Quality Monitor HEALTH QUALITY ONTARIO 2012 REPORT ON ONTARIO S HEALTH SYSTEM

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Quality Monitor HEALTH QUALITY ONTARIO 2012 REPORT ON ONTARIO S HEALTH SYSTEM"

Transcription

1 Quaity Monitor HEALTH QUALITY ONTARIO 2012 REPORT ON ONTARIO S HEALTH SYSTEM

2 This report is a too for driving a cuture of quaity, vaue, transparency and accountabiity throughout the heath system in Ontario. We hope this report wi hep everyone patients, caregivers, heathcare providers and heathcare eaders understand the pubicy funded heath system better, so that a of us can hod ourseves and the system accountabe for demonstrating continuous quaity improvement. This report is prepared in partnership with

3 Tabe of Contents 1 INTRODUCTION AND SUMMARIES Executive summary Attributes framework Data advocacy 7 Sector summaries 1.4 Hospita sector summary Primary care summary Home care summary Long-term care summary 14 2 ACCESSIBLE 16 Accessibe summary 16 3 EFFECTIVE 20 Effective summary 20 4 SAFE 26 Safe summary 26 5 PATIENT-CENTRED 30 Patient-centred summary 30 6 EFFICIENT 32 Efficient summary 32 8 INTEGRATED 36 Integrated summary 36 9 FOCUSED ON POPULATION HEALTH 38 Focused on popuation heath summary EQUITABLE 40 Equitabe summary LHIN ANALYSES 43 LHIN anayses EXAMPLES OF SUCCESS Aternate Leve of Care (ALC) Access Chronic Obstructive Pumonary Disease (COPD) Other successes ENDNOTES ACKNOWLEDGEMENTS MEMBERS OF HEALTH QUALITY ONTARIO 72 7 APPROPRIATELY RESOURCED 34 Appropriatey resourced summary 34 Heath Quaity Ontario Quaity Monitor

4 1.1 Executive summary Ontario s pubicy funded heathcare system is under intense pressure from a combination of spiraing costs, an aging popuation and government budgetary austerity. The chaenge of deivering high-quaity care to a Ontarians remains, however, criticay important. In order to meet the needs of the popuation, Ontario s heathcare system must consistenty adopt evidence-based practices that can improve outcomes, eiminate waste in the system and organize the deivery of heathcare around the patient to create a smooth journey for the individua. This is essentia to ensuring that our heath system is sustainabe for future generations. One of the roes of Heath Quaity Ontario (HQO) is to monitor and report to Ontarians on how we our heathcare system is performing. This Quaity Monitor is HQO s seventh annua report. It describes how the different parts of the system primary care, home care, ong-term care and hospitas perform across nine dimensions of quaity: accessibe, effective, safe, patient-centred, equitabe, efficient, appropriatey resourced, integrated and focused on popuation heath. It anayzes whether quaity has improved or worsened and, where possibe, how Ontario compares to best-performing jurisdictions in Canada and internationay. HQO aso has a roe in driving change throughout the system. It identifies the evidence-based practices that heathcare providers shoud impement, and recommends practice standards, aso based on evidence, that organizations need to foow. It makes recommendations on how heath services shoud be funded in order to encourage the highest quaity. It amasses knowedge about the different toos or approaches that are usefu in impementing best practices and spreads this knowedge to heathcare providers. To that end, this year s Quaity Monitor is divided into a series of two-page themes. The first page describes key findings and presents data on how we compare to others and whether or not we have improved. The second page describes improvement strategies. It highights the evidence-based practices that shoud be impemented, incuding those recommended by the Ontario Heath Technoogy Assessment Committee (OHTAC), now part of HQO. It aso ists practica ideas on how to impement best practices, and references change packages deveoped by HQO that describe these impementation tips in greater detai. Ideas for impementation incude specific improvements to processes of care, tips on how to measure quaity and feed back resuts to providers, cinica decision supports to remind providers to carry out important tasks, staff skis that need to be deveoped, resources that need to be acquired or reconfigured, opportunities for patient engagement to enhance impementation, and accountabiity mechanisms or incentives that need to be designed. These strategies for improvement are aso cassified according to the different audiences that have to impement them providers, patients and poicy-makers. This year s printed version of Quaity Monitor features a more compact design to enhance readabiity. Additiona content, incuding fu graphs for a indicators, wi be made avaiabe onine in stages after the print report is reeased. There are two-page summaries of key findings for hospitas, ong-term care, homecare and primary care, with questions intended to stimuate sef-refection in eaders and caregivers. This year s report continues to highight oca success stories cosey inked to its key findings that demonstrate improvement is possibe. Additiona stories wi aso be made avaiabe onine. How we compied this report HQO examined data from sources that incude Ministry of Heath and Long-Term Care (MOHLTC) databases, Statistics Canada census data and internationa surveys from the Commonweath Fund and others. The Institute for Cinica Evauative Sciences (ICES) heped us conduct many of the data anayses. Researchers, cinica experts and heathcare executives reviewed our findings for accuracy and vaidity. Key findings A sections of this year s report point to one overa theme: progress is being made in many areas, but it has been sow. In order for Ontario s heathcare system to achieve true exceence, the rate of progress needs to be acceerated. Three areas in particuar demonstrate the extent to which this is the case: chronic disease management and avoidabe hospitaizations wait times hospita safety Chronic disease management and avoidabe hospitaizations Chronic diseases are common within the Ontario popuation. Athough there are some positive signs of improvement in the management of chronic diseases, there is sti huge room for improvement. Peope are not routiney receiving a of the evidencebased best practices in chronic disease management that coud maintain their heath. Care is fragmented, especiay when peope are discharged from hospita or move from one provider to another or have mutipe providers. This creates excessive burden on individuas and their famiies, and eads to hospitaizations and readmissions that ikey coud be avoided. 2 SECTION 1.1 Executive summary

5 On the positive side, compications of diabetes, such as heart attacks, strokes, amputations and kidney faiure, are on the decine, and the use of recommended medications to further reduce these compications is rising. This rise, however, is sow and there is room to increase the use of appropriate drugs. Furthermore, ony haf of peope with diabetes are getting the recommended annua eye exam and ony 61% have their feet checked reguary. More than haf of peope with chronic diseases eat poory and are physicay inactive. Many continue to smoke, one in four is obese, and obesity rates are rising. Poor heath habits are more common among those with ow income or education eve; addressing this equity gap wi be essentia to improving overa popuation outcomes. Many chronic diseases fa into the category of ambuatory-care sensitive conditions for which, if primary care is optimized, hospitaizations coud be reduced. Over the past seven years, there has been a steady decrease in the rate of hospita admissions for such conditions and Ontario s rate is now ower than that of most other provinces. However, British Coumbia has ower rates and specific regions in Ontario have rates we beow the provincia average. Discharge transitions among peope admitted to hospita are poor and many peope eave hospita without key information. For exampe, ony one haf of peope discharged from hospita know when to resume usua activities and ony 59% know what danger signs to watch for at home. These figures are even worse for those discharged from emergency departments. In addition, foow-up care is not consistenty arranged. For exampe, one in three patients discharged from hospita for a menta heath condition did not have a foow-up physician visit within 30 days of discharge. Poor coordination at discharge contributes to readmission rates. For chronic conditions such as congestive heart faiure or chronic obstructive pumonary disease, one in five peope is readmitted within 30 days after discharge. Ontario can do better. Some eading sites in the United States have achieved readmission rates that are haf of Ontario s rates, by creating a reiabe discharge-coordination and foow-up process. Strategies for improvement Chronic disease management: Good chronic disease management depends on both patient engagement and strong heath system performance. Patients have responsibiities for adopting a heathy ifestye, understanding their condition and foowing a mutuay agreed upon treatment pan. Heath providers need to cosey monitor patients and ensure they are offered a of the recommended drugs, treatments or therapies. To accompish this, the heath system needs to improve its abiities to: provide timey access to primary care and speciaized services (e.g. rehabiitation); ensure reguary schedued foow up takes pace; ensure providers reguary review use of a recommended best practices at each schedued visit; offer some form of more intensive management for peope identified as being at higher risk, where changes in symptoms or ab vaues are tracked frequenty and immediate adjustments to treatment are made; offer sef-management support, where patients earn to set and meet their own goas; have robust measurement systems so that providers can track how we they are doing on use of best practices, and make this a standard feature of eectronic medica records; impement poicies to encourage heathy behaviour such as better food abeing, restrictions on marketing of unheathy foods and bans in schoos, taxes on unheathy activities and investments in creating safe, heathy communities with access to exercise; and hod organizations accountabe for quaity, through contracts, accountabiity agreements or funding mechanisms. Hospita readmissions and discharge transitions: Some eading American hospitas are achieving significant reductions in hospita readmissions through the use of standardized processes, better patient communication and better foow up after discharge. Exampes incude the foowing: provide written discharge instructions in simpe anguage; empoy teach-back strategies, where staff ask patients expain discharge instructions to verify their comprehension; ensure timey, appropriate foow up with primary care; assess the risk that the individua wi be readmitted (based on standardized toos aready in existence) and ensure that arrangements for more intensive foow up are made for those at highest risk; set and impement standards for timey transmission of information from hospita to primary care, such as discharge summaries and care pans; and use standard orders and discharge checkists to ensure patients have the correct medication and the foow-up they need. Leading hospitas using these techniques are achieving readmission rates for congestive heart faiure of ess than 10%, or haf of Ontario s rate. 1 It wi be important to test whether this eve of success can be repeated at Ontario sites. If so, then this shoud become the new target toward which the system shoud strive. Wait times Wait times exist in a parts of the heathcare system. On the positive side, there have been major improvements in some areas (CT and MRI) and sight improvements in other areas (emergency department waits). However, for primary care visits and pacement into a ongterm care home, waits remain far too ong. Waits for CT scans are now haf of what they were three years ago and, for 90% of peope getting a CT scan, the wait is ess than four weeks. There has aso been a major reduction of 25% in waits for MRIs over the past year. These decreases may be due to increased capacity as we as recent efforts in some sites to improve the efficiency of their scheduing processes. 1 Boutwe, A. Griffin, F. Hwu, S. Shannon, D. Effective Interventions to Reduce Rehospitaizations: A Compendium of 15 Promising Interventions. Cambridge, MA: Institute for Heathcare Improvement; Heath Quaity Ontario Quaity Monitor

6 The ength of stay for emergency department (ED) patients has decreased sighty over the past three years, by about haf an hour. Whie this is wecome, waits are sti too high. High-compexity patients spend on average 11.5 hours in the ED, whie ow-compexity patients spend 4.4 hours. The provincia targets are eight and four hours respectivey. Surgica wait times decreased significanty from 2005 to 2009 but have worsened sighty in the past year, by about three weeks for hip or knee repacements and cataract surgery. In addition, a greater proportion of peope having eective surgery get their surgery within the target time than do peope needing urgent surgery, with about one-third of urgent cancer or hip or knee repacement surgeries not happening within the target time frame. In primary care, ony haf of sicker aduts coud see a doctor or nurse the same or next day when they were unwe, compared to 79% in the United Kingdom, where there has been significant investment in training of primary care workers to impement advanced-access scheduing to hep providers better manage wait ists. Wait times to see a speciaist are poor, with amost haf of sicker aduts in Ontario waiting four weeks or more. Ontario (and Canada as a whoe) is tied with Norway for the worst standing among 11 countries in timey access to speciaist care. Wait times to get into a ong-term care (LTC) home remain far too ong cose to four months. After increasing sharpy between 2005/06 and 2008/09, however, wait times for LTC have at east stabiized and stopped increasing over the past two years. In addition, more peope are being referred to LTC in recent years from the community than from a hospita bed, refecting greater use of the Home First approach, which defers decisions about LTC unti the person is back at home with increased home care assistance, aowing a more reiabe assessment of his or her needs. Party as a resut of the deays in getting into LTC homes, peope who need an aternative eve of care (ALC) are responsibe for 17%, or roughy one in six, hospita days in acute care hospitas in Ontario. This probem has worsened in the past five years. Strategies for improvement In recent years, many Ontario EDs have been impementing process improvements to reduce waits. As part of these improvements, they: streamined processes to reduce turn-around time for ab work or other services; deveoped specia zones for different types of patients (e.g., fast-track areas or observation units); created fexibe schedues for physicians and other staff to enabe increased staffing during peak periods or surges in demand; used information systems to track where the greatest backogs are occurring; and heped patients who are using the ED as a ast resort find the services they reay need, such as a primary care or a menta heath provider. Process improvements within the ED are hepfu, and there is ikey more that coud be done. However, major progress wi occur ony when hospitas are abe to ensure that patients admitted from the ED aways have an inpatient bed to go to. Often, beds are not immediatey avaiabe due to the high number of ALC patients, as noted above, many of whom are waiting for LTC pacement. Thus, addressing this probem is critica to improving ED wait times. There are many approaches to reducing LTC wait times. Among them, heath decision makers and providers can: improve access to home care; provide supportive housing, where individuas ive in their own apartments within a compex that has caregivers readiy avaiabe. One region in Aberta has deveoped supportive housing options that are ess costy than LTC, and LTC waits there remain at ess than one month; prevent deconditioning, or oss of physica functioning and sense of autonomy, as is done by eading hospitas through rehabiitation programs, thus avoiding patients being put on wait ists for LTC; and adopt a Home First approach that assumes that it is premature to decare a person in need of LTC just after admission to hospita and deays such decisions unti patients are discharged from hospita to their homes with additiona home care support as needed, so that a more accurate assessment of the need for LTC can be made. There are many approaches to reducing primary care wait times. Primary care providers can: appy the principes of advanced access and improved office efficiency; track wait times and incoming demand for appointments; ensure that suppy and demand are better matched; and search for efficiencies, such as handing issues over the phone or by e-mai, or deegating tasks to other team members. Hospita safety Ontario has made some progress in reducing some hospita-acquired infections. There have been steady decreases in both ventiatorassociated pneumonia (VAP) and centra ine infections (CLIs), which are associated with a high mortaity rate in intensive care units. Unfortunatey, C. difficie rates have increased sighty in the past year, reversing the gains made in previous years. Hand hygiene compiance before patient contact in hospitas has aso improved, from 53% in 2008 to 72% in The provincia SaferHeathcareNow! and Just Cean Your Hands campaigns may have contributed to these improvements. There is sti room to do better, as many eading hospitas have eiminated VAP and CLIs. Hand hygiene rates, in particuar, shoud continue to rise towards 100%. Hospitas need to continue to be vigiant in foowing a estabished infection-contro procedures. 4 SECTION 1.1 Executive summary

7 Deaths among patients in hospitas are decreasing, with the majority of hospitas seeing a decrease in the past year in their hospitastandardized mortaity rate (HSMR). The mortaity rate one month after a heart attack has dropped to 8.2% in 2009/10 from a high of 10% six years earier. Stroke mortaity rates have seen simiar decines. Strategies for improvement There are many we estabished bundes of evidence-based practices for reducing different types of hospita infections or reducing mortaity: centra ine infections can be eiminated by using proper sterie technique, checking the site daiy for infection and removing the ine as soon as possibe; deaths from sepsis can be reduced by eary identification of cases, giving antibiotics without deay, and treating ow bood pressure aggressivey; venous thromboemboism can be prevented by giving bood thinners to patients at risk of bood cots; surgica compications can be reduced by using antibiotics and bood thinners and maintaining norma temperature and bood sugar; and medication error can be minimized by using strategies such as medication reconciiation, unit dosing, pre-mixed IV soutions, or computerized order entry. The chaenge for heathcare organizations is to ensure that these evidence-based practices are impemented not just some of the time, but a of the time. Inconsistency occurs for a number of reasons, incuding: ack of knowedge of a of these practices or providers who fee busy or rushed with other work and forget to impement them; ack of a standard process for impementation, which further increases the risk that an important task wi be overooked; variations in skis among staff in carrying out a task; physica design faws that may make it impractica to impement the practice; and, providers who may not have bought into the importance of adopting the best practice, and there may be inherent resistance to change. There are many strategies for ensuring reiabe adoption of best practices. Hospitas can: continuousy measure performance and feed back information to providers, such as the practice by eading hospitas of measuring hand hygiene compiance frequenty (e.g., every month) and posting resuts by department; provide checkists, standard order sets or other cinica decision supports to hep remind providers what to do and when; estabish standard processes, engage staff in the design of these processes, test them thoroughy to ensure they are as efficient as possibe and monitor compiance; train staff and, possiby more important, verify that staff have earned how to appy the task propery and consistenty; and, engage patients, for instance by encouraging them to remind providers to wash their hands if they have not done so. Concusion In a of these areas and in many others identified in the report, strategies for improvement can go a ong way toward improving the quaity of Ontario s heathcare system. The singe most important factor in achieving the quaity Ontarians want and deserve is eadership and accountabiity for quaity and safety. Strong eaders generate commitment to quaity by providing repeated messages across the organization, demonstrating an interest in quaity improvement activities and ceebrating success. They set bod targets for improvement in outcomes in their provinciay mandated quaity improvement pans and hod themseves and their managers and staff accountabe for resuts. They empower staff to make changes at the front ine to improve their processes and give them the training and time needed to do so. A of these activities create a cuture of safety, vaue and accountabiity within the heathcare system that wi prope it to the eve of exceence that Ontarians expect and deserve. Heath Quaity Ontario Quaity Monitor

8 1.2 Attributes framework The attributes of a high-performing heath system. Ontarians want their heath system to be: ACCESSIBLE Peope shoud be abe to get timey and appropriate heathcare services to achieve the best possibe heath outcomes. For exampe, when a specia test is needed, you shoud receive it when needed and without causing you extra strain and upset. If you have a chronic iness such as diabetes or asthma, you shoud be abe to find hep to manage your disease and avoid more serious probems. EFFECTIVE Peope shoud receive care that works and is based on the best avaiabe scientific information. For exampe, your doctor (or heathcare provider) shoud know what the proven treatments are for your particuar needs incuding the best ways of coordinating care, preventing disease or using technoogy. SAFE Peope shoud not be harmed by an accident or mistakes when they receive care. For exampe, steps shoud be taken so that edery peope are ess ikey to fa in ong-term care homes. There shoud be systems in pace so you are not given the wrong drug, or the wrong dose of a drug. PATIENT-CENTRED Heathcare providers shoud offer services in a way that is sensitive to an individua s needs and preferences. For exampe, you shoud receive care that respects your dignity and privacy. You shoud be abe to find care that respects your reigious, cutura and anguage needs and your ife s circumstances. EQUITABLE Peope shoud get the same quaity of care regardess of who they are and where they ive. EFFICIENT The heath system shoud continuay ook for ways to reduce waste, incuding waste of suppies, equipment, time, ideas and information. For exampe, to avoid the need to repeat tests or wait for reports to be sent from one doctor to another, your heath information shoud be avaiabe to a of your doctors through a secure computer system. APPROPRIATELY RESOURCED The heath system shoud have enough quaified providers, funding, information, equipment, suppies and faciities to ook after peope s heath needs. For exampe, as peope age they deveop more heath probems. This means there wi be more need for speciaized machines, doctors, nurses and others to provide good care. A high-performing heath system wi pan and prepare for this. INTEGRATED A parts of the heath system shoud be organized, connected and work with one another to provide high quaity care. For exampe, if you need major surgery, your care shoud be managed so that you move smoothy from hospita to rehabiitation and into the care you need after you go home. FOCUSED on POPULATION HEALTH The heath system shoud work to prevent sickness and improve the heath of the peope of Ontario. For exampe, peope shoud receive preventive heath services that can avoid cancer, infectious diseases or other conditions. Individuas need to foow a heathy ifestye and the heath system shoud support the popuation to do so. For exampe, if you don t speak Engish or French it can be hard to find out about the heath services you need and to get to those services. The same can be true for peope who are poor or ess educated, or for those who ive in sma or far-off communities. Extra hep is sometimes needed to make sure everyone gets the care they need. 6 SECTION 1.2 Attributes framework

9 1.3 Data advocacy In order to ensure Ontarians have a compete account of the quaity of their heathcare system, Ontario needs to continue to invest in data coection. Athough Ontario aready has some of the best data in Canada, there are sti major gaps. In some cases, the data exist but are inaccurate or difficut to access, whie in other cases, there are no data at a. HQO beieves it is important to advocate for improved data. Better data means improved reporting, and improved reporting is essentia to better care. This year, HQO has worked with stakehoders and experts to identify the questions about quaity that we cannot answer without better data, why the questions are important, and ideas on how data can be obtained. What data do we want? Data on chronic disease management and primary care access How woud we get it? Adoption of nationa eectronic medica record (EMR) content standards Standardized entry of EMR data Province-wide EMR adoption Use of EMR data to create provincia disease registries What information woud we get from it? Chronic Diseases Management: How many peope in Ontario have certain conditions? Are peope getting the right drugs? Are they being monitored reguary for their conditions? Are chronic diseases we controed? Are physica measures and test resuts of peope with these chronic conditions (e.g., bood pressure, weight, choestero eves) within the desired range? Access: Are peope receiving timey appointments in order to avoid potentiay harmfu deays? Performance: How we are our primary care providers performing? What is the quaity of care in primary care? Comprehensive drug utiization data A comprehensive drug utiization database that incudes a Ontarians (not just those aged 65+) Effectiveness: Are peope receiving the right drugs? Adverse events: How frequenty are drug errors (e.g., drug interactions, wrong dose, wrong drug) occurring? Is there information that wi hep detect inappropriate prescribing or dispensing activity? Is there information on whether or not patients are being prescribed medications that refect best practice guideines? Do we have trending information the types of medications dispensed? Cient experience data Impement provincia primary care, menta heath and ong-term care cient experience surveys Standardized hospita surveys aigned to a common nationa standard Patient experience: How do users of heathcare services fee about the care they receive with respect to communication, courtesy, invovement in decisions and responsiveness to concerns? Access: Are peope abe to get the services they need in a timey manner? Patient-reported outcomes: How do peope perceive their heath and the impact that treatments/services have on their quaity of ife? Appropriateness of services data Coection of data on appropriateness criteria for seect services Eectronic order entry systems where this data coud be entered Efficiency: Are peope receiving unnecessary tests, surgeries or other procedures? Best practices: Are peope receiving care that is based on the best evidence, such as OHTAC recommendations? Heath Quaity Ontario Quaity Monitor

10 1.4 Hospita sector summary Acute care hospitas: summary for boards, CEOs, senior management and cinica eaders Ontario hospitas submit annua quaity-improvement pans as required by the Exceent Care For A Act. These pans describe priorities for improvement and numeric targets to achieve in the fisca year. Hospitas seect indicators from a standard ist and can add additiona indicators as desired. This section summarizes the progress made in the most frequenty chosen topics in quaity improvement pans. Topic area key facts Key questions for heathcare eaders and staff to consider 1. Right care in the right pace ALC (see section 6) Peope who need an aternative eve of care (ALC) are responsibe for 17%, or roughy one in six, hospita days in acute care hospitas in Ontario. This probem has worsened in the past five years, making it an urgent priority in Ontario. Can we identify peope at risk for being ALC earier, so that home care services can be arranged before their heath deteriorates? Are we using rehabiitation resources to hep patients recover their function and return home to ive as independenty as possibe? Are we working with CCACs to appy the Home First approach? Are we working with other stakehoders to promote supportive housing modes or simiar options for frai individuas? What services need to be deveoped in the community or in LTC homes to better serve ALC patients? 2. Hospitaizations for ambuatory care sensitive conditions (ACSCs) and readmissions (see section 3) 3. Discharge/ transitions (see section 8) Over the past seven years, there has been a steady decrease in the rate of hospita admissions for many chronic conditions where hospitaization might have been avoided through better primary care. The most common conditions are congestive heart faiure (CHF) and chronic obstructive pumonary disease (COPD). Ontario s rate is now ower than most other provinces, but higher than some regions in Canada. There is sti ikey room to improve. Readmissions occur frequenty. For common conditions ike CHF and COPD, about one in five patients is readmitted within one month. There has been itte or no improvement in readmissions in recent years, except for heart attack, where readmissions have decined significanty. Many patients are not getting the information they need when eaving the hospita or emergency department (ED). Ony haf of ED patients know what danger signs to ook out for at home and ony six in ten patients know whom to ca if they need hep. About haf of hospita patients don t know when to resume norma activities. Athough most patients know how to take the medications, about a third do not know what side effects to watch for. Can we work with primary care providers to improve chronic disease management and prevention so patients are ess ikey to need hospitaization? Are we identifying peope at high risk for readmission and performing eary discharge panning? Are we making sure patients have a the information they need when they are sent home? Do patients at high risk for readmission have a foow-up appointment with famiy doctor, home care or speciaist soon after discharge? How quicky are we transferring discharge summaries to famiy physicians? Are written discharge instructions routine for a of our patients? Are we giving patients and famiies a chance to ask questions? Are we ensuring there is a documented timey foow-up appointment with primary care and home care if needed? Is there a warm handoff between the most responsibe physician in hospita and the primary care provider? Have we considered post-discharge phone cas to the patient from the hospita? Have we considered using patient navigators or case managers? 4. Emergency department (ED) wait times (see section 2) The tota time spent by patients in EDs has decreased sighty (by about haf an hour) over the past three years, but is sti too high 11.5 and 4.4 hours for high- and ow-compexity patients respectivey. The provincia targets are 8 and 4 hours respectivey. Are we moving patients who do not need to be receiving care in the hospita to the right pace as quicky as possibe? (See ALC questions above). Are we using Lean process improvement techniques to streamine ED processes? Have we considered diverting non-urgent cases away from the ED to aternatives that are most appropriate for their conditions? Are we informing peope about primary care after-hours services, community cinics and teephone heath advisory services? Can we work with other stakehoders to improve primary care services so patients are ess ikey to need ED care? 8 SECTION 1.4 Hospita sector summary

11 Topic area key facts Key questions for heathcare eaders and staff to consider 5. Wait times for speciaists, surgery and CT/MRI (see section 2) Wait times to see a speciaist are poor. Amost haf of sicker aduts in Ontario waited four weeks or more to see a speciaist. Ontario and Canada are tied with Norway for the worst standing among 11 countries in achieving timey access to speciaist care. Wait times for CT and MRI have improved. Waits for CT scans are now haf of what they were three years ago and for 90% of peope getting one, the wait is ess than four weeks. For MRI, there has been a major reduction just in the ast year of 25%. Wait times for many surgeries saw huge reductions from 2005 and However, there has been a sight worsening of wait times (by about three weeks) for hip and knee repacements and cataract surgery. Whie the arge majority of eective surgery cases are done within the target time, many urgent cases miss their target time for exampe, approximatey one-third of urgent cancer, hip and knee repacements are not done within the recommended time frame. Do we use appropriateness criteria to ensure that patients truy require surgery or tests? Are there ineffective hand-offs, poor communication or ack of standardized processes that contribute to deays? Can we ensure some excess capacity for services associated with surgery such as space in the intensive care unit? Are we using eectronic booking systems that ensure a reevant information is captured before a booking can proceed? Have we considered centraized booking systems that coud connect patients to paces with the shortest wait time? Do we monitor key process metrics, such as on-time case starts and downtime, so we can maximize our efficiency and increase our capacity? Do we measure suppy and demand and do we know if they are in baance? Have we ever done queue-cearing bitzes for exampe, temporariy increasing the rate of procedures done unti backog is eiminated? 6. Hospita acquired infections and mortaity (see section 4) Ontario has made progress in reducing hospitaacquired infections. Proper hand hygiene compiance before patient contact in hospitas has improved in the past three years, from 53% to 72%. Devastating infections ike ventiator-associated pneumonia (VAP) and centra ine infections (CLI) are decreasing steadiy. Unfortunatey, C difficie rates have increased sighty in the past year, reversing gains made in previous years. Hospitas need to continue to be vigiant in foowing estabished infection contro procedures. Deaths among hospita in-patients are decreasing. The majority of hospitas have seen a decrease in the past year in their hospita standardized mortaity ratio, which examines deaths for the most common conditions for which peope come to hospita. Specificay, there have been impressive reductions in deaths after heart attacks and stroke. There is very ikey room to continue to improve. How we are we foowing care bundes for preventing hospita infections and reducing mortaity? Do we use standard process maps to ensure key best practices in each bunde happen consistenty and in the right order? Are we auditing hand hygiene frequenty (more than just once a year) and providing feedback to staff on compiance (monthy or quartery, by ward or by provider group)? Are hand washing stations convenienty ocated, never empty, and being used? Are we encouraging patients to ask providers if they have washed their hands? Are we reguary using standardized checkists, order sets or protocos to minimize reiance on memory? If so, are we actuay tracking how we are using them and if they are having an effect? Are we promoting a cuture of safety, where peope fee free to speak up if they see a safety issue? Are we encouraging patients to ask questions about safety? 7. Patient experience (see section 5) There are major opportunities for improving patient experience around communication, engagement in decisions and coordination of care. About one in three hospita patients does not get answers to questions he or she can understand. Do we use methods such as teach-back to verify patients understand a the information they have been given? Do we have transators for peope who speak different anguages? Are we providing cinicay focused customer service and cutura competence training to our staff? 8. Hospita deficits (see section 6) Amost one in four hospitas reported a deficit in FY 2010/11. Compared to the previous year, the number of hospitas in deficit decreased by 15%. The argest decrease was among arge community hospitas. Whie the first instinct when facing a deficit is to cut services, has hospita management carefuy thought of a the different sources of waste in the system and made aggressive pans to eiminate them (e.g., unnecessary tests or services and waste of staffing, space, inventory and suppies)? 9. Information technoogy (IT) (see section 7) Ontario hospitas are making steady progress in impementing IT internay. Amost a hospitas hande diagnostic images eectronicay now. However, there is sti poor interconnectivity between hospitas and other heathcare organizations and providers; ony 21%, for exampe, can send eectronic referras. Can our IT systems connect to pharmacies, abs, hospitas and other providers? What cinica performance indicators are, or are not, tracked by our IT systems? Which ones need to be tracked in the future? How quicky can this information be fed back to providers? Heath Quaity Ontario Quaity Monitor

12 1.5 Primary care summary Primary care: summary for primary care providers, eaders and decision makers Primary care is the cornerstone and point of entry to the heathcare system and the pace where the majority of heath services are initiated and coordinated. Primary care focuses on services reated to heath promotion, iness and injury prevention, as we as the diagnosis, assessment, treatment and management of chronic conditions. Optima access to quaity primary care services is a key determinant of Ontarians heath outcomes. Topic area key facts Key questions for heathcare eaders and staff to consider 1. Access to primary care (see section 2) Waits to see a primary care physician are sti far too ong. Ony haf of sicker aduts coud see a doctor or nurse the same or next day when they were unwe. The UK has invested heaviy in training its primary care workforce to impement advanced access scheduing to hep providers manage their wait ists better. It has the best resut for sicker aduts who coud see a doctor or nurse the same or next day: 79%. Are office efficiency and scheduing modes, such as advanced access, being used and promoted to aow practices to provide faster access to primary care services? Are we tracking wait times and incoming demand for appointments and matching them with suppy? Are our EMRs enabed to track such information? Are we promoting primary care modes that provide after-hours access to care? Are we working in a team? Are we using each team member to his/her fuest capacity? Are we setting expectations for ow wait times in accountabiity agreements with service providers? 2. Chronic disease management (see section 3) There are some positive signs of improvement in the management of chronic diseases. Compications arising from diabetes, such as heart attacks, strokes, amputations and kidney faiure, are on the decine. The use of recommended medications, such as statins for choestero contro, ACEI/ARBs and beta-bockers, is generay rising athough sowy. However, there is sti huge room for improvement. More peope coud sti be on these drugs, and many peope with diabetes are not getting reguar monitoring of their feet and eyes. Many peope with chronic diseases sti smoke, have poor diet and do not get enough exercise, and obesity rates are rising. Are we using methods such as fow sheets to remind us of a best practices to foow? If we have an EMR, does it provide us with data on the percentage of our patients on the right drugs and who have received the proper tests? Do we know the community supports avaiabe for our patients to hep them sustain heathy iving? Have patients identified their own goas for improving their heath? Do they know their targets for good disease contro (e.g., bood pressure < 130/80 for diabetes or A1C < 7)? Have they a been connected with a chronic disease sef-management program? 3. Patient experience (see section 5) About one in four sicker aduts do not get to ask enough questions or fee invoved in decisions about care. About one in three sicker aduts do not beieve someone aways coordinates the care they receive from other doctors or paces. Are we aowing enough time for questions from patients and famiies? Are we promoting standardized patient experience surveys that provide the opportunity to get patients insight and feedback on services received? Are we making the best use of patient information resources to inform patients of their treatment options? Do we have proper integrated heath information systems that enabe patient information sharing and coordination of care? 4. Transitions (see section 8) About one in three patients hospitaized for a menta heath condition do not have foow-up visits arranged within 30 days of discharge. Have we prioritized time in our schedue to see recenty discharged patients prompty? Have we worked with the oca hospita to ensure there is a reiabe process for notifying primary care practices about hospita admissions and discharges? Do we have a process for assessing risk and prioritizing sicker patients for foow-up visits? 10 SECTION 1.5 Primary care summary

13 Topic area key facts Key questions for heathcare eaders and staff to consider 5. Heathy behaviours (see section 9) Ontario has made important progress on smoking in the ast decade, but there has been no improvement on physica inactivity or poor fruit and vegetabe intake, and obesity is graduay getting worse. There is sti room to improve, and British Coumbia outperforms Ontario in many of these areas. Do we ask our patients about their smoking cessation at each visit? Do we have a ist of a smoking cessation supports in our community for our patients? Are we motivating peope to change unheathy behaviour by setting sef-management goas? Are we advocating for heathy food choices in oca schoos and restaurants, and access to exercise? 6. Preventive heath (see section 9) There is sti room for improvement in preventive measures to keep the popuation heathy. More than one-third of seniors did not receive a fu shot, a ten percentage point decrease from 2005, when Ontario recorded its best performance. About one-third of eigibe women sti do not have a mammogram and neary one in four women did not have a Pap test within the recommended timeframes. Rates of screening for coorecta cancer have increased in recent years, but more progress is needed in order to hit the provincia target of 40%. Do we use fow sheets to remind us of a the heath prevention interventions that need to be done during periodic heath exams? Are we using registries to send reminders to patients for preventive services and foow-up care? Do we provide easy access to vaccinations outside primary care offices? Are we promoting payment modes that set expectations for providers to schedue and foow up on screening tests? 7. Equity (see section 10) Vunerabe popuations within Ontario continue to have greater difficuties maintaining a heathy ifestye, use preventive services ess frequenty, and have worse heath outcomes. Peope with ow income and ess education are at greatest risk. How can we improve our outreach to peope with ow income or ess education to improve heath behaviours or preventive screening? What barriers need to be addressed cutura differences, ow iteracy, transportation, convenience of office hours, ocation of services? For ow-income groups, have we considered reducing cost barriers to sports and recreation programs, nutritious food and nicotine repacement therapies? Do we guide immigrants on how to propery seek primary care and preventive services? Are they being provided services in a anguage and manner that they can understand? Heath Quaity Ontario Quaity Monitor

14 1.6 Home care summary Home care: Summary for home and community care eaders, staff and cients Home care (HC) supports peope with compex medica, cinica and psycho-socia needs who have difficuty caring for themseves, and heps them ive independenty in their homes. In Ontario, community care access centres (CCACs) provide cient assessments and care coordination services, and arrange nursing or persona support services, physiotherapy, occupationa therapy, speech-anguage therapy, socia work, nutritiona counseing and reated medica suppies and equipment. To assist HC cients, CCACs work cosey with primary heathcare providers and community support services. The information beow on quaity of HC services for ong-stay CCAC cients identifies areas for improvement and soutions to consider. Topic area Key facts Key questions for heathcare eaders and staff to consider 1. HC wait times (see section 2) 2. Long-term Care pacement (see section 6) 3. Fas (see section 4) Nine out of ten HC cients discharged from hospita, receive their first HC visit within seven days of discharge, whie those referred from the community wait nine days. The median wait for pacement into a ong-term care (LTC) home is 113 days, which is too ong. At the same time, approximatey one in five peope paced in LTC homes do not have high or very high care needs, suggesting their needs coud potentiay be met esewhere. Athough this indicator has improved in the ast two years, there is sti room to improve. More than one in four HC cients reported having a fa in the ast 90 days. This has worsened sighty in the ast two years. Are we invoved eary during the hospita stay to assist peope with timey transition to HC services? Are we screening aduts in the community for their need for HC services eary, before their probems coping at home escaate? Are potentia cients of HC services fuy aware of the types of support they are entited to? Is cient information we coordinated within the HC sector and among the sectors to aow timey access to services? Are we aware of and using aternatives to LTC for those who do not need the fu range of LTC services? Coud more individuas benefit from increased HC, day programs, exercise or rehabiitation programs? Coud supportive housing options, which aow them to ive on their own but in compexes that have some eve of on-site care avaiabe, reduce some of the demand for LTC? Are risk assessments for fas being done routiney and consistenty? Do we do routine safety assessments? Are we checking for poor ighting in the home? Are safety aids (e.g., grab bars) consistenty being instaed and used? Are we encouraging the use of mobiity aids (e.g., wakers) and checking for proper use? Do high-risk cients exercise or receive appropriate physiotherapy and/or rehabiitation to improve strength and baance? Are any cients on a drug with side effects that might cause a fa? Are we working with primary care providers to ensure that reguar medication reviews are done and those at risk for fas are taking vitamin D and cacium? Do we screen cients for vision probems? Do we routiney determine the origin of a cient fa and fix the root cause? 12 SECTION 1.6 Home care summary

15 Topic area Key facts Key questions for heathcare eaders and staff to consider 4. Pressure ucers (see section 4) Among HC cients, 7.9% have had a new or worsening pressure ucer (stage 2 to 4) over the previous 6 months. This has not improved in recent years. Are HC cients at risk for deveoping ucers identified eary? Are risk assessments periodicay updated? Are HC workers we trained in detecting eary signs of pressure ucers? Are they checking for these signs reguary? Are high-risk cients getting specia padding or mattresses to avoid ucers on pressure points? 5. Badder incontinence see section 3) 6. Injuries (see section 4) 7. Pain contro (see section 3) 8. Primary caregiver burden (see section 7) More than haf of HC cients either faied to improve or experienced a recent decrease in badder function compared to their previous assessment. This has worsened in recent years. More than one in ten HC cients reported unexpained injuries assessed over the past 90 days; however, these events are often underreported or undiscosed, and so this rate may be artificiay ow. No change has been seen in the past two years. More than one-third of a persons receiving HC services experience daiy, intense pain enough to disrupt their abiity to perform norma activities. This has worsened in recent years. Neary one in four caregivers of HC cients reports experiencing feeings of distress and/or being unabe to continue in caring activities. This has increased over the past two years. Is there a standard process for screening for and assessing incontinence probems? Are HC cients being offered prompted voiding protocos? Are there enough staff with the right training to teach this technique? Are we working with primary care to identify potentia candidates for surgery for incontinence? Are we checking for safety hazards in the home (e.g., hot water temperature, unsafe eectrica outets and cutter)? Are forma and informa caregivers of HC cients knowedgeabe about injury signs? Do they have access to educationa resources? Are HC cients getting accurate pain assessment? Are staff trained to recognize pain, even in peope with dementia or difficuty communicating? Are we working with primary care providers and pain speciaists to deveop pain management protocos? What supports are avaiabe in the community for primary caregivers of HC cients? Are primary caregivers aware of respite and adut day programs for HC cients? Are caregiver-directed programs accessibe for those who care for HC cients? Heath Quaity Ontario Quaity Monitor

16 1.7 Long-term care summary Long-term care: summary for LTC eaders, staff, residents and famiy members Ontario s ong-term care (LTC) homes provide 24-hour persona support, supervision, nursing and medica care to more than 76,000 peope across the province. Pacement into LTC homes is based on need and is coordinated by Ontario s Community Care Access Centres. To hep residents stay as heathy and independent as possibe, LTC homes offer a wide range of care and services, incuding nursing care, medica treatment, physiotherapy, rehabiitation, specia diets and nutrition, and recreation therapy. Providing residents with safe, effective care in a nurturing, home-ike environment promotes a positive quaity of ife. Topic area Key facts Key questions for heathcare eaders and staff to consider 1. tc wait times and pacements (see section 2) 2. Fas (see section 4) The median wait time for pacement into a LTC home is 113 days neary four months. Athough LTC wait times have stabiized (i.e., stopped increasing) over the past two years, the wait is sti too ong. Given that the current wait is amost four times onger than it was in spring 2005, there is sti substantia room for improvement. At the same time, more than one in five peope paced in LTC homes from home care (HC) do not have high or very high care needs, suggesting their needs coud potentiay be met esewhere. One in seven LTC residents fe in the past month.* One in 40 LTC residents experienced a fa that resuted in an emergency department visit in the past year. No changes have been seen in these areas compared to ast year, and the considerabe variation in the rate of fas across Ontario s LTC homes suggests there is ikey room for improvement. Are aternatives to LTC being deveoped for those who do not have high or very high needs? Coud these persons benefit from more HC, day programs, exercise or rehabiitation programs, or supportive housing options? Are there enough speciaized homes to meet the needs of Ontario s communities? Is there a need for more cuturay specific homes or homes that are equipped to hande particuar conditions such as compex behavioura issues? Are fas risk assessments being done and kept up to date? Are residents receiving reguar exercise or physiotherapy to maintain ower-body strength and baance? Are LTC homes ensuring safe iving spaces for their residents, for exampe by eiminating cutter and ensuring proper ighting? Is protective equipment, such as high/ow beds or hip protectors, being used? Are LTC physicians and nurses working together with pharmacists to review whether residents are taking drugs that might contribute to a higher risk of fas? Are vision probems (which can ead to fas) being reguary assessed and corrected? 3. Pressure ucers (see section 4) Neary one in 36 LTC residents had a pressure ucer that got worse, or deveoped a new, serious pressure ucer in the preceding three months.* Are residents with a high ucer risk being paced on specia, high-density foam mattresses? How coud funding mechanisms for these mattresses be redesigned so that LTC homes receive funding before, and not after the ucer occurs? Are a staff, incuding new hires or temporary staff, trained in recognizing eary signs of pressure ucers before they escaate? Are immobie residents who need to be turned reguary getting this done consistenty? 14 SECTION 1.7 Long-term care summary

17 Topic area Key facts Key questions for heathcare eaders and staff to consider 4. Restraints and worsening behaviours (see section 4) Neary one in six LTC residents were physicay restrained.* No change has been seen over the past year; there is sti room for improvement. Neary one in seven LTC residents dispayed worsening behaviors in the past three months.* No change has been seen in the past year. Are LTC staff and residents famiies being propery educated on the risks associated with restraints (e.g., fas and pressure ucers)? Are aternatives to restraints being used to the fuest extent? (Exampes incude aarms to signa when someone is wandering, or high-ow beds instead of bed rais). Are non-drug strategies for managing dementia-reated behaviours, such as music programs and touch therapy, being used? Is there an adequate range of socia and eisure activities in the home? Because undiagnosed pain can bring out behavioura probems, is pain being recognized in peope with dementia or difficuty communicating? 5. Badder incontinence (see section 3) About one in five LTC residents experienced a decine in badder function in the past three months.* There has been no change in the past year. Are we maximizing the use of strategies ike prompted voiding and badder training to hep improve residents continence? Are there avaiabe staff with the right training to teach these techniques? Are residents being assessed to see if they coud benefit from surgery for incontinence? 6. Pain (see section 3) Approximatey one in eight LTC residents experienced moderate to severe daiy pain in the past three months.* There has been no change in the past year. Is pain being documented as if it were the fifth vita sign? Are staff trained to recognize pain, even among those with dementia or communication difficuties? Are standard pain protocos being used in the home? Is the fu range of pain medications being used, incuding non-narcotic drugs (e.g., nortriptyine, gabapentin, steroid joint injections)? Are non-drug therapies for pain, such as physiotherapy or massage, being used to the fuest? 7. Worsening depression (see section 3) About one in four residents with depression experienced worsening symptoms since their ast assessment.* These rates have remained stabe over the past year. Is there a broad enough range of socia, eisure, entertainment and exercise activities avaiabe? Are residents happy with these activities? Are there opportunities for residents to contribute meaningfuy to the ife of the community? Are we using vounteers or doing enough to encourage visitors? Has pet therapy been considered? If non-drug approaches fai, have residents been offered anti-depressants? 8. Avoidabe emergency department visits (see section 4) For every 100 LTC residents, 5.6 visited an emergency department ast year because of an ambuatory care sensitive condition that is, a condition that coud possiby have been prevented had the underying cause been managed earier on. Are there cinica protocos to identify and address eary signs of an exacerbation of chronic disease before it escaates into something worse? Are physicians avaiabe to assess a resident on-site for a worsening probem when requested? If not, coud nurse practitioners be used? Are there aternatives to on-site assessment, such as remote assessments via teemedicine inks? * Based on the roing average of four previous fisca quarters (tweve months). Heath Quaity Ontario Quaity Monitor

18 2 Wait times in emergency departments, access to primary care, ong-term care and home care Ontario s heath system must provide timey access to the right heathcare services in order to achieve the best possibe heath outcomes. Ontarians shoud have optima access to a primary care provider to provide preventive care, treat acute inesses, manage chronic diseases and coordinate referras. Long waits for an appointment shoud be avoided so that peope s medica condition wi not worsen whie waiting and peope wi ony go to emergency departments (EDs) as a ast resort. 1 Excessive waits in the ED may compromise patients margin of safety and increase the risk of poor outcomes. 2 Peope who need ong-term care (LTC) and home care (HC) shoud access services prompty to obtain the appropriate eve of care, ensure a safe environment and aow them to get the persona care or rehabiitative services they need to function. ED wait times Hours Where coud WE be? 8 hrs for high, 4 hours for ow compexity. 0 Apr 08 Sep 11 High compexity Low compexity High Comp. Target Low Comp. Target Wait times to get into LTC home Days Where coud WE be? Ontario s best past resut 30 days. BETTER 0 Apr Jun 03 Jan Mar 11 The tota time spent by patients in EDs has decreased sighty over the past three years but is sti too high 11.5 and 4.4 hours for high- and ow- compexity patients, given the provincia targets of 8 and 4 hours, respectivey. Recent activities to reduce ED wait times, such as the ED Performance Improvement Program and a pay-for-performance scheme 3 may have contributed to this decrease. However, hospitas must continue to impement process improvements in order to reach provincia targets. Wait times to get into an LTC home continue to be too high cose to four months. Wait times increased sharpy between 2005/06 and 2008/09, but have stabiized (i.e., stopped increasing) in the past two years. Primary Care Access: Waits to see a primary care physician are sti far too ong. Ony haf of sicker aduts coud see a doctor or nurse the same or next day when they were unwe. The UK has invested heaviy in training its primary care workforce to impement advanced access scheduing to hep providers manage their wait ists better. It has the best resuts, with 79% of sicker aduts abe to see a doctor or nurse the same or next day when they were sick. INDICATOR LATEST RESULT PROGRESS? WHERE COULD WE BE? Wait times in EDs 90 th percentie ength of stay for ED patients: High compexity Low compexity 11.5 hours* 4.4 hours* Sight improvement 8 hours (MOHLTC target). 4 hours (MOHLTC target). ED patients who eft without being seen 3.5%* As ow as possibe. 90 th percentie time to physician initia assessment 3.4 hours* Access to primary care % of sicker aduts who do not have a reguar doctor or pace to go for medica care % of sicker aduts who coud see a doctor or nurse on the same or next day the ast time they were sick % of sicker aduts who stated it was easy to get medica care in the evening/on weekend/hoiday without going to ED 3.2%** n/a 0%, Netherands. 50%** n/a 79%, UK. 31%** n/a 65%, UK. Access to LTC and HC Median number of days to LTC home pacement 113 days No change in past 2 years 90 th percentie wait time from appication/discharge to first HC service, by ocation: From community Hospita 9 days No change 7 days Improved 29 days Ontario s best past resut (spring 2005). As ow as possibe. Data source: *NACRS, provided by MOHLTC 2010/11; **Commonweath Fund Internationa Heath Poicy Survey of Sicker Aduts, 2011; MOHLTC Long-term Care Cient Profie Database, Jan Mar 2011; Data refects non-crisis pacements Discharge Abstract Database (DAD), HCD, RPDB, Fisca Quarter /11, provided by ICES 16 SECTION 2 Accessibe

19 Ideas for improvement Wait times in emergency departments: Measurement/feedback: Consider using ED information systems that can pinpoint exact sources of deays, signa when a test is ready for review, and monitor improvements. Some systems use radio-frequency ID (RFID) tags to track patient movement. 4 Eectronic in-patient bed tracking systems can immediatey te the ED when a bed is avaiabe for an admitted patient. 5 Processes: Create designated zones for different types of patients (e.g., fast-track areas, observation units), as speciaization can improve efficiency. 6 Use Lean process improvement techniques to streamine processes, reduce turnaround time for abs or other services. Consider fexibe physician/staff schedues to aow extra staff to come in during peak periods or surges in demand. Smooth out utiization spikes during the week in eective surgery scheduing and hospita discharges. Such patterns (e.g., more discharges on Fridays, few on weekends) can ead to variations in ED wait times. 7,8 Patient engagement: Use written discharge instructions or teach-back to verify that patients understand instructions and decrease return visits (see section 3 chronic disease management). Hep ED patients without a famiy doctor find one, and refer to services such as Heath Care Connect. 9 Identify ED patients with unmet needs (e.g., those with menta heath conditions or frai edery persons) and connect them to other services, such as a menta heath counseing program or home care. Encourage patients to use after-hours services where they exist (e.g., at their Famiy Heath Team, urgent care centres). 10 Access to primary care: Measurement/feedback: Primary care practices shoud ideay track wait times and incoming demand for appointments and ensure demand does not exceed the actua number of appointments that can be suppied. In Aberta, a EMRs approved for use must track this information. 11 Processes Schedue processes such as Advanced Access and Efficiency: Impement the principes of advanced access scheduing, which invoves: monitoring suppy and demand for appointments; ensuring suppy and demand are matched; re-shaping suppy and demand; having contingency pans; and working down the backog. 12 Improve efficiency and eiminate unnecessary visits or wasted time in the office to increase time avaiabe for more appropriate visits. Consider handing issues over the phone, deegating tasks to other team members, improving the office ayout to minimize waking or set up rooms the same to avoid wasted time searching for suppies. 13 Incentives: Consider accountabiity agreements or contracts with expectations for keeping wait times ow. Community Heath Centres now have third next avaiabe appointment in their accountabiity agreements with LHINs. 14 Famiy Heath Teams and other modes of care are expected to provide after-hours services. Patient engagement: Educate patients about when they do or do not need to see a provider. Hande issues over the phone or by e-mai to reduce the number of visits required. Let patients schedue appointments on-ine. Refer patients without primary care to the province s Heath Care Connect service which heps them find a care provider. 15 Access to ong-term care and home care: See strategies for reducing Aternate Leve of Care Days (section 6). Patient Poicy Provider What is happening in Ontario? HQO resources for improvement: HQO offers toos, resources and coaches for primary care teams that aim to reduce wait times and improve processes (see The Advanced Access & Efficiency for Primary Care initiative is now in its fourth wave and has enroed 200 teams in 2011/12. Over the preceding three years, 217 famiy practices aso received this type of support. The Emergency Department Performance Improvement Program (ED-PIP) is competing its fourth and fina wave. This initiative, begun in 2009, has supported 61 EDs to impement the process improvements described above with the hep of expert coaches and practica toos (see Famiy Heath Teams (FHTs) were introduced in 2005 as part of Ontario s strategy to improve access to primary care, chronic disease management and heath promotion. Teams incude doctors, nurse practitioners, registered nurses and other professionas such as dieticians, socia workers, or pharmacists. FHT patients can access after-hours support from a nurse through the Teephone Heath Advisory Service at Famiy Heath Teams have been impemented and are now serving patients. 16 Heath Quaity Ontario Quaity Monitor

20 2 Treatment wait times and access to speciaists When peope are sick, they may need speciaist visits, surgery, speciaized therapy or tests. Waiting too ong for a speciaist can ead to inconvenience, stress and anxiety, 17 as we as a onger period of suffering from symptoms unti they can be treated. More extreme waits can ead to a more extensive surgica procedure or a more advanced stage of disease. Long waits for joint repacement, for exampe, can ead to worsened physica function and increased pain, 18,19 whie excessive waits for coronary interventions carry an increased risk of repeat myocardia infarction and mortaity th percentie wait time for CT & MRI 90 th percentie wait time for hip and knee repacement and cataract surgeries 150 BETTER 350 BETTER Days 75 Days Dec 06 Jan 07 Dec 11 0 Dec 06 Jan 07 Dec 11 CT scan wait time MRI wait time Cataract Surgery Hip Repacement Knee Repacement MRI wait times have seen a major reduction (25%) in the past year. Waits for CT scans have dropped steadiy and are now haf of what they were three years ago. For 90% of peope, the wait is ess than four weeks. Waits may have improved because capacity has increased; some individua hospitas have aso made efforts to improve processes and reduce inefficiencies (see next page). Ontario saw huge reductions in wait times for many surgeries from 2006 to In the past two years, however, there has been a sight worsening of wait times (about three weeks) for hip and knee repacements and cataract surgery. Hospitas need to continue to be vigiant about these wait times or risk osing the gains that Ontario made in the past decade. Amost haf of sicker aduts in Ontario waited four weeks or more to see a speciaist. Internationay, Ontario and Canada are on par with Norway for the worst standing in achieving timey access to speciaist care. INDICATOR LATEST RESULT PROGRESS? WHERE COULD WE BE? Treatment wait times and access to speciaists 90 TH PERCENTILE % OF SURGERIES/PROCEDURES DONE WITHIN TARGET TIME BY PRIORITY LEVEL: WAIT URGENT SEMI-URGENT ELECTIVE CT 33 days*** 91%* 61%* 78%* Improved Idea 100%. MRI 116 days*** 73%* 47%* 34%* Improved Coronary Urgent 7 days** 90%** 95%** 99%** Major artery bypass improvement Semi-urgent 22 days** grafts (CABG) but Eective 46 days** stabe over Angiography Urgent 3 days** 91%** 80%** 98%** the past two years Semi-urgent 18 days** Eective 23 days** Percutaneous Urgent 4 days** 93%** 87%** 98%** coronary Semi-urgent 16 days** intervention Eective 19 days** Cancer surgery 60 days*** 65%* 73%* 90%* 100% for a priority eves Genera surgery 104 days*** 83%* 89%* 96%* and surgeries (achieved by North York Genera Cataract surgery 123 days*** 83%* 87%* 97%* Improved Hospita). 21 Hip repacement 181 days*** 67%* 67%* 86%* but sight recent Knee repacement 197 days*** 63%* 60%* 81%* increase % of sicker aduts who waited four weeks or more to see a speciaist 47% n/a 7% (Switzerand) or 11% (USA). Data source: *Cancer Care Ontario and Wait Times Information System 2011; **Cardiac Care Network, November 2011; ***Cancer Care Ontario and Wait Times Information System 2010/11 fisca year; Commonweath Fund Internationa Heath Poicy Survey of Sicker Aduts, SECTION 2 Accessibe

Frequently Asked Questions

Frequently Asked Questions Community Heathcare Organisations Report & Recommendations of the Integrated Service Area Review Group Frequenty Asked Questions 1. What are Community Heathcare Services? Community Heathcare Services are

More information

Early access to FAS payments for members in poor health

Early access to FAS payments for members in poor health Financia Assistance Scheme Eary access to FAS payments for members in poor heath Pension Protection Fund Protecting Peope s Futures The Financia Assistance Scheme is administered by the Pension Protection

More information

A Description of the California Partnership for Long-Term Care Prepared by the California Department of Health Care Services

A Description of the California Partnership for Long-Term Care Prepared by the California Department of Health Care Services 2012 Before You Buy A Description of the Caifornia Partnership for Long-Term Care Prepared by the Caifornia Department of Heath Care Services Page 1 of 13 Ony ong-term care insurance poicies bearing any

More information

Niagara Catholic. District School Board. High Performance. Support Program. Academic

Niagara Catholic. District School Board. High Performance. Support Program. Academic Niagara Cathoic District Schoo Board High Performance Academic Support Program The Niagara Cathoic District Schoo Board, through the charisms of faith, socia justice, support and eadership, nurtures an

More information

(David H T Lan) Secretary for Home Affairs

(David H T Lan) Secretary for Home Affairs Message We sha make every effort to strengthen the community buiding programme which serves to foster among the peope of Hong Kong a sense of beonging and mutua care. We wi continue to impement the District

More information

Australian Bureau of Statistics Management of Business Providers

Australian Bureau of Statistics Management of Business Providers Purpose Austraian Bureau of Statistics Management of Business Providers 1 The principa objective of the Austraian Bureau of Statistics (ABS) in respect of business providers is to impose the owest oad

More information

Preschool Services Under IDEA

Preschool Services Under IDEA Preschoo Services Under IDEA W e don t usuay think of Specific Learning Disabiities in connection with chidren beow schoo age. When we think about chidren age birth to six, we think first of their earning

More information

Business schools are the academic setting where. The current crisis has highlighted the need to redefine the role of senior managers in organizations.

Business schools are the academic setting where. The current crisis has highlighted the need to redefine the role of senior managers in organizations. c r o s os r oi a d s REDISCOVERING THE ROLE OF BUSINESS SCHOOLS The current crisis has highighted the need to redefine the roe of senior managers in organizations. JORDI CANALS Professor and Dean, IESE

More information

Key Questions to Ask About

Key Questions to Ask About everychid. onevoice. Every time i have to go to the bathroom at schoo, there s a ine. And sometimes they reay need to be ceaned. Maybe the schoo can get some more hep to open up a of the restrooms again.

More information

Introduction the pressure for efficiency the Estates opportunity

Introduction the pressure for efficiency the Estates opportunity Heathy Savings? A study of the proportion of NHS Trusts with an in-house Buidings Repair and Maintenance workforce, and a discussion of eary experiences of Suppies efficiency initiatives Management Summary

More information

A short guide to making a medical negligence claim

A short guide to making a medical negligence claim A short guide to making a medica negigence caim Introduction Suffering from an incident of medica negigence is traumatic and can have a serious ong-term impact on both the physica and menta heath of affected

More information

Accreditation: Supporting the Delivery of Health and Social Care

Accreditation: Supporting the Delivery of Health and Social Care Accreditation: Supporting the Deivery of Heath and Socia Care PHARMACY E F P T O L P E D P E C M F D T G L E F R Accreditation: Supporting the Deivery of Heath and Socia Care June 9, 2015 marks Word Accreditation

More information

Teamwork. Abstract. 2.1 Overview

Teamwork. Abstract. 2.1 Overview 2 Teamwork Abstract This chapter presents one of the basic eements of software projects teamwork. It addresses how to buid teams in a way that promotes team members accountabiity and responsibiity, and

More information

Business Banking. A guide for franchises

Business Banking. A guide for franchises Business Banking A guide for franchises Hep with your franchise business, right on your doorstep A true understanding of the needs of your business: that s what makes RBS the right choice for financia

More information

Education sector: Working conditions and job quality

Education sector: Working conditions and job quality European Foundation for the Improvement of Living and Working Conditions sector: Working conditions and job quaity Work pays a significant roe in peope s ives, in the functioning of companies and in society

More information

Gateshead Carers Strategy

Gateshead Carers Strategy Gateshead Carers Strategy 2014-17 Recognised, Vaued and Supported Contents Page Foreword...3 Executive summary...4 Introduction...5 Strategic Priorities Nationa Drivers...5 Loca Drivers...6 Adut Socia

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 Easy Choice Best Pan (HMO) offered by Easy Choice Heath Pan, Inc. Annua Notice of Changes for 2016 You are currenty enroed as a member of Easy Choice Best Pan (HMO). Next year, there wi be some changes

More information

Order-to-Cash Processes

Order-to-Cash Processes TMI170 ING info pat 2:Info pat.qxt 01/12/2008 09:25 Page 1 Section Two: Order-to-Cash Processes Gregory Cronie, Head Saes, Payments and Cash Management, ING O rder-to-cash and purchase-topay processes

More information

How to Cut Health Care Costs

How to Cut Health Care Costs How to Cut Heath Care Costs INSIDE: TEN TIPS FOR MEDICARE BENEFICIARIES What is one of the biggest financia surprises in retirement? Heath care costs. It s a growing concern among many Medicare beneficiaries,

More information

Professional Kingston

Professional Kingston Professiona Kingston Organisationa and workforce deveopment soutions n Facuty of Business and Law Aways improving 0/1 Contents Wecome 2 Why Kingston? 4 Course portfoio 6 Course detais 8 Work-based earning

More information

Qualifications, professional development and probation

Qualifications, professional development and probation UCU Continuing Professiona Deveopment Quaifications, professiona deveopment and probation Initia training and further education teaching quaifications Since September 2007 a newy appointed FE ecturers,

More information

Infrastructure for Business

Infrastructure for Business Infrastructure for Business The IoD Member Broadband Survey Infrastructure for Business 2013 #5 The IoD Member Broadband Survey The IoD Member Broadband Survey Written by: Corin Tayor, Senior Economic

More information

IMPLEMENTING THE RATE STRUCTURE: TIERING IN THE FEE-FOR-SERVICE SYSTEM

IMPLEMENTING THE RATE STRUCTURE: TIERING IN THE FEE-FOR-SERVICE SYSTEM The New Jersey Department of Human Services Division of Deveopmenta Disabiities 1 IMPLEMENTING THE RATE STRUCTURE: TIERING IN THE FEE-FOR-SERVICE SYSTEM Eizabeth M. Shea Assistant Commissioner Thomas S.

More information

PREFACE. Comptroller General of the United States. Page i

PREFACE. Comptroller General of the United States. Page i - I PREFACE T he (+nera Accounting Office (GAO) has ong beieved that the federa government urgenty needs to improve the financia information on which it bases many important decisions. To run our compex

More information

DOING BUSINESS WITH THE REGION OF PEEL A GUIDE FOR NEW AND CURRENT VENDORS

DOING BUSINESS WITH THE REGION OF PEEL A GUIDE FOR NEW AND CURRENT VENDORS DOING BUSINESS WITH THE REGION OF PEEL A GUIDE FOR NEW AND CURRENT VENDORS TABLE OF CONTENTS INTRODUCTION... 1 GOVERNANCE... 1 COMMONLY PURCHASED GOODS AND SERVICES... 1 HOW TO REGISTER YOUR COMPANY...

More information

endorsed programmes With our expertise and unique flexible approach NOCN will work with you to develop a product that achieves results.

endorsed programmes With our expertise and unique flexible approach NOCN will work with you to develop a product that achieves results. endorsed programmes With our expertise and unique fexibe approach NOCN wi work with you to deveop a product that achieves resuts. NOCN is a eading reguated UK awarding organisation that has been creating

More information

COASTLINE GROUP HUMAN RESOURCES STRATEGY 2015 2017. Great homes, great services, great people.

COASTLINE GROUP HUMAN RESOURCES STRATEGY 2015 2017. Great homes, great services, great people. COASTLINE GROUP HUMAN RESOURCES STRATEGY 2015 2017 Great homes, great services, great peope. Contents Foreword 2 Executive summary 1. Achievements 5 2. Context 7 3. Our peope 9.Objectives 11 5. What we

More information

CUSTOM. Putting Your Benefits to Work. COMMUNICATIONS. Employee Communications Benefits Administration Benefits Outsourcing

CUSTOM. Putting Your Benefits to Work. COMMUNICATIONS. Employee Communications Benefits Administration Benefits Outsourcing CUSTOM COMMUNICATIONS Putting Your Benefits to Work. Empoyee Communications Benefits Administration Benefits Outsourcing Recruiting and retaining top taent is a major chaenge facing HR departments today.

More information

STRATEGIC PLAN 2012-2016

STRATEGIC PLAN 2012-2016 STRATEGIC PLAN 2012-2016 CIT Bishopstown CIT Cork Schoo of Music CIT Crawford Coege of Art & Design Nationa Maritime Coege of Ireand Our Institute STRATEGIC PLAN 2012-2016 Cork Institute of Technoogy (CIT)

More information

Benefits That Count. Colonial Life is the proud sponsor of SHRM s Annual Employee Benefits Survey. coloniallife.com

Benefits That Count. Colonial Life is the proud sponsor of SHRM s Annual Employee Benefits Survey. coloniallife.com Benefits That Count Coonia Life is the proud sponsor of SHRM s Annua Empoyee Benefits Survey cooniaife.com 1 Dear Empoyer: Randa C. Horn President & CEO Coonia Life & Accident Insurance Company 1200 Coonia

More information

Human Capital & Human Resources Certificate Programs

Human Capital & Human Resources Certificate Programs MANAGEMENT CONCEPTS Human Capita & Human Resources Certificate Programs Programs to deveop functiona and strategic skis in: Human Capita // Human Resources ENROLL TODAY! Contract Hoder Contract GS-02F-0010J

More information

Ricoh Healthcare. Process Optimized. Healthcare Simplified.

Ricoh Healthcare. Process Optimized. Healthcare Simplified. Ricoh Heathcare Process Optimized. Heathcare Simpified. Rather than a destination that concudes with the eimination of a paper, the Paperess Maturity Roadmap is a continuous journey to strategicay remove

More information

Uncovered Report: Cash Plan and Private Health Insurance Explained

Uncovered Report: Cash Plan and Private Health Insurance Explained Uncovered Report: Cash Pan and Private Heath Insurance Expained Contents 3 Introduction 4 Cash pan products 6 Private heath insurance products 9 How the two pans match up? 10 Concusion 33256_ONEGI_GEN3480_BRO.indd

More information

Strengthening Human Resources Information Systems: Experiences from Bihar and Jharkhand, India

Strengthening Human Resources Information Systems: Experiences from Bihar and Jharkhand, India Strengthening Human Resources Information Systems: Experiences from Bihar and Jharkhand, India Technica Brief October 2012 Context India faces critica human resources (HR) chaenges in the heath sector,

More information

A guide to understanding Childcare Proceedings

A guide to understanding Childcare Proceedings A guide to understanding Chidcare Proceedings About this guide Care Proceedings are one of the most traumatic and emotiona episodes that can happen in anyone s ife. When Chidren s Services (formery Socia

More information

Undergraduate Studies in. Education and International Development

Undergraduate Studies in. Education and International Development Undergraduate Studies in Education and Internationa Deveopment Wecome Wecome to the Schoo of Education and Lifeong Learning at Aberystwyth University. Over 100 years ago, Aberystwyth was the first university

More information

Older people s assets: using housing equity to pay for health and aged care

Older people s assets: using housing equity to pay for health and aged care Key words: aged care; retirement savings; reverse mortgage; financia innovation; financia panning Oder peope s assets: using housing equity to pay for heath and aged care The research agenda on the ageing

More information

Creative learning through the arts an action plan for Wales

Creative learning through the arts an action plan for Wales Creative earning through the arts an action pan for Waes 2015 2020 Audience The entire teaching workforce and government and nationa partners, incuding regiona education consortia, oca authorities, governing

More information

The Productive Therapist and The Productive Clinic Peter R. Kovacek, MSA, PT

The Productive Therapist and The Productive Clinic Peter R. Kovacek, MSA, PT The Productive Therapist and The Productive Cinic Peter R. Kovacek, MSA, PT Format Interactive Discussions among equa peers Constructive argument Reaity Oriented Mutua Accountabiity Expectation Panning

More information

Helpful hints on how to avoid slips, trips and falls

Helpful hints on how to avoid slips, trips and falls Hepfu hints on how to avoid sips, trips and fas Prevention is better than cure HOUSING AND COMMUNITY LIVING www.uton.gov.uk 2 Introduction As we get oder and ess steady on our feet, there is an increased

More information

Internal Control. Guidance for Directors on the Combined Code

Internal Control. Guidance for Directors on the Combined Code Interna Contro Guidance for Directors on the Combined Code ISBN 1 84152 010 1 Pubished by The Institute of Chartered Accountants in Engand & Waes Chartered Accountants Ha PO Box 433 Moorgate Pace London

More information

Learning from evaluations Processes and instruments used by GIZ as a learning organisation and their contribution to interorganisational learning

Learning from evaluations Processes and instruments used by GIZ as a learning organisation and their contribution to interorganisational learning Monitoring and Evauation Unit Learning from evauations Processes and instruments used by GIZ as a earning organisation and their contribution to interorganisationa earning Contents 1.3Learning from evauations

More information

Apprenticeships. Everything you need to know about Apprenticeships with West Sussex County Council. Apprenticeships

Apprenticeships. Everything you need to know about Apprenticeships with West Sussex County Council. Apprenticeships Apprenticeships Everything you need to know about Apprenticeships with West Sussex County Counci Apprenticeships Apprenticeships September 2013 What is an Apprenticeship? An apprenticeship is a nationay

More information

Person-Centred Care: Walk the talk! SPONSORSHIP PROSPECTUS IQ CONFERENCE / NOVEMBER 25-26 / EDMONTON

Person-Centred Care: Walk the talk! SPONSORSHIP PROSPECTUS IQ CONFERENCE / NOVEMBER 25-26 / EDMONTON Person-Centred Care: Wak the tak! SPONSORSHIP PROSPECTUS IQ CONFERENCE / NOVEMBER 25-26 / EDMONTON Person-Centred Care: Wak the tak! SPONSORSHIP PROSPECTUS About the Conference Join the Aberta Continuing

More information

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow some of which may not appy your account Some of these may

More information

HEALTH PROFESSIONS PATHWAYS

HEALTH PROFESSIONS PATHWAYS T heoffic eofcommuni t yco egeres ea r c ha ndl ea der s hi p Co egeofe duc a t i ona ti i noi s The Heath Professions Pathways (H2P) Consortium is a nationa consortium comprised of nine coeges in five states

More information

Ricoh Legal. ediscovery and Document Solutions. Powerful document services provide your best defense.

Ricoh Legal. ediscovery and Document Solutions. Powerful document services provide your best defense. Ricoh Lega ediscovery and Document Soutions Powerfu document services provide your best defense. Our peope have aways been at the heart of our vaue proposition: our experience in your industry, commitment

More information

Immunisation of healthcare and laboratory staff

Immunisation of healthcare and laboratory staff 12 of heathcare and aboratory staff Heath and safety at work Under the Heath and Safety at Work Act (HSWA) 1974, empoyers, empoyees and the sef-empoyed have specific duties to protect, so far as reasonaby

More information

D VISION. OCtech. orangeburg-calhoun technical college. email askme@octech.edu. call 803.535.1234 or 1.800.813.6519

D VISION. OCtech. orangeburg-calhoun technical college. email askme@octech.edu. call 803.535.1234 or 1.800.813.6519 HeathScienceOutside_Layout 1 8/20/2015 10:04 AM Page 1 D VISION orangeburg-cahoun technica coege focus nursing+heath science emai askme@octech.edu ike us foow us ca 803.535.1234 or 1.800.813.6519 office

More information

Overview of Health and Safety in China

Overview of Health and Safety in China Overview of Heath and Safety in China Hongyuan Wei 1, Leping Dang 1, and Mark Hoye 2 1 Schoo of Chemica Engineering, Tianjin University, Tianjin 300072, P R China, E-mai: david.wei@tju.edu.cn 2 AstraZeneca

More information

DigitalKitbag. Email marketing

DigitalKitbag. Email marketing Emai marketing Who are Digita Kitbag? We re your business marketing team Digita Kitbag is owned and operated by Johnston Press, one of the argest regiona media pubishers in the UK and Ireand. We have a

More information

Asia Pacific Disability Rehabilitation Journal

Asia Pacific Disability Rehabilitation Journal DEVELOPMENTAL ARTICLES Asia Pacific Disabiity Rehabiitation Journa PRIMARY HEALTH CARE AND COMMUNITY BASED REHABILITATION: IMPLICATIONS FOR PHYSICAL THERAPY Tracy Bury* ABSTRACT The Word Confederation

More information

l l ll l l Exploding the Myths about DETC Accreditation A Primer for Students

l l ll l l Exploding the Myths about DETC Accreditation A Primer for Students Expoding the Myths about DETC Accreditation A Primer for Students Distance Education and Training Counci Expoding the Myths about DETC Accreditation: A Primer for Students Prospective distance education

More information

READING A CREDIT REPORT

READING A CREDIT REPORT Name Date CHAPTER 6 STUDENT ACTIVITY SHEET READING A CREDIT REPORT Review the sampe credit report. Then search for a sampe credit report onine, print it off, and answer the questions beow. This activity

More information

How to deal with personal financial problems

How to deal with personal financial problems How to dea with persona financia probems D I S P U T E R E S O L U T I O N Introduction Heping you face the future with confidence In 2014, the eve of consumer debt in the UK grew to reach a seven-year

More information

Corporate Plan 2013-14

Corporate Plan 2013-14 Corporate Pan 2013-14 City of Bradford Metropoitan District Counci Foreword Bradford Counci is committed to working with citizens and partners to protect and improve our quaity of ife at a time when individuas,

More information

Behavioral Health Centers of Excellence

Behavioral Health Centers of Excellence Behaviora Heath Centers of Exceence The Future of Heath Written by: Dae Jarvis, Jarvis and Associates Written for: Nationa Counci for Behaviora Heath Apri 30, 2014 Behaviora Heath Centers of Exceence:

More information

Consumer Directed Community Supports. Lead Agency Operations Manual

Consumer Directed Community Supports. Lead Agency Operations Manual Consumer Directed Community Supports Lead Agency Operations Manua Tabe of Contents Introduction to Consumer Directed Community Supports (CDCS) 1 Impementation of CDCS Statewide 2 1.1 HCBS Program Eigibiity

More information

AUSTRALIA S GAMBLING INDUSTRIES - INQUIRY

AUSTRALIA S GAMBLING INDUSTRIES - INQUIRY Mr Gary Banks Chairman Productivity Commission PO Box 80 BELCONNEN ACT 2616 Dear Mr Banks AUSTRALIA S GAMBLING INDUSTRIES - INQUIRY I refer to the Issues Paper issued September 1998 seeking submissions

More information

Network/Communicational Vulnerability

Network/Communicational Vulnerability Automated teer machines (ATMs) are a part of most of our ives. The major appea of these machines is convenience The ATM environment is changing and that change has serious ramifications for the security

More information

Back to the Basics: Building a Financial Safety Net Begins with Life and Disability Insurance. Benefits at Work Series. A Colonial Life White Paper

Back to the Basics: Building a Financial Safety Net Begins with Life and Disability Insurance. Benefits at Work Series. A Colonial Life White Paper Back to the Basics: Buiding a Financia Safety Net Begins with Life and Disabiity Insurance Benefits at Work Series A Coonia Life White Paper November 2011 Tabe of Contents Executive Summary 1 The Far-Reaching

More information

LADDER SAFETY Table of Contents

LADDER SAFETY Table of Contents Tabe of Contents SECTION 1. TRAINING PROGRAM INTRODUCTION..................3 Training Objectives...........................................3 Rationae for Training.........................................3

More information

Bite-Size Steps to ITIL Success

Bite-Size Steps to ITIL Success 7 Bite-Size Steps to ITIL Success Pus making a Business Case for ITIL! Do you want to impement ITIL but don t know where to start? 7 Bite-Size Steps to ITIL Success can hep you to decide whether ITIL can

More information

The Aviva UK Health Health of the Workplace Report Issue 4. October 2010. aviva.co.uk/health 1

The Aviva UK Health Health of the Workplace Report Issue 4. October 2010. aviva.co.uk/health 1 The Aviva UK Heath Heath of the Workpace Report Issue 4 October 2010 aviva.co.uk/heath 1 Foreword Now in its fourth year, Heath of the Workpace is Aviva s annua study that canvases GP, empoyer and empoyee

More information

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES About ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow, some of which may not appy your account. Some of

More information

Diploma Decisions for Students with Disabilities. What Parents Need to Know

Diploma Decisions for Students with Disabilities. What Parents Need to Know Dipoma Decisions for Students with Disabiities What Parents Need to Know Forida Department of Education Bureau of Exceptiona Education and Student Services Revised 2005 This is one of many pubications

More information

ASSET MANAGEMENT OUR APPROACH

ASSET MANAGEMENT OUR APPROACH ASSET MANAGEMENT OUR APPROACH CONTENTS FOREWORD 3 INTRODUCTION 4 ASSET MANAGEMENT? 6 THE NEED FOR CHANGE 6 KEY PRINCIPLES 7 APPENDIX 1 19 GLOSSARY 20 2 FOREWORD Few things affect our customers ives as

More information

3.3 SOFTWARE RISK MANAGEMENT (SRM)

3.3 SOFTWARE RISK MANAGEMENT (SRM) 93 3.3 SOFTWARE RISK MANAGEMENT (SRM) Fig. 3.2 SRM is a process buit in five steps. The steps are: Identify Anayse Pan Track Resove The process is continuous in nature and handed dynamicay throughout ifecyce

More information

ICAP CREDIT RISK SERVICES. Your Business Partner

ICAP CREDIT RISK SERVICES. Your Business Partner ICAP CREDIT RISK SERVICES Your Business Partner ABOUT ICAP GROUP ICAP Group with 56 miion revenues for 2008 and 1,000 empoyees- is the argest Business Services Group in Greece. In addition to its Greek

More information

History of Stars and Rain Education Institute for Autism (Stars and Rain)

History of Stars and Rain Education Institute for Autism (Stars and Rain) History of Education Institute for Autism () Estabished:: March 15. 1993 in Beijing Founder:: Ms. Tian Huiping (mother of a boy with autism) STARS AND RAIN was founded in 1993 by a parent and is China

More information

Pay-on-delivery investing

Pay-on-delivery investing Pay-on-deivery investing EVOLVE INVESTment range 1 EVOLVE INVESTMENT RANGE EVOLVE INVESTMENT RANGE 2 Picture a word where you ony pay a company once they have deivered Imagine striking oi first, before

More information

We are XMA and Viglen.

We are XMA and Viglen. alearn with Microsoft 16pp 21.07_Layout 1 22/12/2014 10:49 Page 1 FRONT COVER alearn with Microsoft We are XMA and Vigen. Ca us now on 0115 846 4900 Visit www.xma.co.uk/aearn Emai alearn@xma.co.uk Foow

More information

Protection Against Income Loss During the First 4 Months of Illness or Injury *

Protection Against Income Loss During the First 4 Months of Illness or Injury * Protection Against Income Loss During the First 4 Months of Iness or Injury * This note examines and describes the kinds of income protection that are avaiabe to workers during the first 6 months of iness

More information

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l. l l. l l. l l

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l. l l. l l. l l ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow some of which may not appy your account Some of these may

More information

Application Guidance. Applying for a job with the Council Understanding the process and the benefits of working with us

Application Guidance. Applying for a job with the Council Understanding the process and the benefits of working with us Appication Guidance Appying for a job with the Counci Understanding the process and the benefits of working with us Contents Introduction...3 Supporting Empoyees...4 Deveopment Opportunities Saary/Pay

More information

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow some of which may not appy your account Some of these may

More information

ELECTRONIC FUND TRANSFERS. l l l. l l. l l l. l l l

ELECTRONIC FUND TRANSFERS. l l l. l l. l l l. l l l Program Organization = Number "1060" = Type "123342" = "ETM2LAZCD" For = "502859" "TCCUS" "" Name "WK Number = Name "First "1001" = "1" Eectronic = "1001" = Financia "Jane Funds Doe" Northwest Xfer PG1

More information

Leadership & Management Certificate Programs

Leadership & Management Certificate Programs MANAGEMENT CONCEPTS Leadership & Management Certificate Programs Programs to deveop expertise in: Anaytics // Leadership // Professiona Skis // Supervision ENROLL TODAY! Contract oder Contract GS-02F-0010J

More information

Filling the Revenue Gap

Filling the Revenue Gap Fiing the Revenue Gap How Brokers Can Leverage Vountary Benefits to Buid Business Benefits at Work Series A Coonia Life White Paper May 2011 Tabe of Contents Executive Summary 1 Vountary Benefits Create

More information

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l l. l l

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l l. l l ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow, some of which may not appy your account Some of these

More information

Understanding. nystagmus. RCOphth

Understanding. nystagmus. RCOphth Understanding nystagmus RCOphth RNIB s understanding series The understanding series is designed to hep you, your friends and famiy understand a itte bit more about your eye condition. Other tites in the

More information

Message. The Trade and Industry Bureau is committed to providing maximum support for Hong Kong s manufacturing and services industries.

Message. The Trade and Industry Bureau is committed to providing maximum support for Hong Kong s manufacturing and services industries. Message The Trade and Industry Bureau is committed to providing maximum support for Hong Kong s manufacturing and services industries. With the weight of our economy shifting towards knowedge-based and

More information

Advanced ColdFusion 4.0 Application Development - 3 - Server Clustering Using Bright Tiger

Advanced ColdFusion 4.0 Application Development - 3 - Server Clustering Using Bright Tiger Advanced CodFusion 4.0 Appication Deveopment - CH 3 - Server Custering Using Bri.. Page 1 of 7 [Figures are not incuded in this sampe chapter] Advanced CodFusion 4.0 Appication Deveopment - 3 - Server

More information

8x8 Webinar: Prepare Now to Survive a Disaster Later

8x8 Webinar: Prepare Now to Survive a Disaster Later 8x8 Webinar: Prepare Now to Survive a Disaster Later January 23, 2013 2009 NASDAQ-LISTED: EGHT The materias presented in the webinar provided by 8x8, Inc. are intended to provide genera information on

More information

What to do before, during and after a flood

What to do before, during and after a flood Suffok Food Risk Management Partnership What to do before, during and after a food Practica advice on what to do to protect yoursef and your property "Over 5.5 miion properties in Engand and Waes are at

More information

Design Considerations

Design Considerations Chapter 2: Basic Virtua Private Network Depoyment Page 1 of 12 Chapter 2: Basic Virtua Private Network Depoyment Before discussing the features of Windows 2000 tunneing technoogy, it is important to estabish

More information

Integrating Risk into your Plant Lifecycle A next generation software architecture for risk based

Integrating Risk into your Plant Lifecycle A next generation software architecture for risk based Integrating Risk into your Pant Lifecyce A next generation software architecture for risk based operations Dr Nic Cavanagh 1, Dr Jeremy Linn 2 and Coin Hickey 3 1 Head of Safeti Product Management, DNV

More information

The guaranteed selection. For certainty in uncertain times

The guaranteed selection. For certainty in uncertain times The guaranteed seection For certainty in uncertain times Making the right investment choice If you can t afford to take a ot of risk with your money it can be hard to find the right investment, especiay

More information

Hamstring strains. What is a hamstring strain? How do hamstring strains occur? what you ll find in this brochure

Hamstring strains. What is a hamstring strain? How do hamstring strains occur? what you ll find in this brochure what you find in this brochure What is a hamstring strain? How do hamstring strains occur? What you shoud do if a hamstring strain occurs. What rehabiitation you shoud do. Exampe of a return to pay strategy.

More information

Math: Fundamentals 100

Math: Fundamentals 100 Math: Fundamentas 100 Wecome to the Tooing University. This course is designed to be used in conjunction with the onine version of this cass. The onine version can be found at http://www.tooingu.com. We

More information

Auto-Enrolment Services

Auto-Enrolment Services www.mitchecharesworth.co.uk Auto-Enroment Services Part 1: A Unified Soution for Empoyers A combined Payro and Pensions approach to meet your Auto-Enroment obigations autoenroment@mitchecharesworth.co.uk

More information

CERTIFICATE COURSE ON CLIMATE CHANGE AND SUSTAINABILITY. Course Offered By: Indian Environmental Society

CERTIFICATE COURSE ON CLIMATE CHANGE AND SUSTAINABILITY. Course Offered By: Indian Environmental Society CERTIFICATE COURSE ON CLIMATE CHANGE AND SUSTAINABILITY Course Offered By: Indian Environmenta Society INTRODUCTION The Indian Environmenta Society (IES) a dynamic and fexibe organization with a goba vision

More information

Subject: Corns of En gineers and Bureau of Reclamation: Information on Potential Budgetarv Reductions for Fiscal Year 1998

Subject: Corns of En gineers and Bureau of Reclamation: Information on Potential Budgetarv Reductions for Fiscal Year 1998 GAO United States Genera Accounting Office Washington, D.C. 20548 Resources, Community, and Economic Deveopment Division B-276660 Apri 25, 1997 The Honorabe Pete V. Domenici Chairman The Honorabe Harry

More information

Welcome to Colonial Voluntary Benefits. Thank you for your interest in our Universal Life with the Accelerated Death Benefit for Long Term Care Rider.

Welcome to Colonial Voluntary Benefits. Thank you for your interest in our Universal Life with the Accelerated Death Benefit for Long Term Care Rider. Heo, Wecome to Coonia Vountary Benefits. Thank you for your interest in our Universa Life with the Acceerated Death Benefit for Long Term Care Rider. For detai pease ca 877-685-2656. Pease eave your name,

More information

The BBC s management of its Digital Media Initiative

The BBC s management of its Digital Media Initiative The BBC s management of its Digita Media Initiative Report by the Comptroer and Auditor Genera presented to the BBC Trust s Finance and Compiance Committee, 13 January 2011 Department for Cuture, Media

More information

Education Quality Improvement Framework

Education Quality Improvement Framework Education Quaity Improvement Framework for Undergraduate and Postgraduate Medica Education and Training in the UK The duties of a doctor registered with the Genera Medica Counci Patients must be abe to

More information

CONTRIBUTION OF INTERNAL AUDITING IN THE VALUE OF A NURSING UNIT WITHIN THREE YEARS

CONTRIBUTION OF INTERNAL AUDITING IN THE VALUE OF A NURSING UNIT WITHIN THREE YEARS Dehi Business Review X Vo. 4, No. 2, Juy - December 2003 CONTRIBUTION OF INTERNAL AUDITING IN THE VALUE OF A NURSING UNIT WITHIN THREE YEARS John N.. Var arvatsouakis atsouakis DURING the present time,

More information

Older people with type 2 diabetes

Older people with type 2 diabetes Institute of Diabetes for Oder Peope Oder peope with type 2 diabetes European chaenges and the need for improved care Foreword The incidence of type 2 diabetes meitus in Europe is now at epidemic eves.

More information

ELEVATING YOUR GAME FROM TRADE SPEND TO TRADE INVESTMENT

ELEVATING YOUR GAME FROM TRADE SPEND TO TRADE INVESTMENT Initiatives Strategic Mapping Success in The Food System: Discover. Anayze. Strategize. Impement. Measure. ELEVATING YOUR GAME FROM TRADE SPEND TO TRADE INVESTMENT Foodservice manufacturers aocate, in

More information

The definition of insanity is doing the same thing over and over again and expecting different results

The definition of insanity is doing the same thing over and over again and expecting different results insurance services Sma Business Insurance a market opportunity being missed Einstein may not have known much about insurance, but if you appy his definition to the way existing brands are deveoping their

More information