Monthly Archives: July 2014

A designated parking space for moving in to long-term care

At Patients Canada, patients and those close to them partner with health care providers and others to help improve patient and family experience.

We always begin by receiving and listening to the experiences that patients and families have. In the last several blog posts, we spoke about parking as a good example of a policy area that can have a great impact on our experience with health care. In this post, I’d like to share an example of a change that happened as a result of hearing about such experiences and then working together with Baycrest Centre for Geriatric Care to make its policies more patient-friendly.

The day of moving in to a nursing home is a particularly stressful time for a family. Ordinary house moves are considered to be among the most stressful times in anyone’s life, but the move into a long-term care facility is even more traumatic for the new residents and their spouses and children. Often the processes put in place for nursing homes admissions can add to the difficulty of this transition. At one point in time at Baycrest, the requirements for moving in a few pieces of familiar furniture to make the new room more home-like made things difficult. It was necessary to call at least three days in advance to make an appointment at the loading dock at the back of the complex. Once there, Baycrest provided no cart and no further help because of insurance concerns. It was also required that the freight elevator be used to bring the furniture to the floor.

This procedure had evolved over some years as a result of multiple efforts at cost control and risk reduction. It had not been developed with any intention of making life harder for people moving in. It responded to a whole series of problem cases, such as equipment breakdowns and demanding families. Baycrest, like most institutions, has had many cost containment exercises and the lack of help might have emerged from one of them. The requirement to move furniture without any help from the institution was further complicated by the lawyers’ instruction not to give out the names of short-term light moving companies that were familiar with the facility. No doubt, this was to avert any liability should something go wrong.

Here was a process that was obviously unfriendly to new residents and their families. When it was brought to the attention of senior staff, they agreed that this was “low hanging fruit” and could be an “early win” for the process of improving resident and family experience.

A series of meetings over several months resulted in changed policies that were not significantly more costly nor more risky and vastly improved the experience of new residents and their families. They decided that families would be given the names of light moving companies if they need help moving furniture into the resident’s room. If they wanted to do it themselves, a designated parking spot had been created at the front door for families who were helping a new resident move in. And residents and families were able to call in advance to get the help of a porter.

We can suggest that this policy or one like it can improve a somewhat traumatic experience by recognizing the need to help new residents and their families to easily move their clothing and small pieces of furniture into their new home.

The more general lesson is that changes in small policy areas like these can make a big difference to people and their experience within the health care system. If you have experiences to share or would like to help design them get in touch with us at www.patientscanada.ca.

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Rethinking visiting hours

We can see that parking policy should be developed in partnership with patients. Hospital visiting hours are a similar issue. We can trace some of the changes in patient-oriented policy as hospitals become more patient-friendly by looking at policies about visiting hours.

In the early days of the modern hospital, visiting was discouraged. In the comprehensive manual from 1913, The Modern Hospital, the authors are very clear:

We may begin with the flat argument that it would be best for all sick people if all visiting could be prohibited and it is a recognizable situation in nearly every hospital that has visiting days that the temperatures are higher at night on the visiting days than at other times, all else being equal, and this is due to the excitement caused by visitors, not alone one’s own visitors but those who come to see other people…

In considering the visiting question, therefore, we have two or three fundamental ideas in the foreground; one of them is that we ought to restrict visiting as much as possible and we ought in any event to limit visits to the one patient whom visitors come to see. And visits should be as short as possible and whenever it can be done each patient should be restricted to one or two or at least a minimum number of visitors. (Hornsby, Schmidt 490)

In the old days, visiting hours varied by class of patient. Charity (free) patients had severely restricted visiting hours, often limited to a few hours every week. For example, visiting hours for the Children’s Department are listed:

Large (free) wards, 2 to 4 pm Wednesday and Sunday

Small (private ) wards: 1 to 8 pm daily

Private rooms: without other limitations than the order of attending physicians. (Hornsby, Schmidt 340)

Times have changed. Today there is a recognition that patients can benefit from visits, and typically visiting hours have been much extended. Nonetheless there are usually restrictions imposed that vary widely from unit to unit. Restrictions can make things difficult especially if one is trying to stay to support an elderly relative or stay close to a very sick friend.

A recent article in the New York Times describes the view of the Institute for Patient and Family Centred Care (IFPCC) which is to lift all restrictions on visiting hours. They point out that, increasingly, families and those close to patients can play a crucial role in their care. Beverley Johnson, the President of the IFPCC says, “People should go to a hospital with a family member or trusted friend to be an advocate, to ensure continuity, to answer questions and prevent errors.” The article in the New York Times goes on to explain that,

Because she was with her centenarian mother in a Florida hospital, for example, she could explain to a doctor who had never met either of them that that no, her mother did not have a pacemaker, and perhaps he had confused her with a different patient. (Span para 8)

The IFPCC argues that if hospitals do want to partner with patients and their families, it will be important to begin to lift restrictions on visiting hours as a matter of policy. As Johnson says, “You can’t partner with families if you’re locking them out of the hospital, especially when patients are most vulnerable” (Span para 4). We agree that policies about visiting hours should be reviewed with this in mind.

Hornsby J, Schmidt R. The Modern Hospital. Philadelphia, Pennsylvania: W. B. Saunders Company; 1913.

Span, Paula. “A Move to Extend Visiting Hours at Hospitals.” The New York Times. Web. 11 July 2014.

Parking policy from the patient and family perspective

Last week we started to identify some policies that are meant to improve patient experience in health care. Parking costs are a good example of a policy area that is of concern to patients, but one that they are usually excluded from. It’s also a policy area that rarely enters the minds of providers as a factor in patient-centred care.

Parking policy is not central to the range of hospital concerns, but in my experience, discussions about parking take up quite a lot of administrative time – both in terms of privilege (who gets to park where) and cost (how much do we charge employees, patients, doctors, etc.) This is so even though hospital parking does not provide much more than 0.25% of hospital income. As patients begin to participate in health care, this is a pretty straightforward area to redesign with patient input.

We are not alone in this. An editorial from the Canadian Medical Association Journal in January 2012 brought the perspective of some doctors to the issue:

A patient who seeks care in a Canadian hospital has to pay for parking. Parking fees amount to a user fee in disguise and flout the health policy objective of the Canada Health Act… Parking fees are a barrier to health care and add avoidable stress to patients who have enough to deal with. They can and sometimes do interfere with a clinical consultation, reducing the quality of the interaction and therefore of care. Almost every hospital doctor in Canada would be able to narrate anecdotes of patients being preoccupied with parking fees. Such distraction interferes with the clinical consultation. For example, some patients (who have often waited several weeks to see a doctor) try to end a consultation abruptly when they realize that they will have to pay for an additional hour for parking. This is parking-centred health care, which is not compatible with patient-centred health care (Kale).

The editorial goes on to expand the argument about the impact of high parking costs on the doctor-patient interaction. It argues against the resistance of hospital administrators:

Hospital administrators and politicians will argue that they will lose a valuable source of essential revenue if parking fees are abolished and will look to ministers to make good such losses. Though hospitals rake in several million dollars from parking fees, the net revenue from parking is likely to be around 1% of the total revenue. For example, for The Ottawa Hospital, for the fiscal year 2011/12, the net parking revenue is projected at $10.8 million while the total revenue is about $1.16 billion, excluding revenue from parking. That is a small sum to pay to get rid of parking-centred health care (Kale).

A comprehensive study at by the Centre for Health Economics at York University in England concludes:

Donabedian (1973) defined accessibility to health care as “those characteristics of the resource that facilitate or obstruct use by potential clients.” Travel, parking and time costs, both monetary and non-monetary, are one such characteristic. Microeconomic theory predicts that the price of access will affect the level of demand (utilisation by patients or visits from friends or relatives) if access is price-elastic (or cost-elastic). The empirical studies reviewed here provide some support for view that access levels by visitors are sensitive to cost, but the review found no evidence on the relationship between monetary access costs and uptake of hospital services by patients…

The majority of patients attending for outpatient appointments use cars to access the hospital. In England, parking charges vary geographically and the parking experience can sometimes be an additional source of financial pressure, worry and stress (Mason 11).

The report recommends that hospitals be encouraged “to do all they can to make the parking experience a good one” (Mason 11). At Patients Canada, we agree and suggest that a critical component of this effort is to partner with patients to co-design improved parking policies from the patient and family perspective. Patients and families have had both good and bad experiences with parking that can help inform parking policy. Some clear examples concern costs: the cost of frequent use by family members of long stay patients, the high cost of lengthy emergency room visits, costs that deter visits by friends to inpatients, and so on. Another concern is way-finding: the difficulty of getting from the visitors’ parking lot to the part of the hospital to be visited and at times, the great distances involved. Yet others are about the lack of easily accessed information about hospital parking policy: patients and families are often unaware of existing policies that might make the experience of parking easier and less costly.

On Saturday, the New York Times reported that hospitals are extending visiting hours and in some cases, removing restrictions on visiting altogether (Span). This is a significant change that is being advocated by the Institute for Patient and Family Centred Care. It will allow friends and family members more access to patients who can benefit from their company. The impact of this change in visiting policy on parking will make it even more critical to review parking policy. The experience of patients and those close to them can make important contributions to the development of patient-centred policies throughout health care. We will continue our discussion in upcoming blog entries.

Kale, Rajendra. “Parking-centred health care.” Canadian Medical Association Journal 184. 1 (2012): 11.

Mason, Anne. “Hospital Car Parking: The Impact of Access Costs.” Centre for Health Economics, York University CHE Research Paper 59 (2010).

Span, Paula. “A Move to Extend Visiting Hours at Hospitals.” The New York Times. Web. 11 July 2014.

Patient developed health care system

Several weeks ago I wrote that according to the World Health Organization’s definition, we do not have universal healthcare coverage in Canada. I also said that as far as I could tell, we are the only country in the industrialized world that does not have universal coverage. The example that I used was that we do not have coverage for prescription drugs administered outside the hospital. But there is lots more that we don’t have and also some things that we do have that show how limited our system really is.

The reason for this limitation is largely historical. The Canadian publicly-funded health care system began with hospital insurance in Saskatchewan in 1947. We can be proud of that first step – we had hospital coverage a year before the NHS was created in England. However we were left behind once the far more comprehensive NHS was established in 1948. It covered hospitals, drugs, primary care, eye care (with the now famous NHS spectacles), dentistry, and a lot of diverse health care in the community. We never caught up.

Our limited system developed from hospital coverage in Saskatchewan and then for all of Canada in 1961. It was only in 1972 that all provinces provided coverage for doctors. That is where we seem to have stopped – we still do not have national coverage for all those other things covered by the NHS.

A little over ten years ago, I was asked by the researchers for the Romanow Commission to write a description of what a well-functioning health care system in Canada would look like. Brenda Zimmermann and I toiled for months on our paper which was well-received and is still widely referred to. It has since occurred to me that it would be a good idea to develop the specifics of what a well-functioning Canadian health care system would look like from the patient’s point of view. What would the policies of our system look like if patients were to lead us toward a system with universal coverage?

In our paper, Brenda and I used the now widely quoted basic requirement for a well-functioning health care system that: “It should be there for you when you need it.” What we meant was that healthcare should be a support for us in our anxiety and pain when we, or those close to us, are not feeling well. Its policies should encourage caring and generous support for us. We have a way to go to provide such a system at the moment, although lots of things can easily make it better. An excellent example of this, although seemingly innocuous, is parking.

PARKING

At an Open Meeting held by Patients Canada, we tried a new way of gathering peoples’ thoughts about health care services. We collected short phrases about three emergency rooms (ERs): the current state of the ER, the ideal ER and the ER from Hell. We also asked what might characterize each of them. The discussion was lively and everyone had brilliant ideas about what might constitute the emergency room in heaven and not surprisingly, some said that the current emergency room is the ER from hell.

Most everyone enjoyed the exercise and found it gave them a chance to work with others and provided lots to think about. Waiting times were not the only issue. Some more lateral-thinking participants pointed out that in heaven there would be no emergency room at all. If you needed hospitalization, you would go straight in. If you did not, you would be cared for by a community agency. Parking costs loomed high in many of the discussions. In fact, when we created the word clouds from the patients’ lists, the word “Parking” was among the most prominent. For patients, parking costs at emergency departments are an indication of the lack of generosity and compassion displayed by many hospitals. What patients need is reassurance that the institutions who offer care do so with a generosity of spirit that is evident in all their policies.

Below are some of the parking costs at major hospitals in Toronto, as well as the price for on-street metered parking near Toronto General Hospital for 30 minutes and one hour slots. There is no all-day street parking nearby. If you want to visit someone at the Hospital for Sick Children or one of the downtown hospitals and park in their facility, a one hour visit can cost $12.00 and if you go a few minutes over an hour, it will be $18.00.

ParkingWe repeated the exercise with providers at the Central West LHIN with a similarly enthusiastic response. This time there were about 100 participants. We collected their ideas and had volunteers help us to input the material to create another word cloud. Here, “parking” did not appear at all. The most prominent word was “doctor.” The skill and dedication of ER doctors and nurses is certainly critical to the quality of emergency medicine. Providers need the money offered by parking and do not recognize the impact it has on patients and their families.

Parking seems like an odd thing to begin with, but it is useful to show that patients bring a different perspective to policies than providers. It seems that in Canada everyone might want to think about what comprehensive coverage means. In England, there is now a fierce debate as to whether hospitals have the right to charge patients for parking. Comprehensive health care coverage should, according to many advocates, include the cost of parking. Charging for parking, they say, institutes a user fee for health care services.

In Canada, there are other problems with parking. When your relative is in an acute hospital, rehabilitation facility or a long-term care institution for any period of time, the costs of parking add up. What is on offer by many such institutions is a recognition of the extreme costs of daily parking by offering reductions to long-term users. Given the amount of care provided by such family caregivers, the institutions might reduce costs to the level of staff or even give a free pass (like they do to some volunteers), if relatives could guarantee that they are there providing free care and support every day.

The argument made for charging for parking is that it is a significant source of income for the hospitals. However the money might not be worth the impression it makes on us: it demonstrates a lack of generosity and compassion. From the patient point of view these are critical components of care.

A Canada day celebration of Canadian health policy

For the last few weeks I have been writing about health policy in Canada from the patient’s perspective and Paradigm Freeze, a new and interesting book that has a narrow view of the Canadian health care system and hence a somewhat limited view of what constitutes health policy. The selection of policy topics it studies leaves out the most significant policy document in the history of Canada, and one which has had a continuing impact on how Canadians perceive health and healthcare. It is, of course, the Lalonde Report.

The week of Canada Day seems to be a good time to speak about the Lalonde report, A New Perspective on the Health of Canadians. That we no longer think of health as a product of medical science, but rather as a consequence of a complex array of determinants, is in no small measure due to the Lalonde report. Its publication marked a rather rapid paradigm shift around the world concerning the nature of health and health policy. Soon after the report was issued an international movement began to think about health policy in terms of health promotion and overall health status. This resulted in international declarations like the Ottawa Charter for Health Promotion in 1986.

The Lalonde report is named for the then Minister of Health and Welfare, Marc Lalonde, but it was actually written under the leadership of Hubert (Bert) Laframboise, an Assistant Deputy Minister in the Federal Department of Health and Welfare, where he created a “free-wheeling think tank” with which to inform government policy discussions.

The ideas of Thomas McKeown about health and health policy formed the core of this new approach. In the UK the National Health Service (NHS) had been created with the belief that a universally funded health care system would improve the health of the population and eventually reduce the demand for health care. This hope was never realized, and perhaps it never could have met that goal. In this context McKeown’s central idea was that one had to go beyond standard medical services to improve the health of the population. Indeed McKeown’s arguments were a polemic against the view that medical care was a major contributor to improving the health of a population. He argued that the medicine of the day had mistakenly reduced the concept of health to a mechanistic explanation of the state of the human organism.

The approach to biology and medicine established during the seventeenth century was an engineering one based on a physical model.  Nature was conceived in mechanistic terms, which led in biology to the idea that a living organism could be regarded as a machine which might be taken apart and reassembled if its structure and function were fully understood. In medicine the same concept led further to the belief that an understanding of disease processes and of the body’s response to them would make it possible to intervene therapeutically, mainly by physical (surgical), chemical, or electrical methods.

For McKeown,  “the major contributions to improvement in health in England and Wales were from limitations of family size (a behavioural change), increase in food supplies and a healthier physical environment (environmental influences), and specific preventive and therapeutic measures.”

The Lalonde report identifies four major influences on health and speaks of them as constituting the “health field”. The table below describes the four quadrants of the health field.Lalonde report table

Here are some examples of policies that have increased Canadians participation in their own health

There is no question that the Lalonde report marked a paradigm shift in Canadians’ sense of responsibility for their health, however I am offering only a few examples of major change and looking at only one of the quadrants. (For a more complete account please look at Towards A New Perspective on Health Policy)

Exercise

At the time of the Lalonde report moderate exercise meant going to the gym three times a month. After its publication and the introduction of policies and programs that encouraged fitness training, like ParticipACTION, moderate exercise means going to the gym at least three times a week.

Nutrition

In 1974, Canadians ate red meat and few green vegetables. The Canada Food Guide had been dormant since 1961. A new Food Guide emerged in 1977 soon after the Lalonde report. It recommended less red meat and more fruits and green vegetables. Since then Canadians have significantly changed their eating habits for the better.

The Canadian Organic Growers organization was founded in 1975 immediately after the Lalonde report was published. At the time organic foods were sold in the back part of a very few health food stores, but now regulated organic food is now sold in every major supermarket in Canada.

Smoking

At the time of the Lalonde report 46.7% of adults in Canada smoked cigarettes. That number in 2013 was 19.3% proving that policies to reduce smoking have had a strong impact on smoking reduction. According to The Emperor of All Maladies: A Biography of Cancer, smoking reduction campaigns have had a far greater impact on cancer reduction than all the billions of dollars spent on cancer research.

These three sets of policies have had a major contribution to the changing mortality and morbidity rates in Canada. We no longer die in our 60s of heart attacks, of lung cancer and strokes. We live longer and are prone to longer chronic conditions. This is largely due to the paradigm shift that happened after the publication of the Lalonde report, something that I think is worth celebrating on Canada Day.