ASSIGNMENT

22 Healthcare Quarterly Vol.17 No.4 2014

Abstract Eleven Health Care in Canada (HCIC) surveys, spanning 1998–2014, offer a comprehensive overview of the changing perceptions of physician, nurse, pharmacist, administrator and public stakeholders of the nation’s health status, its burden of illness and its quality and cost of care. Overall, there persists a universal sense of quality in our health system – despite evidence that national health status is declining, chronic illnesses are increasing, patients’ timely access to care and ability to afford care are diminishing and all these indicators are predicted to worsen over time. Among the public and health professionals, key priorities for improving future patient care are increasing profes- sional schools’ output and team-based care, along with enhanced use of national supply systems to reduce costs of care. Among HCIC survey partners, the overarching goal has been, and remains, the utilization of knowledge gained from the surveys to facilitate evidence-driven health policy and improved patient care and outcomes. Practical foci are the development of knowledge translation (KT) activities and assessment of their impact. This paper outlines current initi- atives to track reach of member and non-member audiences for HCIC information; to ascertain how they perceive and value the various KT messages, vehicles and metrics; and to potentially identify a hierarchy of efficacy for impact factors. The primary objective is to inform future HCIC survey design and reporting, especially identification of KT vehicles and venues that are most effective in terms of reach and impact in facilitating understanding of, and subsequent action around, the knowledge generated.

What We Thought – In the Beginning The genesis of the Health Care in Canada (HCIC) surveys arose from the perceptive vision of several individuals, in a variety of non-governmental, health-related organizations and businesses, that they needed more timely, and reliable, knowledge and feedback from key players to effectively inform decision- making within their various environments (Ahmed et al. 2009; Appendix A; Appendix B).

From the beginning, the concept of multiple, and diverse, but committed, partners conceiving, financing and managing the surveys was perceived to be uniquely valuable. Although participation has varied somewhat, the 2013–2014 survey members (see sidebar on pg. 23) are very representative of all partner organizations over the years. The concepts of reliably and simultaneously surveying contemporary opinions and perceptions of a broadly representative range of professional health stakeholders, including care providers, administrators and policy makers, as well as representative samples of the general public and patients, were also viewed as unique and valuable among the HCIC partners (Ahmed et al. 2009; Appendix A; Appendix B).

However, in the formative iterations of the HCIC partner- ship, the value of defining how the acquired knowledge was to be translated, and its impact measured, were not specifically addressed. A well-defined knowledge translation (KT) plan was lacking (Graham et al. 2006).

Stakeholder Surveys of Canadian Healthcare Performance: What Are They Telling Us? Who Should Be Listening? Who Should Be Acting, and How?

Joanna Nemis-White, Emily Torr, Amede Gogovor, Lucas Marshall, Sara Ahmed, John Aylen and Terrence Montague; for the Health Care in Canada Survey Members

SPECIAL REPORT

Healthcare Quarterly Vol.17 No.4 2014 23

What We Did – Updating Survey Questions and Tracking Trends Since the inception of the surveys, beginning in 1998, to the present, 2014, the HCIC partnership has represented a broad spectrum of professional, non-governmental, academic and health industry organizations dedicated to improving Canadian healthcare (Ahmed et al. 2009; Appendix A; Appendix B). And, all participating members over the years have contributed to updating the design, implementation, analysis and propagation of the knowledge gained from each survey (Ahmed et al. 2009; Appendix A; Appendix B).

Several key topics identified for interrogation among repre- sentative samples of the general public and physician, nursing, pharmacy and administrative health professional populations over the 11 iterations of the HCIC surveys have remained consistent, allowing for trending insights of major health- care issues to be developed (Ahmed et al. 2009; Appendix A; Appendix B). Sample sizes, however, have varied somewhat over the years, ranging from 1,000 to 2,000 of the general popula- tion and 100 to 200 for each of the four health professional groups (Ahmed et al. 2009; Appendix A; Appendix B).

Principal areas of continued interest have included health status of the public; prevalence of chronic illnesses; access to, and quality and funding of, care; and ideas for change and improvement (Ahmed et al. 2009; Appendix A; Appendix B). More recently, emergent issues such as team-based care, patient- centred care and the huge contribution of friends’ and family members’ provision of non-professional care to patients with chronic illnesses have been added to the surveys’ questions and results (Ahmed et al. 2009; Appendix A; Appendix B). The combination of maintaining key themes, while adding new questions over time, contributed both to the modernization and sustained relevance of the HCIC survey and its findings for HCIC partners and targeted audiences.

What We Found – Quality, Access, Chronic Disease and Patient-Centred Care Overall, there persists a universal sense of quality in our health system. Temporally however, things are changing in Canadian healthcare, as reflected in the evolving perceptions of the profes- sional and public stakeholders (Ahmed et al. 2009; Appendix A; Appendix B). For example, in the public’s view, the prevalence of poor, or fair, health status and the prevalence of chronic illnesses are increasing (Ahmed et al. 2009; Appendix A; Appendix B). And, over the past decade and a half, there has been an eightfold increase in the perception of unduly long wait times for access to care. Wait time is now rated as the most important healthcare issue in the country, displacing the previously top-rated concern of lack of government funding (Appendix B).

Issues of contemporary concern common to both public and professional stakeholders include difficulties in transition from hospital to home care and the high prevalence of non-adherence to prescribed medications. There is also high, and concordant, support among all stakeholders for enhanced patient-centred care, particularly as defined by timely access, caring delivery, partnerships between informed patients and providers and care that reflects current research and expert opinion (Ahmed et al. 2009). However, among these four care priorities, the emphasis on research and expert opinion was rated higher among profes- sional stakeholders, compared with the public responders. Eroding professional engagement due to challenging workload and workplace disorganization and stress were also highlighted by health professionals.

On an optimistic note, emerging issues strongly supported were team-based patient care, including increased use of non-physician professional care givers, as well as enhanced recognition of the value of non-professional family and friend caregivers and enhanced uptake of electronic health records (Appendix A; Appendix B). Increasing professional schools’ output to improve patient access to care and enhanced use of national supply systems to reduce costs of care were also very positively favoured options for the future (Appendix A; Appendix B).

The HCIC surveys have consistently revealed age, sex, income and geographic-based differences in perceptions of health, disease, care access, quality and costs (Ahmed et al. 2009; Appendix A; Appendix B). For example, prevalence of chronic illness is very much directly related to age and inversely related to income (Ahmed et al. 2009, Appendix A). And, perception of timely access to care displays regional disparity (Figure 1), as do perceptions of timeliness and quality of future care (Figure 2).

Joanna Nemis-White et al. Stakeholder Surveys of Canadian Healthcare Performance: What Are They Telling Us? Who Should Be Listening? Who Should Be Acting, and How?

HCIC Members, 2013–2014

Canadian Cancer Society (CCS) Canadian Foundation for Healthcare Improvement (CFHI) HealthCareCAN (formerly Canadian Healthcare Association and Association of Canadian Academic Healthcare Organizations) Canadian Home Care Association (CHCA) Canadian Hospice Palliative Care Association (CHPCA) Canadian Medical Association (CMA) Canadian Nurses Association (CNA) Constance Lethbridge Rehabilitation Center (McGill University) Health Charities Coalition of Canada (HCCC) Institute of Health Economics (IHE) Institute of Work and Health (IWH) Merck Canada POLLARA Strive Health Management CareNet Corporation Ltd.

24 Healthcare Quarterly Vol.17 No.4 2014

What We Did Not Find – Responsible Drivers of Health Innovation Interestingly, considering the intense, long-term interest of the HCIC survey members, most of whom are nationally oriented, non-governmental and non-profit health organizations (Ahmed et al. 2009; Appendix A; Appendix B), we did not find a high degree of support for them as responsible innovators in our health system. It seems they are off the radar, at least in the perceptions of the public (Figure 3), professional providers and administrators (Figure 4), as key players with a responsibility to improve healthcare provision and policy.

What We Now Think – Focused Communication and KT Evaluation Strategies Health of the nation is everybody’s business, as are measuring its status and driving its improvement. The HCIC members certainly believe this mantra. Moreover, they remain committed to improving clinical care and outcomes, as well as policy.

As part of this mantra, the HCIC partners have increasingly realized the need, not only for designing questions and sampling the opinions of consumers, administrators and providers of healthcare, but also for temporal mapping of similarities and changes in data, as well as systematic overviews, sub-group analyses and definition of emerging trends in care and stake- holders’ views on their current and forecasted future importance. In concert with interrogation of the data is the importance of propagation of findings via a robust communications strategy.

However, in today’s information age, there is risk of message overload from a multitude of emails, “tweets” and “likes.” To ensure that a priori-conceived, robustly designed and rigorously acquired information, such as that generated in the numerous iterations of the HCIC surveys, is heard by the audiences that can perceive its evidence-based value – and can act on that value to positively influence healthcare policy and practice decision- making – is a great challenge.

It is, however, an attractive challenge. Thus, concerted efforts are being placed on strategic commu-

nications and KT activities by the partners in this most recent 11th HCIC survey. A formal HCIC KT sub-committee was created to explore optimal methods to reach desired audiences, in consideration of varying themes or key messages, using different tools, formats, timelines and assessment plans. For example, key summary messages were drafted and vetted with members and a series of results’ presentations, for varying venues and duration, including speaker’s notes, were prepared

Stakeholder Surveys of Canadian Healthcare Performance: What Are They Telling Us? Who Should Be Listening? Who Should Be Acting, and How? Joanna Nemis-White et al.

Note: Net Momentum equals improved minus worsened in each region

Future of Healthcare Access – By Region Public Perceptions

TImely Healthcare Services Quality Healthcare Services

BC

Alberta

Prairies

Ontario

Quebec

Atlantic

-37%

-23%

-19%

-20%

-24%

-31%

-22%

9%

14%

2%

-13%

-17%

FIGURE 2. Regional comparison of the Canadian public’s perceptions of likelihood of timely access to, and quality of, future care when asked in the 2013-2014 HCIC survey: “Over the next five years, do you believe that Canadians’ access to timely and quality healthcare services will significantly improve, somewhat improve, somewhat worsen or significantly worsen?”

Note: involved Net Momentum equals “improved” minus “worsened” in each region

Net Momentum

BC

Alberta

Prairies

Ontario

Quebec

Atlantic

-39% Overall

-45%

-33%

-43%

-32%

-48%

-43%

FIGURE 1. Regional comparison of the Canadian public’s perceptions of timely access to care when asked in the 2013–2014 HCIC survey: “Has timely access to healthcare over the past five years improved, worsened or remained the same?”

Healthcare Quarterly Vol.17 No.4 2014 25

and shared with all members, who could, in turn, share findings and opinions within their existing networks. This method, using health social networks for communication, was adopted to enhance dissemination of results because of its demonstrated efficacy to maximize expeditious KT (Montague et al. 2013), as opposed to more traditional methods, such as one-time press- releases. In addition to the presentation series, more traditional KT techniques, including timely preparation of manuscripts, were submitted to peer review (Appendix A; Appendix B).

Hand-in-hand with KT communications of HCIC results has been the creation of a knowledge impact assessment plan. This includes an ongoing documentation of what has been done in translating KT data, such as analyses required to present

or publish, as well as initial assessment of degree of contact, uptake or understanding of such information, and its poten- tial decision-influencing value and subsequent action by HCIC members and their social networks.

Perhaps the most practically enabling HCIC KT impact assessment tool has been the implementation of an updateable roster of all presentations and publications, in all media, by members or non-members; each assessing hoped-for presenta- tion/publication goals, audience(s) reach, their perceived degree of understanding and priorities of perceived impact value/ importance of topics and data and their use of information as evidence for policy/practice decision-making (see Appendix C at www.longwoods.com/content/24113).

Documenting how, where and when the survey findings are being utilized is anticipated to provide significant initial insight into the value of the surveys, in comparison with other research or information initiatives. Follow-up KT evaluation measures will provide additional information on value and utilization of the HCIC data.

A diagrammatic overview model of the evolving HCIC strategy to obtain, translate and measure knowledge impact is summarized in Appendix D (see Appendix D at www.longwoods.com/content/24113).

Our mantra remains that things can be better in Canadian healthcare. Together, these measures are incremental steps to build reliability and sustainability of the future survey designs, especially in terms of determining which vehicles/venues are most effective in audience reach and influence. Knowing if, and understanding how, HCIC results have informed health- care policy and practice decision-making would bring us close to realizing the originally envisioned goals of the early partners to use information to improve policy, practice and outcomes. They are steps along the way to better.

Joanna Nemis-White et al. Stakeholder Surveys of Canadian Healthcare Performance: What Are They Telling Us? Who Should Be Listening? Who Should Be Acting, and How?

Federal and provincial governments/ funding agencies

Research hospitals and academic regional health authorities

The pharmaceutical/biotech industry

Individual researchers, clinicians and health practitioners

Universities and colleges

The general public

Don’t know

Other

Foundations and not-for-profit organizations

21%

18%

14%

9%

7%

4%

3%

2%

23%

FIGURE 3. Public perceptions when asked, in the 2013–2014 HCIC survey: “Which one healthcare stakeholder do you think is currently most responsible for introducing new innovation into the healthcare system in Canada?”

Federal and provincial governments/ funding agencies

Research hospitals and academic regional health authorities

DoctorsSome Consensus Nurses Pharmacists Administrators

The pharmaceutical/biotech industry

Individual researchers, clinicians and health practitioners

Universities and colleges

The general public

Don’t know

Foundations and not-for-profit organizations

21%

19%

17%

17%

6%

5%

5%

2%

9%

15%

13%

25%

22%

6%

7%

3%

0%

9%

22%

13%

15%

25%

4%

11%

4%

0%

6%

18%

7%

28%

19%

8%

7%

4%

5%

4%

FIGURE 4. Health professionals’ perceptions when asked, in the 2013–2014 HCIC survey: “Which one healthcare stakeholder do you think is currently most responsible for introducing new innovation into the healthcare system in Canada?”

26 Healthcare Quarterly Vol.17 No.4 2014

Acknowledgements The authors wish to gratefully recognize the collaboration of Owen Adams of the Canadian Medical Association and Kevin Skilton of Merck, both original contributors to the Health Care in Canada Surveys, for their careful review of this manuscript.

About the Authors Joanna Nemis-White, BSc, is a Principal, Strive Health Management Consulting Inc., Halifax, NS.

Emily Torr, MSc, is a Project Officer, CIHR Institute of Human Development, Child and Youth Health, and Knowledge Translation Consultant to the HCIC Project, Toronto, ON.

Amédé Gogovor, MSc, is a PhD candidate and Research Assistant, Faculty of Medicine, McGill University, Montreal, QC.

Lucas Marshall, B Journ, is a Senior Research Consultant and Associate Vice President, POLLARA Strategic Insights, Toronto, ON.

Sara Ahmed, PhD, is Associate Professor, Faculty of Medicine, McGill University, with appointments in the School of Physical and Occupational Therapy, the University Health Center’s Division of Clinical Epidemiology, Clinical and Health Informatics, and the Centre de recherche interdisciplinaire en réadaptation, Montreal, QC.

John Aylen, MA, is President, John Aylen Communications, and Lecturer in Marketing Communications, John Molson School of Business, Concordia University, Montreal, QC.

Terrence Montague, MD, is a Principal, CareNet Health Management Consulting Ltd., Edmonton, AB.

References Ahmed, S., A. Gogovor, E. Berman, M. Miloff, B. Burnand, M. Krelenbaum et al.; for the 2008 Health Care in Canada Survey Partners. 2009. “Changing Health Care: Stakeholder Perceptions of the Burden of Chronic Disease and the Value of Teams, Communication.” Healthcare Quarterly 12(2): 1–13.

Graham, I.D., J. Logan, M.B. Harrison, S.E. Straus, J. Tetroe, W. Caswell et al. 2006. “Lost in Knowledge Translation: Time for a Map?” The Journal of Continuing Education in the Health Professions 26(1): 13–24.

Montague, T., J. Nemis-White, B. Cochrane, J. Meisner and T. Trasler. 2013. “Partnership and Measurement: The Promise, Practice and Theory of a Successful Health Social Networking Strategy.” Healthcare Quarterly 16(1): 31–37.

For additional perspectives on the Health Care in Canada 2014 Survey see:

Appendix A: Results of the 2013-2014 Health Care in Canada Survey: Challenges and Opportunities

Sara Ahmed, Lucas Marshall, Amédé Gogovor, Wendy Morton, Jill Norman, Joanna Nemis-White and Terrence Montague; for the Health Care in Canada Survey Members

Summary The 2013-2014 Health Care in Canada survey sampled public (n = 1,000), physician (n = 101), nurse (n = 100), pharmacist (n = 100) and administrator (n = 104) perceptions of national health, prevalence and care of chronic illnesses; compared data with previous results; and identified preferred innova- tions to improve future care. Among adults, 79% reported good-to-excellent health, versus 84% in 2007. The prevalence of one or more chronic diseases increased from 37% in 2007 to 58%, with arthritis and cardiovascular diseases most preva- lent (22%), followed by mental (16%), pulmonary (14%) and diabetic diseases (11%). Two-thirds of chronically ill patients reported they always, or often, had access to professional care and needed information, but prolonged wait times, inability to afford care and non-referral were seen as key care impediments. Non-professional care was a very important care component, with 19% of all Canadian adults currently providing active support to a family member or friend with a chronic disease. Acute care was also common, with 15% of chronically ill patients admitted to hospital, and 21% to emergency rooms, within the past year. Public and professionals’ top care improve- ment priorities were increased access to home and community care, and more wellness, disease prevention and patient self- help programs. Enhanced coordinated care was also a priority of all professionals, particularly as facilitated by electronic health records, inter-stakeholder communication and shared decision- making. In this regard, the increased use of non-MD profes- sional providers was also supported by a majority of physicians (62%), nurses (94%), pharmacists (95%) and administrators (83%). Actual participation in coordinated team-based care and health management programs has, however, remained stagnant (34%, professionals; 18%, patients). Patient-centred care, especially readily accessed care delivered with respect and caring, was universally supported. We conclude that the general health of the nation is decreasing and the burden of chronic illness is increasing. Timely access to care remains a top-of-mind issue. However, key improvement opportunities beckon, driven by pan-stakeholder valuing of increased communication; home, community and patient self-management programs; and team- oriented, patient-centred care. Things can be better.

Full article available at: www.hcic-sssc.com

Stakeholder Surveys of Canadian Healthcare Performance: What Are They Telling Us? Who Should Be Listening? Who Should Be Acting, and How? Joanna Nemis-White et al.

Healthcare Quarterly Vol.17 No.4 2014 27

Appendix B: Recent Healthcare Trends in Canada: Perceptions of Quality, Access and Affordability; and Priorities for Improvement, 1998–2014

Terrence Montague, Joanna Nemis-White, Lucas Marshall, Amede Gogvor, Emily Torr and Sara Ahmed; for the Health Care in Canada Survey Members

Summary Drawing on data from 11 iterations of the Health Care in Canada surveys between 1998 and 2014, we summarized trends in citizens’, physicians’, nurses’, pharmacists’ and admin- istrators’ perceptions of the quality, access and affordability of healthcare in Canada, as well as innovative priorities to improve future care, and predictions for its success. We found that timely access to care and affordability of care have become the leading causes of concern in recent years among the public and health professionals alike, displacing inadequate funding and lack of professional staff, the leading causes of concern at the turn of the past century. Moreover, these issues are predicted, by all stakeholders, to likely worsen in the ensuing five years. Nonetheless, the perception among the majority of public and all professional stakeholders of the overall quality of our health system has remained relatively unchanged. In terms of priori- ties to improve care, increasing professional schools’ enrolment remains the public’s number one priority, although support is decreasing. Among professionals, requiring health providers to work in teams has become the number one care improvement priority, and the number two priority among the public. Among both public and all professional stakeholders, the recommenda- tion to fund the development of national supply systems to reduce costs of care is now a top priority, displacing the previ- ously top-ranked options of shifting funding from other health- care arenas, or raising taxes. We conclude that although things are changing in Canadian healthcare and some key factors, like timely access, may be worsening, the perception of overall system quality persists. Canadians, both the public and health professionals, have developed realistic, and shared, priorities for targeted improvement. Optimism appears to outweigh pessi- mism. Things can be better!

Full article available at: www.hcic-sssc.com

Joanna Nemis-White et al. Stakeholder Surveys of Canadian Healthcare Performance: What Are They Telling Us? Who Should Be Listening? Who Should Be Acting, and How?

Healthcare Quarterly Vol.17 No.4 2014

Stakeholder Surveys of Canadian Healthcare Performance: What Are They Telling Us? Who Should Be Listening? Who Should Be Acting, and How? Joanna Nemis-White, Emily Torr, Amede Gogovor, Lucas Marshall, Sara Ahmed, John Aylen and Terrence Montague; for the Health Care in Canada Survey Members

SPECIAL REPORT

Appendix C. HCIC roster: presentation/manuscript/data use

Today’s Date: _____________________________________ (Month/Day/Year) HCIC #: (Internal Use Only)

Authors/Presenters: ____________________________________________________________________________ E.g., Name, Title, Organization; Name, Title, Organization

Audience: ______________________________________________________________________________________ E.g., HCIC members; public; administrators; health academia; media; conference name

Format: ________________________________________________________________________________________ E.g., Poster, 30-minute oral presentation, peer-reviewed manuscript, non-peer reviewed text, one-hour webinar

Presentation/Manuscript/Report Title: ___________________________________________________________

Context:

Research Question/Objectives/Purpose: ___________________________________________________

Hypothesis (if applicable): ________________________________________________________________

Required sub-analysis support/resources (if applicable): ____________________________________ Include desired variables, description of analysis/raw data required and deadline

HCIC Data Utilized: ______________________________________________________________________ E.g., Theme/slides

Potential Impact: ________________________________________________________________________ How will presentation of HCIC results inform/influence health policy/decisions, or other use for results?

Applicable References: __________________________________________________________________

Anticipated date of release/presentation: ________________________________________________________ Date of event, targeted journal/submission deadline

Distribution of support materials: Yes ____ No ____ NA ____ E.g., Electronic or paper-based distribution of HCIC information

Copyright disclaimer included in any print materials? Yes ____ No ____ NA ____

Impact Assessment: _____________________________________________________________________________ e.g., qualitative or quantitative evaluation (poll audience; pre/post survey; media impressions; # audience participants or readers)

Joanna Nemis-White et al. Stakeholder Surveys of Canadian Healthcare Performance: What Are They Telling Us? Who Should Be Listening? Who Should Be Acting, and How?

Healthcare Quarterly Vol.17 No.4 2014

Healthcare Quarterly Vol.17 No.4 2014

Stakeholder Surveys of Canadian Healthcare Performance: What Are They Telling Us? Who Should Be Listening? Who Should Be Acting, and How? Joanna Nemis-White, Emily Torr, Amede Gogovor, Lucas Marshall, Sara Ahmed, John Aylen and Terrence Montague; for the Health Care in Canada Survey Members

SPECIAL REPORT

HCIC Model

O ve

rs ig

ht &

L ea

de rs

hi p

H CI

C m

em be

rs /p

ar tn

er s

Co ns

ul ta

nt s

M cG

ill d

at a

ce nt

re PO

LL A

RA

Activities Develop HCIC survey Conduct HCIC surveyDevelop/sustain

HCIC partnerships

Immediate outcomes

Publications Mailing listCommunications products

E-alerts Website2-pager

Presentations

Evaluation tools

Google analyticsSurvey E-mail platformDirect follow-up with HCIC

Partners/member networks Data

Roster

Longer term/ultimate outcomes

Foster evidence-based policy/practice decisions To make things better!

Impact measurement

Number of downloads

Geographical representation of

web hits

Time spent on page

Qualitative survey

feedback and response rate

Direct follow-up with HCIC

Partners/member networks

E-mail platform

Data

New data requests especially from non-members

Outputs

HCIC survey data HCIC network

Inputs

Financial resources HCIC survey members/organizations

HCIC partner expertise

Project management

Know ledge translation

Evaluation

Appendix D. Overview Model for Gaining, Translating and Measuring Knowledge from the HCIC Surveys