2014-17 Multi-Sector Service Accountability Agreement (M-SAA) An Overview

2014-17 Multi-Sector Service Accountability Agreement (M-SAA)An Overview Presentation to Health Service Providers January 10, 2014

2014-17 M-SAA An Overview • Development and Preparation of the M-SAA • Template Agreement Components • Schedules • Indicators • Next Steps • Questions

What is an M-SAA?Core lever for HSP accountability and performance management • A tool to bring all the various contractual agreements between community HSPs and the LHINs into one document • Required under LHSIA and Ministry-LHIN Performance Agreement (MLPA) • A vehicle to delineate accountabilities and performance expectations • A mechanism to clarify that the HSP will be responsible for performance as well as planning and integration towards the development of a health system

Pan-LHIN Development, Local ExecutionDeveloping provincial templates for local execution • Consistent template agreement for all community sector HSPs developed through comprehensive consultation with HSP associations and member representatives (membership listed in Appendix 1) • Schedules for each sub-sector (CCAC, CHC, MH&A and CSS) developed through consultation with sub-sectors • Individual LHINs negotiate performance indicator targets with each HSP in alignment with pan-LHIN guidelines

M-SAA Development PrinciplesEnabling close ongoing collaboration with the Community Sector • The M-SAA Advisory Committee is co-chaired by Louise Paquette and Scott McLeod and brings together senior executives from M-SAA sector associations, community HSPs and the LHINs to provide a central forum for enabling dialogue on provincial M-SAA issues • The Committee is guided by the following principles: • The process is undertaken with a spirit of trust and collaboration among the province’s community HSPs, sector associations and the LHINs. • The M-SAA will align with provincial health system priorities and be consistent with MOHLTC policy, legislation and regulations. • The M-SAA will strive to streamline processes, minimize administrative burden and provide clarity for HSPs where possible. • Committee membership is shown below

M-SAA StructureComprehensive Consultation through Multiple Tables M-SAA INDICATOR SUPPORT: HEALTH SYSTEM INDICATOR INITIATIVE M-SAA LEGAL COUNSEL SUPPORT: LHIN LEGAL SERVICES BRANCH M-SAA SECRETARIAT SUPPORT: LHIN COLLABORATIVE LOCAL M-SAA IMPLEMENTATION: LHIN M-SAA LEADS

M-SAA Advisory Committee Membership

M-SAA Advisory Committee Membership continued

LHIN/Sector ResponsibilitiesAdvisory Committee and Work Group Mandates M-SAA Advisory Committee • Established to provide advice to the LHIN CEOs and support for the completion of the 2014-17 M-SAA template agreement and schedules in alignment with provincial strategic directions. M-SAA Indicators Work Group • Established to support the M-SAA Advisory Committee. Based on direction from the LHIN CEOs, the Work Group is responsible for producing a series of documents and recommendations including a list of recommended M-SAA indicators, technical specifications, target setting guidelines and education materials. M-SAA Planning & Schedules Work Group • Established to support the M-SAA Advisory Committee. Based on direction from the LHIN CEOs, the Work Group is responsible for producing a series of documents and tools including M-SAA Schedules, CAPS forms and planning submission guide and educational documents.

LHIN/HSP Accountability RelationshipHow do the various CAPS/M-SAA components fit together?

LHIN/Sector ResponsibilitiesWhat are the responsibilities of the LHINs and the HSPs? LHINs are responsible for: • Training and supporting HSPs through the CAPS and M-SAA processes • Negotiating performance targets within the context of a provincial framework • Monitoring the achievement of specific performance goals under the M-SAA and ongoing performance management HSPs are responsible for: • Ensuring governance and operations that support high quality care • Promoting leading performance improvement approaches • Providing access to high quality health services and coordinated health care in an effective and efficient manner • Identifying integration opportunities and engaging the public and stakeholders in any planned service changes.

Process for Finalizing New M-SAAAt a high level, how was the M-SAA developed and finalized? • LHINs revised language in the 2011-14 M-SAA that required updating or would benefit from greater clarity as a draft 2014-17 M-SAA for sector feedback. • Three 3-hour M-SAA Advisory Committee meetings to review and discuss comments and suggestions on draft 2014-17 M-SAA. • 175 sector comments received and individually addressed. • Committee endorsed 2014-17 M-SAA and Schedules on December 17, 2013. • Pan-LHIN commitment to reduce, align and enhance consistency of local indicators. • Committee will continued to meet throughout the life of the agreement to advance M-SAA related priority issues.

M-SAA Content – Articles Article 1 Definitions & Interpretation Clarifies terminology used throughout the document. Article 2 Term and Nature of the Agreement Defines the term of the service accountability agreement as April 1, 2014 to March 31, 2017 . Article 3 Provision of Services Describes how services will be provided in accordance with legislation, applicable policies, e-health/IT compliance and the terms of this agreement. Discusses subcontracting services and conflict of interest. Article 4 Funding Outlines conditions of funding, payment and provision limitations. Procurement and disposition of goods and services are also described. Article 5 Repayment and Recovery of Funding Defines circumstances under which funding may be adjusted and/or recovered

M-SAA Content - Articles continued Article 6 Planning & Integration Discusses multi-year planning CAPS requirements in alignment with LHIN IHSP and priorities. Article 7 Performance Discusses the need for ongoing performance improvement and the mitigating process in the event of performance factors (non-performance). Article 8 Reporting, Accounting and Review Describes the obligations of reporting and record maintenance, French language requirements, disclosure of information, transparency and reviews. Article 9 Acknowledgement of LHIN Support HSP publications are required to note LHIN support, be approved by the LHIN, and indicate views do not necessarily reflect those of the LHIN or Government. Article 10 Representations, Warranties and Covenants Confirms the HSP’s ability to enter into the agreementand carry out the funded services with the appropriate governance, personnel and documentation.

M-SAA Content - Articles continued Article 11 Limitation of Liability, Indemnity & Insurance Outlines the limitation of liability and indemnification for the LHINs and the required insurance provisions for the HSP. Article 12 Termination of Agreement Describes the parameters for termination of the agreement by the LHIN and by the HSP. Article 13 Notice Details how notices to a party must be provided. Article 14Additional Provisions Identifies additional provisions to the agreement. Article 15Entire Agreement Defines the agreement as constituting the entire agreement, superseding all prior agreements.

M-SAA Content - Schedules

Summary of Main Changes - SchedulesWhat are the key changes between current and new Schedules?

Summary of Main Changes (continued)What are the key changes between current and new Schedules?

2014 – 17 M-SAA Indicators

Introducing the Indicators • Health System Indicator Initiative (HSII) • Schedule E Indicators • Performance Standards • Targets Setting • Indicator Work Group Focus and Approach • Summary of Indicators & Technical Specifications • Core Indicators • Community Health Centres (CHC) Indicators • Community Care Access Centres (CCAC) Indicators • Community Service Sector (CSS) Indicators • Mental Health & Addiction (MH&A) Indicators

Performance IndicatorsHealth System Indicators Initiative (HSII) • In April 2010, the LHIN-led HSII was established to create a coordinated, system-based approach to indicator identification, development, maintenance and reporting. • Central to the mandate of HSII is the close collaboration with provincial and national partners in order to leverage their organizational expertise related to indicator development, benchmarking, data extraction, and analysis. • The revised mandate introduced in September 2013 provides a greater focus on alignment to system priorities, advancing system performance improvement through the SAAs and other mechanisms, and enabling monitoring and reporting.

Performance Indicators (Schedule E)Pan-LHIN Performance Indicators and LHIN-Specific Obligations The Performance Schedule (Schedule E) contains the following two indicator sections: 1. Pan-LHIN Indicators are developed through the M-SAA Indicators Work Group through HSII (core indicators are relevant to all LHINs and all community sector HSPs; sector-specific indicators are only relevant to a specified sector). • Performance Indicators are measures of HSP performance for which a Performance Target is set; Technical specifications of specific Performance Indicators can be found in the “M-SAA 2014-17 Indicator Technical Specifications” document. • Explanatory Indicators are measures of HSP performance for which no Performance Target is set.Technical specifications of specific Explanatory Indicators can be found in the “M-SAA 2014-17 Indicator Technical Specifications” document. 2. LHIN-Specific Performance Obligations: A section where each LHIN adds specific performance objectives and obligations for their HSPs is included. LHINs are committed to minimizing any undue burden placed on providers with respect to performance management by focusing on a limited number of outcome indicators aligned with local priorities.

Performance IndicatorsWhy Performance Standards? • All performance indicators have an associated target and standard of performance. Variance outside of the standard triggers the performance management processes in Article 7 of the M-SAA. • The LHIN or the HSP can identify a Performance Factor that “…could or will significantly affect a party’s ability to fulfill its obligations under the Agreement.” • The identification of a Performance Factor is made formally, in writing, to the other party and will include a description of the Factor’s actual or anticipated impact and a description of any action the party is undertaking, or plans to undertake, to remedy or mitigate the Performance Factor.

Performance Indicators ContinuedHow are Indicator Targets and Corridors Determined? • Following the submission of the CAPS, LHINs and HSPs discuss indicator targets that are appropriate to each organization and its local circumstances. Targets are expected to reflect performance and drive continuous improvement. • To complete the targets and corridors for the performance indicators, the following principles will be employed: • Where provincial targets and corridors exist, the LHINs and HSPs will take these into consideration • Where appropriate, use past experience from M-SAA and MLPA indicators • Incorporate analyses of historical variation to inform corridor recommendations • Use % range for financial and volume indicators

Performance ManagementHow are Performance Factors Addressed? • How a LHIN chooses to deal with an indicator outside the corridor depends on a number of factors, including: • What is the realized and/or potential impact on the clients served? • Is this the first blip on an otherwise clean performance record? • Is this a unique event and unlikely to recur? • Are other areas of the organization or other HSPs affected? • What is the LHINs confidence in the HSPs ability to manage performance going ahead? • Depending on the above, the LHIN could choose to start with a less formal tact. The formal process is always available...and can be triggered at any point.

Indicator Work Group Focus & Approach • Review current indicators and develop recommendations to reduce the number of indicators • Develop recommendations regarding the definition and target setting approach for the administrative indicator calculation • Align existing indicators with pan-LHIN imperatives

Core (All Sectors)Performance Indicators • Balanced budget - Fund type 2 • Proportion of budget spent on administration • Variance forecast to actual expenses • Percentage total margin • Service activity by functional centre • Variance of forecasted to actual units of service • Number of individuals served • Percentage of Alternative Level of Care (ALC) days

Core (All Sectors)Explanatory Indicators • Cost per individual serviced by program/service/functional centre • Cost per unit of service by functional centre • Client experience (New Category) Details: • Moved from being only an explanatory indicator for the Mental Health and Addiction sector • Indicators Work Group identified need to enhance linkage with quality and patient experience for all sectors

Community Care Access CentresPerformance Indicators • Access 1: 90th Percentile Wait Time From Hospital Discharge to Service Initiation (Hospital Clients) • Access 2: 90thPercentile Wait time from Community Setting to Community Home Care Services • Percentage people registered with Health Care Connect who are referred (Retired) Details: • Reporting obligations are already in place with the Ministry

Community Care Access CentresExplanatory Indicators • Access: Wait time 1. 90th Percentile wait time from hospital discharge to service initiation (hospital clients) by population groups (short stay, short stay rehab, long-stay complex) • Access: Wait time 2. 90th percentile wait time from Community setting to community home care services by population groups (short stay acute, short stay rehab, long-stay complex) • Average monthly cost per episode (adult short stay, adult long-stay complex, end of life, children medically fragile) • Clients with MAPLe scores high and very high living in the community supported by CCAC (New Category) • Clients placed in LTCH with MAPLe scores high and very high as a proportion of total clients placed (New Category)

Community Care Access CentresNew Explanatory Indicators • Clients with MAPLe scores high and very high living in the community supported by CCAC • Clients placed in LTCH with MAPLe scores high and very high as a proportion of total clients placed Details: • Moved from CCAC performance indicator category • Indicators fit this category and provide valuable information about how the system is functioning and the opportunities for change • Indicators are not a good measure for performance as targets are set locally by each LHIN

Community Care Access CentresDevelopmental Indicators • Percentage of clients with a new or existing pressure ulcer that failed to improve (Retired) • Medication safety (Retired) • Percentage of home care clients who say they have fallen in the last 90 days (Retired) Details • Indicators retired as developmental • Indicators were not identified by HQO as on the Common Quality Agenda

Community Support ServicesExplanatory Indicator • Number of persons waiting for service (by functional centre)

Community Support ServicesDevelopmental Indicators • Average number of days waited for first service (by functional centre) (New Category) Details: • Moved from CSS Explanatory indicator category as the data is not yet available • Move to explanatory in years 2 or 3 • Repeat unscheduled emergency visits within 30 days for mental health conditions (Retired) • Repeat unscheduled emergency visits within 30 days for substance abuse conditions (Retired) Details: • Indicators are difficult to measure - cannot follow clients between the hospital and the community

Community Health Centres Performance Indicators • Cervical cancer screening • Colorectal Screening rate • Inter-professional diabetes care rate • Influenza vaccination rate • Breast cancer screening rate • Periodic health exam • Vacancy Rate (for NPs and Physicians) • Access to primary care clinical service (New) • Individuals served by functional centre (Retired) Details: • Already a Core indicator

Community Health Centres Explanatory Indicators • Emergency visits best managed elsewhere (New) • Client satisfaction – Access (New) • Clinical support staff per primary care provider (New) • Cultural interpretation (New) • Exam rooms per primary care provider (New) • New grads/new staff (New) • Number of new patients (New) • Non-Primary Care activities (New)

Community Health Centres Explanatory Indicators Cont’d • Number of registered clients (New) • Specialized care (New) • Supervision of students (New) • Third next available appointment (New) • Non-insured clients (New) • Repeat unscheduled emergency visits within 30 days for mental health conditions (Retired) • Repeat unscheduled emergency visits within 30 days for substance abuse conditions (Retired) Details: • Data is a challenge as the cell size is small

Community Health Centres Developmental Indicator • CHC clients hospitalized for Ambulatory Care sensitive conditions

Community Mental Health & AddictionExplanatory Indicators • Number of days waited from referral/application to initial assessment complete • Average number of days waited from initial assessment complete to service initiation • Repeat unscheduled emergency visits within 30 days for mental health conditions (New Category) • Repeat unscheduled emergency visits within 30 days for substance abuse conditions (New Category) Details: Moved to Explanatory indicator • Client experience (Retired) Details: Moved to Core indicator

Community Mental Health & AddictionDevelopmental Indicator • OCAN/GAIN Indicator

Next StepsWhat are the work streams and key dates? The LHINs are working collaboratively with their HSPs to finalize M-SAAs by March 31, 2014.

Questions?Comments?

APPENDIX 1: M-SAA Planning & Schedules Work Group Membership

APPENDIX 1: M-SAA Planning & Schedules Work Group Membership continued

APPENDIX 1: M-SAA IndicatorsWork Group Membership

APPENDIX 1: M-SAA IndicatorsWork Group Membership continued

APPENDIX 1: M-SAA Indicators Work Group Membership continued

2014-17 Multi-Sector Service Accountability Agreement (M-SAA) An Overview