Navigating the narrowing effect of public discourse for a healthier future.

This article explores the concerning phenomenon of the narrowing effect in public discourse, particularly in the context of healthcare and Medicare. It discusses the challenges posed by this narrowing effect, the impact of cognitive biases, and the ethical dilemmas faced by healthcare providers and organizations when patients take their concerns public. The article also emphasizes the importance of responsible leadership and offers navigation for overcoming the narrowing of public discourse.

Local Health Integration Networks: Build on their purpose.

This article provides a high-level overview on the creation of Local Health Integration Networks (LHINs) and illustrates the complexities involved in their implementation. To understand regional structures such as LHINs, one must understand the context in which design and execution takes place. The article ends with a commentary on how Ontario is performing post-LHINs and discusses next steps.

The owners have a right to be heard: Patient voice in design and performance improvement.

The Canadian taxpayer is an owner of the healthcare system and the owners have a right to be heard. This article encourages leaders both formal and informal to create cultures that promote ASKing questions to test assumptions held, LISTENing to hear the patient voice, and TALKing with patients and families to create new conversations and narratives. Looking at the label, "healthcare system" what's your contribution to creating health, how will you dedicate yourself to caring about the healthcare consumer and care provider, and what will be your role in creating a new and improved system? An implied question at the foundation of the article is this: Is the difference between managing and leading a difference of empathy?

We have a perfect storm - let's use it.

The lead paper, "Responsibility for Canada's Healthcare Quality Agenda: Interviews with Canadian Health Leaders," is a valuable contribution to the quality and safety improvement conversations taking place across the country. My commentary suggests a dramatic convergence of social, economic, demographic and technological forces has brought healthcare to a threshold of a perfect storm. To brace ourselves against this storm, I have suggested that we need to understand the system not as a structure but as relationships. I argue that alignment is not a concept that is particularly well understood - and we tend to focus almost exclusively on the component of structure.

A call for a new connectivity.

"Twisting the Lion's Tail" is a valuable and timely contribution to the literature on the need to break down silo thinking and acting. If we stay within a narrow silo by suggesting that researchers generate knowledge, practitioners use the knowledge and then researchers evaluate the results, we will not get to the system thinking view articulated in the lead paper. The author hopes his observations presented in this commentary add to the conversation.

What are you prepared to see?

A hospital system is made up of interconnecting circles of complex activity; however, we are conditioned to see and think in straight lines. What we see depends on what we are prepared to see. This article asks the question: What do you see in terms of patient safety and quality of care?

The times they are a-changing: what worked and what we learned in deploying Ontario's Wait Time Information System.

How many days would you be comfortable waiting if you needed cancer surgery? What would you do if someone, not as medically urgent, was able to receive an MRI or CT scan before you? Would you want to know if you could wait less time for treatment at another location or with another clinician? These are some of the dilemmas facing patients and our health system when dealing with the issue of wait times. To address these pressing concerns, in the fall of 2004, Ontario launched its Wait Time Strategy. Two years later, Collins-Nakai et al. (2006) reported that Ontario had moved "from being a laggard to a leader" with respect to wait times. This article summarizes Ontario's work to date to improve access to care, including reviewing the need, action taken and the emerging results. Much can be learned and leveraged from the experiences described in this article and throughout this issue. They can serve as an important starting point for further discussion, improvement and action, for initiatives big and small, by all types of organizations and jurisdictions.

Creating sustained improvements in patient access and flow: experiences from three Ontario healthcare institutions.

Ensuring that patients receive timely, high-quality healthcare is the highest priority of Ontario's hospitals, physicians and nurses. Given that the emergency department (ED) is often the "front door" to our healthcare system, developing approaches to improve access and flow in the ED is important - made more challenging by rising patient demand and acuity. Long-standing efforts to improve the ED system have outlined promising approaches and pushed access and flow up the priority list. Recently, in partnership with the Ministry of Health and Long-Term Care (MOHLTC), several Ontario hospitals participated in an intensive and sustained effort to improve access and flow, with promising results. Participants in these efforts described the initiatives as transformational, and the results have been promising and sustained. This article chronicles the efforts of three hospitals to enable other hospitals, physicians and nurses to learn from these experiences and gain confidence that a similar impact can be achieved in their facilities. Specifically, it discusses the following: The three pillars of sustainable transformation. Hospital case studies. St. Joseph's Health Centre (SJHC), Toronto. London Health Sciences Centre (LHSC) - University Hospital. University Health Network (UHN) - Toronto General and Toronto Western. Advice for other hospitals

Reflections on Ontario's primary healthcare journey.

Despite the prevailing opinion and consensus around how primary healthcare systems should be changed, there is very little agreement on how this should happen and a surprising paucity of research and evaluative evidence related to both system organization and mechanisms for change. The authors reflect on Ontario's experience with primary healthcare renewal and provide insight into lessons learned.

Evaluating outcomes in Ontario's Wait Time Strategy: Part 4.

It is widely recognized that Ontario's Wait Time Strategy is a significant change management initiative. But has the province achieved the goal that it set out for itself in November 2004? This article answers this question, beginning with a brief overview of the major inputs or foundational building blocks of the strategy, followed by a detailed analysis of the major outputs or outcomes of the strategy to date.

The pivotal role of critical care and surgical efficiencies in supporting Ontario's Wait Time Strategy: Part 3.

As part of its Wait Time Strategy, the Ontario Ministry of Health and Long-Term Care provided significant amounts of money to perform more cases with the understanding that improving access by reducing wait times is not just a matter of increasing funding. Rather, fundamental system and practice change is required to sustain improvements in the long term.

Developing a culture to sustain Ontario's Wait Time Strategy.

Ontario's Wait Time Strategy--a significant change management initiative--is designed to improve access to healthcare services in the public system by reducing the time that adult Ontarians wait for services in five areas by December 2006 (cancer surgery, cardiac revascularization procedures, cataract surgery, hip and knee total joint replacements, and MRI and CT scans). These five are just the beginning of an ongoing process to improve access to, and reduce wait times for, a broad range of healthcare services beyond 2006. Change management initiatives are initially successful because of the significant time, attention and resources that are dedicated to the start-up effort. Many initiatives lose their momentum and impact and ultimately fail in the long run since it is difficult to sustain this level of intensity. The probability of success increases if a culture is developed to sustain the initiative into the future. A pivotal element for this sustained culture is accountability for achieving results. If Ontario is to reduce waits for quality healthcare services over the long term, it must shift from a paradigm where no one--or only a few--are accountable for achieving a particular set of results to one where a wide range of players is accountable for achieving a broad range of results. This includes explicit accountabilities of the public, healthcare providers (including physicians, other healthcare providers, professional associations and regulatory bodies), government and Local Health Integration Networks. Tools required to support these accountabilities include developing leaders, aligning incentives to reinforce what needs to be achieved, and developing information systems to provide the data needed to make decisions, and manage and improve performance.

Expert panels and ontario's wait time strategy: part 2.

Expert panels have been widely used in healthcare as a way of bringing knowledgeable people together to examine issues and identify solutions in well-defined areas. Various terms have been used to describe these groups of experts such as "consensus panels," "blue ribbon panels" and "expert committees or panels." Regardless of the term used, panels of healthcare experts have a history of providing invaluable advice to policy- and decision-makers.

Ontario's wait time strategy: part 1.

Ontario's Wait Time Strategy was designed to improve access to healthcare services in the public system by reducing the time that adult Ontarians wait for services in five areas-cancer surgery, cardiac revascularization procedures (cardiac surgery, percutaneous coronary intervention, diagnostic catheterization), cataract surgery, hip and knee total joint replacements and MRI and CT scans. These five are just the beginning of an ongoing process to improve access to, and reduce wait times for, a broad range of healthcare services.

Making performance reports work.

Public performance reporting is an increasingly common health policy tool to support accountability and quality improvement but there are few formal evaluations of this trend. In this review, we suggest that performance reporting may be an effective way to support improvements in performance when it is directed towards groups of providers rather than individuals and that there is enough evidence to support the use and further development of public performance reporting. However, the true impact of performance reporting depends on the policy context around reporting including clarity of strategy, incentives, and support for performance improvement.