Why Primary Health Care implementation will succeed this time

It is not about the drill, but about the holes - that is why Primary Health Care Redesign will work this time in Saskatchewan.  Let me explain ...

I heard this metaphor about a drill and holes that I think applies so well to the Primary Health Care (PHC) context in Saskatchewan.   Your goal is represented by holes in a wooden board and your process is represented by the drill and drill bits.

Drill and drill bits representing the process

or the HOW we do something

Pegboard with holes representing the goal or WHAT we want to achieve.





In June 2002 the Saskatchewan Ministry of Health released a document "The Saskatchewan Action Plan for Primary Health Care".  The goal was clear in the first paragraph of the document:

"The principal goal of the health system is to maintain and improve the health of the people it serves. In Saskatchewan we have been striving for a system that is effective, responsive and sustainable in the longer term. In order to achieve these broad goals we must change how we think about primary health care services, how those services are provided and by whom, and how they relate to the more specialized acute care system."


So why did this plan fail ?  Why are we are talking about Primary Health Care Redesign in 2011 ? Why would an engaged family physician who wanted to implement most of the concepts (like collaborative, team based delivery of care; looking after a whole population of people; improving access and quality improvement) not participate in the implementation ?

The answer is very simple: From 2003 until recently, the Ministry of Health focussed on the drill and drill bits (process) and not on the holes (goal).  They basically said that family physician practices had to qualify to become a Primary Health Care site by doing 2 things: 1) They had to go on an alternate funding model of payment for physicians (as opposed to fee-for-service) and 2) They had to have a Nurse practitioner as part of the team.  Now this might be and over simplification, but although there is nothing wrong with either concept - this was the main reason why most family physicians did not sign up, because the focus was on the process (the drill and drill bits or the HOW).  I am convinced that almost every single physician in the province agreed with the Ministry of Health on the goal of the Saskatchewan Action Plan for Primary Health Care (What the holes in the board should look like.)

Unfortunately this led to a lot of family physicians being marginalized, because they did not want to join these Primary Health Care sites.  Funding for projects were only available to these approved sites and family physicians could only be part of it, if they signed on the dotted line ...  It also caused unnecessary tension between nurse practitioners and family physicians.

In the graph above you can see that from the previous implementation in 2003 until 2011 it was only "approved PHC sites" managed by health regions that got any funding for projects under the PHC umbrella.  Other family physician practices who did not qualify were left on their own regardless of how many quality initiatives for primary care they participated in or how many desirable elements they implemented in their practices.

I strongly believe that for the process to succeed this time, the Ministry of Health  has to focus on WHAT they want to achieve and be enablers towards this goal and leave the HOW to the frontline health care workers, communities and patients.  Every community should be encouraged to build their service delivery model from the ground up instead of being told how to do it, because the delivery teams, funding models and projects might vary significantly between communities.  The sites should qualify for support and funding based on their goals and measurements along the way.  It should also not be an "all-or-nothing" way of qualifying to be a Primary Health Care sites.  Every family physician practice in Saskatchewan should be seen as a Primary Health Care site.  The more desirable elements these practices implement, the more support or funding they should receive.

If you only have a few Primary Health Care sites and you make them as efficient as you can to deliver the highest quality service it will still not benefit the majority of the patients in the province who don't have access to them.  This is the reason why the Ministry of Health and health regions have to see all family physician practices as Primary Health Care sites and then enable them to implement as many desirable elements as possible, because this is the only way that all the patients in the province will have access to high quality primary health care.

 So instead of telling family physicians that they should 1) go on alternate funding and 2) have a nurse practitioner on the team, the approach should rather be to encourage them to implement as many of the above mentioned desirable elements.  Then instead of penalizing family physicians for not being primary health care sites (by not giving any support or funding), the ministry should reward practices with support and funding for projects according to their level of participation.  

You will note that funding models for physician payments is not on the list and that is because one should first put a system in place that works and achieves preset goals and then see what funding model for physician payment will be the best fit.  

You will also note that having a Nurse Practitioner on the team is also not on the list, but rather - team based care delivery with most appropriate provider for most appropriate care.  It should depend on patient needs, the community and available resources who is on the team.  

Having physicians on alternate funding and having nurse practitioners on the team would be an option and not a prerequisite.

There are many ways to drill a hole and as long as the focus is on the hole and not on the drill and drill bits, we will get there.

I believe PHC Redesign in Saskatchewan will succeed this time, because the Ministry of Health under the lead of Assistant Deputy Minister of Health, Ms Lauren Donnelly, (who has the Primary Health Care portfolio) seems to have the focus on the goal this time and is wiling to have patients in partnership with their providers and communities come up with the solutions from the ground up rather than being told what to do.  The challenge for the Ministry is going to be to find the best way to be an enabler and to remove any obstacles that prevent practices from implementing desirable elements in their practices.  What the support is going to be and how it will be distributed will determine the success.  

If we (administration and providers) don't get it right this time we will only have ourselves to blame, because there is a healthy combination of factors that can make this process a success.  We have a Ministry of Health that seems to want to listen and act on input from all stake holders. This was seen in a few information gathering sessions (Chronic disease, Physician engagement, Community engagement and First Nations involvement) held in 2010/2011.  We have many family physicians that have been waiting for more flexibility and options in Primary Health Care so that they can be part of it.

I believe in the quote that "No major health transformation can succeed without significant physician leadership and input..."  and we have a lot of physician leaders that are willing to step up and make this happen.  The Deputy Minister of Health, Mr Dan Florizone has echoed this sentiment on various occasions.  The relationship between physicians and the Ministry of Health is very healthy at the present time.  We have communities that want to get involved.  We have a clear mandate from the patients in the province as was seen in the Patient First Review.

I do sincerely believe that the "tipping point" is near.  As Malcolm Gladwell said in his book, The Tipping Point : "The tipping point is that magic moment when an idea, trend or social behaviour crosses a threshold, tips, and spreads like wildfire." ...  Little causes can have big effects and change does not always happen gradually, but sometimes it happens at one dramatic moment when the right mix of factors are present to reach the "tipping point".

We can draw a graph of what the level of participation of providers on the horizontal axis vs the level of support from administration (health regions and the ministry) on the vertical axis would look like.  The red box shows the practices that are considered Primary Health Care sites:

Looking at the graph above one will recognize that administration (Ministry of Health and health regions) are working on the vertical axis by providing support and being enablers.  Family physician practices which would ALL be considered PHC sites are represented on the horizontal axis.  Administration will need to find ways to remove obstacles and enable family physician practices to implement more desirable elements into their practices.  Family Physician practices need to look at the desirable elements that they have not incorporated yet and see if they can move to the right on the horizontal axis.  While doing all of this the most important thing will be measurements so that we can see where we are making a difference.  Measures need to cover all three aspects of the Triple Aim -

1. Improve the health of the population;
2. Enhance the patient experience of care (including quality, access, and reliability); and
3. Reduce, or at least control, the per capita cost of care.

I have used every opportunity to explain this model to officials in the Ministry of Health and so far I get the impression that they have accepted it and is willing to use this model for physician engagement in Primary Health Care Redesign.

I do believe that by enabling family physicians and by giving them the opportunities and flexibility to implement desirable elements into their practices this model will spread throughout the province and more patients will have access to high quality primary health care when they choose so ...

I am moving my practice as far to the right on the horizontal axis as I can with available resources and I hope the ministry of health and my health region will enable me to do so.  So whether you are an administrator or health care provider, are you going to be an enabler or an obstacle ?

Family Medicine by Jennifer Middleton

I have a BHAG (Big Hairy Audacious Goal).
I want people to hear “family medicine” and know that it refers to a medical specialty dedicated to providing relationship-based, patient-centered health care.
I want people to know that family docs take care of a lot of complicated, challenging diseases – and not usually in isolation.  Our patients have high blood pressure, complications from type 2 diabetes, congestive heart failure, depression, chronic kidney disease, emphysema, anxiety, asthma, and coronary artery disease, to name a few; treating each of those conditions individually is nothing like treating them in relation to each other.

I want people to know that I trained for three years to become an expert in my specialty.  During my family medicine residency, I learned about providing preventive care.  I learned how to treat a multitude of acute problems – colds, fractures, lacerations, rashes, etc.  I learned how to deliver babies, resuscitate victims of cardiac arrest, and drop a central line into a coding patient.  I can take off your moles, skin tags, and warts.  I can remove your ingrown toenail and treat your acne.  I can obtain your pap smear, discuss your birth control options, and treat your STDs.
I want people to know that I can care for your kid and your grandparent.  I routinely counsel teens about sex, drugs, and rock ‘n’ roll.  I am comfortable in offices, hospitals, maternity wards, newborn nurseries, intensive care units, nursing homes, and even patients’ homes.
I want people to know that family medicine residents learn about using the best medical evidence and the latest medical technology to guide decision-making conversations with patients. They can intelligently sift through the tremendous reams of medical studies that are published daily to pull out the information most relevant to their patients.
I want people to know that those residents learn how to work within a healthcare team.  Nurses, medical assistants, pharmacists, care managers, social workers, administrative staff – it takes all of us to provide outstanding care.  These incredibly important people are my hands, eyes, and ears into the thousands of little tasks that must get done every day in the office and at the hospital.
I want people to know that no medical specialty is as devoted to medical education as family medicine.  The Society of Teachers of Family Medicine holds an annual meeting devoted solely to medical student education.  We are one of only a handful of medical specialties with an entire fellowship (post-residency training) devoted to faculty development – training the next generation of academic family medicine teachers, researchers, and leaders.
Lastly, I want people to know that family docs do everything that they do in the context of our patients’ belief systems, families, and communities.  Our specialty is the only one that mandates dozens of hours of educational time during residency about the doctor-patient relationship.  How to help folks quit smoking/over-eating/whatever, how to tell someone that the biopsy did show cancer, how to mediate family disagreements about end-of-life wishes – this behavioral instruction is just as important to a family medicine resident as the pathophysiology, treatment, and prevention of disease.*
If you’re not a family doc, I bet you didn’t know all of those things.  And the blame for that truth lies squarely with us as family docs.  Frankly, other specialties have been better than us at promoting themselves.  You all likely know what a dermatologist or a cardiologist is, even if you’re not working in the medical field. Family docs can learn a lot from how other specialties have advanced the interests of their patients by advancing their specialty’s cause; it’s something we have failed to recognize the importance of until now.
Because of that failure, family medicine is not understood – and thus not valued – by the public, by politicians, by health plan administrators, and by too many of the other people who make decisions about health care in this country.
We need to show them what family medicine is all about.
My BHAG is to share family medicine with the people who don’t know about us yet. I hope that this blog does that in some small way; certainly, many of the family medicine bloggers and tweeters out there are doing it in a bigger way.
But, I don’t think that’s enough.  We need more.  We need an #FMRevolution.  I have to believe that there’s something even bigger, hairier, and more audacious that we could do.  I wish that I knew just what that that big, hairy, audacious thing was. Fortunately, though, I am but one of many.
It will take all of us to get the chorus of family medicine to echo across our nation.
Jennifer Middleton is a family physician who blogs at The Singing Pen of Doctor Jen

Mechanics truly are doctors for cars by Jennifer Middleton

Last week, my car got a flat tire.  I rolled into the local dealership the next day to replace my donut spare with a new tire (along with a new tire for the opposite side, of course).

I had only that one issue on my agenda initially, but as I drove to the dealership, the little sticker in the corner of my windshield reminded me that I was overdue for an oil change.  Oh, and that non-urgent factory recall on the transmission needed attention.  It seemed like a lot to take care of, and I figured I'd probably need a return visit to get all of those issues addressed.

I was a little apprehensive about what they'd be like.  I don't speak "car" very well, you see.  I often have trouble understanding the explanations I get from mechanics, and they often don't understand what I'm referencing when I mention problems in lay car language like "a funny rattling noise."  Much like a physician, they have to ask "when does it happen?"  "how often?"  "what seems to bring it on?" to decipher my car's symptoms and obtain the information they need to diagnose and treat.  I tend to ask a lot of questions, and they tend to need to ask a lot back, which doesn't always go over well in busy carshops.

So, I was pleasantly surprised to discover that this dealership service center was my kind-of place.  Their routine check turned up some filters way overdue for a change (I confess to not being very good at remembering such routine maintenance needs), and their computer system alerted them to the transmission part recall before I could even ask about it.  They offered me a loaner car so that they could take care of the recall - and the filters, and the oil change, and the new tires - in a manner convenient to me and my needs.

And, happily, they explained everything that was going on in plain English. Patiently.  Like they had all the time in the world for me, even when it was clearly very busy there.

I would like to be that kind of doctor working in that kind of practice.  I'd like my patients to rely on my electronic record to prompt us when certain routine health maintenance needs are due.  I'd like for our office to make taking care of their healthcare needs as convenient for them as possible.  I'd like for them to trust that I will understand their non-medical story and share my thoughts back with them in plain English, while giving them my full, non-rushed attention.

The analogy only goes so far (I'll defer comment on car commercials, stereotypical car sales people, etc...), but I was fascinated by the many similarities between that car service center and a medical office.

We could learn a lot from them.

Jennifer Middleton is a family physician and blogs at : The Singing Pen of Doctor Jen

Docs ready for Primary Health Care Redesign by Scott Donaldson

It’s only 8 a.m. Saturday morning and our usually understat­ed calm, cool, and collected president is more than a little excited. But who can blame him for his enthusiasm - Dr. Phillip Fourie’s passion is primary health care reform, and he emphatically states to the delegation that now is the time for physicians, patients, communities and government to work together on the long overdue restructuring of primary health care in Saskatchewan.

Primary health care is about a team of health care providers working in harmony for the good of the patient, the fam­ily, and themselves. It is clearly accepted that not everything tried will work, and that ongoing change is inevitable. It is about enabling the right health care provider to provide the right care at the right time to enhance patient-centred care.

Saskatchewan physicians recognize that the province is unique and that different regions, municipalities, towns, and villages are also unique – and so are the health care needs. The current cookie-cutter, one-size-fits-all approach to primary health care is not always appropriate. Saskatchewan requires a multidisciplinary collaborative primary health care frame­work based on flexibility, adaptability, and ingenuity.

“Primary health care redesign offers opportunities to try new things in team-based patient care, and measure the re­sults. Only then can we focus on providing optimum patient care in each circumstance,” said Dr. Fourie. “In all arrange­ments with other health care providers however, every pa­tient must be connected to a physician or physician group. This is essential for patient- and family-first care.”

For the presentation this morning, Dr. Fourie has lined up three physician leaders who truly demonstrate the endless possibilities that exist in primary health care redesign. Each in different ways has successfully turned perceived obstacles into patient-centred opportunities in primary health care delivery and this morning they share those experiences.

Dr. Lise Morin from Arcola describes how through strong com­munity involvement and a focus on physician work-life bal­ance they developed a centre of excellence that delivers clini­cal services, acute care and ER services to patients in six rural municipalities and two towns. The communities saw the need for well-rested doctors, so they took over the administrative side of health care and provided the clinical infrastructure thus allowing physicians to focus on patient care. “I want to be able to spend the necessary time with each patient,” says Dr. Morin. “By removing administrative pressures off of the physicians, we are able to deliver primary health care services through a team of providers. The end result is that patients, physicians, and other team members are happier.”

To achieve success these physicians first had to overcome preconceived notions in the communities. They really worked hard at explaining to the communities that it is not acceptable for any physician to work 24/7. They also con­vinced the communities that physicians don’t have to live in a community to provide stable sustainable care in that com­munity. Finally, they had to convince communities that they would need to be the ones to step up and make this change happen. Once this occurred, they were well on their way.
The goal was to build on the ‘wheel’ or ‘hub and spoke’ ap­proach to service delivery. “We provide clinical assessments at the spokes and offer acute care when required at the cen­tre of care in Arcola,” says Dr. Morin. “We don’t let doctors work in isolation.”

What makes the model unique is that it focuses on well-being and balance for all. “What we came up with was a philosophy of happy patient, happy practice, and happy physi­cian.” The corporation concept allows incoming physicians, especially new grads, a seamless adjustment into practice where they can focus on patients immediately and learn at an acceptable pace, without the immediate burden of hav­ing to take on the business side of practice. This allows for continuity of patient care. Sharing of patients and their in­formation across the care team is also unique. The concept of ownership has been removed. “We manage patients - we don’t own them.”

Success in creating an innovative compensation model is also noteworthy. Since each physician is compensated through alternative payment from the corporation there is a set workload expectation for each provider and there is set compensation for that. However, if a physician does more than that set threshold they are compensated accordingly. “If a physician works more, then they receive more. This helps maintain physician motivation.”

Despite success, Dr. Morin maintains that there are huge op­portunities available to further improve patient first care and provider satisfaction. “If we had access to health region and government resources it would make such a difference. If we could come to mutually beneficial arrangements to share health care providers more efficiently for diabetic services, or administrative personel for evaluation and as­sessment that would be huge. If we could hire and manage a nurse practitioner and define his or her role according to our needs and compatibility, and still access government funding, that would further improve care.”

Still, Dr. Morin sees much promise in the future. What would be on her immediate wish list? “We’ve built the model based on flexibility. If we have a certain number of physicians then we can expand care to any community within a one hour radius of our centre. When we have fewer physicians, then we retract services accordingly. Ideally, we’d like to maintain a roster of 3-4 physicians in Arcola working with the lone physicians in Carlyle and Redvers. This would allow for optimum patient-centred care while maintaining a one in four ER rotation.”

Next, Dr. H. Schalk Van Der Merwe described how, in Moo­somin, physicians identified service deficiencies in the sur­rounding area and took it upon themselves to find a solu­tion. The result has been a physician led primary health care model with a stable complement of seven physicians pro­viding services to 18,000 patients in five surrounding com­munities. “Physician retention has been very good and has allowed us to deliver ongoing services to patients involving other care providers when appropriate,” says Dr. Van Der Merwe. In contrast to the Arcola example, Moosomin physi­cians take ownership of all clinic management and remain on a fee-for-service payment structure.

Dr. Werner Oberholzer then spoke of the Rural West Primary Care Team centred in Radville. Dr. Oberholzer described how two physicians are able to serve 7000 patients in four communities. Conducting a needs assessment with community input and measuring outcomes has been vital to success. “Instead of telling patients what we were going to provide, we asked each community what they needed,” Dr. Oberhol­zer explained. “Then as a team we designed a way to accom­modate those needs with measurable targets for success.”

By enabling team members to function to full capacity within their respective disciplines, the model creates team commitment and interdisciplinary collaboration. The use of personal assistants to coordinate the care originating from the healthcare providers and allied healthcare professionals enables the physician to provide care in a rural remote re­gion with numerous care centres.

What makes their model unique according to Dr. Oberhol­zer is the EMR capability to accommodate all the healthcare professionals so that all members work within the same pa­tient charts on the EMR, and that each team member’s opin­ion is valued and considered to provide timely, high quality and affordable care. “We have incorporated pharmacy, home care, dietitians, and facility nursing staff working together to provide the best, guideline-based care,” says Oberholzer. “This helps create transparency and safety within the com­mon record.” The basic EMR had to be adapted over a num­ber of months to function adequately, and much time was spent in accomplishing this. The health region also had to be lobbied and convinced that the primary care team mem­bers could and should all work within the same patient re­cord, and traditional models of service delivery and chart­ing/record keeping had to be changed to improve function. There were numerous forms and paper requests that had to scanned and mapped to change to the electronic format, and the time taken to do this was excessive.

Another obstacle at the beginning according to Dr. Ober­holzer was that there was no set model or approach to build the team. When the team was originally formed, the payment model was restricted to contract payment, but this was overcome by taking a sessional fee and blending with a fee-for-service model. This allowed Dr. Oberholzer access to health region resources.

Even though the model is working well, Dr. Oberholzer notes that there are still restrictions placed on team members, ei­ther by the regional health authority or the labor unions that restricts some team members from functioning at full capac­ity. “Change is always a concern, and some practices or prac­tice routines are difficult to change,” says Dr. Oberholzer.

Aside from that, the one addition that would make the model work even better would be another physician to take some of the load off of providing 24/7 emergency room coverage 365 days a year. “A bit of relief would be welcome,” Dr. Ober­holzer humbly states.

“These three non-traditional primary health care examples demonstrate that it is possible to deliver patient-centred care in a team environment in many different ways,” Dr. Fourie proudly stated before encouraging delegates to par­ticipate in breakout sessions to discuss the possibilities and what they believe are essential components for any primary health care site.

If current provincial restrictions on the traditional primary health care model are removed, the opportunities for suc­cess in primary health care redesign are almost limitless, and physicians need to be ready to act.
“Physicians must be ready to participate in primary health care redesign opportunities when they arise so our voices continue to be heard,” stated Dr. Fourie. “The initial examples of primary health care redesign, whether physician, com­munity, or health region driven, should be innovative with as much flexibility in team-based care as possible, and with pre­cise measures in place so we can demonstrate success.”

From the SMA News Digest, Winter 2011 - Article by Scott Donaldson, Director of Communications

A little communication goes a long way

I tried something new on my last 2 ER calls.  I don't know if it is going to change anything, but it passed the "good idea" test with most of the nursing staff that I worked with on these last 2 ER calls.  So what did I do - nothing spectacular and no new concept - I created an opportunity for communication amongst the team in the ER.  To understand it, I will give a little bit of background first.

I am a family physician that works shifts in our local ER.  We don't have full time ER docs and there are 10 of us family physicians that do 12h shifts in the ER - divided equally over the year.  Our ER sees about 50 - 100 visits per day and averages about 1900 visits per month.  We have 1 family physician per 12h (8am to 8pm, 8pm-8am), 3 registered nurses during day (7am - 7pm), 1 registered nurse (9am-9pm), 2 registered nurses during night (7pm-7am), 1 ward clerk and a (new) nurse practitioner who does about 14x12h shifts (normally day time) in a month.

In the past 12 years that I have worked in the ER here, all of us just came to work to do our shifts and for the most part got along quite well together, but we have never had a meeting.  The nurses have handover rounds at 7am and 7pm and the physicians hand over to each other at 8am and 8pm.

On Thursday and Saturday on my last 2 calls I called a meeting at 9am and 7pm and invited everyone - the wardclerk, nurses and even house cleaning.  I explained that I wanted to create opportunity for a huddle before we start the shift and a debrief at the end of the shift.  These meetings only lasted 3-5 minutes.  We discussed the safe environment where anything can be brought up on how to do things better in a no blame atmosphere.  We all want to learn what we can do better.  We discussed our poor "door to needle times" for ST elevation myocardial infarctions (heart attacks) and that we want to get them better.  I was busy with a longer case at 7pm on thursday, so we did not have a debrief, but on Saturday we had both the pre-shift huddle and post-shift debrief.   Some of the nursing staff were so excited that I almost got a hug. 

So what did we learn - the team values communication opportunities and sometimes we don't know when others are scared or uncertain too.  One of the nurses was glad to hear that she was not alone when she felt scared when a little girl of 4 years came in with a severe nut allergy needing epinephrin.  During the debrief I could share that I was scared too when she turned white with blue lips and telling us her tongue feels thick and I can hear wheezing in her chest.  Luckily for all involved the epinephrin worked it's magic and after 4h observation in ER she was playing and being her old self again...

These brief meetings seem so obvious and minor in the scheme of things going on in ER, but on these last 2 calls things felt different and the calls had more a feeling of a "team approach".  Will I keep doing it ?  Well, I will try it for 3 months and reassess - so far it has been a positive experience.

Like the Japanese proverb says: "None  of us is as smart as all of us" .....

The Writing is on the Wall !

Normally when you hear the term "The writing is on the wall", there is a negative connotation to it.  Well, today I want to tell you that often in hospitals the term has a very positive meaning.  I would go so far as to say that if you don't see the writing on the wall at your hospital, you should ask why not....

Over the last year there has been an explosion of quality measures that are being posted on walls in the hospital where I work in Sunrise Health Region.   Things like balance score cards are posted on line.  This is a good thing, because the sooner we get transparent with quality measures and act on them, the sooner our patients will receive the quality of care that they have sometimes (dare I say - often) been denied in the past.

The Saskatchewan Ministry of Health has started implementing Lean projects in some health regions since 2006 and have expanded projects like "Releasing time to care" throughout wards in the province.

If you see these posts on the wall, don't just walk by (like I used to do), no - stop and have a look at what the frontline workers in the Saskatchewan Health Care System have been doing to improve the quality of the service they deliver.

I learned that in our hospital they are constantly measuring Patient experience, Provider Satisfaction, Effective Processes and Specific Initiatives like "falls prevention" on the medicine floors.  The results are posted there for everyone to see and every ward has their own "flavor".  See if you can pick the pediatric floor from the photos and videos below.

I saw the excitement when one of the nurses on the medical ward showed me their new organized supplies room.  (There are photographs on the bulletin boards too.)  They sorted it in color coded plastic containers.  The interesting part came when she told me the red containers have blood related things, the yellow containers have urine related things and so forth.

So the writing is on the wall - what next.  Well, the next steps are not to only focus on the numbers and the graphs, but rather to learn from the discussions that come from trying to understand the numbers and the graphs.

Are you ready to sign the Saskatchewan Health Care System compact ?

As a member of Saskatchewan delegations that visited high performing health systems (like Kaiser Permanente in California, Intermountain Healthcare in Utah and South Central foundation in Alaska), I was struck by the strong sense of common vision or purpose among the health care providers that I had interactions with.  In the last few years I have also been exposed to the concept of compacts, like the ones mentioned on the right side of this blog under the heading: "Compact background".

So I have been thinking about how we can implement these ideas in our health care system where there is not a single employer or organization, but rather a group of independent employers working in a system.

I have created a compact that would represent "The Saskatchewan Health Care System" on one side and any individual, group, practice, department, health region or organization that is a provider of health care in Saskatchewan on the other side.  The compact is inspired by the IHI triple aim and the Health Care Transformation document of the Canadian Medical Association and some of my own thoughts.


The Institute for Healthcare Improvement (IHI) believes that new designs can and must be developed to simultaneously accomplish three critical objectives, or what they call the “Triple Aim”:

1. Improve the health of the population;
2. Enhance the patient experience of care (including quality, access, and reliability); and
3. Reduce, or at least control, the per capita cost of care.

The Canadian Medical Association Health Care Transformation Document has been signed by many other Canadian Health Care organizations.

For Canada’s health care system to be sustainable and patient‐focused, the CMA recommends all level of governments show leadership and implement these five pillars for action:

• Building a culture of patient‐centred care; 
• Incentives for enhancing access and improving quality of care;
• Enhancing patient access along the continuum of care;
• Helping providers help patients; and
• Building accountability and responsibility at all levels.

For the transformation plan to succeed, the following key enablers must be in place:

• Leadership at all levels including strong political leadership.
•  Well‐informed Canadians who understand the need for, and characteristics of, a high‐ performing health system.
• Patients, physicians and other providers actively involved in the reform and management of the system.
• A commitment to sustainability with adequate levels of resources to ensure services are in place.
• Health information technology in place to improve service delivery, manage care within and between services, and monitor and evaluate organization and system performance.
• Incentives properly aligned to support a variety of funding and delivery models that can meet system goals.
• Coordinated health human resources planning at the provincial/territorial and national levels.
• A commitment to support continuous quality improvement and evidence‐informed decision‐making at both the policy and clinical level.

I have posted this compact that I put together with the principles above and some of my own thoughts and ask people to join by making a commitment in the comments section below it.

The target would be to get as many Saskatchewan health care providers  to commit by putting their name down in the comment section.  Even if you are not a Saskatchewan Health Care provider, you can show your support by leaving a comment in the Comment section below the compact.  It is available on my blog in the right hand column under the heading: "Pages" and subtitle: "Saskatchewan Health Care System Compact"


I am curious to see where this journey will take us ....

Relationships and conversations trump bricks and mortar

I used to interpret the phrase "Build it and they will come"  coined in the movie "Field of Dreams" very literally.   I still believe in the concept, but I think that the relationships and conversations that occur will always trump the bricks and mortar.  So what do I mean when I say this ?

I am a solo family physician who has recognized several years ago that working in a group practice would be a far better arrangement for my patients and myself.  Unfortunately there has not been the right opportunity to do this in the city where I work.  I took over my practice in 1999 from another physician, who moved away and my practice had been trapped in something which is fairly well described in a New York Times article titled "Family Physician Can't Give Away Solo Practice".

I started talking to other physicians in the city about forming a group practice since about 2002.  Because my current location only has enough space for 1 physician and so does most other practices in town, the discussion always came up about building a new clinic.  The year 2003 was around the time that Saskatchewan (the province in Canada where I work) started to implement primary health care as defined in the Saskatchewan Action Plan for Primary Health Care.  As the Saskatchewan Medical Association representative for primary health care for my health region (Sunrise), I saw the potential of team based collaborative care and wanted to be part of it.  Unfortunately the implementation of it in the province was flawed and I never moved to become a primary health care site.  (I don't like dwelling on the past, but the fact that the current ministry of health has started on a journey called "Primary Health Care Redesign" should be adequate for anyone to realize that even the ministry of health believes that the previous implementation was less than successful. It was not that the goal or principles were wrong, but rather the implementation strategy.)  

So when I spoke to other physicians about joining up, I also discussed with them about incorporating space for other health care providers like diabetes educators, dieticians, nurses and/or nurse practitioners.   I also spoke about building a facility that would have more space than the initial physicians that start working there, because we are at least 4 family physicians short.  (Currently 10 of us working in a regional centre with a population of 17 000 serving a referral area of about 75-100 000).  I believe that  if you build the ideal facility and create the best working circumstances it would be easy to recruit more health care providers.

Unfortunately nor the ministry of health nor the health region is in the business of building facilities.  Although they supported the idea of a team based group practice, they have not been able to help with funding.  The city council was initially of the same opinion, but luckily that has changed in the last year and they have now committed to some funding to partner with a private investor to build a clinic.  If all goes well ,  building will start in the spring of 2012.  The dilemma that we have not completely solved yet, is that if you build a clinic in the traditional model then the physicians would fund it and have the lease as part of the overhead if they don't own the building.  So in our scenario if we start with 3 physicians in a clinic with space for say 4 more physicians to recruit and also space for other health care providers, space for education sessions, group appointments, student education and visiting specialist office space, then 3 physicians have to pay the overheads for 7 and more.   Even if we get to full quota of 7, it would be difficult to recruit a physician into a scenario where their overheads would go up when one or more of the other physicians would leave.  (I know of another practice elsewhere in the province where 2 or 3 physicians had huge overheads to cover for other physicians that have left.).   So we finally got the health region to commit in principle to provide extra funding to pay for space needed by other health care providers.

So to summarize the last few paragraphs:  facilities or clinics cost a lot of money and ongoing overheads for a team based collaborative practice can be a lot more than what one would pay in a simple group practice where physicians would just co-locate.  I believe that there needs to be a way to support physicians to move to such team based collaborative practices where they only need to pay a fair, stable overhead comparable to national or provincial average regardless of how many other services are provided at the clinic.  What does such a clinic look like ?  Well it would look like something that you would see in Alaska South Central Foundation in Anchorage. Other examples can be found at The Centre for Health Design  and might look like the ambulatory practice of the future.

After several years of focussing on building the facility first with the notion "build it and they would come" and not seeing brick and mortar yet, I changed my strategy in the beginning of 2011.   I came up with the idea to build the team first and then move the team to the new clinic once the brick and mortar is there.   I found that suddenly the project started making progress, even though it is still much slower going than what I would like to see.

I invited interested physicians, other health care providers like pharmacists, nurse practitioners, dieticians, exercise therapists, diabetes education, optometrists, podiatrists and others, the ministry of health, the city council,  the senior management of the health region, First Nations representatives and most important of all - 3 patient representatives to start up a chronic disease management team that would work in a temporary location until our facility is built.  This team would then later expand its mandate to become a multidisciplinary, patient centred, team based primary health care site (wow, what a long definition.)

This was a huge success facilitated by Mary Smile, who used to work at the Health Quality Council with about 40 people attending from the region.  Although progress was slow, suddenly the project started to move along.

We then selected a core group that would do the initial work of setting up the team and clinic.  We  met to come up with a vision statement and some principles.

The most recent session was a team building exercise for the initial provider and admin core team (there were 8 of us including 2 physicians, a receptionist/medical office assistant, a diabetes educator, a dietician, podiatrist, optometrist and the primary care director of the health region - unfortunately the mental health worker, exercise therapist and pharmacist could not make it) on 13 December 2011.

We have not started our clinic yet but we have a team already.

It was during this successful event (evening started with an ice breaker followed by snacks, drink and a board game similar to charades) that I came to the conclusion:  Relationships and conversations will trump bricks and mortar every time ....

Curiosity about Primary Health Care Redesign in Saskatchewan

Curiosity is an interesting thing ... I don't know how you ended up here and I don't know when or where you will be going after this. Well I don't even know what this is ...

What I do know is that you were curious and I only have a few minutes to get your attention. Some of you might say that I only have 140 characters. Well, I say that I have until I land in Denver or until I run out of battery power (I started this blog as a note on my iPad on my way back by air from the IHI meeting in Orlando, Florida and then copied it into this blog.)

I heard an interesting story this week about a shoe shining guy who was shouting out small phrases to passers by. When he was asked what he was doing he said that he had 3 seconds to connect to somebody. (implying that if he does not connect with that person, he would not be able to shine their shoes ...)

If you are still reading this then it means that I still have your attention and it did not take 3 seconds to connect. I do know that if I don't give you what you are looking for, you will be leaving soon.

Now here comes the interesting thing: I want you to stay for only as long as you feel comfortable with what you see, because you can start right now to do something that you feel passionate about.

I am passionate about redesigning primary health care in Saskatchewan as one of the ways to reform the Saskatchewan health care system. I plan to use this page to showcase stories of people like Dr Kishore Visvanathan and organizations who are transforming health care in Saskatchewan. I am not much of a writer, blogger, facebooker or tweeter, but I know that there are others that do these things well that will lead you here. Hopefully you will look at the Saskatchewan stories and do something in your world or share your stories with all of those in Saskatchewan who are making a difference in transforming the Saskatchewan health care system.

So all I ask of you is that next time that we meet in person or connect in cyberspace, please tell me how curious you were, what you are doing in your world and how long it took for us to connect ...

So here is my story ...

I am a family physician in Yorkton, Saskatchewan. I came to Canada in 1999 to do locums (temporary replacements for 3 months for other physicians who went on vacation ). At the end of the 3 months I decided to stay in Yorkton, Saskatchewan, Canada. This lead me on a journey during which I constantly tried to improve the way I practise. I soon realized that there were a lot more than just my practice that had to change. Changes were needed in my health region (Sunrise Health Region).  As I got more involved, I became my health regions primary care representative for the (Saskatchewan Medical Association or SMA).  I then realized that it was not only in my practice or health region - we needed to improve health care delivery for the province.

As time went on I became involved with more SMA work and ended up on the board of the SMA and currently I am serving a term as president of the SMA for 2011/2012. This gave me the opportunity to have input on a provincial level on matters that influence my daily practice.  It also gave me exposure to quality improvement conferences like IHI and Inspire.  I was one of 16 physicians that were sponsored by a group effort of  the Saskatchewan Medical Association, Ministry of Health, Health Quality Council and the College of Physicians and Surgeons of Saskatchewan .  There were others from Saskatchewan too - to make up a total delegation of about 40 people from Saskatchewan.).

I have been working on moving my own practice from the solo practice that I took over to a multi-disciplinary team based group practice. This is another story which I will write about later.

For now, I just want to write about the exciting period of time that we are experiencing in Saskatchewan. We have a provincial government that tells us that they believe in physician leadership to be a major contributor to the transformation of health care in Saskatchewan.  We have a medical association (SMA) that is actively involved in primary care reform as outlined in their primary care framework.  We have the Health Quality of Saskatchewan (HQC) that have been spearheading the quality improvement agenda for the province.  We also have dedicated individuals from many different health care organizations who want to work together for a better solution for the province.  I believe the tipping point is near where we are going to witness the transformation of a mediocre provincial health care system to a health care system that others would want to duplicate.  As Malcolm Gladwell said in his book, The Tipping Point: "The tipping point is that magic moment when an idea, trend or social behaviour crosses a threshold, tips, and spreads like wildfire." ...

Currently the main focus for Minister of Health, honourable Don McMorris and especially his deputy Minister of Health, Mr Dan Florizone is the Saskatchewan Surgical Initiative. (SSI). The Saskatchewan Surgical Initiative is striving to improve surgical patients' care experience and ensure that by 2014, all patients have the option of receiving their surgery within three months.

The SSI is looking at the whole patient experience from before they see their primary care provider until after surgery is completed. Several projects came from this initiative, for example - The Specialist Directory and Primary Health Care Redesign.  These initiatives all came as a result of the Patient First Review which was a report on what patients wanted from the Saskatchewan Health Care System.

I am passionate about Primary Care Redesign and this journey started towards the end of 2010 when the ministry of health got Syntegrity to facilitate discussions between a number of Saskatchewan stakeholders about the future of Primary Health Care in the province. The sessions were divided into different groups that addressed issues on Physician Engagement, Chronic Disease Management, Community Engagement and First Nations.

I attended the Physician Engagement sessions and found the process very productive. Syntegrity facilitated discussions between patients, physicians, nurses, other health care providers, health regions, community representatives, First Nations representatives and more.

During one of these sessions in a small group discussion I had an "Aha" moment and was so excited that I literally jumped up and grabbed the pen out of the surprised facilitators hand and drew a graph that looked something like this:

The vertical axis represents the level of support from the health region and ministry and the horizontal axis represents the number of desirable elements that physicians have implemented in their practises.

So the desirable factors that I am talking about on the horizontal axis are these:

So what I meant was that every physician practice in the province is somewhere on the horizontal axis. The more desirable factors they have in place the more to the right they are on the graph. The support for these practices from the health regions and ministry should increase as they move more to the right. In this model it confirms that every practise in Saskatchewan is part of Primary Health Care delivery. They are all just at different milestones on the journey. So far I have received a lot of support for this model from physicians, some of the ministry health officials and other stakeholders in the province. This is in stark contrast to what the previous model looked like between 2003 and present. In the old model only the "approved" primary health care sites received support. So that graph from the past would look something like this :

In both graphs the red box indicates which practices get support from their health regions or the ministry.

So to summarize - all I ask of the health regions and the ministry is to see how they can enable physician practices to implement more desirable elements into their practices. All I ask of physicians is to look at their own practices and see how many desirable elements they have implemented in their practices and if they are somewhere on the left of the graph then I challenge them to see if they can move to the right on the graph.  This way the transformation in primary care will move along all over the province and not only in a few primary care sites.

So whether you are from a health region, the ministry or whether you are a health care provider I am asking you the question: In the transformation of the health care system in Saskatchewan, are you an enabler or an obstacle ....