December 2, 2011

Proactive Harm Prevention: A Performance Lever in the Health and Social Services Sector

Corps

Ladies and Gentlemen,

It’s a great pleasure to be here today, and I’d like to thank the organizers for giving me this opportunity to share some of the Québec Ombudsman’s observations regarding ways to improve health and social services sector performance.

A few words on the Québec Ombudsman

First a few words on the Québec Ombudsman. As parliamentary ombudsman and an institution of the National Assembly, the Québec Ombudsman serves as a neutral and impartial monitor to see that citizen’s rights are respected in the delivery of public services by over 80 ministries and all health and social services system institutions.

Our actions are not limited to correcting the damage we discover during our interventions. We also seek to prevent harm proactively by analyzing systems and examining parliamentary bills and regulations.

The Québec Ombudsman has broad investigative authority (it is invested with the powers of an investigation commissioner under the Act respecting public inquiry commissions) and conducts systemic analyses that put it in close contact with the real world of service delivery. My team and I collect valuable information on the dynamics of service delivery processes. In doing so we have developed an understanding of the strengths and weaknesses of various performance frameworks, as well as the way they are applied over time by health and social services authorities.

The first task in such a venture is to agree on a notion of what constitutes performance.

Agreeing on a notion of performance

The classic view of performance involves maximizing health benefits with the allotted resources. Note that, as other speakers have mentioned, high-performing health organizations consider it critical to improve every dimension of the services they provide. This means doing more to ensure that services are effective and efficient, delivered in a safe and timely manner, and centered on the patient. 

The notion of better service is thus a strategic lever in attaining and consolidating performance gains. In Québec, we have seen numerous approaches to improving services, most recently “lean management.” Yet assessing overall performance also means considering complex organizational dynamics. Here we might think of such performance frameworks as EGIPSS (Comprehensive and integrated assessment of health systems performance), which incorporates adaptation and value dimensions in addition to the more traditional objects of assessment, i.e., output and goal attainment.

Given the proliferation of performance frameworks and input from experts, you might be wondering what an institution like the Québec Ombudsman might possibly have to add. Well, our status as the government watchdog—and the analytical perspective that goes with it—has provided us with an important insight: when it comes to the performance of Québec’s health and social services systems, patient rights tend to get the silo treatment.

Separation at the expense of performance

The system’s rights monitoring and complaint processing mechanisms remain completely separate. At best, links may be made to administrative performance, but coordination and sharing with such clinical quality improvement mechanisms as the committees of the Council of Physicians, Dentists and Pharmacists is for all practical purposes nonexistent. This despite the increasing integration of administrative and clinical processes, a situation clearly demonstrated by experience, notably through the introduction of clinical governance.

Some may wonder what user rights have to do with the concept of performance. Let’s take the example of home care: we found that proper needs evaluation practices were not uniformly applied by health care institutions, most often due to measures to meet expenditure reduction targets. On grounds of supposed fairness, for example, some institutions reduced services to all patients by the same number of hours in order to serve the maximum number of people. We call these parametric cuts.

So I ask you: is it right, in an effective system, that two persons with the same needs not have access to the same services, merely because they are in different regions, or even institutions? Is it right that someone who moves a few streets away in the same sub-region might see her services cut in half, although her condition remains unchanged?  

Separating performance from the rights central to quality service delivery creates a risk that managers, naturally sensitive to evaluation criteria, might overlook the rights of the most vulnerable. Rights get left out of the accountability equation.

And the concrete results in people’s lives? Perverse effects. It seems obvious that people’s psychosocial needs must be considered in their entirety. People cannot be reduced to just diabetes or asthma cases, much less to an internal organ like a heart or a kidney. While a division of labor with its attendant specialization can bring productivity gains, it can also reduce people to the status of so many diseases or conditions—each with its own standardized list of available services. The Québec Ombudsman often has to remind institutions that they deal with human beings who have rights: that the system must adapt to an individual and not the individual to the system.

We can never forget that most of our programs and services are designed for human beings with manifold and complex needs. Program names attest to this—decreased autonomy related to aging, youth in difficulty, physical disability, intellectual disability and pervasive developmental disorders, addictions, or mental health. Even population-based programs in public health and general services involve complex issues.

Accountability mechanisms: rethinking the terms

Yet current accountability mechanisms—which are based essentially on indicators set out in management agreements—measure performance in terms of physical health. Imposing standards for elective surgery wait times may indeed be a performance measure compatible with patient rights, but this same approach can lead to undesirable effects for vulnerable clienteles.

Here’s an example of the impact of such perverse effects: in 2008, Ministère de la Santé et des Services sociaux released an access plan incorporating wait-time guidelines for initial service delivery to disabled individuals, whether their disability was physical, intellectual, or a pervasive developmental disorder. Performance was assessed on the basis of wait times for initial service. It was forgotten that, for people with complex needs, the right to appropriate care is as much an issue of continuity as it is of access.

We found that individuals would often receive a first appointment within the prescribed period, but would then be placed on a long waiting list while the institution rushed off to meet their initial care deadline for somebody else. Institutions wanted to look good to the ministry.  Our recommendation was therefore that the ministry bring patient rights back into the equation by clarifying the notion of initial care in such a way that it addressed the reason people needed care in the first place.

The limits of comparing institutions

Another problem: performance is often measured by comparing institutions or systems. This traps those involved in a logic of competition. Let me unpack this problem: funding—which of course is a major incentive for individuals and organizations to behave in certain ways—is allocated in the form of an overall budget for an institution or service program. We know that resources are limited, while needs and expectations are not. In some countries, the care budget follows patients if they decide to switch institutions. In such cases it may indeed be useful for patients to have comparative data to base their decisions on.

However, this is not the case in Québec. Instead, institutions want to show the funding provider that—despite their good performance—they need more resources if they are to provide all the services their patients need. Patients’ ability to take advantage of competition among institutions is effectively nil. In fact, if a patient needs expensive care, it is in the institution’s interest not to cultivate loyalty by providing it, but to send him somewhere else.

Now suppose that you were an intellectually disabled young adult with a newly developed serious conduct disorder that made it necessary for you to be removed from your parent’s home. The rehabilitation center specializing in intellectual disabilities would tell you to look to mental health programs for institutional housing because of your conduct disorder. However, the mental health institution would tell you that the problem stems from your disability, and that the rehabilitation center should foot the bill for your housing out of its budget. This is only one of many examples in which users face obstacles to receiving the care they are entitled to.

An unambiguous response to complex needs

Rarely can a single health and social services institution provide all the services that individuals with complex needs are entitled to. Furthermore, it is not uncommon to find that meeting people’s needs requires input from other systems, such as those of education, daycare, or employment and social solidarity.

Yet we regularly come across situations where continuity breaks down and care is not provided because everyone is working in silos. In such an environment, inconsistent incentives—particularly the competition for budget money—constitute an obstacle to the kind of sectoral and inter-sectoral collaboration needed to guarantee good services. Even major task forces such as the Clair and Castonguay commissions have focused on Ministère de la Santé et des Services sociaux and have said little about the role that other ministries and agencies can play, despite the power they have over the determinants of health and well-being.

Here, the Québec Ombudsman has leverage to improve performance. Our actions are not limited by the lines that divide organizations and systems. Our systemic role in making recommendations allows us to facilitate improvements in service delivery and performance, even when the solutions involve more than one sector.

Reaching across organizational boundaries to boost performance

To illustrate the power of this leverage, I will now look at two special reports we produced. For years there had been complaints about the way each system—health and social services, education, daycare, etc.—used different assessment tools to create plans for complex-needs individuals. Information was not shared, and users had to repeat their story for each network, with all the risks of omission that entailed. This also added to the burden of case workers and led to conflicts over which assessment tool was the best. Dissatisfaction was widespread, but none of the ministries had taken the lead in spearheading harmonization. When we tabled our report on services for children with pervasive developmental disorders in the National Assembly in October 2009, we recommended that all actors harmonize their plans and share information. The message was heard and the impasse was broken. Today, a common plan is available online for case workers from all systems to refer to.

Similarly, when we tabled our report on detainees with mental disorders in the National Assembly in February 2010, the ministries of health and social services, justice, and public safety already knew that the health and social services system was best equipped to provide the services such inmates needed. Our recommendation that the government transfer responsibility from Ministère de la Sécurité publique to Ministère de la Santé et des Services sociaux acted as a catalyst for performance improvement and reaffirmed individuals’ right to receive the services their condition required.

Performance includes user’s rights

All this to say that user rights must be incorporated into quality and performance accountability measures. In the course of our studies and investigations, we have also been able to identify certain conditions that help make that integration successful.

Among the critical factors—as others have mentioned—are those relating to leadership and organizational culture. In practice, this means making the transition from a defensive rights culture to a proactive rights culture. By hoping to avoid detection, claiming nonresponsibility, or pleading exceptional circumstances—and thus ducking the task of systemic analysis—institutions miss out on a source of insight that has much to teach them.

The constructive alternative—ensuring rights are respected before a tragedy occurs—forestalls the emotional charge that leads people to look for someone to blame when something goes wrong. It may lead, for example, to greater transparency in dealing with incident and accident reports, a transparency that makes it easier not just to prevent harm from being done, but to improve service quality as well.

By pushing this a bit further, we arrive at the notion of institutional culture. Here I note in passing the positive developments at Ministère de la Santé et des Services sociaux, where my team and I have noticed strong support for the principle of “remedy for one citizen—remedy for all citizens,” which serves as the Québec Ombudsman’s motto. Institutions learn that the failures uncovered by investigations into breaches of patient rights often bring to light key factors affecting the performance of the entire system.

Research in support of performance

I’d like to conclude with another major theme of this seminar: an organization’s capacity to mobilize researchers to find ways to improve performance. Or in other words, its ability to draw on research to support innovation and performance improvement processes. The Québec Ombudsman has a limited ability to verify the impact of research on health institutions. We nonetheless have concerns.

Certain questions may be of interest to researchers, yielding conclusive, research-based data that might then be brought to bear on performance-related decisions.

The burden of collecting performance data can be a barrier to such research. According to reports we have received, it can even get in the way of service delivery. Can we develop indicators that reduce this burden?

And how do we measure performance, given that responsibility is shared between a number of sectoral and intersectoral actors?
Understanding the way accountability mechanisms promote or prejudice user rights would seem another line of research worth pursuing. I would be most interested in the results of such research.

Thank you.