Looking at health care system performance: Lessons from the Commonwealth Fund survey

Sukirtha Tharmalingam, Senior Policy Analyst, Health Council of Canada 

The Health Council of Canada has been pleased to be a key contributor to the design and funding of the annual Commonwealth Fund’s International Health Policy Survey (CMWF IHP survey) since 2009. Using the data collected in these annual surveys, we released a series of bulletins under the banner, Canadian Health Care Matters that focused on different aspects of public/patient and physician perceptions and experiences with our health care system.
The 2013 survey of the general public includes about 100 questions that address a comprehensive range of issues in our health care system.  The report we released today, Where you live matters: Canadian views on health care quality , lets us compare the performance of provincial health systems with that of 10 other high-income countries.  We also compare results from the 2013 survey to the same questions asked in 2004, 2007 and 2010.  We find that Canadians’ experiences with their health care system vary widely across the country and from our international counterparts. For example, if you are in BC, you may be happier knowing that your province outperforms all other provinces in getting a same-day or next-day appointment when needed – 41% of respondents say they can. However, even BC as the best performer lags far behind the other 10 other countries participating in this survey.  In the top performing country Germany, 76% of people surveyed report they can get a same-day or next-day appointment.  Over the past decade, Canada has shown little change in this aspect of access to care – hovering around the 40% range since 2004.  This and other comparisons we present in the bulletin serve to raise flags for others to probe further into the factors that contribute to the variations and trends we see.

Looking back and moving forward

With an eye to the future, there are a few insights and learnings that I would like to share based on working with the CMWF surveys for the last four years.
 
1. Canadians have something to say about their health care system performance and it matters! 

The findings we presented through these reports definitely resonated with Canadians.  This was evident to us through the interest they generated from national and local media and news agencies (the Toronto Star) and (the Globe & Mail), report downloads from our website, references to the statistics we presented, and the plethora of patient stories the reports brought forward.
[The cost of chronic illness] [Worrying about my future] [In search of support: the importance of communication in the heath care system]

2. There are recognizable challenges and limitations to a population based survey data

There are methodological challenges we face when analyzing and reporting on results from these surveys.  Achieving perfectly consistent and comparable survey data across the participating countries and even provinces within Canada is virtually impossible. Examples of some things to consider are variations in response rates, individual interpretation of the survey questions, representativeness of the population being surveyed, or one’s ability to recall an experience. However, tremendous efforts were taken to ensure that we developed questions that were unambiguous and could offer important insights on the health care system. We also employed statistical techniques to help us improve the interpretability of the results.

3. There are recognizable benefits to participating in a cross-sectional annual international survey that assesses health system performance from the perspective of those who interact with it. 

Although self-reported measures derived from population surveys can be challenged, we need to be wary that we are not dismissing results because we think they may not be comparable. There are benefits to these survey findings and the comparative lens (international, provincial, over time) they provide us. It allows us to understand what is being achieved in other countries of similar economic size and income and provokes us to think about where there are potential gains to be made in Canada.  For example, which countries have higher performance and what policy directions and strategies do they share with us? What aspects of the health system have improved over time; which have not?

As the Health Council prepares to wind down in March 2014, we are pleased that CIHI and CIHR-IHSPR have agreed to co-lead the Canadian contributions on future Commonwealth Fund surveys. We have enjoyed the opportunity to bring forward the results from this survey in recent years and have been pleased to collaborate with the health agencies in Alberta, Ontario and Quebec to expand sample sizes in their respective provinces. The self-reported experiences of those who are in direct contact with the health care system provide a unique and vital piece of information that can help to improve the delivery of health care. I hope that this important source of information will continue to play a role in supporting decisions by health care providers, managers, and policy makers. 

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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.

CLICK HERE to see the other videos in the series, Innovations in Wait Times 
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The Home First philsophy - creating safe transitions for patients from acute care to home

Caroline Brereton, RN, MBA is a registered nurse and holds an MBA from Queens University. She is a graduate of the Rotman School of Management Advanced Health Leadership Program.
A senior healthcare executive with 15 years of leadership experience, Caroline became Chief Executive Officer of the Mississauga Halton CCAC in May 2010. Caroline has a vision for a system that is fully aligned to support the needs of patients.

The growing population of seniors across the province will continue to increase pressure on the health sector to provide health care at home, including community services to help seniors move from  hospital to home following acute treatment and programs to help residents remain safely at home for longer. We feel it acutely in our Mississauga Halton communities of South Etobicoke, Mississauga, Oakville, Milton and Halton Hills.  We experienced one of Ontario’s highest growth rates in population, a 12 per cent increase in population from 2006 to 2011.  The Mississauga Halton region is the second fastest growing population of seniors in Canada (projected 32.3 per cent increase in 75 to 84 year-olds and 71.1 per cent increase in seniors 85 and older, by 2013).

 In 2009, anticipating population growth, the Mississauga Halton CCAC, was the first to launch the Home First Philosophy. In collaboration with our region’s hospitals, Trillium Health Partners and Halton Healthcare Services, funding was provided by the Mississauga Halton LHIN.

The philosophy embodied our objective: to slow the growth of alternate level of care (ALC) rates in hospital, while at the same time supporting the province’s goal to increase access aging at home. It was ambitious; the number of ALC days nearly doubled from 9.3 per cent in 2007 to 17.5 per cent in 2008.
The Home First Philosophy was the foundation for a new suite of Wait at Home services and that was our approach to tackling the growing ALC rate. It is a team-based philosophy that promotes safe and timely care, services and supports, which helps to meet the health care needs of patients and families in the most appropriate setting. The Home First philosophy recognizes that the home environment is the best place for recovery and supports people in returning to their homes from hospital wherever possible. It also provides the necessary services to help older adults maintain their continued independence in the community.

Challenges and Hurdles
This new philosophy necessitated changes in workflow, culture and communication. When we introduced it to our patients, staff and partners, it was a huge culture shift in health care thinking for families and physicians.  Traditionally, patients applied to long-term care homes from the hospital.

Physicians were concerned about safety and risk to patients leaving hospital and returning home. We helped physicians understand the quality of care provided in the community through the Mississauga Halton CCAC. We explained our approach and introduced new services that would ensure patients, even those with complex care needs, would be safe at home while they applied for long-term care or recovered and realized they could stay at home safely with services from our CCAC.

Better Outcomes
Together, with our partners, we drove better results and we continue to bring proactive change to the health care system. With innovative efforts and focused teamwork, the consistently low ALC rates in Mississauga Halton is evidence of system integration as a key mechanism for delivering the right care, in the right place, at the right time.  In fiscal 2012/13 our ALC rate was seven per cent and 6.3 per cent in the previous year. This means that 93 per cent of hospital beds in our region were available to patients needing hospital care.

Staying in hospital after surgery or treatment is not in a patient’s best interest. There is an increased risk of infection; and patients become less independent the longer they stay in hospital.The Home First philosophy is an enormous cost savings to our health system. Every ten per cent  shift of ALC patients from acute care to home care results in a $35-million saving.  And most importantly, it provides better outcomes for patients where they are happier and more comfortable in a familiar setting and they tend to recover more quickly.
Recently, a patient’s son, who is caring for his 83-year-old father at home, told us:  “The Mississauga Halton CCAC made it so simple and smooth. You take care of everything – personal support workers, nurses, occupational and physical therapists, medical equipment and supplies.  They brought the hospital to our home.  Now my father is safe and secure, and getting the quality of life he deserves.  My father belongs here.  Without you, we could not do it.  It would have been impossible. It is a blessing to have my dad here.”
However, if a patient and family decide that long-term care is the right place to be, we help them through the process from beginning to end. We start by directing them to our long-term care website – http://mhccac-ltc.com/ –which provides information about wait lists and costs, as well as a virtual tour of our region’s 27 long-term care homes.

At the Mississauga Halton CCAC, we look at health care differently. We recognize health care at home is not the future; it is the reality of health care today.

*Watch the video on the Home First program, part of the Health Council's Wait Times video series.

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