Insights (Essays)

Insights (Essays) July 2020

COVID-19: Canada’s Response Must Now Focus on Quality

Ben Chan

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Canada is now well into its phased plan to reopen the economy following the first wave of COVID-19.  Over a dizzying six-month period, we discovered a new coronavirus and struggled to contain the pandemic that arose from it.  Evidence on what was effective shifted rapidly; we went from avoiding, then implementing travel bans and face masks, and changed from more to less aggressive ventilation strategies.  At first, it was difficult to define a quality strategy because best practices were not yet defined.

Now, however, the desired path forward is clearer: enact mass testing with minimal delay; deploy rapid, thorough contact tracing; isolate exposed individuals and enforce quarantine; maintain physical distancing and use of face masks in confined spaces; and manage the supply chain for PPE, drugs and other resources and ensure appropriate use.  In short, we now know what high-quality COVID-19 management should look like.

Knowing what to do, however, does not automatically translate into flawless execution.  Instead, Canada’s COVID-19 response now exhibits the typical quality problems found in healthcare, sprouting like weeds in a garden.  We have had difficulty increasing testing with variations in access; at a recent hospital shift, I waited three days for test results despite promises of 24-hour turnaround times. Physicians complain about delays in contact tracing or lack of thoroughness (Arthur 2020) and continue to worry about adequacy of PPE supply (CMA 2020).  Lapses in enforcing physical distancing have led to needless deaths of migrant workers (Edmiston 2020).

Now is the time for Canada’s healthcare systems to coordinate a quality strategy for their COVID-19 response and marshal quality management expertise to ensure success.  The WHO (2018) framework for national quality planning offers us guidance. Here is what a quality strategy looks like:

  1. Articulate a clear vision of quality.  Build on the popular mantra: “Test. Trace. Isolate.” Include proper treatment and prevention.
  2. Identify core processes for aggressive management of COVID-19 (see Table 1).  Deploy quality improvement teams to map each step of the process, and continuously identify and root out problems such as miscommunication, poor coordination or misused resources.  Errors – such as when 485 COVID-19-positive cases did not get contact tracing because one hospital assumed that another was responsible for notifying public health(Rocca 2020) – could be avoided with such vigilance. 
  3. Identify people trained in quality management through past programs offered by provincial health quality councils, Canadian Patient Safety Institute, professional associations or other quality programs, and recruit them for the above task. 
  4. Create structures to allow quality teams to share their learnings systematically, such as virtual collaborative projects or communities of practice.  Use existing platforms such as Project ECHO that connects experts to practitioners in remote locations (Arora 2020), or similar approaches developed by health quality councils. 
  5. Develop a clear dashboard with indicators and performance targets that represent progress towards this vision. 
  6. Enact public reporting of key indicators in real time in each region responsible for such activities, along with their performance targets. 
  7. Standardize and streamline data collection. Create data standards and a centralized information system for public reporting.  Given problems with siloed data and reliance on fax machines in some provinces, such a system may take time to develop.  In the interim, draw on low-cost, tried-and-true methods for monitoring quality, such as block sampling 20 cases per week to audit performance on key measures. 
  8. Design a clear accountability framework.  Each process described below should have an “owner”, an indicator and a target.  The organization responsible for the process is held accountable to the local public, media and the respective provincial ministry of health for achieving these targets, and must explain its plans for addressing quality gaps. 
  9. Invest in resources to manage quality.  Ministries of health must earmark funds for quality improvement teams, data collection and analysis, sharing knowledge and maintaining accountability as described above. 
  10. Enact comprehensive capacity planning and demand prediction modelling for each resource.  This includes lab supplies, PPE, ventilators, anesthetic drugs for ICUs and contact tracing staff.  Anticipate the resource requirements for each case of COVID-19 and create a flexible staffing and procurement plan that lets us scale up resources needed in best- and worst-case scenarios.  Coordinate these activities between central and local levels. 

Canada’s federal and provincial governments have invested in quality through the creation of health quality councils and organizations.  Let us leverage these investments to achieve the highest quality response to COVID-19 now and prepare ourselves better for the next phase.  We deserve nothing less.

Table 1: A quality management framework for COVID-19

Strategy

Processes to be optimized

Potential indicators

Test.

Lab:

- ordering process
- swabbing
- swab transport
- lab processing
- delivery of result

Lab turnaround time

Trace.

Contact tracing:

- receipt of positive test result
- taking contact history
- calling contacts
- arranging isolation

Contact tracing time, completion rate

 

 

Isolate.

Isolation:

- ordering of isolation (e.g. returning travellers)
- monitoring of quarantine
- assisting with essential services (e.g.
grocery delivery)
- sanctions for non-compliance

Compliance rate

Prevent.

Transmission prevention:

- physical distancing
- use of face mask in confined spaces
- limits on public gatherings

Compliance rate

Treat.

Ensure supply chain and/or reserve capacity for:

- PPE, contact tracing staff, drugs, supplies
- regular and ICU beds, ventilators

Percentage of regions with available inventory or spare capacity

 

About the Author(s)

Ben Chan is an assistant professor at the Institute for Health Policy, Management and Evaluation at the University of Toronto, Toronto, ON; a consultant at the World Bank, and former CEO of the Health Quality Councils of Saskatchewan and Ontario. He practices medicine part-time in rural communities throughout Ontario

References

Arora, S., K. S. Mate, J. L. Jones, C. B. Sevin, E. Clewett, G. Langley, et al.  2020. Enhancing Collaborative Learning for Quality Improvement: evidence from the Improving Clinical Flow project, a Breakthrough Series Collaborative with Project ECHO. The Joint Commission Journal on Quality and Patient Safety. doi: 10.1016/j.jcjq.2020.04.013. 

Arthur, B. 2020, May 20. Critical Care Doctor Says The ‘Inexcusable’ Ontario Public Health Strategy is Wasting the Lockdown. The Star. Retrieved July 16, 2020. <https://www.thestar.com/opinion/star-columnists/2020/05/20/critical-care-doctor-says-the-inexcusable-ontario-public-health-strategy-is-wasting-the-lockdown.html>.

Canadian Medical Association (CMA). 2020. CMA Rapid Poll on the Supply of Personal Protective Equipment and Mental Health Impact of COVID-19. Retrieved July 16, 2020. <https://www.cma.ca/sites/default/files/pdf/Survey/CMA-rapid-poll-Executive-summary-2_EN.pdf>.

Edmiston, J. 2020, June 8. Migrant Workers in Canada Face Unsafe Working, Living Conditions: Report. Financial Post. Retrieved July 16, 2020. <https://financialpost.com/news/migrant-workers-facing-unsafe-working-living-conditions-report>.

Rocca, R. 2020, June 2. Hundreds of Positive Coronavirus Tests Weren’t Reported to Ontario Public Health Units. Global News. Retrieved July 16, 2020. <https://globalnews.ca/news/7017710/positive-coronavirus-tests-ontario-not-reported/References>.

World Health Organization. 2018. Handbook for National Quality Policy and Strategy: A Practical Approach for Developing Policy and Strategy to Improve Quality of Care. Retrieved July 16, 2020. <https://apps.who.int/iris/bitstream/handle/10665/272357/9789241565561-eng.pdf>.

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