1. Linking Quality Standards and Ministry Program Development
AGHPS Leadership Summit
November 25th, 2016
Fredrika Scarth
Health Quality Ontario Liaison and Program Development Branch
Ministry of Health and Long-Term Care

2. The people of Ontario and their Government:
In 2010, Ontario enacted a landmark piece of legislation called the Excellent Care for All Act
The Excellent Care for All Act (ECFAA) sets out principles and levers to embed a culture of quality and accountability in the delivery of patient-centred health care services.
The people of Ontario and their Government: …
Believe that the patient experience and the support of patients and their caregivers to realize their best health is a critical element of ensuring the future of our health care system
Recognize that a high quality health care system is one that is accessible, appropriate, effective, efficient, equitable, integrated, patient centred, population health focussed, and safe
Believe that quality is the goal of everyone involved in delivering health care in Ontario
Share a vision for a Province where excellent health care services are available to all Ontarians, where professions work together, and where patients are confident that their health care system is providing them with excellent health care

3. Quality as core strategy Capability for improvement
Building blocks of a high quality healthcare system
Health System Funding Reform (HSFR) is one of the key elements for building a high quality healthcare system and to successfully drive ministry priorities such as The Patients First Act
Quality as core strategy
(ECFAA, Patients First)
Capability for improvement
(e.g. HQO evidence, standards, reporting)
Align system levers
(e.g. Ministry program development, funding changes)
To meet these priorities, we need to:
Provide clear direction
Build capability for improvement in the system
Strategically align levers
Enablers:
Strong stakeholder, clinician, and patient engagement
Strong data / measurement and evidence-based practices

4. HSFR goals and objectives
Key Ministry Lever for Quality Improvement: Health System Funding Reform
Health System Funding Reform (HSFR) encourages hospitals and CCACs to find efficiencies and improve the quality of services provided through two key components: the Health Based Allocation Model (HBM) & Quality Based Procedures (QBPs).
HSFR’s goals and objectives are translated into HBAM and QBP components
HSFR goals and objectives
Reflects the needs of the community Equitable allocation of healthcare dollars Better quality care and improved outcomes Moderate spending growth to sustainable levels Adopt/learn from approaches used in other jurisdictions Phased in over time at a managed pace
Health Based Allocation Model (HBAM)
Evidence, health-based funding formula
Enables government to equitably allocate available funding for local health services
Estimates future expense based on past service levels and efficiency, as well as population and health information e.g. age, gender, population growth rates, diagnosis and procedures
Quality-Based Procedures (QBPs)
Clusters of patients with clinically related diagnoses / treatments and functional needs identified by an evidence-based framework as providing opportunity for:
Aligning incentives to facilitate adoption of best clinical evidence-informed practices
Appropriately reducing variation in costs and practice across the province while improving outcomes 4

5. The Evolution of QBPs
At the outset of their launch, the main objectives of QBPs were to:
Reduce provincial variation in care patterns for a specific clinical episode
Improve the quality of care provided for those episodes and increase access, where applicable
Reduce hospital and system costs by driving efficiencies
QBPs have therefore laid the foundation for achieving high quality, efficient, evidence-based care.
The QBP Cycle
QBPs are intended to drive practice change within specific episodes, starting in hospitals and ultimately expanding to the community.
QBPs are intended to reduce variation, enhance quality of care and improve patient outcomes through the development and adoption of evidence-informed best practices
QBPs reimburse providers at an established rate for the provision of a service to a defined patient group, allowing funding to follow the patient and incenting the delivery of high quality and efficient care.

6. QBP Program Review: Optimizing Funding Models to Achieve Quality Objectives
In the summer of 2016, a review of the QBP program was undertaken by the Ministry and key stakeholders (e.g. LHINs, OHA, etc.) to determine:
Whether the episodes of care captured in each QBP are appropriate for the funding mechanism
Whether the model achieves the desired quality objectives for each QBP
Results showed that the QBP program is working and achieving desired effects, but could be optimized to enhance quality care objectives
i.e. Integrated Funding Models (IFMs) such as ‘bundled’ QBPs, where there may be a single payment for an episode of care spanning multiple settings and providers
This revised QBP model creates a renewed opportunity for alignment between Ministry’s strategic funding and program levers as a possible means to support the implementation of HQO’s quality standards
The QBP selection process is also being reviewed to further ensure alignment with HQO Quality Standards

7. Moving Towards Quality Along the Full Patient Journey
Focus of Existing Pilots
Hip Fracture
Stroke
Hip & Knee Replacement
Chronic Obstructive Pulmonary Disease
Chronic Kidney Disease
Acute and Chronic Pain
Mood Disorders/Depression
Dementia
Primary care
Acute care
Post-acute/rehab/home care
Congestive Heart Failure
Palliative Care
The vision for the health care system in Ontario is a higher-performing, better connected, more integrated and patient-centred system for patients and care providers.
Episodic Bundles: Defined episodes of care where symptoms emerge, are treated and abate. Patients follow a predictable care pathway.
Quality standard topic area
Continuous complex Bundles: Conditions that require ongoing care across the continuum. May include acute episodes (ex. COPD exacerbation). Episodes of care may not follow a predictable pathway.
Population-based: Funding for health care services is organized and funded around the needs of a specified local population (e.g. Rural Health Hubs; Primary care capitation and sub-LHIN accountable care organizations; Small Hospital Funding Model).

8. Quality then Funding: Leading with Evidence
Support continuous quality improvement
Develop evidence and care standards
Public monitoring and reporting
Translate evidence into practical tools and quality improvement supports to accelerate adoption
Establish standards of care based on evidence
Monitor and report on quality at system and organizational level
Health Link support
Improving & Driving Excellence Across Sectors (IDEAS)
National Surgical Quality Improvement Program (NSQIP)
Execute an integrated Quality Improvement Plan (QIP) program to support the quality agenda in Ontario
Adopting Research to Improve Care (ARTIC) Program
Support development and adoption of Quality-Based Procedures (QBPs)
Evidence-based recommendations to the Minister (mandated under ECFAA)
Quality Standards (aka clinical care standards) to the Minister and health system (proposed under ECFAA)
Yearly Report (Measuring Up)
Web-based reporting of quality indicators for certain sectors
Personalized Practice Reports (customized data to physicians)
Theme Reports
Work at the direction of the Minister on key areas of quality assurance
(e.g. QCIPA Review, Diagnostic Imaging Quality Report, Quality Oversight of Independent Health Facility / Out-of-Hospital Premises, etc.)
Patient Engagement
Establishment of the Office of the Patient Ombudsman

9. Linking Evidence with Ministry Program Development for System-Wide Quality Improvement
Identification of Access Issue & Burden
HQO Develops Evidence-Based Standards & Recommendations
Collaborative Support for Clinical Implementation
Monitor Implementation & Progress
Reporting on performance to track progress and drive continuous quality improvement

10. Call to Action: Identifying Gaps in Mental Health Care in Ontario
HQO’s quality standards are developed in topic areas identified as having high potential for better quality care in Ontario
The first three quality standards highlight existing gaps in care and draw attention to the critical need to address quality concerns
Schizophrenia: Care for Adults in Hospitals Quality Standard
Schizophrenia is ranked in the top 5 conditions that have the highest impact on the life and health of people in Ontario
Only 25% of people discharged from a schizophrenia-related hospitalization receive the recommended follow-up visit with a physician within 7 days
People hospitalized for schizophrenia have a 12.5% readmission rate within 30 days of discharge
Major Depression: Care for Adults and Adolescents Quality Standard
Only one third of people discharged from hospital with a primary diagnosis of depression or other mood disorders receive the recommended follow-up visit with a physician within 7 days

11. Setting a Framework for Best Practice: Mental Health-related Evidence-Based Quality Standards and Recommendations
HQO has developed two key evidence-based products that create a framework for quality improvement in the area of mental health in Ontario:
Quality Standards
Care standards for clinically-defined patient populations provide recommendations for high quality practice within a specific care pathway to enhance consistency and promote improved health outcomes in areas where gaps currently exist.
Ex: Major Depression: Care for Adults and Adolescents, Schizophrenia: Care for Adults in Hospitals
Evidence-Based Recommendations through Health Technology Assessments (HTAs)
At the request of the Ministry, HQO is currently conducting a comprehensive evidence review (HTA) of psychotherapy (CBT and Interpersonal Therapy) for treatment of Major Depressive Disorder and Generalized Anxiety Disorder. An HTA on rTMS for treatment-resistant depression is also under review.
The HTA results will provide further evidentiary support for interventions recommended as best practice in quality standards

12. Guiding Ministry Response: Engaging System Levers to Close Quality Gaps
HQO’s evidence-based standards and HTAs challenge the Ministry to assess existing programs and prompt consideration of policy and funding that can more adequately support patient care.
Policy Levers
Strategic policy planning to support innovative program development
Governance & Accountability Levers
Identify accountabilities through existing agreements and/or legislation
Formalized partnerships for achievement of health-system goals
Funding Levers
Utilize funding mechanisms/financial incentives such as:
Schedule of benefits, Ontario Drug Benefit, etc. to allow for expanded access to necessary services and treatment
Align funding levers such as QBPs with quality frameworks set out in the standards where appropriate

13. Next Steps: Aligning Measurement and Reporting to Support Continued Quality Improvement
Track implementation through quality standard indicators and continue monitoring quality issue for progress on outcomes
Monitoring and evaluation could be achieved through a variety of mechanisms:
HQO Online System Performance Reporting
Quality Improvement Plans (QIPs)
Accountability indicators
Special reports, as appropriate (e.g. HQO’s Theme Reports and annual Measuring Up Report)
Sub-region tracking at the LHIN level

14. System Overview: Linking Evidence with Ministry Program Development for Quality Improvement in Mental Health
Identification of Access Issue & Burden
HQO Develops Evidence-Based Standards & Recommendations
Collaborative Support for Clinical Implementation
Monitor Implementation & Progress
Quality Standards
Recommendations for best practice along a clinical pathway
Ex: Major Depression Quality Standard
HQO develops implementation plan for the Major Depression Quality Standard
Ex: HQO identified that across facilities in Ontario, the percentage of patients who revisited ED within 30 days of a previous ED visit for major depression varied from 0% to 18.3%
HQO reports on quality indicators outlined in standard
Ministry identifies possible levers to support implementation of the Major Depression Quality Standard
Ministry opportunity to support measurement and evaluation
OHTAC Recommendations
Evidence-based recommendations for relevant treatment interventions/technologies
Ex: structured psychotherapy health technology assessment
Reporting on performance to track progress and drive continuous quality improvement

15. Questions? Fredrika Scarth
Director, HQO Liaison & Program Development Branch
Health System Quality and Funding Division