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Photo of doctors in a hospital corridorLetter from the Region
A focus on
quality care
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Réal Cloutier
Interim President and CEO
Winnipeg Regional Health Authority
Sept/Oct 2018

There has been a lot of public discussion in recent years about the need to create a financially sustainable health-care system in Manitoba. Translation: one that is capable of providing quality care, better value, and improved access - all without breaking the bank.

The reason for the interest is obvious: Health-care costs in Manitoba have risen dramatically over the last decade or so, often outstripping increases in other areas of government spending. As a result, health-care costs remain the single largest government expenditure and continue to put pressure on the provincial budget. I and others in our health-care system are mindful that we have a responsibility to improve and sustain our system for future generations.

But while the problem is clear, the question remains: How do you solve it?

This is where things can get a little confusing.

Some people interpret efforts to build a "financially sustainable health-care system" as code for undermining quality care. This argument suggests that the cost of a particular service or procedure is set, and the only variable in the equation is the number of times it is delivered or performed. As a result, the only way to save money is to cut back on the quality of the services being offered or on the number of procedures being performed.

But this line of thinking assumes that we are maximizing value in everything we do in our health-care system, and we know that cannot be the case in large, complex organizations. The fact is there are always opportunities to look at reducing waste in the way we deliver our services or at alternative models that may be less expensive and more appropriate for patients.

Priority Home is a case in point. This service, which is provided through a partnership between the Region, We Care Home Health Services (part of the CBI Health Group) and ParaMed, allows people to be discharged from hospital sooner and, in some cases, avoid a premature placement in a personal care home. The addition of this service reduces hospital bed use - which is the most expensive health resource in our system - and can even decrease personal care home use, which is more expensive than Priority Home. This adds up to better value for patients and a better match of the right service for their current needs.

Photo of a doctortalking to a patient

Maximizing value in this way is not a radical idea. Every successful organization in the world, whether it is Toyota, Apple, Google, the Mayo Clinic, or the Cleveland Clinic, takes a similar approach. In each case, these organizations focus on one thing: producing a quality product or service at the lowest possible cost. These organizations have an unrelenting focus on continuous improvement.

To that end, they spend a great deal of time rooting out inefficiencies, refining manufacturing processes, and reducing waste. They also have strong strategies around customer and staff engagement as part of their overall improvement activities. These organizations would never compromise quality in their efforts to improve their bottom line, because they know the long-term consequences of those decisions. That's really the kind of thinking we are trying to encourage here at the Winnipeg Regional Health Authority. We want to ensure we are maximizing the use of our resources by supporting innovation and continuous improvement.

So, what does this approach look like in the world of health care? The Region's Diagnostic Imaging Program offers one example.

Last fall, the program pointed out that a significant number of diagnostic imaging clients were not showing up for their appointments - over 15,000 no-shows in 2015-16 alone.

These no-shows resulted in a minimum of $600,000 in wasted resources, not including the duplication of work needed to re-triage, re-book and recall patients who had missed appointments.

The program noted that about 40 per cent of missed appointments were not a result of deliberate action by patients, but rather of gaps in our current system. One fifth of missed appointments were the result of duplicate orders by the ordering physician, 13 per cent came from patients who were not aware of their appointments, seven per cent resulted from the department in question not receiving or processing cancellations from patients, and the final two per cent resulted from departments not receiving a cancellation from the physician.

This problem didn't arise because people in our system were not doing their job - it was a result of having a poorly designed system.

To correct the problem, the program refined its processes. It proposed and executed a three-part campaign, including a "one number to fax" initiative for physicians to ensure that a central hub would receive all faxed appointments and, as such, be able to easily identify duplicate appointments and/or requisitions.

The result is that hundreds of duplicate appointments were identified and eliminated. As an example, the no-show rate for magnetic resonance imaging (MRI) dropped from 5.96 per cent in September to 4.96 per cent in December and down to 4.54 per cent this past June, 2018. That represents an average of 70 recovered MRI appointments per month since the initiative was started. DI is also doing work to reduce no-shows for computed tomography and ultrasound appointments.

This initiative is now being taken beyond the Region and expanded to address wait times in other areas of the province.

An effort to improve the experience for colonoscopy patients is another example of how a focus on quality can lead to better patient care and help rein in costs.

A key part of the initiative, led by Dr. Harminder Singh, a gastroenterologist and Director of Research for the Region's Colonoscopy Program, is a new website called Launched earlier this year, the website is designed to provide information to patients who are about to undergo a colonoscopy, with a view to relieving their anxiety and ensuring they are properly prepared for the procedure.

As Singh explains in a story in this issue of Wave, a colonoscopy is an invaluable tool for detecting colon cancer, with about 30,000 procedures performed in Manitoba every year.

However, the effectiveness of the procedure depends on a patient having a clean bowel. This can only happen if the patient takes the necessary steps to prepare, such as fasting or consuming certain colon-cleaning fluids. Unfortunately, many patients do not prepare properly.

"There are a number of studies that have shown that 10 to 30 per cent of people don't have clean bowels at the time of the colonoscopy," says Singh. "We do see in our practice that people do only part of the preparation because they can't tolerate it, or they believe they have been cleaned out enough."

This, of course, can lead to misdiagnosis or the need to redo procedures. The website is designed to provide patients with the kind of information they need to properly prepare. You can read more about this initiative here.

Singh's group, which is working closely with the Region's endoscopy central intake system, has several other projects on the go to improve patient experience. They include efforts to improve timing of follow-up procedures after removal of polyps, testing different bowel-cleansing laxative regimens for colonoscopy, and colonoscopy quality assessment and improvement initiatives. Members of the group are also working with the Region to strengthen education materials for patients with other health issues, including inflammatory bowel disease, multiple sclerosis, rheumatoid arthritis, adult anxiety and depression, and child anxiety.

These are just two examples of how the Region is using innovative thinking to enhance care and rein in costs. It is through these steps and others that we will continue building a financially sustainable health-care system - one that is capable of providing quality care without breaking the bank. We have more work to do to build this capacity for improvement and integrate it into our culture. Improving our services for patients has to be our primary focus, day in and day out.