HQC Impact Report 28Jan2010

8/9/2019 HQC Impact Report 28Jan2010

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HEALTHQUALITY

SASKATCHEWAN

COUNCIL

BUILDING A CULTURE OF QUALITY

IMPROVEMENT IN SASKATCHEWANSHEALTH CARE SYSTEM: ASSESSING THE

IMPACT OF THE HEALTH QUALITY COUNCILJAN

UARY

2010

In 2001, the Fyke Commission on Medicare

recommended the creation of a Quality Council

with a mandate to improve the quality of health

services in the provinceIn so doing, Saskatchewanwill lead the country in the pursuit of a quality culture

that will be the next great revolution in health care.

The Health Quality Council (HQC), an independent

agency that opened its doors in 2003, has planted and

nurtured an improvement culture in Saskatchewan by

measuring and reporting on the quality of care,

promoting improvement, and engaging its partners in

building a better health system. This document

describes the extent to which the HQC has

accelerated improvement throughout the provinces

health care system and helped build a culture of

quality. It is purposefully organized around some of

HQCs core strategies, to show the connection

between our activities and our mandate.


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Despite the significant amount of public resourcesspent on health care, we know very little about itsquality. One of the key lessons we are learning fromhigh performing health systems elsewhere in the

world is that continuous measurement of andfeedback on health care quality is essential.Several efforts led by the HQC over the past fewyears are putting measurement and monitoringfront and centre in Saskatchewans health caresystem:

We have released 14 high-calibre reports thathelped identify gaps in the quality of health carein this province. Several of these reports including those on diabetes, post-heart attackcare, patient experience in acute care, use ofpotentially harmful medications in long-termcare, and wait times for breast cancer care ledto quality improvement projects that werecollaborations between the Health QualityCouncil and health care providers andorganizations. Further, the reports provided afoundation of solid, locally relevant evidenceupon which conversations about the need forquality improvement in Saskatchewan healthcare could be based. These dialogues rangedfrom discussions between HQC and primary care

practitioners, during recruitment for the ChronicDisease Management Collaborative (described inmore detail later), to discussions among MLAsduring question period in the Legislature,regarding HQCs report on wait times for breastcancer care. A couple of more specific examplesof the impact of our measuring and reportingwork include:

- HQCs first report, on the quality of post-heartattack care, showed that in 2001-02 onlyabout one in five heart attack survivors in

Saskatchewan were dispensed three keymedications proven to save lives and prevsecond heart attacks. By 2005-06, 42% ofheart attack survivors were receiving these

drugs. During this same time frame, heartattack readmissions declined by 20%.

- In 2004, the HQC released a report showinthat 28% of Saskatchewan seniors living long-term care regularly received at least omedication with a high risk of adverse sideffects. We worked closely with eight nursihomes to see if drug treatment improved iwas managed by interdisciplinary teams tincluded a consultant pharmacist. Over thcourse of the project, two-thirds (491) of

residents had at least one drug review, anthose, an average of 2.5 drug-relatedproblems were identified for each residentForty-three per cent (339) of therecommendations were to stop one or moredrugs, 26% (206) to change dosage orinterval, and 14% (112) to start a drug. Thhealth professionals involved in the projecsaid they liked the team approach and wato see it continue.

The methods weve developed to measure qu

for some of our reports have influencedmeasurement beyond Saskatchewan. Forexample, our indicators on quality of asthmacare were published as a research article in Canadian Medical Association Journal, and shave been adopted by the Public Health Agenof Canada for their asthma surveillance systand by the Canadian Institute for HealthInformation as part of their primary care quaindicators set.

MEASURING AND REPORTING FOR LEARNING AND IMPROVEMENT


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In Fall 2008 we launched a new ongoingmeasurement and reporting program, QualityInsight, which includes a regular report on thestate of quality of health care in Saskatchewan.

This work is supported by a provincialcollaboration (the Quality Insight Working Group)that brings together representatives of allregional health authorities, the SaskatchewanCancer Agency, and the Ministry of Health. Thisgroup was recently asked by leaders involved inthe new Saskatchewan Surgical Initiative to leaddevelopment of evaluative measures for trackingits progress.

In 2004 HQC initiated the first province-widemeasurement of patients experience of hospitalcare in Saskatchewan. By continuing to lead andsupport the ongoing collection of this data, weare helping ensure decision makers andproviders have continuous intelligence on thevoice of their customer highlighting opportunitiesfor improvement. In just a few short years, wehave helped the province progress from havingno systematic collection of patient experience

feedback, to a point where 33 hospitals across

10 health regions receive feedback

information from the patient survey on a

monthly basis. We are currently working with ourregional health authority (RHA) colleagues tosurvey individuals about their experience inemergency departments, the results of which wewill report publicly in 2010. These patientsurveys also support Saskatchewan hospitals inmeeting Accreditation Canadas requirementsrelated to hospital quality. Our patientexperience survey was the first in the country

to be recognized by Accreditation Canada. Thisinformation is also starting to be used by RHAs

in their reporting dashboards, and there is brecognition that these indicators must align current and future strategic priorities. Healthregion staff have told us they appreciate our

efforts to help satisfy many quality improvemneeds through a single data collection proce

- A unit team from Royal University Hospitalused this survey information to improve thdischarge process, as part of an HQC-sponsored project focused on dischargeplanning. As a result of a series of smallchanges related to patient flow andcommunication, the percentage of patientrating the discharge process as very good excellent increased from a median value o

42.5% at baseline, to 80% by September2007.

Because of the expertise and reputation wevbuilt through these and other measurement areporting activities, HQC continues to be souout by several external agencies, including:

- National Accreditation Program AdvisoryCommittee, Accreditation Canada

- Health System Scorecard Indicator ExpertGroup, Ontario Ministry of Health and Long

Term Care

- Long-term Care Quality Measurement ExpePanel, Ontario Health Quality Council

- National Hospital Report - Clinical IndicatExpert Group, Canadian Institute for HealtInformation

- Continuing Care Reporting System ExpertAdvisory Group, Canadian Institute for HeaInformation


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- Steering Committee of National EmergencyDepartment Quality Indicators Project, CIHR-funded project based out of Institute forClinical Evaluative Sciences in Toronto

- Chronic Respiratory Disease SurveillanceMethodology Working Group, Public HealthAgency of Canada

- Advisory Committee for Report on ChronicDisease in Canada, Health Council of Canada

- Workshop on Public Reporting on Health CarePerformance, Canadian Health ServicesResearch Foundation.

In 2009 HQC was granted access to theCanadian Institute for Health Information (CePortal, which houses the most up-to-dateHospital Discharge Abstract data available.

is the first agency of its kind in Canada (i.e.,a Health Ministry or RHA) to be granted accethis CIHI tool.


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Until recently, only a handful of people inSaskatchewans health care system were aware ofquality improvement (QI). Today, thousands ofhealth professionals not only know what QI is but

are becoming increasingly proficient inimprovement methodology. By providing hundredsof health care providers and leaders with skills,knowledge, and inspiration for qualityimprovement, we are helping create anenvironment in which they can deliver the mostpatient-centred, effective, and accessible healthcare possible.

Over 200 health system leaders, representingmore than 20 organizations, are currently

participating in our leadership program calledQuality as a Business Strategy (QBS). It isdesigned to help leaders integrate managementfor quality into their organizations. Through theirparticipation in QBS, health organizations arelearning how to support front-line managers andteams working to integrate improvement scienceinto planning, testing, and implementingchanges to make care better and safer forpatients. This series of learning workshops is thefirst time the entire Saskatchewan health caresystem (including the ministry, health regions,

regulatory bodies, unions, educationalinstitutions and others) has come together totalk about what it truly means to work as asystem.

The number of Saskatchewan health systemworkers with quality improvement skills andknowledge continues to grow. Over 1,200providers have participated in various

workshops designed to build QI capability. Inturn, QI departments and leaders have

facilitated workshops in their health regions,supported by HQC training, learning materiaboth. Those who have taken HQCs advancedtraining are now teaching, consulting, and

mentoring others, thereby spreading theirlearning to hundreds of others in their homeorganizations.

In its early years, HQC provided short-termfunding to help health regions and theSaskatchewan Cancer Agency create newpositions that are responsible for leading quimprovement. RHA leaders have recognized tvalue this skill set brings to their organizatioand have continued to expand the number ofpositions dedicated to supporting QI initiativtheir organizations. We also established alearning community, called the QualityImprovement Network (QIN), to connect thesquality improvement leaders and supportlearning and spread of QI best practices

throughout the province. HQC continues tosupport QIN, which is now run collaborativelyits members from the RHAs, SaskatchewanCancer Agency, Ministry of Health, and HealtQuality Council, with the aim to share andleverage QI efforts across the province.

HQC has developed and supported close toquality improvement teams across the syst

and throughout the province. These QIinitiatives range from prototypes (single-siteinitiatives aimed at testing an idea forimprovement) to demonstration sites (tests owhether a successful improvement can berepeated elsewhere), and spread initiatives(attempts to spread a proven best practiceacross the system).

BUILDING CAPABILITY AND LEADERSHIP TO IMPROVE AND SUSTAIN QUALITY


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Over the past couple of years, we have exposedmore than 550 health professional students to

quality improvement curricula through lecturesin various health sciences programs at the

University of Saskatchewan, including Master ofPublic Health, Pharmacy, Master ofPhysiotherapy, Nutrition, and Medicine. This workwas recently recognized by the Academy forHealthcare Improvement, an international

organization of academics and researchersinvolved in quality improvement science, andbe made available on their website in 2010. have also engaged with more than 20 faculty

from the University of Saskatchewan (U of S)Saskatchewan Institute of Applied Science aTechnology (SIAST), to build capacity andcapability for integrating QI content into theihealth sciences curricula.


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We know from research and from success storieselsewhere that health systems which havetransformed themselves have purposefully engagedtheir clinicians. HQC has intentionally focused a

great deal of attention on supporting front-linehealth care professionals to be actively involved inmaking our system better and safer for patients:

In 2005 the HQC launched the Chronic DiseaseManagement (CDM) Collaborative, the largest QIinitiative ever undertaken in this province. Itinvolved more than 25% of family physicians,

hundreds of other health care providers in all

health regions, and approximately 18,000 people

living with diabetes and coronary artery disease

(CAD), and achieved some impressive results:

- The number of people living with diabetes inoptimal control of their condition rose from onein eight, to close to one in five.

- The percentage of people living with diabeteswho received a recommended screening testfor the prevention of kidney disease increasedfrom 48% to 84%.

- The percentage of people living with CAD whohad a healthy lipid ratio < 4.0 increased by23%.

We have heard, anecdotally, that physicians areincreasingly finding value in using flow sheets as adecision-support tool for managing chronic diseases.We will evaluate the first CDM Collaborative in 2010-11, to more fully quantify what improvements wereachieved and sustained.

Physician appetite for these types of learningopportunities continues to grow: 54 primary carepractices have registered for our recently launched

second CDM Collaborative, which will improve cafor people with depression and chronic obstructivpulmonary disease (COPD).

In 2008 HQC launched an improvement stratecalled Releasing Time to Care, which is

designed to help increase the amount of tim

nurses and other providers have for direct

patient care, by decreasing waste in process

Currently 14 units (involving over 1,000 nursesare implementing this program; the plan is to out Releasing Time to CareTM to all medical ansurgical units in the province by March 31, 20Early results look promising:

- The equivalent of 1 FTE position was releas

on the Medical Ward at Moose Jaw UnionHospital by improving shift handover procesNurses are now consistently going home ontime.

- An estimated 270 hours of nursing time wilfreed up by installing a door between the IV(intravenous) and medication rooms on thesurgical ward of Prince Alberts Victoria Hos

- A minimum of 1,900 km of walking will besaved in a year with the installation of a nedoor release on the admissions unit at

Saskatchewan Hospital (North Battleford). Ssay its the best thing thats ever happene

the ward. The change was made three daysafter staff made the request. Patients love i

- With the Creation of the Bone Cupboard oorthopedics unit at Regina General Hospitalhouse in one location all equipment andsupplies to set up traction, staff are saving average of 27.37 hours a year of travel timwithin the hospital. The savings in steps wout to approximately 42 km.

ENGAGING WITH PROVIDERS, PATIENTS, AND THE PUBLIC TO IMPROVE QUALIT


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With the aim of building and supportingphysician leadership in quality improvement,HQC has in partnership with the SaskatchewanMedical Association, College of Physicians and

Surgeons of Saskatchewan, and Ministry ofHealth sponsored over 40 physicians toparticipate in various QI learning opportunities.These experiences have very quickly led to asignificant increase in the involvement ofphysicians in quality improvement discussionsand initiatives (see attached Appendix for moreinformation). One example of the impact of thisinvestment is a story shared by Dr. Mark Wahba(emergency room physician in Saskatoon), who isnow enrolled in HQCs advanced QI capabilityprogram, Quality Improvement Consultant (QIC)School:

We did a PDSA cycle trying to improve how

quickly we saw CTAS (Canadian Triage and

Acuity Scale) 2 patients. A patient with a C

2 is the second highest rating. They are

experiencing chest pain, trauma, overdose,You can see that we hadn't been making m

progress. For over two years we averaged o

39% of patients being seen within the

appropriate time frame. After returning fro

the IHI Forum, I was eager to try something

new. I took on the Physician QI lead for

emergency and got connected with the righ

people. We worked out some plans. We tried

this new idea out and voila! We went to 48

our patients being seen within the appropr

time frame. It was a great team effort and

couldn't have been done without a new wa

thinking about an old problem. Although it

bit early to celebrate, I think we're moving

the right direction like never before.

Percentage of CTAS 2 Patients Seen within Target Timeframe

Current target


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These early efforts yielded broader collaboration,which in turn led to the creation of a multi-agency advisory committee (involving theSaskatchewan Medical Association, College of

Physicians and Surgeons of Saskatchewan,College of Medicine, and Health Quality Council)

called Champions for Quality Improvement, athe development of an online network to engand support physicians in the province. Thislevel of collaboration across agencies and fo

on developing physician leaders for qualityimprovement is unprecedented in Canada.


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HQCs CEO was invited to participate on thesteering committee of the Patient First Review.Our organizations considerable knowledge abouthigh performing health systems and methods for

effectively engaging health system stakeholderswere seen as helpful to the Commissioner, TonyDagnone, his consulting teams, and Ministry ofHealth senior leaders.

HQC is responsible for bringing some of the bestminds from around the world to Saskatchewan,

to help our system learn proven improvementmethodologies, system transformationtechniques, advanced measurement practices,and hear how other systems deal with issuessuch as transparency and accountability. HQChas played a key role in advancing thesediscussions. We have frequently heard fromsenior executives in the Ministry of Health thatthe shift in thinking thats taking place acrossSaskatchewans health system (i.e., more focuson quality and patient-centred care) has beensignificantly influenced by the dialogue andactivities initiated by HQC.

HQC has continued to advance the dialogue inthis province, and nationally, about the key role

of measuring and public reporting about healthsystem quality/performance in learning andimprovement. We reviewed the latest researchevidence on effective strategies and promisingpractices for public reporting as part of a projectcommissioned by the Canadian Health ServicesResearch Foundation (CHSRF) and Ontario HealthQuality Council. We produced a backgroundpaper that lists the principles that guide ouragency's reporting and an updated review of theliterature on this topic. We also hosted a one-dayconference on transparency in June 2008 that

attracted close to 200 health system leadersfrom Saskatchewan and across Canada.

In addition, HQC has been recognized natio

and internationally for its work related to thspread of quality improvement techniques,applications of best practices, use of advancmeasurement techniques, and development production of quality of care indicators. Thronumerous publications, ranging from peer-reviewed research reports to commissionedreviews and discussion documents, HQC hasmade its mark across Canada and the worldput Saskatchewan on the map as an innovain health care improvement.

As part of the first Chronic Disease ManagemCollaborative, HQC led the deployment of anelectronic patient registry and decision

support tool (called the Chronic Disease

Management Toolkit). We did so to helpphysicians and other members of the health team deliver evidence-based care, and with eye to facilitating physician uptake of anelectronic medical record. In September 2009the Ministry of Health made this tool broadlyavailable to all primary care physicians, and

committed to integrating this tool with electrmedical record (EMR) products soon to beimplemented in the province.

INFORMING POLICY


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WHERE TO FROM HERE?

In response to a formal request from HQC, theprovincial government announced in March 2008 it

was providing an additional $5 million (above ourannual core funding) for activities and initiativesaimed at redesigning and improving health care inSaskatchewan. We noted, in our submission togovernment, that system-wide transformation ofSaskatchewans health care system had not yettaken root, and suggested a small investment infocused quality improvement activities in a selectfew health regions (then subsequently spreadingthe improvements to all other regions) held thepotential to save or avoid $10-15 million in totalhealth spending, by preventing inappropriate and

unsafe care, increasing efficiency, and improvingaccess.

To date approximately $1 million of this fundinghas been invested, primarily in efforts to supporthealth care senior executives and governors in theirpursuit of high-quality health care (through theQuality as a Business Strategy initiative) and front-line workers (through Releasing Time to CareTM ). Itis still too early to determine how much moneythese and other HQC improvement programs havesaved. What is evident though is that HQCs

influence and programs have brought about afundamental change in thinking at all levels of thehealth system, away from a provider-centricphilosophy to one that is focused on the needs ofpatients.

There have already been some early and notablechanges in the behaviour of and degree ofcollaboration among health regions, the Ministry ofHealth, and provider groups. RHA board membersare now more regularly asking what does this

mean for Esther? Esther is the name of a fictielderly client created by one high-performinghealth system (Jnkping County Council, Swedto inspire and motivate its administrators,

governors, and providers to improve patient floand coordination of care. What were once rigidboundaries between health regions appear to bsoftening, with RHAs now voluntarily comingtogether to improve care. For example, regions southern Saskatchewan have pooled their efforand resources to improve transitions and patieflow; similarly, RHAs are engaging in a numberMinistry-initiated, system-oriented meetings onhealth system core purpose, strategic directionetc. The best example of this new system-orientpatient-centred focus is the commitment by allpartners to work together on the recentlyannounced Saskatchewan Surgical Initiative, wis intended to improve the entire patient experi including but not limited to reducing surgicawait times to three months within four years. Wthe precise complement of activities that will brequired to achieve this and other aims has yetbe established, what is clear is that this work wrequire significant resources (both financial anhuman). With nearly $4 million of the governme2008 funding for system transformation yet to

allocated; there are opportunities to invest somthis money to improve care for Saskatchewanresidents requiring surgery. HQC will continue tplay a key role in supporting this and otheremerging health system priorities.

At times, the pace of change seems glacial.Looking back over the past two years though, tshift in the tone and nature of conversations wthe health care system is remarkable. Thegroundwork critical to rapid, system-wide chanis forming: There is growing agreement among


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those working in the system and the public(expressed in the Patient First Review) that thesystem needs changing, and increasingcommitment both emotional and professional

to do the work necessary to overhaul the system.The surgical experience priority offers a focused,clearly defined starting point, with specific,measurable goals against which to track progress.It will serve as a solid foundation upon which tobase subsequent changes required (e.g., alignmentof funding with performance; enhancing team-based care; implementing a comprehensiveelectronic health record system, creating andsupporting environments that facilitate the uptakeof ideas, etc).

Transforming health care in Saskatchewan will notbe quick or easy. But it is very clear that it will nothappen under the status quo. These earlybehaviour changes and the influence HQC has hadin them represent the critical steps in movingtowards better health and better care for thepeople of Saskatchewan.

IN CLOSING

The complement of activities the HQC has engain since 2003 has meaningfully and significant

contributed to a growing understanding andexpectation across RHAs, health organizations,the Health Ministry that health care quality is tresponsibility of everyone not just the qualitdepartment. Trying to reduce to a single measthe extent to which a culture of quality, continuimprovement, and patient-centredness has sprthroughout Saskatchewans health care systemneither easy nor appropriate. Nor is itstraightforward to determine how much of thechange and improvement starting to take hold this province can be directly attributed to HQCs

efforts. That said, we have without question beekey contributor to the greater awareness of andfocus on quality now seen among people workinthe health system. We have encouraged andsupported a growing number of managers andproviders to appreciate the importance of qualitimprovement and be able to apply appropriateapproaches and strategies to make care better safer. There is a palpable shift in the culture,toward putting patients first, collaboration, andworking together to improve health care. This isperhaps the truest measure of HQCs impact in

Saskatchewan health care system.


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HIGHLIGHTS

Champions for Quality Improvement advisorycommittee was struck, and represents a unique

partnership between the College of Physicians andSurgeons of Saskatchewan, Saskatchewan MedicalAssociation, College of Medicine, Ministry of Health,the Senior Medical Officer community, and HQC,dedicated to developing and recommendingstrategies to promote physician engagement andleadership in quality.

Online Physician Engagement Network (oPEN) wasdeveloped to connect the physician communityaround health care improvement. Membership isexpanding through word of mouth or involvement in

sponsored events. There are now 54 registered userson the oPEN site and use of the site is gainingmomentum. Physician colleagues are beginning touse the site to share thoughts or lessons learnedfrom their respective sponsored events.The following outlines some changes in practiceand behaviour resulting from Saskatchewanphysicians attending a sponsored event:

One physician enrolled in HQCs QualityImprovement Consultant Program (Mark Wahba)

One physician enrolled in Lean Training (Green

Belt) (Mark OGrady)

Two physicians moved into formalizedleadership positions (Leane Bettin, Mark Wahba)

Three physicians became members ofquality/leadership focused committees (KishoreVisvanathan, Susan Shaw, Jeff Hunt)

One physician is now serving as Clinical Lead forOffice Redesign within CDMC II (KishoreVisvanathan)

Two physicians volunteered to work with HQCimprove their practices as part of an IHI Web Action Series on office redesign (Shabir Mia,Leane Bettin)

Two physicians reported their lessons learnedSMA Representative Assembly meeting and toSenior Leadership Team of Regina QuAppelleHealth Region (Phillip Fourie, Stewart McMilla

Nine physicians have participated in inaugurmeetings of the Surgical Experience GuidingCoalition (Karen Shaw, Susan Shaw, KishoreVisvanathan, Phillip Fourie, Rob Weiler, DavidLedding, Joseph Buwembo, Alain Lenferna, MOGrady)

Two physicians met with their regional ITdepartments to explore capabilities for qualitmeasurement (Guruswamy Sridhar, Phillip Fo

Five physicians are sitting on theirregional/organizational QBS teams (AlainLenferna, Karen Shaw, Kishore Visvanathan,Guruswamy Sridhar, David Ledding)

One physician initiated a personal blog focuson health care and environment and is currensetting up a patient-focused web page showwhether he is on time or running behind sche

(Jason Hosain) Five physicians are continuing to implement

Office Redesign Principles (Kishore VisvanathMark Brown, Mark OGrady, Jason Hosain,Guruswamy Sridhar)

Four physicians enrolled or re-enrolled for CD(John Rye, Stan Oleksinski, Melanie Press, JasHosain)

One physician secured funding to develop papathways for pregnant women (Tania Diener)

APPENDIX: IMPACT OF PHYSICIAN SPONSORSHIP 2008-09


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Health Quality CouncilAtrium Building, Innovation Place241 - 111 Research DriveSaskatoon, SK S7N 3R2www.hqc.sk.ca

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