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The identification of information needs for planning and managing emergency department health services… Smyth, Barbara Laurel 1981

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THE IDENTIFICATION OF INFORMATION NEEDS FOR PLANNING AND MANAGING EMERGENCY DEPARTMENT HEALTH SERVICES IN BRITISH COLUMBIA by BARBARA LAUREL SMYTH B.A., UNIVERSITY OF TORONTO, 1971 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES (The Department of Health Care and Epidemiology) We accept th i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA August 1981 (cT) Barbara Laurel Smyth, 1981 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head o f my department o r by h i s o r her r e p r e s e n t a t i v e s . I t i s understood t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department o f jkj^jX CAJ.P ^ f-rp(j£fsy) tfli The U n i v e r s i t y o f B r i t i s h Columbia 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 Dal DE-6 (2/79) i . ABSTRACT The rapid and accelerat ing growth of hospital Emergency Department u t i l i z a t i o n over the past twenty years has transformed a once well-; defined and well bounded care sett ing into a highly complex and integral component of a to ta l health care system. This increasing role complexity has created a demand by hospital decision-makers for an information system to describe, measure and evaluate Emergency Department a c t i v i t y within the context of broader health care issues and a c t i v i t i e s . This study i s an attempt to ident i f y and integrate the information needs of the hospital decision-makers into a meaningful whole. The evolution of emergency care in B r i t i s h Columbia i s described in order that needs for information w i l l not be developed in i s o l a t i on from the a c t i v i t i e s of major planning, funding and professional groups in the health services. Two major issues are i d e n t i f i e d in the l i t e r a t u r e - the u t i l i z a t i o n of Emergency Departments and thrusts towards c l a s s i f i c a t i o n or categoriza-t ion of Emergency Department c apab i l i t i e s . From t h i s , three major policy/planning foc i are selected - day to day emergency care, d isaster planning, and the "mopping-up" role of Emergency Departments. Ideas about these are developed in l i g h t of s ix c l a s s i f i c a t i on s of inform-ation users ' needs - patient care, management, qua l i ty of care, -'- • i i . s t rateg ic planning, research and development and pol icy-formulat ion. "Needs" were val idated by two panels of major decision-makers from a representative sample of Greater Vancouver Regional Hospital D i s t r i c t Hospitals. The results of the invest igat ion are analyzed in l i gh t of the issues of professional power and control and p o l i t i c a l influences and recommendations made as to the appropriate components of a hospital emergency department information system. ACKNOWLEDGEMENTS The assistance, support and encouragement of many people in the completion of th i s thesis i s recognized and g ratefu l l y acknowledged. F i r s t l y to my thesis committee - Dr. Anne Crichton, Dr. Peter Frost, Mr. Paul Nerland and Mr. Brian Curt is for the i r assistance and in teres t . Special thanks goes to Dr. Anne Crichton for her many hours of help during a l l stages of th i s thes i s . Secondly to my Panel members who believed in the study subject and gave graciously of the i r time and energy. And f i n a l l y to the s t a f f of the B.C. Health Associat ion, in par t i cu la r Mrs. Pa t r i c i a Wadsworth for her gentle; nudges and Ms. Carole Tizzard for her endless patience in the typing of the numerous drafts . - i v -TABLE OF CONTENTS Abstract Acknowledgements 1. INTRODUCTION -. 1 A Background 3 B Purpose 7 C Rationale 9 D The Study 13 1. Objectives 13 2. Def in i t ion of Terms 14 3. Methodology 14 4. Limitations and Constraints 15 5. Chapter Outlines 16 Chapter Summary 18 2. THE EMERGENCY CARE CONTEXT 19 A Emergency Care Within the Canadian Health Care System 19 B Canadian Studies on U t i l i z a t i o n and Role of Emergency Departments 26 C American Pol icy Developments 33 D Categorization of Emergency Room Capab i l i t ie s 38 E Evaluation of Emergency Room Care 43 F Conclusion 47 Summary of Chapter 49 3. INFORMATION SYSTEMS 51 A Ambulatory Medical Care Data 51 B Trends in Federal and Prov inc ia l Information Systems 57 1. Jo int Hospital Funding Project 58 - Data Elements Manual 60 - Uniform Reporting Manual 62 2. Federal Provincial Data Cube Concept 63 C Emergency Department Information Systems 65 D Accreditat ion 67 1. Emergency Department Information 67 2. Disaster Planning 70 E Conclusion - Development of Model of Information Needs 71 Chapter Summary 76 - V -4. EVOLUTION OF THE EMERGENCY HEALTH CARE SYSTEM IN BRITISH COLUMBIA • 78 A Organization, Delivery and Funding of Emergency Care in B r i t i s h Columbia 78 B Emergency Health Services Commission, 1974 81 C Greater Vancouver Regional Hospital D i s t r i c t Studies 82 1. 1970 82 2. 1976 85 3. 1978 86 D Disaster Planning 1978-80 87 E Emergency Nurses Group 89 F Jo int Hospital Funding Project 90 1. Background 90 2. Recommendations 91 3. Implementation 98 G C l a s s i f i c a t i on 100 1. GVRHD 1980 Emergency Department Study 100 2. Hospital Role Study 1978-80 101 3. Provincia l C l a s s i f i c a t i on Study 1980 .104 H Conclusion 105 Chapter Summary 106 5. IDENTIFICATION AND VALIDATION OF EMERGENCY DEPARTMENT INFORMATION, j ; NEEDS 108 A Matrix of Information Needs 108 B Theoretical Ident i f i cat ion of Information Needs 109 C Nominal Group versus Delphi Processes 113 D Val idat ion of Emergency Department Information Needs 119 1. F i r s t Panel of Experts 119 2. Second Panel of Experts 127 E Conclusion 129 .1. Level 1, 2, 3 Information 129 2. Level 4 Information 131 3. Ident i f i cat ion of Soft Data 133 Chapter Summary „...,., 136 6. ANALYSIS, RECOMMENDATIONS AND CONCLUSIONS 137 A Informational P r i o r i t i e s 137 B The Hospital as a Professional Bureaucracy 138 C The Power and Expertise of Physicians 144 D The Information Needs of the Professional Bureaucracy 147 - v i -E Recommendations 151 1. Patient Abstract •.. 154 2. Inventory of Hospital Resources 158 3. Inventory of Community Resources, Hazards and Population I 5 8 F Conclusion 1 5 9 Chapter Summary 161 BIBLIOGRAPHY 164 APPENDICES A F i r s t Panel 1 7 2 B Second Panel • 1 7 6 - 1 -CHAPTER I "The information you have i s not what you want The information you want i s not what you need The information you need i s not what you obtain" F inagle ' s Law on Information INTRODUCTION Emergency Department u t i l i z a t i o n has increased s i gn i f i c an t l y in both Canada and the United States during the past decades. Stewart (1971) reported a 300% increase in v i s i t s to a Hal ifax emergency department from 1956 to 1966, a f te r the introduction of the Hospital Insurance and Diagnostic Services Act in 1957 and before the introduction of Medicare in 1968. Baltzan (1972) noted a 63% increase in Saskatoon from 1965 - 1970, three years af ter private physician care became an insurable benefit to Saskatchewan residents. McKenzie (1971) describes a 300% increase in Hamilton from 1961 to 1971. In B r i t i s h Columbia, the Greater Vancouver Regional Hospital D i s t r i c t (1977) reported an increase of Emergency Department v i s i t s from 174 per 1000 population in 1968 to 300 per 1000 population in 1975 and predicted that i f present trends continue, Emergency Department v i s i t s w i l l reach approximately 350 per 1000 population by 1981. As a result of th i s explosion in Emergency Department u t i l i z a t i o n , there has been a f l u r r y of a c t i v i t y by planners, professional groups - 2 -and researchers to explain and control the growth of emergency department u t i l i z a t i o n , to develop a l ternat ive health care resources for the " inappropriate" users and to develop a co-ordinated system of emergency care. Systems development a c t i v i t i e s within B r i t i s h Columbia have included preventive measures such as seat be l t l eg i s -l a t i o n , pre-hospital care through the Emergency Health Services Act of 1974 and the thrust towards improved standards of hospital emergency care through categorization of c apab i l i t i e s and a pro-l i f e r a t i o n of spec ia l ized manpower. H i s t o r i c a l l y , the role of the Emergency Department was wel l -def ined and bounded in scope. C r i s i s intervention into acute i l lnesses and trauma has been augmented by a primary care counsell ing role with the resu l t that mult ip le and con f l i c t i n g roles are now apparent in Emergency Departments. Unpredictable workloads, variable case-mix and spec ia l ized technology and manpower make i t increasingly complex for those involved in the care and management of Emergency Departments to function e f f e c t i v e l y . At the foundation of th i s turbulent environment i s the lack of a management information system to plan, describe and manage emergency a c t i v i t y to the sa t i s fact ion of those involved in the day to day operations :of the department. - 3 -A. BACKGROUND The health care industry has been described by Bennett (1980) as "drowning in data while being def i c ient in information". This statement holds true for a l l levels of health care de l ivery, whether i t be a program, an i n s t i t u t i o n , or a provincial health care system. The i n a b i l i t y of ex i s t ing health information systems to describe, measure and evaluate health care a c t i v i t y has plagued governments, managers and researchers a l i k e . However, with the reluctant acceptance by a l l providers of the economic r e a l i t y that health care resources are not unl imited, there i s an urgent need for quant itat ive and qua l i t a t i ve information, upon which to base resource a l locat ion decisions. C l i n i c a l and f inanc ia l data, which t r a d i t i o n a l l y have tended to operate in i s o l a t i o n , must be integrated i f informed planning decisions are to be made within and among com-peting sectors of the health care system. This study i s the integration and culmination of various in teres t s , a c t i v i t i e s and re spons ib i l i t i e s of the author over the past f i ve years. While the focus of a c t i v i t i e s has undergone s i gn i f i cant transformation, the underlying concepts, pr inc ip les and concerns have remained constant. The author i s a health record administrator who has become a health services planner. - 4 -To set the stage for the fol lowing chapters, i t i s appropriate to review the events which have led up to the select ion of the study topic - "The Ident i f i cat ion of Information Needs for Planning and Managing Emergency Department Health Services in B r i t i s h Columbia". The scope of th i s top ic , admittedly, i s quite broad. Not only must the external requirements of information reported to th i rd party agencies be assured, but the internal information requirements of the i n s t i t u t i ona l managers, c l i n i c i an s and evaluators must be met in varying degrees of comprehensiveness in order that the users of the data have adequate and appropriate information upon which to base c l i n i c a l , planning, budgetary or s ta f f i ng decisions. As part of the author 's administrative residency at a Greater Vancouver hospital in 1977, a review of the s t a t i s t i c s compiled and reported in some ten ambulatory care units was undertaken. The study (Smyth, 1977)* indicated that the ex i s t ing management information system was inappropriate to serve current i n s t i t u t i ona l needs for information. S p e c i f i c a l l y , i t was indicated that "the data co l lected were based upon t rad i t i ona l government reporting requirements rather than the immediate and future needs of the i n s t i t u t i on for information; there was a lack of standard and uniform terminology which prevented interdepartmental comparisons; the type and amount of s t a t i s t i c a l information co l lected in each ambulatory care unit was not consistent; and the s t a t i s t i c s reported were not and could not be related to e i ther budget or to qua l i ty of care information." Smyth, L., "A Review of the S t a t i s t i c s Compiled in Ten Ambulatory Care Departments at St. Paul ' s Hosp i ta l " , Unpublished Report, St. Paul ' s Hospita l , Vancouver, 1977, p. 3. - 5 -A second area of involvement was with respect to Disaster Planning. In 1978 the Greater Vancouver Regional Hospital D i s t r i c t (GVRHD), in concert with i t s planning mandate, sought to evaluate the disaster preparedness of the hospital emergency f a c i l i t i e s with in the Regional D i s t r i c t . In add i t ion, the GVRHD sought to develop an on-s ite emergency medical response plan, to integrate the a c t i v i t i e s of the emergency health services into a uni f ied regional d isaster plan and to co-ordinate the medical response with the roles and responsi-b i l i t i e s of other agencies. Central to these a c t i v i t i e s , an inventory of Emergency Department resources was made in order to determine c apab i l i t i e s . In s t i tu t iona l health care f a c i l i t i e s were then categorized into "major" receiving hospita l s , "minor" receiving hospitals and "support f a c i l i t i e s " in order to i den t i f y and l i nk the 2 roles and r e spon s i b i l i t i e s of hospital Emergency Departments. A th i rd involvement of the author was with respect to the Jo int Hospital Funding Project, a study undertaken j o i n t l y by the Ministry of Health and the B.C. Health Association in May, 1978. The manner in which hospitals have been funded in B r i t i s h Columbia has been of ongoing concern to both the health care industry and the Ministry of Health for several years. The current system of f inancing hospitals "major" receiving hospitals - the eight acute f a c i l i t i e s characterized by emergency medical communications radio system and capable of receiv ing and t reat ing a l l casualt ies of a disaster. "minor" receiving hospitals - the remaining f i ve acute f a c i l i t i e s in the GVRHD. Not in d i rect radio contact with the disaster s i t e , capable of receiving minor in ju r ie s or providing support s t a f f to major receiving hospita ls . "support" f a c i l i t i e s - the 13 extended or specia l ized acute f a c i l i t i e s in the GVRHD (Grace, Chi ldrens, G.F. Strong) capable of providing s ta f f support or receiving patients discharged from acute f a c i l i t i e s but not capable of receiving or t reat ing casualt ies . - 6 -was i n i t i a t e d some 30 years ago when the type and intens i ty of care provided with in a l l i n s t i t u t i on s was f a i r l y homogeneous. The advances of the past decades in technology and patient care have not been ref lected through progressive modifications to the funding system. For hosp i ta l s , concerns have focused upon the lack of consideration given to the types of patients presenting to the i n s t i t u t i o n , the types and i n ten s i t i e s of services provided, physical plant, or geographical locat ion. For the Ministry of Health, the funding system did not provide s u f f i c i en t information to compare and evaluate the costs and performance of indiv idual hospitals. For both groups, the system was r e s t r i c t i v e in terms of e f fec t i ve long term planning. The Jo int Hospital Funding Project Report (Ernst and whinney, October 1979) released in January 1980, spec i f ies an implementation plan to remedy these def ic ienc ies . F i r s t and foremost among i t s recommend-ations i s the development of. a uniform c l i n i c a l and f inanc ia l data base accessible to both the Ministry of Health and hospitals which would allow comparison and evaluation of hospital costs and a c t i v i t y . The recommendations and implementation strategies of the Jo int Hospital Funding Project Report w i l l be further discussed in Chapter IV. A f i n a l area of involvement of the author in information systems rests with a c t i v i t i e s s pec i f i c to Emergency Care. The Emergency Nurses Group of B r i t i s h Columbia, a special interest group of the Registered - 7 -Nurses' Association of B r i t i s h Columbia, has been concerned about the lack of uniform recording by nurses in Emergency Departments. Workshops were i n i t i a t e d in December of 1979 to develop and p i l o t a uniform documentation record for Emergency Departments, which eventually could be implemented p rov inc i a l l y . I n i t i a l attempts were directed at the development of a documentation form spec i f i c to one professional group - nursing. It was recognized that the information needs of the various users - nurses, physicians and managers, and the uses - patient care, management, evaluation and planning - must be i den t i f i ed before a comprehensive information system could be recommended. Patient care i s the f i r s t level of information need. However, the requirements of higher level needs such as strategic planning and pol icy formulation., must be i den t i f i ed within the tota l system i f an integrat ive information system i s to be developed. B. THE PURPOSE OF THIS STUDY This study attempts to i dent i f y the information needed to describe, plan, organize and evaluate emergency care in l i g h t of the p r i o r i t i e s established by the decision-makers. As Cassel (1973) states: "To be useful any data co l l ec t i on system should develop from an i den t i f i c a t i o n of the major issues in the f i e l d and a spec i f i cat ion of the categories of information needed to resolve these issues or to decide between a l ternat ive courses of ac t i on . " Cassel, John C. "Information for Epidemiological and Health Services Research" Medical Care, Vol. XI, No. 2, March-A p r i l , 1973, Supplement, P. 76. - 8 -The dominant issues in hospital emergency care appear to centre on appropriate/inappropriate u t i l i z a t i o n and c l a s s i f i c a t i o n of c apab i l i t i e s . To be pract ica l and useful to the industry, these issues must also be viewed with in the larger context of the ongoing operational data requirements i den t i f i ed by the Jo int Funding Project. This study makes no attempt to evaluate emergency care per se as provided in indiv idual i n s t i t u t i on s . Measures of e f f i c iency and effectiveness are dependent upon uniform data, i den t i f i c a t i on and va l idat ion of the indicators se lected, and the determination of standards. It i s hoped that, by ident i f y ing and integrat ing the information requirements of the various users, suitable a c t i v i t y i nd ic ie s and standards may l a t e r be developed. The f e a s i b i l i t y of c l a s s i f y i ng and peer grouping of emergency departments i s also considered. The question which th i s Study addresses may be stated as fol lows: "What data elements should be co l lected in hospital Emergency Depart-ment information systems which w i l l meet external reporting require-ments, be useful to plan, describe and evaluate emergency department a c t i v i t y for the various decision-makers with in the hospital and f a c i l i t a t e the development of effectiveness and e f f i c i ency indicators? " - 9 -C. RATIONALE BEHIND THE STUDY Decision-making requires accurate, timely and appropriate information. The amount of information generated in a health care sett ing has become unmanageable because of the lack of i d e n t i f i c a t i o n , organization and integration of the needs of the various users for information. C l i n i c a l , f i n a n c i a l , demographic and administrative information has t r a d i t i o n a l l y been generated and control led through d i f fe rent sources. L i t t l e at tent ion, i f any, has been given to the i den t i f i c a t i on of the users, internal ( c l i n i c i an s and managers) and external (government and accreditators) to the i n s t i t u t i on and to t he i r information requirements. Managerial functions include planning, budgeting, organizing, evaluating and cont ro l l i ng - functions which are dependent upon an accurate, objective assessment of current operations. Evaluation i s a step which both precedes and follows,, each act ion. Quantif iable information regarding the effectiveness and e f f i c iency of operations is paramount for managers i f decision-making i s to be e f fec t i ve . In addit ion to the information required by hospital management for planning, evaluation and control purposes, there are mult iple and d i s jo inted requests from external agencies: the Federal Government requires a c t i v i t y information for interprov inc ia l and interhospita l - 10 -comparisons; the Provincial Government requires a c t i v i t y and cost data in order to evaluate budgets; Accreditat ion requires structure, process and some outcome information to evaluate the qua l i ty of care. A review of the sources and uses of the information co l lected in health care settings reveals a lack of linkage between e f f i c i ency and effect iveness. " C l i n i c a l and f inanc ia l data continue to operate in d i f fe rent spheres with the intersect ion of the two a matter of chance; Smyth's (1977) study of ambulatory care data revealed a lack of communication between the middle management and functional o f f i c e r l eve l s . Department heads voiced concerns about the lack of feedback from the i r superiors regarding t he i r monthly s t a t i s t i c a l reports. It was shown that the content, format and timeliness of the information reported was not conducive to managerial decision-making. U t i l i z a t i o n f igures in i so l a t i on from budget or qua l i ty of care data provides l i t t l e basis for judging departmental performance. The 1977 study also revealed that management and qua l i ty of care standards, re l a t i ve to the data co l lec ted, had not been developed. This i s consistent with the state of the art of health care measure-ment. Emphasis has t r ad i t i o na l l y been placed upon output measurements Connors, Edward J . , "Hospital Systems Aspects" in Operations Research in Health Care - A C r i t i c a l Analys is. Shuman, Spears and Young, John Hopkins Univers ity Press, Baltimore and London, 1975, P. 29 - 11 -such as ;patient days or v i s i t s and to some extent upon the structural and process evaluation of health care systems, rather than health outcomes because the tools for measuring patient status are inadequate-l y developed (Culyer, 1978). Donabedian (1966) has i den t i f i ed a number of de f in i t i ona l problems in health care measurement which i n h i b i t the development of standards. Is the output of the health care system, health care, i . e . service or health i t s e l f , i . e . improved health status? Is the patient (episode of i l l n e s s ) or the v i s i t to be the basis of evaluation? If output i s to be evaluated, the heterogeneity of patient mix requires the development of a weighting or re la t i ve value unit system. The type and amount of emergency resources required to treat a drug overdose are quite d i f ferent from that required to treat a sore throat. Controls that ex i s t are l im i ted to structures. The B.C. Ministry of Health, the Canadian Council on Hospital Accred i tat ion, the l e g i s l a -t ion and regulations of the B.C. Hospital Act, union contracts and professional associations control d i f fe rent inputs of the system. Process c r i t e r i a , in the form of qua l i ty assurance and medical audit are f a i r l y well developed with respect to inpatient care because the episode of i l l ne s s i s more eas i l y i d en t i f i a b l e . However, qua l i ty of - 12 -care a c t i v i t i e s remain within the realm of the physician. The a c t i v i t i e s of other members of the health care team on the process of care have yet to be integrated into the evaluation process. Studies on outputs and outcomes are r e l a t i v e l y few and inadequate. More research i s needed to i so la te the effects of thehhealth care system on health status. The development of Injury Severity Scores (Baker et a l , 1974) and other measures of patient status are viable and pos i t ive attempts to control for status sever i ty upon presentation to the Emergency Department. Such methodologies are necessary in order to more adequately evaluate the outcomes of care. While the d i f f i c u l t y of measuring health care in par t i cu la r and emergency care in general i s apparent, the current economic and p o l i t i c a l climate in B.C. supports the need for i den t i f i ab l e and measurable health outputs and outcomes. Warner (1981) traces.the .h i s tor ica l developments of health care financing in B.C. which have led up to the current thrust of the Ministry of Health away from long range program planning towards f i s c a l accountabi l i ty and cost containment. The dominance of Treasury Board and the replacement of health professionals with f i s c a l managers within the senior levels of the Min istry of Health makes i t even more urgent that an information system be in place. - 13 -D. THE STUDY This study i s threefold in that i t attempts to document ex i s t ing information, to i dent i f y current and future information needs and to recommend improvements to the ex i s t ing information system. 1. Objectives The objectives of the Study are: 1. To document ex i s t ing philosophies, studies and industry concerns with respect to the organization, del ivery and financing of emergency care in B r i t i s h Columbia. 2. To review the l i t e r a tu re and current B.C. a c t i v i t i e s as perta in-ing to emergency care within the Canadian health care context and information systems development in order to develop a workable c l a s s i f i c a t i o n with respect to the i den t i f i c a t i on and categoriza-t ion of Emergency Department information. 3. To i dent i f y the types, uses and users of data consistent with current and future internal and external reporting requirements consistent with the Joint Hospital Funding Study and Hospital Role Study recommendations. - 14 -4. To val idate the information requirements of the various hospital decision-makers - care g ivers, managers, planners and evaluators. 5. To recommend a method of c o l l e c t i o n , analysis and reporting of Emergency Department data. 2. Def in i t ion of Terms Emergency. Not a l l Emergency Departments in B r i t i s h Columbia are organized to provide emergency care only. Day Care Surgery and outpatient services are often included within the Emergency Depart-ment's scope of a c t i v i t y . However, for the purposes of th i s study, 5 booked day care surgery and scheduled ambulatory care services are excluded. Only those a c t i v i t i e s which relate to unscheduled patients presenting to the Emergency Department for treatment w i l l be considered to be within the framework of th i s documentary analysis. 3. Methodology In order to be useful to managers, the data co l lected in any information system should be developed from the dimensions of e f f i c i ency and effect iveness. In add i t ion, the results should also meet the operation-al needs of the B.C. Hospital Funding System in order to be meaningful and pragmatic for B.C. hospita ls . Therefore, a documentation and analysis of ex i s t ing research and operational information requirements "ambulatory care" - scheduled treatments of a non-acute or minor nature such as cast changes, removal of st i tches and medications. - 15 -w i l l be undertaken. Based upon a synthesis of the c l a s s i f i c a t i o n models in the l i t e r a t u r e , the users, uses and frequency of data requirements in s i x classes and levels of data from patient care to pol icy formulation w i l l be i d en t i -f i e d . These s ix information hierarchies are patient care (flow-through), departmental management, qua l i ty of care, s t rateg ic planning, research and development and pol icy formulation at the Ministry of Health l e v e l . The Nominal Group Technique w i l l be used on a representative group of decision-makers drawn from the Greater Vancouver Regional Hospital D i s t r i c t hospitals to ident i f y and p r i o r i ze the routine and special information requirements in l i g h t of dominant issues in emergency care and external constraints imposed by the Jo int Funding Study. The findings of the f i r s t panel of experts w i l l be further val idated by a second group of decision-makers. Analysis of the results w i l l be undertaken in l i gh t of professional power and control in order to recommend an information system that i s both pract ica l and bounded by p r i o r i t i e s . 4. L imitations and Constraints 1. The data elements i den t i f i ed have been selected to complement the Hospital Role Study and recommendations of the Joint Hospital - 16 -Funding Project. The foundation of both of these studies i s a uniform reporting system to f a c i l i t a t e strategic planning, budgeting and monitoring and contro l . While i t i s recognized that internal decision-makers w i l l require more than the core set of information i den t i f i ed in the Uniform Reporting System, integrat ion of the various users' needs i s e s sent ia l . 2. Needs va l idat ion interviews w i l l be l im i ted to the decis ion-makers of Emergency Departments in the Greater Vancouver Regional Hospital D i s t r i c t . 3. This study i s a documentary analysis only and w i l l end without implementation of the Information System recommended and without the development of standards. 5. Chapter Outlines Chapter II describes the evolution of emergency care within the Canadian health care context and reviews the Canadian and American l i t e r a t u r e with respect to the two dominant issues in Emergency Care - the growth in Emergency Department u t i l i z a t i o n over the past 20 years, i t s causes and consequences and the s t r i v i ng for categorization of capab i l i t i e s to ensure adequate standards for hospital emergency care. - 17 -Chapter I I I reviews the research and o p e r a t i o n a l t h r u s t s of information systems f o r ambulatory/emergency care and c l a s s i f i e s s i x l e v e l s of emergency department data requirements - p a t i e n t care, department management, q u a l i t y of care, s t r a t e g i c planning, research and develop-ment and p o l i c y f o r m u l a t i o n . Chapter IV describes the e v o l u t i o n of emergency care and i d e n t i f i e s the l e g i s l a t i v e , planning and p o l i c y t h r u s t s i n B r i t i s h Columbia. Chapter V develops a matrix of information needs based upon the dominant planning issues w i t h i n the operational requirements of the system - d i s a s t e r planning ( c a t e g o r i z a t i o n ) and "mopping-up" ( u t i l i z a -t i o n ) - and v a l i d a t e s the i n f o r m a t i o n needs by Nominal Group Technique with the various h o s p i t a l decision-makers - Emergency Room P h y s i c i a n , Head Nurse, D i r e c t o r of Nursing, Medical D i r e c t o r and A d m i n i s t r a t o r . A f u r t h e r v a l i d a t i o n i s assured by questionnaire to a second group of decision-makers. Chapter VI analyses the r e s u l t s of the survey i n l i g h t of the issue of p r o f e s s i o n a l power and c o n t r o l , presents the conclusions and recommenda-t i o n s of the study and proposes f u r t h e r i n v e s t i g a t i o n s . - 18 -CHAPTER SUMMARY This chapter sets the stage for the study. It begins with a discussion of the author 's previous involvements in areas peripheral to the study subject - the development of ambulatory care s t a t i s t i c s in an acute care f a c i l i t y , d i saster planning in the Greater Vancouver Regional Hospital D i s t r i c t , uniform emergency room documentation by the Emergency Nurses Group of B.C. and the Jo int Hospital Funding Project of the B.C. Health Association and the Ministry of Health. The se lect ion of the Emergency Department as a d iscrete study unit was a synthesis of these d i s t i n c t yet related a c t i v i t i e s into a topic which was both manageable, timely and pract ica l from an indiv idual hosp i ta l , regional and provincial perspective. The importance of accurate, timely and relevant information to the decision makers i s stressed. Measurement problems abound yet the a l locators and providers of care have recognized the necessity of ident i f y ing information needs and developing a uniform information system accessible to both part ies . The objectives of the study have been established to l i nk the theoret ical with the pragmatic. From a broad brush review of current issues and trends in the l i t e r a t u r e through a documentation of current concerns by pro-fes s iona l , government and management groups, the i n i t i a l i den t i f i c a t i on of needs i s streamlined. Val idat ion by hospital decision-makers assures that the data elements recommended meet the needs of the c l i e n t - the hosp i ta l . - 19 -CHAPTER II THE EMERGENCY CARE CONTEXT A. EMERGENCY CARE WITHIN THE CANADIAN HEALTH CARE CONTEXT Before the introduction of health insurance schemes, Hospital Emergency Departments were conceived as c r i s i s intervention centres whose mission was the treatment of trauma patients and those with acute i l l n e s s who could not afford to go to a doctor ' s o f f i c e . Several factors , however, were i n f l u en t i a l in expanding th i s or ig ina l role with the result that these units also assumed a primary care ro le. The predominant structure within the Canadian health care system i s the acute care hosp i ta l . Founded o r i g i n a l l y as voluntary or municipal i n s t i t u t i o n s , hospitals have undergone tremendous change in the past 40 years with the result that a highly complex and sophist icated organization has emerged from re la t i ve obscurity. With the control of infect ious diseases during the 1940's, the major causes of death were eradicated and problems of a v a i l a b i l i t y of and a c ce s s i b i l i t y to health services became evident. This new awareness led to a s h i f t in emphasis in Canadian health care away from health outcomes to health structures. Governments became f i n anc i a l l y involved in the provision of services to t he i r c i t i zens and ef for t s were directed toward ensuring a v a i l a b i l i t y of and f inanc ia l a c c e s s i b i l i t y to health care services. The development of health care services in Canada may be described as a process of " incrementalism". Po l i c ie s and programs were implemented piecemeal on the basis of what already existed rather than in accordance with any long range plan. While the Haegarty Report (1943), in i t s mandate to review health insurance in order to ass i s t the provinces in formulating compre-hensive health plans, supported universal compulsory national health insurance, i t s implementation was subjugated to more urgent p r i o r i t i e s of caring for returning veterans and ra i s ing the standards of d i r e c t l y provided provincial health services with spec i f i c reference to tuber-cu lo s i s , mental health, venereal disease, physical f i tness and financing of publ ic health research and professional t ra in ing grants. The t rans i t ion from a free enterprise system of medical and hospital care to one of subsidized entrepreneurialism or p o l i t i c a l economy occurred over a period of 20 years. The three benchmarks which influenced the provision of acute care services in th i s t rans i t i on period were the National Health Grants of 1948, under,which acute care hospitals were constructed; the Hospital Insurance and Diagnostic - 2 1 -Services Act (1957) required to pick up the operating costs of those hosp i ta l s ; and the Medical Care Act (1968) to pay medical care fees. These cost-sharing federal Acts were implemented in reverse order from the Haegarty recommendations in response to pressures exerted by interest groups, organizations and p o l i t i c i a n s . The provision of government funds for f a c i l i t i e s and services in th i s order led to the development and expansion of acute services, simply because funding was avai lable rather than from any demonstrable need for those services. The order of implementation coupled with the time lag of ten years between the Hospital Insurance and Diagnostic Services Act and the Medical Care Act resulted in strong provider and consumer rel iance upon the acute care hosp i ta l . As the Federal Government began to o f fe r grants in a i d , in most provinces, emergency care became an insurable benefit under the Hospital Insurance and Diagnostic Services Act (1957). In the intervening years between introducing hospital and medical care insurance (1968), patients tended to present themselves to the hospital where care was e s sent ia l l y free rather than to the physic ian ' s o f f i ce where out-of-pocket expenses were incurred. Unti l 1977, medical and hospital financing arrangements were on a 50-50 cost-sharing basis between the Provinces and the Federal Government. - 22 -Subject to the c r i t e r i a of p o r t a b i l i t y , universal coverage, compre-hensiveness of services provided and public administration of the insurance schemes, the Federal Government reimbursed provincial t reasur ies , in the aggregate for 50% of program costs. Under th i s open-ended financing system, there was an overpowering incentive for the Provinces to provide only those services which were cost-sharable, i . e . inpatient acute and physician care. The structures of the Canadian health care system are intertwined with financing arrangements. One reinforces the other. Changes in structure necessitate changes in f inancing. However, changes in structure could not be achieved unt i l the funding arrangements were replaced. Van Loon (1978) has synthesized Le C l a i r ' s (1975) view of the problems and need for change to be carr ied out by the Established Programs Financing Act as fol lows: " - the ten year delay in implementing medical care insurance a f te r hospital insurance was in place. - the large number of hospital beds in Canada; - technological change, improved services, unionization and i n f l a t i o n ; - the lack of cost-sharing for low cost a l ternat ives to hospital care and physician serv ices; - the rapid increase in the number of physicians pract ic ing in the system, pa r t i cu l a r l y because of the services each one uses in enriching his income; - a rapid increase in the use of out-of-hospital diagnostic services caused by the..rapid increase in the number of private laborator ies . " Van Loon, R.M., "From Shared Cost to Block Funding and Beyond: The P o l i t i c s of Health Insurance in Canada". Journal  of Health P o l i t i c s and Pol icy Law, Vol. 2, No. 4 Winter 1978, p. 460. There were pos i t ive incentives for the providers of health care - the physicians and the hospitals to admit patients to hospital and maintain them there unt i l recovery was complete. Volume -admissions and patient days - po s i t i ve l y affected the amount of revenue the hospital would receive. A l so, i t was more economical for physicians to v i s i t a series of patients in hospital rather than to use the overhead of the i r own o f f i ce s . Likewise, inpatient care was an insurable benefit to the pat ient, whereas for the i n te r -vening ten year period between the introduction of hospital insurance and the medical care insurance, physicians ' o f f i c e v i s i t s were an out-of-pocket expense for the patient. The 1960's saw a time of expansion of hospital services, technology came into the forefront and consumer expectations rose. By 1969, the f inanc ia l consequences of th i s process of "incrementalism" and open-ended funding arrangements were evident. The removal of any f i nanc ia l re spons ib i l i t y from the consumer, coupled with increasingly sophist icated technology and r i s i ng public expectations, resulted in uncontrollable provision of acute inpat ient care services by the provinces and uncontrolled u t i l i z a t i o n by consumers of a l l services. The post Medicare years saw a f l u r r y of federal and provincial cost studies demonstrating the f inanc ia l effects of open-ended cost-sharing and advocating a l ternat ive del ivery forms. The Task Force Report on Health Services (1970) recommended that more appropriate types and - 24 -levels of care be u t i l i z e d , and that t i gh te r f i s c a l and management controls be i n s t i t u t ed . The Task Force suggested several p o s s i b i l i t i e s for cutt ing costs: 1) change to block grant system; 2) de l i ver medical services through Community health Centres in order to re l ieve hospita ls; 3) use less highly trained manpower and 4) provide more outpatient care in hospita ls . The Castonguay Report (1971), the Mustard Report (1972) and the Foulkes Report (1973), a l l advocated structural changes to the system in an attempt to contain costs. In 1970, a c e i l i n g was imposed by the Federal Government on i t s cost-sharing of acute bed construction. Extended care, ambulatory and home care were recommended as viable a l ternat ives to inpatient care. However, the f a i l u r e to l eg i s l a te for cost-sharing of these services provided no incentive to the provinces to provide these services. And in 1977 there was a switch from the shared conditional grant system to a modified block funding system. This was motivated by a desire to l i m i t and make predictable federal expenditures, by desire on the part of the provinces to increase the f l e x i b i l i t y of t he i r a l locat ion of federal funds and by a mutual desire to l i m i t any growth of health care costs as proportion of the G.N.P. Concerns related d i r e c t l y to improv-ing medical care del ivery were i n s i gn i f i c an t . The e f fect of these successive changes was to influence the u t i l i z a t i o n of emergency departments of hospita ls . As funding changed, patterns of - 25 -use changed. These changing patterns are made c lear when one reviews the 1 i terature. However, i t was not only the funding of Canadian health services which influenced the use of emergency departments. There were large changes in Canadian society - the population grew from 11 m i l l i on at the beginning of the introduction of health insurance to 23% m i l l i on today. Many of the new Canadians had d i f fe rent t rad i t ions in the way in which they u t i l i z e d health services from the old established population - they sought out hospital care rather than going to general p ract i t ioners . And in the la te s i x t i e s young people l e f t home to travel across the country. They did not want to go to family doctors (even i f they had time to bui ld up a re lat ionship) but sought out impersonal care in non-judgemental emergency departments. Att itudes to general pract i t ioners changed, and a modif ication of the types of resources avai lable in Emergency Departments became evident. As w e l l , shortening of o f f i c e hours and unwillingness to do home v i s i t s changed the patterns of practice of physicians. They began to meet t he i r patients in or refer them to f u l l y staffed emergency departments out of o f f i c e hours. And th i s had f inanc ia l advantages (Crichton and Anderson 1973). There were, and remain today, pos i t ive f i nanc ia l i n -centives on the physician to use the manpower, equipment and supplies of the Emergency Department rather than his own o f f i ce resources. The Medical Services Plan fee schedule is ident ica l in each care sett ing but there is no overhead cost to the physician who uses Emergency Department resources. - 26— Shortening of o f f i c e hours and the decline of home v i s i t s by physicians a f te r the implementation of the Medical Care Act resulted in a decrease of patient a c ce s s i b i l i t y to o f f i ce ambulatory services. Twenty-four hour a c c e s s i b i l i t y was assured by the hospital emergency departments. B. CANADIAN STUDIES ON UTILIZATION AND ROLE OF EMERGENCY ROOMS Studies both within the Canadian and the American health care systems have i den t i f i ed s imi la r trends in the u t i l i z a t i o n of Emergency Depart-ments although the reasons for such trends vary because of d i f f e r i ng ideological approaches and d i f fe rent insurance systems. These studies have been concerned with socio-economic and demographic character i s t i c s of the users, d i s t r i bu t i on of emergent, urgent and non-urgent cases, re lat ionships to the existence and the a v a i l a b i l i t y of the family physician, the re lat ionship to health insurance and the effects of consumer preferences. However, concerns with respect to emergency room u t i l i z a t i o n f a l l into two camps, depending om which role or roles the wr i te r believes i s appropriate or inappropriate for Emergency Departments. 'Bain and Johnson (1971) have i den t i f i ed two roles - the treatment of acute trauma problems and medical emergencies and the treatment of anyone who presents himself to the Emergency Department. Those who bel ieve that Emergency Departments should be devoted to trauma and medical - 2 7 -emergencies have devoted much research to the development of outcome measurements - injury sever i ty scores - and advocate c l a s s i f i c a t i o n of emergency room capabi l i t ies. (Ghent 1976, Landau 1975, Strauch 1979). Those who bel ieve that Emergency Departments shoul'd t reat anyone who presents himself to the Emergency Department are more concerned with i den t i f i c a t i o n of use and abuse, categorization of patients into emergent, urgent and non-urgent, socio-economic and demographic determinants of inappropriate use and the development of a l ternat ive ambulatory care systems to reroute patients to appropriate sett ings. Concerns with respect to the use of the Emergency Department for routine care are based on qual i ty and cost considerations. Schroeder (1979) demonstrated that the episodic nature and lack of systematic follow-up of routine problems seen in Emergency Room settings did not resu l t in good qua l i ty of care and that the Emergency Department care for non-urgent conditions was not cost j u s t i f i e d . Threatened with the impending 1968 Federal Medical Care Act which would adversely a f fect the teaching v i a b i l i t y of the Outpatient Department C l i n i c for indigent pat ients, Robinson and Klonoff (1967) assessed the paediatr ic and adolescent workload of the Emergency Department at the Vancouver General Hospital to determine i t s s u i t a b i l i t y as a subst itute teaching unit . Based upon the low per-centage of admissions (15%) and the high re fer ra l rate to family physicians (75%) for follow-up care, the study concluded that: - 28; -"While prompt medical attent ion was usually indicated, the majority of problems were not urgent and the Emergency Department was becoming a subst itute for the o f f i c e of the family phys ic ian." The conclusion i s not surpr is ing in l i g h t of the lack of medical insurance at the time and the coverage of Emergency Department treatment under the Hospital Insurance and Diagnostic Services Act of 1957. There were pos i t ive f inanc ia l incentives for the patient to seek free medical care in the Emergency Department, rather than pay for care in a physic ian ' s o f f i c e . The study f a i l e d to consider th i s f ac t , categorize the v i s i t s as to severity of i l l n e s s or determine the number of patients who had family physicians. Its main objective appears to have been to leg i t imize the role of the Emergency Department ;as a teaching a l ternat ive to the Outpatient Department. Bain and Johnson (1971) conducted a study of the u t i l i z a t i o n of Toronto's North York General Hospital Emergency Department two years a f te r the introduction of Medicare in Ontario to determine the reasons for " inappropriate" u t i l i z a t i o n with a view to remedying the s i tuat ion . Of the 3,622 records sampled for review, the study i den t i f i ed a d i s t r i bu t i on among Emergent, Urgent and Non-urgent categories of 7.5%, 50% and 42.4%. The study attempted to ident i f y the re lat ionsh ip between Emergency Room u t i l i z a t i o n and the existence Robinson, G.C. and KTonoff, H., "Hospital Emergency Services for Children and Adolescents: A One Year Review at the Vancouver General", CMAJ, Vol. 96, May 1967, p. 1304. of and contact with the family physician. The results of the analysis were poorly presented which jeopardizes the c r e d i b i l i t y of the conclusions. However, the study advised that the public education on the appropriate use of the Emergency Room is one intervention that may reduce Emergency Room u t i l i z a t i o n by non-urgent groups. Stewart (1971), in a study of patterns of medical care in the Emergency Department of the V i c to r i a General Hospita l , Ha l i fax, Nova Scot ia , studied the character i s t i c s of patients using the Emergency Department in two six-month periods, one pr io r to the implementation of medicare and one post-medicine. Stewart found that there were no s t a t i s t i c a l l y s i gn i f i can t differences in diagnosis, re fe r ra l patterns, hospital admission practices or ambulance usage and concluded that long-established patterns of seeking health care .were unaltered by removing any economic barr iers to seeking private physician services. Baltzan (1972) analysed the increase in Emergency Room v i s i t s to Saskatoon Hospitals from 1965 - 1970, years in which physician care was an insurable benefit under the provincial health insurance scheme (1962-1968) and under the federal/provincial cost-sharing arrange-ments (1968 onwards). The data were analysed in re la t ion to pop-ulat ion trends and physician u t i l i z a t i o n . User fees, introduced into Saskatchewan in 1968 "were without apparent e f fect on the number of - 30 -Emergency Room services but they were correlated with a decline 3 in other primary care serv ices " . Baltzan suggested that the increase in Emergency Room v i s i t s represented a transfer from home v i s i t s or physician o f f i ce care to the Emergency Room rather than "new" medical services. Baltzan did not categorize the sever ity of i l l n e s s but rather time since the duration of onset. In 186 or 17.6% of the cases, the i l l ne s s had been present for less than one hour; in 898 cases or 85.4%, less than two days. Baltzan concluded that the acute and unexpected i l l n e s s coupled with the real or perceived unava i l ab i l i t y of physician appointments in the immediate future determined, to a large extent, Emergency Room u t i l i z a t i o n . Vayda et al (1973) in an e f fo r t to add to the Canadian data base on the u t i l i z a t i o n of Emergency Departments and s p e c i f i c a l l y to ident i f y the current role of the Emergency Room at St. Joseph's Hospital in Hamilton, Ontario, attempted to c l a s s i f y the severity of emergency room v i s i t s and re late severity to socio-economic and demographic patterns and to the reasons for se lect ing the Emergency Department as the locat ion of care. Trauma accounted for 50% of the 2608 v i s i t s ; 5.6% were emergent, 60.7% urgent and the remaining 33.7% non-urgent. Vayda concluded that St. Joseph's Hospital served as a trauma centre and as a physician surrogate outside of normal o f f i ce hours (67% of patients v i s i t s were made outside of regular Baltzan, M.A., "The New Role of the Hospital Emergency Department," CMAJ, Vol. 106, 1972, p. 252. practice hours). Eleven percent of patients presenting had no medical insurance. The f indings of th i s study were not unlike the conclusions of Torrens and Yedvab (1970) in t he i r study of New York City Emergency Room U t i l i z a t i o n . Chaiton (1975) in a review a r t i c l e of the determinants of u t i l i z a -t ion postulated that a v a i l a b i l i t y and a c ce s s i b i l i t y to services generated i t s own demand. C i t ing studies by Spitzer et al (1971), Chipman (1973) and Beck (1973), no change in the u t i l i z a t i o n patterns of patients to emergency rooms occurred post-Medicare. The Beck Study, however, showed a 5% increase in low income users a f te r Medicare. A study by the Working Group on Special Care Units in Hospitals of the Federal Provincia l Subcommittee on Quality of Care and Research (1975) advocated rat ional planning of emergency services to define ro les , develop standards and educational resources to better meet emergency health care needs. In a broad-scope but rather sketchy and inconclusive study of Canadian emergency resources, the report advocates a higher p r o f i l e role for emergency medicine within the Canadian health care system. Lees et al (1976) compared the management of two patient populations - those treated in emergency departments and those treated in - 32 -physicians ' o f f i c e s - who had s im i la r non-traumatic sign/symptom complexes. They contend that l i t t l e attention has been devoted to the i den t i f i c a t i on of the qua l i ty of care patients received in both sett ings. Acuity and duration of i l l ne s s influence patient preference for care set t ing . However, differences in invest igat ion, drugs, consultat ion, follow-up and length of care to s im i la r populations were observed. Patient outcomes other than status a f te r one month of care (discharged, hosp i ta l i zed, died, referred, etc.) were not tackled. The only va l i d conclusion drawn from the study was that var iat ions in length of treatment tended to indicate that family physicians encouraged unnecessarily long periods of patient follow-up. Lees advocated further invest igat ion of the qua l i ta t i ve differences between s imi la r complaints in the two settings and the overal l qua l i ty of care provided in accordance with these differences. A study of 10,734 Emergency Department v i s i t s by the Greater Vancouver Regional Hospital D i s t r i c t (1977) indicated that 1,431 (14%) of patients a r r i v ing at Greater Vancouver Regional Hospital D i s t r i c t hospital emergency departments required treatment and subsequent admissions, 292 (3%) were backdoor admissions through the emergency, 5,372 (50%) required treatment in the emergency room but were capable of discharge and 3,639 (33%) of the cases could have been treated in an ambulatory care set t ing . H i s to r i ca l data suggested that the continuing increase in the u t i l i z a t i o n of emergency - 33 -departments appears to be by the casual drop-ins rather than true emergency or urgent cases and att r ibuted th i s increase to changing medical practice and public expectations. E l l i o t t (1978) compared the socio-economic and demographic factors of emergency department users at two Hamilton emergency departments with a random sample of residents (val idated with census data) from the same geographical area. Males, protestants, native-born Canadians and recent residents were over-represented among users at both hospita ls . E l l i o t t explained away these results as a consequence of the greater incidence of trauma among males, f a m i l i a r i t y of Canadians with the system and the probab i l i ty of new residents to the.area not having yet secured the services of a family physician. Instead, he concentrated his analysis on the time of obtaining services - evening, night and weekend hours - as a j u s t i f i c a t i o n of group pract ice within the hosp i ta l . C. AMERICAN POLICY DEVELOPMENTS American studies are reviewed below in order to give a better cover-age of issues. Torrens and Yedvab (1970) contended that studies on Emergency Depart-ment u t i l i z a t i o n patterns have produced con f l i c t i n g and contradictory - 34 -results which prevent e f fec t i ve planning and organizational i n t e r -ventions e i ther to a l l e v i a te inappropriate use or to cope with increasing demand, because of t he i r f a i l u r e to recognize the mult iple roles of an Emergency Department. Torrens suggested that no s ingle model was adequate to describe, predict or explain emergency care because U.S. Emergency Departments were f u l f i l l i n g thcee general roles: 1. Trauma Centre, whereby the emergency room services a complete cross section of the socio-economic spectrum and i s co-ordinated with other emergency serv ices; 2. Physician and ambulatory care substitute outside of normal hours of operation; 3. The family physician for the poor and transient populations who see the emergency room as the log ica l point of entry into the system and view the emergency room as meeting a l l health care needs. Torrens and Yedvab concluded that the role of the hospital Emergency Room i s shaped by the population i t services and by the wi l l ingness of hospital managers to organize to meet i t s role or i dent i f y a l ternat ive settings to meet the demands placed upon i t . Ullman et al (1975) supported the roles i den t i f i ed by Torrens and Yedvab (1970), namely that Emergency Departments are "physician subst i tutes" and "family physicians to the urban poor". By i n t r o -ducing the pat ients ' frequency of v i s i t into the analysis of - 35 -Emergency Room u t i l i z a t i o n , these authors found that the p r o f i l e of u t i l i z a t i o n was dominated by a large group of infrequent users who u t i l i z e d the Emergency Room as a physician substitute and that 21.3% of the to ta l v i s i t s were by high frequency users ( i . e . three v i s i t s or more). However, a disproportionately large number of these "high frequency" users were black, low income and from inner -c i t y areas. Davidson (1978) in support of arguments put forth nearly eight years e a r l i e r , contended that previous studies on u t i l i z a t i o n f a i l e d to address the real question; that i s "why people choose the Emergency Department instead of another source of care". Most studies of Emergency Department u t i l i z a t i o n have focused on user patterns to one or more Emergency Departments, ignored the non-users and provided i n s u f f i c i en t deta i l about the community in which the Department operated and instead have concentrated on socio-economic and demo-graphic variables and i l l ne s s patterns. Davidson proposed that research should be directed at patterns of use and reasons for use in communities with d i f ferent character i s t ic s and hospitals with d i f fe rent c apab i l i t i e s . Perkoff and Anderson (1970) investigated the re lat ionship between demographic cha rac te r i s t i c s , pat ient ' s chief complaint and ultimate s i t e of del ivery of care in an attempt to i so late the determinants - 36 -of u t i l i z a t i o n . In a r e l a t i v e l y unimpressive piece of research the authors i den t i f i ed two roles for the Emergency Department - surrogate physician for out of hours care and primary health care for the negro population. Satin and Duhl (1972), two psych ia t r i s t s , compared the c l a s s i f i c a t i o n of the pat ient ' s presenting complaint into.physical only, physical and psychosocial and psychosocial as determined by the pat ient, the physician in the emergency room and the research psych iat r i s t i n te r -viewer. Not surpr i s ing ly , the biases of the interviewers were evident as 60.9% of those presenting were c l a s s i f i e d as physical and psychosocial compared with 4.9% (patient) and 6.7% (physician). Admittedly, the psychosocial problems of the emergency room are a neglected p r i o r i t y , however the biased results of th i s study which purports to leg i t im ize the ro le of the psych iat r i s t to evaluate and treat Emergency Room patients i s unacceptable. No del ineation of cases among sever ity categories was attempted. The thesis of the authors rests on the " s t r i k i n g frequency" (as determined by psych iat r i s t s ) of the Emergency Department's i n a b i l i t y to deal with psych iatr ic and socia l problems. Kelman and Lane (1976) compared two groups of emergency room patients - those with private physicians (80%) and those without private physicians (20%) and i den t i f i ed that those without tended to be more recent residents in the area, household heads were younger, family s izes smaller and the family member seeking care at the Emergency Room was more t yp i c a l l y an adult rather than a ch i l d . Strategies for reducing inappropriate u t i l i z a t i o n by the group with physicians were f e l t to be unwarranted as the problem lay in patterns of medical care - in pa r t i cu la r the incomplete access to services for ind iv idua l s . Shaw (1977) placed the onus for appropriate u t i l i z a t i o n of Emergency Room f a c i l i t i e s on the hosp i ta l . Shaw concluded that unt i l the indiv idual hospital "defines i t s role in s pec i f i c terms, i t cannot accuse e i ther the patients or the doctors of abusing i t . " ^ This thesis i s consistent with the concerns of Torrens and Yedvab (1970) and Vayda (1973) who proposed that c lear role de f i n i t i on and the i den t i f i c a t i on of a l ternat ive services to meet unmet needs were requ i s i te to the del ivery of "appropriate" medical care within the Emergency Department. Scherzer et al (1980) c l a s s i f i e d the fami l ies of ch i ldren using an inner c i t y Boston Emergency Department with respect to income, race and the existence of a stable physician and hospital re lat ionship to determine the impact on Medicaid and the a v a i l a b i l i t y of neighbour-hood health centres on mult ip le u t i l i z a t i o n patterns i den t i f i ed in a Shaw, Charles, "Emergency Department Use and Abuse," Dimensions  in Health Service, Dec. 1977, P. 10. - 38 -1964 study. The study demonstrated that the increased a v a i l a b i l i t y and a c ce s s i b i l i t y to care through increased community resources and insurance had no af fect on the u t i l i z a t i o n of mult iple providers and that the level of sa t i s fac t ion with the f a c i l i t y and the perceived a b i l i t y of the f a c i l i t y to deal with par t i cu la r i l l nes ses influenced choice of set t ing . D. CATEGORIZATION OF EMERGENCY CAPABILITIES The issue of categorizat ion or c l a s s i f i c a t i o n of hospital and emergency service capab i l i t i e s has been fraught with ph i losophica l , conceptual and operational d i f f i c u l t i e s . The concept of emergency department categorization has arisen from a desire to match demand with supply in the most e f fec t i ve and e f f i c i e n t manner. Patients present to the Emergency Department with varying magnitudes of i n ju r ie s and not a l l Emergency Departments are staffed and equipped to provide adequate i n i t i a l or de f i n i t i v e care. The basic purpose of categorization i s to " i den t i f y the readiness and capab i l i t i e s of the hospital and i t s ent i re s t a f f to receive and t reat adequately and expedit ious ly, emergency pat ients . " There are many c l a s s i f i c a t i on s systems in the l i t e r a t u r e - the American Medical Association (1971 i den t i f i ed four c l a s s i f i c a t i on s : comprehensive, Gibson, Geoffrey, "How Far Have We Come With Categorization?", Hospitals, JAHA, Vol. 51, May 1, 1977, p. 97. - 39 -major, general and basic; the American College of Surgeons (1971) i den t i f i ed three categories: optimal, intermediate and minimal; the Greater Vancouver Regional Hospital D i s t r i c t (1969) i den t i f i ed three categories: l im i t ed , standard and major; Ghent (1976) described but did not name f i ve classes; the Federal Provincial Subcommittee on Quality of Care and Research (1975) described but also did not name four classes of Emergency Room Departments. A l l , however, have one common t r a i t - they concentrate on the structures of the organization and specify somewhat s im i la r quantit ies of inputs that are necessary to meet the standards developed in each class. The major conceptual problem with these c l a s s i f i c a t i o n systems i s t he i r f a i l u r e to address the i den t i f i c a t i on of patient/community needs for Emergency Department service. Gibson (1977) f e l t that severe planning conceptual and methodological def ic ienc ies have prevented any pos i t ive returns on categor izat ion. Threats to professionalism, consumer preference and occupancy rates in community hospitals prevent implementation. P o l i t i c a l inf luences, evident in a l l health care planning processes are not over-ridden by r a t i o n a l i t y . Gibson believed that the usefulness of categorization i s l im i ted to describing resources not improving the d i s t r ibu t ion of these resources nor improving outcomes. - 40 -In a second t reat i se on categor izat ion, Gibson (1978) l i s t e d the l im i ta t ions of ex i s t ing c l a s s i f i c a t i o n methodologies as fo l lows: 1. It describes only the existence of resources not t he i r use, 2. It lacks normative standards against which a community can assess local categorization data, 3. It provides no ins ights into whether and what changes are necessary, 4. It underemphasizes patients and the match between supply and demand, 5. It deals only with c r i t i c a l pat ients, 6. It underemphasizes the primary care content of Emergency Room use and the association between the Emergency Medical System and the wider ambulatory care system. 7. It does not sens i t i ze the community, health planners, admini-s t rat ion and medical s t a f f to the necessity of assessing and improving Emergency Medical Systems within the context of interventions outside the Emergency Medical System. 8. It does not provide a data base for strategies tOgChange e i t h e r t h e structure of service or u t i l i z a t i o n patterns. Bui ld ing on ex i s t ing categorization methodologies, Gibson proposed an alternate methodology to assess the appropriateness of Emergency Department u t i l i z a t i o n . Measures of appropriateness were i den t i f i ed and standards set. For example, a l l ambulance and c r i t i c a l care patients should be taken to comprehensive and major hospita ls . Comparison of actual to standard provides information for estimating the need and d i rect ion of change and in creating a consensus for change. Gibson, G., "Categorization of Hospital Emergency Capab i l i t i e s : Some Empirical Methods to Evaluate Appropriateness of Emergency Department U t i l i z a t i o n , " J . Trauma Vol.18, No. 2, Feb. 18, 1978, P. 100. - 41- -Other measures of appropriateness included system over-response or under-response where patient needs are e i ther not met or met with resource capab i l i t i e s in excess of care requirements. Actual u t i l i z a t i o n patterns provide data for judgement as to whether cate-gor izat ion is too high, too low or appropriate. Gibson's proposal i s based on appropriateness of ex i s t ing resources to meet current demands and may in fact be a better evaluation method of appropriate c l a s s i f i c a t i o n and u t i l i z a t i o n . Landau (1975) suggested that knowledge of epidemiology is necessary to properly locate Emergency Department resources and that ve r t i ca l rather than horizontal categorization i s necessary to segment capab i l i t i e s into several diagnostic categories such as trauma, coronary, high r isk neonatal, alcohol and drug abuse. A concept of ve r t i ca l categorization more c lea r l y i den t i f i e s the types of cases requir ing immediate care and makes provision for the con f l i c t i n g requirements of high cost services, versus the a c c e s s i b i l i t y and qual i ty of care that smal l , high r i sk patient populations demand. Strauch (1979) apparently independently of Landau c l a s s i f i e d Connecticut hospitals in a care capab i l i t y matrix - three categories on seven emergency medical problems - mult iple system in ju ry , cardiac emergency, c r i t i c a l burn, major Central Nervous System, acute tox i ca t i on , psychiatr ic emergency and paediatr ic emergency. - 42 -Cross (1979) was another proponent of ver t ica l categorization because of i t s f l e x i b i l i t y . It may be most appropriate to ensure dispersion of coronary care capab i l i t i e s among a l l hospitals whereas burn or spinal cord Emergency Room capab i l i t i e s are best centra l i zed with in those hospitals with inpatient units. Categorization of the capab i l i t i e s of Emergency Departments i s desirable for two reasons - f i r s t l y to ensure minimum standards are ava i lable to meet the care requirements of emergency pat ients, pa r t i cu l a r l y trauma patients and secondly as a basis for regional i z a -t ion of services and the development of emergency ro les. One of the c r i t i c i sms of the B.C. Hospital Role Study ( 1979) was i t s f a i l u r e to ident i f y emergency services as a discrete care function. The Provincial C l a s s i f i c a t i on Study, i n i t i a t e d in 1979 and the 1980 Greater Vancouver Regional Hospital D i s t r i c t Study have, however, both attempted somewhat cautiously to address standards and roles of Emergency Departments. However, the att i tudes of the public and the i n s t i tu t i ons may possibly prevent any implementation. Detmer (1977) using the Injury Severity Score, compared the treatments to the outcomes of trauma cases in Wisconsin in three categories of c l a s s i f i e d hospitals (area, general and community service) and one category of unc lass i f ied where minimum requirements for c l a s s i f i c a t i o n as a community service were not met. While good qua l i ty care was - 43 -supplied at a l l hosp ita l s , the unc lass i f ied hospitals had a higher percentage of unacceptable care (55% of cases). While the conclusions of the l i t e r a t u r e seem to indicate a case against categorization as i t current ly ex ists as being too unrefined as a planning t o o l , i t nevertheless has potential as a mechanism to upgrade current f a c i l i t i e s with respect to s t ructura l inputs. More research such as that done by Detmer (1977) i s necessary to determine effects of categorization on outcome. E. EVALUATION OF QUALITY OF EMERGENCY CARE The c l a s s i ca l theoret ica l model for the assessment of qua l i ty of care i s Donabedian's "structure-process-outcome framework (1966)." Most of the qua l i ty of care studies during the past ten years have used this> perspective e i ther alone or in combination. Although Donabedian's model does not answer spec i f i c questions about the health of the population served by the system, i t does assert that i f an appropriate structure and an appropriate process are developed and certain outcomes are observed, those outcomes w i l l a f fec t pos i t i ve l y the health of the population (Freeborn and Greenlick, 1972). The underlying assumptions of the model are that good care i s more l i k e l y to be provided when the settings are favorable, that there are acceptable standards of what constitutes goodness and that good care makes a difference in terms of health outcomes. - u -Baker et al (1974) developed the Injury Severity Score to quantify the overal l sever ity of injury in persons who sustained in ju r ie s in more than one area of the body. Based on the Abbreviated Injured Score, the research showed that ISS values were pos i t i ve l y correlated with morbidity and mortal i ty rates and were useful for t r i age, for comparison of mortal i ty experience of varied groups of trauma patients and for describing the trauma case mix of f a c i l i t i e s . Semmlow and Cone (1976) applied Baker's Injury Severity Score to I l l i n o i s Trauma Registry data to val idate the re lat ionship between expected mortal i ty and the Injury Severity Score. Semmlow also i den t i f i ed the re lat ionship of ISS to length of stay and incidence of surgery. Cole et al (1976) reported on the results of a retrospective process audit of the seven (7) most common chief complaints presenting to a Phi ladelphia Emergency Department using a combination of e x p l i c i t and i m p l i c i t process c r i t e r i a . Recognizing the l imi tat ions of th i s method in actual ly r e f l ec t i ng the qua l i ty of care rendered to Emergency Department pat ients, the study of 389 cases nevertheless did ident i f y def ic ienc ies and prospectively f a c i l i t a t e d improvements in recording of care. Many of the deviations from the e x p l i c i t standards established were at t r ibuted to inadequate documentation of history and physical examinations. In addit ion, the treatment prescribed was not - 4 5 -' j u s t i f i e d ' on the b a s i s o f the information a v a i l a b l e to the reviewers. Anderson e t al (1977) i n an attempt to q u a n t i f y r e l a t i o n s h i p s between q u a l i t y o f care and p a t i e n t outcome, developed a somewhat elaborate and confusing research methodology which i n t e g r a t e d process a u d i t , accuracy, l e g i b i l i t y and adequacy of p a t i e n t documentation with Baker's (1974) Injury S e v e r i t y Score. This was then r e l a t e d to p a t i e n t ' s outcome as i d e n t i f i e d through follow-up appointments and readmissions f o r the same i l l n e s s / i n j u r y . Anderson f e l l short of v a l i d a t i n g her methodology but contended t h a t any e v a l u a t i o n of emergency care must be i n i t i a t e d i n the Emergency Room and be l i n k e d to p r e - h o s p i t a l and/or i n p a t i e n t care. K r i s c h e r (1976, 1979) reviewed s i x s e v e r i t y i n d i c e s f o r t h e i r mathe-matical v a l i d i t y and noted d e f i c i e n c i e s i n each. However, K r i s c h e r noted that i n d i c e s are becoming more r e f i n e d to incorporate the determinants of outcomes of care. Roy et a l (1979) used paramedicrobservers to record the treatment process, sequence, time taken and type of personnel i n v o l v e d i n emergency care as an adjunct to normal peer review procedures. Other than to i d e n t i f y the inadequacies of the c l i n i c a l record as a documentation t o o l , the research conclusions were not s u b s t a n t i a l . - 4 6 -Cayten and Evans (1979) in a review a r t i c l e i den t i f i ed the weak-nesses of ex i s t ing methodologies and proposed two general def ic ienc ies of Injury Severity Scores - the lack of va l idat ion of ex i s t ing scores by other than relat ionships to mortal i ty and the improvements necessary in the qua l i t y of the data. They .contend that outcomes are not only dependent upon the qual i ty of care rendered, but also upon the severity of i l l ne s s and injury of patients presenting for emergency care and that in order to evaluate the qual i ty of emergency care, one must control for sever i ty. Although methods are imperfect and often more appropriate to selected types of i l l ne s s or in ju ry , nonetheless a s ta r t has been made. Despite the shortcomings of the methods in existence, i t i s apparent that cont ro l l i ng for the sever i ty of i l l ne s s or injury upon admission is essential to the evaluation of outcomes of emergency care. It i s perhaps eas ier to ident i f y trauma indices than chronic disease ratings where d i s a b i l i t y indices are more subjecti ve. F. CONCLUSION As stated in the introduction of th i s review chapter, there appear to be two major thrusts in the Emergency Department l i t e r a tu re -those studies concerned with standards of Emergency Care - c l a s s i f i c a t i o n and evaluation methods for trauma cases and those devoted to ident i f y ing the determinants of inappropriate u t i l i z a t i o n . Conf l i c t ing emergency roles appears to be at the basis of the dilemma. On the one hand, t r ad i t i ona l concepts of emergency care ident i f y trauma and acute medical conditions as appropriate to the se t t ing ; on the other hand, those presenting at emergency rooms do not respect th i s role designation. In B r i t i s h Columbia, some hospita l s , in an attempt to reduce "inapprop-r i a te u t i l i z a t i o n " have imposed user fees of $10.00 or even $20.00 for non-urgent use. Cox (1979) indicates that there are serious problems with the co l l e c t i on of these addit ional l ev ie s . Less than 50% are co l lected within 30 days of treatment. However, Cox notes that the public continues to demand ambulatory care at Emergency Departments and sees no reason to pay extra. Looney (1978) contends that Emergency Room u t i l i z a t i o n patterns are a subset of soc ieta l trends in that consumers are accustomed to - 48 -convenience even for non-emergency care and have learned that the Emergency Departments have already arisen to meet consumers' demands. Lack of cont inuity and the inappropriate demands placed on highly s k i l l e d manpower and technology are c i ted as a major deterrant to the acceptance of the role of an Emergency Department as providing other than acute and trauma treatment intervent ion. Cost con-s t ra int s within the Canadian Health Care System w i l l probably con-tinue to impede acceptance of the philosophy that Emergency Departments be a l l things to a l l people. Alternat ives to improve the e f f i c i ency and effectiveness of Emergency Room Departments continue to be sought. - 49 -CHAPTER SUMMARY As stated in Chapter I, the development of any useful information system should begin with an i den t i f i c a t i on of the major issues in the f i e l d . Both the Canadian and the American l i t e r a t u r e have i den t i f i ed the thrusts towards categorization and u t i l i z a t i o n . In Canada, the growth in Emergency Department u t i l i z a t i o n was a d i rect consequence of health care funding arrangements, societal trends and physician patterns of pract ice. Expectations that Emergency Department u t i l i z a t i o n would s t a b i l i z e or decrease a f te r the introduction of Medicare were not met. Early Canadian studies were devoted to analyzing the determinants of u t i l i z a t i o n in an attempt to explain behavior and investigate controls against " inappropriate" u t i l i z a t i o n . Quality and cost considerations were paramount in the early 1970's at both the provincial and federal levels as evidenced by the numerous studies on health care del ivery. Fai lure to stem the t ide of emergency department use in both Canada and the United States has led to the emergence of a second concern -the a b i l i t y of ex i s t ing resources in emergency departments to meet the needs of i t s users. Standards were developed on the inputs of the system - the physical plant, the manpower and the equipment. - 50 -The evaluation of emergency care suffers from the same conceptual and methodological problems as inpat ient care. However, because of the traumatic nature of many of the in ju r ie s which are treated in the emergency department, attempts to control for severity on admission have been evident in the U.S. Chapter II has explored the major i ssues. in the f i e l d of emergency department health care. In Chapter I I I, a review of the research and operational thrusts of information systems in ambulatory and emergency care w i l l be undertaken in order to ident i f y the state of the art of information systems and to provide a foundation for the recommendations. - 51 -CHAPTER III  INFORMATION SYSTEMS A. AMBULATORY MEDICAL CARE DATA The most comprehensive treatment of ambulatory care information systems has been reported in the 1972 U.S. Symposium on Ambulatory Medical Care Data. Recognizing the neglect of current systems to ident i f y the needs for information of ambulatory providers, a group of experts was assembled to reach a consensus of a core set of data appropriate for ambulatory care. The U.S. Conference on Ambulatory Medical Care Data (Murnaghan, 1973), issued a series of recommendations as to what types of information ought to be co l lected i n Ambulatory Care Systems. The intent was to provide data which would be useful for the potential users such as hospital administrators, planning groups, l e g i s l a t i v e bodies, and t h i r d party payment agencies. The group recognized that assessment of qua l i ty of care on an indiv idual basis could not be made, however, i t was hoped that the aggregate data would provide some ind icat ion of the care rendered. Because of the lack of a national insurance scheme, ex i s t ing information systems were mult iple and varied, which prevented regional comparison or national aggregation of the: data. The prime concern of the Conference was that comparable data be provided on a national basis. - 52 -The a p p l i c a b i l i t y of th i s core data set to the Canadian Health Care System is questionable because of d i f f e r i ng philosophies and d i f fe rent funding mechanisms. The weighting of the Panel of Experts with researchers and academics would also lead one to question i t s appropriateness to hospital decision-makers. An "encounter" form with a set of 15 items was proposed as a viable data base that would be appl icable to a l l ambulatory care sett ings. Medical, f i n a n c i a l , administrative and demographic data would eas i l y and rout inely be generated as a by-product of the patient-provider contact and useful for patient care, planning, management, evaluation and research purposes. It was recommended that the fol lowing information be co l l ec ted : a) Registration/demographic data: - Patient I den t i f i ca t i on , Name and Unique Patient Identi f i e r - Sex - B i r th Date - Residence ( including z ip code) - Marital Status - Race/ethnic p r o f i l e b) Encounter data: - F a c i l i t y Ident i f i cat ion - Provider Ident i f i ca t ion - Person Ident i f i ca t ion - 53 -- Diagnosis and/or problems - Services and procedures - Medications prescribed - Disposition - Source of Payment* - Cost * 1 The main drawback of th i s otherwise excel lent proposal i s the physician or ientat ion of the encounter. The evaluative focus i s of questionable value as i t appears to be upon the appropriateness of the diagnostic and treatment interventions prescribed by the physician rather than upon the process or outcome of care. In addit ion, diagnostic and therapeutic services provided by A l l i e d Health professionals were not considered "encounters", and were not evaluated, e i ther as a unique encounter or as contr ibuting to the care prescribed by the physician. The l im i t a t i on and drawbacks of the data set were recognized. However, the p r i o r i t y of the recommendations was deemed to be the provision of a c t i v i t y information rather than evaluation of systems performance per se and in th i s respect, the report i s quite comprehensive. Structure, process and outcome information were considered a function of special studies rather than of routine data co l lec t ion mechanisms. The Conference papers which outl ined more spec i f i c concerns are discussed below. * Not included but deemed necessary. 1 Murnaghan, Jane H., "Review of Conference Proceedings", (Report of the Conference on Ambulatory Medical Care Records), Medical Care Supplement Vol. I I, No. 2, March-Apr i l 1973, p. 10-11. - 54 -Freeborn and Greenlick (1973) developed an evaluative framework which flows from the dimensions of e f f i c i ency and effect iveness. Donabedian's structure-process-outcome framework i s l abe l led "technical effect iveness " and to th i s i s added "psychosocial effect iveness" which considers the att i tudes of both recipients and providers of care. The data su itable with in each of these c l a s s i f i c a t i on s are delineated. The dimensions of e f f i c iency are considered to include cost and product iv i ty data, integrated with population character i s t i c s and morbidity data in order that the re lat ionship between impact and e f f i c i ency can be determined. The information suggested may perhaps be excessive considering the lack of empirical va l idat ion of which components pos i t i ve l y a f fect outcome. In add i t ion, the cost of co l l e c t i ng the information pro-posed would be p roh ib i t i ve . Tenney (1973) reviewed the current problems of Ambulatory Care s t a t i s -t i c s , s p e c i f i c a l l y , the lack of purpose in the co l l ec t i on process, the lack of analysis once co l lected and the chronic problems of data accuracy, r e l i a b i l i t y and v a l i d i t y . Data must be ret r ievab le , com-parable and spec i f i c . Pre-requis i te to the construction of any information system i s "the need to es tab l i sh , define, agree upon, promulgate and use standard terms for the events, en t i t i e s and units of Ambulatory Care". Another requirement, i den t i f i ed by Tenney, was that the data co l lected should serve notyonly the internal manage-ment echelonsi,but also the various external demands for information such that only the level of aggregation varies. Tenney, James B., "Information in Developing National S t a t i s t i c s on Ambulatory Medical Care", Medical Care, Supplement II,, March-April 1973, p. -$T. - 55 -Tenney advocated that the v i s i t be the baseline unit of analys i s , a . proposal that was strongly c r i t i c i z e d by other authors (Cooney 1973, White 1973, Fink 1973, Ullman et al 1973), At the Conference they proposed that the patient/episode of i l l n e s s be the unit of measurement. In the i r opinion the v i s i t ' s only usefulness was as an a c t i v i t y ind icator and even that i s l im i ted because of the f a i l u r e to account for case mix. Planning and evaluation cannot be performed on this basis. Cooney (1973) reviewed the problems inherent in separating in-pat ient and out-patient data in hospital based anc i l l a r y services where resource costs were not apportioned. Inadequacies of cost accounting systems prevent the development of mutually exclusive cost categories. A chronic problem of ambulatory care s t a t i s t i c s i s the f a i l u r e of data co l lec t ion systems to define separately the number of pat ients, the number of v i s i t s and the number of procedures in Ambulatory systems and then to l ink them together to develop meaningful u t i l i z a t i o n measures. This concern i s expanded upon by Fink (1973) and Densen (1973), who in t he i r discussion of u t i l i z a t i o n data go to great lengths to d i f f e ren t i a te the v i s i t from the episode of care and bu i ld a case for the use of each unit of analys is. Ullman et al (1973) estimated c l i n i c u t i l i z a t i o n rates of primary care populations using the patient as the basic unit and l inked patients and v i s i t s so that projections were va l i d . - 56 -Gaus (1978) proposed that the data base be designed to co l l e c t information on population, pat ients, provider, problems, procedures and prescr ipt ions, and categorized the major managerial information requirements of ambulatory care systems as the fol lowing: 1. Operational Planning - s ize and composition of the population, u t i l i z a t i o n rates over time. 2. Management Control - monitoring of productiv ity and u t i l i z a t i o n practices of ind iv iduals and departments, including physician patterns of use of anc i l l a r y services. 3. Quality Assurance - peer review and audit. 4. Support Services - f inanc ia l data, accounts receivable and accounts payable, inventory contro l , t h i r d party and government payment agencies. Brenner and Paris (1973) have grouped ambulatory care data require-ments into four major c l a s s i f i c a t i on s - demographic and socio-economic charac te r i s t i c s , diagnostic and therapeutic information, u t i l i z a t i o n of services and f a c i l i t i e s , and costs of services and contend that the data elements i den t i f i ed within each c l a s s i f i c a t i o n are most appropriate for administrative management and c l i n i c a l epidemiology. Hershey and Moore (1975) i den t i f i ed four categories of ambulatory care data - u t i l i z a t i o n , workload, product iv i ty and health status. - 57 -Schneider (1979) described a medical c l a s s i f i c a t i o n system for coding the pat ient ' s reason for v i s i t which would be applicable to a l l facets of ambulatory care, including the Emergency Depart-ment. The Reason for V i s i t C l a s s i f i c a t i on System (RFVCS) surpasses t rad i t i ona l diagnostic c l a s s i f i c a t i o n systems by v irtue of i t s non-s p e c i f i c i t y which allows for i den t i f i c a t i on of symptoms, complaints and requests. The RFVCS is structured on a modular basis to allow data to be co l lected on diagnostic and therapeutic procedures, counsell ing and fol low-up, which allows a high degree of f l e x i b i l i t y and adaptab i l i ty . B. TRENDS IN FEDERAL AND PROVINCIAL INFORMATION SYSTEMS Since the advent of hospital insurance in B r i t i s h Columbia, hospitals have been subjected to mult ip le and d i s jo inted requests for a c t i v i t y information from a number of external paying agencies. Many of these demands have been imposed on hospitals by regulation - the Hospital Act, and the Hospital Insurance and Diagnostic Services Act being the prime controls . Such reporting mechanisms are necessary in order that hospitals receive operating dol lars from the Provincia l Government. However, in tota l there are some 35 Hospital Information A c t i v i t y forms (HIA's) that hospitals must complete on a routine basis. In addit ion, there are another set of forms required to receive cap i ta l funding. - 58 -An unfortunate outcome of these information demands is that the information provided to t h i r d party agencies i s , in a large part, e i ther not fed back to the hospitals at a l l or the time lag of the two or three years necessary for aggregation and manipulation of the data negates any usefulness the information may have had. This s i tuat ion has resulted in hospitals developing dupl icat ive information systems to provide data for internal management purposes. This h i s t o r i c a l dupl icat ion of information systems has resulted in two separate unique and inconsistent data bases. Negotiations with government for funds or programs have reached an impasse because both groups have d i f fe rent data. This has resulted in an adversary role between hospitals and government. The Jo int Hospital Funding Project w i l l be further discussed in Chapter IV. However, in th i s review of information systems i t i s appropriate to include the thrusts : of the Joint Funding Project for uniformity. 1. B.C. Joint. Hospital Funding Project At the outset of the Joint Hospital Funding Project, the need for a uniform information system accessible to both hospitals and the Ministry of Health was i den t i f i ed as a p r i o r i t y . In f ac t , the Pr inc ipa l s agreed that even i f the report was not accepted in i t s en t i re ty , the recommendations on uniform reporting would improve the funding processes s i g n i f i c an t l y . The f i r s t output of the - 59 -Implementation Stage was the development of a Data Base Elements Manual (Ernst and Whinney, May 1980). Based on a supply/demand model of health care del ivery, 16 Data P ro f i l e s (Figure 3.1) were i den t i f i ed and evaluated with respect to t he i r a p p l i c a b i l i t y to the Planning, Budgeting, Payment/ Reconci l iat ion and Monitoring/Control processes. The a v a i l a b i l i t y of each data element with each data p r o f i l e was then determined by a matching to ex i s t ing information sources. The intent of th i s Data Elements Manual was as a reference guide to ex i s t ing and succeeding implementation team members. As data needs became i d e n t i f i e d , the a v a i l a b i l i t y of the information would be sought and i f not ava i lab le , the cost/benefit of co l l ec t i on determined. I t was recognized at the outset that such an endeavor was in fact a monumental task and that i t may have been more appropriate to f i r s t ident i f y needs for information and then match to a v a i l a b i l i t y . However, the importance of the Manual as a document for future years was the over-r id ing c r i t e r i on for th i s manner of development. User needs for information were to be i den t i f i ed with in the context of Jo int Hospital Funding Project requirements and val idated by the major decision-making groups - such as Administrators and Directors of Finance. Other Advisory Groups would be established as the need Figure 3.1 RELATIONSHIP BETWEEN FUNDING PROCESSES AND DATA PROFILES PROFILE •;. ' FUNDING PROCESS PLANNING BUDGETING PAYMENT & RECONCILIATION MONITORING & CONTROL 1. Population Character i st ics: Demographic ** * 2. Population Character ist ics: Socio-Economic ** 3. Population Character ist ics: Health Status ** * 4. Finance: Hospital ** ** ** ** 5. Finance: Non-Hospital ** 6. Manpower: Hospital ** * * 7. Manpower: Non-Hospital ** 8. Health F a c i l i t i e s : Hospital * ** * * 9. Health F a c i l i t i e s : Non-Hospital * 10. U t i l i z a t i o n : Hospital ** ** * ** 11. U t i l i z a t i o n : Non-Hospital * * 12. Health Services: Hospital/Patient ** * * 13. Health Services: Hospital/Non-Patient ** * * 14. Health Services: Non-Hospital/Patient * * 15. Health Services: Non-Hospital/Non-Patient * * 16. Patient Medical Abstract: Hospital * * ** ** NOTE: * * Denotes key use relat ionship * Denotes lesser use relat ionship SOURCE: Ernst and Whinney, Data Elements Manual, May 1980. arose for expert input - i . e . Nurses, Health Record Administrators. This "tops down" approach i s perhaps more pragmatic than es tab l i sh -ing user groups for each service or program provided. Design Concepts Paper - Uniform Reporting System Preliminary to the actual development of budgeting and s t a t i s t i c a l manuals, was the Design Concepts Paper which out l ined the scope, constraints and c r i t e r i a of the Uniform Reporting. This document was prepared to ensure that as wel l as providing for Jo int Funding requirements, other reporting requirements are integrated with in one system f.orthe i n s t i t u t i o n a l co l l ec t i on and reporting procedures. The c r i t e r i a with which to measure the development of the uniform reporting structure were designated as follows (Ernst and Whinney, October 1980): 1. Replace the ex i s t ing monthly reporting system. 2. Replace the annual HS1, HS2 reports how prepared for S t a t i s t i c s Canada to the extent that information i s required. 3. Incorporate recommendations of the Working Committee on Inter-provincial Comparisons to the level of Ministry requirements at th i s time. 4. Provide for ro le s , programs and levels of service currently in place yet be f l e x i b l e enough to accommodate revisions to the role and refinements to programs and levels over time as envisaged by the Hospital Role Study. - 62 -5. Be able to evolve i n t o some form o f d i s e a s e - r e l a t e d group c o s t i n g over time.^ Uniform Reporting Manual The uniform r e p o r t i n g manual (Ernst and Whinney, A p r i l 1981), developed f o r the J o i n t Hospital Funding P r o j e c t , s c h e m a t i c a l l y categorizes a l l acute care i n p a t i e n t , d i a g n o s t i c and t h e r a p e u t i c , a d m i n i s t r a t i v e , ambulatory and a n c i l l a r y s e r v i c e s i n t o a program hi e r a r c h y of f u n c t i o n s , subfunctions, programs, subprograms and a c t i v i t i e s . The i n t e n t of t h i s document i s to provide standard d e f i n i t i o n s of a c t i v i t i e s f o r peer grouping, common s t a t i s t i c s and uniform i n d i c e s . Emergency s e r v i c e s i s a subfunction of the Ambulatory Care f u n c t i o n . The s t a t i s t i c s required o f f a c i l i t i e s are the f o l l o w i n g : i ) Number of v i s i t s i i ) Hours worked by occupational code - budget, i i i ) Hours worked by occupational code - actu a l i v ) Number of ambulatory p a t i e n t s admitted The i n d i c e s manipulated from the s t a t i s t i c s reported on a monthly (4 week period) w i l l be l i m i t e d t o : i ) V i s i t s / h o u r s worked i i ) Occupancy d i s t r i b u t i o n i i i ) Hours worked, a c t u a l , as a percentage of the budgeted hours. Ernst and Whinney, Design Concepts Paper, Ernst and Whinney, Vancouver, October 1980, p. 8. - 63 -2. Federal P r o v i n c i a l Data Cube Concept Developed i n 1979 by the Hospital I n s t i t u t i o n s Sub Group of the Ad Hoc Committee on Health Information, the Data Cube concept ( D i e t i k e r 1979) organizes information concerning input resources to h o s p i t a l s e r v i c e u n i t s and u t i l i z a t i o n of those u n i t s i n an attempt to i d e n t i f y process e f f i c i e n c y and e f f e c t i v e n e s s . The mandate of the Sub Group on Hospital I n s t i t u t i o n s was to develop a set of Canadian data element standards that would meet the c u r r e n t and f u t u r e i n f o r m a t i o n requirements of the i n s t i t u t i o n s , the Provinces and T e r r i t o r i e s and the f e d e r a l government as w e l l as provide meaningful i n t e r p r o v i n c i a l comparisons. Recognizing the l i m i t a t i o n s of e x i s t i n g i n s t i t u t i o n a l r e p o r t i n g systems - the f e d e r a l Annual Return of H o s p i t a l s , Parts I and I I , the P r o v i n c i a l Q u a r terly Hospital Information System and i n d i v i d u a l p r o v i n c i a l M i n i s t r y of Health Information systems, the Task Sub Group i d e n t i f i e d a model which would capture information on three axes: by l e v e l of care (acute, convalescent, r e h a b i l i t a t i v e ) , h o s p i t a l s e r v i c e u n i t s (beds, d i a g n o s t i c and t h e r a p e u t i c , admin-i s t r a t i o n and support) and by input resources (hours, wages, b e n e f i t s ) . The Data Cube Concept i s conceptually sound i n that i t provides a l i n k a g e between c l i n i c a l and f i n a n c i a l i n f o r m a t i o n , e s t a b l i s h e s a - 64 -common terminology and concentrates e f f o r t s on the i d e n t i f i c a t i o n o f a minimum data set that can be aggregated i n many ways f o r the various users. I t s main weakness has been the i n a b i l i t y to o p e r a t i o n a l i z e the concept. The p r o v i n c i a l governments have been unable to agree upon the core data set and have stat e d that t h e i r needs f o r information have not been met. The data set reduces the t r a d i t i o n a l i n f o r m a t i o n reported by some 80% and the P r o v i n c i a l M i n i s t r i e s o f Health are n a t u r a l l y r e l u c t a n t to give up t r a d i t i o n a l i n f o r m a t i o n . Secondly, the r e p o r t i n g systems and computer e x p e r t i s e and hardware which would capture and report information on a t i m e l y b a s i s and th r e e - d i m e n s i o n a l l y , are not i n place. A t h i r d weakness i s the Rata Cube's neglect of the e f f e c t i v e n e s s aspect of care. Process e f f i c i e n c y i s the main output of the model. However, the program d e f i n i t i o n s as c u r r e n t l y being developed under the auspices of the J o i n t Funding Study are attempting to i n t e g r a t e two of the axes - the s e r v i c e u n i t s with input resources with subsequent output i n d i c a t o r s . - 65. -C. EMERGENCY DEPARTMENT INFORMATION SYSTEMS There are several, management information systems avai lable to hosp i ta l s . However, most tend to address one spec i f i c type of information requirement; PAS and HMRI provide patient u t i l i z a t i o n and treatment data on inpat ients ; the HIA 35 ABC a j o i n t Min istry of Health/B.C. Health Association system co l lec t s f inanc ia l and s t a t i s t i c a l information on hospitals fo r monitoring purposes; the B.C. Health Association Hospital Personnel Management System (HPMS) co l l ec t s labor and salary d i s t r ibu t ion information on a l l employees of pa r t i c ipa t ing member i n s t i t u t i on s ; and the Federal HS1 and 2 and Provincial Quarterly Information Systems provide comparative a c t i v i t y data. However, none of these systems i s integrated and adaptable to Emergency Information needs. Selected indices such as the number of Emergency Room v i s i t s , sa lar ies and hours paid versus hours worked, can be laboriously extracted from the many reports. The inadequacies of these indicators are evident. There are however two systems s p e c i f i c a l l y t a i l o red to Emergency Department a c t i v i t y . Both of these were developed in the U.S. which leads one to question the appropriateness and a p p l i c a b i l i t y . - 66- -The PAS (Professional A c t i v i t i e s Study) Emergency Department Study developed by the Commission on Professional and Hospital A c t i v i t i e s (CPHA 1975) i s an information system developed to co l l e c t emergency c l i n i c a l records information and report aggregated data for qua l i ty assurance, management and planning purposes. S imi lar to the i n -patient abstracting systems of PAS and HMRI (Hospital Medical Records I n s t i tu te ) , the Emergency Department Study provides demographic, invest igat ive, treatment and discharge information to ass i s t managers to evaluate u t i l i z a t i o n patterns, types of patients treated and out-comes. The main drawback of this system for Canadian hospitals i s cost. At 30<t per abstract, i t i s more appropriate e i ther to sample cases or to run discrete studies on a selected month's basis. The Hospital Administrative Services Program developed by the American Hospital Association reports selected s t a t i s t i c a l , f inanc ia l and man hour data fo r internal trend and group comparative purposes. Nineteen (19) indicators of Emergency Department a c t i v i t y have been i dent i f ied. Of interest to note i s the 1980 takeover of PAS by the American Hospital Association because of f inanc ia l problems of the Commission on Professional and Hospital A c t i v i t i e s . The American Hospital Association intends to merge the two data bases to provide hospitals with integrated c l i n i c a l and f inanc ia l a c t i v i t y ind icators . D. ACCREDITATION The Canadian Council on Hospital Accred i tat ion, a voluntary organiza-t ion designed to as s i s t hospitals and health care professionals to appraise the i r a c t i v i t i e s , evaluate results and improve the i r cap-a b i l i t i e s , set standards for the organization and del ivery of hospital care through ongoing improvements to structural determinants. This organization now provides the most comprehensive set of standards avai lable to Canadian hospitals. Of relevance to th i s study are those standards applicable to the u t i l i z a t i o n and c l a s s i f i c a t i o n aspects of emergency care. 1. Emergency Department Standards There are a number of Canadian Council on Hospital Accreditat ion standards appropriate to the i d e n t i f i c a t i o n of Emergency Room information: Stantard I - Scope of Emergency Services ->• states that a " w e l l -defined plan for emergency care, based on community agreement and on 5 the capab i l i t y of the hosp i ta l , shal l be currently maintained". Compliance with th i s standard necessitates that the capab i l i t i e s of the hospital Emergency Department to receive and treat patients be Canadian Council on Hospital Accredi tat ion. Guide to Hospital Accred i tat ion. The Counci l, Toronto 1977, p. 47. - 68 -c l ea r l y defined and that th i s role be integrated with other health care resources, i . e . ambulance and other hospitals. Standard II - Organization and Staf f ing - states that "the emergency serv ice, where maintained, shal l be well organized, properly directed and integrated with other departments of the hosp i ta l . Staf f ing shal l be related to the scope and nature of the needs ant ic ipated and the services o f fered. " Compliance with th i s standard necessitates adequate numbers of appropriately trained manpower within the department and avai lable on an as needed basis to meet the patient demands placed on the Emergency Room in concert with i t s ro le . Integration with diagnostic, therapeutic and support services i s essential fo r patient care. Standard III - F a c i l i t i e s and Supplies - states that " f a c i l i t i e s for the emergency service shal l be such as to ensure swift and e f fec t i ve care of the pat ient " .^ Compliance with th i s standard necessitates functional planning information to organize the physical space to most appropriately t reat the types of patients received by the Emergency Department. Also of c r i t i c a l importance i s the a v a i l a b i l i t y of suppl ies, drugs and equipment and a communication system to expedite the demands placed on other hospital departments. Ibid P. 48. Ibid P. 49. - 69 -Standard IV - P o l i c i e s and Procedures - s t a t e s that "emergency p a t i e n t care s h a l l be guided by w r i t t e n p o l i c i e s and s h a l l be supported by appropriate procedure manuals and reference material.'" Of prime importance are treatment p r o t o c o l s , and p o l i c i e s w i t h respect to discharge or admission to h o s p i t a l . The "back door syndrome" p l a n n i n g / p o l i c y problemsis evident or not evident i n h o s p i t a l s depending upon the manner i n which these p o l i c i e s are developed. Standard V - P a t i e n t C l i n i c a l Records - states that "a p a t i e n t ' s c l i n i c a l record s h a l l be kept f o r every p a t i e n t r e c e i v i n g emergency g s e r v i c e ; i t s h a l l be an o f f i c i a l h o s p i t a l record." Documentation standards include the maintenance of a c o n t r o l r e g i s t e r , c h a r t i n g standards ( p a t i e n t i d e n t i f i c a t i o n , time and means of a r r i v a l , h i s t o r y , a l l e r g i e s , c l i n i c a l , l a b o r a t o r y and r a d i o l o g i c a l f i n d i n g s , diagnosis and treatment c o n d i t i o n upon t r a n s f e r or discharge and f i n a l d i s p o s i t i o n ) and s i g n a t u r e s . Also of importance i s r e t r o s p e c t i v e and concurrent q u a l i t y of care assessment. Standard VI - Non-acute Ambulatory Care P a t i e n t s - s t a t e s that "there s h a l l be p r o v i s i o n f o r .the a p p r a i s a l , i n i t i a l treatment and ° I b i d , P. 50 9 I b i d , P. 52 - 70 -disposal of patients presenting themselves at the hospital with non-acute c o n d i t i o n s " . ^ Compliance with th i s standard necessitates the development of an ambulatory care area separate from the Emergency Department when the volume of non-acute patients warrants i t . Casual attendances of patients by private physicians for convenience is discouraged. A f fe ld t (1978) i den t i f i e s s i gn i f i can t changes in the Emergency Department service standards as i den t i f i ed by the U.S. Jo int Commission on Hospital Accreditat ion. Of interest to th i s study i s the thrust by JCAH towards c l a s s i f i c a t i o n . As of January 1, 1978, spec i f i c and general requirements were established for four levels of emergency services. The scope of services and standards for each level were i den t i f i ed . Because of cross inf luences, the Canadian Council on Hospital Accreditat ion w i l l undoubtedly addpt a s im i l a r stance in the future. 2. Disaster Planning Up unt i l 1977, the CCHA was rather non-specif ic with respect to the requirements for d isaster planning. In f ac t , i t s major requirement was that there be wr itten disaster plans for internal and external Ibid, P. 53. - 7(1 -disasters. There was l i t t l e mention of frequency of review and update or of test ing of plans. In the revised 1977 Standards, the Guide states: "the hospital shal l have wr itten plans for the proper and timely care of casualt ies a r i s i ng from both external and internal d i sasters, such plans to be f i l e d with the appropriate provincial agency and rehearsed pe r i od i ca l l y . These plans shal l also i n -clude written instruct ions of actions to be taken in the event of a major work stoppage or slowdown by the hospital labor force or a segment thereof. Instructions w i l l vary according to the s ize of the hospital and services offered. Written d i rect ives must also be issued in s t ruct ing s t a f f what to do in the event of a bomb threat . " Ef fect ive disaster planning is contingent upon a r e a l i s t i c assess-ment of ex i s t ing and potential c apab i l i t i e s in the event of a d isaster. A continuously updated inventory of resources of the hospital and the community i s e s sent ia l . E. CONCLUSION - MODEL OF INFORMATION NEEDS Based upon the state of the art of hospital information systems in general and Emergency Department information systems in pa r t i cu l a r , i t becomes apparent that problems ex i s t with respect to conceptual izat ion, i d e n t i f i c a t i o n , organization and p r i o r i za t i on of information needs. Managers of hospital Emergency Departments cannot operate in i s o l a t i on CCHA Guide to Hospital Accred i tat ion, P. 66. - 72 -of the programs and resources of the hosp i ta l , the health and soc ia l resources avai lable to i t s patients or the resources and people in the community. It i s essential that any i den t i f i c a t i on of emergency information needs not be done in i s o l a t i on of large systems. The types, levels and needs for information i den t i f i ed in the l i t e r a t u r e concentrate pr imar i ly on four foc i - information required for the care and treatment of the pat ient; information needed to manage an Emergency Department and to assess the qual i ty of care provided and that required for strategic planning. Of lesser mention are those information requirements for research and development or po l icy formulation. For the purposes of th is study, a l l s i x levels of information needs w i l l be i den t i f i ed - patient care, management, qua l i ty of care, s t rateg ic planning, research and development and pol icy formulation. It i s recognized that each of these levels requires increasingly sophist icated information, and that each i s of special interest to d i f fe rent decision-makers with the system, from the hands-on emergency nurse or physician, to the managers and planners, the Medical Director, Director of Nursing, Administrator, and to researchers and govern-ment. However, only by the i d e n t i f i c a t i o n , and p r i o r i za t i on of needs can an information system be made most e f fec t i ve . - 73 -The s ix levels of c l a s s i f i c a t i o n , t he i r def in i t ions and scope of a c t i v i t i e s , potential users and frequency with which information may be co l lected i s documented in f igure 3.2. Once the levels of information use have been i d e n t i f i e d , i t i s possible to conceptually develop information p ro f i l e s or c l a s s i -f i ca t ions of the types of information that may be potent ia l l y useful to hospital decision-makers. As th i s study i s concerned with both planning and operational management data, i t i s imperative to recognize that the emergency department must be viewed not only as an interact ion of patients and resources but also in l i g h t of the impact of the hospital and the community on the emergency department. It then becomes^possible to define data elements with in these larger systems. Following f igure 3.2 i s a matrix, derived from the l i t e r a tu re of the s ix uses of information and p ro f i l e s or c l a s s i f i c a t i o n of data elements that may be useful as a s ta r t ing point for the i den t i f i c a t i on of spec i f i c data elements. Once a l i s t of data elements is derived from the matrix, va l idat ion by a panel of decision-makers i s feas ib le . Figure 3.2 EMERGENCY DEPARTMENT - INFORMATION CLASSIFICATION SYSTEM C las s i f i ca t ions Definitions/Scope of A c t i v i t i e s Users Frequency Collected/ Generated Patient Care Diagnosis, treatment, disposit ion and follow-up of patients present-ing at the Emergency Department Emergency Nurse Emergency Physician Routine -da i ly Management Operational planning organizing/scheduling/staffing budgeting/monitoring and control Head Nurse - Director of Nursing Chief of Emergency - Medical Director Routine -da i ly monthly Quality of Care Monitoring of qua l i ty of care Quality assurance/audit Medical Staf f Nursing Staff Monthly Strategic Planning Role determination Program planning Resource a l locat ion Administration - Administrator - Director of Nursing - Medical Director Planners - Greater Vancouver Regional Hospital D i s t r i c t - Ministry of Health Annually Research and Development Organization and delivery of Emergency Room care/ut i l i za t i on Effectiveness and Eff ic iency Structure/process/outcome studies Researchers/ Epidemiologists Special studies Pol icy Formulation Regulatory/1egi s i a t i ve po l i c ies Resource Al locat ion Emergency Health Services Commi ssion/ Ministry of Health ? Figure 3.3 TYPES OF \I N F O R - \ M A T I O N COMMUNITY/REGIONAL PROFILE HOSPITAL PROFILE EMERGENCY DEPARTS ENT PROFILE POPULATION (CATCHMENT AREA) RESOURCES RESOURCES PAT IENTS/ UTILIZ ATION USES OF \. INFORMATION COMM (a) D/SE EPID ( b j HEALTH/ STATUS ( c ) HEALTH/ SOCIAL MOM H/S PROGRAMS MANPOWER COSTS $ MAN EQUIP D (e) EP/ S/E ( f ) CLIN+ D & T (g) OUTCOME (h) CLINICAL PATIENT CARE OPERATIONAL MANAGEMENT QUALITY OF CARE STRATEGIC PLANNING EFFECTIVE-NESS R & D POLICY a) community characteristics - i.e. major industry, health hazards, potential risks b) epidemiological/demographic, socio-economic information - age, sex, residence, income, race c) morbidity and mortality indicators d) other health resources in the community - detoxification centres, long term care f a c i l i t i e s e) demographic - age/sex f) epidemiological, socio-economic - marital status, race, income g) diagnostic and therapeutic clinical information - chief complaint, diagnosis, laboratory/x-ray, etc. h) outcome - dead, discharged, admitted - 76 -SUMMARY OF CHAPTER Chapter III began with a review of the papers presented at the 1972 U.S. Conference on Ambulatory Medical Care Records where a panel of experts i den t i f i ed a core set of data base elements appropriate to any and a l l ambulatory care encounters. In Canada, attempts at the federal and prov inc ia l levels to l ikewise ident i f y a uniform data set have not been so successful. A review of ex i s t ing information systems demonstrated the lack of integrat ion of c l i n i c a l and f inanc ia l systems and also showed the f rust rat ions of managers to integrate mult ip le data sources into a meaningful whole. Trends in the B.C. Jo int Hospital Funding Study i den t i f i ed a core set of information to be co l lected in Emergency Departments although th i s information has yet to be val idated by the industry. Thrusts for information in the l i t e r a tu re appear to be concentrated on four foci - information required for the care and treatment of the pat ient, information needed to manage an Emergency Department, i n fo r -mation required to assess the qual i ty of care and information required for s t rateg ic planning. - 77 -Although the prime focus of the study i s on the information needs of hospital managers, two addit ional foc i were presented - research and development and pol icy formulation. From these s i x levels of information, a matrix was developed which incorporated successively larger types or categories of information needs from the patients and resources of the Emergency Department to the hospital i t s e l f and to the community i t serves. - 78 -CHAPTER IV EVOLUTION OF THE EMERGENCY HEALTH CARE SYSTEM IN B.C. A. TRADITIONAL ORGANIZATION, DELIVERY AND FUNDING OF EMERGENCY CARE IN BRITISH COLUMBIA. As stated in the previous chapter, the ten year time lag between the introduction of the Hospital Insurance and Diagnostic Services Act (1957) and the Federal Medical Care Act (1968) resulted in public dependence upon the acute care hospital and i t s Emergency Department as the focal point for entry into the health care system. This time lag leg i t imized the role of the acute hospital as the major provider of care; a trend which even today i s d i f f i c u l t to revi se. Because the care in an Emergency Department was es sent ia l l y free and h i s t o r i c a l l y has provided a wide range of services such as casts, suture removal or equipment for a $2.00 co-insurance fee, many patients continued to re ly upon the resources of the Emergency Department for par t i cu la r aspects of care, rather than the physic ian ' s o f f i c e . A review of provincia l a c t i v i t i e s over the past ten years in B.C. indicates the evolution of emergency care as a d i s c i p l i ne in i t s - 79 -own r i ght . Whether th i s has arisen from general health care trends such as increasing medical spec i a l i z a t i on , sophist icated technology and the influence of pre-hospital emergency medical systems or the i n a b i l i t y of t rad i t i ona l models of the Emergency Department organization and management to cope with increasing volumes i s open to speculation. However, as a result of the studies of the 1960's, "a number of hospitals began to experiment with the organization of t he i r emergency room services e i ther by i n s t i t u t i n g a " t r i a ge " system to expedite and improve patient care (Weinerman 1964 and 1965) or by i n s t a l l i n g a f u l l - t ime s ta f f of private physicians whose professional e f for t s would be l im i ted to the emergency room alone"' 1 ' . However, from a wealth of information on u t i l i z a t i o n patterns, and the causes and consequences, has developed more concern for evaluation of care rendered - in pa r t i c -u lar, outcomes, standards for organization and del ivery and a thrust towards c l a s s i f i c a t i o n or categorization of departments. This con-centration i s perhaps more evident in the U.S. where d i f ferent influences in.health care de l ivery, such as competition and regulat ion, are in existence than i n Canada, but nevertheless there has been a r i se in use here too as discussed in 2-A and 4 -C . l . Of note, however, within the f i e l d of emergency medicine i n B.C. i s the increasing spec ia l i za t ion of manpower resources and the emergence of new categories of health manpower - the paramedic, the emergency * Torrens, P.R. and Yedvab, D.G., "Variations Among Emergency Room Populations: A Comparison of Four Hospitals in New York C i t y , 1 " Medical  Care, Vol. XII I, No. 12, December 1975, P. 1011-1020. - 80 -physician and the emergency nurse. The 1974 Emergency Health Services Act of B.C. l eg i s l a ted provincial re spons ib i l i t y and control over the del ivery of pre-hospital care and paved the way for the development of paramedic services (discussed in the next sect ion). The Kermacks Report on Nursing Education (1979) recommended the immediate development of post-basic spec ia l t ie s in c r i t i c a l care nursing - such as ICU, obs te t r i c s , neonatal and trauma/emergency. Developmental work has been underway at Douglas College to develop a post-basic emergency nursing t ra in ing program, with a f i r s t class expected to begin in September, 1981. The Canadian Association of Emergency Physicians, a voluntary professional group, has been lobbying for specia l ty c e r t i f i c a t i o n for emergency physicians. Currently, s pec i a l i s t exams are taken under the auspices of the American College of Emergency Physicians. In B.C. appropriate funding for emergency care has been lacking. The $2.00 prov inc ia l co-insurance fee in existence since 1949 has not been increased to r e f l e c t i n f l a t i o n or the changing role of Emergency Departments with respect to improved services provided as a resu l t of spec ia l ized technology and manpower. S t a t i s t i c s that have been co l lected re late purely to the number of v i s i t s . Budgets for Emergency Care are assumed under general - 81 -Operating Budgets. The recognition of the Emergency Department as a spec i f i c allowable budget item w i l l only be assured with the implementation of a new funding system. To set th i s study within the context of B r i t i s h Columbia trends and concerns with respect to the development, organization and funding of Emergency Care as well as North American trends, i t i s appropriate to out l ine some of the more major developments within B.C. B. THE EMERGENCY HEALTH SERVICES COMMISSION - 1974 In May of 1974, the Emergency Health Services Act was promulgated with powers and author i t ies covering the manpower, equipment and communica-tions conponents of an integrated emergency health care serv ice, supervised by a Commission. At f i r s t , the p r i o r i t i e s of the Commission's a c t i v i t i e s were directed at pre-hospital care. A provincial ambulance system and improved t ra in ing standards for attendants led to the development of a new class of manpower in B r i t i s h Columbia, the paramedic. Modelled a f te r the Los Angeles and Seattle systems, the paramedic in B.C. i s second to none in Canada. Other powers of the Commission include medical d isaster planning, delegated to the Medical Off icers of Health in the province and management of the Federal government's Emergency Medical Supplies (MASH un i t s ) . - 82 -Also with in the powers of the Commission, although not exercised unt i l 1980, i s the j u r i s d i c t i o n over hospital Emergency Department standards. The 1980 provincia l c l a s s i f i c a t i o n study (discussed in Section 4-G.3) i s an attempt to co-ordinate hospital emergency resources with the needs and expectations of pre-hospital care resources. C. THE GREATER VANCOUVER REGIONAL HOSPITAL DISTRICT By l e g i s l a t i o n , the Greater Vancouver Regional Hospital D i s t r i c t has as i t s mandate capita l resource and program planning. Inter-mi t tent l y , over a period of ten years, the GVRHD has addressed the planned development of emergency resources with in the Regional D i s t r i c t . ' Studies (1970, 1976, 1978, 1980) i den t i f i ed trends with respect to Emergency Department u t i l i z a t i o n and attempted to quantify in a l og i ca l fashion, the requirements for service with in the Regional D i s t r i c t . It w i l l be noted that Regional Hospital D i s t r i c t s came into existence in 1966 before the Emergency Health Services Commission was establ ished. 1. Emergency Medical Services Study, Apr i l 1970 The 1970 GVRHD study i s perhaps the most comprehensive assessment of regional emergency resources. Individual hospital Emergency Department c a p a b i l i t i e s , workloads and trends were evaluated in - 83 -conjunction with the effects of hospital admitting po l i c i e s , Emergency Department s ta f f i ng p o l i c i e s , an integrated ambulance system and enlarged outpatient f a c i l i t i e s . The study noted that "there i s a trend towards the u t i l i z a t i o n of Emergency Departments as a community health resource by both 2 physicians and pat ients " and that based upon c l a s s i f i c a t i o n of current cases into t r i v i a l , e s sent i a l , urgent and c r i t i c a l , "what i s presently ca l led an emergency department is actua l ly a community diagnostic and treatment centre where an increasingly large proportion of the caseload should not be classed as emergency cases. 3 Based upon population trends, u t i l i z a t i o n patterns, patient sever i ty mix and the re lat ionsh ip between inpat ient beds and admissions through emergency, the ideal d i s t r i bu t i on of emergency beds among GVRHD hospitals was determined. Of more interest and value than the s t a t i s t i c a l determination of bed d i s t r i b u t i on , was the administrative pol icy recommendations. The report spec i f ied at the outset that "the Emergency Department of the hospital i s a treatment area not a holding unit nor i s i t to be used as an admitting o f f i c e " . 4 The dumping syndrome was G.V.R.H.D. 3 G.V.R.H.D. 4 G.V.R.H.D. 1970, p. 84. 1970, p. 33. 1970, p. 34. - 84 -evident as the report advised that "immediate steps should be taken to provide community f a c i l i t i e s fo r special groups such as a lcoho l i c s , the aged, welfare cases and pa r t i cu l a r l y psychiatr ic 5 cases". In addition to recommendations on s t a f f i n g , medical administrative control and u t i l i z a t i o n and audit monitoring, the c r i t e r i a for c l a s s i f i c a t i o n of f a c i l i t i e s into major', standard and l im i ted categories were i den t i f i ed and ex i s t ing hospitals c l a s s i f i e d . Part 2 of the study evaluated ex i s t ing pre-hospital emergency capab i l i t i e s with in the Region. At that time, ambulance services were a mixture of private and volunteer resources, subsidized by mun ic ipa l i t ie s . Vehic le, equipment and t ra in ing standards were non-existent, there was a lack of co-ordination among f i r e and ambulance dispatching and there was no medical input to assess the effectiveness of pre-hospital treatment or po l i c i e s . Many of the recommendations of the Report were implemented with the passage of the 1974 Emergency Health Services Act which has reduced dup l i cat ion, improved service and qua l i ty and f a c i l i t a t e d the development of a tota l emergency health system. 5G.V.R.H.D., 1970, p. 35. - 85 -2. Emergency Services: A S t a t i s t i c a l Review, May 1977 In 1976, the Greater Vancouver Regional Hospital D i s t r i c t i n i t i a t e d a further Emergency Services Study to review and update the previous 1970 study because of changes in practice patterns, the upgrading of old f a c i l i t i e s and proposals for new f a c i l i t i e s . Although th i s Study operated under ident ica l terms of reference to the 1970 Study, i t concluded with a number of observations and proposals for further invest igat ion rather than recommendations. A s h i f t in u t i l i z a t i o n from major re fe r ra l hospitals to the larger community hospitals on the periphery of the Regional D i s t r i c t was noted. Hospital admissions remained f a i r l y constant over the f i ve year period from 1972 to 1976, while the number of Emergency Depart-ment v i s i t s increased by 26% (from 245,946 to 305,289 v i s i t s ) . Categorization of a l l Emergency Room v i s i t s in a two week period into four d iscrete areas showed that one th i rd of the cases a r r i v ing at the Emergency Department could have been treated at an ambulatory care c l i n i c or doctor ' s o f f i c e and 292 cases or 3% of a l l cases were backdoor admissions requir ing no Emergency Room treatment at a l l but simply admitted through the Emergency Room to bypass e lect i ve wait ing l i s t s . This d i s t r ibu t ion of backdoor admissions was found not to be s i gn i f i c an t , much to the surprise of those on the committee. - 86 -There were a number of p o l i c y c o n s i d e r a t i o n s i d e n t i f i e d i n the report which needed to be resolved before planning recommendations could be made. The lack of r e c o g n i t i o n o f the h o s p i t a l Emergency Department as a "department" with s i m i l a r r e c o g n i t i o n , r e s p o n s i b i l -i t i e s and status accorded other medical s p e c i a l t i e s and the chronic f a i l u r e to c l e a r l y d e f i n e , agree upon and implement p o l i c i e s con-s i s t e n t with the r o l e of the Emergency Department were viewed as fundamental b a r r i e r s to the implementation of e f f e c t i v e and acceptable Emergency Room planning recommendations. I t i s of i n t e r e s t to note that the 1976 p r o j e c t i o n s of Emergency Room u t i l i z a t i o n by G.V.R.H.D. h o s p i t a l s made i n 1970 were remarkably c o n s i s t e n t with the actu a l 1976 u t i l i z a t i o n r a t e s . 3. Emergency F a c i l i t y Development i n the C i t y of Vancouver, A p r i l 1968 Another study was undertaken to evaluate the impact o f plans f o r emergency s e r v i c e s by C h i l d r e n ' s , Grace and Shaughnessy h o s p i t a l s (which shared a s i t e ) on the cu r r e n t and planned Emergency Department resources w i t h i n the m u n i c i p a l i t y of Vancouver as a whole. The dominant issues which l e d to the establishment o f the review were an obvious oversupply of emergency resources i f Shaughnessy's proposal f o r a separate Emergency Department were to be implemented and a controversy over whether there should be p h y s i c a l l y separate - 87 -or conjoint adult -paediatr ic Emergency Departments at the Shaughnessy s i t e . In addit ion to recommending, rather weakly, better co-ordination between Hospital Programs and the f a c i l i t i e s to prevent an oversupply, the Report made only one f i rm recommend-at ion. This recommendation was that a s ingle emergency f a c i l i t y with an i n t e r i o r subdivis ion to allow for the separate functioning of an adult emergency and a paediatr ic emergency be planned. Interest ingly or not surpr i s ing ly , there are two separate Emergency Room f a c i l i t i e s currently under construction. D. DISASTER PLANNING - 1978-1980: In June 1978, the Greater Vancouver Regional Hospital D i s t r i c t assumed a d isaster planning funct ion. Previously there had been no co-ordinated emergency medical response, e i ther at the scene of the disaster or at the hospitals. Also lacking was e f fect i ve co-ordination of a l l emergency services including f i r e , po l i ce , ambulance, and mun ic ipa l i t ie s . Each had i t s own plan, but there was no e f fect i ve co-ordination among services. Because of these d i f f i c i e n c i e s and also because casualty manage-ment i s u lt imately a medical r e spons ib i l i t y , the G.V.R.H.D. Disaster Medical Care Committee was formed with the spec i f i c mandate to: - 88 -1. Evaluate current medical, h o s p i t a l and ambulance plans, 2. Update and modify these plans where necessary, 3. Provide a cons o l i d a t e d medical plan f o r the Greater Vancouver Regional Hospital D i s t r i c t , 4. Co-ordinate the emergency medical response with the other emergency s e r v i c e s and provide a means f o r an on-going t e s t i n g of medical preparedness. The Committee, under the chairmanship of an energetic Vancouver emergency p h y s i c i a n , had repre s e n t a t i o n from e i g h t (8) major r e c e i v i n g h o s p i t a l s which i n the event of a d i s a s t e r would c a r r y the brunt o f the c a s u a l t y l o a d , the Greater Vancouver Hospital A d m i n i s t r a t o r ' s C o u n c i l , the Greater Vancouver Regional Hospital D i s t r i c t , the B.C. Medical A s s o c i a t i o n , the Emergency Physicians Group and the Emergency Nurses A s s o c i a t i o n . In the f i r s t year of the Committee's operation a great deal was accomplished. A l l the h o s p i t a l s had t h e i r d i s a s t e r plans reviewed by way of a comprehensive q u e s t i o n n a i r e . Resource c a p a b i l i t i e s were i d e n t i f i e d i n order to a s c e r t a i n the bed, personnel and support s e r v i c e a v a i l a b i l i t y i n the event of a d i s a s t e r . Eight h o s p i t a l s were i d e n t i f i e d as having s u f f i c i e n t resources to be c l a s s i f i e d as major r e c e i v i n g h o s p i t a l s . In a d d i t i o n , an o n - s i t e medical response plan and supporting communi-ca t i o n s package was developed to l i n k the d i s a s t e r s i t e with h o s p i t a l G.V.R.H.D. D i s a s t e r Planning Report, G.V.R.H.D., November 1979, P. 1. - 88 a -receiving capab i l i t i e s . Other e f fo r t s were directed to the preparation of course material for the Emergency Health Services Commission personnel, t r iage o f f i ce r s and f i r e department personnel. The "On-Site Medical Disaster Plan" was tested in co-operation with the f i r e and pol ice departments in March of 1979. Problems were encountered in a l l services, yet resolut ion of plan def ic ienc ies was deemed to need the co-operation of pol ice and f i r e services. There was s u f f i c i en t improvement in medical and hospital co-ordination to improve the care response, however, the f a i l u r e of pol ice and f i r e services to resolve t e r r i t o r i a l imperatives con-tr ibuted greatly to the decline of the Region's e f f o r t s . At l a s t look, the h i r ing of a Greater Vancouver Regional Hospital D i s t r i c t Disaster Co-ordinator with s u f f i c i en t authority to impose co-ordination of the essential emergency services was being proposed to the Board of the Greater Vancouver Regional Hospital D i s t r i c t . Disaster preparedness i s c l ea r l y lacking in the Greater Vancouver Regional Hospital D i s t r i c t . While emergency department and hospital c apab i l i t i e s were i den t i f i ed in 1978, and plans were updated, no further attempt has been made during the past two years e i ther to monitor the i r effectiveness or to practice in concert. - 89 -E. THE EMERGENCY NURSES GROUP The Emergency Nurses Group, a special interest group of the Registered Nurses' Association of B.C. has been ser ious ly concerned about the lack of uniform documentation of Emergency Care to meet jurisprudence requirements and protect i t s members from legal act ion. The o f f i c i a l documentation form for emergency department care i s the Ministry of Health HIA-15 reporting form designed to co l l e c t f inanc ia l and minimal c l i n i c a l information as recorded by physicians. It has been the fee l ing of this group that adequate documentation i s essential to patient care and that the Emergency Nurses Group should take the leadership to provide i t s members with documentation guidelines and format to meet l e g i s l a t i v e , accred i tat ion, management and audit requirements. An Emergency Documentation Workshop was held December 7, 1979, with emergency nurse representatives from eleven (11) of the larger prov inc ia l hosp ita l s , to develop a standard emergency documentation tool and to consider charting c r i t e r i a . Legal, qua l i ty assurance and administrative components of-the c l i n i c a l assessment form were discussed and a consensus reached as to the content and method of presentation of information requirements. A composite documentation form was subsequently developed and p i loted in Emergency Departments. - 90 -F. JOINT HOSPITAL FUNDING STUDY. The Jo int Hospital Funding Project was i n i t i a t e d in May of 1978 to ident i f y an equitable funding system for those health care i n s t i t u t i on s in which programs were being conducted or planned. Its purpose was not to j u s t i f y greater expenditures in the health care f i e l d but to aim for optimum use of avai lable f i s c a l resources in a manner which was understood by a l l part ies . 1. Background The hospitals in B r i t i s h Columbia are funded through a system which or ig inated 30 years ago. Incremental changes have been made to the funding processes but these modifications have not complemented developing health care trends. The concerns voiced by the health care industry over the years have focused on the lack of communica-t ion between government and hospitals regarding funding decisions and on the inequit ies of t reat ing a l l hospitals and the care they provide as i d e n t i c a l . The dominant issues i den t i f i ed with in the Joint Funding Project (Ernst and Whinney, October 1979) are as fo l lows: "The current system f a i l s to recognize hospital uniqueness. Hospital ro les , the types of patients t reated, the intens i ty of service provided, differences in physical plant and - 91 -constraint of geographical locat ion are not taken into consideration by the funding process; The funding system i s i n f l e x i b l e and there are no incentives in the system to contain hospital costs. The system does not encourage the development of inpatient a l ternat ives such as day care and preventive programs or a l ternat ive procedures and innovative techniques which would be more e f fec t i ve and e f f i c i e n t . There are no controls against under -ut i l i za t ion or over-u t i l i z a t i o n ; The funding system does not t i e into the planning or evaluation processes. Services have been developed on incremental basis. High qual i ty i s not rewarded, neither i s there a control against low qua l i ty of care. There i s a dupl icat ion of reporting systems. External reports as submitted to the Ministry of Health are inappropriate for internal monitoring and control purposes and are not shared with the hospitals submitting them." 2. Jo int Funding Project Recommendations The foundation of the Consultant-'s recommendations was a conceptual framework which i den t i f i ed the philosophy and mechanics of the proposed system and an implementation plan. The integrat ion of planning funding and monitoring and control at a provincia l level and at an indiv idual hospital level i s integral to the system (see Chart 4.1). Each of the phases - s t rategic planning, budget planning, interim payments, reconc i l i a t i on and monitoring and Ernst and Whinney, "Study of the B.C. Hospital Funding Program" Vol. I. Evaluation and Recommendations. October 1979, p. 2r)4 (adapted). - 92 -c o n t r o l - has c e r t a i n p r i n c i p l e s , mechanics, d e c i s i o n making c r i t e r i a and data requirements. On May 8, 1979 a p r e l i m i n a r y report was d i s t r i b u t e d to the B.C. Health A s s o c i a t i o n member i n s t i t i t i o n s and M i n i s t r y of Health s t a f f f o r review and feedback to the S e c r e t a r i a t of the J o i n t J o s p i t a l Funding Study. This report o u t l i n e d i n great d e t a i l the f i v e phases of the conceptual framework. Because one of the c o n s t r a i n t s of t h i s study of emergency information i s consistency w i t h the philosophy and recommendations of the J o i n t Funding Study, an explanation of the f i v e phases of the recommended system i s i n order. 1. S t r a t e g i c Planning The foundation of a l l health care systems r e s t s on d e f i n i t i o n of health care needs and the development of a plan to meet these needs at the p r o v i n c i a l , regional and community l e v e l . This requires e f f e c t -i v e c o - o r d i n a t i o n of d e l i v e r y of health s e r v i c e s between government, the paying agency, and the health care d e l i v e r y agencies. Such c o - o r d i n a t i o n c a l l s f o r long range planning so that the e f f e c t i v e n e s s of planning and d e l i v e r y of s e r v i c e s can be measured over a defined time frame. This would i n v o l v e c o s t -b e n e f i t a n a l y s i s and an e v a l u a t i o n of the rates of change i n the l e v e l of health care needs. The mechanics of d e f i n i n g health care needs could be done on the b a s i s of category of i l l n e s s , m o r t a l i t y and morbidity i n d i c e s and a f o r e c a s t of population trends. The development of a plan to meet community needs in v o l v e s the s e t t i n g of goals and o b j e c t i v e s on an i n d i v i d u a l h o s p i t a l b a s i s . Annual budgets would then have to be developed on the b a s i s of these goals and o b j e c t i v e s as they d o v e t a i l i n t o a three or f i v e -year long range plan. A d d i t i o n a l l y , departmentalized and programme o r i e n t e d budgets would be developed to support h o s p i t a l goals and o b j e c t i v e s . H o s p i t a l goals and o b j e c t i v e s would support regional and - 93 -and provincial goals and object ives. The mechanics of th is process would also involve establishment of provincial and regional constraints and l im i ta t ions on ava i lable funds. The decision-making process would occur at a l l steps by having hospitals and the Ministry of Health negotiate a contract for the pro-v is ion of services to ensure that there i s (a) a cont inuity of goals and object ives, (b) a cost benefit evaluation of competing programmes and (c) an integrat ion of p rov i nc i a l , regional and hospital goals and objectives. The fourth requirement of the s t rateg ic planning phase i s one of data. The fol lowing forms of data would be required: a) Demographic population/trends b) Disease indices c) Demand programme requirements d) Supply of programmes inventory e) A cost per output measure by programme type Depending on the scope of data required, data could be co l lected on e i ther a hospital l e v e l , a regional level or a provincial l e v e l . 2. Budget Planning The main features of budget planning would ar ise from a contract for services and dollars, between the hospitals and the province at prices that consider (a) e f f i c iency (not actual costs ) , (*b) spec i f i c hospital con-s t ra in t s ( f i xed cost s ) , (c) recognition of spec i f i c hospital roles in re lat ion to provincial and regional long range plans and (d) budget performance. Annual budgets by hospital departments and by programmes would be reviewed by the Ministry of Health with respect to overal l funding levels attainable and regional demand. By a process of j o i n t negotiat ion, contracts between the Min istry of Health and hospitals would establ ish performance measures. Figure 4.1 HOSPITAL FUNDING SYSTEM CONCEPTUAL FRAMEWORK FLOW CHART Strategic Planning Hospital* "Supply" Moapilel F Kilitiat end Programe Government "Demand" Regional fir Provincial Health Cere Nodi God Setting Howltel ftolea Program Planning Wnlrnl Fret-Veer Go*l Selling Pi 091 am Planning IDfmtnd to Budget Planning Budgeting Program Cvaauelion Evaluation ot Funding Lt.tlt Contract lor Programs and iarvlca Le»ele Program Procurement Coii/Benerit ol Competing Progrerm Interim Payments Perform Servfcn Reconciliation1 Monitoring U Control 4 * Information Boso Interim Ptymenii Moniloring end Control Source: Ernst and Whinney, The Conceptual Framework Flow Chart. 14 in Study of B.C. Hospital Funding Program, Vo l . II October 1, 1979. • ' . . Exh ib i t E x h i b i t s , - 95 -The decision-making requirement for budget planning would be one of providing a f l e x i b l e budget for each ho sp i ta l ' s variable costs (measured by output). On the other hand, certa in f ixed costs would be prospectively determined and funded. Both of these aspects would contribute to the fact that provincial reimbursement of hospitals would be based on actual volumes of approved programmes. Data requirements for budget planning would be in terms of hospital roles measured on the basis of (a) level and in tens i ty of care pro-vided, (b) education, (c) research and (d) spec ia l i zed services. In order that hospitals be appropriately c l a s s i f i e d , certain- committed f ixed costs must be recognized as indiv idual differences of hospita ls . These may include (a) locat ion of f a c i l i t y , (b) age of f a c i l i t y , (c) s ize of f a c i l i t y and (d) physical layout of f a c i l i t y . In order that budget planning be more r e a l i s t i c , i t i s essential that hospital costs be broken down into f ixed costs, f ixed programme costs and marginal or variable programme costs. Furthermore, the volume of services would have to be segregated on both an inpatient and outpatient basis and consider both the level and the in tens i ty of programme treatment. To ensure that health care needs are being met, certain standards for the del ivery of indiv idual programmes in terms of services and treatments would have to be developed. 3.. Interim Payment Determination -The p r inc ip le supporting interim payment deter-mination i s that interim payments serve to get dol lars to the hospitals on a regular basis. The inter im payments should r e f l e c t the cash flow needs of the hospitals in terms of committed f ixed costs, programme f ixed costs, variable costs and certain capita l expenditures. The mechanics proposed are to have hospitals submit per iodic s t a t i s t i c a l and f inanc ia l - 96 -reports to the Min istry. The Ministry could fund hospitals on a pre-determined percentage of f ixed and variable costs (based on s t a t i s t i c s ) . Several a l ternat ive mechanisms could be used to accommodate cash flow (d i f ferent bases for pre-determined f ixed and other allowable costs). It should be noted that the interim payment system should recognize exceptional cases and increase do l la r advances to recognize special s i tuat ions . Under th i s procedure, the government would have to establ ish po l i c ies for timing of payments. The data requirements for the support of an inter im payment system would be monthly programme s t a t i s t i c s on volume, case mix and treatments. Hospital costs would have to be broken down into committed f ixed costs, programme f ixed costs and variable programme costs. 4. R e c o n c i l i a t i o n The pr inc ip les of reconci11iation are to balance, on an annual basis, inter im payments with regard to the contract established in the budget planning phase. Reconc i l l iat ions would have to address appropriate deviations from contract ro les , volumes, case mixes and treatment. Furthermore, reconci11iations could be adjusted for changes in case mix or volume. The mechanics for reconci11iation would be that they performed on a timely annual budget-ing cyc le. Hospitals would have to report volume, case mix and treatment s t a t i s t i c s on a monthly bas i s , so that variable costs could be reimbursed on th i s measure of output. Desicion making would be handled on a prospective bas is, i . e . predetermined (committed and programmed) f ixed costs would be negotiated at the budget planning stage when the contract i s struck. - 97 -V a r i a b l e costs would be funded on the basis of a c t u a l volume and i n t e n s i t y i n c u r r e d at a pre set negotiated rate which considers province wide and h o s p i t a l c l a s s standards. Data requirements f o r r e c o n c i l i a t i o n are s i m i l a r to those required under the i n t e r i m and budget planning phases. In b r i e f , they are a record of programme f i x e d c o s t s , marginal or v a r i a b l e programme c o s t s , fo r e -cast of volumes i n terms of i n p a t i e n t and outpatient l o a d , l e v e l and i n t e n s i t y of treatment and programme volumes. 5. Monitoring and Control The p r i n c i p l e behind monitoring and co n t r o l i s t h a t there should be an ongoing measure of h o s p i t a l q u a l i t y and input. Performance measure-ment would have to be made against pre-determined standards. Some of these could be (a) cost per u n i t of output, (b) treatment, (c) e f f i c i e n c y , (d) a c c r e d i t a t i o n , (e) u t i l i z a t i o n , ( f ) c a p i t a l expenditures and (g) use of funds. The monitor-ing and c o n t r o l system proposed would have measures of performance compared to e s t a b l i s h e d standards. The mechanics of monitoring and co n t r o l would be output measures i n terms o f programmes (volume, case mix and treatment) compiled on a h o s p i t a l , h o s p i t a l c l a s s i f i c a t i o n , regional and p r o v i n c i a l b a s i s . Q u a l i t y and cost measures would have to be compiled on a s i m i l a r b a s i s . Output measures, q u a l i t y measures and cost measures could then be a p p l i e d to the process of s t r a t e g i c planning i n phase one (the feed-back process). P r o v i n c i a l c o n t r o l of the monitoring process would have to be augmented by h o s p i t a l input. - 9a -Data requirements for monitoring and control would be based on developing standard information to establ i sh a linkage between costs, product iv i ty and c l i n i c a l information. Typical data would be (a) cost per unit of output, (b) cost per treatment, (c) e f f i c i ency , (d) accred i tat ion, (e) u t i l i z a t i o n and ( f ) u t i l i z a t i o n of funds... Since the core of th i s Study is the data required by internal hospital decision makers, with respect to planning and managing emergency care within the constraints of the Jo int Funding Project philosophies and reporting requirements, no attempt w i l l be made to deal with broader pol icy issues such as an appeals process or the manner i n which contracts are establ ished. 3. Implementation The implementation of the recommended funding system requires sub-s tant ia l modif ication to the present system and the implementation of s i gn i f i cant new features. Five major categories of implement-ation a c t i v i t i e s were recommended by the Consultants: a) Continuation of the Jo int B.C. Health Association/Ministry of Health re lat ionsh ips. Each party would appoint an Implementation Team responsible to the Jo int Steering Committee to ensure that the requirements of the Ministry of Health and the hospitals are met. Buchanan, J.B.B. Letter to B.C.H.A. Membership on Jo int Hospital Funding Program (adapted), May 8, 1979, p. 2-3. - 99 -b) The development of a uniform reporting system to promote comparability within and among hospital programs. Information would be i den t i f i ed which i s necessary to meet user and Ministry of Health operational and planning data requirements, i . e . u t i l i z a t i o n , performance and cost data. c) The development of a s t rateg ic planning system re la t i ve to health care needs, hospital ro les , peer grouping of hosp i ta l s , and contractual requirements. d) The design of a budgeting system based upon the outputs of the uniform reporting system and spec i f i ca t i on of time frames, level of deta i l required and appropriate f inanc ia l and s t a t i s t i c a l systems. e) Progressive modifications to the system to include the develop-ment of patient c l a s s i f i c a t i o n systems, re l a t i ve value units and case mix p r o f i l e s . P r io r to the release of the Report, the Jo int Steering Committee had indicated that regardless of the acceptance of the funding system modifications proposed by the consultants, a uniform reporting system was es sent ia l . Consistent and uniform data accessible to both the Ministry of Health and the indiv idual hospitals was viewed as a pos i t ive step regardless of the v i a b i l i t y of other recommendations. The Joint Funding Study Report was subsequently approved in p r inc ip le by both the Board of the B.C. Health Association and the Minister of - 100 -Health. Certain pol icy decisions ( i . e . contracts and appeals process) were l e f t to negotiation at a l a t e r date and implementation in phases began with the i den t i f i c a t i on of a uniform reporting system and budget manual. G. CLASSIFICATION STUDIES. 1. Greater Vancouver Regional Hospital D i s t r i c t - 1980 Study The current study (1980) i s operating with the fol lowing terms of reference: 1. To develop minimum standards for emergency rooms in the Greater Vancouver Regional Hospital D i s t r i c t with respect to Physician coverage, s ta f f ing patterns, back-up services, equipment, physical plant requirements and administrative p o l i c i e s ; and 2. To analyze workload to ident i f y the number of emergency room spaces required per catchment area within the Greater Vancouver Regional Hospital D i s t r i c t . As a preliminary step, a log sheet was devised to co l l e c t information on patient a c t i v i t y with in each emergency department in the Region. Data on patient catchment area, i n s t i t u t i o n source, manner of a r r i v a l and d i spos i t ion , presenting complaint, discharge diagnosis and level of severity was co l lected for a two week period to give some idea of u t i l i z a t i o n and complexity of demand placed upon the emergency room. Results of the survey are not yet ava i lab le . Greater Vancouver Regional Hospital D i s t r i c t , Emergency Services Study, G.V.R.H.D., Vancouver, 1980, p. 2. - 101 -It i s worthy to note that the sever ity categories of the 1978 Study have been expanded from four to seven assessment levels based on the tr iage categories defined in the 1978 Disaster Planning On-site Medical Response Plan. 2. Hospital Role Study Although c l a s s i f i c a t i o n of Emergency Department roles i s not an immediate output of the G.V.R.H.D. Study (1980) in the foreseeable future, the potential for c l a s s i f i c a t i o n i s evident. It became apparent in the early stages of the Jo int Hospital Funding Study that the fundamental problems with the financing of hospitals lay outside the funding system. The lack of an overal l provincial health care plan with agreed to " ro le and goal statements" for hospitals had impeded the development of any rat ional and equitable funding system. The need to "upgrade the s t rateg ic planning mechanism" was i den t i f i ed as one of four key problem areas. This led the commissioning of the Hospital Role Study by the Jo int Steering Committee. This Discussion Document produced in August, 1979, was an i n i t i a l attempt to develop a c l a s s i f i c a t i o n of hospital services which would allow peer grouping of hospitals in order to ident i f y performance - 102 -standards among l i k e i n s t i tu t i on s or programs and lead to the eventual determination of appropriate hospital ro les. Developed by the Planning and Development Group, Ministry of Health, the Hospital Role Study, Phase I - A Discussion Paper on Hospital Services in B.C. - i den t i f i ed a matrix of s ix levels of service (three levels of community hosp i ta l s , two levels of re fer ra l f a c i l i t i e s and one provincial one of a kind f a c i l i t y ) and seven inpatient care functions (medical, surgery, obs tet r i c s , psychiatry, paediatr ics , r ehab i l i t a t i on and dent istry) together with a set of i d e n t i f i e r guidelines which would ass i s t hospitals in ident i f y ing the i r current service p r o f i l e . The intent of the document was to develop a common vocabulary and provide a framework for discussion within the health care industry in th i s very complex area of hospital ro les. There was general agreement by the industry (B.C. Health Associat ion, Apr i l 1980) that better overal l planning of our health care system was necessary and that the discussion document had achieved i t s immediate objective in establ i sh ing interest and that i;t.;was a worthwhile study in that i t attempted to define in a log ica l fashion the roles and functions of indiv idual hospita ls . - 103 -Nevertheless many strong concerns and questions were raised by the industry - one set of concerns re la t ing to the document i t s e l f and another set re la t ing to the manner in which the document would be used. With respect to the document i t s e l f , therev/were serious concerns that i t had been produced without any c lear de f i n i t i on of the health care needs of the province; that i s , no attempt was made to ascertain needs and define roles on a sound epidemiological basis. It was f e l t that a ho sp i ta l ' s role should be planned to meet the needs of the population i t serves. It dealt with history rather than what the health care needs are now or w i l l be in the future. A second major concern was the del ineation of a ho sp i ta l ' s inpatient role in i s o l a t i on of i t s ambulatory function and the resources ava i lable in the community. The document gave "inadequate attention to ambulatory care, emergency health services, g e r i a t r i c services, long term care and extended care and to the outreach programs"^ which hospitals have developed, not only to improve service but to reduce inpat ient costs. The B.C. Health Association summary of responses concluded that the Role Study Document described a c l a s s i f i c a t i o n method for acute inpatient functions only and was r e s t r i c t i v e in c l a s s i f y i ng ambulatory, B.C. Health Associat ion, "Hospital Role Study - Summary of Responses from Health Care Industry, B.C.H.A., Vancouver, 1980, p. 12. - 104 -research and teaching functions. It i s ant ic ipated that a revised document w i l l remedy these def ic ienc ies . Concern has also been expressed by the Jo int Steering Committee that the level of deta i l with in the Hospital Role Study is i n -s u f f i c i e n t to the determination of output measures and costs. A separate document has been developed to address th i s defic iency (Design Concepts Manual, August 1980). 3. Provincia l C l a s s i f i c a t i on Study Closely l inked with the a c t i v i t i e s of the Greater Vancouver Regional Hospital D i s t r i c t 1980 C l a s s i f i c a t i on Study and the Hospital Role Study.is the Emergency;Health Services Commission Provincia l C l a s s i f i c a t i on Study. The Commission appointed a group of experts which endeavoured to c l a s s i f y a l l hospitals in the Province with respect to t he i r emergency capab i l i t i e s in concert with the levels of service i den t i f i ed in the revised Hospital Role Study (to be released in the Fa l l of 1981). The or ig ina l s i x levels of service i den t i f i ed have been augmented to eight. To date, the provincia l c l a s s i f i c a t i o n team appears to have a l i a i s on function t rans lat ing the work done i n the Greater Vancouver Regional Hospital D i s t r i c t into a provincial matrix of emergency - 105 -care with i d e n t i f i e r guidelines consistent with the Hospital Role Study rev i s ion. Of interest i s the legitimacy th i s study gives to the emergency physician as the level of physician s pec i a l i s t in c l a s s i f i c a t i o n levels D, E and F and the designation that there shal l be a f u l l - t i m e emergency physician d i rector of the Emergency Unit with departmental status. H. CONCLUSION During the past ten years, a number of studies have been i n i t i a t e d in an attempt to improve the del ivery of emergency health care in the province of B.C. Many of these a c t i v i t i e s were pr imar i ly planning studies on resource capab i l i t i e s and these studies were concentrated in the G.V.R.H.D. where problems in the organization and del ivery of emergency care were most acute. Planning studies were pr imar i ly ad hoc in nature and the data co l l ec t i on mechanisms were not continued beyond the study period. With the i n i t i a t i o n of the Jo int Hospitals Funding Project, there was a s h i f t in focus toward the i den t i f i c a t i on of ongoing operational data in both planning and management purposes and attempts to integrate planning and operational needs for information were- evSdent '.for*$$e~tfirst":t.ime. - 106 -CHAPTER SUMMARY Preceding chapters have traced the e x p l o s i v e growth i n Emergency Department u t i l i z a t i o n as s u b s t i t u t e s f o r p h y s i c i a n o f f i c e s , the t h r u s t s i n the l i t e r a t u r e towards c l a s s i f i c a t i o n of c a p a b i l i t i e s and the l a c k of concurrent development i n information systems to meet the emerging management needs of emergency departments. This chapter reviews recent a c t i v i t i e s i n B.C. where q u a l i t y con-s i d e r a t i o n s are paramount. The emergence of the Emergency P h y s i c i a n , the Emergency Nurse and the paramedic as new c l a s s e s of p r o f e s s i o n a l s has l e d to a questioning of current standards of emergency care. Not only has d i s a s t e r planning come to the f o r e -f r o n t but a l s o ongoing day-to-day opera t i o n a l requirements are of more importance. B e t t e r information systems are necessary to plan, d e s c r i b e , evaluate and monitor emergency care. The s t u d i e s by the Greater Vancouver Regional Hospital D i s t r i c t and the p r o v i n c i a l C l a s s i f i c a t i o n Study were described i n order to focus the s p e c i f i c data elements t h a t may be useful i n an emergency information system. Role and e f f i c i e n c y c o n s i d e r a t i o n s have emerged with the J o i n t Hospital Funding p r o j e c t , i n r e c o g n i t i o n of the f a i l u r e of the e x i s t i n g funding system to match resources to a p r e v i o u s l y i d e n t i f i e d and agreed upon r o l e . - 107 -In concert with the objectives of th i s study, two pol icy or planning foci were derived from the l i t e r a t u r e - the "mopping-up ro le " ( u t i l i z a t i o n ) of emergency departments and the disaster planning ( c l a s s i f i c a t i on ) capab i l i t i e s of the departments. Focusing upon these two areas in addit ion to the ongoing operational needs of managers, allows one to derive data elements that may be useful to an emergency department's information system. - 108 -CHAPTER V IDENTIFICATION AND VALIDATION OF EMERGENCY DEPARTMENT INFORMATION NEEDS A. MATRIX OF INFORMATION NEEDS At the conclusion of Chapter I I I, a matrix was developed which l inked the s ix leve l s of information needs (patient care through pol icy formulation) with the successively larger .systems (hospital and community) to which the emergency department must re la te . The establishment of th i s framework allows one to extract from the l i t e r a t u r e and review of current a c t i v i t i e s , a l i s t of data elements or information categories that may be potent ia l l y useful to emergency department managers. Chapter IV reviewed the a c t i v i t i e s of professional and government groups. This f a c i l i t a t e s the i d e n t i f i c a t i o n of spec i f i c information needs ofi health status, budget, manpower, etc. which allows one tentat i ve ly to ident i f y the i r relevance to the level of information and to the system of information. For example, the age and sex of patients presenting to the emergency would be i r re levant to management in d isaster s i tuat ions , however of extreme importance to management in normal day to day operations or for planning purposes. - 109 -The fol lowing charts depict a tentat ive i den t i f i c a t i on of the information in each matrix: a) general day to day information needs - Figure 5.1a b) disaster planning/capabi l i t ies - Figure 5.1b c) mopping up/ut i l i za t ion - Figure 5.1c B. THEORETICAL IDENTIFICATION OF INFORMATION NEEDS Further refinement and generation of spec i f i c data elements i s enhanced by the a v a i l a b i l i t y of the matrix and spec i f i c data elements can now be i den t i f i ed . Within the community p r o f i l e , i t i s possible to ident i f y community cha rac te r i s t i c s , population and health resources as potent ia l l y useful information categories. Most of th is spec i f i c information i s ava i lable from a multitude of sources but once i den t i f i ed and co-ordinated, the inventory can be updated at year ly i n te rva l s . Within the hospital p r o f i l e , resource a v a i l a b i l i t y i s paramount. More d i f f i c u l t to measure than an inventory of resources, but more c ruc ia l to effectiveness and e f f i c iency are the i n t e r r e l a t i o n -ships and the int rare lat ionsh ips among sub-systems with in the system; how the hospital related to resources in the community, V Figure 5.1.a GENERAL EMERGENCY DEPARTMENT INFORMATION NEEDS TYPES OF \ I N F O R - \ M A T I O N COMMUNITY/REGIONAL PROFILE HOSPITAL PROFILE EMERGENCY DEPARTS ENT PROFILE POPULATION (CATCHMENT AREA) RESOURCES RESOURCES PAT IENTS/ UTILIZ AT ION USES O f \ INFORMATION COMM (a) D/SE HEALTH/ STATUS ( c ) HEALTH/ SOCjAL NON H/S PROGRAMS MANPOWER COSTS $ MAN EQUIP D (e) EP/ S/E ( f ) CLIN+ D & T (g) OUTCOME (h) CLINICAL PATIENT CARE OPERATIONAL MANAGEMENT QUALITY OF CARE STRATEGIC PLANNING EFFECTIVE-NESS R & D POLICY a) community character ist ics - i . e . major industry, health hazards, potential r i sk b) epidemiological/demographic, socio-economic information - age, sex, residence, income, race c) morbidity and mortal i ty indicators d) other health resources in the community - detox i f icat ion centres, long term care f a c i l i t i e s e) demographic - age/sex f) epidemiological, socio-economic - marital status, race, income g) diagnostic and therapeutic c l i n i c a l information - chief complaint, diagnosis, laboratory/x-ray, etc. h) outcome - dead, discharged, admitted Figure 5.1.b DISASTER PLANNING INFORMATION NEEDS - CAPABILITIES TYPES OF \ I N F O R -\ M A T I O N COMMUNITY/REGIONAL PROFILE HOSPITAL PROFILE EMERGENCY DEPARTS ENT PROFILE POPULATION (CATCHMENT AREA) RESOURCES RESOURCES PAT IENTS/ UTILIZ AT ION USES O f \ INFORMATION COMM (a) D/SE EPID W HEALTH/ STATUS ( c ) HEALTH/ SOCJAL NON H/S PROGRAMS MANPOWER COSTS $ MAN EQUIP D (e) EP/ S/E ( f ) CLIN+ D & T (g) OUTCOME (h) CLINICAL PATIENT CARE OPERATIONAL MANAGEMENT QUALITY OF CARE STRATEGIC • PLANNING EFFECTIVE-NESS R & D POLICY a) community characteristics - i.e. major industry, health hazards, potential risks b) epidemiological/demographic, socio-economic information - age, sex, residence, income, race c) morbidity and mortality indices d) other health resources in the community - detoxification centres, long term care f a c i l i t i e s e) demographic - age/sex f) epidemiological, socio-economic - marital status, race, income g) diagnostic and therapeutic clinical information - chief complaint, diagnosis, laboratory/x-ray, etc. h) outcome - dead, discharged, admitted. Figure 5.1.c MOPPING-UP NEEDS - UTILIZATION TYPES OF INFOR-.MAT ION USES OF INFORMATION^ CLINICAL PATIENT CARE OPERATIONAL MANAGEMENT QUALITY OF CARE COMMUNITY/REGIONAL PROFILE POPULATION (CATCHMENT AREA) COMM (a) D/SE EP!F HEALTH/ RESOURCES HEALTH/ SpCjAL NON H/S HOSPITAL PROFILE PROGRAMS MANPOWER COSTS EMERGENCY DEPARTMENT PROFILE RESOURCES MAN EQUIP PATIENTS/UTILIZATION D (e) "ET7" S/E ( f ) CLTN+ D & T (g) STRATEGIC PLANNING EFFECTIVE-NESS R & D POLICY a) community character ist ics - i . e . major industry, health hazards, potential r i sks b) epidemiological/demographic, socio-economic information - age, sex, residence, income, race c) morbidity and mortal i ty indicators d) other health resources in the community - detox i f icat ion centres, long term care f a c i l i t i e s e) demographic - age/sex f) epidemiological, socio-economic - marital status, race, income g) diagnostic and therapeutic c l i n i c a l information - chief complaint, diagnosis, laboratory/x-ray, etc. h) outcome - dead, discharged, admitted - 113 -how the emergency department s t a f f relates with one another and with other departments. This i s " s o f t " information which contributes s i g n i f i c an t l y to the effectiveness of patient flow through the emergency room. Within the emergency department p r o f i l e , information on patients and resources i s c r i t i c a l . Complete and accurate information developed through patient documentation provides the foundation for a c t i v i t y , u t i l i z a t i o n , patterns of practice and role information. Following i s a more complete i den t i f i c a t i on of the information potent ia l l y useful to emergency room managers. Figure 5.2.a Community P ro f i l e Figure 5.2.b Hospital P r o f i l e Figure 5.2.c Emergency Department P ro f i l e C. NOMINAL GROUP VS. DELPHI PROCESSES Recognizing the d i ver s i t y of ro le s , interests and management pos i t ions, there was a need to ident i f y a methodology to reach a consensus on the range of information required. One of the premises of this study i s that the level of aggregation of the data necessary for managers Figure 5.2.a COMMUNITY PROFILE Community Characterist ics Population Health Resources Major industry - agr icu l ture - mining - logging - industry Transportation Systems - highway acce s s i b i l i t y Special Problems - hazards - ski h i l l s - summer resorts - transportation of chemicals - Unemployment Level - Transient Population - communes - immigrants by SD, RHD, Community/ Municipal ity Population by - age - sex - race - marital status - income - poverty vs. a f f l uence Morbidity and Mortal i ty - deaths by major cause - traumas Morbidity -- medical emergencies - chronic diseases Health a) hospital beds by program/ sub program hospital ambulatory care programs b) ambulance EHSC c) other health/social resources 1) mental health a v a i l a b i l i t y ; and types 2) public health a v a i l a b i l i t y and types 3) LTC f a c i l i t i e s - capacity 4) detox i f i ca t ion centres, etc. Physician supply by specia lty Figure 5.2.b HOSPITAL PROFILE Hospital Character ist ics Programs/Profile Manpower Costs Geographic a c ce s s i b i l i t y - travel time matrix a) Beds - inpatient beds by program/sub program - occupancy rate by program/sub program - admissions through E.R. b) Ambulatory Care Programs - type by hours of operati on c) A n c i l l i a r y Services - diagnostic and therapeutic - type by hours of operation Medical s t a f f p r o f i l e - by spec ia l ty and status, i . e . act ive/ consultant Hospital s t a f f p ro f i l e - by category A v a i l a b i l i t y of resources to Emergency - on c a l l system - in-house (24 hrs/day) By program - volume - budget to actual 1 ; f ixed - program - program variable Figure 5.2.c EMERGENCY DEPARTMENT PROFILE RESOURCES PATIENTS Hours of operation # E.R. stations rooms - quiet rooms - minor treatment - reception - family Manpower types and numbers per s h i f t RN's E.P. Social Workers Workload - performance Supplies/Equipment - monitors Costs f ixed costs program costs program variable costs # times OR plugged - overtime - budget to actual Patients -by catchment area (SD) -age/sex -race family MD -occupation -income -marital status -day and time of a r r i v a l demographic socio-economi c C l i n i ca l i : patients by some c l a s s i f i c a t i o n , .e. - symptoms/diagnosis/chief complaint - severity la lb 2a 2b 3 4 mode of a r r i va l emergent, urgent, non-urgent trauma cases ) medical emergencies ) treatments/tests length of time in E.R. Outcome # admitted to hospital admi tted di scharged back door G.P. vs. others # discharged deaths # transfers s e l f - follow up - community agency to other f a c i l i t i e s - 117 -varies with the pos i t ion. The emergency nurse or physician would require very complete information p r i n c i pa l l y about qua l i ty of care on a routine basis, whereas the administrator would require information p r i nc ipa l l y about cost, e i ther less frequently or on an exception basis. The l i t e r a t u r e i s replete with studies on the effectiveness of indiv idual versus group methodologies to generate ideas for problem solving and decision making. Delbecq,. Van den Ven and Gustafson (1975) c i t e a number of studies which demonstrate the super ior i ty of group methods with-respect to both the quantity and the qua l i ty of ideas generated. The Nominal Group Technique and the Delphi Technique are two group methodologies frequently used where indiv idual judgements must be tapped and combined in order to arr ive at decisions for a group which cannot be calculated by one person. These problem-solving or idea generating strategies are ideal for th i s study where consensus on the emergency department information needs of a l l hospitals i s required. As Delbecqij;. Van den Ven and Gustafson (1975) state in the i r comparison of the two methodologies, the techniques are s t r i k i n g l y simi l a r : - 118 -F i r s t , both rely on independent indiv idual work for idea generation. In the Delphi process, i so lated and t yp i c a l l y anonymous respondents independently write t he i r ideas or reactions to a questionnaire. ..NGT group members wr ite the i r ideas on a sheet of paper in s i lence, in the presence of other group members seated around a table. Second, indiv idual judgements are pooled in both techniques. Delphi respondents mail t he i r completed questionnaires to the design and monitoring team who in turn pool and co l l a te the judgements of the respondent group in a feedback report. In NGT, the judgements of the group members are pooled via the round-robin procedure, wherein the ideas of each member are presented to the group and written on a blackboard or f l i p chart. Third, both allow for an idea-evaluation stage. In the Delphi process, the monitoring team mails the feedback report to the respondent group and each respondent i n -dependently reads, evaluates and interprets the ideas on the feedback report. In NGT, the group discusses verba l ly , c l a r i f i e s and evaluates each of the indiv idual ideas of group members that were wr i t ten on the blackboard or f l i p chart. F i n a l l y , in both processes, mathematical voting procedures are used (eg. rank-order or rat ing methods) and the group decision i s arr ived at by a mathematical decision rule., for aggregating the indiv idual judgements. The Nominal Group Technique was selected as the decision-making process because i t has the fol lowing properties: a) equal par t i c ipat ion in the presentation of ideas b) increase in problem-mindedness Delbecq, Van den Ven, Gustaf son.Group Techniques for Program Planning: A Guide to Nominal Group and Delphi Processes, Scott, Foreman and Company, Glenview, 111., 1975, p. 17. - 119 -c) depersonalization - the separation of ideas from personal i t ies d) increase in the a b i l i t y to deal with a larger number of ideas e) tolerance of c on f l i c t i n g ideas f) encouragement of addit ional ideas through process of association 2 g) provision of a wr i t ten record and guide Time constraints and the nature of the process of concensus made the Nominal Group Technique more viable than the Delphi and f a c i l i t a t e d the generation of soft data. This method i s more rewarding to the part ic ipants as they have an opportunity for the exchange of ideas and sharing of information. D. VALIDATION OF EMERGENCY DEPARTMENT INFORMATION NEEDS 1. The F i r s t Panel of Experts - Nominal Group Technique Four i n s t i t u t i on s with in the Greater Vancouver Regional Hospital D i s t r i c t - two community f a c i l i t i e s and two t e r t i a r y f a c i l i t i e s , were selected to provide an adequate cross-representation of concerns and p r i o r i t i e s . The select ion of these f a c i l i t i e s allowed one to provide d i f f e r i ng perspectives on emergency room information needs because of differences in l oca le , type of pat ients, teaching 2 Ib id, P. 47. - 120 -ro le , case mix, catchment area, s ta f f i ng patterns and s ize of f a c i l i t y . Experts were selected because of the i r ex i s t ing roles with in the f a c i l i t i e s - Medical Director, Emergency Physician, Head Nurse and Administrator and because of the i r additional expertise in accred i tat ion, disaster planning, regional hospital planning and emergency documentation. Of f i n a l interest were the i r a f f i l i a t i o n s with professional groups such as the Emergency Nurses Group and the Health Administrators' Association of B.C. In advance of the meeting, the part ic ipants were c i rcu lated with the abstract of the study, an explanation of the Nominal Group Technique and the matrix which i den t i f i ed s i x levels of information needs and the categories of type of information which would focus somewhat t he i r thinking in generating ideas (Appendix A). In round robin format, each indiv idual generated data elements (age/sex of pat ients ) , information categories (sever ity c l a s s i f i c a t i on ) or soft data (the relat ionships of the emergency room with community soc ia l serv ices) , which he deemed of importance. Information was then pr io r i zed into " e s sent i a l , nice to know and not necessary" and further c l a s s i f i e d into the frequency with which the - 121 -information must be generated and report; 1) monthly, 2) year ly, and 3) i n i t i a l l y or upon opening and updated regular ly , to be of value to the decision-makers. The fol lowing pages l i s t the needs for information as i den t i f i ed by the panel of experts in two ways: a) information by p r o f i l e - community, f igure 5.3.a; ho sp i ta l , f igure 5.3.b; and emergency department, f igure 5.3.c; and whether i t i s ' e s s e n t i a l ' , 'n ice to know', or 'not necessary'. b) essential data is categorized into 'hard ' and ' s o f t ' information and i t s frequency of reporting i s indicated in figures 5.3.d and 5.3.e. Figure 5.3.a COMMUNITY PROFILE Community Characterist ics Population Health of Non-Health Resources Major industry* economic development in community, i .e . False Creek, B.C. Place Hazards* - airports - chemical plants Stable or transient population1* Types of Patients in Catchement Area* - age/sex - socio-economic Health a) acute beds per 1,000 pop.** long term care* # community hosp i ta l s * * b) EHSC-avai labi l i ty of* - ambulance - advanced l i f e support (paramedics) c) a v a i l a b i l i t y and l i a i s on with socia l serv ices* d) physician patterns of p rac t i ce * * e) communication systems among f i r e , po l i ce , EHSC and hosp i ta l * f ) protocols for transfer of patients from other communities* g) a v a i l a b i l i t y of private funds in community*** hi) a v a i l a b i l i t y of government resources to develop programs** * essential * * nice to know * * * not necessary INFORMATION NEEDS OF HOSPITAL DECISION MAKERS Figure 5.3.b HOSPITAL PROFILE Hospital Characterist ics Programs/Profile Manpower Costs Po l i c i e s and Procedures* Teaching Commitment** Geographic relat ionship of hospital to other hospitals - community or teaching** Relationships of emergency room to x-ray/lab/ operating room/blood bank* Patterns of Practice of ^Physicians on S ta f f * * - back door admissions - prescr ipt ions - over serv ic ing Hospital and Medical S taf f P r o f i l e by Category* re fer ra l patterns to emergency room medical economics A v a i l a b i l i t y of spec ia l t i e s and resources to emergency department* - in-house 24 hrs/day - on-ca l l * essential * * nice to know * * * not necessary EMERGENCY DEPARTMENT PROFILE Figure 5.3.C Emergency Department Information Needs Organization Resources P a t i e n t s P o l i c i e s , procedures, p r o t o c o l s ; communication system, t r a n s f e r of r e s p o n s i b i l i t i e s * Triage p o l i c i e s * P o l i c y re: deterrent f e e s * P a t i e n t flow to radiology and la b o r a t o r y r e l a t i o n s h i p to blood bank* Medicolegal r e s p o n s i b i 1 i t i e s * Emergency Departmental Status* ( s o f t ) Peer review and au d i t * ( m o r t a l i t y and morbidity rounds) Nurse-physician r e l a t i o n s h i p s * Physical l a y o u t * i n c l u d i n g : # ER s t a t i o n s - quiet rooms - paeds - ENT - p s y c h i a t r i c Manpower* - types and numbers and s k i l l s per s h i f t * - RN and EPs, s o c i a l workers - c l i n i c a l s k i l l s of s t a f f - EPs vs GPs Transfer of r e s p o n s i b i l i t y * P h y s i c i a n p r o f i l e * - ER p r i v i l e g e s of MDs - l i m i t s of r e s p o n s i b i l i t y Costs* - of resources budget to actual D i s a s t e r c a p a c i t y * P a t i e n t p r o f i l e - by geographic area* - age/sex* - demographic and s o c i o -economic** C I i n i c a l * c h i e f complaint and nature of i n j u r y p a t i e n t s c a t e g o r i z a t i o n -emergent, urgent, non-urgent u t i l i z a t i o n of lab and x-ray Length of time i n ER* Family p h y s i c i a n * Problem category** - j a i l - psychotics - a l c o h o l i c s Outcome # admitted to h o s p i t a l * d i s p o s i t i o n * * Workload measurement* * e s s e n t i a l ** nice to know *** not necessary HARD DATA Figure 5.3;.d ESSENTIAL INFORMATION To Know I n i t i a l l y and be Updated as Necessary Monthly Reporting Annual Reporting Types of p a t i e n t s i n catchement area, age/sex, socio-economic - Hazards i n Community - Health f a c i l i t i e s a v a i l a b l e i n community - Other acute h o s p i t a l s - EHSC - ambulance - pr e - h o s p i t a l care - paramedics ALS - major i n d u s t r y economic development - p h y s i c a l layout of Emergency Department Mode of a r r i v a l of p a t i e n t s P a t i e n t p r o f i l e - demographic - age/sex - c l i n i c a l - d i a g n o s t i c - t h e r a p e u t i c - outcome - s e v e r i t y c a t e g o r i z a t i o n Family physician - # admissions to emergency room - workload measurement - costs Morbidity and m o r t a l i t y information as per audits and peer review ( i d e n t i f i c a t i o n through p a t i e n t p r o f i l e of o v e r u t i 1 i z a t i o n by p a t i e n t s and o v e r s e r v i c i n g by physicians i n the emergency room) - Total number of p a t i e n t s by s e v e r i t y category by s h i f t S t a f f mix and t r a i n i n g and s k i l l s - by s h i f t - RNs - S o c i a l Workers S t a f f p h y s i c i a n p r i v i l e g e s i n the emergency room A v a i l a b i l i t y of s p e c i a l t i e s to emergency room - in-house - onOcall D i s a s t e r c a p a c i t y SOFT DATA Figure 5.3ie ESSENTIAL TO KNOW To Know I n i t i a l l y and be Updated as Necessary To Know Monthly To Know Annually P a t i e n t flow to radiology, l a b , blood bank F u l l departmental status? Deterrent fee p o l i c y L i a i s o n and a v a i l a b i l i t y of s o c i a l s e r v i c e s i n c l u d i n g long term care E f f e c t i v e communication with EHSC Mechanisms ( p o l i c i e s and proto-c o l s ) f o r t r a n s f e r s of p a t i e n t s from other f a c i l i t i e s Nurse-physician r e l a t i o n s h i p s Medicolegal compliance P o l i c i e s re: t r a n s f e r of fun c t i o n P o l i c i e s and procedures of h o s p i t a l and of emergency room Peer review and audi t p o l i c i e s Triage p o l i c i e s - 127 -2. Second Panel of Experts A second panel of experts was selected to ensure that the i n fo r -mation p r i o r i t i e s i den t i f i ed by the f i r s t panel were in fact representative of the needs of Greater Vancouver Regional Hospital D i s t r i c t decision-makers. Rather than repeat the Nominal Group Technique and match outcomes, the second group of reviewers was simply c i rcu lated the results of the f i r s t panel and asked to comment as to the appropriateness of items selected and to make any additions or deletions to the information i den t i f i ed (Appendix B). Of the four members surveyed, the two nursing managers were in tota l agreement with the types and scope of information i den t i f i ed by the f i rst panel. The Administrator of a community hospital i den t i f i ed three addit ional types of information to be co l lected under patient data: i ) the length of time the patient spent in the emergency room pr io r to the physic ian ' s a r r i v a l , i i ) why patients were discharged to another acute f a c i l i t y -was th i s because of the severity of the patient upon a r r i va l or because of a lack of a v a i l a b i l i t y of inpatient beds? - 128 -i i i ) the hour rather than the s h i f t in which the patient arr ived at the f a c i l i t y . ( I t was f e l t that unava i l ab i l i t y of physicians outside of o f f i c e hours contributed to the increase in v i s i t s a f te r 5 p.m.). This Administrator also noted that mode of a r r i va l and d i spos i t ion of patient (to home, to family MD) was of l i t t l e interest to administrat ion. The Ministry of Health representative f e l t that in addition to health f a c i l i t i e s in the community an inventory of non-health resources should be made (schools, community centres) in order to i dent i f y back-up bed f a c i l i t i e s where MASH units could be set up. Also, while the a v a i l a b i l i t y of back-up physician spec ia l t i e s to the emergency room was i d e n t i f i e d , i t was f e l t that some time frame or time l i m i t be established to determine how long i t would take to receive/obtain these spec ia l ized manpower resources. Other than these minor expansions of information needs i den t i f i e d , no dramatic changes in emphasis of the f i r s t panel of experts was noted. It i s worthy to note, at th i s point in time, that very few items generated i n i t i a l l y by round-robin technique were subsequently - 129 -evaluated as "not necessary". Whether th i s phenomenon i s a result of the fact that professionals are hesitant to denegrate the ideas of other professionals or whether the level of expertise of the panel members present was such that the items selected were indeed c r i t i c a l or of secondary importance to emergency department managers, remains to be seen. However, none of the items added by the second panel were i den t i f i ed and then discarded by the f i r s t panel. E. CONCLUSION To f a c i l i t a t e analysis of the information i den t i f i ed as essential by the two panels of experts drawn from GVRD hospitals and government, i t may be helpful to relate the data elements back to the o r i g ina l matrix of information hierarchies. 1. Levels 1, 2 and 3 - Patient Care and Management and Quality of Care The fol lowing data elements were i den t i f i ed as e s sent ia l . These elements form the majority (75%) of information needs. Emergency Department Information a) Hard Data i ) resources - physical f a c i l i t i e s , i . e . emergency room stat ions, quiet rooms, paediatr ic rooms, etc. - 130 -- manpower - types and numbers per s h i f t - costs - budget to actual i i ) pat ient ' s p r o f i l e - demographic ) and ) - socio-economic- 1) i . e . by geographic area age, sex, socio-economic - time and mode of a r r i v a l (EHSC, Po l i ce , se l f ) - c l i n i c a l - patients by ch ief complaint/ nature of in jury - patient severity c l a s s i f i c a t i o n , i . e . emergent, urgent, ambulant - u t i l i z a t i o n of laboratory and x-ray - length of time in emergency room - outcome - admitted to hospital - discharged/died workload measurement b) Soft Data - po l i c ie s and procedures, protocols - communication systems - transfer of re spons ib i l i t y - medicolegal r e spons ib i l i t i e s - departmental status of emergency room - peer review and audit - nurse-physician relat ionships - physician p ro f i l e s - i . e . p r i v i l eges/ l im i t s of re spons ib i l i t y , - d isaster capacity - 131 -Hospital Information a) Hard Data i ) character i s t i c s - locat ion of hospital to other community and teaching hospitals i i ) programs - physical re lat ionships of emergency room to laboratory, x-ray, blood bank, operating room - type by hours of operation for patient flow i i i ) manpower - hospital and medical s t a f f p r o f i l e by category - a v a i l a b i l i t y of medical spec ia l t ie s and hospital resources to emergency - in-house or on-cal l system. b) Qual i tat ive Soft Data - po l i c ie s and procedures - teaching commitment - patterns of practice of physicians on s t a f f ( i . e . back door admission, prescr ipt ions, overserving, re fer ra l s to emergency room, medical economics). 2. Level 4 - Strategic Planning Information Including Disaster The fol lowing data elements may be i den t i f i ed as pertaining more to s t rateg ic planning: i ) character i s t i c s - major industry/economic development - hazards - transient or stable population - 132 -i i ) population - demographic - age, sex and socio-economic in catchment area i i i ) resources health - by type of -hospital - long term care f a c i l i t i e s - EHSC - a v a i l a b i l i t y of social services iv) soft data - r e l a t i o n s h i p s / l i a i s o n with social services - physician patterns of practice - a v a i l a b i l i t y of communication systems among f i r e , police EHSC and hospital - protocols for transfer of patients from other hospitals - a v a i l a b i l i t y of private funds in community (for equipment/ programs) - a v a i l a b i l i t y of government resources to develop programs. :._ .Level 5 and 6 - Research and Development and Policy Formulation While no information can be uniquely i d e n t i f i e d as contributing to a data base for policy formulation and research and development, i t may be inferred that components of such a system have previously been i d e n t i f i e d . However, no s p e c i f i c questions or needs were so id e n t i f i e d by virtue of the position of those present. - 133 -3. Ident i f i cat ion of "Soft Data" While the analysis of the information needs so i den t i f i ed by the emergency department users w i l l be undertaken in Chapter VI, i t i s worthy to note at th i s point, the amount of " sof t data" deemed essential by the users. Po l i c ie s and procedures, relat ionships to external health and soc ia l agencies were i den t i f i ed by the panel as contr ibuting s i g n i f i c an t l y to the effectiveness and e f f i c i ency of the emergency room. While the matching of the hard data i den t i f i ed through the matrix with that i d e n t i f i e d by the users y ie lded no surprises and was f a i r l y consistent with that i d en t i f i ed previously, a number of c r i t i c a l issues in emergency care management were discussed in great d e t a i l . It i s th i s soft information that needs to be explored through two avenues - i t s impact on e f f i c iency once quant itat ive output measures have been i den t i f i ed and the degree '.: to which patient care outcomes can be enhanced. While the object of th i s study i s l imi ted to the i den t i f i c a t i on of quant i f iab le information which w i l l contribute to the develop-ment of e f f i c iency and effectiveness measures, i t would be appropriate to review b r i e f l y , i f not analyse as yet, some of the - 134 -soft information i den t i f i ed by the Nominal Group. While hard data such as age, sex i s self -explanatory, other concerns are less expl i c i t . Administrative po l i c ie s and procedures can f a c i l i t a t e or impede the effectiveness of the emergency department, and i t s relat ionships with laboratory, x-ray, blood bank are c r i t i c a l . Po l i c ie s must be cohesive to ensure the support services complement the non-predictable and uncertain patient load in the emergency room. Ful l departmental status for the emergency department i s s t i l l a r e l a t i v e l y new concept to B.C. hospita ls . Ful l recognition of the emergency room on an equal status and plane with other medical services such as the department of surgery i s valued by emergency physicians as an important step to ensure an equal voice in medical a f f a i rs. The issue of deterrent fees to prevent unnecessary u t i l i z a t i o n on the part of emergency department users remains a pol icy decision best l e f t at the local l e ve l . The Ministry of Health co-insurance fee of $2.00 for emergency care has been in existence for 30 years and in no way re f lec t s the average cost of a v i s i t . Some hospitals have implemented a $20.00 or $30.00 fee over and above the co-insurance in an attempt to deter those indiv iduals with sore - 135 -throats who "abuse" the department. Good communication and l i a i s on with other hospita l s , social services and the Emergency Health Services Commission can improve the u t i l i z a t i o n of the emergency department through advance warning of emergencies, appropriate re fer ra l s to emergency and speedy d ispos i t ion of patients once treated. Poor communications and l i a i s on can e f f e c t i v e l y plug the emergency room with patients who should not be there. The expectations of s t a f f v ia -a -v i s administration need to be i den t i f i ed and monitored. What l im i t s are placed on decision making? Who has the authority to admit or transfer patients or to close the emergency room? Who has the authority to monitor what treatments family physicians can carry out in the emergency room and to deny these physicians t he i r " r i gh t " to perform certa in procedures? What are the peer review and audit po l ic ies ? Is peer review s t i l l a medical function or i s i t review on an i n te rd i s c i p l i na r y basis? Are physicians and nurses conjo int ly involved in decision making process to revise departmental po l i c ie s or procedures? Or i s the nurse s t i l l the handmaiden of the physician? The soft issues i den t i f i ed w i l l be discussed in further deta i l in - 136 -the next chapter. Suff ice to say that hard data i s only part of the p icture, more remains to be done in th i s area. CHAPTER SUMMARY Through a synthesis of the l i t e r a tu re on emergency department c las s -i f i c a t i o n and u t i l i z a t i o n , a review of the state of the art of inform-ation systems and an i den t i f i c a t i on of the major issues in emergency health care in B.C., i t was feas ib le to assign spec i f i c data elements to the matrix of information needs. Three pro f i le s were developed - the community, the hospital and the emergency department - in order to f a c i l i t a t e the generation of unique data elements. The Nominal Group Technique was employed on a representative group of Greater Vancouver Regional Hospital D i s t r i c t decision makers to i dent i f y essential data elements. A further va l idat ion was assured by questionnaire to a second group of experts. The information deemed essential was then matched to the theoret ical i d en t i f i c a t i o n of needs. Results showed that the majority of data elements deemed essential could be c l a s s i f i e d as pertaining to patient flow through, qua l i ty of care, management and s t rateg ic planning. - 137 -CHAPTER VI ANALYSIS, RECOMMENDATIONS AND CONCLUSIONS A. INFORMATION PRIORITIES In the preceding chapter, an attempt was made to val idate the information needs of emergency department decision makers and to p r i o r i ze essential information. In addit ion to hard data needs, a number of soft issues not previously i den t i f i ed emerged as an integral part of the information system. Although s i x hierarchies of information needs - patient care or flow through, departmental management, qua l i t y assurance, strategic planning, research and development and pol icy formulation - were presented to the panel members, in order to encourage a wide var iety of responses p r i o r to consensus seeking, the p r i o r i t i e s fo r information were l im i ted to the f i r s t four levels only. Indeed, nearly 75% of the information considered essent ial could be categorized as patient care or management information derived from patient documentation. Community resources, emergency department resources and patient data, together with the relat ionships among the subsystems and systems were the focal point of in teres t . - 138 -Whether th i s outcome i s a resu l t of the fact - that the higher levels of information needs, re l a t i ve to research and develop-ment and pol icy formulation are derived from a manipulation of lower leve l s of data, or whether th i s focus arises from the dominance of the professional care giver rather than the administrator remains to be seen. One possible and quite feas ib le explanation of the preponderance of c l i n i c a l and management information i s the composition of the f i r s t panel. Although the focus of th i s study i s the develop-ment of an information system for emergency department decision makers, the i n i t i a l presence of a Ministry of Health representative may have influenced the outcome of the del ineation of essential information. In add i t ion, recent direct ions with in the Ministry of Health from health programs to f i s c a l accountabi l i ty may have influenced the information se lect ion. However, the f u l l impact of the dominance of Treasury Board s t a f f on the Ministry of Health and hospitals has yet to be seen. The dominance of cost and e f f i c i ency information ( s im i la r to that proposed by the Jo int Hospital Funding Project - Uniform Reporting System) was not evident. If the Study had been done - 139 -12 months l a t e r , perhaps th i s over-r id ing concern for cost data would have been demonstrated. It i s , however, also possible that the outcome i s consistent with the nature of the organizational structure which characterizes professional bureaucracies. In order to analyse the results in l i g h t of professional power and cont ro l , a review of the nature of organizational structures, pa r t i cu l a r l y the professional bureau-cracy, would be he lp fu l . B. THE HOSPITAL AS A PROFESSIONAL BUREAUCRACY Henry Mintzberg (1979) in The Structure of Organizations developed organograms which conceptually categorize organizations into structural configurations based upon the f i ve basic components of a l l organizations - the s t rateg ic apex (top management), the technostructure, the middle l i ne (managers), the support s t a f f and the operating core. Mintzberg's thesis i s that most organizations f a l l c losely into one of his f i ve configurations - the Simple Structure, the Machine Bureaucracy, the Professional Bureaucracy, the D iv i s iona l ized Form and the Adhocracy - and that the organizat ion ' s effectiveness depends - 140 -upon how well the organization harmonizes the elements, which describes each set of configurations. When managers and organizations t r y to mix and match the elements of d i f ferent configurat ions, organizational effectiveness is o f f set by poor design. Diagram 6.1 on the fol lowing page depicts Mintzberg's configuration of the professional bureaucracy. In the hospital se t t ing , neither the technostructure where analysts ass i s t the organization to adapt to i t s environment through standard-i za t ion of techniques nor the middle l i ne management is highly v i s i b l e . Rather the professional bureaucracy i s characterized by a dominant operating core of professionals (physicians) who by v irtue of t he i r expertise in health care, the major output of the hosp i ta l , maintain considerable control over t he i r own work. The professional bureaucracy re l i e s for co-ordination on the standardization of professional s k i l l s which are gained through t ra in ing and indoctr inat ion. It hires duly trained and operating spec ia l i s t s for i t s operating core and then gives them considerable control over t he i r own work. The dilemma ar i ses , however, because the standards, values and objectives of the professional bureaucracy or ig inate large ly outside the organizational structure, in the Figure 6.1 Professional Bureaucracies Five Component Parts Para l le l Hierarchies Source: Mintzberg, p. 361, Figure 19.4. support s t a f f - 142 -realm of the professional associations. The power of expertise of the medical profession is further enhanced by the Canadian ideology of free and se l f governing professions reimbursed on a fee for service payment method which may place them in c on f l i c t with goals and objectives of the i n s t i t u t i o n . The only other part of the professional bureaucracy which i s highly developed i s i t s support s t a f f element. In the case of hospita ls , these "housekeeping" functions - laundry, d ietary, housekeeping, the anc i l l a r y services such as laboratory, x-ray and pharmacy, and the nursing services - have developed to pro-vide the professional medical care givers with as much support as poss ible, to aid them and to provide routine functions. Figure 6.1 also depicts the professional bureaucracy as one where the t rad i t i ona l roles of l i ne and s t a f f are reversed. Etzioni (1959) as quoted by Mintzberg (1978) states: in professional organizations the staff -expert l i ne manager co r r e l a t i on . . . i s reversed... Managers in professional organizations are in charge of secondary a c t i v i t i e s , they administer means to the major a c t i v i t i e s car r ied out by experts. In other words, i f there i s a s t a f f - l i n e re lat ionship at a l l , experts const itute the l i ne (major authority) structures and managers the s t a f f . . . t he f i na l internal decision i s , funct iona l ly speaking, in the hands of various professionals and t he i r . decision making bodies. Mintzberg, Henry, The Structuring of Organizations: A, Synthesis of the Research, Prentice Hall Inc., Englewood C l i f f s , New Jersey, 1978, P. 52. - 143 -Common to hospital organizations and professional bureaucracies in general, are dual administrative hierarchies or l ines of authority - one for the medical s t a f f - the operating core - and another for the support hospital s t a f f . To the professional operating core, the medical s t a f f organization i s a democratic bottoms-up structure where a great deal of power rests with those at the bottom. Professional expertise and s k i l l i s not l imi ted to those in administrative department head or ch ief of s t a f f pos i t ions, a phenomena of the machine bureaucracy. Rather the power rests with expertise and s k i l l re f lected through peer status. While th i s anomaly seems democratic to those professionals with in the hosp i ta l , i t does raise s i tuat ions of confrontation between administration and medical s t a f f and among the medical s t a f f themselves when resource a l l oca t i on decisions can be influenced by those at the operating core. In contrast to the bottom-up structure of the medical s t a f f , the support s t a f f hierarchy resembles a tops-down machine bureaucracy structure where power and status reside in administrative o f f i c e . The role of the professional administrator in the midst of th i s dual authority i s one of negotiat ion, f a c i l i t a t i o n , implementation and boundary spanning. The administrator is often in the unenviable pos it ion of balancing the demands of the medical s t a f f with the - 144 -health care service and needs of the community within the resources a l located to the f a c i l i t y by government. The administrator can, however, have a great deal of power because he operates at the locus of uncertainty and must reconci le the forces of the board of management, the physicians and external agencies. He i s , however, somewhat thwarted in his e f fo r t s at promoting e f f i c i e n t operations by a large operating core over which he has l i t t l e contro l . The administrator ' s needs for information are therefore less detai led although they en-compass more domains. For example, the administrator as boundary spanner must continuously monitor the external environments - the community, government funding, socio-economic developments, etc. -in order to f a c i l i t a t e - the del ivery of health care with in his own i n s t i t u t i on and he must also keep apprised of the a c t i v i t i e s of the support s t a f f over which he has vested authority. C. THE POWER OF EXPERTISE OF PHYSICIANS Professionals j o i n organizations in order to share resources; to establ i sh contact with other professionals or organizations so that they may increase the i r patient load through re fer ra l and thus en-hance the i r income or because c l i en t s often need the services of more than one professional at the same time. - 145 -Professional controls are perceived by the professionals to be the domain of the professional associations. Thus they struggle to ensure that any measures to modify or impact upon the patterns of practice of the physicians must i n i t i a t e from the operating core -the professionals themselves. While accred i tat ion, medical s t a f f by-laws and capita l equipment funds are controls on physicians external to peer review, the work of professionals i s viewed as being too complex to be supervised by managers, hence peer review or qua l i ty of care/audit mechanisms. The administrator, however, must ensure that the mechanisms for peer review and audit ex i s t . This i s at the basis of the dilemma between the professionals and the strategic apex. While the improvements for qual i ty of care remain with in the j u r i s d i c t i o n of the doctors, i t i s the administrator who controls the purse. Tradeoffs and compromises between cost and qua l i ty must often be made in a f i e l d of l im i ted resources. At the outset of th i s chapter, the preponderance of c l i n i c a l inform-at ion needed to treat emergency patients in an e f fec t i ve and e f f i c i e n t manner was noted. In l i g h t of the theory of organizational structure where power rests with the operating core - the physician - th i s emphasis on service information i s appropriate to the organization. - 146 -The administrative information needs are ones of monitoring of the internal a c t i v i t y rather than c l i n i c a l practice per se and of monitoring of the external environment - community resources, catch-ment area population and physician patterns of practice as they impact upon hospital management. Expert power as opposed to administrative power rests with the medical profession who are viewed as soc ia l gatekeepers to the medical care system. The Emergency Department of the acute general hospital remains a focal point of entry to the health care system. It i s well known with in the community and has the potential and legit imacy to admit, transfer or refer a l l who enter the system through th i s route. However, physicians as gatekeepers to the health care system d i rect the type and amount of medical care provided by other professionals. Watkins (1975) supports Greenwood's de f in i t i on of professionals as those who ranked highly on f i ve d i s t i n c t character i s t i c s " a system-a t i c body of theoret ical knowledge, professional author i ty, the sanction of the community, a regulative code of ethics and 2 professional cu l tu re . " Physicians, by v i rtue of the i r t ra in ing and expertise and l icensure, have unt i l now, in B.C., maintained a professional monopoly over Watkins, C. Ken, Social Control , Longman Group L td . , London, 1975, P. 104. - 147 -medical care. I t i s the p h y s i c i a n who decides what l e v e l of care i s r e q u i r e d , what t e s t s and treatments w i l l be ordered and what other p r o f e s s i o n a l s w i l l become in v o l v e d i n the care and treatment of the p a t i e n t . The physician's p r i o r i t y i s s e r v i c e . I t has been the a d m i n i s t r a t o r ' s r o l e to manage the u n c e r t a i n t i e s i n the environment which w i l l f a c i l i t a t e the physician's p r o v i d i n g good p a t i e n t care. However, i n the 1980's, cost c o n s t r a i n t s are beginning to become more s i g n i f i c a n t and c o n f l i c t s between the p r o f e s s i o n a l core and s t r a t e g i c apex w i l l be more pronounced. D. INFORMATION NEEDS OF THE PROFESSIONAL BUREAUCRACY The information needs of the p r o f e s s i o n a l bureaucracy are r e f l e c t e d i n the response of the Nominal Group. Information c o l l e c t e d i n the broad cate g o r i e s of p a t i e n t s , resources, q u a l i t y of care, p o l i c i e s and procedures and i n t e r - r e l a t i o n s h i p s among systems would appear to s a t i s f y the m a j o r i t y of the information needs of the decision-makers consul ted. The "hard" data information i d e n t i f i e d as e s s e n t i a l i s r e l a t i v e l y s t r a i g h t - f o r w a r d to c o l l e c t through e i t h e r worksheet or in v e n t o r y , i s non-threatening and would l i k e l y be of i n t e r e s t and value to - 148 -describe the a c t i v i t y of the Emergency Room. It i s , however, patient care or flow-through information geared towards improve-ments in the day to day operations of the department. It i s g ra t i f y ing to note, however, that the emergency department and i t s patients were not viewed in i s o l a t i on of the community the emergency department serves, nor in i s o l a t i on of the resources ava i lable in the community. In other words, the department i s not viewed as being a l l things to a l l people and needing to duplicate resources in the community. The soft data, i den t i f i ed as e s sen t i a l , also supported the character i s t i c s of the professional bureaucracy as i den t i f i ed by Mi ntzberg. Ful l departmental status for emergency departments was i n i t i a t e d in the U.S. and emerged as a natural progression from recognition of emergency medicine as a c e r t i f i e d spec ia l ty . In B r i t i s h Columbia, only two hospitals have, or are in the process of f i n a l i z i n g , the emergency department service as a medical spec ia l ty . This remains one instance where the dominance of the professional operating core i s less e f fect i ve than other medical spec ia l t ie s in i t s re lat ionships with administrat ion. However, as c l a s s i f i c a t i o n of Emergency Room capab i l i t i e s through the Hospital Role Study takes - 149 -e f f ec t , th i s trend towards increasing spec ia l i za t ion w i l l become more prevalent in the larger i n s t i t u t i on s . Nurse/physician relat ionships and po l i c ie s regarding the transfer of function i l l u s t r a t e the potential areas of c o n f l i c t between the operating core and the support s t a f f . With the emergence of emergency nursing as a spec ia l ty , ex i s t ing role boundaries w i l l become less d i s t i n c t . Although physicians remain l e g i s l a t i v e l y the diagnosticians and the prescribers of treatment, more functions can be transferred to the more highly trained nurses through hospital " t rans fer of function p o l i c i e s " which recognizes special s k i l l s . Triage po l i c ie s in the Emergency Room contribute s i g n i f i c an t l y to the e f f i c i ency of an Emergency Department. The assignment of an Emergency Nurse to screen incoming patients as to the i r p r i o r i t i e s for care and route patients to ambulatory care departments, i f appropriate, f a c i l i t a t e s the work of the Emergency Physician. Departmental hospital po l i c ie s regarding intake and co-insurance fees can also screen the non-acutely i l l patient. The issue of deterrent fees i s often a source of c o n f l i c t between the professional and support s t a f f on one hand and the Board and Administration on the other. Professionals wish to u t i l i z e the i r - 150 -highly spec ia l ized t ra in ing on a regular basis to maintain s k i l l leve ls and competencies, to have s u f f i c i e n t time to devote to medical emergencies and trauma cases and to provide an environment conducive to good patient care. Administrators as boundary spanning agents attempt to meet community needs through the provision of services not avai lable or accessible in the community. However, the inadequate $2.00 government co-insurance fee provides a budgetary constraint to the provision of services over and above these deemed appropriate. Ea r l i e r in th i s study, a documentation of the cost or e f f i c iency trends of the Joints Hospital Funding Project was undertaken. While cost was i den t i f i ed as an essential element of the emergency depart-ment information system, the emphasis given to cost information was mi nimal. The Jo int Hospital Funding Project theorized the presentation of costs on a program basis with reporting of f ixed costs, program costs and program variable costs. This was not i den t i f i ed by the Panel. However, in a l l fairness to the Panel, the i r i den t i f i c a t i on of information needs was more encompassing than the Jo int Funding Project in a c t i v i t y and patient information. Again, the dominance of the operating core in professional bureaucracies may be evident. - 151 -E. RECOMMENDATIONS At the outset of th i s study, i t was stated that unpredictable work-loads, variable case mix and specia l ized technology and manpower make i t increasingly complex for those involved in the care and management of Emergency Departments to function e f f e c t i v e l y . Lacking was a management information system to plan, describe and manage emergency a c t i v i t y to the sa t i s fac t ion of those involved in the day to day operations of the department. Two major issues were i den t i f i ed in the l i t e r a tu re - the u t i l i z a t i o n of Emergency Departments and the thrusts towards c l a s s i f i c a t i o n or categorizat ion of the Emergency Department's c apab i l i t i e s . From this two major pol icy or planning foci were selected - d isaster plann-ing and the "mopping up" role of the Emergency Department in order to f a c i l i t a t e the i den t i f i c a t i on of user needs. Theoretical needs were i den t i f i ed by a synthesis of the issues i den t i f i ed in the l i t e r a t u r e of Emergency Care, in the past, present and future provincia l a c t i v i t i e s in Emergency Care in B.C. and the objectives and processes of the Jo int Funding Study. Needs were then val idated and pr io r i zed by a panel of experts, the resu l t ing prepon-derance of c l i n i c a l information analyzed in l i g h t of the dominance of the operating core in professional bureaucracies. - 152 -The f i n a l objective of th i s study was to recommend a method of c o l l e c t i o n , analysis and reporting of emergency departments' information. The study stops short of implementation and the development of norms or standards around the data presented. Much of the information i den t i f i ed as essential i s avai lable in some form - population data through B.C. Research Foundation, c l i n i c a l diagnostic and therapeutic data on the pat ient ' s chart, s ta f f i ng and budgetary data through the BCHA Hospital Personnel Management System (HPMS) and community health, social services, economic development and community hazards information through prov inc ia l m in i s t r i e s . Other information, i . e . c l a s s i f i c a t i o n of sever i ty , i s e ither not currently co l lected on a routine bas i s , or the state of the ar t i s not s u f f i c i en t to allow i t s capture, i . e . workload measurement. Therefore, i t i s helpful to develop a schematic representation to integrate ex i s t ing systems and to provide the foundation for the development of, as yet, non existent systems. Figure 6.2 provides an overview of ex i s t ing data co l l ec t i on mechanisms avai lable and used and those ava i lab le but not integrated into a tota l information system. The f igure depicts sources and types of data that were i den t i f i ed as essential by the panel of experts. In the core of emergency department - 153 -Figure 6.2 Schematic Representation of Types and/or Sources of Data Deemed Essential Hazards,. Research Population by age/sex y / - Socio-economic Ministry of Economic Development 7/ /TC /EHSC /^Acute hospitals •>/Social services "CoMiuni ty currently reported but not integrated existing but not reported,, collated and/or integrated - 154 -information l i e s the pat ient ' s c l i n i c a l record from which peer review and audit i s performed. Monthly s t a t i s t i c a l reports are compiled from a reg i s t rat ion log which severely l im i t s the information reported. There i s currently no integrat ion among c l i n i c a l , qua l i t y , f inanc ia l (HPMS) or a c t i v i t y information. Moving outwards from the core of the emergency department i s the hospital system and f i n a l l y the community. Data required from those systems may be co l lected through an i n i t i a l inventory of community hazards and resources. Population and economic develop-ment information are ava i lab le through the provincia l min i s t r ie s . 1. The Patient Abstract At the foundation of a c t i v i t y information i s the pat ient ' s record from which most of the essential u t i l i z a t i o n information can be extracted. Once needs have been i den t i f i ed i t i s a simple matter of designing an appropriate' c l i n i c a l abstract or wbrksheet. Recommendation No. 1 - Patient Abstract THAT a patient abstract or worksheet be developed to co l l e c t patient u t i l i z a t i o n information on a routine basis. The Patient Abstracting System would co l l e c t the fol lowing data elements: - 155 -1. Admission Information: Patient ID - age/sex, postal code, SD/Residence code - date and time of a r r i v a l , time of a r r i v a l of M.D. - mode of a r r i v a l - EHSC, F i r e , Po l i ce , Self - re fer ra l/ fami ly physician, transfer from LTC f a c i l i t y , acute ho sp i ta l , socia l service agency - Emergency Room #, Medical Services Plan #. 2. C l i n i c a l Diagnostic and Therapeutic: Chief Complaint/Reason for V i s i t Drugs, Lab, X-ray, Diagnostic, Therapeutic Interventions Final Diagnosis Severity C l a s s i f i c a t i on - emergent, urgent, minor, admission through ER. 3., Discharge Information: Admitted to Hospital Discharged to Home Died Transfer to Other Hospital To Pol ice Reason for Transfer to Other Hospital Time ready for discharge Time of discharge By manipulation of the data, a number of s t a t i s t i c s or indices can be- generated. For example - length of time in E.R. - patients by age/sex residence code - patients by day of week, hour of admission - patients by severity code - treatment patterns - u t i l i z a t i o n rate over time by category or severity by population. A Patient Abstracting System would have many advantages. It would provide more complete information than i s currently ava i lab le. No - 156 -analysis of Emergency documentation i s currently done except through morbidity and morta l i ty rounds. The a b i l i t y to f l ag " inappropriate" u t i l i z a t i o n , develop documentation to substantiate revis ions in po l i c ie s or procedures and to grasp a c t i v i t y i s en-hanced. A common source document - the chart - w i l l s u f f i ce for a multitude of needs - u t i l i z a t i o n review, determination of case mix, re lat ionship of the E.R. to community f a c i l i t i e s or resources as documented through capturing of admission and discharge data and trends in peak a c t i v i t y periods. Such a system w i l l also f a c i l i t a t e the eventual development of work-load indices which must be a combination of the variables which af fect workload in the emergency room - case complexity, pre-admission work up, length of time in emergency room and resources necessary. I t w i l l also be useful to provide some foundation to re la t ing the s ta f f i ng and budgeting to processes, case mix, trends and emergency room capacity. Figure 6.3 depicts the relationship.and uses of the case abstract. It i s recognized that a patient abstracting system i s expensive to implement in paper form and at th i s stage is probably not cost j u s t i f i e d . However, with the trends toward computerization and - 157 -Figure 6.3 Patient Abstract Financial HPMS Manipulate 4 (13 week periods) C-l-i-n-i-ca.1 Community Services - admitted from discharged to pre-hospital U t i l i z a t i o n review - lab x-ray - peer review qual i ty morbidity and mortal i ty information infect ions complications Workload case mix U t i l i z a t i o n Information - numbers and types of patients by day of the week seasonal f luctuat ions trends - case mix - length of time in Emergency Room - 158 -patient care systems, i t would be a simple /matter to add certa in elements to the data base and manipulate the indices. Merging th i s data base with the f inanc ia l data base would then eliminate many of the current problems with the integration of manual and computerized systems which are not on l i n e . 2. Inventory of Hospital Resources Also of use to the Emergency Department Manager i s an inventory of hospital resources, ava i lable to the emergency room - in terms of beds, and s t a f f i ng . While in some respects th i s i s internal manage-ment information, i t i s also essential for d i saster preparedness, therefore, i t is recommended THAT an inventory of hospital resources be maintained to i den t i f y physician spec ia l t ie s and s k i l l s , s t a f f s k i l l s , ava i lab le or potent ia l l y avai lable to the Emergency Room. 3. Inventory of Community Resources, Hazards and Population Within the community system, the need for population, resource and hazard information was i den t i f i ed by the panel members. Again, an inventory updated annually would be the most e f fect i ve method of data co l l e c t i on . B.C. Research Foundation currently publishes pop-ulation data by school d i s t r i c t . - 159 -Co-ordination of th i s type of information i s a task that could r e a l i s t i c a l l y be undertaken by the Greater Vancouver Regional Hospital D i s t r i c t because such information should be co-ordinated across boundaries to ensure e f fec t i ve co-ordination and l i a i s on of resources. Recommendation No. 3 - Inventory of Community Resources, Hazards and Population THAT the Greater Vancouver Regional Hospital D i s t r i c t maintain an inventory of regional hazards, health and socia l service f a c i l i t i e s and population data for use by i t s member f a c i l i t i e s . F. CONCLUSION At the beginning of the study the fol lowing question was formulated: "What data elements should be co l lected in hospital emergency information systems which w i l l meet external reporting require-ments, be useful to plan, describe and evaluate emergency department a c t i v i t y for the various decision makers with in the hospital system and f a c i l i t a t e the development of e f f i c iency and effectiveness ind icators? " The p r i o r i t y for information ar ises from the needs of the operating - 160 -core, the capturing of c l i n i c a l information which can be manip-ulated and i n t e g r a t e d w i t h f i n a n c i a l i n f o r m a t i o n . Research and development and p o l i c y information was of l e s s importance. However, i t i s reasonable that u n t i l the b a s i c needs f o r information are met, research and development are of l e s s e r p r i o r i t y . The information i d e n t i f i e d i s i n the most part obtainable through e x i s t i n g sources. Once the data base i s developed, norms and standards can be developed. Peer grouping of emergency departments with s i m i l a r case mix w i l l allow one to compare a c t i v i t y and cost information as w e l l as outcome. The i d e n t i f i c a t i o n of population data by age and sex allows one to track u t i l i z a t i o n patterns over time and to t e s t the impact of d i f f e r e n t p o l i c i e s , procedures and programs on u t i l i z a t i o n r a t e s . This study may be considered as a p i l o t p r o j e c t a p p l i c a b l e to the emergency department decision-makers w i t h i n the GVRHD. I t provides the t e c h n i c a l b a s i s to the development of an emergency department, information system which can now be implemented and examined f o r v a l i d i t y by other researchers. Information systems are not s t a t i c . P r i o r i t i e s change w i t h e x t e r n a l i n f l u e n c e s such as the recent i n c r e a s i n g dominance of Treasury Board w i t h i n the M i n i s t r y of Health. This pirophesized s h i f t to f i n a n c i a l i n formation by the M i n i s t r y w i l l increase the need f o r adequate and - 161 -appropriate planning and operational data upon which cap i ta l and operating requests can be cost j u s t i f i e d . In the long run, pol icy formulation cannot be addressed unt i l such information systems are in place and standards and norms established. Future direct ions include the merging of the data bases of the Emergency Health Services Commission for pre-hospital care, Emergency Care and the in-pat ient treatment of those admitted. Pol icy planning decisions on the locat ion and standards of emergency care, s t a f f t ra in ing requirements and the roles of emergency depart-ments are dependent upon a uniform and integrated data base. The soft issues i den t i f i ed were not addressed in any d e t a i l . Future research must address the impact of relat ionships and protocols on patient care and provider s a t i s f ac t i on . SUMMARY OF CHAPTER This f i na l chapter attempted to analyse the results of the study in l i g h t of the issues of professional power and contro l . I t was recognized that the composition of the panels influenced the - . 162 -determination of the information deemed to be a p r i o r i t y . However, the results were not inconsistent with the information hierarchy matrix which portrayed successively higher levels of information needs. The recommendations were minimal. Information systems are expensive to implement and ex i s t ing systems in place should be integrated rather than replaced. C l i n i c a l , qua l i ty and f inanc ia l a c t i v i t y information as i den t i f i ed can be l inked. Current emergency systems ignore the foundation of a l l a c t i v i t y - the patient and unless p r i o r i t y i s given to th is component of information, i t i s impossible to l ink c l i n i c a l to ex i s t ing f inanc ia l information. The soft issues were not addressed in any d e t a i l . The Panel members were, however, forceful in the i r be l i e f s that sof t data contributed equal ly, i f not more so, than hard data to the effectiveness and e f f i c iency of emergency departments. The development of emergency care in B.C. has been advanced by i n -creasing spec ia l i za t ion of the human resources. The Hospital Role Study and Provincia l C l a s s i f i c a t i on Study are further attempts to ident i f y the appropriate role of the f a c i l i t y . Once th i s i s achieved, emphasis must s h i f t to the operating of emergency departments, - 163 -the adequacy of resources and patient outcomes. 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White, Kerr L., "Ambulatory Care Data," NAJM, Vol. 288, No. 22, May 31, 1973, p. 1182-3. - 173 -February 19, 1981 Dear : Further to our discussion regarding your kind acceptance to part ic ipate as a panel member in my thesis on Emergency Department Information Systems, please f ind enclosed: a) the abstract of the thesis b) the information matrix (which to my way of thinking simply outl ines various levels of information needs and possible ways of c l a s s i f y i ng types of information that may be useful to managers) c) a descr ipt ion of the methodology (Nominal Group Technique) which is one method of a r r i v ing at a consensus among indiv iduals with varying perspectives and which I intend to employ at our meeting. As I indicated to you, th i s thesis i s aimed at ident i f y ing the core set of data needed to manage hospital emergency care. S p e c i f i c a l l y , the question i s stated: "What data elements/information should be co l lected in hospital Emergency Department Information Systems which w i l l meet external reporting requirements (Ministry of Health/Stats Canada/Joint Funding Project/Hospital Role Study), and be useful to plan, describe and evaluate emergency department a c t i v i t y for the various decis ion-makers within the hospital (Administrator, Director of Nursing, Medical Director, Head Nurse, Emergency Physician) and f a c i l i t a t e the development of effectiveness and e f f i c iency ind icators. While I am looking at general ongoing Emergency Department information requirements, I have reviewed the l i t e r a t u r e and found two discrete foci of current in teres t . One i s the s t r i ve towards categorization or c l a s s i f i c a t i o n of emergency departments according to capab i l i t i e s and a second i s concerned with appropriate or inappropriate u t i l i z a t i o n . To focus these concepts a b i t more, I have selected disaster planning as the " capab i l i t y " concept and the "mopping up ro le " of emergency depart-ments - the e lder l y , the a l coho l i c s , the psychotics - as u t i l i z a t i o n problems. These concepts may ass i s t you in thinking about your information needs. - 175 -NOMINAL GROUP TECHNIQUE The Nominal Group Technique (and variat ions thereof) i s a process of decision making whereby: 1. indiv iduals s i l e n t l y generate those ideas/data elements/information needs independently of other members, 2. each indiv idual in round-robin fashion presents one idea/data element information need which i s documented on a f l i p chart ( i . e . workload measurement in E.R., volume of patients per shift/day of the week, diagnosis), 3. each recorded idea i s discussed for c l a r i f i c a t i o n and evaluation (as to whether i t i s e s sent ia l , nice to know or non-essential), 4. indiv idual voting on p r i o r i t y ideas with the group decision being mathematically derived through rank ordering or rat ing. The objectives of the process are to balance par t i c ipat ion among members and to incorporate mathematical voting techniques in the aggregation of group judgement. LS/17 February 1981 - 176 -APPENDIX B SECOND PANEL: JULY 1981 Ms. Pat McGuire Director of Nursing Royal Columbian Hospital 330 East Columbia Street New Westminster, B.C. V3L 3W7 (also President Emergency Nurses Group 1978-81) Dr. Peter Ransford Senior Medical Advisor Health Department Ministry of Health 1515 Blanshard Street V i c t o r i a , B.C. V8W 3C8 (formally Chairman, Emergency Health Services Commission) Mr. Hugh Ross Administrator Richmond General Hospital 7000 Westminster Highway Richmond, B.C. V6X 1A2 Mrs. E. Whelan Head Nurse, Emergency Shaughnessy Hospital 4500 Oak Street Vancouver, B.C. V6H 3N1 APPENDIX D COMMUNITY PROFILE Community Charac te r i s t i c s Population Health Resources Major industry - a g r i cu l tu re - mining - logging - industry Transportat ion Systems - highway a c c e s s i b i l i t y Special Problems - hazards - ski h i l l s - summer resorts - t ransportat ion of chemicals - Unemployment Level - Transient Population - communes - Immigrants by SD, RHD, Community/ Mun ic ipa l i ty Population by - age - sex - race - marital status - income - poverty vs. a f f l uence Morbidity and Morta l i ty - deaths by major cause - traumas Morbidity -- medical emergencies - chronic diseases Health a) hospi ta l beds by program/ sub program hosp i ta l ambulatory care programs b) ambulance EHSC c) other hea l th / soc i a l resources 1) mental health a v a i l a b i l i t y and types 2) publ ic health a v a i l a b i l i t y and types 3) LTC f a c i l i t i e s - capaci ty 4) d e t o x i f i c a t i o n centres , e t c . Physic ian supply by spec i a l t y Appendix D HOSPITAL PROFILE Hospital Characterist ics Programs/Profile Manpower Costs Geographic acce s s i b i l i t y - travel time matrix a) Beds - inpatient beds by program/sub program - occupancy rate by program/sub program - admissions through Emergency Room b) Ambulatory Care Programs - type by hours of operation c) A n c i l l i a r y Services - diagnostic and therapeutic - type by hours of operation Medical s t a f f p r o f i l e - by spec ia l ty and status, i . e . active/consultant Hospital s t a f f p r o f i l e - by category A v a i l a b i l i t y of resources to Emergency - on c a l l system - in-house (24 hrs/day) By program - volume - budget to actual Appendix D EMERGENCY DEPARTMENT PROFILE RESOURCES PATIENTS Hours of operation Number of Emergency Room stations rooms - quite rooms - minor treatment - reception - family Manpower types and numbers per s h i f t RN's E.P. Social Workers Workload - performance Supplies/Equipment - monitors Costs .fixed costs program costs program variable costs Number of times OR plugges - overtime - budget to actual Patients (SD) demographic socio-economic by catchment area age/sex race family MD occupation i ncome marital status day and time of a r r i v a l C l i n i c a l : patients by some c l a s s i f i c a t i o n , i.e. - symptoms/diagnos/c.c. - severity la lb - admitted 2a 2b - discharged 3 - back door 4 - G.P. mode of a r r i v a l emergent, urgent, non-urgent trauma cases _ ) h medical emergencies ) treatments/tests length of time in Emergency Room Outcome number admitted to hospital number discharged - s e l f fol1ow-up community agency deaths number of transfers to other f a c i l i t i e s 

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