Editorial

As readers reflect on the contents of this issue, their minds may turn – and return – to two key factors: relationships and time. Although these might be dismissed as patently obvious, a closer examination reveals just how crucial they are to the success or failure of healthcare innovations. Relationships are the heart of healthcare, and innovation doesn't come easily. And it won't come at all if health professionals don't have the dedicated time that innovation takes. Only then will time, as the song goes, be on our side.

The goals in this issue's articles are wide-ranging: to leverage value from public procurement; spur health centres to digital heights; increase primary care capacity and health outcomes; and support collaborative, continuous patient care and provider well-being. Reaching those goals will require close attention to relationships and dedicated time – elements paramount to health system progress.

Special Focus on Innovation Procurement in Health Services

Snowdon et al. (2019a) explain the emergence of innovation procurement within the healthcare context and the shift from traditional, lowest-cost vendor selection to value-based procurement. Under that model, outcomes such as quality and safety must be considered when purchasing and contracting for public goods and services. Those goods and services now account for more than 30% of total government spending – more than 13% of Canada's GDP – underscoring the potential impact of this change on economic growth and health system performance.

Healthcare organizations have only recently begun to experiment with new methods of purchasing innovative goods and services for practice, service and system solutions. Snowdon et al. analyze four organizations' first innovation procurement efforts and examine the three new models – competitive dialogue, design contest and innovation partnership – they chose for their initiatives. Four articles, each based on one of these case studies, follow the opening overview (Snowdon et al. 2019b, 2019c, 2019d, 2019e).

The outcomes of all the initiatives were largely successful. Vendors and healthcare teams reported positive and problematic experiences; they welcomed the new nature of their relationships – from supplier to innovation partner – and valued the increased engagement and clearer communication. However, they faced steep learning curves and struggled to meet lengthy time commitments – an especially challenging problem for clinicians.

While acknowledging innovation procurement's pitfalls, the researchers point to preliminary evidence of its value and impact, including stronger organizational capacity to resolve problems, improved performance on system priorities and prospective solutions for future challenges.

Building Effective Family Health Teams

The primacy of relationships – between doctors, patients and caregivers; between primary care physicians, specialists and interprofessional providers; between mentors and mentees; and between sectors inside and outside of healthcare – echoes throughout this section. Challenges and complexities also surface, along with tensions about time. Callaghan et al. (2019) report that the West End Quality Improvement Collaboration, a partnership of six community health centres in Toronto, discovered the importance of group dynamics, shared learning, expertise and the value of investing time.

Cook et al. (2019) examine an Alberta primary care network initiative and probe the meaning and purpose of physician–patient attachment. The project, partly driven by a desire to capture the number of panelled patients (linked to a single provider), reduced the number of patients listed on multiple primary care provider panels from 27% to 4%. The authors discuss what binds and separates attachment between a patient and “most responsible provider” from relational continuity's therapeutic role and informational continuity's focus on integrated systems. Attachment is key to patient-centredness and rightly embedded in a Patient Medical Home (PMH), but the authors point out that so-called attached patients see other providers for the sake of timely access or convenience. That leads to a call for engaged health system partners to reframe physician–patient attachment, clarify its purpose and align it with system priorities.

Clarke and Mehta (2019) look at the workings of three high-performing family health teams (FHTs) through the lens of the PMH, bringing its features into clear relief.

Drawing on the strengths of integrated, collaborative, team-based care – a key PMH function – the Marathon FHT's award-winning HARMS program produced, in 12 months, a 58% reduction in the number of opioids dispensed, a 29% reduction in the number of new opioid prescriptions and a rise from 0 to 20 in the number of patients being treated for addiction.

In Markham, the FHT's homegrown program has the evidence and stories to show it is keeping patients with eating disorders medically stable while awaiting specialized treatment, filling a serious service gap that threatened patients' lives and well-being.

The Peterborough FHT tackled a serious, persistent problem that many residents experienced: little or no access to primary healthcare. By developing two new clinics focused on virtual and rural-based care, the FHT reached residents who previously had no choice but to seek care in an often inappropriate and always costly setting: the emergency department.

Radhakrishnan and colleagues from the Ontario College of Family Physicians tell an inspiring, well-supported story about the spread and evolution of the Collaborative Mentoring Networks and their impact on patients, physicians and the healthcare system (Radhakrishnan et al. 2019). The first network was created in 2001 and focused on mental health; today, physicians have seven networks to support them on critical issues such as addictions and pain, palliative and end-of-life care and medical assistance in dying. It is a story about a particular kind of relationship – unique, individual, tailored to need – between family physicians and mentors with more clinical expertise who provide them with ongoing access to advice and support on patient, clinical, career and therapeutic practice issues. That translates into more care for patients with complex health conditions; fewer specialist referrals and system savings; and less isolated, more resilient family physicians – in short, increased capacity in primary care.

Leadership Development

Craighead et al. (2019) find much to praise about a formal coaching program they examined in a Canadian academic medical department. Given their assessment of its value, they recommend that opportunities for faculty coaching continue through embedded programs. One of the findings reported by the authors showed that the concerns of participants receiving coaching – including finding and keeping a healthy work-life balance, preventing burnout and increasing productivity and options for advancement – were addressed 70% of the time.

Electronic Health Record

Coxon et al. (2019) provide a weighty account of a project that led to overnight change. They report that after St. Joseph's Healthcare Hamilton deployed an electronic health record system across the entire organization at 4 a.m. on December 2, 2017, it rose from the bottom to among the top 2% of Canadian digital hospitals. Hospital leaders share the project's trajectory and recommend how to achieve transformational change “on time, in scope and within budget.” Advice on winning strategies includes: a disciplined single focus with governance and decision-making processes to ensure it; early, ongoing engagement with a whole-of-hospital approach; strong issue management nimble enough to readjust if required; and a clear story, authentic, understood and reflective of staff and patient input, centred on improving patient care.

Gomes and Juurlink's (2019) thoughtful column reveals that time – and analysis based on new and emerging evidence – shows that the swift, sweeping shift in opioid-prescribing guidelines, originally viewed as a bold policy move, now requires recalibration.

The Canadian Institute for Health Information has released results from its first patient experience survey, which provide a snapshot of patients' views on how information was communicated at different points in their hospital stay. Davidson and co-authors (2019) report that 62% of surveyed Canadians said their hospital experience was very good and two-thirds said they felt doctors and nurses listened to them – certainly a prerequisite for a good relationship. However, only 40% said they felt adequately informed about what to do if their condition worsened after leaving hospital, an experience possibly affected by time-related issues.

– The Editors

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