Quality in Primary Care - afhto Improving Quality in Primary Care Report of the Working Group to the Primary Healthcare Planning Group 1 Quality in Primary ... i Improving Quality

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QualityinPrimaryCareFinalReportoftheQualityWorkingGrouptothePrimaryHealthcarePlanningGroup

August2011

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TableofContents

WorkingGroupMembers ................................................................................................................... iii

Abbreviations ..................................................................................................................................... iv

ExecutiveSummary ............................................................................................................................. 1

Section1:Background.......................................................................................................................... 7

DevelopmentandEstablishmentofthePrimaryHealthcarePlanningGroup ......................................... 7

MandateoftheQualityWorkingGroup................................................................................................... 7

Section2:TrendsandCurrentStateofQualityImprovementinPrimaryHealthcareinOntarioandtheChangeImperative............................................................................................................................... 9

CurrentStateofPrimaryCareinOntario ................................................................................................. 9

CurrentStateofQualityinCanadaandOntario.....................................................................................10

CanadaRelativetoOtherCountriesandOntario ...............................................................................10PreventiveCareBonuses ....................................................................................................................12

CurrentStateofQualityImprovementInitiativesinOntario .................................................................13

Section3:TerminologyAssociatedWithQuality ................................................................................ 16

DefiningQuality,QualityImprovement,QualityAssurance,AccreditationandKnowledgeTransfer...16

Section4:StrategiesandEnablersofQuality:ALiteratureReview..................................................... 18

PerformanceMeasurement.................................................................................................................... 18

TripleAimFramework.........................................................................................................................19SuccessStories ....................................................................................................................................22

PerformanceTargets...............................................................................................................................23

ElectronicMedicalRecordandElectronicHealthRecord ......................................................................24

PrimaryHealthcareTeams......................................................................................................................26

PatientEnrolment...................................................................................................................................28

PatientEngagement................................................................................................................................28

ResearchandEvaluation.........................................................................................................................29

FinancialIncentives.................................................................................................................................30

TrainingandSupport ..............................................................................................................................31

PublicReporting......................................................................................................................................33

Accreditation...........................................................................................................................................35

PrimaryHealthcareOrganization/Governance ......................................................................................36

LeadershipDevelopment ........................................................................................................................38

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Section5:GuidingPrinciplesforQualityImprovementinPrimaryHealthcareinOntario ................... 40

GuidingPrinciples ...................................................................................................................................40

Section6Recommendations............................................................................................................ 42

PerformanceMeasurement.................................................................................................................... 42

PerformanceTargets...............................................................................................................................43

ElectronicMedicalRecords/ElectronicHealthRecords..........................................................................44

PrimaryHealthcareTeams......................................................................................................................46

PatientEnrolment...................................................................................................................................47

PatientEngagement................................................................................................................................47

ResearchandEvaluation.........................................................................................................................48

FinancialIncentives.................................................................................................................................49

TrainingandSupport ..............................................................................................................................49

PublicReporting......................................................................................................................................50

Accreditation...........................................................................................................................................50

PrimaryHealthcareOrganization/Governance ......................................................................................51

LeadershipDevelopment ........................................................................................................................51

Section7:ImplementationPlan ......................................................................................................... 52

ActionPlan ..............................................................................................................................................52

EvaluationPlan........................................................................................................................................54

WorkCitedinReport ......................................................................................................................... 55

AppendixA:TermsofReferenceforImprovingQualityinPrimaryHealthcareinOntario................... 81

AppendixB:Trends............................................................................................................................ 83

AppendixCDefiningQuality,QualityImprovement,QualityAssurance,AccreditationandKnowledgeTransfer ............................................................................................................................................. 90

AppendixDTripleAimFramework................................................................................................... 95

AppendixEHQOQualityAttributes ................................................................................................. 97

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WorkingGroupMembersBrianHutchisonHealthQualityOntarioSuzanneStrasbergOntarioMedicalAssociationMembersAngelaCarolCollegeofPhysiciansandSurgeonsofOntarioAlbaDiCensoSchoolofNursing,McMasterUniversityMichelleGreiverFamilyPhysician,NorthYorkFamilyHealthTeamJennieHumbertNursePractitioner,WestNipissingCommunityHealthCentreAnjaliMisraAssociationofOntarioHealthCentresMargieSillsMaerovMinistryofHealthandLongTermCareJohnStronksOntarioCollegeofFamilyPhysiciansLynnWilsonDepartmentofFamilyandCommunityMedicine,UniversityofTorontoWorkingGroupLeadandAuthorofReportMonicaAggarwal

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AbbreviationsAOHC AssociationofOntarioHealthCentresAHRQ AgencyforHealthcareResearchandQualityBSM BlendedSalaryModelCAHPS ConsumerAssessmentofHealthcareProvidersandSystemsCCM ComprehensiveCareModelCHC CommunityHealthCentreCHQI CentreforHealthcareQualityImprovementCIHR CanadianInstituteforHealthResearchCQI ContinuousQualityImprovementCPOE ComputerizedPhysicianOrderEntryCPCSSN CanadianPrimaryCareSentinelSurveillanceNetworkDFLE DisabilityFreeLifeExpectancyDGP DivisionsofGeneralPracticeDHB DistrictHealthBoardsECFAA ExcellentCareforAllActEHR ElectronicHealthRecordEMR ElectronicMedicalRecordFHG FamilyHealthGroupFHN FamilyHealthNetworkFHO FamilyHealthOrganizationFHT FamilyHealthTeamFP FamilyPhysicianGDP GrossDomesticProductGP GeneralPractitionerHALE HealthAdjustedLifeExpectancyHCC HealthCouncilofCanadaHQO HealthQualityOntarioHLE HealthyLifeExpectancyHRA HealthRiskAppraisalICES InstituteforClinicalEvaluativeSciencesIHI InstituteforHealthcareImprovementIOM InstituteofMedicineKT KnowledgeTransferLDL LowDensityLipoproteinLHIN LocalHealthIntegrationNetworkMAS MedicalAdvisorySecretariatMOHLTC MinistryofHealthandLongTermCare

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MSAA MasterServiceAccountabilityAgreementsNHS NationalHealthServiceNP NursePractitionerNPLC NursePractitionerLedClinicOECD OrganizationforEconomicCooperationandDevelopmentOHQC OntarioHealthQualityCouncilOHTAC OntarioHealthTechnologyAdvisoryCommitteeOMA OntarioMedicalAssociationP4P PayforPerformancePDSA PlanDoStudyActPEM PatientEnrolmentModelPHO PrimaryHealthOrganizationPHPG PrimaryHealthcarePlanningGroupQA QualityAssuranceQI QualityImprovementQIIP QualityImprovementandInnovationPartnershipQIP QualityImprovementPlanRNPGA RuralandNorthernPhysicianGroupAgreementTQ TotalQualityTQM TotalQualityManagement


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ExecutiveSummaryPrimaryhealthcareisthefoundationofCanadashealthcaresystem.Theterm,"primaryhealthcare"referstothehealthprofessionalsandprogramsthatarethefirstpointofcontactforpatients.Effectiveprimaryhealthcareiscommunitybased,promoteshealthylifestylesasameansofpreventingdiseaseandinjury,andrecognizestheimportanceofsocialandeconomicfactorsthatcanaffecthealth(HealthCouncilofCanada,2007).Anexcellentprimaryhealthcaresystemensurestherightcareisprovidedattherighttimeintherightwaybytherightperson.Inthisway,primaryhealthcarecanhelptopreventacuteorchronichealthconditions,shortenthedurationofillnesses,andreducetheriskofcomplications(HealthCouncilofCanada,2007).ImprovingthequalityofprimaryhealthcarehasgainedgrowingattentioninCanada(andinOntario).ArecentCommonwealthFundsupported11countrysurvey(2009)rankedCanadainthebottomthreeamongparticipatingcountrieswithrespecttothepercentageofphysiciansreportingthat:theirpracticehadaprocessforidentifyingadverseeventsandtakingfollowupaction;theyusedelectronicmedicalrecords;theirclinicalperformancewasroutinelycomparedwithotherpractices;theirpracticeroutinelyreceivedandrevieweddataonclinicaloutcomesandpatientsatisfaction/experience;theyroutinelyusedwrittenguidelinestotreatpatientswithasthmaorchronicobstructivelungdiseaseanddiabetes;andtheirpracticehadafterhoursarrangementsforpatientstoseeadoctorornursewithoutgoingtoahospitalemergencyroom.Qualityinprimaryhealthcareisanebulousandmultidimensionalconceptandisdefineddifferentlybydifferentstakeholders.Definingqualitycanbedifficultbecauseprimaryhealthcareisacomplexenvironmentinwhichtherearedifferingneedsbasedonthedemographicsofthecommunityandthegeographicregion.Factorsimportantindefiningqualityinonepopulationmaybelessimportantinothersettings.AhighqualityhealthcaresystemisdefinedinTheExcellentCareforAllActasonethatisaccessible,appropriate,effective,efficient,equitable,integrated,patientcentred,populationhealthfocused,andsafe(HealthQualityOntario,2011).Qualityimprovementisastructuredprocessthatincludesassessment,refinement,evaluationandadoptionofprocessesbyanorganizationanditsproviderstoachievemeasurableimprovementsinoutcomestomeetorexceedexpectations.AlthoughthereareavarietyofqualityimprovementinitiativestakingplaceinOntario,thereisnosystemwideandsustainedapproachestosupportingqualityimprovementinprimary


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healthcare.Toaddressthisgap,thePrimaryCareHealthcarePlanningGroup(PHPG)establishedtheQualityWorkingGroupwiththemandatetodeveloprecommendationsontheappropriateapplicationofevidenceinprimarycarepractice,andtoenhancequalityintheprimaryhealthcaresector.Recommendationsweretofocuson:qualityimprovementplanning;trainingandsupport;clinicalandorganizationalbestpracticesandevidenceinformeddeliveryofservices;qualitymeasurementframeworkforprimarycarepractices;and,barriersandenablersofqualityofcare.Toaddressquestionsabouthowtoimprovequalityinprimaryhealthcare,theQualityWorkingGroupreviewed13strategiesandenablersforimprovingquality.Aliteraturereviewwasconductedtodeterminetheimpactdifferentstrategies/enablersmighthaveonthequalityofhealthcare.Insomecases,evidenceregardingtheimpactofspecificinterventionswasfoundtobeconflictingorinsufficient.Recommendationshavebeenpreparedforeachofthe13potentialqualityenablers,informedbyasetofguidingprinciples.Whereevidenceofimpactwasweakorconflicting,theWorkingGrouprecommendationsidentifytheneedtocollectmoredataonwhichtobasequalityimprovementchanges,ortofundresearchandevaluationtogatherdefinitivedataonthesubject.TheWorkingGroupsrecommendationsare:PerformanceMeasurement

Primaryhealthcareperformancemeasurementatthepractice,local,regionalandprovinciallevelsshouldbebasedontheTripleAimFramework(improvedpopulationhealthoutcomes,enhancedpatientexperienceandreduction/controlofpercapitacosts)andtheHealthQualityOntarioattributesofahighperforminghealthsystem(safety,efficiency,effectiveness,personcentredness,timeliness,equity,integration,populationhealthfocus,appropriatelyresourced).

Capacitytomeasureprimaryhealthcareperformanceatalllevelsneedstobedeveloped,drawingonEMR/EHR,administrativeandpatientsurveydata.

Performancemeasurementdatashouldbedisseminatedwidelytodrivechangeandinformdecisionsatthelocalandsystemlevel.

PerformanceTargets

Performanceprioritiesandtargetsshouldbesetmainlyatthepracticeandcommunitylevelstakingintoconsiderationregional/provincial/nationaltargetsifavailable.

Provincialtargetsneedtobecarefullyselectedthroughaprocessofconsultationwithkeystakeholdersandshouldbebasedonshortandlongtermhealthsystemgoals,availablecapacity,evidenceofpotentialforimprovementandhighqualitydata.


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ElectronicMedicalRecord/ElectronicHealthRecord

HighqualityprimaryhealthcarerequiresEMRfunctionalityrecommendedbytheAgencyforHealthcareResearchandQualityandtheInstituteforHealthcareImprovement.TheseorganizationsidentifiedthefollowingattributesascriticalelementsofahighlyfunctioningEMR:

ProactivePatientBasedo Allinvolvedinqualityimprovementshouldbeabletoquerythedatao Thesystemshouldsupportinstantaccesstoqueryresultso Thequeryingsystemshouldallowtheusertoaskanyquestiono Usersshouldbeabletoconstructandrunquerieswithouttechnicalassistanceo Usersshouldbeabletospecifytheinclusionofanydataelementsinquerieso Thesystemshouldsupportdrilldownintodatao Usersshouldbeabletosavequeriesforreuseand/orrefinemento Thesystemshouldsupportthesharingofquerieso Thetypesofactiontakenonthelistsofpatientsinaqueryshouldbeflexibleo Theactiontakenonthelistshouldincorporateandusepatientdatatofurther

segmenttheaction(e.g.,HbA1cfollowup)o Thesystemshouldautomatetheactionswheneverpossible

PlannedCareforIndividualPatientsThewholepatientshould:

o bedisplayedinoneplaceo bedynamico beusedforplanning,treatmentandfollowupo supportcareacrossallconditionsandhealthissues,notjustthecomplaint

associatedwithaparticularencountero bethecentrallocationforotherviewsofpatientdata,suchasrunchartsof

laboratoryresultsandvitalso incorporateevidencebasedpromptsandreminderso provideaportalforthepatientforbothinputandviewingdata,givingthepatient

somecontroloverhis/herrecordMeasurement

o Themeasurementmoduleshouldallowtheusertocustomizeanyreportbyaddingorchangingafilter

o Thequeryandfilterstructuresformeasurementandreportingshouldbeidenticaltothoseusedforthepopulationbasedcaretoolandforremindersandprompts


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Othero Abilitytocustomizethedatapresentedo Easeofuseo Interoperabilityo Dataavailableacrossthecontinuumofcareo Appropriatedatastructuresprovideinformationthatsupportsimprovemento Automation

Commondatastandards,capacityfordatasharing,andappropriatetrainingand

supportforprovidersinmeaningfuluseofEMRsneedtobedevelopedandimplemented.

PrimaryHealthcareTeams

Continueexpandingthenumberofcollaborativeinterprofessionalprimaryhealthcareteams.Teamsshouldvaryinsize,compositionandorganizationalstructuretomeetlocalcommunityneeds.

Interprofessionalcollaborativepracticeopportunitiesthatareconsistentwiththeneedsofthepopulationbeingservedbemadeavailabletoallprimaryhealthcaremodelsregardlessoffundingorproviderpaymentmethods.

Supportcoordination,collaborationand/orintegrationofprimaryhealthcareteams/practiceswithothercommunityhealthandsocialservicestoallowforeffectiveandefficientpatientnavigationthroughthehealthcaresystem.

Toachieveefficienciesandimprovedoutcomes,teammembersshouldfunctionattheirlevelofcompetency,focusingonthepatientsneedsandrecognizingtheimportanceofcontinuityinbuildingtrustingproviderpatientrelationships.

PatientEnrolment

Formalpatientenrolmentreenforcespatientproviderrelationshipsandresponsibilitiesandisfoundationaltoproactive,populationbasedpreventivecareandchronicdiseasemanagementandtosystematicpracticelevelperformancemeasurementandqualityimprovement.OntarioshouldcontinuethespreadofPatientEnrolmentModels.

PatientEngagement

Patientengagementintheformofbothpatientselfmanagementandpatientinvolvementinservicesdesignandplanningiswidelybelievedtobeacriticaldriverofqualityimprovementinprimaryhealthcare.Moreinformationfromevaluativestudiesonthebestapproachestoengagingpatientsisrequired.


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ResearchandEvaluation

Acontinuingflowofresearchandevaluationtoinformprimaryhealthcarepolicyandpracticeisanessentialunderpinningofahighperformingprimaryhealthcaresystemandneedstobesupportedbyadequatefundingofresearch,evaluationandresearchtraining.

Specificareasrequiringfocusedevaluationinclude:approachestopatientengagement,approachestoqualityimprovementtrainingandsupport,costsandbenefitsofprimarycareaccreditation,physicianversusteambasedincentives.

Promisingbutuntriedqualityrelatedinnovationsshouldbeimplementedandevaluatedonasmallscalepriortosystemwideimplementation.

FinancialIncentives

Giventheambiguityofcurrentevidenceandthepotentialforperverseeffectsofpayforperformance(P4P)inprimaryhealthcare,primarycareP4Pincentivesshouldbepursuedwithcautionandbecarefullyevaluated.

TrainingandSupport

Qualityimprovementtrainingandsupportshouldbemadeavailableovertimetoallprimarycareprovidersandorganizations.

Qualityimprovementtrainingshouldbeembeddedinallhealthcareprofessionaltrainingprograms.

PublicReporting

Publicreportingofprimaryhealthcareperformanceattheregionalandprovinciallevelsshouldtrackchangesovertimeandincludecomparisonacrossregions,takingdifferencesinpopulationcharacteristicsintoaccount.

Mandatorypublicreportingofperformanceisnotrecommendedforprimarycarepracticesand/ororganizations.

Accreditation

Primaryhealthcareaccreditationisapotentialdriverofquality.However,evidenceoflastingimpactisrequiredbeforeadefinitiverecommendationcanbemade.Asynthesisofinternationalexperiencewithprimaryhealthcareaccreditationandtheevidence


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regardingitsimpactiscurrentlyunderwayundertheauspicesoftheCanadianHealthServicesResearchFoundationandshouldinformfuturedecisionmaking.

PrimaryHealthcareOrganization/Governance

Localprimaryhealthcareprovidernetworksthatengagepatientsandthepubliccouldplayakeyroleinpromoting,supportingandcoordinatingqualityimprovementinitiativesandinsharingqualityimprovementexpertiseandexperienceamonglocalproviders.

LeadershipDevelopment

Createprogramstosupportthedevelopmentofqualityimprovementleadershipcapacityamongprimaryhealthcarecliniciansandadministrativestaff.


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Section1:Background

DevelopmentandEstablishmentofthePrimaryHealthcarePlanningGroupInJuneof2010,theMcMasterHealthForumheldadialoguewithavarietyofparticipants1onthetopicofSupportingQualityImprovementinPrimaryHealthcareinOntario.Atthisforum,dialogueparticipantsagreedthatOntariolacksasystemwideandsustainedapproachtosupportingqualityimprovementinprimaryhealthcare.ItwasdeterminedthatanoverarchingframeworkforstrengtheningprimaryhealthcareinOntariowasrequired.ForumparticipantsconcludedthatasmallplanninggroupshouldbeestablishedwithamandatetodraftandbuildconsensusonastrategyforstrengtheningprimaryhealthcareinOntario,andtoorganizeasummitatwhichthestrategywouldbedebated,finalizedandapprovedbyabroadbasedgroupofkeystakeholders.ThePrimaryCareHealthcarePlanningGroup(PHPG)wasestablishedandincludedrepresentativesfromtheMinistryofHealthandLongTermCare(MOHLTC),OntarioMedicalAssociation(OMA),RegisteredNursesAssociationofOntario(RNAO),OntarioCollegeofFamilyPhysicians(OCFP)andAssociationofOntarioHealthCentres(AOHC).ThePHPGrecommendedthatfiveworkinggroupsshouldbecreatedtoaddressquality,access,efficiency,accountabilityandgovernancetoinformtheapproachforstrengtheningprimaryhealthcareinOntario.

MandateoftheQualityWorkingGroupInAprilof2011,theQualityWorkingGroupwasestablishedtoproviderecommendationsontheappropriateapplicationofevidenceinprimarycarepracticeandonenhancingqualityintheprimaryhealthcaresector(RefertoAppendixAfortheTermsofReference).ThekeyareasoffocusforthisWorkingGroupincluded:

Qualityimprovementplanning,trainingandsupportintheprimaryhealthcaresector Clinicalandorganizationalbestpracticesandevidenceinformeddeliveryofservices Qualitymeasurementframeworkforprimarycarepractices Barriersandenablersofqualityofcare

1Participantsincludedrepresentativesfromthe:GovernmentofOntario,stakeholderorganizations(e.g.,OntarioMedicalAssociation(OMA),OntarioCollegeofFamilyPhysicians(OCFP),RegisteredNursePractitionersAssociationofOntario(RNAO),AssociationofOntarioHealthCentres(AOHC),AssociationofFamilyHealthTeamsofOntario,DietitiansofCanada),LocalHealthIntegrationNetworks(LHINs),QualityImprovementandInnovationPartnership(QIIP),CancerCareOntario(CCO),regulatorybodiesandacademics.


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TheWorkingGroupwascomposedofrepresentativesfromacademicandresearchinstitutions,professionalassociations,regulatorycolleges,providersandothersystemleaders.TheCoChairsoftheQualityWorkingGroupwereDr.BrianHutchisonandDr.SuzanneStrasberg.


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Section2:TrendsandCurrentStateofQualityImprovementinPrimaryHealthcareinOntarioandtheChangeImperative

CurrentStateofPrimaryCareinOntarioCanadaspends10.4%ofitsgrossdomesticproduct(GDP)onhealthcare(OrganizationforEconomicCooperationandDevelopment,2010).ThisishigherthantheOrganizationforEconomicCooperationandDevelopment(OECD)averageof9.0%.TheCanadianphysiciantopopulationratio(2.3per1,000population)isbelowtheOECDaverage(3.2per1,000).However,thegeneralpractitionertopopulationandnursetopopulationratiosareabovetheaverageformembercountriesoftheOECD(OECD,2010).Familyphysicians(FPs)makeup51%ofthephysicianworkforceinCanada(CIHI,2010).InApril2010,therewere25,886activephysiciansinOntario.Ofthesephysicians,approximately11,550weregeneralpractitioners(GPs)/familyphysicians.OftheGPs/FPs,approximately7,700(67%)wereaffiliatedwithapatientenrolmentmodel(PEM);15001600(1314%)werecomprehensivecareprimarycarephysiciansremuneratedthroughstraightfeeforservice(FFS);andtheremainder(approximately23002800;2024%)wereinfocusedorparttimepractice(ICESandOMA,personalcommunication,May2011).AccordingtotheHealthQualityOntario(HQO)report(2011),93.5%ofOntarianshadafamilydoctor.AsofJune2011,theMinistryofHealthandLongTermCare(2011)reportedthatover9.5millionOntarioresidentswereenrolledtoreceivecarefrom709PEMs.The709PEMsincluded:362FamilyHealthOrganizations(FHOs)(with3,631physicians);238FamilyHealthGroups(FHGs)(with3,003physicians);38RuralandNorthernPhysicianGroupAgreements(RNPGA)(with93physicians);36FamilyHealthNetworks(FHNs)(with346physicians);21BlendedSalaryModel(BSM)(with74physicians);14othergroups(with222physicians);and305physiciansintheComprehensiveCareModel(CCM).AsofAugust2011,therewillbe200FamilyHealthTeams(FHTs)with2,000physiciansandover1,500interprofessionalhealthcareprovidersserving2.5millionenrolledpatients(MOHLTC,personalcommunication,July2011).Inaddition,thereare300GPsandNPsin73CommunityHealthCentres(CHCs)serving367,216patients(AOHC,personalcommunications,July2011).ThereareeightNursePractitionerLedClinics(NPLCs)invariousstagesofimplementationandanadditional18clinicsthatwillbeimplemented.Over5,000OntarioresidentsareregisteredwithaNPLCtoreceiveprimaryhealthcare.Approximately6.5%ofOntariansdonothaveaccesstoafamilydoctor(HQO,2011).Ofthese,overhalfareactivelylookingforanFPbutcannotfindone(HQO,2011).TheseOntarianstendtohavelowerincomesandtobefromthenorthernregions(HQO,2011).ThereareregionaldisparitiesinthepercentageofOntarians


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withafamilydoctor.ThisvariesbyLHINfrom85.8%intheNorthEastLHINto98.1%intheSouthEastLHIN(MOHLTC,2010).

CurrentStateofQualityinCanadaandOntario

CanadaRelativetoOtherCountriesandOntarioCanadahasparticipatedinaseriesofbenchmarkingsurveysthatareconductedbytheCommonwealthFundtotracktrendsinprimarycare.Surveysareconductedannually,providingameanstocomparepracticesandtrendsovertime,andtobenchmarkagainstothercountries.Keyindicatorshavebeendevelopedthatallowperformancetobecomparedbetweenparticipatingcountriesandtoleveragethedataforongoinghealthcareplanning.Surveysofprimarycarephysiciansin2009andadultsin2010showedthatCanadaisperformingwellonsomedimensionsofqualityanddoingpoorlyonothers.Inmostcases,Canadahasbeenmakingprogresswithimprovingscoresonkeyindicatorsofqualityexceptforsafety,efficiencyandaccessibility(RefertoAppendixBfordetailedinformationontrends).Canadaisachievinghighscoresonindicatorsrelatedtoqualitydimensionssuchaseffectiveness(chronicdiseasemanagement),focusonpopulationhealth(preventivecare),patientcentredness(communication)andsomeelementsofefficiency.ThesurveyofCanadianadultsindicatedthatCanadatrailedthetopperformingcountriesonlyslightlyinpreventivecare(exceptPapsmears)andchronicdiseasemanagement.CanadarankedinthetopthreecountrieswithrespecttothepercentageofCanadiansreportingthattheydiscussedattheirregularplaceofcareahealthydietandhealthyeating(52%),exerciseorphysicalactivity(56%)andthingsintheirlifethatworriedthemorcausedthemstress(44%).ComparedtoCanada,Ontarioscoredbetterinthepercentageofpatientswithhypertensionthatobtainedbloodpressureandcholesterolchecksandthepercentageofpatientswithasthma,diabetes,heartdisease,hypertension,highcholesterolthatreportedbeingveryconfidentintheirabilitytocontrolandmanagehealthproblems.AlthoughCanadaisdoingwellinrelationtoothercountriesonchronicdiseasemanagementandprevention,theHQOidentifiesroomforimprovement.The2011HQOannualreportnotedthatonlyhalfofOntarianswithdiabetespatientshavetheireyesandfeetexaminedwithintherecommendedtimeintervalsandslightlyfewerthanhalfaregettingthemedicationtheyneed.TheHQOalsosuggeststhatOntarioneedstodobetterinprevention.Therateofobesityhasincreasedfrom16%to18%overthepasteightyears;andoneinfiveCanadiansissmoking(HQO,2011).Furthermore,onethirdofwomenaged50to69didnothaveamammograminthepasttwoyears;oneinfouradultwomendidnothaveaPaptestinthelastthreeyears;andoneinfiveelderlywomendidnotgetscreenedforosteoporosis.


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TheCommonwealthsurveyssuggestthatthesystemisperformingwellforsomeindicatorsofefficiencywith89%ofCanadianadultsreportingin2010thattheycouldnotrememberatimewhentheirtestresultsinformationwasnotavailableatthetimeoftheirappointmentand92%reportingthatduplicatetestswerenotdone(thishasslightlydeclinedfrom95%in2007).Withrespecttopatientcentredcare:themajorityofCanadianadultsgavehighscorestotheirregulardoctorsoncommunication:85%reportedthattheirregulardoctoralways/oftengivesthemanopportunitytoaskquestionsaboutrecommendedtreatment;89%reportedthattheirregulardoctorexplainsthingsinawaythatiseasytounderstand;83%reportedthattheirdoctorinvolvesthemasmuchastheywantincaredecisions;and80%reportedtheirdoctorspendsenoughtimewiththem.AlmostthreequarterofCanadians(74%)whoreceivedcareinthelastyearreportedthatthequalityofcaretheyreceivedfromtheirregulardoctorwasverygoodorexcellent.Canadaachievedlowerscoresonindicatorsrelatedtoqualitydimensionssuchas;appropriatelyresourced,accessibility,patientcentredcare,safety,equity,andeffectiveness.Physiciansreportedlowratesfor:theadoptionofinformationsystems;adoptionofinterprofessionalhealthcareprovidersinthehealthcaredeliveryteam;providingchronicallyillpatientswithwritteninstructions;providingpatientswithawrittenlistofmedicationsformanagingcare;and,accesstoafterhourarrangementsforpatients.OntarioperformedbetterthantheCanadianaverageintheuseofhealthinformationtechnology/officesystemsandintegrationofinterprofessionalhealthcareproviders.Canadianadultsreportedlowratesforconfidenceintheirabilitytomanagetheircareandrelativelyhighratesof:adversehealthcareincidentssuchasmedicationerrors;mistakesintreatment;incorrectdiagnosticorlaboratorytestresults;and,difficultyobtainingaccesstoprimarycarewhentheyweresick.TheHQO(2011)reportedthatthesystemisnotcompletelyequitablesinceCanadianswithlowincomesorpooreducationareathigherriskofunhealthybehavioursandnotgettinghealthpreventionservices.Forexample,lowerincomeOntariansare36%morelikelytoexperienceanacutemyocardialinfarctionandhavea32%higherrateofinjuryrelatedhospitalizationcomparedtothehighestincomeOntarians.InthemostrecentCommonwealthFundsurveys(2009;2010),Canadarankedinthebottomthreeamongallparticipatingcountrieswithrespecttothefollowingindicators:

percentageofphysiciansreportingthattheirpracticehasaprocessforidentifyingadverseeventsandtakingfollowupaction(10%);thisdeclinedfrom20%in2006

percentageofphysiciansusingelectronicmedicalrecords,whichenablesperformancemeasurementandfeedback(37%)


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percentageofphysiciansreportingthattheirclinicalperformancewasroutinelycomparedwithotherpractices(11%)

percentageofphysiciansreportingthattheirpracticeroutinelyreceivesandreviewsdataonclinicaloutcomesofpatientcare(17%)andpatientsatisfaction/experience(15%)

percentageofphysiciansthatreportedtheroutineuseofwrittenguidelinestotreatasthmaorchronicobstructivelungdisease(76%)anddiabetes(82%)

percentageofphysiciansreportingthattheirpatientsoftenhavedifficultygettingspecializeddiagnostictests(47%)

percentageofphysiciansreportingthattheirpatientsoftenfacelongwaitingtimestoseeaspecialist(75%)

percentageofphysiciansreportingthattheirpracticehasanafterhoursarrangementtoseeadoctorornursewithoutgoingtoahospitalemergencyroom(43%);thishasdeclinedfrom47%in2006(Netherlandswith97%)

percentageofCanadiansthatreportedthatitwasveryeasytocontacttheirdoctor'spracticebyphoneduringregularpracticehours(26%)

percentageofCanadiansthatreportedobtaininganappointmentthesamedaywhensick(28%)

PreventiveCareBonuses

FPs/GPsinPEMsareentitledtoreceivingfinancialincentivesformeetingestablishedthresholdlevelsforperformingpreventivecareactivities.Theamountofthepreventivecarebonusvariesbasedonthelevelofthresholdachieved.Ananalysisoftheuptakeofthefinancialincentivesforinfluenzavaccine,Papsmear,mammogramandchildhoodimmunizationconsistentlyindicatesthatthedistributionisbimodal,withmostphysiciansclaimingattheextremeendsofthethresholdscaleratherthaninthemiddle(MOHLTC,2011).Thisrangedfrom:

37%ofphysiciansbillingnothing(0%)and36%ofphysiciansbillingforthemaximumthreshold(80%)fortheinfluenzavaccine

32.5%ofphysiciansbillingnothing(0%)and45%ofphysiciansbillingforthemaximumthreshold(80%)forPapsmears

29%ofphysiciansbillingnothing(0%)and53%ofphysiciansbillingforthemaximumthreshold(75%)formammograms

31%ofphysiciansbillingnothing(0%)and62%ofphysiciansbillingforthemaximumthreshold(95%)forchildhoodimmunization


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ThesetrendsindicatethatmorephysiciansarereachingthemaximumthresholdforthemammogramandchildhoodimmunizationincentivecomparedtothePapsmearandinfluenzaincentive.ThecolorectalscreeningbonuswasmostwidelyadoptedbyPEMphysicians.Thedistributionforthisincentivewasskewedtowardstheright(thatis,towardsthehighestendoftherange)withmoreconcentrationaroundthemean.Theuptakeoftheincentiverangedfrom:26%ofphysiciansbillingnothing(0%);2%meetingthe15%threshold;8.3%meetingthe20%threshold;8.2%meetingthe40%threshold;21%meetingthe50%threshold;13%meetingthe60%threshold;and21%ofphysiciansbillingforthemaximumthreshold(70%).ThereisgreatvariationamongPEMswithrespecttotheuptakeofeachpreventivecareincentive.However,aconsistenttrendamongalltheincentivesisthatphysiciansintheRNPGAmodelwerethemostlikelytobillnothingforeachincentive;FHOsweresecond;CCMswerethird;FHGswerefourthandFHNswerefifth.PhysiciansinFHNswerethemostlikelytobillforthemaximumthresholdforeachincentive;FHGsweresecond;FHOswerethird;CCMswerefourth;andRNPGAswerefifth.

CurrentStateofQualityImprovementInitiativesinOntarioFederalandprovincialgovernmentsinCanadahaveinvestedinimprovingthequalityoftheprimaryhealthcaresectorthroughavarietyofinitiatives(McMasterForum,2010).Federalinitiativesinclude:

InvestinginaPrimaryHealthCareTransitionFundtosupporttargetedqualityimprovementpilotprojectsbetween2000and2006

EstablishingCanadaHealthInfowaytosupportthedevelopmentofelectronichealthrecords(EHRs)

Provincialinitiativesinclude:

EstablishingtheOntarioHealthQualityCouncil(OHQC)in2005tomonitoraccessandoutcomesandsupportcontinuousqualityimprovementinOntarioshealthcaresystem

Introducingfinancialincentivesforpreventionandchronicdiseasemanagementincomprehensivecaremodels

Fundingandsupportingtheadoptionandimplementationofelectronicmedicalrecords(EMRs)throughOntarioMDandeHealthOntario

Fundingaprimaryhealthcare'atlas'bytheInstituteforClinicalEvaluativeSciences(ICES)anddecisionsupporttoolsbytheCentreforEffectivePractice

EstablishingtheQualityImprovementandInnovationPartnership(QIIP)in2007toleadtheadvancementofqualityimprovementinprimaryhealthcare


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Fundinginitiativestargetedtospecificgroups(e.g.,PrimaryCareAsthmaProgram,ProvincialPrimaryCareCancerNetwork)

EstablishingaccountabilityframeworksbetweenLocalHealthIntegrationNetworks(LHINs)andCHCs

CommissioningoftheMcMasterForumbyQIIPwithfundingfromtheMOHLTCtoconductanenvironmentalscanandestablishacapacitymapbyexaminingthenatureandextentofqualityimprovementactivitiesinprimaryhealthcareinOntario,andtocompleteasynthesisofsystematicreviewsonevidenceabouttheeffectivenessofqualityimprovementinterventionsinprimarycare.Thisworkinformedthedevelopmentofanissuebriefwhichwasusedtofacilitateastakeholderdialogueonqualityimprovementinprimaryhealthcare.

InJune2010,themandateoftheOHQC(nowHealthQualityOntario(HQO))wasexpandedbythegovernmentsExcellentCareforAllAct(ECFAA).Asaresult,HQOhasintegratedtheCentreforHealthcareQualityImprovement(CHQI),QIIP,theMinistryofHealthandLongTermCaresMedicalAdvisorySecretariat(MAS),theOntarioHealthTechnologyAdvisoryCommittee(OHTAC)andtheTechnologyEvaluationFundtoformasingleorganizationwiththeresponsibilityto:coordinate,consolidateandstrengthentheuseofevidencebasedpracticeinitiativesandtechnologies;supportcontinuousqualityimprovement;andcontinuetomonitorandpubliclyreportonhealthsystemoutcomes(HQO,2011).Thelegislationrequiresthateveryhealthcareorganization(currentlydefinedasahospitalwithinthemeaningofthePublicHospitalsAct)(HQO,2011):

Establishaqualitycommitteetoreportonqualityrelatedissues Developanannualqualityimprovementplanandmakeitavailabletothepublic Linkexecutivecompensationtotheachievementoftargetssetoutinthequality

improvementplan Conductpatient/careprovidersatisfactionsurveys Conductstaffsurveys Developapatientdeclarationofvaluesfollowingpublicconsultation,ifsucha

documentisnotcurrentlyinplace,and Establishapatientrelationsprocesstoaddressandimprovethepatientexperience.

AnenvironmentalscancommissionedbyQIIPonqualityimprovementinitiativesinOntarioshowedthatqualityimprovementprogramsinOntariosphysicianledprimaryhealthcarepracticesarefragmentedandlimitedincoverage(McPhersonetal,2010).Thescanidentified24distinctprogramsinwhichthefocusvariedfromdiseaseorcondition,team,organization,region,sector,orapproach.Onlyafewprogramshadafocusonqualityimprovement.Manyoftheprogramswerepilotswithnoclearindicationoftheirpossiblefitintoasystemwideandsustainedapproachtosupportingqualityimprovementinhealthcare.Incommunitygoverned


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healthcareorganizations,16distinctprogramswereidentified.Manyoftheseprogramsintersectedwithqualityimprovementbutwerenotspecificallyfocusedonit.Forthesereasons,Ontariorequiresasystemwideandsustainedapproachtosupportingqualityimprovementinprimaryhealthcare.


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Section3:TerminologyAssociatedWithQuality

DefiningQuality,QualityImprovement,QualityAssurance,AccreditationandKnowledgeTransferTheExcellentCareforAllActdefinesahighqualityhealthcaresystemas:accessible,appropriate,effective,efficient,equitable,integrated,patientcentred,populationhealthfocused,andsafe(HQO,2011).TheMOHLTC,throughtheExcellentCareforAllStrategyhasindicateditscommitmenttoleveragingallnineoftheseattributestoadvancequalityinitiativesacrosstheprovince.Inthefallof2010,aworkinggroupwasformedtoprovideadvicetotheMOHLTCaroundthedesignofQualityImprovementPlans(QIPs).Theconsensuswasthatwhileallnineattributesarevaluable,theQIPsshouldspecificallyfocusonfourofthemforstreamlinedprovincialandpublicreporting:

Safe Effective Accessible PatientCentred

AnexaminationoftheliteratureindicatesthatthereisnouniversallyaccepteddefinitionofQualityImprovement(QI),asitrelatestoprimaryhealthcare.QualityImprovement,ContinuousQualityImprovement(CQI),TotalQuality(TQ),TotalQualityManagement(TQM),andContinuousImprovement(CI)aretermsthatareoftenusedinterchangeably.QIinvolvesastructuredprocessthatincludesassessment,refinement,evaluationandadoptionofprocessesbyanorganizationanditsproviderstoachievemeasurableimprovementsinoutcomestomeetorexceedexpectations(RefertoAppendixC).ThefundamentalconceptunderlyingQIisthatinordertoachieveanewlevelofperformance,thesystemneedstochange.QIemphasizeschangesinprocessesandsystemsofhealthcaredeliveryandmeasurestheimpactofthosechanges.RepeatingtheseprocessescontinuouslytoimprovequalityoutcomesisCQI.QIinitiativescantargetpatients,families,staff,healthprofessionalsandthecommunity.QualityAssurance(QA)activitiesareintendedtoprovideconfidencethatqualityrequirementsarebeingmet.QAinvolvesmeasurementofperformance,usuallyagainstpredefinedstandardsorbenchmarks,andoftenfocusesonidentifyingdeficienciesoroutliers.Qualityassuranceactivitiesmaybeinternaltoanorganizationorconductedbyanexternalagency.Qualityassurancemayormaynotincludeprocessestoaddressidentifiedshortcomings.Inpractice,someprogramslabelledqualityassuranceincorporatetheessentialfeaturesofqualityimprovement.


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Accreditationisarigorousexternalevaluationprocessthatcomprisesselfassessmentagainstagivensetofstandards,anonsitesurveyfollowedbyareportwithorwithoutrecommendations,andtheawardorrefusalofaccreditationstatus(Pomeyetal.,2010).InCanada,accreditationisvoluntaryexceptforFirstNationsfacilities,universityaffiliatedhospitalsandinstitutionsinQuebec.AccreditationCanadaisanationalnonprofitorganizationthatwasestablishedtoguaranteethathealthcareorganizationsinCanadaprovideservicesofacceptablequality.Thisorganizationfollowsinternationalaccreditationprotocolsfortheselfassessmentofhealthcareorganizationsagainstagivensetofstandardsdeterminedbyprofessionalconsensus.Anonsitesurveyisconductedandfollowedbyareportwithorwithoutrecommendationsandtheawardorrefusalofaccreditationstatus.AccreditationCanadahasdevelopedandpilottestedprimaryhealthcareaccreditationstandards.AccreditationisoneofmanypotentialQAactivities.AkeydifferencebetweenQAandaccreditationisthataccreditationofanorganizationtakesplacethroughathirdpartywhereasQAcantakeplaceinternallybyahealthcareorganizationorexternallybyathirdparty.Knowledgetranslation(KT)isarelativelynewtermcoinedbytheCanadianInstitutesofHealthResearch(CIHR)in2000.CIHRdefinedKTas"theexchange,synthesisandethicallysoundapplicationofknowledgewithinacomplexsystemofinteractionsamongresearchersanduserstoacceleratethecaptureofthebenefitsofresearchforCanadiansthroughimprovedhealth,moreeffectiveservicesandproducts,andastrengthenedhealthcaresystem"(CIHR,2005).Inaclinicalsetting,KTcanbedefinedastheeffectiveandtimelyincorporationofevidencebasedinformationintothepracticesofhealthprofessionalsinsuchawayastoeffectoptimalhealthcareoutcomesandmaximizethepotentialofthehealthsystem.KTinterventionsinclude:educationalinterventions(large,smallgroupsessions;continuingmedicaleducation;selfdirectedlearning);linkageandexchangeinterventions(knowledgebrokers,opinionleaders,educationaloutreachvisits);auditandfeedback;informaticsinterventions(education,remindersystems,clinicaldecisionsupportsystems,presentingandsummarizingdata);andpatientmediatedinterventions(selfcareandchronicdiseasemanagement)(Straussetal.,2009).KTinformsthecontentofQIprograms.KTinterventionsandstrategiescanbeusedtofacilitateQI.


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Section4:StrategiesandEnablersofQuality:ALiteratureReviewTheliteratureidentifiesavarietyofpotentialenablersandstrategiesforqualityimprovement.Toinformrecommendationsforimprovingqualityinprimaryhealthcare,aliteraturereviewandanalysisforeachstrategywascompletedandissummarizedinthissection.

PerformanceMeasurementPerformancemeasurementistheprocesswherebyanorganizationestablishestheparametersbywhichprogramsandservicesaremeasuredanddetermineswhetherdesiredoutcomesarebeingachieved.Performancemeasurementisimportanttoqualityimprovementsinceitallowsfor:theidentificationofopportunitiesforimprovement;trackingprogressagainstorganizationalgoals;andcomparingofperformanceagainstbothinternalandexternalstandards.InOntario,currentinitiativesincludetheQIIP/HQOICESprojectinwhichhealthadministrativedatawillbeprovidedtoprimaryhealthcarepracticesparticipatingintheQIIP/HQOLearningCommunity.Thisinformationincludes;demographicandhealthcharacteristicsofthepracticepopulation,provisionofpreventivecare,chronicdiseasemonitoring,ERvisits,specialistreferrals,admissionratesforambulatorycaresensitiveadmissionsandspecificchronicdiseases,andhospitalreadmissionrates.CIHIhasaVoluntaryReportingSystemthroughwhichFPssubmitandreceivefeedbackbasedontheirEMRdata(CIHI,2011).TheCIHIprovidesparticipatinghealthcarepractitionerswith:informationandtools(qualityimprovement,patientcentricproviderfeedbackreports)toimprovequalityofpatientcareandpracticemanagement;aforumbywhichparticipatingPHCclinicianscancollaborateonqualityimprovementandPHCresearch;theabilitytogeneratenewinformationinpriorityareas,suchasaccesstocare,quality,utilizationandoutcomestosupporteffectivepolicydevelopmentandhealthsystemmanagement;and,insightonhowtomakeEMRsmoreusefulforpractitioners.TheCanadianPrimaryCareSentinelSurveillanceNetwork(CPCSSN)providesongoingfeedbackbasedondataextractedfromtheEMRstoparticipatingprimarycarepracticesontheirperformanceandtheirEMRdataquality.CPCSSNisaCanadawideEMRbasedresearchsystemwhichisfocusedonchronicdiseasepreventionandmanagement.ItmakesuseofepidemiologyandpracticebasedprimarycaredatafromFPsandnursepractitioners(NPs).Theprovidersindividualresultsarecomparedtolocalandnationalbenchmarkdata(CPCSSN,2011).


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Theaccountabilityagendahasstressedtheimportanceofusingmeasurableindicatorsofperformancemeasurement(EmanuelandEmanuel,1996;RiesandCaulfield,2004;Segsworth,2003;AucoinandJarvis,2005;Brown,Porcellato,Barnsley,2006).Performancemeasuresshouldbe:clinicallyrelevant;scientificallysoundandtestedbeforeimplementation;feasibletocollect;capableofshowingimprovementovertime;designedandagreedonbyallstakeholderstopreventgaming;andalignedwithnationalmeasures(whenfeasible).Inestablishingperformancemeasuresforqualityimprovementitisalsoimportanttoconsider:crowdouteffectsonotheractivitiesthatmaynotreceiveattentionifcertainmeasuresareemphasized;downstreameffectsoftheprogramonotherhealthcareuse(e.g.,increasedvolumeoftesting,resourcesrequiredtotreatadditionalidentifiedcases);thetemptationtoselectactivitiesthatarerelativelyeasytomeasureratherthanmoreimportantonesthataredifficulttomeasure(MOHLTC,2007).Tobemeaningful,performancemeasurementdatamustbe:timely;consistent;andthemeaningofthedatamustbeunderstood.Welldefined,validlymeasuredperformancedatacanbecomparedbetweenhealthcareorganizationsandprovidersanddisseminatedtoinformdecisionsatthelocalandsystemlevel.

TripleAimFrameworkInCanada,thehealthcaresectorisincreasinglyembracinganewqualityimprovementframeworkreferredtoastheTripleAimFramework.ThisqualityimprovementmodelwasdevelopedbytheInstituteforHealthcareImprovement(IHI),anotforprofitorganizationlocatedinCambridge,Massachusetts.Theconceptdesignstartedin2005andhasbeenadoptedbyabroadrangeofhealthcareorganizationsinNorthAmericaandinternationallysince2007.TheOntarioLHINshaveadoptedtheTripleAimFrameworkasameansofimplementingandtrackingprogresswithhealthcareimprovementinitiatives(Loucks,2011).TheTripleAimFrameworkfocusesonthreeobjectives(the"TripleAim"):

Improvethehealthofthepopulation Enhancethepatientexperienceofcare(includingquality,accessandreliability) Reduce,oratleastcontrol,thepercapitacostofcare


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Figure1TripleAimFramework(InstituteforHealthcareImprovement)AnexampleofasuccessfulTripleAiminitiativecitedbyBeasley(2011)involvedredefiningthewaycarewasprovidedbyalternativehealthcareworkers.Byinvolvingalternatehealthcareworkersandschedulinglonger,lessfrequentclinics,itwaspossibletoimprovepatientaccess,patientsatisfactionandreducethecostofprovidingcaretoafractionoftheoriginalcosts.Berwicketal.(2008)describedfivecomponentsoftheTripleAimframework:individualsandfamilies;definitionofprimarycare;preventionandhealthpromotion;percapitacostreduction;andintegration,socialcapitalandcapabilitybuilding(RefertoAppendixDformoredetails).TheIHITripleAimteamhasputtogetherasetofsuggestedmeasuresthatalsohelptooperationallydefinetheTripleAim.SomeexamplesofcriteriathatrelatetoPopulationHealthinclude:healthylifeexpectancy(HLE):lifeexpectancycombinedwithhealthstatus(e.g.,healthadjustedlifeexpectancy(HALE),disabilityfreelifeexpectancy(DFLE));mortality:lifeexpectancy,yearsofpotentiallifelost,standardizedmortalityrates;healthstatus:singlequestionormultidomainhealthstatus(e.g.,SF12,EuroQol);compositehealthriskappraisal(HRA)score;diseaseburden(e.g.,summaryoftheprevalenceofcertainconditions,summaryofpredictivemodelscores,hospitalandEDutilizationforambulatorycaresensitiveconditions).Examplesofcriteriathatrelatetopatientexperienceinclude:standardquestionsfrompatientsurveys(e.g.,U.S.ConsumerAssessmentofHealthcareProvidersandSystems(CAHPS)or


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HowsYourHealthglobalquestions,NationalHealthService(NHS)WorldClassCommissioningorHealthcareCommissionexperiencequestions,likelihoodtorecommend);andsetofmeasuresbasedonkeydimensions(e.g.,U.S.InstituteofMedicine(IOM)dimensions).Examplesofindicatorsofpercapitacostmightinclude:costpermemberofthepopulationpermonth;or,costsinhighvolume/costcategories(e.g.,secondarycare).Berwicketal.(2008)believethatcertainpreconditionsmustbeinplacebeforehealthcareorganizationscanpursuetheTripleAimframework.Theorganizationorsystemmustrecognizetheneedtodealwiththehealthoftheentirepopulationnotjustindividualpatients.Theremustbeconstraintsonthefinancesavailableortheneedtoprovideanequitablehealthcaredeliverysystem,andtheremustbeanintegratorabletocoordinateservicesandfocusonpopulationhealth,patientexperience,andpercapitahealthcaresimultaneously.TheTripleAimFrameworkincludesrolesforMacroandMicroIntegrators.MacroIntegratorsareorganizationsorgroupsoforganizationsthatmanageresourcestosupportadefinedpopulation(e.g.,aLHIN).MacroIntegratorsworkwithfrontlineserviceprovidersandsystemsthatsupportindividuals.AMicroIntegratorisanindividualorteamthatdeliversthebestormostappropriatecaretoanindividual.AMicroIntegratorcouldbeahealthcareprofessional,orteamofhealthcareprofessionalsresponsiblefordeliveringhealthcare.AprimarycarepracticeororganizationwithanenrolledpatientpopulationcanserveasbothaMacroandMicroIntegrator.KeyindicatorstomeasureandtrackperformanceandongoingqualityimprovementfocusononeormoreoftheTripleAimfoci.Theseindicatorsareusedtomeasurebaselineperformancepriortochangesbeingintroduced,andatvariousperiodsduringandafterachangeismadetodeterminetheextentoftheimprovement,andwhethertheimprovementissustained.KeyindicatorsforaTripleAimprojectshouldalignwiththeIOM*andHQO**qualityindicators(RefertoAppendixEfordefinitions).KeyIndicator Population

HealthPatientExperience

PerCapitalHealthCost

Safety*,** X Effectiveness*,** X Personcenteredness*,** X Timeliness*,** X Equity*,** X X Efficiency*,** XIntegration** X XFocusonpopulationhealth** X Appropriateresources** X


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SuccessStories

AnumberofsuccessstorieshavebeenidentifiedbyhealthcareorganizationsusingtheTripleAimFramework.Theseinclude:QueensHealthNetwork;HealthPartners;QuadMed;BellinHealth;andCareOregon(refertotheIHIwebsitehttp://preview.ihi.org/offerings/Initiatives/TripleAim/Pages/Materials.aspx).GenesysHealthSystemGenesysHealthSystem'ssuccessstoryisapplicabletotheprimarycaresector.GenesysHealthSystemisanonprofit,integratedhealthcaredeliverysystemthatprovidesacontinuumofmedicalcareservicestopatientsinGeneseeCountyandtheareasurroundingFlintMichigan.Itpartnerswithanetworkof150communitybasedprimarycarephysiciansaffiliatedwiththeGenesysPhysicianHospitalOrganization(PHO)(KleinandMcCarthy,2010).GenesysispursuingqualityimprovementusingtheTripleAimframeworkbyengagingcommunitybasedprimarycarephysicianstoenhancecarecoordination,preventivehealth,andefficientuseofspecialtycare.Itisalsopromotinghealththroughthedeploymentofhealthnavigators,whohelppatientsadopthealthybehaviours,andbypartneringwithacountyhealthplantoextendaccesstoprimarycareandotherservicestolowincome,uninsuredcountyresidents(KleinandMcCarthy,2010).Whilethehealthnavigatorprogramfocusesonbehavioursthatwillhavethegreatestimpactonhealthoutcomes,theyalsohelppatientsadaptbehaviourchangeplanstotheirpreferences,interests,andreadinessforchange.Forexample,apatientmaywishtoreducestressbeforetacklingweightloss(KleinandMcCarthy,2010).Genesysalsoengagesinothercommunityeffortstohelpimprovepopulationhealth.ThehealthsystemisamemberoftheGreaterFlintHealthCoalition,whichjoinslocalproviders,purchasers,consumers,insurers,schools,andfaithbasedorganizationsineffortstoimprovethehealthstatusofGeneseeCountyresidents,whiledecreasingcostsandinefficienciesincare.Themodelhashelpedlowertheuseandcostofcarewhileimprovingphysicianperformanceonqualityindicators.AstudybyGeneralMotorsfoundtheautomakerspent26%lessonhealthcareforenrolleeswhoreceivedservicesatGenesysversuslocalcompetitors.Theuseofhealthnavigatorshasimprovedhealthbehavioursandsatisfactionofpatients.Extendingthehealthnavigatormodeltolowincome,uninsuredpatientsenrolledinataxsupportedcountyhealthplanhasledtoimprovedhealthstatusandreduceduseofthehospitalandemergencydepartments(KleinandMcCarthy,2010).Apatientsurveyaskingpatientstoevaluatetheirphysiciansandtheirstateofagreementonafivepointscaleproducedaverageratingsof3.27outof5onwhetherpatientscouldachievelifechanges;3.95outof5onwhethertheproviderteamknewthem;andanoverallsatisfactionof4.4outof5(KleinandMcCarthy,2010).

http://www.commonwealthfund.org/Content/Publications/Case-Studies/2010/Jul/QuadMed.aspxhttp://preview.ihi.org/offerings/Initiatives/TripleAim/Pages/Materials.aspxhttp://www.commonwealthfund.org/Content/Publications/Case-Studies/2010/Jul/Genesys-HealthWorks.aspx


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PerformanceTargetsAPerformancetargetisaquantitativeexpressionofanobjectivetobemetinthefuturebyanorganization,programoremployee.Performancetargetscanbeusedtofacilitatecontinuousqualityimprovementandareoftenusedinpayforperformance(P4P)programs.InOntario,theMOHLTChassignedMasterServiceAccountabilityAgreements(MSAA)withtheLHINswhichincludesectorspecificindicatorsforeachhealthcaresector(MSAA,2011).Intheprimaryhealthcaresector,CHCsarerequiredtoparticipateinaClientAccessforPrimaryCareClinicalServiceProgram.Thisinvolvesdevelopingandcollectingkeyexplanatoryandaccountabilityindicatorsrelatedtohealthequity,valueandaffordability,andquality.Theaccountabilityindicatorsincludebenchmarksofpreexistingdata;maybetiedtodedicatedfundingfromtheMOHTLC;mustbevalid,feasiblemeasuresofsystemperformance;andallowforcomparabilityacrosslikeorganizationsand/orregions.Theexplanatoryindicatorswill:becomplementarytotheaccountabilityindicators;supportplanning,negotiationandproblemsolvingattheprovincial,LHINleveloragencylevel;supporttransparencyandenableplanningdiscussions;andsupportandsustainqualityimprovement,effectivenessandefficiency.CHCshavealsocommittedtoparticipatingintheDataQualityAssessmentToolImplementationproject.ThistoolutilizedtheCIHIDataQualityFrameworkandprovidesaseriesofqualitativeandquantitativequalityindicators.Thereissomeevidencesuggestingthatperformancetargetscanbesuccessfuldriversofqualityifdesignedappropriatelyandareimplementedalongsideotherimprovementinitiatives(generalinspection,regulation,andfinancialincentives).Ifwelldesigned,targetscanhelporganizationsandpractitionersfocusonamanageablenumberofachievablegoals,whichtherebyleadtosystemimprovements.VanHertenandGunningSchepers(2000)concludedthatinorderforperformancetargetstobeeffective,theymustbespecific,measurable,accurate,realisticandtimebound.Performancetargetscanhaveperverseeffectsincluding:neglectofuntargetedaspectsofthehealthsystem;focusonshorttermtargetswithintheproviderscontrolratherthanlongtermorlesscontrollableobjectives;influencebyprofessionalinterests;underminingthereliabilityofthedataduetoaggressivetargets;inducingundesirablebehaviouralresponsesduetoaggressivetargets(Smith,inpress).IntheUK,PublicServiceAgreementsincludedstrategictargetsforallgovernmentdepartments,includingtheHealthMinistry(Smith,2007).TheseAgreementsfocusedprimarilyonoutcomes,suchastheimprovementofmortalityrates,reductionsinsmokingandobesity,andreductionsinwaitingtimes.Incontrasttomostnationaltargetsystems,thisprovedeffectiveinsecuringsomeofthetargetedobjectivesinhealthcare(BevanandHood,2006).


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Thesuccessofthisinitiativehasbeenattributedto:precisetargets;generaltargetsbasedatthelocallevel,ratherthanthenationallevel;professionalsbeingengagedinthedesignandimplementationofsometargets;increasedfinancing,informationandmanagerialcapacitytoorganizations;andattachingincentivestotargets.Basedonthisexperience,performanceprioritiesandtargetsshouldbedevelopedinconsultationwithkeystakeholdersandsetmainlyatthepracticeandcommunitylevel.

ElectronicMedicalRecordandElectronicHealthRecordThetermElectronicMedicalRecord(EMR)generallyreferstoinformationsystemswithinonelocation(e.g.,adoctorsofficeorhospital)whileEHRreferstoasystemwhereinformationfrommultiplesourcescanbepooledand/orshared(OHQC,2010).TheOntariogovernmenthasinvestedsignificantlyinprovidingsubsidiestoprimarycarephysiciansforadoptionofEMRs.Thesesubsidieswerepreviouslyavailabletophysiciansinspecificprimarycaremodelsbutmorerecentlyhavebeenextendedtoallprimarycarephysicians(Hutchison,2011).AsofMay31,2011,therewereapproximately6,500Ontariophysiciansusing,orintheprocessofimplementinganEMR.Thisincludedapproximately4,700communityFPs.Inaddition,300CHCphysiciansreceivedfundingdirectlyfromeHealthOntariotoimplementanEMR(OntarioMD,personalcommunication,June26,2011).Thereissignificantconsensusintheliteratureandfieldthatsophisticatedhealthinformationtechnologyatthepracticelevelisfundamentaltotheprovisionofhighquality,efficientprimaryhealthcare.Informationmanagementsystemsneedto:supportclinicaldecisionmaking;identifycareneeds;supportperformancemeasurementandqualityimprovement;belinkedacrosshealthcaresettings;andsupportpatientsaspartners.ArecenthighqualityreviewfoundthatEHRsthatincludeclinicalinformationmanagementanddecisionsupporttools(particularlythosethattranslatedataintocontextspecificinformation)improvedproviderperformance.ThisreviewfoundsubstantialsavingscouldbeachievedbyimplementingEHRs.However,noneoftheincludedstudiesfocusedonprimaryhealthcare(McMasterHealthForum,2010).Theuseofinformationtechnologyforgeneratingremindersandforclinicaldecisionsupportsystemshasbeenshowntoimprovebothoperationalefficiencyandqualityofcare.Theseimprovementsincluded:increasedfrequencyofscreening;improvedpreventativecareanddiseasemanagement;reducedprescribingerrors;improvementsassociatedwithcomputerizedphysicianorderentry(CPOE)(e.g.,reducedrepeattestsandmoretimelytestsandprocedures);lessmissinginformation;andcostsavings(AHRQ,2007;Mitchell2001;Hunt,1998ascitedinCHSRF,2009).TheuseofEMRshasalsobeenshowntoimprove:overallpatientsatisfactionwiththeirvisits;patientsatisfactionwithphysiciansfamiliaritywiththem;patientprovider


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communication;theuseoftimeduringthevisit,andcomprehensionofdecisionsmadeduringthevisit(Hsuetal.,2005ascitedinCHSRF,2009).Informationtechnologycanalsoleadtoimprovementsinthesystemofcarethroughproactiveplanningforpopulations,queriesandfollowuponsubpopulations,andhavingallpertinentpatientinformationinoneplaceallowingforthedevelopmentofaholisticcareplan(AHRQ,2007ascitedinCHSRF,2009).TheAgencyforHealthcareResearchandQuality(AHRQ)andtheInstituteforHealthcareImprovement(IHI)examinedtherequirementsforanEMRthatsupportsqualityimprovement.TheseorganizationsidentifiedthefollowingattributesascriticalelementsofahighlyfunctioningEMR:ProactivePatientBased

Allinvolvedinqualityimprovementshouldbeabletoquerythedata Thesystemshouldsupportinstantaccesstoqueryresults Thequeryingsystemshouldallowtheusertoaskanyquestion Usersshouldbeabletoconstructandrunquerieswithouttechnicalassistance Usersshouldbeabletospecifytheinclusionofanydataelementsinqueries Thesystemshouldsupportdrilldownintodata Usersshouldbeabletosavequeriesforreuseand/orrefinement Thesystemshouldsupportthesharingofqueries Thetypesofactiontakenonthelistsofpatientsinaqueryshouldbeflexible Theactiontakenonthelistshouldincorporateandusepatientdatatofurthersegment

theaction(e.g.,HbA1cfollowup) Thesystemshouldautomatetheactionswheneverpossible

PlannedCareforIndividualPatientsThewholepatientshould:

bedisplayedinoneplace bedynamic beusedforplanning,treatmentandfollowup supportcareacrossallconditionsandhealthissues,notjustthecomplaintassociated

withaparticularencounter bethecentrallocationforotherviewsofpatientdata,suchasrunchartsoflaboratory

resultsandvitals incorporateevidencebasedpromptsandreminders provideaportalforthepatientforbothinputandviewingdata,givingthepatientsome

controloverhis/herrecord


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Measurement Themeasurementmoduleshouldallowtheusertocustomizeanyreportbyaddingor

changingafilter Thequeryandfilterstructuresformeasurementandreportingshouldbeidenticalto

thoseusedforthepopulationbasedcaretoolandforremindersandpromptsOther

Abilitytocustomizethedatapresented Easeofuse Interoperability Dataavailableacrossthecontinuumofcare Appropriatedatastructuresprovideinformationthatsupportsimprovement Automation

ThereportalsoindicatesthattheEMRmustsupportsystemsfor:informationsharing(e.g.,onedatawarehouseversusinteroperablesystems);dataownership;and,ensuredataaccuracy.EMRfunctionalityisnotnecessarilysufficienttopromoteitsutilizationforqualityimprovement.ProvidingappropriatetrainingandsupporttoprovidersonthemeaningfuluseofEMRisessentialforrealizingthebenefitsoftheEMR.TheCaliforniaNetworksforEHRAdoption(CNEA)programwasinitiatedin2006tospeedtheadoptionandlowerthecostsassociatedwithimplementingEHRsinthestateofCalifornia.Participantsshareexperiencesandlessonslearnedbetweenteamsasameansofacceleratingadoptionrates.Theprogramfoundthatwithoutcontinuous,structuredfollowuptraining,thebenefitsofEHRcannotbefullyrealized(CaliforniaHealthCareFoundation,2010).

PrimaryHealthcareTeamsCollaborativeprimaryhealthcareteamsconsistofavarietyofhealthcareprovidersresponsiblefordeliveringarangeofhealthcareservicestopatients.InOntario,nonFFSmodelsofprimaryhealthcareincludearangeofnonphysicianhealthcareprofessionalswithintheirpractice.InOntario,approximately21%ofFPsworkininterprofessionalhealthcaremodels(CHCs,FHTs)(Hutchison,2011).Thereisapotentialtoextendaccesstononphysicianhealthcareprofessionalstoprimarycarepracticesbasedonpopulationneeds.Agrowingbodyofevidenceshowsthatcollaborativeprimaryhealthcareteamscanimprovepatienthealthandqualityoflife,particularlyforthosewithchronichealthconditions.Suchteamsarealsoaneffectivewaytoprovideprimaryhealthcareservicestorural,remote,andunderservicedareas.


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Collaborativecareforpeoplewithdepressionresultedinimprovementsthatweresustainedoverfiveyears(Gilbodyetal.,2006ascitedinHCC,2009).Patientsreceivingteambasedcarereportedbetterhealthresultssuchaslowerbloodpressure(Tayloretal.,2005ascitedinHCC,2009).Childrenwithasthmahadfewerdaysperyearofsymptomsthanasthmaticchildreninstandardcare(Lozanoetal.,2004ascitedinHCC,2009).Alzheimerspatientshadsignificantlyfewerpsychologicalsymptomsofdementiawithoutincreasingtheirmedication(Callahanetal.,2006ascitedinHCC,2009).Terminallyillpatientsreceivingteammanaged,homebasedprimaryhealthcarereportedsignificantimprovementsinfactorssuchastheirlevelofpainandmentalhealth(Hughesetal.,2000ascitedinHCC,2009).Overweightpatientsbeingtreatedbyamultidisciplinarygroupweremorelikelytoachievetheirweightlossgoalsthanthoseinothertreatmentgroups(Feigenbaumetal.,2005ascitedinHCC,2009).Grumbachetal.(2004)cautionedthatthesuccessofteambasedcarerestsonhowwelldifferenthealthcareprofessionalsworktogethertoformaneffectivelyfunctioningteam.Teammembersshouldfunctionattheirlevelofcompetency,focusingonthepatientsneedsandrecognizingtheimportanceofcontinuityinbuildingtrustingproviderpatientrelationshipstoachieveefficienciesandimprovedoutcomes(CronenwettandDzau,2010).Akeysuccessfactorforteamworkisempoweringteammemberstoperformtasksaccordingtotheirscopeofpractice,experience,andeducation(Schoen,2007).Todate,littleisknownabouttheteamstructures,composition,rolesorrelationshipsthataremosteffectiveandefficientinmeetingtheneedsofspecificpopulations.Collaborationbetweenprimaryhealthcareteamsandothersectorsisimportantinthecoordinationofpatientcare.Integratedhealthsystemsincludeaccesstoacomprehensiverangeofclinicalandhealthrelatedservices.Responsibilityforplanning,providingorprocuring,andcoordinatingallcoreservicesforthecontinuumofhealthrequirementsandforthepopulationservedisassumedbytheintegratedhealthsystem(Leattetal.,2003;MarriottandMable1998,2000).Thisincludesservicesfromprimarycarethroughtertiarycare,andcooperationbetweenhealthandsocialcareorganizations(SimoensandScott,2005).CurrentlycollaborationbetweenprimarycarephysiciansandsomecommunityprovidersisunderdevelopedinOntario.AsurveyexaminingtheperceptionofOntarioFPsoncollaborationwithcommunitypharmacistsindicatedthatphysicianshavefewerthanfiveconversationsaweekwithapharmacistaboutapatientsdrugtherapymanagement,veryfewusedpharmacistsastheirprimarysourceofmedicationinformationandfewparticipatedinhigherlevelcollaborativebehaviour(referringpatientstopharmacistsformedicationreviews)(Pojskicetal.,2010).Physiciansinthestudyreportedsignificantadvantagestocollaborationwithcommunitypharmacists,includingmoreaccuratepatientmedicationlistsandfinancialsavings


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tothehealthcaresystem(e.g.,detectingdoubledoctoring/excessprescriptionuse,reducingneedforspecialistreferral).

PatientEnrolmentPatientenrolmentisaprocessinwhichpatientsinadefinedpopulationorgeographicalareaareformallyregisteredwithaprimarycareorganization,teamorprovider.Patientenrolmentfacilitatesaccountabilitybydefiningthepopulationforwhichtheprimarycareorganizationorproviderisresponsible(Hutchison,2008).InOntario,9.5millionOntarioresidentsareenrolledtoreceivecarefrom709PEMs.Formalpatientenrolmentwithaprimarycareproviderlaysthefoundationforaproactive,populationbasedapproachtopreventivecareandchronicdiseasemanagementandforsystematicpracticelevelperformancemeasurementandqualityimprovement.Itclearlyestablishesprimaryhealthcareprovidersashealthstewardsforadefinedpopulationratherthanprovidersofservicestothosewhopresentthemselvesforcareandclarifiesmutualresponsibilities.OntarioshouldcontinuethegrowthanddevelopmentofPEMs.

PatientEngagementPatientengagementcantaketheformofengagementinonesownhealth,careandtreatmentorinvolvementinthedesign,planninganddeliveryofhealthservices(Parsons,2010).Involvingpatientsinevaluatinghealthneedsandhealthcareperformanceisanessentialcomponentofqualityimprovement.Tounderstandthepatientandfamilyexperiences,shadowingguidelineshavebeendevelopedforhealthcarepractitioners(Digioia,2010).Theguidelinesprovidestepbystepinformationonhowashadowercanfollowthepatientandfamilycareexperience.HQOiscurrentlydevelopingaprimaryhealthcarepatientengagementframework(SpencerCameron,2010).Patientengagementenablespatientstocollaboratewiththeirhealthcareprofessionalsintheselfmanagementoftheircare;toevaluateandshapethedesignanddeliveryofcarewithinthecareteam;toevaluateandshapethestrategicdirectionofhealthcarewithinahealthcareorganization(e.g.,patientfocusgroups/patientinvolvementingovernance/planningandpolicy);andtosupportandadvocateforstrongpartnershipswithpatientsandtheprimaryhealthcarecommunity(SpencerCameron,2010).CoulterandEllins(2006)indicatethereisanassociationbetweentheengagementofpatientsintheirhealth,careandtreatmentand:patientsrecallofinformation,knowledgeandconfidencetomanagetheirconditions;thelikelihoodofpatientsreportingthatthechosentreatmentpathwasappropriateforthem;patientreportingoftheirexperiencesandsatisfactionwithcare;


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and,theuseofhealthcareresources,whereengagedpatientsaremorelikelytoadheretochosencoursesoftreatment,andtoparticipateinmonitoringandpreventionforexample,byattendingscreening.Ithasalsobeenshownthatsomeinterventionstoinvolvepatientsinsharingthedecisionabouttreatmentchoiceresultinpatientschoosinglessinterventionist(andlesscostly)treatmentsthantheircliniciansmightotherwisehaverecommended(Parsonsetal.,2010).Onestudyindicatedthatthereislimitedevidencetosupportinterventionsthatpromotepatientinvolvementinimprovingsafety(Halletal.,2010).OtherstudiesindicatedthattherewasnoclearevidencethatempoweringpatientsthroughaccesstotheirEHRsimprovedqualityofcare(Koetal.,2010;Laugharne,2004;Gyselsetal.,2007).Therearefewreliableandrobuststudiesontheeffectsofpatientinvolvementinthedesign,planninganddeliveryofprimaryhealthcareservices.Involvingthepatientinselfmanagementandinthedesignandplanningofhealthcareservicesiswidelybelievedtobeacriticalstrategyforachievingqualityimprovementinprimaryhealthcare.Moreinformationisrequiredonthebestapproachestopatientengagement.

ResearchandEvaluationAconstantflowofresearchevidencetoinformprimaryhealthcarepolicyandpracticeisanessentialunderpinningofahighperformingandcontinuallyevolvingprimaryhealthcaresystem.Inadditiontoongoingperformancemeasurementandmonitoring,effectivehealthsystemplanningandmanagementrequirefocusedevaluationsoftheimplementationandimpactofkeypolicyandsystemmanagementinnovations.Suchevaluationsallowshortcomingstobeidentifiedandaddressedandsuccessestobereinforcedandspread.Evaluationsofpilotordemonstrationprojectsprovidealowriskopportunitytotesttheeffectivenessofqualityimprovementstrategiesandenablers.Adequatefundingofbothresearchandresearchtrainingareneededtocreateandsustainavibrantandproductiveprimaryhealthcareresearchenterprise.Qualityimprovementresearchthatpertainstotheprimaryhealthcaresectorislimited.Toensureefficiencyandeffectiveness,theremustbeinvestmentinhealthservicesresearchandevaluationfocusingonqualityimprovementintheprimaryhealthcaresector.


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FinancialIncentivesPayforPerformance(P4P)inprimarycarerepresentsasetofstrategiesthatusefinancialleverstoencouragehealthcareproviderstoachievemeasuredstandardsofpatientcaretoimprovequality.P4Pismeanttoincreasepaybackonresourcesinvestedinmedicalcarebyprovidingincentiveswhichincreasethequalityofcareand/ortoincreasetheuseofmedicaltreatmentswithevidenceofenhancedvalueandbetterpatientoutcomes(InstituteofMedicineoftheNationalAcademies,2007;Pinketal.,2006).InOntario,financialincentivesinprimarycarearepaidformeetingestablishedthresholdlevelsforperformingpreventivecareactivities.Theamountofthepreventivecarebonusvariesbasedonthelevelofthresholdachieved.Otherincentivesarefocusedonencouragingtheprovisionofpriorityservices.AstudyfromtheMcMasterUniversityCentreforHealthEconomicsandPolicyAnalysis(Hurleyetal.,2011)assessedOntariophysiciansresponsestofinancialincentives,includingpreventivecareP4Pbonusesandspecialpaymentsforpriorityservices(e.g.,obstetricaldeliveries,prenatalcare,hospitalcare,palliativecare,inofficetechnicalprocedures,homevisits,andcareofpatientswithseriousmentalillness).ThestudyfoundP4Pincentivesledtoanincreaseoverbaselinelevelsintheprovisionoffouroffivepreventiveservices:5.1%forseniorsinfluenzavaccination;7%forPapsmears,2.8%formammography,and56.7%forcolorectalcancerscreening(Hurleyetal.,2011).Therewasnodetectableimprovementfromspecialpaymentsforpriorityservicesabovethresholdlevels.ThereareonlyafewrigorousstudiesofP4P,andoveralltheevidenceofitseffectsisweak(McMasterForum,2010).Thereviewfoundthatfinancialincentivestargetingindividualhealthcareprofessionalsappeartobeeffectiveintheshortrunforsimple,distinct,welldefinedbehaviouralgoals(McMasterForum,2010).Thereislessevidencethatfinancialincentivescansustainlongtermchanges.Halfoftheincludedstudiesfocusedonqualityimprovementinprimaryhealthcare(McMasterForum,2010).P4Piswellsuitedtoaddressissuesofunderusebutlesssuitedtocurtailingoveruseorinappropriateutilization(MOHLTC,2007).Ifimplemented,carefulconsiderationmustbegiventothedesignofaP4Pprogramandpotentialperverseeffects.AreviewofP4PprogramsthatprovidepaymentstoprimarycarephysiciansintheUnitedKingdom,AustraliaandUS(MOHLTC,2007)foundthatitisimportantfortheincentivesandgoalstobealignedandthatpolicymakersandprovidersknowthelinkbetweenperformancemeasuresandtheoverallgoalsofprimarycare.Itisalsoimportantforfinancialrewardstobelinkedtothedesiredoutcomeoractivitytoprovidethedesiredincentive.Tobeeffective,itisnecessarytomeasurebaselineperformancebeforeintroducingtheincentivestodetermine:theextenttowhichperformanceisalreadybeingachieved;howmuchitcanbeimproved;andtoforecastprogramcosts.Thisrequiresensuringdataaccuracy,


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validityandreliabilityofmeasurement(MOHLTC,2007).Whensettingtargetsandpaymentstructures,bothachievementofsetgoalsandimprovementfrombaselinemeasuresshouldberewarded.Unlessthisisdone,targetsmaybeseenasunfairtogoodproviders(ifonlyimprovementisrewarded)orinsufficienttoencouragechangesinpractice(ifonlyattainmentisrewarded)(MOHLTC,2007).SeveralperverseeffectsofP4Phavebeenidentified.Highperformerstendtodobetter,whilepoorperformersimprovemoreslowlyorevendoworse.Netrevenuemaydeclineforthosewhoneedtoinvestthemostinqualityimprovement,andresourcepoorserviceprovidersmaynotinvestsufficientlytoqualifyfortheincentives(CHSRF,2009).Improvementinsomeareasmaybetothedetrimentofothersandtheincentivestructuremaypromotethecherrypickingofwhichpatientsareseen,orwhatservicesareprovided.Extrinsicincentivesmayundermineprovidersintrinsicmotivation(Hutchison,2008).P4Pschemestendtorewardprocessesratherthanoutcomes,andtheprocessesrewardedareonlyasubsetofdeliveryprocesses(oftenthoseforwhichdataareavailable).Focusingontheseratherthantheentiredeliveryprocessmaydivertattentionfromotherareaswhicharealsoimportant(Hutchison,2008;Miller,2007;Rosenthal,2004ascitedinCHSRF)Thereisalsothepotentialtocreateadetrimentaleffectondependentprogramsorservicessuchas:increaseddemandforlaboratorytestsordiagnosticprocedures;potentialiatrogeniceffectsoffindingfalsepositivecases;andincreasedresourcesrequiredtotreatadditionalidentifiedcases(MOHLTC,2007).ManyP4Pschemesmakepaymentstophysiciansbasedonmeasurementsthataremadeatthepracticelevel,orwhichmeasureactivitiesthatareperformedbymembersofthehealthcareteam.AstudyofP4PprogramsinAustralia,U.K.andU.S.foundnursesweretypicallysalariedemployeesofapracticegroupwhichweretypicallyownedbyphysicians(MOHLTC,2007).IntheU.K.thiscausedconflictwhenteamswerenotwellintegratedorcollegial.However,inothersettings(suchasaCaliforniaplanoperatedinaunionizedenvironment),bothprimarycareprovidersandpracticenursesweredirectemployeesofthehealthplanandtheunionwasabletonegotiateperformancepaymentfornursesforactivitiesthatwereprimarilyperformedbythenursingstaff.Paymentsschemesthatrewardhealthcareprofessionalsperformingspecificactivities(ratherthanthepracticegroup)aremorelikelytoensureanequitabledistributionofperformancepayment.Thereislimitedresearchonthepositiveornegativeeffectsincentivesmighthaveonteams.Moreresearchisrequiredinthisarea.

TrainingandSupportQualityimprovementtrainingandsupportcantaketheformofqualityimprovementcollaborativesandcoaching.Acollaborativeisalearnbydoingapproachtoqualityimprovementwhichreliesonspreadingexistingknowledgetoachievethedesiredoutcome.Keyfeaturesinclude:learningqualityimprovementtechniques;sharing"ontheground"


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experiencesandsuccess;and,conductingsmalltestsofchangeknownasPlanDoStudyAct(PDSA)cycles.Coachingisamethodthatcustomizessupportforthepracticeandallowsimprovementexpertstogaingreaterinsightintohowthepracticefunctions.Practicecoacheshelpphysiciansandteamsdeveloptheskillstheyneedtoadaptclinicalevidencetothespecificcircumstancesoftheirpracticeenvironment(AligningForcesforQuality,2010).Qualityimprovementtoolsandtechniquesforplanningandimplementingchangeinclude:Lean,SixSigmaandtheModelforImprovement(Dawdaetal.,2010).Eachframeworkhasadifferentemphasis.Eachseekstofacilitatetheapplicationofevidenceorinnovationreliablyandefficiently.Organizationscommonlyadoptaspectsofmorethanoneframeworkintheirqualityimprovementendeavours.InOntario,theMOHLTCcreatedQIIPtoprovidetrainingandsupporttoprimarycarepractices.Todate,QIIPhascompletedthreelearningcollaborativeswith122FHTandCHCteams(Hutchison,2011).In2010,QIIPlaunchedtheLearningCommunitywhichcombinesvirtualandfacetofacelearningontheapplicationofQImethodsandtoolsandsupportfromqualityimprovementcoaches.InWave1,approximately127interprofessionalhealthcareteamsparticipatedinoneormoreofsixactiongroupsfocusedonimprovingchronicdiseasemanagement(Asthma,ChronicObstructivePulmonaryDisease,Diabetes,Hypertension),preventivecare(IntegratedCancerScreening)andAccessandEfficiency(OfficePracticeRedesign)(QIIP,2011).NinetytwoteamsareparticipatinginWave2whichfocusesonAccessandEfficiency(OfficePracticeRedesign)andincludesparticipantsfrommostprimarycaremodels,includingtraditionalfeeforservicespractices.TheLearningCommunityisbasedontheModelforImprovementandPDSAcyclesofchange,awebbased,realtimeworkspacecalledtheGATEWAY,andsupportfromanexternalqualityimprovementcoach(Hutchison,2011).Thereisincreasingevidencethatqualityimprovementtrainingandsupportcaneffectivelyhelphealthcareprovidersapplyqualityimprovementmethodsintheirpractice.Collaborativestargetingdiabetesmanagementhavebeenshownto:improveHbA1c,lowdensitylipid(LDL)andbloodpressuretestingratesandresults;improvepatienteducation;increasepreventiveprocedures;reducehospitalization;andimprovequalityoflifeindicators(Piatt,2006;Asch,2005;Tsai,2005;SperlHillen,2000;Wagner,2001;Camp,2004,ascitedinCHSRF,2009).IntheUK,theuseofcollaborativesbytheNationalPrimaryCareDevelopmentTeamresultedinimprovedaccesstoprimarycare,reductioninheartdiseasemortality,reductionincoronaryheartdiseasemortality,savingof6,070lives,andimprovementofdiabetescare(CHSRF,2009).InSaskatchewanandBritishColumbia,chronicdiseasemanagementcollaborativesresultedinimprovedoutcomesforpatientswithchronicdisease(HealthQualityCouncilSaskatchewan,2008;Tregillis,2006,ascitedinCHSRF,2009).


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TheIHIsBreakthroughSeriesmodelhas:increasedpatientandprovidersatisfactionandimprovedhealthoutcomesbyenablingparticipantstoshareexperiences;acceleratelearning;andspreadbestpractices.Theseinitiativeshaveresultedin:reducedwaittimesforappointments;reducedwaittimeswhileatthephysiciansoffice;improvedcontinuityofcare;andincreasedpatientandprovidersatisfaction(IHI2008ascitedinCHSRF,2009).Thereisgrowingevidencethatpracticefacilitationpositivelyaffectstheadoptionofevidencebasedpracticeguidelines(Baskervilleetal.,inpress)andhelpsstaffapplyqualityimprovementtechniques(LawrenceandPackwood,1996;Hearnshaw,1998).Evidenceregardingtheimpactofcoachingonfacilitatingqualityimprovementinchroniccaremanagementisgrowing(Wu,2009).AstudybySteiner(2010)foundthatqualityimprovementcoachesresultedinincreasedofficeefficiencyandimprovedcareforpatientswithdiabetesandasthma.AresearchsynthesiscommissionedbyCanadianHealthServiceResearchFoundation(CHSRF)iscurrentlyunderwaytoexaminetheeffectivenessofqualityimprovementinterventionsinprimaryhealthcare.Trainingintheuseofcontinuousqualityimprovementmethodsandmeasurementtechniquesisnotwidelyavailabletohealthcarepractitioners.Providinghandsontrainingandsupporttohealthcarepractitionerscanfacilitatetheadoptionanduseofqualityimprovementmethodsandtools.Qualityimprovementtrainingandsupportshouldbemadeavailableovertimetoallprimarycareprovidersandorganizationsandbeembeddedinallhealthcareprofessionaltrainingprograms.

PublicReportingPublicreportinginhealthcareisamechanismbywhichthepublicisinformedoftheperformanceoftheirhealthcaresystem.Performancereportingcantakeplaceatthesystem,organizationalorproviderlevel.Informationcanbemadeavailabletothepolicymakers,healthcaremanagers,healthcareprovidersandthegeneralpublic.InOntario,theHQOisresponsibleforreportingonthenineattributesofqualityattheprovinciallevel.Publishinginformationinthepublicdomain,toinformthepublicandotherstakeholdersaboutsystemandproviderperformance,isgrowing.Thisinformationoftentakestheformofreportcardsorproviderprofilesthatsummarizemeasures,suchaswaittimes,patientsatisfactionratingsandmortalityrates,acrossproviders.Publicreportingonhealthcarequalityismotivatedbytheprincipleoftransparencyinpubliclyfundedhealthcareandistoutedasanimportantdriverofqualityimprovementandasameansofpromotingconsumerchoice(MorrisandZelmer,2005;Shekelle,inpress;Marshalletal.,2000;Marshalletal.,2003).Publicreportingcanimprovequalitythroughtwopathways:aselectionpathway,wherebyconsumersbecomebetterinformedandselectprovidersofhigherquality;andachange


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pathway,wherebyinformationhelpsproviderstoidentifytheareasofunderperformance,thusactingasastimulusforimprovement(Berwicketal.,2003).Therefore,makinginformationaboutquality(andcosts)widelyavailableisseenasanimportanttoolforqualityimprovement.Althoughpublicreportingattheinstitutionallevel(e.g.,hospitals,integratedhealthorganizationsandhealthplans)isrecognizedtoimprovepatientoutcomes,thereislessevidenceontheimpactthatpublicdisclosureoftheperformanceofindividualprovidersandpracticeshasonqualityimprovementinitiativesandoutcomes.Todate,thereisnoevidencetosuggestthatpatientschangetheirmedicalproviderifdifferencesinqualityaredemonstrated(GalvinandMcGlynn,2003ascitedinSmith,2004;Reinertsenetal.,2008).Thereisstrongerevidencetosuggestthatreportingpromotesqualityimprovementinitiatives(Fung,2008;Sorbero,2008;Doran,2008;Werner,2008;Lindenaueretal.,2007,ascitedinCHSRF,2009).Studiesthatevaluatedimprovementofactualqualitymeasuresidentifiedsomeimprovement,buttheimprovementsweresmall(Castleetal.,2007;Lindenaueretal.,2007,ascitedinCHSRF,2009).Arecentmediumqualityreviewfoundthatpubliclyreleasingperformancedatastimulatesqualityimprovementactivityatthehospitallevel;however,thereviewdidnotidentifyaclearmessageabouttheprimaryhealthcaresector(McMasterForum,2010).InEngland,allNationalHealthServicehealthcareorganizationsareissuedanannualperformanceratingareportcardratingthemfromzerotothreestars,basedonabout40performanceindicators.Poorperformancehasputexecutivesjobsatrisk,andtheinitiativehadastrongeffectonreportedaspectsofhealthcare,suchaswaittimes.However,italsoinducedunintendedbehaviouralconsequencessuchaslackofattentiontosomeaspectsofclinicalquality(AuditCommission,2003;Carvel,2003ascitedinGrol,2004).IntheUnitedStates,twostates(NewYorkandPennsylvania)haveexperimentedwithpublicreportingofpostoperativemortalityratesforcoronaryarterybypassgraftsurgery.Ratesareriskadjustedandpublishedforboththehospitalandtheindividualsurgeon.TheschemesresultedinmarkedimprovementinriskadjustedmortalityinbothNewYorkandPennsylvania(Shekelle,inpress).However,thereisdebateaboutwhethertheseschemeshavebeenbeneficialsinceanumberofadverseoutcomeshavealsobeenreported(SchneiderandEpstein,1996;Dranoveetal.,2003ascitedinGrol,2004).InOntario,provincialinitiativesinvolvingpublicreportingofemergencydepartmentwaittimesandsurgeriesandotherprocedureshaveresultedinimprovedoutcomes.PublicreportingontheOntarioWaitTimeswebsitehasreducedtheamountoftimespentinemergencyroomsbycomplexpatientsbytwohours(HQO,2011).The90thpercentilewaittimesforhipreplacements,kneereplacementsandcataractsurgeriesdecreasedbymorethanhalfsince2005.The90thpercentilewaittimeforCTscansdecreasedfrom2.5monthstoaboutonemonthoverthesametimeperiod.


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Thereisscantevidenceregardingpublicdisclosureofperformancedata,particularlyaboutindividualprovidersandpractices.Majorpublicreportingsystemshavenotbeenrigorouslyevaluated(Hibbardetal.,2003).IntheUnitedKingdom,theQualityandOutcomesFrameworkhasstimulatedgeneralpractitioneractivitysincedetailedresultsforeverypracticeareavailableontheInternet.Barretal.,(2006)foundthathealthcareorganizationsweremorelikelytorespondtopublicreportsthanindividualproviders.Organizationsdevelopculturesandbehavioursthatareoftenattherootofqualityissues,makingitfavourabletoreportatthelevelofthehealthcareorganizationtoachieve:accountability;qualityimprovement;orconsumerchoice.Thereareseveralunintendedconsequencesthatcanresultfromreportingtothepublic.MannionandDavies(2002)arguethatapublicreportmaypromptprovidersandhealthcareorganizationsto:focusonmeasuredclinicalareastothedetrimentofothers;focusononenarrowclinicalareawithoutcoordinatingwithothers;concentrateonshorttermgainsattheexpenseoflongtermgoals;bedisinclinedtoexperimentwithnewapproachestocare;andalterbehaviourtocreateanadvantageattheexpenseofpatients(Marshalletal.,2000).Otherconsequences,suchas:publicdistrustofthesystem;misinterpretationofthereport;andreducedstaffmorale,aremorelikelytooccurwhenthereportmadepublicisdifficulttounderstand(Shekelle,inpress).Wallaceandcolleagues(2007)suggestthatpublicreportingmustclearlyaddressobjective(s),audience,content,products,distributionandimpacts(intendedandunintended)andcarefullyconsideranypotentialadverseoutcomes.Toenhancetheircredibilityandusefulness,publicperformancereportsshouldbecreatedincollaborationwithphysiciansandotherlegitimateinterestgroups(AgencyforHealthcareResearchandQuality,2007;Marshalletal.,2000).Whenreportingdata,carefulriskadjustmentshouldbeimplementedtoofferaccuratecomparisonsbetweenprovidersandtoensurethatthelegitimacyofthecomparisonsisacceptedbyprofessionals(Marshalletal.,2003).Publicdisclosureofinformationshouldalsobeintegratedwithotherqualityimprovementstrategies(Marshalletal.,2000).Giventhepaucityofevidenceontheimpactofpublicreportingatthepracticelevelandthepotentialforunintendednegativeconsequences,atthepresenttimepublicreportingonprimaryhealthcareshouldbeconductedattheprovincialandregionallevelsratherthanatthepracticeorproviderlevel.

AccreditationAccreditationisarigorousexternalevaluationprocessthatcomprisesselfassessmentagainstagivensetofstandards,anonsitesurveyfollowedbyareportwithorwithout


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recommendations,andtheawardorrefusalofaccreditationstatus(Pomeyetal.,2010).Accreditationcanbeavoluntaryoramandatedprocess.InCanada,accreditationisvoluntaryexceptforFirstNationsfacilities,universityaffiliatedhospitalsandinstitutionsinQuebec.AccreditationCanadaisanationalnonprofitorganizationthatwasestablishedtoguaranteethathealthcareorganizationsinCanadaprovideservicesofacceptablequality.Thisorganizationfollowsinternationalaccreditationprotocolsfortheselfassessmentofhealthcareorganizationsagainstagivensetofstandardsdeterminedbyprofessionalconsensus.Anonsitesurveyisconductedandfollowedbyareportwithorwithoutrecommendationsandtheawardorrefusalofaccreditationstatus.Thereislimitedevidencetosuggestthatexternalaccreditationresultsinsustainedqualityimprovement.GreenfieldandBraithwaite(2008)reviewedandanalysedtheliteratureonaccreditationandaccreditationprocesses.Thepicturewascomplex,withimprovementshavingbeenreportedinsomefieldsbutnotinothers.Theirreviewdidnotreportonthedesignorthequalityoftheincludedstudies,anddidnotgivequantitativeestimatesoftheeffectsofaccreditation.TheWorldHealthOrganization(2003)foundtheintroductionofaccreditationprogramsisdirectlytiedtofinancialincentivesandsuggestedmoreinformationisrequiredbeforedeterminingifaccreditationisthemo

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Quality in Primary Care - afhto Improving Quality in Primary Care Report of the Working Group to the Primary Healthcare Planning Group 1 Quality in Primary ... i Improving Quality