Herramientas de la calidad

At the present time surgical ophthalmology services in the South West LHIN are located in, and supported by hospitals. However, a recent experience in Ontario¹¹ illustrates this might not always continue to be the case as some services traditionally delivered by hospitals may move into private or non-profit community-based settings and private ownership. This has already happened with laser (refractive) surgery in many large urban centres and currently some cataract surgeries are offered on a private, consumer-pay basis. The suggestion put forward through the MOHLTC cataract RFP suggests high volume, low-risk procedures can be provided at a lower cost in non-hospital settings.

At this time in the South West LHIN moving any ophthalmologic surgery out of the hospitals would fragment services currently being provided under the broader hospital-based mandate. Having ophthalmologists affiliated with hospitals allows them to provide surgical services without added costs for overhead, staffing and equipment.

and ensures they are available to respond to emergent and urgent cases. Hospital provided services are also evaluated based on clear guidelines in terms of patient safety, quality and accountability for costs and fees associated with any procedure.

The future role of QBP funding of cataract and other ophthalmic surgical procedures needs to be factored into any future decision making about where ophthalmology services are best provided.

At the present time QBP funding only applies to simple cataract procedures. However, there are clear indications this model of funding on a per-case basis will be expanded to include other surgical procedures within

ophthalmology. A process has begun to make retinal surgeries and corneal transplants QBP procedures.

The future of volume-based allocations of specific surgical services can be unpredictable and therefore difficult to plan for. For example, current simple cataract surgery volumes are allocated on a year-by-year basis with no commitment that the volume allocated one year becomes the base for the next one. The Ministry has recently indicated (November-December 2014) that they plan to change the methodology used to allocate cataract surgeries across Ontario and to expand to scope of QBP cataracts to include all cataract surgeries. This instability and unpredictability makes it difficult to plan for long term service delivery.

Depending on the volume of procedures awarded to a hospital and the related fees paid, it could become cost-prohibitive for a hospital to continue offering a specific ophthalmic procedure or offering to offer ophthalmic surgeries in general. If this occurs patients would need to go elsewhere and decisions would need to be made to consolidate services in larger volume centres where, due to higher volumes, the cost per case would be less. This migration could lead to the unintended consequence of limiting access to the other important services, especially medical services comprehensive ophthalmologists provide.

At the present time the reimbursement ophthalmologists receive for performing cataract surgery accounts for a significant portion of their remuneration. Cataract surgery can represent as much as 30% of the remittances received from OHIP. Consolidating cataract surgery into larger volume centres could therefore result in the migration of ophthalmologists away from small centers. It may also result in an ophthalmologist working in two communities – one for surgery and another for their medical ophthalmology practice. This is already happening in a couple of instances in the South West LHIN.

11Community-Based Specialty Clinics are non-profit health providers that will offer select low-risk procedures that are currently provided in acute-care hospital settings. Specialty Clinics will focus on providing high volume procedures, such as routine cataract procedures, colonoscopies, and other procedures that do not require overnight stays in a hospital. Specialty Clinics will be subject to high quality standards, oversight and accountability. They will provide OHIP-insured services with no additional fees. Information source: http://www.health.gov.on.ca/en/pro/programs/ihf/specialtyclinics/

33 At the local LHIN level, a primary objective going forward is being able to respond to provincial allocation decisions, policy changes and directives in a way that reflects local needs and maintains the integrity of the local services system. This is best done collectively rather than on an individual hospital or physician basis. Any unilateral decision to, for example discontinue offering a service, would be highly disruptive and a disservice to both providers and patients.

Recently through a joint task force of the Ontario Hospital Association and the Ontario Medical Association, the following report was published, “A Framework for the Redistribution of Hospital Services “(September 2014). This report speaks directly to changes to hospital funding through the Health System Funding Reform initiatives – primarily the Health-Based Allocation Model (HBAM) and the Quality-Based Procedures Model (QBP). The report lists a set of six guiding principles to inform decision-making involving service redistribution. To quote from the report:

The goals of this framework are:

• To improve quality, value and patient access

• To foster increased collaboration and transparency

• To minimize disruption and instability of service delivery

• To facilitate medical human resource adjustments

• To support a sustainable delivery of health services within available resources

The OMA and the OHA recommend the following six guiding principles be used when considering and/or implementing service redistributions.

1. Quality of Patient Care

• Focus of service redistributions must always be based on the needs of patients and sustaining or enhancing the quality and value of their care

• Strive to ensure patients have equitable access to quality care

• Focus on the principles of evidence-based practice

• Ensure that improvements in quality and value in one service are not made at the expense of quality care in interdependent services

• Ensure that clinical competencies are maintained or enhanced 2. Evidence

• Evidence that all efforts were made to mitigate the need to implement a service redistribution

• Evidence with respect to the potential impacts of the service redistribution should be examined and well understood before a redistribution decision is made

• Evidence that potential risks to patient care have been identified and addressed

• Redistribution decisions should be based on compelling evidence that the dimensions of quality and value have been identified and that quality of care will be improved

• Evidence that stakeholders have been meaningfully engaged prior to and throughout the decision-making and implementation processes

3. Stability

• Ensure inclusive and collaborative transition planning

• Ensure on-going and appropriate access to urgent and emergent services in the impacted HSPs

• Ensure due consideration of the impact on quality and access to all clinical programs and services including those which are not the direct subject of service redistributions and including those in the community

• Establish strategies to minimize disruptions to clinical practice, strive to maintain equitable patient access to programs and services in the impacted communities, and develop mitigation strategies where appropriate

• Ensure, where appropriate, that the teaching and research mandates of impacted HSPs and physicians are supported

34 4. Fairness and Equity

• Recognize impacted physicians as partners in the planning and decision-making processes

• Ensure that the process is respectful of and gives due consideration to the potential impact of service redistributions on patient care, physician workload, practice sustainability, responsibilities, travel and clinical activity

• Ensure all steps have been taken to optimize the ability of impacted physicians to follow transferred services

• Ensure that expectations and allocation of resources for physicians are fair and appropriate, including access to hospital resources

• Ensure fair and equitable criteria for the credentialing appointment and reappointment processes at impacted HSPs which are consistent with relevant HSP bylaws

5. Transparency

• Ensure early communication and stakeholder engagement strategies are executed

• Ensure early, timely and meaningful consultation with all key stakeholders potentially impacted, including community and primary care providers

• Establish transparent processes for revisiting and revising decisions 6. Collaboration and Inclusivity

• Ensure meaningful stakeholder engagement is conducted and includes impacted physicians at both the relinquishing and receiving HSPs, patients, and other health care providers (including primary care physicians), LHINs, communities and academic programs (where applicable) in the decision-making process

Future State Recommendation 16.1

Ophthalmologists and the hospitals with which they are affiliated should meet regularly, on a LHIN-wide basis, to assess the impact of provincial allocation decisions, policy changes and directives to determine the most appropriate system-wide response, including the redistribution of surgical ophthalmology services, especially QBP funded procedures.

Future State Recommendation 16.2

St. Joseph’s Health Care London be asked to take on a support-leadership role with respect to the recommended regional committee.

Target of Recommendation:

All hospitals in the South West LHIN that offer ophthalmology services and affiliated ophthalmologists South West LHIN

Financial and Resource Impact:

Meeting time for those involved, administrative support services, data support services

Intended Outcome of Recommendations 16.1 and 16.2:

Any changes to the location and organization of surgical ophthalmic services will be assessed on a LHIN-wide basis and supported by the people and organizations most directly affected.

Future State Recommendation 17.0

The joint OHA - OMA report , “A Framework for the Redistribution of Hospital Services” September 2014 should be adopted as the framework to be used for future decision-making and implementation of any proposed redistribution of ophthalmic services.

Target of Recommendation:

All hospitals in the South West LHIN that offer ophthalmology services and affiliated ophthalmologists Financial and Resource Impact:

No direct financial impact – requires a collective and corporate commitment

35 Intended Outcome:

Changes to the configuration of surgical services will be assessed using a comprehensive framework and approach.

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