Gregory P. Marchildon

Using the Delphi Method for Qualitative, Participatory Action Research in Health Leadership:

Current pressures on public health systems have led to increased emphasis on restructuring, which is seen as a potential solution to crises of accessibility, quality, and funding. Leadership is an important factor in the success or failure of these initiatives. Despite its importance, health leadership evades easy articulation, and its study requires a thoughtful methodological approach. We used a modified Delphi method in a Participatory Action Research (PAR) project on health leadership in Canada. Little has been written about the combination of Delphi method with PAR. We offer a rationale for the combination and describe its usefulness in researching the role of leadership in a restructuring initiative in “real time” with the participation of health system decision makers. Recommendations are provided to researchers wishing to use the Delphi method qualitatively (i.e., without statistical consensus) in a PAR framework while protecting the confidentiality of participants who work at different levels of authority. We propose a modification of Kaisers (2009) post-interview confidentiality form to address power differentials between participants and to enhance confidentiality in the PAR process.

Primary care in Ontario, Canada: New proposals after 15 years of reform

Primary care has proven to be extremely difficult to reform in Canada because of the original social compact between the state and physicians that led to the introduction of universal medical care insurance in the 1960s. However, in the past decade, the provincial government of Ontario has led the way in Canada in funding a suite of primary care practice models, some of which differ substantially from traditional solo and group physician practices based on fee-for-service payment. Independent evaluations show some positive improvements in patient care. Nonetheless, the Ontario governments large investment in the reform combined with high expectations concerning improved performance and the deteriorating fiscal position of the provinces finances have led to major conflict with organized medicine over physician budgets and the governments consideration of an even more radical restructuring of the system of primary care in the province.

Canada's universal health-care system: achieving its potential

Summary Access to health care based on need rather than ability to pay was the founding principle of the Canadian health-care system. Medicare was born in one province in 1947. It spread across the country through federal cost sharing, and eventually was harmonised through standards in a federal law, the Canada Health Act of 1984. The health-care system is less a true national system than a decentralised collection of provincial and territorial insurance plans covering a narrow basket of services, which are free at the point of care. Administration and service delivery are highly decentralised, although coverage is portable across the country. In the setting of geographical and population diversity, long waits for elective care demand the capacity and commitment to scale up effective and sustainable models of care delivery across the country. Profound health inequities experienced by Indigenous populations and some vulnerable groups also require coordinated action on the social determinants of health if these inequities are to be effectively addressed. Achievement of the high aspirations of Medicares founders requires a renewal of the tripartite social contract between governments, health-care providers, and the public. Expansion of the publicly funded basket of services and coordinated effort to reduce variation in outcomes will hinge on more engaged roles for the federal government and the physician community than have existed in previous decades. Public engagement in system stewardship will also be crucial to achieve a high-quality system grounded in both evidence and the Canadian values of equity and solidarity.

Public reporting on quality, waiting times and patient experience in 11 high-income countries.

This article maps current approaches to public reporting on waiting times, patient experience and aggregate measures of quality and safety in 11 high-income countries (Australia, Canada, England, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland and the United States). Using a questionnaire-based survey of key national informants, we found that the data most commonly made available to the public are on waiting times for hospital treatment, being reported for major hospitals in seven countries. Information on patient experience at hospital level is also made available in many countries, but it is not generally available in respect of primary care services. Only one of the 11 countries (England) publishes composite measures of overall quality and safety of care that allow the ranking of providers of hospital care. Similarly, the publication of information on outcomes of individual physicians remains rare. We conclude that public reporting of aggregate measures of quality and safety, as well as of outcomes of individual physicians, remain relatively uncommon. This is likely to be due to both unresolved methodological and ethical problems and concerns that public reporting may lead to unintended consequences.

The crisis of regionalization

Currently in Canada, there is no consensus concerning the efficacy of regionalization, a reversal of the strong commitment in favour only a decade earlier. Instead, provincial governments are either dismantling regional health authorities in favour of highly centralized structures under the control of ministries of health or actively considering more centralized approaches. There is a general feeling among political leaders that regionalization has failed to achieve its original objectives. However, by not including physicians and primary care within regionalized governance, provincial governments have never given regionalization a real chance. Moreover, given the fact that the status quo prior to regionalization was far from an ideal state and would be almost impossible to return to in any event, some provincial governments should consider implementing a more full-blooded version of regionalization before abandoning the approach.

Hospitals in rural or remote areas: An exploratory review of policies in 8 high-income countries.

Our study reviewed policies in 8 high-income countries (Australia, Canada, United States, Italy, Spain, United Kingdom, Croatia and Estonia) in Europe, Australasia and North America with regard to hospitals in rural or remote areas. We explored whether any specific policies on hospitals in rural or remote areas are in place, and, if not, how countries made sure that the population in remote or rural areas has access to acute inpatient services. We found that only one of the eight countries (Italy) had drawn up a national policy on hospitals in rural or remote areas. In the United States, although there is no singular comprehensive national plan or vision, federal levers have been used to promote access in rural or remote areas and provide context for state and local policy decisions. In Australia and Canada, intermittent policies have been developed at the sub-national level of states and provinces respectively. In those countries where access to hospital services in rural or remote areas is a concern, common challenges can be identified, including the financial sustainability of services, the importance of medical education and telemedicine and the provision of quick transport to more specialized services.

Extreme drought and excessive moisture conditions in two Canadian watersheds: comparing the perception of farmers and ranchers with the scientific record

This study compares climatological data for two climate extremes, severe drought and excessive moisture, to the experience and memories of agriculturalists based on extensive interviews with farmers and ranchers in the southern Great Plains of Canada. The climate data used were the Standardized Precipitation and Evapotranspiration Index. While differences are expected between these quantitative and qualitative sources due to the fact that there is often a gap between any extreme weather event and its impact, there was less difference than expected. However, these gaps are significant because politicians, policy makers and emergency preparedness planners do, or at least should, take into account the perceptions of those most directly affected by climate extremes and understand the instances. The findings confirm the importance of localized and experiential knowledge in climate change adaptation.

Prioritizing health leadership capabilities in Canada: Testing LEADS in a Caring Environment.

This article is the first major empirical test of LEADS in a Caring Environment, the principal leadership capability framework in Canada. The results rank the perceived salience of leadership attributes, given time and budget constraints, while implementing a major organization reform in the Saskatchewan health system. The results also indicate important differences between self-assessed leadership behaviours versus observed behaviours in other leaders that may reflect participants’ expectations of managers with designated authority.

Reflection/Commentary on a Past Article: “Using the Delphi Method for Qualitative Research in Health Leadership”: http://journals.sagepub.com/doi/full/10.1177/160940691401300101

In 2014, we published our application of a modified Delphi method for qualitative, participatory action research (PAR) on health leadership. The lead author (Fletcher) was, at the time, a postdoctoral research fellow working in the area of research methodology. This article was one of her first peerreviewed journal publications. The second author (Marchildon) was Canada Research Chair in public policy and economic history specializing in health policy research. The article reported on a pan-Canadian research project about leadership during health system redesign, which sought to identify best practices in leadership during major health system change. Our project was one of the five regional studies across Canada, each examining a case of health system restructuring. The goal of our case study was to examine leadership practices during the onset of Shared Services—a restructuring initiative to consolidate service delivery and “back-office” functions across Saskatchewan’s 12 health regions. At the time, Shared Services was promoted as an alternative to full consolidation of the health regions. However, some of our participants wondered if Shared Services was a first step toward centralization, a suspicion confirmed years later when the province’s health regions were amalgamated into a single provincial health authority. The project methodology needed to address a policy problem (the requisite leadership capacity needed to achieve health reform/restructuring, although this could be applied to many policy management arenas outside health care), a research problem (the difficulty of defining and measuring health leadership and the contested concept of leadership), and the research design (PAR), which harnesses the knowledge and expertise of participants by integrating them as project collaborators. We faced several challenges in our methodological design. The first pertained to power and confidentiality in a study of distributed leadership. In order to best understand the experience of leading change at different levels of authority, our sample needed to consist of health system leaders at three levels: “front line” units, senior leadership below CEO level, and senior executive leadership in the ministry and health regions. To evaluate effective leadership in practice, participants needed to feel safe commenting on the leadership of those above them, which necessitated careful confidentiality provisions. The second challenge was to find an effective mechanism for sharing and validating results with both our participants and our participant collaborators (i.e., our PAR partners) while preserving confidentiality. The leaders’ busy schedules added an additional layer of difficulty; for many, the change initiative—not to mention the research project examining it—was largely being completed “off the side of their desks,” a commonly heard refrain in our findings. Our underlying challenge, therefore, was to find a method that ensured participant confidentiality while still facilitating dialogue and constant involvement of our participant collaborators. Few of the standard qualitative methods would serve this purpose alone: while in-depth interviews would provide the necessary confidentiality, interview transcripts could not be shared with the participant collaborators and would not allow for the kind of dialogue provided through group methods like focus groups or nominal group technique. Considering the power differentials and high levels of tension and uncertainty participants were experiencing during the Shared Services transition, the lack of confidentiality inherent in group activities made them a non-option. Delphi technique, in contrast, provided an opportunity for iterative dialogue on the interview themes while guarding

The comparative performance of the Canadian and Australian health systems

Using three data sets, each providing an overview of health service delivery in high-income countries, this article provides a high-level comparative analysis of health system performance against specified key performance indicators in two jurisdictions: Canada and Australia. Several variations, nuances, and points of comparison between delivery and organization of care are discussed. The article examines three policy and structural differences that may help explain the comparatively superior performance of the Australian system on most indicators, and two key areas of improvement for the Canadian system were illuminated: a stronger central government role and a national pharmaceutical plan. It is hoped that this article will empower health leaders to take action in these areas.