Health Transformation Hub

Introduction

Nova Scotia Health and IWK Health are advancing multi-year strategies to improve access and care that will clear COVID‑19‑related backlogs, increase surgical, endoscopy and diagnostic imaging volumes, decrease wait lists, and deliver care within wait time targets. The strategies are focused on four key areas:

• Increasing capacity to help more patients access the care they need sooner.
• Ongoing quality improvement to improve patient outcomes and experiences and prevent complications or other outcomes that add to health system pressures.
• Increasing efficiencies to make the most of our resources, including people, infrastructure, and equipment.
• Reducing, diverting, or better distributing demands across the health system

They include:

• Targeted investments, initiatives, and partnerships to support incremental volume increases in each year of the plan.
• Various initiatives, investments, and changes to transform how care is managed and delivered to help sustain the gains achieved for patients.
• Ongoing waitlist validation efforts for surgery, endoscopy, and diagnostic imaging.
• Advancing improvement initiatives based on outcome data gained through participation in the National Surgical Quality Improvement Program (NSQIP). 
• Working with Health Human Resources initiative leads to support planning for workforce needs.

The plan will help teams:

• Clear the backlog of surgeries by the end of 2025-2026.
• Establish manageable waitlists, so that we can routinely and reliably meet surgical, endoscopy and diagnostic imaging wait time targets going forward.
• Transform the system to support to allow improvements to be sustained.

History

In 2022, Nova Scotia Health and IWK Health began advancing multi-year plans to help Nova Scotians receive more timely access to the surgeries and endoscopy services they need. These plans are also supported by overall efforts to increase access to diagnostic imaging services—an essential element of both pre-operative care and the timely diagnosis and treatment of many other health concerns.

Teams were initially focused on restoring services to pre‑COVID‑19 levels and building a strong foundation to allow for further expansion and growth over the coming years.

In the first two years of the plan, teams made significant progress, including:

• Launched electronic referrals for surgery, MRIs and ultrasounds.
• Launched Obesity Care Clinic in Eastern Zone. 
• Purchased and renovated Scotia Surgery clinic. 
• Launched Spine Assessment Clinic in Central Zone.
• Expanded cataract surgery partnership with Halifax Vision Centre.
• Launched Cystoscopy Program at Yarmouth Regional Hospital.
• Launched a shared decision-making module for cardiovascular surgery to help support patient-centred care and appropriate care.
• Added additional registered nurse first assistants to support access to care.
• Piloted family practice anesthesia role.
• Implemented surgical access premium payment initiative to facilitate more surgeries by providing additional compensation to surgeons, surgical assistants and anesthetists supporting surgical cases outside normal operations. 
• Increased the number of outpatient joint replacement surgeries completed, which allow cases to proceed without bed resources being required—freeing up beds for other surgeries.
• Added new medical inpatient beds and OR capacity at Dartmouth General Hospital (DGH) and new medical inpatient beds at Valley Regional Hospital and Aberdeen Hospital to free up surgical beds for surgery patients.
• Expanded access to the Perioperative Nursing Program (PONP) and provided more flexible enrollment options to help support OR nursing capacity.
• Added capacity for additional endoscopy and colonoscopy procedures, including:
  • A new endoscopy suite at DGH to directly support colon cancer screening.
  • Endoscopy and cystoscopy capacity increases at Valley Regional Hospital and Yarmouth Regional Hospital, including the relocation of Medical Day services (transfusions, etc.) from Valley Regional Hospital Day Surgery unit to Soldiers Memorial Hospital Ambulatory Clinic.
  • The addition of new scope days and expanded hours at Colchester East Hants Health Centre.
  • Additional capacity for endoscopy cases at St. Martha’s Regional Hospital and Cape Breton Regional Hospital.

Annual Goals

• Achieve national wait time benchmarks for hip and knee joint replacement surgeries (182 days) and cataract surgeries (112 days) by the end of 2025-2026.
• Reduce the wait lists for magnetic resonance imaging (MRIs), CT scans and ultrasounds by 15% by March 31, 2025, through waitlist validation and increased activity, with zone-specific monthly targets.

Several other performance indicators are monitored and evaluated monthly, including:

• Percentage of surgeries delivered within wait time targets.    
• The proportion of patients on the surgical waitlist relative to the waitlist target (# waiting ÷ targeted # waiting).
• Surgical volumes completed compared to 2019-2020 (pre-COVID).
• The percentage of patients who have been waiting more than 365 days for surgery (long waiters).
• The difference in average surgical consults wait times between the shortest-waiting and longest-waiting health network (CHN).
• The difference in average surgical wait times between the shortest-waiting and longest-waiting health network (CHN) of residence.
• The odds ratio for sampled surgical patients who developed a surgical site infection (SSI) 30-days after surgery.
• The proportion of patients who have their surgery cancelled within 24 hours of their scheduled surgery date.

Key Activities 2024-2025

Some of the key activities identified for 2024-2025 include:

• Develop a medical device reprocessing strategy to support quality and sustainability across the province.
• Stand-up a new eServices Program to support continued use and expansion of eReferrals, including the addition of additional diagnostic imaging modalities and endoscopy.
• Implement plans to help achieve national benchmarks for hip and knee joint replacements and cataract surgeries.
• Develop plans that will support efforts to deliver MRIs, CTs and ultrasounds within national benchmarks.
• Continue to reduce waitlists though validation and increased activity.
• Advance efficiency, quality and appropriateness work including efforts to increase OR efficiencies (i.e., block scheduling, on-time starts) and a diagnostic imaging stewardship program.
• Increase emphasis on accountability and a systems approach to care delivery, including a focus on targets and operational excellence and the need for a systems approach that support the needs, experiences, and preferences of patients—all patients are our patients, all resources are provincial resources. 
• Support the continued expansion of outpatient joint replacement surgery.
• Continue to explore tools and resources to support improved communication and engagement with patients pre- and post-operatively.
• Expand diagnostic imaging rebooking line to include IWK Health.
• Support efforts to expand use of Enhanced Recovery After Surgery (ERAS) program model.
• Increase engagement with patients relative to surgical and diagnostic imaging initiatives and changes. 

Expected Outcomes

• For the third year in a row, volumes will be up, wait lists and wait times will be down and more patients will access care within wait time targets.
• Patients having hip and knee joint replacement and cataract surgeries will have improved satisfaction as services are delivered within national benchmarks. 
• Patient satisfaction with diagnostic imaging services will improve, with more patients having MRIs, CTs and ultrasounds within benchmarks.
• Electronic referrals will be rolled out to all diagnostic imaging modalities and endoscopy services, with increased adoption and use of the tool, and improved provider satisfaction with the tool across all implemented modalities.
• Centralized booking model will in place for all sites and specialties, supporting more timely access to care and improved patient experiences.
• Plans will be developed to support medical device reprocessing quality and sustainability.

Milestones Achieved

• Chiropractors and physiotherapists can opt in to request X-rays.
• New MRI service launched at Dartmouth General Hospital.
• Partnership begins with HealthView Medical Imaging clinic to support publicly funded MRIs and ultrasounds.
• Expanded centralized booking models to all zones.
• Central Zone launched operating room optimization initiative.
• Achieved targets for percentage of surgeons and primary care providers using eReferrals tool to support surgery and diagnostic imaging referrals. 
• Expanded SeamlessMD app pilot to include heart surgery patients. 

2023-2024 Year-end Highlights

Provincial (NSH/IWK)

• Waitlists down > 23% since March 2022.
• 4,114 more patients had surgery in 2023‑24 than in 2019‑20. Volumes were also up 1955 cases compared to 2022‑23.
• 6,022 more patients had endoscopies in 2023-2024 than in 2019‑2020. Volumes were also up 1929 cases compared to 2022‑2023.
• 57% had surgery within target March 2024 (52% May 2022).
• Long waiters (more than 365 days) on wait list down to 21% in March 2024 vs. 25% March 2022.
• Outpatient joint replacements were up for the fourth year in a row, with 1240 more cases completed than before COVID.
• More than 30,000 electronic referrals were sent for surgery, MRIs and ultrasounds in the first year of the new intake model.
• NSH teams completed more CTs, MRIs and ultrasounds in 2023-2024 than the previous year (2022‑23):
  • 16,923 more CTs
  • 721 more MRIs
  • 1887 more ultrasounds

Eastern Zone

• More patients had surgeries within national benchmarks in 2023-2024 than before COVID (2019-2020).
  • Hip replacements: 88% vs.82%
  • Knee replacements: 81% vs. 73%
  • Cataracts surgeries: 86% vs. 85%

Central Zone

• 3,615 additional surgeries were completed compared to before COVID (2019-2020).
• 52% reduction in surgical consult waitlist through the launch of the Spine Assessment Clinic and central intake.

Northern Zone

• Only 5% of patients on the Northern Zone surgical waitlist were waiting more than 365 days, surpassing the 10% target.
• 85% of hip replacement patients and 77% of knee replacement patients received their surgery within national benchmarks.

Western Zone

• 1050 more surgeries completed compared to 2022-2023.
• 12% more diagnostic imaging exams were completed than in 2022-2022.

Engagement Opportunities

To share feedback or expertise or contribute to the initiative please reach out to your local manager or Division Head/Chief or one of the initiative leads:

• Dr. Greg Hirsch, Senior Medical Director, Perioperative (Surgical) Services Network, Nova Scotia Health
• Cindy Connolly, Director, Clinical Networks, Perioperative (Surgical) Services Network, Nova Scotia Health
• Dr. Tim Mailman, Senior Medical Director, Diagnostic and Therapeutic Services Network, Nova Scotia Health
• Lewis Bedford, Senior Director, Diagnostic and Therapeutic Services Network, Nova Scotia Health

Questions or comments related to the initiative can be directed to any of the leads or to Perioperative.Services@nshealth.ca