Care - Access

Service: Risk Management
Subject: Care
Type: Risk Profiles

Access to care issues include but are not limited to: access to health providers, care across the health continuum, access to supplies or diagnostic equipment, and demand for greater than capacity. Access to care challenges may result in wait times (assessment, treatment, discharge), waitlists, poor patient flow and can lead to patient safety issues and dissatisfaction by patients and staff. Not having the right care at the right time can also impact the need for reassessment and system issues for health partners in the patients care continuum. This document contains information entered by HIROC Subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you manage this risk.

Ranking/ratings 

  • Likelihood – average score 3.60
  • Impact – average score 3.60

​​​​​​The Risk Register allows for risks to be assessed on a five-point likelihood and impact scale, with five being the highest.

Key controls/mitigation strategies

  • Patient/Family-Centred Care
    • Patient and family advisory council to bring patient/family perspective to planning
    • Staff education on family meetings engagement
    • Common language for supported discharge process
    • Post-discharge telephone follow-up to avoid hospital re-admission
    • Aboriginal support workers and social workers utilized for family meetings
    • 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”)
    • First Nations Discharge Planning working group
  • System partnerships
    • Pre-planned discharge process with care team involvement for transitions
    • Identifying barriers to discharge and fostering system mitigation strategies
    • Maintain strong collaborative relationships with programs and services
    • Partner meetings with Long Term Care Homes to improve transfer and communication and avoid unnecessary hospital admissions
    • Agreements in place with other hospitals for patients with surgical needs beyond site capacity
    • Agreements in place with other hospitals to absorb surge volumes
    • Strong partnerships and collaborations with contracted vendors
    • Strong partnership with Air Ambulance service
    • Admission avoidance initiatives (e.g. Health Links, Hospital to Home, etc.)
  • Mental Health
    • Crisis intervention team operates from Emergency Department (ED)
    • Mental Health nurses in the ED
    • Mental Health short stay unit within ED
    • Outpatient group appointments as a choice for patients referred
    • Maximize appointments and improve office flow; booking practices to decrease no-shows through reminder calls, and filling of cancellations
    • Intake processes to improve efficiencies and actively triage for acuity
    • Rounds to discuss complex patients with long lengths of stay
    • Staff education on non-violent crisis training
    • Support by crisis team to nurses and mental health patients not on a specialized unit
    • Escalation policy for psychiatry consultation
    • Ongoing strategies to meet patients needs in different ways (e.g. group sessions, exploration of rapid assessment and treatment clinic)
  • Acute
    • Clinical standards, policies, protocols, and procedures to support department/unit care according to provincial standards, accreditation standards and legislation
    • Formal process in place to communicate curtailment/suspension of services at a site to the public
    • Structured practices and processes to address service disruptions including maintenance policies and procedures
    • Overflow beds; surge plan protocols and notifications
    • Daily bed review (admissions, discharges, resources)
    • Daily multidisciplinary patient assessment rounds in ED to prevent admissions
    • Daily safety huddle
    • On-call access on weekends for various health professional groups
    • Bed turnaround time efficiencies
    • Access to physical environment in inclement weather, and increase facility inspections
    • Implementation of physician scheduling software
    • Policy and practices in place for waiting room monitoring and patient reassessments based on the Canadian Triage and Acuity Scale (CTAS) levels in ED
    • On-called ED schedule established
    • Mirrors installed in ED waiting room to enable indirect visualization of waiting areas
    • Alarm system in place for patients to use when they present to sites with locked doors after hours
    • After hour surgery services on-call
    • Emergency surgeries are categorized and standardized based on acuity level
    • Surgery patients have options to request surgery at a centre with shorter waitlist
    • Waitlist Coordinator is available to respond to patient and provider calls
    • Close monitoring and review of any event for patients on waitlist (hospitalization or death)
    • Decreasing barrier to discharge (e.g. Integrated Care Coordinators, Discharge Planners, etc.)
    • Access and Flow Manager
    • Patient transfer checklists
    • Discharge planning commences immediately upon admission
    • Readiness for discharge tools utilized at bullet rounds
    • Standardized discharge process that includes but not limited to follow-up care, medication summaries,
      follow-up appointments, etc.
  • Emergency Medical Services
    • Ambulance diversion protocol in place
    • Weekly meetings to ensure ambulance availability and optimized patient transport to ED
    • Quality improvement reporting and debrief for all ambulance offloads greater than 90 minutes
    • Helicopter modifications to accommodate bariatric patients on standard stretcher
  • Diagnostic Imaging
    • Dashboards and reports for MRI and CT scan
    • Adjustments to booking schedules based on need
    • Expanded diagnostic imaging appointments
    • Downtime prevention strategies
    • Downtime business continuity plan
  • Non-Acute
    • Formal process in place to communicate curtailment/suspension of services at a site to the public
    • Strategies to meet needs in different ways (i.e. group sessions)
    • Programs, group sessions and appointments delivered in the evenings
    • Contingency plan development and resource recommendations for individuals on a waitlist
    • Navigation to programs or community agencies that may assist to meet patient needs
    • Communication with primary care physicians
    • Case review and/or assessment for care planning of changing needs
    • To the extent possible, resources are shifted through workforce planning to meet areas of higher demand
    • Use of Cancer Navigators
    • Flu vaccine campaign
    • Continue implementation of evidence-based care paths
    • Community Health Links for patients with complex needs
    • Expanded Home and Community Coordinator hours to improve discharge planning
    • Primary Care dashboard to support and inform panel management
    • Positions within the Primary Care Program are posted with the ability to work evenings and weekends
    • Extended hours in order to facilitate greater access for patients/clients
    • Increased Home Care wound and IV clinics
    • Long Term Care (LTC) Home bed management policy
    • Harm reduction supplies available at primary health clinics
    • Referrals:
      • Triaged as they are received
      • Letter sent back to referring provider noting that they need to call/provide additional information
        if patient condition changes
      • Attempt to match demand with capacity
  • COVID-19
    • Steering Committee established
    • Regular Bed flow meetings
    • Bed Flow Manager
    • Command Centre implemented
    • Virtual care guidelines (when to consider virtual care vs. in-person)
    • Improved virtual care tools
    • Virtual rounds
    • Service recovery plan for each department
    • Clinical Operations Centre dashboard and unit boards
    • Ambulance Off-Load:
      • Creative ambulance off-load processes and staffing models including the hiring of
        nursing/clinical personnel to facilitate off-load
      • Bed planning exercise to identify all available conventional and unconventional inpatient spaces
    • COVID-19 Patients in ED:
      • Ongoing advocacy and partnerships with funders to obtain funding for additional bed capacity
    • Scheduled Activities:
      • Steering Committee established to oversee the development of an ALC strategy, engaging other sectors including Long Term Care, Home and Community Care and Sub-Acute Care
      • Scheduled activity recovery plan developed which includes regional partnerships
      • Ongoing discussions and relationship-building to leverage regional partnerships for all scheduled activity

Monitoring/indicators

  • Quality
    • Patient/family satisfaction/feedback and/or complaints related to access
    • Incident reports related to access and flow
    • Feedback from system partners if a service is declined
    • Quality review for wait times to assessment and to service initiation
    • Process measures monitoring (e.g. appointment no show rate and referral rate)
    • Support services on-call utilization tracking
    • Reviews related to in-patients who may have benefited from a consultation service during a weekend
    • Quality reviews related to access
    • Quality improvement plan metrics
    • Diagnostic imaging indicators monitoring adherence to scheduling within priority targets
    • Cost overruns
  • Emergency Department (ED)
    • ED patient flow and wait time indicators
    • Admissions from ED
    • ED visits by CTAS levels
    • Mental Health ED indicators
    • % of admitted patients in the ED >24 hours
    • Disposition decision to inpatient bed (time)
    • Ambulance offload time
    • Reporting for all diversions > 90 minutes
  • Census and Audits
    • Audits of documentation of estimated date of discharge documented on admission
    • Average length of stay and readmission rates
    • Daily Access Reporting Tool (DART)
    • Annual overcapacity situation audits
    • Average daily census
  • Human Resources
    • Workload data and staff overtime review
    • Recruitment and position vacancy management
    • Staff culture survey’s monitoring morale
  • Other
    • Closed and open volume by division and priority (surgery, endoscopy, DI)
    • Monitoring visits on off-times (outside clinic hours)
    • Suspension of services reported and monitored
    • Occupancy/vacancy rates
    • Alternate Level of Care (ALC) days
    • Patient transfers to higher levels of care
    • Obstetrical volumes
    • Hip fracture, total knee replacement and total hip replacement audits conducted annually
    • % of days in code gridlock
    • % virtual care for overall visits, including video vs. telephone
    • Monitoring of outpatient waitlists including Long Term Care (LTC) waitlist, Community Mental Health waitlist, surgery waitlists, etc.
Date last reviewed:
This is a resource for quality assurance and risk management purposes only, and is not intended to provide or replace legal or medical advice or reflect standards of care and/or standards of practice of a regulatory body. The information contained in this resource was deemed accurate at the time of publication, however, practices may change without notice.