Accelerating Excellence in Saskatchewan
Saskatchewan's Health Quality Council (HQC) was the first of its kind in the country. Launched in 2003, it evolved from the Health Services Utilization and Research Commission, with a mandate to not only measure and report on healthcare but also work with a range of partners to improve the province's health system.
In late 2007, HQC's board decided to venture beyond narrowly focused quality improvement projects. It was time, the board said, for Saskatchewan to reinvent its healthcare system, using the highest-performing systems in the world as its model. With $5 million in special funding approved by the provincial government in 2008, HQC launched Accelerating Excellence, a multi-level program to rethink, redesign and renew healthcare.
To help maintain momentum and show other provinces whether high-performing healthcare can be achieved in Canada, HQC is documenting its journey toward high-performing healthcare. As board member and University of Toronto professor Ross Baker states, "Transparency might embolden some of those who are reluctant, and make it more difficult to drag behind if the overall project is being reported."
This is the first of a series of articles exploring the different elements of Accelerating Excellence. It explores the initiative's beginnings – with a focus on efforts to engage Saskatchewan's healthcare leaders in making a better, safer system.
Scottish poet Robbie Burns longed for the gift of seeing ourselves as others see us. Last September, Saskatchewan healthcare administrators and board members participating in a leadership workshop were told to do just that – but with the benefit of a camera, a tool not available in Burns's time.
The task was to have patients create a photographic journal of their journey through a healthcare experience. In Sunrise Health Region, northeast of Regina, the camera showed a perspective staff do not see, or stop noticing – confusing and contradictory signs, a broken front door, a row of doctors' parking spots sitting empty while the handicapped parking was full and hours of being left alone – including a wait so long it was too late to get a prescription filled.
As it turned out, the automatic door had been broken, off and on, for months. Apart from the problem it posed to handicapped, sick and older visitors, the repeated hanging of an out-of-order sign on the front door was not likely to inspire confidence in the system.
The photographic journal captured an unfortunate image of healthcare in Sunrise – and a perfect reflection of just how profound a transformation Saskatchewan is aiming to achieve. "Photo journaling lets us see the story through the patient's lens," says Suann Laurent, senior vice-president of health services at Sunrise. "You hear the story, but when you actually see it from the patient's perspective, it's very different from how people in the health system perceive it."
Handing cameras to patients and asking them to record their visits was an "absolutely fabulous" way to help senior managers at Sunrise understand what patient-centred care really means, says Laurent, and how innovative they will have to be to achieve it, changing not just how they act, but how they think.
A new approach to thinking and acting is the whole point of the Quality as a Business Strategy Leadership Learning Collaborative. It is one part of an ambitious plan by HQC to transform healthcare in Saskatchewan. Called Accelerating Excellence, the initiative was launched in 2008. It includes new quality programs for clinicians – Releasing Time to Care for nurses and the Chronic Disease Management Collaborative for primary care teams – and encompasses existing HQC activities, such as its Quality Improvement Consultant program. Supporting all the initiatives is the Quality Insight program, which measures and reports on quality of care.
Modelled after the approaches that have led to successful reinventions of health systems in the United States, Sweden and England, Accelerating Excellence promises to give "people working at all levels in our health system … the knowledge and tools to overhaul our system's current piecemeal collection of disparate parts into a co-ordinated quality-focused system."
Despite an increasing focus on quality in recent years, coordinated system-wide quality programs do not exist in Canada, according to Baker, who has studied high-performing health systems around the world. The Calgary Health Region came close, he says, but the reorganization of Alberta's health system in early 2009 has limited its impact.
Steven Lewis is another HQC board member who supports a leap from focusing on individual quality improvement projects to a range of strategies and tactics that will transform Saskatchewan's entire health system. "The system needs more than slow, steady incremental change if it is going to survive and thrive," he states, adding that HQC's earlier efforts, though admirable on many fronts, did not bring about a widespread shift to new approaches that lead to a profound, sustainable improvement in quality.
To change that, HQC put together a proposal for a "steep and deep" transformation and took it to the Ministry of Health just a couple of months after the election of Premier Brad Wall and the Saskatchewan Party. The new government was receptive and gave the project $5 million.
There was a sense all around that the time was right for a bold move. "I have never seen the stars aligned in this way before," asserts Dan Florizone, now deputy minister of health for Saskatchewan but, at the time of the proposal, the chair of HQC. Florizone attributes the funding less to political change than to a growing realization on all sides that years of putting more and more money into health services has not led to improved care, so money aimed at training people to rethink and run the system in a new, quality-oriented way might be a better investment.
Baker explains Saskatchewan's small size, relatively strong economy and clear vision for healthcare, combined with HQC's five-year history of quality improvement projects, make it an ideal site for developing a high-performance healthcare system.
One of the exceptional systems that Saskatchewan is learning from is Jönköping County Council in Sweden. Over the past 10 years, Jönköping has gained international recognition for its extraordinary ability to make major improvements in healthcare while holding the line on costs. In measures ranging from cost per inhabitant to number of Caesarian sections to rates of depression among people with stroke, Jönköping ranks first in Sweden.
It's not by accident. Jönköping has spent more than a decade developing a culture where continuous learning is expected of everyone from leaders to front-line workers. There is a training institute for studying principles of quality improvement and how to integrate them to achieve better care. Quality and safety concerns are essential to every facet of planning. And it saves money – approximately 2% of net costs.
Participating in the Quality as a Business Strategy program takes a lot of time and effort – senior managers and board chairs must attend a series of six workshops over 18 months and complete "homework" in between the sessions. So when it started, HQC staff were hoping for perhaps seven to 10 organizations to sign up. The Ministry of Health's decision to take part was seen as a breakthrough, but it was just the beginning. There are now 29 groups, including some who are usually at the periphery of healthcare system planning – the College of Physicians and Surgeons of Saskatchewan, the Saskatchewan Association of Licensed Practical Nurses and the Northern Health Strategy.
Signing up, however, does not guarantee commitment. Saskatchewan professionals are as likely as their colleagues anywhere to roll their eyes at something they perceive as the latest management fad, according to Florizone. And Bonnie Brossart, chief executive officer (CEO) of the HQC, said several senior leaders were skeptical. "Early on, the attitude was, 'Just give us the recipe – tell us what high-performing health systems are doing and we'll do it.'" She thinks that is changing, though, since they keep coming back.
Mary Smillie, a senior quality improvement consultant at HQC who is steeped in the theory behind the leadership component of Accelerating Excellence, says there seems to be a pattern of engagement with every session: the first day people arrive skeptical, but by the second day the dialogue is always more lively and energizing. Some have suggested HQC intentionally sets the agenda to do that, but she attributes it to people moving out of their protective shells of busyness and getting engaged in the ideas.
Florizone worries it might be "a sugar high … they get the quality religion and start doing this stuff, but it's not sustainable because it's so easy to fall back into the old problems and the old solutions." That problem is compounded by a common feature of high-performing systems that is lacking in Canada: strong, long-term leadership. Jönköping had the same CEO for two decades, and other models Baker has studied have often had 10 years or more with the same CEO. This is not the Canadian norm, and it increases the need to "entrench" training and commitment to quality in all levels of staff.
A short-term win is another essential ingredient for successful transformation, continues Baker. Without a concrete example of success, change initiatives tend to lose momentum. The Saskatchewan government assigned the goal in October's Speech from the Throne, when it promised to "reduce surgical wait times in Saskatchewan to no longer than three months" within four years. This is not necessarily the goal the system would have set for itself, but – as the province's Patient First Review made clear – it is certainly a major concern of residents, and in a patient-centred system, that's what matters. Florizone believes the massive overhaul of Britain's National Health System worked because they tackled waits first. "If we can transform [wait times], then leading into primary care reform or senior or palliative care is just a natural next step," he explains.
Helping people at every level to think in terms of the system, rather than their job or their unit or even their region, is probably the biggest challenge. It is not just a question of coming out of your own silo, but ceasing to tolerate silos at all. In preparation for the September 2009 leadership workshop, teams had to create a "linkage of processes" map, a schematic of how their organization's processes produce what it does, based on the theories of W. Edwards Deming, the grandfather of quality improvement.
Smillie thinks this is one of the hardest parts of the strategy to understand – and to her surprise, it seemed to be a key for many people who had been skeptics, or at least, less engaged. "A customer doesn't approach the system saying, 'Today I need a little public health,'" she notes. "It's a real challenge for senior leaders because they have been living and breathing their org chart for years." A focus on the product, rather than on departments, leads to a different approach to problems. But it's a big change.
And it's a change that needs support. A systems approach at the delivery level does not work if planning and policy making do not support it, but that is one reason Brossart is so pleased the Ministry of Health has been involved since the beginning. And she sees evidence that the government is already applying principles from the workshop, such as a meeting in April 2009 of 50 healthcare leaders organized by the ministry to develop a common purpose for the healthcare system. They had never invited such a mixed group to discuss policy before.
Florizone agrees that there is shift at the ministry, where staff are writing policy papers that open with patient stories – something he has never previously encountered: "Seeing a policy in terms of before and after, from a patient's point of view, means you see what you're doing and what you should be doing."
The Patient First Review made it clear that people who use services don't care about the boundaries and structures of Saskatchewan's healthcare system, Brossart says, and the system needs to adapt to that reality. It should not be the huge struggle it is, she continues. "We are all much more similar than we are different." Florizone agrees: "This is doing the work of regionalization that wasn't done. We didn't complete it. We set the boards up and made them responsible for integration, and then we left it.
"We want to get this right in Saskatchewan, the birthplace of medicare," he states. "We want to be the birthplace of sustainable medicare, of patient-first medicare."
About the Author
Jane Coutts is a healthcare writer based in Ottawa, Ontario. This article was commissioned by the Health Quality Council.
Baker, R., A. MacIntosh-Murray, C. Porcellato, L. Dionne, K. Stelmacovich and K. Born. 2008. High Performing Healthcare Systems: Delivering Quality by Design. Toronto, ON: Longwoods Publishing Corporation.
Health Quality Council. n.d. Accelerating Excellence. Saskatoon, SK: Author. Retrieved November 2009. <http://www.hqc.sk.ca/portal.jsp?qMgYQm28WdhLfYSWZpG40zBIzBf0QfLQkUwK4QBZaJuGeJ+4XDZ4F1VvI5thiwzu>.
Institute for Healthcare Improvement. n.d. Charting the Way to Greater Success: Pursuing Perfection in Sweden. Cambridge, MA: Author. Retrieved November 2009. <http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/ImprovementStories/ChartingtheWaytoGreaterSuccessPursuingPerfectioninSweden.htm>.
National Health Service Institute for Innovation and Improvement. n.d. The Productive Ward: Releasing Time to Care. Coventry, England: Author. Retrieved November 2009. <http://www.institute.nhs.uk/quality_and_value/productivity_series/productive_ward.html>.
In the next issue of Healthcare Quarterly, this column will discuss Saskatchewan's adoption of Releasing Time to Care™, a successful National Health System initiative that uses straightforward tools and techniques to free up caregivers' time for more direct patient care.
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