Cross-Sectoral Accountability for Patients with Congestive Heart Failure

Key Implications for Decision Makers

This study offers suggestions with regard to accountability for providing seamless care to patients with congestive heart failure.

With regard to people:

  • Seamless care needs the support and commitment of community leaders, such as physicians and administrators.
  • Both retail and hospital pharmacists need to be more involved in treating and monitoring patients with congestive heart failure.
  • Ideally, specialists provide education for other providers.

With regard to process:

  • Congestive heart failure clinics effectively stimulate self-care among patients.
  • Communities would benefit from following the definition of accountability laid down by the auditor general of Canada.
  • At its heart, the main intervention is to have absolute clarity about what medication the patients should be taking.
  • Co-ordination of care requires that people in different sectors have regular communication with one another.
  • Integration of long-term care improves if a specialist nurse practitioner gives education to long-term care nurses.

With regard to tools:

  • Providers need a credible source for tools, including integrated care pathways, discharge checklists, medication charts, and well-tested educational material for both patients and providers.

Executive Summary

This report highlights the efforts of those healthcare providers who are leading the way in providing seamless care to patients with congestive heart failure. We hope that communities will benefit from a study of the people, processes, and tools of these leaders. Information contained in this report was gathered through key interviews and focus groups with healthcare providers in Ontario, followed by a web-based survey completed by healthcare professionals across Canada.


To create an environment where patients experience seamless care requires formally established communication among the sectors. A necessary condition for success is for individuals to come together and form a "cross-sectoral" or "multi-disciplinary" group. The group may consist of top management of various agencies, along with representative family physicians, or it may consist of a mix of healthcare professionals and supervisors. Interestingly, those cross-sectoral groups that include a pharmacist are three times more likely to consider themselves integrated than those without a pharmacist.

Once such a group does come together, it is in a position to develop shared accountability for the three types of continuity of care: management continuity, information continuity, and relationship continuity.

According to the auditor general of Canada, the four elements of accountability are clear roles and responsibilities, clear performance expectations, credible reporting, and reasonable review and adjustment. With respect to accountability for continuity of care, then, communities have developed a variety of useful processes and tools.

Roles and responsibilities

In those communities that have a disease management clinic, such as a congestive heart failure clinic or a cardiac rehabilitation clinic, the focus tends to be strongly patient-centred. In the course of fulfilling their mandate (that is, providing post-acute assessment, education, monitoring, liaison, and lifestyle counselling), such clinics find themselves working with healthcare providers in other sectors to clarify roles.

One emerging role is that of patients getting involved in their own care, and it is often the congestive heart failure clinics that assume the role of training patients to care for themselves.

Performance expectations

Guidelines and integrated care pathways are common ways to express performance expectations. For these to be successfully implemented in a community, is has been found that there must be involvement of individuals from all sectors.

The admission and discharge criteria that are used by hospitals, clinics, and long-term care institutions create a variety of performance expectations. They also create an environment in which patients receive consistent care and in which healthcare can be delivered in a consistently professional manner.

Other examples of performance expectations that improve systemic accountability are those related to waiting lists, referrals, the hospital discharge summary, and patient satisfaction.

Reports and adjustments based on reports

The third element of accountability is "the reporting of credible and timely information on what was achieved and what was learned." The fourth element of accountability is "informed review and feedback on the performance achieved, in which achievements are recognized and necessary corrections made."

There is almost no reporting specifically about co-ordination of care among Ontario congestive heart failure communities. Although clinics do monitor various aspects of their internal operations, they typically do not monitor cross-sector aspects.