overview fraser health

January 2005 3

The Fraser Health Strategic Plan

FRASER HEALTH – AN OVERVIEW

Fraser Health serves more than 1.46 million people, approximately one third of the total provincial population. It is a geographically large area, running East-West from Burnaby to Hope and North-South from the Canada/US Border to Boston Bar. It is the fastest growing of the health authorities and has almost doubled in size since 1981 Between 2004 and 2010, the population is expected to increase by over 152,246 to 1.62 million.

Fraser Health represents 22 municipalities and a large number of communities ranging in size from small rural communities such as Hope, to large, rapidly growing suburban centres such as Surrey. The wide-ranging size of communities and the distances between them create challenges for health service delivery from the perspective of quality of care, equity in access and efficiency.

Exhibit 1 shows how the population is dispersed across Fraser Health. More detailed information is available in the Fraser Health Authority Profile, located on our web site (http://www.fraserhealth.ca/). The profile provides a wealth of information, including expected population growth, socio-economic indicators, current health status, and an overview of current health services in Fraser Health.

The demand for health services in Fraser Health is expected to increase and become more complex because of anticipated population growth and demographic shifts (Exhibit 2). Currently, nearly 12% of the population in Fraser Health is over 65 years old and the median age of the population has been increasing steadily. By 2010, this is expected to increase by 18% or 32,718 people – a significant increase because as people age, they typically require more health services and are more likely to be affected by chronic diseases.

Exhibit 1: Population Proportions, Fraser Health by LHA, 2004

Surrey23%

Hope1%

Burnaby14%

Maple Ridge6%

Tri Cities14%

Langley8%

Mission3%Agassiz -

Harrison1%

New Westminister

4%

S Surrey/White Rock5%

Delta7%

Chilliwack5%

Abbotsford9%

Fraser Health is the largest and fastest growing health authority in

the province.

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Exhibit 2: Age Breakdown for Fraser Health Communities Fraser Health Authority Age Structure 2003 & 2010

70,976 72,806131,179 134,949 165,366 168,405

148,242 176,244

368,750433,788 375,325

442,501

36,27641,228

62,825

78,849 84,714

105,200

0

100000

200000

300000

400000

500000

600000

700000

800000

Popu

latio

n

65+20-640-19

Fraser East

2003 2010

Fraser North

2003 2010

Fraser South

2003 2010

255,494 290,278

562,754647,586 625,405

716,106

When these population numbers are translated into health issues, the potential impact on Fraser Health services can be seen. For example approximately:

• 33,500 Fraser Health residents are living with diabetes

• 156,500 Fraser Health residents suffer from arthritis

• 68,000 Fraser Health residents live with a mental illness

• 78,500 Fraser Health residents live with heart disease

• 5,100 residents are diagnosed with cancer annually1.

• There is an opportunity to optimize early childhood development for some of the 169,400 children and youth under the age of 19 (2010).

Our population is very diverse, and there are a few sub-populations that are especially at risk for poor health outcomes. The Aboriginal population has been identified as a high priority for improving health status and access to health services. In Fraser Health, there are approximately 38,000 Aboriginal people2, with the highest number in Fraser South and the highest proportion of the population in Fraser East. There are large Asian, Indo Canadian, Korean, and Philippine populations in parts of Fraser Health. We acknowledge that existing health services are not always responsive and accessible to these groups, and recognize the importance of developing community specific strategies. For example, health services that are tailored to specific ethnic groups are urgently needed in particular communities, while initiatives aimed at populations suffering from chronic disease are a priority in others.

1 Based on 2001 data. 2 1996 Census data. Includes First Nations (Status and Non Status); Metis; Inuit.

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As we focus on improving and equalizing health status across Fraser Health we have set goals to improve services to our mental health clients, to better manage and support individuals with chronic diseases, and address the particular health needs of our Aboriginal and culturally diverse population.

A Typical Day in the Fraser Health System

Fraser Health’s employees and partners provide a wide range of health care services in a number of locations, including hospitals, residential facilities, client homes, and community health centers, every day. Here is an example of the volume and types of services delivered during a day in Fraser Health.

Not included in this typical day, are the many residents that go to other communities for services. For some people, this is because receiving care in another hospital is their preference, while others need specialized care that is only available in tertiary centres. Some go outside Fraser Health because services are not available locally or there is a very long wait time for local services. This is particularly true for people who need surgery and children who require hospital care. Exhibit 3 provides an overview of where Fraser Health residents receive care.

Everyday in Fraser Health… • 42 babies are born

• 59 long term care assessments are performed by community case managers

• 1052 Fraser Health residents visit the Emergency Department

• 2395 patients occupy an acute care bed

• 400 patients have surgery

• 236 Fraser Health clients take part in activities at Adult Day Program Centres

• 577 home care nursing visits occur

• 7660 Fraser Health residents receive care in long term care facilities

• 660 clients access mental health community services for treatment of mental health disorders and disease

• 22 people die; including 6 from cancer, 4 from heart disease, 2 from stroke, and 1 from injury

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Exhibit 3: Where do Fraser Health residents receive Hospital Care? FHA Residents' Pattern of Use of Pediatric Medical and Surgical Services

2000/2001

67%

24%

9%

FHA Residents' Pattern of Use of Medical Services2000/2001

83%

5%

12%

FHA Residents' Pattern of Use of Surgical Services(including surgical day care) 2000/2001

70%

19%

11%

Fraser Hospitals Vancouver Hospitals Other Hospitals

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Fraser Health is geographically large, so residents of the region may still need to travel within the authority to receive care if it is not offered in their local community. Exhibit 4 shows the major communities within Fraser Health.

Exhibit 4

The scale of operations within Fraser Health, and its importance in the lives of every resident cannot be understated. We are working towards enhancing our ability to anticipate and respond to the needs of Fraser Health residents in order to better address existing service delivery challenges, while continuing to provide health services that residents rely on each day.

January 2005 8


HEALTH CARE TRENDS

There has been a decade of intense debate about health care in Canada. Nationally and internationally there is emerging consensus on the strategies that are necessary to build a sustainable, high quality health system.

Strategies proposed include:

Supporting individuals and communities in optimizing their health: Achieve a better balance between promoting disease and injury prevention and providing care to people who are injured or ill. Most recent reports on health reform emphasize a need to promote a population health agenda with a focus on keeping people well, before they get sick, and moving well upstream to ensure a healthy start among children aged 0-5.

Focusing on improving quality, safety and access: Improve access to care by shortening wait lists for health services and diagnostics, and removing barriers to access for vulnerable groups. Common approaches included new, more responsive models of service delivery and specialized service networks. Improved safety can occur through using technology to automate tasks or processes that are prone to error (e.g., physician order entry).

Increasing availability of community based services and supports: Expand the services covered by public health insurance so that individuals do not have to bear the burden of catastrophic health expenses. Reports included recommendations to increase coverage for home and community care, palliative care and prescription drug costs. The important contribution of informal caregivers is also acknowledged, and several reports recommend changes to reflect the need for caregiver support.

Managing cost drivers to achieve fiscal sustainability: Regardless of whether expenditures are private, public, provincial or

Achieving a balance

A good health care system has four essential ingredients: health promotion, prevention, cure and care. These have different time frames, cost profiles and actions.

Health promotion: Focus on individual and community participation and control over determinants of health, knowledge of health issues, choice about health care and building individual skills and resiliency.

Prevention: Focus on comprehensive, integrated strategies to reduce illness and injury in the whole population, results may not appear for years.

Cure: Focus on evidence-based tests and treatments shown to be effective and to improve patients’ lives.

Care: Focus on the appropriate care—such as chronic disease management, home care, supportive housing, palliative care—for people with illnesses and disabilities that can’t be prevented or cured.

Picture of Health, 2002

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federal, costs need to be managed and there must be evidence of value for resources spent on health care. Strategies include using alternatives to hospital care when clinically appropriate, evaluating outcomes, and assessing new treatment and technology for effectiveness.

Increasing transparency and accountability: Build better accountability mechanisms into the health care system through systematic measurement, reporting to the public, greater local involvement and legal mechanisms such as contracts.

Improving coordination and supply of health human resources: Optimize scarce health human resources by expanding scopes of practice, increasing collaboration between health providers, improving recruitment and retention, and aligning incentives with quality of care.

Reforming primary care: Primary health care is widely recognized as the hub of an integrated health system. The key elements of primary health reform that have been identified are 24/7 availability; multi-disciplinary teams; and alternative remuneration models for health professionals.

Making better use of technology and innovation: Technology offers the possibility of delivering better care by giving caregivers timely access to important information, and streamlining access to care for patients. Most health reform studies recommend investing in better information systems and the development of electronic health records; supporting the adoption of new technology; implementing strategies to assess the impact of new technology; and, support health research.

These trends are described in greater detail in the National and International Health System Reviews: Trends and Directions section of the BC Ministry of Health Planning3 Industry Analysis.

3 www.gov.bc.ca/healthplanning/

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A Picture of the Future

A recently completed report from the UK described a vision of what the health system could look like if the above strategies were implemented. We have taken the liberty of adapting this vision to reflect Fraser Health issues and goals.

Exhibit 5: A Vision for Health Services – The Long Term View4 Patients are at the heart of our vision of health service of the future. With

access to better information, they are involved fully in decisions—not just about treatment, but also about the prevention and management of illness. Health service has moved beyond an ‘informed consent’ to an ‘informed choice’ approach.

The health authority is able to recruit and retain the staff that it requires with the right levels of skills. No longer do chronic shortages among key staff groups act as a constraint on the timely delivery of care. Health care workers are highly valued and well motivated as a result of better working conditions and the opportunity to develop their skills to take on new and more challenging roles for which they are appropriately rewarded.

Modern and integrated information and communication technology (ICT) is being used to full effect, joining up all levels of health care and in doing so delivering significant gains in efficiency. Repetitive requests for information are a thing of the past as health care professionals can readily access a patient’s details through their Electronic Health Record. Electronic prescribing of drugs has improved efficiency and safety. Patients book appointments at a time that suits them and not the service.

In this vision, patients receive consistently high quality care wherever and whoever they are. It is appropriate, timely and in the right setting. Different types of care are effectively integrated into a smooth, efficient, hassle-free service. People are increasingly taking responsibility for their own health and well-being.

When patients need to see their GP, or seek other forms of primary care, they get appointments quickly with staff who are pro-active in identifying what care is required and who is best placed to deal with it. Primary care delivers an increasingly wide range of care, including diagnosis, monitoring and help with recovery. There is a focus on lifestyle, disease prevention and screening. Choices are explained in a clear, jargon-free way. More options are provided for end of life care.

The majority of general and less specialized medical and surgical care has moved out of large hospitals. Hospitals focus almost solely on specialist treatments. There is a new ‘whole systems’ relationship between self-care, primary, secondary, tertiary and social care.

Patients who need hospital care wait within reason—weeks not months, days not weeks, hours not days and minutes not hours. They get the best treatments with minimum variability in outcomes, supported by up-to-date and effective use of technology.

Patients leave hospital quickly when they are medically fit to do so and are transferred speedily to the most suitable setting. In many instances they will return home. If the need is there, they are supported by health care professionals and paid carers, allowing people to enjoy independent lives in their own homes for longer. If necessary they move to a high quality residential placement of their choice, or another quality assisted living setting.

While it would take years to achieve this vision, it provides a clear goal. Together, Fraser Health and the population we serve must share the commitment to work toward a system that is as responsive, coordinated, and effective as this picture of the future.

4 Adapted from “Securing Our Future Health: Taking a Long Term View”, Derek Wanless, April 2002

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THE CASE FOR CHANGE

There are significant opportunities to improve the quality of our health and make better use of the 42% of the provincial budget British Columbians spend on health care. In this section we present the argument for significant change from a quality, health status, worklife and financial perspective.

Why Change? To Improve the Quality and Safety of the Health System

British Columbians are concerned about the future of the health care system. They are concerned about their ability to access health care in a timely manner, the ability of the system to take care of their aging parents and relatives, and the ability of the system to provide the most advanced and effective treatment. People are also interested in how they can affect and improve their own health status.

One of the biggest challenges we face is equalizing the significant variation in health status and access to health services that exists within our communities in Fraser Health. We are developing strategies and targets to meet our goals for improving health care across communities, closing the gaps between communities, and continuously improving the quality of care.

• Across Fraser Health, access to and use of health services varies widely. This is based on historical funding patterns rather than health needs.

The use of hospitals varies widely, and there is a 25% difference in the rate of hospital use between the populations in Fraser Health communities.

People with similar conditions stay in hospitals for different lengths of time, depending on the hospital in which they receive care.

Fraser South is well below provincial targets for access to and use of residential and home care services.

• Patients often remain in hospital beds when a different type of care would better meet their needs. About 400, or 20%, of Fraser Health’s hospital beds are used for people who require an alternative level of care (ALC). This is not only an

Institute of Medicine Round Table

3 categories of quality problems: • overuse • underuse • misuse

January 2005 12


expensive way to provide care, but these patients often do not receive the right kind of care for their needs, which may include services such as rehabilitation or palliative care.

• There is also wide variation in practice across Fraser Health. Between Fraser Health hospitals, there is a 30% difference in the rate of Caesarean-

section deliveries. In 2001, residents of Fraser East were 60% more likely to be hospitalized for mental

illness than Fraser South residents and 40% more likely than Fraser North residents.

• We do not manage the health needs of one of our most vulnerable populations, frail seniors, very well. Care is often fragmented, crisis oriented, and choices limited or expensive. This is a large and growing population, one that needs special attention as we move forward.

• A recent study on medication errors in the US5 found the error rate for the type of drug distribution system used in most of our Fraser Health acute care sites is 11%. If the error rate is similar for the 44,000 medication doses administered daily in Fraser Health sites, the number of errors may be substantial.

• The lack of an integrated waitlist management and scheduling system means that people in some communities wait longer for care than in other communities.

5 To Err is Human, Institute of Medicine, 2001.

We are committed to providing seniors with increased choices to enable seniors to live in their own home and community safely.

Keith Anderson, Vice President Health

Planning & Systems Development

January 2005 13


Why Change? To Improve the Health of the Population

Fraser Health has some of the best health status indicators in the province. Still, the averages hide significant problems with some population groups.

• Status Indians in Fraser North have a life expectancy that is 13 years less than other Fraser Health residents.

• Deaths related to smoking, alcohol and injuries are dramatically higher for Fraser Health Status Indians than for other residents. For example, Status Indians are four times more likely to die of injuries.

• Teen pregnancy rates in some communities in Fraser Health are twice as high as the community with the lowest rate in the province.

• Only half of the population most at risk for breast cancer and cervical cancer is screened regularly.

• Fraser East 0-24 year olds are hospitalized for injuries nearly one and a half times more than other Fraser Health residents the same age.

• Rates of obesity for men and women in Fraser Health are 50% higher than in BC’s healthiest communities.

• Residents in Fraser East have higher rates of arthritis, diabetes and depression than the provincial average.

Toward Better Health, Best in Health Care reflects our commitment to continually improving the health and health status of our population. We will intentionally work to raise health status in all of our communities to the best performance level within Fraser Health and British Columbia.

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Why Change? To Improve the Health of Fraser Health Employees, Physicians, and Volunteers

Fraser Health employees, physicians and volunteers provide excellent front line care and support to the Fraser Health community every day. Our people are skilled, motivated individuals who are dedicated to providing the best in health care.

While working in health care continues to be rewarding, the work environment can be very challenging. Health human resources are under pressure in many areas, and one of the key reasons our health system needs to change is to create a healthier, more sustainable workplace.

Shortages of Skilled Labour

There is a shortage of key health professionals such as specialized nurses, physicians, pharmacists and therapists. Unfilled vacancies and overtime costs decrease our ability to provide the best care possible to our patients, clients and residents. Fraser Health’s current RN vacancy rate is 4.4%, therefore, we need to hire 350 RNs each year to replace normal voluntary resignations. Added to that, 33% of RNs are over 50 years of age and could retire in 2008 and 18% are over 55 years of age now and could retire immediately. There are currently 100 physician vacancies within Fraser Health.

Workplace Absences

Cumulatively, absenteeism because of illness or injury has a significant impact on day-to-day operations in Fraser Health. Fraser Health employees currently use approximately 12 sick days per year per full time equivalent. This equals a loss of 100 productive full time employees over the entire year for sick leave alone. Absences due to WCB and long-term disability claims place additional stress on our resources.

“Be courageous – make the tough decisions now that will lead to

long term sustainability”

Key message from Fraser Health physician leaders

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Morale

Organizational change and budget pressures have been difficult for many, and have created a workplace that is often stressful. The challenges faced by the Fraser Health workforce are not unique. A recent national study of work environments surveyed workers in a variety of occupations, including health professionals, teachers, unskilled manual labour and service workers. Health professionals gave the lowest rating on a cluster of factors that related to a healthy and supportive work environment. This survey also showed that health care professionals ranked the lowest of all occupational groups on the four pillars of positive employment relationships: trust in their employer, commitment to their employer, workplace communication, and decision making influence.

Health care workers have also had to deal with increasing vacancy rates and stress relating to increased overtime. In 2002, stress related disability claims were only slightly less than claims for back related injuries.

Why Change? To Manage Fiscal Pressures

Fiscal pressure will continue to be one of the most significant challenges facing Fraser Health.

In 2004/05 Fraser Health received a budgeted grant of $1.4 billion (excluding funding from PHSA and MSP), or 18.4% of the $7.6 billion provincial budget allocated to health authorities.

The current distribution of resources within Fraser Health is shown in Exhibit 6.

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Approximately 70% of Fraser Health’s resources are currently spent on hospital and residential care facilities. While the strategies outlined in this Plan will shift this balance, it will take time to do so. In the future we expect we will make investments in technology and spend a greater proportion of resources in the community to support independent living and reduce unnecessary hospitalization.

At the same time, as the provision of health care becomes more sophisticated, cost pressures continue to increase.

• Drug costs, wage and benefit costs, and new technology costs have been rising.

• Infrastructure that supports a number of health services, including hospitals and residential care facilities, as well as medical equipment, is in urgent need of upgrading and replacement.

• The aging and growth of the population will also drive operational costs up. An increase in the need for chronic disease management and treatment services, as well as assisted living and home support services is expected.

• Shortage of skilled health care professionals leads to higher costs for overtime and sick leave.

Exhibit 6: Overview of Distribution of Resources by Sector for Fiscal Year 2004/05 (‘000s)

2004-05 Expenses by Sector($000s)

Mental Health $108,5756.39%

Corporate/Support $195,71211.51%

Continuing Care Residential $309,793

18.22%

Acute $866,50850.98%

Continuing Care Community $140,702

8.28%

Strategic Investments/DRP $27,245

1.60%Public Health $51,317

3.02%

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Through investment in technology and redesign of how services are delivered, we expect to make considerable gains in productivity. This will mitigate some of the cost pressures outlined above. For example, Fraser Health is exploring systems and tools that will streamline the booking and scheduling of many services such as diagnostic tests and surgical procedures to allow us to manage access to these services in a more efficient and equitable manner. Significant gains in productivity can be made through implementation of these systems, freeing up resources to reduce waiting times and increase capacity.

Exhibit 7 summarizes the cost pressures faced by Fraser Health and illustrates some of the strategies needed to address these pressures and maintain a sustainable health system.

Exhibit 7: Summary of Cost Pressures

$• Drug costs• Equipment costs• Aging population• Addressing unmet

demand• Improving access• Patient/ family

expectations

$• Clinical service

redesign• Technology related

productivity gain• Standardization

towards best practice

• Appropriate skillmix

• Substitution of subacute, hospice

overview fraser health

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