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PUBLIC ACCOUNTS COMMITTEE
Ms. Diana Whalen (Chairman)
Mr. Leonard Preyra (Vice-Chairman)
Mr. Clarrie MacKinnon
Ms. Becky Kent
Mr. Mat Whynott
Mr. Maurice Smith
Hon. Keith Colwell
Hon. Cecil Clarke
Mr. Chuck Porter
[Mr. Allan MacMaster replaced Hon. Cecil Clarke]
[Hon. Christopher d'Entremont replaced Mr. Chuck Porter]
South Shore District Health Authority
Ms. Alice Leverman, Chief Executive Officer
Mr. Malcolm Pittman, Chief Financial Officer
Mrs. Darlene Henry
Legislative Committee Clerk
Ms. Evangeline Colman-Sadd
Assistant Auditor General
Mr. Neil Ferguson
HALIFAX, WEDNESDAY, MAY 26, 2010
STANDING COMMITTEE ON PUBLIC ACCOUNTS
Ms. Diana Whalen
Mr. Leonard Preyra
MR. LEONARD PREYRA (Chairman): Good morning, I'm going to call this committee to order. This morning we will be talking about the South Shore District Health Authority, an overview of its activities and expenditures and revenues and challenges. Before we do that, I'd like to start by calling on the members and witnesses to introduce themselves.
[Committee members and witnesses introduced themselves.]
MR. CHAIRMAN: Thank you very much. Let's just get the proceedings underway. It's a normal process, we allow for a brief presentation followed by a 20 minute questioning by members of each caucus. I'll hand the floor over to you, Ms. Leverman.
MS. ALICE LEVERMAN: Good morning and thank you Mr. Chairman and committee members for the opportunity to be here today and speak to you about some matters related to South Shore District Health Authority. Joining me, as has been indicated, is Malcolm Pittman, our chief financial officer.
I have had the privilege of working in South Shore District Health Authority since 2001, served as Vice-President of Community Health for a number of years. I accepted a two- year appointment as CEO in January of this year and prior to that, I was acting in that position for a number of months. My opening remarks are going to focus on the three areas of particular interest to you - staffing, emergency room closures and budget.
With respect to staffing, our health system workforce is aging and will shrink significantly over the next five years. The average age of our employees is 46 years of age and approximately 21 per cent of the workforce is eligible to retire in the next five years. South Shore Health has identified the well-being of our workforce as a priority and has many initiatives underway to support the health and safety of our staff.
Recruitment and retention of health professionals is an ongoing challenge. In 2008, in particular, we had 30 vacancies in our nursing complement. We've been able to significantly reduce that number through a combination of recruitment efforts and changes to our staffing mix. At the present time our biggest area of need is for family physicians, particularly in the Bridgewater area.
The South Shore Health Bursary Program, which is supported by our foundations and auxiliary, has helped our recruitment efforts in a significant way. The program has awarded $159,000 to 21 students since 2005. We also support clinical placements in work terms for a variety of health care students and many of those return to work for us.
With respect to training, some highlights are the recent development of a competency-based orientation program and mentoring program for new graduates. We have created a learning lab and introduced electronic learning to provide nurses, in particular, with easy access to ongoing training.
With respect to emergency rooms, the emergency department at Fishermen's Memorial Hospital has been closed overnight since July 2008. Prior to that, the emergency room had been experiencing frequent closures due to staffing issues. At that time, the number of visits to the emergency room overnight was very low, less than two patients per night. Overnight closures have allowed us to staff the emergency room during its busiest time and provide a more reliable and consistent level of service to the community. This 16-hour schedule has greatly reduced our unscheduled closures and in the past year the ER was closed unexpectedly a number of 14 times, for a total of 195 hours, due primarily to our inability to replace nursing staff due to unforeseen injury and illness.
We are taking steps to minimize unscheduled closures including cross-training of emergency room staff between South Shore Regional and Fishermen's, some casual staff who float between the two emergency rooms and actively recruiting paramedics to work on a casual basis for triage. Of course, we are continuing to enhance our primary health care efforts, which does improve access to care during the day and evenings. Unscheduled closures are, of course, a concern to us, because they do have an impact on the already very busy emergency department at South Shore Regional.
Over-crowding in our hospitals has been an almost daily occurrence. We routinely have as many as 10 to 14 admitted patients in our emergency departments. As no doubt you've heard, on May 14th, we had an all-time high of 23 patients, and were over capacity
on every nursing unit in the district. I'm pleased to say that situation, over the last number of days, has shown signs of improvement, in part because of the opening of a new long-term care facility in Bridgewater, Ryan Hall.
We are very enthused about the recent opening of Ryan Hall, and additional new nursing home beds, for a total of 95 long-term care beds that are opening in the district over the next few months. However, more long-term care beds are only part of the solution and we do need to continue to enhance access to primary care and community-based supports that help our seniors remain independent, healthy and safe in their communities.
We are extremely proud of the work that we have done, and are continuing to do, in the community. A few examples of recent accomplishments are the establishment of a multi-disciplinary senior's team, establishment of two new adult day programs and a focus on chronic disease management through self care.
We have built on successes that we've experienced in primary care practices in North Queens, Lunenburg and New Ross, and over the last recent while, we have invested in new primary care collaborative practices in New Germany, Chester and Lunenburg. We are in the process of working through new models in Bridgewater and Mahone Bay and are continuing our efforts to advance the primary health care and hospital initiative in Liverpool.
With respect to budget, South Shore Health spent approximately $80 million last year on behalf of taxpayers to manage and deliver health services within Lunenburg and Queens Counties. Although we have made considerable efforts to reduce costs through efficiency, we have, indeed, struggled over the years to balance our budget in the midst of growing public expectation, increased demand and rising costs. Since 2005 we have requested and participated in several operations reviews and internal audits, which have resulted in improvements in management processes and internal controls.
Our efforts to manage our resources are challenged by our inability to access valid and reliable data. The new SAP system that is currently being implemented, when it is fully functional will improve our administrative processes and provide more accurate and timely information to help us make better strategic and operational decisions. I am also pleased to report that we have made some very significant progress toward increasing our compliance with MIS reporting standards, which is the national reporting methodology we have.
South Shore Health's 2008-09 and 2009-10 business plans have recently been approved by the Department of Health and we were very pleased to receive funding to cover our 2008-09 deficit and some one-time cost pressures, as well as an adjustment to our base of $1.3 million, all in recognition of our significant financial challenges. In order to demonstrate our commitment to living within our means, we also identified, last year, more than $1 million in cost savings and revenue generation.
We are certainly very appreciative of government support and the recognition of our longstanding funding challenges and are equally grateful to the department for the $2.4 million commitment last year to purchase a new CT scanner, digital mammography unit and ultrasound machines.
As part of our commitment to balance the current year, we are creating a quality improvement action plan focusing on quality improvements that make the best use of our limited resources. All staff and physicians participated in this project by sharing their ideas for improving quality and reducing costs. We have begun to implement a number of those ideas already and, of course, will continue to move those forward aggressively over the next several months.
We are excited at South Shore Health with the opportunity to move forward with the new journey of change in health care and with the support of the department and consistent with that direction and our own new strategic directions, we feel confident that we are going to be able to respond to the ever-changing needs of the population in South Shore Health.
With that I do want to say thank you once again for the opportunity and we look forward to the questions and dialogue.
MR. CHAIRMAN: Thank you, Ms. Leverman, for your opening presentation. We'll move to questions from the Liberal caucus for 20 minutes. The time is 9:14 a.m.
MS. DIANA WHALEN: Thank you very much, I appreciate that. Welcome this morning, we are very pleased to have you here. We've had a number of the CEOs over the last number of months, I guess over this last year, primarily around the H1N1, but now we're here to talk in more general terms.
I wanted to start off, if I could, with the emergency rooms which you touched on in your opening remarks. Noting that in the recent accountability report that was brought to the Legislature it showed that Fishermen's Memorial was the number one hospital for closures. You've cast a little bit of light on that by showing that 16 hours a day is the norm at that hospital, but I wanted to ask you something around the lack of nurses - apparently that is the reason whereas we often think it's doctor shortages, and in your case it's nursing shortages.
What I wanted to ask you was first of all, what efforts are you making to mitigate that at the moment?
MS. LEVERMAN: Thank you for the question. The reason for the closures, historically, has been a shortage of nurses - we are constantly focusing on that. We have a complement of ten registered nurses who work on rotation in the emergency room at Fishermen's Memorial Hospital. At the present time we have two of those positions vacant because of short-term maternity leave and illness, so it is a challenge for us to find skilled staff to work on a short-term basis.
We are training emergency room staff to work at both South Shore Regional and Fishermen's, so that is helping us. We also have a casual float team who are trained to work in both locations, and are actively recruiting paramedics to assist in the emergency room with triage. We are focusing on this on a regular basis, but it is a challenge and we do regret when we have to close the emergency room because of staffing shortages.
MS. WHALEN: I noticed as well - and part of the accountability report required, I think it was the Act we passed last year, consultation in the communities - that two different sessions were held in your district area. I'm wondering if you could let me know - I think one was in September and one in March, and what I was interested in is the fact that both of them were held in Bridgewater - I'm wondering why you chose both in Bridgewater, rather than moving around the district to either Liverpool or to the Fishermen's Memorial area?
MS. LEVERMAN: We did have consultation late last Spring and early summer through our strategic planning process, and we did have sessions in all areas of the district. In Lunenburg in particular at the time, because of the closures, there was discussion and consultation about the emergency room closures.
The meeting in September was our annual general meeting that was held in Bridgewater, and in that meeting the issue of emergency room closures was addressed. In March we had an open board meeting, at which time we provided an update on where we were with closures and the steps that we were taking to address that. We do know that next year we will need to undertake a broader consultation, and we have plans to do that.
MS. WHALEN: I guess I'm concerned that the people in the Lunenburg area might have felt that their voice wasn't being heard in this. There was, I think, 18 people at the March meeting, according to the report. I'm just wondering, is there not a heightened concern in the Lunenburg area around the closures at Fishermen's Memorial and around the future of that facility?
MS. LEVERMAN: There always is a concern when we do have to close. As I mentioned earlier, we did have consultation in the Lunenburg area last summer as part of our strategic planning process, so there was the opportunity to have discussion about the emergency room. At the time that we made the decision to reduce the emergency room operation to 16 hours a day, there was considerable consultation with council and the board of trade and the Lunenburg Health Watch Committee.
MS. WHALEN: I wanted to ask you again about the nursing shortages. There was a recent ad for a nurse and it was for Fishermen's Memorial, but it's clearly just for one year, and I'm wondering if you could comment on why you're looking to - and it was an emergency room nurse - I'm wondering why you were looking at that.
MS. LEVERMAN: Yes, that's one of the two temporary positions because of maternity leave.
MS. WHALEN: Okay, so that was getting somebody in place for a maternity leave that's coming up.
MS. LEVERMAN: That's correct.
MS. WHALEN: Were you not looking for anything longer - were there two vacancies as well or just two vacant because of maternity?
MS. LEVERMAN: There are two vacant because of leaves.
MS. WHALEN: So it isn't because you're anticipating a change in that facility at the moment? That's what I was wondering, if you had something in mind about the future.
MS. LEVERMAN: No. It was strictly to replace two of the ten positions that we have in the rotation.
MS. WHALEN: All right. Well as long as we're looking at what the future might hold for Fishermen's Memorial, I was wondering - the deputy minister, who used to be the CEO at South Shore, had actually said publicly in the past, well he has mused about what the facility could be, whether it should be an urgent care facility rather than a full emergency room and some thoughts around that - what your thoughts were on the future of the 24/7 since in your opening comments you've mentioned since 2008 we've gone on a 16-hour daily schedule.
MS. LEVERMAN: We will be working closely with the department around the whole issue of emergency rooms. As you know, Dr. John Ross released his report recently and we will be working very closely to ensure that as we move forward with ensuring access to emergency service throughout the district is in place, we will be consistent with that process.
MS. WHALEN: In other words, you're just waiting, you're in a holding mode? That's what I hear anyway.
MS. LEVERMAN: Yes.
MS. WHALEN: In September 2008 there was a report in the paper that said the Department of Health was giving the South Shore district $650,000 to review the facilities, how the facilities are used. I'd like to know if this report was actually done, if the review was ever done and what were the results.
MS. LEVERMAN: Yes, that funding was for the development of a district-wide master plan that looked at the facilities in the district and the future role. We did complete that process and it's a multi-year initiative that will see the district through, I believe, until 2026. Obviously, because of the magnitude of the work that needs to be accomplished, there is to be a phased-in approach. That master plan is with the Department of Health and our board has outlined our priorities for implementation of that master plan throughout the district.
MS. WHALEN: Could you tell me who conducted the review?
MS. LEVERMAN: We had our own staff, of course, very involved in that, and we had the consultant firm, Agnew Peckham, who worked along with us, but we had extensive consultation from our providers and community members through that process.
MS. WHALEN: Is it possible to get a copy of that report yet? You said it's with the Department of Health now, it's complete.
MS. LEVERMAN: It is with the Department of Health and we are awaiting approval from the department, or a response back from the department to the recommendation as to the first phase of implementation.
MS. WHALEN: Has it been shared with the community in any way? You said there was a lot of consultation.
MS. LEVERMAN: No, the report has not. We have identified the three priority areas: the emergency room at South Shore Regional; the Queens Primary Health Care and Hospital initiative; and the relocation of the six medical beds out of the emergency department, where they currently exist, to be relocated somewhere within Fishermen's Memorial Hospital. Those are the three . . .
MS. WHALEN: The three priorities.
MS. LEVERMAN: Yes.
MS. WHALEN: When was the report completed?
MS. LEVERMAN: It was completed in November 2009.
MS. WHALEN: So the Department of Health has had this report virtually from that time onward?
MS. LEVERMAN: Yes, they have.
MS. WHALEN: Have you had any feedback yet? Any chance to sit down and talk about future steps and what's going to be done with it?
MS. LEVERMAN: We've had some discussion about the Queens initiative and we have been asked to have a look at that and to look at ways in which we might be able to modify the original submission. So we're in the process of doing that at the present time.
MS. WHALEN: And can I just double check, with the $650,000 - was that sufficient to cover the full cost of what was done?
MS. LEVERMAN: It was. I don't have the actual figures here, I believe there was a little bit left over.
MS. WHALEN: So, on budget anyway?
MS. LEVERMAN: Yes.
MS. WHALEN: That is always good to hear. We like to ask financial questions, I know the chairman does. So, yes, indeed. I wondered if Dr. Ross has been to visit your emergency rooms at this point?
MS. LEVERMAN: Dr. Ross has been to the district, he has not worked in the emergency rooms as yet, but we are anticipating his visit in the not too distant future.
MS. WHALEN: Do you see any of the recommendations in your earlier report, the one that was finished in November, that might either guide Dr. Ross or perhaps supercede some of his findings?
MS. LEVERMAN: It's difficult to know at this time until we know a little bit more about the work that he will undertake. Certainly we do know that we have a requirement to address the significant infrastructure issues with the emergency room in Bridgewater. We're very hamstrung by space there so the master plan really lays out a plan for a new emergency room and we will co-locate the ICU near the emergency room to optimize staffing.
MS. WHALEN: It is interesting that you've mentioned the overcrowding in Bridgewater. I'm wondering, with the new hours and the occasional unscheduled closures in Fishermen's Memorial, if you've looked at the impact that has, there's obviously a balance there between the two communities?
MS. LEVERMAN: Yes.
MS. WHALEN: What's the direct impact of these closures on Bridgewater?
MS. LEVERMAN: Well, you know, with the pressures that we're feeling now at South Shore Regional, any additional requirement for patients to come to the South Shore Regional is always an additional pressure and a concern to us. So that's why we're working hard to try to minimize the number of closures at Fishermen's.
MS. WHALEN: Has this overcrowding at Bridgewater been noted over many years or is it a more recent phenomenon?
MS. LEVERMAN: It has been ongoing for some time, but it is certainly getting worse in part because of our aging population, but in the last year and a half, two years, there has been significant new housing development in the Bridgewater area, much of it seniors' housing, so that brings a lot of older individuals with chronic conditions and so forth who find their way to the emergency room.
MS. WHALEN: That just means they're closer now?
MS. LEVERMAN: Yes.
MS. WHALEN: They were probably in the county somewhere, right, but it's more accessible to them?
MS. LEVERMAN: Yes. Many have relocated but equally there are some who have moved into the area from other parts of the province as well.
MS. WHALEN: In terms of doctor shortages, I think you mentioned Bridgewater was a primary area for that, or perhaps the hot spot for you in your district. I was looking at Dalhousie Medical School saying recently that 25 per cent of family physicians are due to retire in, I think, five years. You didn't split it out but you said you have 21 per cent of your workforce that could retire within five years?
MS. LEVERMAN: Yes.
MS. WHALEN: I wonder if you could tell me how many of those are physicians and are they in Lunenburg County, if you could split it down to the one county?
MS. LEVERMAN: I don't have the actual numbers for you. I can certainly get those for you, but we are always on the lookout for family physicians. As you would know perhaps, the younger physicians are looking to practice in a different way. They're not anxious to work in solo practices as many of their predecessors were, and so that's why we are putting a significant effort on working with our community to develop collaborative practice opportunities so that the new graduates who want to come to work in our area have the opportunity to move into those practice settings. It's a big recruitment effort that's underway.
MS. WHALEN: And that is affecting doctors everywhere, I mean, as I say, it is just a new approach to medicine. In terms of the overcrowding, again, if I could go there, when we saw some new nursing homes open here in the metro area, there were some spaces that were dedicated to moving people out of our transitional care units into the new nursing homes so that we could, really, I guess, help move that blockage that was in the system. I am wondering, when you went to open Ryan Hall, and I'm not sure if there was another new facility, but at that time did you dedicate some beds that would help to take people out of your hospital?
MS. LEVERMAN: Yes, Ryan Hall has 50 nursing home beds and 15 residential care beds. Of the 50 beds, at the time of the opening, 20 individuals in hospital were assigned to be relocated, not necessarily to Ryan Hall, because many people who were residing in other nursing homes had requested to be placed in Ryan Hall. As they moved to Ryan Hall then there were additional spaces. So, 20 individuals have been targeted for movement and, as you may know, that nursing home, Ryan Hall, opened on the 19th of May, so it is a process that has started and it will take a few weeks to move those patients.
MS. WHALEN: I actually wasn't aware of the date, that's very recent, I knew it was recent. We're within the first week, really.
MS. LEVERMAN: We have another 28 beds opening in the Fall, 10 in New Germany and 18 in Lunenburg.
MS. WHALEN: I'm glad to hear that you are moving them out of the hospital beds. It is a much better environment for people to begin with, and more cost effective, and it allows you to deal with the overcrowding.
I just wanted to point out that last week there was a report again that there were 23 patients waiting to be admitted to a hospital bed and it forced the district to implement what it called an overcrowding protocol. I wonder if you could tell me what is involved in the overcrowding protocol and, more specifically, does this overcrowding protocol include diverting patients to the Capital District at all?
MS. LEVERMAN: The overcrowding protocol is one that we hope we don't have to use very often. When we do, it really puts everyone in the district on alert and the focus of effort is moving patients through the system as quickly as possible. It does include the opportunity to divert. We have done that, I believe, only on one occasion in the past. We do everything possible to prevent that from occurring. One of the things that is included in the overcrowding protocol is the opportunity to request of the Department of Health what is called a variance that gives priority to hospital patients for placement in available nursing
home beds. So, that was in place for a period of six days to allow movement of individuals from hospital into the available beds.
MS. WHALEN: Thank you, I just wanted to go back to your point about only once have you diverted, and does diverting mean that you have taken them out of the district, sent somebody to another district?
MS. LEVERMAN: Yes, but divert ambulances is what it means.
MS. WHALEN: Okay, I wasn't sure just what that meant. Would that have been to Capital District Health, likely, because we're close?
MS. LEVERMAN: Yes. Capital Health or Valley.
MS. WHALEN: Okay, very good. I know I only have a few seconds left, I think.
MR. CHAIRMAN: A little over a minute.
MS. WHALEN: A minute, good, very good. I just wanted to go quickly to workers' compensation. Last week we had the Workers' Compensation Board here and they said that Health is the number one claimant that they get. Could you tell me what kind of costs you incurred that have to do with workers' compensation, what your rates are like and what the trend has been? I mean the trend goes up as your injuries go up, so I'm thinking maybe Mr. Pittman may be able to help me.
MR. MALCOLM PITTMAN: Thank you, actually, I know the trend has been going up and except for this last year, the rate went down. I don't have the rates with me, I didn't bring that with me, and I don't have the total costs, but I know for this past year, our incidents went down and our rates went down for this year of 2010. I'll have to get you the actual dollar amounts of costs and actual rates and forward that to you.
MS. WHALEN: Okay, that's very good. I would also like to get the physicians who are retiring, that was the other thing that we did mention as well.
In terms of these injuries, do you have a replacement plan in place? A lot of them are, of course, nurses and other health care workers who are injured, do you have a replacement plan in place or a pool of people who can come in, Ms. Leverman?
MS. LEVERMAN: Yes, we do have a casual staff we are able to call on. However, I would not be honest to say that's not a challenge for us. Our efforts are at trying to prevent workplace injury and disability, so we have an injury prevention program and a number of workplace health initiatives underway to try and prevent that from happening in the first place.
MR. CHAIRMAN: Thank you, Ms. Leverman. Ms. Whalen, your time has expired. Before I call on Mr. d'Entremont, the member for Argyle, I was remiss in not introducing Mr. MacMaster who came in shortly after the introductions, the honourable member for Inverness.
We'll now have 20 minutes with the PC caucus. Mr. d'Entremont.
HON. CHRISTOPHER D'ENTREMONT: Thank you very much, Mr. Chairman. Of course to our visitors today, thank you very much for taking time out of your busy schedules to be here and answer questions here in Public Accounts Committee.
I'm going to ask some budget questions, to begin with, so I don't know if it's going to be Ms. Leverman or Mr. Pittman. What is the total budget for South Shore District - what is the total budget?
[9:35 a.m. Ms. Diana Whalen took the Chair.]
MR. PITTMAN: The total for South Shore, the total operating expenses in the last year that we have audited financial statements, for March 2009, we're operating with $77 million - sorry, $79 million were our expenditures, we had revenues of $77 million.
MR. D'ENTREMONT: So, which shows, of course . . .
MR. PITTMAN: Well there was a $1.7 million deficit for that year.
MR. D'ENTREMONT: How does that compare - I mean that's the operations, what was the approved budget from the Department of Health? Is that the $77 million?
MR. PITTMAN: No, actually the Department of Health number would be a lesser number because that number includes revenues from all sources, Department of Health, Health Protection and Promotion, self-generated revenues, which could be donations, cafeteria revenues, things like that, so the actual budget number, and the approved budget document, would be a lesser number. The year that just ended, if you were to look at my budget document that was submitted, it had total revenues of around $69 million. That was in our budget template that we would have submitted.
MR. D'ENTREMONT: Then that's where I want to stay because those are the numbers that I would be aware of over the last number of years, of course, as sitting in the Chair at Department of Health. How does that compare to the other districts? If we're looking at an approximately $70 million budget, how does that compare to South West or Valley or - you really can't compare it to CDHA, of course, because it's the largest, or the IWK, but do you fit in the middle of the pack? Are you high or low, from what you know?
MR. PITTMAN: From what I know, we're very close to the South West budget. I think they might be $1 million or $2 million higher and I think Annapolis Valley might be $10 million or $15 million higher, so we're close to South West, a little bit below Annapolis Valley.
MR. D'ENTREMONT: In the last, let's say the last three or four fiscal years, and the reason I look back at those ones is we were able to keep the district health authorities on budget. I think I was within 0.8 per cent or 1 per cent between 2005-06, 2006-07 and 2007- 08. The district that tended to be underfunded, or offside, depending on which side of the game you were on, was, of course, South Shore. What really caused, I think, the chronic underfunding of South Shore over those number of years, because it was the one that we always had trouble getting on budget.
MR. PITTMAN: I guess there are a number of factors, off the top of my head - I think with the demand of our aging population and the need for certain staffing to service that population, the staffing shortages that we encountered would have driven our overtime costs to continue to service in the way that we needed to service the population with less staff. There were just increasing costs in some of our operation costs, like in our lab, for supplies, drug costs, but the main thing would be the staffing, I think, and the need for extra staffing, or overtime, just to meet the needs of the population was probably the biggest driving force.
MR. D'ENTREMONT: Thank you for that. The concern that I would have with that, of course, is I would probably get the same answer from any of the other CEOs or CFOs from the other districts. All of them, of course, have seen that pressure because of staff shortages in all the districts. They do have to spend a lot of money on overtime and that. So thank you for that answer, even though I find it's - I don't know what the difference would be between other districts because, like I said, it would be a very similar answer.
So, if you're saying there was an adjustment of about $1.3 million from the Department of Health over the last year or so to try to accommodate that funding gap, you had to come up with more money in order to really close that gap on your own. So what has been the impact on your programs in finding some pressure relief, I guess, is what you would call it?
MR. PITTMAN: In the mitigations?
MR. D'ENTREMONT: Yes, the mitigations that you would have had to come up with?
MR. PITTMAN: A lot of the mitigations were cost savings through efficiencies. Some of it was deferrals but a lot of it was - we enacted, in the last year, some of the models of care initiatives, which didn't affect service but did reduce our costs through better use of staff, a more appropriate use of staff.
MADAM CHAIRMAN: Ms. Leverman.
MS. LEVERMAN: If I may just add to that, we also put a fairly significant effort on efficiencies in terms of travel, reducing minor equipment costs, we did defer the filling of some positions to achieve some efficiencies, we did adjust some of our pricing in our cafeterias, a number of those types of things that did not have any direct impact on patient care.
MR. D'ENTREMONT: And $3 for parking at the South Shore Regional when everywhere else it's $2.
MS. LEVERMAN: Yes.
MR. D'ENTREMONT: But no, no, I understand those are things that you have to do to try to find more dollars in order to close that gap. If we look at, the year is going forward, so we have this adjustment in recognition of this gap, where are we looking into the future? Are our eyes on the ball at this point? Do we have the stronger management that's required to keep your eye on the ball in order to make sure that we don't have these funding gaps present themselves so late in the game?
MS. LEVERMAN: Thank you, again, for that question. We do recognize, at South Shore Health that we have received the extra funding and that we are required to live within our means. That's why we've undertaken a very significant initiative that we're calling the quality improvement action plan, where we engaged the front-line staff as well as managers, physicians and volunteers to come up with ideas as to where they see we might find further efficiencies. It has been quite an amazing process and quite amazing to see the ideas that come from the ground when you ask and listen to those suggestions. We are moving forward and we'll be doing that very aggressively and I believe you've hit the nail on the head. Our responsibility, now that we've had that funding adjustment, is to continue to manage those resources as effectively as we can, to find new ways to offer our services, perhaps in a way that will allow us to be more efficient.
MR. D'ENTREMONT: It was always the point, as well, that as you're working with each district health authority in the province, should one go offside you're always worried the other ones would take that kind of move as well. It's always a bit of a challenge for the Department of Health to make sure everybody stays on. When such a large portion of the budget of the Province of Nova Scotia goes to health care and, of course, to the district health authorities, things can go awry quite quickly. It's good to see that we've made those adjustments and, of course, we can look forward on that.
I was also wondering, as we look at the facilities in South Shore, what would be the breakdown - it's probably easy to say the South Shore Regional Hospital, of course, is the one that takes the most dollars - but in comparison to Fishermen's or Queens General, and
even splitting up to the smaller clinics that we do have, North Queens, New Ross or New Germany and Mahone Bay, I believe, is the other sort of satellite clinics that we do have. What kind of cost breakdowns do we find in those areas? What kind of dollars do those use to keep the lights on, for example? What do those facilities cost us?
MS. LEVERMAN: For clarity, is your question, what is the breakdown of the budget for each of the facilities and the community?
MR. D'ENTREMONT: Yes.
MS. LEVERMAN: I am going to defer to Malcolm for the breakdown by facility and if he can't answer it we'll get the information. Before I hand it over to him, I do know that approximately 20 per cent of our budget is spent on community-based activity and the other 80 per cent is more facility-based.
MR. PITTMAN: Unfortunately I am going to have to get you that information, I don't have the breakdown. We do have the breakdown, obviously, back at the office and we can forward that breakdown by facility and by community.
MR. D'ENTREMONT: The reason I ask the question is, what does a facility the size of Queens cost? What does a facility the size of Lunenburg cost? What does a success story like North Queens cost? We have some good models there and exactly what does it cost in order to provide those kinds of facilities in different parts of the province? That's basically the reason why I ask them.
Maybe if I can switch gears just a little bit, and just going back to my time in the Department of Health. We can talk about the master plan and where that is, and then maybe go towards the issue of the Queens Redevelopment Project. Where is the master plan at this point and where is the Queens Redevelopment Project?
MS. LEVERMAN: The master plan is with the Department of Health so we are awaiting word from them regarding that. With respect to the Queens initiative, we did get feedback from the department requesting that we resubmit a revised proposal that would be consistent with the previously committed funding and the available community resources. We are in the process of finalizing and submitting that to the Department of Health and are optimistic that we'll get a response fairly quickly.
MR. D'ENTREMONT: Yes, because if I remember correctly, there was always quite a discussion about two basic projects. You basically had two groups, you had the Queens group and the Lunenburg group and discussing the issue of which project should go first. You always had the Queens issue of saying that, we can fundraise all this, if you can give us
the go-ahead, we could fundraise, we can flip the ratio on its head and we can say, we'll fundraise 75 per cent and you come up with 25 per cent, I think, is what the offer was three years ago. I think we all took a step back from that and said, listen, there are other issues within this district that we need to address, i.e., the overcrowding at the emergency room, the issue of dialysis, there are a whole bunch of issues that need to be addressed first. It would be very good to know what the new master plan is and exactly what it's going to provide to the South Shore district. I think everybody has their own concerns and there are probably a good handful of issues at this point, not just one issue that's attacking us at this point.
Within the master plan, if we talk about the Queen's development project - okay, we'll see where that one ends up in the end, but the more pressing one in my mind at this point is the overcrowding at the ER, the issue of satellite dialysis, or whatever you want to call it in the end - do we have the room at the South Shore Regional today or are we going to have to do some major redevelopment at that site in order to do it? That is one of our newer hospitals, but it's in sort of that age that needs probably a major redevelopment anyway.
MS. LEVERMAN: In the master plan there is provision made for dialysis should there be the decision to establish such a unit in Bridgewater, but certainly the priority - and our board unanimously supported that - at South Shore was for the construction of a new emergency room.
MR. D'ENTREMONT: Is that a full stand-alone facility or would that be a redevelopment within the existing walls?
MS. LEVERMAN: It would be a new piece added on to the current facility that would accommodate the ICU as well as, in Phase I, some diagnostics that are required to be available for an emergency room of that type.
MR. D'ENTREMONT: To move over to Fishermen's, because I see I have about four minutes left in my time, so let's go to Fishermen's for a few moments, and we talked about the emergency room there and the original reason to cut back on the hours had to deal with a nursing shortage. There wasn't necessarily a nursing shortage at Fishermen's, if I remember correctly, it was a nursing shortage at South Shore Regional and we had to transfer some of the nurses from Fishermen's to the Regional - do I recollect that well or am I a little off?
MS. LEVERMAN: Again, I wasn't actively involved at that time. Whether it was a nursing shortage at South Shore or Fishermen's, the reality was we did not have the highly skilled emergency room staff that is required at the district level to allow that emergency to remain open on a 24/7 basis.
MR. D'ENTREMONT: Is it the intention of the district to ever go back to 24/7 with that district? Are we trying to hire more nursing staff in order to have it open 24/7, or has that pretty much been left to the side for the time being?
MS. LEVERMAN: We are not actively working on reopening that emergency room at this time. As indicated earlier, the data demonstrated that during that eight-hour period we had between one and two patients, so it wasn't necessarily the best use of our limited resources to keep that open to accommodate that number of individuals. The community has adapted well to that and our focus is on ensuring that we can keep the 16 hours that we have committed to open on an ongoing basis.
MR. D'ENTREMONT: One final set before I give my time to the NDP caucus. The overcrowding issue, and we've seen a couple of news stories on that in the last few weeks, what are necessarily the causes for it? There can be multiple causes - it can be other districts not accepting patients, or Capital calling off surgeries and things like that that have kept people within your district - what seems to be the main problem? We would always say that alternate level of care, or long-term care, seems to be the block but there are always other issues there, what seem to be the main ones at this point?
MS. LEVERMAN: I think it's a very complex issue and we have issues of input, throughput and output, so why are people coming in the first place, we could talk about that. Some of that relates to chronic disease and our need to more effectively manage that at the community level. Some are the challenges in moving people through the system. It's a capacity issue when they're in there, in hospital, and then output is moving individuals to the appropriate venue for care, whether it is long-term care or back home to the community with their family, with appropriate supports, so it is a very complex issue.
We seem to have peaks and valleys. The day that we had 23, we had a number of trips and falls and cardiac events and so it's difficult to really understand, sometimes, why does that happen. It's a system issue and one that we focus on every day, in terms of flowthrough, to ensure that the people are in the right place, receiving the right care.
MADAM CHAIRMAN: Your time has just elapsed, thank you very much. I'll turn the floor over to Mr. Whynott for the NDP caucus for the next 20 minutes.
MR. MAT WHYNOTT: Thank you very much, Madam Chairman and thank you for coming today. As has already been said, I know you are very busy with the work that you do. I've had the opportunity, over the past number of years, to serve on a board that oversees a children's camp outside of New Ross, Sherbrooke Lake United Church Camp. We sometimes have to take the children to either Lunenburg or Bridgewater and the care that they receive is phenomenal.
I think that all Nova Scotians understand the importance of health care and they want - from what I hear as being an MLA now for about a year - they want good quality care for the best bang for their buck. As a government, as the Minister of Finance says, we're the stewards of the money and they want their money spent wisely, so living within the means of the budget you have is obviously important, It sounds like you, as a health authority, understand that.
In your opening remarks you talked a little bit about staffing and I just wonder how you're addressing staffing shortages that you may see in the future or presently?
MS. LEVERMAN: Well, we are continually on the lookout for staffing, particularly in the area of nursing and lab technologists and, of course physicians, as I mentioned. We do have the privilege of having a bursary program that is supported by our foundations and auxiliary, so that is a significant enabler of recruiting staff. In addition to our continual recruitment efforts, we do participate in a fairly significant way with offering clinical placements for staff, a great deal of emphasis today on inter-professional training and learning opportunities and we are involved in that. We find that many of those students do look forward to coming back to work at South Shore Health. So, it's a variety of initiatives that we undertake, a multi-prong approach to trying to address the requirement to continually secure health professionals. We do attend recruitment fairs for all health staff, from time to time, so a many different-pronged approach to that issue.
MR. WHYNOTT: Okay, great, thank you. I know in your opening remarks you also talked a little bit about the South Shore Health Bursary Program, $159,000 to 21 students. Where do you see the students coming from? Are they mostly Nova Scotians or they from the South Shore? Can you explain that a little bit?
MS. LEVERMAN: Most of them are from the area. We had 7 of 9 who graduated, who have returned to work for South Shore Health, and we do have a return of service agreement with them. So the two who did not choose to come to South Shore Health defaulted on the agreement and did pay us back, or did pay the foundation back, for that. We have another 11 now who are in the course of their studies and have expressed an interest of coming our way. So that is a huge enabler of recruitment for the district.
MR. WHYNOTT: Are other foundations doing that across the province, do you know?
MS. LEVERMAN: I'm not aware of that, that's not to say that it is not happening, but I'm not aware.
MR. WHYNOTT: Can you explain a little bit of the role that EHS might play in the emergency room in Lunenburg or Bridgewater or Queens?
MS. LEVERMAN: Well, as you know, we have one of the finest emergency health systems in the country, if not beyond, and the paramedics have advanced training in many areas so we see them primarily as working in the emergency room to triage individuals as they come in. There are other opportunities, we believe, for EHS staff to work with the district beyond just in the emergency room, but we in the South Shore have great relationships with our EHS staff and find them to be very responsive. When we have had to close the emergency room at Fishermen's, they very often have come and located an ambulance there in the event that someone would show up and are quick to transport, if necessary.
MR. WHYNOTT: I'm quite interested in primary care because, in particular, right now, as an example, in my community, the constituency of, in particular, Hammonds Plains, there are two African Nova Scotian communities that have been asking, for a while, to have some sort of primary care service at the local community centre, or something like that. What are you doing to address the primary care aspect in community-based supports, not necessarily in minority groups, but just as a broad sense throughout the district?
MS. LEVERMAN: It's a favourite topic of mine. We actually are making great headway with primary care, with new models, and, of course, that work requires very close liaison with communities. So we, in the last couple of years, have established brand new collaborative practices in Chester, in New Germany, in Lunenburg; we're actively working with the community of Mahone Bay and Bridgewater to establish practices and, of course, Caledonia, Liverpool and New Ross and an older collaborative practice in Lunenburg are all working well and are providing significantly improved access to primary care for those communities.
So, we feel very strongly that is the way to go and those practices have electronic patient records and a big focus on chronic disease management, which, of course, impacts very positively on the demand that we have for emergency room visits.
MR. WHYNOTT: How many nurse practitioners do you have in your district?
MS. LEVERMAN: We currently have five.
MR. WHYNOTT: What benefits are you seeing as a result of that?
MS. LEVERMAN: Oh, very significant. For example, in our new Lunenburg collaborative practice, the physicians have increased the number of patients they see in that practice by 1,500 with the implementation of the nurse practitioner. It allows our physicians to see those things that only a physician can see. The nurse practitioner, of course, is able to
do a variety of - order a lot of tests, diagnose, and treat in a way that frees up the valuable time that physicians have. They're very, very well regarded in the community.
In fact, our family physicians tell us that very often the request is no longer to see them but to see the nurse practitioner.
MR. WHYNOTT: Are you planning on hiring more nurse practitioners in the future?
MS. LEVERMAN: That certainly is our goal. As we look to improve efficiency in areas where we can improve the health system, that's absolutely where we want to place an increasing emphasis.
MR. WHYNOTT: I know most recently there was an announcement of a new CT scanner and digital mammography unit and ultrasound machines. Correct me if I'm wrong, but that was $2.4 million worth of equipment?
MS. LEVERMAN: That's correct.
MR. WHYNOTT: Can you just explain a little bit the importance for the Department of Health to provide that funding and what will that do for wait times in regard to those machines?
MS. LEVERMAN: Well, all of our former equipment was very old. The imaging ability of those machines was lessened and because of the old technology the ability to process people through those various departments was far less than it is now.
Our new CT scanner is state of the art and the imaging - in fact, I had a tour of the department shortly after it was in place and it's quite amazing to see the clarity and crispness of that, and the same with the ultrasound. With the digital mammography, we're able to increase the volume of women who are both screened and able to be seen for diagnostics. The wait time for mammography, while we've been working at that for some time, has been significantly reduced. The new unit has only been in place for a few weeks, so as the staff increase their skill and practice with that, we know that the volume will increase more and more.
MR. WHYNOTT: Good to hear. I want to move to seniors. More of a generic question, I guess, what is your district doing to try and keep seniors healthier and more active in their communities?
MS. LEVERMAN: Well, seniors are certainly a priority for us in the district. We have a number of initiatives underway. We have in place a seniors' community health team which is a specialized team of professionals who have special training in geriatrics. It's a multi-disciplinary team that works very closely with the geriatricians who come to our
district from the QE II. Those individuals are able to target some of the more complex care needs of our senior population. As a result of those interventions, individuals are able to stay at home for longer periods of time. We have a Challenging Behaviour Resource Consultant who works very closely with our Home Care clients and individuals who are in long-term care, helping staff to manage those behaviours so that they're able to stay at home.
We work very closely with our community partners to establish a variety of volunteer-based activities that support seniors at home, such as senior safety, transportation, visiting. We've recently established, in collaboration with VON in Lunenburg County, a new adult day centre that supports individuals to remain at home. We've opened up a new adult day centre in North Queens Nursing Home and have been able to expand the number of available days, and spaces of adult days, in Queens Manor in Liverpool, so a number of initiatives such as that.
MR. WHYNOTT: How is the uptake?
MS. LEVERMAN: The uptake for adult day, is that your question?
MR. WHYNOTT: Yes.
MS. LEVERMAN: It has been slower to get people to the centre, although it is growing all the time. Transportation is a challenge and we are currently working with VON to find ways in which we might be able to incorporate transportation as a component of that program. It takes a little bit of time for Lunenburgers, in particular, to accept that new type of community support.
MR. WHYNOTT: Thank you, very much. I'm going to share my time with the member for Cole Harbour-Eastern Passage.
MADAM CHAIRMAN: Ms. Kent.
MS. BECKY KENT: This is really encouraging to hear and certainly interesting. I grew up on the South Shore in the Shelburne area. My parents still live there. It's not uncommon for them sometimes to have to either - they get good care in Shelburne, but they might go to Bridgewater, or they may have to go to Yarmouth. I have family in the Bridgewater area as well.
The information around closures, ER closures and all of that, of course has been a concern for Nova Scotians for a long time, certainly our government. You noted here the change in the hours in 2008, and certainly, the information - lots of our colleagues here had questions around the effects of unscheduled closures and such - I'm just wondering, in the information that you talked about, you talk about the cross-training between South Shore
Regional and Fishermen's Memorial. Can you tell me a little more about that? What is it you are referencing and how does that actually unfold into a positive effect for both hospitals?
MS. LEVERMAN: When you have staff who are trained to work in both sites then you increase your capacity overall. The training is really orientation to the facility, working with individual physicians, so they're able to move from one site to another with increased comfort and skill. Of course, the types of individuals who would be seen at the South Shore Regional site are different perhaps than those who are seen at Fishermen's Memorial, so it is the opportunity for our staff at Fishermen's who may not be seeing the degree of acuity on a day-to-day basis at Fishermen's to see that, and that helps to bring up their skills and keep their skills up.
MS. KENT: And I guess more stable employment as well, that the health care providers have work. You're offering them work at both hospitals, so they're getting the hours that they require for providing for their own families.
MS. LEVERMAN: Yes.
MS. KENT: Has that been well received?
MS. LEVERMAN: Yes, it has been. It is always a challenge when you're moving people from an area of work that they're comfortable with, to move them into a new area but we have an expectation that individuals are district employees first and we support them to work in those areas of the organization where they are needed most.
MS. KENT: Can you tell me a little bit more about Ryan Hall? Where is it located? Is it replacing something that was existing there before or is it a new asset to the community? You had mentioned the number of beds in the past but could you tell me a little more about that?
MS. LEVERMAN: Well, Ryan Hall is a wonderful new facility. It's owned by Shannex and it is part of the new bed construction that was an initiative of the Department of Health. It is state of the art. It's beautiful. The residents will be living in pods or houses so it's very much like a home environment, you know, I just cannot say enough good things about it.
MS. KENT: And how has it impacted the wait times and the pressures associated to long-term care and residential care on the South Shore?
[10:15 a.m. Mr. Leonard Preyra took the Chair.]
MS. LEVERMAN: As I mentioned earlier, it opened on the 19th of May and we are in the process now of moving 20 of our patients out of hospital into long-term care beds. It's
a bit of a movement through the system because some individuals who were in other facilities previously have requested a transfer to Ryan Hall. So many of our patients who want to go into Ryan Hall will be required to go to other facilities first and then await the opportunity to move into Ryan Hall when a bed there becomes available.
MR. CHAIRMAN: Thank you, Ms. Leverman. Ms. Kent, I believe your time has expired. We now move into a second round of questions. I believe we have a little less than 13 minutes each but we'll call the time 10:16 a.m. and we'll go back to Ms. Whalen from the Liberal caucus.
MS. WHALEN: I wanted to pick up just quickly on the workers' compensation again, just to ask you in general terms if this is an area of concern to you because since Health and the acute care sector is funded publicly, when I heard that we are the number one claimant, I just thought that this was a concern to all the DHAs. So could you give me just a sense of, again, I guess the approach you have towards it. You said you don't have the exact figures. I would like to know, and we've asked, if you could give me the costs right now that you pay to Workers' Compensation. I would love to know the number of days lost, that sort of thing, if we could have a trend over the last few years, say the last three years, to see just what we're looking at in terms of time off work and number of injuries, but I know if there's a lot of lifting, it's a dangerous area at times if it's not done right. So could you just indicate whether this is a concern to you and to your colleagues, the other CEOs?
MS. LEVERMAN: Absolutely, it is always a concern when we have workers off because of injury as a result of work on the job and we are working very closely with Workers' Compensation to identify areas that we can focus on. We do have a part-time injury prevention coordinator who works very closely, particularly with nursing staff, to ensure that they understand and are using the proper techniques for lifting because, as you've indicated, it is a very demanding job.
As Malcolm mentioned, we have seen a reduction in the numbers of cases of WCB but, what we are seeing is an increase in the length of time that they are off. That's in part, I think, because of the aging workforce. People don't bounce back quite as quickly from injury and we have an active program to get them back to work as quickly as possible.
MS. WHALEN: Great, and you will give me those figures later which I would appreciate.
MS. LEVERMAN: Absolutely.
MS. WHALEN: I just wanted to ask if you're looking at any equipment investments that would help, things like lifts and so on that will mean that there will be fewer injuries?
MS. LEVERMAN: Absolutely, we have a very comprehensive process in place for identifying our equipment needs, and we have had phenomenal support from our foundations and auxiliaries to assist us with the purchase of a variety of equipment, be it lifts or chairs, a variety of things that ensure that our staff can work safely on a day-to-day basis.
MS. WHALEN: I do think there would be some real value in - it's not just the cost of buying the equipment, it's how it would defray your cost of injury, lost time at work, and suffering, and so on. There may be a strong argument to do a lot more of that.
I wanted to ask about your capital equipment priority list. We were given some information but it didn't contain that, and I'm wondering if you have a capital equipment priority list.
MS. LEVERMAN: I'll let Malcolm speak to that.
MR. PITTMAN: We do have a process to identify capital priorities, and then our top priorities are submitted in our business plan request for funding, or we also submit lists to our foundations and auxiliaries. It goes through a process of identification, I guess early in our year, to get ready for the budget. We have clinical engineering involved, as well as all managers, to identify all needs. For our equipment, it goes through a process of review by a committee.
MS. WHALEN: Could I ask, do you have a total dollar figure, right now, on your capital equipment wish list, I guess we'll call it?
MR. PITTMAN: Do I have a dollar figure? No, I don't have it with me. We do have a list and I can provide that.
MS. WHALEN: That would be great if we could get your full list. I understand that you put everything on there, and it has to be prioritized and so on, but I'd like to see it.
I'm wondering if you have any indication about whether or not you'll be getting capital equipment priorities met this year, and if so, which ones?
MR. PITTMAN: For the current year, 2010-11?
MS. WHALEN: Yes.
MR. PITTMAN: I don't have the 2010-11 list with me to actually . . .
MS. WHALEN: You could go back to the year before if you have that list. Another question I have is how far along you are in your 2010-11 business plan, so that's probably
where that list would appear. Maybe Ms. Leverman, you could tell me about your business plan.
MS. LEVERMAN: Yes, the business plan has been submitted to the department and we are awaiting a response. I can tell you, on the capital list, the replacement of cardiac monitors in the district is the number one priority.
MS. WHALEN: Is there any indication of whether it will be met this year?
MS. LEVERMAN: We've had no response.
MS. WHALEN: I wanted to ask you a little bit around your cost savings plan. As was mentioned with some previous questioning, the district had been over budget the last couple of years at least, and at the same time, you're talking about cost reductions. I'm curious how you're doing that, and whether or not the Department of Health has issued any, I guess, directive to say each DHA must look for 1 per cent or a certain amount of reductions. First of all, have you been asked by the Department of Health to look for those reductions across the board?
MS. LEVERMAN: No, we have not specifically been asked to look for across-the-board reductions. What we have committed to is living within the available funding, so last year, as we mentioned previously, we undertook in excess of $1 million in cost savings initiative. We are in the process now of working our way through another list of priorities to achieve efficiencies.
MS. WHALEN: Although your budget went up this year in 2010, it looks like it's actually less than what was forecast for last year, and maybe Mr. Pittman would have that exactly. This would not include a lot of the other programs because the way the budget's shown, you have a lot of stuff broken off into programs like addictions, mental health, and so on. I showed it as $62.6 million in your overall budget, which looks like a 5.8 per cent increase over the year before estimate, but if you look at what your forecast was for the year before, it's actually a reduction. I'm wondering if you're able to live within that to begin with, because it's still a reduction on where you're going to come in at this year. I know you have cost pressures on staffing and contracts and that sort of thing. How is that regarded? Do you see it as still a reduction rather than a great increase? Is it sufficient to meet the needs of your DHA is really what I'm asking.
MR. PITTMAN: Referring to the 2010-11 number as a reduction?
MS. WHALEN: Yes, 2010-11, and you can tell me if I've read it wrong, but my understanding is we're looking at about $1.2 million less than what was forecast last year, in this year's budget. So although it might appear that estimate to estimate you've gone up 5.6 per cent, really you've gone down from your forecast last year. The forecast being what
is really expected to happen, so I'm just wondering about that cost pressure. You've already made the $1 million saving last year so you're looking at a $1.2 million savings further, is that right?
MR. PITTMAN: Yes, that's about right. As Alice mentioned, we're going through a quality improvement review process and we're looking at further reductions in 2010-11 to meet that gap. So we do have an increase, you're right, mostly because of things like wage contract increases and things like that, although there was a reduction of non-wage increases. We do have a number of cost pressures that we are trying to overcome through that quality improvement action plan.
MS. WHALEN: Can I ask you if you have a dollar figure for what the savings need to be, that you find through your quality improvement process in order to balance this year?
MR. PITTMAN: That was an area of $1.7 million.
MS. WHALEN: About 1.7 million. I had said $1.2 million but you also have your increased cost pressures as well that have gone up and inflation. Is there an impact at all from the HST increase that the province is expecting, is not expecting - is happening?
MR. PITTMAN: I do believe that was in the area of $40,000, the cost pressure.
MS. WHALEN: So that would be an additional $40,000, so you have some offset, don't you, toward that? You don't pay all of it, you get some back.
MR. PITTMAN: We only pay 17 per cent of the HST. We get a rebate of 83 per cent.
MS. WHALEN: But it still has an impact. I know when you're depending on the fundraising and communities and support from foundations and so on, every dollar does count very much so I appreciate knowing what that is.
On the staffing side, there are so many questions here, actually whenever you talk to a DHA there's so many different components, I'm always struck by that. On the staffing side, I was interested as well in the impact on recruiting and promoting your area as a desirable area for the professionals to come. Because as you mentioned, it's not just the doctors, it's the lab techs, the diagnostic imaging people and everybody.
On that side, I had a question, wondering whether or not you're using internationally-trained doctors or inviting them to come and do any clinical rotations and so on in your hospitals. It actually relates to a request I had recently from a Canadian student who is studying in the Caribbean and wants to do more than the 12 weeks a year on rotations in Canadian hospitals. They want to come back to their own community and apparently 12 weeks is the maximum allowed and they are not being allowed more time. But there are
hospitals, particularly rural hospitals or smaller town hospitals, that have extra time available. So are you making full use of those students, as well as our Dalhousie students?
MS. LEVERMAN: Yes, we certainly have had international medical graduates in our district and are in the process actually now of some dialogue with one of our physicians to work with one of those graduates. So we certainly do explore those options as we are looking to recruit.
MS. WHALEN: I'd like to mention that I think there's more opportunity if you have needs and those students want to come back to Nova Scotia, a lot of them are Canadian students studying abroad and I think that they're not being fully utilized. I just want to mention that.
I'd like to ask you quickly about H1N1 and the costs and so on associated with it. Have you been reimbursed yet for your costs, from the province, from the Fall H1N1 inoculations?
MR. PITTMAN: We have been instructed to claim that and that we will be reimbursed but actually haven't received a payment yet.
MS. WHALEN: Have you made your claim yet?
MR. PITTMAN: Yes.
MS. WHALEN: Okay, so you're ahead of that, then. Do you know what percentage of residents were actually immunized, Ms. Leverman?
MS. LEVERMAN: I can't give you the exact number but the rate was fairly significant. I want to say in excess of 70 per cent, however, I will get that figure for you. We had a significant uptake among our staff, which historically has been challenging with the regular flu vaccine but we had a very high uptake among our staff.
MR. CHAIRMAN: Thank you, Ms. Leverman. Ms. Whalen, your time has expired and I'm going to hand the next 12 minutes plus to Mr. MacMaster and the PC caucus.
MR. ALLAN MACMASTER: Thank you, Mr. Chairman, and thank you for having the opportunity to ask a few questions. Most of my questions are finance-related so perhaps Mr. Pittman may be most appropriate to respond. I presume that you would use a monthly or quarterly analysis of the budget. Can you tell us what that would look like, what those reports would look like?
MR. PITTMAN: We do a monthly statement and forecast and submit it to our finance committee, which is basically a summary of our revenues and expenditures and analysis of
the various reasons for the variance and for our related forecast, is how that's calculated. That forecast is then put on a template and sent into the Department of Health each month.
[10:30 a.m. Ms. Diana Whalen took the Chair.]
MR. MACMASTER: Are you able to see the costs from - like say, if you were doing a report for the end of May - are you able to see the costs for the month of May, or would you be looking at costs back in February, or January?
MR. PITTMAN: We are usually looking at - if we have a meeting say in May - we would be looking at the, I'm sorry, let's use the month of say July, it's easier. If I had finance committee in July, we would probably be looking at a report, not for June, but for May. So they are usually a month and a half old, the numbers that they would be looking at.
MR. MACMASTER: Sure. What are the main costs and how are they monitored?
MR. PITTMAN: The main costs are staffing. Each manager manages their budget. Each month they are required to do an analysis of their budget and to manage their budget and they forward their analysis to Finance as well as their estimate of their year-end forecast.
MR. MACMASTER: What would some of the other costs be besides staffing?
MR. PITTMAN: Other major costs, well, obviously, the plant and operations of the building; the supplies for the medical units; the drugs to treat the patients with; as well as lab testing costs, it would be a major supply cost.
MR. MACMASTER: Would the labour costs be about 70 per cent and the remainder be about 30 per cent?
MR. PITTMAN: It's somewhere closer to 75 per cent, maybe a little over 75 per cent is staffing costs.
MR. MACMASTER: And what challenges do you have in controlling costs? I know today there was some mention of shortages of staff, which might require you to have to - dealing with that might incur extra costs - but I'll let you speak openly about the challenges that you would have in controlling the costs.
MR. PITTMAN: I think some of the challenges would include just demand, so you could have a higher volume. For example, in your OBS unit, I think this year they had a much higher volume than was anticipated and, therefore, their costs were up. The acuity of the patients can drive a lot of your costs for the drugs and supplies. As I mentioned, I already mentioned the overtime, but it's mostly the demand, I think, on the system coming through the door.
MR. MACMASTER: Is that because of an aging population, is it something that's unique to the area that's being served?
MR. PITTMAN: I don't have those statistics, unless Alice has, as far as the reasons. I would be speculating myself unless Alice wants to address that.
MS. LEVERMAN: Yes, I would say, in part because of the aging population, but also because of the prevalence of chronic disease and the overall health status of the residents, those would be the primary drivers.
MR. MACMASTER: One of the things that you might have is, it's like unforeseen costs, and I can think of H1N1 as an example. Do you have a contingency amount each year in the budget to address those costs?
MR. PITTMAN: No, we don't actually build in a specific contingency into our budget.
MR. MACMASTER: What would the cost be for the H1N1?
MR. PITTMAN: Off the top of my head, I'm thinking in the range of $270,000 to $300,000. I don't have the exact number with me.
MR. MACMASTER: Would you say that would be about the total from the time that the vaccinations were being handed out or given, would that be, primarily, the most that it is going to cost the health authority?
MR. PITTMAN: I think we reached the maximum on that at this point, yes.
MR. MACMASTER: What percentage of the budget would that be for the year? Would it be a pretty small percentage?
MR. PITTMAN: Yes, that would be less than a per cent, I guess, 0.3 or 0.4 per cent.
MR. MACMASTER: Okay, I know each year when you look at the budget, you try to make sure that you live within your means. Are there any costs that are standing out for you that you would focus on today if you had to try to reduce costs?
MR. PITTMAN: I think there are a number of areas we're going to be looking at. We're looking at reducing supply costs, we're looking at reducing, for example, travel costs. We're looking at reducing overtime costs, certainly is one. We're looking at reducing staffing costs just through using the appropriate mix of staff.
MR. MACMASTER: Now, I can appreciate that there are lots of costs that are outside of your control and you mentioned chronic disease as one example. Is there anything that the province can be doing to help those costs that are beyond your control?
MR. PITTMAN: Well, we had a couple of things in the last year, you mentioned H1N1 where we had extra costs that were funded to the province. We had additional costs through implementing the SAP system and some of those costs were also through to the province, because of the extra costs involved in conversion work on that. I mean we incur extra drug costs and oftentimes those costs are picked up, the high-cost drugs, some of them we have to pick up ourselves but a large dollar amount is funded through our high drug costs for patients.
MR. MACMASTER: The province is looking at improving information technology for the health care system. How will that help you and your staff and will it mean that you will have better information when you're preparing your monthly analyses?
MR. PITTMAN: Well, with the implementation this year of SAP, previously the managers who were managing their budgets did not have direct access to any information. They had to request information from Finance and they would get monthly reports. With SAP, they can look at their information on a daily basis to see where their costs are and better manage their position and they get more timely information for the management of the cost centres that they are responsible for.
So, certainly, from the manager's point of view, SAP, I think, has improved their information that they have access to.
MR. MACMASTER: Do you think it would, I don't know if you would have done any analysis on this, but do you think it would lead to a certain percentage-amount reduction in the cost to deliver services for the area?
MR. PITTMAN: I wouldn't put a percentage on it but I think if they were able to better manage, therefore, there should be some improvement in their cost control.
MR. MACMASTER: Do you have any thoughts, the health care budget is in excess of 40 per cent for the province and it has been growing at a rate of 7 per cent each year. Do you feel there is any way that you can help to control the escalating costs of health care? Over the long term it is going to have - and we're already facing problems, and we've been facing them for years- I can't help but think that the only way we're gong to be able to address it is through local measures. Have you any thoughts that you would like to share with that?
MS. LEVERMAN: I think first and foremost, we have an imperative to be as solid in our management of the resources as we can possibly be. I think the biggest bang for the
buck is the focus on the demand and to invest as fully as we can in community-based initiatives and primary health care that will help to keep our population as healthy as possible, and for those who are living with chronic diseases it is to help them to manage those more effectively in the community.
I think the imperative to focus on the demand side is where we are going to see longer-term results and ensure the sustainability of the system overall.
MR. MACMASTER: Thank you. Recently I had a chance to meet with some young medical students - yet-to-become physicians - and one of the things they were saying was to better address doctor shortages in rural areas, they felt there should be some effort to try to ensure young people out in rural Nova Scotia would have an opportunity to gain access to medical school. Do you have any outreach in the region you cover to try to help young people who might have an interest in medicine or to try to expose them to medicine?
MS. LEVERMAN: I'm not really sure what you're asking - are you asking about financial incentives?
MR. MACMASTER: No. I guess what I was just thinking is one of the challenges you have is to have physicians in the area, and I was just wondering if there was anything you're doing, on a very hands-on basis, to try to help young people who live in the area gain access to medical school. There's a good chance those people would be the types who would come back to live in their hometowns to help address the physician shortage that you have.
MS. LEVERMAN: We certainly work very closely with the regional school board and the community college, we work closely with municipalities and the regional development agencies to identify our needs and looking always for opportunities where we may be able to support each other to address those needs. At the present time, certainly our bursary program, we do have one physician currently who is receiving some support through that bursary program. So those are some of the initiatives - and when there are new grads interested in coming back to the area, we do look to our community to help us develop the new models of primary health care that will be attractive to them - probably nothing in particular, but a number of small initiatives and certainly an area where we can do more.
MADAM CHAIRMAN: The time has elapsed. I'm going to turn the floor over to Ms. Kent for the NDP caucus for 12 minutes - I think perhaps you'll share your time, and let me know if you are.
MS. KENT: Thank you. Yes, I'm going to share my time with my colleague so I'll take a very brief few minutes.
I want to go back to the timing, the overnight closures at Fishermen's Memorial. I want to understand a little bit more about how you collect or recognize if someone has been
adversely affected by the change in those hours - how would you know? I note that everything has been very positive since the change and there might be new people who come into the community who would recognize that people would learn that Fishermen's Memorial is closed at night so they would go to Bridgewater - how do you collect that information about the local people who may have to go to South Shore Regional?
MS. LEVERMAN: I think first of all if there were adverse events, we would certainly hear about it in a small community but, equally, if people find their way to South Shore Regional and there has been an adverse event as a result of a time delay, we would certainly know about that. However I do want to say that we work very hard when we do have to close to ensure the community is aware of the closures - we have significant signage at the hospital, we have a phone in place that provides direct access to 911, so we've put a number of measures in place to ensure, to the best of our ability, that that does not happen.
MS. KENT: You noted earlier that EHS as well works with you on that. I was pleased to hear that because that certainly would make a difference, I would think. Although they probably couldn't be there all the time, it certainly would relieve that. To your knowledge, since the change in 2008, have there been any adverse effects?
MS. LEVERMAN: Not that I'm aware of.
MS. KENT: Feedback and information from the community on how things are working in your area, and certainly in ours, is very important - I know it's important in our government with the consultation around improving our health care and such. One of the ways that I know our community here in the Cole Harbour-Eastern Passage area has some influence or engagement is through the community health boards - we have terrific ones in this area, the Dartmouth Community Health Board and Southeastern Community Health Board are the two that are most closely associated to my riding - do you utilize those as well in your area?
MS. LEVERMAN: We do indeed. We have very strong and positive relationships with our community health boards; in fact, each of them presented their three-year plan to our board and of course, as you know, we incorporate those recommendations in our business plan. We have a council which is comprised of the chairman and vice-chairman of each of the community health boards as well as our own district health authority, and we meet on a regular basis to identify issues and work collaboratively on initiatives. We're very proud of the work our community health boards do and the relationship that we have with them.
MS. KENT: I'm glad to hear that because I think it's such an effective way to really have a pulse on what's happening in the local community in relation to health and it empowers people. I think it's an important aspect of our health care right now.
Do you have any issues around volunteerism for the health boards? I know we've faced that a little bit here - although the population is such that you wouldn't think it, it can be challenging.
MS. LEVERMAN: Each of our community health boards has had their annual meeting in the last week and they're always recruiting for new members, but they're an incredibly loyal group of volunteers and when their time is up, if they aren't able to secure a replacement, then they historically have simply signed on for another term. They are the heart and soul of the community, no doubt about it.
MS. KENT: I'm glad to hear that, thank you very much. At this point, Madam Chairman, I'll be passing the mic to my colleague from Halifax Citadel-Sable Island.
MADAM CHAIRMAN: The honourable member for Halifax Citadel-Sable Island.
MR. LEONARD PREYRA: Madam Chairman, I wanted to come back to an earlier question about business plans of the health authority and about capital issues.
The budget for the district health authority has been approved and, as I understand it, $1.7 million was provided to cover a deficit from 2008 that you inherited and $1.3 million has been added to your base funding, so the overall envelope for the health authority has been addressed, that the money for this year - in fact, you've got more money than previous years and the base funding was increased in part to deal with a possible deficit and to meet unmet needs, is that right?
MS. LEVERMAN: That is correct and we are very grateful for that - yes, it has made a big difference.
MR. PREYRA: So the question of business plans really is how you work within that envelope and how you live within your means rather than whether or not the government has approved your details yet.
I have a question about the deficit. If you look at the history of the health authorities, we've gone through this oscillation - you know, in 1996 the Liberal Government decided to bring all those 36 local hospitals into four boards and then the Progressive Conservatives increased it from four to nine, so there has been this oscillation, and largely to deal with cost containment and also to deal with participation at the local level. Yet we continue to see deficits coming out of that process, and my question is how do we ensure that district health authorities will live within their means - and I understand that there are huge, unmet needs up there and I understand that there are huge demands on the system - and we don't have to deal with this recurring issue of deficits?
MS. LEVERMAN: I would say it's an issue of compliance with expectations to the fullest extent possible. We have had significant discussions at our board level about this very issue and our board has made it very clear that as we progress through the year, we will be monitoring, collecting key information, financial indicators that give us a good sense of where we are. As we go through the year, if we're anticipating any additional pressures, then it is incumbent upon us as the leaders in the system to adjust and modify to the fullest extent possible.
Now, of course, there are always things that one cannot predict, so I would not want to sit here and say never is never, but we, as an executive team and management team, as well as our board, are working very hard to ensure that we remain within the funding envelope. It will require, no doubt, some difficult decisions as we go through that but I believe, as public servants, that's what is expected of us.
MR. PREYRA: I have a question as well about emergency room closures, specifically at Fishermen's Memorial. I understood you to say that you had an average of two patients overnight at Fishermen's Memorial and that it was unrealistic to keep that emergency room open overnight based on the volume of traffic that it was seeing. You responded to that by having EHS service on standby in case people show up there but, by and large, you really dealt with what you saw as a better allocation of your resources by closing it overnight - is that a reasonable response there?
MS. LEVERMAN: That's correct and also, as I mentioned earlier, simply our inability to have the trained staff in place on an ongoing basis to operate a 24/7 emergency room.
MR. PREYRA: But it sounds, from your brief at least, that the problem - if it can be described as a problem - was more on the demand side than the supply side, that there wasn't as much of a demand for those services overnight.
MS. LEVERMAN: Yes.
MR. PREYRA: I was also struck by your section on emergency rooms, where most of what you say in your response to the challenge relates to nursing home beds and lack of primary care facilities, and the need to have people who can broaden their scope of practice and deal with it. So little of that seemed to refer to a problem with emergencies as such. Do you keep track of the nature of issues that arise at emergency rooms and what the mix is between primary care issues, nursing home issues, and genuine emergencies in your district?
MS. LEVERMAN: Yes, we do track that on a regular basis. We certainly see significant numbers, particularly at the Regional hospital, of what are called Level Is, IIs, and IIIs, which are the more acute levels; across our hospitals we do see a significant number of Level IVs and Vs, which are of a less urgent nature and certainly those are the kinds of
individuals that we would like to see accessing services within the context of primary care practices.
MR. PREYRA: It sounds like you've made great strides within your authority in dealing with that set of issues, which is really separate from the emergency room issue.
MS. LEVERMAN: Yes, we're working hard at that because we believe that is what is going to ensure we have a sustainable system for the future.
MR. PREYRA: I'm going to follow up on a question about staffing as well. I was on your site yesterday and looked at the number of vacancies and it sounds like the vacancies you have are similar to what we're seeing right across the province, you know, physician shortages, and you've responded to it by broadening the scope of practice for others, but I was also struck by the fact that many of the positions that are being advertised there are short term, limited terms, 60 per cent positions - what impact does that have on your recruitment? Well, two questions, why and what impact does it have on your recruitment?
MS. LEVERMAN: I'm not sure if you're referring to family practitioners or some of the specialists?
MR. PREYRA: Mostly continuing care assistants and nurses. I know you've answered earlier that the nurses were on maternity leave, you know, those kind of positions.
MS. LEVERMAN: Yes, we have brought on board recently a number of new graduates, younger women who are in their child-bearing years, so that does result in the need for us to replace with maternity replacements. With some of our physicians, they do take leaves of absence from time to time, so it requires us to bring in short-term locums to assist. And recently, and very sadly, we lost one of our anaesthetists through an untimely death and so, for example, we will be bringing in a locum until we're able to fill that position on a permanent basis.
MADAM CHAIRMAN: Mr. Preyra, your time has elapsed and that is the end of our questioning this morning.
I would like to offer you the opportunity, if you would like, Ms. Leverman, for a short closing.
MS. LEVERMAN: Thank you, Madam Chairman. In summary I do want to thank all of you for the opportunity to be here and share with you some of our challenges. As I mentioned earlier, we feel very strongly our responsibility is to work to live within our means and to ensure the sustainability of the system over the longer term. So we know we are on a journey of change and we look forward to that, working collaboratively with the
Department of Health and with our own community, to enable that change to happen effectively. So thank you very much.
MADAM CHAIRMAN: Thank you, and thank you very much for joining us today. I had a list of five items that we have requested and I can certainly go over that with you at the end of the meeting. I think a number of them were ones I had asked for, but we want to ensure that you have that and, when the answers are ready, if you could send them to our clerk that would be then distributed to all members of the committee. So I thank you very much for joining us today.
For the members of the committee, the only business is to see that next week we are meeting earlier in the day. It is the Auditor General's Report that will be introduced to us next week, so we're meeting 8:30 a.m. until 9:00 a.m. to look at the report, then 45 minutes in camera, a short break, and we'll do the two hours in public. So I'm hoping that everybody remembers to come at 8:30 a.m. next week. Thank you very much, and with a motion to adjourn we shall do so.
MR. CLARRIE MACKINNON: So moved.
MADAM CHAIRMAN: Thank you very much.
We stand adjourned.
[The committee adjourned at 10:57 a.m.]