1. MUHC Clinical Activity Priority Setting A4R and Beyond ISPHC Priorities 2010 April 24, 2010 Dr Tim Meagher MUHC, Associate Director General Medical Affairs Centre universitaire de santé McGill McGill University Health Centre

2. Created in 1997, the MUHC is the first and largest voluntary merger of teaching hospitals in Canadian history. The Montreal General Hospital The Royal Victoria Hospital The Montreal Children’s Hospital The Montreal Chest Institute The Lachine Hospital The Montreal Neurological Hospital Founded 1822 1893 1903 1913 1934 General Royal Vic Lachine Neuro Chest Children’s

3. MUHC Clinical Activity Priority Setting - context  $2.2 Billion Redevelopment Project :  More complex care, health network leadership mandate  Lachine General Hospital became 6th partner in 2008  HINI  PPP preferred bidder selection MUHC Medical Affairs Directorate – 2010

4. MUHC Clinical Activity Priority Setting - why are we doing this exercise?  Budget  Redevelopment Project  Network Orientation MUHC Medical Affairs Directorate – 2010

5. The McGill RUIS This network of partners assures a broad scope of specialized and ultra- specialized services to 1.7 million people spread across 63% of Quebec’s territory, namely 953,000 km 2. Nunavik 10 497 Terres-Cries-de-la-Baie- James 29 117 Abitibi-Témiscamingue 142 974 Outaouais 345 464 Montréal Centre et Ouest 843 150 Montérégie Ouest 383 658 Faculté de médecine, Université McGill Centre universitaire de santé McGill CH St. Mary Sir Mortimer B. Davis Hôpital général juif Institut Douglas CSSS de la Montagne CSSS Cavendish CSSS du Sud-Ouest-Verdun CSSS de Dorval-Lachine-Lasalle CSSS de l’Ouest-de-l’Ile CSSS du Pontiac CSSS de la Vallée-de-la-Gatineau CSSS des Collines CSSS de Gatineau CSSS de Papineau CSSS du Lac-Témiscamingue CSSS des Aurores-Boréales CSSS Les Eskers de l’Abitibi CSSS de Rouyn-Noranda CSSS de la Vallée-de-l’Or CSSS de Témiscaming-et-de-Kipawa CSSS du Suroît CSSS Jardins-Roussillon CSSS Vaudreuil-Soulanges CSSS du Haut-Saint-Laurent Centre régional de santé et de services sociaux de la Baie-James Centre de santé Inuulitsivik Centre de santé Tulattavik de l’ungava Conseil Cri de la santé et des services sociaux de la Baie-James MUHC Medical Affairs Directorate – 2010

6.  To foster excellence.  To better position the MUHC within the network of healthcare institutions.  To align decision-making processes at all levels of the organization.  To foster culture of fair decision-making, grounded in Accountability for Reasonableness (Daniels, Sabin 2002) MUHC Medical Affairs Directorate – 2010 MUHC Clinical Activity Priority Setting - what is the goal?

7. 5. Work Book Evaluation 1. CAPS Framework 2. Evaluation Criteria 3. Work Book (Beta test) 4. Work Book Submission Period 6. Preliminary & Revisions Process Timeframe June 2009- June 2010 Process Steps # 1-# 7 June-Sept 2009Oct 2009Oct-Dec 2009Jan-Mar 2010 (8 weeks) Mar-Apr 2010June 2010 MUHC Clinical Activity Priority Setting (CAPS) Where are we today? May 2010 7. Final List Priorities We are here! StartFinish MUHC Medical Affairs Directorate – 2010

8.  Conceptual Framework  Criteria Development  CAPS Work Book  Preliminary Observations  Lessons Learned  Next Steps MUHC Medical Affairs Directorate – 2010 MUHC Clinical Activity Priority Setting

9. Conceptual Framework – (Sibbald et al 2009) process elements  Stakeholder engagement (Get the right people involved)  Explicit Process (Make the process clear)  Information Management (Use the right data)  Consideration of Values and Context (Explicitly identify values relevant to MUHC)  RUIS, local network of hospitals, CSSS’s  Revision mechanism (Allow opportunity for review) MUHC Medical Affairs Directorate – 2010

10. Conceptual Framework – (Sibbald et al 2009) outcome elements  Improved stakeholder understanding (Everyone understands why we’re doing this)  Shifted priorities and resources (Resources must follow)  Improved decision making quality (Decisions get better over time)  Stakeholder acceptance (Everyone accepts the decisions)  Positive externalities (Outsiders think you got it right!) MUHC Medical Affairs Directorate – 2010

11. MUHC Clinical Activity Priority Setting  Conceptual Framework  Criteria Development  CAPS Work Book  Preliminary Observations  Lessons Learned  Next Steps

12. MUHC Proposal AHC Criteria Examples Strategic Fit :Extent to which a clinical activity contributes to advancing the strategic directions of the organization. Academic commitments: Education = The role the clinical activity plays in educating future health Professionals. Research = The role the clinical activity plays in establishing and/or using best practices, generating new medical knowledge or developing and/or applying technological innovation. Alignment with external directives = Extent to which a clinical activity is limited by government mandates (e.g. protected programs), and/or contributes to achieving regional or provincial health services objectives. Community Needs= Extent to which the clinical activity and volumes are consistent with health needs of a defined community (or catchments area), including present and future demands. Partnerships (external) = Extent to which the clinical activity works in partnership with other organizations to coordinate the delivery of care to a defined population. Interdependences (internal) = Extent to which the clinical activity coordinates and collaborates with other clinical activities within the organization to enhance quality or optimize resource use. Clinical Impact = Extent to which the clinical activity volumes are sufficient to ensure: - clinical competency - patient safety - effective care Consideration given to the uniqueness of the activity in the local/regional area and to the quality of services provided. Resource Implications = Extent to which the resource context for health services delivery has implications for degrees of freedom in relation to Prioritization. 1.Strategic Fit Positions, or has the potential to position, the MUHC as one of the world’s foremost academic health centres. 2.Academic Health Centre - Teaching Of particular interest is how excellence in teaching supports and relates (e.g. is dependant on, improves) to clinical activity. 3.Academic Health Centre – Research Of particular interest is how the research component supports (e.g. is dependant on, improves) the clinical activity. 4.Health Care Context/Positioning Provides details as to how the clinical activity positions the MUHC as a leader in providing tertiary-quaternary level care within the McGill network of hospitals. It compares clinical activity to other institutions inside and outside the McGill RUIS and describes the extent to which collaborative relationships have developed. It also highlights the regional or provincial designations conferred by the MSSS. 5.Integrated Complex Care The extent to which the clinical activity involves complex care delivery such a interdependent care (Transitions from Paediatrics to Adult), cross-discipline care (cardiac sciences), and inter-professional collaborations (physician, nurse, allied health). 6.Clinical Impact The extent to which this activity is consistent with health care needs (incl. present and future demand) of the community. This includes assessment of the patient volumes (by level of complexity), trends, and innovative care delivery models. Information on the extent to which the clinical activity volumes are sufficient to ensure clinical competence, effectiveness, and safety, if available, should also be provided. 7.Sustainability The extent to which the types of resources used are able to support the current and future development of the clinical activity without compromising others. This includes details such as budget allocations (operating & fundraising), and human resource requirements. MUHC Clinical Activity Priority Setting - criteria development

13. Criterion 1: Strategic Fit Criterion 2: Clinical Impact (needs & trends) Criterion 3: Academic Health Centre – Teaching Criterion 4: Academic Health Centre – Research Criterion 5: Health Care Context – Positioning (leadership & partnership) Criterion 6: Integrated Complex Care Criterion 7: Sustainability MUHC Medical Affairs Directorate – 2010 MUHC Clinical Activity Priority Setting - evaluation criteria

14. MUHC Medical Affairs Directorate – 2010 MUHC Clinical Activity Priority Setting  Conceptual Framework  Criteria Development  CAPS Work Book  Preliminary Observations  Lessons Learned  Next Steps

15.  A self-evaluation tool to evaluate clinical activities based on the 7 criteria.  A series of questions to answer with supporting data.  Scoring of each equally-weighted criterion: 1-3 = low (poor, marginal, fair) 4-6 = moderate (satisfactory, good, very good) 7-9 = high (excellent, outstanding, exceptional)  Clinical teams identify activities to prioritize, increase network collaboration or to divest. MUHC Clinical Activity Priority Setting - work book MUHC Medical Affairs Directorate – 2010

16. MUHC Intranet English http://www.intranet.muhc.mcgill.ca/CAPS/index.html French http://www.intranet.muhc.mcgill.ca/CAPS/index_fr.html MUHC Medical Affairs Directorate – 2010 MUHC Clinical Activity Priority Setting - access to supporting information

17. MUHC Medical Affairs Directorate – 2009 MUHC CAPS Submission/Evaluation Process Preliminary Priorities Work Book Completion SDC Revision Period May 2010 Preliminary Priorities May 2010 Work Book Submission Jan – Mar 2010 Final List of Priorities June 2010 MUHC Priorities 7 Missions CEO Submission Evaluation Mar-Apr 2010 Revision Submissions - SDC review Board Other Stakeholder Groups SDC CLINICAL TEAMS Work Book Submission Criteria & Work Book Development CLINICAL TEAMS Additional Information for SDC consideration Work Book & Data Tool Box MUHC Intranet MUHC Medical Affairs Directorate – 2010

18. MUHC Clinical Activity Priority Setting - work book submission 86 Work Books received:  81 departments or divisions, and 5 ‘core’ clinical support areas (e.g. ER, Pharmacy)  166 separate clinical activities evaluated  Average 60 pages (range 40 to 270), excluding annexes and supporting documents MUHC Medical Affairs Directorate – 2010

19. MUHC Clinical Activity Priority Setting  Conceptual Framework  Criteria Development  CAPS Work Book  Preliminary Observations  Lessons Learned  Next Steps

20. MUHC Clinical Activity Priority Setting - preliminary observations MUHC Themes  Complex / specialised medical care  Transition care across the life span  Innovation focused around the patient  Knowledge transfer to the community  Elderly-aware hospital MUHC Medical Affairs Directorate – 2010

21. Conditions for Success  Accountability culture at all levels of the organization  System wide performance and quality measurement  Coordination of clinical activities between the McGill teaching hospitals.  Evaluate impact prior to accepting mandates or programs MUHC Clinical Activity Priority Setting - preliminary observations

22. MUHC Medical Affairs Directorate – 2010 MUHC Clinical Activity Priority Setting  Conceptual Framework  Criteria Development  CAPS Work Book  Preliminary Priorities  Lessons Learned  Next Steps

23. MUHC Medical Affairs Directorate – 2010 MUHC Clinical Activity Priority Setting - lessons learned After...  10 months of planning and roll-out  2 Town Halls  standing agenda item on 12 committees  67 internal & 10 external presentations  4600 intranet hits  many phone calls, emails, and hand holding later... What have we learned?

24. MUHC Medical Affairs Directorate – 2010 MUHC Clinical Activity Priority Setting - lessons learned  This is not for the faint of heart  ‘Off-the-rack’ models are not available.  ‘Lean’ approach has pros and cons  Communications - no matter how well you think you’ve done……………

25. MUHC Medical Affairs Directorate – 2010 MUHC Clinical Activity Priority Setting - lessons learned, contd.,  Timeline - stick to the schedule!  Clinical ‘Priority’ is a problematic term:  Better to identify activities to ‘grow’ or ‘maintain at current levels’- both may still be ‘priorities’  Unintended positive results:  Capitalizing on CAPS for local strategic planning  Snapshot of all clinical activity - many different uses  Importance of data

26. MUHC Medical Affairs Directorate – 2010 MUHC Clinical Activity Priority Setting  Conceptual Framework  Criteria Development  CAPS Work Book  Preliminary Priorities  Lessons Learned  Next Steps

27. MUHC Clinical Activity Priority Setting implementation  Resources must follow clinical choices:  $$: revisit traditional budgets  HR  Space  Equipment  Infrastructure (IS, telecom, logistics...) MUHC Medical Affairs Directorate – 2010

28. Thank you! MUHC Clinical Activity Priority Setting MUHC Medical Affairs Directorate – 2010