Primary care is the foundation of Ontario’s health care system and more than 137,000 patient care visits are made every day to primary care providers – family physicians, general practitioners and nurse practitioners – in the province.
However the quality of care that patients receive in primary care is largely unknown. Even primary care providers who evaluate their own care have virtually no way to compare the quality of the care they deliver with that of their peers, or to other benchmarks.
The data infrastructure for primary care is weaker than for any other sector in Ontario health care, says Ben Chan, chief executive officer of Health Quality Ontario (HQO), the government agency that is mandated to monitor and report on the quality of health care in Ontario.
“There’s a need for more accountability in the system and the first step is to be able to measure performance…. you can’t manage what you can’t measure,” he says.
Measuring care to improve quality
One primary care clinic that does measure the care it provides is Dorval Medical, a family health team in Oakville Ontario, The clinic was established in 1989 and, in 2009, implemented a system designed to deliver high quality of care, high capacity and lower than average costs.
As a result of its efforts, the clinic is now unique and in a position of leadership in the province, says Rick Glazier, a family physician at St. Michael’s Hospital in Toronto and a research scientist at the Institute for Clinical Evaluative Sciences.
To begin to address the accountability gap on a province-wide basis, HQO is meeting with the Canadian Institute for Health Information and Ontario leaders in primary care next month to seek consensus about a set of key indicators to measure quality of care for primary care providers.
Chan says subsequent challenges will be to ensure greater uptake of EMRs among primary care practitioners (slightly more than half now use them) and to require all vendors of electronic medical records (EMRs) to include the key indicators.
Flexible set of quality indicators
Care providers at the Oakville clinic have already selected a set of 30 to 40 quality indicators, ensuring flexibility so that indicators can be changed or re-weighted as circumstances change, and tailored their EMRs to collect the data.
Indicators include information from patients, for example about their wait times for appointments, and also the number of eligible patients who had received flu shots, vaccinations, and routine screening tests such as Pap smears.
While other primary care providers in Ontario also look at some of these quality indicators, the Oakville clinic is unique in that the patients’ opinions determine the weighting of the indicators. The clinic regularly surveys its 6,700 rostered patients, canvassing for their expectations and their level of satisfaction.
“It crucial to find a process for the public to engage in refinement of the indicators,” says George Southey, the clinic’s founder who provided leadership for the changes.
Same-day medical appointments
The clinic was also an early adopter of the system known as “advanced access” or “open access” for booking patient visits. Advanced access assures the availability of same-day appointments but only about five per cent of primary care providers in the province currently offer this type of access, according to HQO’s Chan.
David Martin, a patient at Dorval Medical, is a former president of the Hospital for Sick Children. “My wife and I liked our previous doctor very much, but the office was always full of sick people and you had to wait,” says Martin, who is 80. In contrast “the whole thing flows beautifully” at Dorval Medical, he says. “You get to see a doctor right away, you don’t have to wait at the lab, you can walk in and get a copy of your lab results the next day. As a patient, you appreciate these things.”
The clinic’s staff includes six doctors, two nurse practitioners, three registered nurses, a lab technician, a part-time pharmacist and part time social worker as well as an executive director and six support staff.
Southey says his effort has been directed at shifting away from the current system in which physicians are paid by government, but are not accountable to government—the public payment/private practice model that has been the dominant paradigm in Canada since the introduction of Medicare.
Capitation payment helped facilitate efficiencies
Dorval Medical was among the first in Ontario to operate on a capitation model—in which payment is based on the number of enrolled patients, not the number of insured services provided. “That got the ball rolling and allowed us to start exploring efficiencies,” says Southey.
The process of transforming the practice was initially disruptive, acknowledges Southey. “I am working in the face of what is economically logical,” he says, laughing. (Southey describes the clinic’s transformation and the rationale behind it in a 125-page document titled The Dorval Model, an Accountable, Performance-Oriented Model for Primary Care.)
For one thing, a key principle behind the clinic’s model is that individual health care providers operate as a group, sharing responsibility, and working to common objectives. As well, physicians share the revenue. “We lost three doctors who did not feel comfortable with that model,” says Southey.
But he’s adamant that measuring the quality of care in a group context is beneficial. “There’s safety for being human within a group— a person who perhaps isn’t performing up to standard can safely improve because they work with people they know and rely on in a trusting relationship. So that is a very positive force for improvement without any threat.” Each month, the clinic produces a report card for each physician and for the practice as a whole.
Knowing how well you are doing
The clinic’s approach appealed so much to newly minted physician Lennox Mirander that he joined the clinic practice just over a year ago. Mirander, 34, was a research scientist before he went to medical school and he appreciates the detailed feedback that’s provided.
“There is internal policing that takes place where we look at access of patients to each physician and our ability to hit goals in terms of prevention for our patients, monitoring diabetes and hypertension and vaccination for children,” he says. “If we don’t have something like that in place, how can you possibly know how well you are doing and where you need to improve?”
Mirander also likes the fact that the model allows him the time to follow his patients in hospital, and to care for patients in long-term care facilities. “I’ve done lots of locums, and there aren’t too many models that allow you to do these things, because they are so committed to sheer volume in clinic that you don’t have ability or time.”
The medical practice’s costs are about $315 a year for each patient and Southey writes in his document that $400 is the comparable amount at other comprehensive primary care practices.
Also vital to the Dorval Model is the maintenance of a comprehensive patient medical record. Southey is working on creating a secure portal so that patients can access their medical record wherever they are.
Dorval Medical’s surveys of patients indicate a very high level of patient satisfaction. In comparison, there’s evidence that, overall, the Ontario public does not feel all that well served by their primary care providers. More than 30 per cent of patients don’t believe their medical care is coordinated, and 25 per cent report that they don’t get to ask enough questions of their primary care providers, according to HQO’s 2012 report.
The Ontario Ministry of Health and Long-Term Care is reviewing the Dorval Model and welcomes suggestions on ways to “develop a more responsive and sustainable primary care sector,” ministry spokesperson Tori Gass wrote in an email. Southey would love to see other primary care clinics adopt his model to establish that it can be widely implemented.