| Consolidation of Acute Mental Health Services in London, Ontario |
Submitted September 22, 1998 by:
| Chair, Department of Psychiatry University of Western Ontario Physician Chief, Mental Health Care Program London Health Sciences Centre |
Appendix A: Program Consolidation Planning Process
Appendix B: Checklist for Implementation
| Executive Summary |
For the past ten years, providers and consumers have planned in a number of ways for the integration of acute mental health services in London. In early 1997, the Health Services Restructuring Commission solidified these planning efforts by directing that all acute mental health services would consolidate at the London Health Sciences Centre.
By late 1997, there was growing concern regarding physician coverage at three acute care sites. Moreover, providers and consumers recognized that administrative efficiencies and increased academic opportunities could be achieved through accelerated consolidation. In addition, most importantly, the critical mass of professionals providing acute mental health services could improve the delivery of accessible, quality care in a more organized, streamlined way.
A Program Transfer Committee was struck to consider the feasibility of consolidating acute mental health services at a temporary site prior to completion of service-specific renovations at the Westminster Campus of LHSC. The target date for the program transfer was set for April 1, 1998, and the moves of the inpatient and outpatient programs at St. Joseph's Health Care London and University Campus were completed by April 15.
A number of factors contributed to the relative success of the program transfer. These included the collaboration between administration and support services at all sites, linkages with senior leadership and the Joint Committee, commitment to the continuity and quality of patient care, clear communication strategies based on input from a number of stakeholders, and regular meetings with staff and physicians to address concerns and needs.
In addition, as the first clinical program to transfer under the directives of the HSRC, the consolidation of mental health services highlighted several issues related to the application of principles and general agreements. The following summary provides an overview of these issues, as well as recommendations to address them:
Functional Planning
Recommendation: The functional planning process should be expanded to provide the basis for planning for program consolidation by adding:
Recommendation: Early consolidation of programs should occur only when care processes consistent with the functional plan can be developed and adequate physical facilities can be established within existing space.
Program Transfer Implementation
Recommendation: A Program Transfer Implementation Steering Committee should be formed with representation from each of the institutions involved and an impartial chairperson.
Logistics Planning
Recommendation: A standing committee should be established at each site to prepare for the ongoing work related to program transfers.
Recommendation: A System Support Team composed of the LHSC and SJHC standing committees should be established, to develop consistent processes and protocols and to address generic logistics planning issues.
Recommendation: A Logistics Planning Committee, a joint committee composed of the membership of the System Support Team and program leadership, should be established to plan and coordinate the logistics of the move.
Recommendation: A project manager should be appointed for a term prior to, during, and briefly following the program transfer.
Recommendation: Counterparts in each of the support areas need to collaborate to ensure the relocation of service is as seamless as possible.
Resource Allocation
A) Financial Resources
Recommendation: A template to facilitate the financial analysis of direct and indirect costs associated with the transfer of the program should be developed jointly by the Finance Departments of the two organizations.
B) Human Resources
Recommendation: The staffing model for the consolidated program should be developed as soon as possible following the decision to transfer a program and confirmation of fiscal resources for the consolidated program.
Recommendation: Payroll transfer procedures require review and improvement.
Recommendation: Clarification of differences in employment relationships is needed, as well as assessment of staff skill levels and experiences.
Recommendation: Unions should be informed about the staffing details when the schedules and effects on existing staff are confirmed.
Recommendation: Sufficient time must be provided for staff who decline to transfer with the program to shift to alternative clinical services.
C) Equipment/Furniture
Recommendation: The functional planning process and planning for consolidation of programs must include identification of required equipment and furnishings, with sufficient time allowed for negotiations regarding the transfer of such items with the program and/or acquisition of items by the receiving hospital. A plan is required for the financing of required acquisitions.
Communications
Recommendation: A clear, coordinated communication plan for the community and key stakeholders should be developed.
Recommendation: Methods of ensuring that staff and patients receive adequate and timely information need to be identified.
Support/Associated Clinical Services
Recommendation: Preparation for patient transfers between sites should be in place well in advance of the move -- for example:
Recommendation: All clinical services should be notified well ahead of the pending program transfer and asked to assess the impact of the consolidation. Services at the receiving site must consider both volumes and patient types in determining the impact on referrals and work.
Information Services
Recommendation: A citywide Information Services agreement needs to be developed with all institutions affected by HSRC directives, to describe the transfer of hardware and information.
Recommendation: Policies and guidelines regarding transfer of information need to be developed. Staff must be informed of these guidelines well in advance of the program transfer and given ample information and time to focus on the process prior to the time of the actual move.
Orientation and Team Integration
Recommendation: Corporate orientations must be scheduled by the receiving organization, as is customary for all new employees. In addition, program-specific orientations must be arranged to focus on the application of existing skills in the new setting.
Recommendation: A plan for orientation and integration must begin well in advance of the move, with a needs assessment of staff and physicians who will actually be transferring.
Recommendation: Early appointment of the leadership of the consolidated program is beneficial.
Recommendation: Ongoing work regarding team integration, which includes staff, physicians, and administration is essential and should be facilitated through external resources, such as Learning Services (LHSC) or Education Services (SJHC) and preferably by facilitators from both organizations in collaboration with program leaders at the receiving organization.
Analysis and Evaluation
Recommendation: Analyses and evaluations should be completed at six months and one year post-consolidation. The evaluations should include the perspectives of physicians and staff in all affected institutions, as well as the community.
| Full Report |
For the past ten years, mental health services providers, as well as consumers and families, have discussed the need to reorganize the system in London and surrounding areas. Consistent with the Graham Report, which identified specific changes necessary to achieve mental health reform, the Thames Valley District Health Council and the Department of Psychiatry, University of Western Ontario, have worked with hospitals, other providers, and consumers to review and revise the mental health service delivery system.
In early 1996, following the report of the London Acute Care Teaching Hospitals Restructuring Committee (LACTHRC), planning with respect to the reorganization of acute mental health services within the Schedule 1 facilities began. Highlights of this planning included a consolidated psychiatric emergency service, a concentration of acute inpatient and outpatient services, and a day treatment program, all to be located at St. Joseph's Health Care London. A task team consisting of representatives from St. Joseph's Health Care London, London Health Sciences Centre, London/St. Thomas Psychiatric Hospital, and community services was formed and began planning for the consolidation of services.
The Health Services Restructuring Commission issued its report in 1997 and directed that all acute mental health services should be located at London Health Sciences Centre. Fortunately, many of the concepts and plans discussed in relation to the LACTHRC report implementation had relevance to the HSRC directives. In the summer of 1997, a task team completed the planing for the Mental Health Care functional program, with a target date of late 1999 for consolidation at the Westminster Campus.
Rationale for Early Consolidation
In late 1997, the acute mental health services at LHSC and SJHC and the Department of Psychiatry experienced growing concern regarding physician and resident shortages, particularly in trying to provide coverage to three acute care sites. As well, it was recognized that clinical and administrative efficiencies could be achieved through consolidation of services; and a centre of academic excellence could also be created with a critical mass of professionals located on one site.
Through the Joint Committee, it was suggested that the program consider an accelerated consolidation, assuming that quality patient care could be maintained and that the available space at South Street could accommodate the services, as an interim measure prior to the relocation to a purpose-designed facility at the Westminster Campus.
A Program Transfer Committee, chaired by Mr. Robert Cunningham, Administrator, London/St. Thomas Psychiatric Hospital, began meeting in December, 1997, initially to consider the feasibility of such an amalgamation; and then, to develop a plan for implementation of the transfer. The Ministry of Health was aware such discussions were occurring and were formally notified about the possibility of consolidation in early 1998.
April 1, 1998, was set as the target date for program transfer, to coincide with the beginning of a new fiscal year. Consolidation was achieved with the move of SJHC inpatient services on April 1 and 2, the move of University Campus inpatient services on April 7 and 8, and the shift of outpatient services from SJHC and UC on April 15.
Overall, the program transfer of acute mental health services was positive. A number of factors were instrumental in the success of the consolidation process; key contributors are highlighted below:
Functional Planning
The functional planning process, in which a program develops a vision of its future services, the linkages across the program, and the resources and facilities required, provides a solid basis on which to build the program transfer plans. All activities related to the transfer of a program should flow from the functional plan. A flowchart with suggested activities and their respective time lines, which links the functional plan and the detailed planning which follows, is attached in Appendix A.
In the accelerated Mental Health Program transfer, the functional program that had been previously developed could not be utilized to guide program transfer plans. This factor has been identified as the single greatest challenge for the consolidation of acute mental health services, with related issues that have persisted following program transfer. The functional plan was not used as a guide for a number of reasons: the program moved to existing space at South Street Campus which could be modified only slightly due to costs; the additional resources related to the final plan directed by the HSRC were not available; and there was little time to redesign clinical protocols and processes to incorporate a new vision. As well, the consolidation of mental health services occurred prior to the release of the HSRC Supplemental Report (July 1998) and the Medical Human Resources Fact Finders Report.
As a result, the space and the pre-existing services and staffing drove the consolidation, which only in some ways resembles the functional plan which more accurately addresses service and academic needs. For example, the functional plan for the Westminster Campus site includes an acute care unit, with two intensive care pods; this secure unit would serve high acuity, unstable patients, with specialized staff providing assessment and intervention. At present, these patients must be served on a large, open unit, with a limited number of intensive care beds. The opportunity to develop a specialized unit at South Street is severely restricted because of the physical design of the facility.
Recommendation: The functional planning process should be expanded to provide the basis for planning for program consolidation by adding:
Recommendation: Early consolidation of programs should occur only when care processes consistent with the functional plan can be developed and adequate physical facilities can be established within existing space.
Program Transfer Implementation
The establishment of a Program Transfer Implementation Steering Committee is vital to the process, to ensure that coordinated planning occurs among the institutions that are involved in conjunction with the Joint Committee. The Steering Committee is responsible for high-level decisions related to the feasibility of the transfer, the appropriate time frames, the risk/benefit analysis for various components of the transfer, and the identification and resolution of significant issues for the institutions or community related to the consolidation of programs.
The Steering Committee needs a clear mandate and linkages with the senior leadership at all affected institutions, as well as with the Joint Committee. Moreover, linkages with the operational leadership at all sites of the program are critical.
The chairperson of the steering committee should be familiar with the service and academic issues of the program, but should be an impartial individual, with no vested interest in the outcome of the transfer. Membership should also likely include the Vice President of Integrated Planning; the Vice Presidents, Managers, and Physician Leaders responsible for the programs at each site; and representatives from Human Resources, Facilities and Communications.
Recommendation: A Program Transfer Implementation Steering Committee should be formed with representation from each of the institutions involved and a impartial chairperson.
Logistics Planning
While each program transfer will be unique, there will be commonalities in the consolidation process, regardless of the clinical service focus. A checklist describing the generic tasks involved in a program transfer is attached in Appendix B. To prepare for the ongoing work related to a series of program transfers, a standing committee is proposed for development at each site.
Membership on these committees at LHSC and SJHC should include:
It is also recommended that these two committees from each site would meet together at regular intervals -- forming a joint LHSC/SJHC System Support Team. This group would develop templates and procedures for generic issues which would be consistent across all sites.
At the time of a program transfer, program leadership from all sites would join the System Support Team, to form the Logistics Planning Committee. This committee would design the detailed work plan and time lines for the transfer.
In addition, because of the magnitude of the work and because of the speed at which much of it must transpire, the appointment of a project manager is critical. There are many details which must be addressed and processes that must be coordinated; it is virtually impossible for an individual who has ongoing responsibilities in another management role to fulfill the project management role as well. Thus, an individual from the program might be seconded for a specified length of time to ensure that the program is a success. The project manager would provide leadership to the Logistics Planning Committee.
Recommendation: A standing committee should be established at each site to prepare for the ongoing work related to program transfers.
Recommendation: A System Support Team composed of the LHSC and SJHC standing committees should be established, to develop consistent processes and protocols and to address generic logistics planning issues.
Recommendation: A Logistics Planning Committee, a joint committee composed of the membership of the System Support Team and program leadership, should be established to plan and coordinate the logistics of the move.
Recommendation: A project manager should be appointed for a term prior to, during, and briefly following the program transfer.
Recommendation: Counterparts in each of the support areas need to collaborate to ensure the relocation of service is as seamless as possible.
Resource Allocation
It is important that the resources to be transferred are identified prior to the program consolidation. The resolution of financial issues drives the program planning, including staffing levels and assignments, equipment and furnishings, etc. Specific resources which must be addressed in program transfers include financial resources, human resources, and furniture/equipment.
A) Financial Resources
The resource allocation must incorporate both direct and indirect costs related to the program. All departments potentially affected in both the receiving and sending organizations need to participate in this process. A template needs to be developed jointly by the Finance Departments of the two institutions to assist programs and support services to identify workload and associated costs. This template needs to incorporate ministry guidelines for calculation of financial resources for program transfer by direct and indirect costs.
Recommendation: A template to facilitate the financial analysis of direct and indirect costs associated with the transfer of the program should be developed jointly by the Finance Departments of the two organizations.
B) Human Resources
Since the Mental Health Program Transfer was the first clinical program consolidation, there were issues identified related to human resources under the citywide agreement. These included the matching of a proposed staffing model and schedule with the resources available following the consolidation, varying interpretations of language in the agreement, and differences in the contracts at the various institutions.
In addition, because of the very aggressive time frame, an inordinate amount of time from Human Resources staff at both LHSC and SJHC was needed to develop seniority lists, meet with union representatives, address payroll issues, and ensure appropriate opportunities for staff to consider their options. Although there was no job loss in the process, staff had a number of concerns about roles, functions, and working conditions at the South Street site. Not only did this put pressure on those within the program who were anxiously awaiting information about what their new jobs would be, it also affected the other areas of the hospital that were less able to access human resources services because of their time commitment to Mental Health.
Furthermore, it is important to assess skill levels, patient care experience, care models, etc., to assist staff in integrating into the new program with competence and confidence and to facilitate the appropriate configuration of staff and to initiate the integration of new clinical teams.
Recommendation: The staffing model for the consolidated program should be developed as soon as possible following the decision to transfer a program and confirmation of fiscal resources for the consolidated program.
Recommendation: Payroll transfer procedures require review and improvement.
Recommendation: Clarification of differences in employment relationships is needed, as well as assessment of staff skill levels and experiences.
Recommendation: Unions should be informed about the staffing details when the schedules and effects on existing staff are confirmed.
Recommendation: Sufficient time must be provided for staff who decline to transfer with the program to shift to alternative clinical services.
C) Equipment/Furniture
The methodology for resource transfer has been developed by the Joint Committee. The agreement for equipment and furniture transfer states:
Upon identification of services being transferred, the sending hospital will compile listings and descriptions of capital assets that are available for transfer to the receiving hospital. The receiving hospital will select and advise the sending hospital of the equipment they wish to receive. Capital assets will be transferred at Net Book Value in exchange for a promissory note. This plan will result in the capital assets value being appropriately reflected in the receiving hospital. The promissory note will be written off. Costs of moving and installing equipment will be borne by the receiving hospital.
The process for transfer of equipment and furniture includes the following steps:
Implementation of this process was a challenge during the planning for transfer of acute mental health services. The following guidelines were developed by the sending facility for identification of equipment and furniture to be retained:
In addition, collaboration among consolidating outpatient services facilitated the identification of required equipment and furnishings and prevented the transport of surplus articles. Consistent with the Physician Support Agreement, physicians' and their secretaries' office equipment and furnishings including clerical computers were sent with the transferring physicians.
Recommendation: The functional planning process and planning for consolidation of programs must include identification of required equipment and furnishings with sufficient time allowed for negotiation regarding the transfer of such items with the program and/or acquisition of items by the receiving hospital. A plan is required for the financing of required acquisitions.
Communications
For all program transfers, communication of the details both within and outside the hospital is important. For the Mental Health Care Program, which serves some of the most vulnerable individuals in the community, communication of appropriate information about the transfer was essential. Focus groups with community agencies and consumers were held to obtain suggestions about how and when such information should be conveyed. Using this feedback, as well as input from providers within LHSC and SJHC, a communications strategy was developed. An off-the-record editorial board meeting was held with the London Free Press, to inform them of the consolidation, to explain the impact on the patient population if the issues were not handled sensitively, and to work collaboratively on the development of a communication plan for the community.
Within the mental health programs at all sites, regular meetings were held, and newsletters were circulated, to ensure that staff had access to consistent information as it became available. Communications for the rest of the hospitals occurred through articles in the newsletters of LHSC, SJHC, and the Joint Committee. Other staff throughout both institutions were encouraged to attend open forums and an open house just prior to the transfer. Presentations were made at several management meetings as well.
Communications outside the hospital consisted of newspaper articles, interviews for radio, flyers and pamphlets, and letters sent to all family physicians and potential referring agencies in the London area. Patients were also contacted and provided with details about the move, including maps and information about their ongoing care.
Recommendation: A clear, coordinated communication plan for the community and key stakeholders should be developed.
Recommendation: Methods of ensuring that staff and patients receive adequate and timely information need to be identified.
Support/Associated Clinical Services
There is as much, if not more, work to be accomplished outside the program as within it, if the program transfer is truly to be a success. While the program must focus on clinical and academic priorities, the support services must find ways to implement these priorities to ensure continuity of care and minimal disruption for the patient. It is important to alert these services as soon as possible that a program transfer will be occurring so that they can realign resources and begin to track the costs associated with facilitating the consolidation.
In some cases, it has been noted that associated clinical services which previous to consolidation had only intermittent involvement with Mental Health, discovered a quite significant impact when the program consolidated. For example, when there were acute mental health services at three sites, clinical dietitians at each hospital could cover the referrals sent to them, in addition to their workload in other areas. However, when all patients and services were transferred to South Street, the dietitian could no longer manage the demands without additional resources.
Recommendation: Preparation for patient transfers between sites should be in place well in advance of the move -- for example:
Recommendation: All clinical services should be notified well ahead of the pending program transfer and asked to assess the impact of the consolidation. Services at the receiving site must consider both volumes and patient types in determining the impact on referrals and work.
Information Services
Under the terms of the citywide agreement with respect to equipment, furnishings, etc., the transferring institution conducts an inventory of all existing equipment and furnishings related to the program and determines which items will be retained and which are available for transfer to the receiving institution. While the identification of items in most cases is relatively straightforward, the issues involving computers are complex. Only in rare occasions would computer equipment not be retained by the transferring institutions; moreover, some of the equipment which is used in one setting is not compatible with that used in another and must be replaced or upgraded. Thus, the receiving institution must bear considerable costs to maintain the information services required by the program.
In addition, the transfer of information from one institution to another is quite complicated and time-consuming, given that much of the data is stored on network files. There are issues to be resolved concerning what is personal/professional information that can be transferred, what is hospital information that must remain with the institution, and in what format this information should be transferred. Within Mental Health, these issues required individual staff to review all their files to determine what should be transferred; and then staff from Information Services had to make the actual transfers of files and data. Because there were no guidelines and policies to direct this work, the exercise was very labour-intensive and at times confusing.
Recommendation: A citywide Information Services agreement needs to be developed with all institutions affected by HSRC directives, to describe the transfer of hardware and information.
Recommendation: Policies and guidelines regarding transfer of information need to be developed. Staff must be informed of these guidelines well in advance of the program transfer and given ample information and time to focus on this process prior to the time of the actual move.
Orientation and Team Integration
The literature regarding mergers and the resultant workplace changes strongly indicates that issues of integration and the development of new teams is critical for success. Staff need a vision of the new program that is created by the merger and a sense of control regarding their roles and functions in the evolving program.
The leadership of the amalgamated program needs to be determined as soon as possible in the consolidation process. Thus, new leaders can work with staff to develop the program vision, foster commitment to and understanding of the new services, and facilitate integration at all levels.
The pace of the Mental Health Program consolidation allowed for only the minimal work concerning integration of staff. All staff were involved in corporate orientation sessions; staff from other sites were invited on an informal and formal basis to visit the South Street site; brief needs assessments were conducted to identify areas of most concern and develop plans for addressing these; and extra staff were scheduled in order to provide support and assistance with orientation during the actual move.
Nevertheless, there was no opportunity to redesign the program prior to the transfer, so that staff in some cases had to move without knowing the precise nature of the work that awaited them. While staff knew that this program development would occur as soon as possible, they needed to continue providing good patient care while dealing with considerable flux and uncertainty. Moreover, there was little time available, because of the pressure of the move and the ongoing patient care demands, to devote to team integration, to build skills and confidence, or to develop more informal interaction patterns and relationships to facilitate support for each other.
Furthermore, there have been some challenges related to the incorporation of physicians into the process of integration. Their time constraints and competing priorities continue to make it difficult for them to be involved in frequent team-building activities; however, emphasis on such initiatives is now receiving considerable attention within the Mental Health Program, as physician commitment to team building and ongoing development is crucial in ensuring that true integration occurs.
In such situations, it is easy for staff to feel demoralized and frustrated, in part because they are experiencing the strain of the transfer without the control that is necessary for them to continue their work. Although frequent communications help to alleviate some of this stress, such reactions must be anticipated; and work must be done throughout the transfer process and for some months afterward, to ensure that integration occurs.
Recommendation: Corporate orientations must be scheduled by the receiving organization, as is customary for all new employees. In addition, program-specific orientations must be arranged to focus on the application of existing skills in the new setting.
Recommendation: A plan for orientation and integration must begin well in advance of the move, with a needs assessment of staff and physicians who will actually be transferring.
Recommendation: Early appointment of the leadership of the consolidated program is beneficial.
Recommendation: Ongoing work regarding team integration, which includes staff, physicians, and administration is essential and should be facilitated through external resources, such as Learning Services (LHSC) or Education Services (SJHC) and preferably by facilitators from both organizations in collaboration with program leaders at the receiving organization..
The impact of program consolidation requires the analysis of a number of factors in order to obtain an accurate measure of success. These factors include the cost of the actual transfer, the ongoing costs/savings of consolidating a program, the effects on quality of patient care, the impact on utilization and practice, the effects on the academic program, and the impact on staff and the quality of work life. Without the inclusion of all the factors, the measurement of the outcome of program consolidation is less than comprehensive and complete.
Certain costs related to the move are relatively straightforward and can thus be tracked by various areas -- for example, time and supplies related to renovations, time and supplies related telecommunications installations, etc. There are also costs regarding staff and management time spent in planning activities, such functional program or staffing model development, in orienting and training staff, and in assisting the logistical aspects of the move, such as planning for patient transfers or photocopying records.
It is somewhat more difficult to assign costs after the move has occurred. For example, while the consolidation of a program may eventually result in savings, there initially may be an increase in costs associated with a new combination of patients and acuity levels, a new mix of skill sets and practice patterns, and other systemic changes outside the hospital which may also have an effect. Some of these costs may be alleviated if sufficient functional planning has occurred prior to the transfer, but is difficult to achieve on short notice. Furthermore, some of the redesign of patient care processes, which may eventually lead to savings, cannot occur until the team has integrated and worked together for some time.
Utilization patterns can be tracked using data such as volumes (inpatients, outpatients, day patients, and emergency visits), length of stay, readmission rates, physician workload, etc. Patient surveys, focus groups, and open community forums are helpful ways of assessing the impact on consumers, families, and other agencies. Other more focused measures of quality, both in terms of clinical services and academic mandate, need to be developed and implemented by specific program areas.
Recommendation: Analyses and evaluations should be completed at six months and one year post-consolidation. The evaluations should include the perspectives of physicians and staff in all affected institutions, as well as the community.
The current report provides a brief overview of the work involved in a program transfer and consolidation. As the first clinical program to consolidate following the Health Services Restructuring Commission's London report and directives, the acute mental health services have led a process of discovery, in which the principles and general agreements of restructuring were applied.
It is clear that as much as possible programs/teams must be prepared with detailed plans for consolidation. The functional program should serve as the basis of the plans for consolidation. However, it is also important that the plans are flexible and adaptable, should situations or time lines change. Moreover, it must be recognized that despite careful planning, there will always a number of details to be addressed at the last minute prior to consolidation. Consideration of these time demands should be included in staffing plans during the time of transfer.