Health System Funding Reform &
Quality-Based Procedures
Melissa Farrell
Assistant Deputy Minister
Health System Quality & Funding Division
Ministry of Health and Long-Term Care
November 13, 2015
Patients First: Action Plan for Health Care
On February 2, the Minister announced Patients First, the next phase of Ontario's plan for
changing and improving Ontario's health system. It exemplifies the commitment to put
people and patients at the centre of the system by focusing on putting patients' needs first.
This plan focuses on four key objectives:
Government
Promise
Health
Promise
Open, transparent, accountable, effectively managed
government that provides value for tax dollars
Patients First
• a caring, integrated experience for patients
• faster access to quality health services
• for all Ontarians at every life stage
Access:
Connect:
Inform:
Protect :
• Providing faster
access to the right
care
• Providing better
home and
community care
• Providing
information to make
the right decisions
about your health
• Ensuring our
universal health
care system is
sustainable for
generations to
come
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•
Reflect needs of the community
•
Equitable allocation of health care dollars
•
Better quality care and improved outcomes
•
Moderate spending growth to sustainable levels
•
Adopt/ learn from approaches used in other jurisdictions
•
Phased in over time at a managed pace
Health Based Allocation Model
(HBAM)
Components
Goals and
Objectives
Health System Funding Reform (HSFR)
Quality-Based Procedures
(QBPs)
• Clusters of patients with clinically related
diagnoses / treatments and functional
needs identified by an evidence-based
framework as providing opportunity for:
• Evidence, health-based funding formula
• Enables government to equitably allocate
available funding for local health services
• Estimates future expense based on past
service levels and efficiency, as well as
population and health information e.g.
age, gender, population growth rates,
diagnosis and procedures
40%
− Aligning incentives to facilitate
adoption of best clinical evidenceinformed practices
30%
− Appropriately reducing variation in
costs and practice across the province
while improving outcomes
3
New HSFR Governance
The Ministry, in collaboration with the Local Health Integration Networks (LHINs), the
Ontario Hospital Association (OHA) and Cancer Care Ontario (CCO),
has introduced a new HSFR governance structure
The Hospital Advisory Committee (HAC) has been charged
with providing advice and recommendations to the Ministry
leadership on improvements to HSFR, including existing and
planned components of HBAM and QBPs that are in alignment
with the Excellent Care for All Act and Patients First: Action
Plan for Health Care
Three working groups will support the work of the
Hospital Advisory Committee:
i) Quality & Policy
ii) Formulae & Tools
iii) Communication, Education & Knowledge Transfer
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Quality-Based Procedures (QBPs)
Vision
Definition
Provide
Opportunities
• QBPs will be developed across the continuum of care, using different
approaches to address the varying needs of patient / client populations
• QBPs are clusters of patients with clinically related diagnoses / treatments
and functional needs identified by an evidence-based framework
• For aligning incentives to facilitate adoption of best clinical evidenceinformed practices
• For appropriately reducing variation in costs and practice across the province
while improving outcomes
• For ensuring we are advancing right care, at the right place, at the right time
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Current Evidence-Based Framework
Identifies QBPs that have the potential to improve patient outcomes first and foremost
•
•
•
•
•
Does the clinical group contribute to a significant proportion of total costs?
Is there significant variation across providers in unit costs/ volumes/ efficiency?
Is there potential for cost savings or efficiency improvement through more consistent practice?
How do we pursue quality and improve efficiency?
Is there potential areas for integration across the care continuum?
•
•
• Are there clinical leaders able to champion change in this area?
• Is there data and reporting infrastructure in place?
• Can we leverage other initiatives or reforms related to practice change
(e.g. Wait Time, Provincial Programs)?
Is this aligned with Transformation priorities?
Will this contribute directly to Transformation system re-design?
•
• Is there a clinical evidence base for an established standard of care
and/or care pathway? How strong is the evidence?
• Is costing and utilization information available to inform development
of reference costs and pricing?
• What activities have the potential for bundled payments
and integrated care?
•
Is there variation in clinical outcomes across providers, regions and
populations?
Is there a high degree of observed practice variation across
providers or regions in clinical areas where a best practice or
standard exists, suggesting such variation is inappropriate?
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Current QBPs Under Consideration
QBP
Agency Oversight
Status
Retinal Disease
Vision Care (UHN)
Draft Clinical Handbook submitted
Coronary Artery Disease
Cardiac Care Network
Draft Clinical Handbook submitted
Aortic Valve Disease
Cardiac Care Network
Draft Clinical Handbook submitted
Cancer Surgery – Breast
Cancer Care Ontario
Draft Clinical Handbook submitted
Cancer Surgery – Thyroid
Cancer Care Ontario
Draft Clinical Handbook submitted
Corneal Transplant
Vision Care (UHN)
Draft Clinical Handbook submitted
Non-Emergent Spine
University Health Network
Draft Clinical Handbook submitted
Paediatric Asthma
Provincial Council for Maternal and Child Health
Draft Clinical Handbook submitted
Shoulder Surgery – Osteoarthritis Cuff
Health Quality Ontario
Draft Clinical Handbook submitted
Sickle Cell Anemia
Provincial Council for Maternal and Child Health
Draft Clinical Handbook submitted
Hysterectomy
Cancer Care Ontario & Health Quality Ontario
In development
Low Risk Delivery
Provincial Council for Maternal and Child Health
In development
Mental Health: Schizophrenia
Mental Health: Dementia with Agitation
Mental Health: Major Depression
Colposcopy
Cardiac Devices
Cardiac Prevention and Rehabilitation
in the Community
Health Quality Ontario
Health Quality Ontario
Health Quality Ontario
Cancer Care Ontario
Cardiac Care Network
In development
In development
In development
In development
In development
Cardiac Care Network
In development
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QBP Adoption Committee
The following principles have been proposed to lead the development of the
Provincial Roadmap for QBP Adoption
1.
QBPs will have a core set of tools and supports to assist adoption.
2.
Each QBP will have a clear process at the outset to determine the adoption strategy for the
QBP led by the lead agency.
3.
The core adoption tools must be supported by a provincial strategy to drive adoption e.g.
measurement and reporting, clinical team engagement and order sets.
4.
Adoption tools and supports will be evidence-based, where possible and will capture
innovation and leverage the strengths of the field. This will including considering spread and
scale strategies.
5.
All partners commit to contributing to and promoting a common on-line location for users to
easily access QBP tools (i.e. QBP Connect).
6.
QBP Adoption tools will be evaluated (ideally in a similar way).
7.
We will celebrate success (awards and rewards).
8.
QBPs will be defined provincially and operationalized locally using LHINs/lead agencies, existing
networks and local leadership who will have a lead role in QBP Adoption.
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QBP Adoption Committee Cont’d
The following core set of adoption tools and supports have been proposed
with the vision that a minimum core set be available for each
Measurement & Reporting Support
•
•
•
•
Baseline data
Ongoing/real-time data
Data support
Audit & feedback
Change Management Tools
•
•
•
•
•
Clinician/care team engagement
strategy
Provincial conferences/webinars
Access to provincial & regional experts
(clinical/data etc.)
Community of practice
Coaching/SWAT Team
Knowledge Transfer Tools
•
•
•
•
•
List of most important best practice
recommendations
Summary QBP pathway
Standardized order set templates
Recommendations on required local &
provincial infrastructure
Implementation toolkit/checklist
Improvement Science
•
•
Goal setting/benchmarking
Evaluation
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Spread vs Scale
SPREAD
SCALE
Horizontal Diffusion
System-wide structural change
One team at a time
Policy levers
Requires champions
Requires political commitment
www.HQOntario.ca
Source: Danielle Martin, Health Quality Transformation Keynote
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10
Clinical Leadership and Excellence
Early
Implementers
Innovators
Early Majority
Late
Majority
Slow
Implementers
Today
Impleme
ntation
To bridge from pockets of excellence, existing tools need to be strengthened to support greater spread:
• Leverage champions from the sector
• Position strong leaders at the forefront who can deliver on the vision
• Develop peer-to-peer supports to accelerate clinical adoption
• Scale up initiatives where investments have shown results
• Effective patient engagement to optimize patient care processes
• Expand quality improvement efforts across continuum of care
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Where to Next?
HSFR
Governance
QBP Adoption
Committee
Regional
Strategy
• Closer review of roles, priorities and direction of HSFR (e.g. Hospital Advisory Committee)
• Map roles and responsibilities (e.g. agencies, hospitals, LHINs, Ministry) for each QBP
and type of activity to support adoption
• Develop some standard approaches that partners support and will deliver for each QBP
• Develop an action plan to start the work, particularly for some of the cross cutting
strategies such as data
• Following the completion of the Pan-LHIN QBP surveys, develop a more standardized
regional adoption strategy for QBPs
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Where to Next Cont’d?
Evolution towards population-based frameworks for service delivery
Single service
QBPs: Evidence &
standards influence
average price
Integration of
clinical care
Health Links: Moving towards models for
comprehensive care in which providers
become accountable for overall outcomes
Integration of care
and funding for 1
episode
Integrated Funding Models: Scaling up a “proof of concept”
approach through an Expression of Interest
Pre-requisites:
• Shared governance
• Shared IT, health analytics, data systems
• Common service accountability agreements
Population-based
integration of
care, and funding
•
•
Common QIP
Common understanding of patient and provider
experience
Population-based frameworks for service delivery: Future direction, based on
evaluation, policy analysis, and innovative implementation
Quality foundation, guided by the Excellent Care for All Act
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