Feature - In Recovery
photos by matthew manor, courtesy of KGH; Above: Newly renovated operating theatre at Kingston General Hospital
Since she became its President and CEO in January 2009, Thompson has been overseeing a similar collaborative building process at Kingston General Hospital. When she arrived it was a troubled institution saddled with a daunting set of problems. Wait times for beds were dramatically out of line with provincial standards. The rate of hospital-acquired infections was too high. Too many acute-care beds were being occupied by patients who should have been receiving care elsewhere. Parts of the hospital were in dire need of upgrading, but there was nowhere near enough money for renovations and barely enough for routine maintenance. Staff morale was on life support, and the number of staff taking sick days was at unprecedented levels. Most serious of all were the finances, which at one point in 2008 were so dire they threatened KGH’s ability to make payroll.
Today, those problems are not what they used to be — in a good way. Some of the big-ticket issues that KGH was grappling with three years ago are, well, not quite as big. Some barely qualify as “issues” anymore. If that seems like faint praise, it’s not. Pulling off organization-wide transformation in a place as large and multi-faceted as KGH calls to mind the old cliché about changing the course of an ocean liner: You can’t do it quickly. Yet, people who know about these things say the scale and rapidity of the changes brought about by KGH staff under Thompson’s leadership are significant.
“This is not BS,” says Dr. Richard Reznick, Dean of Queen’s Faculty of Health Sciences, who has observed and participated in the evolution of KGH since his recruitment from the University of Toronto by Queen’s 18 months ago. “This is real stuff, and it really is remarkable. I think it’s a good example of what can happen when a team is banded together under strong leadership to make things happen.”
A challenging assignment Established in 1835, KGH is arguably Kingston’s most important large institution. Sooner or later, it touches everyone. If you haven’t been treated there yourself, it’s a safe bet you know someone who has. Some 450 physicians work there along with 3,875 nurses, medical residents and allied staff whose work injects an estimated $215 million into the local economy. It has 459 beds and is the only hospital in southeastern Ontario outside Ottawa capable of handling routine cases as well as severe trauma, high-risk pregnancy, cancer, very sick babies, life-threatening injuries and respiratory failure. It’s the only place in the region with the equipment and expertise to perform transplants, heart surgery, life-support, dialysis, brain surgery, stem cell work, radiation therapy for cancer, special imaging and other highly specialized procedures. Because of this, it serves seriously ill patients not only from Kingston, but also from the counties of Hastings, Price Edward, Frontenac, Lennox & Addington, Leeds & Grenville, parts of Lanark and Northumberland counties, the towns of Belleville, Brockville, Smith Falls and Prescott and every community in between — a jurisdiction that includes a population of some 500,000 people.
The basic issue was that, by 2008, KGH was projecting
a $13-million year-end deficit and warning that it would
double in the next year.
Troubled times The situation that brought Leslee Thompson to Kingston boiled down to a long-standing difference of opinion between, on the one hand, Thompson’s predecessor, former CEO Joe de Mora, who had helmed KGH since August 2000, and, on the other hand, the Southeastern Ontario Local Health Integration Network (LHIN). The Belleville-based LHIN was one of 14 across the province set up in 2005 by George Smitherman, Ontario’s then-Minister of Health and Long-Term Care, as part of a massive restructuring of the province’s health care planning system. The LHIN is responsible for health care co-ordination and hospital funding in this part of the province.
The basic issue was that, by 2008, KGH was projecting a $13-million year-end deficit and warning that it would double in the next year. Deficit financing before and during de Mora’s tenure was a practice that had gone essentially unchallenged by KGH’s board of directors. The operating philosophy seemed to be, “Spend whatever is necessary, even if it exceeds the budget, then wait for Queen’s Park to pick up the shortfall” — which, for years, it did. By 2008, the Local Health Integration Network was reluctant to dole out yet more cash to KGH because, despite periodic injections of new funding, it always needed more, even though its patient volumes remained flat.
The LHIN wanted to see a solid business case that justified de Mora’s requests for more money. de Mora thought he had one, produced data that seemed to indicate he was running a tight ship, and maintained that the cause of KGH’s troubles was chronic base underfunding by the province. The LHIN, which in the preceding five years had increased KGH’s base funding by 33 per cent, felt de Mora’s data was vague and superficial. They wanted more.
To solve the impasse, in February 2008, Smitherman as Minister of Health appointed Graham Scott, a former deputy minister of health, to conduct a full investigation of affairs at the hospital. His final report, produced with help from a small, select group of advisers brought in by Scott and delivered in mid-June 2008, was scathing. In painful detail it demolished de Mora’s contention that KGH was running efficiently. In fact, reported Scott, KGH had few financial controls in place, inadequate oversight of operations, and operating policies and procedures that were either broken or non-existent. Many areas of the hospital were running inefficiently and hindering timely patient access to beds. The basic message was that KGH was an institution with great potential and some excellent and dedicated staff, but that ineffective leadership, broken governance and an unsustainable fiscal policy were endangering its long-term viability as a tertiary-care hospital. Scott’s conclusion was that KGH needed new people at the top and a near-complete overhaul of operations.
That wasn’t the only overhaul in KGH’s immediate future. In July 2008, construction crews began work on a long-planned $196-million hospital redevelopment project to renovate 143,000 square feet of the hospital and add 170,000 square feet of new space for an expanded intensive care unit, a pediatric ward, a mental health ward and renovated facilities for dialysis and the Cancer Centre of Southeastern Ontario. Fundraising for the massive project had begun under de Mora’s tenure and was spearheaded by the University Hospital Foundation, the fundraising arm of Kingston’s three hospitals: KGH, Hotel Dieu and Providence Care’s St. Mary’s of the Lake. The finishing touches to this project — a revamped lobby with a new pharmacy and a Tim Hortons kiosk — were well underway at the close of January 2012.
Within five months of Scott’s arrival, de Mora and a number of other senior executives had been asked to resign or been dismissed and replaced on an interim basis by Scott as supervisor; an interim CEO, Janet Davidson; and a new Chief Operating Officer, John McGarry, who was brought in from New Brunswick for the assignment. The KGH board of directors, which Scott had criticized for lax oversight of spending, had nevertheless been spared because its dozen or so members had demonstrated a willingness to learn from their mistakes and to participate in an overhaul of the hospital’s governance.
Chris Cunningham, who sat on the board and is now its chairman, recalls the Scott period as an eye-opener. He was particularly impressed by Maureen Quigley, a health care governance consultant Scott had brought in. Quigley advised the board on current governance rules and how to be more professional by accepting as members not only well-meaning citizens, but people with specific skill sets — law, finance, accounting, human resources and so on — who are demonstrably capable of fulfilling the board’s corporate oversight role.
“It gave the board a graduate seminar on how to run a hospital,” says Cunningham, “and we had a wonderful team to teach us.”
Using Scott’s findings and working with staff and the board in an advisory capacity, the interim executive team drafted a Performance Improvement Plan (PIP) that contained a slew of measures designed to cut $27.3 million in spending and put KGH on solid financial footing within three years. They also began headhunting for a new, full-time senior management team, a search that eventually led to the recruitment of Leslee Thompson.
Thompson’s first 100 days At the time she was hired, Thompson was a vice-president at Medtronic, a publicly traded medical devices company based in Brampton, Ont., but her arrival in Kingston wasn’t a venture into unknown territory. In the 1980s she’d attended Queen’s, first for political science, then nursing. After graduating and working for a few years as a critical care nurse, she became intrigued by health system management and began schooling herself accordingly: first a master’s degree in nursing from the University of Toronto, later an MBA from Western and a professional development stint at the Canadian College of Health Service Executives in Ottawa. Her first senior executive position was at the Royal Alexandra Hospital in Edmonton, after which she returned to Ontario to serve as Chief Operating Officer (COO) at Toronto Western Hospital, Executive VP and COO at Sunnybrook & Women’s Health Science Center — both teaching hospitals — and as VP of Cancer Care Ontario.
In Kingston, her impressive qualifications didn’t exempt Thompson from the reality that in any corporate changing of the guard, there is always a mixture of fear, suspicion and cynicism about the new boss. She had to address this right off the bat while acting on the Performance Improvement Plan, which, in addition to balanced operating budgets, called for a reduction of 157 full-time equivalent positions and shorter wait times for certain services.
Leslee Thompson, President and CEO at KGH
To gather ideas on how to do this, over three months Thompson met with more than 2,000 people, individually and in groups, at all levels of the organization. She introduced herself and her ideas to staff — but most of all, she listened to their answers to the same five questions: What about KGH needs to be preserved and why? What are the top three things that had to change and why? What were they most hopeful that she would do? What were they most concerned that she would do? What advice did they have for her?
Thompson got an earful of both the good and the bad. Some staff felt their work was undervalued and that positive accomplishments often went unrecognized, even when a simple smile or pat on the back from a co-worker or manager would have done the trick. Some felt that management ignored staff suggestions for improvement, which dampened desire to provide constructive feedback. She heard there needed to be better trust and communication among managers, staff and other partners such as volunteers, partner hospitals and the public. Front-line personnel felt like they were working in isolation, without support from managers. Physical plant staff said the elevators were often dirty and left a poor impression of KGH. Many said the food left much to be desired. One of the most telling — and cutting — comments came from a former patient who told Thompson, “I’m afraid to go to your hospital.” To signal a new era of transparency, Thompson had summary notes of what she’d heard posted online so all employees could learn what was said and contribute additional comments and suggestions.
PLAN KGH 2015 All the feedback formed the basis of a comprehensive strategic plan called KGH 2015, with the tagline “Outstanding Care, Always.” Thompson describes the phrase as an aim to which the entire organization can continually aspire, but has acknowledged all along that there would be bumps along the road to reaching that goal. Any problems would be tackled, and solutions found, one by one.
The five-year plan’s overarching theme — patient-centred care — might seem a no-brainer for a hospital, but the phrase has become increasingly common in health care circles in recent years as a way to distinguish between policies and practices designed specifically to benefit patients, as opposed to those that do more to serve the needs of the organization and its health care providers.
KGH 2015 laid out four strategic directions intended to move the hospital closer to its patients-first goal: improved care quality, safety and service for patients; more and better teamwork among physicians, nurses and other care providers; an increase in patient-oriented research; and greater focus on complex-acute and specialty care — the treatments and procedures that smaller community hospitals aren’t equipped to handle. In a sense, it was a roadmap for returning the modern KGH to the things it has always been mandated to do but in varying degrees had somehow drifted away from. The underlying caveat, of course, is that everything had to be done within the hospital’s financial means.
To gather ideas, over three months Leslee Thompson
met with more than 2,000 people, individually and
in groups, at all levels of the organization.
Ground game It’s one thing to put a bunch of fine-sounding statements on paper. It’s another thing to deliver. Now, in the first quarter of 2012, Thompson readily admits that realizing the plan is a work in progress and that much remains to be done before its goals are fully achieved. At the same time, the numbers show that KGH has made some solid advances.
One of the top achievements has been the redrawing of KGH’s financial picture. No part of the hospital was spared from a detailed examination of its operations — led first by John McGarry and later by his successor, Jim Flett, KGH’s current COO — to determine exactly where money was being spent and to identify ways of doing things at less cost without compromising patient care. The measures included a wage freeze for all non-unionized staff; new purchasing agreements with suppliers negotiated by 3SO, a non-profit organization that procures suppliers for KGH and six other eastern Ontario hospitals; and ushering in a plethora of new systems and procedures that allow KGH managers to monitor and measure virtually everything that happens in their unit so that they, the executive team and the board can know how they’re doing compared to their performance targets and other hospitals. Managers were supplied with the support and training they need to manage their budgets within the new systems.
The hospital also worked with Utilities Kingston and a consultant on a variety of water- and energy-conservation measures, including installing dozens of new low-flow toilets, compact fluorescent lighting and new windows, that cut KGH’s energy costs while making it eligible for various provincial incentive programs that offset costs even further.
As a result of these and other measures, KGH eliminated the $24-million deficit it had in 2008. For the past three fiscal years, the hospital has had a balanced operating budget, which is now $400 million annually.
Says Thompson: “What we’ve done is looked at the whole picture and made sure that we’ve got a really balanced approach to achieving our financial goals in the short term, making choices that are going to ensure that the hospital is in a healthy financial position for the long term, and improving performance on a variety of other fronts that will support the ongoing health of the organization.”
One result of the belt-tightening is that KGH now has more money to spend on new equipment, including information management systems, new ventilators, a heart-lung machine and obstetrical ultrasound machines. Three years ago, it had $3 million available. This year it will have over $11 million for capital spending, and the goal is to have upwards of $20 million by the end of 2015. All this money came from internal savings. The feat did not go unnoticed: To reward KGH for its reformed behaviour, the Health Ministry freed up $7 million to enable the hospital to rip out all the carpets from the patient wards. In one long-awaited stroke, KGH eliminated one of its biggest repositories of dust and germs, making the hospital more sanitary and safer for all.
“It’s very clear that the ministry will only help you if you help yourself, drive the change and become a performer,” says Dr. David Zelt, a KGH vascular surgeon who was hired in 2009 as KGH’s Chief of Staff and VP Medical. “Performance gets rewards, gets the support to do better. The lame duck doesn’t get help.”
But bringing the hospital’s finances under control did not come without what business types refer to as “pain.” Typically this is a euphemism for layoffs and firings, but, remarkably, no one was fired or laid off as part of fulfilling the Performance Improvement Plan, which called for a reduction of 157 full-time equivalent positions. The reductions were achieved entirely through attrition. Some staff left the hospital of their own accord, vacant positions were eliminated, and retirements were not replaced — but no one received a dreaded pink slip.
Dr. Louise Rang and third-year medical student Lesley Roberts in the KGH Emergency Department
Instead, the pain seems to refer to the struggles experienced by physicians and staff as they coped with having to do things in a new way that put a major emphasis on accountability and the financial bottom line. In other words, “pain” has simply meant “dealing with change.”
The most public example of this pain came in 2010, after KGH moved to address long-standing complaints from patients and staff about the hospital’s food by awarding a new food-services contract to Compass Group Canada, a company that would prepare and freeze meals at its Mississauga plant and truck them to Kingston. To the surprise of Thompson and the KGH board, who felt the deal would save money and provide higher-quality food, the decision was met with howls. The union that represents KGH’s in-house nutrition services staff — the former providers of KGH’s food — felt that it had been unfairly bypassed during the bidding process for the new contract and that using Compass would sacrifice Kingston jobs. Meanwhile, some area farmers protested that KGH, by outsourcing to a provider hundreds of kilometres away, had squandered a golden opportunity to help sustain the region’s local food movement.
In the end, no nutrition staff lost their jobs, although there was some job-shifting, and senior officials from KGH and Compass are co-operating with National Farmers Union representatives to figure out how to incorporate as much locally grown food as possible in KGH’s menus. Even Dianne Dowling, President of Local 316 of the NFU and initially a critic of the Compass deal, senses that KGH’s desire to do the right thing is genuine. “There was some serious management time devoted to this,” she says.
Another instance of pain involved how the use of KGH’s 11 operating rooms was scheduled. It’s a complicated task that must simultaneously account for factors such as the caseload at any given time, the availability of surgeons and nurses for certain operations, Ministry of Health guidelines on the time frames within which certain types of surgery must be completed, and the fact that scheduled operations might be delayed or moved forward at a moment’s notice because of an emergency requiring immediate surgery. As it was, the hospital’s operating-room scheduling left some rooms underutilized during the day and only one theatre available for use on weekends. The method was creating bottlenecks, backlogs and wait times for surgery that were unacceptable to both patients and the Ministry of Health.
To address this, Zelt asked his surgical program leaders to devise a more efficient way to assign the operating rooms. At first, he recalls, the surgeons were skeptical. Still, they put their heads together, scrutinized what was actually happening at KGH and at other hospitals, and concluded that by shifting some nighttime operations to the daytime and by opening a second operating room on weekends, the overall schedule would be more balanced and flow patients through the system faster and more efficiently. Ultimately, it proved to be short-term pain for long-term gain.
Targets and achievements While the transitions haven’t always been pleasant or easy, they have enabled KGH to make steady progress toward better patient care and resolution of a number of problem areas identified in the Scott report and targeted in KGH 2015.
One such area is hospital-acquired infections such as C. Difficile, sporadic outbreaks of which KGH has grappled with over the past year. The rates of this and other life-threatening infections have decreased somewhat (removing the carpets likely helped), but Thompson says they are still higher than the provincial benchmark. Probably the biggest recent advance toward eliminating “preventable harm” is the vastly higher rate of proper hand hygiene, which is the simplest way to prevent the transmission of germs, but one that visitors and hard-pressed staff in a stressful environment often neglect. Three years ago the hand-washing rate at KGH was approximately 44 per cent, but thanks to the installation of hand-gel dispenser stations throughout the hospital and abundant and conspicuous signage, the compliance rate among all staff is now 90 per cent. Thompson says she won’t be happy until it’s 100 per cent.
On the patient-centred care front, KGH is also earning national accolades for its new Patient and Family Advisory Council, a volunteer group established in February 2010. Composed of 35 former patients and family members of patients and five KGH staff, the council provides input to program teams on how physicians and staff can improve the in-hospital experience of patients. Today, “patient experience advisers” from the group sit on 15 of KGH’s 58 councils and committees to ensure that the patient perspective is considered during clinical planning. Patient advisers are also being integrated into hiring committees and new-staff orientation sessions to show new and potential employees from the outset that the hospital is serious about its patient-first focus. The goal is to have an adviser on every committee associated with patient care so that patient-centred care will become integral to the KGH culture — or, as the executives like put it, part of the hospital’s DNA.
Often, the advisers’ suggestions involve things that might seem insignificant but can make a big difference to patients. For instance, the council suggested that staff and physician nametags be redesigned so that the wearer’s first name would appear in large, easy-to-read lettering on both sides of the tag. As a result, patients never have to wonder with whom they’re having a conversation nor feel awkward or disconnected from staff.
“It’s something that was really frustrating for patients that we’ve now fixed because of their advice and observations,” says Thompson, who says the advisory council has made a “profound” difference to the way KGH works. “Once you start to look at the world through [patients’] eyes and through the lens of how they see things, you look at yourself differently.”
Patient-oriented research One of KGH’s defining characteristics is that it is one of Ontario’s 15 teaching hospitals, which means that it’s one of only a handful of hospitals in the province that conducts complex patient care in conjunction with health care education and research. At KGH, the people leading this work are specialist physicians from Queen’s Faculty of Health Sciences, especially the School of Medicine, the majority of whom teach at Queen’s and practice and conduct research at one or more of Kingston’s three hospitals. Together the physicians and institutions have a mutually interdependent relationship: KGH and its partner hospitals need Queen’s specialists and residents to serve their patients, and Queen’s needs KGH and the others for students’ clinical training and research facilities. But although the physicians divide their time among hospitals and spend much of their time there, they typically identify themselves with Queen’s. KGH and the medical school are also linked at the senior management level: The top people at the medical school also hold executive positions at KGH.
Given that KGH is an academic hospital joined at the hip with Queen’s medical school, another prime focus in KGH 2015 is research. There are about 160 researchers active at the hospital working on a diversity of projects in clinical epidemiology; urology; molecular, cellular and biochemical medicine; and in other non-traditional areas such medical education, medical ethics, health services and health policy. A survey last fall by consulting firm Research Infosource estimated that KGH’s research income — that is, grants from sources such as the federal Canadian Institute for Health Research, industry and corporations, plus agencies and societies such as the Canadian Cancer Society — totalled just over $16 million in 2010, which was a 4.4-per cent increase over 2009. That placed KGH at number 27 on the list of Canada’s top 40 research hospitals. Since the survey, however, KGH has boosted its research funding by some 30 per cent, pushing the 2011 total to $21.5 million. Central to KGH’s research efforts in the future will be the new KGH Research Institute, established in September 2010 to guide and support patient-oriented research. It is headed by Dr. Roger Deeley, KGH’s VP Research, who himself is a renowned cancer researcher.
Although the research agenda may seem irrelevant to the average patient, it’s not, explains Dr. Richard Reznick, the Dean of Queen’s Health Sciences faculty. Patients in a research hospital like KGH receive care in an environment of constant inquiry, because medical students and residents working there expect their professors — the patients’ physicians — to be up to speed on current medical knowledge, standards and methods. Reznick says this expectation of best professional practice tends to improve care for patients.
The research activity also benefits KGH patients in that, without it, the hospital would simply be unable to offer the specialized medical services that make it a complex acute-care hospital. The fact that it is a research hospital is what enables Queen’s and KGH to attract the sorts of practitioners they need: people engaged in advancing medical knowledge through research who can also teach students and treat patients. It’s a tall order, and luring them to Kingston is one of the mandates of the new research institute.
“You can’t run those kinds of programs where you don’t have an active research environment,” says Reznick, who at the end of January was preparing to welcome four new research physicians to Queen’s.
Going forward It’s safe to say that most of the high-level changes wrought at KGH in the past three years will be hard for many, if not most, patients to detect. For them, wait times — to get into emergency, to get from emergency into a hospital bed, to get appointments with specialists and into surgery — can never be short enough. Too, there will always be patients complaining about lousy food or officious doctors or rude nurses who jabbed the needle in too hard. While researching this story, I spoke with a nurse who, when I asked her whether her work life had improved in the last three years, just snorted and described the same-old, same-old stresses of understaffed wards, poor communication by managers and lacklustre morale — all things that Thompson has vowed to turn around.
But I also spoke with patients who told me they’d been blown away by the patience and compassion of the nurses and doctors in the intensive care unit, in the cancer centre, in orthopedics. As for my nurse friend, when she pondered my question further, she said she appreciated the tiny new walkie-talkies that nurses can clip to their uniform and whisper into to summon help from a colleague without leaving a patient’s room. She thought that getting rid of the carpets was a great, long-overdue move, and she allowed that there was probably more teamwork on her ward and more get-togethers intended to boost staff morale. It was still a grind on the front lines, but the working conditions at KGH were slowly getting better.
“Things sure aren’t perfect,” she said. “But I think we’re going in the right direction.”