EXTERNAL REVIEW OF THE COLON CANCER SCREENING CENTRE Full Report

INTRODUCTION In May 2013, Alberta Health Services (AHS) contracted with the reviewers to conduct a review of the Colon Cancer Screening Centre (CCSC) in Calgary to determine whether or not improper preferential access had occurred and if so, what contributing factors existed. To accomplish the task, the reviewers interviewed staff, supervisors, and physicians who worked in the CCSC, reviewed e-mails, and examined patient referrals and charts. The CCSC began with new equipment, good space and a strong commitment to quality improvement and research. Most patients were positive about their experience at the clinic as evidenced in the two patient satisfaction surveys. The scope of this external review was limited to investigation and recommendations in the following areas: 1) A review of preferential access at CCSC, including whether or not improper preferential access occurred, whether it was still occurring, and the root causes; 2) An examination of the informal review which took place in the spring of 2012, including whether or not the review was appropriate, whether a suitable review process was followed, and whether or not the investigation was as thorough and formal as could have reasonably been expected; 3) An assessment of the clinic work environment and culture; 4) An overview and assessment of the clinic triage, booking and wait listing procedures. BACKGROUND In 2003, the Calgary Health Region identified a need for additional capacity for colon cancer screening. An Expression of Interest was issued and then a Request for Proposal. The successful submission came from the University of Calgary, Faculty of Medicine together with the Division of Gastroenterology. In 2008, the Forzani and MacPhail Colon Cancer Screening Centre opened within the organizational structure of the University of Calgary. The purpose of the clinic was to provide a program where patients could receive routine colon cancer screening outside of an acute care setting. By providing this program, it was anticipated that additional resources would then be available to care for those patients who had symptoms or were in need of more acute intervention. According to the document, Governance Model of the Colon Cancer Screening Centre1, the CCSC was to report to the Deans Office and the Division Head of the Department of Gastroenterology. The CCSC Operations Manager and the Director of Research reported to the CCSC Medical Director.

Faculty of Medicine, University of Calgary; power point slides; Governance Model: Colon Cancer Screening Centre and Governance & Management Oversight

CCSC opened as a non-hospital facility accredited by the College of Physicians and Surgeons of Alberta. Policies and procedures were developed by the CCSC Manager, the Director of Research and the Medical Director. According to the CCSC Director of Research in the internal report Factors Affecting Wait Times in the Colon Cancer Screening Centre2, CCSC opened in 2008 with roughly 17,000 referrals that had been received from the FMC over the previous 4 5 years. These referrals were reviewed by the CCSC staff to ensure that they met CCSC criteria. They were then assigned a triage category according to the risk of colorectal cancer. These triage categories are: (1) average, (2) moderate, (3) urgent, and (4) urgent priority. Many of these referrals were 3 5 years old and the demographic information was not always accurate. This created significant challenges for the staff as they tried to contact and schedule patients, resulting in an inability to fill the procedure slots. In addition to this group of referrals, CCSC received 100 150 referrals daily. These came from physicians offices and went through the same screening and assignment of risk as previously described. At the time CCSC opened, it was estimated that approximately 30% of the acute endoscopy unit utilization was related to screening. With the opening of the CCSC, those diagnostic slots were transferred to CCSC to create additional capacity in the acute units. CCSC planned to have one centralized waitlist, using standardized criteria for booking and triaging. However, the reduction in screening slots at the acute centres created some issues for the CCSC physicians in managing their own waitlists so the clinic allowed them to directly refer and book their patients at CCSC. This adaptation resulted in these patients bypassing the CCSC triaging, wait-listing and booking process. The original vision was for the CCSC to operate with an electronic medical record system (EMIS) and to be entirely paperless. However, given the high volume of referrals and the lack of supporting clerical and IT resources, this was not achievable, and the clinic staff reverted to a manual system. This manual system was more time consuming and required additional space and clerical resources. There was not adequate space for the charts that had to be created (given that space had been designed around the assumption of a paperless system), and while there were appropriate resources to perform procedures, there were not enough clerical staff to contact the patients to book the appointments for the procedures. With the transfer of governance to AHS in 2009, additional issues arose, such as human resource concerns with staff transferring between organizations, as well as accountability for lease and equipment, and the concerns with Information Technology (IT) continued. At that time, AHS had imposed a hiring freeze on all departments so the centre was unable to hire additional clerical staff to accommodate their manual record system. In addition, the reporting structures changed such that the Manager and the Medical Director reported into the AHS Calgary Zone organizational structure. In 2011, the decision was made that CCSC would report into the structure at the Foothills Medical Centre (FMC). In the interim, the Medical Director consulted regularly with the original Director of CCSC as evidenced by statements made in minutes of meetings and e-mail correspondence (January 24, 2011, March 17, 2011)3.

Dr. R. Hilsden, Factors Affecting Wait Times at the Colon Cancer Screening Centre: CCSC Internal Report; May 2013 3 E-mail correspondence between A. Rostom and R. Bridges; 2011/03/17; Minutes of CCSC Operations Meeting; 2011/01/24

Due to the number of transitions faced by the CCSC, the original policies and procedures were modified and adapted to the current environment. For example: in the beginning the assignment of patients to triage categories was not standardized as different Registered Nurses were reviewing the referrals. Once this process was assigned to just one or two individuals, the consistency of triage assignment improved. Insufficient clerical resources resulted in decisions to change the booking process to ensure that treatment slots were filled. Unfortunately, the reviewers could not find evidence that these changes were consistently documented or communicated to the staff responsible for implementing the new processes. PREFERENTIAL ACCESS Preferential access is a complex concept requiring an understanding of the context in which it occurs. The reviewers have utilized the definition of preferential access as it is outlined in the Health Services Preferential Access Inquiry Report. In that document, Justice Vertes writes that preferential access implies an advantage, a priority over that which would be regarded as normal access that meets accepted clinical and organizational norms4. He goes on to say: what makes it preferential is that the differentiation is between similarly-situated individuals and based on something other than medical necessity. He states: In my opinion, improper preferential access is any policy, decision or action that cannot be medically or ethically justified, resulting in someone obtaining access in priority to others similarly situated5. In reviewing the information from the CCSC, the reviewers have utilized the above definitions and have concluded that improper preferential access occurred. There were also other circumstances that the reviewers learned of which were incidents of expedited access which may not have been medically indicated but were considered necessary from an operational perspective. The clinic had defined a process for triage, booking and wait-listing6. Referrals were to be faxed to the CCSC. The referrals were then reviewed by a triage clerk to ensure that the referral met the CCSC criteria. Those referrals that were average risk were sent to data entry clerks to be entered into the system. These referrals were then pulled by booking clerks in order of the referral date. For these patients it meant a wait of roughly 2 3 years. For patients who had a risk factor such as family history of colon cancer or a positive Fecal Occult Blood Test, their referrals were screened by a Registered Nurse and classified as Urgent Priority, Urgent or Moderate with Urgent Priority being booked before Urgent and Urgent before Moderate. All patients were booked for a pre-screening appointment where they received information about the procedure and the required preparation. They were also screened for any criteria that would place them at risk for the procedure. The pre-screening appointment could take place in person at the CCSC or over the phone. From 2008 2011, preferential access occurred because many of the 17,000 referrals received when the clinic opened contained inaccurate demographic information. The clerks at CCSC spent a great deal of time trying to contact these patients to book appointments. The high volume of referrals and the lack of
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Health Services Preferential Access Inquiry Alberta , The Hon. John Z. Vertes, Commissioner , Volume 1: Inquiry Report, August 2013, p.91 https://healthaccessinquiry.com/assets/pdf/final-report/v2/CompleteReport.pdf 5 Ibid, p.130 6 AHS CCSC Flow Chart for Referrals to CCSC; CCSC Departmental Procedure; Referral, Triage and Pre-assessment; October 2007.

clerical resources, combined with the inaccurate demographic information on the older referrals from FMC, resulted in booking clerks using the most recent referrals to fill the treatment slots as the demographic information on these recent referrals were generally accurate. This process resulted in some patients receiving a procedure sooner than other patients of similar risk. Although the reviewers found it difficult to understand why there were challenges filling treatment slots when there were 17,000 referrals to draw from, they accept the explanation that this process was necessary from an operational perspective in order to fill the treatment slots. For this reason, the process could be seen as ethically justified, and preferential access in this particular context is not deemed to be improper. Failure to fill the treatment slots would have resulted in even longer wait times. The CCSC was designed to have a centralized waitlist with standardized criteria that would be used to designate patient priority. It was anticipated that by opening the CCSC there would be significant increased capacity that would be created in the acute sites. In order to assist the Endoscopists in the management of waitlists and to encourage them to utilize the CCSC, it was decided that the physicians booking slate (schedule of patients booked for each day) could be made up of 50% of the patients from the physicians private office and 50% from the CCSC centralized waitlist. The patients from the physicians office were often referred to as private patients. These patients did not have a CCSC prescreening appointment as long as they met the CCSC criteria7. It is important to note that this procedure was contrary to a 2009 CCSC policy which stated: an Endoscopist can refer their private patients to the centre. However, these patients will be triaged and prioritized along with the rest of the referred patients8. The minutes of a CCSC Executive Meeting in June of 2008 document this decision to deviate from standard CCSC Procedure. This practice continued until 2010 when CCSC management determined that it was administratively confusing to be maintaining a CCSC list and a list of private patients. It was also felt that the staffing and processes were sufficiently robust that CCSC could move to having a consolidated waitlist and standardized referral process. Therefore the decision was made to discontinue the practice of combining the private patients with the CCSC waitlisted patients. However, the reviewers were unable to find any memo or formal communication documenting the change, and those interviewed were not certain how this decision was communicated. Although this process resulted in some patients receiving faster access to a procedure where it may not have been medically necessary and could be considered improper preferential access, the reviewers accept that this was done to streamline operations. The data shows that improper preferential access occurred after 2010. The clerk, who was responsible for booking Helios Wellness Centre patients and private patients of a senior physician, reported to the reviewers that they did not change their practice and continued to directly book these patients until early 2011 when they transferred to a different department. E-mailed referrals from the senior physician to a CCSC clerk resulted in those patients being directly booked9. Referrals from Helios to the physician also resulted in those patients accessing a procedure sooner than the general CCSC population. Those e-mails occurred in 2011 through until the spring of 2012 when they appear to have stopped. The physician denied that it was their intent to expedite these referrals. However, these patients did receive their procedure in less time than other patients with the same risk stratification. Despite the lack of clarity around events that attempted to address this issue, these referrals for the

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Minutes of CCSC Executive Meeting, June 2008 CCSC Departmental Policy Endoscopist Responsibilities at the Centre, August, 2009; p.2 9 E-mails from Dr. R. Bridges to Olga Koch: Dec. 16, 2011; January 4, 2011; January 18, 2012.

private patients were seen as improper preferential access because they could not be medically or ethically justified. Improper preferential access occurred when patients from the Helios Wellness Centre (Helios) were referred to CCSC. Information about Helios came from interviews with AHS staff and from a review of emails and patient records. Helios is a private medical clinic where members pay an annual fee to receive both insured and uninsured services. It is located, along with the CCSC, in the Teaching Research Wellness Building at Foothills Medical Centre. CCSC clerks noted during interviews that staff members from Helios would bring referrals to the front desk at CCSC. These referrals would be booked without going through the CCSC triage process. The clerks were under the impression that Helios patients were to be given expedited access and had to be booked with one specific physician. They designated the patients as Helios in their documentation to ensure that if the patients needed to be re-booked, it would be readily apparent that they needed to be booked with the senior physician and that their access should be expedited. In reality, a number of physicians performed procedures for the Helios patients. In reviewing the referrals and charts of Helios patients, it is clear they received expedited access in comparison to others with similar risk stratification. It is difficult to know the exact number of Helios patients that were seen at CCSC. The CCSC Research Director identified a total of 78 patients in the report Factors Affecting Wait Times at the Colon Cancer Screening Centre May 2013. However, the reviewers identified a total of 62 referrals from January 2011 to March 2012 so the actual number is likely higher than 78. Patients participating in research trials received expedited access to care. The Research Director reported that they would review the Access database and would offer patients who had been waiting a long period of time the opportunity to participate in research trials. These patients received faster access to a procedure. The Research Director reported that this process had been cleared through the Conjoint Health Research Ethics Board therefore it was not considered to be improper preferential access. In June of 2009, the current CEO of AHS circulated a memo to the senior management group defining improper preferential access as Care that is rendered more quickly than medically indicated or required, rendered more quickly than the current norm of the organization, or a higher quality and/or is more extensive/thorough than the currently provided norm of the organization and offered at a lower cost than is the current norm (i.e. for services or equipment that are non-insured or must be purchased by the patient) 10. The memo went on to say that Alberta Health Services treats all clients and citizens with the same high degree of respect regardless of societal status, occupation, personal relations, income, ethnicity or gender and that preferential or expedited care is not endorsed or encouraged by Alberta Health Services of any of its representatives, staff or physicians. The memo also indicated that any requests for preferential or expedited care were to be directed to the President and CEO of AHS. Some clerks felt that the expedited process occurring at CCSC was inappropriate. However, with one exception, they admitted that they did not ask any questions about it. The reviewers were unable to substantiate the occurrence where one clerk reported asking questions about preferential access in a staff meeting and the question was ignored. There did not appear to be any minutes kept of the meeting, and those who might have been present denied any recollection of the issue being discussed. The other clerks voiced their belief during interviews that the practice must have been known by the

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Dr. D Megran; Requests for Preferential or Expedited Care; Submission for the CEO Report to the Board; May 2009

physicians and the managers of the clinic and if they were not doing anything about it then it must be OK. Others did not see any significance in these expedited bookings. They indicated that they were merely fulfilling their job requirements without questioning existing processes. During interviews, the managers, senior clerks and senior nurses denied any knowledge of improper preferential access. However, there is some evidence that some must have known about this process. Two clerks alleged that the Manager told them that if it was a Helios patient then the person was to be booked right away. One clerk indicated that the Manager would follow up to ensure that the Helios patients were booked in a timely fashion and checked the daily slate to ensure that was occurring11. However, the Manager denied that this was the case. There was also a list of duties for the clerks who worked on the front desk which included the responsibility to book Helios patients12. However, when questioned, the Manager denied that the list would have come from any of the supervisory personnel at CCSC given that it did not have the proper CCSC format. Other clerks have no memory of being told to expedite the booking for these patients in fact, one specifically denied being told by management to book the patients preferentially. In an e-mail exchange in February 2011, the Manager of the Helios Wellness Centre asked for the current CCSC wait time. The Manager of the CCSC responded that that it was 2 years and that is why she is suggesting that Helios refer the patients directly to the senior physician13. If the practice of booking private patients directly to CCSC had stopped, it is unclear why she would have made that statement to the Helios manager. When questioned, the Manager denied any recollection of the context of the memo and said she could not remember why she would have made that statement. An examination of referrals from Helios showed some referrals where the patient is listed as average risk. On the Access database, those same patients show up as Urgent14. In only two situations did the examination of the chart demonstrate that there might be a medical reason for the change in status. This practice of changing the risk from average to urgent priority would indicate that there was a systematic change in risk stratification that was not based on medical criteria. That change would enable the patient to be seen in a shorter period of time. However, as these instances occurred prior to the implementation of the Millenium Scheduler, the reviewers were told it was not possible to discover how this occurred or who was involved. From January of 2011 to March of 2012, there were 18 e-mails from the Helios Manager to the senior physician, copied to the CCSC Manager15. Each e-mail had between 2 to 4 referrals attached and the subject line of the e-mails indicated that the topic was CCSC referrals. When the dates of these referrals were matched to the date of the procedure for these patients, the timelines were much shorter than for non-Helios patients of similar risk stratification. When asked, the Manager denied reading these e-mails. They stated that the e-mails were sent to the senior physician and she was only copied. The Manager said she would not open e-mails directed to the senior physician.

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Copy of CCSC procedure slate for September 28, 2009 List of Reception Responsibilities, January 7, 2009 13 E-mails between Darlene Pontifex and Leah Tschritter; February 14,2011 and February 15, 2011 14 CCSC Access Database matched with referrals 15 E-mails from Leah Tschritter to Dr. R. Bridges with cc to Darlene Pontifex; Jan.17,2011; Feb. 3, 2011; Feb. 24, 2011; Mar.7, 2011; Apr.6,2011; Apr.14,2011; May 10,2011; June 1,2011; July 7,2011; Aug.18,2011; Sept.6,2011; Oct. 3,2011; Nov.27,2011; Dec.22,2011; Jan.16,2012; Feb.3, 2012; Feb.26, 2012; Mar.23,2012.

In January of 2011, the CCSC Manager responded to an e-mail from the Helios Manager asking about the booking of patients referred in early January. The CCSC Manager replied that they are booked for their procedure at the beginning of February16. In April of 2011, The CCSC Manager responded to an e-mail from Helios confirming that average risk patients who had been referred in early April, were booked by mid April17. The Manager was aware that the average wait time for these appointments was closer to 2 years since that had been indicated in an earlier e-mail to Helios. When questioned, the Manager replied that they would not have known that these were average risk patients as they only checked their date of referral and date of booking when responding to the Helios queries. Given the numerous examples where the Manager, was copied on e-mailed referrals which were at variance with CCSC policy and where she was asked by the Manager of the Helios clinic to verify procedure dates, the reviewers find it difficult to understand how she could not know that improper preferential access was occurring at CCSC. One of the physicians working at the clinic told the reviewers that she raised the issue of improper preferential access in a meeting where the Medical Director of the CCSC was present, and she received no response. The Medical Director denied that he received any such questions. It was difficult to substantiate this claim as none of the other meeting participants recalled such an event. The physician also indicated that she did receive a list of clerical duties from the Manager18. Included on that list is the task of booking Helios patients. It is unclear why this task would be differentiated from other bookings, unless they followed a different process. The Executive Director of Medicine at FMC described to the reviewers that she raised the issue of preferential access with the Medical Director in 2011. The Medical Director indicated he did not recall that conversation. She raised the issue again in March of 2012 and this time the Medical Director, although assuring the Executive Director of Medicine, FMC that the matter had been resolved, sent a memo to all physicians who worked at CCSC describing the policy of the centre around preferential access. A recent audit done in the spring of 2013 by the Executive Director of Medicine, FMC, showed that no patient accessed a procedure sooner than would be anticipated given their assigned risk. RECOMMENDATIONS Preferential Access 1. In order to ensure that improper preferential access is not occurring in public waitlists, random audits should be conducted to ensure that practice is consistent with AHS Policy. 2. All managers, physicians and administrators should understand the policies and procedures of AHS. Additional support should be provided to both physician and administrative leaders who are new in their role. This could be achieved through a formal, required orientation and mentoring process. AHS INTERNAL REVIEW OF 2012 In March 2012, the Executive Director of Medicine at FMC approached the CCSC Medical Director with a concern that improper preferential access was occurring in the CCSC, in particular with regard to one

16 17

E-mails between Leah Tschritter and Darlene Pontifex; Jan.4, 2011 January 5, 2011. E-mails between Leah Tschritter and Darlene Pontifex; Apr.12, 2011 Apr.13,2011. 18 AHS/CCSC Reception Responsibilities; January 7, 2010

physician. The Medical Director denied that improper preferential access was occurring; however he subsequently released a memo to the appropriate CCSC physicians and staff outlining the CCSC policy regarding access19. He did not complete an investigation to ascertain the validity of the concerns. The memo from the Medical Director was the first communication to the Senior Vice President and Zone Medical Director, Calgary Zone, indicating that improper preferential access could be an issue in the clinic. As a result, he contacted a number of physician leaders within the Calgary Zone, and he had brief communication with the administrative leads for the program. His investigation seemed to be focused on whether a particular physician had facilitated improper preferential access rather than whether or not there was a broader issue within CCSC. The Senior Vice President and Zone Medical Director, Calgary Zone described the investigation as an informal assessment, rather than a review in order to gauge whether or not there was substance to the concern. He was reassured by the Medical Director that there had been issues in the past, but that they had been dealt with and preferential access was no longer occurring. The Senior Vice President and Zone Medical Director, Calgary Zone consulted with AHS Executives, and they decided that there was insufficient evidence to proceed to a more formal inquiry. The reviewers believe that additional investigation was warranted due to the serious and complex nature of the allegation, with a potential direct impact on patient care. Also, given that the Premier had announced in February of 2012 that a provincial review on preferential access was to occur and that Justice Vertes had been appointed in early March to lead the review, it would seem that this issue should have been addressed in a more systematic and rigorous fashion. The roles of senior leaders in health care organizations are complex with wide spans of control and multiple issues to manage at any one point in time. AHS has a multidisciplinary Investigation Coordination Team that could have been used to review the concerns that were raised in this complaint. In speaking with administrative leaders of CCSC, none of them were aware that an assessment had taken place. Given that AHS has an organizational structure that consists of a dyad leadership team (a medical and administrative leader working together with joint accountabilities), both dyad partners should have been made aware and involved in this internal review. RECOMMENDATIONS AHS INTERNAL REVIEW 1) AHS has implemented a dyad leadership model (a medical and an administrative leader working in tandem with joint accountabilities). Therefore, when a complaint of this nature occurs both dyad partners should be involved in the investigation. One of the dyad partners should be identified as lead and both should be engaged in regular updates as the investigation proceeds. 2) The involvement of AHSs multi-disciplinary Investigation Coordination Team (ICT) should be considered for serious, high risk, or complex allegations.

ASSESSMENT OF THE CLINIC ENVIRONMENT AND CULTURE CCSC is located in excellent physical space however, given the increased volume over the past five years, many areas such as the clerical areas and storage areas are becoming crowded. The hours of operation

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E-mail from Alaa Rostom to several CCSC physicians and administrators; Concerns over endoscopy Queue Jumping CCSC policy on the subject; 2012/03/19.

are extended days, Monday to Friday. Most staff members interviewed enjoyed the team with whom they worked and appreciated the team building and education events. Staff surveys conducted in 2011 and 2013 indicated a high degree of satisfaction although the results for 2013 were a bit lower than in 2011, perhaps as a result of the stress of the Provincial Inquiry20. In spite of the positive reviews in the staff satisfaction surveys, the lack of clear communication within the team was raised as an issue. This was also reflected in the interviews held with staff, especially with the clerical staff. In the early days, staff meetings were not consistently held and minutes were not always taken and posted. It was not clear how decisions were communicated to the clerical staff. Registered Nursing staff reported more consistent and formal staff meetings and direction. CCSC seemed somewhat disconnected from AHS both administratively and clinically. The Clinic Manager seldom attended leadership meetings at the Foothills Medical Centre and the physician reporting structure, particularly following the integration of the CCSC into AHS, was not clear. Originally when CCSC was governed by the University of Calgary, the organization structure contemplated the involvement of the Department of Gastroenterology. However, as the centre moved to AHS and continued its operation, the reviewers were told that decisions were made which had a negative impact on the FMC acute units as senior staff moved from acute units to the CCSC. The impact of these changes did not seem to be discussed nor did there appear to be a mitigation plan. Some of the staff interviewed had high regard for the managers of the clinic. They spoke positively of the open door policy of both the Medical Director and Manager. They felt comfortable approaching the physicians if they had questions. Others were less positive, indicating that it was not a culture where they could question what was being done or where they could raise controversial issues. Certainly there were clerical staff who did not feel they could approach management with their concerns regarding the improper preferential access that was occurring. Those who had concerns about improper preferential access at CCSC seemed unaware of the Safe Disclosure/Whistleblower policy that AHS adopted in January of 2009. This policy provides a vehicle for AHS personnel to safely disclose improper activity occurring within AHS. It also provides protection from retaliatory action for anyone who in good faith discloses improper activity. This was the first leadership position in Calgary for the Medical Director and the first management position for the Manager. CCSC was first organized under the University of Calgary, and it is not known what kind of orientation or support they received in the beginning. The Manager confirmed that she received no formal orientation to her role. In her previous clinical positions, she described that she had received exposure to management tasks such as monitoring budgets, conducting disciplinary processes, and staffing but these were on the job training activities as opposed to a structured education process. She also admitted that she had not taken any formal management courses. In the transfer to AHS, it may have been assumed that both these managers had experience in their role as the clinic had been in operation for a year prior to the transfer. The Manager was an experienced clinician within the area of gastroenterology, but this was her first management role, and there were significant operational challenges within the clinic in the first few years of operation. The Medical Director of CCSC was very involved in the daily operations of the unit. He participated in hiring decisions, budget discussions, equipment discussions, and IT decisions. Although this is commonly part of the role of the Medical
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CCSC Staff Workplace Satisfaction Survey August 2011; Staff Workplace Satisfaction Survey June 2013

Director, the degree to which he was involved is unusual in the opinion of the reviewers and makes it difficult to understand why he would not have known about the preferential access that was occurring. The original reporting structure that was set up by the University of Calgary had the Manager and Research Director reporting to the Medical Director21. This reporting relationship seemed to continue even after the transfer to AHS. The partnership of the dyad structure, that is the organization strategy for AHS, did not seem to be present. The first Director of the CCSC was instrumental in the design and implementation of the CCSC. He was also instrumental in recruiting donors to assist with fundraising for the equipment. He was active in the selection of the first leadership team. Even after the role of Medical Director was transferred to another physician, he seemed to continue to play a role in the clinic as was evidenced in e-mails and minutes of meetings. Staff reported to us that this physician was viewed by them to be a very powerful and with significant influence. The clerk to whom the physician sent his referrals, indicated that she would not question when he asked her to do something. The Manager indicated that she would not open this physicians e-mails, even though they were copied to her. She indicated that she would not have challenged him, even though he was not following the CCSC procedure for booking patients because he was such an influential physician. The Medical Director actively consulted with this physician on many issues. Both physicians have acknowledged that he had a mentoring role with the Medical Director; however his involvement seemed to go beyond that of a mentor. The physician was copied on many of the e-mails that were related to operational issues. For example: the Medical Director consulted with the physician regarding the discipline of another physician22. In the minutes of CCSC operations committee dated January 24, 2011 it is recorded that the Medical Director will be talking with (the physician) around reporting and other issues and will be asking (the physician) if he wants to be part of the operational meetings23. In an e-mail dated 2011/04/12, the Medical Director wrote to the physician saying I generally seek your advice on such issues and didnt do it this time24. This was in response to an e-mail the physician had sent where he strongly disagreed with the decision to book different procedures into CCSC. The physician had indicated to the reviewers that he was not involved operationally with CCSC however the minutes of meetings and e-mail documentation would lead the reviewers to conclude otherwise. There were many positive things that occurred within the clinic. There was a focus on research and quality improvement that was evident. Staff spoke proudly about the work accomplished. Procedures that were standardized within the CCSC became the protocol for other endoscopy units. The Provincial Inquiry has created a certain amount of stress within CCSC. Some staff did not believe the testimony of some of the witnesses in the Inquiry. They asked why certain staff were chosen as witnesses and others were not. They have questions about their manager who is off on administrative leave. They are sorry that the Medical Director has left the program for another position outside of Alberta. However, others report that they just want to move on. Many staff have been hired in the past one to two years, who do not have the history or context of some of the concerns that were raised in the Provincial Inquiry.

21 22

Colon Cancer Screening Centre: Business Process Descriptions; June 15, 2007. E-mail from Dr. Rostom to Dr. Bridges, Late Endoscopist, 2011/03/17. 23 Minutes of the CCSC Operations Meeting January 24, 2011. 24 E-mail from Alaa Rostom to Ron Bridges. Flex Sigs at CCSC, 2010/12/18.

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RECOMMENDATIONS CLINIC ENVIRONMENT AND CULTURE 1) There should be a review and clear definition of roles, responsibilities and reporting relationships of both the Manager and Medical Director roles. 2) Staff meetings, with all CCSC medical and administrative staff, should be held regularly, and decisions made within those meetings should be consistently documented and shared. 3) The clinic should be administratively aligned with the reporting structures of the Foothills Medical Centre and the Department of Medicine, section of Gastroenterology, Calgary Zone. 4) Any new clinics established within AHS should receive organizational support and closer oversight until processes and procedures are functioning at an acceptable level. 5) AHS supervisors and directors should actively support the development of a just and trusting culture where staff feel safe and comfortable in asking questions and where managers are supportive and enable a transparent environment. 6) The AHS Safe Disclosure/Whistleblower Policy should be reinforced on an ongoing basis. This could be done through the annual performance review process and annually at staff meetings.

TRIAGE AND WAITLIST MANAGEMENT When CCSC first opened, it was envisioned that there would be one centre for screening colonoscopies within the Calgary Zone creating greater capacity within the system. Patients would be triaged and treated according to standard guidelines25. Currently referrals are faxed in by family physicians on standardized referral forms. The clerk in triage collects the referrals and completes a preliminary screen to see if all of the information is included on the referral and if the patient meets the CCSC criteria for screening. If there is any question, the referral is handed to a Registered Nurse who will review the referral and, if necessary, ask for more information or assign a risk category of moderate, urgent or urgent priority depending on the information in the referral. If the referral contains all of the required information and meets the CCSC criteria, then the referral is handed over to a data entry clerk who enters the information in Millenium Scheduler. The referral is then filed and pulled up at the appropriate time, depending on the date of the referral. Currently, average risk patients wait 18 24 months to be seen. Slots are available every day for patients who are classified as a higher priority. The wait for those patients is about 2 weeks. Staff reported that this is the shortest wait time in the history of the CCSC. However, even with the improvements that have been made over the 5 years that the clinic has been operational it is still sometimes difficult to fill the procedure slots. On one of the days that the reviewers were in the clinic, a pre-screening session was booked for 19 patients however only 5 actually showed up. Examples were given during interviews of situations where patients cancelled their appointments numerous times or just did not show up. CCSC staff seem to go out of their way to accommodate these changes and this sometimes results in patients being re-scheduled several times. This adversely affects other patients who have spent a long time waiting for their screening appointment. CCSC may want to explore a system where patients are more active in confirming their appointments within a certain time frame and where failure to attend appointments carries some consequence.

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CCSC Flowchart for Referrals; April 2012; and Dr. Hilsden; Factors Affecting Wait Ti mes at the Colon Cancer Screening Centre: CCSC Internal Report; p. 4

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Pre-screening appointments are scheduled for each patient who is referred to the clinic. These appointments are usually in person but can also be conducted over the phone. The purpose of the prescreening is to provide education about the procedure and the patient preparation that is required. The pre-screening education sessions that are offered at the Centre are generally group sessions. Prescreening also includes interviewing the patient one on one to determine their eligibility for the procedure. This is a fairly labour intensive process and could involve some duplication with the screening that may or could take place in the referring physician office. The idea of a centralized waitlist for procedures like screening colonoscopy should be the standard. Standardized, research based criteria and best practices can then be applied to the assessment of the patient and the appropriate priority assigned. It is currently done in Long Term Care when admitting someone to residential care. Some mental health programs have a central triage and waitlist, and some acute programs also have a central intake, triage and waitlist. This has application in a variety of settings. If admitting and wait listing processes were standardized across programs, the opportunity for error is reduced and the most appropriate patient will be cared for in a consistent, prioritized way. Within CCSC, there are a number of handoffs. Quality improvement literature describes a handoff as an opportunity for an error to occur. Booking staff work in very crowded quarters with four staff members in a small room calling patients to book appointments. The possibility of interruption and the noise of everyone talking on the phone are opportunities for error to occur. Staff share office space, which although not that unusual in health care settings, does create less room for privacy and a less positive work environment. The admitting, booking and wait-listing processes in CCSC could benefit from a LEAN process improvement review. This may identify opportunities to reduce handoffs, increase efficiency and provide more room for staff to work. Included in the review should be an examination of the roles and responsibilities of staff as well as a review of the hours of work and whether staggering the hours of staff provides an opportunity for improvement RECOMMENDATIONS TRIAGE, BOOKING, AND WAITLIST MANAGEMENT 1) An electronic system which incorporates documentation and navigation should be implemented in the clinic operation. 2) Given the number of handoffs in the current system, a LEAN review should be completed to streamline the current processes. 3) Given the space constraints, a review of scheduling for the clerks should be performed to improve the utilization of the existing space. 4) A review of the booking process and criteria for the number of times a patient can miss an appointment without consequence should occur. This could involve investigating whether or not a process where the patient actively confirms appointments results in less no shows. 5) AHS explores the opportunity to implement a centralized intake, triage and wait-listing process across a variety of programs.

SUMMARY AND CONCLUSIONS During the course of this external review it became apparent that improper preferential access had occurred in the CCSC. Initially the expedited access may have occurred due to the age of the referrals and the lack of clerical resources required to book patients. However, even after these issues were 12

remedied, improper preferential access continued until 2012 for patients of a particular physician and for patients who were associated with the Helios Wellness Centre. A brief audit done in the spring of 2013 did not indicate any occurrence of improper preferential access. There are a number of interventions that AHS can undertake to ensure that improper preferential access does not occur in other programs. There are also interventions that can be applied to CCSC to ensure that the centre moves forward in a positive way to continue to care for patients who require colon cancer screening.

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