Dr Diane Watson, (then International Visiting Health Services Research Fellow at the Sax Institute from the University of British Columbia, Canada) spoke with the HARC network in April 2009 about ways to strengthen public confidence in the hospital system through research and analysis. HARC stands for the Hospital Alliance for Research Collaboration. HARC is a collaborative network of researchers, health managers, clinicians and policy makers based in NSW, Australia managed by the Sax Institute. HARC Forums bring members of the HARC network together to discuss the latest research and analysis about important issues facing our hospitals. For more information visit saxinstitute.org.au.

1. Research to improve public
confidence and views on quality
in the Canadian health care
system
Diane Watson PhD MBA
International Visiting Health Services Research Fellow
The Sax Institute
29 April 2009

2. Outline
• Health care and reform in Canada
• The “confidence conundrum”
• Research evidence to inform efforts to:
– Build public confidence
– Improve overall views on quality
– Publicly report on progress
• Who needs to know what …

3. Outline
• Health care and reform in Canada
• The “confidence conundrum”
• Research evidence to inform efforts to:
– Build public confidence
– Improve overall views on quality
– Publicly report on progress
• Who needs to know what …

4. Canada

5. Health Care Expenditure per Capita
by Source of Funding in 2004
$7,000 Adjusted for Differences in Cost of Living (US$ PPP)
$6,000 Private Spending
Out-of-Pocket Spending
$5,000
$2,572
Public Spending
$4,000
$803
$3,000 $483 $444 $342
$354 $148
$472 $239 $906 $313
$370 $28
$582 $113
$396
$2,000 $238 $389
$359
$2727
$2,475 $2,350
$1,000 $2,210 $2,176
$1,894 $1,940 $1,917 $1,832 $1,611
$0
a ab a
United Canada France Netherlands Germany Australia United OECD Japan New
States Kingdom Median Zealand
a2003
b2002 (Out-of-Pocket)
Source: The Commonwealth Fund, calculated from OECD Health Data 2006.

6. International Comparison of Spending on Health,
1980–2006
Average spending on health
per capita ($US PPP)
$7,000
United States
$6,000 Germany
Canada
Netherlands
$5,000 France
Australia
United Kingdom
$4,000
$3,000
$2,000
$1,000
$0
90
94
92
96
98
00
02
06
04
80
84
82
86
88
19
19
19
19
19
20
20
20
20
19
19
19
19
19
Data: OECD Health Data 2008 (June 2008).

7. Apr 2001: Prime
Minister
establishes Royal
Commission
Senate
establishes a
Committee
Feb 2003: First
Ministers’ Health
Accord
Sept 2004: First
Ministers’ 10-
Year Plan to
Renew Health
Care in Canada

9. Outline
• Health care and reform in Canada
• The “confidence conundrum”
• Research evidence to inform efforts to:
– Build public confidence
– Improve overall views on quality
– Publicly report on progress
• Who needs to know what …

10. Overall Confidence in the Health Care System Among Adults in Seven
Countries, 2007
100
“Very confident” in “getting high
quality and safe care” when “needed”
80
59
60
% of all adults
40
34 35
30
28 28
24
20
0
Australia Canada Germany Netherlands New Zealand United Kingdom United States
Source: 2007 Commonwealth Fund
International Health Policy Surveys.

11. Population Perspectives on Health Care System Reform Among Adults
in Seven Countries, 1988-2007
100
"Overall the system works well,
only minor changes are needed"
80
Australia
60 Canada
% of all adults
Germany
Netherlands
New Zealand
40 United Kingdom
United States
20
0
1988/1990 1994 1998 2001 2004 2007
Sources: 1998, 2001, 2004 and 2007 Commonwealth Fund International
Health Policy Surveys; Harvard, Harris and Baxter, 1988.

13. Outline
• Health care and reform in Canada
• The “confidence conundrum”
• Research evidence to inform efforts to:
– Build public confidence
– Improve overall views on quality
– Publicly report on progress
• Who needs to know what …

14. Public Confidence in Health Care: A
nationwide exploratory analyses in Canada
• Research questions:
– What underlies confidence among the general public
that they will get high quality, safe care when they
need it?
– What underlies views that everything is fine the way
it is/ only minor reforms are needed?
• Telephone survey of the general population, 2007
– Confidence/ views on reform
– Use and experiences with primary health care,
specialists, hospitals and emergency departments
– Views on overall quality of care received in the past
year

15. Public Confidence in Health Care: A
nationwide exploratory analyses in Canada
• Age, gender, income and health status matter; but are not
strong predictors of public confidence.
• Utilization of family doctors, emergency departments and
hospitals was not significantly related to confidence or
positive views on reform.
• Use of specialists was negatively associated with both
outcomes with high users less likely to be confident and less
likely to think everything is fine/ minor reform is needed.
• The key drivers of public confidence?
– first-hand experiences with care
– people overall views on the overall quality of care that
they received in the past 12 months.

16. Very confident/ Everything is fine the
Adjusted odds ratios confident get way it is/ some
quality/ safe care minor-tune-ups
No regular medical doctor or place 0.37*
Experience at least one unmet need
(past year) 0.51*
Wait in ED
4+ hours 0.38**
Use of specialists
1-3 times 0.65*
4+ times 0.56*
Difficulty getting specialist care
(past year) 0.51* 0.55*
Overall quality of care
Very good 0.46**
Good 0.35** 0.47**
Fair/poor 0.20** 0.37**
Source: Watson et al. What drives public confident in the health care system? An
exploratory look at the contribution of health care use and experiences with care.

17. If our intention is to build/ maintain public
confidence …
• Health care policy makers, managers and providers
need to know about/ improve:
– Regular source of care, unmet need, excessive
times in emergency departments and access to
specialists
– Patients ratings of overall quality of care and the
issues that drive it
• Researchers need to investigate why high use of
specialists is associated with lower levels of public
confidence

18. Outline
• Health care and reform in Canada
• The “confidence conundrum”
• Research evidence to inform efforts to:
– Build public confidence
– Improve overall views on quality
– Publicly report on progress
• Who needs to know what …

19. Systematic reviews/ primary research: What
underlies patient overall ratings of quality of care?
• Staff courtesy/ respect
• Provider/ patient communication
• Teamwork among providers
• Comprehensiveness/ unmet needs
• Access/ timeliness
Larson et al. The relationship between meeting patients’ information needs and their satisfaction
with hospital care and general health status outcomes. Int J Qual Health Care 8: 447-56.
Taylor C. Benger JR. 2004. Patient satisfaction in emergency departments. Emergency Medicine
Journal 21: 528-32.
Wong S et al. 2008. What do people think is important about primary health care. Healthcare Policy
3: 89-104.
Grol R. et al. 1999. Patients’ priorities with respect to general practice: An international comparison.
Family Practice 16: 4-11.

21. Patient Ratings of Overall Quality of Care, NSW
Overnight inpatients, 2008 and 2007
Top 5 key drivers:
• Doctors and nurses working well together
• Treating patients with respect and dignity
• The availability of nurses
• Confidence and trust in nurses
• Courtesy of nurses
Source: NSW Health, Patient Survey 2008.

22. Patient Ratings of Overall Quality of Care, NSW
Admitted patients, 2007
• Overall, 90% of those who were admitted to hospital rated
their care as excellent, very good or good.
• The remainder rate care as fair (6%) or poor (4%).
• The main reasons for rating care as fair/ poor were:
– excessive wait time for care (18%)
– inadequate medication/ management (15%),
– poor quality accommodation (14%)
– poor attitude of staff (13%)
– not enough staff (13%)
– poor technical skill of staff (13%)
– communication problems (12%)
Source: NSW Health, Population Health Survey 2007.

23. Patient Ratings of Overall Quality of Care, NSW
Non-admitted emergency patients, 2008 and 2007
• Top 5 key drivers:
– Giving patients complete information
– Giving patients an explanation of what was done to them
– The availability of doctors
– Courtesy of emergency department staff
– Doctors and nurses working well together
Source: NSW Health, Patient Survey 2008.

24. Patient Ratings of Overall Quality of Care, NSW
emergency department patients, 2007
• Overall, 79% of those who presented to an emergency
department rated their care as excellent, very good or
good.
• The remainder rate care as fair (11%) or poor (9%).
• The main reasons for rating care as fair/ poor were:
– waiting time (61%)
– poor or adequate service (17%),
– not enough staff (12%)
– poor attitude of clinical staff (8%)
– communication problems (7%)
Source: NSW Health, Population Health Survey 2007.

28. Outline
• Health care and reform in Canada
• The “confidence conundrum”
• Research evidence to inform efforts to:
– Build public confidence
– Improve overall views on quality
– Publicly report on progress
• Who needs to know what …

30. Public priorities for HOSPITAL performance reporting in
Canada
Rating 9 to 10 Skill of medical staff
out of 10 Patient satisfaction with care
Serious medical errors
Use of latest technology and equipment
Rating 8 to 9 Extent to which nurses are sensitive and caring
out of 10 Level of coordination: hospital-outside services
Patients provided with useful information at discharge
Job satisfaction of hospital staff
Rating 7 to 8 Wait time for ED for urgent, non-life threatening
out of 10 Wait time for non-emergency surgery
Source: Sandoval GA. 2007. Sustained public preferences on hospital
performance across Canadian provinces. Health Policy 83: 246-256.

31. dwatson@chspr.ubc.ca