Taking the pulse of Ontario: - PDF Free Download

Taking the pulse of Ontario: Performance evaluation as a driver for change Health Quality Transformation 2012 Walter P Wodchis Toronto, October 22, 2012 Leveraging the Culture of Performance Excellence in Ontario s Health System HSPRN is an inter-organization Network funded by the Ontario Ministry of Health and Long Term Care

Some thoughts Healthcare providers are doing their best to provide optimal care in a severely challenged health system. Challenges include fiscal constraint but are primarily brought on by a severe lack of coordination and communication between providers. 2

Ontario Leads in Performance Measurement Ontario Hospital Report Public reporting on hospital performance 1999-2008 Ontario Hospital Association Health Quality Ontario QMonitor: Annual Report on the Health System Long Term Care Website Public Reporting Ministry of Health and Long Term Care

Audiences & Purposes for Performance Measurement Measurement Groups MOHLTC LHINs Health Quality Ontario Associations (OHA) CIHI (Accreditation) Collaboratives /Research Groups Audiences Public System Managers Providers Payers Regulators Research Community Purposes Accountability Transparency Market Function Quality Improvement & Benchmarking New Knowledge

Hospital Report Research Collaborative

MOHLTC Access

myhospitalcare.ca (OHA. c2009-)

Health Quality Ontario

Health Quality Ontario LTC Individual Results - Search By Health Topic http://www.hqontario.ca/en/reporting/ltc/modal/searchbyhealt... INDIVIDUAL HOME RESULTS Close Print SEARCH CRITERIA By Home By Location By Health Topic Falls Percentage of residents who had a recent fall. Falls Incontinence Pressure Ulcers Restraints Search: Home Name Falls 2010-11 Falls 2011-12 A R GOUDIE EVENTIDE HOME(SAL. ARMY) N/A 18.4 AFTON PARK PLACE LONG TERM CARE COMMUNITY 19.1 11.8 ALBRIGHT GARDENS HOMES N/A 11.7 ALEXANDER PLACE 17.9 16.1 ALGOMA MANOR-HOME FOR THE AGED 11.4 13.1 ALGONQUIN NURSING HOME 8.3 12.1 ALLENDALE N/A 16.6 ALMONTE COUNTRY HAVEN N/A 18.0 ANSON PLACE CARE CENTRE 10.3 10.0 ARBOUR CREEK LONG-TERM CARE CENTRE 7.0 6.2 Showing 1 to 10 of 633 entries First Previous 1 2 3 4 5 Next Last

Health Quality Ontario

Canadian Institute for Health Information & Statistics Canada

Hospital Report Research Collaborative

Ontario Ontario has a rich history and tradition of performance measurement. There continue to be some gaps in performance measurement (e.g. primary care). We have great data sources we need to do a better job of using them and particularly linking them together.

How successful are these initiatives? Performance measurement alone cannot change the system But the impacts & effects of changes to the system cannot be known without performance measurement Performance measurement can also direct opportunities for improvement

Where should we be heading? We currently have quite a bit of performance data on hospitals, long term care, home care We have very little performance information about primary and other physician care. We have almost no information on health system performance.

Measurement that follow patients Rehab / CCC / Sub-acute Care Specialist Care Acute (ED, IP, SDS) CCAC Home Care Pharmacy LTC Primary Care Patient Flow Patient Rebound 24

Population-based Measurement and Management We need to understand, track and report on the performance of the health system for individuals Triple Aim: Population health Patient experience (including access, quality, and patient reported outcomes & experience) Cost control Achieving the Triple Aim requires a new perspective on health system performance measurement and improvement

Getting there There are costs associated with performance measurement who benefits (who should pay)? Patients benefit from better care and information. Public benefits from increased accountability. Payers and regulators benefit from increased accountability / assessment of value/return. Government benefits from ability to choose best areas to focus on to improve. Providers benefit from more efficient and better quality of care (better care is why they re in this intrinsic value). Value can be measured by the opportunity cost of not doing anything (missed opportunities for improvement) and/or doing the wrong thing by focusing on the wrong areas.

27 The Future of Performance Measurement in Long Term Care and Home Care: It s Not What It Used to Be John P. Hirdes, PhD Professor, School of Public Health and Health Systems Ontario Home Care Research and Knowledge Exchange Chair University of Waterloo Twitter: @interrai_hirdes www.interrai.org

28 Agenda State of the art information systems for nursing homes and home care circa 1987 Use of interrai instruments in Canada Clinical practice Quality Integrated information systems What worked? What needs improvement Twitter: @interrai_hirdes www.interrai.org

29 Butterworths Series on Individual and Population Aging Series published between 1986-91 About 15 books published by leading gerontologists of the time Gerontology s coming of age in Canada WF Forbes - Founding President Canadian Association and Ontario Gerontology Association - Vice-President of Gerontological Society of America - Mentor and PhD Supervisor Canadian Journal on Aging Special Issue on 25 th Anniversary of series Twitter: @interrai_hirdes www.interrai.org

30 State of the Art in LTC Circa 1986 No national data for LTC beyond age and sex Had to cite small pilot studies for basic clinical information Called for implementation of standardized assessment systems But concerned that introduction of computers into LTC may be difficult Limited conceptualization of quality measurement Focus on survey based methods Could not conceive of QI based methods because standardized clinical information was far-fetched at the time Worried about adequacy of evidence for informing placement into long term care Twitter: @interrai_hirdes www.interrai.org

31 The Future of LTC Authors worried about efforts to make more comfortable nursing homes without improving clinical services emphasizing on interventions to prevent decline or support rehabilitation Drew analogy to National Foundation for Infantile Paralysis in1940-50s investment into basic research on polio rather than creating better iron lungs Twitter: @interrai_hirdes www.interrai.org

32 one might argue that old age homes and vast support structures to care for the helpless aged represent the iron lungs of gerontology. They maintain the elderly, yet do not address the underlying problems. The Future of LTC? Forbes et al., 1987 Twitter: @interrai_hirdes www.interrai.org

33 Implementation & Testing of interrai Instruments 1996 Solid symbols mandated or recommended by govt; Hollow symbols research/evaluation underway RAI 2.0 RAI-HC RAI-MH interrai CMH interrai ESP interrai PC interrai ID interrai ED/AC interrai CA interrai CHA interrai AL interrai LTCF interrai SQoL Twitter: @interrai_hirdes www.interrai.org

34 Implementation & Testing of interrai Instruments in Canada DB Solid symbols mandated or recommended by govt; Hollow symbols research/evaluation underway RAI 2.0 RAI-HC RAI-MH interrai CMH interrai ESP interrai PC interrai ID interrai ED/AC interrai CA interrai CHA interrai AL interrai SQoL Twitter: @interrai_hirdes www.interrai.org

35 Applications of interrai s Assessment Instruments: One assessment multiple applications Case-mix Single Point Entry Care Plan Resource Allocation Evaluate Best Practices Assessment Prevent Gaming Outcome Measures Twitter: @interrai_hirdes Patient Safety Quality Improvement Public Accountability Accreditation Quality Indicators www.interrai.org

36 Beyond the Iron Lungs of Gerontology : Using Evidence to Shape the Future of Nursing Homes in Canada Hirdes, Mitchell, Maxwell & White, Canadian Journal on Aging, 2011 Provides a national profile of LTC residents Most comprehensive clinical profile of LTC in Canada to date Twitter: @interrai_hirdes www.interrai.org

37 Twitter: @interrai_hirdes www.interrai.org

38 Twitter: @interrai_hirdes www.interrai.org

% Clients triggered Triggering rates for two multi-level interrai Clinical Assessment Protocols (CAPs), by prov/terr & setting 100 Falls CAP Mood CAP 80 CCC (2.0) LTC (2.0) CCAC (HC) SH (CHA) CCC (2.0) LTC (2.0) CCAC (HC) SH (CHA) 60 40 20 0 Moderate Risk High Risk www.interrai.org

Risk Adjusted Facility QI Rate 40 Distribution of Risk Adjusted Facility Rates for ADL Decline QI (ADL7D) by Province and Facility Type, Canada 2009-10 50 40 30 20 Better 90th Percentile 10th Percentile Median 10 0 ON LTC ON CCC MB LTC SK LTC BC LTC Twitter: @interrai_hirdes www.interrai.org

41 Health Quality Ontario, LTC Public Reporting Website 2012, Provincial Results Display www.interrai.org

Percent of Residents 42 Percent of residents who fell in the last 30 days, by Ontario LTC home Source: Q4 1112, CCRS, CIHI; graph prepared by Health Quality Ontario 45% 10 th Percentile, 8.5% Median, 13.7% 90 th Percentile, 18.8% 40% 35% 30% 25% 20% 15% 10% 5% 0% Facility www.interrai.org

43 Percent of residents who fell in the last 30 days, by province Source: Q4 1112, CCRS, CIHI; graph prepared by Health Quality Ontario Ontario (n=637) British Columbia (n=274) Manitoba (n=38) Newfoundland and Labrador (n=7) Nova Scotia (n=6) Yukon (n=4) 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% Indicator Rate The box-plots show the location of the 10 th, 25 th, median, 75 th, and 90 th percentiles. www.interrai.org

44 Taking Stock of What We ve Achieved Twitter: @interrai_hirdes www.interrai.org

45 What Worked? Education Continuous, multidimensional training strategy is essential Feedback In-person, webinars, elearning, competency testing, conferences Well-done in some sectors System will fail if it seems like the data go into a black hole Different cycle times for different audiences Clinicians immediate Managers monthly General public annual Benchmarking Sharing data allows you to observe yourself through a different lens Twitter: @interrai_hirdes www.interrai.org

46 IT systems What Worked? cont d Usability, reports, real time access Tremendous variability across vendors Partnerships CIHI interrai partnership made national implementation feasible Provincial and local partnerships supported innovation Research Strong research support by some provincial ministries have facilitates major interrai innovations Twitter: @interrai_hirdes www.interrai.org

47 What Needs to Improve? Clinical use in some sectors Exchange of interrai data between partner agencies Privacy sometimes used as an excuse Power and trust interferes with person s interests Better use of longitudinal information Integrated Assessment Record project has considerable potential Need a longitudinal view WITHIN and BETWEEN settings Integration concept not a guaranteed sell in every sector Need to move to new suite and new CAPs Changing the ENTIRE system is a challenge! Engaging the person and family Human nature seeks path of least resistance Twitter: @interrai_hirdes www.interrai.org

48 Thank you! Questions? Comments? Twitter: @interrai_hirdes www.interrai.org

Canadian Institute for Health Information Dr. Jeremy Veillard Vice President of Research and Analysis Canadian Institute for Health Information 49

Enhancing Ontario s Capacity For Change: The Power of Performance Measurement, Reporting and Improvement 50

Why Is It Important To Measure Health System Performance? Ideally, health system performance measurement and reporting can ensure that: Health systems have a strategic direction focused on improving health outcomes and clearly communicated to system players Policy decisions are informed by appropriate intelligence with regard to health and health system problems and their determinants Healthy public policies are promoted across all aspects of government Relationships between all health stakeholders are regulated in a context of transparency and accountability, which is an important condition for performance improvement 51

Source of control Health System Performance Measures Can be Used for Different Purposes Nature of expected actions Formative Punitive Internal Continuous Quality Improvement Internal Evaluation External Accreditation Performance and Practice Benchmarking P4P Blaming and Shaming Source Modified from Boland & Fowler 2000. 52

Is the Ontario Context Supportive of Health System Performance Measurement and Public Reporting? A clear interest for more comparable performance measurement, in a supportive way Perception of an indicators chaos : need to focus on core measures meeting the needs of various audiences ECFA supportive of the use of evidence in decision-making and alignment between performance measurement and various policy levers (incentives, funding, QIP) An increasing interest in innovation and practice benchmarking, not only performance benchmarking 53

A Positive Approach to HSP Reporting Should Integrate Performance Measurement and Peer Learning Objectives Types of activities Type of Benchmarking Type of measures Public Transparency Report on a set of standardized, comparable indicators on HSP Public Reporting Outcomes Provincial policy makers Transparency Performance Improvement Cooperation Integrated performance reporting with business intelligence capabilities to drive performance benchmarking Performance Benchmarking Outcomes Process Regional Health Authorities Transparency Performance Improvement Cooperation Capacity building On the basis of practice benchmarking activities, support best practices transfer and innovation sharing between jurisdictions Practice Benchmarking Outcomes Process Structure HOSP LTC PHC Others 54

Unleashing the Power of Performance Measurement in the Ontario Context Building blocks required: A unifying health system performance measurement system aligned with government priorities within a broader framework A suite of public performance scorecards meeting the needs of the general public, of policy makers and of system managers An integrated analytical environment responsive to the analytical needs of system managers A shared analytical and research agenda focused on performance improvement priorities Initiatives to support capacity building for system managers across the health system 55

Strong Foundations in Ontario To Harness The Power of Performance Measurement ECFA has all elements necessary to drive performance improvement in a supportive way HQO has a mandate to focus the performance measurement agenda and has a unifying performance framework A tradition for public reporting on health system performance with some level of comfort by system actors Access to some of the best data in the world in comparable ways through CIHI with new data and benchmarking capabilities CHRP PHC VRS CCRS 56

Strong Foundations in Ontario To Harness The Power of Performance Measurement (cont d) Access to various analytical environments through which system managers can drill down through the data (CIHI, ICES, CCO) Relevant analytical and research work (ICES, CIHI, HQO, CCO, Academia, etc ) Some initiatives to support capacity building for system managers through ECFA implementation 57

Some Progress Can Still be Made in Ontario with the Data Some of the best quality data in the world Vital Statistics; administrative data and clinical registries; patient experience surveys; population surveys; electronic medical records Still important data gaps to fill Efficiency and productivity measurement; primary health care (VRS well implemented in Ontario); measurement of integration of care in general Hard to integrate the data for technical (less and less true) and cultural reasons (health care versus population health and social determinants of health) 58

Noticeable Critics About The Performance Management Paradigm in Health Care Risk of focusing on the wrong performance metrics and of inducing wrong behavior changes Quantitative indicators not always the most appropriate to understand how the system performs Difficulty to get actors to take their responsibilities for shared accountability measures (e.g. ALC, readmissions rates) Interdependencies between the different dimensions of health system performance still poorly understood You cannot manage the performance of a complex system with a small number of performance metrics 59

The Path Forward for Ontario Regular public reporting on state of health system performance in ways meeting needs of various audiences (public engagement) System managers to access integrated analytical environment linking permanently larger range of databases yet still respecting privacy An agenda to integrate the data at two levels: across the continuum of care; patient and population health perspectives Improve the timeliness of the data 60

The Path Forward for Ontario (cont d) Focus on capacity building in the system and support the transition from performance benchmarking to practice benchmarking (structure peer learning networks) Greater research and analytical focus on key systems priorities: quality of care, health system outcomes, patient safety, value for money Mobilize key enablers (e.g. HQO, ICES, CIHI) to focus their efforts on needs for performance improvement in Ontario Engage the public and patients in this work 61

Thank you 62