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.