CPSO AssessorConference

Dr. Jeffrey TurnbullApril 23, 2012

Toronto, Ontario

Overview

Health and health care for Canada Quality: the alignment of responsibility to outcomes Performance assessment Shaping the future

Health and Health Care in Canada

the emerging consensus

Reframing the Different Perspectives of Health Care

Health Care as a Public Service

Health Care as a business

Health Care as a Public Service

A social service built upon Canadian values: Equity Shared risk The common good Social justice

A social service guided by professional principles: Compassion Respect Trust Primacy of the patient’s welfare

Health Care as an Economic Engine

Health care as a key component of our economic recovery

Challenges to our Perception of Health Care as a Public Service:Is it sustainable?

System is inadequate to meet 21st century needs Principles of Medicare not being met Canada a “bottom of the pack” performer compared to

other countries Fiscal challenges faced by governments Health care viewed as an inhibitor of growth Changes required to: Improve efficiency/productivity of system Improve quality of care Improve Canadians’ confidence in system

Reframe “Sustainability”

Sustainability debate has focused only on financing

Need to sustain:Universal access to quality patient-centred care that is adequately resourced and delivered along the full continuum in a timely and cost-effective manner.

Several dimensions to sustainability: infrastructure, quality/outcomes, health promotion/disease prevention,

governance/management, public finance

A National Dialogue with Canadians:We heard support for…

A publicly funded health care system Expanded scope of the CHA A strong federal role – equality Accountability mechanisms Innovation, efficiencies Dealing with the bigger picture

Advisory Panel Observations

Health care system could be better for the money spent

Inequities in access; other countries do better in providing access to broader range of services

Need to clarify and separate the management and governance of health care system

Need to better integrate physicians and other components of health care system

Advisory Panel Recommendations

Consider ways to fund services along continuum of care

Advocate for greater accountability of the health care system to people who need care and their families

Advocate for less government micro-management

Support services addressing other determinants of health

From Consensus to ActionPicking at the Seams VS Transformative Change

Scope and Magnitude of Change

Models of care Scope of services provided Governance/Management/Accountability Financing/Sustainability

From Consensus to ActionPicking at the Seams VS Transformative Change

Paradigm Changes

Provider-focused Patient-centeredAcute care paradigm Chronic disease managementIndividual, isolated Group-connected, team-based, practice accountable practiceRhetoric Data/evidenceSilos Integrated regional systems-

based careUnrestricted growth Evidence informed innovationof technology

Principles of the Canada Health Act

Universality Accessibility Comprehensive Public Administration Portable Enhance the Health Care Experience

Patient Centred Quality Health Care

Improve Population Health Prevention Equitable

Value for Money Sustainable Accountable

Principles of the Canada Health Act

Universality Accessibility Comprehensive Public Administration Portable Enhance the Health Care Experience

Patient Centred Quality Health Care

Improve Population Health Prevention Equitable

Value for Money Sustainable Accountable

The Dimensions of Quality

Safety

Quality Management

Process

Competence Acceptability Accessibility

Efficiency Appropriateness Effectiveness

Risk Management –

Patient Safety –

Equipment Safety –

Critical Clinical Incidents -

Hiring Criteria –

Performance Appraisal –

Peer Review –

Credentialing –

Manpower Plan –

Program Plan -

Patient Satisfaction –

Accreditation –

Cooperative Planning -

Utilization Review –

Occupancy Rates –

Bed Allocation –

Patient Satisfaction

Surveys –

Monitoring Wait Lists -

Budget Variance Analysis –

Workload Measurements –

Utilization Review –

Turnaround Times –

Wait Lists –

Occupancy Rates -

Practice Guidelines –

Individual Case Review –

Drug Use Evaluation -

Department Review –

Clinical Appraisal –

Morbidity and Mortality

Reviews –

Outcome Screens –

Audits –

Technology Impact

Assessment -

Source: MacIntosh and McCutcheon, Canadian Journal of Quality in Healthcare, March 1992, Vol. 9, page 21.

Institute of Medicine: Dimensions of Quality

Safe Effective Patient-centred Timely Efficient Equitable

Source: 10M. Crossing the Quality Chasm: A New Health System for the 21 Century

Patient-Centred Care

Seamless access, with no financial barriers, to the continuum of care in a timely fashion, in a manner that takes into consideration the individual needs and preferences of patients and their families and treats them with respect and dignity.

Source: Canadian Medical Association. Toward a blueprint for health care transformation: a framework for action

Charter for Patient-Centred Care

Dignity and Respect Access to care (timeliness, continuity,

comprehensiveness) Safety and appropriateness Privacy and security of information Decision-making Insurability and planning of health services Concerns and complaints

Elements of Quality Movement

From Deming to Berwick, to IHI Set standards (interdisciplinary and informed by evidence) Education to standards Practice to standards Set metrics Measure to metrics Feedback

A word on: Variances Metrics: competence to performance to outcomes The physicians role in outcomes

The Physician’s Role in Quality

Performance assessment – accountability

Our professional responsibility Civic professionalism

Civic Professionalism

“entails not only physicians’ personal commitments to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society.”

Source: Medical Professionalism in the New Millennium: A Physician Charter Annals of Internal Medicine 2002; 136(3):243-6

Formative Regulatory

Division / Department oversight Chief of Staff , MAC , Board oversight

Credentials

Committee

Physician

Measured OutcomesAnticipated

Hospital derivedQualityAlignmentProfessionalism

Department derivedPractice standardsAcademic standards

Individual derivedPeer  standardsPersonal development

Unanticipated

Critical incidentAdverse eventsComplaintsPatient Safety Learning     SystemAuditMedicolegal

Performance Review

(department)

FormativeRecognitionRewardsEducationDevelopmentPractice change

Appointment

Status Review / Change

Critical thresholdSingle severe

Persistent trend

Accountability

Alignment

Responsibility/decision making Resources Outcomes Accountability

Equity and the Social Determinants of Health: a cautionary tale

We are playing around the edges in the health of our community

The Role of Physician Assessment Today and in the Future

Evaluations drivers change We evaluate what we value HCT: look for the levers of change A glimpse into the future

“The new professionalism, grounded firmly on the public’s expectations of doctors, is fundamental to the safety and well being of patients and the health

of the medical profession. It requires the regulatory and educational institutions of medicine, and medical

leaders and teachers, to work closely together to make sure that doctors and students always put the

interests of patients first”Sir Donald Irvine

“Professional membership organizations must stop promulgating weak guidelines and offering evaluation methods to assess and regulate their own coveted

members”Kassirer 2001

“It’s about doctors taking ownership of making their professionalism part of their reality”

Hafferty 2006

“The responsibilities for fostering professionalism are indeed awesome. The obvious question is “are the key players and professional organizations competent and willing to

move ahead?

KR Sethuraman 2006