Appendix A: Report on Performance

The ministry's 2004/05 – 2006/07 Service Plan contained a number of objectives and strategies designed to move the health system toward reaching the ministry's goals. This appendix provides details of the progress in 2004/05 on those reform strategies. The following pages report progress on the ministry's objectives and strategies, as well as actual results of performance compared to the targets set out in the 2004/05 – 2006/07 Service Plan.

For the purpose of this annual report, the availability of timely data remains a challenge. For example, measures that report on hospital performance have a lag between the moment an event occurs and the time when data generated from that event is collected, checked and assembled in a usable format. Generally, the movement of hospital data through the system takes three months; however, because the measures in this report are at a provincial level, the ministry must wait for all hospitals to submit data. Because some data can take up to six months to report, it is impossible to have complete data for all measures by the Annual Service Plan Report publication date. The ministry is working with health authorities to improve the availability of quality data in the future.

Some measures in this report do not have data for 2004/05. Where partial data is available for that period, it is reported; where none is available, the most recent year's data is reported. Performance reporting shows results over several years to illustrate trends and provide context for recent results. Given the size and scope of the health system, viewing results over time gives a clearer, broader indication of performance in a given area.

Results

Core Business: Services Delivered by Partners

The core business, Services Delivered by Partners, comprises the majority of health services delivered to the public. These services span beginning to end-of-life care, health promotion to disease prevention, and primary to acute care. In the 2004/05 Service Plan the ministry identified four objectives under this core business. To achieve these objectives, the ministry works closely with those health care partners that deliver services directly to the public.

Goal: High Quality Patient Care

Objective 1: Provide care at the appropriate level in the appropriate setting by shifting the mix of acute and institutional care to more home and community care.

Our hospitals, community services and health care professionals must be used in the most effective and efficient way possible to lead to the best patient outcomes.

B.C.'s health authorities are the ministry's key partners in changing the structure of the health system. Health authorities have been given the managerial scope to implement large-scale structural changes to how health care services are delivered. These redesign efforts, which were begun in 2001 and are still underway in communities throughout B.C., are shifting the mix of services and health care providers to ensure care is delivered at the most appropriate level and setting. The goal is to create an integrated network of services, which links primary care, diagnostics, home and community care and acute care. In an integrated system the patient will move more easily between various settings and providers, and will not be left waiting at one level for services to be provided at another.

Many patients who are admitted for treatment to a hospital could receive appropriate care in a less intensive setting. The ministry, health authorities and care providers are working together to improve access to family physicians and other community resources so people can get the care they need, without unnecessary hospitalization.

Enhancing primary care is the key to achieving this strategy. Primary care is a patient's first and most frequent point of contact with the health system and supports individuals and families to make the best decisions for their health. Patients access primary care when they visit their doctor, medical clinic, or public health unit. Between 2002 and 2006, B.C. has been allocated $74 million from the Health Canada Primary Care Transition Fund to make improvements in primary care. Most of this funding has supported health authorities' initiatives in providing more comprehensive, accessible primary health care services. Regional initiatives include:

• primary health care organizations;
• networks linking family practices;
• community health centres;
• shared care arrangements providing family practices with specialist consultation and expertise;
• nurse managed care in regions with limited access to physicians; and
• chronic disease management.

Good progress has been made. Through the 2004 working agreement with the British Columbia Medical Association, 30 Professional Quality Improvement Days involving approximately 800 physicians from across the province have been held to provide opportunities for doctors, the province and health authorities to work together to enhance primary care services. Over 2,000 clinicians are now involved in primary care quality improvement initiatives across the province.

To provide 24-hour health resources to all British Columbians province-wide, the ministry also continues to expand the BC HealthGuide Program, giving B.C. residents access to medically approved health information and advice 24 hours a day, seven days a week. This program consists of a 400-page BC HealthGuide Handbook, a companion First Nations Health Handbook, a comprehensive website at http://www.bchealthguide.org, the BC NurseLine and pharmacist services, and the BC HealthFiles. More information on the BC NurseLine can be found under Performance Measure 2.

This rate helps identify opportunities to more efficiently manage resources by focusing expensive, specialized hospital care on those who truly need it, and treating less acute cases in a more cost-effective and clinically appropriate manner. Specifically, when patients are admitted to hospital they are classified into case groups based on their diagnosis. One of these groups is "may not require hospitalization" (MNRH). Asthma and hernia are among the conditions that fall under this category — conditions which can be treated without admission to hospital.

This performance measure helps the ministry assess success of the first part of priority strategy one, to prevent unnecessary hospitalizations.

Results

Annual Target		1999/00	2000/01	2001/02	2002/03	2003/04	2004/05*
				Baseline	-5.0%	-5.0%	-5.0%
	MNRH Rate (cases/1,000 pop)	7.9	7.0	5.9	5.2	5.3	n/a
	% change from previous year		-11.7%	-15.5%	-10.7%	0.1%

Analysis: No data are available for 2004/05. Data for 2003/04 show the MNRH rate remained stable compared to 2002/03; however, taking a longer view of performance shows B.C. has been successful in lowering the MNRH rate as it has declined over 10 per cent since 2001/02. This decrease has been achieved within the context of B.C. already having the lowest MNRH rate in Canada (based on national data for 2001/02, the latest for which MNRH is available).

It is important to note that a target rate of zero MNRH cases is unrealistic. In some instances, a patient's clinical condition and/or patient safety issues that may be taken into account by the admitting physician may well justify admission to hospital, even though the diagnostic coding indicates MNRH. Instead, the idea is to avoid a high, or steadily increasing rate of hospitalization for MNRH conditions, as that would signal problems in the delivery of care at the primary level.

The MNRH measure was originally selected in 1999 through the National Consensus Conference on Population Health Indicators as a way to monitor the strength of the primary care system. Since then, a new measure called Ambulatory Care Sensitive Conditions (ACSC) has emerged to perform this monitoring function and has replaced MNRH at the national level as it better reflects the rising importance of chronic disease treatment in the primary care sector. To stay nationally relevant, and because of strong performance in MNRH rates, in 2005/06 B.C. will switch to monitoring ACSC rates in its performance agreements with health authorities.

British Columbians can call the 24-hour BC NurseLine toll-free and speak with registered nurses specially trained to provide confidential health information and advice on the telephone. The nurses help callers understand and manage health concerns, get health information on home treatment and other care options, and get advice on when to see a health professional. BC NurseLine answers questions about various health topics, tests and medical procedures, and provides information on other community resources. BC NurseLine also provides a pharmacist service from 5 p.m. to 9 a.m. daily to answer medication-related calls. The number of calls to BC NurseLine helps gauge whether British Columbians are accessing health resources that may reduce demand on hospitals and physicians.

Results

			FISCAL YEAR
			2001/02	2002/03	2003/04	2004/05
	Call Volume	Target		Baseline	35.0%	60.0%
	Call Volume		103,471	172,934	250,018	331,429
	% change in call volume over baseline				44.6%	91.7%
	Calls transferred from physicians' offices	Target		Baseline	100.0%	150.0%
	Calls transferred from physicians' offices		335	1,423	7,251	7,991
	% change in calls transferred over baseline				409.6%	461.6%

Analysis: Since it began operating in Spring 2001, BC NurseLine has grown very rapidly. This is attributable to ongoing promotion in government publications; its consistent, 90 per cent plus customer satisfaction, which leads to both good word-of-mouth and repeat callers; and the use of NurseLine as the point of contact in managing public information for public health issues such as SARS, forest fires, West Nile Virus, Avian Flu, and flu campaigns.

An important aspect of NurseLine, captured in the second part of the measure (calls transferred from physicians' offices), is its role as after-hours support for physicians and walk-in clinics. Though up substantially from 2001/02, the growth rate in the number of forwarded calls slowed in 2004/05. This is likely due to the absence of a sustained communications campaign targeting health professionals, an element that will be explored as part of future BC HealthGuide Program education and promotion strategies.

Patients may remain in hospital longer than necessary for various reasons, including lack of available room in a residential facility or lack of community services to support discharge from hospital. The ministry and health authorities have been working to ensure the right mix of services is available so patients can access appropriate services once the need for hospital care has ended. This will result in better care for patients and better use of health system resources.

This measure indicates whether patients have timely access to appropriate care in the most appropriate setting. The days patients spend in hospital after the need for acute care has ended are called alternate level of care (ALC) days. A reduction in ALC days means more appropriate care is being delivered to patients, resulting in more acute care hospital beds being available for those who need acute care.

Results

Annual Target		FISCAL YEAR
		1999/00	2000/01	2001/02	2002/03	2003/04	2004/05*
				Baseline	-5.0%	-5.0%	-5.0%
	ALC Days	379,930	424,922	387,978	338,607	301,936	201,880
	Inpatient Days	2,750,756	2,730,866	2,612,699	2,548,797	2,562,749	1,651,174
	% ALC Days	13.8%	15.6%	14.8%	13.3%	11.8%	12.2%
	% Change in % ALC Days from previous year		12.7%	-4.6%	-10.5%	-11.3%	3.8%

Analysis: Based on data to December 31, 2004, the province does not expect to see further decreases in the ALC rate for 2004/05. However, the health system has made significant reductions in ALC rates over the past few years — the 2004/05 preliminary results still show an 18 per cent decrease in the ALC days rate since 2001/02.

Over the past four years the province has lowered ALC days with a combination of strategies. For example, the move to five regional health authorities in 2001 has allowed for better co-ordination of residential care beds across each region, and a more efficient movement of patients between the acute and residential care setting. In addition, health authorities have added sub-acute, hospice and convalescent care beds to the continuum of care for patients that require a rigorous, but not acute, level of care.

Moving forward, health authorities will continue to monitor ALC days and implement ALC reduction strategies.

While most of the strategies under this objective are focused on providing services outside the hospital, this strategy focuses on ensuring needed hospital services are provided in a timely and high quality manner. Under this strategy, the ministry and all six health authorities have participated in two province-wide projects to improve access to, and effectiveness of, emergency room and surgical services in hospitals across the province.

Government has also made targeted investments to reduce waiting times in key areas for British Columbians. Over $45 million in additional funding was allocated to provide 240 more heart surgeries, 2,000 more orthopaedic surgeries (including hip and knee replacements, arthroscopy and spine surgeries), 500 more cataract procedures and nearly 17,000 more diagnostic procedures. This builds on increased capacity built between 2001 and 2003, including a 21 per cent increase in hip replacements, 33 per cent increase in knee replacements, 20 per cent increase in cataract removals, and 40 per cent increase in angioplasties.

Monitoring wait times for these key services helps ensure patients' cancers are treated as early as possible to achieve the best outcomes. This indicator measures the percentage of patients that begin radiotherapy within four weeks of being ready to treat and the percentage of patients who start chemotherapy within two weeks of being ready to treat.

Results

Analysis: Over 10,000 patients receive radiation therapy treatment each year in B.C. The BC Cancer Agency (BCCA), provider of all radiation therapy treatment, has exceeded the 2004/05 target by providing treatment to 95.5 per cent of patients within four weeks of being ready to treat, defined as the time between a medical oncologist determining a patient is ready for radiation therapy, and that patient receiving it.

In addition, the ministry and BCCA track the other component of a patient's wait: from the family doctor's referral to an oncologist to the patient's first appointment with the oncologist. The median wait here was 12 days.

It should be noted that because data for this measure is from the BCCA scheduling system, not all patients are captured. The most urgent patients never show up on the scheduling system as they receive treatment immediately.

BCCA continues to place a high priority on providing timely access to radiotherapy and has consistently increased the percentage of clients beginning radiotherapy within four weeks of being ready to treat over the last four years.

Chemotherapy

For chemotherapy, the BCCA has a standard in place that patients will receive therapy within 14 calendar days of the physician's order being written. The BCCA has confirmed to the ministry that patients in BCCA centres are being treated within the standard in 90 per cent of cases.

In B.C., about half of all chemotherapy treatments are provided in therapy clinics residing within community hospitals and the other half is provided in chemotherapy centres managed by the BCCA. The Provincial Systemic Therapy Program began the process of collecting chemotherapy wait time statistics from the clinics and centres in 2004/05. Accordingly, future performance reports will be able to report detailed and comparable data.

Currently, British Columbia has excellent cancer outcomes, and leads Canada in survival rates for most cancers.

The ministry and all health authorities have been working together to improve the quality and performance of emergency department services across the province. In 2003/04, the Provincial Emergency Services Project (PESP) released the Emergency Services Short‑term Task Group Progress Report — the report is available at http://www.phsa.ca/AgenciesServices/Services/ on the Provincial Health Services Authority website. All health authorities are making progress in implementing recommendations from that report.

In 2004, the ministry released its first comprehensive survey of Emergency Room care. The results revealed that 85 per cent of the over 14,000 patients surveyed rated the quality of care they received in B.C. emergency rooms as good to excellent. Almost 80 per cent reported waiting an hour or less to see the ER doctor. The full survey report can be found at http://www.mediaroom.gov.bc.ca/events/October7_04e1/.

Analysis: The ministry's 2005/06 – 2007/08 Service Plan includes a measure related to emergency room use: the proportion of patients admitted from an emergency department to an inpatient bed within 10 hours of the decision to admit.

Hospital admissions can either be planned, such as scheduled surgery, or unplanned. This new measure focuses on unexpected hospital admissions that occur through hospital emergency departments. Many people are appropriately treated and released from emergency departments, but some require an extended course of treatment and must be admitted to hospital. Measuring the amount of time from the decision to admit a patient from an emergency department to when the patient is admitted to an inpatient bed will provide an indication of access to appropriate levels of care.

Over the last four years, health authorities have been implementing redesign strategies to shift the balance of care from traditional residential care facilities to home and community options such as assisted living. This new model of care will better meet the needs of clients and their desire for more autonomy as they age. It will also help make the health system more sustainable by focusing resources on providing appropriate care in the appropriate setting, rather than simply admitting the elderly or disabled to facilities designed for complex care.

A significant achievement has been the full implementation of a new access policy for residential care. The policy eliminated long wait lists by ensuring only those people who meet established criteria and require complex care are admitted to a residential care facility. To ensure more efficient use of residential care beds, health authorities have established priority access systems that coordinate the use of beds throughout each region, resulting in faster transitions from acute care to the appropriate care setting.

In 2004/05, health authorities continued to expand home and community care options to meet the diverse needs of seniors and the disabled. Services include assisted living, adult day centres, home support, professional home care nursing and community rehabilitation services, and end-of-life care.

This indicator tracks the percentage of seniors and people with disabilities who have high care needs and receive home support or adult day care services to allow them to remain more independent. Evidence indicates more people can and want to remain at home for as long as possible if they have appropriate support. This improves quality of life and frees up residential care beds for those with more complex care requirements.

Results

		POINT IN TIME
		1999/00 31 Mar. 00	2000/01 31 Mar. 01	2001/02 31 Mar. 02	2002/03 31 Mar. 03	2003/04 31 Mar. 04	2004/05* 31 Dec. 04
	% of clients — Annual Target			Baseline	2.0%	2.0%	5.0%
	Total Number of high needs clients	43,023	44,223	44,076	43,234	43,353	43,922
	# of clients receiving care at home	18,763	19,477	19,277	19,503	20,427	21,207
	% of clients receiving care at home	43.6%	44.0%	43.7%	45.1%	47.1%	48.3%
	Change in % of clients at home from previous year		1.0%	-0.7%	3.1%	4.5%	2.5%

Analysis: Based on preliminary 2004/05 data, there continues to be an increase in the proportion of high needs clients being cared for in the community rather than a facility. Going back to 2001, there are now 10 per cent more high needs clients receiving care at home.

A number of strategies have allowed people to receive care while remaining in their own homes. In improving the quality of home care services, health authorities are now providing enhanced home support services such as cluster care — a way of delivering support by assigning a single home care aide to an apartment building to meet the needs of clients throughout the day — and expanding adult day care programs, an important service to monitor people at risk, keep them engaged in their community, and allow them to remain in their homes for as long as possible. Networks of Excellence for Geriatric Services, which include community outreach, are also expanding. Specialized programs for people with brain injuries are now available to allow clients to remain in the community. Health authorities are also implementing end-of-life care strategies that include providing appropriate supports to allow people to die in their homes rather than an institution, if that is their wish.

This strategy focuses on integrating and providing care in the most coordinated and seamless manner possible to the benefit of patients and health care providers. The first part of the strategy concerns adapting business processes and using technology to allow care providers and facilities such as laboratories and hospitals to share information and provide coordinated care. Developing an electronic health record (EHR) system is essential for electronically linking health information to support clinical and management decision-making. British Columbia continues to make good progress in this regard and is seen nationally as one of the leaders in the development of the EHR.

The second part of the strategy focuses on integrating and coordinating mental health and addiction services. In the past, people with mental illness or substance misuse disorders have generally not received the same level of care and respect as people with a physical illness. Mental illness and addictions are treatable, and with appropriate care and support, people can manage their illness better and achieve their full potential. The ministry is working with its health care partners to create networks of care in each health authority that better integrate mental health and addiction services, as well as working to provide appropriate care in patients' communities to minimize their time spent in institutions, and to improve their access to health professionals.

This measures the percentage of persons who have been hospitalized for a mental health illness and receive at least one follow-up treatment at a community-based Mental Health Centre or with a general practitioner or psychiatrist within 30 days of being discharged from hospital. A high rate of community or physician follow-up indicates well-coordinated, accessible continuity of care for people with a mental health diagnosis.

Results

Annual Target		FISCAL YEAR
		2000/01	2001/02	2002/03	2003/04	2004/05*
		Baseline		3.0%	increase	increase
	% Clients Followed-up	71.5%	73.0%	73.9%	74.9%	76.7%
	Change in % followed-up from previous year		2.1%	1.2%	1.4%	2.4%
	Change in % followed-up from baseline*			3.4%	4.8%	7.3%

Analysis: Based on preliminary data, the 30-day follow-up rate for the approximately 20,000 mental health and addictions clients discharged each year from hospital continues to increase, reaching 76.7 per cent in 2004/05 from the 71.5 per cent 2000/01 baseline.

Physicians and community mental health centres provide the follow-up services. The follow-up is important for the recovery and stability of patients discharged from hospitals and ensures patients are linked with appropriate community programs and resources for subsequent care, treatment and support.

Therefore, monitoring and working to increase the follow-up rate for mental health and addictions clients serves as a high-level gauge of whether the system provides integrated, supportive care.

An important facet of improving follow-up is to increase mental health services that are available in community settings and to ensure effective discharge planning processes are in place that appropriately link patients with community resources. To this end, it is positive to note the percentage of follow-up provided by community mental health centres has increased, from 18.9 per cent in 2000/01 to 36 per cent in 2004/05. On the other hand, physicians' follow-up has remained between 67 per cent and 69 per cent over the past five years.

This measure indicates whether individuals with mental illness have access to timely, appropriate care in the most appropriate setting. Please note this measure is the same as the previous ALC measure (Performance Measure 3), but focuses on people who are hospitalized for a mental health diagnosis. Reducing the number of days that patients spend in hospital after their need for acute care has ended indicates that appropriate services are available in the community.

Results

Annual Target		FISCAL YEAR
		1999/00	2000/01	2001/02	2002/03	2003/04	2004/05*
				Baseline	0.0%	-2.0%	-2.0%
	ALC Days	8,897	9,509	13,925	7,267	8,949	5,587
	Inpatient Days	228,427	232,662	232,382	248,514	257,257	167,377
	% ALC Days	3.9%	4.1%	6.0%	2.9%	3.5%	3.3%
	% Change in % ALC Days from previous year	n/a	4.9%	46.6%	-51.2%	19.0%	-4.0%

Analysis: Based on preliminary data, the 2004/05 target for ALC rate reduction will be met.

The overall rate of ALC days for mental health and addictions diagnoses is low (less than 3.5 per cent) and the total number of individuals receiving greater than one ALC day in 2003/04 and 2004/05 comprises a very small proportion of all mental health and addictions patients in B.C.

More than three-quarters of all ALC days incurred by mental health and addictions patients in the past two fiscal years are associated with those experiencing psychotic disorders, including schizophrenia. While the total number of these patients is relatively low, they tend to consume, on average, a higher number of ALC days than other disorders.

This indicator measures the range of services mental health and addictions clients receive in their own communities or regional health authorities. This performance measure indicates our progress in improving access and availability of mental health and addictions care and community services for individuals in their regions.

Results

Annual Target		FISCAL YEAR
		1999/00	2000/01	2001/02	2002/03	2003/04	2004/05*	Long-Term Target
				Baseline	Increase	Increase	Increase
	% Services Received in Client's Own HA							87.0%
	All Mental Health Services	85.0%	84.2%	83.6%	84.3%	85.0%	85.0%

Analysis: Preliminary data for 2004/05 indicate the proportion of mental health and addictions services received in each client's regional health authority has remained stable at 85 per cent. The overall rate is made up of services provided by physicians, acute care hospitals and community mental health centers.

Core Business: Services Delivered by Partners (continued)

Goal: High Quality Patient Care (continued)

Objective 2: Provide tailored care for key segments of the population to better address their specific health care needs and improve their quality of life.

The ministry is striving to build a health system that provides patient-centred services that respond to a continuum of needs over an individual's lifetime. Most people will need a range of services:

• to help stay healthy with disease prevention and health promotion services;
• to improve health and wellness with episodic care;
• to live with illness or disability by accessing chronic disease management or care; and
• to cope with the end-of-life through hospice or palliative care.

Clearly, one size does not fit all in health service delivery. For instance, the small number of patients who currently need and use health services the most are moving in and out of the health system constantly. These patients tend to have multiple chronic and/or terminal illnesses. Evidence shows our health system does not provide these patients with optimal seamless care and that improvements in care and outcomes can be made through innovation in our models of service delivery.

The ministry is working with health authorities and physicians to design and deliver customized care that addresses the unique needs of specific patient sub-populations. To begin, the focus is on coordinating care for patients with extensive needs, proactively managing chronic diseases, providing better care for the dying, and addressing health inequalities in B.C.'s Aboriginal population. Implementing a patient-centred approach for these populations can improve quality of life and health outcomes for patients and provide better use of health services.

A 2003 study showed a small percentage of B.C.'s population uses a large percentage of medical services. For instance, the data analysis showed that in hospitals, five per cent of patients account for 54 per cent of bed days and 94 per cent of days spent in hospital after the need for hospital care has ended. This data led the ministry to initiate a project to study the most frequent users of the system to find more effective ways of delivering their care. The ministry has been working with health authorities to better understand the common health concerns of this population and to develop evidence-based strategies to improve care.

Research shows other jurisdictions have improved care and reduced costs by introducing specific strategies for high needs populations. For example, providing intensive targeted care in the community to the frail elderly, such as medical, rehabilitative, social and support services, improves their health and reduces the number of hospital admissions, ambulance calls and drug claims. Other examples with similar results include improved end-of-life care and accessible community services for individuals with mental illness.

The ministry has been monitoring the percentage of alternate level of care (ALC) days that high needs patients spend in hospital as an initial indicator for assessing strategies to better serve the highest needs population. For this patient group, ALC days are twice the average compared to the entire population.

This indicator is limited because a highest needs patient can only be defined after the fact - that is, the data will only capture a patient as falling in the highest needs category once that patient has received the threshold number of services to qualify. Preliminary data for 2004/05 is provided below, but given the nature of this indicator it should be noted this data is a less reliable preliminary indication of final full year data than in other parts of this report where preliminary 2004/05 data is used.

Results

Annual Target		FISCAL YEAR
		1999/00	2000/01	2001/02	2002/03	2003/04	2004/05*
					Baseline	-5.0%	-5.0%
	ALC Days	347,037	374,222	352,197	311,919	278,113	182,552
	Inpatient Days	1,473,586	1,484,857	1,465,555	1,441,542	1,433,675	881,639
	% ALC Days	23.6%	25.2%	24.0%	21.6%	19.4%	20.7%
	% Change in % ALC Days from previous year		7.0%	-4.6%	-10.0%	-10.3%	6.7%

Analysis: The highest need group consists primarily of the frail elderly with multiple health problems, persons with multiple chronic medical conditions, persons with significant mental health disorders, and individuals requiring end-of-life services.

In addition to the initiatives outlined in the overall ALC measure (Performance Measure 3), health authorities have specific strategies targeting the highest needs patients. These include chronic disease collaboratives with primary care practitioners and specialists focusing on congestive heart failure, chronic obstructive pulmonary disease, depression and diabetes. Health authorities are also establishing networks of acute hospitals and health centres to optimize roles and referral relationships; enhancing end-of-life care services; expanding community mental health services; and developing self-care, health promotion and illness prevention education programs.

Substantial progress has been made. Data for 2003/04 showed a 10 per cent decrease in the proportion of ALC days over the 2002/03 baseline, continuing the downward movement in the rate since 2000/01. Partial year data for 2004/05 do not show the same decreasing trend, although it may be too early to predict year-end results. Overall, the 2004/05 partial year data still show the ALC rate for highest needs patients is 18 per cent lower than in 2000/01.

A chronic disease is an illness that cannot be cured completely. Diabetes, depression, congestive heart failure, hepatitis C and asthma are all chronic diseases. An estimated 500,000 British Columbians suffer from one or more chronic diseases.

Effective management helps people with chronic diseases stay healthy and independent for as long as possible. The ministry is working with physicians and health authorities to help individuals maintain their health through prevention, early detection and management of chronic conditions. A number of initiatives have been implemented to ensure patients receive the highest standard of chronic disease management and care. Best practices and clinical guidelines have been developed for congestive heart failure, diabetes and other chronic diseases. In addition, in 2003, the ministry launched a two-year project called the Full Service Family Practice Incentive Program. This program aligned physician payment with quality care and provided additional remuneration for services delivered according to guidelines, and also compensated physicians for participating in quality improvement learning collaboratives. The ministry has also created chronic disease patient registries to monitor the impact of improving care, and other web-based tools to support physician practice, including a secure, web-based Chronic Disease Management Toolkit that gives authorized doctors, nurses and other care providers access to tools and information incorporating proven best practices for the treatment and management of chronic diseases.

In September 2003, as part of the push to improve the treatment of chronic conditions in B.C., government introduced a $75 incentive payment per patient per year for family doctors who treat diabetes or congestive heart failure sufferers according to evidence-based, best practice guidelines. The program was the first of its kind in Canada.

Results

Annual Target		FISCAL YEAR
		2003/04*	2004/05*
		30.0%	40.0%
	Total physicians	4,573	4,573
	# Phys. claiming incentive payments	1,524	1,926
	% Phys. claiming incentive payments	33.3%	42.1%

Analysis: When targets were originally set for this measure, because of the program's novelty, it was difficult to know how physicians would react to payments-for-conditions, guideline-based care. It is now clear the program has exceeded expectations.

Results understate true performance. Experience shows there are less actively practicing family physicians than the 4,573 with an MSP billing number. For example, many general practitioners are not involved in regular family practice but have concentrated instead on other aspects of medicine, such as providing emergency room or surgical assistant service. Only about 3,800 regularly provide office services, and quite a number of those work in walk-in-clinics rather than conventional family physician offices, which means the exact number of general practitioners who can be considered full service family physicians is almost certainly less than 3,000.

As a result, the percentage of eligible physicians claiming the incentive payment is likely over 60 per cent.

Over 37,000 British Columbians suffer from congestive heart failure — a chronic disease where the heart is unable to pump enough blood to meet the needs of the body's tissues. Research shows ACE inhibitor and beta blocker drugs, in combination with other treatments, significantly improve health outcomes for congestive heart failure patients; however, the rate of prescription for these drugs does not reflect the highest standard of care. In 2004/05, the ministry and its physician partners continued broad-based work to address and overcome challenges to increasing prescription rates of ACE inhibitors and beta blockers.

Results

		FISCAL YEAR
		2000/01	2001/02	2002/03	2003/04	2004/05*
ACE Inhibitors/ARBs
	Annual Target				Baseline	53.0%
	% patients with CHF who are prescribed ACE Inhibitors/ARBs	41.2%	44.9%	47.2%	48.9%	n/a
Beta Blockers
	Annual Target				Baseline	21.0%
	% patients with CHF who are prescribed Beta blockers	11.1%	13.3%	15.5%	17.5%	n/a

 
Analysis: In the 2003/04 – 2005/06 Service Plan, the target for 2003/04 was to set a baseline and targets. This was achieved, however, the targets were found to be too high, as they did not take into account patients with diastolic heart failure, who comprise approximately half the clients with congestive heart failure. Because most published medical research has so far dealt with systolic failure, there is much less evidence on the appropriate management of diastolic failure, making treatment more uncertain. The targets have been revised to recognize these complexities.

Additionally, improvement in prescription rates for ACE inhibitors and beta blockers should be positively affected by physician uptake of the congestive heart failure incentive claim under the Full Service Family Practice Incentive Program. This program only began in September 2003, halfway through the 2003/04 fiscal year, so its full impact may not yet have been realized.

The ministry and its chronic disease management partners are working on a number of initiatives to improve care for congestive heart failure patients. For example, the ministry has organized structured collaboratives to disseminate and embed evidence-based best practice care for chronic diseases, including congestive heart failure. The collaboratives are 12-18 months long, and emphasize a team-based approach to improving outcomes. B.C.'s first congestive heart failure collaborative involved 35 general practitioners, and 820 patients. By the end of the project, 93 per cent of patients were on ACE inhibitors, and 89 per cent were on beta blockers. Currently, the Northern and Vancouver Coastal Health Authorities have embarked on congestive heart failure collaboratives, while the Vancouver Island Health Authority is midway through a three-year collaborative effort.

In the 2004/05 service plan, the ministry signaled its intention to track HbA_1c tests as an indicator of patients with diabetes being proactively involved in managing their care. With the right tools and information, patients with diabetes are aware of the importance of receiving two HbA_1c tests a year and are proactive in ensuring the tests are scheduled and the results discussed with their physician.

Results

Annual Target	FISCAL YEAR
	1999/00	2000/01	2001/02	2002/03	2003/04	2004/05*
					40%	45%
% patients with diabetes who undergo two or more HbA1c tests on different dates during the year	36.5%	38.5%	38.8%	39.0%	40.6%	n/a

Analysis: Data is not yet available for 2004/05; however data for 2003/04 show the target for HbA_1c testing was met in that year.

2003/04 was a foundational year for chronic disease management in British Columbia. In September of that year, the Full Service Family Practice Incentive Program was introduced and for the first time a physician fee item was directly linked to providing best practice care. For diabetes, one component of this best practice care is for patients to receive two HbA_1c tests per year.

In 2003/04, the Chronic Disease Management (CDM) program also worked to introduce tools to assist physicians in delivering quality care. Much of the initial effort concerned establishing the necessary privacy and security practices for clinical information sharing in a diabetes registry, and working to assist physicians through the start-up process. In 2004/05, the program expanded as health authorities were given funding to promote and support the CDM program at the local level. Cumulatively, this work has led B.C.'s CDM program to be recognized across Canada for innovation.

The ministry and its chronic disease management partners have been, and will continue to work on a number of initiatives to improve care for diabetes patients. For example, like congestive heart failure, the ministry has organized structured collaboratives to disseminate and embed evidence-based best practice care for diabetes. Diabetes collaboratives are 12-18 months long, and emphasize a team-based, patient self-management approach to improving outcomes. B.C.'s first diabetes collaborative involved 49 general practitioners, and led to 7,000 patients receiving evidence-based, clinical guideline care. By the end of the project, 54 per cent of patients were receiving H_1c tests every three months. The Vancouver Island Health Authority's three-year diabetes project is showing excellent results as well. For the 1,800 patients involved in the first wave of the project, 79 per cent received an HbA_1c test within the last six months.

Palliative care is the specialized care of people who are dying; it is an integral part of a health system that meets the needs of people across their lifespan. Good palliative care is provided, where possible, in the setting of a person's choice and is delivered by coordinated teams of physicians, nurses and other health professionals such as pharmacists and nutritionists, and includes family input and volunteer services.

The ministry has worked with partners, including health authorities, physicians and the B.C. Hospice Palliative Care Association, to enhance and coordinate palliative services across the province. In B.C., publicly funded palliative care includes care provided in palliative care units or hospices in hospitals, as well as care provided in a person's home or other community-based setting. To promote innovative palliative care services, the ministry introduced the Palliative Benefits Program, which provides medications, medical supplies and equipment to those who choose to die at home. Previously, those items were only covered if the patient stayed in hospital. The Palliative Benefits Program is an important resource that allows health authorities and care providers to design programs to support people who choose to die at home or in settings outside the hospital.

As first noted in the 2003/04 service plan, the ministry has been monitoring and reporting the percentage of people accessing benefits under the Palliative Benefits Program as an interim measure of availability of end-of-life care services. Although this measure only captures one component of palliative services, it does indicate broader access to palliative care based on the assumption that clients who access the benefits program are likely accessing other palliative services, such as physician, home nursing or hospice care.

In the future, this indicator will be replaced with a more specific measure of access to palliative care. The development of a new measure is discussed in the analysis below.

Results

Annual Target		FISCAL YEAR
		2001/02	2002/03	2003/04	2004/05*
			Baseline	13.0%	15.0%
	Deaths in fiscal year	28,864	28,910	29,684	28,480
	# deaths with at least 1 prescription under Palliative Care Benefit Program	3,447	4,226	4,676	4,228
	% deaths with at least 1 prescription under Palliative Care Benefit Program	11.9%	14.6%	15.8%	14.8%

Analysis: Drug benefits under B.C.'s Palliative Care Benefits Program have been available since 2001. Plan P uptake has increased since its inception as familiarity with the program has grown, and clients choose home as the setting for end-of-life care. The continued enhancement of palliative care, and especially community-based services, will likely lead to further increase in the use of these benefits.>

As signaled in the previous annual report, for the 2005/06 service plan the interim Plan P measure has been replaced by a more comprehensive measure of palliative care services: the percentage of natural deaths occurring in hospital. Currently 56 per cent of natural deaths occur in hospital. The ministry has identified a long-term target to reduce it to 40 per cent by expanding community, home, and hospice care services for end-of-life, while still respecting those who prefer to die in a hospital setting.

Improving the health status of Aboriginal peoples is a priority of government. While significant improvements have been made with respect to the health status of Aboriginal peoples in recent times, the overall health status of the Aboriginal population continues to remain below that of the general population.

The ministry and health authorities are pursuing a number of strategies to improve Aboriginal health. Health authorities are developing and implementing regional Aboriginal health plans, administering targeted regional funding through the Aboriginal Health Initiatives Program, and ensuring coordination and integration of Aboriginal health services into the overall planning and delivery of health programs within the province.

The ministry is also working with stakeholders throughout the province to reduce the incidence and complications of various illnesses. An example is the National Diabetes Surveillance System project, aimed at reducing the incidence and complications of diabetes through leadership in the development, implementation, and national coordination of provincial, territorial, and Aboriginal diabetes surveillance systems. Other priority strategies to improve Aboriginal peoples wellness include targeted actions to reduce smoking rates, deaths due to injuries and preventable hospital admissions, and to improve Aboriginal participation in preventive health strategies such as immunization, mammography and pap smear screenings.

The Ministry of Health Services tracks infant mortality rates and life expectancy because they serve as useful indicators of the overall health status of Aboriginal people. Data for 2003 are not available at the time of publication; however, data for the past decade is presented and provides useful insight for trends in Aboriginal health status.

Results

Analysis: Since 1990 in B.C., the infant mortality rate for the Aboriginal Status Indian population declined from a high of 15.6 per 1,000 live births in 1992 to a low of 4.0 in 2000. Over the past decade, the gap between infant mortality rates in the Aboriginal population and the total B.C. population has decreased to being statistically insignificant. This is a vast improvement over the mid-1990's when the Aboriginal rate was over double the provincial rate.

Analysis: For British Columbians, life expectancy (five-year average) since 1986 has increased steadily from 80.3 to 82.2 years in the general population, and from 69.4 to 73.9 years in the Status Indian population. Although still less, Status Indian life expectancy is growing faster than for other residents of B.C., so the gap is gradually closing in both absolute and relative terms. This positive trend is expected to continue.

Core Business: Services Delivered by Partners (continued)

Goal: Improved Health and Wellness for British Columbians

Objective 3: Keep people as healthy as possible by preventing disease, illness and disability, and slowing the progression of chronic illness to minimize suffering and reduce care costs in the future.

While British Columbians in general are among the healthiest people in the world, certain segments of the population do not share that status. Many citizens are still at risk from factors such as poor dietary habits, obesity, inactivity, accidents and tobacco use. In addition to poor health, the consequence of preventable illness is that vast resources are spent "after the fact" — once a disease or injury has occurred.

In these cases, an ounce of prevention is worth a pound of cure. Services such as public health protection, illness and injury prevention, and chronic disease management are important for maintaining and improving health outcomes, while containing overall health system costs. If we can support British Columbians' efforts to stay healthy and out of the health system, we win on two fronts: people achieve better health, and scarce resources can be used to provide appropriate care for non-preventable illness.

The ministry and its health care partners have used two main approaches for keeping people healthy. The first is to provide health information and resources to support people to manage their health and reduce the burden of disease, injury and disability. The second is to provide effective public health services to prevent illness and disability. These include immunization programs, infectious disease prevention and control, and monitoring and regulating water, food and environmental safety.

Staying healthy or caring for a chronic disease, injury or illness does not begin or end at the doctor's office. In order to stay healthy, or manage diseases like congestive heart failure and diabetes, patients must also participate and take responsibility for their own care. By monitoring their health, improving their diet and getting exercise, patients get the best care possible.

In 2004/05, government launched ActNow BC, the most comprehensive health promotion program of its kind in North America. ActNow BC is a program to promote healthy lifestyles and prevent disease by providing people with the information, resources and support they need to make healthy lifestyle decisions. Specifically, ActNow BC is focused on improving health by promoting physical activity, healthy eating, living tobacco free, and making healthy choices during pregnancy.

Performance Measures: In the 2004/05 service plan, the ministry signaled its intention to track HbA_1c tests as an indicator of patient self-management. This measure is a good indicator of patients being involved in and receiving quality care for a chronic condition (diabetes), but is not a strong measure of the population's overall health. Accordingly, results for the HbA_1c measure are reported under the chronic disease management section of this report (see Priority Strategy 7).

Developing performance measures for increases in physical activity and self-management of health conditions is difficult. Ultimately, the best indicators are improvements in health status and outcomes, which are measured over long periods of time. These indicators can be found in the Provincial Health Officer's Annual Reports, available on the ministry's website http://www.healthservices.gov.bc.ca/pho/ar/index.html.

The ministry, in its 2005/06 – 2007/08 Service Plan, has committed to monitoring and reporting smoking rates and obesity rates as key measures of the impact of ministry and government programs to promote healthy living.

Government plays an important role in monitoring population health and protecting public health. Legislation and regulation of food, air and water quality lays the foundation for communities and citizens to live in healthy and safe environments. Programs that target and prevent certain diseases, like influenza, also contribute to maintaining and improving the health of British Columbians.

In May 2003, the ministry brought into force the new Drinking Water Protection Act. Under the Act, government has dedicated additional resources to drinking water and water source protection to enhance the quality of drinking water in British Columbia. Also, in July 2004 government modernized its Meat Inspection Regulation as part of ongoing improvements to the 2002 Food Safety Act. The new regulation harmonizes its protocols with the National Meat Code, and provides province wide standards for the construction and operation of slaughtering facilities, including a provision that animals raised for sale require mandatory inspection before and after slaughter.

a) Immunization rates for two-year-olds: Immunization programs for children are among the most cost-effective ways to improve population health, prevent illness, and reduce health care costs. In B.C., all infants and preschool children have access to immunizations that protect them from the following diseases: diphtheria, pertussis, tetanus, polio, haemophilus influenza type b, measles, mumps, rubella, and hepatitis B. In 2003, B.C. introduced the meningococcal C conjugate and pneumococcal conjugate vaccine programs. In January 2005, B.C. introduced an infant varicella (chickenpox) program. These new programs are not yet included in the data results.

Results

Target		CALENDAR YEAR
		2004
		85.0%
	Up to date for age	69.2%
	Up to date except booster	88.4%

Analysis: In 2004, BC Centre for Disease Control (BCCDC) assumed responsibility for the analysis and reporting of immunization data. Previously, the ministry had collected data directly from health authorities. Shifting responsibility to the BCCDC has strengthened the data quality and better aligned the process with other public health data activities. A side effect of this change, however, is that 2004 annual data are not comparable to the data reported in 2003.

The 2004 data show that the B.C. rate of complete immunization for two-year-olds at 69.2 per cent, short of the ministry's target of 85 per cent. However, the data also indicate that 88.4 per cent of two-year-olds have received all of their shots except for the booster shot given at 18 months of age. This is encouraging, as it indicates most infants are getting the majority of their early shots. The ministry, BCCDC and health authorities are now working to have a higher percentage of infants receive the 18-month booster shot.

Moving forward, BCCDC will also work with all health authorities to further standardize and improve data quality.

b) Influenza immunization for residents of care facilities.

Results

Analysis: Data for 2004/05 influenza immunizations for residents of care facilities show an increase from 89.7 per cent in 2003/04, to 91.8 per cent, well in excess of the target rate of 85 per cent.

Importantly, this year's data comprises a higher percentage of care facilities across B.C. Last year, data covered 59.4 per cent of facilities. This year, the number of facilities reporting increased in every health authority, to an overall B.C. rate of 68.4 per cent. BCCDC continues to work with health authorities to improve the data quality.

Core Business: Services Delivered by Partners (continued)

Goal: A Sustainable, Affordable Health Care System

Objective 4: Manage within the available budget while meeting the priority needs of the population.

The ministry is committed to working with its partners to manage the health system efficiently to ensure resources are spent where they will have the best outcome. This objective, however, is about more than just keeping costs down - it is also about managing the system in such a way that services are provided effectively and in a high quality manner. With the move to six health authorities, a more streamlined, cost-efficient and accountable governance structure is in place, allowing more resources to flow directly to patient care. In delivering the full continuum of care to local residents, regional health authorities now have the flexibility to make decisions about what programs and services best meet the needs of local people. The result is more responsive and more accountable service.

Each health authority has been working to create networks of health and community services to provide quality, coordinated care. For example, by linking small community hospitals with basic emergency services to larger community and regional hospitals with more complex care capabilities, health authorities are able to provide high quality care and more timely access to multiple levels of service. A coordinated, integrated health system also improves accessibility to physician services, recruitment and retention of family physicians and specialists, and health outcomes for patients.

It is also important that clinical services are organized safely, cost-effectively and at a high quality. Almost all types of medical treatment come with some risk of harm. This is obvious in the case, for example, of surgery or radiation therapy, but it also applies to drugs, many diagnostic tests and other types of treatment. Accordingly, the ministry, health authorities and health professionals have been working together on patient safety initiatives.

Progress: The Patient Safety Task Force (PSTF), a group composed of Vice Presidents of Medicine, Chief Nursing Officers and representatives of the ministry and the Health Care Protection program, was formally inaugurated on May 7, 2004. The PSTF brings together clinical leaders to work on improving patient safety in areas from drug reactions to hospital-acquired infections.

Among other achievements, the PSTF is facilitating a baseline medication safety survey in 50 B.C. hospitals under the Institute for Safe Medication Practices Canada. It has also adopted and disseminated patient safety goals to guide hospital safety improvement, and is leading B.C.'s response to the Canadian Adverse Events Study: The Incidence of Adverse Events in Hospitalized Patients in Canada.

In addition, the ministry has made a one-time investment of $3 million to establish a research chair of patient safety at UBC's faculty of medicine.

When the new governance model for B.C.'s health system and six health authorities was created in 2002, the government made it clear these new authorities would be expected to manage health care in their regions within their budgets. In 2004/05, health authorities became part of the Government Reporting Entity (GRE) and as such are subject to many of the same reporting, budgeting and financial requirements as the rest of government. In accordance with the Balanced Budget and Ministerial Accountability Act, government had to balance the budget in 2004/05, including the operating results of all entities within the GRE. Accordingly, health authorities are expected to balance their budgets each year.

This indicator measures the amount health authorities spend on administrative and support services compared to their total expenditures. Administrative services include finance services, human resources and communications. Support services include maintenance, housekeeping, food services and security. To ensure maximum resources are directed to patient care, in 2002/03 health authorities were given a three-year target of reducing administrative and support services by seven per cent by the end of 2004/05 (compared to 2001/02 levels).

Results

Analysis: Audited financial statements are not available at the time of publication, however preliminary results indicate each health authority has reached the seven per cent reduction target by the end of the 2004/05 fiscal year.

Results

Analysis: Audited financial statements are not available at the time of publication, but preliminary results indicate that health authorities have achieved balanced budgets for the 2004/05 fiscal year.

Core Business: Services Delivered By Ministry

While the vast majority of health services are delivered in partnership with health authorities, physicians and other care providers, the ministry does deliver some services directly to the public.

Goal: High Quality Patient Care

Goal: A Sustainable, Affordable Health Care System

Objective 5: Provide clients with equitable and timely access to services directly delivered by the ministry.

This objective focuses on improving the services the ministry currently delivers directly to the public. Priorities include better integration of ambulance services with other health services, and timely delivery of Medical Service Plan (MSP) and PharmaCare registration services and Vital Statistics services. The ministry has worked to develop new models for delivering these customer services efficiently and effectively, while making the health system affordable.

The B.C. Ambulance Service is a key part of the health care system, providing pre-hospital treatment and transportation. The ambulance service operates 190 ambulance stations across the province and employs approximately 1,250 full-time and 2,000 part-time paramedic and dispatch staff.

The ministry is committed to ensuring the ambulance service delivers responsive and efficient care, and that the service is flexible and financially sustainable to meet the needs of B.C. patients now and in the future. To meet this commitment, the ministry is working to better integrate ambulance services with health authorities, to strengthen coordination of pre-hospital emergency care, and to better manage inter-facility transfers.

In 2004/05, the B.C. Ambulance Service reached a new framework agreement with government. It provides for enhanced training opportunities for paramedics, better service coverage for rural areas, and increased access to Advance Life Support trained paramedics for metropolitan areas.

This measure provides insight as to whether the ambulance service is performing its principal responsibility well — responding to sudden, acute care needs as quickly as possible. Many metropolitan Emergency Medical Services in Canada have adopted a response time goal of less than nine minutes, 90 per cent of the time. Although ideal to strive towards, meeting this goal in all communities can be difficult given the variances in geographic size and population density among communities.

Results

Target		FISCAL YEAR
		2001/02	2002/03	2003/04	2004/05
			5.0%	5.0%	5.0%
	Total # urgent calls in metropolitan settings	19,899	22,337	23,814	27,310
	# Responses within 9 minutes	8,689	11,509	13,099	16,310
	% Responses within 9 minutes	53.8%	57.5%	64.5%	69.3%
	% Change in % responses within 9 minutes	—	6.8%	12.2%	7.4%

Analysis: There are essentially two factors to meeting the nine-minute response time standard:

1) Efficiency — which is the sum of the time it takes to assess a call for help (dispatch time), and for an ambulance crew to respond to the scene of the incident;

2) Availability — whether a unit is available to respond to the incident (unit utilization and deployment).

Preliminary data show the ambulance service continues to improve response time performance. Like the previous year, most improvements resulted from greater efficiency. In Vancouver, for example, the rollout of a Computer Assisted Dispatch system has improved mapping knowledge, automatically identifying locations of callers and electronically signaling an ambulance crew dispatch for an emergency even while information is being collected.

Improving the availability element of response time is more complex, and is affected by the number of ambulances, the geographic location of stations, and the time units spend in hospital. BCAS is working with health authorities to reduce the amount of time paramedics get tied up at emergency rooms waiting for their patients to be admitted.

The Medical Services Plan (MSP) provides coverage to beneficiaries for medically required services provided by physicians and some other health care practitioners. PharmaCare is the province's drug insurance program, which helps British Columbians by providing financial assistance toward eligible prescription drugs and medical supplies. In 2004/05, the ministry administered the two programs, including registering B.C. residents who are eligible for coverage. The ministry was committed to improving registration services, and successfully negotiated an alternative service delivery arrangement with a private sector partner. On April 1, 2005, Maximus BC began a ten-year contract to provide the administrative functions of these programs. The new program is called Health Insurance BC (http://www.hibc.gov.bc.ca).

British Columbia provides one of the best prescription drug coverage programs in Canada. Through the PharmaCare program, British Columbians are insured against catastrophic drug costs. The Fair PharmaCare Plan is the main benefit plan offered by the program. The plan focuses financial assistance on B.C. families who need it most. Started in May 2003, Fair PharmaCare combined the previous major PharmaCare plans — the universal plan and the seniors' plan — into one, with assistance based on families' ability to pay. To receive their maximum level of financial assistance, individuals or families are required to register with the Fair PharmaCare Plan. B.C. families with the lowest incomes will receive immediate financial assistance under the plan, while other B.C. families will pay their full prescription drug costs until they reach their deductible. Once their deductible is reached, PharmaCare will assist families in paying for their eligible drug costs for the remainder of the year.

Results

Analysis: Fair PharmaCare registration reached 69.3 per cent in 2004/05. In addition to Fair Pharmacare Plan registrations, another 160,000-plus low-income individuals in British Columbia received prescription drug coverage as clients of the Ministry of Human Resources. It should be noted that less than half of families registered under Fair PharmaCare make a claim to the plan. Therefore, government does not expect significant increases in registration from the current level, as it is likely those British Columbians who require benefits from the Fair Pharmacare Plan are already registered.

Measuring the amount of time it takes for applications and premium assistance applications to be processed are key indicators of MSP/PharmaCare registration services. Enrolment applications are used for new or returning beneficiaries, while premium assistance applications are for beneficiaries whose income level makes them eligible for reduced premium payments.

Results

			2002/03	2003/04	2004/05
Enrolment Applications		Target	Baseline	8.0	6.0
	Average turnaround rate (weeks)	Actual	16.0	4.5	6.0
Premium Assistance Applications		Target	Baseline	6.0	4.0
	Average turnaround rate (weeks)	Actual	12.0	5.5	4.0

Analysis: Prior to entering into a contract with Maximus BC to provide administrative services for the Medical Services Plan, the ministry made significant efforts to reduce processing times and inventory volume for enrolment and premium assistance applications.

For MSP beneficiary enrollment applications, turnaround time fell 64 per cent from 2002/03. Also, total inventory volumes (backlog) dropped from 20,837 applications in April 2003 to 10,062 in March 2005, while over the same period, inventory more than 60 days old fell from 64 per cent to 11 per cent.

For MSP premium assistance applications, turnaround time fell 66 per cent from 2002/03. Also, total inventory volumes dropped from 17,266 applications in April 2003 to 6,704 by March 2005, while over the same period, inventory more than 60 days old fell from 55 per cent to three per cent.

The ministry's contract with Maximus BC to deliver these services will ensure the capacity is maintained to support or improve on these service levels.

The British Columbia Vital Statistics Agency is responsible for documenting important events for B.C. citizens such as births, marriages and deaths. The Agency has pursued a number of strategies to ensure it provides timely and efficient services. Most notably, it has piloted an electronic service for the registration of births and deaths; maintained customer satisfaction levels while implementing nationally mandated identification security measures; and improved direct electronic access to users of vital event health-related information products from the VISTA data warehouse to support health planning and surveillance activities.

Results

Analysis: The Vital Statistics Agency surpassed its 2004/05 target by completing 90 per cent of the registrations of birth, death, and marriage events in 34 days. The agency will continue to explore strategies for further reduction of registration processing times. Reducing the time between the occurrence and report of vital events will enhance the timeliness of the data collected, thereby making it more valuable to health researchers and planners.

Results

Analysis: The Agency achieved a 97.5 per cent rating for customer satisfaction in areas of courtesy, helpfulness, and promptness. This high rating from customers was achieved even though the Agency has been implementing new security-related initiatives that could have negatively affected customer satisfaction. However, the Agency has managed to maintain high satisfaction levels during the implementation period, and will strive continue to do so as additional security measures are developed and implemented over the next several years.

Results

Analysis: Access to the Vital Statistics data warehouse (VISTA) enables in-depth analyses of mortality and natality health issues to support health surveillance, program planning and monitoring, resource allocation, and health research by individuals and organizations engaged in these activities. In 2004/05, secure access to VISTA was expanded to include all provincial Medical Health Officers, health authorities, staff at the Ministry of Children and Family Development, the Chief Coroner's office, and the BC Centre for Disease Control.

Core Business: Stewardship

Goal: Improved Health and Wellness for British Columbians

Goal: High Quality Patient Care

As steward of the health system, the ministry provides leadership and support to health authorities and other partners in delivering quality health services to the public. The ministry's stewardship objectives and strategies are designed to assist our service delivery partners fulfill the objectives and strategies listed in the previous section, and ensure the health system operates in accordance with government's strategic direction. Stewardship strategies are organized under three objectives, which represent the main components of effective stewardship: Strategic Direction, Support to Partners, and Monitoring, Evaluation and Course Correction.

Each stewardship objective contributes to all three goals of the ministry. That is, effective stewardship by the ministry will contribute to a system with improved health and wellness for British Columbians, and high quality patient care that is sustainable and affordable.

Unlike the previous sections of this report, most performance measures in this section are qualitative. Therefore, performance reporting is primarily based on detailing the ministry's progress in implementing its stewardship strategies.

Objective 1: Direction — Government's strategic direction is clearly defined and communicated and guides service delivery.

The ministry is committed to leading and fostering a culture in which health system activities are evidence-based, well planned and understood, and in which accountability structures exist to ensure strategic directions guide service delivery activities. The ministry's strategic direction for the health system must be well articulated and communicated to the public and to those who deliver services to the public.

The ministry has undertaken several strategies to meet the objective of providing clear strategic direction for the health system. The following pages outline each of the strategies and report on the progress to date in meeting the performance expectations in the 2004/05 – 2006/07 Service Plan.

To be effective the health system needs to be planned, well managed, responsive to patient and public needs and accountable to the public. We need to focus on the changing and diverse needs of British Columbians, and develop short and long term strategies to ensure those needs are met. Those strategies must then be communicated and well understood by all stakeholders in the system, and accountability measures must be in place to ensure the delivery of services meets patient needs.

Target 2004/05: Health system directional plans published; implementation of strategies in progress.

Rationale: The health system is multi-faceted and complex. Planning for a social program as large as the health system occurs on many levels, in many places, and involves numerous health care partners, stakeholders and organizations. To ensure all components of the system are working toward the same goals, the ministry is developing an overall directional plan. The plan will detail the major strategies government will pursue to sustain and improve the publicly funded health system.

Progress: The ministry has substantially completed a long-term directional plan that includes a planning framework, the system shifts required to achieve government's health system goals, and the strategic investments needed to support these shifts. The draft framework was used to develop the ministry's 2005/06 – 2007/08 service plan. The full Directional Plan and supporting materials are expected to be released in Fall 2005.

Target 04/05: Implement surveys and determine baseline data.

Rationale: As the ministry strives to provide clear and timely direction to those who deliver health services, it is also important to receive feedback from the recipients of that direction. Working together will help identify strengths and gaps, and inform our efforts to clarify and improve our strategic direction and communication with our service delivery partners. To begin, we are developing and implementing a survey seeking the opinions of senior health authority personnel. This assessment tool will provide a comparable, clear measure of the ministry's performance over time.

Progress: The ministry is nearing completion of the survey tool with implementation of the survey scheduled for Fall 2005.

Effective stewardship requires that the ministry not only provide strategic direction through broad planning, but also operational support through the research of best practices in service delivery. Scanning other health systems for best practices and incorporating them in B.C. can improve patient care and outcomes. The ministry works with professional groups, such as physicians and other health professionals, to research and develop best-practice guidelines, standards and protocols for use across the system.

Target 2004/05: Develop guidelines for rheumatoid arthritis and chronic obstructive lung disease.

Rationale: Best practice guidelines are an important and growing component of providing quality care. By researching the best outcomes and methods of delivering care across the world, and implementing those practices in B.C., we can help ensure B.C.'s patients are getting the best possible care. In B.C., guidelines and protocols are developed jointly under the direction of the Guidelines and Protocols Advisory Committee (GPAC), jointly sponsored by the B.C. Medical Association and the ministry.

Progress: The chronic obstructive pulmonary disease guideline was approved, and the rheumatoid arthritis guideline is at the approval stage. In all, 16 guidelines were developed in 2004, including diagnosis and management of major depressive disorder, investigation and management of iron deficiency and clinical management of chronic hepatitis B and C.

The goal of public health programs and initiatives is to protect health and prevent disease, injury, premature death and disability, and improve population health. Public health functions encompass programs in four areas - health improvement, prevention of disease, disability and injury, environmental health and emergency health management - delivered using the public health strategies of health promotion, health protection, preventive services, assessment of population health and surveillance of disease.

Target 2004/05: Development of accountability framework completed to ensure health authorities meet core program requirements.

Rationale: The ministry is working with health authorities to develop a set of public health core functions. These will include mandatory, legislated, long-term programs representing the minimum level of public health services that health authorities will be required to provide to their regions and communities. Each program will have clear goals, measurable objectives and an evidentiary base that illustrates effectiveness in protecting and improving people's health and preventing disease, disability and/or injury. The programs will also be supported through identification of best practices and national and international benchmarks. The identification and implementation of public health core functions will help ensure public health capacity within the health authorities remains focused on the most critical areas (i.e., those areas of public health with the greatest potential for positive impact).

Progress: The ministry has distributed an overview document entitled, Public Health Renewal: Core Functions, to health authorities. This is a companion document to the more detailed resource document, Core Functions in Public Health, which will be distributed in the near future. Additionally, a joint health authority and ministry Performance Improvement Process Steering Committee has been created to define the scope of the performance improvement process, and to oversee the development of performance measures by a series of working groups.

Regulated health professions in B.C. have the privilege and responsibility to govern themselves in the public interest. Enhanced quality and accountability mechanisms are needed in response to emerging technology, new research, changing practice standards and higher public expectations for accountability of individual health professionals.

Target 2004/05: "Reserved Actions" model implemented and updating scope of practice regulations underway.

Rationale: Effective self-regulation of health professionals in the future will not be feasible without comprehensive, modernized legislation. There are currently 10 statutes regulating 24 professions, based on an exclusive scope of practice model. The province is working toward an umbrella regulatory framework under a single statute using a shared scope of practice/reserved actions model. This new framework will provide consistency and fairness in requirements relating to governance structures and transparency, registration processes, and inquiry and discipline matters. It will also facilitate development of common jurisprudence, counter perceptions of "hierarchy" among professions, enhance interdisciplinary practice, increase accessibility and consumer choice, and improve cost effectiveness.

Progress: Proposed new regulations were released for optometrists in April 2004 and registered nurses (including nurse practitioners) in November 2004. Both regulations included specified reserved actions based on recommendations of the Health Professions Council. The new regulations for registered nurses (including nurse practitioners) are expected to come into force in 2005.

The outbreak of SARS in 2003 demonstrated the importance of preparation, coordination and communication among health care partners and stakeholders to minimize the impact of communicable disease. Monitoring population health status and detecting and responding to outbreaks of disease and other health-related issues are key functions of the ministry and its partners.

Progress: The ministry works closely with the BC Centre for Disease Control and public health staff in the health authorities to prevent, monitor, and control the occurrence of communicable diseases in the province. For example, the ministry has prepared for the potential arrival of West Nile virus by expanding surveillance and testing in every health authority for the virus, as well as by establishing a provincial planning committee to coordinate British Columbia's approach to preparing for the virus' arrival. The ministry has also directed additional funding towards immunization programs to prevent influenza and meningitis.

Core Business: Stewardship (continued)

Goal: Improved Health and Wellness for British Columbians (continued)

Goal: High Quality Patient Care (continued)

Objective 2: Support — Supports are in place to facilitate the achievement of strategic priorities, and barriers to change have been removed.

The ministry supports its service delivery partners (health authorities and health professionals) in achieving the strategic priorities of the health system; it develops provincial plans for the future supply and effective use of health care professionals, equipment, technology and facilities to ensure the health system has the capacity to meet the population's health needs. The ministry also supports health research and the development of best practices for service delivery, and develops legislative, regulatory and policy frameworks to manage the health system and protect public health and safety.

The ministry has undertaken several strategies to support its partners and the health system. The following pages outline each of the strategies and report on the progress to date in meeting the performance expectations in the 2004/05 — 2006/07 Service Plan.

Decisions in the health care system should be based on evidence. The ministry is working with its partners to develop and strengthen data and information systems to build capacity for evidence-based strategic planning and decision-making. One important component of this work is the Electronic Health Record (EHR) system. It is a cornerstone of government's strategy to deliver faster and more effective treatment to patients, and enable better information collection and sharing.

Target 2004/05: Implement survey and determine baseline data

Rationale: Similar to the performance measure on government strategic direction and feedback, the ministry also wants to receive feedback from the health authorities on the usefulness of data supplied by the ministry. This feedback will help improve the way data is used to support decision-making in the health system.

Progress: The ministry is nearing completion of the survey tool with implementation of the survey scheduled for Fall 2005.

A core function of government is to provide the legislative governance framework for the health system. The ministry regularly assesses the need for new or amended legislation, regulation or policy to ensure the system operates in the public interest.

Target 2004/05: Further reduction in regulations to meet government regulatory reduction targets

Rationale: In 2001, government committed to reduce the overall regulatory burden in British Columbia by one-third to be consistent with global trends in regulatory reform and management. The ministry has worked to reduce regulatory requirements in the health sector to streamline and update the overall legislative framework and reflect an outcome-based approach. This work has been undertaken while recognizing the need to preserve those regulations that are essential to the protection of public health and safety.

The Ministry of Health Services will contribute to government's intention to maintain a zero per cent increase to the baseline regulatory count through the next three fiscal years. The ministry will continue to identify regulatory reduction and reform opportunities, and focus on improving regulations to ensure they are consistently results-based, cost-effective, flexible and promote competitiveness and innovation.

Progress: Government has achieved its target of reducing the overall regulatory burden in B.C. by one-third.

The ministry has made a commitment to include longer-term planning in the management of the health system. This focus provides an opportunity to identify strategies that will effect systemic change in the health system for the long-term. Also, by involving health authorities in developing plans for health facilities and medical equipment, we can ensure capital funding is used in the best manner to meet the population's current and future needs.

Target 2004/05: Health Human Resources plan, IT plans and Capital plan.

Rationale: Health human resource, information technology and capital planning all benefit from a province-wide perspective. Accordingly, the ministry is involved with health authorities and other partners (e.g., Ministry of Advanced Education, universities and colleges, Government of Canada, professional groups) to ensure planning in these fundamental areas is integrated and coordinated to maximize benefits from investments and strategies.

Progress

a) Health human resource planning: Government has made great progress in planning for the future supply of health professionals in British Columbia. In 2004/05, over 450 new educational spaces were created for nurses, allied health professionals and midwives. That brought the total number of new educational spaces created up to almost 2,800 since 2001/02. In addition, the province has also increased physician education spaces (from 120 first-year students in 2000 to 224 first-year students in 2005) through the expansion of the UBC Medical School, including the development of new campuses in Prince George and Victoria.

Health human resource planning remains a priority for the ministry and the government. As part of the 2004 First Ministers' Ten-Year Plan to Strengthen Health Care, British Columbia is participating in developing and publishing a health human resource action plan by December 2005.

b) Information technology planning: The ministry develops and publishes an annual Information Resource Management Plan. A summary of the ministry's plan for 2005/06 is available at: http://www.healthservices.gov.bc.ca/cpa/publications/index.html.

c) Capital planning: The ministry works with health authorities to develop and implement three-year capital plans that address capital needs across the spectrum of provincial health services. In 2005/06, the ministry will be working with health authorities on developing longer-term (10 year) capital plans to meet the future infrastructure requirements of the health system.

Information on capital investments in B.C.'s health system can be found in Appendix B.

Research, evaluation and information management are essential to enhancing our capacity to share knowledge and best practices and continually improve B.C.'s health system. The ministry does this through supporting the work of key health research organizations in B.C.

B.C.'s provincially mandated health research organization, the Michael Smith Foundation for Health Research (MSFHR), works to achieve ministry goals, serving as a catalyst to build B.C.'s capacity for excellence in clinical, biomedical, health services and population health research. Its mandate includes advancing provincial, inter-provincial and national initiatives that expand health research support and opportunities; working with health research stakeholders to identify, prioritize and respond to provincial priorities; and delivering innovative programs to address the key building blocks of a vibrant, sustainable research effort.

In late 2003/04, the ministry provided MSFHR with $24.27 million to fund programs in British Columbia that continue to develop, attract and retain outstanding health scientists and researchers; and to support the newly established Health Services and Policy Research Support Network's research activities in priority areas that support health care re-engineering and innovation. In addition, in February 2005, the province announced a commitment to renew MSFHR's mandate, pledging $100 million in continuing support by 2007. $30 million of that commitment was provided to MSFHR in March 2005.

The ministry also supports and commissions directed research through contracts with universities and organizations to meet its own health research priorities in key service delivery areas:

• UBC's Centre for Health Services Policy Research: $1.45 million in funding for 2004/05
• UNBC's Rural and Remote Health Research Institute: $273,000 in funding for 2004/05
• UBC's Mental Health Evaluation and Community Consultation Unit: $1.13 million for 2004/05
• B.C. Injury Research and Prevention Unit: $538,000 in funding for 2004/05.

In 2004/05, the ministry provided $12.5 million in one-time funding to support the research activities of the following agencies:

• The Brain Research Centre ($1 million)
• The Prostate Centre at Vancouver General Hospital ($1 million)
• Women's Health Research Institute ($2 million)
• Genome B.C. ($5 million)
• Tri-ministry funding to support B.C.'s portion of a larger CIHR Autism Research Project (ministry contribution totaling $500,000)
• Establishment of a Patient Safety Research Chair at UBC ($3 million).

Core Business: Stewardship (continued)

Goal: Improved Health and Wellness for British Columbians (continued)

Goal: High Quality Patient Care (continued)

Goal: Sustainable, Affordable Health Care System

Objective 3: Monitoring, Evaluation and Course Correction — Delivered services meet public needs and are sustainable.

The ministry monitors and evaluates the delivery of services and the health of B.C.'s population to ensure services meet patients' and the public's needs. As part of a commitment to continuous improvement and evidence-based decision-making, the ministry uses its evaluations of health system performance to inform strategic intervention and facilitate course correction if required.

The section contains key strategies the ministry has undertaken to enhance its monitoring and evaluation functions.

Monitoring and evaluating the level, quality and impact of services delivered to the public by the ministry's partners is critical to ensuring the public receives value for health expenditures. The ministry must ensure patients are able to access appropriate services that meet their needs, while at the same time ensuring limited health funding is spent efficiently. To that end, the ministry has developed an accountability and performance-monitoring framework for services delivered by health authorities. In 2002, for the first time in Canada, the ministry established performance agreements with each health authority that outlined expectations and performance targets. These performance agreements continue to be renewed annually, with modifications and improvements being incorporated as experience is gained.

Target 2004/05: Performance agreements signed by all health authorities by May 31, 2004.

Rationale: Performance agreements set out direction and expectations for each health authority for health system governance and health service delivery. They contain specific targets for system performance improvements in key areas, such as emergency services, surgical services, mental health and addiction services, home and community care, public/population health, Aboriginal health, and support and administrative services. Each of these targeted improvements support achievement of the ministry's service plan goals and objectives.

Progress: All regional health authorities signed their performance agreements by August last year, with the Provincial Health Services Authority signing in November.

B.C.'s health services budget has continued to grow - the ministry's budget for 2004/05 was over $10.7 billion and health spending consumed approximately 43 per cent of all government spending. It is important this funding is used wisely to provide the best care and achieve the best outcomes for patients - and that all parts of the system manage within their allocated budgets. The ministry monitors financial status throughout the year so any problems can be identified and addressed, and ensures overall costs remain within its budget.

Target 2004/05: Expenses do not exceed budget.

Progress: Health expenses did not exceed budgeted expenses for 2004/05. For details, please see Appendix B — Report on Resources.

Monitoring the health status of the population is essential for assessing the effectiveness of health programs and services. Health status is influenced by a number of factors including the social, economic and physical environment, personal health practices, individual capacity and coping skills, human biology, early childhood development, health services, gender and culture. While many of these factors lie beyond the jurisdiction of the health system, surveillance and assessment of population health assists government and the ministry address issues or trends and develop healthy public policy.

Target 2004/05: Annual Report produced (topic: air quality).

Rationale: The Provincial Health Officer (PHO) reports publicly each year on the health of the population. The PHO is the senior medical health officer for British Columbia and provides independent advice to the Minister of Health Services and the ministry on public health issues and population health.

Progress: The Provincial Health Officer released the annual report "Every Breath You Take Air Quality in British Columbia, A Public Health Perspective". The report can be found at: http://www.healthservices.gov.bc.ca/pho/pdf/phoannual2003.pdf.

Core Business: Corporate Management

In order to provide effective leadership to the health system and meet its stewardship obligations, the ministry must manage its own operations efficiently and effectively. Corporate management includes managing ministry budgets, human resources and information needs. The ministry included two objectives for Corporate Management in its 2004/05 service plan.

Goal: A Sustainable, Affordable Health Care System (continued)

Objective 1: Appropriate organizational capacity to manage the health system and efficiently deliver necessary services.

The ministry has significantly changed its role in the health system. In the past, the ministry was predominantly involved in the direct delivery of health services. Now, the ministry is primarily focused on being a steward of the health system. This change in focus has required the ministry to develop new areas of expertise, such as planning, monitoring and evaluating services delivered by other agencies. This objective, and the strategy and performance measure below, helps ensure the right mix of skills are available throughout the organization to successfully manage the health system.

In order to achieve the strategic objectives in the service plan, additional effort must be focused on developing and supporting the ministry's employees, and continuing to build an enriching, rewarding and flexible organization. To do so, the ministry has been implementing a human resource strategy that supports the Corporate Human Resource Plan for the Public Service of British Columbia. A summary of the ministry's strategy can be found on its website: http://www.healthservices.gov.bc.ca/cpa/publications/index.html.

Target 2004/05: 65 per cent.

Rationale: In 2003 and 2004 the ministry conducted annual surveys of organizational health. The purpose of the surveys was to measure satisfaction levels and to identify issues of importance to staff in six aspects of organizational health: communication, leadership, personal and professional development, quality of life, recognition and involvement.

Progress: The ministry will either participate in a cross-government survey by the BC Public Service Agency or conduct its own survey in the Fall of 2005.

In 2004/05, the ministry continued its efforts to align employee planning with the overall strategic direction of the ministry. All employees have developed an Employee Performance and Development Plan, which details individual work and development goals that support the ministry's strategic direction. Implementation of employee plans that directly link with organizational strategic plans is expected to focus work effort in key areas of importance and improve employee understanding of the broader implications and impact of their work on the ministry's attainment of its goals.

Core Business: Corporate Management (continued)

Goal: A Sustainable, Affordable Health Care System (continued)

Objective 2: Sound management practices in place.

The first objective under Corporate Management was to have the appropriate personnel with the required abilities in the ministry. The second objective is to have the business and operational practices in place to maximize the human resources and ensure the production of quality work. The ministry is committed to adopting sound management practices and operating in an innovative, enterprising, results-oriented and accountable manner.

Over the past four years the ministry has undergone a shift in its management approach. Structured planning and performance monitoring has become the new standard of operation throughout the organization. In practical terms, this means that strategic priorities and operational plans and activities set at the division, department and individual level are aligned with and contribute to the overall priorities of the ministry and government. The adoption of integrated planning and performance monitoring helps the ministry ensure resources are focused on identified priorities.

Target 2004/05: 80 per cent of divisions have integrated plans.

Rationale: In adopting integrated planning, the ministry has focused initial efforts on the development of service or business plans for each division of the ministry. These plans present the activities each division is undertaking to achieve the ministry's service plan goals, objectives and strategies. (The ministry has nine divisions. A division is an organizational unit headed by an Assistant Deputy Minister.)

Progress: All divisions have prepared plans that align their activities with the goals, objectives and strategies detailed in the ministry's 2005/06 – 2007/08 service plan.

Target 2004/05: 30 per cent of divisions have risk management plans.

Rationale: Government has made a commitment to structured and evidence-based planning and decision-making. Conducting risk assessments of plans, programs or policies can be a useful tool in ensuring sound decisions are made.

Progress: The ministry has made good progress in implementing risk management processes where they will have significant benefit in informing planning and operational decisions. The ministry's corporate audit committee uses risk assessment to assist in developing an annual audit plan. In addition, the ministry has focused on integrating risk methodology into the ministry's project management approaches where it has an immediate impact in assisting project completion. To date, risk assessment and management methodology has been used to assist in complex projects with multiple stakeholders, such as the Small Water Systems Review Project (part of the Drinking Water Action Plan) and the Meat Inspection Regulation consultation project.