After reading through the Hay Group's 400-page report formally titled the "Operational Review and Clinical Audit of The Ottawa Hospital" it felt like I was back on the board. The report rivaled the size the board package I used to receive a few days before each monthly meeting.

However, it seems that Ottawans have followed The Ottawa Hospital (TOH) story with only a passing interest. So here is the Coles notes (I'm quickly dating myself) version.

TOH employs some 9,000 people, has a medical staff of 1,200 and its budget is about half a billion dollars. It is a 932 bed facility spread across three campuses and in fiscal 1999/2000 it racked up 394,161 inpatient days, 139,2444 emergency visits and over 1,000,000 ambulatory care visits (read: dialysis, specialty clinics, etc.) and diagnostic imaging visits.

It is affiliated with the Ottawa Hospital Research Institute (a merger of the Loeb Institute at the Civic and the General campus research group), the Ottawa Regional Cancer Centre, the Heart Institute, and the University of Ottawa faculties of medicine and health sciences. As well it is the regional hospital for an area stretching from Kingston to North Bay to Cornwall. And with all due respect to CHEO, it is the most critical and valuable public institution in Eastern Ontario.

But as the Hay report points out, with a projected working funds deficit of $141 million for 2000/2001, not to mention some $400 million required for HSRC (the restructuring commission from a few years back) and other capital improvements "the financial position of the hospital is clearly unsustainable."

As for the Board and management, the Hay report stated they as yet had "not … yet formally articulated (a) desired role in responding to the health needs of the community nor developed long-range or strategic plans to guide its future growth and development."

And as I noted on Wednesday, the only strategy TOH pursued was one of more money from the Ministry of Health. The Hay group was resolutely and repeatedly critical of this one-track strategy. The Hospital perceived it was entitled to more money.

Entitlement is the key word here. Indeed, it opens a window to the larger challenges in health care. Too start, hospitals in the long-run will be "entitled" to less real funding per patient, not more. This is due to the fact that more and more health care, according to the Canadian Institute of Health Information (CIHI), is being delivered outside of hospitals.

In 1975, almost 45% of health care expenditures (public and private) in Canada were consumed by hospitals. By 2000, this amount decreased to 32%. Over the same period, total expenditures on physicians declined slightly from 15% to about 12%. Conversely, a larger share of Canada's total $95 billion annual health care tab (some 9.2% of GDP) is now being spent on drugs (prescription, etc.) other allied health and non-traditionalproviders as well as in other institutions such as private MRI clinics, laser eye-surgery centres and other specialty facilities.

Part of this is natural due to advancements in technology and less invasive surgical procedures that can be performed outside of traditional hospitals. So where does this leave hospitals? Ideally, to be providing the more specialized and complicated care, referred to as tertiary care. Examples include cancer treatments and resections, trauma services, neurosurgery and organ transplantation.

Indeed, many facilities around Ontario are doing just this. These peer hospitals as they are referred to do receive more funding by various measures as TOH has repeatedly pointed out. But the Hay group report counters this claim somewhat by pointing out that TOH does less of this tertiary care than its peers. Moreover, the Hay report makes it perfectly clear that TOH continues to exceed what it should be doing in the areas of primary and secondary (less complex) care.

And even with lighter volumes (by comparison) of tertiary (again read complex) cases, TOH still has the longest length of stay of any of its peer hospitals and the worst cost over-runs in terms of its actual cost per weighted case (or patient) versus it expected cost per weighted case.

The Hay group also notes that TOH has the best access to extra revenue generation due to our proximity to Quebec and out-of-province billing as compared to TOH's peers. Not to mention the clinical and operating efficiencies, to the tune of $30 million plus annually, that were identified in the report that TOH could have been acting upon up to two years ago.

To be fair, the Ontario government does not escape blame in this sad scenario. As Duncan Sinclair, former chair of the HSRC noted, the government should have merged hospitals last, not first. Primary care reform along with province-wide information technology upgrades for medical record transference and quality control and report should have been pursued first.

As well, province wide wage settlements for nurses were out of the hospital's (all hospitals for that matter) control. And wage harmonization to the highest common denominator was inevitable. Neither of these exigencies was fully factored into Ministry of Health budget allocations for hospitals.

In summary, given the importance of TOH to this city and a good chunk of Eastern Ontario, the province had no choice but to pursue the path it did.

The challenge now is for Dennis Timbrell, pending Cabinet approval, to sort through the Hay group report and get the management team to do what the Board could never do: make tough and necessary decisions to improve clinical and operational efficiencies.

As well, Mr. Timbrell should take a look at the escalations in senior management salaries that took place will the hospital's deficit ballooned. In addition, combing through the hospital's books to track and trace every Ministry announcement of one-time funding along with multi-year improvements to base budget allocations is required.

When Mr. Timbrell's work is done, he will no doubt recommend funding changes, most likely increases, for the Ottawa Hospital, which along with some $30 million or more in efficiencies should put the hospital on the road to recovery in concert with other improvements, including provincially promised long-term care beds, will restabilize our local health care system.

Finally, before he leaves town, Mr. Timbrell must recommend a process to the province for a governance framework - probably a new board - that will ensure that a situation like the one we find ourselves in now, never occurs again.