Understanding the Impact of the Consolidation of Surgical Services in a Major Integrated Health Region

Key Implications for Decision Makers

  • Rapid consolidation of surgical services is possible. However, a slower pace of change would make it easier to monitor changes and to make early corrections to the service model.
  • Despite large funding decreases, consolidating surgical services generally appeared to prevent declines in quality of care and access to services, as did measures taken in other jurisdictions.
  • When planning to redistribute surgical services, key stakeholders should be involved in the decision-making and planning processes as early as possible. A comprehensive communication plan should also be developed for all stakeholders.
  • Changes to surgical services should be based on patient care, education, and research principles. These principles should be developed before changes are implemented.
  • An evaluation plan with measurable indicators should be developed before services are consolidated. In particular, case costing should be used to estimate the effect of consolidation on budgets, so it can be easily determined if cost savings were achieved.
  • If surgical services are consolidated in a regional health system, decision makers should recognize that some surgical services should be available at all sites; for example, ready access to general surgery services in all hospitals to address emergency and urgent patient care needs.
  • Not all activities that are crucial to organizations are obvious or explicit, and these can be unintentionally eliminated when change occurs. One example is that physician communication across different surgical specialties is often informal and can be disrupted when specialties are consolidated at different sites.
  • Inefficiencies in the use of operating rooms can occur with the removal of all low-intensity cases. While overall volumes can be maintained, workloads cannot be balanced to avoid staff and physician 'burnout,' and it is not possible to make the best use of operating room time by slotting in lower-intensity cases.
  • If a service model necessitates that surgeons travel between sites within a region, time normally devoted to teaching, research, and continuing professional development will be lost.

Executive Summary

Purpose

Capital Health, one of Alberta's two major academic health regions, provides a full range of surgical services to patients. In 1995, Capital Health consolidated the delivery of surgical services based on their relative intensities. Two of the region's acute care facilities were designated referral hospitals and began to provide all high-intensity surgical procedures. These facilities continued to provide some low-intensity services. The remaining facilities were designated community health centres1 and provided only low-intensity surgery. The purpose of this project was to investigate the effect of consolidation of surgical services in Capital Health from 1995 to 2001 on patients, providers, students, and the delivery system.

Target audience

The primary target audiences for this report are senior administrators who may be contemplating consolidating surgical services in their integrated health regions. Other audiences include academic, public, and political stakeholders within these regions. In addition, the report may be useful for regional decision makers and stakeholders about to engage in other major region-wide changes.

Methods

The study had three components:

  • a historical document review of the organization's decision-making process;
  • a quantitative analysis of selected procedures for each surgical program that underwent consolidation, to determine the impact of consolidation on patient care; and
  • a series of semi-structured interviews with academic faculty and surgical program directors to determine the impact consolidation had on education and training of medical students and surgical residents.

Main findings

The document review revealed the difficulty in separating the impacts of the consolidation of surgical services from those of other changes occurring at this time of regionalization and budget cuts. The review discovered that many of the region's physicians and staff felt they had not been adequately informed, consulted, and/or involved in decisions around the consolidation of surgical services - decisions that had a direct and fundamental impact on their work. In particular, the implementation of consolidation was reported to negatively impact the quality of work life of surgeons working at two different sites. This impact included increased travel time, increased stress from working at different hospital sites, and creating inefficiencies in the utilization of operating room time because of loss of flexibility when surgeons were booked at different sites.

Based on the quantitative analysis of several index procedures, the consolidation of surgical services generally had neither a positive nor a negative impact on patients' access to care or the quality of care for surgical procedures. Analyses were limited because of lack of available data. In particular, the budgetary implications of the consolidation of surgery could not be assessed.

Semi-structured interviews of academic medical school faculty and surgical program directors reported negative impacts on the training of medical students and surgical residents. One of the effects was that students no longer had the opportunity to experience a blend of complex and routine procedure cases on any given day, as they would be placed at either a high- or low-intensity site for extended periods. Also, increased travel times for surgeons and residents resulted in less time for training, research, and continuing professional development.

Policy implications

Initiation of consolidation

Consolidating surgical procedures is a major change for any health system, and decision makers should not underestimate some organizational cultures' resistance to change. A comprehensive communication plan should be developed as early in the process as possible, outlining the positive effects the changes will have on patient care and education and the research principles on which the changes are based. In addition, since saving money is often the reason for consolidating services, case costing should be used to estimate the effects on budgets. With this common base, key stakeholders can be involved in the decision-making and planning processes at an early stage to help develop, monitor, and refine the changes.

Monitoring effects of consolidation

A monitoring system should be implemented to give decision makers the timely and accurate information they need about the effect of consolidation. The system should include indicators of learning, education, and patient care, which will allow decision makers to respond quickly and make any necessary changes to the consolidation process.

In addition to the ongoing monitoring of its impact, a rigorous evaluation of the process of consolidation is important. All too often, large-scale changes in service delivery are made without an evaluation of successes, barriers and facilitators. Without the benefit of lessons learned from previous actions, subsequent attempts to consolidate are likely to repeat previous mistakes. An evaluation plan incorporating multiple modes of inquiry should be developed prospectively and implemented during consolidation, and the results should be widely available.

Implementation of consolidation

It is inevitable that major changes will have a negative impact on some staff. Any negative effects should be acknowledged, steps should be taken to mitigate them, and ongoing communication with and support for those staff should be considered. One way to minimize negative impacts is to make changes in small stages if possible; this results in a slower pace of change, which makes it easier to monitor the effects and make early corrections.

There are several potential problem areas. First, not all activities that are crucial to the organization are obvious or explicit, and these can be unintentionally lost when change occurs. One example is that physician communication across different surgical specialties is often informal and can be disrupted when specialties are consolidated at different sites. Second, hospitals that lack core surgical services like general surgery face significant emergency and urgent patient care challenges. Finally, while volumes can be maintained, other operating room efficiencies decrease in hospitals that only have high-intensity cases.

Impact on training and education

Large academic health centres are responsible for teaching and research as well as direct service delivery. Surgeons are responsible for their own continuing professional development; therefore, the impact on teaching, research, and continuing professional development should be considered when service delivery changes are made. Academic-affiliated clinicians often also have dual responsibilities of service delivery and education. When they are involved in the planning process, it is important to make explicit whether they are representing direct patient care or academic interests, and then to ensure that both of these interests are represented.


1 For consistency, throughout this report we refer to hospitals in Capital Health, other than the University of Alberta Hospital and the Royal Alexandra Hospital as community health centres. This was the designation used up to 2000, after which the designation was changed to community hospitals.