Status Update on the Activities of the Joint Planning and Priorities Committee

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Hospital Accountability Agreements

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Context

• MYF discussions between Ministry and hospitals
  began in 2002
• Collaboration on MYF through JPPC began in 2003
• Mandatory accountability agreements under Bill 8
• Dec 03 JPPC MYF retreat stressed system
  approach, change management, and importance of
  collaboration

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Collaborative Process

• Six JPPC working groups, with representation from
  hospitals and the Ministry
• Executive Committee
• Performance Agreement
• Incentives, Remediation, and Consequences
• Performance Indicators
• Change Management
• Reference Hospitals
• Early 2004 work of the groups form the basis of
  the current framework which reference hospitals
  will test during 2004/05

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Framework

• The first deliverable of the JPPC process is a
  framework for the accountability relationship
  between hospitals and the Ministry
• The framework defines content and structure for
  an accountability relationship, including roles,
  performance requirements, and supporting
  processes the framework is not a legal
  agreement
• The framework includes the content for a core
  accountability agreement for all hospitals, and
  schedules for negotiation between the Ministry
  and an individual hospital

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Assumptions

• Hospitals and the Ministry will negotiate
  accountability agreements
• The development of the accountability agreement
  will be an iterative process
• The agreement expects significant change for the
  hospitals and the Ministry it is a change
  management document
• The agreement will support and promote system
  integration

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Framework Approach

• Reflect best practice and lessons from other
  jurisdictions
• Use empirical evidence in developing
  recommendations and approach
• Reach consensus through collaboration and
  committee work

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Framework Models

• Review of agreements in various jurisdictions
  provided the basis for Framework development. The
  review included the following jurisdictions
• British Columbia Ministry of Health Services
• Australian state governments
• USA federal and state departments and agencies
• New Zealand Ministry of Health
• United Kingdom NHS
• Environment Canada
• Cancer Care Ontario
• MOHLTC LTC, CCACs, and Mental Health

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Framework Approach Evidence Base

• The Frameworks approach builds on lessons,
  recommendations, and policy developments in
  various jurisdictions and reports. Key sources
  include the following
• BC Office of the Auditor General, Review of
  Performance Agreements
• UK Audit Commission, Achieving the NHS Plan
• Environment Canada, Policy Framework for
  Environmental Performance Agreements
• Government of Western Australia, Performance
  Agreements
• USA General Accounting Office, various reports
• UK Department of Health, Raising Standards
  Alan Milburn, UK Secretary of State, Localism
  From Rhetoric to Reality
• US EPA, National Environmental Performance
  Partnership Program
• OHA, Report from the Task Force on Operational
  Reviews and Supervisor Appointments

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Accountability

• The Ministry is accountable for
• A strategic plan for the health system
• Provincial health policy
• Communication to support system goals
• Resources, including stable and predictable MYF
• Hospitals are accountable for
• Meeting or exceeding their performance
  requirements
• Managing and delivering services as per the
  accountability agreement
• Meeting data quality and reporting requirements

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Roles Responsibilities

• Framework provides joint roles and
  responsibilities in addition to specific roles
  for the Ministry and the hospital
• Intent is to clarify and define current and
  future roles for an accountability relationship,
  not to provide a rule book for either party
• The articulation of roles and responsibilities is
  essential to drive change

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Planning

• Framework identifies three levels of planning
  System, region, and hospital
• Enhancement of system and regional planning is a
  key success factor for improving outcomes,
  specifically system integration
• Framework sets out a potential four-step
  collaborative hospital planning cycle

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Schedules

• Operating Plan
• Operating Budget
• Funding Allocation (including other votes)
• Expected Activity Levels (including priority
  programs)
• Restructuring (Operating and Capital)
• Capital Project Estimates and Approvals
• Performance Indicators
• Reporting Requirements
• Hospital Activities Outside the Agreement
• Regional Programs

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Performance Requirements

• Performance Indicators follows a balanced
  scorecard approach with four domains of
  performance
• Financial health of the organization
• Patient access (throughput) and outcomes
• Organizational health (staff engagement, healthy
  workplace, and productive staff)
• System integration
• Operating Results (still under discussion)
• Net financial results
• Actual operating results (total cases)
• Service profile

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Performance Management

• Responding to Variance
• Importance of pro-active and ongoing performance
  improvement efforts moves beyond simply
  responding to under-performance
• Process for addressing variance from performance
  requirements
• Analyze cause and long-term impact of variance
• Reward positive variance and identify and
  transfer best practice
• Develop action plan to drive-up performance
  (amend or renegotiate schedule, or enter hospital
  performance improvement ladder)

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Performance Management

• Rewarding High Performance
• Evidence-based approach to use of incentives and
  rewards. Literature review of empirical evidence
  on incentive schemes in the public, private, and
  healthcare sectors.
• Caution re widespread and intense use of
  financial incentives, but there is a role for
  time-limited use of financial incentives and
  rewards to drive change
• Strong support for two non-financial incentives
  public recognition of excellence and greater
  freedom for high performing hospitals
• Intensity of incentives and rewards should
  reflect current performance measurement capacity
  and transparency in the system

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Performance Management

• Performance Improvement
• Recognition that improving hospital performance
  requires more than last resorts
• Avoids a punitive approach. Instead focuses on
  proactive and joint approach to drive performance
  improvement
• Introduces a performance ladder perspective a
  continuum of actions to respond to a substantial
  variance from performance requirements
• Performance ladder approach reflects
  recommendations of the OHA Task Force report on
  operational reviews

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Performance Management

• Performance Ladder
• Level I MOH/hospital discussion hospital
  improvement plan
• Level II Peer/MOH paper review of hospital
  performance and improvement plan
• Level III Peer/Mentor/MOH extensive review of
  hospital performance and creation of final
  improvement plan
• Level IV MOH considers statutory intervention

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Performance Management

• Performance ladder policies
• Variance must be within hospital control and
  capacity in order to enter ladder
• Serious performance issues may warrant entry at a
  higher level but defer to lower level when in
  doubt
• Hospital has reasonable time to improve
  performance at each level
• Improving hospital improvement may require
  changes or improvement to Ministry policy or
  practice

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Renegotiation

• Agreements should be able to respond to
  unforeseen circumstances and facilitate
  mid-course adjustment
• Framework identifies a process to amend or
  renegotiate the agreement under certain
  conditions, for example a substantial change in
  provincial health care policy or fiscal conditions

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Issue Resolution

• Issue resolution should be consistent with the
  following principles
• Maintain quality of care
• Maintain integrity of agreement
• Preserve Ministry system plan
• Emphasis on informal resolution
• Process for assisted resolution team of peers
  (Ministry and hospital) to advise and assist
  parties in problem solving and dispute resolution

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Committee Support

• Existing or new advisory bodies will support the
  accountability agreements in three areas
• Continuous quality improvement and hospital best
  practice
• Problem solving and policy development re the
  accountability agreement
• Performance improvement and issue resolution
• Need more discussions re appropriate bodies to
  fulfill these functions

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Negotiation Process

• Potential five step process
• Preliminary stage (may be multi-party)
• Exploration of interests
• Negotiation of interests
• Approval and consultation
• Finalization of schedules

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Policy Requirements Drivers

• Some of the key success factors for the
  Frameworks vision for accountability are as
  follows
• An enhanced provincial capacity for health system
  planning, particularly at the regional level and
  targets for system integration
• A government process and strategy stable and
  predictable multi-year funding for hospitals
• A transparent and consistent set of hospital
  performance requirements linked to government
  goals, e.g. improving financial performance
  (balancing hospital budgets) while building a
  productive and healthy workforce ( nursing FTEs)
• Clear and equitable methods for measuring
  hospital performance, meaningful rewards for high
  performance, and support and infrastructure for
  driving-up hospital performance throughout the
  province

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Next Steps

• April 21 Review and discussion of the Framework
  at the Strategic Initiatives Forum (SIF) of the
  JPPC members are senior executives from the
  MOHLTC and OHA
• May Reference hospitals prepare to test the
  Framework. The JPPC is currently exploring a
  potential hospital/Ministry simulation exercise
  to explore and enhance the design and development
  of an accountability agreement and new
  accountability arrangements between hospitals and
  the Ministry
• Ongoing Elaboration of the policy basis of the
  Framework and enhancement of the Framework within
  the collaborative process

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Appendix Framework Contents