“If you don’t measure, you can’t improve”
Dr. Paul Kurdyak is Medical Director of Performance Improvement and Director of Health Outcomes and Performance Evaluation in the Institute for Mental Health Policy Research at CAMH. He is also Lead of the Mental Health and Addictions Research Program at the Institute for Clinical Evaluative Sciences (ICES). In this Q&A, he explains how a commitment to measurement is driving improvements in mental health and addictions care across the health care system and at CAMH.
Why is it important to measure service use and performance in the mental health and addictions system?
Measurement is important because it shows whether services are being delivered effectively and equitably. Until recent years, the mental health system lagged behind the overall health care system in its ability to measure outcomes. If we aren’t able to measure, there’s no way to strategically identify and improve where there are gaps in care, or to respond to changes in demand.
For example, one of our recent studies showed a 32 per cent increase in emergency department (ED) visits by children and youth with mental health and addictions problems over six years. This suggests there is a lack of access to community care to treat individuals through outpatient services, so parents are bringing their kids to the ED instead. By providing this evidence to health planners, it can help inform their decision-making to address this issue.
I’m also co-chair of a task force that selected a core set of mental health and addictions performance indicators for Ontario. These indicators were selected to show system performance in relation to being client-centred, safe, timely and efficient, as well as effective and equitable.
Investments in the health care system have an impact, so it’s in all of our interests to ensure we’re making wise choices.
How do you decide what to measure?
A useful measure has to be easily understood by patients and providers. This is why it’s important to have public and client engagement in developing health care system indicators. It is important to select measures that tell us something about areas we want to change or get better at. We measure what we do so that we can take action to drive quality improvement.
Any measure has to respond to changes, and have the ability to be measured over time. I can provide several examples from our work with the province. We wanted one indicator to show if services were client-centred. For this, we are looking to measure client satisfaction with care. To measure efficiency, we have identified four indicators. One of these is unscheduled emergency department visits within 30 days, and we get the data from the Canadian Institute for Health Information. To measure equity, we can analyze ICES health care use data by geography, income by neighbourhood, immigration status, age and sex.
We try to focus on measuring a few things, and measuring them very well, so we can concentrate efforts on improvement on those measures.
How are these findings applied to make improvements?
Measurement is just the beginning. It is part of the quality improvement cycle. Once you identify a need, you have to identify a plan to address the need and implement it. Then you measure the outcome, and the cycle continues. There needs to be an ongoing commitment to measuring and improving over time, which can involve a cultural change in an organization or system.
Can you describe a positive impact resulting from measurement at CAMH?
One example at CAMH is reduction of restraint use in the emergency department (ED). Everyone got behind this initiative, from CAMH leadership to front-line staff. We had a way to measure outcomes over time. There is a culture of continuous quality improvement. We’ve reduced the use of restraints in the ED by 80 per cent and maintained this reduction.
I am excited to generate more of these quality improvements by measuring and using data; that is what the new Performance Improvement area of CAMH is all about, and why I recently joined the team as Medical Director.
What are the priority areas for you moving forward?
Wait times and access to care continue to be priorities.
One aspect of access to care, and part of our ongoing work, is the availability of psychiatric care. Based on lack of access, people assumed there was a shortage of psychiatrists. Our research showed that’s not true for the entire province. Toronto has a high proportion of psychiatrists. Yet access is a problem, because of how some psychiatrists are practicing: some Toronto psychiatrists aren’t taking new patients, and they’re seeing the same patients, who are generally less ill, repeatedly. In non-urban areas, the relatively fewer number of psychiatrists tend to have more patients and to have to see more new patients. So the issue that needs to be addressed isn’t about the number of psychiatrists in Ontario.
We need a broader debate on the role of psychiatrists in a publicly funded system, so that Ontario psychiatrists are providing accessible and equitable care to all residents who need specialist-level care. That likely means that psychiatrists will have to adopt to new ways of practicing by working in multi-disciplinary teams and by engaging in new modes of care delivery, such as collaborative care practices integrated with primary care.
What are your priority areas at CAMH?
Measuring the outcomes of our clinical activity with patients throughout their patient journey is a key priority. Our patients interact with the health care system in many ways, such as with their family doctors, through our emergency department, or with community agencies. It is important to understand how these different interactions come together and affect outcomes and experiences for our patients.