Présentation dr tom noseworthy


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Présentation dr tom noseworthy

  1. 1. 11Structures and Processes forCreating & Managing QualityOutcomes & Reducing Waste inAlberta Health ServicesGMF SymposiumApril 19, 2013Montreal, QuebecDr Tom Noseworthy
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 15. 1515Three Operational Clinical Networks (Jan13)• Critical Care• Emergency Services• Surgical Services
  16. 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. 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. 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. 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. 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. 21. 212124. 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. 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. 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. 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. 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. 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. 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. 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. 29. Figure 1: Joshi, Stahnisch & Noseworthy (2009)
  30. 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. 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. 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