In our last column (Villeneuve and Mildon 2013), we shared the topics of 11 project charters developed by the Canadian Nurses Association to respond to the nine-point Call to Action of the National Expert Commission (NEC 2012). The lead recommendation of the NEC was to move Canada's ranking on five key population health and health system performance indicators into the "top five" internationally in five years. That recommendation by the NEC was intended to respond to Canada's mediocre (and in some cases deteriorating) ranking on a number of influential, internationally comparable population health and health system performance indicators. Throughout the tenure of the NEC, its members were troubled by those outcomes when set against constantly rising healthcare spending. Its place as the first recommendation reflects the determination of the commissioners that nurses must join with others to lead efforts required to shift that paradox.

Responding to the "Top 5 in 5" Recommendation

The NEC members were well aware that they were not the first to recommend a shake-up of the way we think about and operate the healthcare system. Through more than a decade of reform, health system leaders have been striving to create a more responsive, effective and sustainable healthcare system. CNA itself has engaged in extensive work, both independently and in collaboration with various partners. For example, in 2011, CNA and the Canadian Medical Association (CMA) defined a set of principles to guide healthcare transformation in Canada. Building on the five pillars of the Canada Health Act, these principles steer our future healthcare system towards public funding, sustainability, adequate resources and universal access to high-quality care. Health professionals and organizations across Canada have endorsed these principles – a powerful expression of their relevance and resonance.

But what are we striving to achieve as a country? And how will we know when we have succeeded? CNA has partnered with other nursing organizations, the Canadian Institute for Health Information (CIHI), Canada Health Infoway and others on three initiatives focused on the advancement of nursing-sensitive outcome indicators to evaluate the quality of nursing care being provided in various healthcare sectors: the National Nursing Quality Report, Canadian Health Outcomes for Better Information and Care (C-HOBIC) and Nursing Quality Indicators for Reporting and Evaluation (NQuIRE) tied to RNAO Best Practice Guidelines.

CNA is equally committed to accountability beyond clinical outcomes, that is, to those at a systemic level. Canada's ranking on a number of key population health and system performance indicators is falling when compared internationally, despite increased financial investments in our healthcare system. For this reason, CNA hosted an indicator colloquium in May 2012. The organization was interested in learning from others about their work in the area of indicators and to begin to make sense of what has been described by many as "indicator chaos" in Canada. Based on what was learned, it was clear that CNA's work in this field must be additive and complementary, rather than duplicative – and that it must align with national and provincial or territorial strategies.

To move forward on the "Top 5 in 5" recommendation, 32 experts from across the health system were invited to a consensus meeting on high-priority health indicators held on June 5, 2013 in Ottawa. In preparation for the consensus conference, CNA worked with Drs. Terrance Sullivan and Adalsteinn Brown to develop and implement an evidence-informed process to guide priority-setting and build national consensus on five high-priority indicators (Sullivan and Brown 2013). Several considerations informed the design of this selection process, including:

• the Institute for Healthcare Improvement's Triple Aim Framework;
• CIHI's draft conceptual framework;
• the paramount importance of the social determinants of health, issues related to health equity and the prevalence of health disparities;
• alignment with primary healthcare principles and the CNA/CMA principles to guide healthcare transformation;
• a focus on areas where Canada is falling behind or trending in the wrong direction; and
• indicators that are particularly sensitive to population health and nursing interventions.

The goal of the meeting was to achieve consensus on a meaningful set of five high-priority population health and system performance indicators. Participants worked from an initial shortlist of 10 indicators that had been identified in advance by CNA and an external reference panel of experts. After a lengthy session, the participants agreed on a list of five high-priority health status and system indicator-based goals:

1. Increase the percentage of primary care practices offering after-hours care.
2. Increase chronic disease case management and navigational capacity in primary care.
3. Increase Canadians' access to electronic health information and services.
4. Decrease hospital admissions for conditions related to uncontrolled diabetes.
5. Decrease the prevalence of childhood obesity.

Participants agreed on a strong case for Canada's "Top 5 in 5," including that this set of goals and related indicators (listed in Table 1) must:

• represent systemic issues that have a high health burden and a corresponding value for the Canadian population;
• reflect public priorities for healthcare and health system change;
• strike a balance between health system and health status improvement;
• be framed within a context of population health and health equity;
• represent a Canadian healthcare agenda that health leaders, service organizations, providers and patients can stand behind; and
• provide an important point of focus for our nation's healthcare stakeholders.

What's Next?

The consensus conference marked the beginning of strengthened collaborative efforts required to improve the health of Canadians and the future of our health system. CNA is working to validate, confirm and seek formal endorsement for the portfolio of five indicator-based goals arrived at during the conference with those who participated and a broader group of stakeholders. In doing so, CNA will build a multilevel framework for action based on the "Top 5 in 5." Current work includes a substantive examination of each indicator with an eye to clarifying how and where nurses can make meaningful contributions and positive impacts, through policy and practice interventions. The "Top 5 in 5" portfolio will also inform CNA's prospective work as we move to implement the NEC's Call to Action. Stay tuned for our next column for an update on the "Top 5 in 5" and the other actions unfolding in response to the NEC's call for action!

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