Final Report of the Federal Advisor on Wait Times

Chapter 2: Benchmarks, Indicators and Ongoing Research

Progress has already been made to improve access to health care across Canada. First Ministers and Ministers of Health have been concerned with the public perception of health care and access to services, both in terms of the availability of quality care and wait times. As a result there have been serious efforts over a number of years to build upon the solid foundation of health care services in Canada.

Provinces under the Canadian constitution have the responsibility for direct service delivery of health care. Provincial delivery systems have developed over time around trends in the provision of medical services nationally and internationally and in response to specific needs of provincial populations. Though provinces may provide a similar range of services by similar professional groups, the organization of service delivery might be quite different.

On the national front, The Hospital Insurance and Diagnostics Act (1957)^[7] was the "largest governmental undertaking since the war and would require federal-provincial cooperation on a scale never before known" providing all Canadians with access to uniform hospital services. The Medical Care Insurance Act followed in 1967. The Canada Health Act (1984) further levelled the playing field by banning extra billing and user fees associated with both medically necessary hospital and physician care. Criteria were established in support of a health care system that is universal, accessible, portable, comprehensive and publicly administered. Efforts to preserve the process of equity and comparability continue to this day.

The recent topic of benchmarks and indicators speak to issues of standards and comparability. Provinces have developed data systems to meet their own needs. There is now a need to develop systems with common data elements to bring definition and consistency in reporting to Canadians. For example, the use of common indicators to measure progress in meeting benchmarks across the country would contribute to this objective.

2.1 The 10-Year Action Plan to Strengthen Health Care

In September 2004 First Ministers agreed to the 10-Year Plan to Strengthen Health Care. The 10-Year Plan committed the provinces and territories to reduce wait times in priority areas, while recognizing different starting points, priorities and strategies across the country. To accomplish this, Ministers of Health were charged with a commitment to establish evidence-based wait time benchmarks beginning with five areas: cancer, cardiac, diagnostic imaging, joint replacement and sight restoration. In addition each province and territory agreed to set multi-year targets to meet the benchmarks by the end of 2007. A third commitment was for provinces and territories to establish comparable indicators of access to health care professionals, diagnostic procedures and medical treatments.

2.2 Terminology

Health scientists do not always agree on definitions for such things as benchmarks, indicators and access targets. When other health professionals, health bureaucrats, politicians or the media enter into the discussion a consensus it is even harder to achieve. It was clear to me early in this project that there was an absence of clear definitions in debate, discussion and media reports that was making the work of wait times harder. There is a need to promote the understanding of accurate wait time terminology for the public, the media and health care providers as well.

What is a wait time?

The federal, provincial and territorial announcement on benchmarks on December 12, 2005 established the following definition of wait time:

A wait time begins with the booking of a service, when the patient and the appropriate physician agree to a service and the patient is ready to receive it. The appropriate physician is one with the authority to determine the nature of the needed service. A wait time ends with the commencement of the service.^[8]

What is a benchmark?

Wait time benchmarks are evidence-based goals that express the amount of time that clinical evidence shows is appropriate to wait for a particular procedure or diagnostic test.^[9] A benchmark may be identified when scientific evidence shows that the outcome of an intervention is negatively affected after a certain period of waiting has elapsed. The nature of a benchmark, due to the evidence that supports it, is such that it does not change from one system to another.

What is an indicator?

Indicators are used to measure how well a system is performing in relation to a benchmark. Comparable indicators have the additional benefit of allowing comparisons across health systems, for example from one province to another. Indicators rely on data collected consistently from one site to another.

What is an access target?

Evidence-based benchmarks have application nationally. Targets, on the other hand, may be set by each province and territory based on the jurisdiction's practical capacity to achieve them. As agreed to in the 10-Year Action Plan, targets are interim performance goals set by each province/territory over a period of time to guide work towards the achievement of the benchmark. A target is discretionary and can take the form of a performance goal.

2.3 Using benchmarks to provide timely access

Measurements against benchmarks will allow Canadians to see how well their province or territory is performing to provide timely access to selected health services. In order to make benchmarks work other system changes are required, all of which provinces are working on:

• Using information technology to collect data on wait times and measure progress;
• Improving the way services are delivered to make them more efficient and patient-focused;
• Managing access using consistent criteria to assess the needs of patients and how urgently they require care;
• Clarifying how managers and health providers are responsible for enhancing access to care;
• Evaluating access to health services and health outcomes to help determine where resources should be directed for the most effective results; and
• Communicating clear information to Canadians who have an interest in wait times.

2.4 Using indicators

Indicators are necessary to measure progress against benchmarks at a later date. Comparable indicators have been used to report annually to Canadians on key areas identified by First Ministers even before the declaration of the benchmarks in December 2005. The September 2000 First Ministers' Communiqué on Health gave direction to Health Ministers to develop a "comprehensive reporting framework, using jointly agreed upon comparable indicators of health status, health outcomes and quality of service"^[10]. In September 2003, fourteen jurisdictions including the federal government released reports to their citizens. The February 2003 First Ministers' Accord on Health Care Renewal directed Health Ministers to develop additional indicators to supplement the previous work on comparable indicator reporting. Provincial reports were released in 2004.

Provinces and territories have now established comparable indicators for health services that have common benchmarks, such as cardiac bypass surgery, radiation therapy for cancer and cataract surgery, to track how well they are improving access to care. Using these indicators, each province and territory will be able to report on access to selected health services. For example, each jurisdiction will be able to identify wait times for hip and knee replacements, and the public will be able to compare results across Canada. The indicators, endorsed by the provinces and territories to meet the commitments of the FMM 10-Year Plan to Strengthen Health Care, were communicated to Health Canada's Deputy Minister in a letter dated March 30, 2006.

2.5 Using access targets

Access targets are another vehicle for developing reasonable standards of care. Access targets can be developed at the provincial level and may reflect the policy or program direction of the provincial government. Provinces and territories have the option of identifying access targets that will motivate the system to improve on wait times for other conditions if they think it appropriate. Access targets could be developed based on consensus of professionals if evidence is not yet available or sufficient.

2.6 Ongoing research to support wait times

The declaration of the first set of benchmarks has given us an evidence-based foundation for measuring progress in reducing wait times in the future. It is my belief that if we are to sustain the work that began with benchmarks, a process for ongoing research and decision-making is needed to guarantee the process is transparent to care providers and the public.

It is my view that future benchmark research should take into account issues of cost and appropriateness. These are issues new to the development of benchmarks and warrant brief discussion here.

Cost per case is an important concept because when a procedure is refined, quality measures have been incorporated and criteria established to determine timeframes and eligibility, the next logical assessment is related to cost per case. Not all procedures, interventions or surgeries can be costed definitively. Many procedures are complex and may be affected differentially by the acuity of the patient or by other factors. But for many procedures that are commonplace in our health care systems, it is possible and desirable to ensure that the cost by unit is comparable from one site to another. It is a necessary step in fulfilling our responsibility to ensure that our resources are used wisely.

Appropriateness is also relevant to benchmarks. Not all patients benefit equally or benefit at all from a particular intervention. Research with respect to benchmarks should tell us not only if an intervention cannot be delayed, but also if and when the procedure is appropriate.

The benchmarks that were announced on December 12, 2005 were established as a result of research undertaken by researchers whose proposals were peer-reviewed. Benchmarks were declared after provincial and territorial Deputy Ministers of Health received advice from the Canadian Institutes of Health Research (CIHR)^[11] and recommended to Ministers of Health that the benchmarks be accepted as evidence-based and used to set standards for appropriate wait times for care.

We propose that CIHR develop a plan to address research associated with benchmark development.

These fall into two areas:

• Research to develop new knowledge that will allow us to establish and declare additional evidence-based benchmarks in the future.
• Health system (operational) research that will result in improvements and interventions in system processes, including the evaluation of the first set of benchmarks to assess their impact on health care outcomes.

The Benchmark Research Agenda

We have not yet tested the efect that benchmarks will have on patient outcomes and on health care systems. This is an important first step in deciding whether additional benchmarks in other clinical areas should be developed. When the time comes to identify additional benchmarks two key issues must be addressed:

• a process to identify priority conditions for developing benchmarks; and
• responsibility for recommending benchmarks and where responsibility lies for declaring national benchmarks.

It is critical that there be an ongoing research process to sustain the effort that began with the declaration of the first set of benchmarks. Our first attempt to produce benchmarks in the five areas identified by First Ministers offered many challenges. Peer-reviewed research in these areas was scant. It was not possible, partly because of the timeframe that is required to mount a request for proposals and to identify suitably qualified researchers from relatively small pools of experts, to identify benchmarks in all five areas. Research to identify cancer related benchmarks and diagnostic imaging benchmarks (for CT and MRI scans) were not identified.

Given the resources that benchmarked care will attract or require, we can expect many clinicians and patients to put forward their choices for benchmarks early on. It is important to determine how the next set of benchmarks will be chosen. This will require a process to establish who decides what research will be undertaken, the order of priority; and what condition, procedure or category the research will focus on for a potential set of new benchmarks. These efforts must be undertaken collaboratively between the research community and governments. It may be that CIHR's research institutes, put in place to focus on research needs in major medical disciplines, can play a role in this respect as well.

It is equally important to decide who will have the responsibility for declaring benchmarks once research has been conducted and evidence is available. It is my view that a "trigger group" consisting of researchers, clinicians and senior officials of government should be responsible for recommending to elected officials the declaration of future benchmarks. I believe that it is necessary for participants to share responsibility for recommendations and to consider perspectives other than pure research. Ministers of Health can have, as a consequence, confidence that a broad range of implications have been considered.

The Health System (Operational) Research Agenda

A substantial amount of work is taking place across the country on issues related to system improvement. This kind of research depends upon root cause analysis that examines roles and procedures associated with care, to identify where efficiencies are absent and bottlenecks exist. Operational research can document patient flows and time procedures, propose change and evaluate its success in meeting new goals. It can examine the role that technology plays in efficient care and also that of care providers, the public or the media play in embracing change or rejecting it. It is in this area of research that the business and industrial practices successful in other fields can be evaluated for application in operating rooms, wards and diagnostic clinics. The machinery of our health care systems - process and flows, organizational design and incentives - can be tested to determine whether it supports or hinders wait time efforts.

The Networked Centres for Health Innovation

Despite the fact that many industries and businesses use queuing theory and industrial practices routinely to streamline their processes, the application of this thinking to health care systems is relatively rare. We have not sufficiently exploited the academic resources available to us from business management schools or industrial engineering. CIHR has proposed that a networked partnership be created between existing health services research centres to develop capacity in management practices . This network is conceived as a partnership between the federal government (represented by CIHR) and provinces/territories to build on existing expertise and collegial relationships in health care systems. Researchers, health care practitioners, health system managers and policy makers could work in collaboration on activities to:

• identify high priority issues and plan research studies on topics within those areas;
• plan knowledge translation activities;
• evaluate the impact of activities on performance of health care systems;
• communicate findings; and
• examine the work of other centres and apply them as appropriate.

2.7 Conclusion

Establishing benchmarks for medical care is a new phenomenon in Canada's health care system. It is too early to know the impact of using benchmarks.

The research described here is proposed to help us find out the effects, to refine or approve our methods, and move on to new solutions if need be. CIHR has systems in place to manage these research processes and the mandate to ensure that new knowledge is transferred to decision-makers and care providers.