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 Audiences Measurement Groups Purposes • • Public • Accountability MOHLTC • • System LHINs • Transparency • Health Quality Managers • Market Function Ontario • Providers • Quality • Associations • Payers Improvement & (OHA) Benchmarking • Regulators • CIHI • New Knowledge • Research • (Accreditation) Community • Collaboratives /Research Groups
Hospital Report Research Collaborative
Hospital Report Research Collaborative
Hospital Report Research Collaborative
Hospital Report Research Collaborative
MOHLTC Access
MOHLTC Access
myhospitalcare.ca (OHA. c2009-)
myhospitalcare.ca (OHA. c2009-)
Health Quality Ontario
Health Quality Ontario
Health Quality Ontario
Health Quality Ontario
Health Quality Ontario LTC Individual Results - Search By Health Topic http://www.hqontario.ca/en/reporting/ltc/modal/searchByHealt... Close INDIVIDUAL HOME RESULTS Print Falls Incontinence Pressure Ulcers Restraints SEARCH CRITERIA Falls By Home Percentage of residents who had a recent fall. By Location Search: Home Name Falls 2010-11 Falls 2011-12 By Health Topic 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 Home Pharmacy CCAC (ED, IP, SDS) Care Primary Care LTC 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 www.interrai.org Twitter: @interRAI_Hirdes
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 www.interrai.org Twitter: @interRAI_Hirdes
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 www.interrai.org Twitter: @interRAI_Hirdes
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 www.interrai.org Twitter: @interRAI_Hirdes
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 www.interrai.org Twitter: @interRAI_Hirdes
32 The Future of LTC? • “… 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.” Forbes et al., 1987 www.interrai.org Twitter: @interRAI_Hirdes
33 Implementation & Testing of interRAI Instruments 1996 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 Solid symbols – mandated or recommended by govt; Hollow symbols – research/evaluation underway www.interrai.org Twitter: @interRAI_Hirdes
34 Implementation & Testing of interRAI Instruments in Canada 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 DB Solid symbols – mandated or recommended by govt; Hollow symbols – research/evaluation underway www.interrai.org Twitter: @interRAI_Hirdes
35 Applications of interRAI’s Assessment Instruments: One assessment … multiple applications Case-mix Single Point Entry Care Plan Resource Allocation Evaluate Assessment Prevent Gaming Best Practices Outcome Measures Quality Indicators Patient Safety Quality Improvement Public Accountability Accreditation www.interrai.org Twitter: @interRAI_Hirdes
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 www.interrai.org Twitter: @interRAI_Hirdes
37 www.interrai.org Twitter: @interRAI_Hirdes
38 www.interrai.org Twitter: @interRAI_Hirdes
Triggering rates for two multi-level interRAI Clinical Assessment Protocols (CAPs), by prov/terr & setting 100 Falls CAP Mood CAP % Clients triggered CCC LTC CCAC SH CCC LTC CCAC SH 80 (2.0) (2.0) (HC) (CHA) (2.0) (2.0) (HC) (CHA) 60 40 20 0 Moderate Risk High Risk www.interrai.org
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