This letter is part of series of Open Letters from Canadian leaders in Healthcare. To see the complete series please click here.  

The past 50 years have brought incredible progress to the aggregation of improvements in the healthcare armamentarium.  We have amassed pertinent knowledge at an unprecedented and ever-increasing pace.  We have achieved stunning technical, pharmacologic, biologic and genetic advances in health interventions, and we are heralding the dawn of the new era of precision medicine.  With this glittering array of achievements, our ability to improve the lot of individual patients across the spectrum of acute and chronic diseases has expanded dramatically.  Canada can boast of having leading edge capability in all of these advances.  But have we made comparable strides in improving the quality of health services for our Canadian population?  Regrettably, the answer is no: our cup of quality, far from brimming over, is perhaps only half full. The recent report of the Advisory Panel on Healthcare Innovation (http://healthycanadians.gc.ca/publications/health-system-systeme-sante/report-healthcare-innovation-rapport-soins/alt/report-healthcare-innovation-rapport-soins-eng.pdf) expounds on this assertion and should be required reading for health leaders at every level, from government policy making to local service provision.

Ideally, every individual in need of health services would receive them when, where and how best suited.  The higher the quality of a health service, the more likely it is to approach this ideal within the population served, and the more likely will the outcome of the specific health problem addressed approach the ideal.  We would expect Canada, as one of the wealthiest countries in the world, with per capita health expenditures among the highest of its peer countries, and cherishing a publicly funded health system, to shine at the forefront of health quality and health outcomes.  But when we examine international benchmarking indicators, we find at best, middling performance in comparison to our peers among developed countries.  Furthermore, looking internally, we find disturbing deficiencies in quality and outcomes of service to certain groups such as indigenous persons, compared to the overall Canadian population.

Why does our health service quality fall short of our expectations?  The Canadian population comprises a complex overlapping mosaic of subpopulations defined by political, geographic, ethnic, cultural, socioeconomic and other factors.  Canada’s health funding, often described as single-payer, actually involves provincial, territorial and federal components, plus private insurers and the users themselves.  At the level of providers of service, one finds a complex mixture of organized publicly funded provincial, regional and local health systems and institutions; also private organizations and practitioners working under contract or with fee for service arrangements with the public system, private insurers and clients.  Furthermore, despite the recent widespread promotion of the mantra of patient-centred care, our health service engines still function in a decidedly institution and provider-centric fashion.  It is little wonder that one finds, at the interface between health services and recipients, evidence of a lack of the disciplined, coordinated practices necessary for optimum quality and outcomes.

The Alberta Quality Matrix for Health (http://hqca.ca/about/how-we-work/the-alberta-quality-matrix-for-health-1/) defines six dimensions of quality: acceptability, accessibility, appropriateness, effectiveness, efficiency and safety, applied across four health states:  being healthy, getting better, living with illness or disability, and end of life.  In effect, the cells of this matrix provide 24 lenses for examination of the quality of health services.  One can immediately appreciate the enormity of the task of studying and improving the six dimensions of quality across the four health states, working within the complex mélange of health funding, systems, organizations and providers described above.  There is no simple prescription for addressing Canada’s health quality dilemma.

The Unleashing Innovation: Excellent Healthcare for Canada report cited above provides a clear and detailed exposition of the challenges and complexity of improving health quality in Canada.  The panel has built on work of previous provincial and federal commissions on health reform, has summarized key national and international benchmarks and has engaged stakeholders across the country.  In thorough discussion of the approaches to innovation required to improve healthcare services in Canada, the report argues that both top-down and bottom-up approaches to innovation are desirable.  While accepting the challenges involved in scaling up innovations in quality made at the meso and micro levels, I wish to return to consideration of the six dimensions of quality in encouraging support for quality improvement at the regional and local level while waiting for macro level policy evolution and system innovation.

Geographic, ethnic, cultural, socioeconomic and other characteristics of the target population influence each of the six dimensions of quality.  Furthermore, acceptability, accessibility and appropriateness are sensitive to characteristics of the individual served.  Finally, the available distribution of providers and institutions must be considered for successful quality improvement ventures.  It is at the local and regional level that understanding of population and provider characteristics is best informed.  Leadership at this level for adaptation and implementation of innovations, whether they are locally generated initiatives or imported best practices, is critical for success.  This argues for fostering a culture of innovation at these levels, building expertise and capacity, and rewarding success.  This will serve health quality well, in the medium and long term, whatever higher level changes in health funding, policies, systems and organizations may be contemplated.

About the Author

Anthony Fields, CM, MD, FRCPC, FACP, DSc(Hon) is Professor Emeritus, Department of Oncology, University of Alberta