Alberta health review gets one small piece of the puzzle right

The review will now go through the political wringer

March 6, 2012
CALGARY, AB, Mar. 6, 2012, Troy Media/ – A year ago, I authored The Decline of Health Services in Alberta, an analysis of the issues plaguing Canadian health care, drawing heavily on examples from Alberta. That report concluded nothing will improve in the health care system until we dump the 100-year-old command-and-control model of management and adopt something more up to date.

The recently released, Review of the Quality of Care and Safety of Patients Requiring Access to Emergency Department Care and Cancer Surgery and the Role and Process of Physician Advocacy by the Health Quality Council of Alberta, gives us overwhelming evidence as to why this is so. The HQCA Review (let’s just call it that and save some paper) adds to the two decade long flood of investigations, audits, white papers and studies, none of which have made, or can make, any difference.

A waste of time

Why? Because all studies are of one of two types; enumerative or analytic. Enumerative studies are those of command and-control and it’s these studies that have characterized examinations of the system, including the current HQCA Review. It’s a fundamental characteristic of enumerative studies that, while useful in describing problems, they are near useless at identifying root causes and, therefore, incapable of making rational recommendations.

For example, in examining The Role and Process of Physician Advocacy (including doctor intimidation) the Review does a good job in its enumerative role of providing a basic description of the problem. Thus, we are informed that 45.2 per cent of physicians reported that advocacy was not directly mentioned in their organizational policies. The question remaining after this, and the other 50 pages of similarly fascinating descriptive statistics is; So what?

Is that good? Bad? How many physicians have actually memorized their organizational policies anyway? Who says that having an advocacy policy is even a good thing? Enumerative studies can’t answer these questions; that’s the role of an analytic studies.

That’s why, despite all the enumerative description, root causes are not identified and recommendations emerge from thin air. We are treated to calls for a just culture policy – a sort organizational group hug in which everyone promises to get along – or recommendations for more policies, procedures, and frameworks that are guaranteed to make things worse.

There is, however, an important exception in the HQCA Review and it concerns emergency wait times. The HQCA had analyzed these, previously reporting that access was improving. Obviously, that wasn’t going to sell this time around.

So the HQCA changed things up. In examining emergency access, the HQCA Review largely abandons the enumerative thinking of command-and-control and adopts a little systems thinking. The subtle clue is the buried reference to the “input – throughput – output model” used to examine emergency wait times. It’s actually the input-process-output model but that’s quibbling, what’s important is that it’s part of analytic systems thinking.

This small change in thinking, changes everything. Recommendations calling for decreasing facility utilization, using dynamic models for capacity planning, and reducing variability in patient demand and treatment all address root causes and for that reason will help reduce wait times.

The reasons why are detailed in The Decline of Health Services in Alberta, but briefly, it’s because Alberta has tried to improve efficiency by increasing utilization, while ignoring the reality that doing so always produces exponential increases in wait times (and actually decreases efficiency to boot). For example, increasing utilization from 90 per cent to 95 per cent, at a minimum, doubles wait times. Move from 95 per cent to 98 per cent, and wait times quadruple. These real-world effects are assumed not to exist in static, bean counter capacity planning producing the disastrous effects observed in Alberta and elsewhere.

Going in the right direction

Decreasing utilization to 85 per cent from 90 per cent, as recommended in the HQCA Review, will produce immediate positive benefits – wait times will unquestionably go down. Setting firm targets is still the wrong way to go, but at least the direction is right. Dynamic capacity planning and variation management will help ensure we don’t get caught in another series of capacity access crises.

The report gives too many indications that the HQCA is uncertain on this new ground, at one point recommending shortening, emergency department throughput – simultaneously impossible and undesirable. Increasing throughput by shortening cycle times would be a good idea though, and probably what they had in mind.

The Review will now go through the political wringer. Much of it can be disposed of and the system will better off. Recommendations concerning emergency wait times, however, are something all political parties can, and should, buy into. They are far from comprehensive, but they will help.


Robert Gerst is a Partner of Converge Consulting Group Inc. and author of the report The Decline of Health Services in Alberta: The triumph of professional over real management, upon which this essay is based. The report, available at, was the leading news download of the Canadian Health Network in 2011 and will be presented at The International Deming Research Seminar at Fordham University in NYC this February.

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