Steve Isaak

1
Hospital Service Accountability Agreement
Indicators
Steve Isaak Executive Director
A partnership of the Ontario Hospital
Association and Ministry of Health and Long-Term
Care in collaboration with Local Health
Integration Networks

2
Overview

• About JPPC
• 2008-10 H-SAA Indicators Process
• Changing View of Board Role
• Future Developments
• Where are we going with accountability?

3
About Us

• Unique collaborative partnership forged in 1992
• Strategic policy issues
• Sector-specific Planning
• Funding
• Accountability
• Multi-stakeholder engagement
• Neutral analytical capacity
• Methodological rigour

4
Our Structure
Strategic Issues Forum
Secretariat
Senior Management Committee
Accountability Committee
Funding Committee
Indicators Volumes
Case Mix Development
Funding Formula
LHIN Future Indicators
IPBA Rates Volumes HBAM
Case Mix Technical Groups

• Financial Capital Health Virtual Team
• System Integration Virtual Team
• - ALC Panel - CCAC Panel
• Organizational Health Virtual Team
• Patient Access Outcomes V Teams
• - CCC - ED
• - Volumes - Stroke
• - Rehab - Readmissions
• - Patient
  Satisfaction

Designated Services
Data Quality
Costing Technical Groups
Ad hoc Groups
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H-SAA Indicator Principles

• Context
• Accountability legal agreement formal planning
  negotiation process funding
• Balance of indicators across domains
• Small number of high-level performance indicators
  for which hospitals are legally accountable
• Complemented by targeted monitoring, explanatory
  and developmental indicators that enable
  performance improvement
• Hospitals must be able to calculate
  indicator/monitor performance during term of
  agreement using local data

• Primary Criteria
• Direct measure (or potential measure) of Ministry
  strategic goal or priority
• Construct validity
• Evidence basis
• Within hospital control
• Responsiveness to change
• Secondary Criteria
• Availability and timeliness of data
• Data quality and reliability
• Acceptability and familiarity including process
  for graduating indicators

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Indicator Renewal Cycle
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Indicator Categories

• Performance Indicators
• Indicators for which LHINs and hospitals
  negotiate a standard of performance, which if not
  met, may trigger consequences under hospital
  service accountability agreement
• Monitoring Indicators
• Indicators that provide context, aid
  interpretation, and support negotiation and
  problem-solving between LHINs and hospitals.
  These indicators are useful in planning exercises
  and in measuring progress. They could potentially
  graduate to become performance indicators
• Developmental Indicators
• Desired indicators where the underlying data
  requirements and/or methodology require further
  work (or more familiarity or feedback from the
  field). Developmental indicators that have gone
  through a pilot testing phase could graduate to
  become monitoring or performance indicators
• Explanatory Indicators
• Indicators that may aid in setting context for
  the interpretation of Performance or Monitoring
  Indicators. These indicators are not considered
  for graduation to performance indicators

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HAPS Guidelines
www.lhins.on.ca Health Care Providers HAPS
Guidelines
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2008-10
Training Development
Financial Health
Organizational Health
Capital Health IT/Med Equipment
Turnover Rate
Paid Sick Time (Full-time)
Operational Efficiency
Vacancy Rate
Paid Overtime (Full-time Part-Time)
Capital Health Facility Condition Index
Current Ratio Consolidated
Staff Satisfaction
Nursing FTE
Total Margin Sector Code 1
Workplace Safety Indicators
Total Margin Consolidated
Readmissions to Own Facility
Readmissions (All Facilities CHF Only)
CCC Skin Ulcers
Mental Health
CCC Index Indicators
ALC Indicators (4)
Volumes
Rehab Indicators
ED Indicators
Stroke Care Index Indicators
Patient Safety
Hospital-CCAC Integration Indicators (4)
System Integration
Patient Access Outcomes
HSMR
Adult IP Sat Indicators
ED Sat Indicators
Paediatric Sat Indicators
Patient Experience
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Financial Health Indicators

• Performance
• Current Ratio Consolidated (no change)
• Total Margin Consolidated (no change)
• Monitoring
• Operational Efficiency (model refined to improve
  stability)
• Explanatory
• Total Margin Sector Code 1 Hospitals (no
  change)
• Developmental
• Capital Health Facility Condition Index (draft
  definition)
• Capital Health IT Medical Equipment (not yet
  defined)

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Resources

• e-Learning Series

• www.jppc.org Events Archived Educational
  Sessions
• www.oha.com Professional Development Distance
  Learning OHA Mediasite

• Topics HAPS WERS Allocation Methodology for
  2008-10 Financial Health Indicators
  Organizational Health Indicators ALC
  Indicators Hospital - CCAC Indicators
  Patient Access Outcomes CCC Indicators ED
  Indicators Stroke Care Indicators Rehab
  Quality of Care Indicators Readmissions
  Service Volumes Indicators JPPC Rate Volume
  Models

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Resources

• JPPC Indicators Tool
• www.jppc.org Resources Data Tools

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Changing View of Board Role

• Old world view
• Hospital Boards primarily responsible for
  organizations financial health
• Unquestionably important, but
• Boards role extends beyond financial
  stewardship
• Mission, strategy, executive leadership, quality
  and safety

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Changing View of Board Role

• In the modern view, boards bear direct
  responsibility for the hospital's mission to
  provide the best possible care and to avoid harm
  to patients. The boards responsibility for
  ensuring and improving care cannot be delegated
  to the medical staff and executive leadership
  ensuring safe and harm-free care to patients is
  the boards job, at the very core of fiduciary
  responsibility. (Institute for Healthcare
  Improvement, 2007)

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Changing View of Board Role

• Recent IHI research on role of governance in
  high-performing organizations shows Boards can
  make an enormous difference
• Value-add from the made-in Ontario approach to
  decentralization will come from provider boards

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Future Directions - some questions

• Are accountability agreements intended to force
  institutions to practice to a minimum standard
  (or else face the consequences), or are they
  intended to encourage and accelerate
  performance/quality improvement?
• Should targets for indicators be set based on
  average performance, or on system-wide
  improvement goals?

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Future Directions - some questions

• How do the indicators in Ontarios accountability
  agreements align? Is there a cascading framework
  (province LHIN provider)?
• Do we have a balance of indicators reflective of
  the multi-faceted components of performance
  improvement?
• Do we monitor performance across all indicator
  domains in the same way?
• How should public reporting fit in?

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Future Directions - what can you do?

• Champion a hospital and system performance/quality
  improvement focus
• Alignment with major quality improvement
  initiatives
• Champion a cascading framework of accountability
  agreements and indicators
• Alignment of indicators that makes sense at the
  hospital level
• Draw from the full set of current H-SAA
  indicators to monitor and drive
  performance/quality improvement
• Pay attention to data quality

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Conclusion

• Accountability Agreements are an important, but
  insufficient tool to drive performance
  improvement in the health care system
• Alignment
• At different levels and across initiatives
• Investment
• Collaborative development
• Tools
• Knowledge and skills

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Contact Us

• Ontario Joint Policy Planning Committee
• 415 Yonge Street
• Suite 1200
• Toronto ON
• M5B 2E7
• 416-599-5772
• www.jppc.org

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Appendix Financial Health Indicator Definitions
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Current Ratio - Performance

• Description
• Number of times a hospitals short-term
  obligations can be paid using hospitals
  short-term assets
• Definition
• Total Assets - credits in current asset accounts
  excluding bad debt debits in current liability
  accounts
• Current Liabilities excluding deferred
  contributions - debits in current liability
  accounts credits in current asset accounts
  (excluding bad debt)
• Calculation
• Calculated using consolidated corporate income
  statements (all fund types sector codes).
  Credits in current assets are really liabilities
  and should be moved to the denominator debits in
  current liability accounts are actually assets
  and should be moved to the numerator. Deferred
  contributions not considered part of current
  liabilities as they are usually related to
  capital
• Target and Corridor
• 0.8 to 2.0 10

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Total Margin - Performance

• Description
• The percent by which total revenues exceed or
  fall short of total expenses, excluding the
  impact of facility amortization, in a given year.
• Definition
• Total Corporate Revenues (excluding
  facility-related revenues and interdepartmental
  recoveries) minus Total Corporate Expenses
  (excluding facility-related and
  inter-departmental expenses)
• Total Corporate Revenues (excluding
  facility-related revenues and interdepartmental
  recoveries)
• Calculation
• Calculated using consolidated corporate income
  statements (all fund types sector codes).
  Exclude inter-departmental recoveries and
  facility-related expenses (e.g. building
  amortization) and revenues (deferred
  contributions)
• Target and Corridor
• 0 or above

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Total Margin - Explanatory

• Description
• The percent by which total revenues exceed or
  fall short of total expenses, excluding the
  impact of facility amortization, in a given year
  for all activity reported under sector code 1 -
  hospitals.
• Definition Calculation
• Identical to Total Margin except that only
  expenses and revenues reported under sector type
  1 are included.
• Rationale and Interpretation
• Provides information on the extent to which the
  Consolidated Total Margin is influenced by
  hospital versus non-hospital related activity.
• Target and Corridor
• None

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Operational Efficiency - Monitoring

• Description
• The percent by which the Actual Cost per Weighted
  Case (CPWC) is above or below the Expected Cost
  per Weighted Case (ECPWC)
• Definition Calculation
• ACPWC ECPWC
• ECPWC
• Rationale and Interpretation
• This indicator is calculated using the Integrated
  Population Based Allocation (IPBA) formula and
  also used in Hospital Report. Model refined in
  June 2007 to improve stability. A negative value
  indicates better than average (expected)
  operational efficiency.
• Target and Corridor
• No formal target

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Facilities Condition Index - Developmental

• Background
• Potential future explanatory indicator (capital
  funding outside current HSAA). Data now being
  collected through Facilities Condition Assessment
  Program (FCAP)
• Definition Calculation (draft under review)
• Deferred Capital Work Current Year Capital
  Requirements
• Current Replacement Value
• Interpretation
• Comparative indicator/benchmark used to indicate
  the relative physical condition of a facility,
  group of buildings, or entire portfolio
  independent of building type, construction
  type, location or cost. Tracked over time, it
  can highlight historical trends (overall
  condition changes) and can give feedback on the
  adequacy of capital renewal funding
• Target Corridor
• Industry standard rating system under discussion