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CNA - CMA Newly Published Guiding Principles

Principles to guide health care transformation in Canada  July 2011

Preamble
The Canadian Medical Association and the Canadian Nurses Association put forward the following principles to guide the transformation of the health care system in Canada toward one that is sustainable and adequately resourced, and provides universal access to quality, patient-centred care delivered along the full continuum of care in a timely and cost-effective manner. Such a system promotes health, effectively manages illness and focuses on outcomes, thereby contributing to a country's social and economic development and well-being [1].

Canada's health care system is in need of transformation to better meet the health needs of Canadians. First, while it is recognized that elements of transformation are already taking place across the country, it is important that regional or jurisdictional change be guided by a common framework. Second, health care transformation must build on the five principles of the Canada Health Act (universality, accessibility, portability, comprehensiveness and public administration) that currently apply only to hospital and physician services. Moving beyond these services, a common set of principles is required to guide a national transformation toward a more effective and comprehensive medicare system. A transformed Canadian health care system demands national standards for service quality and outcomes, for which both federal and provincial/territorial governments share responsibility. 

Principles
The principles below have been organized according to the Institute for Healthcare Improvement's (IHI) Triple Aim Framework, which describes the three goals of "better care for individuals, better health for populations and lower per capita costs" [2]. It has been IHI's experience that all three must be addressed; where organizations address only one or two, results may be achieved to the detriment of the other(s). 

Enhance the health care experience


Patient-centred
The patient must be at the centre of health care. Patient-centred care is seamless access to the continuum of care in a timely manner, based on need and not the ability to pay, that takes into consideration the individual needs and preferences of the patient and his/her family, and treats the patient with respect and dignity [3]. Improving the patient experience and the health of Canadians must be at the heart of any reforms.

A strong primary health care foundation as well as collaboration and communication within and between health professional disciplines along the continuum are essential to achieving patient-centred care.

Quality 
Canadians deserve quality services that are appropriate for patient needs, respect individual choice and are delivered in a manner that is timely, safe, effective and according to the most currently available scientific knowledge. Services should also be provided in a manner that ensures continuity of care. Quality must encompass both the processes and the outcomes of care. More attention needs to be given to ensuring a system-wide approach to quality.

Improve population health
Health promotion and illness prevention
The health system must support Canadians in the prevention of illness and the enhancement of their well-being. The broader social determinants of health (e.g., income, education level, housing, employment status) affect the ability of individuals to assume personal responsibility for adopting and maintaining healthy lifestyles and minimizing exposure to avoidable health risks. Coordinated investments in health promotion and disease prevention, including attention to the role of the social determinants of health, are critical to the future health and wellness of Canadians and to the viability of the health care system. This is a responsibility that must be shared among health care providers, governments and patients, who must be actively engaged in optimizing their health and be involved in decisions that affect their overall health.

Equitable
The health care system has a duty to Canadians to provide and advocate for equitable access to quality care and multi-sectoral policies to address the social determinants of health [4]. In all societies, good health is directly related to the socio-economic gradient - the lower a person's social position, the worse his or her health. The relationship is so strong that it is measurable within any single socio-economic group, even the most privileged.

It is due to the sum of all parts of inequity in society - material circumstances, the social environment, behaviour, biology and psychosocial factors, all of which are shaped by the social determinants of health [5].

Some health inequities are preventable; failure to address them will result in poorer health and higher health care costs than necessary. Improved health literacy (defined as the ability to access, understand and act on information for health) would help to mitigate these inequalities.

Improve value for money
Sustainable
Sustainable health care requires universal access to quality health services that are adequately resourced and delivered along the full continuum in a timely and cost-effective manner. Canada's health care system must be sustainable in the following areas:

•Resourcing: Health services must be properly resourced based upon population needs, with appropriate consideration for the principles of interprovincial and intergenerational equity and pan-Canadian comparability of coverage for and access to appropriate health services. 
◦Financing: The health care system needs predictability, certainty and transparency of funding within the multi-year fiscal realities of taxpayers and governments, and funding options that promote risk-pooling, inter-provincial and inter-generational equity and administrative simplicity.
◦Health human resources: Health care will be delivered within collaborative practice models; pan-Canadian standards/licensure will support inter-provincial portability of all health care providers; health human resource planning will adjust for local needs and conditions.
◦Infrastructure: Health care in the 21st century demands a fully functional health care information technology system as well as buildings and capital equipment.
•Research: Health research in Canada will inform adjustments to health service delivery and to the resourcing of health services.
•Measuring and reporting: Outcome data are linked to cost data; comparable and meaningful performance measures are developed and publicly reported; outcomes are benchmarked to high-performing, comparable jurisdictions.
•Public support: The health care system must earn the support and confidence of the users and citizens of Canada, who ultimately pay for the system. 
Accountable
All stakeholders - the public/patients/families, providers and funders - have a responsibility for ensuring the system is effective and accountable. This includes:

•Good governance: Clear roles, lines of authority and responsibilities are necessary for the funding, regulation and delivery of health care services, even where these may be shared between levels of government and among health care providers. Patients, families and providers must be partners in the governance of the system. 
•Responsible use: Services should be funded, offered and used responsibly. 
•Strong public reporting: Timely, transparent reporting at the system level on both processes and outcomes that can be used and understood by stakeholders and the public are necessary.
•Enforceability and redress: Mechanisms are in place to enforce accountability and provide redress when the system does not fulfill its obligations.
•Leadership/stewardship: Long-term strategic planning and monitoring is necessary to ensure the system will be sustainable.
•Responsive/innovative: The system is able to adapt based on reporting results.
Application of principles and next steps
Over the next several months, a number of health care initiatives will be considered at both the provincial/territorial and federal levels. This will include discussions aimed at signing a new health care accord between the federal government and the provinces/territories. Any such agreements or initiatives must be consistent with the principles set out in this document.

Endnotes
1.World Health Organization. Regional Office for Europe. The Tallinn Charter: Health systems for health and wealth. Copenhagen, Denmark, 2008.
2.See The IHI Triple Aim.
3.Canadian Medical Association. Health care transformation in Canada: Change that works. Care that lasts. Ottawa, 2010.
4.Canadian Nurses Association. Social justice: A means to an end; an end in itself. Ottawa, 2010. 
5.The Marmot Review. Fair society, healthy lives: Strategic review of health inequalities in England in post-2010, February, 2010.

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CNA - CMA Newly Published Guiding Principles

Principles to guide health care transformation in Canada  July 2011

Preamble
The Canadian Medical Association and the Canadian Nurses Association put forward the following principles to guide the transformation of the health care system in Canada toward one that is sustainable and adequately resourced, and provides universal access to quality, patient-centred care delivered along the full continuum of care in a timely and cost-effective manner. Such a system promotes health, effectively manages illness and focuses on outcomes, thereby contributing to a country's social and economic development and well-being [1].

Canada's health care system is in need of transformation to better meet the health needs of Canadians. First, while it is recognized that elements of transformation are already taking place across the country, it is important that regional or jurisdictional change be guided by a common framework. Second, health care transformation must build on the five principles of the Canada Health Act (universality, accessibility, portability, comprehensiveness and public administration) that currently apply only to hospital and physician services. Moving beyond these services, a common set of principles is required to guide a national transformation toward a more effective and comprehensive medicare system. A transformed Canadian health care system demands national standards for service quality and outcomes, for which both federal and provincial/territorial governments share responsibility. 

Principles
The principles below have been organized according to the Institute for Healthcare Improvement's (IHI) Triple Aim Framework, which describes the three goals of "better care for individuals, better health for populations and lower per capita costs" [2]. It has been IHI's experience that all three must be addressed; where organizations address only one or two, results may be achieved to the detriment of the other(s). 

Enhance the health care experience


Patient-centred
The patient must be at the centre of health care. Patient-centred care is seamless access to the continuum of care in a timely manner, based on need and not the ability to pay, that takes into consideration the individual needs and preferences of the patient and his/her family, and treats the patient with respect and dignity [3]. Improving the patient experience and the health of Canadians must be at the heart of any reforms.

A strong primary health care foundation as well as collaboration and communication within and between health professional disciplines along the continuum are essential to achieving patient-centred care.

Quality 
Canadians deserve quality services that are appropriate for patient needs, respect individual choice and are delivered in a manner that is timely, safe, effective and according to the most currently available scientific knowledge. Services should also be provided in a manner that ensures continuity of care. Quality must encompass both the processes and the outcomes of care. More attention needs to be given to ensuring a system-wide approach to quality.

Improve population health
Health promotion and illness prevention
The health system must support Canadians in the prevention of illness and the enhancement of their well-being. The broader social determinants of health (e.g., income, education level, housing, employment status) affect the ability of individuals to assume personal responsibility for adopting and maintaining healthy lifestyles and minimizing exposure to avoidable health risks. Coordinated investments in health promotion and disease prevention, including attention to the role of the social determinants of health, are critical to the future health and wellness of Canadians and to the viability of the health care system. This is a responsibility that must be shared among health care providers, governments and patients, who must be actively engaged in optimizing their health and be involved in decisions that affect their overall health.

Equitable
The health care system has a duty to Canadians to provide and advocate for equitable access to quality care and multi-sectoral policies to address the social determinants of health [4]. In all societies, good health is directly related to the socio-economic gradient - the lower a person's social position, the worse his or her health. The relationship is so strong that it is measurable within any single socio-economic group, even the most privileged.

It is due to the sum of all parts of inequity in society - material circumstances, the social environment, behaviour, biology and psychosocial factors, all of which are shaped by the social determinants of health [5].

Some health inequities are preventable; failure to address them will result in poorer health and higher health care costs than necessary. Improved health literacy (defined as the ability to access, understand and act on information for health) would help to mitigate these inequalities.

Improve value for money
Sustainable
Sustainable health care requires universal access to quality health services that are adequately resourced and delivered along the full continuum in a timely and cost-effective manner. Canada's health care system must be sustainable in the following areas:

•Resourcing: Health services must be properly resourced based upon population needs, with appropriate consideration for the principles of interprovincial and intergenerational equity and pan-Canadian comparability of coverage for and access to appropriate health services. 
◦Financing: The health care system needs predictability, certainty and transparency of funding within the multi-year fiscal realities of taxpayers and governments, and funding options that promote risk-pooling, inter-provincial and inter-generational equity and administrative simplicity.
◦Health human resources: Health care will be delivered within collaborative practice models; pan-Canadian standards/licensure will support inter-provincial portability of all health care providers; health human resource planning will adjust for local needs and conditions.
◦Infrastructure: Health care in the 21st century demands a fully functional health care information technology system as well as buildings and capital equipment.
•Research: Health research in Canada will inform adjustments to health service delivery and to the resourcing of health services.
•Measuring and reporting: Outcome data are linked to cost data; comparable and meaningful performance measures are developed and publicly reported; outcomes are benchmarked to high-performing, comparable jurisdictions.
•Public support: The health care system must earn the support and confidence of the users and citizens of Canada, who ultimately pay for the system. 
Accountable
All stakeholders - the public/patients/families, providers and funders - have a responsibility for ensuring the system is effective and accountable. This includes:

•Good governance: Clear roles, lines of authority and responsibilities are necessary for the funding, regulation and delivery of health care services, even where these may be shared between levels of government and among health care providers. Patients, families and providers must be partners in the governance of the system. 
•Responsible use: Services should be funded, offered and used responsibly. 
•Strong public reporting: Timely, transparent reporting at the system level on both processes and outcomes that can be used and understood by stakeholders and the public are necessary.
•Enforceability and redress: Mechanisms are in place to enforce accountability and provide redress when the system does not fulfill its obligations.
•Leadership/stewardship: Long-term strategic planning and monitoring is necessary to ensure the system will be sustainable.
•Responsive/innovative: The system is able to adapt based on reporting results.
Application of principles and next steps
Over the next several months, a number of health care initiatives will be considered at both the provincial/territorial and federal levels. This will include discussions aimed at signing a new health care accord between the federal government and the provinces/territories. Any such agreements or initiatives must be consistent with the principles set out in this document.

Endnotes
1.World Health Organization. Regional Office for Europe. The Tallinn Charter: Health systems for health and wealth. Copenhagen, Denmark, 2008.
2.See The IHI Triple Aim.
3.Canadian Medical Association. Health care transformation in Canada: Change that works. Care that lasts. Ottawa, 2010.
4.Canadian Nurses Association. Social justice: A means to an end; an end in itself. Ottawa, 2010. 
5.The Marmot Review. Fair society, healthy lives: Strategic review of health inequalities in England in post-2010, February, 2010.

Back