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March 2010

Sooner, Safer, Smarter: A Plan to Transform the Surgical Patient Experience

Table of Contents

Table of Contents

Case Studies:

“We want health care to be patient- and family-centred.”

- Dan Stroman

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A Word from the Patient, First

A Word from the Patient, First

As one of five patient advisors involved with the Saskatchewan Surgical Initiative, I am witnessing remarkable efforts by health care professionals, doctors, nurses, administrators, the Ministry of Health and patients, as they work together for the people of Saskatchewan. I don’t have to fight tooth and nail to keep a patient’s perspective before the coalition members. They clearly value my contributions and are listening.

I am discovering that health care is complex. The average citizen may not be aware of how much thought, research, and discussion goes on “behind the scenes” in order to deliver health care.

One of the challenges we face in this initiative is a change in philosophy. We want health care to be patient- and family-centred. This is why patients were asked to be on the Guiding Coalition. But patients must also be involved in their own health care. It is our health and we need to take ownership of it. This initiative will work if we participate in our health care by asking questions and insisting that we are people and not just patients. We need to rediscover our value and be involved in our personal health. There are a lot of really good people out there working on our behalf. Maybe we can be one of them.

Dan Stroman

Patient Advisor

“I am encouraged to see that this initiative aims to transform the whole surgical value stream, from primary care to post-surgical recovery.”

- Peter Barrett

A Message from a Physician Leader

A Message from a Physician Leader

I welcome this plan to improve the Saskatchewan patient’s surgical experience and address the access issues identified in the Patient First review. If we only improve the wait for surgery without improving quality and safety, we won’t have advanced the vision Patient First Commissioner Tony Dagnone placed before us. His report also identified prolonged waits to see specialists, delays in diagnostic testing and challenges in providing the primary care that might have prevented the need for surgery in the first place. That is why I am encouraged to see that this initiative aims to transform the whole surgical value stream, from primary care to post-surgical recovery.

Physician, provider and patient engagement will be critical to any successful health system transformation. That’s why I am delighted to join an impressive group of front-line health care professionals, patients and system leaders in developing and advancing this plan. The goals of the surgical initiative are ambitious, but achievable if we put the interests of patients first. If we can do this in surgery, we can then transfer what worked well to other equally important sectors of our health care system.

Dr. Peter Barrett

Physician Leader

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“The ultimate goal of the Saskatchewan Surgical Initiative is to prove to patients each and every day that health care in Saskatchewan can be accessible, safe, sustainable, and of the highest quality.”

- Don McMorris

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A Message from the Minister of Health

A Message from the Minister of Health

The Patient First Review commissioned by this government confirmed that we all want a health system that takes excellent care of patients and also empowers care providers to do their best work.

Studying the review’s findings, my colleagues and I saw an exciting opportunity to begin transforming our health system in a way that would make an immediate difference.

By focusing on surgical care first, we could target one of the greatest areas of concern to patients. We could improve health-care access for thousands of patients, while working closely with health-care leaders and providers to develop patient-first ways of delivering care. This is just the beginning of a transformation of the broader health-care system. In time, other initiatives will follow, such as improving primary health care and fully realizing our vision of a patient- and family-centred health system.

We have set a target to reduce surgical wait times to no more than three months within four years. The ultimate goal of the Saskatchewan Surgical Initiative is to prove to patients each and every day that health care in Saskatchewan can be accessible, safe, sustainable, and of the highest quality. Our challenge and opportunity is to deliver an example of patient-first care that will prompt change throughout the system.

The goals in this plan are ambitious: yet imagine the results, not only for patients and their families, but for the health care teams who find themselves making a positive difference for people every day.

I have tremendous faith in the commitment and capability of the health professionals, providers, leaders, and patients who are working together to make ‘patient first’ a reality in Saskatchewan. This plan is the product of their combined vision; I thank everyone who has played a part in developing this plan and I look forward to seeing its results in the months and years ahead.

Honourable Don McMorris Minister of Health

FPO

The Saskatchewan Surgical Initiative

The Saskatchewan Surgical InitiativeIn response to the provincial government’s throne speech of October 2009, Saskatchewan physicians, nurses, health care administrators, former surgical patients, other health sector organizations and associations, health unions and Ministry of Health officials have been working together on a plan to:

X improve the experience of Saskatchewan surgical patients;

X reduce surgical wait times to no more than three months within four years;

X ensure that short wait times can be sustained into the future; and

X make changes that result in better and safer care for surgical patients.

The Saskatchewan Surgical Initiative’s Plan for better surgical care is based on five measurable objectives under which numerous changes and initiatives are already in progress or under development. Three of these objectives (‘transformations’ in this plan) are specific to surgical care. Two (‘foundations’) apply to the health system as a whole, but will be fundamental to reaching our surgical care goals.

Transformation #1: Shorter waits for surgical care

Although Saskatchewan is now keeping pace with the demand for surgeries, we must continue to make progress on the patient wait list to ensure all patients receive their surgery in a timely manner and to prepare for steadily increasing demand as Saskatchewan’s population ages.

Excessive waits for surgery can be harmful to patients by impeding their mobility, affecting their livelihood, and subjecting them to prolonged periods of pain and discomfort.

It’s one thing to achieve short wait times; it’s another challenge to ensure those wait times remain the norm for years to come. If we reduce wait times without transforming the entire system, new backlogs will emerge. We need to make lasting, fundamental changes in the health system so that surgical care remains accessible and of high quality for our future generations.

Transformation #2: A better experience for patients and families

Putting the patient first at every step of the process goes far beyond simply doing more surgeries. It means improving the patient experience at every step of the surgical journey.

The Patient First Review called for better communication with patients and a more coordinated, seamless journey through the health care system. Health care providers

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Shorter waits for surgery

Better patientexperience

Safer, higher quality care

Support for good healthPatient- and

family-centered providers

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The Saskatchewan Surgical Initiative

need to better communicate with each other as well as with patients and families, so that everyone involved has the information they need and understands the next steps in the care journey. Patients should not be left on their own to navigate a bewildering maze of services.

From the first visit to the family doctor to rehabilitation and recovery, we want surgical patients and their families to be treated as full partners in decisions about their care and in the delivery of that care. We want them to be delighted with the care they receive.

Transformation #3: Safe, high quality care

We want surgical care in Saskatchewan to be guided by practices and principles that ensure the highest standards of service, quality and safety. These will be measured and reported. This will ensure that errors will be eliminated or minimized and, when identified, will be dealt with promptly.

Saskatchewan was the first province to mandate the reporting of critical incidents in the health system. Critical incidents are reviewed; the recommendations from these reviews improve health system quality and safety so that similar incidents do not recur.

Clinical and care pathway practices informed by the best evidence should be the standard across the province, no matter where a patient receives services. For example, if a particular protocol has been proven to reduce the risk of surgical site infections, that protocol should be observed consistently wherever surgeries are performed in Saskatchewan.

Foundation #1: Support for good health

Any effort to improve surgical care must include the promotion of health and prevention of injury so that more Saskatchewan people can delay the need for surgery – or avoid it altogether (e.g. falls prevention).

By helping communities and individuals maintain and protect their health, we do a great deal to manage the demand on the surgical care system, ensuring that surgical care is accessible for those who need it.

Foundation #2: Patient- and family-centred providers

No plan can succeed without committed people ready to put it into action. Without a stable and adequate supply of appropriately trained health professionals, any jurisdiction will struggle to meet the demands of its populace.

While working to shift our focus to the needs of patients and families, the system must also provide a safe, positive, empowering environment for health professionals and providers who want to deliver truly excellent care and develop in their careers.

The Plan: An OverviewThis document has been designed for health-care consumers as well

as health-care providers. It serves as an overview of the key work being done to transform surgical care, while also providing more detailed information or links to additional background. Throughout the document, anecdotes involving a fictional patient and his

Our PartnersThe Saskatchewan Surgical Initiative is guided by the cooperative effort of two important advisory groups.

The Executive Sponsorship Group provides strategic leadership, advice and direction for the Surgical Initiative and champions the transformation of the patient’s surgical experience in Saskatchewan. This group represents higher-level decision makers and is made up of 22 members from the Health Quality Council, Regina Qu’Appelle, Saskatoon and Cypress health regions, Saskatchewan Union of Nurses, College of Physicians and Surgeons of Saskatchewan, Saskatchewan Medical Association, Saskatchewan Registered Nurses Association, Kaizen Institute Lean Advisors, senior leaders of the Ministry of Health, and two patient advisors.

The Guiding Coalition represents the front line experience and is comprised of 65 members including physicians, nurses, therapists and other providers, all 12 health regions, health care unions, regulatory bodies, Health Quality Council, Ministry of Health, and three patient advisors.

Transformation #1: Shorter Waits for Surgical Care

family serve to illustrate the impact on services when patient-first principles are put into practice.

The initiatives identified in this plan are intended for implementation over the next four years. While some are already well underway and may be in place throughout the health system within a year, others will require more time to ensure they become a workable, sustainable solution in Saskatchewan. For some system changes, providers will need time to adjust and adopt a new way of doing things. For others, implementation will be guided by the availability of financial and human resources. While implementation schedules may vary, all initiatives in this document represent system improvements to be made by 2014.

As these projects and initiatives progress, details and updates will be posted at www.health.gov.sk.ca/saskatchewan-surgical-initiative. Over the weeks and months ahead, this site will include examples of how patient- and family-centred care and evidence-informed best practices are being implemented in Saskatchewan. After you’ve read this document, you may wish to bookmark this website as a source of future updates.

Transformation #1: Shorter Waits for Surgical Care“Access delayed is access denied.”

- Patient First Review Report to the Minister of Health

While progress has been made in reducing wait times in recent years, there are too many people in Saskatchewan waiting too long for surgery that will relieve pain, improve mobility, and restore health and quality of life. As of December 31, 2009, about 28,700 people were waiting for surgery, 4,300 had been waiting for longer than 12 months, and nearly 1,700 for longer than 18 months. The Government of Saskatchewan has pledged that by 2014, no Saskatchewan resident will wait more than three months for her or his surgery. This will be the time from when a patient and surgeon decide surgery is the best option to the time surgery is actually performed. However, it is recognized that some residents may choose to wait longer due to a number of reasons, including personal availability or the desire to see a particular surgeon.

There is no all-encompassing solution to reducing wait times and eliminating the long line of patients yet to receive their surgeries. The health system is actually a complex web of interwoven systems that greatly affect each other, and surgical access problems arise due to a number of issues that must be thoughtfully yet decisively addressed. These issues include:

X Inconsistency in involving patients when deciding the most appropriate form of treatment;

X Bottlenecks that delay appointments for diagnostics and initial consultations with surgeons;

X Large differences among surgeons in the number of patients they see and the length of their waiting lists;

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Progress on Wait Times

Progress has been made in reducing wait times for surgery. For example:

In the past four years, the number of people waiting more than 12 months for surgery has dropped by about 51 per cent – from 8,700 to 4,300 and the number waiting more than 6 months has dropped by about 27 per cent from 14,700 to 10,700.

From July 1 to December 31, 2009, 85 per cent of all patients received their surgery within 6 months and 93 per cent received it within one year;

The new surgical pathway for hips and knees has meant that the number of people waiting longer than six months for a hip or knee procedure has dropped by 31 per cent since March of 2009, while the number of people waiting longer than one year has dropped by 45 per cent.

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Transformation #1: Shorter Waits for Surgical Care

X Inefficiencies in operating room scheduling and recovery bed management;

X Imbalances in the number of surgeons, anaesthesiologists and operating room (OR) staff relative to service needs in different parts of the province;

X Outdated record keeping systems as we await the full implementation of electronic health records; and

X Pressure on surgical beds by other non-surgical admissions.

It is important to note that ‘more surgeries’ means more surgical patients, which often means a need for more diagnostic procedures, more recovery beds, more rehabilitation and home care capacity. As with so many aspects of health care, increasing volumes in one area necessitates increasing capacity in many other areas. Otherwise, the ‘ramping up’ of surgical volumes only creates logjams elsewhere.

Addressing the surgical backlog in isolation is not a solution that can be sustained in the future. Nor is “doing more” the only answer. We must also look for ways to deliver surgical care more effectively and efficiently, without compromising quality or safety. When processes are streamlined and standardized, and providers have the support and resources they need to do their jobs well, the health system’s capacity will improve as a matter of course.

With these considerations in mind, a number of changes and initiatives are under way to improve access to surgical care. We will measure our success by the percentage of elective-surgery patients who receive their surgeries within three months and by our ability to meet target timeframes along the surgical care continuum. Emergent and urgent cases, such as cancer surgery, will continue to receive the highest priority. Improvement strategies will benefit access to care regardless of whether a person requires elective, emergent or urgent surgical care.

1. TO INCREASE CAPACITY FOR SURGICAL CARE, WE ARE:

Increasing surgical volumes

An additional 3,000 surgeries will be performed in Saskatchewan in the 2010-11 fiscal year while changes are implemented to help the system perform more effectively and efficiently. In all, the health care system will need to increase its present surgical volume by just over eight per cent over the next four years in order to eliminate the surgical backlog and achieve the three-month wait time target. Increases in diagnostic and laboratory capacity will need to coincide with increases in surgical volumes if any lasting progress is to be made on wait lists.

Options for increasing capacity in hospitals will include: moving some procedures that can be safely performed in a clinic setting out of ORs, increasing volumes through more effective scheduling and management of recovery and OR beds, making better use of surgical capacity in regional hospitals, and expanding scheduled surgical hours. Targeted funding from the provincial government will address the costs associated with increased surgical volumes.

Provincial funding in 2010-11 will support:

X 3,000 additional surgeries

X 2,500 more CT scans

X Renovations to enhance OR and post-operative bed capacity

X Implementation of an electronic Surgical Information System in two regions

X Numerous system improvement initiatives identified in this plan

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Transformation #1: Shorter Waits for Surgical Care

Introducing third-party delivery of out-patient surgery and MRI/CT scans

To help Saskatchewan residents get their surgeries sooner, third-party health facilities will be permitted to provide out-patient surgery and specialized diagnostic imaging within the publicly funded and administered system, beginning in 2010-11. Third-party facilities will operate within the single-payer Medicare system and will treat patients from the public wait list so there is no opportunity for queue jumping. Our policy states that third party delivery must be financially responsible, and that the cost of services must be equal to or less than the cost of publicly-delivered services. Third-party facilities will also be required to meet all safety and quality standards. These facilities will be authorized to provide limited services under contract with a Regional Health Authority and will be issued a licence under The Health Facilities Licensing Act.

2. TO IMPROVE PATIENT FLOW AND SYSTEM EFFICIENCY, WE ARE:

Establishing and expanding safe, streamlined, patient care pathways for surgical care

Streamlined patient surgical care pathways help to ensure that the right care providers become involved at the right time, and that providers, patients and families are continually engaged in a clear understanding of all steps throughout the pathway. Surgical care pathways are applied consistently to all patients preparing for a particular procedure, and help patients from their initial consultation with a family physician through to their post-surgical recovery and rehabilitation at home. This approach also contributes to a healthier work environment for providers; by knowing their respective roles and consistently practicing quality care, they are enabled to work as an effective, productive, caring team.

A standardized patient pathway for hip and knee surgeries has already been introduced in several health regions. It has resulted in immediate improvements in the patient experience and increased the numbers of completed hip and knee replacements. Surgical care pathways are now being developed for spinal and prostate surgeries, with the development of gynaecological pathways to follow.

Identifying and eliminating inefficient processes

Every surgical care journey involves many steps, and some parts of the process add more value for patients than others. By applying LEAN and other quality improvement approaches that many organizations have used to increase their effectiveness, Saskatchewan’s surgical care system will see more effective use of resources and time, and will be able to provide better care to more patients. This will be achieved by engaging frontline providers and health care leadership in developing a culture of continuous improvement.

Several hospital wards in Saskatchewan have already implemented a program known as Releasing Time to Care, which finds activities or processes that hinder nurses and other providers from spending time with patients. For example, nursing time on one unit at the Regina General Hospital has been freed up so that nurses are spending about twice as much time in direct patient care. The goal is to have all medical and surgical wards implementing Releasing Time to Care by 2012.

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When 64 year old Robert needed surgery to replace his ailing right knee, he was apprehensive about the number of trips he would need to make to Regina for his various pre-operative assessments and information sessions. He was pleased and surprised to learn that many of those appointments would be done in one day, under the same roof.

When Robert and his wife Linda arrived at the multidisciplinary clinic in Regina, the assessment team agreed that a joint replacement was likely Robert’s best option. A nurse practitioner and physiotherapist reviewed the next steps with Robert and Linda, taking care to ensure they both understood what was ahead and how best to prepare for the procedure. Before their time at the clinic ended, Robert had received coaching on some exercises and diet changes that would help his chances for a positive surgical outcome.

After a full day of information and discussion, Robert and Linda were both tired, but they agreed that having to make five or six trips into the city would have left them a great deal more tired.

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Transformation #1: Shorter Waits for Surgical Care

Supporting physicians in redesigning their practices

A number of physicians in the province are implementing significant changes to their practices in order to be able to see more patients, reducing the time people wait for a consultation. The ‘advanced access’ model is already being implemented with positive results by a urology practice in Saskatoon, an otolaryngology (ear-nose-throat) practice in Regina, a general practice physician in Moose Jaw, and the Sleep Disorders Centre at Regina General Hospital. The goal is to introduce the advanced access model to more physician practices across the province over the next four years.

Improving how operating room time is allocated

Our present system, for the most part, assigns OR times based on a complicated formula that considers the length of a surgeon’s waiting list. A group of surgeons and health system leaders are working together to develop recommendations for operating room allocation and scheduling with the goal of reducing wait times in general. A patient- and family-centred health care system requires a balanced approach that ensures that wait lists are coming down while allocating fair proportions of OR time to surgeons.

Expanding the Surgical Information System

The Surgical Information System (SIS) is a new computerized system that is being integrated with the province’s Surgical Registry. The new system will collect even more information about surgical bookings, wait lists, OR usage, equipment and supplies, available staff, and other facets of surgical care. This new system will help health regions ensure that all of these components are available for the scheduled surgery so valuable OR time is not lost. By expanding the SIS to all surgical care locations, the health system will gain a provincial view of the entire surgical system, enabling better use of the province’s surgical capacity.

The Prince Albert Parkland Health Region was the first in the province to implement the Surgical Information System. Cypress and Prairie North Health Regions will be added in 2010-11, with other regions to follow.

3. TO MAKE THE BEST USE OF OUR SURGICAL CARE RESOURCES, WE ARE:

Establishing pooled referrals

The primary purpose of adopting a pooled referral system is to reduce patient wait times. With the traditional referral process, patients are referred to a specific surgeon. A pooled referral system assigns the patient to the next available qualified surgeon within a practice or specialty. Pooled referral systems offer patients multiple access points to receiving care from a qualified specialist, thereby reducing the time a patient may wait to receive treatment. Patients can still ask to see a particular surgeon, knowing they may wait longer, depending on that surgeon’s wait list.

Some surgical practices in Saskatchewan are using the pooled referral system. Work is currently underway to support more practices in adopting this patient- and family-centred model of care.

Quality Improvement Initiatives

X By streamlining endoscopy processes (a procedure that looks inside the body using an instrument), the Five Hills Health Region has achieved efficiencies which will create an extra half-day capacity resulting in 470 additional scope procedures being performed each year.

X An emergency department in the Saskatoon Health Region has achieved a 28 per cent reduction in the time it takes for an emergency patient awaiting a bed to be moved to a medical unit.

X By making it easier to move between the intravenous and medication rooms, surgical ward nurses at the Victoria Hospital in Prince Albert have freed up an estimated 270 hours per year for direct patient care.

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Transformation #2: A Better Patient Experience

Making more appropriate use of acute care beds

Currently, individuals waiting for placement in long-term care will often remain in a hospital until a space becomes available for them. Individuals needing long-term care are more appropriately placed in a facility designed to deliver such care. Keeping these individuals in acute care beds can also create a shortage of beds for those requiring acute care, including surgical patients. A surgeon and OR team may be ready to do a procedure, the operating room may be available, but if there is no bed in which the patient can recover, the surgery will need to be rescheduled.

The province’s long-term care needs are currently being reviewed so that the system can work toward appropriate bed levels. In the meantime, health regions are adding or increasing options for patients who are compromised to the point that they can not be managed easily at home, but whose severity of illness does not require the use of an acute care bed.

MEASURING PROGRESS

We will evaluate our progress in timely access by measuring:

X Number of patients waiting for surgery more than 3 months and 12 months

X Number of surgeries performed annually

X Wait times for MRIs and CT scans

X Extent to which clinical pathways have been implemented for hip and knee, prostate, spine, and gynaecological surgeries

X Number of physicians participating in clinical practice redesign

X Number of specialist groups using pooled referrals

X Number of acute care beds occupied by patients awaiting long-term care placement

X Wait times from family physician referral to office-appointment with a surgeon [once the methodology has been developed]

Transformation #2: A Better Experience for Patients and Families“Good decisions are made when the patient is informed and understands the implications of a choice, there is evidence supporting the choice, and the patient’s values and preferences have been respected.”

Patient First Review Report to the Minister of Health

While the health system has tended to focus exclusively on clinical outcomes, the patient experience is an important part of quality care. Patients and families come away from their care journeys with vivid memories of how they were treated and whether or not they felt respected and cared for.

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Pooled Referrals

Robert is referred to a “pool” of orthopaedic surgeons with experience in doing knee replacements; his procedure will be performed by the specialist with the next available opening. Robert is also given the option of choosing a specific surgeon, with an understanding that this will likely mean a longer wait.

He opts for the pooled referral and his procedure is scheduled for a date that doesn’t conflict with an upcoming trip to Phoenix or his grandson’s soccer tournament.

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Transformation #2: A Better Patient Experience

In fact, better outcomes result when patients and families are treated as partners in the process, fully informed and consulted at every step.

How will the system begin to evaluate its success in providing patient-centred care? It will start by asking the patients how we’re doing. Standardized surveys will ask patients how strongly they agree with the following statement: “I get exactly the care I want and need, exactly when I want and need it.”

1. TO IMPROVE ACCESS TO INFORMATION FOR PATIENTS AND FAMILIES, WE ARE:

Introducing a patient referral guide website for surgery

Family physicians in Saskatchewan can currently go online to access a directory of Saskatchewan surgeons with information about their surgical practices to help the referring physician select the most appropriate specialist. Information available on the website includes: type of procedures performed and not performed, wait times for consultation with a surgeon and wait times to receive treatment. By making this information available to patients as well, the patient and physician can share in the decision-making about the referral. For some patients, it will be most important to be seen as soon as possible; they may even decide to consult with a surgeon in another health region in order to be seen sooner. Others may choose to wait longer for the particular surgeon with whom they wish to consult.

The greater the number of surgeons who will provide their wait-time information, the more comprehensive and helpful this website will be for patients and their physicians.

The patient referral guide website will be adapted for public use and fully accessible to the public this spring.

Supporting patients and providers with tools for shared decision-making

Most care providers would agree that well-informed patients, acting as full partners in their care, will have a better care experience and, often, better outcomes. Sometimes, however, the partnership between patient and provider is hindered by a number of dynamics, ranging from their own assumptions and attitudes to the pressure of very busy schedules. Both parties could benefit from practical tools that enable them to communicate effectively and engage in mutually respectful and productive dialogue.

With assistance from the University of Ottawa, representatives from health regions, the Health Quality Council, the Ministry of Health, former patients and the health research community is developing a practical model of ‘shared decision-making’ that can be applied by clinicians while working with their patients. This framework will first be implemented in four targeted surgical areas, including hip and knee replacement, spine, and prostate surgery.

Shared decision-making

By the time Robert sat down with his family doctor to discuss his deteriorating knee, he had already assumed he was bound for surgery. He was surprised, then, to discover his doctor was assuming no such thing. Instead, she asked Robert a series of questions about the extent of his discomfort, its impact on his mobility, and the physical activities that were most important to him. The two of them discussed the relative risks and benefits of the surgical option. As Robert talked, he grew more relaxed and shared some of his misgivings about undergoing a knee replacement. His doctor then went online and walked him through a “medical map” that outlined the steps that would be involved.

Although both Robert and his doctor eventually agreed that he should consult with an orthopaedic surgeon, Robert already felt better about the idea; he felt that he’d made an informed choice, and that no one else was making his decisions for him.

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Transformation #2: A Better Patient Experience

2. TO PROVIDE PATIENT- AND FAMILY-CENTRED CARE, WE ARE:

Developing a provincial patient- and family-centred model of health care

While many health regions currently emphasize patient- and family-centredness in their services, this philosophy is not formally embedded in the missions of health care delivery organizations, or in the standards to which health care planners, managers and care providers are accountable. As such, it is an ideal that may or may not be followed.

The Ministry of Health is working with its partners in the health system to develop a framework for patient- and family-centred care that will set the stage for the redefinition of the care relationship. This approach will recognize patients and families as valued partners in health care planning, delivery and evaluation. Employers will be able to set expectations for their employees, and patients will know what they can expect and ask of the people in the system.

Developing standardized patient surveys

No matter where they live or where they receive services, patients should benefit from the same high standards of care. To encourage a system-wide adoption of patient- and family-centred principles, a standard province-wide patient survey is being developed to promote the system in working towards a common goal.

The Health Quality Council (HQC) has been instrumental in working with 33 hospitals across 10 health regions to collect monthly survey feedback from patients. The HQC is currently working with regional health authorities to survey individuals about their experience in Emergency Departments. A public report on the findings will be published in 2010-11.

MEASURING PROGRESS

We will evaluate our progress in improving the surgical patient’s experience by measuring:

X Extent to which shared decision-making has been implemented in surgery and diagnostics

X Impact of shared decision-making on demand for surgery

X The number of times the public have accessed the patient surgical referral guide website

X Patient experience as reflected in standardized exit surveys

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Improving Patient Satisfaction

By using patient experience information, a team at the Royal University Hospital participated in a HQC-sponsored improvement project focused on improving discharge planning.

By implementing a series of small-scale changes related to patient flow and communication, the team saw percentage of patients rating the discharge process as very good or excellent increase from a median value of 42.5% at baseline to 80% by September 2007.

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Transformation #3: Safe, High-Quality Surgical Care

Transformation #3: Safe, High-Quality Surgical Care“Continuous improvement in quality and safety is integral to a progressive workplace culture and is what patients expect from those who deliver health care.”

Patient First Review Report to the Minister of Health

A patient-first health system will be an exceptionally safe, high-quality health system. Surgical care like many types of medical care involves a level of risk, and that risk varies widely, depending on the nature of the procedure and the health issue that has necessitated it. However, the risks are usually very low, and can be further minimized by following consistent practices that have been proven to increase the safety of a course of treatment.

By standardizing best practices across the province, we will go a long way to ensuring that Saskatchewan patients are receiving safe, high-quality surgical care.

We can measure our effectiveness and improvement in this area by measuring adherence to best standards of care, as well as monitoring and evaluating the rate of adverse events associated with surgical care in Saskatchewan.

1. TO PROVIDE SAFER, HIGH-QUALITY CARE, WE ARE:

Implementing surgical safety checklists in operating rooms

It is simple yet proven: when safety protocols are put in writing and systematically checked, safety outcomes improve. This principle applies whether you are talking about the air transportation industry, for example, or health care. Standardized safety checklists are currently being implemented in operating rooms around the province. These checklists, based on those developed by the World Health Organization (WHO), cover procedures and practices beginning before the patient enters the operating room, and continuing until the patient has exited.

Working to reduce preventable surgical site infections

Saskatchewan has joined Safer Healthcare Now!, a national campaign that assists organizations in reducing the number of injuries and deaths related to adverse events such as medication incidents and infections.

Surgical site infections (SSI) can increase the amount of time a patient remains in hospital, and therefore increases health care costs. SSIs can often be prevented through appropriate pre- and post-operative interventions. Health regions and hospitals will work towards implementing and monitoring the use of protocols to reduce the frequency of surgical site infections.

Implementing a medication reconciliation program

Adverse drug events and potential harm can occur when patients are transferred from one health care setting to another without a comprehensive medication review being completed. To prevent medication errors at patient transfer points, a formal medication

Improving Safety

Refer to the WHO website for further information about patient

safety checklists:

www.who.int/patientsafety/safesurgery/en

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Transformation #3: Safe, High-Quality Surgical Care

reconciliation program will be implemented in Saskatchewan that is in compliance with Accreditation Canada standards and consistent with Safer Healthcare Now! As this program is implemented across the province, patients admitted to a health facility or seen and treated in the Emergency Department will have a “Best Possible Medication History” taken using the Saskatchewan Pharmaceutical Information Program (PIP) form upon entry to a health care facility. The PIP currently provides authorized health care professionals (e.g. pharmacists and physicians) with confidential access to patient medication records for medications that are filled in retail pharmacies.

Learning from critical incidents to improve patient safety

It is mandatory in Saskatchewan to report critical incidents that occur in the health care system. The information provided through these reports is valuable for gaining insight into current practices and improving patient safety.

The analysis of critical incidents and the province-wide distribution of learnings reduces the risk of reoccurrence of similar incidents. The province will be undertaking a comprehensive review of legislation and regulations for reporting, the processes for follow-up, and communication about critical incidents. This review will inform future actions directed towards improving the quality and safety of patient care in Saskatchewan.

2. TO SUPPORT SAFE PATIENT CARE, WE ARE:

Building electronic medical and health records

Eliminating information gaps is central to improving safety. For example, when a patient arrives unconscious in an emergency department, information about that patient is a valuable asset to the health care team. The Electronic Health Record (EHR) is a provincial initiative that will provide a centralized source of information about a patient’s lab tests, radiology results, drug information, and other important health information.

The EHR will reduce medication errors, improve flow of communication across care settings, and give clinicians and patients the right information when and where they need it. Other benefits include: more time spent on direct patient care, increased accuracy of care, avoidance of unnecessary complications, increased compliance with evidence-based best practices and increased capacity to see more patients.

Additionally, the Saskatchewan Medical Association, in partnership with the Ministry of Health, is leading the implementation of Electronic Medical Records (EMR). The EMR is a software used in physician clinics. EMRs automate a clinic’s office functions and replace paper-based health charts with an electronic system that stores office visit and other health-related information. EMRs have the capacity to download patient information from the EHR.

The goal of an EHR combined with an EMR is to have the right information in the right hands at the right time to make timely effective health decisions.

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The surgical journey continues at home...

Linda comes to pick up Robert from the hospital at the appointed day and time, and they drive home. The next day, the couple receives a telephone call from a home care nurse and physical therapist, to find out how Robert is doing. At every key stage throughout Robert’s care journey, clinical information had been entered into his electronic health record (EHR).

Once entered, that information was immediately available to Robert’s primary care team in his home town, so they could follow up with his continued recovery and rehabilitation. Robert’s first physiotherapy appointment is scheduled for one week after his surgery.

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Foundation #1: Supporting Good Health

MEASURING PROGRESS

We will evaluate our progress in improving the quality and safety of surgical care by measuring:

X Extent to which surgical safety checklists have become standard procedure in Saskatchewan operating rooms

X Implementation across the province of surgical site infection prevention protocols

X Extent to which a formal medication reconciliation program has been implemented

X Number of physicians using electronic medical records

Foundation #1: Supporting Good Health“One of the most powerful ways to build a sustainable, patient- and family-centred health system is to help Saskatchewan people avoid becoming patients in the first place.”

Patient First Review Report to the Minister of Health

While some illnesses and injuries occur due to factors beyond our control, many are preventable through effective maintenance of health and through safe practices at work, home, or play.

There are many factors that play an important role in determining the overall health of Saskatchewan residents and, by extension, the ongoing demand on the province’s surgical-care resources.

By working toward community and home environments that help Saskatchewan people maintain and protect their own health and safety, we are also managing the demand for surgical services, which is likely to escalate with the aging of our population.

TO REDUCE THE NEED FOR SURGERY ARISING FROM CHRONIC DISEASE AND INJURY, WE ARE:

Working to reduce falls and fall-related injuries

In Saskatchewan, 3,000 hospitalizations every year are a result of a senior’s fall, many of which occur in long-term care facilities. Forty per cent of those are hip fractures. On average, older adults who are hospitalized due to a fall spend forty to fifty per cent longer in hospital.

Guided by Safe Saskatchewan’s Seniors’ Fall Injury Prevention Strategy (SFIPS) and the Safer Healthcare Now! campaign, health system partners are identifying ways to reduce the risks of falls for seniors. By creating safer environments and helping older adults reduce their own risks, we can help seniors retain their mobility and avoid the debilitating injuries that often lead to surgery.

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Foundation #2: Patient-Centred Providers

Working to improve children’s oral health in populations at risk

Dental disease is mostly preventable. Many pre-school children in Saskatchewan, however, suffer with diseased and abscessed teeth, due in part to poor nutritional habits. In many cases, this leads to a need for surgery. By providing education to family members and others on healthy nutritional habits for children at risk starting at birth, we can help more of these children avoid the need for surgical intervention. Educational tools for front-line providers, healthy dental programming in early childhood programs, and expansion of oral health awareness activities within organizations that deliver programming to at-risk populations are examples of a few of the initiatives that will help to improve children’s oral health.

Encouraging reduced tobacco use

Tobacco use is considered the single most preventable cause of disease, disability and death, yet Saskatchewan continues to have high rates of tobacco use, especially among young people. The Ministry of Health continues to engage community partners in a comprehensive, coordinated approach to preventing and reducing tobacco use among Saskatchewan youth and supporting those who want to quit smoking. This will make it easier for people to make healthy choices.

Supporting Saskatchewan residents in achieving healthy body weight

People often become overweight because of the everyday environments in which they live. Multifaceted approaches to addressing body weight are the most beneficial. The Ministry of Health will work with its community partners to make it easier for Saskatchewan residents, no matter what their weight, to make healthier choices by developing a comprehensive health promotion framework.

MEASURING PROGRESS

We will evaluate our progress in supporting good health by measuring:

X Rates of falls and fall-related injuries in long-term care facilities

X Percentage of young people in Saskatchewan who smoke

X Progress on a comprehensive health promotion framework developed by the Ministry of Health with its community partners

Foundation #2: Patient- and Family-centred Providers“While the vast majority of health care providers want to deliver patient- and family-centred care, they are too often constrained, discouraged or disabled by a system that encourages them, implicitly and explicitly, to put other interests ahead of patient interests.”

Patient First Review Report to the Minister of Health

A patient- and family-centred health system makes for a profoundly rewarding work environment for health professionals, as they are encouraged and enabled to use their education and competencies to their fullest to care for patients.

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Foundation #2: Patient-Centred Providers

In a patient-first health system, care providers experience the satisfaction and growth that comes with being part of a team focused on a common goal. Providers are supported in their efforts to deliver excellent care and are given opportunities to work within their full scope of practice. This means a more effective and efficient distribution of responsibilities and workload among health care staff. With input from the front line, the patient-first system streamlines processes so that care providers have more time to provide care.

A patient- and family-centred health system will also attract patient- and family-centred providers who, in turn, will contribute their ideas and enthusiasm for patient-first care.

In addition, effective workforce planning will be critical to the success of the Saskatchewan Surgical Initiative. Surgical capacity to provide patient- and family-centred care is greatly influenced by the availability of specialists, operating room nurses, anaesthesiologists, and other disciplines.

The Ministry of Health is engaged with its partners in the health system on a number of recruitment and retention initiatives, including development of a provincial physician recruitment agency to enhance and coordinate recruitment efforts across the province.

In partnership with health care employers, the Ministry is studying and measuring the factors that contribute to a satisfied workforce so that Saskatchewan can become an increasingly attractive place in which to build a health care career.

TO ENSURE AN ADEQUATE SUPPLY OF SERVICE PROVIDERS WITHIN SASKATCHEWAN’S HEALTH SYSTEM, WE ARE:

Developing a 10-year Health Human Resource Plan

Building on the findings of the Patient First Review, this plan will lay out an approach to ensuring Saskatchewan has the required health professionals to support a patient- and family-centred health system for the next decade and beyond. The plan will be completed and released in the fall of 2010-11.

Stabilizing and strengthening Saskatchewan’s nursing workforce

The Ministry of Health created the Provincial Nursing Council to provide the direction on strategies to sustain and strengthen the provincial nursing workforce. The council has representation from unions, education, professional associations, regional health authorities, government and the Saskatchewan Cancer Agency.

In February 2008, the Government of Saskatchewan and the Saskatchewan Union of Nurses (SUN) launched a formal partnership with the aim of filling 600 nursing vacancies and hiring 200 additional registered nurses over three years.

Working to increase the number of physicians in Saskatchewan

Saskatchewan’s physician recruitment strategy, released in May 2009, aims to reduce the number of physicians leaving the province, increase the number of Saskatchewan medical graduates who establish practices in the province, and provide training in rural and regional centres for more Saskatchewan medical students and residents.

Strengthening Saskatchewan’s workforce

By the end of 2009, health regions were employing more than 600 more nursing full-time-equivalent positions than they were in 2007/08.

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Conclusion: The Fourth ‘S’

MEASURING PROGRESS

We will evaluate our progress in ensuring a stable and adequate supply of health care providers by measuring:

X Achievement of the targets contained in the government’s partnership with the Saskatchewan Union of Nurses (SUN)

X Progress on completion and implementation of the 10-Year Human Resource Plan

X Annual turnover of Saskatchewan physicians

X Retention of medical graduates from the University of Saskatchewan

Conclusion: The Fourth ‘S’ The title of this document – ‘Sooner, Safer, Smarter’ – is an attempt to express in the simplest of terms what we want to achieve as we transform the surgical care experience for patients. We want to reduce the amount of time Saskatchewan people wait for surgery. We want to do everything possible to ensure patients are safe while receiving care. We want to work together more effectively and efficiently, making the best use of our resources and the skills and training of providers. Sooner, safer, smarter.

There is a fourth ‘S’, however, that is present in nearly every page of this plan and is crucial to any lasting success in building a patient- and family-centred health system. As we work together to transform the surgical patient experience, we must also work toward sustainability – the capacity of the health system to meet the ever-evolving needs of Saskatchewan people, today and well into the future.

One of the characteristics of a sustainable health system is unity of purpose and alignment of priorities. If everyone is working to put patients and families first, that common vision helps to inform even the most difficult choices about service delivery and resource allocation. With everyone pulling in the same direction, there is much less waste of energy. This has been seen with the Saskatchewan Surgical Initiative, where the differing perspectives and interests of providers, administrators, and patients, and others are coming together in an exciting synthesis.

Most of the initiatives contained in this plan will contribute in some way to the sustainability of surgical services in Saskatchewan. By eliminating the current backlog of patients waiting for their procedures, we prepare ourselves for an anticipated increase in surgical demand associated with our aging population. By establishing consistent clinical pathways, we help patients and families move through the system more smoothly and efficiently, creating a better experience for them while also increasing the system’s capacity. By working toward environments that support healthy and safe choices, we begin to see fewer people on the operating table with injuries or illnesses that could have been prevented.

Further work will be completed on establishing benchmarks and evaluating progress. This will be publicly reported, beginning in 2010-11.

The Saskatchewan Surgical Initiative represents an exciting first step toward a truly patient- and family-centred system of health services. Its success will depend on the energy, innovations and commitment of the thousands of health care professionals and providers, leaders and managers, patients and families who affect or are affected by the surgical care experience.

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Appendix A: Putting it All Together

Health Promotion +

Disease PreventionPrimary Care Diagnostics

LaboratoryReferral toSpecialist

DiagnosticsLaboratory

Pre-surgery/Pre-admission

clinic

Increase surgical volumes (with corresponding diagnostics, laboratory, therapies, home care)

Third-party delivery of out-patient surgery and MRI/CT scans

Establish and expand patient care pathways for surgical care • hip and knee pathway • prostate pathway • spine pathway • gynaecology pathway

Identify and eliminate inefficient processes • Releasing Time to Care • Lean and other quality improvement projects

• Support physicians to redesign their practices • Advanced Access

Introduce a patient referral guide website for surgery

Expand the Surgical Information System

Establish pooled referrals for surgery

Support patients and providers with tools for shared decision-making

Develop a Patient- and family-centred model of health care

Develop standardized patient surveys

Learn from critical incidents to improve patient safety

Implement a medical reconciliation program

Build electronic medical and health records

Develop a 10-year health human resource plan Stabilize and strengthen the nursing workforce/Increase the number of physicians

Saskatchewan Surgical Initiative Provincial Initiatives Along the Surgical Value Stream

Improve children’s oral health in populations at risk

Reduce falls and fall-related injuries

Reduce tobacco use

Support for healthy body weight

Shorter Waits for Surgical Care

Better Experience for Patients

Safe, High-Quality Surgical Care

Supporting Good Health

Patient- and Family-Centred Providers

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Appendix A: Putting it All Together

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DiagnosticsLaboratory

Pre-surgery/Pre-admission

clinicSurgery Post-Op

Recovery/Ward Therapies

Increase surgical volumes (with corresponding diagnostics, laboratory, therapies, home care)

Third-party delivery of out-patient surgery and MRI/CT scans

Establish and expand patient care pathways for surgical care • hip and knee pathway • prostate pathway • spine pathway • gynaecology pathway

Identify and eliminate inefficient processes • Releasing Time to Care • Lean and other quality improvement projects

Improve operating room time allocation

Make more appropriate use of acute care beds/Appropriate placement of long-term care patients

Expand the Surgical Information System

Establish pooled referrals for surgery

Support patients and providers with tools for shared decision-making

Develop a Patient- and family-centred model of health care

Develop standardized patient surveys

Implement surgical safety checklist in operating rooms

Learn from critical incidents to improve patient safety

Reduce preventable surgical site infections

Implement a medical reconciliation program

Build electronic medical and health records

Reduce falls and fall-related injuries

Develop a 10-year health human resource plan Stabilize and strengthen the nursing workforce/Increase the number of physicians

Home Rehabilitation/Home care/

Residential care

Saskatchewan Surgical Initiative Provincial Initiatives Along the Surgical Value Stream

For more information, contact: Saskatchewan Ministry of Health T.C. Douglas Building 3475 Albert Street Regina, Saskatchewan S4S 6X6 General Inquiries: (306) 787-0146 Toll-free: 1-800-667-7766 (Saskatchewan only) E-mail: info@health.gov.sk.ca www.health.gov.sk.ca/saskatchewan-surgical-initiative