Flawed planning at root of new hospital’s problems

by George Le Masurier | Jan 17, 2018

Already overcapacity, Comox Valley Hospital planners overlooked whole departments and made assumptions on capacity and the new iHealth software that have worsened the bed shortage and added to worker stress, overtime and low morale.

This is the second in a series of articles about problems surfacing at the new Comox Valley Hospital. Future articles will look at how the change in culture and procedures and the lack of residential care beds in the Comox Valley has contributed to these issues.

UPDATE: This article has been updated to correct the original report that the hospital cost $350 million.

When the new Comox Valley Hospital opened in October 2017, patients and the public were welcomed into a bright, spacious and high tech facility.

The $331.7 million CVH is 2.82 times larger than St. Joseph’s General Hospital, and took nearly a decade to plan and construct.

Comox Valley and Campbell River health care workers devoted thousands of hours to planning the new CVH and the also new Campbell River Hospital.

But just three months and a few weeks into operation at CVH, some compromises and oversights made in the planning process are showing up as operational inefficiencies and contributing to a serious decline in staff morale.

Entire departments were overlooked, and faculty assumptions made on hospital capacity and number of beds caused physicians and other department leaders to write letters of complaint about the planning process to Vancouver Health Authority executives in Victoria.

VIHA responded by hiring a new planning firm, but it was too late to change many decisions already set in stone.

A two-month investigation by Decafnation has found that that these issues and an accumulation of other major and minor issues, rooted in the planning process itself, has frustrated staff who already feel overworked, and has cost taxpayers excessive overtime expenses.

A sampling of design problems

Here’s a snapshot selection of current problems related to hospital design and planning, according to sources from CVH medical and support staffs, including physicians, department leaders and front-line workers.

All sources spoke on conditions of anonymity.

Overcapacity — The new hospital was built with 153 beds for patients, but yonly budgeted for 129 beds. The extra, unbudgeted beds were planned to open over the next eight years as the community grew.

But on the day the it opened, the hospital was already overcapacity.

On Jan. 9, CVH had 166 admitted patients for 129 beds. On Jan. 10, 2018, it had 168, already 39 more patients than opened or available acute care beds.

Because the operating budget for staffing was set during the planning process for a far lower number of patients, overcapacity equates to understaffing, overwork and unexpected overtime costs.

The cause of the problem is obvious: roughly 46 of those acute care beds are occupied by patients requiring an alternate level of care (ALC). These are mostly elderly patients who no longer need acute care, but for whom VIHA doesn’t have available beds in residential care.

This is not a new problem. St. Joseph’s General hospital suffered for years from overcapacity, and a high number of patients in acute care beds who would be more appropriately served in residential care.

During the planning and construction phases, the ALC and overcapacity issues were raised in public meetings. And the CVH design and consulting firms gave assurances that by the time the hospital was built, there would be adequate residential care beds in the Comox Valley.

But last summer VIHA abruptly pulled back its 2016 Request For Proposal for 70 new/replacement residential care beds, and has not reissued it. A new RFP is expected sometime early this year, pushing the timeline for additional residential care beds out two or more years.

The Comox Valley Hospital has an ability to temporarily increase room capacity as necessary, according to Dr. Jeff Beselt, VIHA’s Executive Medical Director for Geography 1, which includes Campbell River, Courtenay, Comox and Mount Waddington/Strathcona.

“When we are experiencing increased patient volumes, we open overflow areas – this is usual practice when Island Health hospitals experience high patient volumes,” Beselt said.

“We encourage everyone who is unsure of whether they need to come to hospital to connect with their primary care provider, go to a walk-in clinic or call HealthLink BC at 811 to speak to a medical professional,” he said. But Beselt added that if anyone thinks they need urgent or emergency care, they should go to the Emergency Department.

“Depending on urgency, there could be a longer wait due to the high patient volumes,” he said.

FURTHER READING: The differences between acute care and residential (or long-term) care

Floor plan vs. staffing — The hospital’s design is so spacious that most people can’t tell the building is overcapacity.

That looks good, but the design requires medical and support staff to walk further every day, and those increased distances make almost every task take longer than it did at St. Joseph’s. As a result, employees have less time in their day to do their jobs.

In other words, the sheer size of the new hospital has unintentionally created its own staffing shortage.

Food service workers, for example, are now walking up to 15 km per day where they walked fewer than five km at St. Joseph’s. It sounds like that should be a benefit, except food service workers are pushing tall carts heavy with food trays, and many of the mostly female food workers are small in stature.

CVH has only installed traffic mirrors at some corridor intersections, so staff cannot see all adjoining hallways. St. Joseph’s had nearly 200 mirrors. At every intersection without mirrors, food workers have to stop their carts, check for oncoming traffic, then get the carts re-started and maneuver around corners.

This has contributed to delays in meal deliveries to patients, and has the potential to cause musculoskeletal injuries for food service workers.

There are yellow sticky notes on CVH walls where additional traffic mirrors are needed. But staff has been told the hospital ran out of money to complete the project.

Other departments have similar issues that apparently weren’t taken into account when staffing levels and budgets were decided.

For example, the new medical imaging department is three times further from the emergency room (ER) than it used to be, so hospital porters are regularly needed to move patients. But the porter staff is slim and their work takes longer because of the longer distances they now travel.

This means medical radiation technologists are often waiting for the next patient, which slows down the system and contributes to longer ER waiting times.

And, in a separate issue, patients are getting lost trying to find the medical imaging department, which also slows down the patient flow. In some cases, say our sources, they are waiting an hour for a x-ray that should have taken 15 minutes.

The spacious floor plan has had other unintended consequences, too.

In the Cancer Care unit, nurses now have more room to work around patients. But the treatment chairs are spaced so far apart from each other that patients can no longer see or talk to each other. The socializing that many patients enjoyed during their long treatments has been unintentionally eliminated.

Pre-risk assessments ignored — Based on experiences in other hospitals and public buildings, Worksafe B.C. and VIHA conducted pre-occupation risk assessments of all CVH departments and identified issues that required mitigation.

But in many cases, our sources say, the required post-occupation risk assessments have not been done, and many corrections identified in the pre-occupation risk assessments have also not been done.

For example, Worksafe B.C. has already flagged CVH for an issue identified in the Intensive Care Unit pre-occupation risk assessment. At St. Joseph’s, the ICU was 400 square feet in one room with a four-bed telemetry ward attached. Staff shared the samespace and were able to easily and safely cover each others breaks, etc.

At CVH, the ICU is 1,200 square feet in four private rooms. The telemetry is essentially it’s own unit. Staff can no longer cover for each other safely, but staffing has remained the same, despite staff suggestions and concerns.

Because they are two separate units, staff suggested they be staffed as such for safe patient care.

Worksafe B.C. asked CVH for its post-occupancy risk assessment (what actions had been taken to address this previously identified risk issue), but CVH hadn’t done one.

Health records overlooked — The new hospital was consciously designed without a room to store its voluminous health records, which are now taking up space meant for other purposes.

The hospital was planned to be a paperless workplace based on the anticipated introduction of the controversial iHealth software, which didn’t exist at the time and has subsequently stalled in Nanaimo due to physician complaints.

Hospital planners decided to solve the problem by storing paper records off-site. Then they changed their minds and had to scramble to accommodate both records and staff in a building with no designated space for either.

Health records are currently stored in what was planned to be a much-anticipated staff workout room. A new building, possibly a portable, will be required to house the records until they are no longer needed, if ever.

Meanwhile, the staff that transcribes health records, does data reconciliation and coding are working out of unopened acute care patient rooms using repurposed, non-ergonomic desks and chairs.

How these and many other issues arose can be traced back to the original planning process.

Flawed planning at the root

Back in 2010, the Comox Strathcona Regional Hospital District Board, comprised of local elected officials, provided VIHA with $3 million to expedite preparation of a business plan for submission to Treasury Board.

The contribution was made on the condition that it would be part of the board’s 40 percent capital contribution to the construction project, according to Charlie Cornfield, of Campbell River, the current CSRHD board chair.

“Treasury always requires a business plan to accompany a project before they will give project approval,” Cornfield said. “We funded the business case. The actual case preparation, hiring etc. was done by VIHA.

“Having said that, we were involved in determining the number of beds, and services provided at each hospital.”

VIHA used the funds to hire a dozen planning consultants, one of whom was a “functional facility programmer,” who had no major new hospital experience.

The functional programmer’s job is described by International Health Consultants as:

“The functional plan of a clinical department, hospital or other healthcare facility establishes the portfolio of services to be offered and the dimensioning of the structures needed to carry out these services.

Therefore, the functional plan forms the basis for any healthcare infrastructure project.”

FURTHER READING: What is a functional facility programmer?

The hospital planning process involved representatives from four main groups:  Campbell River Hospital (a VIHA site), St. Joseph’s, VIHA management and PartnershipsBC’s contractors.

Some of those who attended the meetings to plan and design the new hospital say that VIHA personnel from sites other than CRH were rarely at the table. Most meetings were attended by CRH, St. Joseph’s and the private contractors hired by PartershipsBC, most often the functional programmer.

The initial conceptual drawings of the new hospital that were released in June 2011 contained numerous errors, say our sources: for example, nuclear medicine was missing, the pharmacy at Campbell River was shown as a tiny room, health records storage was not included and radiology was given a wall of windows (the processing and reading of x-rays require minimum light levels).

After the B.C. Treasury Board approved the business plan for both hospitals, which had been kept secret from employees and department leaders, and the Request For Qualifications was issued, it was discovered that entire departments such as the laboratory and pharmacy at CVH had been forgotten. Amendments were issued.

According to people who attended a September 2012 meeting of both hospitals’ department leaders, the planning consultants said the hospital would be designed as if it would never be overcapacity, and that planning for 2025 capacity and growth was sufficient.

Our sources say planners were challenged at the meeting on the short window to reach full capacity of 153 beds for a major publicly-funded facility.

The consultants also said at the September 2012 meeting, according to our sources, that the hospital was being designed as acute care facility only, not as an outpatient clinic.

That design premise ignored an important health care trend to limit overnight stays, and a St. Joseph’s study (related to paid parking issues) that 97 percent of patient and visitor vehicles in its parking lot were there for reasons that did not include an overnight bed; e.g. x-rays, physio, day surgery, endoscopy procedures, etc.

That same month, the first equipment lists for each department were circulated to department leaders and were found to be “unbelievably inaccurate,” according to a source.

When the business plan was finally shared with department leaders in December 2012, more errors came to light. For example, there was no oxygen or suction resuscitation equipment in the treadmill testing room, the laboratory was given a bedpan washer, for which there was no need, but no staff bathroom, and more.

At this point, several St. Joseph’s and Campbell River physicians and department leaders became sufficiently alarmed to send separate letters to VIHA executives expressing strong concerns about what they saw as a flawed planning process.

Shortly after receiving the letters in 2013, VIHA announced that it would conduct a “peer review” of the facilities plan. Shortly after that, VIHA issued a tender for a new facilities programmer.

But the Treasury Board’s approval had locked down the building’s size, number of inpatient beds and the total budget, nearly eliminating any changes to most of the facility’s original plan.

When a new planning firm was appointed, it resigned from the job in less than 24 hours. A third firm was subsequently found to finish the job.

So, in January of 2013, hospital planners learned that due to miscalculations in the original plan, which could not be changed after Treasury’s approval, many departments had to shrink their floorspace to order to make room for the undersized or forgotten departments. And this set off a series of inter-departmental battles for space.

Now what?

Many of the problems at CVH would be diminished, if not eliminated, by moving the roughly 46 ALC patients into residential care beds. But that’s not going to happen anytime soon.

Tim Orr, VIHA’s director of residential services, told Decafnation that a new RFP for residential care beds in the Comox Valley will be reissued sometime early this year.

“Island Health is committed to improving access to community-based facility care for seniors across Vancouver Island,” he said.

Next: How the change in culture and procedures from St. Joseph’s to Comox Valley Hospital has has affected staffing and patient care.