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Excellent Care for All StrategyBreakfast with the Chiefs

Adalsteinn BrownMinistry of Health and Long-Term Care

13/5/2010

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While health care costs in Ontario have been rapidly increasing, it is unclear whether the quality of care delivered to patients has been enhanced

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Source: CIHI data 2009. In current dollars.

Recession begins

Government announces 18% reduction on hospital funding over 3 years

Health Services Restructuring Commission begins hospital bed closures and restructuring

Social Contract

Caps and clawbacks on physician compensation

Barer-Stoddart report – reductions to medical school spaces Steeper rate

of growth than pre-recession

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Source: CIHI data 2009. In current dollars.

Recession begins

Government announces 18% reduction on hospital funding over 3 years

Health Services Restructuring Commission begins hospital bed closures and restructuring

Social Contract

Caps and clawbacks on physician compensation

Barer-Stoddart report – reductions to medical school spaces Steeper rate

of growth than pre-recession

Source: CIHI data 2009. In current dollars.

Recession begins

Government announces 18% reduction on hospital funding over 3 years

Health Services Restructuring Commission begins hospital bed closures and restructuring

Social Contract

Caps and clawbacks on physician compensation

Barer-Stoddart report – reductions to medical school spaces Steeper rate

of growth than pre-recession

Source: Canadian Institute for Health Information

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We know that adoption of evidence can have a significant effect on enhancing quality through reducing clinical variation…

OHTAC Recommendations (FY 2005): Arthroscopic debridement of the knee has thus far only

been found to be effective for medical compartmental osteoarthritis. All other indications should be reviewed with a view to reducing the use of arthroscopic debridement as an effective therapy

Arthroscopic lavage of the knee alone is not recommended for any stage of osteoarthritis

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OHTAC recommendation

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…and at the same time, reducing cost while simultaneously improving the patient experience

Providing patients with written discharge instructions has been shown to decrease readmission, particularly in CHF

Sault Ste Marie Group Health Centre demonstrated that sustained reduction of CHF readmission of over 40% is possible through targeted quality improvement efforts

Enhanced Feedback for Effective Cardiac Treatment (EFFECT) demonstrated that public report cards on hospital performance can be an effective method for improving the quality of cardiac care

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Top 10% of readmission types responsible for 60% of cost = $415M

Top 20% of readmission types responsible for 80% of cost = $536M

All readmissions = $705M [upper end costs and excluding physician fee component]

CHF

COPD

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Tillsonburg District Memorial Hospital reducing readmissions and and hospital days

Mississauga Halton CCAC/LHIN redesigning criteria and processes to change culture while creating better outcomes for seniors and reducing ALC numbers.

Humber River Regional Hospital and North York General Hospital established a mobile Nurse Led Outreach Team that has prevented unnecessary ED visits

Ottawa Heart Institute supports ~ 1,200 patients from B.C. to N.L. with 13 hospital satellite sites and decreased heart failure 30-day readmission rate from 54% to14.8%.

Sault Ste. Marie Group Health Centre’s congestive heart failure discharge program reduced the number of readmissions by 43%.

Bluewater Health, St. Joseph’s Health Centre, Trillium Health Centre and Markham Stouffville Hospitals are piloting a lean/quality improvement program that aims to free up clinicians’ time on acute medical units in order to provide more direct patient care.

Hamilton Health Sciences used a lean process redesign to improve patient, information, and work flow in outpatient clinics.

Thunder Bay has reduced Bed Empty Time by 25% (four hours to three), by implementing lean process redesign.

Orillia Soldiers Memorial’s ED patients waiting time for initial physician assessment has decreased by 50%, and the number of people who leave without being seen has been reduced to 0.

Scarborough Hospital implemented a new discharge planning process and use unit whiteboards to increase the number of patients discharged before 11 am, and reduce overall length of stay.

LHIN Regions

1. Erie St. Clair

2. South West

3. Waterloo Wellington

4. Hamilton Niagara Haldimand Brant

5. Central West

6. Mississauga Halton

7. Toronto Central

8. Central

9. Central East

10. South East

11. Champlain

12. North Simcoe Muskoka

13. North East

14. North West

While there are many examples of quality improvement success stories across Ontario, our challenge is to have a more systematic approach

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Leadership Quality and system design is a

core strategy Focus on patient first Engaged staff workforce and

physicians Strategic alignment of aims,

measures and activities Incentives and accountability Innovation, design and redesign of

services Capability for improvement Incentives and accountability Information technology and

meaningful measurement

A range of factors contribute to the design of a sustained systematic approach to quality

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The Excellent Care for All Strategy is designed to build the foundation for a high performing health system

Where We Are Excellent Care for All Strategy

Leadership

Quality as Core Strategy

Focus on Patient First

Engaged Workforce

Aligned Aims & Measures

Incentives & Accountabilities

Capability for Improvement

Quality Committee of the Board

Annual QI Plans

Compensation Linked to Quality

Critical Incident Reporting

Patient Surveys

Statement of Values

Patient Based Payment

Evidence Based Funding

Support for QI Initiatives

Public Reporting of Quality Indicators

Staff Surveys

Quality Committee of the Board (Some Hospitals)

Annual QI Plans (Some Hospital)

Compensation Linked to Quality (Some Hospitals)

Patient Surveys (Most Hospitals)

Patient Based Payment (e.g. Incremental Wait Times )

Evidence Based Funding (e.g. PET Scans)

Support for QI Initiatives (e.g. QIIP, ED-PIP, Flo Collaborative)

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The strategy will help ensure that care is centered around the person and enhances the patient experience

Recovery, Rehabilitating and Managing

Monitoring and Preventing

Diagnosing Intervening

Patient Satisfaction Surveys

Statement of Values

Evidence Based Clinical Practice Guidelines and Continuous Quality Improvement

Patient Education

Evidence Based Diagnostic Testing

Public Reporting Hub: Quality, Patient Safety, Wait Times

Evidence Based Practices to Reduce Avoidable Hospitalization

Patient Relations Process

Evidence Based Practices to Reduce Readmissions

Measures to Prevent Duplicate Diagnostic Tests

Money follows the patient

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The Excellent Care for All Strategy will also help create a culture focused on continuous quality improvement throughout the system

Strong CQI Culture at the Organization Level

Quality Committees of the Board, Publicly available annual quality

improvement plans Executive compensation linked to quality Patient relations process Patient/client/caregiver surveys Staff surveys to assess Declarations of values Critical incident reporting

Supported at the System Level

Proposed expanded mandate of OHQC: Provide recommendations to the

health system on clinical practice guidelines and protocol

Provide recommendations in consultation with the public, to the Minister concerning the Government of Ontario's provision of funding for health care services and medical devices

Patient based Payment Support from Quality Improvement

organizations

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Ontario’s patient-based payment approach will draw from over 25 years of international funding policy evolution

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Sweden

1995 Italy

1997 NorwaySpain

1998 JapanFinland

2000 Denmark

2003 England

2004 France

2005 Germany

An emerging focus on quality and evidence-based care

United States: 14.1% decrease in cost per admission, 2.4% reduction in overall system costs over 4 years; 6.7% decrease in average LOS)

Australia (Victoria): Up to 25% reduction in cost per admission over 5 years Sweden (Stockholm): 1% reduction in total costs

United States: 14.1% decrease in cost per admission, 2.4% reduction in overall system costs over 4 years; 6.7% decrease in average LOS)

Australia (Victoria): Up to 25% reduction in cost per admission over 5 years Sweden (Stockholm): 1% reduction in total costs

Norway: 40% reduction in wait times over 2 years

Denmark: 17% reduction in wait times one year after implementation

Ontario (Wait Time Strategy): Reduced 90th percentile wait times for hip replacement from 351 to 153 days, knee replacement from 440 to 184 days

Norway: 40% reduction in wait times over 2 years

Denmark: 17% reduction in wait times one year after implementation

Ontario (Wait Time Strategy): Reduced 90th percentile wait times for hip replacement from 351 to 153 days, knee replacement from 440 to 184 days

Australia: 3% reduction in adverse events among complex patients

England: Introduction of ‘Best Practice Tariffs’ based on costs of clinical best practice treatment for a patient condition

United States: Associated with decreases in mortality; non-payment policies for never events

Australia: 3% reduction in adverse events among complex patients

England: Introduction of ‘Best Practice Tariffs’ based on costs of clinical best practice treatment for a patient condition

United States: Associated with decreases in mortality; non-payment policies for never events

Emphasis on cost containment

Improving access and reducing wait times

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We have only begun the journey to a truly sustainable, patient-centered and quality-focused health system

Weeks Months Years

Excellent Care for All Act

Patient-based Payment Simulations

Recommendations from OHQC

Further Recommendations on Evidence-Informed Funding

Strengthened Critical Incident Reporting

Patient-Centered Care Across Continuum

Sustained Culture ChangeInter-Professional

Collaboration

Fully Engaged Patient

Innovation Tournament

Engaged Workforce and Physicians

Focus on Patients First

Quality as a Core Strategy

Capability for Improvement

Incentives and Accountability

Patient Based Payment

Strategic Alignment of Aims, Measures and Activities

Sustainable Healthcare SystemInnovation, design and

redesign of services

Meaningful Measurement

Act

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Evaluations of Pilot QI Initiatives

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Thank you.