Healthcare - Reaching our Potential Demands Improvement

Hugh B. MacLeod is CEO of the Canadian Patient Safety Institute. His interests lie in the areas of system/integrative thinking, sustainability, and organizational cultures that create high performance.

Better health, better care, better value for all reminds me of the key messages in the book “From Good to Great” by Jim Collins. After researching Great Organizations he found the following characteristics/attributes:

1. They have an obsession for quality. 
2. They get the price point for services and products correct. 
3. They are never satisfied with their decision processes.  
4. They truly understand their customers. 

This recent report from the Health Council of Canada confirms that healthcare needs to improve on all these fronts. I hope this report helps shift mindsets, for example: stop advocating for and planning around a sickness model; create a space for new conversations that includes the patient voice;  ask new questions that will lead to a deep exploration of assumptions we hold and make.

Without exploring the facts contained in this report and our assumptions, healthcare will continue to be hostage to an indifference to failure and will be unable to reach its improvement potential.

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Better Together

Shelly Jamieson is the CEO of The Canadian Partnership Against Cancer.

I found great value in your retrospective report Better health, better care, better value for all. It is a thoughtful and rich summary of what happened, what worked and what could have been done differently now that we look back at the Accord.

I find the report’s position that the broader and balanced transformation of the health care system needs to be guided by explicit and overarching vision interesting. This is especially true for cancer; a complex disease that cannot be tackled by one organization alone.

Two key enablers of meaningful change outlined in the report – the spread of innovation on a large scale, and measurement and reporting – are built into the model that the Canadian Partnership Against Cancer operates in.

Strategic considerations
In many ways, we play a unique role in Canada. Working with partners, at national and provincial levels, including with the patient community, we identify gaps that are common to several jurisdictions, and address them by leveraging innovation, experience and knowledge from across the country. We identify where progress is being made and try to accelerate it and its reach. To ensure we are having an impact, we set specific targets that align with our goals and measure against them.

The partners that we work with commit to this approach, to staying engaged and contributing to the pan-Canadian process while implementing multi-year plans locally. Our strategic plan is developed with them; we act where there is strong alignment and/or significant gaps that need to be filled.

Observing the cancer system
We take this one step further with our System Performance work. We work with national, provincial and territorial partners to develop cross-Canada indicators to demonstrate how the cancer system is performing. Those providing the data for our system performance reports and those actively involved in determining what will be reported have great ownership of the results. They contribute the evidence, and then are charged with using it to motivate improvement in their jurisdictions.

I have watched over the past decade how new ways to improve health care have emerged as a result of a pan-Canadian dialogue. Our work is one example of this and I truly believe that, together, side by side with our partners, we are making progress towards reducing the burden of cancer on all Canadians.

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Ten Years and Still Waiting for Change

Linda Silas is President of the Canadian Federation of Nurses Unions.

As a nurse who has practiced for many years and now has the honour to sit at many policy tables, I am confident that, when others read this excellent report from the Health Council of Canada (HCC), they also will ask themselves: “Haven't we learned anything in the last decade or two?” The HCC report, Better health, better care, better value for all, remains positive while it highlights a decade of disappointing results. Despite many unimplemented recommendations, in its latest report the Health Council still urges us to find an explicit vision of what we want to achieve. 

It reminds us that the recent focus on quality, safety and a cost-effective health system go back to the Kirby and Romanow reports and the promises in the 2003 Health Accord. What the Health Council of Canada politely omits is that it is all about politics, or should I say, it is all about politicians. While the evidence and recommendations are abundant, well thought out and achievable, these publicly funded tomes are left to gather dust because they don't fit the political agenda of the day.

Canadians want a focus on health care. We know there are things we could be doing to make improvements, but as soon as the ballots are counted the promises are quickly broken. To go from the original 50-50 split in cost-sharing to the federal government paying 11 or 12 percent by 2016 sends a clear negative message. The Federal Government is effectively saying to provinces: “This is your problem to solve.” Unfortunately, Canadians are the ones suffering as the response of most provinces and territories proves less than inspired, choosing to revert back to what resembles the early 1990s. 

Canadians have to speak out or we will lose universality in health care. We need to control waste, to stop unnecessary testing and to contain the cost of prescription drugs. We need to move beyond a boom-and-bust approach to planning, and to manage our human resources with a more comprehensive approach. 

The Canadian Nurses Association's Expert Commission from June 2011 reminded us: “Above all do no harm. Safe, high-quality health care and services should be a national goal.”

The Commissioners also said that nurses are a key link in the chain of safety and must be leaders in developing and sustaining a comprehensive national commitment to safety and quality in health care and services.

My organization, the Canadian Federation of Nurses Unions, in a recent research paper by Dr. Lois Berry, has highlighted the link between quality care and safe staffing:  
“Nurses are the largest health professional group in the health system. They are well-educated, highly skilled, and positively regarded by the patients and families they serve. And yet they continue to practice in systems that do not engage their expertise in making decisions about patient care, or how nurses should be assigned to provide that care. The system lacks the nimbleness to adjust available nursing hours to changes in patient acuity, and the political will to create systems that acknowledge that matching nurse staffing levels to patient needs saves lives.”

Nurses deliver more care than any other group in the health system. Politicians would do well to listen to experienced voices from the front line and stop ignoring evidence-based recommendations we all pay for. The loss of the Health Council of Canada will be felt for many years to come. Without the political will to implement positive recommendations, nothing will change.

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Reflection on the Health Accords: A Glass Half-Full?

Owen Adams is the Vice-President, Policy & Research at the Canadian Medical Association.

Buying Change
A common refrain about the 2003 and 2004 Health Accords is that “they bought time, not change”.  I think that if you take a step back to the largely forgotten 1997 report of the National Forum on Health (NFH) it may be seen that this was the initial impetus to several targeted federal investments that have resulted in reforms in health care in Canada. The NFH put forward key recommendations including calls for a national health information system, a transition fund to support innovation in home care, pharmacare, primary care and integration, and a national population health institute. These recommendations were acted on virtually immediately in the 1997 federal budget, including a $150 million Health Transition Fund (HTF).  This was followed by further targeted investments in the 2000 Health Accord, including an $800 million Primary Health Care Transition Fund  (PHCTF), and $500 million each in health information technology and medical equipment. Although there were undoubtedly several contributing factors, I think that these federal and provincial/territorial, investments have brought about change. For example, the use of electronic patient records by family physicians has more than doubled from 23% in 2006 to 57% in 2012. The HTF and PHCTF led to the development and widespread uptake of new primary care models such as Primary Care Networks in Alberta and Family Health Teams in Ontario.
Wait Times
With regard to the Wait Time Reduction Fund (WTRF) of the 2004 Accord and its initial five priority areas, I think the hope was that it would be “the rising tide that lifts all boats”. Clearly this has yet to happen. With few exceptions, governments have not expanded benchmarks beyond the initial five areas and in its 2013 report the Wait Time Alliance has reported that in many regions and specialties no substantial or sustained progress has been achieved in recent years. Although most jurisdictions have begun to at least measure and report on wait times beyond the initial five, this is highly variable across the country. The Organization for Economic Cooperation and Development has recently highlighted the role of Activity-Based Funding in lowering wait times and this is beginning to happen in Canada in several jurisdictions. One by-product of the WTRF that I would speculate will have a payoff in the medium term is that is has stimulated the growth of operations research in the health field in Canada, at places such as the Centre for Research in Health Care Engineering at the University of Toronto.  I would venture that such research will lead to improvements in health care productivity. I would add that the series of Taming of the Queue conferences has effectively created a community of practice for sharing experience in managing wait times across jurisdictions.

Accountability
One failure of the Accords has been in the area of regular public reporting to Canadians using comparable indicators of health care performance and health outcomes,
which started with the 2000 Health Care Agreement in Canada. The provinces and territories published an initial set of reports in 2002 and a second set in 2004, but since that time, with the exception of Nunavut in 2011, only the federal government has continued the comparable indicators reports, the most recent being for 2010.
The cessation of these reports highlights the difficulty of holding governments to account to one another; at the end of the day, governments must be held accountable to their citizens. In this regard one disappointment is that no Canadian government has yet enacted a patient charter that would set out rights and responsibilities with respect to health and health care. Various proposals have been introduced over the years, and Alberta came close in 2010 with the passage and assent of the Alberta Health Act, which provided for a health charter, but it has not been proclaimed.
However, there has been a growth industry around indicator reporting and benchmarking by organizations such as the Conference Board of Canada, and the Canadian Institute for Health Information has developed a performance measurement framework and will be coming out with an initial set of indicators in the near future.
In closing, I think that one of the reasons that a transformed health system remains elusive is that we do not have a shared vision of what success will look like from the viewpoint of the end-user patient. Peggy Leatt and colleagues set out an appealing nine-point vision in 1999 (p.16) and I would commend readers to it.
Finally, I would add that no organization advocated more forcefully for the creation of the Health Council of Canada than the Canadian Medical Association, and its departure will leave a void, but I hope that its thoughtful and creative work such as the Health Innovation Portal will be built upon and not reinvented.

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Don’t Stand Idly By

Michael McBane is the National Coordinator of the Canadian Health Coalition.
The latest Health Council report on the state of health care in Canada is an important assessment of what worked in the 2004 Health Accord, what didn’t and where to go from here. In the report’s call for action, the Council outlines the irreplaceable role for the federal government: “the federal government should play a central role in providing funding to ensure a level of equity across Canada and continue to represent the fundamental ‘Canadian’ perspective through active participation in health system planning and policy development.”

On the eve of the expiry of the 2004 Health Accord, our health care system is at a critical juncture. The Harper government made it clear that there will be no new accord (or even a discussion). Instead of committing to appropriate levels of funding to meet the needs of a growing and aging population, the Harper government unilaterally announced a $60 billion cut to health transfers and equalization payments.

In keeping with its ‘cut and run’ approach to health care, the Harper government also cut the Health Council itself. When Harper doesn’t like the message, he kills the messenger.

The Harper plan will fragment the health care system into 14 separate systems. His goal is to eliminate national standards in health services and, as a consequence, access to care will depend largely on where you live. The only obstacle that stands in the way of Harper’s plan is the people of Canada.

During the annual premiers meeting in July, the CHC released a Nanos poll. Eight in ten Canadians said they want Prime Minister Harper to call a First Ministers’ Meeting to secure a plan for the future of health care in Canada. Four in ten Canadians stated they are likely to vote for another federal party if the one they currently support does not present a plan for the future of health care.

Federal funding of health care in Canada started out at 50% and will drop below 20% under Harper. The general consensus is that federal funding needs to be roughly 25% of health care expenditures in order to fulfill its essential role as guardian of national standards under the Canada Health Act, and in order to facilitate the transition to a more comprehensive system that meets the needs of an aging population.

Federal leadership is also essential to controlling costs (e.g. prescription drugs). Short term strategic federal investments are required in order to save billions down the road. The evidence shows that countries with higher public spending have better value for money and better health outcomes. The transformative change the Health Council is calling for won’t happen in the current federal leadership vacuum.

Federal government leadership is the glue that keeps national Medicare together.  Canadians must not stand idly by as Harper systematically dismantles it.

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Health for All Through Collaborative Leadership

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Barbara Mildon, RN, PhD, CHE, CCHN(C) is President of the Canadian Nurses Association.

One word — ALL.
Three letters represent one of the most striking notions of the Health Council of Canada’s (HCC) report: Better health, better care and better value for all. Safeguarding and promoting health and equity for every person is a principle that underpins the nursing profession.


It was this same principle that inspired our independent National Expert Commission project. If the health-care system is meant to serve and support Canadians, then Canadians deserve the opportunity to be engaged in its transformation. A year of consultations with the Canadian public of all ages, educators, policy- and decision-makers, registered nurses (RNs) and other health-care providers culminated in the final report, A Nursing Call to Action, which contained a nine-point plan of action (CLICK FOR VIDEO).

The leading recommendation from the Commission and a cornerstone of CNA’s health transformation work is ensuring Canada ranks among the top five nations on five key health status and system performance indicators by 2017. This recommendation springs from a troubling mismatch between health spending and results in Canada. Despite ballooning investments and budgets, Canada’s health system performance and population outcomes have stalled or even dropped compared with international rankings. To achieve our Top 5 in 5 goal, all of us — Canadians, health-care providers, governments, employers and others — must be actively engaged in health-care transformation.

In the spring of 2013, CNA hosted a consensus conference for 32 representatives from provincial/territorial health quality councils and ministries of health, regional health authorities, branches of the federal government, academics, health system administrators and experts in indicator measurement. After a long day of healthy and robust discussion and debate, the group achieved consensus on a draft portfolio of five priority health status and system goals. They can be found in our new report, Canada’s Top 5 in 5: Building National Consensus on Priority Health-Improvement Indicators . The indicators, and the consensus exercise itself, are an important focal point toward achieving real change, and one that all the participants were ready to stand behind.

Back to the word “all.” We read in the HCC report that the triple aim of better health, better care and better value should be framed by an overarching goal of health for all, echoing the milestone declaration from 35 years ago of global health leaders at the International Conference on Primary Health Care. They declared that urgent action was needed “by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world.” This declaration, and the importance it places upon primary health care, has guided CNA and Canada’s nurses for decades as we work for better population and strengthened health systems. Recently, CNA published a new position statement and a leadership in action series to demonstrate how RNs are advancing the principles of primary health care and demonstrating their ability to lead transformation.
 
HCC’s call for leadership and collaboration for a high-performing health-care system that will benefit all Canadians is one that cannot be missed, and is one that Canada’s nurses are answering. 

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Health accords coming to a close but work has just begun

Dr. Jack Kitts, Chair of the Health Council of Canada and CEO of the Ottawa Hospital.
Ten years ago, the federal, provincial, and territorial governments set out to fix an ailing health care system. The result was the 2003 and 2004 health accords. With an eye to public accountability, the First Ministers also established the Health Council of Canada to monitor progress and outcomes against the commitments made in the health accords and to track the impact on health care reform across the country.

The Health Council has carried out that mandate through the last decade, producing more than 50 reports while engaging the public, patients, and other system stakeholders in how to improve our health system.

With the health accords ending in 2014, the federal government made the decision to wind up funding for the Health Council.

In this, one of our last reports, we draw on our accumulated knowledge and insights into Canada’s health system to look back on the investments and impact of the health accords as a driver for health reform across Canada. Our conclusion: The outcomes have been modest and Canada’s overall performance is lagging behind that of many other high-income countries. The status quo is not working. We need to do the business of health reform differently.

However, we can learn from the approach used in the design and implementation of the health accords. This report outlines some key lessons on what worked well and what didn’t. Building on these observations and the recommendations of others who have examined successful strategies for health system improvement, we set out an approach for achieving a higher-performing health system.

All of us have a stake in the future of our health system.

Most of us, our families, and our friends, have had first-hand experience with health care in Canada—both good and bad. We need to make health care in Canada better. We need to see greater progress in reforming health care than we’ve seen over the last 10 years. We need a high-performing health system that will benefit all Canadians—today and for generations to come. In achieving that vision, all governments, health care organizations, health care providers, and the public have a role to play.

The health accords and the Health Council may be coming to a close, but the work has just begun.

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Health Equity Among Provinces

Ian Culbert is the Executive Director of the Canadian Public Health Association.

On behalf of the Canadian Public Health Association, I would like to congratulate the Health Council of Canada for developing this look-back, look-forward approach. CPHA is supportive of the position that is being taken concerning the need to continually improve health care delivery without additional cost, while improving equity.

While providing a thoughtful analysis of the impact of a decade of increased investment in health care spending, the report also raises some important questions about equity and how this fundamental principle is played out across Canada. In the section entitled, “Assessing the impact: Inequities in care and health,” the question of Canadians’ ability to get “access to the care they need, when they need it, regardless of where they live or what they can pay” is probed through an analysis of comparable statistics for various provinces and territories. While it can be recognized intuitively that differences exist, further study is required to identify whether these are true differences or whether they are simply a reflection of the differing priorities and operating considerations of the various provinces and territories. Unquestionable, however, is the devastating inequity related to the health and well-being of First Nations, Inuit and Métis peoples.

Beyond increased funding for the health care system itself, increasing attention needs to be paid to upstream efforts to prevent disease and injury. Taking action to address the social determinants of health helps keep communities healthy and reduces the need for emergency, acute and chronic care services. If all the players who are part of Canada’s publicly funded health system can work together on the social determinants of health, we will ensure that Canadians achieve the highest possible quality of life.

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A Time for Bold Leadership and Collaborative Action

Phil Dresch is the Interim President & CEO of the Canadian Healthcare Association.
 
Three key concepts stand out for me in the Health Council of Canada’s (HCC) most recent report: (1) the importance of leadership; (2) ensuring equity; and, (3) collaboration.

The report calls for “strong and sustained leadership” and rightly identifies leadership as a “key enabler” for health system change.  Evidence shows that leadership plays the critical role in improving health system performance. With this in mind, every year, we at the Canadian Healthcare Association (CHA), in partnership with the Canadian College of Health Leaders, come together with around 800 health leaders to focus on health leadership in Canada. CHA will continue to push for bold and courageous leadership to address challenges and achieve excellence in our health care system.

Perhaps one of the most pressing areas for bold leadership and collaborative action is with respect to seniors’ health. By 2036, 25% of the Canadian population will be over the age of 65. In CHA’s recent pre-budget submission to the House of Commons Standing Committee on Finance, we recommend that the federal government create a National Commission on Seniors and Health, working with provinces, territories and other stakeholders to develop a strategy to address the many health issues related to Canada’s aging population.
  
Canadians clearly want to see leadership and action in this area.  According to an August 2013 IPSOS Reid National Report Card on Health Care, 93% of respondents said that Canada needs a pan-Canadian strategy to address seniors’ health care issues.  Furthermore, 89% believed that all levels of government should work closely together, with a majority (78%) saying that the federal government has an important role to play in a seniors’ strategy. We will be watching for leadership and collaborative action to address the health priorities and needs of Canada’s fastest-growing population.

Another fundamental issue addressed in the report is equity. The HCC’s inclusion of equity for all Canadians is a strong addition to the Triple Aim approach.  In our recent pre-budget brief, CHA also highlights issues of equity such as the wide variability in access to pharmaceuticals among Canadians. Ten percent of Canadian seniors, for instance, admit to skipping prescription drugs due to the financial burden.  As the HCC report emphasizes, Canadians expect their health care system to provide high quality, equitable care, “whether a Canadian lives in British Columbia, Nova Scotia, the Northwest Territories, or elsewhere.”  Increasingly, however, this is not the case. From pharmaceuticals, to timely access to knee replacement surgery, or even having a family doctor, persistent health disparities and inequities are a cause for concern and action.

Moving forward, whether we are talking about the health of Canada’s seniors, or ensuring equity within and among all provinces and territories, it will be bold leadership and collaboration of all stakeholders that will drive needed change.  I was encouraged by the emphasis that the Honourable Rona Ambrose placed on “partnership,” “working together,” and the need for “policy leadership and collaboration” in her first speech as Minister of Health.  We at CHA, alongside Canadians, will be watching optimistically to see if these words of openness and partnership are matched with leadership and collaborative action.

Building on our progress in digital health to benefit Canadians

Photo by Tim Fraser

Richard C. Alvarez, ICD.D is President and CEO of Canada Health Infoway
  
"Better health. Better care. Better value. For all. Canadians expect, and deserve, no less.” 
We couldn’t agree more with these statements in the conclusion of the Health Council of Canada’s recent report.
But how do we get there?

As the pan-Canadian organization tasked with implementing our country’s digital health strategy, we know what it’s like to face big challenges. It has taken time to build our foundation and put core systems in place across the country. But we are now starting to see tremendous progress on the availability and use of electronic health records, electronic medical records and telehealth systems. This growth in availability and use is resulting in concrete benefits. In fact, we estimate $8.6 billion in benefits to Canadians and our health care system since 2007.

That’s good news, but our job is not finished. We need to accelerate our progress so all Canadians will benefit from digital health. And we need to focus on improving the patient experience and giving people a bigger role in their health care.

That’s what Canadians want too. We consulted with hundreds of them and developed a refreshed strategic plan that sets out key “opportunities for action” for digital health. Things like being able to monitor chronic health conditions from the comfort of home, scheduling medical appointments online, and e-prescribing to reduce medication errors.

Are these the right opportunities to pursue? Thought leaders in Canadian health care think so.

How do we get from “opportunities” to reality? We need to ensure that key enablers are in place. The Health Council’s report defines five key enablers for health care transformation – leadership, policies and legislation, capacity building, innovation, and measurement and reporting. These are largely the same as the digital health enablers we define in our strategic plan.

It will be a challenge for us to address these enablers. But Canadian health care leaders say we’re on the right path.

The journey ahead won’t be easy, for the digital health agenda or for broader health system transformation. But with a clear vision, and a clear path, it is possible to achieve our shared goals of better health, better care and better value, for all Canadians.

I welcome your input on this blog post. Feel free to contact me with your comments.

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