Saskatchewan's Health Quality Council (HQC) was launched in 2003 with a mandate not only to 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 it was time for Saskatchewan to reinvent its healthcare system, using the highest-performing systems in the world as its model. And 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 Saskatchewan's journey toward high-performing healthcare. This sixth and final article in the series discusses the next step in Accelerating Excellence.

There's a new reality show coming to Saskatchewan: Extreme Healthcare Makeover. Two years into Accelerating Excellence, the plan to transform care in the province, deputy health minister Dan Florizone wants to make it real. Not everywhere at once – he's thinking a handful of places. And not overnight – it could take months, even several years, to do what he's got in mind. But it's clear to him he needs tangible examples of transformed healthcare to persuade the people of the province it's time for a radical new approach.

"It'll be Patient First on steroids," Florizone says in an interview in Regina, referring to a recent provincial consultation on healthcare, which led to a decision to focus the system on what patients feel and need, rather than on the mechanics of delivery. He – and pretty much everyone he works with – is deeply committed to transforming the system to be both "patient-centred" and permanently working to improve quality, like all the best high-performing health systems in the world. But at this meeting in Regina on developing a rural health strategy, he's run up against a wall of resistance. Municipal representatives overtly mistrust talk of transforming the health system. They want what they've always wanted, a doctor in town and a hospital nearby. Talk of chronic disease management and clinics with team care sounds second-best to them.

It's clear to Florizone that explaining and advocating have reached their limits. Now it's time to show people what effective 21st century healthcare looks like. He wants to get "small tests of change" in place, functioning models of reformed primary care in some places, initiatives to speed up access and improve quality of surgical care running in others. He wants to "drill down" through every step of patient experiences. "We'll follow patients, get it all down and thought through, we'll talk about the individual and scale it up from there." In the shorter term, at the meeting, he's signing up one doubter after another to come on a tour of Alaska's Southcentral Foundation health system (one of the high-performing models Saskatchewan is using in its transformation). It's increasingly obvious that for this crowd, only seeing will bring believing.

Helen Bevan agrees. She is director of service transformation at the National Health Service's Institute for Innovation and Improvement in London. She has led change initiatives for 15 years and over that time, she's learned people come around to change only when it's clearly demonstrated the alternative is better. "We need to do things in a different way and people need to get used to that, but it's hard to sell a concept," she admits in a phone interview from London.

In fact, Saskatchewan already has dozens of successful change tests under way, but many of them, despite impressive results, may be largely invisible to most patients, as efficiencies often are once they're in place. At Regina General Hospital, for example, delays and cancellations in magnetic resonance imaging (MRI) were so chronic, it was the equivalent of unplugging one of their two machines for an entire 16-hour shift each week. Patty Curtis, a nurse and clinical educator for diagnostic imaging, set out to improve things, sure she knew exactly what the problem was – that Emergency Medical Services ambulance teams, who drive patients from Pasqua Hospital across town, couldn't keep on schedule.

Two years later, after a Lean process review, she knows transferring patients was only part of the problem. It turned out 73% of doctors weren't filling out the forms properly – but the forms were badly designed. Patients who could safely have come by car were being sent by ambulance – but there was no process for assessing who needed an ambulance (introducing one has saved 16 ambulance round trips a week). Specialists forgot to tell community patients about their appointments. It all added up – it's hard to pinpoint exact numbers, because the length of MRIs varies, but the hospital may be able to do as many as 500 more procedures per year.

Many wards and regions are having their own successes with Lean, redesigning whole departments to make them more efficient. Quality improvement programs are changing care, increasing prevention, decreasing duplication, helping providers focus on what works for patients. Dozens of primary care physicians and practices have joined HQC's chronic disease management program; close to 50 people will have trained in the Quality Improvement Consultant program by the end of the year. Releasing Time to Care, the program designed to improve nursing on acute-care wards, introduced in the fall of 2008, has reached 52 wards. Its successes range from fewer falls by patients to nurses spending more time on direct care and working less overtime. The fact is, however, healthcare across the country and around the world is full of good, even great, innovations that make a big difference to patients and providers, but they don't spread and they leave care, as a whole, unchanged. Can Saskatchewan move from improved to transformed?

Bevan, who has twice visited the province to support the HQC's work on Accelerating Excellence, says some of the essential pieces are in place for transformation. "I see lots and lots of great examples of local change. The really tough bit is how you go from lots of small changes to transforming the system," she explains. "Saskatchewan is one of the few places that has the ambition and intentionality to make change happen." She cites the HQC's continuing efforts to learn from others (which she calls "stealing with pride") and its investment in training in quality improvement at all levels as keys to potential success.

Göran Henriks is director of development for Jönköping County Council, a health authority in Sweden that has become one of the best in the world over the past dozen years. He's also travelled to Saskatchewan to work with the quality council. He lists several essentials for success: top management who lead by example; values and strategic aims that remain constant through the years and are the basis for every decision; excellent information-technology and data gathering to give prompt feedback to workers on everything from patient flow to clinical results; and an unwavering focus on customer needs.

But there's another, crucial, condition, which both Bevan and Henriks worry may be missing in Saskatchewan: strong, long-term leadership. Bevan says research shows it takes 10–15 years to transform a health system. "So much is about clear, consistent, sustainable leadership and sometimes that's very hard to get in a public system, with an election cycle every four or five years," she points out. Henriks observes that leaders must embrace the organization's values, keep them fresh over time and imbue every decision with them. But in Saskatchewan, as elsewhere, there is a tendency to move through even the highest level jobs every few years. On top of that, many top administrators are nearing retirement age, Health Minister Don McMorris has been in the job four years (a long time by political standards) and while Dan Florizone is relatively new in his position, deputy ministers often get shuffled. None of that bodes well for following through on transforming the system.

Bevan and Henriks are also both concerned that Saskatchewan's regional leaders may feel quality improvement was imposed on them and see it as secondary to their main work. "Quality is management," Henriks explains. "Seeing it as an add-on is dangerous. The biggest challenge is to make improvement work everyday work, so you focus on measures and feedback and patients and inhabitants and your strategic dialogue every day."

Bevan says changes become mainstream when people feel an emotional connection to the system's values and their intrinsic motivation is commitment to those values. Henriks and Douglas Eby, vice-president of medical services at Southcentral Foundation's Alaska Native Medical Center, both say their organization tests every idea against their core values. If it fits, it is acted on – and, also important, unassailable. Jönköping goes so far as to limit the consultants and academics it brings in, in case their values don't match the county council's. Instead, Jönköping staff go out to learn about new things, then interpret the ideas according to the organization's values.

However, having a completely values-driven staff may not be possible, which is why Bevan believes it's necessary to set goals and hold leaders accountable for meeting them. You can't, she says, transform a health system if you keep bailing people out. Eby agrees measurement and reporting are essential both for delivering high-quality care and for ensuring accountability. Data, he says, show whether you're the great Wizard of Oz, or just an old man behind a curtain. "Data is a very powerful motivator, but only with consequences," he observes.

And that raises another problem: setting goals and measuring results requires good performance data. Every type of information – including wait times, numbers of patients seen, statistics on diseases and treatments and all administrative work, not just patient records – must be computerized for a high-performing system to function, Henriks asserts. And all that information has to be available promptly to feed back to the people who work with patients so they can improve the work they do. Saskatchewan isn't there yet, as the fourth article in this series shows.

Bonnie Brossart, the HQC's chief executive officer, can see the truth in all the concerns the international observers have about Saskatchewan's progress. Leadership positions have, almost by definition, had limited terms in Canada and in any case, Saskatchewan's CEOs are definitely an older group. But she thinks she's starting to see signs of succession planning, which never happened before.

More important, perhaps, than individuals continuing in their jobs is how well-established the values that guide those positions are. Saskatchewan has a set of five values (respect, engagement, excellence, transparency and accountability) and accompanying principles to guide planning, Brossart notes. They were developed by consensus by the regional board chairs, CEOs and provider representatives, not dictated from above. But they haven't really come to life yet. "You know you have common values when you see them in action," she says. "They are still words on a page and it will take very concerted, dedicated focus to move them from words on paper to words in action."

That would seem to demand accountability measures and consequences, and Brossart doesn't doubt they will come, but she is a little cautious. Bevan's work with the National Health Service makes her very focused on compliance because that's how the NHS works. But high-performing systems are based on commitment, Brossart says. Also, there can be a fine line between measuring progress and micro-managing – is your goal better access, which is value driven and can be achieved in a number of ways, or having every physician see 20 patients a day, which may sacrifice values to getting results? The answer will change the way patients experience care.

Brossart is very aware of pressure to produce results that show Accelerating Excellence is making progress. She says she senses a change, in the way people talk about healthcare, in the perspective they take to planning, but HQC's ability to measure progress remains "spotty and piecemeal."

"We're not there in a quantifiable way that resonates with policy makers, but it is a different world. We actually have healthcare workers curious and interested in how to change their work environment in a way they never were before."

She supports Florizone's plan for tests of change. She believes if communities see their neighbours getting "robust, timely, effective primary care from a multidisciplinary team" they may be persuaded to stop their fruitless hunts for physicians willing to work in the 24/7 model of 50 or 100 years ago and move on to the way high-performing health systems operate, with their emphasis on support, prevention and focus on the individual.

All in all, she admits, there are still many gaps in care in Saskatchewan, but it doesn't feel nearly as hit and miss as it used to. Accelerating Excellence is making a difference, she's sure. "I wouldn't say we are in a transformed state, but we have reached a place where we don't want to go back to the old ways."

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