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Presentations, Questions & Ministerial Address

Day 1: Thursday, March 24, 2011

Keynote Address: How to Turn Ideas into Action

Transforming a Northern Health System

Case Studies on Improving Access in Canadian Northern & Rural Communities

Address from the Federal Minister of Health

Turning Ideas into Action: Engaging Providers -- The Saskatchewan Experience

Small Discussion Groups

Turning Ideas into Action: Patient Engagement in Transforming Health Systems

Summary of Day 1

Presentations & Questions – Day 2: Friday, March 25, 2011

Keynote Address: How to Turn Ideas into Action

Sasha Karakusevic, South Devon Health Community, U.K.

In his roles as Director of Strategy for South Devon (U.K.) Health Community and Director Health Innovation Education Cluster (South West U.K.), Dr. Sasha Karakusevic has experienced the impact of a number of changes to health policy.

The keynote address focused on the need to secure public trust in the health system to enable further improvement and offered that addressing the wait times experience is a good place to start.

The thesis presented by Dr. Karakusevic is that to build public trust, the delivery of health services needs to be transformed in such a way that delays are “taken away.” The task of transformation, according to Dr. Karakusevic, involves drawing lessons from the approaches used successfully by businesses to engage people.

Dr. Karakusevic shared that in the 1990s the average wait for health services in the U.K. was 80 days; when wait times climbed to 110 days, political concern triggered direction to change the system. He reviewed strategies put in place to support policies to address wait times for health services.

One of the strategies involved government funding support for innovations. Other strategies included reallocation of existing resources -- the South Devon health community removed 200 beds from the health system, enabling investment in other services.

He focused on the analysis of the effectiveness of the strategies.

His conclusion is that the following specific processes and structures underpin successful strategies:

  • Re-frame delivery of health services to focus on and support the patient as a customer;
  • Expect significant outcomes only in the medium- and long terms;
  • Adopt a systems approach, balancing the interests of various providers, the values of the community and a long-term vision;
  • Seek out and strive for world-class standards -- the standards should not only be used as a basis for comparison, but as a learning tool; learn from them and use the standards as a means to glean information and collaborate;
  • Focus data collection to generate insight on actions needed;
  • Measure to identify blockages to flow of patients;
  • Analyze data to determine patterns among waiting patients;
  • Follow-up on outliers;
  • Encourage discussion among teams to discuss data as well as the results of data analysis;
  • Involve senior decision-makers;
  • Be specific about the gain(s) to be made when proposing changes and new investments;
  • Recognize the importance of clinician-to-clinician relationships;
  • Enable team-based work, including all services/providers needed to support the patient; and
  • Support engagement of clinicians and patients through ongoing education, training, and coaching.

The presentation summarized specific innovations related to the introduction of a national booking system to identify the first available service, including collaborative design of care pathways (which reduced the need for beds by over 280) across the South West Region in delivery of hip/knee replacement surgery and care.

In response to a question about the decision-making processes in the National Health Service (NHS), Dr. Karakusevic advised that the process is fast-paced and needs to secure the accountability of decision-makers.
Based on his experiences, Dr. Karakusevic described himself as optimistic about the future accessibility of health services.

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Transforming a Northern Health System

Donna Galbreath & Douglas Eby, Southcentral Foundation, Alaska, U.S.A. 

In their presentation on the Southcentral Foundation in Alaska, Dr. Donna Galbreath and Dr. Douglas Eby spoke of the radical transformation they achieved from rethinking the platform on which the health system is based.

Central to this transformation was the introduction of the ‘customer-owner’ concept in which the patient is an active and equal partner with the health team.

The presentation by Drs Galbraith and Eby included demographic information about the Southcentral Foundation client base, including:

  • 140,000 statewide clients;
  • 55,000 local clients including 10,000 in over 50 remote villages; and
  • Expanding local population (7%/yr).

Ninety per cent of the determinants of chronic conditions are in the control of the individual.

In acknowledgement of this, health planners and practitioners must change the manner in which they practice to position the patient as the owner of their health and healthcare. He stressed that primary care providers have the greatest potential to effect change.

Dr. Eby noted that Canada continues to tweak the health system, when what is really needed is an entirely new approach based on a social platform focused on primary care. He likened the Canadian approach to using a car to do the work of an airplane or bus.

It was noted that 70 per cent of the money and 80 per cent of people are on the low acuity side of health care, yet the majority of dollars and attention are spent on the high acuity side of the system (tertiary care).

The success in Alaska came from refocusing; this included a complete retooling of what it means to be a primary care physician in the system. Dr. Eby noted that this transformation was realized with no injection of new monies.

The presentation was followed by a question and answer session which brought forward additional information on the Alaska experience.

They first clarified that the services in this model are delivered in small villages. The team works directly as well as via email, phone and telehealth with patient customers in remote/rural sites.

Another participant questioned whether this transformation occurred with a unionized environment. The workforce was not unionized in Southcentral Foundation but this did not eliminate the need to spend a lot of time listening to staff and their issues or concerns.

The final point of discussion focused on the role of queuing theory in this transformation. Dr. Eby emphasized that queuing is not the sole answer: “We must fix the problem and not the queue,” he said.

During the question period, a comparison was offered from the audience of the situation in the South Devon (U.K.) Health Community and the experience at the Southcentral Foundation in Alaska. It was noted that both had:

  • focused on the patient/customer;
  • emphasized community;
  • enabled innovation along the entire change management process; and
  • provided education, training and coaching for providers.

In response to a question about staff buy-in, Dr. Eby advised that staff need time to talk about change and how new ideas and approaches link to working with patients.

He advised that the conversations with staff never end; each new hire needs time to talk about the system and approach used at the Foundation.

In addition, the Foundation monitors performance data and coaches staff when necessary about the operational values of the Foundation.

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Case Studies on Improving Access in Canadian Northern & Rural Communities

Dr. Geoff Smith, Dr. Alexander Macdonald, and Dr. Ruth Vander Stelt each presented initiatives put in place to deal with waitlists. Relocation of services was the approach used in two of the three presentations. All three presentations spoke to collaboration among clinicians and team-based efforts.

Dr. Geoff Smith

Dr. Smith stated that pediatric dentistry has the longest wait time compared to other procedures across the country. For children living in remote areas of Newfoundland and Labrador, the issue was two-year waits for dental procedures requiring anaesthesia.

A second issue related to the need for the children to travel to St. John’s for the procedures.

Dr. Smith proposed a program – Operation Tooth -- which involved dentists travelling to remote regions and using locally based hospital facilities.

The program involved collaboration among the dental profession, surgeons, government planners, as well as administrators in each of the four Regional Health Authorities.

The location of the first clinic was chosen based on analysis of the waitlist to identify the most urgent cases.

Through Operation Tooth, the lengthy waitlists for pediatric dental procedures in the province have been addressed, and 80 per cent of cases are now addressed within 90 days.

Dr. Smith reported high satisfaction with the program among patients and their parents.

Dr. Alexander Macdonald

Dr. Macdonald shared the results of two initiatives implemented in Nunavut to accelerate access to tertiary care and to orthopaedic surgery.

Dr. Macdonald reminded the audience of the expansive geography of Nunavut as well as the cultural diversity of the people living there.

Similar to the thinking behind Operation Tooth, the first initiative was about bringing care to patients. The idea was spearheaded by a Licensed Practical Nurse and an orthopaedic surgeon.

It relied on a team of three retired surgeons travelling to health centres in small communities which are staffed by Nurse Practitioners and Registered Nurses.

The initiative produced positive system outcomes (waits for orthopaedic surgery have been reduced by six to 12 months), as well as cost savings.

The second initiative brought air ambulance services closer to the patient population.

Prior to the initiative, air ambulance support for critically ill people in Nunavut came from Montreal, requiring up to 16 hours of emergency care to stabilize patients before they had access to necessary care.

Based on reviews of past cases and expert advice, the government of Nunavut located a jet and medical team in Iqaluit. This initiative has facilitated timely access to health care.

Dr. Macdonald underscored that the success of both initiatives was dependent on having physicians who are willing to travel to provide care.

Ruth Vander Stelt

Dr. Ruth Vander Stelt described an initiative in the west Quebec community of Pontiac to address the backlog of people waiting to see a physician.

The initiative was triggered by a needs analysis which showed that:

  • local family physicians were not taking new patients; and
  • patients were using the emergency department (ED) to deal with primary care issues because they (patients) did not have a family doctor.

Three physicians analyzed the needs of people presenting at the ED. For the most urgent cases, the three negotiated with their colleagues to have the patient added to their roster.

The patients with less urgent needs were sent to a once-a-week ‘transition clinic’, staffed by local physicians and aimed at assigning each patient to a family physician.

The creation of the clinic did not require any new funding; it was staffed by local family physicians who stepped up to coordinate their efforts and address the needs of patients who had been using the ED for their health care.

Several benefits of the initiative were described in the presentation: within one year, 95 per cent of patients were assigned a family physician; visits to the ED by users of the clinic declined by 68 per cent; and satisfaction levels of both providers and patients increased.

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Address from the Federal Minister of Health

The Honourable Leona Aglukkaq, Minister of Health

CMA President Dr. Jeff Turnbull introduced the Honourable Leona Aglukkaq, Minister of Health. He acknowledged the leadership of the federal government on the issue of wait-times.

She congratulated providers, facilities and governments for their efforts to improve access to care.

The Minister confirmed that in Budget 2010 the Government of Canada committed that the Canada Health Transfer will continue to increase, as planned, through 2013-14.

She also reviewed the investments of the federal government in the wait times guarantees, electronic health records and in human resource planning.

The Minister described the recent report from the Canadian Institute for Health Information that showed eight of 10 patients are experiencing waits within the range of the benchmarks as encouraging.

The Minister recognized the challenges of delivering health services in rural and remote regions. Her perspective is that people who have an opportunity to learn and work in remote areas are more likely to choose to practice in those areas.

Minister Aglukkaq spoke about the government’s recently announced supports for family medicine residencies in rural areas. She also referenced the proposal in the March 2011 federal budget for tuition reimbursements for nurses and doctors who practice in non-urban areas.

She stated that the federal government is working with provincial and territorial governments to find innovative ways to address health issues.

The Minister also reviewed a number of the elements included in the proposed March 2011 federal budget, including an anticipated $100M funding for brain research.

She also spoke about the renewal of the Canadian Cancer Control Strategy, including allocating $250 million over five years to help the Canadian Partnership for Cancer to focus on people in the North.

Minister Aglukkaq spoke about the initiatives of the federal government to foster healthy weights of the population, and among Aboriginal people in particular. She described proposed legislative changes to food labels to ensure that the language is easy to understand.

The Minister concluded her remarks by underscoring the importance of innovation to the health system. She described the Taming of the Queue conference as important to making the best innovative ideas a reality.

Dr. Turnbull thanked the Minister for her remarks.

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Turning Ideas into Action: Engaging Providers: The Saskatchewan Experience

This session involved two presentations and small group discussions about the importance of engaging providers in system transformation.

Saskatchewan offered the backdrop for both presentations with the first speaker focused on engaging physicians and the second on nurses and other health providers.

Dr. Martin Vogel

The premise of Dr. Vogel’s presentation is that strong physician leadership is common to high-performing systems. He made a distinction between ‘providing leadership’ and ‘leading’.

Dr. Vogel noted that leadership requires engagement, which relies on relationship-building, trust and commitment.  

PhysicianEngagementFramework

Leadership capacity and skills help to improve quality and patient safety. The Saskatchewan Medical Association plays a role in building physician leadership skills.

Dr. Vogel noted that ideas rarely move into action without passion.

He suggested that through both his passion and leadership, Dan Florizone, Health Deputy Minister in Saskatchewan, has enabled the adoption of innovative ideas and changes to the delivery of health services in that province.

Dr. Marlene Smadu

Dr. Smadu’s address focused on the valuable contributions of people working in the health system. She noted that the workforce in Saskatchewan numbers 40,000 people, who are all committed to providing the best care they can.

However, to optimize their performance and productivity, health workers need support and they need to be enabled to generate the necessary changes to make the system more effective.

This enabling requires trust and respect; it means showing people that they and their ideas are welcomed and valuable.

Dr. Smadu suggested that the results of the recent efforts of Dan Florizone, Health Deputy Minister, to engage the nursing workforce offer an illustration of the potential benefits of engaging staff.

Dr. Smadu talked about two initiatives that promote interprofessional collaboration to bring about transformation of the health system. She cited the decision in Saskatchewan to implement the Releasing Time to Care program, developed by the NHS Institute for Innovation and Improvement.

The program is a patient-centred approach to improving the quality of care and services by all clinicians. Releasing Time to Care is an initiative that supports innovation and problem-solving.

Her second example was the introduction by the Saskatchewan Union of Nurses (SUN) of the Patients and Families First Challenge, a vehicle to optimize quality care.

The Challenge encourages and supports patients, members of the public, patient advocacy groups, as well as SUN members to identify and test innovations that will improve patient-centred care.

Dan Florizone (commentary)

In his commentary, Dan Florizone suggested that there is ample evidence upon which to transform health care in Canada.

In answer to his own rhetorical question, - "So what is the problem?" - Mr. Florizone identified lack of engagement; hierarchy within the workforce; decision-making silos; and lack of clear responsibility for the whole of the patient journey.

He stressed that leadership at all levels is the key, but that leadership at the front line is of critical importance.

The need for passion was reinforced; passion is the "sweet spot," according to Mr. Florizone. He noted that Canada is at a fragile point in the transformation of the health system.

Developing a learning culture will generate passion and ideas to transform the system. The challenge, he commented, is maintaining persistence.

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Small Discussion Groups

TQ conference participants were seated in small groups to discuss three questions.

1. The first question was “Identify three ideas for engaging providers in improving access.” Responses included:

  • Need to ensure that all providers -- not just doctors and nurses -- are at the table from the beginning and participating with the mindset that they need to come with solutions, not just problems
  • Sharing patient stories of what is working well and what is not working well is powerful
  • Identify and empower leaders
  • Need for government to empower their workers
  • Offer providers an opportunity to process things at all times, not just a meeting once in a while
  • Need one passionate person who can engage many others

2. The second question, “Are there any potential barriers to these approaches and, if so, what are they?” produced the following responses from participants:

  • Physicians doubt they have been heard
  • Physicians doubt they will be heard; doctors have no power
  • Shortage of health professionals in rural/remote areas
  • Physicians see themselves as experts in many areas; they are not used to working in teams -- need to socialize them as such
  • Need for the right people at the right time to make the right decisions

3. The third question, “Now identify one actionable thing you could try when you return to your organization” elicited the following responses:

  • Provide incentives
  • Need to train physicians to manage systems, not just patients
  • Identify and coach leaders as part of a team – learning to lead together
  • Write a letter to the Council on Aging and Minister of Health about what was said here today -- that we should be the best in the world
  • Need to act not only in our professional practice, but also act politically as an individual by writing to our MPs and provincial politicians
  •  Bring the discussion to family practice meeting and talk about patients as experts on their own health
  • Embrace true patient-centeredness
  • Provide leadership training for younger physicians to get new ways of doing things
  • Address serious problem with lack of respect between doctors and administrators
  • Celebrate successes
  • Strengthen standards to reflect new norm
  • Convince team we need to have a couple of more meetings and bring in customers-owners

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Turning Ideas into Action: Patient Engagement in Transforming Health Systems

This session involved two presentations and small group discussions about the value of communication among patients, patient representatives and providers. Both presentations described initiatives in acute care: one in a six-hospital complex; the other in a regional children’s hospital.

In both cases, there was interest in re-shaping processes to improve accessibility and quality of care. Both equally recognized that the experiences and perspectives of patients could, and should, inform the delivery of care.

Dr. Patricia O’Connor & Brenda MacGibbon

Based on research showing that workplace design is challenging the safety and quality of health care, Dr. Patricia O’Connor developed a project aimed at transforming the processes and structures involved in delivering care.

Drawing on the Transforming Care at the Bedside (TCAB) program created by Robert Wood Johnson Foundation and the Institute for Healthcare Improvement, the project focused on changes to improve the safety and patient-centredness of care, as well as the vitality and teamwork of staff.

In 2010, the Canadian Health Services Research Foundation provided funding as a PEP (Patient Engagement Project) to Dr. O’Connor and her team to engage patients and their representatives in this health care improvement project.

The project was tested in five units with Registered Nurses, Social Workers, Dieticians, and 20 patient representatives, mainly from the hospital’s Patient Committee. Some of them contributed to the project design, which includes an evaluation plan measuring indicators of both patient and staff outcomes measures.

The 20 Patient Committee members participate in workgroups with hospital decision-makers; attend biweekly webinars with hospital unit teams; and visit hospital units each week.

The 20 also try to meet regularly with inpatients to discuss their experiences and suggestions on how to improve care and some of them were involved with the in-depth interviews with patients after they were discharged.

The theory is that patients are sometimes more comfortable sharing their stories and ideas with patient representatives than with health professionals.

Dr. O’Connor and Brenda MacGibbon, one of the Patent Committee members, spoke about one low-cost addition to the physical environment that has improved communication among the care team as well as patient satisfaction -- a whiteboard has been set up for each patient.

The board is used to identify the procedures scheduled on a given day, as well as the physician and nurse responsible for the patient that day. The patient is encouraged to write down questions and concerns on the whiteboard as well.

Other innovations include involving an interprofessional team in the admission process. This has reduced the time required for admission from 4.23 hours to one hour.

A third example was the redesign of the physical environment to allow co-location of supplies and patient information. This has reduced the time to prepare a room for chemotherapy from 14 minutes to six minutes.

Evaluations show improvements in both patient and provider satisfaction. Providers have also identified increases in work efficiency.

Chantal Krantz, Nathalie Major-Cook, & Nimet Karim

The second presentation described a project which started in March 2010 in response to evidence about health services for children and in the Champlain Local Health Integration Network (LHIN) of Ontario.

In regard to children with complex chronic conditions, the literature findings show that care is fragmented; parental stress is high; hospitalization is frequent and prolonged; as well as medical errors and duplication can occur when care is not well coordinated.

Prior to the project, several of the children had not seen a pediatrician for over a year.

A care coordination project was proposed. Wagner's Care Coordination Model for chronic disease management was used to frame the project.

CoordinatedCareModel

 

 The project focuses on medically fragile and complex children, each of whom is dependent on high intensity care and/or technological devices.

The project involved families in designing, implementing and evaluating changes to care processes and structures. The project drew on leadership of the hospital CEO as well as partnership of the Family Forum, a patient engagement organization created in 1994.

The project features the identification of a family coordinator for each medically fragile child.

The coordinator helps navigate the health, social, education and recreation systems, making necessary links among services and care providers in the hospital and the community.

In addition, each patient is assigned a 'most responsible physician', who co- leads with the parent, a Family-Focused Team of providers from various disciplines.

Talking with family and patients, the Team is able to understand the needs of the patients and design services and care models to meet those needs using existing resources in the system.

One of the resulting changes was improved communication and engagement with parents, as well as a comprehensive approach to care coordination post-involvement in the project.

Although is too early to draw conclusions, the anticipated benefits of this project are: improved overall family and staff satisfaction; greater system efficiencies such as reduced duplication of services and tests or procedures; as well as improved health status as evidenced by reduced ED visits, reduced inpatient length of stay, reduced events of hospitalization, reduced family stress and improved overall family health.

An Advisory Committee was established to address barriers between services in the hospital and those available through community partners. Data have been collected over the initial months and will be evaluated.

In the meantime several challenges were identified:

  • Communication among large multiprofessional teams -- this will be improved once a shared electronic health records system between family, community and hospital providers is underway;
  • Lack of standardized pediatric tools to evaluate family feedback for this population;
  • Changing practices both in the community and the hospital as well as role clarification;
  • Lack of mechanism to track time needed to coordinate care and navigate through the system;
  • Absence of processes and services to transition this population to adult care ; and
  • Inadequate funding to move project beyond the pilot stage.

Commentary:

Following the two presentations, Dr. Donna Galbreath and Dr. Douglas Eby commented on the opportunity to learn from patients.

They suggested that health facilities need to ensure all staff – health professionals, admissions and cafeteria personnel, etc. – be skilled in patient engagement.

Dr. Eby recommended that in terms of patient engagement, facilities “plan for the common and accommodate the uncommon.”

They also endorsed the use of navigators, referencing the thinking in some settings of using volunteers in that role.

In the subsequent small group discussions, TQ conference participants shared stories illustrating barriers and enablers to patient engagement.

Several endorsed the navigation/coordination role; one participant suggested that an important function of that role is maintaining the momentum of care.

Other interventions confirmed the value of communication with patients and families. One suggested that patients’ perspectives “force you to think about the work you are doing and get you out of your rut.”

One participant suggested that patient complaints to regulatory boards and professional associations are triggered by the absence of opportunities for patients to have their perspective “listened to.”

Participants identified the need to create various types of points of access for patients and families to provide information or feedback and ask questions. For example, patient and family perspectives should be part of all conferences related to the health system.

One participant spoke of a conference organized by seniors in Saskatchewan to discuss issues related to aging; the conference agenda includes discussion of options for delivering health services.

Focus groups, patient committees, and patient surveys were all identified as means of soliciting views and ideas from patients and family.

There was also a reminder that the system has to be ready to listen to, and learn from, patients whose feedback is negative or related to social and psychological issues (as well as issues of physical health).

One intervener suggested that there should be remuneration of the costs incurred by patients and families to participate in engagement activities.

A staffer from the Canadian Health Services Research Foundation advised the TQ conference participants of a call for proposals for projects related to patient engagement in service delivery and evaluation.

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Summary of Day 1

Co-chair Ernie Schuster offered a list of the 11 messages he was taking home from the first day of the conference: 

  • Plan for the common and accommodate for the uncommon;
  • Measure enough to secure actions;
  • Relationships between the patient and provider are important, as is the balance between primary care and tertiary care;
  • A care coordinator is key;
  • Excellence is a product of education, training and coaching;
  • Healthcare has to be delivered at the point of need;
  • Diseases are not the primary diagnosis -- rather anxiety, loneliness and family dysfunction are;
  • Transformation of the health system must recognize that health is in the control of the ‘owner-customer’ (currently the system is based on the model of the ‘passive patient’ approach);
  • Reduce demand in ER by offering services to unattached patients;
  • High performing healthcare systems include strong physician leadership;
  • Healthcare workers go to work everyday trying to do their best but the system does not support them; and
  • Engagement does not happen without relationship-building, trust and commitment.

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