Identify leaders in healthcare performance and quality improvement in Canada; .... In order to mitigate data challenges,
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National Health Leadership Survey on Performance and Quality Improv Improvement Conducted by PricewaterhouseCoopers for the Canadian Health Services Research Foundation Final Report January, 2011
Contents Executive Summary
2
Approach and Methodology
3
Key Findings
4
Conclusion
9
Appendix 1: Interview Guide
10
Appendix 2: Themed Responses by Question
11
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Executive Summary Canada spends more than $190 billion annually on healthcare, and healthcare expenditures are rising faster than overall economic growth. At the same time, there is an expectation for increasing demand for healthcare services among the aging baby-boom generation, a shift in focus to person-centred care, a renewed emphasis on patient safety, and ongoing public concerns about wait times and access. These trends, among others, are contributing to greater scrutiny of health system performance and growing concerns about the sustainability of Canada’s universal healthcare system. As a result, there is heightened pressure to identify ways to deliver high quality healthcare in a more cost-effective manner. PricewaterhouseCoopers (PwC) was retained by the Canadian Health Services Research Foundation (CHSRF) to conduct a National Health Leadership Survey on Performance and Quality Improvement to: • • • •
Understand what Health Leaders are thinking; Identify leaders in healthcare performance and quality improvement in Canada; Establish a channel for continued engagement with Health Leaders; and Gather insights for use in CHSRF’s programs and events.
Interviews were conducted with 53 Health Leaders from across Canada representing hospitals, regional health authorities, quality councils and government. Below are the key findings, which provide insight into the current status of and opportunities for Canada’s quality agenda: • • • • • • •
Pockets of leadership exist across Canada; Knowledge transfer and physician engagement are required to advance the quality agenda; A “culture of quality” is needed at the individual, institutional, provincial and national levels; There is a need to measure and report on performance and quality outcomes; There was agreement on the use of public reporting as an incentive to improve quality and performance, but mixed opinions on the use of personal incentives to advance the quality agenda; and There is a need to identify external enablers and infrastructure to facilitate the quality agenda.
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Approach and Methodology PwC used a structured interview approach to collect the necessary qualitative data for the project. CHSRF developed email invitation text and an interview guide (see Appendix 1) which were reviewed by PwC, resulting in minor revisions to these documents. PwC also developed an analysis plan to describe how information would be collected, aggregated and themed, which CHSRF approved. PwC submitted the invitation text, interview guide, and analysis plan to Institutional Review Board (IRB) Services for ethics review, which granted approval after making minor revisions to some of the text to improve clarity. In order to select interviewees, CHSRF developed a list of 77 national Health Leaders who were invited to participate. The President of CHSRF sent the invitation to underscore the importance and urgency CHSRF placed on the project. PwC followed up with each invitee to schedule one-on-one interviews. Up to five attempts were made to encourage participation and schedule the interviews, with a specific goal of achieving representation of Health Leaders from across Canada. Although few invitees refused participation (two), some were not able to participate due to scheduling conflicts. PwC conducted all interviews in English and French by telephone or inperson during the period of July 26 through to October 27, 2010. Grounded Theory1 principles were used to analyze the interview data (see Figure 1). Grounded Theory1 is a systematic methodology that involves generating theories from data during the research process. Data are collected, reviewed, coded and subsequently re-visited if new themes emerge during additional data collection. This process continues until a point is reached where no new themes emerge. The data collection and analysis plan comprised three phases of interviews and analyses. PwC de-identified all responses to protect respondent confidentiality. These inductive steps were used to analyze the interview data, develop themes or categories, and revise the interview guide or probing questions to reflect the analysis in order to gain deeper insights in subsequent interviews. Interviews included closed and open-ended questions. Data interpretation was guided by identifying key themes. Minor revisions were made to the interview guide after nine interviews were completed (phase 1), and these revisions were submitted to IRB and received approval. Figure 1: Grounded Theory Analysis Approach
Potential Interview Pool N = 77
Conduct 9 Interviews
Analyze Interview Themes Revise questions if necessary Conduct 20 Interviews
Analyze Interview Themes Revise questions if necessary Conduct 24 Interviews
Analyze Interview Themes
1 Glaser BG, Strauss A. Discovery of Grounded Theory. Strategies for Qualitative Research. Sociology Press, 1967
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Key Findings Participant Profile The following table indicates the number of Health Leaders invited from each province and the actual participation rate. The highest proportions of participants were from Ontario, followed by Quebec.
Province
Number Invited
Interviews Completed
Participant / Invited (by Province)
Number Interviews Completed (by province) / Total Interviews
Ontario
15
14
93%
26%
Quebec
13
9
69%
17%
British Columbia
7
5
71%
9%
Alberta
8
3
38%
6%
Manitoba
6
5
83%
9%
Saskatchewan
5
3
60%
6%
Nova Scotia
7
4
57%
8%
New Brunswick
3
2
67%
4%
4
3
75%
6%
PEI
3
1
33%
2%
Territories
5
3
60%
6%
National
1
1
100%
2%
Total
77
53
Newfoundland / Labrador.
69%
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The following table shows the distribution of participants by type of organization. Twenty-five representatives from Regional Health Authorities (47.2%) responded and comprised the largest group, followed by 15 hospital representatives (28.3%).
Regional Health Authority 25
Hospital
Quality Council
Government
15
5
4
Professional 2
Association 3
The Existence of Pockets of Leadership and the Need for Knowledge Transfer and Physician Engagement Interviewees were asked to identify who they felt (both organizations and individuals) provided leadership defining, enabling, and/or delivery performance and quality improvement in healthcare at the provincial/territorial and/or national levels. The responses suggest that there are pockets of leadership in healthcare quality improvement throughout Canada. Examples included provincial health quality councils, the Canadian Patient Safety Institute, Accreditation Canada, Canadian Institute for Health information, l’Institut national d’excellence en santé et en services sociaux (INESSS), the Canadian Health Services Research Foundation, selected regional health authorities, and individual hospitals where quality improvement initiatives have taken a prominent role (see Appendix 2 for details of organizations and individuals receiving multiple mentions). Perhaps it is expected, and even desirable, to have distributed resources that are dedicated to improving healthcare services delivery (locally, regionally, nationally). The inculcation of a quality culture may be facilitated better when more individuals and agencies are supporting performance and quality improvement. Although interviewees acknowledged these pockets of leadership exist, they saw a challenge transferring and translating the knowledge from these sources into behavioural and practice changes that can be adapted at the individual, institutional, provincial and national levels. It is difficult to make progress on the quality agenda if consensus on the criteria for quality is lacking, if different performance metrics are used, or if strategies for adoption and implementation are not articulated clearly. The Health Leaders suggested that another barrier to implementing quality improvement initiatives is an absence of consistent leadership (at all levels) with a defined focus on and commitment to quality. At the institutional level, some interviewees questioned the role and perceived limited involvement of Boards of Directors; these individuals argued that some Boards appear to be disengaged from providing a vision and setting expectations for quality and performance. They felt that quality improvement initiatives are being managed “off the side of the desk” in some institutions, which demonstrates a failure in senior leadership’s commitment to quality. Many interviewees commented that quality improvement initiatives often lack a standardized and consistent approach and many organizations are perceived to be working independently. Although individual organizations can still improve quality by working independently, respondents felt that collaboration across organizations enhances efficiencies, the sharing of best practices, and reduces duplication of effort for the mutual benefit of providers. Additionally, limited physician engagement and physician champions for quality improvement were cited as challenges to achieving improvements in quality. Interviewees suggested that physicians had to be engaged and invested in the dialogue early in the process in order to build buy-in from this critical stakeholder group and facilitate adoption and implementation of the quality agenda. Several noted that a lack of capacity in terms of both resources and skills was another barrier to the success of quality improvement initiatives. For example, some suggested that an absence of knowledge translation of best practices and limited training in process improvement (i.e. LEAN techniques) were inhibitors to quality improvement. Some stated that there simply are not enough professionals with healthcare quality and process
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improvement skills to meet the demand, so consultants are brought in to implement changes. The use of consultants was seen as an inferior solution to in-house resources, because process changes are difficult to sustain after the hired experts have completed their work and leave the organization to pursue other engagements.
The Need to Adopt a “Culture of Quality” Interviewees were asked their opinions concerning challenges to advancing quality and performance improvement and what could be done to overcome these challenges. Health Leaders indicated that the current culture in healthcare organizations have failed to fully (or even partially) embrace quality and that solutions to this issue need to start at the top of an organization, with leadership (Boards of Directors, CEOs) setting the example that would cascade down, and permeate staff goals and objectives and delivery expectations. They felt strongly that a culture that embraces safety, efficiency and continuous quality improvement has to be embedded and integrated into the day-to-day business of the healthcare setting. Interviewees also discussed the need for change management strategies to facilitate the transition to a culture of quality. Moving front-line staff through the phases of change (from being informed, to educated, to fully committed) can only be accomplished with the appropriate resources and focus required to alter long-standing behaviours. Some Health Leaders commented that they have taken very deliberate steps to change the culture of their organizations by bringing in U.S. consultants focused specifically on this task. Attracting and recruiting staff with the knowledge and skills needed for change is another key element of change management voiced during the interviews. Linking quality to position descriptions would be an important step to creating a culture of quality and performance expectations. Many interviewees suggested that the public is a critical stakeholder and should be included in the quality improvement discussion, in response to the current dialogue on person-centred care. These respondents felt that the public is a key change agent to help drive quality in healthcare. A frequently mentioned example was “For Patients’ Sake.” the Patient First Review Commissioner’s Report in Saskatchewan.
Measurement and Reporting on Quality Indicators Health Leaders participating in the interviews suggested there is an urgent need for clear, evidence-informed measurement strategies and tools. Again, they noted that different metrics are employed across institutions, which seriously limits inter-institutional and inter-jurisdictional comparisons. Furthermore, the absence of common definitions and tools to measure quality indicators jeopardizes planning to improve healthcare delivery. Interviewees also noted the lack of consensus and difficulty in determining which indicators are most beneficial for tracking and reporting. Indicators, targets, and benchmarks utilized for comparisons were felt to be inconsistent across organizations, and therefore make direct comparisons difficult. One example of this challenge is the application of measurement and reporting frameworks that assess hospital performance. Currently, hospital performance assessment is being done in some provinces, such as through the Ontario Wait Times Strategy, but this does not permit comparisons to hospitals in other provinces. Some Health Leaders interviewed also expressed little confidence in the current data that are being collected, and some worried that there has been inappropriate analysis and interpretation of some of the data that have been used to guide decision-making regarding which services are to be delivered and how services are to be delivered. Interviewees discussed the need for a “level playing field,” where organizations are compared to one another, in which the metrics reported are standardized across organizations. In order to mitigate data challenges, interviewees stressed the importance of aligning indicators across organizations and systems. Some argued there is a need to increase internal and public reporting and evaluation, and include quality and cost data in accountability frameworks—they believe public accountability enables all of the players in the health system to understand their relative rankings and facilitates decisions about what gaps exist and priorities for change. In addition, some argued that public accountability enables the public to make informed choices about what levels of health services they can expect from their local healthcare institutions. This empowering of the patient can be seen in the U.S., where hospital performance reporting allows patients to select which institution they would like to visit, and encourages hospitals to perform to gain patients and earn the associated insurance payments.
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Some indicated that the lack of a common definition of “quality healthcare” was an obstacle to moving forward. However, the failure to develop a common definition, indicators and data collection and interpretation tools should not preclude initiatives to improve the quality of healthcare. There is growing expectation that healthcare must be safe, efficient and effective. Consequently, some of the Health Leaders indicated that quality improvement must press forward at the institutional, regional, provincial and national levels, alongside discussion and debate that leads to greater consensus on the quality agenda.
Incentives Interviewees were asked whether incentives are needed to enable healthcare performance and quality improvement. Positive incentives discussed included financial reimbursement (both at the individual and organizational level), awards for quality achievement, peer-recognition initiatives, career development opportunities (e.g. additional training and education) and increased resources. Examples of negative incentives included the publication of poor performance compared to peers and the withdrawal of funding if targets are not met. There were mixed views on the role of incentives to shape the uptake of a quality agenda, and whether incentives should be “carrots, sticks, or both.” For example, there was strong support for public reporting / peer comparisons; the majority of interviewees felt reporting stimulates practice change because it publicizes performance and motivates organizations and staff to improve. Some Health Leaders interviewed, however, expressed concern over public reporting frameworks, such as the possibility that institutions manipulate data to show positive outcomes. It was felt this challenge could be avoided by using standardized data collection and analysis processes (as discussed above) for transparency and fairness. Interviewees were also asked to comment on financial incentives to senior executives and their perception of the efficacy of these to change culture and behaviour. Responses were mixed. Some felt this could help bring about change and adoption of quality at a faster pace. Others felt that incentives to senior executives to meet quality standards miss the point, as illustrated by the statement: “Personal incentives are like paying people extra for doing their job.” The accuracy and precision of data collection (and previously mentioned potential for data manipulation) was also seen as a barrier to the acceptance of personal incentives for senior executives. Another concern expressed was the potential misalignment of incentives in which institutions or individuals are reimbursed for volume (quantity) rather than quality of care.
External Enablers to Facilitate the Quality Agenda Interviewees were asked about the state of enabling infrastructure to support quality and performance improvement within Canada. Many of the Health Leaders interviewed felt there was insufficient support in Canada to facilitate a quality agenda, and that current organizations contributing to this enabling infrastructure lack a cohesive, common vision of quality. In the absence of adequate infrastructure, organizations that are currently supporting quality and performance improvement have significant opportunities to work in a more coordinated manner, and to look at strategies to shore up jurisdictions within Canada that are struggling to imbed quality improvement programs. Leaders from less populated provinces and territories noted inequities across the country, with more populated provinces having quality councils and other enabling infrastructure that they lacked. Interviewees were also asked about the need for a national organization or consortium of organizations to support quality and performance improvement. Some felt that some type of national body is required to coordinate provincial resources and provide the necessary leadership to create policies that support an efficient, evidence-informed, pan-Canadian quality agenda. Some believed a national initiative that includes oversight, shared provincial participation in governance, and mechanisms to identify innovation and assess the evidence to facilitate quality improvement is required. As mentioned previously, some leaders indicated that organizations, such as quality councils, present different perspectives on quality. These differences may be interpreted as inconsistent interpretations of quality improvement policies and strategies, and thereby contribute to confusion about how to address quality control and improvement, which a national coordinating entity could help direct.
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Some interviewees favoured a consortium approach with provincial and territorial representation, reflecting Canada’s regional approach to funding healthcare. Others believed that rather than investing more resources in the creation of a new national entity, it would be more beneficial and efficient to leverage existing infrastructure to incorporate modules from proven initiatives in other jurisdictions. Many Health Leaders expend resources to receive consulting support from external agencies, such as the Institute for Health Improvement in the United States (an annualized range of $12,500 to almost $3,400,000, with an average of approximately $600,000, was reported). Considerable efforts are being made to obtain information to bolster quality improvement program planning, policy, implementation, and evaluation from Canadian (CHSRF was mentioned most often) and non-Canadian (IHI was mentioned most often) organizations and agencies. While the level of investment in consulting and training varied (based on institutional budgets), Health Leaders described the importance of leveraging expertise and experience from others inside and outside the health system.
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Conclusion CHSRF’s National Health Leadership Survey on Performance and Quality Improvement provides critical insights and lessons for the future of the healthcare quality agenda in Canada. The country has leaders in quality and performance improvement working diligently and effectively in each province; however, in order to optimize this expertise, there is a need to share information and evidence to support the implementation of initiatives on the front lines of healthcare delivery that will have a direct impact on patient care. The successful adoption of quality and performance improvement initiatives is also predicated on effectively engaging physicians throughout the process to gain their support and adoption. Based on the interviews with Health Leaders, if Canada’s quality agenda is to gain momentum, two important barriers must be addressed: 1) the need to effectively transform the culture of healthcare organizations to one that actively embraces change and innovation, and is therefore ready to adopt new ways to deliver healthcare that is safe, efficient and effective; and 2) the need to establish universal measurement and reporting systems to report on quality outcomes that have integrity and agreement among healthcare leaders and front-line staff. If these challenges can be addressed, they will become enablers of rather than barriers to quality and performance improvement. A comprehensive change management strategy would be necessary to begin the difficult task of transforming the culture of healthcare organizations, which could be led nationally, and implemented locally. While views differed on the need for a national organization or consortium to lead the quality agenda in Canada, the majority of interviewees felt healthcare organizations need assistance to implement quality improvement initiatives. In larger provinces, organizations that support quality improvement are being created, but that is not the case in less populated provinces and territories, and should be addressed. If some type of national consortium could be defined, interviewees suggested its governance might include provincial representation and stakeholders, including the public. They would discuss and debate the evidence on initiatives to improve quality, help identify opportunities for policy, contribute data for national surveillance, and facilitate monitoring and reporting to demonstrate accountability. Overall, Health Leaders participating in the interviews felt that a cohesive, comprehensive national approach to healthcare performance and quality improvement would be beneficial to Canadians. It would allow for the current enabling infrastructure to organize around national objectives and priorities, while gaining efficiencies through a more strategic and collaborative approach to the quality agenda.
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Appendix 1: Interview Guide 1.
In your province, who are leaders in quality and performance improvement (both organizations and individuals)?
2. Nationally, who are leaders in quality and performance improvement (both organizations and individuals)? 3. What specific initiatives are positively driving quality and performance improvement? Who is leading these initiatives? 4. What are the challenges to quality and performance improvement in your sector and what could be done to overcome these challenges? 5.
What is the best way to accelerate healthcare quality and performance improvement in your sector?
6. Are incentives needed to enable healthcare performance and quality improvement? If yes, what type? 7.
Approximately how much money would you have spent in the last two years on external professional services to improve quality and performance?
8. Have you used the consulting or training services of the US Institute for Health Improvement, or other US consultants? 9. Where do you go to learn about quality and performance improvement? 10. Does Canada have sufficient enabling infrastructure to support delivery organizations in quality and performance improvements? What type of governance structure would be needed to ensure sectoral support? 11. Which organizations are contributing to this enabling infrastructure in your province? 12. Does Canada need a national organization or consortium of organizations to support quality and performance improvement, similar to the Institute for Innovation and Improvement in the UK or the Institute for Health Improvement in the US? 12b. If yes, who should fund such a pan-Canadian organization or consortium of organizations? 12c. How should funding be structured if more than one source?
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Appendix 2: Themed Responses by Question
11
Question: In your province and nationally, who are leaders in quality and performance improvement (individuals)?
12
Question: In your province and nationally, who are leaders in quality and performance improvement (organizations)?
13
What specific initiatives are positively driving quality and performance improvement? Who is leading these initiatives?
Canadian Patient Safety Institute (CPSI) • • •
Safer Healthcare Now! Governance for patient safety Hand Hygiene
Accreditation of healthcare organizations by Accreditation Canada
Performance reporting (Ontario performance reporting / peer comparisons — Michael Baker)
Government legislation , such as: • •
Ontario’s Excellent Care for All Act Quebec legislating health organizations invest in quality (passed in 2007)
Patient First Review, For Patients’ Sake— Saskatchewan — Tony Dagnone
Institute for Clinical Evaluative Sciences (ICES) — reporting on variations in clinical practice across Ontario
Ontario Wait Times Strategy
National Paediatric Surgical Wait Times Initiative — Hospital for Sick Children
Alberta - program to formalize patient safety education — John Cowell
Hospital scorecards — Canadian Patient Safety Institute and Canadian Institute for Health Information
Releasing Time to Care: The Productive Ward — NHS Institute for Innovation and Improvement, Dan Florizone leading in Saskatchewan
General concepts mentioned • •
More active role by boards of directors in driving quality and performance improvement LEAN movement
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What are the challenges to quality and performance improvement in your sector?
Lack of leadership and focus on quality, competing priorities and management of quality initiatives “off the side of the desk”
Many organizations are trying to work on quality improvement, but all are doing their own thing
Culture of healthcare organizations / difficulty to change
Poor data / information and reporting
Lack of skills (intellectual, LEAN, process mapping)
Lack of clarity as to which indicators to track and/or benchmarks and targets
Lack of capacity / resources
No clear definition of quality
Physicians operate outside of the system • • • •
Misalignment between physician and hospital funding Not driving quality agenda even though they should Need to be engaged Need champions
Boards not engaged and not providing vision for organizations, do not understand front line
Perception of lack of money, there is enough, but we have to be smarter with how resources are used
Misalignment of incentives to pay by volume not quality
Lack of funding for post acute care / quality is focused on acute care, not community care
Knowledge translation of best practices
Health human resources; turnover of staff in the North, don't have consistent people to move
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What could be done to overcome these challenges?
Leadership to allow focus: • • •
Government leadership (e.g. Ontario ECFAA, Quebec legislation) Boards Senior and middle management
Accountability framework: • • • • •
Agreements Right people at the table Reporting and evaluation (internal and public) Must have data (quality and cost) Develop national benchmarks that reduce unwarranted variance
Funding for programs to enhance quality
Change culture / change management skills
Focus and coordination: work nationally on 3 or 4 initiatives that need to be improved
Person-centred: patients and public need to be engaged, every other business talks to customers
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Are incentives needed to enable healthcare performance and quality improvement? If yes, what type?
Strong support for public reporting / peer comparisons
Some support for additional resources for programs (volume) / infrastructure etc. •
Incentives to do extra work — don't like as it shows you are not funding at the right level
Support for incentives to senior executives was mixed: • • • • •
More participants did not support incentives to senior executives Some do not support at all, others suggested both carrots and sticks Must be careful how this is done, but could be helpful — the wrong incentives can be detrimental Personal incentives are like paying people extra for doing their job and don't change culture Uncomfortable with personal incentives — can turn into a game and risk of manipulation
For those who did articulate support for an incentive-based approach, they must be aligned with goals and the desired change
Need incentives for family physicians / other physicians for lasting change
Education and/or training could be an incentive and lever for driving change
Cannot be punitive if mistakes are made
Cannot incent CEOs to achieve quality metrics, when they cannot control physician practice, but can incent them to put the right system in place
Show that the work is resulting in positive change to motivate staff
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Approximately how much money would you have spent in the last two years on external professional services to improve quality and performance?
Many organizations did not spend any funds on external professional services
There were 28 participants that indicated they did spend money on external professional services. Over two years, the following statistics were calculated: • • •
Minimum: $25,000 Maximum: $6,720,000 Average: $1,227,500
The type of work solicited from external consultants included: • • • • • •
LEAN / process improvement / patient flow Purchase of additional tools or courses for medical leaders Kaplan / Norton balanced scorecard work Change management Review of hospital programs or quality programs (infection control, laboratory, adverse events) Institute for Health Improvement (IHI) consultants
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Have you used the consulting or training services of the US Institute for Health Improvement, or other US consultants?
Approximately half of interview participants have sent staff to IHI events and courses
Many also attended courses and conferences in Boston, or events that were conducted by IHI in Canada
Approximately one in five participants had not used the consulting or training services of IHI
Participants reporting using other US-based consultants, including: • • • •
McKinsey Deloitte & Touche Studer Group (for change management services) Sullivan Group (for operating room benchmarking)
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Where do you go to learn about quality and performance improvement?
Most participants indicated multiple sources for learning about quality and performance improvement, with the Institute for Health Improvement (IHI) being the predominant source for over half of participants
The chart below lists the sources and number of mentions for sources mentioned more than once
Sources
Mentions
Institute for Health Improvement (IHI)
27
Canadian Health Services Research Foundation (CHSRF)
6
Canadian Patient Safety Institute (CPSI)
5
Accreditation Canada
4
Resources internal to their organization
4
Institute for Strategy and Competitiveness - Harvard University - Michael Porter's course Peer reviewed literature
3 3
Canadian Institute for Health Information (CIHI)
3
Canadian College of Health Service Executives (CCHSE)
3
National Institute for Health and Clinical Excellence (NICE)
3
BC Patient Safety and Quality Council
3
Canadian Agency for Drug Technology and Health (CADTH)
3
National Health Service (NHS) Academic Health Centres
2
Other industries (aviation, aerospace, automotive, home depot, grocery)
2
Kaiser Permanente
2
Networking with people
2
Health Quality Council Saskatchewan sponsored events
2
Institute for Clinical Evaluative Sciences (ICES)
2
Inter-Mountain Health
2
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Does Canada have sufficient enabling infrastructure to support delivery organizations in quality and performance improvements?
The most frequent response was that Canada does not currently have sufficient enabling infrastructure
Some participants felt enabling infrastructure was sufficient •
Some felt that, although there was enough infrastructure, the organizations supporting quality and performance improvement had significant opportunities for improvement, especially operating in a more coordinated manner - An example of this was the notion that the quality councils from across the country often have different approaches to their mandates
There were regional differences in response to this question, with some feeling that there were disparities from province to province with a need in Atlantic Canada for more support
Both participants from smaller provinces and large academic hospitals from all provinces agreed that large institutions were well supported
What type of governance structure would be needed to ensure sectoral support (of enabling infrastructure)?
Responses were mixed
Of those that did respond (approximately one in four), the following were the major themes: •
There should be a national body to coordinate provincial resources to ensure there is an efficient approach to quality and performance improvement - A strategic national agenda is missing - There is a need for a pan-Canadian policy that is aligned with funding
Provinces should create a consortium of collaborating organizations in order to share experiences
A joint governance structure is needed that has all provincial ministries and ministers at the table to agree on what is important to focus on
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Which organizations are contributing to enabling infrastructure in your province?
22
Does Canada need a national organization or consortium of organizations to support quality and performance improvement, similar to the Institute for Innovation and Improvement in the UK or the Institute for Health Improvement in the US?
There was not universal support for a national organization or consortium to support quality and performance improvement
The predominant response to this question was that a consortium of provincial organizations would be the best approach
•
The major rationale for this approach was the provincial nature of healthcare funding in Canada and federal / provincial politics could be a barrier to a single national organization
•
It was noted that the various Health Quality Councils in Canada already meet twice annually
There were also significant comments relating to the Canadian Patient Safety Institute (CPSI) and its national role •
Approximately one in five thought that CPSI could play the role of a national quality and performance improvement organization that could provide coordination across provinces
•
A few commented that CPSI was formed to play this role, while others thought their mandate was more patient safety, which was only a component of quality
•
Similarly, a few participants commented that the Health Council of Canada should / has been playing this role
For those that supported a national organization or consortium, the following roles and/or functions were suggested: • • • •
Developing a national strategy and agenda for quality and performance improvement Collecting and reporting of data Education / knowledge translation Research
Some participants did not believe this type of organization was necessary, citing: • • •
The provincial nature of healthcare There are already numerous organizations focusing on quality The fact that there already are consortiums such as between Accreditation Canada, CPSI, and the Health Quality Councils
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If yes, who should fund such a pan-Canadian organization or consortium of organizations? How should funding be structured if more than one source?
For those who supported a national organization or consortium, the predominant response was a federal–provincial sharing of funding
Other thoughts by participants included: • •
Funding should be completely federal Building on the Institute for Health Improvement’s funding model: - Health provider organizations should contribute money so they have some “skin in the game” (could be fee for services / consulting model) • In contrast, some thought health provider organizations did not have funds to contribute - Private funding could be used, but should be careful to avoid conflicts
Structure of funding •
Cost sharing among provinces based on population - Suggestion of 30% provincial funding and 70% fee for services
•
Provincial ministries of health need to work out how to share cost
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