CEO Janet Knox addresses Halifax Chamber of Commerce

Janet Knox spoke to the Halifax Chamber of Commerce April 12.
Janet Knox spoke to the Halifax Chamber of Commerce April 12.

Janet Knox, CEO and President of Nova Scotia Health Authority, spoke to the Halifax Chamber of Commerce on April 12 about the successes and challenges around the organization’s journey to improving access to programs and services, and the overall health of all Nova Scotians:

You can’t listen to the news, read an opinion piece or scroll through social media without seeing or hearing something about Nova Scotia’s health system.

Words like ‘ailing,’ ‘broken,’ and ‘crisis’ are being used to describe a system that is, admittedly, under significant pressure. There are similar headlines across the country.

Addressing our challenges means making some real changes to how we deliver care. Yet, change is often met with resistance, disappointment, or even hostility.

Why are we so committed to protecting a system that so many people say is failing us?

Good afternoon. I’m pleased to be here to talk to you about some of the successes and challenges we’re facing on our journey to improving health, care and access for all Nova Scotians.

I understand the concern and frustration of Nova Scotians who don’t have a family doctor or nurse practitioner. And those who are waiting too long for mental health care, a test or procedure or a nursing home.

These are long standing challenges that we are working hard to address. They are what make our efforts to create a more responsive and sustainable health system so important. It’s what keeps me coming to work every day.

I also have to say that what we see in the media does not reflect the bulk of what happens in our health system every single day. Staff, doctors, volunteers, and learners come to work with a desire to make a difference, and they do. Every day, thousands of people receive exceptional care and service.

Celebrating our accomplishments creates the energy we need to address the challenging and complex issues that we are facing. And, helps us attract and keep the talent that we so desperately need.

I know people are eager to see results…. I understand that…. I want that too.

It’s why I took on this job nearly five years ago. I believed then, as I do now, that a province-wide health authority offers Nova Scotia the best opportunity to modernize and transform our health system so that we are able to meet the needs of our residents today and create a healthier future.

We are now four years into what is arguably the largest and most complex restructuring in Nova Scotia’s history. Much of that work has been invisible to the public.

I know it’s hard for people to understand how consolidating thousands of policies and procedures, or going from 45 separate union contracts to four actually makes a difference to health.

Or, how successfully completing our first province-wide Accreditation contributes to better care and improves the system.

Words like policy and procedure, accreditation, and collective bargaining sound very sterile, bureaucratic and cold. So I can understand the perception that little is happening, or that it’s happening too slowly.

But anyone who works in the system will tell you there has been a lot of change in a short amount of time.

Implementing large scale change in a complex, integrated system, across a broad and diverse demographic and geography takes time. We need to ensure the decisions we make are thoughtful, well-planned and based on evidence.

This is not simple, quick or easy.

Our integrated health authority structure was just the beginning. I can say with confidence that we are seeing better alignment and integration and more consistency and coordination within programs and services. Equally important, we have created a solid foundation that will allow for fundamental changes in how we deliver care to Nova Scotians.

Government’s investment in redevelopment projects in Halifax and Cape Breton are good examples. We’re not simply replacing aging hospitals. We are modernizing and transforming care delivery in these communities by looking at the needs of the population we’re serving and then redesigning our programs and services to meet those needs. We’re investing in community-based care, maximizing our existing infrastructure and building, and expanding where necessary so that we can make the best use of our talent, expertise and resources.

The hospital-based model we have now doesn’t work the way it did when it was designed 50 years ago.

Times have changed. Our population has changed. Technology has changed. Care has changed. We know more about health and wellness. We can do more for people, but If we aren’t prepared to change, then we better be prepared to accept more of the same, or worse. Here’s why.

Nova Scotians are among the least healthy Canadians.

We have high rates of cancer, cardiovascular diseases, chronic respiratory diseases and diabetes. More than 60 per cent of deaths are attributed to these four causes. This is not surprising when you consider that we have a higher percentage of smoking, heavy drinking and obesity than the national average.

We also have a population challenge.

As the general population ages, so too does our workforce. More care providers are retiring as global demand for them increases, making vacancies difficult to fill. It’s even harder to attract young professionals to some of our rural communities.

Calls to hire more doctors and nurses and open more hospital and long-term beds just isn’t as simple as it may seem with fewer people entering the workforce than leaving it.

We have to be strategic about where we place providers and recognize the instability that can result when services are reliant on one or two people. We have to maximize use of technology and be open to new models of care so that we are using the skills and talents of our care providers effectively. Use of telemedicine to evaluate, diagnose and treat patients from a distance and use of point-of-care testing to give faster access to results at the bedside are good examples.

And finally, health care continues to cost more and more, which leaves very little for the other services that Nova Scotians rely on  many of which have a direct or indirect impact on health and wellness. In 2019-20, Nova Scotia Health Authority will spend about $2.2 billion on health care – and that’s projected to grow.

Demand is one factor, but there are other factors, too. With over 40 hospitals and health centres, we have a very large physical footprint  far greater and older than the national average. Many of our buildings and equipment are in need of significant repair or replacement – which represents hundreds of millions of dollars.

We do our best to control costs, and are proud of our energy and environmental stewardship efforts, which just this year resulted in an additional $930,000 in energy savings and represents more than 5,100 tons of carbon dioxide that will not go into our atmosphere. But more and more money is going into maintaining buildings and equipment, rather than care and equally importantly, health promotion and illness prevention.

Health is about more than dollars, of course. The challenge is that we are spending more and not getting healthier.

All of this has contributed to a health system in need of both fine tuning and realignment.

Our hospitals are routinely at 95 per cent or above occupancy. We know that a rate of 85 per cent is needed for more efficient patient flow. There are many people in hospital who could be cared for in another setting if that support was available.

Hospitals serve as a social safety net. There are many different reasons that can prevent or delay discharge. This contributes to overcrowding in our emergency departments and has a domino effect  increased wait times, delays in ambulance offloads, cancelled surgeries, and on and on. The system, as I noted earlier, is complex and integrated.

Our focus is on improving timely access to community-based care and services and realigning our resources with a focus on the right care, by the right provider,  in the right place, at the right time. In some cases we may need to move resources around, stop doing something that offers little or no value or take a different approach for better results.

For example, we currently have 38 emergency departments and Collaborative Emergency Care centres in Nova Scotia – some of which experience frequent closures. We need to carefully consider the balance between points of access and quality of care. Having too many locations may mean people can be seen very quickly, but may also mean providers aren’t seeing a volume or variety enough of true emergencies to maintain a high level of skill.

It may also impact availability of primary care resources as many of these sites are staffed by family doctors. On the other hand, having too few locations may mean patients have too far to go, or too long to wait to access that care. It’s important to find the right balance when we look at care delivery.

Our vision for a healthier Nova Scotia is built on a strong foundation of primary health care , in which Nova Scotians have access to a collaborative family practice team in their local community. Doctors, nurse practitioners, family practice nurses, and other providers work together to provide a full range of ongoing care to their patients.

This is top of mind for Nova Scotians and the key priority for us.

Other areas that have built strong primary health care systems based on this model have healthier populations and lower rates of hospitalization. It also helps recruit and retain health professionals in our communities.

Today, there are almost 80 collaborative family practice teams in various stages of development and we continue to build and strengthen these teams.

Since March 2017, we have hired 130 nurse practitioners, family practice nurses and other health professionals to work in these teams.

Over 80,000 Nova Scotians have found a family practice since we started tracking this information in November 2016.

At the same time, we are working hard to recruit family doctors. We developed a comprehensive recruitment strategy, created a provincial advisory committee, and worked with our partners to create more training opportunities for residents and a new practice-ready assessment program for foreign-trained doctors.

We are increasing community and physician involvement in recruitment, enhancing supports for candidates and newly recruited physicians and building on our local, national and international recruitment efforts. We have recruited 130 doctors, including 58 family doctors and 72 specialists this year, and 344 in total since recruitment was transferred to us in 2016.

Many Nova Scotians experience mental health and addictions issues. We are improving access to mental health and addiction care and support for people and their families. We’re enhancing our response to children and youth through the Schools Plus Program. We have added clinical resources to our community, crisis response and urgent care clinics. And more psychiatrists are using video conferencing and other technologies to support patient care.

In addition, we are implementing a new standardized central intake line that will make it easier for Nova Scotians to access the care they need. Four years ago, each district health authority had multiple ways to access this services which was confusing to the public.

We have also been challenged to meet the national seven-day standard for urgent care. Today, I can tell you that between October and December 2018, 86 per cent of the time, patients who were triaged as urgent were seen within seven days or less. Our goal for this year is 100 per cent.

There remains much to do and we are committed to making those improvements.

We know many individuals in this province are waiting for hip or knee replacements and have launched a multi-year plan to improve access, promote wellness and improve the quality of care.

The plan includes a new streamlined referral process and inpatient model, four additional surgeons, enhanced and expanded orthopedic assessment clinics and more than 70 additional full-time equivalent positions in roles such as nursing, physiotherapy and occupational therapy.

For the last two years our data showed an increase in joint replacements and a wait list reduction. Early data is also showing that lengths of stay are decreasing, too.

Let me tell you about the model of care. We have created a shift from an illness model to a wellness model – which is an approach that we would like to expand to all of our programs and services.

For our teams who have helped put this model in place, it represents a fundamental shift in how we think about and care for patients. After all, patients with hip or knee issues are not necessarily sick, so why treat them like they are?

All patients now receive a timely initial assessment from an orthopedic assessment clinic team, access to rehabilitation programs and other education and supports leading up to their surgery and are encouraged to work with a personal coach to help them on their journey.

After surgery, patients can expect to be up and dressed early the next morning, ready to take part in group activity classes which help recovery and prevent complications. Some patients are even returning home the same day. Convalescing in a hospital bed for days after getting a new hip or knee is a thing of the past.

We are hearing wonderful stories from staff, physicians and patients and their families about the positive impact this is having.

Efforts like these are helping change the way we deliver patient care, inform ongoing improvement in other programs and services, and are key to our system’s future.

And we continue to foster a Home First philosophy that promotes safe and timely care, as well as services and supports to help people stay healthy and independent at home for as long as possible. There’s more to do, but since March 2015, the number of people waiting for both long-term care and home support has been reduced by about 50 per cent.

The INSPIRED COPD Outreach Program is another great example. This program provides education and support to people with chronic obstructive pulmonary disease and their families in their homes. These patients have fewer symptoms, lower risk of complications and spend less time in hospital. In an early analysis of facility usage for 51 patients from Cape Breton, six months after enrolling in the program, emergency department visits, admissions and bed days decreased by more than 70 per cent.

These are just a few examples of the efforts underway within the heath system to incorporate advances in science and technology, best practices based on research and the needs of the population into how we deliver safe, quality and appropriate care.

As a teaching and research organization we have a responsibility to explore, evaluate and implement new technologies, treatments and approaches to care like these. Making this shift is hard work. It’s important work. And we’re starting to see proof that it’s working.

I’ve left some key facts and figures about NSHA and the improvements we are making on your tables, which I hope will give you a sense of the tremendous amount of work underway. We don’t want to shy away from the dialogue about what we can do better, but there is a lot of misinformation out there. And there's a lot of missing information about the people who are working hard every day to make things better  stories of compassion, care, collaboration and innovation. I encourage you to follow us on Facebook, Twitter and Instagram, and please subscribe to our monthly newsletter to stay up to date.

Our health is personal and precious. We all want a health system we can rely on – one that supports us to be healthy and where we can depend on having access to primary care, get a test or a medical procedure, or a hospital bed in a reasonable amount of time when it is needed. That can happen if we start thinking about our providers, programs and facilities as a network of interconnected resources that can be better coordinated to better serve all Nova Scotians.

Change is hard. It’s natural to be afraid of what we might lose. But what if this fear is preventing us from being open about the opportunities for better health and better care? How much could we stand to gain?

Creation of a provincial, integrated health authority was an opportunity to transition from an outdated, historical health care model to a modern one and to be more strategic in the way we deliver, fund, resource and plan services to adjust for the realities facing our health system and our province.

We have a choice. Today I’m asking you to be part of the solution.

There is a lot of great work happening, and we are seeing progress, but there is a lot of heavy lifting left to do. Improving health, access and care for all Nova Scotians requires all of us to come together to find solutions, to be open to change and to embrace the possibilities that are before us. And we’re going to need courage, resilience and perseverance.

I’ve spent the bulk of my career 30-plus years, working in Nova Scotia. I am retiring this summer and I am doing so with so much hope and optimism for the future. I’ve been inspired by conversations with our teams, partners, patients and families, as well as with communities that want us to spend more time promoting health and wellness and less time protecting the status quo; that believe we can find solutions if we work together toward a common goal – healthy people and healthy communities.

We have a solid foundation for that to happen and I truly believe that our success will mean a healthier and more prosperous future for all of us  and for our children and grandchildren.

Thank you.