1. 11
Structures and Processes for
Creating & Managing Quality
Outcomes & Reducing Waste in
Alberta Health Services
GMF Symposium
April 19, 2013
Montreal, Quebec
Dr Tom Noseworthy

2. 22
Compared to other Provinces
Alberta is
• Not less expensive (highest per capita, higher
service intensity & higher unit costs)
• Not more accessible (maybe less)
• Not the country’s best quality for most
outcomes (with clear exceptions)
• Not the longest, or health-adjusted, length of life

3. 33
825
557
875
627
1048
306
0
200
400
600
800
1000
1200
South Zone Calgary Zone Central Zone Edmonton Zone North Zone Best Large RHA/Zone
(Central LHIN, ONT)
Age-StandardizedRate(per100,000)
Source = CIHI Health Indicators
Injury Hospitalization - 2010/11

4. 44
11.21
8.73
7.68
5.92
4.29
5.53
0
2
4
6
8
10
12
South Zone Calgary Zone Central Zone Edmonton Zone North Zone Best Large RHA/Zone
(Central West LHIN,
ONT)
Risk-AdjustedRate(per1,000)
Source = CIHI CHRP
5-Day In-Hospital Mortality Following Major Surgery - 2010/11

5. 55
Alberta Health Services
• One health care delivery system for entire Province
• ‘Third way’- Canada (no regions, all regions, one)
• Largest health system in Canada- 3.7 million
• Budget $12B, 100,000 employees, 7500 doctors
• Formed 2008, 5 Zones in 2010, Networks in 2012
• Nine clinical networks launched to date
• Up to six more planned

6. 66
How will the Provincial Clinical Mandate of
AHS be Accomplished? Structures
• Strategic Clinical Networks
• Clinically-led change
• Performance measurement, research & best
evidence drive practice
• Clinical care pathways
• Clinical variance management & peer review

7. 77
Goals of Clinical Networks?
• Achieve the best outcomes
• Practice the highest quality of clinical care
• Seek the greatest value from resources used
• Engage clinicians in all aspects of this work

8. 88
Why Clinical Networks?
• Networks are positive ways for all partners
along a broad continuum to be involved in
planning & improving care & service delivery
• Networks have been shown to be an effective
mechanism to ensure collaboration, joint
decision-making and shared learning
• Networks are a sound model to promote the
use/uptake of clinical experience, knowledge
and evidence-based clinical pathways to
reduce clinical variation & improve care

9. 99
17.87
11.71
20.93
13.41
18.23
11.71
0
5
10
15
20
25
South Zone Calgary Zone CentralZone Edmonton Zone North Zone Best Large RHA/Zone
(Calgary Zone, AB)
Risk-AdjustedRate(per100)
Source = CIHI CHRP
30-Day In-Hospital Mortality FollowingStroke - 2010/11

10. 1010
What are Strategic Clinical Networks (SCNs)?
• Collaborative clinical teams with a provincial
strategic mandate to improve quality & outcomes
• Led by clinicians, driven by clinical needs,
focused on outcomes & based on best evidence
• Comprised of an all-inclusive membership, with
25 core members (community & specialty
clinicians, patients, policy-makers, researchers)
& leadership (0.5 Senior Medical Director, 0.5
Strategy Vice-President & 0.3 Scientific Director)

11. 1111
How do SCNs Work?
• Broad mandate:
– Specific populations: seniors, women's health, children
– High impact: cardiovascular disease & stroke
– High burden: diabetes, obesity & nutrition, amh
• Scope encompasses entire continuum of care
– From population health & prevention to primary care to
acute care to chronic disease management to palliation
• Projects & resources
– Driven by evidence and focused on improving outcomes
and eliminating waste

12. 1212
Planned Support & Resources for Each SCN
• Dedicated Business Intelligence Unit
– Project management, clinical analytics, case costing, quality
improvement, pathway development, patient safety,
knowledge management, health technology assessment
• Embedded research capability and expertise
• Education & skills development for leaders
• Funding including:
– Seed money for innovation, initiatives, and research
– Remuneration of core members
– Opportunities to retain savings that are realized

13. 1313
First Six SCNs (June 12/12)
• Addiction and Mental Health
• Bone and Joint Health
• Cancer Care
• Cardiovascular Health and Stroke
• Obesity, Diabetes and Nutrition
• Seniors’ Health

14. 1414
Three Operational Clinical Networks
Similar to SCNs
i. Provincial, clinically led teams
ii. Similar infrastructure & resources
Differ from SCNs
i. Responsible across populations
ii. Operationally focused
iii. Social determinants/ EOL agenda not
required in projects

15. 1515
Three Operational Clinical Networks (Jan13)
• Critical Care
• Emergency Services
• Surgical Services

16. 1616
Proposed SCNs (Fiscal 2013)
• Population Health and Health Promotion
• Primary Care & Chronic Disease Management
• Maternal Health
• Newborn, Child, and Youth Health
• Neurological Disease, ENT, and Vision
• Complex Medicine (GI, Kidney & Respiratory)

17. 1717
Proposed SCN & OCN Projects 2013
Obesity, Diabetes
& Nutrition
SCN
Bone & Joint
SCN
Surgery
OCN
Emergency
OCN
Addiction &
Mental Health
SCN
Cardiovascular
Health and Stroke
SCN
Insulin
Pump
criteria
Rural Stroke
Program
Vascular Risk
Reduction
C-CHANGE
Enhancing
recovery
after surgery
ART
E-referral
Fragility &
Stability -
Hip Fracture
Rx and
Prevention
Inappropriate
use of
antipsychotics
Cancer
SCN
Critical Care
OCN
Seniors’ Health
SCN
Depression
Pathway
Safe Surgery
Checklist
aCATS TBDTBD
Hip & Knee
5 year Plan
Lung
Cancer
Elder
Friendly
Care*

18. 1818
Project Scope:
• Create standards and clear definition of rural stroke
unit care
• Implement early supported discharge (ESD) &
enhanced stroke unit care in 5 small stroke centres
• Implement enhancements to stroke unit care for 10
rural primary stroke centres
System Impact:
• Acute care
• Transition management
• Long term care
Project Financials:
•Q4 (12/13): $ 141,964
•13/14: $1,745,950
• TOTAL Project: $2,873,594
Benefits to be Realized:
Short term – Jan 31/ 13 – Mar 31 /14
• ESD implemented in 5 small centres serving100
patients
• 26% reduction in length of stay; 3 persons avoid
nursing home care; 1 life saved
Long term– 1- 3 year window
• 214 new patients per year receive ESD and over 1000
new patients per year receiving full stroke unit services;
23 lives saved/year; 17 patients avoid nursing homes
after stroke/year
• Reduction in length of stay of over 20%
CV&S: Rural Stroke Action Plan

19. 1919
How Alberta Health Services Will Achieve its
Clinical Mandate (Processes)
• Strategic & Operational Clinical Networks
• Clinically-led change
• Performance measurement, research & best
evidence drive practice
• Clinical care pathways & models of care
• Clinical variance measurement & management

20. 2020
Variance Management
• Variance is everywhere you look for it
• Variation makes the world go around – but…
• How much variation is ‘good’
• Lessons from financial variances & management
• Variance points to a need to ask why & manage it

21. 2121
24.2
23.0
35.0
50.6
37.5
47.8
40.8
28.9
53.6
26.0
41.4
0
10
20
30
40
50
60
NL/LB PEI NS NB Que Ont Man Sask AB BC Canada
MRI Exams per 1000 Population - 2009
Source: CIHI - National Survey of Selected Medical Imaging Equipment, 2009
Supply and Utilization

22. 2222
280
221
298
258
318
176
0
50
100
150
200
250
300
350
South Zone Calgary Zone CentralZone Edmonton Zone North Zone Best Large RHA/Zone
(CentralLHIN, ONT)
Age-StandardizedRate(per100,000)
Source = CIHI Health Indicators
PrematureMortality - 2006-2008

23. 2323
431
237
408
240
551
180
0
100
200
300
400
500
600
South Zone Calgary Zone CentralZone Edmonton Zone North Zone Best Large RHA/Zone
(CentralLHIN, ONT)
Age-StandardizedRate(per100,000)
Source = CIHI Health Indicators
AmbulatoryCare Sensitive Conditions Hospitalizations - 2010/11

24. 2424
Clinical Variance Measurement
• Variance points to a need to ask why & manage it
• Variance measurement & management does this
• Small-areas clinical variation apparent for 30 years
• Multiple explanations for small-areas clinical variation
• Clinical variance management requires measurement
• Measurement necessitates sound health informatics
& clinical analytics

25. 2525
Clinical Variance Management
• Management requires measurement
• Compare to evidence, others & target best practice
• Some clinical variance is justified, some is not
• Unjustifiable variance is costly
• Unjustifiable variance adversely affects patients
• Managing clinical variance is sensitive & complex
• At some point, examines individual practices

26. 2626
Managing Individual Clinical Variance (1)
• The essence of professional self-regulation
• Comparative assessment of individual physician
performance may be required
• How is this best done & by whom
• What is the legal/moral mandate to protect identity
• Globe & Mail vs professional ‘privilege’

27. 2727
Managing Individual Clinical Variance (2)
• Understand the determinants of decision-making
• Lessons from behaviour modification
• Modification menu ( education, feedback,
participation, incentives, penalties & rules)
• Individual modalities do not work
• Habitual behaviours are hard to change

28. 2828
DEFINITION
Health Technology Reassessment (HTR) is a
structured, evidence-based assessment of the
clinical, social, ethical & economic effects of a
technology, currently used in the health care
system, to inform optimal use of that
technology in comparison to its alternatives.
Clement & Noseworthy IJTAHC 2011

29. Figure 1: Joshi, Stahnisch & Noseworthy (2009)

30. 3030
Scope of Reassessment
• HTA focuses on introduction of new technologies
• HTR focuses on existing technologies:
– Obsolescence- when new supersedes old
– Waste (overuse, misuse)- scope of use
• Reassessment common in other fields
• Reassessment of health technologies is not
widely considered, practiced or standardized
• Reassessment may lead to no change; reduced
scope of use; decommissioning & disinvestment

31. 3131
Health Technology Reassessment is HTA +
• Clinical Synthesis
• Comparative effectiveness
• Economic evaluation of costs & benefits
+
• Impact analysis
• Intended consequences
• Unintended
• Social context
• Feasibility assessment

32. 3232
Proposed Reassessment Projects
• Knee MRI following injury
• Optimal cardiac imaging for cardiac conditions
• Antipsychotic use in elderly patients in LTC
• Nitrous Oxide use in Critical Care