Quality of Healthcare in Canada: Potential for a Pan-Canadian Measurement Standard
commentary Dan Florizone, BComm, MBA Deputy Minister of Health, Saskatchewan u
Abstract Saskatchewan has embarked on a journey to transform the quality of its healthcare. Through our experiences, we have learned many lessons that could be useful to the development of a pan-Canadian system of measurement aimed at bettering care. However, measurement in isolation is insufficient to achieve improved healthcare. The system needs to be linked to a common improvement agenda. Creating a system- atic approach to improvement is only possible through developing the capacities of leaders and front-line staff, by alignment through a common purpose, by focusing on value from the perspective of the customer and by creating measures backed by best practice that are transparent and accountable.
Measurement in isolation is insufficient to and among organizations, regions and nations. achieve improved healthcare. The past decade Within Canada, there have been measurement has seen a growing focus on the quality of initiatives led by governments, national agen- healthcare worldwide. A discernible sign of cies such as the Canadian Institute for Health this movement has been increased attention on Information, hospitals, other healthcare deliv- measurement for the purposes of accountability ery organizations, academic researchers and and quality/performance improvement within health quality councils.
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In general, the stated aim of these various to address their shortcomings and to influ- measurement initiatives has been to provide ence them to improve is to get them to think information needed to stimulate and help to sustain improvements and accountability in healthcare. However, by and large, few of these initiatives have been able to deliver Proper measurement of outcomes important and sustained improvements. The and cost is the single most shortcoming of many measurement initiatives powerful lever for improving is that they have not been linked to a system- health care delivery. atic approach to healthcare improvement, including the development of capacity and capability for quality/performance improve- of the patient as a customer of the health ment among the people who run the health system. Similarly, improved accountability system and deliver care. and transparency to the patient through qual- Currently, Canadian provinces are ity measures will inform the customer of the approaching quality individually and at reality of healthcare. An informed customer differing paces within their own jurisdictions, should demand more of the health system, rather than through a pan-Canadian strategy further influencing quality improvement by (Sutherland et al. 2012). This functions as the health system. both a benefit and a challenge to creating one Canadian standard of measurement for qual- Why Quality? From the Perspective of ity. It can be seen as a benefit because provin- the Customer, It Creates Value in the cial governments have finally begun to see the System value of measuring health quality; but it is a Michael Porter, a professor at Harvard challenge in the sense that differing health Business School, argues that “value [as defined systems are not measuring the same things to by the customer] should define the framework the same extent, which makes comparisons of for performance improvement in health care” data quite difficult. (2010); he continues: “Rigorous, disciplined Although a pan-Canadian approach to measurement and improvement of value is the health quality has not largely been formally best way to drive system progress. Yet value undertaken, work has occurred involving great in health care remains largely unmeasured collaboration with the health system and its and misunderstood” (2010: 2477). Although partners in Saskatchewan through quality initi- great strides have been made in advancing the atives such as Lean, Accelerating Excellence, quality agenda in Saskatchewan through Lean and Quality as a Business Strategy. The next and other quality initiatives, there has yet to step in the quality journey is to establish pan- be a consistent set of measures created that all Canadian measurements, one standard that parties agree on and adhere to. The need for provinces can adhere to rather than over- quality measurement will become even more whelming our partners with indicator chaos. pressing as we continue on our quality journey Leadership is important to further advance as “proper measurement of outcomes and cost the quality agenda, as are creating value for is the single most powerful lever for improving the customer and ensuring accountability and health care delivery.” (Porter 2010: 12). transparency of the agreed-upon measures. From the patient’s perspective, value The only way to motivate health systems has become an increasing priority in
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Saskatchewan since 2009, when the Patient cal and surgical acute care wards through- First review documents were released out the province and is also being spread to (Dagnone 2009). These reports made several emergency departments, long-term care and recommendations that influenced the system’s mental health wards. Another provincial transformation from a provider-centred quality initiative is Clinical Practice Redesign system to one with more of a customer focus. (CPR), led by the Health Quality Council Creating value from the perspective of the (HQC). CPR focuses on improving patient customer feeds into and supports the Triple experiences and health outcomes through Aim approach – a positive patient experience, heightened efficiency and improved access, as better health outcomes and sustainable costs well as through increased provider and staff (Institute for Healthcare Improvement 2007). satisfaction. Although these quality initiatives are remarkable, consistent measurement based Quality Journey in Saskatchewan: on best practices is lacking, leaving a void in Creating a Systematic Improvement our quality journey. Approach The Saskatchewan Ministry of Health Filling the Quality Measurement Void has been embarking on the quality jour- Within the health system, HQC has ney through Lean since 2008. The goal has attempted to fill the quality measurement been to empower employees to innovate and void by launching Quality Insight in 2007 change work processes that did not produce and subsequently creating its website, Quality value for patients, families, residents, clients Insights Online (http://www.qualityinsight. and those who provide services (Florizone ca/), in 2011. Quality Insight is a provincial 2011). Through our Lean efforts, we aim to initiative supporting health quality measure- create and maintain an unwavering focus on ment guided by a working group (Teare et al. the patient, enhance the quality of care and 2011). The group is committed to transpar- safety of patients and employees, lower costs, ency, which is evident in its website, which increase productivity, increase patient satisfac- displays reports on over 100 indicators of qual- tion and raise employee morale. ity within the health system (Teare et al. 2011). In 2009, the ministry, regional health The site is intended to be a “one-stop shop” for authorities and the Saskatchewan Cancer system quality and performance measurement. Agency agreed to a common approach for In 2008, HQC also launched Accelerating ensuring quality through the use of the Lean Excellence, a multi-level program to rethink, methodology province-wide. There are now redesign and renew healthcare, using the approximately 150 Lean teams across the highest-performing health systems in the health system that are actively pursuing qual- world as models. Accelerating Excellence ity improvements. has focused on four key drivers of health Two other provincial quality initiatives system transformation: developing leadership are having remarkable impacts on the health for quality; engaging clinicians in improve- system in Saskatchewan. Releasing Time ment; building the capability of health teams to Care (RTC) is a Lean-based patient- to improve care; and building the measure- centred initiative that improves safety, qual- ment system needed to provide feedback and ity, staff satisfaction, patient experience and accountability. the amount of direct care time for patients. A component of Accelerating Excellence RTC is now implemented in 90% of medi- was a collaborative leadership learning
40 Quality of Healthcare in Canada: Potential for a Pan-Canadian Measurement Standard program called Quality as a Business Strategy system with a common purpose. This has led (QBS). This program engaged senior leader- to the health system undertaking a shared ship teams from all regional health authori- approach to system-wide strategy planning, ties, the Saskatchewan Cancer Agency, the prioritization and deployment. This shared Ministry of Health, HQC and many other purpose has given new impetus and focus for healthcare-related organizations in a two-year development of a common set of metrics that journey consisting of six learning workshops can be used to measure progress on achieve- and intervening action periods. In all, more ment of the shared goals. than 250 health system leaders were involved. Viewing each healthcare organiza- These leaders were equipped with tools and tion and its inter-relationships in service of approaches to patients system-wide has also led to different thinking about what is required of measure- • establish and communicate the purpose of ment. The health system needs information their organization, to meet the needs of different hierarchical • view their organization as a system, levels of organization and decision-making • design and manage a system for gathering from strategic (boards and senior leaders) to information to improve, tactical (programs) to transactional (points • develop a plan for improvement integrated of care). It also requires careful attention to with regular business planning and different information needs at various levels of • manage individual and team improvement health system. Most national initiatives focus activities. primarily on the strategic level; but if these measures do not cascade all the way down Although designing and managing an to the patient-provider interface, then only a information system (i.e., measurement and limited impact on improvement will result. reporting) was one of the topics, capability in Information and measurement cannot each of the listed areas is crucial to the effec- be siloed – simply measuring performance tive design and use of measurement. within a particular process or healthcare These initiatives have been a step in the organization or sector. We have begun to right direction in establishing standards for develop measurement systems and a capabil- quality measurement, while educating on the ity to measure the quality of the longitudinal value to the customer and engaging leaders in a journey of patients as their health needs are transparent way. The next step in the journey is dealt with in different areas of the system to take all we have learned and collaborate with (e.g., primary care, emergency, acute care other provinces to create a national standard. and continuing care). Looking at the entire healthcare continuum from the perspective of Developing Capability for Leadership the patient is not only more valuable to the and Front-Line Staff to Support healthcare system aiming to improve, but it Measurement for Quality also provides more value to the patient. Having a clear and shared purpose and stay- Learning opportunities and capacity also ing true to it over the long term are vital for need to be created in order for front-line staff success. An important development during to measure for improvement. Transparent the QBS experience was that leaders of health measures focused on improvement created and organizations across Saskatchewan agreed backed by front-line staff are key as staff are to put the patient first and act as a unified more engaged to improve quality than if they
41 HealthcarePapers Vol. 12 No. 1 were not involved in the process. This allows sense of “ownership” in the measurement for a sense of ownership in the process, as well system by the health system. Measures must as creating measures that have meaning for also be transparent and accountable to both providers, leaders and patients. providers and our ultimate customer – the patient. All of these pieces together are crucial Transparency and Accountability of to the creation of a sustainable pan-Canadian Measures measurement system. Transparency and accountability of measures Although Canadian provinces are feed into creating value from the patient’s approaching quality improvement individually perspective. Customers of the health system and at differing paces within their own juris- cannot be expected to make informed choices dictions, rather than through a pan-Canadian about their care unless they have as much strategy, there has been talk of creating a pan- information as possible. We must not only Canadian acute care patient experience tool to measure and publish measures related to help hospitals identify performance improve- safety but also fi nd better ways to capture ment activities. Although these discussions are patient satisfaction and other indicators. in the preliminary stages, this is a positive step There is also a need to educate the intended in moving forward the quality agenda. A pan- audience on how to use and interpret the Canadian tool would not only allow hospitals measures released to them. to compare results nationally but would also As quality measures become more trans- serve as a tool to enable comparability with parent, there is an added incentive for the patient experience data internationally. It health system to improve. Becoming more would help us to identity good performances transparent and accountable also creates a sense and to learn from past experiences. It would of competition for healthcare providers to offer also open the door to other collaborative the best service possible. This was seen in a opportunities to improve care. project involving physician patterns in ordering If the shift toward quality is as important tests. Some physicians were ordering substan- as we say it is, perhaps a single institution tially more tests than their counterparts were. accountable for measuring and reporting on Once a comparative chart displaying ordering quality on a pan-Canadian basis needs to be patterns was released to all physicians and they created. It is hoped that this would curb what could view each other’s data (education on has been described as indicator chaos: the fact best practices was also provided), behaviours that governments and other organizations profoundly changed for the positive. are asking our partners for an ever-increasing number and variety of measurement improve- Conclusion ment indicators; this is distracting them from, In order for a pan-Canadian strategy to be rather than aiding in, quality efforts (Teare et successful, shared priorities using cascad- al. 2011) and, in turn, not creating value in the ing measurement from the top down to the eyes of the patient. patient-provider and from the bottom up are Measurement, leadership, staff and patient needed. Engaged leadership coupled with engagement and quality improvement capa- informed front-line staff and patients must bility are tightly intertwined elements that occur prior to decision-making in order for feed off each other to create synergies for quality improvement to occur. There is a need health system transformation. Therefore, to for collaborative development and shared be optimally useful, any national healthcare
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quality/performance measurement initiative March 1, 2012.
All around us, people are at work leading change in healthcare. All of these leaders have a journey of experience from which they have learned (and are learning!) lessons. - Paul Batalden, Editor
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