RESPONSE TO GUEST COMMENTARY
Finding economies of scale and coordination of care along
the continuum to achieve true system integration
Maura Davies, BSc, BEd, MHSA, FCCHL
Abstract—Is it time to reduce hospitals and replace them with digitally enabled distributed specialty service delivery channels that
focus on ambulatory care, urgent care, and patient reactivation? Is delivery system integration immaterial if care is standardized and
supported by integrated information systems? Maybe Lean methodology needs to be applied across the entire delivery systems,
not just within its component functions and processes. Comments are offered on each of these perspectives.
I
s the centre of our universe, at least what is often viewed
as the centre of our health system, about to shift? In his
commentary, Colin Goodfellow suggests that it needs to
shift dramatically, with a significant reduction in hospitals,
replaced by “digitally enabled distributed specialty service
delivery channels” that focus on ambulatory care, urgent
care, and patient reactivation. In addition, Goodfellow
argues that delivery system integration is “immaterial” if
care is standardized and supported by integrated informa-
tion systems. He also states that Lean methodology needs
to be applied across the entire delivery systems and not
just within its component functions and processes. I will
comment on each of these perspectives.
I find it interesting when my Ontario colleagues comment
on integrated health systems and, in many cases, argue for
perpetuation of the current hospital-centred model in the
only province that has not adopted regional models of
integrated health systems. Goodfellow references the claim
of the Ontario Hospital Association that integrated systems in
Canada on average cost 10% more than non-integrated
systems in Canada. I am not familiar with the evidence to
support this claim but suspect it compares apples and
oranges. Having worked in an integrated system for many
years, nine of them in Saskatchewan, I would not want to
work in any other model. When talking to Ontario colleagues,
I often feel that we are in a different business, a sentiment I
have heard expressed by others working in regional systems,
where we have responsibility for the full continuum of care
and improving the health of our community as well as
improving the delivery of health services.
I agree with Goodfellow that we need to re-envision the
role of hospitals. When compared with even a decade ago,
From the Saskatoon Health Region, Saskatoon City Hospital, Saskatoon,
Saskatchewan, Canada.
Corresponding author: Maura Davies, BSc, BEd, MHSA, FCCHL, Saskatoon
Health Region, Corporate Office, Level 1 Administration, Saskatoon City
Hospital, 701 Queen Street, Saskatoon, Saskatchewan, Canada, S7K 0M7.
(e-mail: Maura.Davies@saskatoonhealthregion.ca)
Healthcare Management Forum 2014 27:158–160
0840-4704/$ - see front matter
& 2014 Canadian College of Health Leaders. Published by Elsevier Inc. All rights
reserved.
http://dx.doi.org/10.1016/j.hcmf.2014.08.006
hospitals are increasingly a virtual intensive care unit. The
acuity and complexity of patients admitted to hospital are
much higher. Particularly in larger urban centres, where
bed occupancy tends to run near 100% or higher, only the
very sickest patients get admitted. All too often, these
patients remain in hospital when more appropriate set-
tings of care are not available or resourced to meet client
needs after the acute hospital phase is completed. I agree
that if we could improve patient flow and provide care in
the right place by the right person, we would have more
appropriate utilization of acute care beds and ultimately
require fewer of them.
So why don't we just do this? In some cases, this is
starting to happen, even in the presence of resistance by
some care providers and communities. Across Canada,
there has been a disproportionate preoccupation with
building hospitals, with a much smaller investment in
alternative care settings such as ambulatory care, hospice,
rehabilitation centres, assisted living housing, or long-term
care. In Saskatoon, there are three hospitals within close
proximity, which traditionally offered many of the same
services. There continues to be some opposition to ration-
alizing these services, differentiating the role of each
hospital and redefining the role of one site to focus more
on day surgery, ambulatory care, and rehabilitation. As part
of our 2014-2015 business plan and strategy to enhance
patient flow and reduce waits in our emergency depart-
ments, Saskatoon Health Region will be expanding and
repurposing some of our acute care beds to add capacity
for patients with complex behavioural problems and those
requiring longer periods of convalescence. Ideally those
services would be available outside a hospital or long-term
care facility, but in the absence of community resources we
are working within existing facilities. Although there will be
an initial investment in additional staff, furniture, and
equipment, we have calculated that there will actually be
a reduction in operating costs by providing care in a more
appropriate setting, with a different staffing mix. There is
ample evidence of the potential positive impact on patient
experience, emergency department waits, and patient flow
though this approach. Time will tell if we achieve those
results.
 FINDING ECONOMIES OF SCALE AND COORDINATION OF CARE ALONG THE CONTINUUM TO ACHIEVE TRUE SYSTEM INTEGRATION
It should be noted that much hospital construction is
being done to meet changing demographics (eg, popula-
tion growth in urban centres) and replacement of aging
facilities that pose risks to both patient and staff safety and
do not meet modern standards and needs for team-based
models of care, patient confidentiality, and infection
control.
Goodfellow references the increasing adoption of Lean
across many jurisdictions. I agree that the size of hospitals
can be affected by applying both Lean design and Lean
principles in managing patient flow. The new regional
hospital in Five Hills Health Region, Saskatchewan, is being
designed with fewer beds and no emergency department
waiting room. Part of the Lean work in Five Hills includes
focused attention on reducing lengths of stay and improv-
ing patient flow in advance of moving into their new
hospital. They are proving it can be done.
So, do I agree with Goodfellow's premise that we should
be reducing our reliance on hospitals and largely replacing
them with smaller, more specialized and decentralized care
settings? Yes and no. Clearly our hospitals are occupied by
many individuals who would be better cared for in
alternate settings. I do not believe that should mean a
return to a large number of small autonomous facilities, as
largely existed before the establishment of health districts
in Saskatchewan and the infamous closure of 52 small-
community hospitals. There are inherent inefficiencies in
very small facilities and a middle ground needs to be
found where economies of scale and coordination of care
along the continuum are achieved. In addition, recruitment
and retention of staff in small autonomous facilities are
often challenging. If you build it, they may not come.
Goodfellow argues the case for clinical integration
supported by enabling information technology, presum-
ably including but not limited to electronic health records.
He appears to dismiss the benefits of system integration.
I agree that system integration, such as the regional
structures in Saskatchewan, does not equate to clinical
integration. For me, it is not a case of either-or but rather
the need for both clinical and system integration. Inte-
grated health systems reflect the continuum of care and
enable smoother transitions of care, as we are starting to
see in regions such as Island Health where enhanced home
care and care planning are enhancing flow and client care.
Yes, this can be achieved in non-regional structures when
different agencies agree to collaborate, but it is enabled
when all those services fall under the same umbrella.
I agree that many provinces, including Saskatchewan, have
a long way to go in achieving clinical integration. I do not
believe it is as simple as standardization of care and
integrated information systems. I believe that clinical
integration needs to also include joint planning and robust
mechanisms to monitor and report clinical outcomes.
Collaboration, including clinical cross-coverage, needs to
be part of clinical integration, especially where there are a
small number of subspecialists who cannot be expected to
Healthcare Management Forum  Forum Gestion des soins de santé – Winter/Hiver 2014
provide continuous coverage. Despite the difficulties expe-
rienced in Alberta with establishment of a single provincial
region, my impression is that their approach to province-
wide clinical networks is showing promise and we can
learn from them.
Largely conspicuous from Goodfellow's arguments is
reference to the need for closer integration of primary
healthcare into other aspects of our system. Many regional
structures include some primary healthcare teams, but the
majority of family physicians function fairly autonomously,
with little interaction with other parts of the system except
ordering diagnostic tests and referring more complex
patients to specialists. Fee for service funding models
provide little incentive or support for many physicians to
function as part of an integrated system of care. It is my
belief that to achieve full system integration, a different
structure and physician funding models will be required to
achieve a system that truly supports the triple aim of better
patient- and family-centred care, better value for the
money invested in healthcare, and better health of our
population. I recently had the great honour of meeting and
discussing this with Stephen Shortell, whom Goodfellow
cites in his article, and whose research and writings have
informed much of my learning about integrated health
systems.
Goodfellow makes numerous references to Lean techni-
ques throughout his article and the potential to apply Lean
design at the system level. Goodfellow states that ongoing
continuous improvement “can never happen throughout
every service line in a multi-service facility like our legacy
hospitals.” I find this a very curious statement. In my
region, as part of our Lean management system, clinical
services are not organized along traditional hospital
departments. They are structured along service lines (eg,
seniors health, child health, mental health, and addictions)
that reflect the care needs of targeted populations,
regardless of care setting (urban/rural or facility/community).
Although we are only 2 years into adoption of our
provincial Lean management system, our intention is to
ensure Lean thinking, tools, and methods apply to all
aspects of our health system and not selected service lines.
The experiences of Virginia Mason, ThedaCare, and other
well established Lean organizations prove this can be
accomplished with demonstrable improvements in service
quality and efficiency, patient, and staff satisfaction.
All too often in healthcare, people think about Lean as
another tool in their “quality toolkit,” to be applied when
they want to tackle improvements to specific processes.
Goodfellow's comments reflect the need to differentiate
between using Lean tools on a particular “Lean project” as
opposed to adopting a Lean management system, few of
which exist in Canada. Increasingly, eyes are on Saskatch-
ewan, which has adopted a Lean management system
based on the Toyota Production System for the entire
health system. This includes a province-wide approach to
strategy development and deployment (hoshin kanri) and
159
Davies
alignment of all parts of the system to achieve a shared
purpose—better health, better care, better value, and
better teams. It involves a shared commitment to very
ambitious system goals, for example, no harm to patients
or healthcare providers, no emergency department waits,
access to primary healthcare on day of choice, and access
to elective surgery within 3 months. Other aspects of our
Lean management system include cross-functional man-
agement across traditional departments and units and
above all, a focus on daily visual management and
improvement at the point of care and service. This is a
very different way of working and a very different way of
managing the system. It redefines the roles of system
leaders and requires them to follow leader standard work,
a fairly foreign concept to most of us.
A good example of the entire Saskatchewan system
working as an integrated health system is the Saskatch-
ewan Surgical Initiative. Over a 4-year period, achievement
of sooner, safer, smarter surgical care was identified as a
provincial priority (or hoshin). The results in improved
access, adoption of evidence-based practices (eg, spine
pathway), and safer care (eg, use of surgical checklist and
160 Healthcare Management Forum  Forum Gestion des soins de santé – Winter/Hiver 2014
surgical site infection bundles) have been truly remarkable.
Although certainly part of our success has been a consid-
erable infusion of funding to build more surgical capacity,
I do not believe these results could have been achieved
without our regional structures, commitment to “think and
act as one,” and accountability for province-wide results
within our Lean management system.
So, where from here? I hope and expect to see more
options for providing care in the most appropriate setting
by the most appropriate care team. We need to accelerate
the adoption of electronic health records and other
technology (eg, Telehealth and robotics) to support our
care. I anticipate there will continue to be refinements in
the regional structures in many provinces, as is scheduled
to occur this year in Nova Scotia. As more Canadian
organizations adopt Lean as their management system
and leverage the knowledge and experience of more
mature Lean systems, we will demonstrate our ability to
eliminate waste, improve efficiency, and add value to our
customers. We will position hospitals as a necessary but
not sufficient part of our care network that meets the
needs of our population.