The way to get there – Working toward balance in Quebec’s health care system
Ruth Vander Stelt, MD
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We are closer than we think to achieving success in repairing Quebec’s health care system. In this third and final article in a series on its issues, I focus on how to achieve a system that would be balanced with respect to quality, accessibility, safety, and affordability.
KEY WORDS: provincial health care system, Quebec, accessibility, costs, clinicians, managers, common goals, co-management
The goal of any health care system is to provide high-quality, accessible, safe, and affordable health care. Given that health care is a basic necessity in any society, stakeholders must find sustainable solutions for the populations under their care. As seen in the first two articles in this series,1,2 the solution to the problems currently experienced in Quebec must be based on four principles: Top
The chosen solution should simultaneously:
Based on these principles and the direction of the solution, I suggested in the second article of this series2 that Quebec rally its clinicians and managers around a robust mechanism of resource synchronization that allows for an ongoing response to the question: “Of all the things we could try to improve, which should we improve first?”3 Using this method, we will be able to remain focused on what impedes patient flow. At the same time, it will become perfectly clear that some of our activities — carried out with great effort and, at times, significant cost — do nothing to improve either patient or system outcomes. We will thus abandon these efforts in favour of avenues that reap obvious results. Top
Why delve into this question of improving health care? In fact, we have no choice but to address the issue, as our health care system cannot continue on its current path. Health care workers are often exhausted, which compromises the quality and safety of care. Costs continue to escalate, and society will soon be unable to afford the advances of modern science. Physicians and managers work in conditions that are far too “siloed” to be able to make the improvements needed to cure the ills of the system. At the end of the day, patients still suffer, and society does not get its money’s worth. Top
The biggest error we can make in the current context is to assume that the pressure we are experiencing is normal, that there is nothing we can do, that the pace of cost increase is impossible to catch up with, that success would be too complicated or require too much effort — in short, that costs or collective fatigue will break the system before we are able to fix it. The reality is quite the contrary. Top
In fact, it is by challenging these assumptions that we will be able to identify the key element at the heart of the solution, i.e., the patient–clinician relationship. In doing what is best for patients and making all health care workers accountable to them, we will build a system that not only honours the needs of individuals, but also respects the community through the compilation and management of individuals’ information. This notion of accountability to patients is not controversial for physicians, managers, or policymakers. We, thus, need to shift our thought process toward the growing notion that we are all accountable to patients for the results of our actions. Top
The method to use
The second article in this series2 laid the foundation for a desired future for our health care system, namely a state of balance where clinicians and managers work together, relying on dynamic and powerful information technology that sheds light on the constraints that prolong trajectories of care. In reality, patients should only find themselves in the health care system for clinical reasons, not organizational or administrative ones. By consecrating their collective efforts within the same continuous improvement process, clinicians and managers would find solutions for each problem, while constantly reevaluating the impact of each measure undertaken on the lives of patients and the experience of employees. These solutions would, therefore, be tailored to each clinical and geographic reality, while providing ongoing information to policymakers at every level of the system.
The road ahead
For this new system to become established, a series of necessary and sufficient steps must be followed. Necessary, because each step must be carefully and methodically completed to achieve the desired result; sufficient, because, as a whole, these steps will be enough to produce the desired effect. When these crucial steps are completed, the desired future will inevitably fall into place.
Above all, it is important to achieve enough of a consensus to establish a medium-scale arena to test the constraints management method in Quebec (see Figure 1). At the same time, ongoing training must take place, progressive support must be obtained from the professional community, and results must be made available for external review and critique. This will lay the foundation for an expansion phase with the method deployed throughout the province. Top
To establish this testing ground, a sufficient number of stakeholders will have to agree with the principles listed above and believe in the criteria against which any solution must be judged. In addition, a minimum level of knowledge and skills is necessary to deploy the approach, as is the case in western Quebec, where it has already been attempted on a small scale with very promising results.
Thankfully, there are sufficient medical and administrative structures in place in Quebec to begin the methodical management of constraints. To the extent that administrative structures can, at times, constrain the free flow of patients within the system, the larger administrative districts created by Bill 10 provide new opportunities to dynamically manage patient flow, as well as for enhanced communication between health care professionals. Furthermore, regional institutions now have a certain population-based mandate both inside and outside the traditional care framework. This will help them address entire patient trajectories, including keeping them from entering the system and helping them exit establishments when care is no longer required. Top
As part of the testing ground, physicians and managers will attend meetings focused on patient flow. They will contribute to the continuous elimination of constraints, which will be brought to light with the help of robust and dynamic software. They will develop policies and procedures that will be constantly reassessed to ensure that they themselves do not become constraints. Physicians and managers will remain attentive to each other with the goal of maximizing their professional performance. If any professional lacks the tools needed to perform to the best of their ability, the reasons will be sought out to remedy the problems and eliminate any constraints involved. In the case of both physicians and managers, constraints will be directed to higher levels when needed and, if necessary, to the institution’s governing authorities.
Physicians will become accustomed to airing their clinical opinions across the system in a methodical fashion. To do this, they will rapidly learn to communicate to the system what they already tell patients. For instance, “Sir, we expect you’ll be in hospital for four days based on your condition” will translate into a prescription placed on file for an expected discharge date in four days time. If the preliminary diagnosis of the illness becomes more complex and the expected discharge date is postponed, the physician will immediately update the situation in the file. For the statement, “Your case requires that you undergo surgery in the next month,” the surgeon will write a maximum time limit of one month on the admission forms. For this example, “Your baseline abdominal ultrasound must be done in six months,” the exact date will be indicated on the requisition. Top
Using this method, patients become the pivot point in the system; they are located at the centre of all decision-making. Clinicians serve as antennas surrounding their patients, listening attentively to their needs and providing the driving force with regard to their health requirements (Figure 2). In terms of the greater health care system, it receives the information signals provided by clinicians. Its role is to uncover and eliminate any constraints to the clinically determined flow of patients.
Managers will, therefore, be specifically tasked with continually identifying any obstruction to the flow of patients as indicated by clinicians. They will distribute the management of flow throughout the institution based on established levels of constraint. When an obstruction is identified, it will be added to the agenda for joint meetings that address patient flow. Top
In short, the only way to increase the overall flow rate of the system is to increase patient flow through the constraints of all health care trajectories. To do this, physicians and managers must:
Using this method, it will be clear at any particular time where the constraints are, where patients are accumulating in the system, in short, where the price is being paid — from all standpoints — for administrative delays and where, in contrast, patients’ clinical needs are being met. Top
With regard to education, basic training in constraints management is required. In addition, opportunities should be created for dynamic and ongoing feedback on the results of any change of practice, any new policy or procedure being tested, or any new objective set in place. Progressive training aimed at generalizing the approach at the provincial level will then be needed.
Finally, it is of utmost importance to pursue open and ongoing reflection so that everyone understands exactly why the successes occurred. This step is crucial, because solutions for Sainte-Justine Children’s Hospital in Montréal, for example, could prove to be a total disaster at the health centre in the northern Quebec village of Kuujjuaq, and constraints at the Gaspé Hospital in Chandler could be quite different from those of the McGill University Health Centre. Top
In reality, it is the method that is used and the achievement of tangible results that will unite the troops, rather than supposed solutions applied in areas where problems do not exist. It should also be noted that today’s constraints in all these places will not necessarily be the same tomorrow and that there will be no one-size-fits-all solution to the difficulties that plague us, even in the absence of dynamic information management by competent professionals, i.e., physicians and managers.
Finally, Quebec must make its successes known; making the results of each location available for external assessment and critique is essential. The constraints management method must be applied rigorously and scientifically to learn, not only from successes, but also from failures experienced elsewhere in the province. We will, thus, be able to discover regions with similarities in terms of particular pathologies or trajectories and other regions that are unique, where innovative research can be conducted. Top
Continuous and dynamic information sharing will allow us to uncover unique solutions that, up until now, may have been suspected to be possible, but were not implemented. We will witness growing and self-sustaining feedback loops that increase patient flow as we implement the steps outlined above, specifically:
Expertise in managing constraints will increase and there will be a ripple effect from one end of the health care system to the other. Regional institutions will be able to provide robust recommendations to policymakers with regard to population-based health. Together, regional institutions will be able to integrate elements of learning into a provincial collaboration guide. They will also be able to provide ongoing dynamic information to the Ministry of Health and Social Services that will favour decision-making that is increasingly aligned with the needs of local populations.
Taken together, these steps will lead to the solution to the problems in our health care system: focusing on patient flow to unite clinicians and managers around patient need. Patients will then benefit from seamless care pathways across all the diagnostic and therapeutic interventions they may require. In fact, they will remain in the health care system only for the time needed to treat their specific case — not for administrative or organizational reasons. Top
We are closer than we think to achieving success in repairing Quebec’s health care system. We have health care workers driven to make a difference in patients’ lives and managers who are motivated to increase the system’s performance. We have stakeholders who defend the public and others who negotiate on behalf of their members; they all say that the system is broken and that they would like to help put it back together. We have professionals who seek, above all, to work to the best of their abilities in brilliant careers on the cutting edge of science and technology, wanting nothing more than to concentrate on the clinical aspects of care rather than on administrative and organizational delays. We have patients who rightly demand quality, affordable, safe, and sustainable health care services. And finally, we have a society that seeks to balance the quality and cost of the health care system by acting, not only on care as such, but also on prevention. Furthermore, the structures are in place to create the vision I have just described.
The criteria for success are clear. We must first focus on the patient by taking on the collective responsibility we have toward them. Next, to create a health and social services system that will be successful and sustainable, we need to rapidly improve the quality, safety, timeliness, and affordability of care without creating more complexity for staff. By rallying clinicians and managers around patient flow, we will create a system that better meets their needs as well as those of society. Top
In the first article in this series, I expressed an understanding of the current reality of Quebec’s health care system. The second article proposed a solution that will lead to an ideal future for our citizens. This third article outlines the path to which we must commit if we wish to move from the current state of affairs to the desired future. As we have seen, we must establish an inexorable process that will produce an efficient system of which we can all be proud.
There is no doubt in my mind that we are constantly creating our own future. I wish to be part of a brilliant future in the society where I have chosen to live. That is why I suggest challenging the current assumptions in health care and innovating by configuring the entire system around patients’ clinical needs. To meet this goal, I suggest deploying constraints management in a medium-sized environment, thereby gaining expertise unique to Quebec. The desired harmonization between patient need and the system’s response can then be spread across the entire province to create a high-quality, safe, accessible, and sustainable system for the residents of our province. The final question remains: when do we start? Top
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 Leadership 2017;3(3):91–5. Available: https://tinyurl.com/lrpsnqp
2.Vander Stelt R. An ideal future for Quebec’s health care system: the desire for a state of equilibrium. Can J Physician Leadership 2017;3(4):129-33. Available: https://tinyurl.com/v8s89ue
3.Knight A, Vander Stelt R. Seeing differently: applying the theory of constraints in health care. Can J Physician Leadership 2015;1(3):20-3. Available: https://tinyurl.com/y9lb2hg3
4.Theory of constraints. Itasca, Ill.: Vorne Industries; 2016. Available: https://tinyurl.com/cj459kl (accessed August 2017).
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.
Correspondence to: firstname.lastname@example.org
Note: The original version of this article appeared in the January/February 2017 issue of Santé Inc. (http://santeinc.com/2017/01/le-chemin-a-parcourir/).
This article has been reviewed by a panel of physician leaders.