IDEAS

1. www.ideasontario.ca
G. Ross Baker, Ph.D.
Institute of Health Policy, Management and
Evaluation
University of Toronto
The QI Imperative:
Supporting System Transformation

2. www.ideasontario.ca 2
Faculty Disclosure
• Faculty: G. Ross Baker
• Relationships with commercial interests:
– Grants/Research Support: Canadian Patient Safety Institute;
Canadian Foundation for Healthcare Improvement; Canadian
Institutes for Health Research; Ontario Ministry of Health and Long
Term Care
– Speakers Bureau/Honoraria: Institute for Patient and Family
Centered Care; Saskatchewan Health Quality Council; Canadian
Foundation for Healthcare Improvement;
– Consulting Fees: Canadian Foundation for Health Care
Improvement; Health Foundation (UK)
– Other: Faculty member, University of Toronto

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Healthcare’s Perfect Storm
u Growing
prevalence
of
chronic
disease
u
New
technology
improves
outcomes
but
increases
costs
u Rising
public
expecta;ons
u Professional
autonomy
trumps
system
change
u Aging
workforce
u Limited
integra;on
across
services
and
organiza;ons
u LiAle
appe;te
for
increased
taxa;on
or
user
fees

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Ontario Responses to the
Perfect Storm
• Fairer funding
• Expanding access
• Better use of health human resources
• Integrating care across settings
• Expanding home and community care
• Greater emphasis on promoting healthy behaviours
• Improving quality at the front lines
How do we make this happen?
Ontario’s
Ac;on
Plan

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Quality By Design
• Goal: Understand the strategies and investments of high
performing healthcare systems to inform strategy in
Ontario
• Methods:
– Literature review
– Case study selection and visit
– Detailed analysis and development of cases
– Translation to Ontario context

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Quality by Design helps to define strategies & models for
achieving and sustaining improvement in Ontario
Literature
Review
Cross-case
Analysis
Case Site
Selection
& Visits
Synthesis of
frameworks
and elements
Translation
to Ontario
Context
What are the existing frameworks &
elements of improvement capability?
Case
preparation
and final
reports
Cross case
summary
and revised
framework
Knowledge Transfer
Kit
Leadership Series
Policy options
How have exemplary systems
invested in
improvement capability?
Where is Ontario in terms
of improvement capability
and how might we proceed?
PHASE 1 PHASE 2 PHASE 3
METHODS
PRODUCTS

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Systems Selected for
Detailed Study
• 5 International systems
– Jonkoping County Council, Sweden
– Intermountain Healthcare, Salt Lake City, UT
– Henry Ford Health System, Detroit, MI
– Veterans Health Administration-- VISN 1 (New
England) and White River Junction VAMC Vermont,
USA
– Birmingham East and North PCT and Heart of
England Foundation Trust, Birmingham, England
• 2 Canadian systems
– Calgary Health Region, Alberta
– Trillium Health Centre, Mississauga

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Ten Themes in High Performing Systems
Leadership
and
Strategy
Organiza2onal
Design
Improvement
Capabili2es
Quality
and
system
improvement
as
the
core
strategy
Robust
primary
care
teams
at
the
centre
of
the
delivery
system
Organiza2onal
capaci2es
and
skills
to
support
performance
improvement
Leadership
ac2vi2es
that
embrace
common
goals
and
align
ac2vi2es
throughout
the
organiza2on
More
effec2ve
integra2on
of
care
that
promotes
seamless
care
transi2ons
Informa2on
as
a
plaCorm
for
guiding
improvement
Promo2ng
professional
cultures
that
support
teamwork,
con2nuous
improvement
and
pa2ent
engagement
Effec2ve
learning
strategies
and
methods
to
test
and
scale
up
Providing
an
enabling
environment
buffering
short-­‐term
factors
that
undermine
success
Engaging
pa2ents
in
their
care
and
in
the
design
of
care.

9. www.ideasontario.ca 9
SWEDEN
Jönköping
Eksjö
Värnamo
WHAT...
Regionally elected political body that
funds, plans and delivers services
as a dominant focus
WHO...
3 healthcare districts across 13
municipalities
Population of 340,000
9900 staff
3 hospitals, 34 care centres (primary
care, specialized care, rehabilitation
facilities, and pharmacies)
WHY...
”For a good life in an attractive county”
Jönköping - in a rural area of Sweden with a relatively small population
- has been profiled internationally for their quality infrastructure and
performance…

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Quality As A Core Strategy
• Since the mid 1990s, Jönköping’s senior team paired their longstanding commitment
to strong financial performance with a strategic focus on quality improvement.
• Established a closer link between finance and quality, honing in on value for patients
instead of just costs.
• Through self-assessment using the Swedish Baldrige/QUL criteria, and an introduction
to the principles of total quality management, began to use these as a framework for
developing a more central and strategic focus on quality.
• Maintained an ongoing strategy of modest capital expenditures, removing waste and
improving quality as a means of cost reduction.
• The County Council estimates that its work on efficiencies has led to 80 million crowns
(SEK) savings, or 2% their net costs with the savings reinvested in continued
improvements in care

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Quality as a Strategy
“Quality is nothing “special”; it should be
integrated in everything that we are doing. I
think it is very dangerous to have an
agenda where you talk Monday about
finances, Tuesday about quality and
Wednesday about another thing. You must
work with all these at the same time”
Sven-Olof Carlsson, former CEO
Jönköping County Council

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Creating the Capability to
Redesign and Improve Care at
Jönköping
• Qulturum “ a meeting place for quality and culture” provides support for system-wide
and unit-based projects to ensure ongoing learning and support to staff and leaders as
they make changes to processes of care.
• Have made over 800 measurable improvements spanning all of the County Council’s
seven strategic aims.
• 4000 of the 9000 staff members and leaders across the system have received action-
based quality improvement training at Qulturum.
• Despite the participation of physicians in education at Qulturum, Jönköping’s leaders
realized that they needed a parallel approach of introducing improvement to the next
generation of clinicians. Jönköping initiated a partnership with a medical school and
other health professions programs in Sweden.

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Intermountain Healthcare
WHAT…
A not-for-profit integrated health system in
Utah and southeastern Idaho – initially a gift
from the Latter-Day Saints church – that
provides excellent clinical care at affordable
rates
WHO…
22 hospitals, Health Insurance Plan (with 5
Provider Networks), Physician group with
2200 affiliated physicians, Community care
services
26,000 FTE employees
WHY…
“To provide the best clinical practice, service
experience and genuine care and concern
delivered in a consistent and integrated way
at the lowest appropriate cost.”
IHC

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An Integrated Clinical Information
Informs the System Of Care
• Brent James noted that “an early start created the strongest medical informatics
system globally…and much of Intermountain’s success in integrating patient care is
attributed to this strong clinical informatics system.”
• When comparing the availability of data in IHC’s system in the mid 1990s to the
requirements generated throughout the development of their clinical integration
strategy, IHC’s information system had only 50-70% of the data needed. The
clinical integration strategy was a key driver for the development of the clinical
repository.

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15.3
14
15.3
14.5
14.7
11.6
12.8
11.8
12.6
12.8
15.1
12.1
9.9
8.8
6.8
6.5
6
6.1
53
53
63
53
57
45
56
52
41
52
62
46
49
35
21
21
26
28
110
87
119
109
124
91
107
94
100
105
118
87
81
67
57
57
46
52
0
20
40
60
80
100
120
140
Number
of
pa2ents
0
10
20
30
40
50
%
of
all
primiparous
deliveries
Bishop's
score
<
10
Bishop's
score
<
8
Goal:
Reduce
"inappropriate"
nullip
inducBons
by
50%
IHC’s Labour and Delivery Program reduced the
number of inappropriate elective inductions…

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…and in parallel reduced costs
1000
1200
1400
1600
1800
2000
Average
combined
variable
cost
($)
1000
1200
1400
1600
1800
2000
Expected
maternal
and
fetal
combined
variable
cost
Goal:
hold
increase
to
no
more
than
6.85%
Actual
combined
variable
cost
B.
James.
IHC

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Providing Improvement Methods and
Tools Supports Better Care
“Even today, we still have
people within our system who
viscerally oppose our ongoing
shift to clinical process
management and improvement.
…. Change is hard. However,
we have enough people who
“get it” –and are deeply
convinced of and committed to
it – that we can move vigorously
ahead” … Brent James (2007)

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Leadership in High Performing
Health Care Systems
• Leadership at all levels is crucial for supporting
improvement
• These systems had long serving senior leaders and
smooth transitions between CEOs that maintained
strategic investments and directions
• Leadership training and development was a key
element, either at an organization level (IHC,
HFHS, Jonkoping) or system level (VHA, NHS)
• Leadership was collective and participative

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Growing Impact of QI Efforts
• Healthcare quality improvement efforts are based on the
work of Deming, Shewhart, Juran and others reaching
back 80 or more years
• But applications to healthcare are much more recent:
– Berwick, Batalden and colleagues created the first major
“demonstration project” in the late 1980s
– IHI was formally launched in 1991
– Quality Healthcare Network was created in 1993
– The Saskatchewan Health Quality Council and Cancer Care
Ontario launched in 2002
– HQO created (as Ontario Health Quality Council) in 2004
• Large scale application of QI in Canada is still barely a
decade old

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Core Elements of the QI
Imperative
• Focus on meeting the needs of patients and clients, not the needs of
organizations
• To make improvements, we first need to be clear about the aims of
improvement, how we will measure the changes that lead to
improvement and what changes are needed that will lead to
improvement
• Real improvement comes from changing processes and systems,
not stressing individuals within the system
• Measurement guides improvement but should be used for learning
not judgement
• Improvement requires action, not just planning
• Improvement expertise must be linked with clinical and system
knowledge
• Leadership is critical
Adapted
from
Berwick,
1996

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Quality Improvement Builds on
Other Crucial Initiatives
• Evidence of effective practice
• Changes in funding formulas to support more
appropriate care (in the most appropriate settings)
• New models of care and more effective care teams
• Working to full scopes of practice
Quality improvement tools provide a robust method
for implementing and integrating many changes

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What you will be able to do:
Core Competencies
• Identify system improvement opportunities for
healthcare quality
• Design, develop, and implement effective
change through mastery of quality
improvement methods
• Use data for improvement
• Lead and influence improvement

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Growing QI Resources in
Canada
• Quality councils
• Growing success with QI
methods
– Safer Healthcare Now!
– Provincial collaboratives and
initiatives
• Growing investments in QI
capacity and capability

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“It is a new system and a lot of the old tools won’t work
anymore. Those who cling to their old tools and allow
our organization to disintegrate will find little sense
either in the burning present or in the challenging
future.”
Donald Berwick, “Escape Fire” 1999
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