CFHI On Call Webinars

System Transformation without a Template: Delivering Care for ‘Ms. Smith’ and the Whole Population

Held December 9, 2014

The third of 4 webinars in our Caring for the 5% Webinar Series.


Healthcare as we know it is highly facility-based and fragmented. Population health needs, as we understand them, are increasingly chronic and complex. How do health system leaders spur change, at the scale required, to align the care that is offered with that which is needed? How do leaders develop ‘whole-population’ approaches to care, while still recognizing the individual care needs of ‘Ms. Smith’ – individual patients and their families?

"System innovations of this magnitude have no template”1 – that’s how Alberta Health Services (AHS) put it when they launched the Strategic Clinical Networks (or SCNs) in 2012. In an effort to deliver the most optimal and effective care to patients, AHS has 10 SCNs (covering such areas as Addiction and Mental Health; Cardiovascular Health and Stroke; Diabetes, Obesity and Nutrition; Respiratory Health; and Seniors Health), each with a provincial scope and mandate to deliver sustainable, high-quality healthcare for all Albertans.2

“Populations are not homogeneous - they are made up of groups who have different healthcare needs, using different bundles of services, at different costs”3 – that’s one of the big takeaways from the British Columbia Ministry of Health’s data-driven approach to understanding the current and future healthcare needs of BC residents. ‘Health System Matrix,’ as it’s called, relies on ‘big data,’ helping to understand the unique needs of patient populations across the province (from end of life, frail in residential care, to healthy/low users, and non-users) as well as a more practical approach to examining service use (getting away from silo-driven utilization data such as physician services and hospital care to understanding “service lines” such as obstetrics and mental health and substance use).

Join this On Call webinar as we learn about whole-province, whole-population approaches to system transformation in Alberta and British Columbia.


  • Discuss the health needs of the population and healthcare improvements required to meet their needs, keeping in mind an ‘individualized’ approach to care
  • Learn about two examples of whole-population approaches that are driving system-wide transformative efforts in healthcare
  • Glean lessons on population-based healthcare that applies to your own organization or department


Speaker Biographies:

Martha BurdMartha Burd, Director, Performance Monitoring and Analysis Branch, Planning and Innovation Division, BC Ministry of Health.

Martha Burd is the Director, Health System Analysis team in the BC Ministry of Health. Martha has a Masters in Economics, and joined the Ministry in 1993 after many years teaching economics and consulting. Martha is the lead architect of the Health System Matrix project, which is the BC Ministry of Health’s unique and innovative approach to understanding the current and future health care needs of the province’s residents through the lens of population segmentation. Now in its fourth year, the Health System Matrix project is also a demonstration of Big Data - how data from divergent administrative databases can be transformed into a broad population risk adjustment tool that makes sense to health care planners, administrators, and clinicians. Martha’s experience in the Ministry includes managing data support services, leading a wide range of analysis and evaluation projects, the development of the Population Needs Based Funding allocation model, and forecasting models for acute care and home and community care services. Martha has participated in many national committees, and is currently on the Canadian Institute for Health Information’s advisory groups for Case Mix, Health System Efficiency, and the development of a Population Risk Adjusted Grouper.

Thomas NoseworthyThomas William Noseworthy,  Professor of Health Policy and Management, Department of Community Health Sciences and Institute for Public Health, University of Calgary, CM, MD, MSc, MPH, FRCPC, FACP, FCCP, FCCM, CHE 

Tom Noseworthy is Professor of Health Policy and Management, Department of Community Health Sciences and Institute for Public Health, University of Calgary. He is the former Head of that Department and inaugural Co-Director of that Institute. Dr Noseworthy is a physician, with specialty certification in the Royal College of Physicians and Surgeons of Canada, the American Colleges of Physicians, American College of Chest Physicians and American College of Critical Care Medicine. Dr Noseworthy is the former Vice President, Medical Services, and CEO of the Royal Alexandra Hospitals, Edmonton; and, Chair of the Department of Public Health Sciences, Faculty of Medicine and Dentistry, University of Alberta. He holds a Master of Science in Experimental Medicine from the University of Alberta, and a Master of Public Health - Health Policy and Management from Harvard University.

Dr Noseworthy has been a member of the National Statistics Council since 1999. He served as a member of the Prime Minister’s National Forum on Health from 1994-1997, and chaired the Steering Committee; co-chaired the Advisory Council on Health Infostructure (Federal Health Minister) from 1997-1999; chaired the Senior Reference Committee for Alberta Wellnet from 1997-2002; and, was Chair of the Western Canada Waiting List Project from 1999-2006, and now chairs a research collaboration funded by CIHR as an Emerging Team. His research has been published in over 100 papers and book chapters and focuses on health care access and improving quality management of waiting times for scheduled services. He was a founding Director of Canadian Doctors for Medicare in 2007. He currently is a member of the Expert Panel on the Timely Access to Health and Social Data for Health Research and Health System Innovation of the Council of Canadian Academies; and, is a member of the Institute Advisory Board for the CIHR Institute of Health Services and Policy Research.


Stephen Samis, Vice-President, Programs, CFHI

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Jennifer VermaJennifer Verma, Senior Director, Collaboration for Innovation and Improvement, CFHI

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