1. A STRATEGIC APPROACH TO THE REALLOCATION OF RESOURCES BASED ON THE SOUNDNESS OF INTERVENTIONS GERTRUDE BOURDON, CHIEF EXECUTIVE OFFICER DANIEL LA ROCHE, HEAD OF EVALUATION, QUALITY AND STRATEGIC PLANNING, EXTRA FELLOW COHORT 9 CEO Forum, CFHI February 6, 2013

2. The CHU de Québec: recognized in the field and in the region Most important University Hospital in Quebec, among the 3 most important in Canada; Regional and superregional centre serving 1.7 M people Named Canadian Model by Accreditation Canada in: Governance TeleHealth Skills Development of managerial staff Systemic screening of distress among cancer patients Decision-making integrated to strategic directions Most important employer in Quebec City 13,820 employees 1,700 doctors, pharmacists and dentists 550 researchers 1,048 graduate students More than 800 volunteers

3. A Four-Fold Mission  Healthcare  1,800 beds  235,000 yearly ER visits  584,000 visits for specialized external services  85,000 surgeries  Teaching  265,000 days of rotation  Research  Funding of $89 M  Close to 550 researchers  Health technology assessment  Recognized by the Canadian Foundation for Healthcare Improvement as a high-potential organization in the use of research evidence

4. The Intervention Project  Team of EXTRA fellows, cohort 9  Daniel La Roche, Head, Evaluation, Quality and Strategic Planning (DEQPS)  Martin Coulombe, Assistant, Evaluation, DEQPS  Dr Marc Rhainds, Medical and Scientific co-manager, Health Technology Assessment Unit

5.  Three studies have estimated that about a third of healthcare expenditures in the USA could be avoided:  $700 to $910 billion each year  45%= sub-optimal utilisation of resources (over- treatment, utilisation not justified by evidence, inefficient utilisation, etc.)  55%= fraud, abuse, administration, price-fixing, etc. The context: US Evidence

6. The context: Canadian Evidence  Canadian Association of radiologists (2010):  30% of diagnostic imaging procedures in Canada might be unnecessary  Operational costs of imaging in Canada are $2.2 billion/year

7. The context: CHU de Québec  Committee of Major Cost Generators (CMCG): subcommittee of Management Committee, created in 2008  Mandate: identification of the major cost generators and development of strategies to generate savings and reduce expenditure increases.  Medical and office supplies  Human resources  Specific professional practices  Main Strategies:  Streamlining medical and office supplies in order to reduce inventories  Acting with suppliers (i.e. call for tenders)

8. A Reallocation Example  Project: Reducing the variety of anesthesia tubings at the CHU de Québec  A multitude of tubings with different types, sizes and suppliers  Clinicians selecting a reduced number of tubings  Call for tenders  Recurrent savings of $300,000  Reallocation of savings to the Chronic Pain Clinic

9. Aim and Objectives of our Project To include the consideration of evidence in the Major Cost Generators process (MCGC) Aim To have a medical leader included in the MCGC To develop a disinvestment and reallocation process for the institution To identify local disinvestment opportunities To make the reallocation process permanent through a policy of the Board of Directors Objectives

10. Relevant Factors  Easier access to resources might lead to overuse  A disinvestment process implemented at the institution level cannot target a similar level of potential savings as that identified for a full healthcare system as in the American studies  Institutions do not control the decisions of the MSSS (Health and Social Services Ministry) about access to resources  Some payments for services are not charged to the budgets of the institutions (RAMQ--Quebec Health Insurance Plan--, insurers, etc.)

11. Relevant Factors  Amount spent for medications and supplies for care provision and diagnostics at the CHU de Québec  $155M/year  Realistic disinvestment potential  5% = $7.75M/year

12. Basic Principles  Voluntary disinvestment and reallocation based on:  Evidence  The situation at the CHU de Québec  The participation of interested clinicians  Reallocation  In the departments/units having generated the savings (95%)  In health technology assessment (5%) to make the process permanent after EXTRA

13. Basic Principles  Initial focus should be on the overuse of medical resources  major factor explaining the high level of healthcare expenditures  exposes patients to unjustified risks

14. Reassessment and Reallocation Reassessment of an intervention based on evidence Phased disinvestment and change management Follow-up of change implementation and impacts, and measurement of savings Reallocation based on evidence Follow-up of disinvestment sustainability and its impacts

15. Benefits for Patients  Improvement of quality and safety of care  Increased accessibility of care  Avoiding interventions having no added value

16. Issues  Resources dedicated to the definition and support of disinvestment mechanisms  Limits of information systems  Political, clinical and social challenges related to the withdrawal of any established technology  Resistance to change  Availability of scientific evidence  Physicians’ compensation sytem (fee-for-service)

17. Questions Any questions?