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IndependentAssessmentCommitteeReport

ConstitutedunderArticle8.01ofthe

CollectiveAgreement

Between

HumberRiverHospital

And

OntarioNurses’Association

June12,2016

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June12,20162016Ms.SusanBlairOntarioNursesAssociationProfessionalPracticeSpecialistOntarioNurses'Association85GrenvilleStreet,Suite400Toronto,Ontario,M5S3A2Ms.MargCzausChiefNursingExecutiveHumberRiverHospital1235WilsonAve.Toronto,ON,M3M0B2DearMs.BlairandMs.Czaus,ThemembersoftheIndependentAssessmentCommitteehaveconcludedourreviewandrespectfullysubmittheReportoftheIndependentAssessmentCommitteethatwasconstitutedunderArticle8.01ofthecollectiveagreementbetweenHumberRiverHospitalandtheOntarioNursesAssociation.ThisreportcontainstheIndependentAssessmentCommittee’sfindingsandrecommendationsregardingtheProfessionalWorkloadComplaintsubmittedbyNursesfromtheHemodialysisUnitatHumberRiverHospital.TheprocessundertakenthroughanIndependentAssessmentCommitteeprovidesauniqueopportunityfordiscussionanddialoguebetweenallthepartiesregardingthecomplexissuesandconditionsthatunderlieaProfessionalWorkloadComplaint.TheCommitteehasmade18recommendationsinfiveareasregardingissuesthatimpacttheworkloadofRegisteredNurses.TheMembersoftheIndependentAssessmentCommitteeunanimouslysupportallrecommendationsinthisreport.TheCommitteehopesthattherecommendationswillassisttheHospitalandtheAssociationtofindmutuallyagreeableresolutionswithregardtonursingworkloadissuesintheHemodialysisUnit.

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TableofContents

1. Introduction.......................................................................................................................................71.1.OrganizationoftheIndependentAssessmentCommitteeReport.................................................71.2.ReferraltotheIndependentAssessmentCommittee......................................................................71.3.JurisdictionoftheIndependentAssessmentCommittee.................................................................81.4.ProceedingsoftheIndependentAssessmentCommittee............................................................12Pre-Hearing................................................................................................................................12Hearing......................................................................................................................................14PostClosureofHearing..............................................................................................................16

2. PresentationoftheProfessionalResponsibilityWorkloadComplaint.................................172.1 InformationonHumberRiverHospitalandtheHemodialysisUnit............................................172.2 HistoryofStaffinginHemodialysisUnitsince2011.......................................................................172.2.1 Staffingin2011...............................................................................................................172.2.2 StaffingChangesfrom2011-2013....................................................................................182.2.3 StaffingChangesin2013/2014........................................................................................192.2.4 StaffingChangesin2015/2016........................................................................................192.2.5 CurrentStaffing...............................................................................................................202.3 WorkloadConcernsofRegisteredNursesandDiscussionsattheHospitalAssociationCommittee.....................................................................................................................................................212.4 MeetingsbetweenAssociationandHospitalPriortoIAC...................................................24

3 Discussion,AnalysisandRecommendations..............................................................................263.1 RegisteredNurseStaffingandSchedulingToEnsureAdequateandSafeRNStaffing.............263.2 PatientVolumes,TypesofTreatmentandScheduling..................................................................313.3 Documentation.....................................................................................................................................323.4 CommunicationandDecisionMaking..............................................................................................323.5 ProcessforManagementofProfessionalResponsibilityWorkloadReportForm(PRWRFs)..333.6 Recommendations:..............................................................................................................................33

4. Conclusion.......................................................................................................................................35

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AppendicesAppendix1:LetterfromAssociationApril30,2014

Appendix2:EmployerGrievanceJune12,2014

Appendix3:LetterfromHospitalLegalCounselSeptember12,2014

Appendix4:LetterfromLegalCounselforAssociationSeptember25,2014

Appendix5:LetterfromLegalCounselforHospitalOctober4,2014

Appendix6:LetterfromIACChairOctober142014

Appendix7:LetterfromLegalCounselforAssociationOctober21,2014

Appendix8:LetterfromLegalCounselforHospitalOctober23,2014

Appendix9:LetterfromIACChairNovember4,2014

Appendix10:AgendaforIAC

Appendix11:InformationRequesttoHospital

Appendix12:AttendeesatIAC

Appendix13:RNandRPNStaffinginHemodialysisUnitinApril2016(MondaytoFriday)

Appendix14:RNandRPNStaffinginHemodialysisUnitinApril2016(SaturdayandSunday)

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1. Introduction

1.1. OrganizationoftheIndependentAssessmentCommitteeReport

TheIndependentAssessmentCommittee(IAC)Reportispresentedinfiveparts:

1. IntroductionThissectionoutlinesthereferraloftheProfessionalWorkloadComplainttotheIAC,reviewstheIAC’s jurisdiction as outlined in the Collective Agreement, and summarizes the Pre-Hearing,HearingandPost-Hearingprocesses.2. PresentationoftheProfessionalResponsibilityWorkloadComplaintThissectionpresentsthecontextofpracticerelatingtotheprofessionalworkloadcomplaintintheHemodialysisUnitatHumberRiverHospital;summarizestherelevanthistoryleadingtothereferraloftheprofessionalworkloadcomplainttotheIAC;andreviewsthepresentationsbytheOntario Nurses’ Association (‘the Association’), Humber River Hospital (‘the Hospital’) at theHearing.3. Discussion,AnalysisandRecommendations4. SummaryandConclusions5. ReferencesandAppendices

ThesubmissionsandexhibitsoftheOntarioNurses’AssociationandHumberRiverHospitalareonfilewithbothparties.

1.2. ReferraltotheIndependentAssessmentCommittee

ThisReportaddressestheprofessionalworkloadcomplaintsofRegisteredNursesfromtheHemodialysisUnitatHumberRiverHospital.TheAssociationstatedthefollowingintheirpre-hearingsubmission:

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“ONA submits this Professional Responsibility Complaint to be the result of the employer, assigning ahigh number of patients to individual RNs and groups of RNs. As perArticle 8 of theHospital CentralAgreementRNshavesubmitted180PRWRFstodocumentwhenhavebeenaskedtoperformmoreworkthanisconsistentwithpatientcare.”1

1.3. JurisdictionoftheIndependentAssessmentCommittee

The IAC is convened under the authority of Article 8.01 on Professional Responsibility in the CentralHospitalAgreementbetweentheOntarioNurses’AssociationandHumberRiverHospital.Article8.01states:2

8.01 The parties agree that patient care is enhanced if concerns relating to professional practice,

patient acuity, fluctuating workloads and fluctuating staffing are resolved in a timely andeffectivemanner.IntheeventthattheHospitalassignsanumberofpatientsoraworkloadtoanindividualnurseorgroupofnurses such that theyhave cause tobelieve that theyarebeingasked toperformmoreworkthanisconsistentwithproperpatientcare,theyshall

i) atthetimetheworkload issueoccurs,discussthe issuewithintheunit/programtodevelop

strategiestomeetpatientcareneedsusingcurrentresourcesii) If necessary, using established lines of communication as identified by the hospital, seek

immediateassistancefromanindividual(s)(whocouldbewithinthebargainingunit)whohasresponsibilityfortimelyresolutionofworkloadissues.

iii) Failingresolutionoftheworkloadissueatthetimeofoccurrenceoriftheissueisongoingthenurse(s)willdiscusstheissuewithherorhisManagerordesignateonthenextdaythattheManager (or designate) and the nurse are both working or within five (5) calendar dayswhichever is sooner. Complete the ONA/Hospital professional Responsibility WorkloadReport Form. The manager (or designate) will provide a written response on the

1SubmissiontotheIndependentAssessmentCommitteebyOntarioNurses’Association,2016,p.62CollectiveAgreementBetweentheHospitalandOntarioNurses’Association,Article8–ProfessionalResponsibility,March31,2014,p.23.

(a)

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ONA/HospitalProfessionalResponsibilityWorkloadReportFormtothenurse(s)within5daysofreceiptoftheformwithacopytotheBargainingUnitPresident.When meeting with the manager, the nurse(s) may request the assistance of a Unionrepresentativetosupport/assisther/himatthemeeting.

iv) Everyeffortwillbemadetoresolveworkloadissuesattheunitlevel.AUnionrepresentativeshallbe involved inany resolutiondiscussionsat theunit level. Thediscussionsandactionswillbedocumented.

v) Failing resolution at the unit level, submit the ONA/Hospital Professional ResponsibilityWorkload Report Form to the Hospital-Association Committeewithin twenty (20) calendardays fromthedateof theManager’s responseorwhensheorheought tohaverespondedunder(iii)above.TheChairoftheHospital-AssociationCommitteeshallconveneameetingofthe Hospital-Association Committee within fifteen (15) calendar days of the filing of theONA/Hospital Professional ResponsibilityWorkloadReport Form. TheCommittee shall hearandattempttoresolvetheissue(s)tothesatisfactionofbothpartiesandreporttheoutcometothenurse(s).

vi) Priortotheissue(s)beingforwardedtotheIndependentAssessmentCommittee,theUnionmayforwardawrittenreportoutliningtheissue(s)andrecommendationstotheChiefNursingExecutive.ForprofessionalsregulatedbytheRHPA,otherthannurses,theUnionmayforwardawrittenreportoutliningtheissue(s)andrecommendationstotheappropriateseniorexecutiveasdesignatedbytheHospital.

vii) AnysettlementarrivedatunderArticle8.01 (a) iii), iv),orv) shallbesignedby theparties.(Article8.01(a),(viii),(ix)and(x)and8.01(b)appliestonursesonly)

viii) Failingresolutionoftheissue(s)withinfifteen(15)calendardaysofthemeetingoftheHospital-AssociationCommitteetheissue(s)shallbeforwardedtoanIndependentAssessmentCommitteecomposedofthree(3)registerednurses;onechosenbytheOntarioNurses'Association,onechosenbytheHospitalandonechosenfromapanelofindependentregisterednurseswhoarewellrespectedwithintheprofession.ThememberoftheCommitteechosenfromthepanelofindependentregisterednursesshallactasChair.Ifoneofthepartiesfailstoappointitsnomineewithinaperiodofforty-five(45)calendardaysofgivingnoticetoproceedtotheIndependentAssessmentCommittee,theprocesswillproceed.ThiswillnotprecludeeitherpartyfromappointingtheirnomineepriortothecommencementoftheIndependentAssessmentCommitteehearing.

ix) The Assessment Committee shall set a date to conduct a hearing into the issue(s) withinfourteen(14)calendardaysof itsappointmentandshallbeempoweredto investigateas is

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necessaryandmakewhatfindingsasareappropriateinthecircumstances.TheAssessmentCommitteeshall render itsdecision, inwriting, to thepartieswithin forty-five (45)calendardaysfollowingcompletionofitshearing.

x) ItisunderstoodandagreedthatrepresentativesoftheOntarioNurses'Association,includingthe Labour Relations Officer(s), may attend meetings held between the Hospital and theUnionunderthisprovision.

xi) Any issue(s) lodged under this provision shall be on the form set out in Appendix 6.Alternately,thelocalpartiesmayagreetoanelectronicversionoftheformandaprocessforsigning.

xii) The Chief Nursing Executive, Bargaining Unit President and the Hospital-AssociationCommittee will jointly review the recommendations of the Independent AssessmentCommitteeanddevelopan implementationplan formutuallyagreedchanges. i) The listofAssessmentCommitteeChairsisattachedasAppendix2.DuringthetermofthisAgreement,the central parties shallmeet as necessary to review and amend by agreement the list ofchairsofProfessionalResponsibilityAssessmentCommittees.

b) i) Thepartiesagree thatshouldaChairbe required, theOntarioHospitalAssociationandtheOntarioNurses'Associationwillbecontacted.TheywillprovidethenameofthepersontobeutilizedonthealphabeticallistingofChairs.ThenametobeprovidedwillbethetopnameonthelistofChairswhohasnotbeenpreviouslyassigned.

ii) Should the Chairwho is scheduled to serve declinewhen requested, or it becomes obviousthatsheorhewouldnotbesuitableduetoconnectionswiththeHospitalorcommunity,thenextpersononthelistwillbeapproachedtoactasChair.

iii) Eachpartywillbear thecostof itsownnomineeandwill shareequally the feeof theChairandwhateverotherexpensesareincurredbytheAssessmentCommitteeintheperformanceofitsresponsibilitiesassetoutherein.

InaccordancewithArticle8.01(ix)‘TheAssessmentCommitteeshallrenderitsdecision,inwritingtothepartieswithinforty-five(45)calendardaysfollowingcompletionofitshearing’.

TheIAC’sjurisdictionthusrelatestowhetherregisterednursesarebeingrequestedand/orrequiredtoassumemoreworkthanisconsistentwiththeprovisionofproperpatientcare.Workloadisinfluencedbybothdirectfactors(e.g.nurse-patientratio,patientacuity/complexityofcarerequirements,patientvolume) and indirect factors (e.g. roles and responsibilities of other care providers, physicalenvironment of practice, standards of practice, and systems of care). The IAC is responsible for

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examining factors impactingworkload, and formaking recommendations to addressworkload issues.ConcernsoutsideofworkloadarebeyondthejurisdictionoftheIAC.In thematter of arbitration between Brantford General Hospital and the Ontario Nurses Associationboth parties acknowledged that while according to the collective agreement the IAC’s report is notbindingupontheparties,“thepartiesstressedto theboardthat theassociationandtheparticipatinghospitalsallfeelboundbythefindingsofsuchcommittees.”3TheIAC’sjurisdictionceaseswithsubmissionofitswrittenReport.Thefindingsandrecommendationsofthe IAC provide an independent external perspective to assist the Association and the Hospital toachievemutuallyagreeableresolutionstoworkloadissues.TheIACisnotanadjudicativepanel,anditsrecommendations are not binding. In accordance with Professional Responsibility Article 8 of theCollectiveAgreement,theIACwascomprisedofthreeRegisteredNurses.ThemembersoftheIndependentAssessmentCommitteewere:ChairpersonLeslieVincentFortheAssociationAngelaPreocaninFortheHospitalSylviaRodgers

3ArbitrationHearingBrantfordGeneralHospitalandOntarioNursesAssocation,September8,1986.

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1.4. ProceedingsoftheIndependentAssessmentCommittee

Pre-Hearing

OnApril30,2014theAssociationnotifiedtheHospitalandtheIACChairinaletterthattheAssociationwas confirming an Independent Assessment Committee to investigate a complaint at Humber RiverHospitalandconfirmingtheChairasLeslieVincent,theAssociationnominee,AngelaPreocanin;andtheHospitalNominee,TrevaMcCumber.(Appendix1).TheIACmembersmetbyteleconferenceonMay21,2014anddiscussedthefollowingissues:

• OverviewoftheIACprocessandtimeframes;• ProposeddatesfortheIAC;• InformationrequirementsforthecommitteetoassistintheIAC’sprocessanddeliberations.

OnMay28,2014 the IACproposed to theHospitaland theAssociation that the IACbescheduled forNovember24-26,2014.TheAssociationagreedtothesedates,buttheHospitaldidnotreplyregardingtheiravailability.OnJune12,2014theHospitalfiledanEmployergrievance,statingthattheAssociationhadviolatedthecollectiveagreementarticles1,6and8.(Appendix2).OnJuly28,2014theIACchairagainaskedbothpartiesfortheiravailabilitytoholdtheIAConNovember24-26,2014. TheAssociationagreed;butnoresponsewasreceivedfromtheHospital.OnSeptember12,2014theIACchairrequestedthatbothpartiessubmittheirbriefstotheIACbyOctober31,2014.OnSeptember12,theHospital’s legalcounselsentalettertotheIACchairrequestingthattheIACbeadjourned until the grievance filed on June 12, 2014 has been properly resolved through arbitration.(Appendix3)OnSeptember25,thelegalcounselfortheAssociationsentalettertotheIACchairaskingthattheIACproceedonNovember24,2014.(Appendix4)On October 4 2014, legal counsel for the Hospital sent a letter to the IAC chair stating theirdisagreementwith the position byONA that the IAC should proceed, and stating their view that thegrievancebeheardpriortotheIAC.(Appendix5)

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OnOctober14,theIACchairsentalettertobothpartiesstatingthatwhiletheIACpanelwaspreparedtoproceedonNovember24,2014,itwasnecessaryfortheHospitalandtheAssociationtoresolvetheirissuesrelatedtothegrievanceandthetimingoftheIAC.(Appendix6)OnOctober 21, 2014 legal counsel for the Association sent a letter to the IAC chair stating that theAssociationwasreadytoproceedwiththeIACinNovember.(Appendix7)OnOctober23,2014legalcounselfortheHospitalsentalettertotheIACchairrequestingadjournmentoftheIACuntilthegrievancewasheld.(Appendix8)On November 4, 2014, the IAC chair sent a letter to both parties stating that an impasse had beenreachedbetweenthepartiesregardingthetimingoftheIAC,andreluctantlycancellingtheIACuntilthegrievancewasheardin2015.(Appendix9)OnSeptember30,2015,theIACchairwasnotifiedbytheAssociationthataftertwodaysofmediation,thattheHospitalhadwithdrawnthegrievance;andagreedtoproceedwiththeIACinFebruary2016.OnOctober16, 2015, the IACpanelproposed thedatesofMarch2-4, 2016 for the IAC.Bothpartiesagreedtothesedates.OnJanuary10,2016TheIACchairrequestedthatbothpartiessubmittheirbriefsonFebruary8,2016.OnJanuary23,2016thatIACchairsenttheagendafortheIAC(Appendix10)andaninformationrequestfordatafromtheHospital(Appendix11).TheIACalsorequestedatouroftheHemodialysisUnitonthefirstdayoftheIAC.ThefollowinggroundrulesforconductduringtheIACwereprovided:

1. Adheretotheagendaandthetimeframesforpresentation;2. Opportunitywillbegiventoaskquestionsforclarityattheendofeachpresentation.Ifeither

partyhasaquestion,pleaseindicatethistotheChair;3. Pleasespeakfromyourownperspectiveandexperience;4. Donotraiseissuesrelatedtoindividuals;thepanelisnotconvenedtoaddressanyconcerns

regardingindividualperformance;5. Theproceedingsofthehearingareconfidentialandnottobediscussedoutsidethehearing

exceptforthepurposeofpreparingoftheIACmeeting;6. Thebriefs,presentations,discussionandanydistributeddocumentsinthishearingarenottobe

sharedwithotherparties.7. MaintainaprofessionaldemeanoratalltimesduringtheIACmeeting.

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On February 22, 2016, the IAC met in preparation for the IAC meeting and to review the briefssubmittedbybothparties.OnFebruary25,2015, the IACchairwasnotifiedbytheHospitalnominee,TrevaMcCumber, thatshewasunfortunatelyunabletobepresentattheIAConMarch2-4.DespiteeffortsbytheHospitaltofindanalternatenominee,theIACwascancelledandrescheduledforMarch29-31,2016.ThenewnomineenamedbytheHospitalwasSylviaRodgers.OnMarch 28, 2016 the IAC chair was notified that the Hospital nominee was unable to attend theMarch 29-31, 2016 IAC due to family issues. The IAC was subsequently rescheduled for April 20-22,2016.ThepanelmetinpreparationfortheIAConApril20,2016priortothetouroftheHemodialysisunit.Priortothehearing,bothpartiesconfirmedwhowouldbeinattendanceatthehearing.

Hearing

Wednesday,April202016TheIACmetattheHospitalat1000HoursonMarch29,2016andweregreetedbyrepresentativesofthe Hospital and members of the Association. The IAC was provided with an extensive tour of theHemodialysisunit.ThetourservedtofamiliarizetheIACwiththeworkenvironmentandphysicallayoutoftheunit.ThefollowingindividualsfromtheHospitalwereonthetour:

• MelanieTremblay,Director,NephrologyProgram• DilshadPirani,Manager,Nephrology• JenniferDuteau,ClinicalPracticeLeader

ThefollowingindividualsfromtheAssociationwereonthetour:

• AnneGibb,RNHemodialysis• ElizabethAstillero,RNHemodialysis• MarianaMarkovic,ProfessionalPracticeSpecialist,LabourRelationsOfficer,ONA

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Followingabreak,TheIAChearingconvenedat1300houraspertheagenda(Appendix10).ParticipantsandObserversontherespectivehearingdatesarelistedinAppendix12.Following introductionoftheIACCommitteemembersandrepresentativesoftheAssociationandtheHospital,theIACChairreviewed:

• ThejurisdictionalscopeoftheIAC,includingthepurposeoftheIAC;and• The ground rules for the Hearing procedure including confirmation that all participants

understoodandagreed.Ms.MarianaMarkovic, Professional Practice Specialist (PPS), presented on behalf of the Association.The Association’s presentation was based on their written Pre-hearing submission and supportingexhibitsaswellasasummaryofthe187ProfessionalResponsibilityWorkloadReportForms(PRWRFs)submittedbytheRegisteredNursesoftheHemodialysisUnitbetween2011and2016.Melanie Tremblay, Director of the Nephrology Program; Dilshad Pirani, Manager of the NephrologyProgram; and Jennifer Duteau, Clinical Practice Leader presented on behalf of the Hospital. TheHospital’spresentationwasbasedontheirwrittenpre-hearingsubmissionandsupportingexhibits.ThursdayApril21,2016TheIACChairresumedtheHearingat0900hours.MelanieTremblay,DilshadPiraniandJenniferDuteauprovidedtheHospital’sresponsetotheAssociation’ssubmission.MembersoftheHospitalparticipatedin the subsequent discussion. Ms. Markovic provided the Association’s response to the Hospital’ssubmission.OthermembersoftheAssociationalsoparticipatedinthesubsequentdiscussion.The IAC Chair adjourned the Hearing at approximately 1730 hours. Following adjournment of theHearing, the IACmet during the evening to review and synthesize the information provided, and toidentifykeyissuesrequiringadditionalclarificationandtheirrespectivequestionsforthefinaldayofthehearing.

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Friday,April22,2016TheIACchairresumedthemeetingat0900hr.MembersoftheIACaskedfurtherquestionsinordertounderstanda rangeof issues inmoredetailandgaining furtherclarityof the issuesarising frombothparties’presentations.The IACChairconcludedthehearingbythankingMs.AngelaPreocanin,AssociationNomineeandMs.SylviaRodgersHospitalNominee;aswellasalltheparticipantsfortheirengagementandcontributionsintheHearingprocess.TheIACChairalsocommunicatedthehopethatthepartieswillbeabletomoveforward to seek resolution to the issues. The Chair also confirmed that IAC anticipated providing thefinalreportwithin45days.TheIACChairclosedtheHearingatapproximately1300hours.

PostClosureofHearing

TheIACmetinpersononMay2,2016.Atthismeeting,theIAChadextensivediscussionandreviewedthedraftreportandanalysis.Followingthemeeting,allIACmemberscontributedtothenextversionofthereportandrecommendations.ThereportwasfinalizedonJune2,2016.

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2. PresentationoftheProfessionalResponsibilityWorkloadComplaint

2.1 InformationonHumberRiverHospitalandtheHemodialysisUnit

The Hemodialysis Unit at Humber River Hospital (HRH) is located in Toronto, Ontario. Humber RiverHospital isaregionalacutecarehospitalandservesacatchmentareaofmorethan850,000peopleinthe northwest Greater Toronto Area. In October 2015 the HRH moved into a new hospital at 1235Wilson Ave. in Toronto. The hospital has approximately 650 beds, employs approximately 3400employeesincluding1200RegisteredNurses(RNs)and300RegisteredPracticalNurses(RPNs).TheHemodialysisIn-CentreUnitisdividedintotheeastandwestwingswith61dialysisstations.Thereis a central patient care station in eachwingwith views of all dialysis stations. The unit services 350patients. There is an interprofessional team includingRNs,RPNs,physicians, socialworkers,dieticiansandpharmacists.Theunitoperates7daysaweek from0700-2300,with24-houroncall coverage foremergencytreatments.Onweekends,onlyhalftheunitisopen.Threetypesofservicesareprovided:

• Conventionalhemodialysis:4hourtreatments,3timesaweek• Shortdailyhemodialysis:patientsreceiving2-3hourtreatments,5-7timesperweek• AcutedialysisisperformedintheICU,Emergency,CardiacCareandin-patientunits

MostpatientsreceivetheirtreatmentintheIn-Centrewithexceptionofthosepatientsthataretooilltobemovedtothecentrefromtheirunitofcare.

2.2 HistoryofStaffinginHemodialysisUnitsince2011

2.2.1 Staffingin2011

In2011,theHemodialysisUnitwaslocatedattheChurchStreetSiteofHumberRiverHospital.Theunithadtwowingswithatotalof61dialysisstations.Staffing:• TwoChargeNursesondaysandtwoonevenings; theChargeNurseshavenopatientassignment,

buttakeoneifnecessary

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• Table1displaystheRNStaffingbyPeriodofDay(notincludingResourceNurseandChargeNurse)Table1:RNStaffingbyPeriodDayShift NumberofRNs0700–1100 221100–1500 30including8FloatRN1500–1900 26including8FloatRN1900–2300 18AcuteoffUnit 0700–1100 31100–1500 31500–1900 3

• RNsareassignedtoapodof3chairsandhave3patienttreatmentsgoingsimultaneously• Majorityoftreatmentsin2011were3to4.5hours long,3timesaweek.Short2-hourtreatments

wereincreasingatthetime.

2.2.2 StaffingChangesfrom2011-2013

During the period of 2011 to 2013 numerous changes in nurse staffing and themodel of care wereimplemented.Thechangesincluded:• Two(2)RNsfrombasestaffwereassignedtooffunitpatients;• RemovaloftheChargeNursefrom8hourdayandeveningshift;• ImplementingtheroleofResourceNurseinMarch2012;• ImplementationofanewdeliverycaremodelandRegisteredPracticalNurses(RPNs)intotheunit.

TheRPNsreplacedsix(6)RNsonthe8-hourdayshiftandeveningshifts;• ReducingthenumberoffloatRNsfrom8(eight)to5(five)onboththedayandeveningshifts;• Implementationofanewmasterschedule.RPNsassignedto8hoursshifts;RNsassignedto8-hour

shifts(Days,evenings)and10-hourshifts(TallDay(TD),Tallevening(TE));• SettingtheNursetopatientratioat:3:1conventional;2:1shortdaily;2:1segregation;• Increasingthedialysisassistanthours;

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• Additionofanadditionalclericalshiftfrom1500-2300;• Conductingareviewofnon-RNdutieswasconductedandthenassigningactivitiestoother

personnel;• Bringingnewhemodialysismachinesintoservice:• Hiringanewmanagerfortheunit.• Table2displaystheRNStaffingbyPeriodofDay

Table2:RNStaffingbyPeriodDayShift NumberofRNs0700–1100 221100–1500 25including3FloatRNs1500–1900 21including3FloatRNs1900–2300 18AcuteOffUnit 0700–1100 31100–1500 31500–1900 3

2.2.3 StaffingChangesin2013/2014

• Theroleoffloatnurseswaseliminated.

2.2.4 StaffingChangesin2015/2016

• The RPN staffing was increased from six (6) to seven (7) on days and evenings; and RN staffingreduced.

• OneFloatRNwasaddedon8-hourdays inApril2016toprovidebreakcoveragetoselectedpodsandtotheChargeandResourceNurses.TheHospitalstatedthatthisshiftwouldbeaddedontheweekendinthenearfuture.

• AschedulingchangeinRNswasimplementedinApril2016.o 9(nine)TEshiftswerereducedto5(five)o 7(seven)8hr-eveningswereincreasedto12o 3(three)oftheTEshiftsareallocatedtooff-unittreatments.

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2.2.5 CurrentStaffing

TheRNandRPNstaffareequallydividedacrossbothsidesoftheunit.EachnurseisassignedtoaPodof3stations.ThereisaChargeNurseandaResourceNurseonbothdayandeveningsshifts.TwoRNsareoncallatnight.AgraphicaldepictionoftheRNandRPNstaffingbyhourofday4onMondaytoFridayisincludedinAppendix13andSaturday-SundayinAppendix14.ThecurrentstaffingintheHemodialysisunitforRNsMondaytoFridayis:• 0700–1500:8RN• 0700–1700:6RN• 1500–2300:12RN• 1300–2300:5RN(2incentre;and3offunit)• 1(one)RNon8-hrdayshiftforbreakreliefThecurrentstaffingforRPNsMondaytoFridayis:• 0700–1500:7RPNs• 1500–2300:7RPNsOnweekends,thestaffingisreduced,asonlyonesideoftheunitisopen.ThecurrentstaffingintheHemodialysisunitforRNsonweekendsis:• 0700–1500:3RN• 0700–1700:4RN• 1500–2300:7RN• 1300–2300:2RN(foroffunit)• 1(one)8-hrRNtobeaddedonDayshiftforbreakrelief• ThereisoneChargeNurseondaysandeveningsThecurrentstaffingforRPNsonweekendsis:• 0700–1500:4RPNs• 1500–2300:4RPNs

4RNandRPNStaffingbyHourofDayonMondaytoFriday;andSaturday/SundayprovidedbyHumberRiverHospitalatIAConFriday,April22,2016.

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Otherstaffincludes:• ClericalStaff:staggeredshiftswithcoveragefrom0600-2330.• DialysisTechnologists• DialysisAssistants• 1530-2330:1DA• HousekeepingAdditional,thefollowingstaffworkMondaytoFriday:• BodyAccessCoordinator• IndependentDialysisCoordinator• ClinicalPracticeLeaders• ClinicalInstructor• PatientCareManager• PatientServiceCoordinatorprovidesadditionalsupportafterhours

2.3 WorkloadConcernsofRegisteredNursesandDiscussionsattheHospitalAssociationCommitteeTherewere187ProfessionalResponsibilityWorkloadResponsibilityForms(PRWRFs)submittedbetween2011and2016.• 2011:21PRWRFs• 2012:75PRWRFs• 2013:61PRWRFs• 2014:19PRWRFs• 2015:4PRWRFs• 2016:7PRWRFsDuring thepresentation theAssociation stated that the nursingworkloadproblemsare as a result offollowingissues:• ProfessionalPracticeincludingpracticestandards,nurseleadership• Patientacuity• RNandRPNpractice• Fluctuatingworkload• Fragmentedandinterruptedcare• FluctuatingstaffingandRNstaffing• ExcellentCareforAllAct,2010.

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TheAssociationprovided37recommendations5intheirbriefsubmissionforresolutionoftheworkload.TherecommendationscanbesummarizedunderRNandRPNstaffing,patientassignments, leadershipand leadershipaccountabilityandresponsibility,governancestructureengaging front linestaff; timelyand effective processes to resolve workload concern, education support; a fatigue managementprogram,documentationandmodelofcare.• RNandRPNstaffing:

o Basestaffingaccountsfortime/resourcesforconsultation;patientassessment;patientcareneeds; receiving report; documentation; replacement for orientation and professionaldevelopment

o RN/RPNstaffingmixo RPNroleclarityo RNsreplacedwithRNso Increasestaffingof4RNs/dayassignedtoroleofFloatNurseon11.25hr.tourso Adjust staffing to80/20RN toRPN ratio;Replace4RPNsoutof7working regular8hour

toursonDaysandEveningso Utilizebestpracticeguidelines/standardswithregardtostaffingandworkload

• Patientassignments:o UseofevidencebasedtoolsandtheThreeFactorframeworkinmakingdecisionsregarding

RPNstaffing;andsubsequentlyforpatientassignmentso Appropriate assignment of patients to RNs and RPNs; engagement of nursing staff in

assignmentdecisionso Patientassignmenttoolandpolicytobedevelopedandevaluated

• Leadershipandleadershipaccountabilityandresponsibility;• Governance structure engaging front line staff; engagement in planning, development of healthy

workenvironment;• Timely and effective processes to resolve concerns related to professional practice, acuity,

workloadsandstaffing;• Educationsupportanddedicatededucator;• Comprehensivefatiguepreventionandmanagementprogram;• Standardized documentation and handover (transfer of care) at end of patient runs and shift

change;and

5SubmissiontotheIndependentAssessmentCommitteebyOntarioNurses’Association,p.46-49.

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• Modelofcaretoreducefragmentationofcare.TheAssociationstatedthattheincreasingpatientworkloadrequiresRegisteredNurses(RNs)toperformmore work than is consistent with proper patient care. During and following the presentation, theAssociationrespondedtoquestionsofclarificationfromboththeHospitalandIAC.Melanie Tremblay, Director of the Nephrology Program; Dilshad Pirani, Manager of the NephrologyProgram;andJenniferDuteau,ClinicalPracticeLeaderpresentedonbehalfoftheHospital.Thecontentof the Hospital’s presentation was based on their written pre-hearing submission. The presentationprovidedtheHospital’sviewon:• HospitalaccountabilitiestotheOntarioRenalNetwork;• Programleadership;• TransitionfromChurchsitetoWilsonsite;• ModelofCare;• Orientationofstaffandcompetenciesofstaff;• PatientschedulingandassignmenttonurseswithintheHemodialysisUnit;• Nursingworkloadthroughoutshifts;atchangeover.TheHospitalrecommendationsincluded:• AdditionalRNstaffforbreak/reliefsupport;hoursandshiftsbasedonunitactivity;• Schedulingtooptimizestaffutilizationandassessworkload;• Completeenvironmentalscanregardingstaffingandpatientpopulation;• RefiningPatientNeedsAssessmentTooltoidentifyRNonlyassignments;• A regular review process to assess and document patients for stability/predictability to support

patientassignmentstoappropriatestaffwithappropriateworkload;• ProcessesforstafftoupdatetheResourceNurseonsignificantchanges/eventsduringdialysis;• EstablishandmonitorstatisticstoreflectsignificanteventincludingtransferofcarefromRNtoRPN;

admissionofpatientspost-dialysis;numberofpatientsrequiringpost-dialysisobservations;numberof daily treatments, off unit treatments, urgent unplanned off unit treatments, cardiac arrests,circumstanceswhenstaffingnotadequate,replacingRNswithRPNsduetounavailability;

• Meetingregularlywithstafftoaddresstheirconcerns;• Establishingapracticecommittee;• ConsultationwithRPNAOreRPNrole;• WorkingwithunionpartnersretimelyaddressingofworkloadcomplaintsasperArticle8.01.

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2.4 MeetingsbetweenAssociationandHospitalPriortoIAC

TherewereseveralmeetingsbetweentheAssociationandtheHospitalinanefforttoresolvetheissuesarisingfromthePRWRFs.InitiallythePRWRFSrelatedtotheHemodialysisunitwerediscussedintheHospitalAssociationCommittee(HAC).

OnFebruary3,2012,Ms.MarianaMarkovicnotifiedtheHospitalthattheAssociation’sintenttobringforththeissueofprofessionalresponsibilityrelatedtotheongoingproblemsidentifiedinthePRWRFs,andifnotresolved,torefertheissuestoanIndependentAssessmentCommittee.

AProfessionalResponsibilityCommitteemetonFebruary28,2012;April3,2012;June26,2012;November7,2012.Fourteenissueswereidentifiedanddiscussedduringthesemeetingsincludingstaffing,vacancies,overtime,equipment,rolesandresponsibilitiesofvariousteammembers,assignments,offunittreatments,patientvolumeandacuity.InformationwasprovidedbytheHospitaltotheAssociationonroledescriptions,staffing,sicktime,modelofcare,patienttreatments,educationsessionsandstaffmeetings.

FollowingtheNovember7meeting,theHospitalprovidedaLetterofUnderstandingtotheAssociationthatdetailedalistofimprovementstoaddressmostoftheprofessionalresponsibilityconcerns.ImprovementsidentifiedbytheHospitalwere:

• NewcaredeliverymodelimplementedinOctober2012toresolveRNsbeingpulledoffunitduringchangeovertodooffunittreatments.

• Patientassignmentschangedtoputallconventionaltreatmentsatmainpods;andshort(2hr.)treatmentsinexpansionC100.ThischangewastoresolveanRNpickingupa2nd2-hourpatient.

• Anewmasterscheduleasimplementedwithafloatnurseassignedperpodduringchangeover.• Theratioofstaffwastobe3:1forconventionaltreatments;2:1forshortdailytreatments;and

2:1forpatientsrequiringsegregation.• Anadditionaldialysisassistantshiftwasimplementedfrom1000-1800inordertoprovide

additionalsupportatchangeoverandforoff-unittreatments.• RoleofResourceNurseimplementedwithnopatientassignment.• Additionalclericalassociateshiftimplementedbetween1500-2300.• PatienttreatmentspotsassignedbytheResourceNursestobalanceworkloadassignmentsof

RNs.• Newdescriptionforfloatnursesimplementedwithnopatientassignment.• Non-nursingdutiesassignedtoclericalstaff,housekeeping,anddialysisassistants.

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TheLetterofUnderstandingwasnotexecuted.

ItwasagreedtoestablishaHemodialysisUnitTaskForceandtermsofreferenceweredevelopedinJune2012.Thepurposeofthetaskforcewastodevelop,implementandevaluateeffectivestrategiestoaddressworkloadconcernsnotedundertheprofessionalresponsibilityconcernssubmittedsinceSeptember2011.Thestatedmeasureofsuccessofthetaskforcewastoidentifystrategieswithintheallocatedresourcestoensuretheachievementofpositivepatientoutcomes.6AccordingtotheminutesprovidedintheHospitalbrief,theTaskForcemetonfouroccasionsbetweenDecember2012andFebruary2013.7OnApril3,2013,theAssociationadvisedtheHospitalthattheunionwouldnotbecontinuingthetaskforcebecauseRPNswerebeingintroducedintotheunit.

OnJune18,2013,theAssociationadvancedtheProfessionalResponsibilityComplainttotheOntarioHospitalAssociationtoidentifythenextavailableIACchair.

TheHospitalfiledanemployergrievanceonJune12,2014.FollowingthegrievancefiledbytheHospital,bothpartiesparticipatedintwodaysofmediationonJanuary26,2015andSeptember29,2015.TheHospitalwithdrewthegrievanceonSeptember29,2015;andbothpartiesagreedtomeetonNovember2and3,andDecember18,2015;andsubsequentlyonFebruary2,2016.Theissuesdiscussedduringthesemeetingswere:

• November2-3,2015:Professionalpractice,patientacuity,fluctuatingworkloadandfluctuatingstaffing;

• December18,2015:RN/RPNassignment,modelofcare,rolesofRNandRPNoninterprofessionalteam,communication,breaksandeducationforRPN;

• February2,2016:reviewofprocessforassignments;breakassignmentsandacuitytoolfollow-up.

6TermsofReference–HemodialysisTaskForce,SubmissionsonBehalfoftheHumberRiverHospital,Tab9.

7DialysisTaskForceMeetingAgendasandMeeting,SubmissionsonBehalfoftheHumberRiverHospital,Tabs11-14.

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3 Discussion,AnalysisandRecommendations

FiveissuesthatimpactonnursingworkloadintheHemodialysisunitwereidentifiedbytheIAC.Theissuesare:

1. RegisteredNurseStaffingandSchedulinga. DeterminingtheAssignmentofRNorRPNtoPatientstoensureadequateandsafeRN

Staffingb. SupportingConsultationandCollaborationamongNursingStaffc. NurseScheduling

2. PatientVolumes,TypesofTreatmentandScheduling3. Documentation4. CommunicationandDecisionMaking5. ProcessforManagementofProfessionalResponsibilityWorkloadReportForms

3.1 RegisteredNurseStaffingandSchedulingToEnsureAdequateandSafeRNStaffing

Nursestaffingisrecognizedasastructuralmeasureofqualityandadequacyofstaffinglevelsislinkedtopatientsafetyandqualityofcare.Ongoingevaluationofnursestaffingandoutcomesrelatedtopatientsafetyandqualityareessential.Since2011therehasbeensteadyerosionofRegisteredNurse(RN)staffcomplementintheHemodialysisunit,primarilyduetolayoffs,attritionandreplacementoffulltimepositionswithparttimepositions.DuringthesameperiodoftimetherehavebeenfrequentchangesinRNschedulingwithregardtothenumberofRNspershiftandthedurationofshifts.Inadditiontherehavebeenmanychanges,includinglayoffs,whichhavealteredthenumberoffullandparttimeRNsworkinginthehemodialysisunit.ThehospitalprovidedcomparativedataonRNbudgetedFTEsandheadcountfrom2013-20168,whichisreproducedinTable3.TotalRNFTEsdecreasedby14.05FTEsfrom73.43in2013to59.38in2016.Duringthesameperiod,theRPNstaffbudgetincreasedto7.82FTEs.Thisresultedinanetdecreasein6.23FTEsinRNstaffing(14.05less7.82),whilepatientvolumeshaveremainedthesameintheprevalentchronicdialysispatientsandincreasedintheacuteoffunitpatientpopulation.

8DataonRNandRPNBudgetedFTEs2013–2016,HumberRiverHospital,SubmittedtoIAConFriday,April22,2016.

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Table3:BudgetedRNandRPNStaffingandHeadcountfrom2013–2016.TypeofStaff 2013-2014 2014-2015 2015-2016

FTE Headcount FTE Headcount FTE Headcount

RNFulltime 60 60 46 46 44 44

RNParttime 13.42 22 13.67 25 15.38 23

CasualRN 10

TotalRN 73.43 80 59.67 71 59.38 77

RPNFulltime 4 4 4 4

RPNParttime 3.85 6 3.82 17

TotalRPN 10 7.82 21

DeterminingAssignmentofRNorRPNtoPatientstoEnsureAdequateandSafeRNStaffing:

In2012-2013theHospitalconsultedotherhospitalswhereRPNswereemployedinhemodialysisunits.DuringthisconsultationtheHospitalexaminedthescopeoftheRPNroleinhemodialysis,qualifications,orientationprocesses,aswellastheratiosofRNstoRPNs.AdecisionwasmadebytheHospitaltogotoa70/30RN:RPNstaffingmodelintheHemodialysisUnit.

TheHospitalcreatedaCollaborativeModelofPracticeforHemodialysis:RegisteredNurseandRegisteredPracticalNurseinPartnership9andaDialysisUnitAcuityMonitoringTool9,todeterminewhichpatientsshouldbeassignedtoanRNorRPNbasedoncomplexity,predictabilityandriskofnegativeoutcomes.DuringlaterdiscussionswiththeOntarioNurses’Association,ONArecommended

9SubmissionsonBehalfoftheHospital,Tab38.

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theuseofanotheracuitymonitoringtooldevelopedbyGrandRiverHospital.TheHospitalprovideddata10ontheconcurrentapplicationofbothtoolsontheprevalentdialysispatientpopulationintheHumberRiverDialysisunit.ThisapplicationwasconductedbytheClinicalPracticeLeaderandtheResourceNurseinNovember2015andagaininFebruary2016ontheprevalentdialysispatientpopulation.Table4providestheresultsofthisapplicationandthenumber/percentageofpatientsthattheoreticallycouldbeassignedtoanRPN,orshouldbeassignedtoanRN.

Table4:AssignmentofPatientstoRNorRPNbasedontheApplicationofDialysisUnitAcuityMonitoringTool

Dateofapplicationofmonitoringtool

TotalNumberofPatientsAssessed

ToolUtilized TotalnumberandPercentagethatShouldbeAssignedtoanRN

TotalnumberofPatientsthatcouldbeAssignedtoanRPN

November18,2015

318 HRH 14(4.4%) 304(95.5%)

February2016 287 HRH 76(26%) 211(73%)

287 GrandRiver 170(59%) 125(43%)

Thetwotoolsprovidedwidelyvaryingestimatesofthenumberofpatientstobeassignedtoeithercategoryofnurses.Neitheroftheacuitymonitoringtoolshasundergoneaformal,rigorousevaluationforreliabilityandvalidity.

TheHRHacuitymonitoringtoolhasonlybeenutilizedintermittentlyasameanstodeterminetheproportionofpatientsthatcouldtheoreticallybeassignedtoanRPNorshouldbeassignedtoanRN.Onadailybasis,theResourceNursedeterminestheassignmentbasedonclinicaljudgementandutilizingtheacuitymonitoringtoolasaresource.Patientrecordsandtheshifttransferreportareusedasotherdatasourcestomaketheassignments.TheResourceNursealsoutilizestheCommunityWidePatientSchedulingTool(CWPST)whichiscompletedbytheclericalstaff.TheCWPSTisthetoolwherepatients

10SubmissionsonBehalfoftheHospital,Tab28and29.

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areassignedtostationandtimefortheirtreatment.OncetheResourceNursehasdeterminedthenurseassignments,thisinformationisaddedtotheCWPST.

Recentlynewpreandpostassessmentscreenswereaddedtothepatientrecord.TheelementsofthePostassessmentscreencontainsselectedindicatorsfromtheHRHacuitymonitoringtool.TheresultsofthepostassessmentscreenareautomaticallyaddedtotheCommunityWidePatientSchedulingToolforeachpatient,inanefforttoassisttheResourceNurseinmakingappropriateassignments.

Itisunknownifthesearethebestindicatorstoutilizeorifmoreordifferentindicatorsshouldbeaddedtobereflectiveofpatientcondition/reactionstotreatment.Forexample,shouldtheindicatorforcriticalresultsbemoresensitivetoanycriticalresultinthelast3months?Isthisthemostsuitabletimeframeforevaluation?DoestheResourceNursehavereadyaccesstoallthepertinentinformationonalmost300hemodialysispatientsandtheircurrentstatustomakethebestjudgementonnurse—patientassignmentsonadailybasis?

Theredidnotappeartoberegularandsystematicmonitoring/evaluationofnursestaffingandtheadequacyofRNstaffing.Theinfrequentuseofanon-validatedacuitytoolisinsufficient.WhiletheHospitalreportsdatatotheOntarioRenalNetworkfortheongoingmonitoringofhemodialysisprograms,theindicatorsarerelatedtopatientvolumes,typeofcare,timelinessandlocationofcare.Recentbenchmarkingstudy11conductedbytheHospitalin2016includedsomestaffingindicators(e.gnumberofnursesoneachshift,proportionofRNs/RPNs)butdidnotincludewhatmethods/toolsotherhemodialysisunitsutilizetodeterminenursestaffing.

SupportingConsultationandCollaborationamongNursingStaff

TheCollegeofNursesofOntarioPracticeGuidelineonRNandRPNPractice:theClient,theNurseandtheEnvironment12utilizesthreefactors(theclient,theenvironmentandthenurse)toguidedecisionmakingoncare-providerassignmentsandtheneedforconsultationandcollaboration.TheHRHCollaborativeModelforPracticeforHemodialysisstatesthatRNsandRPNswillconsultandcollaborateasnecessaryforpatientcare.

TheRPNsconsultRNsonaregularbasisalthoughtherehasbeennoevaluationofthedegree/frequencyofconsultation/collaborationwiththeexceptionofthemonitoringofTransferofAccountability.11SubmissionsonBehalfoftheHospital,Tab37

12CollegeofNursesofOntario.RNandRPNPractice:theClient,theNurseandtheEnvironment,2014

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However,TOAonlyoccurswhentheconsultation/collaborationprocessisinsufficienttomeetpatientneeds,andthereforeisnotagoodmeasureofthetimeandworkloadinvolvedwithongoingconsultationandcollaborationamongRNsandRPNs.

EffectiveandtimelyconsultationandcollaborationbetweenRNsandRPNsisessentialtoprovidesafeandqualitypatientcare.Arguably,thepatientsintheHRHhemodialysisunitthatareassignedtoRNsaremorecomplexthanthoseassignedtoRPNs,astheRNsmustbeassignedtothosepatientswhoarelessstable,lesspredictableandathigherriskofnegativeoutcomes.Inaddition,RNsareassignedtoalloffunitpatients.TheRNsviewtheRPNsastheircolleaguesandunderstandtheirprofessionalaccountabilityandresponsibilitytosupporttheRPNSthroughconsultation,collaborationand/ortransferofaccountability.

However,thetimeinvolvedinconsultingandcollaborationwithRPNsisadditionalworkfortheRNs.ThiswasdescribedbytheRNsaschallenginggiventhecurrentavailabilityofRNsintheunitespeciallyduringbreaksandtimesofpatientturnover.Additionally,theRNmustcontinuethecareofherownpatients,whileconsultingwiththeRPN,possiblyresultingininterruptionsand/ordelaysincare.

NurseScheduling:

CurrentlytheRNsworkacombinationof8-hourand10-hoursshifts;withstarttimesof0700,1300or1500.AsaresultofthelengthandstarttimeofRNshifts,theRNstaffinghaspeaksandvalleysduringatypical18-hourworkday,rangingfrom14-23RNsatanyonetimeduringweekdays.ThetimeofgreatestoverlapofRNshiftsis1300-1700.DuringtheperiodsoflowerRNstaffingthereisalackofadequateRNcoverageorshiftbreaksandpatientturnover.ThereisfrequentdemandfortheChargeandResourceNursestoprovidepatientcare(breakcoveragefornurses,patientsrequiringobservationetc.),divertingthemawayfromtheirleadershiproles.Recentlyanewshiftfrom0700-1500wasaddedduringtheweekbecauseoftheneedtoprovidebreakcoveragefortheChargeNurseandResourceNurse,breakcoverageforthepodswithprivaterooms,andforpatientsrequiringobservationaftertreatment.Thegeographyofunitissuchthatsomepodsarenotvisiblefromthenursingstations,makingbreakcoveragechallenging.

Overthelast5years,thereappearstohavebeenlittleengagementofand/ordiscussionwiththenursingstaffregardinganyofthedecisionsregardingnursestaffing/schedulingbeforeorafterimplementation.Norwasitevidentthattherewasanysystematicevaluationbymanagementofthemanystaffingandschedulingchanges.

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3.2 PatientVolumes,TypesofTreatmentandScheduling

TheIn-CentreHemodialysisUnitcurrentlyprovidescareto357chronicdialysispatients13.Thisvolumeofpatientsisunvariedoverthelastyears.Theunitalsoprovidesacuteoffunittreatmentstoadmittedpatients.TheHospitalprovidedacomparisonofpatientvolumesbetween2014-2015and2015-2016(Q3).14ThisdataisdisplayedinTable5.

Table5:PatientVolumes2014-2016.

TypeofPatient 2014-2015 2015-2016(asofQ3)

Level3(1:1offunitpatients) 1,558 2,057

InFacility(3to4hourtreatments)

40,777 41,215

InFacility(2hourtreatments)

17,652 17,410

Whiletheinfacilitypatientvolumesarerelativelyunchanged,therehasbeenasharpincreaseinthenumberofLevel3offunitpatientssincethetransitionoftheHospitaltotheWilsonSite(from1,158in14/15to2,057in15/16).TheHospitalbelievesthatthisisduetotheincreaseinICUbeds(from27to40)sincethetransition,resultinginanincreaseddemandforacutedialysisinthispatientpopulation.TheHospitalalsonotedthatthenumberofpatientstransferredbytheHospitalthroughCriticallhassignificantlydecreasedsincetheadditionalICUbedshaveopened.TheconsiderableincreaseinLevel3offunitpatientsishavingasignificantimpactonRNworkloadasonlyRNsareassignedtothesepatientsduetotheircomplexity,instabilityandriskfornegativeoutcomes.TheHemodialysisprogramatHumberRiverHospitalhasasignificantlylargernumberofpatientson2-hourtreatments(versus3or4hourtreatments)incomparisontoothersimilarunits.Thisresultsinahigherturnoverofpatientseveryday.Patientturnoverisassociatedwithaconsiderableamountofworkloadthatisnotaccountedforinthecurrentstaffinglevels.13OntarioRenalNetwork,PrevalentChronicDialysisPatients,HumberRiverHospitalQ3FY15/16ProgramScorecard

14PatientVolumes2014-2016.HumberRiverHospital.ProvidedtoIAConFriday,April22,2016.

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Patientsarescheduledfortreatmentduringoneof3shiftsinthemorning,afternoonorevening.Eachtreatmentpodhas3chair/bedsandstarttimesare15minapart.Keepingtothescheduleforstarttimesisnotalwaysachievableduetomanyfactorsincludingpatientfactors(delayinarrivaltotheunit,accessissues)and/ordialysismachineissues.Asaresultnursingstaffarefrequentlygettingbehindjustastheystarttheshiftbecausedelaysarecommonandprobablyunavoidable.Thereisnotaspecificstandardforstarttimesspacingindialysisunits,andapparentlyvariesfrom15-30mindependingonthehospital.TheRNsnotedthatitisverychallengingtoadequatelyassesseachpatient,initiatetreatmentanddocumentcareduringthis45minutetimeframe.Documentationisfrequentlydeferredtolaterintheshift.

3.3 Documentation

HumberRiverHospitalcurrentlyusesMeditechfortheelectronichealthrecordforclients.NursesdothemajorityoftheirdocumentationinMeditech.Thepaperbasedpatientflowsheet(utilizedtorecordreadingsandotherinformationduringtreatmentfromthedialysismachines)wasdiscontinuedafterthemovetoWilsonsiteasthenewunithasIntegratedBedsideTerminals(IBTs)andacomputerstationwithineachpod.ItwasplannedthatnursescouldenterdatautilizingtheIBTSandthecomputerstations.However,theIBTsaretheentertainment/communicationdeviceforpatients,soinpracticaltermsarenotavailabletothenursingstaff.ThedialysismachinesnotinterfacedwithMeditech.Asaresult,nurseswereobservedbytheIACmemberswhileonatouroftheunittoberecordinginformation/dataonavarietyofinformalflowsheetsasameanstoretaindatafordocumentationintheelectronichealthrecord.Thisdocumentation“workaround”seemsunavoidableatthistimegiventhattheDialysismachinesarenotinterfacedwithMeditech.

Inaddition,thetightstarttimesandrapidpatientturnoverresultinlittleornotimefortimelyandappropriatedocumentationduringthefirsthoursofcare.

3.4 CommunicationandDecisionMaking

Theengagementofnursingstaffinameaningfulwayregardingtheirworkandworkconditionsisessentialincreatinganeffectiveworkenvironmenttosupporthighqualitypatientcare.

CommunicationwithstaffisbothformalandinformalintheHemodialysisUnit.Emailisrelieduponextensivelytocommunicateinformationtonursesincludingdecisionsregardingstaffing.Somechangesappeartobeimplementedattimeswithnoformalcommunication(e.g.schedulechanges).TheClinical

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PracticeLeadersendsaweeklyemailtoallstaffwithclinicalandsafetyupdates,educationopportunitiesandotherinformationshefeelsthestaffmayrequire.Therewerenoinformationboardsforstaffintheunit.Performancedata(e.g.ORNreportcards)aresharedwithstaffintermittentlybutthisseemedtobeprimarilyverbal.Thestaffmeetingsareintermittentandshortinduration;andminutesarenotconsistentlydone.

Importantdecisionsonstaffingandschedulingappeartobemadebyleadershipwithlittleornoconsultationand/ordiscussionwithnursingstaff.TheHemodialysisTaskForcewasnotsustainedduetotheAssociation’swithdrawalfromthemeetings.Whiletherewasconsiderableengagementofstafftosupportthetransitiontoanewhospital,issuesofstaffingandworkloadwerenotdiscussedaspartofthetransitionplanning.

3.5 ProcessforManagementofProfessionalResponsibilityWorkloadReportForm(PRWRFs)

Duringtheperiodof2011to2016therewere187professionalresponsibilityworkloadreportformssubmittedbyRNstotheHospital.Duringthistimetherewasahaphazardprocessfortimelyreviewofformsandcommunicationbacktostaff.TheprocessforaddressingPRWRFs,asoutlinedinthecollectiveagreementwasnotconsistentlyfollowed.EffortsrelatedtotheHemodialysisTaskForce,establishedtoworkonworkloadissues,werenotsustained.Inthefallof2015andwinter2016,thepartiesdidmeetonthreeoccasions,butwerenotsuccessfulinreachinganagreementontheworkloadissues.

3.6 Recommendations:

TheIndependentAssessmentCommitteemakesthefollowingrecommendationsregardingworkloadissuesintheHemodialysisUnitatHumberRiverHospital.

RelatedtoRN/RPNAssignments:

1. Conductaformalevaluationoftheacuitymonitoringtoolsforreliabilityandvalidity.TheevaluationshouldminimallyincludetheacuitytooldesignedbyHumberRiverHospitalandthetooldesignedbyGrandRiverHospital.

2. DevelopasetofindicatorsforregularevaluationofRNstaffing;andwhichcanalsobecomparedwithotherhemodialysisunits.ThismayincludeRN/RPNhoursofcareperday,andratioofhourstopatienttreatments.

3. EvaluatethepostassessmentscreentodeterminetheutilityofthecurrentindicatorsindeterminingRNorRPNassignment;andreviseasnecessary.

4. InadditiontotheprospectiveuseoftheacuitymonitoringtoolinassigningpatientstoRNsandRPNs,conductaregularretrospective“realtime”auditofwhethertheassignmentswere

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appropriate.ThiswouldprovidesomemeasureofevaluationoftheacuitytoolandtheabilityoftheResourceNursestomakeappropriateassignmentsbasedontheinformationavailabletothem.

5. DevelopamethodforquantifyingthenumberandtypeofconsultationsandcollaborationeffortsmadeonadailybasisbetweenRNsandRPNs.TheidentificationofwhyRPNsconsultRNswouldinformbothappropriatenessofpatientassignmentsandopportunitiesforimprovementincare.

RelatedtoNurseStaffing:6. Maintainthenewlyimplemented8-hrFloatRNshiftondaysforbreakcoverageofisolationrooms,

ChargeNurseandResourceNurse.7. IncreaseRNstaffingonadailybasisbyincreasingthenumberofRNsinafloatnurserole.This

staffingincreasewill:a. EnsureRNtimeandavailabilitytoengageineffectiveconsultationandcollaborationwith

RPNs;b. EnsurethattheRPNshavereadyaccesstoanRNduringbreaks;c. Provideadequatebreakcoverage;d. Alignstaffingwithpatientvolume,caredemandsandturnover;e. Allowforunplannedevents/delays(e.g.patientsrequiringobservation;accessissues;late

arrivalofpatientsfrominpatientfloors);f. Supporttimelydocumentationofcare;g. FreeuptheChargeNurseandResourceNursefrombreakcoverage;h. Sickcallcoverage.

ThiscouldbeaccomplishedbystartingtwoTEeveningshiftsearlierthanthecurrentstarttimeandbyadding2.8FTEsinadditionalRNhours,deployedtotheroleofFloatNurses.

a. AddTwofloatRNs;assigningonetoeachsideoftheunit;startingat1100(MondaytoFriday)

b. Add2FloatRNsonSaturdayandSundaywithstaggeredstarttimes.(e.g.oneat11,andonelater).

c. Starttwo(2)oftheTERNsatanearliertime(e.g.1200)8. ReviewtheFulltimeandParttimecomplementofRNstoensureadequatenumberofRNsavailable

toworkintheunit.RelatedtoPatientVolumesandScheduling:

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9. Closelymonitorvolumeandtypeofpatientandstaffaccordingly(offunit,2hourtreatments).IncreasetheRNstaffingtosupporttheincreasedvolumeinacuteoffunitthathasbeenexperiencedposttransitiontoWilsonsite

10. Staggerstarttimes30minaparttoallownursesadequatetimeforassessment,initiationoftreatmentanddocumentation.

RelatedtoDocumentation:11. Ensurethereisadequatetimeintheshifttosupporttimelyandaccuratedocumentationofpatient

careintherecord.12. DevelopaninterfacebetweenthedialysismachinesandtheMeditechhealthrecord.13. Implementaflowsheetfornursesuntilinterfaceisachieved.

RecommendationsforCommunicationandDecisionMaking:

14. Createaregularstaffforumwhereissuesrelatedtostaffing,schedulingandotheroperationalissuesintheunitcanbediscussedwithleadership.

15. CreateaQualityBoardorotherareaforpostingofperformancedataonhemodialysisincludingpatientvolumes.

16. Ensurethatstaffarenotifiedofupcomingstaffmeetings,withanopportunitytocontributetotheagenda;agendasandminutesshouldbereadilyavailable.

17. Establishregularstaffhuddlesduringeachshifttosupporttimelydiscussionsofpatientflow,safetyconcerns,otherissuesofconcernetc.

RecommendationsreProcessforManagementofPRWRFs:

18. FormaSub-HACcommitteeforhemodialysisunittodiscussmonthlyifthereareworkloadcomplaintstoreview.

4. Conclusion

ThisreportcontainstheIndependentAssessmentCommittee’sfindingsandrecommendationsregardingProfessionalWorkloadComplaintsubmittedbyNursesfromtheHemodialysisUnitatHumberRiverHospital.TheprocessundertakenthroughanIndependentAssessmentCommitteeprovidesauniqueopportunityfordiscussionanddialoguebetweenallthepartiesregardingthecomplexissuesandconditionsthat

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underlieaProfessionalWorkloadComplaint.TheCommitteehasmade18recommendationsinfiveareasregardingissuesthatimpacttheworkloadofRegisteredNurses.TheMembersoftheIndependentAssessmentCommitteeunanimouslysupportallrecommendationsinthisreport.TheCommitteehopesthattherecommendationswillassisttheHospitalandtheAssociationtofindmutuallyagreeableresolutionswithregardtonursingworkloadissuesintheHemodialysisUnit.

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Appendix1:LetterfromtheAssociationApril30,2014.

ntoIACChair,October28,2013

April 30, 2014 Leslie Vincent SENT VIA EMAIL 716 Windermere Ave. Toronto, ON, M6S 3M1 Dear Ms. Vincent, Re: Humber River Hospital – Hemodialysis Unit, Professional Responsibility Complaint – Proceeding to an Independent Assessment Committee – Ontario Nurses’ Association, File No. 201202042 Thank you for accepting the request to chair the next IAC investigation and hearing. In accordance with Article 8.01 of the Central Hospital Agreement set out between Ontario Nurses’ Association (ONA) and Humber River Hospital (HRH), the Labour Management Committee (HAC) has met on a number of occasions and exchanged letters of communication several times in attempts to bring resolution to workload issues causing RNs working in the Hemodialysis Unit to believe that they are being asked to perform more work than is consistent with proper patient care. Ontario Nurses’ Association considers the unresolved workload issues to constitute Professional Responsibility concerns, as applied to regulated health professionals by the College of Nurses of Ontario (CNO) under the Regulated Health Professions Act (RHPA). The Association views the professional responsibility concerns of RNs to be a result of being assigned more work by the Employer than what is consistent with proper patient care. The RNs working in the Hemodialysis Unit at the HRH have identified workload issues and the work environment to make it difficult to provide safe quality patient care and to practice safely in accordance with the professional standards set out by the CNO for RNs. The effect of the workload and the working environment on RNs relates to professional practice, patient acuity, fluctuating workloads, and fluctuating staffing. Attempts at working towards resolution of workload issues that constitute professional practice concerns at HAC meetings with the Employer have been unproductive. The Employer is resolved to move forward to an IAC hearing to address the professional practice responsibility concerns that have been presented to them. The Association has no other recourse at this time but to forward this matter to a hearing before the Independent Assessment Committee. To this effect ONA respectfully submits this Professional Responsibility Complaint to the IAC.

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Ms. Leslie Vincent Page 2 Humber River Hospital – Hemodialysis Unit, Professional Responsibility Complaint – Proceeding to an Independent Assessment Committee – ONA File 201202042

ONA’s Nominee is Angela Preocanin, RN, and her contact information is:

Angela Preocanin, RN 3257 Woodward Ave. Burlington L7N 2M7 Tel: 905-512-7413 Email: apreocanin@cogeco.ca

We are informed that the Employer’s Nominee is Treva McCumber, RN, DHSc, and her contact information is:

Treva McCumber, RN, DHSc Vice President, Transitions, Diagnostics & CNO Royal Victoria Regional Health Centre 201 Georgian Drive Barrie, ON L4M 6M2 Tel: 705-728-9090 Ext. 46000 Fax: 705-728-2408 Email: mccumbert@rvh.on.ca

Once you have the information you require, it is our understanding that as the IAC Chair you will communicate with the two Nominees to set up a date for the hearing that is agreeable to both parties, the Employer and ONA. We thank you for your assistance in this matter. Sincerely, ONTARIO NURSES’ ASSOCIATION

Mariana Markovic Mariana Markovic Professional Practice Specialist Labour Relations Officer C:

Catherine Green, HRH, Manager Labour Relations Melanie Tremblay, HRH, Renal Program Director Scott Jarrett, HRH, Vice President of Patient Relations Reuben Devlin, HRH, President & CEO Mary Veneziano, Executive Administrative Assistant to the President & CEO and Board of Directors, on behalf of Paul Allison, HRH, Board of Directors Chair Micheal Howell, ONA, Local Coordinator and BUP Sheri Street, ONA, Servicing LRO Doug Anderson, ONA, Manager Provincial Services Team Beverly Mathers, ONA, Manager South District Service Team Valerie McDonald, ONA, Manager Labour Relations David McCoy, OHA, Manager Labour Relations Angela Preocanin, RN, ONA Nominee

39

Appendix2:EmployerGrievanceJune12,2014

From: Green, Catherine cgreen@hrh.caSubject: FW: ONA Grievance

Date: June 16, 2014 at 8:02 AMTo: Leslie Vincent (leslvincent@sympatico.ca) leslvincent@sympatico.caCc: dmccoy@oha.com, Jarrett, Scott SJarrett@hrh.ca, Czaus, Margaret MCzaus@hrh.ca

Hi Leslie

Please find attached an Employer Grievance which we sent to ONA on Friday concerning the Hemo IAC.

If you have any questions, please do not hesitate to contact me.

Thanks

Catherine Green RNManager, Labour RelationsTel. 416-747-3780Fax. 416-747-3758email: cgreen@hrh.ca

“Please note Humber River Hospital has moved to a new email address extension, @hrh.ca Please update your contact information. ThankYou.”

40

Appendix2:Page2ofEmployerGrievance

41

Appendix3:LetterfromHospital’sLegalCounselSeptember12,2014.

42

43

Appendix4:LetterfromLegalCounselforAssociationSeptember25,2014.

44

45

Appendix5:LetterfromLegalCounselofHospitalOctober4,2014

Hicks Morley Hamilton Stewart Stone LLP JASON GREEN77 King St. W., 39th FLoor, Box 371, TD Centre jason-green@hicksmoniey.comToronto, ON M5K 1KB Direct: 416.864.7337Tel: 416.362.1011 Fax: 416.362.9680 Cell: 416.268.5180

Toionto File No. 631-490October 4, 2014

LcndonVIA EMAIL

Ms. Leslie VincentChair, lAG Panel716 Windermere AvenueToronto, Ontario M6S 3M1

Dear Ms. Vincent:

Re: Humber River Hospital and Ontario Nurses’ Association (ONA)Dialysis IAC

We are in receipt of Ms. Mcintyre’s letter of September 25, 2014 and can advise youthat the Hospital fundamentally disagrees with the position taken by ONA.

As you are likely aware, the Independent Assessment Committee (lAG) is a processdefined under Article 8 of the collective agreement between the Hospital and ONA. Tothe extent the Committee has any jurisdiction over workload concerns, it must be foundwithin the language of Article 8.

A review of that article makes it clear that an Independent Assessment Committeehearing is the final step in a thorough process that is designed to address workloadcomplaints that a nurse (or nurses as the case may be) genuinely believes negativelyimpacts proper patient care. These concerns are to be addressed by both the nurseand the Hospital at the earliest possible opportunity.

In order to achieve the goal of a timely resolution, the Article sets out a number ofmandatory steps that nurses must take in advancing their complaints. It is patently clearon the face of the language that an Independent Assessment Committee can only beconvened once the previous steps have been taken and no resolution of the workloadcomplaints achieved.

In the case of the workload complaints that ONA is attempting to place in front of thispanel, there are numerous breaches of the procedural requirements of Article 8. In theHospital’s view, these breaches are significant and prevent ONA from referring theworkload complaints to an IAC.

46

47

48

Appendix6:LetterfromIACChairOctober14,2014

Leslie Vincent RN Consultant 716 Windermere Ave., Toronto, ON, M6S 3M1

October 14, 2014

VIA EMAIL

Dear. Ms. McIntyre and Mr. Green,

I am in receipt of the letter from Ms. McIntyre, dated September 25, 2014; and the letter from Mr.

Green, dated October 3, 2014.

While the members of the Independent Assessment Committee are prepared to proceed with IAC

hearing on November 24-26, 2014, it is clear that the Hospital and the Association are at odds regarding

the timing of the IAC given the current grievance regarding the IAC process.

As I have previously communicated, I believe the Hospital and the Association need to resolve your

issues regarding the grievance and the timing of the IAC hearing. The IAC panel will not be deciding on

the merit of this grievance as we do not have this responsibility as our mandate; nor do I think we

should be placed in a position to be mediating between the two parties regarding this dispute.

I look forward to hearing the outcome of your discussions.

Sincerely,

Leslie Vincent

CC.

Mariana Markovic, Ontario Nurses Association

Doug Anderson, Ontario Nurses Association

Marg Czaus, Humber RIver Hospital

Treva McCumber, Hospital Nominee, IAC

Angela Preocanin, ONA Nominee, IAC

49

Appendix7:LetterfromLegalCounselforAssociationOctober31,2014.

50

Appendix8:LetterfromLegalCounselforHospitalOctober23,2014.

51

52

Appendix9:LetterfromIACChairNovember4,2014.

Leslie Vincent 716 Windermere Ave, Toronto, ON, M6S 3M1

Phone: 416-767-8773 E-mail: leslvincent@sympatico.ca

November 4, 2014. Ms. Mariana Markovic Ontario Nurses’ Association 85 Grenville Street, Suite 400 Toronto, Ontario, M5S 3A2 Mr. Jason Green Hicks Morley Hamilton Stewart Storie LLP 77 King St. W., 39th Floor, Box 371, TD Centre Toronto, ON, M5K 1K8

Dear Ms. Markovic and Mr. Green,

I am in receipt of letters from Ms. McIntyre, dated October 21, 2014; and Mr. Green, dated October 23, 2014. Despite considerable efforts encouraging the parties to resolve the procedural issues in dispute, we find ourselves at an impasse regarding the dates to convene the Independent Assessment Committee for the Hemodialysis Unit at the Humber River Hospital.

With regret, I am canceling the planned IAC dates of November 24-26, 2014 and will proceed to find a new date for the IAC in 2015. I would expect that we convene the IAC before the end of February 2015, and I will proceed to determine the availability of the IAC panel members.

Sincerely,

Chair, Independent Assessment Committee for Humber River Hospital Copy – Elizabeth J. McIntyre, Cavalluzzo Copy – Doug Anderson, Ontario Nurses Association Copy – Marg Czaus, Humber River Hospital Copy – Treva McCumber, Hospital Nominee Copy – Angela Preocanin – ONA Nominee

53

Appendix10:AgendaforIAC

Agenda

WednesdayApril20,2016

HolidayInn3450DufferinSt.Toronto,M6A2V1

RoomTBD

Time Item Participants

09:00–10:00 IACPanelPreparationMeeting IAC

10:00–12:00 Tour of Dialysis Unit at Humber River Regional

Hospital

IAC, HRRH and

ONA

13:00—13:15 IntroductionandReviewofProceedingsby

Chairperson

IACChair

13:15—14:45 OntarioNurses’AssociationSubmissionPresentation

Responsetoquestionsofclarificationfrom:• IndependentAssessmentCommittee• HumberRiverRegionalHospital

IAC, HRRH and

ONA

14:45—15:00 Break All

15:00—16:30 HumberRiverRegionalHospitalSubmission

Presentation

Responsetoquestionsofclarificationfrom• IndependentAssessmentCommittee• OntarioNurses’Association

IAC, HRRH and

ONA

16:30 ReviewofProcessforThursday,April21,2016

AdjournmentofHearing

IACChair

54

Agenda

ThursdayApril21,2016

HolidayInn3450DufferinSt.Toronto,M6A2V1

RoomTBD

Time Item Participants

09:00–12:00 Humber River Regional Hospital Response to OntarioNurses’AssociationSubmissionResponsetoquestionsfrom• IndependentAssessmentCommittee• OntarioNurses’Association• Discussion

IAC, HRRH and

ONA

12:00–13:00 LunchBreak All

13:00–16:00 OntarioNurses’AssociationResponsetoHumberRiverRegionalHospitalResponsetoquestionsfrom• IndependentAssessmentCommittee• HumberRiverRegionalHospital• Discussion

IAC, HRRH and

ONA

16:00-16:15 ReviewofProcessforFriday,April22,2016

AdjournmentofMeeting

IACChair

16:15

onwards

IndependentAssessmentCommitteeMeeting

IAC

55

Agenda

Friday,April22,2016

HolidayInn3450DufferinSt.Toronto,M6A2V1

RoomTBD

Time Item Participants

09:00—12:00 QuestionstobothPartiesbyIndependentAssessmentCommittee

IAC, HRRH andONA

12:00—12:30 Closing Remarks and Identification of Next Steps byChairperson

IACChair

12:30 ClosureofHearing All

12:30—14:30 IndependentAssessmentCommitteeMeeting IAC

56

Appendix11:DataRequesttoHospital

InformationRequesttoHumberRiverHospitalforIAC

1. UnitandPatientInformation(since2013)a. TypesoftreatmentprovidedbyHemodialysisUnitb. Annualpatientvolumesbytypeoftreatmentandanyacuitymeasuresthatareutilizedc. Descriptionofanyworkloadormeasurementtoolusedtoassessnursingworkload

2. UnitOrganization

a. OrganizationalchartofnursinginHemodialysisuniti. RoledescriptionsforTeamLeader/ChargeNurseorotherformalnursingleadership

rolesbelowlevelofManagerii. RoledescriptionforManager

b. Listofotherprofessionalswhoworkregularlyintheunittosupportingdirectandindirectpatientcare(e.g.alliedhealth,dialysisassistants,renaltechnologists,clericalstaffetc.)

c. Jobdescriptionsofstaffthatdirectlysupportdialysis(e.g.dialysisassistants,renaltechnologists).

d. DescriptionofhowHemodialysisunitisorganized;areasandfunctions.e. Numberofchairs/stretchersinunit(physicalcapacity);numberinoperationandstaffed;f. MasterSchedule;copyoflastsixpostedschedules;copyofadailyassignmentsheetg. Clinicalpolicyregardingactionstobetakenifvolumesexceedscapacity;includingany

procedures/policiesregardingcallinginadditionalstaffbecauseofhighvolumesh. IndicatorsbeingutilizedtoevaluateefficiencyandeffectivenessoftheHemodialysisunit

3. ProfessionalPractice

a. Outlineoforientationprogramfornewnursingstaffinthehemodialysisunit(lengthandoutlineofcontent)

4. Staffingdata(for2013-2014,2014-2015,and2015-2016forHemodialysisUnitforRNs

a. BudgetedFTEsb. Activefulltime,parttime,casual,agencyFTEs(totalpaidhoursinFTEs);c. NumberofFT,PT,Casualpositions(i.e.headcount)d. SicktimeinFTESe. OvertimeinFTEs;percentageofOTonweekendsifpossible

5. OtherStaffingInformationa. TurnoverrateforRNsforlast3years

57

b. Jobpostinginformationorrequirementsc. Experienceprofile-Averageyearsofexperienceinunit;numberofjuniorstaff(lessthan2

years’experience)d. Numberandtypeofpositionspostedinthecurrentfiscalyear;andcurrentvacanciese. Numberofnursingstaffonmodifiedwork;orhavepermanentaccommodations

6. Other

a. Copyoflocalcollectiveagreement;

58

Appendix12:AttendeesattheIAC

AssociationAttendees:

MarianaMarkovic,RN,ProfessionalPracticeSpecialist,LRO,ONADanielleBisnar,LegalCounselforONAMikeHowellRN,BargainingUnitPresident,LocalCoordinatorSheriStreetRN,LabourRelationsOfficer,ONAElizabethAstilleroRN,HemodialysisAnneGibbRN,HemodialysisNadineCruickshankRN,ProfessionalPracticeSpecialist,LRO,ONAObserversVickiMcKenna,RN,ONA1stVicePresidentHospitalAttendees:

MargCzaus,ChiefNursingOfficerScottJarrett,VicePresident,PatientServicesKarenAdams,VicePresident,HumanResourcesandOrganizationalEffectivenessMelanieTremblay,Director,NephrologyDilshadPIrani,Manager,NephrologyMarisaVaglica,Director,ProfessionalPracticeJenniferDuteau,ClinicalPracticeLeaderSarahEvesandKathyrnBird,LegalCounselfortheHospital

59

Appendix13:RNandRPNStaffinginHemodialysisUnitinApril2016(MondaytoFriday)

M-Fstaffingpattern21pods

Hourofday7

89

1011

1213

1415

1617

1819

2021

22RN0700-1500

88

88

88

88

RN0700-17006

66

66

66

66

6RN1500-2300

1212

1212

1212

1212

RN1300-23002

22

22

22

22

2RN1300-2300offunit

xxxx

xxxx

xxxxx

33

33

33

33

33

totalRN14

1414

1414

1419

1923

2317

1717

1717

17TotalRNinunit

1414

1414

1414

1616

2020

1414

1414

1414

RPN0700-15007

77

77

77

7RPN1500-2300

77

77

77

77

totalRN/RPNunit21

2121

2121

2123

2327

2721

2121

2121

21

totalstaff21

2121

2121

2126

2630

3024

2424

2424

24

add1RNApril4NEW1

11

11

11

1

ResourceNurse1

11

11

11

11

11

11

11

1ChargeNurse

11

11

11

11

11

11

11

11

offunitinunitNewnotinnumbersstaffcomeon8hrshiftchangestaffleave

60

Appendix14:RNandRPNStaffinginHemodialysisUnitinApril2016(SaturdayandSunday)

S_Sstaffingpattern11pods

Hourofday7

89

1011

1213

1415

1617

1819

2021

22RN0700-1500

33

33

33

33

RN0700-17004

44

44

44

44

4RN1500-2300

77

77

77

77

RN1300-2300RN1300-2300offunit

22

22

22

22

22xx

totalRN7

77

77

79

913

139

99

99

9TotalRNinunit

77

77

77

77

1111

77

77

77

RPN0700-15004

44

44

44

4RPN1500-2300

44

44

44

44

totalRN/RPNunit11

1111

1111

1113

1315

1511

1111

1111

11

totalstaff11

1111

1111

1114

1417

1713

1313

1313

13

add1RNApril4NEW1

11

11

11

1

ResourceNurseChargeNurse

11

11

11

11

11

11

11

11

offunitinunitNewnotinnumbersstaffcomeon8hrshiftchangestaffleave