PROCEEDINGS REPORT - 2013 ONTARIO STROKE FORUMontariostrokenetwork.ca/wp-content/uploads/2014/09/Proceedings-R… · 2 2013 Ontario Stroke Network Forum Proceedings Report Final The

1 2013 Ontario Stroke Network Forum Proceedings Report Final

The 2013 Ontario Stroke Network (OSN) Forum was held on November 25, 2013. The purpose of this year’s OSN Forum was to: 1. Update and discuss Quality Based Procedure (QBP) clinical implementation and overview of

pricing for phase 1 stroke QBP (Emergency Department, acute, Inpatient rehabilitation) and plans for phase 2 (community/outpatient Transient Ischemic Attack [TIA] and rehabilitation)

2. Validate and contextualize the stroke QBP indicators and draft indicator report 3. Consider the Accreditation Canada Stroke Distinction Program as an enabler for QBP

implementation 4. Support networking and facilitate information sharing The Forum was attended by 80 individuals from the following groups:

Regional Program Directors (RPD)

Regional Stroke Steering Committee (RSSC) Chairs

Regional Medical Directors

Regional Stroke Centre Administration Liaisons

District Stoke Coordinators

Local Health Integration Network (LHIN) Representatives

Ministry of Health and Long Term Care (MoHLTC) Representatives See Appendix A for the names and contact information of attendees. The Forum consisted of four sessions (see Agenda): Session 1 - QBP Clinical Engagement and Pricing Session 2 – OSN-SPOR QBP Demonstration Project Session 3 - Indicator Validation Session 4 - Stroke Distinction as an Enabler to QBP Highlights from each session were:

Session 1 - QBP Clinical Engagement and Pricing Michael Stewart, Project Lead – Quality Alignment to Payment, Health Quality Branch of MOHLTC, presented on the QBP Clinical Engagement and Pricing (see Appendix B for presentation slides) and Fredrika Scarth, Manager – Quality Program and Health Quality Ontario Liaison with MOHLTC, provided an overview of Community Based Quality Procedures. Key points from the QBP Clinical Engagement and Pricing presentation were:

There is a need for change and transformation in order to straighten out cost curve

The current Health System Funding Reform-HSFR (e.g. Health Based Allocation Model-HBAM and QBP) is a very different approach for transformation than previously used with focus is on quality to improve care. Thirty percent of the provincial budget will be allocated for QBPs.

PROCEEDINGS REPORT - 2013 ONTARIO STROKE FORUM


The basis for the approach to funding reform is the Excellent Care for All Act and that health care system is focused on the quality of care and the best use of resources. The goal is that funding will follow patients along continuum of care journey supporting integration of care across sectors.

There is no target for financial savings. Given the complexity of the funding reform it will be an iterative process (not linear as Slide 7 indicates but circular) with a focus on avoiding unintended consequences.

There are four concurrent streams – Acute, Post-Acute transition, Community and Indicators

Key points from the presentation on Community Based Quality Procedures were:

There is a strong culture of change within Community Care Access Centres (CACC)

It is believed that the application of the funding models will be quite different for the community

The Functional (vs. medical) need is a key driver of service patterns

There are currently two distinct CCAC programs of care – short stay (defined episode, goal is discharge from service), and long stay (needs fluctuate over time, goal avoid institutionalization) with the following characteristics:

o Long Stay - variable service utilization with primary driver being personal support services

o Short Stay - more homogenized service utilization, drivers are RN and therapies services

The initial focus will be on first 60 days post discharge care before looking a longer stay needs

See Appendix C for Questions and Answers/Discussion for the Session.

Session 2 – OSN-SPOR QBP Demonstration Project Christina O’Callaghan, Executive Director of Ontario Stroke Network, and Dr. Mark Bayley, Medical Director and a Clinician Scientist at the Brain and Spinal Cord Rehabilitation Program of the Toronto Rehabilitation Institute, provided an update regarding the connection between the Canadian Institutes for Health Research – CIHR Strategy for Patient Oriented Research (SPOR) Project and the HSFR (see Appendix B for presentation slides). Key elements of the presentation were:

There are 12 Ontario SPOR Support Units (OSSU) and two Demonstration Projects

The OSN focused on QBP implementation is one of two demonstration Projects (the other is Patients Canada). Results from the stroke QBP will be applied to the implementation of other QBP’s

That Implementation Research methods will be used

The challenges include missing data, particularly in community settings

The attendees were asked for feedback on the proposed research questions and advice/recommendations on how to advance the SPOR work It was noted that an opportunity to respond would be provided in the evaluation survey

http://www.health.gov.on.ca/en/public/programs/ecfa/


Questions and Answers/Discussion: Q1. Why is there is not an explicit patient-focus in the research questions?

A. Patient focus is thought to be embedded in the research questions. It was agreed that the patient focus should be more explicit in the research question.

Q2. How is this work being funded?

A. The OSN is being funded through Ontario’s CIHR-SPOR funding. There may be additional money available within OSSU for research calls and the OSN will be ready to response to such research calls.

Session 3 - Indicator Validation Thomas Custers – Manager – Quality and Performance and Evaluation with the MoHLTC, presented on Indicator Validation (see Appendix B for presentation slides). Key Elements from the presentation were:

Ministry has developed an integrated scorecard approach to monitor the impact of QBP implementation and to provide clinicians and administrators with information to support planning and improvement

The Ministry is seeking input to prioritize and contextualize the results of indicators that were selected by the stroke QBP clinical expert panel as important for evaluating the implementation impact of QBP implementation

One goal is to be transparent – goal is for hospital-level results to be shared with and among facilities

The indicators will be reassessed in one year and will be informed by SPOR work

The Indicator Validation Report will be released as an appendix to the QBP Stroke Clinical handbook

Target date for first report is Winter 2014

The Breakout session goals were reviewed i.e. to obtain feedback on: o Indicator prioritization o Contextualization of the results o Driving Improvement

Summary of the Breakout session notes are available in Appendix B, the overall themes from the breakout session were:

Acute Stroke Unit Care is a critical indicator and should be included now not on the future list since Stroke Units will help drive much of the other required changes

Indicators not necessarily aligned with domains (e.g. Access Domain)

Indicators can’t stand on their own, need to look at combination of results

Importance of using real time data to drive change

Patient experience appears to be missing


Notes for the individual groups from the Breakout session are also available in Appendix B. T. Custers’ additional comments in response to the breakout session feedback included:

Will work with Canadian Institute for Health Information and other ministry partners to assess the feasibility of accurately capturing and reporting a Stroke Unit indicator on the baseline report

In order to limit the burden on hospitals of additional data collection, plan is to start with what is currently available using existing provincial data sources and then fill the gaps as they are identified

Patient experience indicator currently under development – the work on how to measure patient experience across the continuum of care is underway in collaboration with ministry partners

Session 4 - Stroke Distinction as an Enabler to QBP Cally Martin, Regional Program Director – Stroke Network of Southeastern Ontario, Richard Jewitt, Program Operational Director for Medicine at Kingston General Hospital, Jo-anne Marr, Executive VP Operations, COO and Chief Nursing Executive of Mackenzie Vaughan Hospital, and Dr. Al Jin, Assistant Professor Medicine (Neurology) at Queen’s University and Regional Medical Lead of Stroke Network of Southeastern Ontario based out of Kingston General Hospital, presented on their experience achieving Stroke Distinction through Accreditation Canada (see Appendix B for presentation documents). Key elements of the presentation were:

Early adopter grant from OSN helpful to enable completion of program

Program provided a structure and framework for improving processes, adoption of best practice, evaluation of patient outcomes

Data needs to be submitted every six months and therefore supports continuous monitoring of performance and sustained improvement

KGH and Mackenzie Vaughan Hospital have started preparation for the next review which is required every two years

Cost includes financial ($12-23K depending on which services are being accredited) as well as in-kind commitment, in particular human resources

Data collection/management is resource-intensive but informative.

Outcomes include: o Better patient experience o Improved patient outcomes (e.g. decreased in-hospital mortality and readmission rates) o Achievement of core performance indicators prepares for QBP indicators o Creation of a united team and engaged - staff understand why they are doing certain

things and are willing to work towards quality improvements o Greater levels of engagement in stroke care at all levels of the organization

Reinforced the importance of data - if you don’t measure it you don’t know where to focus your work

The OSN would like to thank all presenters and attendees of the 2013 OSN Forum for their contribution to making the day a success. The results of the Evaluation Survey for the Forum are available in Appendix D. We look forward to working with our partners in the planning of the 2014 OSN Forum.


APPENDIX A

Attendee Names and Contact Information

Note: consent obtained to share this information from attendees and anyone who did not provide consent there name was removed from the list

Name Region, Email &/or phone number

AA details (if applicable) Comments

Regional Program Directors

Paula Gilmore

Southwest [email protected] (519) 685-8500 x 32214

Elissa Najm [email protected] (519) 685-8500 x32462

Darren Jermyn

Northeast [email protected] (705) 523-7100 x 3138

Robyn Cameletti [email protected] (705) 523-7100 x 1586

Caterina Kmill

Northwest [email protected] (807) 684-6702

Kathleen Bulloch [email protected] (807) 684-6703

Beth Linkewich

North & East GTA [email protected] (416) 480-6100 x 7300

Supreet Grewal [email protected] (416) 480-6100 x3157

Jim Lumsden Champlain [email protected] (613) 798-5555 x16167

Dianne Sullivan [email protected] (613) 798-5555 x 16153

Louise MacRae

Central South [email protected] (905) 527-4322 x 44425

Kelly Law [email protected] (905) 527-4322 x 46049

Jennifer Breaton attended on behalf of Central South

Cally Martin Southeast [email protected] (613) 549-6666 x 3562

Charlette Eves [email protected] (613) 549-6666 x3853

Cheryl Moher

Central East [email protected] (705) 728-9090 x 46300

Theresa Uniac [email protected] (705) 728-9090 x46320

Nicole Pageau

West GTA [email protected] (905) 848-7580 x 3551

Maria Atzori [email protected] (905) 848-7580 x5475

Shelley Sharp

Toronto West [email protected] (416) 603-5076

Nan Amarasinghe [email protected] (416) 603-6271

Jacquie Willems

Southeast Toronto [email protected] (416) 864-6060 x 3537

Art Austriaco [email protected] (416) 864-6060 x2815

District Stroke Coordinators Linda Butler Southwest

[email protected] (519) 352-6401 x 6900

Carla Dolanjski

Northeast [email protected]

Natalie Carle attended on

mailto:[email protected]


























(705) 267-2131 x 3202 Carla’s behalf

Linda Dykes Southwest [email protected] (519) 464-4400 x 4465

Lisa Fronzi Central South [email protected] (519) 751-5544

Leanne Hammond


Shelley Hawton


Mary Lou Kairiss


Christanne Lewis

Southeast [email protected] (613) 969-7400 x 2874

Amy Maebrae-Waller


Pam Mancuso


Unable to attend

Judy Murray Central East [email protected] (905) 883-1212 x 3882

Doris Noble Southwest [email protected] (519) 272-8210 x 2298

Krista Miller [email protected] (519) 272-8210 x 2299

Amanda Plozzer


Irene Murray Central East [email protected] 705-789-0022 x 6005

Charlene Quan attended on Irene’s behalf

Joan Ruston-Berge


Denise St. Louis

Southwest [email protected] (519) 973-4411

Gwen Stevenson


Jennifer White

Central East [email protected]





















(705) 743-2121 x 3946

Holly Woermke

Champlain [email protected] (613) 732-3675 x 7310

Regional Steering Committee Chair Ilsa Blidner Toronto West

[email protected] (416) 932-8498

Lucy Bonanno

West GTA [email protected] (905) 272-9700 x 225

Patricia Dwyer

Southwestern [email protected]

Karen Gill Southeast [email protected] (613) 549-4874

Unable to attend

Jo-anne Marr

Central East Stroke Network [email protected] (905) 883-2045

Anna Themelis [email protected] (905) 883-1212 x 7564

Sabine Mersmann


Laurie Tomasini [email protected] (613) 732-3675 x 6161

Lynda Powell Northeast [email protected] (705) 522-0770

Unable to attend

Tina Smith North & East GTA [email protected] (416) 946-3023

Brian Thompson


Gaye Walsh Southeast Toronto [email protected] (416) 444-4175

Regional Stroke Admin Liaison Lindsey Crawford


Richard Jewitt

Southeast [email protected] (613) 549-6666 x3911

Susan MacRae [email protected] (613) 549-6666 x2107

Kathryn LeBlanc


Kelly Law [email protected] (905) 527-4322 x 46049

Unable to attend

Andrea Lee Northeast alee@ hsnsudbury.ca (705) 523-7100 x1271

Kirstin Urso [email protected] (705) 523-7100 x 3917

Janet Toronto West Margaret Klys























Newton [email protected] (416) 603-5431


Jim O'Neill Southeast Toronto [email protected] (416) 864-6060 x 5161

Dijana Jovic [email protected] (416) 864-6060 x 5162

Unable to attend

Ken Shulman North & East GTA [email protected]

Dilshad Ratansi [email protected]

Unable to attend

Karen Stockton


Julie O'Brien [email protected] (613) 737-8899

Cathy Vandersluis


Robin Emery [email protected] (519) 685-8500 x34875

Regional Medical Directors Rick Swartz North & East GTA


Melissa Cherny-Bayer [email protected] (416) 480-6100 x 83724

Dr. Karl Boyle attended on behalf of Dr. Swartz

Dr. Andre Douen

West GTA [email protected] (905) 896-3811

Cheryl Sta.Ana [email protected] (905) 896-3811

Dr. Ayman Hassan


Debbie Hayes [email protected] 807-684-6707

Dr. Al Jin Southeast [email protected] (613) 549-6666 x 6320

Dr. Derek Krete

Central East [email protected] (705) 740-8351

Jennifer Mongraw [email protected] (705) 743-2121 x 2298

Dr. William McMullen

Northeast [email protected] (705) 674-3181 x3138

Dr. Mike Nicolle

Southwest [email protected] (519) 663-3236

Sue Robinson [email protected] (519) 663-3236

Dr. Wes Oczkowski

Central South [email protected] (905) 529-4100

Judy Macrae [email protected] (905) 529-4100

Dr. Dan Selchen

Southeast Toronto [email protected] (416) 864-5855

Sherry Small [email protected] (416) 864-5855

Dr. Frank Silver

Toronto West [email protected] (416) 603-5416

Alex Pop [email protected] 416-603-5416

Dr. Grant Stotts

Champlain [email protected] (613) 737-8899 x78798































Ministry of Health and Long Term Care Debika Burman


Thomas Custers


Elizabeth Monteleone [email protected] (416) 325-0626

Elsa Ho [email protected] (416) 326-6542

Kristen Kathiravelu


Paul Lee [email protected] Unable to attend

Fredrika Scarth


Michael Stewart


Leonie Haynes [email protected] (416) 325-0256

Local Health Integration Network Martha Auchinleck

North East LHIN [email protected]

Unable to attend

Derek Bodden

Hamilton Niagara Haldimand Brant LHIN [email protected]

Ligaya Byrch North Simcoe Muskoka LHIN [email protected]

Marc Demers

North East LHIN [email protected]

Mark Edmonds

Central West LHIN [email protected] (905) 455-1281 x 259

Heather Gray

North West LHIN [email protected]

Carol Halt North East LHIN [email protected]

Libby Little Waterloo Wellington LHIN [email protected]

Megan Yamoah [email protected]

Susan Plewes

North Simcoe Muskoka LHIN [email protected]

Sue Colwell [email protected]

Unable to attend

Mladen Samac

Waterloo Wellington LHIN [email protected]

Unable to attend

Lynn Singh Central LHIN [email protected]

Simmy Wan attended on behalf of Lynn

Christopher Sulway

Toronto Central LHIN [email protected]

Vicky Walker Champlain LHIN [email protected]

Trixie Williams

Central East LHIN [email protected]


























Kim Young Hamilton Niagara Haldimand Brant LHIN [email protected]

Health Quality Ontario Naushaba Degani


Gail Dobell [email protected] (416) 323-6868 x 268

Erik Hellsten [email protected] (416) 323-6868 x 302

GTA Rehab Network Charissa Levy


Ontario Hospital Association Cyrelle Muskat

[email protected]

Ontario Medical Association Susanne Bjerno

[email protected]

Ontario Stroke Network Dr. Mark Bayley

Co-Chair QBP [email protected] (416) 597-3422 x 3943

Sarah Murphy [email protected] (416) 597-3422 x 3943

Dr. Ruth Hall ICES [email protected] (416) 480-4055 x 2975

Jen Levi – Research Assistant [email protected] (416) 480-4055 x 3364

Jennifer Jackson


Linda Nutbrown [email protected] (647) 943-3198

Linda Kelloway



Matthew Meyer


Malcolm Moffat

OSN Board Chair [email protected] (416) 480-6154

Pat Mahoney [email protected] (416) 480-4113

Unable to attend

Chris O'Callaghan

Co-Chair, QBP [email protected] TO: (647) 943-3198 LO: (519) 679-8189























APPENDIX B

Presentations & Documents

i) Agenda

Agenda Nov 25 2013 Ontario Stroke Network Forum - Final.pdf

ii) QBP Clinical Engagement and Pricing

OSN - Nov 25 2013 v4 QBP.pdf

iii) OSN – SPOR QBP Demonstration Project

OSN Forum SPOR presentation Nov 25 2013.pdf

iv) Indicator Validation

Draft baseline report - Stroke QBP - Validation Session.pdf

v) Notes from Breakout session on Indicator Validation

November 2013 OSN Forum Indicator Validation Report Back Summary.pdf

Breakout Session Indicator Validation Feedback 2013 OSN Forum.xls

vi) Stroke Distinction as an Enabler to QBP

QBP Stroke Distinction BN July 22 2013.pdf

Stroke Distinction OSN forum Presentation for nov 25 2013 FINAL.pdf


APPENDIX C

Session 1 - Question and Answer/Discussion Q1. When looking at Home Care and post-hospital medical care there is not much difference – is this provider driven? A. This could be business decision by CCACs (i.e. not driven by best practice but by business

practice). There are significant concerns regarding CCAC practice of rationing care (e.g. authorization of four Physiotherapy visits) as standard practice. There are required enhancements for CCAC to deliver closer to best practice since Rehab needs are quite different.

Q2. What is the thinking regarding costing for acute stroke unit care?

A. Designated stroke unit care is recommended. The Regions/LHINs will need to decide how to

implement the funding for stroke unit care.

Q3. Are the CCAC referral patterns currently based on resources versus functional goals? A. The data is currently lacking regarding this information.

Q4. How does a Rehab model fit into the CCAC short stay/long stay model of care? A. People enter home care with differing levels of care needs and functional status and

therefore different funding is required. This needs to be taken into account when developing new care models. It is recognized that it is challenging to move away from a clinical pathway approach.

Q5. What is the timeline for completion of phase 2 (community) QBP implementation? A. The funding change will not occur in FY1415. We are hoping to have recommendations

from Expert Panel by spring 2014 on best practice and recommendations for implementation. Remember this is intended to be an iterative process over a number of years as the full continuum of care is developed.

Q6. How will QBP address the difficulty of transferring care between facilities? A. It is too early to say right now. This is work that still needs to be completed. Q7. What is the strategy to implement QBP between acute care and the rest of the continuum? For example, the drivers for implementing changes in acute care rest in inpatient rehab and there are currently no proposed changes to rehab as of yet. A. We are totally committed that we will need to go back and change things as this is

implemented. As we define the community funding we will need to review the acute model to address any unintended consequences that occur. We are anticipating changes every six months for the first few years. This will feel like it is being done in silos however, this is not the intention. To change the entire continuum at once is not feasible.


Q8. Are there any contingency funds available to manage factors that could impact ability to transfer from acute care to rehab (e.g. outbreaks)? A. The QBPs are precisely defined. Hospitals will still have global funding. This will require

creative management.

Q9. Is the system able to support the transformation to Designated Stroke Units?

A. The Ministry supports the Expert Panel’s recommendation for Designated Stroke Units and will define key aspects regarding these units. The innovation and implementation will come from the Regions. It is recognized that this will likely require up-front investment at the LHIN level to create access to acute stroke unit care. The regions will be expected to identify the challenges to the Ministry and the Ministry will work to remove these barriers.

Q10. Please comment on the fact that parts of the Health Care system operates “M-F 8 – 4” not 7 days per week? A. Health care is a 24/7 operation and for best care operating “Monday to Friday - 8 to 4”

practices need to change.

Q11. How can we help you? A. Don’t be shy. Tell us about the challenges you are having; come forward with your

questions and concerns. Please do not expect us to have an answer to every question but we can’t start thinking about it if we do not know it is a question/concern. We will continue trying to visit you in the field.


APPENDIX D

Evaluation of Forum 25 participants responded to the Forum survey. The summarized results of this feedback include:

Session 1 – QBP Clinical Engagement and Pricing o 72% of responders felt the session was informative o 58.4% of responders felt there was sufficient time for discussion/Q&A o 79.2% of responders felt they had learned information that they could use in their

region/role

Session 2 – OSN-SPOR QBD Demonstration Project o 91.6% of responders felt they understood the goals of the Demonstration Project o Valuable feedback was provided for each of the proposed research questions

Session 3 – Indicator Validation o 76.5% of responders felt the session was informative o 87.5% of responders felt the Breakout session was useful o 87.6% of responders felt they had learned information that they could use in their

region/role

Session 4 – Stroke Distinction as an Enabler to QBP o 88.3% of responders felt the session was informative o 93.8% of responders felt they had learned information that they could use in their

region/role

Overall Comments o 70.6% of responders felt the time to meet and network with their colleagues was ‘just

right’ o 94.1% of responders felt the Forum either met (64.7%) or partially met (29.4%)their

expectations The list of recommended topics for future Forums is as follows:

1) Follow up and future QBP work over the three year implementation including information on final pricing and on development of QBP Indicators

2) Progress to date or lessons learned that could be shared re QBP implementation. It might be beneficial to have presentations "one year later" from a region or centre that had great success in implementing QBP and one that is struggling or had more challenges, including: what worked and what didn't; how they engaged; who they engaged; plan to implement; largest challenges etc…..

3) Community QBPs – progress in development and implementation plan 4) A financial analysis/predictions of the potential impact of stroke rehab QBPs 5) LHINs to present on how they each support the Regional Stroke Strategies