How queueing theory can improve wait times

In this video blog, Dr. David Stanford of the University of Western Ontario demonstrates how queueing theory can influence wait times and how simple changes can have a big impact on reducing them.

In addition, the University of Western Ontario has announced a new mathematical finding by an international research team led by Dr. Stanford. It provides the health care system with a more balanced approach to how patients are selected for treatment, which will consequently decrease wait times.

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Minding the Gaps in Quality Improvement in Canada

John G. Abbott

John G. Abbott is the CEO of the Health Council of Canada

What can Canada gain by upping its investment to advance the health quality improvement agenda? And, in what areas should it invest?

A lot, in my opinion; and the focus needs to be on increasing the capability and capacity of our system and its leaders to deliver transformative change. 

This week, the Health Council of Canada held a national symposium on quality improvement under the theme: Towards a High-Performing Health Care System: The Role of Canada’s Quality Councils. 

Dr. Ross Baker

Over 200 senior leaders from across the country converged to talk about health system performance measurement and reporting, and building system capacity for quality improvement.  It was clear that there is no ‘one size fits all' when it comes to performance measurement or reporting and each jurisdiction with a quality and/or patient safety organization (there are seven in total) have adopted approaches that are working for them. So what are the gaps in Canada’s current quality improvement approach that need to be closed?

The first gap is the absence of a burning platform for transformative change so that quality improvement is embedded in everything we do in health care. Are health leaders and Canadians themselves convinced that we need to improve the quality of the care being delivered in each hospital, clinic and doctor’s office in this country? The evidence says we need to, but is that enough to make the case?

Panel on Building System Capacity for Quality Improvement

The second gap or challenge is treating QI as an add-on. Shouldn’t our health system encourage all its leaders to begin their day with the question: what have we got to do today to ensure all our activities deliver safe and appropriate care for our patients; and end their day by asking:  how do we know that we achieved this objective? If QI is its own silo, we are not going to achieve transformative change in any setting.

The third gap relates to resources. We need to increase the level of investment in resources to successfully design and manage a QI agenda. We need to train people at the front lines and in the back rooms to think as one, using a common language around performance improvement.  We need to continually support the work of quality councils in this country who in turn are aligning their activities in support of the health systems that they both monitor and engage on quality improvement initiatives.

A fourth gap is not appreciating the magnitude of managing complex system change.

A fifth gap lies in the area of technology and information sharing. We need to leverage the use of today’s technology to collect data and share information about system performance and patient outcomes in a consistent and timely way that can be used by all parts of the system to improve the quality of care.

No one organization or system has all the answers to addressing these gaps. All in all, we need to collaborate within and across organizations and jurisdictions to build capacity and capability in all these areas.  The Health Council’s report on the proceedings of its event will cover these points in greater detail and will be released on December 16, 2013 at www.healthcouncilcanada.ca.

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The evidence we need

At a knowledge translation (kt) conference two years ago in Gatineau, Quebec, the KT research community seemed to agree that value judgments, tacit knowledge and peer opinion will always exert a certain level of influence on health care decision-makers. However, the game-changer was really the power of evidence to inform decisions, making them more transparent, objective and defensible. One can make the leap to say that evidence is more than fundamental to sound decision-making; it is a necessary consideration in the pursuit of something I value even more: wisdom.

Enter the launch of a new online tool called the Evidence-Informed Healthcare Renewal (EIHR) Portal on a McMaster University site to which policy and decision-makers have been turning for a while. The difference is that this portal is the only one of its kind dedicated exclusively to health care renewal in Canada and is the accomplishment of a number of national health care organizations and entities (including the Health Council). As a Health Council representative on the portal steering committee, I can attest that this portal has already met with enthusiasm and support from researchers and many governments. 

I hope you’ll delve into some of the different formats like videos that present rich evidence on innovative practices throughout the country.

From my experience, journalists are well-served by consolidated health system evidence on the Evidence Network, health care professionals are increasingly served through the Canadian Virtual Health Library, and now researchers, policy and decision-makers can turn to the EIHR portal as a comprehensive hub that draws from multiple contributors.

If your area is healthcare renewal, I also invite you to the Health Council’s site because every aspect of our evidence-based reporting is implicitly linked to renewal. We underline all our work with a focus on innovative practices that have the power to transform the system.

“Will it work here?” is the next question you’ll have to answer for yourself. 

Christine Pierroz, Director of Communications, Health Council of Canada

Set national goals to achieve progress in health care

Originally published as a letter to the editor in the Regina Leader Post.

The absence of a robust and available set of comparable health indicators makes it difficult to hold the health system accountable for improving population health. As this recent Regina Leader-Post article noted, without valid comparisons, how do we measure success? Perhaps we can replace the discussion on national standard with a need to have national vision, performance targets for health care and health outcomes and the leadership to achieve them.

By way of example, the federal and provincial governments did not set out clear parameters for change in the 2003 Health Accord or the 2004 10-Year Plan. Most commitments were vague and set with low expectations; and were in place more to put provinces and territories on an equal footing instead of pushing them towards excellence in health care.

If we are to see improvements in health delivery across Canada, our governments need to set clear policy goals with both measurable health outcomes and supporting health indicators so the public can hold health system leaders accountable for performance. We can harness the existing data collection and measurement capacity of CIHI and Statistics Canada, as well as that of provincial health quality councils and related agencies to get this information. Agencies such as ours can then report more effectively to Canadians who in turn can hold their governments and the system to account.

Once we have a shared vision across Canada supported by comprehensive goals complete with concrete targets, that’s when we will see real progress take place. For further information, visit our website at healthcouncilcanada.ca and download our report on measuring and reporting on health system performance.

John G. Abbott, CEO, Health Council of Canada

Better local connections will make better nationwide indicators

Dr. Gary Teare joined the Health Quality Council (Saskatoon, SK) in January 2005 as Director of Quality Measurement and Analysis. At the Health Quality Council, Gary leads a team of researchers and analysts in the Council’s work of measuring and reporting on the quality of health care in Saskatchewan and helping to develop performance measurement capability in the health system.  Gary’s own research has largely focused on issues of health care performance measurement.

As we approach the denouement of the “10-Year Plan to Strengthen Health Care” put forward by the Health Ministers in 2004, the Health Council of Canada concludes in their Progress Report 2012: Health care renewal in Canada that while much progress was made, important opportunities were missed.  One of these they point out is the ongoing lack of nationally shared health system performance goals accompanied by a set of comparable metrics by which we hold ourselves accountable to the public for progress.

Indeed, in another of their reports,  Measuring and reporting on health system performance in Canada: Opportunities for improvement, released in May 2012, the Council  points out the virtual impossibility of their assigned task of monitoring and reporting on the provinces’ progress on agreed goals of the 2004 Federal/Provincial/Territorial Health Accord, given the largely inadequate and somewhat “chaotic” state of measurement of health and health care across Canada.

Not that there isn’t quite a bit of good measurement and reporting on health and health care quality and performance happening. It’s mainly that these efforts are being carried out by a variety of national, provincial and regional organizations in a largely uncoordinated manner.  Due to this lack of coordination, Canadians are not realizing maximal benefit from all the intelligent, detailed and costly work being done across this country to create metrics and report on health system performance.  I fear thus far our cumulative efforts may be generating more heat than light.

To realize the goals of all this measurement work – namely to stimulate and support health care improvement and contribute to public accountability, we will need more than carefully crafted, comparable indicators reported at facility, regional and provincial levels by means of user-friendly, media attention-grabbing public reporting.  While these have some effect, they also can divert attention and resources from development and support of more localized measurement for improvement.

Like politics – all health care is local.  Improvement happens at the interface of patients and the people serving them or it doesn’t happen at all. Thus far, we have collectively relied too much on a “top down” approach – hoping that by highlighting performance or quality gaps at a population level we can motivate and inform improvements to care processes and outcomes. Unfortunately, presenting data on outcomes of care processes in the absence of sufficient information about the underlying processes does not help those responsible for the performance to respond in highly productive ways.

In future, much more attention needs to be paid to providing the support that very localized care delivery teams (including both clinical and administrative functions) need to enable them to identify their performance gaps and measure progress as they focus on specific improvement aims.  Not all measurement at this local level need be highly standardized or comparable (though some should be) – mostly it has to be very timely (daily), highly visible, and meaningful to the people trying to make improvements.  Importantly – where local improvement work needs to be linked to regional, provincial or national improvement aims – a connection, via logical or arithmetical measurement cascades, needs to be made between local and higher-level measurement.

So, Canada – let’s certainly continue to invest in the development of indicators that are comparable across the country.  These are important to understanding disparities in health and care and can play a role in improvement.  However – let’s commit to working harder to coordinate the work of various agencies that measure and build capacity to measure health care performance, to avoid creating duplications and distractions. Instead let’s have national, provincial and regional players work together to build stronger measurement connections between local care processes and wider health system improvement ambitions.

Comparable Indicators – A powerful tool to drive change

Dr. Ben Chan is President and CEO of Health Quality Ontario.

The Health Council of Canada's 2012 Progress Report describes numerous advances over the last decade in public reporting, both at the provincial and pan-Canadian levels.  But are we maximizing our ability to compare health system performance across the country?   The answer, it appears, is no.  The Council’s  report notes, for example, that many jurisdictions feel the indicators agreed on through the First Ministers’ Accord aren’t sufficient for their own measurement and reporting needs.  Why, then, is it so difficult to create a robust set of meaningful indicators for cross-national comparisons?

One reason presented by the report is that provinces appear interested in creating measurement systems for their own needs.  There is certainly evidence of that in Ontario, where the province has invested heavily in reporting on surgical wait times, hospital acquired infections and other patient safety measures.  For most of these measures, there are no equivalents elsewhere in the country.  Provinces with a firm agenda for quality cannot afford to wait for national consensus on indicator definitions before pushing for improvement.

But does the “narrow provincial focus” argument really explain the aspirations of individual provinces?   Not quite.  Here in Ontario, one of the strongest messages I’ve been hearing from local CEOs is a huge interest in benchmarks.  This thirst for comparable data is in no small part due to the quality improvement plans legislated for hospitals under the Excellent Care for All Act, 2010 (ECFAA).   Hospitals are required by law to set numeric targets for improvement for each fiscal year.  As a result, hospitals are looking for guidance as to what their evidence-based targets should be, and want to incorporate the strategies employed by high performers elsewhere.   This demand will only grow as the requirements of the ECFAA are spread to other parts of the health system, suc h as primary care.

The thirst for comparisons goes further.  Already, in our annual Quality Monitor report, we ask tough questions as to why we’re not matching the best results achieved elsewhere, in areas where good interprovincial comparisons exist.  Why, for example, does Colchester-Hants, Nova Scotia have a flu vaccination rate of 82%, when Ontario’s average is 68%? What are they doing that we’re not, but should be?  We’re also asking ourselves why the overall rate of hospitalization for ambulatory-sensitive conditions is 275 per 100,000 in Ontario, compared to a mere 162 in Richmond, B.C.

To achieve robust pan-Canadian reporting, we can build on our current successes in creating nationally standardized data sets and surveys. CIHI and Statistics Canada have made huge contributions to the country by making data sets like the Discharge Abstract Database and Canadian Community Health Survey available.   Some obvious next steps could be common definitions for reporting on wait times, and a minimum core set of standardized patient experience questions for primary, acute, long-term and community-based care.

Electronic medical records (EMRs) also represent a treasure trove of information on what should be one of our top priorities: providing better chronic disease management (CDM).  EMRs are proliferating across the country, and many EMR vendors operate now in multiple provinces.  Health Quality Ontario is currently advocating for more stringent EMR vendor specifications in order to ensure that standardized data on CDM is collected.  Our close partnership with CIHI can help ensure that these standards contribute to national standards.
 
All of us want to improve and to be among the top performers, but the only way we can truly know how we are performing is through comparison, to ourselves and to others. What we need now is a paradigm shift that recognizes that nationally standardized data sharing is one of our most powerful tools to drive change.  Indeed, it is in the self-interest of each province to do whatever we can to advance sharing of comparable indicators.

Comparable Indicators – a focus for conversation on better health care

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.

Redesigning a healthcare system with its complex organic properties, powerful interest groups, and its political game is much more challenging than the transformation of the auto sector, housing sector and the financial sector combined. Add to this a landscape of multiple players promoting numerous indicators which compete and confuse the system, rather than help us to learn and improve.

The recent global financial meltdown has raised new conversations in corporate board rooms about return on investments, outcomes not outputs, consumerism, ethics, codes of conduct, public transparency, baseline measurements, quality improvement, risk management, third party validation, rewards and consequences, etc.

The focus in healthcare should be on common areas of real value creation, such as: transparency, reduction of variation, greater coordination across the continuum of care, use of evidence, and obligations of citizens themselves not to abuse the system.. Public reporting with a focused set of comparable indicators will raise necessary conversations and important questions.  Are we using our money wisely?  What are the health outcomes for the investments?  Why do we have such a variance in care, spending and outcomes performance by province, by geographic area? Policy-makers and funders need to ensure the assumptions underlying their long-term healthcare plans reflect both the real economics of the market and the healthcare performance outcomes of the provider organizations.

Canadians deserve a responsive and responsible health system – that is, a healthcare system that evaluates progress; measures quality, performance or the patient experience; and shares learning.

It is important to acknowledge the role that partnerships of many national and jurisdictional organizations play in the quest for a safer healthcare system. Accreditation Canada, the Institute for Safe Medication Practices, the Canadian Institute for Health Information, Canada Health Infoway, the Canadian Agency for Drugs and Technologies in Health, provincial health quality councils, the Health Council of Canada and others are dedicated to helping organizations and peers improve the safety of healthcare.  Such partnerships foster a coordinated effort that minimizes duplication and promotes the very best in patient safety.

Through collaborative relationships, the implementation of key initiatives is enhanced, ensuring that patients see results sooner rather than later. 

What health care can learn from sports

A new blog by Steven Lewis, Mark Wahba and Mary Smillie was launched in October, 2011, with the purpose of creating “a community of thinkers, writers and readers interested in exploring how health and medicine can learn from the development, use and application of statistical analyses in sports.”

The authors of “Meaningful Analogies in Sports and Health” (M.A.S.H.) were inspired by the Michael Lewis book, Moneyball (now a major motion picture starring Brad Pitt) – a chronicle of the Oakland A’s manager’s success in building his baseball team on a budget by using data. The blog operates on the premise that health care could be better if data as well as concepts from baseball and other sports were used to improve decision making and overall quality.

Interesting concepts are discussed, and new ways of thinking about evidence-based decision making are presented. Not only are the discussions relevant to those of us in health and health care policy, but are also often of interest to the public. For example, one post discusses performance measurement in figure skating, and shows how a former scoring system overvalued certain metrics, similar to the way certain health care performance measurements are undervalued.  

The best part is that the discussions make meaningful analogies to issues in sports, a topic more widely accessible to the public than the usual health care policy forums.

Susan Brien, Policy Lead, Health Council of Canada

Think big, start small, act now: Tackling indicator chaos

The health quality councils of Saskatchewan, Alberta and British Columbia, in partnership with the Canadian Patient Safety Institute recently released their proceedings report from the national summit held in May to discuss health indicator reporting in Canada. We participated in the summit, along with other national organizations including the Canadian Institute for Health Information and Statistics Canada, Accreditation Canada, provincial health quality councils, provincial and territorial ministries of health and academic leaders in health indicator development and reporting.

The report summarizes the outcomes from the meeting, which were to bring together stakeholders involved in health indicator reporting from across Canada to work towards a national alignment of health indicator reporting priorities.  The report acknowledges the vast expertise in health indicator reporting in Canada and the capacity that exists to measure health system performance.  However, in the words of one of the organizers, Gary Teare, the way forward is “… to step back and try to understand how to connect the expertise and use it to the best advantage across the country”.

For more information, read the full report.

Susan Brien, Policy Lead, Health Council of Canada

Indicator Report Season

In the health performance measurement world, June is when the newest indicator reports are released. To kick off this “indicator report season”, we released our Progress Report 2011 on May 31.  Although the report does not officially report on health indicators, the report synthesizes other reports to provide a Pan-Canadian snapshot of the progress in health care renewal.

Here are some indicators reports out last month you may find interesting:

·        Health Quality Ontario released its annual indicator report, QMonitor, on June 2.  QMonitor reports on over 200 indicators of quality of care and population health at the provincial and Local Health Integration Network (LHIN) level.

·        The Canadian Institute for Health Information released its annual Health Indicators report on June 8.  Health Indicators 2011 reports on over 80 indicators and this year introduced 5 new indicators related to mental health.  Data in this report is reported at the health region, provincial/territorial and national level.

·        The Canadian Stroke Network released The Quality of Stroke Care in Canada 2011 report on June 16.  This report evaluates the quality of stroke care across Canada using data from the Canadian Stroke Registry.

·        The Wait Time Alliance released its report Time Out! Report Card on Wait Times in Canada on June 20.  The report card grades provinces on their progress in reducing wait times in the 5 priority areas set out in 2004, going beyond these 5 priority areas, availability of wait time information on their websites and the impact of alternate levels of care on wait times.

·        Statistics Canada released the latest results from the Canadian Community Health Survey on June 21.  This national, cross sectional survey collects health-related information (as reported by Canadians) at the health region level.  The June 21, 2011 release contains data from the 2010 cycle of the survey.

·        The first phase of results from the 2010 National Physician’s Survey was released on June 27.  This survey polls physicians, medical residents and medical students and reports results on a provincial and pan-Canadian basis. The June 27 release contains information gathered from physicians from all disciplines, and survey results from medical residents and students will be released in fall of 2011.

·        The OECD released OECD Health Data 2011 on June 30.  This report compares Canada’s expenditures on health and other health-related resource use to 34 other participating countries.

If you know of other health indicator reports published recently that are relevant to health care performance and health outcomes in Canada, please share!

Susan Brien, Policy Lead, Health Council of Canada