1 2013 Ontario Stroke Network Forum Proceedings Report Final The 2013 Ontario Stroke Network (OSN) Forum was held on November 25, 2013. The purpose of this year’s OSN Forum was to: 1. Update and discuss Quality Based Procedure (QBP) clinical implementation and overview of pricing for phase 1 stroke QBP (Emergency Department, acute, Inpatient rehabilitation) and plans for phase 2 (community/outpatient Transient Ischemic Attack [TIA] and rehabilitation) 2. Validate and contextualize the stroke QBP indicators and draft indicator report 3. Consider the Accreditation Canada Stroke Distinction Program as an enabler for QBP implementation 4. Support networking and facilitate information sharing The Forum was attended by 80 individuals from the following groups: Regional Program Directors (RPD) Regional Stroke Steering Committee (RSSC) Chairs Regional Medical Directors Regional Stroke Centre Administration Liaisons District Stoke Coordinators Local Health Integration Network (LHIN) Representatives Ministry of Health and Long Term Care (MoHLTC) Representatives See Appendix A for the names and contact information of attendees. The Forum consisted of four sessions (see Agenda ): Session 1 - QBP Clinical Engagement and Pricing Session 2 – OSN-SPOR QBP Demonstration Project Session 3 - Indicator Validation Session 4 - Stroke Distinction as an Enabler to QBP Highlights from each session were: Session 1 - QBP Clinical Engagement and Pricing Michael Stewart, Project Lead – Quality Alignment to Payment, Health Quality Branch of MOHLTC, presented on the QBP Clinical Engagement and Pricing (see Appendix B for presentation slides) and Fredrika Scarth, Manager – Quality Program and Health Quality Ontario Liaison with MOHLTC, provided an overview of Community Based Quality Procedures. Key points from the QBP Clinical Engagement and Pricing presentation were: There is a need for change and transformation in order to straighten out cost curve The current Health System Funding Reform-HSFR (e.g. Health Based Allocation Model- HBAM and QBP) is a very different approach for transformation than previously used with focus is on quality to improve care. Thirty percent of the provincial budget will be allocated for QBPs. PROCEEDINGS REPORT - 2013 ONTARIO STROKE FORUM
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1 2013 Ontario Stroke Network Forum Proceedings Report Final
The 2013 Ontario Stroke Network (OSN) Forum was held on November 25, 2013. The purpose of this year’s OSN Forum was to: 1. Update and discuss Quality Based Procedure (QBP) clinical implementation and overview of
pricing for phase 1 stroke QBP (Emergency Department, acute, Inpatient rehabilitation) and plans for phase 2 (community/outpatient Transient Ischemic Attack [TIA] and rehabilitation)
2. Validate and contextualize the stroke QBP indicators and draft indicator report 3. Consider the Accreditation Canada Stroke Distinction Program as an enabler for QBP
implementation 4. Support networking and facilitate information sharing The Forum was attended by 80 individuals from the following groups:
Regional Program Directors (RPD)
Regional Stroke Steering Committee (RSSC) Chairs
Regional Medical Directors
Regional Stroke Centre Administration Liaisons
District Stoke Coordinators
Local Health Integration Network (LHIN) Representatives
Ministry of Health and Long Term Care (MoHLTC) Representatives See Appendix A for the names and contact information of attendees. The Forum consisted of four sessions (see Agenda): Session 1 - QBP Clinical Engagement and Pricing Session 2 – OSN-SPOR QBP Demonstration Project Session 3 - Indicator Validation Session 4 - Stroke Distinction as an Enabler to QBP Highlights from each session were:
Session 1 - QBP Clinical Engagement and Pricing Michael Stewart, Project Lead – Quality Alignment to Payment, Health Quality Branch of MOHLTC, presented on the QBP Clinical Engagement and Pricing (see Appendix B for presentation slides) and Fredrika Scarth, Manager – Quality Program and Health Quality Ontario Liaison with MOHLTC, provided an overview of Community Based Quality Procedures. Key points from the QBP Clinical Engagement and Pricing presentation were:
There is a need for change and transformation in order to straighten out cost curve
The current Health System Funding Reform-HSFR (e.g. Health Based Allocation Model-HBAM and QBP) is a very different approach for transformation than previously used with focus is on quality to improve care. Thirty percent of the provincial budget will be allocated for QBPs.
PROCEEDINGS REPORT - 2013 ONTARIO STROKE FORUM
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The basis for the approach to funding reform is the Excellent Care for All Act and that health care system is focused on the quality of care and the best use of resources. The goal is that funding will follow patients along continuum of care journey supporting integration of care across sectors.
There is no target for financial savings. Given the complexity of the funding reform it will be an iterative process (not linear as Slide 7 indicates but circular) with a focus on avoiding unintended consequences.
There are four concurrent streams – Acute, Post-Acute transition, Community and Indicators
Key points from the presentation on Community Based Quality Procedures were:
There is a strong culture of change within Community Care Access Centres (CACC)
It is believed that the application of the funding models will be quite different for the community
The Functional (vs. medical) need is a key driver of service patterns
There are currently two distinct CCAC programs of care – short stay (defined episode, goal is discharge from service), and long stay (needs fluctuate over time, goal avoid institutionalization) with the following characteristics:
o Long Stay - variable service utilization with primary driver being personal support services
o Short Stay - more homogenized service utilization, drivers are RN and therapies services
The initial focus will be on first 60 days post discharge care before looking a longer stay needs
See Appendix C for Questions and Answers/Discussion for the Session.
Session 2 – OSN-SPOR QBP Demonstration Project Christina O’Callaghan, Executive Director of Ontario Stroke Network, and Dr. Mark Bayley, Medical Director and a Clinician Scientist at the Brain and Spinal Cord Rehabilitation Program of the Toronto Rehabilitation Institute, provided an update regarding the connection between the Canadian Institutes for Health Research – CIHR Strategy for Patient Oriented Research (SPOR) Project and the HSFR (see Appendix B for presentation slides). Key elements of the presentation were:
There are 12 Ontario SPOR Support Units (OSSU) and two Demonstration Projects
The OSN focused on QBP implementation is one of two demonstration Projects (the other is Patients Canada). Results from the stroke QBP will be applied to the implementation of other QBP’s
That Implementation Research methods will be used
The challenges include missing data, particularly in community settings
The attendees were asked for feedback on the proposed research questions and advice/recommendations on how to advance the SPOR work It was noted that an opportunity to respond would be provided in the evaluation survey
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Questions and Answers/Discussion: Q1. Why is there is not an explicit patient-focus in the research questions?
A. Patient focus is thought to be embedded in the research questions. It was agreed that the patient focus should be more explicit in the research question.
Q2. How is this work being funded?
A. The OSN is being funded through Ontario’s CIHR-SPOR funding. There may be additional money available within OSSU for research calls and the OSN will be ready to response to such research calls.
Session 3 - Indicator Validation Thomas Custers – Manager – Quality and Performance and Evaluation with the MoHLTC, presented on Indicator Validation (see Appendix B for presentation slides). Key Elements from the presentation were:
Ministry has developed an integrated scorecard approach to monitor the impact of QBP implementation and to provide clinicians and administrators with information to support planning and improvement
The Ministry is seeking input to prioritize and contextualize the results of indicators that were selected by the stroke QBP clinical expert panel as important for evaluating the implementation impact of QBP implementation
One goal is to be transparent – goal is for hospital-level results to be shared with and among facilities
The indicators will be reassessed in one year and will be informed by SPOR work
The Indicator Validation Report will be released as an appendix to the QBP Stroke Clinical handbook
Target date for first report is Winter 2014
The Breakout session goals were reviewed i.e. to obtain feedback on: o Indicator prioritization o Contextualization of the results o Driving Improvement
Summary of the Breakout session notes are available in Appendix B, the overall themes from the breakout session were:
Acute Stroke Unit Care is a critical indicator and should be included now not on the future list since Stroke Units will help drive much of the other required changes
Indicators not necessarily aligned with domains (e.g. Access Domain)
Indicators can’t stand on their own, need to look at combination of results
Importance of using real time data to drive change
Patient experience appears to be missing
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Notes for the individual groups from the Breakout session are also available in Appendix B. T. Custers’ additional comments in response to the breakout session feedback included:
Will work with Canadian Institute for Health Information and other ministry partners to assess the feasibility of accurately capturing and reporting a Stroke Unit indicator on the baseline report
In order to limit the burden on hospitals of additional data collection, plan is to start with what is currently available using existing provincial data sources and then fill the gaps as they are identified
Patient experience indicator currently under development – the work on how to measure patient experience across the continuum of care is underway in collaboration with ministry partners
Session 4 - Stroke Distinction as an Enabler to QBP Cally Martin, Regional Program Director – Stroke Network of Southeastern Ontario, Richard Jewitt, Program Operational Director for Medicine at Kingston General Hospital, Jo-anne Marr, Executive VP Operations, COO and Chief Nursing Executive of Mackenzie Vaughan Hospital, and Dr. Al Jin, Assistant Professor Medicine (Neurology) at Queen’s University and Regional Medical Lead of Stroke Network of Southeastern Ontario based out of Kingston General Hospital, presented on their experience achieving Stroke Distinction through Accreditation Canada (see Appendix B for presentation documents). Key elements of the presentation were:
Early adopter grant from OSN helpful to enable completion of program
Program provided a structure and framework for improving processes, adoption of best practice, evaluation of patient outcomes
Data needs to be submitted every six months and therefore supports continuous monitoring of performance and sustained improvement
KGH and Mackenzie Vaughan Hospital have started preparation for the next review which is required every two years
Cost includes financial ($12-23K depending on which services are being accredited) as well as in-kind commitment, in particular human resources
Data collection/management is resource-intensive but informative.
Outcomes include: o Better patient experience o Improved patient outcomes (e.g. decreased in-hospital mortality and readmission rates) o Achievement of core performance indicators prepares for QBP indicators o Creation of a united team and engaged - staff understand why they are doing certain
things and are willing to work towards quality improvements o Greater levels of engagement in stroke care at all levels of the organization
Reinforced the importance of data - if you don’t measure it you don’t know where to focus your work
The OSN would like to thank all presenters and attendees of the 2013 OSN Forum for their contribution to making the day a success. The results of the Evaluation Survey for the Forum are available in Appendix D. We look forward to working with our partners in the planning of the 2014 OSN Forum.
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APPENDIX A
Attendee Names and Contact Information
Note: consent obtained to share this information from attendees and anyone who did not provide consent there name was removed from the list
v) Notes from Breakout session on Indicator Validation
November 2013 OSN Forum Indicator Validation Report Back Summary.pdf
Breakout Session Indicator Validation Feedback 2013 OSN Forum.xls
vi) Stroke Distinction as an Enabler to QBP
QBP Stroke Distinction BN July 22 2013.pdf
Stroke Distinction OSN forum Presentation for nov 25 2013 FINAL.pdf
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APPENDIX C
Session 1 - Question and Answer/Discussion Q1. When looking at Home Care and post-hospital medical care there is not much difference – is this provider driven? A. This could be business decision by CCACs (i.e. not driven by best practice but by business
practice). There are significant concerns regarding CCAC practice of rationing care (e.g. authorization of four Physiotherapy visits) as standard practice. There are required enhancements for CCAC to deliver closer to best practice since Rehab needs are quite different.
Q2. What is the thinking regarding costing for acute stroke unit care?
A. Designated stroke unit care is recommended. The Regions/LHINs will need to decide how to
implement the funding for stroke unit care.
Q3. Are the CCAC referral patterns currently based on resources versus functional goals? A. The data is currently lacking regarding this information.
Q4. How does a Rehab model fit into the CCAC short stay/long stay model of care? A. People enter home care with differing levels of care needs and functional status and
therefore different funding is required. This needs to be taken into account when developing new care models. It is recognized that it is challenging to move away from a clinical pathway approach.
Q5. What is the timeline for completion of phase 2 (community) QBP implementation? A. The funding change will not occur in FY1415. We are hoping to have recommendations
from Expert Panel by spring 2014 on best practice and recommendations for implementation. Remember this is intended to be an iterative process over a number of years as the full continuum of care is developed.
Q6. How will QBP address the difficulty of transferring care between facilities? A. It is too early to say right now. This is work that still needs to be completed. Q7. What is the strategy to implement QBP between acute care and the rest of the continuum? For example, the drivers for implementing changes in acute care rest in inpatient rehab and there are currently no proposed changes to rehab as of yet. A. We are totally committed that we will need to go back and change things as this is
implemented. As we define the community funding we will need to review the acute model to address any unintended consequences that occur. We are anticipating changes every six months for the first few years. This will feel like it is being done in silos however, this is not the intention. To change the entire continuum at once is not feasible.
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Q8. Are there any contingency funds available to manage factors that could impact ability to transfer from acute care to rehab (e.g. outbreaks)? A. The QBPs are precisely defined. Hospitals will still have global funding. This will require
creative management.
Q9. Is the system able to support the transformation to Designated Stroke Units?
A. The Ministry supports the Expert Panel’s recommendation for Designated Stroke Units and will define key aspects regarding these units. The innovation and implementation will come from the Regions. It is recognized that this will likely require up-front investment at the LHIN level to create access to acute stroke unit care. The regions will be expected to identify the challenges to the Ministry and the Ministry will work to remove these barriers.
Q10. Please comment on the fact that parts of the Health Care system operates “M-F 8 – 4” not 7 days per week? A. Health care is a 24/7 operation and for best care operating “Monday to Friday - 8 to 4”
practices need to change.
Q11. How can we help you? A. Don’t be shy. Tell us about the challenges you are having; come forward with your
questions and concerns. Please do not expect us to have an answer to every question but we can’t start thinking about it if we do not know it is a question/concern. We will continue trying to visit you in the field.
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APPENDIX D
Evaluation of Forum 25 participants responded to the Forum survey. The summarized results of this feedback include:
Session 1 – QBP Clinical Engagement and Pricing o 72% of responders felt the session was informative o 58.4% of responders felt there was sufficient time for discussion/Q&A o 79.2% of responders felt they had learned information that they could use in their
region/role
Session 2 – OSN-SPOR QBD Demonstration Project o 91.6% of responders felt they understood the goals of the Demonstration Project o Valuable feedback was provided for each of the proposed research questions
Session 3 – Indicator Validation o 76.5% of responders felt the session was informative o 87.5% of responders felt the Breakout session was useful o 87.6% of responders felt they had learned information that they could use in their
region/role
Session 4 – Stroke Distinction as an Enabler to QBP o 88.3% of responders felt the session was informative o 93.8% of responders felt they had learned information that they could use in their
region/role
Overall Comments o 70.6% of responders felt the time to meet and network with their colleagues was ‘just
right’ o 94.1% of responders felt the Forum either met (64.7%) or partially met (29.4%)their
expectations The list of recommended topics for future Forums is as follows:
1) Follow up and future QBP work over the three year implementation including information on final pricing and on development of QBP Indicators
2) Progress to date or lessons learned that could be shared re QBP implementation. It might be beneficial to have presentations "one year later" from a region or centre that had great success in implementing QBP and one that is struggling or had more challenges, including: what worked and what didn't; how they engaged; who they engaged; plan to implement; largest challenges etc…..
3) Community QBPs – progress in development and implementation plan 4) A financial analysis/predictions of the potential impact of stroke rehab QBPs 5) LHINs to present on how they each support the Regional Stroke Strategies