CDMR

Today I was up in Question Period and I called on the Minister of Health, Terry Lake, to protect Vancouver Island patients by insisting that Island Health release its evidence in support of their new controversial patient care model. I also called on the Minister to initiate an independent review of the model.

Island Health’s controversial new patient care model, titled Care Delivery Model Redesign (CDMR), will be implemented at Victoria General and Royal Jubilee Hospitals on April 23, 2014. Under CDMR Island Health would cut 100 baseline nursing positions and replace them with 95 baseline Health Care Aid positions. Whereas Registered Nurses have a 4-year bachelor’s degree, Health Care Aids have up to 6 months of training.

Here is the question I asked:

On April 23, Island Health will implement a new patient care model—Care Delivery Model Redesign (otherwise known as CDMR) — at Victoria General and Royal Jubilee Hospitals. In their CDMR Fact Sheet, Island Health claims that the model will lead to “improved quality and patient safety”. Island Health claims the model is based on evidence but has yet to make their evidence publicly available. An internal surveys show that 88% of nurses working under CDMR at Nanaimo Regional Hospital would not feel comfortable having a family member cared for on their unit. And last week I held a town forum on CDMR that raised a number of additional concerns.

As a publicly-funded body, Island Health has an obligation to be accountable to British Columbians.

Will the Minister of Health step in to insist that Island Health release its evidence for public scrutiny?

Answer from The Honourable Terry Lake, Minister of Health
(Hansard Blues extract)

Hon. T. Lake: Thank you to the member for Oak Bay–Gordon Head for the question. I had mentioned that I’ve had an opportunity to travel around the province and meet a lot of the people who care for our patients in all kinds of settings. I think members on both sides of the House agree on the tremendous work that nurses and other health care professionals do for British Columbians.

It’s about appropriateness of care — the right care, the right provider, at the right place, right time, with the right resources. This is an effort on behalf of Island Health to ensure that we have those five Rs in place. This patient care model is to wrap services around the patient, which in some cases is appropriate in some situations. Some wards, where there are more personal care duties, are where you can use other professionals to aid the highly-trained nurses, who can then spend more time doing patient care plans.

This was a result of a study done by Island Health. It’s about providing the right care to the right patient at the right time with better outcomes. That is the goal, and that is what I believe will be happening, at the end of the day, with this new model.

Here is my supplemental question:

The research is clear. Increasing the Nurse to Patient ratio beyond 1 to 4—as will happen under CDMR—leads to higher mortality rates and higher morbidity rates. Just last week, a study of more than 400,000 patients in 300 hospitals across Europe published in the prestigious medical journal Lancet found that increasing a nurses’ workload by even 1 patient, increased the mortality rate by 7%.

There’s also substantive research to suggest that increased nursing levels:

• reduce length of hospital stays
• reduce the rate of adverse events;
• reduce nurse turnover rates.

All of these are actually cost savings measures.

This is why jurisdictions like California have responded to the evidence and legislated nurse-staffing ratios. CDMR goes against this research.

Honourable Speaker, The Minister of Health has a responsibility to protect patients.

Will the Minister step in to protect patients by insisting that Island Health release its evidence for public scrutiny and by initiating an independent review of the program?

Answer from The Honourable Terry Lake, Minister of Health
(Hansard Blues extract)

Hon. T. Lake: I mentioned in my first answer that it’s the appropriateness that’s important. We must be led by evidence. The member is quoting from a study in the Lancet that looked at surgical patients, not medical patients, not rehabilitation patients — surgical patients.

In that particular instance it may not be appropriate to move away from the one-to-one type of nursing model that is in place for surgical patients that are being looked after, after a surgery. However, for rehabilitation, the use of health care aides, along with LPNs and led by RNs, is a much more efficient system, allowing nurses to do the job that they are highly trained to do.

That is the appropriate situation, and that is the intent of looking at new and better ways of caring for our patients in the hospital system of British Columbia.

……………….

Last week I held a public Town Hall on CDMR with representatives from the Association of Registered Nurses of BC, the BC Nurses Union, the UVic School of Nursing and the UVic Nursing Students Society. Island Health was invited but unfortunately declined to participate.

As a publicly-funded body, Island Health has an obligation to be accountable to British Columbians. As Minister of Health, Mr. Lake has a responsibility to protect patient safety. There is enough credible research out there to raise serious questions about the controversial patient care model. That is why I have called on the Minister to insist that Island Health release its evidence for public scrutiny and to initiate an independent review of the model.

Sources:

Nurse Staffing and Financial Outcomes http://ww.w.massnurses.org/files/file/Legislation-and-Politics/3_08CE_NurseStaff.pdf

Improving Nurse-to-Patient Staffing Ratios as a Cost-Effective Safety Intervention: http://vwvw.massnurses.org/files/file/Legislation-and-Politics/Cost_Effectiveness_Study.pdf

The Association of Registered Nurse Staffing Levels and Patient Outcomes: http://www.ona.org.3pdns.korax.net/documents/File/pdf/KaneRNStaffingPatientOutcomesMedCare.pdf

State-Mandated Nurse Staffing Levels Alleviate Workloads, Leading to Lower Patient Mortality and Higher Nurse Satisfaction: http://innovations.ahrq.gov/content.aspx?id=3708

Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study: http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673613626318.pdf

 California Nursing Staff Level Regulations: http://www.cdph.ca.gov/services/DPOPP/regs/Documents/R-37-01_Regulation_Text.pdf

Last night I held a public Town Hall on Island Health’s new Patient Care Model. According to Island Health, the new model (titled Care Delivery Model Redesign, or CDMR), will shift from a nurse-centered approach to a team-centered approach that will see an increased role for health care aids. Under the model, Island Health will be cutting 100 baseline nursing positions in 21 units at the Royal Jubilee and Victoria General Hospitals and replacing these positions with 95 new baseline Health Care Aid position.

According to Island Health the model (titled Care Delivery Model Redesign, or CDMR) will address strains on the health care system while increasing the care time a patient receives. However, critics have argued that it could put patients at risk as nurses are replaced with health care aids that are inadequately trained for their new role.

Many constituents wrote me with their concerns about the patient care model. In response, I met with key stakeholders including Island Health, the BC Nurses Union and the College of Registered Nurses of British Columbia.

What became clear is that while Island Health states that the new patient care model is evidence-based, they have yet to release their evidence for public review. Meanwhile, health care research clearly suggests that the new model could have significant implications on the quality of care a patient receives.

The purpose of the town hall was to bring together the different perspectives so that we could become informed about this change to our health care system.

I was pleased that our panel could include:

• Dr. Noreen Frisch, Professor and Director of the UVic School of Nursing
• Dr. Paddy Rodney, Board Member of the Association of Registered Nurses of BC and Professor at the UBC School of Nursing
• Adriane Gear, South Island Co-Chair at the BC Nurses Union
• Sara Shorten, Representative of the UVic Nursing Student Society

Island Health was invited but unfortunately chose not to participate.

In December, I wrote to Dr. Brendan Carr, President and CEO of Island Health and requested that further implementation of the new patient care model be paused until comprehensive, independent and publically-available evaluations can be completed. I also requested that key stakeholders, such as BC’s Registered Nurses and Licensed Practical Nurses be further involved in these evaluations and in developing any plans involving the realignment of care teams.

I will continue to voice these concerns in the coming weeks and encourage constituents to raise their voices as well.

On April 23, 2014 Island Health (VIHA) will launch a new Patient Care Model at the Royal Jubilee and Victoria General Hospitals. According to Island Health the model (titled Care Delivery Model Redesign, or CDMR) will address strains on the health care system while increasing the care time a patient receives. According to the BC Nurses Union, it could put patients at risk as highly trained nurses are replaced with significantly less-trained health care aids.

Many constituents have already written Andrew Weaver with their concerns about the patient care model. The purpose of this town hall is to try to bring together the different perspectives so that we can all get informed about this significant change to our health care system.

Panelists include: Dr. Noreen Frisch, Professor and Director of the Uvic School of Nursing; Dr. Paddy Rodney, Director at Large – Association of Registered Nurses of British Columbia and Professor at UBC School of Nursing; Sara Shorten, representative from the Uvic Nursing Student Society; Adriane Gear, South Island Regional Co-chair – British Columbia Nurses Union.

Island Health was invited but declined to participate.

Format: Andrew Weaver will moderate a panel discussion and Q&A

Date: February 27, 2014

Time: 19:00-20:30

Location: Oak Bay Recreation Centre Lounge, 1975 Bee St.

Everyone welcome!

FOR IMMEDIATE RELEASE

Media Statement—December 5, 2013

Andrew Weaver calls on Island Health to delay implementation of new Patient Care Model

Victoria BC – Andrew Weaver, MLA for Oak Bay-Gordon Head, has called on Island Health to delay the implementation of their new patient care model, titled Care Delivery Model Redesign (CDMR), until comprehensive, independent and publically-available evaluations can be completed.

CDMR is Island Health’s controversial approach to redesigning nursing care at island hospitals. It is scheduled to be implemented at Royal Jubilee and Victoria General Hospitals in the New Year. Under CDMR, Island Health would implement a team-based nursing approach between Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Health Care Aids (HCAs), with HCAs playing a significantly larger role in patient care delivery.

According to Island Health, the new model will address strains on the system while increasing the individual care time a patient receives. However, critics argue that the new model is overly focused on cutting costs and will put patients at risk. They argue that nurses will be stretched too thin to provide adequate care to patients, making one RN responsible for up to 10 to 12 patients, and that Health Care Aids do not have the necessary training to safely take on this larger role.

“Health care professionals are raising serious concerns about CDMR, research suggests it could be problematic, and its impact on our health care system could be significant,” says Andrew Weaver. “Yet while Island Health states that CDMR is an evidence-based approach to health care, they have not released their evidence for public scrutiny.”

In response to concerns raised by several constituents, Andrew Weaver met with executives from Island Health, the British Columbia Nurses Union and the College of Registered Nurses of British Columbia last week.

“I applaud Island Health’s efforts to find new and innovative ways to more effectively and efficiently meet patients’ care needs. However, major changes like CDMR should be grounded in evidence. It is for this reason that I have written to Dr. Brendan Carr, President and CEO of Island Health, to request the following:

1. That further roll-out of CDMR, including all plans at Victoria General and Royal Jubilee Hospitals, be delayed until comprehensive, independent and publically-available evaluations of CDMR can be completed.
2. That relevant stakeholders, including representatives of BC’s Registered Nurses and Licensed Practical Nurses, be further involved in the evaluation of current CDMR pilots as well as in the development of future plans involving the realignment of care teams.”

For background on CDMR, please click here.

Media Enquiries please contact:
Mat Wright – Press Secretary – Andrew Weaver MLA
Mat.wright@leg.bc.ca
Mobile (1) 250 216 3382

Overview

Island Health (formerly VIHA) is reconfiguring nursing care teams in medical and surgical units at select hospitals as a part of a new Patient Care Model called Care Delivery Model Redesign (CDMR). The reconfiguration is a part of a nation-wide trend to change how care is provided to patients in hospitals. In essence, CDMR would implement a team-based nursing approach between Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Health Care Aids (HCAs), with HCAs playing a significantly larger role in patient care delivery.

According to Island Health, the new model will address strains on the system while increasing the individual care time a patient receives. However, critics argue that the new model is overly focused on cutting costs and will put patients at risk. In essence, they argue that nurses will be stretched too thin to provide adequate care to patients, making one nurse responsible for up to 10 to 12 patients, and that Health Care Aids do not have the necessary training to safely take on this larger role.

Andrew Weaver, MLA for Oak Bay-Gordon Head and Deputy Leader of the BC Green Party, is calling on Island Health to delay further implementation of CDMR until comprehensive, independent and publically-available evaluations can be completed. If critics are right, the cost of going forward with CDMR will be borne by patients who may well receive inadequate and potentially harmful care in island hospitals.

Background

Health Authorities across the province are faced with the challenge of continuing to provide quality service in the context of limited budgets, staffing challenges and changing demographics, principally defined by an aging population. This context has led Island Health to explore new ways of meeting patients’ care needs. One approach has been CDMR.

According to Island Health, over the past several years researchers have been collecting data on typical patient care needs so as to better calibrate their care teams to those needs. There are 3 main types of health care professionals that make up an affected care team:

1. Registered Nurse (RN)—A licensed and regulated nurse requiring an undergraduate degree and representing the highest level of training of the three types of professionals.
2. Licensed Practical Nurse (LPN)—A licensed and regulated nurse that works under an RN and requires a two-year certificate of training.
3. Health Care Aid (HCA)—An unlicensed and unregulated care provider that supports an RN or LPN to provide basic care to patients. HCA’s generally complete a four-to-five month training course, but there are no regulated standards for HCA training programs or HCAs in general.

The conclusion from Island Health’s research is that HCAs could play a larger role in providing basic care (e.g. bed baths, patient mobility). The result is CDMR—an approach that would see HCA’s take on this larger role and effectively reduce the number of RNs and LPNs on medical and surgical units. However, HCAs are not a regulated profession meaning there is no quality control or scope of practice governing their training or role in the health care system.

Island Health introduced CDMR at Cowichan Hospital and Saanich Peninsula Hospital roughly two years ago. CDMR was then introduced at Nanaimo Regional Hospital in September 2013, with additional plans to implement it at Victoria General Hospital and Royal Jubilee Hospital in January or February 2014.

Differing Perspectives

Both Island Health and the British Columbia Nurses Union have been vocal about CDMR, offering differing perspectives.

Island Health: According to Island Health CDMR is a ‘data-driven’ model that will allow care teams to better meet patient needs, provide more staff hours per patient and address, in part, staffing issues such as overtime. Island Health asserts that HCAs are sufficiently trained to offer support services, such as bed baths and mobility support, as a part of a broader care team. Island Health also states that they have been conducting on-going studies of CDMR to evaluate the care model.

Link to Island Health’s publications on CDMR: http://www.viha.ca/about_viha/news/new-patient-care-model.htm

BCNU: The BC Nurses Union has been highly critical of CDMR citing research that suggests such care models would have negative impacts on patient care outcomes and arguing that the data on which CDMR is based has not been released for public scrutiny to know if CDMR would be any different. The BCNU is in favour of team-based care models, but argues that the teams need to have the right make-up of skills and CDMR as proposed does not offer this. They suggest that CDMR would stretch nurses too thin, making them responsible for more patients than they can safely care for and offering too large a role to unregulated and inadequately-trained HCAs. They suggest that patients may receive inadequate and potentially harmful care as one RN may be required to care for up to 10 or 12 patients.  As such, they have expressed concerns that it would be difficult for them to provide the standard of care required by the College of Registered Nurses of British Columbia, the College of Licensed Practical Nurses of British Columbia and the College of Registered Psychiatric Nurses of British Columbia.

Link to BCNU’s statements on CDMR: https://www.bcnu.org/Search.aspx?search=cdmr

Academic Research: There is no publicly available research specifically on CDMR itself, as CDMR is a tailor-made model for Vancouver Island. However there is significant academic research looking at “nurse staffing” levels and what happens when you decrease the number of highly trained RNs and increase the number of comparatively less-trained LPNs or HCAs. The research generally suggests that this change is associated with a significant drop in the quality of care a patient receives. There is enough of this research out there to raise serious questions about the risks associated with CDMR.

Two Canadian researchers who have published in this area are: Dr. Linda O’Brien-Pallas and Dr. Linda McGillis Hall

Questions

It is difficult at this stage to definitively assess whether CDMR is a good model or not. Island Health claims to have data that suggests it is. However, their evaluations are not publicly available and run contrary to existing academic research. Nurses are highly opposed, arguing they will not be able to provide sufficient quality care under CDMR since they will be responsible for more patients than they can manage. What is clear is that if critics are right, CDMR may have a significant impact on the quality of care patients receive in BC hospitals and lead to a rise in potentially harmful care situations. This context begs three key questions.

1. If there is research showing the success of CDMR, then when will Island Health make it available?
2. CDMR has been implemented at Cowichan and Saanich Peninsula Hospitals for two years. Has Island Health evaluated CDMR in these settings and if so, when will the evaluations be made publicly available?
3. If Island Health has not yet completed comprehensive evaluations showing that CDMR is a successful model, then why are they rolling it out in more and more hospitals amidst strong opposition that raises serious questions about its validity as a care model?

Andrew Weaver on CDMR

In light of the potentially serious risks associated with CDMR, Andrew Weaver is calling on Island Health to:

1. Delay further roll-out of CDMR, including all plans at Victoria General and Royal Jubilee Hospitals, until comprehensive, independent and publically-available evaluations of CDMR can be completed.
2. Further involve relevant stakeholders, including representatives of BC’s Registered Nurses and Licensed Practical Nurses, in the evaluation of current CDMR pilots as well as in the development of future plans involving the realignment of care teams.