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Improving Hospital Performance

Partner Institute: 
Canadian Policy Research Networks (CPRN), Ottawa
Survey no: 
(13) 2009
MacAdam, Margaret
Health Policy Issues: 
Quality Improvement, Responsiveness
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no


Canadian hospitals are having trouble coping with increasing wait times in Emergency Departments (EDs). Recent reports of improvements in hospital operations indicate that quality of care in hospitals could be improved through greater attention to internal hospital processes, especially in the EDs as well as to divert patients from using the ED when other alternatives are equally or perhaps more appropriate

Purpose of health policy or idea

About 15% of Canadians or 3.5 million people over age 12 received care for their more recent injury  or had their most recent care provided by staff in an Emergency Department (EDs).  Of these, more than one million (1.1 M) were admitted for hospitalization.  Over half of all hospital admissions (60%) were admitted from EDs.  Patients admitted to hospital through the ED were more likely to be older and sicker than patients admitted through other means such as planned admissions (CIHI, 2007).  Some provinces such as Ontario have identified reducing wait times in EDs as a new quality of care initiative.  Among a number of causes of long ED wait times, one could be inefficient processes in the ED.  The Province of Ontario has developed new performance management targets and financial incentives to encourage more efficient and effective use of  EDs. 

Main points

Main objectives

In May 2008, the Ministry of Health and Long-Term Care (MOHLTC) announced a new investment of $109 M (Cdn) to reduce wait times in EDs.  Of the total new investment, $30M will be targeted to the 23 Hospital EDs with the greatest wait times.  The Ministry also allocated $38.5 m to increase home care services and enhance integration between hospitals and the community$4.5m for additional nurses in EDs to assist with reducing ambulance offload delays, $22M to Local Health Integration Networks to help provide community alternatives to hospital care, and lastly $4.5m for nurse-led outreach teams to provide residents of  LTC facilities with timely and appropriate care in the LTC facility to avoid transfers to hospital EDs.  All of these targeted initiatives are intended to help to reduce ED wait times inside and outside the hospital.

Type of incentives


Groups affected

hospitals, patients

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Characteristics of this policy

Degree of Innovation traditional traditional innovative
Degree of Controversy consensual consensual highly controversial
Structural or Systemic Impact marginal marginal fundamental
Public Visibility very low neutral very high
Transferability strongly system-dependent rather system-neutral system-neutral

There need to be policy supports such as financial and performance incentives that are based in the regional system to influence successful uptake of improved hospital performance in other parts of the country. Barriers such as the quality of hospital leadership, lack of performance and financial incentives could prevent transferability to other areas within a province or other provinces/countries. 

Political and economic background

In a publicly financed health care system, problems in hospital services often receive media coverage.  In recent years media coverage of temporary closure of EDs, long wait times, and deaths of patients in the ED received widespread publicity.  Not only  do these problems indicate poor access and quality of care, but they also increase pressure on government and politicans to respond to the issues.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Origins of health policy idea

Hospital restucturing in Canada began in the 1990s when every province took steps to restructure its hospitals because of perceived over capacity of inpatient beds.  Since then hospital services, along with problems in the primary care system, and rising health care costs, have frequently been in the forefront of policy attention. 

In 2001 a study of the effects of hospital restructuring (closing several short-term hospitals and increasing ambulatory care) in Montreal found that EDs experienced a marked increase in volume (overcrowding) after the restructuring.  There were multiple reasons for this but the main ones were: the community sector was unable to adapt to the reduction in inpatient beds, access to hospital beds became more restricted for patients in EDs, the average length of stay of hospitalized patients began to rise.  As well, some hospitals seemed to have too few beds to be able to safely respond to fluctuations in demand (Roberge, 2001).  These reasons undoubtedly were also at play in other parts of the country as reports of ED problems began to be reported in various jurisdictions. 

Today an additional issue has been the inablity to discharge patients who no longer require hospital care.  In Ontario these patients occupy 20% of hospital beds and are a major barrier to improving the efficiency of the ED.  Thus the new investment by the Ministry of Health and Long-Term Care represents a timely multi-focused attempt to improve ED and overall hospital performance.

Initiators of idea/main actors

  • Government
  • Providers
  • Patients, Consumers

Approach of idea

The approach of the idea is described as:

Stakeholder positions

There was little discussion about the new funding.  Stakeholders, ranging from patients to physicians to hospitals, have a vested interest in effective and efficient hospital care.  The announcement was greeted positively and has been widely promoted by the Liberal Party of Ontario and individual Liberal politicians.  The opposing Conservative Party did not issue a news release in response to the announcement.  The most influential supporters of the initiative to the government were hospital leaders.

Actors and positions

Description of actors and their positions
Ontario Governmentvery supportivevery supportive strongly opposed
Hospitalsvery supportivevery supportive strongly opposed
Ontario Hospital Associationvery supportivevery supportive strongly opposed
Patients, Consumers
Hospital patientsvery supportivesupportive strongly opposed

Influences in policy making and legislation


Legislative outcome


Actors and influence

Description of actors and their influence

Ontario Governmentvery strongvery strong none
Hospitalsvery strongvery strong none
Ontario Hospital Associationvery strongvery strong none
Patients, Consumers
Hospital patientsvery strongstrong none
Ontario Government, Hospitals, Ontario Hospital AssociationHospital patients

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The new funding is flowing to health providers.  In February of 2009, the Ministry followed up the 2008 announcement with news that Ontario is setting targets for ED wait times.  For patients with minor conditions the target is that 90% of patients will spend a maximum of 4 hours.  Current performance for these patients is 4.6 hours.  For patients with complex conditions, the target is that 90% will spend a maximum of 8 hours but the current performance is13.5 hours.  Ontario is the first province in Canada to establish ED wait times and is perhaps the first jurisdiction in North America to do so.

Monitoring and evaluation

It is too early to evaluate the success or the initiative.

Expected outcome

Ontario is making investments in three types of interventions designed to improve ED performance:

  • increasing access to alternatives to the ED
  • increasing the capacity and improving processes in the ED; and
  • speeding the flow of inpatients through the hospital 

Reports from some Ontario hospitals that have already tackled some of these issues indicate that improving ED performance can reduce wait times within six months for both lighter and heavier care patients by up to 60 percent (MacLeod, et al 2008).  Providing alternatives to hospital EDs can also avoid ED visits among long-term care facilitity residents (The Globe and Mail 2009).  The question will be whether these early gains in some parts of the Province can be achieved in other settings.  As well, it would be useful for the government to undertake a cost effectiveness evaluation of the inititaives to ensure that the system is receiving value for money.

Impact of this policy

Quality of Health Care Services marginal rather marginal fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low neutral very high

It is difficult to evaluate the cost efficiency of the new investments because there have been no cost-effectiveness studies.


Sources of Information

Canadian Institute for Health Information (CIHI). Understanding Emergency Department Wait Times: Access to Inpatient Beds and Patient Flow. 2007.

Canadian Institute for Health Information (CIHI). Understanding Emergency Department Wait Times: How Long to People Spend in Emergency departments in Ontario. 2007.

Mac Leod, H, B. Bell, K. Deane and C. Baker. Creating Sustained Improvements in Patient Access and Flow: Experiences from Three Ontario Healthcare Institutions.  Healthcare Quarterly 11:3. 2008.

Ministry of Health and Long-Term Care, Ontario. Ontario targets shorter ER times. 2009.

Ministry of Health and Long-Term Care, Ontario. Enhanced home care coverage and efforts trageted at poorest performing emergency rooms lead the way. 2008.

Ministry of Health and Long-Term Care, Ontario. Ontario's $109 Million investment to reduce wait times in the emergency room. May 30, 2008.

Roberge, D. The Effects of System Restructuring on Emeregency Room Overcrowding in Montreal Centre. Canadian Health Services Research Foundation. June 2001.

Author/s and/or contributors to this survey

MacAdam, Margaret

Senior Fellow, Canadian Policy Research Network

Suggested citation for this online article

MacAdam, Margaret. "Improving Hospital Performance". Health Policy Monitor, April 2009. Available at