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Women and Children’s Program Clinical Service Review Report

December 2018 Prepared on behalf of the Women and Children’s Clinical Service Review Co-Leads: Dr. Zoutman and Linda Calhoun

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Preface

This report was prepared on behalf of the Co-Leads of the Women and Children’s clinical service review. This report is intended to be a composite of the many seminal reviews and reports that have been undertaken over the last many years, and the past and current perspectives, ideas and points of view shared by the numerous program team members, and our community members who have provided their input and expertise.

The Co-Leads fully endorse the recommendations put forward in this report and look forward to advancing these ideas through further discussion with the Senior Leadership Team, the External Advisors, and ultimately the Board of Directors.

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Table of Contents Preface ............................................................................................................................................ 2

Section 1.0: Executive Summary ..................................................................................................... 4

Section 1.1: Purpose of the Review ............................................................................................ 4

Section 1.2: Overview of Reports and Analysis .......................................................................... 4

Section 1.3: Summary of Recommendations.............................................................................. 5

Section 2.0: Introduction ................................................................................................................ 6

Section 2.1: Brief History of the Hospital.................................................................................... 6

Section 2.2: Program Background .............................................................................................. 6

Maternal Newborn Services ................................................................................................... 7

Children’s Services................................................................................................................... 7

Section 2.3: Structure of the Program ........................................................................................ 8

Section 2.4: Purpose of the Review ............................................................................................ 8

Section 2.5: Review of Decision Making Structure ..................................................................... 9

Section 2.6: Glossary of Terms .................................................................................................. 10

Section 3.0: Review of Findings .................................................................................................... 11

Section 3.1: Overview of the reports and analysis completed to date .................................... 11

Section 3.2: Key Findings and Recommendations .................................................................... 12

Theme: Program structure and delivery ............................................................................... 12

Theme: Strategic vision ......................................................................................................... 16

Theme: Governance and structure ....................................................................................... 17

Theme: Clinical care .............................................................................................................. 18

Theme: People and culture ................................................................................................... 19

Theme: Physical environment .............................................................................................. 21

Theme: Communications and marketing ............................................................................. 21

Theme: Service delivery processes ....................................................................................... 22

Section 4.0: Implementation and Transition Planning ................................................................. 23

Section 5.0: Consolidated Recommendations .............................................................................. 25

Section 6.0: Appendix...................................................................... ………………………………………………26

Appendix A: Summary of Key Findings and Recommendations from Reports and Analysis ……… 28

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Section 1.0: Executive Summary

Section 1.1: Purpose of the Review

As part of the new strategic vision for the newly established Scarborough Health Network (SHN), the hospital is undertaking clinical service reviews across all of the hospitals clinical programs. The intention of these reviews is to assess the current state of the program and determine what the future state of the program should be, and what actions need to be taken to move towards the future vision. This is particularly important because SHN includes a wide variety of programs, services and sites within its network. The clinical service reviews will help the organization take an enterprise wide view of the network, focus on providing the highest quality of care across all clinical services, and develop the best course of action for each program and service.

The Women and Children’s program was the first program to begin the clinical service review process, due to a sense of urgency and clear desire on behalf of the program team and external stakeholders to determine the path forward for the program. The Women and Children’s program has had a number of reviews over the last decade that have highlighted the need for change.

This document is intended to be a composite report that captures the essence and recommendations from all of the past seminal reviews and the current perspectives of internal and external stakeholders including our communities. The recommendations in this report were developed in consultation with the program team, and are consistent with the recommendations that experts have provided in their reviews.

The recommendations in this document will need to be reviewed in conjunction with the broader clinical service planning and Master Planning that is underway for SHN. Part of this work will be to determine the vision for each of the hospital sites within the network. The recommendations in this report are intended to support this work and provide a perspective for the Women and Children’s program.

Section 1.2: Overview of Reports and Analysis

This report is a composite of a number of seminal documents that have been developed over the last decade. The chart below provides a list of the key reports and events that have informed where the program is today.

1998 The Scarborough Centenary Hospital merged with the Ajax and Pickering General Hospital to form the Rouge Valley Health System (RVHS)

1999 The Scarborough Grace and Scarborough General hospitals merge to form The Scarborough Hospital (TSH)

2012 Corpus Sanchez International Consultancy (CSIC) completes a review of the maternal newborn and child care program at The Scarborough Hospital

2013 The Central East LHIN Board passed a motion (Motion 1b) directing RVHS and TSH to participate in a facilitated integration process; the process concluded that RVHS and TSH should merge but the merger did not take place as planned

2015 (Jan) The Motion 1b final report on the service delivery model for maternal-child youth is concluded; there is no final decision made on the future state service delivery model

2015 (Nov) The Minister of Health and Long-Term Care created the Scarborough / West Durham panel, which concluded that there should be a merger of The Scarborough Hospital (including TSH Birchmount and TSH General) with the Rouge Valley Hospital System (RVHS) Centenary Sites

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2016 RVHS Centenary Site and TSH merge to form Scarborough and Rouge Hospital (SRH)

2017 Master Planning activities begin to chart a path forward for the next 10-20 years

2018 (June) An external expert in Obstetrics is asked to complete an analysis of safety related concerns at the Birchmount and an extensive review of the delivery of obstetrical

2018 (June) The new Strategic Plan for the hospital is completed and the Scarborough and Rouge Hospital changes its name and becomes Scarborough Health Network (SHN)

2018 (Dec) Deloitte co-design process to develop a preferred direction for the high-level future state model of the program

Section 1.3: Summary of Recommendations

Themes Recommendations

Program structure and delivery

1. The Birthing and Core Paediatrics1 cluster of services be delivered at the General and Centenary sites.

2. The Women and Children’s program continue clinical services planning to determine how the other clinical programs be delivered.

Strategic vision 3. The Women and Children’s program, in conjunction with the broader SHN, develop a clear vision that aligns to the SHN clinical service planning that is underway.

Governance 4. The Women and Children’s program develop a unified governance model for the medical side of the program. The program establish a corporate chief and medical director for obstetrics and gynaecology, a corporate chief of midwifery and a corporate chief and medical director for paediatrics.

Clinical care 5. The Women and Children’s program continue to identify leading clinical practices, and actively implement evidence based clinical practices in a consistent manner across the program.

People and culture 6. SHN, and the Women and Children’s program specifically, develop opportunities for staff, physicians and clinicians across the program to meet one another, and build a stronger community over time.

7. The Women and Children’s program take targeted action to develop a high-functioning team, across the program.

8. The Women and Children’s program develop a strategy to improve recruitment and retention amongst clinicians and physicians.

Physical environment 9. SHN undertake a detailed assessment of the infrastructure implications of the clustering of services, including space, renovation and equipment impacts, and any secondary impacts on other services.

10. The Women and Children’s program invest in developing patient and family friendly environments to improve patient care and the overall experience of patients and their families.

Communications and marketing

11. SHN, and the Women and Children’s program specifically, actively market the program within and outside the hospital. Connections be made with

1 The Birthing and Core Paediatrics cluster is a group of services that need to be co-located with labour and delivery. The cluster includes birthing, NICU, paediatric inpatient medicine, paediatric inpatient surgery and paediatric day surgery.

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the community to improve their overall knowledge of what the program has to offer, including the specialty programs that exist.

Service delivery processes

12. The Women and Children’s program, in conjunction with related programs, undertake a review of all care delivery processes to ensure safe and seamless transitions of care required to move forward with Recommendation 1.

Implementation and transition planning

13. SHN undertake efforts to secure funding and investment required to move forward with Recommendation 1.

14. The Women and Children’s program develop detailed transition plans to execute the recommendations outlined in this report and continue detailed clinical service planning.

15. The Women and Children’s program develop a clear communications plan to support knowledge sharing with hospital stakeholders and the broader community.

16. The Women and Children’s program, in conjunction with SHN, work to prioritize the activities moving forward. The Program establish processes and metrics to monitor the quality of care provided to patients during the transition and provide regular reports to the SLT, Medical Advisory Committee (MAC) and, through the MAC and Chief of Staff, to the Board of Directors.

Section 2.0: Introduction

Section 2.1: Brief History of the Hospital

On April 28, 2016, the Minister of Health and Long-Term Care announced his support for the implementation of the recommendations of the Scarborough/West Durham Expert Panel, which was tasked with providing recommendations to address infrastructure needs, improvements to access, and the integration of acute health care services in Scarborough and the West Durham region. Legacy Rouge Valley Health System ( RVHS) was divided, as the Ajax-Pickering site became a part of Lakeridge Health (a large community hospital in Durham Region) and the Centenary site merged with The Scarborough Hospital’s General and Birchmount sites to create a new hospital corporation in Scarborough with the temporary name Scarborough and Rouge Hospital. On November 22, 2018, the hospital transitioned to its permanent name Scarborough Health Network.

SHN is now the third largest community hospital in Ontario (by budget), behind Trillium Health Partners and William Osler Health System.

Section 2.2: Program Background Scarborough Health Network (SHN) Women and Children’s program provides inter-professional care and a collaborative model that involves obstetricians, paediatricians, midwives, family physicians, nurses, and allied health staff. The program offers a complete range of services for our diverse community in a welcoming and caring environment. These services include prenatal classes, antenatal breastfeeding classes, perinatal inpatient services, midwifery, non-stress test clinic and genetic counseling. Other well established Women’s Health Services include: sexual assault clinic, early pregnancy assessment clinic (EPAC), minimally invasive gynecologic surgery, urogynecology, maternal fetal medicine (MFM) and a community of practice in cervical screening and colposcopy. By specializing in maternal, child and adolescent health care we are able to ensure that families in Scarborough and surrounding catchment areas have access to high quality care.

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Maternal Newborn Services

Service Description Prenatal Services • Antenatal Assessment Unit

• Non Stress clinic • Prenatal Classes/Support • Early Pregnancy Assessment • Maternal Fetal Medicine (MFM) Clinic • Breastfeeding Classes

Intrapartum • Inpatient Services • Obstetrician/Gynaecologist onsite 24/7 • Midwifery Program • Highly Skilled Staff • Diverse Cultural Care • Labour and Delivery Recovery and Postpartum Rooms • One on one nursing support throughout active labour

Postpartum Care • Breastfeeding support and outpatient clinic in conjunction with public health • Lactation Support • Care by Parent Rooms • Family Sleep Rooms • Walk in Breastfeeding Clinic • Newborn Assessment Clinic • Neonatal Intensive Care Unit • Perinatal Bereavement Support

Children’s Services

Service Description Neonatal Intensive Care Unit

• Providing care to infants up to level 2C

Paediatric Inpatient Unit

• Acute care beds • General paediatrics for medicine and surgical inpatients

Short Stay Paediatric Unit/Paed Link

• Provides care for stable patients requiring short term (<8 hours) observation and/or treatment

• Paedlink • Ambulatory Care Outpatient Subspecialty Clinics • Neonatal Follow-up • Paediatric Consult • Newborn Follow-up • Preadmit • Health Outcomes for Paediatric Program (HOPPS) • Developmental Clinic • Hematology • Gastroenterology

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• Sickle Cell • Others

Day Surgery • Ears, Nose, Throat, and Oral • Orthopaedics (including Scoliosis up to 23 years old) • Plastics (including Pulse dye laser surgery); Urology

Satellite Programs • Pediatric Oncology Clinic Note: child and adolescent mental health services are provided through the Mental Health Program

Section 2.3: Structure of the Program Below is an overview of the structure of the Women and Children’s program.

Section 2.4: Purpose of the Review

As part of the strategic vision for the newly established Scarborough Health Network (SHN), the hospital is undertaking clinical service reviews across all of the hospitals clinical programs to ensure high quality, efficient care in all programs across the network. The intention of these reviews is to assess the current state of the program and determine what the future state of the program should be, and what actions need to be taken to move towards the future vision. This is particularly important because SHN includes a wide variety of programs, services and sites within its network. The clinical service reviews will help the organization take an enterprise wide view of the network, and develop the best course of action for each program and service.

The Women and Children’s program was the first program to begin the clinical service review process, due to a sense of urgency and clear desire on behalf of the program team and external stakeholders to determine the path forward for the program. The Women and Children’s program has had a number of reviews over the last decade that have highlighted the need for change.

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This document is intended to be a composite report that captures the essence and recommendations from all of the past seminal reviews that have touched on the Women and Children’s program, and develop a clear set of recommendations on behalf of the Co-Leads of the Women and Children’s program review, Dr. Zoutman and Linda Calhoun. The recommendations in this report were developed in consultation with the program team, and are consistent with the recommendations that experts have provided in their reviews.

The recommendations in this document will need to be reviewed in conjunction with the broader clinical service planning and Master Planning that is underway for SHN. Part of this work will be to determine the vision for each of the hospital sites within the network. The recommendations in this report are intended to support this work and provide a perspective for the Women and Children’s program.

Section 2.5: Review of Decision Making Structure

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Section 2.6: Glossary of Terms For the purposes of this document, below are definitions of a number of key terms used in this document.

Term Definition Internal staff survey Refers to the survey of internal staff and physicians of the Women and

Children’s program that was completed by SHN in the fall of 2018. 152 staff and physicians across the three sites responded to the survey2.

External survey Refers to the survey of external community members that was completed by Crestview Strategies in the fall of 20183. 64 community members responded to the survey.

Primary care physician survey Refers to the survey of primary care physicians that was completed by SHN in the fall of 20184. 22 primary care physicians responded to the survey.

Co-design session Refers to the co-design sessions that were facilitated by Deloitte in the fall of 2018.

Co-design session attendees Refers to the physicians, clinicians and staff that attended the co-design sessions in the fall of 2018. 30 stakeholders participated in the co-design sessions.

Stakeholder Inteviews Refers to targeted internal consultations that were facilitated by Deloitte in the fall of 2018. 17 stakeholders were interviewed5.

Stakeholder Focus Groups Refers to targeted internal consultations that were facilitated by Deloitte in the fall of 2018. 26 stakeholders participated in the focus groups6.

Program team Refers to all those individuals that work within the Women and Children’s program (this term is inclusive of clinicians, physicians and staff).

Clinicians Refers to the professional staff that work in the Women and Children’s program (including nurses, midwives, physiotherapists , etc.).

Physicians Refers to the medical doctors that work in the Women and Children’s program.

Staff Refers to the support staff that work in the Women and Children’s program.

Steering Committee Refers to the committee that was established to provide input and guidance during Deloitte’s work in fall 20187.

2 Note: Refer to Appendix E for detailed findings of the internal survey of staff and physicians of the Womend and Children’s program completed in the fall of 2018. 3 Note: Refer to Appendix G for external community survey completed by Crestview in fall 2018. 4 Note: Refer to Appendix F for detailed findings of the primary care physician survey completed in fall 2018. 5 Note: Refer to Appendix B slide 37 for detailed list of stakeholders interviewed by Deloitte in fall 2018. 6 Note: Refer to Appendix B slide 38 for detailed list of stakeholders that participated in focus groups by Deloitte in fall 2018. 7 Note: Refer to Appendix C for Steering Committee terms of reference and members.

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Section 3.0: Review of Findings

Section 3.1: Overview of the reports and analysis completed to date This report is a composite of a number of seminal documents that have been developed over the last decade. The chart below provides a brief synopsis of the key reports that have informed where the program is today.

1998 The Scarborough Centenary Hospital merged with the Ajax and Pickering General Hospital to form the Rouge Valley Health System (RVHS).

1999 The Scarborough Grace and Scarborough General hospitals merge to form The Scarborough Hospital (TSH).

2012 Corpus Sanchez International Consultancy (CSIC) completes a review of the maternal newborn and child care program at The Scarborough Hospital.

2013 The Central East LHIN Board passed a motion (Motion 1b) directing RVHS and TSH to participate in a facilitated integration process; the process concluded that RVHS and TSH should merge but the merger did not take place as planned.

2015 (Jan) The Motion 1b final report on the service delivery model for maternal-child youth is concluded; there is no final decision made on the future state service delivery model.

2015 (Nov) The Minister of Health and Long-Term Care created the Scarborough / West Durham panel, which concluded that there should be a merger of The Scarborough Hospital (including TSH Birchmount and TSH General) with the Rouge Valley Hospital System (RVHS) Centenary Sites.

2016 RVHS Centenary Site and TSH merge to form Scarborough and Rouge Hospital (SRH).

2017 Master Planning activities begin to chart a path forward for the next 10-20 years.

2018 (June) An external expert in Obstetrics is asked to complete an analysis of safety related concerns at the Birchmount and an extensive review of the delivery of obstetrical

2018 (June) The new Strategic Plan for the hospital is completed and the Scarborough and Rouge Hospital changes its name and becomes Scarborough Health Network (SHN).

2018 (Dec) Deloitte completed a co-design process to develop a preferred direction for the high-level future state model of the program.

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Section 3.2: Key Findings and Recommendations

For the last decade or more, there have been ongoing discussions about the Women and Children’s programs and services, and how they are delivered across the Scarborough Health Network (SHN), and SHN’s many previous incarnations. These conversations, reports and analysis have revealed a lot of important information about the program, but have also left the SHN staff, physicians, clinicians, and the community stakeholders with many questions and an uncertainty about the future of the program. The purpose of this section is to bring structure to the past reports and analysis that have been completed and begin to chart a path forward for the program. This section will go into eight key themes and will bring forward recommendations for the program moving forward.

Theme: Program structure and delivery

In the fall of 2018 Deloitte conducted a number of engagement activities that were intended to help the program coalesce around a preferred direction moving forward. Deloitte’s work culminated in two co-design sessions where about 30 program team members collectively worked through the data and analysis to date and arrived at a preferred direction. The recommendations in this section are consistent with the preferred direction of the co- design session attendees.

Maintaining the full program at three sites is unsustainable

Throughout all the engagement activities, the vast majority of the team agreed that the current three-site model for the Women and Children’s program is not sustainable moving forward. Clinicians and physicians raised that the program did not have a high enough number of births to sustain labour and delivery at three sites and that having the full program operating at three sites caused a number of challenges. Challenges include inability to keep physicians and clinicians busy for the duration of their shifts, difficulty attracting top talent and retaining talent because of the lack of learning potential in a low volume unit, and difficulty accessing necessary support services like anesthesia and surgical assists. Overall, stakeholders tended to agree that the program does not have adequate birth volumes to necessitate providing the full suite of services on all three sites.

The Birthing and Core Paediatrics cluster must be co-located

Labour and delivery services are linked to other services that are provided by the program, so it was important to establish which ‘cluster’ of services need to be co-located with labour and delivery, in the interest of providing high quality care to our communities. This was discussed during the co-design sessions and attendees tended to agree on a core cluster of services that need to be co-located with labour and deliver, which includes birthing, neonatal intensive care unit (NICU), paediatric inpatient medicine, paediatric inpatient surgery and paediatric day surgery.

The Birthing and Core Paediatrics cluster be delivered at two sites

Some program team members wanted the cluster of services to be delivered at one site, instead of two sites. To determine the feasibility of this, the Capital Planning group at SHN completed an analysis.

The capital planning analysis showed that to co-locate the cluster of services at any one of the sites would cost approximately $100 million dollars, would take about 7 years to implement, and would require going through the

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Ministry of Health and Long-Term Care’s established capital planning processes (see below for estimates). Given this, it was clear that moving to one-site was not a solution for the program in the short to medium time horizon (5-10 years), but could be considered as part of the Master Planning activities underway.

Summary: Feasibility of Consolidating the Birthing and Core Paediatrics Cluster on One-Site Site Description of Impact Time and Cost

Estimate Birchmount • Consolidating the Women and Children’s program would require

+/- 100,000 sq.ft of space • This would result in 2 ½ floors of existing space being required to

be repurposed for the Women and Children’s program • This would impact practically all other programs and services and

only 20,000 sq.ft of space will be remaining for other clinical services (i.e., the emergency department)

Timeline: 90-94 months Cost Estimate: $136M-$204M

Centenary • Expansion of Birthing Suite (Including NICU) to accommodate 6500 Births per annum

• Expansion of Paediatrics Inpatient Unit to accommodate additional 10 beds

• Convert additional space at the Centenary site to accommodate outpatient and other services

• Scope may require the relocation of other programs to other sites

Timeline: 74-79 months Cost Estimate: $84M-$126M

General • Infrastructure and building systems capacity for expansion is significantly limited

• Irregularity and variations in floor plate configuration, structural grid, floor to floor height impose design constraints

• Limited “land” to construct new +/- 100,000 sq.ft of consolidated new build

• Consolidation at the General would impact a large number of other programs and services; impact would be far greater than consolidating at the Centenary Site

Capital Planning did not complete a cost analysis due to the significant structural constraints

The Birthing and Core Paediatrics cluster be delivered at the Centenary and General sites

When determining where the program should be delivered, a number of considerations were taken into account. Below is an overview of the key considerations that informed the recommendation that the Birthing and Core Paediatrics cluster should no longer be delivered at the Birchmount.

Declining market share

The hospital market share of pregnancy and childbirth activity has declined at the General and Birthmount sites by 4% and 5% respectively since 2005/06. During this same time period the market share for the Centenary site increased by 3%, however the market share for the Centenary has also been declining since 2012/13.

The data also shows that mothers who live in the Birchmount catchment area are more likely to deliver at the General, instead of their most convenient location, which would be the Birchmount. Over the last three years 24% of mothers who live in the Birchmount catchment area chose to deliver at the Birchmount. An equal number of these mothers (24%) chose to travel to North York General to deliver. The Centenary, on the other hand, captures 41% of the market share for those who live in their catchment area, and the General captures 28%. Overall, this

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illustrates that expecting mothers are making choices about where to have their babies and in many cases they are not choosing their most convenient hospital.

The Birchmount site has had a long standing challenge with the community’s perception of the hospital. This long history started in 2003 when the Birchmount was the site for the SARS cases during the epidemic. The public perception of the site was further impacted in 2008 when there were maternal deaths at the site.

These issues have continued to cause damage to the sites’s reputation and may have contributed to a disproportionate decrease in deliveries compared to neighbouring hospitals. In 2014/15 there was a significant investment in the Birchmount site, including a rebranding strategy that was done in conjunction with community members, and a four year investment plan that was initiated to try and recapture market share. The investment

Public sentiment

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plan included recruiting three new obstetricians with expertise in minimally invasive surgery, and a $2M dollar renovation of the birthing unit. Despite these investments, the number of births at the Birchmount has not grown.

The General and Centenary sites do not have the same historical quality of care perception challenges, and tend to be well regarded in the community.

Low volumes of births and the impact on quality of care

The Birchmount site has fewer births than both the Centenary and General sites. The low number of births may impact the quality of care that patients receive. Low volumes can cause physicians and clinicians to not be able to perform at their best because they are not accumulating experiences and being exposed to complex cases as frequently as they would in a higher volume unit. This can result in physicians and clinicians being less well equipped to handle complex cases when they do arise.

Recruitment and retention

The Canadian health care system is experiencing human resource challenges in all areas. Since these challenges will only increase as the work force continue to age, it is important to focus on creating working conditions and offering health professionals opportunities that are attractive and competitive. An underlying theme arising from the internal staff survey is the urgent need to improve the recruitment and retention of specialized health care professionals. Concentrating specialized and talented staff in fewer locations allows them to focus on their areas of specialty. Improving recruitment and retention is not only about ensuring patients have the best possible experiences and outcomes but also ensuring there are enough health care professionals to work at SHN.

The research on consolidating services is clear – by concentrating health care teams at fewer locations, patients can be cared for more effectively. By focusing the program in this way, patients benefit from coordinated care and health professionals are able to work together more effectively to ensure all the patient’s needs are met.

The Birchmount site has had a particularly hard time recruiting and retaining staff due largely to the low volume of births. Nurses are joining the practice at the Birchmount but are leaving when an opportunity presents itself for them to work in a higher volume unit – whether that means moving to a different site within SHN, or leaving the network altogether.

Other considerations

The main concern regarding consolidation of services that was noted by a number of program team members during the interviews and co-design sessions facilitated by Deloitte, was accessibility. There was a concern that not having labour and delivery services at the Birchmount site may make it less accessible for people to access care, especially for those individuals who already face barriers to accessing care.

In order to get a better understanding of this challenge, SHN conducted a brief survey of women who were coming into the three sites to give birth, and what their mode of transportation was. The findings show that the vast majority of women arrive at the hospital by taking their own car, a family car, or someone else drives them. This shows that while accessibility is an important consideration, it seems to be less of a challenge when women are arriving at the hospital to deliver, versus all the other times in their life that they may need to access a hospital for other services. Moving forward,

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the program should consider what services the community near the Birchmount needs to be able to access in a convenient location, versus those services that they may be more able to travel to access.

Conclusion

For all the reasons mentioned above, the recommendation being put forward is that birthing and core paediatrics be delivered at the Centenary and General – this recommendation was also the preferred direction of program team involved in the co-design sessions, and was the recommendation put forward by the External Expert in Obstetrics in the 2018 review. The expert’s report in 2018 recommended phasing out obstetrical services at the Birchmount due to declining birth volumes, the inability to attract women to the site, and concerns about the provision of safe and effective care for those who give birth at the Birchmount.

More work needs to be done to determine how the rest of the services should be delivered. Accessibility was a concern that was noted a number of times; more work should be done to determine how best to deliver services in a way that is accessible for the community, and specifically people within the community who may face barriers to accessing services.

Theme: Strategic vision

In 2018 a new strategic plan and vision for SHN was developed. The purpose of the new strategic plan was to outline what the vision, mission and strategic direction is for the newly established SHN. In a similar vein, it is crucial to develop a clear strategic direction for the Women and Children’s program, overall, and specifically, for each of the program sites. This will be particularly important for the Birchmount site that will be undergoing a significant change because of Recommendation 1.

In 2012, the CSIC report emphasized the importance of clearly articulating the new purpose for a site, because removing core services without replacing it with a credible focus may make it the change even more challenging. This is important advice, and the program team involved in the co-design sessions in 2018 reiterated the importance of this. They were clear that the focus and brand of the Birchmount site should be determined before the communications about the program are disseminated. Their perspective was that by determining a new vision for the hospital the community and other stakeholders are likely to view the change as less of a ‘loss’, and more so a change in focus.

When developing the future vision for the Birchmount, specifically, the corporation should consider the needs and desires of the community north of the 401, and specifically those individuals who may not have access to private transportation.

Recommendation 1:

The Birthing and Core Paediatrics cluster of services be delivered at the General and Centenary sites.

Recommendation 2:

The Women and Children’s program continue clinical services planning to determine how the other clinical programs be delivered.

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When thinking about the program overall, the program team members involved in the co-design sessions in 2018 identified a number of potential ideas that could form part of the future vision for the program. Below are a number of the ideas that they raised:

• Urgent afterhours clinic; • Dedicated women’s health centre; • Complex paediatrics clinic; • Community outreach clinics; • Developing new ways to deliver services, including leveraging technology such as OTN; • Building partnerships with tertiary centres in the area; • Building partnerships with other health programs and services, including Kids Health Alliance, Mount Sinai

for the MFM clinic, SickKids to support complex care needs; and • Building community partnerships to improve population health, including public health, schools,

community centres.

The future state vision for the program should also be consistent with the direction outlined in the ‘Future Model of Care’ document, which includes:

• Patient/family supported and inclusive care; • Health equity and improved access to care; and • Care closer to home.

The future state vision should aim to invigorate the program, and develop a program that is a source of pride for the program staff and community.

This work will need to be done in conjunction with SHN and consider the clinical services planning that is underway. SHN will be developing a future vision for each of the sites as clinical service planning continues; the ideas raised through this review should inform the thinking moving forward.

Theme: Governance and structure

There is a need to develop a standardized corporate governance structure for the program, and move away from site- specific structures. The administrative side of the program has already developed a new governance structure with a single program lead, but the medical side of the program continues to have one chief for obstetrics and gynaecology for the Birchmount and the Centenary, and a different chief for the General. On the paediatrics side, there is a chief for the Birchmount and the General, and a different chief for the Centenary. In addition, for midwifery, there is a head for the Birchmount and the General, and a separate head for the Centenary.

The new governance structure should span across program sites and make it clear to all stakeholders that decisions will be made at a program level, while considering all program sites. The governance structure should also include implementing standardized governance meetings, quality rounds and mortality and morbidity rounds, so there is a shared understanding of the program overall. A new governance structure that reflects a united program on the administrative and medical side is a starting point to breaking down the siloed mentality that exists, and will have significant downstream effects on program policy, processes, decision-making, culture and standards.

Recommendation 3:

The Women and Children’s program, in conjunction with the broader SHN, develop a clear vision that aligns to the SHN clinical service planning that is underway.

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Note: The recruitment of corporate chiefs and medical Directors is underway and aligned with the new SHN medical leadership structure.

Theme: Clinical care

While the overall quality of care within the Women and Children’s program is strong, there are still quality of care problems that may reflect risk to the safety of patients. These include:

• Program team members do not feel that they have the support they need to deliver excellent quality of care to patients; the internal survey9 found that 53.3% of respondents answered ‘neutral, disagree, or strongly disagree’ to the question ‘I feel that I have the required support to deliver excellent quality of care to my patients’

• Poor communication amongst staff, which has led to gaps in accountabilities, and created confusion and ambiguity between clinicians

• Clinicians across different sites do not have strong relationships with one another, which makes it challenging to deliver consistent service and learn from one another

• The low volume of births overall makes it difficult for physicians and other clinical staff to maintain their competencies and improve them over time

• The low volume of births has also contributed to the high rate of attrition and turnover, which has made it challenging to maintain the highest levels of care; specifically the lack of experienced nurses was noted by respondents in the internal staff survey

• The lack of consistent use of evidence based practices was noted in the internal staff survey • The shortage of nursing staff, and other staff was also noted in the internal staff survey

The issues noted above do not cause poor quality of care in and of themselves, but they do increase the risk that quality of care may be negatively affected. Overall, there is a need to improve the patient experience and quality of care, and address some of these related issues to avoid them having a significant impact on the care patients receive in the future. The recommendation below will need to be implemented in conjunction with a number of the other recommendations in this report that seek to address governance, people and culture and service delivery processes.

9 Refer to Appendix E for internal survey of staff and physicians of the Women and Children’s program completed in the fall of 2018.

Recommendation 4:

The Women and Children’s program develop a unified governance model for the medical side of the program. The program establish a corporate chief and medical director for obstetrics and gynaecology, a corporate chief of midwifery and a corporate chief and medical director for paediatrics.

Recommendation 5:

The Women and Children’s program continue to identify leading clinical practices, and actively implement evidence based clinical practices in a consistent manner across the program.

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Theme: People and culture

While there are many positive parts of the culture within the Women and Children’s program, historical issues, feelings of inequality, and simply the blending of what was three distinct entities into a single program has caused some challenges over time. The challenges with the culture within the program are not new; the CSIC report from 2012 raised concerns about the culture10 and the external expert in Obstetric’s report from 2018 echoed the sentiments. Three of the most persistent challenges are outlined below.

‘Us versus them’ mentality

The interviews and focus groups conducted by Deloitte in 2018 found that the three sites tended to view themselves as distinct and in some instances there was an ‘us versus them’ mentality; all stakeholders noted the challenges that this poses and said that it needed to be resolved. There was a feeling amongst some that stakeholders in the program are looking out for what is best for themselves and the practice at their site, instead of taking a view of what is best for the program overall. The survey to staff also validated this feeling; one respondent referred to it as ‘in-fighting’ and noted that it was a significant challenge for the program.

Short-staffed and overworked

The internal survey of program staff revealed that there was a common feeling across the team of being overworked, due to not having enough staff. Respondents also noted that this problem is exacerbated when people are overworked, because it can also increase the number of people who are off or call in sick. As well, it has an impact on retention, which is also a challenge for the program overall.

Ambiguity and a lack of support

The internal survey of program staff also revealed that staff are not feeling supported across a number of dimensions; not having support from their colleagues, not feeling like the program leadership is supporting them, and not feeling like they have the equipment and resources to do their job. The internal survey findings highlighted this challenge:

• 24.3% of respondents answered ‘neutral, disagree, or strongly disagree’ to the question ‘When managing a complex situation, I feel like I have the support that I need from my colleagues’

• 53.3% of respondents answered ‘neutral, disagree, or strongly disagree’ to the question ‘I feel that I have the required support to deliver excellent quality of care to my patients’

Team members are also frustrated by the ambiguity that exists within the program and the lack of direction moving forward. In the CSIC report from 2012 it emphasized the importance of making a decision regarding consolidation quickly and giving staff assurances of continuity moving forward. This did not transpire and six years later the team is very frustrated. This has had a significant impact on the programs culture and has permeated across all staff and all sites.

Moving forward there is a clear need to take action to consciously build knowledge, trust and respect across the whole program, including all levels of staff and all sites. This will help to improve the culture overtime and support the retention of top talent, and attract new talent into the program.

10 Note: The CSIC report from 2012 was only referencing the General and Birchmount site, as it was written before the Centenary site was merged to form SHN. All references to the CSIC report are only relevant to the General and Birchmount sites.

Recommendation 6:

SHN, and the Women and Children’s program specifically, develop opportunities for staff, physicians and clinicians across the program to meet one another, and build a stronger community over time.

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In addition to building a stronger culture for the program and addressing some of the challenges that currently exist, the Women and Children’s program needs to invest and take targeted action to develop a high-functioning team across the program. This will likely involve adopting some proven methodologies and engaging in robust programs that will help to shift the culture and improve the overall functioning of the program team. For example, the program should consider implementing the Team STEPPS and/or MOREOB program.

Obstetrical Nursing, as a practice discipline, is complex and situational. The skills of labour and delivery nurses range from coaching a women through natural labour to recognizing and responding to critical cases that require immediate life sustaining interventions for both mom and baby. While many consider labour a natural process, nurses require the knowledge and skills to deal with both complications of the mother as well as the fetus in utero and newborn. Clinically expert nurses are distinguished from their colleagues by their often intuitive ability to efficiently make critical clinical decisions while grasping the whole nature of a situation. Because of their superior performance, expert nurses are often consulted by other nurses and relied upon by physicians to recognize subtle changes with patients and initiate appropriate action to prevent adverse events. In line with current Canadian nursing workforce trends, an increasing proportion of nurses are retiring resulting in an influx of novice nurses. Novice nurses, those with less than 2 years of practice experience have formal education but limited practical experience. Expert practice develops as nurses gain experience in a specialized practice setting, reflect on and learn from their experience. The skill mix of novice vs. experienced nurses during patient care can be a concern. A paucity of nursing literature recognizes that a staffing mix of 50% novice nurses can impact quality of care as compared to hospital units that have 20% novice nurses.

Recruitment and retention is particularly challenging for the program in its current state. It has been difficult to retain and recruit nurses into the program. As is evidenced by the data provided, the Birchmount has a particular challenge retaining experienced registered nurses (RN’s) within the program. This results in having a higher percentage of new nurses with minimal experience. While many of the previous recommendations will also impact recruitment and retention, the program should develop a strategy to directly address the challenge and improve rates over time.

Recommendation 7:

The Women and Children’s program take targeted action to develop a high-functioning team, across the program.

Recommendation 8:

The Women and Children’s program should develop a strategy to improve recruitment and retention amongst clinicians and physicians.

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Theme: Physical environment

In order to support Recommendation 1, the consolidation of Birthing and Core Paediatrics at the Centenary and General sites, SHN will need to undertake a detailed assessment of the infrastructure changes that will be required. This review should be done in conjunction with the other areas of the hospital who may be impacted by the changes.

The Women and Children’s program should invest in developing more family friendly environments for the patients that they serve. For example, provide breastfeeding rooms so that new moms are able to have privacy when they are learning to breastfeed; develop spaces that are more comfortable for kids, so they are able to feel more at home in the environment. These changes are intended to improve the overall patient care and improve the experience that patients and their families have at SHN.

Theme: Communications and marketing

The new public brand and name for SHN provides a great opportunity for the Women and Children’s program to reposition itself within the community. Recognizing that there have been challenges with the public image of the hospital in the past, it will be particularly important to be clear about how the program has changed and what is now has to offer.

Despite the issues of the past, there is a clear sentiment amongst the program team, that ‘if you build a great program, people will come’. Given this, it is clear that the first order priority must be to build an exceptional Women and Children’s program at SHN. Following this, there is also a need to improve communications and marketing, and develop channels to build a brand for the program in the community, and communicate evidence of the great program out to the community.

The CSIC report from 2012 highlighted the need to proactively market the program to the community; this is a recommendation that still holds true today. The results of the primary care physician survey also emphasized this point; multiple physicians noted that while they were familiar with the one off services that SHN offers, they did not know that a full Women and Children’s program existed. Given this, it is clear that while the first priority must be to improve the quality of care, a clear communication and marketing strategy is crucial to ensure there is knowledge of the program in the community.

SHN, and the Women and Children’s program specifically, should also continue to seek to learn more about the women and children in the community that they are looking to serve. By better understanding the needs and desires of those in the community, the program can continually iterate and evolve to meet emerging needs.

Recommendation 9:

SHN will undertake a detailed assessment of the infrastructure implications of the clustering of services, including space, renovation and equipment impacts, and any secondary impacts on other services.

Recommendation 10:

The Women and Children’s program will invest in developing patient and family friendly environments to improve patient care and the overall experience of patients and their families.

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Since health care is important to everyone and we know our community and patients have a vested interest in their local system, we have engaged the services of Navigator Canada’s leading high stakes public and communication strategy firm, to craft a comprehensive strategy for the roll out of this report. Specifically, Navigator has prepared proactive and reactive communications materials to solve any complicated public affairs challenges that may arise from this report.

Theme: Service delivery processes

In light of the merger in 2016 and the recommendations put forward in this report to consolidate birthing and core paediatrics onto two sites, and to develop a new medical governance model (refer to Recommendations 1 and 4) there is a pressing need to reassess the program processes that exist. The process review should seek to understand what processes or ways of working exist across all three sites, what does best practice dictate, and therefore, how can the processes be adapted to reflect each site’s unique needs while also adhering to best practice. This is also particularly important to help ensure safe and seamless transitions of patients across services and sites.

While the review should include all processes, particular attention should be paid to the transition processes, as they will be significantly impacted by the changes. For example, a few specific processes include:

• Transfer protocols: these protocols will need to be reconsidered given that birthing and core paediatrics will only be delivered at the Centenary and General sites

• Emergency department (ED) protocols: these protocols will need to be adapted to ensure that paediatricians, and other subspecialties, are able to be reached for a consultation

• EMS protocols for transfer to the ED: these protocols will need to be adapted given that patients that may need immediate obstetrics or paediatrics support should likely be redirected to the Centenary or General sites

The review of the service delivery processes should look to build on the strength of the program at each site, and together develop consistent processes for the program.

Recommendation 12:

The Women and Children’s program, in conjunction with related programs, undertake a review of all care delivery processes to ensure safe and seamless transitions of care required to move forward with Recommendation 1.

Recommendation 11:

SHN, and the Women and Children’s program specifically, actively market the program within and outside the hospital. Connections be made with the community to improve their overall knowledge of what the program has to offer, including the specialty programs that exist.

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Section 4.0: Implementation and Transition Planning

Implementing the recommendations outlined in this report will require significant time and effort, and will require continued leadership from across the organization. Throughout the history of the Women and Children’s program there have been a number of instances where change was about to happen, but was stalled for one reason or another. The program team and the community will be looking for the organization to make a clear decision and take active steps to further that decision in the short term. There is a strong feeling across the program that there is a need for change, and the program team, especially, will be looking for leadership to be decisive.

Moving forward, the program should specifically consider technology, process, capabilities, facilities and infrastructure and change management. Many of these considerations are included in previous sections. Below is a summary of each of these considerations.

Consideration Description Technology SHN consider investing in new technologies to support the future program and enable

different processes. For example, OTN will be a crucial technology to connect the ED at the Birchmount site with specialists at the Centenary or General sites. Additional technologies SHN should consider are:

▪ Adapting Telehealth ▪ Using ‘My Chart’ technology to provide accessible view of results ▪ Providing virtual access to post-op instructions

Process There is a significant need to develop consistent processes across the three sites to enable better quality of service and ensure best practices are being utilized across all sites. With the change in program structure there will be a particular need to establish processes such as:

▪ ED transfer protocols ▪ Quality improvement processes ▪ Referral process ▪ Coverage models (i.e., anesthesia coverage model)

Capabilities SHN ensure processes and structures are in place to enable access to the right skills and capabilities at the right time, via telemedicine, phone or in-person. This will be important to maintain patient safety and quality standards. It will be particularly important to consider:

▪ Timely and appropriate access to anesthesia, interventional radiology, paediatrics and obstetrician / gynaecology

▪ TeamSTEPPS – consider programs to build consistent quality of service amongst program staff

Facilities and Infrastructure

SHN consider how to make the physical environment that the program is operating out of more family friendly; some specific ideas for this are:

▪ Dedicated in-patient areas for kids (separate from adults) ▪ Making an area of the emergency room more ‘child friendly’ and inviting

Change Management

SHN consider that there has been a significant amount of change within the hospital overall, and the Women and Children’s program, over the last few years. The program consider how to implement the recommendations outlined in this report, while also being sensitive to the experience of front-line staff. It will be important to develop methods and tools to support the program team through the change.

If the Board decides to implement the recommendations in this report, there are a number of important steps that will need to take place that are outlined in the recommendations below.

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Recommendation 13

SHN undertake efforts to secure funding and investment required to move forward with Recommendation 1.

Recommendation 14:

Recommendation 15:

Recommendation 16:


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Section 5.0: Consolidated Recommendations

Themes Recommendations

Program structure and delivery


2. The Women and Children’s program continue clinical services planning to determine how the other clinical programs should be delivered.

Strategic vision 3. The Women and Children’s program, in conjunction with the broader SHN, develop a clear vision that aligns to the SHN clinical service planning that is underway.

Governance 4. The Women and Children’s program develop a unified governance model for the medical side of the program. The program establish a corporate chief and medical director for obstetrics and gynaecology, a corporate chief of midwifery and a corporate chief and medical director for paediatrics.

Clinical care 5. The Women and Children’s program continue to identify leading clinical practices, and actively implement evidence based clinical practices in a consistent manner across the program.

People and culture 6. SHN, and the Women and Children’s program specifically, develop opportunities for staff, physicians and clinicians across the program to meet one another, and build a stronger community over time.

7. The Women and Children’s program take targeted action to develop a high-functioning team, across the program.

8. The Women and Children’s program develop a strategy to improve recruitment and retention amongst clinicians and physicians.

Physical environment 9. SHN undertake a detailed assessment of the infrastructure implications of the clustering of services, including space, renovation and equipment impacts, and any secondary impacts on other services.

10. The Women and Children’s program invest in developing patient and family friendly environments to improve patient care and the overall experience of patients and their families.

Communications and marketing

11. SHN, and the Women and Children’s program specifically, actively market the program within and outside the hospital. Connections should be made with the community to improve their overall knowledge of what the program has to offer, including the specialty programs that exist.

Service delivery processes

12. The Women and Children’s program, in conjunction with related programs, undertake a review of all care delivery processes to ensure safe and seamless transitions of care required to move forward with Recommendation 1.

Implementation and transition planning

13. SHN will undertake efforts to secure funding and investment required to move forward with Recommendation 1.



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Recommendations and Evaluation: Prioritization and implementation timelines

Short-term Recommendations that should be prioritized and implemented in the next 6-12 months


2. The Women and Children’s program, in conjunction with SHN, work to prioritize the activities moving forward. The Program establish processes and metrics to monitor the quality of care provided to patients during the transition and provide regular reports to the SLT, Medical Advisory Committee (MAC) and, through the MAC and Chief of Staff, to the Board of Directors.

3. SHN will undertake efforts to secure funding and investment required to move forward with Recommendation 1.

4. SHN undertake a detailed assessment of the infrastructure implications of the clustering of services, including space, renovation and equipment impacts, and any secondary impacts on other services.


6. The Women and Children’s program, in conjunction with related programs, undertake a review of all care delivery processes to ensure safe and seamless transitions of care required to move forward with Recommendation 1

7. The Women and Children’s program develop a unified governance model for the medical side of the program. The program establish a corporate chief and medical director for obstetrics and gynaecology, a corporate chief of midwifery and a corporate chief and medical director for paediatrics.

8. The Women and Children’s program develop a clear communications plan to support knowledge sharing with hospital stakeholders and the broader community.


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Medium-term Recommendations that should be initiated in the next 6-12 months, but will be implemented over the next 1-3 years, or on an ongoing basis

9. The Women and Children’s program continue clinical services planning to determine how the other clinical programs should be delivered.

10. The Women and Children’s program, in conjunction with the broader SHN, develop a clear vision that aligns to the SHN clinical service planning that is underway.

11. The Women and Children’s program continue to identify leading clinical practices, and actively implement evidence based clinical practices in a consistent manner across the program.

12. SHN, and the Women and Children’s program specifically, develop opportunities for staff, physicians and clinicians across the program to meet one another, and build a stronger community over time

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Section 6.0: Appendix

Overview of Appendix Documents

Section Document Brief Description

A Summary of Key Findings and Recommendations from Reports and Analysis

There are eight seminal reports that were used to develop this composite report. This section includes a summary of each of the seminal reports.

B Deloitte Engagement Summary Report

The report Deloitte developed in December 2018, which was the culmination of a number of engagement activities.

C Steering Committee Terms of Reference

The Terms of Reference for the Steering Committee that was established in 2018 to support Deloitte’s engagement activities.

D Co-Design Data The data that was provided to the co-design session attendees to inform the discussion.

E Internal Staff Survey Questions and an Overview of Responses

The questions that internal staff were asked as part of the internal staff survey that was completed in the fall of 2018 and an overview of responses.

F Primary Care Physician Survey Questions and an Overview of Responses

The questions that primary care physicians were asked as part of the internal staff survey that was completed in the fall of 2018 and an overview of responses

G External Survey Questions The questions that external stakeholders were asked as part of the internal staff survey that was completed in the fall of 2018.

H Wallpaper Exercise A wallpaper exercise that was completed to provide an opportunity for the program team to provide input on the future vision for the program.

I Mode of Transportation Survey

A survey of mothers coming into the hospital site for deliveries was conducted to determine how they travelled to the hospital.

J Women and Children’s Program Vacancies

Data that shows the vacancies within the program.

K Women and Children’s Nursing Staff Skill Mix

Data that shows the relative experience levels of nursing staff across the three sites.

L Interview Questions The interview questions that were used in discussions with program team members by Deloitte in the fall of 2018.

M Focus Group Questions The focus group questions that were used in discussions with program team members by Deloitte in the fall of 2018.

N Co-Design Session Materials (Session 1 & 2)

The materials that were used to facilitate the co-design sessions in the fall of 2018.

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Appendix A: Summary of Key Findings and Recommendations from Reports and Analysis

This section includes a detailed overview of each of the seminal documents that have informed the recommendations and analysis put forward in this report.

Name Author Date 1 Enabling Improvement in the Maternal

Newborn and Child Care Program at The Scarborough Hospital, Report from the External Review

Corpus Sanchez International Consultancy

July 2012

2 Rouge Valley Health System and The Scarborough Hospital Facilitated Integration Process

Rouge Valley Health System and The Scarborough Hospital

November 2013

3 Final Report: Motion 1b Collaborative Rouge Valley Health System and The Scarborough Hospital

January 2015

4 The Report of The Scarborough / West Durham Panel

The Scarborough / West Durham Panel

November 2015

5 Independent External Review of the Obstetrical Program at the Birchmount

External Expert in Obstetrics June 2018

6 Scarborough Health Network Strategic Plan: 2018 – 2023

Deloitte June 2018

7 Future Model of Care – Maternal Child and Paediatrics

Deloitte and Resources Planning Group

September 2018

8 Engagement Summary Report: Future Service Delivery Model for Women’s and Children’s

Deloitte December 2018

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#1

Name: Enabling Improvement in the Maternal Newborn and Child Care Program at The Scarborough Hospital, Report from the External Review Author: Corpus Sanchez International Consultancy Date: July 2012

In 2012, Corpus Sanchez International Consultancy (CSIC) completed an external review of the Maternal Newborn and Child Care program at The Scarborough Hospital (TSH). The CSIC team was asked to review data and meet with staff at all levels, all disciplines and from both sites, and develop recommendations to improve the program moving forward. The CSIC team did not seek input from the Central East LHIN or community agencies, but instead focused on systems that TSH controls.

Overall, the review found that while the hospital had some excellent outcome indicators such as Caesarian section and VBAC rates as evidence of the quality of maternity care provided there are opportunities for the program to improve. The report’s findings were summarized into seven key themes.

Theme 1: Inertia and lack of integration progress

Since the merger of the two hospitals in 1999, they found that there has been an integration of the program leadership and that most standards and procedures are common, but there has been minimal impact on front line staff, and that the two sites largely work in separate silos. As well, they found there to be a lack of respect between the staff at the two sites, which was demonstrated by disrespectful language and a ‘we versus them’ mentality.

Theme 2: To consolidate or not

The discussion of whether to consolidate the program from two sites to one site has been a frequent discussion point since the merger in 1999. The continuing discussion and lack of progress made for a very challenging environment at both sites. They found that the lack of consolidation may be inhibiting the creation of a stronger presence for TSH in maternal/child care in TSH, the LHIN and the GTA. It was clear that the integration would have many pros and cons, and that it would be disruptive in the short-term, however many people did view it as a source of opportunity.

Another source of discussion was, if the program is consolidated on one site, which site should be chosen. Below is a brief summary of some of the considerations when considering each site.

TSH-General site:

• Embolization services would be available plus the depth of specialty services in medicine and surgery may be greater than at TSH-Birchmount site to support those patients who become very ill

• TSH-Birchmount would be diminished and would require a flagship program to maintain its profile • Community near TSH-Birchmount would be bitterly opposed to the loss of the program, especially

without any credible replacement focus • Potential of the ‘furnace effect’; everything moves at a fast pace and the intensity of work can burn out

the staff

TSH-Birchmount site:

• There may be secondary impacts in that some other services might need to be relocated to TSH-General; this could include some surgical services

• The room necessary for embolization could not be re-established at the TSH-Birchmount because of the significant cost; those who need the service would need to be transferred

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• The Scarborough community might be very supportive of consolidating at TSH-Birchmount whereas the community around TSH-General might be satisfied the majority of other services are still available at TSH- General

• The current reputation of the TSH-Birchmount might push more women who would normally choose the TSH-General to go somewhere other than TSH-Birchmount

Overall, the review team generally supported consolidation at one site however, more work would need to be undertaken to determine the impacts and feasibility.

Theme 3: The importance of team in the clinical care environment

The review team’s main finding was that there is minimal linkage or teamwork between the TSH-General and TSH- Birchmount sites. The staff across the two sites work independently from each other. They found that staff from both sites often remark about how the other site seems to be better off and that they get more resources. Comments like this were particularly common from people who had never visited the other site.

TSH-Birchmount staff continue to be concerned that their program will be closed, which has been discussed numerous times in the past. There are a few other factors that also make the situation at TSH-Birchmount difficult; it was a site for SARS cases during the epidemic, and there were maternal deaths in between 2007 and 2012 that were highly publicized in the media. These events have caused damage to the sites’s reputation and may have contributed to a disproportionate decrease in deliveries compared to neighbouring institutions.

Theme 4: Create a vision

A clear vision for the program is lacking because of the uncertainty regarding consolidation. It will be important to resolve the question of consolidation so that a more solid foundation for the program can be established and the program can build a clearer vision. Even in the absence of a direction on consolidation, TSH should develop a clear vision for the program moving forward, and involve staff in this process.

Theme 5: Quality of care

Overall, staff perceived the quality of care at both sites to be very good. The data demonstrated that most of the key quality measures were consistent with peer hospitals. They also noted that the participation in the MoreOB program likely contributed positively to the overall patient safety culture that exists. While staff viewed the overall care to be very good they did note a few issues that could contribute to an increase risk (i.e., appropriate planning for the safest intervention environment for high risk cases, ongoing competencies of technical abilities must be reviewed especially with low volumes, current critical mass at each site can be problematic during ‘crisis mode’ when sufficient people to fill in urgently cannot be found, etc.). The review team found that there may be potential to use data and audits to further improve quality standards.

Theme 6: Accountability in clinical care

The review found that there were multiple incidents where individuals, medical and non-medical, did not act in a manner that most would consider best practice. These incidents were not critical in and of themselves, but they do reflect some slipping of standards and a lack of accountability for the use of best practice. Accountability for behaviours could definitely be improved in the program. Part of this is ensuring that people understand what the expectations are, and the other part is holding them accountable on a routine basis for any behaviour that does not meet acceptable standards. The review team highlighted a need to make standards known and to monitor compliance, and address any issues as soon as they arise.

Theme 7: Operational environment

The review team found that staffing for the mixture of units in the program can be challenging because of the unpredictability of obstetrics and the poor efficiency of small NICU and paediatric units.

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#2 Name: Rouge Valley Health System and The Scarborough Hospital Facilitated Integration Process Author: Rouge Valley Health System and The Scarborough Hospital Date: November 2013

In March 2013, the Central East LHIN Board passed a motion directing Rouge Valley Health System and The Scarborough Hospital to participate in a Facilitated Integration process. The purpose of the process was to design and implement a Scarborough Cluster hospital service delivery model – through integration of front-line services, back office functions, and leadership and/or governance – in order to improve client access to high quality services, create a readiness for future health system transformation and make the best use of the public’s investment.

The Integration Leadership Committee (ILC) discussed and debated a variety of approaches to integration including, simple cooperation through to a merger of the corporation. The ILC concluded that the most effective way to evaluate the potential benefits of integration was through a high-level opportunity analysis of what would be possible with a merger of the two organizations. It was the view of the ILC that a merged entity offered the greatest likelihood of achieving the benefits of integration because of a single management and governance accountability structure.

The review demonstrated that the status quo is not an option because:

• Both hospitals are facing flat or negative Provincial funding (similar to all hospitals) – combined with increasing patient volumes, complexity and a growing population

• Both hospitals are facing inflation of 4-5% with flat revenue and a requirement to balance their budget

• Both hospitals have weak balance sheets with constrained liquidity and cash flow, although one has cash resources and has not drawn on its short term borrowing facilities

• Both hospitals have varying, but constrained or limited financial means to replace aged equipment and buildings and to invest in improving services, although investments have been made over the last 5 years

Using the framework of the four guiding principles – Collaboration, Accessibility, Sustainability and Excellence (CASE) – significant opportunities and benefits were identified to improve care, access and value. Stakeholder input and the output of the Working Groups provided concrete ideas that would benefit the communities of Scarborough and West Durham. The ILC determined that these opportunities can be achieved from designing a strong, single hospital with a new brand and a shared vision. Together the two hospitals can position themselves to better respond to the needs of their communities, address fiscal challenges more effectively, and take advantage of the fast changing health care environment.

A number of stakeholders emphasized the importance of creating a hospital system to support the attraction and retention of talented physicians, clinicians and care providers. A strong hospital system is an essential component of a strong, local health care system. Some stakeholders summarized the new hospital system as a “magnet hospital” for patients, donors, physicians, clinicians, staff and community partners.

There were also determined to be financial benefits to the merger of the two hospitals, albeit not in the short- term. The analysis indicates cumulative savings by the end of year three in the $13 to $15 million range providing a payback of three years (post the 3-year Implementation Phase) on the needed upfront investments. Consistently, stakeholders described a vision of a new hospital system that includes significant facilities renewal and expansion for the Scarborough and West Durham communities. Without these investments in facilities infrastructure, the merged hospital would have some of the oldest operating rooms in Ontario (circa RVHS and TSH Preferred Integration Plan – Final Report Page 30 1957), undersized emergency departments and physical constraints that would limit additional economies of scale and operating efficiencies. With improved facilities and capacity, the financial opportunities could increase to a total of $41 million.

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Along with benefits always go associated risks. These have been well articulated by stakeholders. One significant risk is the challenge of implementation. This can be mitigated through strong governance and executive and physician leadership. The selection of a strong Board of Directors with a broad range of skills and expertise and the capacity and willingness to devote substantial time and energy to the integration process over the next three years will be key to success. This Board must also in turn select a strong and experienced CEO and Chief of Staff to lead and manage the organization going forward.

A merged hospital would be the seventh largest of over 150 in Ontario. It would rank (based on 2011/12 figures) first in surgical cases and second in overall emergency department visits. With this size would come influence, which would not only benefit the residents of Scarborough and West Durham. A merged hospital would continue to provide regional programs; it would strengthen existing programs; and it could develop new or enhanced services for the community through Centres of Excellence, clinics and partnerships with other providers.

The merger of the two organizations has the potential to create a hospital system that is positioned to succeed through the broader health system transformation, to deliver increased quality, access and range of services not currently available to the citizens of Scarborough and West Durham. Overall, the strength of this value proposition is not in the short-term, but rather in the longer-term in which the hospitals are able to position themselves to better serve their communities, create a shared vision for a transformed local health care system, address fiscal challenges together, and take advantage of the fast changing health care environment.

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#3

Name: Final Report: Motion 1b Collaborative Author: Rouge Valley Health System and The Scarborough Hospital Date: January 2015

On March 26, 2013 the Central East Local Health Integration Network (LHIN) passed the following motion (Motion 1b) and directed The Scarborough Hospital (TSH) and Rouge Valley Health System (RVHS) to fulfill the following: “…in partnership with the Rouge Valley Health System, local stakeholders and physician leaders, TSH is to develop a Service Delivery Model for Maternal‐Child‐Youth (MCY) services (which includes obstetrics, neonates and pediatrics) for the Scarborough Cluster. Additionally, consider a LHIN‐wide centre for Advanced in‐patient Paediatric care as recommended in the 2009 Hospital Clinical Services Plan* co‐located with the advanced Level 2c in‐patient Neonatal centre and sited in the Scarborough cluster. The Centre will act as a LHIN wide resource and be accountable for coordinating sub‐specialty programs to meet the needs of the North East, Durham and Scarborough clusters. The deliverables of this Service Delivery Model for Maternal‐Child‐Youth (MCY) services process will include:

• Providing an overview of the current state of Maternal‐Child‐Youth services within the Scarborough Cluster; Providing a future state for an Integrated Maternal‐Child‐Youth Service Delivery Model in the Scarborough Cluster (see pg.12 “Summary of Motion 1b Deliverables and Final Report Content for details)

Be it resolved that the LHIN approves an amendment to the March 27th 1b motion and confirms that the timing be realigned with the Scarborough Cluster Hospitals integration planning process with the clear expectation that a proposed integrated service delivery model for Maternal Child Youth (MCY) services in the Scarborough cluster and a LHIN wide advanced Neonatal and paediatric program, which will consider the findings of the Expert Panel and be developed in partnership with stakeholder and physician leaders, be submitted to the LHIN no later than March 2014.”

A collaborative working group was established to move the motion forward. It included stakeholders from each organization – the group was intended to ensure a balanced perspective across the Scarborough region and create linkages to the broader Central East region. The membership was composed of:

• Staff, physicians, and midwives from RVHS and TSH • Representation from the Central East LHIN • Representation from the Central East LHIN Maternal Child Working Group • Health system partners • Community members

In light of the scope and complexity involved in integrating neonatal, paediatric and maternal services a phased approach was adopted:

• Phase 1 – Creating the Enablers of Success • Phase 2 – Designing the Model • Phase 3 – Implementing the Model • Phase 4 – Evaluating the Model

The working group reviewed and assessed three key service delivery models. The three models were:

• TSH Centre for Regional Advanced Neonatal and Paediatric Care • RVHS Centre for Regional Advanced Neonatal and Paediatric Care • Central East LHIN Integrated Regional Advanced Neonatal and Paediatric program

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After assessing each of these models against a set of key evaluation criteria the working group did not come to a consensus on a preferred model. However, both organizations recognized the opportunity to improve access to Regional Advanced Paediatric and Neonatal care in Scarborough and the Central East LHIN. The Board’s of both TSH and RVHS approved separate and different recommendations to the Central East LHIN.

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#4

Name: The Report of The Scarborough / West Durham Panel Author: The Scarborough / West Durham Panel Date: November 2015

In March 2014, a merger between The Scarborough Hospital (TSH) and Rouge Valley Health System (RVHS) did not proceed as had been originally planned. In early April 2015, Dr. Eric Hoskins, Minister of Health and Long-Term Care, created the Scarborough/West Durham Panel to develop a plan for how acute healthcare programs and services should be configured to better meet the needs of residents in Scarborough and West Durham.

Over a six month period, the eight member Panel, composed of senior healthcare leaders and two community representatives, conducted extensive stakeholder engagement including more than 40 consultations, nine focus groups, surveys, two town hall meetings and six site visits, and reviewed capacity plan information, as a basis for developing a recommended path forward.

Early discussions with the Boards and management of TSH and RVHS and community stakeholders highlighted the need for the Panel to consider the broader context of health service delivery across the care continuum, in Scarborough and Durham, to ensure that recommendations developed for the acute sector would advance a system of care for local residents. This expanded scope was supported by the Ministry of Health and Long Term Care (MOHLTC) and Central East Local Integrated Health Network (Central East LHIN).

Many organizations and individuals made themselves available for consultations and submitted documents for Panel review and consideration. Several key messages were heard consistently from stakeholders consulted, including but not limited to: • Scarborough and Durham are in many ways different communities. Each has its own vulnerable populations,

patient flows, growth patterns and care delivery pressures;

• A clear strategic direction is required for acute program and service delivery across both regions and it must be acted upon soon to achieve the service integration necessary for excellent and equitable care;

• Existing governance and management structures do not optimally or comprehensively support integrated service planning and delivery; and,

• Capital investment in these regions is needed to provide equitable access to care for the residents of Scarborough and Durham.

The report outlines key findings from the Panel’s consultation process, and includes 12 recommendations in the following areas: governance and structure; enhanced integrated care delivery; capital investment; LHIN boundaries and relationships; and, implementation plan.

The report specifically highlights their findings with regards to the maternal, child and youth services.

“Maternal, child and youth services (MCY) have been a source of controversy and conflict for many years in Scarborough. Initially, conflict revolved around the proposed relocation of services between the Birchmount (formerly Grace) and the General Sites of TSH. Public and provider opposition led to the appointment of an Expert Panel that held hearings and ultimately rejected the service moves proposed by TSH and left the status quo in place, with maternity services offered at both sites. The Central East LHIN also intervened as a sequel to its 2009 Clinical Services Plan. It sought a facilitated consensus between TSH and RVHS to create Advanced MCY Services. No consensus emerged on a preferred option. In this Panel’s view, the ongoing dispute over MCY services needs to be resolved as a matter of priority by the LHIN and the future health corporation(s).”

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Depending on plans for future LHIN boundaries and relationships, Scarborough may become more closely aligned with services in the Toronto Central LHIN. This would allow Scarborough to both create internal Centres of Excellence among its sites, and better align its resources with other organizations in the Toronto Central LHIN.

#5

Name: Independent External Review of the Obstetrical Program at the Birchmount Date: June 2018

An external expert in Obstetrics conducted an analysis of safety related concerns at the Birchmount and an extensive review of the delivery of obstetrical services at the newly integrated Scarborough and Rouge Hospital (SRH). Due to the declining birth volumes, the inability to attract women to the site, and concerns about the provision of safe and effective care for those who give birth at the Birchmount, the expert concluded that obstetrical services should be phased out at the Birchmount.

The review notes that significant efforts have been made to try and change the culture of care and affect positive change, but the problems persist. The external expert notes that many challenges may accompany his recommendation but that with clarity of vision, consensus building and strong leadership, these challenges can be met.

Furthermore, the benefits of this change can outweigh the negative impacts. The consolidation on two sites will continue to offer the women of Scarborough options. Further, the expert notes that higher volumes, dedicated anesthesia and paediatrics and the availability of surgical assists will facilitate improved outcomes and safety. Higher volumes will also permit the recruitment of maternal fetal medicine specialists and further inform the provision of care for higher acuity patients, and call schedules including second on call, will be attainable with an increased critical mass of obstetricians.

The external expert in Obstetrics concludes that what is needed moving forward is the desire on the part of the medical teams to move ahead with the provision of safe, effective, and equitable care for the women of Scarborough.

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#6

Name: Scarborough Health Network Strategic Plan: 2018 – 2023 Author: Scarborough Health Network Date: June 2018

In June 2018, Scarborough Health Network’s new strategic plan was completed. The strategic planning process provided a unique opportunity to meet the current and future challenges facing the Scarborough population and health system, to create momentum for change, and to announce a bold vision and path forward. The strategic plan strived to remain authentic to the legacy and history of SHN and represents an important opportunity to advance the organization.

The strategic plan process focused on understanding and better defining SHN’s role in the health system, SHN’s commitment to patients and families, and SHN’s commitment to professional staff and employees. Each of these aspects of SHN’s role informed the vision and strategic direction for the hospital moving forward.

Below is a snapshot of the Strategic Plan:

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#7

Name: Future Model of Care – Maternal Child and Paediatrics Author: Deloitte and Resources Planning Group Date: September 2018

As part of the Master Planning activities underway, an assessment was done to determine what the future model of care should be for SHN. The analysis was completed by Resources Planning Group (RPG), in conjunction with Deloitte.

The foundation of Future of Clinical Service Delivery at SHN is grounded in the integration of service delivery across the continuum of acute and community care. The ultimate goal of SHN is to provide equitable care delivery in the Scarborough and Central East LHIN region; patients will have access to the same high quality care irrespective of where and how they access health services. To serve the unique needs of the Scarborough community and Central East LHIN, Future Clinical Service Delivery Planning at SHN therefore embraces a health systems perspective and places an emphasis on integrated primary care and community-based services.

SHN champions a patient supportive and inclusive approach that provides timely access to the right care, supports the patient in their journey to optimal health and includes them as active members in the development of care plans and delivery of care. The organization is committed to working with community partners to deliver integrated care closer to home; to supporting patients and their families through health education and transparency; and to planning for sustainable health service delivery through illness prevention and health promotion.

SHN embraces the changing role of the community hospital and aims to provide services that will meet the multifaceted needs of patients both within the hospital and in the community. As resources and service delivery shift to support patients in the home and community, those patients who access services in hospital are becoming increasingly complex. This complexity encompasses both higher acuity patients, and patients living with and managing multiple co-morbidities. To serve this population, SHN aspires to take a dual pronged approach; to take a population health perspective to focus on early detection and intervention, and to expand the scope and acuity of services provided in hospital.

SHN is inspired by the changing landscape of the future of care delivery and understands its importance to successfully implement population health services, provide care closer to home and expand its acute care services. Future healthcare systems will be built on innovative technologies and care models, as well as collaborative partnership models. The aforementioned have impacts on how, when and where health services are delivered and thus will have tangible impacts on service utilization. SHN has embraced and planned for the changing landscape throughout the capital planning process.

Recognizing its role in the larger health system, SHN has embraced and incorporated foundational elements of the Scarborough/West Durham Panel Report, the Central East LHIN Integrated Health Service Plan and the Patients First: Action Plan for Health Care. To ensure regional coordination, additionally, to enhance the integration of services and minimize redundancies, SHN has consulted with surrounding health service providers. An integrated and collaborative approach to service delivery will facilitate SHN’s ability to support the provincial priorities including accessibly and timely healthcare, home care and mental health and addictions care.

The continued success of women and children’s care at SHN will evolve and expand into a Strengthened Program of Excellence for Women and Children. The program aspires to provide holistic care as a fully integrated program and to support patients and their families across the continuum of care from conception, birth, early life, and childhood through adolescence. Patients and their families will be supported to achieve positive health outcomes throughout transitions and through high quality and continuous care. It is the goal of the Women and Children’s program to provide a comprehensive scope of services and serve patients and their families within Scarborough.

The model of care for each sub program are founded on the principles below.

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Maternal Child and NICU

1. Patient/Family Supported and Inclusive Care

The primary objective of a Strengthened Program of Excellence for Maternal Child and Pediatric Health is to promote the health and wellness of mothers and babies and to provide care that supports their autonomy of choice. Quality care, positive health outcomes and an individualized approach are paramount to helping patients and their families as they engage in family planning, conception, through to antenatal care, labour and delivery and postnatal care.

2. Health Equity and Improved Access to Care

The program is committed to improving access to the services it provides and envisions doing so through expanded community based services and a multidisciplinary team approach. Community based clinics will provide culturally sensitive care in multiple languages to promote health equity. Care will be provided by a range of care providers including obstetricians, pediatricians, family physicians, midwives, obstetrical and pediatric nurses and advanced practice nurse practitioners.

Pediatrics

1. Patient/Family Supported and Inclusive Care

The care provided within the program recognizes the strong relationship between the patient and the family unit, and that both must be supported to achieve optimal health outcomes. Patients and families will be actively included in the care planning and care delivery process taking into account cultural, ethnic and socioeconomic needs. The patient and family will be supported throughout their journey across the spectrum of outpatient and community based care to inpatient services. The program is committed to ensuring a child friendly experience.

2. Care Closer to Home

In partnership with the Hospital for Sick Children, the scope of services provided will be expanded to support patients and families within the Scarborough and Central East LHIN community. The strengthened pediatric program will support expansion to include child and youth mental health and pediatric complex care.

Preferred Model for Future Care Service Delivery

The future service delivery model of the Women and Children’s program is still being considered. While the current Master Plan vision will see the equal distribution Maternal, NICU and Pediatric services across two sites the program is committed to reviewing a one site model once the short- medium term service model is finalized. In this model, it is imperative that pediatric services be co-located with obstetric services.

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#8

Name: Engagement Summary Report: Future Service Delivery Model for Women’s and Children’s Author: Deloitte Date: December 2018

Deloitte was engaged in September 2018 to work with the Women and Children’s program to build on the numerous previous reviews, engagements, and studies that have taken place, and help the organization coalesce around the preferred direction for the Women and Children’s program moving forward. Stakeholders, both internal to SHN and external, have been sharing ideas and having discussions about the program for years – this was an important step to help key stakeholders within the organization gain alignment on the preferred direction moving forward.

This was accomplished through a consultative approach that was informed by the findings from previous reports and analysis that has taken place. Specifically, the findings from the following reviews and analysis (see below) was shared with the stakeholders as part of a series of co-design sessions that brought internal stakeholders together to discuss and align on the preferred direction for the future state model. The information within the following documents served as the evidence base by which the internal stakeholders developed their preferred direction for the future of the program.

• Co-design session participant discussions were informed by the following reviews and analysis: o External Expert in Obstetrics Report; o Master Planning data, including future state projections; o Capital Planning estimates; and o Other data, including market share, delivery rates, and information about the Scarborough

community.

After significant discussion amongst the co-design session participants, the group was able to arrive at three primary outcomes that summarize their preferred direction. The three outcomes are:

1. The co-design session attendees agreed that in the short- and medium-term (1-10 years), the Birthing and Core Paediatrics5 cluster move to a two-site model at the General and Centenary sites.

2. The co-design session attendees also agreed that while the remaining services (Ambulatory Outpatient, Prenatal, Postnatal and Gynaecology) can be provided at all or any of the three sites, further work will need to be undertaken to determine where they should be delivered.

3. The long-term future model for the program was not agreed upon by the co-design session attendees; there is a need to continue this discussion as part of the Master Planning activities underway.

Outcome 1: The co‐design session attendees agreed that in the short‐ and medium‐term (1‐10 years), the Birthing and Core Paediatrics cluster should move to a two‐site model at the General and Centenary sites.

Consensus Position

• The co-design session attendees agreed that the current model of providing Birthing and Core Paediatrics services at three-sites was not sustainable in the long-term and was having negative impacts on the quality of service, patient safety and provider satisfaction; given this it was agreed that the current three- site model should not be maintained

5 Core Paediatrics includes: Paediatric Inpatient Medicine, Paediatric Inpatient Surgery and Paediatric Day Surgery

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• While some co-design session attendees believed that moving to a one-site model should be the preferred approach, they understood the data provided and agreed that it would not be feasible in the short- to medium-term to consolidate services on one-site

• The co-design session attendees agreed that the Birchmount was likely not the best option for one of the two sites, due to the decline in market share and the significant decline in deliveries, despite recent investments and program enhancements

• Therefore, co-design session attendees agreed that the General and the Centenary would be the best sites from which to deliver the Birthing and Core Paediatrics cluster of services

• This finding is also supported in the external expert in Obstetric’s clinical review, which states, “Based on my review, it is my opinion that obstetrical services should be phased out at the BM (Birchmount). Declining birth volumes, the inability to attract women to the site and a very real and present concern for the provision of safe and effective care for those who give birth at the BM are the primary reasons.”

Other Opinions and Considerations

• Some co-design session attendees argued that Paediatrics Day Surgery should not be included in the Birthing and Core Paediatrics cluster. The argument was that a paediatrician is not required to be on site when performing Paediatric Day Surgery, and therefore does not have to be co-located with the remaining Birthing and Core Paediatrics cluster

Outcome 2: The co‐design session attendees also agreed that while the remaining services2 (Ambulatory Outpatient, Prenatal, Postnatal and Gynaecology) can be provided at all or any of the three sites, further work will need to be undertaken to determine where they should be delivered.

Consensus Position

• The co-design session attendees agreed that the remaining services (Ambulatory Outpatient, Prenatal, Postnatal and Gynaecology) can be provided at all or any of the three sites, given that they are not dependent on the services provided as part of the Birthing and Core Paediatrics cluster

• It was also agreed that where services are provided should be determined with a clear understanding of the vision for each of the three sites, and specifically the vision for the Birchmount

• It was also agreed that additional work will need to be undertaken in order to better understand the vision for each site, and therefore what services should be delivered by each site in order to provide the best possible service for the community and the highest quality patient care

Other Opinions and Considerations

• Some co-design session attendees argued that if the Birchmount is not going to have the Birthing and Core Paediatric cluster services, than all other obstetrical and paediatric services should also not be provided at the Birchmount. The intention was that this would make it more clear to the community that there are no obstetrical or paediatric services at the Birchmount, and would help clearly delineate the roles of each hospital

• Other attendees – on the other hand – argued that it would be very helpful to have some of the obstetrical and paediatric services (i.e., prenatal, postnatal services, and/or paediatric outpatient clinics) at the Birchmount because it could improve accessibility for the neighborhoods North of the 401

• Some attendees raised the possibility of the Birchmount becoming a centre for outpatient women and children’s health by providing Gynaecology services and some pre- and post-natal services

• When determining how the remaining services are delivered, it is important to also consider what capabilities the services need to be able to access. In the case of ambulatory clinics they will need to be

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able to access core hospital diagnostics and multidisciplinary teams (nursing, allied health, lactation consultants, mental health); gynaecology will need to access core hospital diagnostics, multidisciplinary teams, the OR, and interventional radiology

Outcome 3: The long‐term future model for the program was not agreed upon by the co‐design session attendees; there is a need to continue this discussion as part of the Master Planning activities underway.

Given that the long-term future model will need to be determined in conjunction with the Master Planning activities, it was not the focal point of the discussion during the co-design sessions.

APPENDIX B

A

EN G A G EMEN T SUMMA RY REPO RT – F U T U R E S E RV I C E D E L I V E RY M O D E L Women and Children’s Program

CONFIDENTIAL – DO NOT DISTRIBUT

ABOUT THIS REPORT The purpose of this report is to present the findings from engagement that was undertaken to develop a future state operating model for the Women and Children’s program at Scarborough Health Network (SHN). The findings outlined in the report represent the perspectives that were shared by numerous stakeholders, based on their clinical experience, knowledge of the Women and Children’s program, and their commitment to building the best possible program for the women and children of Scarborough.

This report is intended to communicate the preferred direction based on stakeholder engagement in October and November, 2018. This report will also support the subsequent decision making bodies in their work moving forward, including the Steering Committee, Senior Leadership Team, the Medical Advisory Committee, the Expert Advisors, and ultimately, the Board of Directors.

TA BLE OF CONTENTS

Project Context 3

Project Objectives & Approach 8

Overview of the Current State Findings 12

Context for Designing the Future State Model 18

Key Consultation Findings & Preferred Direction 24

Implementation Considerations 34

Appendix 36

2

CONFIDENTIAL – DO NOT DISTRIBUTE

PROJECT CONTEXT

3

PROJECT OVERVIEW • This project was intended to build on the numerous previous reviews, engagements, and studies that have taken place, to help

the organization coalesce around the preferred direction for the Women and Children’s program moving forward. Stakeholders, both internal to SHN and external, have been sharing ideas and having discussions about the program for years – this was an important step to help key stakeholders within the organization gain alignment on the preferred direction moving forward.

• This was accomplished through a consultative approach that was informed by the findings from previous reports and analysis that has taken place. Specifically, the findings from the following reviews and analysis (see below) was shared with the stakeholders as part of a series of co-design sessions that brought internal stakeholders together to discuss and align on the preferred direction for the future state model. The information within the following documents served as the evidence base by which the internal stakeholders developed their preferred direction for the future of the program.

• Co-design session participant discussions were informed by the following reviews and analysis: o External Expert in Obstetrics Report; o Master Planning data, including future state projections; o Capital Planning estimates; and o Other data, including market share, delivery rates, and information about the Scarborough community.

4

2008 – There were two critical events at theScarborough Grace that significantly impactedthe way the hospital was perceived.

2015 – The MOHLTC Panel on the Integration in Scarborough and West Durham found that thematernal child and youth program has been asource of conflict for many years.

2018 – External expert in Obstetrics is asked to undertake a review of the obstetrics program and resolves that many of the previous challenges that have been raised have not been addressed and “the current situation is not sustainable”.

KEY HISTORICAL EVENTS As noted, there have been numerous reviews, engagements, and reports over the last decade that led SHN to undertake this project. Below is a brief summary of some of the most poignant events and reviews in SHN’s recent history.

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1998 - The Scarborough Centenary Hospitalmerged with the Ajax and Pickering GeneralHospital to form the Rouge Valley Health System (RVHS).

1999 - The Scarborough Grace and ScarboroughGeneral hospitals merge.

2012 – The Corpus Sanchez review found thatthe quality of care was perceived to be generallygood, although there were issues identified toimprove patient safety. Due to issues surroundingdeclining market share and financialsustainability, the review suggested consolidatingservices to one site.

2013 – Central East Local Health Integration Network (LHIN) passed the motion (Motion 1b) for The Scarborough Rouge Hospital and RougeValley to develop a Service Delivery Model for MCY services for the Scarborough Cluster.

2016 – The Scarborough Hospitals and Centenarysite (formerly Rouge Valley) merge.

2017 – Master Planning activities begin to chart the path for the next 10-20 years for theScarborough Health Network.

TIME HORIZON FOR FUTURE S TATE MODEL For the purposes of this project, it was important to contextualize the timeframes that SHN is considering with regards to the future state model of the Women and Children’s program. This project was particularly focused on the short- to medium-term time horizon, as opposed to the long-term, which will be considered as part of the Master Planning activities underway.

Short-term Medium-term Long-term – Master Planning

1-5 years

2019-2023

5-10 years

2023-2028

10-15 years

2028-2033

For the purposes of this document, the future state model is referring to what the program should look like in the short- to

medium-term. In the short- and medium-term the program will need to leverage existing facilities. The long-term

perspective will be addressed through the Master Planning activities that are underway.

8

PROGRAM REVIEW GOVERNANCE MODEL Deloitte’s work – as well as a number of other inputs – are intended to help the Co-Leads of the Women and Children’s program review develop recommendations for the Senior Leadership Team to bring forward to the Expert Advisors, MAC, and ultimately the Board.

Medical Advisory Committee Board Members

The role of the Medical Advisory Committee is to provide expert input and advice to the Board

The Board is the final decision making body; it will make a decision on the recommendation that they are presented with by the Senior Leadership Team.

Senior Leadership Team

Steering Committee Co-Leads of the Review

The role of the Steering Committee is to provide input and advice to the approach and objectives at each stage of the engagement, as well as provide input to the future model of the Women and Children’s program.

The role of the Senior Leadership Team is to review and discuss the recommendations and determine whether to bring them forward to the Board.

Co-design session attendees input and preferred direction*

*Note: the input and preferred direction from the co-design session attendees is an important input into the Co-Leads. The 7 Co-Leads will also consider numerous other inputs from previous reports and analysis.

The role of the co-leads is to review all of the findings from the engagement process, as well as the numerous previous reviews, and to make recommendations to the Senior Leadership Team, as to the best path forward for the program.


PROJECT OBJECTIVES & APPROACH

8

PROJECT OBJECTIVES Deloitte was engaged to support Scarborough Health Network in developing a future state model for the Women and Children’s program.

Deloitte was engaged in September 2018 to work with the Women and Children’s program at Scarborough Health Network (SHN) to co-develop a future state model for the Women and Children’s program with stakeholders and clinical leaders.

The project had four primary objectives:

1. Gain a high-level understanding of the current service delivery model to set the context for future state visioning discussions

2. Engage with stakeholders to gain a common understanding of the current state and the potential opportunities for the future of the program

3. Facilitate co-design sessions with relevant stakeholders to gain consensus on the future Women and Children’s program model

4. Provide high-level recommendations on the profile of the sites delivering the programs and key phased implementation milestones, where relevant

9

PROJECT APPROACH

Deloitte’s work to develop the future state model had three phases: Setting the Stage, Co-Designing the Future, and developing the Final Report. Below is a summary of the three phases.

Weeks 1 - 4 Weeks 5 - 6 Weeks 7 - 10

The objective of ‘setting the stage’ was to garner a holistic view and understanding of the current state of the Women and Children’s program through data analysis, document reviews and stakeholder interviews. Deloitte also developed and aligned on design principles and decision making criteria to use when developing the future state model.

This phase included significant stakeholder engagement, as summarized on the following slide.

The objective of ‘co-designing the future’ was to design and align on the future state model with key stakeholders. The co-design sessions included presentations, group discussions, and breakout discussions to capture all relevant perspectives and input.

The objective of the ‘final report’ – this document - is to provide a detailed summary of the preferred direction for the future state model, based on the outputs of the co-design sessions. This document also includes implementation considerations.

Note: this report frequently references ‘co- design session attendees’. These are individuals who attended the co-design sessions in the previous phase. All co-design session attendees are listed in the Appendix.

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Setting the Stage Co-Designing the Future Final Report

S TAKEH OLDER ENGAGEMENT OVERVIEW Deloitte’s work involved significant stakeholder engagement across all three SHN sites, including facilitated engagement, surveys, data analysis, and other engagement techniques. This engagement was conducted to help develop a clear understanding of the current and future state of the program.

Overview of Engagement Activities Overview of Stakeholders Engaged

Facilitated Engagement (in-person & over the phone)

Surveys

Data Analysis & Review

Other Engagements

Internal Stakeholders:

19 Women and Children’s program leaders

198 Women and Children’s program physicians and clinicians

13 Other (i.e., Allied Health, administration, etc.)

External Stakeholders:

3 PFAC and CAC members

56 External Community Members

8 Patients in Hospital

23 Primary Care Physicians

Led by Deloitte Led by Crestview Strategies Led by SHN

Note: these activities were undertaken to support the co-design process. This does not capture all analysis, research, or engagement 11 that has been completed by SHN to-date.

17 Interviews

5 Focus Groups

2 Co-Design

Sessions

Internal Staff

Survey

External Community

Survey

Primary Care

Physician Survey

Spot Audit on

Transportation1

SHN’s Data Analysis from

Master Planning

Capital Planning Analysis and Estimates

Wallpaper Exercise


OVERVIEW OF THE CURRENT STATE FINDINGS

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CURRENT S TATE ANALYSIS OVERVIEW The current state analysis was conducted to gain a clear understanding of the current model for the Women and Children’s program, specifically the strengths of the program, and the opportunities to improve the program over time.

• There have been a number of changes over the last decade within

the health system in Scarborough. Given this, and the evolving needs of the community, SHN is at an important point in their history. This context is important to consider when thinking about the current program and the path forward.

• Through the consultations it was clear that there are many strengths of the program that should be amplified in the future state model.

• Current state data and consultations to-date also illustrates the potential opportunities that exist to build on the current strengths of the program. These opportunities will allow SHN to configure a program that is best suited to serve the needs of women and children in Scarborough.

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CONTEXT OF THE SCARBOROUGH COMMUNITY In order to understand the current state of the program, it is important to understand the broader context in Scarborough and beyond that will impact the program in the coming years.

Scarborough is an evolving community that is unique to other areas in Ontario or across Canada. There are a number of things that make it a unique context, including:

• Scarborough is a significant part of the broader Central East Local Health Integration Network (CE LHIN), and has a role to play in serving the whole CE LHIN community

• Scarborough is a community with a strong social fabric that prides itself on its diversity and its strong public institutions

• Scarborough has a number of great schools, community centres, health care services, and programs to support people from all walks of life

• The average household income in Scarborough is less than the overall population of Ontario by 16% - 27%; there is a higher percentage of low income people in Scarborough than the overall Central East LHIN

• In general, Scarborough has a 20% - 36% higher population of immigrants than the overall Central East LHIN

• Scarborough South has a slightly higher population of lone parent families compared to the North and the overall Central East LHIN

There are also a number of trends in labour volumes that will change the landscape in Scarborough, including:

• Labour volume is expected to increase by 15% over the next 20 years

• Neonatal and paediatric services admissions are expected to increase by 24% over the same period

Given this, and the unique Scarborough population, there is a need to unite the Women and Children’s program and prepare for 14 this growth to ensure the community continues to have access to world class services, and the care they need and deserve.

STRENGTHS OF THE PROGRAM Program stakeholders shared that the Women and Children’s program plays an important role within the community and the broader hospital network by providing vital services and excellent care to the women and children of Scarborough.

Consultation Findings: Highlights of the Women and Children's Program

• Most interviewees agreed that a primary strength of the program was the ability to provide services that are culturally relevant and accessible • They also noted that diversity is a strength of the program and their ability to ‘meet the client where they are at’ is a key differentiator of the program • They also appreciated that SHN takes a holistic approach by providing family centered and person-based care

• Most interviewees highlighted that midwives are an especially important part of the inter-professional team and provide personalized care for pregnant women and newborns • Many people specifically noted that SHN is one of the four hospitals in the GTA that provide water birth as an option, which has been a great way to attract women into the program • They also noted that SHN offers exceptional clinics that are crucially important for women and children in the community (i.e. EPAC clinic, regional genetics clinic, maternal fetal

medicine clinic, paediatric sub specialty services for children, teens and families, and the sexual assault care centre)

• Many interviewees noted that the program and patients benefit greatly from having physicians and staff that are highly trained and committed to providing best-in-class services and care to the women and children they serve

• They also noted that obstetricians and the overall health team are a major factor that encourage women to deliver at SHN

• Many interviewees highlighted that the paediatric oncology satellite clinic provides close-to-home, specialized cancer care to children and families from east Toronto and west Durham. In partnership with The Hospital For Sick Children and the Paediatric Oncology Group of Ontario (POGO), the clinic offers a variety of services including: chemotherapy, blood work, and transfusions

• They also noted that SHN develops excellent discharge plans using the resources available and within close proximity to patients for ease of access and convenience 15 • They also noted that SHN is able to serve critically ill patients through excellent support from the ICU, NICU and Paediatrics

The patients are provided with holistic care in a way that is culturally relevant and accessible

The program provides excellent care and a range of important services

The program’s staff, including physicians, nurses and midwives, are exceptionally talented and skilled in their work

The program’s staff, including physicians, nurses and midwives, are resourceful and committed to providing the best possible care

OPPORTUNITIES TO BUILD ON THE STRENGTHS OF THE PROGRAM (1/2) Program stakeholders emphasized the tremendous opportunity that exists to build on the strengths of the current Women and Children’s program, and develop a future state model that is best positioned to address the needs of women and children in Scarborough now and in the future.

Opportunity Area Description

Quality & Safety While overall SHN has high standards of quality and safety, previous incidents and reports have highlighted the need to continue to improve both quality and safety. For example, the Corpus Sanchez report (2012) noted that “Quality of care was perceived to be generally good by TSH staff and the review team although issues were identified that improve patient safety”. The External Expert in Obstetrics report (2018) also noted that “The patient safety concerns persisted with frequent SAFE reports, near misses and bad outcomes”. Through stakeholder interviews, physicians and clinicians who work in the program also noted that with the integration of the three sites into one program there is a need to better standardize processes to improve patient quality and safety, overall.

Moving forward, SHN should build on the strong foundation of quality and safety standards, and move towards the consistent implementation of best practices across all three sites and consistent processes to support the standards.

Service Excellence SHN has a strong track record of providing high quality service to the women and children of Scarborough, but more can be done to further improve the patient experience. Data shows that SHN has had a 3% loss in market share for deliveries since 2005/06 and mothers who live in the SHN catchment area are choosing to deliver outside of the three SHN sites in significant numbers1. In addition, physicians and clinicians that work in the program also believe that more can be done to improve the patient experience (i.e., dedicated spaces for children, more family friendly units, more services tailored to the needs of the community, more culturally sensitive practices, etc.).

Moving forward, SHN should endeavor to build a program that strives for service excellence at all times, and is focused on delivering a service that is the first choice for families in Scarborough and beyond.

Footnotes: 1Source: SHN - Pregnancy Trends 16

OPPORTUNITIES TO BUILD ON THE STRENGTHS OF THE PROGRAM (2/2) Program stakeholders emphasized the tremendous opportunity that exists to build on the strengths of the current Women and Children’s program, and develop a future state model that is best positioned to address the needs of women and children in Scarborough now and in the future.

Opportunity Area Description

17

Organizational Effectiveness With the merger of TSH and Rouge Valley to form SRH (now SHN), and the Women and Children’s program operating across three sites there is an opportunity to bring the program together and operate more as a single unit. In the current model there is significant variation in the culture, ways of working and program structures that are in place across the three sites. Beyond the quality and safety impacts of this, this has also caused there to be organizational impacts on the culture of the Women and Children’s program that has impacted retention and staff satisfaction. For example, some interviewees noted that there is distrust and poor communication amongst staff in the program, which has, in some cases, lead to gaps in accountabilities and created confusion.

Moving forward, SHN has an opportunity to break down the silos that currently exist between the program and across the three sites, and build one united program. It will be important to ensure that the strengths that currently exist within the program are amplified moving forward, and the learnings and experience of the staff are considered.

Program Sustainability While it is clear that there are many strengths of the program, the quantitative and qualitative data demonstrates that the Women and Children’s program is not sustainable in its current form. As noted previously, SHN’s market share of deliveries has decreased by 3% since 2005/06. The data also shows that a significant number of mothers who live in the SHN catchment area are choosing to deliver at a site outside of SHN. This data is also reinforced by the qualitative findings from the interviews conducted. Multiple interviewees noted that the low volume of births has caused a deterioration of skills amongst clinicians that may impact patient safety, and has impacted their ability to access the appropriate subspecialists when required (specifically anesthesia).

Moving forward, SHN has a great opportunity to build a program that is more sustainable in the long-term. To do this, SHN will need to consider how to attract families to use their services, instead of looking beyond SHN for support. Most interviewees echoed the sentiment that ‘if you build a great program, people will come’. This should be the aspiration for the program moving forward.


CONTEXT FOR DESIGNING THE FUTURE STATE MODEL

18

DESIGNING THE FUTURE MODEL When designing the future model for the program, it was important to ensure alignment with the future vision for SHN, and to ensure the strengths of the program are amplified.

The future model of the program was founded on a number of important components: international models of care, the newly established strategic direction for the Scarborough Health Network, the guiding principles and the decision making criteria.

- The international models of care were used to inspire the co-design attendees to consider the ‘art of the possible’ for what the program could be in the future;

- The newly established Strategic Plan and vision for the Scarborough Health Network was an important foundation for the future state model;

- The guiding principles were established at the outset of Deloitte’s work to set the context and provide the guide posts for the review; and

- The decision making criteria were established to reflect the goals, objectives and desired attributes of the future model for the program.

These components should continue to be used by SHN leadership and the Board to make decisions about how the future state model of the Women and Children’s program should be designed.

19

INTERN AT IONAL MODELS OF CARE The international models of care in the areas of women and children’s health were used help the co-design attendees think more broadly about what the program could be, and what services it could offer.

Take Home HPV Screening Te lemedicine Early Pregnancy Unit

20

Model Description The (HPV) screening program provideswomen with a kit they can take home to collect a vaginal sample. After droppingtheir test into any Canada Post box, resultsare then available online through a secure portal within a week.

Model Description Telemedicine is the use of communications and information technology to deliver health and health care services, information and education where clinicians and patients are physically separated. The Telemedicine Program at SickKids connects the health-care team at SickKids with patients and health-care professionals provincially, nationally, and internationally.

Model Description The early pregnancy unit provides a flexible ‘women-centred’ model of service delivery, where women in early pregnancy gain timely access to be assessed and treated forcomplications, and receive appropriate counseling and follow-up care by experienced doctors.

Observed or IntendedOutcomes

Intended outcome is to increase access to HPV screening for women who are uncomfortable or experience difficulty getting to an appointment for a physicalexam, leading to improved health outcomesfor this patient population.


This service functions effectively and assistsin the reduction of ED visits as well as providing early intervention, counseling and support to women at a very sensitive time.


• Increases access to medical specialty

consultations • Reduces travel time for patients and cost

savings for families • Enables professionals to maintain and

enhance their continuing medical education • Ensures continuity in treatment • Reduces the need for hospitalization and

emergency room visits

21

STR ATEGIC DIRECTION SHN’s Strategic Plan from 2018-2023 was a foundational element for the co-design sessions, as it was important that the co- design session attendees continually considered if the future model was aligned with this vision.

PROJECT GUIDING PRINCIPLES The following guiding principles were used for the development of the future state model. These guiding principles align with other SHN initiatives, including The Scarborough/West Durham Panel Report, the Strategic Plan, and the Master Planning.

• A commitment to high-quality and safe patient care

• An ongoing commitment to SHN’s newly established vision statement, Canada’s leading community teaching health network – transforming your health experience, and value statements, Compassionate, Inclusive, Courageous, Innovative

• An ongoing commitment to integration of services and improving services through collaboration, accessibility, sustainability and excellence

• Acknowledgement that change is needed and has been a long time coming; there is no appetite for the status quo that is unsustainable, it is time for decision and action

• A commitment to continue active community engagement and participation in system redesign

• A commitment to working with each other as well as advancing broader health system transformation

• A commitment to maintain alignment with the Master Planning activities currently underway

• An acknowledgement of the significant change management challenges and a commitment to leverage our shared cultures of

continuous improvement to mitigate risks that threaten timely and effective implementation of integration opportunities

22

DECISION MAKING CRITERIA The decision making criteria were used for assessing the potential future state models and determining the best path forward.

Patient-Centric

• Ability to limit the number of hand-offs and strive to provide a seamless experience for patients

• Ability to create a welcoming and functional physical environment to enhance patient experience

Strategic Fit • Consistency and alignment with SHN’s Strategic Plan and Master Planning

Quality

• Ability to consistently deliver the highest quality of service for Scarborough Health Network patients and clients that meets or exceeds industry best standards

• Ability to access a range of specialists and subspecialists relevant to patient needs

• Ability to capture data required to measure and monitor clinical outcomes

Access • Ability to provide access to high quality care

• Ability to provide patients with access to care that reflects the diversity of the population being served

• Ability to leverage external partnerships and relationships to improve access to care and quality of care

Sustainability

• Ability to make efficient use of our assets (e.g., operating rooms, beds, equipment, etc.)

• Ability to make efficient use of our talent and staff (e.g., recruitment & retention, supports for the services delivered (e.g., dedicated anesthesiology), manage fluctuations, maximize skillsets, etc.)

• Capacity to absorb future growth (physical growth and financial growth)

• Minimize loss of market share and potential to improve market share over time through building a strong brand

23


KEY CONSULTATION FINDINGS & PREFERRED DIRECTION

24

APPROACH FOR ARRIVING AT THE PREFERRED DIRECTION FOR THE FUTURE STATE MODEL Below is a summary of the approach that was taken to arrive at the preferred direction for the future state model.

Who the program is intending to serve?

What services should the program offer?

How the program should be delivered?

Summary of Evaluated Options Preferred Direction

25

WHO THE PROGRAM SHOULD BE SERVING Co-design session attendees were asked to first reflect on who the program is intending to serve; this was important to understand and align on before getting further into the design.

• While there was agreement that women, children, and their families that live in Scarborough should be the focus, many attendees

also noted the importance of not assuming that the group is homogenous – there are many people with different needs that should also be considered.

• Below highlights some of the specific groups of people that were noted repeatedly.

26

Women and children who don’t have access to private transportation

Women and children from neighbouring communities, across the whole CE LHIN

Women and children who want the best possible care for themselves

and their families

Women and children that are new to the community and those that are long-time

residents

Women, children and their families that live in Scarborough

Women and children who have access to private transportation

Women and children who would tend to drive out of Scarborough to another

hospital

SERVICES THE PROGRAM SHOULD BE OFFERING The co-design session attendees were then asked to reflect on what services women and children in the community need access to, whether they are delivered by SHN or provided in the community.

• Co-design session attendees were asked to reflect on the current services offered by the program (as shown in the Service Map), and provide insight into what should change or be added

• Attendees agreed that the current services should continue to be provided, but that a number of

additional services should be considered to continue to meet the evolving needs of the Scarborough community, including:

o Out-patient clinics such as, multidisciplinary complex care clinic, infectious disease, bronchoscopy, after-hours paediatric urgent care

o Mental health supports for new moms and children o Parenting skills classes, including lactation, sleeping, nutrition, and mental health

o Supports for expecting and new moms, including genetics, smoking cessation, substance abuse, antenatal assessments, diabetes

o Programs for children and adolescents, including eating disorder clinic, mental health, drug and alcohol, behaviour supports

o Paediatric gynaecology Note: the services listed above were items that were raised by co-design session attendees. Additional work will need to be undertaken to determine how these services should be delivered. See Appendix for additional suggestions from participants. 27

SERVICE INTERDEPENDENCIES It was then important to understand how the services that should be offered in the Women and Children’s program are related to each other, and how they are interdependent.

Please note: Some co-design session attendees believe that Paediatrics Day Surgery should not be included in the cluster above.

28 Footnote: 1Core Paediatrics includes: Paediatric Inpatient Medicine, Paediatric Inpatient Surgery and Paediatric Day Surgery

1. All services under Core Paediatrics1 have to be co-located within a full service

acute hospital for clinical proximity and provider proximity

2. All Birthing and NICU services have to be co-located for clinical proximity and provider proximity

3. All NICU and Core Paediatrics1 services have to be co-located for clinical

proximity and provider proximity

Key Findings from the Co-Design Sessions Findings 1, 2, and 3 result in requiring the Birthing

and Core PaediatricsCluster to be co-located.

Birthing & Core Paediatrics Cluster

4. The Emergency Department must have 24/7 availability to consult with Paediatrics, OB/GYN, and anesthesia

5. Gynaecology (surgery) and Anesthesia have to be co-located for provider

proximity and clinical proximity 6. Obstetrical care and Anesthesia have to be co-located for clinical proximity

and provider proximity

SUMMARY OF EVALUATED OPTIONS After considering who the program is serving, what services should be provided, and how those services are interrelated, an analysis was completed by SHN to understand the implications of co-locating the Birthing and Core Paediatrics cluster at one, two, and three sites. Below is a summary of the options and the potential benefits and drawbacks, as expressed by the attendees.

Option 1 One-site Model

Description The Birthing and Core Paediatrics1 cluster should be delivered at one-site2

Option 2 Two-site Model

The Birthing and Core Paediatrics1 cluster should be delivered at two-sites2

Option 3 Three-site Model [Current Model]

The Birthing and Core Paediatrics1 cluster should be delivered at two-sites2

Potential Benefits

• Improved access to specialists by having them consolidated at one physical location

• Economies of scale could improve the ability to have dedicated subspecialists for birthing and core paediatrics1 (i.e., dedicated anesthesia coverage)

• Economies of scale could also improve the ability to have dedicated space for birthing and core paediatrics1 (i.e., dedicated wing for babies and kids, separate from adult services)

• Improve SHN’s brand by creating a ‘center of excellence’, attracting more patients and physicians

• Increased volume of deliveries and paediatric visits would improve the overall quality of physicians, improve satisfaction and retention, and attract high-performing clinicians to SHN

• Improved communication between physicians and clinicians by having them co-located

• Economies of scale would improve the ability to have dedicated subspecialists for birthing and core paediatrics1

• Economies of scale would also contribute to a more even volume of births (i.e., the significant peaks and valleys in deliveries would be evened out with greater volume)

• Increased volume of deliveries and paediatric visits would improve the overall quality of physicians, improve satisfaction and retention, and attract high-performing clinicians to SHN

• Improved communication between physicians and clinicians by having them located on fewer physical sites

• Maintaining the program at three sites would provide convenient access to services for women and children in Scarborough (this is particularly important for families that rely on public transit or walking to access services)

Potential Drawbacks

• Concern about whether the high volume of deliveries consolidated at one site may have a negative impact on patient safety

• Volume of deliveries may not be sufficient to warrant a dedicated anesthesiologist for labour and delivery

• Having a relatively low volume of deliveries at three-sites causes resources to be used inefficiently, physicians to not have exposure to a wide range of complex cases and a deterioration of skills over time

Feasibility

Footnotes:

• Based on the capital planning analysis conducted by SHN it would take approximately 6-8 years to complete a consolidation to one site and because the cost is over $10M it would require going through the MOHLTC Capital Planning process

• The timeframe for this is such that it would need to be included in Master Planning for SHN, as a whole

• Based on the capital planning analysis conducted by SHN it would take approximately 10-12 months to consolidate services on two-sites and because the cost is under $10M it would not require going through the MOHLTC Capital Planning process

• It is technically feasible to maintain services at three-sites

29

1Core Paediatrics includes: Paediatric Inpatient Medicine, Paediatric Inpatient Surgery and Paediatric Day Surgery 2A detailed configuration of the remaining services (i.e., Ambulatory Outpatient, Postnatal, Prenatal and Gynaecology) is yet to be determined

DECISION MAKING CRITERIA MODEL ASSESSMENT Following the co-design sessions, the decision making criteria were used to assess each of the three models, and assess their ability to meet patient needs, align with the strategic fit, and meet standards of quality, access and sustainability. The table below describes how each of the evaluated options, in principle, align with the decision making criteria.

In this assessment it appears that the one-site model and two-site model are equally good options; due to the feasibility limitations of moving to a one-site model in the short or medium-term, the two-site model is the preferential option. One-Site Model Two-Site Model Three-Site Model

Patient-Centric

Limit the number of hand-offs and strive to provide a seamless experience for patients

Create a welcoming and functional physical environment to enhance patient experience

Strategic Fit Consistency and alignment with SHN’s Strategic Plan and Master Planning

Quality

Consistently deliver the highest quality of service for Scarborough Health Network patients and clients that meets or exceeds industry best standards

Access a range of specialists and subspecialists relevant to patient needs*

Capture data required to measure and monitor clinical outcomes

Access

Provide access to high quality care

Provide patients with access to care that reflects the diversity of the population being served

Leverage external partnerships and relationships to improve access to care and quality of care

Sustainability

Make efficient use of our assets (e.g., operating rooms, beds, equipment, etc.)

Make efficient use of our talent and staff

Capacity to absorb future growth (physical growth and financial growth)

Minimize loss of market share and potential to improve market share over time through building a strong brand

Note: this is a cursory analysis based on current information and intention moving forward. Additional work will need to be undertaken when the future state 30 model is being built out to ensure continued alignment with the decision making criteria. * Access refers to the ability to consult with specialists and subspecialists, whether that is in-person, over the phone, or using other technology (i.e., OTN)

SUMMARY OF PREFERRED DIRECTION At the conclusion of the co-design sessions there were three primary outcomes of the discussion. These three primary outcomes summarize the preferred direction of the co-design session attendees and will provide a framework to design the remainder of the future state model.

The co-design session attendees had an opportunity to discuss each of the three options. After a robust discussion, the co-design session attendees aligned on three primary outcomes.

Primary Outcomes:

1. The co-design session attendees agreed that in the short- and medium-term (1-10 years), the Birthing and Core Paediatrics1 cluster should move to a two-site model at the General and Centenary sites.

2. The co-design session attendees also agreed that while the remaining services2 (Ambulatory Outpatient, Prenatal, Postnatal and Gynaecology) can be provided at all or any of the three sites, further work will need to be undertaken to determine where they should be delivered.

3. The long-term future model for the program (one-site vs. two-sites) was not agreed upon by the co-design session attendees; there is a need to continue this discussion as part of the Master Planning activities underway.

Footnotes: 1Core Paediatrics includes: Paediatric Inpatient Medicine, Paediatric Inpatient Surgery and Paediatric Day Surgery 2A detailed configuration of the remaining services (i.e., Ambulatory Outpatient, Postnatal, Prenatal and Gynaecology) is yet to be determined

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PREFERRED DIRECTION (1/2) Below are the key future state model outcomes and preferred direction from the co-design sessions.

1. The co-design session attendees agreed that in the short- and medium-term, the Birthing and Core Paediatrics1 cluster should move to a two-site model at the General and Centenary sites.

Consensus Position

• The co-design session attendees agreed that the current model of providing Birthing and Core Paediatrics1 services at three-sites was not sustainable in the long-term and was having negative impacts on the quality of service, patient safety and provider satisfaction; given this it was agreed that the current three-site model should not be maintained

• While some co-design session attendees believed that moving to a one-site model should be the preferred approach, they understood the data provided and agreed that it would not be feasible in the short- to medium-term to consolidate services on one-site

• The co-design session attendees agreed that the Birchmount was likely not the best option for one of the two sites, due to the decline in market share and the significant decline in deliveries, despite recent investments and program enhancements3

• Therefore, co-design session attendees agreed that the General and the Centenary would be the best sites from which to deliver the Birthing and Core Paediatrics1 cluster of services

• This finding is also supported in Dr. Zaltz’s clinical review2, which states, “Based on my review, it is my opinion that obstetrical services should be phased out at the BM (Birchmount). Declining birth volumes, the inability to attract women to the site and a very real and present concern for the provision of safe and effective care for those who give birth at the BM are the primary reasons.”

Other Opinions & Considerations

• Additional conversations will need to take place in order to determine the future model for paediatric day surgery.

Footnotes: 1Core Paediatrics includes: Paediatric Inpatient Medicine, Paediatric Inpatient Surgery and Paediatric Day Surgery 2Source: Dr. Zaltz’s Final Report (June 2018) 32 3Source: SHN - Pregnancy Trends

PREFERRED DIRECTION (2/2) Below are the key future state model outcomes and preferred direction from the co-design sessions.

co-design sessions.

Footnote: 1Core Paediatrics includes: Paediatric Inpatient Medicine, Paediatric Inpatient Surgery and Paediatric Day Surgery

2. The co-design session attendees also agreed that while the remaining services (Ambulatory Outpatient, Prenatal, Postnatal and Gynaecology) can be provided at all or any of the three sites, further work will need to be undertaken to determine where they should be delivered.

Consensus Position

• The co-design session attendees agreed that the remaining services (Ambulatory Outpatient, Prenatal, Postnatal and Gynaecology) can be provided at all or any of the three sites, given that they are not dependent on the services provided as part of the Birthing and Core Paediatrics1 cluster

• It was also agreed that where services are provided should be determined with a clear understanding of the vision for each of the three sites, and specifically the vision for the Birchmount

• It was also agreed that additional work will need to be undertaken in order to better understand the vision for each site, and therefore what services should be delivered by each site in order to provide the best possible service for the community and the highest quality patient care

Other Opinions & Considerations

• Some co-design session attendees argued that if the Birchmount is not going to have the Birthing and Core Paediatric1 cluster services, than all other obstetrical and paediatric services should also not be provided at the Birchmount. The intention was that this would make it more clear to the community that there are no obstetrical or paediatric services at the Birchmount, and would help clearly delineate the roles of each hospital

• Other attendees – on the other hand – argued that it would be very helpful to have some of the obstetrical and paediatric services (i.e., prenatal, postnatal services, and/ or paediatric outpatient clinics) at the Birchmount because it could improve accessibility for the neighborhoods North of the 401

• Some attendees raised the possibility of the Birchmount becoming a centre for outpatient women and children’s health by providing Gynaecology services and some pre- and post-natal services

• When determining how the remaining services are delivered, it is important to also consider what capabilities the services need to be able to access. In the case of ambulatory clinics they will need to be able to access core hospital diagnostics and multidisciplinary teams (nursing, allied health, lactation consultants, mental health); gynaecology will need to access core hospital diagnostics, multidisciplinary teams, the OR, and interventional radiology

3. The long-term future model for the program (one-site vs. two-sites) was not agreed upon by the co-design session attendees; there is a need to continue this discussion as part of the Master Planning activities underway.

Given that the long-term future model will need to be determined in conjunction with the Master Planning activities, it was not the focal point of the discussion during the

33


IMPLEMENTATION CONSIDERATIONS

34

IMPLEMEN TAT ION CONSIDERATIONS The implementation of the future model will require careful planning and change management efforts. Below are a list of some of the implementation considerations that have been identified.

SHN will need to invest in new technologies to support the new operating model and enable different processes. For example, OTN will be a crucial technology to connect the ED at the Birchmount site with specialists at the Centenary or General sites. Additional technologies SHN should consider are: Adapting Telehealth Using ‘My Chart’ technology to provide accessible

view of results Providing virtual access to post-op instructions

SHN should consider how to make the physical environment that the program is operating out of more family friendly; some specific ideas for this are: Dedicated in-patient areas for kids (separate

from adults) Making an area of the emergency room more

‘child friendly’ and inviting

There is a significant need to develop consistent processes across the three sites to enable better quality of service and ensure best practices are being utilized across all sites. With the change in operating model there will be a particular need to establish processes such as: ED transfer protocols Quality improvement processes Referral process Coverage models (i.e., anesthesia coverage

model)

SHN should consider how to continually keep the program staff, the broader hospital network and the community apprised of next steps and how the change in model may effect them. An important step will be to consider all requirements for HR planning (i.e., staff and physician). Communication and change management will continue to be a significant aspect of developing any future state operating model for the program.

SHN will need to ensure that processes and structures are in place to enable access to the right skills and capabilities at the right time, via telemedicine, phone or in-person. This will be important to maintain patient safety and quality standards. It will be particularly important to consider: Timely and appropriate access to anesthesia,

interventional radiology, paediatrics and obstetrician / gynaecology

TeamSTEPPS – consider programs to build consistent quality of service amongst program staff

Managing Obstetrical Risk Efficiently Program (MORE OB)

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Technology Process Capabilities

Facilities & Infrastructure Other


APPENDIX

36

DE TA ILED LIST OF STAKEHOLDER ENGAGEMENT

Steering Committee Members Interviews

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Scarborough & Rough Hospital 1. Dr. Peter Azzopardi 2. David Belous 3. Glyn Boatswain 4. Linda Calhoun 5. Dr. Norman Chu 6. Tama Cross 7. Dr. Karen Chang 8. Dr. Amir JanMohamed 9. Dr. Colette Rutherford 10. Dr. Dick Zoutman

11. Leigh Duncan

12. Dr. Jeremy Hew

13. Rochelle Maurice

14. Dr. Kushal Raghubir

15. Dr. Georgina Wilcock

16. Amir Janmohamed

17. Jeremy Hew Issues Management Firm - Navigator (Oct 30 - Present)

20. Lanny Cardow

21. Jamie Crawford-Ritchie Deloitte

22. Kristin Mendoza

23. Lisa Purdy

24. Iksheeta Shah

25. Alison Sproat

Name Title Site

1. Dr. Colette Rutherford Chief of Obstetrics & Gynaecology Birchmount & Centenary

2. Dr. Georgina Wilcock Chief of Obstetrics & Gynaecology General

3. Tama Cross Midwifery Lead Birchmount & General

4. Dr. Peter Azzopardi Chief of Paediatrics Birchmount & General

5. Dr. Karen Chang Chief of Paediatrics Centenary

6. Dr. Vinod Raghubir Paediatric Site Lead Birchmount

7. Dr. Jeremy Hew Interim Co-Chief of Anaesthesia Birchmount

8. Dr. Norman Chu Chief of Emergency Birchmount & General

9. Dr. Mike Chapman Chief of Surgery Birchmount & General

10. Dr. Dov Soberman ED Physician All three sites

11. Dr. Sandy Finkelstein Chief of Medicine Birchmount

12. Dr. Tim Devlin Gastroenterologist Birchmount & General

13. Dr. Amir Janmohamed Cardiologist & MSA President Centenary

14. Linda Calhoun Vice President Clinical Programs All three sites

15. Glyn Boatswain Director Women and Children

Program All three sites

16. Michelle O'Connor Manager Women & Children's Program Birchmount

17. Claudia Browne Clinical Practice Leader Birchmount & General

DE TA ILED LIST OF STAKEHOLDER ENGAGEMENT

Focus Groups

Name Department Site 1. Dr. Sam Ko Obstetrician/Gynaecologist General 2. Dr. Lamide Oyewumi Obstetrician/Gynaecologist Centenary 3. Dr. Muhammad Akhter Hamid Paediatrician Centenary 4. Dr. Stephanie Kay Paediatrician General 5. Dr. David Esser Chief of Surgical Assist General 6. Sanaz Kama Midwife (Diversity Group) Birchmount 7. Dr. Sharon O’Brien Obstetrician/Gynaecologist General 8. Dr. Malcolm Tai-Pow Anaesthesiologist Birchmount 9. Maryam Rahimi Midwife (Sages Femmes Group) Birchmount 10. Prashanthini Selvarajah Nurse/Labour and Delivery Birchmount 11. Dr. Tineke Vermaat Paediatrician Birchmount 12. Dr. Joanne Ma Obstetrician/Gynaecologist Centenary 13. Dr. Leah Tattum Paediatrician General & Birchmount 14. Dr. Michael Chang Division Head ENT Centenary 15. Dr. Marc Gelman ED Physician General & Birchmount 16. Dr. Donna Barnwell Obstetrician/Gynaecologist General 17. Dr. Nathan Roth Obstetrician/Gynaecologist Birchmount 18. Dr. Jill Solomon Paediatrician General 19. Sheila Redman Charge Nurse, NICU Centenary 20. Dr. Anita Mo Obstetrician Centenary 21. Dr. Mary Cheng Obstetrician Birchmount 22. Dr. Hubert Wong Paediatrician Centenary 23. Dr. Mohamed Ahmed Paediatrician General 24. Dr. Chandra Subramanian Anaesthesiologist General 25. Patricia MacLaughlin Nurse/Paediatrics General 26. Dr. Neely Noticewala Paediatrician Birchmount

38

DE TA ILED Co-design Session Attendees

LIST OF STAKEHOLDER ENGAGEMENT

39

Name Department Site Attended Co-

Design Session #1 Attended Co-Design

Session #2 1. Dr. Peter Azzopardi Paediatrics Birchmount & General x x 2. Dr. Karen Chang Paediatrics Centenary x x 3. Dr. Vinod Raghubir Paediatrics Birchmount x x 4. Dr. Georgina Wilcock Obstetrics & Gynaecology General x x 5. Dr. Colette Rutherford Obstetrics & Gynaecology Birchmount & Centenary x x 6. Tama Cross Diversity Midwifery Group Birchmount and General x x 7. Michelle O’Connor Women & Children’s Program Birchmount x x 8. Meghan Cellamare Obstetrics Centenary x x 9. Kamani Abdul NICUs All Sites x x 10. Dr. Michael Silver Obstetrics & Gynaecology Birchmount x x 11. Dr. Jing Qin Obstetrics & Gynaecology Birchmount x x 12. Dr. David Samra Obstetrics & Gynaecology Centenary x x 13. Dr. Caroline Huh Obstetrics & Gynaecology Centenary x x 14. Dr. Sam Ko Obstetrics & Gynaecology General x 15. Dr. Nina Venkatarangam Obstetrics & Gynaecology General x x 16. Dr. Stephanie Kay Paediatrics Birchmount x x 17. Dr. Latifa Yeung Paediatrics Centenary x x 18. Dr. Leah Tattum Paediatrics General x x 19. Claudette Leduc Sages Femmes Midwifery Group Midwifery Lead, Centenary x 20. Sook Park Paediatrics Birchmount x x 21. Lindsay Forsey NICU Centenary x x 22. Nazima Khan Obstetrics General x 23. Dr. Jeremy Hew Anaesthesia Birchmount x x 24. Dr. Mojgan Davallou Anaesthesia Centenary x 25. Dr. John Oyston Anaesthesia General x x 26. Dr. Norman Chu Emergency Medicine Birchmount & General x x 27. Dr. Michael Chapman Surgery Birchmount & General x x 28. Dr. Jon Hummel Surgery Centenary x x 29. Dr. Sandy Finkelstein Internal Medicine Birchmount x x 30. Dr. David Esser Surgery General x x 31. Nadia Rampersad Respiratory Therapy All Sites x x 32. Susan Easton Obstetrics & NICU Centenary x x 33. Carolyn Tyson Patient Family Advisor N/A x x 34. Dr. Olivia Tsai Anaesthesia Centenary x x 35. Roleta Kalichava Obstetrics General x x 36. Hoda Kayal Capital Planning N/A x

SUGGESTIONS TO CONSIDER IN FUTURE SERVICE PLANNING Below is an overview of the additional programs and services that co-design session participants identified in the session. These ideas should be considered in future service planning.

[1] Labour & Delivery

o Mental Health for OB o Maternal Clinic

o Group Prenatal Care o Access to Genetics o Parenting Classes o Antenatal Assessment Clinics (e.g., vitamins,

ITTN, etc.)

o OB Medicine Clinic (including chronic conditions)

o Immediate access to Blood Banks o ICU o Dedicated Anesthesiologist o Child Care Services o Doula services o Lactation Clinic o MFM Perinatal Health o Home Care

[1] Clinics

o Multidisciplinary Complex Care Clinic o Infectious Disease Clinic

o Bronchoscopy o Paediatric Urgent Care (after-hours) o Smoking Cessation Clinic o Substance Abuse Clinic o Domestic Violence Clinic o Eating Disorders Clinic o 24/7 Access to Mental Health Clinic o Fertility Clinic o Enhanced Miscarriages and Abortion Clinics

o Developmental Paediatrics Speech and Language Clinic

o Pediatric Psychiatry and Psychotherapy Specialist / Clinic

o Child Life Specialist / Clinic

[1] Gynecology

o Paediatrics Gynecology

[1] Other

o Palliative Care

o Pediatrics Bereavement

o Educational opportunities for families

o Family Practice

o Paediatric Surgery Sub-Specialty o More Comprehensive Programs

(e.g., hernias)

40

APPENDIX C

Women & Children’s Program Future Clinical Service Delivery Model Design

Steering Committee

Terms of Reference

Role 1. Direction: The purpose of the Committee is to ensure a structure and process exists to receive and review the recommendations related to the future state service delivery model of the of the Women and Children program.

Advice from this Committee on the future Women and Children program model shall be considered by the Senior Leadership Team. Broad consultation of stakeholders and facilitated co-design sessions will support transparency of decision making on the future Women and Children program service delivery model.

The Committee shall determine timelines by which the recommendations on the future state service delivery model will be made, including key phased implementation milestones, where relevant.

2. Alignment:

This Committee supports the mission, vison, values and strategic directions of Scarborough Health Network.

3. Authorization:

To act as an Advisory Committee to the Senior Leadership Team.

Responsibilities The Committee shall: 1. Provide oversight of the consultation and engagement

activities related to the co-design of the future Women and Children program clinical service model design.

2. Review matters and seek or receive information/reports arising from the consultation and engagement plan.

3. Consult and seek input from other stakeholders on matters before the Committee, if required.

4. Communicate to the Senior Leadership Team and other relevant stakeholders the progress and deliberations of

1

the Committee. 5. Coordinate messages for consultations between

Deloitte, Crestview/Navigator and other parties involved in other SRH initiatives and community engagement, where required.

6. Ensure the respective project workplans from Deloitte and Crestview/Navigator are consolidated and integrated.

7. Ensure clear lines of communication to internal staff, physicians, CE LHIN, the Ministry of Health and Long- Term Care, hospital foundation, agencies, consumers, and the media.

8. Accept reports from the Women and Children Clinical Service Model Project sub-committee.

9. Ensure that major milestones and timelines of the Women and Children Clinical Service Model Design sub- committee work plan are achieved and are consistent with the strategic plan and facilities master plan.

Membership Membership:

Position Member Name Vice-President [Co-Chair]

and [Chair] Clinical Service Delivery Model Project sub-committee

Linda Calhoun

Chief of Staff [Co-Chair] Dr. Dick Zoutman Director Women &

Children’s Glyn Boatswain

Women and Children Program Divisional Chiefs

Dr. Colette Rutherford Dr. Georgina Wilcock Dr. Peter Azzopardi Dr. Karen Chang Dr. Vinod Raghubir

Midwifery Lead Tama Cross Chief of Anesthesia Dr. Jeremy Hew Chief of Emergency Dr. Norman Chu Medical Staff Association

President Dr. Amir Janmohamed

Corporate Communications David Belous/Leigh Duncan Deloitte Representative[s] Lisa Purdy

Kirsten Mendoza

Crestview/ Navigator

Consultants

2

Patient Family Advisor Carolyn Tyson Clinical Bioethicsit (Ad hoc) Rochelle Maurice

Frequency of Meetings and Manner of Call

Meetings: • The Committee will meet a minimum of bi- weekly or at

the call of the Co-Chair. Minutes and Agenda:

• A standard agenda format will be used for all meetings and will be complied in consultation with committee members.

• Minutes will be taken and distributed by the Committee’s Administrative Support member and a record of decisions, salient discussions, and Action Items will be kept as documentation.

• Action Items from the previous meeting will be reviewed after the approval of minutes at every meeting.

• Agenda and minutes will be distributed prior to the meeting.

Sub-Committees:

• Clinical Project Team – Chair Linda Calhoun [includes: SHN, Deloitte, Crestview/Navigator representatives]

Resources Administrative Support: • Administrative support will be provided by the

program. Location:

• Meetings are located at the SHN sites, members may participate by teleconference.

Reporting • The committee is accountable to the Senior Leadership Team through the Vice President Patient Services.

Date Approved October 3, 2018 Date of Last Review October 3, 2018

3

APPENDIX D

SUPPORTING DATA FOR REFERENCE Department of Obstetrics and Gynaecology, and Women’s and Children’s Program

ABOUT THE SCARBOROUGH COMMUNITY

COMMUNITY SNAPSHOT

100%

Population (years of age)

90%

80%

70%

60%

50%

40%

30%

Ages 75+

Ages 65 - 74

Ages 19 - 64

Ages 0 - 18

20%

10%

0% Central East

LHIN

Scarborough North Health

Scarborough South Health

Link Community Link Community

3

Key observations: • The general household income in Scarborough is less than the general population of Ontario by 16% - 27% • In general, Scarborough has between 20% - 36% of higher immigrant population than the overall Central East LHIN • There is a higher percentage of low income people in Scarborough than the overall Central East LHIN • Scarborough South has a slightly higher population of lone families compared to the North and the overall Central East LHIN

Median Household Income

Median Household Income

Scarborough South Scarborough North Ontario

Population of Lone Parent Families 25% 20% 15% 10%

Central East LHIN Scarborough North Scarborough South

Health Link Community Health Link Community

Low Income Population 25% 20% 15% 10%

Central East LHIN Scarborough North Scarborough South

Health Link Community Health Link Community

Immigrant Population

Central East LHIN Scarborough North Scarborough South Health Link Community Health Link Community

7% 9% 6%

8% 7% 9%

63%

62%

63%

23%

23%

19%

$80,279

$67,638

58,819

69%

53%

33%

24%

20%

19%

20%

20%

14%

PRIORITY NEIGHBOURHOODS IN SCARBOROUGH

4 Source: https://www.google.com/maps/d/u/0/viewer?ll=43.769171158925836%2C- 79.26189399999998&spn=0.171068%2C0.271912&msa=0&mid=1B5tE0CABb- uBtOqz4F00egFzpeY&z=11

http://www.google.com/maps/d/u/0/viewer?ll=43.769171158925836%2C-

http://www.google.com/maps/d/u/0/viewer?ll=43.769171158925836%2C-

SCARBOROUGH LOW INCOME NEIGHBOURHOODS IN SCARBOROUGH

This map colours each region by the percentage of people in poverty by the low-income measure after tax (LIM-AT)

Birchmount site

Centenary site

General site

5

Source: https://censusmapper.ca/maps/844?index=0#15/43.8204/-79.3205

AVERAGE INCOME AFTER TAX PER CAPI TA

Average Income After Tax, After Shelter Cost Per Capita, City of Toronto, 2015

6

SUBSIDIZED TENANTS

Subsidized Tenants, Percentage of All Housing City of Toronto, 2016

7

HOW FAST IS THE SCARBOROUGH POPUL AT ION GROWING?

8

Key Observations: • Scarborough’s population is

expected to increase by roughly 25% over the next 20 years, slightly faster than the provincial average

HOW FAST IS THE SCARBOROUGH POPUL AT ION AGING?

9

Key Observations: • The SRH catchment is expected

to age more slowly than the provincial average

HOSPITAL DEMAND GROWTH IS CORREL AT ED WITH AGING

10

Key Observations: • Inpatient hospital use by

Ontario’s 70+ population is roughly 4 times higher than that of any other age group

A. Community snapshot

BASELINE DEMOGRAPHIC FORECASTS – INPATIENT ADMISSIONS

Scarborough & Rouge Hospital: Forecasted Inpatient Acute Care Admissions

Site Partition 2016/17 2021/22 2026/27 2031/32 2036/37 20yr

Growth

General

Newborn and Neonate 2,775 3,110 3,348 3,450 3,463 25% Obstetric 2,830 3,130 3,202 3,217 3,277 16% Pediatric 434 479 516 538 547 26% Total 6,039 6,719 7,066 7,204 7,288 21%

Birchmount

Newborn and Neonate 1,906 2,137 2,299 2,367 2,374 25% Obstetric 1,926 2,128 2,184 2,198 2,231 16% Pediatric 423 464 502 528 540 28% Total 4,255 4,729 4,986 5,092 5,145 21%

Centenary

Newborn and Neonate 2,260 2,532 2,721 2,795 2,799 24% Obstetric 2,287 2,525 2,593 2,593 2,622 15% Pediatric 974 1,060 1,142 1,197 1,228 26% Total 5,521 6,118 6,455 6,586 6,649 20%

Scarborough & Rouge Hospital

Newborn and Neonate 6,941 7,780 8,368 8,611 8,636 24% Obstetric 7,043 7,783 7,978 8,008 8,130 15% Pediatric 1,831 2,003 2,160 2,263 2,315 26% Total 15,815 17,566 18,507 18,882 19,082 21%

Sources: DAD 2016/17 Statistics Canada 2016 Census, MOF Population Projections

11

Key observations:

• With no change in practice, growth of the SRH catchment implies that over the next 20 years SRH’s:

• Newborn/neonate admissions will increase by 24 percent

• Obstetric admissions will increase by 15 percent

• Paediatric admissions will increase by 24 percent

OB/GYN PHYSICIAN OFFICES

12

Freedman, Samra

Cheng, Tam, Kurup, Mahmoud, Ko

Birchmount

Costa Oyewumi, Sohn, Mo

Cramer, OBrien, Venkatarangam,

Harikumar

Centenary Roth, Jia Kirupananthan

Damla, Logaridis, Kalaichandran, Huh,

Ma, Rutherford Adelrazek, Owen,

Peng, Wilcock

Yeung

General Aneja, Qin, Jacobson Barnwell, Iqbal

Ko, Hew Silver

Jegatheeswaran

DELIVERY RATES


DELIVERY RATES Obstetric discharges by hospital for residents of Scarborough North and Scarborough South Sub-region

Scarborough resident pregnancy and childbirth discharges by hospital Site

Combined Scarborough North and South

2005/06

2006/07

2007/08

2008/09

2009/10

2010/11

2011/12

2012/13

2013/14

2014/15

2015/16

2016/17

Scarborough General Hospital 2,481 2,291 2,272 2,190 2,078 2,010 2,103 2,142 1,913 2,003 1,827 1,878 Rouge Valley Centenary 1,463 1,489 1,637 1,531 1,693 1,686 1,584 1,675 1,607 1,643 1,514 1,502 Scarborough Birchmount Hospital 1,787 1,698 1,822 1,599 1,505 1,446 1,364 1,391 1,282 1,145 1,189 1,173 North York General Hospital 922 967 964 962 901 965 880 900 888 849 813 792 Toronto East General Hospital 496 576 582 557 593 576 551 576 529 526 569 502 Sinai Health System - Mount Sinai Site 444 332 363 344 386 382 366 396 394 351 421 439 Sunnybrook Health Sciences Centre 159 169 173 184 211 177 282 281 312 307 312 336 St. Michael's Hospital 165 201 175 198 206 211 201 201 195 172 149 147 Markham Stouffville Hospital 170 139 155 155 128 149 111 130 144 154 146 175 Rouge Valley Ajax and Pickering 39 66 63 63 55 72 69 82 66 84 57 41 Other 171 164 174 150 184 145 156 124 123 119 113 121 Total 8,297 8,092 8,380 7,933 7,940 7,819 7,667 7,898 7,453 7,353 7,110 7,106

14

Key observations:

• In general, Obstetric discharges of Scarborough residents decreased by 14% over the past 11 years, from 8,297 to 7,106. More specifically,

• General site – obstetric discharges decreased by 24%

• Centenary site - obstetric discharges increased by 3%

• Birchmount site - obstetric discharges decreased by 34%

DELIVERY RATES BY PROVIDER

15

Key observations:

• In general, deliveries performed by Family Practitioners and Obstetrics/Gynecologists have decreased and deliveries performed by Midwives have increased. More specifically, including the forecast for 2018/2019:

• Family Practitioners – decreased by 57%

• Midwives – increased by 108%

• Obstetrics/gynecologists – decreased by 25%

MARKET SHARE


MARKET SHARE OVERALL

Hospital market share of pregnancy and childbirth activity Site


2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17

Scarborough General Hospital 30% 28% 27% 28% 26% 26% 27% 27% 26% 27% 26% 26% Rouge Valley Centenary 18% 18% 20% 19% 21% 22% 21% 21% 22% 22% 21% 21% Scarborough Birchmount Hospital 22% 21% 22% 20% 19% 18% 18% 18% 17% 16% 17% 17% North York General Hospital 11% 12% 12% 12% 11% 12% 11% 11% 12% 12% 11% 11% Toronto East General Hospital 6% 7% 7% 7% 7% 7% 7% 7% 7% 7% 8% 7% Sinai Health System - Mount Sinai Site 5% 4% 4% 4% 5% 5% 5% 5% 5% 5% 6% 6% Sunnybrook Health Sciences Centre 2% 2% 2% 2% 3% 2% 4% 4% 4% 4% 4% 5% St. Michael's Hospital 2% 2% 2% 2% 3% 3% 3% 3% 3% 2% 2% 2% Markham Stouffville Hospital 2% 2% 2% 2% 2% 2% 1% 2% 2% 2% 2% 2% Rouge Valley Ajax and Pickering 0% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% Other 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% Total Obstetric Discharges 8,297 8,092 8,380 7,933 7,940 7,819 7,667 7,898 7,453 7,353 7,110 7,106

17

Key observations:

• Market share for the General site and Birchmount site decreased by 4% and 5% respectively since 2005/2006

• Market share for the Centenary site increased by 3% since 2005/2006

• However, since 2012/2013, market share has been declining

• Keeping in mind that the total number of deliveries have decreased by 14% in the Scarborough area


MARKET SHARE (CALCULATING THE DIFFERENCE)

Table 3

Scarborough General Hospital 0 -129 -234 -182 -296 -328 -190 -220 -316 -196 -299 -247 Rouge Valley Centenary 0 62 159 132 293 307 232 282 293 346 260 249 Scarborough Birchmount Hospital 0 -45 17 -110 -205 -238 -287 -310 -323 -439 -342 -357 North York General Hospital 0 68 33 80 19 96 28 22 60 32 23 2 Toronto East General Hospital 0 92 81 83 118 109 93 104 83 86 144 77

Sinai Health System - Mount Sinai 0 -101 -85 -81 -39 -36 -44 -27 -5 -42 41 59 Sunnybrook Health Sciences 0 14 12 32 59 27 135 130 169 166 176 200 St. Michael's Hospital 0 40 8 40 48 56 49 44 47 26 8 6 Markham Stouffville Hospital 0 -27 -17 -8 -35 -11 -46 -32 -9 3 0 29 Rouge Valley Ajax and Pickering 0 28 24 26 18 35 33 45 31 49 24 8 Other 0 -3 1 -13 20 -16 -2 -39 -31 -33 -34 -25 Total 0 0 0 0 0 0 0 0 0 0 0 0

Key observations:

Because of market share changes from 2005/06 to 2016/17:

• The Birchmount site had 357 fewer obstetric discharges in 2016/17 with a decrease of 5% in market share

• The General site had 247 fewer obstetric discharges 2016/2017 with a decrease of 4% in market share

• SHN Centenary had 249 more obstetric discharges in 2016/2017 with an increase of 3% in market share

• Sunnybrook had 200 more obstetric discharges in 2016/2017 with an increase of 5% in market share

Discharges lost and gain bed due to market share changes


Site 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17


MARKET SHARE TRENDS - BIRCHMOUNT

Where did mothers living in the Birchmount site catchment area deliver in the last 3 years (FY 15/16 – FY 17/18)

19

Key observations:

• 31% of mothers in the Birchmount catchment area delivered at the General site while only 24% delivered at the Birchmount site

• Mothers in the Birchmount site catchment area equally delivered at North York General (24%)

• 62% of mothers in the Birchmount catchment area delivered within the SRH network

MARKET SHARE TRENDS - CENTENARY

Where did mothers living in the Centenary site catchment area deliver in the last 3 years (FY 15/16 – FY 17/18)

20

Key observations:

• 41% of mothers living the Centenary site catchment area delivered at the Centenary site

• The General site was the next option mothers living in this area opted to deliver at (20%)

• 74% of mothers in the Centenary catchment area delivered within the SRH network

MARKET SHARE TRENDS - GENERAL

Where did mothers living in the General site catchment area deliver in the last 3 years (FY 15/16 – FY 17/18)

21

Key observations:

• 28% of mothers living the General site catchment area delivered at the General site

• Michael Garron was the next most common hospital mothers living in this area opted to deliver at (19%)

• 56% of mothers in the General catchment area delivered within the SRH network

FY 18 / 19 OUTSIDE CATCHMENT VOLUME OF DELIVERIES

22

Key observations:

• 25% of SRH’s deliveries come from outside the catchment

OBSTETRICS: THE SRH MARKET SHARE AND C ATCH MENT

Scarborough & Rouge Hospital: Catchment and Market Share

Scarborough & Rouge Hospital General Birchmount Centenary Sub-Region

Admissions

Catchment Market

Share

Admissions

Catchment Market

Share

Admissions

Catchment Market

Share

Admissions Catchment Market Share

Scarborough South 3,405 48% 65% 1,303 46% 25% 727 38% 14% 1,375 60% 26% Scarborough North 1,150 16% 61% 575 20% 31% 447 23% 24% 128 6% 7% Durham West 723 10% 19% 144 5% 4% 167 9% 4% 412 18% 11% Eastern York Region 703 10% 17% 413 15% 10% 193 10% 5% 97 4% 2% North York Central 358 5% 8% 121 4% 3% 172 9% 4% 65 3% 2% East 221 3% 6% 118 4% 3% 64 3% 2% 39 2% 1% Durham North East 134 2% 4% 32 1% 1% 30 2% 1% 72 3% 2%

Other 349 5% 0% 124 4% 0% 126 7% 0% 99 4% 0% Total 7,043 100% 5% 2,830 100% 2% 1,926 100% 1% 2,287 100% 1%

Sources: DAD 2016/17

23

Key observations:

• Most of the patients that go to SRH’s Obstetrics admissions come from Scarborough South (48%)

• 65% of Scarborough South’s patients come to SRH for Obstetrics

OBSTETRICS: WHO ELSE SERVES THE SRH C ATCH MENT?

Sub-Region Sub-Region

Admissions Scarborough

& Rouge

Toronto East General Hospital

Sinai Health System

North York General Hospital

Sunnybrook

Markham- Stouffville Hospital

Lakeridge Health

Corporation

Other

Scarborough South 5,226 65% 9% 7% 6% 5% 2% 1% 4% Scarborough North 1,885 61% 2% 3% 24% 4% 3% 0% 3% Durham West 3,831 19% 1% 5% 4% 4% 16% 47% 3% Eastern York Region 4,056 17% 1% 4% 21% 3% 45% 0% 9% North York Central 4,300 8% 6% 8% 49% 14% 1% 0% 14% East 3,771 6% 49% 16% 4% 13% 0% 0% 12% Durham North East 3,435 4% 0% 3% 1% 1% 8% 73% 9% Grand Total 26,504 25% 10% 7% 15% 7% 11% 17% 8%

Sources: DAD 2016/17

24

Key observations:

• 65% of Scarborough South’s patients and 61% of Scarborough North’s patients come to SRH for Obstetrics

• Overall, 25% of the greater Scarborough area come to SRH for Obstetrics, followed by 17% that go to Lakeridge Health Corporation

APPENDIX E

INTERNAL SURVEY Fall 2018

0

INTERNAL SURVEY QUESTIONS

1. What is your role at Scarborough and Rouge Hospital? Physician Nurse Midwife Allied Health Administration Other

2. How long have you been with Scarborough and Rouge Hospital? 0-5 years 5-10 years 10-15 years 15-20 year 20+ years

3. Which site(s) do you primarily work at? Centenary Birchmount General

4.What makes you most proud of the Women’s and Children’s program?

7. When managing a complex situation, I feel like I have the support that I need from my colleagues. Strongly Agree Agree Neutral Disagree (explain why) Strongly Disagree (explain why)

8. What services are critical for the Women’s and Children’s program to offer to meet the needs of women and children in Scarborough?

9. What, if any, services should the Women’s and Children’s program stop offering?

10. What are some new and/or innovative services that the Women’s and Children’s program should offer to meet the needs of women and children in Scarborough?

11. Do you have any other comments or feedback?

5. What are some of the current challenges in the Women’s and Children’s program?

6. I feel that I have the required support (e.g., training, physical resources and access to specialties/clinicians) to deliver excellent quality of care to patients. Strongly Agree Agree Neutral Disagree (explain why) Strongly Disagree (explain why) 1

INTERNAL SURVEY FINDINGS ( 1 /3 )

All current programs!

Resources for Breastfeeding

Specialty clinics

All services under Birthing

Dedicated Obstetrical Anesthesiologist

Paediatrics and all the outpatient clinics associated with it

Adequate staffing of nurses

Massive transfusion protocols

Midwifery

Water Births

Antenatal care

Early pregnancy clinics

Compassionate bereavement care

Services that are inclusive to LGBTQ families and surrogacy

Multicultural approach and knowledge is important in our service deliver

Timely care to triage patients in out-patient department

Doula services

After hours urgent care for Paediatrics

24/7 access to a mental health clinic

MFM perinatal mental health

Telemetry

Educational opportunities for families (e.g., child’s new diagnosis)

Improved ultrasound services

Breastfeeding classes and clinics in-house

Fertility clinics

Prenatal care by frontline staff as part of the hospital culture

Incorporating an Indigenous approach into clinical care

Lactation consultant

Child Life Specialist

Eating disorder program

Increased community outreach into areas of Scarborough the need more paediatric support

Better care for miscarriages and abortion services 2

Better access to leading technology

Question 10: What are some new/innovative services that the Women’s and Children’s program should offer?

Question 8: What services are critical for the Women’s and Children’s program to offer?


3

Question 6: I feel that I have the required support (e.g., training, physical resources and access to specialties/clinicians) to deliver excellent quality of care to patients.

Note:

• Majority of the respondent were Physicians and Nurses (85%)

• Majority have been working at SRH for 10+ years (66%)

• The survey captures an almost equal distribution of respondents across the three sites


4

Note:

• Majority of the respondent were Physicians and Nurses (85%)

• Majority have been working at SRH for 10+ years (66%)

• The survey captures an almost equal distribution of respondents across the three sites

Question 7: When managing a complex situation, I feel like I have the support that I need from my colleagues.

APPENDIX F

PRIMARY CARE PHYSICIAN SURVEY Fall 2018

0

SURVEY QUESTIONS

1. Are you a primary care physician? Yes

2. Is your practice based out of Scarborough? Yes No

3. Which area(s) have you referred patients to within the Women’s and Children’s program at Scarborough and Rouge Hospital? (Select all that apply) Obstetrics for pregnant women Gynecological care Pediatric care Midwifery If none of the above, please explain:

4. What Hospital services are you aware of as part of our Women’s and Children’s program? Some examples of the services we offer are: breastfeeding clinic, pediatric services, obstetrics and gynecology services, colposcopy clinic, birthing and midwifery services.

5. What informs your decision about where to refer a patient? (Select all that apply) Reputation Quality of service Access to specialists Existing relationships Other:

6. What site are you most likely to refer a patient to for a birth? Birchmount General Centenary Other:

7. What barriers have you encountered in accessing services for your patients? Language Location Timely service Other:

8. What is your overall impression of the Women’s and Children’s program services offered by Scarborough and Rouge Hospital?

9. What services are critical for the Women’s and Children’s program to offer to meet the needs of women and children in Scarborough?

10. Do you have any other comments or feedback?

1

PRIMARY CARE PHYSICIAN SURVEY ( 1/ 6)

2

Question 3: Which area(s) have you referred patients to within the Women’s and Children’s program at Scarborough and Rouge Hospital? (Select all that apply)

Note:

• 10 complete responses were received for this survey

PRIMARY CARE PHYSICIAN SURVEY (2 / 6 )

3

Note:


Question 5: What informs your decision about where to refer a patient? (Select all that apply)


4

Note:


Question 6: What site are you most likely to refer a patient to for a birth?


5

Note:


Question 7: What barriers have you encountered in accessing services for your patients?


All of the programs

Breastfeeding

Genetics

Colposcopy

Paediatrics Clinic

Birthing

Midwifery

Mammogram / Breast Screening clinic

Unware the services were part of a “program”

Unware of the “Breastfeeding Clinic” and “Colposcopy Clinic”

For Colposcopy, patients referred directly to Gynecologists

Unclear as to who is involved (personnel-wise)

Good

Excellent

Patients like it

Individual relationships are good

Could use more advertising on non-medical services (e.g., breastfeeding clinics)

Need more psychiatry options for post-partum patients

6

Question 4: What hospital services are you aware of as part of our Women’s and Children’s program? (Some examples of the services we offer are: breastfeeding clinic, pediatric services, obstetrics and gynecology services, colposcopy clinic, birthing and midwifery services.)

Question 8: What is your overall impression of the Women’s and Children’s program services offered by Scarborough and Rouge Hospital?


All of the programs

OB, high risk

Domestic violence / abuse counselling

General gynecological / OB and Paediatric care

Mental Health services

Developmental Pediatrics and speech and language

Pediatric psychiatry and psychotherapy

Delivery and Inpatient services - other services could potentially be offered in community or at the hospital as a hub site

Verification of referral

Timely communication

Advertise the program to family doctors

Challenge with dealing in cultural differences across the sites

Need for Paediatrics for ER coverage, so would be difficult to close one obstetrical site (e.g., Birchmount)

An updated mailing of current services, including Galaxy and list of current OBS/GYN doctors

A better understanding of the Paediatrics services which are an extension of hospital for SickKids referrals

Some HSC referrals are carried out by off site providers (e.g. Galaxy)

7

Question 9: What services are critical for the Women’s and Children’s program to offer to meet the needs of women and children in Scarborough

Question 10: Do you have any other comments of feedback?

APPENDIX G

Crestview Strategies Survey Questions

What are the most important factors in making the choice of where to have a baby?

Obstetrician or other health team of my choice Close to home/travel time Programs and other supports available Reputation Referral from my family doctor Word of Mouth Other:

If you are expecting or have become a parent in the past 5 years, are you choosing to have a...

Hospital birth at Scarborough and Rouge Hospital - Birchmount Hospital Hospital birth at Scarbough and Rouge Hospital - Centenary Hospital Hospital birth at Scarborough and Rough Hospital - General Hospital Home Birth Birth at Birthing Centre This question does not apply to me Other hospital

If you are expecting or have become a parent in the past 5 years, which health care professional will/did you choose to deliver your baby?

Obstetrician Midwife Family Physician

Which services are important for you in making your decision of where to give birth (i.e. pre-birth education classes)?

What additional services would you like to see in a future Women’s and Children’s program at Scarborough and Rouge Hospital?

How could Scarborough and Rouge Hospital improve the experience of parents through their pregnancies and after they have a baby?

APPENDIX H

WALLPAPER EXERCISE FINDINGS Fall 2018

0

WALLPAPER EXERCISE

Educated staff with an emphasis on continuous learning

Modern, clean facility & units

Up-to-date equipment

Accessible to the community

All services required for the program to be co-located

Properly and adequately funded

Provide proper guidance to patients during registration (e.g., NST)

Family centered care after delivery

Safe

Respect for diversity

Improved EPAC clinics

Full-time lactation consultants

1

Question: What should the Women’s and Children’s program aspire to be in the eyes of the community?

APPENDIX I

Ambulance

Ambulance

Midwife

Total 14 4 1 0 0 3

Mode of Transportation #

Site

Postal Code

Date

Time

My own car or family car

Someone drove me in their car (not mine or my family's car)

Taxi or ride hailing service

Public transit

By foot

Other

1 C M1C 1K9 18-Oct-18 2000 1


Site

Postal Code

Date

Time




Public transit

By foot

Other

1 B M2J 1L9 18-Oct-18 1000 1 2 B M1R 2X8 18-Oct-18 1445 1 3 B M1E 1L7 19-Oct-18 1700 1 4 B L4B 0C2 19-Oct-18 0230 1 5 B M1W 3B5 20-Oct-18 0835 1 6 B N3W 0B3 20-Oct-18 1915 1 7 B M1K 2M7 20-Oct-18 1055 1 8 B M1B 1Z9 20-Oct-18 1615 1 9 B M4C 5A2 21-Oct-18 0213 1 10 B M1K 4H6 22-Oct-18 0955 1 11 B L1J 1C2 22-Oct-18 0340 1 12 B M1J 1Z5 22-Oct-18 0000 1 13 B M2N 2T5 22-Oct-18 0350 1 14 B M1L 3N2 31-Oct-18 0221 1 15 B M2J 4R2 31-Oct-18 0057 1 16 B M3A 2E9 31-Oct-18 2323 1 17 B M1H 3H8 31-Oct-18 0640 1 18 B M1C 3R8 31-Oct-18 0623 1 19 B L3S 1S8 31-Oct-18 1631 1 20 B M1E 5H3 31-Oct-18 1053 1 21 B MEA 2P7 31-Oct-18 2024 1 22 B M1V 1E8 31-Oct-18 0829 1

2 C M1S 4L1 18-Oct-18 1400 1 3 C L1J 4K3 18-Oct-18 1100 1 4 C L1V 7H3 18-Oct-18 1137 1 5 C M1E 5H2 18-Oct-18 1054 1 6 C M3A 2Y2 18-Oct-18 0705 1 7 C M1H 2R3 18-Oct-18 2100 1 8 C M1X 1V7 18-Oct-18 1100 1 9 C M1E 2L1 18-Oct-18 0900 1 10 C M1B 3S3 19-Oct-18 1350 1 11 C L1S 7R6 19-Oct-18 1300 1 12 C M1E 3G5 19-Oct-18 0810 1 13 C M1B 6JC 20-Oct-18 0830 1 14 C M1C 1W5 20-Oct-18 0830 1 15 C M1E 1G6 21-Oct-18 1330 1 16 C M1P 5B9 21-Oct-18 1430 1 17 C M1E 5H3 21-Oct-18 1012 1 18 C M1J 2G9 21-Oct-18 0800 1 19 C L1T 4H2 22-Oct-18 1300 1 20 C M1P 3J2 22-Oct-18 0900 1 21 C M1E 2E8 22-Oct-18 1845 1 22 C M1E 3S3 22-Oct-18 1235 1 23 C M1J 2G8 22-Oct-18 0630 1 24 C M1P 4V9 23-Oct-18 0756 1 25 C L1N 2R3 23-Oct-18 0900 1 26 C L1Z 0S3 23-Oct-18 0810 1 27 C L1W 2X6 23-Oct-18 1040 1 28 C L1T 4P6 24-Oct-18 0820 1 29 C L3S 3V5 24-Oct-18 0700 1 30 C L0C 1H0 24-Oct-18 0720 1 31 C M1C 5H4 24-Oct-18 0753 1 32 C M1B 2P6 24-Oct-18 0920 1 33 C L1G 1X6 24-Oct-18 0715 1 34 C M1B 2C4 24-Oct-18 2300 1 35 C M1B 5E9 24-Oct-18 1244 1

Did not specify

Total 48 3 0 0 0 1


Site

Postal Code

Date

Time




Public transit

By foot

Other

1 G M1E 2T5 19-Oct-18 2352 1 2 G M1H 1V1 19-Oct-18 2255 1 3 G L3S 4M8 19-Oct-18 2027 1 4 G M1K 2W7 19-Oct-18 1654 1 5 G M1K 1P4 19-Oct-18 1640 1 6 G M1S 5B2 19-Oct-18 1307 1 7 G L3S 3E2 20-Oct-18 0712 1 8 G M1W 3X8 20-Oct-18 0425 1 9 G M1E 4W5 20-Oct-18 0200 1 10 G L3S 4M9 20-Oct-18 2350 1 11 G M1B 1T5 20-Oct-18 0630 1

36 C M1E 4V4 25-Oct-18 1239 1 37 C L1M 1E6 25-Oct-18 1130 1 38 C M1B 4N5 25-Oct-18 1203 1 39 C M1B 2H9 25-Oct-18 1636 1 40 C L3P 7A3 25-Oct-18 0230 1 41 C M6N 4L3 26-Oct-18 1415 1 42 C L1S 3R9 27-Oct-18 0805 1 43 C M1S 1V7 27-Oct-18 1811 1 44 C M1C 0C8 28-Oct-18 0830 1 45 C L1T 2B1 28-Oct-18 0740 1 46 C M1J 3L6 28-Oct-18 0830 1 47 C M1B 1Z6 28-Oct-18 0846 1 48 C L6B 0C3 29-Oct-18 1044 1 49 C M1C 1A9 29-Oct-18 0806 1 50 C M1E 3Y7 29-Oct-18 1955 1 51 C M1E 4S8 29-Oct-18 0643 1 52 C M1X 1T2 29-Oct-18 0720 1

12 G M1J 1J5 20-Oct-18 0957 1 13 G M1G 1H6 21-Oct-18 1200 1 14 G M4C 5N3 22-Oct-18 1248 1 15 G L1T 3K6 22-Oct-18 1157 1 16 G M1P 4S9 22-Oct-18 2307 1 17 G L6C 2C7 22-Oct-18 1149 1 18 G L1Z 1G4 22-Oct-18 0642 1 19 G M1J 1T7 23-Oct-18 2220 1 20 G L6E 0R7 23-Oct-18 0117 1 21 G M1E 3S5 23-Oct-18 0434 1 22 G M1L 0B3 23-Oct-18 0411 1 23 G M1B 2R4 23-Oct-18 1313 1 24 G L1M 1K3 23-Oct-18 1200 1 25 G L3R 2L8 23-Oct-18 0603 1 26 G M1V 4X7 23-Oct-18 0155 1 27 G M1B 2P4 23-Oct-18 0001 1 28 G M1V 3G4 24-Oct-18 1208 1 29 G M1K 1R8 24-Oct-18 0955 1 30 G M3A 1E3 24-Oct-18 0121 1 31 G M1M 3W2 24-Oct-18 0413 1 32 G M1P 0A9 24-Oct-18 1651 1 33 G M1W 2B4 24-Oct-18 1812 1 34 G M6G 3X3 24-Oct-18 2010 1 35 G M3A 1Y8 24-Oct-18 2202 1 36 G M1L 1S1 25-Oct-18 0427 1 37 G M1X 1V3 25-Oct-18 0620 1 38 G M1B 2Z8 26-Oct-18 0345 1 39 G M1J 1J5 26-Oct-18 1 40 G M1T 0A4 26-Oct-18 0835 1 41 G L3S 3G5 26-Oct-18 1625 1 42 G M1B 1Y1 26-Oct-18 1820 1 43 G M1K 2M7 27-Oct-18 0910 1 44 G L3S 3B4 27-Oct-18 0952 1 45 G M1B 1Z5 27-Oct-18 1314 1

46 G M1E 2S7 27-Oct-18 1800 1 Total 43 1 2 0 0 0

APPENDIX J

WOMAN’S AND CHILDREN’S VACANCIES August 22, 2018

SITE

VACANCIES

HIRING STATUS

SKILL MIX CURRENT VACANCIES

Centenary Site (Obstetrics)

4 Temporary Full Time RNs

Hired 2 temporary full time RNs

One experienced new hire

One new grad (will require six weeks orientation)


2 Permanent Full Time RNs Hired two Full time RNs Fully trained obstetrical nurses

No vacancies

4 Temporary Part time RNs Will convert to positions to permanent part time

4 Temporary Part time RNs

2 Permanent Part time Hired two Permanent Part

Time

Fully skilled No vacancies

1 Part time RPN

Filled

Transfer from surgery _ has post-partum

experience (will need 3 weeks of orientation)

No vacancies

Summary of Centenary vacancies


4 Temporary Part Time RNs

No outstanding NICU or Peds vacancies

75% of Staff are Senior

SITE

VACANCIES

HIRING STATUS

SKILL MIX CURRENT

VACANCIES

General Site (Obstetrics)

1 Part Time RN Interview scheduled for August 24th, 2018

1 Part time RN vacancy

Summary of General

vacancies

1 Part Time RN

No outstanding NICU or Peads vacancies

80% are Senior Staff

Birchmount Site (Obstetrics)

30 Full Time and Part Time RN positions

3 Part Time RN

No appropriate resumes received

Interviews scheduled with 3 new grads (awaiting their

license)

3 Part Time RN

2 Part Time RPN Interview scheduled for

August 23, 2018

2 Part Time RPN

Summary of Birchmount vacancies

14 of 30 RNs staff are juniors = 47%

6 of 14 RNP staff are juniors = 43%

Birchmount Site

(NICU)

2 Part Time RN

4 of 19 RNs staff are juniors = 20%

Birchmount Site

(Pediatrics)

0 vacancies

2 of 12 RN staff are juniors = 16 %

APPENDIX K

Women & Children’s Program Nursing Staff Skill Mix December 2018

Birthing Services - RNs Birchmount Centenary General # FT RN 19 26 25 # PT RN 12 15 18 # of New Grads 10 6 11 # of experienced RNs* 18 35 32 Total Number of Permanent RN Positions

31 41 43

% Skill Mix RN 18/31= 58% are experienced

35/41= 85% are experienced


*experienced = 3 years of experience: high risk assessment, triage, circulating and scrub nurse for C-section cases, and charge role

Birthing Services - RPNs

Birchmount Centenary General # FT RPN 4 5 6 # PT RPN 9 5 8 # of new grads RPN 7 0 1 # of experienced RPNs* 6 10 13 Total Number of Permanent RPN positions

13 10 14

% Skill Mix RPN 6/13= 46% are experienced



*experienced = 1-2 years of experience: scrubbing for C-section

NICU - RNs Birchmount Centenary General # FT RN 8 26 11 # PT RN 11 3 11 # of New Grads 5 3 3 # of experienced RNs* 9 26 19 Total Number of Permanent RN Positions

19 29 22




*experienced = 2-3 years of experience: primary nurse at high risk deliveries, IVs, and charge nurse

Pediatrics- RNs December 2018

Birchmount Centenary General # FT RN 4 16 4 # PT RN 8 7 7 # of New Grads 3 4 0 # of experienced RNs* 9 19 12 Total Number of Permanent RN Positions

12 23 12


19/23 83% are experienced


*experienced = 2 years of experience: charge (adding PALS as a pre-requisite for hiring)

APPENDIX L

SRH – Women’s and Children’s Program

Interview Guide Objectives:

- To understand the current state of the program

- To understand the unqiue strengths and specific challenges

- To understand what opportunities exist to improve the program in the future

Probing Questions:

1. What are the unique strengths of the services we offer our community that you feel we should seek to preserve and strengthen?

2. What are the specific challenges that we currently face in delivering these services to our

community that we must seek to improve?

3. Now that we are “Scarborough Health Network” (SHN), with our new Strategic Plan, Mission, Vision and Values; what do you feel are the opportunities to provide the highest quality, patient centred, cost effective and sustainable serves to our community?

4. Anything else you would like to tell us.

APPENDIX M

SRH – Women’s and Children’s Program

Focus Group – Interview Guide Objectives:

- To validate and build upon the interview findings

- To understand how people imagine the future state of the program

- To understand what makes people excited and nervous about the future

Introduction:

- The purpose of today’s focus group session is to get your input on the current state of the Women and Children’s program and the potential future state of the program

Probing Questions:

Current State

- We are going to start by getting a deeper understanding of the current state of the Women and Children’s program at SRH.

1. What makes the Women and Children’s program at SRH unique from other hospital or community programs?

2. What are some of the challenges the program faces currently? How are these challenges similar or different across sites?

Probe on the following topics:

• Ability to utilize skill sets

• Volume of work

Future State

- We now want to switch gears to thinking about the future. For this next part, we want you to think about how you picture the Women and Children’s program in the future, and what needs to be done in the near term (1-3 years) in order to address some of the current state challenges and prepare for the future. We know that the current model of care for the Women and Children’s program is not sustainable in the long term, so we want to think beyond our current structure to what it could be in the future.

1. What should the program look like in the future?

2. How should the program be organized?

3. What skills and capabilities do we need?

- To close, we want to understand how you are feeling about the future.

4. What makes you most excited about the future?

5. What makes you nervous about the future?

APPENDIX N

F U T U R E S E RV I C E D E L I V E RY M O D E L F O R T H E W O M E N ’ S A N D C H I L D R E N ’ S P R O G R A M C O - D E S I G N S E S S I O N # 1 Department of Obstetrics and Gynaecology, and Women’s and Children’s Program

2

A few words from our CEO, Liz Buller

3

Opening remarks from Linda Calhoun &

Dick Zoutman

4

STRATEGIC DIRECTION

4

YOUR FACILI TATO RS

Lisa Purdy Dr. Johan Viljoen Kristin Mendoza

5

Hello, my name is

.

TODAY’S OBJECTIVES

• Clear understanding amongst participants of the purpose of the review • Gain alignment on who we are serving and what services should be offered

• Gain an understanding on how the services interact with each other and clearly

articulate the interdependencies within the services • Discuss the future state governance model for the program

7

OUR PLAN FOR THE EVENING

5:00PM – 5:30PM Opening Remarks & Introductions

5:30PM – 5:55PM Context, Guiding Principles & Case Examples

5:55PM – 6:10PM Activity #1: Who Are We Serving?

6:10PM – 7:00PM Activity #2: What Services Are We Offering?

7:00PM – 7:20PM Dinner Break

7:20PM – 8:05PM Activity #3: How Do The Services Interact?

8:05PM – 8:45PM Activity #4: How Is The Program Governed?

8:45PM – 9:00PM Next Steps

8

RULES OF ENGAGEMENT

1. Be respectful Treat all members as equals, allowing everyone to share their input freely and respecting their unique point of view.

2. Challenge yourself and the status quo Share your thoughts freely, ask probing questions and constructively challenge ideas.

3. Be patient-centered Consider the perspective of patients and families and ensure their needs remain at the forefront of decision-making.

4. Own the future Take ownership of the future state vision; all members should be engaged and actively involved in shaping the future.

5. Think holistically Think beyond your current role. When making decisions and providing input, think holistically about SHN and the broader healthcare

system.

6. Respect confidentiality Please do not share documents, decisions or outcomes of the sessions beyond this group, without previous approval.

9

PROJECT GUIDING PRINCIPLES

• A commitment to high-quality and safe patient care

• An ongoing commitment to SHN’s newly established vision statement, Canada’s leading community teaching health network – transforming your health experience, and value statements, Compassionate, Inclusive, Courageous, Innovative

• An ongoing commitment to integration of services and improving services through collaboration, accessibility, sustainability and excellence

• Acknowledgement that change is needed and has been a long time coming; there is no appetite for the status quo that is unsustainable, it is time for decision and action

• A commitment to continue active community engagement and participation in system redesign

• A commitment to working with each other as well as advancing broader health system transformation

• A commitment to maintain alignment with the Master Planning activities currently underway

• An acknowledgement of the significant change management challenges and a commitment to leverage our shared cultures of continuous improvement to mitigate risks that threaten timely and effective implementation of integration opportunities

10

DECISION MAKING CRITERIA

11

Strategic Fit

• Consistency and alignment with SHN’s Strategic Plan and Master Planning

Quality

• Ability to consistently deliver the highest quality of service for Scarborough Health Network patients and clients that meets or exceeds industry best standards

• Ability to access a range of specialists and subspecialists relevant to patient needs

• Ability to capture data required to measure and monitor clinical outcomes

Access • Ability to provide access to high quality care

• Ability to provide patients with access to care that reflects the diversity of the population being served

• Ability to leverage external partnerships and relationships to improve access to care and quality of care

Sustainability

• Ability to make efficient use of our assets (e.g., operating rooms, beds, equipment, etc.)

• Ability to make efficient use of our talent and staff (e.g., recruitment & retention, supports for the services delivered (e.g., dedicated anesthesiology), manage fluctuations, maximize skillsets, etc.)



Patient-Centric

• Ability to limit the number of hand-offs and strive to provide a seamless experience for patients

• Ability to create a welcoming and functional physical environment to enhance patient experience

WHAT ARE WE SEEING ELSEWHERE

TAKE HOME HPV SCREENING INNO VAT ION IN C A R E MODE L S

13

Observed or Intended Outcomes

Intended outcome is to increase access to HPV screening for women who are uncomfortable or experience difficulty getting to an appointment for a physical exam, leading to improved health outcomes for this patient population

Model Description

The (HPV) screening program provides women with a kit they can take home to collect a vaginal sample. After dropping their test into any Canada Post box, results are then available online through a secure portal within a week.

EARLY PREGNANCY UNIT INNO VAT ION IN C A R E MODE L S

14

Observed or Intended Outcomes This service functions effectively and assists in the reduction of ED visits as well as providing early intervention, counseling and support to women at a very sensitive time.

Model Description

The early pregnancy unit provides a flexible ‘women- centred’ model of service delivery, where women in early pregnancy gain timely access to be assessed and treated for complications, and receive appropriate counseling and follow-up care by experienced doctors.

REMOTE MONITORING INNO VAT ION IN C A R E MODE L S

15

Observed or Intended Outcomes

• Remote, real time measurement and reporting of vitals

• Releases acute care resources • Enables informed follow-up between clinicians and

patients in discussing their care

Model Description

Remote Monitoring technologies allow health care providers and hospitals to track patients’ vital signs and other clinical data from the comfort of their own home without having to keep them in hospitals. These solutions allow clinicians to set clinical parameters and links to patients through the app via text or video.

TELEMEDICINE INNO VAT ION IN C A R E MODE L S

16

Model Description

Telemedicine is the use of communications and information technology to deliver health and health care services, information and education where clinicians and patients are physically separated.

Another tool - developing a secure online shared care plan available to all caregivers (parents, physicians and therapists) that will serve children living at home with rare, complicated and life-threatening health problems. It will include appointment scheduling and communication capabilities in addition to the shared care plan.

Observed or Intended Outcomes • Increases access to medical specialty consultations • Reduces travel time for patients and cost savings for families • Enables professionals to maintain and enhance their continuing

medical education • Ensures continuity in treatment • Reduces the need for hospitalization and emergency room visits

xtraordinary Caring. Every Person. Every Time.

SHN:J 11

ACTIVITY # 1 Who are we serving?

WHO ARE WE TRYING TO SERVE?

Women and children from neighbouring communities

Women and children who don’t have access to private transportation Women and children who

want the best possible care for themselves and their families

Women, children and their families that live in Scarborough

Women and children who would tend to drive out of Scarborough to a hospital downtown

Women and children who have access to private transportation

19

ACTIVITY #1

Discussion Question:

• Are there any specific parts of our community that we want to keep in mind as we move forward with the future model?

Instructions:

• In small groups, with the people sitting around you, please discuss this question for 5 minutes

• We will then share out as a group

20

Objective: Gain alignment on who we are trying to serve as part of the Women’s and Children’s program

To Consider …

• During the consultations most of you said that our diversity and our ability to serve a diverse population was a primary strength of SRH.

ACTIVITY # 2 What services are we offering?

SERVICE MAP – CURRENT S TATE

Neonatal Follow-up Clinic

Essential Clinical Services

Obstetrics Paediatrics Gynaecology Services delivered in collaboration with another org.

Sexual Assault & Domestic Violence Clinic

Emergency Department

EMS

Interventional Radiology

Anesthesiology

Scoliosis Clinic

Hematology Clinic

Inpatient Medicine

Paedlink/Short Stay Clinic Pediatric Day/Consult Clinic

Paediatric Day Surgery

Pediatric Occupation Therapy (to age 7)

Neurology Clinic

Ambulatory Outpatient

Diabetes & Nutrition/Diabetic Education

Respiratory Syncytial Virus Prevention Clinic Immunology/Allergy Clinic

Adolescent Medicine Clinic Gestational Diabetes Education Clinic

Preschool Speech and Language Services

Asthma Clinic

Healthy Outcomes for Pediatric Program

Regional Child & Adolescent Mental Health Program

Dermatology Clinic

Nephrology Clinic Rheumatology Clinic

Gastroenterology Clinic Constipation Clinic

22

Pre-Natal

Non-stress Testing Genetics Clinic

EPAC Breastfeeding Classes

Maternal Fetal Medicine

Birthing

Pediatric Day Surgery Pediatric pre-operative and post-operative care

Inpatient Pediatric Beds (medical/surgical) Pulse Dye Laser Surgeries

Gynaecology

Gynaecology Day Surgery Gynaecology In-patient

Services delivered through collaborations

Paediatric Oncology (SickKids) Sickle Cell Disease (SickKids)

Endocrinology (Community- based paed. Staff)

Cardiology (Community-based paed. Staff)

Respirology (Community-based paed. Staff)

Infectious Disease (Community- based paed. Staff) Till I Sleep/Prenatal Presence at

Induction Program

Family Maternity Centre

Birthing Centre

Neonatal Intensive Care Unit (level llb)

Midwifery Services

Neonatal Intensive Care Unit (level llc)

Neonatal Bereavement Program

Breastfeeding Clinic

Doula Services

Post-Natal

Infant Hearing Program in collab. with TPH

Breastfeeding Support in collab. with TPH

Lactation/Newborn Assessment Clinic

Living and Learning with Baby in collab. with TPH

Psychiatric Mental Health program

ACTIVITY #2

Overview:

• We want to understand what the full suite of services that the Women’s and Children’s program should be offering are, regardless of site or location

• We also want to understand if there are any gaps in our current services or other modifications we should make

Instructions:

• We are going to break into small groups, as assigned

• We will work together in small groups for 20 minutes and then share out and discuss as a group

• We will be providing you with some guidance around the potential future state model from the Master Planning activities – please use this as a 23 reference

Objective: Gain alignment on the services the program should be offering

To Consider …

• What are the unmet needs of your patients?

• What issues are they facing that could be addressed?

• What do they need beyond labour and delivery?

Activity 2: Obstetrics What services should we be offering in the new operating model that add value and enhance patient care?

PLEASE REFER TO THE ‘CURRENT SERVICES MAP’ FOR A LIST OF SERVICES UNDER EACH CATEGORY

REMINDER: if any of your answers are specific to a single service, please clarify that by adding the service name in brackets.

To Consider … • What are the unmet needs of your patients? • What issues are they facing that could be addressed? • What do they need beyond labour and delivery?

Are there any services we should consider delivering differently?

What services should we consider adding? Is there anything we should change about existing services?

Post-Natal



Birthing



Pre-Natal

BREAK OUT GROUPS (1 / 2 )

Focus Area: Obstetrics

Lecture Theatre Dr. Colette Rutherford Obstetrician & Gynaecologist Dr. Michael Silver Obstetrician & Gynaecologist Dr. Leah Tattum Paediatrician Dr. Jeremy Hew Anaesthetist Dr. Michael Chapman Surgeon Dr. Sandy Finkelstein Internal Medicine Claudette Leduc Midwife

25

Irene Strickland Centre Dr. Georgina Wilcock Obstetrician & Gynaecologist Dr. Caroline Huh Obstetrician & Gynaecologist Dr. Vinod Raghubir Paediatrician Dr. John Oyston Anaesthetist Dr. Jon Hummel Surgeon Tama Cross Midwife Susan Easton Social Worker

Videoconference Room Dr. Sam Ko Obstetrician & Gynaecologist Dr. David Samra Obstetrician & Gynaecologist Dr. Jing Qin Obstetrician & Gynaecologist Dr. Mojgan Davallou Anaesthetist Dr. David Esser Surgical Assistant Nazima Khan Obstetrical Nurse Kamani Abdul Clinical Practice Leader, NICU


Focus Area: Paediatrics

26

Mabel Crolly Boardroom Dr. Peter Azzopardi Paediatrician Dr. Latifa Yeung Paediatrician Dr. Norman Chu Emergency Medicine Nadia Rampersaud Clinical Practice Leader, Respiratory

Therapy Lindsay Forsey NICU Nurse Meghan Cellamare Clinical Practice Leader, Obstetrics

Admin Conference Room Dr. Karen Chang Paediatrician Dr. Stephanie Kay Paediatrician

Dr. Nina Venkatarangam Obstetrician & Gynaecologist Michelle O’Connor Manager

Sook Park Paediatric Nurse Carolyn Tyson Patient Family Advisor

POTENTIAL FUTURE STATE MODEL (1 / 4 )

Maternal Child and NICU Clinic Based Care: Screening, Antenatal Care and Follow-up

27

Overview of Model of Care

• Obstetrics including high risk obstetrics, gynecology, and other women’s health services • Comprehensive antenatal risk assessment, patient education and prenatal and antenatal services • Patients will be engaged early to develop a personalized birthing plan that will include:

o Obstetricians, Midwives, and Family Physicians for delivery o Type of birth

• Postnatal teaching, education and support • Day care and support services will be provided to improve access to care • Community based postnatal care and follow-up will also include a visiting program, where nurses perform visits to support

patients in their homes • In the future model of care the sexual assault program will be incorporated into the Emergency Program rather than the

Maternal Child and Pediatric Program Types Types of clinics to be included:

• Interprofessional Obstetrical Clinic • Gestational Diabetes Mellitus Clinic • Maternal Fetal Medicine Clinic • Antenatal/Parenting Clinic • Breastfeeding Clinic • Genetics Clinic • NST Clinic


Maternal Child and NICU Inpatient: Maternity/NICU


• The model of care will be a fully integrated Labour Birth Recovery Postpartum (LBRP) model of service delivery to improve continuity of care and health outcomes

• The program will expand the scope of services it provides to support patients as they prepare for birth o The program will develop its own in house program to support unit tours, birthing and new parent classes o The program will partner with Toronto Public Health to provide accessible screening and clinics

• The NICU will be co-located with maternity and labour and delivery services to ensure continuity of care and patient/family inclusive care

• A graduated model of care will inform NICU services: o In collaboration with Hospital for Sick Children and partnerships such as Kids Health Alliance (KHA), the NICU will be

equipped to manage appropriate higher intensity level of care patients. o A NICU step down unit will support patients requiring lower acuity support

28


Paediatrics Clinic Based Care: Pre-Disease, Early Diagnosis, Follow-up


• Integrated care model that addresses the needs of the whole patient and family from early diagnosis to treatment and transition back to primary care by providing as much of that paediatric emergency, inpatient and subspecialty care as close to home as possible

• Model will enable and support early discharge post an emergent event and or acute event by enabling access to immediate services outside of the hospital

• Day care and support services will be provided to improve access to care • An electronic patient portal will provide education, navigation and community forum

Types Types of clinics to be included: • Pediatric Urgent After Hours Care • Pediatric Complex Care • Transitional Aged Youth Program to serve patients aged 17-19 as they transition care • Pediatric subspecialty medical and surgical clinics

29


Paediatrics Emergent Care

Paediatrics Inpatient

30


• Integrated care model where community supports are engaged early and throughout inpatient care and focus on the whole patient. The model will take an understanding of the patient in relation to the family unit and will be supportive and inclusive

• Services will be co-located to ensure patients receive care from specialized staff and to provide care in a an environment that is age appropriate and supports patients from infancy through adolescence

• Building on the success of the Ronald McDonald room, the program will provide spaces for socialization and for family overnight stays


• Building on the success of the PAEDLINK and pediatric outpatient day program, specialized triage and fast track process for pediatric population

• Separate waiting area • Support of families and loved ones during the patient journey through ongoing communication and education • Presence of child care and physical spaces in the emergency department to support families and improve accessibility of care

DINNER BREAK

ACTIVITY # 3 How do the services interact?

ACTIVITY #3

Overview:

• We want to understand how the services interact with each other; what services need to be physically situated in the same location and what services need to be accessed

Instructions:

• We are going to break into small groups, as assigned


33

Objective: Gain an understanding of how the services interact with each other; clearly articulate the interdependencies within the services

To Consider …

• Think beyond the current state and what we have been doing to date

• Try to move beyond preconceived notions to what could be possible


Focus Area: Obstetrics

Lecture Theatre Dr. Colette Rutherford Obstetrician & Gynaecologist Dr. Michael Silver Obstetrician & Gynaecologist Dr. Leah Tattum Paediatrician Dr. Jeremy Hew Anaesthetist Dr. Michael Chapman Surgeon Dr. Sandy Finkelstein Internal Medicine Claudette Leduc Midwife

34

Irene Strickland Centre Dr. Georgina Wilcock Obstetrician & Gynaecologist Dr. Caroline Huh Obstetrician & Gynaecologist Dr. Vinod Raghubir Paediatrician Dr. John Oyston Anaesthetist Dr. Jon Hummel Surgeon Tama Cross Midwife Susan Easton Social Worker

Videoconference Room Dr. Sam Ko Obstetrician & Gynaecologist Dr. David Samra Obstetrician & Gynaecologist Dr. Jing Qin Obstetrician & Gynaecologist Dr. Mojgan Davallou Anaesthetist Dr. David Esser Surgical Assistant Nazima Khan Obstetrical Nurse Kamani Abdul Clinical Practice Leader, NICU


Focus Area: Paediatrics

35

Mabel Crolly Boardroom Dr. Peter Azzopardi Paediatrician Dr. Latifa Yeung Paediatrician Dr. Norman Chu Emergency Medicine Nadia Rampersaud Clinical Practice Leader, Respiratory

Therapy Lindsay Forsey NICU Nurse Meghan Cellamare Clinical Practice Leader, Obstetrics

Admin Conference Room Dr. Karen Chang Paediatrician Dr. Stephanie Kay Paediatrician

Dr. Nina Venkatarangam Obstetrician & Gynaecologist Michelle O’Connor Manager

Sook Park Paediatric Nurse Carolyn Tyson Patient Family Advisor

Activity 3: Obstetrics What are the interdependencies between services and what other requirements are needed to provide optimal patient care and experience?

PLEASE REFER TO THE ‘CURRENT SERVICES MAP’ ATTACHED WITH THIS PAGE TO COMPLETE THIS WORKSHEET

REMINDER: if any of your answers are specific to a single service, please clarify that by adding the service name in brackets.

To Consider … • Think beyond the current state and what we have

been doing to date • Try to move beyond preconceived notions to what

could be possible

Are there any other services (outside this category) that you need to be in the same physical location as?

What diagnostic support do you need to deliver these services?

What skills and competencies do you need to deliver these services?

Post-Natal




Birthing




Pre-Natal

ACTIVITY # 4 How is the program governed?

BEST PRACTICES IN PROGRAM GOVERNANCE

Cohesive & United: Governance structure is coordinated across all areas of the program and different sites; areas of the program do not operate in silos - they operate in a united fashion

Simple & Efficient: Governance and decision-making is easy to understand and navigate, minimizing bureaucracy and administration

Empowerment & Ownership: Program areas are empowered and take ownership of decision- making in their area; escalated decisions are supported by clear recommendations

Content Rich, Data Light: Decision-making is supported by the quality (content rich), rather than the quantity (data heavy) of information; depth of analysis is proportionate to the risk and impact of the decision (avoid analysis paralysis)

One Decision, One Voice: Discussion and debate within governance forums is welcomed; once made, all parties are united in the decision

Documentation & Communication: All decisions are clearly documented and communicated to relevant stakeholders in a timely manner

Govern the Governance: Monitor and adapt governance to ensure it is working as intended / designed 38

ACTIVITY #4

Overview:

• We want to get your input on how the program should be governed

Instructions:

• We are going to break into small groups and work on developing what a new governance model for the program could look like


39

Objective: Articulate and align on core aspects of the governance model

To Consider …

• Governance has two aspects to it

Clinical governance

Administrative governance

Activity 4: Program Governance What should the Women's and Children's program governance structure look like?

To Consider … • Governance has two aspects to it Clinical governance Administrative governance

REMINDER: please only use titles – do not use individuals names!

Sample governance structure

What do you hope this new structure will accomplish?

MOVING FORWARD

CO- DESIGN SESSION # 2 AGENDA This agenda is for the co-design session on October 30th.

Objectives:

• Gain alignment on how the services should be delivered, including:

o Processes and standards

o Partnerships / alternative delivery models

• Develop and align on an implementation roadmap with clear objectives and milestones to achieve

• Align on key considerations moving forward, including any subsequent decisions that need to be made

Agenda:

42

5:00PM – 5:20PM Opening Remarks

5:20PM – 5:40PM Recap from Session #1

5:40PM – 6:50PM Activity #1: How Should We Be Configured? [Part 1]


7:10PM – 7:45PM Activity #1: How Should We Be Configured? [Part 2]

7:45PM – 8:30PM Activity #2: Implementation Roadmap

8:30PM – 9:00PM Next Steps

Thanks for coming – See you on October 30th

F U T U R E S E RV I C E D E L I V E RY M O D E L F O R T H E W O M E N ’ S A N D C H I L D R E N ’ S P R O G R A M C O - D E S I G N S E S S I O N # 2 Department of Obstetrics and Gynaecology, and Women’s and Children’s Program

TODAY’S OBJECTIVES

• Gain alignment on the current context and planning realities that will inform the future model

• Gain alignment on the future state model for the Women’s and Children’s program,

based on major categories of service and principles for service distribution across SRH

2

OUR PLAN FOR THE EVENING

5:00PM – 5:10PM Opening Remarks

5:10PM – 5:40PM Capital Planning Analysis

5:40PM – 6:30PM Stakes in the Ground

6:30PM – 7:00PM Activity #1: Configuring “Core” Services


7:30PM – 8:30PM Activity #2: Configuring Other Program Services

8:30PM – 9:00PM Alignment & Next Steps

3

RULES OF ENGAGEMENT

1. Be respectful Treat all members as equals, allowing everyone to share their input freely and respecting their unique point of view.

2. Challenge yourself and the status quo Share your thoughts freely, ask probing questions and constructively challenge ideas.

3. Be patient-centered Consider the perspective of patients and families and ensure their needs remain at the forefront of decision-making.

4. Own the future Take ownership of the future state vision; all members should be engaged and actively involved in shaping the future.

5. Think holistically Think beyond your current role. When making decisions and providing input, think holistically about SHN and the broader healthcare

system.

6. Respect confidentiality Please do not share documents, decisions or outcomes of the sessions beyond this group, without previous approval.

4

A REMINDER – OUR DECISION MAKING CRITERIA

Patient-Centric

• Limit the number of hand-offs and strive to provide a seamless experience for patients

• Create a welcoming and functional physical environment to enhance patient experience

Strategic Fit • Consistency and alignment with SHN’s Strategic Plan and Master Planning

Quality

• Consistently deliver the highest quality of service for Scarborough Health Network patients and clients that meets or exceeds industry best standards

• Access a range of specialists and subspecialists relevant to patient needs

• Capture data required to measure and monitor clinical outcomes

Access

• Provide access to high quality care

• Provide patients with access to care that reflects the diversity of the population being served

• Leverage external partnerships and relationships to improve access to care and quality of care

Sustainability

• Make efficient use of our assets (e.g., operating rooms, beds, equipment, etc.)

• Make efficient use of our talent and staff



5

OUR PROCESS FOR TODAY

Capital Planning Analysis • Provide an evidence base for our discussion

Stakes in the Ground • Discuss and align on the “core” design elements that will inform how the program

is configured

Discuss and Align on Options for the Future State • Discuss the potential future state options and align on a preferred model

Principles for the Delivery of Other Program Services • Discuss and align on principles that should be adhered to when considering how

the other program services are configured

6

REMINDER OF PROGRAM ENHANCEMENTS At the last co-design session we discussed a number of ways in which the current Women’s and Children’s Program

should be enhanced moving forward. Below are a few ideas that were raised:

• Improved mental health supports for new moms;

• Provide more supports to help new moms with breastfeeding;

• Increase supports for domestic violence and substance abuse;

• Further improve ability to provide services that are inclusive of the diversity that exists in Scarborough;

• Improve the physical environment to make it more welcoming for women and children;

• And many other ideas …

It is important to keep in mind throughout today’s discussion that the current program model is not optimal in terms of patient safety, quality of service, or provider satisfaction.

We want to focus this evening on how we can demonstrably improve the Women’s and Children’s Program, in order to provide the highest quality of care for women and children in Scarborough.

7

TIME HORIZON

Short-term Medium-term Long-term – Master Planning

1-5 years

2019-2023

5-10 years

2023-2028

10-15 years

2028-2033

OUR FOCUS:

When we are discussing the future state model, we are thinking about what we want our program to be in the medium-term and what we can get started on in the short- term to get us there. Note: in the short- and medium-term the program will need to leverage existing facilities. 8

CAPITAL PLANNING ANALYSIS Evidence Base for Our Discussion

FOUNDATIONAL DESIGN ELEMENTS

There are two important foundational design elements that will inform all subsequent discussions around the design of the future state model.

Before moving forward, we would like to gain alignment on the following two design elements:

1. The Women’s and Children’s program needs to operate as a single program across the three sites; standards of quality and clinical practice should be consistent

2. Providing labour and delivery (i.e., birthing services) at all three sites is not a sustainable model

10

PLENARY DISCUSSION:

Is the group agreed on the two design elements listed above?

CLINICAL SERVICE PLANNING

Volume Trends – Birchmount Site

B i rch m oun t S i te D e l i ve r i e s by Prov i de r Group T i m e P e r i o d : 2 0 0 7 / 0 8 t o 2 0 1 8 / 1 9 Y T D ( A p r - S e p )

Hospital Provider Service 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 YTD (Apr- Sep)

2018/19 YE FORECAST

Birchmount Site FAMILY PRACTITIONER 192 171 135 108 122 95 75 75 93 73 49 15 30

MIDWIFE 177 176 180 183 195 213 189 191 223 277 238 133 265

OBSTETRICS/GYNECOLOGIST 2,358 2,153 1,961 1,925 1,745 1,788 1,573 1,449 1,436 1,380 1,433 657 1,310 Birchmount 2,727 2,500 2,276 2,216 2,062 2,096 1,837 1,715 1,752 1,730 1,720 805 1,606

11

3,000 Birchmount Site Deliveries by Provider Group

2,500

2,000

1,500

1,000

500

0 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 YE

FORECAST

FAMILY PRACTITIONER MIDWIFE OBSTETRICS/GYNECOLOGIST Total Deliveries

# of

del

iver

ies


Volume Trends – General Site Ge n e ra l S i te D e l i ve r i e s by Prov i de r Group T i m e P e r i o d : 2 0 0 7 / 0 8 t o 2 0 1 8 / 1 9 Y T D ( A p r - S e p )


2018/19 YE FORECAST

General Site FAMILY PRACTITIONER 544 556 489 483 407 351 368 360 323 264 270 133 265

MIDWIFE 1 11 17 9 49 47 37 32 18 36

OBSTETRICS/GYNECOLOGIST 2,377 2,232 2,235 2,201 2,290 2,450 2,227 2,334 2,156 2,285 2,279 1,128 2,337 General 2,921 2,789 2,724 2,685 2,708 2,818 2,604 2,743 2,526 2,586 2,581 1,279 2,638

12

3,500 General Site Deliveries by Provider Group

3,000 2,500 2,000 1,500 1,000

500

0 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 YE

FORECAST


# of

del

iver

ies


Volume Trends – Centenary Site Ce n te n a ry S i te D e l i ve r i e s by Prov i de r Group T i m e P e r i o d : 2 0 0 7 / 0 8 t o 2 0 1 8 / 1 9 Y T D ( A p r - S e p )


2018/19 YE FORECAST

Centenary Site FAMILY PRACTITIONER 35 18 27 10 7 7 12 11 7 10 5 0 0

MIDWIFE 10 23 39 39 47 47 69 84 66 77 62 47 94

OBSTETRICS/GYNECOLOGIST 2,099 1,969 2,257 2,171 2,026 2,170 2,064 2,077 1,999 1,965 2,051 1,016 2,032 Centenary 2,144 2,010 2,323 2,220 2,080 2,224 2,145 2,172 2,072 2,052 2,118 1,063 2,126

13

2,500 Centenary Site Deliveries by Provider Group

2,000

1,500

1,000

500

0 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 YE

FORECAST


# of

del

iver

ies


MARKET SHARE TRENDS - BIRCHMOUNT

Where did mothers living in the Birchmount site catchment area deliver in the last 3 years (FY 15/16 – FY 17/18)

14

Key observations:

• 31% of mothers in the Birchmount catchment area delivered at the General site while only 24% delivered at the Birchmount site

• Mothers in the Birchmount site catchment area equally delivered at North York General (24%)

• 62% of mothers in the Birchmount catchment area delivered within the SRH network

MARKET SHARE TRENDS - GENERAL

Where did mothers living in the General site catchment area deliver in the last 3 years (FY 15/16 – FY 17/18)

15

Key observations:

• 28% of mothers living the General site catchment area delivered at the General site

• Michael Garron was the next most common hospital mothers living in this area opted to deliver at (19%)

• 56% of mothers in the General catchment area delivered within the SRH network

MARKET SHARE TRENDS - CENTENARY

Where did mothers living in the Centenary site catchment area deliver in the last 3 years (FY 15/16 – FY 17/18)

16

Key observations:

• 41% of mothers living the Centenary site catchment area delivered at the Centenary site

• The General site was the next option mothers living in this area opted to deliver at (20%)

• 74% of mothers in the Centenary catchment area delivered within the SRH network

Women and Children Programme Short and medium term strategies

Overview of Options

18

Two-Site Model

1. Configuration 1

2. Configuration 2

One-Site Model

1. Consolidate core components of the program at Centenary

2. Consolidate core components of the program at General

3. Consolidate core components of the program at Birchmount

W&C – MEDIUM TERM Options for Moving to ONE Site Option 1 – Centenary:

Consolidation of Program to the Centenary Site would require:

• Expansion of Birthing Suite (Including NICU) to accommodate 6500 Births per annum

• Expansion of Paediatrics Inpatient Unit to accommodate additional 10 beds

• Convert additional space at the Centenary site to accommodate outpatient and other services

• Scope may require the relocation of other programmes to other sites

19

W&C – MEDIUM TERM Options for Moving to ONE Site Option 1 – Centenary:

Note: Given the scale of the change, this would need to go through MOHLTC Capital Planning processes.

The Mental Health Program was used as a proxy given that a program of its scale would need to be moved in order to accommodate the expansion. No service realignment discussion has occurred with Mental Health Program.

20

Implementation Sequencing

Sub- project Capital Cost Estimate

Timeline

Phase 1 – new build

Expansion of existing Birthing Centre

$ 63,000,000 MOH – 5 stages - 54 to 60 months -

Phase 2 - Partial Decanting – W&C from General / Birch to Centenary

$ 500,000 + 2 months

Phase 3 Mental Health Renovations at the Birchmount

$ 23,600,000 + 6 months

Phase 4 Renovations of Partial floors – Mental Health to W&C Ambulatory – Centenary

$ 17,700,000 + 12 months

Totals $105,000,000 74 to 79 months

W&C – MEDIUM TERM Options for ONE Site Option 2 – General:

Consolidation of the Program to the General Site is relatively more complicated for a number of reasons, including:

• Infrastructure and building systems capacity for expansion is

limited • Irregularity and variations in floor plate configuration, structural

grid, floor to floor height impose design constraints • Limited “land” to construct new +/- 100,000 sq.ft of consolidated

new build • Consolidation at the General would impact a large number of other

programs and services; impact would be far greater than consolidating at the Centenary Site

21

W&C – MEDIUM TERM Options for ONE Site Option 3 – Birchmount:

Consolidation of Program to the Birchmount Site is relatively more complicated for a number of reasons, including:

• Consolidating the W&C program would require +/- 100,000

sq.ft of space • This would result in 2 ½ floors of existing space being

required to be repurposed for the W&C program • This would impact practically all other programmes and

services and only 20,000 sq.ft of space will be remaining for other clinical services (i.e., the emergency department)

22

W&C – MEDIUM TERM Options for ONE Site Option 3 – Birchmount:

Implementation Sequencing

Sub- project Capital Cost Estimate

Timeline

Phase 1 – FMC expansion on level 4

• Renovate space in receiving sites

• Decant units 4A and 4D • Construction

$ 69,000,000 MOH – 5 stages - 54 to 60 months -

Phase 2 - Paeds, NICU on level 3


• Decant units 3A,B,C and D • Construction

$ 49,000,000 + 12 to 14 months

Phase 3 – Outpatient Clinics


• Decant units level 2

$ 28,000,000 + 12 to 14 months

Phase 4 • Misc. $ 23,000,000 + 6 months

Totals $169,000,000 90 to 94 months

23

W&C – SHORT-TERM Options for 2 Sites Cen/Gen OPTION 1:

Note: we are not looking for you to decide on this option or the next today. Instead, we want to understand if you are aligned on a one-site model or two-site model, and at which sites.

24

W&C Service Realignment Model:

FMC: 50%Centenary 50 %General

PAEDIATRICS: 50% Centenary +5 50%General+5

L&D: 50% Centenary 50% General

NICU: 5 New Centenary 5 New General

CLINICS: Proportionate

Scope: • Relocate Nephrology

inpatient beds to CP1 • Relocate ALC from CP1

General to 4B Birchmount • Paeds to move into T2 at

the General. • Refresh Centenary

Birthing Centre and Paeds

Cost: $ 2.2 to 2.3 MM

Implementation: 10-12 Months upon approval

W&C – SHORT-TERM Options for 2 Sites Cen/Gen OPTION 2:

25

Scope: • Inpatient Paeds to move

to CP1 • Relocate ALC from CP1

General to 4B Birchmount • Refresh Centenary

Birthing Centre and Paeds

Cost: $ 1.35 to 1.45 MM

Implementation: 4 -5 Months upon approval


FMC: 50%Centenary 50 %General

PAEDIATRICS: 50% Centenary +5 50%General+5

L&D: 50% Centenary 50% General

NICU: 5 New Centenary 5 New General


SHARING OTHER IDEAS & OPTIONS

26

STAKES IN THE GROUND Setting the context

SETTING THE CONTEXT FOR OUR DISCUSSION ( 1/ 3)

• The chart below provides potential ‘stakes in the ground’ that are intended to help set the context for subsequent conversations around configuration

• We are looking to understand where there is agreement and where there are differing opinions • We will look to discuss the following design elements and then move into a discussion around siting • There will be subsequent work required to address the potential exceptions when developing the detailed future state model

Description of Design Elements (FOR DISCUSSION)

Source

Alignment Potential Exceptions Co-design

Attendees Steering

Committee

1

The Women’s and Children’s program needs to operate as a single program across the three sites; standards of quality and clinical practice should be consistent

- SRH’s Mandate - SRH’s Strategy - 2013 Motion 1B

TBC

2

Providing labour and delivery (i.e., birthing services) at all three sites is not a sustainable model

- 2012 Corpus Sanchez Review

- 2018 Dr. Zaltz’s Clinical Review

- Interviews, Focus Groups and Surveys

TBC

28



Source

Alignment Potential Exceptions Co-design

Attendees Steering

Committee

3

All services under Core Paediatrics1 have to be co-located for clinical proximity and provider proximity; they must also be situated within a full service acute hospital

- Expert input - Co-design Session #1

Outcomes

TBC

TBC

4

All birthing and NICU services have to be co-located for clinical proximity and provider proximity

- Expert input - Interviews, Focus Groups

and Surveys - Co-design Session #1

Outcomes

TBC

TBC

TBC

5

All NICU and ‘Core Paediatrics1 services have to be co-located for clinical proximity and provider proximity

- Expert input - Interviews, Focus Groups

and Surveys - Co-design Session #1

Outcomes

TBC

TBC

TBC

1Core Paediatrics includes: Paediatric Inpatient Medicine, Paediatric Inpatient Surgery and Paediatric Day Surgery

29



Source

Alignment Potential

Exceptions Co-design Attendees

Steering Committee

6

The Emergency Department must have 24/7 access to on-call Paediatrics and OB/GYN

- Expert input - Interviews, Focus Groups and Surveys

- Co-design Session #1 Outcomes

TBC

TBC

TBC

7

Gynaecology (surgery) and Anesthesia have to be co-located for provider proximity and clinical proximity



TBC

8

Obstetrical surgery and Anesthesia have to be co-located for clinical proximity and provider proximity



TBC

30 1Core Paediatrics includes: Paediatric Inpatient Medicine, Paediatric Inpatient Surgery and Paediatric Day Surgery

Given the 2012 and 2018 review recommendations and extensive engagement, maintaining labour and delivery services at all three sites is not sustainable. Further, ‘Core Paediatrics’, NICU, and birthing must be co-located for provider and clinical proximity. This means that Birthing, Core Paediatrics1, NICU and Anesthesia must be delivered at the same site and must be co-located within a full service acute

setting.

BIRTHING & CORE PAEDIATRICS CLUSTER

31


Birthing NICU

Paediatric Inpatient Medicine

Paediatric Inpatient Surgery

All services must be co- located within a full service acute hospital setting

ACTIVITY # 1 Configuring “core” services

DISCUSSION & GAINING ALIGNMENT

DISCUSSION QUESTIONS:

1. Do you agree that the birthing and core paediatrics cluster* must be delivered at the same site(s), and within a full service acute hospital setting?

2. What do you think the direction for the program should be in the long-term? Please indicate where the birthing

and core paediatrics cluster should be delivered.

3. What do you think the direction for the program should be in the short- to medium-term? Please indicate where the birthing and core paediatrics cluster should be delivered.

*Birthing and Core Paediatric cluster includes: birthing, NICU, anesthesia, paediatric inpatient medicine, 33 paediatric inpatient surgery, paediatric day surgery

INSTRUCTIONS:

Please discuss Question 1, 2 & 3 in your breakout groups (30 minutes)

Share out the majority position from your group, and highlight any other opinions shared by group members (30 minutes)

ACTIVITY #1: CONFIGURING CORE SERVICES

Instructions: Discuss question 1, 2 and 3 as a group and complete the chart. Consider the decision making criteria in your group discussions.

QUESTION 1: Do you agree that the birthing and core paediatrics cluster* must be delivered at the same site(s), and within a full service acute hospital setting?

QUESTION 2: What do you think the direction for the program should be in the long-term? Please indicate where the birthing and core paediatrics cluster should be delivered.

QUESTION 3: What do you think the direction for the program should be in the short- to medium-term? Please indicate where the birthing and core paediatrics cluster should be delivered.

Majority Position: Majority Position: (circle the site names) Centenary General Birchmount

Majority Position: (circle the site names) Centenary General Birchmount

Rationale: Rationale: Rationale:

Other opinions: Other opinions: Other opinions:

*Birthing and Core Paediatric cluster includes: birthing, NICU, anesthesia, paediatric inpatient medicine, 34 paediatric inpatient surgery, paediatric day surgery

BREAKOUT GROUPS

35

GROUP 3 Dr. Peter Azzopardi Dr. Karen Chang Dr. Latifa Yeung Dr. Stephanie Kay Dr. Jon Hummel Dr. Olivia Tsai Michelle O’Connor Nadia Rampersaud Lindsay Forsey Sook Park Meghan Cellamare

GROUP 2 Dr. Nina Venkatarangam Dr. David Samra Dr. Colette Rutherford Dr. Jing Qin Dr. Sam Ko Dr. Vinod Raghubir Dr. John Oyston Dr. Mojgan Davallou Dr. Sandy Finkelstein Claudette Leduc Roleta Kalichava Kamani Abdul

GROUP 1

Dr. Georgina Wilcock Dr. Caroline Huh Dr. Michael Silver Dr. Leah Tattum Dr. Jeremy Hew Dr. Norm Chu Dr. Michael Chapman Dr. David Esser Tama Cross Susan Easton Carolyn Tyson

DINNER BREAK

ACTIVITY # 2 a) Configuring other program services

CONFIGURATION DESIGN PRINCIPLES

Below are initial configuration design principles, for your review and input.

Emergency Protocols: 1) ED physicians and clinical teams will need support for ongoing skills maintenance and certifications (e.g., PALS

etc.); 2) Site(s) without birthing and paediatrics will not have the clinical support services or provider base to engage in

emergency high-risk cases; and 3) Protocols for patient stabilization and transfer will be needed

Ambulatory Services: 1) Ambulatory services that require subspecialties or other hospital-based supports should be located in the

hospital 2) Patient safety and access should be considered closely when determining where ambulatory services that do not

require subspecialties or other hospital-based supports should be delivered (i.e., remain in the hospital, delivered in the community, etc.)

38 PLENARY DISCUSSION:

Do you agree with the principles stated above? Are there any other principles you would highlight?

CONFIGURING OTHER PROGRAM SERVICES

• Now that we have discussed how we are going to deliver the birthing and core paediatrics cluster (the grey categories), we want to discuss how to configure the other services that the program offers (the blue with red outline categories)

• We are going to focus our discussion on three specific areas:

o Outpatient obstetrics; including both pre-natal and post-natal

o Ambulatory outpatient

o Gynaecology

Note: we are not intending to discuss each service individually. The intention is to provide direction on the main overarching services, and identify any appropriate principles to help build out the detail in the next 39

stage of planning.

INSTRUCTIONS:

Please work with your group to complete the worksheet by indicating which core services should be delivered on each site; also review the decision making criteria and indicate if the model you are suggesting supports the criteria (20 minutes)

Share out the majority position from your group, and highlight any other opinions shared by group members

40

Inpatient Paediatric Beds (medical/surgical) Child and Youth Mental Health


SERVICE MAP (CURRENT STATE)

Ambulatory Outpatient

Pediatric Occupation Therapy (to age 7)

Diabetes & Nutrition/Diabetic Education

Respiratory Syncytial Virus Prevention Clinic

Immunology/Allergy Clinic

Adolescent Medicine Clinic

Gestational Diabetes Education Clinic

Preschool Speech and Language Services

Asthma Clinic

Healthy Outcomes for Pediatric Program

Regional Child & Adolescent Mental Health Program

Neurology Clinic

Dermatology Clinic

Nephrology Clinic

Rheumatology Clinic

Gastroenterology Clinic

Constipation Clinic

Hematology Clinic

Scoliosis Clinic

Till I Sleep/Prenatal Presence at

Induction Program

Essential Clinical Services

Birthing and Core Paediatrics Cluster Other Program Services

Sexual Assault & Domestic Violence Clinic

Emergency Department

EMS

Interventional Radiology

Anesthesiology

Paediatric Inpatient Medicine/Surgery

Paedlink/Short Stay Clinic Paediatric Day/Consult Clinic

Pre-Natal

Non-stress Testing

Genetics Clinic

EPAC

Breastfeeding Classes

Maternal Fetal Medicine

Birthing

Family Maternity Centre

Birthing Centre

Neonatal Intensive Care Unit (level llb)

Midwifery Services

Neonatal Intensive Care Unit (level llc)

Neonatal Bereavement Program

Breastfeeding Clinic

Doula Services


Paediatric pre-operative and post-operative care

Pulse Dye Laser Surgeries

Gynaecology

Gynaecology Day Surgery

Gynaecology In-patient

Services delivered through collaborations

Paediatric Oncology (SickKids) Sickle Cell Disease

(SickKids)

Endocrinology (Community- based paed. Staff)

Cardiology (Community-based paed. Staff)

Respirology (Community-based paed. Staff)

Infectious Disease (Community- based paed. Staff)

Post-Natal

Infant Hearing Program in collab. with TPH

Neonatal Follow-up Clinic

Breastfeeding Support in collab. with TPH

Lactation/Newborn Assessment Clinic

Living and Learning with Baby in collab. with TPH

Psychiatric Mental Health program

ACTIVITY #2 a): CONFIGURING OTHER PROGRAM SERVICES Instructions: (1) For all the services listed on the left, please tick the boxes to indicate at which sites the services should be provided and (2) provide a rationale to why you provided the response you did.

Birchmount Centenary General

Please provide a rationale for your responses

Gynaecology surgery

*Birthing and Core Paediatric cluster includes: birthing, NICU, anesthesia, paediatric inpatient medicine, paediatric inpatient surgery, paediatric day surgery 41

Complete based on earlier discussion in Activity #1

Birthing & Core Paeds Cluster1

Emergency Outpatient Paediatrics

Outpatient Obstetrics: Pre-natal

Outpatient Obstetrics: Post-natal

ACTIVITY # 2 b) Configuring other program services

CONFIGURING OTHER PROGRAM SERVICES – BIRCHMOUNT SITE

Ideas to consider … - Women’s Health Centre, which could include services like,

• Colposcopy Clinic • Day Surgery Clinic • Early Pregnancy Assessment Clinic (EPAC) • Gynaecological Oncology Clinic • Etc.

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PLENARY DISCUSSION:

What role can the Birchmount site play in enhancing the health of women and children in the community?

• Consider the community that surrounds the Birchmount site and what specific needs they may have, and the needs of women in the community, beyond labour and delivery.

MOVING FORWARD

MOVING FORWARD

• Confirmation of preferred short- and medium-term option with Steering Committee

• Develop final recommendations for the Steering Committee to bring forward to SLT, and subsequently, the Board

• Conduct service realignment discussions with impacted programmes

• Confirmation of scope details

• Budget confirmation, and SLT and Board approval

• Implementation kick-off

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Scope: • Inpatient Paeds Capacity

fulfillment • New C Section OR on 4th

floor Birchmount • Convert Chalet to new

NICU • Renovate Paeds and

Postpartum • May require decanting 4D

Cost: $ 3.85 to 3.95 MM

Implementation: 10 to 12 Months upon approval

APPENDIX: W&C – SHORT-TERM Options for 2 Sites Cen / Birch OPTION 3:

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FMC: 50%Centenary 50 % Birchmount

PAEDIATRICS: 50% Centenary +5 50% Birchmount+5

L&D: 50% Centenary 50% Birchmount

NICU: 5 New Centenary 5 New Birchmount
