Table of Contents
CANADIAN HEALTHCARE: A BRIEF OVERVIEW
2 RECOMMENDATION ONE
GOING LEAN IN HEALTHCARE
3 RECOMMENDATION TWO
UNIVERSAL PRESCRIPTION DRUG COVERAGE
4 RECOMMENDATION THREE
INCORPORATING VIRTUAL HEALTH PRACTICES
A THE SEVEN TYPES OF MUDA ACCORDING TO LEAN THINKING
B STRATEGIC PLAN FOR VIRGIN MASON HOSPITAL
C ANESTHESIA SHADOW BOARD BEFORE & AFTER 5S
Canadian Healthcare: A Brief Overview
Canada’s universal healthcare system, frequently referred to as “Medicare,” was introduced in 1962 solely to the province of Saskatchewan by premier, Tommy Douglas. In 1964, Emmet Hall published the Hall Commission, which recommended that all provinces and territories adopt a universal healthcare program similar to Saskatchewan. By 1972, all provinces and territories had established universal health coverage programs, providing medically necessary services to all Canadians. The Canada Health Act of 1984 was enacted with the mandate “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers” (L. Hughes- Marsh, personal communication, September 20, 2010). The Act has five principles: (1) public administration, healthcare must be administered by the provinces on a non-profit basis by public authority; (2) comprehensiveness, health insurance plans must cover all medically necessary services; (3) universality, all insured residents are able to access public healthcare services; (4) portability, provinces are required to cover citizens when they are temporarily absent from their home province; and (5) accessibility, all insured citizens have reasonable access to insured services (Canadian Health Care, 2004). The aforementioned policies and principles have assisted in creating the universal, glorious and free healthcare system that historically Canadians have been so proud to adopt as part of their identity.
The 2010 Report Card however, suggests that this attitude is shifting. When compared with six other developed nations on the performance of their healthcare systems, Canada ranked sixth, only placing ahead of the United States, the one country that does not have universal healthcare. Factors measured include: quality of care, access, efficiency, equity and health outcomes (L. Hughes-Marsh, personal communication, September 20, 2010). These findings provide evidence that Canadians no longer hold the same value for their once glorified, universal healthcare system. Instead, the system receives an abundance of criticism for its inability to provide quality care to all citizens and is thus currently facing many challenges and structural reforms. This report will outline three recommendations to improve the current Canadian healthcare system: going lean in healthcare, establishing universal prescription drug coverage programs and incorporating virtual health practices into the Canadian healthcare system. Since healthcare is mandated on a provincial level, the aforementioned recommendations will be primarily targeted to Ontario. Once these recommendations have successfully been adopted in Ontario, the federal government can encourage other provinces and territories to adopt similar practices.
Going Lean in Healthcare
Lean thinking was developed at Toyota Manufacturing plants in Japan and involves eliminating waste “so that all work adds value and serve’s the customer’s needs” (Innovation Series 2005: Going Lean in Health Care, 2005). At Toyota Manufacturing plants, management looked for ways to eliminate waste (or muda in Japanese) in the current system of vehicle production. Lean thinking involves distinguishing value-added from non-value-added steps, removing the seven types of muda (Appendix A); simply stated it is striving for perfection, so that all steps add value to the process. Although healthcare and the manufacturing of vehicles seem very different on the surface, the end result of providing value to the customer, in this case the patient, is the same. Both focus on zero defects through quality, safety, cost and customer and employee satisfaction. Striving for perfection in healthcare is necessary to avoid injuries. In the United States, while working at 99.9% levels of quality, approximately 500 incorrect surgeries are performed each week (D. Lee, personal communication, October 8, 2009). This statistic emphasizes the importance of striving for zero defects and going lean.
Through the adoption of lean thinking, hospitals can develop a strategy, similar to that of Virginia Mason Hospital and Medical Center in the United States (Appendix B), which places the patient first. Here, kaizen, continuous improvement of processes, is an important part of the corporate culture. Studies have shown that when applied carefully, lean thinking can have a tremendous impact on the productivity, cost and quality of services provided by an organization (Innovative Series: 2005, Going Lean in Healthcare, 2005). When hospitals focus on the specified needs of the patient, he or she is better able to flow through the system without waits or delays, thereby creating a more efficient process. Through value stream mapping, hospitals identify specific activities necessary to deliver services to the patient and eliminate muda.
One such example is the 5-S (Sort, Simplify, Standardize, Sweep and Self-Discipline) method of organizing workspaces. The method embraces the philosophy that all items have a place, and that they all should be in that place, clean and ready to use for the next worker (D. Lee, personal communication, October 8, 2009). This simple organizational philosophy can significantly increase the productivity of a workplace through neatly arranging and appropriately labeling articles so that workers can easily locate specific items (Appendix C). The differences with respect to the organization of the workbenches in Figures 2 and 3 of Appendix C are shocking. In Figure 3, all medical items are neatly placed and labeled in their designated spot, while in Figure 2 everything is cluttered; an accident waiting to happen.
Another important component of lean thinking, involves establishing standard work. Taiichi Ohno, Vice President of Toyota Motor Corporation states that, “Where there is no standard, there can be no kaizen” (D. Lee, personal communication, October 8, 2009). Standard work is the safest, most efficient way to perform a particular task and yields the highest quality result. The four steps comprising standard work include observing the work, analyzing and identifying muda, eliminating muda by trying out the process and creating a new standard for the work cycle. Similar to all lean practices standard work is continuously improved, hence kaizen.
Lean healthcare has the ability to improve the quality of care, safety of workplaces and patient and employee satisfaction, while improving productivity and thereby reducing costs. It puts patient satisfaction first and focuses on meeting his or her needs, which should be the standard when delivering care. If the patient is not satisfied, the operation, procedure or service was not successful. Workplaces involved in the delivery of healthcare services must adopt lean thinking strategies, so that they can be incorporated into the organization’s corporate culture. As with implementing any new strategy or program, initially resistance from staff will exist. Lean thinking challenges all employees to work together, emanating the lean philosophy throughout the entire organization. With the participation of all healthcare staff and administration, the waste in the current Canadian system can continue to be identified and eliminated, thereby positively influencing, costs, quality, productivity and the delivery of medical services in a timely manner.
Universal Prescription Drug Coverage
Throughout Canada a nationwide, universal prescription drug program does not exist.
The Ontario Drug Benefit (ODB) program allows select populations to receive prescription drug coverage. This includes those who are: over the age of 65, long-term care home residents, residents of Homes for Special Care, recipients of services through the Home Care program and registered in the Trillium Drug Program. In contrast, a large proportion of the provincial population who are ineligible for the ODB program have two options: to either use a private insurance plan or pay out of pocket (Ontario Ministry of Health and Long Term Care, 2009).
From a global perspective, Sweden has one of the largest aging populations in the world, yet has one of the highest life expectancies. When compared with Canada, Sweden has a greater life expectancy, lower infant mortality rate and spends both less per capita and a lower percentage of their GDP on healthcare (World Health Organization, 2008). Similar to Canada, Sweden has a universal healthcare system, however, unlike Canada, they provide prescription drug coverage to their citizens.
The state, county councils and patients finance prescription drugs in Sweden. Since the county councils oversee healthcare, they are responsible for covering the cost of all inpatient medicines. Taxes are levied to finance such benefits. The outpatient prescription drug program applies to all legal residents of Sweden; the county councils receive grants from the government, which are allocated toward this. In 2005, the state paid approximately 2.2 billion Euros, which was more than sufficient to cover the cost. Although the state and county councils pay for a large proportion of outpatient medicine, patients also contribute. However, the policy does not allow citizens to spend more than 200 Euro in a 12-month period on prescription drugs. On average, patients cover approximately 21% of the cost associated with outpatient medicine. All costs for children under the age of eighteen in an individual family are grouped together. Persons who cannot afford to spend the 200 Euro maximum can apply to have costs subsidized. The county councils have committees that assess all individuals and families on a case-by-case basis (Pharmaceutical Benefits Board, 2007). In Ontario, the Local Health Integration Networks (LHINs) would oversee this process. The program is structured around the usage of more cost efficient generic rather than brand name drugs. However, if a patient specifies that he or she would like the brand name drug, they are required to pay the cost difference between the two products.