The independent analysis of the Vancouver Island Health Authority (VIHA, or Island Health) delivered by external consultants Ernst & Young two weeks ago concluded that an electronic health records system implemented at Nanaimo Regional General Hospital (NRGH) was “not properly planned or implemented.”
Consultants also found that the poorly functioning system, known as iHealth, was additionally challenged by “a general climate of distrust in the hospital.”
The Ernst & Young report reinforces the findings of another external analysis conducted by the Vector Group in early November that described the atmosphere at the Nanaimo hospital as “toxic,” an environment caused by management bullying its workers, retaliation and secrecy.
FURTHER READING: The Ernst & Young report
While those two analyses refer to NRGH specifically, north Island health care workers describe similar situations at the new Comox Valley and Campbell River hospitals.
After a two-month investigation involving multiple interviews with more than 30 different sources at both hospitals, Decafnation has found the facilities were not properly planned and that employees feel the concerns they raised during the process were ignored, and that decisions and information were kept secret. And they now fear retaliation for speaking out.
The purpose of Decafnation’s four-part series was to give these employees a voice in the hope that Island Health executives would start to listen to front-line workers and implement a genuine effort to mitigate the problems that can still be fixed.
And the public has a right to know that our communities didn’t get the hospitals we were promised.
FURTHER READING: The four-part series and other health care stories
Decafnation urges the B.C. Ministry of Health to conduct external studies at the two north Island hospitals similar those undertaken at Nanaimo, and to hold Island Health executives accountable.
The top executive of the region that includes the Nanaimo hospital no longer works for Island Health. Yet, all of the top executives involved in the planning of the two north Island hospitals remain in place.
FURTHER READING: Island Health exec sacked
And there’s more that needs to be done.
REVIEW ISLAND HEALTH — An external review should be done of Island Health itself. It’s clear that changes are needed at an organization where such mismanagement is allowed to occur.
RETURN TO LOCAL HOSPITAL DISTRICTS? — An analysis of Island Health might find that a restructuring of regional health authorities could have prevented these problems. The former B.C. Government merged the province’s 52 local hospital districts into five regional health authorities. The Vancouver Island Health Authority is further broken down into five geographic areas. Geo 1, which includes our two new hospitals is massive, extending from Courtenay to the whole north Island and portions of the mainland’s upper west coast.
The province used this same logic to break the large Comox Strathcona Regional District into two smaller jurisdictions, and it has improved local governance.
REVERSE THE P3 REQUIREMENT — The NDP government should reverse the trend toward building all major infrastructure projects in the province under public-private partnerships (P3). The new Cowichan Valley Hospital, which is now in the planning stages, should not be built as a public-private partnership.
Numerous studies have pointed out the dubious benefits of P3 facilities, some going so far as to say they are a bad deal for taxpayers.
FURTHER READING: P3’s double the cost of government borrowing; The hidden price of public-private partnerships
Many of the problems at the two north Island hospitals resulted from private companies pushing decisions during the planning process based on profitability, rather than what would best serve the community or health care workers.
PROPERLY FUND THE HOSPITALS — Planners badly misjudged the necessary capacity at both hospitals. As a result, both hospitals have been overcapacity since they opened and will never be adequate without further expansion. But the low morale among staff could be improved if Island Health properly staffed the hospitals based on reality.
Both north Island hospitals are incurring excessive overtime and most employees are stressed. That’s not a healthy or successful way to run any organization, public or private.
BUILD RESIDENTIAL BEDS ASAP — Island Health’s failure to assess the residential care requirement in the Comox Valley is epic. They don’t seem to know what to do. But those who work in the field of community Health Services know. The Comox Valley needs up to 200 new residential beds immediately.
It will take three years to get a new facility up and running. But with new funding right now, St. Joseph’s could reactivate its award-winning transitional care unit to accommodate the people who need that level of care but who are now taking up more expensive acute care beds at the Comox Valley Hospital. That would help to solve many issues surrounding overcapacity and understaffing.
COMMUNITY HEALTH SERVICES — Unpaid caregivers and those employed in home support programs need more funding. The Comox Valley needs more Adult Day Care programs and more respite beds.
At least a third of unpaid caregivers (usually family members) are in distress because the province isn’t supporting them with greater access to ADC programs and respite beds. They are burnt out, angry, and they deserve better for attending to their loved ones. Not to mention that unpaid caregivers save the province $3.5 billion per year.
SUPPORT ST. JOSEPH’S — The St. Joseph’s board of directors has an excellent vision to create a Dementia Village and campus of specific care for seniors on its former 17-acre hospital site. There should be no conflict between the Catholic-run facility and the Canadian Medical Assistance in Dying law, as 95 percent of patients currently in The Views (St. Joe’s residential care facility) suffer with dementia. And dementia patients don’t qualify for MAiD.
Taking these actions will move health care in the Comox Valley and Campbell River in a positive direction, and diminish the human toll on workers and patients that bad planning has created.
Those responsible for planning the hospitals that fell short of their promises and the community’s expectations should be disciplined.
And the provincial government must reverse policies from former governments that have fostered these problems.
It’s too late (or too early) to renovate our new hospitals, but swiftly addressing these issues will make the best of our given situation and support dedicated health care workers who continue to act professionally and provide the best patient experiences possible.
With the Island’s largest over-65 population percentage and one of the lowest number of residential care beds per capita, Comox Valley caregivers are in distress and hospital workers feel the brunt of overcapacity and understaffing. VIHA says more beds and support services are coming, but health care workers worry they won’t be enough to fix “a system in chaos.”
This is the fourth in a series of articles about problems surfacing at the new Comox Valley Hospital. Previous articles have examined staff morale, hospital planning and changes in culture and procedures.
Unexpected problems at the new $350 million Comox Valley Hospital — low staff morale, overcapacity, understaffing and overtime expense — have largely resulted from questionable decisions in the planning process and a shift to Vancouver Island Health Authority (VIHA) culture and procedures, according to sources in a two-month investigation by Decafnation.
But there’s another elephant in the room: The failure of the B.C. Ministry of Health to provide sufficient resources for seniors health care has pushed the Comox Valley to a crisis point.
The new CVH was built for a maximum capacity of 153 beds, although it was budgeted and staffed for only 129. That left room to add 24 additional beds by 2025, based on planners growth projections.
But the hospital has had more than 150 admitted patients on a regular basis since it opened. On Jan. 10, 2018, there were 168 admitted patients, already 15 over the expected 2025 maximum capacity and 39 over the number for which VIHA has budgeted and staffed the hospital.
That has escalated the understaffing problem and heightened awareness of inefficiencies in the building’s floor plan. It’s caused patient flow issues affecting the emergency department and the Intensive Care Unit, say our sources.
The winter months are typically the most stressful for health care providers everywhere as influenza and other illnesses tend to peak, which CVH planners would have taken into account. But that’s not the critical source of overcapacity at CVH.
About 46 of those 168 patients on Jan. 10 required an alternate level of care (ALC). These are patients, mostly elderly, who no longer need acute care and should be discharged and transferred to specialized care beds, usually in a residential care facility — sometimes referred to as long-term care.
Except there aren’t any residential care beds available.
This is not a new problem for the Comox Valley, or Vancouver Island. Almost every Island community has struggled with a shortage of residential care beds for over a decade.
But our sources say the shortage has already reached crisis proportions in the Comox Valley, and it’s about to get worse.
How did this happen?
The Comox Valley has a higher percentage of its population over the age of 65 (26 percent) than Victoria (21 percent), and both are higher than the provincial average (18 percent).
We also have the highest percentage in B.C. of people over the age of 85 who are now living independently, say our sources. When those people can no longer live on their own, the Comox Valley will suffer the most.
And yet, the Comox Valley also has one of the lowest number of residential care beds per capita funded by VIHA, according to our sources. But they say the VIHA method of determining the right number of beds for a community is vague.
For example, British Columbia has a total number of residential care beds equal to 7.4 percent of province’s population over age 75. That number drops to 6.8 percent on Vancouver Island, and goes down further to 5.3 percent for the Comox Valley.
Or, if VIHA based the number of residential care beds on 75 beds per 1,000 people over the age of 75, which is roughly the provincial average, then Vancouver Island would be short by 10 percent and the Valley by a whopping 30 percent.
There is an immediate need for more than 150 additional residential care beds in the Comox Valley, our sources say. Some put the number closer to 200.
Some of our sources attributed the problem, in part, to a 2003 shift in senior health care policy.
That was the year the B.C. Liberal government introduced a new assessment process to restrict access to residential care to only those needing “complex care,” meaning medical services. The result was that those who qualified for residential care were more acute (sicker), and this shortened the length of stay from 2.5 years to 1.8 years.
FURTHER READING: Residential long-term care planning: The shortcomings of ratio-based forecasts
Our sources believe this caused VIHA to decide fewer residential care beds were needed to service the same intake rate.
How has this affected the new hospital?
Those responsible for planning the new CVH made the assumption that although there were 40-some ALC patients in acute care beds at St. Joseph’s, the new hospital would have none. They incorrectly assumed there would be sufficient residential care bed capacity in the Comox Valley by the time the hospital opened.
That strategy might have worked, or at least diminished the current problems at CVH, except VIHA was slow in issuing a Request for Proposals and awarding the contract for new or replacement beds. And then, it cancelled the RFP completely.
On Sept. 30, 2016, the Vancouver Island Health Authority (VIHA) issued an RFP for 70 new or replacement residential care beds for the Comox Valley. The press release said contracts would be awarded in April 2017.
Construction would start in the summer of 2017 and the beds would not open until the summer of 2019, nearly a year and a half after the hospital opened in October of 2017.
But, on Aug. 3, 2017, VIHA cancelled the RFP, shortly after its board of directors decided the four hospice beds located at St. Joseph’s should be moved to a secular facility that could provide Medical Assistance in Dying (MAiD).
Tim Orr, the director of residential services for VIHA, told Decafnation that the restriction on providing MAiD at the Catholic-operated site was one of several factors in the decision to cancel the 2016 RFP.
As of Jan. 23, 2018, no new RFP has been issued. Given the original three-year time frame from issuing an RFP to opening the beds, the Comox Valley is unlikely to see any new residential care beds before 2021.
With ALC patients unaccounted for by planners, CVH was overcapacity when it opened its doors and has remained so for the first four months. This has exacerbated the transitional problems at the new hospital.
These problems include patient flow. There are usually no available beds for people treated in the emergency department (ER) who need to stay overnight. So the ER expansion area has been filled with acute care patients.
The same problem occurs in the Intensive Care Unit, our sources say. Due to timing issues, there is often not an acute care bed to move patients out of ICU when they no longer need that specialized care.
FURTHER READING: Strengthening seniors care delivery in B.C.; Abbeyfield closure highlights seniors housing issues
And the additional unnecessary cost to taxpayers is significant. Acute care beds cost taxpayers between $800 to $2,000 per day, while residential care beds typically cost about $200.
The BC Care Providers Association has proposed redirecting some acute care funding to the development of new long-term residential care facilities.
Caregivers in distress
Hospital workers aren’t the only Comox Valley people affected by the residential care bed shortage. Family members are on the front line of this problem.
“The system is in chaos,” said one source. “And family caregivers are covering it up.”
According to B.C. Seniors Advocate Isobel Mackenzie there are roughly one million unpaid caregivers in B.C. 91 percent of them are family members, usually adult children (58 percent) or spouses (21 percent).
Mackenzie estimates these unpaid caregivers save the provincial government $3.5 billion per year.
In an August 2017 report, “Caregivers in Distress: A Growing Problem,” Mackenzie said 31 percent of unpaid caregivers were in distress in 2016, which represented a 14 percent increase in the actual number of distressed caregivers over the previous year.
She defines ‘distress’ as anger, depression and feeling unable to continue.
This has resulted in horrific personal tragedies.
Multiple sources have collaborated accounts of unpaid caregivers falling ill themselves due to the stress for caring for loved ones, including medical emergencies that require hospital stays. This means their loved ones also end up in acute care hospital beds, waiting for a residential care bed from there.
Some unpaid caregivers have even been stressed to the point of dropping their loved ones off at the hospital emergency department and refusing to take them back home, although this is rare, according to our sources.
Caregivers are distressed because there is so little help available.
The experience of trying to get a loved one onto the list for a residential care bed can be a long and frustrating experience, our sources say. The patient must not only meet the “complex care” requirement, but must also exceed the care that Community Health Services (formally called Home and Community Care) are able to provide.
The Comox Valley has only two Adult Day Care programs that give caregivers a break to attend to personal matters, such as cleaning their house, running errands and looking after their own health through exercise or socializing.
And the wait to get into ADC programs can take up to a year, and it’s restricted to one or two days per week.
In her report, Seniors Advocate Mackenzie said that access to ADC programs has declined by five percent across B.C. and that the number of days accessed was also reduced by two percent.
There are only two publicly funded respite beds for the Valley’s population of 66,500, so it can take caregivers up to a year to schedule a bed. Respite beds take loved ones for a week or two to give the caregiver a break.
The Comox Valley does have one additional private respite bed. It requires a 14-day minimum stay at $200 per day, which is unaffordable for some caregivers.
How VIHA has responded
Tim Orr, the director of residential services for VIHA, told Decafnation that “Enhancing residential care bed capacity in the Comox Valley is a top priority.”
“We are currently experiencing high patient volumes at our hospitals, including North Island Hospital Comox Valley campus,” he said. “Patient volumes do not appear to be tied to any one cause, and the Emergency Department is busy with patients presenting for a wide range of issues. Occupancy fluctuates daily; and often several times throughout the day depending on ER volumes and patient discharges.”
But Orr cannot say when VIHA will issue an RFP to build more residential care beds here. It’s expected, but not guaranteed, that the RFP will be released sometime this winter.
In response to questions from Decafnation, Orr said VIHA recognizes that the Comox Valley needs more complex care beds and is working with the province to issue an RFP for additional complex care beds.
“This new capacity will help meet the current need and Island Health will continue to monitor the need in communities across Vancouver Island and add capacity where most needed as resources come available,” he said.
Orr said VIHA looks at the population over 75 years of age in addition to reviewing what home supports and other community resources are in place.
“The general population health is also a determining factor that drives demand for LTC and Island Health then determines which communities have the greatest need for new long term care capacity,” he said.
NDP MLA Ronna-Rae Leonard gave Decafnation the following statements:
“The new Comox Valley (residential care) facility was long anticipated in our community. I understand Island Health is taking a step back … Our government is working hard to increase the overall residential care spaces in the Comox Valley to address the aging population needs.
Regarding other issues raised in the Decafnation series, she said, “I look forward to hearing the results and how any issues that have been raised will be addressed. I have passed along the concerns I’ve heard about the new hospital to the Minister’s office.”
The Comox Valley ranks among the favorite places for Canadians to retire. So it’s no surprise that our population has aged at a rate nearly double the provincial average.
Without a major expansion of seniors health care infrastructure to deal with this influx, the problems at the new Comox Valley Hospital and the distress felt by unpaid caregivers in our community will worsen.
Our sources say that in addition to “hundreds more” residential care beds, the Comox Valley also needs improved access to ADC programs and more timely access to respite care. They also feel a review of Community Health Services may be required.
The Comox Valley Hospital is not only a new building, inside there’s a brand new management culture and procedures that some say takes a step backward in patient care and staff morale.
This is the third in a series of articles about problems surfacing at the new Comox Valley Hospital. Previous articles have examined staff morale and how the hospital was designed and planned. A future article will look at how the lack of residential care beds in the Comox Valley has contributed to these issues.
UPDATE: This article has been updated to clarify that Tandem Health manages the north Island hospitals and receives a monthly fee for the service and that the Campbell River hospital has been managed by VIHA only since the health authority’s creation in 2001, not since the opening of the 60-year facility.
Most people have been faced with dramatic changes in their working or personal lives, and how well each individual adapts to that change depends on a variety of unique circumstances.
For long-time employees of St. Joseph’s General Hospital, the transition to the new Comox Valley Hospital operated by the Vancouver Island Health Authority (VIHA) has presented a triad of difficult changes, including a less flexible management style and some systems that are less efficient and effective.
So, after the first three-and-a-half months of operation, a two-month investigation by Decafnation has learned the changes have pushed staff morale down to a new low.
First, St. Joseph’s was run like a small, independent local business. It won the 2013 Chamber of Commerce award for Business of the Year.
FURTHER READING: Annual Chamber of Commerce awards; Culture of fear, bullying at VIHA Nanaimo hospital
St. Joseph’s building was physically small. People worked in close proximity. The systems and procedures allowed people to move around among departments, helping colleagues as needed.
These things created a tight bond and camaraderie among employees that doesn’t exist at the much larger CVH operated by the multi-jurisdictional VIHA, according to our sources.
Second, St. Joseph’s was a publicly funded hospital operated autonomously by local management and a board of directors. The new CVH is a public-private partnership operated by VIHA in a building managed by the private sector, which receives a monthly fee for the service.
Third, while St. Joseph’s was by no means a laggard in medical and systems technology, the new hospital has brought more technology to the workplace.
Dr. Jeff Beselt, Island Health’s Executive Medical Director for Geography 1, which includes Campbell River, Courtenay, Comox and Mount Waddington/Strathcona said VIHA understands that it takes some people longer to adapt to change.
“We all miss that closeness,” said Beselt, who worked in the region for several years before the change. “I recognize that some people are really hurting.”
He said VIHA has blended its ways of doing things with St. Joseph’s procedures to create the best quality patient care, and to support staff through the change.
“But this is the new system (procedures and technology at CVH),” he said. “This is the future; the old system is over. We’re just part-way on that journey.”
But some of those new systems have reduced efficiency, affected patient care and battered staff morale.
Patient care issues
Medications — Physicians and nurses have told Decafnation that new technology has resulted in some patients getting their medications late. For some on strict regimes, such as those in severe pain, this is a critical issue.
The new automated medication dispensing technology is designed to reduce errors, which Beselt said occurs more often in hospitals than people are aware.
The system restricts nurses from dispensing medication for more than one patient at a time, which makes the process take longer, but staffing has not increased.
“Adding more checks and balances requires more people … but it improves patient care,” he said.
Colonoscopies — The new hospital is doing fewer colonoscopies than were done at St. Joseph’s. Beselt estimated about 20 percent fewer, though sources estimated the reduction as high as 50 percent.
Beselt said the drop is due to introducing the Provincial Infection Control Network standards, which VIHA uses at all of its acute care sites.
“These stringent requirements extend the reprocessing time of the rooms, scopes and other associated equipment between patients to ensure the highest standard for patient safety.” he said.
Microbiology laboratory — St. Joseph’s Hospital employed staff and equipment to do microbiology analysis in its laboratory in order to provide physicians with timely results before deciding on patient treatment options.
It was a medical service that a local hospital could decide to provide, but one that VIHA decided to centralize. There is no microbiology lab at CVH or the new Campbell River Hospital. All samples are sent to the microbiology lab in Victoria.
Yet smaller hospitals in other B.C. health authorities have retained their microbiology labs. Both Cranbrook, which operates 73 acute care beds, and Fort St. John, which has 55 acute care beds, have microbiology labs.
There are 248 potential acute care beds between Campbell River and Comox Valley hospitals.
Our medical sources could not say if relocating microbiology lab work to Victoria, lengthening the time to get results, had affected patient care. But a source said the new time lag had played a role in a recent case at Campbell River Hospital, though Decafnation was unable to confirm that information.
“Due to provincial privacy legislation, Island Health (VIHA) cannot comment on individual patients and their care,” Beselt said.
Centralized staffing — Department leaders and local staffing clerks no longer arrange staffing for their areas. All staffing for Vancouver Island hospitals has been centralized in Victoria and Campbell River.
When someone calls in sick, the information goes to Victoria or Campbell River where an automated text or email is sent out to all the relevant VIHA employees asking for people to fill that person’s shift. But department leaders don’t know who might not show up for work that day and cannot make arrangements with their staff to fill the gap.
Everything has to go through the automated system. Any given staff member might get numerous automated messages every day, blowing up their phones.
But due in part to low staff morale, those vacant shifts often go unfilled, resulting in a volume of overtime uncommon at St. Joseph’s.
Front desk issues — Clerical workers at CVH only have access to portions of hospital computer systems relevant to their departments. This provides security but also prevents clerical people from helping out in other departments for which they don’t have computer access, and it’s also causing problems at the front admitting desk.
The front admitting desk was supposed to be supported by four to six universal admitting clerks who were cross trained to admit all out patient appointments. That training has not yet occurred.
There are now two or three clerks doing admitting for Ambulatory Care patients and another two to three clerks doing admitting for Medical Imaging patients.
In the morning, the ambulatory care admitting clerks are busy, and the medical imaging clerks are not busy. In the afternoon, the medical imaging clerks are super busy and the ambulatory care clerks are standing around.
“This looks terrible to the people waiting to be called,” said a source. “They don’t understand why there are clerks standing around talking and they are being kept waiting, and in fact some will lose their appointments.”
This problem was identified at the front desk pre-occupancy risk assessment, but has not been addressed.
Our sources say doctors and numerous patients have complained about this.
Bureaucracy — The transition to a more bureaucratic organization has taken a greater toll on former St. Joseph’s employees.
As one source put it, “Comox is just getting introduced to the ineffectiveness of (VIHA) whereas Campbell River staff are more aware of the futility already.”
Campbell River Hospital has been managed by VIHA since the the health authority was created in 2001.
Department leaders at St. Joseph’s had the flexibility to fine tune their operations for the greatest efficiency, which isn’t allowed by the Vancouver Island Health Authority. To make a necessary change now, they have to go to different levels and committees.
“St. Joseph’s staff were either not listened to or respected by (VIHA) from the very start of this process,” the source said, adding that CVH staff are really in a period of grief and mourning.
“Campbell River staff have lived and breathed (VIHA) and transitioning into a new privately owned building has been easier, but the buildings are just flawed in so many ways,” the source said.
FURTHER READING: VIHA fires alleged “trouble maker,” not perpetrators
No cafeteria — There’s no cafeteria at CVH where staff can meet colleagues from different departments. There is only a bright, but small bistro operated by the locally-owned Rocky Mountain Cafe in Comox.
This seems like a small thing, according to our sources, but they say it illustrates the VIHA culture of keeping people isolated in silos.
Our sources say St. Joseph’s staff expressed concerns about how this would affect the culture of the new hospital.
“Not only has the one gathering place been lost,” said a source. “The transit to and from that place also brought about a culture where everyone talks to everyone else on the way to/from the cafeteria. Short of linens? Well, just stop and talk with the staff who supply linens on the way to the cafeteria. Need to submit a last-minute payslip into payroll? Well, just stop by and drop it off to meet the deadline on the way to lunch.”
Despite inefficiencies in some of the VIHA systems and their unfavorable effect on staff morale, VIHA has not yet taken steps to mitigate the cultural change for St. Joseph’s employees, or to acknowledge that some of the old systems might produce as good or better results.
Next: How the lack of adequate residential care beds in the Comox Valley has contributed to the stress and low morale of hospital staff, and its effect on patient care.
FURTHER READING: Hospital helipads may be unusable; Flawed planning at root of hospital’s problems; Low morale at new Comox Valley Hospital
Already overcapacity, Comox Valley Hospital planners overlooked whole departments and made assumptions on capacity and the new iHealth software that have worsened the bed shortage and added to worker stress, overtime and low morale.
This is the second in a series of articles about problems surfacing at the new Comox Valley Hospital. Future articles will look at how the change in culture and procedures and the lack of residential care beds in the Comox Valley has contributed to these issues.
UPDATE: This article has been updated to correct the original report that the hospital cost $350 million.
When the new Comox Valley Hospital opened in October 2017, patients and the public were welcomed into a bright, spacious and high tech facility.
The $331.7 million CVH is 2.82 times larger than St. Joseph’s General Hospital, and took nearly a decade to plan and construct.
Comox Valley and Campbell River health care workers devoted thousands of hours to planning the new CVH and the also new Campbell River Hospital.
But just three months and a few weeks into operation at CVH, some compromises and oversights made in the planning process are showing up as operational inefficiencies and contributing to a serious decline in staff morale.
Entire departments were overlooked, and faculty assumptions made on hospital capacity and number of beds caused physicians and other department leaders to write letters of complaint about the planning process to Vancouver Health Authority executives in Victoria.
VIHA responded by hiring a new planning firm, but it was too late to change many decisions already set in stone.
A two-month investigation by Decafnation has found that that these issues and an accumulation of other major and minor issues, rooted in the planning process itself, has frustrated staff who already feel overworked, and has cost taxpayers excessive overtime expenses.
A sampling of design problems
Here’s a snapshot selection of current problems related to hospital design and planning, according to sources from CVH medical and support staffs, including physicians, department leaders and front-line workers.
All sources spoke on conditions of anonymity.
Overcapacity — The new hospital was built with 153 beds for patients, but yonly budgeted for 129 beds. The extra, unbudgeted beds were planned to open over the next eight years as the community grew.
But on the day the it opened, the hospital was already overcapacity.
On Jan. 9, CVH had 166 admitted patients for 129 beds. On Jan. 10, 2018, it had 168, already 39 more patients than opened or available acute care beds.
Because the operating budget for staffing was set during the planning process for a far lower number of patients, overcapacity equates to understaffing, overwork and unexpected overtime costs.
The cause of the problem is obvious: roughly 46 of those acute care beds are occupied by patients requiring an alternate level of care (ALC). These are mostly elderly patients who no longer need acute care, but for whom VIHA doesn’t have available beds in residential care.
This is not a new problem. St. Joseph’s General hospital suffered for years from overcapacity, and a high number of patients in acute care beds who would be more appropriately served in residential care.
During the planning and construction phases, the ALC and overcapacity issues were raised in public meetings. And the CVH design and consulting firms gave assurances that by the time the hospital was built, there would be adequate residential care beds in the Comox Valley.
But last summer VIHA abruptly pulled back its 2016 Request For Proposal for 70 new/replacement residential care beds, and has not reissued it. A new RFP is expected sometime early this year, pushing the timeline for additional residential care beds out two or more years.
The Comox Valley Hospital has an ability to temporarily increase room capacity as necessary, according to Dr. Jeff Beselt, VIHA’s Executive Medical Director for Geography 1, which includes Campbell River, Courtenay, Comox and Mount Waddington/Strathcona.
“When we are experiencing increased patient volumes, we open overflow areas – this is usual practice when Island Health hospitals experience high patient volumes,” Beselt said.
“We encourage everyone who is unsure of whether they need to come to hospital to connect with their primary care provider, go to a walk-in clinic or call HealthLink BC at 811 to speak to a medical professional,” he said. But Beselt added that if anyone thinks they need urgent or emergency care, they should go to the Emergency Department.
“Depending on urgency, there could be a longer wait due to the high patient volumes,” he said.
FURTHER READING: The differences between acute care and residential (or long-term) care
Floor plan vs. staffing — The hospital’s design is so spacious that most people can’t tell the building is overcapacity.
That looks good, but the design requires medical and support staff to walk further every day, and those increased distances make almost every task take longer than it did at St. Joseph’s. As a result, employees have less time in their day to do their jobs.
In other words, the sheer size of the new hospital has unintentionally created its own staffing shortage.
Food service workers, for example, are now walking up to 15 km per day where they walked fewer than five km at St. Joseph’s. It sounds like that should be a benefit, except food service workers are pushing tall carts heavy with food trays, and many of the mostly female food workers are small in stature.
CVH has only installed traffic mirrors at some corridor intersections, so staff cannot see all adjoining hallways. St. Joseph’s had nearly 200 mirrors. At every intersection without mirrors, food workers have to stop their carts, check for oncoming traffic, then get the carts re-started and maneuver around corners.
This has contributed to delays in meal deliveries to patients, and has the potential to cause musculoskeletal injuries for food service workers.
There are yellow sticky notes on CVH walls where additional traffic mirrors are needed. But staff has been told the hospital ran out of money to complete the project.
Other departments have similar issues that apparently weren’t taken into account when staffing levels and budgets were decided.
For example, the new medical imaging department is three times further from the emergency room (ER) than it used to be, so hospital porters are regularly needed to move patients. But the porter staff is slim and their work takes longer because of the longer distances they now travel.
This means medical radiation technologists are often waiting for the next patient, which slows down the system and contributes to longer ER waiting times.
And, in a separate issue, patients are getting lost trying to find the medical imaging department, which also slows down the patient flow. In some cases, say our sources, they are waiting an hour for a x-ray that should have taken 15 minutes.
The spacious floor plan has had other unintended consequences, too.
In the Cancer Care unit, nurses now have more room to work around patients. But the treatment chairs are spaced so far apart from each other that patients can no longer see or talk to each other. The socializing that many patients enjoyed during their long treatments has been unintentionally eliminated.
Pre-risk assessments ignored — Based on experiences in other hospitals and public buildings, Worksafe B.C. and VIHA conducted pre-occupation risk assessments of all CVH departments and identified issues that required mitigation.
But in many cases, our sources say, the required post-occupation risk assessments have not been done, and many corrections identified in the pre-occupation risk assessments have also not been done.
For example, Worksafe B.C. has already flagged CVH for an issue identified in the Intensive Care Unit pre-occupation risk assessment. At St. Joseph’s, the ICU was 400 square feet in one room with a four-bed telemetry ward attached. Staff shared the samespace and were able to easily and safely cover each others breaks, etc.
At CVH, the ICU is 1,200 square feet in four private rooms. The telemetry is essentially it’s own unit. Staff can no longer cover for each other safely, but staffing has remained the same, despite staff suggestions and concerns.
Because they are two separate units, staff suggested they be staffed as such for safe patient care.
Worksafe B.C. asked CVH for its post-occupancy risk assessment (what actions had been taken to address this previously identified risk issue), but CVH hadn’t done one.
Health records overlooked — The new hospital was consciously designed without a room to store its voluminous health records, which are now taking up space meant for other purposes.
The hospital was planned to be a paperless workplace based on the anticipated introduction of the controversial iHealth software, which didn’t exist at the time and has subsequently stalled in Nanaimo due to physician complaints.
Hospital planners decided to solve the problem by storing paper records off-site. Then they changed their minds and had to scramble to accommodate both records and staff in a building with no designated space for either.
Health records are currently stored in what was planned to be a much-anticipated staff workout room. A new building, possibly a portable, will be required to house the records until they are no longer needed, if ever.
Meanwhile, the staff that transcribes health records, does data reconciliation and coding are working out of unopened acute care patient rooms using repurposed, non-ergonomic desks and chairs.
How these and many other issues arose can be traced back to the original planning process.
Flawed planning at the root
Back in 2010, the Comox Strathcona Regional Hospital District Board, comprised of local elected officials, provided VIHA with $3 million to expedite preparation of a business plan for submission to Treasury Board.
The contribution was made on the condition that it would be part of the board’s 40 percent capital contribution to the construction project, according to Charlie Cornfield, of Campbell River, the current CSRHD board chair.
“Treasury always requires a business plan to accompany a project before they will give project approval,” Cornfield said. “We funded the business case. The actual case preparation, hiring etc. was done by VIHA.
“Having said that, we were involved in determining the number of beds, and services provided at each hospital.”
VIHA used the funds to hire a dozen planning consultants, one of whom was a “functional facility programmer,” who had no major new hospital experience.
The functional programmer’s job is described by International Health Consultants as:
“The functional plan of a clinical department, hospital or other healthcare facility establishes the portfolio of services to be offered and the dimensioning of the structures needed to carry out these services.
Therefore, the functional plan forms the basis for any healthcare infrastructure project.”
FURTHER READING: What is a functional facility programmer?
The hospital planning process involved representatives from four main groups: Campbell River Hospital (a VIHA site), St. Joseph’s, VIHA management and PartnershipsBC’s contractors.
Some of those who attended the meetings to plan and design the new hospital say that VIHA personnel from sites other than CRH were rarely at the table. Most meetings were attended by CRH, St. Joseph’s and the private contractors hired by PartershipsBC, most often the functional programmer.
The initial conceptual drawings of the new hospital that were released in June 2011 contained numerous errors, say our sources: for example, nuclear medicine was missing, the pharmacy at Campbell River was shown as a tiny room, health records storage was not included and radiology was given a wall of windows (the processing and reading of x-rays require minimum light levels).
After the B.C. Treasury Board approved the business plan for both hospitals, which had been kept secret from employees and department leaders, and the Request For Qualifications was issued, it was discovered that entire departments such as the laboratory and pharmacy at CVH had been forgotten. Amendments were issued.
According to people who attended a September 2012 meeting of both hospitals’ department leaders, the planning consultants said the hospital would be designed as if it would never be overcapacity, and that planning for 2025 capacity and growth was sufficient.
Our sources say planners were challenged at the meeting on the short window to reach full capacity of 153 beds for a major publicly-funded facility.
The consultants also said at the September 2012 meeting, according to our sources, that the hospital was being designed as acute care facility only, not as an outpatient clinic.
That design premise ignored an important health care trend to limit overnight stays, and a St. Joseph’s study (related to paid parking issues) that 97 percent of patient and visitor vehicles in its parking lot were there for reasons that did not include an overnight bed; e.g. x-rays, physio, day surgery, endoscopy procedures, etc.
That same month, the first equipment lists for each department were circulated to department leaders and were found to be “unbelievably inaccurate,” according to a source.
When the business plan was finally shared with department leaders in December 2012, more errors came to light. For example, there was no oxygen or suction resuscitation equipment in the treadmill testing room, the laboratory was given a bedpan washer, for which there was no need, but no staff bathroom, and more.
At this point, several St. Joseph’s and Campbell River physicians and department leaders became sufficiently alarmed to send separate letters to VIHA executives expressing strong concerns about what they saw as a flawed planning process.
Shortly after receiving the letters in 2013, VIHA announced that it would conduct a “peer review” of the facilities plan. Shortly after that, VIHA issued a tender for a new facilities programmer.
But the Treasury Board’s approval had locked down the building’s size, number of inpatient beds and the total budget, nearly eliminating any changes to most of the facility’s original plan.
When a new planning firm was appointed, it resigned from the job in less than 24 hours. A third firm was subsequently found to finish the job.
So, in January of 2013, hospital planners learned that due to miscalculations in the original plan, which could not be changed after Treasury’s approval, many departments had to shrink their floorspace to order to make room for the undersized or forgotten departments. And this set off a series of inter-departmental battles for space.
Many of the problems at CVH would be diminished, if not eliminated, by moving the roughly 46 ALC patients into residential care beds. But that’s not going to happen anytime soon.
Tim Orr, VIHA’s director of residential services, told Decafnation that a new RFP for residential care beds in the Comox Valley will be reissued sometime early this year.
“Island Health is committed to improving access to community-based facility care for seniors across Vancouver Island,” he said.
Next: How the change in culture and procedures from St. Joseph’s to Comox Valley Hospital has has affected staffing and patient care.
This is the first article about problems surfacing at the new Comox Valley Hospital. Future articles will look at issues arising from the planning process, the change in culture and how the lack of residential care beds in the Comox Valley has contributed to these problems.
UPDATE: This article has been updated to correct the estimated cost of the new hospital originally reported as $350 million. And also to correct that VIHA does not lease the building from Tandem Health, which manages the facility, but that it pays a monthly management fee, and that while St. Joseph’s General Hospital was frequently overcapacity it was not on the hospital’s last day due to an intentional effort to reduce the number of patients prior to the move.
The new $331.7 million Comox Valley Hospital, which sits atop Ryan Road hill on 13.3 acres, looks like a shiny symbol of regional progress and modernity.
But inside the three-month old building, the working environment is not as pretty.
Questionable decisions and compromises made during the planning process have created operational inefficiencies that, when combined with a dramatic change in management culture, have caused a decline in staff morale during the hospital’s first three months of operation.
And yet, not all staff and physicians have had exclusively “unfavorable experiences” at the new hospital.
Our sources say they generally recognize the hospital’s many improvements over St. Joseph’s General Hospital; among them, more comfortable patient rooms, a quieter and brighter environment, leading edge technology and uncluttered hallways. And, it’s new.
But during a two-month investigation, involving nearly two dozen interviews, Decafnation has learned there are concerns about some operations at the new hospital and whether the facility is sufficient to service a growing and aging Comox Valley population for very long.
Our sources say they are not just unhappy about their personal working conditions. They are distressed over the failure of Vancouver Island Health Authority to staff the hospital sufficiently and the excessive amount of money being spent on overtime.
The hospital has been significantly overcapacity since it opened, as St. Joseph’s frequently was during its last years of operation. Yet, CVH was designed and budgeted (staffed) as if it would never have more than the projected number of inpatients.
It appears that planning teams did not take into account the increased size of the hospital and the advance to single patient rooms in the units and the Intensive Care Unit when the budget and staffing levels were set. Those changes require even more staff given the same workload, our sources say.
Overcapacity has caused, among other issues, the cancellation of at least two surgeries, a temporary shut-down of the emergency room and forced VIHA to use areas of the hospital that it had not planned to open for years.
And that appears to have increased the stress felt by many hospital employees, from food service workers to clerical staff to nurses.
Staff say they are frustrated that the hospital’s technology has them “locked down,” making them unable to help out different departments during peak periods, as they used to do at St. Joseph’s. They have concerns about patient care, and are disillusioned by what they see as a lost opportunity to have built a better facility for the community.
And they’re angry that management has not listened carefully enough to front-line workers, or addressed the issues they have raised, in some cases going back years into the planning process.
Almost everyone spoke on conditions of anonymity because they fear retribution from VIHA management.
One support staff member described the CVH working environment as worse than the “toxic” atmosphere reported at Nanaimo Regional General Hospital by an independent analysis in November.
FURTHER READING: Culture at Nanaimo hospital is “toxic,” report
“Every day, I meet someone crying in a hallway,” said the source, who is a current CVH employee. “We’d be worse than Nanaimo (hospital). I’d say 90 percent of staff are unhappy with the new hospital.”
VIHA and local elected officials have a different point of view.
Stressing the positives
Charlie Cornfield, of Campbell River and chair of the Comox Strathcona Regional Hospital District, which has no operational responsibility for CVH, but funds 40 percent of hospital capital costs, said the new hospital “is as good as it gets.”
“It’s quite reasonable with a project of the size and complexity of CVH to have hiccups,” he said. “It could take years to work these out. Give the system a chance.”
MORE INFO: Comox Stathcona Regional Hospital District
Dr. Jeff Beselt, VIHA’s Executive Medical Director for Geography 1, which includes Campbell River, Courtenay, Comox and Mount Waddington/Strathcona, said workers in other island hospitals are envious of the newsness and cutting edge technology and other features at CVH.
“We have an amazing hospital that we can grow into for decades,” he said. “We have to learn how to use what we have. It’s a long journey.”
Beselt chose not to characterize staff morale as good or bad.
“It varies on who you speak with,” he said. “It takes some people longer to adapt … the process was exhilarating and draining at the same time, for all of us.”
Beselt said the hospital has done non-compulsory “pulse check surveys” to measure staff morale, but would not disclose their results. And he emphasized that “staff well-being is very important to us.”
He acknowledged that supporting staff through such a dramatic change is “a hard thing to do well,” but he said VIHA is making a strong effort. And he recognizes that some people, especially those who came over from St. Joseph’s are “really hurting.”
Our sources also recognized that adapting to new processes and a new employer, which they say is less flexible and so far deaf to their concerns, has exacerbated the operational problems.
St. Joseph’s Hospital was smaller and run like a family or a locally-owned business. CVH is nearly three times larger (428,683 square feet versus 151,975 square feet) and is run like a large multi-jurisdictional corporation, including many layers of management.
Our sources say a major factor in the hospital’s low morale is that staff feel like they’re under a gag order, which prevents them from working through their grief to acceptance of a new workplace reality.
“We feel like we’re not allowed to say we’re unhappy or talk about things we think are being done wrong,” said one medical staff and a former St. Joe’s employee. “And senior leadership — who are probably also exhausted from this project — are not willing to listen.”
Beselt said CVH management is committed to listening. He noted that its newly-formed Quality Operations Committee brings front-line worker issues to hospital leaders.
Several sources said crying was a daily routine. A sign was once posted in a private nook of the building that read: “Crying section: 15 minute limit.” It was a reference to the number of people wanting to use the space.
P3 versus public
And, there’s another factor affecting discontent at the new hospital
St. Joseph’s was a public and denominational hospital, not directly run by VIHA. Comox Valley Hospital is a public-private partnership (P3).
FURTHER READING: North Island Hospital’s project
The P3 arrangement means that VIHA provides the operating funds for the hospital. The building itself is managed by Tandem Health — VIHA pays a monthly fee for this service to Tandem — the private partner, which is itself a consortium of companies. One of those is Honeywell, which is responsible for the building and everything from signs on the walls to safety mirrors for navigation in the hallways.
The public-private partnerships (P3) at CVH has created confusion and frustration, and intensified the amount of change for former St. Joseph’s employees.
For example, simple maintenance issues were previously resolved in-house. Now tasks like getting light bulbs redirected or dimmed are described as an exercise in futility, as hospital-employed maintenance staff has been decimated.
Private companies are responsible for maintenance on the equipment or services they provide, but are routinely slow to respond. And staff is unclear about who to call to fix problems and who is responsible.
Will all of these issues naturally work themselves out over time? Are they just hiccups, or imaginary issues conjured by former St. Joseph’s Hospital employees too set in their ways?
It’s difficult to determine which problems are simple growing pains or a natural resistance to change, which are systemic and which need immediate attention and which can wait.
But all of our sources agreed, the accumulation of scores of large and small problems has created a staff morale problem, not to mention the physical strains of overwork, working short-staffed and excessive overtime.
Next: A sampling of problems, large and small, and how the planning process went awry with errors and compromises.