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 HEALTH:STATE 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. HMO’s • 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 know:Murray,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

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 1994“WHEN 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 today’s system(waits,quality)

24. GOVERNANCE“Purposing Function” • Purpose of Administration in Health Care • Improve health • Link activities and results in order to avoid superfluous or harmful activities • Efficient administration • Efficiency=cost/benefit • Benefit in health care is improved health where dimensions are comfort, function and survival • Appropriate access

25. 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

26. 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).

27. 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

28. Evaluating our Communities’ Health: Experiences from a Community HealthBoard Chair Ryan Sommers, BSc., Masters Candidate Department of Community Health & Epidemiology Dalhousie University

29. 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

30. 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)

31. 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

32. 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)

33. 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)

34. 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

35. 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)

36. 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

37. 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

38. 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

39. But, there are some problems…. …and some further steps to help improve CHBs functions...

40. 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

41. 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)

42. Issues and Challenges facing CHBs and Evaluation • Accountability • Consistent reporting mechanism (Report cards) • Need to incorporate evaluation • Presentation’s 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?)

43. 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

44. Governance Models and Evaluation Janet Rigby, MSc Department of Community Health & Epidemiology Dalhousie University

45. 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

46. 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)

47. 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 )

48. 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

49. 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)

50. 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?