Why Building The Case For Quality?
Every day, millions of Canadians have some sort of encounter with the healthcare system. Many benefit tremendously from the hard work of experienced, dedicated professionals. But it is increasingly clear that many don’t get the quality of care they need and deserve.
An increased number of studies have found lack of quality in many aspects of healthcare. Elderly people in nursing homes suffer from malnutrition and pressure sores; asthmatics repeatedly wind up in hospital; and complications from diabetes go unchecked. Children aren’t vaccinated; women don’t get their Pap tests; and time and again, we hear of prevention not recommended and treatments not administered. On the other hand, patients receive inappropriate treatment they do not need which leaves them worse off. However, these incidents are not often seen as symptoms of an overarching quality problem.
Quality of care — or the lack of it — has indeed remained fairly low-profile. For the last decade, Canadians have been preoccupied with access to care. Waiting lists, lack of equipment and shortages of professionals have dominated discussion. Whether the care people were getting was worth the wait and the worry rarely came up.
Fortunately, that is changing. Governments have established quality councils with varying mandates that identify a number of roles and responsibilities, including performance measurement, public reporting, developing evidence-based standards and providing strategies for improving quality of care. Organizations are trying to change their cultures to build in quality-improvement programs that will continually test and renew the care being given. The idea that “mistakes happen,” probably due to a moment of carelessness, is being replaced with an understanding that care systems must be carefully constructed to eliminate opportunities for mistakes to be made.
The Canadian Health Services Research Foundation is responding to the increased understanding of the importance of quality with this Building the Case for Quality initiative. It’s part of a strategy launched in 2006 to promote knowledge exchange on the Foundation’s four priority themes — managing for quality and safety; management of the healthcare workplace; primary healthcare; and nursing leadership, organization and policy. The goal of Building the Case for Quality is to raise awareness among healthcare managers, policy makers and others about the evidence on healthcare quality and ways to improve it.
No one sets out to provide bad care. So why is there so much of it? Saskatoon-based health consultant Steven Lewis says it’s because Canada’s approach to healthcare is outdated. We’ve been working under the assumption, he says, that smart, well-trained people would inevitably provide high-quality care. We held on to an old-fashioned belief that if things went wrong, it was because nothing could be done.
The real problem, he says, is that Canada continues to treat healthcare as a cottage industry instead of the enormous, complicated organism that it is. All manner of breakthroughs have been made in types of care, but the system itself has stagnated.
Recent research bears his thesis out. The Commonwealth Fund, a U.S. health-research organization, ranked Canada sixth among six Western nations for the quality of its healthcare. The fund based its assessment of quality on whether the care is “right” (that is, effective), safe, co-ordinated and patient-centred. Canada was last on all but safety, where it placed fifth, ahead of the U.S. but behind Australia, Germany, New Zealand and the United Kingdom. (In the overall ranking, Canada came fifth, placing ahead of the United States on access, efficiency and equity and ahead of the U.S., U.K. and New Zealand on healthy living).
Being rated last for effective, co-ordinated and patient-centred care, and poorly for access, efficiency and equity, certainly suggests the problem lies with the system, not individuals. It is not that our health professionals can’t give good care; but there are often barriers to getting it and the links among different types of care can be haphazard or non-existent. These gaps and lack of continuity of care take a toll in time and health outcomes, increase suffering and drive up costs.
Concern for the overall quality of the healthcare system is a relatively new phenomenon. Previously, notions of quality were applied to individual episodes of care, which were good if you felt you’d been treated well and bad if you came away with a horror story. But improvements in data collection and analysis have allowed us to begin to measure and compare what different types of care accomplish, and a picture of where care is falling short at organizational and population-wide levels is becoming clearer. Where we have started to gather better statistics, we can see patterns emerge from the mass of individual events. Often those patterns show that care in Canada does not measure up to that in other countries and, within this country, quality of healthcare varies from province to province, region to region and even from one ward in a hospital, or one city neighbourhood, to another.
But it doesn’t have to be that way. Like all complicated problems, the issue of improving the quality of healthcare can seem overwhelming, which sometimes paralyzes action. But around the country, people at every level, from individuals to organizations to governments, are tackling quality issues one small step at a time. In one city, operating rooms at two hospitals were studied to find out why one had consistently better results; adopting a similar staff schedule improved outcomes at the less-successful hospital. One province has set up forums — electronic and face-to-face — where family doctors learn from each other how to improve their care for chronic illnesses. The number of chronically ill patients getting recommended care has increased from 50 percent to 75 percent. Although the scale differs, the prescription is the same: use data comparisons to identify an area where quality is a problem, then look for research and best practices on how to raise the level of care and adapt them for your setting.
The quality improvement stories related in Building the Case for Quality show how it is possible to improve quality at every level in healthcare, in small and large spheres. By offering the series of Quality Conversations, quality-related research evidence, and events that will bring together researchers and decision makers, the Foundation hopes to encourage organizations and care providers to talk about evidence on how to bring excellence to healthcare and provide tools for tackling quality issues.