Session 2 Quality-Based Procedures: Improving Quality and Consistency ... · Session 2...
Transcript of Session 2 Quality-Based Procedures: Improving Quality and Consistency ... · Session 2...
Session 2 – Quality-Based Procedures: Improving
Quality and Consistency in the Health System
Speakers: Laura Park-Wyllie, Erik Hellsten,
Stacey Brener, Dr. David Alter, Dr. Doug Lee
Moderator: Laura Park-Wyllie
Presenter Disclosure
2
• Session Name: Quality-Based Procedures: Improving Quality
and Consistency in the Health System
• Presenters: Laura Park-Wyllie (moderator), Stacey Brener, Erik
Hellsten, Dr. David Alter, Dr. Douglas Lee
• Relationships with commercial interests:
– Not Applicable
Disclosure of Commercial Support
• This session has received no commercial support
3
Mitigating Potential Bias
• Not applicable
4
Session Objectives
1. Learn about Health Quality Ontario’s approach to developing
evidence-informed, quality-based episodes of care
2. Learn about a high-level implementation strategy that leverages
stakeholder relationships to encourage the uptake of evidence-
based practices across the health system
5
Data Meets Clinical Intuition:
Developing the QBP Patient Cohorts and
Stratification Approach
Erik Hellsten
7
Excellent Care for All Act, 2010
(c) to promote health care that is supported by the best available scientific evidence by,
(i) making recommendations to health care organizations and other entities on standards of care in the health system, based on or respecting clinical practice guidelines and protocols, and
(ii) making recommendations, based on evidence and with consideration of the recommendations in subclause (i), to the Minister concerning the Government of Ontario’s provision of funding for health care services and medical devices
Why Us? HQO’s Legislated Mandate with Respect to
Funding
Why Quality Based Procedures? (QBP) Context for this Work
The Ministry asked HQO to work with expert panels to develop analysis and recommendations to inform the new Quality-Based Procedures episode-based hospital funding policy for the following clinical areas:
Congestive Heart Failure (Clinical Handbook published)
Chronic Obstructive Pulmonary Disease (Clinical Handbook published)
Stroke (Clinical Handbook published)
Hip Fracture (Clinical Handbook finalized)
Primary Hip and Knee Replacement (In progress)
Pneumonia (In progress)
Key tasks:• Define patient cohort(s), scope of the episode of care, subgroups, risk adjustment approach
• Identification of evidence-based recommended practices, key performance indicators and implementation considerations
Х Out of scope: Unit costing analysis, pricing, payment design
HQO tasked with completing all the above for each area in 5 months
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HQO’s Quality-Based Procedure Process
9
Expert Panel
Comprised of
clinical,
administrative,
community,
and ministry
experts
Patient cohort and
stratification
approach developed
using administrative
data in conjunction with
the expert panel
Recommended
Practices developed
with evidentiary
support and expert
panel consensus
Implementation
levers and barriers to
the recommended
practices
Expert Panel
Comprised of
clinical,
administrative,
community,
and ministry
experts
OH
TA
C
Indicators to identify
outcome measures of
successful
implementation and
ongoing utilization of
good clinical practices
identified in the QBP
Nodal Network
knowledge dissemination
plan developed jointly with
key health system
partners
Phase II
DevelopmentPhase III
Measurement
& KTNN
Phase I
Preparation
HQO’s Quality-Based Procedure Process
10
Patient cohort and
stratification
approach developed
using administrative
data in conjunction
with the expert panel
Where We Started:
Mapping the COPD Patient Journey Through an Acute Exacerbation
11
Not
responding
Assess
Severity of
Exacerbation
Patient
presents
at ED with
COPD acute
exacerbation
ED
DIAGNOSTICS- Spirometry
- X-ray
Mild
Severe
Acute
respiratory
failure
TREATMENT
IN ED- Antibiotics
- Cortisosteroids
DISCHARGE PLANNING- Refer to smoking cessation counselling
- Vaccinations (influenza & pneumococcal)
- Refer to pulmonary rehab
- Refer to GP for follow-up visit in 2 weeks
INPATIENT
TREATMENT- Antibiotics
- Steroids
Admit to
medical /
respiratory
ward
HOME- Pulmonary rehab
- GP follow-up
- Outpatient care
Death
Death
Recovery
GO TO
INPATIENT
TREATMENT
Recovery
NPPV + USUAL CARE
FOR RESPIRATORY
FAILURE
Admit to medical /
respiratory ward
Recovery
GO TO
DISCHARGE
PLANNING
Death
IMV + USUAL CARE
FOR RESPIRATORY
FAILURE
Recovery
Death
Elicit patient
preference for
ventilation
Pass
GO TO
DISCHARGE
PLANNING
Fail
SPONTANEOUS
BREATHING
TEST
WEAN
FROM
IMV
GO TO
IMV
Episode trigger event
Episode endpoint
Health state / response
Intervention module
‘Go to’ specified module
Assessment point
Not
responding /
acute R.F.
Not responding
GO TO
NPPV
VAP
Recovery
VAP
GO TO ACUTE
RESPIRATORY
FAILURE
GO TO
DISCHARGE
PLANNING
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Where We Finished: The Episode of Care Model for Acute Exacerbations of COPD
Patient presents with
suspected exacerbation
of COPD
Usual medical
care (in ED /
outpatient)
NPPV
IMV
Go to usual
medical care
(inpatient)
Go to ventilation
(NPPV or IMV)
Severe Level of care
Usual medical
care (inpatient)
Go to IMV
End of life care
Wean
from IMVDecision on
ventilation
modality or
palliative care
Treatment fails
Recovers
Treatment fails
Assess recovery
ModerateLevel of care
MildLevel of care
Assess recovery
Assess recovery
Assess recovery
Discharge planning
& full clinical
assessment
Assess
level of care
required
Home
Home
Home
Home
Recovers
Recovers
Recovers
Treatment fails
Treatment fails
Discharge planning
& full clinical
assessment
Discharge planning
& full clinical
assessment
Usual medical
care (inpatient)
Discharge planning
& full clinical
assessment
N = 43,215Pr = 1.0
N = 19,337Pr = 0.447
N = 22,054Pr = 0.511
N = 1,824P = .042
N = 773P = .018
N = 1051Pr = .024
Legend
Care module
Assessment node
Episode endpoint
Death
Usual medical
care (inpatient)
13
-10.9%
-2.5%
15.2%
-11.4%
-2.6% -1.6%
17.8%13.8%
-4.8%-7.7%
-35.8%
5.9%
47.2%
-3.4%
3.5%
-3.8%-6.4%
11.0%
-40.0%
-20.0%
0.0%
20.0%
40.0%
60.0%
% D
iffe
ren
ce
in
Re
so
urc
e In
ten
sit
y W
eig
ht
(RIW
)
Patient Characteristics
Comorbidity Index = 2
Age ≥75 yrsActivities of Daily Living > 2
(Severely Impaired)
Comorbidity
Index = 0
Patient Characteristics Driving Variation in Hip Fracture Utilization
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Stratifying the Hip Fracture Population:
Drawing on Clinical Experience
0
100
200
300
400
500
600
13
5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49
# Cases (2010 / 11)
Total Acute IP LOS (Days)
Admit from Community - 'Complex'
Admit from LTC
Admit from Community - 'Healthy'
Median LOS: 10 days
Median LOS: 6 days
Median LOS: 8 days
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The Hip Fracture Episode of Care: Presentation to 90 Days Post-Admission
Hip Fracture Inpatient
Orthogeriatric Care ProgramPatient presents
with suspected
hip fracture
Assess and
medically
stabilize
No surgery
Home with rehab / follow-up
N = 12,860
Pr = 1.0
Counts and proportions from Discharge
Abstract Database (2011/12) and Hip
Fracture Scorecard (Q1Q2 FY2011-12)
Most responsible diagnosis or comorbidity
diagnosis of S72.0*, S72.1* or S72.2*,
excluding S72.00*
Legend
Care module
Assessment node
Pathway endpoint
Decision to treat /type of surgery /anesthesiaon treatment
Conservative
treatment
Surgery
Decision on post-acute care path
Post-op
stabilization
& early
mobilization
Home-based
rehabilitation
Home withfollow-up
Pr = 0.18
Long-termcare (with rehab)
Long-termcare
Inpatient
rehabilitation
Pr = 0.42 Pr = 0.09 Pr = 0.21
Transfer in
/ out of
hospital for
surgery
Repatriation to
index hospital
CCC / slow
stream rehab
Patient’s pre-fracture level of care
LTCCommunity
‘Healthy’
Community
‘Complex’
N = 7,066
Pr = 0.548N = 3,557
Pr = 0.276
N = 2,275
Pr = 0.176
Post-acute care to 90 days
following index hospitalization
Pre-op
careSurgery
Episode of Care Evidence Synthesis for
Recommended Practices
Stacey Brener
HQO’s Quality-Based Procedure Process
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Expert Panel
Comprised of
clinical,
administrative,
community,
and ministry
experts
Patient cohort and
stratification
approach developed
using administrative
data in conjunction with
the expert panel
Recommended
Practices developed
with evidentiary
support and expert
panel consensus
Implementation
levers and barriers to
the recommended
practices
Expert Panel
Comprised of
clinical,
administrative,
community,
and ministry
experts
OH
TA
C
Indicators to identify
outcome measures of
successful
implementation and
ongoing utilization of
good clinical practices
identified in the QBP
Nodal Network
knowledge dissemination
plan developed jointly with
key health system
partners
Phase II
DevelopmentPhase III
Measurement
& KTNN
Phase I
Preparation
HQO’s Quality-Based Procedure Process
18
Recommended
Practices developed
with evidentiary
support and expert
panel consensus
Sample Care Pathway
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Patient
Groups
Inpatient care
Module 1
Module 2
Module 3 Module 5Module
6
Module
7Module 4
Decision
Module
8Module 9
Module
10
Decision
End
Post-acute care
Legend
Care module
Assessment node
Episode endpoint
Index
Event
Index event
1 to 20 recommendations for
each of the modules
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Approach to Applying Evidence to Modules
• Identify guidelines covering entire pathway with guidance from medical librarians, and confirmed with Expert Panel
• Use AGREE II instrument to rate and identify 3-4 best clinical guidelines developed with most methodological rigour, including at least 1 contextually relevant (Canadian) guideline.
Patient
Groups
Inpatient care
Module 1
Module 2
Module 3 Module 5 Module 6Module
7Module 4
Decision
Module 8 Module 9 Module 10
Decision
End
Post-acute care
Index Event
Appraisal of Guidelines for Research & Evaluation II
6 domains
1) Scope and Purpose
2) Stakeholder Involvement
3) Rigour of Development
4) Clarity of Presentation
5) Applicability
6) Editorial Independence
Evidence-based Care Module
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Approach to Applying Evidence to Modules
• Identify guidelines covering entire pathway with guidance from medical librarians, and confirmed with Expert Panel
• Use AGREE II instrument to rate and identify 3-4 best clinical guidelines developed with most methodological rigour, including at least 1 contextually relevant (Canadian) guideline.
• Begin to populate the relevant modules with Canadian guidelines, while flagging controversy between the guidelines
• Identify related previously conducted HQO evidence based analyses and OHTAC recommendations
Patient
Groups
Inpatient care
Module 1
Module 2
Module 3 Module 5 Module 6Module
7Module 4
Decision
Module 8 Module 9 Module 10
Decision
End
Post-acute care
Index Event
Decision Determinants Framework which is considered for all
OHTAC recommendations:
o Overall clinical benefit
o Value for money
o Consistency with societal and ethical values
o Feasibility of adoption into the health care system
Evidence-based Care Module
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Approach to Applying Evidence to Modules
Evidence-based Care Module
• Identify guidelines covering entire pathway with guidance from medical librarians, and confirmed with Expert Panel
• Use AGREE II instrument to rate and identify 3-4 best clinical guidelines developed with most methodological rigour, including at least 1 contextually relevant (Canadian) guideline.
• Begin to populate the relevant modules with Canadian guidelines, while flagging controversy between the guidelines
• Identify related previously conducted HQO evidence based analyses and OHTAC recommendations
• A Rapid Review may be conducted for areas of conflict or controversy or where uncertainty around the evidence exists
• In some cases, it may be appropriate for HQO to proceed to a full Evidence based analysis (EBA) and revise the episode of care recommendations accordingly.
Patient
Groups
Inpatient care
Module 1
Module 2
Module 3 Module 5 Module 6Module
7Module 4
Decision
Module 8 Module 9 Module 10
Decision
End
Post-acute care
Index Event
Evidence Products Comparison
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Rapid Review
Vs.
Evidence Based Analysis
Question 1 Specific Question Potentially Multiple Questions
Time Frame 2 Weeks 16 Weeks
Literature Search 5 to 10 years Comprehensive
Types of Studies Systematic reviews/ Meta-
analyses
Comprehensive
Outcomes 2 (up to 4) No limit
Type of Analysis Summary of a synthesis report
- Summarize as reported in
SR
Original Synthesis Report
- Meta-analysis + Qualitative Analysis
- Selection of appropriate studies, subgroups
Quality
Assessment
Use SR assessment or
GRADE
GRADE all outcomes comprehensively
Economics None Full Economic Analysis
Contextualization Limited expert panel feedback • Multiple Expert panel meetings on a specific
topic, contact primary authors and additional
experts in field,
• OHTAC review and recommendation
• Decision Determinants
Inferences Very Low/Cautious Interpretation
of Findings
Moderate-High/Evidence Based Conclusions
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Evidence-based Care Module
• Identify guidelines covering entire pathway with guidance from medical librarians, and confirmed with Expert Panel
• Use AGREE II instrument to rate and identify 3-4 best clinical guidelines developed with most methodological rigour, including at least 1 contextually relevant (Canadian) guideline.
• Begin to populate the relevant modules with Canadian guidelines, while flagging controversy between the guidelines
• Identify related previously conducted HQO evidence based analyses and OHTAC recommendations
• A Rapid Review may be conducted for areas of conflict or controversy or where uncertainty around the evidence exists
• In some cases, it may be appropriate for HQO to proceed to a full Evidence based analysis (EBA) and revise the episode of care recommendations accordingly.
• Utilize expert consensus where evidence is limited, not contextually relevant or nonexistent
Patient
Groups
Inpatient care
Module 1
Module 2
Module 3 Module 5 Module 6Module
7Module 4
Decision
Module 8 Module 9 Module 10
Decision
End
Post-acute care
Index Event
Approach to Applying Evidence to Modules
2525
Patient
Groups
Inpatient care
Module 1
Module 2
Module 3 Module 5Module
6
Module
7Module 4
Decision
Module
8Module 9
Module
10
Decision
End
Post-acute care
Legend
Care module
Assessment node
Episode endpoint
Index
Event
Index event
1 to 20 recommendations for
each of the modules
Sample Care Pathway
QBP – Physician Perspective
Dr. David Alter
Perspectives
• Co-Chair of the Quality Based Procedures, Congestive Heart
Failure
• Health Services Research
• Physician
27
RationaleAligning system-expenditures with care-quality in hopes of
improving efficiency, accountability, and outcomes of care
28
Evidence
29
Empirical Data
30
1. Prevalence (i.e., proportion of patients in different pathways)
2. Interferences on quality indicators
Empirical Data
Independent predictors of 30-day death or re-admission
among patients hospitalized with congestive heart failure
31
Consensus – Pathway Development
32
Consensus – Pathway Development
33
Implementation
34
Health Quality Ontario (HQO) Knowledge
Translation Nodal Network
Laura Park-Wyllie
HQO Knowledge Translation Approach
1. Engagement with experts and stakeholders is integrated
throughout evidence development process.
2. Knowledge dissemination plan and implementation
considerations are developed jointly with key health system
partners.
36
Integrated Knowledge Translation Nodal Network
Framework
37
OHA Implementation and KT
OMA Implementation and KT
CAHO Implementation and KT
CCAC Implementation and KT
OCFP Implementation and KT
CCN, OSN, Implementation and KT
LHINs Implementation and KT
RNAO Implementation and KT
Macro Node
Collaboration with Experts &
Stakeholders
Secondary Node [
Key Strategic Partners Activate
Knowledge Translation Networks to Promulgate
and Implement Episode of Care
HQOMonitor Key Performance Indicators for
Episode of care
Review and
Monitor KPIs for
Episode of Care
HQO
HQO
Development of Episode of Care and Indicators
Key Stakeholders
Experts
EDS Hybrid Model
Multi-Stakeholder Integrated Knowledge Translation
Nodal Network Process From Evidence Development to Knowledge Translation/Implementation Support for Best Practice Implementation
KTNN Phases KTNN Process
HQO Expert panel
Clinical Evidence-based
Best Practice
KT Strategy and
Implementation Planning
Development of
Implementation Tools
Pilot Test
Delivery and Dissemination
Ongoing Implementation
Support
Consideration of Feedback
Engagement and Input
Identify Clinical
Champions
Develop Collaborative
KT Strategy
Identify Implementation
Tools
Conduct Early
Evaluation
Lead the Dissemination
Utilize Indicators,
Support Networks
Bring Feedback via
Loop
• KTNN partners nominate experts to panels.
• KTNN may participate in panel meeting, if appropriate
• HQO Chairs and expert panel members become
clinical champions and provide leadership for
adoption.
• Develop strategy for knowledge translation and
implementation support.
• Identify tools and levels that could be developed.
• HQO and KTNN partners develop tools as
relevant to their constituencies.
• If appropriate, KT partners may evaluate
implementation approach.
• Provincial and regional meetings
• Target stakeholder briefings, Educational Sessions,
Training Workshops, Newsletters, Toolkits
• Episode of Care Indicators
• Regional Support Networks
• Community of Practice Networks
• KTNN partners provide feedback from field to HQO
to ensure products are useful to team.
Moving Beyond the QBP to Evaluation and
Implementation
Dr. Douglas Lee
HF Recommendations – Acute Phase
40
Mechanical ventilation PA monitoring
BIPAP IABP, assistive devices
Oxygen Monitor electrolytes, renal
function, troponins, CXR
Lasix IV or PO Record fluid input/output
IV vasoactive agents Record weight
Telemetry Other therapies (ASA, IV
heparin, statins)
1:1 nurse-to-patient ratio ECG
ACE inhibitors/ARBs Assessment of precipitating
factors (e.g., infection,
ischemia)
Beta-blockers Discuss advanced directives
Ultrafiltration Vital signs
HF Recommendations – Subacute Phase
41
Daily weights Renal function assessment
6-hr input/output Assessment for ischemia:
Coronary angiography
Non-invasive risk
stratification
Revascularization
procedure
Salt restriction Assessment of valvular heart
disease
Evaluation for valve surgery
or repair
Fluid restriction Screen for complications (e.g.,
arrhythmia, urosepsis, COPD,
renal failure, pneumonia)
Electrolytes
HF Recommendations – Discharge Planning
42
Diuretic monitoring and
management
Predischarge functional capacity
and mobility assessment
Evidence-based
pharmacotherapy
Predischarge cognitive and
social support assessment
Counselling
Medication
Lifestyle (alcohol, smoking)
Daily weight and self-
monitoring
Diet
Physical activity
Advanced care directives
Physician appointments:
GP/FP, Internal Medicine,
Cardiology
Timely documentation
Discharge notes dictated &
sent to PCP within 1 week
Moving Beyond the QBP: HF Indicators
43
44
Acute Heart Failure Risk Stratification
• Respiratory distress
• Hypoxemia
• Severity of pulmonary edema
• Poorly responsive to furosemide
• Hemodynamic compromise
• Significant arrhythmias
• Positive troponin
• Concomitant acute life-threatening disorders
45
46
Moving Beyond the QBP:
Improving Quality of HF Care Decisions in the ED
47
0100200300
400500600700800900
1,000
0.0
0
0.0
4
0.0
8
0.1
2
0.1
6
0.2
0
0.2
4
0.2
8
0.3
2
0.3
6
0.4
0
0.4
4
Nu
mb
er
of
Pati
en
ts
Admitted
Discharged
Overlap
Region
For Death
Analysis
(30 day)
Predicted Probability of Death
Overlap Predicted Prob of Death:
4.8-6.5% 30-d mortality
1189 Discharged
3704 Admitted
Lee DS, et al. Circulation: Heart Failure 2010; 3:228-35
Mortality: Discharged vs. Admitted
48
0
2
4
6
8
10
12
14
0 10 20 30 40 50 60 70 80 90 100
% M
ort
ality
Days to Death
Lee DS, et al. Circulation: Heart Failure 2010; 3:228-35
Early Follow-up of HF: Improved Survival
49
0.80
0.82
0.84
0.86
0.88
0.90
0.92
0.94
0.96
0.98
1.00
100 150 200 250 300 350 400
Survival Time (days)
% S
urv
iva
l Card+PC
Card
PC
No MD
A: Card+PC vs. PC:
HR 0.79 (0.63-1.00) p=0.045
B: PC vs. NoMD:
HR 0.75 (0.64-0.87) p<0.001
A
B
Lee DS, et al. Circulation 2010; 122:1806-1814
Rationale: In Ontario Emergency Departments
• Inefficiency: Some low risk HF patients are unnecessarily
admitted to hospital instead of having effective community based
follow-up care
• Safety: Some high risk HF patients are inappropriately
discharged – will die at home
50
Aim Statement
• To reduce admission rates of low-risk heart failure (HF) patients
presenting to the emergency department by 25% while reducing
the discharge of high risk HF patients.
51
Quality Improvement TeamChristopher Sulway, PT, TCLHIN
Douglas S. Lee, MD, UHN
Shanas Mohamed, RN, UHN
Medical Staff Nursing Allied Health /
Admin
H. Ross, MD – PMCC HF Lead
S. Sabah, MD – ED Assoc Head
H. Abrams, MD – Chief, GIM
B. Coke, MD – GIM
A. Woo, MD – Head, Echo Lab
H. Amad, MD – UHN Cardiology
R. Iwanochko, MD – TWHCardiology
Site Lead
S. McIntaggart – VP Clinical
L. Flockhart – PMCC Clinical
Director
K. Partridge – Amb. Clinics
P. Neilsen – Cardiology Ward
L. Belford – ACNP, PMCC HF
P. Lui – Pharmacy
O. Fernandes – Pharmacy
S. Miguel – Clinics booking
L. Biclar – Echo booking
CCAC
Summary of Findings
• Reasons for high number of low risk HF being admitted
• No criteria and poor practices to assess risk in HF patients
• No process in ED to monitor low and medium risk patients to decide if admission is needed
• No reliable follow up in community
– Too many phone calls to ensure appropriate follow-up
– Concern of poor transition (slip through crack)
• No easy way to make a referral 24-7
53
54Date of download:
6/15/2012
Copyright © The American College of Physicians.
All rights reserved.
From: Prediction of Heart Failure Mortality in Emergent Care: A Cohort Study
Emergency
Heart failure
Mortality
Risk
Grade
Ann Intern Med. 2012;156(11):767-775. doi:10.7326/0003-4819-156-11-201206050-00003
EHMRG HF Risk Stratification in the ED
55
Intervention – Quality Improvement in CHF Care
(QUICC) Initiative
1. Risk stratification: EHMRG decision support algorithm
2. Checklist to assist in deciding safety of discharge
3. Rapid 24-hr follow-up clinic
4. Automatic referral to rapid home care visit
5. ED virtual observation unit
56
57
58
0
10
20
30
40
50
60
Low Med High
0
10
20
30
40
50
60
Low Med High
Potential Impact in Ontario
Risk Profiles (Fiscal 2007 data)
Hospital Admitted Discharged% %
34%
42%
24%
51%
37%
12%
Ontario Statistics: Follow-up (Fiscal 2007 data)
59
4852
50 51
58
42
0
10
20
30
40
50
60
70
80
90
100
Low Med-
High
Low LowMed-
High
Med-
High
% Follow-up
by FP w/in
2 days
Family MD or C
w/in 2 days
% Follow-up
by C w/in
7 days
% o
f P
tsD
isc
ha
rge
d f
rom
ED
Reflections on Current and Future State
• HQO began it’s QBP program just over 1 year ago.
• To date, HQO has developed 6 evidence-based, best practice, clinical handbooks to inform quality-based funding policy for Ontario.
• An additional 5 handbooks are actively in-development with provincial expert advisory panels (community-based focus).
• The QBP program of work within HQO has led to an active and productive period of developing customized evidence synthesis, analytic, and engagement methods to support the development of QBP evidence-based best practices.
60
Reflections on Current and Future State
• New innovative research (risk stratification) and proof-of-concept
programs (specialized heart failure clinic models) have been
associated with HQO’s QBP work.
• A recent focus in the evolution of HQO’s QBP program has been
on collaborating with key strategic health system partners to
facilitate the knowledge translation and uptake of the QBP best
practices.
• The Ministry is using QBP clinical best practices to develop the
funding policies (episode of care pricing) under a separate
timeline.
• Looking forward 2013-2014: Community-based QBPs
61
Thank You
62