Achieving high quality in a health care system, as in any other enterprise, requires that the factors necessary for success be defined, measured, continually monitored and openly reported.
The good news is that almost all jurisdictions and professional bodies in Canada are beginning to take the quest for measureable high quality care seriously, albeit with emphasis on different aspects of the task and with varying degrees of success. There is marked but unsurprising inconsistency across the country, with its quasi-independent provincial jurisdictions and the silos of professional and organizational interests, but the report just released by the Health Council of Canada Which way to quality? Key perspectives on quality improvement in Canadian health care systems, presents an interesting snapshot of the good intentions and the good ideas that are being pursued.
In Ontario, the 2010 “Excellent Care For All” act set a clear path for quality improvement in the health care system, mandating the development and implementation of a formal process in every organization and hospital in the province. Quality-of-care committees must now be set up to report to the organizations’ boards; annual quality improvement plans with clear indicators and targets must be developed and made available to the health ministry and the public; achievement of targets outlined in the plans becomes linked to executive compensation as a significant incentive. Requirements for similar activities in the primary care sector will follow as the provincial plan unfolds. Health Quality Ontario (HQO) was set up to direct, support, monitor and report on these activities. This whole initiative has raised the health care quality bar in Ontario and deserves enthusiastic support, but there are some awkward bumps in the road ahead.
There is wide agreement now on what quality in health care means although how to achieve it still causes much discussion. In summary it means timely access to care that is necessary, centered on the patient, safe, effective (that is, causing better health) and sustainably affordable. Unfortunately, not all of the changes required for success are wildly popular with physicians, politicians or even the public. The traditional fierce independence of physicians must eventually give way to truly integrated multi-professional teams and organizations. Not all politicians have an appetite for the changes in policy and legislation that would be needed, and the public tends to be suspicious of any interference with current services.
The quality agenda in any health care system also has to deal with the insatiable demand for more and more expensive services – services that often bring a very small benefit at huge cost. There are serious questions about just how necessary all the current consultations, tests, prescriptions and procedures really are, and these questions must be answered on the basis of rigorous evidence rather than tradition, belief systems or vested interests. Sustainable affordability means that value for money is very much a quality issue because of what is called the “opportunity cost” of any publicly provided health service, namely the alternative use of the money that could bring much greater benefit to more people. These issues provide ample fodder for debate among the health care professions, the politicians and the public alike, but we cannot continue to avoid them.
No commentary on health care quality in Canada can avoid stressing the need for a cooperative national agenda. As demonstrated in the Health Council report there have been some remarkable initiatives in most provinces, some of them quite intense as in British Columbia, Alberta, Saskatchewan and Ontario, but national cooperation remains elusive. It is not surprising that progress in Canada as a whole has been difficult, slow and patchy with so many provincial jurisdictions and an increasingly disinterested federal government. In addition to ongoing measurement, evaluation and adjustment, any successful quality improvement process must involve the powerful motivator of regular comparison with peers. Is it unreasonable to suggest that we should build, as a nation, some shared activities, goals, expectations and reporting mechanisms in the best interests of high quality in what we still like to call Canada’s health care system?