Ontario Health CEO admits system is under ‘tremendous strain’ and talks about 5 challenges rocking hospitals
Back when he was CEO of Lakeridge Health - a busy, five-hospital system in Durham region - Matthew Anderson typically got up at 5 a.m. to start solving the most pressing problems of the day.
Now, as president and CEO of Ontario Health, his days start at 4 a.m.
That extra workday hour is just the smallest indicator of the beleaguered state of the province's health system.
There are very, very tough things to solve," he says. Right now, job one is to solve things in the here and now. But we do that with an eye to ... how we're going to function going forward, to try and break this cycle once and for all."
Anderson sat down with the Star recently for a rare interview about the state of the province's health-care system, which is facing long-running, systemic challenges that have been exacerbated by COVID-19. The results are increasingly coming into the public spotlight.
Across the province, hospitals are seeing record wait times in ERs, patients languishing on surgical wait lists and exhausted staff fleeing in droves, leaving those who remain defeated, burned out and calling for help.
Anderson, a seasoned health system leader, took on his role at Ontario Health on Feb. 1, 2020, eight months after the super agency" was formed to oversee health-care administration in the province. When announcing his hiring, then-health minister Christine Elliott said Anderson will play a key role in driving real improvements that patients will experience first-hand and that (will) help end hallway health care."
Within weeks, Canada found itself facing a pandemic.
Now, two and a half years later, front-line staff and health leaders say the system Anderson was hired to lead is collapsing.
Asked if this is true, Anderson does not concede a collapse. What he says, is that the system is under tremendous strain."
Many of these are chronic challenges and now we need to solve them in a very short time frame," says Anderson.
It's a big shift that we're talking about - quantum to what we've done before. And to some degree, failure is not an option. We've got to get these things done in order to keep everybody safe."
In a wide-ranging interview, Anderson answered questions about a health system reaching a crisis point, and spoke to what Ontario Health - an agency formed to integrate a siloed system - is doing to address critical challenges.
The problem in ERs
The third pandemic summer has hit hospital emergency departments hard.
There are record-long waits, with reports of ill and injured patients waiting days in ERs for a hospital bed. In May, the average wait for a patient admitted to hospital was 20 hours. That has increased from about 14 hours back in 2012.
Ongoing staffing shortages alongside an increase in staff absences due to COVID have led to some emergency departments in July to scale back operations or temporarily close, including an ER in Perth, southwest of Ottawa, that was shut down for almost three weeks.
Patients, too, are coming in sicker because of delayed care during the pandemic, meaning they need more time to be evaluated and treated.
There's less space, it takes more time, and there are fewer staff trying to do what they were doing before," Anderson says.
As well, since May, ER patient volumes are almost back up to pre-pandemic levels, he says. They are hovering at about 500,000 people a month, after numbers dropped in 2020 and 2021, according to data from Ontario Health.
Even before the pandemic, it was a challenge to adequately staff some emergency departments, particularly during overnight shifts in smaller hospitals, Anderson says, noting Ontario Health has a division whose main job has been historically working with hospitals to staff ERs" with physicians.
This year, the number of shifts that can't be filled by a staff physician is far higher than in previous years, he says. And there are fewer doctors willing to take on additional shifts. This has led, he says, to a situation where our supply has gone down as our demand has gone up considerably."
But the current most critical challenge is a shortage of nurses, something hospitals typically manage on their own. This July is the first time the province has tracked impacted ERs due to nursing shortages.
There has been one unplanned ER closure since 2006 due to a lack of doctors, according to Ontario Health. So far in July alone, according to data from the agency, released exclusively to the Star, 10 emergency departments have had to temporarily close because of a shortage of nurses.
A further concern with crowded emergency departments is that they reveal pressure points in other places in the system, such as home-care supports for elderly residents, Anderson says.
Whatever is going wrong in the health-care system, it's going to manifest itself in the ER ultimately. We watch that intake to give us information on where we might be having problems somewhere else in the system, to shore something up there."
Staffing challenges
From the emergency department to the ICU, hospitals have struggled to maintain sufficient staffing levels to keep patients safe. And Omicron has made this worse.
Staffing metrics are hugely important; we look at that weekly," Anderson says. Though they're also a stress on the system, Ontario Health does not track staffing vacancies in hospitals.
In the short term, Anderson says a priority is to prevent more staff from leaving hospitals and he acknowledges those who remain - from doctors and nurses to guards and cleaners - are tired and burned out from pandemic care.
Ontario Health is also working with other agencies and ministries to get more people into the system" quickly and safely, he says.
It takes a number of years to train a nurse and a number of years to train a physician, so what are the things we can do immediately?"
For example, the agency is meeting with the College of Nurses of Ontario to see how they can fast-track internationally trained nurses to have a really solid pipeline of people coming into the system."
Anderson also pointed to personal support workers as another means to shore up the health-care workforce, noting about 50 per cent of PSWs who get certified don't end up working in the profession.
How do we start to bring them back into the health-care system? We're having those conversations now."
Additionally, the province is working with health system partners, from paramedics to community pharmacists to physical therapists, to ensure professions can work to their full scope of practice," Anderson says.
We want to make sure we don't have a registered nurse doing things that a PSW could be doing. We want to make sure we're taking full advantage of their skills."
Patients awaiting discharge
Hospitals are reporting a high number of alternate level of care" or ALC patients this summer, preventing the flow of patients through the hospital.
ALC patients are those who no longer need acute-care beds but who are waiting to be placed in long-term care or can't be safely discharged home due to a lack of home-care services in the community.
A bottleneck of ALC patients can trigger a backup of patients needing to be admitted from the emergency department, leading to hallway medicine. Fixing overcrowded hospitals was a key commitment that helped Doug Ford get elected in 2018; the premier promised in 2019 that hallway health care" would end within a year.
Anderson says the number of ALC patients in hospitals has been growing almost unabated for 20 years."
It became even more of a challenge after the province closed ward rooms in long-term care early in the pandemic to help prevent COVID spreading among residents, taking about 4,000 beds out of the system, he says.
Currently, there are about 4,800 ALC patients. That's among the highest monthly totals the province has had, says Anderson.
That's 4,800 people in hospital beds that need to be somewhere else in the health-care system," he says, noting many of these patients would prefer to be in long-term care or at home with their families.
Staffing challenges in long-term care and home care have in recent months meant hospitals are discharging fewer ALC patients.
Anderson says Ontario Health, ministries and other agencies are working on two broad strategies: daily meetings among regional care providers to figure out how to safely move more individual patients, and finding ways to create more system capacity.
In some regions, Ontario Health is working with retirement homes to have them accept ALC patients who would be supported by either nurses or home-care workers, he says.
These are the things underway now to try to alleviate some of this pressure; it's a big job - 4,800 people. These are big numbers to move on to try to release some of the pressure in the system."
Surgical wait lists
Ontario hospitals are struggling to catch up on a massive backlog of scheduled surgeries, with thousands of patients waiting beyond recommended clinical benchmarks.
Wait times for elective procedures, including for joint replacements and cataract surgeries, surged during the pandemic following three provincially mandated surgical shutdowns to free up staff and space during COVID peaks. Emergency surgeries and urgent surgeries, including those for cancer and heart conditions, continued throughout the pandemic.
Currently, about 212,000 people are waiting for a scheduled surgery, up from 198,000 before the pandemic hit in January 2019, according to data provided by Ontario Health.
Anderson says the province's immediate focus is on long waiters" - people waiting for scheduled surgeries beyond what is clinically responsible."
Across Ontario, 110,000 people are considered long waiters." That compares to 40,000 long waiters" in January 2019, according to Ontario Health data. The agency stated that most waiting beyond clinical targets are those scheduled for joint replacements, cataracts and gynecological procedures.
With all the other pressures facing hospitals, Anderson says it's been difficult to make inroads on the surgical backlog. We're basically holding it in check at the moment."
And though it's been five months since Ontario lifted the directive to pause elective surgeries during the winter Omicron wave, Anderson says many hospitals have not gotten back to pre-pandemic surgical volumes.
He adds that scaling back or shutting down elective procedures will be a last-resort measure during any future COVID patient surges.
A secondary - but equally pressing - concern is that wait lists aren't as big as they should be due to the pandemic rollback of screening and prevention programs, Anderson says, noting the province is slowly ramping up those services.
That's the group we worry the most about because they are not receiving care. They're not on a wait list and being managed in the system."
Pandemic pressures
Before COVID, hospitals could expect one surge of patients every year during the winter flu season.
It would last about eight to 10 weeks, and it would generally start in December and generally be over in February or the beginning of March," Anderson says. This surge would be about 10 weeks and the system would have the rest of the year to recover and operate normally."
There have now been seven COVID-fuelled patient surges in the last two and a half years, with hospitals bracing for another wave predicted for the fall. Anderson says each of these waves has had the same impact on the health system as the pre-pandemic single winter surge - and sometimes greater.
Instead of having nine to 10 months to recover, we're getting two or maybe three months in between these waves. That's not a lot of breaks for our teams, for our health-care providers."
The relentlessness of COVID waves is an ongoing, outside pressure that hospitals must plan for long term while also coping day to day. Seven waves in, Anderson says hospitals have become a more intense working environment with fewer staff to keep them running.
Looking ahead to the fall, top priorities for leaders across the system will be to find ways to shore up staff and to safely discharge more ALC patients to prevent bottlenecks in hospitals, with an eye on preserving scheduled surgeries, he says.
We're in a very different place now this wave. There are many stresses and challenges on the people who work in the system."
Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvie