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Over the last 15 years, there has been a trend in Canada to centralise the provision of health services that were previously administratively and fiscally decentralised. Canadian policy rhetoric on centralisation often identifies improved innovation as an anticipated outcome. This paper challenges the assumed relationship between centralisation and innovation. We incorporate evidence from the management literature into the debate on the structure of health systems to explore the effects that centralisation is likely to have on innovation in health systems. The findings of this paper will be of interest to international policymakers, who are currently grappling with the prospect of maintaining a decentralised approach or adopting a more centralised health system structure in the future.

This paper focuses on the ethics of how to approach the introduction of MAiD as an organizational ethics challenge, a focus that diverges from the traditional focus in healthcare ethics on the ethics of why MAiD is right or wrong. It describes a method co-designed and implemented by ethics and medical leadership at a tertiary hospital to develop a values-based, grassroots response to the decriminalization of assisted dying in Canada. This organizational ethics engagement method embodied core tenants that drew inspiration from a variety of sources, including poetic ones. These tenants are: make the problem bigger; focus on values; cultivate open moral spaces; and trust emergence. The paper describes how these tenants were put into practice in order to create a rigorous and sustainable MAiD program that delivers high-quality care to patients and families while honoring the moral diversity of the hospital workforce. One of the goals in sharing this method is to provide a roadmap for healthcare organizations in Canada and other jurisdictions around the world that are facing the challenge of responding to patient requests for MAiD following the decriminalization of this care option.

Like other Canadian provinces, Quebec managed shortages of Personal Protective Equipment (PPE) in the early weeks of the COVID-19 pandemic. Two years later, with hindsight, what lessons can we learn from this logistics crisis? It is precisely to better understand the decisions made by the supply chain players in the province of Quebec that this paper was written. To fully understand the events, this paper first describes the Quebec healthcare system. Then it retraces the series of events and actions during the first wave, at a time when it was most challenging to procure PPE. It also specifies the main characteristics of the supply chain in the Quebec healthcare sector. Finally, it analyzed these data to come up with recommendations to help public decision makers adopt better supply chain management practices.

PurposeThe purpose of this paper is to explore the appropriation of control rooms based on value-based integrated performance management tools implemented in all publicly funded health organizations in Quebec (Canada) as a form of legitimate sociomaterial work.Design/methodology/approachMulti-site organizational ethnographic case studies in two Integrated health and social services centers, with narrative process analysis of triangulated qualitative data collected through non-participant observation (163 h), individual semi-structured interviews (N = 34), and document review (N = 143).FindingsThree types of legitimate sociomaterial work are accomplished when actors appropriate control rooms: 1) reformulating performance management work; 2) disrupting accountability work and; 3) effecting value-based integrated performance management. Each actor (tools, institutions and people) follows recurrent institutional work-paths: tools consistently engage in disruptive work; institutions consistently engage in maintaining work, and people consistently engage in creation work. The study reveals the potential of performance management tools as “effective integrators” of the technological, managerial, policy and delivery levels of data-driven health system performance and improvement.Practical implicationsThis paper draws on theoretically informed empirical insights to develop actionable knowledge around how to better design, implement and adapt tool-driven health system change: 1) Packaging the three agents of data-driven system change in health care: tools, institutions, people; 2) Redefining the search for performance in health care in the context of value creation, and; 3) Strengthening clinical and managerial relevance in health performance management practice.Originality/valueThe authors aim to stimulate new and original scholarship around the under-theorized concept of sociomaterial work, challenging theoretical, ontological and practical conceptions of work in healthcare organizations and beyond.

BackgroundThere are few examples of the practical application of the concepts of social accountability, as defined by the World Bank and WHO, to health system change. This paper describes a robust approach led by First Nations Health Authority and the Rural Coordination Centre of British Columbia. This was achieved using partnerships in British Columbia, Canada, where the health system features inequities in service and outcomes for rural and Indigenous populations. Social accountability is achieved when all stakeholders come together simultaneously as partners and agree on a path forward. This approach has enabled socially accountable healthcare, effecting change in the healthcare system by addressing the needs of the population.InnovationOur innovative approach uses social accountability engagement to counteract persistent health inequities. This involves an adaptation of the Boelen Health Partnership model (policymakers, health administrators, health professionals, academics and community members) extended by addition of linked sectors (eg, industry and not-for-profits) to the ‘Partnership Pentagram Plus’. We used appreciative inquiry and deliberative dialogue focused on the rural scale and integrating Indigenous ways of knowing along with western scientific traditions (‘two-eyed seeing’). Using this approach, partners are brought together to identify common interests and direction as a learning community. Equitable engagement and provision of space as ‘peers’ and ‘partners’ were key to this process. Groups with varying perspectives came together to create solutions, building on existing strengths and new collaborative approaches to address specific issues in the community and health services delivery. A resulting provincial table reflecting the Pentagram Plus model has fostered policies and practices over the last 3 years that have resulted in meaningful collaborations for health service change.ConclusionThis paper presents the application of the ‘Partnership Pentagram Plus’ approach and uses appreciative inquiry and deliberative dialogue to bring about practical and positive change to rural and Indigenous communities.

The COVID-19 pandemic rapidly forced Canadian post-secondary students into remote learning methods, with potential implications on their academic success and health. In recent years, the use of social media to promote research participation and as a strategy for communicating health messages has become increasingly popular. To better understand how the pandemic has impacted this population, we used social media platforms to recruit students to participate in a national bilingual COVID-19 Health Literacy Survey. The purpose of the survey was to assess the health literacy levels and online information-seeking behaviors of post-secondary students in relation to the coronavirus. This paper outlines the social media recruitment strategies used for promoting participation in the survey among Canadian post-secondary students during the pandemic. Facebook, Twitter, and Instagram accounts were created to promote the online survey. The objective of this paper is to examine the use of Instagram, Facebook, and Twitter as survey recruitment strategies tailored to students. Data analytics from these platforms were analyzed using descriptive statistics. We found that the most commonly used platform for survey dissemination was Twitter, with 64800 total impressions recorded over 3 months. The use of social media as a survey recruitment strategy showed promise in the current context of COVID-19 where many students are participating in online learning and for a study population that actively uses these platforms to seek out information.

In this paper, I offer a personal and professional narrative of how Canada went from prohibition to permission for medical assistance in dying (MAiD). I describe the legal developments to date and flag what might be coming in the near future. I also offer some personal observations and reflections on the role and impact of bioethics and bioethicists, on what it was like to be a participant in Canada's law reform process, and on lessons that readers in other jurisdictions might take from Canada's experience.

There is a growing disconnect between regulatory agencies that are promoting expedited approval to medicines based on early phase clinical evidence and health technology assessment (HTA) agencies that require robust clinical evidence to inform coverage decisions. This paper provides an assessment of the evidence gap between regulatory and HTA agencies on medicines receiving conditional marketing authorisation (MA) and examines how HTA agencies in France, England, Scotland, and Canada interpret and appraise evidence for these medicines. A mixed methods research design was used to identify the types and frequency of parameters raised in the context of HTA decision-making for all conditional approvals in Europe and Canada between 2010-2017. Significant heterogeneity was found across the HTA agencies in England, Scotland, France, and Canada in the assessment of medicines receiving conditional MA, with the highest likelihood of rejection present in Quebec (50%) and Scotland (25%). Rejected medicines were more likely to have unresolved uncertainties related to the magnitude of clinical benefit, study design, and issues in economic modelling. More systematic use of joint early dialogue and conditional reimbursement pathways would help clarify evidence requirements and avoid delays in patient access to innovative medicines.

This paper depicts a case study of an organizational strategy for the promotion of ethical practice when introducing a new, high-risk, ethically-charged medical practice like Medical Assistance in Dying (MAiD). We describe the development of an interprofessional program that enables the delivery of high-quality, whole-person MAiD care that is values-based and sustainable. A "care ecology" strategy recognizes the interconnected web of relationships and structures necessary to support a quality experience of MAiD for patients, families, and clinicians. This program exemplifies a care ecology approach that addresses common barriers to entry to MAiD practice, and also meets the needs of a variety of stakeholders through the creation of patient and family resources, team supports, standards of practice, professional development opportunities, organizational infrastructure, and community partnerships. We also describe how a thriving care ecology evolves to remain resilient, and to enable integration as the needs of the organization, team and program change over time. The design and development of this program may be adapted to other jurisdictions and organizations where MAiD is introduced, or where new patient populations become eligible for MAiD. This care ecology model may also be applicable to the creation of sustainable programs that provide other morally controversial or novel clinical services.

This study assessed the attitudes and needs of physicians and health professional staff at a tertiary care hospital in Canada regarding the introduction of physician assisted dying (PAD) during 2015–16. This research aimed to develop an understanding of the wishes, concerns and hopes of stakeholders related to handling requests for PAD; to determine what supports/structures/resources health care professionals (HCP) require in order to ensure high quality and compassionate care for patients requesting PAD, and a supportive environment for all healthcare providers across the moral spectrum. This study constituted a mixed methods design with a qualitative descriptive approach for the study’s qualitative component. A total of 303 HCPs working in a tertiary care hospital completed an online survey and 64 HCPs working in hospital units with high mortality rates participated in 8 focus group discussions. Both focus group and survey data coalesced around several themes to support the implementation of PAD following the decriminalization of this practice: the importance of high quality care; honoring moral diversity; supporting values (such as autonomy, privacy, beneficence); and developing resources, including collaboration with palliative care, education, policies and a specialized team. This study provided the foundational evidence to support the development of the PAD program described in other papers in this collection, and can be a model for gathering evidence from stakeholders to inform the implementation of PAD in any healthcare organization.

The Royal Canadian Mounted Police (RCMP), like all public safety personnel (PSP), are frequently exposed to potentially psychologically traumatic events that contribute to posttraumatic stress injuries (PTSI). Addressing PTSI is impeded by the limited available research. In this protocol paper, we describe the RCMP Study, part of the concerted efforts by the RCMP to reduce PTSI by improving access to evidence-based assessments, treatments and training as well as participant recruitment and RCMP Study developments to date. The RCMP Study has been designed to (1) develop, deploy and assess the impact of a system for ongoing annual, monthly and daily evidence-based assessments; (2) evaluate associations between demographic variables and PTSI; (3) longitudinally assess individual differences associated with PTSI; (4) augment the RCMP Cadet Training Program with skills to proactively mitigate PTSI; and (5) assess the impact of the augmented training condition (ATC) versus the standard training condition (STC). Participants in the STC (n = 480) and ATC (n = 480) are assessed before and after training and annually for 5 years on their deployment date; they also complete brief monthly and daily surveys. The RCMP Study results are expected to benefit the mental health of all participants, RCMP and PSP by reducing PTSI among all who serve.Les membres de la Gendarmerie royale du Canada (GRC), comme l’ensemble du personnel de la sécurité publique, sont fréquemment exposés à des événements potentiellement traumatiques sur le plan psychologique qui contribuent à la survenue de blessures de stress post­traumatique. Le peu de travaux de recherche disponibles sur le sujet limite l’étude de ces blessures. Le présent article décrit l'étude de la GRC, qui fait partie des efforts concertés que la GRC a déployés pour réduire les blessures de stress posttraumatique en améliorant l'accès aux évaluations, aux traitements et aux formations fondés sur des données probantes, le recrutement des participants, ainsi que les développements de l'étude de la GRC à ce jour. L’étude de la GRC a été conçue pour : 1) élaborer et mettre en place un système d’évaluations annuelles, mensuelles et quotidiennes fondées sur des données probantes et en évaluer l’effet; 2) évaluer les associations entre les variables démographiques et les blessures de stress post­traumatique; 3) évaluer de manière longitudinale les différences individuelles associées aux blessures de stress post­traumatique; 4) intégrer au Programme de formation des cadets de la GRC des compétences permettant d’atténuer de façon proactive les blessures de stress post­traumatique et 5) évaluer l’effet de la formation renforcée (FR) par rapport à la formation standard (FS). Les participants à la FS (n = 480) et à la FR (n = 480) sont évalués avant et après la formation, ainsi que chaque année pendant cinq ans à compter de la date de leur déploiement; ils répondent également à de courts sondages mensuels et quotidiens. Les résultats de l'étude de la GRC devraient être bénéfiques pour la santé mentale de tous les participants, pour la GRC et pour le personnel de la sécurité publique, car ils contribueront à réduire les blessures de stress post­traumatique de tous ceux qui servent la population.Research is limited on how to mitigate posttraumatic stress injuries (PTSIs) among Royal Canadian Mounted Police (RCMP) who are exposed to potentially psychologically traumatic events. The RCMP Study has been designed to develop, deploy and assess the impact of skills taught to proactively mitigate PTSI. RCMP cadets recruited into the study to receive the augmented training are assessed before and after training and annually for 5 years on their deployment date. The RCMP Study results are expected to benefit the mental health of study participants, RCMP and other public safety personnel by mitigating PTSI among all who serve.On dispose de peu de recherches sur les moyens d’atténuer les blessures de stress post­traumatique chez les membres de la Gendarmerie royale du Canada (GRC) qui sont exposés à des événements potentiellement traumatiques sur le plan psychologique. L’étude de la GRC a été conçue pour mettre au point des compétences permettant d’atténuer de façon proactive les blessures de stress post­traumatique, pour intégrer ces compétences à la formation offerte aux cadets et pour en évaluer les effets. Les cadets de la GRC recrutés dans le cadre de l’étude en vue de suivre une formation renforcée sont évalués avant et après la formation ainsi que chaque année pendant cinq ans à compter de la date de leur déploiement. Les résultats de l’étude de la GRC devraient être bénéfiques pour la santé mentale des participants de l’étude, pour la GRC et pour les autres membres du personnel de la sécurité publique, en contribuant à atténuer les blessures de stress post­traumatique de tous ceux qui sont au service de la population.

This paper highlights findings on cancer trends from the Canadian Cancer Statistics 2021 report. Trends were measured using annual percent change (APC) of age-standardized incidence rates. Overall, cancer incidence rates are declining (-1.1%) but the findings are specific to the type of cancer and patient sex. For example, in males, the largest decreases per year were for prostate (-4.4%), colorectal (-4.3%), lung (-3.8%), leukemia (-2.6%) and thyroid (-2.4%) cancers. In females, the largest decreases were for thyroid (-5.4%), colorectal (-3.4%) and ovarian (-3.1%) cancers.Cet article met en lumière les tendances en matière de cancer tirées des résultats du rapport Statistiques canadiennes sur le cancer 2021. Ces tendances ont été mesurées à l’aide de la variation annuelle en pourcentage (VAP) des taux d’incidence normalisés selon l’âge. Globalement, les taux d’incidence du cancer sont en baisse (−1,1 %), mais avec des variations en fonction du type de cancer et du sexe du patient. Ainsi, chez les hommes, les plus fortes baisses par année ont été observées pour le cancer de la prostate (−4,4 %), le cancer colorectal (−4,3 %), le cancer du poumon (−3,8 %), la leucémie (−2,6 %) et le cancer de la thyroïde (−2,4 %). Chez les femmes, les diminutions les plus marquées ont été observées pour le cancer de la thyroïde (−5,4 %), le cancer colorectal (−3,4 %) et le cancer de l’ovaire (−3,1 %).Overall, cancer incidence is declining at a rate of −1.1% per year. In males, the two largest decreases were for prostate (−4.4% per year) and colorectal (−4.3% per year) cancer. In females, they were for thyroid (−5.4% per year) and colorectal (−3.4% per year) cancer. Melanoma (males: 2.2% per year; females: 2.0% per year) and multiple myeloma (males: 2.5% per year; females: 1.6% per year) rates are increasing. Cancer trends in Canada are dynamic and type-specific. The decreases for prostate and thyroid cancer underscore the importance of updating testing practices based on best evidence.Dans l’ensemble, l’incidence du cancer diminue à un taux de −1,1 % par année. Les deux plus fortes baisses ont été observées chez les hommes pour le cancer de la prostate (−4,4 % par année) et le cancer colorectal (−4,3 % par année) et, chez les femmes, pour le cancer de la thyroïde (−5,4 % par année) et le cancer colorectal (−3,4 % par année). Les taux de mélanome sont en hausse (hommes : 2,2 % par année; femmes : 2,0 % par année) ainsi que ceux de myélome multiple (hommes : 2,5 % par année; femmes : 1,6 % par année). Les tendances en matière de cancer au Canada sont dynamiques et elles dépendent de chaque type de cancer. La diminution de l’incidence du cancer de la prostate et du cancer de la thyroïde souligne l’importance de mettre à jour les pratiques de dépistage à partir des meilleures données probantes.

In Canada, government mandates for patient-centred care (PCC) vary across the 10 provinces and three territories. Although basic medical and hospital services are provided for all, health care options for patients also depend on having private insurance. Thus, the current design of the Canadian healthcare system has several implications for PCC and shared decision-making (SDM). Since 2007, this is our fourth update on SDM in Canada. The aim of this paper is to provide an update on the current state of SDM and patient and public involvement in Canada. Overall, we still observed the difficulty of implementing any sort of national strategy partly because of the decentralized nature of the healthcare system. Second, national professional education programs are complicated by licensure and scope of practice variations across jurisdictions. Third, there are variations in the availability of different options covered by universal healthcare. Canada has experienced some favorable development as PCC is now explicitly articulated in the policies of most provinces and territories and there are increased efforts to give patients more access to their electronic health records. However, patient and public engagement (PPE) reform in health programs and governance remains an exception, and continuing centralization of governance structures may reduce their responsiveness to patient priorities. In a 2018 survey, 47.2% of respondents reported that they were not told by their health professional that they had a choice about treatment. Nonetheless, decision aids and decision coaching are increasingly available for health-related decisions and the Ottawa Hospital Research Institute's decision aid inventory has ensured continued leadership in this area. Diverse jurisdictions are starting to embed decision aids into care pathways, with some decision aids being included in clinical practice guidelines. The COVID-19 pandemic may have had a negative impact on SDM by removing decision choices due to emergency public health mandates, but stimulated new research and decision aids. Canada continues to assign health research funding to SDM and PCC, and a program dedicated to patient-oriented research is central to this effort. Guides and frameworks are increasingly available for planning and evaluating PPE. Finally, various initiatives are attempting to involve and empower Indigenous peoples through PPE and SDM.

The Canadian Institutes of Health Research - Institute of Health Services and Policy Research's (IHSPR) Strategic Plan 2021-2026 (CIHR IHSPR 2021) aims to accelerate healthcare system transformation to achieve the Quadruple Aim and health equity through research. This special issue features a collection of commentaries from academic and health system leaders who were invited to respond to IHSPR's strategic plan and share insights regarding the opportunities the plan presents and areas where more attention may be needed. The present paper features a response from the IHSPR team and outlines the next steps regarding implementation. IHSPR is deeply grateful to the commentary authors for their insight, advice and recommendations, which will help to inform the implementation of the plan.

Elder abuse and neglect continues to be a gray area when it comes to convicting perpetrators such as family, friends, strangers, and caregivers who commit any form of physical, psychological, financial, neglect, or sexual abuse towards an elder. This is due to the legal definition being vague and non-transparent. The legal and health systems rely on two different definitions of what is deemed to be elder abuse and neglect in Canada when reviewing or assessing allegations of such abuse. Elder abuse and neglect increased throughout the COVID-19 pandemic, during which Ontario and the rest of Canada experienced staffing shortages in long-term care homes and for those cared for at home. Elder abuse in Indigenous communities poses special problems, in particular that of spiritual abuse that occurs when an Indigenous elder is forced to practice and develop religious beliefs other than their own. The law in Canada, including the Criminal Code, has proven to be an ineffective mechanism to combat elder abuse.

Although healthcare managers make increasingly difficult decisions about health innovations, the way they may interact with innovators to foster health system sustainability remains underexplored. Drawing on the Responsible Innovation in Health (RIH) framework, this paper analyses interviews ( n=37) with Canadian and Brazilian innovators to identify: how they operationalize inclusive design processes; what influences the responsiveness of their innovation to system-level challenges; and how they consider the level and intensity of care required by their innovation. Our qualitative findings indicate that innovators seek to: 1) engage stakeholders at an early ideation stage through context-specific methods combining both formal and informal strategies; 2) address specific system-level benefits but often struggle with the positioning of their solution within the health system; and 3) mitigate staff shortages in specialized care, increase general practitioners’ capacity or patients and informal caregivers’ autonomy. These findings provide empirical insights on how healthcare managers can promote and organize collaborative processes that harness innovation towards more sustainable health systems. By adopting a RIH-oriented managerial role, they can set in place more inclusive design processes, articulate key system-level challenges, and help innovators adjust the level and intensity of care required by their innovation.

Presently, Canadian drug policy has embraced the language of harm reduction, yet the implementation of policy and services does not reflect traditional harm reduction philosophy. The PC government’s 2018 remodeling of safe consumption sites in Ontario necessitates an analysis of the discursive elements present within the policy announcement. Applying the “What is the Problem Represented to be” (WPR) framework acknowledges the social and political context the policy process occurs in and illuminates how problems identified in a policy are representative of dominant cultural and social beliefs surrounding drug use. 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BACKGROUND AND AIMS: There is little information on consumption patterns across the diverse range of cannabis product types. This paper examines trends in consumption patterns in Canada and the United States (US) between 2018-2020. DESIGN: Repeat cross-sectional surveys were conducted as part of the International Cannabis Policy Study online survey in 2018 (n=27,024), 2019 (n=45,426), and 2020 (n=45,180). SETTING: Respondents were recruited from commercial panels in Canada and US states that had and had not legalized non-medical cannabis (US 'legal' and 'illegal' states, respectively). PARTICIPANTS: Respondents were male and female participants aged 16-65 years. MEASUREMENTS: Data on frequency and consumption amounts were collected for nine types of cannabis products, including dried flower and processed products (e.g., oils and concentrates). Consumers were also asked about mixing cannabis with tobacco. Socio-demographic information was collected. FINDINGS: Dried flower was the most commonly used product, although use in the past 12 months declined between 2018 and 2020 in Canada (81% to 73%), US legal (78% to 72%) and illegal states (81% to 76%; p

Background Efforts have been made by health research granting agencies to bring research closer to patients’ concerns. In Canada, such efforts were formalized in 2011 with the funding of the Strategy for Patient-Oriented Research (SPOR)’s research networks to address research priorities identified by patients and accelerate the translation of research findings into patient care and health care policy. Among these networks, SPOR Diabetes Action Canada (DAC) has created patient-partner circles to facilitate their integration within the network. The nature of the relationships within this atypical patient-oriented research network is systematically explored in this paper. Methods A cross-sectional social network study was conducted among the SPOR DAC’s network members to examine inter-individual interactions, and the topics discussed the most between members. Descriptive data analyses were conducted to explore which discussion topics were discussed most among members whose primary roles were research, administration, governance, and patient representation. Results The response rate was 51.9%, providing data on 76.5% of the maximum number of connections in the network. The survey captured 2763 inter-individual relationships. Responses to a sub-question inserted in the survey show that 482 of these relationships (17,4%) existed before joining the network in collaboration on a research project. Most ties captured in the survey were yearly or quarterly, while few relationships were monthly, weekly, or daily. In measured relationships, members discussed several topics, the most frequent being scientific research, patient engagement, network coordination and governance, and operations and management. The topics associated with the most significant proportion of relationships captured in the survey were scientific research (45.4%) and patient engagement (40.7%). Management & operations and governance & coordination follow, corresponding to 24.3 and 23.9% of the captured relationships. All discussion topic subnetworks were either somewhat or highly centralized, meaning that relationships were not equally distributed among members involved in these discussions. Of the 1256 relationships involving exchanges about scientific research, 647 (51.5%) involved a researcher, 419 (33.3%) an administrator, 182 (14.5%) a patient partner, and 82 (6.5%) a member whose primary role is network governance. Conclusions Scientific research and patient engagement were the most common topics discussed, consistent with the patient-centered research at the heart of the SPOR Diabetes Action Canada network. The study identified several relationships where a patient partner has discussed scientific research with a researcher. However, relationships involving research discussions were three times more common between a researcher and an administrator than between a researcher and a patient partner, although twice as many patient partners as administrators participated in the survey. The institutionalization of patient-partner involvement in large research networks is an evolving practice for which optimal engagement methods are still being explored.