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The member of the scheduling team responsible for that work unit would receive the request along with a list of employees that have the skill-sets and availability to work in that vacationing staffer's place. "They assign that work according to the various union collective agreements," he said. However, if the matter is unfolding in a shorter period of time, such as if someone was calling in sick for a shift scheduled to start later today, there's a different protocol. "Obviously that needs more immediate attention. There's an actual telephone call from a manager or a supervisor at (the unit) to a dedicated line in the scheduling centre," he said. Together, the employee's manager would work with the scheduling team to sort out the appropriate person to be offered the shift. Why is Horizon making this change? The goal is to lighten the administrative load on health-care managers across the province so they can focus on the day-to-day delivery of care.

"We're taking that sort of task or transaction work out of the nursing units. Typically, it's done by ward clerks or, in many cases, the managers themselves. It consumes a lot of their time. But that's only part of their job. They have responsibilities for other operational requirements in their various units," he said. Doull said the health authority also sees value in managing schedules in a consistent way across the province. "What we want to do for all of the areas is standardize the processes and the application of the collective agreement rules. So instead of having (more than) 200 people in Horizon who have as some small part of their job (tried) to get by in doing scheduling work as best they can with no formal software support or training, we're going to bring that into a purpose-built department," he said. "And there are efficiency payoffs for that, both financial and operational, for us as an organization." He did acknowledge that there will still be room for personal interventions by managers, particularly if a quick conversation at the office door can resolve a pressing matter easily and effectively.

If a matter is of an urgent nature, the employee can contact their manager or appointed supervisor directly and have a conversation about the request for time off and the manager can figure out a specific way to handle the situation. "All the manager is going to do is simply call the centre in Saint John, or email the staffing team that they work with, and say, 'An employee has talked to me. This is what we're going to do and here's how I want you to deal with the shift on Saturday,'" he said. "The manager always has that direct-line option to deal with things that are of a more timely nature." Although, too much of that can be a problem, said Doull, explaining that in some units across the province managers can fall into routines where the easiest employee to reach, or the most willing employee to work, receives most of the overtime or sick-time shift offers. "Later on, one of the four or five people (ahead of the preferred employee) may very well come back and say, 'I have a grievance because I should have been offered that shift. What are you going to do for me?' And we may be in a situation of having to, in effect, pay twice for time that needs to be worked," he said.

"I wouldn't characterize it that it happens often, but it certainly happens often enough that we know about it and it's one of the problems that we're specifically trying to solve." Members of the scheduling team are working to determine which site will be the next to adopt this new staffing system. Ultimately, when the scheduling team is fully operational and slotting shifts for units across Horizon, a team of 21 staff members will be working at the Saint John centre between the hours of 5 a.m. and 11 p.m. "That's roughly 70 full-time equivalent (positions for our team)," he said.

Doull said he knows many employees are likely worried about this change, but the move is expected to create significant savings for Horizon. "What we're looking to do is return time to managers and clinical staff," he said. "We know patients have a better experience if they know who the manager is in their area and they're able to interact with them regularly ... We know staff are more satisfied at work if they're able to have access to their manager." There are also savings expected through reductions in payroll errors.

"If someone puts in the wrong code for a specific number of hours and an employee gets paid the wrong thing, we know how often we're going back and correcting these. What this system will do is take a lot of the manual data entry of our pay processes away," he said. "It'll be automated and driven by what the employee is scheduled to work." It should also help to highlight problems in specific units, he said. "If we have an area, for example, that is using a lot of overtime, we'll know who is not there, why they're not there, which positions are not actually filled because there's nobody to work them, and we'll be better able as an organization to identify where our recruiting issues are," he said.

Ralph McBride, CUPE Local 1252's provincial co-ordinator, said he's concerned about the economic impacts the move could have on communities across the province. "We're not overly impressed with centralizing services. We see this as taking away important jobs in rural New Brunswick and moving them to urban centres," he said. "We think there are economic hard times happening currently in the Miramichi. This won't help." There are no plans to integrate this system with scheduling protocols used by the Vitalité Health Network. The Daily Gleaner requested information from the Vitalité Health Network on how the province's other regional health authority schedules its staff and the paper is still waiting for a response.

Boudreau has said the move will save the province millions of dollars through efficiencies brought in by a private company. However, the union's document paints a poor picture of privatization of services in health-care facilities in other jurisdictions. "We believe it is important for New Brunswickers to understand the impact of such a move, especially when it comes to the cleanliness of a building which the public relies on everyday," Robinson said. Last year, the Horizon Health Network started a regular audit of the cleanliness of hospitals being serviced by unionized public sector workers. Auditor General Kim MacPherson reported that health-care workers weren't cleaning their hands as required and that the standards to do so weren't even the same within the two regional health authorities.

Robinson said Friday that policies have been established and changes made that are addressing cleanliness concerns. "And they have improved on their targets of cleaning in the hospital sector," she said. The union claims its research into the three companies they believe are being considered to take over those services - Sodexo, Aramark and Compass - shows a poor track record. The union said it's also concerned about the quality of food declining. The union wants to keep the management of hospital environmental services in-house. It also wants fair wages and benefits for cleaning and food services staff to ensure against high turnover and gaps in training. The union also stated lay-offs and staff reductions would be a poor way to balance the budget.

"The cost associated with treating hospital-acquired infections, managing public relations fiascoes and defending lawsuits would defeat any possible savings while destroying the public trust." The Province of New Brunswick expects to have completed talks with a private contractor for the management of health-care cleaning and food services before the end of the year.

Bruce McFarlane, Health Minister Victor Boudreau's director of communications, said Friday that the province is "still in current discussions with the preferred proponent and we hope to have completed the process sometime this fall." McFarlane sent The Daily Gleaner an email statement Friday afternoon after the New Brunswick Council of Hospital Unions CUPE local 1252 released a 20-page document critical of the government's plan to privatize housekeeping, food services and porter services at hospitals. "We want to clarify that we are only outsourcing the management of the services," said McFarlane, who added that the ministry had not yet received the document.

"CUPE staff will remain in their union and will continue to be employees of the Province of New Brunswick." Norma Robinson, president of CUPE Local 1252, said she is "very concerned that the Liberal government is negotiating with a private firm to take over the management of food and cleaning services in the province's hospitals." Robinson said she's worried the move could lead to further privatization. In an interview with Brunswick News in April, Boudreau said the government wants to give the private sector a greater role in the province's health-care system.

Boudreau has said the move will save the province millions of dollars through efficiencies brought in by a private company. However, the union's document paints a poor picture of privatization of services in health-care facilities in other jurisdictions. "We believe it is important for New Brunswickers to understand the impact of such a move, especially when it comes to the cleanliness of a building which the public relies on everyday," Robinson said. Last year, the Horizon Health Network started a regular audit of the cleanliness of hospitals being serviced by unionized public sector workers. Auditor General Kim MacPherson reported that health-care workers weren't cleaning their hands as required and that the standards to do so weren't even the same within the two regional health authorities.

Robinson said Friday that policies have been established and changes made that are addressing cleanliness concerns. "And they have improved on their targets of cleaning in the hospital sector," she said. The union claims its research into the three companies they believe are being considered to take over those services - Sodexo, Aramark and Compass - shows a poor track record. The union said it's also concerned about the quality of food declining. The union wants to keep the management of hospital environmental services in-house. Calls made to Sodexo, Aramark and Compass were not returned by press time.

Private project managers also tend to charge higher legal and management fees. As well, they must return profits to their owners. Aficionados of public-private partnerships insist that while all of this may be true, privately managed projects are far more likely to come in on time and under budget. That is the argument used by Infrastructure Ontario, the body charged with handling public-private deals. It says that if the 74 projects had been handled by the public sector, delays and overruns would have cost taxpayers - in net terms - about $6 billion more. It also says that publicly managed projects are five times more likely to come in over budget than privately managed ones. Is any of this true? Lysyk is not convinced. She points out that Infrastructure Ontario has no empirical evidence to back up its claims and instead bases them on the judgment of outside advisers who, her report says, make their case "anecdotally" and tend to cast publicly managed projects "in a negative light." She also notes that Infrastructure Ontario's initial cost estimates for public-private partnerships are systematically inflated. One result (which she is too polite to mention) is that private-public schemes usually appear to come in under budget. That makes everyone look good.

The Liberals may be the grand priests of private-public partnerships. But they are not the only ones to embrace this particular theology. In the 1990s, Bob Rae's New Democratic Party government famously arranged for a private consortium to finance, build and operate Highway 407, largely to avoid saddling the province with $1 billion more in debt. Yet in the end, the Rae government had to borrow the $1 billion itself - and then pass it on to the consortium. The private-sector partners just couldn't raise the cash as cheaply. Little has changed since then. On the face of it, public-private partnerships seem a good way to save money. In reality, as Lysyk has confirmed, they usually cost taxpayers more. Thomas Walkom is a news services columnist.

these facilities, ambiguities exist around the private and public entities involved in the management of each home and its employees. "The history is quite patchy. Think about how much government has changed in 40 years, how the health authorities are structured. From what we understand, and this is extremely confusing, we think that the five homes were always owned and operated as non-profit legal entities, with local boards, and the staff within those homes were clearly employees of the homes," said Noonan.

But what we think happened, at least in our area, is that an organization [called Health Services Management Group] wanted to have a presence in these communities. So they co-located themselves, we think, next to these homes. They sometimes shared facilities." Sometimes, the two entities would share space, resources, even people, Noonan says. In the early 1990s, Health Services Management Group was given some of the responsibilities for the management of these nursing homes by the provincial government.

Over time, those responsibilities - such as payroll - were transferred to the health authorities, which has caused some complications, she said. Even though the Nashwaak Villa manages employee hours, Horizon Health Network issues the cheques and manages human resources issues and support. "It's just evolved through history. What that has resulted in is that it's unclear to everyone who the employer is," she said, explaining that her board cannot find any formal documentation that explains the division of responsibilities. "The nurses have a bargaining unit and the CUPE folks have a bargaining unit. Our folks are the only ones in the province who work in a unionized nursing home who are governed under the collective agreements of the public service. That's just the way it's been. They've always been considered members."

There are times the situation has created problems for administrators. "It's hard to manage the day-to-day of the nursing home in a way that is efficient and that's not distracting from the resident care when you're constantly navigating through these different channels and there's ambiguity. When I call the payroll department, for example, and ask them to pay a new nurse a certain amount of money, following the collective agreement, they might say to me, 'No, Horizon doesn't pay that way.' I'm not being treated autonomously from the corporate entity of Horizon Health, even though we are a separate entity. It's a lot for the employees. The processes are such that it's unclear to them if they work for Horizon or Nashwaak Villa. And that creates a lot of tension, at times." In recent months, Noonan said her board asked the unions that represent her employees to work with them to sort this out. But those unions believe no changes are needed, taking the position that a collective bargaining agreement is in place and the nursing home facilities can simply work within the terms of those contracts.

Noonan said that her board of directors has decided it needs clarity and has filed an application with the provincial labour and employment board to investigate the matter. What would happen if the labour and employment board rules that Nashwaak Villa is completely autonomous from any other organization, which would mean its employees could no longer be part of a bargaining unit involving colleagues from the Horizon Health Network? It could mean that the facility's employees could retain, or lose, their seniority. Their pay could increase, or decrease, as could their benefits. There are many uncertainties at this point, said Noonan. "We haven't begun any discussions around a transition, if there is one. So that would be done in a negotiation," she said.

"But we think [the impacts would be negotiable] in terms of what the salaries might be. Our funding model would change, as we're funded through the Department of Social Development. But what it would mean for the employees is that they've been part of a bargaining unit, one of the largest units, and the big question mark is: Would I get to keep my seniority? We don't know the answers to that because all the parties haven't gotten together to talk. That's what we're trying to do with this." Obviously, that's concerning for the employees, said Noonan, who added they are in uncertain times. Ralph McBride, provincial co-ordinator for CUPE Local 1252, said the spectre of layoffs, related to a quest for efficiencies within the province's health authorities or to proposed changes to the professional staffing ratio in nursing homes, has created concerns for the employees at Nashwaak Villa.

That's one of the bad things for the employees to be caught up in," he said. "With their employment status with Horizon, if there is a skill-mix change, and there does happen to be layoffs, or a reduction in care-givers, they'd have a bigger pool to bump into. If they become a single employer, as they've indicated, then that limits the ability for people to move around and find a new job." He said his union will do what it can to support its members, explaining that in his view the current situation is manageable. "We're saying they've got a collective agreement. I think what the Villa is trying to say is that they're not recognizing that," he said.

Do they? Lysyk looked at 74 public-private projects started since 2005 to answer that question. She found that, in total, they cost $8 billion more than if they had been built and managed by the government alone. In one telling example, she looked at the construction of two near-identical buildings for an unnamed Mississauga college. The first, handled by the public sector, was completed on time and on-budget. Over the objection of the both the college and then mayor Hazel McCallion, the government decreed that the second building be funded and handled by a private project manager. When the figures are adjusted for inflation and other variables, that second building is expected to cost taxpayers 10 per cent more per square foot. The reason is straightforward. Big projects are always built with borrowed money. And governments can borrow far more cheaply than private firms.

Private project managers also tend to charge higher legal and management fees. As well, they must return profits to their owners. Aficionados of public-private partnerships insist that while all of this may be true, privately managed projects are far more likely to come in on time and under budget. That is the argument used by Infrastructure Ontario, the body charged with handling public-private deals. It says that if the 74 projects had been handled by the public sector, delays and overruns would have cost taxpayers - in net terms - about $6 billion more. It also says that publicly managed projects are five times more likely to come in over budget than privately managed ones.

Thomas Walkom's column appears Wednesday, Thursday and Saturday.

States have dabbled in managed care for decades. The trend accelerated in the 1990s, with the share of Medicaid patients under this form of care reaching 72% by 2009.

The result is a country with two distinct tiers of health care. Most Americans with private insurance are still horrified by thoughts of health-management organisations and prefer to pay fees for each medical service. For the poor, managed care is becoming the norm.

The next step is to integrate care for those eligible for both Medicaid and Medicare, the federal programme for the old. These “duals” account for almost 40% of Medicaid’s costs and just 15% of its population.

The outcome of Douglas v Independent Living Centre will have profound implications for the future of Medicaid.

Ms Vescovo, who argues that California’s payment cuts would eviscerate her clients’ access to services, worries that under managed care the disabled might not be able to see the specialists they need.

The question is how to supervise the experiments with managed care that are being carried out in various states. To date, Medicaid beneficiaries have been able to challenge the states in court. However, if the Supreme Court rules against ILCSC, that avenue will be closed. The Centres for Medicare and Medicaid Services (CMS) technically can intervene if states do not provide proper access to care. In reality, CMS has few tools to do so.

Paul Brunet, president of the Conseil pour la protection des malades, expressed concern about the potential unintended consequences of the government's costcutting measures. "Oh yeah, certainly patient care will suffer," Brunet said. "Longterm care facilities are going to take most of the hit. We know that." Some institutions, however, have signalled to the government that they won't cut the number of medical tests. "At this stage, it's out of the question to re-evaluate the pertinence of medical tests for patients," said Joëlle Lachapelle, a spokesperson for the Centre hospitalier de l'université de Montreal.

(A standard complete blood count test, for example, costs a hospital $5.77, while a private clinic will charge more than $60 for it. Private insurance would cover most, if not all, of the latter fee.) The CHUM must cut $15.4 million in its 2015-2016 budget, and of that sum, $11.3 million is supposed to come from an optimization measure called "pertinence of care and physical health services." Lachapelle said the CHUM will focus on reducing overtime rather than cutting the number of tests and procedures. Joanne Beauvais, Barrette's press attaché, denied that the government is pressuring hospitals to cut patient care.

"We are not cutting funding for care, but implementing measures to help clinical professionals provide better care by foregoing tests and procedures that are expensive and shown not to result in either improved recovery or better diagnostics," Beauvais responded in an email. "We expect the progress we will be making over the next year to yield recurrent savings of $150 million." The $583 million in "optimization" savings breaks down as follows Cutting $220 million in payroll costs by abolishing 1,300 management positions. Avoiding "unnecessary" (Beauvais's word) tests and procedures, saving $150 million. Not funding leap year day: $64 million.

Persuading hospitals to team up in buying goods and services to save $35 million. Additional "compressions" that are unspecified: $114 million. The CHUM will have to cut through attrition 15 managers out of 337. The MUHC, in contrast, will have to cut more than 100 managers out of 459. A cloud of fear and anxiety has descended over the managerial ranks at both the CHUM and MUHC. Ian Popple, a spokesperson for the MUHC, said the reduction in the number of managers will be carried out over three years. "Part of the reduction will be done by attrition as managers leave or retire," he explained. "Other reductions will have to occur by transforming some manager positions into professional-level positions (that pay less) in order to meet the ministry target. We are looking at every option, but there remains a shortfall that is requiring ongoing work to address."

Beauvais dismissed the notion that the government is actually making cuts: "These are not cuts. Quebec cannot afford the kind of growth rate in health-care spending we experienced over the past decades, and the system is clearly able to do more with less. The best-performing teams in the network prove it. Since the health-care budget keeps growing, those measures are not cuts. They are a strong inducement to everyone in the system to improve their game." Quebec has budgeted $32.8 billion this fiscal year on health care, an increase of 1.4 per cent, but less than the 5-per-cent annual hikes of previous years. aderfel@montrealgazette.com twitter.com/Aaron_Derfel

The McGill University Health Centre has not yet figured out where it will have to cut to make up the $2.5-million leap-year day shortfall. • VINCENZO D'ALTO, MONTREAL GAZETTE FILES / Of all the "optimization measures" that Quebec is imposing, the most controversial is compelling doctors to stop ordering tests that the government is now considering "unnecessary."

A surging rat population in the hospital's cafeteria and food preparation area has prompted management to step up rodent control efforts in recent weeks. Inspectors believe that despite the increase, the rodents do not pose an imminent health risk to the hospital's patients, visitors or staff, said Richard Taki, regional director of health protection for Vancouver Coastal Health. But the results of last month's inspection highlight the hospital's ongoing challenges dealing with vermin, a situation hospital management and health inspectors say has been exacerbated by demolition and construction work in recent months. Inspection reports from 2013 show Vancouver Coastal Health had previously identified issues with rats and mice in the hospital cafeteria and more recently, last month's inspection found signs the problem had worsened.

"I don't think it's any different from any restaurant that has a rodent problem. They have rodents, they're under control, they've got a company looking after it. They're working toward resolving a problem, but you know, we live in a city that has rats everywhere." Nurses have seen the pest problem worsen, along with general cleanliness, said Claudette Jut, regional chair of the B.C. Nurses Union council. The Hospital Employees Union has identified the issue of short staffed cleaning and food service in the hospital and raised it "on several occasions" with the private contractor who employs the workers, said HEU spokesman Mike Old. "It's hard for us to tell what exactly has contributed to the rat infestation," said Old. "But it's a problem, I think, that the delivery of services is so badly fragmented because of privatization."

Frank Levenheck, director of facilities management for B.C. Women's and Children's Hospital, said demolition and construction on the hospital campus has contributed to the cafeteria's rodent issue. Over the past three weeks, hospital management has increased its efforts, Levenheck said, which includes working to seal holes in the building that act as entry points for vermin, more frequent cleaning and more frequent visits from the pest control company. Demolition for the hospital redevelopment began last May. Excavation began in August and is scheduled to be complete in February. Eight months before demolition began, hospital management had been directed to improve rodent control, records show. A VCH inspection on Sept. 3, 2013 found issues with "Inadequate Insect/Rodent Control," noting: "Areas have not been cleaned and Manager not aware if Pest Control has been in to specifically address these new sightings. Communication between services found to be poor and lacking in followup."

A week later, a followup reinspection report dated Sept. 10, 2013, noted: "Rat droppings still to be THOROUGHLY cleaned from underneath the heater vents in the production area. Noted mouse droppings in warehouse areas have not been cleaned up." The next Inspection Report, from July 2014, does not specify whether the rodent situation had improved or worsened since the problems noted in the report from the September before. The July 2014 report was the most recent posted to the Vancouver Coastal Health website until Postmedia News contacted the health authority this month to ask about inspections. Taki acknowledged the Dec. 22 inspection and provided Postmedia with a copy of the report, which was subsequently uploaded to the health authority's website.

Kristy Anderson, a spokeswoman from the provincial Ministry of Health, said if an inspector finds a food service establishment is not responsive to food safety notices or orders, the establishment "could be fined or ultimately be required to shut down until the situation is remedied. To our knowledge this has never occurred in a hospital or health authority-run facility."

Eight months before demolition, management at B.C. Women's and Children's Hospital had been directed to improve rodent control, records show.

But if union workers are still on the job, it seems highly likely to us that all union rights previously achieved by way of collective bargaining with the actual employer - you taxpayers by way of government - are still in play. CUPE representative Norma Robinson has already voiced concerns. She says the department has already told the union that it is taking bids from three big private-sector providers - Sodexo, Aramark and Compass Group - toward signing a 10-year contract in three or four months. She is certainly within her rights to ask what impact that contract will have on the contract public sector workers have with government.

Perhaps the minister prefers to wait until the contract is signed before saying more, but it seems to us that whatever efficiencies the successful bidder intends to achieve will depend a lot on how it and the union co-operate within the strictures of collective agreements. It is one thing to centralize a kitchen service, for example, and another to respect any pertinent contractual language, such as 'manning' and seniority. Ms. Robinson already sees this move as the first step toward privatization of health care. While Ms. Robinson has said nothing further in that regard, some might interpret that statement as a harbinger of labour unrest for the health department over the course of that private 'management contract.'

Having said that, we are optimistic that some efficiencies will be achieved immediately if all management functions are removed from the collective agreements; it is logical to expect as much given the bidding process should get taxpayers to the lowest price possible for those specific functions. And while we sympathize with union concerns, we endorse privatization of health care; the more the better.

Not long ago union voices were predicting dire consequences when laundry services were centralized for the sake of efficiency. They didn't happen. Should anyone voice similar concerns about a private-sector management contract about, for example, the quality of hospital food, many a patient might chuckle. This government is trying to reduce massive debt and stop deficit spending. Thus it is welcome news to also hear Horizon Health Network CEO John McGarry suggest private health-care firms could move such professions as physiotherapy, audiology and dietetics out of the province's hospitals, which he also notes are too numerous.

Medical buildings often have standard benchmarks — basing the number of examination rooms, for example, on the expected volume of patients. Ms. Brandenberg and her team instead used C.P.I. to map out common paths that patients, staff members, supplies and information would flow through. They worked in an empty office building, using cardboard mock-ups of surgical sites, recovery rooms, anesthesia areas and waiting rooms. Fifty staff members then play-acted various scenarios to test the design’s effectiveness. The final design reduces walking distances and waiting times for patients by grouping related facilities together and creating rooms that can be used for more than one purpose. The hospital was able to shave 30,000 square feet and $20 million off of the new building

Last year, amid rising health care expenses nationally, C.P.I. helped cut Seattle Children’s costs per patient by 3.7 percent, for a total savings of $23 million, Mr. Hagan says. And as patient demand has grown in the last six years, he estimates that the hospital avoided spending $180 million on capital projects by using its facilities more efficiently. It served 38,000 patients last year, up from 27,000 in 2004, without expansion or adding beds.

checklists, standardization and nonstop brainstorming with front-line staff

The program, called “continuous performance improvement,” or C.P.I., examines every aspect of patients’ stays at the hospital

The system is just one example of how Seattle Children’s Hospital says it has improved patient care, and its bottom line, by using practices made famous by Toyota and others. The main goals of the approach, known as kaizen, are to reduce waste and to increase value for customers through continuous small improvements.

“The health care industry could be on the verge of an efficiency revolution, because it is currently so far behind in applying operations management methodologies,” says Professor Litvak.

All medical centers, especially larger ones, would have significant return on investment by using operations management techniques like C.P.I., says Eugene Litvak, president and chief executive of the Institute for Healthcare Optimization and an adjunct professor of operations management at the Harvard School of Public Health.

Similar methods are now in place at other hospitals and health systems, including Beth Israel Deaconess Medical Center in Boston, Park Nicollet Health Services in Minneapolis and Virginia Mason Medical Center, also in Seattle.

TO be sure, not everyone believes that factory-floor methods belong in a hospital ward. Nellie Munn, a registered nurse at the Minneapolis campus of Children’s Hospitals and Clinics of Minnesota, thinks that many of the changes instituted by her hospital are inappropriate. She says that in an effort to reduce waste, consultants observed her and her colleagues and tried to determine the amount of time each of their tasks should take. But procedure times can’t always be standardized, she says. For example, some children need to be calmed before IV’s are inserted into their arms, or parents may need more information. “The essence of nursing,” she says, “is much more than a sum of the parts you can observe and write down on a wall full of sticky notes.”

one-day strike by the Minnesota Nurses Association against six local health care corporations, including her employer, partly in protest of lower staffing levels her union thinks have resulted from hospitals’ “lean” methods

the Lean Enterprise Institute

George Labovitz, a management professor at Boston University, says there are limits to performance-improvement methods in hospitals. “Human health is much more variable and complex than making a car,” he said, “so even if you do everything ‘right,’ you can still have a bad outcome.”

Joan Wellman & Associates, a process improvement consulting firm in Seattle

examine the “flow” of medicines, patients and information in the same way that plant managers study the flow of parts through a factory

In a typical workshop at Seattle Children’s, a group of doctors, nurses, administrators and representatives of patients’ families set aside a 40-hour week to work through C.P.I. methods. They plot each “event” a patient might encounter — like filling out forms, interacting with certain staff members, having to walk various distances or having to wait for assistance — and brainstorm about how each could be improved, or even eliminated.

it never ends

Standardization is also a C.P.I. cornerstone. Last year, 10 surgeons at Seattle Children’s performed appendectomies, and each doctor wanted the instrument cart set up differently. The surgeons and other medical staff members used C.P.I. to come up with a cart they all could use, reducing instrument preparation errors as well as inventory costs.

Combined with other savings and income, that amount might provide some retirees with all they need for decades. But everything changes when, for instance, an aging father struggling with dementia requires more help than his wife and children can manage. Plans that looked solid on paper are no match for their bills. "Within the first year most people are tapped out," said Joe Caldwell, director of long-term services at the National Council on Aging. "Middle-class families just aren't prepared for these costs." Many who can afford it buy insurance to help pay for long-term care years in advance, when insurers are less likely to reject them. But even those with insurance, like Ranzman, come up short. Forced to improvise, they sell the house and lean on family. They move in with their adult children, or arrange for their children to move in with them.

Some can save money by switching to different facilities. On average, a shared room in a nursing home runs nearly $11,000 a year less than a private room, and a room in an adult-family home runs cheaper still. Still, there's not a lot of room for creativity, said Liz Taylor, a self-employed geriatric care manager in Lopez Island, Washington. "The amount of care you need dictates the price," she said, "and there aren't that many ways around it." Hiring an aide to spend the day with an elderly parent living at home is often the cheapest option, with aides paid $20 an hour in some parts of the country. But hiring them to work around the clock is often the most expensive, Taylor said. "Needing help to get out of bed to use the bathroom in the middle of the night means you need a nursing home," she said.

EVICTED To Roslyn Duffy, it seemed that her mother, Evelyn Nappa, had everything she needed. After a stroke made it difficult to live alone, Nappa moved from Arizona to Seattle to be near her daughter and soon settled into The Stratford, an assisted-living facility, where she quickly made friends of fellow residents and the staff. "The care was great," Duffy said. "We loved that facility." With the sale of the house in Arizona, Nappa's savings appeared sufficient to cover 10 years at The Stratford, enough to last until she reached 100. Duffy said that the home's directors told her not to worry about her mother running out of money and winding up on Medicaid, even though the government program pays just a portion of what many facilities charge. After all, many of the same homes that refuse to admit seniors on Medicaid will keep those who spend all their savings and wind up on the program. "'We will keep her here' - that's what they said," Duffy recalls. "But I didn't get that in writing." A representative from the nursing home declined to comment.

As Nappa's dementia progressed, she needed more attention. That meant moving her from an independent unit that cost $3,000 a month, to a dementia unit that cost $6,000. Trips to the emergency room, hearing aids and other costs that Medicare didn't cover added up. Soon enough, the money that was supposed to last 10 years was gone in two. Duffy enrolled her mother in Medicaid, confident that The Stratford's management would keep its promises. Two months later, she received a letter saying her mother had 30 days to find a new home. Duffy protested, writing letters to the management and local newspapers, and succeeded in keeping her mother at the Stratford for two months until social workers helped line up an adult family home willing to take Medicaid payments.

But the stress and the change of surroundings strained her mother's health, Duffy said. Six weeks after moving, she was dead. "She declined so quickly," Duffy said. "Being in familiar surroundings is hugely important for dementia patients. There's no doubt in my mind that the move hastened her death. It was devastating, just devastating." NEW HOME Ranzman's story has a happier ending. Her daughter pulled her out of the Amsterdam Nursing Home and rented a house in Smithtown, Long Island, with a patio and a backyard full of azaleas and trees. It was Ranzman's own space. She had round-the-clock aides, a large window and plenty of sunlight. Her daughter, Goldblum, noticed that Ranzman's memory improved quickly. Her mother seemed happier and more alert. "It was less than half the cost of a nursing home and a million times nicer," Goldblum said. "She showed such improvement." Goldblum paid $36,000 a year for the house and her mother's long-term care insurance paid the home-health aides. The move saved around $250,000 a year in expenses. What's more important to Goldblum is that her mother seemed content when she died in April at age 86, lying in bed and surrounded by family. "It was a wonderful ending," she said.

"New Brunswickers have been very clear - change is necessary and government needs to get its fiscal house in order," Macfarlane said. "We can no longer continue with the status quo. "We are undergoing a strategic program review to look for efficiencies and to uncover programs or services that could be changed or discontinued as well as find sources for revenue." McGarry said in a speech to the Rotary Club of Saint John in the Port City on Monday that a needed ideological shift in health care should see even greater use of private health-care firms.

"I think there are opportunities for the private sector to get more involved in our system in the things that we don't do as well as we should," he said. "Publicly paid, but privately delivered, contracted. "Do some of the services we provide under a public system really belong in the public system?" McGarry specifically cited outpatient services. "If you look at hospitals these days, you find so many ambulatory care services that are in the hospital system," he said. "Sometimes there is a private provider out in the community.

We have physio, there is private physio. We have audiologists, there are private audiologists. We have dietitians, there are private dietitians. You start to say, 'How did we ever get into this?' "As we start to shrink our infrastructure, these are the things that pop out." McGarry said the health authority is now at the beginning of five-year plan to redirect $48 million currently being spent on hospital infrastructure.

Meanwhile, the government has declined to reveal the prospective proponent of the food and cleaning services contract until a deal is finalized. But CUPE spokeswoman Norma Robinson says the Department of Health has informed the union that food and facilities management giants Sodexo, Aramark and Compass Group are involved in the bidding process. She said the union was told that the government is seeking a 10-year contract, first negotiating with Sodexo, to hammer down a deal within the next three to six months.

Sodexo has previously confirmed its interest in the contract to the Telegraph-Journal. Robinson said on Tuesday that questions remain as to what the impact of any deal will be on current public sector workers. "We don't know what this contract is going to look like from the union perspective," she said. "They are saying it's just the management today, but what does that look like when Sodexo gets in here? "What does that look like for the employees of the system."

Robinson added: "John McGarry has a five-year health plan that he is rolling out. The government says it's on a fiscal cliff saying there is money to be saved in health care. I think this is the first step to the privatization of health care."

"We've been managing our budgetary costs for years," she said, "but this is the first year we've considered staffing restructuring as a practice to balance the budget's bottom line." Since PSWs are trained for a smaller scope of work than RPNs, they are compensated at a lower rate. Wilson-Trider said it should be made clear that there will still be RPNs on the hospital's team. Though there will be fewer RPNs, the team of PSWs will work to lighten their workload by taking care of certain tasks. The restructuring of the care model for the hospital's Rosamond Unit is just one aspect of the changes made to the AGH's budget this year. During the winter months, AGH conducted an internal comprehensive review of the hospital's revenues and expenditures, looking for efficiencies and asking for suggestions from staff.

The review, Wilson-Trider said, had a target figure of a five per cent change to the budget's bottom line, either in increased revenue or decreased expenditures. The cuts to RPN positions will account for some of that five per cent change, but the review also found other areas to cut costs, such as supply cost savings and energy management practices. Also, the hospital reviewed their service costs and found that they were charging below the average for private rooms, something they've adjusted for 2015. "These changes are a way of living within our means from a budget standpoint while providing the least impact to current patient care and the patient experience," Wilson-Trider said.

Protest Anita Comfort, one of the RPNs whose job is being eliminated, has been working at AGH for 21 years. She's among one of many soon-to-be-laidoff RPNs who have been at the hospital for decades, and she says that level of dedication can't be replaced. "We know our hospital, we know our patients and we know how to care for them," she said. "There's simply not going to be the same level of care without us." Comfort was one of more than 30 demonstrators who marched the street in front of AGH on March 16, asking for honks of support from passing cars.

Affected RPNs, friends, family, union representatives and even patients came out to show their support, holding signs boasting messages such as "Cuts hurt everybody," and "My skills are vital to patient care." Linda Melbrew, president of the local chapter of the Canadian Union of Public Employees (CUPE), which represents the RPNs, was present for the demonstration, showing the union's support for saving their jobs. "We're asking the hospital to reconsider their decision," she said, "and we're also asking for the province to provide better funding for our hospitals so something like this doesn't have to happen at all." Representatives from the Ontario Nurses Association also showed their support during the demonstration, holding signs and marching among the affected RPNs.

Cathy Porteous, another of the RPNs who will lose her job because of the cuts, also mentioned the hospital's appearance on the Sunshine List: a list of employees whose annual salary rates are $100,000 or more. She said she heard there are 10 such employees with the AGH. "Why can't they make cuts in that area," that's what we want to know," she said. "Instead of cutting from the front lines of patient care, maybe they should take a look at their own salaries." When asked about the Sunshine List later in an interview, Wilson-Trider said the hospital doesn't have 10 employees being paid more than $100,000 annually - instead, they have nine.

Those employees, she explained, are all high-level employees and not all of them are paid by AGH itself. Among those on the Sunshine List are the director of care for the hospital's Fairview Manor (FVM) and the manager for Lanark County Ambulance Services. "These managers are already stretched," she said. "Between managing the hospital and their accountability to the LHIN (Local Health Integration Network) and the ministry, they're stretched." Many of the demonstrators voiced another concern as well: that patients will not receive the same level of care with a team of PSWs than they would with RPNs. "The don't call it complex care for nothing," said Debbie Tipping, whose husband, like Marie Campbell's, receives care in the Rosamond Unit, also called the Complex Continuing Care Unit.

Since PSWs don't go through the same level of training as RPNs and therefore are not qualified to perform certain tasks, Tipping said she is concerned her husband's care could suffer. "We don't want to lose the nurses we've come to know and love," Campbell said. Patient care While Wilson-Trider said the AGH is appreciative of the work the affected RPNs have put in over the years, she also said that she thinks the new care model will benefit patient care. "I actually think that this will be good for patient care," she said. "The new PSWs will be there to support the RPNs, who will be working at their full scope of practice."

"Patient care," she added, "is of the utmost importance here, and we have taken every measure to ensure that that level of care is maintained." Over the next few months, as the new model of care is phased in and positions are jostled around, Wilson-Trider said that the AGH will be following the union's collective agreement and working with the union the whole way through. "We appreciate the commitment and high quality of care that all of our staff has demonstrated and continues to demonstrate," she said, "and we're also very appreciative of the care they've given to our patients." Illustration: • Kelly Kent, Metroland / On Monday, March 16, more than 30 demonstrators took to the street outside Almonte General Hospital (AGH) to protest the hospital's new model of care that will cut 10 registered practical nurse (RPN) positions from its team of sta . AGH's new model of care comes in light of budget challenges passed down from the province's freeze on funding. Some of the a ected RPNs, above, held signs reading "My skills are vital to patient care."

You want to look at companies that are primarily taking costs out of the system, payers rather than providers," he said. "Providers such as hospitals and other facilities aren't necessarily adding to the problem, but they are in the cost bucket that are trying to be taken out of the system in the U.S." Mitchell aims to build concentrated portfolios (35 to 45 names) of high-quality businesses that generate high returns on invested capital, strong recurring free cash flow, have a portfolio of irreplaceable assets, and finance their operations with low leverage.

Valuation itself is not a catalyst," he said. "It makes more sense to buy high-quality business that have generated strong returns historically, and offer enough return for the risk you're taking." For example, Mitchell only buys stocks that offer a total return of 15 per cent of more. Another holding, Medtronic PLC, a medical device company that typically grows its revenues between four and six per cent, appears to fit the bill.

Although its spine business is in a secular decline, the company is innovating and developing new therapies around catheters and drugcoated balloons. As a result, Mitchell expects it will grow its revenue at 10 per cent over the next three to five years. The company is also benefiting from a tax inversion following its purchase of U.K.-domiciled Covidien PLC, which freed up US$9 billion of cash that was outside the U.S. this past quarter. Medtronic thinks it can generate US$40 billion of free cash flow in the next five years, roughly half of which is set to be returned to investors in the form of dividend increases, share buybacks or special dividends.

They can allocate capital to other businesses and grow," Mitchell said. "It's also trading at a discount to its health-care peers, so it offers great upside." The portfolio manager also has a position in Novartis AG, which is still the largest pharma company in the world until the merger between Pfizer Inc. and Allergan PLV is complete. Like many names in the sector, Novartis faces pressure from generic drugs entering the market. That's the case with its cancer drug Gleevec. However,

Mitchell noted that Novartis has taken steps to replace its sales with another drug. But what's most compelling about this story is its pipeline of other drugs, including Entresto, which treats heart conditions and has shown strong efficacy and improvement versus existing drugs. Mitchell noted that it has "blockbuster" potential, with revenue potential of US$5 billion annually at peak. Similarly, Cosentyx, which treats severe cases of psoriasis that can cause arthritis, could be another big winner for Novartis. Mitchell also sees opportunity in Daimler AG, which is held in his global portfolios. While many people point to the auto industry as a sign of strength in the U.S. economy, Mitchell looked to Europe to find a German auto maker that has performed well.

He noted that China, a key market for many luxury auto makers, recently reduced taxes on small and mediumsized businesses, and Daimler has resolved a dispute it had with local dealerships there. "They've also put a number of their vehicles on a common platform with common parts, which brings down costs and boosts margins," Mitchell said. "With a better mix of highermargin, higher-value vehicles, I expect sales to pick up."

yler Anderson, National Post / Portfolio manager Dennis Mitchell sees a steady path to growth in biotech, pharma and other health-care stocks.

Carson estimated that 60 to 70 per cent of St. Joseph's operating budget is labour. That leaves just 30 to 40 per cent for supplies, which is typical for most hospitals, she says. Of that, about one per cent is spent on food: a bare-bones budget of $7.43 to cover three meals and two snacks per patient, per day.

Carson said she prepared simple meals relying on cheaper whole ingredients, buying canned tomatoes and raw onions and garlic, instead of more expensive frozen prepared pasta sauce.

"Our cooks are feeling really proud of what they're producing and creating,"

Working with raw ingredients also made it easier to avoid things like gluten, salt, dyes, allergens or other contaminants that could harm individual patients

say you have all the Toronto hospitals buying their lettuce from some supplier in California and there's a problem with salmonella or something. That could be really bad."

According to an outbreak analysis by the Public Health Agency of Canada, almost 80 per cent of confirmed cases lived in a long-term care home, or were admitted to a hospital that had served deli meats taken from large packages.

In early 2012, the Canadian Coalition for Green Health Care produced a report on food service in Ontario hospitals and LTCs that looked specifically at the challenges and opportunities of incorporating local foods. It surveyed 137 food service managers, representing 16.7 per cent of the food service departments in all the hospitals and LTCs in Ontario. Food services managers placed safety at the top of their priorities (100 per cent). It was closely followed by nutrition (97 per cent); sensory qualities, like texture and temperature (97 per cent); and low cost (88 per cent). Least important to Ontario hospital food managers, according to the survey, were fairness or fair trade in product sourcing (30 per cent); food origin (24 per cent); and "naturalness" (15 per cent).

Eighteen per cent of acute-care hospital administrators reported using conventional cooking methods for patient meals "most" (80 to 100 per cent) of the time, while 70 per cent of long-term care administrators reported doing so.

Brendan Wylie-Toal, Sustainable Food Manager for the Canadian Coalition for Green Health Care

This article was produced by Tyee Solutions Society with funding provided by the Hospital Employees Union (HEU).

After leaving that hospital in July, 2005, Mr. Georgiou took a top position with the province's procurement agency, Infrastructure Ontario. But outside of his day job, the former executive began working for a private family construction business, Toronto Engineering Company (TECO). By March, 2006 - and until December, 2007 - TECO was working for St. Joseph's hospital. During this period, Mr. Georgiou became involved in a scheme to defraud York University with bogus construction invoices.

Mr. Georgiou used two family businesses, including TECO, to invoice the university for $64,800 worth of renovation work he acknowledges his company never performed. (Mr. Georgiou was not charged criminally and reached a settlement with the university.) When The Globe presented evidence to St. Joseph's last September that the hospital had also done business with TECO, the health centre hired Deloitte to investigate. The firm completed its probe this past spring. Deloitte found that over the course of nearly two years, St. Joseph's Health Centre processed 18 TECO invoices worth about $223,000 for repairs, painting and project management. The report shows Ms. Bahl approved all but five. (The hospital's thenproject manager of redevelopment, Doug Wilson, signed off on the rest.)

Deloitte found no evidence that Mr. Georgiou declared his TECO ties to the hospital, although internal hospital e-mails suggest Ms. Bahl was aware of his connection, the review states. Through their lawyers, Mr. Georgiou and Ms. Bahl criticized the fairness of the reviews. The report was not a full-blown audit and drew no conclusions. Deloitte did not interview Mr. Georgiou, Ms. Bahl or any other former hospital employees or vendors.

In a letter to The Globe, Mr. Georgiou's lawyer, Gavin Tighe, said TECO's dealings with St. Joseph's began after Mr. Georgiou left, so there was no conflict, but that, regardless, his client disclosed those ties. "TECO competitively bid on work at St. Joseph's Health Centre," Mr. Tighe wrote, adding that "TECO did not at any time contract or pay BJ Quality Flooring or Darwin Fisher Flooring to perform work." Deloitte also determined that there "may also have been an attempt to conceal" the involvement of Ms. Bahl's husband in the renovation projects.

Travis Walker, a lawyer representing Ms. Bahl, wrote to The Globe that Ms. Bahl "denies any impropriety" and that "any potential conflict of interest was disclosed to senior management" and "no concerns were ever raised." It is not clear exactly what policies Mr. Georgiou and Ms. Bahl may have violated, because St. Joseph's has refused to comment on the rules it had in 2007. A hospital spokesperson said "gaps in the procurement process at the time are historical and have since been mitigated" and that Deloitte unearthed "no substantive findings that indicate any further exploration is required." St. Joseph's would not answer questions on the report. When Mr. Georgiou left St. Joseph's Health Centre, he was one of the most powerful and connected members of the hospital, having served as vice-president for five years and interim CEO for 10 months.

About a month before he began working for Infrastructure Ontario in January, 2006, Mr. Georgiou's family members registered TECO in Ontario. Mr. Georgiou's wife, Helen Saoulli, and her parents were listed as directors. Mr. Georgiou acted as a project manager for TECO, according to a statement he made during the York investigation. Over the next two years, TECO invoiced St. Joseph's for work that included installing a new security gate for the emergency department, wall patching and painting, and disposal of chemical waste, documents obtained through a Freedom of Information request show. BJ Quality Flooring, the company owned by Ms. Bahl's husband, Bojidar Danef, was listed as a subcontractor on seven of the quotes, the Deloitte review found.

The auditing firm noted there may have been an attempt to conceal Mr. Danef's involvement because, at some point in the process, BJ Quality Flooring was changed to "Darwin and Fisher" [sic] - except that the contact name, telephone number and price stayed the same. Doug McDonald, owner of Darwin Fisher, a commercial flooring company in Mississauga, says his company has never done business with TECO and he has no idea why TECO invoices would include it. Mr. McDonald noted that during that period, Darwin was doing extensive work for St. Joseph's, and that on some occasions, he hired Mr. Danef as a subcontractor. Last November, Mr. Georgiou's employment as vice-president of St. Michael's Hospital was terminated after The Globe revealed his involvement in the York fraud, and later the fact that he had private business ties to the president of a construction company that won a $300-million contract with the hospital that Mr. Georgiou had overseen and helped award. After those stories were published, Markham Stouffville Hospital - where Ms. Bahl was then a senior executive overseeing a redevelopment project - launched an internal probe when a whistleblower came forward with concerns. The findings brought a wave of departures, including those of Ms. Bahl and Mr. Wilson, who had left St. Joseph's and was working with Ms. Bahl in Markham. Mr. Wilson could not be reached for comment.

The Markham Stouffville review, which Deloitte also conducted, found that Ms. Bahl hired five of the hospital's contractors to renovate her 6,480-square-foot home, received favourable pricing from some and awarded renovation contracts at Markham Stouffville to her husband's flooring company and her late uncle's window-covering business. It appears Ms. Bahl also mixed her professional connections with her personal life when she was at St. Joseph's hospital. Deloitte found evidence that one of the hospital's furniture vendors "assisted Ms. Bahl in procuring office furniture for her home at a 50-per-cent discount from the list price," the report said. In another instance, Deloitte noted Ms. Bahl may have tried to circumvent hospital procurement policy by counselling an art supplier to invoice through a company that was already doing work for the hospital, rather than submit a payment request directly.

"This is the only way I can cover the cost," Ms. Bahl wrote to the art supplier in an e-mail obtained by Deloitte.

Lean manufacturing or lean production is a practice that considers the expenditure of resources for any goal, other than the creation of value for the end customer, to be wasteful and thus a target for elimination.

you need to look at how in fact you can build that hospital in a way that will provide for the most efficient staff processes

lean construction is an adaption of lean manufacturing principles and practices to the design and construction process

As part of this new approach, Dyble said the ministry of health is also moving forward on a different way of managing capital projects. According to Dyble, capital boards have been created to provide an overarching look at the capital program for big projects with a cost of more than $50 million. They look at how much is being spent on rehabilitation and projects, to make sure the best possible capital projects are provided in the future. The project board is made up of senior members from Ministry of Health Services, the health authority, Partnerships BC and the Ministry of Transportation and Infrastructure.

Some $445 million worth of commodities are sent for processing each year, a nearly 50 percent increase since 2006.

The Center for Science in the Public Interest has warned that sending food to be processed often means lower nutritional value

A 2008 study by the Robert Wood Johnson Foundation found that by the time many healthier commodities reach students, “they have about the same nutritional value as junk foods.”

Roland Zullo, a researcher at the University of Michigan, found in 2008 that Michigan schools that hired private food-service management firms spent less on labor and food but more on fees and supplies, yielding “no substantive economic savings.”

privatization was associated with lower test scores, hypothesizing that the high-fat and high-sugar foods served by the companies might be the cause

in 2010, Dr. Zullo found that Chartwells was able to trim costs by cutting benefits for workers in Ann Arbor schools, but that the schools didn’t end up realizing any savings

Why is this allowed to happen? Part of it is that school authorities don’t want the trouble of overseeing real kitchens. Part of it is that the management companies are saving money by not having to pay skilled kitchen workers.

In addition, the management companies have a cozy relationship with food processers, which routinely pay the companies rebates (typically around 14 percent) in return for contracts. The rebates have generally been kept secret from schools, which are charged the full price.

Last year, Andrew M. Cuomo, then the New York State attorney general, won a $20 million settlement over Sodexo’s pocketing of such rebates. Other states are following New York and looking into the rebates; the Agriculture Department began its own inquiry in August.

the rebate abuses are continuing, now under the name of “prompt payment discounts,” under an Agriculture Department loophole

New York State requires rebates to be returned to schools, but the Sodexo settlement shows how unevenly the ban has been enforced.

Dorothy Brayley, executive director of Kids First, a nutrition advocacy group in Pawtucket, R.I., told me she encountered resistance in trying to persuade Sodexo to buy from local farmers.

The Agriculture Department proposed new rules this year that would set maximum calories for school meals; require more fruits, vegetables and whole grains; and limit trans fats.

the most committed foes of the rules are the same corporations

Their lobbying persuaded members of Congress to block a once-a-week limit on starchy vegetables and to continue to allow a few tablespoons of tomato sauce on pizza to count as a vegetable serving.

One-third of children from the ages of 6 to 19 are overweight or obese.