al hubs.
5
A regiona
al service de
elivery mode
el cannot fun
nction properrly without e
efficient patie
ent flow in an
nd
out of the
e hub hospitals – allowin
ng these loca
ations to serrvice ongoing high levelss of demand
d.
Travel distances and
d associated travel time for patients to access esssential med
dical service
es
also incre
ease in a hig
ghly regionalized system
m. Timely an
nd dependab
ble transporrt of non-urge
ent
patients between
b
cen
ntralized reg
gional hub ho
ospital locatiions and disspersed com
mmunity hosp
pital
locations
s is essentiall to the functtioning of the
e non-urgen
nt patient carre system in Ontario.
Howeverr, non-urgent patient tran
nsportation in Ontario is not funded or delivered
d in a
consisten
nt/transparent fashion ac
cross the pro
ovince. Insttead, ad-hocc and dissim
milar urban an
nd
northern//remote arra
angements have
h
evolved
d in parallel. This is prob
blematic for p
patients and
d
health se
ervice provid
ders across the
t North Ea
ast LHIN.
System
S
Plan
nning & Fun
nding in Urb
ban Ontario
o
ding and delivery of non--urgent patie
ent transporttation in urba
an Ontario h
has evolved
The fund
according
g to the follo
owing realitie
es:

y the vast ma
ajority of the
eir annual bu
udgeted vehiicle hours off
Urban EMS providers deploy
ce to achiev
ve municipal Council-app
proved emerrgency respo
onse time ta
argets. Urban
n
servic
EMS providers do not typicallly budget fo
or significant Code 1-2 non-emergen
nt transfer
mes, nor do their
t
deployment plans typically
t
iden
ntify significa
ant vehicle h
hours of servvice
volum
for no
on-emergentt patient tran
nsportation call
c volumess.

Urban EMS serviices have re
elatively high
h levels of syystem busyn
ness – referred to in the EMS
comm
munity as un
nit hour utilization (UHU)). Urban EM
MS services typically strive for an ide
eal
UHU in the range
e of 35%. UHU above 40%
4
is underrstood to degrade EMS deploymentt plan
perfo
ormance, and
d lead to hig
gher Code 3--4 emergenccy response times.

High emergency call volumes
s associated
d with popula
ation growth
h and aging d
demographics –
bined with worsening hospital emerg
gency deparrtment off-loa
ad delays – are generating
comb
ongoing critical shortages in ambulance unit availabiility. The inccidence of “zzero units
able” is grow
wing across Ontario’s
O
urb
ban EMS se
ervices. Therre is no remaining EMS
availa
6
capacity (in reserrve) to servic
ce demand for
f non-urge
ent patient trransfers in m
many urban
jurisd
dictions on many
m
days. Significant
S
delays
d
in ressponding to sscheduled re
equests for C
Code
1-2 non-urgent patient transffers are com
mmon – often
n measured in days rather than hourrs.

Urban hospitals have
h
reacted
d to chronic delays in EM
MS delivery of non-emergent Code 2
ate sector co
ompanies to
o deliver time
ely nonpatient transfers by contracting with priva
medic non-u
urgent patien
nt transportation servicess. Urban ho
ospitals have
e somehow
param
carve
ed out fundin
ng within the
eir existing ba
ase budgetss for these non-paramed
dic transporttation
contrracts – thereby freeing up significantt EMS param
medic vehicle hours to d
deal with
escallating deman
nds for Code
e 3-4 emergency call vo
olumes. Following a critiical report byy the
Provincial Ombud
dsman, non--paramedic transfer age
encies will so
oon face imp
pending
province-wide Highway Trafffic Act regula
ations and g uidelines se
etting out min
nimum vehiccle,
ng and equip
pment stand
dards.
staffin

the urban Ontario
m a funding perspective,
p
O
syste
em for delive
ering non-urg
gent patient
From
transportation is characterize
ed by the folllowing realitties:
 Local property taxpay
yers fund approximately 50% of EMS
S deployed
s/budgets. These
T
resources are dire
ected primarrily towards meeting the
e
resources
demand for
f Code 3-4
4 emergency
y calls – not Code 1-2 no
on-urgent pa
atient transfe
ers.
 A robust commercial
c
and industrial property ttax base abssorbs much of the fiscal
burden as
ssociated with the local 50% share o
of budgeted EMS vehicle hours of
service. Residential
R
property
p
taxpayers are ssheltered fro
om the full co
ost of the loccal
share of the
t EMS bud
dget.
 Non-urgent, non-para
amedic patie
ent transfer ccontracts are
e primarily fu
unded by
wide revenu
ues (e.g. inco
ome/sales ta
axes) funneled through rregional hosspital
province-w
budgets. Local prope
erty taxpayers avoid thesse costs alto
ogether in m
many urban E
EMS
jurisdictions.
7
Northern
N
& Remote
R
Sys
stem Planniing and Fun
nding
o Service De
eliverers Ass
sociation (NO
OSDA) has addressed tthe need to
The Nortthern Ontario
restructure funding and
a delivery of non-urgent patient tra
ansportation
n northern Ontario. The
per EMS Con
ncerns in Northern
N
On
ntario (2010)) has highlig
ghted the
NODSA position pap
following realities:

hern/remote EMS provid
ders deploy the
t vast maj ority of theirr annual bud
dgeted vehiccle
North
hours
s of service to
t achieve Code
C
4 emerrgency respo
onse covera
age over larg
ge expansess of
territo
ory. Code 1--2 service de
elivery capac
city inevitablly comes at the expense
e of Code 3--4
coverrage.

North
hern/remote EMS provid
ders do not ty
ypically grap
pple with hig
gh levels of ssystem busyyness
or UH
HU – emerge
ency call vollumes are lo
ow at most b
bases relative
e to urban ssystems.
Resp
ponse times are understa
andably slow
wer than in u
urban setting
gs; not a surrprise given the
challe
enges of finite EMS reso
ources and large amoun
nts of sparse
ely populated
d territory.
North
hern/remote system perfformance is defined by cconsistency of Code 3-4
4 coverage – not
Code
e 3-4 response times.

The use
u of “fixed” paramedic
c resources for
f Code 3-4
4 response ccoverage, an
nd Code 1-2
2
transport work, creates an inherent tension in Northe
ern/remote E
EMS service
es. Growing
and for Code
e 1-2 transpo
orts is linked
d to the incre
eased region
nalization of hub hospita
al
dema
servic
ces in recen
nt years.

From
m a funding perspective,
p
the Northern
n non-urban
n system for delivering non-urgent
patient transporta
ation is charracterized by
y the followin
ng realities:
 Loc
cal property taxpayers fu
und approxim
mately 50% of the EMS deployed re
esources.
 The
e absence of
o a robust co
ommercial and
a industria
al property ta
ax base to ab
bsorb any
me
eaningful porrtion of the 50%
5
local sh
hare of the E
EMS budget. Instead, re
esidential
pro
operty taxpay
yers absorb almost the entire
e
50% l ocal share o
of EMS budg
gets.
8
In summary:
These prrovince-wide
e non-urgentt transportation funding a
and local taxx burden diffferences
between urban and non-urban
n
se
ettings shou
uld be recogn
nized as Northern/remotte jurisdictio
ons
across Ontario
O
seek to rationaliz
ze non-urgen
nt patient tra
ansportation planning, de
elivery and
funding/taxation mod
dels - in partnership with
h the LHINs.
C. Rev
view Meth
hodology
y & Patien
nt Centred
d Princip
ples
Revie
ew Methodo
ology
ance Concep
pts Consultin
ng Inc. was retained in Q
Q2 2013/14 to deliver an
n evidencePerforma
based re
eview of non--urgent patie
ent transporttation acrosss the North E
East LHIN. When retain
ned,
Performa
ance Concep
pts had alrea
ady completted two simillar evidence
e-based non--urgent patie
ent
transporttation review
ws focused on
o Thunder Bay
B and Ken
nora/Rainy R
River districtts within the
North We
est LHIN.
C
off community
y hospital, hu
ub hospital, E
EMS, CACC
C and community
A Projectt Advisory Committee
stakehold
ders was established to advise and provide dire
ection to the review (the Committee’s
9
terms of reference an
nd members
ship can be found
f
in App
pendix #2). Overall projject leadersh
hip
ordination wa
as provided by
b North East LHIN stafff. The revie
ew has been executed
and co-o
according
g with the fo
ollowing meth
hodology co
omponents:

in
nterviews witth staff from 15+ commu
unity hospita
als across the LHIN;

in
nterviews witth staff from the LHIN’s four
f
regiona
al “hub” hosp
pitals located
d in Sudburyy,
North
N
Bay, Timmins and Sault Ste. Marie;
M

In
nterviews witth senior sta
aff from the eight
e
EMS p roviders delivering emergency and nonurgent patient care servic
ces across th
he LHIN;

nterviews witth a represe
entative of the ORNGE n
northern Onttario manage
ement team;
In

nterview with
h representa
atives from th
he Sudbury based Platin
num private sector transsfer
In
se
ervice;

Facilitated thrree rounds of
o consultatio
ons of comm
munity and h
hub hospital staff within e
each
off the five non
n-urgent tran
nsfer hub ca
atchment are
eas;

Three facilitatted “summit”” working se
essions of eig
ght EMS serrvices to revview/refine
Performance
P
Concepts te
echnical mod
deling of varrious system
m performancce issues/rissks;

Facilitated “sttress testing” sessions with
w commun
nity hospital,, hub hospita
al and EMS staff
(w
within each of
o the five tra
ansfer hubs)) to review/re
efine draft fin
ndings and
re
ecommendations;

A consultation session with the five North
N
East E
EMS dispatch
h services (i.e. Central
Ambulance
A
Communicati
C
ions Centres
s or CACCs)).

Detailed
D
and wide-ranging technical/q
quantitative modeling byy the Perform
mance Conccepts
te
eam using va
arious MOHLTC and EM
MS data setss;

Development
D
t of 3rd party evidence-ba
ased system
m restructurin
ng findings a
and
re
ecommendations by the Performanc
ce Conceptss team.

Five Project Advisory
A
Committee mee
etings held tthroughout tthe review process to en
nsure
tim
mely projectt execution, provide direction on keyy quantitative
e modeling issues, endo
orse
ke
ey project te
eam findings
s, and “stress
s test” draft rrecommendations.
10
Patie
ent Centred
d Review Priinciples
The following figure sets
s
out the principles th
hat have govverned this rreview. These principless
sured that the restructuriing recomme
endations arre efficient, e
equitable an
nd patienthave ens
centred. Adherence to the principles by Perrformance Co
oncepts and
d the Projectt Advisory
ee has ensu
ured the revie
ew was both
h evidence-b
based, and cconducted in
n a collabora
ative
Committe
fashion with
w diverse stakeholders from acros
ss the LHIN..
11
D. Situ
uation An
nalysis – Stakehold
S
der Qualiitative Fe
eedback
EMS
S Perspectiv
ve on Non-u
urgent Tran
nsportation System Pe
erformance
EMS lead
dership acro
oss the North
h East LHIN share a com
mmon set off perspective
es concernin
ng
the perfo
ormance of th
he current non-urgent pa
atient transp
portation mo
odel, and the
e role of EMS
S
within tha
at model. Th
hese commo
on perspectiives are as ffollows:

The
T aging po
opulation and
d resulting patient dema nd will drive
e Code 3-4 e
emergency ccall
vo
olume increa
ases beyond
d current res
sourcing leve
els.

Northern
N
rem
mote local tax
x base not ro
obust enoug
gh to addresss emergent and non-urg
gent
demand/budg
get pressure
es within EMS system ass currently cconfigured.

Erosion
E
in EM
MS Code 3-4
4 coverage and
a responsse times crea
ated by difficcult-to-predicct,
unbudgeted CACC
C
mand
dated Code 1-2
1 workload
d. Some EM
MS services report they are
r
tim
me targets in performancce plans sub
bmitted to MO
OHLTC.
not meeting response

Overlapping
O
non-urgent
n
(Code
(
1-2) and
a emergen
nt (Code 3-4
4) calls occurring within a
an
EMS
E
single-u
unit-base cov
verage zone
e constitutess a serious risk managem
ment scenarrio for
EMS.
E

In
ncreasingly inflexible EM
MS deployme
ent plans rattioning non-u
urgent transsfer resource
es to
prevent furthe
er response time erosion
n, control un
nbudgeted C
Code 1-2 up--staffing &
overtime costts.

Code
C
3 up-co
ode of non-u
urgent transfe
ers by physiicians in order to “work a
around”
ates instant coverage rissk events fo
deployment plan
p
rationing
g of EMS resources crea
or
EMS.
E

EMS
E
units fro
om outlying communities
c
s (delivering non-urgent patients to h
hub hospitalls)
offten get pulle
ed into Code
e 3-4 worklo
oad peaks byy CACC. Th
his problem is exacerbatted
by Code 3-4 offload
o
delay
y at hub hos
spitals.
EMS lead
dership’s ov
verall observ
vations indica
ate that a fun
ndamental te
e
ension existts around the
utilization
n of finite paramedic resources. Sho
ould these p
paramedic re
esources be deployed (a
and
protected
d) exclusively for higher priority Code 3-4 emerg
gency covera
age and targ
geted respon
nse
12
times? Or
O should “fix
xed cost” parramedic reso
ources also be used to m
maximize effficiency by
executing
g medically necessary Code
C
1-2 inte
er-facility tra
ansfers – desspite potentiial impacts o
on
Code 3-4
4 coverage? Quantitativ
ve modeling of EMS deli very of Code
ers
e 1-2 non-urrgent transfe
will provide evidence
e-based insig
ghts around system efficciency, effecctiveness and risk
ment.
managem
Com
mmunity Hospital Persp
pective on Non-urgent
N
t Transporta
ation System Performa
ance
nity hospital stakeholder across the North East L
LHIN share a common sset of
Commun
perspectives concern
ning the perfformance off the current non-urgent patient transsportation
model. These
T
comm
mon perspec
ctives are as follows:

Unreliable
U
EM
MS availability/timeliness
s for the ride
e into the recceiving hub h
hospital
(m
moderate pro
oblem).

Unreliable
U
EM
MS availability/timeliness
s for the patiient repatria
ation ride bacck from rece
eiving
hub hospital (major
(
problem).

Patient
P
impac
cts (i.e. risks
s) associated
d with long la
and transferr rides acrosss isolated
ro
oadways com
mbined with potential ad
dverse winte
er weather evvents.

Stranded
S
patiients & nurse escorts at receiving hu
ub hospitalss and varying
g degrees off hub
ho
ospital frontlline staff sup
pport/cooperration with th
hese escortss.

Unbudgeted
U
nurse
n
escortt costs at sm
mall commun
nity hospitalss are being a
absorbed ass
unbudgeted system-wide
s
e costs assoc
ciated with tthe regional care model..

Compromised
C
d Code 3-4 EMS
E
deploy
yment plans at some basses across L
LHIN due to
Code
C
1-2 worrkload remov
ving ambula
ance units fro
om the comm
munity.

Airport
A
tarmac transport delays
d
for ho
ospital escorrts/patients ((at destinatio
on “hub” hosspital
airports) due to ORNGE and/or
a
land EMS unrelia
ability.
13

Code
C
1-2 rela
ated up-stafffing problem
ms/delays forr EMS servicces, resulting
g in late/missed
patient appointments.

MOHLTC
M
has
s a longstanding busines
ss protocol tthat ORNGE
E non-urgentt air ambulance
ca
alls must me
eet a minimu
um 240 km distance
d
thre
eshold. How
wever, actua
al MOHLTC
historic practiices reflect an
a inconsiste
ent applicatio
on of the OR
RNGE fly/no
o fly businesss
ule across th
he North Eas
st LHIN.
ru

Deployment
D
plan
p
policies
s generally re
equire EMS units to drop Code 2 pa
atients at hub
b
hospitals & im
mmediately return
r
to bas
se to restore
e eroded Cod
de 4 coverag
ge. This ressults
n the direct creation
c
of sttranded patient escorts a
and associa
ated staff sch
heduling
in
problems at community
c
hospitals.
h

Patient
P
care & control “ha
and-off” frictiion between
n communityy hospitals, h
hub hospitalss,
ORNGE
O
and land EMS providers.
p

Concerns
C
with EMS dispa
atch perform
mance & deccision-making when overlapping Cod
de 12 and Code 3-4
3 calls occ
cur at a single ambulance
e base.

Community
C
demographic
d
cs & elderly patient
p
co-m
morbidities (p
patients sicke
er than Code 2
su
uggests). The aging demographic is most pronounced in E
Elliot Lake wh
here the median
age of the po
opulation is 47
4 years, verrsus an Onta
ario-wide avverage of 40 years.
d of individu
Approximatel
A
y 35% of the
e Elliot Lake
e population is composed
uals aged 65
5+
which
w
is the 2nd highest in
n Canada. Concerns
C
tha
at elderly pa
atient transfe
er demand w
will
grow, and the
e risk of long
g land transfe
er trips need
ds to be reco
ognized.

Transfer
T
disp
patch Code 3 “up-coding” acknowled
dged & expla
ained as a patient advoccacy
so
olution (by physicians)
p
to
o a broken transportatio
t
on system.

Patient
P
care & control hand-offs. Many commun ity hospitalss intrigued byy the Thunde
er
Bay
B pilot project to provid
de care by hub hospital sstaff, while ccommunity h
hospital
physicians crredentialed to provide sim
mple orders .
14

Universal
U
sup
pport among
g community
y hospitals fo
or the North East LHIN 2
2013 EMS pilot
projects; as proven
p
solutiions to fix the current no
on-urgent pa
atient transpo
ortation systtem.
Community
C
hospitals
h
wan
nt pilot resou
urces scaled
d upwards to
o benefit all L
LHIN hospita
als
and high volu
ume transit le
egs.
Commun
nity hospital stakeholder observation
ns paint a piccture of an u
unreliable no
on-urgent pa
atient
transporttation system
m, characterrized by a fla
awed funding
g model, silo
o-driven stakkeholders an
nd
the absence of integrated planning and decis
sion-making
g. On the po
ositive side, community
hospitals
s are strongly
y supporting
g of the impro
ovement op portunities in
nherent in th
he North Easst
LHIN 201
13 pilot proje
ects, and the
e currently evolving Nortth West LHIN
N patient ca
are and contrrol
pilot in th
he Thunder Bay
B district.
Hub
b Hospital Perspective
P
on Non-urg
gent Transp
portation Sy
ystem Perfo
ormance
Stakeholders across the North East
E
LHIN’s five
f
transporrtation hub h
hospitals (i.e
e. Health
Sciences
s North, Nortth Bay Regio
onal Health Centre, Tim mins & Distrrict Hospital, Sault Area
Hospital, and Temisk
kaming Hosp
pital) share a common sset of perspe
ectives conccerning the
ance of the current
c
non-u
urgent patien
nt transporta
ation model. These com
mmon
performa
perspectives are as follows:
f

Non-urgent
N
trransportation
n solutions MUST
M
suppo
ort hub hosp
pital patient o
outflow
re
equirements
s.

There
T
is an overriding
o
ne
eed for a “nerve centre” b
business unit within/acro
oss the LHIN
N
hubs to quartterback non--urgent trans
sport logisticcs:

No
on-urgent prrocedure bo
ookings, sele
ansport reso
ource for rid
de in,
ection of tra
se
election of tra
ansport reso
ource for ride
e back.

Ma
aximize utiliz
zation of EM
MS non-para
amedic transsfer servicess, and LHIN EMS
pa
aramedic pilo
ot project res
sources.

Ride home log
gistics out off the hub hosspital for Co
ode 1 patientts are the ke
ey.
15

Patient
P
care & control policies (impac
cting commu
unity hospita
als) vary acro
oss hub
hospitals


Ex
xample: Norrth Bay polic
cy to assum
me Code 1-2
2 patient care and conttrol in
Em
mergency Department versus
v
other hubs.
Recognition
R
of
o communitty hospital nu
urse escort p
process problems; trying
g to work witth
co
ommunity ho
ospitals on solutions
s
without LHIN fu
unding.

Significant
S
log
gistical challenges need
d to be consi dered in anyy system to transfer asp
pects
off community
y hospital pa
atient care to
o hub hospita
al staff. The
ese include:


Pa
atient care logistics re. any future community hospital phyysician orde
ers to
hu
ub hospital holding
h
area staff.

Ph
hysical spac
ce planning and
a logisticss for any futu
ure holding a
areas.

Hu
ub hospital holding
h
area
a staffing imp
pacts and co
osts.
Im
mpact of com
mmunity hos
spital physiciian Code 3 ““up-coding” of non-urgen
nt “schedule
ed
e monitored
but stable” tra
ansfers on hub
h hospitals
s needs to be
d.


Sa
ame patient profile is a Code
C
2 call in the morning when EM
MS available
e, but
Co
ode 3 up-cod
ded in aftern
noon.
Strong
S
suppo
ort for refining & expandiing 2013 LH
HIN pilot proje
ect resource
es/solutions to
address the challenges
c
of
o the ride in and the ride
e out (both lo
ocally and lo
onger interhospital runs)).
ORN
NGE Perspe
ective on No
on-urgent Transportati
T
ion System Performan
nce
ORNGE provides me
edically nece
essary transportation forr Code 1-2 p
patients acro
oss the proviince,
where the transfer distance betw
ween facilities exceeds 2
240 km. Con
ntracted fixe
ed wing aircrraft
S
Offfer Agreeme
ent (SOA) de
elivers ORNG
GE non-urge
ent patient transportatio
on.
under a Standing
ORNGE medical dire
ectors establish non-urgent patient ccare standarrds for the organization;
p
th
he transfer of
o care for a llow CTAS m
medically sta
able Code 1--2
most notably by not permitting
c to an EMS
S or transfer service non--paramedic attendant.
patient by an ORNGE paramedic
16
Historically, EMS serrvices in Thu
under Bay an
nd Sudbury have proven
n unreliable in moving
ORNGE Code 1-2 pa
atients from the respectiive airport ta
armacs to Th
hunder Bay Regional He
ealth
s Centre (TB
BRHSC) or Health
H
Sciences North (H
HSN) in a tim
mely fashion
n. These EMS
Sciences
services have been preoccupied
p
d with high Code
C
3-4 eme
ergency ressponse workload, promp
pting
C
1-2 callls. During 2012-2013
2
O
ORNGE relie
ed on private
e transfers
endemic delays for Code
nder Bay and
d Platinum in
n Sudbury) tto move thesse patients.
services (i.e. Ambutrrans in Thun
aramedics rode along with
w the patie
ent all the wa
ay to the TBRHSC or HS
SN in
Howeverr, ORNGE pa
order to comply
c
with the medicall directors’ risk managem
ment policiess on non-urg
gent patient
ground trransfers. The time dela
ays associate
ed with the O
ORNGE parramedic ride
e to the hosp
pital,
and back
k to the airpo
ort tarmac, re
esulted in ta
armac detenttion fees beiing levied on
n the fixed w
wing
aircraft. As well, dailly aircraft utiilization was negatively iimpacted byy tarmac dela
ays.
ury the ORNGE detention fees increased from $
$150k to $18
80k when Pla
atinum was
In Sudbu
retained to provide la
and transporrtation for Co
ode 1-2 tran sfers. The p
previously delayed “no
E
airport ride in 2011
1 permitted the transfer tto occur at th
no ORNGE
charge” EMS
he airport; n
paramed
dic was required to travel to HSN. In
n 2012 and 2
2013 the mo
ore timely pu
urchased
Platinum ride from th
he airport req
quired ORNG
GE medics tto ride along
g, thereby crreating even
elays. Total annual costts to ORNGE
E from the P
Platinum tran
nsport mode
el exceeded
longer de
$350k in 2012. ORN
NGE has now
w discontinu
ued its arrang
gement with
h Platinum to
o transfer tarrmac
f
the Sud
dbury airporrt to HSN. For the time b
being, Sudb
bury EMS am
mbulances m
move
patients from
these OR
RNGE tarma
ac patients – with all the same delayy problems e
experienced in 2011.
17
A solution to the airp
port tarmac patient
p
transffer problem – by creatin
ng a timely/dependable
armac based
d transfer bettween an OR
RNGE param
medic and a land EMS p
paramedic – is
airport ta
an opera
ational prioritty for ORNG
GE. ORNGE expenditure
es associate
ed with the S
Sudbury tarm
mac
patient trransfer probllem have rep
portedly dec
creased from
m their peak of $350k in 2012. Furth
her
ORNGE expenditure
e reduction frrom the 2012 peak is po
ossible if a timely/reliable
e paramedicc-todic transfer solution
s
on th
he tarmac is enacted.
paramed
gent Transp
portation Sy
ystem Perfo
ormance Ch
hallenges/P
Problems
Overall Non-urg
The following figure “maps”
“
the key
k challeng
ges/problemss with the no
on-urgent pa
atient
m across the
e LHIN. This
s high-level p
process map
p reflects the
e “patient
transporttation system
journey” from the com
mmunity hos
spital to the hub hospita l (in green), and the retu
urn trip backk to
the comm
munity hospiital (in black) following th
he test/proce
edure at the
e hub hospita
al. The
challenge
es/problems
s identified with
w the curre
ent model (a
as identified by key stake
eholders) are
e
superimp
posed in red across the process map.
18
19
Nortth West LHIIN Patient Care
C
and Co
ontrol Pilot
The Nortth West LHIN
N is currently
y funding a non-urgent
n
ttransportatio
on patient “ca
are and control”
pilot proje
ect involving
g Thunder Bay Regional Health Scie
ences Centre
e and a large portfolio o
of
community hospitals. The follow
wing pilot pro
oject facts arre relevant fo
or purposes of this revie
ew:

TBRHSC
T
(hub hospital) would
w
accep
pt partial care
e & control ffor low acuityy “treat & retturn”
Code
C
1-2 patients from co
ommunity ho
ospitals.

ypically diagnostic imaging tests/pro
ocedures.
Ty

TBRHSC
T
has
s established
d a 3 patientt holding are
ea in diagnosstic imaging.

Holding
H
area to be staff by
b a 1FTE RPN.
R


eginning at 9-10
9
a.m. (pa
atients mustt be returned
d before 7 p.m.
8-hour shift be
hile Superiorr North EMS
S medics stil l on shift).
wh

En
nvisioning tw
wo trained RPN staff to e
ensure cove
erage acrosss weekly worrk
sc
chedule.

Prrojected 1:3 staff to patie
ent ratio with
h frequent pa
atient turnovver anticipate
ed.
Key
K implementation issue
e is establish
hing credenttials for com
mmunity hosp
pital physicia
ans
at TBRHSC; no transfer of
o responsib
bility to TBRH
HSC physicians.

Region-wide
R
re-credentia
aling process
s for physicia
ans already underway in
n NW LHIN;
would
w
be exp
panded to res
solve care & control pro
oblems.


Communiity hospital physician
p
will be able to
o issue mino
or scope ord
ders to TBR
RHSC
staff (e.g. IV or meds)) for “treat & return” Cod
de 1-2 patien
nts.

If these patients require emergen
ncy care duriing time at T
TBRHSC the
ey would pro
oceed
to ER like
e any other in
ndividual.

Participatting commun
nity and hub
b hospitals w
will need to m
make legal w
wording cha
anges
to their ho
ospital by-law
ws; lawyers currently wo
orking on this matter in tthe NW LHIN
N.
Two
T
phase ro
ollout is plan
nned. Phase
e 1 for patien
nts with no re
equirementss for orders tto be
fillled at TBRH
HSC and Phase 2 for pa
atients with o
order require
ements.
20
2013
3 North Eas
st LHIN Pilot Projects
In 2013, the North Ea
ast LHIN imp
plemented three pilot prrojects to exp
plore alterna
atives to the
traditiona
al EMS paramedic-based model for delivering no
on-urgent pa
atient transp
portation.
Sudbury EMS collaborated with Health Scien
nces North ((HSN) to delliver a non-a
ambulance
community flow car”. Th
his vehicle (p
previously an
n ambulance
e, but with m
markings and
d
patient “c
radio rem
moved) proviided short ha
aul patient trransfers of p
primarily Cod
de 1 patientss out of Hea
alth
Sciences
s North. The
e vehicle was not include
ed in the EM
MS deployme
ent plan and
d could not b
be
pre-emptted from its patient
p
trans
sfer work by ambulance dispatch (CACC). The community flow
car was staffed
s
by tw
wo Sudbury EMS
E
paramedics, and d
deployed on a 12-hour sshift, seven d
days
per week
k.
Manitouliin-Sudbury EMS
E
deliverred a non-pa
aramedic tra nsfer service
e consisting of two dual
stretcherr vehicles de
eployed Mon
nday-Friday 0800-1900
0
d
daily. The p
prime function of the pilot was
to facilita
ate the transffer of Code 1-2 patients from the two
n Health Cen
ntre facilitiess, and
o Manitoulin
Espanola
a Regional Hospital
H
and Health Centre, to-and-ffrom Health Sciences No
orth in
es are staffe
Sudbury.. The pilot’s
s two non-am
mbulance tra
ansfer vehicle
ed by non-pa
aramedic firsst-aid
attendants who received enhanc
ced training on
o stretchers
rs, patient mo
obility and d
disease
sion. These
e vehicles routinely waite
ed in Sudburry to return p
patients to th
he facility of
transmiss
origin, so
o stranding of
o patient and escort werre significan tly reduced.
Timiskam
ming EMS ad
dapted the SW
S LHIN Pa
atient Transp
port Decision
n Guide (algorithm) for th
heir
use, so that hospital staff could determine
d
th
he most apprropriate tran
nsport solutio
on. EMS
ed all in-distrrict non-eme
ergency calls
s between 07
700-1600 da
aily. A private transfer
performe
provider executed all of the out-o
of-district non-emergenccy calls 24 hours a day, and in-district
calls betw
ween 1600-0
0700 daily. Calls that th
he private tra
ansfer provid
der was not able to do w
were
reassigne
ed to EMS fo
or completio
on.
The three
e pilot projec
cts have delivered signifficant and m
measurable im
mprovementts in the
functionin
ng of the EM
MS emergency response
e system and
d the non-urrgent transpo
ortation mod
del.
21
Almost 5,200 EMS emergency
e
coverage
c
hou
urs have bee
en recovered
d and re-dep
ployed as
originally
y intended by
y EMS deplo
oyment plans. Overall, E
EMS system
m “busyness”” due to non
nurgent tra
ansfer workload (i.e. call volume) wa
as reduced tto more man
nageable levvels at
overwork
ked Manitoulin-Sudbury EMS bases. Both the frrequency an
nd duration o
of patient offfload
delays att the Health Sciences No
orth emerge
ency departm
ment were re
educed by 12
2 percent.
Problema
atic up-codin
ng of schedu
uled non-urg
gent procedu
ures (to urge
ent status) byy communityy
hospital physicians
p
has
h largely dissipated
d
ac
ccording to E
EMS leadersship. EMS ssurveys of
community hospital medical
m
and administrative staff iden
ntified enthu
usiastic supp
port for the p
pilots,
v
elimin
nation of the highly problematic stran
nded patientt escort.
and the virtual
The following table contains
c
high
hlights of pilo
ot project pe
erformance in
ndicator data
a.
22
The pilot projects hav
ve provided the Perform
mance Conce
epts team fu
undamental iinsights into key
o the restructuring soluttion/model th
hat will be re
equired LHIN
N-wide to cre
eate a stable
e,
aspects of
dependable non-urge
ent patient trransportation system.
Overall Stakeho
older Obserrvations
EMS providers, community hosp
pitals and hub hospitals a
across the N
North East LHIN
independ
dently advan
nced the follo
owing overall observatio
ons about the
e non-urgen
nt patient
transporttation model:
 The
T non-urge
ent patient system
s
that pre-dated
p
th
he 2013 pilott projects is not sustaina
able
from
f
patient--centred or financial
f
pers
spectives for communityy hospitals. However,
significant
s
fin
nancial savin
ngs at comm
munity hospittals are posssible with su
uccessful
implementation of the recommended
d new non-u
urgent transp
portation mo
odel.
 The
T non-urge
ent patient transportatio
on system tha
at pre-dated
d the 2013 pilot projects was
a major prob
blem for hub hospitals; creating patie
ent flow blocckages, conttributing to
offload
o
delay
y in emergen
ncy departments, and re
esulting in strranded community hosp
pital
patients
p
and escorts with
hin the hub hospitals.
h
23
 The
T regional hubs mode
el of non-urge
ent patient ccare will not be financially sustainab
ble for
community
c
hospitals
h
facing aging de
emographic pressures – unless patie
ent
transportatio
on becomes far more reliable in/out o
of hub hospiitals and the
e system
becomes
b
sca
alable for an
nticipated inc
creases in trransfer volum
mes.
 System
S
reliability and the
e patient exp
perience imp
proved significantly whe
en the pilot
projects
p
were
e implementted in 2013. Scalable an
ent non-ambulance
nd permane
resources
r
for long-haul patient
p
trans
sfers betwee
en hospitals are necessa
ary.
24
E. Situ
uation An
nalysis - Evidence
E
Based Q
Quantitatiive Modelling
In order to
t test the pe
erspectives and observa
ations of the
e various EM
MS, community and hub
hospital stakeholders
s
s, the Perforrmance Concepts projecct team has undertaken extensive
quantitative modeling
g of the EMS
S (and privatte provider) non-urgent transportatio
on system th
hat
d the 2013 pilot
p
projects
s. The quantitative mode
eling has bee
en conducte
ed using 2012
pre-dated
calendarr year data frrom EMS pro
oviders, as well
w as the e
existing priva
ate transfer ssupplier in
Sudbury (Platinum).
As noted
d in the follow
wing figure, modeling
m
ha
as been cond
ducted LHIN
N-wide on tra
ansfer volum
mes,
vehicle hour
h
outputs,, EMS system “busyness” by base, a
and overlapping Code 1
1-2 and 3-4
overlapping calls. EM
MS base-specific analys
sis has been
n undertaken
n where app
propriate, in o
order
stand Code 3-4 patient risk
r posed by Code 1-2 w
workload.
to unders
For purpo
oses of mod
deling LHIN-w
wide pattern
ns of Code 1 -2 transfer vvolumes and
d vehicles ho
ours
of outputt, an In/Out modeling
m
approach has been used b
by Performa
ance Concep
pts. The In/O
Out
approach
h focuses on
n community
y hospital/fac
cility Code 1 -2 non-urgent “traffic” flo
owing in and
d out
of the LH
HIN’s four hu
ub hospitals located in Sudbury, Norrth Bay, Sault Ste. Marie
e, and Timmins.
A mini-hu
ub in New Liiskeard (featturing a CT scanner)
s
ha s also been modeled to complete th
he
In/Out an
nalysis.
25
The figurre below pro
ovides a conc
ceptual illusttration of the
e In/Out ana
alysis acrosss the LHIN. T
The
analysis documents patient Code
e 1-2 flow (b
by any EMS service) into
o a hub hosp
pital and bacck to
the facilitty/residence of origin.
26
IN/O
OUT Analysiis – Sudburry Hub
The following table highlights
h
the
e 2012 Sudb
bury hub’s “IN
N” flow of Co
ode 1-2 non
n-urgent tran
nsfers
i
and
a hospitals
s). The larg est flows of inter-hospita
al transfers tto
(i.e. highest volume institutions
Health Sciences Norrth originate at Elliot Lak
ke Saint Jose
eph Hospital (250), ORN
NGE patientss
E
Ho
ospital (181)), Mindemoyya Hospital (115), Little
from the Sudbury Airrport (200), Espanola
H
(95)), and North Bay Region
nal Health Ce
entre (91).
Current Hospital
y “IN” Flow of Code 1-2
2 Transfers
Sudbury
The total number of 2012
2
Sudbu
ury hub “IN” Code
C
1-2 tra
ansfers is 1,9
941.
The Code 1-2 transfe
er duration (i.e. transfer minutes) “sttop watch” iss turned on b
by an ambullance
deploying
g for the tran
nsfer patientt pick-up, and does not tturn off until ambulance arrival at He
ealth
Sciences
s North. The
e same “stop
p watch” app
plies to all 5 transportatio
on hub IN/O
OUTS.
27
Sudbury
y “OUT” Flo
ow of Code 1-2 Transfe
ers
The table
e above high
hlights the 20
012 Sudbury
y “OUT” flow
w of Code 1--2 non-urgen
nt transfers ((i.e.
highest volume
v
institutions and hospitals).
h
The large
est flows of inter-hospita
i
al transfers outwards
o
fro m Health Scciences Nortth are traveliing
to Elliot Lake
L
Saint Joseph Hosp
pital (318), th
he Sudbury A
Airport for O
ORNGE transsport (269),
Espanola
a Hospital (2
201), Mindem
moya Hospittal (126), Litttle Current H
Hospital (119
9), Kirkland Lake
Hospital (49), and No
orth Bay Reg
gional Health Centre (46
6).
The total number of 2012
2
Sudbu
ury hub “Out”” Code 1-2 t ransfers is 2
2,915.
28
IN/O
OUT Analysiis – North Bay
B Hub
h
the
e 2012 North
h Bay hub’s “IN” flow of Code 1-2 no
on-urgent
The following table highlights
transfers
s (i.e. highest volume ins
stitutions and
d hospitals).
The large
est flows of inter-hospita
i
al transfers to
o North Bayy Regional H
Health Centre
e originate a
at
West Nip
pissing Gene
eral Hospitall (171), ORN
NGE patientss from the Ja
ack Garland Airport (98)),
Temiskaming Hospital (61), and Health Scie
ences North (47). Ruthe
erglen (relay)) calls
predomin
nantly origina
ate at the Mattawa Gene
eral Hospita
al.
North Ba
ay “IN” Flow
w of Code 1-2
1 Transferrs
al number of 2012 North Bay hub “IN
N” Code 1-2 transfers is 731.
The tota
The following table highlights
h
the
e 2012 North
h Bay hub “O
OUT” flow off Code 1-2 n
non-urgent
s (i.e. highest volume ins
stitutions and
d hospitals).
transfers
29
North Ba
ay “OUT” Flow
F
of Code
e 1-2 Transfers
The large
est flows of inter-hospita
i
al transfers outwards
o
fro m North Bayy Regional H
Health Centrre
are trave
eling to Westt Nipissing General
G
Hospital (263), H
Health Scien
nces North (9
91), Jack
Garland Airport
A
to lin
nk-up with ORNGE (85), Temiskamin
ng Hospital (84), and Ma
attawa Gene
eral
Hospital (36).
The total number of 2012
2
North Bay
B hub’s “O
OUT” Code 1-2 transferss is 1,290.
IN/O
OUT Analysiis – Sault Hub
H
The following table highlights
h
the
e 2012 Saultt hub’s “IN” fflow of Code
e 1-2 non-urg
gent transfers
(i.e. highest volume institutions
i
and
a hospitals
s).
The large
est flows of inter-hospita
i
al transfers to
o Sault Area
a Hospital orriginate at th
he Sault Airp
port
with inco
oming ORNG
GE patients (143),
(
Blind River Hospittal (90), and
d Thessalon Hospital (62
2).
30
Sault “IN
N” Flow of Code
C
1-2 Trransfers
The total number of 2012
2
Sault hub’s
h
“IN” Co
ode 1-2 tran
nsfers is 584.
Sault “O
OUT” Flow of
o Code 1-2 Transfers
The following table highlights
h
the
e 2012 Saultt hub’s “OUT
T” flow of Co
ode 1-2 non--urgent transsfers
(i.e. highest volume institutions
i
and
a hospitals
s).
The large
est flows of inter-hospita
i
al transfers outwards
o
fro m Sault Area hospital are traveling to
the Saultt Airport (152
2) for connections to OR
RNGE, Blind River Hosp
pital (92), and
d Thessalon
n
Hospital (46).
The total number of 2012
2
Sault hub’s
h
“OUT” Code 1-2 trransfers is 1,210.
31
IN/O
OUT Analysiis – Timmin
ns Hub
The following table highlights
h
the
e 2012 Timm
mins hub’s “I N” flow of Code 1-2 non
n-urgent tran
nsfers
i
and
a hospitals
s).
(i.e. highest volume institutions
s “IN” Flow of Code 1-2
2 Transfers
s
Timmins
est flows of inter-hospita
i
al transfers in
nto Timminss and Districtt Hospital (T
TDH) originate at
The large
the Timm
mins Airport for
f ORNGE (408), Kapu
uskasing Hosspital (182), Anson General Hospita
al
(159), Kirkland Lake Hospital (13
36), Lady Minto Hospitall (116), Bing
gham Memorial Hospital (72),
H
(51),, Chapleau Hospital
H
(35)), and Engle
ehart District Hospital (17
7).
Hearst Hospital
2
Timmin
ns hub’s “IN” Code 1-2 ttransfers is 1
1,686.
The total number of 2012
The table
e on the nex
xt page highlights the 2012 Timmins hub’s “OUT
T” flow of Co
ode 1-2 nonurgent tra
ansfers (i.e. highest volu
ume institutio
ons and hosspitals).
The large
est flows of inter-hospita
i
al transfers outwards
o
fro m Timmins a
and District Hospital are
e
traveling to the Timm
mins Airport (373)
(
for con
nnection to O
ORNGE, Kapuskasing H
Hospital (221
1),
Anson General (218)), Kirkland la
ake Hospital (166), Ladyy Minto Hosp
pital (113), B
Bingham
oth Rock Fallls (68), Hea
arst (50), Eng
glehart Distrrict Hospital (21) and
Memorial (73), Smoo
Chapleau
u Hospital (2
20).
32
The total number of 2012
2
Timmin
ns hub’s “OU
UT” Code 1--2 transfers is 2,199.
Timmins
s “OUT” Flo
ow of Code 1-2 Transfe
ers
IN/O
OUT Analysiis – New Lis
skeard Hub
b
The following table highlights
h
the
e 2012 New Liskeard hu
ub’s “IN” flow
w of Code 1-2
2 non-urgen
nt
transfers
s (i.e. highest volume ins
stitutions and
d hospitals).
New Lisk
keard “IN” Flow
F
of Cod
de 1-2 Transfers
The large
est flows of inter-hospita
i
al transfers in
nto New Liskkeard’s Tem
miskaming Hospital origin
nate
at the Kirrkland Lake Hospital (16
69), Engleha
art and Distri ct Hospital ((76), North B
Bay General
Hospital (84), and Su
udbury’s Hea
alth Science
es North (24)). Airport ca
all volume is minor (7).
33
The total number of 2012
2
New Liskeard hub’s “IN” Code
e 1-2 transfe
ers is 455.
New Lisk
keard “OUT
T” Flow of Code
C
1-2 Tra
ransfers
The following table highlights
h
the
e 2012 New Liskeard hu
ub “OUT” flow
w of Code 1-2 non-urgent
s (i.e. highest volume ins
stitutions and
d hospitals).
transfers
The large
est flows of inter-hospita
i
al transfers outwards
o
fro m Temiskam
ming Hospita
al are traveling to
the Kirkla
and Lake Ho
ospital (223), Englehart and
a District Hospital (111), North Ba
ay General
Hospital (60), Health Sciences North
N
(15), Earlton Airporrt (18) and T
TDH (6).
The total number of 2012
2
New Liskeard hub’s “OUT” Co
ode 1-2 transsfers is 590.
Und
derstanding IN/OUT Tra
ansfer Volum
me Varianc
ces
The follow
wing table summarizes IN
N/OUT Code
e 1-2 non-urg
gent patientt transfer flow
ws across th
he
North Eastt LHIN’s five
e transportation hubs.
As docume
ented within
n the table, th
he OUT tran
nsfer volume
es exceed the IN transfer volumes by a
significant margin in each hub. Th
here are a number of rea
asons for this pattern off transfer
volumes:
34

Physician
P
up--coded trans
sfers are nott included in “sending ho
ospital” totalss (these Cod
de 3
trransfers are best unders
stood as “urg
gent” Code 2 patients, based on phyysician judgm
ment
about the clin
nical impact of
o delayed te
ests due to ttransfer ride
e delays)

Over-triaged
O
Code 3 transfers (DCPI 2 algorithm
m) who return
n as Code 1 transfers

Code
C
3-4 tran
nsfer patientts whose con
ndition impro
oves significcantly via treatment at hu
ub
ho
ospital & the
en return as Code 1 tran
nsfers
Non-urge
ent transporttation restructuring recommendation
ns in this rep
port will need
d to recognizze
the challe
enge posed by significan
nt Code 1 pa
atient repatrriation OUT vvolumes.
T Non-urgen
nt Transferr Volumes
Summarry of IN/OUT
Notes:
es not include 500+
5
North Ba y Hospital non-paramedic tra
ansfer
1) North Bay data doe
e trip volumes are
a not tracked
d on in/out basis.
vehicle trips, because
2) Prev
viously in this re
eport, hub hosp
pital-specific in
n/out informatio
on has been co
orrectly
presented. In the cons
solidated summ
mary table abo
ove, duplicate ccases have bee
en
ed (i.e. in some
e instances one
e hospital’s tran
nsfer “in” may a
also be anothe
er
remove
hospita
al’s transfer “ou
ut”), and thus th
he numbers are
e not strictly a ssummation of tthe
individu
ual hospitals’ in
n/out volume.
35
Parrry Sound No
on-Urgent Transfer
T
Re
eferral Patte
ern
The prev
vious In/Out analysis doc
cuments pattient movem ent flows within the LHIN. Howeverr,
West Parry Sound Health Centre
e has a unique referral p
pattern for itss Code 1-2 ttransfers –
primarily moving patiients outside
e of the Nortth East LHIN
N to destination hub hospitals locate
ed in
Muskoka
a, Simcoe Co
ounty, and th
he GTA. Th
herefore, Parrry Sound EMS transfer workload do
oes
not show
w up in the IN
N/OUT analy
yses. Howev
ver Performa
epts has doccumented the
e
ance Conce
following Parry Soun
nd “OUT” vollume transfe
er pattern forr 2012:


A tottal of 167 lon
ng-haul Code 1-2 transfe
ers to Wayp
point Mental Health Centtre (74), Orillia
Sold
diers Memoriial Hospital (24),
(
Royal Victoria
V
Hos pital (18), So
outh Muskoka Memorial
(15),, and Huntsv
ville District Hospital
H
(18).
Thes
se transfer volumes
v
consumed a tottal of 283 lon
ng-haul transsfer hours.
Recomm
mendations in
n this review
w will address
s the unique
e Code 1-2 transfer referrral patternss
found in Parry Sound
d.
deling Non-u
urgent Tran
nsportation Service De
elivery Outp
puts – EMS Vehicle Hou
urs
Mod
The Perfformance Co
oncepts proje
ect team has
s modeled 2
2012 EMS no
on-urgent tra
ansfer outpu
uts –
expresse
ed as Code 1-2
1 vehicle hours
h
of serv
vice. IN/OU T transfer vo
olumes and average tra
ansfer
durations
s have been used to calc
culate vehicle hours of sservice acrosss all 5 transsportation hu
ubs.
The following table sets
s
out the total
t
2012 Code 1-2 tran
nsfer output hours by hub. The totall
non-urge
ent transfer output
o
hours
s range from 6,477 in the
e Sudbury hub, 1,727 ho
ours in the N
North
Bay hub,, 1,910 hours
s in the Sault hub, 4,910
0 hours in th
he Timmins h
hub, and 1,3
392 hours in the
New Lisk
keard hub. These
T
outpu
ut hour totals
s include botth IN and OU
UT transfer vvolumes.
The IN/O
OUT transferrs feature du
urations that fall into two distinct cate
egories – short haul tran
nsfers
with averrage durations less than
n an hour (on
ne way), and
d long-haul ttransfers with average
durations
s of 90+ minutes (one way). Long-h
haul transfer output hourrs range from
m 4,357 in th
he
Sudbury hub, 939 ho
ours in the North
N
Bay hub, 1,015 hou
urs in the Sa
ault hub, 3,5
510 hours in the
n the New Liiskeard hub..
Timmins hub, and 1,211 hours in
36
Summarry of EMS Code
C
1-2 Tra
ansfer Outp
put Hours
ocuses on lo
ong-haul pattient transferr volumes, o
output hourrs, and dura
ation
The following table fo
ub).
(by transportation hu
Long-ha
aul Code 1-2
2 Transfer Volumes
V
& Mean
M
Durattion
Hub
2012 EMS
S
Long-Hau
ul
Transfer
Volumes
s
2012
2 EMS
Long
g- Haul
Tran
nsfer
Ho
ours
M
Mean LongHa
aul Transfer
Duration
(Hours)
Sudbury
2,230
4,3
357
2.01
North Bay
934
93
39
1.26
Sault
573
1,0
015
1.77
Timmins
1,893
3,5
510
1.87
Ne
ew Liskeard
918
1,2
211
1.46
Total
5,548
11,,032
---
37
The Sudbury hub experienced 2,230 long-ha
aul Code 1-2
2 transfers w
with an avera
age duration
n of
d 934 long-h aul transferss with an ave
erage duratiion of
2.01 hours. The Norrth Bay hub experienced
ult hub experienced 573 long-haul trransfers with
h an average
e duration off
1.26 hours. The Sau
1.77 hours. The Tim
mmins hub ex
xperienced 1,893
1
long-h
haul transferrs with an avverage durattion
N
Liskeard
d hub experienced 918 long-haul tra
ansfers with an average
e
of 1.87 hours. The New
urations mea
asure patien
nt transfer tim
me – they do
o NOT includ
de
duration of 1.46 hourrs. These du
me for empty
y ambulance
es to return to base follow
wing a comp
pleted IN or OUT patient
return tim
transfer leg.
Longer in
nter-hospital Code 1-2 trransfers reprresent signifficant EMS C
Code 3-4 ressponse cove
erage
risk, acco
ording to EM
MS and comm
munity hosp
pital stakehollders. Stake
eholders havve also
suggeste
ed that short-haul Code 1-2 transfers
s do not rep resent comp
parable risk since
ambulances need no
ot leave theirr Code 3-4 emergency
e
ccoverage zones to execu
ute this workk.
Mod
deling EMS System Bus
syness – Unit
U Hour Uti
tilization (UH
HU) by Base
EMS sys
stem “busyne
ess” is an im
mportant mettric to review
w when conssidering restrructuring options
for non-u
urgent patien
nt transporta
ation. Exces
ssive system
m busyness n
negatively im
mpacts Code
e 3-4
emergen
ncy call cove
erage and response time
es. Code 1-2
2 response rreliability (i.e
e. promptnesss) is
also nega
atively impacted by exce
essive ambu
ulance syste
em busynesss.
System busyness
b
in the Ontario EMS sectorr is measure
ed using unitt hour utilizattion or UHU.
UHU calc
culates the percentage
p
of
o a deploye
ed vehicle ho
our of servicce that is con
nsumed by
actively responding
r
to
t a Code 1--4 call. For modeling
m
pu
urposes, Perrformance Concepts
Consultin
ng has calcu
ulated two distinct UHU data
d
sets forr all EMS ba
ases in the N
North East LH
HIN:
Code 1-2
2 non-urgentt calls, and Code
C
3-4 em
mergency ca
alls. These tw
wo UHU sce
enarios have
e
been furtther refined on
o the basis
s of a “peak daytime”
d
twe
elve-hour pe
eriod defined
d as 7am to 7pm.
Peak day
ytime UHU is
s the key me
etric becaus
se the vast m
majority of Co
ode 1-2 tran
nsfers are
executed
d during this twelve-hourr window. This report w ill focus on tthe “peak da
aytime” UHU
U
calculatio
ons in order to assess th
he risk posed
d by system busyness.
38
The following table sets
s
out the “peak
“
daytim
me” Code 1-2
2 and Code 3-4 UHUs fo
or EMS base
es
he LHIN. It also
a
presentts a consolid
dated Code 1
1-4 UHU. Th
he Code 1-2 UHU is
across th
calculate
ed by creating a ratio deffined by a “T
Time on Call s” numerato
or and a “Daytime Deplo
oyed
Minutes” denominato
or. The resu
ulting ratio is
s a percentag
ge of daytim
me deployed vehicle time
e
umerator calculation inclludes
(minutes) consumed by Code 1-2 workload. The “Time on Calls” nu
nsfer travel time,
t
patientt offload time
e at the desttination hosp
pital, and retturn time to
initial tran
base. A caveat - the
e formula callculates a “high end of a
accurate” UH
HU value, be
ecause each
Code 1-2
2 call is assu
umed to inclu
ude return time to base – a situation
n that does n
not always o
occur
(but usua
ally occurs). The same ratio calcula
ation formula
a applies to tthe Code 3-4
4 UHU pane
el.
The UHU
U results are
e best unders
stood by sep
parating EM S bases into
o two catego
ories; single
ambulance daytime bases
b
versu
us multi-ambulance dayt ime bases. Both base ccategories a
are
negatively impacted by an inordinately high UHU. The ssystem busyyness risk is acute for sin
ngle
ambulance bases wh
here long-ha
aul Code 1-2
2 transfers crreate a “zero
o units availa
able” covera
age
ompromises Code 3-4 co
overage and
d response tiimes.
gap that seriously co
39
2012 Peak Daytime
D
Unit Hour Utilization
n (UHU) – Code
e 1-2, 3-4, 1-4 T
Transfers
40
There are
e a number of multi-am
mbulance da
aytime base
es across the
e LHIN with inappropriattely
high Cod
de 1-2 UHU ratios. Kapu
uskasing (65
5%), Elliot La
ake (55%), IIroquois Fallls (41%),
Timmins (33%), Mind
demoya (37%
%), and Kirk
kland Lake (4
43%) all feature UHU ra
atios exceeding a
system busyness
b
risk threshold of
o 30 percen
nt. It should be noted th
hat Kapuskassing’s daytim
me
UHU of 65%
6
somewhat exaggerrates the “on
n-the-ground
d” system bu
usyness beca
ause many n
nonurgent tra
ansfers are actually
a
up-s
staffed with ambulance resources not budgeted
d in the
deployme
ent plan. EM
MS deploym
ment plan veh
hicle hours tthat are supp
posed to be devoted
primarily to Code 3-4
4 emergency
y coverage, are being co
onsumed byy Code 1-2 w
workload.
ses are often being removed from th
heir emergency coverag
ge zones forr
Vehicles at these bas
not be the re
esult at multilong-haul inter-hospital transfers. While “zerro available units” may n
educed emergency response capaciity (below planned levelss) is frequen
ntly
ambulance bases, re
g.
occurring
e a number of single-am
mbulance daytime
d
bas
ses across th
he LHIN with
h alarmingly high
There are
Code 1-2
2 UHU ratios
s. Examples
s include Blin
nd River (17
7%), Thessalon (41%), L
Little Currentt
(16%), Espanola (21%), West Niipissing (22%
%) and Engl ehart (18%)). At all of the
ese bases, tthe
Code 1-2
2 UHU ratios
s suggest fre
equent “zero
o units availa
able” emerge
ency coverage gaps. EM
MS
services often respon
nd to “zero available
a
uniits” by movin
ng ambulancces from an adjacent ba
ase
d bases (the
ereby providing sub-optim
mal emergency coverag
ge for both
closer to the exposed
ult is a signifficant risk “spike” re. em
mergency ressponse capa
ability on virtu
ually
bases). The net resu
asis.
a daily ba
ode 3-4 UHU
U workload is combined with Code 1
1-2 UHU workload for these at-risk
When Co
bases, th
he risk mana
agement result is even more
m
problem
matic.
41
Mod
deling EMS Emergency
y Coverage Risk Assoc
ciated with Code 1-2 N
Non-Urgent
Worrkload
The following table (2
2 panels) do
ocuments a significant
s
rissk event for EMS servicce providers –
2 and Code 3-4 calls witthin a given base’s cove
erage zone. When a Co
ode
overlapping Code 1-2
o
with
h a Code 1-2
2 transfer alrready in prog
gress, EMS emergency
3-4 emerrgency call overlaps
coverage
e and respon
nse times ca
an be negativ
vely impacte
ed. This is e
especially tru
ue if the Cod
de 12 call is a long-haul transfer
t
removing an am
mbulance fro m its emergency respon
nse coverage
zone. Th
he overlapping call risk spikes
s
when
n the EMS ba
ase in questtion only dep
ploys one
ambulance at any giv
ven time.
Overlapp
ping calls are
e more frequ
uent at bases with more than one am
mbulance de
eployed – ovverall
emergen
ncy readiness is negative
ely impacted
d but the situ
uation does n
not always e
equate with ““zero
units ava
ailable”. How
wever, at the
e 12-hour sin
ngle unit basses across a
all 5 hubs, “zzero units
available
e” is the prac
ctical reality for
f all overla
apping calls involving lon
ng-haul Code 1-2 transfe
ers –
units redeployed from
m adjacent bases
b
to min
nimize risk siimply canno
ot avoid unaccceptably lon
ng
ncy response
e times. The
e overlapping call modelling is not ap
pplicable in a large urba
an
emergen
system like Sudbury EMS where
e multiple units service a single busyy Code 4 ressponse
catchment area.
verlapping Call
C Risk Ev
vent by EMS
S Base
2012 Ov
EMS Servicce
Algoma
Algoma
Algoma
Algoma
Algoma
EMS
E
Base
Blind River ‐ Single Ambulan
nce
Elliot
E
Lake
Hornepayne
e ‐ Single Ambulance
Thessalon ‐ Single Ambulan
nce
Wawa ‐ Single
S
Ambulance
e
Overlapp
pedCalls
36
6
108
85
1
198
8
5
Codee 3‐4 Calls
594
11840
78
542
358
Cochrane
Hearst Base ‐ Single Ambulance
6
46
624
Cochrane
Kapuskasingg ‐ Single Ambulance
446
6
11038
Cochrane
Cochrane
Cochrane
Cochrane
Cochrane
Cochrane
Parry Sound
Parry Sound
Parry Sound
Parry Sound
Parry Sound
Cochrane ‐ Single Ambulance
Iro
oquois Falls
Matheson ‐ Single Ambulan
nce
Smooth Rock ‐ Single Ambulaance
South Porcupine
P
Base
Tim
mmins Base
Paarry Sound
Burks Falls ‐ Single Ambulan
nce
Seguin ‐ Single
S
Ambulancee
South Riverr ‐ Single Ambulaane
Powassan ‐ Single Ambulan
nce
15
5
260
0
4
8
73
3
141
19
192
2
8
8
6
13
3
472
535
226
230
11265
33699
11691
678
297
616
654
Oveerlap % Code 3‐4
6%
59%
1%
37%
1%
7%
43%
3%
49%
2%
3%
6%
38%
11%
1%
3%
1%
2%
42
EMS Servicce
Man‐Sud
Man‐Sud
Man‐Sud
Man‐Sud
Man‐Sud
Man‐Sud
Man‐Sud
Man‐Sud
Man‐Sud
Man‐Sud
NIPISSING
G
NIPISSING
G
NIPISSING
G
NIPISSING
G
Sault
Sault
Timiskamin
ng
Timiskamin
ng
Timiskamin
ng
EMS Base
Noelville ‐ Single Ambulance
Hagar ‐ Single Ambulancce
Gogama ‐ Single Ambualn
nce
Foleyet ‐ Single Ambulan
nce
Chapleau ‐ Single Ambulance
Little Current ‐ Single Ambu
ulance
Mindemoya
M
Massey ‐ Single Ambulan
nce
Wikweikon
ng ‐ Single Ambulance
Espanola ‐ Single Ambulance
Mattawa ‐ Single Ambulance
NB Main Base
W Nipissing ‐ Single Ambullance
NB Ferriss‐ Single Ambulance
Garden River ‐ Single Ambu
ulance
Old Gaarden River Road
d
Englehartt‐ Single Ambulance
Kirkland Lake
Temiskaming Shores
Overlap
ppedCalls
1
5
1
7
3
5
55
244
2
6
10
5
52
12
10
052
206
2
26
7
16
663
3
34
564
5
269
2
Codde 3‐4 Calls
456
355
249
55
247
556
678
557
769
774
311
4969
1390
1521
539
9297
525
1231
1355
O
Overlap % Code 33‐4
0%
1%
0%
13%
1%
10%
36%
1%
1%
7%
4%
21%
15%
2%
1%
18%
6%
46%
20%
Algoma EMS
E
feature
es two bases
s with a high
h-risk profile,, and one ba
ase with a m
moderate riskk
profile – Elliot Lake, Thessalon
T
and
a Blind Riv
ver respectivvely. Algom
ma’s Thessalo
on base dep
ploys
a single daytime
d
(12 hour) ambulance, and in 2012 face
ed 198 overla
apping call e
events
represen
nting 37% of its Code 3-4
4 call volume
e. The mult i-ambulance
e (daytime) E
Elliot Lake b
base
faced 1,0
085 overlapp
ping call eve
ents represen
nting 59% off its Code 3--4 call volum
me. Blind Rivver
faced 36 overlapping
g calls impac
cting 6% of its Code 3-4 call volume
e.
Cochrane
e EMS overs
sees three multi-ambula
m
ance bases ((daytime) wiith a high pe
ercentage of
Code 3-4
4 call volume
e impacted by
b overlapping Code 1-2
2 calls – Kap
puskasing, Irroquois Fallss and
Timmins. The single
e ambulance
e Hearst bas
se deals with
h 7% of its an
nnual emerg
gency calls b
being
2 overlapping transfers.
negatively impacted by Code 1-2
Parry Sound EMS ha
as one base that is signiificantly impa
acted – the Parry Sound
d base with ttwo
daytime (8
( and 12 ho
our) deploye
ed ambulanc
ces. At the P
Parry Sound
d base, overllapping Code 1-2
non-urge
ent transfers negatively impact appro
oximately on
ne-in-ten em
mergency callls.
43
Manitoulin-Sudbury EMS
E
deals with
w significa
ant overlapp ing call burd
dens at two m
multi-ambula
ance
36%) and Litttle Current ((10%). Annual 2012 overlapping ca
all
(daytime) bases – Mindemoya (3
s at these two bases tota
al 244 and 55 respective
ely.
incidents
Nipissing
g EMS faces
s significant overlapping
o
call burdenss at two bases – West N
Nipissing (15
5%)
and the Main
M
Base in
n North Bay (21%). Wes
st Nipissing is a single-a
ambulance d
daytime
deployme
ent base, wh
hile the Nortth Bay base is a multi-am
mbulance (d
daytime) basse.
Sault EM
MS has an 18
8% rate of ov
verlapping Code
C
3-4 callls at its multti-ambulance
e Old Garde
en
urban ba
ase – 1,663 total
t
calls in 2012.
Temiskaming EMS deals
d
with sig
gnificant ove
erlapping ca ll risk at two multi-ambulance (daytime)
ke and Temiskaming Shores. Kirkla
and Lake (46
6%) faced 56
64 overlappiing
bases – Kirkland Lak
nts in 2012. Temiskamin
ng Shores (2
20%) faced 2
269 overlapp
ping call eve
ents in 2012.
call even
EMS
S Quantitatiive Modeling
g Conclusio
ons
The following figure highlights
h
re
elevant non-u
urgent patien
nt transporta
ation restruccturing insigh
hts
generate
ed by Perform
mance Conc
cepts quantittative modelling of EMS data.
44
The IN/O
OUT quantita
ative modelin
ng exercises
s have confirrmed the exiistence of tw
wo distinct
categorie
es of non-urg
gent patient transfers:
 Short-haul tra
ansfers (less
s than an hour) that typiccally DO NO
OT require EM
MS units to
le
eave their res
spective bas
se emergenc
cy response
e coverage zzones.
 Lo
ong-haul tra
ansfers (typic
cally approac
ching 90 min
nutes or more) that DO require EMS
S
units to leave
e their base’s
s emergency
y response ccoverage zo
ones for exte
ended period
ds of
tim
me.
The risk profile assoc
ciated with lo
ong-haul non-urgent tra nsfers is sig
gnificant – im
mpacting EMS
ncy performa
ance across the North Ea
ast LHIN. R
Risk associatted with dayytime EMS
emergen
system busyness,
b
an
nd emergenc
cy coverage
e breakdown s, spikes at certain base
es across the
LHIN.
In contrast, short-hau
ul non-urgen
nt transfers delivered
d
by EMS create
e materially less emerge
ency
coverage
e risk; there is no quantittative modelling case tha
at justifies th
he replaceme
ent of efficie
ent
fixed-cos
st ambulance
es executing
g this medica
ally necessa
ary work with
hin the local communities
covered by their exis
sting bases.
45
Patie
ent Escort Costing
C
Analysis
e on the nex
xt page conta
ains three co
osting scena
arios develop
ped by the P
Performance
e
The table
Concepts
s project tea
am regarding
g community
y hospital co
osts associatted with the provision of
patient escorts for long-haul non-urgent patie
ent transferss.
The costing scenario
os are modeled using the
e following fo
formula:
C
2012 EMS Code 1-2 and up
p-coded Cod
de 3 long-ha
aul transportt hours/volum
mes
1. Compile
by
b hub;
M
a pa
atient escort “in hospital” time estima
ate (4/5/6 ho
our scenarioss) by the hub
b’s
2. Multiply
lo
ong-haul call volume to calculate tottal annual “in
n hospital” p
patient escorrt hours;
3. Add
A total long-haul trans
sport hours to total “in ho
ospital” esco
ort hours for each hub
(yielding
(
tota
al required patient escortt hours);
4. Multiply
M
total required pa
atient escort hours by a $
$45/hour co
ost factor to e
establish a to
otal
patient
p
escorrt costing forr each hub, across
a
each
h of the three
e costing sce
enarios.
The three
e costing sce
enarios yield
d an estimatted annual ccommunity hospital patie
ent escort co
ost
range of $1.82 M to $2.48
$
M, usiing the 2012
2 long-haul p
patient transsfer volumes/hours mode
eling
eady cited in this report.
data alre
46
Community
y Hospital Patie
ent Escort Cos
sting Scenarios
s
47
F. Situ
uation An
nalysis – Funding,
F
Governa
ance & De
ecision-M
Making
Systtem Fundin
ng re. the No
on-Urgent Patient
P
Tran
nsportation System
The fund
ding of non-u
urgent patien
nt transporta
ation is not c onsistent accross the Pro
ovince. In re
ecent
years, urrban Ontario
o has been steadily
s
evolv
ving towardss a hospital-funded mod
del. Both
community hospitals and second
dary/tertiary hospitals in urban Ontario have funded private
atient transfe
er services. Private secttor contracto
ors are a neccessity, give
en the inability of
sector pa
overburd
dened urban EMS provid
ders to delive
er timely/dep
pendable no
on-urgent tra
ansfer servicces.
Commun
nity hospitals
s are funding
g the transpo
ortation and escort costss of their “tre
eat and returrn”
patients, while secon
ndary/tertiary
y hospitals are
a funding p
post-procedu
ure patient re
epatriation ffor
n patient flow
w reasons. Urban
U
hospitals across O
Ontario are ssomehow fin
nding non-urrgent
their own
transfer funding
f
within their existting base budgets - budg
gets that do not have a d
designated ““line
item” for this service..
Urban ho
ospital fundin
ng of non-urrgent patientt transfers allready existss in the North East LHIN
N – at
Health Sciences Norrth and the North
N
Bay Re
egional Hea lth Centre. T
g is
This funding
nantly directe
ed towards short-haul
s
trransfers thatt create posiitive patient flow impactss for
predomin
these hospitals.
Consortiu
ums of hosp
pitals are ban
nding togeth
her in some p
parts of Onta
ario to provid
de efficient a
and
consisten
nt private co
ontractor purchasing arra
angements a
and pricing. As an exam
mple, a recen
nt
initiative in the South
hwest LHIN has
h generate
ed a high-qu
uality fee-forr-service sing
gle contracto
or
C
sttaff qualifica
ation and veh
hicle configu
uration servicce levels havve been
model. Contractor
standardized across the Southwest LHIN.
Large ho
ospitals in the
e Southwestt LHIN are making
m
use o
of the contra
actor to secu
ure timely,
dependable rides forr patients. However,
H
sm
maller commu
unity hospita
als reportedly cannot find
d
budget ro
oom to utilize
e the fee-forr-service priv
vate contracctor, and are instead optting for continued
“free” am
mbulance transfers. The Southwest LHIN’s
L
hosp
pital funded m
model is dem
monstrating that
small hos
spitals with limited budgets may opt for “free & ffast” EMS tra
ansfers via u
up-coded Co
ode 3
48
requests from some physicians. A LHIN sub
bsidy for sma
all hospitals would seem
m to be required
on-paramedic transfer re
esources. P
Potential cossts for small community
for them to secure no
s could be re
educed by co
ontrolling the
e required nu
umber of escort staffed transfers.
hospitals
Reinvestted patient escort
e
financial savings could
c
be use
ed to partiallyy fund non-p
paramedic
contracte
ed providers.
A “non-urgent transfe
er-provider” funding mod
del represen
nts a viable/p
preferred altternative to tthe
urban ho
ospital funded model. Prresumably, a transfer-prrovider fundiing model co
ould supportt
unavoida
able and nec
cessary EMS
S paramedic
c costs assocciated with n
non-urgent transfer upstaffing to
o preserve Code
C
3-4 cov
verage. A trransfer-provvider funding
g model could also support
an EMS non-parame
edic transfer model, a prrivate sector provider mo
odel, or inno
ovations like the
Sudbury EMS (param
medic staffed
d) non-ambu
ulance flow ccar.
In one sc
cenario, a no
on-urgent tra
ansfer-provid
der based fu
unding mode
el could stan
nd independe
ently,
not requiring busines
ss process changes
c
or im
mprovementts at particip
pating hospittals. In a sta
atusquo trans
sfer-providerr funding mo
odel, non-urg
gent transferr rides in the
e North Eastt LHIN would
d
continue to chase sc
cheduled pro
ocedures arrranged by ho
ospitals in a separate sillo. The fund
ded
ent ride would be a reacttive “one-off”” arrangeme
ent to accom
mmodate a se
eparately
non-urge
schedule
ed procedure
e at a hub ho
ospital for a single patien
nt. It should
d be noted th
hat this reactive
“chase th
he single pattient” model has historic
cally eroded EMS capab
bility to servicce non-urgent
transfers
s.
Alternativ
vely in a sec
cond scenariio, a non-urg
gent transferr-provider funding mode
el could be
integrate
ed with new/rrestructured business prrocesses to improve the
e cost-effectiveness of no
onurgent pa
atient transp
portation. Bu
usiness proc
cess improve
ements could reduce the
e dollar amo
ount
of a frontt-end financial investmen
nt by creatin
ng ongoing ccapacity for m
multiple patients on the
same vehicle during transport. The
T practice of “chasing the scheduled procedure” with a last
cheduled rid
de could be re-assessed
r
d. Non-transsportation prrocess chang
ges as per the
minute sc
North We
est LHIN’s Thunder
T
Bay
y “holding are
eas” pilot co
ould eliminate
e stranded p
patients/esco
orts
and achie
eve financia
al savings.
49
In essence, a non-urrgent transfe
er-provider fu
unding mode
el would beccome a criticcal compone
ent of
er non-urge
ent transporrtation chang
ge manage
ement initiatitive.
a broade
Perforrmance indiicator
derived results targ
gets, transpa
arent resultts reporting against targets, and a fee-for-re
esults
service le
evel contract would beco
ome part and parcel of tthe provider based fundiing model.
Using Key Performanc
Long
g-Haul Systtem-Wide Planning
P
& Operations
O
ce Indicatorrs
The curre
ent non-urge
ent patient trransportation
n “system” iss characterizzed by a serries of
independ
dent, non-inttegrated bus
siness proce
esses. For e
example:

Absence
A
of a staffed LHIN-wide “nerv
ve centre” m
mandated to provide inte
egrated plann
ning,
operational stteering & res
sults reportin
ng. A nerve
e centre coulld coordinate
e the proced
dure
cheduling an
nd long-haull transportation provision
n sides of th
he non-urgen
nt patient care
sc
lin
ne of busine
ess. Allocatio
on of the “rig
ght” transpo rtation vehiccle solution, using a
co
onsistent pa
atient algorith
hm, could be
e achieved a
across LHIN hospitals.

Absence
A
of system-wide,, reliable perrformance m
measuremen
nt data to info
orm long-haul
sy
ystem plann
ning, operatio
onal steering
g, and resultts reporting. The curren
nt ADRS data
sy
ystem used by MOHLTC
C to collect/rreport ambu lance Code 1-4 call data
a from acrosss
th
he province (originally po
opulated with local CAC
CC dispatch d
data) is clea
arly inadequa
ate
fo
or system pla
anning and reporting
r
purposes. Keyy Performan
nce Indicatorrs (KPI) of
se
ervice delive
ery unit costs
s, process execution,
e
an
nd quality for patients do
o not yet exisst LHIN
although beginning steps
s towards pe
erformance m
measuremen
nt were requ
uired by the L
e three 2013 pilot projectts. Given the
e absence o
of KPI, future
e performance
as part of the
argets derive
ed from histo
oric data tren
nds do not yyet exist. A p
public, transsparent resullts
ta
re
eport card to
o share perfo
ormance datta and drive continuous improvemen
nt also doess not
ex
xist.
Performa
ance Concep
pts Consultin
ng has deve
eloped the fo
ollowing set o
of Key Perfo
ormance
Indicatorrs (KPI) to inform future stakeholder
s
discussion/ffinalization o
of results based businesss
planning and reportin
ng.
50
Service Delivery Ou
utputs & Effficiency
A
Code
e 1-2 long-ha
aul transfers
s by LHIN fu nded route lleg (3-year ttrend lines)
a) Annual

# long-ha
aul Code 1-2
2 transfer pa
atients delive
ered

urs delivered
# “on the
e road” long-haul transfer vehicle hou
d versus pla
anned

UHU by long-haul
l
route leg (% deployed
d
veh
hicle hours sspent deliverring patientss)

% stretch
her “seats” occupied
o
for each long-h
haul route/leg
g

Cost per deployed lo
ong-haul tran
nsfer vehicle
e hour

Cost per delivered lo
ong-haul tran
nsfer hour

Cost per long-haul transfer patient
Busiiness Proce
ess Executio
on
b) % Code 1-2 long-haul land transfers
s where patie
ent arrives o
on-time for th
he test/proce
edure
- as originally
y scheduled (3-year tren
nd line)
c) % Code 1-2 long-haul tra
ansfers featu
uring patientt delivery witthout a hub hospital
mandated
m
pa
atient escortt (3-year tren
nd line)
d) Patient
P
escort hours per 100 long-ha
aul transfer p
patients (3-yyear trend lin
ne)
Patie
ent Impact
e) % Code 1-2
2 long-haul transfers featuring
f
“sa
ame day” rreturn of pa
atient to orriginal
community
c
hospital/LTC
h
facility by no
n later than 8 p.m. (app
plied only to “treat and re
eturn”
transfer patie
ents)
This porttfolio of KPI will
w provide a comprehe
ensive “dash board” for planning and monitoring of
the long--haul non-urg
gent patient transfer sys
stem. The a mount/cost//utilization off transport
service will
w be tracke
ed. The on-ttime success
s rate will be
e tracked. T
The performa
ance of the
system in
n generating
g cost reducttion via redu
uced use of p
patient esco
orts will be tra
acked – a ke
ey
non-trans
sportation ch
hange mana
agement cha
allenge. Fina
ally, patient impact will b
be tracked b
by
monitorin
ng the overa
all length of the “treat and
d return” cyccle – a critica
al element o
of the overalll
patient experience.
51
Short-Haul Tran
nsfers - Key
y Performan
nce Indicato
ors
nt transfers delivered
d
by
y EMS also rrequire perfo
ormance measurement ttools
Short haul non-urgen
ement and a
accountabilityy reporting. The key is tto
that can be implemented for systtem manage
e EMS system
m performan
nce benefits generated b
by freeing up
p vehicle ho
ours of servicce
measure
previouslly consumed
d by long-ha
aul non-urgen
nt transfers. EMS Code
e 3-4 respon
nse time
reduction
ns, and reduced UHU arre examples of relevant indicators. EMS cost pe
er transfer h
hour
delivered
d is also a meaningful effficiency indicator.
Horiizontal Lead
dership & Policy-Makin
P
ng Authority
ty
To date, the non-urgent patient transfer
t
system across t he North Ea
ast LHIN hass been
ed of a range
e of health care
c
actors budgeting
b
an
nd operating within verticcal silos. Th
he
compose
non-urge
ent “system” has actually
y been a non
n-system witth little horizzontal co-ord
dination talking
place. This silo-base
ed reality is not
n unique to
o North Easst Ontario; it is the norm across most of
the province. The no
on-urgent pa
atient transportation line of businesss has not bee
en recognize
ed as
such, nor has it been
n managed or
o funded with the focus necessary tto ensure su
uccess.
nize this prob
blem, and the need for d
dedicated lea
adership and
d policy-makking.
Stakeholders recogn
On a pos
sitive note, th
hen NE LHIN
N’s three 2013 pilot proje
ects have su
ucceeded in
n building the
e
beginning
gs of coordin
nated operations and co
ohesion amo
ong the 30+ EMS and ho
ospital actorrs.
Howeverr, leadership
p and policy-making are not yet prop
perly structurred/focused to provide th
he
necessarry horizontall system leadership and
d manageme
ent.
In order to
t provide ho
orizontal sys
stem-wide le
eadership, co
ommunity ho
ospitals, hub
b hospitals, E
EMS,
ORNGE, CACCs and
d private sec
ctor providerrs will need tto work toge
ether in a flexible, nonbureaucrratic setting. An empow
wered working group (sta
affed by seniior managem
ment) would be
ideal; witth an overrid
ding patient-c
centred man
ndate to provvide leadersship on plann
ning, policymaking and
a operational levels.
52
G. Find
dings & Recomme
R
endations
s
Findings and recomm
mendations have been organized
o
intto the follow
wing categoriies:
1. New Operrational Model
2. Hospital Based
B
Busine
ess Process
s Improveme
ents
eadership, Policy
P
& Decision-Making
g
3. System Le
4. System Fu
unding
nications
5. Stakeholder Commun
al Path
6. Implementation Critica
ew Operatio
onal Model
1. Ne
The reco
ommended new
n
operatio
onal model is
s evidence-b
based; it draws from the IN/OUT, UH
HU,
and overrlapping calls
s modeling. The new op
perational m
model recogn
nizes the datta-supported
d
existence
e of distinct short-haul
s
and long-hau
ul non-urgentt transfer clu
usters. The new model
addresse
es long-haul transfers – leaving the existing
e
land
d ambulance
e-based delivery approa
ach
(dispatch
hed by CACC
C) intact for short-haul trransfers. Th
he new long--haul model is derived frrom
Performa
ance Concep
pts’ quantitative evaluatiion of the cu
urrent transfe
er system’s performance
e
problems
s. The new model is con
nsistent with
h many of the
e improveme
ent insights provided byy the
2013 pilo
ot projects.
The key components
s of a restruc
ctured opera
ational mode
el for non-urg
gent transpo
ortation are
recomme
ended as follows:
1-1
Sh
hort-haul Code 1-2 trans
sfers should continue witth EMS & prrivate contra
actors acrosss the
LH
HIN. CACCs
s and/or hos
spitals will co
ontinue to disspatch these
e transfers a
according to the
ex
xisting processes.
1-2
Lo
ong-haul Cod
de 1-2 transffers to be de
elivered via a new blend
d of EMS non
n-paramedicc
mu
ulti-patient vehicles,
v
para
ramedic flow
w cars, poten
ntial contractted private trransfer serviices
an
nd “dead hea
ad” ambulan
nce units (across the enttire LHIN).
1-3
Lo
ong-haul Cod
de 1-2 transffers to be de
elivered via rregularly sch
heduled tran
nsfer legs/routes
an
nd multi-patie
ent transfer vehicles (rec
commended
d detailed routes outlined
d across all 5
53
LH
HIN hospital transportatio
on hubs). Routes
R
shoulld be design
ned to move patients into
o hub
ho
ospitals and return them to communiity hospitals in a timely, cost-effectivve and
pre
edictable fas
shion.
1-4
The
e following specific
s
two-way routes/l
/legs are reco
ommended for the restrructured
ope
erational mo
odel. The recommended
d initial resou
urce deploym
ment can be
e refined sub
bject
to an
a initial perriod of opera
ations – for in
nstance wee
ekend routess can be con
nsidered if
pattient volumes merit addiitional transp
port capacityy beyond currrent EMS a
and nonam
mbulance res
sources. Spllit shifts can also be imp
plemented ass required o
on 8-hour rou
utes.
1-5
In addition
a
to th
he eight sche
eduled non-urgent transsportation routes, the follllowing
tran
nsportation service
s
levell and staff co
onfiguration adjustmentss are recomm
mended:
a)) Expand th
he annual op
perating hou
urs of the currrent North B
Bay Regiona
al Health Ce
entre
dual strettcher/wheelc
chair transferr vehicle to 1
12 hours M--F. The adde
ed 4 hours p
per
54
day (1,04
40 annual ho
ours) would be
b delivered
d as long-hau
ul non-urgen
nt transfer ho
ours.
Based on
n North Bay hospital
h
fore
ecasts, these
e long-haul ttransfer hourrs may be re
edeployed on weekend
ds and adjus
sted on sele cted weekda
ays.
b)) Reconfigu
ure the staffi
fing of the Su
udbury EMS
S non-ambula
ance commu
unity flow ca
ar to
consist off a primary care
c
paramedic (PCP) an
nd a non-pa
aramedic drivver attendan
nt
qualified in
i advanced
d first aid. Th
his configura
ation will havve a lower unit cost
compared
d to the 2013
3 pilot projec
ct, while still providing pa
aramedic ca
apability as
required. The 12-hou
ur, 7 days/we
eek deploym
ment pattern would rema
ain unchanged
c)) Deliver th
he relatively low
l
annual volume
v
of Ch
hapleau Hosspital - Timm
mins & Distriict
Hospital long-haul
l
Co
ode 1-2 trans
sfers using e
existing EMS
S ambulance
e resources
(funded as
a per 1-6 b) below).
1-6
ven the some
ewhat uniqu
ue out-of-LHIIN pattern off non-urgentt IN/OUT transfers
Giv
ass
sociated with
h the West Parry
P
Sound Health Cen tre (i.e. soutth-bound refferral pattern
ns),
the following se
ervice delive
ery/funding re
ecommenda
ations are ap
ppropriate:
a)) Parry Sou
und EMS am
mbulances sh
hould contin
nue to provid
de long-haul Code 1-2 no
onurgent tra
ansfer servic
ces for patien
nts at WPSH
HC. Due to a
annual transsfer
volumes/p
patterns, this
s service willl not be routte based, bu
ut will continu
ue the existiing
“one off” reactive
r
tran
nsportation model
m
now in
n place.
staffing costs
s associated
d with provid
ding required
d Code 3-4 ccoverage du
uring
b)) EMS up-s
WPSHC long-haul
l
Co
ode 1-2 non--urgent transsfers will be funded as p
per the
recommended non-urrgent transportation provvider-based funding model. This un
nique
omponent sh
hould be tied
d to an MOU
U setting outt performancce indicator
funding co
derived re
esults targetts, and annu
ual results rep
porting requ
uirements.
55
1-7
Perrformance Concepts
C
has
s considered
d long-haul ttransfer vehiicle staffing and equipment
con
nfiguration op
ptions from a risk manag
gement persspective.
a) The follow
wing staffing
g configuratio
on options a re recomme
ended for de
etailed review
w by
the Leade
ership Workiing Group (s
see Recomm
mendation 3--1) during th
he upcoming
g
implemen
ntation phase
e of restructuring:
b)) Although qualification
ns for Param
medics, PSW
Ws and RPNss are well esstablished, th
here
are none for the proposed Driver//Attendant. At a minimu
um, all emplo
oyees of the
e
transfer service
s
shoulld feature the following:











Vulne
erable Person
ns Backgrou
und Check
Class F Driver’s License
L
with a clean drivving record
H
an
nd Influenza
Immunization for Hepatitis
A CPR and AED certiffication
First Aid,
Trainiing for stretc
cher, stair ch
hair and oxyg
gen deliveryy equipment use and
mainte
enance
Trainiing for safe movement,
m
handling
h
and
d positioning
g of patients
Trainiing in basic response
r
pro
rocedures in the event off a medical e
emergency
during
g transport
Trainiing in use off communica
ations equipm
ment
Trainiing in docum
mentation req
quirements
Trainiing in basic isolation
i
pre
ecautions
Trainiing in WHMIIS, infection control and vehicle/equiipment clean
ning
c)) For all of the risk-based staffing configuration
c
ns the follow
wing vehicle e
equipment
inventory is recomme
ended:



cher(s) and certified
c
mou
unting system
m(s) (Baria
atric capabiliity if deemed
d
Stretc
neces
ssary).
Stair Chair
C
Linen and Blankets (sufficientt quantities tto exchange
e after each ttransfer)
56











Toiletiing Supplies
s (Bed pan(s
s), urinal(s), toilet paper, wipes, one each for evvery
patien
nt normally carried)
c
Basic disinfection and cleanin
ng supplies
e
Fire extinguisher
Winte
er Survival Kit
Ki
Radio
o communica
ating on prov
vincial CACC
C frequencie
es, and cellu
ular telephon
ne
AVL (automated
(
vehicle
v
locatting) technollogy to allow
w immediate location
confirm
rmation
First Aid
A kit
Autom
mated Extern
nal Defibrilla
ator
Bag/V
Valve/Mask manual
m
resu
uscitator (sin
ngle use) and
d oral airwayys
“M” Oxygen
O
Cylinder, Regulator and Flow
wmeter
“D” Ox
xygen Cylind
der, Regulattor and Flow
wmeter for tra
ansportation
n to and from
m
hospittal
d) For mode
erate risk veh
hicle staffing
g configuratio
ons, the follo
owing equipment should
d
suppleme
ent the basic
c equipment listed above
e:





Blood
d Pressure Cuff
C and Stetthoscope
Pulse Oximeter
s
Isolatiion Supplies
Portab
ble Suction and
a accesso
ories
Selection of oxyge
en administrration suppliies
er risk vehicle
e staffing co
onfigurationss, the followin
ng equipmen
nt should
e) For highe
suppleme
ent the basic
c equipment listed above
e:





f)
Monito
or/Defibrillattor (instead of
o AED)
Symp
ptom Relief Medications
M
meter
and Glucom
BLS Response
R
Kiit
C-Spiine Collars (p
potential pattients encou
untered)
CPAP
P
The proce
ess for settin
ng long-haull “within vehiicle” staffing
g and equipm
ment
configurations should
d address the
e northern/re
emote risk fa
actors found
d across the
North Eas
st LHIN’s lon
ng-haul trans
sfer environm
ment:



Inclem
ment winter weather
w
Long transfer routte distances/
s/travel timess
spitals during
g transfers
Isolatiion from hos
57
The curre
ent non-urge
ent patient trransportation
n system accross the North East LHIN suffers fro
om a
lack of co
oordination across
a
hospital based te
est/procedurre scheduling
g processess, and the
CACC/EMS process for deliverin
ng timely/reliiable transpo
ortation. The following
recomme
endations ad
ddress this fu
undamental “no air traffiic controller”” system ma
anagement
problem.
1-8
Cre
eate a North
h East “Coord
rdination Cen
ntre” for long
g-haul non-u
urgent transp
portation sysstem
ma
anagement th
hat integrate
es the parallel processess of non-urg
gent procedu
ure/test
sch
heduling and
d patient ride
e scheduling
g.
s
ministration id
deally delive
ered by a sin
ngle CACC fo
or
a)) Coordinattion Centre staffing/adm
the entire North East region unde
er a fee-for-sservice contrract. A multitiple CACC
delivery option
o
for the
e Coordinatio
on Centre fu
unction can b
be considere
ed by the
Leadership Working Group,
G
with an onus on rigorous gua
arantees by CACCs to
deliver se
eamless systtem planning
g/delivery no
ot impacted by CACC E
EMS dispatch
h
boundarie
es.
b)) The Coorrdination Cen
ntre willprov
vide leadersship region-w
wide with hub
b hospital pa
atient
flow team
ms, EMS and
d non-EMS trransfer provviders, and o
other North E
East CACCss.
c)) South We
est LHIN ride
e selection algorithm
a
to b
be adopted & adjusted ffor internal u
use
by CACC
C Coordinatio
on Centre sta
aff with no re
equirement for commun
nity hospital sstaff
to decide on patient trransport mo
ode using the
e algorithm.
d) Coordinattion Centre dispatches
d
all
a long-haul non-ambula
ance non-urg
rgent transfer
vehicle re
esources & flows
fl
any am
mbulance de ad head ride
es to CACCss.
1-9
ogy tools to integrate
i
sys
ystem operattions data fo
or both
Utillize informattion technolo
tes
st/procedure scheduling and ride pro
ovision.
a)) Constructt a web hosted databas
se/application
n for community & hub hospitals across
the LHIN to documen
nt schedule
ed “long-ha ul” non-urg
gent proced
dures/tests.
58
b)) Ensure fu
unctionality so
s scheduled
d tests or pro
ocedures ca
an be viewed
d (i.e. forwarrded
to) Coord
dination Centtre CACC sttaff for purpo
oses of reserrving space for the patie
ent
on the applicable non
n-urgent tran
nsfer vehicle and route.
c)) Build func
ctionality into
o the web ho
osted databa
ase/applicatiion for comm
munity & hub
b
hospitals across the LHIN
L
to view
w available non-urgentt transfer ro
oute “open
hen schedulling procedu
ures/tests, th
hereby ensurring a match
h between
seats” wh
schedulin
ng slot and riide.
2. Hospital Based
B
Busiiness Proce
ess Improve
ements
Non-urge
ent patient care restructu
uring is a change manag
gement challlenge that e
extends beyo
ond
the logisttics of ride provision.
p
Ho
ospitals and physicians will need to review and adjust existiing
patient discharge pra
actices (and other internal business process) to make a sch
hedule driven
n
nsportation system
s
workk. Transporttation restruccturing and
long-haul non-urgentt patient tran
internal hospital
h
business proces
ss refinemen
nts will need to proceed in a coordin
nated, paralle
el
fashion.
d for hospita
al driven change manage
ement exten
nds to comm
munity hospittal/hub hospital
The need
patient ca
are and control processes. Stakeho
olders from E
EMS, comm
munity hospittals and hub
hospitals
s have all acknowledged
d that the currrent commu
unity hospita
al patient esccort system
approach
h (mandated
d by hub hos
spital policies
s) is not cosst-effective. Therefore th
he following
“care and
d control” rec
commendation is offered
d:
2-1
Phased implem
mentation off hub hospita
al staffed “ho
olding areas”” for non-urg
gent transferr
pattients (buildiing on the Th
hunder Bay pilot projectt approach u
underway in the North W
West
LH
HIN). Pilot “h
holding area”” to feature the
t following
g:
ot site selectiion/implementation by Q
Q3 2014/15
a)) Initial pilo
b)) Holding area
a
hub hos
spital staffing
g funded by community hospitals exxperiencing
reduced patient
p
escorrt spending (i.e. savingss).
59
c)) Track pattient escort savings
s
to pa
artially fund hub hospita
al “holding arreas” in the
longer terrm after pilott project end
ds.
d) Secure es
stimated 20%
% reduction in patient esscort expend
ditures acrosss NE LHIN
communitty hospitals in Year 1 off pilot, via red
duced duratiion of long-h
haul transferrs.
stimated 90%
% reduction in patient esscort expend
ditures acrosss NE LHIN
e) Secure es
communitty hospitals (3 year time
eframe), as h
holding areas are complletely
implemen
nted and hub
b hospital ma
andated pattient escorts are eliminatted.
3. System Leadership,
L
Policy, & Decision-Ma
D
aking
ent non-urge
ent transporttation system
m is beginnin
e away from a vertical, siloThe curre
ng to evolve
based “non-system” that has nott served patients well. T
The 2013 pilo
ot projects h
have been
instrumental in highlighting the benefits
b
of an
n integrated approach to
o patient tran
nsportation. In
order to address
a
the need for integrated, “sy
ystem based ” manageme
ent of non-urgent patien
nt
transporttation (i.e. eliminating sillos), the follo
owing recom
mmendationss are made cconcerning
leadership, policy, an
nd decision-making.
3-1
eate a perma
anent North East Non-U
Urgent Transp
portation Le
eadership W
Working Group
p
Cre
a)) Represen
ntation could
d include the Coordinatio
on Centre CA
ACC, 5 transsfer hub
hospitals, 5 rotating trransfer inten
nsive commu
unity hospita
als (one per hub), all
viders, and 1 EMS short
rt-haul transffer liaison.
contracted long-haul transfer prov
b)) Implemen
nt system-wiide data man
nagement re
eforms to im
mprove on exxisting
inadequate ADRS/EP
PCR data se
ets. Use data
a for business planning and
performan
nce measure
ement/reporrting.
sults-based system
s
plann
ning, featuriing an annua
al long-haul transportatio
on
c)) Adopt res
business plan with pe
erformance indicator
i
derrived targetss. Do so by operationaliz
izing
60
the Key Performance
P
e Indicators (KPI)
(
include
ed in this rep
port. Compilile performan
nce
trends in a publicly re
eported dash
hboard.
d) Establish risk-based long-haul
l
tra
ansfer vehiclle staffing co
onfigurationss (i.e. policy)) for
posed route//leg.
each prop
e)) Establish vehicle equ
uipment conffigurations (ii.e. policy) fo
or each prop
posed route/l/leg
nagement approach notted above.
based on the risk man
4. System Funding
F
The Nortth East LHIN
N should imp
plement a ne
ew “hybrid” fu
funding mod
del for non-urrgent patientt
transporttation consis
sting of the following
fo
com
mponents:
4-1
“Sta
atus quo” EM
MS cost-sha
ared funding for Code 3--4 emergenccy coverage and short-haul
Cod
de 1-2 trans
sfers. This re
ecommenda
ation will havve no budgett impact on E
EMS service
es
unle
ess their gov
verning bodiies choose to
t cancel hig
ghly utilized ambulance ttransfer
resources being
g replaced as
a per this re
eview’s reco
ommendation
ns.
4-2
atus quo” ho
ospital fundin
ng arrangem
ments for sho
ort-haul non--urgent transsfers deliverred
“Sta
via i) the contra
acted provide
er at Health Sciences N
North, and ii) the non-parramedic tran
nsfer
veh
hicle operate
ed by North Bay
B Regiona
al Health Ce
entre. Health
h Sciences N
North will no
o
long
ger be required to fund long-haul
l
tra
ansfers using
g its contraccted providerr (i.e. service
e
cap
pacity to be dedicated
d
to
o short haul work
w
exclusiively within tthe City of G
Greater Sudb
bury).
4-3
A new
n
“non-urg
gent transferr provider” fu
unding mode
el should be put in place
e to fund long
ghau
ul Code 1-2 transfers across the Norrth East. Fu
unding will be
e based on the annual
num
mber of sche
eduled/deplo
oyed vehicle
e hours for de
esignated trransfer leg ro
outes
rec
commended across the region.
r
Provi
viders will be selected forr a multi-yea
ar term – mo
ost
like
ely by way off an open RF
FP process.
61
4-4
OR
RNGE should
d work collab
boratively wiith Sudbury EMS, the CA
ACC and M
MOHLTC to
iden
ntify and imp
plement opp
portunities re
e. Sudbury E
EMS parame
edic commun
nity flow carr
serrvices (i.e. non-ambulan
n
nce) to/from Sudbury airp
rport. Discusssions could
d reflect pote
ential
ope
erational sav
vings at ORN
NGE and flow car fundin
ng arrangem
ments. Prompt flow car
serrvice to/from the airport will
w replace the
t existing “best effortss” by Sudburry EMS
ambulance resources that have historic
cally resulte d in significa
ant delays in
n delivering n
nont
on. The enhanced Sudb
bury EMS flo
ow car servicce delivery m
model
urgent patient transportatio
will execute tim
mely paramed
dic-to-param
medic patientt hand-offs a
at the airportt. The
w car service delivery arrrangement would be a unique solution
recommended Sudbury flow
n-ambulance
e paramedic service leve
el that does not apply to
featuring an enhanced non
ditional land ambulance “best effort”” airport tarm
mac service llevels delive
ered at airport
trad
tarm
macs across
s the Provinc
ce.
Tracking
g System Fiinancial & Operational
O
l Efficiencie
es: The execcution of thiss review hass
made it clear
c
that the
e current mix
x of EMS, ORNGE and h
hospital data
a collection ssystems do not
provide for
f easy systtem performance monito
oring. Howe
ever, system
m efficiency trracking will b
be
important to steer on
ngoing restru
ucturing deciisions, and e
establish sysstem funding
g mechanism
ms
nvest a portio
on of identified cost savings associa
ated with resstructuring. IInformation
that re-in
system re
efinements/iintegration will
w be neces
ssary to supp
port the follo
owing recom
mmendation:
4-5
e recommen
nded Leaderrship Working Group sho
ould docume
ent future syystem financcial
The
and
d operationa
al efficiencies
s from restru
ucturing and
d apply these
e efficienciess and saving
gs (in
parrt) to future in
nitiatives wh
here approprriate. Efficie
encies could be derived from the
follo
owing:
a)) EMS vehiicle hours tra
aditionally us
sed for non--urgent transsportation th
hat are freed
d-up
for emerg
gency respon
nse or redep
ployed for otther emergin
ng health carre priorities ssuch
as commu
unity parame
edicine.
b)) EMS operating costs traditionally
y associated with non-urg
rgent transpo
ortation in hiigh
t
have be
een identified
d by District Service Boa
ards to gene
erate
volume trransfer legs that
financial savings.
s
62
c)) Communiity hospital patient
p
esco
ort savings associated with shorterr non-urgent
transfer durations
d
gen
nerated by th
he more dep
pendable an
nd timely rou
ute based lon
nghaul syste
em (i.e. fewe
er escort hou
urs).
d) Communiity hospital patient
p
esco
ort savings associated with increassed volume o
of
transfers not requiring
g an escort once
o
hub ho
ospital holdin
ng areas are
e implemente
ed
s).
(i.e. fewerr escort trips
5.
5 Stakehollder Commu
unications
f non-urge
ent patient tra
ansportation
n restructurin
ng to be succcessfully implemented,
In order for
stakehold
der business
s rules and practices
p
will need to be
e changed. C
Clear and co
oncise
communication with stakeholders will be critical. The ovverall objectives, new op
perational
usiness rules
s concerning
g restructurin
ng will need to be clearlyy communica
ated.
realities, and new bu
Clear una
ambiguous communicat
c
tion regardin
ng the restru cturing proccess will allow
w EMS, CAC
CC,
hospital administrativ
a
ve staff, nurs
sing staff and physicianss to adjust a
accordingly. The followin
ng
recomme
endations sh
hould guide subsequent
s
communica
ation activitie
es/efforts.
A comprehen
nsive comm
munications plan should
ld be develloped by th
he newly fo
ormed
5-1
Leadership Working
W
Gro
oup, as partt of the ove
erall impleme
entation pla
an for non-u
urgent
patient trans
sportation re
estructuring.. The comm
municationss plan shou
uld considerr the
fo
ollowing:
Objectives
O

To
T use a variiety of appro
oaches and tactics
t
to enssure that all target audie
ences
understand how
h
the chan
nge process will affect th
hem.

As
A the restruc
cturing occu
urs, to develo
op communiications mecchanisms tha
at allow for ttwoway
w informatiion flow so that
th necessa
ary adjustme
ents can be m
made in a tim
mely manne
er.
63
Key
K Messag
ges

HEALTH
H
CAR
RE PARTNE
ERS ARE IM
MPROVING A
ACCESS TO
O CARE WH
HEN AND
WHERE
W
IT’S NEEDED – This restruc
cturing plan recommend
ds a model that meets th
he
needs for timely, safe and
d cost-effecttive non-urge
ent patient ttransfers into
o and out of hub
hospitals in North
N
East Ontario,
O
while
e safeguardi ng needed E
EMS covera
age in
co
ommunities across the region.
r

PREPARING
P
G FOR AN AG
GING POPU
ULATIONS A
AND CLINIC
CAL INTEGR
RATION
MODELS
M
- This plan com
mplements other activitie
es to positive
ely transform
m the health care
sy
ystem to carre for Northe
erners. This review respo
onds to changing popula
ation
demographics, and the im
mplementatio
on of clinica
al integration models that require tim
mely
emergent and
d non-urgent transportattion systemss be in place
e to support the moveme
ent of
patients into and
a out of th
he hub centrres. The Norrth East LHIN
N’s 2013-20
016 Integrate
ed
Health
H
Servic
ce Plan focus
ses on strate
egies to inte
egrate and re
ealign the local health
sy
ystem to bettter care for Northerners
s, particularlyy the region’’s older adullts and frail
elderly.

COLLABORA
C
ATION IS CR
RITICAL – Key
K project p
partners inclu
uded all 25 N
NE LHIN
hospitals, 41 LTCHs, 8 EMS
E
services
s, ORNGE, 5 Central Am
mbulance Co
ommunicatio
on
Centres.
C
A trransparent evidence-bas
e
sed processs was used to
o assess the
e current nonurgent transfe
er system in the North East,
E
make re
ecommenda
ations for a ffuture modell and
im
mplement the
e model goin
ng forward.

RECOMMEN
R
NDATIONS ARE
A
PATIEN
NT/PEOPLE
E-FOCUSED
D – These incclude: timelyy
access to serrvices for patients; impro
oved patient experiencess with non-u
urgent transffers
to
o and from acute
a
care fa
acilities or to//from hospita
als and LTC
CHs; decreassed pressure
es in
EDs,
E
EMS an
nd inpatient units
u
related
d to patients awaiting tim
mely transferrs; sustainab
bility
off emergency
y medical se
ervices in all communitie
es.
Target
T
Audie
ences and Stakeholder
S
rs

The
T public an
nd users of the health ca
are system.

Organizations
O
s partnering in the review
w and its im plementation – EMS, ho
ospitals,
DSSABs,
D
CA
ACCs, etc.

Health
H
service providers (acute, long-term care, ccommunity, primary carre, CCAC) an
nd
gion.
administrative
e leadership
p across the NE LHIN reg

Health
H
profes
ssionals – including phys
sicians, para
amedics, hosspital nursin
ng staff and
so
ocial workerr.
64
6. Implemen
ntation Critiical Path
Performa
ance Concep
pts Consultin
ng has cons
sidered imple
ementation p
priorities for restructuring
g
non-urge
ent patient tra
ansportation
n according to
t the follow
wing critical p
path timefram
mes:



Do
D NOW
Do
D SOON
Do
D LATER
This phased rollout approach
a
is expressed
e
in
n the 3-yearr implementa
ation critical path set outt
ext page). Do
D NOW wo
ork focuses on
o establishiing the new decision-ma
aking and syystem
below (ne
managem
ment units – the Leaders
ship Working
g Group, the
e Coordinatin
ng Centre and a dedicatted
project management
m
t resource to
o drive the re
estructuring a
agenda forw
ward.
Do SOON work will address
a
the start up cha
allenges of th
he new operrational model, including
g the
RFP proc
cess for sele
ecting route leg providerrs. Budget d
developmentt, data mana
agement also fall
into this timeframe.
t
Finally th
he Do LATER
R period willl feature the roll out of ho
ospital busin
ness process changes
around patient
p
“care and control”” holding are
eas expected
d to generatte significantt savings in
community hospital patient
p
escort costs.
or the recom
mmended “lo
ong-haul” nonIt should be noted that the implementation critical path fo
ansportation
n model will need
n
to be coordinated
c
with action iitems emerg
ging from the
e
urgent tra
North Ea
ast LHIN’s re
ecently comp
pleted Clinica
al Services R
Review (CSR). To effe
ectively
implement the clinica
al integration
n models rec
commended in the Cliniccal Services Review req
quires
ponsive and timely
t
emerg
gent and non-urgent tra nsportation systems be in place to
that resp
support the
t moveme
ent of patientts into and out
o of the Hu b centres. T
The CSR an
nd Non-Urge
ent
Patient Transportatio
T
on Review are complementary proje
ects aimed at providing tthe best care
e to
the regio
on’s residents
s at the rightt place and right time.
65
66
H. APP
PENDICE
ES
#1 – Definitio
ons of Land
d Ambulanc
ce Dispatch
h Codes 1-4
#2 – Terms of
o Reference and Membership of tthe Non-Urg
gent Patien
nt
Transportati
T
visory Com
mmittee
on Review Project Adv
67
APPEN
NDIX #1
68
APPEN
NDIX #2
REVIEW
W OF NO
ON-URG
GENT PA
ATIENT T
TRANSF
FERS
IN NORTH
N
EAST O
ONTARIO
O
AND
A
DEV
VELOPM
MENT OF
O A NEW
W BUSIN
NESS MODEL
PROJECT ADV
VISORY C
COMMIT
TTEE
Terms of Refere
ence
Reviewed
R
by
y the Advisory Committe
ee on June 2
27, 2013.
PURPOS
SE
pose of the Advisory Co
ommittee is to provide strategic gu
uidance and
d input to the NE
The purp
LHIN and
d the projectt consultant re. the deve
elopment of a model tha
at meets the needs for timely,
safe and cost-effectiv
ve non-urgent patient tra
ansfers into and out of h
hospital centtres in North East
eguarding needed
n
Em
mergency M
Medical Serrvices (EMS
S) coverag
ge in
Ontario while safe
communities across the region.
OBJECT
TIVES
ctives will be to:
The Adviisory Committee’s objec
A
in the completion
c
of
o the major project taskks, per the Project Charter, such as
1) Assist
providing inpu
ut regarding:
a. Analysis of the cu
urrent state
b. Identiffication of op
pportunities and challen ges for a futture non-urg
gent patient
transffer business and service
e model
c. Development of clinically
c
driven process maps and trransfer vehiccle/staff
standa
ards
d. Identiffication of integration an
nd coordinatiion mechaniisms to supp
port and faciilitate
non-urgent patien
nt transfers in
n the North E
East
S
stakeholder consultation me
echanisms a
and review th
he resulting stakeholderr
2) Suggest
fe
eedback.
3) Assist
A
in proje
ect commun
nications actiivities.
4) Review
R
and provide
p
feedback on the draft projecct report.
69
SCOPE
ements are within/outside
w
e the boundaries of the project?
What ele
In Sc
cope:


Transportatio
T
on for the folllowing patient groups be
etween hosp
pitals, or from
m hospitals tto
LTCHs/patien
nt residences:
o Stable
e medical co
ondition; and
d
o Requiiring a stretc
cher vehicle; or
o Ambu
ulatory or sem
mi-ambulato
ory inpatientss/LTC reside
ents; or
o Requiiring a nursin
ng or other health
h
provid
der escort
Transportatio
T
on of ED patiients requirin
ng access to
o a schedule
e 1 bed or pssychiatric
assessment under
u
the Me
ental Health
h Act
Out of
o Scope:


Transportatio
T
on for medica
al appointme
ents within a communityy or between
n communitie
es
Addressing
A
hospital cost pressures re
elated to the
e use of proffessional sta
aff during patient
trransportation
n
COMMIT
TTEE MEMB
BERSHIP
The Com
mmittee mem
mbership (o
of no more than 15) w
will include rrepresentatio
on from the
e key
project partner secto
ors:







Hospitals
H
(larrge and sma
all)
LTCHs
EMS
E
Designa
ated Delivery
y Agents (i.e
e. municipaliities or DSSA
ABs)
Certified
C
Land
d Ambulance
e Operators
Central
C
Ambu
ulance Comm
munications Centres
ORNGE
O
Other
O
TBD
ognized thatt some mem
mbers may have multip
ple roles. C
Committee m
members are
e not
It is reco
participatting on beha
alf of their ow
wn individual organizatio
ons.
70
Considerration will be
e given to both
b
sectora
al and geogrraphic repre
esentation in
n the selection of
Committe
ee members
s.
Ex officio
o members will include the MOHLT
TC, NE LHIN
N ED Physiccian Lead, N
NE LHIN sta
aff as
appropria
ate, and the third party project
p
consu
ultant.
RS
MEMBER
y Belzile – Nipissing
N
EM
MS Jean Guy
Elaine Bllakeborough
h – Sault Are
ea Hospital
Nancy Bo
oody – Matta
awa Genera
al Hospital Don Brisbane – Com
mmunity Mem
mber hrane EMS Jean Carrriere – Coch
Heather Cranney – Canadian
C
Re
ed Cross Sandra Fox
F – Comm
munity Memb
ber Tracy Fre
ench – Kirkla
and & Distric
ct Hospital Nicole Ha
aley – Espanola Region
nal Hospital and
a Health C
Centre Robin Jo
oanisse – Sa
ault Area Hos
spital Jo-Ann Lennon-Murp
L
phy – West Nipissing
N
Ge
eneral Hosp ital Michael MacIsaac
M
– Manitoulin-S
Sudbury EMS Josee Mitron – Hôpittal Notre-Dame Hospitall (Hearst) Joe Nicholls – City of Greater Su
udbury EMS
Pierre Oz
zolins – St. Joseph’s
J
Ge
eneral Hospital (Elliot La
ake) Marc Pic
card – North Bay CACC Don Pierrce – Sudburry CACC Dr. Jason
n Prpic – No
orth East Bas
se Hospital
Rob Smith - ORNGE
E Grace Stt. Jean – Health Science
es North (Su
udbury) Jim Stew
wart – Nipissing EMS Steve Trinier – Cochrane EMS Mike Trodd – Timiska
aming EMS C (ex-officio
o) MOHLTC
Jack Cru
uikshank N (ex-officio) NE LHIN
Kathleen
n Bain Micheline
e Beaudry Philip Kilbertus (Chairperson) T
Kristen Taus
71
ROLES AND
A
RESPO
ONSIBILITIE
ES
s are expected to pro
ovide resourrces to the
e work of tthe Advisoryy Committe
ee as
Members
necessarry and apprropriate (e.g
g. time, expe
ertise, inform
mation). Th
he NE LHIN
N will provide the
Advisory Committee with the support of its planning ressources (sta
aff time, information, me
eeting
logistics)) as appropriiate.
REPORT
TING RELAT
TIONSHIP / ACCOUNT
TABILITY
dress its adv
vice to the N E LHIN Chie
ef Executive
e Officer.
The Adviisory Committee will add
DECISIO
ON–MAKING
G
Advisory Committee decisions will
w be based on conse nsus. If consensus is not possible
e, the
son may calll a vote. A simple
s
majority favourab
ble vote of th
hose membe
ers in attend
dance
chairpers
will be ne
eeded to res
solve or app
prove any iss
sue requiring
g a vote. A simple majority of mem
mbers
will consttitute a quorrum.
CONFIDENTIALITY
Members
s will respec
ct the privacy of Advisorry Committe
ee participan
nts and agre
ee not to disclose
information or views
s expressed by individu
uals during m
meetings. Deliberation
ns should re
emain
al agreemen
nt and conse
ensus to ma
ake them public. In add
dition,
confidenttial until there is genera
all Comm
mittee mem
mbers must agree to not
n disclose
e any otherr confidentia
al informatio
on or
documen
ntation. All materials prroduced by the
t Committtee will rema
ain the prop
perty of the N
North
East LHIN.
MEETING
G FREQUENCY
w be held over
o
the du
uration of the
e project with additiona
al project acctivity
Monthly meetings will
occurring
g via email in
n between meetings.
m
72
Most me
eetings will be held by
y teleconference/video conference
e although 1-2 face-to
o-face
meetings
s may be req
quired (likely
y in Sudbury as a centra
al location within the regiion).
CT COMPLE
ETION
PROJEC
ected that the
e Advisory Committee
C
will
w conclude
e its work in tthe fall of 20
013 or before
e.
It is expe
73