Dear Colleagues,

Accountability has become one of the most important words in health care and we were wise to have included "accountable" as the sixth word in our Purpose Statement. I am proud that UHN is recognized as the most accountable hospital in Canada. Under Tom Closson's leadership, we started to p​​ost performance information on our website for everyone to see. The Ministry of Health has followed UHN's example by insisting that all hospitals submit the results of their performance on a regular basis. We now report on a variety of aspects of hospital performance measures- and sometimes this multiplicity of Ministry accountabilities creates conflicting goals within our organization. I want to speak about that issue and explain what your Senior Management Team is doing about these potential conflicts.

The most obvious example of potential conflict is the dual accountability presented by Surgery and Emergency Department (ER) wait time targets. UHN has been at the forefront of the Surgical Wait Times program and we have substantially expanded many of our scheduled surgical services (cancer, hip and knee, neurosurgery, heart and cataract). The success of our surgical wait times performance is now conflicting with the Ministry's direction to reduce Emergency Room (ER) wait times. Managing the variable ebb and flow of ER patients requiring hospital admission frequently means that medical patients are "bed-spaced" to surgical units. This results in a quicker admission from the ER and improves ER wait times- but the presence of bed-spaced patients on surgical units can result in cancellation of scheduled surgery because the planned surgical bed is being used for an admitted ER patient.

To this point, our Escalation and Repatriation Protocols have dramatically improved ER performance- and very few scheduled surgeries have been cancelled. However it is clear that this will be a continuing problem and requires thoughtful planning.

Your Senior Management Team has taken the approach that the needs of admitted patients waiting for a bed in the ER and the needs of scheduled surgery patients are equal. Most of our scheduled surgery is performed for urgent healthcare needs and people re-arrange their lives and the lives of family members to schedule surgery. It is very disruptive and contrary to patient-centred care to cancel surgery- just as it is contrary to patient-centred care to leave an admitted patient waiting on a stretcher in the ER. Here's what we will be trying to ensure that we limit surgical cancellations- we probably cannot eliminate the problem- but here's how we will strictly minimize it.

First of all, we are going to re-review and tighten up our processes for admitting and discharging all patients. A recent comparison of our discharge processes to other hospitals' showed that we have implemented most initiatives that may reduce length of stay through our ED-GIM redesign project. One initiative that has been successful at other hospitals is expansion of Medical Ambulatory Clinics that see both ER patients and recently discharged patients. These clinics have improved discharge planning and admission avoidance here and at other hospitals. Drs. John Parker, Michael Baker and Charlie Chan are going to work in the Medical and Complex Care Program to expand our current activity to a daily ambulatory clinic and to find out whether this will further reduce our utilization of medical beds. Dr. Howie Abrams and his colleagues Nic Szecket, Dante Morra, and Wayne Gold are already implementing changes around the call system used to admit patients across our Clinical Teaching Units and we think that this coverage change will also improve utilization of medical beds.

We are also going to continue to carefully balance the needs of ER and surgery patients. Occasionally, we will admit an ER patient to the hallway of an in-patient unit. We will now, also occasionally, take this approach when there is a risk that a surgery is going to be cancelled due to lack of beds. In this situation, we will ask the Unit Team to consider placing their most stable patient in the hallway so that the scheduled surgical patient can be admitted following the operation and avoid cancellation. These decisions will be facilitated by our Directors and Vice-Presidents as part of our Escalation Policy for bed management. Our units are well staffed (along with the Nursing Resource Teams) and our experience with hallway patients to date has shown that we can facilitate care using this protocol.

We will also balance the demands on our beds in other ways. For example, we have reduced scheduled surgery by a bit more than 5% of capacity to reduce some of the strain on our units. We are also trying to reduce the medical demand for in-patient beds (for example, by sending our TWH nurses into nursing homes to stabilize patients without the need for an ambulance transfer to our ER as reported in Saturday's Globe and Mail).

Accountability is an important concept- but increasingly we are facing competing responsibilities that require constant management and leadership. I will be sending further "Straight Talks" about our accountabilities in the days to come.



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