Provincial Spending will only follow Federal Spending. Will Healthcare be on the Agenda?!

A major factor causing long emergency room (ER) wait times is the high number of alternate level of care (ALC) patients occupying acute care hospital beds, making it difficult to admit patients from the ER to hospital. ALC patients are unable to be discharged because the appropriate level of care they require is not always available.

Not a short term problem

This was released by the Canadian Institute for Health Information's (CIHI) in 2006: There were almost 73,000 patients designated as ALC patients among 2.4 million patients admitted to acute care hospitals outside of Quebec between April 1, 2004 and March 31, 2005.1 This is up by 13.6% from 2003-2004 and 19.6% from 2002-2003.

This was released by CIHI last week (January 14, 2009):
In 2007–2008, there were more than 74,000 hospital stays for alternate level of care (ALC) patients in Canada (outside of Quebec and Manitoba), representing more than 1.7 million hospital days, according to a new analysis by the Canadian Institute for Health Information (CIHI). The analysis, Alternate Level of Care in Canada, provides a first look at patients in acute care hospitals across Canada who no longer need acute services, many of whom are waiting to be discharged to a setting more appropriate to their needs.

Some highlights of the analysis include:
-- The equivalent of almost 5,200 beds was occupied by ALC patients in acute care hospitals.
-- Overall, dementia accounted for almost one-quarter of ALC hospitalizations and more than one‑third of ALC days in 2007–2008.
-- 83% of adult ALC patients were admitted to an acute care hospital through the emergency department, compared to 63% of non-ALC patients.
-- Most ALC patients were discharged to a long-term care facility (43%), while 27% were discharged home and 12% died during their hospitalization.

This is a national crisis in healthcare. Provinces are taking the lead to come up with answers. In Ontario Dr. Alan Hudson and Dr. Kevin Smith are dedicated to the task. The hospitals, community organizations, the associations, the integration networks and the governments are all collaborating.

And the media is even suggesting solutions.
Judy Steed's column is one example
Special to the Star

PROBLEM: In Canada, "bed blockers" – older people stuck in hospital, ready for discharge, lacking the home support they require – occupy 5,000 hospital beds and consume $200 million annually. They clog emergency departments and expand wait times for others.

SOLUTION: Hospitals in Denmark eliminated bed blockers by creating a stiff incentive to get elders moving. Municipalities are required to pay for those who stay in hospital past discharge dates. That got communities working to move seniors on – to rehab or home care.

. . . hospitals agree that community care is the answer. "I'm CEO of the Ontario Hospital Association and we think the solution is in the community," Tom Closson told me when he was CEO of the University Health Network. An effective long-term home care system is the answer, he says – only then will seniors discharged from hospitals and nursing homes be diverted from emergency departments.

Closson and his colleagues in community care and home care know that solutions will require spending and they know that provincial spending will be dependent on federal spending. They are counting on Mr. Flaherty taking note. Not only can investments bolster the economy, they can improve healthcare. Without it, they say, access, quality and human resources to care for the sick will be dramatically affected.

Help two Ontario farm girls complete medical school. An Investment Opportunity with Two-Fold Return.

Two rural Ontario sisters and their family are looking for finances to complete their training as medical doctors at the Royal College of Surgeons in Ireland. Well-placed in their classes, they will graduate in 2011 and 2013. Offering an 8% return on investment, interest payments would be made until June 2011 when principal and interest payments would begin. Beyond personal guarantees, the girls offer their family business and farm, which has been in the family for 30 years, as additional security. For added security, third party management of the funds would be welcomed. Interested? Call toll-free 888.301.3477 or emailto: medical-investment@live.ca

Can Shoppers Drug Mart Do Anything Right?

Shopping for specialty items is a pain at the best of times. Try finding a seasonal affective disorder light. Sure there are some specialty stores that carry them. But few. Shoppers Drug Mart carries them and has cornered the market. Not a good time to restrict access -- especially if you have stores just about everywhere. And, by all appearances (looking through the window), they do offer a good array of lights to choose from. But I arrive at one of the few stores that actually carries these lights and I can't get in. Its 8 pm. I can get into the main store using the same entrance (Danforth and Main area in Toronto) and buy groceries, chocolate, cheap pop, cosmetics and yes a good array of over the counter pills and products. But try a specialty item. Humbug. If it’s a little-out-of-the-ordinary healthcare item the doors are closed. Once again Shoppers Drug Mart demonstrates that their mission is shareholder value. Consumers be damned.

So now it’s 9 a.m. and I will drive to a store. It's not nearby. I can go by car and make my purchase. I still lose half a day in the process + the time last night.

And call them to get this message. "We close at 7 pm." But get there and find that its really 6 pm.

p.s. I dropped by four stores. Three of their pharmacists had no idea what I was talking about. One wondered if I bought these lights there regularly. The other had no idea what I was asking for. A third realized what it was but had never seen or heard about one at Shoppers. Oyez, oyez oyez.

But some faint praise. The excessive space dedicated to chocolate, cheap pop, cheap butter tarts and Danish pastries has been taken down at the Queen and Carlaw store. Stocking clerks tell me that head office insisted. If they remove all of it maybe they can earn their partnership with the Diabetes Association.

Anton Hart

by Neil Seeman

Canada's most widely read major newspapers are outperforming health blogs on reporting important clinical content. However, both newspapers and health blogs are performing poorly in this regard. Major Canadian newspapers (on average) covered just 37% of what clinical experts considered critically important medical news in 2007. By comparison, the most popular 50 health blogs, on average, covered just 23% of these stories. However, these averages obscure important findings. When isolating general interest health blogs - a minority of the top 50 health blogs, most of which cater to a particular illness, such as diabetes or autism - one finds that, in all instances, these general interest blogs fare at least as well as and usually significantly better than general interest newspapers in reporting critical medical stories. The most popular such general interest health blogs include The Wall Street Journal's health blog (http://blogs.wsj.com/health/), The Health Care Blog (www.thehealthcareblog.com/) and Kevin M.D. Medical Weblog (www.kevinmd.com/blog/).

Also revealing is the overall performance of the 50 leading health blogs, as compared with popular newspapers, on the governance criteria measured in this analysis. The vast majority ( > 90%) of these popular health blogs lack drug industry sponsorship or overt partisanship that is readily detectable by the user. By comparison, drug industry sponsorship of events (other than direct-to-consumer advertisements) is not uncommonly seen in Canadian newspapers; and all major newspapers in Canada offer overt partisan commentary on health and medical issues on the editorial page - the "official voice" of the newspaper - and these editorials are usually written by anonymous editorial writers who rarely possess any clinical credentials.

As Figure 1 illustrates, health blogs can stand to do a better job of avoiding general industry sponsorship and offering users clear confidence regarding the privacy of user-submitted content. By comparison, newspapers fall down entirely on these scores, with no major newspapers in Canada prohibiting industry sponsorship or providing prominent assurances to letter writers (online or in print) that their submitted health content will be kept private in a manner that observes the Health on the Net Foundation code of conduct (HONcode) or equivalent privacy practices. Finally, 60% of the most popular health blogs are moderated partially or fully by SMEs, usually practising clinicians. The same cannot be said of major Canadian newspapers, whose health reporters and editors seldom have any clinical or graduate-level credentials in any health-related field. In many cases, newspapers do not have dedicated health editors.

More on this topic here.

Investing in future doctors. Here is an offer to consider.

An idea whose time has come
An Investment Opportunity with Two-Fold Return. Help two Ontario farm girls complete medical school.
Two rural Ontario sisters and their family are looking for finances to complete their training as medical doctors at the Royal College of Surgeons in Ireland. Well-placed in their classes, they will graduate in 2011 and 2013. Offering an 8% return on investment, interest payments would be made until June 2011 when principal and interest payments would begin. Beyond personal guarantees, the girls offer their family business and farm, which has been in the family for 30 years, as additional security. For added security, third party management of the funds would be welcomed. Interested? Call toll-free 888.301.3477 or email: medical-investment@live.ca.

How can local, provincial and federal politicians make a constructive difference to healthcare in Canada?

How can local, provincial and federal politicians make a constructive difference to healthcare in Canada? Here are three comments from three levels of government representing Sault Ste. Marie in Ontario’s near north. To respond use this blog or send a note to the publisher@longwoods.com

From the middle of Canada: Elaine Della-Mattia comments in the Sault Star (click on the title)

. . . all area politicians agree that health care will be a major issue locally in the coming year.

(Mayor John) Rowswell called health care the No. 1 priority for council in 2009. In fact, he believes the issue will be a priority across the province.

(Sault Member of Provincial Parliament, David) Orazietti said he's predicting some relief to the doctor shortage with the first class of the Northern Ontario Medical School graduating.

"A good portion of these students were born and raised in Northern Ontario and I have huge expectations that many will remain in the North and practice here," he said.

(Sault Member of Parliament, Tony) Martin said he continues to be concerned for the Sault's aging population and their health care needs. Martin said he will encourage and work with government to support front-line workers dealing with the added demand. He said he's been personally energized by the political activity that has taken place the last month, along with many other Canadians.

What are your suggestions? How should they leverage their political position. What would be a constructive strategy for your mayors, your provincial or state representatives , your representatives in congress?

Transforming Healthcare Organizations

Healthcare Quarterly, 10(Sp) 2006: 10-19
Transforming Healthcare Organizations
Brian Golden

Abstract:
Imagine you are a member of a hospital's executive team, having just left a meeting in which you and other members discussed the possible introduction of an ambitious Computerized Physician Order Entry (CPOE) system. Around the conference table you and others questioned whether CPOE would be the most effective way to realize your hospital's commitment to patient safety. Other issues that were raised included whether clinicians would support or resist the change, whether staff would have sufficient skills, where to begin, affordability and whether to proceed incrementally or with a "big bang." While there was much disagreement with respect to each of the issues, there was near unanimity around two important decisions - CPOE would be implemented and you would be the executive responsible for the system's design and implementation. This article, based on the experiences of a multi-site hospital, and drawing on past research on organizational change, provides a Four-Stage model to help change leaders in healthcare. Although relying on Toronto's University Health Network to illustrate the change model, the model is intended to speak to change leaders implementing various types of complex changes in all healthcare organizations.

To read the complete article click here

Dear Mr. Harper: Try a Post-Partisan Approach to Public Health Policy | Neill Seeman Essay

November 4, 2008

Dear Stephen,

In 2001, we worked on a historic legal challenge to expand free speech in this country. We fought so-called election “gag laws” (enacted federally in 2000) that limit spending by third party groups – of all ideological persuasions – during political campaigns. Although our arguments failed at the Supreme Court of Canada, this was a popular cause – applauded by many legal, academic, and media commentators across the political spectrum.

Under our line of reasoning, organizations opposed to, say, seal hunting should be constitutionally entitled to advertise during elections to promote their cause. The current law, one might argue, creates a "two-tier" system, where political parties are free to advertise during an election campaign within certain limits, yet third parties are silenced.

Building up to that landmark legal challenge, you reached out to people from a variety of political camps. Yet today, some members of the media and academia unfairly characterize you as intolerant of views that differ from your own; I know this to be untrue. Given your passion for the airing of different political views – the same passion that led you to doggedly challenge Elections Canada’s limitations on third party spending during campaigns – I have a suggestion on how to show global leadership during your new mandate: Pursue a postpartisan approach to the creation of effective public health policy.

As I argue in the current special edition of HealthcarePapers focused on obesity, “post-partisanship” is unlike “bipartisanship”. Bipartisanship is horse-trading – in its best incarnation, this means crafting patchwork legislation that allows all sides to feel satisfied that some thread of their vision or ideological essence found its way into law. The process plays to ego, not good policy.

In its worst incarnation, bipartisanship is merely rhetoric on the campaign trail, and nothing more. On the other hand, “postpartisanship”, a vision of politics championed by Governor Arnold
Schwarzenegger of California and New York Mayor Michael Bloomberg, is a more sophisticated decision-making model that breathes life into novel policy ideas to yield maximum, lasting impact.

In HealthcarePapers , I apply the vision of post-partisanship – elucidated in the book Radical Middle: The Politics We Need Now by Marc Satin – to health policy. I argue that the 10 political principles of post-partisanship Satin describes are ideally suited to public health, since public health policy-making, such as anti-obesity initiatives or mental health improvement strategies, necessarily requires long-term, multi-sector solutions that are enabled by strong legislative supports. Representatives wedded to a long-term public health cause also need to sustain lasting relationships across party lines in order to buttress the original legislation with interim evaluations, re-investments and other policy supports. Herein lies one of the practical benefits of a post-partisan approach to decision-making.

As noted by Satin, the 10 post-partisan principles are as follows:
1. Relationships are as important as convictions.
2. Criticism needs to be well-balanced by self-criticism.
3. There must be an overriding commitment to dialogue and deliberation.
4. There must be an overriding commitment to diversity of opinions and perspectives.
5. Compromise is not the only endgame.
6. Be simultaneously creative and practical.
7. Demonstrate a penchant for big ideas.
8. Support a bias for action.
9. Demonstrate concern with values and principles.
10. Have a long-term vision.

I believe that these 10 principles can provide the basis for a priority setting public health policy model that will temper political self interest. Under this vision, diverse decision-makers can come together from the outset of planning and policy debate; decision-makers can feel free to disclose their competing interests; and validated analytical techniques can be used to select the most innovative, unbiased and criteria-based ideas from among all those considered.

Post-partisan decision-making, in advance of landing on any final policy proposal, allows multi-sector partners to select weighted solution criteria (a process formally referred to as multi-criteria decision-making analysis). The process enables a neutral, independent commission with assigned legislative power (comprised of members nominated by all parties) to identify the cognitive and partisan biases that may have inadvertently crept into any final, recommended policy solutions.

This process can serve innovation. As the global financial crunch tightens its noose on governments, we require innovation in the service of better value. Public health is a good place to start. Unlike other domains of health care policy (such as hospital management), both the federal and provincial governments have constitutional jurisdiction over key areas germane to public health.

Federal constitutional authority extends to “peace, order and good government” and all matters not explicitly assigned to provincial authority. The Department of Health Act provides a federal mandate to protect against the spread of disease, to provide surveillance, to guide public health research (e.g. via the Canadian Institutes for Health Research) – and to advance the physical, mental and social well-being of Canadians.

Stephen: You have the unique opportunity to make post-partisanship the new culture of Parliament. A first step might be to create a multiparty committee of independent members from across Canada charged with designing the weighted criteria by which potentially high-impact public health policies should be assessed prior to design and implementation. The criteria might include: estimated policy magnitude; the effectiveness, if known, of current interventions; the ability to effect change in the near- and long-term; and cost effectiveness.

We are in an era of zero-sum budgeting and fiscal challenge while tackling the steady, unyielding onslaught to our health care system from increasing rates of chronic disease such as diabetes, cancer, heart disease and asthma. Governments face a stark choice: innovate; or implode, borrowing against the future and creating further intergenerational inequity in order to sustain the health care system.

The good news is that you will not be the first to embrace postpartisanship. And we have seen dividends come from such an approach in the arena of public health. Consider that Gov. Schwarzenegger’s state has witnessed a dramatic percentage decline in teen pregnancy rates. This is especially impressive since it occurred during mass migration to the state of sub-populations with very high teen pregnancy rates such as those seen outside of California.

California’s ambitious plan to curb teenage pregnancy – as with the governor’s new leadership in the battle against childhood obesity through mandated school physical activity- and healthy-lunch initiatives – would never have taken place but for Mr. Schwarzenegger’s continued openness to opposing viewpoints.

Like any other political model, post-partisanship is just a suite of ideals that will only succeed if elevated to a science. In the pursuit of more innovative and cost-effective public health interventions, you possess the skills to make the approach work. This is the kind of politics Canada’s health system needs now.

Neil Seeman
Senior Resident in health system innovation
Massey College at the University of Toronto,
Adjunct Professor of Health Services Management
Ryerson University.
In 2001, legal and policy advisor to Prime Minister Stephen Harper
in Harper v. Canada (AG)
Email: neil.seeman@utoronto.ca

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High Performing Healthcare Systems: Delivering Quality by Design. Toronto: Longwoods Publishing.

Longwoods has just launched the book "Systems" -- full title is High Performing Healthcare Systems: Delivering Quality by Design. It has its own blog, See: http://qualitybydesign.blogspot.com/ Here is part of Adalsteinn Brown's Foreword to the Book

Citation Information Brown, A. 2008. "Foreword." High Performing Healthcare Systems: Delivering Quality by Design. 9-10. Toronto: Longwoods Publishing.

Quality remains one of the great trade-offs in Canada's healthcare system. Every person working in the system agrees with the importance of quality, and many make it an explicit part of their personal and professional missions. Today, for example, when confronted by clear evidence of poor quality in their own practices and organizations, clinicians and administrators rarely question the validity of the information and they respond quickly to solve the problems identified. At the same time, however, most clinicians and administrators believe that large-scale improvement is unaffordable. Although quality continues to rise in importance, and nearly every study published identifies room for improvement, something stops us from achieving the high quality we desire. The work of G. Ross Baker - who led the Quality by Design initiative and, with Peter Norton, the landmark study on patient safety in Canada - lays out the challenge clearly. Every day in Canada's healthcare system preventable errors arise in hospitals, long-term care facilities and physicians' offices. These errors lead to extra costs, poor health and, in many cases, avoidable deaths. Yet the pursuit of safety and quality remains the something extra that many of the people working in our system can follow up on only at the end of a busy day. . . . .