Moral dilemmas, funding scarcities, human resources shortages, knowledge gaps – surviving and thriving in today's healthcare environment is anything but simple or dull. In this issue of Healthcare Quarterly you will read about colleagues across Canada drawing on deep reservoirs of ingenuity and expertise to plan and implement solutions that, despite all the many hurdles we must every day surmount, make working in our sector an endlessly rewarding experience.
Healthcare systems always have abundant priorities; less often do they have enough funds to pay for them all. In our first article, Jennifer Gibson and her co-authors discuss a pilot project in three of Ontario's local health integration networks (LHINs) that involved developing and deploying an economics-and-ethics framework to guide priority setting and resource allocation. Despite the challenges of upholding "fairness" while "seeking to optimize 'benefit' for the available resources," participants found the framework improved both the credibility and defensibility of decisions.
The unsteady alignment between economics and ethics reappears in Roderick Slavcev's look at problems afflicting "universal access" to healthcare in Canada. Seeking to inspire reflection and, no doubt, to spark debate, Slavcev contends that we are doing a dreadful job of integrating the various "players" across the healthcare continuum. Focusing largely on the pharmaceutical arena, Slavcev criticizes scientists for disregarding issues of access and governments for failing to balance equity of access with the economics of spurring on scientific innovation.
Our final piece in this section introduces a concept new to me: "group priority sort." This leadership tool, Adina Jacobson and her co-authors explain, involves diverse stakeholders in consensus-building and consultation activities aimed, ultimately, at informing (rather than making) decisions. In addition to outlining the methodology, Jacobson et al. point out that "participants experience it as meaningful and instructive" and it leads to feelings of "ownership" of ensuing decisions – results that, at least in my experience, the Delphi process does not always attain.
We often hear that there is nothing more important than patient safety. But the absoluteness of that goal belies the complexity of achieving it. Trillium Health Centre, located in Mississauga and West Toronto, recently bolstered its patient-safety efforts by extending its board of directors' governance to include care quality. Patti Cochrane and her co-authors explain Trillium's use of "big dot indicators" and "driver diagrams" to plan, measure and report on quality metrics Aside from the governance-related benefits for board members, one of the most exciting effects of this widely-applicable initiative is the galvanic effect driver diagrams have had on clinical staff and even administrators.
To call something simple does not necessarily mean it lacks moral gravity or practical consequence. Robert Sibbald and his co-authors present a good example of this is in their case for meeting clinicians' "basic" ethical and legal obligations to end-of-life patients (one might compare here the system-focused ethical and financial concerns addressed by Gibson et al.). Drawing on Ontario law and examples, Sibbald et al. argue that a well-designed checklist could both minimize common mistakes (e.g., misidentifying a patient's substitute decision-maker) and help deal with conflicts among healthcare providers and with family members. "Patient centred, process oriented and values driven": these marks of a checklist useful at a particularly stressful juncture surely could be extended to many other instances of interpersonal relations and information management fraught by uncertainty and tension.
Health Human Resources
One of the biggest challenges facing healthcare planning today is the shortage of family physicians providing in-patient care. In order to help policy makers respond appropriately, Vandad Yousefi and Mark Evans created a hospital medicine (aka hospitalist) maturity framework specifically geared to Canada (the third framework discussed in this issue). Acknowledging that evidence is still lacking on care quality and resource use in Canadian hospitalist programs, Yousefi and Evans set out the stages and defining characteristics of hospital medicine in a framework aimed at supporting better-informed human resources policies and more trenchant research.
The discussion of the "quality journey" by Accreditation Canada's Wendy Nicklin and Jonathan Mitchell adds a useful gloss on several of the other pieces in this issue (notably, those by Slavcev, Cochrane et al. and Sibbald et al.). Nicklin and Mitchell summarize the past decade's "fast-forward" developments arising from governments', boards' and healthcare leaders' articulated focus on quality and efficiency under the umbrella of patient safety. While generally upbeat about the decade's accomplishments, the authors' brief thoughts on continuing crises and future risks sound a valuable cautionary note.
On the Web
Rounding off your reading is a short piece by Andrew Clairmont and Emily Maddocks that presents eight online resources relevant to population health policy and intervention research. While the directory they present is not vast, the sites are judiciously selected and described according to content, scope and usefulness. As this type of cataloguing matures, I will be interested to see more attention paid to site-to-site comparisons, especially across international frontiers.
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