Opportunities to improve health care processes and services outcomes in Canada

Opportunities to improve health care processes and services outcomes in Canada

R Douglas Wilson MD MSc FRCSC, Professor Emeritus Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Alberta Health Services.

ABSTRACT: Purpose: This scoping review identifies opportunities to improve health care processes and services outcomes in Canada and discusses some potential policy options. Methods: The review covers Canada’s prioritization process for health services, quality of care, comparative spending and quality between OECD countries, and evidenced-based service change opportunity. These focused areas for reproductive care are used to highlight the large-scale clinical scenarios that have an evidenced-based national context during 2000-2022 Findings: The analysis indicates important health care strengths but serious long-standing weaknesses and threats that require medical system leadership recognition and considered implementation of potential quality improving opportunities. When compared to other Organization for Economic Co-operation and Development counties, Canada has average health care outcomes, lower ranking overall for health system quality indicators (11/12) and higher costs. Conclusions: New priority and quality improvement strategies are needed as low-quality measurement and high levels of inappropriate care have been identified.  More political, medical, and public recognition, questioning, debate, and understanding of this evidenced-supported health care dilemma, in Canada, is required.

SUBMITTED: 14 APR 2022 | PUBLISHED: 11 JUL 2022

DISCLOSURE: None declared.

CITATION: Wilson, R Douglas (2022). Opportunities to improve healthcare processes and services outcomes in Canada. Canadian Health Policy, JUL 2022. ISSN 2562-9492, https://doi.org/10.54194/LHSA7302, canadianhealthpolicy.com

INTRODUCTION

Health policy reform in Canada

A 2002 Canadian Senate Report ‘The Health of Canadians- The Federal Role’ commented that ‘there is no perfect solution. Everyone involved will have to be prepared to compromise to make health care reform work for the benefit of all Canadians. Insisting on perfection, or attempting to obtain everything one wants, will doom reform to failure’. [1] Twenty years later, health policy reform remains a difficult and cumbersome process in Canada.

Canada does not have a single national health care plan, but rather 13 provincial and territorial health insurance plans, plus 1 federal health insurance plan covering the aboriginal population (non-insured health benefits program, NIHB), with these systems operating under a federally designated requirement for common features and basic standards of coverage. Under the Canada Health Act, a universal, publicly funded health insurance program is mandated to ensure that all Canadian residents have reasonable access to medically necessary hospital and physician services on a prepaid basis, with uniform terms and conditions. [2] [3] Despite the benefits of this model, there are persistent problems that leave room for improvement in the system, especially regarding efficiency of processes and the quality of services.

The variety of gaps in health care needs and services would include the politically driven focus for clinical service delivery, the lack of a validated health care priority process with audit, the lack for ‘real’ inter- provincial collaboration for human resource and service management, and the recent COVID-19 pandemic. Canada’s 2021 provincial-national health spending was greater than $300 billion ($ CAN) but measurable health care quality outcomes are lacking. [4] A lack of knowledge translation success over the last 20 years, has been identified as a barrier to health policy reform and it has been suggested that efforts in quality improvement might better be focused on increasing health care system resilience and devising better models of care. [5] [6]

The objective of this paper is to identify health care processes and services quality improvement opportunities for Canada’s provincial health care systems.

METHODS

A scoping review was used for the analysis. Heterogeneous literature labelling was done with relevance to date, location (country or context), source (peer-reviewed or grey literature), and origin (health care discipline or government policy). A significant proportion of the scoping data sources were from federal and provincial government controlled-public websites with possible inherent bias. Other government associated sources such as Organization for Economic Cooperation and Development (OECD) and health care directed quality and safety peer-reviewed publications are identified through PubMed and internet subject-based topic search. In additions, key words, report titles, and authors were utilized.

The scoping review areas were related to Canada and included: prioritization process; quality of care; comparative spending and quality between OECD countries; and evidenced-based service change opportunity. Focused areas (reproductive care) are used to highlight large scale clinical scenarios that have an evidenced-based national context. PUBMED was the evidenced based resource, English only, using keywords health-care access, health-care quality, health-care outcomes, maternal morbidity, maternal mortality, health-care spending, health-care reform, quality improvement, alternative payment models, physician payment, maternity care models, appropriate care, inappropriate care, population health.   The grey literature internet search used keywords provincial health-care priority, provincial health-care business planning, Organization for Economic Co-operation and Development, and Canadian Institute for Health Information (CIHI).

This scoping review used limited data sources (peer-reviewed and grey literature) for a national evidenced-based policy review of Canada’s provincial health care governance process (past and present) and their outcomes for health care prioritization, quality of care, spending cost, and opportunities for health care model change. The scoping review results can be used to inform and engage health care political (federal and provincial health ministries) and medical administrative leadership toward identified areas where more focused, measurable, and sustainable quality improvement activity could benefit from comparative international quality outcome measures. [7]

RESULTS

Healthcare spending

Canadian health spending is summarized in TABLES 1-2. The spending data is based on the OECD’s System of Health Accounts (2011). [8] The tables show 2019 per-person spending in Canadian dollars, health spending as a percentage of gross domestic product (GDP) and the public/private split for 9 selected OECD countries, including Canada. Canada is among the highest spenders on health care in the OECD. Compared to other OECD counties, Canada was above the average for per capita spending on health care, but the public share contribution (defined as the sum of government expense and compulsory health insurance expense) was below average. Health care is a government expense in OECD countries and accounts for a large share of the public budgets. Health spending has typically outpaced economic growth over the past two decades. Health spending in Canada (excluding investment expenditure in the health sector) was 10.2% of GDP (2013 / peak 2010, 10.6%), compared to the OECD average of 8.9%, United States (over 16%) and 11.0% in Germany and France. Health spending is a fiscal concern for governments, as health care is predominantly publicly funded in most OECD countries, OECD estimates average health spending to reach 11.3% of GDP by 2030, if costs are not adequately contained. OECD countries report that it is more difficult to achieve savings in health compared to other government spending areas. [8-16]

TABLE 1: OECD comparison of health spending as a % total government expenditure 2015.

COUNTRY	HIGHEST TO LOWEST
Ireland / UK	18.4
Sweden / Canada	18.3
Norway	17.5
Denmark	15.8
France	15.3
OECD	15.3
Austria	15.1
Spain	14.9
Italy	13.4
Korea	12.5
Portugal	12.3
Mexico	11.3
Poland	10.7
Greece	8.9

TABLE 2: OECD health care spending.

	US$ Per Capita	GDP%	Public $ %	Private $ %
OECD	$5,074	8.8%	73%	27%
Canada	$6,666	10.8%	70%	30%
United States	$13,590	16.8%	49%	51%
France	$6,547	11.1%	84%	16%
Germany	$8,091	11.7%	85%	15%
Sweden	$6,892	10.9%	85%	15%
Netherlands	$7,124	10.2%	83%	17%
Australia	$6,106	9.4%	69%	31%
New Zealand	$5,228	9.1%	80%	20%
United Kingdom	$5,586	10.2%	79%	21%

Healthcare quality indicators

The Pan-Canadian Health Data Strategy Report 1 highlighted certain shortcomings of the provincial health care delivery systems including failure to create a quality evaluation and outcome process for determining the provincial health care service priorities and inadequate collection of health service outcome data for audit, measurement, and evidence-based service spending [17]. However, some evaluative analyses have been published by independent research organizations.

The ‘Mirror-Mirror 2021: Reflecting Poorly – Health Care in the US (Canada) compared to Other High-Income Countries’, published by The Commonwealth Fund (August 4, 2021), summarizes the inability of the Canada’s divided provincial health care systems to provide a high-quality / cost-effective service level comparable to outcomes in other ‘national’ health care systems. The data years (2017 to 2021) were evaluated with inclusion from longitudinal GDP spending data and the performance of health care systems of 11 high-income countries. An analysis of 71 performance measures across five domains (access to care, care process, administrative efficiency, equity, and health care outcomes) was drawn from the OECD and World Health Organization. The top-performing countries were Norway, the Netherlands, and Australia (the additional countries were Canada; France; Germany; New Zealand; Sweden; Switzerland; United Kingdom; United States).  Four features that distinguish top performing countries from Canada and United States were 1) they provided for universal coverage and remove cost barriers; 2) they invested in primary care systems to ensure that high-value services are equitably available in all communities to all people; 3) they reduced administrative burdens that divert time, efforts, and spending from health improvement efforts; and 4) they invested in social services, especially for children and working-age adults (TABLE 3). [18]

Recent Organization for Economic Cooperation and Development (OECD) health-care quality reports highlight the concerns for the Canadian health care system when compared to other OECD country health care systems. [17-18] Canada’s OECD report card for 2021 is summarized in TABLE 4. The results reflect health status indicators, Insurance coverage, public satisfaction, utilization and resources. Life expectancy is a key indicator for the overall health of a population; avoidable mortality focuses on premature deaths that could have been prevented or treated. Diabetes prevalence shows morbidity for a major chronic disease; self-rated health offers a more holistic measure of mental and physical health. For population health smoking, alcohol consumption and obesity are the three major individual risk factors for non-communicable diseases, contributing to a large share of worldwide deaths. Air pollution is also a critical environmental determinant of health.

Good quality care also requires health services to be safe, appropriate, clinically effective and responsive to patient needs. The overuse, underuse or misuse of antibiotics and other prescription medicines contribute to increased antimicrobial resistance and represent wasteful spending. Having sufficient health care resources is critical to a resilient health system. More resources, though, do not automatically translate into better health outcomes – the effectiveness of spending is also important. Health spending per capita summarizes overall resource availability. The number of practicing doctors and nurses provide further information on the supply of health workers. Hospital beds is an indicator of acute care capacity.

The data show Canada’s quality indicators continue to be average with increased spending (cost). [19] For the 18 OECD indicators, Canada had 14 average and 5 better than average rankings with OECD country comparison with higher health spending. Health systems are increasingly asking patients about the outcomes and experiences of their care. Preliminary results show improvements in patient-reported outcomes. Although the number of doctors and nurses have increased over the past decade in nearly all OECD countries, shortages persist.

TABLE 3: Comparison of OECD Quality Outcomes.

Overall Quality Measurement (overall rank)	Canada (10)	USA (11)	Norway (1)	Netherlands (2)	Australia (3)
Care process	4	2	8	1	8
Access to care	9	11	2	3	6
Administrative efficiency	7	11	1	8	2
Equity	10	11	8	5	1
Health care outcomes	10	11	2	4	1

TABLE 4: Canadian health system indicators.

Canadian Health for 2021	Canada Number	OECD average Number
Life expectancy (LE)	82.1 years	81.0
Avoidable mortality (AVM)	172 deaths per 100,000	199 deaths per 100,000
Chronic Disease Morbidity	7.6 % of population	6.7 % of population
Self -Health	2.8% in poor health	8.5% in poor health
Daily smokers (% population aged 15+)	10.3	16.5
Alcohol litres consumed per capita (% pop. aged 15+)	8	8.7
Overweight / obese Population with BMI ≥ 25 (% pop. aged 15+)	59.8	56.4
Ambient air pollution Deaths (per 100 000 population)	10	29
Population eligible for core services	100 (% population)	98.0 (% population)
Population satisfied with availability of quality health care	78 (% population)	71.0 (% population)
Expenditure covered by compulsory prepayment	70.2 (% total expenditure)	74.0 (% total expenditure)
Safe primary care: antibiotics prescribed (defined daily dose per 1000 people)	14.2	17.0
Effective primary care: avoidable COPD admissions (per 100 people, age‑sex standardized)	213	171
Effective preventive care: mammography screening within the past 2 years (% women aged 50‑69)	62.0	61.7
Effective secondary care: 30‑day mortality following AMI (per 100 000 admissions, age‑sex standardized)	4.6	6.6
Health spending per capita (USD PPP)	$5370	$4000
Hospital beds per 1000 population	2.5	4.4
Doctors practicing physicians per 1 000 population	2.7	3.8
Nurses: practicing nurses per 1 000 population	10.0	8.8

The prioritization process for health care services

Two provincial health care systems were compared using their published strategic plans: Alberta (2020-2022) and Ontario (2020-2023). TABLE 5 indicated that both Alberta and Ontario have a quadruple focus which are supported by measurable KPIs. While separately created, both Provinces appeared to have very similar focus for service planning and support, based on a high level of comparison. The provincially directed care plans had more prioritized process funding (for patient and health care provider) compared to minimal funding for outcome / quality of life measurement focus (for the patient health care service and experience). Alberta’s 10-year vision indicated their focus remains on process related support for access and quality, propelling the organization toward greater efficiency, value and integration. This vision aligns with Governmental Alberta Health’s policy direction and government priorities, but would require changes by AHS administrators, front-line staff, hospitals, physicians, patients and clients, and communities across Alberta. [20]

TABLE 5: Comparison of two Provincial Health and Business Plans for 2020-2022/2023.

Directed Health Care Focus	Alberta	Ontario
Quadruple Aim	·    Improve the experiences of patients and families	·    Enhanced patient experience
	·    Improve patient and population health outcomes	·    Improve population health
	·    Improve the experience and safety of our people	·    Enhanced provider experience
	·    Improve financial health and value for money	·    Improved value
Objectives and Priorities	·    Community and home care	·    Covid-19 Pandemic focus
	·    Sustainability and integration for addiction and MH	·    Promote excellence, access, and continuous innovation in our areas of direct clinical focus (cancer; renal care; organ transplant; senior care; population health)
	·    Leverage technology and innovation	·    Drive key provincial transformations (end of hallway care; improve addiction and MH care; advance care; embed digital first across the system)
	·    Implement Surgical Initiative and reduce imaging wait times	·    Enhance health system operations (front-line capacity; modernize the supply chain; establish provincial lab system; establish patient safety initiatives)
	·    Health promotion	·    Continuously improve as a high performing organization (support for our people; health equity; engage with diverse set of partners; complete integration of Ontario Health; balanced budget; continuously improve and innovate
	·    Improve health outcomes and access
	·    Continue to implement ‘Our People Strategy’
	·    Financial sustainability via cost saving and reduced expenditures

The short-term overview for Ontario (2020-2023) PHO’s Strategic Directions are summarized as: to provide scientific and technical expertise in the context of health system change, for public health modernization, COVID-19 pandemic care; to accelerate integrated population health monitoring; to enable policy, program and practice action; and to advance public health evidence and knowledge. [21]

The Provincial comparisons indicate that only short-term solutions are considered. A longer vision for population is required. Clinical service considerations, related to the social determinates of health, would offer larger impacts on health care quality and population health rather than the continued use of practice guideline implementation strategies [22]. The use of health care outcome data-information (quantitative; qualitative), multiple sources of input (patient; provider; ethical; economic; policy), collaboration, change management process methodology, and clear service objectives, process, and deliverables with decision / implementation counselling-considerations are required for broad -based prioritized care decisions. [22-24] Provincial approaches to priority are variable and a national priority agreement could coordinate a more collaborative and equitable process. An ethical weighted priority process developed for spending of federal health-care funding has been used and could be considered for Canadian health-care systems.

Oregon has used a prioritization methodology process that places a high emphasis on preventive services and chronic disease management by including a 5-factor summation impact calculation (Figure 1): Impact on Healthy Life; Impact on Suffering; Population Effects; Vulnerability of Population Affected; Tertiary Prevention (fatal (cancers, strokes, end stage renal disease) and nonfatal (fracture, psychotherapy) conditions). This priority tool was created to equitably direct the clinical use of limited tax-based health care funding for appropriate cost-effective and preventive clinical outcomes.  The prioritization calculation starts with a clinically weighted consensus priority level and is further modified by the clinical impact calculation, effectiveness, and need for service (Figure 1). This tool places higher priority for health care spending on maternity care, pediatric care, addiction, mental health and chronic disease management with less emphasis on cancer and some emergency medical and surgery care. [25]

Figure 1: Oregon Clinical Care Prioritization Tool equation.

Scoring 100 to 1             30 to 0                                     5 to 0                 1 always / 0 never Category   X     Impact on Healthy Life   X   Effectiveness X   Need for Service = Total Weight             Impact on Suffering Population Effects Vulnerability of Population Affected Tertiary Prevention                      Sum of Five Impact Measure Scores Category weight: maternity / newborn (100); primary and secondary prevention (95); chronic disease management (diabetes, hypertension, asthma, schizophrenia); comfort care (65); fatal (40) and non-fatal (20) medical and surgical services.  Effectiveness: To what degree does the treatment achieve its intended purpose?  Range of 0 (no effectiveness) to 5 (high effectiveness).

Appropriate healthcare

A substantial percentage of the Canadian health care received is inappropriate and results in cost implications. [26-27] Inappropriate health care occurs when effective clinical practices are underused, ineffective clinical practices are overused or other practices are misused. These clinical scenarios can lead to negative patient experiences [28], poor health outcomes [29-30] and inefficient use of scarce health care resources. [31] An evaluation of the Canadian clinical care practice, using defined appropriate and inappropriate practice, found that some practice areas did not conform fully to evidence-based recommendations, as inappropriate care included underuse (failure to provide a clinical practice when patient benefits clearly outweighed the risks), overuse (providing a clinical practice when its potential for harm exceeds the possible benefit) and misuse (when an appropriate clinical practice is selected but a preventable complication occurs and as a result the patient does not receive the full potential benefit of the practice) [26].  The evidence sources for assessing the appropriateness or inappropriateness of the 228 clinical practices, over 12 years, were reported. Most studies (n = 165, 94.3%) cited a national or international guideline as the source for recommended care. Other evidence sources included systematic reviews or meta-analyses (n = 29, 16.7%) and quality indicators (n = 1, 0.6%) [17]Median proportions and interquartile range (IQRs (%)) for overall inappropriate use (30.0%), underuse (43.9%) and overuse (13.6%) by care category (diagnostic or therapeutic) and their 10 subcategories are summarized by diagnostic (laboratory test; referral; assessment; screening; blood test; imaging) and therapeutics (acute care procedure; biophysical therapy; psychosocial therapy; medications). Diagnostics practices were inappropriately used, on average, 28% of the time (IQR 12.7%– 50.4%). The lowest overall proportion of inappropriate use of diagnostics was in imaging tests (median 13.8%, IQR 4.5%– 29.0%), whereas the highest proportions were in laboratory tests (median 48.4%, IQR 26.4%–73.0%) [10]. Therapeutics practices were inappropriately used, on average, 34.0% of the time (IQR 10.0%–61.1%), with the lowest overall proportions of inappropriate use for medications (median 25.9%, IQR 5.8%– 60.2%) and the highest proportions for acute care procedures (median 53.5%, IQR 21.8%–71.4%). Underuse was statistically higher than overuse for both diagnostic and therapeutic practices. [26]

Equitable healthcare

Health equity, including important patient, racial, ethnic, and geographic groups, requires quality measurement for improving the quality of care [32]. The patient voice in health care service model creation allows for clinically meaningful, patient-centered, and high-value care. The higher ranked outcome measurement characteristics would include: clinically relevant, meaningful to the patient, actionable (decisions based on results), feasible to observe, inclusive of important patient populations (maternity / newborn; primary and secondary prevention; chronic disease management; and fatal / non-fatal medical and surgical services). The lower ranked outcome characteristics are observable differences within a reasonable period of time; associated cost savings, and minimization of provider reporting burden. [33]

For Canada rural/remote care and maternal/newborn care are under-represented for prioritized clinical outcome quality improvement. Marginalized rural and remote populations in Canada have limited or difficult access to care with variable health outcomes. The health care access and services for indigenous persons in Canada is complex and involves the First Nations, Inuit and Métis people, while the federal, provincial and territorial governments share certain degrees of jurisdiction [34-36].

While high-income countries have infrastructure and interventions that may keep maternal mortality at levels below 12 deaths per 100,00 live births, the Canadian national comparative data for maternal reproductive adverse event outcomes indicate significant variance for the provincial prevalence and the levels of reproductive event surveillance [37-46]. Increased data-sharing (national, provincial, community) is required for more accurate and representative quality measurement. [47] Achieving safer maternity care requires implementation planning and monitoring of the change process protocols. [48] The UK has recognized the need for change in systems and thinking; maternity care models with seamless multidisciplinary care, starting pre-conception, is required; the effectiveness of intra-partum fetal surveillance; the use of quality local review of care; the need for sustained and substantial increases in resources for maternity services (urban and rural). [49] Canadian maternal morbidity studies (HELLP; pre-eclampsia; maternal anemia; operative vaginal delivery; vaginal birth after previous cesarean delivery; post-partum hemorrhage; stillbirth) have indicated nationally increased maternal -fetal risk outcomes and the need for directed practice change. [50-58] Canada does not have a national pregnancy surveillance system for maternal mortality or morbidity although some provinces have annual perinatal surveillance reporting systems (British Columbia; Alberta; Ontario; Nova Scotia). Maternal mortality and morbidity surveillance provides an important indicator for national health and socioeconomic status. [59-65] There is a strong international focus by the WHO for reduction of the maternal mortality rate in high and medium-low-income countries. [66-68] Maternal mortality rates (annual number of female deaths per 100,000 live births from any cause related to or aggravated by pregnancy or the condition management (excluding accidental or incidental causes for 2017)) for high income countries have Canadian rates at 10 compared to Norway 2, Sweden 4, Netherlands 5, Australia 6, Germany 7, UK 7, Switzerland 9, NZ 9, and USA 19. [69]

Evidenced-based Clinical Service Change Opportunity

A 2009 review of the Canadian system observed that the provincial single payer model [70]:

• applies only to physicians and hospital services (all other services, prescription drugs / medical devices use variable funding sources)
• is an anomaly in the OECD systems, as Canada has strict requirements (no co-pay or extra charges) but the third highest private spending component (30% private insurance / out of pocket / other costs)
• has 14 single payer systems (10 provincial / 3 territories / 1 federal for focused areas) with individualized health insurance plan within the federal legislation framework for physician and hospital services
• has policy variation across province boundaries largely related to different approaches for the horizontal and vertical integration of the hospital and community sectors and physician models of remuneration

Provincial-Territorial primary health care services are the first point of contact with the health care system. In general, primary health care serves a dual function with providing a direct provision of first-contact health care services and the triage /coordination of patients’ health care services to ensure continuity of care (referrals to and coordination with other levels of care). [70]

Health-policy innovation and Alternate Payment Plan (APP) for primary care provide examples of both, success and continued need. In Canada, the most ambitious primary care reform is found in Alberta, Ontario, Manitoba, and the Northwest Territories. [71] The use of APP models of care needs to be developed, offered widely, expanded, and carefully studied, to allow the creation of high-quality, accessibility, team-based care while supporting comprehensive family medicine. [72] The availability for enhanced service skill considerations, to increase office-based family medicine choices, are required as 20% of family medicine graduates complete an extra year usually focused on emergency and hospitalist services. [73]

The provincial population geography (urban versus rural-remote) in the provincial health system has some economy of scale for per capita cost (considering population per square km) but the use of bonus payments for access has urban success that is not identified in rural models. [74] The type of hospital service (teaching-urban vs non-teaching) has variable cost and quality of care impact [75].

The OECD has considered the importance of health care policies which target physician remuneration. [76]. The different types of alternate payment plan (APPs) used in Canada are summarized (TABLE 6). The three ‘pure’ physician payments are considered fee for service (FFS), capitation, and salary. The health care system’s decision makers need to better understand and balance the potential increased fiscal cost (salary) with improved health care access, quality, and satisfaction (patient and provider) (TABLE 6). [77]

TABLE 6:  Alternative Payment Plans used in Canada Health Care Systems.

APP	Description	Rationale	Total Canada APPs	Location
Block funding	Used by specialist groups in academic centers	Allow equal support for all activities	22%	ON /NS
Blended	Salary plus FFS	Quantity with stability	16%	QC
Capitation	Predominately in primary care practices	Acceptance of healthier patients	16%	ON
On-call	On-call stipends plus FFS	Added support for out of hours FFS	12%	Canada
Salary	Predominately in rural areas	Stable income supports patient care	11%	NFLD / Territories
Contract	Service contract related payments	Stable designated care	11%	BC
Sessional	Hourly payment for community PT physicians	Fills clinical service gaps	8%	Canada
Northern Incentives	Working in northern rural communities	Service need identified	4%	ON / BC
Non -APP / FFS		Quantity of care

Maternity care APP has considered the options for pay-for-performance (related to designated quality thresholds); shared savings (FFS payments combined with reconciliation between a targeted episode and an actual episode price over a defined time period); bundled payments (a specific set of activities tied to an episode of care with financial benefit from less care but financial risk of complications); and global payments (payment for an entire population and the entire continuum of care). Risk mitigation strategies seem to be relevant tools, to increase APM uptake and protect providers from (initially) bearing too much (perceived) financial risk. If more APPs and fiscal innovation for physician remuneration were provided / available, other important clinical dynamic models of care could be considered or implemented. Directed team-based management with protocol driven care would decrease provider and outcome variance with clinical audit and feed-back processes. [78]

A surgical pathway approach has identified innovative process and implementation approaches for measurement and enhanced efficiency. Achieving balance between surgical efficiency and patient needs requires [79]:

• Trust, collaboration, innovation, increased human resources at multiple levels and stages
• The reality of surgical booking: scheduled 60% and emergency 40%; scheduled surgery has performance analysis while emergency surgery is less studied
• The use of a central triaged access / prioritization process
• Team-based vs single surgeons for increased flexibility, quality, and safety; modelling of multiple surgeon-based teams using surgical discipline and volume metrics
• Financial considerations for provider (independent vs surgical framework agreement) and facility budgets including expanded OR resource access (longer OR hours)
• Appropriate scheduling with specific (measured and validated) procedure-based mean or median times and their associated variance
• The case mix variance on a surgical list may need to be adjusted

APP provision and acceptance would require improvement, correction and evaluation which requires measurement oversight (quantitative or qualitative) of the identified clinical process and deliverable elements. Important surgical quality improvement processes have initially used the Act-Plan-Do-Check process (Surgical Safety Checklist; Enhanced Recovery After Surgery in multiple surgical disciplines). The implementation of surgical access procedures and operating room surgical performance metrics are important for APP utilization, efficiency, safety, and measurement of quality and safety (TABLES 7-8). [77, 80, 81]

A CMA Position Statement for ensuring equitable access to care is summarized in TABLE 9. These patient and system barriers are important considerations to allow for the success of any new health processes and models. Cost saving or efficiency cannot be the only goals as the health system outcomes, provided in a cost-effective process and environment for both the patient and provider, are important long-term and sustainable outcomes. [82]

TABLE 7:  Surgical Access QI Process.

Process Level		Methodologic Approach		Data Creation and Evaluation Complexity
	Secondary Data Analysis (Clinical/ Administrative / Registry)	Qualitative Analysis	Intervention / Trial	(Moderate to Complex)
Presentation	Delayed presentation related to lack of primary care	Patient-reported factors for early vs delayed presentation	Trial to improve timely screening efforts for vulnerable patient population with community outreach	Moderate
Surgeon referral	Timeliness of referral based on different patient populations	Referral processes or networks between providers and surgeons re timely access	Trial of patient navigator to facilitate patient process based on referral point of entry	Complex
Work-up and Intervention	Odds ratio for timely, indicated, evidenced-based care based on patient, surgeon, and hospital factors	Factors in patient- surgeon relationship that may affect the decision to pursue timely, evidenced-based care	Trial of same day imaging or medical consultation as part of pre-surgical work=up to decrease delay and enhance informed consent	Complex
Postsurgical care and follow-up	Compare patient factors associated with quality post operative care	Identify best practices in post- surgical discharge and follow-up	Trial of community health workers, transportation, and other services to improve timely initiation of adjuvant treatment post- surgery	Moderate

TABLE 8:  Rational Performance Metrics for OR: principles of efficiency and process.

Performance element	Advantage	Limitation	Perceived incentive or gaming
Start time	·    Easy to measure ·    Start and end are clear	·    Definitions are required re anesthesia / surgery ·    No correlation for start to finish ·    HR feelings of judgement	·    Potential for concurrent surgical start-finish gaming
Utilization	·    OR resource issue	·    High utilization over- running/ over-booking is rewarded	·    Under utilization
Cancellations	·    Important to patient experience	·    Same day cancellation ·    Does not account for the extent of surgery ·    Cancellation may be patient based	·    Rewards under booking may effect prioritization ·    Surgery may occur on patients that should be cancelled
Operation #	·    Easy to measure	·    Does not account for operating times and variance	·    Teams may avoid long cases or take shortcuts with safety issues
Gap times	·    Elimination of gaps should allow better ·    utilization	·    Longer OR lists increase ·    gap time increase	·    Actual gap times are modest ·    Gap times can be eliminated by using a ‘parallel’ process with the use of two teams/ ORs
Efficiency	·    Rational/ balanced measure ·    Correlates with financial performance	·    Complex	·    None

TABLE 9: Summary from CMA Position Statement: Ensuring Equitable Access to Care: Strategies for Governments, Health System Planners, and the Medical Profession.

Barriers to equitable access occur on both the patient and health care system or supply side. Common barriers include:
Demand Side or Patient Barriers	Supply Side or System Barriers
Health literacy	Services not located in areas of need
Cultural beliefs and norms	Patients lack family physicians
Language	Lack of management of chronic disease
Cost of transportation	Long waits for service
Time off work for appointments	Payment models which don’t account for complexity of patients
Access to child care	Coordination between primary care and speciality care and between health care and community services
Payment for medications or other medical devices/treatments	Standardization of referral and access to specialists and social services
Immobility- due to physical disabilities, and/or mental health barriers	Lack of needs-based planning to ensure that population has necessary services
Cognitive issues, such as Dementia, that adversely affect ability to access and comply with care	Attitudes of health care workers

DISCUSSION

The role of federal political leadership in Canadian health care administration has been one of fiscal sharing / delegation rather than one of clinical prioritized leadership and responsibility as in other OECD countries (other than USA). Canada is further challenged because it does not have a mandatory and comprehensive national tracking system for quality. The Canadian Institute for Health Information (CIHI) houses multiple Canadian health databases, but it does not collect information on all clinical practices available in Canada. [3]

Inappropriate care is a pressing problem in health care, largely because it causes iatrogenic harm to patients and often interferes with the delivery of high-value care. It may lead to negative patient experiences, poor health outcomes and inefficient use of scarce health care resources. Previous reviews on inappropriate care provided much needed stimuli to the field of health care quality by elevating global recognition that inappropriate care is not only a serious and widespread problem, but one to which no health sector is immune. Each of these reviews found high levels (50% on average) of inappropriately used practices and laid the foundation for several quality improvement initiatives in these countries. [26-31, 83-87]

Researchers have identified several failures in the Canadian health care system including [5, 26]:

• Research evidence identifies the shortfalls in the delivery of effective care to patients either not receiving effective care or receiving ineffective care.
• The failure of knowledge translation to address the clinical issues of overuse or underuse.
• Larger national health care problems (pandemic; systematic racism; climate crises; economic inequity) minimize the value of incremental quality improvement reports.
• Quality improvement efforts could add more value if directed toward increased health care system resilience and support for enhanced models for clinical care.
• Advocacy (political / medical) related to decreasing the social determinants of health ‘gaps’ which may have larger impact on overall quality and population health compared to funding for guideline recommendation implementation.

New clinical outcomes are not easy to achieve as there needs to be a balanced prioritized process for patient care (quality / strategic safety / harm reduction / transparency) with the appropriate resources (human / funding / time / team) to sustain the desired health care outcome. [88]

Policy makers and clinical providers need to consider, not only the behavioral incentives associated with payment methods but the need for the continued surveillance of quality, safety, access, and improved HRQoL outcomes for all APP activities. A number of APP lessons are summarized as [89]:

• Lessons for policymakers / Regardless of the APM chosen, overall spending on primary care must increase to achieve health system aims.
• Lessons for payors / The small-scale and unsustainable design of many APM pilot programs creates payor “pilotitis” as the process must foster “learning at scale”.
• Lessons for researchers / more robust evaluation; with stronger comparison groups; increased transparency of results; evaluations of how APMs promote or inhibit health equity; and how to adjust for variation in social determinants of health without excusing poor quality.
• Lessons for providers / APMs that promote flexibility and pursuit of end outcomes over process measures increase both patient satisfaction & primary care provider wellness.

The key factors for successful health care innovation are reported to include a strong relative advantage for change; compatibility with the values, context, and needs of the potential adopters (federal-provincial-provider administration); capacity building; supportive infrastructure; sufficient time and fiscal sustainability for demonstration and scaling of the health care systems. [90]

Canadian Provinces continue to create a politically focused health-care, ‘top down’ directives with minimal support for true population health outcomes as the identified annual priorities are directed toward treatment for chronic disease (renal / cancer / addiction / mental health) with minimal service priority for prevention strategies.

Advocacy for the patient and their needs has a long and deep tradition in medicine. Physicians should be advocates for health care improvement but the challenge for that advocacy role must be very clearly defined (CMPA Safety of Care) as the process to discussion and change must be ‘timely and possible’. [91]

The outcome from two 2002 Parliamentary and Senate reports (recommendations or principles) and the 2008 ‘A 10-Year Plan to Strengthen Health Care’ show continued policy deficiencies indicating the inability for the present Canadian health care governance model to: provide or mandate a national-provincial collaboration process; to determine the national health care priorities; or to support or recognize the need for national improvement / change for health care access, quality, and outcomes. [1, 92-93] Provincial health care priorities continue to be directed to political ‘burning platforms’ not the ‘real’ health care priority needs as indicated by OECD comparisons [8, 18-19]. The Expert Advisory Group for the Pan-Canadian Health Data Strategy Report 1 wrote that, ‘There is no “smoking gun” – the challenges to implementation are the result of a complex set of interactions between multiple levels of government, health professionals and organizations, and the public and private sector with the common goal of access to data while preserving privacy and confidentiality. Accordingly, there are no simple solutions or easy fixes.’ An additional comment indicated that ‘the current Canadian health data ecosystem impedes the best possible health outcomes, results in a poor patient and provider experience, and incurs higher cost’. [17]

This scoping review evaluation of the provincial -based health care systems is summarized, using a Strength-Weakness-Opportunity-Threats (SWOT) analysis (TABLE 10). Many of the SWOT elements were present, before the COVID -19 pandemic, but the Canadian provincial health care system continues to demonstrate important performance deficiencies and access needs which require urgent consideration as fiscal pressure and cost-effective health care are not in balance.

CONCLUSIONS

The scoping review of the Canadian health care system identifies the need for recognition of deficiencies, new clinical priority determining processes, models of care (team-based; remuneration innovation), and quality improvement strategies as low-quality measurement and high levels of inappropriate care have been clearly identified.  The OECD based cumulated health outcomes for the federal-provincial-territorial health care systems have Canada ranking in the lowest quality measurement areas for four of the five quality comparisons (access to care, administrative efficiency, equity, health care outcomes) with the only higher quality ranking for the care process, once hospital access had occurred.  More political, professional provider, and public recognition, questioning, debate, and understanding of this data-supported health care dilemma, in Canada, is required.

TABLE 10: SWOT Analysis for the Canadian Health Care System.

Strengths	Opportunities (limited high-level list)
I.         Federal and provincial cost sharing allows for universal patient care access II.         National accredited hospital based tertiary and quaternary care for emergency / medical / surgical / imaging / laboratory services III.         Fee-for-Service health care providers are committed to volume-based remuneration and their independent (small business owners) IV.         Alternate Payment Plan health care providers are committed but are more focused in their activity provision and remuneration based on the agreement V.         Well-trained / educated service pool for MD, nursing, and associated health care providers VI.         Excellent university and technical school resources VII.         National research infrastructure CIHR VIII.         National health information CIHI IX.         Canada has a social conscience X.         International financial positions with G7 and G20 XI.         International membership in OECD XII.         PHAC but has limited capacity and influence	I.         Recognition, but limited, that health care provision requires new business considerations (strategic focus; people management; finances; operations; core business marketing) II.         All providers in the health care system (professional / staff) should be employees (0.75 FTE minimum) with clear service deliverables and employment benefits III.         Consideration for evidenced-based health care prioritization with social determinants of health vs the present politician ‘voter driven’ care IV.         Discussion related to new quality and fiscal consideration for national or regional (Western; Ontario; Quebec; Eastern Canada) health care delivery models / start small and move to expansion with evidence V.         Expanded training positions at University, Professional Schools, Residency, and associated Health Care human resources VI.         Discussion and process for improved patient-focused health care system, provider-focused work environment, QI collaborative process, and HRQoL outcomes
Weaknesses	Threats
I.         Canada: small population, large geography, 20% live rural or remote II.         Decreased quality and appropriate provision of health care is significant and evidenced-based III.         The 14 health care systems have limited collaboration or planning or information technology connection for appropriate, ethical-priority-based clinical health care IV.         Geographic-regional restriction for patient access to care at provincial borders V.         Provincial health care administrative redundancies x14 on multiple levels VI.         Human resource planning, funding and supply: MD education and directed service needs; nursing education and supply; physician assistants; advanced practice nursing; associated health professionals VII.         Lack of collaborative ability for MDs to move from province to province due to Provincial College’s redundancy VIII.         Limited financial control over MD providers; MD remuneration models with no equitable relative value correction IX.         Individual provision of care (with some collaborative service coverage arrangements) over team-based alternate payment plan models of care (with service and overhead costing) X.         Directed care areas: rural and remote care; models of care for primary and chronic disease management; mental health – addiction coverage; long term care HR provision XI.         No national process for drug and medication contracts XII.         No comprehensive national process for outcome and quality measurement; other process directed audit by CIHI XIII.         Patient misconceptions re access and provision of health care; is it a privilege or a right? XIV.         Review of 2002 evaluation-planning shows that no implementation has occurred for repetitive health care promises (pharmaceuticals / provincial electronic records (that will not provide national access) / primary health care and prevention / improving access and quality /rural and remote care / home care opportunity / indigenous health care)	I.         The ‘status quo’ is no longer an acceptable choice as pressures on health care show vulnerability (COVID-19; vaccine hesitancy; chronic care; long term care quality / safety; rural and remote care) II.         Increased fiscal pressures on provincial budgets with and without federal collaboration / contribution III.         More dependency by the provinces for federal transfer payments IV.         Decreased health care quality outcomes as highlighted by OECD analysis V.         Overall inappropriate care 30% (underuse of evidenced -based care 44%; overuse of ineffective evidenced-based care 14%) VI.         Human resource needs with hospital directed nursing at the top but more training and positions will be required if model of care changes are considered VII.         Increasing total health care and per capita costs (immunology and genetic therapies) VIII.         Increasing patient co-morbidity will impact care pathways, medication cost, and hospital use IX.         Social determinates of health and climate change environmental impact X.         Other governmental fiscal non-related health care priorities XI.         Increasing patient choice to non-validated health care choices as they have lost faith in the non-patient focused health care system

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