Quality-Based Procedures

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Quality-Based Procedures

Fiscal Year 2015/16 Volume Management

Instructions and Operational Policies for Local

Health Integration Networks

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1.0 Introduction

The purpose of this document is to provide direction to Local Health Integration Networks (LHINs) regarding the in-year management of Quality-Based Procedures (QBP) under Health System Funding Reform (HSFR). Specifically, this document outlines policies regarding QBP reallocations, reconciliations and recoveries for the 2015/16 fiscal year. This document also contains other general requirements and conditions related to QBPs (see Appendix).

1.1 Scope

These instructions apply to LHIN-managed QBPs (see Figure 1). Cancer Care Ontario (CCO) will provide separate instructions regarding volume management for CCO-managed QBPs.

There will be no movement of volumes and funding between LHIN-managed and CCO-managed QBPs.

Figure 1. LHIN-Managed QBPs in Hospitals

Figure 2. LHIN-Managed QBPs in the Community

Notes:

1) See Sections 2.0 and 5.1 for instructions regarding reallocations and reconciliations of non-cardiac vascular QBPs.

2) See Section 4.3 for instructions regarding reallocations from the Community Care Access Centre (CCAC) to Hospital Outpatient Rehabilitation.

Elective

Community Rehab Hip and Knee Replacement (CCAC / Hospital

Outpatient) (note 2)

Non-Elective Chronic Obstructive Pulmonary Disease (COPD)

Stroke

Congestive Heart Failure (CHF) Hip Fracture

Pneumonia Neonatal Jaundice Elective

Primary Unilateral Hip and Knee Replacement Primary Bilateral Hip and Knee

Replacement

Inpatient Rehab (Hip and Knee Replacement)

Unilateral Cataract Non-Cardiac Vascular (note 1)

Tonsillectomy Knee Arthroscopy

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2.0 Reallocations

LHINs have discretion to perform the following QBP reallocations, provided the movement is consistent with the Principles for LHIN-Managed Volume Movement (see Section 3.0).

QBP Reallocations Example

Hospital QBPs

Within QBPs Hip Replacement from Hospital A to Hospital B

Between QBPs

within Elective and Non-Elective categories (see Figure 1)

Hip Replacement from Hospital A to Knee Replacement at Hospital B

Stroke at Hospital A to Congestive Heart Failure at Hospital A

Non-Cardiac Vascular Consult with ministry

Community QBPs

Within QBPs Hip Rehabilitation from CCAC to Hospital Outpatient

Between QBPs CCAC Hip Rehabilitation to CCAC Knee Rehabilitation

Between Sectors

Within QBPs Inpatient Rehabilitation to Outpatient Rehabilitation at Hospital A The movement of volumes between elective and non-elective QBPs (see Figure 1) is not permitted.

Prior to implementing any reallocations of non-cardiac vascular QBPs, LHINs are required to consult with the ministry by contacting [email protected].

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3.0 Principles for LHIN-Managed Volume Movement

The goal of Health System Funding Reform (HSFR) is to implement a strategic funding system that promotes the delivery of high-quality health care services across the continuum of care, and is driven by evidence and efficiency. Based on the key principles of quality, sustainability, access, and integration, HSFR aligns with the four core principles of the Excellent Care for All Act.

As such, LHINs will be required to ensure that QBP volume movement is based on the following principles, which align with the Quality Domains in the QBP Integrated Scorecards.

Quality Domain Principles

Effectiveness Supports improved outcomes of care and reduced adverse events (e.g.

infections) by considering how results vary across providers.

Appropriateness

Supports improved appropriateness by considering how care aligns with the QBP Clinical Handbooks and in a way that avoids overuse, underuse or misuse where appropriate (e.g. substitution from inpatient to

outpatient, less invasive procedures, discharge to community, reduced lengths of stay).

Integration

Supports improved integration by considering how all parts of the health system are organized, connected and working with one another to provide high quality care (e.g. reduce 30 day readmission rate).

Efficiency

Supports improved efficiency by considering the best use of available resources to yield the maximum benefit (e.g. proportion of QBPs with actuals costs less than the QBP price).

Access

Supports improved access by considering whether those in need of care are able to access services when needed (e.g. wait times, distance patients have to travel to receive appropriate care related to the QBP).

Patient- Centeredness

Supports improved patient-centeredness by considering how results vary across providers (e.g. rate of patients involved in treatment decision, coordination of care).

Innovation Supports adoption of innovative changes in the delivery of health care services.

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4.0 Rates for Reallocations

4.1 One-Time Reallocations

LHINs will have discretion to perform reallocations at a funding rate determined by the LHIN, provided the volume movement:

 Results in the same or more volumes being completed for reallocations within QBPs.

 Is cost neutral and does not result in a funding pressure. If the reallocation results in savings, the LHIN may use the savings to invest in additional QBP services.

This applies to both reallocations between HSFR hospitals and between HSFR and non-HSFR hospitals.

4.2 Permanent Reallocations

LHINs are required to identify permanent reallocations (i.e. intended to impact future years) in their QBP Volume Movement Reports. The ministry will adjust the Case Mix Index (CMI) of the receiving hospital based on the CMI of cases being received, as needed, to ensure that the net impact is cost neutral.

For permanent reallocations between HSFR hospitals and non-HSFR hospitals, the amount of funding to be transferred will be based on the CMI of the HSFR hospital.

4.3 Reallocations From CCAC to Hospital Outpatient

Currently, hospital outpatient rehabilitation is not funded as a QBP. As a result, for reallocations of QBP Unilateral/Bilateral Hip and Knee Replacement Rehabilitation from the CCAC to

hospitals for outpatient rehabilitation, the hospitals will be provided with non-QBP base funding.

For permanent reallocations from CCAC to hospital outpatient, the LHIN will need to:

• Input a base funding recovery batch in the Allocation Payment and Tracking System (APTS) for the CCAC;

• Input a base payment batch in APTS for the hospitals for an amount that is lower than or

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5.0 Reconciliations and Recoveries

5.1 Year-End Recovery of Funds

The ministry will reconcile the 2015/16 QBP funded volumes against actual volumes achieved for each hospital and CCAC (i.e. surplus CCAC QBP funding cannot be offset against other CCAC pressures). Any funds not used for the specific intended purpose will be subject to recovery by the ministry at year-end.

For hospitals, the ministry will net volumes and funding within the elective and non-elective QBP categories (see Figure 1) for each hospital, with the exception of non-cardiac vascular.

There will be no netting between elective and non-elective QBPs or between hospitals in the LHIN. LHINs and health service providers will not receive additional funding if the total netted funding amount exceeds their allocated funding. Funding and volumes for non-cardiac vascular QBPs will be reconciled separately.

The data sources for year-end actuals are:

 Hospitals – Canadian Institute for Health Information (CIHI) Discharge Abstract Database (DAD) / National Ambulatory Care Reporting System (NACRS); and

 CCACs – Home Care Database (HCD).

LHINs/hospitals that are in the process of significant shifts in activity away from QBPs towards non-QBP services should work with the ministry prior to fiscal year-end to determine any appropriate adjustments to their QBP allocation that would impact year-end reconciliation.

5.2 Rates for Recoveries

The ministry will use the hospital-specific funding rate and CCAC-specific funding rate for the purposes of reconciliation (i.e. to calculate the value of services over or under the allocated volumes).

The hospital-specific rates and CCAC-specific rates are listed in the 2015/16 HSFR Impact Analysis provided to each LHIN (see “HBAM-Adjusted Total Cost Per Case” or “HBAM- Adjusted Direct Cost Per Case”, depending on the QBP).

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6.0 Process

The following table outlines the process for QBP volume management in 2015/16:

Date Activity

July 2015

Ministry distributes HSFR funding letters to LHINs, including QBP funding and volumes for hospitals and Community Care Access Centres (CCACs).

July 2015 to March 2016

LHINs may reallocate QBP volumes at their discretion (see Section 2.0) based on Principles for LHIN-Managed Volume Movement (see Section 3.0), or consult with the ministry for Non-Cardiac Vascular QBPs.

LHINs inform the ministry of QBP reallocations by submitting a QBP Volume Movement Report to the ministry at

[email protected] no later than February 23, 2016.

LHINs submit Allocation and Payment Tracking System (APTS) requests related to reallocations. All APTS requests must occur no later than March 8, 2016.

Ongoing (up to June 30,

2016)

Hospitals report QBP volumes to the Canadian Institute for Health Information (CIHI) Discharge Abstract Database (DAD) / National Ambulatory Care Reporting System (NACRS). The 2015/16 year-end cut-off date for reporting is June 30, 2016.

Hospitals also report QBP volumes via the Self Reporting Initiative (SRI). The 2015/16 year-end cut off for reporting is June 30, 2016.

CCACs report clinical cases and services to the Homecare Database (HCD) on quarterly basis.

September to December 2016

Ministry issues reconciliation letters to hospitals and CCACs

(copying LHINs) and recovers funding associated with QBP volumes not completed.

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Appendix: General Conditions

LOCAL HEALTH INTEGRATION NETWORK (LHIN) CONDITIONS 1 – General Conditions Applicable to All QBPs

1. The LHIN agrees to work collaboratively with its service providers to:

a. Facilitate the adoption of evidence-based best practices; and

b. Maximize use of the Wait Time Information System (WTIS), Critical Care Information System (CCIS), Surgical Efficiency Targets Program (SETP) and Emergency Room National Ambulatory Care Reporting System (ER NACRS) Initiative and meet the reporting requirements set out in the 2015/16 Wait Time Strategy Conditions of Funding.

HEALTH SERVICE PROVIDER (HSP) CONDITIONS 2 – General Conditions Applicable to All QBPs

1. The HSP agrees to:

a. Ensure that the delivery of QBP services will not result in a decrease of service levels in any other service areas (not funded by the QBP), unless part of system planning with the LHIN;

b. Plan accordingly to provide services evenly throughout the year;

c. Work with Access to Care at Cancer Care Ontario (CCO) to update their monthly WTIS surgical volume targets to reflect reallocations and report all completed surgical procedures to the WTIS (where applicable); and

d. Provide data on any other indicators as may be required by the LHIN.

3 – General Conditions Applicable to Acute Primary Unilateral and Bilateral Hip and Knee Replacement, Knee Arthroscopy, Cataract Surgery and Vascular Surgery 1. The HSP will work towards meeting Ontario’s Wait Time Access Targets, QBP Quality

Indicator Targets and SETP Key Performance Indicator Targets as listed below.

Ontario’s Wait Time Access Targets

Ontario’s Wait Time Access Targets

Priority Level

Primary Hip & Knee Replacement (Bilateral/Unilateral)

Knee Arthroscopy

Cataract Surgery

Tonsillectomy (Paediatric Otolaryngic

Surgery)

Vascular Surgery

I 7 days Immediate 24 hours 24 hours

II 42 days 42 days 21 days 14 days

III 84 days 84 days 42 days 56 days

IV 182 days 182 days 182 days 182 days

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QBP Quality Indicator Targets

QBP Quality Indicators Target

% of patients receiving primary hip replacement and primary knee replacement (unilateral and bilateral) discharged to home for rehabilitation

90%

% of Patients receiving primary hip replacement and primary knee replacement (unilateral and bilateral) with an average length of stay of 4.4 days

90%

SETP Key Performance Indicator Targets

SETP Key Performance Indicators Target

% First Case Start On-Time or Early 85%

% Utilization 7am – 3pm 90 – 100%

% Patients Screened Prior to Surgery 100%

% Surgical Checklist Compliance 100%

% Same Day Cancelled or Postponed <5%*

*Hospitals with % Same Day Cancelled or Postponed rate higher than 5% at the beginning of the fiscal year and the reasons within their control (Bed Not Available, Delayed Schedule/Not Enough Time, Hospital Resources, Hospital Staff Unavailable) account for more than 20% of the overall rate, will be expected to work towards reducing the controlled rate by 20% by the end of the fiscal year.

2. The HSP will examine the wait time and surgical efficiency data on a regular basis to ensure patients are receiving access to surgical consultations and surgical procedures appropriately. The HSP will:

a. Ensure no patient waits longer for their surgical procedure than the assigned priority access target without reassessment, and will account for the number of patients that have been reassessed and their status;

b. Review and analyze the reasons patients are waiting beyond target timeframes and act to improve performance; and

c. Review and analyze surgery cancellation reasons and act to reduce the overall cancellation rate to help improve patient satisfaction.

3. The HSP will provide the following performance data to the LHIN for the period April 1, 2015 to March 31, 2016:

a. Details (if requested) regarding the extent to which the quality indicator targets for primary unilateral and bilateral hip and knee replacement procedures are being met; and

b. Details (if requested) regarding the extent to which the surgical volumes are

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services will be considered upon completion of the vascular services review and recommendations by the Cardiac Care Network’s Vascular Care Working Group.

Hospitals permitted to use AA QBP funding for EVAR Services

LHIN Hospital(s)

South West London Health Sciences Centre

Hamilton Niagara Haldimand Brant

Hamilton Health Sciences Centre Mississauga Halton Trillium Health Centre

Toronto Central St. Michael’s Hospital University Health Network

Sunnybrook Health Sciences Centre

Champlain The Ottawa Hospital

North East Health Sciences North (Sudbury Regional)

4 – General Conditions Applicable to Community Care Access Centres Regarding Rehabilitation Services for Primary Unilateral and Bilateral Hip and Knee Replacement Procedures

1. The CCAC will provide encrypted client-level data through SRI/CHRIS to their LHIN for the periods of April 1, 2015 to September 30, 2015 and October 1, 2015 to March 31, 2016.

2. LHINs have the option of reallocating rehabilitation cases between CCACs and hospital outpatient departments (see Section 4.3 for instructions).

5 – General Conditions Applicable to Hospital Outpatient Rehabilitation Services for Primary Unilateral and Bilateral Hip and Knee Replacement Procedures

1. For hospital primary unilateral and bilateral hip and knee replacement rehabilitation services reallocated from the CCAC to hospital outpatient departments, the Hospital agrees to:

a. Use the funding to deliver hospital outpatient rehabilitation services for unilateral and bilateral hip and knee rehabilitation and not for other programs and services;

and

b. Report hospital outpatient rehabilitation volumes for unilateral and bilateral hip and knee replacement patients via the Self Reporting Initiative (SRI).

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Quality-Based Procedures