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Shifting clinical accountability and the pursuit of quality: Aligning clinical and administrative approaches
FEATURE ARTICLE
Shifting clinical accountability and the pursuit of quality: Aligning clinical and administrative approaches by Mark J. Dobrow, Terrence Sullivan, and Carol Sawka
Mark J. Dobrow, PhD, is a Scientist with the Cancer Services and Policy Research Unit of Cancer Care Ontario, and Assistant Professor for the Department of Health Policy, Management and Evaluation at the University of Toronto.
Terrence Sullivan, PhD, is the President and Chief Executive Officer of Cancer Care Ontario, and Associate Professor for the Departments of Health Policy, Management and Evaluation and Public Health Sciences at the University of Toronto.
Carol Sawka, MD, FRCPC, is the Vice-President of Clinical Programs for Cancer Care Ontario, and Associate Professor for the Departments of Medicine, Health Policy, Management and Evaluation and Public Health Sciences at the University of Toronto.
Abstract This paper presents a narrative review of the literature on clinical accountability, and draws particularly on England’s experience establishing “clinical governance” as a base to examine the establishment of a clinical accountability framework for cancer services in Ontario. The review suggests that clinical governance and accountability approaches that actively mesh clinical and administrative approaches at both system and local levels are more likely to be effective in improving quality of care.
A
ccountability has become a popular buzzword in Canadian health services, directing increasing scrutiny towards clinical performance. Two national reviews on the Canadian health care system1,2 and a number of national consultation exercises3-5 have emphasized the need for health care professionals, managers, policy-makers and researchers to consider accountability relationships within the Canadian health system. However, while accountability now routinely emerges in health care discourse, some have suggested this may be more rhetoric than substantive dialogue.6-8 This paper presents a narrative review9 of the literature on clinical accountability, drawing on England’s experience in establishing “clinical governance” as a base to examine the establishment of a clinical accountability framework for cancer services in Ontario.
Shifting clinical accountability Clinicians have multiple accountabilities, including to patients, clinical colleagues, professional regulatory colleges/associations, health care organizations, public or private payers, legal systems and governments, and can be held accountable for their professional competence, clinical and financial performance, adherence to best practice and/or legal and ethical conduct.10-14 Historically, professional accountability has dominated the medical profession,15 reflecting individual patient-clinician relationships that preserve clinical autonomy for decisions made in the patients’ best interests. This agency relationship is based on an informational imbalance between the principal (patient) and agent (clinician)13 and is characterized by the inherent uncertainty regarding preferences, risks and expected outcomes of specific health interventions.16 Increasingly, there are signs that the professional model of accountability is being challenged in health care.17,18 Evidence-based guidance and performance measurement/reporting have exposed persistent deficiencies in the quality of care provided19,20 and altered the context for what constitutes expertise.12 Clinicians are increasingly asked to monitor and justify their own practice both for quality and cost.21 There is a trend towards more collaborative, transdisciplinary practice reducing the ongoing interactions an individual clinician has with an individual patient.21 In this context, managerial accountability becomes increasingly more relevant. Managerial accountability is based on a hierarchical relationship between administrative and clinical parties where expectations are clear, the means to achieve them are known and credible information on performance is available.12,15 Administra6
Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2008
SHIFTING CLINICAL ACCOUNTABILITY AND THE PURSUIT OF QUALITY: ALIGNING CLINICAL AND ADMINISTRATIVE APPROACHES
tors can contrast evidence-based expectations against actual performance to drive their relationships with clinicians. Associated with an expanding role for managerial accountability, clinical accountability is increasingly influenced by the legal context. Legal accountability involves a relationship between two relatively autonomous parties12 and can reflect binding contracts where evidence-based guidance is transformed into explicit performance expectations. With the recent establishment of national wait time targets for various health services22 and legal challenges (e.g., Chaoulli/Zeliotis) attempting to define health service rights and obligations,23,24 the medico-legal implications of more explicit expectations are just beginning to surface. Mello et al.25 commented that, from an American perspective, “[e]fforts by aggressive medical malpractice attorneys could rapidly transform…[evidence-based] standards from marketplace advantages for compliant hospitals to performance expectations required by law.” Furthermore, legal accountability underlies recent interest in value-based purchasing (e.g., pay-for-performance, payfor-participation, pay-for-reporting) where incentives for performance improvements are incorporated into agreements between health care purchasers and providers.26-29 In fact, Emanuel and Emanuel21 suggest that “[a]t the level of the physician-patient relationship, one of the most important threats to professional accountability is the financial incentive.” As financial incentives make explicit the expectations and outcomes of clinical activities, clinicians, especially physicians, may increasingly have less control over their own practice, making professional accountability less relevant. These shifting clinical accountabilities are set within the broader context of political accountability, where stakeholders are given “voice” to express their satisfaction or dissatisfaction with prevailing policies.12,15 However, while there is growing interest in enhancing the role of the public in influencing accountability,6,30 political accountability is challenged by a range of methodological questions linked to the nature of representation, processes of citizen engagement and methods of deliberation, that reflect varying objectives and a low degree of control for achieving clinical accountability.12,15 With the professional model of clinical accountability no longer a firmly entrenched feature of our health care systems, managerial and legal accountability are becoming increasingly more important. Constant reform of health system governance reflects ongoing adaptation to this evolving context with important ramifications at all levels, particularly for clinicians.
greater use of performance information, reduce clinical practice variation and develop mechanisms to address poor performance at individual, team and organization levels.33 Many commentators observed that the clinical governance framework was not really new, but rather another approach for focusing on quality improvement.33-36 However, the reforms were positioned as a “whole-systems” approach that was necessary to integrate fragmented quality improvement activities and initiate organizational commitment to the structures, systems, status and multidisciplinary culture necessary to improve quality of care.33,36,37 This included the establishment of two key agencies, including the National Institute for Clinical Excellence (NICE – later renamed the National Institute for Health and Clinical Excellence) to set evidence-based standards and the Commission for Health Improvement (later renamed the Healthcare Commission) to monitor performance, within a structure of disease-specific national service frameworks and national frameworks for assessing performance.31,32 In addition to systematically developing the supporting infrastructure necessary for clinical governance, these reforms also placed a duty on NHS organizations to be accountable for quality. Premised on “corporate” governance, a statutory requirement was established for each NHS organization’s Chief Executive Officer, on behalf of the board, to be held accountable for assuring the quality of clinical services, producing regular reports on service quality in the same way as was done to meet existing financial statutory duties.32,33 This integration of corporate and clinical governance was the defining, but perhaps least definable, part of the NHS reforms.35,38 While managers’ and clinicians’ responsibilities became more intertwined, how to align corporate and clinical objectives represented a complex challenge.18,39 Operationalizing this “integrated governance” to reflect the broad scope of clinical practice exposed tensions between individual and population-based objectives11,35 and from a health system perspective, challenged clinicians to both recognize and balance responsibility for quality of care provided and resources utilized.40 Malcolm and Mays41 pose two critical questions:
Clinical governance Approaching the end of the past millennium, the National Health Service (NHS) in England embarked on a prolonged and systematic reformation, centred on the introduction of “clinical governance.”31,32 Clinical governance was initially and somewhat ambiguously “…defined as a system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.”32 The intent was to establish a systematic approach to increase focus on quality, incorporate
It appears that the NHS has bought into the need to devolve responsibility for management of resources, by explicitly linking the use of financial incentives to clinical performance. The NHS has recently launched several value-based purchasing initiatives, including payment by results, which is based on national tariffs used to pay providers for the volume and type of work performed,42 practice-based commissioning, which allows regional authorities (e.g., primary care trusts) to contract with General Practitioner (GP) practices to encourage the development of innovative services,43 and the general medical services contract, which provides additional financial
“[s]hould clinical governance…be implemented simply as an extension and formalisation of current initiatives to monitor and audit performance, promote quality, and maximise clinical effectiveness through guidelines and evidence-based practice? Or is it a mechanism through which teams of clinicians improve the quality of care while sharing the management of scarce resources?”
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Figure 1. Integrated approach to clinical accountability.
incentives to GPs for performance based on a large number of quality indicators.44 While the interest in value-based purchasing reflects global movements,26 it may also reflect the challenges of operationalizing clinical governance locally. The Clinical Governance Support Network initially established in 1999 to provide a centralized resource and networking forum for those charged with implementing clinical governance, has recently been disbanded, with the “view that most of the functions currently undertaken by the network could be carried out more appropriately at a local level.”45 So where does this leave clinical governance in England? Some have questioned whether clinical governance has suffered from lofty goals and inconsistent implementation.38,46 The complex institutional changes and refinements that initially dominated the clinical governance agenda may, paradoxically, represent the simple part of the strategic reformations. The NHS has greater structural capacity to support clinical governance than ever; however, these structures also create hierarchical silos that do not necessarily mesh with condition-focused clinical work.47 The NHS experience suggests that a system-wide approach can provide the infrastructure and tools needed to enhance clinical governance; however, real performance improvement requires extended focus on implementation locally. Drawing on the evolving English experience with clinical governance, we consider similar efforts in a different context – the Ontario cancer system. Clinical accountability in the Ontario cancer system While acknowledging the inherent differences between the English and Canadian health systems,48-50 efforts to develop a clinical accountability framework in the Ontario cancer system have been informed by the NHS experience and may provide a glimpse of future health system governance in Canada. Following recommendations from the Cancer Services
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Implementation Committee in December 2001,51 Ontario’s provincial cancer agency, Cancer Care Ontario (CCO), embarked on a restructuring process that systematically altered the roles and responsibilities among key stakeholders in the Ontario cancer system.52,53 CCO no longer directly delivers cancer services to patients, divesting these responsibilities to newly established Regional Cancer Programs (RCPs), based at 14 host hospitals in Ontario. CCO remains the main advisor to the Ontario Ministry of Health and LongTerm Care and now purchases services from the RCPs. CCO established two leadership councils, one comprising mainly clinical leaders, to promote and evaluate quality and safety of care and cancer control for organizations providing cancer services (Clinical Council) and another comprising mainly provincial and regional administrative leaders, to address strategic issues relating to CCO’s provincial cancer plan, integration agreements and matters of performance (Provincial Leadership Council). CCO’s Program in Evidence-Based Care, through groups of clinical experts across the province, maintains its role in the development of clinical practice guidance, while the Cancer Quality Council of Ontario was established to monitor and publicly report on the cancer system’s performance.54 All of this is set within the broader restructuring of the Ontario health system, including the development of Local Health Integration Networks.55 These structural changes were complemented by significant provincial investment in health information systems infrastructure. CCO is currently developing or enhancing a number of important clinical information systems with efforts made to identify and document all current data holdings, specify CCO’s data requirements from the RCPs and establish on-line access to cancer-related data for a broad range of stakeholders.56 This coincides with specific initiatives to develop province-wide computerized physician order entry
SHIFTING CLINICAL ACCOUNTABILITY AND THE PURSUIT OF QUALITY: ALIGNING CLINICAL AND ADMINISTRATIVE APPROACHES
and electronic pathology information management systems that were intended to improve the timeliness, completeness and quality of data reporting. The overhaul of CCO’s information management system also includes focused effort on enhancing capacity to measure, monitor and report on wait times for cancer care and support the monitoring of performance by CCO and the Quality Council. The Cancer System Quality Index provides baseline performance data on more than 20 cancer quality indicators that are publicly accessible and regularly updated.54 This system restructuring and investment in information systems has begun to make available essential tools for enabling clinicians and managers to take on new functions. However, as the NHS experience has revealed, these developments reflect necessary but insufficient steps in the development of a broader clinical accountability framework. Further efforts have focused on the challenging task of operationalizing the defined clinical accountability framework locally. CCO has integrated both clinical and administrative approaches to engage key stakeholders at multiple levels to incorporate clinical accountability activities into their daily work (see Figure 1). The clinical approach involves refocusing CCO’s provincial clinical programs to engage clinical leaders (e.g., in radiation oncology, systemic therapy, surgical oncology, nursing, health human resources, prevention/screening, palliative care, supportive care, pathology and social work) throughout Ontario. These clinical leaders form a network of clinicians who play central roles in the development, interpretation and application of clinical practice guidance, establishing a base of knowledge on what should be done (guidelines/standards) and a means for structuring evaluation and assessment of what is done (performance) in the cancer system. In addition to this clinical program focus, clinical leadership is also being fostered by cancer disease site (e.g., lung, breast, prostate, gastrointestinal, genitourinary, gynecology, head and neck, haematology, melanoma, sarcoma and neuro-oncology). Numerous provincial disease site teams, involving multidisciplinary clinical experts from across the province, support the systematic review of evidence and actively contribute to the development of clinical practice guidance. As important, development of local disease site teams and the support of multidisciplinary cancer conferences (tumour boards) are actively encouraged to facilitate multidisciplinary exchange of information about best practice.57 These local disease site teams are increasingly taking on a leadership role for defining clinical accountability locally and may be the most effective approach to influence clinical discourse, culture and accountability. While the clinical approach places the onus on clinicians to drive successful quality improvement initiatives, efforts are also being made to establish clinical accountability as a central part of cancer system management. With system restructuring efforts and investments in information systems providing the base, the administrative approach extends responsibility for clinical quality and broadens the set of tools available to improve performance. With greater capacity to measure and report on perform-
ance, performance management is becoming a central component of both clinical and administrative leadership responsibilities. Regional clinical and administrative leaders are expected to use performance data to identify gaps in quality of care and target opportunities for quality improvement for their RCPs. Performance data also provides a basis for articulating expected roles/responsibilities through the development of formal contracts and agreements. For example, CCO and the RCPs have entered into contractual relationships with respect to performance (e.g., cancer program integration agreements). A quarterly review brings provincial and regional administrative and clinical leaders to the same table to examine performance and identify improvement strategies. Funding levers further support the integration of clinical and administrative approaches. Funding is linked to quality of care through formal agreements with individual Ontario hospitals to allocate incremental cancer surgery cases (46 hospitals), systemic therapy (24 hospitals) and/or colonoscopies for a colorectal cancer screening program (58 hospitals) as part of a wait time strategy. Participating hospitals are required to participate in RCP activities, adopt standard pathology checklists, capture cancer stage and submit data. The development and evolution of alternate payment plans for specialty provider groups (e.g., medical oncologists, radiation oncologists, surgical oncologists) preserves research time and more clearly sets out performance expectations. Regional administrative leaders use stipends to attract local clinicians to take on responsibility for promoting and coordinating regional quality improvement efforts in surgical oncology and palliative care. Also, an innovation fund has been set up to support projects that evaluate the role that innovative practices can play in driving system-wide quality of care improvements. For example, current projects are evaluating the use of alternate care provider models, such as nurse endoscopists for colorectal cancer screening, advance practice radiation therapists and general practitioners in oncology, which can be applied across Ontario. The integration of clinical and administrative approaches to accountability is best reflected in CCO’s performance improvement cycle. This cycle is based on four key elements that draw on both clinical and administrative input to identify and collect data/information, develop clinical and policy relevant knowledge, actively transfer that knowledge to key stakeholders and, as discussed above, establish performance management as the mechanism to formally engage clinical and administrative leaders in integrated quality improvement efforts (see Figure 2). The development of organizational standards for thoracic surgery in Ontario is a particularly relevant example.58 Clinician-driven data on volume-outcomes relationships for esophagectomy and pneumonectomy led to the development of organizational standards for thoracic surgical oncology based on the contributions of both clinical and administrative leaders. Mechanisms for transferring the developed knowledge to stakeholders included reporting the data publicly on the Cancer System Quality Index59 and through academic publications58 and engaging regional administrative and surgical oncology leaders to explain the organizational standards to clinical and management colleagues. Additional Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2008
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Figure 2. Cancer Care Ontario’s performance improvement cycle.
funds for thoracic surgical oncology were directed to hospitals that agreed to be held accountable for implementing the thoracic surgery standard as part of a cancer surgery agreement with CCO. Together, the clinician-driven standard for thoracic surgical oncology, public reporting of regional- and hospitalspecific volume-outcomes relationships and the contractual linkage of additional funds to the standard have created important synergies. These efforts have been effective in consolidating activity in hospitals where improved outcomes should be achievable. Conclusions Clinical accountability is evolving. Professional accountability no longer dominates clinical accountability relationships, with managerial and legal accountability becoming increasingly more relevant. This reflects more complex relationships among key stakeholders and raises questions about the legitimacy of evolving roles and responsibilities. However, with greater understanding of these evolving accountability relationships, there are also opportunities to significantly improve quality of care. Health system governance has begun to adapt through the implementation of key structural components, advancing a performance-based culture and increasing the responsibility of managers for clinical performance in many contexts.50 Clinical leaders are beginning to adapt to this evolving context as well, by re-evaluating medical professionalism and re-thinking the clinician’s position within the health care system.18,20,60-62 However, maintaining clinical autonomy and emphasis on the individual rather than the population remain fundamental objectives of medical associations that may conflict with the shift away from the professional model of clinical accountability.47,63,64 Will efforts to integrate clinical and administrative approaches towards the common goal of improved quality of care be successful? This review suggests that it is unlikely that one approach or initiative alone will make a significant impact 10
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on quality of care. At minimum, operationalizing clinical accountability requires a systematic and comprehensive strategy with involvement of all major stakeholders. The NHS experience with clinical governance has directed this focus on clinical accountability and exposed the complex operational environment for implementing clinical governance locally. Subsequent efforts in the Ontario cancer system to mesh clinical and administrative approaches at provincial, regional and local levels may provide a Canadian model for using accountability as a base to achieve improvements in quality of care. References 1.
2.
3.
4.
5.
6.
7. 8.
9.
Romanow RJ. Building on Values: The Future of Health Care in Canada. Commission on the Future of Health Care in Canada,2002. Kirby MJL, LeBreton M. The health of Canadians - The federal role (Volume six: Recommendations for reform). Standing Senate Committee on Social Affairs, Science and Technology. Government of Canada,2002. Gagnon D, Menard M. Listening for direction: National consultation on health services and policy issues. Canadian Health Services Research Foundation,2001. Dault M, Lomas J, Barer M. Listening for direction II: National consultation on health services and policy issues for 20042007. Canadian Health Services Research Foundation,2004. Canadian Health Services Research Foundation. Listening for direction III: Preliminary research themes areas. [Accessed March 31, 2008]. Available from: http://www.chsrf.ca Fooks C, Maslove L. Rhetoric, fallacy or dream? Examining the accountability of Canadian health care to citizens. Canadian Policy Research Networks,2004. Loughlin M. On the buzzword approach to policy formulation. Journal of Evaluation in Clinical Practice,2002;8(2):229-42. Sullivan T, Flood CM. Chrétien’s prescription for medicare: A green poultice in lieu of accountability. Canadian Medical Association Journal,2004;170(3):359-60. Mays N, Pope C, Popay J. Systematically reviewing qualitative and quantitative evidence to inform management and policymaking in the health field. Journal of Health Services Research
SHIFTING CLINICAL ACCOUNTABILITY AND THE PURSUIT OF QUALITY: ALIGNING CLINICAL AND ADMINISTRATIVE APPROACHES
and Policy,2005;10(Suppl 1):6-20. 10. Shortell SM, Waters TM, Clarke KWB, Budetti PP. Physicians as double agents: Maintaining trust in an era of multiple accountabilities. Journal of the American Medical Association,1998;280:1102-8. 11. Degeling P. Reconsidering clinical accountability. An examination of some dilemmas inherent in efforts to bolster clinician accountability. The International Journal of Health Planning and Management,2000;15(1):3-16. 12. Deleon L. Accountability in a ‘reinvented’ government. Public Administration,1998;76(3):539-58. 13. Emanuel EJ, Emanuel LL. What is accountability in health care? Annals of Internal Medicine,1996;124(2):229-39. 14. Buetow S, Elwyn G. The window mirror: A new model of the patient-physician relationship. Open Medicine,2008;2(1). 15. Dubois CA, Denis JL. Accountability in Canadian health care systems: Fitting the pieces of the puzzle together. In: Davies HTO, Tavakoli M, editors. Health care policy, performance and finance: Strategic issues in health care management. Aldershot, UK: Ashgate Publishing Limited,2004. 16. Arrow K. Uncertainty and the welfare economics of medical care. The American Economic Review,1963;53(5):941-73. 17. Tuohy CH. Agency, contract, and governance: Shifting shapes of accountability in the health care arena. Journal of Health Politics, Policy and Law,2003;28(2-3):195-216. 18. Doctors in society: Medical professionalism in a changing world. Report of a working party. Royal College of Physicians of London,2005.. 19. Crossing the quality chasm: A new health system for the 21st Century. Institute of Medicine,2001. 20. Millenson ML. The silence. Health Affairs,2003;22(2):103-12. 21. Emanuel EJ, Emanuel LL. Preserving community in health care. Journal of Health Politics, Policy and Law,1997;22(1):14784. 22. Ontario Ministry of Health and Long-Term Care. First ever common benchmarks will allow Canadians to measure progress in reducing wait times (press release). [Accessed May 1, 2008]. Available from: http://www.health.gov.on.ca 23. Ries NM, Caulfield T. Accountability in healthcare and legal approaches. Canadian Policy Research Networks,2004. 24. Flood CM, Sullivan T. Supreme disagreement: The highest court affirms an empty right. Canadian Medical Association Journal,2005;173(2):142-3. 25. Mello MM, Studdert DM, Brennan TA. The Leapfrog Standards: Ready to jump from marketplace to courtroom? Health Affairs,2003;22(2):46-59. 26. Figueras J, Robinson R, Jakubowski E. Purchasing to improve health systems performance: Drawing the lessons. In: Figueras J, Robinson R, Jakubowski E, editors. European observatory on health systems and policies series: Purchasing to improve health systems performance. Berkshire, UK: Open University Press,2005. 27. Birkmeyer NJO, Birkmeyer JD. Strategies for improving surgical quality - Should payers reward excellence or effort? New England Journal of Medicine,2006;354(8):864-70. 28. Doherty RB. Politics calls for a compromise in tactics, not principles. [Accessed May 1, 2008]. Available from: http://www.acponline.org/ 29. Dudley RA. Pay-for-performance research: How to learn what clinicians and policy makers need to know. Journal of the American Medical Association,2005; 294:1821-3. 30. Abelson J, Gauvin FP. Engaging citizens: One route to health care accountability. Canadian Policy Research Networks,2004.
31. Department of Health. The new NHS: Modern, dependable. London, UK: The Stationery Office,1997. 32. Department of Health. A first class service: Quality in the new NHS. London, UK: Crown Copyright,1998. 33. Walshe K, Freeman T, Latham L, Wallace L, Spurgeon P. Clinical governance: From policy to practice. Birmingham, UK: Health Services Management Centre, University of Birmingham,2000. 34. Pringle M. Clinical governance in primary care: Participating inclinical governance. British Medical Journal,2000; 321(7263):737-40. 35. Rosen R. Clinical governance in primary care: Improving quality in the changing world of primary care. British Medical Journal, 2000;321(7260):551-4. 36. Halligan A, Donaldson L. Implementing clinical governance: Turning vision into reality. British Medical Journal, 2001;322:1413-7. 37. Huntington J, Gillam S, Rosen R. Clinical governance in primary care: Organisational development for clinical governance. British Medical Journal,2000;321(7262):679-82. 38. Degeling PJ, Maxwell S, Iedema R, Hunter DJ. Making clinical governance work. British Medical Journal,2004;329(7467):67981. 39. Deighan M, Cullen R, Moore R. The development of integrated governance. London, UK: The NHS Confederation,2004. 40. Degeling P, Maxwell S, Kennedy J, Coyle B. Medicine, management, and modernisation: A “danse macabre?” British Medical Journal,2003; 26:649-52. 41. Malcolm L, Mays N. New Zealand’s independent practitioner associations: A working model of clinical governance in primary care? British Medical Journal,1999;319(7221):1340-2. 42. Audit Commission. Early lessons from payment by results. London, UK: Author,2005. 43. Policy and Strategy Directorate, Department of Health. Health reform in England: Update and commissioning framework. London, UK: Department of Health,2006. 44. Shekelle P. New contract for general practitioners. British Medical Journal,2003;326(7387):457-458. 45. National Health Service. The future of the CGST. [Accessed March 31, 2008]. Available from: http://www.cgsupport.nhs.uk/ 46. Thomas M. The evidence base for clinical governance. Journal of Evaluation in Clinical Practice,2002;8(2):251-4. 47. Degeling P. Realising the development potential of clinical governance. Clinical Chemistry and Laboratory Medicine,2006; 44(6):688-91. 48. Tuohy CH. Dynamics of a changing health sphere: The United States, Britain, and Canada. Health Affairs 1999;18(3):114-34. 49. Blendon RJ, Schoen C, DesRoches C, Osborn R, Zapert K. Common concerns amid diverse systems: Health care experiences in five countries. Health Affairs,2003;22(3):106-21. 50. Sullivan T, Dobrow MJ, Schneider E, Newcomer L, Richards M, Wilkinson L, et al. Améliorer la responsabilité cliniques et performance en cancérologie [Improving clinical accountability and performance in the cancer field]. Pratiques et Organisation des Soins,2008;39(3):207-15. 51. Cancer Services Implementation Committee. Report of the Cancer Services Implementation Committee. Toronto, ON: Ontario Ministry of Health and Long-Term Care;2001. 52. Thompson LJ, Martin MT. Integration of cancer services in Ontario: The story of getting it done. Healthcare Quarterly,2004;7(3):42-8. 53. Sullivan T, Dobrow M, Thompson L, Hudson A. Reconstructing cancer services in Ontario. HealthcarePapers,2004;5(1):69-80. Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2008
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54. Greenberg A, Angus H, Sullivan T, Brown AD. Development of a set of strategy-based system-level cancer care performance indicators in Ontario, Canada. International Journal for Quality in Health Care,2005;17(2):107-14. 55. Ontario Ministry of Health and Long-Term Care. Local Health System Integration Act;2006. [Accessed May 1, 2008]. Available from: http://www.health.gov.on.ca 56. Cancer Care Ontario. IM/IT strategic plan 2008-2011. [Accessed May 1, 2008]. Available from: http://www.cancercare.on.ca 57. Wright FC, De Vito C, Langer B, Hunter A. Multidisciplinary cancer conferences: A systematic review and development of practice standards. European Journal of Cancer,2007;43(6):1002-10. 58. Sundaresan S, Langer B, Oliver T, Schwartz F, Brouwers M, Stern H, et al. Standards for thoracic surgical oncology in a single-payer healthcare system. The Annals of Thoracic Surgery,2007;84(2):693-701.
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59. Cancer Care Ontario and Cancer Quality Council of Ontario. Cancer System Quality Index. [Accessed May 2, 2008]. Available from: http://www.cancercare.on.ca 60. Hedberg CA. Value based purchasing for physicians under Medicare. Hearing before the Subcommittee on Health of the Committee on Ways and Means. U.S. House of Representatives. Session 109-50. [Accessed May 1, 2008]. Available from: http://waysandmeans.house.gov 61. Clancy CM, Scully T. A call to excellence. Health Affairs,2003;22(2):113-5. 62. Richardson WC, Corrigan JM. Provider responsibility and system redesign: Two sides of the same coin. Health Affairs,2003;22(2):116-8. 63. Lewis S. Physicians, it’s in your court now. Canadian Medical Assocation Journal,2005;173(3):275-7. 64. Schumacher A. Doctors put patients first in health care debate. Canadian Medical Association Journal,2005;173(3):277-8.
Shifting clinical accountability and the pursuit of quality: Aligning clinical and administrative approaches by Mark J. Dobrow, Terrence Sullivan, and Carol Sawka
Mark J. Dobrow, PhD, is a Scientist with the Cancer Services and Policy Research Unit of Cancer Care Ontario, and Assistant Professor for the Department of Health Policy, Management and Evaluation at the University of Toronto.
Terrence Sullivan, PhD, is the President and Chief Executive Officer of Cancer Care Ontario, and Associate Professor for the Departments of Health Policy, Management and Evaluation and Public Health Sciences at the University of Toronto.
Carol Sawka, MD, FRCPC, is the Vice-President of Clinical Programs for Cancer Care Ontario, and Associate Professor for the Departments of Medicine, Health Policy, Management and Evaluation and Public Health Sciences at the University of Toronto.
Abstract This paper presents a narrative review of the literature on clinical accountability, and draws particularly on England’s experience establishing “clinical governance” as a base to examine the establishment of a clinical accountability framework for cancer services in Ontario. The review suggests that clinical governance and accountability approaches that actively mesh clinical and administrative approaches at both system and local levels are more likely to be effective in improving quality of care.
A
ccountability has become a popular buzzword in Canadian health services, directing increasing scrutiny towards clinical performance. Two national reviews on the Canadian health care system1,2 and a number of national consultation exercises3-5 have emphasized the need for health care professionals, managers, policy-makers and researchers to consider accountability relationships within the Canadian health system. However, while accountability now routinely emerges in health care discourse, some have suggested this may be more rhetoric than substantive dialogue.6-8 This paper presents a narrative review9 of the literature on clinical accountability, drawing on England’s experience in establishing “clinical governance” as a base to examine the establishment of a clinical accountability framework for cancer services in Ontario.
Shifting clinical accountability Clinicians have multiple accountabilities, including to patients, clinical colleagues, professional regulatory colleges/associations, health care organizations, public or private payers, legal systems and governments, and can be held accountable for their professional competence, clinical and financial performance, adherence to best practice and/or legal and ethical conduct.10-14 Historically, professional accountability has dominated the medical profession,15 reflecting individual patient-clinician relationships that preserve clinical autonomy for decisions made in the patients’ best interests. This agency relationship is based on an informational imbalance between the principal (patient) and agent (clinician)13 and is characterized by the inherent uncertainty regarding preferences, risks and expected outcomes of specific health interventions.16 Increasingly, there are signs that the professional model of accountability is being challenged in health care.17,18 Evidence-based guidance and performance measurement/reporting have exposed persistent deficiencies in the quality of care provided19,20 and altered the context for what constitutes expertise.12 Clinicians are increasingly asked to monitor and justify their own practice both for quality and cost.21 There is a trend towards more collaborative, transdisciplinary practice reducing the ongoing interactions an individual clinician has with an individual patient.21 In this context, managerial accountability becomes increasingly more relevant. Managerial accountability is based on a hierarchical relationship between administrative and clinical parties where expectations are clear, the means to achieve them are known and credible information on performance is available.12,15 Administra6
Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2008
SHIFTING CLINICAL ACCOUNTABILITY AND THE PURSUIT OF QUALITY: ALIGNING CLINICAL AND ADMINISTRATIVE APPROACHES
tors can contrast evidence-based expectations against actual performance to drive their relationships with clinicians. Associated with an expanding role for managerial accountability, clinical accountability is increasingly influenced by the legal context. Legal accountability involves a relationship between two relatively autonomous parties12 and can reflect binding contracts where evidence-based guidance is transformed into explicit performance expectations. With the recent establishment of national wait time targets for various health services22 and legal challenges (e.g., Chaoulli/Zeliotis) attempting to define health service rights and obligations,23,24 the medico-legal implications of more explicit expectations are just beginning to surface. Mello et al.25 commented that, from an American perspective, “[e]fforts by aggressive medical malpractice attorneys could rapidly transform…[evidence-based] standards from marketplace advantages for compliant hospitals to performance expectations required by law.” Furthermore, legal accountability underlies recent interest in value-based purchasing (e.g., pay-for-performance, payfor-participation, pay-for-reporting) where incentives for performance improvements are incorporated into agreements between health care purchasers and providers.26-29 In fact, Emanuel and Emanuel21 suggest that “[a]t the level of the physician-patient relationship, one of the most important threats to professional accountability is the financial incentive.” As financial incentives make explicit the expectations and outcomes of clinical activities, clinicians, especially physicians, may increasingly have less control over their own practice, making professional accountability less relevant. These shifting clinical accountabilities are set within the broader context of political accountability, where stakeholders are given “voice” to express their satisfaction or dissatisfaction with prevailing policies.12,15 However, while there is growing interest in enhancing the role of the public in influencing accountability,6,30 political accountability is challenged by a range of methodological questions linked to the nature of representation, processes of citizen engagement and methods of deliberation, that reflect varying objectives and a low degree of control for achieving clinical accountability.12,15 With the professional model of clinical accountability no longer a firmly entrenched feature of our health care systems, managerial and legal accountability are becoming increasingly more important. Constant reform of health system governance reflects ongoing adaptation to this evolving context with important ramifications at all levels, particularly for clinicians.
greater use of performance information, reduce clinical practice variation and develop mechanisms to address poor performance at individual, team and organization levels.33 Many commentators observed that the clinical governance framework was not really new, but rather another approach for focusing on quality improvement.33-36 However, the reforms were positioned as a “whole-systems” approach that was necessary to integrate fragmented quality improvement activities and initiate organizational commitment to the structures, systems, status and multidisciplinary culture necessary to improve quality of care.33,36,37 This included the establishment of two key agencies, including the National Institute for Clinical Excellence (NICE – later renamed the National Institute for Health and Clinical Excellence) to set evidence-based standards and the Commission for Health Improvement (later renamed the Healthcare Commission) to monitor performance, within a structure of disease-specific national service frameworks and national frameworks for assessing performance.31,32 In addition to systematically developing the supporting infrastructure necessary for clinical governance, these reforms also placed a duty on NHS organizations to be accountable for quality. Premised on “corporate” governance, a statutory requirement was established for each NHS organization’s Chief Executive Officer, on behalf of the board, to be held accountable for assuring the quality of clinical services, producing regular reports on service quality in the same way as was done to meet existing financial statutory duties.32,33 This integration of corporate and clinical governance was the defining, but perhaps least definable, part of the NHS reforms.35,38 While managers’ and clinicians’ responsibilities became more intertwined, how to align corporate and clinical objectives represented a complex challenge.18,39 Operationalizing this “integrated governance” to reflect the broad scope of clinical practice exposed tensions between individual and population-based objectives11,35 and from a health system perspective, challenged clinicians to both recognize and balance responsibility for quality of care provided and resources utilized.40 Malcolm and Mays41 pose two critical questions:
Clinical governance Approaching the end of the past millennium, the National Health Service (NHS) in England embarked on a prolonged and systematic reformation, centred on the introduction of “clinical governance.”31,32 Clinical governance was initially and somewhat ambiguously “…defined as a system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.”32 The intent was to establish a systematic approach to increase focus on quality, incorporate
It appears that the NHS has bought into the need to devolve responsibility for management of resources, by explicitly linking the use of financial incentives to clinical performance. The NHS has recently launched several value-based purchasing initiatives, including payment by results, which is based on national tariffs used to pay providers for the volume and type of work performed,42 practice-based commissioning, which allows regional authorities (e.g., primary care trusts) to contract with General Practitioner (GP) practices to encourage the development of innovative services,43 and the general medical services contract, which provides additional financial
“[s]hould clinical governance…be implemented simply as an extension and formalisation of current initiatives to monitor and audit performance, promote quality, and maximise clinical effectiveness through guidelines and evidence-based practice? Or is it a mechanism through which teams of clinicians improve the quality of care while sharing the management of scarce resources?”
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Figure 1. Integrated approach to clinical accountability.
incentives to GPs for performance based on a large number of quality indicators.44 While the interest in value-based purchasing reflects global movements,26 it may also reflect the challenges of operationalizing clinical governance locally. The Clinical Governance Support Network initially established in 1999 to provide a centralized resource and networking forum for those charged with implementing clinical governance, has recently been disbanded, with the “view that most of the functions currently undertaken by the network could be carried out more appropriately at a local level.”45 So where does this leave clinical governance in England? Some have questioned whether clinical governance has suffered from lofty goals and inconsistent implementation.38,46 The complex institutional changes and refinements that initially dominated the clinical governance agenda may, paradoxically, represent the simple part of the strategic reformations. The NHS has greater structural capacity to support clinical governance than ever; however, these structures also create hierarchical silos that do not necessarily mesh with condition-focused clinical work.47 The NHS experience suggests that a system-wide approach can provide the infrastructure and tools needed to enhance clinical governance; however, real performance improvement requires extended focus on implementation locally. Drawing on the evolving English experience with clinical governance, we consider similar efforts in a different context – the Ontario cancer system. Clinical accountability in the Ontario cancer system While acknowledging the inherent differences between the English and Canadian health systems,48-50 efforts to develop a clinical accountability framework in the Ontario cancer system have been informed by the NHS experience and may provide a glimpse of future health system governance in Canada. Following recommendations from the Cancer Services
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Implementation Committee in December 2001,51 Ontario’s provincial cancer agency, Cancer Care Ontario (CCO), embarked on a restructuring process that systematically altered the roles and responsibilities among key stakeholders in the Ontario cancer system.52,53 CCO no longer directly delivers cancer services to patients, divesting these responsibilities to newly established Regional Cancer Programs (RCPs), based at 14 host hospitals in Ontario. CCO remains the main advisor to the Ontario Ministry of Health and LongTerm Care and now purchases services from the RCPs. CCO established two leadership councils, one comprising mainly clinical leaders, to promote and evaluate quality and safety of care and cancer control for organizations providing cancer services (Clinical Council) and another comprising mainly provincial and regional administrative leaders, to address strategic issues relating to CCO’s provincial cancer plan, integration agreements and matters of performance (Provincial Leadership Council). CCO’s Program in Evidence-Based Care, through groups of clinical experts across the province, maintains its role in the development of clinical practice guidance, while the Cancer Quality Council of Ontario was established to monitor and publicly report on the cancer system’s performance.54 All of this is set within the broader restructuring of the Ontario health system, including the development of Local Health Integration Networks.55 These structural changes were complemented by significant provincial investment in health information systems infrastructure. CCO is currently developing or enhancing a number of important clinical information systems with efforts made to identify and document all current data holdings, specify CCO’s data requirements from the RCPs and establish on-line access to cancer-related data for a broad range of stakeholders.56 This coincides with specific initiatives to develop province-wide computerized physician order entry
SHIFTING CLINICAL ACCOUNTABILITY AND THE PURSUIT OF QUALITY: ALIGNING CLINICAL AND ADMINISTRATIVE APPROACHES
and electronic pathology information management systems that were intended to improve the timeliness, completeness and quality of data reporting. The overhaul of CCO’s information management system also includes focused effort on enhancing capacity to measure, monitor and report on wait times for cancer care and support the monitoring of performance by CCO and the Quality Council. The Cancer System Quality Index provides baseline performance data on more than 20 cancer quality indicators that are publicly accessible and regularly updated.54 This system restructuring and investment in information systems has begun to make available essential tools for enabling clinicians and managers to take on new functions. However, as the NHS experience has revealed, these developments reflect necessary but insufficient steps in the development of a broader clinical accountability framework. Further efforts have focused on the challenging task of operationalizing the defined clinical accountability framework locally. CCO has integrated both clinical and administrative approaches to engage key stakeholders at multiple levels to incorporate clinical accountability activities into their daily work (see Figure 1). The clinical approach involves refocusing CCO’s provincial clinical programs to engage clinical leaders (e.g., in radiation oncology, systemic therapy, surgical oncology, nursing, health human resources, prevention/screening, palliative care, supportive care, pathology and social work) throughout Ontario. These clinical leaders form a network of clinicians who play central roles in the development, interpretation and application of clinical practice guidance, establishing a base of knowledge on what should be done (guidelines/standards) and a means for structuring evaluation and assessment of what is done (performance) in the cancer system. In addition to this clinical program focus, clinical leadership is also being fostered by cancer disease site (e.g., lung, breast, prostate, gastrointestinal, genitourinary, gynecology, head and neck, haematology, melanoma, sarcoma and neuro-oncology). Numerous provincial disease site teams, involving multidisciplinary clinical experts from across the province, support the systematic review of evidence and actively contribute to the development of clinical practice guidance. As important, development of local disease site teams and the support of multidisciplinary cancer conferences (tumour boards) are actively encouraged to facilitate multidisciplinary exchange of information about best practice.57 These local disease site teams are increasingly taking on a leadership role for defining clinical accountability locally and may be the most effective approach to influence clinical discourse, culture and accountability. While the clinical approach places the onus on clinicians to drive successful quality improvement initiatives, efforts are also being made to establish clinical accountability as a central part of cancer system management. With system restructuring efforts and investments in information systems providing the base, the administrative approach extends responsibility for clinical quality and broadens the set of tools available to improve performance. With greater capacity to measure and report on perform-
ance, performance management is becoming a central component of both clinical and administrative leadership responsibilities. Regional clinical and administrative leaders are expected to use performance data to identify gaps in quality of care and target opportunities for quality improvement for their RCPs. Performance data also provides a basis for articulating expected roles/responsibilities through the development of formal contracts and agreements. For example, CCO and the RCPs have entered into contractual relationships with respect to performance (e.g., cancer program integration agreements). A quarterly review brings provincial and regional administrative and clinical leaders to the same table to examine performance and identify improvement strategies. Funding levers further support the integration of clinical and administrative approaches. Funding is linked to quality of care through formal agreements with individual Ontario hospitals to allocate incremental cancer surgery cases (46 hospitals), systemic therapy (24 hospitals) and/or colonoscopies for a colorectal cancer screening program (58 hospitals) as part of a wait time strategy. Participating hospitals are required to participate in RCP activities, adopt standard pathology checklists, capture cancer stage and submit data. The development and evolution of alternate payment plans for specialty provider groups (e.g., medical oncologists, radiation oncologists, surgical oncologists) preserves research time and more clearly sets out performance expectations. Regional administrative leaders use stipends to attract local clinicians to take on responsibility for promoting and coordinating regional quality improvement efforts in surgical oncology and palliative care. Also, an innovation fund has been set up to support projects that evaluate the role that innovative practices can play in driving system-wide quality of care improvements. For example, current projects are evaluating the use of alternate care provider models, such as nurse endoscopists for colorectal cancer screening, advance practice radiation therapists and general practitioners in oncology, which can be applied across Ontario. The integration of clinical and administrative approaches to accountability is best reflected in CCO’s performance improvement cycle. This cycle is based on four key elements that draw on both clinical and administrative input to identify and collect data/information, develop clinical and policy relevant knowledge, actively transfer that knowledge to key stakeholders and, as discussed above, establish performance management as the mechanism to formally engage clinical and administrative leaders in integrated quality improvement efforts (see Figure 2). The development of organizational standards for thoracic surgery in Ontario is a particularly relevant example.58 Clinician-driven data on volume-outcomes relationships for esophagectomy and pneumonectomy led to the development of organizational standards for thoracic surgical oncology based on the contributions of both clinical and administrative leaders. Mechanisms for transferring the developed knowledge to stakeholders included reporting the data publicly on the Cancer System Quality Index59 and through academic publications58 and engaging regional administrative and surgical oncology leaders to explain the organizational standards to clinical and management colleagues. Additional Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2008
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Figure 2. Cancer Care Ontario’s performance improvement cycle.
funds for thoracic surgical oncology were directed to hospitals that agreed to be held accountable for implementing the thoracic surgery standard as part of a cancer surgery agreement with CCO. Together, the clinician-driven standard for thoracic surgical oncology, public reporting of regional- and hospitalspecific volume-outcomes relationships and the contractual linkage of additional funds to the standard have created important synergies. These efforts have been effective in consolidating activity in hospitals where improved outcomes should be achievable. Conclusions Clinical accountability is evolving. Professional accountability no longer dominates clinical accountability relationships, with managerial and legal accountability becoming increasingly more relevant. This reflects more complex relationships among key stakeholders and raises questions about the legitimacy of evolving roles and responsibilities. However, with greater understanding of these evolving accountability relationships, there are also opportunities to significantly improve quality of care. Health system governance has begun to adapt through the implementation of key structural components, advancing a performance-based culture and increasing the responsibility of managers for clinical performance in many contexts.50 Clinical leaders are beginning to adapt to this evolving context as well, by re-evaluating medical professionalism and re-thinking the clinician’s position within the health care system.18,20,60-62 However, maintaining clinical autonomy and emphasis on the individual rather than the population remain fundamental objectives of medical associations that may conflict with the shift away from the professional model of clinical accountability.47,63,64 Will efforts to integrate clinical and administrative approaches towards the common goal of improved quality of care be successful? This review suggests that it is unlikely that one approach or initiative alone will make a significant impact 10
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on quality of care. At minimum, operationalizing clinical accountability requires a systematic and comprehensive strategy with involvement of all major stakeholders. The NHS experience with clinical governance has directed this focus on clinical accountability and exposed the complex operational environment for implementing clinical governance locally. Subsequent efforts in the Ontario cancer system to mesh clinical and administrative approaches at provincial, regional and local levels may provide a Canadian model for using accountability as a base to achieve improvements in quality of care. References 1.
2.
3.
4.
5.
6.
7. 8.
9.
Romanow RJ. Building on Values: The Future of Health Care in Canada. Commission on the Future of Health Care in Canada,2002. Kirby MJL, LeBreton M. The health of Canadians - The federal role (Volume six: Recommendations for reform). Standing Senate Committee on Social Affairs, Science and Technology. Government of Canada,2002. Gagnon D, Menard M. Listening for direction: National consultation on health services and policy issues. Canadian Health Services Research Foundation,2001. Dault M, Lomas J, Barer M. Listening for direction II: National consultation on health services and policy issues for 20042007. Canadian Health Services Research Foundation,2004. Canadian Health Services Research Foundation. Listening for direction III: Preliminary research themes areas. [Accessed March 31, 2008]. Available from: http://www.chsrf.ca Fooks C, Maslove L. Rhetoric, fallacy or dream? Examining the accountability of Canadian health care to citizens. Canadian Policy Research Networks,2004. Loughlin M. On the buzzword approach to policy formulation. Journal of Evaluation in Clinical Practice,2002;8(2):229-42. Sullivan T, Flood CM. Chrétien’s prescription for medicare: A green poultice in lieu of accountability. Canadian Medical Association Journal,2004;170(3):359-60. Mays N, Pope C, Popay J. Systematically reviewing qualitative and quantitative evidence to inform management and policymaking in the health field. Journal of Health Services Research
SHIFTING CLINICAL ACCOUNTABILITY AND THE PURSUIT OF QUALITY: ALIGNING CLINICAL AND ADMINISTRATIVE APPROACHES
and Policy,2005;10(Suppl 1):6-20. 10. Shortell SM, Waters TM, Clarke KWB, Budetti PP. Physicians as double agents: Maintaining trust in an era of multiple accountabilities. Journal of the American Medical Association,1998;280:1102-8. 11. Degeling P. Reconsidering clinical accountability. An examination of some dilemmas inherent in efforts to bolster clinician accountability. The International Journal of Health Planning and Management,2000;15(1):3-16. 12. Deleon L. Accountability in a ‘reinvented’ government. Public Administration,1998;76(3):539-58. 13. Emanuel EJ, Emanuel LL. What is accountability in health care? Annals of Internal Medicine,1996;124(2):229-39. 14. Buetow S, Elwyn G. The window mirror: A new model of the patient-physician relationship. Open Medicine,2008;2(1). 15. Dubois CA, Denis JL. Accountability in Canadian health care systems: Fitting the pieces of the puzzle together. In: Davies HTO, Tavakoli M, editors. Health care policy, performance and finance: Strategic issues in health care management. Aldershot, UK: Ashgate Publishing Limited,2004. 16. Arrow K. Uncertainty and the welfare economics of medical care. The American Economic Review,1963;53(5):941-73. 17. Tuohy CH. Agency, contract, and governance: Shifting shapes of accountability in the health care arena. Journal of Health Politics, Policy and Law,2003;28(2-3):195-216. 18. Doctors in society: Medical professionalism in a changing world. Report of a working party. Royal College of Physicians of London,2005.. 19. Crossing the quality chasm: A new health system for the 21st Century. Institute of Medicine,2001. 20. Millenson ML. The silence. Health Affairs,2003;22(2):103-12. 21. Emanuel EJ, Emanuel LL. Preserving community in health care. Journal of Health Politics, Policy and Law,1997;22(1):14784. 22. Ontario Ministry of Health and Long-Term Care. First ever common benchmarks will allow Canadians to measure progress in reducing wait times (press release). [Accessed May 1, 2008]. Available from: http://www.health.gov.on.ca 23. Ries NM, Caulfield T. Accountability in healthcare and legal approaches. Canadian Policy Research Networks,2004. 24. Flood CM, Sullivan T. Supreme disagreement: The highest court affirms an empty right. Canadian Medical Association Journal,2005;173(2):142-3. 25. Mello MM, Studdert DM, Brennan TA. The Leapfrog Standards: Ready to jump from marketplace to courtroom? Health Affairs,2003;22(2):46-59. 26. Figueras J, Robinson R, Jakubowski E. Purchasing to improve health systems performance: Drawing the lessons. In: Figueras J, Robinson R, Jakubowski E, editors. European observatory on health systems and policies series: Purchasing to improve health systems performance. Berkshire, UK: Open University Press,2005. 27. Birkmeyer NJO, Birkmeyer JD. Strategies for improving surgical quality - Should payers reward excellence or effort? New England Journal of Medicine,2006;354(8):864-70. 28. Doherty RB. Politics calls for a compromise in tactics, not principles. [Accessed May 1, 2008]. Available from: http://www.acponline.org/ 29. Dudley RA. Pay-for-performance research: How to learn what clinicians and policy makers need to know. Journal of the American Medical Association,2005; 294:1821-3. 30. Abelson J, Gauvin FP. Engaging citizens: One route to health care accountability. Canadian Policy Research Networks,2004.
31. Department of Health. The new NHS: Modern, dependable. London, UK: The Stationery Office,1997. 32. Department of Health. A first class service: Quality in the new NHS. London, UK: Crown Copyright,1998. 33. Walshe K, Freeman T, Latham L, Wallace L, Spurgeon P. Clinical governance: From policy to practice. Birmingham, UK: Health Services Management Centre, University of Birmingham,2000. 34. Pringle M. Clinical governance in primary care: Participating inclinical governance. British Medical Journal,2000; 321(7263):737-40. 35. Rosen R. Clinical governance in primary care: Improving quality in the changing world of primary care. British Medical Journal, 2000;321(7260):551-4. 36. Halligan A, Donaldson L. Implementing clinical governance: Turning vision into reality. British Medical Journal, 2001;322:1413-7. 37. Huntington J, Gillam S, Rosen R. Clinical governance in primary care: Organisational development for clinical governance. British Medical Journal,2000;321(7262):679-82. 38. Degeling PJ, Maxwell S, Iedema R, Hunter DJ. Making clinical governance work. British Medical Journal,2004;329(7467):67981. 39. Deighan M, Cullen R, Moore R. The development of integrated governance. London, UK: The NHS Confederation,2004. 40. Degeling P, Maxwell S, Kennedy J, Coyle B. Medicine, management, and modernisation: A “danse macabre?” British Medical Journal,2003; 26:649-52. 41. Malcolm L, Mays N. New Zealand’s independent practitioner associations: A working model of clinical governance in primary care? British Medical Journal,1999;319(7221):1340-2. 42. Audit Commission. Early lessons from payment by results. London, UK: Author,2005. 43. Policy and Strategy Directorate, Department of Health. Health reform in England: Update and commissioning framework. London, UK: Department of Health,2006. 44. Shekelle P. New contract for general practitioners. British Medical Journal,2003;326(7387):457-458. 45. National Health Service. The future of the CGST. [Accessed March 31, 2008]. Available from: http://www.cgsupport.nhs.uk/ 46. Thomas M. The evidence base for clinical governance. Journal of Evaluation in Clinical Practice,2002;8(2):251-4. 47. Degeling P. Realising the development potential of clinical governance. Clinical Chemistry and Laboratory Medicine,2006; 44(6):688-91. 48. Tuohy CH. Dynamics of a changing health sphere: The United States, Britain, and Canada. Health Affairs 1999;18(3):114-34. 49. Blendon RJ, Schoen C, DesRoches C, Osborn R, Zapert K. Common concerns amid diverse systems: Health care experiences in five countries. Health Affairs,2003;22(3):106-21. 50. Sullivan T, Dobrow MJ, Schneider E, Newcomer L, Richards M, Wilkinson L, et al. Améliorer la responsabilité cliniques et performance en cancérologie [Improving clinical accountability and performance in the cancer field]. Pratiques et Organisation des Soins,2008;39(3):207-15. 51. Cancer Services Implementation Committee. Report of the Cancer Services Implementation Committee. Toronto, ON: Ontario Ministry of Health and Long-Term Care;2001. 52. Thompson LJ, Martin MT. Integration of cancer services in Ontario: The story of getting it done. Healthcare Quarterly,2004;7(3):42-8. 53. Sullivan T, Dobrow M, Thompson L, Hudson A. Reconstructing cancer services in Ontario. HealthcarePapers,2004;5(1):69-80. Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2008
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Dobrow, Sullivan, and Sawka
54. Greenberg A, Angus H, Sullivan T, Brown AD. Development of a set of strategy-based system-level cancer care performance indicators in Ontario, Canada. International Journal for Quality in Health Care,2005;17(2):107-14. 55. Ontario Ministry of Health and Long-Term Care. Local Health System Integration Act;2006. [Accessed May 1, 2008]. Available from: http://www.health.gov.on.ca 56. Cancer Care Ontario. IM/IT strategic plan 2008-2011. [Accessed May 1, 2008]. Available from: http://www.cancercare.on.ca 57. Wright FC, De Vito C, Langer B, Hunter A. Multidisciplinary cancer conferences: A systematic review and development of practice standards. European Journal of Cancer,2007;43(6):1002-10. 58. Sundaresan S, Langer B, Oliver T, Schwartz F, Brouwers M, Stern H, et al. Standards for thoracic surgical oncology in a single-payer healthcare system. The Annals of Thoracic Surgery,2007;84(2):693-701.
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59. Cancer Care Ontario and Cancer Quality Council of Ontario. Cancer System Quality Index. [Accessed May 2, 2008]. Available from: http://www.cancercare.on.ca 60. Hedberg CA. Value based purchasing for physicians under Medicare. Hearing before the Subcommittee on Health of the Committee on Ways and Means. U.S. House of Representatives. Session 109-50. [Accessed May 1, 2008]. Available from: http://waysandmeans.house.gov 61. Clancy CM, Scully T. A call to excellence. Health Affairs,2003;22(2):113-5. 62. Richardson WC, Corrigan JM. Provider responsibility and system redesign: Two sides of the same coin. Health Affairs,2003;22(2):116-8. 63. Lewis S. Physicians, it’s in your court now. Canadian Medical Assocation Journal,2005;173(3):275-7. 64. Schumacher A. Doctors put patients first in health care debate. Canadian Medical Association Journal,2005;173(3):277-8.