Ontario CHCs and the Quality Agenda

Eastern Region CHC Data Consortium QI WorkshopMay 7, 2010 Ottawa

Michael M. Rachlis MD MSc FRCPCwww.michaelrachlis.ca

Outline• Why the attention to health care quality?• CHCs tend to do well compared with other

PHC models, but…• CHCs need to get well ahead of the curve to

protect the CHC model of care• Health care boards have important and

emerging roles for quality oversight• Final thoughts

Why the attention to healthcare quality?

• Health care is rife with quality problems• PHC is a high risk environment• Some of us have known this for a long time• But the Canadian system and Ontario in

particular is now focussing on quality

Health care is rife with quality problems

• Studies in more 7 countries indicate that 5-10% of all deaths in developed countries are due to preventable deaths in hospitals– In Canada that means 9000 – 24,000 deaths per year

• The 2004 Canadian Adverse Events Study cites that 7.5 % of hospital patients have an adverse event (AE)– 185,000 are associated with an AE and 70,000 of these

are potentially preventable

PHC is also a high risk environment

• UK research for the Primary Care Trigger tool indicated that 1/3 patients > 75 suffered an adverse event in the previous year

• Twenty percent of Canadian women > 65 take benzodiazepines on a long term basis

• Thousands of patients with chronic disease die because they don’t get proper follow up

• Canada’s PHC performance lags that of other countries

92 91 89

66

5449

36

2619 15 14

0

25

50

75

100

NZ AUS UK ITA NET SWE GER US NOR FR CAN

Practices with Advanced Electronic Health Information Capacity

Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

%

6

89

71 68 65

43 41 40

25 2417

12

0

25

50

75

100

UK SWE NZ NET US GER ITA NOR AUS CAN FR

%

Practice Routinely Receives and Reviews Data on Patient Outcomes

Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians7

1519 20

26 27 29 3238

49 50

67

0

25

50

75

100

CAN NET NOR AUS US NZ UK FR SWE ITA GER

Time Spent Reporting or Meeting Regulations is a Major Problem

Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

%

8

Canadian health care is inefficient

• Canadians could get PHC from a regular provider within 24 hours

• We could get elective specialty care within 1 week

• We could get elective surgery within 2 months

Delivering health services without adequate primary health care is like pulling your goalie in the first period.

You score lots of goals but lose every game.

Ontario in particular is now focussing on quality and performance mgmt

• Changes in the health care environment are driving:– Accountability – Performance measurement– Patient safety– Governance

CHCs tend to do well compared with other PHC models, but it’s like winning a high jump competition against dwarves –

the bar is reallllly low!

“Who is doing this better?”

• “Last year, we reported community health centres did the best job of providing evidence-based chronic disease management in the province, despite working with the most disadvantaged people. The kind of careful management community health centres routinely give for diabetes and heart disease can keep people out of hospital and help them live longer.”

(Ontario Health Quality Council 2009)

CHC have better performance for:

• Chronic Disease Management• Individual Health Promotion• Comprehensiveness• Community Orientation.

Per Muldoon 2010

CHC have equivalent performance to others for:

• Disease prevention

Per Muldoon 2010

But CHC have less favourable performance for:

• Accessibility• Costs of PHC

Per Muldoon 2010

What are the numbers? (per Muldoon 2010)

NACHC, 1,709

VHA, 1877

FFS,1,479

Non Multidisc capitation,1,695

Multidisccapitation,

1,495

CHC,956

NACHC, 1,092

VHA, 939

FFS,1479

Non Multidisccapitation,

1,695

Multidisccapitation,

1,121

CHC,490

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Per family physician Per primary care provider

Comparisons of panel size esimates

US

US

Ontario

Ontario

CHC

CHC

CHCs need to be ahead of the curve to protect their model of care

• FHTs are catching up with chronic disease management and prevention and some are embracing QI and innovation

• CHCs remain marginal players in the ON health policy agenda

Attributes of High Performing Health Systems Ontario Health Quality Council. April 2006. (www.ohqc.ca)

1. Safe2. Effective3. Patient-Centred4. Accessible5. Efficient6. Equitable7. Integrated8. Appropriately resourced9. Focused on Population Health

The “Quality Agenda” is nearly synonymous with the “Second Stage of Medicare”. It’s written for CHCs!

“I am concerned about Medicare – not its fundamental principles -- but with the problems we knew would arise. Those of us who talked about Medicare back in the 1940’s, the 1950’s and the 1960’s kept reminding the public there were two phases to Medicare. The first was to remove the financial barrier between those who provide health care services and those who need them. We pointed out repeatedly that this phase was the easiest of the problems we would confront.” Tommy Douglas 1979

Catching Medicare’s second stage

“The phase number two would be the much more difficult one and that was to alter our delivery system to reduce costs and put and emphasis on preventative medicine…. Canadians can be proud of Medicare, but what we have to apply ourselves to now is that we have not yet grappled seriously with the second phase.”

Tommy Douglas 1979

The Second Stage of Medicare is delivering

health services differently to keep people well

Health care boards have important and emerging roles for

quality oversight

The new Excellent Care Act for All will:

• Mandate more hospital quality reporting • Mandate hospital board quality committees• Mandate hospital QI plans• Increase the responsibility of hospital boards for

quality• Permit regulations which would apply the act to

other health organizations besides hospitals• Enhance the role of the Ontario Health Quality Council• And a lot more

CHC board’s have no legislated responsibilities for quality, but

• Hospital boards will shortly have these mandates

• CHCs are also funded by LHINs– It’s going to happen to you too!

• Don’t we believe in community governance?

Engaging boards for quality

• Establish a Skilled and Qualified Board– Ensure the Board is knowledgeable– Effective Use of a Quality Committee– Board Leadership – Identify and Manage Risks– Selecting and Monitoring Performance Measures

– “The single most important step the board can take to contribute to quality to establish a process and a schedule for monitoring and assessing performance in areas of hospital operations that contribute to quality.”

Per Cochrane 2010

Set Strategic Aims

Health System & Team

May be 100’s in total

Organizational

(Dozens of indicators)

Monitoring Performance: Big Dots and Smaller Dots…

Big Dots(< 6)

Micro-system

Meso-system

Macro-system

Per Cochrane 2010

29

CHCs and Quality Oversight project

• CHC Consultation Lessons– No consistent sector response: wide range of

quality initiatives that differ in approach and scope

– Lack of board-level governance focus– Lack of meaningful system guidance (LHIN

indicator requirements ID need but no solution)

30

CHCs and Quality Oversight project

• CHC Consultation Lessons (cont’d)– Growing sector identity and collaboration

(BHO, Performance Management Committee)– Opportunity for shared learning and action– Different capacities by centre and geography• Can someone tell me what the truth is about

Purkinje?

Final thoughts• Be the “useful engine”• Align yourselves with the quality agenda– Be the first group of Canadian PHC centres using

the UK Primary care trigger tool

• Demonstrate you perform better than other PHC models on traditional quality indicators– Chronic disease management

Final thoughts• Then you can show the way for other

dimensions of quality that you value exceptionally, e.g. Patient-centred care, equity

• Demonstrate the value of citizen engagement and community governance

Canadians deserve to receive access to:

• PHC from a regular provider within 24 hours

• Elective specialty care within 1 week

• Elective surgery within 2 months

Final thoughts• Culture eats evidence for breakfast, e.g.

reducing waits and delays requires process improvement – advanced access -- but implementing advanced access frequently requires dramatic cultural change– Enhancement of implicit scopes of practice• Including non-professionals and patient self

management

– Re-design of team relationships– Who’s valued by whom

Crossing the Quality Chasm: Ten Rules to Heal the Health Care System (www.iom.edu)

1. Care should be based upon continuous healing relationships instead of mainly in-person visits.2. Care should be customized for individual patients’ needs and values instead of being dictated by professionals.3. Care should be under the control of patients not professionals.4. Knowledge about care should be shared freely between patients and providers and between different providers. This transfer should take maximal advantage of leading-edge information technology. Patients should have unrestricted access to their records.5. Clinicians should make decisions on the basis of the best scientific evidence. Care should not vary illogically from clinician to clinician or from place to place.

Crossing the Quality Chasm: Ten Rules to Heal the Health Care System

6. Safety is the responsibility of the whole system not individual providers.7. The content of care is made transparent instead of being held in secret. The health system should give as much information as is required to patients and families to enable them to fully participate in clinical decisions, including where to seek care.8. Patients’ needs should be, as much as possible, anticipated and not treated in a reactive fashion.9. The health care system should continually decrease waste (goods, services, and time) instead of focusing on cost reduction.10. Providers should cooperate and work in high-functioning teams instead of attempting to work in isolation. Concern for patients should drive cooperation among providers and drive out competition based upon professional and organizational rivalries.

Final thoughts• Don’t re-invent wheels– Visit the Saskatoon CHC!– Use existing instruments like the UK trigger tool,

the General Practice Assessment Questionnaire, etc.

• Strengthen relationships with US CHCs– They have been some of the most successful

health organizations to implement continuous quality improvement as a culture

Medicare is in the balance!

Summary:• Health care quality is a big issue– Especially in PHC

• CHCs tend to do well compared with other PHC models, but…

• CHCs need to get well ahead of the curve to protect the CHC model of care

• Health care boards have important and emerging roles for quality oversight

• Be true to your hearts and then use your heads

“Courage my Friends, ‘Tis Not

Too Late to Make a Better World!”

Tommy Douglas(per Alfred Lord

Tennyson)