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Health Care, Community Health and Governance

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Ryan Sommers, Department of Community Health & Epidemiology ... Health System Performance, Health Affairs, Chevy Chase; May/Jun 2001; Vol. 20,3; pg. ... – PowerPoint PPT presentation

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Title: Health Care, Community Health and Governance


1
Health Care, Community Health and Governance
  • Dr. David Zitner, Director Medical Informatics
  • Ryan Sommers, Department of Community Health
    Epidemiology
  • Janet Rigby, Department of Community Health and
    Epidemiology
  • Dalhousie University
  • Partly supported by
  • Health Cares Hidden Face
  • An AIMS/Max Bell Foundation Project.
  • May 8th, 2002 - CES Conference 2002

2
ORGANIZATIONAL STRUCTURE INFLUENCES HEALTH CARE
AND EVALUATION
  • Current circumstance overview
  • Provincial/National (Zitner)
  • What happens in real world (Sommers)
  • Governance model and solutions(Rigby) including
    unbundling the functions insurance, governance
    admin, evaluation

3
Monopoly Health CareUnknown Quality
  • Dr. David Zitner, Director of Medical Informatics
  • Dalhousie University

4
CURRENT CIRCUMSTANCE
  • Public not satisfied with management
  • 56 feel health system is mismanaged
  • 90 believe excellent care is received from
    clinicians
  • Most believe admin. changes make care worse not
    better The public is kind, we are missing vital
    information for management -access results.

5
PUBLIC HEALTHSTATE SECRET
  • UNREGULATED MONOPOLY
  • LACK OF INFORMATION TO MANAGE
  • SEPARATE INSURANCE, ADMINISTRATION AND
    GOVERNANCE, REGULATION, AND EVALUATION.
  • STRENGTHEN ROLE AS REGULATOR

6
PUBLIC/PRIVATE SECTORS
  • REVENUE MUST BE GREATER THAN EXPENSES
  • CANADIAN HEALTH CARE
  • Underservicing as a method to cut costs
  • Same as criticism of U.S. HMOs
  • Proximity of care
  • Menu of services
  • Waiting times

7
CANADA HEALTH ACT
  • Access (excessive waiting times)
  • Portability( different menu of services)
  • Comprehensiveness (drugs, physio, menu not known)
  • Universality (WCB. Well connected, Armed forces
    have preferred access and Occupational Health
    Circumstance
  • PUBLIC ADMINISTRTATION-Enforced

8
ACCOUNTABILITY
  • Public release of performance data is common in
    the united states. There are many different types
    of reports published by healthcare providers and
    governments national magazines publish
    information about the "best" Hospitals, health
    insurance plans and physicians world wide web
    sites allow people to compare physicians,
    hospitals and plans
  • For a variety of reasons there is relatively
    little comparative organizational performance
    data available to the public in Canada. This may
    be because of the single-payer system, and of a
    more general cultural difference towards public
    accountability. (What does the public want to
    knowMurray,M., Kline, D Hospital Quarterlyvolume
    two number two Winter 1998-1999)

9
Operating in the Dark, Over and Over again!
Who waits?? How Long?? Who Gets Better?
Worse? Who is most likely to have poor
outcomes? Error Detection???
Compare with www.phc4.org
10
ACCESS/ WAITING TIMES
COMFORT
SEVERITY
FUNCTION
PUBLIC WANTS INFORMATION ABOUT RESULTS OF
CARE- CHANGES IN -COMFORT, FUNCTION, LIKLIHOOD
OF DEATH .
WAIT TIME, FATE OF WAITING PATIENTS
11
DATA GATHERING
  • CIHI 95,000,000 x 2 190,000,000
  • Discharge Abstract Data Base (DAD)
  • Provinces even more to populate DAD
  • 1,500,000 for a 400-500 bed hospital
  • LENGTH OF STAY BY DIAGNOSIS
  • CIHI Data may not be accurate according to CIHI
    warning and technical notes even though its used
    for management and studies

12
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13
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14
AUDITOR GENERAL
...In relation to the Canada Health Act, I
observed that Health Canada does not have the
information it needs to effectively monitor and
report on compliance. So,within those areas of
federal responsibility it is clear that better
quality information is required... (Dennis
Desautels, Jan. 2000 response to OID)
15
What do we know about performance of
public/private
  • Governments spend heavily on information but do
    not link activities and results or have routine
    measures of waiting time
  • No evidence that public provision has better
    overall outcomes or that people rank Canadian
    system as superior to other systems (Blendon,
    R.J., Kim, M., Benson, J.M., The Public Versus
    the World Health Organization on Health System
    Performance, Health Affairs, Chevy Chase May/Jun
    2001 Vol. 20,3 pg. 10-21)

16
USA COMPARISON
  • USA
  • 15 OF HOSPITALS, 12 OF BEDS ARE FOR PROFIT.
    REMAINING ARE NOT FOR PROFIT
  • Neonatal outcomes
  • Very low birth weight babies require intensive
    medical treatment.

17
INFANT MORTALITY
886/1000
13.5
2000-2499
13.8
18
WHAT INFORMATION IS AVAILABLE? QUALITY?
  • We lack basic information to enable governments
    to fulfill the appropriate regulatory role
  • Normally governments regulate monopolies. In this
    case government is the monopolist!

19
DATA QUALITY
  • FALSE ALARMS
  • Length of stay by diagnosis and analysis
  • CIHI - the data might be inaccurate
  • CONTEXT INEFFICIENCY
  • INCREASED LOS because of lack of community
    resources which are the responsibility of same
    group as the group closing hospitals.

20
DM COMMITTMENT 1994WHEN LESS IS BETTER
  • Timely access must be guaranteed and information
    about waiting times made public
  • That quality of care will be ensured by ongoing
    monitoring and publication of outcomes as changes
    are implemented

21
Bill 34-CONFLICT OF INTEREST?
  • To govern, plan, manage, monitor, evaluate and
    deliver health services in a health district
  • The minister determines the services provided in
    a district
  • Other purposes
  • avoid duplication of services
  • meet needs of health district(all needs? Whose?
    Will people move to districts which support their
    particular health problem?

22
To maintain and improve the health of the
residents
  • But other services, sanitation, economic
    development, education, environment are aimed at
    maintaining community health! Is this a
    duplication?
  • Distinguish between illness care and community
    development
  • Health boards could monitor community health to
    provide information on effectiveness of other
    programs (E.G. Number of smokers reflects
    education) and provide effectiveness report.
  • Need to report on benefit of services provided.

23
CONFLICTS OF INTEREST
  • Payment, governance and evaluation are all
    governed by the same structure
  • Consider independent governance for payment and
    evaluation separate from administration
  • Regulated monopolies would not be allowed to
    sustain some of the attitudes and results which
    exist in todays system(waits,quality)

24
PUBLIC PRIVATE
  • MONOPOLISTIC
  • SELF REGULATED
  • WAIT TIMES NOT KNOWN
  • LITTLE CHOICE
  • COMPETITIVE
  • EXTERNAL REGULATION
  • TRACKS DEMAND
  • CHOICE

25
GOVERNANCEPurposing Function
  • Purpose of Administration in Health Care
  • Improve health
  • Link activities and results in order to avoid
    superfluous or harmful activities
  • Efficient administration
  • Efficiencycost/benefit
  • Benefit in health care is improved health where
    dimensions are comfort, function and survival
  • Appropriate access

26
Existing system (multi tier)
  • Armed forces, Workers Compensation patients have
    different levels of care and access
  • Excessive waiting times
  • Public lacks confidence in health care management
  • Unreliability of existing Canadian data
  • beds, resources, outcomes

27
SEPARATE FUNCTIONS
  • Shouldice hospital, is a private organization
    which contracts to provide a specialized set of
    services.
  • Solutions
  • Most efficient provider provide service whether
    in public or private sector
  • Need explicit performance guarantees about
    quality (results and waiting time).

28
RECOMMENDATIONS
  • Distinguish between insurance system, service
    delivery and evaluation components
  • Implement appropriate information systems-how
    many people get better? worse? Who waits? How
    Long? Community Context? Who has poor results and
    reasons
  • Implement surveillance systems not projects.
    Today Heart disease is well studied but no
    overall information systems exist
  • Implement real time wait list systems
  • Implement proper prompting systems to support
    clinical care, health services administration,
    research, teaching

29
Private/Public Now
  • 30 Private sector spending on health care
    similar to circumstance before Medicare
  • 1970 77 of MD expenditures public
  • Canada today 99 of MD costs and 92 of hospital
    costs
  • Denmark pay 87 of MD services
  • France pays 60 of MD services

30
Governance Structure
  • Common governance questions
  • Access, results, systems for improvement
  • Need common IT infrastructure for patients
  • In Province of 1,000,000 multiple governing
    bodies is silly.
  • Distinguish Governance and Administration
  • Administration of components within overall
    governance structure, reporting systems to public

31
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32
PURPOSE OF HEALTH CARE ACTIVITIES
  • WHAT DO PEOPLE EXPECT?
  • IMPROVED HEALTH
  • DIMENSIONS
  • COMFORT
  • FUNCTION
  • SEVERITY (LIKLIHOOD OF DYING)
  • TIMELY ACCESS TO CARE
  • LINKING ACTIVITIES TO RESULTS

33
Evaluating our Communities Health Experiences
from a Community HealthBoard Chair
  • Ryan Sommers, BSc.,
  • Masters Candidate
  • Department of Community Health Epidemiology
  • Dalhousie University

34
Presentation Overview
  • My Experiences
  • What is a Community Health Board (CHB)?
  • What does a community health board do?
  • Evaluating the Health of the Community and
    Citizen Involvement
  • Our approach to evaluation
  • Challenges / Issues
  • Conclusions

35
Introduction - My Experiences
  • Graduate Student - Department of Community Health
    Epidemiology, Dalhousie University
  • Volunteer Co-chair, Cobequid Community Health
    Board
  • Largest CHB in NS, 1/4 the size of Capital Health
    District Authority, Bedford, Sackville and
    Surrounding Areas, 90 000 people
  • Also co-chair the Capital Health Council of
    Chairs (Group that represents all 7 CHB in the
    Hfx and surrounding areas)

36
Introduction
  • Citizen involvement and health reform
  • Not necessarily a new phenomenon
  • Historically, Canadians have been very active in
    the health care system
  • Part of health care regionalization
  • Most jurisdictions involve citizens as part of a
    board that is responsible for the management and
    administration of health services at the regional
    and local level

37
Citizen Participation
  • Reasons for citizen engagement in health care
  • Incorporate individual and community preferences
    and values into health care decisions
  • Improve accountability and government
    responsibility
  • Strategy to help improve the health of
    communities (empower communities for greater
    self-reliance)
  • Key component of primary health care, health
    promotion and community (WHO - Primary Care, part
    of Health Promotion and Health for All)

38
Models of Citizen Engagement
  • Most Cdn jurisdictions operate under a
    regionalized structure - with a board consisting
    of citizens
  • Some provinces have two levels of involvement
  • Regional / District level boards (e.g. District
    Health Authorities)
  • Local level advisory groups (e.g. BC and Alberta
    Community Health Councils)

39
Citizen Engagement Models
  • Most research has focused
  • At the regional level (ex. J. Lomas)
  • Examined roles and responsibilities of these
    groups, decision making and health care rationing
    (ex. Oregon)
  • Governance and administration (more supportive
    rather than evaluative)
  • Little focus on local level involvement (e.g.
    Community Health Boards)
  • Presentation - Examine the role of NS advisory
    groups in the evaluation of community health
    issues and performance
  • Basically, an evaluation of CHB evaluation
    capabilities

40
What is a Community Health Board?
  • Volunteer Community Boards
  • 10 - 15 members per board
  • Everyday citizens (from a variety of backgrounds)
  • Represents a variety of distinct communities
  • Seven community health boards in the Capital
    Health Authority (Hfx and surrounding areas)
  • Support staff provided by the DHA (Capital Health)

41
What does a Community Health Board do?
  • The Eyes, Ears and Voice for our communities
  • Primary responsibility Identify our communities
    health needs and issues
  • Produce of a Community Health Plan
  • Develop partnerships with other community groups
    and organizations (Community Development)
  • Administer Community Health Grants from the DoH
  • Do not govern or manage health services
  • Address issues from a Population Health
    perspective

42
Assessing Our Communities Health
  • Primary function of CHB
  • Consult with citizens around the health issues
    confronting their communities
  • Highly qualitative
  • Consists of focus groups, survey and public
    meetings
  • Community Health Plan - identifies major issues
    and proposes community based solutions

43
Assessing Our Communities Health
  • Advantages
  • Local citizens consult with their fellow
    neighbors about common community and health
    concerns
  • Community members sharing and discussing common
    issues
  • Relatively a quick way to gain community input
  • Active form of volunteerism

44
But, there are some problems.
and some further steps to help improve CHBs
functions...
45
Issues and Challenges facing CHBs and Evaluation
  • Standardize processes and operations
  • Currently no standard data collection analysis,
    common evaluation techniques (I.e. standard
    surveys or evaluative models)
  • Unable to make comparisons across CHBs and
    regions (everyone is doing something different)
  • Allows better comparison
  • Roles and Responsibilities
  • Define the level and process for public
    participation
  • Develop specific goals

46
Issues and Challenges facing CHBs and Evaluation
  • Better information needed
  • Need pertinent, local data (ex. Hospital visits,
    health outcomes, determinants of health)
  • Criticism of regionalization model data not in
    place to support its activities
  • Limits CHB ability to identify real vs. non-real
    health concerns
  • Problems accessing information (costs,
    manipulation and level of data)
  • Lacking community level information (if present
    fragmented)

47
Issues and Challenges facing CHBs and Evaluation
  • Accountability
  • Consistent reporting mechanism (Report cards)
  • Need to incorporate evaluation
  • Presentations basic message
  • Monitor it activities (Are CHBs making a
    difference?)
  • Can be measured at various levels? (But what do
    we choose?) How do we measure? What do we
    measure?
  • Define a method (No one has ever done this!!!)
  • Develop quick and easy methods to evaluate and
    assess community priorities and preferences
    (better methods to identify community health
    issues)
  • Internal evaluations (Are we working properly?)

48
Conclusions
  • NS CHB model has a number of advantages over
    other forms of citizen engagement
  • Help make the shift (acute to community based)
  • Pivot point
  • Keeps health issues at a scale people can relate
    to and believe that they have an impact
  • Need to be patient still evolving
  • Capital Health CHBs have made a number of
    significant gains (intersectoral collaboration,
    advocacy)
  • The incorporate of stronger, standardized
    evaluation methods will help improve CHB
    performance and improve health
  • Evaluation can play a stronger role

49
Governance Models and Evaluation
  • Janet Rigby, MSc
  • Department of Community Health Epidemiology
  • Dalhousie University

50
Presentation Overview
  • Health authorities and governance
  • Evaluation within governance
  • Nova Scotia model of health care
  • Evaluation within N.S. model
  • Carver Governance Model
  • Program logic model HEALNet RRC
  • Barriers to effective evaluation in NS model
  • Solutions

51
Health Authorities Governance
  • ...there is little in the literature on
    governance that focuses specifically on regional
    health authorities... (Frankish et al, 2002,
    P.1475)
  • What is the governance structure of the new
    regionalization in Nova Scotia?
  • Does this structure allow for effective
    evaluation?
  • (Frankish J, Kwan B, Ratner P Wharf Higgins J,
    Larsen C. Challenges of citizen participation in
    regional health authorities. Social Science
    Medicine, 2002, 54 1471-1480)

52
Governance and Evaluation
  • Governors need to know what regional health
    authority effectiveness means and how resources
    are being used (HEALNet RRC. 2001. Strategies
    for Informed Democratic Decision-Making, Module
    4, available at http//www.regionalization.org )

53
Nova Scotia System
  • Have two Board levels District Health
    Authorities who have a governance board and the
    Community Health Boards who have a legislated
    function within the DHA
  • Community Health Boards provide necessary
    planning information to DHA

54
Nova Scotia Model
Support DHA, develop and evaluate policies
NS Department of Health
Regional decision making, administration and
management of health services
District Health Authority (DHA) (9)
Identify local health issues, community
development, does not administer services
(primarily advisory)
Community Health Boards (CHB) (7 in Capital
Health)
55
Evaluation in N.S. Model
  • Within current governance structure, Department
    of Health is responsible for evaluating the
    performance of the DHAs and CHBs.
  • Who evaluates the Department of Health?

56
Carver Governance Model
  • Model provides set of principles and concepts
    which can be used no matter how Board is
    structured.
  • Carver states that the model provides an
    integrated system of governance
  • A board is owned and exists to represent the
    owners.
  • (from Carver Carver, Carvers Policy
    Governance Model in Nonprofit Organizations,
    available at http// www.Carvergovernance.com )

57
Key elements of Governance Model
  • The Boards primary relationship is with the
    owner
  • The Board has total authority and total
    accountability for the organization
  • Carver recommends that there be one point of
    delegation (such as a CEO) for meeting all the
    Boards expectations for organizational
    performance.

58
Governance Model
  • 3 items are required for accountability
  • Performance expectations need to be defined
    clearly
  • The expectations need to be assigned clearly
  • Need to check to see that expectations are being
    met (evaluation)

59
Levels of decisions
  • Board controls definition of success
  • Ends decisions are about changes to people
    outside the organization along with the cost or
    priority (Board level decisions)
  • Means decisions is any decision that is not an
    ends decision (delegate level decisions)

60
Model from HEALNet RRC
  • HEALNet RRC suggests using a program logic model
    to frame the purpose, objectives and indicators
  • Uses basic principles of evaluation models
  • Also emphasizes clarity of specifics

61
Models ?framework ?clarity
  • Carver Governance model provides one framework
  • Similar framework espoused by HEALNet RRC
    (Regional Research Center)
  • Operating within framework allows for clarity of
    roles, responsibilities and expectations

62
Evaluation within Model framework
  • Evaluation is an integral part of the Boards job
  • Expectations and assignments must be clear before
    Board can assess performance of its staff
  • Evaluation of the Board? How does the model
    incorporate this?

63
Evaluation within N.S. system
  • Evaluation plan being developed by Department of
    Health.
  • Lack of clarity in roles and responsibilities
    make formulation of process evaluation difficult

64
Evaluation of CHBs
  • Evaluation of CHBs has been mandated as a
    responsibility of the Department of Health
  • CHBs are to have input on evaluation plan
  • Within governance model, this is the process
    since true owner of CHBs are the Government.

65
Barriers to effective evaluation in N.S. structure
  • Lack of standardization
  • Accountability
  • Roles and responsibilities not clear
  • With continuing restructuring, who is evaluating
    the actual structure has the change in
    regionalization actually improved the state of
    health care?

66
What is needed?
  • For all levels of structure
  • - Clarification of roles responsibilities
  • - Clear outline of specifics (structure, process,
    and expectations (impacts/ outcomes)) for
    evaluation
  • - Use of program logic models to help clarify
    above

67
Questions?DISCUSSION?ANSWERS
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