Background Document for Consultation: Proposed Fraser Health Medical Governance Model Working Draft 6/19/2009 1
Table of Contents Introduction and Context Purpose of this Document 1 Clinical Integration 1 Program Management Overview 2 Proposed Medical Governance Structures Principles 6 Physician Leadership Positions 7 Roles and Accountabilities 8 Physician Compensation 8 Medical Staff Structure 9 Physician Leadership Development 10 Next Steps 11 Working Draft 6/19/2009 2
Introduction & Context The Purpose of this Document This document outlines a draft framework for the evolution of medical governance within Fraser Health, one which aligns with our proposed program management model and supports our broader strategy to develop an integrated health system. This document is intended to provide a starting point for discussions with medical leaders across Fraser Health. It describes key concepts including guiding principles, assumptions, governance structures, leadership roles and accountabilities. This has been developed based on experience and lessons learned from other jurisdictions and will be refined and elaborated on once consultation on this draft is concluded. The Context: Clinical Integration Developing an Integrated Health System is one of Fraser Health s six strategic imperatives aimed at ensuring we have a sustainable and responsive health system that meets the needs of Fraser Health residents. In addition to the work on Program Management, there are a number of other related initiatives underway that support clinical integration (Appendix 1) 5 Goals of Clinical Integration Increase understanding of system integration to reflect the needs of our population Align primary, acute and community networks to deliver the right care, in the right place Create integrated service, clinical governance and leadership models Use clinical information and technology to advance integration and quality of care and service Redesign the care delivery system to support leading practice and enhance efficiency Briefly, the Clinical Integration work falls into three broad grouping: Understanding Service Needs: these projects build on the work done over the last number of years to forecast our population s service needs in acute care, community care, transition support and primary care and how that fits with our current capacity. Determining How Services Will Be Delivered: This set of activities will help us determine how we will deliver services in the future to meet these demands. These are projects related to siting Working Draft 6/19/2009 3
and consolidation of services taking into account access, flow and transportation issues. Defining our Service Model: This final set of interrelated initiatives will help us define how Fraser Health will organize itself to deliver care and service. This initiative on program management and related ones on medical governance, care models, and professional practice are part of that process. Together, these initiatives will guide our planning and resource allocation as we move forward to achieve our vision of Better Health, Best in Health Care. Physician leaders have been and will continue to be engaged in all of these initiatives. Going forward, it is important that our Medical Staff Governance structure aligns with our proposed program management structure and that it supports our overall integration strategy. Program Management Model.Program Management is an organizational model where a defined leadership team is given the clinical and fiscal accountability for delivering, and/or arranging to deliver a set of services for a defined population or group. Program Types Fraser Health s programs will be organized around: Clinical Services Programs: These are programs that are organized along a service stream i.e. Services such as critical care, diagnostics, home care, or surgical care. A key focus of the Clinical Services programs will be to reduce variation in practice, streamline services, implement best practice and improve access to services. Clinical Population Programs: These programs are designed to meet the needs of a clinical population such as those with mental health and addictions issues, or renal disease. These programs function across the acute to community continuum and focus on coordinating functions / services and fostering multidisciplinary coordinated care. A key goal is to ensure that the patient/client s journey is seamless and that the care pathway is based on best / leading practice. Population Health Programs: The third type of program is that focused on a broader population such as the older adult, aboriginal population, or child and youth. These programs will deliver some services but clearly not all services. Their primary goal will be to influence health practice and policy for their defined populations across Fraser Health. Working Draft 6/19/2009 4
Most Health Authorities across the country that have implemented program management have a mix of these types due to the complexity and scope of the functions and relationships associated with operating a regional system for health. In addition to Fraser Health owned services, many programs will have contracts or agreements with non FH owned organizations / groups who provide care and service to this population. An integrated system will have strong partnerships across a range of stakeholders. Program Characteristics Program management supports stronger clinical governance or clinical accountability for continuous improvement of the quality of care and service. Every program will have a defined scope and the accountability to ensure that the services provided to the target population are effective and responsive, and consistent with evidence-based standards and performance metrics. The programs will ensure that all undertakings align with FH s strategic directions and themes and any specific MoH commitment or performance expectation. The programs will also have fiscal accountability for ensuring that the assigned resources are used to achieve optimal outcomes, with this reflected in a three year service plan. Program Characteristics Clinical and fiscal accountability Clearly defined leadership team with clinical governance responsibility Serves a defined population with a common set of needs Has a Fraser Health wide responsibility as defined by program scope. (Draft) Program Structure The proposed program structure for Fraser Health was determined using the following criteria as a lens to assess which services should be managed in a program and how quickly. These include criteria related to: Legitimacy (there is a clear rationale to have these services run as a program ) Feasibility (based on a number of factors related to HR, size, etc.) Process Used To Determine Programs Assessment criteria o Legitimacy o Feasibility o Support Lessons learned from other jurisdictions Support (there is strong enough support within the organization to move this forward or that support can be developed) These criteria are phased. The legitimacy lens was used as the first test as there was clearly no need to move to the others if that test failed. As indicated earlier, these criteria are a lens through which the SC and core team worked through and defined a draft structure. Working Draft 6/19/2009 5
The assessment was also guided by the lessons learned from other jurisdictions and the literature lessons related to size and number of programs for instance e.g. that a smaller number of larger programs was easier to manage than a proliferation of small programs. Program Roles and Accountabilities Exhibit 3 begins to outline the potential role and functions of the program in four broad areas. Exhibit 3. Proposed Roles and Accountabilities of the Programs Planning / Policy / Standardization / Service Delivery Models Develops a service plan which sets the strategic direction for the population or service for FH. Develops clinical service models, identifies opportunities that promote integration, standardization and consolidation across Fraser Health based on community, population and service needs and understanding of evidence based and leading practice models. Influences and/or sets policy and practice related to their population and / or service Represents FH externally on provincial committees or groups Operational Management / Partnerships / Workforce Planning Promotes great workplaces Establishes and manages the program budget in line with service plan. Seeks progressive partnerships with internal and external groups / bodies with key interfaces with the program. Conducts workforce planning (with HR and with the Division / Department Heads) Acts as the clinical, care and service expert for FH Monitors and reports on performance Quality Management Leads program-related improvement and quality initiatives, including overseeing quality and patient safety for the program/service; Develops a yearly quality performance work plan, which includes performance monitoring Oversees development, approval, and implementation policy and standards; Ensure implementation of standardized practice Leads accreditation and other auditing processes; follows up on recommendations and Required Organizational Practices; Addresses recommendations from audits, reports, surveys, and legislative requirements (e.g., Patient Quality Review Board, Patient Safety Reviews, Patient Satisfaction (Experience) Surveys, Office of the Auditor General Reports, Coroner Reports, etc.) Receives and actions direction from Fraser Health Quality Performance Committee and its four Sub-Committees (Safety & Risk Management; Medication and Therapeutics; Infection Prevention & Control; Medical Devices, Technology & Reprocessing) Academic Mandate Collaborates with partners to support the teaching / training mandate and goals of Fraser Health Identifies and supports the advancement of FH s research priorities Working Draft 6/19/2009 6
The above list of roles and accountabilities would be fine tuned during the implementation process and program specific indicators and monitoring mechanisms established. One of the goals of program management and the clinical integration imperative is to strengthen Fraser Health s clinical governance and bring more clinical / physician leadership to system wide planning and quality improvement. The restructuring of the medical governance with clear differentiation of the practice and program roles is key to achieving this goal. In the next section of this document key concepts of our proposed medical governance model are presented as a basis for discussion with physician leaders in Fraser Health. Working Draft 6/19/2009 7
Proposed Medical Governance Model: Key Concepts This model represents a significant shift in how physician leaders are engaged in Fraser Health. It is based on the premise that FH values physician expertise and ability to contribute to the health authority operations and quality and safety initiatives, and that more not less physician engagement and voice is important if we are to achieve our goals of clinical and operational excellence. There are two aspects to discussions around medical governance. The first is how is a medical staff is organized to self-govern. Under the current legislative framework, health authorities are expected to provide bylaws that define the structure of its medical staff. The organized medical staff is then accountable to the Board for the credentialing and privileging of its members. As well the organized medical staff is accountable for the quality of care provided by its members and for providing medical advice to the Board. The second aspect of medical governance relates to defining how the medical staff will be engaged by the health authority to assist in directing the planning and operations of the health authority. There is no doubt that the medical staff organization and the process of engagement has not kept pace with as Fraser Health has evolved from individual hospitals to the second largest, integrated health authority in Canada. A new model of medical governance is needed to reflect the current realities in Fraser health. Key assumptions underlying this model are: Fraser Health will move to full program management model over the next two fiscal years. The Medical Staff Bylaws and Rules & Regulations will be reviewed and revised as necessary to reflect the revised governance model and defined legislated responsibilities of the medical staff. Fraser Health is committed to a more integrated Lower Mainland clinical and operational service model. The physician leadership model will evolve over time as the program management model evolves. Physician leaders will be involved in the further development of Fraser Health s research and academic mandate. Working Draft 6/19/2009 8
Principles 1 The proposed governance has a number of guiding principles. 1. In accepting an appointment to FH Medical Staff, all physicians agree to contribute to the administrative responsibilities of the Department or Division to which they are assigned by attending meetings, participating in quality assurance activities, and assuming other leadership roles as determined collaboratively with the Department/Division Head. 2. Physician leadership positions at FH are appointed by FH senior administration and are accountable to the President & CEO and Board through one of the following mechanisms: MAC Committee structure; Clinical Department / Division Structure; Program Management Structure. 3. The physician leadership structure does not exist in isolation, but internally works in collaboration with the corresponding administrative and professional practice leaders and externally with relevant leadership structures within the medical education programs. 4. All physician leadership positions are term positions based on a written agreement or contract. Reappointment processes are agreed upon in advance and generally conform to policies outlined in the Medical Staff Rules. 5. Written leadership agreements are agreed to prior to all appointments. These are prepared and approved by the Medical Affairs Office and signed by both the incumbent and the appropriate FH Senior Leader. These include role and expectations of the position, reporting and accountability; compensation and non monetary perquisites, process for regular review and conditions required for renewal. Physician Leadership Positions Physician leadership positions in Fraser Health will fall into two broad categories. Roles and Responsibilities of Physician Leaders Position Role Department Heads, Division Heads, As mandated by the Medical Staff Bylaws and Associate Department Heads Rules and Regulations are responsible for Medical Staff professional practice and academic affairs Physician Program Leaders (PPL), Assistant Physician Program Leaders, Physician Leaders. i.e. they focus on the practitioner, Provide management support for the programs in conjunction with operational leaders; i.e. they focus on the program patients, residents and the care and service processes and outcomes. 1 Adapted from PHC Physician Leadership Guidelines (Third Draft) March 16, 2009 Working Draft 6/19/2009 9
The roles may not be independently exclusive of one another and there will be situations when one physician leader holds more than one role. Policy Statements Regarding Position Titles Each position title clearly identifies whether the position is part of the Departmental Structure or Program Management Structure. These titles are consistent with role and mandate of the position and should identify or suggest to whom that position reports. The terms Department Head, Division Head, Associate Head, and Assistant Head are used exclusively for Department and Division leaders. The terms Physician Program Director, Assistant Physician Program Director, and Physician Lead are exclusively used within the Program Management Structure. All physician program leadership positions, regardless of the title, report directly to the Physician Program Director who, as part of the program management team reports directly to the applicable Clinical Vice President. Wherever practical, physicians with Department/Division positions will also hold corresponding Program Management Positions. Roles and Accountabilities Department / Division Leadership Positions Medical Management Responsible for organization of the medical staff for the Department/Division including: Ensuring professional standards are established and maintained. Developing performance plans for each member and regularly evaluating members. Privileging and credentialing and advising HAMAC on reappointments, Resolving performance / behavioral issues as required. Physician resource planning (in conjunction with the program leaders), recruitment, retention, and mentorship. Program Management Leadership Positions Responsible with other members of the Program Team for the service delivery planning, budget development, operations and performance management of the program. (See Exhibit 3 ) Identifies physician resource requirements in collaboration with the Division / Department Head. Identifies quality of care concerns and refers to Division/Department Heads. Provides relevant program information to the Department/Division Heads as required Working Draft 6/19/2009 10
Responsible for developing, with members of the Department, standards of clinical practice for the Department and ensuring that the Department embers work within established standards. Establishing a quality assurance/quality improvement structure and program for the Department, which carriers out the functions of review, evaluation, and analysis of the quality of medical care and utilization of FHA resources. Monitoring and evaluating the utilization of FHA resources by members of the Department in order to ensure effective and efficient use of these resources. Responsible for leading Department / Division planning, setting annual objectives and participating in Fraser Health strategic planning. Responsible for providing leadership on all aspects of teaching and research within and related to Dept/Division including working with the Universities to ensure that education programs and research activities are being sufficiently promoted and supported. Responsible for all budgets under Department/Div control Participates on internal and external regional/provincial senior committees or task forces Meets regularly with VP Medicine to review professional practice, strategic directions, recruitment and retention and academic affairs. Quality of Care / Utilization Supports the Program s quality improvement and quality monitoring activities (Exhibit 3) Participates with the program team to implement evidence based clinical pathways and practice guidelines Planning Responsible with other Program Leaders for program clinical service planning including identifying opportunities for consolidation, integration, and more standardization of practice. Participates in capital planning as it impacts the program Academic Promotes the academic mandate including research within the program s multidisciplinary team Administration Responsible with program team for dayto-day management of program area and collaborates on budget planning. Participates on program committees and internal/external committees as needed. Meets regularly with the Operational Program Leader & VP to establish program priorities. Working Draft 6/19/2009 11
Physician Leadership Compensation The leadership within Fraser Health recognizes that in order to attract and retain quality physician leaders to these positions, it must provide compensation that reflects the time and responsibility of the position. This compensation model will need to be guided by a set of principles and be competitive with competitive with similar physician leadership positions in the provincial health authorities. More detailed work by a task group is recommended to work up a draft compensation grid. This work could be guided by The VCHA Medical Leadership Compensation Framework, the Physician Master Agreement negotiated between government and the BCMA. As part of this work, policies related to perquisites should be established. Medical Staff Structure The following recommendations are made in terms of structure. Health Authority Medical Advisory Committee (HAMAC) HAMAC will play a key role in supporting quality and patient safety in Fraser Health. It is the senior committee of the organized medical staff and interacts directly with the Board of Directors of Fraser Health. Given the proposed implementation of Program Management it is recommended that: Representatives from Physician Program Directors be invited to sit on HAMAC. The subcommittee structure be evaluated and consideration be given to establishing regional subcommittees in areas such as: Appointment and Reappointment, Privileging, and Quality. 2 Local Medical Advisory Committees (LMAC) It is proposed that local medical advisory groups continue and that their role evolves to one that represents the medical community from their respective geographical area including the general practitioner and community based physicians. The role of the LMACs would need to be explored in consultation with the medical community but could include addressing CME and advising on local / emerging needs. 2 Quality committees of HAMAC to align with the proposed FH Quality Management Framework. Working Draft 6/19/2009 12
Clinical Transformational Steering Committee (CTSC) One of the structures that is proposed to help FH strategically manage across programs, sites, and services is a FH Clinical Leadership Council. The Council would have representation from the administrative and physician program leads, operational Vice Presidents, and appropriated Physician Department / Division Heads. Their role would be to proactively manage cross program issues and ensure that the vision of moving to a clinically integrated system that is focused on delivering high quality standardized care in a sustainable manner is achieved. Site Leaders Group The new model does not envision site based medical directors although it is recognized that there will be a need for site based medical leaders. These site leaders will work along side a site based operational leader to ensure smooth operation of the hospital across the programs. These positions would be part time and one site leader could manage more than one site e.g. ARH and Mission Memorial Hospital. Medical Staff Associations It is expected that local medical staff associations will continue to meet. To further enhance communication with physicians it is suggested the Vice President of Medicine, other Vice Presidents and Senior Medical Directors, meet twice a year with the Medical Staff Associations Presidents in order to enhance the opportunity for improved input and dialogue. Working Draft 6/19/2009 13
Proposed Pathways of Physician Engagement BOARD CEO EXECUTIVE HAMAC VP MEDICAL LMACS CLINICAL TRANSITION STEERING COMMITTEE MEDICAL DIRECTORS GROUP LOCAL MEDICAL STAFF ASSOCIATIONS SUBCOMMITTEES SUBCOMMITTEES Leadership Competencies and Development The suggestions for re-designing the Medical Staff Governance structures that are outlined in this document will strengthen the organization s ability to integrate and standardize care throughout the health authority. These issues, however, will be challenging to implement and will more likely succeed if the physician leaders are provided with leadership education and supports. The physician leaders will be consulted regarding their needs in leadership development and the recommendations will most likely include: Systems processes and thinking Performance management Resource management Root cause analysis Conflict resolution Strategic planning Programs for leadership education as well as the development of a new infrastructure to support Department Heads are currently under development. Working Draft 6/19/2009 14
Next Steps It is proposed that: A Clinical Transformation Steering Committee, consisting of physician leaders and FHA executive be established to guide the further development and refinement of this governance structure including the compensation structure. This model be presented to HAMAC and the LMAC groups for review and comment, then circulated to physicians in FHA Representatives from FH Medical Executive host a series of conversations with FHA physician leaders to review the proposed model and seek feedback. Presentation of proposed model at QBM Further implementation planning with the CTAG group then initiate implementation of the model starting with the Physician Program leadership group. One of Fraser Health s strategic imperatives is Progressive Partnerships. This includes progressive partnerships with our physician leaders. The further evolution of Fraser Health s medical governance model is critical to our success in achieving a sustainable and responsive health system. **** Working Draft 6/19/2009 15
Appendix One: Clinical Integration Strategic Imperative Working Draft 6/19/2009 1
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