Health Human Resources (HHR) in Canada Part 1: What is to be gained from HHR Planning?

John G. Abbott, CEO, Health Council of Canada

Health care always has been and always will be a labour-intensive industry. Canada, like most developed countries, spends a large proportion of health care spending on training and paying health care professionals.

The Canadian Institute for Health Information (CIHI) reported that between 1998 and 2008, total public sector spending grew at about 7% per year. In other words, over the course of a decade, public spending on health care doubled from about $60 billion to $121 billion. And from 2008 to 2012, public spending grew by another 20% (to $145 billion).

This analysis also showed that a significant portion of the increase went to higher wages for a larger workforce. Again, using CIHI’s figures, more than 360,000 regulated nurses were employed in Canada in 2011, an increase of more than 8% since 2007. This was nearly twice the rate of population growth in Canada.

There is a growing recognition that we could get a better return on our health human resource investments by organizing professionals to work more effectively. Primary health care teams are a good example of this.

We need to reframe our approach and our thinking to see the health workforce as the means; and, where the end is better health outcomes for Canadians, not just more care provided by more professionals.

So, how is Canada doing in its drive to achieve a high-performing health system through its people?

I will present three pressing policy challenges, each of which stems from a mismatch between our health care needs and our supply of health professionals – and what may be needed to solve them from re-occurring.

Reliance on internationally-trained professionals 

 

Canada has long relied on internationally trained doctors and nurses to staff our health care systems, particularly in rural and remote areas. While recent data are hard to come by, it is clear that our system is reliant on international graduates. In the 2010 National Physicians Survey, about 1 in 6 physicians reported that they completed their medical education outside Canada or the US. This in itself is not bad, but when we rely continuously on foreign nationals to meet our needs, then we and their governments have a problem.

Does Canada aim to become self-sufficient in its supply of health care professionals or will we continue our system of international recruitment? If we continue to recruit, how will we direct international graduates to where they are most needed?

The solution is a commitment to self-sufficiency with both the health and education and training sectors developing a joint plan to help Canada achieve this.

Underutilization of specialist physicians 

 

The second issue is one that was unheard of even five years ago: under- and unemployed specialist physicians. It takes large amounts of resources to train a medical specialist, which yields a “zero return” if they cannot practice due to a lack of capacity in acute care or other systems. We’re hearing stories in the media of eager young surgeons who can’t get operating room time, while patients wait for care.

A number of stakeholders are calling for better national human resource planning and better information for medical students to give them a clearer picture of their chances of landing a job in particular specialties, and in specific regions of the country.

The solution is better modelling of provincial needs and matching with specialist supply. Medical school seats and post-graduate training slots are adjusted accordingly.

Struggle to recruit a workforce for home care

 

The final issue speaks to our ability to care for the growing number of Canadian seniors. In our recent report we found that that seniors and their families want to receive care at home, most provincial systems are investing in home care services. Canada certainly needs to boost its home care services, as they are integral to a high-performing health care system today. But staffing these services presents huge challenges that run the gamut of human resource issues. From compensation, to education and training, to quality assurance and working conditions, the home care sector struggles to find staff to meet their clients’ needs.

Personal support workers (aka community health workers or continuing care assistants) provide most home care services, particularly for long-term clients. Personal support workers are unregulated and their training currently varies between provinces and territories.

The solution is to designate this sector as a growth sector, allocate additional training funds, upgrade quality improvement programs and realign the compensation and benefits regime to give this sector a higher status within the health care system.

Canada’s goal remains a high-performing health care system. To arrive there we need to tackle our health human resource challenges in a way that is strategic. In saying that, any approach has to be explicit, proactive, measured and bolstered by a common evidence base.

In my next blog post I’ll outline some of the steps we, as a country, need to take to improve the management of our health human resources with the goal of attaining the high-performing health care system that all Canadians want.

The Saskatchewan Health Care Quality Summit

The 2013 Saskatchewan Health Care Quality Summit was held last week in Regina, and we were there to present our recent report Which way to quality? and to demonstrate the Health Innovation Portal.

 

What Happened?

 

The Summit featured dynamic keynote speakers including Helen Bevan, Brent James and ePatient Dave. Helen Bevan launched the conference with a discussion of change and being an “organisational radical” that fosters innovation and improvement. Brent James talked about the importance of data, with a focus on cost in the quality improvement efforts that Intermountain Health has undertaken.  He stated, like W. Edwards Deming, that “cheaper is not always better, better is always cheaper.” ePatient Dave closed the Summit with a compelling and moving personal story of being diagnosed with kidney cancer, googling for his health, and being an active and engaged participant in his treatment planning.

The conference had over 600 attendees, an impressive 10% of whom were patients. The involvement of patients is starting to gain broader recognition with the Patients Included Badge, created by Lucien Engelen and his team, and introduced at the Summit by ePatient Dave.

What Did We Learn?

1. Building energy for change in the long term makes a difference in fueling high performance  
2.  Better care at lower cost is achievable with the appropriate structures and strategies.
3. Let patients help.  Patients are the most under-used members of the health care team and have a lot to offer in improving the health care system.
4. There are many strong efforts for improving health care quality in Saskatchewan, across Canada and beyond from which we can learn.

What Did We Do?

 

Health Council of Canada staff who attended the Summit were impressed by the quality of presentations, including the Know Your Status Project and the Surgical Patient Experience Project. We were also pleased to demonstrate the Health Innovation Portal to attendees with a focus on the innovative practices we have profiled under the theme, “System Level Quality Improvement.” People were drawn to our interactive iPad kiosks and were excited to try out and learn more about this web-based tool. Several conference attendees and presenters will also soon be submitting their innovative practices and programs to the portal, so stay tuned for updates.

 

 

What are we doing next?

Thanks again to everyone who came to visit the Health Council of Canada booth! If you want to provide your feedback on the Health Innovation Portal, please participate in our ongoing evaluation. Click here to fill out our quick survey.

 

Next up, we’ll be attending the Accreditation Canada Quality Conference2013: Sustaining Success! on May 9-10, so please drop by to try out the Health Innovation Portal.

Patient engagement in health quality improvement

Dr. Dennis Kendel, Councillor, Health Council of Canada

While most Canadian citizens are pleased with health services in this country, information from around the world tells us there is considerable room for improvement in these services.

As part of these improvement efforts, Canada’s provincial and territorial Premiers have committed to an exciting new initiative to promote and share innovative approaches to delivering safer and better health care. Premier Brad Wall of Saskatchewan is a leader in this pan-Canadian process.

In Saskatchewan, the Ministry of Health, all Regional Health Authorities, and the Health Quality Council are collaborating in an unprecedented improvement effort to ensure that future health services in this province are optimally safe, appropriate, and high quality. As part of this effort, these agencies are engaging many health care workers across the province in improvement work using LEAN methodologies.

Another key improvement initiative under way in Saskatchewan is an effort to ensure that all citizens have access to primary care services that are patient centred, community designed and team delivered. This means, if a patient has a chronic or complex health condition, they would receive much more integrated and coordinated care from a team of health care professionals (nurses, pharmacists, social workers, family physicians, etc.). This team would collaborate in making care safer and better for the patient. Their combined expertise applied in a team approach could reduce medication errors and ensure more efficient scheduling of diagnostic tests.

However the most compelling aspect of the health quality improvement work in Saskatchewan is the effort to engage many patients and citizens in the process. Many quality improvement projects include patient and family participants who are making contributions to the success of this work.

On April 10 and 11, the Health Quality Council is convening a Quality Summit symposium in Regina that will bring together hundreds of participants to share knowledge about health care quality improvement from across Saskatchewan, Canada, and around the world. What is most exciting about the plans for this Quality Summit is that the Government of Saskatchewan will fund all participation costs for up to 80 patients and family members. This is another step forward for Saskatchewan, where the engagement of patients and families in health care quality improvement has moved beyond tokenism to become foundational.

However, patient and family engagement in health care quality improvement should not just occur at conferences and workshops. It needs to occur every day in every setting in which health care services are delivered. Next time a patient visits their family doctor, they should ask him/her about quality improvement efforts in primary care and whether he/she is engaged in the process.

As well, here’s how every citizen can play a role in improving health care services and their own personal health.

• When the health care services you receive do not meet your needs or expectations, speak up and let the workers providing your care know how you feel. 
• Offer constructive suggestions on how health care professionals could make your future health care experiences better. 
• Expect health care providers to listen to you and act in response to your suggestions. 

Your life and your health are at stake. Become actively engaged in a process that improves both your healthcare experiences and your future health status. Citizens can and should take an active role in improving the quality of the health care system as well as their own health care.

Quality Activities in British Columbia

Dr. Les Vertesi, Councillor, Health Council of Canada

The Health Council’s latest report, Which way to quality: Which way to quality? Key perspectives on quality improvement in Canadian health care systems, finds that quality in health care has been a key issue for governments and health care providers alike for more than a decade. The health literature tells us of the avoidable cost, both human and financial that burden our system because of a quality issue - medical errors. Canada is not different in this regard from other countries. Efforts at improving system quality are evidenced by the health quality councils of one sort or another in many Canadian provinces, each tasked with the job of putting quality into practice. Some limited gains are claimed by almost everyone, but measureable large scale change other than in some subspecialty areas, is not easy to find.

The province of British Columbia has followed a path similar to the other provinces but with two initiatives that are worthy of special mention. The first has to do with wait list reduction and the second with reducing post-operative infections and other complications.

Access to care is one of the pillars of quality and one of the most persistent complaints voiced by Canadians. Other than some easing in selected high priority areas such as hip and knee surgery, Canadians still wait on average longer for care than almost any other developed nation. This is in spite of ample international evidence that funding policies (apart from the total amount of money) are a major factor behind our wait list problem. Countries that cling to fixed global budgets in hospitals tend to have long waitlists, while those that let money follow services needed by patients do not.

In 2010 BC became the first Canadian province to bring in a limited form of Activity Based Funding (ABF) in which funding follows the patients, not the hospitals, much as it does in European countries. One of the largest Vancouver hospitals recently showed how they used the inherent flexibility of ABF over a nine month period to produce a 24% overall reduction in waits and a 70% reduction in the longest wait times all with only a marginal (3%) increase in cases.

In the realm of safety and reduction of complications, BC spent $12 million in the previous year to enroll 22 of their largest hospitals in the National Surgical Quality Improvement Program (NSQIP). The NSQIP is a quality improvement process developed by the American College of Surgeons that boasts over 450 member hospitals in the US, including some of the centres with the best reputations for quality. The system collects detailed data on postoperative complications from each hospital and feeds a risk-adjusted score back to each hospital. It is this risk-adjustment along with the relative standing when compared to other hospitals doing the same work that makes the NSQIP results so compelling.

It is not the first time a Canadian hospital has become part of NSQIP, but the experience of one BC hospital that joined NSQIP before ABF tells the story. Their first results showed they were among the worst performing of the hospitals in the cohort and that feedback shook their confidence enough to force some serious changes. Two years later they had improved to better than the cohort average, with proven drops in post operative infections and return trips to the operating room, along with a shortened length of stay. The patient experience was clearly safer and better, but those empty beds were quickly filled with more patients and because they were still held to a fixed budget, their financial situation became worse not better. Effectively they had achieved true quality and had been punished for it. There are many examples in Canada of innovative practices, but few are sustained in the long run. Could it be because our funding system has been inadvertently punishing quality where and when it does occur?

Today, the situation in BC under activity based funding should be different. NSQIP is set to help bring big improvements in real quality and ABF will at least in theory compensate for any increase in workload that results. Nobody actually makes money with hospitals in Canada nor will that change with ABF, but at least we will no longer be punishing quality. We can only wait and see if that will make a difference.

Quality in health care: the road ahead

Dr. Charles J. Wright, Councillor, Health Council of Canada 

Achieving high quality in a health care system, as in any other enterprise, requires that the factors necessary for success be defined, measured, continually monitored and openly reported. The good news is that almost all jurisdictions and professional bodies in Canada are beginning to take the quest for measurable high quality care seriously, albeit with emphasis on different aspects of the task and with varying degrees of success. There is marked but unsurprising inconsistency across the country, with its quasi-independent provincial jurisdictions and the silos of professional and organizational interests, but the report just released by the Health Council of Canada Whichway to quality? Key perspectives on quality improvement in Canadian health caresystems, presents an interesting snapshot of the good intentions and the good ideas that are being pursued.

In Ontario, the 2010 “Excellent Care For All” act set a clear path for quality improvement in the health care system, mandating the development and implementation of a formal process in every organization and hospital in the province. Quality-of-care committees must now be set up to report to the organizations’ boards; annual quality improvement plans with clear indicators and targets must be developed and made available to the health ministry and the public; achievement of targets outlined in the plans becomes linked to executive compensation as a significant incentive. Requirements for similar activities in the primary care sector will follow as the provincial plan unfolds. Health Quality Ontario (HQO) was set up to direct, support, monitor and report on these activities. This whole initiative has raised the health care quality bar in Ontario and deserves enthusiastic support, but there are some awkward bumps in the road ahead.

There is wide agreement now on what quality in health care means although how to achieve it still causes much discussion. In summary it means timely access to care that is necessary, centered on the patient, safe, effective (that is, causing better health) and sustainably affordable. Unfortunately, not all of the changes required for success are wildly popular with physicians, politicians or even the public. The traditional fierce independence of physicians must eventually give way to truly integrated multi-professional teams and organizations. Not all politicians have an appetite for the changes in policy and legislation that would be needed, and the public tends to be suspicious of any interference with current services. The quality agenda in any health care system also has to deal with the insatiable demand for more and more expensive services – services that often bring a very small benefit at huge cost. There are serious questions about just how necessary are all the current consultations, tests, prescriptions and procedures, and these questions must be answered on the basis of rigorous evidence rather than tradition, belief systems or vested interests. Sustainable affordability means that value for money is very much a quality issue because of what is called the “opportunity cost” of any publicly provided health service, namely the alternative use of the money that could bring much greater benefit to more people. These issues provide ample fodder for debate among the health care professions, the politicians and the public alike, but we cannot continue to avoid them.

No commentary on health care quality in Canada can avoid stressing the need for a cooperative national agenda. As demonstrated in the Health Council report there have been some remarkable initiatives in most provinces, some of them quite intense as in British Columbia, Alberta, Saskatchewan and Ontario, but national cooperation remains elusive. It is not surprising that progress in Canada as a whole has been difficult, slow and patchy with so many provincial jurisdictions and an increasingly disinterested federal government. In addition to ongoing measurement, evaluation and adjustment, any successful quality improvement process must involve the powerful motivator of regular comparison with peers. Is it unreasonable to suggest that we should build, as a nation, some shared activities, goals, expectations and reporting mechanisms in the best interests of high quality in what we still like to call Canada’s health care system?

Necessity breeds innovation: Shooting the wait times video series at “The Taming of the Queue 2013”

Waiting can be tough but it’s a fact of life and something we all deal with. It is one thing to wait in line at the coffee shop or for the new iPhone release, and quite another to wait for health care. Waiting to see your family physician for a checkup; waiting to be seen in the emergency room; or being on a wait list for surgery, are all things Canadians experience daily.

In Canada, longer than normal wait times pervade our health care system and physicians, policy makers and other health experts agree that we need to take action.

That’s what some leading organizations and provinces are doing. Starting in late spring, the Health Council will be releasing a video series on wait times in Canada.

In preparation for this series, I was in Ottawa late last month to shoot footage of the Taming of the Queue conference. My colleague, Media Specialist Terry Glecoff and I were on hand to gather interviews from conference participants. We captured a variety of insights on the issue and responses to the complex question: why do we wait?

Dr. Tom Noseworthy of Alberta Health Services responds to questions posed by Media Specialist Terry Glecoff

One of our subjects, Dr. Tom Noseworthy, Associate Chief Medical Officer, Strategic Clinical Networks & Clinical Care Pathways for Alberta Health Services, put it as such:

“In a universal health care system where everybody is included, they are usually challenged by access – getting people in – when people are not all included it’s easier to achieve access. But we have long wait times in Canada, and we need to retool the system to make it better. So we’ve got it right on the inclusion side with universality. We don’t have it right on waiting times.”

The Canadian Medical Association's Stephen Vail with Ari Grief, Project Lead for our upcoming wait times video series

In addition to shooting footage, I had the opportunity to talk to health leaders about their views on wait times. My main takeaway from the conference is that there are numerous innovative practices working to reduce wait times around Canada in a variety of settings – it’s just a matter of spreading the word to other jurisdictions across the country. 

Along with Dr. Noseworthy’s interview, we captured a range of different perspectives on wait times. These insights will be revealed together with innovative practices that are working to reduce wait times in our upcoming video series.

Stay tuned.

By Ari Grief, Bilingual Communications Specialist/Project Lead Wait Times in Canada Video series.

Health Council reveals winners of fourth annual Health Innovation Challenge

Today we announced the winners of the fourth annual Health Innovation Challenge. In September, we challenged college and university students to find innovative practices in Canadian health care, tell us why the innovations are working, and how they can be applied in the rest of the country.

Over 100 students across Canada participated, submitting a total of 74 essays explaining which innovative practices they think could change the future of health care in Canada. From a shortlist of 10, we will be awarding first, second and third in each of the individual and group categories.

Winning entries came from the University of Alberta, Dalhousie University, McMaster University, the University of Northern British Columbia and the University of Toronto.

“The winners of this year’s Challenge truly showed us the importance of sharing innovation” said John G. Abbott, CEO, Health Council of Canada. “They found some great practices that are working locally and we should pay attention to see if we can learn from them and use them in our own work.”

The Health Council of Canada identifies and shares hundreds of innovative practices from across the country on the Health Innovation Portal. Winning Challenge entries will be featured across the Council’s online properties. Winners also receive a cash prize and the chance to apply for a summer internship at the Health Council of Canada office in Toronto, Ontario.

Full Winners List: 

Category: Individual 

First Place 
Mary Qiu
University of Toronto
Preventing Acute Care Hospital Readmissions Through the Use of a Virtual Ward

Second Place Sophia Harrison
University of Northern British Columbia
A New Way Forward: Improving the Health Status of British Columbian First Nations with the Tripartite First Nations Health Plan

Third Place Jake Yorke
Dalhousie University
Collaborative Emergency Centres: Improving Access to Primary and Emergency Care in Rural Nova Scotia

Category: Group

First Place Aaron Lau, Alexandre Tran, Yvonne Tse

McMaster University
The McMaster PIPER Project: A Novel Approach to Interprofessional Education through Simulation-Based Learning

Second Place Haley Augustine & Rakesh Gupta
Dalhousie University
Chronic Disease Management Strategy: Diabetes Quality Collaborative

Third Place Kathryn Reid & Joshua Plante
University of Alberta
Changing Practice Paradigm through Innovative Policy