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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 t h i s thesis as conforming to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA August 1981 (cT)  Barbara Laurel Smyth, 1981  In  presenting  requirements  this thesis  f o r an a d v a n c e d  of  British  it  freely available  agree for  that  Columbia,  f u l f i l m e n t of the  degree a t the U n i v e r s i t y  I agree that f o r reference  permission  scholarly  i n partial  the Library  shall  and study.  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ABSTRACT  The rapid and a c c e l e r a t i n g 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 s e t t i n g into a highly complex and i n t e g r a l component of a t o t a l health care system. role complexity has created a demand by h o s p i t a l  This increasing decision-makers  f o r an information system to describe, measure and evaluate Emergency Department a c t i v i t y w i t h i n 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 i d e n t 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 f o r information w i l l not be developed in i s o l a t i o n from the a c t i v i t i e s of major planning, funding and professional groups i n the health s e r v i c e s .  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 c a t e g o r i z a t i o n of Emergency Department c a p a b i l i t i e s .  From t h i s , three major  policy/planning f o c i are selected - day to day emergency care, d i s a s t e r planning, and the "mopping-up"  r o l e of Emergency Departments.  Ideas  about these are developed in l i g h t of s i x c l a s s i f i c a t i o n s of information users' needs - patient care, management, q u a l i t y of care,  -'-  •  ii.  s t r a t e g i c planning, research and development and p o l i c y - f o r m u l a t i o n . "Needs" were v a l i d a t e d 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 r e s u l t s of the i n v e s t i g a t i o n are analyzed in l i g h 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 t h i s thesis i s recognized and g r a t e f u l l y acknowledged.  F i r s t l y to my thesis committee - Dr. Anne C r i c h t o n , Dr. Peter Frost, Mr. Paul Nerland and Mr. Brian C u r t i s f o r t h e i r assistance and i n t e r e s t .  Special thanks goes to  Dr. Anne Crichton f o r her many hours of help during a l l stages of t h i s t h e s i s .  Secondly to my Panel members who believed in the study subject and gave graciously of t h e 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 A s s o c i a t i o n , i n p a r t i c u l a r Mrs. P a t r i c i a Wadsworth f o r her gentle; nudges and Ms. Carole Tizzard f o r her endless patience in the typing of the numerous d r a f t s .  -ivTABLE OF CONTENTS  Abstract Acknowledgements  1.  INTRODUCTION -. A Background B Purpose C Rationale D The Study 1. 2. 3. 4. 5.  2.  3 7 9 13  Objectives D e f i n i t i o n of Terms Methodology L i m i t a t i o n s and Constraints Chapter Outlines  13 14 14 15 16  Chapter Summary  18  THE EMERGENCY CARE CONTEXT  19  A B  19  C D E F  3.  1  Emergency Care Within the Canadian Health Care System Canadian Studies on U t i l i z a t i o n and Role of Emergency Departments American P o l i c y Developments Categorization of Emergency Room C a p a b i l i t i e s Evaluation of Emergency Room Care Conclusion  26 33 38 43 47  Summary of Chapter  49  INFORMATION SYSTEMS  51  A B  Ambulatory Medical Care Data Trends i n Federal and P r o v i n c i a l Information Systems  51 57  1.  J o i n t Hospital Funding Project - Data Elements Manual - Uniform Reporting Manual Federal P r o v i n c i a l Data Cube Concept  58 60 62 63  Emergency Department Information Systems Accreditation  65 67  1. 2.  67 70  2. C D  E  Emergency Department Information Disaster Planning  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 B C  D E F  G  Organization, Delivery and Funding of Emergency Care in B r i t i s h Columbia Emergency Health Services Commission, 1974 Greater Vancouver Regional Hospital D i s t r i c t Studies  78 81 82  1. 2. 3.  82 85 86  Disaster Planning 1978-80 Emergency Nurses Group J o i n t Hospital Funding Project  87 89 90  1. 2. 3.  90 91 98  5.  Background Recommendations Implementation  Classification 1. 2. 3.  H  1970 1976 1978  GVRHD 1980 Emergency Department Study Hospital Role Study 1978-80 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 1980  100 101 .104  Conclusion  105  Chapter Summary  106  IDENTIFICATION AND VALIDATION OF EMERGENCY DEPARTMENT INFORMATION, j ; NEEDS 108 A Matrix of Information Needs B Theoretical I d e n t i f i c a t i o n of Information Needs C Nominal Group versus Delphi Processes D V a l i d a t i o n of Emergency Department Information Needs  E  6.  100  108 109 113 119  1.  F i r s t Panel of Experts  119  2.  Second Panel of Experts  127  Conclusion  129  .1. Level 1, 2, 3 Information 2. Level 4 Information 3. I d e n t i f i c a t i o n of Soft Data Chapter Summary „...,.,  129 131 133 136  ANALYSIS, RECOMMENDATIONS AND CONCLUSIONS  137  A Informational P r i o r i t i e s B The Hospital as a Professional Bureaucracy C The Power and Expertise of Physicians D The Information Needs of the Professional Bureaucracy  137 138 144 147  -vi-  E  F  Recommendations  151  1. 2. 3.  154 158  Patient Abstract •.. Inventory of Hospital Resources Inventory of Community Resources, Hazards and Population  I  58  Conclusion  1 5 9  Chapter Summary  161  BIBLIOGRAPHY  164  APPENDICES A B  F i r s t Panel Second Panel  1 7 2  •  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 i n a g l e ' s Law on Information  INTRODUCTION Emergency Department u t i l i z a t i o n has increased s i g n i f i c a n t l y i n 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 H a l i f a x emergency department from 1956 to 1966, a f t e r the introduction of the Hospital Insurance and Diagnostic Services Act in 1957 and before the i n t r o d u c t i o n of Medicare in 1968.  Baltzan (1972) noted a 63% increase i n Saskatoon  from 1965 - 1970, three years a f t e r private physician care became an insurable benefit to Saskatchewan residents. a 300% increase in Hamilton from 1961 to 1971.  McKenzie (1971) describes 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 i n 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 r e s u l t of t h i s explosion i n 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 t e r n a t i v e health care resources f o r the " i n a p p r o p r i a t e " users and to develop a co-ordinated system of emergency care.  Systems development a c t i v i t i e s w i t h i n B r i t i s h  Columbia have included preventive measures such as seat b e l t l e g 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 c a t e g o r i z a t i o n of c a p a b i l i t i e s and a prol i f e r a t i o n of s p e c i a l i z e d manpower.  H i s t o r i c a l l y , the r o l e of the Emergency Department was w e l l - d e f i n e d and bounded in scope.  C r i s i s i n t e r v e n t i o n into acute i l l n e s s e s and  trauma has been augmented by a primary care counselling r o l e with the r e s u l t that m u l t i p l e and c o n f l i c t i n g roles are now apparent i n Emergency  Departments.  Unpredictable workloads, variable case-mix and s p e c i a l i z e d technology and manpower make i t i n c r e a s i n g l y complex f o r those involved i n the care and management of Emergency Departments to function e f f e c t i v e l y . At the foundation of t h i s turbulent environment i s the lack of a management information system to p l a n , describe and manage emergency a c t i v i t y to the s a t i s f a c t i o n of those involved i n the day to day operations :of the department.  - 3 -  A.  BACKGROUND  The health care industry has been described by Bennett (1980) as "drowning i n data while being d e f i c i e n t in information".  This  statement holds true f o r a l l l e v e l s of health care d e l i v e r y , whether i t be a program, an i n s t i t u t i o n , or a p r o v i n c i a l health care system.  The i n a b i l i t y of e x i s t i n g 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 u n l i m i t e d , there i s an urgent need for q u a n t i t a t i v e and q u a l i t a t i v e information, upon which to base resource a l l o c a t i o n decisions.  C l i n i c a l and f i n a n c i a 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 w i t h i n and among competing sectors of the health care system.  This study i s the i n t e g r a t i o n and culmination of various  interests,  a c t i v i t i e s and r e s p o n s i b i l i t i e s of the author over the past f i v e years. While the focus of a c t i v i t i e s has undergone s i g n i f i c a n t transformation, the underlying concepts, p r i n c i p l e s 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 f o r the following chapters, i t i s appropriate to review the events which have led up to the s e l e c t i o n of the study t o p i c - "The I d e n t i f i c a t i o n of Information Needs f o r Planning and Managing Emergency Department Health Services in B r i t i s h Columbia". The scope of t h i s t o p i c , admittedly, i s quite broad.  Not only must  the external requirements of information reported to t h i r d party agencies be assured, but the i n t e r n a l information requirements  of  the i n s t i t u t i o n a l managers, c l i n i c i a n 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 t a f f i n g  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. study (Smyth, 1977)* indicated that the e x i s t i n g management  The  information  system was inappropriate to serve current i n s t i t u t i o n a l needs f o r information.  S p e c i f i c a l l y , i t was i n d i c a t e d that  "the data c o l l e c t e d were based upon t r a d i t i o n a l government reporting requirements rather than the immediate and future needs of the i n s t i t u t i o n 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 c o l l e c t e d i n each ambulatory care unit was not c o n s i s t e n t ; and the s t a t i s t i c s reported were not and could not be r e l a t e d to e i t h e r budget or to q u a l i t y of care i n f o r m a t i o n . " Smyth, L.,  "A Review of the S t a t i s t i c s Compiled i n Ten Ambulatory Care Departments at St. P a u l ' s H o s p i t a l " , Unpublished Report, St. P a u l ' s H o s p i t a 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 d i s a s t e r preparedness of the hospital emergency f a c i l i t i e s w i t h i n the Regional District.  In a d d i t i o n , the GVRHD sought to develop an o n - s i t e  emergency medical response plan, to integrate the a c t i v i t i e s of the emergency health services into a u n i f i e d regional d i s a s t e r plan and to co-ordinate the medical response with the roles and responsib 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 capabilities.  I n s t i t u t i o n a l health care f a c i l i t i e s were then  categorized into "major" receiving h o s p i t a l s , "minor" receiving hospitals and "support f a c i l i t i e s " in order to i d e n t i f y and l i n k the 2  roles and r e s p o n s i b i l i t i e s of hospital Emergency  Departments.  A t h i r d involvement of the author was with respect to the J o i n t Hospital Funding P r o j e c t , a study undertaken j o i n t l y by the M i n i s t r y 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 M i n i s t r y of Health f o r several years.  The current system of financing 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 r e c e i v i n g and t r e a t i n g a l l c a s u a l t i e s of a d i s a s t e r . "minor" receiving hospitals - the remaining f i v e acute f a c i l i t i e s in the GVRHD. Not in d i r e c t radio contact with the d i s a s t e r s i t e , capable of receiving minor i n j u r i e s or providing support s t a f f to major receiving h o s p i t a l s . "support" f a c i l i t i e s - the 13 extended or s p e c i a l i z e d acute f a c i l i t i e s i n the GVRHD (Grace, C h i l d r e n s , G.F. Strong) capable of providing s t a 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 r e a t i n g c a s u a l t i e s .  - 6 -  was i n i t i a t e d some 30 years ago when the type and i n t e n s i t y of care provided w i t h i n a l l i n s t i t u t i o n s was f a i r l y homogeneous.  The  advances of the past decades i n technology and patient care have not been r e f l e c t e d through progressive modifications to the funding system.  For h o s p i t a 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 t e n s i t i e s of services provided, physical p l a n t , or geographical l o c a t i o n .  For the M i n i s t r y of Health, the funding system  did not provide s u f f i c i e n t information to compare and evaluate the costs and performance of i n d i v i d u a l h o s p i t a l s .  For both groups, the  system was r e s t r i c t i v e i n terms of e f f e c t i v e long term planning. The J o i n t Hospital Funding Project Report (Ernst and whinney, October 1979) released in January 1980, s p e c i f i e s an implementation plan to remedy these d e f i c i e n c i e s .  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 i n a n c i a l data base a c c e s s i b l e to both the M i n i s t r y 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 s t r a t e g i e s of the J o i n t Hospital Funding Project Report w i l l be f u r t h e r discussed i n 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 p e c i f i c to Emergency Care.  The Emergency Nurses  Group of B r i t i s h Columbia, a special i n t e r e s t 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 f o r Emergency Departments, which eventually could be implemented p r o v i n c i a l l y .  I n i t i a l attempts  were directed at the development of a documentation form s p e c 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 d e n t i f i e d before a comprehensive information system could be recommended. information need.  Patient care i s the f i r s t l e v e l of  However, the requirements of higher l e v e l needs  such as s t r a t e g i c planning and p o l i c y formulation., must be i d e n t i f i e d w i t h i n the t o t a l system i f an i n t e g r a t i v e information system i s to be developed.  B.  THE PURPOSE OF THIS STUDY  This study attempts to i d e n t 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) s t a t e s :  "To be useful any data c o l l e c t i o n system should develop from an i d e n t i f i c a t i o n of the major issues in the f i e l d and a s p e c i f i c a t i o n of the categories of information needed to resolve these issues or to decide between a l t e r n a t i v e courses of a c t i o n . "  Cassel, John C.  "Information for Epidemiological and Health Services Research" Medical Care, V o l . XI, No. 2, MarchA 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 capabilities.  To be p r a c t i c a l and useful to the industry, these  issues must also be viewed w i t h i n the l a r g e r context of the ongoing operational data requirements i d e n t i f i e d by the J o i n t Funding Project.  This study makes no attempt to evaluate emergency care per se as provided in i n d i v i d u a l i n s t i t u t i o n s .  Measures of e f f i c i e n c y and  effectiveness are dependent upon uniform data, i d e n t i f i c a t i o n and v a l i d a t i o n of the i n d i c a t o r s s e l e c t e d , and the determination of standards.  It i s hoped t h a t , by i d e n t i f y i n g and i n t e g r a t i n g the  information requirements of the various users, s u i t a b l e a c t i v i t y i n d i c i e 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 n g and peer grouping of emergency departments i s  also  considered.  The question which t h i s Study addresses may be stated as f o l l o w s :  "What data elements should be c o l l e c t e d in hospital Emergency  Depart-  ment information systems which w i l l meet external reporting requirements, be useful to plan, describe and evaluate emergency department a c t i v i t y f o r the various decision-makers w i t h i n the hospital and f a c i l i t a t e the development of effectiveness and e f f i c i e n c y i n d i c a t o r s ? "  - 9-  C.  RATIONALE BEHIND THE STUDY  Decision-making  requires accurate, timely and appropriate information.  The amount of information generated i n a health care s e t t i n g has become unmanageable because of the lack of i d e n t i f i c a t i o n , organization and i n t e g r a t i o n of the needs of the various users f o r 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 c o n t r o l l e d through d i f f e r e n t sources.  L i t t l e a t t e n t i o n , i f any, has been given to the  i d e n t i f i c a t i o n of the users, i n t e r n a l ( c l i n i c i a n s and managers) and external (government and a c c r e d i t a t o r s ) to the i n s t i t u t i o n and to t h e i r information requirements.  Managerial  functions include planning, budgeting,  organizing,  evaluating and c o n t r o l l i n g - functions which are dependent upon an accurate, o b j e c t i v e assessment of current operations.  Evaluation  i s a step which both precedes and follows,, each a c t i o n .  Quantifiable  information regarding the effectiveness and e f f i c i e n c y of operations i s paramount f o r managers i f decision-making i s to be e f f e c t i v e .  In a d d i t i o n to the information required by hospital management  for  planning, evaluation and control purposes, there are m u l t i p l e and d i s j o i n t e d requests from external agencies:  the Federal Government  requires a c t i v i t y information f o r i n t e r p r o v i n c i a l and i n t e r h o s p i t a l  - 10 -  comparisons; the P r o v i n c i a l Government requires a c t i v i t y and cost data in order to evaluate budgets; A c c r e d i t a t i o n requires s t r u c t u r e , process and some outcome information to evaluate the q u a l i t y of care.  A review of the sources and uses of the information c o l l e c t e d i n health care settings reveals a lack of linkage between e f f i c i e n c y and e f f e c t i v e n e s s .  " C l i n i c a l and f i n a n c i a l data continue to  operate i n d i f f e r e n t spheres with the i n t e r s e c t i o n 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 levels.  Department heads voiced concerns about the lack of feedback  from t h e i r superiors regarding t h e 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.  Utilization  figures in i s o l a t i o n from budget or q u a l i t y of care data provides l i t t l e basis f o r judging departmental performance.  The 1977 study also revealed that management and q u a l i t y of care standards, r e l a t i v e to the data c o l l e c t e d , had not been developed. This i s consistent with the state of the a r t of health care measurement.  Emphasis has t r a d i t i o n a 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 A n a l y s i s . Shuman, Spears and Young, John Hopkins U n i v e r s i t y 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 s t r u c t u r a l and process evaluation of health care systems, rather than health outcomes because the t o o l s f o r measuring patient status are inadequatel y developed (Culyer, 1978).  Donabedian (1966) has i d e n t i f i e d a number of d e f i n i t i o n a l problems i n 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 r e l a t i v e value unit system. The type and amount of emergency resources required to t r e a t a drug overdose are quite d i f f e r e n t from that required to t r e a t a sore throat.  Controls that e x i s t are l i m i t e d to s t r u c t u r e s .  The B.C. M i n i s t r y of  Health, the Canadian Council on Hospital A c c r e d i t a t i o n , the l e g i s l a t i o n and regulations of the B.C. Hospital Act, union contracts and professional associations  control d i f f e r e n t inputs of the system.  Process c r i t e r i a , in the form of q u a l i t y assurance and medical audit are f a i r l y well developed with respect to i n p a t i e n t care because the episode of i l l n e s s i s more e a s i l y i d e n t i f i a b l e .  However, q u a l i t y of  - 12 -  care a c t i v i t i e s remain w i t h i n 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 s o l a t e the e f f e c t s 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 p o s i t i v e attempts to control f o r status s e v e r i t y 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 p a r t i c u l a r and emergency care i n general i s apparent, the current economic and p o l i t i c a l climate i n B.C. supports the need f o r i d e n t i f i a b l e and measurable health outputs and outcomes.  Warner (1981) traces.the . h i s t o r i c a l developments of health care financing in B.C. which have led up to the current thrust of the M i n i s t r y of Health away from long range program planning towards f i s c a l a c c o u n t a b i l i t y and cost containment.  The dominance of  Treasury Board and the replacement of health professionals with f i s c a l managers w i t h i n the senior l e v e l s of the M i n i s t r y of Health makes i t even more urgent that an information system be in place.  - 13 -  D.  THE STUDY  This study i s t h r e e f o l d in that i t attempts to document e x i s t i n g information, to i d e n t i f y current and future information needs and to recommend improvements to the e x i s t i n g information system.  1.  Objectives  The objectives of the Study are: 1.  To document e x i s t i n g philosophies, studies and industry  concerns  with respect to the organization, d e l i v e r y and financing of emergency care i n B r i t i s h Columbia.  2.  To review the l i t e r a t u r e and current B.C. a c t i v i t i e s as p e r t a i n ing to emergency care w i t h i n 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 d e n t i f i c a t i o n and categorizat i o n of Emergency Department information.  3.  To i d e n t i f y the types, uses and users of data consistent with current and future i n t e r n a l and external reporting  requirements  consistent with the J o i n t Hospital Funding Study and Hospital Role Study  recommendations.  - 14 -  4.  To v a l i d a t e the information requirements of the various hospital decision-makers - care g i v e r s , 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.  D e f i n i t i o n 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 w i t h i n the Emergency Department's scope of a c t i v i t y .  However, f o r the purposes of t h i s study, 5  booked day care surgery and scheduled ambulatory care excluded.  services are  Only those a c t i v i t i e s which r e l a t e to unscheduled patients  presenting to the Emergency Department f o r treatment w i l l be considered to be w i t h i n the framework of t h i s documentary a n a l y s i s . 3.  Methodology  In order to be useful to managers, the data c o l l e c t e d in any information system should be developed from the dimensions of e f f i c i e n c y and effectiveness.  In a d d i t i o n , the r e s u l t s should also meet the operation-  al needs of the B.C. Hospital Funding System in order to be meaningful and pragmatic f o r B.C. h o s p i t a l s .  Therefore, a documentation and  analysis of e x i s t i n g research and operational information requirements  "ambulatory care" - scheduled treatments of a non-acute or minor nature such as cast changes, removal of s t i t c h e s 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 l e v e l s of data from patient care to p o l i c y formulation w i l l be i d e n t i fied.  These s i x information hierarchies are patient care (flow-  through), departmental management, q u a l i t y of care, s t r a t e g i c  planning,  research and development and p o l i c y formulation at the M i n i s t r y 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 h o s p i t a l s to i d e n t i f y and p r i o r i z e the routine and special information requirements in l i g h t of dominant issues in emergency care and external constraints imposed by the J o i n t Funding Study. The findings of the f i r s t panel of experts w i l l be further validated by a second group of decision-makers.  Analysis of the r e s u l t s w i l l  be undertaken i n l i g h t of professional  power and control in order to  recommend an information system that i s both p r a c t i c a l and bounded by p r i o r i t i e s .  4.  L i m i t a t i o n s and Constraints  1. The data elements i d e n t i f i e d have been selected to complement the Hospital Role Study and recommendations of the J o i n t Hospital  - 16 -  Funding P r o j e c t .  The foundation of both of these studies i s a  uniform reporting system to f a c i l i t a t e s t r a t e g i c planning, budgeting and monitoring and c o n t r o l .  While i t i s recognized  that i n t e r n a l decision-makers w i l l require more than the core set of information i d e n t i f i e d in the Uniform Reporting System, i n t e g r a t i o n of the various users' needs i s e s s e n t i a l .  2.  Needs v a l i d a t i o n interviews w i l l be l i m i t e d to the d e c i s i o n 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 w i t h i n 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 n g f o r c a t e g o r i z a t i o n of c a p a b i l i t i e s to ensure adequate standards f o r hospital emergency care.  - 17 -  Chapter I I I r e v i e w s the r e s e a r c h and o p e r a t i o n a l t h r u s t s o f  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 o f emergency department data r e q u i r e m e n t s - p a t i e n t c a r e , department management, q u a l i t y o f c a r e , s t r a t e g i c p l a n n i n g , r e s e a r c h  and  develop-  ment and p o l i c y f o r m u l a t i o n .  Chapter IV d e s c r i b e s the e v o l u t i o n o f emergency care and the l e g i s l a t i v e ,  p l a n n i n g and  policy thrusts in B r i t i s h  identifies Columbia.  Chapter V develops a m a t r i x o f i n f o r m a t i o n needs based upon the dominant p l a n n i n g  i s s u e s w i t h i n the o p e r a t i o n a l requirements o f  system - d i s a s t e r p l a n n i n g  ( c a t e g o r i z a t i o n ) and  "mopping-up"  the  (utiliza-  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 w i t h the v a r i o u s h o s p i t a l d e c i s i o n - m a k e r s - Emergency Room P h y s i c i a n , Head Nurse, D i r e c t o r o f N u r s i n g , Medical A f u r t h e r v a l i d a t i o n i s assured  D i r e c t o r and  Administrator.  by q u e s t i o n n a i r e t o a second group o f  decision-makers.  Chapter VI a n a l y s e s  the r e s u l t s of the survey i n l i g h t o f the i s s u e o f  p r o f e s s i o n a l power and  c o n t r o l , presents  the c o n c l u s i o n s and  t i o n s o f 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 .  recommenda-  - 18 -  CHAPTER SUMMARY This chapter sets the stage f o r the study.  I t 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 s a s t e r 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 J o i n t Hospital Funding Project of the B.C. Health Association and the M i n i s t r y of Health.  The s e l e c t i o n of the Emergency Department as a d i s c r e t e 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 i n t o a topic which was both manageable, timely and p r a c t i c a l from an i n d i v i d u a l h o s p i t a l , regional and p r o v i n c i a l  perspective.  The importance of accurate, timely and relevant information to the decision makers i s stressed.  Measurement problems abound yet the  a l l o c a t o r s and providers of care have recognized the necessity of i d e n t i f y i n g information needs and developing a uniform information system accessible to both p a r t i e s .  The objectives of the study have been established to l i n k the t h e o r e t i c a l 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 prof e s s i o n a l , government and management groups, the i n i t i a l i d e n t i f i c a t i o n of needs i s streamlined.  V a l i d a t i o n by hospital decision-makers  assures  that the data elements recommended meet the needs of the c l i e n t - the hospital.  - 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 a f f o r d to go to a d o c t o r ' s o f f i c e .  Several f a c t o r s , however,  were i n f l u e n t i a l in expanding t h i s o r i g i n a l r o l e with the r e s u l t that these units also assumed a primary care r o l e .  The predominant structure w i t h i n the Canadian health care system i s the acute care h o s p i t a 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 , h o s p i t a l s have undergone tremendous change in the past 40 years with the r e s u l t that a highly complex and s o p h i s t i c a t e d organization has emerged from r e l a t i v e obscurity.  With the control of i n f e c t i o u s 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 c e s s i b i l i t y to health services became evident.  This new awareness  l e d to a s h i f t in emphasis in Canadian health care away from health outcomes to health s t r u c t u r e s .  Governments became f i n a n c i a l l y involved  in the provision of services to t h e i r c i t i z e n s and e f f o r t s were  directed toward ensuring a v a i l a b i l i t y of and f i n a n c i a 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".  P o l i c i e s and programs were implemented piecemeal on the basis of what already e x i s t e d rather than in accordance w i t h any long range plan.  While the Haegarty Report (1943), in i t s mandate to review health insurance i n order to a s s i s t the provinces in formulating comprehensive 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 f o r returning veterans and r a i s i n g the standards of d i r e c t l y provided p r o v i n c i a l health services with s p e c i f i c reference to tuberc u l o s i s , mental h e a l t h , venereal disease, physical f i t n e s s and financing of p u b l i c health research and professional t r a i n i n g grants.  The t r a n s i t i o n 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 i n t h i s t r a n s i t i o n period were the National Health Grants of 1948, under,which acute care h o s p i t a l s were constructed; the Hospital Insurance and Diagnostic  -  21-  Services Act (1957) required to pick up the operating costs of those h o s p i t a 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 i n t e r e s t groups, organizations and p o l i t i c i a n s .  The provision of  government funds f o r f a c i l i t i e s and services in t h i s order led to the development and expansion of acute s e r v i c e s , simply because funding was a v a i l a b l e rather than from any demonstrable need f o r 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 r e l i a n c e upon the acute care h o s p i t a l .  As the Federal Government began to o f f e r grants in a i d , i n most provinces, emergency care became an insurable b e n e f i t 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 s e n t i a l l y free rather than to the p h y s i c i a n ' s o f f i c e where out-of-pocket expenses were incurred.  U n t i 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, comprehensiveness  of services provided and p u b l i c administration of the  insurance schemes, the Federal Government reimbursed p r o v i n c i a l t r e a s u r i e s , in the aggregate f o r 50% of program costs. Under t h i s open-ended financing system, there was an overpowering incentive f o r the Provinces to provide only those services which were cost-sharable, i . e . i n p a t i e n t acute and physician care.  The structures of the Canadian health care system are intertwined with financing arrangements.  One reinforces the other.  necessitate changes in f i n a n c i n g .  Changes in structure  However, changes in structure could  not be achieved u n t 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 f o r change to be c a r r i e d out by the Established Programs Financing Act as f o l l o w s : " - the ten year delay in implementing medical care insurance a f t e r hospital insurance was in place. - the large number of hospital beds in Canada; - technological change, improved s e r v i c e s , unionization and inflation; - the lack of cost-sharing for low cost a l t e r n a t i v e s to hospital care and physician s e r v i c e s ; - the rapid increase in the number of physicians p r a c t i c i n g in the system, p a r t i c u l a r l y because of the services each one uses in enriching his income; - a rapid increase in the use of o u t - o f - h o s p i t a l diagnostic services caused by the..rapid increase in the number of private l a b o r a t o r i e s . " 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 P o l i c y Law, V o l . 2, No. 4 Winter 1978, p. 460.  There were p o s i t i v e incentives f o r the providers of health care - the physicians and the hospitals to admit patients to hospital and maintain them there u n t i l recovery was complete.  Volume -  admissions and patient days - p o s i t i v e l y affected the amount of revenue the hospital would receive.  A l s o , i t was more economical  f o r physicians to v i s i t a series of patients in hospital rather than to use the overhead of t h e i r own o f f i c e s .  Likewise, i n p a t i e n t  care was an insurable benefit to the p a t i e n t , whereas f o r the i n t e r vening ten year period between the i n t r o d u c t i o n of hospital insurance and the medical care insurance, physicians' v i s i t s were an out-of-pocket expense f o r the patient.  office The 1960's  saw a time of expansion of hospital s e r v i c e s , technology came i n t o the f o r e f r o n t and consumer expectations rose.  By 1969, the f i n a n c i a l consequences of t h i s process of "incrementalism" and open-ended funding arrangements were evident.  The removal of any  f i n a n c i a l r e s p o n s i b i l i t y from the consumer, coupled with i n c r e a s i n g l y s o p h i s t i c a t e d technology and r i s i n g public expectations, resulted in uncontrollable provision of acute i n p a t i e n t 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 p r o v i n c i a l cost studies demonstrating the f i n a n c i a l e f f e c t s of open-ended and advocating a l t e r n a t i v e d e l i v e r y forms.  cost-sharing  The Task Force Report on  Health Services (1970) recommended that more appropriate types and  - 24 l e v e l s of care be u t i l i z e d , and that t i g h t e r f i s c a l and management controls be i n s t i t u t e d .  The Task Force suggested several p o s s i b i l i t i e s f o r c u t t i n g costs: change to block grant system; 2) d e l i v e r medical services  1)  through  Community health Centres in order to r e l i e v e h o s p i t a l s ; 3) use less  highly  t r a i n e d manpower and 4) provide more outpatient care in h o s p i t a l s .  The  Castonguay Report (1971), the Mustard Report (1972) and the Foulkes Report (1973), a l l advocated s t r u c t u r a l 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 costsharing of acute bed c o n s t r u c t i o n .  Extended care, ambulatory and home  care were recommended as viable a l t e r n a t i v e s to i n p a t i e n t care.  However,  the f a i l u r e to l e g i s l a t e f o r 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 h e i r a l l o c a t i o n 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 r e l a t e d d i r e c t l y to improv-  ing medical care d e l i v e r y were i n s i g n i f i c a n t .  The e f f e c t of these successive changes was to influence the u t i l i z a t i o n of emergency departments of h o s p i t a l s .  As funding changed, patterns of  - 25 use changed.  These changing patterns are made c l e a r when one reviews  the 1 i t e r a t u r e .  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 o n at the beginning of the introduction of health insurance to 23% m i l l i o n today.  Many of  the new Canadians had d i f f e r e n t t r a d i t i o n s in the way in which they u t i l i z e d health services from the old established population - they sought out h o s p i t a l care rather than going to general p r a c t i t i o n e r s . And in the l a t e s i x t i e s young people l e f t home to t r a v e l across the country.  They did not want to go to family doctors (even i f they had  time to b u i l d up a r e l a t i o n s h i p ) but sought out impersonal care in nonjudgemental emergency departments.  A t t i t u d e s to general p r a c t i t i o n e r s  changed, and a m o d i f i c a t i o n of the types of resources a v a i l a b l e 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 p r a c t i c e of physicians.  They began to meet  t h e i r patients in or r e f e r them to f u l l y s t a f f e d emergency departments out of o f f i c e hours. Anderson 1973).  And t h i s had f i n a n c i a l advantages (Crichton and  There were, and remain today, p o s i t i v e f i n a n c i a 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 c e resources.  The  Medical Services Plan fee schedule i s i d e n t i c a l i n each care s e t t i n g but there i s 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 t e r the implementation of the Medical Care Act resulted in a decrease of patient a c c e s s i b i l i t y to o f f i c e ambulatory s e r v i c e s .  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 w i t h i n the Canadian and the American health care systems have i d e n t i f i e d s i m i l a r trends in the u t i l i z a t i o n of Emergency Departments although the reasons f o r such trends vary because of d i f f e r i n g i d e o l o g i c a l approaches and d i f f e r e n t insurance systems.  These  studies have been concerned with socio-economic and demographic c h a r a c t e r i s t i c s of the users, d i s t r i b u t i o n of emergent, urgent and non-urgent cases, r e l a t i o n s h i p s to the existence and the a v a i l a b i l i t y of the family p h y s i c i a n , the r e l a t i o n s h i p to health insurance and the e f f e c t s 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 w r i t e r believes i s appropriate or inappropriate f o r Emergency Departments. 'Bain and Johnson (1971) have i d e n t i f i e d 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 b e l i e v e that  Emergency Departments should be devoted to trauma and medical  -  27-  emergencies have devoted much research to the development of outcome measurements - i n j u r y s e v e r i t y scores - and advocate c l a s s i f i c a t i o n of emergency room c a p a b i l i t i e s . ( G h e n t 1976, Landau 1975, Strauch 1979). Those who b e l i e v e that Emergency Departments shoul'd t r e a t anyone who presents himself to the Emergency Department are more concerned with i d e n t i f i c a t i o n of use and abuse, c a t e g o r i z a t i o n of patients into emergent, urgent and non-urgent, socio-economic and demographic determinants of inappropriate use and the development of a l t e r n a t i v e ambulatory care systems to r e r o u t e patients to appropriate s e t t i n g s . Concerns with respect to the use of the Emergency Department for routine care are based on q u a l i t y 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 r e s u l t i n good q u a l i t y of care and that the Emergency Department care f o r nonurgent 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 f e c t the teaching v i a b i l i t y of the Outpatient Department C l i n i c f o r indigent p a t i e n t s , Robinson and Klonoff (1967) assessed the p a e d i a t r i c 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 s u b s t i t u t e teaching u n i t .  Based upon the low per-  centage of admissions (15%) and the high r e f e r r a l rate to family physicians (75%) f o r follow-up care, the study concluded that:  - 28; -  "While prompt medical a t t e n t i o n was usually i n d i c a t e d , the majority of problems were not urgent and the Emergency Department was becoming a s u b s t i t u t e f o r the o f f i c e of the family p h y s i c i a n . "  The conclusion i s not s u r p r i s i n g 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 p o s i t i v e f i n a n c i a l incentives f o r the  patient to seek free medical care in the Emergency Department, rather than pay f o r care i n a p h y s i c i a n ' s o f f i c e .  The study  f a i l e d to consider t h i s f a c t , categorize the v i s i t s as to s e v e r i t y of i l l n e s s or determine the number of patients who had family physicians.  Its main o b j e c t i v e appears to have been to l e g i t i m i z e  the r o l e of the Emergency Department ;as a teaching a l t e r n a t i v e 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 t e r the i n t r o d u c t i o n of Medicare in Ontario to determine the reasons f o r " i n a p p r o p r i a t e " u t i l i z a t i o n with a view to remedying the s i t u a t i o n .  Of the 3,622 records sampled f o r review, the study  i d e n t i f i e d a d i s t r i b u t i o n among Emergent, Urgent and Non-urgent categories of 7.5%, 50% and 42.4%.  The study attempted to i d e n t i f y  the r e l a t i o n s h i p 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 f o r Children and Adolescents: A One Year Review at the Vancouver General", CMAJ, V o l . 96, May 1967, p. 1304.  of and contact with the family physician.  The r e s u l t s 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 i s one i n t e r v e n t i o n 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 i n the Emergency Department of the V i c t o r i a General H o s p i t a l , H a l i f a x , Nova S c o t i a , studied the c h a r a c t e r i s t i c s of patients using the Emergency Department in two six-month periods, one p r i o 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 g n i f i c a n t differences in diagnosis, r e f e r r a l patterns, hospital admission practices or ambulance usage and concluded that long-established patterns of seeking health care .were unaltered by removing any economic b a r r i e r s to seeking p r i v a t e physician s e r v i c e s .  Baltzan (1972) analysed the increase in Emergency Room v i s i t s to Saskatoon Hospitals from 1965 - 1970, years i n which physician care was an insurable b e n e f i t under the p r o v i n c i a l health insurance scheme (1962-1968) and under the f e d e r a l / p r o v i n c i a l cost-sharing arrangements (1968 onwards).  The data were analysed in r e l a t i o n to pop-  u l a t i o n trends and physician u t i l i z a t i o n .  User fees, introduced i n t o  Saskatchewan in 1968 "were without apparent e f f e c t on the number of  - 30 -  Emergency Room services but they were c o r r e l a t e d with a decline 3  in other primary care s e r v i c e s " .  Baltzan suggested that the  increase i n Emergency Room v i s i t s represented a t r a n s f e r from home v i s i t s or physician o f f i c e care to the Emergency Room rather than "new" medical s e r v i c e s .  Baltzan d i d not categorize the s e v e r i t y  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 n e s s had been present f o r 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 u n a v a i l a b i l i t y of physician appointments i n 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 f o 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 i d e n t i f y the current r o l e of the Emergency Room at St.  Joseph's  Hospital in Hamilton, Ontario, attempted to c l a s s i f y the s e v e r i t y of emergency room v i s i t s and r e l a t e s e v e r i t y to socio-economic and demographic patterns and to the reasons f o r s e l e c t i n g the Emergency Department as the l o c a t i o n 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 c e 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 CMAJ, V o l . 106, 1972, p. 252.  Department,"  p r a c t i c e hours). medical insurance.  Eleven percent of patients presenting had no The f i n d i n g s of t h i s study were not unlike  the conclusions of Torrens and Yedvab (1970) in t h e i r study of New York C i t y 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 i o n postulated that a v a i l a b i l i t y and a c c e s s i b i l i t y to services generated i t s own demand.  C i t i n g studies by S p i t z e r et al (1971),  Chipman (1973) and Beck (1973), no change i n 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 t e r Medicare.  A study by the Working Group on Special Care Units i n Hospitals of the Federal P r o v i n c i a l Subcommittee on Quality of Care and Research (1975) advocated r a t i o n a l planning of emergency services to define r o l e s , develop standards and educational resources to b e t t e r 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 r o l e f o r emergency medicine w i t h i n the Canadian health care system.  Lees et al (1976) compared the management of two patient populations - those treated in emergency departments and those treated i n  - 32 -  physicians'  o f f i c e s - who had s i m i l a r non-traumatic sign/symptom  complexes.  They contend that l i t t l e a t t e n t i o n has been devoted  to the i d e n t i f i c a t i o n of the q u a l i t y of care patients received in both s e t t i n g s .  Acuity and duration of i l l n e s s influence patient  preference f o r care s e t t i n g .  However, differences i n i n v e s t i g a t i o n ,  drugs, c o n s u l t a t i o n , follow-up and length of care to s i m i l a r populations were observed.  Patient outcomes other than status a f t e r  one month of care (discharged, h o s p i t a l i z e d , died, r e f e r r e d , e t c . ) were not t a c k l e d .  The only v a l i d conclusion drawn from the study  was that v a r i a t i o n s i n length of treatment tended to i n d i c a t e that family physicians encouraged unnecessarily long periods of patient follow-up.  Lees advocated f u r t h e r i n v e s t i g a t i o n of the q u a l i t a t i v e  differences between s i m i l a r complaints in the two settings and the o v e r a l l q u a l i t y of care provided i n accordance with these d i f f e r e n c e s .  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) i n d i c a t e d that 1,431  (14%) of  patients a r r i v i n g at Greater Vancouver Regional Hospital  District  hospital emergency departments required treatment and subsequent admissions, 292 (3%) were backdoor admissions through the emergency, 5,372 (50%) required treatment i n the emergency room but were capable of discharge and 3,639 (33%) of the cases could have been treated i n an ambulatory care s e t t i n g .  H i s t o r i c a 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 a t t r i b u t e d t h i s increase to changing medical p r a c t i c e and p u b l i c expectations.  E l l i o t t (1978) compared the socio-economic and demographic f a c t o r s of emergency department users at two Hamilton emergency departments with a random sample of residents ( v a l i d a t e d with census data) from the same geographical area.  Males, protestants, native-born  Canadians and recent residents were over-represented among users at both h o s p i t a l s .  E l l i o t t explained away these r e s u l t s 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 p r o b a b i l i t y 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 p r a c t i c e w i t h i n the h o s p i t a l .  C.  AMERICAN POLICY DEVELOPMENTS  American studies are reviewed below in order to give a b e t t e r coverage of issues.  Torrens and Yedvab (1970) contended that studies on Emergency Department u t i l i z a t i o n patterns have produced c o n f l i c t i n g and contradictory  - 34 -  r e s u l t s which prevent e f f e c t i v e planning and organizational i n t e r ventions e i t h e r to a l l e v i a t e inappropriate use or to cope with increasing demand, because of t h e i r f a i l u r e to recognize the m u l t i p l e roles of an Emergency Department.  Torrens suggested that  no s i n g l e 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 r o l e s :  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 s e r v i c e s ;  2.  Physician and ambulatory care s u b s t i t u t e outside of normal hours of operation;  3.  The family physician f o r the poor and t r a n s i e n t populations who see the emergency room as the l o g i c a l point of entry i n t o 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 w i l l i n g n e s s of hospital managers to organize to meet i t s r o l e or i d e n t i f y a l t e r n a t i v e settings to meet the demands placed upon i t .  Ullman et al (1975) supported the roles i d e n t i f i e d by Torrens and Yedvab (1970), namely that Emergency Departments are "physician s u b s t i t u t e s " and " f a m i l y physicians to the urban poor".  By i n t r o -  ducing the p a t i e n t s ' frequency of v i s i t i n t o 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 s u b s t i t u t e and that 21.3% of the t o t a 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 d i s p r o p o r t i o n a t e l y large number of these  "high frequency" users were black, low income and from i n n e r - c i t y areas.  Davidson (1978) in support of arguments put f o r t h 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 c a r e " .  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 e n t d e t a i l about the community in which the Department operated and instead have concentrated on socio-economic and demographic v a r i a b l e s and i l l n e s s patterns.  Davidson proposed that  research should be d i r e c t e d at patterns of use and reasons f o r use i n communities with d i f f e r e n t c h a r a c t e r i s t i c s and h o s p i t a l s with different capabilities.  Perkoff and Anderson (1970) investigated the r e l a t i o n s h i p between demographic c h a r a c t e r i s t i c s , p a t i e n t ' s c h i e f complaint and ultimate s i t e of d e l i v e r y of care i n an attempt to i s o l a t e 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 d e n t i f i e d two roles f o r the Emergency Department - surrogate physician for out of hours care and primary health care f o r the negro population.  Satin and Duhl (1972), two p s y c h i a t r i s t s , compared the c l a s s i f i c a t i o n of the p a t i e n t ' s presenting complaint i n t o . p h y s i c a l only, physical and psychosocial and psychosocial as determined by the p a t i e n t , the physician in the emergency room and the research p s y c h i a t r i s t i n t e r viewer.  Not s u r p r i s i n g l y , 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 r e s u l t s of t h i s study which purports to l e g i t i m i z e the r o l e of the p s y c h i a t r i s t to evaluate and t r e a t Emergency Room patients i s unacceptable.  No d e l i n e a t i o n of  cases among s e v e r i t y categories was attempted.  The t h e s i s of the  authors rests on the " s t r i k i n g frequency" (as determined by p s y c h i a t r i s t s ) of the Emergency Department's i n a b i l i t y to deal with p s y c h i a t r i c and s o c i a l problems.  Kelman and Lane (1976) compared two groups of emergency room patients - those with p r i v a t e physicians (80%) and those without p r i v a t e physicians  (20%) and i d e n t i f i e d that those without tended to be  more recent residents in the area, household heads were younger, family sizes smaller and the family member seeking care at the Emergency Room was more t y p i c a l l y an adult rather than a c h i l d . Strategies f o r 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 p a r t i c u l a r the incomplete access to services for i n d i v i d u a l s .  Shaw (1977) placed the onus f o r 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 h o s p i t a l .  Shaw concluded that u n t i l the  i n d i v i d u a l hospital "defines i t s r o l e in s p e c i f i c terms, i t cannot accuse e i t h e r 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 l e a r r o l e d e f i n i t i o n and the i d e n t i f i c a t i o n of a l t e r n a t i v e services to meet unmet needs were r e q u i s i t e to the d e l i v e r y of "appropriate" medical care w i t h i n the Emergency Department.  Scherzer et al (1980) c l a s s i f i e d the f a m i l i e s of c h i l d r e n using an inner c i t y Boston Emergency Department with respect to income, race and the existence of a stable physician and hospital r e l a t i o n s h i p to determine the impact on Medicaid and the a v a i l a b i l i t y of neighbourhood health centres on m u l t i p l e u t i l i z a t i o n patterns i d e n t i f i e d in a  Shaw, Charles, "Emergency Department Use and Abuse," in Health Service, Dec. 1977, P. 10.  Dimensions  - 38 -  1964 study.  The study demonstrated that the increased a v a i l a b i l i t y  and a c c e s s i b i l i t y to care through increased community resources  and  insurance had no a f f e c t on the u t i l i z a t i o n of m u l t i p l e providers and that the level of s a t i s f a c t i o n 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 p a r t i c u l a r i l l n e s s e s  influenced  choice of s e t t i n g .  D.  CATEGORIZATION OF EMERGENCY CAPABILITIES  The issue of c a t e g o r i z a t i o n or c l a s s i f i c a t i o n of hospital and emergency service c a p a b i l i t i e s has been fraught with p h i l o s o p h i c a 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 f e c t i v e and e f f i c i e n t manner.  Patients present to the  Emergency Department with varying magnitudes of i n j u r i e s and not a l l Emergency Departments are s t a f f e d and equipped to provide adequate i n i t i a l or d e f i n i t i v e care.  The basic purpose of categorization i s  to " i d e n t i f y the readiness and c a p a b i l i t i e s of the hospital and i t s e n t i r e s t a f f to receive and t r e a t adequately and e x p e d i t i o u s l y , emergency  patients."  There are many c l a s s i f i c a t i o n s systems i n the l i t e r a t u r e - the American Medical Association (1971 i d e n t i f i e d four c l a s s i f i c a t i o n s :  Gibson, Geoffrey,  comprehensive,  "How Far Have We Come With C a t e g o r i z a t i o n ? " , H o s p i t a l s , JAHA, V o l . 51, May 1, 1977, p. 97.  - 39 -  major, general and b a s i c ; the American College of Surgeons (1971) i d e n t i f i e d three categories:  optimal, intermediate and minimal; the  Greater Vancouver Regional Hospital D i s t r i c t (1969) i d e n t i f i e d three categories:  l i m i t e d , standard and major;  Ghent (1976) described  but d i d not name f i v e c l a s s e s ; the Federal P r o v i n c i a l 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 s p e c i f y somewhat s i m i l a r q u a n t i t i e s of inputs that are necessary to meet the standards developed i n each c l a s s .  The major conceptual problem with these c l a s s i f i c a t i o n systems i s t h e i r f a i l u r e to address the i d e n t i f i c a t i o n of patient/community needs f o r Emergency Department s e r v i c e .  Gibson (1977) f e l t that severe planning conceptual and methodological d e f i c i e n c i e s have prevented any p o s i t i v e returns on c a t e g o r i z a t i o n . Threats to professionalism, consumer preference and occupancy rates in community h o s p i t a l s prevent implementation.  Political  influences,  evident in a l l health care planning processes are not over-ridden by rationality.  Gibson believed that the usefulness of c a t e g o r i z a t i o n  i s l i m i t e d to describing resources not improving the d i s t r i b u t i o n of these resources nor improving outcomes.  - 40 -  In a second t r e a t i s e on c a t e g o r i z a t i o n , Gibson (1978) l i s t e d the l i m i t a t i o n s of e x i s t i n g c l a s s i f i c a t i o n methodologies as f o l l o w s : 1.  It describes only the existence of resources not t h e i r use,  2.  It lacks normative standards against which a community can assess l o c a l c a t e g o r i z a t i o n data,  3.  It provides no i n s i g h t s 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 p a t i e n t s ,  6.  It underemphasizes the primary care content of Emergency Room use and the a s s o c i a t i o n between the Emergency Medical System and the wider ambulatory care system.  7.  It does not s e n s i t i z e the community, health planners, adminis t r a t i o n and medical s t a f f to the necessity of assessing and improving Emergency Medical Systems w i t h i n the context of interventions outside the Emergency Medical System.  8.  It does not provide a data base f o r s t r a t e g i e s t O g C h a n g e 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.  B u i l d i n g on e x i s t i n g c a t e g o r i z a t i o n methodologies, Gibson proposed an a l t e r n a t e methodology to assess the appropriateness of Emergency Department u t i l i z a t i o n . and standards set.  Measures of appropriateness were i d e n t i f i e d  For example, a l l ambulance and c r i t i c a l care  patients should be taken to comprehensive and major h o s p i t a l s . Comparison of actual to standard provides information for estimating the need and d i r e c t i o n of change and in creating a consensus f o r change.  Gibson, G., "Categorization of Hospital Emergency C a p a b 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 t h e r not met or met with resource c a p a b 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 f o r judgement as to whether categ o r i z a t i o n i s too high, too low or appropriate.  Gibson's proposal i s based on appropriateness  of e x i s t i n g  resources  to meet current demands and may i n f a c t be a b e t t e r 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 i s  necessary  to properly locate Emergency Department resources and that v e r t i c a l rather than horizontal categorization i s necessary to segment c a p a b i l i t i e s into several diagnostic categories such as trauma, coronary, high r i s k neonatal, alcohol and drug abuse.  A concept of  v e r t i c a l categorization more c l e a r l y i d e n t i f i e s the types of cases requiring immediate care and makes provision for the c o n f l i c t i n g requirements of high cost s e r v i c e s , versus the a c c e s s i b i l i t y and q u a l i t y of care that s m a l l , high r i s k patient populations demand. Strauch (1979) apparently independently of Landau c l a s s i f i e d Connecticut h o s p i t a l s in a care c a p a b i l i t y matrix - three categories on seven emergency medical problems - m u l t i p l e system i n j u r y , cardiac emergency, c r i t i c a l burn, major Central Nervous System, acute t o x i c a t i o n , p s y c h i a t r i c emergency and p a e d i a t r i c emergency.  - 42 -  Cross (1979) was another proponent of v e r t i c a l c a t e g o r i z a t i o n 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 c a p a b i l i t i e s among a l l h o s p i t a l s whereas burn or spinal cord Emergency Room c a p a b i l i t i e s are best c e n t r a l i z e d w i t h i n those hospitals with i n p a t i e n t u n i t s .  Categorization of the c a p a b i l i t i e s of Emergency Departments  is  desirable f o r two reasons - f i r s t l y to ensure minimum standards are a v a i l a b l e to meet the care requirements of emergency p a t i e n t s , p a r t i c u l a r l y trauma patients and secondly as a basis f o r regional i z a t i o n of services and the development of emergency r o l e s .  One of the  c r i t i c i s m s of the B.C. Hospital Role Study ( 1979) was i t s f a i l u r e to i d e n t i f y emergency services as a d i s c r e t e care f u n c t i o n .  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, 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 a t t i t u d e s of the public and the  i n s t i t u t i o n s may possibly prevent any implementation.  Detmer (1977) using the Injury Severity Score, compared the treatments to the outcomes of trauma cases i n Wisconsin i n three categories of c l a s s i f i e d h o s p i t a l s (area, general and community service) and one category of u n c l a s s i f i e d where minimum requirements f o r c l a s s i f i c a t i o n as a community service were not met.  While good q u a l i t y care was  - 43 -  supplied at a l l h o s p i t a l s , the u n c l a s s i f i e d 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 i n d i c a t e a case against c a t e g o r i z a t i o n as i t c u r r e n t l y e x i s t s 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 r u c t u r a l inputs.  More  research such as that done by Detmer (1977) i s necessary to determine e f f e c t s of c a t e g o r i z a t i o n on outcome.  E.  EVALUATION OF QUALITY OF EMERGENCY CARE  The c l a s s i c a l t h e o r e t i c a l model f o r the assessment of q u a l i t y of care i s Donabedian's  "structure-process-outcome  framework (1966)."  Most of  the q u a l i t y of care studies during the past ten years have used t h i s > perspective  e i t h e r alone or in combination.  Although  Donabedian's  model does not answer s p e c 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 c e r t a i n outcomes are observed, those outcomes w i l l a f f e c t p o s i t i v e 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 s e t t i n g s are favorable, that there are acceptable standards of what constitutes goodness and that good care makes a difference i n terms of health outcomes.  -u Baker et al (1974) developed the Injury Severity Score to quantify the o v e r a l l s e v e r i t y of i n j u r y i n persons who sustained i n j u r i e s in more than one area of the body.  Based on the Abbreviated Injured  Score, the research showed that ISS values were p o s i t i v e l y c o r r e l a t e d with morbidity and m o r t a l i t y rates and were useful f o r t r i a g e , f o r comparison of m o r t a l i t y experience of varied groups of trauma patients and f o r 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 v a l i d a t e the r e l a t i o n s h i p between expected m o r t a l i t y and the Injury Severity Score.  Semmlow also  i d e n t i f i e d the r e l a t i o n s h i p of ISS to length of stay and incidence of  surgery.  Cole et al (1976) reported on the r e s u l t s of a retrospective process audit of the seven (7) most common c h i e f complaints presenting to a Philadelphia 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 i m i t a t i o n s of t h i s  method in a c t u a l l y r e f l e c t i n g the q u a l i t y of care rendered to Emergency Department p a t i e n t s , the study of 389 cases nevertheless did i d e n t i f y d e f i c i e n c i e s 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 a t t r i b u t e d to inadequate documentation of h i s t o r y and physical examinations.  In a d d i t i o n , 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 i n f o r m a t i o n a v a i l a b l e t o the r e v i e w e r s .  Anderson  e t a l (1977) i n an attempt t o 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 c a r e and p a t i e n t outcome, developed a somewhat e l a b o r a t e and c o n f u s i n g r e s e a r c h methodology which i n t e g r a t e d process a u d i t , a c c u r a c y , l e g i b i l i t y and adequacy o f p a t i e n t documentation w i t h Baker's (1974) I n j u r y S e v e r i t y S c o r e .  T h i s was  then r e l a t e d t o  p a t i e n t ' s outcome as i d e n t i f i e d through f o l l o w - u p appointments r e a d m i s s i o n s f o r the same i l l n e s s / i n j u r y .  Anderson  fell  and  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 o f emergency c a r e must be i n i t i a t e d i n the Emergency Room and be l i n k e d t o p r e - h o s p i t a l and/or i n p a t i e n t c a r e .  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-  m a t i c a l 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 t h a t i n d i c e s are becoming more r e f i n e d t o i n c o r p o r a t e the d e t e r m i n a n t s o f outcomes o f c a r e .  Roy e t a l (1979) used p a r a m e d i c r o b s e r v e r s t o r e c o r d the t r e a t m e n t p r o c e s s , sequence,  time taken and type o f personnel i n v o l v e d i n  emergency c a r e as an a d j u n c t to normal  peer review p r o c e d u r e s .  Other than t o i d e n t i f y the i n a d e q u a c i e s o f the c l i n i c a l a documentation  r e c o r d as  t o o l , the r e s e a r c h c o n c l u s i o n s were not s u b s t a n t i a l .  -  46-  Cayten and Evans (1979) in a review a r t i c l e i d e n t i f i e d the weaknesses of e x i s t i n g methodologies and proposed two general d e f i c i e n c i e s of Injury Severity Scores - the lack of v a l i d a t i o n of e x i s t i n g scores by other than r e l a t i o n s h i p s to m o r t a l i t y and the improvements necessary i n the q u a l i t y of the data.  They .contend  that outcomes are not only dependent upon the q u a l i t y of care rendered, but also upon the s e v e r i t y of i l l n e s s and i n j u r y of patients presenting f o r emergency care and that in order to evaluate the q u a l i t y of emergency care, one must control f o r severity.  Although methods are imperfect and often more  appropriate to selected types of i l l n e s s or i n j u r y ,  nonetheless  a s t a r t has been made.  Despite the shortcomings  of the methods in existence, i t i s  apparent that c o n t r o l l i n g f o r the s e v e r i t y of i l l n e s s or i n j u r y upon admission i s e s s e n t i a l to the evaluation of outcomes of emergency care.  It i s perhaps e a s i e r to i d e n t 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 t h i s review chapter, there appear to be two major thrusts i n the Emergency Department l i t e r a t u r e 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 f o r trauma cases and those devoted to i d e n t i f y i n g the determinants of inappropriate u t i l i z a t i o n .  C o n f l i c t i n g emergency roles appears to be at the basis of the dilemma. On the one hand, t r a d i t i o n a l concepts of emergency care i d e n t i f y trauma and acute medical conditions as appropriate to the s e t t i n g ; on the other hand, those presenting at emergency rooms do not respect t h i s r o l e designation.  In B r i t i s h Columbia, some h o s p i t a l s , i n an attempt to reduce "inappropr i a t e u t i l i z a t i o n " have imposed user fees of $10.00 or even $20.00 f o r non-urgent use.  Cox (1979) i n d i c a t e s that there are serious problems  with the c o l l e c t i o n of these a d d i t i o n a l l e v i e s . c o l l e c t e d w i t h i n 30 days of treatment.  Less than 50% are  However, Cox notes that the  public continues to demand ambulatory care at Emergency Departments and sees no reason to pay e x t r a .  Looney (1978) contends that Emergency Room u t i l i z a t i o n patterns are a subset of s o c i e t a l trends i n that consumers are accustomed to  - 48 -  convenience even f o r non-emergency care and have learned that the Emergency Departments have already arisen to meet consumers' demands.  Lack of c o n t i n u i t y and the inappropriate demands placed on highly s k i l l e d manpower and technology are c i t e d as a major deterrant to the acceptance of the role of an Emergency Department as providing other than acute and trauma treatment i n t e r v e n t i o n .  Cost con-  s t r a i n t s w i t h i n the Canadian Health Care System w i l l probably continue to impede acceptance of the philosophy that Emergency Departments be a l l things to a l l people.  A l t e r n a t i v e s to improve  the e f f i c i e n c y and effectiveness of Emergency Room Departments continue to be sought.  - 49 -  CHAPTER SUMMARY  As stated i n Chapter I, the development of any useful information system should begin with an i d e n t i f i c a t i o n of the major issues i n the f i e l d .  Both the Canadian and the American l i t e r a t u r e have  i d e n t i f i e d the thrusts towards c a t e g o r i z a t i o n and u t i l i z a t i o n .  In Canada, the growth i n Emergency Department u t i l i z a t i o n was a d i r e c t consequence of health care funding arrangements, s o c i e t a l trends and physician patterns of p r a c t i c e .  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 t e r the i n t r o d u c t i o n 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 " i n a p p r o p r i a t e " u t i l i z a t i o n .  Quality and cost  considerations were paramount in the e a r l y 1970's at both the p r o v i n c i a l and federal l e v e l s as evidenced by the numerous studies on health care d e l i v e r y .  F a i l u r e to stem the t i d e of emergency department use i n both Canada and the United States has led to the emergence of a second concern the a b i l i t y of e x i s t i n g resources in emergency departments to meet the needs of i t s users.  Standards were developed on the inputs of  the system - the physical p l a n t , the manpower and the equipment.  - 50 -  The evaluation of emergency care suffers from the same conceptual and methodological problems as i n p a t i e n t care.  However, because  of the traumatic nature of many of the i n j u r i e s which are treated i n the emergency department, attempts to control f o r s e v e r i t y on admission have been evident in the U.S.  Chapter II  has explored the major i s s u e s . i n the f i e l d of emergency  department health care.  In Chapter III,  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 i d e n t i f y the state of the a r t of information systems and to provide a foundation f o r the recommendations.  - 51 -  CHAPTER  III  INFORMATION SYSTEMS  A.  AMBULATORY MEDICAL CARE DATA  The most comprehensive treatment of ambulatory care information systems has been reported i n the 1972 U.S. Symposium on Ambulatory Medical Care Data.  Recognizing the neglect of current systems to i d e n t i f y the needs  f o r information of ambulatory providers, a group of experts was assembled to reach a consensus of a core set of data appropriate f o r 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 c o l l e c t e d i n Ambulatory Care Systems.  The i n t e n t was to  provide data which would be useful f o r the p o t e n t i a l users such as h o s p i t a l a d m i n i s t r a t o r s , 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 q u a l i t y of care on an i n d i v i d u a l basis could not be made, however, i t was hoped that the aggregate data would provide some i n d i c a t i o n of the care rendered.  Because of the lack of a national  insurance  scheme, e x i s t i n g information systems were m u l t i p l e and v a r i e d , 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 b a s i s .  - 52 -  The a p p l i c a b i l i t y of t h i s core data set to the Canadian Health Care System i s questionable because of d i f f e r i n g philosophies and d i f f e r e n t funding mechanisms.  The weighting of the Panel of  Experts with researchers and academics would also lead one to question i t s appropriateness to h o s p i t a l decision-makers.  An "encounter" form with a set of 15 items was proposed as a v i a b l e data base that would be a p p l i c a b l e to a l l ambulatory care s e t t i n g s . Medical, f i n a n c i a l , a d m i n i s t r a t i v e and demographic data would e a s i l y and r o u t i n e l y be generated as a by-product of the p a t i e n t provider contact and useful f o r patient care, planning, management, evaluation and research purposes.  It was recommended that the  following information be c o l l e c t e d :  a)  Registration/demographic data: - Patient I d e n t i f i c a t i o n , Name and Unique Patient Identi f i e r - Sex - B i r t h Date - Residence ( i n c l u d i n g z i p code) - M a r i t a l Status - Race/ethnic p r o f i l e  b)  Encounter data: - F a c i l i t y Identification - Provider I d e n t i f i c a t i o n - Person I d e n t i f i c a t i o n  - 53 -  - Diagnosis and/or problems - Services and procedures - Medications prescribed -  Disposition  - Source of Payment* - Cost*  1  The main drawback of t h i s otherwise e x c e l l e n t proposal i s the physician o r i e n t a t i o n 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 a d d i t i o n , diagnostic and therapeutic  services provided by A l l i e d Health professionals were not considered "encounters", and were not evaluated, e i t h e r as a unique encounter or as c o n t r i b u t i n g to the care prescribed by the physician.  The l i m i t a t i o n 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 t h 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 c o l l e c t i o n mechanisms. The Conference papers which o u t l i n e d more s p e c 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 V o l . II, No. 2, MarchA p r 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 e n c y and e f f e c t i v e n e s s . structure-process-outcome  Donabedian's  framework i s l a b e l l e d " t e c h n i c a l e f f e c t i v e n e s s "  and to t h i s i s added "psychosocial  e f f e c t i v e n e s s " which considers the  a t t i t u d e s of both r e c i p i e n t s and providers of care. w i t h i n each of these c l a s s i f i c a t i o n s are delineated.  The data s u i t a b l e The dimensions  of e f f i c i e n c y are considered to include cost and p r o d u c t i v i t y data, integrated with population c h a r a c t e r i s t i c s and morbidity data i n order that the r e l a t i o n s h i p between impact and e f f i c i e n c y can be determined. The information suggested may perhaps be excessive considering the lack of empirical v a l i d a t i o n of which components p o s i t i v e l y a f f e c t outcome.  In a d d i t i o n , the cost of c o l l e c t i n g the information pro-  posed would be p r o h i b i t i v e .  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 i n the c o l l e c t i o n process, the lack of analysis once c o l l e c t e d 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 . parable and s p e c i f i c .  Data must be r e t r i e v a b l e , com-  P r e - r e q u i s i t e to the construction of any  information system i s "the need to e s t a b l i s h , d e f i n e , agree upon, promulgate and use standard terms f o r the events, e n t i t i e s and units of Ambulatory Care".  Another requirement, i d e n t i f i e d by Tenney,  was that the data c o l l e c t e d should serve notyonly the i n t e r n a l management echelonsi,but also the various external demands f o r information such that only the level of aggregation  Tenney, James B.,  varies.  "Information i n 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 a n a l y s 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 t h e i r opinion the v i s i t ' s only usefulness was as an a c t i v i t y i n d i c a t o r and even that i s l i m i t e d because of the f a i l u r e to account f o r case mix.  Planning and evaluation cannot be performed  on t h i s b a s i s .  Cooney (1973) reviewed the problems inherent i n separating i n - p a t i e n t and o u t - p a t i e n t data i n hospital based a n c 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 c o l l e c t i o n systems to define separately the number of p a t i e n t s , the number of v i s i t s and the number of procedures i n Ambulatory systems and then to l i n k 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 i n t h e 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 r e n t i a t e the v i s i t from the episode of care and b u i l d a case f o r the use of each unit of a n a l y s i s .  Ullman et a l  (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 i n k e d patients and v i s i t s so that projections were v a l i d .  - 56 -  Gaus (1978) proposed that the data base be designed to c o l l e c t information on population, p a t i e n t s , provider, problems, and p r e s c r i p t i o n s , and categorized the major managerial  procedures information  requirements of ambulatory care systems as the f o l l o w i n g :  1.  Operational Planning - s i z e and composition of the population, u t i l i z a t i o n rates over time.  2.  Management Control - monitoring of p r o d u c t i v i t y and u t i l i z a t i o n practices of i n d i v i d u a l s and departments, i n c l u d i n g  physician  patterns of use of a n c i l l a r y s e r v i c e s . 3.  Quality Assurance - peer review and a u d i t .  4.  Support Services - f i n a n c i a l data, accounts receivable and accounts payable, inventory c o n t r o l , t h i r d party and government payment  agencies.  Brenner and Paris (1973) have grouped ambulatory care data requirements i n t o four major c l a s s i f i c a t i o n s - demographic and socioeconomic c h a r a c t e 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 d e n t i f i e d w i t h i n each c l a s s i f i c a t i o n are most appropriate f o r administrative management and c l i n i c a l epidemiology.  Hershey and Moore (1975) i d e n t i f i e d four categories of ambulatory care data - u t i l i z a t i o n , workload, p r o d u c t i v i t y and health status.  - 57 -  Schneider (1979) described a medical c l a s s i f i c a t i o n system f o r coding the p a t i e n t ' s reason f o r v i s i t which would be applicable to a l l facets of ambulatory care, including the Emergency Department.  The Reason f o r V i s i t C l a s s i f i c a t i o n System (RFVCS) surpasses  t r a d i t i o n a l diagnostic c l a s s i f i c a t i o n systems by v i r t u e of i t s nons p e c i f i c i t y which allows f o r i d e n t i f i c a t i o n of symptoms, and requests.  complaints  The RFVCS i s structured on a modular basis to allow  data to be c o l l e c t e d on diagnostic and therapeutic procedures, counselling and follow-up, which allows a high degree of f l e x i b i l i t y and a d a p t a b i l i t y .  B.  TRENDS IN FEDERAL AND PROVINCIAL INFORMATION SYSTEMS  Since the advent of hospital insurance in B r i t i s h Columbia, h o s p i t a l s have been subjected to m u l t i p l e and d i s j o i n t e d requests f o r 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 Act being the prime c o n t r o l s .  Services  Such reporting mechanisms are  necessary i n order that hospitals receive operating d o l l a r s from the P r o v i n c i a l Government.  However, in t o t a l there are some 35  Hospital Information A c t i v i t y forms (HIA's) that h o s p i t a l s must complete on a routine basis.  In a d d i t i o n , there are another set of  forms required to receive c a p i t a l funding.  - 58 -  An unfortunate outcome of these information demands i s that the information provided to t h i r d party agencies i s , in a large p a r t , e i t h e r not fed back to the hospitals at a l l or the time lag of the two or three years necessary f o r aggregation and manipulation of the data negates any usefulness  the information may have had.  This s i t u a t i o n has resulted in h o s p i t a l s developing d u p l i c a t i v e information systems to provide data f o r i n t e r n a l management purposes. This h i s t o r i c a l d u p l i c a t i o n of information systems has resulted i n two separate unique and i n c o n s i s t e n t data bases.  Negotiations with  government f o r funds or programs have reached an impasse because both groups have d i f f e r e n t data.  This has resulted i n an adversary  role between h o s p i t a l s and government.  The J o i n t Hospital  Project w i l l be f u r t h e r discussed i n Chapter IV.  Funding  However, i n t h i s  review of information systems i t i s appropriate to include the thrusts of the J o i n t Funding Project for uniformity.  1.  B.C. Joint. Hospital Funding Project  At the outset of the J o i n t Hospital Funding P r o j e c t , the need f o r a uniform information system accessible to both h o s p i t a l s and the M i n i s t r y of Health was i d e n t i f i e d as a p r i o r i t y .  In f a c t , the  P r i n c i p a l s agreed that even i f the report was not accepted in i t s e n t i r e t y , the recommendations on uniform reporting would improve the funding processes s i g n i f i c a n 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 d e l i v e r y , 16 Data P r o f i l e s (Figure 3.1) were i d e n t i f i e d and evaluated with respect to t h e i r a p p l i c a b i l i t y to the Planning, Budgeting, Payment/ R e c o n c i l i a t i o n 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 e x i s t i n g information sources.  The i n t e n t of t h i s Data Elements Manual was as a reference guide to e x i s t i n g 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 a v a i l a b l e , the cost/benefit of c o l l e c t i o n determined.  I t was recognized at the outset that such an endeavor  was i n f a c t a monumental task and that i t may have been more appropriate to f i r s t i d e n t i f y needs f o r 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 f o r future years was the o v e r - r i d i n g c r i t e r i o n f o r t h i s manner of development.  User needs f o r information were to be i d e n t i f i e d w i t h i n the context of J o i n t Hospital Funding Project requirements and validated 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 •;. '  FUNDING PROCESS  PROFILE PLANNING 1. Population C h a r a c t e r i s t i c s :  Demographic  2. Population C h a r a c t e r i s t i c s :  Socio-Economic  3. Population C h a r a c t e r i s t i c s :  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 r e l a t i o n s h i p * Denotes l e s s e r use r e l a t i o n s h i p SOURCE: Ernst and Whinney, Data Elements Manual, May 1980.  BUDGETING  PAYMENT & RECONCILIATION  MONITORING & CONTROL  **  **  * * ** *  *  **  *  *  **  *  ** * * * * * **  * * *  **  arose f o r expert input - i . e . Nurses, Health Record Administrators. This "tops down" approach i s perhaps more pragmatic than e s t a b l i s h ing user groups f o r 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 o u t l i n e d the scope, constraints and c r i t e r i a of the Uniform Reporting.  This document  was prepared to ensure that as well as providing f o r J o i n t Funding requirements, other reporting requirements are integrated w i t h i n one system f.orthe i n s t i t u t i o n a l c o l l e c t i o n and reporting procedures. The c r i t e r i a with which to measure the development of the uniform reporting s t r u c t u r e were designated as follows (Ernst and Whinney, October 1980): 1.  Replace the e x i s t i n g monthly reporting system.  2.  Replace the annual HS1, HS2 reports how prepared f o r 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 Interp r o v i n c i a l Comparisons to the level of M i n i s t r y requirements at t h i s time.  4.  Provide f o r r o l e s , programs and l e v e l s of service c u r r e n t l y in place yet be f l e x i b l e enough to accommodate revisions to the role and refinements to programs and l e v e l s over time as envisaged by the Hospital Role Study.  - 62 -  5.  Be a b l e t o e v o l v e over  time.^  Uniform R e p o r t i n g  The  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  Manual  u n i f o r m r e p o r t i n g manual ( E r n s t and Whinney, A p r i l  developed f o r t h e J o i n t H o s p i t a l Funding P r o j e c t ,  1981),  schematically  c a t e g o r i z e s a l l a c u t e c a r e 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 hierarchy of functions, subfunctions, activities.  The i n t e n t o f t h i s document i s t o p r o v i d e  definitions of a c t i v i t i e s and  programs, subprograms and standard  f o r peer g r o u p i n g , common s t a t i s t i c s  uniform i n d i c e s .  Emergency s e r v i c e s i s a s u b f u n c t i o n The  statistics i)  o f t h e Ambulatory Care f u n c t i o n .  r e q u i r e d o f f a c i l i t i e s a r e the f o l l o w i n g :  Number o f v i s i t s  ii)  Hours worked by o c c u p a t i o n a l  code - budget,  iii)  Hours worked by o c c u p a t i o n a l  code - a c t u a l  iv) The  Number o f ambulatory p a t i e n t s a d m i t t e d  i n d i c e s m a n i p u l a t e d from t h e s t a t i s t i c s  reported  on a monthly (4  week p e r i o d ) w i l l be l i m i t e d t o : i) ii) iii)  V i s i t s / h o u r s worked Occupancy d i s t r i b u t i o n Hours worked, a c t u a l , as a percentage o f the budgeted hours.  E r n s t and Whinney, Design Concepts Paper, E r n s t and Whinney, V a n c o u v e r , October 1980, p. 8.  -  2.  Federal  Provincial  Developed i n 1979  organizes  -  Data Cube Concept  by the H o s p i t a l I n s t i t u t i o n s Sub  Hoc Committee on H e a l t h 1979)  63  information concerning  input resources to h o s p i t a l u n i t s i n an attempt t o  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 o f the Sub  Group on H o s p i t a l I n s t i t u t i o n s was  a s e t o f Canadian data element standards  t o develop  t h a t 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 r e q u i r e m e n t s o f the i n s t i t u t i o n s ,  the  P r o v i n c e s 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 p r o v i d e meaningful i n t e r p r o v i n c i a l  Recognizing  Ad  I n f o r m a t i o n , the Data Cube c o n c e p t ( D i e t i k e r  s e r v i c e u n i t s and u t i l i z a t i o n o f those i d e n t i f y process  Group o f the  as  comparisons.  the l i m i t a t i o n s o f e x i s t i n g i n s t i t u t i o n a l  reporting  systems - the f e d e r a l Annual Return o f H o s p i t a l s , P a r t s I and I I , the P r o v i n c i a l Q u a r t e r l y H o s p i t a l I n f o r m a t i o n System and p r o v i n c i a l M i n i s t r y of Health  individual  I n f o r m a t i o n systems, the Task  Group i d e n t i f i e d a model which would c a p t u r e i n f o r m a t i o n on axes:  by l e v e l o f c a r e ( a c u t e , c o n v a l e s c e n t ,  Sub three  rehabilitative),  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 , admini s t r a t i o n and s u p p o r t )  and by i n p u t r e s o u r c e s  ( h o u r s , wages, b e n e f i t s ) .  The Data Cube Concept i s c o n c e p t u a l l y sound i n t h a t i t p r o v i d e s l i n k a g e between c l i n i c a l  and  financial  a  information, establishes a  - 64 -  common t e r m i n o l o g y  and c o n c e n t r a t e s  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 s e t t h a t can be a g g r e g a t e d i n many ways f o r t h e various  users.  I t s main weakness has been t h e i n a b i l i t y t o 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 t o agree  upon t h e core data s e t and have s t a t e d t h a t t h e i r needs f o r i n f o r m a t i o n have not been met.  The data s e t reduces t h e t r a d i t i o n a l  i n f o r m a t i o n r e p o r t e d by some 80% and t h e P r o v i n c i a l M i n i s t r i e s o f Health a r e n a t u r a l l y r e l u c t a n t t o g i v e up t r a d i t i o n a l  information.  S e c o n d l y , t h e 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 c a p t u r e and r e p o r t i n f o r m a t i o n on a t i m e l y b a s i s and t h r e e - d i m e n s i o n a l l y , a r e not i n p l a c e .  A t h i r d weakness i s t h e Rata  Cube's n e g l e c t o f t h e e f f e c t i v e n e s s a s p e c t o f c a r e .  Process  e f f i c i e n c y i s t h e main o u t p u t o f t h e 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 b e i n g the a u s p i c e s two  developed under  o f the J o i n t Funding Study a r e a t t e m p t i n g  to integrate  o f t h e axes - t h e s e r v i c e u n i t s w i t h i n p u t r e s o u r c e s  subsequent o u t p u t i n d i c a t o r s .  with  - 65. -  C.  EMERGENCY DEPARTMENT INFORMATION SYSTEMS  There are several, management information systems a v a i l a b l e to hospitals.  However, most tend to address one s p e c 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 i n p a t i e n t s ; the HIA 35 ABC a j o i n t M i n i s t r y of Health/B.C. Health Association system c o l l e c t s f i n a n c i a l and s t a t i s t i c a l information on hospitals f o r monitoring purposes; the B.C. Health Association Hospital Personnel Management System (HPMS) c o l l e c t s labor and salary d i s t r i b u t i o n information on a l l employees of p a r t i c i p a t i n g member i n s t i t u t i o n s ; and the Federal HS1 and 2 and P r o v i n c i a l 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 , s a l a r i e s and hours paid versus hours worked, can be l a b o r i o u s l y extracted from the many reports.  The inadequacies  of these i n d i c a t o r s are evident.  There are however two systems s p e c i f i c a l l y t a i l o r e d to Emergency Department a c t i v i t y .  Both of these were developed i n 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 c o l l e c t emergency c l i n i c a l records information and report aggregated data f o r q u a l i t y assurance, management and planning purposes.  S i m i l a r to the i n -  patient abstracting systems of PAS and HMRI (Hospital Medical Records I n s t i t u t e ) , the Emergency Department Study provides  demographic,  i n v e s t i g a t i v e , treatment and discharge information to a s s i s t managers to evaluate u t i l i z a t i o n patterns, types of patients treated and outcomes. cost.  The main drawback of t h i s system f o r Canadian hospitals i s At 30<t per a b s t r a c t , i t i s more appropriate e i t h e r to sample  cases or to run d i s c r e t e 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 i n a n c i a l and man hour data f o r i n t e r n a l trend and group comparative  purposes.  Nineteen (19) i n d i c a t o r s of Emergency Department a c t i v i t y have been i dentified.  Of i n t e r e s t to note i s the 1980 takeover of PAS by the American Hospital Association because of f i n a n c i a 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 i n a n c i a l a c t i v i t y i n d i c a t o r s .  D.  ACCREDITATION  The Canadian Council on Hospital A c c r e d i t a t i o n , a voluntary organizat i o n designed to a s s i s t hospitals and health care professionals  to  appraise t h e i r a c t i v i t i e s , evaluate r e s u l t s and improve t h e i r capa b i l i t i e s , set standards f o r the organization and d e l i v e r y of hospital care through ongoing improvements to s t r u c t u r a l determinants.  This  organization now provides the most comprehensive set of standards a v a i l a b l e to Canadian h o s p i t a l s .  Of relevance to t h i s study are those standards a p p l i c a b l e 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 A c c r e d i t a t i o n 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 f o r emergency care, based on community agreement and on 5  the c a p a b i l i t y of the h o s p i t a l , s h a l l be c u r r e n t l y maintained". Compliance with t h i s standard necessitates that the c a p a b i l i t i e s of the hospital Emergency Department to receive and t r e a t patients be Canadian Council on Hospital A c c r e d i t a t i o n . Guide to Hospital A c c r e d i t a t i o n . The C o u n c i l , Toronto 1977, p. 47.  - 68 -  c l e a r l y defined and that t h i s r o l e be integrated with other health care resources, i . e . ambulance and other h o s p i t a l s .  Standard II - Organization and S t a f f i n g - states that "the emergency s e r v i c e , where maintained, s h a l l be well organized, properly directed and integrated with other departments of the h o s p i t a l .  Staffing shall  be r e l a t e d to the scope and nature of the needs a n t i c i p a t e d and the services o f f e r e d . "  Compliance with t h i s standard necessitates adequate numbers of appropriately t r a i n e d manpower w i t h i n the department and a v a i l a b l e on an as needed basis to meet the patient demands placed on the Emergency Room i n concert with i t s r o l e .  Integration with d i a g n o s t i c ,  therapeutic and support services i s e s s e n t i a l f o r p a t i e n t 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 s h a l l be such as to ensure s w i f t and e f f e c t i v e care of the p a t i e n t " . ^  Compliance with t h i s standard necessitates  functional planning information to organize the physical space to most appropriately t r e a t 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 s u p p l i e s , drugs and equipment and a communication system to expedite the demands placed on other hospital departments.  Ibid P. 48. Ibid P. 49.  - 69 -  S t a n d a r d IV - P o l i c i e s and  Procedures - s t a t e s t h a t "emergency  p a t i e n t c a r e 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 u p p o r t e d by a p p r o p r i a t e  procedure manuals and  reference  Of prime importance are t r e a t m e n t p r o t o c o l s , and respect  to discharge or admission to h o s p i t a l .  syndrome" p l a n n i n g / p o l i c y  problemsis evident  shall  material.'"  policies The  be  with  "back door  o r not e v i d e n t  in  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 - s t a t e s t h a t "a  patient's  clinical  r e c o r d 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 r e c o r d . "  Documentation s t a n d a r d s i n c l u d e the maintenance o f a c o n t r o l r e g i s t e r , c h a r t i n g s t a n d a r d s ( p a t i e n t i d e n t i f i c a t i o n , time  and  means o f 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  radiological  f i n d i n g s , diagnosis  t r a n s f e r or d i s c h a r g e and  final  and  t r e a t m e n t c o n d i t i o n upon  d i s p o s i t i o n ) and  o f importance i s r e t r o s p e c t i v e and  signatures.  Also  concurrent q u a l i t y of care  assessment.  S t a n d a r d VI - Non-acute Ambulatory Care P a t i e n t s - s t a t e s "there  ° 9  shall  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  I b i d , P.  50  I b i d , P.  52  that  treatment  and  - 70 -  disposal of patients presenting themselves at the hospital with non-acute c o n d i t i o n s " . ^  Compliance with t h 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 p r i v a t e  physicians for convenience is discouraged.  A f f e l d t (1978) i d e n t i f i e s s i g n i f i c a n t changes in the Emergency Department service standards as i d e n t i f i e d by the U.S. J o i n t Commission on Hospital A c c r e d i t a t i o n .  Of i n t e r e s t to t h 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, s p e c i f i c and general requirements were established f o r four l e v e l s of emergency s e r v i c e s . for each l e v e l were i d e n t i f i e d .  The scope of services and standards Because of cross i n f l u e n c e s ,  the Canadian Council on Hospital A c c r e d i t a t i o n w i l l  undoubtedly  addpt a s i m i l a r stance in the future.  2.  Disaster Planning  Up u n t i l 1977, the CCHA was rather n o n - s p e c i f i c with respect to the requirements f o r d i s a s t e r planning.  In f a c t , i t s major requirement  was that there be w r i t t e n d i s a s t e r plans for i n t e r n a l and external  I b i d , P. 53.  - 7(1 -  disasters.  There was l i t t l e mention of frequency of review and  update or of t e s t i n g of plans.  In the revised 1977 Standards, the  Guide states: "the hospital s h a l l have w r i t t e n plans f o r the proper and timely care of c a s u a l t i e s a r i s i n g from both external and i n t e r n a l d i s a s t e r s , such plans to be f i l e d with the appropriate p r o v i n c i a l agency and rehearsed p e r i o d i c a l l y . These plans s h a l l also i n clude w r i t t e n i n s t r u c t i o n s 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 i z e of the h o s p i t a l and services o f f e r e d . Written d i r e c t i v e s must also be issued i n s t r u c t i n g s t a f f what to do in the event of a bomb t h r e a t . " E f f e c t i v e d i s a s t e r planning is contingent upon a r e a l i s t i c assessment of e x i s t i n g and potential c a p a b i l i t i e s in the event of a disaster.  A continuously updated inventory of resources of the  hospital and the community i s e s s e n t i a l .  E.  CONCLUSION - MODEL OF INFORMATION NEEDS  Based upon the state of the a r t of hospital information systems in general and Emergency Department information systems in p a r t i c u l a r , i t becomes apparent that problems e x i s t with respect to c o n c e p t u a l i z a t i o n , i d e n t i f i c a t i o n , organization and p r i o r i z a t i o n of information needs. Managers of hospital Emergency Departments cannot operate i n i s o l a t i o n  CCHA Guide to Hospital A c c r e d i t a t i o n , P. 66.  - 72 -  of the programs and resources of the h o s p i t a l , the health and s o c i a l resources a v a i l a b l e to i t s patients or the resources people in the community.  and  It i s e s s e n t i a l that any i d e n t i f i c a t i o n  of emergency information needs not be done in i s o l a t i o n of large systems.  The types, l e v e l s and needs f o r information i d e n t i f i e d in the l i t e r a t u r e concentrate p r i m a r i l y on four f o c i - information required f o r the care and treatment of the p a t i e n t ; information needed to manage an Emergency Department and to assess the q u a l i t y of care provided and that required f o r s t r a t e g i c planning.  Of  l e s s e r mention are those information requirements f o r research and development or p o l i c y formulation.  For the purposes of t h i s study, a l l s i x l e v e l s of information needs w i l l be i d e n t i f i e d - patient care, management, q u a l i t y of care, s t r a t e g i c planning, research and development and p o l i c y formulation. It i s recognized that each of these l e v e l s requires  increasingly  s o p h i s t i c a t e d information, and that each i s of special i n t e r e s t to d i f f e r e n t 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 government.  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 z a t i o n of needs  can an information system be made most e f f e c t i v e .  - 73 -  The s i x l e v e l s of c l a s s i f i c a t i o n , t h e i r d e f i n i t i o n s and scope of a c t i v i t i e s , potential users and frequency with which information may be c o l l e c t e d i s documented in f i g u r e  3.2.  Once the l e v e l s 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 r o f i l e s or c l a s s i f i c a t i o n s of the types of information that may be p o t e n t i a l l y useful to hospital decision-makers.  As t h 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 i n t e r a c t i o n 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 w i t h i n these  l a r g e r systems.  Following f i g u r e 3.2 i s a matrix, derived from the l i t e r a t u r e of the s i x uses of information and p r o 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 t a r t i n g point f o r the i d e n t i f i c a t i o n of s p e c i f i c data elements.  Once a l i s t of data elements i s derived from  the matrix, v a l i d a t i o n by a panel of decision-makers  is feasible.  Figure 3.2 EMERGENCY DEPARTMENT - INFORMATION CLASSIFICATION SYSTEM  Classifications  Definitions/Scope of A c t i v i t i e s  Users  Frequency Collected/ Generated  Patient Care  Diagnosis, treatment, d i s p o s i t i o n and follow-up of patients presenting at the Emergency Department  Emergency Nurse Emergency Physician  Routine daily  Management  Operational planning organizing/scheduling/staffing budgeting/monitoring and control  Head Nurse - Director of Nursing Chief of Emergency - Medical D i r e c t o r  Routine daily monthly  Quality of Care  Monitoring of q u a l i t y of care Quality assurance/audit  Medical S t a f f Nursing S t a f f  Monthly  Strategic Planning  Role determination Program planning Resource a l l o c a t i o n  Administration - Administrator - D i r e c t o r of Nursing - Medical Director Planners - Greater Vancouver Regional Hospital D i s t r i c t - M i n i s t r y of Health  Annually  Research and Development  Organization and delivery of Emergency Room c a r e / u t i l i z a t i o n Effectiveness and E f f i c i e n c y Structure/process/outcome studies  Researchers/ Epidemiologists  Special studies  P o l i c y Formulation  Regulatory/1egi s i a t i v e p o l i c i e s Resource A l l o c a t i o n  Emergency Health Services Commi ssion/ M i n i s t r y of Health  ?  Figure 3.3  COMMUNITY/REGIONAL PROFILE  TYPES OF \INFOR\MATION USES OF \ . COMM INFORMATION (a)  POPULATION (CATCHMENT AREA) HEALTH/ D/SE STATUS EPID (c) (bj  EMERGENCY DEPARTS ENT PROFILE  HOSPITAL PROFILE  HEALTH/ SOCIAL  MOM H/S  PAT IENTS/ UTILIZ ATION  RESOURCES  RESOURCES PROGRAMS  MANPOWER  COSTS  $  MAN  EQUIP  EP/ D S/E (e) ( f )  CLIN+ D & T OUTCOME (h) (g)  CLINICAL PATIENT CARE OPERATIONAL MANAGEMENT QUALITY OF CARE STRATEGIC PLANNING EFFECTIVENESS R & D POLICY a) b) c) d) e) f) g) h)  community characteristics - i . e . major industry, health hazards, potential risks epidemiological/demographic, socio-economic information - age, sex, residence, income, race morbidity and mortality indicators other health resources in the community - detoxification centres, long term care f a c i l i t i e s demographic - age/sex epidemiological, socio-economic - marital status, race, income diagnostic and therapeutic c l i n i c a l information - chief complaint, diagnosis, laboratory/x-ray, etc. 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 d e n t i f i e d a core set of data base elements appropriate to any and a l l ambulatory care encounters.  In Canada, attempts at the  federal and p r o v i n c i a l l e v e l s to l i k e w i s e i d e n t i f y a uniform data set have not been so s u c c e s s f u l .  A review of e x i s t i n g information systems demonstrated the lack of i n t e g r a t i o n of c l i n i c a l and f i n a n c i a l systems and also showed the f r u s t r a t i o n s of managers to integrate m u l t i p l e data sources i n t o a meaningful whole.  Trends in the B.C. J o i n t Hospital Funding Study i d e n t i f i e d a core set of information to be c o l l e c t e d in Emergency Departments although t h i s information has yet to be v a l i d a t e d by the industry.  Thrusts f o r information in the l i t e r a t u r e appear to be concentrated on four foci - information required for the care and treatment of the p a t i e n t , information needed to manage an Emergency Department,  infor-  mation required to assess the q u a l i t y of care and information required for s t r a t e g i c planning.  - 77 -  Although the prime focus of the study i s on the information needs of h o s p i t a l managers, two a d d i t i o n a l f o c i were presented - research and development and p o l i c y formulation.  From these s i x l e v e l s of  information, a matrix was developed which incorporated successively l a r g e r types or categories of information needs from the patients and resources of the Emergency Department to the h o s p i t a l and to the community i t serves.  itself  - 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 i n the previous chapter, the ten year time lag between the i n t r o d u c t i o n 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 f o r entry into the health care system. This time lag l e g i t i m i z e d the r o l e 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 i n an Emergency Department was e s s e n t i a 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 f o r a $2.00 co-insurance fee, many patients continued to r e l y upon the resources of the Emergency Department f o r p a r t i c u l a r aspects of care, rather than the physician's  office.  A review of p r o v i n c i a l a c t i v i t i e s over the past ten years i n B.C. indicates the evolution of emergency care as a d i s c i p l i n e i n i t s  - 79 -  own r i g h t .  Whether t h i s has arisen from general health care  trends such as increasing medical s p e c i a l i z a t i o n , s o p h i s t i c a t e d technology and the influence of pre-hospital emergency medical systems or the i n a b i l i t y of t r a d i t i o n a l models of the Emergency Department organization and management to cope with increasing volumes i s open to speculation.  However, as a r e s u l t of the  studies of the 1960's, "a number of hospitals began to experiment with the organization of t h e i r emergency room services e i t h e r by i n s t i t u t i n g a " t r i a g e " 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 i m e s t a f f of private physicians whose professional e f f o r t s would be l i m i t e d 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 f o r evaluation of care rendered - in p a r t i c u l a r , outcomes, standards f o r organization and d e l i v e r y and a thrust towards c l a s s i f i c a t i o n or c a t e g o r i z a t i o n of departments.  This con-  centration i s perhaps more evident i n the U.S. where d i f f e r e n t influences i n . h e a l t h care d e l i v e r y , such as competition and r e g u l a t i o n , are i n existence than i n Canada, but nevertheless there has been a r i s e i n use here too as discussed i n 2-A and 4 - C . l .  Of note, however, w i t h i n the f i e l d of emergency medicine i n B.C.  is  the increasing s p e c i a l i z a t i o n of manpower resources and the emergence of new categories of health manpower - the paramedic, the emergency  * Torrens, P.R. and Yedvab, D.G., " V a r i a t i o n s Among Emergency Room Populations: A Comparison of Four Hospitals in New York C i t y , " Medical Care, Vol. X I I I , No. 12, December 1975, P. 1011-1020. 1  - 80 -  physician and the emergency nurse.  The 1974 Emergency Health Services  Act of B.C. l e g i s l a t e d p r o v i n c i a l r e s p o n s i b i l i t y and control over the d e l i v e r y of pre-hospital care and paved the way f o r the development of paramedic services (discussed i n the next s e c t i o n ) .  The Kermacks Report on Nursing Education (1979) recommended the immediate development of post-basic s p e c i a l t i e s i n c r i t i c a l care nursing - such as ICU, o b s t e 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 r a i n i n g 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 f o r s p e c i a l t y c e r t i f i c a t i o n f o r emergency physicians.  C u r r e n t l y , s p e c i a l i s t exams are taken  under the auspices of the American College of Emergency Physicians.  In B.C. appropriate funding f o r emergency care has been l a c k i n g . The $2.00 p r o v i n c i a l co-insurance fee i n 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 r o l e of Emergency Departments with respect to improved services provided as a r e s u l t of s p e c i a l i z e d technology and manpower.  S t a t i s t i c s that have been c o l l e c t e d r e l a t e purely to the number of visits.  Budgets f o r Emergency Care are assumed under general  - 81 -  Operating Budgets.  The recognition of the Emergency  Department  as a s p e c i f i c allowable budget item w i l l only be assured with the implementation of a new funding system.  To set t h i s study w i t h i n the context o f 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 o u t l i n e some of the more major developments w i t h i n B.C.  B.  THE EMERGENCY HEALTH SERVICES COMMISSION - 1974  In May of 1974, the Emergency Health Services Act was promulgated with powers and a u t h o r i t i e s covering the manpower, equipment and communications conponents of an integrated emergency health care s e r v i c e , 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 d i r e c t e d at pre-hospital care.  A p r o v i n c i a l ambulance  system and improved t r a i n i n g standards f o r attendants led to the development of a new c l a s s of manpower i n B r i t i s h Columbia, the paramedic.  Modelled a f t e r the Los Angeles and S e a t t l e systems, the  paramedic i n B.C. i s second to none i n Canada.  Other powers of the Commission include medical d i s a s t e r planning, delegated to the Medical O f f i c e r s of Health i n the province and management of the Federal government's (MASH u n i t s ) .  Emergency Medical  Supplies  - 82 -  Also w i t h i n the powers of the Commission, although not exercised u n t i l 1980, i s the j u r i s d i c t i o n over h o s p i t a l Emergency Department standards.  The 1980 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  (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 c a p i t a l resource and program planning.  Inter-  m i t t e n t l y , over a period of ten years, the GVRHD has addressed the planned development of emergency resources w i t h i n the Regional District.'  Studies (1970, 1976, 1978, 1980) i d e n t i f i e d trends with  respect to Emergency Department u t i l i z a t i o n and attempted to quantify i n a l o g i c a l fashion, the requirements f o r service w i t h i n 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 i n t o existence i n 1966 before the Emergency Health Services Commission was e s t a b l i s h e d .  1.  Emergency Medical Services Study, A p r 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 e f f e c t s of hospital admitting p o l i c i e s , Emergency Department s t a f f i n g 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 p a t i e n t s "  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 s e n t i a l , urgent and c r i t i c a l ,  "what  i s presently c a l l e d an emergency department i s a c t u a l l y a community diagnostic and treatment centre where an i n c r e a s i n g l y  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 s e v e r i t y mix and the r e l a t i o n s h i p between i n p a t i e n t beds and admissions through emergency, the ideal d i s t r i b u t i o n of emergency beds among GVRHD hospitals was determined.  Of more i n t e r e s t 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 o n , was the administrative p o l i c y  recommendations.  The report s p e c i f i e d at the outset that "the Emergency  Department  of the hospital i s a treatment area not a holding u n i t nor i s to be used as an admitting o f f i c e " .  G.V.R.H.D. 1970, p. 84. 3  G.V.R.H.D. 1970, p. 33.  4  G.V.R.H.D. 1970, p. 34.  4  The dumping syndrome was  it  - 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 f o r special groups such as a l c o h o l i c s , the aged, welfare cases and p a r t i c u l a r l y p s y c h i a t r i c 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 f o r 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 i m i t e d categories were i d e n t i f i e d and e x i s t i n g  hospitals  classified. Part 2 of the study evaluated e x i s t i n g pre-hospital c a p a b i l i t i e s w i t h i n the Region.  emergency  At that time, ambulance  services  were a mixture of private and volunteer resources, subsidized by municipalities.  V e h i c l e , equipment and t r a i n i n g 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 p o 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 d u p l i c a t i o n , improved service and q u a l i t y and f a c i l i t a t e d the development of a t o t a l emergency health system.  5  G.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 f u r t h e r Emergency Services Study to review and update the previous 1970 study because of changes in p r a c t i c e patterns, the upgrading of old f a c i l i t i e s and proposals f o r new f a c i l i t i e s .  Although t h i s Study  operated under i d e n t i c a l terms of reference to the 1970 Study, i t concluded with a number of observations and proposals f o r f u r t h e r i n v e s t i g a t i o n rather than recommendations.  A s h i f t in u t i l i z a t i o n from major r e f e r r a l h o s p i t a l s to the l a r g e r community h o s p i t a l s 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 v e  year period from 1972 to 1976, while the number of Emergency Department 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 i n a two week period i n t o four d i s c r e t e areas showed that one t h i r d of the cases a r r i v i n g at the Emergency Department could have been treated at an ambulatory care c l i n i c or d o c t o r ' s o f f i c e and 292 cases or 3% of a l l cases were backdoor admissions r e q u i r i n g no Emergency Room treatment at a l l but simply admitted through the Emergency Room to bypass e l e c t i v e waiting l i s t s .  This d i s t r i b u t i o n of backdoor admissions was found  not to be s i g n i f i c a n t , much to the surprise of those on the committee.  - 86 -  There were a number o f p o l i c y c o n s i d e r a t i o n s r e p o r t which needed t o be r e s o l v e d b e f o r e c o u l d be made.  i d e n t i f i e d i n the  planning  recommendations  The l a c k o f r e c o g n i t i o n o f t h e h o s p i t a l Emergency  Department as a "department" w i t h 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 s t a t u s accorded o t h e r medical s p e c i a l t i e s and t h e c h r o n i c f a i l u r e t o 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 cons i s t e n t w i t h t h e r o l e o f t h e Emergency Department were viewed as fundamental b a r r i e r s t o t h e i m p l e m e n t a t i o n o f e f f e c t i v e and acceptable  Emergency Room p l a n n i n g  recommendations.  I t i s o f i n t e r e s t t o note t h a t t h e 1976 p r o j e c t i o n s o f 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 w i t h t h e a c t u a l 1976 u t i l i z a t i o n  3.  rates.  Emergency F a c i l i t y Development i n t h e C i t y o f Vancouver, A p r i l 1968  A n o t h e r s t u d y was undertaken t o e v a l u a t e  t h e impact o f p l a n s 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 t h e c u r r e n t and planned Emergency Department resources  w i t h i n t h e m u n i c i p a l i t y o f Vancouver as a whole.  dominant i s s u e s which l e d t o t h e e s t a b l i s h m e n t an o b v i o u s o v e r s u p p l y o f emergency resources proposal  The  o f t h e review were i f Shaughnessy's  f o r a s e p a r a t e Emergency Department were t o be implemented  and a c o n t r o v e r s y  o v e r whether t h e r e s h o u l d  be p h y s i c a l l y s e p a r a t e  - 87 -  or conjoint a d u l t - p a e d i a t r i c Emergency Departments at the Shaughnessy s i t e .  In a d d i t i o n to recommending, rather weakly,  b e t t e r 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 r m recommendation.  This recommendation was that a s i n g l e emergency f a c i l i t y  with an i n t e r i o r subdivision to allow f o r the separate functioning of an adult emergency and a p a e d i a t r i c emergency be planned. I n t e r e s t i n g l y or not s u r p r i s i n g l y , there are two separate Emergency Room f a c i l i t i e s c u r r e n t l y under c o n s t r u c t i o n .  D.  DISASTER PLANNING - 1978-1980:  In June 1978, the Greater Vancouver Regional Hospital D i s t r i c t assumed a d i s a s t e r planning f u n c t i o n .  Previously there had been  no co-ordinated emergency medical response, e i t h e r at the scene of the d i s a s t e r or at the h o s p i t a l s .  Also l a c k i n g was e f f e c t i v e  co-ordination of a l l emergency services i n c l u d i n g f i r e , p o l i c e , ambulance, and m u n i c i p a l i t i e s .  Each had i t s own p l a n , but there  was no e f f e c t i v e co-ordination among s e r v i c e s .  Because of these d i f f i c i e n c i e s and also because casualty management i s u l t i m a t e l y a medical r e s p o n s i b i l i t y , the G.V.R.H.D. Disaster Medical Care Committee was formed with the s p e c i f i c mandate t o :  - 88 -  1.  E v a l u a t e c u r r e n t m e d i c a l , h o s p i t a l and ambulance p l a n s ,  2.  Update and modify t h e s e p l a n s where n e c e s s a r y ,  3.  P r o v i d e a c o n s o l i d a t e d medical Regional H o s p i t a l D i s t r i c t ,  4.  C o - o r d i n a t e the emergency medical response w i t h t h e o t h e r emergency s e r v i c e s and p r o v i d e a means f o r an on-going t e s t i n g o f medical preparedness.  p l a n f o r t h e G r e a t e r Vancouver  The Committee, under t h e c h a i r m a n s h i p o f an e n e r g e t i c Vancouver emergency p h y s i c i a n , had r e p r e 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 t h e event o f a d i s a s t e r would c a r r y  t h e b r u n t o f t h e c a s u a l t y l o a d , t h e G r e a t e r Vancouver H o s p i t a l A d m i n i s t r a t o r ' s C o u n c i l , t h e G r e a t e r Vancouver Regional H o s p i t a l D i s t r i c t , t h e B.C. M e d i c a l A s s o c i a t i o n , t h e Emergency P h y s i c i a n s Group and t h e Emergency Nurses A s s o c i a t i o n .  In t h e f i r s t y e a r o f t h e Committee's o p e r a t i o n a g r e a t deal was accomplished.  A l l t h e h o s p i t a l s had t h e i r d i s a s t e r p l a n s  by way o f a comprehensive q u e s t i o n n a i r e .  reviewed  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 o r d e r t o a s c e r t a i n t h e bed, personnel and s u p p o r t s e r v i c e a v a i l a b i l i t y i n t h e event o f 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 h a v i n g s u f f i c i e n t r e s o u r c e s t o be c l a s s i f i e d as major r e c e i v i n g  hospitals.  In a d d i t i o n , an o n - s i t e medical c a t i o n s package was developed  G.V.R.H.D.  response  p l a n and s u p p o r t i n g communi-  t o l i n k the d i s a s t e r s i t e with hospital  D i s a s t e r P l a n n i n g Report, G.V.R.H.D., November 1979, P. 1.  - 88 a -  receiving c a p a b i l i t i e s .  Other e f f o r t s were directed to the  preparation of course material f o r the Emergency Health Services Commission personnel, t r i a g e o f f i c e r s and f i r e department personnel.  The "On-Site Medical Disaster Plan" was tested i n co-operation with the f i r e and p o l i c e departments i n March of 1979.  Problems were  encountered i n a l l s e r v i c e s , yet r e s o l u t i o n of plan d e f i c i e n c i e s was deemed to need the co-operation of p o l i c e and f i r e s e r v i c e s . There was s u f f i c i e n t improvement i n medical and hospital coordination to improve the care response, however, the f a i l u r e of p o l i c e and f i r e services to resolve t e r r i t o r i a l imperatives cont r i b u t e d g r e a t l y to the decline of the Region's e f f o r t s .  At l a s t  look, the h i r i n g 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 e n t a u t h o r i t y to impose coordination of the e s s e n t i a l 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 e a r l y l a c k i n g i n the Greater Vancouver  Regional Hospital D i s t r i c t .  While emergency department and  hospital 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 1978, and plans were updated, no f u r t h e r attempt has been made during the past two years e i t h e r to monitor t h e i r effectiveness or to p r a c t i c e i n concert.  - 89  E.  -  THE EMERGENCY NURSES GROUP  The Emergency Nurses Group, a special i n t e r e s t group of the Registered Nurses' Association of B.C. has been s e r i o u s l y concerned about the lack of uniform documentation of Emergency Care to meet jurisprudence requirements and protect i t s members from legal action.  The o f f i c i a l documentation form f o r emergency department  care i s the M i n i s t r y of Health HIA-15 reporting form designed to c o l l e c t f i n a n c i a l and minimal c l i n i c a l information as recorded by physicians.  It has been the f e e l i n g of t h i s group that adequate  documentation i s e s s e n t i a l to p a t i e n t 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 , a c c r e d i t a t i o n , management and audit requirements.  An Emergency Documentation Workshop was held December 7, 1979, emergency nurse representatives from eleven (11)  with  of the l a r g e r  p r o v i n c i a l h o s p i t a l s , to develop a standard emergency documentation tool and to consider charting c r i t e r i a .  Legal, q u a l i t y assurance  and a d m i n i s t r a t i v e components o f - t h e 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 l o t e d i n Emergency  Departments.  - 90 -  F.  JOINT HOSPITAL FUNDING STUDY.  The J o i n t Hospital Funding Project was i n i t i a t e d i n May of 1978 to i d e n t i f y an equitable funding system f o r those health care i n s t i t u t i o n s i n which programs were being conducted or planned. Its purpose was not to j u s t i f y greater expenditures i n the health care f i e l d but to aim f o r optimum use of a v a i l a b l e f i s c a l  resources  i n a manner which was understood by a l l p a r t i e s .  1.  Background  The hospitals in B r i t i s h Columbia are funded through a system which o r i g i n a t e d 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 communicat i o n between government and h o s p i t a l s regarding funding  decisions  and on the i n e q u i t i e s of t r e a t i n g a l l h o s p i t a l s and the care they provide as i d e n t i c a l .  The dominant issues i d e n t i f i e d w i t h i n the  J o i n t Funding Project (Ernst and Whinney, October 1979) are as follows: "The current system f a i l s to recognize h o s p i t a l uniqueness. Hospital r o l e s , the types of patients t r e a t e d , the i n t e n s i t y of service provided, differences i n physical plant and  - 91 -  constraint of geographical l o c a t i o n 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 i n the system to contain hospital costs. The system does not encourage the development of i n p a t i e n t a l t e r n a t i v e s such as day care and preventive programs or a l t e r n a t i v e procedures and innovative techniques which would be more e f f e c t i v e and e f f i c i e n t . There are no controls against u n d e r - u t i l i z a t i o n or overutilization; The funding system does not t i e i n t o the planning or evaluation processes. Services have been developed on incremental b a s i s . High q u a l i t y i s not rewarded, neither i s there a control against low q u a l i t y of care. There i s a d u p l i c a t i o n of reporting systems. External reports as submitted to the M i n i s t r y of Health are inappropriate for i n t e r n a l monitoring and control purposes and are not shared with the h o s p i t a l s submitting them."  2.  J o i n t Funding Project Recommendations  The foundation of the Consultant-'s recommendations was a conceptual framework which i d e n t i f i e d the philosophy and mechanics of the proposed system and an implementation plan.  The i n t e g r a t i o n of  planning funding and monitoring and control at a p r o v i n c i a l level and at an i n d i v i d u a l hospital level i s i n t e g r a l to the system (see Chart 4.1).  Each of the phases - s t r a t e g i c planning, budget  planning, i n t e r i m payments, r e c o n c i l i a t i o n and monitoring and  Ernst and Whinney, "Study of the B.C. Hospital Funding Program" V o l . 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 d a t a r e q u i r e m e n t s . r e p o r t was  On May  d i s t r i b u t e d t o the B.C.  i n s t i t i t i o n s and M i n i s t r y o f Health  8, 1979  Health  a  preliminary  A s s o c i a t i o n member  s t a f f f o r review  feedback t o the S e c r e t a r i a t o f the J o i n t J o s p i t a l  and  Funding Study.  T h i s r e p o r t o u t l i n e d i n g r e a t d e t a i l the f i v e phases of conceptual  the  framework.  Because one  o f the c o n s t r a i n t s o f t h i s study of emergency  information  i s c o n s i s t e n c y w i t h the p h i l o s o p h y  of the J o i n t Funding S t u d y , an e x p l a n a t i o n  and  recommendations  o f the f i v e phases o f  the recommended system i s i n o r d e r . 1.  Strategic  Planning  The f o u n d a t i o n o f a l l h e a l t h care systems r e s t s on d e f i n i t i o n o f h e a l t h c a r e needs and the development o f a plan t o meet t h e s e needs a t the p r o v i n c i a l , r e g i o n a l and community l e v e l . This requires e f f e c t ive co-ordination of d e l i v e r y of health services between government, the p a y i n g agency, and the h e a l t h 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 p l a n n i n g so t h a t the e f f e c t i v e n e s s o f p l a n n i n g and d e l i v e r y o f s e r v i c e s can be measured o v e r a d e f i n e d time frame. T h i s 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 r a t e s o f change i n the l e v e l o f h e a l t h care needs. The mechanics o f d e f i n i n g h e a l t h care needs c o u l d be done on the b a s i s o f c a t e g o r y o f i l l n e s s , m o r t a l i t y and m o r b i d i t y i n d i c e s and a f o r e c a s t o f p o p u l a t i o n trends. The development of a p l a n t o meet community needs i n v o l v e s the s e t t i n g o f 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 t o be developed on the b a s i s o f these g o a l s 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 t h r e e o r f i v e y e a r l o n g range p l a n . A d d i t i o n a l l y , d e p a r t m e n t a l i z e d and programme o r i e n t e d budgets would be developed t o s u p p o r t h o s p i t a l g o a l s and o b j e c t i v e s . Hospital g o a l s and o b j e c t i v e s would support r e g i o n a l and  - 93 -  and p r o v i n c i a l goals and o b j e c t i v e s . The mechanics of t h i s process would also involve establishment of p r o v i n c i a l and regional constraints and l i m i t a t i o n s on a v a i l a b l e funds. The decision-making process would occur at a l l steps by having h o s p i t a l s and the M i n i s t r y of Health negotiate a contract f o r the prov i s i o n of services to ensure that there i s (a) a c o n t i n u i t y of goals and o b j e c t i v e s , (b) a cost b e n e f i t evaluation of competing programmes and (c) an i n t e g r a t i o n of p r o v i n c i a l , regional and hospital goals and o b j e c t i v e s . The fourth requirement of the s t r a t e g i c planning phase i s one of data. The following forms of data would be required: a) b) c) d) e)  Demographic population/trends Disease indices Demand programme requirements Supply of programmes inventory A cost per output measure by programme type  Depending on the scope of data required, data could be c o l l e c t e d on e i t h e r a hospital l e v e l , a regional l e v e l or a p r o v i n c i a l l e v e l .  2.  Budget Planning  The main features of budget planning would a r i s e from a contract f o r services and dollars, between the h o s p i t a l s and the province at prices that consider (a) e f f i c i e n c y (not actual c o s t s ) , (*b) s p e c i f i c h o s p i t a l cons t r a i n t s ( f i x e d c o s t s ) , (c) recognition of s p e c i f i c hospital roles in r e l a t i o n to p r o v i n c i a l and regional long range plans and (d) budget performance. Annual budgets by h o s p i t a l departments and by programmes would be reviewed by the M i n i s t r y of Health with respect to o v e r a l l funding l e v e l s a t t a i n a b l e and regional demand. By a process of j o i n t n e g o t i a t i o n , contracts between the M i n i s t r y of Health and h o s p i t a l s would e s t a b l i s h performance measures.  Figure  HOSPITAL CONCEPTUAL  Moapilel end Programe  Interim Payments  Budget Planning  Program Planning  God Setting  F Kilitiat  FUNDING SYSTEM  FRAMEWORK FLOW CHART  Strategic Planning  Hospital* "Supply"  4.1  Program Cvaauelion  Budgeting  Wnlrnl  Reconciliation  1  Monitoring  U Control  Perform Servfcn  4*  Contract lor Programs and iarvlca Le»ele  Howltel ftolea  Government "Demand" Regional fir Provincial  Source:  Pi 091 am Planning  Fret-Veer Go*l Selling  Health Cere Nodi  Ernst 14  I D f m t n d to  and Whinney, in  Study  October  1,  of  Evaluation ot Funding Lt.tlt  The  B.C.  1979.  Conceptual Hospital  • ' . .  Framework  Funding  Program Procurement Coii/Benerit ol Competing Progrerm  Flow  Program,  Interim Ptymenii  Chart.  Vol.  Information Boso  II  Exhibit Exhibits,  Moniloring end Control  - 95 -  The decision-making requirement f o r budget planning would be one of providing a f l e x i b l e budget for each h o s p i t a l ' s v a r i a b l e costs (measured by output). On the other hand, c e r t a i n f i x e d costs would be prospectively determined and funded. Both of these aspects would contribute to the f a c t that p r o v i n c i a l reimbursement of hospitals would be based on actual volumes of approved programmes. Data requirements f o r budget planning would be in terms of hospital roles measured on the basis of (a) l e v e l and i n t e n s i t y of care provided, (b) education, (c) research and (d) s p e c i a l i z e d s e r v i c e s . In order that h o s p i t a l s be appropriately c l a s s i f i e d , certain- committed f i x e d costs must be recognized as i n d i v i d u a l differences of h o s p i t a l s . These may include (a) l o c a t i o n of f a c i l i t y , (b) age of f a c i l i t y , (c) s i z e 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 e s s e n t i a l that hospital costs be broken down i n t o f i x e d costs, f i x e d programme costs and marginal or v a r i a b l e programme costs. Furthermore, the volume of services would have to be segregated on both an i n p a t i e n t and outpatient basis and consider both the l e v e l and the i n t e n s i t y of programme treatment. To ensure that health care needs are being met, c e r t a i n standards for the d e l i v e r y of i n d i v i d u a l programmes in terms of services and treatments would have to be developed.  3.. Interim Payment Determination The p r i n c i p l e supporting i n t e r i m payment determination i s that i n t e r i m payments serve to get d o l l a r s to the h o s p i t a l s on a regular b a s i s . The i n t e r i m payments should r e f l e c t the cash flow needs of the h o s p i t a l s in terms of committed f i x e d costs, programme f i x e d costs, v a r i a b l e costs and c e r t a i n c a p i t a l expenditures. The mechanics proposed are to have h o s p i t a l s submit p e r i o d i c s t a t i s t i c a l and f i n a n c i a l  - 96 -  reports to the M i n i s t r y . The M i n i s t r y could fund h o s p i t a l s on a pre-determined percentage of f i x e d and v a r i a b l e costs (based on s t a t i s t i c s ) . Several a l t e r n a t i v e mechanisms could be used to accommodate cash flow ( d i f f e r e n t bases f o r predetermined f i x e d and other allowable c o s t s ) . It should be noted that the i n t e r i m payment system should recognize exceptional cases and increase d o l l a r advances to recognize special s i t u a t i o n s . Under t h i s procedure, the government would have to e s t a b l i s h p o l i c i e s f o r timing of payments. The data requirements f o r the support of an i n t e r i m 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 i x e d c o s t s , programme f i x e d costs and v a r i a b l e programme costs.  4.  Reconciliation  The p r i n c i p l e s of r e c o n c i 1 1 i a t i o n are to balance, on an annual b a s i s , i n t e r i m payments with regard to the contract established in the budget planning phase. R e c o n c i l l i a t i o n s would have to address appropriate deviations from contract r o l e s , volumes, case mixes and treatment. Furthermore, reconci11iations could be adjusted f o r changes in case mix or volume. The mechanics f o r reconci11iation would be that they performed on a timely annual budgeting c y c l e . Hospitals would have to report volume, case mix and treatment s t a t i s t i c s on a monthly b a s i s , so that v a r i a b l e costs could be reimbursed on t h i s measure of output. Desicion making would be handled on a prospective b a s i s , i . e . predetermined (committed and programmed) f i x e d costs would be negotiated at the budget planning stage when the contract i s struck.  - 97 -  V a r i a b l e c o s t s would be funded on t h e b a s i s o f 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 a t a p r e s e t n e g o t i a t e d r a t e which c o n s i d e r s p r o v i n c e wide and h o s p i t a l c l a s s s t a n d a r d s . Data requirements f o r r e c o n c i l i a t i o n a r e s i m i l a r t o those r e q u i r e d under t h e i n t e r i m and budget p l a n n i n g phases. In b r i e f , they are a r e c o r d o f programme f i x e d c o s t s , marginal o r v a r i a b l e programme c o s t s , f o r e c a s t o f volumes i n terms o f i n p a t i e n t and o u t p a t i e n t l o a d , l e v e l and i n t e n s i t y o f t r e a t m e n t and programme volumes.  5.  M o n i t o r i n g and C o n t r o l  The p r i n c i p l e b e h i n d m o n i t o r i n g and c o n t r o l i s t h a t t h e r e s h o u l d be an ongoing measure o f h o s p i t a l q u a l i t y and i n p u t . Performance measurement would have t o be made a g a i n s t pre-determined standards. Some o f these c o u l d be ( a ) c o s t p e r u n i t o f o u t p u t , (b) t r e a t m e n t , ( 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 e x p e n d i t u r e s and (g) use o f funds. The m o n i t o r i n g and c o n t r o l system proposed would have measures o f performance compared t o e s t a b l i s h e d standards. The mechanics o f m o n i t o r i n g and c o n t r o l would be o u t p u t measures i n terms o f programmes (volume, case mix and t r e a t m e n t ) c o m p i l e d 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 , r e g i o n a l and p r o v i n c i a l b a s i s . Q u a l i t y and c o s t measures would have t o be c o m p i l e d 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 c o s t measures c o u l d then be a p p l i e d t o t h e process o f s t r a t e g i c p l a n n i n g i n phase one ( t h e f e e d back p r o c e s s ) . P r o v i n c i a l c o n t r o l o f t h e m o n i t o r i n g process would have t o be augmented by h o s p i t a l i n p u t .  - 9a Data requirements f o r monitoring and control would be based on developing standard information to e s t a b l i s h a linkage between c o s t s , p r o d u c t i v i t y 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 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 and ( f ) u t i l i z a t i o n of funds...  Since the core of t h i s Study is the data required by i n t e r n a l hospital decision makers, with respect to planning and managing emergency care w i t h i n the c o n s t r a i n t s of the J o i n t Funding Project philosophies and reporting requirements, no attempt w i l l be made to deal with broader p o l i c y issues such as an appeals process or the manner i n which contracts are e s t a b l i s h e d .  3.  Implementation  The implementation of the recommended funding system requires subs t a n t i a l m o d i f i c a t i o n to the present system and the implementation of s i g n i f i c a n t 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 J o i n t B.C. Health Association/Ministry of Health r e l a t i o n s h i p s .  Each party would appoint an Implementation  Team responsible to the J o i n t Steering Committee to ensure that the requirements of the M i n i s t r y of Health and the hospitals are met.  Buchanan, J.B.B.  L e t t e r to B.C.H.A. Membership on J o i n t Hospital Funding Program (adapted), May 8, 1979, p. 2-3.  - 99 -  b)  The development of a uniform reporting system to promote comparability w i t h i n and among hospital programs.  Information  would be i d e n t i f i e d which i s necessary to meet user and M i n i s t r y 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 r a t e g i c planning system r e l a t i v e to health care needs, hospital r o l e s , peer grouping of h o s p i t a l s , and contractual requirements.  d)  The design of a budgeting system based upon the outputs of the uniform reporting system and s p e c i f i c a t i o n of time frames, level of d e t a i l required and appropriate f i n a n c i a l and statistical  e)  systems.  Progressive modifications to the system to include the development of patient c l a s s i f i c a t i o n systems, r e l a t i v e value units and case mix p r o f i l e s .  P r i o r to the release of the Report, the J o i n t Steering Committee had indicated that regardless of the acceptance of the funding system modifications proposed by the consultants, a uniform reporting system was e s s e n t i a l .  Consistent and uniform data accessible to both the  M i n i s t r y of Health and the i n d i v i d u a l hospitals was viewed as a p o s i t i v e step regardless of the v i a b i l i t y of other recommendations.  The J o i n t Funding Study Report was subsequently approved i n p r i n c i p l e by both the Board of the B.C. Health Association and the M i n i s t e r of  - 100 -  Health.  Certain p o l i c y 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 d e n t i f i c a t i o n 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 f o l l o w i n g terms of reference: 1. To develop minimum standards f o r emergency rooms i n the Greater Vancouver Regional Hospital D i s t r i c t with respect to Physician coverage, s t a f f i n g patterns, back-up s e r v i c e s , equipment, physical plant requirements and administrative p o l i c i e s ; and 2. To analyze workload to i d e n t i f y the number of emergency room spaces required per catchment area w i t h i n the Greater Vancouver Regional Hospital D i s t r i c t . As a preliminary step, a log sheet was devised to c o l l e c t information on patient a c t i v i t y w i t h i n 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 s p o s i t i o n , presenting complaint, discharge diagnosis  and l e v e l  of s e v e r i t y was c o l l e c t e d f o r 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 a v a i l a b l e .  Greater Vancouver Regional Hospital D i s t r i c t , Emergency Services G.V.R.H.D., Vancouver, 1980, p. 2.  Study,  - 101 -  I t i s worthy to note that the s e v e r i t y categories of the 1978 Study have been expanded from four to seven assessment l e v e l s based on the t r i a g e categories defined i n 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) i n the foreseeable future, the potential f o r 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 J o i n t Hospital Funding Study that the fundamental problems with the financing of h o s p i t a l s lay outside the funding system.  The lack of an o v e r a l l p r o v i n c i a l  health care plan with agreed to " r o l e and goal statements" f o r h o s p i t a l s had impeded the development of any r a t i o n a l and equitable funding system.  The need to "upgrade the s t r a t e g i c planning  mechanism" was i d e n t i f i e d as one of four key problem areas.  This  led the commissioning of the Hospital Role Study by the J o i n t 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 i d e n t i f y performance  - 102 -  standards among l i k e i n s t i t u t i o n s or programs and lead to the eventual determination of appropriate hospital r o l e s .  Developed by the Planning and Development Group, M i n i s t r y of Health, the Hospital Role Study, Phase I - A Discussion Paper on Hospital Services in B.C. - i d e n t i f i e d a matrix of s i x l e v e l s of service (three l e v e l s of community h o s p i t a l s , two l e v e l s of r e f e r r a l f a c i l i t i e s and one p r o v i n c i a l one of a kind f a c i l i t y ) and seven i n p a t i e n t care functions (medical, surgery, o b s t e t r i c s , psychiatry, p a e d i a t r i c s , r e h a b i l i t a t i o n and d e n t i s t r y ) together with a set of i d e n t i f i e r guidelines which would a s s i s t hospitals i n i d e n t i f y i n g t h e i r current service p r o f i l e .  The i n t e n t of the document was to  develop a common vocabulary and provide a framework f o r  discussion  w i t h i n the health care industry in t h i s very complex area of hospital r o l e s .  There was general agreement by the industry (B.C. Health A s s o c i a t i o n , A p r i l 1980) that better o v e r a l l planning of our health care system was necessary and that the discussion document had achieved i t s immediate o b j e c t i v e i n e s t a b l i s h i n g i n t e r e s t and that i;t.;was a worthwhile study i n that i t attempted to define in a l o g i c a l the roles and functions of i n d i v i d u a l h o s p i t a l s .  fashion  - 103 -  Nevertheless many strong concerns and questions were raised by the industry - one set of concerns r e l a t i n g to the document i t s e l f and another set r e l a t i n g 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 l e a r d e f i n i t i o n 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 b a s i s .  It was  f e l t that a h o s p i t a l ' s role should be planned to meet the needs of the population i t serves.  It dealt with h i s t o r y rather than what  the health care needs are now or w i l l be in the f u t u r e .  A second major concern was the d e l i n e a t i o n of a h o s p i t a l ' s i n p a t i e n t role in i s o l a t i o n of i t s ambulatory function and the resources a v a i l a b l e in the community.  The document gave "inadequate a t t e n t i o n  to ambulatory care, emergency health s e r v i c e s , g e r i a t r i c s e r v i c e s , long term care and extended care and to the outreach  programs"^  which h o s p i t a l s have developed, not only to improve service but to reduce i n p a t i e n t 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 f o r acute i n p a t i e n t 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 n g ambulatory,  B.C. Health A s s o c i a t i o n , "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 a n t i c i p a t e d that a revised  document w i l l remedy these d e f i c i e n c i e s .  Concern has also been expressed by the J o i n t Steering Committee that the l e v e l of d e t a i l w i t h i n the Hospital Role Study i s 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 t h i s d e f i c i e n c y (Design Concepts Manual, August 1980).  3.  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  Closely l i n k e d 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 o n Study and the Hospital Role Study.is the Emergency;Health Services Commission 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.  The Commission appointed a group of experts  which endeavoured to c l a s s i f y a l l hospitals i n the Province with respect to t h e i r emergency c a p a b i l i t i e s in concert with the l e v e l s of service i d e n t i f i e d i n the revised Hospital Role Study (to be released in the F a l l of 1981).  The o r i g i n a l s i x l e v e l s of service  i d e n t i f i e d have been augmented to e i g h t .  To date, 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 team appears to have a l i a i s o n function t r a n s l a t i n g the work done i n the Greater Vancouver Regional Hospital D i s t r i c t into a p r o v i n c i a l matrix of emergency  - 105 -  care with i d e n t i f i e r guidelines consistent with the Hospital Role Study r e v i s i o n . the  Of i n t e r e s t i s the legitimacy t h i s study gives to  emergency physician as the l e v e l of physician s p e c i a l i s t i n  c l a s s i f i c a t i o n l e v e l s D, E and F and the designation that there s h a l l be a f u l l - t i m e emergency physician d i r e c t o r 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 d e l i v e r y of emergency health care i n the  province of B.C.  Many of these a c t i v i t i e s were p r i m a r i l y  planning studies on resource c a p a b i l i t i e s and these studies were concentrated i n the G.V.R.H.D. where problems in the organization and d e l i v e r y of emergency care were most acute.  Planning studies were p r i m a r i l y ad hoc i n nature and the data c o l l e c t i o n mechanisms were not continued beyond the study period. With the i n i t i a t i o n of the J o i n t Hospitals Funding P r o j e c t , there was a s h i f t in focus toward the i d e n t i f i c a t i o n of ongoing operational data i n both planning and management purposes and attempts to i n t e g r a t e planning and operational needs f o r information were- evSdent  '.for*$$e~tfirst":t.ime.  -  106  -  CHAPTER SUMMARY  Preceding  c h a p t e r s have t r a c e d 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 , 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 o f and the l a c k o f c o n c u r r e n t  the  capabilities  development i n i n f o r m a t i o n systems t o  meet the emerging management needs o f emergency departments.  This chapter reviews  r e c e n t a c t i v i t i e s i n B.C.  s i d e r a t i o n s are paramount.  The  where q u a l i t y  emergence o f the Emergency  P h y s i c i a n , the Emergency Nurse and the paramedic as new p r o f e s s i o n a l s has emergency c a r e .  classes of  l e d to a questioning of c u r r e n t standards Not o n l y has  con-  of  d i s a s t e r p l a n n i n g come to the f o r e -  f r o n t but a l s o ongoing day-to-day o p e r a t i o n a l requirements are o f more importance.  B e t t e r i n f o r m a t i o n systems are n e c e s s a r y and m o n i t o r emergency c a r e . Regional  The  to plan, describe, evaluate  s t u d i e s by the G r e a t e r  H o s p i t a l D i s t r i c t and the p r o v i n c i a l  Vancouver  Classification  Study  were d e s c r i b e d i n o r d e r t o f o c u s the s p e c i f i c data elements t h a t may  be u s e f u l i n an emergency i n f o r m a t i o n system.  efficiency  Role  and  c o n s i d e r a t i o n s have emerged w i t h the J o i n t H o s p i t a l  Funding p r o j e c t , i n r e c o g n i t i o n o f the f a i l u r e o f the f u n d i n g system t o match r e s o u r c e s agreed upon r o l e .  existing  to a previously i d e n t i f i e d  and  - 107 -  In concert with the objectives of t h i s study, two p o l i c y or planning f o c i were derived from the l i t e r a t u r e - the "moppingup r o l e " ( u t i l i z a t i o n ) of emergency departments and the d i s a s t e r planning ( c l a s s i f i c a t i o n ) c a p a b i l i t i e s of the departments. Focusing upon these two areas in a d d i t i o n 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 III,  a matrix was developed which  l i n k e d the s i x l e v e l s of information needs ( p a t i e n t care through p o l i c y formulation) with the successively l a r g e r .systems (hospital and community) to which the emergency department must r e l a t e .  The establishment of t h i s framework allows one to e x t r a c t 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 p o t e n t i a 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 s p e c i f i c information needs ofi health s t a t u s , budget, manpower, e t c . which allows one t e n t a t i v e l y to i d e n t i f y t h e 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 r e l e v a n t to management in d i s a s t e r s i t u a t i o n s , however of extreme importance to management in normal day to day operations or f o r planning  purposes.  - 109 -  The f o l l o w i n g charts depict a t e n t a t i v e i d e n t i f i c a t i o n of the information i n each matrix: a) general day to day information needs - Figure b) d i s a s t e r p l a n n i n g / c a p a b i l i t i e s - Figure c) mopping u p / u t i l i z a t i o n - Figure  B.  5.1a  5.1b  5.1c  THEORETICAL IDENTIFICATION OF INFORMATION NEEDS  Further refinement and generation of s p e c 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 s p e c i f i c data elements can now be i d e n t i f i e d .  Within the community p r o f i l e , i t i s possible to i d e n t i f y community c h a r a c t e r i s t i c s , population and health resources as p o t e n t i a l l y useful information categories.  Most of t h i s s p e c i f i c information  i s a v a i l a b l e from a multitude of sources but once i d e n t i f i e d and co-ordinated, the inventory can be updated at y e a r l y i n t e r v a 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 r u c i a l to effectiveness and e f f i c i e n c y are the i n t e r r e l a t i o n ships and the i n t r a r e l a t i o n s h i p s among sub-systems w i t h i n the system; how the h o s p i t a l r e l a t e d to resources i n the community,  V  Figure 5.1.a GENERAL EMERGENCY DEPARTMENT INFORMATION NEEDS  COMMUNITY/REGIONAL PROFILE  TYPES OF \INFOR\MATION USES O f \ COMM INFORMATION (a)  POPULATION (CATCHMENT AREA) HEALTH/ D/SE STATUS (c)  EMERGENCY DEPARTS ENT PROFILE  HOSPITAL PROFILE  HEALTH/ SOCjAL  NON H/S  PAT IENTS/ UTILIZ AT ION  RESOURCES  RESOURCES PROGRAMS  MANPOWER  COSTS $  MAN  EQUIP  EP/ CLIN+ D S/E D & T OUTCOME (h) (e) (f) (g)  CLINICAL PATIENT CARE OPERATIONAL MANAGEMENT QUALITY OF CARE STRATEGIC PLANNING EFFECTIVENESS R & D POLICY a) b) c) d) e) f) g) h)  community c h a r a c t e r i s t i c s - i . e . major industry, health hazards, p o t e n t i a l r i s k epidemiological/demographic, socio-economic information - age, sex, residence, income, race morbidity and m o r t a l i t y i n d i c a t o r s other health resources i n the community - d e t o x i f i c a t i o n centres, long term care f a c i l i t i e s demographic - age/sex e p i d e m i o l o g i c a l , socio-economic - marital s t a t u s , race, income d i a g n o s t i c and therapeutic c l i n i c a l information - c h i e f complaint, diagnosis, l a b o r a t o r y / x - r a y , e t c . outcome - dead, discharged, admitted  Figure 5.1.b DISASTER PLANNING INFORMATION NEEDS - CAPABILITIES  EMERGENCY  COMMUNITY/REGIONAL PROFILE  TYPES OF \INFOR\MATION  POPULATION  HOSPITAL  DEPARTS ENT  PROFILE  PROFILE PAT IENTS/ UTILIZ AT ION  RESOURCES  RESOURCES  (CATCHMENT AREA) USES O f \ COMM INFORMATION  (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  EFFECTIVENESS R & D  POLICY  a) b) c) d) e) f) g) h)  community characteristics - i . e . major industry, health hazards, potential risks epidemiological/demographic, socio-economic information - age, sex, residence, income, race morbidity and mortality indices other health resources i n the community - detoxification centres, long term care f a c i l i t i e s demographic - age/sex epidemiological, socio-economic - marital status, race, income diagnostic and therapeutic c l i n i c a l information - chief complaint, diagnosis, laboratory/x-ray, etc. outcome - dead, discharged, admitted.  Figure 5.1.c MOPPING-UP NEEDS - UTILIZATION  EMERGENCY DEPARTMENT PROFILE  COMMUNITY/REGIONAL PROFILE  TYPES OF INFOR.MAT ION  POPULATION  HOSPITAL PROFILE PATIENTS/UTILIZATION  RESOURCES  RESOURCES  (CATCHMENT AREA) USES OF COMM INFORMATION^ (a)  D/SE  !F P E  HEALTH/  HEALTH/ SpCjAL  NON H/S  PROGRAMS  MANPOWER  COSTS MAN  EQUIP  D (e)  "ET7" CLTN+ S/E  D &T  (f)  (g)  CLINICAL PATIENT CARE  OPERATIONAL MANAGEMENT  QUALITY OF CARE  STRATEGIC PLANNING  EFFECTIVENESS R & D  POLICY  a) b) c) d) e) f) g) h)  community c h a r a c t e r i s t i c s - i . e . major industry, health hazards, p o t e n t i a l r i s k s epidemiological/demographic, socio-economic information - age, sex, residence, income, race morbidity and m o r t a l i t y indicators other health resources i n the community - d e t o x i f i c a t i o n centres, long term care f a c i l i t i e s demographic - age/sex epidemiological, socio-economic - marital status, race, income diagnostic and therapeutic c l i n i c a l information - chief complaint, diagnosis, laboratory/x-ray, e t c . 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 a n 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 f o r a c t i v i t y , u t i l i z a t i o n , patterns of p r a c t i c e and r o l e information.  Following i s a more complete i d e n t i f i c a t i o n of the information p o t e n t i a l l y useful to emergency room managers.  C.  Figure  5.2.a  Community P r o f i l e  Figure  5.2.b  Hospital P r o f i l e  Figure  5.2.c  Emergency Department P r o f i l e  NOMINAL GROUP VS. DELPHI PROCESSES  Recognizing the d i v e r s i t y of r o l e s , i n t e r e s t s and management  positions,  there was a need to i d e n t i f y a methodology to reach a consensus on the range of information required.  One of the premises of t h i s study i s  that the l e v e l of aggregation of the data necessary f o r managers  Figure  5.2.a  COMMUNITY PROFILE  Community C h a r a c t e r i s t i c s  Population  Health Resources  Major industry - agriculture - mining - logging - industry  by SD, RHD, Community/ Municipality  Health  Transportation 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 - transportation of chemicals - Unemployment Level - Transient Population - communes - immigrants  Population by - age - sex - race - marital status - income - poverty vs. a f f l uence Morbidity and M o r t a l i t y - deaths by major cause - traumas Morbidity - medical emergencies - chronic diseases  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) d e t o x i f i c a t i o n centres, etc. Physician supply by s p e c i a l t y  Figure 5.2.b HOSPITAL PROFILE  Hospital C h a r a c t e r i s t i c s  Geographic a c c e s s i b i l i t y - travel time matrix  Programs/Profile  Manpower  Costs  a) Beds - i n p a t i e n t beds by program/sub program - occupancy rate by program/sub program - admissions through E.R.  Medical s t a f f p r o f i l e - by s p e c i a l t y and status, i . e . active/ consultant  By program - volume - budget to actual  Hospital s t a f f p r o f i l e - by category  fixed - program - program variable  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  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)  1 ;  Figure 5.2.c EMERGENCY DEPARTMENT PROFILE  RESOURCES 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 i x e d costs program costs program variable costs # times OR plugged - overtime - budget to actual  PATIENTS 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 c a l : patients by some c l a s s i f i c a t i o n , i .e. - symptoms/diagnosis/chief complaint - s e v e r i t y l a lb admi tted 2a 2b di scharged 3 back door 4 G.P. mode of a r r i v a l emergent, urgent, non-urgent trauma cases ) vs. others medical emergencies ) treatments/tests length of time i n E.R. Outcome # admitted to hospital self # discharged - follow up - community agency deaths # transfers to other f a c i l i t i e s  - 117 -  varies with the p o s i t i o n .  The emergency nurse or physician would  require very complete information p r i n c i p a l l y about q u a l i t y of care on a routine b a s i s , whereas the administrator would require information p r i n c i p a l l y about cost, e i t h e r 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 i n d i v i d u a l versus group methodologies to generate ideas f o r problem solving and decision making.  Delbecq,. Van den Ven and  Gustafson (1975) c i t e a number of studies which demonstrate the s u p e r i o r i t y of group methods with-respect to both the quantity and the q u a l i t y of ideas generated.  The Nominal Group Technique and the Delphi Technique are two group methodologies frequently used where i n d i v i d u a l judgements must be tapped and combined in order to a r r i v e at decisions f o r a group which cannot be c a l c u l a t e d by one person.  These problem-solving  or idea generating s t r a t e g i e s are ideal f o r t h i s study where consensus on the emergency department information needs of a l l h o s p i t a l s i s required.  As Delbecqij;. Van den Ven and Gustafson (1975) state i n t h e 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 r e l y on independent i n d i v i d u a l work f o r idea generation. In the Delphi process, i s o l a t e d and t y p i c a l l y anonymous respondents independently w r i t e t h e i r ideas or reactions to a questionnaire. ..NGT group members w r i t e t h e i r ideas on a sheet of paper in s i l e n c e , in the presence of other group members seated around a t a b l e . Second, i n d i v i d u a l judgements are pooled i n both techniques. Delphi respondents mail t h e i r completed questionnaires to the design and monitoring team who in turn pool and c o l l a t e 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 w r i t t e n on a blackboard or f l i p chart. T h i r d , both allow f o r 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 i n t e r p r e t s the ideas on the feedback report. In NGT, the group discusses v e r b a l l y , c l a r i f i e s and evaluates each of the i n d i v i d u a l ideas of group members that were w r i t t e n 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 r a t i n g methods) and the group decision i s a r r i v e d at by a mathematical decision rule., for aggregating the i n d i v i d u a l judgements.  The Nominal Group Technique was s e l e c t e d as the decision-making process because i t has the f o l l o w i n g properties: a) equal p a r t i c i p a t i o n in the presentation of ideas b) increase i n problem-mindedness  Delbecq, Van den Ven, G u s t a f s o n . G r o u p Techniques f o r Program Planning: A Guide to Nominal Group and Delphi Processes, S c o t t , Foreman and Company, Glenview, 111., 1975, p. 17.  - 119 -  c) depersonalization - the separation of ideas from personalities d) increase in the a b i l i t y to deal with a l a r g e r number of ideas e) tolerance of c o n f l i c t i n g ideas f) encouragement of a d d i t i o n a l ideas through process of association 2  g) provision of a w r i t t e n record and guide  Time constraints and the nature of the process of concensus made the Nominal Group Technique more v i a b l e than the Delphi and f a c i l i t a t e d the generation of s o f t data.  This method i s more rewarding to the  p a r t i c i p a n t s as they have an opportunity f o r 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 o n s w i t h i n 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 s e l e c t i o n of these f a c i l i t i e s allowed  one to provide d i f f e r i n g perspectives on emergency room information needs because of differences i n l o c a l e , type of p a t i e n t s , teaching  2  I b i d , P. 47.  - 120 -  r o l e , case mix, catchment area, s t a f f i n g patterns and s i z e of facility.  Experts were selected because of t h e i r e x i s t i n g roles w i t h i n the f a c i l i t i e s - Medical D i r e c t o r , Emergency Physician, Head Nurse and Administrator and because of t h e i r additional expertise in a c c r e d i t a t i o n , d i s a s t e r planning, regional hospital planning and emergency documentation.  Of f i n a l i n t e r e s t were t h e 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 p a r t i c i p a n t s were c i r c u l a t e d with the abstract of the study, an explanation of the Nominal Group Technique and the matrix which i d e n t i f i e d s i x l e v e l s of information needs and the categories of type of information which would focus somewhat t h e i r t h i n k i n g i n generating ideas (Appendix A).  In round robin format, each i n d i v i d u a l generated data elements (age/sex of p a t i e n t s ) , information categories ( s e v e r i t y c l a s s i f i c a t i o n ) or s o f t data (the r e l a t i o n s h i p s of the emergency room with community s o c i a l s e r v i c e s ) , which he deemed of importance.  Information was then p r i o r i z e d into " e s s e n t i a l , nice to know and not necessary" and f u r t h e r 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) y e a r l y , and 3) i n i t i a l l y or upon opening and updated r e g u l a r l y , to be of value to the  decision-makers.  The f o l l o w i n g pages l i s t the needs f o r information as i d e n t i f i e d by the panel of experts in two ways: a)  information by p r o f i l e - community, figure 5.3.a; h o s p i t a l , figure 5.3.b; and emergency department, figure 5.3.c; and whether i t i s  b)  ' e s s e n t i a l ' , ' n i c e to know', or 'not  essential data i s categorized into ' h a r d ' and  necessary'.  'soft'  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 C h a r a c t e r i s t i c s Major industry* economic development in community, i . e . False Creek, B.C. Place  Population  Health of Non-Health  Types of Patients in Catchement Area* - age/sex - socio-economic  Health  Resources  a) acute beds per 1,000 pop.** long term care* # community h o s p i t a l s * * b) E H S C - a v a i l a b i l i t y o f * - ambulance - advanced l i f e support (paramedics)  Hazards* - airports - chemical plants  c) a v a i l a b i l i t y and l i a i s o n with social services* Stable or transient population * 1  d) physician patterns of p r a c t i c e * * e) communication systems among f i r e , p o l i c e , EHSC and h o s p i t a l * f ) protocols f o r t r a n s f e r 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 C h a r a c t e r i s t i c s P o l i c i e s and Procedures* Teaching Commitment** Geographic r e l a t i o n s h i p of h o s p i t a l to other hospitals - community or teaching**  Programs/Profile  Manpower  Relationships of emergency Patterns of P r a c t i c e of room to x-ray/lab/ ^Physicians on S t a f f * * operating room/blood bank* - back door admissions - prescriptions - over s e r v i c i n g  Costs  r e f e r r a l patterns to emergency room medical economics  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 s p e c i a l t i e s and resources to emergency department* - in-house 24 hrs/day - on-call  * essential * * nice to know * * * not necessary  F i g u r e 5.3.C EMERGENCY DEPARTMENT PROFILE  Organization 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 o f responsibilities* Triage  policies*  P o l i c y re: deterrent  fees*  P a t i e n t flow t o r a d i o l o g y and l a 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 (soft) Peer review and a u d i t * ( m o r t a l i t y and m o r b i d i t y  Status*  Emergency Department I n f o r m a t i o n Needs  Resources  Patients  Physical layout* including: # ER s t a t i o n s - q u i e t rooms - paeds - ENT - psychiatric  Patient p r o f i l e - by g e o g r a p h i c a r e a * - age/sex* - demographic and s o c i o economic**  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  c h i e f c o m p l a i n t and n a t u r e o f injury patients categorization emergent, u r g e n t , non-urgent u t i l i z a t i o n o f l a b and x-ray Length o f time i n ER*  Transfer  of responsibility*  rounds)  Nurse-physician r e l a t i o n s h i p s *  Physician p r o f i l e * - ER p r i v i l e g e s o f MDs - limits of responsibility Costs* - o f resources budget t o a c t u a l Disaster  * essential ** n i c e t o know *** n o t n e c e s s a r y  CIinical*  capacity*  Family p h y s i c i a n * Problem c a t e g o r y * * - jail - psychotics - alcoholics Outcome # admitted t o h o s p i t a l * disposition** Workload measurement*  F i g u r e 5.3;.d HARD DATA To Know I n i t i a l l y and Updated as Necessary  ESSENTIAL INFORMATION be  Monthly R e p o r t i n g  Annual  Types o f p a t i e n t s i n catchement a r e a , age/sex, socio-economic  Mode o f a r r i v a l  - 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 a c u t e h o s p i t a l s - EHSC - ambulance - pre-hospital care - paramedics ALS  Patient p r o f i l e - demographic - age/sex - c l i n i c a l - diagnostic - therapeutic - outcome - severity categorization  - major i n d u s t r y economic development - p h y s i c a l l a y o u t of Emergency Department  of  patients  S t a f f physician 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  Family p h y s i c i a n - # admissions to emergency room - workload measurement - costs M o r b i d i t y and m o r t a l i t y i n f o r m a t i o n as per a u d i t s 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 p h y s i c i a n s i n the emergency room) - T o t a l number o f p a t i e n t s by c a t e g o r y by s h i f t S t a f f mix and t r a i n i n g and - by s h i f t - RNs - S o c i a l Workers  Reporting  severity  skills  Disaster  capacity  Figure 5.3ie SOFT DATA  ESSENTIAL TO KNOW  To Know I n i t i a l l y and be Updated as Necessary P a t i e n t flow t o radiology, l a b , b l o o d bank  To Know Monthly  To Know A n n u a l l y  L i a i s o n and a v a i l a b i l i t y o f social services including l o n g term care  P o l i c i e s and procedures o f h o s p i t a l and o f emergency room  E f f e c t i v e communication w i t h EHSC  Peer review and a u d i t policies  F u l l departmental s t a t u s ? Deterrent  fee policy  Mechanisms ( p o l i c i e s and p r o t o cols) for transfers of patients from o t h e r 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  Policies re: function Triage  transfer of  policies  - 127 -  2.  Second Panel of Experts  A second panel of experts was selected to ensure that the i n f o r mation p r i o r i t i e s i d e n t i f i e d by the f i r s t panel were in fact representative of the needs of Greater Vancouver Regional Hospital District  decision-makers.  Rather than repeat the Nominal Group Technique and match outcomes, the second group of reviewers was simply c i r c u l a t e d the r e s u l t s 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 d e n t i f i e d (Appendix B).  Of the four members surveyed, the two nursing managers were in t o t a l agreement with the types and scope of information i d e n t i f i e d by the f i r s t panel.  The Administrator of a community hospital i d e n t i f i e d three a d d i t i o n a l types of information to be c o l l e c t e d under patient data: i)  the length of time the patient spent in the emergency room p r i o r to the p h y s i c i a n ' s a r r i v a l ,  ii)  why patients were discharged to another acute f a c i l i t y was t h i s because of the s e v e r i t y of the patient upon a r r i v a l or because of a lack of a v a i l a b i l i t y of i n p a t i e n t beds?  - 128 -  iii)  the hour rather than the s h i f t in which the patient a r r i v e d at the f a c i l i t y .  ( I t was f e l t that u n a v a i l a b i l i t y  of physicians outside of o f f i c e hours contributed to the increase i n v i s i t s a f t e r 5 p.m.). This Administrator also noted that mode of a r r i v a l and d i s p o s i t i o n of patient (to home, to family MD) was of l i t t l e i n t e r e s t to administration.  The M i n i s t r y 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 d e n t i f y back-up bed f a c i l i t i e s where MASH units could be set up.  A l s o , while the a v a i l a b i l i t y of back-up physician s p e c i a 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 s p e c i a l i z e d manpower resources.  Other than these minor expansions of information needs i d e n 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 t h 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 t h i s phenomenon i s a r e s u l t  of the f a c t that professionals are hesitant to denegrate the ideas of other professionals or whether the l e v e l 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 d e n t i f i e d 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 d e n t i f i e d as essential by the two panels of experts drawn from GVRD hospitals and government, i t may be helpful to r e l a t e the data elements back to the o r i g i n a l matrix of information h i e r a r c h i e s .  1.  Levels 1, 2 and 3 - Patient Care and Management and Quality of Care  The f o l l o w i n g data elements were i d e n t i f i e d as e s s e n t i a 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 s t a t i o n s , quiet rooms, p a e d i a t r i c rooms, e t c .  - 130 -  - manpower - types and numbers per s h i f t - costs - budget to actual ii)  patient's profile - demographic ) and ) - socio-economic- )  i . e . by geographic area  1  age, sex, socioeconomic - time and mode of a r r i v a l (EHSC, P o l i c e , s e l f ) - c l i n i c a l - patients by c h i e f complaint/ nature of i n j u r y - patient s e v e r i t y 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 - p o l i c i e s and procedures, protocols - communication systems - t r a n s f e r of r e s p o n s i b i l i t y - medicolegal r e s p o n s i b i l i t i e s - departmental status of emergency room - peer review and audit - nurse-physician  relationships  - physician p r o f i l e s - i . e . p r i v i l e g e s / l i m i t s of r e s p o n s i b i l i t y , - d i s a s t e r capacity  - 131 -  Hospital  Information  a) Hard Data i ) c h a r a c t e r i s t i c s - l o c a t i o n of hospital to other community and teaching hospitals i i ) programs - physical r e l a t i o n s h i p s of emergency room to laboratory, x-ray, blood bank, operating room - type by hours of operation f o r 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 s p e c i a l t i e s and hospital resources to emergency - in-house or o n - c a l l system. b) Q u a l i t a t i v e Soft Data - p o l i c i e s and procedures - teaching commitment - patterns of p r a c t i c e of physicians on s t a f f ( i . e . back door admission, p r e s c r i p t i o n s , overserving, r e f e r r a l s to emergency room, medical economics).  2.  Level 4 - S t r a t e g i c Planning Information Including  Disaster  The following data elements may be i d e n t i f i e d as pertaining more to s t r a t e g i c planning: i ) c h a r a c t e r i s t i c s - major industry/economic -  development  hazards  - t r a n s i e n t or stable population  - 132 -  i i ) population - demographic - age, sex and socio-economic i n catchment area i i i ) resources health - by type o f h o s p i t a l -  - long term care  facilities  - EHSC - a v a i l a b i l i t y of s o c i a l services iv) s o f t data - r e l a t i o n s h i p s / l i a i s o n with s o c i a l services - physician patterns of p r a c t i c e - a v a i l a b i l i t y of communication systems among f i r e , p o l i c e EHSC and hospital - protocols f o r t r a n s f e r o f patients from other h o s p i t a l s - a v a i l a b i l i t y of p r i v a t e funds i n community ( f o r 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 P o l i c y Formulation  :  While no information can be uniquely i d e n t i f i e d as c o n t r i b u t i n g to a data base f o r p o l i c y formulation and research and development, i t may be i n f e r r e d 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  i d e n t i f i e d by v i r t u e o f the p o s i t i o n of those present.  - 133 -  3.  I d e n t i f i c a t i o n of "Soft Data"  While the analysis of the information needs so i d e n t i f i e d by the emergency department users w i l l be undertaken i n Chapter VI,  it  i s worthy to note at t h i s point, the amount of " s o f t data" deemed e s s e n t i a l by the users.  P o l i c i e s and procedures, r e l a t i o n s h i p s to  external health and s o c i a l agencies were i d e n t i f i e d by the panel as c o n t r i b u t i n g s i g n i f i c a n t l y to the effectiveness and e f f i c i e n c y of the emergency room.  While the matching of the hard data i d e n t i f i e d through the matrix with that i d e n t i f i e d by the users y i e l d e d no surprises and was f a i r l y consistent with that i d e n t i f i e d previously, a number of c r i t i c a l issues i n emergency care management were discussed in great d e t a i l .  It i s t h i s s o f t information that needs to be  explored through two avenues - i t s impact on e f f i c i e n c y once q u a n t i t a t i v e output measures have been i d e n t i f i e d and the degree '.: to which patient care outcomes can be enhanced.  While the object of t h i s study i s l i m i t e d to the i d e n t i f i c a t i o n of q u a n t i f i a b l e information which w i l l contribute to the development of e f f i c i e n c y and effectiveness measures, i t would be appropriate to review b r i e f l y , i f not analyse as y e t , some of the  - 134 -  s o f t information i d e n t i f i e d by the Nominal Group.  While hard data  such as age, sex i s s e l f - e x p l a n a t o r y , other concerns are less expl i c i t .  A d m i n i s t r a t i v e p o l i c i e 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 with laboratory, x-ray, blood bank are c r i t i c a l .  relationships  P o l i c i e s must be  cohesive to ensure the support services complement the nonpredictable and uncertain patient load in the emergency room.  F u l l departmental status f o r 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. h o s p i t a l s .  Full 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 p o l i c y decision best l e f t at the l o c a l l e v e l .  The M i n i s t r y of Health co-insurance  fee of $2.00 f o r emergency care has been in existence for 30 years and i n no way r e f l e c 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 i n an attempt to deter those i n d i v i d u a l s with sore  - 135 -  throats who "abuse" the department.  Good communication and  l i a i s o n with other h o s p i t a l s , s o c i a l 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 r e f e r r a l s to emergency and speedy d i s p o s i t i o n of patients once treated.  Poor communications and l i a i s o n 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 i a - a - v i s administration need to be i d e n t i f i e d and monitored. making?  What l i m i t s are placed on decision  Who has the a u t h o r i t y to admit or t r a n s f e r patients  or to close the emergency room?  Who has the a u t h o r i t y to  monitor what treatments family physicians can carry out i n the emergency room and to deny these physicians t h e i r " r i g h t " to perform c e r t a i n procedures?  What are the peer review and audit p o l i c i e s ?  Is peer review  s t i l l a medical function or i s i t review on an i n t e r d i s c i p l i n a r y basis?  Are physicians and nurses c o n j o i n t l y involved i n decision  making process to revise departmental p o l i c i e s or  procedures?  Or i s the nurse s t i l l the handmaiden of the physician?  The s o f t issues i d e n t i f i e d w i l l be discussed in f u r t h e r d e t a i l  in  - 136 -  the next chapter.  S u f f i c e to say that hard data i s only part of  the p i c t u r e , more remains to be done in t h i s area.  CHAPTER SUMMARY  Through a synthesis of the l i t e r a t u r e on emergency department 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 , a review of the s t a t e of the a r t of information systems and an i d e n t i f i c a t i o n of the major issues in emergency health care in B.C., i t was f e a s i b l e to assign s p e c i f i c data elements to the matrix of information needs.  Three p r o f i l e 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 d e n t i f y essential data elements.  A f u r t h e r v a l i d a t i o n was  assured  by questionnaire to a second group of experts.  The information deemed e s s e n t i a l was then matched to the t h e o r e t i c a l i d e n 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, q u a l i t y of care, management and s t r a t e g i c planning.  - 137 -  CHAPTER VI  ANALYSIS, RECOMMENDATIONS AND CONCLUSIONS  A.  INFORMATION PRIORITIES  In the preceding chapter, an attempt was made to v a l i d a t e the information needs of emergency department decision makers and to p r i o r i z e e s s e n t i a l information.  In a d d i t i o n to hard data  needs, a number of s o f t issues not previously i d e n t i f i e d emerged as an i n t e g r a l part of the information system.  Although s i x h i e r a r c h i e s of information needs - patient care or flow through, departmental management, q u a l i t y assurance, s t r a t e g i c planning, research and development and p o l i c y formulation - were presented to the panel members, i n order to encourage a wide v a r i e t y of responses p r i o r to consensus seeking, the p r i o r i t i e s f o r information were l i m i t e d to the f i r s t four l e v e l s only.  Indeed, nearly 75% of the information  considered e s s e n t i a l could be categorized as patient care or management information derived from patient documentation. Community resources, emergency department resources and patient data, together with the r e l a t i o n s h i p s among the subsystems and systems were the focal point of i n t e r e s t .  - 138 -  Whether t h i s outcome i s a r e s u l t of the f a c t - t h a t the higher l e v e l s of information needs, r e l a t i v e to research and development and p o l i c y formulation are derived from a manipulation of lower l e v e l s of data, or whether t h i s focus arises from the dominance of the professional care giver rather than the administrator remains to be seen.  One possible and quite f e a s i b l e 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 t h i s study i s the develop-  ment of an information system f o r emergency department decision makers, the i n i t i a l presence of a M i n i s t r y of Health representative may have influenced the outcome of the d e l i n e a t i o n of e s s e n t i a l information.  In a d d i t i o n , recent d i r e c t i o n s w i t h i n the M i n i s t r y of Health from health programs to f i s c a l a c c o u n t a b i l i t y may have influenced the information s e l e c t i o n .  However, the f u l l impact of the  dominance of Treasury Board s t a f f on the M i n i s t r y of Health and h o s p i t a l s has yet to be seen.  The dominance of cost and e f f i c i e n c y information ( s i m i l a r to that proposed by the J o i n t Hospital Funding Project - Uniform Reporting System) was not evident.  If the Study had been done  - 139 -  12 months l a t e r , perhaps t h i s o v e r - r i d i n g concern f o r 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 r e s u l t s in  l i g h t of professional power and c o n t r o l , a review of the nature of organizational s t r u c t u r e s , p a r t i c u l a r l y the professional bureaucracy, would be h e l p f u l .  B.  THE HOSPITAL AS A PROFESSIONAL BUREAUCRACY  Henry Mintzberg (1979) in The Structure of Organizations developed organograms which conceptually categorize organizations i n t o s t r u c t u r a l configurations based upon the f i v e basic components of a l l organizations - the s t r a t e g i c apex (top management), the technostructure, the middle l i n e (managers), the support s t a f f and the operating core.  Mintzberg's t h e s i s i s that most organizations f a l l c l o s e l y i n t o one of his f i v e configurations - the Simple S t r u c t u r e , the Machine Bureaucracy, the Professional Bureaucracy, the D i v i s i o n a l i z e d Form and the Adhocracy - and that the o r g a n i z a t i o n ' 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 f e r e n t c o n f i g u r a t i o n s , organizational effectiveness i s o f f s e t by poor design.  Diagram 6.1 on the f o l l o w i n g page depicts Mintzberg's configuration of the professional bureaucracy.  In the h o s p i t a l s e t t i n g , neither the technostructure where analysts a s s i s t the organization to adapt to i t s environment through standardi z a t i o n of techniques nor the middle l i n e management i s highly visible.  Rather the professional bureaucracy i s characterized by a  dominant operating core of professionals (physicians) who by v i r t u e of t h e i r expertise in health care, the major output of the h o s p i t a l , maintain considerable control over t h e i r own work.  The professional bureaucracy r e l i e s f o r co-ordination on the standardization of professional s k i l l s which are gained through t r a i n i n g and i n d o c t r i n a t i o n .  It hires duly t r a i n e d and operating  s p e c i a l i s t s f o r i t s operating core and then gives them considerable control over t h e i r own work.  The dilemma a r i s e s , however, because  the standards, values and objectives of the professional bureaucracy o r i g i n a t e l a r g e l y outside the organizational s t r u c t u r e , in the  Figure  6.1  Professional Bureaucracies Five Component Parts P a r a l l e l Hierarchies  support s t a f f  Source:  Mintzberg, p. 361, Figure 19.4.  - 142 -  realm of the professional a s s o c i a t i o n s .  The power of expertise  of the medical profession i s f u r t h e r enhanced by the Canadian ideology of free and s e l f governing professions reimbursed on a fee f o r s e r v i c e payment method which may place them i n c o n 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  h o s p i t a l s , these "housekeeping" functions - laundry, d i e t a r y , housekeeping, the a n c i l l a r y services such as l a b o r a t o r y , x-ray and pharmacy, and the nursing services - have developed to provide the professional medical care givers with as much support as p o s s i b l e , to aid them and to provide routine functions.  Figure 6.1 also depicts the professional bureaucracy as one where the t r a d i t i o n a l roles of l i n e and s t a f f are reversed.  Etzioni  (1959) as quoted by Mintzberg (1978) s t a t e s : in professional organizations the s t a f f - e x p e r t l i n e manager c o r r e l a t i o n . . . 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 c a r r i e d out by experts. In other words, i f there i s a s t a f f - l i n e r e l a t i o n s h i p at a l l , experts c o n s t i t u t e the l i n e (major authority) structures and managers the s t a f f . . . t h e f i n a l i n t e r n a l decision i s , f u n c t i o n a l l y speaking, in the hands of various professionals and t h e 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 h o s p i t a l organizations and professional  bureaucracies  i n general, are dual administrative hierarchies or l i n e s of authority - one f o r the medical s t a f f - the operating core - and another f o r 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 i m i t e d  to those i n a d m i n i s t r a t i v e department head or c h i e f of s t a f f p o s i t i o n s , a phenomena of the machine bureaucracy.  Rather the  power rests with expertise and s k i l l r e f l e c t e d through peer status.  While t h i s anomaly seems democratic to those  professionals  w i t h i n the h o s p i t a l , i t does r a i s e s i t u a t i o n s 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 o c a t i o n 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 r o l e of the professional administrator i n the midst of t h i s dual authority i s one of n e g o t i a t i o n , f a c i l i t a t i o n , implementation and boundary spanning.  The administrator is often i n the unenviable  p o s i t i o n of balancing the demands of the medical s t a f f with the  - 144 -  health care service and needs of the community w i t h i n the resources a l l o c a t e d 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 r e c o n c i l e the forces of the board of management, the physicians and external agencies.  He i s , however, somewhat  thwarted in his e f f o 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 c o n t r o l .  The a d m i n i s t r a t o r ' s  needs f o r information are therefore less d e t a i l e d although they encompass more domains.  For example, the administrator as boundary  spanner must continuously monitor the external environments - the community, government funding, socio-economic developments, e t c . in order to f a c i l i t a t e - the d e l i v e r y of health care w i t h i n his own i n s t i t u t i o n 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 a u t h o r i t y .  C.  THE POWER OF EXPERTISE OF PHYSICIANS  Professionals j o i n organizations in order to share resources; to e s t a b l i s h contact with other professionals or organizations so that they may increase t h e i r patient load through r e f e r r a l and thus enhance t h e i r income or because c l i e n 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 a s s o c i a t i o n s .  Thus they struggle to  ensure that any measures to modify or impact upon the patterns of p r a c t i c e of the physicians must i n i t i a t e from the operating core the professionals  themselves.  While a c c r e d i t a t i o n , medical s t a f f by-laws and c a p i t a 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 q u a l i t y of care/audit mechanisms.  The a d m i n i s t r a t o r , however, must ensure that the mechanisms f o r peer review and audit e x i s t .  This i s at the basis of the dilemma between  the professionals and the s t r a t e g i c apex.  While the improvements  f o r q u a l i t y of care remain w i t h i n 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 q u a l i t y must often be made i n a f i e l d of l i m i t e d resources.  At the outset of t h i s chapter, the preponderance of c l i n i c a l informa t i o n needed to t r e a t emergency patients i n an e f f e c t i v e 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 - t h i s emphasis on service information i s appropriate to the organization.  - 146 -  The administrative information needs are ones of monitoring of the i n t e r n a l a c t i v i t y rather than c l i n i c a l p r a c t i c e per se and of monitoring of the external environment - community resources, c a t c h ment area population and physician patterns of p r a c t i c e as they impact upon h o s p i t a l management.  Expert power as opposed to administrative power rests with the medical profession who are viewed as s o c i a l gatekeepers to the medical care system.  The Emergency Department of the acute general hospital  a focal point of entry to the health care system.  remains  I t i s well known  w i t h i n the community and has the p o t e n t i a l and legitimacy to admit, t r a n s f e r or r e f e r a l l who enter the system through t h i s route.  However, physicians as gatekeepers to the health care system d i r e c t the type and amount of medical care provided by other professionals. Watkins (1975) supports Greenwood's d e f i n i t i o n of professionals  as  those who ranked highly on f i v e d i s t i n c t c h a r a c t e r i s t i c s " a systema t i c body of t h e o r e t i c a l knowledge, professional a u t h o r i t y , the sanction of the community, a regulative code of e t h i c s and 2  professional c u l t u r e . "  Physicians, by v i r t u e of t h e i r t r a i n i n g and expertise and l i c e n s u r e , have u n t i l now, in B.C., maintained a professional monopoly over  Watkins, C. Ken, Social C o n t r o l , Longman Group L t d . , London, 1975, P. 104.  - 147 -  medical  care.  I t i s the p h y s i c i a n who  i s r e q u i r e d , what t e s t s and other professionals w i l l  decides what l e v e l o f  treatments w i l l  be o r d e r e d  care  and what  become i n v o l v e d i n the care and  treatment  o f the p a t i e n t .  The  physician's p r i o r i t y i s service.  I t has been the  administrator'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 p h y s i c i a n ' s p r o v i d i n g good p a t i e n t c a r e . the 1980's, c o s t c o n s t r a i n t s are b e g i n n i n g and  However, i n  t o become more s i g n i f i c a n t  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  i n f o r m a t i o n needs o f the p r o f e s s i o n a l b u r e a u c r a c y are r e f l e c t e d  i n the response o f the Nominal Group.  Information  c o l l e c t e d i n the  broad c a t e g o r i e s o f p a t i e n t s , r e s o u r c e s , q u a l i t y o f c a r e , and  procedures and  policies  i n t e r - r e l a t i o n s h i p s among systems would appear t o  s a t i s f y the m a j o r i t y o f the i n f o r m a t i o n needs o f the  decision-makers  consul t e d .  The  "hard"  data i n f o r m a t i o n 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 t o c o l l e c t through e i t h e r worksheet o r i s non-threatening  and would l i k e l y be o f i n t e r e s t and  inventory, 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 improvements in the day to day operations of the department.  It i s  g r a t i f y i n g to note, however, that the emergency department and i t s patients were not viewed in i s o l a t i o n of the community the emergency department serves, nor in i s o l a t i o n of the resources a v a i l a b l e 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 s o f t d a t a , i d e n t i f i e d as e s s e n t i a l , also supported the c h a r a c t e r i s t i c s of the professional bureaucracy as i d e n t i f i e d by Mi ntzberg.  Full departmental status f o r emergency departments was i n i t i a t e d i n 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 s p e c i a l t y .  In B r i t i s h Columbia,  only two h o s p i t a l s have, or are i n the process of f i n a l i z i n g , the emergency department service as a medical s p e c i a l t y .  This remains  one instance where the dominance of the professional operating core i s less e f f e c t i v e than other medical s p e c i a l t i e s in i t s r e l a t i o n s h i p s with a d m i n i s t r a t i o n .  However, as c l a s s i f i c a t i o n of  Emergency Room c a p a b i l i t i e s through the Hospital Role Study takes  -  149  -  e f f e c t , t h i s trend towards increasing s p e c i a l i z a t i o n w i l l  become  more prevalent in the l a r g e r i n s t i t u t i o n s .  Nurse/physician r e l a t i o n s h i p s and p o l i c i e s regarding the t r a n s f e r of function i l l u s t r a t e the p o t e n t i a l 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 s p e c i a l t y , e x i s t i n g 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 t r a i n e d nurses through hospital " t r a n s f e r of function p o l i c i e s " which recognizes special skills.  Triage p o l i c i e s i n the Emergency Room contribute s i g n i f i c a n t l y to the e f f i c i e n c y of an Emergency Department.  The assignment of an  Emergency Nurse to screen incoming patients as to t h e 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 p o l i c i e s regarding intake and co-insurance fees can also screen the non-acutely i l l p a t i e n t .  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 t h e i r  - 150 -  highly s p e c i a l i z e d t r a i n i n g on a regular basis to maintain s k i l l l e v e l s 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 a v a i l a b l e 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.  E a r l i e r i n t h i s study, a documentation of the cost or e f f i c i e n c y trends of the Joints Hospital Funding Project was undertaken.  While  cost was i d e n t i f i e d as an e s s e n t i a l element o f the emergency department information system, the emphasis given to cost information was mi nimal.  The J o i n t Hospital Funding Project theorized the presentation of costs on a program basis with reporting of f i x e d costs, program costs and program v a r i a b l e c o s t s . Panel.  This was not i d e n t i f i e d by the  However, i n a l l fairness to the Panel, t h e i r i d e n t i f i c a t i o n  of information needs was more encompassing than the J o i n t Funding Project in a c t i v i t y and patient information.  Again, the dominance  of the operating core i n professional bureaucracies may be evident.  - 151 -  E.  RECOMMENDATIONS  At the outset of t h i s study, i t was stated that unpredictable workloads, v a r i a b l e case mix and s p e c i a l i z e d technology and manpower make i t i n c r e a s i n g l y complex f o r those involved i n 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 s a t i s f a c t i o n of those involved in the day to day operations of the department.  Two major issues were 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 the thrusts towards c l a s s i f i c a t i o n or c a t e g o r i z a t i o n of the Emergency Department's c a p a b i l i t i e s .  From  t h i s two major p o l i c y or planning f o c i were selected - d i s a s t e r planning and the "mopping up" role of the Emergency Department in order to f a c i l i t a t e the i d e n t i f i c a t i o n of user needs.  Theoretical needs were i d e n t i f i e d by a synthesis o f the issues i d e n t i f i e d in the l i t e r a t u r e of Emergency Care, in the past, present and future p r o v i n c i a l a c t i v i t i e s in Emergency Care i n B.C. and the objectives and processes of the J o i n t Funding Study.  Needs were then  v a l i d a t e d and p r i o r i z e d by a panel of experts, the r e s u l t i n g preponderance of c l i n i c a l information analyzed i n l i g h t of the dominance of the operating core i n professional  bureaucracies.  - 152 -  The f i n a l objective of t h i s study was to recommend a method of c o l l e c t i o n , analysis and reporting of emergency information.  departments'  The study stops short of implementation and the  development of norms or standards around the data presented.  Much of the information i d e n t i f i e d as e s s e n t i a l i s a v a i l a b l e in some form - population data through B.C. Research  Foundation,  c l i n i c a l diagnostic and therapeutic data on the p a t i e n t ' s chart, s t a f f i n g and budgetary data through the BCHA Hospital  Personnel  Management System (HPMS) and community h e a l t h , s o c i a l  services,  economic development and community hazards information provincial ministries.  through  Other information, i . e . c l a s s i f i c a t i o n of  s e v e r i t y , i s e i t h e r not c u r r e n t l y c o l l e c t e d on a routine b a s i s , or the state of the a r t i s not s u f f i c i e n t to allow i t s capture, i . e . workload measurement.  Therefore, i t i s h e l p f u l to develop  a schematic representation to integrate e x i s t i n g systems and to provide the foundation f o r the development of, as y e t , non e x i s t e n t systems.  Figure 6.2 provides an overview of e x i s t i n g data c o l l e c t i o n mechanisms a v a i l a b l e and used and those a v a i l a b l e but not integrated into a t o t a l information system.  The figure depicts sources and types of data that were i d e n t i f i e d as e s s e n t i a l by the panel of experts.  In the core of emergency  department  - 153 -  F i g u r e 6.2  Schematic Representation of Types and/or Sources of Data Deemed Essential  Hazards,. Ministry of Economic Development  Research Population by age/sex - Socio-economic y /  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 p a t i e n t ' 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 r e g i s t r a t i o n log which severely l i m i t s the information reported.  There i s c u r r e n t l y no i n t e g r a t i o n among  c l i n i c a l , q u a l i t y , f i n a n c i a 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 c o l l e c t e d through an i n i t i a l inventory of community hazards and resources.  Population and economic develop-  ment information are a v a i l a b l e through the p r o v i n c i a l m i n i s t r i e s .  1.  The Patient Abstract  At the foundation of a c t i v i t y information i s the p a t i e n t ' 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 d e n t i f i e d 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 c o 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 c o l l e c t the following 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 , P o l i c e , S e l f - r e f e r r a l / f a m i l y physician, t r a n s f e r from LTC f a c i l i t y , acute h o s p i t a l , s o c i a l s e r v i c e agency - Emergency Room #, Medical Services Plan #. 2.  C l i n i c a l Diagnostic and Therapeutic: Chief Complaint/Reason f o r 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 o n - emergent, urgent, minor, admission through ER. 3., Discharge  Information:  Admitted to Hospital Discharged to Home Died Transfer to Other Hospital To P o l i c e Reason f o r Transfer to Other Hospital  Time ready f o r 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 i n E.R. - patients by age/sex residence code - patients by day of week, hour of admission - patients by s e v e r i t y code - treatment patterns - u t i l i z a t i o n rate over time by category or s e v e r i t y by population.  A Patient Abstracting System would have many advantages.  It would  provide more complete information than i s c u r r e n t l y a v a i l a b l e .  No  - 156 -  analysis of Emergency documentation i s c u r r e n t l y done except through morbidity and m o r t a l i t y rounds.  The a b i l i t y to f l a g  " i n a p p r o p r i a t e " u t i l i z a t i o n , develop documentation to substantiate r e v i s i o n s in p o l i c i e s or procedures and to grasp a c t i v i t y i s enhanced.  A common source document - the chart - w i l l s u f f i c e for a  multitude of needs - u t i l i z a t i o n review, determination of case mix, r e l a t i o n s h i p 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 i n 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 workload indices which must be a combination of the variables which a f f e c t workload in the emergency room - case complexity, pre-admission work up, length of time i n emergency room and resources necessary.  It  w i l l also be useful to provide some foundation to r e l a t i n g the s t a f f i n g and budgeting to processes, case mix, trends and emergency room capacity.  Figure 6.3 depicts the relationship.and uses of the case a b s t r a c t .  It i s recognized that a patient abstracting system i s expensive to implement in paper form and at t h i s stage i s probably not cost justified.  However, with the trends toward computerization and  - 157 Figure 6.3 Patient Abstract  Financial  Manipulate 4 (13 week periods)  HPMS 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 q u a l i t y morbidity and m o r t a l i t y information infections 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 l u c t u a t i o n s trends - case mix - length of time in Emergency Room  - 158 -  patient care systems, i t would be a simple /matter to add c e r t a i n elements to the data base and manipulate the i n d i c e s .  Merging  t h i s data base with the f i n a n c i a l data base would then eliminate many of the current problems with the i n t e g r a t i o n 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, a v a i l a b l e to the emergency room - in terms of beds, and s t a f f i n g .  While in some respects t h i s i s i n t e r n a l manage-  ment information, i t i s also e s s e n t i a l f o r d i s a s t e r preparedness, therefore, i t is recommended THAT an inventory of hospital resources be maintained to i d e n t i f y physician s p e c i a l t i e s and s k i l l s , s t a f f s k i l l s , a v a i l a b l e or p o t e n t i a l l y a v a i l a b l e 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 d e n t i f i e d by the panel members.  Again, an  inventory updated annually would be the most e f f e c t i v e method of data c o l l e c t i o n .  B.C. Research Foundation c u r r e n t l y publishes pop-  u l a t i o n data by school d i s t r i c t .  - 159 -  Co-ordination of t h 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 f e c t i v e co-ordination and l i a i s o n 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 s o c i a l service f a c i l i t i e s and population data f o r 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 following question was formulated: "What data elements should be c o l l e c t e d in hospital emergency information systems which w i l l meet external reporting r e q u i r e ments, be useful to plan, describe and evaluate emergency department a c t i v i t y f o r the various decision makers w i t h i n the h o s p i t a l system and f a c i l i t a t e the development of e f f i c i e n c y and effectiveness  indicators?"  The p r i o r i t y for information a r i s e s from the needs of the operating  160  -  -  c o r e , the c a p t u r i n g o f c l i n i c a l u l a t e d and  integrated with financial  development and  The  Research  and  of l e s s importance.  However,  t h a t u n t i l the b a s i c needs f o r i n f o r m a t i o n are  met,  and development are o f l e s s e r p r i o r i t y .  information i d e n t i f i e d  existing  information.  p o l i c y i n f o r m a t i o n was  i t i s reasonable research  i n f o r m a t i o n which can be manip-  sources.  i s i n the most p a r t o b t a i n a b l e  Once the data base i s d e v e l o p e d , norms and  s t a n d a r d s can be developed. with similar  case mix w i l l  Peer g r o u p i n g o f emergency departments a l l o w one  i n f o r m a t i o n as w e l l as outcome. data by age and  through  sex a l l o w s one  The  t o compare a c t i v i t y and identification  of  population  to t r a c k u t i l i z a t i o n p a t t e r n s  time and t o t e s t the impact of d i f f e r e n t p o l i c i e s ,  cost  procedures  over and  programs on u t i l i z a t i o n r a t e s .  T h i s study may  be c o n s i d e r e d  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 d e c i s i o n - m a k e r s 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 t o the development o f an emergency department, i n f o r m a t i o n system which can now v a l i d i t y by o t h e r  Information  be implemented and examined f o r  researchers.  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 r e c e n t i n c r e a s i n g dominance o f T r e a s u r y Board w i t h i n the M i n i s t r y o f H e a l t h . i n f o r m a t i o n by the M i n i s t r y w i l l  T h i s pirophesized s h i f t t o  financial  i n c r e a s e the need f o r adequate  and  - 161 -  appropriate planning and operational data upon which c a p i t a l and operating requests can be cost j u s t i f i e d .  In the long run, p o l i c y formulation cannot be addressed u n t i l such information systems are in place and standards and norms established.  Future d i r e c t i o n s include the merging of the data bases of the Emergency Health Services Commission f o r pre-hospital  care,  Emergency Care and the i n - p a t i e n t treatment of those admitted. P o l i c y planning decisions on the l o c a t i o n and standards of emergency care, s t a f f t r a i n i n g requirements and the roles of emergency departments are dependent upon a uniform and integrated data base.  The s o f t issues i d e n t i f i e d were not addressed in any d e t a i l . Future research must address the impact of r e l a t i o n s h i p s and protocols on patient care and provider s a t i s f a c t i o n .  SUMMARY OF CHAPTER  This f i n a l chapter attempted to analyse the r e s u l t s of the study in l i g h t of the issues of professional  power and c o n t r o 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 r e s u l t s were not inconsistent with the information hierarchy matrix which portrayed successively higher l e v e l s of information needs.  The recommendations were minimal.  Information systems are expensive  to implement and e x i s t i n g systems i n place should be integrated rather than replaced.  C l i n i c a l , q u a l i t y and f i n a n c i a l a c t i v i t y  information as i d e n t i f i e d can be l i n k e d .  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 t h i s component of information, i t i s  impossible  to l i n k c l i n i c a l to e x i s t i n g f i n a n c i a l information.  The s o f t issues were not addressed i n any d e t a i l .  The Panel members  were, however, f o r c e f u l i n t h e i r b e l i e f s that s o f t data contributed e q u a l l y , i f not more so, than hard data to the effectiveness and e f f i c i e n c y of emergency departments.  The development of emergency care in B.C. has been advanced by i n creasing s p e c i a l i z a t i o n of the human resources.  The Hospital Role  Study and 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 are f u r t h e r attempts to i d e n t i f y the appropriate r o l e of the f a c i l i t y .  Once t h i s i s achieved,  emphasis must s h i f t to the operating of emergency departments,  - 163 -  the adequacy of resources and p a t i e n t outcomes.  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NAJM, V o l . 288, No. 22,  - 173 -  February 19,  1981  Dear : Further to our discussion regarding your kind acceptance to p a r t i c i p a t e as a panel member in my thesis on Emergency Department Information Systems, please f i n d enclosed: a) the abstract of the thesis b) the information matrix (which to my way of thinking simply o u t l i n e s various l e v e l s of information needs and possible ways of c l a s s i f y i n g types of information that may be useful to managers) c) a d e s c r i p t i o n of the methodology (Nominal Group Technique) which is one method of a r r i v i n g at a consensus among i n d i v i d u a l s with varying perspectives and which I intend to employ at our meeting. As I i n d i c a t e d to you, t h i s t h e s i s i s aimed at i d e n t i f y i n g 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 s t a t e d : "What data elements/information should be c o l l e c t e d i n hospital Emergency Department Information Systems which w i l l meet external reporting requirements ( M i n i s t r y 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 f o r the various d e c i s i o n makers w i t h i n the hospital (Administrator, Director of Nursing, Medical D i r e c t o r , 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 i e n c y i n d i c a t o r s . 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 d i s c r e t e foci of current i n t e r e s t . One i s the s t r i v e towards c a t e g o r i z a t i o n or c l a s s i f i c a t i o n of emergency departments according to c a p a b 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 d i s a s t e r planning as the " c a p a b i l i t y " concept and the "mopping up r o l e " of emergency departments - the e l d e r l y , the a l c o h o l i c s , the psychotics - as u t i l i z a t i o n problems. These concepts may a s s i s t you i n thinking about your information needs.  - 175 -  NOMINAL GROUP TECHNIQUE  The Nominal Group Technique (and v a r i a t i o n s thereof) i s a process of decision making whereby: 1.  i n d i v i d u a l s s i l e n t l y generate those ideas/data elements/information needs independently of other members,  2.  each i n d i v i d u a l i n 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., shift/day of the week,  3.  volume of patients per  diagnosis),  each recorded idea i s discussed f o r c l a r i f i c a t i o n and evaluation (as to whether i t i s e s s e n t i a l , nice to know or n o n - e s s e n t i a l ) ,  4.  i n d i v i d u a l voting on p r i o r i t y ideas with the group decision being mathematically derived through rank ordering or r a t i n g .  The objectives of the process are to balance p a r t i c i p a t i o n among members and to incorporate mathematical voting techniques i n 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 M i n i s t r y of Health 1515 Blanshard Street V i c t o r i a , B.C. V8W 3C8 (formally Chairman, Emergency Health Services 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  Commission)  APPENDIX  D  COMMUNITY PROFILE  Community  Characteristics  Major i n d u s t r y - agriculture - mining - logging - industry  T r a n s p o r t a t i o n Systems - highway a c c e s s i b i l i t y  S p e c i a l Problems - hazards - ski h i l l s - summer r e s o r t s - t r a n s p o r t a t i o n of chemicals -  Unemployment Level  - Transient Population - communes - Immigrants  Population  Health  by SD, RHD, Community/ Municipality  Health  P o p u l a t i o n by - age - sex - race - marital status - income - poverty vs. a f f l uence M o r b i d i t y and M o r t a l i t y - deaths by major cause - traumas  Morbidity - medical emergencies - chronic diseases  Resources  a) h o s p i t a l beds by program/ sub program h o s p i t a l ambulatory c a r e programs b) ambulance EHSC c) o t h e r h e a l t h / s o c i a l resources 1) mental h e a l t h and t y p e s 2) p u b l i c h e a l t h and types 3) LTC f a c i l i t i e s 4) d e t o x i f i c a t i o n etc. P h y s i c i a n supply by  availability availability - capacity centres,  specialty  Appendix D HOSPITAL PROFILE  Hospital C h a r a c t e r i s t i c s  Programs/Profile  Manpower  Costs  Geographic a c c e 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  Medical s t a f f p r o f i l e - by s p e c i a l t y and status, i . e . active/consultant  By program - volume - budget to actual  b) Ambulatory Care Programs - type by hours of operation  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)  c) A n c i l l i a r y Services - diagnostic and therapeutic - type by hours of operation  Hospital s t a f f p r o f i l e - by category  Appendix D EMERGENCY DEPARTMENT PROFILE  RESOURCES 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  PATIENTS Patients by catchment area (SD) age/sex race family MD occupation i ncome marital status day and time of a r r i v a l  demographic socio-economic  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. - s e v e r i t y l a l b - 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 _ ) medical emergencies ) treatments/tests length o f time i n Emergency Room h  Supplies/Equipment - monitors  Costs .fixed costs program costs program variable costs Number o f times OR plugges - overtime - budget to actual  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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