2014-17 Multi-Sector Service Accountability Agreement (M-SAA)An Overview

Presentation to Health Service ProvidersJanuary 10, 2014

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Development and Preparation of the M-SAA

Template Agreement Components

Schedules

Indicators

Next Steps

Questions

2014-17 M-SAA An Overview

• A tool to bring all the various contractual agreements between community HSPs and the LHINs into one document

• Required under LHSIA and Ministry-LHIN Performance Agreement (MLPA)

• A vehicle to delineate accountabilities and performance expectations

• A mechanism to clarify that the HSP will be responsible for performance as well as planning and integration towards the development of a health system

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What is an M-SAA?Core lever for HSP accountability and performance management

• Consistent template agreement for all community sector HSPs developed through comprehensive consultation with HSP associations and member representatives (membership listed in Appendix 1)

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Pan-LHIN Development, Local ExecutionDeveloping provincial templates for local execution

• Schedules for each sub-sector (CCAC, CHC, MH&A and CSS) developed through consultation with sub-sectors

• Individual LHINs negotiate performance indicator targets with each HSP in alignment with pan-LHIN guidelines

• The M-SAA Advisory Committee is co-chaired by Louise Paquette and Scott McLeod and brings together senior executives from M-SAA sector associations, community HSPs and the LHINs to provide a central forum for enabling dialogue on provincial M-SAA issues

• The Committee is guided by the following principles:

• The process is undertaken with a spirit of trust and collaboration among the province’s community HSPs, sector associations and the LHINs.

• The M-SAA will align with provincial health system priorities and be consistent with MOHLTC policy, legislation and regulations.

• The M-SAA will strive to streamline processes, minimize administrative burden and provide clarity for HSPs where possible.

• Committee membership is shown below

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M-SAA Development PrinciplesEnabling close ongoing collaboration with the Community Sector

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M-SAA StructureComprehensive Consultation through Multiple Tables

M-SAA Advisory Committee

M-SAA Indicators Work Group

M-SAA Planning & Schedules Work Group

M-SAA INDICATOR SUPPORT: HEALTH SYSTEM INDICATOR INITIATIVE

M-SAA LEGAL COUNSEL SUPPORT: LHIN LEGAL SERVICES BRANCH

M-SAA SECRETARIAT SUPPORT: LHIN COLLABORATIVE

LOCAL M-SAA IMPLEMENTATION: LHIN M-SAA LEADS

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M-SAA Advisory Committee MembershipSector Organization Individual, Title

LHIN NE LHIN Louise Paquette, CEOLHIN CW LHIN Scott McLeod, CEOLHIN NE LHIN Kate Fyfe, Senior DirectorLHIN CW LHIN Brock Hovey, Senior DirectorLHIN CW LHIN Neil McIntosh, DirectorCHC AOHC Adrianna Tetley, Executive DirectorCHC Davenport Perth

Neighbourhood CHC Kim Fraser, Executive Director

CSS OCSA David Hughes, Director, Membership DevelopmentCSS CANES Community Care Gord Gunning, CEO

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M-SAA Advisory Committee Membership continued

Sector Organization Individual, TitleCMH&A Addictions & Mental Health

OntarioDavid Kelly, Executive Director

CMH&A CMHA Ontario Camille Quenneville, CEOCMH&A CMHA Toronto Steve Lurie, Executive DirectorCCAC OACCAC Sharon Baker, COOCCAC CE CCAC Don Ford, CEOLTC OANHSS Jeff Graham, Director, Public PolicyLTC City of Toronto Reg Paul, General Manager, LTC Homes & ServicesLTC OLTCA Paula Neves, Director of Health Planning and ResearchLTC Extendicare Inc. Christina McKey, VP, Eastern Operations

M-SAA Advisory Committee Established to provide advice to the LHIN CEOs and support for the completion of the

2014-17 M-SAA template agreement and schedules in alignment with provincial strategic directions.

M-SAA Indicators Work Group Established to support the M-SAA Advisory Committee. Based on direction from the

LHIN CEOs, the Work Group is responsible for producing a series of documents and recommendations including a list of recommended M-SAA indicators, technical specifications, target setting guidelines and education materials.

M-SAA Planning & Schedules Work Group Established to support the M-SAA Advisory Committee. Based on direction from the

LHIN CEOs, the Work Group is responsible for producing a series of documents and tools including M-SAA Schedules, CAPS forms and planning submission guide and educational documents.

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LHIN/Sector ResponsibilitiesAdvisory Committee and Work Group Mandates

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LHIN/HSP Accountability RelationshipHow do the various CAPS/M-SAA components fit together?

Community Accountability

Planning Submission(CAPS)

è

Multi-sector Service Accountability

Agreement(M-SAA)

èQuarterly Reports

[Ontario Healthcare Report Standards (MIS)]

è

RemediationNegotiation,

Implementation of Consequences

Planning Commitment Measurement Adjustment

Negotiations/Consultations Negotiations

LHINs are responsible for:

• Training and supporting HSPs through the CAPS and M-SAA processes

• Negotiating performance targets within the context of a provincial framework

• Monitoring the achievement of specific performance goals under the M-SAA and ongoing performance management

HSPs are responsible for:

• Ensuring governance and operations that support high quality care

• Promoting leading performance improvement approaches

• Providing access to high quality health services and coordinated health care in an effective and efficient manner

• Identifying integration opportunities and engaging the public and stakeholders in any planned service changes.

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LHIN/Sector ResponsibilitiesWhat are the responsibilities of the LHINs and the HSPs?

LHINs revised language in the 2011-14 M-SAA that required updating or would benefit from greater clarity as a draft 2014-17 M-SAA for sector feedback.

Three 3-hour M-SAA Advisory Committee meetings to review and discuss comments and suggestions on draft 2014-17 M-SAA.

175 sector comments received and individually addressed.

Committee endorsed 2014-17 M-SAA and Schedules on December 17, 2013.

Pan-LHIN commitment to reduce, align and enhance consistency of local indicators.

Committee will continued to meet throughout the life of the agreement to advance M-SAA related priority issues.

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Process for Finalizing New M-SAAAt a high level, how was the M-SAA developed and finalized?

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M-SAA Content – ArticlesArticle 1 Definitions & InterpretationClarifies terminology used throughout the document.

Article 2 Term and Nature of the AgreementDefines the term of the service accountability agreement as April 1, 2014 to March 31, 2017 .

Article 3 Provision of Services Describes how services will be provided in accordance with legislation, applicable policies, e-health/IT compliance and the terms of this agreement. Discusses subcontracting services and conflict of interest.

Article 4 FundingOutlines conditions of funding, payment and provision limitations. Procurement and disposition of goods and services are also described.

Article 5 Repayment and Recovery of FundingDefines circumstances under which funding may be adjusted and/or recovered

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M-SAA Content - Articles continued

Article 6 Planning & IntegrationDiscusses multi-year planning CAPS requirements in alignment with LHIN IHSP and priorities.

Article 7 Performance Discusses the need for ongoing performance improvement and the mitigating process in the event of performance factors (non-performance).

Article 8 Reporting, Accounting and ReviewDescribes the obligations of reporting and record maintenance, French language requirements, disclosure of information, transparency and reviews.

Article 9 Acknowledgement of LHIN SupportHSP publications are required to note LHIN support, be approved by the LHIN, and indicate views do not necessarily reflect those of the LHIN or Government.

Article 10 Representations, Warranties and CovenantsConfirms the HSP’s ability to enter into the agreement and carry out the funded services with the appropriate governance, personnel and documentation.

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M-SAA Content - Articles continued

Article 11 Limitation of Liability, Indemnity & InsuranceOutlines the limitation of liability and indemnification for the LHINs and the required insurance provisions for the HSP.

Article 12 Termination of Agreement Describes the parameters for termination of the agreement by the LHIN and by the HSP.

Article 13 NoticeDetails how notices to a party must be provided.

Article 14 Additional ProvisionsIdentifies additional provisions to the agreement.

Article 15 Entire AgreementDefines the agreement as constituting the entire agreement, superseding all prior agreements.

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M-SAA Content - Schedules

Schedule Title DescriptionA Description of Services Describes the services delivered by the HSP, client

populations and geography served

B Service Plan Describes the financial and statistical status of the HSP

C Reports Identifies, describes and sets due dates for HSP reporting

D Directives, Guidelines, Policies Identifies applicable MOHLTC policies

E Performance Identifies indicators, standards and local performance requirements

F Template for Project Funding Template used for funding special projects

G Declaration of Compliance Form to be completed by the HSPs Board of Directors to declare that the HSP has complied with the terms of the Agreement

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Summary of Main Changes - SchedulesWhat are the key changes between current and new Schedules?

SCHEDULE DIFFERENCE COMMENTSSchedule A • None

Schedule B • Schedule B1 - Added row 2 (HBAM) and row 3 (QBP) planning targets along with their functional centres for use by CCAC’s

Schedule C • Revised dates revised to reflect appropriate reporting period.

• Updated to reflect that Supplementary Reporting (including AAH) - Quarterly Report and Annual Reconciliation Report (ARR) will be reported through SRI

• Self Reporting Initiative (SRI) has replaced the Web Enabled Reporting System (WERS) for reporting

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Summary of Main Changes (continued)

What are the key changes between current and new Schedules?

SCHEDULE DIFFERENCE COMMENTSSchedule D • Updated to reflect current directives, guidelines

and policies

• Added Guideline for Community Health Service Providers Audits and Reviews, August 2012

• Added note indicating that the Community Financial policy is currently under review

• Intended to LHINs in undertaking a transparent process in identifying and responding effectively and consistently to HSPs

• Review process includes MOHLTC, LHINS and community sector representatives

Schedule E • See update from Indicators Work Group

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Summary of Main Changes (continued)

What are the key changes between current and new Schedules?

SCHEDULE DIFFERENCE COMMENTSSchedule F • Updated to reflect HSP “services” rather than

“deliverables”Schedule G • Added Appendix 1 - Exceptions

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2014 – 17 M-SAA Indicators

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Health System Indicator Initiative (HSII) Schedule E Indicators Performance Standards Targets Setting Indicator Work Group Focus and Approach Summary of Indicators & Technical Specifications

– Core Indicators– Community Health Centres (CHC) Indicators– Community Care Access Centres (CCAC) Indicators– Community Service Sector (CSS) Indicators– Mental Health & Addiction (MH&A) Indicators

Introducing the Indicators

• In April 2010, the LHIN-led HSII was established to create a coordinated, system-based approach to indicator identification, development, maintenance and reporting.

• Central to the mandate of HSII is the close collaboration with provincial and national partners in order to leverage their organizational expertise related to indicator development, benchmarking, data extraction, and analysis.

• The revised mandate introduced in September 2013 provides a greater focus on alignment to system priorities, advancing system performance improvement through the SAAs and other mechanisms, and enabling monitoring and reporting.

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Performance IndicatorsHealth System Indicators Initiative (HSII)

The Performance Schedule (Schedule E) contains the following two indicator sections:

1. Pan-LHIN Indicators are developed through the M-SAA Indicators Work Group through HSII (core indicators are relevant to all LHINs and all community sector HSPs; sector-specific indicators are only relevant to a specified sector).

• Performance Indicators are measures of HSP performance for which a Performance Target is set; Technical specifications of specific Performance Indicators can be found in the “M-SAA 2014-17 Indicator Technical Specifications” document.

• Explanatory Indicators are measures of HSP performance for which no Performance Target is set. Technical specifications of specific Explanatory Indicators can be found in the “M-SAA 2014-17 Indicator Technical Specifications” document.

2. LHIN-Specific Performance Obligations: A section where each LHIN adds specific performance objectives and obligations for their HSPs is included. LHINs are committed to minimizing any undue burden placed on providers with respect to performance management by focusing on a limited number of outcome indicators aligned with local priorities.

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Performance Indicators (Schedule E)Pan-LHIN Performance Indicators and LHIN-Specific Obligations

• All performance indicators have an associated target and standard of performance. Variance outside of the standard triggers the performance management processes in Article 7 of the M-SAA.

• The LHIN or the HSP can identify a Performance Factor that “…could or will significantly affect a party’s ability to fulfill its obligations under the Agreement.”

• The identification of a Performance Factor is made formally, in writing, to the other party and will include a description of the Factor’s actual or anticipated impact and a description of any action the party is undertaking, or plans to undertake, to remedy or mitigate the Performance Factor.

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Performance IndicatorsWhy Performance Standards?

• Following the submission of the CAPS, LHINs and HSPs discuss indicator targets that are appropriate to each organization and its local circumstances. Targets are expected to reflect performance and drive continuous improvement.

• To complete the targets and corridors for the performance indicators, the following principles will be employed:

• Where provincial targets and corridors exist, the LHINs and HSPs will take these into consideration

• Where appropriate, use past experience from M-SAA and MLPA indicators

• Incorporate analyses of historical variation to inform corridor recommendations

• Use % range for financial and volume indicators

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Performance Indicators Continued

How are Indicator Targets and Corridors Determined?

How a LHIN chooses to deal with an indicator outside the corridor depends on a number of factors, including:

• What is the realized and/or potential impact on the clients served?• Is this the first blip on an otherwise clean performance record?• Is this a unique event and unlikely to recur?• Are other areas of the organization or other HSPs affected?• What is the LHINs confidence in the HSPs ability to manage

performance going ahead?

Depending on the above, the LHIN could choose to start with a less formal tact. The formal process is always available...and can be triggered at any point.

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Performance ManagementHow are Performance Factors Addressed?

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Review current indicators and develop recommendations

to reduce the number of indicators

Develop recommendations regarding the definition and

target setting approach for the administrative indicator

calculation

Align existing indicators with pan-LHIN imperatives

Indicator Work Group Focus & Approach

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Balanced budget - Fund type 2 Proportion of budget spent on administration Variance forecast to actual expenses Percentage total margin Service activity by functional centre Variance of forecasted to actual units of service Number of individuals served Percentage of Alternative Level of Care (ALC) days

Core (All Sectors)Performance Indicators

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Cost per individual serviced by program/service/functional centre

Cost per unit of service by functional centre Client experience (New Category)

Details: – Moved from being only an explanatory indicator

for the Mental Health and Addiction sector– Indicators Work Group identified need to

enhance linkage with quality and patient experience for all sectors

Core (All Sectors)Explanatory Indicators

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Access 1: 90th Percentile Wait Time From Hospital Discharge to Service Initiation (Hospital Clients)

Access 2: 90th Percentile Wait time from Community Setting to Community Home Care Services

* Percentage people registered with Health Care Connect who are referred (Retired)

Details:– Reporting obligations are already in place with the

Ministry

Community Care Access CentresPerformance Indicators

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Access: Wait time 1. 90th Percentile wait time from hospital discharge to service initiation (hospital clients) by population groups (short stay, short stay rehab, long-stay complex)

Access: Wait time 2. 90th percentile wait time from Community setting to community home care services by population groups (short stay acute, short stay rehab, long-stay complex)

Average monthly cost per episode (adult short stay, adult long-stay complex, end of life, children medically fragile)

Clients with MAPLe scores high and very high living in the community supported by CCAC (New Category)

Clients placed in LTCH with MAPLe scores high and very high as a proportion of total clients placed (New Category)

Community Care Access CentresExplanatory Indicators

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Clients with MAPLe scores high and very high living in the community supported by CCAC

Clients placed in LTCH with MAPLe scores high and very high as a proportion of total clients placed

Details:– Moved from CCAC performance indicator category – Indicators fit this category and provide valuable

information about how the system is functioning and the opportunities for change

– Indicators are not a good measure for performance as targets are set locally by each LHIN

Community Care Access CentresNew Explanatory Indicators

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* Percentage of clients with a new or existing pressure ulcer that failed to improve (Retired)

* Medication safety (Retired)* Percentage of home care clients who say they have

fallen in the last 90 days (Retired)

Details – Indicators retired as developmental – Indicators were not identified by HQO as on the

Common Quality Agenda

Community Care Access CentresDevelopmental Indicators

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Number of persons waiting for service (by functional centre)

Community Support ServicesExplanatory Indicator

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Average number of days waited for first service (by functional centre) (New Category)

Details:– Moved from CSS Explanatory indicator category as

the data is not yet available– Move to explanatory in years 2 or 3

* Repeat unscheduled emergency visits within 30 days for mental health conditions (Retired)

* Repeat unscheduled emergency visits within 30 days for substance abuse conditions (Retired)

Details: – Indicators are difficult to measure - cannot follow

clients between the hospital and the community

Community Support ServicesDevelopmental Indicators

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Community Health Centres Performance Indicators

Cervical cancer screening Colorectal Screening rate Inter-professional diabetes care rate Influenza vaccination rate Breast cancer screening rate Periodic health exam Vacancy Rate (for NPs and Physicians) Access to primary care clinical service (New)* Individuals served by functional centre (Retired)

Details:– Already a Core indicator

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Community Health Centres Explanatory Indicators

Emergency visits best managed elsewhere (New)

Client satisfaction – Access (New)

Clinical support staff per primary care provider (New)

Cultural interpretation (New)

Exam rooms per primary care provider (New)

New grads/new staff (New)

Number of new patients (New)

Non-Primary Care activities (New)

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Community Health Centres Explanatory Indicators Cont’d

Number of registered clients (New)

Specialized care (New)

Supervision of students (New)

Third next available appointment (New)

Non-insured clients (New)

* Repeat unscheduled emergency visits within 30 days for mental health conditions (Retired)

* Repeat unscheduled emergency visits within 30 days for substance abuse conditions (Retired)

Details:– Data is a challenge as the cell size is small

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Community Health Centres Developmental Indicator

CHC clients hospitalized for Ambulatory Care sensitive conditions

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Community Mental Health & AddictionExplanatory Indicators

Number of days waited from referral/application to initial assessment complete

Average number of days waited from initial assessment complete to service initiation

Repeat unscheduled emergency visits within 30 days for mental health conditions (New Category)

Repeat unscheduled emergency visits within 30 days for substance abuse conditions (New Category)

Details: Moved to Explanatory indicator * Client experience (Retired)

Details: Moved to Core indicator

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OCAN/GAIN Indicator

Community Mental Health & AddictionDevelopmental Indicator

The LHINs are working collaboratively with their HSPs to finalize M-SAAs by March 31, 2014.

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Next StepsWhat are the work streams and key dates?

CAPS Submitted to the LHIN No v 15

CAPS Reviewed and Adopted by the LHIN75% complete

Local M-SAA Orientation for HSPsJan 10

CW LHIN Board to Approve M-SAA Template Jan 22

CW LHIN to prepare M-SAA SchedulesJan 14 - 28

LHIN to meet with HSP's to negotiate performance expectations

Jan 28 Feb 14

LHINs to Prepare M-SAAs Feb 15–28

LHIN to distribute Final M-SAAs to HSPsMar 5

HSP Board Approval of M-SAAs Mar 31

LHIN Board Approval of M-SAAs (by Mar 31) Mar 31

Post M-SAAs to Websites April 10

Nov Dec Jan Feb Mar Apr

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Questions?

Comments?

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Sector Organization Individual, TitleLHIN CW LHIN Brock Hovey, Senior Director, Health System PerformanceLHIN CW LHIN Neil McIntosh, Director, Performance and AccountabilityLHIN CH LHIN Patrick Manhire, Senior Accountability SpecialistLHIN HNHB LHIN Jim Borysko, Advisor ,Health System PerformanceLHIN NE LHIN Kate Fyfe, Senior DirectorLHIN SE LHIN Mike McClelland, Senior Financial AnalystLHIN MH LHIH Shehnaz Fakim, Senior Lead, Health System Performance

Management

APPENDIX 1: M-SAA Planning & Schedules Work Group Membership

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APPENDIX 1: M-SAA Planning & Schedules Work Group Membership continued

Sector Organization Individual, TitleLTC OLTCA Paula Neves, Director of Health Planning and ResearchLTC OANHSS Jeffrey Graham, Director, Public Policy

CCAC SE CCAC Carol Ravnaas, Sr. Director Strategic Partnerships & Accountability

CSS Ontario March of Dimes Jason Lye, Associate DirectorCHC Brock CHC Ron Ballantyne, Executive Director

CMHA Riverside Community Counseling Services

Jon Thompson, Director

MOHLTC MOHLTC Vanita Bhandari, Manager, Data Standards Unit , Health Data Branch

MOHLTC MOHLTC Christine Brown, Team Lead, Planning & Negotiations, LLB

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APPENDIX 1: M-SAA Indicators Work Group Membership

Sector Organization Individual, TitleLHIN NE LHIN Kate Fyfe, Senior DirectorLHIN NW LHIN James Anderson, Performance and Contract Management

ConsultantLHIN MH LHIN Heather Kundapur, Senior Lead, Health System PerformanceLHIN TC LHIN Greg Stevens, Senior Consultant, Performance ManagementLHIN NWLHIN Kevin Holder, Senior Consultant, Funding & PerformanceLHIN ESC LHIN Pete Crvenkovski, Director, Performance Quality and

Knowledge ManagementLHIN HNHB LHIN Philip Christoff, Director, Quality & Risk ManagementLHIN HNHB LHIN Rosalind Tarrant, Director, Access to Care

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APPENDIX 1: M-SAA Indicators Work Group Membership continued

Sector Organization Individual, TitleLHIN HNHB LHIN Gaya Amirthavasar, Health Information AdvisorLHIN WW LHIN Ted Alexander, Manager, Contracts and AccountabilityCSS Cheshire London Angela McMillan, Attendant Services ManagerCSS Ontario March of Dimes Lee Harding, Director, Independent Living ServicesCSS Dale Brain Injury Services Sue Hillis, Executive Director

CCAC TC CCAC Anne Wojtak, Senior Director, Performance Management & Accountability

CCAC OACCAC Rod Millard, Director, Information ManagementCMHA Reconnect Mental Health

ServicesMohamed Badsha, COO

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APPENDIX 1: M-SAA Indicators Work Group Membership continued

Sector Organization Individual, TitleCHC AOHC Jennifer Rayner, Regional Decision Support SpecialistLTC OLTCA Paula Neves, Director of Health Planning and ResearchLTC OANHSS Dan Buchanan, Director of Financial Policy

MOHLTC MOHLTC Naomi Kasman, Senior Health Analyst, Health Analytics Branch

MOHLTC MOHLTC Soma Mondal, Manager , Health Analytics Branch