Peterborough peer review deeply flawed

April’s release of the peer review into the Peterborough Regional Health Centre has unleashed a storm of criticism after recommending the closure of 71 beds and reduction of 151.5 full-time equivalent jobs at the hospital. After years of planning and building the new hospital, the cuts would take it to below the bed count it originally had at the Civic Hospital and St. Joseph’s Health Centre.

Having raised funds and paid dearly for the local share of the new hospital’s costs, Peterborough’s residents are understandably upset about this turn of events.

If the bed cuts take place, it will mean about a third of the new hospital beds will remain empty and unstaffed.

Worst still, the Peer Review indicated that at the “leap of faith” the LHIN took in approving its accountability agreement in March may be in vain – as drastic as these proposed cuts are, the Peer Review indicates that there will not be sufficient savings this year to balance the budget.

Did the Peer Review get it right?

What is remarkable in the final report is how little reference there is to anything learned on site by the peer review. Most of the recommendations are based on provincial benchmarking, not on local conditions. Surprisingly, given the Peer Review questions the quality of much of Peterborough’s data, it is not hesitant to make major decisions based on what it feels the data should be.

There is little reference to the high percentage of seniors Peterborough serves. Nor is there any reference to seasonal fluctuations resulting from an influx of summer cottagers. Nor is there any reference to what some patients say are high cancer rates in the city. All of these are considerable factors that draw on services from the hospital.

Further, in most of the performance metrics the Peer Review considered, most are actually middle of the pack or better, suggesting the Peer Review isn’t looking at Peterborough because its badly operated, but because of its burgeoning deficit.

Some examples: Four of its six safety indicators are better than the provincial average.  It indicates its ER is already efficient, boasting the third lowest rate of admission from emergency department visits among 21 peer hospitals.  The average length of stay in the intensive care unit for medical patients is among the lowest in the peer group, 15^th of 21 hospitals.  Average length of stay for surgical patients in the ICU is 11^th of 21 hospitals.  It states the surgical program operates very efficiently, usually putting it in the top 25 per cent provincially. Average length of stay for in the newborn and neonatal unit is 5.12 days, placing Peterborough 13^th of 21 peer hospitals. The report lauds the mental health program as “one that is effectively managed.” It says the hospital’s end-stage renal disease program is generally efficient.  While larger than it needs to be, the peer review said it was impressed with the equipment and physical plant of diagnostic imaging. While complaining about the wait for non-urgent CT scans, it does acknowledge the hospital is providing many more scans than they are getting paid for. It says the lab is “very efficient in its utilization of laboratory procedures” – the fourth lowest. It said the management of medical and surgical supply costs was among the best.

Further, the execution and redevelopment of the hospital is described by the Peer Review as “excellent,” the construction on budget and with very few change orders compared to other such projects.

These are hardly examples of a hospital that is being badly run.

Some of the comparisons are flawed, given not all of the peer hospitals offer the same level of service. For example, it states PRHC has the 3^rd highest costs in interventional cardiology and angiography when compared to its peer group. Many of these peer hospitals do not even offer angiography.

Many of the recommendations are contradictory.

While the peer review acknowledges the difficulties in retaining hospitalists, it actually proposes decreasing their annual income to save money. How will paying hospitalists less actually improve retention?

It complains of the number of alternate level of care (ALC) patients, but then the report suggests that the hospital may have been designating more patients as ALC than the definition warranted.

While it proposes cutting 71 beds, it expects Peterborough to make available 20 to 30 beds every day at midnight in order to accommodate the following day’s admissions. It also states that patients are left in intensive care longer due to a present lack of available medical beds. How will fewer beds change this situation? Surprisingly, it complains of a lack of revenue from premium accommodations, yet acknowledges they won’t even have these beds if their plan is implemented.

Up until the time it moved into the new amalgamated facility, Peterborough’s expenses and revenues ran a roughly parallel path, expenses slightly higher than revenues. However, while the expenses continued on a rather predictable path, revenues started to flatten after the move to the new hospital.

Had funding for Peterborough been modestly better over the last six years, the financial situation would have never gotten this out of control.  Today Peterborough has a working capital deficit of almost $90 million.

What is remarkable is the number of recommendations that involve more funding, not less. Nowhere are these new expenditures totaled.

The report is most scathing when it describes the assumption made by the hospital’s leadership that additional funding would be coming.  Had funding come years earlier, Peterborough today would be a reasonably well-functioning hospital by any standards.

The report also ignores the 11 other hospitals the province chose to rescue from dire financial straits. Was it reasonable to expect the same would happen for Peterborough? Yes.  So why didn’t it?

The bottom line is Peterborough is a large regional health care provider that needs to be funded appropriately to get the job done. Too many of the assumptions and recommendations in the peer review are pie in the sky, reliant on external conditions that simply don’t exist. It is compared to peer hospitals that often operate in large urban centers where multiple hospitals are present.

The Peterborough area has too few long term care beds. The Central East CCAC is struggling financially – this winter it was only accepting the most acute patients. The LHIN has some money for interim ALC beds, but it’s not nearly enough for the region, and there is no indication that enough retirement homes will be willing to step up their facilities to take on these patients.

This winter’s peer review is a deeply flawed document. The province needs to first provide all the post-construction funding Peterborough was promised, and next look at how it can help the hospital get on firm footing without gutting the needed regional services the hospital was initially built to provide.