12.3: Health System Transformation

Institute for Healthcare Improvement Triple Aim Framework

Health care is in a constant state of change, often with multiple change initiatives of various scales occurring simultaneously. Some are more successful than others, but all are designed to find solutions to complex problems facing the health care system. Many of these changes are aligned with the Institute for Healthcare Improvement’s Triple Aim framework, which has as its goals: (1) improving the patient experience, (2) improving the health of the population, and (3) reducing the per capita cost of health care (IHI, n.d.) This set of goals is often referred to as better care, better health, and better value and was the framework for the National Expert Commission’s inquiry and its final report, A Nursing Call To Action: The Health Of Our Nation, The Future Of Our Health System (2012). The Commission set out to discover the most efficient, effective, and sustainable ways to meet the changing and pressing health needs of Canadians in the twenty-first century. According to the Commission,

Registered nurses are deeply engaged in system transformation because they care about human health and about delivering responsible health care. But more than caring, it is the professional and social responsibility of nurses to take a strong leadership stand on behalf of Canadians. (p. 1)

Policy- and decision-makers, spurred on by the Triple Aim framework, have recognized that a large-scale transformation of the health system is required to meet the desire to achieve sustainable and high-quality health care for Canadians.

Transformation of the Canadian Health Care System (Major Foci)

Concerns over the financial sustainability of the health care system, as well Canada’s declining health care system performance among Commonwealth countries and growing need for health care services, have prompted governments to begin to transform the system through various funding, structural, and programming policies. Seven key elements of the transformation are set out below.

Primary health care. The paradigm of care is beginning to shift to one premised on primary health care and the social determinants of health. In 1978, the WHO adopted the primary health care approach as the conceptual basis for effective health care delivery. The five principles of primary health care are:

1. accessibility,
2. public participation,
3. health promotion,
4. appropriate technology, and
5. intersectoral cooperation.

Community. Efforts are underway to gradually shift health care services from the hospital setting to the community, with care being provided closer to home.

Delivery of health services. The nature of health care delivery is also changing. Canada’s current social policies, with a focus on marginalized populations and the recommendations of the Truth and Reconciliation Commission, require increased inclusivity, which will have an impact on the delivery of care.

Interprofessional practice. Nurses are increasingly practising within, and leading, interprofessional teams.

Establishment of professional boundaries. Participation in interprofessional teams requires nurses and nurse leaders to practise within their professional boundaries and to clearly define such boundaries to other professionals. Canadian nurses’ professional boundaries are explicitly described within their provincial legislation for registered nurses (see, for example, The Registered Nurses Act, 1988), standards and competencies documents (see, for example, SRNA, 2013). Registered nurses are also “accountable to the Standards of Practice and nursing values outlined in the Code of Ethics” (SRNA, 2018).

Chronic disease management. Chronic disease management has become a priority given the rising rates of chronic disease and an aging population. Seniors experienced rising rates of cancer, diabetes, and high blood pressure between 2003 and 2009 (CIHI, 2011). Studies have shown that high-cost users of health care represent only a small proportion of the population but consume a large proportion of health care funding. For example, “approximately 1.5% of Ontario’s population, represented by the top 5% highest cost-incurring users of Ontario’s hospital and home care services, account for 61% of hospital and home care costs” (Rais et al., 2013). Predictably seniors account for the majority of high-cost users and health care costs.

Technology. Technology, used by both health care providers and the general population, is altering the way in which people and their health care providers interact within the system. It also enables the provision of big data analytics to support evidence-informed decision making.

From the Field

Big data provides new opportunities to store and index previously unusable, siloed, and unstructured data for use by health care stakeholders. Analytics creates new business value by transforming previously unusable data into new predictive insights and actionable knowledge.

For more information on big data, see the Canada Health Infoway white paper titled “Big Data Analytics in Health.”

Essential Learning Activity 12.2.1

For more information on primary health care, watch this video titled “The Five Elements of Primary Health Care” (2:45), then answer the following question:

1. What are the five elements of primary health care?

For additional examples of primary health care, watch two more videos and answer the questions that follow.

“Hand in Hand: Interdisciplinary Teams in Community Health Centres” (13:45)

1. What is at the centre of interdisciplinary care?
2. What is the health promoter’s role?
3. How can you ensure that communication occurs within an interdisciplinary team?

“Teams Manage Chronic Disease in Canada” (5:00)

1. Why is Ross a “lucky man”?