Table Of ContentTransforming the Delivery of
Operative Anesthesia Services
in Ontario
Report & Recommendations of the
Operative Anesthesia Committee
May 2006
TABLE OF CONTENTS
SUMMARY OF RECOMMENDATIONS.........................................................................1
EXECUTIVE SUMMARY ................................................................................................3
BACKGROUND AND CONTEXT...................................................................................4
OPERATIVE ANESTHESIA COMMITTEE.....................................................................6
UPDATE ON ACADEMIC ANESTHESIA SERVICES IN ONTARIO..............................8
ANESTHESIA CARE TEAM.........................................................................................10
Context............................................................................................................................10
Description of ACT Model...............................................................................................10
Anesthesia Assistants.....................................................................................................12
Benefits of the ACT Model..............................................................................................13
Challenges with the ACT Model......................................................................................14
NEXT STEPS .............................................................................................................19
APPENDIX 1 - STATUS REPORT ON ANESTHESIA SERVICES AT ONTARIO’S
ACADEMIC HEALTH SCIENCE CENTRES .......................................20
Transforming the Delivery of Operative Anesthesia Services in Ontario May 2006
Report & Recommendations of the Operative Anesthesia Committee
SUMMARY OF RECOMMENDATIONS
The 2004 Physician Services Agreement provided for the formation of the Operative Anesthesia
Committee (OAC) in recognition of the pressures facing operative anesthesia in Ontario’s
hospitals.
The OAC is to provide recommendations to support stable and adequate access to anesthesia
services in Ontario hospitals. The Agreement provides $5 million in new funding to support
operative anesthesia, based on the Committee’s recommendations.
After considerable deliberation and wide ranging consultation, including the OMA Anesthesia
Section meeting in September 2005, the OAC:
1) Asked Dr. Marshall to update his 2003 review of anesthesia services at Ontario’s AHSCs
and to gain an understanding of the current use of, support for and the potential of the
Anesthesia Care Team (ACT) concept to address the anesthesia shortage.
2) Defined the ACT model, outlining roles, responsibilities and training requirements. In
addition, the OAC identified the benefits and challenges associated with this new
approach to providing anesthesia services.
3) Established a costing sub-committee to explore current funding of operative anesthesia,
estimate the impact of investments in the 2004 Physician Services Agreement and
evaluate additional options to better support operative anesthesia.
Based on the work outlined above, a paper entitled Transforming the Delivery of Operative
Anesthesia Services in Ontario was developed by the OAC. This document recommends:
#1 Formal introduction of the ACT model
Establish ACT demonstration sites in Academic Health Sciences Centres (AHSCs) and
community hospitals. Evaluate the demonstration sites, modify the model and set
minimum requirements for viability and expected outcomes. Explore different funding
models for ACTs (e.g. APP, AFP, fee-for-service). Roll out the ACT model across the
province.
#2 Widespread training and use of anesthesia assistants in the delivery of anesthesia
services in a variety of practice settings (e.g. AHSCs and community hospitals)
Bring together a group of stakeholders to develop a common definition of anesthesia
assistant, define their roles and responsibilities and agree on training requirements.
Introduce and/or expand training opportunities across Ontario.
#3 Changes to the Schedule of Benefits, which will allow the use of supervision in a
fee-for-service practice environment and encourage the provision of operative
anesthesia services
Replace the anesthesia fee (base & time units) with a supervisory payment when
someone other than an anesthesiologist provides anesthesia care. Reinvest the savings
achieved through this change to the Schedule of Benefits in other anesthesia services.
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Further support the provision of operative anesthesia services through other specified
investments.
The Committee agreed that the above-noted recommendations must be considered in their
entirety and not as a collection of stand-alone recommendations.
The Committee is now focused on costing the proposed recommendations:
(cid:190) ACT model demonstration sites for AHSCs and community hospitals
(cid:190) Supervisory payments
(cid:190) Schedule of Benefit changes (e.g. triple time units for intra-operative anesthesia)
The OAC plans to finalize all documents and recommendations for submission to the Physician
Services Committee by June 2006.
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EXECUTIVE SUMMARY
For several years the Canadian anesthesiology community has been concerned about a growing
shortage of anesthesia personnel. This national shortfall was made particularly relevant to Ontario in
light of the provincial government’s announcement of its Wait List Initiative in the Fall of 2003. Even
though anesthesiologists sacrificed academic activity to ensure the provision of clinical services,
surgical wait times continued to grow, operating rooms were closed and surgeries cancelled.
Despite recent efforts to address the situation, including increasing medical school enrollment and
anesthesia residency training positions and investing in academic anesthesia services, the
anesthesia shortfall continued to grow. The Ontario Medical Association (OMA) and the Ministry of
Health and Long-Term Care (MOHLTC) recognized that immediate action was required and called
for the establishment of the Operative Anesthesia Committee (OAC) in the most recent Physician
Services Agreement.
To support stable and adequate access to anesthesia services in Ontario hospitals, the OAC is
calling for the formal introduction of Anesthesia Care Teams (ACTs). The ACT is an innovative
model of care which calls for a significant change to the way anesthesia services are currently
provided. Specially trained other health professionals assist in the provision of anesthesia services
under the direct supervision of an anesthesiologist. This model of care will provide better access to
anesthesia services in a more efficient and cost cost-effective manner. It will also allow all ACT team
members to fully utilize their skills and experience in the provision of anesthesia services, a key
component in transforming the provision of
health care.
Outlined below are the Committee’s 3 major recommendations. The steps suggested to implement
these recommendations are detailed in the report:
#1 Formal introduction of the ACT model
Establish ACT demonstration sites in Academic Health Sciences Centres (AHSCs) and
community hospitals. Evaluate the demonstration sites, modify the model and set minimum
requirements for viability and expected outcomes. Explore different funding models for ACTs
(e.g. APP, AFP, fee-for-service). Roll out the ACT model across the province.
#2 Widespread training and use of anesthesia assistants in the delivery of anesthesia
services in a variety of practice settings (e.g. Academic Health Sciences Centres and
community hospitals)
Bring together a group of stakeholders to develop a common definition of anesthesia
assistant, define their roles and responsibilities and agree on training requirements.
Introduce and/or expand training opportunities across Ontario.
#3 Changes to the Schedule of Benefits, which will allow the use of supervision in a fee-
for-service practice environment and encourage the provision of operative anesthesia
services
Replace the anesthesia fee (base & time units) with a supervisory payment when someone
other than an anesthesiologist provides anesthesia care. Reinvest the savings achieved
through this change to the Schedule of Benefits in other anesthesia services. Further support
the provision of operative anesthesia services through other specified investments.
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BACKGROUND AND CONTEXT
Shortage of Anesthesiologists
The shortage of anesthesiologists is a growing concern across all jurisdictions in and outside of
Canada. Many studies have examined the supply of anesthesiologists and have confirmed that there
are insufficient numbers to meet current and predicted future demands.
Two recent Canadian studies found the current supply of anesthesiologists to be inadequate and
forecast an increasing deficit over time. While the magnitude of the problem varies from province to
province and continues to worsen, Ontario appears to have the largest absolute shortfall of
anesthesiologists in Canada.
• The Ryten Report, commissioned by the Association of Canadian University Departments of
Anesthesia, identified an 8% shortfall of anesthesiologists in Canada (114 in Ontario) in 2000.
This same study projected the deficit would grow to 656 anesthesiologists in Canada (459 in
Ontario) by 2016.
• The 2002 Engen Study identified an immediate need for 228 full-time equivalent (FTE)
anesthesiologists in Canada and suggested that by 2007 560 FTE anesthesiologists would be
required.
There are several factors associated with the increasing shortage of anesthesiologists in
Canada:
• The 1991 Barer Stoddart report, Toward Integrated Medical Resource Policies for Canada,
resulted in an 11.3% reduction in Canadian medical school enrollment over three years in the
early 1990s. This was followed by a similar reduction in postgraduate positions in 1997.
• The opportunity for pursuing specialty training after becoming licensed as a physician in Ontario
(re-entry) was closed with the introduction of the Regulated Health Professions Act in 1993. Prior
to 1993, physicians could get a license to practice medicine in Ontario once they completed their
1-year rotating internship. Under this system, licensed physicians were able to access residency
positions to complete specialty training and a significant number of residency spots were
available for practicing physicians returning to training. The Act eliminated the 1-year rotating
internship as a pathway to licensure and required that physicians complete either a 2-year family
medicine program or a 4 - 5 year specialty training program in order to qualify for independent
practice. In doing so, the informal pathway to reentry was closed.
• Effective July 1997, the Royal College of Physicians and Surgeons of Canada no longer
recognized non-North American medical school training as meeting part of the requirements for
its own specialty training programs thereby limiting the supply of International Medical
Graduates.
Impact on Operative Anesthesia
The anesthesiologist shortage in Ontario has resulted in growing surgical wait times, cancelled
surgeries, operating room closures and delays in diagnostic testing. The role of the anesthesiologist
outside the operating room has also expanded over time and this has compounded the negative
impact on operative anesthesia. The institution of same-day admission policies in the 1990s
imposed the need for pre-anesthetic clinics to assess and evaluate patients before surgery.
Simultaneously, the development of sophisticated post–operative pain services has resulted in
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multiple post-operative visits by anesthesiologists, further encouraged by fee-for-service
remuneration.
Recent Efforts to Address Ontario Shortfall
Since the late 1990s, a number of steps have been taken to address the anesthesiologist
shortage in Ontario. These efforts include:
• Ontario medical school enrollment has increased by 34%, growing from 526 positions in 1994 to
704 positions in 2004.
• Ontario anesthesia residency training positions have increased by 32%, growing from 140
positions in 1998 to 185 positions in 2004.
• International Medical Graduates (IMGs) are now recruited under academic certificates issued by
the College of Physicians and Surgeons of Ontario.
• A formal re-entry program has been established beginning with 25 positions for both third year
family medicine and specialties. In 2000, a further 15 spots were added bringing the total to 20
spots for family medicine and 20 spots for specialties. Physicians are required to return a
maximum of two years in an under-serviced area in return for government funded training.
• $6 million annually was invested in academic anesthesia services beginning in 2003 resulting in
the recruitment of 39 FTE anesthesiologists at Ontario’s Academic Health Science Centres
(AHSCs). Dr. John Marshall was asked to review anesthesia services, staffing, compensation
and workload at Ontario’s AHSCs and provide recommendations that led to this new investment.
• An Anesthesia Assistant Graduate Certificate Program was launched at the Michener Institute.
This is a joint initiative involving the Michener Institute and the University of Toronto. The
program, which originally offered basic or technical training, has recently expanded to include
advanced or clinical training. Applicants’ skills and experience are assessed to determine their
point of entry into the program.
• The Operative Anesthesia Committee was established in June 2005.
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OPERATIVE ANESTHESIA COMMITTEE
2004 Physician Services Agreement
The 2004 Physician Services Agreement provided for the formation of the OAC in recognition of the
pressures facing operative anesthesia in Ontario’s hospitals. According to Section 27.3 of the 2004
MOHLTC-OMA Physician Services Agreement:
“The Parties agree that there is an urgent need to address the challenges
facing operative anesthesia in Ontario’s hospitals. Accordingly, the Parties
agree to establish a committee with representation from the OMA and
MOHLTC to develop recommendations for addressing this issue in a
timely fashion including opportunities for Schedule of Benefits redefinition,
other physician payment strategies and the use of anaesthesia extenders.
This committee will consult with the OHA as appropriate. The MOHLTC
agrees to provide physician funding beginning October 1, 2005.”
The Agreement also provides over $52 million in annual funding for anesthesia services including
increases to unit fees and base units ($26 M+), targeted fee increases ($7M+), increased and
expanded hospital on-call coverage payments ($13 M) as well as new funding to support operative
anesthesia ($5M). Use of funding to support operative anesthesia is to be based on the
recommendations of the OAC
OAC Terms of Reference
The OAC is to provide recommendations to support stable and adequate access to anesthesia
services in Ontario hospitals. Areas of focus include:
• Understanding current and anticipated service demands and workforce issues
• Short and longer term strategies to support the use of anesthesia assistants
• Applicability of various funding approaches
• Consideration of changes to fee-for-service payment program
• Discussion of longer term alternate funding approaches
• Impact of short and long term recommendations on the Wait Time Strategy
• Other longer term recruitment and retention strategies for anesthesia
• Potential impact on anesthesia requirements in the Local Health Integration Network
environment
The OAC consists of five members appointed by each of the OMA and MOHLTC (see table
below for details). The Chair, Dr. Jack Kitts, was appointed jointly by the OMA and
MOHLTC.
Operative Anesthesia Committee – Membership
Chair/Facilitator – Dr. Jack Kitts
OMA MOHLTC Support
Dr. David Bevan Ms. Bernita Drenth Ms. Danielle Claus, Consultant
Dr. Steve Brown Ms. Susan Fitzpatrick Ms. Honorata Bittner, PSC Secretariat
Dr. John Cain Dr. Alan Hudson Mr. David Mackey, PSC Secretariat
Dr. Geraint Lewis Mr. Hugh MacLeod Mr. Jim Simpson, OMA
Dr. John Marshall Ms. Peggy Taillon, The Ottawa Hospital
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Committee Focus
The OAC has closely examined current and planned initiatives to address the anesthesiologist
shortage. While encouraging, it is clear that significant additional effort is required, effort that looks
beyond existing service and funding models in order to better meet current and future service
demands. After considerable deliberation and wide ranging consultation, including the OMA
Anesthesia Section meeting in September 2005, the OAC:
1) Asked Dr. Marshall to update his 2003 review of anesthesia services at Ontario’s AHSCs and to
gain an understanding of the current use of, support for and the potential of the ACT concept to
address the anesthesia shortage.
2) Clearly defined the ACT model, outlining roles, responsibilities and training requirements. In
addition, the OAC identified the benefits and challenges associated with this new approach to
providing anesthesia services.
3) Established a costing sub-committee to explore current funding of operative anesthesia estimate
the impact of investments in the 2004 Physician Services Agreement and evaluate additional
options to better support operative anesthesia.
This report focuses on the ACT model. A separate paper, which deals with the funding of operative
anesthesia, is currently under development.
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UPDATE ON ACADEMIC ANESTHESIA SERVICES IN ONTARIO
Methodology
Questionnaires were sent to the Chiefs of Anesthesiology and to the Directors or Managers of Peri-
operative Services at each of the AHSC institutions. Following the return of the questionnaires, Dr.
Marshall conducted telephone interviews with each Anesthesiology Chief and Peri-Operative
Services Manager. The interviews at the two children’s hospital were conducted in person, as these
sites were not included in the original report.
The purpose of the interviews was two-fold. First, confirm the data submitted in the returned
questionnaires and clarify any ambiguity. Second, obtain an understanding as to how specific
services were delivered at each site with particular focus on the roles played by anesthesia
assistants and nurses in supporting anesthesia activities at each stage of the peri-operative process.
Findings
A summary of Dr. Marshall’s findings is outlined in the chart below. There are two points of particular
interest. First, it appears the anesthesiologist shortfall across Ontario AHSCs has not changed
significantly between February 2003 and November 2005. This is due to an almost parallel increase
in the volume of services (expressed as Daily Anesthetic Locations) and the general increase in FTE
anesthesiologists, 35 and 42 respectively. This reflects the pent up demand for services met by the
increasing staff complement. In the absence of the $6 million investment annually, which assisted in
the recruitment of the 42 FTE anesthesiologists, the situation at AHSC would be profoundly worse.
Staffing Formula Components Feb.2003 Nov.2005 Difference % Change
Daily Anesthetic Locations 323.5 358.2 34.7 10.7%
Required Anesthesia FTE 398.7 446.2 47.6 11.9%
Actual Anesthesiologist FTE 333.7 375.4 41.7 12.5%
Actual Assistant/RN Equivalent 5.9 15.6 9.7 163.6%
Anesthesiologist FTE
Shortfall FTE 59.1 55.3 -3.8 -6.4%
Second, the use of other health professionals to assist in the provision of anesthesia services has
grown significantly in the last two to three years. In February 2003, these individuals represented
approximately 6 anesthesia FTEs, while in November 2005, they represented almost 16 FTEs, a
growth of 164%. These individuals contributed significantly to reducing the anesthesia shortfall.
Without anesthesia assistants and registered nurses (RNs), the anesthesiology shortage would have
been 65 FTE instead of the 55 FTE.
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Description:The 2004 Physician Services Agreement provided for the formation of the
Operative Anesthesia. Committee (OAC) in recognition of the pressures facing
