Ontario’s decision to move more hospital-based services to the community is a sensible and laudable policy that has to be backed up with appropriate safety and quality regulation, as well as reimbursement practices.
In the last couple of years, in the face of clear, published evidence of quality problems in at least some private clinics conducting procedures in Ontario, the Ontario College of Physicians and Surgeons (CPSO) wisely introduced an important tool in the regulation of physicians working in “out of hospital premises” (OOHP), now regulated under the Medicine Act. A number of “Standards” are associated with the regulation, which cover a range of obligations for the designated Medical Director and Most Responsible Physicians operating in the clinic. This has led to the inspection of multiple clinic settings where physicians practice and a significant and important push to raise standards for those clinics that were deficient.
Recent stories by Theresa Boyle in the Toronto Star have highlighted several serious Hepatitis-C infections acquired in 3 private endoscopy clinics in Ontario over the last 3 years (Downsview Endoscopy Clinic, North Scarborough Endoscopy Clinic, the Ontario Endoscopy Clinic). The Rothbart pain clinic also appears to have infected nine patients with bacteria following epidural injections, which caused serious harm including epidural abscess, incontinence and meningitis. The disclosure of these recent serious harms to a number of individuals across different clinic settings raises questions about the adequacy of infection control in some community clinics and the need to strengthen the current standards with respect to four points.
Happily, Health Minister Hoskins has stepped up to the plate this past Saturday with clarity and created an imperative for transparency from both the CPSO and the local Public Health authorities when it comes to identifying the clinic status and reporting their performance publicly.
Here are four areas to consider for the ministry in their commitment to deepen the transparency commitment in legislation.
1. Raise the standard of infection control
It appears that in a number of these clinics, infection control procedures were not adequate. A revisiting of the existing CPSO standard for safe injection and infection control is warranted to raise the standard and not see standards as a ‘middle road’. The use of multi-dose vials in outpatient settings are associated with “frequent and recurring infectious transmission risk” according to Public Health Ontario and other sources. The CDC notes that although multi-dose vials can be used for more than one patient, ideally they should be used for only one patient to maximize safety. Such calls have been repeated elsewhere. Raising the ‘standard’ by making the safer choice easier is the prudent course here.
2. Robust public reporting and disclosure
We know that public reporting and disclosure of safety and quality performance in hospital settings drive improvements in care, largely by appealing to the natural instincts of physicians and program leaders to do a better job. All hospitals in Ontario are required to report on hospital acquired infections and individual data can be viewed, with ease, on the Health Quality Ontario website. It is unclear why the CPSO has so little detailed information on investigations on its public website but happily this may be about to change with Minister Hoskins intervention. In community clinics we need a ‘standard’ to post publicly simple indicators of quality, such as infection control and adverse events on each clinic website as a Standard of Care. The ‘standard’ of practice in such clinics should be public reporting on their own or through the college. In association with regular inspection, public reporting is key to keeping everyone honest and on their toes for safety and quality.
3. Identify clearly who is responsible for follow-up, notification and recall
Precisely who is responsible for the orderly notification and recall of potentially affected patients who may have been exposed to an infection at an OOHP clinic? That responsibility is anything but clear based on the cases mentioned in The Toronto Star. Once again the logically responsible entity is the clinic itself, with assistance from public health for tracing and follow-up. This is not specified in the current standard and as a consequence patients who may have been infected may remain totally unaware. Some clarity on follow-up and notification in the proposed legislative reform is a sensible idea.
4. Do not reimburse procedures that harm patients
Most, but not all, services provided in community clinics are reimbursed directly to the physicians or the corporate entity who owns them. In the UK and US, many preventable, hospital-acquired infections constitute “never events” which are not reimbursed by public and many private payers. The UK List includes wrongly prepared injectable medication. “Never events” were introduced by Ken Kizer when he was leading the National Quality Forum in the US. Ontario to the best of my knowledge has never adopted a ‘never events’ list for non-reimbursement, even though the case was made to do so during the creation of Health Quality Ontario. The Ontario MOHLTC should reconsider a “never events” list, given the number of other jurisdictions who have generated safety improvements associated with public reporting and non-reimbursement for these adverse events. In 2003 Minnesota became the first American state to report serious adverse health events. In 2013 in Minnesota registered the largest decrease in these events since the inception of the reporting system.
The shift towards more community service providers doing out of hospital procedures and working in potentially more efficient environments must be accompanied by a learning culture of safety and quality regulation. These recent serious and preventable injuries create a moment of opportunity to strengthen safety in these community clinics. Let’s hope that Minister Hoskins can seize the moment and implement a new standard of safety in these clinics.