Invitational Workshop on Access to Care Research Syntheses - Summary Report

January 15, 2008
Toronto, Ontario

Hosted by:

CIHR Institute of Health Services and Policy Research,
The Conference of Provincial and Territorial Deputy Ministers of Health, and
Health Canada

In collaboration with:

CIHR Knowledge Synthesis and Exchange Branch,
CIHR Institute of Aboriginal Peoples' Health, and
CIHR Institute of Population and Public Health

Table of Contents

To request a copy of the full report, please contact Meghan McMahon at meg@ihspr.utoronto.ca or 416-978-5172.

Key Messages

The Workshop

  • The Invitational Workshop on Access to Care Research Syntheses built upon a novel and longstanding partnership between CIHR, the Conference of Provincial and Territorial Deputy Ministers of Health and Health Canada to improve timely access to quality healthcare.
  • The workshop brought together 15 researchers and 18 decision makers from across the country, as well as six partners, to support and facilitate the sharing and use of information generated through research syntheses (funded between 2004-2007) in the area of access to care.
  • Presentations centred on four sub-themes within access to care: wait times; patient flow and care trajectory; organization, management and delivery of healthcare services; and improving access to care for vulnerable and underserved populations. Break-out and plenary discussions centred on the four themes as well as issues that were not central to the synthesis presentations but that were determined important by decision makers (e.g., facilitators and barriers to change).

A Success Story

  • The Alberta Bone and Joint Health Institute's (ABJHI) nationally-renowned hip and knee replacement pilot project demonstrates the important role that research evidence can play in reducing wait times and improving both patient and provider satisfaction. The ABJHI developed an evidence-based hip and knee replacement care model that: generated a decline of 80% in consultation waiting time and 90% in surgery waiting time; reduced length of hospital stay by 30%; enhanced patient accountability and education; and did not increase costs. Based on these results, the model is currently being implemented as the standard of care in other regions of the province.

Partnerships to Bridge the Research-to-Policy Gap

  • Decision maker participants agreed that research can play an important role in the decision-making process, but commented that the timing of research is critical (e.g., the research timeframe often exceeds the decision-making timeframe). They expressed interest in being involved in research, and noted that being involved from the early stages can increase the relevance and usefulness of the research. Researchers commented that researcher-decision maker partnerships can be challenging due to frequent decision maker turnover. CIHR's Partnerships for Health System Improvement (PHSI) program was highlighted as a valuable tool for supporting a partnered and applied approach to high-quality health services and policy research that responds to decision maker priorities. CIHR's Knowledge Synthesis and Exchange Branch offers a variety of funding opportunities and tools to support collaborative and action-oriented research.
  • Decision maker participants noted that federal and provincial governments value research and consider it critically important to their work. They also highlighted the important role for CIHR to (continue to) play in building a policy-relevant evidence base in access to care and facilitating the translation of this evidence to policy makers.

Discussion Highlights

  • Participants identified the importance of knowledge translation (KT) initiatives to promote and foster discussion of research findings, best practices and potential policy implications between and among researchers and decision makers. CIHR should continue to encourage and support KT initiatives and should continue to build meaningful partnerships at the national level to advance coordinated national research agendas.
  • CIHR's partnership with the Provincial/Territorial Ministries of Health in 2005 was highlighted as a successful initiative that contributed to the establishment of evidence-informed wait times benchmarks at the national level. Discussion centred on whether this partnership model could be adopted to address other challenges that span provincial boundaries and to foster collaboration across the country on key health system challenges.
  • Discussions centred on facilitators and barriers for improving access to quality care. Leadership, organizational culture, change management, and physician autonomy received significant attention. Participants recommended targeted research in these areas.
  • Participants agreed that in many cases we know what needs to happen to improve access to care but less is known about how change should occur (e.g., implementation strategies, change management, etc.).
  • An organization's culture was identified as a key factor that can enable or prohibit reform (e.g., a culture of conflict prohibits change). Changing organizational culture is challenging and requires collaboration at multiple levels. Effective change is more likely if it comes from the bottom-up and is supported top-down.
  • Effective leadership and physician engagement were recognized as key enablers for change. Physician autonomy was highlighted as a barrier to change.
  • Interdisciplinary research and collaboration across sectors were highlighted as important enablers for change (e.g., the health sector can learn from the successes of other sectors that have grappled with queue management).
  • Decision makers highlighted their need for timely health services research to frame, support and introduce key issues into the public domain (e.g., important issues that the public ought to be informed of but that are not often featured in the media) and to help inform public opinion
  • Participants felt strongly that increased efforts to profile and recognize the important role for health services and policy research in strengthening the healthcare system are warranted.
  • Participants recognized that the overall objective of health services research and health care decision-making is to improve care for the patient – (e.g., improve the health of Canadians).

Knowledge Exchange

  • The workshop provided an open forum for knowledge exchange and discussion among researchers and decision makers committed to improving timely access to quality healthcare. This type of workshop was praised as critical in efforts to increase linkages between researchers and decision makers as well as to increase awareness and use of research evidence in policy- and decision-making.

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Executive Summary

Background and Context

Canadians expect timely and co-ordinated access to high quality healthcare services and treatments. Canadians also expect that these services and treatments are based on the best and most current evidence available and that they will improve their health and quality of life. Although these expectations are well-founded, meeting them is a challenge for federal, provincial and territorial governments alike. For the most part, policy makers are aware of the problems and where there are gaps in the system. Now they need evidence-backed approaches and implementation strategies to improve access to and quality of appropriate care across the continuum.

A wealth of high quality and policy-relevant information on access to care exists; however, it can be difficult and time consuming for decision makers to wade through the research literature and assess the quality of the evidence. Accordingly, since 2004 the CIHR Institute of Health Services and Policy Research (IHSPR) has funded a series of research syntheses focused on access to healthcare. Many of these syntheses have been funded through a novel and long-standing partnership between CIHR-IHSPR and the Provincial/Territorial Ministries of Health and Health Canada. The objective is to build a high-quality, research-informed evidence base for decision makers to draw upon when making decisions designed to improve timely access to appropriate healthcare services.

Recognizing the importance of sharing the access to care synthesis knowledge with decision makers and providing an opportunity for linkage and exchange, a one-day invitational Access to Care Research Syntheses Workshop was held on January 15, 2008 in Toronto. The workshop, which brought together 15 access to care synthesis researchers and 18 decision makers from across the country, was sponsored through a partnership between CIHR-IHSPR, the Conference of Provincial and Territorial Deputy Ministers of Health and Health Canada and involved collaboration with CIHR's Knowledge Synthesis and Exchange Branch, Institute of Aboriginal Peoples' Health and Institute of Population and Public Health.

Workshop Objectives and Format

The workshop's primary objective was to create a forum for interaction, exchange and mutual learning between researchers and decision makers in the area of access to care in order to support and facilitate knowledge translation in this important area of research and policy. Additional objectives were to identify how synthesis research can help inform policy, to highlight areas where research is still needed, and foster the formation and development of partnerships between researchers and decision makers committed to working together to improve access to care in Canada.

The workshop had three main components: panel presentations, structured break-out sessions, and a plenary discussion. Panel presentations featured access to care research synthesis projects funded between 2004 and 2007 and were organized around four policy-relevant themes: Wait Times; Patient Flow and Care Trajectory; Organization, Management and Delivery of Health Care Services; and Improving Access to Care for Vulnerable and Underserved Populations. The presentations stimulated discussion and acted as the foundation for in-depth discussions during structured break-out sessions. These sessions provided an opportunity for decision makers to describe their respective policy contexts, related information needs and specific policy questions with the researchers. A concluding plenary group discussion provided workshop participants the opportunity for open dialogue. Dialogue centred on information gaps, facilitators and barriers for change, the importance of health services research in policy- and decision-making, and strategies to increase linkages between researchers and policy makers.

Discussion Highlights and Key Messages

The plenary discussion can be captured under five key themes: partnerships, challenges, opportunities for improvement, barriers and facilitators to change, and best practices.

  • Partnerships – Participants felt strongly that strengthening partnerships between researchers and decision makers is critical to increasing decision makers' awareness of existing research evidence and improving the likelihood that research evidence will contribute to evidence-informed decision making. Participants identified a key role for CIHR in creating (i) funding opportunities that encourage and support partnered, applied and policy-relevant research, and (ii) knowledge translation (KT) initiatives that facilitate and increase linkages between researchers and policy makers.
  • Challenges – Participants identified potential challenges to productive and meaningful researcher-decision maker partnerships including: inconsistent timeframes between research generation and decision-making (e.g., the research timeframe tends to exceed the decision-making timeframe); frequent turnover among decision makers (making the establishment of sustainable and long-term relationships challenging); a perceived over-supply of research that identifies and quantifies problems and under-supply of research that identifies solutions and implementation strategies; and lack of awareness about the abundance of research and best practices underway across the country.
  • Opportunities for Improvement – Discussions highlighted key opportunities for improvement, including: the timeliness of research; facilitating closer linkages between researchers and decision makers; increasing the promotion and recognition of the value of health services research; developing targeted communications and marketing the value of health services research to a wide range of stakeholders (including decision makers, the media and the public); creating more opportunities for KT and sharing best practices between researchers and decision makers; and assessing the potential value and impact of partnerships between CIHR and the Deputy Ministers around national issues (e.g., build on the success of the wait times initiative) .
  • Barriers and Facilitators to Change – Discussion centred on barriers and facilitators to change with regards to improving timely access to quality care. Leadership (at the physician and organizational level), organizational culture (e.g., a culture that encourages and supports change), change management, and structural reforms such as capitation were identified as potential facilitators. Physician autonomy, organizational culture (e.g., a culture of conflict prohibits change), and inadequate health information systems were flagged as potential barriers. Participants suggested further research in these areas may be warranted.
  • Best Practices – The discussion highlighted three best practices: (i) the CIHR-Provincial/Territorial Ministries of Health partnership that contributed to the establishment of the first ever evidence-informed wait times benchmarks in Canada; (ii) Alberta's Hip and Knee Wait Times project, which generated a new evidence-based model of care that significantly reduced wait times, improved patient and provider satisfaction, and did not increase costs; and (iii) KT initiatives such as this workshop that bring researchers and decision makers together and that provide an opportunity to learn about and discuss research evidence and best practices.

Conclusion

CIHR-IHSPR has long recognized the importance of supporting research and KT that aims to improve Canadian's access to healthcare services. IHSPR, in partnership with the Provincial/Territorial Ministries of Health and Health Canada, has supported a series of access to care research syntheses designed to understand the existing body of knowledge and to learn from the experiences of jurisdictions in Canada and abroad. The 2008 Invitational Access to Care Syntheses Workshop showcased the results of the syntheses and provided an open forum for knowledge exchange and discussion among researchers and decision makers committed to improving timely access to quality and appropriate healthcare.

Synthesis findings and potential policy implications were translated to decision makers through the 14 presentations that were delivered by renowned CIHR-funded synthesis researchers. Linkage and exchange occurred throughout the workshop and was facilitated through roundtable break-out sessions and a plenary group discussion where participants discussed the findings, information gaps and critical areas in need of further attention and research. The workshop appears to have met its core objectives and participant evaluations revealed a high level of satisfaction with the workshop as a whole. 

Overall, the workshop reinforced the importance of policy-relevant access to care research that identifies best practices, practical solutions and implementation strategies for use by policy- and decision-makers. The workshop also reinforced the importance of research tools and KT initiatives that support collaborative research in this critical area.


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Appendix I - Workshop Agenda

"Invitational Workshop on Access to Care Research Syntheses"
Hosted by: Canadian Institutes of Health Research, Conference of Provincial & Territorial Deputy Ministers of Health and Health Canada		 Date: January 15, 2008
Time: 8:00am to 4:30pm
Location: Metropolitan Hotel, Toronto, Ontario
Room: Mandarin Ballroom ''B'' (lower level)
Agenda
Time Item Speaker
08:00 – 08:30 Breakfast Mandarin Ballroom ''A''
08:30 – 08:40 Welcome and Opening Remarks Colleen Flood
08:40 – 09:00 "A Wait Times Success Story": The Alberta Hip and Knee Project Cy Frank
09:00 – 09:05 Overview of the Day Brian Postl (facilitator)
09:05 – 09:55 Panel Presentations – Wait Times Researchers:
Pierre-Gerlier Forest, Boris Sobolev, Ross Davies and Blair O'Neill, Tom Noseworthy and Michael Carter, William Hodge, Greg Knoll
09:55 – 10:10 Discussion/Response Period – Wait Times Decision Makers (All)
10:10 – 10:25 Health Break  
10:25 – 10:55 Panel Presentations – Patient Flow and Care Trajectory Researchers:
Keith Willoughby, Boris Sobolev, Marcy Winget
10:55 – 11:10 Discussion/Response Period – Patient Flow and Care Trajectory Decision Makers (All)
11:10 – 11:45 Panel Presentations – Organization, Management and Delivery of Health Care Services and Improving Access to Care for Vulnerable and Underserved Populations Researchers:
Esther Suter, Sharon Straus, Jean-Louis Denis, Elizabeth McGibbon
11:45 – 12:00 Discussion/Response Period – Organization, Management and Delivery of Health Care Services and Improving Access to Care for Vulnerable and Underserved Populations Decision Makers (All)
12:00 – 13:00 Lunch Mandarin Ballroom ''A''
13:00 – 13:15 Overview and Instructions for Break-out Sessions Brian Postl
13:15 – 14:45 Break-out Sessions All
14:45 – 15:00 Health Break  
15:00 – 16:00 Plenary Group Discussion All (led by Brian Postl)
16:00 – 16:15 Closing Remarks Alan Hudson and Abby Hoffman
16:15 – 16:30 Workshop Evaluation Brian Postl / Workshop Organizers

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Appendix II - Research Syntheses Projects and Project Partners

Principal Investigator / Workshop Presenter Research Syntheses Projects: Project Names Funding Partners
Theme: Wait Times
Dr. Thomas Noseworthy &
Dr. Michael Carter
(Alberta and Ontario)		 Operations Research in Queue Management: Development of Scheduling Systems for Hip and Knee Replacement Surgery IHSPR; Conference of Provincial and Territorial (P/T) Deputy Ministers (DMs) of Health; Health Canada
Dr. Pierre-Gerlier Forest Organizational determinants of waiting time management for health services - A policy review and synthesis IHSPR; IPPH; KT
Prof. Boris Sobolev
(British Columbia)		 The utility of instruments for reporting waiting times for elective surgery and associated risks: A systematic review IHSPR; IPPH; KT
Prof. Boris Sobolev
(British Columbia)		 Mapping the delivery of cardiac surgical care in four BC hospitals and developing a taxonomy of peri-operative processes IHSPR; Conference of P/T DMs Health; Health Canada
Dr. William Hodge
(Ontario)		 An Investigation of the Relationship Between Cataract Surgery Wait Times and Rates of Surgery IHSPR; Conference of P/T DMs Health; Health Canada
Dr. Ross Davies &
Dr. Blair O'Neill (Ontario)		 A systematic review of waiting times for cardiac services and procedures IHSPR; ICR; ICRH;
Conference of P/T DMs Health
Dr. Greg Knoll
(Ontario)		 Research synthesis: evidence-based management of waiting lists for kidney transplantation IHSPR; Conference of P/T DMs Health; Health Canada
Theme: Patient Flow and Care Trajectory
Prof. Boris Sobolev
(British Columbia)		 Research synthesis of approaches to patient-flow simulation in surgical care IHSPR; Conference of P/T DMs Health; Health Canada
Dr. Marcy Winget
(Alberta)		 Database linkage to identify and quantify use of key health services from pre-diagnosis to treatment and time between services for colorectal cancer patients IHSPR; Conference of P/T DMs Health; Health Canada
Dr. Keith Willoughby
(Saskatchewan)		 Flow Matters: Using Operations Research to understand and improve the flow of medicine patients in the Saskatoon Health Region IHSPR; Conference of P/T DMs Health; Health Canada
Theme: Organization, Management and Delivery of Health Care Services
Dr. Esther Suter (Alberta) Health systems integration definitions, processes and impact - a research synthesis IHSPR; IPPH; IAPH; KT
Dr. Sharon Straus(Ontario) Mapping interventions for care co-ordination IHSPR; IPPH; IAPH; KT
Dr. Jean-Louis Denis (Quebec) In search of performance :Governance and accountability models and strategies for new organizational forms and innovative mandates in health care settings IHSPR; IPPH; IAPH; KT
Theme: Improving Access to Care for Vulnerable and Underserved Populations
Dr. Elizabeth McGibbon
(Nova Scotia)		 Inequities in access to health services for rural African Canadian and aboriginal populations in Canada: A scoping review IHSPR; IPPH; IAPH; KT

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Appendix III – List of Participants

Colleen Flood (co-host), CIHR – IHSPR
Abby Hoffman (co-host), Health Canada
Alan Hudson (co-host), Ontario Ministry of Health and Long-Term Care
Brian Postl (facilitator), Winnipeg Regional Health Authority

Partners:

CIHR – Christine Fitzgerald
CIHR-IHSPR: Dale McMurchy, Ellen Melis
CIHR-KSE – Leah Jurkovic
CIHR-IPPH – Fiona Webster
CIHR-IAPH – Cynthia Stirbys
Health Canada – Linda St-Amour, Monica Aziz (absent), Sheryl Harris (absent)
Conference of Provincial/Territorial Deputy Ministers of Health – Greg Hein (absent)

Researchers:

Michael Carter, University of Toronto
Ross Davies, Ottawa Heart Institute
Jean-Louis Denis, DASUM / Université de Montréal
Pierre-Gerlier Forest, Foundation Pierre Elliott Trudeau Foundation
Cy Frank, Alberta Bone and Joint Health Institute
William Hodge, University of Ottawa Eye Institute
Greg Knoll, The Ottawa Hospital
Elizabeth McGibbon, Saint Francis Xavier University
Tom Noseworthy, University of Calgary
Blair O'Neill, Dalhousie University and Capital Health
Boris Sobolev, University of British Columbia
Sharon Straus, Foothills Medical Centre
Esther Suter, Calgary Health Region
Keith Willoughby, Health Quality Council
Marcy Winget, Alberta Cancer Board

Decision Makers:

Sally Brown, Heart and Stroke Foundation of Canada
Michel Bureau, Ministère de la Santé et des Services sociaux du Québec
Jean Cox, Manitoba Health
Melissa Farrell, Ontario Ministry of Health and Long-Term Care
Don Ferguson, New Brunswick Department of Health and Wellness
Rebecca Harvey, British Columbia Ministry of Health
Monte Kehler, Nunavut Health and Social Services
Michele Lahey, Capital Health
Kathryn McDade, Health Canada
Gavin Brown, Health Canada
Alison Millar, British Columbia Ministry of Health
Rachelle O'Sullivan, Nova Scotia Department of Health
Janice Sanger, Newfoundland and Labrador Department of Health and Community Services
Julie Swettenham, Canadian Healthcare Association
Prudence Taylor, Alberta Health and Wellness

Project Management/Secretariat:

Krissy Davidge, CIHR – IHSPR
Meghan McMahon, CIHR – IHSPR
Michèle O'Rourke, CIHR – IHSPR
Linda St-Amour, Health Canada