A new paper by University of Toronto researchers argues that we need to look beyond the typically dismal rankings for Canada’s health-care system, realize what’s working well, build off of those examples and embed quality improvement into health professional education. We agree and believe that we can make meaningful improvements in our system today by spreading the managerial and policy models that are already working well. We can also start to innovate (and evaluate) more substantial changes to our system.
In the October 1, 2018 edition of the CMAJ, Drs. Irfan Dhalla and Joshua Tepper presented an overview of the quality of health care in Canada. Basing their results largely off of the most recent versions of the Commonwealth Fund and the Organisation for Economic Co-operation and Development’s (OECD) cross-national comparisons they reached a very Canadian conclusion:
Canadians are healthier than ever before, and in many respects, the quality of health care provided to Canadians is also better than ever. However, there are still large gaps between what we know to be high-quality health care and the care that many Canadians receive.
Building off the Institute of Medicine’s six dimensions of quality, they go onto make a number of important observations about how to improve quality, many of which are particular to a single payer system like ours. These include the importance of expanding coverage to include cost-effective treatments (e.g. drugs and psychotherapy), rebalancing our spending in health towards primary care, using information technology so that patients and providers can work more closely together and effectively engaging patients in decisions about their care and how to improve it.
Dhalla and Tepper make two related points that we want to explore more in this blog. The first is their assertion that, in many respects, Canadians receive better care than ever. This statement may have surprised many readers. The authors list a number of points to support this assertion such as internationally leading cancer survival rates and that “Commonwealth Fund surveys show Canadians tend to report good experiences with their physician compared with individuals living in other high-income countries.”
We agree that there are strengths and that we can do better. But we also believe it’s critical to learn from our successes. Although the people of Ontario wait too long for most types of care – and hallway medicine has become far too commonplace as hospitals struggle with overcrowding – virtually every cardiac centre now performs better than target on access to cardiac care with variation in wait times for cardiac surgery often measured in hours rather than weeks.
So what worked well with cardiac surgery? In this case – as in many other cases in Ontario – lining up clinical insight and expertise,public performance reporting, and clear goals aligned to funding led to a dramatic turnaround. Evidence-based care coupled with granular data and the right incentives made a real difference. Significant concerns about Ontarians dying on cardiac surgery wait lists have now disappeared due to these changes and to advances in interventional cardiology.
In our system, improvement needs to be whole systems improvement. We need policy, organization, and clinical leadership and quality improvement to effect lasting positive change. It also means we need to look beyond the typically dismal rankings for Canada in the Commonwealth Fund reports (#9 out of 11 countries in 2017) to see what is working and build off of those examples. We might also be wise to look at the Canadian data by province as we don’t have a national health system but a series of provincial quasi-systems.
Their second point is around the preparation and support of health professionals. Dhalla and Tepper argue strongly for embedding quality improvement into the education of health professionals and ensuring that professionals find joy in their work. We see these as related arguments. If we celebrate our successes and encourage health professionals to engage in regular quality improvement exercises, we believe we will start to move towards a stronger,higher quality system while creating better work environments.
This is not a problem solved by training alone. It means that improvement needs to be seen as part of every health professional’s job and to do that we need to create time and rewards for such efforts. This would require us to increase such training now, rather than waiting for it to trickle down through our formal educational system. More people working on improvement now seems attractive, but to do so we need to make sure that these responsibilities are not merely one more job on an already over-burdened workforce. We need to approach these changes with caution and with a commitment to evaluation so that we truly build better sustainability, quality and work life.
Finally, it is worth talking about the rating systems that underlie Dhalla and Tepper’s review. The results reported in these systems do not always reflect patient experience nor the general perception on the ground.For example, the Commonwealth report regularly ranks the UK’s National Health Service as the top performer. But it’s clear from a quick read of their detailed data that key measures like deaths that could have been prevented by health care are worse in the UK than in Canada and the media coverage in the UK regularly talks about a system in crisis. Moreover, we need to make sure that these rating systems reflect what is important in Canada. We all subscribe to the Institute of Medicine’s six dimensions of quality, but how value these dimensions and what we include under each dimension will and should vary amongst countries. Looking back to our first blog post on the importance of listening to patient complaints, we believe it is important that Ontario (and Canada) pick a small set of critically important measures of performance, like patient experience and outcomes, and then work relentlessly towards improvement on these measures and with goals and standards that make sense to our patients and providers. The alternative is to get caught up in measures selected by outside groups and jump from one set to another without consideration of what we need and want from our system and how we are changing.
We hope that in the near future, articles on quality of care in Canada will talk about overwhelming improvements and how we finally have the system we want, although we expect this sort of boasting may be uncomfortable for us as Canadians. However, we know that there is a lot we can do today to get there and a lot we can learn by looking in our own backyard.
Adalsteinn Brown is Dean and Professor at the Dalla Lana School of Public Health. Kevin Smith is President & CEO of University Health Network.
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Photo by Daniel von Appen.