During wave one of the COVID-19 pandemic, the rapid rise in cases and alarming news of struggling health care systems from around the globe triggered the government to delay and cancel non-essential surgeries and procedures across Ontario. The government took this step to protect capacity at Ontario hospitals, especially within intensive care units, to prepare for a surge in patients infected with COVID-19. This has led to a sizable and growing backlog, in addition to existing, pre-pandemic wait lists.

Early on, anticipating the significant demand for health care services arising from this backlog, Ontario Health's West region initiated the development of a plan that would enable the region's health care providers to serve as many patients as possible, attending to the areas of highest need first. The region was united in its goal to ensure a coordinated, seamless approach that would maximize the contributions of each provider to meet the communities' unmet and emerging needs.

"In a period of unprecedented pressure on our hospital system it has been inspiring to see the way the hospitals in the Ontario Health (West) region have come together to ensure vital surgical and procedural care is still being provided to our patients," said Dr. Stephen Kelly, Surgeon-in-Chief, Hamilton Health Sciences, a member of the core planning team.

Setting Up for Success

In early spring 2020, Ontario Health West began working on its approach to surgical resumption (see below for a full list of key stakeholders). A regional governance structure was established to respond to the global pandemic, facilitated by Ontario Health West (OH West), including hospital CEO triad leads (in total, four triads were created, with representation from hospitals, public health and community leaders), tertiary centre hospital CEOs and surgical designates. Notably, the triad leads all had surgical resumption tables as well, which ensured all hospital sites/clinicians across OH West were kept up to date and had opportunity for input.

Teamwork and partnership built on growing trust amongst hospital leaders, partners and supporting teams was integral to the strategy really taking off. This was strongly driven by transparent data and information sharing, a high "say-do" attitude by the full team, and a highly collaborative relationship and approach. In particular, transparency in three key areas – guiding principles, process and data – was instrumental in strengthening trust amongst all involved.

"The transparency and collaboration between hospital teams with our West region approach allowed us to complete more priority surgical volumes in support of patient care," noted Mark Walton, OH West Regional Lead (Interim). "I'm extremely proud of our hospital partners and region."

Meeting weekly for the last 16 months, the team worked on a regional strategy, inclusive of key priorities, and action items, using data to ensure implementation priorities were nimble and constantly reevaluated in our dynamic healthcare environment.

"It was important that all partners felt confident and aligned with the analyses that fundamentally informed our decision-making," said Dr. Gillian Kernaghan, President and CEO St. Joseph's Health Care London. "Ontario Health West has been a great support in that sense, providing us with the flexibility to 'slice and dice' the data in a way that resonated with the team and allowed us to make dynamic decisions with confidence."

The West's Approach and Strategy

Four key enablers guided the strategy development and solutions:

• Service Line Optimization: Each hospital identified their top one to three service lines for surgical focus in the fiscal year. Service lines are defined as surgical focus areas with sufficient completed case volume to have proven quality outcomes, surgical expertise and efficiency, as well as meet a clear patient need based on open case volumes. This focus was a critical enabler, because if each hospital tried to focus on everything, the overall impact on surgical volumes as a regional team would be hindered. Focusing on service lines positioned the region to have transparent and engaging dialogue across the region about cascading or reallocating surgical volumes to other hospital sites, which was a key strategic lever in the region.

• Identify and activate latent operating room (OR) capacity: Identify and locate unused OR capacity at all West region hospitals and/or identify where hours of operation could be extended to meet patient care needs.  Significant latent OR capacity at community hospitals was leveraged to maximize surgical volumes.

• Optimize use of procedure rooms: Determine where case volumes could be moved out of an operating room (OR) into a procedure room to reduce the requirement of specific health and human resources where possible and to generate additional OR capacity.

• Increase capacity by partnering with community providers (Leverage Public Hospitals Act (PHA) 4(2): When patient waitlists over priority targets could not be mitigated through the above three enablers, hospital footprints were expanded through partnerships with alternate health care providers. For example, increased cataract volumes were completed through PHA 4(2) hospital expansions in both Waterloo and Windsor with a significant impact on completed case volumes that would not have been possible otherwise.

OH West is a widely diverse region spanning a large geographic area and 41 hospitals. These enablers provided a valuable framework for regional solutions, which were then tailored to local geographies for the greatest impact.

The starting point was to create a "nine-tile" dashboard, which considered both waitlist performance and acute occupancy percentage as a composite measure. This approach offered the team a foundational reference point that was used to help validate key decisions such as inpatient versus ambulatory volumes at each hospital.  The team kept a vigilant eye on this dashboard, as it helped ensure all of our teams were being set up for success.  When one or both of these metrics shifted a hospital into another tile on the dashboard, previous decisions would be revisited and adjusted as needed. 

Two core regional strategies were then implemented across the West region:

Cascading surgical cases to identified latent OR capacity enabled the region to maximize completed volumes (right surgery, right place), leveraging the three key enablers indicated above. As noted, each hospital identified their top service lines, had the opportunity to look at their wait lists – with an emphasis on priority over target wait lists – and reallocate volumes and funding to respond to the areas of highest need within their service lines. For example, the same surgical procedure could be moved from one hospital to another that offered the same service and had capacity to increase its volumes. It also allowed volumes to be reallocated between hospitals so that lower acuity services could be moved to smaller hospitals allowing those services to continue, while larger hospitals focused on the longer wait lists for patients that were more complex. This was made possible and encouraged as there was no financial penalty for working together in the region. 

In essence, there was a pull of resources to the areas of highest need based on an assessment of clinical capabilities and resources, existing relationships and gaps in care or services. This was done intra-organizationally, between organizations or across organizations at the sub-region or regional level. For example, Tillsonburg Hospital pulled cataract volumes into their procedure room completing more than 550 additional cases, leveraging surgeon resources from Woodstock and Simcoe. "The efficiency we gained using this collaborative approach doubled the volumes we would have completed otherwise, serving patients in the region immediately and setting us up for continued impact moving forward," commented Sandy Jansen, President and CEO, Alexandra Hospital Ingersoll and Tillsonburg District Memorial Hospital.

Initial challenges were primarily related to the logistics of cascading surgical volumes to other hospitals. For example, some community hospitals did not historically have funded volumes for Quality-Based Procedures (QBPs) or Wait Time procedures. Working closely with the Ministry of Health (MOH) and relying on their volume management reallocation (VMR) policy, funded volumes were seamlessly cascaded to these hospitals as they operationalized latent OR capacity.

Piloted and scaled same-day-joints (surgical smoothing initiative) across 17 West region hospitals. Hospitals currently completing same-day-joints accelerated their volumes and mentored hospitals piloting same-day-joints to support a goal of a higher percentage of ambulatory surgeries in the region. A playbook with process flows, order sets, equipment lists, clinical pathways, etc. was developed with full region participation and co-chaired by surgeon leads in London and Hamilton, Dr. Steve MacDonald and Dr. Daniel Tushinski. Not only did this initiative substantially increase surgical volumes, it also impacted best practice standardization and implementation across West region hospitals.

Patient Outcomes

Patient outcomes were significant, with more than 3,000 additional surgical cases completed in Fiscal Year 2020/2021 than would have been completed otherwise, and more than 600 conservable patient days saved given the increased volume of same-day joint surgeries. The tables below help illustrate overall outcomes:

Key Learnings

• Thinking, speaking and implementing as a regional health system drives patient and system outcomes that would not be possible otherwise. Health system funding, performance and accountability, working closely and collaboratively with hospital CEOs, surgeons, clinical teams and the MOH, have clearly accelerated some of the required infrastructure and supports needed to act as an integrated health system. 
• Keeping the patient at the forefront and trusting that other core elements like funding would follow, helped the regional team move further, faster and build momentum for continued evolution moving forward.
• Maintaining a laser focus by narrowing service lines at each provider organization helped us achieve more with the same resources while maintaining consistent quality of care across the region and achieving more equitable access to services.

For questions or more information, please contact Sandra Smith, Director Performance, Accountability and Funding Allocation, Ontario Health West at sandra.smith@ontariohealth.ca