Strategic planning in academic paediatric hospitals: The need for child health input

Abstract

Over the past two decades, a number of Canadian paediatric academic programs, previously operated as separate hospitals, have been integrated into larger teaching hospitals or regional health authorities. The present article describes the recent experience of the Children’s Hospital of Western Ontario within the London Health Sciences Centre (London, Ontario) to illustrate the potential deleterious effects of planning, system and program changes in a large academic hospital without child health input at the executive decision-making level. The vision of the London Health Sciences Centre Executive Leadership Team and Board of Directors was divergent from that of the paediatric health care providers, which resulted in the resignation of a number of paediatric subspecialists and compromised the ability of the Department of Paediatrics to deliver paediatric care and educate future professionals. The present article highlights the need for the involvement of paediatric stakeholders in strategic planning in the hope that other academic centres can learn from this experience.

Modern paediatric specialized care is primarily delivered by interdisciplinary teams within child health programs and academic health sciences centres. The incorporation of these programs within academic centres and teaching hospitals has occurred for a number of reasons, including the need for children to have ready access to expensive technologies, laboratory facilities and a core complement of child health specialists. Increasingly, these specialized paediatric programs are relied upon to deliver care to children with the most complex illnesses, and to coordinate care across large geographic areas and among a diverse group of health care providers. Physicians associated with these programs are usually engaged in child health education and research as members of teaching faculties of Canada’s medical schools; they serve as essential resources for the education of future child health care professionals. Table 1 documents the ratio of paediatric subspecialists to children for Canada and the United States as reported to the Paediatric Chairs of Canada and the American Board of Pediatrics (1–10). The table demonstrates significant variability in the number of subspecialists in specific domains of practice. At the time of the strategic planning exercise described in the present paper, the number of subspecialists practicing in London, Ontario, was generally fewer than that reported for other Canadian academic centres serving comparable numbers of children.

TABLE 1.

Paediatric subspecialist-to-child ratios for Canada and the United States according to the Paediatric Chairs of Canada and the American Board of Pediatrics

Specialty	Paediatric Chairs of Canada, 1999/2000 (9)*	Paediatric Chairs of Canada, 2002/2003 (10)†	American Board of Pediatrics, 2006 (1–8)‡
Cardiology	1/95,651	1/120,121	0.5–5.5/100 000
Hematology/oncology	1/1,976,779 1/78,031	1/386,990 1/101,867	0.3–15.5/100 000
Nephrology	1/148,258	1/220,811	0.2–1.1/100 000
Neonatal-perinatal medicine	1/51,345	1/53,511	1.9–14.6/100 000
Critical care	1/109,821	1/126,817	0.5–6.4/100 000
Endocrinology	1/150,899	1/175,411	0.3–2.2/100 000
Pulmonology	1/164,732	1/200,202	0.3–3.7/100 000
Gastroenterology	1/144,642	1/146,489	0.3–2.9/100 000

^*Data obtained for children up to 14 years of age;

^†Data obtained for children up to 18 years of age;

^‡Not all American states have paediatric subspecialists

Over the past two decades, four of Canada’s paediatric academic programs, previously operated as separate hospitals, have been integrated into new entities either as a result of hospital mergers or the implementation of regional or provincial health authorities. These hospitals include the Janeway Children’s Health and Rehabilitation Centre (St John’s, Newfoundland and Labrador), the Izaak Walton Killam Hospital (Halifax, Nova Scotia), the Montreal Children’s Hospital (Montreal, Quebec) and the British Columbia Children’s Hospital (Vancouver, British Columbia). Importantly, both the Izaak Walton Killam Hospital and the British Columbia Children’s Hospital have provincial mandates in child health as a result of provincial health restructuring. While some individuals support this change (11), studies in the United States suggest that freestanding children’s hospitals provide a wider range of paediatric services and higher acuity care (12). A number of factors have likely contributed to the decline in the number of freestanding children’s hospitals. Among these factors is the belief that the integration of paediatric academic hospitals into academic health science centres will benefit child health service delivery through economies of scale with the elimination of duplicated services and expensive technologies.

Changes in these hospitals have occurred in some instances without anticipation of the impact of a new corporate structure or without the participation of paediatric health experts in the decision-making process. Failure to involve child health leaders in this process can lead to further problems in the delivery of specialized care to children given the inherent unpredictability of change in complex systems. The recent experience of the Children’s Hospital of Western Ontario (CHWO) within the London Health Sciences Centre (LHSC) in London, Ontario, illustrates the potential deleterious effects of planning system and program changes in a large academic hospital without child health input at the executive decision-making level. We hope that other academic centres can learn from London’s experience.

SIZING AND SCOPING

The CHWO is operated as a paediatric academic hospital within a comprehensive tertiary academic hospital (LHSC), which serves a population of 1.5 million people and approximately 400,000 children. It is the largest acute care hospital in southwest Ontario and is fully affiliated with the University of Western Ontario. Table 2 provides CHWO’s hospital activity statistics for 2002/2003. These data demonstrate that CHWO is a significant provider of paediatric care.

TABLE 2.

Activity statistics for the Children’s Hospital of Western Ontario for 2002/2003

	n
Patient discharges	3247
Children’s emergency visits	36,306
Day surgery/one-day stays	2604
Paediatric critical care unit admissions	684
Paediatric medical unit visits	12,350

In 2000/2001, a comprehensive review of LHSC’s clinical and academic programs, referred to as ‘sizing and scoping’, arose from the recommendations of a government-sponsored operational review. This review concluded that the LHSC could not continue to be ‘all things to all people’ and that difficult decisions were needed to retain some programs, while discontinuing others. The hospital administration established a Steering Committee to review 14 clinical programs or ‘clusters’. Paediatric administrators were involved in one of the cluster teams, with child health experts involved in others clusters such as medicine, surgery, psychiatry and transplantation. The recommendations of the cluster teams were brought to the Steering Committee and the LHSC Executive Leadership Team. These latter groups did not include physicians or senior administrators directly involved in child health care.

After some consideration of the impact on postgraduate training programs, the LHSC Executive Leadership Team decided to close selected tertiary programs. It did recognize that the consequences of terminating specific programs could not be fully anticipated or predicted, but it also believed that bold decision-making was required to achieve operational, clinical and financial efficiencies.

In October 2001, acting on the advice of the Executive Leadership Team, the Board of the LHSC endorsed a vision for child health care that did not support the appointment of a comprehensive array of paediatric subspecialists, and that terminated the Congenital Heart Surgery Program. The new vision called upon child health care leaders to ‘forego expansion’ of subspecialty programs in child health and the appointment of additional clinical teachers in a variety of paediatric subspecialties, including infectious diseases, gastroenterology, rheumatology, respirology and several surgical child health paediatric subspecialties, including neurosurgery, urology and plastic surgery. The Board believed that the needs of children requiring paediatric subspecialty care could be met by utilizing adult-trained specialists in a variety of disciplines, including internal medicine. Infants and children requiring tertiary and quaternary paediatric services were to be referred to other Ontario academic hospitals.

This vision for paediatric care endorsed by the Board was contrary to that of the University’s Department of Paediatrics and the paediatric cluster planning team; it was also contrary to the recommended vision of child health experts involved in a departmental review in June 2001. Furthermore, the Board recommendations were presented to the medical staff for implementation without a mechanism for review.

Paediatric physician leaders, including the Chair/Chief of Paediatrics during the strategic planning exercise, called for a review of the Board’s plan through the University, hospital and provincial government. Fortunately, the LHSC Board did agree to this review on the basis of new information. The Board’s decision helped quell increasingly bitter commentary in the local media. Although most of the concern was expressed over the loss of cardiac surgery, the London and southwest community interpreted the Board’s decision to not support paediatric specialty care as an indication that in the future, the hospital and its leadership may further reduce its support of paediatric specialized care programs. The Minister of Health, on behalf of the government of Ontario, did agree to review the sizing and scoping recommendations in paediatrics, including the decision to close the Congenital Heart Surgery Program.

All of these reviews identified concerns for the viability of paediatric academic programs in the face of continued small numbers of clinical teachers. They also reinforced the need for a comprehensive funding arrangement to support paediatric physicians engaged in the delivery of specialized care, education and research. The provincial review affirmed CHWO as a major provider of paediatric specialized care in Ontario and, ultimately, influenced the Board to change its position with respect to supporting the appointment of additional paediatric specialists. The Board also agreed to advocate for a comprehensive paediatric alternate funding arrangement to support specialized paediatric care.

However, the sizing and scoping proposal had resulted in the resignation of a number of child health specialists in a variety of disciplines. At the time of the announced sizing and scoping recommendation in October 2001, CHWO’s full-time paediatric subspecialty medical faculty exclusive of paediatric emergency specialists included 19 physicians, with one further specialist scheduled to begin a full-time appointment in early 2002. Over the ensuing months, eight specialists resigned their positions, with another physician deciding not to relocate to London. An additional paediatric surgical specialist also departed London.

LESSONS LEARNED

Process concerns

Our recent experience has shown us that a flawed decision-making process during the strategic planning for academic paediatric hospitals can yield decisions with undesirable and far-reaching impacts. LHSC’s sizing and scoping recommendations failed to define an effective strategy ahead of time to communicate the decisions being made and their rationale to all stakeholders, including the general public. The decision-making criteria used to end programs were not explicit, and there was an initial failure to acknowledge the need to revisit and revise decisions in light of new information. Overall, the process did not include a predetermined strategy for dispute resolution.

A paper by Gibson et al (13) on resource allocation in health services organizations outlines a framework for ethical priority setting based on five principles. The first condition is relevance, where all decisions must be based on evidence or principles. The second condition is publicity, or transparency. The third condition is revision, which allows for challenge and dispute resolution. The fourth and fifth conditions are enforcement and empowerment, respectively, which require public regulation of the process and minimization of power differentials in decision making.

Unanticipated outcomes

The decisions of the Executive Leadership Team and the LHSC Board were divergent from the vision of the paediatric health care providers and resulted in the resignation of a number of paediatric subspecialists, which compromised the department’s ability to deliver paediatric care and educate future professionals. It became clear that decisions taken by one group in a highly interdependent environment would likely impact other groups. For instance, closure of the Congenital Heart Surgery Program led to the resignation of paediatric critical care and cardiology specialists essential to the mission of a paediatric academic hospital.

It also became clear that the sizing and scoping exercise failed to understand and anticipate an increasing role for paediatric subspecialists in child health care delivery (14,15). Decision-makers assumed child health care could continue to be provided by subspecialists not specifically trained in tertiary- and quaternary-level paediatric care. This assumption did not take into account the fact that adult-trained specialists often feel uncomfortable and unprepared to care for children with unique health care needs. Paediatricians and paediatric subspecialists undergo four to seven years of postgraduate training almost exclusively with children, while some adult-trained subspecialists in internal medicine spend less than three months training with children (16). As a result, few adult specialists are prepared to care for children with complex, evolving health care needs. Dedicated paediatric medical and surgical sub-specialists play a unique role in the health care system by providing specialty and subspecialty clinical, educational and research expertise to children and youth.

FOLLOW-UP RESOLUTION

Fortunately, the LHSC Board listened to the concerns of departmental leadership and subsequently developed a formal decision review process based on explicit criteria. The provincial review did support the closure of the congenital heart surgical program, to be replaced by the creation of a province-wide paediatric cardiac care network. The hospital also developed a new corporate organizational structure to bring the concerns of child health professionals to health care planning. The government of Ontario established an alternate funding arrangement to enhance recruitment and retention of child health professionals to the university and to the southwestern Ontario region.

The lessons learned from this exercise may benefit other academic institutions anticipating changes in child health during this era of increasing consolidation, program integration and an aging population. Because Canada’s paediatric academic programs are now largely incorporated into larger academic centres serving both adults and children, lessons learned from the LHSC exercise are important factors to consider in maintaining Canada’s capacity to care for our sickest children and educate future child health professionals.