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Présentation dr tom noseworthy

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  • 1. 11Structures and Processes forCreating & Managing QualityOutcomes & Reducing Waste inAlberta Health ServicesGMF SymposiumApril 19, 2013Montreal, QuebecDr Tom Noseworthy
  • 2. 22Compared to other ProvincesAlberta is• Not less expensive (highest per capita, higherservice intensity & higher unit costs)• Not more accessible (maybe less)• Not the country’s best quality for mostoutcomes (with clear exceptions)• Not the longest, or health-adjusted, length of life
  • 3. 338255578756271048306020040060080010001200South Zone Calgary Zone Central Zone Edmonton Zone North Zone Best Large RHA/Zone(Central LHIN, ONT)Age-StandardizedRate(per100,000)Source = CIHI Health IndicatorsInjury Hospitalization - 2010/11
  • 4. 4411.218.737.685.924.295.53024681012South Zone Calgary Zone Central Zone Edmonton Zone North Zone Best Large RHA/Zone(Central West LHIN,ONT)Risk-AdjustedRate(per1,000)Source = CIHI CHRP5-Day In-Hospital Mortality Following Major Surgery - 2010/11
  • 5. 55Alberta 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
  • 6. 66How will the Provincial Clinical Mandate ofAHS be Accomplished? Structures• Strategic Clinical Networks• Clinically-led change• Performance measurement, research & bestevidence drive practice• Clinical care pathways• Clinical variance management & peer review
  • 7. 77Goals 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
  • 8. 88Why Clinical Networks?• Networks are positive ways for all partnersalong a broad continuum to be involved inplanning & improving care & service delivery• Networks have been shown to be an effectivemechanism to ensure collaboration, jointdecision-making and shared learning• Networks are a sound model to promote theuse/uptake of clinical experience, knowledgeand evidence-based clinical pathways toreduce clinical variation & improve care
  • 9. 9917.8711.7120.9313.4118.2311.710510152025South Zone Calgary Zone CentralZone Edmonton Zone North Zone Best Large RHA/Zone(Calgary Zone, AB)Risk-AdjustedRate(per100)Source = CIHI CHRP30-Day In-Hospital Mortality FollowingStroke - 2010/11
  • 10. 1010What are Strategic Clinical Networks (SCNs)?• Collaborative clinical teams with a provincialstrategic 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, with25 core members (community & specialtyclinicians, patients, policy-makers, researchers)& leadership (0.5 Senior Medical Director, 0.5Strategy Vice-President & 0.3 Scientific Director)
  • 11. 1111How do SCNs Work?• Broad mandate:– Specific populations: seniors, womens 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 toacute care to chronic disease management to palliation• Projects & resources– Driven by evidence and focused on improving outcomesand eliminating waste
  • 12. 1212Planned Support & Resources for Each SCN• Dedicated Business Intelligence Unit– Project management, clinical analytics, case costing, qualityimprovement, 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
  • 13. 1313First 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
  • 14. 1414Three Operational Clinical NetworksSimilar to SCNsi. Provincial, clinically led teamsii. Similar infrastructure & resourcesDiffer from SCNsi. Responsible across populationsii. Operationally focusediii. Social determinants/ EOL agenda notrequired in projects
  • 15. 1515Three Operational Clinical Networks (Jan13)• Critical Care• Emergency Services• Surgical Services
  • 16. 1616Proposed 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)
  • 17. 1717Proposed SCN & OCN Projects 2013Obesity, Diabetes& NutritionSCNBone & JointSCNSurgeryOCNEmergencyOCNAddiction &Mental HealthSCNCardiovascularHealth and StrokeSCNInsulinPumpcriteriaRural StrokeProgramVascular RiskReductionC-CHANGEEnhancingrecoveryafter surgeryARTE-referralFragility &Stability -Hip FractureRx andPreventionInappropriateuse ofantipsychoticsCancerSCNCritical CareOCNSeniors’ HealthSCNDepressionPathwaySafe SurgeryChecklistaCATS TBDTBDHip & Knee5 year PlanLungCancerElderFriendlyCare*
  • 18. 1818Project Scope:• Create standards and clear definition of rural strokeunit care• Implement early supported discharge (ESD) &enhanced stroke unit care in 5 small stroke centres• Implement enhancements to stroke unit care for 10rural primary stroke centresSystem Impact:• Acute care• Transition management• Long term careProject Financials:•Q4 (12/13): $ 141,964•13/14: $1,745,950• TOTAL Project: $2,873,594Benefits to be Realized:Short term – Jan 31/ 13 – Mar 31 /14• ESD implemented in 5 small centres serving100patients• 26% reduction in length of stay; 3 persons avoidnursing home care; 1 life savedLong term– 1- 3 year window• 214 new patients per year receive ESD and over 1000new patients per year receiving full stroke unit services;23 lives saved/year; 17 patients avoid nursing homesafter stroke/year• Reduction in length of stay of over 20%CV&S: Rural Stroke Action Plan
  • 19. 1919How Alberta Health Services Will Achieve itsClinical Mandate (Processes)• Strategic & Operational Clinical Networks• Clinically-led change• Performance measurement, research & bestevidence drive practice• Clinical care pathways & models of care• Clinical variance measurement & management
  • 20. 2020Variance 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
  • 21. 212124.223.035.050.637.547.840.828.953.626.041.40102030405060NL/LB PEI NS NB Que Ont Man Sask AB BC CanadaMRI Exams per 1000 Population - 2009Source: CIHI - National Survey of Selected Medical Imaging Equipment, 2009Supply and Utilization
  • 22. 2222280221298258318176050100150200250300350South Zone Calgary Zone CentralZone Edmonton Zone North Zone Best Large RHA/Zone(CentralLHIN, ONT)Age-StandardizedRate(per100,000)Source = CIHI Health IndicatorsPrematureMortality - 2006-2008
  • 23. 23234312374082405511800100200300400500600South Zone Calgary Zone CentralZone Edmonton Zone North Zone Best Large RHA/Zone(CentralLHIN, ONT)Age-StandardizedRate(per100,000)Source = CIHI Health IndicatorsAmbulatoryCare Sensitive Conditions Hospitalizations - 2010/11
  • 24. 2424Clinical 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
  • 25. 2525Clinical 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
  • 26. 2626Managing Individual Clinical Variance (1)• The essence of professional self-regulation• Comparative assessment of individual physicianperformance may be required• How is this best done & by whom• What is the legal/moral mandate to protect identity• Globe & Mail vs professional ‘privilege’
  • 27. 2727Managing 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
  • 28. 2828DEFINITIONHealth Technology Reassessment (HTR) is astructured, evidence-based assessment of theclinical, social, ethical & economic effects of atechnology, currently used in the health caresystem, to inform optimal use of thattechnology in comparison to its alternatives.Clement & Noseworthy IJTAHC 2011
  • 29. Figure 1: Joshi, Stahnisch & Noseworthy (2009)
  • 30. 3030Scope 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 notwidely considered, practiced or standardized• Reassessment may lead to no change; reducedscope of use; decommissioning & disinvestment
  • 31. 3131Health Technology Reassessment is HTA +• Clinical Synthesis• Comparative effectiveness• Economic evaluation of costs & benefits+• Impact analysis• Intended consequences• Unintended• Social context• Feasibility assessment
  • 32. 3232Proposed 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