The topic of improvement informs many of the articles in this issue of Healthcare Quarterly, and it is at the very heart of our first section, which focuses on Lean methods in healthcare. For over a decade, Lean has gripped the minds of many healthcare leaders. The short preface introduces some of Lean's key concepts and controversies. That is followed by three articles addressing specific applications of Lean in Canada. Lucille Perreault and her colleagues examine a Lean management pilot project at Ottawa's Montfort Hospital aimed at maintaining improvements (critically, reduced wait times) that had already been achieved over the previous four years. Using tools such as scorecards linked to organizational priorities, quality huddles and work standardization, the pilot units accomplished sustained improvements and employee satisfaction rose.
David Wood examines experiences at three other Ontario hospitals as they implemented government-directed Lean approaches in their emergency departments. Addressing how Lean was adopted in order to tease out the implementation factors that determine variant levels of success, Wood dissects the roles of leadership, staff engagement and motivation. On a vaster scale, Saskatchewan's implementation and evaluation of Lean forms the basis of the third piece. Leigh Kinsman et al. summarize the initiative's background and its proposed evaluation methods. This multi-year longitudinal evaluation is especially exciting for the insights it will provide into the complexities of large-scale health system transformation.
We move next to two essays that look at improvement efforts overseas. The first surveys the involvement of Canada's University Health Network in helping the Kuwait Cancer Control Center (KCCC) enhance cancer care services. Driven by an accreditation process mandated by Kuwait's health ministry, the "local customized approach" has achieved multi-faceted benefits for the KCCC and its patients, such as improved patient flow and staff accountability, as well as the introduction of the concept of a culture of continuous quality improvement.
Addressing hospital performance, Casimiro Dias and Ana Escoval focus on the advantages that accrue to organizations that have high degrees of "organizational flexibility" – a quality that has risen in importance since the global economic crisis of 2008. Examining the intersections among flexibility, strategy and innovation in 95 Portuguese hospitals, Dias and Escoval uncover evidence supporting the replacement of customary strategic management by strategic flexibility, which they regard as a "bottom-up model" of creative innovation suited to our uncertain times.
The threat of a pandemic has led jurisdictions around the world to develop critical care triage protocols. In 2009, a task force at the University of Toronto Joint Centre for Bioethics attempted to refine the "urgent" care criteria found in the utilitarian Ontario Health Plan for an Influenza Pandemic. Shawn Winsor (the task force's co-chair) et al. outline the research and consultative processes involved in this refinement, and they explain the task force's argument for two secondary triage criteria – first come, first serve and random selection – should an influenza pandemic outstrip care resources "on a wide scale."
From ethics, we turn to the related domain of the law; specifically, legal issues attending end-of-life care. Taking as her cue the Supreme Court of Canada's judgement in the much-publicized case of Cuthbertson v. Rasouli (October 18, 2013), Lawyer Daphne Jarvis sees this result, as well as the history of decisions arrived at by Ontario's Consent and Capacity Board, as "arguably" carrying weight in provinces and territories outside Ontario when conflicts arise between medical teams and patients' substitute decision-makers over the withholding of treatments.
Tacking back and forth between individual and organizational concerns is a constant in healthcare. In their article, Shelanne Hepp et al. studied seven primary care networks in Alberta to illuminate the organizational factors that improve inter-professional (IP) team functioning. Their research disclosed the importance of, among other things, leadership, physical space and information technology. Of even greater interest are the authors' numerous "targeted organizational strategies" to improve IP team functioning in primary care, including the creation of interdisciplinary management teams, comprehensive stakeholder engagement and the co-location of care providers.
In Ken Tremblay's interview with Marilyn Emory, the CEO of Toronto's Women's College Hospital, Emory notes, "there is huge promise for the healthcare system if we can scientifically assess what tests are essential and which are okay to eliminate from the standardized approaches we always use." This observation is germane to our final article, which examines the troubling issue of "inappropriate" diagnostic imaging (DI). Zeroing in on "why" physicians order DI and on "how" they do it, Janessa Griffith et al. identify several "socio-technical" factors to consider when attempting to alter physicians' practices. Coupling a literature review with physician telephone interviews, the researchers identified motivating elements such as patients' demand for testing and physicians' concerns over legal liability. Meanwhile, respondents' views on the potential role of methods to encourage appropriate ordering – computerized decision support, guidelines, education, better communication, restricting ordering authority – present a host of areas that warrant more investigation in order to reduce costs and improve patient safety.
– The Editors
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