Care - Access

Access issues include but are not limited to access to healthcare providers, access to healthcare services across the health continuum, access to supplies or diagnostic tests. Access to care challenges, where access not available or where demand is greater than capacity, can result in wait times (assessment, treatment, discharge), waitlists, poor client/resident/patient flow, and can lead to safety issues and dissatisfaction by clients/residents/patients and healthcare providers. This document contains information entered by HIROC Subscribers (across all participating healthcare sectors) in the Risk Register application to help you in your assessment of this risk.

Key Controls / Mitigation Strategies

• Person and Family-centered Care: 
  • Include the perspectives of Client/Resident/Patient, family advisory council, and representatives of equity deserving groups in planning
  • Conduct education for healthcare providers on family meetings and engagement of Client/Resident/Patient advocates
  • Involve Client/Resident/Patient and families early in discharge planning 
  • Leverage discharge planning working groups, support workers, and social workers to facilitate family meetings, for equity-deserving groups
  • Follow Jordan’s Principle (as per the Government of Canada (2021), “Jordan’s Principle makes sure all First Nations children living in Canada can access the products, services and supports they need, when they need them”. Jordan’s Principle (2021), Government of Canada. Retrieved October 15, 2024, from https://www.sac-isc.gc.ca/eng/1568396042341/1568396159824. 
• Operational Practices: 
  • Include Client/Resident/Patient, family and care team in all transitions of care
  • Identify barriers to discharge and develop system-wide mitigation strategies
  • Implement admission avoidance initiatives (e.g. Health Links, Hospital to Home, Aging in Place initiatives)
  • Maintain strong collaborative relationships with programs, services, Emergency Medical Services (EMS) and Air Ambulance services
  • Hold regular partner meetings with long-term care (LTC) homes and home care support services to improve transfers, discharges, communication and avoid unnecessary hospital admissions/re-admissions 
  • Develop agreements with other hospitals for Clients/Patients with surgical needs beyond site capacity to assist with surge volumes
  • Adhere to Provincial/Territorial Repatriation Policy/Zone specific Standard Operating Procedures 
  • On-call access on weekends for various health professional groups
  • Develop structured practices and processes to communicate curtailment/suspension of services/address service disruptions
  • Maintain strong partnerships and collaborations with contracted vendors
  • Create EMS offload overflow spaces to free up ambulance units so they can respond to emergencies or return to post
  • Consider minor injury clinics, mobile clinics, expansion of home health teams, and virtual care options
  • Implement community outreach initiatives and self-referral for wellness screening, chronic disease management, nutritional support, socialization and support groups 
  • Implement rapid access model for critical services (i.e., oncology)
  • Optimize utilization of Human Resources 
  • Utilize workforce planning to meet the areas of higher demand 
  • Implement scheduling software 
  • Employ innovative staffing models and strategies, e.g.:
    • role redesign and cross training between departments/units
    • allied health support on weekends to facilitate discharges
    • management of manage unfilled physician/care provider shifts)
• Acute
  • Develop clinical standards, policies, protocols, and procedures to support department/unit care according to provincial/territorial standards, accreditation standards, and applicable legislation
  • Ensure overflow bed plans in place (e.g., off service bed flow plan, over capacity/influenza outbreak surge plan protocols and notifications)
  • Standardize discharge process that includes but not limited to follow-up care, medication summaries, follow-up appointments, post-discharge telephone calls and/or Client/Resident/Patient discharge summary document
  • Maintain real time Client/Resident/Patient flow dashboards with daily bed reviews (admissions, discharges, resources)
  • Ensure discharge planning commences immediately upon admission
  • Develop readiness for discharge tools to be utilized at bullet rounds 
  • Conduct daily safety huddle and multidisciplinary assessment rounds in the Emergency Department (ED) 
  • Use of medical directives in triage and care pathways to expediate care
  • Utilize after hour surgery consult services and resources developed to support (e.g., emergent surgeries, bed mapping, off-service and transfer criteria, bed allocation management) 
  • Offer surgery patients the procedure at a centre with a shorter waitlist 
  • Engage a waitlist Coordinator to respond to client/patient and provider calls 
  • Develop policies and practices for waiting room monitoring and client/patient reassessments based on the Canadian Triage and Acuity Scale (CTAS) levels in ED 
  • Strengthen community outreach initiatives for vulnerable populations
  • Ensure access/Flow Manager has a key role in Client/Resident/Patient flow, monitoring data, facilitating repatriation requests with physicians, staff and sites - decreasing barriers to discharge, same day, extended hours and weekend appointments for clinic, x-ray and pharmacy to facilitate greater access 
  • Explore multi-client/patient transfer vehicles for greater efficiency
    • Stretcher service for non-acute transfers
    • Utilize transfer checklists
• Non-Acute
  • Develop strategies to meet needs in different ways (e.g., programs, group sessions and appointments delivered in the evenings)
  • Enable navigation to programs or community agencies that may assist to meet Client/Resident/Patient needs (e.g., Cancer Navigators, Community Health Links, Handi Van)
  • Ensure communication with primary care physicians
  • Conduct case review and/or assessment for care planning of changing needs 
  • Develop contingency plan and resource recommendations for individuals on a waitlist
  • Implement evidence-based care paths 
  • Improve discharge planning through expanded/weekend coverage for Home and Community Coordinator 
  • Extend primary care clinic hours to facilitate greater access for Client/Resident/Patient
  • Increase/develop capacity for home care wound and intravenous (IV) care
  • Ensure LTC bed management policy in place
  • Make harm reduction supplies available at primary health clinics
• Emergency Medical Services: 
  • Ensure Ambulance diversion protocol is in place
  • Conduct weekly meetings to ensure ambulance availability and optimized Client/Resident/Patient transport to ED
  • Quality improvement reporting and debrief for all ambulance offloads greater than 90 minutes
  • Helicopter modifications to accommodate bariatric clients/patients on standard stretcher
  • Balanced coverage by moving rested and available units into areas where staff are on mandatory rest
  • Additional training for primary care paramedics to negate the need for nurse escorts on catheterization lab transfers from rural areas
• Diagnostic imaging (DI):
  • Implement dashboards and electronic reports for magnetic resonance imaging (MRI) and computed tomography (CT) scan
  • Adjust booking schedules based on need
  • Expanded diagnostic imaging appointments, evening and weekend appointments
  • Develop downtime prevention strategies and Business Continuity Plan (BCP)
• Mental Health (MH):
  • Optimize referrals process: 
    • Triaged as they are received
    • Letter sent back to referring provider noting that they need to call/provide additional information if patient condition changes
    • Process to match demand with capacity
  • Implement crisis intervention team for Emergency Department (ED) 
  • Consider adding MH nurses and/or short stay MH unit within ED
  • Create support mechanism for staff and mental health clients/residents/patients on a non-MH unit by MH crisis team
  • Develop community crisis support line and/or mobile crisis team 
  • Maximize appointments and improve flow, booking practices to decrease no-shows through reminder calls, and filling of cancellations 
  • Optimize intake processes to improve efficiencies and actively triage for acuity 
  • Conduct rounds to discuss complex patients with long lengths of stay
  • Consider in-person and/or virtual weekly Psychiatry clinics at the rural sites
  • Develop an escalation policy for psychiatry consultation
  • Explore strategies to meet client/residents/patient needs in different ways (e.g., outpatient group appointments as a choice, group sessions, exploration of rapid assessment and treatment clinic) 
  • Pilot mobile Rapid Access Addiction Medicine (RAAM) services

Monitoring / Indicators

• Quality:
  • Monitor and review Client/Resident/Patient and family satisfaction, feedback and complaints related to access
  • Monitor and review events and incident reports related to access and flow to evaluate impact to Client/Resident/Patient on the waitlist (hospitalization or death) 
  • Collect feedback from system partners if a service is declined or suggestions for improvement
  • Primary care dashboard to support and inform LTC panel management
  • Conduct quality review for wait time to assessment and to service initiation 
  • Monitor Process measures (e.g., appointment no show rate and referral rate)
  • Develop and monitor Support Services on-call utilization 
  • Conduct reviews related to inpatients who may have benefited from a consultation service during a weekend 
  • Monitor quality reviews related to access
  • Develop and monitor quality improvement plan metrics
  • Monitor Diagnostic Imaging indicators for adherence to scheduling within priority targets
  • Develop and monitor equity and access indicator (e.g., by postal codes)
• Emergency Department:
  • Develop and monitor ED patient flow and wait time indicators
  • Monitor ED admissions and re-admissions
  • Monitor ED visits by CTAS levels
  • Develop and monitor Mental health ED indicators
  • Monitor percentage of admitted patients in the ED >24 hours
  • Monitor disposition decision to inpatient bed (time) and bed turnaround time efficiencies 
  • Monitor Ambulance offload time
  • Report all diversions greater than 90 minutes
• Human Resources: 
  • Develop and monitor workload data and staff overtime review
  • Develop and monitor recruitment and position vacancy tool
  • Conduct and monitor staff culture survey results
• Additional indicators to Monitor and Audit:
  • Documentation of estimated date of discharge documented on admission 
  • Average length of stay
  • Daily Access Reporting
  • Annual overcapacity situation
  • Average daily census
  • Closed and open volume by division and priority (surgery, endoscopy, DI)
  • Number of transfers to other sites/care levels
  • Number of after-hours surgery consults; surgeries performed 
  • Number of evening and weekend clinic visits/discharges
  • Suspension of services 
  • Alternate Level of Care (ALC) days
  • Primary care dashboard to support and inform LTC panel management  
  • Transfers to higher levels of care
  • Obstetrical volumes
  • Hip fracture, total knee replacement and total hip replacement 
  • Percentage of days in code gridlock
  • Percentage of virtual care for overall visits, including video vs. telephone
  • Outpatient waitlists including LTC waitlist, community mental health waitlist, surgery waitlists, etc.