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.