1

REPORT

WORKING GROUP DE

APRIL 9, 2014

Version 4.0

2

1. Clinical Services within the Lower Mainland

1.0 Lower Mainland Considerations

The service profile of FH includes the tiers of services outlined in Figure 1. FH is geographically adjacent

to the academic health centres and other facilities of the western lower mainland, which provide

services to their respective local communities as well as a range of medical specialties for the entire

province. An analysis of the flow of patients from FH into Vancouver and consideration of the role FH

plays now and in the future within the lower mainland system of care identifies opportunities to

consider adjustments to boundaries, differentiation of facility roles and formalized collaborative

initiatives for service planning, and clinical service improvements. Lower mainland system collaboration

would ensure the development of a single plan for achieving the new Ministry of Health (MOH) health

priorities.

For over a decade Fraser Health has been engaged in an ongoing intensification of service self-

sufficiency at all levels from primary to tertiary and beyond. This effort requires building a range of

capacity in specialty services, and academics in order to achieve the underlying strategic priority. The

risk is that this could result in the unnecessary duplication of the most specialized and difficult to

resource services. When viewed from the perspective of a network of services available across the lower

mainland, opportunities exist to regard service self-sufficiency from a system wide as well as a

geographic perspective.

The most specialized services and academic activity (teaching and research) in the province are

concentrated in Vancouver at PHSA, PHC and VCH. Along with UBC these partners have committed to

establishing an academic health sciences centre (AHSN) which can function as a hub for an academic

health science network for the province. The AHSN can be used as a platform for service and academic

capacity building and achieving the strategic priorities for British Columbia as inaugurated and updated

by the MOH. Required is a balance between geographic considerations and broader opportunities to

integrate key system improvements that achieve optimum patient outcomes, the best use of very scare

and specialized human inputs and the best available value for money. This shift in strategic focus drives

a different approach to service planning, investment, decision making and accountability.

3

Figure 1

Current health authority boundaries in the lower mainland represent historical factors which are not

always the most relevant from a population and patient perspective. Factors, which drive potential

patients to seek a location for care, include:

o Proximity to where they live and/or where they work

o Historical relationships with providers especially family physicians

o Location of specialty services

o Reputation of providers and sites

o Family care giver support

o Other factors such as waiting times

In that sense the movement of patients can be seen as movement of molecules through a semi-

permeable membrane. Nevertheless, the tide of growth is eastward within the Fraser Valley with a

particular concentration of growth in Fraser South. The challenge is to ensure that excellence in care

accompanies that growth in as organic a fashion as feasible.

Constructive organic growth in the care environment requires that the health infrastructure, from

facilities to people, processes, and structures match the population growth, tempered by a

corresponding reality: at least for very complicated programs and procedures, critical masses of

practitioners and patient volumes are always needed. Thus, careful intentional inter-regional planning is

required to ensure that care services are developed in a logical needs based fashion. In this instance

4

“need” refers not only to the population need for care but also the parallel need for professional

specialties to maintain excellence in the currency of care, a fundamental instrument of quality care for

all British Columbians.

1.1 Patient Flow – the Statistics

The degree to which Fraser Health appropriately provides care for its residents within its own

boundaries is an issue of seemingly perennial observation and discourse. For the year 2012/13, Table 1

examines the percentage of Fraser Health residents who receive inpatient-medical, inpatient-surgical or

day-surgical care within their own HA, compared with the percentage of all Vancouver Coastal Health

medical and surgical services that are being provided to Fraser Health residents.

Much of the care Vancouver Coastal Health provides for Fraser Health residents is related to patterns of

physician referral, proximity of Vancouver Coastal Health services for many Fraser Health residents, and

one-of-a-kind provincial and tertiary services offered only in Vancouver Coastal Health. Nonetheless,

some of these services can be provided in Fraser Health now and could be repatriated. This would

require a careful review by the two HAs and the MoH on issues of resourcing and the resource

distribution necessary to provide these services in Fraser Health.

Table 1:

% Bed Days in Fraser Health Facilities that are

Fraser Health Patients

% Bed Day in Vancouver Coastal Health Facilities

that are Fraser Health Patients

Inpatient Medical 94.2% Inpatient Medical 11.3%

Inpatient Surgical 92.8% Inpatient Surgical 24.9%

Day Surgical

The PHSA is also an

important destination for FH

patients, with 33.4% of PHSA

bed days that are FH

residents

93.6% Day Surgical 26.2%

CHANGE IN ACUTE CARE PATIENT FLOW BY CLINICAL CATEGORY

Building from the previous presentation, Table 2 (next page) displays the percentage increase in acute

care workload for Fraser residents handled in Fraser Hospitals since 2005/06, examining the growth by

major clinical category (MCC).

5

6

Examination of Table 2 identifies an encouraging underlying trend; Fraser Health handled approximately 92% of the growth in weighted caseload volume from 2005/06 to 2012/13. Major clinical areas where the FH local response rate exceeded the average local growth level in terms of weighted caseload include: diseases of the respiratory, digestive, pancreatic, kidney, urinary, male reproductive, blood and lymphatic systems, mental diseases/disorders and burns. Circulatory disorders grew by 24.8% in FH since 2005/06 (weighted inpatient and outpatient caseload combined) versus an average FH weighted caseload growth rate of 28.5%.

Clinical areas with above average growth in Vancouver Coastal weighted caseloads used by Fraser

Health residents include: diseases and disorder of the eye, ENT, circulatory, hepatobiliary, pancreatic,

blood, lymphatic, burns and trauma. Blood disorders, hepatobiliary/pancreatic and burns cases

originating in FH grew at above average rates of caseload- weighted workload growth in both FH and

VCHA facilities. The circulatory system weighted caseload growth rate was split 85% FH/15% VCHA, very

close to the 92%/8% split for over all weighted caseload growth absorption.

CHANGE IN ACUTE CARE BASED PATIENT FLOW BY SURGICAL AND MEDICAL COMPONENTS

However, concentration on major clinical categories masks the underlying differentiation between

surgical and medical growth rates. Further analysis of the clinical categories in Table 2, disaggregated

into medical surgical components, demonstrates that surgical weighted caseloads originating from FH

grew by almost exactly the same amount in each HA, 14.4% in FH, 14.3% in VCHA from 2005/06 to

2012/13.

This ratio is entirely different for medical caseloads with FH workload growth for FH residents at 38.7%

over the same 8 year time period compared to 7.7% growth in VCHA (for FH residents). Unique among

the identified major clinical categories, all of the FH weighted caseload growth in mental health diseases

and disorders was handled in Fraser Health facilities.

Table 3 provides specific details of Fraser Health caseloads handled in VCHA facilities over the three year

2010/11 to 2012/13 time period. Viewed in this way from the Vancouver perspective, it is clear that the

resources devoted to FH residents are increasing even while FH absorbs increasing percentages of local

volumes. The reason is the much higher rate of population growth in FH. Responding to the acute care

pressure associated with population growth in the lower mainland is a shared responsibility which

cannot be addressed by either VCHA or FH acting alone. Evidence from the 3 year span ending March

31, 2013 suggests that VCH workload for FH residents has “stuck” at approximately 30,000 cases, 35,000

weighted cases, and 100,000 patient days. Weighted inpatient surgical workloads are climbing, modestly

year over year, as part of the mix. In the absence of directed efforts, renewed growth pressure within

VCH originating from FH residents should be expected.

Although the FH “local capture” rate is lower for child and youth populations, with implications for both

FH and PHSA, there is available evidence of remarkable progress in the repatriation of maternity care. In

general, FH self-sufficiency is relatively low for paediatric medical and surgical services, around 60%.self-

sufficiency rates for neonatology level 3 and child psychiatry were around 59% and 30% respectively.

FH’s relatively low self-sufficiency rates for Paediatrics services are particularly important as FH is the

home region for much of the projected growth in child and youth populations. On the other hand, the

close proximity of a world class Children’s Hospital will always represent an attractive alternative venue

7

for service development and care. Patient needs, family needs, availability of specialized resources, ease

of access, care networking and partnership development are all important considerations as the balance

between PHSA and FH is addressed over time. Progress over the full age spectrum, broaching both the

location of content and care obliges the participation of all three HAs involved in lower mainland care

delivery.

Table 3: Fraser Health Workload in VCHA Facilities, 3 Year Trend

Table 4 provides a percentage breakdown of the weighted case workload for Fraser Health. The local FH

workload retention rate is increasing, and the proportion of transfers out to PHSA is down about a third

in terms of weighted workload from the peak in 2003/04. As with VCHA, however, a decreasing FH

outflow percentage does not necessarily correspond to a declining proportion of workload in receiving

hospitals, simply because the FH population grows so much faster than that of VCHA and the rest of BC.

Table 5 reports weighted caseload treated in PHSA Hospitals. The actual voulme of weighted cases

originating in FH is down from 2003/04 as the rate of treatment within FH increased, but the percentage

of PHSA workload originating in FH increased modestly from 36.3% to 37.0%. the percentage of BC

Children’s workload provided to FH residents increased to 41.4% in 2012/13 from 38.3% in 2003/04.

Conversely,BC Women’s workload provided to FH residents decreased to 31.7 % in 2012/13 from

33.43% in 2003/04. Reflecting a ocncerted effort to repatriate less complex deliveries.

8

Table 4: Weighted Caseload Distribution of FH Patients

Table 5: Weighted Caseload in PHSA Hospitals by Place of Patient Residence

PATIENT FLOW – ANALYSIS BY LOCATION OF MEDICAL PRACTITIONER

This section provides an analysis of patient mobility extended to medical practitioners in the fee for service (FFS) sector. Encounters by place of residence and location of provider were tracked over time. In this location of provider analysis, providers associated with PHSA facilities are included in the VCH regional contingent. It should be noted that not all medical clinical activity is captured in the fee for service payment system, and the examination is limited to visits without weighting for intensity or fee differentiation. Provider billing location is not necessarily equitable with the service delivery site. Laboratory medicine is particularly problematic in this regard. Nonetheless, general trends are evident:

9

The 2012/13 percentage split for GP services has the split of Fraser Health visits distributed

between FH and VCH with an 85.9% capture by FH, very similar to the split for hospital cases,

although there would be a very small likelihood of an overriding cause and effect relationship

between the location of primary care resources and secondary service delivery.

The 2012/13 percentage split for non-laboratory specialist services has the split of Fraser Health

visits distributed between FH and VCH with a 78.2% capture by FH, lower than the rate of

inpatient services capture.

The 2005/06 to 2012/13 growth rate in in FFS encounters for GP services delivered in Fraser for

Fraser residents was 9.3%. The observed growth rate in FFS encounters for GP services delivered

in VCH for FH residents was 2.1%. These numbers are both lower than the population growth or

hospital workload growth in evidence over the same time interval.

The 2005/06 to 2012/13 growth rate in in FFS encounters for non-laboratory specialist service

delivered in Fraser for Fraser residents was 55.2%, far higher than population or hospital activity

growth rate. Based on FFS encounters, the growth rate for non-laboratory specialist services

delivered in VCH for FH residents was 8.1%. This number is lower than the population growth or

hospital workload growth.

The broad brush picture emerging is one of:

A substantial buildup of specialist capacity within Fraser Health over and above the rate of

population growth;

A FH specialist capacity increase that is obviously important for the patients of all Health

Authorities in the lower mainland as service delivery patterns change with time;

A specialist capacity increase that has been necessary for FH to handle the 90% retention of

incremental acute hospital care volumes that has been achieved but which has not been

sufficient to enable repatriation of hospitalized acute clinical care beyond the observed modest

repatriation of admitted mental health patients over the past 8 years.

,

The chain of events from symptom development to presentation in a medical office to diagnosis to

intervention decision to intervention location is complex, and further study is required to unpack the

variables at play within each specialty and sub-specialty.

Recommendation 1: The FH Board, the PHSA Board, and the VCH Board should commit to joint planning

activities to model and structure the desirable evolution of patient population growth rates over time.

Ministry of Health buy in and participation will be necessary to anchor this planning process within the

parameters of fiscal reality, and to incorporate full consideration of implications for the physician

services funding system

Recommendation 2: The FH Board, the PHSA Board, and the VCH Board should commit to joint planning

activities to model the desirable distribution of medical resources by specialty, as needed to facilitate

the modelled distribution of clinical and patient service activities.

10

FOCUS ON PATIENT FLOW FROM BURNABY AND DELTA TO VCH AND PHSA

Residents of the Burnaby LHA and a portion of the Delta LHA make more extensive use of VCHA facilities

than other local areas within Fraser Health. The issue in the Delta LHA surfaces in association with the

western part of the community (Ladner, Tsawwassen) where patients move northward as part of a

regularized and acknowledged pattern of care.

In 2012/13 10,110 cases from Burnaby were treated in VCHA. In total, 39.5% of inpatient and day surgery cases, 24.6% of medical cases and 30.9% of overall cases were treated in VCHA facilities. Consideration of flow dynamics in boundary situations obliges a focus on patients leaving the local health area for care as a prerequisite for analysis. Map 1 below displays the pattern of external patient movement, once the 44% of the weighted caseload treated in Burnaby General is factored out of the pattern (assumption: the Burnaby General share of the overall Burnaby LHA pattern of use is, in the short term, independent of Health Authority placement).

Map 1

The most significant findings portrayed in Map 1:

Of the weighted inpatient cases leaving Burnaby, 9.8% went to SPH, 25.6% to VGH, 7.5% to other Van Coastal facilities, 3.1% to BC Women’s, and 5.4% to BC Children’s, a total of slightly

11

over 50% of those seeking care outside of Burnaby are leaving FH for facilities elsewhere in the lower mainland.

Of the weighted inpatient cases leaving Burnaby, 32.7% went to the Royal Columbian, 3.4% to Eagle Ridge, 2.8% to Surrey Memorial and 5.7% to Queens Park. These facilities account for approximately 44% of the weighted caseload leaving Burnaby, that portion staying with Fraser Health (approximately 6 % of the 44% total is for rehabilitation cases).

The small residual percentage seeks treatment elsewhere in BC.

Table 6 focuses on use of the Vancouver General Hospital by Burnaby residents:

Noteworthy in the growth pattern is the substantial ramp up in the use of VGH in 2010/11. Just as Burnaby residents are crossing to VGH in greater numbers, there is a large movement to Burnaby from Vancouver for care. On average in 2012/13, Vancouver Coastal residents used 111 beds in FH, while FH used 275 beds in VCH. If Burnaby was repositioned into VCHA in 2012/23 with no change in referral patterns, 7204 cases would had left for the scaled down FH, 22.0 % of all cases, 21,8% of medical cases, and 26.8% of surgical cases. Regional self-sufficiency in terms of weighted caseload deployment would improve modestly if Burnaby was repositioned within Vancouver Coastal. Map 2 displays out migration from Delta. It can be seen that the trends associated with the Burnaby LHA do not apply to the Delta LHA. Regional self-sufficiency would not increase with a theoretical

12

relocation of the Delta LHA into VCHA. Unlike the Burnaby LHA utilization profile, Delta LHA use of Surrey and the Royal Columbian easily “trumps” VGH and SPH use once residents leave the local LHA for care. Cutting the LHA into two parts is not considered viable as the LHA construct has underlying community focused validity

Map 2

The pyramidal structure featured in Figure1 discloses that functional elements and facility roles are at least as important as service referral patterns when boundary changes are contemplated as a means of enhancing service effectiveness. For example, the lower mainland health authorities could be reconstructed along service delivery lines, better distinguishing between levels in the care hierarchy, concentrating tertiary services and bundling secondary and community services in different ways. A full examination of programs and alternative service delivery structures is an important precursor before any micro-tuning of boundaries is advanced to the decision stage.

Considered boundary changes must align with health system strategy and enhance health services delivery with effective health promotion and prevention; integrated and targeted primary and community care; and provision of high quality hospital services responsive to local demographics and population needs. Any change must improve quality health care services for local residents, and must

13

reflect actual and projected referral patterns. Changes brought forward must advance in a fashion where a quality of care benefit is made available without material exposure to incremental costs.

Given the cross flow of patients in both direction between the Burnaby LHA and Vancouver, and the analysis on trends presented earlier, there is considerably more merit in a possible reassignment of the Burnaby LHA than for the Delta LHA

Recommendation 3: The matter of possible changes in HA boundaries should be considered in a larger

context including service design and service structures. Any move to reposition LHAs should be initiated

by the Ministry of Health, and advanced in consultation with appropriate parties.

2. Joint VCH-FHA Clinical Planning and the Provincial Context

In light of the time constraints the Review Committee focused its considerations on potential for

duplication, overlap or misalignment in high intensity clinical services.

In the latter part of 2013, VCH and FH established a clinical planning committee, composed of CEO, VP of

Medicine, CFO and senior operational leaders to study and make recommendations on action to deal

with the areas described below.

a) Strengthen joint physician workforce resource co-planning with the following as priorities;

psychiatry, thoracic surgery, stroke neurology, pathology, radiology and otorhinolaryngology

There have been issues recruiting and siting these individuals appropriately. Joint physician

planning would likely enable recruitment processes for highly sought after professionals. VCH

provides opportunities for specialty fellowship training; ideally these individuals could be attracted

to work in FH with adequate planning. As well, in areas where there may be issues with on-call,

better joint planning between VCH and FH would allow for resourcing during times of crisis and for

better call coverage when adequate resources may not be available.

There have been instances when specialist services work across the health authorities, but often this

is done haphazardly without consideration for the system of care and patient need. This needs to

change.

b) Acceleration of clinical alignment/standardization in the lower mainland with the priorities being

stroke and oncological surgery and then cardiac services and cataracts.

c) Conduct appropriateness planning;

d) Explore co-planning on Emergency Department growth demand analysis and response

e) Align further patient transfer and flow working with BCAS/PTN

14

Clinical improvement is a continuous process for all health care providers. Provincially there are

multiple mature service platforms that can be used more effectively to ensure a population health and

continuum focused approach to improvement and optimum performance. These include Cardiac

Services BC, Stroke Services BC, BC Renal Program, Perinatal Services BC, Child Health BC etc. There are

also a number of Adult and subspecialty Councils that could be more effectively leveraged for this

common purpose.

Recommendation 4: The FH Board should commit to working with the VCH Board to ensure that service

planning and improvement activities are conducted through the province wide service platforms and

Councils focused on standardization and performance improvement based upon best evidence informed

practice. They may wish to pass joint Board enabling resolutions to ensure this takes place.

To reinforce the opportunity for the Lower Mainland organizations to formalize efforts to continuously

improve clinical and operational performance three examples are described. Each highlighting areas

within Trauma, Stroke and Cardiac where more collaborative/joint planning and decision making

processes between Fraser, Vancouver Coastal and Providence Health would definitely support improved

clinical outcomes and improved system-wide capacity optimization. In keeping with the inter health

authority learning potential arising from the FH review, there are opportunities to improve the

processes of care for the population that the Lower Mainland HAs serve through formalized

collaboration between FH, VCH, PHSA and PHC and emergency health services.

2.1 Trauma Care: Access and Quality

A provincial trauma planning committee exists with representation from the health authorities, BCAS

and elements of the Ministry of Health. The two major sites for serious adult trauma services in the

lower mainland are the Royal Columbian Hospital and the Vancouver General Hospital. The main site for

serious pediatric trauma services is BC Children’s Hospital. The Trauma Association of Canada accredits

the VGH and BCCH sites.

Sites for major trauma require the support of many different services including robust ICU, General

Surgery, Orthopedics, Thoracic Surgery and a number of medical subspecialties. Moreover, major

trauma patients contribute significantly to long length of stay. Within that field, there currently exist two

highly sub-specialized trauma services namely the adult spinal cord unit and the adult burns unit at

Vancouver General Hospital. At this time, there would appear to be no recommendations from the

provincial planning committees to make changes to this model.

VCH Plastics Surgery trauma service has been the recipient of major cases from the FH including

fractured jaws, severed digits, limbs and other complicated plastics cases which have been refused

service by FHA surgeons. This has, in part, required VCH to create special contracts with these surgeons.

15

Recommendation 5: FH Board should ensure that RCH complete the requirements to be accredited by

the Trauma Association of Canada.

Recommendation 6: FH should continue work with VCH and the PHSA based provincial trauma

coordinating office to determine which patients are appropriate to transfer to a tertiary facility for

trauma.

2.2 Stroke Care: Access and Quality

BC has had amongst the worst stroke outcomes in the country. For that reason, provincial funds were

made available in 2011/12 to begin the planning for improved stroke services through Stroke Services

BC.

A mature stroke program requires: rapid access clinics for transient ischemic attacks (secondary

prevention), professional support for acute thrombolytic therapy in the ED, acute stroke care

wards/units, acute as well as long term integrated rehabilitation units. Optimum stroke care requires

health authorities to designate specific stroke roles for their hospitals. The hospitals with higher levels of

expertise to manage hyper-acute, and acute inpatient care of stroke (CT scanning and 60 minute door to

needle time for thrombolysis 24/7, dedicated stroke unit beds) need to work closely with EHS and the

Patient Transfer Network to ensure hot strokes are transported to the nearest appropriate site within

the recommended time.

FH has not been successful in implementing consistent use of thrombolytics in the emergency

departments of designated stroke sites (RCH, SMH and ARH). As a result, they have not been fully able

to implement ambulance bypass to designated stroke sites. The issue is twofold. RCH is a designated

stroke site, but their emergency is resistant to accepting further volumes given their current capacity

issues. In the case of SMH, the emergency department and neurology have not embraced or

implemented the use of thrombolytics. ARH has made modest improvements.

This has resulted in patients who are eligible for thrombolysis not receiving it. Consequently, some

community hospitals within FH (including SMH) contact VGH when they receive a stroke patient who

may be eligible for thrombolysis. The patient is then transported to the VGH site. This is not good

patient care as it introduces undue time delays to a treatment that is time sensitive, as well, it impacts

EHS/PTN resources and it impacts volumes at VGH. A further issue arises after the patient completes

their acute care in that there is a need to repatriate the patient back to FH for ongoing

acute/rehabilitation.

Advances in non-invasive interventional neuro-radiological treatments require skills based upon a

critical mass of experience and this needs to be coordinated in a logical fashion within the Province.

In-patient rehabilitation and/or specialized slow stream rehabilitation may benefit from consolidation of

resources to create an improved, more specialized centre of care to achieve better patient outcomes

that would only be feasible with the critical mass that could arise from both health authorities planning

and implementing together. Across FH and VCH there are disparate stroke inpatient rehabilitation

16

resources with differing criteria for acceptance etc. This difference results in more patients being

discharged to long-term care (evidenced in the 2010 National Stroke Audit). Joint planning to

consolidate inpatient stroke rehabilitation could allow for economies of scale, improved patient

outcomes and improved acute and residential bed utilization.

Using nationally accepted data and intentional resource redistribution, VCH has over three years been

able to significantly improve stroke outcomes (death rates, appropriate discharge sites, thrombolytic

treatments), albeit still not at best levels for Canada.

The number of “stroke neurologists “ however, is very skewed towards the western end of the lower

mainland (VCH) and thus innovative methods to provide these services are needed for the FH

population. Fortunately, a common provincial Picture Archival Communication System (PACS) and the

use of other tele-health services can assist.

A common lower mainland strategy for stroke care excellence is one of the goals of the VCH-FH senior

clinical planning committee. Cross-site credentialing, dedicated contracts for stroke neurologists,

adherence to the best evidence informed criteria for acute medical and invasive care, and for acute and

chronic rehabilitation are needed.

Recommendation 7: FH and VCH should continue with lower mainland strategies to ensure that the

outcomes for stroke care, (primary and secondary prevention, acute stroke management and acute and

chronic rehabilitation) are the best that evidenced informed practice can achieve. This will require joint

planning for physician resources, common credentialing, and cooperation with EHS and the Patient

Transport Network.

2.3 Cardiac Care: Access and Quality

Within the Lower Mainland (LM), there is sufficient Catheterization Laboratory and Heart Surgery

physical capacity; however it does not align with regional service demand (from the perspective of being

self-sufficient within the region).

FH serves approximately 75% of the angioplasty demand and 60% of heart surgery with the remainder

being provided by VGH and SPH. The flow of patients to the VCH sites is not by design, and not always

triaged according to urgency. Consequently there are significant wait time issues with an increasing

number of patients exceeding the recommended wait time.

The LM Review of cardiac services cited the need for a LM triage process. Triage Coordinators and

regional staff as well as Cardiac Services BC have struggled with wait time management issues especially

for diagnostic catheterization and heart surgery over the years Some top down direction, support and

timely expectations will serve to fast track some action on this front to be followed with a collaborative

planning process as a 5-7 year sustainable plan is required given timeframes for proposed capital re-

development plans.

Procedure utilization and appropriateness are issues that may affect wait times. The LM review noted

that the BC rate for coronary re-vascularization per acute myocardial infarction was 21% higher than the

Canadian, adjusted for age and sex. This suggested more room for medical rather than revascularization

17

intervention. This was particularly true for FH. In addition there was a higher rate of utilization at RCH of

diagnostic catheterization and revascularization after controlling for demographic, clinical and patient

characteristics. Moreover outcomes and efficiency did not compare well with Ontario.

While VCH has academics (post graduate training and research) as one of its priorities, FH is almost

solely focused on clinical services. RCH has over the last several years, developed the full continuum of

tertiary cardiac services, providing an environment for RCH to take on more teaching and academic

responsibilities. By 2030, the population of the Lower Mainland is projected to be approximately 3.5

million people with almost two thirds of the population living within the boundaries of FH. That

population should have access to the best practices afforded by association with an academic program.

System-wide cooperation is a key consideration for an effective cardiac system. A coordinated approach

is required to balance workloads across sites and to respond to patient needs in a timely and safe

manner. A key message from this review is that the current system tends to be reactive rather than

proactive and that a clearly articulated vision and strategic plan for cardiac services is required. The

population growth in the Fraser Valley, the declining referrals to downtown hospitals, and the major

capital redevelopment plans currently on the table for RCH and SPH suggests the timing is right for

implementation of key decisions regarding the future roles and program focus of cardiac sites

throughout BC.

Overall, the Review Team has concluded that CSBC has been unable to establish an inclusive relationship

with the HAs in the Lower Mainland that makes all involved think in terms of the “collective us” as

opposed to “ we “ and “they”. (Cardiac Report)

Recommendation 8: FH Board needs to work with VCH Board to ensure that capital resources are

presently best utilized in the lower mainland and that future capital planning reflects population needs

given the academic and research context upon which they are based. Both boards need to ensure that

both HA and BC Cardiac services provide a coordinated triage function for the lower mainland that

enables the best outcomes utilizing the most effective and efficient methodologies

3. Academic Health Science Network

Historically, the Provincial Health Services Authority (PHSA), Providence Health Care (PHC) and

Vancouver Coastal Health (VCH), have individually operated as academic health science centres (AHSCs)

for British Columbia. In partnership with their primary academic partner, the University of British

Columbia (UBC), as well as other academic partners, these three health authorities have delivered on

the tripartite AHSC mission of care, education and research. They have provided the province’s most

highly specialized acute care, provided clinical training for physicians, nurses and other health providers,

and conducted 80 per cent of the health research that takes place within the province. Collaboration

exists on many levels, from formal affiliation agreements that articulate research and education

arrangements between the health authorities and university partners, to the vital collaboration amongst

researchers affiliated with different entities that drive innovative and breakthrough discoveries.

Traditional roles and traditional relationships have served British Columbians well for many years.

However, health authorities and academia face new challenges and pressures. While they are all

18

individually responding to those challenges and pressures, the absence of strategic linkages between

these organizations, including at the governance level, is limiting their ability to successfully support the

needs of British Columbia today and into the future.

A bold new vision – one that integrates the shared AHSC functions of PHSA, PHC, VCH and UBC at its hub

and strategically connects other players through a provincial academic health science network - – is

needed to drive improvements in patient outcomes and efficiencies within the BC health system. BC is

uniquely positioned, within Canada and internationally, to establish this model - the BC Academic Health

Sciences Centre and Network - and to achieve the benefits it can deliver.

3.1 The Current Situation

The current situation includes the following; PHSA, PHC and VCH are responsible for the hospitals and

agencies that provide the lion’s share of health authority AHSC functions – specialist care, clinical

training/education, and research - for the province. UBC operates the sole medical school in the

province through a distributed Faculty of Medicine model that delivers medical education through

partners located in the Interior, Northern BC, Victoria, and the Lower Mainland.

The BC HAs have varied health research interests and levels of activities. The distributed teaching model, unique population health challenges and features and development of specialty services provide greater opportunities to coordinate, align and leverage existing research clusters to achieve regional and system wide benefits. The current profile of research clusters includes:

o Vancouver based academic health science centres – this includes larger tertiary centres in Vancouver where the majority of biomedical and clinical research occurs.

o Simon Fraser University and Fraser Health Authority o Northern Health Authority and the University of Northern British Columbia o Interior Health Authority and UBC Okanagan o Vancouver Island Health Authority and the University of Victoria o Community, public health and social service agencies and multiple advanced education

organizations interested in advancing interdisciplinary science and population and system science

The impact of technology also requires a broader engagement of engineering, computer science, Biology and other expertise to advance a province wide research and innovation agenda. PHSA, PHC and VCH all have individual academic liaison committees that support communication between the senior leadership level of the health authorities with the vice provost/dean of medicine level of UBC. However, there is no mechanism that enables joint forward planning and issues resolution at a senior level between UBC and the three health authorities that drive the bulk of academic health. Nor is there a mechanism to bring government to the same table. Funding for AHSCs is complicated and derives from several sources, including global health authority budgets, university salaries, alternate physician funding plans, external grants/awards, and philanthropy. Pressures on government funding sources, and the unpredictability of external grant/award and philanthropy sources, makes it difficult to achieve the predictable and stable funding needed to fulfill the tripartite mission. Because of the

19

interdependence of that mission– and the multiple roles played by key individuals such as subspecialist physicians – instability in one area of funding such as research can significantly destabilize delivery of patient care. This poses significant and real challenges for recruitment and retention – challenges, which are further, exacerbated by competitive health research investments in other countries. While UBC, PHSA, PHC and VCH are the major academic health players in BC, Simon Fraser University, University of Victoria, University of Northern BC and others have growing roles in supporting academic health. Fraser Health, Interior Health, Island Health and Northern Health have growing roles providing clinical training because of the distributed medical school model, and an emerging role in health research. Differing policies and operations, and the lack of linkage between these various players’ results in inefficiencies, and potential duplication of resources.

Health research infrastructure and funding has increased in BC over recent years, in particular as a result of the funding programs of the Michael Smith Foundation for Health Research and Genome British Columbia; however, health research funders at all levels need to better understand the tangible outcomes resulting from their investment in health research. This requires a heightened emphasis on translational research. The province faces increasing demands for care as a result of its increasing and aging population. There is a need to focus health research on system sustainability to support innovation and improvement in how services are delivered. Shortages of qualified and trained health professionals are a problem in many areas. The ability of the province to ensure availability of health human resources is hampered by the lack of linkages between the health authorities identifying the need, the universities and colleges planning and delivering the education programs to train those disciplines, and the health authorities providing the clinical training. Funding from Industry for late stage science and commercialization requires a significant critical mass, efficient governance and management and a clear strategic focus. Many other jurisdictions have embraced health and life science research as an area of significant economic growth, diversification and sustainable job creation.

3.2 The Proposed BC Academic Health Science Centre and Network Model

The proposed new model would establish a single BC Academic Health Science Centre comprising the

province’s major academic health cluster - PHSA, PHC, VCH and applicable UBC components– at its hub.

Linked to this hub and driving the integrated mission and improvements to all reaches of the province

would be an associated BC Academic Health Science Network representing health authority dyads – the

spokes, BC academic institutions, and government, including the Ministries of Health, Advanced

Education and Jobs and Economic Development.

The BC Academic Health Science Centre structure would more strongly integrate care, research and

education and would form an essential underpinning for the Network by providing the planning,

coordination and services to support driving improvements for patients and the public throughout the

entire province. Single secretariats to support the three core mandates of care, research and education,

would be established to improve administrative efficiency and reduce duplication. Governance

20

structures at the Centre and Network levels would be established to improve planning and alignment

with provincial priorities. Such a network must be focussed on clear, achievable deliverables to be

successful and designed to support other contributors like Michael Smith Foundation for Health

Research, BCCRIN and the Personalized Medicine initiative to name a few.

3.3 The Benefits

A governance structure that ensures all of the players that are part of the system of academically-based care, education and research are brought to a single table where they can plan, prioritize, and resolve issues.

Stronger links between care, research and education – so that clinical needs are addressed through research and education.

A clear, shared health research agenda that builds on BC’s internationally established strengths drives innovation and aligns with the province’s need for improved outcomes and sustainability.

An enhanced focus on translational research, with research results more quickly translated into changes in patient practices and outcomes.

Less competition within the province, enabling BC to compete more successfully outside the province, drawing in more external grants and industry involvement.

Improved performance of health research as an economic driver through increased commercialization and outside investment revenue and through the positive contribution to BC’s economy by a growing knowledge-based workforce.

Improved administrative efficiency and effectiveness.

Strengthened recruitment and retention at all levels – from nursing to highly specialized physicians upon whom entire clinical care programs depend.

Recognized national and international leadership through establishment of the first model that builds on the foundation of strength provided by the province’s traditional major academic health players, while achieving integration and driving improvements throughout the entire province.

3.4. Conclusion

Because of its health authority structure, and single, distributed medical school program, BC is uniquely

positioned to lead the country in the establishment of a new model for academic health science.

The established AHSCs within PHSA, PHC and VCH, together with the leading education and research

partner, UBC, provide a core foundation uniquely and centrally located within the province’s urban

centre of Vancouver. Internationally renowned research enterprises already exist within these facilities.

Rich databases, unique within Canada, capture province-wide patient data in areas such as cancer, renal

disease, cardiac disease, transplantation, medical genetics, infectious diseases, and perinatal services.

The regional health authority structure provides a framework upon which a network can be built that

integrates care/education/research in collaboration with other partners throughout the province, and

that supports faster translation of research to improve patient outcomes and system sustainability.

By capitalizing on these unique BC assets, the BC Academic Health Science Centre & Network will

improve patient and population health outcomes, contribute to sustainability, and act as an economic

engine for the province.

21

Recommendation 9: The FH Board should review research spending to ensure it is aligned with role and

unique population characteristics and is contributing to improved patient outcomes and value

generation.

Recommendation 10: FH should enter into a MOU with the Academic Institutions in Vancouver to

establish the AHSN to ensure that all future investments in research are optimized.