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P R O V I N C I A L C O N T E X T

VISION, PRIORITIES

AND DIRECTION

North East Local Health Integration Network:

INTEGRATED HEALTH SERVICE PLAN

DECEMBER 2006

Sommaire en français inclu.

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North East LHIN: Provincial Context - Vision, Priorities and Direction

T A B L E O F C O N T E N T S

Executive Summary / Sommaire

1.0 Introduction

...

1

2.0 Equity and Access

...

2

Community Engagement ... 2

Service Integration... 3

3.0 Quality and Efficiency

...

4

The Health Results Team: Health System Strategy Map ... 4

Ontario Health Quality Council ... 4

Sustainability... 4

Creating Efficiencies ... 5

Culture of Accountability... 5

4.0

Wellness: Promotion and Prevention

...

6

Ministry of Health Promotion ... 7

Public Health: Dealing with Infectious Disease and Emergencies ... 7

5.0 Information and Communication

...

9

Consultation and an Informed Public... 9

Information Management ... 10

6.0 Other Ontario Priority/Strategic Areas

...

12

Improved Access through Reduced Wait Times... 12

Services for Ontario’s Francophone Population ... 13

Aboriginal Health and Wellness ... 13

Primary Care Reform ... 14

Health Human Resources... 15

Mental Health and Addiction ... 16

Ambulance, Emergency and Critical Care Services ... 16

Stroke Strategy... 17

Diabetes Strategy... 17

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North East LHIN: Provincial Context - Vision, Priorities and Direction

EXECUTIVE SUMMARY

The Provincial Context background paper provides an overview of the provincial

parameters within which the North East Local Health Integration Network (NE LHIN) will undertake its work.

The work of the NE LHIN will be guided by the four key values of Equity and Access, Quality and Efficiency, Wellness: Promotion and Prevention, and Information and

Communication.

Equity and Access

Equity and Access refer to the fair and just allocation of decision making, resources and services. A key element of equity and access involves participatory decision-making which is being addressed by the LHINs through their community engagement strategies. The Local Health Integration Act, 2006, mandates the development of community engagement strategies, stating that a community’s health needs and priorities are best developed by the community, health care providers, and the people they serve. The term, “community” is inclusive and includes all members and stakeholders of the health care “community”, including health care providers, professionals, clients, consumers, consumer support groups, patients, funders, residents and citizens.

The Act states in the preamble that“the people of Ontario and their Government believe that the health system should be guided by a commitment to equity and respect for diversity in communities”.

To enhance equity, the rules that govern our institutions, organizations, policies and practices must be transformed and our decision-making processes must be more inclusive.

The Act recognizes “the need for communities, health service providers, Local Health

Integration Networks and the government to work together to reduce duplication and better co-ordinate health service delivery to make it easier for people to access health care. The government envisions an integrated health system that delivers the health services that people need, now and in the future”.

Clients must be able to navigate through the health system easily and quickly as their needs for services change. Service integration and partnerships, combined with improved patient and client record technology, will support high quality health services in which patients no longer have to repeat health history or tests for each service provider they see.

Quality and Efficiency

The Ministry’s Health Results Team for Information Management (HRT-IM) has developed a Health System Strategy Map which identifies nine strategic themes, synthesized from Ministry policies, plans and directions. All of these themes relate directly or indirectly to quality and efficiency:

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Increase availability of high quality, relevant evidence.

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Increase access to, and uptake of, evidence for decision-making and accountability.

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Increase productive use and

appropriate allocation of resources across the system.

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Increase access to key health care services.

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Improve patient-centredness, integration and quality of health services.

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North East LHIN: Provincial Context - Vision, Priorities and Direction

EXECUTIVE SUMMARY

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Improve health behaviours, health promotion and disease prevention.

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Improve clinical outcomes.

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Improve health status.

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Increase sustainability and equity of the health system.

The Ontario Health Quality Council, an independent body created to monitor the health care system, has been charged with the responsibility of monitoring and reporting to the people of Ontario on:

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Access to publicly funded health services;

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Health human resources in publicly funded health services;

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Consumer and population health status; and

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Health system outcomes.

Preserving a health system in Ontario that lives within the principles of the Canada Health Act is a high priority. On June 7, 2004, the Ontario government passed Bill 8, the Commitment to the Future of the Medicare Act, 2004, making universal public Medicare the law in Ontario. The Act clearly reflects the belief that the health system must be patient-centred and responsive to need, regardless of a person’s ability to pay. Queue-jumping, extra billing, and other characteristics of two-tier Medicare are now illegal in Ontario. All governments in Canada agree that simply providing more money for services will not yield permanent solutions to the challenges we face. The Health Council of Canada 2006 Annual Report states, “In Canada, the typical policy response to deal with backlogs has been to increase capacity by allocating additional resources through selective one-time funding. This may reduce wait one-times for some patients in current queues, but without

better management and redesign of patient flows, this strategy will not reduce waits for the long term. Research has demonstrated that applying principles of system engineering and flow management can be dramatically effective at little additional cost.”

Wellness: Promotion and

Prevention

A number of factors beyond health services determine the health and wellness of

individuals. These factors include: genetics, living and working conditions, income, social status, physical environment, personal health practices, and coping skills. The system of health care services is only one of a number of significant components.

In pursuit of the goal of “keeping Ontarians healthy” the government has undertaken a number of initiatives, beginning with the creation of a separate Ministry of Health Promotion. This new ministry is responsible for advancing the government’s preventative health initiatives including healthy lifestyles, sport, physical activity, recreation, disease prevention, and community health awareness. This ministry recently published “Healthy Ontarians in a Healthy Ontario – A Strategic Framework”. Identifying the following five priorities:

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A Smoke-Free Ontario

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Healthy and Active Living

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Injury Prevention

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Mental Health and Addiction Initiatives

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North East LHIN: Provincial Context - Vision, Priorities and Direction

EXECUTIVE SUMMARY

Information and

Communication

Ministry policies, initiatives and guidelines consistently recognize that information and communication are critical ingredients in the development and maintenance of a sound health care system. The public must be well-informed of programs, policies, and new directions in order to access appropriate services and participate meaningfully in the decision-making process. It is commonly accepted that information sharing in health care is essential and that it must be linked on a number of levels. Health care is a knowledge-based business. It is also accepted that the sharing of information among providers will be key to the delivery of services at appropriate quality and lower cost. At any level, and under any organizational format, there is a growing demand for systems that share information. Increasing use and dependency on technology in health care is evidenced by the rapid

growth in new diagnostic procedures and instruments, administrative, financial, and clinical applications as well as information systems and the use of internet technology. Developments in this field yield numerous benefits to the health care system, individual organizations, staff and patients.

Information management is a critical component in the Ministry’s health system transformation agenda.

The Health Results Team has indicated that:

“a health system built on a faulty wiring system will produce the wrong information at the wrong time; waste energy and fall short of full capacity; cannot be managed optimally; and, most importantly, cannot demonstrate performance against its key accountabilities”.

The Ministry’s information management strategy is aimed at addressing the system-wide need for better information management through:

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Producing better data.

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Supporting accountability and quality improvement through performance measurement.

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Supporting evidence-based decision-making.

Standards for data quality must be set, the data collected by health care providers must be better coordinated, and the resulting information must be consolidated into a common, integrated knowledge base.

Other Ontario Priority/

Strategic Areas

Additional provincial priorities and strategic directions underway in Ontario include:

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Improved Access Through Reduced Wait Times

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Services For Ontario’s Francophone Population

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Aboriginal Health and Wellness

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Primary Care Reform

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Health Human Resources

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Mental Health and Addiction

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Ambulance, Emergency and Critical Care Services

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Stroke Strategy

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Diabetes Strategy

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SOMMAIRE

RLISS du Nord-Est : Contexte provincial

Le présent document donne un aperçu des paramètres provinciaux qui encadreront les activités du Réseau local d’intégration des services de santé (RLISS) du Nord-Est. Le travail du RLISS du Nord-Est sera guidé par les quatre valeurs clés suivantes : équité et accès; qualité et efficacité; mieux-être : promotion et prévention; et information et communication.

Équité et accès

L’équité et l’accès concernent la distribution juste et équitable de la prise de décision, des ressources et des services. Cette valeur exige notamment d’assurer une prise de décision participative, ce dont les RLISS s’occupent par le biais des stratégies de mobilisation communautaire. Selon la Loi de 2006 sur l’intégration du système de santé local, qui exige l’élaboration de stratégies de mobilisation communautaire, ce sont la collectivité, les fournisseurs de soins de santé et la population qu’ils servent qui sont le mieux en mesure d’établir les besoins et les priorités sanitaires de la collectivité. Le terme « collectivité » englobe tous les membres et les intervenants du secteur de la santé, y compris les fournisseurs de soins, les professionnels de la santé, les clients, les consommateurs, les groupes de défense des consommateurs, les patients, les bailleurs de fonds, les résidents et les citoyens.

Dans son préambule, la Loi indique que la « population de l’Ontario et son gouvernement (...) croient que le système de santé devrait être guidé par un engagement à l’égard de l’équité et un respect de la diversité des collectivités ». Or, pour améliorer l’équité, il est nécessaire de modifier les règles qui régissent nos institutions, nos organisations,

nos politiques et nos pratiques, et de rendre les processus de décision plus inclusifs. Par ailleurs, la Loi reconnaît « le besoin qu’ont les collectivités, les fournisseurs de services de santé, les réseaux locaux d’intégration des services de santé et le gouvernement de travailler ensemble dans le but de réduire le double emploi et de mieux coordonner la prestation des services de santé de sorte qu’il soit plus facile pour la population d’accéder aux soins. (...) [Le gouvernement] conçoit un système de santé intégré qui réponde aux besoins actuels et futurs de la population en matière de services de santé ».

Les clients doivent être capables de cheminer facilement et rapidement dans le système de santé, car leurs besoins en services évoluent. L’intégration des services et les partenariats, jumelés aux progrès de la technologie d’enregistrement des patients et des clients, aideront à fournir des services de santé de grande qualité et éviteront aux patients de fournir leurs antécédents médicaux ou de passer des tests chaque fois qu’ils consultent un fournisseur différent.

Qualité et efficacité

L’Équipe des résultats dans le domaine de la santé pour la gestion de l’information, formée par le ministère de la Santé et des Soins de longue durée, a élaboré une carte des stratégies relatives au système de santé qui précise neuf thèmes stratégiques découlant des politiques, des plans et des directives ministériels. Ces thèmes concernent tous directement ou indirectement la qualité et l’efficacité.

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SOMMAIRE

RLISS du Nord-Est : Contexte provincial

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Augmenter le nombre de résultats

d’expérience clinique pertinents et de grande qualité disponibles.

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Améliorer l’accès aux résultats

d’expérience clinique et leur application à la prise de décision et à la responsabilité.

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Accroître l’utilisation productive et

l’affectation adéquate des ressources dans l’ensemble du système.

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Faciliter l’accès aux services de santé clés.

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Améliorer l’intégration et la qualité des services de santé et rendre ces services plus axés sur le patient.

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Améliorer les comportements de santé, la promotion de la santé et la prévention des maladies.

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Améliorer les résultats cliniques.

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Améliorer l’état de santé.

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Accroître la viabilité et l’équité du système de santé.

Le Conseil ontarien de la qualité des services de santé, un organisme indépendant qui surveille le système de santé, a été chargé de suivre les questions suivantes et d’en faire rapport à la population de l’Ontario :

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accès aux services de santé publics;

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état des effectifs employés dans les services de santé publics;

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état de santé des clients et de la population;

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problèmes que connaît le système de santé.

La préservation d’un système provincial de santé conforme aux principes de la Loi canadienne sur la santé constitue une grande priorité. Le 7 juin 2004, le gouvernement de l’Ontario a adopté le projet de loi 8, la Loi de 2004 sur l’engagement d’assurer l’avenir de l’assurance-santé, qui fait de l’assurance-santé publique et universelle la loi en Ontario. La Loi reflète clairement la

conviction que le système de santé doit être axé sur le patient et répondre aux besoins de ce dernier, peu importe sa capacité de payer. Les traitements de faveur, la surfacturation et d’autres caractéristiques du système de santé à deux vitesses sont maintenant illégaux en Ontario.

Au Canada, les différents ordres de gouvernement savent qu’il ne suffit pas d’augmenter le financement des services pour répondre de façon permanente aux défis auxquels nous faisons face. Le rapport annuel de 2006 du Conseil canadien de la santé indique ce qui suit : « Au Canada, la politique normalement adoptée en réaction à des arriérés consiste à accroître les capacités par un surcroît de ressources en financement ponctuel et sélectif. On peut ainsi réduire les délais pour certains patients qui sont actuellement en liste d’attente, mais si on ne sait pas mieux gérer et réaménager les charges de patients, on ne réussira pas par cette stratégie à diminuer les temps d’attente à long terme. La recherche démontre que, en appliquant les principes du génie des systèmes et de la gestion des flux, on peut remporter des succès considérables sans guère alourdir les coûts. »

Mieux-être : promotion et prévention

La qualité du système de santé n’est qu’un des nombreux facteurs importants qui ont un effet sur la santé et le mieux-être. Mentionnons également l’hérédité, les conditions de vie et de travail, le revenu, le statut social, l’environnement physique, l’hygiène de vie personnelle et les habiletés d’adaptation. Afin de « garder les Ontariennes et les Ontariens en santé », le gouvernement provincial a entrepris diverses initiatives, à commencer par la création d’un ministère de

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SOMMAIRE

RLISS du Nord-Est : Contexte provincial

la Promotion de la santé distinct. Celui-ci est responsable de la mise en oeuvre des projets du gouvernement en matière de promotion d’une meilleure santé, notamment par des habitudes saines de vie, du sport, de l’activité physique, des loisirs, de la prévention de la maladie et des campagnes de sensibilisation à la santé communautaire. Le Ministère a publié récemment l’approche stratégique Des Ontariennes et des Ontariens en santé, un Ontario en santé, qui cerne cinq priorités :

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un Ontario sans fumée;

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un mode de vie sain et actif;

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la prévention des blessures;

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des initiatives en matière de santé mentale et de prévention des toxicomanies;

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des programmes pour les enfants et les adolescents.

Information et communication

Dans ses politiques, ses initiatives et ses directives, le MSSLD reconnaît de façon constante que l’information et la communication sont des éléments indispensables du développement et du maintien d’un système de santé de qualité. En effet, le public doit être bien informé au sujet des programmes, des politiques et des nouvelles orientations afin de pouvoir accéder aux services exigés et de participer pleinement à la prise de décision. Il est généralement admis que le partage des renseignements est essentiel à tout système de santé, et que ce partage doit se faire entre plusieurs niveaux. Rappelons que le secteur de la santé est fondé sur le savoir. On reconnaît en outre que la prestation de services de qualité à un coût raisonnable dépend du partage des renseignements entre fournisseurs. Peu importe le niveau et le type d’organisation, la demande de systèmes d’échange d’information augmente. Le recours

et la dépendance accrus à la technologie dans le secteur de la santé s’expliquent par l’évolution rapide des procédures et des instruments de diagnostic, des applications administratives, financières et cliniques ainsi que des systèmes d’information, et par l’utilisation de la technologie d’Internet. Les progrès dans ce domaine génèrent de nombreux bienfaits pour le système de santé, les organismes de santé, le personnel et les patients.

La gestion de l’information est également un élément crucial du programme ministériel de renouvellement du système de santé.

L’Équipe des résultats dans le domaine de la santé indique ce qui suit : « Un système de santé fondé sur un «réseau de câbles» défectueux produit des informations erronées et livrées au mauvais moment. Il gaspille l’énergie et ne permet pas d’utiliser pleinement sa capacité. Un tel système ne peut pas être géré de façon optimale, et, surtout, ne permet pas d’afficher son rendement par rapport à ses principales sphères de responsabilisation. »

La stratégie ministérielle de gestion de l’information vise à répondre au besoin d’améliorer la gestion de l’information dans l’ensemble du système. Pour ce faire, il faut :

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produire de meilleures données;

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favoriser la responsabilisation, améliorer la qualité par la mesure du rendement;

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renforcer la prise de décision fondée sur l’expérience clinique.

Il convient également de fixer des normes de qualité des données, de mieux coordonner les données recueillies par les fournisseurs de soins et de regrouper les données ainsi

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SOMMAIRE

RLISS du Nord-Est : Contexte provincial

obtenues dans une base de connaissances commune et intégrée.

Autres priorités et orientations stratégiques en Ontario

Parmi les autres priorités et orientations stratégiques provinciales, mentionnons les suivantes :

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amélioration de l’accès aux services grâce à la réduction des temps d’attente;

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services aux francophones de l’Ontario;

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santé et mieux-être des Autochtones;

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réforme des soins primaires;

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ressources humaines en santé;

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santé mentale et prévention des toxicomanies;

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services d’ambulance et d’urgence et soins aux malades en phase critique

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stratégie de prévention des accidents cérébrovasculaires;

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stratégie de lutte contre le diabète; plan d’Action Cancer Ontario.

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1 North East LHIN: Provincial Context - Vision, Priorities and Direction

This component of the Integrated Health Service Plan (IHSP) will define the provincial parameters within which the North East Local Health Integration Network (LHIN) will undertake its work. Contextual factors, and the province’s vision, priorities and strategic directions will be reviewed and categorized to assist and guide LHIN activities. Relevant legislation, Ministry media releases, speeches by the Premier, Minister, and Ministry

representatives, as well as documents and reports released by government health agencies and special purpose bodies, have been analyzed.

The North East LHIN Local Vision IHSP

background paper summarizes our Vision, Values and Priorities under four broad themes or categories. For comparative purposes and to demonstrate alignment and compatibility with provincial strategies, the following “Our Values” categories, as listed below, have been applied to this synthesis of provincial context.

Our Values

Equity and Access

“The fair and just allocation of decision- making, resources, and services.”

Quality and Efficiency

“The best possible services achieved through optimal use of finite resources.”

Wellness: Promotion and Prevention

“A system that is outcome and wellness oriented.”

Information and Communication

“Informed providers and consumers sharing a comprehensive, integrated information system.”

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North East LHIN: Provincial Context - Vision, Priorities and Direction 2

“The fair and just allocation of decision-making, resources, and services.”

The goals enunciated in Ontario’s current health strategy address the need to create a patient-centred health system, reduce wait times, and provide better access to doctors, nurses, and comprehensive care through Primary Care Reform. Meaningful community engagement, service integration and structural refinement are also referenced frequently in Ministerial releases as high priorities that appropriately fit within the equity and access theme.

Community Engagement

Participatory Decision-Making: Stakeholder Input and Empowerment

While outlining the government’s broad commitment to provide leadership in community engagement and be responsive to health needs at the local level, the

Honourable George Smitherman, Minister of Health and Long-Term Care, indicated in June of 2004 that, “our vision is of a system where all providers speak to one another in the same language, where there are no longer impenetrable and artificial walls between stakeholders and services: a system driven by the needs of patients, not providers”.

In keeping with their mandate to improve access to coordinated, quality health care for the people and communities of Ontario, all Local Health Integration Networks (LHINs) have received support and encouragement from the Ministry to develop comprehensive strategies for community engagement and local health planning. The North East LHIN has embraced the province-wide commitment to actively engage in open communication

and broad, inclusive consultation through the development of positive stakeholder relationships.

Legislation creating Local Health Integration Networks, and governing their activity, mandates the development of community engagement strategies, stating that a

community’s health needs and priorities are best developed by the community, health care providers, and the people they serve. The term, “community” is applied by the Ministry in an inclusive manner to embrace all members and stakeholders of the health care “community”, including health care providers, professionals, clients, consumers, consumer support groups, patients, funders, residents and citizens.

Equitable Distribution of Resources

The Local Health System Integration Act, 2006, in the preamble, states that, “the people of Ontario and their Government believe that the health system should be guided by a commitment to equity and respect for diversity in communities”.

Funders, policy makers, planners, and service providers must involve the public meaningfully to ensure that services and programs are accessible, available and appropriate to the people who are entitled to use them. In examining existing programs and services, the government will attempt to identify the different kinds of barriers to resources and opportunities that the people of Ontario face. To enhance equity, the rules that govern our institutions, organizations, policies and practices must be transformed and our decision-making processes must be more inclusive. The North East LHIN’s interest in developing a tool or framework to assist in the

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3 North East LHIN: Provincial Context - Vision, Priorities and Direction

2.0 EQUITY AND ACCESS

evaluation of equity will be addressed in the next section of this report.

Service Integration

Seamless Access

The Local Health System Integration Act, 2006, recognizes “the need for communities, health service providers, Local Health

Integration Networks and the government to work together to reduce duplication and better co-ordinate health service delivery to make it easier for people to access health care. The government envisions an integrated health system that delivers the health services that people need, now and in the future”.

Clients must be able to navigate through the health system easily and quickly as their needs for services change. Initiatives to create a seamless service have been launched on several fronts. Service integration and partnerships, combined with improved patient and client record technology, will support high quality health services in which patients no longer have to repeat health history or tests for each service provider they see. Multidisciplinary, comprehensive health centres, established through Primary Care Reform and the introduction of Family Health Teams, will serve as a first point of contact for the public.

Structural and System Refinement (LHIN Development)

The government has embarked on significant structural and system change to better plan, coordinate and fund the delivery of health care services at the local level, through the development of Local Health Integration

Networks. The legilsation states that,

“the purpose of this Act is to provide for an integrated health system to improve the health of Ontarians through better access to health services, coordinated health care and effective and efficient management of the health system at the local level by Local Health Integration Networks”. Further, the Act directs LHINs to develop an integrated health service plan for the local health system and identify opportunities to integrate the services of the local health system to provide coordinated, effective and efficient services.

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North East LHIN: Provincial Context - Vision, Priorities and Direction 4

3.0 QUALITY AND EFFICIENCY

“The best possible services achieved through optimal use of finite resources.”

The Health Results Team:

Health System Strategy Map

The Ministry’s Health Results Team for Information Management (HRT-IM) has developed a Health System Strategy Map which identifies nine strategic themes, synthesized from Ministry policies, plans and directions. All of these themes, as outlined below, relate directly or indirectly to quality and efficiency:

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Increase availability of high quality, relevant evidence.

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Increase access to, and uptake of, evidence for decision-

making and accountability.

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Increase productive use and appropriate allocation of

resources across the system.

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Increase access to key health care services.

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Improve patient-centredness, integration and quality of health services.

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Improve health behaviours, health promotion and disease prevention.

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Improve clinical outcomes.

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Improve health status.

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Increase sustainability and equity of the health system.

Ontario Health Quality Council

On September 12, 2005, the Minister of Health and Long-Term Care announced the formation of the Ontario Health Quality Council, an independent body created to monitor the

health care system and reports to the public on how well it is performing. Specifically, the Council has been charged with the responsibility of monitoring and reporting to the people of Ontario on:

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Access to publicly funded health services;

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Health human resources in publicly funded health services;

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Consumer and population health status; and

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Health system outcomes.

The Ontario Health Quality Council has hosted a series of stakeholder sessions in support of continuous quality improvement, and its first report, released in April 2006, has identified a number of access issues that warrant further investigation.

Sustainability

Preserving a health system in Ontario that lives within the principles of the Canada Health Act is a high priority. On June 7, 2004, the Ontario government passed Bill 8, the Commitment to the Future of the Medicare Act, 2004, making universal public Medicare the law in Ontario. The Act clearly reflects the belief that the health system must be patient-centred and responsive to need, regardless of a person’s ability to pay. Queue-jumping, extra billing, and other characteristics of two-tier Medicare are now illegal in Ontario. Health care spending in Ontario has grown at an average annual rate of 8% over the past five years. This rate of spending is approximately twice the rate associated with spending on everything else. The province’s growth rate is projected to average 3.2%

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5 North East LHIN: Provincial Context - Vision, Priorities and Direction

3.0 QUALITY AND EFFICIENCY

per year for the next few years. Minister Smitherman, in his World Health Day speech, April 7, 2005, asked the question: “Does anyone seriously believe we can responsibly sustain 8% growth in health care spending? It’s very simple, and terribly clear. Health care, as we inherited it, was not sustainable.”

Creating Efficiencies

All governments in Canada agree that simply providing more money for services will not yield permanent solutions to the challenges we face. The Health Council of Canada 2006 Annual Report states, “in Canada, the typical policy response to deal with backlogs has been to increase capacity by allocating additional resources through selective one-time funding. This may reduce wait one-times for some patients in current queues, but without better management and redesign of patient flows, this strategy will not reduce waits for the long term. Research has demonstrated that applying principles of system engineering and flow management can be dramatically effective at little additional cost.”

In October 2004, the Ministry of Health and Long-Term Care established the Surgical Process Analysis and Improvement Expert Panel to recommend a plan to improve surgical efficiencies in Ontario’s hospitals. The Report identified eleven best practice targets that can improve efficiencies and are considered critical for patient safety. Other essential efficiencies will be achieved in Ontario as a result of the comprehensive waiting time reduction strategy combined with significant structural and system refinement.

Culture of Accountability

The Local Health Integration Act, 2006, addresses the importance of: “public

accountability and transparency to demonstrate that the health system is governed and

managed in a way that reflects the public interest and that promotes efficient delivery of high quality health services to all Ontarians”.

Accountability embraces the concept of ensuring that decisions are linked to outcomes and helps to clarify expected benefits. This requires clearly defined roles and responsibilities, evaluation mechanisms built into policies, and the reexamination of effectiveness at all stages of implementation. As previously referenced, the Health

Results Team for Information Management has identified the need to increase access to evidence for decision-making and

accountability. In addition, the Local Health System Integration Act specifies requirements for accountability agreements between the Ministry of Health and Long-Term Care and LHINs, and between LHINs and health service providers. The Ministry will set standards, targets and measures for these agreements that align with the Ministry’s policies and strategic plan.

The strategy map proposed by the Health Results Team provides a tool that will

articulate the connections between provincial goals and local health system strategic plans. This approach will help organize measures for accountability agreements and set performance expectations for accountability purposes by identifying areas of underperformance in each LHIN. Measures for accountability purposes must appropriately balance output and outcome measures.

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North East LHIN: Provincial Context - Vision, Priorities and Direction 6

4.0 WELLNESS: PROMOTION AND PREVENTION

A number of factors beyond health services determine the health and wellness of

individuals. These factors include: genetics, living and working conditions, income, social status, physical environment, personal health practices, and coping skills. The following chart categorizes the many factors that influence our health, illustrating that our system of health care services is only one of a number of significant components.

Ontario’s Minister of Health and Long-Term Care has repeatedly emphasized three overarching priorities, the first of which is “keeping Ontarians healthy”. In pursuit of this goal, the government has undertaken a number of initiatives, beginning with the creation of a separate Ministry of Health Promotion.

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7 North East LHIN: Provincial Context - Vision, Priorities and Direction

4.0 WELLNESS: PROMOTION AND PREVENTION

Ministry of Health Promotion

The Honourable Jim Wilson was appointed as Ontario’s first Minister of Health Promotion in June 2005. In this new portfolio, he is responsible for advancing the government’s preventative health initiatives including healthy lifestyles, sport, physical activity, recreation, disease prevention, and community health awareness.

The Ministry of Health Promotion recently published “Healthy Ontarians in a Healthy Ontario – A Strategic Framework”. The Framework identifies the following five Ministry priorities:

Priorities for a Healthy Ontario

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A Smoke-Free Ontario was highlighted by the Smoke-Free Ontario Act

prohibiting smoking in all enclosed public places and workplaces as of May 31, 2006. Prevention programs aimed at youth, cessation programs, and protection initiatives to help Ontarians avoid second-hand smoke are included in the strategy.

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Healthy and Active Living will include comprehensive initiatives that target two of the primary risk factors for chronic disease – physical inactivity and unhealthy eating. The Ministry’s goals include working collaboratively with partners to make healthy eating choices easier and increasing physical activity participation.

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Injury Prevention will include programs to prevent and reduce injuries where Ontario residents work, learn and play.

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Mental Health and Addiction Initiatives

will focus on mental wellness including prevention of addiction and problem gambling, combined with an overall emphasis on wellbeing.

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Programs for Children and Youth will be the Ministry’s first priority, recognizing that behaviours and attitudes

developed in childhood last a lifetime. Healthy, active children become healthy, active adults.

Public Health: Dealing with

Infectious Disease and

Emergencies

Legislative amendments passed in 2004 strengthen the powers and independence of Ontario’s Chief Medical Officer of Health and the Ministry began planning for the creation of an Ontario Health Protection and Promotion Agency. Dr. Sheela Basrur, in her Chief Medical Officer of Health Report, 2005, presented in January 2006 to the Ontario Legislative Assembly, identified the following activities and priorities:

Progress made to date includes:

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An ongoing review of the capacity of the Province’s public health units.

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Planning for the creation of Ontario’s first Public Health Agency.

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Strengthened capacity to control infectious diseases with the creation of a Provincial Infectious Diseases Advisory Committee (PIDAC), Regional Infection Control Networks, infection control training for frontline health care workers and increased funding to raise the number of infection control professionals.

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North East LHIN: Provincial Context - Vision, Priorities and Direction 8

4.0 WELLNESS: PROMOTION AND PREVENTION

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Establishment of the Emergency Management Unit to coordinate responses to health emergencies and outbreaks.

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The release of an updated and detailed plan for an influenza pandemic.

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Creation of the Ministry of Health Promotion.

Areas of continuing concern include:

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Shortage of staff and inadequate facilities and technology with the Public Health Laboratory system must be addressed

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Vacancies in Medical Officer of Health and other positions at public health units is a priority.

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Emergency planning and response involving First Nations communities’ needs to be developed and coordinated with all levels of government.

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Communications with frontline medical staff needs to be strengthened to help recognize, control and prevent infectious diseases.

Ontario Health Protection and Promotion Agency

The new Ontario Health Protection and Promotion Agency will support the Chief Medical Officer of Health and provide expert scientific leadership and technical advice for the health sector. The Ministry has established an Agency Implementation Task Force to provide technical advice on the development and implementation of Ontario’s Health Protection and Promotion Agency.

Health Unit Funding and Structure

With regard to funding for public health units, the Ministry’s target is to cover 75% of public health unit funding by 2007/08. Currently, the province’s share of public health funding has increased to 55%. In addressing public health unit structure and capacity, the Chief Medical Officer of Health has indicated, in her 2005 Report, that: “Ontario’s 36 local public health units are the frontline of the province’s health protection system. There are a number of important questions regarding how they are structured and whether they have sufficient capacity to protect and promote the health of all Ontarians. Many public health units have longstanding vacancies in their Medical Officer of Health positions, as well as difficulties recruiting other types of public health professionals.”

The final report of the Local Public Health Capacity Review Committee was released on May 4, 2006. This report provides recommendations to the provincial

government to improve the capacity of local public health units to protect and promote health. The recommendations cover a broad range of topics including the amalgamation of eight groupings of health units reducing the number of health units in Ontario to twenty-five. The report also makes recommendations on governance, proposing independent boards of health with membership equally divided between public representatives, selected by the board, and municipal representatives. Health unit budgets would be approved by the province, with 75% of cost shared programs to be funded provincially with the remaining 25% to be municipally funded. The report states that the province should guarantee continued full funding of the current 100-per-cent-funded programs. The document also

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9 North East LHIN: Provincial Context - Vision, Priorities and Direction

5.0 INFORMATION AND COMMUNICATION

Ministry policies, initiatives and guidelines consistently recognize that information and communication are critical ingredients in the development and maintenance of a sound health care system. The public must be well-informed of programs, policies, and new directions in order to access appropriate services and participate meaningfully in the decision-making process. It is commonly accepted that information sharing in health care is essential and that it must be linked on a number of levels. Health care is a knowledge-based business. It is also accepted that the sharing of information among providers will be key to the delivery of services at appropriate quality and lower cost. At any level, and under any organizational format, there is a growing demand for systems that share information. Increasing use and dependency on technology in health care is evidenced by the rapid

growth in new diagnostic procedures and instruments, administrative, financial, and clinical applications as well as information systems and the use of internet technology. Developments in this field yield numerous benefits to the health care system, individual organizations, staff and patients.

Information is an important component of the Ontario Government’s integration initiative. The information infrastructure necessary in an integrated system must be flexible in design and significantly different in scope and capacity. The potential to share information is one of the most important byproducts of enhanced partnerships, linkages and integration. An information technology infrastructure can be the first foundational step in the development of a truly integrated, cooperative system.

Consultation and an Informed

Public

Providing the public with appropriate information is a critical step in ensuring that the health care system is accessible and responsive to need. A previous section of this report stresses the importance of community engagement and participatory decision-making. The Ministry’s Health Results Team, in their first annual report, indicated that: “consultation is the cornerstone of transformation. The Health Results Team approach has been to seek solutions in concert with stakeholders and communities. Not only do they bring practical experience from the frontlines of the health care system, but also their direct participation is essential to building the confidence and support that will sustain the transformation for years to come”.

New relationships are formed by new dialogue and the Health Results Team has been innovative in engaging all levels of stakeholders. It has utilized new methods of communications, new participants, multiple structures, new channels such as interactive web links, print media, regular bulletins and updates, expert panels, action groups, local provider groups and established provincial organizations.

Ministry and LHIN representatives have traveled to all parts of the province to meet with many providers, consumers and the general public to discuss Ministry directions, listen to concerns, and seek input on

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North East LHIN: Provincial Context - Vision, Priorities and Direction 10

5.0 INFORMATION AND COMMUNICATION

Information Management

There are nearly 100 separate health information data bases in Ontario, many of which contain the same data, and there are nearly 2,000 separate performance indicators in use in Ontario. Many of these provide only limited information, are difficult to interpret, or do not relate to the Government’s key health priorities. The Health Results Team has indicated that: “a health system built on a faulty wiring system will produce the wrong information at the wrong time; waste energy and fall short of full capacity; cannot be managed optimally; and, most importantly, cannot demonstrate performance against its key accountabilities”.

The Health Results Team has identified the following important steps:

Information Management - Principles for Change:

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Build on existing strengths inside and outside the Ministry.

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Reduce impact and burden of data collection on providers and bureaucrats.

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Use technology as an accelerator, not a solution.

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Maintain transparency of process inside and outside the Ministry.

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Integrate information management reforms into existing structures. The Ministry’s information management strategy is aimed at addressing the system-wide need for better information management through:

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Producing better data.

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Supporting accountability and quality improvement through performance measurement.

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Supporting evidence-based decision-making.

Standards for data quality must be set, the data collected by health care providers must be better coordinated, and the resulting information must be consolidated into a common, integrated knowledge base. To date, the Ministry’s Information

Management Team has documented the data that the Ministry of Health and Long-Term Care has. They have identified where and how data is collected, where it is stored, who has access to what information, and who makes decisions based on the information. In September 2005, the Ministry released the Ontario Health Planning Data Guide, the first comprehensive index of all health planning data.

The Information Management Team has reduced the burden for Community Care Access Centres to report on the services they deliver, so that the focus can be on the management of care and they have completed the first ever clinical-data blitz with Ontario hospitals. This work was done in collaboration with the Institute for Clinical Evaluative Sciences, the Hospital Report Research Collaborative, the Canadian Institute for Health Information (CIHI), and the Joint Policy and Planning Committee. The project entailed province-wide sessions to improve the quality of the acute inpatient and ambulatory care data submitted to CIHI by all Ontario hospitals.

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11 North East LHIN: Provincial Context - Vision, Priorities and Direction

5.0 INFORMATION AND COMMUNICATION

In addition, as of December 1, 2005, the Information Management Team helped create 14 Local Data Management Partnerships to enhance the health system’s capacity to manage information and address data quality issues. The new Local Data Management Partnerships bring together health information management officials from hospitals and the community care sector in each of the new Local Health Integration Networks. They will work together to identify best practices, standards, tools and policies for better data quality and management.

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North East LHIN: Provincial Context - Vision, Priorities and Direction 12

6.0 OTHER ONTARIO PRIORITY/STRATEGIC AREAS

Improved Access through

Reduced Wait Times

The National Waiting Times Reduction Strategy arose out of discussions at the 2004 Annual Conference of Federal, Provincial and Territorial Ministers of Health, at which time it was agreed that meaningful reductions in wait times in at least the following five key areas would be achieved by March 31, 2007: cancer, cardiac services, diagnostic imaging, joint replacements and sight restoration.

Ontario’s Wait Time Strategy was launched in November 2004, setting 2006 as the target date for results in the five procedures agreed upon nationally.

Steps in Ontario’s Wait Time Reduction Strategy

The first step in operationalizing Ontario’s Strategy will involve gathering information from hospitals related to waiting times for the five priority health service areas in order to evaluate current wait times.

The Ministry launched a Wait Time Strategy web site in October 2005, making wait time data available to both providers and the public. By the end of 2006, the web site will have complete information on wait times for the five key health service areas and ultimately the web site will provide information on every type of surgery being performed in the province.

In addition, the Institute for Clinical Evaluative Sciences (ICES) released a Wait Time Atlas for the Province of Ontario in April 2005.

The second important step involves the establishment of benchmarks. In December 2005, Provincial and Territorial Health

Ministers announced common national benchmarks for ten key medical services including the five priority areas.

On December 16, 2005, Ontario took a more aggressive approach to shortening wait times, announcing targets that are more stringent than the nationally accepted benchmarks in the five key areas (cataract surgery, hip/knee replacements, cardiac bypass surgery, MRI/CT scans, and cancer surgery).

The third step involves much needed service augmentation. A series of Ontario Government funding awards over the past two years have targeted service expansions of the following magnitudes:

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8% more CT scans

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11% more cancer surgeries

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16% more cataract surgeries

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17% more cardiac procedures

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28% more hip and knee replacements

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42% more MRI scans

The enhancement and creation of efficiencies (fourth step) is a key element in the Wait Time Strategy. The Health Council of Canada’s 2006 Annual Report indicates that better management and the redesign of patient flows are needed to reduce wait times in the long term. The allocation of additional resources through selective one-time funding is not enough.

As previously referenced, in October 2004, the Ministry of Health and Long-Term Care in Ontario established the Surgical Process Analysis and Improvement Expert Panel to address and improve surgical efficiencies. The Panel’s June 2005 Report recommends that LHINs measure the surgical performance of hospitals within their networks using agreed upon benchmark targets, report a

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13 North East LHIN: Provincial Context - Vision, Priorities and Direction

6.0 OTHER ONTARIO PRIORITY/STRATEGIC AREAS

minimum data set of quality and efficiency indicators to the public, and make planning and resource decisions accordingly.

Recommendation 21 in the Report states that: “Local Health Integration Networks should review the surgical services that exist, and identify opportunities to develop regional surgical systems that promote efficiencies, safety and meet local needs. These systems should consider a range of options including Centres of Excellence for surgery, more specialized surgeries in a few hospitals, and less complex, higher volume surgeries in a wider range of hospitals”.

The Health Quality Council, established in September 2005 and discussed in the “Quality and Efficiency” section of this report, has been asked by the Minister to assess and monitor wait times in Ontario, reporting the results publicly.

Services for Ontario’s

Francophone Population

The Local Health System Integration Act reiterates the Government’s belief that: “the health system should be guided by a commitment to equity and respect for diversity in communities in serving the people of Ontario and respect the requirements of the French Language Services Act in serving Ontario’s French-speaking community”. The 20th anniversary of the French Language Services Act in 2006 provided the government with an opportunity to reiterate its commitment to the progress of Ontario’s French-language communities, while celebrating their social, economic and cultural contributions. The Act recognizes in its preamble that French is a historic and honoured language of the province and states

that the government wishes to preserve it for future generations.

The French Language Services Act guarantees the right to receive provincial government services in French from head offices of the government and from offices located in or serving 24 designated areas in which 10% or more of the population is Francophone. Over 200 government-funded organizations in Ontario have been designated with respect to the provision of their services in French. The Minister responsible for Francophone Affairs oversees the implementation and administration of the Act and is supported in doing so by the Office of Francophone Affairs.

Aboriginal Health and Wellness

The Local Health System Integration Act states that the people of Ontario and their Government must: “recognize the role of First Nations and Aboriginal peoples in the planning and delivery of health services in their communities”.

In 1990, Aboriginal organizations and the relevant Government Ministries developed the Aboriginal Healing and Wellness Strategy, expressing a strong commitment to combat the alarming conditions of poor health and family violence faced by Aboriginal people in Ontario. This policy and service initiative engages Aboriginal people and the Government of Ontario in a partnership to promote health and healing among Aboriginal people.

Since its inception, the Strategy has funded the following program types:

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Community Wellness Workers

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North East LHIN: Provincial Context - Vision, Priorities and Direction 14

6.0 OTHER ONTARIO PRIORITY/STRATEGIC AREAS

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Health Liaison Staff

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Health Outreach Workers

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Healing Lodges and Treatment Centres

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Women’s Family Shelters

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Aboriginal Health Access Centres

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Treatment Centres

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Outpatient Hostels

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Maternal and Child Centres

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Health Advocacy Developers

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Translators

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Information Centres

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Aboriginal Health Planning Authorities

Primary Care Reform

The Ministry of Health and Long-Term Care’s Family Health Teams: Info Kit states that: “primary health care renewal is the foundation on which the transformation of Ontario’s health care system rests. Primary health care renewal encompasses improved access to primary health care services and it helps weave the various parts of our health system together. The implementation of Family Health Teams is the central transformation strategy through which the Government will provide more Ontarians with access to primary care.”

The Ministry is committed to making the system more patient-centred and responsive to local needs. Primary health care is viewed as the navigator of the health care system, providing clinical services as close to home as possible, system access, and continuity of care.

Extensive Primary Care Reform initiatives are underway to provide better access to comprehensive, around-the-clock health care to people in their own communities, through the introduction of Family Health Teams and

other complementary issues designed to increase the supply of health professionals, particularly doctors and nurses, in Ontario.

The Development of Family Health Teams

Family Health Teams (FHTs) are locally driven primary health care delivery organizations that include family physicians, nurse practitioners, nurses, and a range of other health care professionals who work in a team to provide comprehensive primary health care services to a defined population. With a focus on keeping patients healthy, the physicians, nurse practitioners, nurses, and other members of the Family Health Team will work in partnership with local public health units and other community-based health care organizations to improve services in areas such as chronic disease management and community-based health promotion and disease prevention activities. Family Health Teams may include, as appropriate, mental health workers, physician specialists, diagnostic services, linkages to home care services, and some outpatient surgery services.

The Government has set a goal of establishing 150 Family Health Teams by 2007 to improve access to primary health care services for over 2.5 million Ontarians. Following the Wave 3 round of Family Health Team applications, in excess of 170 FHTs have been approved for development throughout Ontario, including the following 17 projects currently underway in the Northeast.

Other Primary Care Initiatives

In addition to, and compatible with the development of Family Health Teams, the following primary care initiatives have been

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15 North East LHIN: Provincial Context - Vision, Priorities and Direction

6.0 OTHER ONTARIO PRIORITY/STRATEGIC AREAS

cited by the Ministry of Health and Long-Term Care as top priorities:

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Increasing the number of educational places for physician, nurse practitioner, and nurse training.

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Creating incentives for nurses employed by facilities with nurse practitioner vacancies to be educated to the nurse practitioner level.

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Encouraging licensure of international medical graduates.

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Creating incentives for older nurses to remain in the workforce.

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Guaranteeing employment for graduating nurses.

Health Human Resources

Recruitment, retention and the distribution of physicians and other health professionals will continue to be a challenge in Ontario and

throughout Canada. Ontario’s current health strategy is based on three goals, repeated often in Ministerial speeches and documents:

1) Keeping Ontarians Healthy 2) Reducing Wait Times

3) Providing Better Access to Doctors and Nurses

The third goal warrants attention throughout all of Ontario but is particularly important in the North. Fewer family physicians are providing a full service family practice and there is a growing demand for continuity of care and chronic disease management and prevention. Family physicians are being challenged to alter their traditional methods of practice and new configurations of service delivery will be necessary to optimize scarce human resources.

The Ontario Government has initiated a multifaceted approach – one that includes FAMILY HEALTH TEAMS ANNOUNCED FOR THE NORTH EAST LHIN

Anson General Hospital Iroquois Falls Blue Sky Family Health Team North Bay Burk’s Falls and District Family Health Team Burk’s Falls City of Lakes Family Health Team Sudbury East End Family Health Team Timmins Elliot Lake Family Health Team Elliot Lake Englehart and District Family Health Team Englehart Espanola and Area Family Health Team Espanola Haileybury Rural and Northern Physician Group Haileybury Kirkland Lake Family Health Team Kirkland Lake Municipality of Assiginack Manitowaning Northeastern Manitoulin Family Health Team Little Current Parry Sound Family Health Team Parry Sound Temagami Medial Central Family Health Team Temagami Township of South Algonquin Family Health Team Whitney Wawa Family Health Team Wawa White Pines Family Health Network Timmins

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North East LHIN: Provincial Context - Vision, Priorities and Direction 16

6.0 OTHER ONTARIO PRIORITY/STRATEGIC AREAS

both short- and long-term strategies. Current Ministry initiatives focus on the enhancement of overall system capacity by improving access to primary health care through Family Health Teams. Family medicine and primary care needs are also being addressed through an increase in the number of educational places for physician and nurse practitioners. Additional nurse training has been

implemented along with new educational incentives for nurses including the Minister’s announcement on May 8, 2006 to provide Ontario nursing graduates with a “guarantee of employment”. Freeing up health human resources through data rationalization and operational efficiencies, while building the analytic capacity in the provider community, is a top priority and efforts to eliminate unnecessary data collection have had a significant impact.

Mental Health and Addiction

“Making It Happen” (1999), a provincial level policy document on mental health, provided a framework for a comprehensive mental health service delivery system throughout Ontario. As a result of this work, the Ministry established nine regional Mental Health Implementation Task Forces, charged with the responsibility of looking for ways to:

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Provide a greater range of services in the community;

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Improve access to mental health services;

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Tailor services to those with mental health needs;

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Link services so those with mental illness can move seamlessly within the system; and

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Ensure services are based on best practices.

A provincial forum of the Mental Health Implementation Task Forces, including Chairs of all the Task Forces, was held in January 2001, to identify provincial issues and make recommendations to the Ministry on the implementation of mental health reform. All Mental Health Implementation Task Forces, the provincial forum, and the Forensic Mental Health Services Expert Advisory Panel

have completed final reports. Many of the recommendations have yet to be implemented although the Ministry has begun to invest more heavily in mental health programming. Over the past few years, the issue of

concurrent disorders (the presence of both an addiction and a mental health disorder experienced by the same individual) has gained prominence provincially and nationally. Based on the frequency with which integration of mental health and addiction services were cited as high priority at the November 2004 NE LHIN Integration Priorities session, it is likely that addressing concurrent disorders through integrated mental health/addiction services will remain a priority across Ontario.

Ambulance, Emergency and

Critical Care Services

In 2005, the Minister of Health and Long-Term Care established a Hospital Emergency Department and Ambulance Effectiveness Working Group to offer advice on enhanced access and quality of service in emergency departments. The Working Group issued its report in the summer of 2005, presenting 15 recommendations identifying ways for hospitals and ambulances to transfer patients more efficiently from ambulance paramedics to the hospital emergency department. The following three themes emerged from the report:

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17 North East LHIN: Provincial Context - Vision, Priorities and Direction

6.0 OTHER ONTARIO PRIORITY/STRATEGIC AREAS

1) System commitment on the part of all stakeholders.

2) Accountability across all stakeholders to each other and to

the citizens of Ontario for emergency patient care.

3) The expansion of capacity through enhanced efficiencies

and additional services when all other means have been

exhausted.

On January 30, 2006, the government announced the $96 million comprehensive action plan to reduce wait times at hospital emergency departments, consistent with the report of the Hospital Emergency Department and Ambulance Effectiveness Working Group.

Stroke Strategy

The Heart and Stroke Foundation of Ontario launched the Coordinated Stroke Strategy in 1998 as a three-year demonstration project to test a model of region-wide coordinated stroke care across the continuum of care. In June of 2000, the Minister of Health and Long-Term Care endorsed the “Report of the Joint Stroke Strategy Working Group” and approved a four-year stroke strategy committing to an investment of over $70 million.

Ontario’s Stroke Strategy Principles

1) Comprehensiveness 2) Integration

3) Evidence-Based Stroke Practices 4) Province-Wide Equity

Regional and District Stroke Centres have special roles in providing advanced stroke care and in coordination and leadership. There are currently nine regional stroke centres in Ontario and seven district stroke centres.

Diabetes Strategy

A Diabetes Advisory Committee, established in 1992, launched a ten-year strategic plan for designing and implementing effective programs to prevent diabetes and its complications. The plan focused on people in communities at greatest risk, including Northern Ontario, Ontario’s Aboriginal population, and seniors.

Cancer Care Plan

Cancer Care Ontario is the province-wide cancer agency mandated by the Government of Ontario to provide strategic direction and leadership for all components of Ontario’s cancer control system, including the operation of Regional Cancer Centres.

In 2001, the Ministry of Health and Long-Term Care asked Cancer Care Ontario to lead the development of a long-term plan for cancer prevention and early detection in Ontario. The plan entitled, “Targeting Cancer: An Action Plan for Cancer Prevention and Detection (Cancer 2020)” was released in May 2003. Cancer 2020 is a comprehensive action plan for cancer prevention and early detection. The goal is to reduce cancer incidence and mortality in Ontario by the year 2020.

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North East LHIN: Provincial Context - Vision, Priorities and Direction 18

6.0 OTHER ONTARIO PRIORITY/STRATEGIC AREAS

Ontario Cancer Plan Priorities

1) Broaden the development and use of provincial standards and guidelines. 2) Implement regional cancer programs. 3) Close the gap by reducing demand for

cancer services and increasing capacity.

4) Implement rapid access strategies. 5) Invest in performance measurement

and accountability.

6) Advance the coordination and focus of cancer research efforts.

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Contact Us

TELEPHONE

705-840-2872 866-906-5446 (Toll Free)

FAX

705-840-0142

ADDRESS

555 Oak Street East, 3rd Floor, North Bay, ON P1B 8E3

LINKS

www.lhins.on.ca/english/northeast/northeast.asp www.lhins.on.ca/french/northeast/northeast.asp

North East

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