http://www.msss.gouv.qc.ca/ministere/observatoiresss/index.php?assessing-initiatives-to-transform-healthcare-systemslessons-for-the-canadian-healthcare-system

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Brief analytical summaries or syntheses #25

Assessing initiatives to transform healthcare systems:

Lessons for the Canadian healthcare system

Summary

Canada has invested significant financial resources and energy (including numerous federal and provincial commissions) in efforts to make the healthcare system more responsive to evolving needs. Nonetheless, there is general consensus that Canada’s healthcare systems have been too slow to adapt. This paper suggests avenues that governments can take to support the transformation of the healthcare system to provide better care and services.

Background

This paper suggests that money alone cannot improve healthcare. A clear vision and a coherent set of strategies are required to transform the system and achieve better alignment between the care offered and the care the population needs today (primary healthcare, more effective management of chronic diseases, mental health, etc.). Canada has invested significant financial resources and energy (including numerous federal and provincial commissions) in efforts to make the healthcare system more responsive to evolving needs. Nonetheless, there is general consensus that Canada’s healthcare systems have been too slow to adapt.

A 2008 report by the Health Council of Canada concludes that since the 2003 Health Accord there have been improvements in access to care in some clinical priority areas, such as hip and knee replacement and cataract surgery. However, it also identifies a number of areas where “progress on the accord commitments is not a cause for celebration” (HCC, 2008:34). These areas include drug coverage and safe and appropriate prescribing; home care; aboriginal health; primary healthcare; the healthcare workforce; electronic health records and information technology; and accountability.

The Council’s conclusions raise questions about how governments can further support change and on which policy options and instruments they should rely.

Analysis and results

Our analysis identified six themes that are crucial for an integrated and systemic approach to healthcare transformation:

Strategic realignment

No significant changes will occur without a serious attempt to realign the system to meet patient needs and evolving demands. Such realignment requires concerted efforts across subsectors of healthcare systems. At the delivery level, it implies large-scale organizational development initiatives to implement new models and processes of care. It is important to recognize that reforms which aim to strengthen primary healthcare and implement more effective chronic disease management and population health interventions will inevitably challenge the predominant logic of the current system.

Organizations as the engine for delivery and change

Organizational capacity is an essential ingredient in improving healthcare delivery. Increased reliance on team-based organizations and networks is an indication of growing recognition that more effective organizations can deliver better care. Organizational transformation is highly demanding. When implementing new organizational arrangements such as networks and inter-professional teams, it is essential to closely and deliberately manage the change process. Diverse organizational forms are needed to meet evolving and shifting demands.

Professional cultures

Transformation requires new professional roles and the engagement of the medical profession. Various options have been considered to stimulate changes in professional culture, with most attention being paid to the medical profession. Economic levers are not sufficient to get the commitment of professionals to improve care and services and lead change initiatives. More attention should be paid to the development of new professional roles in the healthcare system such as nurse practitioners, patient navigators and health assistants. The development of professional roles that link clinical and managerial functions may be part of the solution. Individuals would need to be trained and recruited to fulfill those roles.

Creating an enabling environment

Achieving improvements requires effective governance, well-defined and appropriate goals and targets, effective reporting mechanisms and well-designed financial (for example, hospital funding, pay for performance) and non-financial incentives. However, system transformation also requires policies that stimulate engagement of professionals, along with acquisition of new competencies and skills by both healthcare managers and providers. In addition, funding-renewal and incentive mechanisms need to be coupled with the capacity to monitor and adjust these policy instruments.

Patient engagement

Care is more than the encounter between a health professional and a patient; it is also a function of organizational context and system policies. Patient engagement and public participation should be a hallmark of good governance in healthcare, and strategies should be designed to make these happen. Patients can be involved in the design of services and citizens can participate in policy decisions if healthcare systems and organizations develop deliberate strategies to support such involvement. Recent experiences with expert patients and citizen councils, such as the Citizens’ Council of the U.K.’s National Institute for Health and Clinical Excellence, support the notion that patient and citizen involvement can be nurtured. Finally, the promotion of self-care can be a strategy to reinforce the role of patients in decisions about the delivery of health services.

Evidence-informed policy-and decision-making

Evaluation of the effectiveness of initiatives to improve care is crucial for healthcare system transformation. Since the early 1990s, many efforts have been made to produce evidence in priority areas, to find new ways of packaging evidence (such as through knowledge syntheses) and to disseminate evidence more effectively to practitioners and decision-makers. Today, there is a need to design strategies to enhance organizational capacity to integrate evidence into practice, as well as better coordination among research-based evidence, policy-making and politics.

Conclusion

This paper suggests avenues that governments can take to support the transformation of the healthcare system to provide better care and services. The recommendations are based on a very basic principle: constant re-organization of the system will not deliver better care. Structural changes have often been implemented without a clear rationale and with potentially detrimental effects on the system. The political context is a major factor in healthcare system transformation. While we strongly advocate for major efforts, investments and transformative initiatives at the delivery level, we also underscore the need for innovations and experiments that will increase communications between the research community, policy-makers and the political sphere. We also recommend the development of strategies to better involve professionals in leading transformation and improvement initiatives, while recognizing that transformation implies direct challenges to professional power and monopolies.

Implications and recommendations

One key element of any transformative strategy is a clear picture of what needs to be changed. Canada needs an integrated vision and approach to achieve healthcare system transformation. Healthcare systems tend to reproduce their dominant logic (in Canada it means that more and more resources are invested in specialized care) and consequently neglect other areas where major care deficits persist. Without vigorous human resources policies that favour a new mix of skills, including new professional roles and innovative models of inter-professional teams, current care deficits will not be alleviated.

Human resources don’t work in a vacuum. An enabling environment and organizations that support professional and clinical practices can have a significant impact on the provision and quality of care and services. New organizations and governance models are essential elements of a large-scale improvement strategy. Initiatives to renew primary healthcare in Canada in the last ten years clearly illustrate that an inherent tension in transformation is how to challenge healthcare professionals and stakeholders to adopt new ways of thinking and working while keeping them fully engaged in the transformation process. Renewal of delivery organizations requires strong leadership from and close connection between the management and clinical worlds. It is essential to recruit and train individuals to effectively bridge these two worlds.

Professionals and organizations can make important progress at the local level. However, to support improvement and spread good practices, better communication and mutual learning between the policy and delivery levels are needed. Debates among providers, organizations and the government too often focus on the level of financial resources and incentives available to achieve improvements in the healthcare system. While financial resources and economic incentives can play a role in orienting the provision of care and services, strategies to develop a commitment to better care seem more promising. In order to realign the system to meet evolving health needs, initiatives that support patient engagement and citizen participation, as well as the use of evidence to inform change, are crucial. Both types of levers are potentially powerful instruments to channel organizational and professional strategies toward improvement.

Source

Assessing initiatives to transform healthcare systems: Lessons for the Canadian healthcare system


Gouvernement du Québec
© Gouvernement du Québec, 2017