Journal of Nursing Management, 2016, 24, 50–58
Quality-based procedures in Ontario: exploring health-care leaders’ responses PAMELA BAXTER R N , P h D 1, LAURA CLEGHORN M A 1, KIM ALVARADO R N , P h D 2, GRETA CUMMINGS 3 4 1 5 R N , P h D , DEBORAH KENNEDY B S c P T , M S c , COLLEEN MCKEY R N , P h D and KATHY PFAFF R N , P h D 1
Associate Professor, McMaster University, School of Nursing, Hamilton,Ontario, 2Hamilton Health Sciences Centre, Surgical Oncology, Orthopaedics and Critical Care, Hamilton, Ontario, 3University of Alberta, Faculty of Nursing, Edmonton, Alberta, 4Sunnybrook Health Sciences Centre, Holland Orthopaedic & Arthritic Centre, Toronto, Ontario and 5 University of Windsor, Faculty of Nursing,Windsor, Ontario, Canada
Correspondence Pamela Baxter School of Nursing McMaster University 1280 Main St. W. HSB 3N28C Hamilton, Ontario Canada L8S 4K1 Ontario Canada E-mail: [email protected]
BAXTER P., CLEGHORN L., ALVARADO K., CUMMINGS G., KENNEDY D., MCKEY C. & PFAFF K.
(2016) Journal of Nursing Management 24, 50–58 Quality-based procedures in Ontario: exploring health-care leaders’ responses Aim To examine health-care leaders’ initial response to the implementation of orthopaedic quality based procedures (QBPs) in hospitals across Ontario, Canada. Background In 2012, Ontario, Canada shifted 91 hospitals to a patient-based funding (PBF) approach. This approach funds health-care organisations based on the number of patients treated with select procedures known as QBPs. Methods An exploratory descriptive design was employed to better understand health-care leaders’ early implementation experiences. Seventy organisational leaders from 20 hospitals participated in six focus groups and four interviews to discuss their initial responses to the implementation of two QBPs (primary unilateral hip replacement and primary unilateral knee replacement). Qualitative data underwent content analysis. Findings Three key major themes emerged; (1) responding to change, (2) leading the change and (3) managing the change. Within each of these themes, barriers and benefits were identified. Conclusion Leaders are accepting of PBF and QBPs. However, challenges exist that require further exploration including the need for a strong infrastructure, accurate and timely clinical and financial data, and policies to prevent unintended consequences. Implications for nursing management Implementing QBPs requires careful planning, adequate and appropriate resources, vertical and horizontal communication strategies, and policies to ensure that unintended consequences are avoided and positive outcomes achieved. Keywords: health-care, leadership, patient-based funding, quality-based procedures Accepted for publication: 22 August 2014
Introduction Canadian health-care leaders are facing significant changes in hospital payment policy as they shift 50
away from the traditional block-funding model that grants annual lump sums to hospitals (Collier 2008a), to a patient-based funding (PBF) approach (often referred to as quality-based funding or DOI: 10.1111/jonm.12271 ª 2014 John Wiley & Sons Ltd
Health care leaders responses to quality-based procedures
activity-based funding). Using this funding approach, hospitals are paid based on the type and quantities of patients they treat with select procedures known as quality based procedures (QBPs). Patient-based funding considers patients as a source of revenue rather than a cost. This perspective is intended to motivate hospitals and health-care providers to increase their efficiency levels, thereby increasing their revenue (British Columbia Medical Association 2010). Patient-based funding has been in use in the United States, Australia, and Europe for over 30 years (Street et al. 2007, Sharma 2009, Busse et al. 2011, Blumenthal & Dixon 2012), and it is reported to achieve many positive outcomes for patients including: decreased wait times, improved access to care; decreased lengths of stay, and in some cases, overall improved quality of care (Schrey€ ogg et al. 2006, Street et al. 2007, Collier 2008b, Farrar et al. 2009, O’Reilly et al. 2012, Stewart 2012). In the past 3 years, PBF has been introduced within the provinces of Alberta, British Columbia, Quebec and most recently, Ontario (Sutherland et al. 2013). One key component of PBF approaches is the use of QBPs. In April 2012, four QBPs (hip replacement, knee replacement, cataract surgery and dialysis and other treatments for chronic kidney disease) were introduced in 91 Ontario hospitals (MOHLTC 2012), with additional QBPs to be phased in over the next 2 years. This shift is requiring health-care leaders at all levels to consider ‘how’ to implement changes to adapt to this new funding approach while still achieving its intended outcomes of effective, efficient and accessible quality health-care. For the purpose of this paper, a health-care leader is defined as ‘an individual who creates vision and goals, and mobilises and manages resources to produce a service, change or product consistent with the vision and goals’ (Newland 2005). These individuals play a critical role in successfully transitioning their organisations to PBF and QBPs. One critical element for organisational transformation is the commitment of these leaders to quality and change and to promote it within the organisation (Lukas et al. 2007). To effectively promote and sustain change, leaders must also develop sound change strategies that align with the vision, mission and values of the organisation and be held accountable for these strategies and for demonstrating improved outcomes (Harber & Ball 2003). Currently, there is a gap in the literature related to the implementation of PBF and QBPs from the healthcare leader’s perspective, and this view is vitally important to supporting their successful integration ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
into the Canadian health-care system. Therefore, a systematic review of the international literature was conducted by Baxter et al. in 2013 to gain a better understanding of leaders’ experiences implementing PBF in acute care settings within developed countries (unpublished data). This review included 12 261 articles, 22 of which met pre-determined inclusion criteria and were reviewed for quality by two independent reviewers. Quantitative studies were appraised using an adapted version of Cummings et al.’s tool (2008), designed to evaluate studies with exploratory, nonexperimental, correlational or cross-sectional designs. Qualitative studies were appraised using Letts, Wilkins, Law, Stewart, Bosch and Westmoreland’s Critical Review Form – Qualitative Studies (Version 2.0) (Letts et al. 2007). Of the 22 articles, 14 were found to be relevant, 10 articles originated in the United States, all scoring low to medium for quality. Although none of the articles were directly related to leaders’ experiences implementing PBF or QBPs, they did provide insight into the topic by proposing some prerequisites for success, benefits, barriers and challenges, strategies to achieve the intended outcomes, as well as unintended consequences. More importantly, the review supported the need for rigorous high quality research to examine the implementation of PBF and QBPs from the health-care leader’s perspective. To date, no research has been conducted that specifically examines health-care leaders’ perspectives on the implementation of this new funding approach and the challenges it poses.
Materials and methods Study aims The aims for the current study were to gather healthcare leaders’ early responses to the implementation of PBF in Ontario hospitals and specifically QBPs related to joint replacement surgery, explore barriers and facilitators encountered while implementing PBF and orthopaedic QBPs and to explore strategies and innovations developed in response to PBF and QBPs.
Methods To achieve the aims for this study, an exploratory descriptive design was utilised. This approach allows researchers to gain first-hand knowledge of the participants’ experiences (Sandelowski 2010) in order to inform practise (Thorne 2008). When new or unexpected truths are discovered, this design also allows 51
Health care leaders responses to quality-based procedures
Ethical approval McMaster University Ethics Board (#13-585).
References Blumenthal D. & Dixon J. (2012) Health-care reforms in the USA and England: areas for useful learning. The Lancet 380 (9850), 1352–1357. British Columbia Medical Association (2010) Valuing quality: patient-focused funding in British Columbia. Available at: http://www.cihi.ca/CIHI-ext-portal/pdf/internet/patient_focused_ funding_en, accessed 10 February 2014. Bull M.J. (1988) Influence of diagnosis-related groups on discharge planning, professional practice, and patient care. Journal of Professional Nursing 4, 415–21. Busse R., Geissler A. & Quentin W. (2011) Diagnosis-related groups in Europe moving towards transparency, efficiency and quality in hospitals. Available at: http://eurodrg.projects. tuberlin.de/publications/1_EuroDRG_FC_Busse_Berlin171111. pdf, accessed 23 November 2013. Cohen M., McGregor M.I., Ivanova I. & Kinkaid C. (2012) Beyond the Hospital Walls: Activity Based Funding Versus Integrated Health Care Reform. Canadian Centre for Policy Alternatives, Vancouver, BC. Available at: http://www.policyalternatives.ca/sites/default/files/uploads/publications/BC%20O ffice/2012/01/CCPA-BC_ABF_2012.pdf, accessed 23 November 2013. Collier R. (2008a) News: patient-based funding model endorsed. Canadian Medical Association Journal 179 (6), 522. Collier R. (2008b) Activity-based hospital funding: boon or boondoggle? Canadian Medical Association Journal 178 (11), 1407–1408. Conrad D.A., Saver B.G., Court B. & Heath S. (2006) Paying physicians for quality: evidence and themes from the field. Joint Commission Journal on Quality and Patient Safety 32 (8), 443–451. Cormack D. (2000) The Research Process in Nursing, 4th edn. Wiley, San Francisco, CA. Cummings G., Lee H., MacGregor T. et al. (2008) Factors contributing to nursing leadership: a systematic review. Journal of Health Services Research and Policy 13, 240–248. Durkin E.M., Deutsch A. & Heinemann A.W. (2010) Inpatient rehabilitation facilities: variation in organizational practice in response to prospective payment. Medical Care Research and Review 67 (2), 149–172. Ettelt S., Thompson S., Nolte E. & Mays N. (2006) Reimbursing highly specialised hospital services: the experience of activity-based funding in eight countries. A report commissioned by the Department of Health. London School of Hygiene and Tropical Medicine 35, 1–2. Farrar S., Yi D., Sutton M., Chalkley M., Sussex J. & Scott A. (2009) Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis British Medical Journal 339, 3047e. Goldman L.E., Henderson S., Dohan D.P., Talavera J.A. & Dudley R.A. (2007) Public reporting and pay-for-performance: safety-net hospital executives’ concerns and policy suggestions. Inquiry 44, 137–145. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
Harber B. & Ball T. (2003) From the blame game to accountability in health. Policy Options 24 (10), 49–54. Health Policy Solutions (2011) Activity-based funding for Australian public hospitals: towards a pricing framework. Available at: http://www.ihpa.gov.au/internet/ihpa/publishing.nsf/Content/EB8EFD07DF85BC70CA25798300033BE1/$File/IHPA% 20Draft%20Pricing%20Framework_long%20 version.pdf, accessed 26 March 2014. Letts L., Wilkins S., Law M., Stewart D., Bosch J. & Westmorland M. (2007) Critical Review Form – Qualitative Studies (Version 2.0). Available at: http://.srs-mcmaster.ca/Portals/20/ pdf/qualreview_version2.0pdf, accessed 10 June 2013. Lukas C.V., Holmes S.K., Cohen A.B. et al. (2007) Transformational change in health care systems: an organizational model. Health Care Management Review 32 (4), 309–320. Mannion R. & Davies H.T. (2008) Payment for performance in health care. British Medical Journal 336 (7639), 306– 308. Mannion R., Marini G. & Street A. (2008) Implementing payment by results in the English NHS. Journal of Health Organization and Management 22 (1), 79–88. Ministry of Health and Long-Term Care (2012) Health system funding reform. Patient-based funding overview. Available at: http://health.gov.on.ca/en/pro/programs/ecfa/default.aspx/docs/ ecfa_funding_pres.pdf, accessed 10 February 2014. Natale J.E., Joseph J.G., Honomichl R.D., Bazanni L.G., Kagawa K.J. & Marcin J.P. (2011) Benchmarking, public reporting, and pay-for-performance: A mixed-methods survey of California pediatric intensive care unit medical directors. Pediatric Critical Care Medicine 12, e225–e32. Neuendorf K.A. (2002) The Content Analysis Guidebook. Sage Publications, Thousand Oaks, CA. Newland J. (2005) Leadership task force report: a joint project of The Canadian College of Health Service Executives, The Academy of Executive Nurses, The Canadian Society of Physician Executives, and Human Resources Skills Development Canada. Available at: www.cchse.org, accessed 6 December 2013. O’Reilly J., Busse R., Hakkinen U., Or Z., Street A. & Wiley M. (2012) Paying for hospital care: the experience with implementing activity-based funding in five European countries. Health Economics, Policy and Law 7, 73–101. Quaye R. (2001) Professional integrity in the age of managed care: views of physicians. International Journal of Health Care Quality Assurance 14 (2), 82–86. Ridder H., Doege V. & Martini S. (2007) Differences in the implementation of diagnosis-related groups across clinical departments: a German hospital case study. Health Services Research 42 (6), 2120–2139. Sandelowski M. (2010) What’s in a name? Qualitative description revisited. Research in Nursing and Health 33 (1), 77–84. Sautter K.M., Bokhour B.G., White B. et al. (2007) The early experience of a hospital-based pay-for-performance program. Journal of Healthcare Management 52 (5), 95–107. Schrey€ ogg J., Tiemann O. & Busse R. (2006) Cost accounting to determine prices: how well do prices reflect costs in the German DRG-system? Health Care Management Science 9 (3), 269–279. Sharma A. (2009) Inter-DRG resource dynamics in a prospective payment system: a stochastic kernel approach. Health Care Management Science 12 (1), 38–55.
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Table 1 Sample description n = 70 Executive senior management (e.g. President, Executive Vice-President, CEO, Chief of Staff) Middle management [e.g. Director (programme, clinical, surgical services, operations, system performance, surgery, medical); Manager (project, programme, team, surgery)] Surgeons (orthopaedic, general) Front-line managers Clinicians Patient advisor
16 33
12 3 5 1
Responding to change All of the participants described responding to PBF and QBPs in a positive manner. One participant captured the dominant perspective in this way: ‘Changes to Ontario’s funding model were necessary and has forced stakeholders to think about their current practises and to consider alternatives’. Participants described how they had responded by examining ‘why’ they do things the way they do and by asking themselves, ‘how’ they could alter current practises in order to determine where cut-backs could be made and where volumes could be increased. However, participants also described the transition period as ‘difficult’ and ‘challenging’. One administrator described it in this way, ‘The bomb was dropped and we are picking up the pieces’. Although they described the early transition period as tumultuous, the participants consistently and emphatically spoke of their determination to achieve positive outcomes and to improve the quality of care for their patients. This commitment to quality was driven by their commitment to the mission/vision associated with the funding reforms.
weather conditions. Or, to have patients air lifted from remote northern locations to urban centres which presented negative consequences for the patient, family and hospital.
Leading the change Leaders described how leading the change was thwarted by several challenges/barriers. The first major barrier was a lack of organisational preparedness. Several participants stated that the hospitals were not well prepared for the transition to PBF and QBPs due to a lack of information and communication. This led to a poor understanding of the anticipated changes, their role in supporting the changes, and their ability to communicate what was required of those they were responsible to lead. ‘The administrators don’t understand the initiative’. ‘It was the only time we got information other than two days before we were to implement or something like that, very little time, so we had QBPs and we had just seen the list and we had no idea what was going on’. Participants also felt that it was difficult to lead when they were given very little opportunity to provide input into the funding changes. They stated that a top-down approach was taken during the development of the revised funding approach and that their expertise had not been sought out during the planning phase. An additional barrier to leading the change was a perception that PBF was less about quality, patient-centred care and more about cost containment. Yet, as health-care providers they believed that their first responsibility was to the patient.
‘The only thing that kept it from blowing up was buy-in to the mission/vision’.
‘The patient-centred piece goes by-the-by with this funding approach’.
‘We’re excited to be part of this [PBF initiative], we want it to be as positive as can be’.
‘[The] purpose of PBF is cost containment, not quality, and getting this across to stakeholders is very challenging’.
Health-care leaders also responded with caution, noting that the funding reforms could have negative consequences for their patients, their practises and their organisations. For example, some indicated that community hospitals would have to send patients to centres with larger surgical volumes, which would be disadvantageous to patients and their families. This was particularly problematic in northern locations where to send a patient to another hospital could require patients to drive several hours in extreme ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
While participants spoke of several barriers, they also recognised that leading the change had led to many benefits including the coordination of activities to promote efficiency across disciplines, greater collaboration and communication amongst team members from different disciplines, greater physician-leadership engagement and better collaboration and communication with community physiotherapists. They also mentioned that PBF promoted greater consistency in care 53
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delivery and several opportunities including the opportunity to develop and implement innovative care delivery models and new roles, and the opportunity to gain a better understanding of the needs that each healthcare team member had when providing orthopaedic care.
Managing the change Participants made it clear that, despite the challenges associated with implementing PBF and QBPs, they were indeed managing the change effectively and seeing positive patient results including reduced lengths of stay and greater efficiency. Participants discussed several strategies that had been employed to achieve these outcomes including the development of standardised orders and care pathways (where they were not present before), standardised equipment and supplies, the development of new roles to promote smooth transitions for patients throughout their journey, and the development of consistent communication pathways. However, participants expressed concern about how to manage; (1) ‘cherry picking’, (2) data collection, analysis and management demands and (3) case costing. The concept of ‘cherry picking’, or risk selection, was discussed in four of the meetings and in individual consultations. This is where the healthiest patients are selected to ensure that there are fewer complications and less recovery time (in order to save money). Several participants knew that this was an issue that had arisen in other countries and recognised the potential for this to occur in Ontario. ‘Will need to watch for “cherry picking” and choosing those patients who will have good outcomes will be selected’. ‘Obliged to treat the healthiest of that category because you’ll get more funding and that’s counterintuitive to pushing those patients out in the community. I want to bring those patients in’. One significant barrier to managing the change was the impact on human resources. This was due to the amount and types of data that need to be collected and analysed. Some hospitals were advantaged in this area and had strong pre-existing data support teams. However, smaller hospitals indicated that they did not have the same level of support and worried about the impact of future QBPs on the amount of work they would present for the decision support team. ‘We’re lucky to have a great decision support team, excellent team, but at some point they’re 54
going to break, we have to hire more people as we get hundreds of QBPs’. A final area of concern that the participants identified was the issue of case costing. Once again, the leaders felt they had received little information about case costing and were finding it difficult to engage in this activity without having current costs available to them. ‘We’ve had difficulty costing out services; we have a sense, but costing, we don’t know exactly what things cost’. Several participants talked about the burden of case costing to them as an organisation: ‘Case costing is a huge part of this and few hospitals are on case costing, so the case costing hospitals are at a huge advantage and we don’t have the dollars to get into case costing anymore. We’re going to be forced to do it and it’s going to take dollars out of our bottom line’. One of the challenges with case costing was identified as trying to be cost effective without negatively impacting the quality of care. One participant summed up the challenge this way: ‘We have worked with case costing in depth: the challenge is to find more savings without compromising outcomes. At the end of the day, decisions need to be made based on each patient’. There was a general sense that case costing data were not accurate at all facilities. One participant suggested that there needed to be a standardised approach to understand costs. In the meantime, the participants noted that it will be important to examine how data are gathered at various hospitals and how they are reported. Participants also talked about the need for a mechanism to absorb additional costs that are not covered by case costing.
Discussion The findings provide a set of early responses from health-care leaders and identify key barriers, benefits and concerns related to the implementation of QBPs in orthopaedic care. From the data, we know that if leaders believe in the mission and vision, they will remain supportive of an initiative, such as funding reform, even if the mechanisms for implementing the proposed change are not well understood. In this case, participants believed that PBF was a better option ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
Health care leaders responses to quality-based procedures
than global funding to promote efficiency within the health-care system. They also believed that PBF had the potential to benefit patients. This finding is consistent with earlier studies including the work conducted by Quaye (2001) who interviewed 28 health-care leaders in Sweden 7 years after the implementation of the diagnostic related groups system (one form of patientbased funding). Findings from that qualitative study suggested that 90% of respondents were supportive of similar funding reforms believing that funding reform had led to increased productivity and efficiency in their hospitals. Other studies have also discussed the importance of a commitment to quality improvement as being a prerequisite for implementing funding reforms such as PBF (Conrad et al. 2006, Goldman et al. 2007, Sautter et al. 2007, Mannion & Davies 2008, Sussex & Farrar 2009). From this study, it is evident that several prerequisites are required to lead this type of organisational change, the first being knowledge. To achieve an effective and efficient transition, a clear understanding of ‘what’ the shift will look like and require from leaders and staff, ‘how’ the shift is to occur, and ‘who’ and ‘what’ resources are essential. It is clear that strong leadership is required, and that those in leadership need to be engaged early in the process for two reasons: (1) to ensure that the change is appropriate and able to meet the needs of the community, the care providers and administrators and (2) to ensure buy-in across the organisation (Ridder et al. 2007, Sautter et al. 2007). Those in leadership must have a positive attitude about the potential of the funding reform to bring about positive changes for patients. This finding is supported by several studies (Conrad et al. 2006, Ridder et al. 2007, Mannion & Davies 2008, Durkin et al. 2010, Wharam et al. 2011). Each found the need for a positive attitude when faced with implementing new funding reforms into health-care organisations. Some authors in this area suggest that it is not enough for the leaders to be positive, but that the institution must also be accepting of funding approach changes (Conrad et al. 2006, Mannion & Davies 2008) and that there must also be a longstanding commitment to quality improvement and wide-spread staff support to promote long-term adoption (Goldman et al. 2007). In order to lead change leaders require clear, concise and consistent communication through one consistent pathway to avoid unnecessary confusion regarding the implementation process and so that they, in turn, can garner support for the initiative from others within the organisation. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
Leaders must be engaged early in the development of funding reform in order to (a) understand the reforms and (b) understand ‘how’ to effectively promote change in their organisations. This finding is consistent with those of Goldman et al. (2007) and Wharam et al. (2011), who indicated the importance of physician buy-in when implementing funding reform in hospitals. In his study of P4P (pay-forperformance) implementation in Safety Net Hospitals in California, Wharam and colleagues interviewed hospital executives and reported that physician buy-in was difficult to gain, but crucial for optimal P4P development and that physician input ensured greater validity for quality measures (Wharam et al. 2011). Managing the significant change initiatives associated with funding reform is not a simple task and requires that leaders be prepared, knowledgeable and committed. It also requires leaders to think ahead, anticipate unintended consequences and build in strategies to overcome them during the initial implementation. Various unintended consequences have been described by health-care leaders in England (Mannion & Davies 2008, Mannion et al. 2008), the United States (Bull 1988, Conrad et al. 2006, Goldman et al. 2007, Sautter et al. 2007, Durkin et al. 2010, Natale 2011) and Sweden (Quaye 2001). Leaders in the current study described ‘cherry picking’ as a potential unintended consequence. Mannion and Davies also noted the potential for health-care leaders to engage in ‘cherry picking’. Other unintended consequences have been described as concealment and escape tactics (Conrad et al. 2006, Durkin et al. 2010), opportunistic behaviour, gaming (Mannion & Davies 2008), patients discharged sooner and quicker, stress on families (Bull), and unplanned readmissions to hospital (Mannion et al. 2008). To date, no literature could be found that suggested strategies to avoid these unintended outcomes in organisations where funding was tied to the patient. Managing the change requires accurate and reliable data to inform decision making and to ensure accurate case costing. In particular, three factors represent significant case costing challenges for leaders when implementing QBPs. These are: (1) the lack of human resources to collect and analyse the data, (2) the lack of available and accurate pricing for supplies and services and (3) the lack of consistency within the organisation, department, hospital unit and individual health-care providers. While PBF is being implemented following 30 years of international experience, its implementation is also occurring at a time when those countries are shifting toward more integrated models of health-care funding 55
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that incorporate the health-care system as a whole, rather than simply the funding of hospitals (British Columbia Medical Association 2010, Health Policy Solutions 2011, Blumenthal & Dixon 2012, Cohen et al. 2012, Victoria Department of Health 2013). The United States (diagnostic related groups), Australia (activity-based funding) and England (activity-based funding) have experienced challenges with similar funding models including: limited evidence of increases in quality of care, risk selection, early discharge, and increases in administrative costs, and financial pressures (Ettelt et al. 2006, Thompson 2006, Street & Maynard 2007, British Columbia Medical Association 2010, Sutherland 2011, Blumenthal & Dixon 2012). These countries can provide Canada with valuable lessons regarding PBF, one of the most valuable being the need to combine global funding with patient-based funding (Collier 2008b). Such an approach may address the aforementioned challenges. Although conducted in Ontario, Canada, this study provides new findings that should be considered by international leaders as they continue to experience changes in funding reform. That is, it is important to consider the identified barriers and challenges when responding to, leading and managing funding reform approaches, such as the implementation of QBPs.
Limitations As with all studies, this study recognises two key limitations. First, the use of focus groups rather than oneon-one interviews may have discouraged some leaders from expressing their unique or conflicting viewpoints regarding the implementation process. Second, individuals from various strata in the organisational chart were sitting together to discuss the issue of QBP implementation. This fact may have been intimidating and may have resulted in undisclosed perspectives. The PI informed all participants that if they wanted to add information or if they had something additional to share that was not captured they could contact the PI directly, but no one followed up.
Conclusion Leaders’ early responses to the implementation of QBPs in orthopaedic care reveal a general commitment to see system changes that benefit the health-care system, organisation, patient and health-care provider. However, leaders in Canada are currently faced with several challenges when implementing orthopaedic QBPs and these include; a lack of adequate involvement in 56
planning; a lack of communication with those responsible for implementing the change at a broader system level; and an inadequate infrastructure in smaller community hospitals. Health-care leaders are concerned about the complexity of the funding shift and its impact on the quality of care, data management and case costing. Similar issues surrounding funding reform have been identified in other countries and have forced them to reconsider how they fund patient activity. The hospitals included in this study included large teaching hospitals with significant numbers of resources. It is important to explore the experiences of leaders in ‘less affluent’ hospitals and those providing care in remote and rural settings. Further research is needed to continue to explore health-care leaders’ responses to health-care funding reform across Ontario, Canada, and globally and to share strategies for effective implementation.
Implications for nursing management Nursing management can play a key role in developing effective QBP implementation plans and in building strong, effective implementation teams that are collaborative, innovative and productive. However, it is important that those in nursing management positions be involved early in the planning process, making every effort to be involved in the steering committee. Those chosen to lead implementation teams must be committed positive leaders who have a firm understanding of the goals associated with QBP implementation and knowledge of its potential to benefit patients, the health-care team and the organisation. Those responsible for implementation need to clearly understand their role in the implementation process and to know what resources they have available to support their implementation efforts. In addition, leaders need to anticipate potential unintended consequences and to develop policies early in the adoption process to thwart them. Developing effective communication pathways prior to implementation (both horizontal and vertical) will promote team collaboration, effectiveness and efficiency. With strong, committed leaders, the positive outcomes associated with QBP implementation can be realised.
Source of funding This work was supported by the University of Ottawa [grant number 06551] and the Canadian Institutes of Health Research [grant number, 126835]. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
Health care leaders responses to quality-based procedures
Ethical approval McMaster University Ethics Board (#13-585).
References Blumenthal D. & Dixon J. (2012) Health-care reforms in the USA and England: areas for useful learning. The Lancet 380 (9850), 1352–1357. British Columbia Medical Association (2010) Valuing quality: patient-focused funding in British Columbia. Available at: http://www.cihi.ca/CIHI-ext-portal/pdf/internet/patient_focused_ funding_en, accessed 10 February 2014. Bull M.J. (1988) Influence of diagnosis-related groups on discharge planning, professional practice, and patient care. Journal of Professional Nursing 4, 415–21. Busse R., Geissler A. & Quentin W. (2011) Diagnosis-related groups in Europe moving towards transparency, efficiency and quality in hospitals. Available at: http://eurodrg.projects. tuberlin.de/publications/1_EuroDRG_FC_Busse_Berlin171111. pdf, accessed 23 November 2013. Cohen M., McGregor M.I., Ivanova I. & Kinkaid C. (2012) Beyond the Hospital Walls: Activity Based Funding Versus Integrated Health Care Reform. Canadian Centre for Policy Alternatives, Vancouver, BC. Available at: http://www.policyalternatives.ca/sites/default/files/uploads/publications/BC%20O ffice/2012/01/CCPA-BC_ABF_2012.pdf, accessed 23 November 2013. Collier R. (2008a) News: patient-based funding model endorsed. Canadian Medical Association Journal 179 (6), 522. Collier R. (2008b) Activity-based hospital funding: boon or boondoggle? Canadian Medical Association Journal 178 (11), 1407–1408. Conrad D.A., Saver B.G., Court B. & Heath S. (2006) Paying physicians for quality: evidence and themes from the field. Joint Commission Journal on Quality and Patient Safety 32 (8), 443–451. Cormack D. (2000) The Research Process in Nursing, 4th edn. Wiley, San Francisco, CA. Cummings G., Lee H., MacGregor T. et al. (2008) Factors contributing to nursing leadership: a systematic review. Journal of Health Services Research and Policy 13, 240–248. Durkin E.M., Deutsch A. & Heinemann A.W. (2010) Inpatient rehabilitation facilities: variation in organizational practice in response to prospective payment. Medical Care Research and Review 67 (2), 149–172. Ettelt S., Thompson S., Nolte E. & Mays N. (2006) Reimbursing highly specialised hospital services: the experience of activity-based funding in eight countries. A report commissioned by the Department of Health. London School of Hygiene and Tropical Medicine 35, 1–2. Farrar S., Yi D., Sutton M., Chalkley M., Sussex J. & Scott A. (2009) Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis British Medical Journal 339, 3047e. Goldman L.E., Henderson S., Dohan D.P., Talavera J.A. & Dudley R.A. (2007) Public reporting and pay-for-performance: safety-net hospital executives’ concerns and policy suggestions. Inquiry 44, 137–145. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
Harber B. & Ball T. (2003) From the blame game to accountability in health. Policy Options 24 (10), 49–54. Health Policy Solutions (2011) Activity-based funding for Australian public hospitals: towards a pricing framework. Available at: http://www.ihpa.gov.au/internet/ihpa/publishing.nsf/Content/EB8EFD07DF85BC70CA25798300033BE1/$File/IHPA% 20Draft%20Pricing%20Framework_long%20 version.pdf, accessed 26 March 2014. Letts L., Wilkins S., Law M., Stewart D., Bosch J. & Westmorland M. (2007) Critical Review Form – Qualitative Studies (Version 2.0). Available at: http://.srs-mcmaster.ca/Portals/20/ pdf/qualreview_version2.0pdf, accessed 10 June 2013. Lukas C.V., Holmes S.K., Cohen A.B. et al. (2007) Transformational change in health care systems: an organizational model. Health Care Management Review 32 (4), 309–320. Mannion R. & Davies H.T. (2008) Payment for performance in health care. British Medical Journal 336 (7639), 306– 308. Mannion R., Marini G. & Street A. (2008) Implementing payment by results in the English NHS. Journal of Health Organization and Management 22 (1), 79–88. Ministry of Health and Long-Term Care (2012) Health system funding reform. Patient-based funding overview. Available at: http://health.gov.on.ca/en/pro/programs/ecfa/default.aspx/docs/ ecfa_funding_pres.pdf, accessed 10 February 2014. Natale J.E., Joseph J.G., Honomichl R.D., Bazanni L.G., Kagawa K.J. & Marcin J.P. (2011) Benchmarking, public reporting, and pay-for-performance: A mixed-methods survey of California pediatric intensive care unit medical directors. Pediatric Critical Care Medicine 12, e225–e32. Neuendorf K.A. (2002) The Content Analysis Guidebook. Sage Publications, Thousand Oaks, CA. Newland J. (2005) Leadership task force report: a joint project of The Canadian College of Health Service Executives, The Academy of Executive Nurses, The Canadian Society of Physician Executives, and Human Resources Skills Development Canada. Available at: www.cchse.org, accessed 6 December 2013. O’Reilly J., Busse R., Hakkinen U., Or Z., Street A. & Wiley M. (2012) Paying for hospital care: the experience with implementing activity-based funding in five European countries. Health Economics, Policy and Law 7, 73–101. Quaye R. (2001) Professional integrity in the age of managed care: views of physicians. International Journal of Health Care Quality Assurance 14 (2), 82–86. Ridder H., Doege V. & Martini S. (2007) Differences in the implementation of diagnosis-related groups across clinical departments: a German hospital case study. Health Services Research 42 (6), 2120–2139. Sandelowski M. (2010) What’s in a name? Qualitative description revisited. Research in Nursing and Health 33 (1), 77–84. Sautter K.M., Bokhour B.G., White B. et al. (2007) The early experience of a hospital-based pay-for-performance program. Journal of Healthcare Management 52 (5), 95–107. Schrey€ ogg J., Tiemann O. & Busse R. (2006) Cost accounting to determine prices: how well do prices reflect costs in the German DRG-system? Health Care Management Science 9 (3), 269–279. Sharma A. (2009) Inter-DRG resource dynamics in a prospective payment system: a stochastic kernel approach. Health Care Management Science 12 (1), 38–55.
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Stewart M. (2012) Quality Based Procedures. Paper Presented at the Ontario Health Information Management Association Meeting, 4 October 2012. Ministry of Health and Long-Term Care, Toronto, ON. Street A. & Maynard A. (2007) Activity based financing in England: the need for continual refinement of payment by results. Health Economics, Policy and Law 2 (4), 419–427. Street A., Vitikainen K., Bjorvatn A. & Hvenegaard A. (2007) Introducing activity-based financing: a review of experience in Australia, Denmark, Norway and Sweden Centre for Health Economics, Research Paper 30. Available at: http://www.york.ac.uk/che/pdf/rp30.pdf, accessed 10 April 2014. Sussex J. & Farrar S. (2009) Activity-based funding for National Health Service hospitals in England: managers’ experience and expectations. European Journal of Health Economics 10 (2), 197–206. Sutherland J.M. (2011) Hospital payment mechanisms: an overview and options for Canada. Available at: www.chsrf.ca, accessed 26 November 2013.
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Sutherland J., Liu G., Crump T. & Repin N. (2013) Hospital Funding Policies: Where are We on Hip and Knee Replacements? Study Data Bulletin #4. UBC Centre for Health Services and Policy Research, Vancouver, BC. Thompson D. (2006) EHR value: don’t expect what you don’t plan for. Healthcare Financial Management 60 (12), 58–62. Thorne S. (2008) Interpretive Description, 2nd edn. Left Coast Press, Walnut Creek, CA. Victoria Department of Health (2013) Activity-based funding. Available at: http://health.vic.gov.au/, accessed 10 November 2013. Wharam J.F., Frank M.B., Rosland A.M. et al. (2011) ‘Payfor-performance’ as a quality improvement tool: perceptions and policy recommendations of physicians and program leaders. Quality and Management in Health Care 20 (3), 234–245.
ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
Quality-based procedures in Ontario: exploring health-care leaders’ responses PAMELA BAXTER R N , P h D 1, LAURA CLEGHORN M A 1, KIM ALVARADO R N , P h D 2, GRETA CUMMINGS 3 4 1 5 R N , P h D , DEBORAH KENNEDY B S c P T , M S c , COLLEEN MCKEY R N , P h D and KATHY PFAFF R N , P h D 1
Associate Professor, McMaster University, School of Nursing, Hamilton,Ontario, 2Hamilton Health Sciences Centre, Surgical Oncology, Orthopaedics and Critical Care, Hamilton, Ontario, 3University of Alberta, Faculty of Nursing, Edmonton, Alberta, 4Sunnybrook Health Sciences Centre, Holland Orthopaedic & Arthritic Centre, Toronto, Ontario and 5 University of Windsor, Faculty of Nursing,Windsor, Ontario, Canada
Correspondence Pamela Baxter School of Nursing McMaster University 1280 Main St. W. HSB 3N28C Hamilton, Ontario Canada L8S 4K1 Ontario Canada E-mail: [email protected]
BAXTER P., CLEGHORN L., ALVARADO K., CUMMINGS G., KENNEDY D., MCKEY C. & PFAFF K.
(2016) Journal of Nursing Management 24, 50–58 Quality-based procedures in Ontario: exploring health-care leaders’ responses Aim To examine health-care leaders’ initial response to the implementation of orthopaedic quality based procedures (QBPs) in hospitals across Ontario, Canada. Background In 2012, Ontario, Canada shifted 91 hospitals to a patient-based funding (PBF) approach. This approach funds health-care organisations based on the number of patients treated with select procedures known as QBPs. Methods An exploratory descriptive design was employed to better understand health-care leaders’ early implementation experiences. Seventy organisational leaders from 20 hospitals participated in six focus groups and four interviews to discuss their initial responses to the implementation of two QBPs (primary unilateral hip replacement and primary unilateral knee replacement). Qualitative data underwent content analysis. Findings Three key major themes emerged; (1) responding to change, (2) leading the change and (3) managing the change. Within each of these themes, barriers and benefits were identified. Conclusion Leaders are accepting of PBF and QBPs. However, challenges exist that require further exploration including the need for a strong infrastructure, accurate and timely clinical and financial data, and policies to prevent unintended consequences. Implications for nursing management Implementing QBPs requires careful planning, adequate and appropriate resources, vertical and horizontal communication strategies, and policies to ensure that unintended consequences are avoided and positive outcomes achieved. Keywords: health-care, leadership, patient-based funding, quality-based procedures Accepted for publication: 22 August 2014
Introduction Canadian health-care leaders are facing significant changes in hospital payment policy as they shift 50
away from the traditional block-funding model that grants annual lump sums to hospitals (Collier 2008a), to a patient-based funding (PBF) approach (often referred to as quality-based funding or DOI: 10.1111/jonm.12271 ª 2014 John Wiley & Sons Ltd
Health care leaders responses to quality-based procedures
activity-based funding). Using this funding approach, hospitals are paid based on the type and quantities of patients they treat with select procedures known as quality based procedures (QBPs). Patient-based funding considers patients as a source of revenue rather than a cost. This perspective is intended to motivate hospitals and health-care providers to increase their efficiency levels, thereby increasing their revenue (British Columbia Medical Association 2010). Patient-based funding has been in use in the United States, Australia, and Europe for over 30 years (Street et al. 2007, Sharma 2009, Busse et al. 2011, Blumenthal & Dixon 2012), and it is reported to achieve many positive outcomes for patients including: decreased wait times, improved access to care; decreased lengths of stay, and in some cases, overall improved quality of care (Schrey€ ogg et al. 2006, Street et al. 2007, Collier 2008b, Farrar et al. 2009, O’Reilly et al. 2012, Stewart 2012). In the past 3 years, PBF has been introduced within the provinces of Alberta, British Columbia, Quebec and most recently, Ontario (Sutherland et al. 2013). One key component of PBF approaches is the use of QBPs. In April 2012, four QBPs (hip replacement, knee replacement, cataract surgery and dialysis and other treatments for chronic kidney disease) were introduced in 91 Ontario hospitals (MOHLTC 2012), with additional QBPs to be phased in over the next 2 years. This shift is requiring health-care leaders at all levels to consider ‘how’ to implement changes to adapt to this new funding approach while still achieving its intended outcomes of effective, efficient and accessible quality health-care. For the purpose of this paper, a health-care leader is defined as ‘an individual who creates vision and goals, and mobilises and manages resources to produce a service, change or product consistent with the vision and goals’ (Newland 2005). These individuals play a critical role in successfully transitioning their organisations to PBF and QBPs. One critical element for organisational transformation is the commitment of these leaders to quality and change and to promote it within the organisation (Lukas et al. 2007). To effectively promote and sustain change, leaders must also develop sound change strategies that align with the vision, mission and values of the organisation and be held accountable for these strategies and for demonstrating improved outcomes (Harber & Ball 2003). Currently, there is a gap in the literature related to the implementation of PBF and QBPs from the healthcare leader’s perspective, and this view is vitally important to supporting their successful integration ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
into the Canadian health-care system. Therefore, a systematic review of the international literature was conducted by Baxter et al. in 2013 to gain a better understanding of leaders’ experiences implementing PBF in acute care settings within developed countries (unpublished data). This review included 12 261 articles, 22 of which met pre-determined inclusion criteria and were reviewed for quality by two independent reviewers. Quantitative studies were appraised using an adapted version of Cummings et al.’s tool (2008), designed to evaluate studies with exploratory, nonexperimental, correlational or cross-sectional designs. Qualitative studies were appraised using Letts, Wilkins, Law, Stewart, Bosch and Westmoreland’s Critical Review Form – Qualitative Studies (Version 2.0) (Letts et al. 2007). Of the 22 articles, 14 were found to be relevant, 10 articles originated in the United States, all scoring low to medium for quality. Although none of the articles were directly related to leaders’ experiences implementing PBF or QBPs, they did provide insight into the topic by proposing some prerequisites for success, benefits, barriers and challenges, strategies to achieve the intended outcomes, as well as unintended consequences. More importantly, the review supported the need for rigorous high quality research to examine the implementation of PBF and QBPs from the health-care leader’s perspective. To date, no research has been conducted that specifically examines health-care leaders’ perspectives on the implementation of this new funding approach and the challenges it poses.
Materials and methods Study aims The aims for the current study were to gather healthcare leaders’ early responses to the implementation of PBF in Ontario hospitals and specifically QBPs related to joint replacement surgery, explore barriers and facilitators encountered while implementing PBF and orthopaedic QBPs and to explore strategies and innovations developed in response to PBF and QBPs.
Methods To achieve the aims for this study, an exploratory descriptive design was utilised. This approach allows researchers to gain first-hand knowledge of the participants’ experiences (Sandelowski 2010) in order to inform practise (Thorne 2008). When new or unexpected truths are discovered, this design also allows 51
Health care leaders responses to quality-based procedures
Ethical approval McMaster University Ethics Board (#13-585).
References Blumenthal D. & Dixon J. (2012) Health-care reforms in the USA and England: areas for useful learning. The Lancet 380 (9850), 1352–1357. British Columbia Medical Association (2010) Valuing quality: patient-focused funding in British Columbia. Available at: http://www.cihi.ca/CIHI-ext-portal/pdf/internet/patient_focused_ funding_en, accessed 10 February 2014. Bull M.J. (1988) Influence of diagnosis-related groups on discharge planning, professional practice, and patient care. Journal of Professional Nursing 4, 415–21. Busse R., Geissler A. & Quentin W. (2011) Diagnosis-related groups in Europe moving towards transparency, efficiency and quality in hospitals. Available at: http://eurodrg.projects. tuberlin.de/publications/1_EuroDRG_FC_Busse_Berlin171111. pdf, accessed 23 November 2013. Cohen M., McGregor M.I., Ivanova I. & Kinkaid C. (2012) Beyond the Hospital Walls: Activity Based Funding Versus Integrated Health Care Reform. Canadian Centre for Policy Alternatives, Vancouver, BC. Available at: http://www.policyalternatives.ca/sites/default/files/uploads/publications/BC%20O ffice/2012/01/CCPA-BC_ABF_2012.pdf, accessed 23 November 2013. Collier R. (2008a) News: patient-based funding model endorsed. Canadian Medical Association Journal 179 (6), 522. Collier R. (2008b) Activity-based hospital funding: boon or boondoggle? Canadian Medical Association Journal 178 (11), 1407–1408. Conrad D.A., Saver B.G., Court B. & Heath S. (2006) Paying physicians for quality: evidence and themes from the field. Joint Commission Journal on Quality and Patient Safety 32 (8), 443–451. Cormack D. (2000) The Research Process in Nursing, 4th edn. Wiley, San Francisco, CA. Cummings G., Lee H., MacGregor T. et al. (2008) Factors contributing to nursing leadership: a systematic review. Journal of Health Services Research and Policy 13, 240–248. Durkin E.M., Deutsch A. & Heinemann A.W. (2010) Inpatient rehabilitation facilities: variation in organizational practice in response to prospective payment. Medical Care Research and Review 67 (2), 149–172. Ettelt S., Thompson S., Nolte E. & Mays N. (2006) Reimbursing highly specialised hospital services: the experience of activity-based funding in eight countries. A report commissioned by the Department of Health. London School of Hygiene and Tropical Medicine 35, 1–2. Farrar S., Yi D., Sutton M., Chalkley M., Sussex J. & Scott A. (2009) Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis British Medical Journal 339, 3047e. Goldman L.E., Henderson S., Dohan D.P., Talavera J.A. & Dudley R.A. (2007) Public reporting and pay-for-performance: safety-net hospital executives’ concerns and policy suggestions. Inquiry 44, 137–145. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
Harber B. & Ball T. (2003) From the blame game to accountability in health. Policy Options 24 (10), 49–54. Health Policy Solutions (2011) Activity-based funding for Australian public hospitals: towards a pricing framework. Available at: http://www.ihpa.gov.au/internet/ihpa/publishing.nsf/Content/EB8EFD07DF85BC70CA25798300033BE1/$File/IHPA% 20Draft%20Pricing%20Framework_long%20 version.pdf, accessed 26 March 2014. Letts L., Wilkins S., Law M., Stewart D., Bosch J. & Westmorland M. (2007) Critical Review Form – Qualitative Studies (Version 2.0). Available at: http://.srs-mcmaster.ca/Portals/20/ pdf/qualreview_version2.0pdf, accessed 10 June 2013. Lukas C.V., Holmes S.K., Cohen A.B. et al. (2007) Transformational change in health care systems: an organizational model. Health Care Management Review 32 (4), 309–320. Mannion R. & Davies H.T. (2008) Payment for performance in health care. British Medical Journal 336 (7639), 306– 308. Mannion R., Marini G. & Street A. (2008) Implementing payment by results in the English NHS. Journal of Health Organization and Management 22 (1), 79–88. Ministry of Health and Long-Term Care (2012) Health system funding reform. Patient-based funding overview. Available at: http://health.gov.on.ca/en/pro/programs/ecfa/default.aspx/docs/ ecfa_funding_pres.pdf, accessed 10 February 2014. Natale J.E., Joseph J.G., Honomichl R.D., Bazanni L.G., Kagawa K.J. & Marcin J.P. (2011) Benchmarking, public reporting, and pay-for-performance: A mixed-methods survey of California pediatric intensive care unit medical directors. Pediatric Critical Care Medicine 12, e225–e32. Neuendorf K.A. (2002) The Content Analysis Guidebook. Sage Publications, Thousand Oaks, CA. Newland J. (2005) Leadership task force report: a joint project of The Canadian College of Health Service Executives, The Academy of Executive Nurses, The Canadian Society of Physician Executives, and Human Resources Skills Development Canada. Available at: www.cchse.org, accessed 6 December 2013. O’Reilly J., Busse R., Hakkinen U., Or Z., Street A. & Wiley M. (2012) Paying for hospital care: the experience with implementing activity-based funding in five European countries. Health Economics, Policy and Law 7, 73–101. Quaye R. (2001) Professional integrity in the age of managed care: views of physicians. International Journal of Health Care Quality Assurance 14 (2), 82–86. Ridder H., Doege V. & Martini S. (2007) Differences in the implementation of diagnosis-related groups across clinical departments: a German hospital case study. Health Services Research 42 (6), 2120–2139. Sandelowski M. (2010) What’s in a name? Qualitative description revisited. Research in Nursing and Health 33 (1), 77–84. Sautter K.M., Bokhour B.G., White B. et al. (2007) The early experience of a hospital-based pay-for-performance program. Journal of Healthcare Management 52 (5), 95–107. Schrey€ ogg J., Tiemann O. & Busse R. (2006) Cost accounting to determine prices: how well do prices reflect costs in the German DRG-system? Health Care Management Science 9 (3), 269–279. Sharma A. (2009) Inter-DRG resource dynamics in a prospective payment system: a stochastic kernel approach. Health Care Management Science 12 (1), 38–55.
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Table 1 Sample description n = 70 Executive senior management (e.g. President, Executive Vice-President, CEO, Chief of Staff) Middle management [e.g. Director (programme, clinical, surgical services, operations, system performance, surgery, medical); Manager (project, programme, team, surgery)] Surgeons (orthopaedic, general) Front-line managers Clinicians Patient advisor
16 33
12 3 5 1
Responding to change All of the participants described responding to PBF and QBPs in a positive manner. One participant captured the dominant perspective in this way: ‘Changes to Ontario’s funding model were necessary and has forced stakeholders to think about their current practises and to consider alternatives’. Participants described how they had responded by examining ‘why’ they do things the way they do and by asking themselves, ‘how’ they could alter current practises in order to determine where cut-backs could be made and where volumes could be increased. However, participants also described the transition period as ‘difficult’ and ‘challenging’. One administrator described it in this way, ‘The bomb was dropped and we are picking up the pieces’. Although they described the early transition period as tumultuous, the participants consistently and emphatically spoke of their determination to achieve positive outcomes and to improve the quality of care for their patients. This commitment to quality was driven by their commitment to the mission/vision associated with the funding reforms.
weather conditions. Or, to have patients air lifted from remote northern locations to urban centres which presented negative consequences for the patient, family and hospital.
Leading the change Leaders described how leading the change was thwarted by several challenges/barriers. The first major barrier was a lack of organisational preparedness. Several participants stated that the hospitals were not well prepared for the transition to PBF and QBPs due to a lack of information and communication. This led to a poor understanding of the anticipated changes, their role in supporting the changes, and their ability to communicate what was required of those they were responsible to lead. ‘The administrators don’t understand the initiative’. ‘It was the only time we got information other than two days before we were to implement or something like that, very little time, so we had QBPs and we had just seen the list and we had no idea what was going on’. Participants also felt that it was difficult to lead when they were given very little opportunity to provide input into the funding changes. They stated that a top-down approach was taken during the development of the revised funding approach and that their expertise had not been sought out during the planning phase. An additional barrier to leading the change was a perception that PBF was less about quality, patient-centred care and more about cost containment. Yet, as health-care providers they believed that their first responsibility was to the patient.
‘The only thing that kept it from blowing up was buy-in to the mission/vision’.
‘The patient-centred piece goes by-the-by with this funding approach’.
‘We’re excited to be part of this [PBF initiative], we want it to be as positive as can be’.
‘[The] purpose of PBF is cost containment, not quality, and getting this across to stakeholders is very challenging’.
Health-care leaders also responded with caution, noting that the funding reforms could have negative consequences for their patients, their practises and their organisations. For example, some indicated that community hospitals would have to send patients to centres with larger surgical volumes, which would be disadvantageous to patients and their families. This was particularly problematic in northern locations where to send a patient to another hospital could require patients to drive several hours in extreme ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
While participants spoke of several barriers, they also recognised that leading the change had led to many benefits including the coordination of activities to promote efficiency across disciplines, greater collaboration and communication amongst team members from different disciplines, greater physician-leadership engagement and better collaboration and communication with community physiotherapists. They also mentioned that PBF promoted greater consistency in care 53
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delivery and several opportunities including the opportunity to develop and implement innovative care delivery models and new roles, and the opportunity to gain a better understanding of the needs that each healthcare team member had when providing orthopaedic care.
Managing the change Participants made it clear that, despite the challenges associated with implementing PBF and QBPs, they were indeed managing the change effectively and seeing positive patient results including reduced lengths of stay and greater efficiency. Participants discussed several strategies that had been employed to achieve these outcomes including the development of standardised orders and care pathways (where they were not present before), standardised equipment and supplies, the development of new roles to promote smooth transitions for patients throughout their journey, and the development of consistent communication pathways. However, participants expressed concern about how to manage; (1) ‘cherry picking’, (2) data collection, analysis and management demands and (3) case costing. The concept of ‘cherry picking’, or risk selection, was discussed in four of the meetings and in individual consultations. This is where the healthiest patients are selected to ensure that there are fewer complications and less recovery time (in order to save money). Several participants knew that this was an issue that had arisen in other countries and recognised the potential for this to occur in Ontario. ‘Will need to watch for “cherry picking” and choosing those patients who will have good outcomes will be selected’. ‘Obliged to treat the healthiest of that category because you’ll get more funding and that’s counterintuitive to pushing those patients out in the community. I want to bring those patients in’. One significant barrier to managing the change was the impact on human resources. This was due to the amount and types of data that need to be collected and analysed. Some hospitals were advantaged in this area and had strong pre-existing data support teams. However, smaller hospitals indicated that they did not have the same level of support and worried about the impact of future QBPs on the amount of work they would present for the decision support team. ‘We’re lucky to have a great decision support team, excellent team, but at some point they’re 54
going to break, we have to hire more people as we get hundreds of QBPs’. A final area of concern that the participants identified was the issue of case costing. Once again, the leaders felt they had received little information about case costing and were finding it difficult to engage in this activity without having current costs available to them. ‘We’ve had difficulty costing out services; we have a sense, but costing, we don’t know exactly what things cost’. Several participants talked about the burden of case costing to them as an organisation: ‘Case costing is a huge part of this and few hospitals are on case costing, so the case costing hospitals are at a huge advantage and we don’t have the dollars to get into case costing anymore. We’re going to be forced to do it and it’s going to take dollars out of our bottom line’. One of the challenges with case costing was identified as trying to be cost effective without negatively impacting the quality of care. One participant summed up the challenge this way: ‘We have worked with case costing in depth: the challenge is to find more savings without compromising outcomes. At the end of the day, decisions need to be made based on each patient’. There was a general sense that case costing data were not accurate at all facilities. One participant suggested that there needed to be a standardised approach to understand costs. In the meantime, the participants noted that it will be important to examine how data are gathered at various hospitals and how they are reported. Participants also talked about the need for a mechanism to absorb additional costs that are not covered by case costing.
Discussion The findings provide a set of early responses from health-care leaders and identify key barriers, benefits and concerns related to the implementation of QBPs in orthopaedic care. From the data, we know that if leaders believe in the mission and vision, they will remain supportive of an initiative, such as funding reform, even if the mechanisms for implementing the proposed change are not well understood. In this case, participants believed that PBF was a better option ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
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than global funding to promote efficiency within the health-care system. They also believed that PBF had the potential to benefit patients. This finding is consistent with earlier studies including the work conducted by Quaye (2001) who interviewed 28 health-care leaders in Sweden 7 years after the implementation of the diagnostic related groups system (one form of patientbased funding). Findings from that qualitative study suggested that 90% of respondents were supportive of similar funding reforms believing that funding reform had led to increased productivity and efficiency in their hospitals. Other studies have also discussed the importance of a commitment to quality improvement as being a prerequisite for implementing funding reforms such as PBF (Conrad et al. 2006, Goldman et al. 2007, Sautter et al. 2007, Mannion & Davies 2008, Sussex & Farrar 2009). From this study, it is evident that several prerequisites are required to lead this type of organisational change, the first being knowledge. To achieve an effective and efficient transition, a clear understanding of ‘what’ the shift will look like and require from leaders and staff, ‘how’ the shift is to occur, and ‘who’ and ‘what’ resources are essential. It is clear that strong leadership is required, and that those in leadership need to be engaged early in the process for two reasons: (1) to ensure that the change is appropriate and able to meet the needs of the community, the care providers and administrators and (2) to ensure buy-in across the organisation (Ridder et al. 2007, Sautter et al. 2007). Those in leadership must have a positive attitude about the potential of the funding reform to bring about positive changes for patients. This finding is supported by several studies (Conrad et al. 2006, Ridder et al. 2007, Mannion & Davies 2008, Durkin et al. 2010, Wharam et al. 2011). Each found the need for a positive attitude when faced with implementing new funding reforms into health-care organisations. Some authors in this area suggest that it is not enough for the leaders to be positive, but that the institution must also be accepting of funding approach changes (Conrad et al. 2006, Mannion & Davies 2008) and that there must also be a longstanding commitment to quality improvement and wide-spread staff support to promote long-term adoption (Goldman et al. 2007). In order to lead change leaders require clear, concise and consistent communication through one consistent pathway to avoid unnecessary confusion regarding the implementation process and so that they, in turn, can garner support for the initiative from others within the organisation. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
Leaders must be engaged early in the development of funding reform in order to (a) understand the reforms and (b) understand ‘how’ to effectively promote change in their organisations. This finding is consistent with those of Goldman et al. (2007) and Wharam et al. (2011), who indicated the importance of physician buy-in when implementing funding reform in hospitals. In his study of P4P (pay-forperformance) implementation in Safety Net Hospitals in California, Wharam and colleagues interviewed hospital executives and reported that physician buy-in was difficult to gain, but crucial for optimal P4P development and that physician input ensured greater validity for quality measures (Wharam et al. 2011). Managing the significant change initiatives associated with funding reform is not a simple task and requires that leaders be prepared, knowledgeable and committed. It also requires leaders to think ahead, anticipate unintended consequences and build in strategies to overcome them during the initial implementation. Various unintended consequences have been described by health-care leaders in England (Mannion & Davies 2008, Mannion et al. 2008), the United States (Bull 1988, Conrad et al. 2006, Goldman et al. 2007, Sautter et al. 2007, Durkin et al. 2010, Natale 2011) and Sweden (Quaye 2001). Leaders in the current study described ‘cherry picking’ as a potential unintended consequence. Mannion and Davies also noted the potential for health-care leaders to engage in ‘cherry picking’. Other unintended consequences have been described as concealment and escape tactics (Conrad et al. 2006, Durkin et al. 2010), opportunistic behaviour, gaming (Mannion & Davies 2008), patients discharged sooner and quicker, stress on families (Bull), and unplanned readmissions to hospital (Mannion et al. 2008). To date, no literature could be found that suggested strategies to avoid these unintended outcomes in organisations where funding was tied to the patient. Managing the change requires accurate and reliable data to inform decision making and to ensure accurate case costing. In particular, three factors represent significant case costing challenges for leaders when implementing QBPs. These are: (1) the lack of human resources to collect and analyse the data, (2) the lack of available and accurate pricing for supplies and services and (3) the lack of consistency within the organisation, department, hospital unit and individual health-care providers. While PBF is being implemented following 30 years of international experience, its implementation is also occurring at a time when those countries are shifting toward more integrated models of health-care funding 55
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that incorporate the health-care system as a whole, rather than simply the funding of hospitals (British Columbia Medical Association 2010, Health Policy Solutions 2011, Blumenthal & Dixon 2012, Cohen et al. 2012, Victoria Department of Health 2013). The United States (diagnostic related groups), Australia (activity-based funding) and England (activity-based funding) have experienced challenges with similar funding models including: limited evidence of increases in quality of care, risk selection, early discharge, and increases in administrative costs, and financial pressures (Ettelt et al. 2006, Thompson 2006, Street & Maynard 2007, British Columbia Medical Association 2010, Sutherland 2011, Blumenthal & Dixon 2012). These countries can provide Canada with valuable lessons regarding PBF, one of the most valuable being the need to combine global funding with patient-based funding (Collier 2008b). Such an approach may address the aforementioned challenges. Although conducted in Ontario, Canada, this study provides new findings that should be considered by international leaders as they continue to experience changes in funding reform. That is, it is important to consider the identified barriers and challenges when responding to, leading and managing funding reform approaches, such as the implementation of QBPs.
Limitations As with all studies, this study recognises two key limitations. First, the use of focus groups rather than oneon-one interviews may have discouraged some leaders from expressing their unique or conflicting viewpoints regarding the implementation process. Second, individuals from various strata in the organisational chart were sitting together to discuss the issue of QBP implementation. This fact may have been intimidating and may have resulted in undisclosed perspectives. The PI informed all participants that if they wanted to add information or if they had something additional to share that was not captured they could contact the PI directly, but no one followed up.
Conclusion Leaders’ early responses to the implementation of QBPs in orthopaedic care reveal a general commitment to see system changes that benefit the health-care system, organisation, patient and health-care provider. However, leaders in Canada are currently faced with several challenges when implementing orthopaedic QBPs and these include; a lack of adequate involvement in 56
planning; a lack of communication with those responsible for implementing the change at a broader system level; and an inadequate infrastructure in smaller community hospitals. Health-care leaders are concerned about the complexity of the funding shift and its impact on the quality of care, data management and case costing. Similar issues surrounding funding reform have been identified in other countries and have forced them to reconsider how they fund patient activity. The hospitals included in this study included large teaching hospitals with significant numbers of resources. It is important to explore the experiences of leaders in ‘less affluent’ hospitals and those providing care in remote and rural settings. Further research is needed to continue to explore health-care leaders’ responses to health-care funding reform across Ontario, Canada, and globally and to share strategies for effective implementation.
Implications for nursing management Nursing management can play a key role in developing effective QBP implementation plans and in building strong, effective implementation teams that are collaborative, innovative and productive. However, it is important that those in nursing management positions be involved early in the planning process, making every effort to be involved in the steering committee. Those chosen to lead implementation teams must be committed positive leaders who have a firm understanding of the goals associated with QBP implementation and knowledge of its potential to benefit patients, the health-care team and the organisation. Those responsible for implementation need to clearly understand their role in the implementation process and to know what resources they have available to support their implementation efforts. In addition, leaders need to anticipate potential unintended consequences and to develop policies early in the adoption process to thwart them. Developing effective communication pathways prior to implementation (both horizontal and vertical) will promote team collaboration, effectiveness and efficiency. With strong, committed leaders, the positive outcomes associated with QBP implementation can be realised.
Source of funding This work was supported by the University of Ottawa [grant number 06551] and the Canadian Institutes of Health Research [grant number, 126835]. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
Health care leaders responses to quality-based procedures
Ethical approval McMaster University Ethics Board (#13-585).
References Blumenthal D. & Dixon J. (2012) Health-care reforms in the USA and England: areas for useful learning. The Lancet 380 (9850), 1352–1357. British Columbia Medical Association (2010) Valuing quality: patient-focused funding in British Columbia. Available at: http://www.cihi.ca/CIHI-ext-portal/pdf/internet/patient_focused_ funding_en, accessed 10 February 2014. Bull M.J. (1988) Influence of diagnosis-related groups on discharge planning, professional practice, and patient care. Journal of Professional Nursing 4, 415–21. Busse R., Geissler A. & Quentin W. (2011) Diagnosis-related groups in Europe moving towards transparency, efficiency and quality in hospitals. Available at: http://eurodrg.projects. tuberlin.de/publications/1_EuroDRG_FC_Busse_Berlin171111. pdf, accessed 23 November 2013. Cohen M., McGregor M.I., Ivanova I. & Kinkaid C. (2012) Beyond the Hospital Walls: Activity Based Funding Versus Integrated Health Care Reform. Canadian Centre for Policy Alternatives, Vancouver, BC. Available at: http://www.policyalternatives.ca/sites/default/files/uploads/publications/BC%20O ffice/2012/01/CCPA-BC_ABF_2012.pdf, accessed 23 November 2013. Collier R. (2008a) News: patient-based funding model endorsed. Canadian Medical Association Journal 179 (6), 522. Collier R. (2008b) Activity-based hospital funding: boon or boondoggle? Canadian Medical Association Journal 178 (11), 1407–1408. Conrad D.A., Saver B.G., Court B. & Heath S. (2006) Paying physicians for quality: evidence and themes from the field. Joint Commission Journal on Quality and Patient Safety 32 (8), 443–451. Cormack D. (2000) The Research Process in Nursing, 4th edn. Wiley, San Francisco, CA. Cummings G., Lee H., MacGregor T. et al. (2008) Factors contributing to nursing leadership: a systematic review. Journal of Health Services Research and Policy 13, 240–248. Durkin E.M., Deutsch A. & Heinemann A.W. (2010) Inpatient rehabilitation facilities: variation in organizational practice in response to prospective payment. Medical Care Research and Review 67 (2), 149–172. Ettelt S., Thompson S., Nolte E. & Mays N. (2006) Reimbursing highly specialised hospital services: the experience of activity-based funding in eight countries. A report commissioned by the Department of Health. London School of Hygiene and Tropical Medicine 35, 1–2. Farrar S., Yi D., Sutton M., Chalkley M., Sussex J. & Scott A. (2009) Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis British Medical Journal 339, 3047e. Goldman L.E., Henderson S., Dohan D.P., Talavera J.A. & Dudley R.A. (2007) Public reporting and pay-for-performance: safety-net hospital executives’ concerns and policy suggestions. Inquiry 44, 137–145. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 50–58
Harber B. & Ball T. (2003) From the blame game to accountability in health. Policy Options 24 (10), 49–54. Health Policy Solutions (2011) Activity-based funding for Australian public hospitals: towards a pricing framework. Available at: http://www.ihpa.gov.au/internet/ihpa/publishing.nsf/Content/EB8EFD07DF85BC70CA25798300033BE1/$File/IHPA% 20Draft%20Pricing%20Framework_long%20 version.pdf, accessed 26 March 2014. Letts L., Wilkins S., Law M., Stewart D., Bosch J. & Westmorland M. (2007) Critical Review Form – Qualitative Studies (Version 2.0). Available at: http://.srs-mcmaster.ca/Portals/20/ pdf/qualreview_version2.0pdf, accessed 10 June 2013. Lukas C.V., Holmes S.K., Cohen A.B. et al. (2007) Transformational change in health care systems: an organizational model. Health Care Management Review 32 (4), 309–320. Mannion R. & Davies H.T. (2008) Payment for performance in health care. British Medical Journal 336 (7639), 306– 308. Mannion R., Marini G. & Street A. (2008) Implementing payment by results in the English NHS. Journal of Health Organization and Management 22 (1), 79–88. Ministry of Health and Long-Term Care (2012) Health system funding reform. Patient-based funding overview. Available at: http://health.gov.on.ca/en/pro/programs/ecfa/default.aspx/docs/ ecfa_funding_pres.pdf, accessed 10 February 2014. Natale J.E., Joseph J.G., Honomichl R.D., Bazanni L.G., Kagawa K.J. & Marcin J.P. (2011) Benchmarking, public reporting, and pay-for-performance: A mixed-methods survey of California pediatric intensive care unit medical directors. Pediatric Critical Care Medicine 12, e225–e32. Neuendorf K.A. (2002) The Content Analysis Guidebook. Sage Publications, Thousand Oaks, CA. Newland J. (2005) Leadership task force report: a joint project of The Canadian College of Health Service Executives, The Academy of Executive Nurses, The Canadian Society of Physician Executives, and Human Resources Skills Development Canada. Available at: www.cchse.org, accessed 6 December 2013. O’Reilly J., Busse R., Hakkinen U., Or Z., Street A. & Wiley M. (2012) Paying for hospital care: the experience with implementing activity-based funding in five European countries. Health Economics, Policy and Law 7, 73–101. Quaye R. (2001) Professional integrity in the age of managed care: views of physicians. International Journal of Health Care Quality Assurance 14 (2), 82–86. Ridder H., Doege V. & Martini S. (2007) Differences in the implementation of diagnosis-related groups across clinical departments: a German hospital case study. Health Services Research 42 (6), 2120–2139. Sandelowski M. (2010) What’s in a name? Qualitative description revisited. Research in Nursing and Health 33 (1), 77–84. Sautter K.M., Bokhour B.G., White B. et al. (2007) The early experience of a hospital-based pay-for-performance program. Journal of Healthcare Management 52 (5), 95–107. Schrey€ ogg J., Tiemann O. & Busse R. (2006) Cost accounting to determine prices: how well do prices reflect costs in the German DRG-system? Health Care Management Science 9 (3), 269–279. Sharma A. (2009) Inter-DRG resource dynamics in a prospective payment system: a stochastic kernel approach. Health Care Management Science 12 (1), 38–55.
57
P. Baxter et al.
Stewart M. (2012) Quality Based Procedures. Paper Presented at the Ontario Health Information Management Association Meeting, 4 October 2012. Ministry of Health and Long-Term Care, Toronto, ON. Street A. & Maynard A. (2007) Activity based financing in England: the need for continual refinement of payment by results. Health Economics, Policy and Law 2 (4), 419–427. Street A., Vitikainen K., Bjorvatn A. & Hvenegaard A. (2007) Introducing activity-based financing: a review of experience in Australia, Denmark, Norway and Sweden Centre for Health Economics, Research Paper 30. Available at: http://www.york.ac.uk/che/pdf/rp30.pdf, accessed 10 April 2014. Sussex J. & Farrar S. (2009) Activity-based funding for National Health Service hospitals in England: managers’ experience and expectations. European Journal of Health Economics 10 (2), 197–206. Sutherland J.M. (2011) Hospital payment mechanisms: an overview and options for Canada. Available at: www.chsrf.ca, accessed 26 November 2013.
58
Sutherland J., Liu G., Crump T. & Repin N. (2013) Hospital Funding Policies: Where are We on Hip and Knee Replacements? Study Data Bulletin #4. UBC Centre for Health Services and Policy Research, Vancouver, BC. Thompson D. (2006) EHR value: don’t expect what you don’t plan for. Healthcare Financial Management 60 (12), 58–62. Thorne S. (2008) Interpretive Description, 2nd edn. Left Coast Press, Walnut Creek, CA. Victoria Department of Health (2013) Activity-based funding. Available at: http://health.vic.gov.au/, accessed 10 November 2013. Wharam J.F., Frank M.B., Rosland A.M. et al. (2011) ‘Payfor-performance’ as a quality improvement tool: perceptions and policy recommendations of physicians and program leaders. Quality and Management in Health Care 20 (3), 234–245.
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