Improving Quality at Toronto Central LHIN 2012/13 Year in Review
Quality is an integral part of Toronto Central (TC) LHIN s Integrated Health Services Plan 2013-16, reflected in the goal, Better Health Outcomes for People through Equitable Access to Quality Care. TC LHIN began its work to create a system approach to quality in 2010, creating a subgroup of its Health Professionals Advisory Committee (HPAC) to examine how quality is being measured at a systems level locally, nationally and internationally. From this work, TC LHIN undertook a significant initiative (under the guidance of the Toronto Central LHIN Quality Table) to begin a comprehensive approach to measuring quality, incorporating equity, and ensuring the primacy of the patient experience in our collective understanding of quality. The ensuing document provides highlights of the accomplishments of the Quality Initiative of the 2012/13 Fiscal Year. HIGHLIGHTS: Six big dot quality indicators used to measure quality at a systems level ALL TC LHIN funded sectors hospitals, Community Care Access Centre, Community Health Centres, Community Support Services, Community Mental Health and Addictions, and Long-Term Care identified small dot indicators measurable in their sectors that contribute to achievement of the big dot quality indicators ALL TC LHIN funded sectors reporting data on the small dot quality indicators defined for their sectors part of the Service Accountability Agreement Requirements Data sources drawn where possible from existing local and provincial assets: Ontario Common Assessment of Need (OCAN), Resource Matching and Referral (RMR), RAI Equity a core component of the Quality Initiative As of April 2, 2013, an initiative rolled out across the LHIN for ALL TC LHIN hospitals to collect standardized, recordlevel sociodemographic data Multiple initiatives underway to improve capture and measurement of patient experience Definitions of complex patients developed IF YOU WANT TO FIND OUT MORE ABOUT IMPROVING QUALITY AT TC LHIN, READ ON!
II. SYSTEM QUALITY INDICATORS The impetus for the quality work at the TC LHIN was the lack of system-wide quality indicators to measure quality across the continuum. It was observed that sectors work in silos and implement individual quality improvement initiatives while some of the greatest issues for patients occur during transitions of care. The patient experience is not always considered adequately. Additionally, the system is heavily reliant on indicators where good data was available. As a result, frequently measured indicators such as readmissions and repeat emergency department (ED) visits are examined without adequate consideration of the factors affecting these indicators that take place outside hospital walls. Further, there is no ability to analyze quality indicators from an equity perspective or to see the proportionate impact of initiatives on different segments of the population, as there is no standard collection of socio-demographic data in the health care system. The TC LHIN Quality Indicators Task Group (QITG) was formed (now the TC LHIN Quality Table), comprised of representatives from all six LHIN funded sectors, primary care, public health, Ministry of Health and Long-term Care (MOHLTC), Health Quality Ontario (HQO), Ontario Hospital Association (OHA), Regional Geriatric Program, GTA Rehab Network, frontline providers and others, and a patient and a caregiver. The group selected themes to focus on and identified four main criteria in assembling systems indicators: Comprehensiveness across sectors Alignment with TC LHIN priorities, MOHLTC, HQO, primary care and public health Focus transitions, chronic diseases, high potential to impact, system-wide Validity and Feasibility measurable, reliable, actionable etc. Overarching theme: To improve overall health status of people living within the TC LHIN as well as residents from outside our LHIN who receive care from our health service providers, and to improve outcomes and experience of care. Three inter-related themes Identified by the TC LHIN Quality Table 1. Theme 1: Appropriate Access to Care Focus on avoidable time in hospital Avoidable inpatient time Avoidable ED use 2. Theme 2: Transitions of Care Focus on Patient Experience Communication/Information transfer to patient during transition Timeliness of hand-off of transition communication between providers Length of time waiting from time of referral to receiving next service 3. Theme 3: Care for Patients with Complex and High Care Needs Appropriate management of patients with complex high care needs
Six Big Dot System Indicators: 1. Inpatient Readmissions within 30 days of discharge for selected case mix groups, or CMG, (stroke, chronic obstructive pulmonary disease, congestive heart failure, Cardiac case mix groups, pneumonia, diabetes,gastrointestinal, asthma, mental health, and addictions) 2. Repeat unscheduled ED use within 30 days for any reason (may focus on Canadian triage acuity scale 4 & 5 (CTAS 4 & 5)) 3. Percentage of hospital patients (ED or inpatient) who knew important discharge aspects e.g. danger signals to watch after going home, medication related information, when to resume usual activities, who to call if they need help (NRC Picker and other surveys) 4. 90 th Percentile Decision Time (Number of days from the date that the referral is sent to final response (Accept, Deny)). (RM&R and other databases) 5. 90 th Percentile Waiting Time from acceptance to admission (Acute/Rehab/complex continuing care) (Resource Match &Referral and other databases) 6. Percent of patients with complex high care needs identified that are targeted/receiving appropriate care (e.g. intensive case management (In Development) Figure 1 Sample of Big Dot/Small Dot Indicator Alignment and initial data: Inpatient Readmissions within 30 Days
Rate of ED visits per 1,000 Residents A C E G I K M O Q S U W Y AA AC AE AG AI TC LHIN IMPROVING QUALITY AT TC LHIN: 2012/13 YEAR IN REVIEW Where are we today? Data collection, reporting and analysis are well underway, and the first TC LHIN System Quality Report is anticipated in Q2 2013/14. The first data being analyzed is already showing interesting results. For example, the graph below is related to Big Dot Indicator #2: Repeat unscheduled ED use within 30 days for any reason (may focus on CTAS 4 & 5), and represents one small dot indicator for the long-term care sector: rate of transfer to ED per 1000 active TC LHIN residents. Results ranged from 145 per 1,000 to 12,888 per 1,000 and further analysis demonstrated no discernible relationship between acuity of patients and rate of ED visits. This early data shows significant opportunity for improvement. 1,400 2a) Rate of Transfer to ED per 1,000 Active LTC Residents by Long Term Care Facility, TC LHIN (2011/12) 1,200 1,000 800 600 400 200 0 Source: CIHI NACRS, 2011/12 Long Term Care Home III. EQUITY Toronto s population is remarkably diverse. Over 40% of the populations are immigrants and an estimated 16,200 TC LHIN residents are from Aboriginal communities. Toronto is also home to the largest lesbian, gay, bisexual and transgendered community in Canada. Vast differences in income and education are part of Toronto. Close to a quarter of the population is low income; a significant number of whom are children, youth, senior women, recent immigrants, visible minority groups and those living in a lone parent family. For the TC LHIN, equitable health care means everyone has access to the same high standard of care no matter whom they are, what they earn, what language they speak and where they live, and is the core element of achieving the ALL in Excellent Care for All.
Measuring Health Equity Based on results of a three-year project executed by Mount Sinai Hospital, Centre for Addiction and Mental Health, St. Michael s Hospital and Toronto Public Health, TC LHIN has mandated all TC LHIN hospitals to collect patient level demographic data, beginning in each hospital by April 2, 2013. This firstin-canada regional approach to equity measurement is a best practice in other parts of the world and will: Elucidate who is receiving care Help delineate differences in access, outcomes, and quality of care between segments of the population Allow for stratification of quality measures by demographic data (e.g. re-admission rates, diabetes, cancer screening, etc.) Facilitate the development of evidence-based quality improvement interventions for reducing health inequities Core questions to be asked by all hospitals include: 1. What language do you feel most comfortable speaking in with your health care provider? 2. Were you born in Canada? (If no, what year did you arrive?) 3. Which of the following would best describe your racial or ethnic group? 4. Do you have any of the following disabilities? 5. What is your gender? 6. What is your sexual orientation? 7. What was your total family income before taxes last year? 8. How many people does your income support in your household? Language Services Toronto Literature has demonstrated the importance of communication in health care. When a care provider and patient do not understand each other, safety and quality of care are compromised. Patients cannot engage in medical decision-making, clinicians have challenges adequately assessing a patient s condition, and patient self-management and adherence to discharge instructions are compromised when a patient is not fully proficient in the language in which care is being provided. The TC LHIN identified that a number of hospitals provided over-the-phone interpretation services, under individual contract, paying vastly different rates for phone interpretation ranging from $1.71/minute to $8/minute. The LHIN saw an ideal opportunity for hospitals and other agencies to bulk purchase over-the-phone interpretation services as a means to cutting costs while offering consistent, high-quality medical interpretation services to people who are less proficient in English or French. Language Services Toronto emerged as a consortium of organizations committed to providing interpretation services, under a single contract. Launched in October 2012, Language Services Toronto provides real-time phone interpretation 24 hours a day, seven days a week in 170 languages, including
Aboriginal languages. Patients with limited ability to communicate in English visiting different hospital emergency rooms, clinics and health centres across the GTA will benefit from higher quality care and have a better experience as a result of this vital service. There are currently 33 partners in the program from the TC LHIN and beyond, paying less than $1.50 a minute for over-the-phone interpretation services. The TC LHIN is providing funding for community agencies to participate to trial the effectiveness of using over-the-phone interpretation services in the community sectors. As many community agencies do not have budgets that can support this service, TC LHIN is paying for the agencies that have expressed initial interest. IV. PATIENT EXPERIENCE Patients experience is a key element of understanding quality care. For TC LHIN, work kicked off in 2012/13 to improve measurement and reporting of patient experience and capture of patient voices of those with greatest needs that are not well served or heard. Measurement of Patient Experience Currently, each organization and sector works in silos to measure and improve quality. Most problems occur for patients during transitions, when patients move from one service to another. Yet there has been little information about the patient s experience across their care journey and collaboration to improve patient care. In 2012/13, TC LHIN conducted 40 engagements with more than 30 unique health service providers (HSPs) with respect to current processes and procedures for patient experience data collection and quality improvements. HSP tools (surveys and questionnaires) and their corresponding reports have been collected for more than 30 HSPs. The findings include: Limited to no standardization both within and across sectors with respect to patient experience measurement. No established common indicators or a common methodology for collection and interpretation of patient experience data across the continuum in the TC LHIN. Only a handful of organizations have sophisticated systems for collection, interpretation and public reporting. Even fewer organizations are consistently reporting results back to the front line as a means to implement quality improvements with respect to patient experience. Most organizations and sectors are measuring patient experience in English and French only Most captures of patient experience data focuses on satisfaction with a single episode of care; little to no information capture about transitions, communication between and among providers, and coordination of care Sample size for patient experience data collection is usually small
TC LHIN is exploring a range of opportunities that arose from this current state assessment. Two projects that have been initiated in 2012/13 are: a) development of a common survey tool that will be used to evaluate client satisfaction in community support services for seniors. The survey will be piloted with Adults Day Programs and Enhanced Adult Day Programs with the expectation to expand the evaluation of client experience in other Community Support Services (CSS) programs for seniors across the Community Navigation and Access Program (CNAP) agencies. b) Implementation of an email-based patient experience survey tool in a few organizations to obtain timely patient experience feedback. The larger sample size for the survey creates high quality, actionable feedback from which a management team can make informed decisions for service improvement. Patient Engagement with Hard to Reach Though collectively there is a high volume of engagement activity in the health care system, it is not coordinated for the groups being engaged, approaches are not always culturally competent or appropriate to the context of the populations affected. The commonly used methodologies are designed for populations who are able to be accessible e.g., have the time to participate, speak English or French, are literate, are comfortable with the group processes used, are mobile and can access transportation to get to and from meetings etc. As a result, these processes tend to be based on uniformity and consistency and are not responsive to variability and diversity. They also tend to reflect the perspectives of groups that are educated, relatively socially and economically advantaged, conform to Canadian social and cultural norms, and speak the same language. TC LHIN has a focus on developing targeted strategies to meaningfully engage residents who face barriers to participation. Our approach involves analyzing which groups are excluded from public and patient engagement processes; and identifying those within these groups who have difficulty accessing appropriate health services as well as people who are at risk and have unmet health care needs. We then develop specific, customized strategies designed in collaboration with the members of a target community for engaging community members in a dialogue about their health and health care. Each strategy is unique and can take significant time, planning and resources. For example, funding for attendant care or to compensate caregivers for a lost day of work may be required so that housebound seniors with disabilities have the support they need to participate in an event or communicate via interviews and other processes. An example of this work is a project in the Mount Dennis community led by Patient Destiny to engage specific communities in this high priority neighbourhood: new immigrants; single-parent families; and at-risk seniors from across ethnocultural groups.
V. DEFINING COMPLEX POPULATIONS The highest users of the healthcare system are defined differently through literature, experts, and policy. Strictly speaking, the highest users of healthcare resources are those who, when ranked, have the greatest expenditures associated with their health care utilization. Using this strict definition, the following should be noted: These high users include many individuals for whom costs cannot easily be reduced (complex neonates, transplant patients, etc). Accordingly, the LHIN took an expansive view of high users when considering complex users, frequent users, and the highest users of the system. The TC LHIN has worked on identifying these groups through two different, but related processes, namely through the work of the Community Care Access Centre (CCAC) and through the LHIN s Quality Table. The TC LHIN s Quality Table has used a number of strategies to better identify and understand which specific groups should be included when considering complex populations and 1%-5% high users. The intent of this work is also to understand how to measure the impact of improvement efforts among high users. The relevance of this work continues to grow with the advent of Health Links. The approach employed has been multifaceted and included a review of the Analysis of High Cost users prepared by Health Analytics Branch and incorporated information presented at the MOHLTC High Users conference. In addition, TC LHIN conducted literature reviews, requested rapid literature reviews and conducted an analysis of disease prevalence in TC LHIN. The TC LHIN interviewed key informants who have worked on initiatives and/or looked at indicators related to complex patients in TC LHIN and other areas. Further processes are underway to define high users in the community sectors. VI. STANDARDIZED DISCHARGE SUMMARY In 2012/13, organizations in the Toronto Central LHIN, under the leadership of the GTA Health Information Collaborative committed to the development of a standardized discharge summary template. Recognizing the significance of a discharge summary for patients, primary care practitioners in the community and other care providers, the hospitals committed to developing a consistent standardized set of fields that would lead to: More seamless transitions in care Fewer adverse health events as a result of increased communication between care providers Reduced requests for additional information Reduced hospital re-admission rates and repeat visits to the emergency department Improved health outcomes among complex patients Greater knowledge of discharge instructions among patients A standard discharge summary template was approved in February 2013, and all TC LHIN hospitals have agreed to implement this template, where possible electronically, in 2013/14.
VII. ALIGNMENT TC LHIN s Quality Initiative is closely aligned to key strategic provincial directions: MOHLTC Action Plan to provide faster access and stronger links to primary care by leading with Quality and Safety to support consistent coordinated responses to high-priority issues in the system. Excellent Care for All Act... Measuring quality for patients at the system level utilizing quality indicators established in engagement with stakeholders throughout the continuum of care that will be included in accountability agreement will foster a systematic shift toward evidenced based quality improvement to patient care Seniors Strategy The five principles guiding this strategy are a focus on access, equity, choice, value and quality. Health Links: The Ministry s Strategic Aims for Health Links and associated indicators closely align with TC LHIN s Quality Indicators. More than half of the indicators identified by the Ministry are already part of TC LHIN s Quality Indicator Framework and measurement, analysis and improvement strategies related to these indicators are already underway. To find out more about TC LHIN s Quality Initiative, and what is planned for 2013/14, please contact: Rachel Solomon Rachel.solomon@lhins.on.ca or Cynthia Damba Cynthia.damba@lhins.on.ca