Introduction

Improving the performance of emergency room services in our hospitals has been a priority in Montreal for many years now and though there have been periods of improvement sustained performance have not been achieved. Considerable investment has been made to discharge patients more rapidly especially those who need long term and convalescent care and though momentary improvement is observed it is not maintained. A new approach is called for that will insure both appropriate and efficient use of our emergency rooms.

Emergency rooms have been managed institution by institution with local plans focused on how the hospital manages patients that arrive on foot or by ambulance. This approach has not changed the way the population uses emergency room services nor how healthcare can be offered differently. The Montreal Regional Health and Social Services Agency (the Agency), responsible for the management of all health and social services on the island of Montreal in partnership with the CEOs of each health care institution has decided to develop a regional approach with an integrated management model to manage and coordinate all emergency room activity on the island of Montreal. These partnerships lead to a program of integrated emergency room management based on the following six priorities:

  1. Implement an integrated regional management model for emergency room services

  2. Reduce the number of visits in emergency rooms by 50%

  3. Insure the management by primary care physicians and by the local health networks of vulnerable and chronically ill patients.

  4. Revise the processes and the utilisation of resources related to the discharge of patients from hospitals.

  5. Develop a program of care and follow-up for the elderly (before, during and after a hospital stay).

  6. Improve internal management of emergency rooms as well as services on the ward.

  1. Implanting A Regionally Integrated Management Model For Emergency Room Services

The following measures were proposed to insure the implementation of a regionally integrated action plan for the improvement of emergency room services.

a. The creation of a committee composed of all the CEOs of hospitals with emergency room services and CEOs of the 12 Local Health Networks in Montreal, meeting once a month with the mandate to approve the regional action plan for emergency room management, execute the plan in each of their institutions, and make recommendations to the President Director General (PDG) of the Agency as to the needs of their institutions to achieve the determined result.

    1. The creation of a working group with a representative nominated by the board of each hospital responsible for the successful functioning of emergency services in the hospital as well as the PDG and representatives of the Agency. The mandate of this working group is to: validate a regional action plan developed by a group of experts from different sectors of the hospital, primary care, home care, and long term care services. Insure that a process is set up in each of their institutions to develop a local emergency room services improvement plan. Recommend the regional action plan to the PDG of the Agency who will then seek approval of all the CEOs.

    2. The creation of a committee of the Medical directors of all the emergency rooms on the island to make recommendations on all issues relating to medical concerns including manpower, staffing, facility and equipment issues needed to improve emergency room services.

    3. Insure that there is representation of ambulance services on all the committees.

  1. Reduce the Number of Visits In The Emergency Room By 50%

  1. Develop a strategy of intervention for frequent users of emergency room services (chronically ill patients, nursing homes, retirement residences, etc.).

  2. Complete the development of multi disciplinary network clinics with increased hours of walk-in services.

  3. Insure a 24/7 availability of medical services with access to diagnostic service.

  4. Revise the criteria for directing ambulances to emergency rooms by looking for alternatives when appropriate.

  5. Revise quotas of ambulances per emergency room to take into account hospitals offering specialised services and having a teaching mandate.

  6. Develop a communication strategy with the population that will insure optimal utilization of emergency room services.

  1. Insure the management by primary care physicians and local health networks of vulnerable and chronically ill patients

  1. Complete the system of 60 medical centers on the island of Montreal to insure the access of all Montrealers to a designated family physician (not obligatory) or their team. (Kaiser Model).

  2. Develop multidisciplinary primary care teams in each of the medical centers responsible for managing the care of their patients.

  3. Implement a model of chronic care management.

  4. Insure that patients that are identified as vulnerable patients by emergency room staff or at a walk-in clinic have a family physician or are provided with one.

  1. Revise the processes and the utilisation of resources related to the discharge of patients from hospitals

  1. Develop a discharge planning strategy, 7/7, in hospitals, rehab centers, convalescent hospitals to insure efficient and timely use of resources.

  2. Insure that admissions to hospital, long term or rehab beds are made during weekends 7/7.

  3. Insure a permanent 7/7 mechanism of communication and coordination between hospitals and the local health network of origin responsible for managing the care of a person living on their territory.

  4. Insure the availability of additional resources, convalescent beds or intensive home care services, to respond to peaks in emergency room activity that require rapid discharge of hospital beds.

  1. Develop a program of care and follow-up for the elderly (before, during and after a hospital stay)

  1. Develop a “geriatric approach” in the emergency room and on the wards of a hospital to insure the management of elderly patients that will maintain maximum autonomy.

  2. Develop mobile geriatric teams that will be able to respond to the immediate needs of the elderly in their home or retirement residence, nursing homes included, to avoid utilisation of emergency room services and to maintain the autonomy of the elderly.

  3. Develop a managed care model for the elderly that provides a case manager to elderly persons who register and meet certain criteria of vulnerability.

  4. Develop community support for the elderly through the various community groups supported by the Agency and insure coordination with the managed care model.

  1. Improve internal management of emergency rooms as well as services on the ward

  1. Develop a hospital wide plan for the management of the emergency room.

  2. Insure the commitment of senior management and the board to make the emergency room a priority for the hospital.

  3. Insure there is daily management of discharges and admission 7 days a week with physician commitment to this schedule.

  4. Improve the IS systems that will allow for immediate access to the data required to manage the emergency room efficiently.

  5. Integrate the local health network into the management of the emergency room insuring access to all hospital data on the patient.

  6. Provide all data to the regional management system that will allow for better coordination and transfer of activity on a city wide basis.

The Implementation of the Regional Plan

The six priorities were presented to the CEOs of the Montreal region and were accepted as the starting point of the integrated management plan for the island of Montreal. The committees were set up and the expert working group presented a plan that was approved by the CEOs. Local plans were developed and the majority has been approved by the boards of each hospital. During this period of four months, between September and December 2007, data was collected on a regional basis, twice a day, and reviewed by the team at the Agency. (Table 1) A conference call was held with the person responsible for emergency room services in the hospital each time that targets were not met especially as concerned the number of patients waiting longer than 48 hours in the emergency room.

It is not my intention to go into detail on each of the six priorities but I will indicate what measures were taken for two.

Priority 3. Insure the management by primary care physicians and local health networks of vulnerable and chronically ill patients.

The first strategy to achieve this priority is to complete the system of 60 medical centers on the island of Montreal. The population approach which was one the key principals of the health reform implemented in Quebec in 2004 divided the island of Montreal into 12 territories and created a local health care network responsible for evaluating and providing the health and social services required by their population. Each network is mandated to support and encourage the development of medical centers on their territory and to sign a contract with them for services.

The strategy to implement the primary care network began with the development of Family Practice Groups (FPG). Grouping of 5 to 10 full time equivalent (FTE) family physicians who by signing a contract with the Agency and the local health and social service networks receive $450,000 in staff and support to register patients, increase accessibility and insure 7 day access to their registered patients. Fourteen of these FPGs have been accredited in Montreal.

The second phase of this strategy saw the creation of Network Medical Clinics (NMC) to more specifically respond to the needs of Montréal. These medical groups consisted of 5 to 10 FTE physicians who agree to work in a group, increase accessibility to 12 hours a day and 8 hours on the weekend, and offer as many hours of patient visits with appointment as hours of walk in service from the physicians in the group. The NMC also were responsible for finding a family physician for those patients that were seen in the walk-in clinic and were considered a vulnerable patient (chronic illness, elderly, mental health problems) and who did not have a family physician. Availability of basic diagnostics imaging on the site was also a requirement. In return each center received up to $260,000 in staff and support. In addition corridors were established with acute hospitals and agreements made so that a patient needing urgent investigation or care did not have to pass through the emergency room but could go directly to the service required (diagnostic testing). Twenty MNC have been accredited by the Agency and there are now 35 medical groups with formal contracts and responsibilities.

The third phase in the strategy is to increase the number of medical centers to 60 and evolve each center into an integrated medical center with 15 FTE family physicians, 15 professionals and 15 support staff to be able to roster 30,000 patients and insure the management of their care on the Kaiser model. The third stage is the most complex as it requires family physicians to work with a multidisciplinary team of professionals in their office. This is something they have not been trained to do and have not done in Quebec since the implementation of fee for service in 1970. In conjunction with the faculty of medicine of McGill and the University of Montreal two pilot multidisciplinary teaching units have been set up as model integrated medical centers to insure the training of both physicians and other professions and to develop the clinical models for working with patients.

The Kaiser model has been shown to reduce utilization of emergency room services by 50% among their patients and it is the objective of this strategy to achieve these targets for Montreal. The application of a managed care model as will as chronic disease management have been shown as the two key elements that must be in place if emergency room utilization targets are to be met.

Priority 6. Improve Internal Management of Emergency Rooms as Well as Services on the Ward

Each hospital in Montreal was required to develop and put into place a plan to improve emergency room functioning based on the emergency room guide that had been produced by the ministry. A guide that was accepted by all as the way things should be done yet the culture and habits of each medical staff made implementation of the guide difficult. The Agency decided to engage the services of a world class consulting firm that had a proven track record in the management of emergency room services as well as an implementation tools that worked. A large complicated teaching hospital with poor emergency room performance was chosen after the management team and board of the hospital agreed to work with the consultants to implement the emergency room improvement plan. This four month project is being completed as I am writing this article and the impact on the hospital has been significant. The key to success rests with the ongoing leadership of the CEO and the board as it will take much longer than four months to change the culture of the organisation.

Realising the difficulty that each hospital was experiencing with the implementation of their local plan for emergency room improvement and the value added by the consulting firm provided to the hospital doing the pilot project it was decided by the CEOs to look at implementation of the consultants program on a city wide basis. To this end a training program was developed by the consulting firm that will be offered to two representatives from each hospital, chosen for their capability to lead a major project management team and their credibility in the hospital. The training program will be given over a period of 12 months and the objective is to teach the representatives of each hospital how to implement the improvement plan and then validate each step of the implementation with the training team.

The plan is divided into four main sections: the diagnosis, solution design, implementation, and maintenance. The diagnostic phase defines the data that must be collected and the tools to analysis the data. The solution design phase chooses those areas where greatest improvement is possible. The implementation phase sets up the working teams in the hospital to change the processes and create a new way of doing things. The fourth phase introduces the changes needed to sustain the new environment, evaluate performance, insure feedback and guarantee daily management of the hospital in relation to the emergency room.

The Agency has set up an emergency room management team that will take the training program with the representatives of the hospital and make sure that all the issues before admission to the emergency room and at discharge of the patient from the hospital are managed well. It is believed that this roll out of the integrated emergency room management plan will allow for city wide improvement of emergency room services and insure no one is left behind.

Conclusion

The management of emergency room services on a city wide bases and the development of an integrated plan is in the process of being implemented. Data collection on a daily bases 7/7/365 and the daily feedback that has been put into place are a key to insuring improvement. The high level of transparency among hospitals and the ability to better coordinate ambulance services, rehab and chronic bed availability as well as home care services by the Agency will lead to much more efficient emergency room services and reaching the performance targets that have been established.

The key to success remains the people involved and their commitment to insure that patients in the emergency room are treated as a priority and their comfort and quality of care are first and foremost not only on the minds of the staff in the emergency room who are already committed by on all personnel in the health system.