Essays

Essays October 2018

Breaking the mould: the transformation of Ontario’s hospitals

Hedieh Javaheri and Nirusan Rajakulendran

Image for essay 

Introduction

As Canadians, our healthcare system is a focal point of our society. It was designed on the principle that healthcare is a social good and that all residents should have equal access to essential services. Canadians take pride in the fairness and equity that has become the hallmark of our healthcare system. However, in recent years various challenges have threatened to destabilize a system that is depended on by so many. They include:

  • increasing demands for services;
  • rising healthcare costs;
  • a fragmented system with suboptimal communication and coordination; and 
  • a demand for improved quality of care

For the first time in history, Canada’s elderly population is outnumbering its youth. There are more individuals aged 65 and older than there are children aged zero–14.[1] This aging population has introduced a capacity challenge with an upsurge in demand for care around serious chronic conditions. Aside from these demand-driven challenges, provinces also function under a fragmented healthcare system, where care is optimized at the unit level, but remains disjointed at the system level. The exchange of information and coordination of patients is suboptimal. There is a need to create a more integrated system that operates holistically. Furthermore, with the consumerization of healthcare, patients are demanding the same level of care that they have come to expect from other service providers. There is a need for patient-centric models of care focused on improved quality and satisfaction.

Innovative care models from around the world

Outside of Canada, innovative healthcare institutions have made significant advancements in addressing the four challenges listed above.  

Outpatient model: Tackling increasing demand and cost

The outpatient model of care is increasingly used to tackle rising challenges around capacity and access to services. For example, Montefiore Medical Center in the Bronx, New York, is a 12-story outpatient center with zero overnight beds. This hospital officially opened in November 2014 and offers outpatient surgery for conditions that once required hospitalization to treat. The outpatient model empowers the hospital to send patients home for faster recovery while reducing wait times and capacity challenges for both inpatient and outpatient surgeries.[2]

Smart and virtual hospitals: improved operational efficiency with increased communication and coordination

Technology is being leveraged to create new and radical care models. Two concepts currently being explored by a select number of jurisdictions are smart hospitals and virtual hospitals. Smart hospitals are institutions that have clinical processes, management systems and infrastructure that are enabled by an underlying digitized network of interconnected assets.[3] Important components of a smart hospital include [1] the ability to leverage its digital infrastructure to provide services or insights which were not previously available, [2] offering better patient care and experience, and [3] improving operational efficiencies.3

The University of Pittsburgh Medical Center (UPMC) was one of the early pioneers of the smart hospital concept. Launched in 2008 in partnership with IBM, UPMC’s SmartRoom technology includes features that provide clinicians with relevant real-time patient information at the bedside, simplifying workflow for nurses and improving documentation.[4]

Virtual hospitals, on the other hand, are hospitals without patients or beds. These facilities are home to large medical teams that provide care and consultation to patients through two-way cameras, online-enabled instruments and other sensors and devices.[5] Mercy Virtual Care Centre in Chesterfield, Missouri, is the world’s first and most advanced example of a virtual hospital — an electronic intensive care unit designed specifically to support the delivery of telehealth services, including telestroke, nurse on call and physician teleconsultations.Virtual hospitals enable health providers to deliver better and more efficient patient care at a lower cost.[6]

Hospital design: Greater quality of care and satisfaction through design

Research has shown that hospital design elements (private rooms with windows, natural light, noise control and more) are associated with shorter stays in hospitals and higher patient satisfaction.[7],[8] Florida Hospital Celebration Health, is a stellar example of a patient-centered hospital design, showcasing both innovation and excellence. This 227-bed, state-of-the-art, resort-like hospital was built in 1997 adjacent to Walt Disney World and is a centrepiece of the community. Patient rooms incorporate large windows with an abundance of natural light and are designed with smart technology to give patients more control. Similarly, the exterior landscape is designed to foster an environment for recovery and healing.[9],[10] A review of over 600 studies has shown that patient satisfaction is directly linked with environmental factors such as views of nature, noise reduction, ease of path finding, and sense of control over the environment. Every touchpoint in a healthcare facility provides an opportunity to deliver an experience — and institutions should incorporate patient-centric design elements to improve patient satisfaction.10

Ontario’s Story

Over the past few years, a number of hospitals across Ontario have been actively working to reimagine the way that care is provided. The goal for many of these hospitals is to optimize, redesign or build new models of care that can address the current and future needs of the population.

We had the chance to speak with three forward-looking hospitals, each tackling a unique challenge within the Ontario healthcare system:

  1. Women’s College Hospital: ambulatory care model to increase operational efficiency and manage rising demand for services.
  2. Bridgepoint Active Healthcare: improving quality of care and patient satisfaction through design.
  3. Mackenzie Health: leveraging digital infrastructure to create a more connected and integrated approach to care.

Women’s College Hospital: increasing efficiency while meeting demand

In 2005, Women's College Hospital (WCH), located in downtown Toronto, became the first independent, academic ambulatory care hospital in Canada. Since then, the institution has been a leader in solving some of the most prevalent challenges in our healthcare system. The Government of Ontario decided to transition WCH to a model of solely outpatient as part of a bigger agenda to restructure healthcare services across the province.

WCH is, ironically, a hospital designed to keep people out of the hospital. It has evolved surgical and anesthesia processes for knee replacements, breast reconstruction and thyroid surgery, all in an effort to shorten the in-hospital recovery period to less than one day. The hospital is using technology to help patients communicate with healthcare providers so that they can leave on the same day of surgery to recover safely at home. Through the outpatient model, WCH aims to close health gaps, offload the pressure on hospital beds, save money for the system, and increase patient satisfaction.

According to WCH, in order to achieve new and better outpatient models across Ontario, providers need to test those models first and understand how they work. This was the idea behind the WCH for Health System Solutions and Virtual Care (WIHV). Created five years ago, it is a living laboratory that develops and evaluates novel healthcare services. The hospital’s goal was to ensure that any new model of care would be tested against healthcare’s “triple aim”: [1] better the experience for patients and providers, [2] improve health, and [3] save the healthcare system money (or at least hold costs at a sustainable level).

Over the last five years, WCH has worked with partners inside and outside the province, figuring out how to spread and scale successful projects. The hospital’s new strategic plan reinforces its commitment to revolutionize health systems — to develop, implement and evaluate solutions, including new ways of delivering services over the next five years.

One of the projects that WCH has been working on involves evaluating an app that reminds patients with chronic kidney disease to re-order supplies and monitor aspects of their health while managing home dialysis treatment. This type of self-management helps people maintain optimal health and prevent avoidable issues that might result in a visit to the hospital. WIHV has also evaluated software that lets patients with diabetes track their blood sugar levels and receive daily diet and lifestyle tips. Additionally, WIHV is looking at the benefits of things like at-home HPV testing kits that allow women to mail in samples and access results online. And the hospital is working with leaders in primary care to create faster access to advice (roughly half of Ontarians aren’t able to see their doctor on the same day that they call).

Through projects like these, WCH intends to show how some of the barriers to accessing care can be removed, all while getting the best value for its resources. If the hospital can help patients stay on top of their care and create a fast track to advice from healthcare teams — especially at critical moments where the only alternative would be the emergency department — it will go a long way towards improving sustainability across the system.

Over the next five years, the WCH wants to work for all Ontarians to drive solutions that improve efficiencies, convenience, access and effectiveness. An exciting aspect of this strategic vision is Women’s Virtual, a virtual care centre that will advance technology-enabled care delivery and consultations and identify opportunities to make care more accessible, affordable and comprehensive. The goal is simple: patients will no longer have to physically seek out care or reorient their lives to gain access to specialists.

Bridgepoint Active Healthcare: improving quality and satisfaction through design

A member of the Sinai Health System and affiliate of the University of Toronto, Bridgepoint Active Healthcare (Bridgepoint) embodies innovative architectural design in healthcare, serving to better meet the lifelong needs of people living with multiple health conditions.

Previously known as Riverdale Hospital, Bridgepoint opened in 2013 in Toronto’s east end, rising high above the Don Valley. The state-of-the-art, 10-storey, 680,000-square foot building represented the future of healthcare.

According to Jane Merkley, executive vice president, chief nurse executive and chief operating officer, Sinai Health System, “the central design features of the new Bridgepoint hospital create an environment of health, wellness, healing. It’s a place to activate patients and get them mobilized.” The holistic model that inspired the hospital design emphasized movement away from the illness paradigm of healthcare. That is, shifting away from a place where patients are dependent, passive recipients. Bridgepoint was designed as an environment of patient-centric care where people are empowered to self-manage. Jane notes that the hospital has all the design and programming to ensure that patients and families are engaged. “If you go over to Bridgepoint, you feel like there’s something different in the air,” she says. “It’s an optimistic, hopeful environment”.

Kate Wilkinson, vice president, quality and clinical programs, explained to us that a number of key transformations took place to enhance the patients’ psycho-social well-being, and reduce adverse events such as falls and infections.  

The former Bridgepoint hospital contained mostly four-bedded rooms — very few semi-private and private — and had a few centralized washrooms for patients to share. In the new building, even with the same number of beds, the physical footage was increased by nearly 250 per cent; the number of units increased from 9 to 14, while reducing the numbers of beds per unit from 50 to 32. With a combination of semi-private and private rooms, each room has its own washroom and greater physical footage so that patients are not at close proximity.

Concerning accessibility, each unit is also outfitted with bariatric rooms with special design elements like double doors, extra wide bathroom doors, and special equipment tested for appropriate weight restrictions. The patient rooms also have horizontal and vertical floor to ceiling windows, enhancing patients views. It all creates a feeling of inspiration and connection to the community — whether in bed, sitting on a wheelchair, or standing, patients will have uninterrupted views. Even in a semi-private room, every bed space has access to an unimpeded window, even if a roommate’s curtain is drawn. Every room also has the capacity for temperature control and management, air quality and lighting.

Bridgepoint’s design focuses on transforming its entire footprint (the size of a city block) into a “campus of wellness.” Quite a bit of care and attention was given to the design of the hospital’s outdoor space: the patios and the connection with the adjacent areas such as parks and the neighbourhood. These areas were built with the goal of motivating patients to get well, and for them to eventually have the confidence to go home. Every single room in the hospital, whether it be a patient room or activity room, has one of four fantastic uninterrupted views: north to Riverdale park, south to Lake Ontario, east into the Riverdale community or west to the Toronto skyline.

All of these design features have been influential in boosting patient satisfaction — social and physical therapy that gets patients in a different state of mind and advances recovery.

As Jane and Kate further explain, one of the primary and recent focuses of Bridgepoint is changing the hospital’s policies and programming to create a more comfortable stay for caregivers. Often, when caregivers stay at hospitals for long periods, they suffer from burnout. In response, the hospital is launching a patient family care strategy that is intended to alleviate this stress. One example is the creation of a caregiver centre which will be designed with caregiver feedback. The first phase involves providing 24-hour access to loved ones under the new family presence policy. The second phase will create physical spaces that can be used by caregivers while they are in the hospital.

Findings from a preliminary report on the Bridgepoint pre- and post-occupancy evaluation by Dr. Celeste Alvaro show that patients have “experienced an increase in satisfaction, displayed greater self-efficacy in mobility and increased perceptions of improvements in their mental health relative to the old hospital”.[11]

Moving forward, it is recommended that future hospitals also follow the Bridgepoint model and incorporate design features such as quality outdoor spaces, access to natural light, and uninterrupted views of the outdoors. This will increase patient satisfaction and contribute to faster recovery.

Mackenzie Health: improving care and satisfaction through design

According to the CEO and President of Mackenzie Health, Altaf Stationwala, the healthcare industry is making great strides at integrating smarttechnology in our community hospitals.

Mackenzie Health’s vision is to create a world-class health experience for its patients and community using a two-hospital model of care. The organization currently operates the Mackenzie Richmond Hill Hospital and a network of community-based locations. In late 2020, the institution will open Canada’s first smart hospital, Mackenzie Vaughan Hospital.[15]

Designed through the eyes of a patient, Mackenzie Vaughan Hospital will feature paperless and smart automated systems that enable seamless communication between people, processes and technology. Systems and medical devices will “talk” to each other to maximize information exchange, allowing staff to coordinate care around the needs of patients and families. The interconnectivity at Mackenzie Vaughan Hospital will allow clinical teams and physicians to provide safe and faster care with real-time location tracking of patients and easy access to patient information via dashboard monitors.

In July 2017, Mackenzie Health was the first hospital in Canada to go live with the end-to-end Epic electronic medical record (EMR) system, a key stepping stone to engage community care providers. Epic EMR generates insightful analytics that help drive informed healthcare decisions and quality improvement initiatives. As part of Epic EMR, patients and members of the community receive access to their health records on MyChart, an online platform. With MyChart, patients can monitor their appointment calendars, check in online seven days prior to their next hospital visit and review clinical notes. This step towards online connectivity provides patients the opportunity to play an active role in their healthcare journey.

Following the implementation of Epic EMR, Mackenzie Health was recognized by HIMSS Analytics for achieving Stage 6 on the HIMSS Electronic Medical Record Adoption Model (EMRAM). As of 2017, only 1.7 per cent of Canadian hospitals had achieved this level of functionality with their EMR.[16]A core component of Mackenzie Health’s evolution is to leverage information received from Epic EMR and integrate it with primary clinical care teams, physicians and community partners.

The new Mackenzie Vaughan Hospital is just the start. Stationwala strives for a virtual hospital as an extension of the physical environment of a regular hospital. For him, an ideal virtual hospital would integrate smart technology to connect patients with physicians and clinical care providers. In turn, physicians and nurses would be able to leverage the use of telecommunication and remote health monitoring technologies to provide quality clinical healthcare from the convenience of their home.[17]

While there are currently no virtual hospitals in a Canada, Stationwala sees the potential with the support of smart technology. “I do think there will come a time when the implementation of virtual hospital becomes a reality,” he says. “With such technology, patients will be able to access an extension of services without having to actually travel to a hospital. Similar to the Ontario Telemedicine Network (OTN) and its videoconferencing, hospitals could host a virtual monitoring centre and communicate with patients who have been discharged or are experiencing chronic issues — video call would be a part of their at-home care experience.”

The ability to extend care beyond the physical footprint of a hospital can make it easier for patients with severe chronic diseases or other diagnoses to receive care from the comfort of their home. Doing so has the potential to reduce hospitalization costs, address wait times for an appointment, avoid travel to a physical hospital and minimize patient exposure to stress, anxiety and the risk of infections.

Through the launch of Canada’s first smarthospital and implementation of Epic EMR, Mackenzie Health is enhancing healthcare delivery and the flow of information. But while technology presents opportunities to address challenges in our healthcare system, we still need human-to-human interaction. Stationwala puts it best: “Healthcare is about people caring for people. The technology is really there to free up the provider so they may spend more face-to-face time with the patient. I hope we never lose that.”

The Future of Hospitals

Hospitals of the future will be very different from those of today. They will continue serving diverse patients with diverse needs. However, their primary aim will be to keep patients outside of the hospital.[12] The hospital of the future will shift to an outpatient model, offering same-day surgeries and free-standing emergency rooms. We will see an increase of “smart hospitals” that turn to digital technology to monitor and treat patients in the comfort of their own home.[13] Similarly, we can expect to see hospitals with architectural designs that are centered around the patient, catering directly to their needs.

Healthcare providers across Ontario are already reimagining the various ways that care is provided, setting an example for other institutions. Anthony Dale, president and CEO of the Ontario Hospital association, had this to say: “In our highly complex and interconnected healthcare system, innovative solutions, such as new models of care, are central to meeting growing demand and helping our hospitals continue to deliver the quality of care that Ontarians have come to expect.”[14]Change is on the horizon and healthcare institutions will need to build resilient teams that are capable of collaboratively and efficiently responding to future challenges. Hospitals in Ontario have already started to revolutionize healthcare practices, creating an opportunity for other institutions across the country to advance of our valued healthcare system.


[1] Canadian Medical Association. 2016. “The State of Seniors Health Care in Canada.” Available at: https://www.cma.ca/En/Lists/Medias/the-state-of-seniors-health-care-in-canada-september-2016.pdf.

[2] Daily News. 2014. “Montefiore Medical Center opens 12-story bedless outpatient center in the Bronx.” Available at: http://www.nydailynews.com/new-york/bronx/montefiore-opens-massive-bronx-bedless-surgery-center-article-1.2006077.

[3] Healthcare IT News. 2017. “Understanding smart hospitals and why most aren't there yet.” Available at: https://www.healthcareitnews.com/blog/understanding-smart-hospitals-and-why-most-arent-there-yet#gs.p=g2kr4.

[4] IBM. 2010. “IBM and UPMC Partner to Make 'Smart' Patient Room Even Smarter.” Available at: https://www-03.ibm.com/press/us/en/pressrelease/32217.wss.

[5] Mercy Virtual. “World's First Facility Dedicated to Telehealth.” Available at: http://www.mercyvirtual.net/worlds-first-virtual-care-center/.

[6] Politico. 2017. “A hospital without patients.” Available at: https://www.politico.com/agenda/story/2017/11/08/virtual-hospital-mercy-st-louis-000573.

[7] U.S. Department of Health and Human Services. 2005. “The Hospital Built Environment: What Role Might Funders of Health Services Research Play?” Available at: https://archive.ahrq.gov/professionals/systems/hospital/hospbuilt/hospenv2.html.

[8] Business Insider. 2014. “Hospitals In the Future Will Look Totally Different.” Available at: https://www.businessinsider.com.au/celebration-health-hospital-of-the-future-2014-5.

[9] Florida Hospital Celebration Health. Available at: https://www.floridahospital.com/celebration-health/our-location/about-us.

[10] Patient Experience Journal. 2017. “Evaluating variables of patient experience and the correlation with design.” Available at: http://pxjournal.org/cgi/viewcontent.cgi?article=1176&context=journal.

[11] Bridgepoint Active Healthcare. 2014. “Design and Evaluation: The Path to Better Outcomes.” Available at: http://www.bridgepointhealth.ca/en/what-we-do/resources/research/path_to_better_outcomes_preliminary_report.pdf.

[12] Politico. 2017. “A hospital without patients.” Available at: https://www.politico.com/agenda/story/2017/11/08/virtual-hospital-mercy-st-louis-000573.

[13] Bridgepoint Active Healthcare. 2014. “Design and Evaluation: The Path to Better Outcomes.” Available at: http://www.bridgepointhealth.ca/en/what-we-do/resources/research/path_to_better_outcomes_preliminary_report.pdf.

[14] Toronto Star. 2018. “He got his knee replaced at a Toronto hospital. A few hours later he was climbing stairs.” Available at: https://www.thestar.com/news/gta/2018/04/11/he-got-his-knee-replaced-at-a-toronto-hospital-a-few-hours-later-he-was-climbing-stairs.html.

[15] Mackenzie Health. 2018. “Building Canada’s First Smart Hospital.” Available at: https://www.mackenziehealth.ca/en/about-us/building-canada-s-first-smart-hospital-.aspx

[16] HIMSS Analytics. “Electronic Medical Record Adoption Model.” Available at: https://www.himssanalytics.org/emram.

[17]Politico. 2017. “A hospital without patients.” Available at: https://www.politico.com/agenda/story/2017/11/08/virtual-hospital-mercy-st-louis-000573.

Acknowledgment

Special thanks to Zayna Khayat, future strategist, Saint Elizabeth Health Care, for her guidance and expertise, and to the following collaborators and reviewers for their partnership and insight.

Collaborators
  • Altaf Stationwala, president and CEO, Mackenzie Health
  • Cheryl Woodman, chief strategy and quality officer, Women’s College Hospital
  • Danielle Martin, vice president medical affairs and health system solutions; co-founder of WIHV, Women’s College Hospital 
  • Jane Merkley, executive vice president, chief nurse executive and chief operating officer, Sinai Health System
  • Kate Wilkinson, vice president, quality and clinical programs, Sinai Health System

Reviewers

  • Louise Murphy, manager, MaRS Market Intelligence
  • Maggie Clark, senior associate, MaRS Partnerships
  • Mei Burgin, director, MaRS Market Intelligence 
  • Shahab Shahnazari, senior manager, Health Data Initiatives 
  • Sheryl Thingvold, senior advisor, MaRS Health Venture Services

Comments

Be the first to comment on this!

Note: Please enter a display name. Your email address will not be publically displayed