A CCC Health Services Planning Guide and Framework for New Brunswick
Note: The contents of this paper are an amalgamation and synthesis of material taken from a number of national and provincial reports published over the last several decades, previous DOH Strategic Planning documents, as well as from various papers and articles written by Ken McGeorge, Jean-Guy Finn, James Carter and James Wolstenholme.
- The nature of the complex, costly health services system is only one factor that affects human health and longevity — the others are biology/genetics, environment and lifestyle, and all have significant effects. We all have a responsibility to see they are suitably addressed.
- Given on-going health care clinical and technological advances, there is an ever increasing ability to detect, diagnose and treat health problems, and manage chronic conditions.
- Resources to fund the overall system, which includes public health, acute care/active treatment for both physical and mental health problems, and long term care — are finite.
- Despite numerous national and provincial studies and reports, books and mediia stories over the past 50+ years, many of the problems associated with the health care system have not been effectively addressed, if at all. This is due, at least in part, to the lack of an accepted, clear, comprehensive vision of how the system should look and function, and a sustained commitment and effort to pursue this vision by political and administrative leaders.
- The current level of resources could provide more total service to the population if ‘properly’ allocated and used.
- NB has a relatively small and aging population spread over a large area, has been experiencing slow population growth rate for decades and is becoming more urbanized, albeit slowly. About 85% of people live within 50 km of one of the province’s 7 main urban areas.
- An aging population has a greater incidence and prevalence of chronic health problems/conditions that require clinical management over longer periods.
- The current system is often able to address acute episodic, life-threatening problems, sufficiently well that many people appear prepared to overlook its various documented shortcomings. The fact that the system does some things reasonably well makes introducing constructive design and operational changes to achieve significant service improvements more challenging.
- Maintaining the status quo is always in the interest of some service providers and some recipients of any service. They are familiar and comfortable with ‘what is’ and are concerned over the effects any major changes could have on them, even if there are overall societal benefits.
The Problem – Symptoms and Their Causes
To truly understand this complex field, one must get beneath the surface. Issues and topics typically discussed in the media, at public meetings, press conferences, etc. are usually symptoms of underlying problems.
Symptoms: what experts have identified and people have experienced and expressed:
- Many citizens still lack timely access to quality, consistent primary care (e.g. family doctor, nurse practitioner, or other recognized care providers): many such people have chronic diseases such as Dementia, heart or lung problems, diabetes, etc., which require careful therapeutic management.
- Overcrowded emergency departments: often long wait times to be seen for what are primary care problems at a time when some other provinces and jurisdictions have found solutions to this issue (a chronic problem that the COVID-19 pandemic has temporarily ameliorated).
- Typically long wait times for access to most specialized diagnostic and treatment services. While the province has more doctors and nurses per capita than most other provinces, according to NB Health Council data, other factors impede timely access.
- Diagnosis and treatment for conditions with obscure/difficult to diagnose symptoms is often long and ponderous, often resulting in inappropriate treatment; there is a perception that the number of persons seeking timely and definitive diagnosis and care outside the province is rising.
- Many acute care hospital beds are used for Long Term Care (ALC) situations, thereby limiting the ability of the acute care component of the system to carry out its functions in a timely manner. This contributes to excessive waiting times for acute care diagnosis and treatment services.
- Care of elders or others with non-acute, chronic conditions in acute care hospitals for protracted lengths of time when what they actually require an alternative type of care, is generally recognized as both inappropriate and inadequate.
- Health services in smaller communities and rural areas are inconsistent in availability, quality and comprehensiveness.
- The health system is influenced by many advocacy groups representing professionals, labor and patient/disease groups that naturally tend to place priority on their interest and preferences.
- There is a significant missed or late diagnosis rate in relation to dementia, which presents a serious challenge to individuals, their families and the service network.
- Duplication and questionable location of some specialty services, with no provincial plan based on objective clinical and administrative criteria.
- Professionals often operate independently in silos, often in competition, when integration and coordination would be a far better approach in terms of continuity of care, and therefore overall efficiency and effectiveness for any given level of resources.
Causes of the Symptoms:
Governance/Health Authorities: no knowledgeable body is in charge; Boards are advisory only, with no authority/power or accountability; CEO’s are accountable to the Premier, albeit technically through a cabinet minister.
There is no identifiable performance review or performance management system for CEOs. Political involvement in clinical decisions such as service location is not uncommon. The current approach is contrary to generally accepted principles of good governance.
Persons appointed to middle and senior management positions don’t always possess the training, certification and experience, in health services management that is necessary for credibility and effectiveness. While there are certain generic, transferable skills that people may have, Health and Long Term Care are areas of specialty just as nuclear energy or transportation systems. Relevant training and experience are important factors for those in system leadership, oversight and regulation roles.
Clear, consistent vision for evolution of the province’s health care service network based on that vision for the orderly long term development/evolution of health care services to the best use of all available resources (people, buildings, equipment, etc) to ensure optimal service efficiency, effectiveness and quality to improve health outcomes, i.e. duration and quality of life.
Acute and long term care regulation is divided between two separate government departments: Health and DSD, which makes system planning, management and service coordination more difficult and both time and energy-consuming than is necessary.
An inadequate electronic information and communication network, including a comprehensive electronic patient record and digital I.D., that connects system components in a timely and accurate manner to facilitate direct service provision, as well as system performance and analysis and evaluation.
The Desired Situation – Vision and Goals
- A clinically sustainable, patient centered service network that encompasses direct health care and public health services (prevention, response and education)
- Clearly stated system parameters: vision, mission, values, goals and performance measures.
- A service network that encompasses both physical and mental health and includes all service categories, i.e.:
- Prevention, inc. postponement (individual and population health protection)
- Detection and diagnosis;
- Long term and chronic condition care and management, inc. palliative care;
- Ancillary support (e.g. ambulance/EMT services, prescriptions, telecare; population and individual health education)
- A service network that includes all available delivery methods to ensure the most suitable method of providing services can be utilized in each case, i.e.:
- Ambulatory/outpatient, inc. LTC day services;
- Technology-based: remote/on-line consultation/e-diagnosis and monitoring, etc.
- A service network that is able to readily respond to the particular needs of urban areas, rural areas, the elderly, the disabled, etc. This includes a robust pandemic and epidemic preparedness, response and amelioration capability.
- A service network that reflects the basic principles of: universality, comprehensiveness, accessibility, portability, and public administration, i.e. a centrally planned, funded and coordinated system (vs. an unplanned, ad hoc, competitive system), since most Canadians consider the health care system to be, in effect, a vital public service and a fundamental component of our society’s ‘social safety net’.
- System design and operation and individual patient care decision-making (what, where, when, how), based on clinical evidence of safety, timeliness, efficacy and probability of success.
- Continuing collaboration and coordination between the active treatment and long term/chronic care components of the overall system to ensure quality service provision in the most appropriate setting and in a timely manner.
- A logical allocation of responsibility, authority and accountability, with stated performance objectives and indicators that are coupled with regular monitoring and reporting. This must apply to governing boards, and all those in authority within the health and long term care system.
Prerequisites for System Improvement Initiatives to Be Successfully Pursued
- Government willingness to approve a system improvement plan, to appoint a knowledgeable team to implement it and resist the temptation to override evidence-based clinical decision making when ‘local’ or interest group pressure is applied to maintain the status quo. The Department of Health would be assigned to oversee and regularly report to the government on progress.
- A defined vision and mission, with goals to be achieved, that’s been approved by government. The province and the health care sector need a vision for health care. “Cost control/cut the budget” is not a vision; “Ensure that every New Brunswicker has timely, reliable access to effective, quality and efficient health care services” is a vision. Leaders shape and communicate the vision, then ensure that the plan and all decisions taken, difficult as they may be, line up with and further its achievement.
- A rolling, adaptable multi-year action Plan with required actions, priorities and sequences, and performance measures. The Plan would address: What services will be available; Where they will be located; How they will be provided; Who will provide them; How to ensure enough skilled personnel, service sites, equipment, supplies and technology (both clinical and management information/communication); Who has what responsibility, authority and accountability for service provision, management and performance (i.e. how well the system is performing in relation to inputs, outputs and outcomes, including regular public reporting).
- A knowledgeable, capable, dedicated and focused DOH management team that remains in place for a reasonable period (vs. frequent senior personnel changes). Continuity and sustained, consistent leadership are essential factors, coupled with complementary capabilities in Health Authority organizations. Management of change ability is an essential skill.
- Appropriate authority allocation to take the needed actions coupled with associated responsibility and accountability. That is, governance model that delegates implementation of provincially approved system goals to the Health Authorities, with sufficient responsibility (and the associated authority and accountability) to take action within the parameters of the government approved provincial plan — overseen by the Department of Health.
- A system/service network organizational structure that supports the needed changes rather than being an impediment that complicates action or enables resistance to them.
- Active cooperation from the province’s health care professional organizations. In particular, willingness on the part of the Medical Society, Nurses’ Association and others to work with the Department of Health to accelerate the process of Primary Care improvement so it becomes a solid foundation for the overall system: establish multi-disciplinary primary care health centers throughout the province, with secondary and tertiary services focused mainly in regional hospitals to ensure sufficient service volume to attract and retain an adequate number of specialized personnel with specific service expertise, as well as patient safety.
- An integrated, comprehensive patient and provider electronic health record (including medications/prescriptions) and an administrative and clinical information system that together ensure service provision and resource management are efficient, effective and meet recognized quality standards — coupled with regular monitoring and public reporting on progress and population health needs and outcomes, as well as system inputs and outputs. This would include use of point-of-care electronic diagnosis and documentation tools. A comprehensive patient, provider and service communication network, including digital I.D. for secure access to and sharing of clinical information and enable use of ‘medical apps’. This would make the timely sharing of vital information more effective. [For instance if you need to know who has the best treatment for irritable bowel syndrome in the province, where would you go now?] Services in the province will improve remarkably when there is efficient sharing of integrated information. Once again, a sustained commitment and highly qualified personnel and leadership is necessary in order for this initiative to succeed. Furthermore, it is an inexorable trend and NB could benefit from ‘getting on board’ and becoming a demonstration site.
- Reliable sources of a sufficient supply of various types of health care personnel, supported by a dynamic needs projection methodology. This involves training, recruitment, and retention.
- Public understanding that while hospitals are important service sites, there is also a significant patient safety risk involved with hospitalization. Infection and cross contamination are only two of the serious risks at play when one is admitted to a hospital. Therefore, patients need to be admitted for the shortest period of time required to deal with their clinical situation. Individuals also must be made aware of and encouraged to take a continuing interest in and responsibility for their own health status – not only in terms of personal lifestyle choices, but also the environment.
Key System Design and Operational Implications – The Way Forward and How to Know When We’ve Arrived
- A rolling, adaptable multi-year Provincial Plan for Health Care Services improvement based on a clear patient-centered vision and realistic expectations. [The basics are already done and a small team of capable individuals should be able to create a provincial plan implementation sequence (e.g. Gantt Chart) of concurrent and consecutive actions in a matter of months.] This plan would describe an approach for ensuring sensible system design, organization, operation/resource use and performance standards at the primary, secondary, and tertiary levels of care. It would include components for Primary (including Rural) Care, Acute Care, Long Term Care, Mental Health Care and Epidemic/Pandemic preparedness.
- Wide-spread availability of Primary Care provided by co-located inter-disciplinary health professional collaborative teams; community health service/primary care centers; and in-home care, as appropriate. The teams would include physicians, nurse practitioners, nurses, PTs, OTs, STs, dietitians, pharmacists, and health educators/counsellors – with the numbers in any location based on population and service volume. The best health care service takes place when health care professionals work together in an integrated, collaborative, collegial manner. Therefore, government and health authority policy must be directed at providing incentives to ensure such integration and collegiality is achieved and maintained. A sustained transition/migration plan would be required to move from the current situation of a myriad of independent physician’s offices with limited, if any, other on-site professional personnel.
- The ultimate goal is to have a network of primary care interdisciplinary service sites located around NB, e.g. with 80 km or less from anyone’s place of residence, and with specified weekday, evening and weekend hours. These would ultimately replace most, if not all, independent physician and other health professional offices (see Appendix 3).
- Where population warrants, primary care centers could have one or more satellite offices with more limited hours of operation.
- Make more extensive use of nurse practitioners in primary care collaborative practice settings to augment physician services.
- In regard to Rural Health Care: this is an important component of the envisaged primary care services network, which must be integrated with those provided by the regional centers in Bathurst, Campbellton, Edmundston, ,Fredericton, Miramichi, Moncton, and Saint John. This means making the best use of all existing facilities to serve the health care needs of their areas, which may involve a degree of repurposing in some instances. Two useful documents regarding how to improve Rural Health Care are Ontario’s Rural and Northern Health Care Report and the CFPC’s Rural Road Map for Action.
- Th envisaged Primary Care ‘program’ could be overseen by a dedicated branch of the DOH, in cooperation with the DOH Hospital Services Branch and the HAs.
Secondary and Tertiary Care
- Consolidation of secondary and tertiary services in a limited number of hospitals so as to ensure sufficient service volume to maintain provider skill, service quality ad patient safety and ensure a critical mass of service providers that support each other and attract additional professional talent.
- The envisaged primary care service network would allow separation of primary care physician duties and hospital duties, with hospitals being defined as the province’s larger facilities in Campbellton, Edmundston, Fredericton, Saint John, Georges-L Dumont, Moncton, Bathurst and Miramichi. In these facilities, referred patients would be managed during their hospital in-patient stay by hospital-based physicians who maintain communication with the primary care physician(s). This approach requires a comprehensive, integrated electronic patient and provider record system.
- Maintain provincial centers of expertise for specialized diagnostic and treatment services that require highly trained professional and associated support staff as well as sophisticated equipment and other supplies. This means Tertiary Services must be located predominately in Saint John and Moncton (tertiary rehab is already located in Fredericton and represents an exception), while various secondary services would be focused in each of other regional centers, in relation to the population base.
- Smaller hospitals in other locations would retain an important, meaningful role in provision of primary care, basic active treatment, post-acute follow up, urgent care and (some) emergency services, augmented by the ambulance services network, and could possibly participate in seniors’ services/long term care coordination.
- Make optimal use of tele-medicine/e-medicine technologies to minimize patient travel requirements for diagnosis, treatment and rehabilitation, as well as for continuing staff education/training in relation to clinical best practices, including web-based learning. This applies to both physical and mental health services.
- Make more extensive use of physician assistants and hospital-based MDs in secondary and tertiary care hospitals to allow physicians to focus on more complex situations, thereby reducing wait times for needed services. Physician assistants may also be useful as part of the primary care teams.
- Support full scope of practice/service for all health care personnel.
- Organize secondary and tertiary clinical services on a provincial (or at least Health Authority) basis to improve coordination and continuity of care, with a clinical organization for each specialty service that ensures excellence, examines service quality, monitors effectiveness, and ensures that the right skill mix is in place in order to respond to the needs of the province. In so doing, the province can ensure that patients have available to them the very best in skills with the organization, which would also enable sub-specialty development where volume warrants. Clinical services would be organized in a way that ensures groups of not less than 4 specialists providing service to a given area. In areas in which specialist’s number less than 4, the service would be consolidated with the nearest appropriate clinical service.
- Develop a provincial (or at least Health Authority) booking/scheduling system for major diagnostic and surgical procedures.
- Establish Clinical investigation units: this refers to a multi-disciplinary clinical investigation capability to deal with cases for which symptoms are obscure and diagnosis is difficult would be examined and investigated by a multi-disciplinary team. The goal would be to achieve an accurate diagnosis on a timely basis so that treatment can follow in a timely manner. One or two such units in the province, e.g. one in each HA, may prove efficient.
Emergency and Urgent Care
- Create Urgent Care Units (Urgicenters) associated with hospitals to permanently reduce the use of emergency units – so the latter can focus on their intended purpose: real emergencies. Urgent Care Centers associated with regional hospitals would take a substantial portion of the service load from Emergency Departments that is created by the large volume of non-emergency cases. They would include physicians, nurse practitioners, and other health team personnel and manage patients with non-emergency, non-life-threatening conditions that nonetheless cannot realistically be dealt with by Primary Care centers. Over time, they and the primary care centers network would replace ad hoc ‘after-hours clinics’.
- Clinical management of emergency departments in regional hospitals by Emergency Room physicians specifically trained in Emergency Medicine.
Long Term Care
- Minimize the number of active treatment/acute care hospital beds that are occupied by those awaiting placement in an alternate level of care, i.e. in-home, ambulatory or residential, by expanding ambulatory and in-home service capacity and increasing residential care capacity only where clearly necessary.
- Transfer long term care residential (nursing home and special care home), day services and in-home services responsibility to the Department of Health. Also, establish multi-facility, not-for-profit nursing home organizations separate from the two Health Authorities to replace individual nursing home boards wherever feasible. (The existing private Shannex facilities and private special care homes would continue as is.) Assign these new organizations the responsibility for residential, ambulatory/day services and in-home care in their coverage areas, with appropriately trained, skilled and remunerated management/administrative staff, as well as direct care and support personnel. (A less extensive option is to facilitate contract management services to small homes by large ones.) For both nursing homes and special care homes, maintain appropriate, comprehensive quality care standards and conduct regular and unannounced inspections coupled with public reporting, i.e. consistent standards, consistently monitored and enforced. The current lack of integration within the long term care field explains, at least in part, why some provinces have moved ahead of New Brunswick in care for the aging initiatives (e.g. Ontario’s Primary Care Collaborative Memory Clinics (Dr. Linda Lee); Prime Care Family Health Teams; nursing homes without walls, which is conceptually similar to NB’s successful Extra-Mural Program). Given the considerable difference between orientation and nature of active treatment and long term care, combining these two complex functions in one organization, such as the HAs, is not advisable.
- Maintain not-for-profit as the primary model for nursing homes, with a limited number of for-profit homes to facilitate regular operational efficiency and quality comparisons. Actively promote ‘service campuses’ that offer various levels of residential care. In any event, those managing the Long Term Care system must have sufficient training and experience in the Long Term Care Field.
- Establish a Health and Long Term Care Leadership and Innovation Center, e.g. affiliated with UNB and U de M, that would provide training and development for those working in managerial leadership roles and that would oversee the development of a culture of person-centered care and visionary leadership throughout the health and long term care system. This could involve partnerships with, for example, Planetree, Dr. Bill Thomas, the Magnet Hospital organization and others.
Mental illness affects 1 in 5 Canadians directly or indirectly in any given year. Mental health problems and illnesses have a high economic cost and take an even greater human toll. Mental health is more than the absence of illness. Just like physical health, it is a resource. It gives the capacity to enjoy life and deal with challenges. It is both a health and a social policy issue that warrants focused and sustained attention by specialized personnel.
- Adapt the Mental Health Services Commission of Canada’s Strategy to NB and prepare an implementation plan. Mental health care would be part of the Health Authorities’ mandate as a separate organizational component with dedicated resources.
- Ensure adequate resources for the province’s Integrated Service Delivery Teams, since they have a key role to play in effectively and efficiently addressing complex cases.
Key Facilitating Actions
- Revise the physician payment methods to reduce the emphasis on activity volume and more effectively encourage accountability for both individual and population health. Also eliminate or revise the physician billing number rules (e.g. shift to an FTE-based system) to support the introduction of the above system design and operation features.
Compensation for specialists should be on the basis of a pooled income with an income ceiling. This would contribute to a better sense of teamwork, could free up some funds for program development, and should stimulate research and academic pursuits. An optimal approach may require a variety of methods.
Alternate compensation models for health care providers could help to ameliorate concerns about moving to new models of care while preserving an incentive to maintain service volume. For example, remuneration for primary care physicians (as members of primary care center clinical teams) on a capitation rather than fee-for-service basis (or some combination of the two) could prove to be a preferable approach for all concerned. In some, instances salaries may also be a useful option.
- As part of a Human Resources Strategy to support the provincial plan, establish dynamic (regularly updated) health professional supply and distribution targets that reflect the above system design and operational features and use these to engage in multi-year human resources planning with universities and other supply sources. Recruitment and retention strategies are a vital part of this initiative.
- Transfer the Extra-mural Program, Ambulance/EMT Service and Telecare back to the Health Authorities to improve service planning, operational coordination and continuity of care. These important functions require dedicated management that recognizes the specialized nature of the services, i.e. they should not be rolled/absorbed into the existing HA management structure. A small DOH oversight function is also needed.
- Similarly, transfer all Public Health functions to the Department of Health to ensure a single authority and accountability center for provision of this vital component of the system. A fragmented approach to public health services is not in the public interest in terms of planning, surveillance, preparedness and rapid response.
- Increased focus on proven prevention services to improve lives and help limit system costs. While many diseases like dementia, ALS, MS and other chronic degenerative diseases currently have no proven, significant prevention potential, there are others like some cardiac and respiratory conditions, and also obesity, that lend themselves to positive results from educational/preventive strategies. There is a continuing need to help people understand the reality of what works and the long term benefits of adhering to a healthy lifestyle.
- Use External Reviews and/or Coroner inquests as tools for system improvement. Such reviews would concentrate on determining the factual basis for situations that otherwise rapidly become media and political issues, often generating much public concern and often in the absence of real facts. Decision-makers would be much better served if there was an established practice of External Reviews conducted by non-partisan, experienced reviewers selected for their skill and analytical ability, not their political persuasion.
- Maintain a separate body (NB Health Council?) that monitors and regularly reports publicly on system population health and health service outcomes as well as inputs (resources) and outputs (activity volumes). It would have a policy analysis, planning, advisory and best practice focus, and could serve to enhance public communication on topics that matter such as obesity, diabetes, fitness, hospital risk factors, diagnostic and surgical wait times, etc., via regular public system performance and service quality reports. Effective governance and management structures are essential factors.
- Provincial Resource allocation on a consistent, objective basis in relation to service needs and priorities, with a continuing emphasis on achieving optimal use of all currently available resources to achieve stated population health outcomes, i.e. personnel, buildings, equipment, funds.
- A Health Authority internal resource allocation method that promotes service efficiency and ensures maintenance of a comprehensive range of service types and delivery methods. This includes budgets that limit the ability of health authorities to transfer internal resources among major service components.
- Actively promote and support a positive, patient-centered organizational and service culture in both the service provision and administrative components, including a shared vision of quality service and timely, a staff orientation program, employee and patient engagement strategies, considerate communication among staff and with patients and their families, a patient and family advisory council, regular service satisfaction surveys
- Support medical research in order to attract personnel and maintain centers of expertise, including identification and promulgation of best practices in relation to both service provision and clinical administration.
- Support establishment of a national prescription drug plan with income based coverage.
A Public Service Model
A significant portion of Canada’s health care system is clearly a not-for-profit public sector service rather than a for-profit activity such as in the U.S.A. It is a major element of the nation’s social safety net and although far from perfect in design and operation, is seen by many, if not most Canadians, as a fundamental aspect of our national identity. Therefore, perhaps the overall system should be viewed from this public sector service perspective.
A key question is how to allow those with relevant clinical and resource management expertise to run this complex system to achieve optimal results while also retaining sufficient political accountability to the public for the system’s overall design and operational features, as well as the public sector resources expended by it “for the public good’.
Since politicians are accountable to citizens for society’s major ‘social safety net’ components, including health care, they understandably want to ‘be involved’ in decisions that affect them and their constituents — and also their own jobs. Hence, a logical and workable distribution of responsibility, authority and accountability is a key factor.
One option is to establish an arm’s length governance and service management and operation structure, with appropriate responsibility and authority, along with a comprehensive and robust set of regularly reported performance indicators (focused on outcomes, but also monitoring key inputs and outputs). The public and politicians could then use these parameters to assess the system’s performance and that of those who operate it on their behalf, in relation to specified standards of timely access, effectiveness, efficiency and quality. If the standards are not met and there’s no good reason for that situation, then the system operators are held accountable.
Such an approach may not be perfect (since no human construct ever is), but it’s certainly preferable to ad hoc pressure and/or self-interest based decision-making (interference?) with little regard for the wise use of finite public resources.
Not withstanding the above, the Department of Health would still be required to provide overall health care system policy and operational management direction and oversight, and to function as keeper/maintainer of a relevant and progressive Provincial Plan.
What if Nothing is Done?
The current system’s service provision problems and inefficiencies will continue and therefore the system’s resource base will continue to provide less service to the people of NB than could be provided with these resources. This means overall population health will be lower than it could be if optimal use was made of the system’s people, facilities, equipment and technology. This, in turn, will reduce the level of resources available for other important public sector services.
Note: A massive effort to implement the outlined framework within a limited time frame may well be beyond any province’s capability. Therefore, a more drawn out approach would be more practical. It is essential not to be daunted by the seeming magnitude of the task, but to get started. Once the Plan has been prepared, publicized and explained, a starting point to implementation could be primary care, with emphasis on establishing a few of the envisaged ‘model’ primary care centers to demonstrate its advantages to all concerned. In regard to governance, HA Boards consisting of people appointed for their relevant expertise, objectivity and big picture thinking ability, not for political allegiance and not elected (which creates a ‘power base’ with no corresponding fiscal accountability) is also a vital initial step, as is having CEOs report to them, and a capable DOH management team.
Regardless of the time frame involved, a logical sequence of both concurrent and consecutive, steps is a key aspect of a successful implementation process for the desired end product. Having a sound, ‘timeless’ Plan, i.e. one that takes a sufficiently ‘big picture’ approach and therefore does not require regular and extensive revision, also increases the ability to take advantage of any opportunities that may arise unexpectedly, because they can be sensibly incorporated into the overall Plan.
Excerpts from 1987 DHCS Strategic Plan
Social Policy Mission Statement: To ensure that all citizens have a comparable opportunity to live healthy lives, develop their capability for self-sufficiency, and their ability to participate in and contribute to society in a positive manner.
Social Policy Goals:
1. To ensure individuals and communities have the knowledge and skills required for them to contribute to society economically and socially
2. To ensure provision of a network of services that preserve and restore physical and mental health, and facilitate positive social functioning.
Health Services System Objectives:
1. To increase good physical and mental health in the population by reducing the incidence and prevalence of physical and mental illness and/or injury, and premature death.
2. To minimize functional disability and dependency resulting from physical and/or mental health problems
3. To ensure the provision of long term/chronic care services for those who are unable to be fully self-sufficient due to age, disability and/or other factors.
4. To define, monitor and maintain timely access, effectiveness, quality and efficiency standards in regard to the use of all health service system resources to ensure timely, consistent, equitable service provision.
This requires a comprehensive range of service types and service delivery methods and an appropriate mix among them in order to achieve and maintain a coordinated and responsive service network.
Clearly stated Service Outcome Goals and associated Performance Measures/Indicators are also required.
Appendix 1: Additional Comments on Human Resource Needs (source: Ken McGeorge)
A commitment to leadership and vision means that people are appointed to positions of leadership by virtue of their leadership capacity and professional training. Once appointed, leaders need to be cultivated and given opportunities to further improve their skills. Those who provide advice to elected officials must have opportunities to keep their skills and knowledge current, i.e. continuing education is a necessity. Knowledge of the system and experience in leading change must be prerequisites for those appointed to leadership positions in health and social services. Elected officials, having approved a vision for the future and a plan to achieve it, need to let the leaders lead and make sure that they do.
The culture that needs to be created in health care is one that emphasizes service excellence as a non-negotiable matter. Service excellence has little if anything to do with availability of money. It has everything to do with attitude and leadership. Jim Senegal, the founder of Costco, when explaining that company’s success, said: “Culture is not the most important thing….it is the ONLY THING!” In a new culture for health and long-term care, the following elements are essential:
Those in leadership must become educated about the importance of service system culture, including
it’s relationship to consistent, effective, efficient provision of quality services.
General agreement regarding the type of culture needed in health services and facilities;
Obtain expertise in organizational culture development and standardized educational resources;
Train all existing managers and executives and ensure all are receiving consistent training
Make training in culture an essential element of managerial training:
Lean Six Sigma: it must be mandatory that all senior and middle executives become certified at the
green belt level; apply LSS in each area of the operation, particularly those in which patient/public
contact is part of the daily routine.
Create a leadership institute to provide basic and advanced leadership skills development for
those within the civil service and within the health care delivery system. It could be associated with
Use personnel assessment tools such as Pathfinder for determining suitability for senior positions both
in the civil service and care delivery system.
Leadership training for physicians in positions of clinical management or influence would be
mandatory; developed in consultation with the CMA, CCHL, and other relevant clinical organizations.
In particular, government personnel involved in health system management must have a sufficient understanding of that system, given its size and complexity. Therefore:
a. Senior staff in the relevant departments must include a solid mix of people who have had training and education that would qualify them for certification in the CCHL; added to that, some staff must have had experience in successfully managing a major care facility.
b. Strong leaders from the service provision field should be seconded to serve, if only for term appointments, in key leadership roles in these key departments.
c. Toxicity must be identified and corrected through development of a new organizational culture.
d. The practice of using staff secondments to minimize staff complement numbers needs to be assessed.
e. The issues of rapid turnover and lack of accountability must be dealt with. In any other area of economic activity, executives are held accountable for performance; the same standard must be applied to these departments. This means linking responsibility, authority and accountability. Persons holding senior executive roles in these departments need to have had education, training, and experience in the field that they are administering.
For instance, the persons administering the Long-Term Care Program must have had experience and training in the Long-Term Care field, in which there is a professional certification process. Similarly, in Health, various ADM positions must be filled with persons experienced in working with physicians, nurses, unions in the leadership of hospitals or clinics. Training programs in health administration have grown significantly across the country as has the Canadian College of Health Leaders, all in an attempt to improve the quality of leadership and decision-making in the health and long-term care field. If the government cannot recruit such persons, a secondment process such as that used in the Ontario Ministry of Health would give the department some new and fresh thinking.
Appendix 2: Additional Comments on Aging Population Services (source: Ken McGeorge)
Create a coherent approach to serving an aging population: For 50 years, governments and health professionals have worried about the days in which we now live. Conference after conference has posed the same question: how will we respond to the health service requirements posed by an aging population. But in all those years, there has been limited coherent and sustained action.
Properly serving an aging population involves action on several fronts:
Healthy Aging Strategy focusing on the things that actually work and are useful (the Department of Healthy and Inclusive Communities is doing a good job of charting a course for this strategy; there are many resources available virtually free that need to be tapped and embedded in such a strategy); complementary health strategies must be encouraged.
Seniors Primary Care Centers: as part of the Primary Care initiative, service centers need to have a particular focus on Seniors Health and Social issues. In that way, frail senior would be effectively managed by an area’s Primary Care service center. Managing through the current complexity of primary care is an exhausting and frustrating experience for many seniors and their caregivers. “One Stop Shopping” is not only desirable, it is absolutely feasible without a lot of cost and does involve some restructuring of expectations and duties within the context of primary care reform. It is not nearly as complex as some might suggest, particularly if leaders are allowed to lead.
Service Campus concept: Shannex, Lock Lomond, Spencer, and York Care Centre operate ‘campuses’ that provide an array of long term care services in which people can move from independent living apartments through assisted living and eventually to a nursing home. The ideal situation would be to have all the health and social services required available on-site so that there is a natural progression for an elder as frailty increases. This concept can be applied in rural communities as well as in cities and it makes the care of frail elders more compassionate and efficient.
Adopt a regional form of management for long term care: in such an important area of society, long term care services must be managed efficiently with an eye to best practices, optimum quality and security, and constant improvement of quality. Restructure the way in which resources are allocated and managed,
allowing local and regional discretion on staffing priorities. There are operating advantages to operating nursing homes differently from acute care, so a simple merger with Horizon and Vitalite is not a magic solution. However, there is much room to manage nursing homes and other long-term care organizations under one organizational umbrella on a regional basis.
Rather than using a standard average hours of care per resident per day method of resource allocation, adopt a long term care version of the active treatment system’s case mix grouping – resource intensity weighting (CMG-RIW) methodology. This would more accurately reflect the resources needed to care for the particular mix of residents in any given residential setting, thereby increasing equity among facilities.
In regard to transferring the Long Term Care functions of the Department of Social Development to the Department of Health; ensure that there is a sufficient number of people in key positions that have relevant experience, and therefore credibility, managing in the long-term care system.
General oversight of the Home First Strategy would be by the Department of Health’s Long Term Care component, with implementation by the regional LTC organizations in close cooperation with primary care centers. Role clarification between the two is essential for success, again with an allocation of authority that is consistent with assigned responsibility and accountability.
Develop mandatory leadership development, performance assessment, and performance management for all who serve in managerial positions.
Develop a capacity for innovative thinking. A dynamic service field like health care requires sustained visionary leadership rather than a ‘minding the store’ mind-set.
In regard to not-for-profit vs. for profit long term care facilities and services, regardless of the content of marketing efforts by the latter, ultimately a for-profit company must indeed make a profit. This has to come from somewhere — staff ratios, staff mix, staff pay levels, service quality standards, increase productivity, etc. Perspectives vary about feasibility and desirability of profit-making enterprises operating various aspects of society’s social safety nets/‘public services’. In any event, their ‘prime directive’ is about doing what’s best for the organization’s owners, senior managers and stockholders. That’s not to suggest for-profits are inherently unwilling or unable to provide quality ‘public services’, but that they must make a sufficient profit margin somehow in order to make it worthwhile to themselves. Therefore, government must establish and enforce clear parameters regarding how that’s achieved. Otherwise, it’s caveat emptor for both government and for individual recipients of long term care services. These comments are in reference to services provided by for-profit companies that are fully or partly funded by public sector resources.
Appendix 3: Additional Comments on Primary Health Care (source: James Wolstenholme)
In order to improve timely and equitable access to effective primary health care, so as to: 1) reduce the incidence of people becoming more ill and requiring emergency department as well as secondary or tertiary level care, 2) improve population health outcomes, and 3) ensure more efficient use of available resources, more is needed than just increasing the number of ‘independent’ family practitioners.
What is required is shifting to an interdisciplinary team approach that involves primary health care centers that have a mix of family practitioners, nurse practitioners, physician assistants, physiotherapists, respiratory therapists, pharmacists, dietitians, kinesiologists, medical social workers and mental health professionals, admin. support staff, etc., that are able to deal with a wide variety of physical and mental health problems in the initial stage — before they become more serious. In addition, this would allow an increased focus on prevention/health education services aimed at helping people to remain more healthy for a longer time, thereby reducing the number who need more intensive, and much more expensive, acute and chronic care for longer periods.
The new generation of health professionals of all types recently or now being trained increasingly understand the benefits of the above approach to service provision, and the number of family practice physicians who will be retiring in the next decade or so offers an opportunity to begin a deliberate shift to the interdisciplinary primary care model, rather than just replacing independent physicians with no change to an outmoded, inefficient and at times ineffective service delivery model.
The key features of such a deliberate shift to the method of service provision, supported by a comprehensive patient and provider electronic record, would be that everyone would be on the roster of a collaborative care team for the vast majority of their health care related needs.
Such a model would be able to provide services for a longer portion of every day, e.g. 12 hours on weekdays, 8 hours on Saturday and 4-6 hours on Sunday. This would reduce ER usage, especially when combined with urgent care units associated with hospitals, that would be able to deal with non-emergency cases, which account for the majority of ER visits.
Primary health care centers would allow the each professional to function to their full scope of practice, rather than underutilizing the most highly trained and most expensive team members. This would mean fewer of the ‘top tier’ professionals would be needed.
For example, nurse practitioners are able to perform close to 80% of the services of a family practitioner. This means the latter’s time could be largely focused on patients who present with more complex situations.
Primary health care teams could be located so that everyone in the province is no more than a 1 hour away. Satellite office teams with a smaller range of personnel within a 30 minute drive would be warranted to reflect the current distribution of independent family practitioners and to ensure a reasonable distribution of service volume. Ambulance/EMT services would still be available for emergency situations throughout the province.
The goal could be to have 30 centers and 24 satellite offices, as follows:
Zone 1: centers in Moncton/Dieppe (4), Sackville, Riverview, Shediac, Richibuctou and Bouctouche; satellites in Riverside-Albert and Port Elgin
Zone 2: centers in Saint John (4), Quispamsis/Rothesay (2), Sussex and St. Stephen; satellites in St. George, St. Andrews and Grand Manan
Zone 3: centers in Fredericton (4), Oromocto, Woodstock and Perth-Andover; satellites in Doaktown, Stanley, Nackawic, Fredericton Junction, Harvey, Minto/Chipman, Coles Island, Gagetown, Plaster Rock and Florenceville
Zone 4: centers in Edmundston and Grand Falls; satellites in Ste Anne de Madawaska, Baker Brook, St. Quentin
Zone 5: centers in Campbellton and Dalhousie; satellite in Jacquet River
Zone 6: centers in Barthurst, Caraquet and Tracadie; satellite in Shippagan
Zone 7: center in Miramichi; satellites in Baie Ste. Anne, Neguac, Rogersville and Blackville
Such a new approach to locating the province’s primary care sites would take careful planning and time. The starting point could be to group all family physicians, nurse practitioners and family practice nurses where future primary care centers would be located. Areas where family physician are retiring would be a factor to consider in terms of which locations to begin with.
Another approach would be to establish a few strategically located centers as demonstration sites. Also, clearly express that the interdisciplinary team model represents the future of primary health care delivery in NB.
A plan to increase the number of nurse practitioner and physician assistant positions in the province is an essential component if the new model is to be successfully implemented. It includes supply arrangements with training institutions and a recruitment strategy. This must also be synchronized with limiting the number of new independent family physician positions, otherwise any available resources will continue to be allocated to the latter and the needed shift will never be achieved. The money saved by limiting the number of family physicians would fund the increased number of nurse practitioners and physician assistants — the annual cost of a family physician is more than 3 times that of a nurse practitioner or physician assistant.
Clearly, incentives would be required for family physicians to participate in the new primary care model, although this should be less of an issue for younger and new practitioners. In any event, such key factors as physician supply management by limiting billing numbers, covering the cost of terminated office space leases, and options to fee-for-service payment would have to be addressed.
The lead responsibility and associated authority for detailed transition plan development and implementation would be assigned to the Health Authorities, with general oversight by the Department of Health.
Appendix 4: Patient-centered Care Definition (source: Horizon Health Strategic Plan)
Care that is truly patient and family centered considers patients’ cultural traditions, their personal values and preferences, their family situations and their lifestyles when responding to their needs. It seeks to give patients and their loved ones an opportunity to collaborate with health care professionals in making clinical decisions. Patient and family centered care puts responsibility for important aspects of self-care and monitoring in patients’ hands – along with the tools and support they need to carry out that responsibility. Patient and family centered care ensures that transitions between providers, departments and health care settings are respectful, coordinated, and efficient.
The goal is to offer each patient the distinct care he or she requires in a compassionate manner that enables them to have tangible input into their care from start to finish. The intent is to improve care outcomes for patients and their families by improving the care experience they have when interacting with the service network, and engaging them in decisions relating to their own care and health. The goal is to ensure that patients and their families have the information, knowledge and support they need to make informed choices about their care/treatment.
Note: Jean-Guy Finn’s Results Based Logic Model component of the CCC Health Services Planning Guide/Framework is contained in separate document intended to be attached to this one. Draft 3 prepared by James H. Carter, June 2020