Analytical Activism - Ontario Health Care

[Bill Rathborne]

This morning I heard on our local radio station that the local hospital administrators were scrambling and in some cases canceling operations because of a shortage of acute care beds, primarily because of a lack of long-term care facilities in the community or community services where people could be cared for at home. (When I agreed to prostate removal surgery I was given a one page notice that if scheduled, my surgery could be cancelled with as little as 24 hours notice)

I was thinking about this and all of the many "factors" involved and the "random/statistical" distribution of arrivals at emergency, high-priority surgeries identified, surgeon availability, etc., etc. (the number of factors could be mind boggling) So I'm thinking that the "false economy" of strangling almost all aspects of the health care chain "probably" sub-optimizes throughput capacity and maximizes costs. So I'm thinking that "IF" they had a model that simulated the "system" they could see things like an optimal capacity at each "point" or node and where the most critical strangulation is appearing (high leverage point?)

I think that SD modeling is an appropriate methodology to allow for far more effective decision making. My - uninformed - impression is that the "administrators" are just constantly reacting to cost pressures from the government and everyone is playing pass-the-buck and pointing fingers at each other. For example, there is a "local health integration network" http://www.southwestlhin.on.ca/ whose role seems quite nebulous, but a hospital administrator said "I hope the LHIN can assist us" and the LHIN administrator essentially said, "the hospital is on its own."

I'm in the process of composing a letter to - oh, EVERYBODY! - strongly urging looking at Structured Thinking/SD modeling, etc., so that they can make optimal decisions and not just flail around maximizing costs and minimizing delivery.

My initial googling indicates that this is not unheard of!

I'll post the letter when I eventually get it composed and have identified "enough" recipients (victims!)

[Bill Rathborne]

Below is the text of the letter I sent. I had to selectively trim from top and bottom because I kept getting a Thwink server error when I included the entire contents of the letter. (One of those -"it is not a bug, it is a feature" things?)

This was sent to the Ontario Minister of Health and cc'd to the Premier of the provence and the Board Chairs of the London Hospital and the LHIN.

Recent reports in London indicate that health care delivery is being compromised by apparent restrictions in long-term care facilities. However, it would appear that the inherent complexity (many components) and dynamic nature (time variant behaviour) of health care delivery is far more complex than can be managed by ad hoc responses to budget constraints and urgent situations created by shortages at various nodes in the network.

For government policy makers, regional health authorities, and hospital administrators, it is critically important that all stakeholders understand the structural dynamics of the health care system at various levels and agree on policies and allocations that will optimize cost, service delivery, and achieve wait-times targets.

The ad hoc allocation of resources and fire-fighting responses to periodic crises is like the suspension bridge swinging in the wind. All players want to keep the bridge from falling but actions and reactions based on “feel” and “experience” often creates a string of unintended consequences and ultimate disaster.

Structural Analysis, System Improvement Processes, and Systems Dynamics Modeling (SD) are all available tools designed specifically for complex and dynamic systems like the Health Care System and can provide invaluable insights into how decisions and actions can destabilize or stabilize a system. Based on sound scientific principles, SD provides an environment where stakeholders at all levels of the system can understand the system dynamics and agree on common allocation decisions in order to optimize both service delivery and costs.

The suggestion that the shortage of long-term care in London is creating the current situation may or may not be accurate. However, both the cause and cure cannot ever be known with a high degree of confidence if the complexity and dynamic nature of the system is not understood and modeled.

The utilization of the tools of Structural Thinking and Systems Dynamics Modeling (ST/SD) is also a learning system that enables all stakeholders to identify newly learned characteristics and incorporate them into increasingly robust and valuable models.

As indicated in the links below,(had to remove this to make it post) this is not entirely new to the health care field and many resources may be available in order to get started.

However, this is in itself complex and demanding and a modest “trial” site may be extremely valuable in permitting the development of a learning curve for stakeholders.

The potential benefits are however substantial for all. I cannot urge you strongly enough to make the decision to invest in ST/SD on an exploratory basis initially in order to eventually bring understanding and stability to an otherwise wildly swinging system.

The last web link (thwink) in the list below is a site dedicated to utilizing the ST/SD approach to addressing the global sustainability challenge, however, it is easily translatable to the complex and dynamic health care system.

Then in this morning's newspaper is the quoted article. Fairly clear indication of a complex, dynamic system beyond the control of the numerous administrators.

London Free Press
LHSC given emergency priority in bed crunch
Fri, May 23, 2008
By JOHN MINER

London's hospital pain is becoming everybody's hospital pain.

In a bid to open up beds to patients now being treated in hallways and conference rooms, London Health Sciences Centre has applied for and has been granted emergency priority -- called Level A1 -- for any spaces that open in long-term care homes throughout the region. That means a patient in a Middlesex or Elgin County hospital who is at the top of the list for a bed at a long-term care home will be bumped by someone discharged from LHSC if a space opens.

"As soon as London goes on Level A1 designation, we start to back up," said Nancy Maltby-Webster, chief operator for Strathroy General Hospital. "Our patients waiting to get into nursing homes have no ability to do that as long as they are Level A1."

The acting medical officer of health for Elgin County, Dr. Sharon Baker, has written the provincial government about the priority LHSC patients have over patients at St. Thomas Elgin General Hospital. "This puts Elgin County residents and St. Thomas Elgin General Hospital patients at risk," Baker wrote to Liberal MPP Steve Peters, with a copy to Health Minister George Smitherman. LHSC president Cliff Nordal said the hospital realizes its request for emergency priority stretches other hospitals.

The request for the emergency designation was made after LHSC, the trauma centre for the region handling the most serious accident cases, had to stop taking new trauma patients for 48 hours because it had no space in its intensive care unit, Nordal said.
"When circumstances like that happen it causes us a great deal of concern," he said. Any trauma patients during that period would have to be taken to Toronto or the U.S., Nordal said.

LHSC has been given the A1 priority designation for three weeks. At the root of the problem is what medical officials call "bed block." LHSC says it has had to treat patients in hallways and cancel dozens of surgeries because of a high number of patients in the hospital that are filling beds, but no longer require acute care. The patients would be discharged to a long-term care home, but there are long waiting lists for spots.

Ontario's Health Ministry has approved additional long-term care beds in the London area, but there are no spades in the ground yet, Nordal said. Michael Barrett of the South West Local Health Integration Network, the provincial agency allocating health resources in the region, said London's situation is "severe." Barrett said a series of proposals to provide short-term relief will be made to the health network's meeting in June. Options that will be presented to the board include:
- Paying for spaces for patients who can't afford it in retirement homes and long- term care homes.
- Using geriatric emergency management nurses to treat seniors so they won't have to be admitted to hospital.
- Setting up a system where people can call to have assistance in the home instead of going to an emergency department for a problem.