It's about the Relationships: Reflections from a Provincial Quality Council on Building a Better Healthcare System
The mandate of Saskatchewan's Health Quality Council (HQC) is to play a hands-on role in health system transformation by working collaboratively with government, regional health authorities, health professions and citizens. Instead of the traditional, representative model, HQC is governed by an "expert board." Because board members do not represent their own organization or profession, they have stayed focused on the "system" nature of HQC's mandate, working with individuals and organizations committed to improving quality at a system level.
In recent years, HQC has achieved a significant shift in attitude toward quality improvement throughout Saskatchewan's healthcare system, realized partly through building strong, effective relationships with those managing and delivering care. Hundreds of front-line providers, managers and leaders are now learning and applying quality improvement methods to improve healthcare quality. Since its inception, HQC has moved to a higher level of interdependence with other healthcare system stakeholders, helping advance the quality agenda so that everyone has a greater understanding about mutual responsibilities.
The Commission also recommends the creation of a Quality Council with a mandate to improve the quality of health services in the province. The Council should be an evidence-based organization, arm's length from government and reporting to the Legislative Assembly. In so doing, Saskatchewan will lead the country in the pursuit of a quality culture that will be the next great revolution in health care.
(Government of Saskatchewan 2001)
It is hard to believe that a decade has passed since Commissioner Ken Fyke's visionary recommendation. While several provinces have since established their own quality councils, the mandate of Saskatchewan's Health Quality Council (HQC) – to play a hands-on role in health system transformation by working collaboratively with government, regional health authorities, health professions and citizens – makes it unique. Although it may be premature to describe the changes over the past ten years as a revolution, there has been a tangible shift in our provincial health system's aspirations, vocabulary and behaviour. Today, there is a widespread, unwavering focus on and commitment to improving healthcare quality here and across the country (Sullivan et al. 2011). We are regularly asked how we came to play such a collaborative and influential role within this province's health system. This essay describes factors behind our achievements to date and some of our disappointments and ongoing challenges.
The passing of The Health Quality Council Act in November 2002 laid the foundation for HQC to succeed (Government of Saskatchewan 2002). As this piece of legislation was the first of its kind in Canada, the Ministry of Health sought fairly broad input from health system leaders. The result was legislation that was broad and ambitious, and based on an understanding that HQC was to actively work to advance the quality agenda. Government took a calculated risk in creating an agency whose mandate included publicly reporting – warts and all – on a health system funded by, and perceived to be run by, government. The legislative mandate gave force and clarity to both the HQC's mandate and degree of independence. Of those provinces that have created their own quality organizations, Alberta and Ontario have similarly enacted legislation (Government of Alberta 2011; Government of Ontario 2010).
The policy makers behind our legislation departed from the norm by recommending that HQC's board of directors be an "expert board" rather than the traditional, representative model. The minister of mealth submits a list of potential candidates for selection by Cabinet. Saskatchewan's lieutenant governor in council appoints HQC board members for a three-year term and reappoints existing directors for subsequent terms. From the outset, we have been governed by a board of 12 provincial, national and international leaders from healthcare and other fields with expertise in clinical care, system administration and management, health system research, health policy and quality improvement. This diverse makeup has yielded several benefits. Because board members do not come to the table representing their own organization or profession, the group has always stayed focused on the "system" nature of our mandate – and on working with individuals and organizations who share this commitment to improving quality at a system level. The involvement of board members from outside the province demonstrated government's commitment to learning from elsewhere and ensured that crucial deliberations were grounded in both local context and learning and innovation from other health systems. So many of the improvement ideas and approaches that are being applied in Saskatchewan have been stolen shamelessly from elsewhere and carefully adapted to the local environment. A tangible benefit of having an expert board is the strategic relationships they have helped us build with leaders from other high-performing health systems from across the globe.
While establishing and nurturing relationships with global colleagues has been key in informing our approach to health system transformation in Saskatchewan, the quality of our relationship with our health system partners in this province is even more critical to our work. Our Saskatchewan board members – and indeed everyone who works at HQC – are actively involved in maintaining these all-important connections. The board chair, vice-chair and CEO work as ambassadors, building bridges with health regions, health professions and government. Recognizing that engaging physicians would be critical to the success of HQC, government made the conscious decision to appoint a physician as the first chair. Naming a nursing leader as vice-chair was also a strategic move, given the environment at that time. Having the CEO of a Regional Health Authority as chair for a period enabled the agency to strengthen engagement and relationships with this key constituency. HQC board members have participated at all significant provincial meetings as official representatives of the agency or when called upon to bring this perspective.
Strong, constructive relationships between an agency like a quality council and other organizations in the health system are critical to advancing improvement ambitions; transforming healthcare challenges us to rethink how we have always done things. Not surprisingly, these relationships have been tested over the years. There have been instances where stakeholders, such as the Ministry of Health, objected to content and key messages in HQC's public reports. Similarly, HQC has at times been frustrated when policy makers have not addressed gaps in policy or incentives we identified as having the potential to improve quality. Appealing to people's altruism and in some cases underwriting some or all of their expenses for participating in quality improvement programs, we learned, was an insufficient catalyst for transformational change.
For many years, one of the biggest challenges the HQC faced was complacency among some health system leaders; people were hesitant to set bold targets and invest resources accordingly to address poor quality. There may have been a perception that quality improvement was someone else's job, possibly HQC's – this despite the fact that our $5.5 million operating grant represented just 0.1% of the overall healthcare budget. There has been a significant shift in attitudes in recent years, spurred in part by our efforts to regularly challenge the status quo, but we achieved the shift through strong, effective relationships with those managing and delivering care. As a result, hundreds of front-line providers, managers and leaders are now learning and applying quality improvement methods to improve healthcare quality throughout Saskatchewan's healthcare system. There is growing appreciation for and use of publicly available performance data as a foundation for ongoing improvement (Health Quality Council 2012a). As well, more people living with chronic diseases are receiving evidence-based care, and more patients in hospitals are benefitting from improved processes, thanks to the lean-based improvement strategy Releasing Time to Care™ (Health Quality Council 2010; Health Quality Council 2012b).
Both the board and staff at HQC have had many philosophical and practical discussions over the years about our theory of change. By default, we have followed an eclectic approach, which, in many ways, reflects the importance of our relationships and collaboration with our partners (especially, working with them wherever they are at, in terms of readiness for change) and a continuous quality improvement approach to our own methodologies and theories.
HQC's role in the health system has evolved from one of more implied independence to becoming a better partner. This has involved some organizational learning about how to work more skilfully and collaboratively with our many partners, to foster a culture where all are learning and focusing on our respective roles. We have moved to a higher level of interdependence, where we still see ourselves playing a role in advancing the agenda so that everyone has a greater understanding about our mutual responsibilities. Some may argue the shift from independence to partnership requires trade-offs; we feel it is more constructive to determine which approach is most effective (and when) to accomplish the collective goals HQC shares with its health system colleagues. Just as partnering and leveraging our respective talents to meet these ambitions will be critical, there will also be times when, given our provincial perspective and role, an independent voice or perspective is what's required to make further progress.
There are challenges ahead, ones that will demand even greater risk-taking and courage on the part of all stakeholders – governments, health regions and agencies such as quality councils. What is known, however, is that we will be unsuccessful in reaching our ambitions without an unwavering focus on patient-centred care, publicly available information on health system quality, a commitment to build and support those doing the work, the skills and capacity to continuously improve, and a collective, system-wide focus on health system improvement. These elements, critical to system transformation, will remain grounded in solid, respectful relationships.
About the Author(s)
Bonnie Brossart, MA, is CEO of the Health Quality Council (Saskatchewan) in Saskatoon, Saskatchewan.
The author gratefully acknowledges the guidance of current HQC Board Members Charlyn Black, Maura Davies, Dan Fox and Dennis Kendel; past HQC Board Members Peter Barrett, Steven Lewis and Marlene Smadu; and colleague Greg Basky in the development and review of the manuscript.
Government of Alberta. 2011. Health Quality Council of Alberta Act. Edmonton, AB. Retrieved December 31, 2011. <http://www.qp.alberta.ca/documents/Acts/h07p2.pdf>.
Government of Ontario, 2010. Excellent Care for All Act. Toronto, ON. Retrieved July 16, 2012. <http://www.e-laws.gov.on.ca/html/source/regs/english/2010/elaws_src_regs_r10445_e.htm>.
Government of Saskatchewan. 2001. The Commission on Medicare Final Report (Fyke Report). Regina SK. Retrieved December 31, 2011. <http://www.health.gov.sk.ca/medicare-commission-final-report>.
Government of Saskatchewan. 2002. The Health Quality Council Act. Regina, SK. Retrieved December 31, 2011. <http://www.qp.gov.sk.ca/documents/english/Statutes/Statutes/h0-04.pdf>.
Health Quality Council. 2010. Building a Culture of Quality Improvement in Saskatchewan's Health Care System: Assessing the Impact of the Health Quality Council. Saskatoon SK. Retrieved July 16, 2012. <http://www.hqc.sk.ca/download.jsp?21jsu4cwaJJn8Hx2sLjGMDBIzBf0QfLQkUwK4QBZaJvvJuDAeOe2/Q==>.
Health Quality Council. 2012a. Quality Insight. Saskatoon, SK. Retrieved July 16, 2012. <http://www.qualityinsight.ca>.
Health Quality Council. 2012b. Releasing Time to Care: The Productive Ward. Saskatoon, SK. Retrieved July 16, 2012. <http://www.hqc.sk.ca/portal.jsp?w9OrgXzJ6G2qY7R58y47yDBIzBf0QfLQkUwK4QBZaJvEYgnWT8wYaVVvI5thiwzu>.
Sullivan, T., F. Ashbury, J. Pun, B.M. Pitt, N. Stipich and J. Neeson. 2011. "Responsibility for Canada's Healthcare Quality Agenda: Interviews with Canadian Leaders." Healthcare Papers 11(3):11–21. Retrieved January 15, 2012. <http://www.longwoods.com/content/22554>.
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