Access – Charting the Course: The Northeast Avalon Community Health Needs Assessment

ACCESS Charting the Course

T H E N O R T H E A S T A V A L O NC O M M U N I T Y H E A L T H N E E D S A S S E S S M E N T

June 16, 2010

Mr. Michael O’KeefeChairperson, Board of TrusteesEastern Health

Dear Mr. O’Keefe:

It is my pleasure to submit Access – Charting the Course: The Northeast Avalon Community HealthNeeds Assessment to the Board of Trustees of Eastern Health. This is the third report completed aspart of Eastern Health’s mandate under the Regional Health Authorities Act to assess health andcommunity services needs on an ongoing basis. The Board’s Strategic Plan aims to complete theseassessments throughout the region by 2011. To date, Eastern Health has completed assessments onthe Burin Peninsula (2006) and Southern Avalon (2007); in early 2010 the Discovery Zone(Bonavista-Clarenville area) assessment began and the Conception Bay North area assessment isscheduled to commence in 2010 as well.

As with past assessments, a Steering Committee of Eastern Health staff and an Advisory Committeeof community members guided the process and provided valuable insight. Many representatives fromthe Northeast Avalon provided input and I acknowledge the level of enthusiasm and involvement inthis assessment.

Assessing the needs of this region was challenging due to the size of the population andcomprehensiveness of services offered. As such, the process chosen for this assessment was to focuson several key issues and a limited number of recommendations to bring about meaningful changes.Additionally, the assessment highlights several priority areas on which to focus next as we strive toachieve our vision of Healthy People, Healthy Communities.

The passion and commitment concerning the health and vibrancy of this region was evidentthroughout the process of completing this assessment. I look forward to collaborating with internaland external stakeholders to implement the stated recommendations, monitor our progress and openlyreport back to stakeholders.

Sincerely,

Vickie KaminskiPresident and Chief Executive OfficerEastern Health

AcknowledgementsEastern Health gratefully acknowledges the input and expertise of numerous individuals andgroups during the process of conducting this needs assessment. Many representatives of theNortheast Avalon – both internal and external to Eastern Health – gave generously of their timeto provide feedback and share their candid opinions about the area. Dedicated people also helpedto promote the assessment and motivated others to get involved.

It is obvious that people are passionate about health and are committed to making improvementsin our communities. Thank you for taking the time to participate in this needs assessment andfor providing ongoing direction throughout the process.

There are a number of people, in particular, who we thank for their contribution in bringing thisassessment to completion:

• Residents of the Northeast Avalon:

o Telephone survey participantso Key informantso Focus group participantso Emergency Room survey participantso Community partners who attended the initial consultation sessiono Community partners who hosted and helped promote focus group sessionso Residents and community groups who provided written and/or oral submissions

• Advisory Committee members: Maureen Bethel, Maurice Brewster, Sondria Browne, LindaJanes, Shirley Murphy*, Jack Strawbridge, Ed Wade* Eastern Health gratefully acknowledges the contribution of Advisory Committee member Shirley Murphy, whopassed away on June 5, 2010. We appreciate the opportunity to have worked with Shirley on this needs assessmentand we extend our sincere condolences to her family.

• Steering Committee members: Dr. David Allison, Lisa Browne, Cathy Burke, Beverley Clarke,Bernadette Duffett, Dawn Gallant, Dr. John Guy, Gillian Janes (Project Coordinator), WayneMiller (Chair), Natalie Moody (Alternate Member), Laura Woodford

• Research Expertise (through both Eastern Health and Memorial University ofNewfoundland): Dr. Brendan Barrett, Donna Bruce, Krista Butt, Dr. Mike Doyle, Katie Little,Kimberley Manning, Kelly McNamara, Dr. Meghan Walsh

• Health Quality Council of Alberta: Tim Cooke and Charlene Morrison

A C C E S S - C H A R T I N G T H E C O U R S E2

• Human Investigation Committee of Memorial University of Newfoundland: Linda Purchase

• Employees within Eastern Health:

o Administrative Support: Patricia Rideouto Clerical Support: Heather Gardner, Roxann Organo Clinical Efficiency Department: Kathy Fowler, Elizabeth Kennedyo Communications: Angela Lawrence, Robyn Lush, Laura Woodfordo Decision Support/Information Management: Gerard Gibbons, Sharon Lehr, Joy

Thompson o Diagnostic Imaging: Sharon Quinlan, Shawn Thomas, Susanne Walsho Emergency Department managers (Michele Clarke and Darryl Cooze) and staff at both

St. Clare’s Mercy Hospital and the Health Sciences Centreo Executive Assistants: Karen McDonald, Dianne Smitho Health Information Systems and Informatics: Serge Beaulieuo Key informants who participated in interviewso Library Services: Debra Kearsey and Jordan Pikeo Management Engineering Departmento Pastoral Care and Ethics: Reverend Stephen Flower and Dr. Rick Singleton o Planning: Jane Macdonald

• Community Medical Advisory Committee

• Newfoundland and Labrador Statistics Agency, Department of Finance

T H E N O R T H E A S T A V A L O N C O M M U N I T Y H E A L T H N E E D S A S S E S S M E N T 3

Executive Summary

IntroductionEastern Health is the largest health services organization in the province of Newfoundland andLabrador. With a budget of over $1 billion, the organization provides the full continuum ofhealth services (community, acute and long-term care) and has both regional and provincialresponsibilities. The Eastern Health region extends west from St. John’s to Port Blandford andincludes all communities on the Avalon, Burin and Bonavista Peninsulas.

One of the responsibilities of a health authority within the provincial Regional Health AuthoritiesAct is to assess health and community service needs in its region on an ongoing basis. In 2008-2009, the Northeast Avalon was the third area of the region to be assessed within Eastern Health,and included the following communities: Avondale, Bauline, Colliers, Conception Bay South,Conception Harbour, Flatrock, Harbour Main-Chapel’s Cove-Lakeview, Holyrood, Logy Bay-Middle Cove-Outer Cove, Marysvale-Georgetown, Mt. Pearl, Paradise, Petty Harbour-MaddoxCove, Portugal Cove-St. Philips, Pouch Cove, St. John’s, and Torbay. Bell Island was not includedin this assessment since Eastern Health participated in a needs assessment of that area in 2006.

Why conduct a needs assessment?• The purpose of a community health needs assessment is to:

o Gather information about the health of a particular area from both a factual and anopinion perspective;

o Start and continue dialogue with many individuals and groups from the community;o Increase public participation and engagement in the health of the region;o Lead to stronger partnerships between the community and its health board;o Provide the organization with a better understanding of what communities feel they

need in order to be healthier;o Prioritize identified issues;o Recommend actions to address the issues.

What does a needs assessment have to do with the provision of health andcommunity services?• In short, a community health needs assessment helps Eastern Health to better understand

local needs; the better it understands the needs, the better able it is to provide services for theoverall population.


• A community health needs assessment looks at and acts upon the broad range of factors andconditions that have a strong influence on health, also known as the “determinants of health”,which include factors such as Income and Social Status, Social Support Networks, Educationand Literacy and Health Services.

Methodology • A Different Approach: Different from past assessments, the Northeast Avalon report started

with a telephone survey to identify key themes. Focus groups and key informant interviewstook place afterwards and were based on the themes that emerged from the telephone survey.

• Limitations: In order to address limitations from primary research, Eastern Health typicallylooks to validate information in the primary research methods and “triangulate” the data byusing several different sources. If a theme emerges in several primary research methodologiesit most likely is a pressing issue.

• Further Primary Research: Subsequent focus groups, key informant interviews and written/oralsubmissions confirmed the findings of the telephone survey in addition to providing a richlevel of detail on access to health services, wait times, and other community health needs toconsider for future prioritization.

• Emergency Room (ER) Survey: An extensive survey with patients of both the Health SciencesCentre and St. Clare’s Mercy Hospital ERs provided substantial primary research informationinto reasons for visiting the ER and potential alternatives.

• Internal Information: Internal Eastern Health reports and data provided insight into patternsof use and the size and scope of the issues identified.

• Secondary Research: A literature review provided further context, particularly in terms of ERwait times and access to specialty services in other jurisdictions.

• Committees: Two committees were established to guide the process: a Steering Committeecomprised of Eastern Health managers and an Advisory Committee made up of individualswho were selected based on a public call to sit on the committee.

Priority AreasBased on initial feedback from the telephone survey, three main areas were prioritized forrecommendations and action planning:

• Wait times in the Emergency Room (ER)• Access to specialists• Access to Diagnostic Imaging (DI)


While wait times within these three services emerged as the focus of this particular assessment,Eastern Health recognizes that there are other concerns to address within the Northeast Avalonarea. Several of these issues are highlighted for future planning and prioritizing.

Common IssuesThere are a number of common challenges that cut across the three priority areas of ER, specialistsand DI:

1. Waitlist Management

• Accessing and Maintaining Data: There are challenges with Eastern Health’s capacity to reporton data related to the ER, specialists and DI. Data on wait times have been a challenge tomaintain, analyze and report.

• Managing Waitlists: Managing waitlists for specialists and DI is complex. Resources arerequired to ensure the accuracy of waitlists and track different wait time measures.

• Recommendation: Eastern Health has an approved Client Centred Waitlist ManagementStrategy, thus it is recommended that the organization seek additional funding to fullyimplement this plan.

2. Communications

• Need for Enhanced Public Awareness and Education: Waitlist processes need to be betterexplained and efforts to reduce wait times within the ER, with specialists and with DI mustbe communicated more effectively.

• Recommendation: Eastern Health should initiate the public posting of wait time indicators toassist the public in their understanding of the challenges that the health system currently faces.

3. Monitoring Progress

• It is important to measure the effectiveness of interventions over the long term.

• Recommendation: Eastern Health’s Board of Trustees should report back to the public on theprogress of the recommendations and issues raised two years after the release of this report.

• Recommendation: Eastern Health’s President and CEO should provide semi-annual updates tothe Board of Trustees on the progress towards the successful implementation of therecommendations of this report.


Highlights of Three Priorities: ER, Access to Specialists and DI What is the problem?

• Lengthy wait times • Communication challenges

What are the reasons for the long wait?

• Increasing demands on existing resources• Need for data

What do we recommend?

(1) For the ER:(a) Increase the availability of responsive/less urgent care in the community;(b) Increase access to health professionals outside of the hospital setting; (c) Commit to further analyzing the need for additional human resources (particularly

physicians and nurse practitioners) within ERs at both Health Sciences Centre and St.Clare’s;

(d) New Technology: implement an electronic system such as a “Bed-board”, as identified inthe Patient Flow Study;

(e) Improve communications.

(2) For Access to Specialists:(a) Implement fully the Client Centred Waitlist Management Strategy of Eastern Health; (b) Improve communications;(c) Develop better mechanisms for information exchange between Eastern Health and GP’s

Offices for enhanced coordination of patient care;(d) Commit to researching a visionary “Model of Care for 2020”.

(3) For DI:(a) Develop a Patient-Centred Delivery of Services Strategy for DI;(b) Explore options for patients who reside in the Northeast Avalon to travel elsewhere in

the Eastern Region (outside of the Northeast Avalon) to avail of DI services; (c) Develop a plan for online booking of DI services; (d) Develop a communications strategy specific to DI.


Related Initiatives and Requirements Several major initiatives within Eastern Health are converging in response to challenges identifiedwithin the organization over the long term, all of which tie closely to the issues brought forwardin this needs assessment. These include:

• St. John’s Hospital-Based Health Services Redevelopment;

• Patient Flow Study – particularly in regard to supports for Alternate Level of Care Patients(ALC) in the community;

• Initiatives to improve bed availability throughout the system;

• Balancing demands within Paramedicine and Medical Transport for routine patient transfersand emergency response;

• Enhancing efforts to address shortages of professionals;

• Initiatives related to navigation of the system.

Beyond Wait Times: What Else Did We Hear?A broad range of issues were brought forward through the process of conducting this assessment,particularly through focus groups and key informant interviews. While wait times within adultservices emerged as the focus of this assessment, Eastern Health recognizes that there are otherconcerns to address within this geographic zone. As such, this assessment will set the stage forseveral areas that warrant further investigation for future strategic planning and needsassessments:• Mental Health services• Meeting diverse needs• Emphasizing preventative approaches to health


ConclusionThe Northeast Avalon region is changing and the ways in which Eastern Health responds toneeds must evolve. Eastern Health will continue to be challenged in the ways it provides servicesand supports within communities, especially as public awareness and expectations continue toincrease.

In brief, improving wait times requires resources: either improve efficiency within existingresources or add additional resources. Many opportunities exist by which Eastern Health canimprove access to services, which is a key determinant of health. Undoubtedly, this will requirebold, innovative approaches and a strong commitment from all levels of the organization and ourcommunity partners as we strive to achieve our vision of Healthy People, Healthy Communities.


TABLE OF CONTENTS

Introduction.....................................................................................................................14

Why conduct a needs assessment? ............................................................................................16What does a needs assessment have to do with the provision of health and communityservices?.........................................................................................................................................17What is the profile of the Northeast Avalon? ..........................................................................18

Methodology and Summary of Findings ...............................................................21

Overview of process ....................................................................................................................22Summary of Findings..................................................................................................................25Highlights of the ER Survey......................................................................................................28

Wait Times in the Emergency Room .......................................................................32

What is the problem?..................................................................................................................33What are the reasons for the long wait?....................................................................................37What do we recommend?...........................................................................................................38How will we know we have succeeded?.....................................................................................40

Access to Specialists ......................................................................................................41


Wait Times for Diagnostic Imaging..........................................................................48


Related Initiatives and Requirements ......................................................................55

Longer-Term Initiatives and Requirements..............................................................................56Current Initiatives to Expand/Improve ....................................................................................56

Beyond Wait Times: What Else Did We Hear? .....................................................58

Conclusion .......................................................................................................................61


TABLE OF FIGURES

Figure 1: Map of Eastern Health (Northeast Avalon Area Outlined) ...............................................15

Figure 2: Map of Northeast Avalon Communities ...............................................................................16

Figure 3: Breakdown of Northeast Avalon into Telephone Survey Sub-Regions .............................24

Figure 4: Average Physician Wait Time, Health Sciences Centre.......................................................35

Figure 5: Average Physician Wait Time, St. Clare’s ..............................................................................35

Figure 6: Average Bed Wait Time, Health Sciences Centre.................................................................36

Figure 7: Average Bed Wait Time, St. Clare’s ........................................................................................36


TABLE OF TABLES

Table 1: Average Bed Wait Time (in hours) for all Triage Levels......................................................36

Table 2: Median Wait Time (Days), Non-Urgent Exams, 3rd Quarter Comparison (October 1 – December 31) for City Hospitals ...................................................................50


TABLE OF APPENDICES

Appendix A: Terms of Reference - Northeast Avalon Community Health Needs Assessment SteeringCommittee.................................................................................................................................63

Appendix B: Terms of Reference - Community Health Needs Assessment Advisory Committee ......64

Appendix C: Northeast Avalon Community Health Needs Assessment Consultation SessionSummary Notes........................................................................................................................65

Appendix D: List of Key Informants.............................................................................................................66

Appendix E: Standardized Questionnaire Used to Guide Key Informant Interviews (External,General) .....................................................................................................................................67

Appendix F: Standardized Questionnaire Used to Guide Key Informant Interviews (Internal andExternal, Specific).....................................................................................................................68

Appendix G: List of Focus Group Sessions Conducted with Community Partner Agencies ................69

Appendix H: Standardized Questionnaire Used to Guide Focus Group Discussions............................70

Appendix I: Northeast Avalon Community Health Needs Assessment Telephone Survey .................71

Appendix J: Northeast Avalon Community Health Needs Assessment Emergency Room SurveyReport ........................................................................................................................................72

Appendix K: ER Data (Internal to Eastern Health) ...................................................................................73

Appendix L: Backgrounder - Client Centred Waitlist Management Strategy for Eastern Health .......74

Appendix M: Written Submissions Request ................................................................................................75

Appendix N: Written/Oral Submissions Received .....................................................................................76

Appendix O: Secondary Resource Materials................................................................................................77

Appendix P: Newsletters Circulated During the Community Health Needs Assessment....................78

Appendix Q: Profile of the Northeast Avalon from Community Accounts .............................................79


14 A C C E S S - C H A R T I N G T H E C O U R S E

1 INTRODUCTION

15T H E N O R T H E A S T A V A L O N C O M M U N I T Y H E A L T H N E E D S A S S E S S M E N T

Eastern Health is the largest health services organization in the province ofNewfoundland and Labrador. With a budget of over $1 billion, the organizationprovides the full continuum of health services (community, acute and long-term care)and has both regional and provincial responsibilities. As seen in Figure 1 below, theEastern Health region extends west from St. John’s to Port Blandford and includes allcommunities on the Avalon, Burin and Bonavista Peninsulas.

FIGURE 1: MAP OF EASTERN HEALTH (NORTHEASTAVALON AREA OUTLINED)

The provincial Regional Health Authorities Actindicates that one of the responsibilities of ahealth authority is to assess health andcommunity service needs in its region on anongoing basis. To date, Eastern Health hascompleted needs assessments on the BurinPeninsula (2006) and the Southern Avalon(2007). In 2008-2009, the Northeast Avalonwas chosen as the next area of the region toassess, which included the followingcommunities: Avondale, Bauline, Colliers,Conception Bay South, Conception Harbour,Flatrock, Harbour Main-Chapel’s Cove-Lakeview, Holyrood, Logy Bay-MiddleCove-Outer Cove, Marysvale-Georgetown,Mt. Pearl, Paradise, Petty Harbour-MaddoxCove, Portugal Cove-St. Philips, Pouch Cove, St. John’s, and Torbay.

Notably, Bell Island was not included in thisassessment since Eastern Health participated

in a needs assessment of that part of theregion in 2006 as a member of the Bell IslandHealth and Wellness Committee.

Why conduct a needsassessment?A community health needs assessmentgathers information about the health of aparticular area from both a factual and anopinion perspective. Once issues areidentified, they are prioritized andrecommendations are made around the issues.This provides the organization with a betterunderstanding of what communities feel theyneed in order to be healthier.

A community health needs assessment helpsto start and continue dialogue with manyindividuals and groups from the community.

St. John’s

Torbay

Pouch Cove

Portugal Cove

Petty Harbour

n’sSt John

Paradise

Maddox Cove

St. Philips

nnsStt.. JoJohnhn

CM dd

Mt. Pearl

Marysvale

HolyroodAvondale

Colliers

ConceptionBay South

CoColll ieConception

Harbour

P

dH l dd

Harbour Main

Chapels Cove

FIGURE 2: MAP OFNORTHEAST AVALONCOMMUNITIES


This can lead to increased participation and engagementin the health of their region and lead to strongerpartnerships between the community and its health board(Cavanagh & Chadwick, 2005). The Board of Trustees ofEastern Health recognizes that communities have thecapacity to identify and respond to issues that are ofconcern to them.

What does a needs assessmenthave to do with the provision ofhealth and community services?In short, a community health needs assessment helpsEastern Health to better understand local needs; thebetter it understands the needs, the better able it is toprovide services for the overall population.

Population health is an approach to health that aims toimprove the health of the entire population and to reducehealth inequities among population groups. In order toreach these objectives, it looks at and acts upon the broadrange of factors and conditions that have a stronginfluence on health, also known as the “determinants ofhealth”.

As an example of the impact of determinants of health,studies suggest that the distribution of income in a givensociety may be a more important determinant of healththan the total amount of income earned by societymembers. Large gaps in income distribution lead toincreases in social problems and poorer health among thepopulation as a whole (Public Health Agency of Canada,2003).

The Determinantsof Health

• Income and Social Status

• Social Support Networks

• Education and Literacy

• Employment/Working Conditions

• Social Environments

• Physical Environments

• Personal Health Practices and Coping Skills

• Healthy Child Development

• Biology and Genetic Endowment

• Health Services

• Gender

• Culture


What is the profile of theNortheast Avalon?1

An area of contradictions:provincial comparisonsThe Northeast Avalon is unique in manyways. This economic zone (Northeast AvalonRegional Economic Development Board) isdifferent from others in the province in that ithas the largest population within the smallestgeography of any zone.

This area experienced a 4.5% increase inpopulation between 2001 and 2006, while theentire province had a population decline of1.5% during that same period.

The Northeast Avalon is home to most of thebusinesses in the province and, according to2006 data, leads the province in having thehighest percentage of the population with aBachelor’s Degree or higher (23.7% comparedto 15.1% for the province).

In this zone, 15.8% of people aged 18-64 donot have a high school diploma, as comparedwith 25.1% for the province as a whole(2006).

In 2006, personal income per capita in thisregion was $25,500; personal income percapita for the province was $22,900.

In 2006, half of the couple families in theNortheast Avalon had incomes greater than$71,500; half of the couple families in theprovince had incomes greater than $56,500.Half of the lone-parent families in the regionhad incomes of less than $27,800 in 2006;half of the lone-parent families in the provincehad incomes of less than $25,300.

According to the 2006 Census, 18.8% offamilies in the Northeast Avalon are headedby single parents, compared with a provincialaverage of 15.5%.

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1 Statistical information for this section found at www.communityaccounts.ca (2010) and includes Bell Island. Community Accountsincludes data from a variety of sources, including national and provincial health surveys and Census data.

Photography: Northeast Avalon Regional Economic Development Board (Colliers, Harbour Main) Newfoundland and Labrador Tourism/Hans G. Pfaff (St. John’s)


http://www.communityaccounts.ca

In 2008, 10.4% of the population in this zonereceived Income Support Assistance at somepoint, which was similar to the provincialaverage of 10.0% for the same year.

The Employment Insurance Incidence in2008 for the Northeast Avalon was 15.1%compared with 34% for the province overall.

An area of regional disparityWithin the Northeast Avalon region itself,there is considerable disparity: rural – urban;the traditional fishing industry – the modernoil and gas sector; population growth –population decline; areas of prosperity – areasstruggling.

While the overall area had population growth,there are marked differences between somecommunities within this zone. For instance,between 2001 and 2006, the populations inTorbay/surrounding area and Paradiseincreased by 36.9% and 36.4%, respectively,while Avondale experienced a populationdecline of -6.8%.

In 2006, personal income per capita in thezone ranged from a low of $13,000 to a highof $26,900.

In 2008, the incidence of Income SupportAssistance ranged from a low of 2.5% in LogyBay-Middle Cove-Outer Cover to a high of13.4% in St. John’s.

Employment Insurance Incidence in 2008ranged from a low of 12.1% in Mount Pearlto a high of 54.5% in Marysvale-Georgetown.

An area of increasing diversityDemographics are changing: between 1996and 2006 there was a significant increase inthe population aged 55+, while there wereoverall declines in the population up to 39years of age. The greatest increase was in theage group 55-59, which increased by 71.9%,while the most significant decline was in theage groups of 5-9 (-18.6%) and 10-14 (-18.5%).

The Northeast Avalon region is becomingmore culturally diverse; the vast majority ofimmigrants to the province are in this region.There is increasing awareness about meetingdiverse needs within the Northeast Avalon.For instance, this zone has the highestnumber of community-based organizationsrepresenting a wide range of mandates, suchas advocacy, education, awareness and supportaround issues of sexual orientation, culturalcompetence and all levels of ability.

The Northeast Avalon region isbecoming more culturally diverse; thevast majority of immigrants to theprovince are in this region.



Health profile of the Northeast AvalonAccording to the Canadian Community Health Survey (2007-08), 65.3% of individuals in theNortheast Avalon rated their health as either “very good” or “excellent”, compared with 61.8% forthe province and 59.2% for Canada.

The rate of smoking in the Northeast Avalon in 2007-08 was 18.0% compared with 19.9%provincially and 17.0% nationally.

The rate of adult obesity in this zone (2007-08) was 22.7%; the provincial rate was 25.4% whilethe national rate was 17.1%.

Diseases of the circulatory system accounted for 11.2% of hospital morbidity/separations2

between 2003 and 2005. These diseases were also the highest at the provincial level (13.5%) forthat same timeframe.

____________________________________________________________________

2 Refers to patients who leave hospital due to either death or discharge.

Photography: Northeast Avalon Regional Economic Development Board (Mount Pearl, Outer Cover and Petty Harbour)

2 METHODOLOGYAND SUMMARYOF FINDINGS


Overview of process

A Different ApproachDue to the size of the population andcomprehensiveness of services offered withinthe Northeast Avalon, Eastern Health took adifferent approach to the needs assessment ofthis area as compared with past assessments.Previously, telephone surveys, focus groupsand key informant interviews occurredsimultaneously. The Northeast Avalonassessment, on the other hand, started with atelephone survey to identify key themes.Questions on the survey centred ondemographic information, primary healthcare3, satisfaction with services, navigation ofthe system and confidence in the system.Focus groups and key informant interviewsthen took place and were based mainly on thethemes that emerged from the telephonesurvey.

LimitationsIt is important to note that while primaryresearch such as telephone surveys providesimportant insights, each methodology haslimitations. In the case of a telephone survey,the obvious limitation is that respondentsmust have a land line phone. Anotherlimitation with telephone surveys in recentyears is the difficulty reaching people who

tend to use cell phones and text messagingmore than land lines. In order to addresslimitations from primary research, EasternHealth typically looks to validate informationin the primary research methods and“triangulate” the data by using several differentsources. In other words, if a theme emergesin several primary research methodologies itmost likely is a pressing issue.

Community ConsultationThe results of the telephone survey provideda starting point for further investigation. Aconsultation session was held withcommunity stakeholders to discuss the resultsof the survey and get their perspectives on themain themes arising from the survey.Representatives of 36 community-basedorganizations reinforced our belief in theimportance of getting input from a variety ofmethods – not only a telephone survey. Basedon feedback from that consultation, focusgroup sessions were arranged withcommunity partners who represent a broadrange of perspectives. Emphasis was placed ongetting input from some groups of people whomay be harder to reach through a telephonesurvey.

___________________________________________________________________

3 Primary health care refers to the first or “primary” contact an individual has with health services, such as through a family doctor or otherhealth professional. Secondary care refers to “assessment, diagnosis, treatment and preventative services associated with more complexproblems, and is generally provided by specialist physicians and other specialized health professionals”. Tertiary care refers to “highlyspecialized diagnostic and treatment services where patients are referred from other hospitals or physicians” (Manitoba Health, 2002).


Further Primary ResearchSubsequent focus groups, key informantinterviews and written/oral submissionsconfirmed the findings of the telephonesurvey in addition to providing a rich level ofdetail on access to health services, wait times,and other community health needs toconsider for future prioritization.

Emergency Room (ER) SurveyAn extensive survey with patients of both theHealth Sciences Centre and St. Clare’s MercyHospital ERs provided substantial primaryresearch information into reasons for visitingthe ER and potential alternatives.

Internal InformationInternal Eastern Health reports and dataprovided insight into patterns of use and the

size and scope of the issues identified. It isimportant to note that there have beenlimitations in capturing internal data, whichare outlined further throughout this report.

Secondary ResearchA literature review provided further context,particularly in terms of ER wait times andaccess to specialty services in otherjurisdictions.

CommitteesTwo separate committees were established toguide the process: a Steering Committeecomprised of Eastern Health managers andan Advisory Committee made up ofindividuals who were selected based on apublic call to sit on the committee.


Left to right: Gillian Janes, Maureen Bethel, Sondria Browne, Maurice Brewster, Jack Strawbridge, Wayne Miller,Linda Janes. Missing from photo: Shirley Murphy, Ed Wade.

FIGURE 3: BREAKDOWN OF NORTHEAST AVALON INTOTELEPHONE SURVEY SUB-REGIONS

HolyroodHolyroo

Avondale

Conception HarbourColliersC lli

Marysvale

Harbour Main - ChapelsCove - Lakeview

ConceptionBay South

Petty Harbour -Maddox Cove

MOUNTPEARL

ST. JOHN’SParadise

Freshwater

P

Freshwaater

Lance Cove

Wabana

Bauline

Pouch Cove

Flatrock

Torbay

T. JST

Portugal Cove -St. Philip’s

Logy Bay - OuterCove - Middle Cove

�

�

ZONE 19

Area A: St. John’s, Mt. Pearl, Petty-Harbour-Maddox Cove: 503 interviews

Area B: Conception Bay South, Paradise: 203 interviews

Area C: Pouch Cove, Bauline-Flatrock-Torbay, Logy Bay-Middle Cove-Outer Cove, Portugal Cove-St. Philip’s: 202 interviews

Area D: Harbour Main-Chapels Cove-Lakeview, Holyrood, Avondale, Conception Harbour, Colliers, Marysvale: 124 interviews


Summary of Findings

Highlights of Telephone SurveyA local research firm was engaged to conductthe telephone survey. Calls took place betweenFebruary 9-18 and on March 3, 2009.

There were 1,032 completed interviews andthis sample size provides a margin of error of+ 3.1 percentage points 19 times out of 20.

The participation rate for the survey was33.5% (number of completed calls divided bylive answers plus those eligible to complete thesurvey).

The Northeast Avalon area was subdividedinto four smaller areas for comparability:

• Area A – St. John’s, Mt. Pearl, Petty-Harbour-Maddox Cove: 503 interviews

• Area B – Conception Bay South, Paradise:203 interviews

• Area C – Pouch Cove, Bauline-Flatrock-Torbay, Logy Bay-Middle Cove-OuterCove, Portugal Cove-St. Philip’s: 202interviews

• Area D – Harbour Main-Chapels Cove-Lakeview, Holyrood, Avondale,Conception Harbour, Colliers, Marysvale:124 interviews

There was no statistically significantdifference in the responses from the fourareas. In other words, the region was verysimilar in terms of participants’ responses.

Access to family physicians• 97.3% of respondents have a family

physician (General Practitioner, or GP)4

and 77.2% of those have had the samefamily physician for 5 years or more

• 90% of people with a family doctor travel20 minutes or less from their home totheir family phyician’s clinic

• 74% saw their family physician between 1and 6 times in the past 12 months

• 77% can see their family doctor within aweek for a non-urgent reason

• 52% can see a family doctor (notnecessarily their family doctor) at theirclinic the same day for an urgentappointment

Dissatisfaction with wait times• Telephone respondents were asked to

indicate their levels of satisfaction withvarious health and community services.Highest levels of satisfaction were seen inCommunity Health Nursing, AmbulanceServices, Allied Health/RehabilitationServices and X-ray Services/BloodCollection Services.

_____________________________________________________________________

4 For comparison purposes, the rate of access to GPs was 88.7% and 88.0% in the Burin Peninsula and Southern Avalon NeedsAssessments, respectively.


• Highest levels of dissatisfaction were seenin Emergency Rooms, Access toSpecialists, and Access to SpecialtyDiagnostic Imaging (DI) Services.

• Dissatisfaction levels were mainly withwait times for adult services.

Key informant interviewsInterviews were completed with keyinformants both within and outside ofEastern Health between July 2009 andJanuary 2010.

Standardized questionnaires were developedin conjunction with both the SteeringCommittee and Advisory Committee to guidethe key informant interviews.

Lists of external and internal stakeholdersinterviewed are included in Appendix D.Questions for both types of interviews areincluded in Appendices E and F.

External Interviews• Representatives from 18 organizations

provided both a broad overview of theNortheast Avalon region as well as morespecific details about wait times in theER, for specialists and for DI.

• The majority of these interviews werecompleted in person, while two werecompleted by telephone.

• Four organizations were contactedmultiple times for an interview but wereunable to participate.

• Notes from all interviews weretranscribed and key themes wereidentified, which include:

o Concerns about wait times in thefocus areas;

o An emphasis on using limitedresources efficiently;

o A range of communications issues,from awareness of how to navigatethe system to better collaborationbetween agencies;

o A wide range of community healthneeds.

Internal Interviews• Fourteen staff members of Eastern

Health were interviewed in person andone by telephone.

• Notes were transcribed and analyzed toidentify key themes.

• The main themes from these interviewspertained to:

o Competing demands on resources;o The need to use limited funds most

effectively;o Ways to improve communication

with both internal and externalstakeholders;

o The need for preventative approachesto reduce or eliminate demands forservices in the long term.

Representatives from 18 organizationsprovided both a broad overview of theNortheast Avalon region as well asmore specific details about wait times inthe ER, for specialists and for DI.


Focus groupsThirteen focus groups comprising a total of117 participants were completed betweenOctober and December 2009.

A standardized questionnaire was developedin conjunction with both the SteeringCommittee and Advisory Committee to guidethe focus groups.

A list of community groups involved is foundin Appendix G and the questions are includedin Appendix H.

Notes were transcribed and analyzed toidentify key points:

• Agreement with the emphasis on waittimes;

• Emphasis on efficient use of resources;

• Improving communications and providingsupport for clients and families in dealingwith health issues;

• The importance of prevention;

• The ongoing need for Mental Healthservices.

Focus group participants also provided keypoints about access to GPs in the NortheastAvalon:

• While GP access is generally very goodwithin the Northeast Avalon, there are“pockets” of people who have difficultyfinding and/or retaining a GP.Newcomers to the area – whether fromelsewhere in the province or newimmigrants to the province – have

difficulty knowing where to go to find aGP who is taking new patients.

• The word “access” should be used in thebroadest sense; even though peoplegenerally have a GP they may still facebarriers such as lack of transportation orchildcare, language barriers or evenphysical access to clinics.

• Additionally, community members mayhave a GP but feel uncomfortablediscussing certain issues or even facerejection (e.g. stigma associated withAIDS, Hepatitis, sexual orientation orsexual health issues).

• Patients who do not have a doctor orcannot get in to see their GP may go to awalk-in clinic; however, walk-in clinicsreportedly have a limited capacity andpatients may be turned away when clinicsreach capacity.

• Many patients choose to go to the ER ifthey do not have a doctor or cannot get into see their GP in a timely manner.

• There is a popular perception that goingto the ER will result in quicker access tospecialists and DI.

• For people who do not have access to aGP, continuity of care can be affected. Forexample, newcomers to the area mayexperience delays in referrals for specialtyareas (e.g. psychiatry) if they cannot finda new GP to coordinate follow-up carewith their former GP.


Written and oral submissionsA public call for submissions about the health needs of the Northeast Avalon was advertised inthe media from October-November 2009. The advertisement invited submissions fromindividuals, community partners and service organizations. Thirteen submissions were receivedon a variety of issues: six from individuals and seven on behalf of community-based organizations.A copy of the advertisement is included in Appendix M while a list of submissions and topics isincluded in Appendix N.

Highlights of the ER SurveyBased on feedback from the telephone survey,it was decided that further research wasnecessary to learn more about the underlyingissues surrounding long ER wait times in theNortheast Avalon. A survey of patientstriaged (ranked)5 as either Level IV or V (i.e.less urgent) was developed to find out moreabout why they visit the ER and possiblealternatives to the ER.

Following a literature review that includedvarious survey tools, the EmergencyDepartment Patient Experience Survey(2008), conducted by the Health QualityCouncil of Alberta (HQCA), was selected asthe basis for the Northeast Avalon ER survey.The HQCA survey was based on an originalsurvey conducted by Picker Europe for theBritish National Health Service.

The survey was adapted to meet local needs

and permission was granted by the HumanInvestigation Committee of MemorialUniversity of Newfoundland to conduct thesurvey at both the Health Sciences Centreand St. Clare’s ERs between September andDecember 2009.

A total of 693 surveys were administered topatients who presented with Level IV andLevel V symptoms (i.e. less urgent) in theEmergency Room (ER) at St. Clare’s MercyHospital (361 respondents, or 52.1%) andthe Health Sciences Centre (332respondents, or 47.9%).

Survey results were analyzed in January 2010and the overall survey report is found inAppendix J. Survey participants wereinstructed to select all applicable options;therefore, for many of the survey questions,responses may exceed 100%.

_____________________________________________________________________

5 Further explanation of Triage Levels is provided on page 34


Why Are Patients Choosing the ER?46.3% indicated that they felt the ER was thebest place for their medical problem.

27% of respondents indicated they were toldto visit the ER.

19% indicated it was the only choice availableat the time.

18.3% indicated it was the most convenientplace to go.

Who is Advising Patients to Visitthe ER?56.1% of patients indicated they had not beenadvised by anyone to go to the ER, but haddecided to go on their own.

Friends or family had advised 21.2% ofpatients to visit the ER.

Patients who selected “Other” (13.6%)indicated they were advised to go to the ERby their employer or a medical professionalincluding a doctor/physician, home-carenurse, and community health nurse.

11.4 % were advised to go to the ER by theirfamily doctor.

What is the Description of theirCurrent Medical Problem?The majority of patients (64.6%) felt theircurrent health problem was “somewhat

urgent” while 19.2% felt their problem was“urgent”.

42.8% indicated that their reason for visitingthe ER was due to a new injury or accident(unrelated to a previous injury or accident).

26.7% were at the ER due to a new illness orcondition (unrelated to a previous illness orcondition).

15.3% visited the ER due to a worsening of apre-existing medical condition.

16.7% of patients specified that they hadvisited the ER earlier that month for the samemedical problem.

Approximately 18% of patients indicated thatthey were waiting for at least one servicerelated to the problem that brought them tothe ER: 6.6% of patients were waiting for amajor diagnostic test (e.g. CT scan, MRI, X-ray), 5.3% were waiting to see a specialist, and2.2% were waiting for a minor diagnostic test(e.g. blood or lab tests) at the time of their visit.

Are Patients Visiting the ERBecause They Are Unable to SeeTheir GP?Approximately 90% of the patients surveyedin the ER specified they had a family doctor,while approximately 10% indicated they did not.


Just under half of the patients (43.4%) visitingthe ER acknowledged that, within the pastyear, they had frequented the ER at least oncebecause they could not get in to see theirfamily doctor.

Approximately 40% of the patients visited theER between 1 and 4 times and 3.5% visited 5or more times within the past 12 months dueto an inability to see their family doctor.

Priority AreasBased on initial feedback from the telephonesurvey, there are three main areas that wereprioritized for recommendations and actionplanning:

• Wait times in the ER• Access to specialists• Access to DI

While wait times within these three servicesemerged as the focus of this particularassessment, Eastern Health recognizes thatthere are other concerns to address within theNortheast Avalon area. As such, this reportwill also highlight issues that particularlyemerged through focus groups and keyinformant interviews for future planning andpriorities. Some of these areas includeservices for children, seniors, and clients inneed of Mental Health services. Issues ofincreasing individuals’ capacity to take greaterownership of their own health and supportfor prevention and early intervention werealso brought forward.

It is also important to point out that inaddition to needs assessments there are manyaspects to planning within Eastern Healthand numerous initiatives ongoing within ourvarious program areas. Thus, this report mustbe considered within the overall context ofplanning within Eastern Health to addressboth short-term and long-term program andservice needs, some of which are highlightedin this report.

Common IssuesThere are a number of common challengesthat cut across the three priority areas of ER,specialists and DI. While they are commonconcerns to all three priority areas there aredifferences in how to address these concernsin each area, which will be outlined insubsequent sections of this report. As a briefintroduction, the issues of common concernare highlighted:

1. Waitlist ManagementAccessing and Maintaining Data

There is a growing need to collect, collate andanalyze data, however there are challengeswith Eastern Health’s capacity to report ondata related to the ER, specialists and DI.Data on wait times have been a challenge tomaintain, analyze and report.

Managing WaitlistsManaging waitlists for specialists and DI iscomplex. There is a vast array of individualcases, procedures, and locations for


procedures to be performed as well asdiagnostic testing to coordinate. There is alsoa limited capacity to determine the level ofurgency and appropriateness of manyreferrals, which impacts on current resources.Resources are required to ensure the accuracyof waitlists and to track different wait timemeasures. Dedicated resources are alsorequired to capture data, ensure accuracy,provide timely access as well as monitor dataover time.

Recommendation: Eastern Health has anapproved Client Centred WaitlistManagement Strategy, thus it isrecommended that the organization seekadditional funding to fully implement this plan.

2. CommunicationsNeed for Enhanced Public Awarenessand EducationMany people have expressed concern that thedifficulties associated with waiting are notknowing why the wait times are as long asthey are or where they fit in the queue. Thepublic generally does not know how levels ofurgency are ranked within the health system,which can lead to frustration when peopleperceive their situations as urgent. Waitlistprocesses need to be better explained andefforts to reduce wait times within the ER,with specialists and with DI must becommunicated more effectively.

Recommendation: Eastern Health shouldinitiate the public posting of wait timeindicators to assist the public in theirunderstanding of the challenges that thehealth system currently faces.

3. Monitoring ProgressIt is important to measure the effectiveness ofinterventions over the long term. Thisinvolves identifying key indicators of successto track progress over time and compareprogress with established benchmarks.

Recommendation: Eastern Health’s Board ofTrustees should report back to the public onthe progress of the recommendations andissues raised two years after the release of thisreport.

Recommendation: Eastern Health’s Presidentand CEO should provide semi-annualupdates to the Board of Trustees on theprogress towards the successfulimplementation of the recommendations ofthis report.



3 WAIT TIMES INTHE EMERGENCYROOM


What is the problem?

Lengthy wait times and overcrowdingOf the Northeast Avalon telephone surveyrespondents who have used the ER, 36% were“very dissatisfied”; 88% of those respondentsreferred to long wait times as the reason fortheir dissatisfaction.

Of the Northeast Avalon telephone surveyrespondents who indicated they are unable toget an urgent appointment with their familydoctor, 78% went to an ER.

Telephone survey respondents who reportedhaving gone to an ER were asked how longthey waited from the time they registered tothe time they were seen by a doctor: 47% saidthey waited less than 4 hours; 47% said theywaited 5-9 hours; and 6% said they waited 10hours or more.

ER survey and focus group participants alsorelayed that they experience long waits whenthey go to the ER for less urgent issues.

After-hours access is a problem: manycommunity members do not have access to aGP on evenings and weekends. There are very

few walk-in clinics in the area, thus the ER istheir only option.

Research indicates that patients who leave theER without being seen by a physician mightbe at risk of developing complications andmay end up returning to the ER with worsehealth conditions. During the fiscal year2008-09, 8% of the total patients who visitedboth the Health Sciences Centre and St.Clare’s ERs left without being seen; during thefiscal year 2009-10, the rate rose to 11%.These rates are higher than those found in anumber of Canadian studies in which the ratevaried between 1.4% and 3.57% (Kennedy,MacBean, Brand, Sundararajan and Taylor,2008).

A key theme that emerged from the Northeast Avalon Community Health NeedsAssessment was dissatisfaction with wait times in the Emergency Room (ER).Various sources clearly outlined dissatisfaction with prolonged waits as well as theneed for more open communication about wait times and processes.

Research indicates that patients wholeave the ER without being seen bya physician might be at risk ofdeveloping complications and mayend up returning to the ER withworse health conditions.

Patients who are admitted to hospital throughthe ER have to wait on stretchers if there isno bed available. This may lead to furtherproblems associated with overcrowding suchas a lack of privacy or the risk of acquiringrespiratory infections.

Some community members describe a loss ofdignity associated with waiting in a crowdedhall while feeling sick and vulnerable.

Overcrowding in the ER also impacts onParamedicine and Medical Transportresources. For example, ambulances thatarrive at the Health Sciences Centre or St.Clare’s can get diverted from one site to theother when either ER is crowded. This is achallenge to co-ordinate and maintain, as bothsites receive patients from all over the province.

CommunicationCommunity members report that there canbe poor communication about how long theywill have to wait in the ER. The publicgenerally does not know how levels of urgencyare ranked, or “triaged”, in the ER, which canlead to frustration when people perceive theirsymptoms as urgent. This is particularlyproblematic for individuals who are notfamiliar with the health system or who mayface other barriers such as low literacy skillsor a lack of community supports.

What do we know from internalinformation?When analyzing Eastern Health data andreports it is important to explain the triageprocess in the ER. The Canadian Associationof Emergency Physicians (CAEP) defines“triage” as “sorting or prioritizing….[It]requires a team of providers capable ofcorrectly identifying patients’ needs, settingpriorities and implementing appropriatetreatment, investigation and disposition”(2009). The Canadian EmergencyDepartment triage and acuity scale, or CTAS,involves five categories with recommendedtimes, which are listed in brief below:

• Level I - Resuscitation: requiresimmediate attention by physician

• Level II - Emergent: attention byphysician within 15 minutes

• Level III - Urgent: attention by physicianwithin 30 minutes

• Level IV - Less Urgent: attention byphysician within one hour

• Level V - Non Urgent: attention byphysician within two hours

Appendix K provides the number of lessurgent patients and the highest volume ofthese patients at both the Health SciencesCentre and St. Clare’s.


FIGURE 4: AVERAGE PHYSICIAN WAITTIME, HEALTH SCIENCES CENTRE

FIGURE 5: AVERAGE PHYSICIAN WAITTIME, ST. CLARE’S

Average Physician Wait TimeThe average physician wait time in the ER is the measure of time between when a patient registersin the ER until the patient first sees a physician. Based on comparisons with the aforementionedCAEP recommendations, data for the Health Sciences Centre (Figure 4) indicate that averagewait times for Levels III and IV have been most problematic.

Also based on CAEP recommendations, data for St. Clare’s (Figure 5) indicate that average waittimes for Levels III and IV are most problematic; however, the wait time for Level V has beenshorter than the recommendation for two of the last three fiscal years.


FIGURE 6: AVERAGE BED WAIT TIME,HEALTH SCIENCES CENTRE

FIGURE 7: AVERAGE BED WAIT TIME,ST. CLARE’S

Average Bed Wait TimeAnother aspect of wait times in the ER thataffects patient flow is the amount of time it takesfor a patient admitted to hospital through the ERto move to an available bed within the hospital.In 2007, the CAEP recommended that alladmitted patients be transferred out of the ER toan inpatient area within two hours of the decisionto admit. The graphs in Figure 6 and Figure 7provide the average bed wait times for 2007-2010within both St. John’s ERs:

• While there have been some improvements,most wait times have been increasing andexceed the recommended benchmarks.

• The average bed wait time at St. Clare’s ER islower than at Health Sciences Centre ER;however this is mainly due to limited bedspace at St. Clare’s to hold patients in the ER,as compared with the Health Sciences Centre.

• While these graphs break down the waittimes by triage level, it is also important toconsider average wait times for all triage levelscombined. These are provided in Table 1.

2007/08 2008/09 2009/10

St. Clare’s 3.2 3.4 3.7

HSC 6.2 5.6 7.4

TABLE 1: AVERAGE BED WAIT TIME (INHOURS) FOR ALL TRIAGE LEVELS


What are the reasons forthe long wait?

High demands on resourcesData indicates a steady increase of ER visitsover the last several years: in 2007/08 therewere 85,304 visits to both Health SciencesCentre and St. Clare’s ERs (combined); in2008/09 the number increased to 85,898,while in 2009/10 it increased again to 86,537.

It is difficult to process patients faster to makeup time when there is not enough space toassess them appropriately. For instance, mostpatients need to be able to lie down to beassessed properly, as opposed to seated in a chair.

Many stakeholders are of the opinion that thegeneral public perceives that going to the ERprovides quicker access to specialists and/orDI, as there are long wait times for theseservices as well. This prompts some people togo to the ER rather than make anappointment with their GP.

Responding to a vast range of client needs alsopresents many challenges. There areincreasingly complex health issues within theNortheast Avalon, which has a direct impacton the resources available to treat such issues.For example, this area’s rates of obesity andsmoking – both of which are well known toincrease health risks – exceed national averages.

There are numerous factors that affect bedavailability for patients to transfer from theER to other floors in the hospital. Thesefactors include the patients who require anAlternate Level of Care (ALC) but cannot bedischarged from hospital in a timely fashionwhen there is limited bed availability in long-term care, the high demand for CommunityCare Nurses and other health professionals toprovide home-based services, and the lack ofhome supports to assist with daily activitieswithin the community. In addition,Paramedicine and Medical Transportresources are currently challenged to balancedemands between routine patient transfersbetween sites and emergency response.Shortages of professionals – particularlywithin Nursing and Allied Health – also havean impact on bed availability and timelydischarge.

Need for DataPresently, Eastern Health captures data on thetriage levels and various wait times (i.e. keyperformance indicators, or KPI) in theEmergency Departments at both the HealthSciences Centre and St. Clare’s. A key piece ofdata that is not currently collectedelectronically for administrative purposes isthe patients’ presenting diagnosis comparedwith disposition on discharge. Thiscomparison would enable the organization tolook beyond utilization and to explore issuesof client outcomes.


___________________________________________________________________

6 The CMAC, formed in 2009, is comprised of representative GPs from the community who liaise with Eastern Health to address issuesof common concern in the Northeast Avalon.

What do werecommend?Timely access should be a priority in the ER,yet there are many competing demands forresources like specialized staff and adequatespace. Eastern Health requires a strongcommitment from all levels of the organizationand community partners in response to thesecompeting demands – not only in terms ofallocating sufficient resources to solveproblems but also to ensure accountability andcompliance with new approaches. Further,there must be flexibility and an openness tochange. The following recommendations arespecific to the ER:

(1) Increase the availability ofresponsive/less urgent care in thecommunity. Recommendation: Develop a proposal forEastern Health’s Executive Team thatdescribes a model of care for less urgentconditions to be offered outside of thehospital setting that would seek to relievepressure from the ERs. • This proposal should be developed inconsultation with the Community MedicalAdvisory Committee (CMAC)6 and otherpartners and would be based on research andinternal data to determine details on whattype of services to offer, at what times, andwhere.

• This proposal with recommendations foraction should be forwarded within oneyear of commencement of itsdevelopment.

(2) Increase access to healthprofessionals outside of the hospitalsetting. Recommendation: Based on data indicatingareas of greatest need, collaborate withpartners to offer services in the communitythat would help to relieve pressure in theER. These services need to target patientgroups that internal data indicate are morelikely to be frequent users of ERs as well asspecific geographic locations. This wouldentail working with community-basedorganizations that already have well-established programs in the community andhave strong links with community members.There are a number of partnerships alreadyestablished between Eastern Health andcommunity-based agencies to offer health-related services outside of Eastern Healthfacilities, such as:

• The Salvation Army New Hope Centrehas been arranging to provide both a nursepractitioner and GP through dedicatedclinical space at that site on a weekly basis;

• The MacMorran Community Centreoffers the services of a nurse practitionerto area residents on a weekly basis;


• Community Health nurses have offeredclinics such as foot care on-site for clientsof the Gathering Place;

• Choices for Youth recently began toprovide a nurse practitioner for clients atthe Carter’s Hill youth services site indowntown St. John’s.

(3) Commit to further analyzingthe need for additional humanresources (particularly physiciansand nurse practitioners) within ERsat both Health Sciences Centre andSt. Clare’s. Recommendation: Develop a proposal forapproval by Eastern Health’s ExecutiveTeam with recommendations on additionalhuman resources needed for each ER. Thiswould require further research and analysispertaining to the volume and acuity ofpatients, as well as recommendations fromagencies such as CAEP.

• This proposal would be developed inconsultation with health professionalswithin the ER and would include a reviewof recommendations from the PatientFlow Study completed in 2009.

• This proposal and recommendationsshould be forwarded to the ExecutiveTeam within six months ofcommencement.

(4) New Technology Recommendation: Implement an electronicsystem such as a “Bed-board”, as identified inthe Patient Flow Study.

• The Patient Flow Study identified theBed-board as a “technology based solutionthat electronically provides informationregarding the status of patient beds on thein-patients floors in order to facilitatetransfers from the EmergencyDepartment” (Global Solutions, 2009).

• This system would enable staff andphysicians to be notified quickly whenbeds are available throughout the hospital,thus improving the movement of patientsfrom the ER.

(5) Improve communication bothinternally and externally.Recommendation: Develop acommunications strategy to (a) betterexplain the triage system and wait times inthe ER to the public and (b) outline theefforts underway to reduce wait times in theER to both staff and the public.

• Include an education component forpatients regarding options available for lessurgent issues as well as the appropriate useof the ER.


• Identify mechanisms for people seeking anew GP to find updated information onGPs accepting new patients. In particular,the College of Physicians and Surgeons ofNewfoundland and Labrador recentlyannounced that it will provide informationon GPs accepting new patientsthroughout the province through itswebsite, www.cpsnl.ca. This link can beincluded on the Eastern Health website.Additionally, Eastern Health’s website caninclude the Department of Health andCommunity Services’ telephone numberthat lists GPs taking new patients.

How will we know we have succeeded?While it is essential to dedicate resources and implement new approaches to improve wait timeswithin the ER, it is equally essential to measure the effectiveness of efforts over the long term.An evaluation strategy for ER wait time initiatives should include:

• The establishment of a reporting system for quality improvement measures with specificindicators. Established targets would be reported on an annual basis (e.g. average bed waittime, percentage of patients that leave the ER without being seen by a physician).

• An expansion of effective partnerships with community groups to reduce the use of ER forless urgent issues, such as the partnership between Eastern Health and the Salvation ArmyNew Hope Centre in downtown St. John’s. An evaluation of these new partnerships shouldbe conducted to determine their impact on visits to the ER for less urgent issues.

• Evidence-informed initiatives for reducing wait times in the ER and sharing what is learnedfor the benefit of other related initiatives both internal and external to Eastern Health.


http://www.cpsnl.ca

4 ACCESS TOSPECIALISTS



Lengthy wait timesCommunity stakeholders indicate that theyconsider wait times for specialistappointments (e.g. surgeons, psychiatrists)and procedures (e.g. surgeries) to be too long.Wait times are compounded: patientsexperience long waits for referrals tospecialists, long waits for specialty testing,waits for results, and further waits for follow-up procedures.

Stakeholders also indicate that they oftenexperience long waits on the day of theirappointment and may feel rushed through theappointment.

There are ongoing challenges with measuringwait times within Eastern Health. Theorganization needs to be able to monitor thelength of waits and compare data withprovincial and national benchmarks over thelong term.

CommunicationCommunity members indicate they often feelthey have very little information about whythey have to wait, how long they can expect towait, or how the various waitlists areestablished.

Patients’ understanding and acceptance of theprocess are further impacted by feelings ofstress and vulnerability. This is a particularproblem for those who face other barriers,such as low literacy skills or a lack of supports.


High demands on existing resourcesThere are many competing demands: inaddition to primary care for residents of theNortheast Avalon, Eastern Health providestertiary services for the province.

A second theme that emerged from the needs assessment was dissatisfaction withwait times for specialists. This issue was first raised in the telephone survey andreinforced by participants at the community consultation, focus groups and keyinformant interviews.

Eastern Health has begun a number of initiatives to improve wait times and efficiencyin numerous areas, however there are ongoing challenges. Responding to thesechallenges will require bold approaches and a strong commitment from all levels ofthe organization to bring about meaningful improvements.


Although workforce planning for physiciansis ongoing at both regional and provinciallevels, a number of specialist vacancies remainthroughout various program areas. There aremany reasons for these vacancies, not the leastof which is intense competition to hirephysicians who are in high demand nationallyand internationally.

There is also a need for additional space(including Operating Room space) andadministrative support to accommodateexpanding specialty services.

There are shortages of other professionals thathave an overall impact - particularly nursingand allied health professionals. Even withmore throughput (i.e. quantity of procedurescompleted) within the surgery program thereis still the predicament of bed availabilitywhen there is a shortage of nurses to care forpatients. Likewise, shortages of allied healthprofessionals, such as physiotherapists andoccupational therapists, have a major impacton discharge planning and the likelihood ofpatients being able to return home.

Similar to the problem identified for the ER,there are numerous factors affecting bedavailability, particularly regarding timelydischarge of patients to the community orother institutions. Bed availability in long-term care, demands for community care

nurses and other health professionals toprovide home-based services, and lack ofhome supports to assist with daily activitieswithin the community all directly affect thehospital setting. As well, Paramedicine andMedical Transport resources are currentlychallenged to balance demands betweenpatient transfers and emergency response.

Responding to diverse client needs alsopresents many challenges. For example, focusgroup participants mentioned that somepeople may require more time with aspecialist, especially if the patient’s firstlanguage is not English.

Waitlist ManagementData on wait times have been a challenge tomaintain, analyze and report for variousservices. Eastern Health is working tomonitor wait times for specialists toeventually track progress and compare datawith provincial and national benchmarks overtime. For example, during the period April-June 2009, 73% of the patients requiringSurgical Fixation of Hip Fracture werecompleted within the 48-hour benchmark;almost 99% were completed within 72 hours7.

Dedicated resources are required to ensureaccuracy and timely access to data. Forinstance, Eastern Health’s surgical waitlists

__________________________________________________________________

7 Surgical Fixation of Hip Fracture refers to emergency hip fracture repair, often resulting from a slip or fall, and not elective surgeriessuch as joint replacement.


provide data to measure the time fromdecision to treat (i.e. point at which thespecialist and the patient agree to proceed)until surgery takes place; however, furtherdata is required about the length of waitbetween an initial referral to a specialist untilthe actual appointment with that specialist.

Currently there is limited capacity todetermine the level of urgency andappropriateness of many specialist referralswithin Eastern Health.

Waitlists for services continue to grow inmany areas. For example, during the firstquarter of the 2009-2010 fiscal year (April 1– June 30, 2009) the waitlist for orthopedicsurgery grew by 24%; during the secondquarter it grew by 45%. In other words, morenew referrals for orthopedic surgery arecontinually added to the waitlist than arecompleted.

Likewise, waitlists for urology have also beengrowing: the waitlist grew by 18% in each ofthe first and second quarters of 2009-2010.

What do werecommend?There are many challenges to ensuring timelyaccess to specialists: there are competingdemands for resources that affect the mannerin which specialists currently deliver services.There needs to be commitment from all levelsof Eastern Health and other healthprofessionals who use Eastern Health servicesto resolve issues, ensure compliance, andembrace new approaches to service delivery.The following recommendations are specificto improving access to specialists:

(1) Implement fully the ClientCentred Waitlist ManagementStrategy of Eastern Health. Background: The Clinical Efficiencydepartment of Eastern Health, whose goal isto improve client access to health care services,has developed a Client Centred WaitlistManagement Strategy for Eastern Health. Inaddition to data management and monitoring,the strategy includes collaborative approachesto screening for appropriateness of referrals toservices. Details on this strategy are found inAppendix L.

Recommendation: Seek sufficient resources tofully implement the Client Centred WaitlistManagement Strategy of Eastern Health,both in regards to data management as wellas human resources for program management.

• A budget proposal should be forwardedto the Executive Team within six months

Eastern Health has begun a numberof initiatives to improve wait timesand efficiency in numerous areas.


of commencement that would outline thefunding requirements for a Wait TimeDepartment. This department would bededicated to wait time management andwould include dedicated InformationTechnology (IT), project managementand clerical “super user” supportresources8 .

• The priority positions to seek would beIT programmers and data analysts, asthere is a growing need to collect, collate,and analyze data related to waitlistmanagement. These positions wouldaddress current challenges associated withmanual processes in the collection andanalysis of wait time data.

• The Wait Time Department would usewait time data to monitor and evaluateservices and re-align them as needed.

• Further resources would, of course, beneeded as the strategy expands to includeall services. Thus, it is necessary tocommit to reviewing required resources toimplement this strategy over the long term.

(2) Improve communications:Background: It is important to improveopenness and transparency about what thechallenges are, some potential solutions, andhow plans are progressing. For example, theJaneway ORs (Operating Rooms) arecurrently under expansion to increase capacityfor adult surgeries. As well, Eastern Healthparticipates in a number of inter-provincial

and federal programs focusing on wait times,such as the Patient Wait Time Guarantee forradiation therapy and selected cardiac bypasssurgery.

Recommendation: Improve openness andtransparency by developing a comprehensivecommunications strategy for both internaland external stakeholders to (a) better explainthe waitlist process for specialists and (b)outline the efforts underway to reduce waittimes for specialists.

i. The communications strategyshould include an educationcomponent for patients regardingwhat they can expect while inhospital, how long they can expectto be hospitalized, and the supportsthey will need upon release. Thiswill have the benefit of helpingimprove bed availability throughtimely discharge.

ii. Provide up-to-date information onwait times to the public (e.g. throughthe Eastern Health website).

iii. Report back to the communitywithin two years of the release ofthis report to provide an update onprogress in improving access tospecialists.

_____________________________________________________________________

8 A “super user” is a person, usually a clerk in a department or program of Eastern Health, who is given extra training on a particularaspect of an IT system. He/she can provide immediate assistance in implementing changes or troubleshooting rather than referring tothe Information Management & Technology department.


(3) Develop better mechanisms forinformation exchange betweenEastern Health and GP’s offices forenhanced coordination of patient care.Recommendation: Investigate the cost andfeasibility of implementing an IT system foronline referrals to specialists, booking of testsand procedures, confirmation ofappointments and receipt of test results. Sucha system would enable GP’s offices to bettercoordinate patient referrals and easily accessup-to-date information. This is particularlyimportant given that GPs and their officeadministrators are critical to the coordinationof patient referrals and they need timely accessto information. Although in recent yearsthere has been an expansion of the Meditechsystem9 to GP’s offices for the sharing of testresults, this system is one-directional. A newsystem must be more interactive and enableGPs to fully coordinate the continuity of carefor patients.

• Develop a Project Charter to be approvedby Eastern Health’s Executive Teamwithin three months of commencement.

• A final analysis of this investigationshould be presented to Eastern Health’sExecutive Team within one year ofcommencement.

• The Community Medical AdvisoryCommittee (CMAC) should be asked toprovide input into policies and proceduresto help improve linkages between EasternHealth and GPs.

(4) Commit to researching avisionary “Model of Care for 2020”.Given the demographics of this region, havingresearchers focus on models of care torespond to the needs of the population inadvance of other initiatives would be strategic.

Recommendation: Beyond responding tocurrent problems, Eastern Health shouldexplore the development of research focusedon models of care pertaining to chronicdisease management and the relationshipbetween primary, secondary and tertiary care.

• The goals of this research focus should beto:

i. Research, pilot and evaluate newapproaches for the care andmanagement of patients (inpatientsand ambulatory) with multiplechronic conditions and multi-systemfailure;

___________________________________________________________________

9 Meditech, or Medical Information Technology, Inc., is the software system used within Eastern Health.


ii. Research new relationships betweenGPs and specialists for the care ofpatients. For example, referrals tospecialists may be reduced if thereare increases in the capacity of GPsto treat complex patients in somecircumstances.

iii. The organization should seek to hirea PhD prepared clinician to lead ateam in this focus.

iv. This leader would be responsible fordeveloping proposals to advance thisvisionary model.

How will we know we have succeeded?It is important to dedicate resources to evaluate wait time initiatives to improve access tospecialists. An evaluation strategy for specialist wait time initiatives should entail:

• Establishment of a reporting system for quality improvement measures with specificindicators.

• Reporting of established targets on an annual basis (e.g. average wait times for particularprocedures).

• Creation of initiatives for reducing wait times for specialists that are evidence-informed.

• Sharing the findings for the benefit of related initiatives both within and outside of EasternHealth.


5 WAIT TIMES FORDIAGNOSTICIMAGING



Lengthy wait timesCommunity members clearly articulate thatthey consider wait times for diagnosticimaging to be too long - particularly for CT,MRI and Ultrasound.

Stakeholders relay that their DI wait times arecompounded: they experience long waits forreferrals, waits for tests, waits to find outresults, and then further waits for follow-upappointments and procedures.

Health professionals voice frustration withthe inability to provide timely service: longwaits affect timely diagnosis and care.

The continuity of care may be impacted bylengthy wait times. For example, if a patientmoves out of the area while awaiting services,the referral process must start again inanother jurisdiction.

Although Eastern Health is generally able torespond to emergent needs in a timely way,internal data on wait times for DI have been achallenge to maintain and analyze for all levelsof urgency. The organization needs to be ableto monitor the length of waits and comparedata with provincial and national benchmarksover time.

Table 2 provides data on non-urgent examswithin St. John’s Hospitals as one indicationof wait times.

• Median wait times exceed the nationalbenchmarks established by the CanadianAssociation of Radiologists.

• The median wait times for CT andUltrasound have been increasing, with theexception of Ultrasound in 2007-2008.

The third key theme that emerged from the Northeast Avalon Community HealthNeeds Assessment was dissatisfaction with wait times for Diagnostic Imaging (DI).Information gathered from various sources clearly outlined dissatisfaction withprolonged waits for service, the associated stress involved with awaiting diagnosis, aswell as the need for more open communication about wait times and processes.

Eastern Health is involved in several initiatives to improve wait times and efficiencyin DI but challenges still exist. As with other areas, tackling these challenges requiresinnovative approaches and a high level of dedication to making changes throughoutthe organization.


*Represents median wait time for end of quarter for eachmodality (e.g. MRI of head, MRI of neck, etc.)**During the 2007-2008 fiscal year the median wait time forMRI was greatly reduced due to a second MRI being put intooperation and the commencement of increased hours of operation(i.e. both scanners now operate 16 hours per day, five days perweek).***In December 2006 an additional four ultrasound technologistswere funded – two allocated to St. Clare’s and two allocated toHealth Sciences Centre – resulting in an annual exam increaseof 34,676 exams to reduce wait time.

CommunicationSimilar to issues identified with accessingspecialists, community members report theyoften feel they have very little informationabout why they have to wait or how thevarious waitlists are organized.

Patients’ understanding and acceptance ofwait times are further influenced by theirfeelings of stress and vulnerability. Manypatients also face other obstacles, such aslanguage barriers or disabilities that affecttheir understanding of the various processes.


High demands on resourcesIn short, the demand for resources continuesto be high as Eastern Health provides bothprimary care for the Northeast Avalon andtertiary services for the province as a whole.For example:

• 3,091 MRIs were completed at the HealthSciences Centre between April 1, 2007 –March 31, 2008; for the same months of2008-2009 there were 3,990 completed,which was approximately a 23% increase.

• During 2007-2008 there were 12,956 CTscans completed at the Health SciencesCentre, while in 2008-2009 there were13,552. This represents an approximate4% increase.

Demand for testing grows with technologicalimprovements. Expectations increase witheducation and awareness about servicesavailable and their potential benefits; there is

TABLE 2: MEDIAN WAIT TIME (DAYS), NON-URGENT EXAMS, 3RD QUARTER COM-PARISON (OCTOBER 1 – DECEMBER 31) FOR CITY HOSPITALS*

Test Target Benchmark 2006-2007 2007-2008 2008-2009

CT 30 42 55 76

MRI (Adult) 30 425 57** 72

Ultrasound 30 65 32*** 71


also an increased reliance on technology toprovide diagnosis.

Improving the situation is not just a matter ofacquiring equipment that is moresophisticated; there are safety and humanresource implications as well. Subspecialtiesrequire more radiologists and technologistswith specialized training. The program alsoneeds support staff to maintain centralizedappointments, which ensures efficient flow ofpatients through the service.

There are many challenges associated withresponding to diverse client needs. Forinstance, some focus group participantshighlighted the need for more physicallyaccessible facilities while others mentioned theneed for “open” MRI to accommodate patientswho are obese or fear enclosed spaces;however, there are limitations to the scope ofexams and image quality of an open MRI.

Space is another major issue that affects waittimes: Eastern Health is limited by thephysical space available in which to work orinstall additional equipment.

At present there is limited capacity todetermine the level of urgency andappropriateness of many DI referrals withinEastern Health.

Educational NeedsAnother significant impact on resourcesinvolves meeting educational needs. As an

organization whose lines of business includeadvancing knowledge, Eastern Health hasresponsibilities in terms of research,education, knowledge dissemination andeducating the next generation of healthprofessionals. As a teaching and academicorganization, time must be dedicated toensuring the educational objectives ofstudents are met. While such educationalneeds exist throughout the organization, theywere particularly highlighted for the DIprogram.

• Eastern Health provides training forradiology in conjunction with MemorialUniversity of Newfoundland’s Faculty ofMedicine.

• Eastern Health collaborates with theCollege of the North Atlantic to provideclinical opportunities for technical trainingfor students of the Medical Radiographyand Ultrasound programs.

• Technologists require thorough on-the-job training, particularly for subspecialties.Eastern Health has been working with theCollege of the North Atlantic to expandprograms in Ultrasound and Radiography.As well, Eastern Health provides somefunding for staff to avail of bursaries fortechnical training and distance educationprograms.

Waitlist ManagementWaitlist management within DI is complexbecause it allows for both inpatient andoutpatient appointments. The ER is oftenseen as a last resort for people if they cannotget to see their GP and there is an underlying


public perception that going to the ER willresult in quicker access to DI. This impactson resources throughout the system.

While the program deals well withemergencies, it also endeavours to be proactiveto prevent problems from getting to a crisislevel. Limited resources must be usedefficiently and effectively to provide optimalservice and thereby improve patient outcomes.

Any inappropriate use of urgencyclassifications by ordering physicians impactsthe ability of DI to provide services to thosewho need it most in a timely manner.

Resources for IT infrastructure and staff areneeded to better capture data on wait times,track data over time and, ultimately, betterinform decisions.

What do werecommend?Balancing timely access, limited resources andcompeting demands is an ongoing dilemmawithin the DI program. Again, dedicationfrom all levels of Eastern Health and otherprofessionals who use our services is requiredto improve the situation, from an openness totrying new approaches to ensuringaccountability and compliance with newapproaches. The following suggestions arespecific to the DI program:

(1) Develop a Patient-CentredDelivery of Services Strategy for DI.Recommendation: In consultation withstakeholders, develop a strategy for patient-centred delivery of services within DI. Thiswould involve developing options andcoordinating services to meet patient needs ina timely manner.

• This strategy must address such keyissues as:

o the development of clear indicatorsfor wait times;

o an approach for the regular reportingof indicators both internally to otherdepartments and to the public;

o an approach for the prioritizationand appropriateness of referrals;

o a means for annual reporting ofestablished targets.

• This strategy should be forwarded to theExecutive Team of Eastern Health withinsix months of commencement of itsdevelopment.

• The strategy must have measurable goalswith specific timelines.

• The patient-centred strategy would tie toEastern Health’s Waitlist ManagementStrategy, as DI wait lists are included inthe latter.

• Eastern Health’s DI strategy should alsobe linked with the provincial DiagnosticImaging Urgency Classification Strategy.Since 2007, Eastern Health has beenparticipating in the provincial DiagnosticImaging Urgency Classification Strategy,which will also enable comparisonsbetween Regional Health Authorities.


(2) Explore options for patientswho reside in the Northeast Avalonto travel elsewhere in the EasternRegion (outside of the NortheastAvalon) to avail of DI services. Background: Although there was a previousattempt to explore this issue within the DIprogram, based upon feedback during thisNeeds Assessment the issue should be re-explored.

Recommendation: It is recommended that anew project be initiated with more specificobjectives and with an evaluation component,developed in consultation with EasternHealth’s Applied Research Department.

• The project should ensure that schedulingoptions be discussed with patients whoreside in the Northeast Avalon before areferral is made to DI. For example, thereshould be processes in place for GPswithin the Northeast Avalon to refer toall sites within the Eastern Health region.GPs and the public should be able to viewwait times within various DI sites andmake choices based on this information.

(3) Develop a Plan for onlinebooking of DI services. Recommendation: Require the InformationManagement and Technology Department todevelop an “options paper” for EasternHealth’s Executive Team within one year ofcommencement. This paper would clearlyoutline the various approaches for the

implementation of an IT system for onlinebooking of DI services.

• The paper must clearly outline technologyneeds, system costing, andimplementation timeline.

• Such a system would enable GP’s officesto better coordinate patient referrals andeasily access up-to-date information.

• This system should include an electronicphysician “decision tool” that wouldrequire the referring physician to entersome key information regarding thepatient’s clinical picture and would, inturn, recommend the most appropriatemodality/exam for diagnosis or evensuggest that imaging is not indicated.This type of tool would help in addressingthe appropriate use of DI.

• The system must be user friendly for GPsand their office administrators, as they aregenerally the coordinators/managers ofpatient referrals and they need timelyaccess to information.

• This system should also enable confirmationof DI appointments by patients.

(4) Develop a communicationsstrategy specific to DI.Recommendation: Within Eastern Health’sbroader communication strategy there shouldbe a specific focus on DI issues.

This focus should:

• Improve openness and transparency by(a) explaining the waitlist process for DIand (b) outlining the efforts underway toreduce wait times in DI.



For example, hours of operation for MRIwere lengthened as of 2008. This hasincreased the amount of time that testingcan take place (i.e. up to 16 hours/day).

• Increase education for GPs and heightenpublic awareness regarding appropriatenessof exam requests and clinical indicationsfor exams based on patient’s clinicalpicture (as per appropriateness guidelinesfor DI provided by the CanadianAssociation of Radiologists).

• Provide up-to-date information on DIwait times to the public (e.g. through theEastern Health website).

• Report back to the community withintwo years to provide an update onimproving wait times in DI.

How will we know we have succeeded?Again, the importance of evaluating initiatives cannot be understated. Some specificrecommendations for measuring success within DI involve:

• The establishment of a reporting system for quality improvement measures with specificindicators.

• Establishing targets that would be reported on an annual basis (e.g. average wait times forparticular tests such as MRI and CT Scans and/or increase in annual exam volumes).

• Ensuring initiatives for reducing wait times for DI are evidence-informed.

• Sharing the findings for the benefit of related initiatives both within and outside of EasternHealth.


6 RELATEDINITIATIVES ANDREQUIREMENTS

Longer-Term Initiativesand Requirements

St. John’s Hospital-Based HealthServices RedevelopmentSince 2009, Eastern Health has been workingwith consultants to develop a MasterProgram and Master Plan for hospital-basedhealth services in St. John’s. This involves longrange planning to determine the services tooffer in coming years, the resources needed tosupport these services and how the servicesshould be organized. Physical spaceconsiderations are particularly importantaspects of the redevelopment process.

Patient Flow Study An outside consultant completed a study ofhospital patient flow (from admitting todischarge) in 2009. Numerous recommendationsto improve efficiencies within the St. John’shospital system have become available sincethe Northeast Avalon assessment began.Many of the suggestions do not necessarilyinvolve fiscal commitments but rather thestreamlining of current processes.

A key aspect of this study that impacts onwait times is the need for increased home careand home supports to facilitate timelydischarge of patients from hospital. Presently,patients who require an Alternate Level ofCare (ALC) must stay in hospital untilcommunity supports and/or appropriateequipment are available, thus affecting bedavailability. Eastern Health must work withpartners to emphasize the importance ofaccess to appropriate home care and homesupports in terms of improving overall waittimes.

Current Initiatives toExpand/ImproveMany of the ongoing initiatives withinEastern Health can be expanded or adjustedto improve wait times on the whole. These include:

• Continuing to tackle bed availability; thisincludes enforcing the established policyof discharging patients earlier in the dayand establishing “special care” beds as anoption between the Intensive Care Unitsand the floors;

It is important to consider the overall context in which the Northeast AvalonCommunity Health Needs Assessment has been taking place. Several majorinitiatives within Eastern Health are converging in response to challenges identifiedwithin the organization over the long-term, all of which tie closely to the issuesbrought forward in this needs assessment.


• Further exploring the means withinParamedicine and Medical Transport tobalance demands for timely patienttransfers along with emergency response;

• Enhancing efforts to address shortages ofphysicians and other health professionals.While there have been improvements (e.g.the surgery program was recently able toopen additional beds by increasing thenumber of staff available), there is anongoing need to recruit and retainprofessionals throughout theorganization. Some examples ofinnovative incentives provided byparticipants include:

o Support for childcare arrangements;o Support in finding housing; o Financial incentives to pay down

student debt; o Strengthening linkages between

Eastern Health and students who gooutside of the province forspecialized training;

o Increasing bursaries available fortraining in areas where it ischallenging to recruit and retain staff(e.g. technological training for DIstaff );

• Many of the issues identified relate tonavigation of the system, which EasternHealth has already identified as a priorityin its Strategic Plan 2008-2011. Thereneeds to be more communication aboutwhat is being done to address ongoingnavigational challenges.


Photography: Northeast Avalon Regional Economic Development Board (Avondale, Flatrock and Marysvale)


7 BEYOND WAITTIMES: WHAT ELSEDID WE HEAR?


As such, this assessment will set the stage forseveral areas that warrant furtherinvestigation for future strategic planning andneeds assessments, including:

• Mental Health services• Meeting diverse needs• Emphasizing preventative approaches to

health

Mental Health ServicesWhile Eastern Health has a wide range ofMental Health initiatives already in place andthere has been significant investment in theMental Health and Addictions program overthe last number of years, communitymembers repeatedly voiced concerns aboutaccess to mental health services for all agegroups. It is recognized that recent fundinghas enabled the enhancement of existingservices and the introduction of a number ofnew services based on need, such as theNavigators and Networks (NavNet) initiative,the Assertive Community Treatment (ACT)Team, the Opioid Treatment Centre, theEating Disorders Day Treatment Program(HOPE) and the Mobile Crisis ResponseService, among others. Yet, furtherinvestigation in the area of Mental Health iswarranted and may include evaluation

components to ensure programs and servicesare meeting clients’ needs – not only for thoseindividuals with diagnosed illnesses but forthe promotion of Mental Health, in general,in our communities.

Notably, Eastern Health is moving forwardwith its Strategic Plan for Mental Health andAddictions. Issues brought forward bystakeholders during the Northeast AvalonCommunity Health Needs Assessment willbe fed back to the Mental Health andAddictions Program to continue addressingidentified gaps and ongoing priorities. Keymessages brought forward about MentalHealth services to consider include thefollowing:

• The importance of an emphasis onproactive approaches to avoid issuesgetting to a crisis level;

• A need for collaboration and coordinationbetween agencies in providing services toclients;

• A need for flexible approaches to meetclient needs;

• A need to address ongoing lengthy waitsfor Mental Health and Addictionsprofessionals such as social workers andpsychologists, and not just psychiatrists;

A broad range of issues were brought forward through the process of conducting thisassessment, particularly through focus groups and key informant interviews. Whilewait times within adult services emerged as the focus of this assessment, EasternHealth recognizes that there are other concerns to address within this geographic zone.

• The importance of outreach, as there arestill many marginalized people withmental health issues who have very fewsupports.

Meeting Diverse Needs The Northeast Avalon is becoming morediverse and responding to stakeholder needsrequires equally diverse approaches. This areaof the province has the highest number ofcommunity-based organizations representinga wide range of mandates, such as advocacyfor issues related to sexual orientation,multiple cultures, and all levels of ability. Eventhough Eastern Health has been makingprogress toward addressing identified needs,such as through the development of aDiversity Strategy to increase awareness ofdiversity and inclusion for employees andclients, further work is required to determinehow to best respond to changing needs.

Many issues identified in this assessmentrelate to navigating within Eastern Healthand this has already been identified as apriority area in the Strategic Plan 2008-2011.Two key messages about diversity that cameforward from stakeholders and warrantfurther exploration are:

• Training opportunities for managementand staff should be explored in terms ofbuilding sensitivity and awareness on awide range of client needs;

• Many community partners/potentialpartners within the Northeast Avalon canprovide relevant training or serve in a

consultative capacity for Eastern Healthto learn more about effectively meetingdiverse needs.

Emphasizing Preventative ApproachesSimilar to the previous community healthneeds assessments completed on the BurinPeninsula, Southern Avalon and Bell Island,numerous preventative aspects of healthemerged throughout the Northeast Avalonassessment. Prevention and early interventionrelate to all aspects of the health continuum:within community, acute care and long-termcare. Indeed, preventative measures areclosely related to the current issue of waittimes: if prevention is not emphasized, therewill always be long wait times because thelevel of demand will not decrease.

Emphasizing preventative approaches tohealth is another area that warrants furtherinvestigation through future assessments.There are many areas where an emphasis onproactive approaches (versus reactive) havebeen well established within Eastern Healthbut resources are stretched. As well, there areareas where preventative approaches havebeen emerging and should be supported toexpand. Further research should beconsidered that focuses on how regionalhealth authorities can support and empowercommunities and individuals in takingownership of their health through preventionand early intervention.


8 CONCLUSION



The Northeast Avalon region is changing and the ways in which Eastern Healthresponds to needs must evolve. Eastern Health will continue to be challenged in theways it provides services and supports within communities, especially as publicawareness and expectations continue to increase.

In brief, improving wait times requires resources: either improve efficiency within existingresources or add additional resources. Many opportunities exist by which Eastern Health canimprove access to services, which is a key determinant of health. Undoubtedly, this will requirebold, innovative approaches and a strong commitment from all levels of the organization and ourcommunity partners as we strive to achieve our vision of Healthy People, Healthy Communities.

Photography: Northeast Avalon Regional Economic Development Board (Bauline, Conception Harbour and Middle Cove)

63

APPENDIX A:Terms of Reference - Northeast AvalonCommunity Health Needs AssessmentSteering Committee

1.0 Purpose The Northeast Avalon Community Health Needs Assessment Steering Committee will oversee the community health needs assessment for the Northeast Avalon area excluding Bell Island. 2.0 Duties The duties of the committee are to:

2.1 Oversee the development of a community health needs assessment plan 2.2 Seek advice from the Northeast Avalon Community Health Needs Assessment

Advisory Committee 2.3 Review and provide feedback on the primary and secondary research findings of

the community health needs assessment and the draft report 2.4 Approve the community health needs assessment results 2.5 Evaluate the community health needs assessment process

3.0 Membership The committee will be chaired by Wayne Miller, Senior Director, Corporate Strategy and Research. The Chair will report to the CEO on the activities of the committee. The Committee will include the following representation:

- Wayne Miller - Senior Director, Corporate Strategy and Research, Chair - Beverley Clarke - Chief Operating Officer, Community, Children & Women’s and

Mental Health Services - Cathy Burke - Director, Emergency/Ambulatory Care - Laura Woodford - Manager, Strategic Communications - Dawn Gallant - Manager, Primary Health Care - Dr. John Guy - Director, Medical Services - Bernadette Duffett - Manager, Health Promotion - Dr. David Allison - Medical Officer Public Health - Lisa Browne - Planning Specialist - Gillian Janes - Planning Specialist

4.0 Meetings The Committee shall meet every 4-6 weeks, or at the call of the chair, until the completion of the assessment. 5.0 Quorum A majority (50% plus 1) of all members shall constitute a quorum. February 23, 2009

64

APPENDIX B:Terms of Reference - Community HealthNeeds Assessment Advisory Committee

1.0 Purpose The purpose of the Community Health Needs Assessment Advisory Committee is to provide advice and feedback on the Northeast Avalon Community Health Needs Assessment to the Health Needs Assessment Steering Committee of Eastern Health. 2.0 Duties The duties of the Community Health Needs Assessment Advisory Committee are to:

2.1 Act as a resource to the Health Needs Assessment Steering Committee on the Northeast Avalon

2.2 Serve as a mechanism to exchange ideas related to the Northeast Avalon

Community Health Needs Assessment

2.3 Respond to questions from the Community Health Needs Assessment Steering Committee

3.0 Membership The committee shall consist of individuals representing organizations that shape the health of individuals and communities (Health Canada’s determinants of health). The committee will be facilitated by Wayne Miller or Gillian Janes. The facilitator will report to the Health Needs Assessment Steering Committee. Membership shall include, but not be limited to, representatives from the following areas:

Employment & Working Conditions Education Social Support Networks Income and Social Status Physical Environment Healthy Child Development Seniors Youth and Teens

4.0 Meetings The committee shall meet a minimum of four times during the course of the completion of the needs assessment. The initial meeting will be to update the committee on the needs assessment plan. Subsequent meetings will be called to exchange ideas and update the Advisory Committee about the progress of the needs assessment. A concluding meeting will present the results of the needs assessment. 5.0 Quorum A majority (50% plus 1) of all members shall constitute a quorum.

65

APPENDIX C:Northeast Avalon Community HealthNeeds Assessment Consultation SessionSummary Notes

Comfort Inn, St. John’s June 17, 2009

The following notes summarize the small group discussions from each table, written comments submitted by some participants, as well as flip charts notes for other issues participants identified that had not been included in the formal presentation or subsequent group discussion. For clarity and ease of reading, issues identified have been grouped into common themes. List of Groups Represented: AIDS Committee of Newfoundland and Labrador; ALS Society of Newfoundland and Labrador; Alzheimer Society of Newfoundland; Association for New Canadians; Avalon Prostate Cancer Support Group; Buckmasters Circle Community Centre; Canadian Diabetes Association; CBS Community Resource Network; City of St. John's; Coalition on Richer Diversity; Community Health Promotion Network Atlantic; Community Services Council; Community Youth Network; Correctional Services Canada; Daybreak Parent Child Centre; Department of Health & Community Services; Department of Justice (Victim Services); Eastern Health; Independent Living Resource Centre; Newfoundland and Labrador Lung Association; Planned Parenthood Newfoundland & Labrador Sexual Health Centre; Prints of Family Literacy Network; Riding of Kilbride; Riding of Signal Hill-Quidi Vidi; Seniors Resource Centre; Shalom; St. John's Native Friendship Centre; Status of Women's Council; Town of Conception Bay South; Town of Flatrock; Town of Logy Bay-Middle Cove-Outer Cove; Town of Torbay; Turnings; Universal Access Network; Vibrant Communities; Wellness Coalition-Avalon East; Women's Centre Issue #1: Are there groups of people who have difficulty accessing family doctors? Who are they and why do they have difficulty? Accessibility and Barriers • Accessibility of office (e.g., doctor availability - hours and days office is open) • Length of wait • Lack of photo IDs/MCP card can be a barrier (especially for new arrivals to the province);

Physicians will not see someone without an MCP # • Doctors not being sensitive – e.g., reproductive choices, STIs; Can be traumatizing for

individual and makes it difficult to access services • People who are chronically ill may have difficulty getting out to see a physician • Mentally challenged; may need respite worker • Need wheelchair/stroller access • Need patient advocates • People may be “between” doctors (e.g., when their doctor retires or moves there may be a

period of time when they do not have a family doctor and use the ER); they may be the “vocal” group we hear from as not having a family doctor

• Transportation: o There is no mass transit outside St. John’s/Mount Pearl o May have to prioritize: pay for transportation to doctor or pay for other necessities

(when people have a fixed income) o May depend on others for transportation if they have mobility issues (e.g.,

Wheelway, family member) • Children/young families:

o Child care – can be difficult to find someone to look after your children while you go to the doctor

o Young families can have difficulty getting health care for their children • Cultural barriers:

o Cultural sensitivity – includes sensitivity toward local groups, such as Aboriginals • Seniors:

o Have physician, but cannot get to appointments o Often need extra care or special arrangements for transportation - ambulance

transport costs $230 o Depend on family to get medical care – even when in long term care setting, it is

the family member who must take responsibility for doctor appointments, emergencies (e.g., broken arm), etc.

o Not many GPs do home visits o Perception that seniors often have complex and multiple issues, which can take

more time; Some clinics restrict seniors (or others) to just one or two concerns per appointment and make them come back for other issues

Perceptions/Experiences/Stigma • Perception that physician’s knowledge may be limited concerning a particular condition a

patient might have • Some people are fearful, so when they feel sick they go directly to the ER in order to get

their issue addressed right away • Patient might not be comfortable visiting family doctor about a particular issue • People with complex health issues may avoid family doctor or may be asked to find

another doctor (e.g., feel they cannot get help for a variety of issues from the family doctor, stigma associated with AIDS, Hepatitis, homosexual and transgender issues, physical disabilities, sexual health issues)

• University students who have more complex needs than the university clinic can handle • Fear of being judged • Stigma – some physicians are afraid to deal with lifelong chronic diseases and do not want

patients with these conditions in their waiting rooms (e.g., HIV, Hepatitis C) • Lack of access to professionals they can relate to (e.g., immigrants, transgender) • Some people think of ER as “outpatients”, as if it is an open clinic

• Negative approach from receptionist at doctor’s office • We, as a healthcare system, encourage the use of ER – if you can not get an appointment

with your family doctor you are referred to ER • Some people are not aware of the purpose of an ER: for emergency, urgent issues Communication and Literacy • Some people may have communications issues that affect whether they would visit a

family doctor • Low literacy levels, especially if they are new immigrants • Also, “health literacy” issues: Do people understand what the doctor said and what follow

up is needed? Do they understand the diagnosis? Did they know (or remember) what to ask? Note: Buckmasters Circle Community Centre has a good practice of developing a patient card to remind people what to ask

• Immigrant and refugee barriers: cost, language, culture, religion, access to prior health records

“Hard to reach” populations/Limitations of telephone survey • Individuals who do not have a telephone, especially people living in poverty or who have

low incomes and might not have continual telephone access; No Internet access • Some people would not be able to participate in 20-minute telephone interview • Young females needing prenatal care • People with no fixed address and/or no medical records; getting healthcare may be the last

thing on their minds; stress and anxiety associated with setting up an appointment • Women who are not comfortable with their own family doctor for women’s health needs • People moving into province from other areas who don’t know where to go for services • For some hard to reach people, the consequences of not getting earlier intervention in

health care can be extreme (e.g., people with addictions could end up at the Waterford for long periods or in the prison system)

• Offenders: o complex health issues; need continuity of care and collaboration; good to have a

multidisciplinary team to help address complex issues (e.g., Mental Health, Addictions, Infections Diseases)

o Having access to one or more physicians who are willing to work with offenders would be ideal to help manage their care and avoid difficulties such as drug- seeking, doctor shopping, stigma, etc.

o There are stigma issues, and we need people who are comfortable working with offenders and their issues; we need to be able to protect offenders and the general public

o Need more programs in our prison system to help offenders with addictions issues

o Too many of our provincial inmates have serious mental health issues and they belong in a hospital such as the forensic unit of the Waterford and not prison

Collaboration • Suggest conducting key informant interviews and focus groups with additional groups;

community partners could help with this in terms of who to reach, how to reach them, and to get a better understanding of their issues

• Noted that family doctors are not part of Eastern Health, but are willing to work with us to find creative solutions

• Community Medical Advisory Committee (CMAC): involves both community GPs and Eastern Health representatives; willingness to work together and introduce some new ideas, innovative solutions (e.g., continuing Medical Education credits – suggest exploring avenues for advocacy groups to provide GPs with information on issues identified/community awareness); If coursework not already developed, could it be developed?

• Recommendation to review HRLE study on transportation that was recently completed • Need patient advocates • Need a community health centre model, where holistic supports are in place to support

primary health care team (e.g., housing workers, mental health workers, youth workers, family support); this model is used in many provinces; connects individuals who may be disengaged

Other Issues/Key Themes for Question #1 • Does access to a physician equate to health care? • Alternative Health Providers: Can there be another entry point to health care other than

the physician? Need to look at other models, not just GPs who operate busy clinics (e.g. nurse practitioner); If GPs transferred some of their tasks such as immunizations and blood pressure checks to other professionals their time may be freed for other clients and those with complex needs

• Have to be your own patient advocate and be accountable for your own health; people have varying levels of ability to act on their own and it can be difficult for some people who get “lost in the shuffle”; basic premise: not everyone can advocate for themselves

• Immigrant health care providers – some have trouble getting their credentials recognized, but they could have helped break language and cultural barriers for others from the same area. Are we providing enough support for them to become qualified?

• ER waiting room is not conducive for very ill, elderly or weak people; many can not sit that long

Suggest Key Informant Interviews With: • People who did not participate in phone survey due to not having a phone, time, etc. • People with disabilities

• New immigrants • Young women • People not living at a fixed address • Those having difficulties with transportation • MUN students • Suggested going to Gathering Place and soup kitchens to talk to people; There are many

community groups that can help with some of these issues, and we need to work together Issue #2: Why do people go to emergency departments instead of a family doctor? What are barriers that stop them from seeing a family doctor? Note: many of the same issues identified in question #1 were the same for question #2 Accessibility and Barriers • After-hours access to services; people are working during the hours their doctor’s office is

open • Financial reasons – if it is closer to go to ER rather than GP, or if an agency like

Correctional Services Canada will pay for transportation to ER but not visit to GP, then people make decisions that make sense to them

• Some people do not have a family doctor • Attitude of the family doctor – if someone is embarrassed by their problem or does not

want to talk to their doctor, the emergency department gives them more anonymity • Physicians do not do home visits • Some doctors refuse to do procedures (e.g., digital rectal exams and pap smears); need

more barrier-free walk-in clinics; current walk-in clinics are often full Perceptions/Experiences/Stigma • Perception that it is quicker to get access to specialists and care; ER is seen as a channel to

move people to the appropriate services • Do not like family physician’s diagnosis; want a second opinion • Desperate to get services – go to emergency department and refuse to leave until you get

service • Safety and security reasons – service providers covering their own liabilities, such as for

mental health issues (e.g., if there is a risk of self-harm or suicide they would refer client to ER)

• Physicians are in demand; perceptions that physicians can interview for patients and only accept those that they want to deal with

• Caregiver burnout – people bring their loved ones to the emergency department because they cannot deal with them anymore, then leave them there

• People who know they will need various types of tests go to emergency department to get them all done at the same time (e.g., if you suspect you will need an x-ray you do not bother going to the GP)

• GPs send patients if they do not have the equipment or expertise in their office (e.g., for stitches)

• Lack of awareness of what is out there (e.g., blood work can be done at home, there are some walk-in clinics)

• Mental health lens – the general practitioner will refer you to a counselor and other therapy and that is the only help you have, so when you have a mental health crisis, the emergency department is your only option

Navigation • People go to Planned Parenthood asking where to go for services; Planned Parenthood

has developed lists of resources available and how to find them • Navigation of the system is an issue – how do people find the services they need?; Need to

find ways to channel people more appropriately • Smaller areas can have one entry point to all services; Access to providers can be harder in

larger areas • Need outreach support Other Issues/Key Themes from Question #2 • Health Line – did it help or make use of emergency departments worse? • Alternate to ER: would be helpful to have multi-disciplinary teams within clinics in the

city, such as nurse practitioner in the downtown area • Fee-for-service physicians – requiring physicians to have a clinic a couple of nights a week • People with addictions problems often prefer going to their family doctor because the

physicians at the emergency department will often assume they are there to get drugs and there is a trust issue, whereas they can develop a relationship with their family physician who will understand their particular needs and issues better

• Suggestion: put surveys in waiting rooms of emergency departments for people to fill out while they’re waiting

• “Continuity of care” and “coordination of care” are key words Issue #3: How are wait times for specialists and specialty DI impacting the people of the Northeast Avalon? What are the barriers that they encounter? Do you have suggestions as to what can be done to address these issues? Awareness and Education • People need to understand the process (of being involved in the health care system) and

the availability of other options; can you travel to get the services somewhere else?

Communication/Navigation • If condition changes, there is no real process to let someone know that you need care faster

other than going to your family doctor • Lack of understanding of how the system works and why you have to wait; this causes

concern and frustration Negative Impacts • Suffering • Discomfort • Financial loss (especially for people who go away to get service) • Reduced quality of life, even possible loss of life • Isolation – cannot do the recreation and social activities they could before condition

worsened, which further affects quality of life and even mental health Suggestions/Key Issues Identified • Better education and networking with community organizations, including GPs • Family doctors can make an appointment with the specialist, but should then also refer

people to community support groups to help alleviate stress while they’re waiting • People with addictions (especially opiates) sometimes end up on the street or breaking the

law while waiting to see a specialist to help with their issue – some specialists are unable to deal with the kind of people who have addiction issues and their special needs; this creates safety issues for others in the community when these people are not treated; should fast-track some of these people; need to encourage more doctors to get involved in methadone treatment

• Need to encourage provincial and federal counterparts to work together • Early intervention with chronic disease management prevents complications in the future

and reduces need for services; need “upstream” approach • Adherence to guidelines for use of services and referrals:

o Physician refers someone to a specialist when they could be treated by the family doctor (e.g. diabetes management)

o Referring people for specialty DI tests that are not necessary • Physicians can prepare patients for the appointment – having any workup necessary done

in advance would reduce the time needed with the specialist. That would eliminate an initial visit just to have tests ordered; better use of time and more efficient use of resources; More communication between GPs and specialist/DI (as opposed to various unconnected doctors providing care)

• Central intake process – there may be a shorter wait time in another region or area of the region that people could be referred to (if they could travel); this would require public education and integration of services; could create other issues with transportation, cost, etc., but would provide an option to reduce the demand on specialists in an area and free them up for those who could not avail of the option to go elsewhere

• Waiting time does not just mean from the time the appointment is made with a specialist. It often begins long before that while people are referred to alternative treatments to try first – and there is a wait for each of these other stages as well. It can be years between the first complaint and the time the specialist is seen, so there is compounded waiting (e.g., wait for appointment with doctor, with physiotherapist, etc.)

• Mental health is affected as well, especially for people who fear for their lives while they are waiting

• Use equipment outside regular hours to get more people through • Need more physicians who are certified to diagnose and treat Fetal Alcohol Spectrum

Disorder (FASD) • Need a holistic approach to health that includes social determinants of health; need to

focus on prevention, early intervention and health promotion with the long-term goal of reducing the need for tertiary care

• Determining the percentage of no-shows for appointments, and how to utilize these spots effectively (e.g. call-in list)

• Need to look at gap in service re: youth with complex mental health needs; young people leave the province for treatment, therefore removed from their support systems

• Educate staff on how to respond to questions from patients re: why they have to wait • Let people know the available options • Many offenders have a hard time seeking assistance re: additions and physical or sexual

abuse - there are limited services available and by the time they are scheduled to see someone they have already fallen through the cracks of the health care system right into the justice system

• Many clients would not get to specialized care without advocacy • Federal government – tax incentives (?) • Look at the scope of practice, principles of Primary Health Care and use specialists as

consultants for other professionals; not always necessary for them to provide direct care Flip Chart Notes: Additional Issues Identified by Participants Prevention/Linkages • More emphasis needed on prevention and prevention-based programs, especially youth • Focusing on supporting healthy people, healthy communities – different community

activities • Need to look at how we can more closely link health needs to delivery of community

services (i.e. recreation) at municipal level; How can we collectively support and provide the services needed to keep people active and healthy?

• Concerned about people who are under-represented in the survey (people with a disability, vision, hearing, mental health, elderly people, etc.). Focus seems to be on medical model rather than a healthy community (participation, diet, exercise, prevention, etc.)

Navigation • One point of entry for New Canadians into supports from Eastern Health – a “navigator” Specific Needs • Health care in our prisons (e.g., mental health, infection control) • We need street health clinics (no IDs required – street level access) • Access to needles and safe needle disposal at hospitals • Providing support to people and families living with ALS • Understanding of the challenges and needs of refugee and immigrant populations (e.g.

interpretation services)

66

APPENDIX D:List of Key Informants

A. External to Eastern Health 1. Clowe’s Ambulance Service: Derrick Clowe, Owner/Operator and Bernard O’Brien,

Primary Care Paramedic, Ferryland* 2. Coalition on Richer Diversity: Barbara Burnaby, Coordinator 3. College of the North Atlantic: Gail Gosse, Campus Administrator and Michelle Smart,

Nurse, Prince Philip Drive Campus 4. Department of Health and Community Services: Janice Sanger, Provincial Wait Time

Coordinator, Board Services, Regional Health Operations 5. Department of Justice: Anita Stanley, A/Provincial Manager of Victim Services 6. Eastern School District** 7. Egale Canada: Susan Rose, Volunteer, Education Committee 8. Gibbons Ambulance Service: George Gibbons, Manager and Primary Care Paramedic,

St. Mary’s* 9. Hickey’s Ambulance Service, CBS** 10. Human Resources, Labour and Employment: Cynthia King, Regional Director and Lori

Rose, Regional Manager (Income Support), Avalon Region 11. Memorial University Health Centre, Memorial University of Newfoundland: Dr.

Norman Lee 12. Memorial University of Newfoundland Council of the Students Union** 13. Multicultural Women’s Organization of Newfoundland and Labrador: Kaberi Sarma-

Debnath, Coordinator, Melly Swamidas, Volunteer Board Member, and Yamuna Kutty, Volunteer Board Member

14. Municipalities Newfoundland and Labrador: Lucy Stoyles, Avalon Representative 15. Newfoundland and Labrador Housing Corporation: Elizabeth Bourgeois, Team Leader

and Sean Kilpatrick, Policy Analyst, Policy and Research Department 16. Northeast Avalon Regional Economic Development Board: Christine Snow, Executive

Director

17. Refugee and Immigrant Advisory Council: Jose Rivera, Chair 18. Royal Canadian Mounted Police (RCMP): Mike Ouellette, Sgt. of Operations, Avalon

East District 19. Royal Newfoundland Constabulary: Insp. Ab Singleton, Supt. June Layden (Patrol

Services), A/Supt. Jim Carroll (Criminal Investigation Division) and Sgt. Junior Small, (Training Section)

20. Rural Secretariat: Michelle Yetman, Regional Planner, Avalon Region 21. Ryan’s Ambulance Service, Trepassey** 22. St. John’s Native Friendship Centre: Paula Delaney, Aboriginal Patient Navigator

(Note: dual reporting relationship with Eastern Health) B. Internal to Eastern Health 1. Community Health Services/Public Health Program, Ann Manning, Director 2. Emergency Department, Health Sciences Centre: Darryl Cooze, Manager 3. Emergency Department, St. Clare’s Mercy Hospital: Michele Clarke, Manager 4. Emergency Program, Adult Acute Care (St. John’s): Geralynn Tulk, Clerk II

(Appointment Bookings) 5. Emergency Program, Adult Acute Care (St. John’s): Dr. Scott Wilson, Clinical Chief 6. Long Term Care, St. John’s: Glenda Compton, Director 7. Diagnostic Imaging, Medical Services and Diagnostics: Dr. Geoff Higgins, Clinical

Chief 8. Medicine Program, Adult Acute Care (St. John’s): Janet Templeton, Director 9. Mental Health & Addictions Program, Community, Children & Women’s Health and

Mental Health Services: Kim Baldwin, Assistant Director 10. Paramedicine and Medical Transport Department, Emergency Program Adult Acute

Care, St. John’s: Corey Banks, Manager 11. Perioperative Program, Adult Acute Care, St. John’s: Maria Tracey, Director

12. Rural Avalon and Peninsulas, Integrated Health Services: Calvin Morgan, Manager of Environmental Health

13. Rural Avalon, Integrated Health Services: Judy O’Keefe, Director 14. Surgery Program, Adult Acute Care (St. John’s): Joan Bursey, A/Director 15. Surgery Program, Adult Acute Care (St. John’s): Dr. William Pollett, Clinical Chief *Although outside of the Northeast Avalon Region, private ambulance operators were contacted since they frequent the Emergency Departments within the region **Contacted for an interview but unavailable to complete

67

APPENDIX E:Standardized Questionnaire Used toGuide Key Informant Interviews(External, General)

1. Who does your organization represent? (demographics of clientele, geographic region, scope, etc.)

2. From your organization’s perspective, what are the challenges to the health and

community services system? 3. What are the challenges to accessing the health and community services system? 4. Overall, what do you consider to be the main health and community services

concern(s) of the Northeast Avalon Region? 5. In your opinion, how can these health concerns be reduced or eliminated? 6. In your opinion, what would need to happen in order for the people of the region to

achieve an optimal state of health? 7. Of all the concerns we discussed here today, how would you prioritize the issues that

are most important to address? 8. Have we missed anything that you would like to comment on regarding the health and

community services-related needs of this region? 9. Is there a particular person or group that you feel I should consult during the needs

assessment?

68

APPENDIX F:Standardized Questionnaire Used toGuide Key Informant Interviews (Internaland External, Specific)

1. Who does your organization represent? (demographics of clientele, geographic region, scope, etc.)

2. From your organization’s perspective, what are the challenges related to:

a. Emergency Room use? b. Access to Diagnostic Imaging? c. Access to Specialists?

3. In your opinion, how can these concerns be reduced or eliminated? 4. Of all the concerns we discussed here today, how would you prioritize the issues that

are most important to address? 5. Have we missed anything that you would like to comment on regarding the health and

community services-related needs of this region? 6. Is there a particular person or group that you feel I should consult during the needs

assessment?

69

APPENDIX G:List of Focus Group Sessions Conductedwith Community Partner Agencies

Focus Group (and # of participants)

Location Date

1. Residents of CBS (arranged in partnership with CBS Community Resource Network) (3)

St. Peter’s Church Hall, Upper Gullies, CBS

October 21, 2009

2. Seniors (arranged in partnership with the City of St. John’s Recreation Department) (9)

City of St. John’s Recreation Boardroom, Crosbie Pl., St. John’s

October 22, 2009

3. Representatives from various Faith Groups (arranged in partnership with Pastoral Care and Ethics, Eastern Health) (10)

Health Sciences Centre, Lecture Theatre B St. John’s

October 22, 2009

4. Representatives of the Independent Living Resource Centre (10)

Independent Living Resource Centre, Escasoni Place, St. John’s

October 23, 2009

5. Representatives of the Buckmasters Circle Area (arranged in partnership with Buckmasters Circle Community Centre) (12)

Buckmasters Circle Community Centre, St. John’s

November 5, 2009

6. Clients of The Gathering Place (8) The Gathering Place Military Road, St. John’s

November 10, 2009

7. Staff Members of the Association for New Canadians (6)

Association for New Canadians Language School, Smithville Cres., St. John’s

November 13, 2009

8. Representatives of Stella Burry Community Services (13)

Emmanuel House, Cochrane Street, St. John’s

November 16, 2009

9. Representatives of the Salvation Army New Hope Centre (19)

Salvation Army New Hope Centre, Springdale St., St. John’s

November 24, 2009

10. Youth (arranged in partnership with the Community Youth Network) (6)

Youth Services Site Carter’s Hill Place, St. John’s

November 25, 2009

11. Clients of the Association for New Canadians (6)

Association for New Canadians Language School, Smithville Cres., St. John’s

November 27, 2009

12. Representatives of Conception Bay Centre (Arranged in partnership with the Turk’s Gut Heritage Committee) (9)

Turk’s Gut Heritage Centre Marysvale

November 30, 2009

13. Representative Administrative Professionals from GP’s offices (arranged in partnership with the Community Medical Advisory Committee) (6)

Eastern Health Major’s Path Site, St. John’s

December 2, 2009

Total number of Participants: 117

70

APPENDIX H:Standardized Questionnaire Used toGuide Focus Group Discussions

1. Do you have difficulty accessing a family doctor? Why or why not? 2. Why do people go to Emergency Departments instead of a family doctor? 3. What are the challenges related to:

a. Emergency Room use? b. Diagnostic Imaging? c. Access to Specialists?

4. In your opinion, how can these concerns be reduced or eliminated? 5. Of all the concerns we discussed here today, how would you prioritize the issues that are

most important to address? 6. Do you have any other comments regarding the health and community services-related

needs of this region?

71

APPENDIX I:Northeast Avalon Community HealthNeeds Assessment Telephone Survey

Northeast Avalon Community Health Needs

Assessment Telephone Survey Report

By

Telelink Research

March 28, 2009

Eastern Health Northeast Avalon Health Survey

Telelink Research Page 1

Introduction About Eastern Health Eastern Health is the largest integrated health authority in Newfoundland and Labrador and offers the full continuum of health and community services, including public health, long-term care, community services, hospital care and unique provincial programs and services. The organization was created on April 1, 2005 through the merger of seven health organizations. The geographic catchment area for Eastern Health is the area east of, and including, Port Blandford, and includes the Avalon, Burin, and Bonavista Peninsulas as well as Bell Island - a population of over 290,000. With a geographic territory of approximately 21,000 square kilometers, the boundaries of Eastern Health include 111 incorporated municipalities, 69 local service districts, and 66 unincorporated municipal units. Eastern Health has the provincial responsibility for providing tertiary level health services which are offered through its academic healthcare facilities and provincial programs such as the Provincial Genetics and Provincial Perinatal Program. The organization has approximately 12,000 staff with 27 health service facilities (seven acute care facilities, six community health centres, 12 long-term care facilities and provincial cancer care and rehabilitation centres), and community-based offices in 30 communities. The organization partners with many organizations, particularly Memorial University of Newfoundland. Eastern Health and Memorial University collaborate on the creation of new knowledge through many research activities and work together to provide solid education and work experience for the next generation of health providers. Needs Assessments One of the responsibilities of a regional health authority in the province of Newfoundland and Labrador is to assess health and community services needs on an ongoing basis. In 2005, Eastern Health’s Board of Trustees identified completion of community health needs assessments as a strategic priority. To date, needs assessments have been completed on Bell Island (2006), the Burin Peninsula (2006) and the Southern Avalon (2007). Northeast Avalon Community Health Needs Assessment The Northeast Avalon Community Health Needs Assessment was initiated by Eastern Health in December 2008. Telelink Research, a division of Telelink Call Centre Inc., St. John’s, NL, was contracted by Eastern Health to conduct a telephone survey. The survey is one component of the primary research to be conducted by Eastern Health. Other methodologies used include focus groups, key informant interviews, and written and oral submissions.



Methodology

Survey Instrument The questionnaire used in this telephone survey is based upon questionnaires developed by Ann Ryan, Dr. Veeresh Gadag, and others from Memorial University’s Health Research Unit (HRU). The survey builds upon other HRU instruments used in needs assessments for the Grenfell Regional Health Service Survey (2000), Bell Island (2005), downtown St. John’s (2005) and the Burin Peninsula (2006). It was modified for the Southern Avalon telephone survey and further modified for the Northeast Avalon telephone survey. (Appendix A) The questionnaire was programmed into Telelink’s Computer Assisted Telephone Interviewing (CATI) system. It was piloted with 25 residents in the region before the full survey was conducted and no changes were deemed necessary. The region was divided into four areas: St. John’s, Mt. Pearl, Petty-Harbour-Maddox Cove Conception Bay South, Paradise Pouch Cove, Bauline-Flatrock-Torbay, Logy Bay-Middle Cove-Outer Cove, Portugal

Cove-St. Philip’s Harbour Main-Chapels Cove-Lakeview, Holyrood, Avondale, Conception Harbour,

Colliers, Marysvale For convenience, future references to these areas will be as follows: St. John’s CBS-Paradise Pouch Cove Holyrood

The intent of the telephone survey was to capture the views of residents of the Northeast Avalon who were 19 years of age and older.



Surveying Process Most interviews were conducted between February 9 and February 21, 2009; however, an additional interviewing session was undertaken on March 3, 2009 to augment the number of interviews in the Holyrood area. Interviews were conducted using a Computer Assisted Telephone Interviewing (CATI) system and an automatic dialer. All listed residential telephone numbers for each of the sampling areas were obtained from an electronic database and were randomized prior to being loaded into the automatic dialer. The dialer placed calls, and those that were live-answered were passed to an available agent. The agent introduced herself and invited the respondent to take part in the survey as follows: “Hello, my name is ________________. I am calling on behalf of Eastern Health, the regional health board responsible for providing health and community services in your area. I am calling about a health survey and I would really appreciate some of your time this morning/ afternoon/ evening.” If the person agreed, and was determined to be at least 19 years of age, the agent read the “Statement of Verbal Consent” and proceeded with the interview. Statement of Verbal Consent: Before we begin, let me tell you a bit more about our survey and the conditions of your participation. We are asking people about some of the health issues in your community and about your use and satisfaction with the health care system. Your participation in this telephone survey is very important and will take approximately 20 minutes to complete. Your comments will be held in the strictest confidence, results will be combined with others and no names will ever be used. You may refuse to answer any of the questions you wish. You can end the survey at any time. Your participation will help us better understand the particular needs for health and social programs in your area. Would you mind answering these questions now?



During the course of the survey, a total of 6,233 calls were made, resulting in 1,032 completed interviews. Complete details of outcomes of the calling process are in Table 1.

Table 1

Call Outcomes

Outcome Number Percent

Complete 1032 16.5 Refused 2046 32.8 Answering machine 1359 21.8 No answer 1065 17.0 Busy 383 6.0 Not in service 219 3.5 Ineligible / Age 110 1.7 Abandoned 19 < 1 %

Totals 6233 100.0

A sample of size 1,032 has a margin of error of ± 3.1 percentage points 19 times out of 20.



The 1,032 completed interviews were distributed throughout the survey region as shown in Table 2.

Table 2

Distribution of Completed Interviews

St. John’s 503

CBS-Paradise 203

Pouch Cove 202

Holyrood 124

Total 1032 Data analysis The collected data was imported into an SPSS (Statistical Package for the Social Sciences) computer program for analysis. Prior to analysis, the data was weighted by population, 19 years of age and older, in each region. Weighting ensures that neither sub-region is given disproportional representation within the total survey. The analyses in this document are all based on the weighted data.



Demographic Information of Respondents



Gender Figure 1 presents the gender of respondents. The gender division for the survey area is approximately 53 percent female and 47 percent male (Statistics Canada Census 2006). With 66.8 percent of respondents to the survey being female, the sample is clearly biased toward females.

Figure 1

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%

Female Male

66.8%

33.2%

Distribution of Interviews by Gendern = 1032



Age Figure 2 presents age of respondents. From this figure it can be determined that approximately 80 percent of respondents to the survey are 40 years of age or older. Given that age groups over the age of 40, within the survey area, comprise approximately 60 percent of the population (Statistics Canada Census 2006), the sample is somewhat biased toward these age groups.

Figure 2

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Up to 29 years

30 to 39 years

40 to 49 years

50 to 59 years

60 to 69 years

Above 70 years

Refused

4.6%

14.2%

23.8% 23.5%

19.2%

13.1%

1.6%

Distribution of Interviews by Agen = 1032



Income Figure 3 presents annual before-tax incomes of all respondents to the survey. Given the high percentage of respondents who refused to answer the question on total household income, there is no merit in attempting to determine if the sample is biased toward any particular income bracket

Figure 3

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

More than $80 K

$50 K to less than

$80 K

$20 K to less than

$50 K

Less than $20 K

Refused

29.3%

17.5%20.1%

6.5%

26.6%

Distribution of Interviews by Total Household Incomen = 1032



Section 1

Health Services



Health Services – Family Doctors Family doctors play a key role in the delivery of health care. Access to a family doctor is also important for accessing other required health and community services. Of the 1,032 respondents to the survey, only 28 of them, 2.7 percent, reported that they did not have a family doctor. This contrasts with the numbers in the surveys of Burin, and the Southern Avalon where the percentage of those reporting no family doctor was approximately 12 percent.

Figure 4

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Have Family Doctor No Family Doctor

97.3%

2.7%

Incidence of Family Doctorn = 1032



Respondents who do not have a family doctor The analysis which follows considers reasons for not having a family doctor, what one does for health care needs in the absence of a family doctor, and whether there is a statistically significant difference in the age, gender, and income between those having, and those not having a family doctor. Reasons for not having a family doctor When asked why they did not have a family doctor, eight of those 28 respondents, or 29 percent of them, gave being “new to the community” as the reason for not having a family doctor. Three others reported that their previous family doctor had left the area. All other responses to this question indicate that the respondents either have no need for a family doctor, or could not verbalize a pertinent response.

Figure 5

0%

5%

10%

15%

20%

25%

30%29%

18%17% 16%

12%8%

Reasons for not having a family doctorn = 28



Options for care in the absence of a family doctor When asked, “What do you do if you need services normally provided by a family doctor?” ten of the 28 respondents, 36 percent, reported they go to the Emergency Room (ER) at a hospital. Other responses are detailed in Figure 6.

Figure 6

The “Other” component of these responses include: Going to the clinic of their former family doctor to see if another doctor there will treat

them (3), Ask a friend to refer them to a family doctor (2).

0%

20%

40%36%

24% 22%17%

2%

What do you do if you need services normally provided by a family doctor?



Use of Emergency Room When questioned further, it was found that only two of these ten respondents had actually visited an ER in the past twelve months.

Figure 7

Both of these individuals: had visited an ER between 1 and 4 times in the past 12 months,

each had waited less than four hours,

each ranked the waiting time as “three” on a “one to five” scale.

Use of Community Health nurse Further analysis shows that there is no significant difference in being seen by a public health nurse in these two groups, that is, those with and those without a family doctor (p = .857).

0%

20%

40%

60%

80%

100%

Never 1-4 times

81%

19%

Times to ER because of no family doctorn = 10



No family doctor by Gender of respondent

When the data is examined by “Gender”, it can be seen that the majority of those without a family doctor are males which is in marked contrast to the gender composition of those with a family doctor (p = .003).

Figure 8

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Have family doctor No family doctor

32.5%

57.1%67.5%

42.9%

Incidence of family doctor by respondent gender n = 1032

Male

Female



No family doctor by Age of respondent Analysis of the data to examine the incidence of family doctor by age of respondents, shows that those respondents up to age 49 are less likely to have a family doctor than are those 50 years of age and over (p = .006).

Figure 9

No family doctor by household income of respondent Further analysis shows that there is no significant difference in income between these two groups, that is, those with, and those without a family doctor (p = .884).

0.0%5.0%

10.0%15.0%20.0%25.0%30.0%35.0%

Up to 29 years

30 to 39 years

40 to 49 years

50 to 59 years

60 to 69 years

Above 70 years

Refused

4.2%

14.0%

23.5% 23.6%19.6%

13.4%

1.7%

17.2%20.7%

34.5%

20.7%

3.4% 3.4%

Incidence of family doctor by respondent age

Have family doctor No family doctor



Respondents who have a family doctor

(Unless otherwise indicated, the data in this section is for the 1004 respondents who reported having a family doctor)

Location of family doctor

From Figure 10 it can be seen that the largest concentration of family doctor offices is in the St. John’s / Mount Pearl region. A small number of respondents reported that the office of their family doctor is outside the survey area. Three respondents from St. John’s reported the location of their family doctor is in Bay Bulls and six respondents from the Holyrood area reported it as being in or near Bay Roberts.

Figure 10

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%

65.5%

13.1% 9.2% 4.0% 2.7% 1.2% 0.9% 0.1% 0.1% 0.6%

Location of Family Doctor



Incidence of visiting family doctor Figure 11 shows that the largest, single group of respondents, 46 percent, had visited a family doctor from one to three times in the past twelve months. Just over three percent reported not having visited a family doctor in that period.

Figure 11

When the data is analyzed by age and gender, it can be seen that approximately 93 percent of males, up to age 29, have seen a doctor one to three times or not at all in the past twelve months while approximately 41 percent of females, up to age 29, reported seeing a family doctor in the same period (p = .010). It can be further seen that 28 percent of male respondents in the 30 to 39 year age bracket reported seeing a family doctor more than four times in the past twelve months while approximately 76 percent females in the same age group reported seeing a family doctor in the same period (p = .000). No other significant differences can be seen by gender or age.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

7 times or more

4-6 times 1-3 times None Don't know

21.9%

32.2%

41.6%

3.2% 1.0%

Incidence of Visiting Family Doctor



Tenure with family doctor Figure 12 shows that the majority of respondents, 77 percent, have been going to their current family doctor for five years or more. Only four percent of them have been going to their current doctor for less than a year.

Figure 12

When the data is further analyzed, no significant differences can be seen in Tenure with family doctor by gender or age.

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%

5 years or more

2 years to less than 5 years

1 year to less than 2 years

Less than 1 year

77.2%

14.6%4.1% 4.0%

How long going to family doctor



Travel time to office of family doctor From Figure 13, it can be seen that the largest single group of respondents, nearly 58 percent, reported that travel time to the office of their family doctor is ten minutes or less. Just over 90 percent of them require 20 minutes or less to arrive at the office of their family doctor.

Figure 13

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

10 min or less

11 to 20 min

21 to 30 min

31 to 40 min

41 to 50 min

51 to 60 min

61 to 90 min

Don't know

57.8%

32.7%

7.3%0.9% 0.3% 0.4% 0.1% 0.5%

Time to travel from home to office of family doctor



Satisfaction with travel time As can be seen from Figure 14, just over 80 percent of respondents gave their satisfaction with travel time to the office of their family doctor a ranking of Five, or “Very Satisfied”. It can be further concluded from Figure 14 that just over 92 percent of them were at least “Satisfied”, a ranking of Four or greater, with travel time to the office of their family doctor.

Figure 14

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Five Four Three Two One No opinion

82.4%

10.1% 5.0% 1.2% 0.7% 0.5%

Satisfaction with travel time to office of family doctor



Satisfaction with location of office of family doctor As can be seen from Figure 15, just over 80 percent of respondents reported a ranking of Five, “Very Satisfied” with the convenience of the location of the office of their family doctor. It can be further concluded from Figure 15 that nearly 91 percent of them were at least “Satisfied”, a ranking of Four or greater, with the convenience of the location of the office of their family doctor.

Figure 15

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%


80.3%

10.5% 5.3% 2.1% 1.1% 0.7%

Satisfaction with convenience of location of office of family doctor



Wait times for non-urgent appointment As can be seen, from Figure 16, answers to the question, “When you call your family doctor's office to set up an appointment for a non-urgent reason, how long do you usually have to wait before you get to see the doctor?” were clustered around the center of a continuum ranging from “Same Day” to “More than three weeks”. Indeed, it can be concluded from Figure 16 that less than six percent of all respondents to this question reported having to wait more than two weeks for a non-urgent appointment.

Figure 16

0.0%5.0%

10.0%15.0%20.0%25.0%30.0%35.0%40.0%

Same day Next day More than two days but less than a week

More than 1 week but less than 2

weeks

More than 2 weeks but less than 3 weeks

More than 3 weeks

17.8%21.8%

38.1%

16.9%

3.9%1.5%

Wait times to set up appointment for a non-urgent reason



Satisfaction with wait times for appointments with family doctor Figure 17 shows that a small majority of respondents, slightly over 50 percent, ranked their satisfaction with wait times for an appointment as Five, or “Very Satisfied”. It can be further concluded from Figure 17 that just over 70 percent of them were at least “Satisfied” a ranking of Four or greater, with the wait times to schedule an appointment with their family doctor.

Figure 17

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%


50.3%

19.9%16.4%

6.6% 5.8%1.0%

Satisfaction with wait times to get an appointment to see family doctor



Wait times at office of family doctor As can be seen, from Figure 18, answers to the question, “From the time that you arrive at the doctor's office to the time that you see the doctor, how long do you usually wait before you get to see the doctor?” were clustered around the center of a continuum ranging from “No wait time” to “More than sixty minutes”. Indeed, it can be concluded from Figure 18 that nearly sixty percent of all respondents to this question reported having to wait more than 30 minutes to see a doctor from the time they arrive at the office.

Figure 18

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

No wait time

1-15 minutes

16-30 minutes

31-60 minutes

More than 60 minutes

1.5%

23.7%

34.0%

27.6%

13.2%

Wait times to see doctor after arrival at office



Satisfaction with wait times at office of family doctor Figure 19 shows that the largest single group of respondents, nearly 42 percent, ranked their satisfaction with wait times at the office of their family doctor as Five, or “Very Satisfied”. It can be further concluded from Figure 19, that just over 63 percent of them were at least “Satisfied”, a ranking of Four or greater, with the wait times once they arrive at the office of their family doctor.

Figure 19

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%


41.8%

21.4%18.2%

10.0%8.0%

0.6%

Satisfaction with wait times at office of family doctor



Availability of alternative family doctor for non-urgent appointment As can be seen, from Figure 20, when respondents were asked, “If you need to see a doctor and your family doctor is not available, are you usually able to see another family doctor in the same clinic?”, a majority of them, just over 63 percent, responded “Yes”.

Figure 20

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%

63.3%

14.4%1.6% 2.3%

17.0%

1.4%

Availability of another family doctor in same clinic



Availability of alternative family doctor in same clinic for urgent appointment As can be seen from Figure 21, a majority of respondents, 52 percent, reported they could normally see a family doctor in the same clinic on the same day for an urgent appointment. Approximately 20 percent of them reported either not being able to get such an appointment, or only sometimes.

Figure 21

0.0%

20.0%

40.0%

60.0% 52.3%

16.6%

3.0% 3.0%

23.0%

2.0%

Availability of alternative family doctor for urgent appointment



Alternative sources of medical care when family doctor not available in same clinic In total, 197 respondents reported either not being able to get an urgent appointment in the same clinic, on the same day, or only sometimes. Of that number, a majority, 78 percent, reported that they have gone to the emergency room of a hospital. Only three percent of them reported they would go without care.

Figure 22

0%10%20%30%40%50%60%70%80%

Go to the ER of a

hospital

Use Health

Line

Go without

care

Have no occasion

Walk In Clinic

Look for another

clinic

78%

3% 3% 5% 6% 4%

Alternative sources of medical care when family doctor not available

n = 197



Wait times in emergency room Those respondents who reported they have gone to an emergency room were then asked, “How long do you usually have to wait from the time you are registered to the time you are seen by a doctor?” Figure 23 shows that nearly half of them, 47 percent, reported they have waited less than four hours. An identical number reported they have waited from five to nine hours. Only six percent reported having waited ten hours or more.

Figure 23

0%5%

10%15%20%25%30%35%40%45%50%

Less than 4 hours 5-9 hours 10 hours or more

47% 47%

6%

Wait times in ERn = 153



Satisfaction with wait times in emergency room As can be seen from Figure 24, 57 percent of respondents reported a ranking of One, “Very Dissatisfied” with the wait times in an emergency room. It can be further concluded from Figure 24 that only 17 percent of them were at least “Satisfied”, a ranking of Four or greater, with the wait times in an emergency room.

Figure 24

Further analysis of the data shows that, nearly 44 percent of those who reported emergency room wait times of less than four hours were at least “Dissatisfied” with that waiting time. Twenty-eight percent of them were at least “Satisfied”. Nearly 84 percent of those who reported having to wait from five to nine hours said they were “Very Dissatisfied” with the wait times. However, just over four percent said they were at least “Satisfied”. All respondents who had to wait ten hours or more reported being “Very Dissatisfied”.

0%

10%

20%

30%

40%

50%

60%


10%7%

12% 9%

57%

6%

Satisfaction with wait times in ERn =153



Community Health Nurses

Incidence of being seen by community health nurse As can be seen from Figure 25, just over 15 percent of respondents reported they had been seen by a community health nurse.

Figure 25

When the data is further analyzed, it can be seen that the majority, 77 percent, of those having been seen by a community health nurse in the past twelve months are female (p = .002).

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Yes No

15.4%

84.6%

Have you been seen by a community health nurse in the past twelve months?



Frequency of being seen by community health nurse Figure 26 shows that the majority, 69 percent, of those respondents who had been seen by a community health nurse, had been seen from one to four times.

Figure 26

0%

20%

40%

60%

80%

1- 4 times 5 - 9 times 10 - 19 times 20 or more times

69%

11% 10% 11%

How many times have you been seen by a community health nurse in the past twelve months?

n= 159



Dentists

Incidence of visiting a dentist Figure 27 shows that the majority, just over 69 percent, reported having visited a dentist in the past twelve months.

Figure 27

Further analysis of the data shows that there is no significant difference between males and females in their incidence of visiting a dentist in the past twelve months (p = .638).

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%

Yes No

69.4%

30.6%

Have you seen a dentist in the past twelve months?



Urgent dental appointments Figure 28 shows that just over 35 percent of respondents reported they could get an appointment to see a dentist on an urgent basis on the same day it was needed. An almost equal number, 34 percent, reported that they have not had a need to request an urgent dental appointment.

Figure 28

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Yes No Sometimes Have had no occasion

35.2%

27.6%

2.9%

34.4%

If you need an urgent appointment to see a dentist, can you normally see a dentist on the same day?



Satisfaction with Health Services Confidence in the system All 1,032 respondents to the survey were asked, “Based on your own experience, how satisfied or dissatisfied are you with Health and Community Services?” Figure 29 shows that nearly half of all respondents said they were “Satisfied” with Health and Community Services and a further 16 percent said thay were “Very Satisfied”. Cumulatively, 65 percent of all respondents reported that they were at least “Satisfied” with Health and Community services. Cumulatively, only 13 percent of those questioned reported a level of dissatisfaction with Health and Community Services.

Figure 29

Further analysis of the data shows that, for respondents to the survey, age and gender are not determining factors in levels of satisfaction with health and community services.

0%5%

10%15%20%25%30%35%40%45%50%

16%

49%

17%10%

3% 5%

Satisfaction/Dissatisfaction with Health and Community Services



Comparison of health and community services with twelve months ago Respondents were then asked to compare Health and Community Services in their area with what they were twelve months ago. Figure 30 shows that the majority, 61 percent, said that things were the same. A relatively small portion, 15 percent, said that things were worse than a year previous, and 19 percent had no opinion. Five percent of the respondents were of the opinion that things were better than they were a year ago.

Figure 30

Further analysis of the data shows that, for respondents to the survey, females (16.3%) were somewhat more likely than males (13.1%) to report that health and community services had worsened over the past twelve months. Conversely, fewer females (4.1%) than males (7.9%) reported that health and community services had become better over the past twelve months (p = .004).

0%

10%

20%

30%

40%

50%

60%

70%

Better The same Worse No opinion

5%

61%

15%19%

Comparison of Health and Community Services with a year ago



Satisfaction with selected Health and Community Services. Respondents were next asked to rate their satisfaction with selected Health and Community Services. The question was posed as follows: On a scale from 1 to 5 with 1 being “Very dissatisfied” and 5 being “Very satisfied”, please rate your overall satisfaction with the following services. Or it may be that you have not used the service, or have no opinion. Respondents who ranked a service as “Very Dissatisfied” were then asked for a reason for that ranking. Care must be taken when interpreting the results of the “Very Dissatisfied” respondents due to the low frequency of this response. Respondents who gave a service a ranking of one, two, three, or four, were asked if that service is getting better or worse. All other responses were excused from further questioning on that particular service. The material which follows details the outcome of this line of questioning.



Community health nursing / Public health nursing Approximately 69 percent of all respondents reported they had not used community health nursing or had no opinion on the service. Figure 31 shows that of the 319 respondents to this service, a majority, 55 percent, were “Very Satisfied” with the service. It can be determined from Figure 31 that, cumulatively, 82 percent of those respondents were at least “Satisfied” with community health nursing. Only two percent of that number were “Very Dissatisfied”.

Figure 31

0%10%20%30%40%50%60%

Very Satisfied

Satisfied Neither Dissatisfied Very Dissatisfied

55%

27%

14%

3% 2%

Community health nursing/public health nursing n = 319



Why very dissatisfied with Community Health nursing / Public health nursing? As can be seen from Figure 32, only six of 319 respondents to this service gave a ranking of “Very Dissatisfied”. Of that number, four gave “Poor service, insufficient staff” as a reason. The other two could not give a defined reason.

Figure 32

0.%10.%20.%30.%40.%50.%60.%70.%

65%

35%

Community health nursing/Public health nursing n = 6



Is Community Health nursing / public health nursing getting better or worse? In total, 143 respondents were asked if community health nursing / public health nursing is getting better or worse. The largest group of respondents, 38 percent, said there was no change.

Figure 33

0%

5%

10%

15%

20%

25%

30%

35%

40%

Better Worse No Change No Opinion

15%

21%

38%

26%

Community health nursing/public health nursing n = 143



Emergency Room at a hospital Approximately 28 percent of all respondents reported they had not used an emergency room at a hospital or had no opinion on the service. Figure 34 shows that of the 740 respondents to this service, the largest segment, 36 percent, were “Very Dissatisfied” with the service. It can be determined from Figure 34 that, cumulatively, 52 percent of those respondents were at least “Dissatisfied” with emergency room at a hospital. Only 18 percent of that number were “Very Satisfied”.

Figure 34

0%

5%

10%

15%

20%

25%

30%

35%

40%

Very Satisfied


18%15% 15% 16%

36%

Emergency room at a hospital n = 740



Why very dissatisfied with Emergency Room at a hospital? Of the 263 respondents who said they were “Very Dissatisfied” with emergency room at a hospital, the vast majority, 88 percent, referenced long wait times as the reason.

Figure 35

The “Other” component in Figure 35 references “Negative attitude of staff.”

0.%10.%20.%30.%40.%50.%60.%70.%80.%90.%

88%

8% 2% 3%




Is Emergency Room at a hospital getting better or worse? As can be seen from Figure 36, the majority of respondents, 61 percent, said that emergency room at a hospital is getting worse. Only five percent of them said it was getting better.

Figure 36

0%

10%

20%

30%

40%

50%

60%

70%


5%

61%

23%

12%




Access to specialists Approximately 28 percent of all respondents reported they had not required access to specialists, or had no opinion on the service. As can be seen from Figure 37, the two ends of the scale, “Very Dissatisfied” and “Very Satisfied”, are almost equally represented, at 26 percent and 23 percent, respectively. The remainder of the scale is also evenly balanced in the 16 to 17 percent range.

Figure 37

0%

5%

10%

15%

20%

25%

30%

Very Satisfied


23%

16% 17% 17%

26%

Access to specialists n = 743



Why very dissatisfied with access to specialists? Of the 195 respondents who said they were “Very Dissatisfied” with access to specialists, the overwhelming majority, 91 percent, gave “Wait times too long” as the reason for their dissatisfaction.

Figure 38

0%10%20%30%40%50%60%70%80%90%

100%

0%

91%

5% 3% 1%




Is access to specialists getting better or worse? The majority of respondents to this question, 60 percent, said that access to specialists is getting worse. Only four percent of them said it was getting better. Nevertheless, 25 percent of them said there is no change in access to specialists.

Figure 39

0%

10%

20%

30%

40%

50%

60%


4%

60%

25%

11%




Ambulance services Approximately 74 percent of all respondents reported they had not used an ambulance or had no opinion on the service. Figure 40 shows that of the 272 respondents to this service, the largest segment, 66 percent, were “Very Satisfied” with the service. It can be determined from Figure 40 that, cumulatively, 86 percent of those respondents were at least “Satisfied” with ambulance services. Only three percent of that number were “Very Dissatisfied”.

Figure 40

0%

10%

20%

30%

40%

50%

60%

70%

Very Satisfied


66%

20%

9%2% 3%

Ambulance services n = 272



Why very dissatisfied with Ambulance services? Only 11 respondents reported being “Very Dissatisfied” with ambulance services. Six of these 11 respondents gave long wait times as their reason, three of them referenced poor service, insufficient staff, one of them referenced cost, and another mentioned the negative attitude of staff.

Figure 41

0%

10%

20%

30%

40%

50%

60% 55%

9%

27%

9%




Are Ambulance services getting better or worse? The largest single group of respondents to this question, 46 percent, said that there is no change in ambulance services. Twelve percent of them said that ambulance services were getting better, while 20 percent of them said that ambulance services were getting worse.

Figure 42

0%

10%

20%

30%

40%

50%


12%

20%

46%

22%




Home care / home support Approximately 86 percent of all respondents reported they had not used home care / home support or had no opinion on the service. Figure 43 shows that, of the 148 respondents to this service, the largest segment, 35 percent, were “Very Satisfied” with the service. It can be determined from Figure 42 that, cumulatively, 48 percent of those respondents were at least “Satisfied” with home care / home support services. However, 18 percent of that number were “Very Dissatisfied”.

Figure 42

0%5%

10%15%20%25%30%35%

Very Satisfied


35%

13%

21%

13%18%

Home care/home support n = 148



Why very dissatisfied with Home care / home support? In total, 27 respondents were “Very Dissatisfied” with home care / home support services. For the most part, 29 percent, respondents referenced poor service, insufficient staff as the reason. This is reinforced, to some extent, with the unique responses captured in responses categorized as Other in Figure 43.

Figure 43

“Other” component consists of comments as recorded by the interviewer: No training provided for workers - they just take them off the street - quality of work

terrible - some are really dirty. Don't consider them to be government employees - and are not being paid for their work.

Four or five girls in one stretch of time - did not get a chance to know any of them.

0%

5%

10%

15%

20%

25%

30%

35%

14%16%

2%

29%

5%

34%

Home care/home support n = 27



Home care did not show up after having a heart attack. Recent incident with a family member - discharged from hospital, assumed that because

she was given telephone numbers for private care workers no home care support put in place. (From 75 year old woman)

Just for the lack of it.

Not enough staff for homecare - more qualified workers into the system.

Not available when needed - took children and wife to do all of it.

Home care not available just after my surgery - no one available - but my nurse tried.

Wanted more home care support for a loved one in my family and it was refused -

currently getting 12 hours per day and wanted some more.



Is home care / home support getting better or worse? The majority of respondents to this question, 51 percent, said that home care / home support is getting worse. Only ten percent of them said that the service was getting better, while 17 percent of them said there was no change.

Figure 44

0%

10%

20%

30%

40%

50%

60%


10%

51%

17%21%

Home care / home support n = 97



Long term care Approximately 84 percent of all respondents reported they had not used long term care or had no opinion on the service. It can be determined from Figure 45 that, cumulatively, 41 percent of those expressing an opinion were at least “Satisfied” with the service. However, 17 percent of them were “Very Dissatisfied”.

Figure 45

0%

5%

10%

15%

20%

25%

Very Satisfied


25%

16%

25%

18% 17%

Long-term care n = 164



Why very dissatisfied with long-term care? In total, 28 respondents were “Very Dissatisfied” with long-term care. Fourteen of these 28 respondents gave wait times too long, and ten of them gave poor service, insufficient staff as the reason for their dissatisfaction.

Figure 46

0%5%

10%15%20%25%30%35%40%45%50%

11%

50%

1%

39%

Long-term care n = 28



Is long-term care getting better or worse? The majority of respondents to this question, 54 percent, said that long term care was getting worse. Only nine percent of them said the service was getting better, while 29 percent of them said there was no change in the service.

Figure 47

0%

10%

20%

30%

40%

50%

60%


9%

54%

29%

8%

Long-term caren = 123



Mental Health Services Approximately 84 percent of all respondents reported they had not used mental health services, or had no opinion on the service. It can be determined from Figure 48 that, cumulatively, 32 percent of those expressing an opinion were at least “Satisfied” with the service. However, it can be determined that, cumulatively, 42 percent of them were at least “Dissatisfied”, with 26 percent of them being “Very Dissatisfied”.

Figure 48

0%5%

10%15%20%25%30%

Very Satisfied


16% 18%

25%

16%

26%

Mental health services n = 161



Why very dissatisfied with mental health services? In total, 41 respondents were “Very Dissatisfied” with mental health services. Long wait times combined with poor service, insufficient staff accounted for 37 percent of the reasons given for being “Very Dissatisfied”. For the most part, 45 percent, respondents gave various personal reasons as detailed in the Other component following Figure 49.

Figure 49

“Other” component consists of comments as recorded by the interviewer: Appears there are no services available.

Discriminated against - no care provided - lack of resources for people with mental

illnesses. Doesn't meet needs of the population that are in need of service.

0%5%

10%15%20%25%30%35%40%45%50%

12%17%

3%

20%

2%

45%




Don’t seem to be dealt with. Feel like writing a book - very bad in this day and age - same as it was 100 years ago.

Waterford Hospital really needs help - hospital should be burned to the ground.

Know someone who needed the service and couldn’t get assistance.

Lack of mental health services for children as well as adults.

Lack of resources - lack of understanding - outside the city is worse - little funding.

No access to specialist.

Not able to access it.

Not getting the care they should.

Not having the proper place to go for care - hearing impaired - closing the school down

oblivious to any need for it - totally ignoring the issues that are out there - nothing for addictions services - nothing for children - nothing for families of these persons - no help or after care.

People not getting needs met - time is too long - not enough service.

The protocols are negligent.

There are no mental health facilities for emergency for mental health issues other than

police.



Are mental health services getting better or worse? The majority of respondents to this question, 52 percent, said that mental health services were getting worse. Only 13 percent of them said the service was getting better, while 22 percent of them said there was no change in the service.

Figure 50

0%

10%

20%

30%

40%

50%

60%


13%

52%

22%

14%




Addictions services Approximately 92 percent of all respondents reported they had not used addictions services, or had no opinion on the service. It can be determined from Figure 51 that, cumulatively, 28 percent of those expressing an opinion were at least “Satisfied” with the service. However, it can also be determined that, cumulatively, 50 percent of them were at least “Dissatisfied”, with 34 percent of them being “Very Dissatisfied”.

Figure 51

0%5%

10%15%20%25%30%35%

Very Satisfied


11%

17%22%

16%

34%

Addictions services n = 82



Why very dissatisfied with addictions services? In total, 28 respondents were “Very Dissatisfied” with addictions services. Long wait times combined with poor service, and insufficient staff accounted for 42 percent of the reasons given for being “Very Dissatisfied”. For the most part, 49 percent, respondents gave various personal reasons as detailed in the Other component following Figure 52.

Figure 52

“Other” component consists of comments as recorded by the interviewer: Does not feel there is a commitment to it.

Limited resources. Programs we have are not national standards.

Not enough for the people who need it.

Services aren’t available to help addictions before they start.

0%5%

10%15%20%25%30%35%40%45%50%

1%

12%

30%

8%

49%




Not enough funding.

Involved in working with children with serious mental health and substance abuse - need

a treatment centre - people inside have been asking for this for 25 years. The law cannot do anything with it now - it is up to you.

Not enough facilities.

No programs in place.

Tried to quit smoking - and called the help line - they had people there who did not know

what they were talking about - useless – (she quit on her own afterwards). Not enough advertising.



Are addiction services getting better or worse? The largest single group of respondents to this question, 40 percent, said that addiction services were getting worse. However, 32 percent of them said the service was getting better, while 22 percent of them said there was no change in the service.

Figure 53

0%5%

10%15%20%25%30%35%40%45%


32%

40%

22%

6%




Child, Youth and Family Services Approximately 87 percent of all respondents reported they had not used Child, Youth and Family Services, or had no opinion on the service. It can be determined from Figure 54 that, cumulatively, a majority, 52 percent of those expressing an opinion were at least “Satisfied” with the service. Only eleven percent of them were “Very Dissatisfied”.

Figure 54

0%5%

10%15%20%25%30%

Very Satisfied


25% 27% 27%

10% 11%

Child, Youth and Family Services n = 139



Why very dissatisfied with Child, Youth and Family Services? In total, 16 respondents were “Very Dissatisfied” with Child, Youth and Family Services. Poor service, insufficient staff accounted for 39 percent of the reasons given for being “Very Dissatisfied”. For the most part, 50 percent, respondents gave various personal reasons as detailed in the Other component following Figure 55.

Figure 55

“Other” component consists of comments as recorded by the interviewer: Hard to access - needs to be user friendly.

Haven't come through for me.

Lack of youth programs.

No one seems to be paying any attention.

0%5%

10%15%20%25%30%35%40%45%50%

6%

39%

6%

50%




Stressful to workers. Things could be handled better. And more efficiently.



Is Child, Youth and Family Services getting better or worse? The largest single group of respondents to this question, 35 percent, said that Child, Youth and Family Services were getting worse. However, 23 percent of them said the service was getting better, while 32 percent of them said there was no change in the service.

Table 56

0%

5%

10%

15%

20%

25%

30%

35%

40%


23%

35% 32%

10%




X-ray services / blood collection services Approximately 13 percent of all respondents reported they had not used X-ray services / blood collection services, or had no opinion on the service. It can be determined from Figure 57 that, cumulatively, a majority, 68 percent of those expressing an opinion were at least “Satisfied” with the service. Only six percent of them were “Very Dissatisfied”.

Figure 57

0%

10%

20%

30%

40%

Very Satisfied


39%

29%

19%

7% 6%

X-ray services/blood collection services n = 894



Why very dissatisfied with X-ray services / blood collection services? In total, 55 respondents were “Very Dissatisfied” with X-ray services / blood collection services. An overwhelming majority of them, 88 percent gave long wait times as the reason for being “Very Dissatisfied” with the service. Nine percent of those respondents gave various personal reasons as detailed in the Other component following Figure 58.

Figure 58

“Other” component consists of comments as recorded by the interviewer: Don’t tell you results of anything- patient should be well informed as to what they should

be told about the results of everything and everything that is going to be put into their system.

0%10%20%30%40%50%60%70%80%90%

88%

3%9%

X-ray services /blood collection services n = 55



Sent lady home without support of wheel chair or crutches - technician working was unknown to his trade - lady had a very bad sprain - still feeling the results of it.

Should be done at the doctors and you should not have to pay because it is done at the

doctor’s office. To have a blood test done now we have to make an appointment and you might have to

wait until the next week to get it done.

We pay and have someone come in to do it.



Are X-ray services / blood collection services getting better or worse? The largest single group of respondents to this question, 46 percent, said that there was no change in X-ray services / blood collection services. However, 30 percent of them said the service was getting worse, while only 14 percent of them said the service was getting better.

Figure 59

0%

10%

20%

30%

40%

50%


14%

30%

46%

10%

X-ray services /blood collection services n = 547



Specialty Diagnostic Services (CT, MRI) Approximately 44 percent of all respondents reported they had not used specialty diagnostic services, or had no opinion on the service. It can be determined from Figure 59 that, cumulatively, 42 percent of those expressing an opinion were at least “Satisfied” with the service. However, it can also be determined that, cumulatively, 37 percent of them were at least “Dissatisfied”, with 22 percent of them being “Very Dissatisfied”.

Figure 59

0%

5%

10%

15%

20%

25%

30%

Very Satisfied


26%

16%

22%

15%

22%

Specialty Diagnostic Servicesn = 582



Why very dissatisfied with Specialty Diagnostic Services? In total, 126 respondents were “Very Dissatisfied” with specialty diagnostic services. An overwhelming majority of them, 92 percent, gave long wait times as the reason for being “Very Dissatisfied” with the service. Two percent of those respondents gave various personal reasons as detailed in the Other component following Figure 60.

Figure 60

“Other” component consists of comments as recorded by the interviewer: I had the worst reaction to the dye that has ever been seen - did not track down why.

No confidence in the system.

0%10%20%30%40%50%60%70%80%90%

100%

1%

92%

3% 2% 1% 2%

Specialty Diagnostic Services n = 126



Is Specialty Diagnostic Services getting better or worse? The largest single group of respondents to this question, 48 percent, said that specialty diagnostic services were getting worse. However, 27 percent of them said there was no change to the service, while only nine percent of them said the service was getting better.

Figure 61

0%5%

10%15%20%25%30%35%40%45%50%


9%

48%

27%

16%

Specialty Diagnostic Services n = 430



Allied Health / Rehab services (PT, OT, SLP) Approximately 70 percent of all respondents reported they had not used Allied Health / Rehab services, or had no opinion on the service. It can be determined from Figure 62 that, cumulatively, 64 percent of those expressing an opinion were at least “Satisfied” with the service. Only nine percent of them were “Very Dissatisfied”.

Figure 62

0%

5%

10%

15%

20%

25%

30%

35%

40%

Very Satisfied


39%

25%

16%

11% 9%

Allied health/rehab services n = 314



Why very dissatisfied with Allied health / rehab services? In total, 30 respondents were “Very Dissatisfied” with Allied Health / Rehab services. A majority of them, 61 percent gave long wait times as the reason for being “Very Dissatisfied” with the service. Thirteen percent of those respondents gave various personal reasons as detailed in the Other component following Figure 63.

Figure 63

“Other” component consists of comments as recorded by the interviewer: All kinds of services for people with physical loss - no services for people with vision

loss At post surgery there is nothing for you in the way of Physiotherapy - what you can do,

what you can't do exactly to get yourself back on your feet

0%

10%

20%

30%

40%

50%

60%

70% 61%

14%

3% 5% 5%13%




Once children start school do not qualify for speech therapy - this service should be extended - need to provide more therapists ... speech especially.

Special kind of therapy for bladder disease - physio type of therapy - one person was

doing it ... she’s gone now - women's problems neglected.



Are Allied health / rehab services getting better or worse? The largest single group of respondents to this question, 32 percent, said that there was no change in Allied health / Rehab services, followed closely by 28 percent who said the service was getting worse. However, 19 percent of them said the service was getting better.

Figure 64

0%

5%

10%

15%

20%

25%

30%

35%


19%

28%

32%

22%




Inpatient care Approximately 56 percent of all respondents reported they had not used inpatient care services, or had no opinion on the service. It can be determined from Figure 65 that, cumulatively, 57 percent of those expressing an opinion were at least “Satisfied” with the service. Only ten percent of them were “Very Dissatisfied”.

Figure 65

0%

5%

10%

15%

20%

25%

30%

35%

40%

Very Satisfied


36%

21% 22%

11% 10%

Inpatient care n = 449



Why very dissatisfied with inpatient care? In total, 44 respondents were “Very Dissatisfied” with Inpatient care services. A majority of them, 59 percent gave poor service, insufficient staff as the reason for being “Very Dissatisfied” with the service. Twenty-nine percent of those respondents gave various personal reasons as detailed in the Other component following Figure 66.

Figure 66

“Other” component consists of comments as recorded by the interviewer: Baby had to have surgery done last year and she was obviously going to stay in with him

and had to sleep on a hospital floor. Discharge time too quick after surgery.

0%

10%

20%

30%

40%

50%

60%

2%6%

59%

4%

29%




Environment ... dirty bed pans.

Kick you out before you are healed - in-hospital care too short.

Nurses excellent – I find the doctors like to play God.

No place to be if you are healthy – no bedside manner - patients had to help patients

because nurses were too busy – not even to get a drink of water – visitors had to help patients.

Saw a nurse between 8 and 8:30 in the morning and didn’t see another nurse until 4:00

when being discharged.

Waiting for answer from doctors who weren’t available when needed – Nursing service

was fine.



Is inpatient care getting better or worse? The majority of respondents to this question, 55 percent, said that Inpatient care was getting worse. However, 26 percent of them said there was no change in the service while only four percent of them said the service was getting better.

Figure 67

0%

10%

20%

30%

40%

50%

60%


4%

55%

26%

15%




Navigating the System

Sources of information about health services such as prenatal care, mental health and addictions information, or information about how to get a loved one into a long-term care facility As can be seen from Table 3, the largest single group of respondents to this question, 36 percent, reported they would consult a family doctor if they needed any of these health services. Eleven percent of them reported that they did not know where to go to find such information.

Table 3

If you needed a health service such as prenatal care, mental health and addictions information, or information

about how to get a loved one into a long-term care facility, how would you get the information you needed about the service?

n = 1032 Percent

Ask family doctor 36.3

Use the internet 11.6

Ask a friend or family member 9.0

Check the telephone book 8.3

Ask a Community Health Nurse / Public Health Nurse 8.2

Community Health/Social Services 3.1

Social Worker 2.5

Call a hospital 2.5

Use Health Line 1.7

Contact a not-for-profit agency 1.5

Call Eastern Health 1.3

Deal directly with facility 1.1

Works with Health Care 1.0

Seniors Resource Centre .5

Don’t know 11.4

Total 100.0



Further analysis of the data shows that age is not a determining factor in how respondents to the survey would get information on a needed health service. However, when the data is observed by gender, it can be seen that more males (15.0%) than females (9.7%) reported that they would not know where to find the required information. It can also be seen that more females (38.6%) than males (32.1%) said they would seek the required information from a family doctor.



Ease of arranging health services In total, 21 percent of respondents reported they had to arrange health services for themselves or for someone else. As can be determined from Figure 29, 53 percent of those having to arrange health related services reported that doing so was at least “Somewhat easy”. However, 12 percent of them reported that making these arrangements was “Very difficult”.

Figure 68

Further analysis of the data shows that, when describing the ease/difficulty of arranging health services, there are no significant differences across ages (p = .241), and no significant differences by gender (p = .479).

0%

5%

10%

15%

20%

25%

30%

35%

Somewhat easy

Very easy Somewhat difficult

Very difficult

No opinion

28%25%

32%

12%

2%

Ease of arranging health servicesn = 217



Health and Community Problems

Health Related Problems Respondents were asked, “In your opinion, what is the single most important issue facing our health and community services system?” Of the 1,032 responses, approximately half of them were sufficiently short and cryptic to be standardized as shown in Table 4. For the most part, this segment was dominated by shortages of nurses and doctors and wait times

Table 4

Problem/Issue Percent

N = 1032

No problems with the system 2.1%

Not much experience with system 0.5%

Shortage of nurses 5.0%

Shortage of doctors 4.0%

Shortage of doctors and nurses 7.2%

Long wait times (undefined) 7.2%

Lack of funding (undefined) 1.3%

Shortage of specialists 2.0%

Lack of facilities & care for seniors 0.8%

Addiction & mental health issues 0.9%

Wait time in ER 1.6%

Wait time for specialists 3.7%

Lack of staff (undefined) 4.1%

Improper diagnosis/faulty tests 0.9%

No opinion 9.4%



The remainder of the responses to this question were sufficiently complex that standardization would detract from the message that respondents intended to convey. However, an examination of the responses reveal that, for the most part, the principal concern centers around a perceived shortage of nurses, doctors, and specialists and the resulting impact of the shortages on wait times for appointments, tests, test results, surgeries, and other procedures. The complete list of these responses, as recorded by the interviewers, is in Appendix B.



Not Necessarily Health Related Problems Respondents were asked, “What do you think is the biggest problem, not necessarily health related, currently facing your community?” Table 15 shows that, among defined problems, health care, mentioned by 14 percent of respondents was the largest single grouping. The economy and illegal drugs followed distantly at approximately five percent of respondents for each.

Table 5

Problem / Issue Percent

Health Care 14.3%

The economy 5.5%

Illegal drug use 5.2%

Shortage of doctors 4.9%

Unemployment 4.7%

Condition of the roads & other infrastructure 4.2%

Shortage of nurses 3.5%

Crime 2.6%

Availability of support for the elderly(housing, home care, meals, activities) 1.9%

Lack of recreational facilities 1.7%

Snow Clearing 1.5%

Lack of services for teenagers 1.2%

Lack of recreational activities 1.1%

Government funding 1.0%

Out-migration 0.9%

Over development (housing etc.) 0.9%

Housing conditions 0.8%

Water/sewer services 0.8%



Problem / Issue Percent

Poverty 0.7%

Alcohol abuse 0.6%

Low levels of Education 0.6%

Recycling 0.6%

Lack of schools 0.5%

Traffic volume 0.5%

Air or water pollution 0.4%

Depression or other mental health conditions 0.4%

Hospital parking 0.4%

Low Wages 0.4%

Prescription drug abuse 0.4%

Lack of public transportation 0.3%

Unhealthy schools 0.3%

Cancer 0.2%

Gambling 0.2%

Lack of support groups (cancer, bereavement, etc.) 0.2%

No problems 0.1%

Other 5.5%

Don't know / No opinion 30.9%

Total 100.0%

Appendix A

Questionnaire

Eastern Health: Telephone Survey for Northeast Avalon Introduction: Hello, my name is ________________calling on behalf of Eastern Health, the regional health board responsible for providing health and community services in your area. I am calling about a health survey. I would really appreciate some of your time this morning/ afternoon/ evening. Before we proceed, are you at least 19 years old? (Respondents must be 19 years of age or older to be eligible to complete this survey. If the speaker is eligible, then go to statement of verbal consent. If speaker is ineligible or unwilling, ask if there is another eligible person in the home who could answer the survey.) Statement of Verbal Consent: Before we begin, let me tell you a bit more about our survey and the conditions of your participation. We are asking people about some of the health issues in your community and about your use and satisfaction with the health care system. Your participation in this telephone survey is very important and will take approximately 20 minutes to complete. Your comments will be held in the strictest confidence, results will be combined with others and no names will ever be used. You may refuse to answer any of the questions you wish. You can end the survey at any time. Your participation will help us better understand the particular needs for health and social programs in your area. Would you mind answering these questions now? (Make appointment, if person is willing, but not available to answer the questions at the current time.)

Page A 2

A. Primary Health Care 1a. Do you have a family doctor?

1) Yes (Continue at Q2b) 2) No (Skip to Q2d)

2b. Could you tell me in which community your family doctor is located?

1) St. John’s 2) Mt. Pearl 3) Conception Bay South 4) Paradise 5) Torbay 6) Portugal Cove-St. Philips 7) Holyrood 8) Avondale 9) Other (Text box)

2c. In the past 12 months, how many times have you seen your family doctor?

1) None 2) 1-3 times 3) 4-6 times 4) 7 times or more 5) Don’t know

Skip to Question 3

Page A 3

2d. Could you tell me the reasons why you do not have a family doctor? (PROBE)

1. No doctor in the area 2. Doctors in the area are not taking new patients 3. Have not looked for a regular family doctor 4. Previous family doctor has left the area 5. New to the community 6. Too far to travel 7. Never sick / Not often sick 8. Not satisfied with doctor 9. Doctors come and go too often (high turnover) 10. A doctor of the gender I want is not available (i.e. want a female doctor) 11. No reason identified 12. Other (Text box)

(Check boxes for multiple responses)

2e. What do you do if you need services normally provided by a family doctor?

1. Go to the Emergency Department of a hospital (Continue at Q2f – all others to Q10a)

2. Use Health Line / Access care by telephone (Department of Health and Community Services’ toll-free phone line)

3. Go without care 4. Not applicable/Have no occasion 5. Other (Text box)

2f. How many times in the past year have you gone to the Emergency Department

because you don’t have a family doctor?

1. Never (Skip to Question 10) 2. 1-4 times (Skip to Question 9a) 3. 5-9 times (Skip to Question 9a) 4. 10 or more times (Skip to Question 9a)

Page A 4

3. How long have you been going to your current family doctor?

1) Less than 1 year 2) 1 year to less than 2 years 3) 2 years to less than 5 years 4) 5 years or more

4a. On average, how long does it take you to travel from your home to your family

doctor’s office?

1 Less than 10 minutes 2 11 to 20 minutes 3 21 to 30 minutes 4 31 to 40 minutes 5 41 to 50 minutes 6 51 to 60 minutes 7 61 to 90 minutes 8 Don’t know

4b. On a scale of 1 to 5, with 1 being "Very dissatisfied" and 5 being "Very satisfied”,

how satisfied are you with the travel time to your family doctor? 1 2 3 4 5 6 (No opinion)

4c. Using the same scale, how satisfied are you with the convenience of the location of

your doctor’s office?

1 2 3 4 5 6 (No opinion)

Page A 5

5a. When you call your family doctor's office to set up an appointment for a non-urgent

reason, how long do you usually have to wait before you get to see the doctor?

1) Same day 2) Next day 3) Less than a week 4) More than 1 week but less than 2 weeks 5) More than 2 weeks but less than 3 weeks 6) More than 3 weeks

5b. On a scale of 1 to 5, with 1 being "Very dissatisfied" and 5 being "Very satisfied”,

how satisfied are you generally with the wait time to get an appointment with your family doctor?

1 2 3 4 5 6 (No opinion) 6a. From the time that you arrive at the doctor’s office to the time that you see the doctor,

how long do you usually wait before you get to see the doctor? 1) No wait time 2) 1- 15 minutes 3) 16-30 minutes 4) 31-60 minutes 5) More than 60 minutes

6b. On a scale of 1 to 5, with 1 being "Very dissatisfied" and 5 being "Very satisfied”

how satisfied are you with this length of time? 1 2 3 4 5 6 (No opinion)

Page A 6

7. If you need to see a doctor and your family doctor is not available, are you usually

able to see another family doctor in the same clinic?

1. Yes 2. No 3. Sometimes 4. Not applicable (solo practice) 5. Situation has not occurred 6. Don’t know

8a. If you need an urgent appointment to see any family doctor, can you normally see a

family doctor in the same clinic on the same day?

1. Yes (Skip to Q10a) 2. No (Continue at Q8b) 3. Sometimes (Continue at Q8b) 4. Not applicable (solo practice) (Skip to Q10a) 5. Situation has not occurred (Skip to Q10a) 6. Don’t know (Skip to Q10a)

8b. When you don’t get an urgent appointment to see any family doctor, what do you do

for medical care?

1. Go to the Emergency Department of a hospital (Continue at Q9a – all others to Q10a)

2. Use Health Line / Access care by telephone (Department of Health and Community Services’ toll-free phone line)

3. Go without care 4. Not applicable/Have no occasion 5. Other (Text box)

Page A 7

. 9a. When you’ve gone to the Emergency Department, how long do you usually have to

wait from the time you are registered to the time you are seen by a doctor? Would it be ....

1) Less than 4 hours 2) 5-9 hours 3) 10 hours or more

9b. On a scale of 1 to 5, with 1 being “very dissatisfied” and 5 being “very satisfied” how

satisfied are you with this wait time? 1 2 3 4 5 6 (DK) 7 (NA)

Now, I’d like to ask you some questions about community health nurses. These are nurses who provide a variety of services, including preschool health clinics, prenatal education, international travel clinics and follow-up care and treatment such as dressing changes.

10a. Have you seen a community health nurse (also called a public health nurse) in the last

twelve months? (not a nurse practitioner)

1) Yes (Continue at Question10b) 2) No (Skip to Question11a) 3) Refused (Skip to Question11a)

10b. How many times did you see a community health nurse in the last twelve months?

1) 1-4 times 2) 5-9 times 3) 10-19 times 4) 20 or more times 5) Refused 6) Don’t know

Page A 8

11a. Have you seen a dentist in the last twelve months?

1) Yes 2) No 3) Refused

11b. If you need an urgent appointment to see a dentist, can you normally see a dentist on

the same day?

1. Yes 2. No 3. Sometimes 4. Not applicable / Have had no occasion 5. Refused

B. Confidence in the System 12a. Based on your own experience, how satisfied or dissatisfied are you with health and

community services? Would you say ....

1) Very dissatisfied 2) Dissatisfied 3) Neither satisfied or dissatisfied 4) Satisfied 5) Very satisfied 6) Don’t know (Do not read)

12b. Compared to 12 months ago, do you think that health and community services in your

area are: 1) Better 2) The same 3) Worse 4) No opinion (Do not read) 5) Refused (Do not read)

Page A 9

12c. The next set of questions is about your satisfaction with particular health and

community services. On a scale from 1 to 5, with 1 being "Very dissatisfied" and 5 being "Very satisfied”,

please rate your overall satisfaction with these services. Or it may be that you have not used a given service or have no opinion.

Code: 6 = Do not use service, 7 = No opinion 1 2 3 4 5 6 7 (If “1” is selected, ask the follow-up questions) (If 2, 3, or 4 is selected, ask the “Better or worse” question) (If 5, 6, or 7 is selected, go to next item in list)

12c_1 Community health nursing/ public health nursing 12c_1a Why are you very dissatisfied with Community health nursing/ public health nursing?

1 Care not available in your area 2 Wait times too long 3 Expensive without insurance 4 Can’t get appointments 5 Poor service, insufficient staff 6 No reason identified 7 Other (Text box)

12c_1b Is Community health nursing/public health nursing getting better or

worse.

1. Better 2. Worse 3. No change 4. No opinion

12c_2 Emergency room at a hospital 12c_3 Access to specialists (i.e. gynaecologists, urologists, neurologists) 12c_4 Ambulance services 12c_5 Home care/home support 12c_6 Long-term care (nursing services)

Page A 10

12c_7 Mental health services 12c_8 Addictions services 12c_9 Child, youth and family services 12c_10X-ray services/blood collection services 12c_11 Speciality Diagnostic Services (i.e. CT, MRI) 12c_12Allied health/rehab services (PT, OT, SLP) 12c_13Inpatient care

C. Navigating the System 13a. If you needed a health service such as prenatal care, mental health and addictions

information, or information about how to get a loved one into a long-term care facility, how would you get the information you needed about the service?

1) Ask family doctor 2) Ask a Community Health Nurse (Public Health Nurse) 3) Use the internet 4) Check the telephone book 5) Contact a not-for-profit agency (i.e., Cancer Society, Mental Health

Association) 6) Ask a friend or family member 7) Other (Text box)

13b. In the past twelve months, have you had to arrange health services for yourself or

someone else?

1) Yes (Continue at Q13c) 2) No (Go to Q14)

13c. Would you say it was easy or difficult for you to arrange these services? (Prompt

for Somewhat or Very)

1. Somewhat easy 2. Very easy 3. Somewhat difficult 4. Very difficult 5. No opinion

Page A 11

D. Health and Community Problems 14. In your opinion, what is the single most important issue facing our health and

community services system? Text box 15. What do you think is the biggest problem, not necessarily health-related, currently

facing your community? Text box E. Demographics To finish off this survey, I just have a few questions about you and your household. These questions are for informational purposes only and will be summarized. 16. Could you tell me in what year you were born, please? Text box 17. Could you tell me in which community you live?

1. Avondale 2. Bauline 3. Colliers 4. Conception Bay South 5. Conception Harbour 6. Flatrock 7. Harbour Main-Chapels Cove-Lakeview 8. Holyrood 9. Logy Bay-Outer Cove-Middle Cove 10. Marysvale 11. Mt. Pearl 12. Paradise 13. Petty Harbour-Maddox Cove 14. Portugal Cove-St. Philips 15. Pouch Cove 16. St. John’s 17. Torbay 18. Other (Text box)

Page A 12

18. Considering all of the members of your household, about what would you estimate the total yearly income before taxes to be? Would it be….

1) Less than $10,000 2) $10,000 to less than $20,000 3) $20,000 to less than $30,000 4) $30,000 to less than $40,000 5) $40,000 to less than $50,000 6) $50,000 to less than $60,000 7) $60,000 to less than $70,000 8) $70,000 to less than $80,000 9) $80,000 or more 10) Refused 11) Don’t know

This completes our survey. On behalf of Eastern Health, I would like to thank you very much for your time and comments. A public report on the needs of the people of your area will be written by Eastern Health. It will be available on the website at www.easternhealth.ca in late Summer or early Fall of this year.

19. Gender

1) Female

2) Male 3) Undetermined

http://www.easternhealth.ca

Appendix B

Text responses to the question:

In your opinion, what is the single most important issue facing our health and community services system?

Eastern Health Capital Coast Health Survey

Appendix B

Single most important issue facing health and community services

Telelink Research Page B 1

A lot more improvement in it I guess A quicker wait time for cancer patients Access and availability to all health services. Access to allied health professionals and the waiting time for children especially Access to better health care. Better access to doctors and specialists Access to diagnostic equipment - people are dying to get access to this equipment Access to diagnostic tests and access to specialists and long wait times for these things Access to doctor on weekends - family doctor recordings say go to emergency - thinks there should be a central location seven days a week Access to emergency rooms and specialists Access to emergency services having to wait long times and availability of specialists in emergency rooms Access to health care providers doctors, specialists, nurses. The facilities are old, no air conditioning - Ex: St.Claire's Access to information Access to resources such as clinics, doctors Access to services Access to special services and the wait times Access to specialist and overall staffing shortages and wait times in emergency Access to specialist services Access to specialists - wait times too long for procedures and x-rays Access to specialists without having to wait for long periods. Access to services such as MRI. Get referred to another place so you do not have to pay for it. Access to specialty services that require testing Access to the doctors Accessibility - poor attitude of nurses Access to specialists Accessibility of family doctors and specialists Addictions and mental health issues, breakdown in system increases crime - their children are affected - system not being addressed properly Adequate staffing for nursing and allied health to provide the required service Anything to do with Children Approach to health services Availability and quickness Availability of access to health care in a timely manner Availability of appointments to see doctors Availability of beds Availability of doctors - both family doctors and specialists Availability of doctors - x-ray blood, work seems to take such a long time Availability of doctors and specialists


Appendix B



Availability of doctors for new patients Availability of health care professionals Availability of professionals such as doctors and nurses Availability of workers - need updated equipment - decline in population Availability of services Baby boomers ageing - demands on system Being able to get in to see a specialists in a reasonable period of time Being able to get into hospital for surgery when needed - nursing shortage Being able to obtain fast and efficient care at the same time - keeping the lines of communication open between patient and family Being accessible to the public and appointments in a timely fashion. Better management of the resources they have Better organization so there would not be so longer wait time for specialist and testing Better pay and treatment for the nurses Cancer treatment Care at the hospital - time it takes to get in to see a specialist, and the overall nursing care Care for seniors -facilities to put them in that are affordable and in good condition Care for the aged - need more places for seniors Child care - being able to get in to see doctors for children Communication between public and health care providers lines of communication need to be open so that there is not so much negativity. more team work between these sectors Completely disorganized. Need to re-organize Concerned about the nurses going on strike Cooperation within the system itself. Coordination of access to the services in the medical profession Cost of medications and supplies Current conservative government helping the elderly with in-home care and try to keep these people in their home and by increasing the wages of home care support Cut down on the wait times for CT scans and MRIs and things like that. The quicker this stuff is done the better Demand is greater than supply Diabetes education Diagnostic technologists - the way in which it is used in regards to its reporting Disability people. Disorganization - need more communication between departments Dis-organization and poorly run Dissatisfaction of the nurses Doctor recruitment to fill hours Doctor shortage and wait time in emergency due to this shortage Doctors and nurses being overworked


Appendix B



Don't think everything should be just looked at with pharmaceutical drugs I don't even think the doctors know what is in the drugs Education and understanding for staff and patients Emergency - long waits- looking after seniors Emergency centers at hospital have too long wait times Employees happy doing their job Ensuring tests are done properly and results are valid Everyone is overworked - not enough staff Everyone seems to be passing the buck to others Extreme work load of nurses and doctors - it is awful - based on being in the hospital Failure to educate and retain local doctors Funding resources all staff Getting access to needed services Getting appointments to get things done Getting diagnosed quickly Getting more doctors; Shortage of nurses; Let LPN's do more work. Let other staff do more work to lessen work load on the doctors and the nurses. Getting people back their information on time and having it accurate from test results Getting seen quickly for testing Getting the information that you need Getting things done - like surgery and things Getting to the doctor when you need one - if you are sick - you cannot wait a week Good hospital service Good physicians Government avoiding the real issue Government refusal to see health care crisis and to deal with it promptly Have better services because she is on social services and can't afford to see a dentists and eye specialists Have doctors, nurses and beds available for use. Nurses are overworked due to shortage of staff Haven't had any personal problem, but would like to see more staff, less wait times and not having to wait for beds Having a family doctor is important Having nurses who are adequately paid Having the right people and the right amount of people to keep system going. Staffing as in housekeeping nurses, specialist Health care professionals being over worked Health care professionals leaving for work elsewhere and leaving our nurses and doctors with a bigger work load. Health Care system is an open door. Sometimes patient care is not necessary and sometimes it is but it has to be monitored both on the beneficiary and the provider end of things.


Appendix B



Health care system is under staffed and under paid and we cannot compete with the US and we are losing nurses and doctors to other places. The facilities here are not adequate. Help for Behaviour problems in teenagers Home care in need of help Homecare people should be able to stay in their home with someone to assist getting meals etc. It's the cheapest way to go - bring back nursing assistants Hospital care - length of time spent in hospital and type of care you get while there Hospital care that when someone goes to the hospital that they be cared for Hospital situation lack of workers Hospital staffing and wait for appointments Hospital wait time - for surgeries and emergency room. How easy it is to get prescription drugs off the street Human resources and funding Human resources within the health care system - good people are needed I feel the Doctors and Nurses are very lazy today they are not worried about the care of the patient - they are only worried about themselves. I guess not enough of doctors and I guess that's why there is so long of a wait at the emergency room at the hospital Improve your services and don't let them slip to a worse level then they are now. In emergency situations mental health services need to be addressed other than through the police because these people are very sick and need professional medical care at the time. Inconsistency - had great public nurses and then not so good and same for nurses and other medical staff in hospitals Inefficient system and shortage of doctors and I don't feel the breast feeding support for new mothers is adequate Keeping doctors and specialists in the province by paying them more Keeping medical doctors - community doctor who knows you Labour management Lack nurses and doctors and specialist in the health system Lack of an adequate number of specialists to cut down on wait time Lack of awareness regarding available services Lack of communication between departments Lack of communication between the different health care branches Lack of community services - people don't know where to turn Lack of confidence in health care because of what has happened in the past Lack of doctors (Gps and all specialists) If we had more doctors it would cut down in the wait time the entire system will benefit Lack of Doctors and Nurses and Health Professionals Lack of doctors and shortages of nurses and long waiting periods Lack of doctors and specialists


Appendix B



Lack of doctors and specialist Lack of equipment Lack of doctors and Lack of nurses Lack of everything - doctors - waiting times Lack of facilities Lack of facilities and the people using them lack of funding for personnel including physicians nurses lab and x-ray technicians all sectors seem to be under funded and under staffed Lack of funding from the government and lack of nurses Lack of funding from the government for nurses, physicians and support staff i.e. technicians, housekeeping, dietary Lack of government funding for long term care facilities Lack of health care professionals for the volume of work Lack of health care staff such as nurses and doctors Lack of home care staff and lack of facilities to take care of these people Lack of knowledgeable staff - nurses, supervisors, residents, specialists Lack of management Lack of medical personnel - ends up with wait times - the attention to detail is not there. Lack of medical staff - doctors leaving the province Lack of medical staff Lack of money - funds - losing too many people because there aren’t any decent offers. They go to where the money is. Better benefits and pay away. Lack of nurses doctors specialists ect. Lack of nurses not medical emergency Lack of nurses specialists and doctors and travel for those having to come to St. John's with appointments being cancelled and whatever Lack of nurses - too much work for them Lack of nurses - trying to come up with an agreement Lack of nurses and health care professionals Lack of nurses and shortage of doctors and shortage of hospital beds. Lack of nurses and their struggle to get better recognized for the short staff and overall care Lack of nursing - growing need for more health care professionals need more facilities Lack of nursing - nurses doing more than nursing duties Lack of nursing staff and support staff Lack of patient care Lack of people and people screening and not answering their calls. Lack of physicians more likely specialist Lack of professionals i.e. nurses doctors specialists Lack of Professionals in Rheumatology Lack of qualified people to handle our elderly like specialist and those qualified to handle these cases


Appendix B



Lack of qualified staff ex. doctors nurses and technical professionals Lack of regard for medical personnel in the province i.e. nurses Lack of resources - not enough money for extra staff Lack of resources and staff Lack of resources both in equipment and personal e.g. doctors and nurses Lack of Services Lack of Services Lack of services both including equipment and personnel - long wait times. Lack of skilled people Lack of specialist and nursing and too long wait for test Lack of specialist people - have to wait long time to see some one Lack of specialty services and the waiting time therein Lack of staff - nurses doctors dieticians secretaries - Lack of staff all over - everything is just falling apart Lack of staff and proper equipment Wait times too long Lack of staff in all sections of health care - not just the nurses. Lack of staff in the medical profession and social community health. Lack of staff so you don’t have to wait so long Lack of staff to provide service like blood collection X- rays Lack of sufficient home care support to help keep people in their own homes Lack of support for seniors - shortage of staff to cover the general population Large line ups in the emergency room length of time to wait to see specialist and get certain test done Long term care services for seniors and more nurses to supply this need Long term care. Home care services geared towards those with severe disabilities as opposed to people who are aging and only mildly need the service help over the hump to get better Long term care; wait time to see specialist Long time waiting to have important surgery done e.g. heart surgery Long wait and lack of physicians Long wait times - lack of personnel Long wait times to get to see specialists and diagnostic tests - nursing services pushed to the limit - need more nurses Long wait times to see a doctor in the waiting room Long wait times to see doctors and specialists Long wait to see a Specialist and a long wait to get into the hospital Long waiting time and lack of doctor Long waiting times for everything. You wait for your family doctor then you wait for your specialist and then you are pretty much gone if there is anything seriously wrong with you Long waits for diagnosis services Long waits in emergency room due to lack of skilled staff


Appendix B



Long waits for seeing family doctors and emergency services Loss of professionals from the health service - nurses, doctors, x-ray tech, and specialists Loss of doctors, especially specialists Loss of faith in the health system due to things she has heard on the news Lot of information to get but not easily obtained for almost anything. If you don't know the right person your will have trouble Low staffing numbers - nursing - not enough support Makes older people wait too long - thinks they should be looked after first - and not made to wait Management extremely poor Manpower. I don't think there is just enough Doctors and Nurses Medical care and hospital care. The wait time for specialists, and long term care for the elderly Mental health - not enough help in the medical field to support those who need it Mental health issue as related to medical attention and social assistance. Cannot get to talk to someone about dependant’s problem. Nowhere to go. Mental health issues - lot of people over drugged - very little rehabilitation - more education needed re depression More care brought into it - too many cut backs. More staff More doctors more beds settling with the nurses issues More doctors and health professionals More doctors in emergency unit - that is why emergency is hung up More doctors so there would be less waiting time and more specialists More nurses and more space with more nurses is needed. More nurses and more doctors are needed and to keep them here it means pay them more. More qualified doctors and nurses. I think doctors are overworked More services such as doctors specialists etc More specialists more doctors and more people in the medical system More staff and shorter wait time More staffing - nurses - specialists - doctors - too much wait time for tests results and surgery needed Need more doctors and more access to diagnostics tests Need more doctors, nurses and health care professional to provide faster access to service Need more nurses, doctors and beds open up to serve the patients Need more services because of an aging population Need of more Doctors and Nurses and the Hospitals need to be upgraded. Need of more practices in rural areas Needs more nurses - give them more money Needs new hospital No health insurance for those with pre-determined illnesses. No money - not enough nurses or doctors - lot of people with no family doctor - hospitals - with shortages of nurses


Appendix B



Non communication within administration and they are unaware of what goes on Not easy access to services Not enough accountability in the Health Care system and more training Not enough clinics for young people and children who need counseling. Building are not up to date Government will not subsidies these places Community nurses do not go into school on emergency basis. i.e. checking for head lice Not enough communication between departments Not enough diagnostic service for the number of people using it Not enough doctors long waiting times- Not enough doctors or nurses - the ones that are there are over worked Not enough doctors, nurses and facilities, and people abusing system Not enough employees’ i.e. Doctors. Not enough nurses - nursing care has dropped considerably in the hospital Not enough hands on people Not enough health Professionals Not enough hospital beds and hospitals - money is the big thing - ambulances are too expensive - over $200.00 living in a certain area Not enough Medical People Not enough medical staff. Doctors nurses and specialist. Not enough money to provide services needed and people are not taking care of themselves due to unhealthy life styles Not enough nurses - too many doctors and specialists leaving here to go to other places Not enough nurses and ambulances and hospitals needs to be bigger - more machinery Not enough nurses and specialists in certain areas Not enough of the positive things get out-always hear negative remarks. Not enough people - that is why there are long wait times for testing and treatments. Not enough doctors and specials Not enough people working in the system. Have not got time to deal with you personally as they used to. Hospital staff seem to be rushed. Long waits to see doctor Not enough professionals to meet the demand Not enough services for everyone Not enough staff i.e. emergency room - there isn't enough staff `- wait times Not enough staff - waiting times Not enough staff to cover the needs of the people - nursing shortage Not enough staff. Especially doctors Not enough workers, nurses, doctors, specialists Not enough doctors, nurses and support staff Not enough medical professionals - too long wait times to get medical attention Not enough people to do the work. Example: nurses doctors to cover the needs and services. Not enough professional people in the health care system


Appendix B



Nurses and staff needs to be reorganized Nurses are very dissatisfied and have to learn to keep our nurses by giving them equal pay as other nurses across North America Nurses controversy in respect to the pending strike Nurses getting too greedy - making good money Nurses over worked; shortage of them Nurses walking by patients like they have no compassion. Maybe overworked - don't know Nursing care and the lack of numbers and this is cause for stressing people that are in that field Nursing issues Nursing shortage - to encourage nurses to stay offer more money Nursing shortage and overwork and poor salaries Nursing situation One on one patient care Out patients. Overall long term waiting for Lab results - Emergency waiting room is terrible - waiting in Doctors’ offices etc. Overall wait time in the health care system. Would like to say that she followed her doctor when she moved because she was so good overworked nurses and doctors Patient care in the hospital Patients being number one priority and anything pertaining to patient needs should be main focus People getting sick and having to go to the emergency room and the way sent home from the hospital and the Dirt that is in the hospitals... it's very Dirty Perceived intent of government to privatize health services Poor service with optometrists Professional people getting paid too much for lack of work being done. Prompt diagnosis and prompt treatment Proper diagnosis Provide more service workers providing better care and more quickly with regards to hospital care in emergency room Providing safe care for patients Public confidence in the system - access to specialist and specialty services and more specialists Quality of care Quality of care and long wait time to get certain test done so you can proceed with care Quality of practioners Quick access to CT Scans MRIs. Wait times too long. Resources need for communication Resourcing with regard to adequate facilities and personnel - lack of nurses, doctors and specialists Restricted budgets causing limited services


Appendix B



Retaining doctors Retaining doctors. keeping doctors here Retention and expansion of doctors and nursing staff Retention and recruitment of specialists - nursing shortage - lack of programming for populations with children - mental health and addictions Retention in the nursing and physicians area Retention of doctors and attracting them Retention of doctors and attracting them Revamped system in the hospital Services in the hospital are bad and the long wait time to see specialists Services not being there Shortage nurses and doctors and specialist doctors Shortage nursing and all labour units Shortage of all staff in hospitals - doctors, nurses, support staff Shortage of child services Shortage of doctors and nurses - daycare subsidizing Shortage of doctors and nurses and a sho9rtage of professionals here in the province Shortage of Doctors and Nurses and the care is going down, like people waiting to go into hospital and people needing treatment Shortage of doctors and shouldn't have to wait so long to see the doctor Shortage of doctors and specialist moving out of province and the younger doctors understaffed Shortage of doctors and specialists Shortage of doctors in the hospitals and in rural Newfoundland and oncologists for the cancer clinic Shortage of doctors, specialists and hospital care Shortage of medical care staff e.g. nurses doctors and specialists but no problem with the service just the wait time and appointment set up Shortage of medical professionals Shortage of medical staff and personnel Shortage of nurses doctors and staff Shortage of nurses - wait time is too long to see doctors ect Shortage of nurses and doctors and blood collectors Shortage of nurses and doctors and money to pay them Shortage of nurses and doctors and social workers etc. Shortage of nurses and doctors, specialists Shortage of nurses and have enough beds in the hospital Shortage of nurses and hospital beds Shortage of nurses and line ups at emergency rooms


Appendix B



Shortage of nurses and shortage of space in hospitals in emergencies. Shortage of space in hospital and there is not enough health care providers for the space that is needed with x-rays and the like Shortage of nurses and specialists Shortage of nurses and specialists Shortage of nurses and the long wait periods to see specialists Shortage of nurses and the work load they have .They are overworked and working longer hours Shortage of nurses and their issues Shortage of nurses that causes long wait times in emergency Shortage of nurses; If you have to have tests done if there are no nurses then the test has to be done at a later date. Shortage of people working in facilities Shortage of personnel in health care Shortage of physicians and wait times Shortage of professionals Shortage of qualified personnel ex. doctors and nurses Shortage of space, programs and money... Particularly for elder care Shortage of staff in a hospital; doctors Shortage of staff. Staff is very overworked. Shortages of doctors hard to get home help Shortages of nurses and; doctors and availability of health care Should be more Doctors at emergency in the Hospital should not be multiple appointments booked at the same time Should pay more attention to the people who are sick provide more care more support in the community - seems not to be doing their jobs right. Situation with the nurses So many people in need of medical attention and not enough out there to help Sometimes you get a doctor who is not willing to help you - someone who cares for you Specialist not getting paid enough Specialists and emergency room Specialists shortage and nursing shortage Specialists/doctors leaving province for higher pay. Also, lengthy time to wait for appointments Staff overworked Staff overworked, too busy Staffing and funding Staffing from doctors to nurses to LPNs. We have an aging population in this province and don't think we have the people to support it Staffing of health care - doctors, nurse, tech and lab Shortage of staff in hospital e.g. nurses. Need to put more money in health care to hire enough people to do the job


Appendix B



Strained work force Surgery wait times and cancellations Taking care of the nurses Tests should be more readily available. CT scans/MRIs The ability to get a doctor and the wait time. The availability of doctors - too many patients for each doctor The availability of doctors in emergency room The availability of having testing done when you need it The correct care for senior citizens and injured workers The doctors and the nurses are dissatisfied and everything just escalates from there. Doctors and nurses are overworked. Health care is not what it used to be. Doctors don't just become Doctors. It's a monetary thing now. The government needs to provide more funding and keep our graduates in the province. The hospital system - emergency department - surgery etc. The hospitals are understaffed The insurance covering the services The lack of home support for elderly The lack of Nurses skills and Facilities for a different type of health problems for example Children diagnosed with Autism that are aggressive etc. The lack of specialists and the wait time to see a specialists The lack of staff all around The long wait in emergency and long wait in surgery and waiting time for scans etc The long wait time for results The long wait time in the hospitals because of lack of doctors The long wait time to get in for tests The long wait times for tests and surgeries The long waits for appointment times The nurses are not given the credit for what they are. Shortage in nursing. The nurses should go back to a 8 hour shift because 12 hour shifts are too long The overall availability of Specialized resources The pending nurses strike The problem getting a family doctor The quality care in the hospital The quality of the services. The health care staff is very overworked The resources - with the number of patients sent home there is not really enough care to look after these patients The response in the emergency room at a hospital and the wait list for Specialists The services are getting bad because of the shortage of nurses and doctors The shortage of nurses and fear of strike The situation with the nurses and specialist leaving the province


Appendix B



The time to get in to see a doctor or time to wait in the emergency room at a hospital. The wait for diagnostic services. If you need an MRI not enough people available The wait list for surgery The wait time to get an appointment The wait times for Various testing is very slow and it takes a long time to get them back. Maybe if they worked overtime in the evenings or on the weekends it would save time. There seems to be a lot of rooms there but not enough staff. The wait times to see a specialist and many people given the same appointment time The way the system is set up - not enough doctors resulting not enough time for patient care The whole system needs to be revamped The whole thing needs to be evaluated They have lost control because they are too big and needs to get back to the way they were. Time factor - wait times - damage that can be done waiting for services to get a proper diagnosis. Time frame for treatment Time it takes to get in to get MRI or operations or other things that are urgent to get done Time management - things are not being done in a timely manner Time waiting for operation (wait list to have operation) Timely diagnosis of tests To get seen right away Too long wait times for everything Too long to wait for ultra sounds and special x- rays and physical therapy Too long wait times and shortage of nurses Too long wait times for surgery Too long wait times to see doctors Too long wait times; not enough staff Too many people being seen by too few health specialists Too much wait time in emergency due to staff shortage and overwork Transportation to health care Travel time to get to health services Treatment of our aging population. We are not dealing with mental health. Mental health does not have the focus it should have. The senior citizens are going to have mental health issues and they won’t be dealt with properly. Trying to get into cancer doctors - mammograms to get lump in breast examined - wait time too long Trying to keep all our own health care workers here to work Uncertainty of nurses Understaffing of hospitals and family doctors. Upgraded health care system and more nurses - hospitals in rural areas upgraded so the people would not have the expense of traveling to other areas


Appendix B



Wait time especially for CT Scans MRIs and long wait times to get to see specialists such as Rheumatologist Wait time for appointments etc. due to Lack of medical Staff Wait time for specialist and testing done and people going to emergency rooms unnecessary Wait time for specialty diagnostic services too long Wait time for Specialty services such as testing exams etc. Wait times and professional quality of the doctors Wait times in general like in the hospital, also at family doctors office. Wait times - lack of professionals Wait times - lack of specialists Wait times - meaning the amount of time that a person has to wait for a CT Scan MRI or anything. I guess it's because there is not enough staff to cover what needs to be done in such areas and therefore I guess both are of equal importance Wait times - too long to get appointments and to wait - when actually to an appointment at the hospital or specialist Wait times and number of doctors available Wait times and the ability to provide top health care Wait times are too long for all services. Wait times for all health services Wait times for appointments tests. etc. Wait times for appointments - trying to find out where to go - especially with Drug Addictions Wait times for appointments and in the emergency department Wait times for appointments with specialist and not enough specials to meet the needs Wait times for Diagnostic services Wait times for EVERYTHING! Wait times for procedures like operations Wait times for specialist emergency doctors the overall health system Wait times for tests Wait times for tests to see a doctor etc. Wait times in hospital and waiting for appointments for doctors Wait times in hospitals and in general doctors and specialists Wait times in the health care system overall whether specialist -x-ray or dentist Wait times overall at hospital and other services Wait times to see doctors and specialists fixing things that are not broke i.e. with social workers Wait times to see specialist and to be seen at a hospital Wait times too long to see Doctors and Nurses Wait to see doctor and get results from test Wait too long for access to treatment Wait too long to see doctor - and test results like a CT or MRI Waiting for things that need to be done. Specialist operations


Appendix B



Waiting period at a hospital in the emergency room. Waiting periods for MRIs, CT scans ect. Waiting periods to see specialists. Why are CT scans and MRIs not used in the night time - they work 9-4 then are shut down? Waiting time and more family doctors Waiting time for getting beds in hospital and seeing doctors Waiting time for specialists and waiting time in emergency rooms Waiting time for tests and Surgeries and such Waiting time to get scans and MRI Waiting times - shortage of nurses Waiting times to see specialists and to have a procedure done Waiting too long to have something done We don't have enough facilities, doctor and equipment We need more doctors more specialists and the wait time for appointments should be a lot shorter We need more doctors and more nurses. More specialist doctors are needed also Workers overworked, need more money put into helping them out. Doctors and nurses are over worked. Working conditions for nurses

72

APPENDIX J:Northeast Avalon Community HealthNeeds Assessment Emergency RoomSurvey Report

Emergency Room Survey Report Katie Little, BSc. (Hons.), MSc. Candidate

Survey Methodology

Wait time in the Emergency Room (ER) was identified as a significant issue in the Northeast Avalon Needs Assessment. A literature review indicated that long ER wait times were by no means unique to the Northeast Avalon region. Canadian and international research on this and related topics has been ongoing for decades. Such research includes: The Canadian Agency for Drugs and Technology in Health (2006) published a series

of reports measuring overcrowding in Canadian ERs. Lega and Mengoni (2008) conducted research in Italy to determine why patients

choose emergency care. The Working Group for Achieving Quality in Emergency Departments (2008) has

focused their research on similar issues within New Zealand. It was determined that local research was essential to learn more about long ER waits in the Northeast Avalon. A review of relevant patient surveys was conducted to find an appropriate tool that met local needs. Upon reviewing various survey tools, the Emergency Department Patient Experience Survey (2008), conducted by the Health Quality Council of Alberta (HQCA), was selected as the basis for Eastern Health’s survey. The HQCA survey was developed following an extensive review and was based on an

original survey conducted by Picker Europe for the British National Health Service. The HQCA survey tool was extremely useful for Eastern Health in that it had already

been validated in both Canada and Britain. With the permission of the HQCA, portions of the tool were further modified to

meet Eastern Health’s needs. Eastern Health received approval to conduct the survey from the Human

Investigation Committee of Memorial University of Newfoundland. The adapted survey involved gathering information about patients presenting with less

urgent conditions at the Health Sciences Centre and St. Clare’s ERs, the characteristics of these individuals, and reasons for their visit.

Eastern Health’s survey took place between September and December 2009 and results were analyzed in January 2010. The survey is included at the end of this section. Patients triaged as Level IV and V (as per the Canadian Emergency Department

triage and acuity scale, or CTAS) were identified by a triage nurse, and then invited to complete the Emergency Department Questionnaire. When patients consented, a research nurse surveyed the patient in an ER waiting room.

A total of 693 surveys were administered to patients who presented with Level IV and Level V symptoms in the Emergency Room (ER) at St. Clare’s Mercy Hospital (n = 361, 52.1%) and the Health Sciences Centre (n = 332, 47.9%) in St. John’s.

In order to maximize sample sizes at St. Clare’s Mercy Hospital and the Health Sciences Centre, research nurses focused on surveying ER patients during the busiest

hours and days of the week. However, the amount of time research nurses spent at each ER and the time of day spent collecting data varied depending on established active ER times outlined in internal Eastern Health data (Cognos database).

Similar percentages of patients were surveyed daily between Monday and Friday (approximately 16.5% - 20% surveyed daily), and similar percentages of patients were surveyed on Saturday and Sunday (approximately 5% each day).

The distributions of patients surveyed by day of the week are displayed in Figure 1.

17.0%

19.0%

16.6%

19.9%

17.5%

5.1%

4.9%

0% 5% 10% 15% 20% 25%

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Percentage of Respondents

Figure 1: Distribution of Patients Surveyed by Day

Most patients (46.1%, n = 317) were surveyed in the afternoon between 12:00 and

15:59. In the morning, between 8:00 and 11:59, 35.2% (n = 242) of patients were surveyed, while only 13.8% (n = 95) were surveyed in the early evening between 16:00 and 19:59. Close to 5% (n = 33) were surveyed before 8am or 8pm and later.

Survey Results Who Was Surveyed in the Emergency Room? Survey results indicate a similar percentage of males (51.3%, n = 355) and females

(48.7%, n = 337) were surveyed in the ER. Most of the patients surveyed in the ER were between 20-29 years (n = 195, 28.3%),

18.1% (n = 125) were between 30-39 years, 18.1% (n = 125) between 40-49 years, 16.4% (n = 113) between 50-59 years, 10.7% (n = 74) between 60-69 years, and 7.3% (n = 50) of people surveyed were 70 years old and over. A small proportion (n = 7, 1%) were under 20 years old.

Most survey respondents indicated that their highest level of education completed was high school (31.4%), followed by completion of college or technical school (26.2%). Individuals with graduate degrees (Masters or Ph.D.) frequented the ER the least (3.3%). The distribution of survey participants’ highest level of education can be seen in Table 1.

Table 1: Highest Level of Education n % Grade School or Some High School 87 12.6% Completed High School 217 31.4% Some University or College 109 15.8% Completed College or Post-Secondary Technical School 181 26.2% Completed University Degree 75 10.8% Post-Grad Degree (Masters or Ph.D.) 23 3.3%

98.0% (n = 676) percent of patients surveyed were Caucasian. 98.8% (n = 685) of patients surveyed indicated English was their primary language. 60.5% (n = 393) of patients surveyed owned their own residence and 38.5% (n = 250)

rented their residence; while six (0.9%) patients lived in a residential facility or seniors’ lodge and one patient lived in a nursing home or long-term care centre.

Why Are They Choosing the Emergency Room? When patients were asked why they chose to go to the ER instead of somewhere else,

such as a doctor’s office, 46.3% indicated that they felt the ER was the best place for their medical problem. Twenty-seven percent of respondents (n = 188) indicated they were told to visit the ER, while 19.0% (n = 132) indicated it was the only choice available at the time, and 18.3% (n = 127) indicated it was the most convenient place to go. Frequently cited in “Other” reasons was a patient’s inability to see their family physician in a timely fashion.

The frequency distribution of responses is shown in Figure 2. Percentages may total over 100% and frequencies may total over 693, as respondents were indicated to select all that apply.

321

188

127

15

132

0 50 100 150 200 250 300 350

Best place for my medical problem

I was told to go to the ER

Only choice available at the time

Most convenient place to go

Other

Frequency

Figure 2: Frequency of Responses as to Why Patients Chose to Visit the ER instead of Somewhere Else

Patients were given the opportunity to explain why they choose to go to the ER instead of somewhere else. The most frequent comments included the following: Unable to get in to see family physician Needed medical services (most frequently sited – X-Ray) Necessary or higher urgency problem Advised by family physician to visit ER Family physician located outside of St. John’s (out-of-town and out-of-province

patients) Clinics full/no after-hours clinic Advised by ER physician to visit the ER at another hospital or at a later date

Who is Advising Them to Visit the Emergency Room? Patients were instructed to indicate all of those who had advised them to go to the ER.

More than half of the patients surveyed (n = 389, 56.1%) had not been advised by anyone to go to the ER, but had decided to go on their own. Friends or family had advised 21.2% (n = 147) of patients to visit that day. Patients who selected “Other” (n = 94, 13.6%) indicated they were advised to go to the ER by their employer or by a medical professional including a doctor/physician, home-care nurse, and community health nurse. Another 11.4 % (n = 79) were advised to go to the ER by their family doctor.

Distributions of all responses can be seen in Figure 3. Percentages may total over 100% and frequencies may total over 693, as respondents were indicated to select all that apply.

389

147

94

79

21

18

6

0 50 100 150 200 250 300 350 400 450

No one, I decided

Friend or Family

Other

Family Doctor

Health Line

Specialist Doctor

Walk-in Clinic Doctor

Frequency

Figure 1: Frequency of Responses as to who Advised Patients to Visit the ER How are Patients Getting to the Emergency Room? The majority of patients (n = 578, 83.5%) arrived at the ER by car; however, 6.1% (n

= 42) walked, 5.3% (n = 37) arrived by taxi, 2.3% (n = 16) arrived in an ambulance, 1.9% (n = 13) had taken the bus, and 0.9% (n = 6) arrived at the ER by another method not mentioned.

It took 71.7% of patients (n = 490) up to 15 minutes to get to the ER and 19.8% (n = 135) of patients up to 30 minutes to arrive. However, it took 3.5% (n = 24) of patients between 30 minutes and an hour, and 4.7% (n = 32) more than an hour to get the ER. Two patients were uncertain how long it took to arrive at the ER.

What is the Description of their Current Medical Problem? The majority of patients (n = 448, 64.6%) surveyed felt their current health problem

was somewhat urgent while 19.2% (n = 133) felt their problem was urgent. Table 2 lists the frequency of responses by perceived urgency.

Table 2: Urgency of Patients’ Current Health Problem Urgency N %

Not urgent 77 11.1% Somewhat urgent 448 64.6%

Urgent 133 19.2% Possibly life-threatening 25 3.6%

Life-threatening 10 1.4% Total 693 100.0%

The majority of patients (n = 293, 42.8%) indicated that their reason for visiting the

ER was due to a new injury or accident (unrelated to a previous injury or accident) and 26.7% (n = 183) were at the ER due to a new illness or condition (unrelated to a previous illness or condition). Combined, approximately 70% of patients were in the ER for a new medical issue.

15.3 % (n = 105) visited the ER due to the worsening of a pre-existing chronic illness or condition.

Distribution of all responses regarding problem descriptions can be seen in Figure 4.

42.8%

26.7%

15.3%

7.0%

6.0%

1.8%

0.4%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

New injury/accident not relatedto a previous injury

New illness or condition notrelated to a previous illness

Worsening of pre-existingchronic illness or condition

Complications or problems fromrecent care

Follow-up

Other

Routine care of pre-existingchronic illness or condition

Percentage of Respondents (%)

Figure 4: Distribution of Responses Regarding Description of Current Medical Problem Had Patients Previously Seen a Health-Care Provider for the Same Medical Problem? More than half (n = 419, 60.5%) of the survey respondents indicated that they had

not seen a health-care provider for the same problem that brought them to the ER. However, nearly a quarter of those who had, (n = 169, 24.4%) had seen their family doctor. Approximately 6.0% (n = 41) had previously seen a specialist for the same issue. Approximately 3% (n = 20) had been to a walk-in clinic and 1% (n = 8) had seen their home-care nurse. Close to 7% (n = 49) indicated that they had seen another, unspecified, health-care professional. The most frequent “Other” response was that the patient had previously seen another ER physician (in another hospital, or at an earlier time).

The frequency of responses regarding whether or not, and whom, patients had previously seen for the same medical problem can be seen in Figure 5. Frequencies may total over 693 as participants were indicated to select all applicable answers.

Results indicate that the time since seeing that health-care provider varied with 12.7% (n = 88) having seen the health-care provider less than a day before visiting the ER, 4.8% ( n = 33) within 1 to 2 days before their visit, 9.4% (n = 65) within 3 to 7 days before their visit, 6.6% (n = 46) within 8 to 30 days before their visit, and 5.3% (n = 37) having seen the health-care provider more than 30 days before their visit.

419

169

49

41

20

8

0 50 100 150 200 250 300 350 400 450

Did not see anyone

Family Doctor

Other

Specialist

Walk-in clinic/urgent care

Home-care nurse

Frequency

Figure 5: Frequency of Responses for Having Previously Seen a Health-Care Provider for the Same Problem

Are Patients Revisiting the Hospital or Emergency Room for the Same Medical Problem? More than 80% (n = 562, 81.1%) of patients surveyed indicated that they had not

been in a hospital or an ER earlier that month for the same presenting medical problem. However, 16.7% (n = 116) of patients specified they had visited the ER and 1.3% (n = 9) had been admitted to hospital earlier that month for the same medical problem.

Are Patients Visiting the Emergency Room While Waiting for Medical Services Relating to the Current Problem? Approximately 18% (n = 125) of patients indicated that they were waiting for at least

one service related to the problem that brought them to the ER. 6.6% of patients (n = 46) were waiting for a major diagnostic test (e.g. CT scan, MRI,

X-ray), 5.3% (n = 37) were waiting to see a specialist, and 2.2% (n = 15) were waiting for a minor diagnostic test (e.g. blood or lab tests) at the time of their visit. Approximately 5% of patients (n = 33, 4.8%) indicated “Other”; however most patients did not specify which service they were awaiting related to their medical problem.

Distribution of services patients were awaiting related to their medical problem can be seen in Figure 6. Participants were instructed to select all applicable answers.

46

37

33

15

6

5

3

1

0 5 10 15 20 25 30 35 40 45 50

Major Diagnostic Test

Specialist

Other

Minor Diagnostic Test

Family Doctor

Surgery

Specific Treatment/Therapies

Major Non-Surgical Procedures

Frequency

Figure 6: Frequency of Responses Regarding the Services Patients Were Awaiting for the Current Medical Problem

How Many Patients Have a Family Doctor? Approximately 90% (n = 619, 89.8%) of the patients surveyed specified they have a

family doctor, while 10% (n = 70, 10.2%) indicated they do not. These proportions did not differ by site.

How Often Do Patients Frequent Their Family Doctor? Patients were asked to specify how many times, within the past year, they had seen

their family doctor. Approximately 40% (n = 263, 40.3%) had seen their family doctor between 1 and 3 times in the last 12 months, 24.7% (n = 161) had seen their family doctor 4 to 6 times, 25.9% (n = 169) had seen their family doctor 7 times or more, and 8.3% (n = 54) had not seen their family doctor at all within the last year. Approximately 1% (n = 5) were unsure. The results indicate that a large proportion of the patients surveyed have been utilizing the services provided by their family physician.

Are Patients Visiting the Emergency Room Because They Are Unable to See Their Family Doctor? Just under half of the patients (43.4%) visiting the ER acknowledged that, within the

past year, they had frequented the ER at least once because they could not get in to see their family doctor.

Approximately 40% (n = 268, 39.9%) of the patients visited the ER between 1 and 4 times and 3.5% (n = 24) visited 5 or more times within the past 12 months due to an inability to see their family doctor.

However, slightly over half (n = 379, 56.6%) indicated that this question did not apply to them, suggesting they had not visited the ER within the past 12 months because they were unable to see their family physician.

Who Are The Patients Without a Family Doctor? 10% of the patients surveyed in the ER indicated they did not have a family physician. Approximately 63% (n = 44, 62.9%) of the patients without a family doctor were

male, while 37.1% (n = 26) were female. Analysis showed that males were significantly less likely to have a family doctor than females, 2(1, N = 688) = 4.16, p = .041.

More than half (n = 43, 61.4%) of the patients without a family doctor were between 20 and 29 years old. A total of 14.3% of patients (n = 10) without a family doctor were between 30 and 39 years old and 12.9% of patients (n = 9) were between 50 and 59 years old.

With respect to the education level of the patients without a family doctor, 7.1% (n = 5) had completed grade school or some high school, 27.1% (n = 19) had completed high school, 20.0% (n = 14) had some university or college, 27.1% (n = 19) had completed college or post-secondary technical school, 10.0% (n = 7) had completed university, and 8.6% (n = 6) had completed a post-graduate degree.

When gender, age, and educational experience were examined simultaneously: • Males between 20 and 29 years old who had completed high school or

completed college/technical school indicated more frequently that they did not have a family doctor.

• Females between 20 and 29 years old who had some university or college or completed university or college indicated more frequently that they did not have a family doctor.

Why Don’t These Patients Have a Family Doctor? The three most common reasons for not having a family doctor were:

1. the patient was new to the community (n = 22, 31.4%), 2. the patient had not looked for a family doctor (n = 21, 30.0%), and 3. the patient felt they were never sick or not sick often ( n = 18, 25.7%).

Distribution of responses regarding why patients do not have a family doctor can be seen in Figure 7. Percentages may total over 100% as respondents were indicated to select all applicable responses.

31.4%

30.0%

25.7%

17.1%

10.0%

8.6%

4.3%

1.4%

1.4%

1.4%

0.0%

0.0%

0% 5% 10% 15% 20% 25% 30% 35%

New to the Community

Have not Looked for Family Doctor

Never Sick/Not Often Sick

Other

Previous Family Doctor Left Area

Doctor Not Taking New Patients

Not Satisfied with Doctor

No Doctor in Area

High Turnover of Doctors

No Reason Identified

Too Far to Travel

No Reason Identified

Percentage of Responses

Figure 7: Distribution of Responses Regarding Why Patients Do Not Have a Family Doctor

Are Patients Utilizing Other Services? 75.2% of patients (n = 519) had not visited a walk-in clinic, nursing station, or other

clinician for their own care within the past 12 months, while approximately a quarter (n = 171, 24.8%) had visited at least once in the past year.

• Eleven percent (n = 79, 11.4% ) visited 1 time, 9.9% (n = 68) visited 2-4 times, 2.8% (n = 19) visited 5-10 times, and 0.7% visited a walk-in clinic, nursing station, or other clinician for their own care more than 10 times within the past 12 months.

The majority of patients (n = 617, 89.4%) had not visited an alternative medical provider within the past 12 months.

98.5% (n = 675) of patients surveyed indicated they presently do not receive home-care services, while 1.5% (n = 10) indicated they do receive home-care services. None indicated that they were waiting for home-care services at present.

What is the Current Health Status of Patients? Approximately 69% of patients (n = 475) rated their health as Good, Very Good, or

Excellent in the last month before being surveyed. The distribution of patients’ self-rated health can be seen in Table 3.

Table 3: Patients Self-Rated Health During the Last 4 Weeks Self-Rated Health n % Very poor 19 2.7% Poor 82 11.8% Fair 117 16.9%

Good 173 25.0% Very good 197 28.4% Excellent 105 15.2% Total 693 100.0%

36.7% (n = 254) of patients indicated they had a long-standing physical or mental

health problem or disability, while 63.3% (n = 438) indicated they did not. When asked if this long-standing health problem affected their day-to-day activities,

36.5% (n = 92) felt it affected their day-to-day activity to some extent, while 31.7% (n = 80) felt it definitely did and the same proportion (n = 80, 31.7%) felt that their long-standing health problem did not affect their day-to-day activities at all.

Additional Comments Provided by Patients At the end of the survey, patients were given the opportunity to provide additional comments related to their visit. Frequently cited comments and suggestions included the following, in no particular order: Long wait times in the ER (uncomfortable if in pain) Confusing triage/registration process Doctors not attentive/compassionate to patients Suggestion: Increase number of physicians and nursing staff to reduce wait times Suggestion: Increase number of community clinics, 24-hour clinics, or after-hours

clinics Suggestion: Increase ER space/segregate patients by illness/increase patient privacy

Introduction Hello, my name is ____________________ and I am conducting a survey on behalf of Eastern Health. I would really appreciate some of your time this morning/afternoon/evening. Before we proceed, are you at least 19 years old? Statement of Consent: Before we begin, let me tell you about our survey and the conditions of your participation. We are asking people about their visit to the Emergency Room followed by information about their usual medical care. Your participation in this survey is very important to us and will take approximately 10 minutes to complete. Your comments will be held in the strictest confidence, results will be combined with others, and no names will ever be used. You may refuse to answer any of the questions you wish. You can end the survey at any time. Your participation will help us better understand the particular needs of Emergency Room patients, as we are completing a Community Health Needs Assessment for Northeast Avalon. This report will be publicly available when it is completed in 2010. Would you mind answering these questions now? Date: ______________ Day of Week: _________________ Time: __________________ Site: St. Clare’s General Hospital, Health Sciences Complex Participant’s Postal Code:

Emergency Department Questionnaire

1. Please identify all those who advised you come to the Emergency Department: My personal family doctor Yes No My specialist doctor Yes No A doctor at a walk-in clinic Yes No A friend or family member Yes No The Health Line phone-line nurse Yes No No one, I decided on my own Yes No Other (please specify): 2. Why have you chosen to go to the Emergency Department, instead of somewhere else

such as a doctor’s office? FILL-IN ALL THAT APPLY The Emergency Department was the only choice available at the time. The Emergency Department was the most convenient place to go.

I (we) thought the Emergency Department was the best place for my medical problem.

I was told to go to the Emergency Department rather than somewhere else.

Other: Would you like to provide further details about why you chose to go to the Emergency Department instead of somewhere else? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Would you describe your health problem as: Life-threatening Possibly life-threatening Urgent, risk of permanent damage Somewhat urgent, needed to be seen today Not urgent, but I wanted to be seen today 4. How did you travel to the Emergency Department? In an ambulance By car By taxi On foot By bus Other: 5. When you came to the Emergency Department, how long did it take you to get here?

Up to 15 minutes Up to 30 minutes More than 30 minutes, but no more than 1 hour More than 1 hour Don’t know / Can’t remember

6. Thinking about the medical problem that brought you to the Emergency Department; would you say that your problem is . . .

A new injury or accident not related to a previous injury or accident A new illness or condition not related to a previous illness or condition Complications or problems following recent medical care Worsening of pre-existing chronic illness or condition Routine care of a pre-existing chronic illness or condition I was told to return to the Emergency Department for follow-up care Other: Would you like to provide further details about your current medical problem? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. At some earlier time in the last month, were you in hospital or the Emergency Department for the same problem? FILL IN ALL THAT APPLY

Yes, I was in an Emergency Department Yes, I was admitted to a hospital No

8. Before this Emergency Department visit, did you see a health-care provider for the same problem? FILL IN ALL THAT APPLY

No Go to 10 Yes, my personal family doctor Go to 9 Yes, a doctor at a walk-in clinic or urgent care centre Go to 9 Yes, a specialist Go to 9 Yes, my home-care nurse Go to 9 Other Go to 9 9. When did you see the health-care provider(s) mentioned above for the same

problem? FILL IN ALL THAT APPLY Less than 1 day before my visit Within 1 to 2 days before my visit Within 3 to 7 days before my visit Within 8 to 30 days before my visit More than 30 days before my visit 10. Before your Emergency Department visit, were you already waiting for any of the

following in relation to the same medial reason for which you came to the ER? FILL IN ALL THAT APPLY

To see a specialist Major diagnostic tests (such as CT scan, MRI, X-ray or Ultrasound) Minor diagnostic tests (blood or lab tests, etc.) Surgery Major non-surgical procedures (such as angioplasty, angiogram, or bowel scope)

Specific treatments or therapies To see my personal family doctor Other: The next section of the survey involves questions about your usual medical care. 11. Do you have a family doctor? Yes Go to 13 No Go to 12 12. Could you tell me the reasons why you do not have a family doctor? (check all

applicable responses) No doctor in the area

Doctors in the area are not taking new patients Have not looked for a regular family doctor Previous family doctor has left the area

New to the community Too far to travel Never sick/not often sick Not satisfied with doctor Doctors come and go too often (high turnover) A doctor of the gender I want is not available No reason identified Other

13. In the past 12 months, how many times have you seen your family doctor? None 1 - 3 times 4 - 6 times 7 times or more Don’t know 14. In the past 12 months, how many times have you gone to the Emergency Department

because you could not get in to a family doctor? (include this visit) 1- 4 times 5 to 9 times

10 or more times Not applicable

15. In the past 12 months, how many times have you visited a walk-in clinic, nursing

station, or other clinic FOR YOUR OWN CARE? 0 times 1 time 2 to 4 times 5 to 10 times More than 10 times 16. In the past 12 months, how many times in total have you visited an Alternative

Medicine provider such as a Chiropractor, Acupuncturist, Chinese Medicine Provider, or Naturopath?

0 times

1 time 2 to 4 times 5 to 10 times More than 10 times 17. Male or female? Male Female 18. What was your year of birth? 19. What is the highest level of school that you have completed? Grade school or some high school Completed high school Post-secondary technical school Some university or college Completed college diploma Completed university degree Post-grad degree (Masters or Ph.D.) 20. Overall, how would you rate your health during the past 4 weeks? Excellent Very good

Good Fair Poor Very poor 21. Do you have a long-standing physical or mental health problem or disability? Yes Go to 22 No Go to 23 22. Does this problem or disability affect your day-to-day activities? Yes, definitely Yes, to some extent No 23. Do you receive home-care services at present? Yes No, but I am waiting for home-care services No 24. Where do you presently live? My own house, condominium, or apartment A rented house, condominium, or apartment A residential facility or seniors’ lodge A nursing home or long-term care centre 25. What is the postal code of your home address?

26. What language do you mainly speak at home? English Other 27. Would you say you are . . . ? White / Caucasian Native Canadian / Aboriginal Chinese Latin American Black Asian (please specify) Other (please specify) 28. Do you have any additional comments, concerns or issues?

The last two questions involve additional research related to our Community Health Needs Assessment for Northeast Avalon. Your participation is voluntary. 29. May we contact you if we have additional questions about your experience?

Yes Name: ______________________ Phone Number: ________________

No 30. Would you like to know about focus groups on health care issues if they are held in

your community?

Yes Name: ______________________ Phone Number: ________________

No

73

APPENDIX K:ER Data (Internal to Eastern Health)

Table 1 and Table 2 provide a snapshot of the number of “less urgent” and “non urgent” visits to the ER at both the Health Sciences Centre and at St. Clare’s Mercy Hospital. While triage is subjective and rates can vary between sites, the Tables below provide an indication of the number of visits at both sites. The highest volumes of Level IV and V patients for this period were between 8:00

a.m. and 4:00 p.m. on Mondays and weekends The vast majority of Level V patients are at St. Clare’s

Table 1

Health Sciences Centre

Top 3 Highest Volumes of Patients Triaged as Level IV and V for the years 2007-2010

2007/08 2008/09 2009/10 Level IV Busiest Days Monday

8:00-16:00Monday

8:00-16:00Monday

8:00-16:00 Sunday

8:00-16:00Sunday

8:00-16:00Sunday

8:00-16:00 Saturday

8:00-16:00Friday

8:00-16:00Tuesday

8:00-16:00 Total # of Level IV Patients 17,004 17,748

17,404

Level V Busiest Days Monday

8:00-16:00Monday

8:00-16:00Monday

8:00-16:00 Saturday

8:00-16:00Sunday

8:00-16:00Friday

8:00-16:00 Sunday

8:00-16:00Saturday

8:00-16:00Saturday

8:00-16:00 Total # of Level V Patients 4,316 4,656

4,261

Table 2

St. Clare’s Mercy Hospital Top 3 Highest Volumes of Patients Triaged as Level IV and V

for the years 2007-2010

2007/08 2008/09 2009/10 Level IV Busiest Days Monday

8:00-16:00Monday

8:00-16:00Monday

8:00-16:00 Sunday

8:00-16:00Tuesday

8:00-16:00Sunday

8:00-16:00 Wednesday

8:00-16:00Wednesday 8:00-16:00

Tuesday 8:00-16:00

Total # of Level IV Patients 11,039 11,985

11,886

Level V Busiest Days Monday

8:00-16:00Monday

8:00-16:00Monday

8:00-16:00 Saturday

8:00-16:00Saturday

8:00-16:00Sunday

8:00-16:00 Sunday

8:00-16:00Tuesday

8:00-16:00Saturday

8:00-16:00 Total # of Level V Patients 15,741 15,526

16,205

74

APPENDIX L:Backgrounder - Client Centred WaitlistManagement Strategy for EasternHealth

The Clinical Efficiency department of Eastern Health, whose goal is to improve client access to health care services, has developed a Client Centred Waitlist Management Strategy for Eastern Health. This strategy is regional (i.e., applicable across all of the Eastern Health region) and can be implemented wherever patients must wait for services. Initially, the strategy was developed to address adult and pediatric surgical waitlists but has grown to include 15 waitlists at various stages of development within programs across the entire Eastern Health region: Rheumatology, Mental Health, Community Allied Health, Speech Language Pathology, Long Term Care, Gastroenterology, Ophthalmology (Janeway), Rehabilitation and Diagnostic Imaging.

The strategy involves three main phases: Pre-implementation phase which consists of: (1) an environmental scan (2) current processes

and waitlist review, (3) developing baseline documents which include an urgency classification tool to facilitate prioritizing clients on the waitlist according to need, and defining measureable and appropriate wait time intervals. These documents form the basis for evaluation of the key performance indicators.

Implementation phase which consists of (1) implementing recommended changes to streamline

processes, (2) electronically capturing client wait time information, (3) communicating changes to all stakeholders. Recommended changes, for example, may include development of a standardized referral form. The referral form is reviewed upon receipt by a clinician who determines referral appropriateness and client urgency (if not already assigned by the referring agent). The strategy also recommends that the referring agent be notified that their client’s referral has been received and the client has either been placed on the waitlist or given an appointment. If the referring agent wishes an earlier appointment they may make direct contact with the service provider. As well, inappropriate referrals are redirected as needed.

Many of these streamlining recommendations are supported by the Patient Flow Study

completed by Global Solutions Healthcare Consulting/Siemens Healthcare in 2009. This study was integral to the review and streamlining of current and future referral processes across Eastern Health.

Monitoring and evaluation phase which consists of (1) reporting our performance against the

established key performance indicators identified at the strategy onset, (2) implementing measures to ensure data quality, (3) developing and/or strengthening wait time policies, (4) providing periodic review to ensure changes are effectively addressing issues of client access to service.

Challenges to implementation: Implementing this strategy requires significant resources to improve wait time management in various specialty areas. This is complex, as there are presently many waitlists maintained within specialist offices within private practice, Eastern Health as well as Memorial University. Resources are required in multiple areas, especially in IT and Clinical Efficiency to support the implementation of the strategy within a timely manner. An additional challenge to implementation is the mandatory requirement of health professionals to exclusively use the centralized intake process.

75

APPENDIX M:Written Submissions Request

Northeast Avalon Community Health Needs Assessment Eastern Health is conducting a community health needs assessment in the Northeast Avalon region, which includes the following communities: Avondale, Bauline, Colliers, Conception Bay South, Conception Harbour, Flatrock, Harbour Main-Chapel’s Cove-Lakeview, Holyrood, Logy Bay-Middle Cove-Outer Cove, Marysvale, Mt. Pearl, Paradise, Petty Harbour-Maddox Cove, Portugal Cove-St. Philips, Pouch Cove, St. John’s, and Torbay. The purpose of a needs assessment is to gather information about the health needs and resources of a community to determine what issues are most important and to develop a plan to address those priorities. A health needs assessment looks at the things that determine the health of a community, from income and education to physical and social environments. Written submissions (either hard copy or electronic) about the health needs of the Northeast Avalon are invited from individuals, community partners and service organizations. Submissions should be received by November 10, 2009 at the office of: Gillian Janes Planning Specialist Planning, Quality and Research Eastern Health Room 1209, Southcott Hall 100 Forest Road St. John's, NL A1A 1E5 ph:(709)777-6773 fax: 777-8257 email: [email protected]

mailto:[email protected]

76

APPENDIX N:Written/Oral Submissions Received

Topic: Aging Issues Network: key issue - home supportive services Association of Registered Nurses of Newfoundland and Labrador: priority areas Building capacity in supporting older adults and the need for home care (private

submission) Canadian Hard of Hearing Association Newfoundland and Labrador: key issues Community-based physiotherapy (private submission) Community-based speech language pathology (private submission) Employment and working conditions, training (private submission) ER use and electronic access to reports (private submission) Food Security Network: food security and health The Murphy Centre: input from youth on focus group questions Recreation Newfoundland and Labrador: key considerations Provincial Open MRI Unit for Health Care (private submission)* Special Olympics: Healthy Athletes initiative

*Submission received following focus group session.

77

APPENDIX O:Secondary Resource Materials

Allison, D., Longerich, L., Ryan, A., & Thompson, G. (2005). Assessment of Primary Health Care Needs in the Downtown Area of St. John’s. St. John’s, Newfoundland: Memorial University of Newfoundland, Health Research Unit, Division of Community Health, Faculty of Medicine.

Barter, R. (2006, March 25). Health care burdened by basic flaw. [Letter to the editor]. The

Telegram, p. A11. Boland, B., Earle, A., McConnell, S., Brothers, D., & McConnell, S. (2008). Navigators and

Networks: Harnessing resources and meeting the needs of individuals with complex needs. St. John’s, NL.

Carret, M., Fassa, A., & Kawachi, I. (2007). Demand for emergency health service: factors

associated with inappropriate use. BMC Health Services Research, 7:131. Canadian Agency for Drugs and Technology in Health (2006). Technology Report: Measuring

Overcrowding in Emergency Departments: A Call for Standardization. Retrieved May 29, 2009, from http://www.cadth.ca/media/pdf/320a_overcrowding_tr_e_no-appendices.pdf

Canadian Association of Emergency Physicians. (2007). Position Statement on Emergency

Department Overcrowding. Retrieved December 18, 2009, from http://www.caep.ca/template.asp?id=37C951DE051A45979A9BDD0C5715C9FE

Canadian Association of Emergency Physicians. (2009). Implementation Guidelines for the

Canadian ED Triage & Acuity Scale (CTAS). Retrieved December 18, 2009, from http://www.caep.ca/template.asp?id=98758372CC0F45FB826FFF49812638DD#A.%20GENERAL%20TRIAGE%20GUIDELINES

Cavanagh, S., & Chadwick, K. (2005). Summary: Health Needs Assessments at a Glance: Health

Development Agency. Retrieved January 28, 2010, from http://www.nice.org.uk/media/150/35/Health_Needs_Assessment_A_Practical_Guide.pdf

College of Family Physicians of Canada (The). (2006). When the Clock Starts Ticking: Wait Times in

Primary Care (Discussion Paper). Mississauga, ON: Author. Curtis, P. (2006, February 13). 'Frequent flyers' costing NHS £2.3bn a year: Research seeks to

slash the half a million people regularly admitted as emergencies. The Guardian. Retrieved July 3, 2009, from http://www.guardian.co.uk/uk/2006/feb/13/health.society

Global Solutions Healthcare Consulting: Siemens Healthcare Canada. (2009, December).

Eastern Health Patient Flow Study Summary Report. St. John’s, NL: Author.

http://www.cadth.ca/media/pdf/320a_overcrowding_tr_e_no-appendices.pdf

http://www.caep.ca/template.asp?id=37C951DE051A45979A9BDD0C5715C9FE

http://www.caep.ca/template.asp?id=98758372CC0F45FB826FFF49812638DD#A.%20GENERAL%20TRIA

http://www.nice.org.uk/media/150/35/Health_Needs_Assessment_A_Practical_Guide.pdf

http://www.guardian.co.uk/uk/2006/feb/13/health.society

Han, A., Ospina, M., Blitz, S., Strome, T., & Rowe, B. (2007). Patients presenting to the emergency department: the use of other health care services and reasons for presentation. Canadian Journal of Emergency Medicine, 9 (6), 428-434.

Health Council of Canada. (2005). Home Care: A background paper to accompany Health Care

Renewal in Canada: Accelerating Change (2005). Retrieved December 30, 2009, from http://www.healthcouncilcanada.ca/docs/papers/2005/BkgrdHomecareENG.pdf

Health Council of Canada. (2009). Value for Money: Making Canadian Health Care Stronger.

Retrieved February 25, 2009, from http://www.healthcouncilcanada.ca/docs/rpts/2009/HCC_VFMReport_WEB.pdf

Health Quality Council of Alberta (2008). Emergency Department Patient Experience Survey:

Author. Kenney, M., MacBean, C.E., Brand, C., Sundararajan, V., & Taylor, McD. (2008). Review

article: Leaving the emergency department without being seen. Emergency Medicine Australasia, 20, 306-313.

Lega, F., & Mengoni, A. (2008). Why non-urgent patients choose emergency over

primary care services? Empirical evidence and managerial implications. Health Policy 88, 326-338.

Manitoba Health. (2002). Primary Health Care: Working Together for Better Health.

Retrieved May 17, 2010, from http://www.gov.mb.ca/health/phc/framework.html Moore, L., Deehan, A., Seed, P., & Jones, R. (2009). Characteristics of frequent attenders in

an emergency department: analysis of 1-year attendance data. Emergency Medicine Journal, 26, 263-267.

Morgan, D., & Ploughman, M. (2009). Rehabilitation Gaps and Needs Assessment Eastern

Health. St. John’s, NL: Eastern Health.

Paramedicine and Medical Transport, Eastern Health (2009). General Annual Report. St. John’s, NL: Author.

Penney, J. (2007). Tracking of admissions from ER to inpatient beds. St. John’s, NL: Eastern

Health. Penney, J. (2008). Emergency department triage: Comparison of triage practices at the Health

Sciences Centre and St. Clare’s Mercy Hospital. St. John’s, NL: Eastern Health.

http://www.healthcouncilcanada.ca/docs/papers/2005/BkgrdHomecareENG.pdf

http://www.healthcouncilcanada.ca/docs/rpts/2009/HCC_VFMReport_WEB.pdf

http://www.gov.mb.ca/health/phc/framework.html

Public Health Agency of Canada (2003). What Makes Canadians Healthy or Unhealthy? Retrieved January 28, 2010 from http://www.phac-aspc.gc.ca/ph-sp/determinants/determinants-eng.php#unhealthy

Putting the brakes on inappropriate ER utilization. (2005). Disease Management Advisor,

11(3), 28-32. Siminski, P. Bezzina, A., Lago, L., & Eagar, K. (2008). Primary care presentations at emergency departments: rates by age and sex. Australian Health Review, 32 (4),

700-709. Wait Time Alliance. (2009). Unfinished Business: Report Card on Wait Times in Canada.

Retrieved December 30, 2009, from http://www.waittimealliance.ca/June2009/Report-card-June2009_e.pdf

Working Group for Achieving Quality in Emergency Departments. (2008). Recommendations to Improve Quality and the Measurement of Quality in New Zealand Emergency Departments. Retrieved March 9, 2009, from http://www.moh.govt.nz/moh.nsf/pagesmh/8783/$File/quality-ed-jan09.pdf

http://www.phac-aspc.gc.ca/ph-sp/determinants/determinants-eng.php#unhealthy



http://www.waittimealliance.ca/June2009/Report-card-June2009_e.pdf

http://www.waittimealliance.ca/June2009/Report-card-June2009_e.pdf

http://www.moh.govt.nz/moh.nsf/pagesmh/8783/$File/quality-ed-jan09.pdf

78

APPENDIX P:Newsletters Circulated During theCommunity Health Needs Assessment

The Northeast Avalon

The Regional Health Authorities Act indicates that one of the responsibilities of a health authority in our province is to assess health and community service needs in its region on an ongoing basis. To date, Eastern Health has completed needs assessments on the Burin Peninsula (2006), Bell Island (2007), and the Southern Avalon (2007).

The next area to be assessed is the Northeast Avalon (minus Bell Island), geographically represented by the map at right. This area has a population of 188,265 (80,044 households). With 37.2% of the province’s population, it is the most heavily populated economic zone board in the province. At 1,389 km2, it is geographically, the smallest zone in the province.

Eastern Health believes that communities have the strengths, knowledge and

skills necessary to originate programs which influence the determinants of health and which promote overall

health and well-being.

JUNE 2009, ISSUE 1

The Process

To date, we have completed a telephone survey of 1,032 people in the Northeast Avalon. The results of this survey have been provided to the Northeast Avalon Community Health Needs Assessment Steering Committee, the Planning Committee of the Board of Trustees and the newly created Community Medical Advisory Committee (consisting of Community GPs). We have also met with representatives of the Emergency Department, Clinical Efficiency, Research, Information Management and Tech-nology and the consultants undertaking a patient flow study in order to get their reactions to the results.

On June 17, 2009, we will be hosting a consultation with our community partner groups to get their perspective. We will be explaining the needs assessment process and sharing the results to date. It will also be an opportunity for us to hear their per-spective on our findings from the telephone survey.

Findings Related to Family Physicians

Who has a family physician? • 97.3% of respondents have a family physician and 77.2% of

those have had the same family physician for 5 years or more

• 90% of people with a family doctor travel 20 minutes or less from their home to their family physician clinic

• 74% saw their family physician between 1 and 6 times in past 12 months

• 77% can see their family doctor within a week for a non-urgent reason

• 52% said they can see a family doctor (not necessarily their family doctor) at their clinic the same day for an urgent appointment

Who doesn’t have a family physician? • Most often, males under the age of 50 • They don’t have a family doctor because they have never

been sick/not sick very often or they are new to the community

• If they need a doctor, they go to an Emergency Department or a walk-in clinic

Findings Related to Emergency Departments

Of the respondents who indicated they are unable to get an urgent appointment with their family doctor, 78% went to an Emergency Room.

Those respondents who reported having gone to an Emergency Department were asked how long they waited from the time they registered to the time they were seen by a doctor. Forty-seven per cent said they waited less than 4 hours, 47% said they waited 5-9 hours and 6% said they waited 10 hours or more.

Findings Related to Access to Specialists and Specialty DI Services

In addition to Emergency Department, the other areas of dissatisfaction that came from the telephone survey were with access to specialists and access to specialty diagnostic imaging services. These services had the largest response in terms of use of services.

The concern around these services was with the wait times.

Analyzing the Results The results of the telephone survey are one piece of the needs assessment process. We will be analyzing the results and conducting further primary research such as key informant interviews and focus group sessions.

We will also be further exploring the themes that arose from the needs assessment results: access to Emergency Rooms for patients triaged at levels 4 and 5; access to specialists; access to specialty diagnostic imaging services.

We will be making use of existing secondary resources around the health and well-being of the people in the Northeast Avalon. If you have any secondary resources that would assist us, please contact us.

Contact Information We will keep you informed about the Northeast Avalon Needs Assessment as it progresses. For further information, please contact: Lisa Browne at 466-5863 Gillian Janes at 777-6773 [email protected] [email protected]

Telephone Survey Findings

A research firm was engaged to conduct a telephone survey. Calls took place between February 9 – 18 and on March 3, 2009. There were 1,032 completed interviews and this sample size provides a margin of error of + 3.1 percentage points 19 times out of 20. The participation rate (number of completed/live answers and eligible) for the survey was 33.5%



Community Involvement Eastern Health is committed to involving community groups and individuals to get their feedback and advice on health needs in the area. On June 17, community stakeholders were invited to attend a consultation session to learn about the results of our telephone survey and to provide their perspectives on the main themes that arose from the survey: wait times in Emergency Rooms (ER), access to specialists, as well as access to specialty diagnostic imaging, such as CT scans and MRI. Thirty-six community-based organizations representing a broad range of interests attended this session and summary notes were widely shared afterwards with stakeholders across the region.

In addition, interviews with various key informants (both internal and external to Eastern Health) have been ongoing. These interviews have provided a broad view of the Northeast Avalon, such as the challenges associated with the wide range of income levels within our population and the rate of population change within our communities. Within this relatively small geographic area, a significant contradiction exists between communities that have experienced tremendous population growth and others that have seen a population decline. For instance, between the 2001 and 2006 Census, the populations in Torbay and Paradise increased by 36.9% and 36.4%, respectively, while Avondale experienced a population decline (-6.8%).1

Throughout October and November, we have been conducting a number of focus groups to get input from people who may not have been represented in the telephone survey. These focus groups will also provide opportunities for us to confirm the findings of the survey results. We have been thrilled with the level of support from partner agencies who are helping to carry out these focus groups, such as the Buckmaster’s Circle Community Centre, The Gathering Place, the Independent Living Resource Centre and the Community Youth Network.

November 2009, ISSUE 2

The Steering Committee of the Northeast Avalon Community Health

Needs Assessment is pleased to provide an update on our progress. The

Northeast Avalon includes the following communities: Avondale, Bauline, Colliers, Conception Bay South,

Conception Harbour, Flatrock, Harbour Main-Chapel’s Cove-Lakeview,

Holyrood, Logy Bay-Middle Cove-Outer Cove, Marysvale, Mt. Pearl, Paradise,

Petty Harbour-Maddox Cove, Portugal Cove-St. Philips, Pouch Cove, St. John’s,

and Torbay.

_______________________________________ 1Source: Census information provided by www.communityaccounts.ca

http://www.communityaccounts.ca

Call for Written Submissions In addition to the above, Eastern Health issued a call to the public in October to provide written submissions on what they identify as community health needs in the Northeast Avalon. Information submitted from individuals, community partners, and service organizations provides various perspectives that add to the needs assessment.

Learning More about Wait Times Given the information provided in the telephone survey regarding access to family doctors and our own internal data about ER waiting times, we have been gathering further information about why patients with less urgent conditions visit the ER at both Health Sciences Centre and St. Clare’s. We have developed a survey for patients in the ER waiting room who are triaged at level four and five (as per the Canadian Triage and Acuity Scale) to determine when and why they use ER versus family physicians and/or nurse practitioners.

In addition, we are supporting ongoing initiatives within Eastern Health to improve wait times related to specialist services and diagnostic imaging. This involves working closely with Eastern Health’s Clinical Efficiency Unit, whose purpose is to lead clinical efficiency initiatives within all Clinical Programs and Departments of Eastern Health.

Community Advisory Committee In September, Eastern Health issued a request for submissions from the public to find individuals interested in sitting on a Community Advisory Committee (CAC) for our needs assessment. The purpose of the CAC is to support the needs assessment by providing advice and feedback on the process and outcomes.

The CAC is made up of individuals from across the region who have an interest and experience in the determinants of health, which include such areas as employment and working conditions, education, social support networks, income and social status as well as physical environment.

The Steering Committee was pleased with the level of interest expressed from the community and it was a challenge to make a final selection of members. We are happy to announce that the following seven representatives will serve on this committee until spring 2010 when the Community Health Needs Assessment for Northeast Avalon will be complete:

• Maureen Bethel • Maurice Brewster • Sondria Browne • Linda Janes • Shirley Murphy • Jack Strawbridge • Ed Wade

Contact Information

We will continue to keep you informed about the Northeast Avalon Needs Assessment as it progresses. We welcome your feedback and suggestions, which can be made directly by contacting:

Gillian Janes at 777-6773

[email protected]

Northeast Avalon Community of Petty Harbour


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APPENDIX Q:Profile of the Northeast Avalon fromCommunity Accounts

Economic Zone 19 – Northeast Avalon Regional Economic Development Board Profile Economic Zone boundaries on Community Accounts are based on areas serviced by postal codes and may differ from the official zone boundaries. As a result a section of the Salmonier line in Economic Zones 17 and 18, and a portion of the community of Marysvale in Economic Zone 18 are included with Economic Zone 19. Demographics The 2006 Census population for Economic Zone 19 - Northeast Avalon Regional Economic Development Board was 188,265. This represents an increase of 4.5% since 2001. Over the same period, the entire province experienced a population decline of 1.5% since 2001 (505,470 in 2006, down from 512,930).

Income, Consumption and Leisure The 2006 income for every man, woman, and child (personal income per capita) in Economic Zone 19 - Northeast Avalon Regional Economic Development Board was $26,900. For the province, personal income per capita was $22,900. After tax personal income per capita, adjusted for inflation, was $17,000 for Economic Zone 19 - Northeast Avalon Regional Economic Development Board in 2006. For the province it was $14,900. Half of the couple families in Economic Zone 19 - Northeast Avalon Regional Economic Development Board had incomes of more than $71,500 in 2006. Half of the couple families in the province had incomes of more than $56,500. Half of the lone-parent families in Economic Zone 19 - Northeast Avalon Regional Economic Development Board had incomes of less than $27,800 in 2006. Half of the lone-parent families in the province had incomes of less than $25,300.

The 2006 self-reliance ratio for Economic Zone 19 - Northeast Avalon Regional Economic Development Board was 86.1%. This is a measure of the community's dependency on government transfers such as: Canada Pension, Old Age Security, Employment Insurance, Income Support Assistance, etc. The higher the percentage of income that comes from transfers the lower the self-reliance ratio. The provincial self-reliance ratio for 2006 was 78.5%.

According to the 2006 Census, in Economic Zone 19 - Northeast Avalon Regional Economic Development Board 71.9% of homes were owned versus rented compared to 78.7% for the province and 68.4% for Canada. According to the 2001 Census, the average value of dwellings in Economic Zone 19 - Northeast Avalon Regional Economic Development Board was $111,250. The provincial average was $76,285 and the Canadian average was $162,710 in 2001. In Economic Zone 19 - Northeast Avalon Regional Economic Development Board, in 2001, 70.0% of homes were owned versus rented compared to 78.2% for the province and 65.6% for Canada. Employment and Working Conditions The unemployment rate for May 2006 for people aged 15 and older was 10.4%.The provincial unemployment rate was 18.6%. The employment rate for the entire year 2005 for those aged 15 and older was 67.5%. The provincial employment rate for the same period was 63.3%.

The number of individuals in Economic Zone 19 - Northeast Avalon Regional Economic Development Board who received Income Support Assistance at some point in the year 2008 was 18,915. The 1991 figure was 25,590. The total number of children ages 0 to 17 in Economic Zone 19 - Northeast Avalon Regional Economic Development Board who were in families on Income Support Assistance in 2008 was 5,160. The figure for 1991 was 9,720.

The number of individuals in Economic Zone 19 - Northeast Avalon Regional Economic Development Board who collected Employment Insurance at some point in the year 2008 was 15,800. The 1992 figure was 34,700. The average benefits for those individuals collecting Employment Insurance in Economic Zone 19 - Northeast Avalon Regional Economic Development Board in 2008 was $5,400 while the average benefits in 1992 was $5,500. In comparison, the provincial average benefits in 2008 was $7,500. 15.1% of the labour force in Economic Zone 19 - Northeast Avalon Regional Economic Development Board collected Employment Insurance in 2008. This was lower than the provincial rate of 34.0%.

Education, Literacy, Skills and Training Census 2006 reported 15.8% of people 18 to 64 years of age in Economic Zone 19 - Northeast Avalon Regional Economic Development Board do not have a high school diploma compared to 25.1% of people in the entire province.

In Economic Zone 19 - Northeast Avalon Regional Economic Development Board about 23.7% of people aged 25 to 54 had a Bachelor's Degree or higher in 2006 compared to 15.1% in the province as a whole.

In 2006, in Economic Zone 19 - Northeast Avalon Regional Economic Development Board, 90.5% of people 25 to 34 years of age had at least a high school diploma. This compares to 85.4% in the entire province and 89.1% for Canada.

Health A major indicator of well-being is how a person rates their own health status. In 2005, 68.0% of individuals in Economic Zone 19 - Northeast Avalon Regional Economic Development Board rated their health status from very good to excellent. The provincial number in 2005 was 64.5%. In 2005, for Canada, 60.2% of individuals age 12 and over rated their health status as very good to excellent. The rate of smoking (current daily smokers) in Economic Zone 19 - Northeast Avalon Regional Economic Development Board in 2005 was 17.5%. The provincial rate was 19.3%. The percentage of people who were obese (adult body mass index 30 or greater) in Economic Zone 19 - Northeast Avalon Regional Economic Development Board in 2005 was 22.6%. The provincial rate was 24.5%.In 2005 the rate of smoking in Canada for those 12 years of age or older was 16.6%, and the percentage of people obese was 15.8%. The highest percentage (11.2%) of hospital morbidity/separations during the period 2003 to 2005 for Economic Zone 19 - Northeast Avalon Regional Economic Development Board was due to diseases of the circulatory system. At the provincial level, diseases of the circulatory system also accounted for the highest percentage at 13.5%.

Data Sources Data compiled by the Community Accounts Team based on custom tabulations from the following: Demographics: Census of Population 1986 to 2006, Statistics Canada.

Income, Consumption and Leisure:

Canada Customs and Revenue Agency summary information as provided by Small Area and Administrative Data Division, Statistics Canada. Census of Population 2001 and 2006, Statistics Canada.

Employment and Working Conditions: Census of Population 2006, Statistics Canada. Department of Human Resources, Labour and Employment. Human Resources and Skills Development Canada.

Education, Literacy, Skills and Training:

Census of Population 2006, Statistics Canada.

Health: Newfoundland and Labrador Centre for Health Information, Clinical Database Management System. Canadian Community Health Survey (CCHS), 2005, Statistics Canada.

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Access – Charting the Course: The Northeast Avalon Community Health Needs Assessment

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