The recent announcement of proposed changes by the administration at St. Joesph's hospital has galvanized a wide spectrum of citizens in opposition, compelling everyone to become experts in the very complex topic of hospital funding and management policy.
The plan would convert the second floor of the hospital, which currently houses twenty-four medical and surgical beds, to a new “transitional care” unit with twenty-two beds, and a new recently announced common area.
The third floor, which currently has thirty-four beds, and is used for medical care, will contain thirty-nine surgical and medical beds with two additional stretchers.
The change would allow for the dismissal of around seventeen full-time equivalent position registered nurses, and a saving of around a million dollars, which just happens to be the amount that the hospital is in arrears from last year's budget.
Michael Pontus, St. Joe's CEO insists that the changes are done primarily from the point of view of patient care, and that savings are a necessary but secondary factor. But he is having a tough time convincing others.

Transitional Care

The acute care beds, and the services that go along with them on the second and third floors are meant for patients who are in some stage of crisis requiring medical care. They are not designed for people who are recovering, and/or awaiting placement outside the hospital, for example in a long-term care residence.
Recovering patients need a different set of services to prepare them to leave the hospital, and an environment other than what a typical hospital provides.
Barb Biley, a worker at the hospital and member of the St Joseph's Health Coalition says “For the last several years there has been a problem of people in the hospital who are assessed and waiting placement, or require additional care, receiving inappropriate care and occupying acute care beds.”
Michael Pontus says that these patients are growing in number, while because of improvements in surgical procedures and so on, acute care patients are recovering faster and staying in the hospital less time, so that while our population has increased, the need for acute care beds has actually declined. Meanwhile, workers on the hospital wards say that the opposite is true- there is an everyday acute bed shortage which will only grow worse over time, especially if beds are removed.
Anyone who has had an elderly relative stuck in St. Joe's awaiting placement would agree that the current arrangement is not satisfactory. Patients need services such as physiotherapy, and a less clinical environment to recover faster. Michael Pontus says that this is the real threat to acute care beds- the growing number of “transitional” patients who are not getting the care they need.
He says- “This is not a new concept. Transitional units have been in place a long time. Some see it as post-stroke, rehab unit, or psycho-geriatric. Our is more generic to the entire community. Ontario came out with a paper supporting this and they are implementing them. We looked at it from the patients' perspective, and efficiency.
We now have fifty-nine beds on the second and third floors, all acute care. Twenty-five will be transitional, and we will add more beds to the third floor.
Pontus says the need for transitional beds is growing- “We are looking after transitional patients in an acute model. We will be congregating transitional on one floor and giving them more appropriate services to shorten their stay. What made this happen was our concern for the patients. There would be a growing number if we don't move them through. We can apply the savings to our shortfall and avoid reductions to other acute phases of the hospital. Also we position ourselves for the government's- new “pay for performance”, which will start next year. Units that are efficient and have capacity will get more funding.”
Critics of the change question whether the idea will work. Rocky Moise, a surgeon at the hospital, says that the doctors in particular have asked to see information on where these types of wards have been implemented, and some data on how effective they are. So far, after repeated requests, they have had no response- “VIHA says they have transitional care units. Campbell River has twenty-four beds. When did it happen? Did RNs lose their jobs?”
Barb Biley says part of the solution to the problem is to create more capacity in the community- “The province has repeatedly promised to address the problem. In October of 2009, when the hospital administration presented their cost-saving plan to staff there was an indication that there would be long-term care beds in the community to free up.
This has not happened. The Comox Valley Seniors Village is a fully functional campus, from independent living to complex care. The problem is that the contract was awarded in 2005 to Retirement Concepts, which runs fourteen homes in BC, for profit. The contract was for public and private beds. Now the public beds are full, and thirty- five private beds are sitting empty, because no one can afford to pay $180/day, or $5,500 month.”
Biley also points out the twenty-six beds at the closed Laurel Lodge. If all these beds were made available, the backlog of waiting patients at St. Joe's would virtually disappear.

Nurses

Perhaps the most intense resistance to the proposal concerns the firing of up to seventeen registered nurses, whose salaries will comprise the savings that the hospital requires to meet its budget shortfall. There are currently 310 nurses employed by the hospital, including casual workers.
Michael Pontus weighs in- “Nurses are terrific but they oversee the activity of these people- the care aides and physios. We're not degrading the nurses, but they are not the right mix for the patient.”
Meanwhile Juanita Munroe, a registered nurse who works in the relief pool at the hospital says: “This is a huge change. I can understand them trying to figure out the best steps. But we are already losing staff. There are not enough nurses for mentoring students.”
Munroe says that the last few years have seen a great deal of change at St. Joe's, including repeated cuts to staff levels, which is causing increased work load and anxiety among workers.
Foe example, clinical coordinators have been gradually phased out of existence, in favour of clinical nurse leaders.
Now on evenings, weekends, and stat holidays, there is no on at all filling that crucial role.
Starting last January, cuts on the surgical floor eliminated two RN positions.
And when the maternity and pediatric wards were recently combined, it became difficult to find appropriately trained staff. The hospital has been trying to fill nurse manager and clinical nurse leader positions for months without success. Juanita Munroe says this is because there may be no one out there who is trained in both these disciplines.
She adds: “They're eliminating roles, and it's a waiting game, to see how units are handling it, not filling the roles, saving money at the expense of staff and patients. I don't think the administration is backing quality of care.”
Munroe is also concerned about the loss of acute care beds. There are twelve day care beds on the first floor, which because of cost cutting recommended by the Corpus Sanchez report (see below), are open only until 10 pm every night. Munroe asks- “If someone needs to stay overnight- where do they go? There will be two stretchers on the third floor. Nurses are concerned that won't be enough.”
The present situation does not inspire confidence - “Often patients are stuck in an overflow area if there are no beds, at the back of emergency, where there is no bathroom, or windows.”
Also, only registered nurses can admit acute patients, and none are planned for the transitional unit.
And if a more widespread problem occurs, such as a flu epidemic, and there is a need for more acute care, if they need to bring in RNs- will they still be here?
Rocky Moise agrees- “I have a hard time giving up acute care beds. Easily a couple of times a week, there are more patients than acute care beds. Last Friday there were around fourteen more. Nurses in emergency opened up the old pediatric ward- this is before the cut of ten to eleven beds. It happens all the time. And this is at peak efficiency. The north island is expected to grow by 12% by 2014, to 137,000, and 83% of the growth will be in the Comox Valley. People in the seventy-five or older age group are growing faster here than anywhere else on the island. We should have a huge increase in beds, not a cut. It's not good planning for the new hospital, when we will need more than we have now.”
Meanwhile, Michael Pontus is working out the details- “There is a sixty-day consultation with the unions- we amend things. We save a little less, but get it right. The number of nurses displaced will be less than originally announced. We are looking at relief pools, adjusting from full-time, retirement and leave of absence. We are also talking with VIHA- what's the best way of getting displaced nurses new positions?”
The administration recently added another sixty days to the original sixty of ongoing discussion and negotiation with medical staff, and promise no changes will occur until the end of July.


Funding
By implementing these changes the hospital will save a million dollars.
Michael Pontus says- “Our expenditures exceed our revenues at the moment. We need to deal with this without reducing acute services.”
But critics say the problem is artificial, created by chronic underfunding from VIHA.
Mike Holland, a Courtenay lawyer and federal liberal candidate says that the proof is in the numbers, and that the problem begins with systemic manipulation- “They're passing the buck- both the health authorities and the provincial government are forcing areas into deficit. When you look at the services expected, compared with the money offered- it's impossible- the authorities pass the deficit onto the regions to make their own books look better.”
Holland says in spite of this, the provincial government has tried to keep things fair in regional terms, by using a funding formula which quantifies the needs of each region according to criteria such as population numbers, the elderly, first nations, etc. Vancouver Island has been treated well in this regard- he says “We received 20% of the money although we have 18% of the population” in 2003. That is where the fairness stops.
When he served on Courtenay council some years back, Holland was also on the regional and St. Joseph's hospital boards. This is when he delved into the way VIHA was distributing resources across the island. We are in the North Region along with Campbell River and the rest of the north island.
Holland says- “I knew the north island was being shortchanged financially. The figures from VIHA in 2003 showed the following funding pattern- $1,450 per person in the greater Victoria area, $1,100 in the Nanaimo area, and only $950 per person here. Even factoring out administration, and island-wide services based in Victoria, this was a shocking difference.”
Holland says “A letter was sent to VIHA from the regional hospital board asking what the funding formula was. They said they had no formula- it was based on “historic funding patterns”- “VIHA spends about 50% less per person here than in Victoria. At 3 ½% of VIHA's $1.2 billion budget that's $36 million we're shortchanged every year.”
This policy of favoritism extends to what kind of facilities can be funded. For example, in Victoria, VIHA funds hospice beds, but our community needs to pay for them ourselves.
Holland continues- “I researched population from the 50's to the present. There have been remarkable shifts in demographics. Nanaimo has gone up from 12% to 18% now. Our area, including Campbell River used to be 7% of the island population, now it's 10 1/2%.”
So while our population has gone up, the funding formula remains mired in some “historic” pattern of unfairness- “All the political parties have done it- Socreds, NDP, Liberals. The idea seems to be 'If Victoria people are treated well, all must be right in the world.” Perhaps it is no coincidence that “All VIHA directors have a Victoria history.”
Holland allows- “The figures are not recent, but nothing has changed. If they don't have a formula, its the same old card game.”


Efficiency
Everyone applauds the staff at St. Joe's for their work, especially with the limited resources available.
Mike Holland says- “St. Joe's does an incredible job with what they have. They are forced to run the leanest operation on the island. But a hospital is about a lot more than pure efficiency. A hospital needs to be ready for disaster. You don't have that flexibility when you cut things down to the bone.”
A few years ago the Corpus Sanchez Group was brought in to assess where cuts could be made. The study found that St. Joe's was already running at peak efficiency. In fact, they realized the hospital was underfunded, and recommended an increase, which added $4.7 million to the hospital's baseline funding.
In spite of this, last year, the hospital faced a budget shortfall of about a million and a half dollars. The administration found ways to save money, including beginning a program of paid parking, and increasing off-time for surgeons. But there was still $1 million left to account for. It is this deficit that the proposed change is meant to address.
Rocky Moise confirms that St. Joe's has become expert at doing more with less-
“We shouldn't have to cut nurses. We are either one or two on the island for cost per case. Everything we do is at a better price than the other hospitals on the island. The staff is being very efficient, using the appropriate medication and not keeping people in the hospital longer than needed. It's a huge team effort. Every other hospital should have to cut to be as efficient as us.”
Moise believes that only a combined effort will have an impact- “The physicians, nurses administration and board should be approaching VIHA for more money. It is up to the board members to get the info and pursue it instead of just balancing the budget.”
Mike Holland concurs- “We've been starving for heath dollars. In the foreseeable future, when anything has to be cut, keep away from the north island, and any new spending should be here- thats how you move to parity.”
On the other hand, Michael Pontus does not seem to believe that the funding level is an issue for St Joe's- “We speak with VIHA all the time, and negotiate and they have given us a significant amount against our shortfall. Last year we were running $4.7 million over our budget. A hired consultant said we should have that money, and VIHA added it to our baseline, along with inflation and a salary component. VIHA says we're funded fairly in relation to their other facilities. All we can do is ask. So we need to do cost saving, like all facilities.”
Michael Pontus is well aware of growing resistance to the plan, but believes people will come around- “You have to get a concept out there, concrete enough for people to work with. This is currently the right thing to do. We think the more we present this to people, they will see how it protects acute care and is better for transitional. People are looking solely at beds. They don't understand how many are taken up with transitional patients. We are already functioning inefficiently and running over our budget because of it.
Transitional care beds are all considered acute. We are increasing acute care beds in the valley.”
He continues- “This is done in the best interests of the hospital and the community. If I wasn't doing it from this thing, I would be doing it from some other aspect of acute care. But that's not the primary motive. Let's do what's right and see what comes from it.”