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Study shows why the people in policy change matter

By Jennifer Lee

Around the world, countries are trying to make healthcare more sustainable by improving access to high quality care, while at the same time managing costs. One way that governments have tried to meet these challenges is by changing the way hospitals are funded.

In Canada, the Ontario government has led this charge by implementing Quality-based Procedures, moving hospitals away from global budgets to paying a set price to cover all care for patients admitted with specific diagnoses, such as pneumonia or for specific procedures like knee replacements.

As a part of this shift, hospitals were also given handbooks for doctors and nurses that contained evidence-based care pathways unique to each condition or procedure. The hope was that a combination of “patient-based payments” and care pathways would encourage “the right care, in the right place, at the right time” at a lower cost. 

But in moving from policy to practice, things haven’t play out exactly as expected. In a recent study, researchers from the Women’s College Hospital Research Institute and the Women’s College Hospital Institute for Health System Solutions and Virtual Care (WIHV), Karen Palmer and Dr. Noah Ivers, interviewed a number of hospital leaders and front-line management to get a glimpse of how they viewed the changes.

Overall, they found that success in rolling-out these budget changes was affected when the policy drifted away from the original goals. Factors such as long timelines between policy design and implementation in hospitals, staff turnover in government and inconsistent messaging all affected how the policy was perceived and how it was implemented.

In highlighting the challenge, one hospital-based implementer felt that “the emphasis, I believe, was originally much more on financial than on outcomes for patients. And I feel now that when you approach it from the outcomes for patients, it does change things a little.” Acknowledging this, a policy-level key informant said, “you go and ask people in the field, sometimes it’s a bit of a black box… it hasn’t been really well-communicated and well-transitioned to the field.”

In general, when policies are created, they often take into account risk, cost, and the potential for savings, but research like this shows that it takes even more to be successful. Achieving big change in complex healthcare systems is difficult and it’s very important to make special efforts that ensure everyone involved in implementing a policy is the same page.

“It takes courage and vision to make major policy shifts and bumps along the way are inevitable,” says WIHV’s Karen Palmer. Noah Ivers agrees that, “Ontario should be lauded for its efforts to date: what’s critical is the willingness to evaluate, learn, and share the lessons openly with all stakeholders, so that the health system gradually can improve its ability to deliver the best possible outcomes for patients at reasonable costs.” 

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