By Dr. Les Vertesi
The Health Council’s latest report, Which way to quality? Key perspectives on quality improvement in Canadian health-care systems, finds that quality in health care has been a key issue for over a decade.
The literature tells us of the avoidable costs that burden our system because of a quality issue – medical errors.
Efforts at improving system quality are evidenced by provincial health quality councils, tasked with putting quality into practice.
Limited gains are claimed by almost everyone, but measurable, large-scale change is hard to find.
British Columbia has followed a path similar to the other provinces, but with two initiatives that are worthy of special mention.
Access to care is a pillar of quality, but other than in selected high-priority areas, such as hip and knee surgery, Canadians still wait on average longer for care than most other developed nations. This lengthy wait-list problem occurs in spite of ample evidence that funding policies (apart from the total amount of money) are a major factor behind our wait-list problem.
Countries that cling to fixed global budgets in hospitals tend to have long wait-lists.
In 2010, B.C. became the first province to bring in a limited form of Activity Based Funding (ABF) where funding follows patients, not hospitals. One of the largest Vancouver hospitals recently showed how it used the flexibility of ABF over nine months to produce a 24 per cent overall reduction in waits and a 70 per cent reduction in the longest wait times, all with only a three per cent increase in cases.
In the realm of safety and reduction of complications, B.C. spent $12 million in the previous year to enrol 22 large hospitals in the National Surgical Quality Improvement Program. The NSQIP is a quality improvement process that boasts over 450 member hospitals in the United States. The system collects data on post-operative complications from hospitals and feeds a risk-adjusted score back to each hospital.
The experience of one B.C. hospital that joined NSQIP before ABF tells the story. Its first results showed it was among the worst performing hospitals, so it made some serious changes. Two years later, it had improved to better than the average, with proven drops in post-operative infections and return trips to the operating room, along with a shorter stay.
The patient experience was safer and better, but those empty beds were quickly filled with more patients, and since it was still held to a fixed budget, its financial situation worsened. It had achieved true quality, and was punished for it.
Today, the situation in B.C. under ABF should be different. NSQIP is set to help improve quality and ABF will in theory compensate for any increase in workload that results.
Nobody actually makes money with hospitals in Canada nor will that change with ABF, but at least we will no longer be punishing quality.
Dr. Les Vertesi is a Health Council of Canada councillor.