COVID-19: Five Learnings that Could Transform Ontario Healthcare
The SouthWestern Academic Health Network or SWAHN brings together leaders from hospitals, universities, colleges, research institutions and other healthcare organizations in Southwestern Ontario to facilitate interprofessional collaboration and knowledge-sharing to contribute toward excellence in research, education and clinical practice. As healthcare leaders and SWAHN members, we have been actively involved in contributing to, and learning from, each other during the current COVID-19 epidemic.
It is clear that the various organizations within the healthcare system in Ontario have cooperated to manage the challenge of COVID-19 and – together with the public – avoided the high volumes of cases seen in other areas of the world in the early weeks of the pandemic. We experienced tragic losses of life in long-term care and retirement residences, but other sectors stepped in to share the burden. In many areas, a great deal of problem-solving took place in a short time based on a limited but evolving understanding of the disease.
Are there lessons in this crisis that could make our system stronger as we face a second wave of the virus, and whatever lies beyond it? Based on our first-hand experiences through SWAHN, we believe there are.
1. Networks make us stronger.
At every point, from local to regional to provincial, the hospital system kicked into a very collaborative, multi-layered structure. Silos were collapsed and resources, even personnel were shared.
On a regional level, hospital leadership supported each other, meeting virtually weekly. In the Ontario Health West region that includes 43 CEOs, regional subcommittees addressed medications, PPE, human resources and other challenges. A virtual warehouse was created so that leadership knew what supplies were available across the region – allowing them to quickly access needed items from organizations with lower demand if hotspots developed. Regional hubs stepped in to create field hospitals in the eventuality that hospitals were overwhelmed.
On a local level, the pandemic accelerated all networking that has been taking place in healthcare. When hospitals and hospital staff stepped in to assist long-term care homes where outbreaks had occurred – providing care, PPE, and testing – it was widely covered in the media. Less well-known to the public was the support of long-term care for hospitals just before the pandemic was declared, accepting some patients from hospitals in order to open up beds and resources to prepare for the expected surge of COVID-19 patients. The pandemic will ultimately inform the ongoing development of Ontario Health Teams (OHTs), as acknowledged by the Ontario government (Ontario Government n.d.). Some long-term care homes which previously did not see the OHTs as relevant may be encouraged to become involved.
Hospital Infection Prevention and Control staff shared their expertise with long-term care by addressing cleaning, PPE, layout and other daily practices. This expertise is typically not found in long-term care. However, when publicly paid hospital staff go into a long-term care residence – most of which are private companies – to provide assistance, it raises questions about our long-term care model. Conversely, if long-term care homes had access to hospital-level infection prevention and control, would this lessen future influenza outbreaks? And, how would that affect annual flu surges in acute care?
The challenge: When silos break down between organizations, roles and responsibilities must be defined — a potentially challenging task during a crisis.
2. Distinguish what is vital, elective, and unnecessary.
As hospitals and primary care slowly open up non-urgent services, it may take 12-18 months to catch up with tests, surgeries and procedures postponed during the COVID-19 shutdown. It is vital for clinicians to discern which procedures add value to the patient and which do not. This would build on the work of Choosing Wisely Canada™, a health education campaign aimed at encouraging physicians to reconsider broad screening of specific tests that may cause patients more harm than good due to false positives, follow-up testing, and increased stress.
This is an area where academic researchers can provide vital assistance to clinicians in understanding the true cost/benefit of backlogged procedures. For instance, if the waiting list for MRIs is long, it would be important to understand when an x-ray could be a reasonable or even a superior substitute.
Some tests may be part of ‘defensive medicine’ aimed at avoiding patient complaints or lawsuits (CMPA n.d.). MRIs are seen by many patients as providing more accurate diagnostics. It is therefore important to provide patients and physicians with data demonstrating its validity for patients. These decisions need to be based on providing the best care to patients, noting that they also have the potential to create healthcare savings.
In a similar way, it would be enormously helpful to have research to better understand when virtual or in-person patient-physician appointments are appropriate. During this pandemic, virtual care has been used to reduce the risk of transmitting the coronavirus and preserve PPEs. It would be valuable to know if there is a potential to provide quicker access to care through the continued use of virtual visits for some patients.
The challenge: Both patients and clinicians tend to resist reductions in testing. Will we have data available quickly enough to inform decisions and reduce waitlists over the next year?
3. We need a reliable supply chain.
Our healthcare sector needs to value resilience, not just cost-savings. Early in the pandemic, we suddenly became aware of our extraordinary vulnerability when relying on imported PPE and ventilators. However, even if a far-sighted administrator had foreseen such difficulties, their ability to take action would have been limited because Ontario legislation requires hospitals to choose vendors based on the lowest price. This makes it difficult for Canadian manufacturers to compete, encouraging the use of disposable PPE and supplies over those that are reusable. It was only in the extraordinary circumstances of the pandemic’s first wave that Grey Bruce Health Services in the Grey Bruce Region, ON, could purchase reusable ventilator masks for staff who were heavily exposed, ensuring they are better prepared for future surges. Legislation should be changed to allow for the consideration of multiple factors in choosing vendors.
This vulnerability was also demonstrated in the shift made by pharmacies to provide only 30-days-worth of medications to avoid shortages (Chidley-Hill 2020). Low stocks of certain drugs were already a concern before COVID-19 hit. Pharmacy students from the University of Waterloo in Waterloo, ON, on placement in the spring, often found that much of their time was spent sourcing medications. Here again, Canadians are dependent on importing many of their medicines. However, even those manufactured domestically rely on ingredients sourced globally, especially from China or India.
The challenge: Increasing domestic manufacturing would likely increase costs, and it would take time to develop new supply chains.
4. Consider micro-credentials to improve staffing in long-term care.
When the COVID-19 pandemic struck, students in Ontario colleges studying to become personal support workers (PSW) had completed 30 weeks of study and were about to begin the last stage of training – placements in residential care. However, the pandemic led long-term care homes to close to family members and students alike in order to protect their residents. This meant most of the cohort of new PSWs were unable to earn their certificate and begin work. This was frustrating for them, and disappointing for desperate and understaffed homes. Skipping the placement phase was not an option, as it is key to helping students gain the real-world experience they need to perform safely and effectively. At Fanshawe College in London, ON, this has now been addressed via simulation labs. Some long-term care homes eventually opened up to summer placements, enabling new PSWs to graduate.
Now colleges and their employer partners are discussing new ways to transform PSW training, including looking at it with a national lens — different provinces have different titles and training for this position. One solution being considered is micro-credentials, which would use quality assurance processes to convert PSW training standards to competencies, with 6–8 weeks of training followed by practicum or simulation. This might lead a student to receive a new designation, such as supportive care worker, which would also be a step on a pathway to further training toward becoming a PSW. This has the potential to help address understaffing in long-term care.
The challenge: The development of new credentials, curriculum and scope of practice involves many partners. Can it be done in a timely way? How would pay rates be affected by a new role?
5. Take care of staff so they can take care of patients.
Taking care of healthcare workers is important at any time, as the toll of burnout on physicians, nurses and staff is clear. The Ontario government has embraced the quadruple aim in healthcare, embedding it into the preparation documents establishing OHTs. The quadruple aim states that improving the experience of clinicians is necessary in order to improve patient health outcomes and experience, and reduce costs (Bodenheimer and Sinsky 2014).
During the long hours and uncertainty of the first wave of the pandemic, health professionals had little evidence to base their actions on, and images of the overwhelmed hospitals of Italy and New York were ever-present. The stress on physicians and staff was enormous at work, and they feared bringing the disease home to their families. Bluewater Health in Sarnia, ON, put in place a resiliency support system, with staff from the mental health unit walking the COVID-19 unit to identify and assist staff members who were struggling. Otherwise, some of these workers had no one to turn to; they did not want to burden their already worried family members, and may not have felt safe sharing their struggles and vulnerability with colleagues.
Bluewater Health already had an established Culture of Kindness Employee Council, and it partnered with the Wellness Committee to bring treats, drinks and donated meals to staff working long hours and sometimes living apart from their families.
It is important to recognize that individuals respond to stress in different ways. This may be heightened because of challenges rising from their home life, such as living with vulnerable family members or schooling young children at home. Therefore, it is important that healthcare leaders avoid and discourage vilifying employees who seem overly cautious or cavalier. It is vital that leaders act with kindness, listen to and address concerns, and offer flexibility whenever possible.
Healthcare workers demonstrated their own flexibility during the pandemic. The normal rules of engagement, including collective agreements, were suspended, enabling a nimbleness that healthcare leaders do not usually demonstrate. Physicians and staff showed willingness to take on new ways of working, in the short term at least, in order to do what was best for their patients and colleagues.
The reality is that stress on healthcare professionals will not end with the pandemic. We will face long waitlists for all procedures along with frustrated patients and families. Continuing to support employees will be important in helping them meet these challenges.
The challenge: It is hard to measure the effectiveness of this mental health support.
While healthcare organizations prepare for many more months of the ongoing pandemic, knowledge-sharing is vital and the members of SWAHN will continue to support one another. When we eventually emerge from the pandemic, the challenges facing our healthcare system will be emphasized, and we will rely on each other to find effective solutions to long waitlists, among others. We believe these five lessons learned from the COVID-19 pandemic offer a promising place to start.
About the Author(s)
Gary Sims, MEd, BScN, is the president and CEO of Grey Bruce Health Services in Ontario.
Mike Lapaine, MBA, BA, is the president and CEO of Bluewater Health in Sarnia, ON.
Dave Edwards, BScPhm, PharmD, MPH, is the Hallman Director at the School of Pharmacy, University of Waterloo in Waterloo, ON.
Pam McLaughlin, Med, BScN, is the dean at the Faculty of Health, Community Studies and Public Safety, Fanshawe College in London, ON.
Bodenheimer, T. and C. Sinsky. 2014. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. The Annals of Family Medicine 12(6): 573–76. doi: 10.1370/afm.1713.
Canadian Medical Protective Association (CMPA). n.d. "Defensive Medicine" and Good Care. Retrieved October 23, 2020. <https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/patient_safety/Legal_liability/defensive_medicine_and_good_care-e.html>.
Chidley-Hill, J. 2020, May 31. Ontario’s 30-Day Limit on Prescriptions Over Drug Shortage Fears Expected to End by July 1. The Star. Retrieved October 23, 2020. <https://www.thestar.com/news/canada/2020/05/31/ontarios-30-day-limit-on-prescriptions-over-drug-shortage-fears-expected-to-end-by-july-1.html>.
Ontario Government. n.d. Become an Ontario Health Team. Ministry of Health and Ministry of Long-Term Care. Retrieved October 23, 2020. <http://health.gov.on.ca/en/pro/programs/connectedcare/oht/>.
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