Canada’s Top 5 in 5
In 2011, the Canadian Nurses Association made a decision to establish and fund a national commission focused on health system transformation, the National Expert Commission. In 2012, the commission presented an action plan, the lead recommendation of which was to ensure that Canada ranks among the top five nations on five key population health status and system performance indicators in the next five years. In this article, the authors outline the selection of the these indicators and the associated goals for improvement.
Members of the National Expert Commission
Maureen A. McTeer, BA, MA, LLB, LLM, LLD (hons), co-chair
Marlene Smadu, RN, EdD, co-chair
The Honourable Sharon Carstairs, PC, BA, MAT, LLD (hons)
Thomas d'Aquino, BA, JD, LLD, LLM
Robert G. Evans, OC, PhD
Robert Fraser, RN, MN
Francine Girard, RN, PhD
Vickie Kaminski, RN, BScN, MBA
Julie Lys, RN, NP, MN
Sioban Nelson, RN, PhD, FCAHS
Charmaine Roye, BSc, MDCM, FRCSC
Heather Smith, RN
Rachel Bard, RN, MAEd (ex officio)
Judith Shamian, RN, PhD, LLD (hons), DSci (hons), FAAN (ex officio)
Michael Villeneuve, RN, MSc (ex officio, executive lead)
Commission Process and Reporting
After a lengthy deliberation on topics and methodology, the Canadian Nurses Association (CNA) made a decision in 2011 to establish and fund a national commission focused on health system transformation. The National Expert Commission (NEC; Table 1) was launched in May 2011 to strengthen the contribution of nursing in health system transformation, to support the sustainability of Canada's publicly funded, not-for-profit medicare system and to inform CNA's policy work going forward. The NEC was charged with identifying innovations and best-value investments for the health system, with an eye to strategies making the most effective use of the country's nursing workforce. The commission represents the first time Canada's nurses have spearheaded a transformation initiative on this scale.
CNA chose to position the NEC as an arm's-length, independent entity led by two external co-chairs – Maureen McTeer and former CNA president Dr. Marlene Smadu – and a roster of esteemed Canadians from the fields of politics, business, academia, economics and healthcare. The commission was managed by a secretariat of staff seconded from CNA and supported by externally contracted experts.
Through 2011 and 2012, the commission met regularly, conducted extensive background research and commissioned three research syntheses through the Canadian Foundation for Health Improvement. In a creative process brokered and led by MASS LBP, commissioners consulted with Canadians (including members of government, health professionals, business leaders, academics and the public) in YMCA Canada locations across the country, as well as in many other individual and group meetings. With the gracious support of their Excellencies, Governor General David Johnston and Mrs. Johnston, the commission held a national roundtable on Aboriginal health and healing at Rideau Hall. Online submissions were solicited and received from across the country, and formal public polling was conducted for the NEC by Nanos Research.
The commission tabled its final report with a nine-point, evidence-driven action plan (accompanied by extensive background documents and fact sheets) in June 2012. Framed as a call to action both to and from nurses, the commission used the Institute for Healthcare Improvement's "Triple Aim" (better health, better care, better value) as its organizing framework. The commissioners also considered evidence in a fourth pillar – best nursing – by which it meant the best use of nurses and nursing to support the Triple Aim. As such, the action plan focuses on improving population health, making healthcare more effective and centred on improving patient experiences, optimizing value for the dollars we all invest and maximizing the roles – and potential roles – of the country's nurses.
Top 5 in 5
Aiming for the nation's 150th birthday in 2017, the lead recommendation of the NEC was to ensure that Canada ranks among the top five nations for five key population health and system performance outcomes in the next five years. That recommendation sprung from the concern of the commissioners about a troubling mismatch between spending and results. Now exceeding $200 billion nationally, annual healthcare costs account for nearly 50% of some provincial/territorial budgets. Governments and healthcare leaders are scrambling to find ways to rein in spending while building sustainability and improving the patient experience, quality of care and the health of the public overall. By the time the 2004–2014 Health Accord expires next year, an additional $41 billion of federal funds will have been transferred to the provinces and territories to tackle health and system outcomes. Despite that investment and ballooning budgets, some of Canada's health system performance and population health outcomes have stalled or even dropped in comparative international rankings. And the accord failed to generate promised deliverables such as a national pharmaceuticals strategy or expanded access to primary care around the clock.
From the NEC's nine-point plan, CNA developed 11 distinct projects to bring these recommendations to life and to action. The first project charter responds to the Top 5 in 5 recommendation. To act on it, CNA held a consensus conference in June 2012 that included 32 representatives from provincial/territorial health quality councils and ministries of health, regional health authorities, branches of the federal government and academics; health system administrators; and experts in indicator measurement. To prepare for the meeting, CNA worked with health policy experts Terrence Sullivan and Adalsteinn Brown and a skilled reference panel to produce an evidence-based, priority-setting process for reaching a national consensus on five priority health and system indicators.
Chosen from hundreds of possible indicators, 10 were selected using criteria such as international comparability, scientific validity, value, burden, relevance to Canadians and achievability (sensitivity to a five-year window of transformation). CNA also examined indicators in the Canadian context – where could Canada maintain a strong performance or show substantial improvement? The indicators chosen had to add value, not duplicate existing efforts; as one participant put it, the indicator work should "build on the existing scaffolding." The short list of 10 indicators was the starting point for the consensus meeting.
Whatever work we all do as professionals must also be engaging to the public. Opinion polling conducted for CNA by Nanos Research before the consensus meeting revealed that the top health systems concerns of those sampled were accessibility, sustainability (members of the public have heard all the talk and are very concerned), effectiveness and efficiency. CNA is keenly aware from this polling and the previous surveys conducted for the commission that the work has to embody elements that are likely to interest and excite the public.
There was extensive discussion during the meeting about the need to move to a different level of conversation and debate if we really are going to achieve transformation. Participants certainly are aware of public concern, but there is also public fatigue with our seeming inability to "get on with it" and make the value-added changes we all keep talking about. As one participant noted, all the talk about transformation is "wearing a bit thin" absent an action plan being implemented. Saying that "there is tremendous power (for some) in maintaining the existing confusion," another participant urged that we really must nail down and surmount the dynamics that "are keeping us from getting to the hardball issues we all know are holding up change." Examples of successful enablers could help the process.
After a lengthy debate, the group achieved consensus on a draft portfolio of five priority indicator-based goals:
- Increase the percentage of primary care practices offering after-hours care
- Increase chronic disease case management and navigational capacity in primary care
- Increase Canadians' access to electronic health information and services
- Reduce hospital admissions for conditions related to uncontrolled diabetes
- Reduce the prevalence of childhood obesity
The consensus conference group agreed that these indicators accomplish the following (detailed below):
- Represent systemic issues that have a high burden and corresponding value within the Canadian population
- Reflect public priorities for healthcare and health system change
- Strike a balance between health system and health status improvement
- Represent a Canadian healthcare agenda that healthcare leaders, service organizations, providers and patients can stand behind
- Provide an important point of focus for our nation's healthcare stakeholders
Represent Systemic Issues That Have a High Burden and Corresponding Value
It was agreed that the five indicators will have a substantial impact on the health of the population, individual quality of life and cost of the healthcare system relative to other Canadian health system challenges.
Reflect Public Priorities
Public polling undertaken as part of this project revealed that Canadians prioritize the healthcare system's ability to serve their needs ahead of the quality of the service they receive. Canada's Top 5 in 5 reflect this prioritization by focusing primarily on improvements to accessibility, sustainability, efficiency, effectiveness and equity. They shift our focus from acute care settings to primary and community-based care, chronic disease prevention and management, increasing patient participation and the need to improve the patient experience at every encounter.
Strike a Balance
Healthcare leaders agree on the need to consider equity as a principal component of the Triple Aim framework. While Canada's Top 5 in 5 are primarily focused on improving important processes in the healthcare system, most of the indicators support the need to improve access to community-based care, where the potential for health status improvement, disease prevention and an increased focus on the social determinants of health is greatest.
Represent a Canadian Healthcare Agenda That People Support
The vast majority of consensus conference participants indicated that this work is well aligned with their organization's interests, and that they are committed to moving Canada's Top 5 in 5 forward. Close to two thirds of participants indicated that they would be willing to seek endorsement from their organizations for the portfolio of indicator-based goals.
Provide a Focus for Our Nation's Healthcare Stakeholders
Today, governments, health agencies, associations, planning and service delivery organizations, providers, patients and the public are signalling the same message – we cannot continue the way we have been going. Many have developed reports and measures to illuminate this message. With today's environment of "indicator chaos" and a lack of clarity on the role of the federal government in healthcare, a common and focused vision is welcomed.
The results of the consensus process have been received by the CNA board. The final report has just been finalized, and this document will further inform the board members as they discuss next steps. In the weeks ahead, CNA will begin to elaborate a framework for action that will articulate nursing contributions and multi-level opportunities to engage a broad coalition of (multi-professional) partners in policy and practice interventions that will drive improvements on Canada's Top 5 in 5. Stay tuned to future issues of Healthcare Quarterly, where CNA will share its framework for action on the Top 5, report on the implementation of the remainder of the NEC's action plan and seek the participation of health system leaders across Canada.
About the Author(s)
Michael Villeneuve, RN, MSc, is a lecturer and associate graduate faculty in the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, in Toronto, Ontario; and principal at Michael Villeneuve Associates.
Don Wildfong, RN, MSc, is senior nurse advisor for leadership and knowledge translation in the Policy and Leadership Division of the Canadian Nurses Association, in Ottawa, Ontario. To reach CNA regarding Canada's Top 5 in 5, please contact firstname.lastname@example.org.
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