In the first article of this series, I sketched a portrait of the current reality on Quebec’s health care scene, describing the symptoms of deep affliction within our system. Here, I envision a desirable future: a health care system that would be balanced with respect to quality, accessibility, safety, and affordability. In the next issue, I will propose a way to achieve the desired result, using an evidence-based approach.
KEY WORDS: provincial health care system, Quebec, accessibility, costs, clinicians, managers, common goals, co-management
In the first article in this series,1 we saw that Quebec’s health care system is in a state of major turmoil. It is far from sustainable and barely meets the expectations of the population. Physicians and managers have a common goal of offering quality, accessible, safe, and affordable care to the people of Quebec, and they are striving to achieve this goal with good will.
However, both physicians and managers have to deal with daily priorities that are often conflicting or parallel. Managers are constantly scrambling both to reduce the costs of the health care system and to make it more accessible. Physicians feel torn between their responsibility to meet the needs of individual patients, who require treatment now, and the obligation to address the needs of the larger population, who will need our health care system sooner or later. We have seen, however, that these two professions are beginning to work together more closely, as they both value accessibility and the interests of the community. We have also seen how the concept of medical and administrative co-management could provide a glimmer of hope. Top
Considering the different dilemmas faced by clinicians and managers, I have proposed that the solution to problems in Quebec’s health care system be based on four principles:
A clinically-led, patient-oriented approach
The primary objective of improving patient flow
A focused process of ongoing improvement
Removal of local measures of optimization
In the first article in this series,1 I concluded that any solution should simultaneously:
Create an ever-flourishing health and social services system
Rapidly improve the quality, safety, and timeliness of care provided to patients
Rapidly improve the affordability of care
Not create more complexity for staff
I sketched a portrait of the current reality on Quebec’s health care scene, describing the symptoms of deep affliction within our system. In this second article, I envision a desirable future: a health care system that would be balanced with respect to the objectives listed above. In the next issue, I will propose a way to achieve the desired result, using an evidence-based approach. The method is similar to that used by a clinician who observes the symptoms of a disease, takes a comprehensive approach to determining the etiology, prescribes a remedy proven by science, then makes conclusions based on the evidence at hand.
The primary objective of the health care system
In any society, the primary objective is to have fewer and fewer residents using the health care system for the simple reason that they have less and less need for it. When citizens do find themselves in need of care, they wish it to be, ideally, of high quality and delivered in an accessible, safe, and sustainable environment. Furthermore, as taxpayers in a fair and just society, they would like to feel proud about contributing to a system they care about and that is indispensable to their individual and collective well-being. Top
Health care users also expect representatives of the system, namely clinicians, managers, and support staff, to speak with one voice. They expect the flow in the system that receives them, treats them, and returns them to their homes to be as pleasant as that of their favourite café or restaurant.
The desired future of a health care region
In the system we seek, it is the patient — as an individual as well as a member of a community — who is the central concern. It cannot be otherwise, as, without patients, there is no system. This fundamental idea is above all a clinical one. In this desired future, it will be clinical physicians who establish diagnoses with the help of efficient tools and techniques. These same physicians will make full use of their skills by treating patients at a time that suits each individual need, while continually re-evaluating clinical evolution and prescribing the required treatment at the right time. Top
In the meantime, managers will follow the trajectory of care for each patient in real time and in perfect harmony with patients’ clinical needs. When a particular test or consultation is needed, managers will work closely with physicians in a co-management environment to ensure that each intervention is performed according to a medically required timeline. For patients in hospital, any examinations or consultations will be performed within 24 hours. For outpatients, consultations will take place immediately, in the case of an emergency, or within a week or a month for non-urgent cases.
Clinical teams and managers will pay constant attention to ensure that disruptions in the flow of patients are resolved in a manner consistent with patients’ needs. By identifying which task or resource is most often the cause of delays and by constantly optimizing the synchronization of resources, teams will quickly improve patient flow, most often without the use of additional resources. Clinical administration meetings will continually aim to answer this essential question: of all the things we could try to improve, which should we improve first? Top
Once we become accustomed to keeping pace with patients’ clinical needs, the cultural environment will become one in which any wait time in addition to that which is clinically required will be collectively deemed harmful, not only in terms of the patient’s diagnostic trajectory, but also in terms of the flow of other patients through the system, the safety of the health care environment, and the quality of care provided. Thus, there will be no need for clinical requirements to be subject to administrative delays. Instead, management will adapt to the clinical reality and treat each patient appropriately, thus mobilizing the medical team’s skills in an optimal fashion.
Physicians and managers will be continuously supported in their close monitoring of patient trajectories by a dynamic information technology (IT) system that delivers the required information in real time to pertinent stakeholders and managers. In addition to purely logistical data, health care workers will continually provide the clinical data required to identify any and all constraints to patient flow. Top
Given that, in each trajectory, there is often a predominant obstacle or bottleneck, the IT system will show what actually happens in real time, beyond hearsay, rumours, personalization, and blame. Bottlenecks will sometimes be occasional and, at other times, recurrent; but in all cases, physicians and managers will work closely together to identify places where action is required to accelerate patient flow. This process will also allow for impact assessment of any improvement attempted in the field.
Although the situation in Alma may differ from that in the Outaouais region, the key element is that partners in co-management will apply the same method, that is, they monitor patient flow so that health care users can exit the system as quickly as possible, after being treated in a humane and professional fashion, consistent with the expectations of a so-called developed society.
The higher the position a manager holds in the hierarchy of the system, the more access the IT system will give them to data that will allow them to see all the dynamics at hand, and the more able they will be to make informed decisions based on real wait times, for everything from an MRI scan to a coronary angiogram to a social work referral. Decisions made at the collective level will, thus, be based on solid numbers related to real, not perceived, individual needs. Data revealing both interesting and relevant conclusions will be available for comparison among the various regions of the province. As for the Ministry of Health and Social Services, it will be able to apply solutions based on conclusive data from each region, while taking into account how data differ from one region and one health care team to another. Top
Because co-management teams will have a thorough understanding of all that is blocking patient flow, it will be easier at all levels of the network to eliminate local optimization measures, as these act like brakes on overall fluidity. If accelerating the passage of a particular patient from one place in the system for a given cost has no impact on the patient’s trajectory or on health care outcomes, the effort will not be recommended. In fact, attempts to improve certain steps of a trajectory without affecting the trajectory as a whole will increasingly be recognized as local optimization efforts, which have every chance of increasing cost and workload without having a positive impact on the lives and health of patients.
Similarly, clinician and management teams outside institutions will work to provide appropriate and timely care, based on clinical need. They will, thus, manage to avoid having some patients enter the health care system. These teams will ensure that trajectories of care outside hospitals are working well, taking into account various risk factors as well as the role that social determinants of health in play in different regions of the province. Top
Natural repercussions of this future system
By following this approach, health care workers everywhere will help create a flourishing health and social services system, where accessibility will go hand in hand with clinical necessity. This system will rapidly improve the quality, safety, timeliness, and accessibility of patient care.
It is of utmost importance to note that these improvements will not produce increasing complexity for staff. Rather than being considered the culprits of the system’s failures, health care workers will be viewed and treated as valuable sources of information and improvement. After all, the workers themselves only stand to benefit from a healthy, rational, and fulfilling work environment in which they are proud to evolve.
With more fluid trajectories of care, bed shortages and wait lists will become rare, health care workers will be called on for less and less overtime work, and staff will have more time to improve the quality of care. Furthermore, staff retention will increase with subsequent reductions in training costs, and any recruitment will be made substantially easier. Top
On the management side, costs engendered by the health care system will noticeably and progressively decrease until such time as patients remain in the hospital for clinical reasons only. The continuous synchronization of care trajectories will also allow costs to be precisely calculated and compared. Health care institutions will have more balanced budgets, and savings resulting from improved management will be available for reinvestment in prevention.
As for members of Quebec’s councils of physicians, dentists and pharmacists, they will be increasingly able to make full use of their expertise. Their hard work will be even more rewarding, as they will have helped optimize the fluidity of care trajectories. This new situation will contribute to creating a happier, more committed, motivated, and productive medical profession.
The councils will acquire progressive knowledge as to their members’ contributions to management, their need for training, the time required for further education, as well as the associated costs. They will, thus, be able to offer detailed recommendations to their boards of directors. They will also be able to provide improved guidance to their members in terms of their obligations toward quality of care and the cost of treatment. As these environments become more focused on the quality of care, they will attract practitioners and researchers with complementary areas of expertise.
Regarding the training of future physicians and continuing medical education, more and more emphasis will be placed on the role and responsibility of the physician with regard to care management and the costs engendered by medical prescriptions, including diagnostic tests and treatments. A change in culture will come about gradually. Physicians will thus be increasingly aware of the impact of their professional actions on the trajectory of care and on systems operations costs. Top
The role of IT workers will constantly adapt to real patient need. These technicians will learn to detect bottlenecks and apply the most suitable solutions possible while meeting the requirements of clinicians and managers. Appropriate components of big data collected across the province will be compiled and compared, allowing for an overview of the entire system and providing experts with relevant population data. Governmental policymakers will, thus, have the necessary evidence to make appropriate health decisions, and the government of Quebec will claim its place as a leader in health IT.
The societal impact of a flourishing health region
Once health care institutions begin providing more and more high-quality, accessible, and affordable care for the population of their area, they will be able to place more focus on prevention. Population health will improve, the Ministry of Health and Social Services will meet its objectives more easily, and society will likely be more productive. Treasury Board might decide to redistribute money otherwise spent on health care to other social or governmental services. Quebec society will be healthier and more fulfilled and, thus, better equipped to take on other ongoing challenges.
At first glance, the desired future as described in this analysis might seem elusive, a future that will come to pass the day pigs fly. However, on closer examination, we can see that we are fully capable of translating this ideal into reality. We have the expertise we need to respond positively to society’s expectations, which demand first-class performance from their system. To achieve these aims, we need to follow a series of logical steps specifically designed to create a system in which we all want to work or receive care. The third article in this series will address the prerequisites for building this system. Top
We have laid the groundwork for the future we desire for the Quebec health care system. By following the principles of a clinically based, patient-centred approach, by focusing on trajectories of care, by following a process that allows for continuous improvement, and by systematically avoiding local optimization, we will be able to design a high-performance health and social services system. Any solution must simultaneously create an ever-flourishing health and social services system; rapidly improve the quality, safety, and timeliness of care provided to patients; and rapidly improve financial accessibility to the care offered without creating more complexity for staff.
In this future health care system, patients will benefit from their clinicians’ professional expertise. Clinicians will work alongside managers, using powerful and dynamic technological systems that shed light on the elements that prevent patients’ trajectories of care from being clinically appropriate. Together, clinicians and managers will work to find solutions for each problem they encounter, while constantly re-evaluating the impact of the measures they apply on the lives of patients and the experience of employees.
This improvement process is based on the concrete results of our actions in each of the province’s regions. In this system, all health care workers will be part of the solution and will be able to treat all patients with care and compassion.
1.Vander Stelt R. The currrent reality in Quebec’s health care system—auscultation of an ailing system: the symptoms and their causes. Can J Physician Leadersh 2017;3(3):91–5.
Ruth Vander Stelt, BA, MD, CMFC, MM, is a family physician practising in the Pontiac region of western Quebec. She has also served as president of the Association médicale du Québec.