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Title: Section Title


1
(No Transcript)
2
Welcome Address
  • Sue Smith - Conference Chair
  • Director, Clinical Support Services,
  • Hamilton Health Sciences

3
Agenda
  • 845 Health Care Structure Health Care Funding
  • 1030 Break
  • 1045 Health Care System Responsiveness
  • 1200 Lunch
  • 100 Health Care Business Technology
    Movement Towards Integration
    Standardization
  • 205 Break
  • 215 Health Care Business Technology
    Innovation Development Assessment
  • 315 The Outcomes of Collaboration, Cultivation,
    Celebration
  • 345 Conference Close

4
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5
Opening Address
  • Jeff Lozon
  • President and CEO,
  • St. Michaels Hospital

6
  • Video Wound Care

7
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8
Health Care Structure Local Health Integrated
Networks
  • John King - Moderator
  • Executive Vice President, Hospital Services
  • Chief Administrative Officer,
  • St. Michaels Hospital

9
Transformation Journey So Far
  • Hugh MacLeod
  • Associate Deputy Minister Executive Lead of the
    Health Results Team,
  • Ontario Ministry of Health and Long-Term Care

10

Single Goal Improve Access and Quality
  • The future is not what it used to be.
  • Rapid change is possible in a large, politically
    sensitive, financial stressed, publicly
    administered healthcare system.
  • Improved quality, better service, and reduced
    cost can all be achieved at the same time.

11
TransformationFraming the Play
  • First Principle. Treat health care reform
    organically rather than structurally or
    fiscally
  • Second Principle. Apply the principle of
    momentum.
  • Third Principle. Apply the leverage

12
Build On Lessons from the Business World
  • Build a quality Product
  • Get your price point as low as possible
  • Explore alternate distribution systems
  • Pay attention to customer service

13
Improving the Ontario Healthcare System
  • Building Blocks Access, Accountability,
    Performance, Quality, Patient Centred Care
  • The New Building Blocks Now Drive.New
    Conversations
  • Out of the new conversations, we are now seeing
    examples of System Helping System
  • Key element of the play is the Democratization
    of Access to Information (Transparency)
  • Next Wave Performance Improvement (Quality
    Safety)

14
Update on Local Health Integration Networks
  • Presented by
  • Pat Mandy, CEO, Hamilton Niagara Haldimand Brant
    LHIN
  • Barry Monaghan, CEO, Toronto Central LHIN
  • June 21, 2006

15
LEGISLATION principles values
Ministry of Health Long-Term Care Provincial
standards, policy strategic direction
  • 10-year strategic plan and provincial
    priorities
  • Standards and directives
  • Ministry-LHIN accountability agreements
  • Funding models and LHIN funding envelope

Local Health Integration Networks (LHINs) Local
planning, accountability, funding allocation
COMMUNITY ENGAGEMENT
COMMUNITY ENGAGEMENT
  • Integrated Health Services Plan (3-year
    plan)
  • LHIN-provider accountability agreements
  • Integration directions
  • Service planning, funding and allocation

Service Providers Delivery of services programs
16
LHIN Activities
  • Community Engagement
  • Integrated Health Services Plan (IHSP)
  • Best Practice Initiatives

17
Overview Toronto Central LHIN Joint Health and
Disease Management ProgramPresentation to
Building Common Ground Conference
  • Presented by
  • Barry Monaghan, CEO
  • Toronto Central LHIN

18
Overall Gap Cases Completed within Target
Source Interim wait times database, Wait Times
Information Office
June 2006
Note Priority 4 targets used in absence of
priority-level data
Target April 2007
19
Joint Health and Disease Management Program Goals
  • Program Goals
  • To improve joint health in the TC LHIN by
  • Improving access to services
  • Integrating components of care including Primary
    Care, Specialist Care, Rehabilitation, Community
    support services, Education and the determinants
    of Health for joint disease
  • Objectives
  • Improve access, and reduce wait times for hip and
    knee replacement surgery
  • Increase cost-effectiveness and efficiencies as a
    result of an integrated model of care and
    surgical room efficiencies
  • Improve quality of care for patients, through the
    development and implementation of best practice
    guidelines

20
Joint Health and Disease Management Program Key
Principles
  • Initial focus is on increased access to hip and
    knee replacement surgery and will therefore have
    a positive impact on the Ministrys goal of
    improved access and reduced wait times
  • Scope of the program is LHIN-wide and therefore
    contributes to the Ministrys transformation
    agenda
  • Current facility-specific joint health
    initiatives within the LHIN are being
    incorporated and folded into the program to
    facilitate the system helping the system
  • Program designed around an integrated model of
    care and improved patient flow
  • Focus is on arthritis care using a chronic
    disease management framework

21
Project Governance Structure
22
TC LHIN Wait Times for Hip and Knee Replacements
TC LHIN wait times for hip and knee replacements
have generally decreased over the past 8 months
Goal is to achieve the 90th percentile of
Priority 4 Access Targets by March 2007
Hip Replacement
Knee Replacement
Median wait time
P4 Access Target
90th percentile wait time
Data Source MOHLTC Wait Times
  • Wait times for hip and knee replacement surgery
    are improving
  • Patients generally waiting 96 days less for hip
    replacements than 8 months ago
  • Patients generally waiting 178 days less for
    knee replacements than 8 months ago

Data collection started in July 2005 N4 does
not support a statistically significant trend
23
TC LHIN Must Address System and Hospital-Level
Efficiencies
  • Appropriate surgical consultation using standard
    assessment referral process
  • Distribution of patients across LHIN based on
    capacity, throughput quality outcomes
  • Hip and Knee health education early in the
    disease process
  • Coordination of post-operative community services
    prior to surgery
  • Unequal distribution of wait times
  • One facility performing majority of hip knee
    surgeries
  • Inappropriate non-surgical patient referrals
  • Variability in amount type of hip knee
    education for patients
  • Majority of referrals from outside TC LHIN
  • Delays in discharge from hospitals

Implications for maximizing patient throughput
  • Single, Centralized Intake/Referral Centre
  • Standard assessment process
  • Appropriate referrals to surgeons
  • Early education programs for hip knee health
  • Customized patient care plans
  • Post-operative service planning prior to surgery
  • Centralized OR booking process
  • IM/IT solution

24
Proposed TC LHIN Joint Health and Disease
Management Model
Population Health Strategies to influence
lifestyle behaviours that affect joint health
(e.g., healthy weights, healthy activity, injury
prevention), awareness programs for early
detection of arthritis
Referring Physician
TC LHIN Joint Health Disease Mgmt Program
Triage
Medical Candidate
Surgical Candidate
Medical Model(Osteo-Arthritis Disease Mgmt)
Surgical Model(Intake Assessment Centre)
Clinical Guidelines, Education Tools Care
Pathways
Hip Knee Assessment Team
OA Mgmt Education Centres
  • Assessment for surgery by Hip Knee Assessment
    Team
  • Patient choice of surgeon or shortest wait list
  • Education Support
  • Rehabilitation
  • Medication Pain Mgmt

Standards Quality
Information Management Support
Human Resources, Education Training
Research Program Evaluation
Surgical Team Assessment Care Planning at
Pre-Admit Clinics
  • Book OR
  • Coordinate Post-OP services
  • Pre-OP Preparation

H
25
Next Steps
  • Present recommendations at June 26th Steering
    Committee
  • Final approval of the Proposed Joint Health
    System Model
  • Decisions on configuration will be made post June
    30th
  • Present Progress Report to Alan Hudson and Hugh
    MacLeod including
  • recommendations for additional hip and knee cases
    in 06/07 and
  • recommended next steps for implementation of the
    Joint Health System Model

26
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27
Health Care Funding
  • John King Moderator
  • Executive Vice President, Hospital Services
    Chief Administrative Officer,
  • St. Michaels Hospital

28
New Funding Model
Maureen Adamson Assistant Deputy Minister,
Corporate Services and Organizational
Development, Ontario Ministry of Health and
Long-Term Care
29
Collaborate. Cultivate. Celebrate.
30
Celebrate
  • Passion
  • Purpose
  • Vision

31
Cultivate
  • Awareness
  • Choice
  • Mastery
  • Learning
  • Global
  • Home Grown

32
Cultivate - More
  • Courage
  • Determination
  • Humility

33
Collaborate
  • Relationships
  • Trust
  • Alignment

34
Commitment
  • Hearts Minds
  • Listening to Divergent Voices
  • From Answers to Questions

35
Thank You!
36
Health Care Funding
  • Ontarios Wait Times Strategy

Peter Glynn, Ph.D. Senior Advisor Access to
Services and Wait Times Strategy, Health Results
Team, Ontario Ministry of Health and Long-Term
Care
37
Access and Wait TimesRight Care at the Right
Time in the Right Place
  • Goal
  • A comprehensive system that ensures Ontarians
    receive timely and appropriate access to health
    services by Dec 2006.
  • Scope
  • Wait time reduction in five areas cancer,
    cataract, hipknee joint replacement, cardiac
    procedures and MRI exams.

38
Strategy Elements
  • Accountability hospitals responsible for
  • Wait times and access management
  • Equity of access for patients and for
    information about access
  • Access Management
  • Consistent method of prioritizing patients
  • Provincial registry for the five key services
  • Capacity
  • Improved efficiency in hospitals as a result of
    maximizing existing resources
  • Increased capacity and volumes in hospitals
  • Evaluation
  • Measurement of rates of procedures,
    appropriateness, wait times, patient outcomes,
    and quality of care
  • Communication
  • Public reporting of wait times on website

Data Information Knowledge
39
Transformation
  • Authority
  • Responsibility
  • Accountability

40
Transformation and Change Management Model
  • Supports
  • Development of registry
  • Audit of allocated volumes
  • Targets for wait times
  • Sign backs for volumes to enhance accountability
  • Implementation of best practices
  • A provincial approach to Information Management
    and Information Technology
  • Hospital Agreement on
  • Price
  • Quality
  • Information
  • Accountability

Wait Time Strategy Volume increases for 5 key
services
  • Aligned Tactics
  • Efficiency Fund - knowledge transfer
  • Expert Panel on Surgical Process Analysis and
    Improvement-Coaching teams

41
The expert panel reports
  • A key strategy to provide advice on how to
    address the profound problems of timely and
    appropriate access
  • Cancer Surgery
  • Hip and knee joint replacement
  • Cataract Surgery
  • Surgical process Improvement
  • MRI and CT
  • Wait time Information Strategy
  • Have provided advice on many aspects of managing
    access
  • We are already moving ahead with many of the
    recommendations
  • All reports are available on the Ministry of
    Health Web site under the Wait Time Strategy
    section

42
Increasing Capacity
Additional
Increase 2006/07 vs. 2003/04 Cardiac procedures
11 Hip Knee 37 Cataract
32 Cancer surgery 11 MRI Scans 44
Global
Purchased Service with Conditionality
43
The Price!
  • Cataract Surgery
  • 750
  • Hip and knee Surgery
  • Community Hospitals Primary 6,882
                                              Revision
    8,796
  • Teaching Hospitals              Primary
    8,930                                            
    Revision 10,776
  • MRI
  • 385/Hour

Note Prices for surgery were developed by JPPC
in 2005
44
The Price!
  • Cancer Surgery

Note Prices for surgery were developed by JPPC
in 2005
45
Better Information, Better DecisionsWait Time
Information System
WTIS High Level Information Flows
4
46
WTIS/EMPI Implementation Timeline
  • Phase 1 5 hospitals by March 06
  • UHN
  • Hamilton Health Sciences
  • Grey Bruce Health Services
  • Grand River Regional
  • Southlake Regional
  • Phase 2 50 hospitals by Dec 06
  • Phase 3 77 hospitals by June 07

All Hospitals
Phase 3 Hospitals WTIS Implemented June/07
Phase 2 Hospitals WTIS Implemented Dec/06
Phase 1 Hospitals 5 Hospitals WTIS by Mar/06 18
of cases
Implementation of WTIS and EMPI in Phase 2
hospitals will begin immediately following Phase
1, with preparation activities occurring before
March 2006
50 Hospitals 80 of funded cases
77 Hospitals 100 of Funded Cases
100 Hospitals
47
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48
The WTIS will incorporate Targets and Priority
Classification Systems
  • Priority Rating Tools can be used to ensure that
    all patients with similar clinical need are
    treated in the same timeframe, irrespective of
    their surgeon, hospital, or geographic location.
  • Targets can be used to give patients a sense of
    how quickly they should be receiving treatment.
  • Targets can also be used to measure how well our
    health system is performing However, targets
    can only be used in this fashion if we have wait
    time data to measure against these targets!

49
Ontario Targets and Priorities
50
The Data to make Decisions
Patient and primary care provider make informed
decisions about where to be treated
Hospital board make informed decisions about
where to put its resources
Wait Times Web Site Data by hospital, Oct. 05
www.ontariowaittimes.com
51
HOW ARE WE DOING?
52
cases completed within targetFebruary/March
2006
Note Priority 4 targets used in absence of
priority-level data
Source Interim wait times database, Wait Times
Information Office
53
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54
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55
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56
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57
Reasons for Variation are Complex!
  • Important to remember that this isnt about good
    and bad
  • Data now provides the facts for hospitals (and
    LHINs) to
  • Understand waiting
  • Understand how they compare with others
  • Analyze the multiple causes
  • Consider program design or redesign
  • To work in partnership with physicians to meet
    the needs of patients
  • In other words, take charge of patient access to
    needed care

58
Summary!
  • Access Management
  • Organized Care
  • Patient Centered
  • Quality
  • Efficiency
  • Effectiveness
  • ACCOUNTABILITY

59
www.ontariowaittimes.com
THANK YOU
60
Structure Funding Moderated Q A
61
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62
Break
63
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64
Health Care System Responsiveness
  • Sue Smith Moderator
  • Conference Chair
  • Director, Clinical Support Services,
  • Hamilton Health Sciences

65
Provincial Responsiveness Planning Pandemic
Planning In Ontario
  • Mark Breen
  • Acting Senior Manager, Emergency Management Unit,
  • Ontario Ministry of Health and Long-Term Care

66
Provincial Responsiveness PlanningPandemic
Planning In Ontario
Mark Breen Acting Manager Emergency Management
Unit June 21, 2006
67
The World View
68
Characteristics of an Influenza Pandemic
  • Requirements
  • Introduction of a novel (new) influenza virus
  • Highly contagious human to human transmission
    happens easily
  • New virus causes serious illness and/or death
  • Population has little/no immunity
  • Occurs roughly three times a century and
    international impact
  • Usually starts in southeast Asia
  • Current Status
  • New virus
  • Limited spread to humans
  • Limited transmission to date
  • Avian flu with 50 mortality
  • In place
  • Overdue
  • Began in southeast Asia (recently to Africa,
    Asia, Europe)

69
World Health Organization Pandemic Phases
70
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71
Important Reminders
  • Influenza Pandemic ? Seasonal Influenza
  • Influenza Pandemic ? SARS
  • Influenza Pandemic ? Avian Influenza
  • BUT
  • Important Lessons to be Learned from Each

72
Ontario Perspective
73
Ontario Health Plan for an Influenza Pandemic
(OHPIP) Overview
  • Goals
  • Minimize serious illness and overall deaths
    through appropriate management of Ontarios
    health care system
  • Minimize societal disruption in Ontario as a
    result of influenza pandemic
  • Strategic Approach
  • Be ready establish comprehensive contingency
    plans at provincial and local level
  • Be watchful practice active screening and
    monitor emerging epidemiological and clinical
    information
  • Be decisive act quickly and effectively to
    manage the epidemic
  • Be transparent communicate with health care
    providers and Ontarians

74
Updates in OHPIP 2006
  • Antiviral strategy
  • Stockpile to treat 25 of the population
  • Prophylaxis strategy to be developed nationally
  • Clinical care pathway for acute care including
    triage and critical care
  • Occupational health and safety chapter
  • Surgical masks for patient care N95 respirator
    for aerosol-based procedures hierarchy of
    controls
  • Public health measures
  • Pandemic Lab Manual tests available
    recommended tests etc
  • Community strategy
  • Surge capacity for health care workers
  • Communications manual
  • Pandemic Plan for Long-Term Care Homes
  • Paediatric chapter
  • First Nations chapter

75
OHPIP Supplies and Equipment
  • Templates for stockpiles by health care sector
  • Organizations stockpile for 4 weeks, MOHLTC
    stockpile for 4 weeks
  • Resources in place for MOHLTC to begin
    stockpiling Personal Protective Equipment
  • Gloves, gowns, surgical masks, eye protection,
    alcohol-based hand rinse
  • Challenges during a pandemic
  • Market overwhelmed
  • Supply chain business continuity
  • Potential border restrictions

76
Command and Control in an Influenza Pandemic
  • Use IMS structure
  • Legislative framework
  • Emergency Management Act Bill 56 passed third
    reading
  • Health Protection and Promotion Act
  • Chief Medical Officer of Health responsible
  • Role of Commissioner of Emergency Management/EMO
    to support lead ministry
  • Ministry Emergency Operations Centre/EMU
    operational direction
  • LHINs not engaged at this time

77
Emergency Response in the Ministry
  • EEMC Executive Emergency Management Committee
  • PEOC Provincial Emergency Operations Centre

78
Information Cycle
79
Important Health Notice
Highlights text box public health and
infection control measures Details of outbreak
case definition, number of cases, detailed
control measures Signed by CMOH, EMU
80
http//www.health.gov.on.ca/pandemic
Launched May 8, 2006
81
Lets Get Personal
82
Personal Preparedness
  • Be informed
  • Stay healthy
  • Hand washing
  • Cough/sneeze etiquette cover mouth and nose
    dispose of tissues wash hands
  • Avoid overcrowding when possible, particularly
    challenging with multi-generational families and
    housing shortage
  • Identify contingency plans
  • Daycare unavailable
  • Food shortages
  • Limited fuel
  • Caring for the ill at home
  • Reach out
  • Support of neighbours, friends and family who may
    have difficulty managing in a pandemic

83
Resources
  • Emergency Management Unit
  • http//www.health.gov.on.ca/pandemic
  • WSIB
  • http//www.wsib.on.ca/wsib/wsibsite.nsf/public/fl
    u_resources
  • CDC
  • http//pandemicflu.gov/plan/pdf/businesschecklist
    .pdf

84
Contacts
  • For questions, contact
    Emergency Management
    Unit staff at
  • 1 866 212-2272 Healthcare Providers Hotline
  • 1 866 331-0339 Employers Health Hotline
  • Email emergencymanagement_at_moh.gov.on.ca

85
Hospital Planning for Pandemic Influenza
  • John King - Co-Chair TAHSN Pandemic Taskforce
    Steering Comm.
  • Executive Vice President Chief Administrative
    Officer,
  • St. Michaels Hospital

86
Outline
  • Toronto Academic Health Sciences Network
    Taskforce
  • Key messages
  • Next steps

87
TAHSN taskforce
  • Co-chaired with Dr. Michael Gardam
  • Attempt to coordinate planning efforts in the
    absence of regionalization
  • Minimize duplication
  • Minimize staff confusion
  • Learn from SARS experience
  • The TAHSN Pandemic Planning Task Force consists
    of
  • Baycrest
  • CAMH
  • Hospital Business Services
  • Hospital for Sick Children
  • MOHLTC
  • Mount Sinai Hospital
  • St. Michaels Hospital
  • St. Josephs Hospital
  • Sunnybrook Health Sciences Centre
  • Toronto East General
  • Toronto Medical Laboratories
  • Toronto Public Health
  • Toronto Rehabilitation Institute
  • University Health Network
  • University of Toronto
  • Womens College Hospital

88
TAHSN tasks
  • Communication
  • Staff safety and support
  • Triage
  • Lab/IT
  • Human resources
  • Physicians
  • Linkages with other plans

89
Communication
  • Common plan
  • Transparency, frequent communication
  • Staged approach matching WHO phases
  • We must emphasize that you cannot over
    communicate during this stressful period

90
Staff safety issues
Of course this unknown flu that you and everyone
else has caught is harmless, Mr. Bell.
91
Protective equipment
  • A hotly debated issue that is not going away
  • Droplet/contact versus Airborne precautions
  • ONA, OPSEU position
  • Can we secure enough supplies to protect our
    staff for duration of flu period?
  • Hospitals and agencies 4 weeks of supplies,
    MOHLTC 4 weeks of supplies
  • Can the suppliers provide the necessary supplies?
  • Alternate storage arrangements must be planned

92
Antiviral prophylaxis
  • Who will look after patients if we are sick?
  • Mathematical models typically assume unlimited
    healthcare resources
  • Healthcare worker prophylaxis has a large impact
    on societal morbidity and mortality
  • This is our only insurance policy
  • Our decision was to purchase anti-viral
    prophylaxis for all staff, physicians and
    volunteers for a 56 day course
  • Planning is now underway for security, storage
    and distribution of anti-virals
  • Need to involve various decision makers when
    determining distribution (how much, how often?)

93
Triage
  • Where will flu patients be seen?
  • What will happen with outpatient clinics?
  • Which inpatient programs will be scaled back?
  • Logistical considerations
  • How does this fit into local plans?
  • Need to work with Public Health and the provinces
    on assurance of assessment centres

94
Human Resources issues
  • Proactively discuss
  • Update unions regularly
  • Proactively discuss how to deal with
    pandemic-related grievances
  • Staff working in more than one facility
  • Staff refusing to work

95
Ethical issues
  • Decisions will be made that will tip the ethical
    scale
  • Which patients will receive treatment?
  • Treatment of patients in less then ideal
    conditions
  • Forcing staff to work
  • Who will receive scarce resources?

96
Coping mechanisms
  • Develop arrangement with employee assistance
    program for staff support
  • Have crisis management program
  • Education of staff to fully understand the risks

97
Redeployment Centre
  • HR to manage operation of centre
  • Develop a generic framework for a centre
    (provided in TAHSN plan)
  • principles and guidelines
  • Redeployment will require clinical expertise
  • Requires ability to track all staff
  • Will our staff be asked to work and provide
    support in the community?

98
Volunteers
  • Determine how volunteers are going to be used
  • Proactively discuss with volunteers their
    possible roles
  • If may be asked to fill union roles, discuss with
    unions proactively

99
Staff medical concerns
  • Proactively discuss possible redeployment of
    pregnant staff
  • OHS will make individual decisions regarding
    staff with high risk medical conditions
  • Who will care for ill staff?
  • Can they safely go home?

100
Child care/Elder care
  • Staff should proactively discuss with their
    families, their roles during a pandemic
  • Healthcare workers must be considered the
    essential worker in the family
  • Duty to care will certainly be challenged with
    family illnesses

101
What can you do?
Prepare like you would for any emergency
  • Waterless hand wash
  • Non-prescription medications
  • Knife, can opener etc..
  • Learn about your work and community plan
  • Food and water
  • Batteries, flashlights
  • Radio
  • Contact information
  • Alternate child care/elder care arrangements

102
Key messages
  • Planning is not wasted
  • Human resources and communications issues will
    make or break you
  • Protective measures, antiviral prophylaxis are
    hot topics
  • Determine what is planned for you in your region
  • Security arrangements to protect supplies and
    antivirals in a chaotic period needs attention
  • How do we distribute anti-viral medications?
  • Still questions related to who will take charge
    during a pandemic
  • BE PREPARED!
  • The TAHSN Pandemic Influenza Planning Guidelines
    can be obtained from www.tahsn.ca

103
Post traumatic stress or lessons learned?
104
Thank you
105
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106
Perioperative Services Environmental Control
Operating Room CRISIS
  • Valerie Zellermeyer, RN, MHSc, CPN (C),
  • Program Director Perioperative Services,
  • St. Michaels Hospital

107
  • Video OR Rain Forest

108
Perioperative Services Environmental Control
Failure
  • Chronology (July 18, 2005)
  • 0615 hrs Honeywell and flow control
    commissioning Valve closed after losing signal
    caused a fitting to leak in the chiller water
    system. Engineering shut off water
  • 0630 hrs OR 13 Nursing Staff notice increase
    temperature
  • 0640 hrs Fire Alarms going off

109
Perioperative Services Environmental Control
Failure
  • Chronology (July 18, 2005)
  • 0705 hrs ORs Humidity, ORs postponed.
  • Project Manager OR, noticed change, pulled
    equipment out, paged Engineering paged Medical
    Director. Nurses reported the rooms were
    extremely humid. Case packs were damp. All
    cases were put on hold. OR 17 implants packaging
    surfaces were wet with condensation film.
    Supplies damp. Manager Engineering notified
    through locating STAT - with immediate response
  • 0715 hrs All OR Fire alarms going off
  • 0730 hrs Chief, Surgery, Exc. VP, CMO and
    covering Program Director, Infection Control and
    Housekeeping notified

110
Perioperative Services Environmental Control
Failure
  • Chronology (July 18, 2005)
  • 0800 hrs Engineering paged again Security
    contacted to find Engineering for room
    temperature and humidity readings
  • 0815 hrs 2 chillers started. Eng. Manager came
    up to the OR and notified that Engineering was
    fixing the problem. Asked to get humidity and
    temperature readings
  • 0830 hrs Emergency and Trauma Leader notified.
    Closed to Trauma and EMS/Criticall. All surgeons
    notified. ORs closed to noon. Prioritize
    patients. Patients in OR notified delay

111
  • Chronology (July 18, 2005)
  • 0845 hrs Implants checked and were dry in OR 17
    (Storage)
  • 0905 hrs Administrator on Call notified
    Organized stakeholder meeting. Notified Finance
  • 0915 hrs Eng. Manager notified that the
    humidity was greater than 60 standard. All
    morning cases put on hold. Surgeons notified to
    prioritize their OR cases

112
  • Chronology (July 18, 2005)
  • 1000 hrs Director of Perioperative Services
    notified
  • 1100 hrs Status Meeting Stakeholders, Command
    Centre activated and Action Planning with OR,
    Vendor Administration, Logistics, CPD,
    Housekeeping, Infection Control, Engineering for
    recovery. Cancelled afternoon cases. Surgeons
    and patients notified. MOHLTC notified (Irv
    Mapa) (1330)
  • Action Plan Quarantine Products, monitor
    temperature, humidity. Decant OR and Sterile
    Corridor, purchase replacement products, Project
    Clean, Equipment Check, Restock

113
Perioperative Services Environmental Control
Failure
  • Chronology (July 18, 2005)
  • 1530 hrs Status Meeting Stakeholders and Action
    Planning.
  • All scheduled cases were cancelled for July 19,
    20, 2005. Surgeons, Patients and Staff notified.
    Criticall, Trauma, EMS remained closed until
    0800 hrs July 19, 2005. Receiving held open
    until 700 PM
  • 1600 hrs 1 OR opened, available for emergency
    surgery
  • 2000 hrs Status Meeting in Command Centre. OR
    1 5 opened for surgery
  • 2200 hrs The Sterile Core was decanted, product
    counted and quarantined and moved to 4 Shuter
    (old CVICU). OR day staff sent home

114
Perioperative Services Environmental Control
Failure
  • Chronology (July 19, 2005)
  • 0100 hrs Command Centre closed. Marriott Hotel
    Accommodations for Manager on Call and
    Administrator on Call, Manager of Engineering and
    key staff
  • 0430 hrs In house emergency case (perforated
    bowel). Case completed, MSICU patient stable.
    ICP tracking and ENCON form completed
  • 0730 hrs Command Centre opened. Team meeting
    and status updated. OR s 1, 2, 5, 7 are ready
    and cleaned. ORs were prioritized based on
    humidity readings. Assessed EMS/Trauma status
    committed to noon target

115
Perioperative Services Environmental Control
Failure
  • Chronology (July 19, 2005)
  • 1200 hrs All humidity readings within normal
    range (lt 60). OR s 1, 2, 3, 5, 7, 9, 10, 11
    12 ready and cleaned. Decision made to open to
    trauma and EMS and Medical Director Emergency
    notified and Trauma Team Leader and MOHLTC (Irv
    Mapa) updated
  • 1600 hrs select team members meet. Supplier
    status review and equipment review. Review of
    chronology documentation
  • 2000 hrs Command Centre closed

116
Technical Explanation
Excessive humidity was allowed to go in to the
OR because the saturation dew point was 94 which
meant that the air hits a cold surface and
condenses. The relative humidity in the OR at
that time before the incident would have been
below 55 and the surfaces would be 18 C causing
excessive condensation.
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Patient Management
  • Cases cancelled
  • Scheduled
  • Monday 41
  • Tuesday 47
  • Emergency/Urgent 6
  • Personal contact to patient by surgeon or
    management
  • Letter explaining situation and apology and
    referred to Patient Affairs
  • Case Recovery Plan in Process

126
Staff Support
  • This incident required significant extended hours
    of staff overtime and dependent on the good will
    of staff as no code orange was called.
  • Operating Room, CPD, Day Surgery, PACU,
    Perioperative Leadership Team, Vendor Admin,
    Logistics, Periop Pharmacy RT, Admin Support,
    Medical Leadership, Engineering, Housekeeping,
    Biomedical Engineering, Public Affairs, Infection
    Control, Security Catering
  • Actions taken included Team meetings, Internal
    and External communications through Public
    Affairs. Hydration measures to cope with
    significant heat and humidity. Catering to
    sustain energy. Other measures after hours
    accommodation, taxi chits. Recognition to staff
  • Crisis assistance to Labour and Birth by
    Perioperative staff team

127
Risk Management Environment
  • Engineering
  • July 18, 2005 Humidity and temperature monitoring
  • ORs (hourly)
  • Sterile Corridor (hourly)
  • Ambulatory ORs
  • Recovery
  • Housekeeping
  • Staffing scheduled to project clean
  • CVICU, cleaning for quarantine

128
Risk Management Supplies
  • Relevant suppliers alerted. Confirmation of
    product integrity from Vendor and manufacturer
    recommendations as to Sterility, Functionality
    and Safety
  • Team decision to Quarantine supplies and
    quarantine location confirmed
  • Sourcing Direct and Hamilton Health Sciences
    Warehouse extended hours and additional
    shipments. Processes began on July 18th at 1330
    and completed by 0400 on July 19th (16 hours)
  • Scheduling location and cart builds for
    replacement OR TPL Supplies
  • Extended hours in Receiving
  • July 19th 0800 to 2000 back order management and
    contingency backorders - product of 20.
    Clinical team will assess critical product gaps
    and Vendor Admin mitigate
  • TPL Carts built for ORs and Ambulatory ORs on
    July 19th. Approximately 12 carts
  • Drugs assessed and affected drugs were
    quarantined and replaced
  • Financial liability documentation products,
    drugs
  • Anaesthetic carts re-stocked
  • Suture carousels are contaminated and will be
    ordered for replacement.
  • Supplies Management required deployment of
    approximately 130 OR Staff to expedite the
    decanting process and facilitate the entire
    recovery process

129
Risk Management Equipment
  • Equipment assessed for humidity damage,
    functionality and safety
  • Equipment Suppliers were called in for validation
    and corrective action
  • Equipment was tested to ensure operational
    integrity
  • Equipment failure 1 (monitor)
  • Equipment missing in action dopplers
    (temporarily)
  • Biomedical team worked with OR/RT team and
    suppliers
  • Documentation completed on each piece of
    equipment by Perioperative Biomedical Engineering

130
Successes
  • Handled in house emergency in 21 hours
  • Open for emergency cases in 30 hours
  • Open for scheduled cases in 48 hours
  • OR was completely cleaned
  • Teams worked in harmony and were mutually
    supportive
  • Tracked supplies for insurance and recovery

131
Action Plans
  • Recommend
  • Monitoring plan for humidity and temperature and
    early alarm system
  • Emergency Action Plan associated with alarm
  • Procedures have been established in the OR for
    product protection (covers, storage)
  • Review of Environmental issues in the OR
  • Develop after hours supplier contact list
  • Complete Supply Chain project for Consignment
  • Note If the Supply Chain re-design had not
    occurred this incident would have potentially
    closed down the ORs for 2 weeks. (7,000 items)
  • Note Expedite supply storage for consignment in
    a warehouse safe environment
  • Emergency contacts for equipment suppliers
    supply manufacturers
  • Establish critical reference values which trigger
    actions
  • Insurance Recovery and tracking for all out of
    pocket costs Documentation binder assembly

132
Action Plans
  • 1) Reduce impact of outdoor conditions
  • Air recirculation capability, automatically
    controlled by outdoor/indoor RH
  • Variable Speed Fan Control (Slower speed allows
    for greater dehumidification)

133
Action Plans
  • 2) Minimize disruption of air supply due to
    maintenance, unexpected failure and repairson
    Supply Air Handling Units
  • Redundant Supply Air Handling Units and Variable
    Speed Fan Control (Run all units at 50)

134
Action Plans
  • 3) Maintain lower humidity levels in Operating
    Rooms during summer
  • Raised temperature space set-point from 18C to
    20C
  • Installation of Humidity monitoring system

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Accomplishments
  • Humidity monitoring system installed in December
    2005
  • New AHU craned into place end of April
  • Core ORs scheduled for completion end of June
  • Ambulatory ORs scheduled for completion end of
    July

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Questions For Discussion
  • What is the root cause of this failure?
  • Could it have been prevented?
  • If not, then what safety precautions and
    processes should be put in place to minimize risk
    i.e. timing and scheduling of work, advanced
    communication and notification on-site
    management.
  • Was there anything else we could have done
    differently?

137
Health Care System Responsiveness Moderated Q A
138
Health Care System Responsiveness Moderated Q A
  • Alcon Canada
  • Baxter Corp
  • Boston Scientific
  • Cardinal Health
  • Carl Zeiss Canada
  • Coherent AMT INC
  • Datex-OHMEDA (Canada) INC
  • Edwards Lifesciences Canada INC
  • Logihedron
  • Johnson and Johnson
  • Karl Stortz
  • Medtronic of Canada LTD.
  • Smith Nephew
  • Sorin Group
  • St. Jude Medical
  • Stryker Canada
  • Wright Medical Technology
  • Zimmer Canada
  • Hamilton Health Sciences

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Lunch
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Health Care Business Technology Movement Towards
Integration and Standardization
  • Paul Faguy - Moderator
  • Integrated Vice President, Clinical Support
    Hospital Services, Hamilton Health Sciences and
    St. Josephs Healthcare Hamilton

143
  • Video - Standardization

144
  • Strategy without tactics is the slowest route to
    victory.
  • Tactics without strategy is
  • the noise before defeat.
  • Sun Tzu

145
Standardization and Integration
  • Adds value by lowering costs of acquisition and
    actual cost of products
  • Improving the service to the end users by
    implementing best practice
  • Creating economies of scale
  • Accelerating quality improvement through focus on
    patient safety, communications and information
    sharing

146
Inevitability of Progress
  • USA IDNs
  • Great Britain - CPHs

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There is nothing more difficult to take in
hand, more perilous to conduct, or more
uncertain in its success, than to take the lead
in the introduction of a new order of things.
Niccolo Machiavelli

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Moderate Expert Panel Integration and
Standardization
  • E-Commerce New Contracting Platform
  • Rick Cochrane President and CEO, Medbuy
    Corporation

150
Moderate Expert Panel Integration and
Standardization
  • E-Commerce New Contracting Platform
  • Rick Cochrane President and CEO, Medbuy
    Corporation
  • Distribution Standardization
  • Keith Whorley Senior Consultant, Logihedron Inc.

151
Moderate Expert Panel Integration and
Standardization
  • E-Commerce New Contracting Platform
  • Rick Cochrane President and CEO, Medbuy
    Corporation
  • Distribution Standardization
  • Keith Whorley Senior Consultant, Logihedron
    Inc.
  • Product Standardization
  • Patrick Smith Manager, Purchasing, Hamilton
    Health Sciences

152
Moderate Expert Panel Integration and
Standardization
  • E-Commerce New Contracting Platform
  • Rick Cochrane President and CEO, Medbuy
    Corporation
  • Distribution Standardization
  • Keith Whorley Senior Consultant, Logihedron
    Inc.
  • Product Standardization
  • Patrick Smith Manager, Purchasing, Hamilton
    Health Sciences
  • Clinical Practice Standardization
  • Dr. Michael Marcaccio Chief of Surgery,
    Hamilton Health Sciences

153
Moderate Expert Panel Integration and
Standardization
  • E-Commerce New Contracting Platform
  • Rick Cochrane President and CEO, Medbuy
    Corporation
  • Distribution Standardization
  • Keith Whorley Senior Consultant, Logihedron
    Inc.
  • Product Standardization
  • Patrick Smith Manager, Purchasing, Hamilton
    Health Sciences
  • Clinical Practice Standardization
  • Dr. Michael Marcaccio Chief of Surgery,
    Hamilton Health Sciences
  • Information Metrics Clinical Networking
  • Bala Kathiresan Hamilton Niagara Haldimand
    Brant LHIN Integrated Vice President Chief
    Information Officer

154
Moderate Expert Panel Integration and
Standardization
  • E-Commerce New Contracting Platform
  • Rick Cochrane President and CEO, Medbuy
    Corporation
  • Distribution Standardization
  • Keith Whorley Senior Consultant, Logihedron
    Inc.
  • Product Standardization
  • Patrick Smith Manager, Purchasing, Hamilton
    Health Sciences
  • Clinical Practice Standardization
  • Dr. Michael Marcaccio Chief of Surgery,
    Hamilton Health Sciences
  • Information Metrics Clinical Networking
  • Bala Kathiresan Hamilton Niagara Haldimand
    Brant LHIN Integrated Vice President Chief
    Information Officer

155
Health Care Business Technology Movement Towards
Integration and StandardizationModerated Q A
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Contractual Relationships
  • Paul Faguy
  • Integrated Vice President, Clinical Support
    Hospital Services, Hamilton Health Sciences and
    St. Josephs Healthcare Hamilton
  • Patrick Smith
  • Manager, Purchasing,
  • Hamilton Health Sciences

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Focus On Healthcare Supply Chain Integration
159
i-SCM Project - Overview
  • The FOHSCI Project is in response to a Ministry
    of Finance initiative.
  • OntarioBuys Mission
  • To facilitate and accelerate the widespread
    implementation of
  • integrated supply chain management (iSCM) leading
    practices in
  • Ontarios Broader Public Sector (BPS)
  • Role
  • Champion iSCM leading practices
  • Provide funding of iSCM projects
  • Measure and report on iSCM performance against
    benchmarks
  • Not a supply chain service provider or project
    implementer
  • OntarioBuys works collaboratively with the BPS,
    supporting their iSCM efforts so that they can
    better serve Ontario

160
i-SCM Project - Overview
  • FOHSCI Focus on Healthcare Supply Chain
    Integration
  • Current Project goal is to examine the
    feasibility of comprehensive shared services for
    a wide range of supply chain services
  • 18 hospitals participating in the detailed
    implementation analysis
  • Information Technology will be a key enabler to
    efficiencies
  • Report to be submitted to the Ministry of Finance
    October, 2006

161
Focus On Healthcare Supply Chain Integration
FOHSCI
  • 18 Hospitals
  • 3.2 Billion
  • 600 Million on Med / Surg and Material Management

162
i-SCM Project Hospital Participants
  • Cambridge Memorial Hospital
  • Brant Community Healthcare System
  • Guelph General Hospital
  • Groves Memorial Hospital
  • Grand River Hospital
  • Hotel Dieu Shaver
  • Hamilton Health Sciences
  • Joseph Brant Memorial Hospital
  • Norfolk General Hospital
  • Niagara Health System
  • North Wellington Health Care
  • St. Joseph's Health Centre Guelph
  • St. Joseph's Healthcare Hamilton
  • St. Michael's Hospital
  • St. Mary's General Hospital
  • St. Peter's Hospital
  • West Haldimand General Hospital
  • West Lincoln Memorial Hospital

163
Focus On Healthcare Supply Chain Integration
FOHSCI
  • Individual hospital participation
  • Well informed local decision making
  • Comprehensive full sharing of information

164
Focus On Healthcare Supply Chain Integration
FOHSCI
Regional
GPO
Group
Local
165
Focus On Healthcare Supply Chain Integration
FOHSCI
  • Best value at time
  • Cost
  • Quality
  • Service
  • Flexibility
  • Transparency for members
  • Bias to standardization

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Break
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Health Care Technology Innovative Development
and Assessment
  • Joan McLaughlin - Moderator
  • Director, Supply Chain and Support Services,
  • St. Michaels Hospital

170
  • Video Guardrails

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Health Technology Assessment in OntarioFrom
Evidence to Policy
  • Dr. Leslie Levin MD FRCPC
  • Head Medical Advisory Secretariat,
  • Ministry of Health and Long-Term Care

172
Health Technology in Ontario
  • One of the most important cost drivers in U.S.
    and Canada accounts for 30 of unsustainable
    medical inflation
  • The medical device field has become one of the
    most innovative and profitable segments of the
    economythe medical device market is expected
    to grow by double digits for years to come. New
    York Times January 21, 2006
  • Utilization in Ontario (Hay Group, 2003) between
    1996 and 2002 for health technologies accounted
    for
  • 117 ? in physician fees vs. 17 for
    non-technology
  • 16 ? in procedures in acute care services
  • 29 ? in technology dependent same day surgery
  • 46 ? in hospital costs for technology-related
    CMGs vs. 23 for non-technology
  • 6 ? in utilization rate for
    technology-related CMGs vs. 3? for non-
    technology
  • Cost pressures compounding at gt0.5 billion per
    year
  • Need to balance expenditure against effectiveness
  • The most effective way of managing escalating
    health care costs is by developing organized,
    evidence-based health technology assessment
    (Bodenheimer, 2005)

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THE ONTARIO HEALTH CARE SYSTEM
174
Health Technology Assessment in Ontario
Health Technology Assessment in Ontario
JOINT POLICY PLANNING COMMITTEE (JPPC)
Provincial Guidelines Committee (Dissemination) OM
A OHA CPSO CNO OCFP
DEPUTY MINISTER
ONTARIO HEALTH SYSTEM
INTERDIVISIONAL COMMITTEE
Hospitals, Community Agencies, LHINs,
(Implementation)
Recommendation
Health System Requests
Health Technology Utilization Guidelines of
Ontario (Health TUGO) Steering Committee, Expert
Panels
Professional Feedback Loop
Ontario Health Technology Advisory Committee
(OHTAC)
OHTAC guideline development recommendation
Outcomes Tracked By Health Results Team ,
ICES, etc... Utilization and patient outcomes
UHN Usability Lab
Further Analysis required
OHTAC safety and training recommendation
Cardiac arrhythmia
Urinary Inconti-nence
PET
Expert Panels to integrate technologies around
disease states
  • Genetic screening
  • Diabetes
  • (Pre-OHTAC)

Medical Advisory Secretariat (Evidence-based
Platforms) Experts, industry
Cardiac Imaging
Arthritis
Health Quality Council, MOHLTC, LHINs
OHTAC field evaluation recommendation
Cancer-Remains under CCO
E-Base (ICES, PATH, CHEPA)
Field Evaluation Studies PATH, Experts,
Institutions
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Point of Inflection Portal of Recommendation
OHTAC Prioritization
Evidence-based analysis (GRADE) on effectiveness
related to patient outcomes and system
efficiencies
Active engagement of provincial experts industry
Ontario specific info on practice patterns,
trends utilization for current other
technologies around the disease state.
MAS HTPA
Economic analysis (MOHLTC budget impact,
comprehensive lit review, Ontario based
cost-effectiveness, downstream costs and savings,
sensitivity analysis, Bayesian and Markov
modeling)
MAS/OHTAC
Ethical, legal, regulatory, societal and human
resource issues
Recommendation to DM 60 days later Disseminate
on Website E-Bulletin
OHTAC Critical Review Determining the strength
of recommendation based on weighing risks
benefits
176
OHTAC Decision and Technology Trajectories
Approval with no Restrictions
Approval with Restrictions
UHN Usability Lab
Health TUGO
PATH
Guideline Development
Safety Human Factors Analysis
Integration of Technologies
Field Evaluation
Opportunity For Revision
Rejected
Professional Feedback Loop
Hospitals Community
Specialists, experts, academic institutions
Expert Panels
MAS/OHTAC
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Diffusion Curve - Diffusion Phase
Information Management (Health Results Team)
Tracking
ICES
Volume of new and competing
technologies
Health Quality Council
Performance (e.g. patient outcomes, accuracy and
system efficiencies)
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Field Evaluation Conditional Coverage
  • The provision of funding for new health
    technologies to enable data collection for
    determining the clinical and/or economic value of
    a technology and to support a definitive funding
    policy.
  • (Summit on Conditional Coverage of New Medical
    Technology, Medical Technology Leadership Forum,
    1999).

179
Conditional Coverage on the Rise
  • Conditional Coverage will likely expand
  • Fiscally strained health systems and more
    expensive health technologies, will raise
    evidence thresholds for funding decisions.
  • Non-drug health technologies not always subject
    to the same standard of proof of effectiveness
    cost-effectiveness as drugs in pre-marketing
    studies. Failure of licensing agencies to apply
    stringent evidence to non-drug technologies will
    fuel demand for conditional coverage.
  • Increasing need to improve our understanding of
    the systemic effects of health technologies and
    to use this to develop diffusion strategies
    especially for disruptive technologies (e.g.,
    multi-slice CT, endocardial ablative techniques,
    PET).
  • Concerns regarding safety.

180
Examples of Conditional Coverage
  • United States
  • Australia
  • Ontario, Canada

181
Field Evaluation Studies
  • Considered if the health technology seems
    effective, is
  • likely to have an important impact on patient
    outcomes but
  • Cost/volume/systems impact justifies test of
    generalisability (efficacy vs. effectiveness)
  • Quality of evidence is too questionable to
    justify a multimillion dollar multi-year
    investment
  • Concerns re off-label diffusion
  • NNT and per unit cost are unacceptably high
  • Technology is potentially disruptive
  • Available follow-up data insufficient
  • Unresolved patient safety issues
  • Conducted mainly by PATH (Also OCOG, UHN more
    recently)
  • arms length
  • design, execute with experts AHSC etc, analysis
    and reporting
  • 3 Million (4 year agreement, 10 projects) plus
    the cost of devices

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Example 1. Field Evaluation of PET
  • In 1999, nuclear medicine recommended funding for
    40,000 PET scans phased in, based on evidence of
    effectiveness.
  • 2001 ICES systematic review concluded -
    insufficient evidence on the clinical utility of
    PET, and its impact on patient outcomes.
  • FDG used in PET scanning only approved for
    clinical trial application by Health Canada
  • In 2002, MOHLTC funded PET evaluations through
    the Ontario Clinical Oncology Group on the advice
    of a newly appointed PET Steering Committee to
    advise MOHLTC on uptake and diffusion of PET.
  • Currently 3 RCTs, 2 observational trials and 4
    registry studies for additional 4 cancer
    indications

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Provincial PET Steering Committee
MOHLTC
5 Trial Steering Committees
Clinical Centres Investigators
External Safety Efficacy Monitoring Committee
FDG Suppliers
PET Quality Assurance Subcommittee
Health Canada
PET Scan Readers Subcommittee
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Example 2. Drug Eluting Stent (DES)
  • MAS HTPA in 2002 confirmed potential diffusion
    pressure and effectiveness of DES for low risk
    patients
  • Initial RCTs reported restenosis rates fell from
    23 to lt5 for lower risk patients (Arteries with
    shorter and wider stenosis and without diabetes)
    -anticipated spread to include all patients
  • DES costs 1,200 more than the bare metal stent
    with projected incremental cost gt 10 million and
    rising
  • Policy required to handle diffusion of this
    promising technology
  • Funding for D
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