organized curiosity

Improving health care through research


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What is the Ideal Health Care System for Nova Scotia?

alice and cheshire

We are now two weeks into the new organization of health care in Nova Scotia. With only two health authorities, the IWK and the Nova Scotia Health Authority, the hope is better planning and better care will result. It is important to articulate where we want to end up but I think we need to know where we want to go. As Yogi Bera, is quoted as saying “If you don’t know where you are going, you might end up someplace else.”

I am also reminded of the conversation that Alice in Wonderland had with the Cheshire Cat.

“Would you tell me, please, which way I ought to go from here?”

“That depends a good deal on where you want to get to,” said the Cat.

“I don’t much care where—” said Alice.

“Then it doesn’t matter which way you go,” said the Cat.

“—so long as I get SOMEWHERE,” Alice added as an explanation.

“Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.”

A lot of the time, it appears we don’t know where we are going in health care. We need guidelines.

Fortunately, there have been models developed about health care. Most people who are not intimately involved in health care planning (and that includes most health care professionals) don’t know about them but I believe they can actually provide us a helpful road map.

Let me tell you about 3 models that I think make a lot of sense.

The Triple Aim Framework was developed by the Institute for Healthcare Improvement which for a long time was headed by Don Berwick. Berwick is a guru of healthcare improvement.  The Framework asserts that any healthcare initiative should have 3 simultaneous aims.

The first of the three aims is improving the experience of care which begins with a focus on patients and families and includes high satisfaction, excellent outcomes, especially patient reported outcomes and functioning. For example, patients and families should be and should feel that their needs are at the centre of the healthcare system and that patients’ quality of life is the best it can be.
triple aim

The framework’s second aim focuses on population health. For example, focusing on children with mental health problems who end up in clinics without considering the children who are poor or marginalized and don’t make it to the clinic isn’t good enough.

The third aim is to improve cost effectiveness of interventions. A less expensive way of delivering service means more people can be served. Delivering services that don’t work is a waste and wasting money is unethical.

The second model that I want to tell you about is the Chronic Care Model. It has been developed by Ed Wagner of the McColl Centre for Healthcare Innovation at Group Health Research Institute in Seattle. There are several things that I like about the Chronic Care Model. First of all, we do acute care quite well and it is chronic care that we fall down on. Second, the model emphasizes the need for partnership between the health system and the community and between health care providers and patients. Each group has responsibilities to fulfill.

chronic care

The Chronic Care Model is very widely used across Canada and in Nova Scotia. Although it was originally designed for chronic care in adults, it is just as applicable for kids.

If you look at the figure, you see that the Health system needs a good clinical information system. The Nova Scotia One Person, One Record promises to be this system. It could move us very far forward in designing a system that works. But we need it sooner not later.

The last model I want to tell you about is the Learning Healthcare model.  The Learning Healthcare model has been developed by the Institute of Medicine of the National Academies of the United States. It has a very simple criterion. Every patient should get the best care and we should learn from each patient experience to improve the system. The table outlines some key elements.

learning healthcare

As you can see, the three models are complementary. They overlap. But each is a bit different in its emphasis.

From my perspective, a couple of things are important. The health system should adopt specific models and guidelines and make them public. The public (and the government) should hold the system accountable.

So, for example we all have to:

  • Complain when the patient/family experience is not optimum.
  • Compliment when it is.
  • Point out waste.
  • Lobby government to ensure the system can be more responsive.

Do we need more money to do this?  Many have pointed out that about a third of what we do in healthcare has no evidence that it works or even may do harm. If we stopped these things we would have the money.

~Dr. Patrick McGrath

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