11

Structures and Processes for Creating & Managing Quality

Outcomes & Reducing Waste in Alberta Health Services

GMF SymposiumApril 19, 2013

Montreal, QuebecDr Tom Noseworthy

22

Compared to other Provinces

Alberta is• Not less expensive (highest per capita, higher

service intensity & higher unit costs)• Not more accessible (maybe less)• Not the country’s best quality for most

outcomes (with clear exceptions)• Not the longest, or health-adjusted, length of life

33

825

557

875

627

1048

306

0

200

400

600

800

1000

1200

South Zone Calgary Zone Central Zone Edmonton Zone North Zone Best Large RHA/Zone (Central LHIN, ONT)

Age

-Sta

ndar

dize

d Ra

te (p

er 1

00,0

00)

Source = CIHI Health Indicators

Injury Hospitalization - 2010/11

44

11.21

8.73

7.68

5.92

4.29

5.53

0

2

4

6

8

10

12

South Zone Calgary Zone Central Zone Edmonton Zone North Zone Best Large RHA/Zone (Central West LHIN,

ONT)

Risk

-Adj

uste

d Ra

te (

per 1

,000

)

Source = CIHI CHRP

5-Day In-Hospital Mortality Following Major Surgery - 2010/11

55

Alberta Health Services

• One health care delivery system for entire Province• ‘Third way’- Canada (no regions, all regions, one) • Largest health system in Canada- 3.7 million • Budget $12B, 100,000 employees, 7500 doctors• Formed 2008, 5 Zones in 2010, Networks in 2012• Nine clinical networks launched to date• Up to six more planned

66

How will the Provincial Clinical Mandate of AHS be Accomplished? Structures

• Strategic Clinical Networks• Clinically-led change• Performance measurement, research & best

evidence drive practice• Clinical care pathways• Clinical variance management & peer review

77

Goals of Clinical Networks?

• Achieve the best outcomes• Practice the highest quality of clinical care• Seek the greatest value from resources used• Engage clinicians in all aspects of this work

88

Why Clinical Networks?

• Networks are positive ways for all partners along a broad continuum to be involved in planning & improving care & service delivery

• Networks have been shown to be an effective mechanism to ensure collaboration, joint decision-making and shared learning

• Networks are a sound model to promote the use/uptake of clinical experience, knowledge and evidence-based clinical pathways to reduce clinical variation & improve care

99

17.87

11.71

20.93

13.41

18.23

11.71

0

5

10

15

20

25

South Zone Calgary Zone Central Zone Edmonton Zone North Zone Best Large RHA/Zone (Calgary Zone, AB)

Risk

-Adj

uste

d Ra

te (p

er 1

00)

Source = CIHI CHRP

30-Day In-Hospital Mortality Following Stroke - 2010/11

1010

What are Strategic Clinical Networks (SCNs)?

• Collaborative clinical teams with a provincial strategic mandate to improve quality & outcomes

• Led by clinicians, driven by clinical needs, focused on outcomes & based on best evidence

• Comprised of an all-inclusive membership, with 25 core members (community & specialty clinicians, patients, policy-makers, researchers) & leadership (0.5 Senior Medical Director, 0.5 Strategy Vice-President & 0.3 Scientific Director)

1111

How do SCNs Work?

• Broad mandate:– Specific populations: seniors, women's health, children– High impact: cardiovascular disease & stroke– High burden: diabetes, obesity & nutrition, amh

• Scope encompasses entire continuum of care– From population health & prevention to primary care to

acute care to chronic disease management to palliation

• Projects & resources – Driven by evidence and focused on improving outcomes

and eliminating waste

1212

Planned Support & Resources for Each SCN

• Dedicated Business Intelligence Unit– Project management, clinical analytics, case costing, quality

improvement, pathway development, patient safety, knowledge management, health technology assessment

• Embedded research capability and expertise• Education & skills development for leaders• Funding including:

– Seed money for innovation, initiatives, and research– Remuneration of core members– Opportunities to retain savings that are realized

1313

First Six SCNs (June 12/12)

• Addiction and Mental Health• Bone and Joint Health• Cancer Care• Cardiovascular Health and Stroke• Obesity, Diabetes and Nutrition• Seniors’ Health

1414

Three Operational Clinical Networks

Similar to SCNs

i. Provincial, clinically led teams

ii. Similar infrastructure & resources

Differ from SCNs

iii. Responsible across populations

iv. Operationally focused

v. Social determinants/ EOL agenda not required in projects

1515

Three Operational Clinical Networks (Jan13)

• Critical Care• Emergency Services• Surgical Services

1616

Proposed SCNs (Fiscal 2013)

• Population Health and Health Promotion• Primary Care & Chronic Disease Management• Maternal Health• Newborn, Child, and Youth Health• Neurological Disease, ENT, and Vision• Complex Medicine (GI, Kidney & Respiratory)

1717

Proposed SCN & OCN Projects 2013Obesity, Diabetes

& NutritionSCN

Bone & JointSCN

Surgery OCN

Emergency OCN

Addiction & Mental Health

SCN

Cardiovascular Health and Stroke

SCN

Insulin Pump criteria

Rural Stroke Program

Vascular Risk Reduction

C-CHANGE

Enhancing recovery

after surgery

ARTE-referral

Fragility & Stability -

Hip Fracture Rx and

Prevention

Inappropriate use of

antipsychotics

Cancer SCN

Critical Care OCN

Seniors’ HealthSCN

Depression Pathway

Safe Surgery Checklist

aCATS TBDTBD

Hip & Knee 5 year Plan

Lung Cancer

Elder Friendly Care*

1818

Project Scope:• Create standards and clear definition of rural stroke

unit care• Implement early supported discharge (ESD) &

enhanced stroke unit care in 5 small stroke centres• Implement enhancements to stroke unit care for 10

rural primary stroke centres

System Impact:• Acute care• Transition management

• Long term care

Project Financials:•Q4 (12/13): $ 141,964•13/14: $1,745,950• TOTAL Project: $2,873,594

Benefits to be Realized:Short term – Jan 31/ 13 – Mar 31 /14• ESD implemented in 5 small centres serving100

patients • 26% reduction in length of stay; 3 persons avoid

nursing home care; 1 life savedLong term– 1- 3 year window • 214 new patients per year receive ESD and over 1000

new patients per year receiving full stroke unit services; 23 lives saved/year; 17 patients avoid nursing homes after stroke/year

• Reduction in length of stay of over 20%

CV&S: Rural Stroke Action Plan

1919

How Alberta Health Services Will Achieve its Clinical Mandate (Processes)

• Strategic & Operational Clinical Networks• Clinically-led change• Performance measurement, research & best

evidence drive practice• Clinical care pathways & models of care• Clinical variance measurement & management

2020

Variance Management

• Variance is everywhere you look for it• Variation makes the world go around – but…• How much variation is ‘good’• Lessons from financial variances & management• Variance points to a need to ask why & manage it

2121

NL/LB PEI NS NB Que Ont Man Sask AB BC Canada0

10

20

30

40

50

60

24.223.0

35.0

50.6

37.5

47.8

40.8

28.9

53.6

26.0

41.4

MRI Exams per 1000 Population - 2009

Source: CIHI - National Survey of Selected Medical Imaging Equipment, 2009

Supply and Utilization

2222

280

221

298

258

318

176

0

50

100

150

200

250

300

350

South Zone Calgary Zone Central Zone Edmonton Zone North Zone Best Large RHA/Zone (Central LHIN, ONT)

Age

-Sta

ndar

dize

d Ra

te (p

er 1

00,0

00)

Source = CIHI Health Indicators

Premature Mortality - 2006-2008

2323

431

237

408

240

551

180

0

100

200

300

400

500

600

South Zone Calgary Zone Central Zone Edmonton Zone North Zone Best Large RHA/Zone (Central LHIN, ONT)

Age

-Sta

ndar

dize

d Ra

te (p

er 1

00,0

00)

Source = CIHI Health Indicators

Ambulatory Care Sensitive Conditions Hospitalizations - 2010/11

2424

Clinical Variance Measurement

• Variance points to a need to ask why & manage it• Variance measurement & management does this• Small-areas clinical variation apparent for 30 years• Multiple explanations for small-areas clinical variation• Clinical variance management requires measurement• Measurement necessitates sound health informatics

& clinical analytics

2525

Clinical Variance Management

• Management requires measurement• Compare to evidence, others & target best practice• Some clinical variance is justified, some is not• Unjustifiable variance is costly• Unjustifiable variance adversely affects patients• Managing clinical variance is sensitive & complex• At some point, examines individual practices

2626

Managing Individual Clinical Variance (1)

• The essence of professional self-regulation• Comparative assessment of individual physician

performance may be required• How is this best done & by whom• What is the legal/moral mandate to protect identity • Globe & Mail vs professional ‘privilege’

2727

Managing Individual Clinical Variance (2)

• Understand the determinants of decision-making• Lessons from behaviour modification• Modification menu ( education, feedback,

participation, incentives, penalties & rules)• Individual modalities do not work• Habitual behaviours are hard to change

2828

DEFINITION

Health Technology Reassessment (HTR) is a structured, evidence-based assessment of the clinical, social, ethical & economic effects of a technology, currently used in the health care system, to inform optimal use of that technology in comparison to its alternatives.

Clement & Noseworthy IJTAHC 2011

Figure 1: Joshi, Stahnisch & Noseworthy (2009)

3030

Scope of Reassessment• HTA focuses on introduction of new technologies• HTR focuses on existing technologies:

– Obsolescence- when new supersedes old– Waste (overuse, misuse)- scope of use

• Reassessment common in other fields• Reassessment of health technologies is not

widely considered, practiced or standardized • Reassessment may lead to no change; reduced

scope of use; decommissioning & disinvestment

3131

Health Technology Reassessment is HTA +

• Clinical Synthesis• Comparative effectiveness

• Economic evaluation of costs & benefits

+• Impact analysis

• Intended consequences• Unintended • Social context

• Feasibility assessment

3232

Proposed Reassessment Projects

• Knee MRI following injury• Optimal cardiac imaging for cardiac conditions• Antipsychotic use in elderly patients in LTC• Nitrous Oxide use in Critical Care