The first set of evidence-based benchmarks for medically acceptable wait times, announced in December 2005, were developed, in part, through a novel partnership between the Provincial and Territorial Ministries of Health, the Canadian Institutes of Health Research (CIHR) and Canada's health services research community. Responding to a direct request for assistance and demanding timelines from the Provincial and Territorial Ministries of Health, CIHR mounted a rapid-response funding process and supported eight Canadian teams to synthesize evidence to inform the development of the first set of benchmarks. This experience demonstrated that both the research funding process and research syntheses themselves can rapidly inform policy making in even the most heated of environments.

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In September 2004, as a key part of the $41 billion, 10-year plan to strengthen healthcare, Canada's First Ministers agreed to build on past efforts to reduce wait times and improve access to care (Government of Canada 2004). In the following months, especially in the wake of Chaoulli v. Québec, the commitment to establish evidence-based benchmarks for medically acceptable wait times in five clinical areas by December 31, 2005, became the highest-profile element of this agreement.

The Ministers of Health announced the first set of these benchmarks on December 12, 2005. These benchmarks were, at least in part, the product of a partnership between the Provincial and Territorial Ministries of Health, the Canadian Institutes of Health Research (CIHR) and Canada's clinical and health services research community. While research and policy making processes are often distinct and asynchronous, in this case the research community and intermediaries such as CIHR were able to mobilize themselves to seize a window of opportunity to inform public policy. The purpose of this paper is to describe this successful knowledge translation process - the rapid-response commissioning of research teams to systematically identify, select, appraise and synthesize evidence - and to reflect briefly on factors in the policy environment that may have increased the potential for this research to have an influence.

Research Synthesis Can Be Rapid and Responsive

In January 2005, the Provincial and Territorial Deputy Ministers of Health requested assistance from CIHR in assembling research evidence in time to inform the development of wait time benchmarks for a December 2005 deadline. Only once before had CIHR developed a Request for Application (RFA) process - during the SARS crisis - with such unforgiving timelines. But by May 2005, an international review committee, established by CIHR to conduct an arm's-length assessment of the relevance and scientific merit of the proposals, had adjudicated 17 grant applications and chosen eight Canadian research teams to conduct research syntheses in sight restoration, joint replacement and cancer. Research syntheses in cardiac services and diagnostic imaging were not funded, because proposals were either not received or not ranked highly enough to be fundable.  

Funded teams were not asked to recommend specific benchmarks, nor to undertake primary research. Rather, they were to (1) synthesize Canadian and international evidence on the relationships between patient characteristics, health service wait times and mortality, health status or quality of life; (2) summarize wait time benchmarks already in use, nationally or internationally, and the research evidence (if any) used to support their selection; and (3) (after the December 2005 deadline facing the Ministers) identify priority areas and questions for future research.  

The teams reported on the first two objectives only five months after the start of funding, in October 2005. These reports were submitted directly to the Ministries, and CIHR facilitated opportunities for real-time knowledge translation, bringing the researchers and policy makers together to discuss the findings in more detail. CIHR released plain-language summaries of the main findings and links to the full reports on its website for general access in November. On December 12, 2005, the Ministers of Health announced Canada's first set of wait time benchmarks, which related closely to benchmarks suggested by the research syntheses.  

What Made This Knowledge Translation Process Successful?  

The policy making process is not linear or predictable. It always takes place in the context of a complex array of institutional arrangements (e.g., structures, past policies), interests (e.g., among elected officials, civil servants, societal interest groups) and ideas (e.g., research and other forms of evidence), as well as values, which are influenced by individuals and external events (Lavis 2006).  

This complexity means that the policy making process often appears to be a "black box," with little apparent way to determine if, how and to what extent research evidence has been considered in a given decision. The establishment of wait time benchmarks, which took place in a heated political environment, was undoubtedly as subject to the array of institutional arrangements, interests and ideas as any other policy decision. Yet the influence of research evidence in this policy decision was clear, in both the original request to CIHR for assistance and the development of the resulting benchmarks. A number of factors appear to have contributed to the success of this particular knowledge translation process.

Timeliness

The timeliness of research evidence can obviously increase its prospects for research use (Lavis 2006). Researchers who can provide scientific evidence in a timely manner, using methods of communication appropriate to their audiences, are more likely to have their work inform decision-making. In this case, there was an urgent need for a policy decision owing to the prevailing political climate and prior public commitments to establish "evidence-based benchmarks for medically acceptable wait times … by December 31, 2005" (Government of Canada 2004). CIHR and the research community were able to respond to this requirement for high-quality, timely research evidence with sufficient speed to inform the policy decision.

Investment in evidence-informed decision-making

In the last few months of 2005, questions were occasionally raised by the media and others on the value of looking for research evidence to inform the development of benchmarks when other jurisdictions had proceeded without it. Yet from the outset, the Ministers were committed to investing in reviews of scientific evidence and to ensuring that their benchmarks were informed by the best internationally available research evidence. They and CIHR recognized that the research syntheses would be but one source of relevant information. The Ministers and CIHR also knew, going into this process, that there might be clinical areas in which rigorous evidence of the type being sought would be thin. But it is important to know when there is no research evidence, or when current evidence is insufficiently convergent to support an evidence-informed benchmark. This knowledge can assure Canadians that policy decisions do not contradict existing scientific evidence, and it provides the research community and policy makers with a clear picture of where further work is required.  

Trusted relationships

It is well known that regular interactions between researchers and policy makers increase the prospects for research use (Lavis 2006). Decision-makers who seek trusted research partners with whom to work, and who engage actively and from the outset in defining their needs for evidence, are more likely to use it when making decisions. In this case, key senior CIHR staff had established relationships with key Provincial and Territorial Ministries of Health. The Ministries partnered with CIHR in funding successful research teams, and were able to interact directly with the researchers to discuss the resulting evidence. Importantly, CIHR was able to act as an "honest broker" in this process, suggesting that credible intermediaries can play an important brokering role to bring policy and research communities together.  

Credible, accessible evidence

An important corollary is the credibility of both the message and the messenger, in this case. Systematic reviews based on all extant research are a more reliable source of research evidence than individual studies, which can be biased or easily contested. The responsible research teams were selected using high-quality peer review processes. The evidence was presented in a format that directly spoke to the Ministers' needs, and conference calls were conducted between the Ministries and researchers to ensure clarity and completeness in the translation of new knowledge.  

This paper is not intended as a comprehensive overview of this particular policy making process. Many external factors (including input from other parties, such as the Federal Adviser on Wait Times), as well as internal factors not known to us, will also have influenced the political decisions. However, this example does offer some insights for researchers and organizations interested in ensuring that their research is taken into account in the complex process of policy formulation.

Looking Ahead

The process of establishing wait time benchmarks allowed healthcare system leaders to forge new types of working relationships with CIHR and broaden existing relationships with researchers. Most encouragingly, the landmark announcement of the first set of national benchmarks in December 2005 was just the beginning of one phase of this partnership. CIHR hosted an invitational workshop in December 2005, as part of the partnered process of mapping a forward research and knowledge translation agenda on improving timely access to high-quality care. Among the themes that emerged from that workshop were the importance of further work focusing on the key determinants of wait times at a local level; the need to ensure that "appropriateness" screens become an integral part of wait time management systems; and the huge potential of applying a "process flow" lens to the re-engineering of access queues across the country. An additional research team was funded in 2006 under a second round of the original competition to conduct a systematic review of wait times for cardiac services and procedures. In June 2006, CIHR, in partnership with the Provincial and Territorial Ministries of Health and Health Canada, launched a second Request for Applications to fund pilot projects and research syntheses in new priority areas, identified in part through gap analyses conducted by the original eight research teams and in part through the invitational workshop.  

The establishment in December 2005 of a set of evidence-informed benchmarks would not have been possible without committed policy makers, nimble clinical and health services researchers and a flexible and responsive research funding agency. These and other factors resulted in an environment conducive to research-informed policy. We hope that this experience will be a powerful and positive precedent, leading to strong, productive and enduring partnerships for the benefit of all Canadians.  

Repères pour les temps d'attente, preuves cliniques pour la recherche et processus d'application des connaissances

Résumé

Le premier ensemble de repères fondé sur des preuves cliniques pour les temps d'attente acceptables, annoncé en décembre 2005, a été élaboré, en partie, grâce à un partenariat innovateur entre les ministères provinciaux et territoriaux de la Santé, les Instituts de recherche en santé du Canada (IRSC) et le milieu canadien de la recherche sur les services de santé. Répondant à une demande d'assistance directe des ministères provinciaux et territoriaux de la Santé et faisant face à des délais serrés, les IRSC ont mis en place un processus de financement rapide et appuyé huit équipes canadiennes chargées de synthétiser des preuves cliniques en vue d'informer l'élaboration du premier ensemble de repères. Cette expérience a démontré que le processus de financement de la recherche et les synthèses de recherche elles-mêmes peuvent rapidement éclairer l'élaboration de politiques, et ce, même dans les environnements les plus fébriles.

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