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Use of a Program Logic Model to Guide the Development of a Strategic Plan for Wellington County Hospitals Network
ORIGINAL ARTICLE
Use of a Program Logic Model to Guide the Development of a Strategic Plan for Wellington County Hospitals Network Brenda Fraser, MSc, BSc, currently works as a health planner with the Waterloo RegionWellington-Dufferin District Health Council.
R. Grant Hollett, MSc, BA, is a health planner with the Waterloo RegionWellington-Dufferin District Health Council.
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by Brenda Fraser and R. Grant Hollett
n recent years, the healthcare system in Ontario has undergone substantial change, much of it in response to directives issued by the Health Services Restructuring Commission (HSRC). Hospital closures, mergers and restructuring, and the reorganization of community-based services have been driven by the need to increase the operating efficiency and effectiveness of the healthcare system. One approach to achieving these objectives for the healthcare system is the development of integrated service delivery systems in which groups of organizations (such as hospitals and community-based agencies) work together to ensure that a defined population has access to a comprehensive and coordinated continuum of healthcare programs and services.
The Ontario Ministry of Health and Long-Term Care (MOHLTC) and the HSRC appreciated that integrated service delivery systems have the potential to address many of the problems relating to access to quality healthcare experienced in rural and northern areas of the province. In 1997, the MOHLTC issued The Rural and Northern Healthcare Framework. The Framework mandated the formation, in designated rural and northern areas of the province, of networks of small- to medium-sized hospitals and (over the longer term) community health service providers. Through joint planning, sharing of resources, the use of new technologies and innovative, cost-effective, approaches to service delivery, each network will work toward the provision of a comprehensive and coordinated range of health services for residents of its area.
Abstract This article describes how the Wellington County Hospitals Network successfully used a program logic model as a decision-making framework to guide the development of the Network’s first strategic plan. The advantages and disadvantages of this approach to the development of a strategic plan and identification of short-term priorities for action by the Network are discussed.
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Wellington County Hospitals Network Wellington County Hospitals Network (WCHN)1 is one of 18 hospital networks formed in Ontario since the release of The Rural and Northern Healthcare Framework. Established in 1999, WCHN includes three acute care hospital corporations across the following four sites: (1) Groves Memorial Community Hospital, Guelph General Hospital and North Wellington Healthcare Corporation; (2) St. Joseph’s Healthcare, Guelph (a complex continuing care, rehabilitation and long-term care facility); (3) Homewood Health Centre (a psychiatric hospital); and (4) the Community Care Access Centre of Wellington-Dufferin. In a report submitted to the HSRC in September 1999,2 the WCHN described the organizational structure, vision, mission and values that guide its activities. The Network is a collaborative model that recognizes the autonomy of all member organizations and the roles and responsibilities of the boards of all Network members. It is focused on identifying “shared opportunities”
• strengthening what each member does well (the unique roles of the hospitals and the Community Care Access Centre);
activities on which members of the Network could work together. Various opportunities were identified and discussed: shared clinical and diagnostic services, joint human resource plans, common physician credentialing, to name just a few.
• enhancing opportunities for sharing and collaboration among agencies (joint partnership role); and
Need For a Decision-Making Framework
and providing a vehicle for supporting the following interrelated roles of the member organizations:
• identifying and developing better ways to collectively meet the healthcare needs of local residents (Network role). To accomplish its mission, the WCHN established the following planning and decision-making structure: • a joint planning committee made up of board chairs, chief executive officers (CEOs) and chiefs of staff; • a network coordinating committee (NCC) with prime responsibility for executive leadership made up of CEOs of participating organizations; and
With the release of the Principles and Guidelines document in May 2000 and the requirement to submit an implementation plan by March 2001, members of the NCC recognized the need for some type of framework to guide their decision-making about which service development opportunities should be the focus of Network activities over the coming years. While the Network had
Values
The Network will:
Quality
• provide the highest quality of care as cost-effectively as possible; • redirect savings from clinical and administrative efficiencies to sustain and enhance needed healthcare programs; • strive to ensure the availability of a fully coordinated infrastructure of services for residents of Wellington County; • use the latest technology and recent developments in clinical care to support delivery of care; • apply knowledge-based continuous improvement techniques and benchmarking principles to ensure optimal healthcare standards;
Service
Following submission of its report to the HSRC in September 1999, members of the Network’s NCC continued to meet monthly to discuss issues of mutual concern and identify service development
• ensure timely access to healthcare for all who require it; • seek to understand the needs and changing expectations of the communities we serve and respond with leadership and accountability;
Implementation Planning In May 2000, to support the implementation of the Rural and Northern Healthcare Framework, the MOHLTC issued Principles and Guidelines for the Implementation of the Rural and Northern Hospital Networks. The document was designed to guide the development by each network of plans to implement the Ministry’s vision for rural hospital and health networks. These plans were to be submitted to the Ministry by March 31, 2001.
Two experienced planners with the District Health Council were assigned (on a part-time basis) to support the Network with the development of the decision-making framework. Both had regularly attended the meetings at which Network service development opportunities were discussed, and they appreciated the difficulties that NCC members were having identifying mutually acceptable priorities for action.
Figure 1: Values of Wellington County Hospitals Network
• time-limited working or task groups made up of relevant front-line staff and stakeholders. The Waterloo Region–Wellington-Dufferin District Health Council has provided planning and technical support to the WCHN since its formation, and the Executive Director of the District Health Council is a non-voting member of the WCHN.
articulated a vision, mission and set of values to guide its work, translating these into concrete strategic activities had remained a challenge. The District Health Council offered to provide staff support for the development of such a framework, and members of the NCC agreed to dedicate meeting time to this task during the fall of 2001.
• invest in appropriate staff training and development initiatives; • encourage a workplace environment characterized by trust and respect; Rural Health
• support an evolution that sustains and enhances the current level of healthcare available to rural residents; • ensure that rural healthcare providers have new opportunities and the support needed to evolve in their role; • use new and emerging technology to support rural-based physicians and healthcare professionals; • develop appropriate, viable and functional linkages to ensure the delivery of more specialized services when required;
Change Adaptive
• use new knowledge, best practices and emerging healthcare technologies in support of the communities we serve; • individually and collectively, bring forward new ideas that advance the cause and commitment of the Network; and • work together to promote an environment that fosters the spirit, opportunity and support needed to innovate.
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The planners facilitated a discussion of decision-making criteria based on the Network’s mission, vision and values. Members of the NCC were asked to frame potential criteria in terms of questions that reflect the values of the Network as articulated in the 1999 report to the HSRC (figure 1). Examples of the questions asked include the following: Will the service development activity increase service coordination? Will it result in improved recruitment and retention of human resources? Will local access to specific health services improve? The exercise generated a list of more than 30 values-driven questions that could be asked to evaluate potential service development opportunities for the Network. After the meeting, as the District Health Council staff reviewed the material and began to sort and consolidate the questions/criteria, it became clear that most fell into two groups: Network outcomes—questions related to desired changes for the organizations and the service system such as the following: • Does this activity have the potential to create an opportunity for reinvestment in another part of the service system? • Will the activity contribute to building an integrated system of care? • Will the activity advance the reputation of the WCHN and assist in attracting human and other resources to the area? Population outcomes—questions related to desired changes for residents of Wellington County or consumers served by the Network such as the following: • Will there be improvements in the health status of residents of Wellington County? • Can the activity be expected to increase consumer satisfaction? • Will residents have better access to healthcare?
A Logic Model of WCHN At this point, it occurred to the planners that a decision-making framework based on a logic model might be a useful tool to
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enable NCC members to evaluate the strength of the relationship between a particular network service development opportunity and the desired network or population health outcomes (figure 2). Application of the logic model approach provided a way of translating the high level strategic directions contained in the Network vision, mission and values into outcomes that could be linked to activities to be operationalized by the Network. Figure 2: Generic Logic Model The broad parts of the overall program
Component
Activity
The services that relate to each program component and provide the means whereby outcomes are achieved
The things that will change as a result. The ends that are pursued
Outcome
A logic model is a conceptual tool used to gain an understanding of the structure and rationale of health and social service programs.3 Although logic models were initially used to plan program evaluations, they have proven useful in program planning and, more recently, in the design and planning of systems of programs and services.4 One of the District Health Council planners working with the NCC had collaborated with an external consultant on a planning exercise in which a logic model was used to support the design of a regional mental health system.
A logic model comprises three parts: components or functions, activities and outcomes. Each of these parts is intended to relate “logically” to one another. The model also visually delineates how activities and services will be organized and delivered to produce the desired changes (i.e., outcomes) in the short and longer term. While most programs have various features designed to achieve certain results, the logic model organizes program components into a coherent whole and makes both the activities and the rationale for undertaking these activities explicit. Drawing on other experiences with the application of logic models and the results of the previous discussions among NCC members about service development opportunities, the planners presented the concept of a decision-making framework based on a logic model at the next meeting of the NCC. In their presentation, the planners grouped the service development opportunities identified by NCC members at previous meetings into five categories: clinical programs, human resources, information technology, clinical support and leadership. These categories became the components of the Network Logic Model (figure 3). They then presented a “mock logic model” for rehabilitation services showing the relationship between implementation objectives (activities that the NCC might undertake to develop or improve rehabilitation services) and the expected outcomes of those activities for the Network and its members (network outcomes) and the health of the population (population health outcomes). This application of a logic model differed from traditional applications, because it
Figure 3: Components and Subcomponents of a Network Logic Model Logic Model Components
Clinical Programs
Human Resources
Subcomponents • Rehabilitation • Physicians • Mental health • Health and • Acute care support • Complex personnel continuing care • Long-term care
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Information Technology
Clinical Support
Leadership
•Clinical information •Human resources and infrastructure
• Laboratory • Pharmacy • Diagnostics (digital imaging)
•Advocacy •Communication
Between meetings, the planners took the material generated in the small group work, integrated it at the appropriate point into the logic model, and then presented the revised model for discussion/refinement at the next meeting. Through this iterative process, the NCC developed a detailed Network Logic Model. The logic model defines the implementation objectives (Network activities) and outcomes (Network and population health) for programs and services within each of the five components (clinical programs, human resources, information technology, clinical support services and leadership). This material now forms the core of the Network’s strategic plan. Figure 4 shows, as an example, the implementation objectives and outcomes defined for rehabilitation, one of the subcomponents of the component clinical programs.
Clinical Programs
Rehabilitation
Mental Health
To develop a local rehabilitation service model that embodies these principles: quality; rural health; change adaptive; & service (accessibility).
Acute
Complex Continuing Care
Long-Term Care
Network Outcomes
Increase in hospital-based resources for rehabilitation.
To develop sizing & siting recommendations for local rehabilitation beds & services to support the above model. To advocate support and resources from the MOHLTC where needed. To participate in the planning & development of regional rehabilitation services.
Increase in clinical cohesiveness between community and hospital-based rehabilitation providers. Establishment of integrated rehabilitation services to increase ability to attract, recruit and retain required professionals. Increase in the range of rehabilitation services available to residents. Decrease in inappropriate use of acute hospital beds and improved flow from acute to rehabilitation beds and programs within Wellington County & with regional programs. Maximize the equitable distribution of rehabilitation resources across Wellington County.
With community partners reflecting continuity of care, implement the rehabilitation model for Wellington County.
Population Health Outcomes
Having agreed to this approach to the development of a decision-making framework, the NCC held four further meetings. At these meetings, the members worked in small groups, with guidance from District Health Council planners, to define the potential activities (implementation objectives) for each of the services/elements (subcomponents) within the five components of the model. For each potential activity, work group members considered what outcomes could reasonably be expected from this particular initiative. If the outcomes were not consistent with the desired Network or population health outcomes (figure 3), the potential activity was not included in the logic model.
Components
NCC members readily appreciated that this approach would have the benefit not only of assisting with the selection of appropriate service development opportunities for the Network but also of simultaneously defining the elements of an action plan to realize these opportunities and the criteria to evaluate the outcomes.
Figure 4: Logic Model for Rehabilitation Services
Implementation Objectives (Network Activities)
was not based on programs but on systems. It articulated outcomes and activities that a group of healthcare providers agreed to pursue collectively versus those of a single agency.
WCHN Strategic Plan and Priorities for Action The next step for the NCC involved setting priorities for action in the immediate future (2001–2002) among the components and subcomponents of the Network Logic Model. Members agreed to give highest priority to activities of strategic importance, that is, activities that: • will foster collaborative efforts among Network members and create a foundation for other Network activities; • have potential for success over the short term; • are feasible given the resources that WCHN has or will acquire; and • are consistent with current MOHLTC priorities. Five components/subcomponents were agreed upon as priorities for 2001–2002 (figure 5) through a traditional prioritysetting exercise involving NCC members.
Increase in accessibility to rehabilitation services. Increase in positive clinical and functional rehabilitation outcomes for patients/clients. Increase in consumer satisfaction with rehabilitation services. Increase in the number of people able to return to their home environment following rehabilitation.
The strategic plan (Network Logic Model) and priorities for 2001–2002 were presented to WCHN’s Joint Planning Committee and the boards of all the member organizations early in 2001. Each of these bodies endorsed the plan and the priority activities for 2001–2002 prior to their submission to the MOHLTC.5 Since submitting its implementation plan, the NCC has developed more detailed action plans for several of the five priority areas and is now working on initiatives concerning repatriation opportunities (acute care), development of a local rehabilitation services model (rehabilitation) and investigation of the potential to link Network hospitals via shared digital imaging (clinical support services). Member organizations of the WCHN are positive about the results of their first joint project. The strategic plan is a tangible outcome of the work of the Network that validates the collaborative
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Figure 5: Priorities for Action 2000–2001 Logic Model Component
Subcomponent
Clinical Programs
Acute Care
Priority
Activities to Be Initiated
#1
• analyze data and develop service profiles to identify repatriation opportunities; • develop a system of access to acute care services within Wellington County and between Wellington • County and services in other jurisdictions; • identify strategic directions for clinical programs in WCHN; • explore and identify new opportunities to work together across the WCHN for example, networkwide nurse practitioner, common clinical pathways;
Human Resources
Physicians
#2
• develop and implement a regional model for specialist and primary care that would include consideration of deployment, recruitment, primary care pilot projects, incentive structures; • understand the collective resources available to support physicians, for example, operating rooms, support staff, etc.; • implement a common physician credentialing process for hospitals;
Clinical Support Services
Diagnostics (Digital imaging)
#3
• determine the most appropriate partnerships within the WHCN related to digital imaging; • host an educational session on digital imaging services for the WCHN; • identify recruitment needs and opportunities;
Clinical Programs
Rehabilitation
#4
• develop a local rehabilitation service model that embodies the principles of quality, rural health, change adaptive and service/accessibility; • develop sizing and siting recommendations for local rehabilitation beds and services to support the model;
Clinical Programs
Long-Term Care
#5
• develop an understanding of the issues regarding the long-term care sector and its capacity, and the implications for the hospital sector; and • work with the CCAC on refining the discharge and long-term care placement process.
network model chosen by the members. The plan has also helped to raise the profile of the WCHN locally and to demonstrate the potential benefits of the Network for the healthcare system in Wellington County. But what about the approach taken by the NCC to the development of the strategic plan? Did the use of the logic model offer advantages over other, more conventional, ways of developing strategic and short-term action plans? NCC members identified the stepwise, structured process, employing a common
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language, as one advantage of the logic model. The most significant benefits from the viewpoints of members and District Health Council planners were, however, that the logic model focused discussions and provided a rationale for current and future decision-making; and enabled NCC members (who represent organizations with a diversity of roles, interests and issues) to find common ground. Focused discussions and a rationale for current and future decision-making: This attribute was particularly helpful. The requirement to clearly state the outcomes
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expected of a potential network activity ensured that discussion and decisionmaking were focused on outcomes that members had mutually agreed to be desirable. There was, therefore, a clear rationale for including or excluding any service development opportunity and associated activities proposed by a member of the NCC. In addition, defining the activities that the Network would need to undertake to achieve the desired outcomes within each service component or subcomponent (such as rehabilitation, acute care, or diagnostics) assisted members to identify short-term priorities for action. The process gave NCC members a preliminary understanding of the resource and other implications of embarking upon a particular initiative and therefore its feasibility over the short term. As described earlier, NCC members did not lack ideas about what the Network might do. The logic model process helped to solve the problem of “where to start.” Finding common ground: Once again, the focus on outcomes (which, as described, flowed from the Network’s vision and values) facilitated identification of shared interests and common ground. In addition, the small work group process used to develop the detail of the Network Logic Model provided a valuable opportunity for NCC members to build relationships and develop mutual trust and respect while working through a shared task.
Drawbacks to the Approach There were, of course, some drawbacks to the approach. It required NCC members— who as CEOs of their respective organizations are largely focused on the “big picture” and outcomes in their dayto-day responsibilities—to devote significant time to issues of process and detail. For some members, this was a less appealing aspect to the approach. The other drawback related to time commitment. This was less of an issue for NCC members who each devoted a total of 20 hours to the seven meetings required to formulate decision-making criteria (two meetings), develop the detailed Network Logic Model (four meetings) and establish short-term priorities for action (one meeting). Overall, NCC members considered that the results justified the time they
invested in the process. For the two District Health Council planners, the time commitment was more significant. They estimate that, over the same period, they each devoted 60 to 65 hours (for a total staff time of 120 to 130 hours) to meeting facilitation, preparatory work in advance of NCC meetings, documentation and report writing. The availability of this level of staff support for the work of the NCC members undoubtedly contributed to the success of the project. In the opinions of the NCC members, other factors that are also important to the successful use of a logic model process for planning purposes include the following: • prior development of a shared vision, mission and values among participants in the planning process; • access to expertise in the development and use of logic models; and • commitment of dedicated time to the process. NCC members also note that the process is more likely to be successful if the level of trust and communication among participants is high. Facilitation of the process by individuals with an understanding of the functions and issues of concern to the participating organizations is helpful but probably not essential.
Acknowledgements The authors wish to express their thanks to the members of the Network Coordinating Committee of the Wellington County Hospitals Network for their active participation in the creation of the Network Logic Model. They include Richard Ernst, Chief Executive Officer, Guelph General Hospital; Ross Kirkconnell, Executive Director, Community Care Access Centre of Wellington-Dufferin; Pierre Noel, Chief Executive Officer, North Wellington Healthcare Corporation; Dr. Edgardo Perez, Chief Executive Officer, Homewood Health Centre; Rita Soluk, Chief Executive Officer, St. Joseph’s Healthcare Guelph; and Carolyn Skimson, Chief Administrative Officer and Executive Director, Groves Memorial Community Hospital.
References and Notes
2. Wellington County Hospitals Network (Network #3). Report to the Health Services Restructuring Commission re: rural/northern hospital restructuring. The Network; September 17, 1999. 3. Rush B, Ogborne A. Program logic models: expanding their role and structure for program planning and evaluation. The Canadian Journal of Program Evaluation 1991;6(2):93–105. 5. Julian DA. The utilization of the logic model as a system level planning and evaluation device. Evaluation and Program Planning 1997;20(3):251–257. 6. Wellington County Hospitals Network. Report to the Ministry of Health and Long-Term Care on the implementation plan for Network #3. The Network; March 31, 2001.
1. Members of the Wellington County Hospitals Network: Community Care Access Centre of Wellington-Dufferin, Groves Memorial Community Hospital, Guelph General Hospital, Homewood Health Centre, North Wellington Health Care Corporation and St. Joseph’s Healthcare Guelph.
Conclusion The WCHN has successfully used a logic model as a decision-making framework to support development of a strategic plan and identify short-term priorities for action by the Network. The process enabled the WCHN to develop plans that are based on the Network’s values and focused on mutually desired outcomes for both the Network itself and the population of Wellington County. The strategic plan is flexible and can be modified to respond to changing needs and priorities. Service development opportunities that may emerge in the future can be readily evaluated for consistency with the desired outcomes before being incorporated into the plan. This structured, outcome-focused approach to planning could be particularly helpful in situations where planning may be hampered by an apparent lack of common interests and shared purpose among participants.
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Use of a Program Logic Model to Guide the Development of a Strategic Plan for Wellington County Hospitals Network Brenda Fraser, MSc, BSc, currently works as a health planner with the Waterloo RegionWellington-Dufferin District Health Council.
R. Grant Hollett, MSc, BA, is a health planner with the Waterloo RegionWellington-Dufferin District Health Council.
I
by Brenda Fraser and R. Grant Hollett
n recent years, the healthcare system in Ontario has undergone substantial change, much of it in response to directives issued by the Health Services Restructuring Commission (HSRC). Hospital closures, mergers and restructuring, and the reorganization of community-based services have been driven by the need to increase the operating efficiency and effectiveness of the healthcare system. One approach to achieving these objectives for the healthcare system is the development of integrated service delivery systems in which groups of organizations (such as hospitals and community-based agencies) work together to ensure that a defined population has access to a comprehensive and coordinated continuum of healthcare programs and services.
The Ontario Ministry of Health and Long-Term Care (MOHLTC) and the HSRC appreciated that integrated service delivery systems have the potential to address many of the problems relating to access to quality healthcare experienced in rural and northern areas of the province. In 1997, the MOHLTC issued The Rural and Northern Healthcare Framework. The Framework mandated the formation, in designated rural and northern areas of the province, of networks of small- to medium-sized hospitals and (over the longer term) community health service providers. Through joint planning, sharing of resources, the use of new technologies and innovative, cost-effective, approaches to service delivery, each network will work toward the provision of a comprehensive and coordinated range of health services for residents of its area.
Abstract This article describes how the Wellington County Hospitals Network successfully used a program logic model as a decision-making framework to guide the development of the Network’s first strategic plan. The advantages and disadvantages of this approach to the development of a strategic plan and identification of short-term priorities for action by the Network are discussed.
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Wellington County Hospitals Network Wellington County Hospitals Network (WCHN)1 is one of 18 hospital networks formed in Ontario since the release of The Rural and Northern Healthcare Framework. Established in 1999, WCHN includes three acute care hospital corporations across the following four sites: (1) Groves Memorial Community Hospital, Guelph General Hospital and North Wellington Healthcare Corporation; (2) St. Joseph’s Healthcare, Guelph (a complex continuing care, rehabilitation and long-term care facility); (3) Homewood Health Centre (a psychiatric hospital); and (4) the Community Care Access Centre of Wellington-Dufferin. In a report submitted to the HSRC in September 1999,2 the WCHN described the organizational structure, vision, mission and values that guide its activities. The Network is a collaborative model that recognizes the autonomy of all member organizations and the roles and responsibilities of the boards of all Network members. It is focused on identifying “shared opportunities”
• strengthening what each member does well (the unique roles of the hospitals and the Community Care Access Centre);
activities on which members of the Network could work together. Various opportunities were identified and discussed: shared clinical and diagnostic services, joint human resource plans, common physician credentialing, to name just a few.
• enhancing opportunities for sharing and collaboration among agencies (joint partnership role); and
Need For a Decision-Making Framework
and providing a vehicle for supporting the following interrelated roles of the member organizations:
• identifying and developing better ways to collectively meet the healthcare needs of local residents (Network role). To accomplish its mission, the WCHN established the following planning and decision-making structure: • a joint planning committee made up of board chairs, chief executive officers (CEOs) and chiefs of staff; • a network coordinating committee (NCC) with prime responsibility for executive leadership made up of CEOs of participating organizations; and
With the release of the Principles and Guidelines document in May 2000 and the requirement to submit an implementation plan by March 2001, members of the NCC recognized the need for some type of framework to guide their decision-making about which service development opportunities should be the focus of Network activities over the coming years. While the Network had
Values
The Network will:
Quality
• provide the highest quality of care as cost-effectively as possible; • redirect savings from clinical and administrative efficiencies to sustain and enhance needed healthcare programs; • strive to ensure the availability of a fully coordinated infrastructure of services for residents of Wellington County; • use the latest technology and recent developments in clinical care to support delivery of care; • apply knowledge-based continuous improvement techniques and benchmarking principles to ensure optimal healthcare standards;
Service
Following submission of its report to the HSRC in September 1999, members of the Network’s NCC continued to meet monthly to discuss issues of mutual concern and identify service development
• ensure timely access to healthcare for all who require it; • seek to understand the needs and changing expectations of the communities we serve and respond with leadership and accountability;
Implementation Planning In May 2000, to support the implementation of the Rural and Northern Healthcare Framework, the MOHLTC issued Principles and Guidelines for the Implementation of the Rural and Northern Hospital Networks. The document was designed to guide the development by each network of plans to implement the Ministry’s vision for rural hospital and health networks. These plans were to be submitted to the Ministry by March 31, 2001.
Two experienced planners with the District Health Council were assigned (on a part-time basis) to support the Network with the development of the decision-making framework. Both had regularly attended the meetings at which Network service development opportunities were discussed, and they appreciated the difficulties that NCC members were having identifying mutually acceptable priorities for action.
Figure 1: Values of Wellington County Hospitals Network
• time-limited working or task groups made up of relevant front-line staff and stakeholders. The Waterloo Region–Wellington-Dufferin District Health Council has provided planning and technical support to the WCHN since its formation, and the Executive Director of the District Health Council is a non-voting member of the WCHN.
articulated a vision, mission and set of values to guide its work, translating these into concrete strategic activities had remained a challenge. The District Health Council offered to provide staff support for the development of such a framework, and members of the NCC agreed to dedicate meeting time to this task during the fall of 2001.
• invest in appropriate staff training and development initiatives; • encourage a workplace environment characterized by trust and respect; Rural Health
• support an evolution that sustains and enhances the current level of healthcare available to rural residents; • ensure that rural healthcare providers have new opportunities and the support needed to evolve in their role; • use new and emerging technology to support rural-based physicians and healthcare professionals; • develop appropriate, viable and functional linkages to ensure the delivery of more specialized services when required;
Change Adaptive
• use new knowledge, best practices and emerging healthcare technologies in support of the communities we serve; • individually and collectively, bring forward new ideas that advance the cause and commitment of the Network; and • work together to promote an environment that fosters the spirit, opportunity and support needed to innovate.
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The planners facilitated a discussion of decision-making criteria based on the Network’s mission, vision and values. Members of the NCC were asked to frame potential criteria in terms of questions that reflect the values of the Network as articulated in the 1999 report to the HSRC (figure 1). Examples of the questions asked include the following: Will the service development activity increase service coordination? Will it result in improved recruitment and retention of human resources? Will local access to specific health services improve? The exercise generated a list of more than 30 values-driven questions that could be asked to evaluate potential service development opportunities for the Network. After the meeting, as the District Health Council staff reviewed the material and began to sort and consolidate the questions/criteria, it became clear that most fell into two groups: Network outcomes—questions related to desired changes for the organizations and the service system such as the following: • Does this activity have the potential to create an opportunity for reinvestment in another part of the service system? • Will the activity contribute to building an integrated system of care? • Will the activity advance the reputation of the WCHN and assist in attracting human and other resources to the area? Population outcomes—questions related to desired changes for residents of Wellington County or consumers served by the Network such as the following: • Will there be improvements in the health status of residents of Wellington County? • Can the activity be expected to increase consumer satisfaction? • Will residents have better access to healthcare?
A Logic Model of WCHN At this point, it occurred to the planners that a decision-making framework based on a logic model might be a useful tool to
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enable NCC members to evaluate the strength of the relationship between a particular network service development opportunity and the desired network or population health outcomes (figure 2). Application of the logic model approach provided a way of translating the high level strategic directions contained in the Network vision, mission and values into outcomes that could be linked to activities to be operationalized by the Network. Figure 2: Generic Logic Model The broad parts of the overall program
Component
Activity
The services that relate to each program component and provide the means whereby outcomes are achieved
The things that will change as a result. The ends that are pursued
Outcome
A logic model is a conceptual tool used to gain an understanding of the structure and rationale of health and social service programs.3 Although logic models were initially used to plan program evaluations, they have proven useful in program planning and, more recently, in the design and planning of systems of programs and services.4 One of the District Health Council planners working with the NCC had collaborated with an external consultant on a planning exercise in which a logic model was used to support the design of a regional mental health system.
A logic model comprises three parts: components or functions, activities and outcomes. Each of these parts is intended to relate “logically” to one another. The model also visually delineates how activities and services will be organized and delivered to produce the desired changes (i.e., outcomes) in the short and longer term. While most programs have various features designed to achieve certain results, the logic model organizes program components into a coherent whole and makes both the activities and the rationale for undertaking these activities explicit. Drawing on other experiences with the application of logic models and the results of the previous discussions among NCC members about service development opportunities, the planners presented the concept of a decision-making framework based on a logic model at the next meeting of the NCC. In their presentation, the planners grouped the service development opportunities identified by NCC members at previous meetings into five categories: clinical programs, human resources, information technology, clinical support and leadership. These categories became the components of the Network Logic Model (figure 3). They then presented a “mock logic model” for rehabilitation services showing the relationship between implementation objectives (activities that the NCC might undertake to develop or improve rehabilitation services) and the expected outcomes of those activities for the Network and its members (network outcomes) and the health of the population (population health outcomes). This application of a logic model differed from traditional applications, because it
Figure 3: Components and Subcomponents of a Network Logic Model Logic Model Components
Clinical Programs
Human Resources
Subcomponents • Rehabilitation • Physicians • Mental health • Health and • Acute care support • Complex personnel continuing care • Long-term care
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Information Technology
Clinical Support
Leadership
•Clinical information •Human resources and infrastructure
• Laboratory • Pharmacy • Diagnostics (digital imaging)
•Advocacy •Communication
Between meetings, the planners took the material generated in the small group work, integrated it at the appropriate point into the logic model, and then presented the revised model for discussion/refinement at the next meeting. Through this iterative process, the NCC developed a detailed Network Logic Model. The logic model defines the implementation objectives (Network activities) and outcomes (Network and population health) for programs and services within each of the five components (clinical programs, human resources, information technology, clinical support services and leadership). This material now forms the core of the Network’s strategic plan. Figure 4 shows, as an example, the implementation objectives and outcomes defined for rehabilitation, one of the subcomponents of the component clinical programs.
Clinical Programs
Rehabilitation
Mental Health
To develop a local rehabilitation service model that embodies these principles: quality; rural health; change adaptive; & service (accessibility).
Acute
Complex Continuing Care
Long-Term Care
Network Outcomes
Increase in hospital-based resources for rehabilitation.
To develop sizing & siting recommendations for local rehabilitation beds & services to support the above model. To advocate support and resources from the MOHLTC where needed. To participate in the planning & development of regional rehabilitation services.
Increase in clinical cohesiveness between community and hospital-based rehabilitation providers. Establishment of integrated rehabilitation services to increase ability to attract, recruit and retain required professionals. Increase in the range of rehabilitation services available to residents. Decrease in inappropriate use of acute hospital beds and improved flow from acute to rehabilitation beds and programs within Wellington County & with regional programs. Maximize the equitable distribution of rehabilitation resources across Wellington County.
With community partners reflecting continuity of care, implement the rehabilitation model for Wellington County.
Population Health Outcomes
Having agreed to this approach to the development of a decision-making framework, the NCC held four further meetings. At these meetings, the members worked in small groups, with guidance from District Health Council planners, to define the potential activities (implementation objectives) for each of the services/elements (subcomponents) within the five components of the model. For each potential activity, work group members considered what outcomes could reasonably be expected from this particular initiative. If the outcomes were not consistent with the desired Network or population health outcomes (figure 3), the potential activity was not included in the logic model.
Components
NCC members readily appreciated that this approach would have the benefit not only of assisting with the selection of appropriate service development opportunities for the Network but also of simultaneously defining the elements of an action plan to realize these opportunities and the criteria to evaluate the outcomes.
Figure 4: Logic Model for Rehabilitation Services
Implementation Objectives (Network Activities)
was not based on programs but on systems. It articulated outcomes and activities that a group of healthcare providers agreed to pursue collectively versus those of a single agency.
WCHN Strategic Plan and Priorities for Action The next step for the NCC involved setting priorities for action in the immediate future (2001–2002) among the components and subcomponents of the Network Logic Model. Members agreed to give highest priority to activities of strategic importance, that is, activities that: • will foster collaborative efforts among Network members and create a foundation for other Network activities; • have potential for success over the short term; • are feasible given the resources that WCHN has or will acquire; and • are consistent with current MOHLTC priorities. Five components/subcomponents were agreed upon as priorities for 2001–2002 (figure 5) through a traditional prioritysetting exercise involving NCC members.
Increase in accessibility to rehabilitation services. Increase in positive clinical and functional rehabilitation outcomes for patients/clients. Increase in consumer satisfaction with rehabilitation services. Increase in the number of people able to return to their home environment following rehabilitation.
The strategic plan (Network Logic Model) and priorities for 2001–2002 were presented to WCHN’s Joint Planning Committee and the boards of all the member organizations early in 2001. Each of these bodies endorsed the plan and the priority activities for 2001–2002 prior to their submission to the MOHLTC.5 Since submitting its implementation plan, the NCC has developed more detailed action plans for several of the five priority areas and is now working on initiatives concerning repatriation opportunities (acute care), development of a local rehabilitation services model (rehabilitation) and investigation of the potential to link Network hospitals via shared digital imaging (clinical support services). Member organizations of the WCHN are positive about the results of their first joint project. The strategic plan is a tangible outcome of the work of the Network that validates the collaborative
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Figure 5: Priorities for Action 2000–2001 Logic Model Component
Subcomponent
Clinical Programs
Acute Care
Priority
Activities to Be Initiated
#1
• analyze data and develop service profiles to identify repatriation opportunities; • develop a system of access to acute care services within Wellington County and between Wellington • County and services in other jurisdictions; • identify strategic directions for clinical programs in WCHN; • explore and identify new opportunities to work together across the WCHN for example, networkwide nurse practitioner, common clinical pathways;
Human Resources
Physicians
#2
• develop and implement a regional model for specialist and primary care that would include consideration of deployment, recruitment, primary care pilot projects, incentive structures; • understand the collective resources available to support physicians, for example, operating rooms, support staff, etc.; • implement a common physician credentialing process for hospitals;
Clinical Support Services
Diagnostics (Digital imaging)
#3
• determine the most appropriate partnerships within the WHCN related to digital imaging; • host an educational session on digital imaging services for the WCHN; • identify recruitment needs and opportunities;
Clinical Programs
Rehabilitation
#4
• develop a local rehabilitation service model that embodies the principles of quality, rural health, change adaptive and service/accessibility; • develop sizing and siting recommendations for local rehabilitation beds and services to support the model;
Clinical Programs
Long-Term Care
#5
• develop an understanding of the issues regarding the long-term care sector and its capacity, and the implications for the hospital sector; and • work with the CCAC on refining the discharge and long-term care placement process.
network model chosen by the members. The plan has also helped to raise the profile of the WCHN locally and to demonstrate the potential benefits of the Network for the healthcare system in Wellington County. But what about the approach taken by the NCC to the development of the strategic plan? Did the use of the logic model offer advantages over other, more conventional, ways of developing strategic and short-term action plans? NCC members identified the stepwise, structured process, employing a common
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language, as one advantage of the logic model. The most significant benefits from the viewpoints of members and District Health Council planners were, however, that the logic model focused discussions and provided a rationale for current and future decision-making; and enabled NCC members (who represent organizations with a diversity of roles, interests and issues) to find common ground. Focused discussions and a rationale for current and future decision-making: This attribute was particularly helpful. The requirement to clearly state the outcomes
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expected of a potential network activity ensured that discussion and decisionmaking were focused on outcomes that members had mutually agreed to be desirable. There was, therefore, a clear rationale for including or excluding any service development opportunity and associated activities proposed by a member of the NCC. In addition, defining the activities that the Network would need to undertake to achieve the desired outcomes within each service component or subcomponent (such as rehabilitation, acute care, or diagnostics) assisted members to identify short-term priorities for action. The process gave NCC members a preliminary understanding of the resource and other implications of embarking upon a particular initiative and therefore its feasibility over the short term. As described earlier, NCC members did not lack ideas about what the Network might do. The logic model process helped to solve the problem of “where to start.” Finding common ground: Once again, the focus on outcomes (which, as described, flowed from the Network’s vision and values) facilitated identification of shared interests and common ground. In addition, the small work group process used to develop the detail of the Network Logic Model provided a valuable opportunity for NCC members to build relationships and develop mutual trust and respect while working through a shared task.
Drawbacks to the Approach There were, of course, some drawbacks to the approach. It required NCC members— who as CEOs of their respective organizations are largely focused on the “big picture” and outcomes in their dayto-day responsibilities—to devote significant time to issues of process and detail. For some members, this was a less appealing aspect to the approach. The other drawback related to time commitment. This was less of an issue for NCC members who each devoted a total of 20 hours to the seven meetings required to formulate decision-making criteria (two meetings), develop the detailed Network Logic Model (four meetings) and establish short-term priorities for action (one meeting). Overall, NCC members considered that the results justified the time they
invested in the process. For the two District Health Council planners, the time commitment was more significant. They estimate that, over the same period, they each devoted 60 to 65 hours (for a total staff time of 120 to 130 hours) to meeting facilitation, preparatory work in advance of NCC meetings, documentation and report writing. The availability of this level of staff support for the work of the NCC members undoubtedly contributed to the success of the project. In the opinions of the NCC members, other factors that are also important to the successful use of a logic model process for planning purposes include the following: • prior development of a shared vision, mission and values among participants in the planning process; • access to expertise in the development and use of logic models; and • commitment of dedicated time to the process. NCC members also note that the process is more likely to be successful if the level of trust and communication among participants is high. Facilitation of the process by individuals with an understanding of the functions and issues of concern to the participating organizations is helpful but probably not essential.
Acknowledgements The authors wish to express their thanks to the members of the Network Coordinating Committee of the Wellington County Hospitals Network for their active participation in the creation of the Network Logic Model. They include Richard Ernst, Chief Executive Officer, Guelph General Hospital; Ross Kirkconnell, Executive Director, Community Care Access Centre of Wellington-Dufferin; Pierre Noel, Chief Executive Officer, North Wellington Healthcare Corporation; Dr. Edgardo Perez, Chief Executive Officer, Homewood Health Centre; Rita Soluk, Chief Executive Officer, St. Joseph’s Healthcare Guelph; and Carolyn Skimson, Chief Administrative Officer and Executive Director, Groves Memorial Community Hospital.
References and Notes
2. Wellington County Hospitals Network (Network #3). Report to the Health Services Restructuring Commission re: rural/northern hospital restructuring. The Network; September 17, 1999. 3. Rush B, Ogborne A. Program logic models: expanding their role and structure for program planning and evaluation. The Canadian Journal of Program Evaluation 1991;6(2):93–105. 5. Julian DA. The utilization of the logic model as a system level planning and evaluation device. Evaluation and Program Planning 1997;20(3):251–257. 6. Wellington County Hospitals Network. Report to the Ministry of Health and Long-Term Care on the implementation plan for Network #3. The Network; March 31, 2001.
1. Members of the Wellington County Hospitals Network: Community Care Access Centre of Wellington-Dufferin, Groves Memorial Community Hospital, Guelph General Hospital, Homewood Health Centre, North Wellington Health Care Corporation and St. Joseph’s Healthcare Guelph.
Conclusion The WCHN has successfully used a logic model as a decision-making framework to support development of a strategic plan and identify short-term priorities for action by the Network. The process enabled the WCHN to develop plans that are based on the Network’s values and focused on mutually desired outcomes for both the Network itself and the population of Wellington County. The strategic plan is flexible and can be modified to respond to changing needs and priorities. Service development opportunities that may emerge in the future can be readily evaluated for consistency with the desired outcomes before being incorporated into the plan. This structured, outcome-focused approach to planning could be particularly helpful in situations where planning may be hampered by an apparent lack of common interests and shared purpose among participants.
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