Government leadership can scale-up system improvements: Solutions series, part IV
This is the fourth part of a series examining the policy barriers and solutions to reducing surgical wait times in Canada. The series has been adapted from a research paper by Andrew Longhurst. The complete paper with reference list for the footnotes is available here.
Canada has been called “a country of perpetual pilot projects.”[1] In 2006, the federal government’s advisor on wait times released a comprehensive report with recommendations on how governments can reduce waits. The report highlighted the need for the federal government to take a much greater role working with provinces to develop, support, and spread promising and successful innovations across the country. The report recommended that each province develop administrative and leadership capacity for wait time coordination across its health regions. It also recommended that provinces adopt the following evidence-based practices: common waitlists and centralized referral to specialties (i.e., single-entry models) with patients assigned to the first available slot for intervention; case management and team-based care; appropriateness; and pre-habilitation programs to ensure fitness for surgery; system-wide electronic health records; and a public education campaign to inform Canadians about what is being done to improve wait times.[2]
Moving from pilot projects to system-level change is not easy. International evidence indicates that success depends on frontline providers championing improvement efforts. Dr. Don Berwick, of the US-based Institute for Healthcare Improvement and one of the founders of the international quality improvement movement, has suggested that instead of trying to improve performance based on a complex set of financial incentives, health systems should focus on “placing more trust in the intrinsic motivation of the healthcare workforce.”[3] He recommends putting more effort into learning and less effort into “managing carrots and sticks.”[4]
Indeed, health care systems that have improved quality and timely access have built the administrative and clinical capacity needed to spread and scale innovations methodically and systematically.[5]
Canada has been slow to develop its health care improvement infrastructure. It has evolved differently across the country, often without legislation to drive system improvement. The 2004-2014 Health Accord supported many promising pilot projects across the country, but most provinces failed to sustain and spread the local initiatives that showed great promise at reducing wait times. There is currently no national organization responsible for evaluating, spreading, and coordinating provincial efforts to reduce waits. The Health Council of Canada, which operated from 2003 to 2014, was established to support federal and provincial coordination, spread improvement initiatives, and provide public accountability. However, it lacked independence from government and the ability to hold provinces accountable through national standards.[6] There is currently no federal leadership supporting provinces to increase their health system improvement expertise and capabilities.
Canada has been slow to develop its health care improvement infrastructure
Andrew Longhusrt
Scaling up promising practices often falls to provincial ministries of health, health authorities, and quality councils. Quality improvement organizations (often called “quality councils”) have been established in many provinces. These organizations vary significantly across the country in terms of their mandates and ability to move from micro-improvement projects to system-level change—or in other words, to simultaneously drive change with frontline clinicians and with senior leadership.[7]
In Canada, Health Quality Ontario provides one of the best examples of an organization supporting system-level improvement. However, most provincial improvement organizations aren’t empowered by legislation. This severely limits their independence and ability to lead improvement and require cooperation from government and health authorities. Canada should look to build its health system learning and improvement infrastructure based on the internationally recognized Healthcare Improvement Scotland, which supports system-wide learning and improvement in the Scottish National Health Service.[8]
[1] Begin et al., 2009.
[2] Postl, 2006, p. 11-14.
[3] Berwick, 2016, p. 1329.
[4] Ibid.
[5] McDermott et al., 2015, pp. 273-284; Ham, 2016; Dayan and Edwards, 2017; NHS Scotland and Institute for Healthcare Improvement, 2018.
[6] Healthy Debate, 2011.
[7] Contrast with Scotland’s approach in Dayan and Edwards (2017).
[8] Dayan & Edwards, 2017; McDermott et al., 2015; Milligan et al., 2018, pp. 33-34.
