Quality assurance review makes extensive recommendations for health system improvement: Past experiences point to way forward

EDMONTON, Feb. 22, 2012 /CNW/ - The Health Quality Council of Alberta (HQCA) has released its independent review of issues related to the quality of care and safety of patients requiring access to emergency department (ED) care, lung cancer surgery, physician advocacy and the impact of physician intimidation. Dr. John Cowell, HQCA's Chief Executive Officer, called the ten month review an epic journey into the past.

The review found the following:

Emergency Care

• University of Alberta Hospital (UAH) ED physician concerns about patients waiting unacceptably long times for ED services in 2008, including waiting for a hospital bed, were justified. Patients' safety margins were compromised and many suffered. One patient who left the UAH ED without being seen after a five-hour wait nearly died, but was able to be resuscitated.
• However, no deaths can be attributed to excessive wait times in the UAH ED.
• No further action needs to be taken regarding patient charts reviewed or the lists of patients identified by the UAH ED physicians for the years 2008 to 2010.
• Wait times in Alberta's urban EDs are still too long. The way forward lies in dedicating critical resources into improving acute care in-patient occupancy rates. Rates are affected by the number of beds and time patients stay in those beds. This has implications throughout the system. Until this major block to patient flow is resolved, wait times and crowding in urban emergency departments will not substantively improve.

Lung Cancer Surgery

• The allegation that about 1,200 patients were on a waiting list for lung surgery in Edmonton is unfounded, as is the claim that 250 patients died while on a lung surgery waiting list. An extensive review of data, documents  and in-depth interviews with knowledgeable individuals turned up no evidence of poorer patient outcomes for Edmonton lung cancer patients; mortality rates for Edmonton and Calgary were the same and comparable to national averages.
• There is no basis for suggesting that knowledge about illegal or unethical behavior was suppressed by former ministers of Health and Wellness, the former CEO of Capital Health or the Registrar of the College of Physicians & Surgeons of Alberta.
• The claim that physicians who raised issues about lung surgery wait times in the former Capital Health were punished, driven out of the province or paid out in millions because of advocating on behalf of patients is not supported by the facts.
• A public inquiry into these issues is neither required nor recommended.

Physician Advocacy and Intimidation

• There have been widespread instances of physicians experiencing intimidation and muzzling when advocating for patients and evidence of a culture of fear and alienation across the province. Physicians report difficulty in knowing to whom and how to advocate.
• Massive reorganization at the system level and within Alberta Health Services has further blurred lines of authority and accountability. This lack of stability and clarity within the system is intertwined with the problems found around advocacy, intimidation and lack of a 'just culture' where people are seen to be and are treated appropriately and fairly and where relationships are built on trust.
• HQCA is recommending that no further major restructuring in the system be done without a clear plan, rationale and consultation.
• HQCA is further recommending that the time and money that would be needed for  a public inquiry into intimidation and advocacy should instead be devoted to:
• Establishing a task force to develop recommendations on clear lines of authority in the system
• Instructing AHS' board of directors to make establishing a just culture in AHS a priority
• Developing policies and education about physician advocacy, including an appeal process
• Conducting an independent review of the College of Physicians & Surgeons of Alberta's investigative and support roles to address serious concerns raised by physicians

In total, the HQCA has made 21 recommendations on ways to deal with the critical issues in acute care inpatient bed management and emergency department wait times, improving the quality and safety of care, as well as improvements in relationships between physicians, the health system and the public.

"The quality assurance teams spent thousands of hours reviewing hundreds of patient charts, conducting interviews and analyzing data. A total of 2,046 of Alberta's 7,964 physicians answered our survey on their experiences with advocating for patients and we held in-depth discussions with another 99 key stakeholders on that issue alone," said Dr. Cowell. "It's been a thorough, exhaustive process. The HQCA is satisfied that it got to the bottom of the issues and left no material avenues unexplored."

"The quality assurance teams have provided the health system with a detailed road map for the future," said Dr. Cowell. "The issues leading up to this review emerged from events in Edmonton and the experiences of physicians. However, our investigation looked broadly and its findings apply to the whole system and everyone working within it. There are tremendous opportunities here to create a safer and stronger health system that will benefit all Albertans."

The review was conducted as a quality assurance activity under section 9 of the Alberta Evidence Act. Under its terms, documents are not released and those who shared experiences and insights receive anonymity.

The Health Quality Council of Alberta gathers and analyzes information and collaborates with Alberta Health and Wellness, Alberta Health Services, health professions, academia and other stakeholders to translate that knowledge into practical improvements to health service quality and patient safety in the health care system.

A backgrounder is available along with the complete report and can be downloaded at http://www.hqca.ca/.

Interviews with Dr. Cowell can be arranged by calling Karen Fantin at 403-815-4883