Canada: Overview Of The Second Report Of The Premier's Council On Improving Healthcare And Ending Hallway Medicine: Part III

Health Law Bulletin
Last Updated: September 30 2019
Article by Laurie M. Turner and Andrew Gunpat

Background

This bulletin is part III of the three-part series on the second report of the Premier's Council on Improving Health Care and Ending Hallway Medicine (the "Council"), entitled A Healthy Ontario: Building a Sustainable Health Care System (the "Report") (PDF). The Report was contemplated by the Council's first report, Hallway Health Care: A System Under Strain (the "First Report") (PDF), which was published in January 2019.

The Council was created in October 2018, for the purpose of (among other things) providing recommendations to the Premier, Deputy Premier and the Minister of Health and Long-Term Care, in respect of four objectives (the "Objectives"), specifically, improving health and wellness outcomes, achieving higher patient satisfaction, using taxpayers' dollars more efficiently and lowering wait times.

Many of the themes that run through the Council's ten "strategic policy" recommendations identified in the Report (the "Recommendations") - such as integration, collaboration, alignment and efficiency - are consistent with the themes of the province's new Connecting Care Act, 2019 (the "CCA"). As further detailed in our various bulletins on the CCA,1 among other things, that act aims to integrate the health care system through:

  • its creation of a central agency to oversee Ontario's healthcare system (often referred to as the "Super Agency" or "Ontario Health");2 and
  • its establishment of "integrated care delivery systems" (often referred to as "Ontario Health Teams").3

In his delivery of the Report, Dr. Rueben Devlin, the Council's chair, recognizes the "significant initiatives" that had been taken by the government towards meeting the Objectives since the First Report, and expressed support for its establishment of Ontario Health and Ontario Health Teams under the CCA. Despite these acknowledgements, however, the chair deemed these initiatives to be a "good start" and emphasized the need for additional work to be done to achieve the Objectives.

Part I of this three-part series on the Report, summarized the first five Recommendations,4 while Part II summarized Recommendations 6 to 8 and the key aspects of chapters 1 ("We Hear You, Ontario") and 2 ("The Vision for Health Care in Ontario"). This bulletin will summarize the remainder of the Report, being:

  • Recommendations 9 and 10, each of which fall into the category of "Capacity"; and
  • Chapter 4 ("Reporting Progress Throughout the System").

Chapter 3: Recommendations 9 and 10

Recommendations 9 and 10 fall within the category of "Capacity". Each of the Recommendations in this category relate to maximizing the current capacity of the province's health care system in order to:

  • relieve short-term capacity pressures; and
  • achieve the correct balance of resources within the health care system (e.g. health care providers, health care services and leadership) to respond to evolving health care demands.

As with the other Recommendations, the Report sets forth numerous "action items" that the Council proposes be taken to give effect to Recommendations 9 and 10.

Recommendation 9

Recommendation 9: Address short- and long-term capacity pressures including wait times for specialist and community care by maximizing existing assets and skills and making strategic new investments. Build the appropriate health care system for the future.

Through this Recommendation, it is suggested that policy makers should focus on designing and investing in a system that offers preventative, strategic and integrated support. It is also suggested that embracing technology and evidence-based solutions would assist in ensuring that Ontarians are part of a system that supports them throughout their healthcare journey by providing consistent, reliable and appropriate services based on their needs.

The short-term action items for this Recommendation are split into two groups, particularly those which focus on:

1. Maximizing existing resources to increase capacity

For example, through:

  • performing reviews of current processes (e.g. patient assessments) to eliminate redundancy and identify manners to cause increased time and resources to be spent delivering care to patients;
  • proliferating technology that reinforces process improvements, such as scheduling decisions, in order to achieve efficiencies; and
  • reviewing the roles and responsibilities of health care professionals (presumably to identify overlap), and confirming that such professionals are well supported (e.g. have access to sufficient resources) and are capable of, and actually are, "maximizing" their permitted scope of practice.

2. Targeting new resources to increase capacity

For example, through:

  • expanding the services and beds available in communities demonstrating the biggest capacity challenges; and
  • pursuing new investments to be allocated to mental health and addictions services (in particular, for "evidence-based" community services and supports).

The long-term action items for Recommendation 9 focus on the government's establishment of a "comprehensive and strategic long-term capacity plan for health care",5 aimed at ensuring that equitable and quality health care is available to patients province wide. The Council suggests numerous considerations for inclusion in the long-term capacity plan, including, for example:

  • the capacity plan should be guided by transparent principles for planning and should utilize "foresight and scenario modelling";
  • available data should be drawn on in order to: (i) determine priority populations; and (ii) focus resources on anticipated demands on the health care system (with a view to acting proactively rather than reactively);
  • consult with the public regarding how: (i) health care should be paid for; and (ii) to sustain the province's public health care system; and
  • the capacity plan should be updated every three years;

Recommendation 10

Recommendation 10: Champion collaborative and inter-professional leadership development focused on system modernization capabilities.

While the Council expressly provides that it believes that the health care system is properly moving toward a team-based integrated care system, it also notes that such a system requires effective leadership and members with the right mix of skills. The Council proposes that in order for significant transformative change to occur in the health care sector, collaborative partnerships and strong relationships with system leaders are necessary.

The action items associated with this Recommendation provide a general outline for what the Ontario government should account for when promoting leadership development. The Council submits that if the government provides clear expectations, transparent information, and leadership support and guidance, it will foster "system and culture change and will deliver the integrated and modern health care services Ontarians deserve".6

The Report establishes two action items for the government in respect of this final Recommendation:

  • Support leaders in the health sector and take steps to ensure that such leaders have the skills and tools necessary to: (i) lead by example; and (ii) deliver support to the sector during the significant change in culture that is proposed.
  • Encourage "intersectoral leadership development" with a view to fostering new relationships between care providers, while, at the same time, supporting new methods of integrated care around the needs of patients.

Chapter 4: Reporting Progress Throughout the System

Chapter 4 focuses on identifying and tracking the progress made within the province's health care system to end hallway health care specifically and improve the health care system more generally. As a means to this end, the Council recommends that the government create a "health system scorecard", with such performance being scored against the four objectives of the "Quadruple Aim Framework".7 More specifically, the Council recommends that the scorecard would report on:

  • Access to and availability of health care services across the province.
  • In the short term, health care indicators that are currently being tracked, and in the long-term, new health care indicators that are tracked in the future in response to gaps identified in the information being collected and reported on by the government.
  • A reduced scope of health care indicators. In particular, a reduced set of indicators that are deemed "valuable" on account of their ability to be used as a tool to improve quality and value in the health care system.

The Council subsequently recommends that information from the scorecards would be drawn on to "inform reporting and accountability of Ontario Health, Ontario Health Teams and other health service providers."8

This chapter identifies 8 indicators that it is proposed could be used to improve outcomes with a view to ending hallway health care and otherwise improve the health care system:

Indicator Description
Hallway Health Care
  • The Council regards this as the "top-line indicator" in this regard
  • Measured by counting the number of patients admitted to a hospital but who are required to wait overnight in an unconventional space (such as on a stretcher) for a hospital room to become available
Access to Primary Care
  • Measures the ability of patients to access primary care in a timely manner within their community
Mental Health and Addictions in Emergency Departments
  • Measures the frequency of patients with who access emergency departments for non-urgent mental health and addictions matters
Emergency Department Wait Times
  • Measures wait times to access to care in emergency departments
Hospital Readmission Rate
  • Measures the number of patients who are re-admitted to hospital in order to identify where community supports may be lacking
Alternate Level of Care (ALC)
  • Measures the percentage of patients who are occupying a hospital bed but do not require the services provided by the hospital with the goal of identifying circumstances where health care can be provided more appropriately (e.g. at a lower cost, with better patient outcomes) in a non-hospital setting
Long-Term Care and Home Care Wait Times
  • Measures wait times to access long-term care and home care throughout the province
Patient Experience, Including Access to Digital Health
  • The Council recommends that additional information about patient experience should be gathered, including patient experience as it relates to digital health records and virtual care visits
  • Measures whether digital innovation is becoming more prolific throughout the province's health care system

This chapter closes by identifying areas for future development in the health care system, with the understanding that the constant modernization of the health care system and addition of technological innovation will result in a necessity for the government to refine its approach to indicator development and reporting. To understand patient and provider experience, the Council suggests that accurately capturing patient experience in all aspects of the health care system is paramount. When assessing value for money, the Council advises the government to work to develop indicators that measure patient and overall population health outcomes against the cost of administering and delivering services in the most efficient way.

Conclusions

Though the Report does not contemplate any future reports being delivered by the Council, the Government did announce that the Council will provide it with advice in respect of the development of Ontario Health and Ontario Health Teams. As noted in the Introduction, Fasken has published numerous bulletins in respect of the new Ontario Health Team model, Ontario Health and the CCA.9 As steps continue to be taken to implement the significant changes contemplated by the CCA, Fasken will publish additional bulletins to highlight these changes.

If you are wondering how you can play a role in the government's ongoing development of its new health care policy, you may consider providing the Council with feedback on the Reports and/or the health care system more generally. The Council encourages continued participation, directing those who wish to submit feedback to email the Council at hallwayhealthcare@ontario.ca.

COMPLETE LIST OF RECOMMENDATIONS

Category Recommendation #s
Integration
  • Put patients at the centre of their health care. Patients should be well-supported and treated with dignity and respect throughout all interactions with the health care system.
  • Improve patients' and providers' ability to navigate the health care system, simplify the process of accessing and providing care in the community, and improve digital access to personal health information.
  • Support patients and providers at every step of a health care journey by ensuring effective primary care is the foundation of an integrated health care system.
Innovation
  • Improve options for health care delivery, including increasing the availability and use of a variety of virtual care options.
  • Modernize the home care sector and provide better alternatives in the community for patients who require a flexible mix of health care and other supports.
Efficiency & Alignment
  • Data should be strategically designed, open and transparent, and actively used throughout the health care system to drive greater accountability and to improve health outcomes.
  • Ensure Ontarians receive coordinated support by strengthening partnerships between health and social services, which are known to impact determinants of health.
  • As the health care system transforms, design financial incentives to promote improved health outcomes for patients, population health for communities and increased value for taxpayers.
Capacity
  • Address short– and long–term capacity pressures including wait times for specialist and community care by maximizing existing assets and skills and making strategic new investments. Build the appropriate health care system for the future.
  • Champion collaborative and interprofessional leadership development focused on system modernization capabilities.

Footnotes

[1] See (for example): Introduction of Bill 74: The People's Health Care Act, 2019, Ontario's Proposed Super-Agency: The Creation of Ontario Health Under Bill 74, Bill 74: Integration and Accountability in Ontario's Health System under the Connecting Care Act, 2019 , Labour and Employment Transitions in Ontario's Health System under The People's Health Care Act, Designation Process for Ontario Health Teams, Ontario Health Teams: Integrated Governance and Funding, Getting Connected: Digital Health and Information Sharing under Bill 74

[2] See Fasken's bulletin, Ontario's Proposed Super Agency: The Creation of Ontario Health under Bill 74, for additional information regarding Ontario Health, including its proposed composition and powers.

[3] See Fasken's bulletin, Ontario Health Teams: Integrated Governance and Funding, for additional information on Ontario Heath Teams. The Ministry of Health and Long-Term Care has proceeded with the process for establishing Ontario Health Teams. In early August, the Ministry published the list of: (i) 31 applicants invited to submit full applications to become Ontario Health Teams; and (ii) 41 applicants regarded as being "in development" (meaning those applicants that the Ministry regarded as demonstrating a higher degree of readiness to become Ontario Health Teams.

[4] A complete list of the Recommendations - which are organized into four categories, namely, Integration, Innovation, Efficiency & Alignment and Capacity - is included at the end of this bulletin.

[5] Second Report, p. 36.

[6] Page 38.

[7] Refer to Part I of this Bulletin for further information on Ontario Health Teams.

[8] Page 39.

[9] The statute through which Ontario Health Teams and Ontario Health were introduced.

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