1. Primary health care performance measurement initiatives across three Canadian provinces
Martin-Misener, R., Johnston, S., Burge, F., Blackman, S., Scott, C., Wong, S. T.
Contact:
Background
Knowledge about performance has been shown to impact primary health care (PHC) system functioning and is a key PHC strategy. Cross-provincial comparisons can help to illuminate the spread and uptake of mechanisms which inform and promote system performance. PHC performance measurement (PM) can be used as a mechanism for quality control (e.g. accountability, citizen/patient engagement, etc.) and can drive QI.
Objective: To compare general trends in performance measurement (PM) strategies in three Canadian provinces.
Methods
Design: Multiple comparative embedded case study.
Setting: Cases are three comparable health regions: Fraser East, BC; Eastern Ontario Health Unit, ON; Central Zone, NS.
Data sources: (Table 1)
Published and grey literature discussing innovations implemented in PHC settings over a 10-year period
In-depth interviews with purposively selected key informants (e.g. PHC decision-makers, physicians leads, regulatory agencies)
Focus groups with purposively selected patients and clinicians
Analysis: NVivo (v. 11) was used to manage and perform content analysis to identify themes within and across cases. The coding structure was developed by researchers through iterative collaboration, using inductive and deductive processes.
Results
National / multi-provincial initiatives (e.g. CIHI) measure PHC performance in all three provinces.
We found variance in provincial actions taken to develop PM and reporting infrastructure (Tables 2 & 3).
In BC, this is driven mostly through engagement in creating QI infrastructure and support for providers and practices.
ON’s overall framework, as well as provincial initiatives such as a patient survey, provider performance reports shared quarterly on administrative data measures, and annual performance reports (e.g report on primary care, 2017 report on overall system). This approach is serving accountability, public engagement, and QI.
NS built an overall framework and has focused on facilitating the use of performance data to improve practice but has put less focus on efforts to measure and supply data.
Conclusions
All three provinces are conceptualizing or have created performance frameworks. ON is the furthest along in developing performance measurement and reporting infrastructures.
Acknowledgements
This work is funded by:
A comparative case study
Table 1. Number of data sources coded to PM node
Table 2. Illustrative quotes
BC interview participant
“We also don’t have in BC an external body that – If you look at Canada, you have CIHI, you have… for one. These groups that are really focus on looking at the evaluation outcomes. We don’t really do that in BC particularly well. We don’t really have one group.”
ON interview participant
“And then there’s the evidence-based medicine, or evidence-based policy drivers which I argue that by publicly reporting on this data, it might actually improve the quality of care and that’s the reason to do it.”
NS interview participant
“Beyond that, as I say, the vast majority of primary care providers in Central Region, urban particularly, are family physicians.  And there is no mandated performance reporting except for through administrative billing requirements.”
Published & grey literature
Decision maker & clinician interviews
Patient & clinician focus groups
Total 34 21 2
British Columbia 17 6 1
Ontario 12 7
Nova Scotia 5 8
Table 3. Examples of PHC performance initiatives in each region
Fraser East, British Columbia
Eastern Ontario Health Unit (EOHU), Ontario
Central Zone, Nova Scotia
The Joint Standing Committee on Rural Issues (2001) oversees a number of programs to enhance rural practice and support rural providers.   
The GPSC hosted ( ) the Professional Quality Improvement Days in order to hear from ~1000 FPs about the issues facing family practice in the province. A similar process occurred for the 2015 Visioning consultations with FPs to hear their thoughts on the future of primary care.
The Practice Support Program (PSP), initiated in 2007, offers learning modules to support FPs and their team members.
The Excellent Care for All Act (2010) pushed forward the agenda of quality improvement. This initiative led to the collapse of several provincial QI initiatives (e.g. OHQC, QIIP) into a single organization, Health Quality Ontario (HQO). The HQO oversees multiple initiatives in the province:
A Primary Care Performance Measurement Framework for Ontario report outlines 9 priority primary care domains with respective measurement priorities and measures at the practice and system levels. In Quality in primary care: Setting a foundation for monitoring and reporting in Ontario, HQO reports about performance related to access, service provision, and coordination.
The Primary Care Quality Advisory Committee supports provincial QI in primary care
Regional Quality Tables focus on regional QI in alignment with the provincial QI agenda
eLearning modules offer courses for primary care (e.g. advanced access and efficiency training)
Quality Improvement Plans, a requirement for healthcare organizations, involve reporting on predefined metrics for performance
The report, A Primary Health Care Evaluation System for Nova Scotia, (2006) focused on a provincial PHC evaluation framework, building a logic model and evaluation tools.
The Quality Framework Dashboard (2008) encompasses performance indicators, and data collection tools include measures on Accreditation Canada performance domains.
As part of the Quality in Practice initiative, the Practice Facilitator Framework introduces a practice facilitator to work with family physician practices on practice-level QI initiatives.
MEASURING AND IMPROVING THE PERFORMANCE OF PRIMARY HEALTH CARE IN CANADA