Champlain Regional Orthopedic Program and

Transcription

Champlain Regional
Orthopedic Program and
Service Distribution Proposal
By: The Champlain Orthopedic Program Planning Initiative
June 2013
1
Table of Contents
Acknowledgements ......................................................................................................................................................3
Executive Summary .....................................................................................................................................................5
Introduction..................................................................................................................................................................9
Overview of the Champlain LHIN __________________________________________________ 10
Profile of Orthopedic Care in Champlain ____________________________________________ 11
The Platform for Change _________________________________________________________ 17
Evidence in Support of a Regional Approach ........................................................................................................18
Integration Literature ____________________________________________________________ 18
Principles Of Successful Integrated Health Systems ____________________________________ 20
Overview of Existing Regional Program Models ______________________________________ 22
Service Delivery Model Literature__________________________________________________ 22
Communities of Practice Literature _________________________________________________ 23
Regional Orthopedic Program Planning Process .................................................................................……….25
History and Planning Goals _______________________________________________________ 25
Guiding Principles for Program Development _________________________________________ 26
Champlain Regional Orthopedic Program Model ..................................................................................................28
Primary Goal __________________________________________________________________ 28
Objectives and Opportunities ______________________________________________________ 29
Conceptual Framework __________________________________________________________ 30
Key Program Elements __________________________________________________________ 31
Clinical Elements of the Regional Orthopedic Program _________________________________ 34
Champlain Regional Orthopedic Service Delivery Model .....................................................................................35
Conceptual Service Delivery/Distribution model ______________________________________ 38
Considerations for Sustainability ___________________________________________________ 40
Stakeholder and Community Engagement ..............................................................................................................40
Summary and Conclusions .......................................................................................................................................41
Program Recommendations ......................................................................................................................................42
Program Implementation Workplan .......................................................................................................................46
Program Budget Year One .......................................................................................................................................51
References ...................................................................................................................................................................52
2
Appendices
Appendix A: Procedure for Acute Orthopedic Injuries Referred to CritiCall for Champlain LHIN Nov 15 2011
Appendix B: Algorithm for Acute Ortho Referrals through CritiCall in LHIN 11 – Nov 15 2011
Appendix C: Quality Based Procedures 2013-14 and 2014-15 (as of June 18 2012)
Appendix D: Summary of Integration Structures (from Literature Scan)
Appendix E: Review of Existing Regional Programs
Appendix F: Service Delivery Model Review Eastern Counties (Deloitte, Nov 2009)
Appendix G: Project Charter: Champlain Orthopedic Program Planning Initiative
Appendix H: Champlain Orthopedic Program Planning Initiative – Distribution Working Group: Planning
Considerations
Appendix I: Regional Orthopedic Program & Distribution Model: Stakeholder Communication and Consultation
Plan
Appendix J: Roles/Responsibilities Champlain LHIN Orthopedic Surgeons
3
Acknowledgements
Thank you to the members of the Champlain LHIN Orthopedic Program Planning Initiative for
their invaluable participation in the development of the proposal:
Heather Arthur
Cornwall Community Hospital
Chief Clinical Officer
Holly Burns
Champlain LHIN
Project Manager - COPPI
Dr. P. Chang
Orthopedic Surgeon
Dr. Geoffrey Dervin
The Ottawa Hospital
Chief, Orthopedic Surgery
Nancy Desrosiers
Hawkesbury General Hospital
RN, Director of Perioperative Services
Paula Doering
The Ottawa Hospital
Senior Vice-President, Clinical Programs
Dr. Andrew Falconer*
Queensway Carleton Hospital
Chief of Staff
Dr. Philippe FleuriauChateau
Hôpital Montfort
Orthopedic Surgeon
Colin Goodfellow
Kemptville District Hospital
CEO
Marielle Heuvelmans
Hawkesbury General Hospital
VP Patient Care Services
Sari Kline
Champlain LHIN
Lead, Emergency Departments & Wait Times
Dr Jean-Pierre Laflèche
Hôpital Montfort
Orthopedic Department Chief
Pierre Noel*
Pembroke Regional Hospital
CEO
Lucille Perreault
Hôpital Montfort
VP Clinical Services
Kim Peterson
Community Care Access Centre
Vice-President Client Services
Dr. Raj Prihar
Medical Director of Peri-Operative Services
Dr. Jim Randall
Orthopedic Surgeon
Dr. Chris Raynor
Orthopedic Surgeon
Brian Schnarch
Champlain LHIN
Senior Epidemiologist
Maureen Sly-Havey
Reg. Hip & Knee Rplcmnt Prog
Project Manager
Toni Surko
Carleton Place & District Hospital
CEO
Maureen Taylor-Greenly
VP Patient Care and Chief Nursing Officer
Catherine Van Vliet
Kemptville District Hospital
Director, Pt Services & Integration
Claudine Wathier-Doucet
Criticall
Client Relations Manager
Helen Zipes
The Ottawa Hospital
Clin Dir, Rehab Ctr & TOH Academic FHT
*Co-Chairs
4
Executive Summary
The health care system in Ontario is facing major challenges that are impacting the system’s
ability to provide the level of service residents expect and deserve. Orthopedic care is a high
volume, high cost service that crosses multiple sectors – thereby providing significant
opportunities for system improvement. In the Champlain LHIN:
•
•
•
•
•
•
17,000 surgical procedures are completed annually
Orthopaedic surgery hospitalizations utilize 7.9% of acute care beds and 8.2% of ALC days
Orthopedic patients represent 40.5% of all inpatient rehabilitation patients and 29.4% of
inpatient rehabilitation bed days
There are 42,500 hospital outpatient rehabilitation visits annually for hip and knee
replacement patients. Orthopedic patients represent over 90% of all hospital outpatient
rehab.
39,207 emergency visits in 2011/12 were related to musculoskeletal disorders, representing
7% of all emergency visits.
Musculoskeletal related hospital costs in Champlain in 2009-10 were estimated at $96.5
million.
The Champlain Local Health Integration Network (LHIN) recognizes that the development of a
regional approach to service delivery can make a significant contribution to addressing these
challenges and as such, has embarked on a regional planning exercise for the coordination and
integration of orthopaedic service delivery.
What are the Issues?
The evidence to support the evolution of orthopedic care in the Champlain LHIN from a
complex voluntary network of organizations and institutions to a formalized collaborative
program focusing equally on quality, accessibility and efficiency is strong.
Over the past five years, significant work has taken place to improve, streamline and coordinate
orthopedic services in the Champlain LHIN, primarily focused on total joint replacements. It is
time now to consolidate and build upon those gains. The volume and complexity of orthopedic
care, recent changes to funding, provincial priorities, performance variation and the projected
growth in demand all point to the need for more collaborative, better organized and more
accessible orthopaedic care to address these demands.
REASONS AND RATIONALE FOR A REGIONAL ORTHOPEDIC PROGRAM
Reasons
1. To improve access to
service
Rationale
•
•
•
Wait Times in Champlain LHIN exceed targets
Some patients wait longer than others; access is not equal
Travel time especially for emergency care is long for some patients
5
•
2. To optimize distribution •
of Resources
•
•
3. To improve Quality and •
Safety
•
4. To enhance efficiency
•
and sustainability
•
•
•
5. To enhance integration •
across the continuum of
•
care
•
Expected 22% in demand for ortho procedures over next 10 yrs
Surgeons are available; Operating rooms are available
Surgery cancellations due to bed availability/ALC
Patients want care “close to home”
Regional variations in quality & safety indicators not routinely
monitored; emphasis has been on efficiency & access
Best practices may not be implemented consistently
Costs for equivalent treatment vary between sites
Some patients may not be in optimal site eg. pre & post visits
TOH seeking to decant a portion of primary & secondary services
Need to make best use of available “shrinking” funding
Telemedicine under-utilized
Rehabilitation not standardized/integrated to patient need
Coordination of patient’s care throughout system disjointed
What is the Approach?
The proposed regional orthopaedic program is a formal network of providers led by a
coordinating body with the primary goal of improving the health of the orthopedic patient
population in the Champlain LHIN by delivering high quality, accessible, financially sustainable
care.
The building blocks to achieve the goal are integration and an organized delivery system. The
three core functions of the regional program will be: planning, service delivery and performance
management.
PRIMARY GOAL OF THE REGIONAL ORTHOPEDIC PROGRAM
Core
Functions:
To improve the hea lth of the orthopedic pa tient popula tion in
the Cha mpla in LHIN by delivering high qua lity, a ccessible,
fina ncia lly sustaina ble ca re a nd service in a n integrated a nd
orga nized ma nner .
Planning
Serv ice
Deliv ery
Perf ormance
Management
Integration
(def n)
“Serv ices, prov iders, and
organizations f rom across the
continuum working together
so that serv ices are
complementary, coordinated,
in a seamless unif ied sy stem,
with continuity f or the client”
(Accreditation Canada, 2006).
Organized Delivery System
(def n)
“A network of organizations that
prov ides or arranges to prov ide
a
coordinated
continuum
of
serv ices to a def ined population
and is willing to be held clinically
and f iscally accountable f or the
outcomes and health status of
the population serv ed”
(Shortell, 1996)
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Regional Orthopedic Program Structures
1. Leadership Structure – to provide oversight, direction and coordination, to monitor &
manage issues of accountability and sustainability of the new program; and to conduct
strategic planning and engagement activities.
2. Service Distribution Plan – to advise on methods to coordinate access and service
delivery throughout the region.
3. Community of Practice Framework – to engage and integrate interprofessional clinicians,
create a clinical advisory body, and to provide a forum for quality improvement,
innovation & standardization of best practice.
What are the Recommendations?
The plan described in this proposal is framed around the following “foundational”
recommendations:
•
The establishment of a Regional Orthopedic Program in the Champlain LHIN to support
the organization, integration and co-ordination of orthopedic care.
•
The establishment of formalized partnership agreements between participating
organizations to support the objectives, structures and authority of the program.
•
The establishment of an oversight/leadership structure.
•
Formalization of an agreement between the Regional Orthopedic Program and the LHIN
which defines authority of the Regional Program, reporting structure, decision making
limitations, deliverables and the responsibility of the program in advising the LHIN on
distribution of orthopedic quality based funding.
•
Adoption of the proposed service delivery model. The immediate priorities include:
providing support to Cornwall Community Hospital to ensure that the orthopedic
program is viable, sustainable and able to meet performance targets; program planning to
develop a full service orthopedic program at Pembroke Regional Hospital (excludes
tertiary, spinal, and other specialized services); developing the shared resource model
which allows smaller centres to provide focused orthopaedic services provided by
surgeons from Champlain full service hospitals.
•
Adoption and establishment of a Communities of Practice Framework for orthopedic care
in the Champlain LHIN.
Additional priority recommendations to support these foundational requirements are included in
the proposal.
7
What Needs to be Done?
Over the next 12 months, the following steps need to be addressed in order to initiate a
successful regional orthopedic program.
•
Secure approval/endorsement from the Champlain LHIN and Health Service Providers
•
Secure program funding
•
Create a transitional team to manage the transition from the current state to the proposed
Regional Program
•
Establish a Steering Body for the Regional Program including recruitment of the Program
Coordinator, Administrative Support and Lead Physician
•
Initiate a Community of Practice Framework including Membership, Terms of Reference,
objectives, appointment of facilitators
•
Identify high priority actions for the Regional Program and begin implementation
•
Initiate steps to implement the proposed Distribution/Service Delivery Model including a
financial analysis of the impact of redistribution on the organizations currently providing
orthopaedic services.
What Will Change?
Orthopedic care is a service that plays a significant role in healthcare in the Champlain LHIN.
As the population grows and as complexity in healthcare evolves and specializes, it is apparent
that there is a need for coordination and integration of orthopedic services.
The benefits of a regional approach to service delivery include equal, quicker and “closer to
home” access, enhanced coordination of care, seamless transition for individuals between service
providers and sectors, the forum to focus on region-wide standards for quality and safety, and the
opportunity to create a financially viable and sustainable orthopedic service.
The goal, broadly stated, is “the right care, at the right time, in the right place”. A regional
approach to orthopedic care can satisfy this goal. As with other regional programming
initiatives, there are both challenges and opportunities to be managed, however the benefits for
the patient and community must be the foundation for the directions taken and the decisions
made.
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Introduction
The health care system in Ontario is experiencing major challenges that are having a negative impact
on the system’s ability to provide the level of service residents expect and deserve. System
integration changes are being implemented to address emergency room overcrowding, inappropriate
utilization of acute care beds, and the looming shift in aging demographics.
The Champlain LHIN recognizes that the development of a regional approach to service delivery can
make a significant contribution to addressing these challenges and as such, has focused on sectors of
the system that have the potential to make the biggest impact. Orthopedic care is a high volume,
high cost service that crosses multiple sectors - thereby providing significant opportunities for system
improvement.
There is strong evidence to support the evolution of orthopedic care in the Champlain LHIN from a
complex voluntary network of organizations and institutions to a formalized collaborative program
focusing equally on quality, accessibility and efficiency of clinical care.
Over the past five years, significant effort has taken place to improve, streamline and coordinate
orthopedic services in the Champlain LHIN, primarily focused on hip and knee joint replacements. It
is time now to consolidate and build upon those gains. The growing volume and complexity of
orthopedic care, recent changes to funding, provincial priorities, performance variation and the aging
population all point to the need for strong integration and coordination.
The benefits of a regional approach to service delivery include enhanced coordination of care,
seamless transition for individuals between services, equal and improved access to service including
“care closer to home”, and the opportunity to create a financially viable and sustainable orthopedic
service.
This proposal has been sponsored and led by a network of orthopedic care stakeholders in the
Champlain LHIN. The proposal provides the following:
•
An Overview of the Champlain LHIN
•
Profile of orthopedic care in Champlain
•
The platform for change
•
A summary of relevant literature
•
An overview of the planning process
•
A proposed regional orthopedic program model
•
A proposed service delivery model
•
Recommendations for Implementation
•
A proposed budget.
9
Overview of the Champlain LHIN
Champlain is Ontario’s easternmost LHIN. It shares a 465 km long border with Québec and, at
18,000 km2, covers an area three times the size of Prince Edward Island. There are six subregional planning areas: Renfrew County, Ottawa (West, Centre, and East), North Lanark/North
Grenville and Eastern Counties. The 2011 Champlain population numbered 1.2 million in 2011.
Two-thirds live within a 30 minute drive of the centre of Ottawa with one in five in rural areas
and one in six in large towns and small cities.
Figure 1: Map of Champlain, showing large towns and planning areas
In 2011-12, the Champlain LHIN allocated $2.45 billion to 158 health service providers
(agencies) to manage 240 programs, with accountability attached to each. As shown in Table 1,
over 70 % of the LHIN’s allocation is spent by the hospital sector.
Table 1: Champlain LHIN Funding Programs and Funding Allocation by Sector
($Millions, 2011-12)
Programs Sector
20 Hospitals
63 Long Term Care Homes
1 Community Care Access Centre (many service
locations)
36 Community Mental Health
11 Community Health Centres (plus satellites)
83 Community Support Services*
26 Addictions and Problem Gambling Agencies
240
Allocation ($M)
$1,749,070
$318,676
$195,660
% of total
71.4%
13.0%
8.0%
$64,557
$52,831
$48,554
$20,908
$2,450,256
2.6%
2.2%
2.0%
0.9%
100%
Note: There are 158 distinct agencies. Many receive funding for more than one type of program and some agencies
have multiple sites.
*Including acquired brain injury programs and assisted living services in supportive housing programs.
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The regional orthopedic program and recommendations outlined in this document are aligned
with the Champlain LHIN’s Integrated Health Services Plan, 2013-16 (IHSP) 1. The IHSPs
vision, mission and strategies and several of its key result areas underpin this proposal.
Vision: “healthy people and healthy communities supported by a quality, accessible health
system”.
Mission: “building a coordinated, integrated and accountable health system for people where
and when they need it”.
Strategies:
• Build a strong foundation of integrated primary, home and community care
• Improve coordination and transitions of care
• Increase coordination and integration of services among hospitals (organizing regional
programs is specifically identified as an action)
Key Result Areas
1. More people are involved in planning their health services
2. More people receive quality, evidence based care
3. More people with mental health conditions and addictions have access to services
4. More seniors are cared for in their communities
5. More people with complex health conditions are able to manage their conditions
6. More people at end of life, families and caregivers receive palliative care supports in their
setting of choice
The proposed orthopedic program is most closely aligned with key result area #2 and to a lesser
extent with #4 and #5.
Profile of Orthopedic Care in Champlain
Orthopedic care is a major component of healthcare services provided in the Champlain LHIN.
There are approximately 17,000 orthopedic surgeries performed annually. Almost half (49.8%)
require an inpatient stay. Taken together, orthopedic surgery hospitalizations utilize 7.9% of the
region’s acute care beds (based on total length of stay), and 8.2% of the alternative level of care
days. Major orthopedic surgery in Champlain is concentrated at the Queensway-Carleton
Hospital, The Ottawa Hospital, l’hôpital Montfort and to a lesser extent CHEO (for the pediatric
population), the Cornwall Community Hospital and the Kemptville District Hospital.
1
Champlain LHIN IHSP 2013-2016
11
Table 2: Orthopedic Procedures Completed by Site 2 and Surgery Type (Champlain
Hospitals, 2009-10, inpatient and day surgery combined)
Grouper
TOH TOH
TOH
KDH CP ARH PRH AGH RVH HGH WD Total
QCH General Civic Mont
CCH CHEO
DMH
MH
fort River
side
Knee, Rplc
669
703 171 453
- 124
*
- 2,120
HipRplc
562
667 196 222
- 105
*
- 1,752
Foot
331
136 191 187 355 104
82 24
5
2
6
6
2
- 1,431
Excprt knee
1,174
238
29 118 178 199
35
18 244 114
1
0
0
0
0
Shoulder
230
206 178 153 170 108
19
1 54 11
1
- 1,131
Ankle Surgery
253
221 161 163
61
65
61
1
3
3
3
1
- 1 997
Repair Knee
984
66
1
31 153 130 208
0 268 127
0
0
0
0
Knee - Other
693
88
77 104 112
90
72
63 30 45
2
8
2
0
ACL Repair
80
16
70 140 250
13
32 38
- 639
Fix femur
503
100
138 110
85
47
23
Hipfract. & other
64
191
47
47
10
16
19
1
- 395
pin Fus/ScolRpr
- 272
6
45
- 323
Fix tib & fib
50
66
93
25
1
8
18
- 1 262
Spine Surgery
- 231
15
- 246
Fix radius &
53
36
47
65
7
16
15
- 239
ulna
Rpr Spin Vert
6 201
9
4
2
- 222
Fix humerus
12
19
26
20
2
64
- 143
Remove devtib
15
10
24
15
24
5
12
5
- 110
fib
Fix elbow
80
14
21
20
7
3
15
Fix clavicle
74
17
12
18
14
1
8
4
Excisinterv disc
71
59
7
5
Amput. femur
45
2
40
2
1
Red. rad, ulna
26
4
2
3
1
7
7
1
1
Other (659
344
606 749 233 224 140
497
7 10 33 46 64 17 17 9 2,997
codes)
Total
3190
3165 3160 2273 1553 1103
996 617 306 95 75 64 27 21 11 16657
*KDH began performing total knee and hip replacements in 2011 and 2012
Rehabilitation is typically required after major orthopedic surgery as well as for many minor
procedures and non-surgical cases. In 2011-12 in Champlain, there were 1,461 orthopedic
inpatients in designated rehabilitation beds for 6,186 days (equivalent to 71 beds at 90%
occupancy) as shown in table 3. Orthopedic patients made up 40.5% of all inpatient rehab
patients and 29.4% of all bed days.
2
Excluded due to no (or very low) volume: Glengarry Memorial Hospital, St. Francis Memorial Hospital and Deep River District Hospital.
Abbreviations- QCH: Queensway-Carleton Hospital, TOH: The Ottawa Hospital, General, CCH: Cornwall Community Hospital, CHEO:
Children’s Hospital of Eastern Ontario, KDH: Kemptville District Hospital, CDDMH: Carleton Place and District Memorial Hospital, HGH:
Hawkesbury General Hospital, ARH: Arnprior Regional Health, WDMH: Winchester District Memorial Hospital, PHR: Pembroke Regional
Hospital, AGH: Almonte General Hospital, RVH: Renfrew Victoria Hospital. Procedure groupings based on grouper specially developed for the
LHIN by PRH Decision Support based on CACS and CCI codes (NACRS) and CMG and CCI codes (DAD).
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Table 3: Inpatient Rehabilitation Episodes and Equivalent Beds by Site and Patient Group
(Champlain Hospitals, 2011-12)
IP rehab episodes
(equiv beds*)
Knee replacement
TOH
General
238 (6.8)
QCH
Hip replacement
Other orthopedics
Hip fracture
23 (0.9)
Mont
fort
78 (2.5)
Bruy
ère
4 (0.4)
Pem
Corn
TOH
broke
wall
Rehab
37 (1.5) 10 (0.5) 8 (0.5)
Total
398 (13.1)
162 (5.4)
38 (1.4)
45 (1.9)
8 (0.6)
35 (2.0) 8 (0.5) 4 (0.2)
300 (12.0)
107 (4.0)
70 (3.8)
47 (1.9)
61 (6.5)
49 (2.7) 25 (1.3) 12 (1.2)
371 (21.4)
76 (2.6)
116 (6.7)
51 (2.1)
93 (9.3)
30 (2.2) 23 (1.0) 3 (0.3)
392 (24.2)
Total orthopedics 583 (18.8) 247 (12.8) 221 (8.3) 166 (16.8) 151 (8.4) 66 (3.3) 27 (2.2) 1,461 (70.7)
Although many patients receive hospital outpatient and community-based rehabilitation, the data
is not collected and compiled in a standardized fashion. From a recent focused survey, it is
known that there were 3,373 hips and knee replacement outpatient rehabilitation patients seen at
15 sites across Champlain in 2011-2012. There were also 872 clients who received rehabilitation
through the Community Care Access Centre. Total joint replacement clients are estimated to
represent approximately 50% of the total outpatient orthopedic rehabilitation caseload. An
estimate for private physiotherapy clinics is not available although a very rough estimate based
on reports from hospital outpatient departments would suggest that fewer than 5% of total hip
and knee patients access private physiotherapy to meet their rehabilitation needs.
In addition to surgery and rehabilitation patients, musculoskeletal disorders accounted for 39,207
emergency visits and 1,314 non-surgical acute care hospital admissions in 2011-12. Presenting
problems range from sprains, fractures, dislocations, tendon/ligament injuries, and back/pelvis
injuries to chronic pain. The prevalence of these injuries supports partnerships between
orthopaedic care providers and other sectors. The development of a “Falls Prevention Program”
for the elderly is an excellent example of this type of collaborative effort.
In the primary care setting, musculoskeletal disorders (MSD) are also widespread. More than one
in five Ontario residents (22.7%) made at least one ambulatory care physician visit for an MSDrelated condition in 2006-07. Those visits made up, in turn, more than one quarter (27.3%) of all
ambulatory care physician visits during the period. Injuries, arthritis and related conditions,
synovitis and various bone and spine conditions were the most commonly reported problems. 3
MSD-related hospital costs in Champlain in 2009-10 were estimated at $96.5 million ($62.5 M
acute care, $10.0 M day surgery, $5.5 M emergency department, $18.5 M inpatient
rehabilitation). The estimate includes medical and surgical patients but excludes complex
continuing care hospitals, long term care homes, physician fees (for consultations and
interventions), outpatient and community-based rehabilitation, diagnostic imaging, prescription
3
MacKay, C., Canizares, M., Davis, A. M. and Badley, E. M. (2010). Healthcare utilization for musculoskeletal
disorders. Arthritis Care Res, 62: 161–169. doi: 10.1002/acr.20064
13
drugs, as well as various out-of-pocket costs such as privately engaged residential and home
support services.
Orthopedic care spans the age spectrum; however, those 60-years and older are
disproportionately represented. They account, for example, for 60% of the inpatient surgical
patients and 73% of the related bed days but only 20% of the population in Champlain. Falls
among seniors (65+) result in 5.1% of all admissions for seniors and 1.7% of admissions for all
age groups combined. Based on demographic trends, it is estimated that there will be a 22%
increase in orthopedic surgical needs over the next 10 years.
While elective orthopedic procedures, primarily total hip and knee joint replacements, have been
the focus of attention for the Ministry of Health and Long Term Care and the LHINs for a
number of years, hip and knee replacements account for only 23% of all orthopedic procedures
performed (see Figure 2).
Figure 2: Orthopedic Procedures by Type
(Champlain Hospitals, 2009-10, inpatient & day surgery combined)
In addition, wait time data (see figure 3) shows that there are many other elective procedures
which require attention. Wait times for forefoot surgical interventions, for instance, significantly
exceed hip and knee replacement wait times and the number of patients waiting for shoulder
procedures is close to the number awaiting hip replacement.
14
Figure 3: Elective Orthopedic Surgery 90th Percentile Wait Times (from decision-to-treat to
surgery, procedures with 30+ Cases, Champlain Sites between Jan 1 & June30/12)
15
The impact of emergency orthopedic (trauma) care in the Champlain LHIN is significant. There
is approximately 1 emergency orthopedic surgery case for every 3 elective procedures. Emergent
cases represent a challenge and burden, particularly for orthopedic healthcare providers in
Ottawa and Cornwall. Four Champlain hospitals (TOH, QCH, Montfort and CCH) provide the
majority of adult emergency orthopedic care while CHEO handles most pediatric emergencies.
Orthopedic Service Delivery and Distribution
Full service (elective and emergency) adult orthopedic care is provided in four Champlain LHIN
hospitals:
•
•
•
•
The Ottawa Hospital (Civic Site, General Site, Riverside Site)
Montfort Hospital
Pediatric orthopedic care is provided by the Children’s Hospital of Eastern Ontario (CHEO). In
addition, referrals from outlying hospitals are accepted at CHEO for follow-up orthopedic care
after emergent care (casting, for instance) is initiated. Complex adult orthopedic trauma care,
and all back, neck and spinal orthopedic interventions are centralized at TOH.
Minor orthopedic interventions and care are provided at a number of the smaller community
and/or rural hospitals. These services typically evolved in one of two ways:
1) In relation to the specific interest/expertise of a community’s orthopedic surgeon(s), or
2) When a number of smaller community hospitals recognized a need for components of
orthopedic care and recruited interested surgeons from outside their community.
For instance, Carleton Place, Arnprior, and Winchester hospitals provide minor day surgical
procedures performed by surgeons from one of the full-service hospitals. A number of
Champlain hospitals (e.g. Pembroke Regional Hospital) provide consultation/assessment by
orthopedic surgeons affiliated with a full-service hospital, while others (e.g. Deep River) provide
outpatient physiotherapy services for patients who return home after having their procedures
performed in a larger, urban hospital.
A partnership between a full service hospital (The Ottawa Hospital) and a small community
hospital (Kemptville District Hospital) provides low risk patients requiring total hip and knee
replacements the opportunity to have their surgery in Kemptville. Surgeons travel from Ottawa
to Kemptville. The arrangement was initiated as a strategy to improve access. The service is
limited to a select patient population.
A Centralized intake and assessment clinic model for total knee and hip replacements is in
place in the Champlain LHIN. Compliance is monitored at the local level and targets for
performance have been set. Satellite total joint assessment is in place between the Queensway
16
Carleton Hospital and the Pembroke Regional Hospital whereby an assessor travels to Pembroke
to provide assessment “closer to home”. For this rural population, the prehabilitation component
of care is provided by the Pembroke Regional Hospital, patients travel to Ottawa for surgery and
then receive their rehabilitation (whether inpatient or outpatient) in Pembroke.
The development of a Falls Prevention Program which is in progress steered by the Champlain
LHIN adds a prevention component to orthopaedic and geriatric care.
Emergency orthopedic care in Champlain has been organized for a number of years and is
facilitated by CritiCall, a roster system and 24-hour emergency referral service for physicians
across Ontario. Emergent/urgent cases are directed to accepting hospitals, based on a defined
rotation. This system speeds access to urgent care for patients by averting the need to contact
multiple hospitals and negotiate the patient transfer. In 2011-12, 801 orthopedic cases were
referred for consultation. Of these, 608 were transferred to a receiving orthopedic hospital. 4
This rotation for the distribution of trauma cases in the Champlain LHIN was collaboratively
negotiated by orthopedic surgeons providing emergency care and hospital administrators (see
Appendix A and B for Criticall Orthopedic Referral Procedure and Algorithm). This model has
served as an example for other LHINs across the province, and typically functions very well,
with some issues arising when hospitals are over capacity.
The Platform for Change
From a national and provincial perspective, orthopedic care has been in the spotlight for a
number of years, particularly focused on the need to improve wait times for hip and knee
replacements. There are a number of reasons why orthopedic care has been targeted for
healthcare reform and change:
•
The discrete and boundaried nature of orthopedics makes it a prime candidate for
standardization of best practices. The majority of orthopedic procedures/interventions have a
distinct beginning and end, with a continuum of care that is generally predictable. 5
•
Orthopedics volume is high and expensive, which makes it a target for attention. As noted
earlier, Champlain hospital costs related to orthopedics exceed $96 million. The direct acute
care hospital costs for primary joint replacements alone are around $21 million.
•
Clinical, financial and utilization data is available for orthopedics, allowing Ontario’s new
funding model (Health-Based Accounting Model, including Quality Based Procedures) to be
applied relatively easily. “Quality Based Procedures (QBPs) are clusters of patients with
clinically related diagnoses or treatments that have been identified by an evidence-based
framework as providing opportunity for process improvement, clinical re-design, improved
4
CritiCall Ontario, 2012
5
McEachern, 1996
17
patient outcomes, enhanced patient experience and potential cost savings (expected because
of the 40th percentile funding methodology)”. 6 For a full description of HBAM and QBP
Funding Changes, please click on the following link:
http://www.ohima.ca/eventdocs/Presentation%20to%20OHIMA%20Michael%20October%2
04%202012%20vMGS%20FINAL.pdf.
In 2012-13, the first four QBPs were introduced: primary hip replacement, primary knee
replacement, cataract surgery and chronic kidney disease (including dialysis). Providers will
be reimbursed on a per case basis. (See Appendix C for a draft summary of Year 2 and 3
Quality Based Procedures).
•
Integration is a primary focus of the Ministry of Health and Long-Term Care, and of each
LHIN. Orthopedics in the Champlain LHIN is amenable to integration, coordination and
organization.
•
Variation in performance exists – between the Champlain LHIN and other LHINs and
among providers of orthopedic care within the Champlain LHIN.7 For instance, between
LHINs, only the Northeast LHIN 90th percentile wait times exceed those in the Champlain
LHIN and within the Champlain LHIN itself, referrals via central intake vary significantly
between surgeons practicing in different hospitals.
Evidence in Support of a Regional Approach
Integration Literature
A review of the literature confirms that for decades Canadian policymakers have been
considering integration as a means of controlling escalating healthcare costs and improving
access and effectiveness 8. The majority of available literature is focused on integration rather
than regional program development specifically and, as such, tends to be conceptual rather than
operational. In general, health system integration is described along a continuum from informal
to formal, defined by the intensity of the governance between the providers. Whatever the
integration structure, it is understood that “the primary purpose of integrated care should be to
improve the quality of patient care and patient experience and increase the cost-effectiveness of
care.” 9
The importance of integration processes are emphasized in the literature. Multiple levels of
integration processes are recommended – from macro or system level (e.g. funding levels) to
micro or clinical level (e.g. standardized protocols).
6
Stewart, 2012
7
Orthopedic Scorecard, 2011/12; Ontario Hip and Knee Replacement Report 2010/11
8
9
Change Foundation, 2009; Leatt,1996; Leatt 2000; Marriot & Mable 2002
Curry, 2010, p3
18
Relationship building, collaborative planning and decision making are additional integration
processes that enable success. “Integration requires an interactive, interdependent relationship to
be formed among the various integrated entities. Simply aggregating a system’s operating units
into a common reporting structure will not create a seamless, well-coordinated healthcare
system.” 10
There is no evidence to support that one type of integrated healthcare model is dominant or has a
more successful outcome, perhaps because there are so many contextual factors that affect the
delivery of healthcare services. 11 These factors include diversity of populations, geographical
issues, competition, provider resistance and funding mechanisms. As a result, “it is likely that
healthcare is too complex for a one-size-fits-all solution.” 12
Further, there is little evidence to support formal organizational integration as necessary when
integrating care. Provided that formal agreements are in place, virtual integration through
integrated provider networks can be as effective. Policy makers are encouraged to focus on
clinical and service integration using multiple strategies and levels of integration to achieve best
outcomes. In fact, “what matters most - is clinical and service-level integration that focuses on
how care can be better provided around the needs of individuals especially where this care is
being given by a number of different professionals and organizations.” 13
10
11
Shortell, 2000
Armitage, 2009: Curry, 2010; Dash, 2009; Goodwin, 2011; Shotell, 2000; Suter, 2007
12
Armitage, 2009, p7
Goodwin, 2011, p3
13
19
Principles of Successful Integrated Health Systems
While there is no dominant integration model or strategy identified in the literature, there are a
number of principles which appear consistently, and are associated with successful integration in
healthcare. 14 These are:
1) Comprehensive Services across the Continuum of Care: All core services along the
continuum of health for the population served must be planned, provided, and co-ordinated.
2) Patient Focus: The patient is at the centre of operations, not the providers. Needs
assessments must drive planning, information management and improved patient satisfaction
and outcomes.
3) Geographic Coverage and Rostering: The system takes responsibility for an identified
population in a geographic area.
4) Standardized Care Delivery through Inter-professional Teams: Shared protocols, such as
best practice guidelines and clinical care pathways, are essential to standardized care.
Inter-professional teams collaborate to ensure care is effective and efficient. Interprofessional decision-making, education, and communication are all necessary elements of
collaborative, integrated care.
5) Performance Management: Performance monitoring systems, including indicators to
measure outcomes at different levels, are characteristic of successful integration. Measuring
care and process outcomes and using the data for service improvement are integral. Targets
and rewards provide incentives.
6) Information Systems: Systems to track utilization and outcomes are necessary. Data
management across systems is critical to integration. Similarly, electronic health records
ensure that providers have and share clinical information, avoiding duplication or negative
impacts on patients. Information systems must also enable system-wide registration,
scheduling and tracking of clinical-care activities. Decision support (data analysis) is
critical to planning and performance management at the provider, organization and
jurisdiction levels.
7) Organizational Culture and Leadership: Implementation and operation of an integrated
health system requires leadership with vision and organizational culture(s) that are
congruent with the vision. Clashing cultures is one of the reasons cited for failed integration
efforts. It can arise from competition conflict or professional differences. An acute-care
mindset is often a cultural barrier.
8) Physician Integration: Physicians must play a key leadership role in the design,
implementation and operation of an integrated health system. Their participation cannot be
underestimated. Linkage between administrators and physicians is essential to successful
integration.
14
Suter, 2007
20
9) Governance Structure: A strong, focused governance structure is essential for successful
integration. Barriers include competition, too many levels of management, and lack of a
coordinated vision at the governing level. An effective governance structure can facilitate
the contractual relationships or networks that promote coordination.
The governing body must be diverse enough to represent all constituencies, yet the structure
should be flat to be responsive. Responsibilities include care-management mechanisms to
promote quality, patient focus and appropriate use of resources. In addition, strategic
planning and decision making must encompass both the financing and delivery of medical
care. Lastly, physician and community representation is strongly recommended.
10) Financial Management: Cost control is usually one of the incentives for integration;
however, evidence does not strongly support this claim. In fact,” integration may result in
increased cost before it provides savings.” 15 Funding is cited as one of the barriers to
integrated service. Ontario’s new health-based allocation funding model (HBAM), with
funding for different services bundled according to patient need is an attempt to address this
barrier. It may be an enabler for integration of orthopedic care. Separate physician
remuneration mechanisms, however, continue to be a challenge for integration.
While the principles described above must be considered when integrating a health system,
“there is little evidence to demonstrate which of those principles, if any, are more relevant or if a
certain combination leads to more successful integration.” 16 Instead, it is perhaps more relevant
for the stakeholders to seek consensus on which principles in which combinations are most
important for a specific integration initiative.
15
16
Suter, 2007, p.32
Suter, 2007, p33
21
Overview of Existing Regional Program Models
A review of the following existing regional programs was conducted to identify successful
frameworks (see Appendix E for a summary of each program): 17
•
Toronto Central LHIN Joint Health and Disease Management Program
•
Champlain Maternal Newborn Regional Program
•
Champlain Regional Cancer Program
•
Champlain Hospice Palliative Care Program
•
Rehabilitation Network of Champlain
In summary, while the primary focus of the model or the reason for regionalization may vary,
there are a number of commonalities among all the reviewed program models which may be
used to guide the implementation of a successful Regional Orthopedic Program in the Champlain
LHIN.
•
•
•
•
A combined clinical-administrative leadership
Models built on trust, collaboration and partnerships, (rather than formalized merged
organizational structures) are the norm and are showing success
All require a coordinating body to create and sustain changes
Most of the models monitor and determine service delivery structures to meet demand
and capacity balance
All function under the same guiding principles of access, quality and efficiency
All transitioned from a network type of structure to a more formalized structure
•
All have mandates to integrate and coordinate.
•
•
Service Delivery Model Literature
In 2010, a review of service delivery models was completed by Deloitte Consulting, for the
Champlain LHIN-sponsored Eastern Counties Clinical Service Distribution Plan exercise. 18 The
review highlights important considerations for the distribution of orthopedic services. Three
generic service delivery models were considered: local service provision, district service
provision and LHIN-wide level provision. Each option has advantages and disadvantages
depending on the clinical focus. The delivery models presented focus around the types or levels
of service provided or affiliated with a site (see Appendix F). Key success factors for service
delivery models are identified and closely match integration principles with the following added
considerations:
17
MacLeod, 2009; Champlain Regional Maternal Newborn Program, 2009; The Ottawa Regional Cancer Centre,
2012; Planning Council of the Champlain Hospice Palliative & End of Life Network, 2010; Rehab Network of
Champlain, 2012
18
Champlain LHIN Eastern Counties Clinical Services Planning, 2010
22
•
•
•
•
Locate services strategically to minimize impact of distance on access
Standardize practice and clarify provider responsibilities to improve coordination across
the continuum
Designate centres of excellence to provide training, resource material and leading
practices
Define services that can be provided at each centre – Service Inventory Map
Centralization versus decentralization poses a significant distribution challenge especially in the
Champlain LHIN which, geographically, is largely a rural region. The primary principle used by
the National Health Service to re-organize healthcare delivery in the United Kingdom is
“decentralize where possible, centralize where necessary.” 19
Decentralization has advantages from the perspectives of an individual patient and a system.
Decentralization results in better access, because care is closer to home. It also contributes to the
goal of “one-stop shopping”, where multiple visits and duplication are reduced.
Other jurisdictions are using the same approach to plan regionally, but also recognize
decentralization as a strategy to shift care away from hospitals into the community by creating
capacity in the community. Examples include the growth of ambulatory surgical centers in the
United States as well as Alberta’s move to transfer routine services out of hospitals to
community and primary care providers. Centralization, of course, must be planned when the
indication is present (e.g., highly complex, low-volume procedures where specialization is
required).
Communities of Practice Literature
“Communities of practice are groups of people who share a concern, a set of problems, or a
passion for a topic; and who deepen their knowledge and expertise in their area by interacting on
an ongoing basis.” 20
Community of practice is a social science concept that has been adopted successfully in industry
as a tool to engage staff in organizational improvement. The basic tenet is that of knowledge
management. In business arenas, “knowledge intensive organizations use the model to share
“tacit” knowledge that is informal and, therefore, hard to document.” 21
In the social science realm, communities of practice are viewed as social structures that support a
‘learning organization’ by “promoting individual competence, encouraging a culture of systems
thinking, developing cohesive vision, supporting team learning and integrating different
perspectives.” 22
19
Dash, 2009, p.31
20
Fung-Kee-Fung, 2008 p.177
21
Grol, Wensing & Eccles, 2005 in Fung-Kee-Fung, 2008
22
Senge, 1999 in Fung-Kee-Fung, 2008
23
The healthcare system has recently begun to examine the potential benefits of applying a
community of practice model as a framework for quality improvement because of the following
three trends in healthcare:
1) Focus on the patient and the needs and preferences for services
2) Shift from the focus on fragmentized subspecialty tasks to integrated evidence-based disease
management; and
3) Emphasis on efficiency of clinical practice due to economic pressures. 23
Cancer surgery in the Champlain LHIN has benefited from the introduction of a community of
practice framework. The formalized, collaborative learning environment between health
professionals and organizations has led to innovation, professional development, engagement in
quality improvement initiatives, and evidence-based decision making, based on data. The
framework is easily translated to orthopedics and could serve multiple functions to support a
regional approach to orthopedic care.
As is the case in other jurisdictions such as Britain, the emphasis to date in Ontario has been on
efficiency and access. 24 The next step in the evolution of healthcare reform in Ontario is to
ensure the clinical quality platform maintains status equal to access and efficiency. Communities
of practice naturally create and support the quality forum by:
•
•
•
•
•
•
23
24
Providing a forum for knowledge acquisition, transfer and translation between all providers
Connecting the administrative priorities and the clinical priorities
Allowing broad clinical input into decision making
Integrating care across the continuum and among organizations
Providing a forum for clinical priority setting and strategy development
Creating an environment that builds relationships and collaboration.
Fung-Kee-Fung, 2008, Fung-Kee-Fung 2009, Fung-Kee-Fung 2011
The Change Foundation, 2009
24
Regional Orthopedic Program Planning Process
History and Planning Goals
In 2010, the Chief Executive Officers of hospitals in the West Ottawa Valley undertook a
planning exercise to better coordinate services provided to the populations of their catchment
areas. Based on an analysis of data and key opportunities for improving access, quality and
sustainability, surgical services was identified as a high priority. A West Champlain Surgical
Services Steering Committee was formed including CEOs of surgical hospitals in the Western
part of Champlain (Almonte General Hospital, Arnprior Regional Hospital, Carleton Place
Hospital, Kemptville District Hospital, Pembroke Regional Hospital, Queensway Carleton
Hospital, Renfrew Victoria Hospital) and The Ottawa Hospital.
Three areas for opportunity were identified:
1) General surgery
2) Orthopedic surgery; and
3) Urology
Orthopedics was identified as the first priority, but since the service of orthopedics as a major
surgical service was centralized to four major hospitals primarily in the City of Ottawa (TOH,
Hôpital Montfort, Queensway Carleton Hospital and Cornwall Community Hospital); it became
evident that a regional approach was needed.
In part because of the emphasis placed on total joint replacement surgery by the Ministry of
Health and Long-Term Care, a Regional Orthopedic Planning Committee was already in place.
This committee was focused on performance management (including wait times) and some
clinical management priorities such as a central intake and assessment model for total joint
replacement.
As regionalization throughout the province formalized, it became evident that any reorganization of services must include the entire region, and could be facilitated with support
from the LHIN. As a result, efforts to coordinate orthopedic services expanded regionally, and in
early 2011, a LHIN-endorsed Champlain Orthopedic Program Planning Initiative (COPPI) was
undertaken.
The Regional Orthopedic Planning Committee merged with the COPPI efforts to form a strong,
engaged group of clinical experts and decision makers with the purpose of producing a plan for
recommendation to the Champlain LHIN 25 (see Appendix G - COPPI Project Charter). Figure 5
describes the two primary planning goals.
25
Champlain Orthopedic Program Planning Initiative Project Charter, Feb 2012
25
Figure 5: Champlain Orthopedic Program Planning Initiative (COPPI) Planning Goals
Champlain Orthopedic Program Planning Initiative
Planning Goals
a) Develop a Regional Program Model
b) Develop a Service Delivery Distribution Model
This document is the key output of the COPPI Leadership Group. It articulates a regional
orthopedic program model, including:
•
•
•
•
•
•
•
Program Goals, Objectives and Rationale
Governance Structure including functions and key program elements
Service delivery distribution model and plan
Implementation Recommendations
Funding requirements
Stakeholder Engagement Plan
Year One Implementation workplan
Guiding Principles for Program Development
The planning process for the regional program and the distribution plan was guided by a set of
principles which was developed and endorsed by the Orthopedic leaders in the region. These
principles will be applied on an ongoing basis, and used as a tool to promote the vision of an
integrated, regional orthopedic program. They will also be used as a basis for evaluation of the
program:
•
Optimal Patient Flow and Clinical Coherence: the organization of orthopedic services will
be aligned by site to ensure optimized and efficient clinical interdependencies and patient
flow.
•
Appropriate Critical Mass: the organization of orthopedic services will be structured to
ensure that programs/services have appropriate critical mass (i.e. volume) to allow for the
provision of safe, effective, efficient and timely services while reflecting rural considerations.
•
Enhanced Accessibility: the organization of orthopedic services will be structured to
improve patient access to high quality programs / services (i.e. wait time, closer to home)
•
Quality of Care: the organization of orthopedic services will ensure quality of care
standards and practices, clinical outcomes, safety and risk management are optimized.
•
Enhanced Cost Effectiveness: the organization of orthopedic services will be structured to
create a more effective and efficient service cost profile and will not result in increased
system funding for operations.
26
•
Integration and Service Coordination: the organization of orthopedic services will result in
greater integration and coordination of services.
•
Patient Experience: the organization of orthopedic services will be structured to enhance the
patient’s experience and a focus on the patient’s needs will be maintained throughout the
planning process.
•
Francophone services: service distribution should be consistent with French language
service designation. Any changes to distribution must take into account the impact on
Francophone clients and, where possible, aim to improve access to French language
services. Le Réseau des services de santé en français de l'Est de l'Ontario will be engaged as
appropriate.
•
Financial resources: any redistribution of orthopedic clinical services will be achieved
within the existing funding allocation for the sector.
•
Human resources: any changes to the organization of orthopedic services will be planned
and implemented with proper consideration of human resource implications.
•
Evidence-based approaches: clinical services planning will make use of best available
evidence.
•
Teaching and research opportunities: the configuration of orthopedic services will be
structured in keeping with teaching and research needs. 26
In addition to the guiding principles, a number of additional planning considerations particularly
relevant to distribution of services were identified such as provincial and LHIN priorities,
funding mechanisms, impact on other sectors and impact on aboriginal & immigrant populations.
Appendix H provides a full description of the additional planning considerations.
26
Champlain Orthopedic Program Planning Initiative Project Charter, Feb 2012
27
Champlain Regional Orthopedic Program Model
Primary Goal
Figure 6 articulates the definition of the proposed regional orthopedic program – a formal
network of providers led by a coordinating body with the primary goal of improving the health of
the orthopedic population in the Champlain LHIN by delivering high quality, accessible,
financially sustainable care and service.
The building blocks to achieve the goal are integration and an organized delivery system. The
three core functions of the regional program will be: Planning, Service Delivery and
Performance Management.
Figure 6: Definition and Primary Goal - Champlain Regional Orthopedic Program
28
Objectives and Opportunities
The rationale supporting specific objectives and opportunities are summarized in Figure 7.
Figure 7: Objectives and Opportunities of a Regional Approach 27
OBJECTIVES & OPPORTUNITIES OF THE CHAMPLAIN REGIONAL ORTHOPEDIC PROGRAM
Objectives/Opportunities
1. To improve access to
service
Rationale
•
•
•
•
2. To optimize distribution of
Resources
3. To improve Quality and
Safety
4. To enhance efficiency and
sustainability
5. To enhance integration
across the continuum of care
27
•
•
•
•
•
•
•
•
•
•
•
•
Wait Times in Champlain LHIN exceed targets
Some patients wait longer than others; access is not equal
Travel time is long for some patients especially for
urgent/emergent orthopedic care
Demand for ortho procedures is expected to increase 22% over
next 10 years
Surgeons are available
Operating rooms are available
Surgeries are cancelled due to bed availability/ALC
Regional Variations in performance not routinely monitored;
emphasis has been on access & efficiency
Best practices may not be planned or implemented consistently
Costs for equivalent treatment vary between sites
Some patients may not be in optimal site eg. pre & post visits
TOH seeking to decant a portion of primary & secondary
services
Need to make best use of available funding
Telemedicine under-utilized
Rehabilitation not standardized/ integrated to patient need
Coordination of patient’s care throughout system disjointed
(prevention/treatment)
COPPI Project Charter, 2012 p2
29
Conceptual Framework
The Regional Orthopedic Program, as conceptualized in Figure 8, will be overseen by a Steering
Committee reporting to the Champlain LHIN. The committee will act in an advisory capacity to
the LHIN, and will be chaired by a Champlain LHIN Orthopedic Physician Leader in
conjunction with an Administrator from one of the participating orthopedic organizations.
For the first two years, while the program is maturing, it is recommended that the LHIN CEO (or
delegate) participate actively. The primary mandate of the committee will be to establish the core
infrastructure, implement and monitor integrative functions, ensuring service is coordinated and
the program dimensions of access, efficiency and quality are addressed.
The core functions of the regional program will be planning, service delivery and performance
management. An executive team will provide guidance, support, and act on behalf of the
committee to liaise with and report to the LHIN. An Orthopedic Program Coordinator and the
Physician Lead, along with administrative support, will make up the executive. A health service
provider with orthopedic services will act as host to the executive team. Since rehabilitation
plays an integral part in orthopedic care, there will be a formal link with the Rehabilitation
Network of Champlain.
The accountabilities of the program will be operationalized via two subcommittees: the Clinical
and Advisory Subcommittee and the Resource/Performance Management Subcommittee.
The Clinical Advisory Subcommittee will function using a Community of Practice Framework.
The mandate of the subcommittee will be to focus on clinical quality improvement and provide
advice to the Steering Committee regarding matters such as program requirements and clinical
practice changes. There will be a core group who will be represented on the Steering Committee.
The broader membership of the “community of practice” will be inter-professional and will
represent the direct and indirect providers of orthopedic care. Specific details and terms of
reference for the Clinical Advisory Subcommittee will be developed as a component of program
implementation.
It is expected that the executive team will provide support to the Clinical Advisory Committee /
Orthopedic Community of Practice to coordinate strategic priority setting, facilitate clinical
changes, standardize care/processes and coordinate special projects, as identified by the
subcommittee or steering committee.
The second subcommittee, which will report to the Steering Committee, will be responsible for
resource and performance management. The membership will be representative of the providers
of orthopedic services including rehabilitation. Specific details and terms of reference for the
Resource and Performance Management Subcommittee will be developed as a component of
program implementation. The committee will be accountable for recommendations to the
30
Steering Committee regarding annual volume allocations, distributing/re-distributing services,
human resource planning, monitoring performance indicators, and preparing an annual
orthopedic capacity and quality plan.
Figure 8: Conceptual Model: Champlain Regional Orthopedic Program
Key Program Elements
According to the literature review, there are a number of program elements which must be
considered and incorporated when planning integration. Figure 9 identifies these elements,
describes the current status, suggests how a regional model can better satisfy the elements, and
suggests strategies to operationalize the model.
Figure 9: Key Program Elements of the Regional Orthopedic Model
Key Program Elements of the Regional Orthopedic Model
Key
Element
Comprehensive
Care
Current Model
Silos of care by different
provider types; funding
separate
Proposed Model
Regional Program
Structure which
incorporates all providers.
Regional Orthopedic
Steering/Advisory
Committee with equal
Operationalizing the
Model
Facilitated integration through
patient based funding and
care pathways across the
continuum
31
Standardization
Central Intake in place but
processes vary between
organizations
Clinical Pathway – acute care
pathways in place at each
organization but vary in
compliance
Geographic
Coverage
Orthopedic Care is
centralized primarily in Ottawa
Patient Focus
Current Model is procedure
based
Performance
Management
Current model monitors
performance indicators for
TJR thru Regional Network;
compliance/change is
voluntary; only TJR tracked
Information
Systems
Performance data for select
procedures available; Shared
pt. information systems not
available
Referral system is manual.
Access to Information for
clinicians and patients is
limited
Regional Planning Network
monitors indicators and
shares information
Organizational
Culture and
Leadership
membership from
stakeholders
Central Intake Standardized Processes
Common Clinical
Pathways (GP to surgeon
referral to rehab to follow
up)
Clinical Practice
Guidelines for common
high volume orthopedic
diagnoses
Re-distribute orthopedic
care to communities with
capacity to provide select
orthopedic services;
provide support to sustain
quality
Quality Based Procedures
provides structures for
patient centered model
Sub group of Regional
Steering Committee
responsible for
performance tracking and
performance improvement
guided by annual
Orthopedic Quality Plan;
Connect funding to
performance
Monitoring of additional
orthopedic Services
including emergency
services
Regional program long
term information system
strategy development
The members of a
Regional Program share
region-wide vision and
mission. Decision making
is collaborative but not
competitive.
Revise assessment center
model/processes; assessors
travel to patients;
surgeon/assessor clinics
implemented at all sites;
redistribute patients based on
wait times
Centralized Wait Time
Coordination
Adopt Communities of
Practice Model
Community of Practice Model
Redistribution Plan
Designated organizational
contacts liaise with Project
Manager
Patient Satisfaction Surveys
Patient participation in
planning
Annual agreements for
orthopedic services based on
meeting targets
Common clinical data
measurement guided by
clinical advisory sub group
Quarterly/bi-annual
performance teleconferences
facilitated by Orthopedic
Governing Body
Develop common e-referral
system for family physicians
Common tool to collect
relevant/required data at the
organizational level eg. use of
pathways/functional status
Regional Leader supported by
Advisory Committee;
sponsored via Champlain
LHIN. A common
vision/mission is developed.
Formal agreements developed
32
Physician
Integration
Orthopedic Surgeons have
participated in Regional
Orthopedic Planning
Committee; focus is
performance based
Regional Model focuses on
quality and clinical
improvements in addition
to efficiency and access.
Clinical leadership
/engagement is necessary.
Governance
Structure
The ROPC and LHIN have
provided leadership for
planning. There is not a
formal governance structure
A Regional Model includes
a formalized governance
structure
Financial
Management
Funding for select Orthopedic
procedures – annual &
incremental (Wait Time
Strategy)
Other orthopedic services
included in base funding or
organizations
Funding Reform provides a
Regional Program with a
funding model to match the
orthopedic population
and renewed annually
Communities of Practice
Model Knowledge
Transfer/Research
Physician-Administrative
Structure
Annual Clinical Quality
Improvement Plans
Terms of Reference for
Steering Committee and
Working Groups
Job Descriptions and
Accountabilities for Program
Leader(s)
Strategic Plan with Annual
Work Plans
Develop funding model for all
orthopedic Quality Based
Procedures Case Costing
Project
33
Clinical Elements of the Regional Orthopedic Program
The continuum of orthopedic care extends from prevention to rehabilitation. While the primary
focus of attention has been on elective surgical interventions, there is a need to incorporate those
clinical elements associated with emergency surgical and non-surgical orthopedic care when
planning regionally. Similarly, it is important to recognize that orthopedic care relies on
professionals across many health care disciplines in diverse settings. Family practitioners,
surgeons, anaesthesiologists, sports medicine experts, nurses, physiotherapists and their aides,
among others, are all crucial. Primary care, emergency care, acute care (including surgery),
outpatient and community care all contribute. Effective and efficient orthopedic care, organized
around the patient’s need, requires an understanding and collaboration across the full spectrum.
The COPPI Project Charter (Appendix G, p.6) provides a description of the services, sectors and
professional disciplines which fall within the scope of regional orthopedic program planning.
It is expected that the focus of attention for the upcoming 3 years will be on the Orthopedic
Quality Based Procedures as identified by the Ministry of Health and Long Term Care, however
the work of the Regional Program will not be limited to these types of clinical conditions.
34
Champlain Regional Orthopedic Service Delivery Model
The secondary goal of the Champlain Orthopedic Program Planning Initiative was to develop a
distribution model for orthopedic services throughout the LHIN. The model needs to best meet
patient need and organizational capacity, while adhering to the attributes of a high-performing
health system: accessible, effective, safe, patient-centred, equitable, efficient, appropriately
resourced, integrated and focused on population health. 28
The principles and planning considerations which underpin the Regional Framework were also
used to guide the development of the distribution model. The proposed distribution or service
delivery model is based on the type of orthopedic service that is provided by each organization
and is focused around geographical location of acute care hospital services in the LHIN. The
distribution model is focused around acute-care hospitals only as a starting point because the
majority of orthopedic care involves some aspect of acute-care. Identifying where that acute-care
will be provided is one means of organizing the continuum of care. As the model evolves, the
complementary parts of the continuum of orthopedic care will be addressed and distributed
accordingly.
While acute-care orthopedic care in the Champlain LHIN has been primarily centered in the
Ottawa area, there is data to support the re-distribution of services to be provided closer to home.
A detailed review of the data identified:
1. A critical mass of orthopedic patients in the Renfrew County area to support a fullservice orthopedic program (defined below) at the Pembroke Regional Hospital.
2. A critical mass of orthopedic patients in the Cornwall area to maintain and strengthen
Cornwall Community Hospital’s existing full-service program.
3. A critical mass of Hawkesbury-area patients (including an estimated number from
adjacent areas of Quebec) to support consideration of an orthopedic “focus centre”
(defined below)
The potential for program development is based only on critical mass (volumes) in relation to
patient residence. Other considerations, such as readiness (human and medical resources,
infrastructure etc.), quality and efficiency need to be assessed separately as part of
implementation planning. Similarly, it is prudent to complete a financial analysis of the impacts
to current orthopaedic hospitals if volumes are redirected to a new site.
The following Renfrew County example illustrates the critical mass ‘math’ logic:
•
28
Patients who lived closer to Pembroke Regional Hospital or Renfrew Victoria Hospital
than any other surgical hospitals underwent 1215 (874+341) non-tertiary orthopedic
procedures in 2009-10 (green cells, Table 4).
Health Quality Ontario, 2012, p6
35
•
The estimated operating room time for those procedures plus the non-surgery activity
(e.g. consultations), amounts to work for the equivalent of 4.7 (3.3 + 1.4) full time
equivalent orthopedic surgeons (green circles, Figure 10). In other words, patients from
those areas required the services of 4.7 full time orthopedic surgeons.
•
The majority of that care in 2009-10 was provided at the Queensway Carleton Hospital
and The Ottawa Hospital with a smaller amount at the Montfort and elsewhere (blue
cells, Table 4).
Table 4: Orthopedic Procedures Completed Backyard (Patient’s Closest Surgical Hospital)
and Site 29 (Champlain hospitals and neighbouring areas, 2009-10, inpatient and day
surgery combined, tertiary cases excluded)
Tx Site/ QCH ARH AGH CPDMH KDH WDMH RVH PRH Civic Gen River CHEO UOHI Mont- CCH HGH Other Total
*
side
fort
LHIN
Backyard
Hosp
QCH
1169 4 31
103 205
.
.
. 424 336 274 143
3 136
1
.
77 2,906
Arnprior
130 25
5
9 12
.
.
. 38 43 24 14
.
24
1
.
9 334
Almonte
64 3 11
17 3
.
.
. 20 16 21
9
.
18
.
.
11 193
Cltn Place 112
.
4
40 8
.
.
. 33 30 15 14
.
20
.
.
13 289
Kemptville 80 2
2
3 38
1
.
. 53 72 39 14
.
11
2
.
74 391
Winchest.
51
.
.
2 26
11
.
. 56 67 28 19
.
47 52
.
48 407
RVH
88 31
3
3 9
. 20 2 24 62 21 16
.
18
.
.
44 341
Pembroke 223 30
1
8 22
. 15 62 191 113 41 31
.
65
.
.
72 874
TOH/CHEO 568
. 10
66 150
.
.
. 705 822 456 169
4 281 13
.
65 3,309
Montfort 250
.
2
32 101
1
.
. 325 591 389 146
2 1207 31
1
52 3,130
Cornwall
22
.
.
. 3
3
.
. 46 90 42 26
.
21 754
.
40 1,047
Hawkesb.
13
.
.
1 2
.
.
. 32 59 40 13
1 183 31 15
3 393
HGMH
9
.
.
.
.
.
.
. 14 19
9 14
.
34 94
.
4 197
Elsewhere 226 3
4
30 38
3 6 11 363 410 177 254
6 167 67
5 16384 18,154
Total
3005 98 73
314 617
19 41 75 2324 2730 1576 882 16 2232 1046 21 16896 31,965
*KDH volumes have increased since beginning to offer knee and hip replacement surgeries in 2011 and 2012.
29
Backyard based on closest hospital to patients by drive time. Elsewhere includes patients from outside Champlain hospital ‘backyards’, including out-of-province
patients. The elsewhere group includes all patients from North East and South East LHINs even if they were not treated in Champlain. “Other LHIN hosp” includes
Ontario hospitals outside Champlain. The 16,384 are North East and South East residents who were treated outside of Champlain and are not of interest here.
Excluded due to very no (or very low) volume: Glengarry Memorial Hospital, St. Francis Memorial Hospital and Deep River District Hospital. Abbreviations- QCH:
Queensway-Carleton Hospital, TOH: The Ottawa Hospital, General, CCH: Cornwall Community Hospital, CHEO: Children’s Hospital of Eastern Ontario, KDH:
Kemptville District Hospital, CDDMH: Carleton Place and District Memorial Hospital, HGH: Hawkesbury General Hospital, ARH: Arnprior Regional Health,
WDMH: Winchester District Memorial Hospital, PHR: Pembroke Regional Hospital, AGH: Almonte General Hospital, RVH: Renfrew Victoria Hospital. Procedure
groupings based on grouper specially developed for the LHIN by PRH Decision Support based on CACS and CCI codes (NACRS) and CMG and CCI codes (DAD).
36
Figure 10: Estimated # of Orthopedic Surgeon FTEs Required by Area of Patient
Residence (2009-10) 30
Preceding the development of a Regional Program and Distribution Model, the Kemptville
District Hospital (KDH) embarked on an innovative partnership with The Ottawa Hospital
(TOH) to open a focused orthopedic centre providing total hip and knee replacement procedures.
Surgeons from TOH perform cases at KDH. The proposed distribution model incorporates this
level of care but expands on the partnership to introduce the concept of a “shared resource
model” for the Champlain LHIN. The concept envisions KDH as a type of satellite service site
shared by and collaborating with the full service hospitals and their surgeons. The model is
designed to make optimal use of available capacity, reduce costs and help meet volume and wait
time targets. In addition, the concept provides an element of choice for the patient who may
choose to have surgery in a smaller centre, perhaps with a shorter wait time.
While there have been challenges such as difficulty in identifying a funding methodology to
account for low acuity cases, the Kemptville model sets the stage for future development of
shared resource centres throughout the LHIN to provide specific types of procedures in a focused
30
Estimates for 2009-10. Areas defined by closest drive time for hospitals with surgery or endoscopy services. Patients allocated to areas based on postal code,
irrespective of where they had their surgery. FTEs required based on 2000 hours/year (38.5/week * 52 weeks) and assuming 2 hours of other work for each surgery
(“cutting”) hour. Hours based on number of procedures multiplied by the average time (including room turnover) per procedure type. Out-of LHIN patients were
assigned to the area of the hospital where they actually received treatment. Emergency volumes based on 34.4% of IP cases (LHIN average). See LHIN Reference
Document: “Champlain Surgical Volumes and Market Share Analysis” for additional information.
37
manner. Minor foot and ankle interventions, for instance, are appropriate for a “focus care
setting.” The Holland Centre which operates a major total joint replacement program in the
absence of other full service supports in Toronto, for instance, has supported this type of
arrangement very successfully for a number of years.
Conceptual Service Delivery/Distribution Model
The model identifies five different levels of service according to hospital: academic/tertiary,
full-service, focus centre (shared resource), partial service (shared resource), and
satellite/telemedicine service (see Figure 11). The model is a hybrid type of model incorporating
elements of distribution models which are of benefit to the Champlain LHIN in terms of patient
need, geographic setting, and capacity. The model relies on a Regional Program structure to
ensure sustainability, coordination and access.
Figure 11: Distribution Model
The proposed services to be provided at each type of site are described in Figure 12. Services
and volumes at each site will be monitored by the Regional Program and recommendations for
changes/expansions would be made to the LHIN by the Regional Program.
38
Figure 12: Service Levels by Type of Site
Type of site
Description of service
Academic / tertiary Inpatient and Day Surgery Procedures (full range; ALL neck & spine)
Tertiary/Quaternary Care including Complex Trauma
24 hour Emergency on call & access to ORs
Accepts rotational distribution of Orthopedic Trauma Cases
Leads Research/Teaching Activities
Inpatient, Outpatient & Community Physiotherapy available & accessible
Orthopedic Clinic
Inpatient and Day Surgery Procedures
Full service
Major and Minor Procedures
24 hour Emergency on call & access to ORs
Accepts rotational distribution of Orthopedic Trauma Cases
Inpatient, Outpatient & Community Physiotherapy available & accessible
Orthopedic Clinic
“Shared Resource” Inpatient and Day Surgery Procedures
Types of procedures limited and specific
Focus centre
Formal Affiliation Agreement with host hospital(s) as shared resource to add system
Major or minor
capacity
No 24-hour emergency orthopedic on call or access to ORs
Outpatient & Community Physiotherapy available & accessible
“Shared Resource” Day Surgery Procedures only – limited types
Open to orthopedic surgeons in the LHIN; requires formal commitment
Partial Service
Formal Affiliation Agreement with host hospital(s)
Minor
No 24-hour emergency orthopedic on call or access to after-hours ORs
Outpatient & Community Physiotherapy available & accessible
No procedures
Satellite/
No 24-hour emergency orthopedic on call or access to after-hours ORs
Telemedicine
Pre and post assessments via TeleHealth
Components of care may be offered in FHC or CHCC or Health HUB
Outpatient physiotherapy may be available
Community physiotherapy available & accessible
39
Considerations for Sustainability
While there are many benefits associated with decentralizing orthopedic care, there are a number
of challenges which must be identified and managed prior to initiating any change, during the
transition, and monitored on an ongoing basis. Considerations which require attention in the
proposed distribution model include:
1) Cross privileging of surgeons among hospitals
2) Service agreements between organizations participating in a shared-resource or focus-centre
arrangement that describes types and levels of services provided (major and minor), volume
commitments, contingency plans and funding arrangements.
3) After-hours coverage plans for physicians in shared resource centres
4) Access to physiotherapy for patients close to home, regardless of where their procedure is
performed (e.g. review of closed referral systems).
5) Shared information systems and scheduling systems to facilitate movement of patients and
surgeons among orthopedic sites.
6) A coordinating/governing body to ensure distribution model is equitable, efficient, safe and
provides the appropriate level and type of care based on evidence and demand.
7) Impact of distribution changes on organizations and physicians, if transfer of funding is
required to match planned activity.
Stakeholder and Community Engagement
Stakeholder engagement is an integral component of the orthopedic planning process.
Community engagement is also a primary objective of the Champlain LHIN, and a legal
requirement as defined in the Local Health System Integration Act, 2006. 31 A Stakeholder
Engagement Plan was developed to ensure the regional orthopedic program meets the needs of
the patients, community, healthcare providers, and Ministry of Health and Long-Term Care (see
Appendix I). The plan includes activities required, and the level of engagement required to
communicate, consult and/or engage stakeholder groups.
31
Jabbar, 2010
40
Summary and Conclusions
Orthopedic care is a service that plays a significant role in healthcare in the Champlain LHIN.
Volume and complexity, changes to health care funding, provincial priorities, performance
variation and the growing population need all point to the need for integration and coordination.
The evidence is strong to support the evolution of orthopedic care in the Champlain LHIN from a
complex voluntary network of organizations and individuals to a formalized collaborative
program focusing on quality, accessibility and efficiency of clinical care.
The benefits of a regional approach to service delivery include equal, quicker and “closer to
home” access, enhanced coordination of care, seamless transition for individuals between service
providers and sectors, the forum to focus on region-wide standards for quality and safety, and the
opportunity to create a financially viable and sustainable orthopedic service.
The goal, broadly stated, is “right care, right time, and right place”. A regional approach to
orthopedic care can help satisfy this goal. As with other regional programming initiatives, there
are both challenges and opportunities to be managed, however the benefits for the patient and
community must be the foundation for the directions taken and the decisions made.
The following sections of the proposal provide recommendations for implementation of a
regional program and distribution model, a Year One implementation workplan, and budget
requirements.
41
Program Implementation Recommendations
The following recommendations highlight the Champlain Orthopedic Program Planning
Initiative’s project planning work which supports the development of a regional orthopedic
program and distribution model. The recommendations are focused around the key elements of a
successfully integrated healthcare system.
The foundational recommendations for
implementation are bolded.
1) Comprehensive Services across the Continuum of Care
a) Recommend that a Regional Orthopedic Program be established - to integrate and
coordinate silos of care. The core functions of the program are: planning, service
delivery and performance management. The program goals are to improve access,
quality of care and efficiency.
b) Formalize liaison structure with Rehabilitation Network.
c) Develop an evaluation framework with tools, measures and targets to monitor the
performance of the regional orthopedic program; incorporate annual program reports to
the stakeholders.
d) Include all components of the continuum of orthopedic care (e.g. prevention, primary
care referral, chronic disease management) in the mandate and activities of the Regional
Program.
2) Patient Focus
a) Consider the implementation of a one number to call model for specialized orthopedic
consultation by referring primary care providers.
b) Gain consensus on relevant key patient outcomes; develop indicators to measure
successful outcomes
c) Develop a community communication tool to provide information and education to
patients and caregivers regarding changes in orthopedic care as a result of a regional
model.
d) Ensure Orthopedic Service is available in French Language as requested
3) Geographic Coverage
a) Recommend that the proposed service distribution model be adopted for the Champlain
LHIN. The immediate priorities include: providing support to Cornwall Community
Hospital to ensure that the orthopedic program is viable, sustainable and able to meet
performance targets; program planning to develop a full service orthopedic program
at Pembroke Regional Hospital (excludes tertiary, spinal, and other specialized
services); developing the shared resource model which allows smaller centres to
42
provide focused orthopaedic services provided by surgeons from Champlain full service
hospitals. .
b) Designate a “lead contact” at each organization providing orthopedic and orthopedic
rehabilitation.
4) Standardization and Evidence Based Practice
a) Recommend the central intake and assessment clinic model be utilized and/or revised to
ensure standardization; consider travelling assessors; incorporate assessor/surgeon
clinics at all surgical sites.
b) Consider the expansion of the central intake and assessment model to other orthopedic
diagnoses. Develop criteria to determine feasibility and appropriateness.
c) Identify and implement regional quality improvement initiatives aimed at access, quality
and efficiency through the Community of Practice framework.
d) Develop, implement and monitor regional clinical practice protocols and pathways.
e) Implement a comprehensive communication strategy for all care providers (e.g. primary,
acute, rehabilitation) that includes written operational guides to describe the
standardized processes and procedures.
f) Identify and incorporate research and academic teaching activities & roles including the
role for non-tertiary sites and community organization in these activities.
5) Performance Management
a) Implement an orthopedic regional scorecard based on the provincial scorecards and
incorporating local relevant quality indicators. Incorporate rehabilitation
(physiotherapy) indicator targets.
b) Ensure quarterly review of Performance Indicators (Orthopedic Scorecard plus local
indicators); develop action plans when targets are not being met.
c) Engage Wait Time coordinators regionally on an ongoing basis to ensure data reporting
is standardized and scheduling practices are optimized
6) Information Systems
a) Consider the development of an electronic referral system for orthopedic consultation.
b) Ensure the availability of local data to guide clinical decision making and support
community of practice work
c) Develop common tools to collect relevant/required data at the organizational level (e.g.
use of pathways, functional levels and create a database to warehouse the data.
7) Organizational Culture and Leadership
43
a) Develop a common vision and mission for orthopedic care in the Champlain LHIN that is
supported by all providers and guides regional program decisions and activities.
b) Develop a three - to five-year orthopedic plan based on priority setting with three arms:
clinical quality improvement, access and efficiency.
c) Focus on integration processes; identify the barriers to success; use a LEAN process via
Community of Practice to identify what successful integration looks like and then develop
work plans to eliminate each of the barriers to success.
8) Leadership Structure
a) Establish an agreed upon oversight structure
b) Develop formalized partnership agreements between participating organizations at the
outset regarding:
i.
Defined levels of participation in the regional program
ii.
Decision making processes, authority, shared vision and objectives
iii.
Level of service provision
iv.
Implementation of standardized clinical care and service protocols
v.
Participation in Communities of Practice
vi.
Willingness to contribute “in kind” resources for project work
vii.
Participation in data collection
viii.
Willingness to share costing information with the Regional Program
c) Formalize an agreement between the Regional Program and the LHIN which defines
authority of the Regional Program, reporting structure, decision making limitations,
deliverables and the responsibility of the program in advising the LHIN on distribution
of orthopedic quality based funding.
d) Quarterly performance teleconference with provider agencies - facilitated by governing
body
e) Implement Joint physician/administrative leadership at the Steering Committee level.
f) Develop clear terms of reference for each of the committees of the Regional Program
g) Active participation of LHIN Senior member during transition phase
h) Develop Job Descriptions and Accountabilities for Program Leader(s).
i) Incorporate a finance advisor in the oversight structure.
9) Physician Integration
a)
Adopt a Communities of Practice Model – set annual budget to sustain Community of
Practice work. Engage a physician and facilitator to implement the model.
44
b)
Recruit an Orthopedic Physician Lead. Engage the assistance of other successful
Regional Model physician leaders.
c)
Designate a surgeon champion in each organization, crucial for mentoring, building
networks, building confidence and implementing change.
d)
Develop Regional Orthopedic Surgeon profile/responsibilities- separate from the hospital
agreements which regional credentials and expectations, including coverage for
emergency care (see Appendix J – Draft Roles/Responsibilities Champlain LHIN
Orthopedic Surgeons)
e)
Develop a plan to engage all professional providers and physicians that provide
orthopedic care (eg. anaesthesiologists, primary care physicians, physiotherapists)
10) Financial Management
a) Complete a financial analysis of the impacts of re-distribution of orthopaedic services on
current organizations to inform decision making prior to implementing distribution
changes.
b) Initiate a process to allow costing comparisons for high volume orthopedic
procedures/interventions/care between providers of orthopedic care in the Champlain
LHIN and external to the LHIN. Identifying costs will allow for recommendations to be
made regarding the most efficient model of care delivery for targeted interventions.
c) Develop a plan to operationalize the requirements of a quality based procedure funding
model. For instance, determine how the funding for a patient will follow the patient
throughout the continuum of care and how the funding will be allocated to different care
providers.
d) Develop criteria for exceptional funding mechanisms/requirements (eg. based on clinical
acuity variations).
45
Program Implementation Workplan
To successfully implement a regional orthopedic program and distribution plan, several
important activities need to occur. The implementation work plan outlined in this section of the
proposal focuses on a number of key objectives that need to be addressed within the first year. A
Gantt chart below outlines the timelines for the workplan.
Objectives for Year 1 include:
•
Securing and approval/endorsement from the LHIN Board of Directors and the Health
Service Providers
•
Secure program funding
•
Managing the transition to the proposed Regional Program
•
Establishing a Steering Body for the Regional Program including recruitment of the
Program Coordinator, Administrative Support and Lead Physician
•
Initiating a Community of Practice Framework including membership, Terms of Reference,
objectives, appointment of facilitators
•
Identify high priority actions for the Regional Program and begin implementation
•
Develop a three year strategic work plan which incorporates quality, access and
sustainability.
•
Initiate steps to implement the proposed Distribution/Service Delivery Model including a
financial analysis of the impact of redistribution on the organizations currently providing
orthopaedic services.
Objective 1: To secure program funding and approval (Month 1-2)
Action Steps/Activities
Implement Stakeholder &
Community Engagement
Plan
Considerations
Approval/Endorsement Steps:
•
LHIN Senior Management Team & Board
•
Hospital & CCAC CEO’s/Chiefs of Staff
Timeline
Jan–
May/13
Consultation Steps:
•
Engage stakeholders – Orthopedic Surgeons
MoH:
•
Utilize ICOP as a means of highlighting plans
•
Determine funding streams: innovation/start-up
46
Objective 2: To manage the transition to the proposed Regional Program (Month 2- 4)
Establish a Transition
Group
Considerations
Member competencies include:
•
Knowledge of healthcare systems
•
Knowledge or experience with program development
Timeline
May-July/13
Membership:
•
Clinical representation
•
Representative with experience in regional program
development
Activities/Responsibilities:
•
Develop Terms of Reference for the Steering Body and
the subcommittees
•
Develop job descriptions for program positions
•
Identify competencies and proposed membership of the
Regional Leadership/Steering Committee; ensure
representation from all sectors and geographical areas
•
Develop a draft agreement between the
Leadership/Steering Committee and the LHIN which
includes reporting obligations and accountabilities
•
Solicit targeted feedback regarding the transition process
•
Ensure that current network strengths are recognized and
not lost
•
Identify barriers and obstacles to implementation and
develop mitigation strategies
•
Manage other transition related issues including media
and communication
Objective 3: To establish a Steering Body for the Regional Program including recruitment
of the Program Coordinator, Administrative Support and Lead Physician (Month 3-4)
Secure membership for
Considerations
As per recommendations of Transition Group
Timeline
July-Sept/13
47
the Steering/Leadership
Committee and organize
initial meeting
Recruitment of Key
Positions
Program Coordinator/Manager and Administrative Support
•
Secure a host hospital for compensation
•
Determine Selection Committee
•
Post and interview for positions
Sept/13
Physician Leader
•
Approach Chiefs of Orthopedic Services to solicit
interest in Physician Leader position
•
Orientate & Familiarize leader with program
proposal and distribution plan
•
Secure liaison with Bone and Joint Network
Leadership
Objective 4: To initiate a Community of Practice Framework (Month 6-11)
Secure support from
Expert
Considerations
•
It is essential to plan the Community of Practice
Framework carefully to ensure acceptance/engagement of
clinical providers
•
Develop a long term plan for Community of Practice
activities – content TBD as initiative progresses
•
Plan initial Community of Practice event for success
•
Engage Orthopedic Leaders as presenters
Timeline
Sept/13Feb/14
Identify Community of
Practice Facilitators and
Orthopedic Experts in
specific fields
Objective 5: To identify high priority actions for the Regional Program and begin
Implementation (Month 6-11)
Approve TOR for
Leadership Committee
Considerations
Timeline
Oct/13Feb/14
48
Establish TOR,
membership and
workplans for
subcommittees
Develop Program Budget
Finalize accountability
Regional Program
agreement with the LHIN
Establish a plan for
ongoing stakeholder
engagement
Initiate website
development
Confirm provincial
performance indicators;
identify system standards
& indicators for program
evaluation
Objective 6: Draft a three-year strategic work plan that incorporates quality, access and
efficiency. (Month 11-12)
Develop a Framework for
a preliminary strategic
plan that supports
recommendations from
Regional Program
proposal
Considerations
Community of Practice Framework – to consult with
clinicians and identify clinical priorities
Timeline
Feb-Apr
2014
Performance and Resource Management Subcommittee – to
identify performance priorities
Objective 7: Initiate steps in implementing the proposed Distribution/Service Delivery
Model (Month 9-12)
Develop Workplans with
the Hospitals who will see
changes as a result of the
Distribution Plan
Considerations
Detailed Inventory Current Orthopedic Services
Initiate Impact Analyses for Change in Services e.g.
Pembroke, Kemptville, Hawkesbury including associated
supports such as rehabilitation (inpatient, outpatient, and
community), assessment model, diagnostic imaging, inpatient
care, emergency care.
Timeline
Dec/13–
March/14
49
Complete financial analysis of impact of suggested redistribution plans of current orthopaedic providers.
Identify and Engage
affected services
Rehabilitation Network:
•
Develop a plan that matches orthopedic rehabilitation
needs to the distribution plan
Telemedicine:
•
Initiate contact with Telemedicine provider to identify
opportunities for technology utilization
Regional Orthopedic Program and Distribution Model
Year 1 Implementation Timeline:
April 2013 – March 2014
Stakeholder
Engagement
Objective #1
LHIN Board
Presentation
Start up funding
Approval
Objective #2
Transition Planning
Objective #3
Steering Committee
Physician Lead
Objective #4
Develop Community of Practice Framework
Objective #5
Develop Program Components
Objective #6
Develop 3 yr
Strategic Work plan
Objective #7
Initiate Distribution Model Plan
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
50
Program Budget Year One
Compensation Costs
Estimated
(annualized)
Program Manager/Coordinator
Administrative Support
Medical Lead
Informatics Technician
Data/Decision Support Analyst
Total Compensation Costs
Operating Expenses
Purchased Services
Meeting Expenses/Community of
Practice Network sessions
Translation
Travel Expenses
Office Space
Office Equipment and Supplies
Total Operating Expenses
Total Compensation &
Operating
Cost Considerations
$120,000
$25,000
$50,000
$25,000
1.0FTE
0.5FTE
0.2FTE
Web development and maintenance, elearning, telemedicine/consultation,
information repository
Database building for clinical
institution-specific indicator tracking;
report generation; provide data support
for regional clinical improvement
initiatives
$220,000
Estimated Cost
Considerations
$30,000 Funds for expert services on an as
needed basis (e.g. facilitators,
Community of Practice expert)
$10,000 Champlain wide inter-professional
collaborative 2 – 4 times per year with
working groups in between (rent,
materials)
Steering Committee and subcommittee
meeting expenses
$10,000
$50,000
$270,000 It is expected that expenses for Year
One Implementation will be higher than
subsequent years. Opportunities for feesharing from participating organizations
will be investigated. Similarly, once the
program is in place, there is an
opportunity to have a Program Lead
from one of the organizations take
responsibility for leading the program.
51
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%204%202012%20vMGS%20FINAL.pdf
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55
Appendix A
Final Procedure for Acute Orthopaedic injuries excluding multi-system
trauma & spine referred to CritiCall for Champlain LHIN
1. Purpose
a. Montfort Hospital, Queensway Carleton Hospital, The Ottawa Hospital and Cornwall
Hospital and their orthopaedic surgeons have agreed to provide consultation and/or
clinical care for acute emergent orthopedic injuries excluding multi-system trauma,
spine referred to CritiCall for Champlain LHIN.
2. Eligibility of orthopaedic fractures in this process
a. Applies to emergent acute orthopedic injuries excluding multi-system trauma, spine
that may require hospital admission and /or surgery.
b. Physician Referrals requiring transfers unless life or limb threatening from 23h000800 would be deferred until 8 am
3. Exclusion in this procedure
a. Out of province physician referrals
b. Physician referrals for patient assessments in outpatient orthopedic clinic
4. On call Rotation Agreement
a. The Cornwall Community Hospital and their orthopedic surgeons have agreed to
provide consultation and clinical care to acute orthopedic calls coming from the
Glengarry Memorial Hospital through CritiCall
b. The Montfort Hospital, The Ottawa Hospital, and Queensway Carleton Hospital and
their orthopedic surgeons have agreed that acute orthopedic calls through CritiCall will
be contacted in the following calling order and Hospital distribution:
i.
ii.
iii.
iv.
Montfort Hospital
The Ottawa Hospital , General Campus
The Ottawa Hospital, Civic Campus
v. The Ottawa Hospital General Campus
5.
Role of CritiCall Medical Director
a.
The CritiCall Medical Director would resolve disputes for reasons other than
complexity. It is acknowledged that this would be an uncommon situation.
6.
Role of the Orthopedic Participating Hospitals & Surgeons
6a. Participating Hospitals:
i.
Hospital Bed Board/Admitting will be responsible for organizing a bed to accept
the patient within the time frame as required by the patient’s clinical condition.
ii.
Accepting Hospital is responsible to make arrangements with the sending hospital
if the patient has been listed when they have the next available bed.
iii.
Sending hospital to organize transportation.
6b.
Orthopedic Surgeons
i.
Participating hospitals and their surgeons have agreed to provide consultation
advice and or clinical care.
ii.
The Orthopedic surgeons would speak with the referring physician to offer
consultation and determine if transfer is required for surgery and or admission.
1/2 | P a g e
Approved on November 15 2011 by CritiCall & LHIN 11 Regional Ortho Planning Committee
iii.
7.
8.
The orthopedic surgeon receiving the call would be expected to accept the patient
for their management
iv.
Make arrangement for admission if the bed is confirmed “available”.
v.
If after discussion with the referring physician, the surgeon concludes that the
patient fits the category of injury best managed at the TOH Civic then the surgeon
will directly discuss acceptance of the patient with the TOH Civic orthopedic
surgeon on call. CritiCall would be notified that the hospital site would take the
next call.
Role of the CritiCall Call Agent
a. Refers to the next available Ottawa hospital based on the following regional LHIN
distribution as follows: 1) Montfort Hospital 2) Queensway Carleton Hospital 3)
TOH General 4) TOH Civic 5) TOH General.
b. Connects Glengarry Memorial Hospital to Cornwall as primary site and moves to the
next available Ottawa orthopedic surgeon as contingency.
c. Contacts the on call orthopedic surgeon from the rotation site through Switchboard.
d. Connects the referring physician-orthopedic surgeon for consultation and or patient
transfer discussion
e. When the orthopedic surgeon concludes that the case is complex and requires higher
level of care, the Call Agent contacts TOH Civic orthopedic surgeon for consultation
or transfer.
f. CritiCall notifies the referring physician of the patient acceptance.
Role of the Sending Hospital
a.
The Sending hospital is responsible for arranging transportation.
9.
Evaluation
a.
Issues related to this regional orthopedic process are reported to the Champlain
LHIN Regional Orthopedic Planning Committee.
b.
Transfers occurring through CritiCall will be collated on a monthly basis by
CritiCall representative and reports provided to the Champlain LHIN Regional Orthopedic
Planning Committee.
2/2 | P a g e
Approved on November 15 2011 by CritiCall & LHIN 11 Regional Ortho Planning Committee
Appendix B
Process for referrals of acute orthopedic injuries excluding multi-system trauma & spine (from
the Region outside of Central Ottawa)
Referring physician
contacts CritiCall with
emergent orthopedic
case
CritiCall refers to next available on the list to
contact orthopedic surgeon in the following
calling order:
o
o
o
o
o
The Montfort Hospital
TOH General
TOH Civic
TOH General
CritiCall contacts ortho surgeon
through Switchboard
CritiCall connects Glengarry to Cornwall as
primary site and moves to next available Ottawa
site as contingency.
Acceptance
CritiCall Ontario conferences in referring physician &
orthopedic surgeon for consultation and/or patient
transfer discussion.
Complex case
*For dispute other than reasons of complexity
Ortho surgeon concludes higher level
of care is required at TOH Civic
Ortho surgeon
accepts patient
CritiCall conferences in on call CritiCall Associate
Medical Director with Orthopedic Surgeon for
resolution
Patient transport
arrangements made
with sending facility
CritiCall conferences in: 1) Ortho surgeon
2) TOH Civic ortho surgeon 3) referring
physician, for patient consultation and/or
patient transfer discussion
TOH Civic advises CritiCall of alternate site
or patient acceptance at TOH Civic and
transfer arrangements made by sending
facility;
Note: Physician Referrals from 23h00-0800 unless life and/or limb threatening would be deferred until 8 am
Final Algorithm approved on November 15 2011 by LHIN 11 Regional Orthopedic Planning Committee
Appendix C
(Stewart, 2007)
Interim Quality Based Procedures List for Stakeholder Consultation
(FY 2013/14 and 2014/15)
This list has been developed for stakeholder consultation. We expect health sector experts to provide us advice on where we can make
the biggest impact on patient care.
Evidence-based framework for selecting Quality Based Procedures
Year
Quality Based Procedure *
2013/14
Coronary Artery Disease with Surgical
Intervention
Caesarean Section
Kidney Disease
Chemotherapy - Systemic Treatment
Reduce mortality and improve responsiveness in processes of care (i.e. CABG completion within
recommended waiting time).
Reduce inappropriate readmissions and variation in practice. Improve adoption of clinical practice
guidelines.
Optimize length of stay and reduce post-operative complications.
Reduce inappropriate hospital admissions and readmissions through self-management and optimize use of
pulmonary rehabilitation. For example, literature cites achievable reductions in readmission rates are up to
20% for COPD.
Improve outcomes (i.e. reduce mortality and improve physical functioning), reduce inappropriate
readmissions and complications (i.e. DVT).
Reduce adverse outcomes (i.e. infections) and improve responsiveness in processes of care (i.e. time done
for patients waiting in hospital on temporary pacemakers).
Reduce colorectal cancer mortality and improve access to colorectal cancer screening. Improve standards
and appropriateness of care.
Reduce inappropriate variation in practice.
Reduce time spent for institutionally delivered care in the face of alternative options.
Reduce adverse events such as medication errors.
Gastrointestinal Surgery
Gastrointestinal Disorders
Pneumonia
Reduce mortality and post-operative complications. Optimize length of stay.
Reduce mortality.
Reduce mortality and optimize length of stay.
Coronary Artery Disease
Improve outcomes (i.e. reduce mortality and morbidity). Improve responsiveness in processes of care.
Congestive Heart Failure
Phase 2 Orthopaedics
Chronic Obstructive Pulmonary Disease
Stroke
Cardiovascular Surgery
Colonoscopy
2014/15
Cardiovascular Other
Neurosurgery
GI Bowel Surgery
Improve adoption of clinical practice guidelines. Reduce inappropriate variation in treatment (i.e. radiation
treatment utilization) and optimize efficient use of resources to improve palliative care.
Reduce mortality and complications with better management in the community setting.
Improve outcomes (i.e. reduce mortality). Improve adherence to Cancer Care Ontario standards and
improve access. An HPB Centre should carry out a minimum of 50 index HPB cases per year.
Improve adoption of clinical practice guidelines (i.e. ECHO).
Reduce mortality and complications (i.e. bleeding, blood clots or infections).
Reduce complications (i.e. surgical-site infections) and optimize length of stay.
Other Transplants and Related Disorders
Reduce post-operative complications and optimize length of stay.
Cancer
Respiratory Disorders
Hepatobiliary Liver & Pancreas
Under
Consideration
Key Quality Objectives
Gynaecology
Spinal
Respiratory Other
Hepatobiliary Surgical
Thoracic Surgery
Cancer Surgery
Gastric Bypass
Vision Care
Reduce inappropriate variation in practice. Canada's hysterectomy rates are double compared to Britain,
Sweden, Netherlands and Norway.
Optimize length of stay and reduce post-operative complications.
Optimize use of diagnostic imaging.
Reduce mortality and complications with better management in the community setting.
Improve outcomes (i.e. reduce mortality). Improve adherence to Cancer Care Ontario standards and
improve access. An HPB Centre should carry out a minimum of 50 index HPB cases per year.
Reduce mortality and post-operative complications. Optimize length of stay.
Improve adoption of clinical practice guidelines. Reduce inappropriate variation in treatment (i.e. radiation
treatment utilization) and optimize efficient use of resources to improve palliative care.
Improve access, reduce mortality and post-operative complications, optimize length of stay.
Improve access, reduce mortality and post-operative complications, optimize length of stay
Link to Minister's Action Plan
Average Direct Cost per
Weighted Case **
$4,376
Improving outcomes of care, reducing complications, adverse events,
length of stay, variation and readmissions will advance in particular the
Minister's Action Plan regarding "high quality care" (The Right Care...)
and help improve "timely access to care" (... At the Right Time) as
scarce healtcare resources will be used more efficiently and effectively
In many instances the evidence that drives QBP are directly targeted on
reducing wait times and as such QBPs will result in "timely access to
care" (…At the Right Time) for a number of procedures
$4,217
$4,448
$4,457
$4,380
$4,853
In addition, QBPs will advance the Minister's Action Plan regarding
"keeping Ontario Healthy" by improving for example access to cancer
screening and the priority around ensuring patients are receiving "care
as close to home as possible" (... And in the Right Place...)
QBPs will lead to better outcomes of care and reduce complications and
as such advancing the Minister's Action Plan regarding "high quality
care" (The Right Care…)
$4,485
$4,215
$4,389
$4,855
$4,403
$4,367
$4,470
$4,319
$4,339
Advance "high quality care" (The Right Care…) and "timely access to
care" (...At the Right Time…) by optimizing LOS which will free up
hospital beds for those who need them.
$4,655
Advance "high quality care" (The Right Care…) by improving outcomes
and reducing complications and variation while advancing "care as close
to home as possible" (… And in the Right Place…).
$4,359
$4,502
$4,504
$4,286
$4,962
$4,461
"High quality care" (The Right Care…) and improving "timely access to
care" (… At the Right Time) as a result from optimizing care provision
due to introduction for evidence-based QBPs.
$4,551
$4,407
$4,408
"High quality care" (The Right Care…) and improving "timely access to
care" (… At the Right Time) as a result from optimizing care provision
due to introduction for evidence-based QBPs.
$4,318
…And in the Right Place (Care as Close to Home as Possible)
$4,450
$4,632
$3,751
$4,852
* Quality Based Procedures were identified using an evidence- and quality-based framework. Please refer to supplemental sheet for details on Quality Based Procedures by HBAM Inpatient Groupers (HIGs)
** Average Direct Cost per Weighted Case is based on the Ontario Case Costing Initiative (OCCI) costs using 2010/11 data.
June 18, 2012
Interim Quality Based Procedures List for Stakeholder Consultation
(FY 2013/14 and 2014/15)
This list has been developed for stakeholder consultation. We expect health sector experts to provide us advice on
where we can make the biggest impact on patient care.
Evidence-based framework for selecting Quality Based Procedures
YEAR
QUALITY BASED PROCEDURE
Acute Inpatient
Case Volume *
Provincial Average
Length of Stay
Average HIG Weight
for Provincial Cases
Average Direct Cost per
weighted case for OCCI
Cases
14,050
34,989
18,303
23,815
16,948
7,411
404,421 **
36,930
7,957
3,804
9.62
6.69
11.35
7.90
11.82
7.27
1.00
3.24
10.70
5.76
4.17
1.75
2.46
1.46
2.00
2.73
CACS weights only ***
0.76
2.00
1.12
$4,376
$4,217
$4,448
$4,457
$4,380
$4,853
$4,485
$4,215
$4,389
$4,855
2013/14
Coronary Artery Disease with Surgical Intervention
Stroke
Colonoscopy
Caesarean Section
Kidney Disease
2014/15
Pneumonia
Cancer
Neurosurgery
GI Bowel Surgery
37,567
57,254
28,213
47,877
11,712
4,866
16,293
14,595
3,284
10,916
1,381
5.08
5.04
7.27
4.43
11.84
13.53
6.64
5.46
10.34
13.94
17.51
1.42
0.88
1.54
0.96
2.04
4.27
1.25
1.08
3.60
3.78
5.68
$4,403
$4,367
$4,470
$4,319
$4,339
$4,655
$4,286
$4,359
$4,502
$4,504
$4,962
Under Consideration
Gynaecology
Spinal
Respiratory Other
Thoracic Surgery
Cancer Surgery
Gastric Bypass
Vision Care
21,792
14,362
9,883
10,823
7,771
2,653
3,016
1,647
1,825
2.56
5.21
7.21
5.91
4.83
7.41
4.18
2.77
3.31
0.90
1.08
1.59
1.17
1.11
2.93
1.43
1.44
0.76
$4,461
$4,551
$4,407
$4,408
$4,318
$4,450
$4,632
$3,751
$4,852
These numbers are preliminary and are subject to change.
* Provincial Case Volumes have been extracted from the Canadian Institute for Health Information's (CIHI) Discharge Abstract Database (DAD) and grouped using HBAM Inpatient Grouper methodology (HIGs). Provincial case volumes are based on
2010/11 data and are reflective of acute inpatient treatment.
** This number solely reflects the ambulatory visits for colonoscopy.
*** The Ontario-specific Comprehensive Ambulatory Classification System (CACS) weights are the ambulatory care weights used within HBAM.
June 18, 2012
Interim Quality Based Procedures List for Stakeholder Consultation (FY 2013/14 and 2014/15)
Quality-Based Procedures by HBAM Inpatient Groupers (HIGs)
This list has been developed for stakeholder consultation. We expect health sector experts to provide us advice on where we can
make the biggest impact on patient care.
Evidence-based framework for selecting Quality-Based Procedures
HBAM INPATIENT
GROUPER (HIG)
CODE
HBAM INPATIENT GROUPER (HIG) LONG DESCRIPTION
YEAR
2013/14
Coronary Artery Disease with Surgical
Intervention
161
162
170
172
174
Implantation of Cardioverter/Defibrillator
Cardiac Valve Replacement
Coronary Artery Bypass Graft without Coronary Angiogram with MI/Shock/Arrest with Pump
Coronary Artery Bypass Graft without Coronary Angiogram without MI/Shock/Arrest with/without Pump
Pacemaker Implantation/Removal Except Cardioverter/Defibrillator Implant
175
176
196
Percutaneous Coronary Intervention with MI/Shock/Arrest/Heart Failure
Percutaneous Coronary Intervention without MI/Shock/Arrest/Heart Failure
Heart Failure without Coronary Angiogram
317
319
726
727
729
766
Revised Hip Replacement without Infection
Revised Knee Replacement without Infection
Hip Replacement with Trauma/Complication of Treatment
Fixation/Repair Hip/Femur
Replacement/Fixation/Repair of Tibia/Fibula/Knee
Fracture of Femur
139a
139b
Chronic Bronchitis
Stroke
025
026
028
029
Hemorrhagic Event of Central Nervous System
Ischemic Event of Central Nervous System
Unspecified Stroke
Transient Ischemic Attack
179
181
182
185
Cardiac Conduction System Intervention
Abdominal Aorta Intervention
Bypass/Extraction of Vein/Artery of Limb
Other/Miscellaneous Vascular Intervention
Colonoscopy
CACS cells
Biopsy Lower Digestive System
Inspection Digestive Tract
Partial Excision Anus, Rectum, Intestine
Biopsy Esophagus, Stomach
June 18, 2012
YEAR
2014/15
Caesarean Section
HBAM INPATIENT
GROUPER (HIG)
CODE
558a
558b
559a
559b
560a
Primary Caesarean Section, with induction
Primary Caesarean Section, with induction with obstetric comorbidity
Primary Caesarean Section, no induction
Primary Caesarean Section, no induction with obstetric comorbidity
Caesarean Section with uterine scar, no induction
Kidney Disease
477
480
Renal Failure
Kidney Disease
638
639
Chemotherapy/Radiotherapy Admission for Neoplasm
Other Chemotherapy
233
234
228
229
225
226
227
231
232
237
Complicated Appendectomy
Simple Appendectomy
Complex Hernia Repair
Non-Complex Hernia Repair
Non-Major Excision/Repair of Upper Gastrointestinal Tract, Unplanned
Non-Major Excision/Repair of Upper Gastrointestinal Tract, Planned
Endoscopic Large Intestine/Rectum Resection without Colostomy
Minor Upper Gastrointestinal Intervention
Minor Lower Gastrointestinal Intervention
Other Intervention with Gastrointestinal Diagnosis
248
249
253
254
255
256
257
258
Severe Enteritis
Non-severe Enteritis
Inflammatory Bowel Disease
Gastrointestinal Hemorrhage
Gastrointestinal Obstruction
Esophagitis/Gastritis/Miscellaneous Digestive Disease
Symptom/Sign of Digestive System
Other Gastrointestinal Disorder
Pneumonia
135
136
138
141
Aspiration Pneumonia
Bacterial Pneumonia
Viral/Unspecified Pneumonia
Upper/Lower Respiratory Infection
June 18, 2012
YEAR
HBAM INPATIENT
GROUPER (HIG)
CODE
193a
194a
194b
202
203a
204a
207a
208a
Myocardial Infarction/Shock/Arrest with Coronary Angiogram
Myocardial Infarction/Shock/Arrest without Coronary Angiogram
Myocardial Infarction/Shock/Arrest without Coronary Angiogram with Comorbid Cardiac Conditions
Arrhythmia without Coronary Angiogram
Unstable Angina/Atherosclerotic Heart Disease with Coronary Angiogram
Unstable Angina/Atherosclerotic Heart Disease without Coronary Angiogram
Angina (except Unstable)/Chest Pain with Coronary Angiogram
Angina (except Unstable)/Chest Pain without Coronary Angiogram
Cancer
250c
284
038
132
357
628
Digestive Malignancy - Other
Hepatobiliary/Pancreatic Malignancy
Neoplasm of Central Nervous System
Malignant Neoplasm of Respiratory System
Musculoskeletal Malignant Neoplasm
Lymphoma
130
142
Respiratory Failure
Other Lung Disease
285
286
287
288
Cirrhosis/Alcoholic Hepatitis
Liver Disease except Cirrhosis/Malignancy
Disorder of Pancreas except Malignancy
Disorder of Biliary Tract
205
206
209
213
Syncope
Benign Hypertension
Other/Miscellaneous Cardiac Disorder
Other/Miscellaneous Vascular Disease
Neurosurgery
005
009
012
Insertion of Shunt/Brain Monitor
Excision/Repair of Brain
Open Carotid Endarterectomy
GI Bowel Surgery
221
222
223
Colostomy/Enterostomy
Open Large Intestine/Rectum Resection without Colostomy, Unplanned
Open Large Intestine/Rectum Resection without Colostomy, Planned
450
618a
725
762
Kidney Transplant
Bone Marrow/Stem Cell Transplant
Organ Transplant with Trauma/Complication of Treatment
Complication of Transplanted Organ
June 18, 2012
YEAR
Under
Gynaecology
Consideration
HBAM INPATIENT
GROUPER (HIG)
CODE
501
502
505
507
509
524
Hysterectomy with Malignancy
Hysterectomy with Non Malignant Diagnosis
Ovarian/Fallopian Tube Intervention with Non Malignant Diagnosis except Endoscopic Approach
Repair/Brachytherapy/Other Intervention on Female Reproductive System except Tube/Ovary
Therapeutic Intervention on Female Reproductive System, Laparoscopic Approach
Disorder of Menstruation/Endometriosis/Non-inflammatory Disorder of Female Reproductive System
334
341
370
739
747
770
761
Major Foot Intervention except Soft Tissue without Infection
Shoulder/Rotator Cuff Intervention
Inflammatory and Reactive Arthropathy
Reduction/Fixation/Repair Upper Body/Limb except Fixation/Repair of Shoulder
Reduction/Fixation/Repair of Ankle/Foot
Other Fracture/Dislocation of Arm/Shoulder
Fracture/Dislocation/Rupture of Pelvis/Sacrum/Coccyx
Spinal
313
314
360
364
771
Spinal Vertebrae Intervention
Other Intervention on Back/Neck
Vertebral/Disc Disease
Back Pain/Strain
Spinal Injury
Respiratory Other
097
143
148
149
200
Influenza/Acute Upper Respiratory Infection
Disease of Pleura
Other Respiratory Disorder
Symptom/Sign of Respiratory System
Pulmonary Embolism
278
280
281
Laparoscopic Cholecystectomy with/without Common Bile Duct Exploration
Dilation/Drainage of Common Bile Duct
Extraction/Destruction of Calculus Common Bile Duct
Thoracic Surgery
112
114
Open Thoracic Lung Resection
Endoscopic Lung Resection
Cancer Surgery
387
615
Unilateral Total/Radical Excision of Breast
Intervention with Lymphoma
Gastric Bypass
422
Gastric Bypass
June 18, 2012
YEAR
Vision Care
HBAM INPATIENT
GROUPER (HIG)
CODE
050
051
054
055
056
063
064
065
748
Orbit/Eyeball Intervention
Lens Extraction/Insertion
Sclera/Choroid/Retina Intervention without Vitrectomy
Lacrimal System Intervention
Other Ophthalmic Intervention
Inflammation of Orbit
Major Ophthalmology Disorder
Other Ophthalmology Disorder
Other Intervention for Trauma/Complication of Treatment
June 18, 2012
Appendix D
Summary of Integration Structures (from Literature Scan)
Integration structures are described in terms of degree of integration, type of integration and
level of integration .
Typology of Integration Structures 1
Degree of Integration
Type of Integration
Linkage/Network
Vertical
Coordination
Horizontal
Organizational
Service
Clinical
Functional
Physician
Level of Integration
Macro
Meso
Micro
Degrees of integration: (Curry, 2010)
•
Linkages: organizations agree to collaborate to improve outcomes
•
Co-ordination: organizations put defined structures and processes in place to overcome
fragmentatioin
•
Merged: establishment of new organization or program with pooled resources
.All three degrees of integration can be real, entailing mergers between organizations, or virtual,
characterized by contractual relations(e.g. alliances or partnerships).
Types of integration are also identified in the literature (Suter, 2007; Curry, 2010; Shortell,
1996 ) These include:
•
Vertical: when two or more organizations/services delivering care to a population at
different levels come together (e.g.acute-care and CCAC).
•
Horizontal: where two or more organizations or services delivering care at a similar level
come together (e.g. hospital mergers).
•
Service: integration of different clinical services at an organizational level (for example,
multi-disciplinary teams).
•
Clinical: where functions and activities are organized around patient care and services.Care
is integrated into a single or coherent process within and/or across professions (e.g. shared
guidelines and protocols).
•
Functional: the coordination of key supportive, non-clinical functions and activities (e.g.
Human Resources, Finance) across operating units.
1
Suter, 2007, p17; Curry, 2010 p4; Shortell et al 2000 sl17
•
Physician: economically linking physicians to the system and fostering their participation in
planning, management and governance.
Levels of integration make up yet another typology (Curry, 2010). Three levels of integration
are described:
•
Macro: providers deliver integrated care to an entire population (e.g. Health Maintenance
Organizations).
•
Meso: providers seek to deliver care for a particular population with the same condition or
need through the use of pathways/guidelines (e.g. Chronic Obstructive Pulmonary Disease).
•
Micro: integrated care is provided to individual service users through care coordination,
care planning, or technology, for instance.
APPENDIX E
REVIEW OF EXISTING REGIONAL PROGRAMS
Toronto Central LHIN Joint Health and Disease Management Program (MacLeod, 2009) is a
collaborative effort which began in 2005 in response to the Wait Time Strategy focus on total joint
replacements. Key highlights of the program model include:
o A clear, clinical focus to improve care and access for joint replacement patients;
o LHIN guidance and participation in the model (the LHIN CEO chaired the steering
committee);
o An executive committee as well as a clinical council to provide advice and facilitate
consensus building among partners;
o Voluntary participation initially which evolved to accountability agreements between partners;
o Development of program deliverables, performance measures and reporting mechanisms.
Elements of system change associated with the model and envisioned to extend to other patient
populations were wait times, best practices, human resources, information technology, accountability,
and knowledge transfer.
As of 2012, the program continues to be a model for orthopedic care in Ontario.
Champlain Maternal Newborn Regional Program (Blueprint, 2009): is a broader type of regional
program, based on a service delivery model defined by the scopes of care provided at each
participating organization. The program is relatively new, but developed from a well-established
network organization (Perinatal Partnership Program of Eastern and Southeastern Ontario). The three
key elements of this program are:
o Planning
o Service delivery, and
o Performance management
Governance is a shared, collaborative model among the Champlain LHIN, maternal and newborn
health service providers, partner organizations and other stakeholders. Service integration, quality
improvement and sustainability are guiding principles of the program.
Champlain Regional Cancer Program (The Ottawa Regional Cancer Centre, 2006; Doering,
2012): in place since 2006, this program evolved via a network of regional partners who provided
cancer surgery in the region. The program links:
o Cancer care provider organizations, and
o Patients and decision makers involved in prevention, screening, diagnosis, treatment,
supportive and palliative care.
The program focuses on access to service within local communities, ensuring provincial and regional
standards for cancer care are met, and on integrating and coordinating cancer care. The program is a
hub-and-spoke model, with the hub (Ottawa Regional Cancer Assessment Centre) providing
leadership to seven satellite cancer programs.
Wait times provided the initial impetus for change, but quality is embedded in the program through a
number of elements such as disease site-specific Communities of Practice, clinical guidelines of care,
and multi-disciplinary care conferencing.
Capacity building and collaboration are identified as key enablers of the program. The Regional
Cancer Surgery Program reports to the Regional Cancer Program, which in turn, reports to Cancer
Care Ontario. There is a regional Vice President for Cancer Care in the Champlain LHIN.
Champlain Hospice Palliative Care Program (Champlain Hospice Palliative Care Program Plan,
2010): is the most recent program to adopt a formalized, regional approach.
Goals of the program are to:
o Integrate and coordinate current services
o Improve access for palliative patients
o Develop a strategic, regional program plan, and
o Provide leadership/direction for regional palliative care providers via a program council
structure informed by a variety of advisory groups.
Knowledge translation, performance measures and common standards are identified as priorities.
Rehabilitation Network of Champlain (Rehabilitation Network of Champlain, 2012): This network
of program planners, administrators and clinicians is working to develop a regional rehabilitation
program to achieve similar goals of coordination, access, standardization and sustainability.
Appendix F
Appendix G
Project Charter Champlain Orthopedic Program Planning Initiative (COPPI)
Draft Version: 1.5 12/21/2011 Project Charter: Champlain Orthopedic
Program Planning Initiative
1. Revision History
Version* Author
0.2
Brian
Schnarch
1.0
1.0
1.2
1.3
1.4
Date
Reviewed by
06/21/11 Pierre Noel, Lisa
Sullivan, Sari Kline
06/23/11 ROPC
06/30/11 West Champlain
Surgical Steering
Committee
06/29/11 Champlain LHIN Senior
Management Team
09/26/11 Hospital/CCAC CEO
meeting
Nov, Dec LHIN staff and P. Noel
11
Summary of changes
Assorted
Surgeon Advisory Group added to planning structure
Assorted changes, primarily to planning structure and
membership of Leadership Group
Revisions to planning structure and timelines.
Assorted
Hawkesbury and Kemptville added, timelines updated,
governance structure and project management clarified,
signoff page removed, various revisions for clarity
*Version that was reviewed.
2. Background
Over the years, surgical services have developed separately in 14 hospitals (16 sites) across
Champlain. Four hospitals (five sites) provide joint replacements, and nine others offer “light”
orthopedic procedures (e.g. hand surgery, carpal tunnel release, knee arthroscopy). All acute care
hospitals assess and refer orthopedic patients.
In recent years, there has been some coordination in the management of orthopedic surgery, including
central intake for joint replacements and a shared orthopedic call schedule involving four hospitals.
Much more can be done at the regional level to harmonize and coordinate orthopedic surgical care in
order to ensure quality, access and sustainability. A regional orthopedic program has the potential to
improve services in five key areas:
1) Opportunity to improve access to services.
a) Wait times: Some patients wait longer than others
b) Distances: Some patients travel further even though some treatments might be provided
closer to home.
c) Non-urgent transportation is uneven
2) Opportunity to optimize distribution of resources
a) Available medical manpower (e.g. surgeons avail. to do more/ canceled surgeries)
b) Available operating room capacity
c) Available beds (ALC and occupancy constraints)
Coordinating resources as regional assets can increase efficiency, equity & access.
Draft Champlain Orthopedic Program Planning Initiative (COPPI) Project Charter (v 1.5 Dec 21, 2011)
Page 1
3) Opportunity to Continue Improving Quality/Safety
a) Best practices may not be implemented consistently
b) Regional variations in performance (other than wait time) not routinely monitored
4) Opportunity to Enhance Efficiency/Sustainability
a)
b)
c)
d)
Costs for equivalent treatments vary between sites
Some patients may not be in the optimal place (e.g. pre/post visits in smaller hospitals)
TOH seeking to decant portion 1ary/2ary cases
Need to make best use of available funding (including wait times, PCOP)
5) Opportunity to enhance integration across continuum of care
a)
b)
c)
d)
Patient-centered coordination/navigation through system
Transfers and standards for rehabilitation portion of stay
Integration between prevention and treatment activities
Telemedicine
The Champlain LHIN’s mission involves:
“linking services that help people stay healthy by building a coordinated,
integrated, and accountable health system for people where and when they need
it. Our mission is based on a strong foundation of local community engagement,
comprehensive planning, and appropriate resource allocation.”
The development of regional programs is a key strategy for achieving that mission.
Following a detailed review of data, issues and opportunities, the West Champlain Surgical Services
Steering Committee1 prioritized the development of a regional program in orthopedics. In May 2011, the
Steering Committee, the Regional Orthopedic Planning Committee2 and the Champlain LHIN agreed to
collaborate on the initiative. This charter seeks to outline the details of the project.
1
The West Champlain Surgical Steering Committee includes hospital CEOs from Pembroke Regional, Renfrew Victoria, Arnprior Distict Memorial, Carleton Place, Almonte, Queensway‐Carleton, Kemptville and the Ottawa Hospital. The Regional Orthopedic Planning Committee includes administrators and surgeons from the Ottawa Hospital, Queensway‐Carleton, Montfort and Cornwall Community plus representatives from Criticall, the Champlain LHIN and the Manager of the Regional Hip and Knee Central Intake Centre. 2
Page 2
3. Purpose:
The purpose of the Champlain Orthopedic Program Planning Initiative is to produce a plan for
recommendation to the Champlain LHIN board. The plan will articulate a regional orthopedic program
model that addresses all key components, including:
a) The program’s model
i) structure (governance, accountability, clinical and administrative leadership)
ii) roles and functions (e.g. service coordination, performance monitoring and management,
stakeholder engagement)
iii) funding requirements and model
b) Any changes to the distribution of orthopedic services
c) A business case (why the program should be implemented)
d) An implementation timeline and strategy
The planning initiative will consider the full continuum of orthopedic care as defined in section 6, below.
The initiative will be implemented in keeping with the guiding principles (section 4, below) and planning
considerations (section 5, below).
The plan may include recommendations related but not limited to:




Program standards, best practices, clinical pathways, protocols, reporting systems
Referral systems
Funding models
Medical manpower
4. Guiding Principles
The work of the initiative’s planning committee(s) will be guided by the following principles:
a)
b)
c)
d)
e)
f)
g)
Optimal Patient Flow and Clinical Coherence: the organization of surgical services will be
aligned by site to ensure that clinical interdependencies and patient flow is optimized and is
efficient.
Appropriate Critical Mass: the organization of surgical services will be structured to ensure
that programs/services have appropriate critical mass (i.e. volume) to allow for the provision
of safe, effective, efficient and timely services while reflecting rural considerations.
Enhanced Accessibility: the organization of surgical services will be structured to improve
patients access to high quality programs/services (i.e. wait time, closer to home)
Quality of Care: the organization of surgical services will ensure quality of care standards
and practices, clinical outcomes, safety and risk management are optimized.
Enhanced Cost Effectiveness: the organization of surgical services will be structured to
create a more effective and efficient service cost profile and will not result in increased
system funding for operations.
Integration and Service Coordination: the organization of surgical services will result in
greater integration and coordination of services.
Patient experience: the organization of surgical services will be structured to enhance the
patient’s experience and a focus on the patient’s needs will be maintained throughout the
planning process.
Page 3
h)
i)
j)
k)
l)
Francophone services: Service distribution should be consistent with French language
service designation. Any changes to distribution must take into account the impact on
Francophone clients and, where possible, aim to improve access to French language
services. The Réseau des services de santé en français de l'Est de l'Ontario should be
engaged as appropriate.
Financial resources: any redistribution of surgical clinical services will be achieved within
the existing funding allocation for the sector.
Human resources: any changes to the organization of surgical services will be planned and
implemented with proper consideration of the human resource implications
Evidence-based approaches: hospital clinical services planning will make use of best
available evidence
Teaching and research opportunities: the configuration of surgical services will be
structured in keeping with teaching and research needs.
5. Planning Considerations
The development of a plan for a regional orthopedic program will be directed by the guiding principles
above. However, a number of additional considerations should also be contemplated:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
Provincial priorities, initiatives and plans: The plan should take into account and align
with provincial projects, initiatives and plans, including wait times and the Orthopedic Quality
Scorecard.
Champlain priorities and plans: The plan should take into account and align with the
Champlain LHIN’s priorities and plans, including the Integrated Health Services Plan.
Health service providers’ priorities and plans: The plan should take into account and align
with the priorities and plans of the region’s hospitals and other health service providers,
including capital and program plans.
Alternate level of Care (ALC): Impact on ALC should be considered in the formulation of
recommendations.
Current roles: Recommendations should not be limited by the mandates, roles and current
service configurations. Recommendations could include changes to the role or scope or
volumes of orthopedic services provided by Champlain hospitals, the CCAC and other health
service providers.
Funding mechanisms: Recommendations may require funding redistribution. Mechanisms
and obstacles to implementing proposed changes should be considered.
Information technology: Integration of programs and services may be enabled or may
depend on the integration of information systems. Recommendations should consider IT
needs and align with the Champlain eHealth strategy as appropriate.
Impact on other sectors: The impact or potential impact of recommendations on other
sectors not specifically in scope (see # 6 below) should be assessed and considered.
Patients and services outside of Champlain: Recommendations and planning should
consider the provision of care to patients from outside the Champlain region.
Recommendations should also consider information about any planned changes to
orthopedic services in areas that ‘send’ patients to Champlain.
Transportation: The planning exercise should consider the transportation needs of patients,
particularly when considering changes in service distribution or locations. Likewise, existing
transportation services and plans should be a consideration in planning orthopedic services.
Early successes: It will take time to complete the plans and implementation of a regional
program. En route, short-term strategies and interim steps that provide clinical or other
benefits should be considered. This will help to sustain support for (full) implementation of the
plan. The interim steps should be consistent with the overall plan.
Page 4
l)
m)
n)
Evaluation: Evaluating the benefits of change is key to success. Performance metrics and
success indicators should be identified prior to implementing changes. They should be
measured (as baseline), reported and tracked as the project/implementation progresses.
Aboriginal populations: Any changes in service distribution should improve service access
for Aboriginal people. The Aboriginal Health Circle Forum should be engaged if/as
appropriate.
Immigrant populations: Any changes in service distribution should improve service access
for Immigrant populations.
Page 5
6. Scope
The following services are in scope:
Service
Referral/triage
Pre admission workup
Pre-surgical clinical visits
Surgical interventions of various kinds and levels of complexity (e.g. knee replacement, hip replacement, hip
In
scope
Central
Central
Central
Central
fracture, leg bone fractures, other hip and knee procedures, knee arthroscopy, foot surgery, ankle surgery, ACL
Repair, shoulder surgery, hand surgery, carpal tunnel release)
Post operative recovery
Post operative rehabilitation- inpatient
Post operative rehabilitation- outpatient
Post operative rehabilitation- community
Post operative clinical visits
Ancillary services (e.g. laboratory, diagnostic imaging, pharmacy)
Prevention
Community follow-up
Central
Central
Central
Central
Central
Yes
Yes
Indirect
*Including services provided via telehealth.
The following sectors are in scope:
Sector
In scope
Adult* acute care hospitals that provide orthopedic surgery Central
Acute care hospitals that do not provide orthopedic surgery Yes
Rehabilitation hospitals
Central
Community Care Access Centre
Central
Primary Care (re referrals, follow-up and minor procedures) Indirect
*CHEO plays a unique, specialized role. The Leadership Group will determine how best to link with CHEO’s pediatric orthopedic services.
Services provided by the following professionals are in scope:
Professions
In scope
Orthopedic surgeons
Central
Other surgeons who do minor orthopedic procedures
Central
Other physicians responsible for patients after surgery
Yes
OR trained RNs, RPNs and Assistants
Yes
Recovery room nurses
Yes
Anesthetists
Yes
Physiotherapists, Occupational Therapists, PT assistants, OT assistants Yes
Legend:



Central: the element is in-scope and is core or central to the project.
Yes: the element is in scope but not central to the project
Indirect: the element has some impact on planning and/or will experience some impact as a
result of the plan
Page 6
7. Key Activities and Timelines
2012
2
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
1.Establish, Launch Planning Committee
2.Identify chair(s) of steering committee
3.Identify, secure PM, support resources
4.Finalize project charter
5.Develop communications/engagement plan
7.Determine, launch working groups as needed
8.Collect, compile and review data
9.Analyze and synthesize issues, SWOT analyses …
10.Define program roles and functions
11.Define program structure, funding model
12.Define any changes to service distribution
11.Recommend interim steps, short term opportunities
12.Full draft business case, program model, timeline
13.Engage stakeholders, communicate
14.Final plan for recommendation to LHIN Board
Page 7
8. Planning Structure
Champlain LHIN
Regional Orthopedic Planning Committee Working Groups if needed
Champlain Orthopedic Program Plan Leadership Group
Stakeholders (via engagement) Surgeon Advisory Group
The Leadership Group will be responsible for the development of the plan in consultation with
stakeholders. The Leadership Group will establish a surgeon advisory group and working groups as
required. The Leadership Group reports and is accountable to the LHIN for deliverables. The
Leadership Group should report progress and seek direction from the hospital/CCAC sector table
and others as required. The Regional Orthopedic Planning Committee will be kept informed of key
developments and engaged for input and direction as required.
Final decisions, including approval/acceptance of the Champlain Orthopedic Program Plan will be
made by the Champlain LHIN Board of Directors in accordance with the Local Health System
Integration Act (2006). Local hospital and health service providers will be responsible for
implementation of the decisions at the local level.
Note: The role (and potentially the name) of the Regional Orthopedic Planning Committee is
expected to change as a result of this initiative. In the short term, the ROPC may decide to ‘move’
some of its planning activities to the COPPI Leadership Group. In the longer term, most if not all, of
ROPC’s functions will transfer to the regional program (assuming one is established).
9. Project Management Structure
Specific project management roles and responsibilities will be determined by the Leadership Group
in consultation with the LHIN and the health service providers involved. Individuals who may take
responsibility for specific roles and responsibilities could include:





The Leadership Group chair(s)
Other members of the Leadership Group
Other staff affiliated with participating health service provider organizations
Champlain staff (CEO, Senior Director, Health Integration, Health Service Planning Lead,
Senior Epidemiologist, Program Assistant)
Consultant(s)
Page 8
Some of the roles and responsibilities to be allocated may include:
a.
b.
c.
d.
e.
f.
g.
h.
i.
Setting meeting agendas
Coordinating meetings
Meeting minutes and document management
Directing the day-to-day functioning of the project work
Management of project budget (if applicable)
Oversight of work of consultants, including RFP development and selection (if applicable)
Oversight of working groups, if applicable
Ensuring timeframes, deadlines, deliverables are met
Preparing draft reports and documents (e.g. business plan; program structure, roles, functions,
requirements, funding model; implementation timeline and strategy etc.)
j. Development and implementation of engagement and communication plans
 Linking with other committees (e.g. Chiefs of Staff, CNOs)
 Engaging with the community, the public, Francophone and Aboriginal communities
 Project updates to LHIN senior management and LHIN Board
 Project updates to hospital/HSP CEOs
k. Collection, review, analysis of data
l. Literature review and synthesis
Page 9
10.
Leadership Group Terms of Reference
Purpose and mandate:
The Champlain Orthopedic Program Plan Leadership Group will guide and ensure completion of the
Champlain Orthopedic Program Planning Initiative as outlined in the Project Charter. Other
business or activities will not be addressed without a formal change to the terms of the Charter.
Role:
The Leadership Group is an advisory body that will make recommendations to the Champlain LHIN.
Membership:
The Leadership Group includes the following representatives:







Orthopedic leadership from:
o Cornwall Community Hospital
o Hôpital Montfort
o The Ottawa Hospital
o Queensway-Carleton Hospital
Clinical VPs from the:
o Cornwall Community Hospital
o Hôpital Montfort
o The Ottawa Hospital
o Pembroke Regional Hospital
o Hawkesbury General Hospital
o Queensway-Carleton Hospital*
CEO of the Kemptville District Hospital
CEO of a small community hospital
Chair of the West Champlain Surgical Steering Committee*
Chair of the Regional Orthopedic Planning Committee*
VP of the Champlain Community Care Access Centre
Representative from the Rehabilitation Network of Champlain- RNOC

LHIN staff and/or HSP Administrative staff (ex-officio)

*: co-chairs of the COPPI Leadership Group.
Note: stakeholders not represented on the membership (e.g. CHEO and Bruyere) will be informed of progress and have
opportunities to provide feedback via the project’s stakeholder engagement and communications strategies.
Terms of Membership:
Members will be identified by their hospital/health service provider or another reasonable method
for those representing RNOC and small community hospitals. Members will serve for the duration of
the planning project (i.e. until the purpose and activities outlined in the charter are completed.)
Members who cannot attend a specific meeting may send a delegate/alternate on an exceptional
basis. Members who cannot attend a meeting will notify the chair(s) in advance. If a member is
Page 10
unable to participate on a regular basis, they and the chair(s) will determine an appropriate course
of action.
Responsibilities of Members:
Members will:





Participate in meetings, providing expert advice and feedback.
Seek to represent the broad interests of the health system and population needs rather than
the specific interests of individual agencies or interest groups.
Work to reach consensus with other members.
Champion the planning exercise and share information about key project developments with
their home organizations and colleagues, as applicable. Note however, that respect for the
integrity of the planning process may sometimes require that members not share specific
information at specific times (e.g. until consensus is reached).
Serve as champions during implementation of the plan (if applicable).
Mechanisms by which members report to and engage their ‘constituents’ and home organizations
will be developed as part of the communications/ engagement strategy.
Responsibilities of Chair(s):
The chair or chairs (one or two) will be selected by members. In addition to the responsibilities of all
members, the Chair(s) will:






Call meetings
Set meeting agendas
Facilitate meetings in such a manner that all members have the opportunity to express their
views, that agenda items are adequately addressed and meeting objectives are achieved.
Facilitate the reaching of consensus
Ensure follow up on action items arising from meetings
Oversee or arrange for evaluation of the group’s process and effectiveness
Responsibilities of Surgeon Leader:
The Surgeon Leader will be selected by members. In addition to the responsibilities of all members,
the Surgeon Leader will


Champion the planning exercise and share information about key project developments with
orthopedic surgeons
Facilitate input and feedback from orthopedic surgeons to the Leadership Group.
Meetings
Meetings will be held approximately once per month at the discretion of the chair(s). Meetings will
generally be held face-to-face with teleconference or videoconferencing options available at the
discretion of the chair(s). Meetings will vary in duration, from 1 hour to full day sessions, depending
on meeting agenda and purpose. Meetings may piggyback or be combined with meetings of the
Regional Orthopedic Planning Committee.
Page 11
Sub-committees and working groups
Sub-committees or working groups, including potentially a surgeon advisory group may be initiated
as required, at the discretion of the members.
Quorum:
A quorum shall consist of 50% of total members plus 1 (one). Discussions will seek to reach
consensus. If consensus cannot be reached, the views and opinions of dissenting members will
be noted in the minutes and transmitted to the Champlain LHIN Board of Directors when
presenting recommendations.
Evaluation:
The Leadership Group will undertake to evaluate its own process and effectiveness.
Page 12
APPENDIX H
CHAMPLAIN ORTHOPEDIC PROGRAM PLANNING INITIATIVE (DISTRIBUTION
WORKING GROUP): ADDITIONAL PLANNING CONSIDERATIONS
PLANNING CONSIDERATIONS
Provincial
priorities,
initiatives and
plans
Alignment with, and consideration of, provincial projects, initiatives and
plans, including wait times and the Orthopedic Quality Scorecard.
Champlain
priorities and plans
Alignment with, and consideration of, the Champlain LHIN’s priorities and
plans, including the Integrated Health Service Plan.
Health service
providers’
priorities and plans
Alignment with, and consideration of, the priorities and plans of the region’s
hospitals and other health service providers, including capital and program
plans
Alternate Level of
Care (ALC)
Impact on ALC should be considered in the formulation of recommendations.
Current roles
Recommendations should not be limited by the mandates, roles and current
service configurations.
Recommendations could include changes to the role or scope or volumes of
orthopedic services provided by Champlain hospitals, the CCAC and other
health service providers.
Funding
mechanisms
Recommendations may require funding redistribution. Mechanisms and
obstacles to implementing proposed changes should be considered.
Information
technology
Integration of programs and services may be enabled or depend on the
integration of information systems. Recommendations should consider IT
needs and align with the Champlain eHealth strategy, as appropriate.
Impact on other
sectors
The impact or potential impact of recommendations on other sectors not
specifically in scope should be assessed and considered.
Patients and
services outside of
Champlain
Recommendations and planning should consider the provision of care to
patients from outside the Champlain region.
Transportation:
The planning exercise should consider the transportation needs of patients,
particularly when considering changes in service distribution or locations.
Likewise, existing transportation services and plans should be a consideration
in planning orthopedic services.
Early successes
It will take time to complete the plans and implementation of a regional
program. En route, short-term strategies and interim steps that provide clinical
Recommendations should also consider information about any planned
changes to orthopedic services in areas that ‘send’ patients to Champlain.
or other benefits should be considered. This will help to sustain support for
(full) implementation of the plan. The interim steps should be consistent with
the overall plan.
Evaluation
Evaluating the benefits of change is key to success. Performance metrics and
success indicators should be identified prior to implementing changes. They
should be measured (as baseline), reported and tracked as the
project/implementation progresses.
Aboriginal
populations
Any changes in service distribution should improve service access for
Aboriginal people. The Aboriginal Health Circle Forum should be engaged, as
appropriate.
Immigrant
populations
Any changes in service distribution should improve service access for
immigrant populations.
(COPPI Distribution Working Group Terms of Reference, 2012)
Appendix I
Regional Orthopedic Program & Distribution Model: Stakeholder
Communicatation and Consultation Plan (updated March 13, 2013)
Purpose of the Document:
Communication, consultation and engagement are integral to the success of the Regional Orthopedic Program and Distribution model planning process.
The purpose of this document is to outline the activities required and the level of engagement required (eg. information only vs approval vs feedback).
Questions to be answered:
1. What are the benefits of a Regional Orthopedic Program and why is it being planned?
2. How will the plan change the way that orthopedic care is delivered?
3. How will patients navigate the orthopedic system and continuum of care for their care needs?
4. Since many providers are involved, is the governance model presented the appropriate model to provide oversight and coordination?
5. What is expected of the stakeholders/providers and what can they contribute to make the model successful?
6. Are there gaps and opportunities in the model and distribution plan?
What is the Regional Orthopedic Program and Distribution Model?
 Core Functions: planning, service distribution & performance management
 Primary Goal: to improve the health of the orthopedic patient population in the Champlin LHIN by delivering high quality, accessible,
financially sustainable care and service in an integrated and organized manner
 Collaborative decision making model; mandate is to guide quality, performance and access
 Distribution Plan is based on service levels; relies on a co-ordinating regional structure; de-centralizes orthopedic service (care closer to home)
Levels of Communication/Engagement and activities required:
Involve:
What does “Involve” mean? To work directly with stakeholders to plan structure, processes and policy which create the framework for a regional
orthopedic program that is congruent with the needs of orthopedic patients in the LHIN and is built upon the current service provision model
How will stakeholders be involved? By participating on the COPPI Leadership Committee
Who will these stakeholders include? See COPPI Leadership Membership
Consult:
What does “Consult” mean? To consult stakeholders on draft plans or on issues; feedback from stakeholders has an influence on decisions
Who will be consulted? LHIN Senior Management Team; Champlain CEO Forum; Orthopedic Surgeons in the LHIN; Ontario Bone and Joint
Network; Orthopedic Rehabilitation Providers (RNOC); Association of Small Hospitals; Vice Presidents of Patient Care Group; Citizen Advisors
How will stakeholders be consulted? Meetings, consultation forums.
Inform:
What does “Inform” mean? To provide stakeholders with balanced and objective information which will assist them in understanding the changes to
the system and allow input to explore problems, alternatives, opportunities and/or solutions
Who will be informed? Orthopedic service providers and consumers; Public at large, primary care health providers; indirect stakeholders who will be
impacted by the change
How will stakeholders be informed? Postings on the Champlain LHIN website (Q&A fact sheets, activities updates), press releases, articles in local
newspaper; direct mailouts; community forums
Stakeholder Group
COPPI Leadership
Groups
Who
Champlain LHIN
reps,
Administrators
&Surgeons from
TOH, QCH, MH,
CCH, KDH,
RNOC, CCAC,
Central TJAC,
HDH, PRH,
Role & Level of Engagement
(Involve/Consult/Inform)
(Involve)
Advisory to the CH-LHIN CEO and Board of
Directors to make recommendations on the
following:
 Provide expert clinical advice
 Provide, analyze and validate decision
making data
 Choice of program & distribution
models
 Participate in organizing & delivering
stakeholder consultations
How & When – Planned Activities
Active throughout planning stage:
• Meetings beginning Jan- July12 to analyze data
provide advice, receive education re: models;
consensus on planning assumptions, principles
and direction
• Aug 7/12 - adoption of conceptual model with
refinements
• Sept 12/12 – adoption of preliminary
Distribution Service Model
• Sept/12 – Jan/13: share models with decision
makers in respective organizations to solicit
feedback, inform, answer questions
Hospital/CCAC
CEOs
All CH-LHIN
CEO’s
(Involve, Consult)
Leaders in the CH-LHIN who will need to
provide support to the regional program and
distribution changes by:
 Championing the model in their
institutions
 Liasing with physicians in their
institutions to engage commitment
 Providing resources to sustain the
program
LHIN Leadership and Co-Chairs of COPPI presented
model and consult at Hospital/CEO Meeting – Feb 12,
2013
Focus Group – led by T. Schonberg (QCH) re:
improving Wait Times (through standardiazation and
utilization of Central Intake) Jan – April, 2013; project
complete June 2013
Chiefs of Staff
All Chiefs of Staff
from Champlain
LHIN Hospitals
(Consult)
Physician Leaders in their organizations who
will need to provide support to the regional
program and distribution changes by:
institutions
 Liasing with physicians in their
institutions to engage commitment
COPPI Co-Chair (Dr A. Falconer – Chief of Staff
QCH) presented to a forum of Chiefs of Staff (May
2013)
Orthopedic
Surgeons
All Orthopedic
Surgeons who
provide service in
the CH-LHIN
(Consult)
Surgeons in each institution who provide
elective and emergency orthopedic care who
will need to participate in the various
components of the model (eg. communities of
practice, central assessment, affiliations
between hospitals that provide different levels
of orthopedic care, clinical standardization,
human resource planning) by:
 Understanding the regional model
 Providing constructive, critical
feedback
 Providing clinical expertise/knowledge
Member of the COPPI Leadership Group to present to
an all surgeons meeting (Date TBD)
CEO & Medical
Leaders
(Consult & Information)
 Review model with CHEO medical,
Member of the COPPI Leadership Group
There are 5 orthopedic Surgeons – request a dept mtg
Children’s Hospital
of Eastern Ontario
Each ortho surgeon Rep from ortho hospitals to book
time for the Regional Program presentation at their
departmental/divisional meetings. Each will present to
their own group with particpation from A Falconer or P
Noel plus a LHIN rep. After initial CEO mtgs with C
LeClerc.
Include Anesthesia in these meetings
Get consensus at these four mtgs then plan a joint
meeting of all ortho surgeons from all acute care
hospitals. All surgeon mtg – planned July 2013
Francophone
Population
Le Reseau
Orthopedic
Rehabilitation
Providers
Rehabilitation
Network of CHLHIN
(RNOC)
clinical and administration staff to
ensure understanding and determine
implications for CHEO
(Consult)
 Review proposal to ensure needs of
Francophone residents are met
time. Same representation as above. Invite Nsg, Chief
of Staff and others as identified by CHEO to that
meeting.
Contact and engage Le Reseau representatives Nov/12
complete – final proposal and request for formal
feedback sent June 2013
(Involve)
Regional Network with representation from all
Physiotherapy providers with ability to advise
on:
 Available rehab services
 Clinic best practice standards
 Appropriate rehab settings and
locations
RNOC Chair engaged by LHIN COPPI staff Aug/12 to
request members to participation on RNOC/COPPI
Working Group whose purpose is to plan appropriate
rehab services to match Orthopedic Regional Model
and Distribution Plan
• RNOC committee – presentation by J.
Humphries (MOH) re: HBAM funding model
& impact on rehab Sept/12
• RNOC/COPPI Working Grp – 1st mtg Aug
24/12
• Working Grp to provide recommendations to
LHIN re: rehab capacity – for submission of
Integrated Orthopedic Capacity Plan
• COPPI to provide updates on planning activities
at each meeting
• Participation in COPPI/RNOC Working Grp
• Requested to complete data template for TJR
(inventory of outpt service provided) – Sept 28th
deadline; data will be compiled and shared with
the providers (Oct/12)
Hospital Outpatient (Involve)
Physiotherapy
Directors/Managers of Outpatient
Providers
Rehabilitation Services at all hospitals that
provide outpatient physiotherapy to orthopedic
patients.
Role:
 provide data on service provision
 define/describe treatment models
 participate in planning exercises to
improve access/quality
Private
(Consult and Inform)
Physiotherapy
Role:
Providers
 Be aware of changes to treatment
protocols/pathways
Determine if a common communication path exists –
contact a large private organization (Oct/12) done
Request information re: type and amount of services
provided if available (Oct/12)
CCAC
Physiotherapy
Providers
Experts/Advisors
Bone & Joint
Network
Champlain
Regional Cancer
Program
Leaders
Communities
of Practice Experts
 Plan service to match model and
distribution plan
 Determine potential for partnerships
between hospital providers or other
organizations to provide rehab for
orthopedic patients in underserviced
areas
(Involve and Inform)
CCAC Director of Therapies – role is to:
 Provide data on service provision
 Define/describe treatment models and
role for community-based ortho rehab
in the CH-LHIN
(Consult)
Rhona McGlasson (Bone & Joint Network)
Dr. J. Waddell (Bone & Joint Network)
 Provide advice on model components
or activities based on prior experience
and/or expert knowledge
(Consult)
Paula Doering (Regional VP Cancer Care)
Dr M. Fung-kee-Fung (Expert – Communities
of Practice Model)
Provide information (via written correspondence) of
changes in model & surgical service distribution
changes
Jan.Feb/13
•
•
Participation in COPPI/RNOC Working Grp
Requested to complete data template for TJR
(inventory of outpt service provided) – Sept 28th
deadline; data will be compiled and shared with
the providers (Oct/12) done
Apr/12: teleconference re: advice for Devt stage
June/12: mtg with Rhona McGlasson re: progress
Sept/12: teleconference MOH & RM re: IOCP
Nov/12: Send draft reports to Rhona McGlasson (B&J
Network) for feedback. Done
Re-consultation June/13 – will attend all surgeon mtg
in July/13
June/12 – P Doering consulted – VP Regional Cancer
Program
June/12 – R Morash – Regional Cancer Coordinator re:
Regional program, Comm of Practice, data collection
(Consult)
Sept 19/12 – Dr M. Fung-kee-Fung consulted re:
Dr M. Fung-kee-Fung (Regional Cancer
Communities of Practice – will provide further
Program Leader)
guidance/advice if req’d.
 Provide advice/expert knowledge on
relevance/appropriateness of applying a
Community of Practice model in
orthopedics based on prior experience
Clinical/Orthopedic (Consult)
Planning Experts
Maureen Sly-Havey (Project Manager Central
TJAC)
Debbie Kennedy (Manager, Rehabilitation and
Program Development
Holland Orthopaedic & Arthritic Centre)
Dr. J. Gordon (Lead Surgeon Central TJAC)
Champlain VP Pt
(Consult)
Forum for Chief
Care /Nurse
Nursing Leaders in the CH-LHIN who will
Nursing Executives
need to provide support to the regional
(FCNE) – CH-LHIN Leaders from
Hospitals,
program and distribution changes by:
Educational
Institutions,
institutions
CCAC, Ottawa
 Providing a forum and feedback on
Public Health
roles/opportunities for clinical quality
improvement
Primary Health
(Consult and Inform)
Primary Health
Care Teams
Practitioners who refer patients for specialized
Providers
General
orthopedic care and who follow up post
Practitioners/Nurse procedure/consultation
Practitioners
Role:
 Understand processes associated with
referral
 Provide feedback on gaps/opportunities
to improve orthopedic care
(Inform and Consult)
Emergency Services CESN
Provide information re: changes to emergency
Personnel
referral/orthopedic care for emergency patients
- Seek input/advice
(Consult)
Accessors/Recipients Patients who have
of Orthopedic Care received orthopedic Focus group of post op orthopedic patients
care
receiving class format physiotherapy at one of
the outpatient physiotherapy clinics
Role:
 Provide input on the model and
Aug/12
Aug/12 – teleconference; additional material provided;
Holland Centre criteria for surgery at Holland Centre
provided
Nov 2, 2012 – Dr Gordon – met with project team (SK,
BS, HB); provided advice for physician engagement.
COPPI Reps to present model and consult at FCNE
meeting (Date TBD)
Project Manager to provide updates as planning
progresses
L Perrault, K Peterson and M Taylor-Greenly will
present to this group
Provide written material (Feb/13)
Access a general mtg if available (Jan/13)
There is a Regional Primary Care Lead (Dr L Donahue)
who chairs quarterly meetings – access this group to
provide information.
Attend CESN meeting to present proposal
A Falconer with LHIN reps
Nov-Dec/12 Project Manager to approach QCH or
Montfort or Riverside re attending a physio class; liase
with Maureen Sly-Havey re: an survey as 1st step of
implementation work
distribution plan
 Identify gaps & opportunities to
improve orthopedic care
Patients who will
require orthopedic
care
Consider – questionnaire to be administered by
TJAC assessor to pts
(Inform)
Written material for GP offices
To receive communication re: changes to the
Articles in local newspapers
services provided
Open Forum for communities affected
Supporting Documents
Community Engagement Reference Guide, LHIN
LHIN Community Engagement Guidelines and Toolkit.Ministry of Health and Long Term Care. February 2011
APPENDIX J
CHAMPLAIN LHIN ORTHOPEDIC REGIONAL PROGRAM
Roles/Responsibilities of Champlain LHIN Orthopedic Surgeons
Intent:
The Champlain Regional Orthopedic Program recognizes that the resources (including
Human Resources) required to ensure integrated, organized and coordinated orthopedic
care are shared. The following is meant as a guideline for Orthopedic Surgeons practicing
in the Champlain LHIN to ensure that access to orthopedic care is fair and equitable. It is
intended to define the role of the surgeon as a participant in the Regional Orthopedic
Program.
Roles/Responsibilities of Orthpedic Surgeons:
1. Participate and provide orthopedic emergency/on-call coverage to patients in the
Champlain LHIN.
2. Participate in the Orthopedic Communities of Practice Model which
 acts as a clinical advisory forum for the Regional Program
for long term strategic planning
 plans and delivers professional education for orthopedic care for all providers
 standardizes clinical care throughout the region based on evidence
 develops and sustains collaborative relationships between those providing
orthopedic care (interdisciplinary, clinical-administrative, inter-organization)
3. Participates in Centralized Assessment Models
4. Help to meet regional performance targets, including management of wait times,
length of stay and inpatient rehabilitation rates.
(Update Jan 2, 2013)

Champlain Regional Orthopedic Program and

Transcription

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