Report of the Musculoskeletal Expert Panel

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					Report of the Musculoskeletal Expert Panel

  Submitted to the Health Operations Committee by the
  Musculoskeletal Expert Panel Secretariat

  April 2008
Table of Contents
Executive Summary--------------------------------------------------------- 2

1. Background-------------------------------------------------------------- 3
    1.1. Expert Panel Process---------------------------------------------- 4
    1.2. Musculoskeletal Expert Panel------------------------------------ 5

2. The Expert Panel’s Advice--------------------------------------------- 6
    2.1. The Principles ------------------------------------------------------ 7
    2.2. Considerations for Health Operations Committee--------------7

3. Summary and Conclusions----------------------------------------------11


1. Musculoskeletal Expert Panel Terms of Reference----------------- 13
2. List of Panel Members-------------------------------------------------- 15
3. List of Secretariat-------------------------------------------------------- 16

Executive Summary
Expert panels have been identified as a central component of British Columbia’s (BC)
wait times strategy. In January 2008, the Ministry of Health (Ministry) through its Health
Operations Committee 1 established the first expert panel: a Musculoskeletal Expert Panel
(the panel) to share knowledge and provide advice on how to improve access to care for
musculoskeletal patients in general, and meet the provincial access targets for hip and
knee joint replacement surgery, in particular.

This panel was comprised of clinical, administrative and research expertise from the
regional health authorities and the Ministry. It made use of an independent facilitator and
was supported by a secretariat based in the Health Authorities Division of the Ministry.

The panel identified examples of innovative care delivery within British Columbia, and
other jurisdictions, but also differences and challenges across the province that must be
accommodated in planning.

The panel supports the development of a patient-centered approach to effective and
efficient management of joint replacement surgery. System planning should take into
account six key areas: data and information systems; funding; models of care delivery;
health human resources; organization and coordination of care; and facilities and
infrastructure. Specific advice was offered for each area. The panel encourages the
Health Operations Committee to appoint a task force to draft a plan of action and report
back within two months.

The panel was able to complete its task, the endorsement of a final report in three months.
Based upon the evaluations of panel meetings, the majority of the participants have found
the panel process rewarding and their voices heard. Similar process should be considered
when the next priority area is identified.

 The Health Operations Committee is a Ministry/health authority collaborative forum. The purpose of this
committee is to review health authority operational opportunities, issues and challenges, as well as
government and health system priorities, evaluate their impact, and provide advice and leadership on
addressing these matters.


In September 2004, Canadian First Ministers agreed to the 10-Year Plan to Strengthen
Health Care. 2 This included a commitment by the provinces and territories to reduce wait
times in five key areas (cancer, cardiac, sight restoration, joint replacement, and diagnostic
services) by developing evidence-based wait time benchmarks in the priority areas. A key
component of this plan was setting targets to attain these benchmarks, while recognizing
that each jurisdiction had different starting points, priorities and strategies.

There is an important difference between wait time benchmarks and access targets.
Benchmarks express a patient wait time that clinical evidence and consensus point to as
appropriate for a particular procedure. Access targets specify a percentage of patients to
be completed within the benchmark wait time and a timeline for attainment. While the
benchmarks are applicable across Canada, the access targets will differ across the country
and will reflect each jurisdiction’s ability, capacity and readiness to achieve the

The BC government has developed a comprehensive and proactive strategy to achieve the
First Ministers Meeting commitments. The components of the strategy are aligned with
the 10-Year Plan and best practice. Key components of the strategy entail addressing
existing surgical backlogs and introducing system changes necessary to sustain targeted
performance in the future. Despite efforts to address orthopaedic access, hip and knee
joint replacement was identified as the largest area of concern with among the longest
surgical wait times. Similar to other jurisdictions, it was the first focus area identified by
the province.

BC’s approach to setting access targets, consistent with the First Ministers Meeting
benchmarks, employed mathematical modeling to estimate the additional number of cases
and the timeframe required.


BC’s first provincial access target, the access target for hip and knee joint replacement
surgery has been approved as: completion of 90 percent of joint replacement surgeries
within 26 weeks by March 2010.

   1.1. Expert Panel Process
The use of expert panels, comprised of healthcare leaders, has been a feature of many
provincial strategies to move toward the wait time benchmarks agreed upon by First
Ministers. The use of expert panels is a central component of BC’s provincial wait times
strategy to help inform direction for system improvement needed to meet provincial
access targets.

Recognizing the need to engage stakeholders and care providers, the intent of the expert
panels will be to provide advice on clinical and system improvement opportunities from
referral of the patient from primary care through to post surgical outcome. Panel members
contribute clinical, administrative and research leadership and work within a government-
defined mandate to provide advice on reaching the access targets through a focus on
opportunities for innovation, best practices and quality improvement.

It was proposed that BC first establish a musculoskeletal expert panel to address the
hip/knee joint replacement access target endorsed in December 2006. Panels in the other
priority areas may be established pending Ministry and the Health Operations Committee
approval and the successful evaluation of the musculoskeletal panel.

It was acknowledged at the outset that a narrow focus on hip/knee joint replacement was
required to address the wait time access target. While this focus was deemed necessary in
light of the task at hand, the preferred course of action would seek strategies to improve
access to joint replacement that would be comprehensive and applicable to the broader
musculoskeletal case mix.

Recognizing that joint replacement surgery represents just one component of
musculoskeletal care, BC’s approach will be system-wide and apply across the broader

case mix as far as practicable, and care will be taken to ensure that a narrow focus on
hip/knee joint replacement does not have an adverse effect on other orthopedic and related

      1.2. Musculoskeletal Expert Panel
The musculoskeletal expert panel was established by and reports to the Ministry through
the Health Operations Committee, a Ministry/health authority collaborative forum chaired
by the Assistant Deputy Minister of the Health Authorities Division at the Ministry. The
panel’s terms of reference were endorsed by both the Health Operations Committee and
the panel members (Appendix 1).

The panel included representation from the five regional health authorities and included
administrators, researchers and clinicians, as nominated by the Health Operations
Committee and confirmed by the Ministry (Appendix 2). Recognizing their key role in
the management of care delivery, administrators were drawn from among senior staff of
the regional health authorities. The range of clinical representation was broad, including:
general practice, orthopaedics, rheumatology, nursing and rehabilitation therapy.

A small secretariat was established within the Health Authorities Division of the Ministry
to provide support to the panel through its deliberations by arranging meetings, providing
background information, developing supporting materials, establishing a reference library
via a SharePoint site, 3 recording panel meeting discussions and authoring the final report
on panel participants’ deliberations for submission to the Health Operations Committee
(Appendix 3).

It was decided at the outset that all panel members would participate as equals and no
chair would be appointed. An external independent facilitator was retained to lead the
discussion, work with the members to define agendas and ensure productive meetings in
accordance with the panel’s mandate.


The terms of reference established the musculoskeletal expert panel as a time-limited
process. The expert panel met for the first time on January 22, 2008 and received
background information including presentations on wait time access targets across Canada
and progress to date in BC. The panel articulated five overarching principles to inform
system improvement, and system barriers to achieving the targets. Six key theme areas
for focus were then identified.

The second meeting of the panel was held on February 12, 2008. Panel members received
a presentation on the Surgical Patient Registry, reviewed the key theme areas that had
been identified, and considered potential solutions related to Area #1 data and information

At the third panel meeting on March 3, 2008, panel members discussed the remaining
areas: funding; models of care; health human resources; organization of care; and,
facilities and infrastructure. The secretariat was instructed to circulate a document
containing the principles and issues for input, and draft a final report for review at the
fourth meeting.

A fourth and final panel meeting was held on April 8, 2008 for members to provide
feedback to the secretariat on its draft final report prior to submission to the Health
Operations Committee.


The panel’s advice to the Ministry and Health Operations Committee begins with a
statement of five principles which guided its actions going forward to achieve wait time
access targets for hip and knee joint replacement surgery. These principles address issues
of quality, universality, effectiveness and efficiency and should be reflected in all
subsequent action.

   2.1. The Principles
The panel set out the following overarching principles that need to be taken into account
when planning for system improvement in access to hip and knee joint replacement.

   1. While there are considerable quality improvement efforts underway across the
      province and progress being made in reducing wait times and improving patient
      experience, further concerted effort is required to support the Province to meet the
      target for joint replacement surgery and to make needed improvements to
      musculoskeletal health.

   2. The Expert Panel’s advice must recognize different circumstances and challenges
      across the province and be applicable in all health authorities, recognizing that
      there will not be a “one size fits all” solution.

   3. Improvement efforts should recognize the continuum of care for the patient – from
      first contact with the health care system through to specialists and surgery to
      completion of rehabilitation and return of function.

   4. The focus of these efforts should be on patient-centered approaches that are

   5. This work is part of the broader healthcare delivery system in BC and the impact
      of strategies to meet the wait time targets must be considered.

   2.2. Considerations for Health Operations Committee
In the course of its deliberations the expert panel identified a number of systemic barriers
and areas for improvement in order for BC to achieve the wait time targets. In doing so,
the panel highlighted six key areas for change: data and information systems; funding;
models of care; health human resources; organization and coordination of care; and,
facilities and infrastructure. These are not presented here in terms of relative importance.
Each area has the ability to improve patient care for the hip and knee joint replacement
patient. Moreover, this report constitutes a first step along the path to achieving the wait
time targets. It presents the perspective of BC experts and leaders in the field, and lays the
framework for changes which, if implemented in a timely manner, will facilitate achieving
the targets for hip and knee replacement surgery.

Area #1     Data and Information Systems
   1. Minimum Data Set
         o A province-wide, standardized and mandatory, minimum data set should be
            specified for all information systems pertaining to hip or knee joint
            replacement and consequences should be described for non-compliance.

   2. Data Linkable
         o All data pertaining to hip or knee joint replacement patients should ideally
             be in an electronic format with information systems linkable within the
             existing infrastructure. At a minimum, standard data definitions should be
             used to facilitate comparability across databases such as the Electronic
             Health Record, office-based booking software, the Surgical Patient
             Registry, Medical Services Plan, the Discharge Abstract Database,
             PharmaNet, joint replacement registries, etc.

   3. Quality and Outcome Measurement
         o Provincial standards should be defined for monitoring quality of care from:
             presentation at primary care; through referral for diagnostic testing;
             surgical consultation and the decision to wait list the patient; to surgery;
             post operative rehabilitation; and, functional outcome.

   4. Data Privacy and Confidentiality Considerations
         o Data collection protocols, quality audits, privacy and confidentiality
             requirements, and patient consent provisions should be provincially defined
             and monitored.

   5. Efficiency and Elimination of Unnecessary Duplication
          o A strategic approach to information system design in a new model for
              hip/knee joint replacement surgery will minimize unnecessary duplication
              in the collection of data. Information collected at one point in the care
              pathway – by the appropriate person – should be available to other
              authorized persons further downstream, as appropriate.

Area #2     Funding
   1. Case Costing
         o A comprehensive standardized model for case-costing is needed to support
            efficient delivery of hip and knee joint replacement surgery. This must
            have the capacity to reflect regional variation in the cost of service
            provision and be clearly identified in the health authority budget.

    2. Activity-based Funding 4
          o Pay-for-performance or activity-based-funding should be considered,
               emphasizing a funding-follows-the-patient model with clearly defined
               health authority-specific targets.

    3. Security of Funding
          o Funding should be: i) clearly identified for a specified number of joint
              replacement patients; ii) protected within a health authority budget; iii)
              clearly accounted for in the health authority’s financial statements; and, iv)
              predictable into the future.

    4. Support for system transition
          o It must be recognized that implementation of a new model of care
              described above requires infrastructure support and change management.

Area #3       Models of Care
   1. Patient-Centered and Integrated Approach
          o Patient-centered practice promotes the active participation of patients and
              families and a wide range of key health care disciplines and professions. A
              patient-centered approach acknowledges patient goals and values, provides
              mechanisms for continuous communication among providers, and fosters
              respect for the contributions of all care givers.

             o An integrated model will define clear roles and accountabilities for the
               wide range of care providers needed to support effective musculoskeletal
               health, including prevention programs, primary care providers, medical
               specialists, and rehabilitation therapists.

    2. Essential Components
          o Any new model for hip and knee joint replacement should feature efficient
              use of facilities and clinical services and should include:
              - Centralized patient referral and intake at appropriate facilities across the
              - Standardized assessment of patient need, urgency and readiness for
              - Standardized objective measures of patient status or outcome at
                  specified points from referral through to post operative outcome; and,
              - Provision of patient and family education and support in preparation for
                  surgery and prevention of disease.

  As per the 2008 Speech from the Throne, the government intends to move toward a new province wide
patient-centred funding model, which “will tie funding to performance and to increased service levels in
specific priority areas, like emergency care and surgical backlogs”.

   3. Key Linkage with Primary Care
         o A clear role for primary care and family medicine in patient education and
            management throughout the musculoskeletal patient journey must be

           o Educational materials and resources must be centrally available to primary
             care providers to support their ability to make appropriate referrals and to
             support their effective management of patients throughout the patient

Area #4       Health Human Resources
   1. Efficiencies and Scope of Practice
          o Efforts should be made to achieve greater efficiency within orthopaedic
              surgical practice by ensuring that the patient is seen at the right time, by the
              appropriate orthopaedic practitioner(s).

           o Work is needed to identify areas in the care path where the current scope of
             practice might be expanded or new staff, for example, physician extenders
             may be included.

           o Changes to scope of practice will require better coordination among
             Ministries and organizations responsible for human resources planning or
             training, for example better communication between the Ministry and the
             Ministry of Advanced Education for Health Human Resource strategies.

   2. Recruitment, Training and Staff Retention Strategies
         o The new model of care will require actions to attract and retain existing
             staff through workplace improvements such as appropriate staffing ratios,
             operating room continuing education, etc.

           o Collaboration is needed in planning the training and recruitment of health
             care professionals among health authorities, professional associations,
             Ministry of Advanced Education, and the Ministry.

Area # 5     Organization and Coordination
   1. Provincial Forum on Musculoskeletal Health
         o A body similar to the existing Provincial Musculoskeletal Council is
             needed to facilitate communication on musculoskeletal health issues. This
             should include physicians, nurses, allied health care professionals,
             researchers, health authority administrators and government

           o A supported forum would include the following elements:
             - Structured to ensure accountability and communication within the
                broad musculoskeletal care community;
             - Clearly defined terms of reference, mandate or tasks;
             - Reporting structure with clear accountability;

               -   Dedicated support for activities, facilitation and communication; and,
               -   Meetings located to allow participation by all health authorities.

Area # 6     Facilities and Infrastructure
   1. Capacity Requirement Planning
         o There is an ongoing need for accurate modeling of current and future
             demand to inform health authority and system-wide planning of facility and
             infrastructure needs.

   2. Optimal Facility Use
         o Management intervention is required to ensure optimal use of existing
            infrastructure and facilities such as extending hours of operation and
            creating dedicated orthopaedic wards and staffing.
         o If adequate public capacity is not available, consideration should be given
            to using private facilities for publicly funded services.


The Ministry through its Health Operations Committee established a musculoskeletal
expert panel to share knowledge and provide advice on how to improve access to care for
musculoskeletal patients in general, and meet provincial wait time access targets for hip
and knee joint replacement surgery, in particular.

The panel reviewed how musculoskeletal care was currently delivered across BC,
identified barriers that would have to be addressed to achieve the targets and provided
input to planning in six key areas: data and information systems; funding; models of care
delivery; health human resources; organization and coordination of care; and facilities
and infrastructure.

In the course of its work, the panel identified pockets of innovative practice within BC’s
musculoskeletal health community and across other jurisdictions that may be applicable in
other health authorities. Linkages among clinical, administrative and research experts
were strengthened and there is momentum to develop a plan of action to support the
implementation of a provincial strategy for hip and knee joint replacement surgery.

This report summarizes the expert panel's advice to the Health Operations Committee.
The panel strongly supports the advancement of a coordinated province-wide strategy to
meet the 2010 access targets for hip and knee joint replacement and improvements to
musculoskeletal patient population in general. The panel recognizes that there are
differences and challenges across BC that must be accommodated without compromising
patient care. System improvement for hip and knee joint replacement surgery should be
patient-centered and be continuous from primary care through orthopedic service and
rehabilitation and return of function.

At a high level, the expert panel identified six key elements that a provincial strategy to
address the hip and knee joint replacement access targets will need to include (as above).
Further work is necessary to establish a detailed implementation strategy and to prioritize
a plan of action to move forward. It is suggested that the Health Operations Committee
retain a provincial musculoskeletal forum with representation from the Musculoskeletal
Expert Panel and Ministry staff to initiate this process by drafting a plan of action with a
report back to the Health Operations Committee within two months.

It is anticipated that the Health Operations Committee will take the panel’s report under
advisement and use it as the basis for action going forward. Meeting the established wait
times access target for hip and knee joint replacement surgery is planned for March 2010,
approximately two years out.

The panel process has been valuable not only in detailing the characteristics of a better
way to manage hip and knee joint replacement surgery, but is creating momentum and a
will to move forward collectively. The expert panel process has worked well. It was able
to move expeditiously from introduction of the problem through endorsement of a final
report in three months. When the next priority area is identified, a similar approach
should be considered.

This report is respectfully submitted to the Health Operations Committee by the
Musculoskeletal Expert Panel Secretariat.

Appendix 1 – Musculoskeletal Expert Panel Terms of Reference

The use of expert panels that consist of acknowledged clinical, management and research
leaders has been a feature of many provincial strategies in order to move towards the 2005
First Ministers’ Meeting (FMM) wait times benchmarks. Expert panels have been
identified as a central component of British Columbia’s (BC) wait times strategy.


The Musculoskeletal Expert Panel (the panel) will bring recognized experts together to
share expert knowledge and provide advice on how to improve access and the care for
musculoskeletal patients in BC.


The panel’s work may include, but is not limited to:
   o Strategic guidance to the Ministry of Health (the Ministry) to identify existing
      system barriers and propose strategies to meet BC’s approved access target for hip
      and knee joint replacement in all regional health authorities: 90 percent of cases
      completed within 26 weeks by March 2010 (from date of surgical booking to
   o Identification of quality improvement initiatives and alternative practices in BC
      and other jurisdictions;
   o Identification of existing issues/barriers related to access, wait times and quality of
      care for the musculoskeletal population;
   o Identification of opportunities for improving efficiencies and effectiveness in wait
      times and access for the musculoskeletal patient population; and,
   o Organization of services to meet future demand.


The panel includes representation from the five regional health authorities and includes
regional health authority administrators, researchers, clinicians and other individuals with
special expertise, as nominated by the Health Operations Committee and confirmed by the

Conduct of Meetings

All panel members will participate as equals. An external independent facilitator will
work with the members to define agendas and ensure productive meetings in accordance
with the panel’s mandate.

Governance & Accountability

The panel will be established by and accountable to the Ministry and health authorities
through the Health Operations Committee (the Committee). The Terms of Reference for
the panel will be submitted to the Committee for approval. Panel members will volunteer
their time in both preparation for, and participation in the meetings. The Ministry will
cover travel and meeting costs and offer an honorarium to non-salaried panel participants.

Deliverables and Timelines

Deliverables will be identified by the panel at the initial meeting.
The panel is time-limited. It will meet until the deliverables are achieved. The final
product will be a report submitted to the Ministry of Health by way of the Committee.

Project Management & Secretariat

A small secretariat, housed in the Ministry, has been established with responsibility for
providing secretarial support to the panel.

Appendix 2 – List of Panel Members
#      Name                    Title                                     Organization
                               Executive Director, Pharmacy,
    1 Bob Clark                Diagnostic & Surgical Services            VIHA
                               Division Head of Orthopaedics, South
    2 Dr. Patrick McAllister   Island                                    VIHA
    3 Dr. Richard Nuttall      Primary Care Physician                    VIHA
                               Executive Director, Corporate Planning
    4 Michael Leisinger        & Health Information                      NHA
                               Chief Operating Officer, Northeast
    5 Lee Hall                 HSDA                                      NHA
    6 Dr. Bas Masri            Orthopaedic Surgeon                       VCHA
                               Physical Therapy Practice Coordinator,
                               Mary Pack Arthritis Program & GF
    7 Catherine McAuley        Strong Rehab Centre                       VCHA
    8 Dr. Ken Hughes           Orthopaedic Surgeon                       VCHA
    9 Dr. Kam Shojania         Rheumatologist                            VCHA
                               Surgical Services Clinical/Orthopaedic
10 Denise Dunton               Leader                                    IHA
                               Corporate Director, PHC Physician
11 Clay Barber                 Engagement                                IHA
12 Dr. Gary O'Connor           Orthopaedic Surgeon                       IHA
13 Dr. Albert Chan             Orthopaedic Surgeon                       FHA
14 Valerie MacDonald           Clinical Nurse Specialist, Orthopaedics   FHA
                               Director, Analysis, Medical Services
15 Jeremy Higgs                Division                                  Ministry

Appendix 3 – List of Secretariat
#   Name                 Title                                   Organization
1   Alison Millar        Director, Access/ Wait Times Strategy   Ministry
2   John McGurran        Wait Times Advisor                      Consultant
3   Lillian Bayne        Expert Panel Facilitator                Consultant
4   Rong Maggie Zhang    Project Manager                         Ministry
5   Jackie Flagg         Project Manager                         Ministry
6   Jennifer Power       Project Manager                         Ministry


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