Thresholds and wait times

I have been thinking quite a lot recently about thresholds for health care intervention. In health care, if there is a scarcity of a resource, then the threshold for intervention typically goes up and if there is an excess of a resource, the threshold of intervening goes down.

Let’s take an example; If you have an illness that responds well to antibiotics and you go to a very busy physician, she will say, “Take a full course of the antibiotic and you will be OK. “If she is not so busy, she might say, “Take the antibiotics and book an appointment in two weeks.”

Both are equally good responses but apportion the doctor’s time differently.

Because health care tends to be supply driven, when the supply goes up it always gets used, but with a lower threshold of use.

A second important idea in health care is coming to understand the consequences of a shift in population morbidity from acute infectious disease to long term chronic conditions. If someone has an acute infections disease there is usually a very clear test to see if the disease is present and a very clear protocol for responding to it. However in the case of chronic conditions the measures are often less clear and individual patients can respond differently to medical treatment.

A good example of this change is the identification of diabetes or hypertension in a patient. Here there are lots of borderline cases and a variety of responses are possible. Pharmaceutical companies have been very aware of this change and have found ways to bring medications to the supply system for lower and lower thresholds. There are now drugs available for pre-diabetic conditions, for earlier and earlier indications of possible heart disease and so on.

If we take these two ideas together then we can find new ways of thinking about waiting lists.

When waiting lists were very long in the UK, I met a doctor, while I was working there, who confided in me that when he had a patient who wanted her varicose veins stripped, he would say, “Of course. I will put you on the waiting list.” This meant to him that she would never have the procedure because the list was so long and she was at the bottom of it. This would save him from having to spend time explaining to her why he thought that the procedure would do no good aesthetically and why it was not necessary for health reasons.

Waiting lists are often managed by managing the threshold for intervention. If there was an acute problem then people would jump the queue. A study by colleagues at the King’s Fund showed that acutely ill patients had very short waits for surgical procedures. It would be interesting to see how much that has changed since then.

We have also learned that because of the change in our understanding of cancer, “watch and wait” is a good way to respond to many early detections of cancer. That is very hard for us to take, since we have been raised to think that every last bit of cancer must be eradicated form your body or else you will die. It is worth wondering how much some of these lists are part of this watch and wait way of thinking.

A Five-year Plan for the NHS

Several weeks ago, Simon Stevens who is head of the English National Health Service (NHS), published Five Year Forward View. The report details his plan for the NHS, and it’s well worth a read because it is remarkably relevant to the Canadian context.

He describes a context that is quite similar to ours: an aging population with multimorbidity as the major epidemiological feature. The excellent hospital sector and well-developed primary care network of general practitioners is not adequate or entirely appropriate for the population served by the NHS.

He recognizes that there must be a “radical upgrade in prevention and public health”  (NHS 9). The failure to do this in the last decade has resulted in “a sharply rising burden of avoidable illness” (NHS 3). In Canada, the weakness of public health initiatives has been marked by similar increases in obesity, diabetes and other preventable conditions.

Secondly, he sees that patients must “gain far greater control of their own care – including the option of shared budgets combining health and social care. The 1.4 million full time unpaid carers in England will get new support, and the NHS will become a better partner with voluntary organisations and local communities” (NHS 3).

This is clearly what must happen in Canada too, but there are few policymakers here who have such thoughts because of the severe limitations on the boundaries of our healthcare system. The relationship between the system and voluntary organizations is pretty sparse, and the idea of giving patients and caregivers control over any funds for their care is certainly not top of mind. It is time to include patients and family caregivers in discussions about their perceived needs and consider new ways of providing funds to meet them.

Thirdly, the document argues that:

The NHS will take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The future will see far more care delivered locally but with some services in specialist centres, organised to support people with multiple health conditions, not just single diseases. (NHS 3)

Importantly, he does not plan any structural changes in the NHS. Reforms will not involve changing the governance or boundaries of the many organizations that make up the NHS. It will include strengthening primary care, integrating access to a wide variety of services that will avert unnecessary hospital visits, and increasing the already abundant community services (which are notably sparse in Canada).

We recommend that policymakers take a good look at the document and consider how it might be applied in the Canadian context.

 

National Health Service. Five Year Forward Review. England: National Health Service, 2014. Web.

The Canadian Cardiovascular Congress

It is clear that there has been a major shift in focus from acute to chronic care – chronic disease is now on everyone’s mind. I am currently writing this blog entry from the Canadian Cardiovascular Congress, where the first welcoming session began with a long talk by Perry Kendall, Provincial Health Officer of British Columbia. His audience of heart professionals was given a short primer on public health issues. He began by pointing out how much the Lalonde report had changed our understanding of the health field and specifically noted that only a quarter of good health was due to interventions by our current healthcare system. He then covered a range of topics – everything from inequalities in health to obesity. Not a mention was made of infectious diseases, not even Ebola.

The longest part of his talk was about the difficulty in changing the amount of unhealthy food that is being distributed in Canada by a very well-organized food industry. The industry has tried to minimize and even block change in every area from labelling to sodium and sugar content of foods. They declare publicly that they are in favour of these changes, but they work very hard to defer them or stop them entirely. Kendall said that reducing the sugar and fat content of processed food is hard work and would continue to be. For example, the first attempt to introduce voluntary reductions of salt in processed foods at the federal level was rejected out of hand by the Prime Minister’s Office. Efforts to do this at the provincial level will be long and drawn out because of the large number of constituencies. And because compliance is voluntary, there is no certainty when and how the food industry will respond.

He talked quite a bit about the contributors to chronic disease in Canada and could not cover everything. I noticed that on one of his slides there was some material that he did not speak to at all. It is an area where doctors themselves contribute to the ill health of people with chronic diseases, and it seemed like the part they really needed to hear. According to the slide, a significant portion of people with chronic conditions are made worse by overmedication. It was somewhat surprising to me that Kendall did not allude to this problem at all. Here is an area where the heart community could make a difference to public health by developing better practices. Perhaps they were aware of these efforts and there was nothing for Kendall to add.

This became a bit more problematic when I looked through the program. The Platinum sponsors of the congress are AstraZeneca, Bayer, Bristol-Myers Squibb, and Pfizer. I went into the exhibition hall and one of the handouts was a “passport” that you could have stapled at all the important stations to win an iPad. The Passport participants were almost all drug companies. In fact, the exhibition hall was filled with exhibits by drug companies and equipment companies. Becel was the only healthy food company with a stand, and there were almost no exhibits devoted to chronic care prevention.

Right now in Canada, we are the second highest users of prescription drugs in the world after the United States. We spend over $900 per person per year on prescription drugs (Lexchin and Gagnon). I think that this is because our healthcare system offers few options to doctors. If you get high blood pressure, an early stage of heart disease, it is easiest to offer medication to control it. If you have high cholesterol, it is similarly easiest to provide statins. And if you have multiple conditions you will have a good chance of being prescribed many different drugs. Often as you get older these many drugs can cause their own problems.

Our healthcare system is not set up to offer the range of supports needed to avert the four main chronic conditions: heart disease, lung disease, cancer and diabetes. But this deficit is becoming more obvious. I hope that the next Cardiac Congress will be more devoted to averting early stages of heart disease in a drug-free manner, by imposing lifestyle changes. It is time for the change to be more thoroughgoing.

 

Lexchin, Joel and Gagnon, Marc-André. “CETA and Intellectual Property: The debate over pharmaceutical patents.” http://labs.carleton.ca/canadaeurope/wp-content/uploads/sites/9/CETD-Policy-Brief_CETA-and-pharmaceutical-patents_MG_JL.pdf. Oct 2013. 7 pages. Web. 27 Oct 2014.

Six Key Performance Targets (KPTs) for hospitals

As President of Patients Canada, I’m excited to share the work we’ve been doing on Key Performance Targets (KPTs) with those of you following my blog. It’s a very important project and I invite your feedback and comments. Find more information about Patients Canada on our website.

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It’s time to bring together a few small changes that would have a big impact on the patient’s hospital experience with the idea that these changes would be clear indications that hospitals are indeed becoming more patient and family-centred. I have spoken of them individually, but now it’s time to bring a few of them together and explain how they are derived from our experiences with healthcare.

I was talking with someone who wanted to know more about bringing back dignity to the hospital gown and I mentioned that there were other examples of Key Performance Targets (KPTs) derived from experience.

“For example,” I said, “parking costs can be really burdensome for some people.” I was about to go on when she interrupted me.

“Oh, when my husband had a stroke, I was paying more than $75 a day in parking as I visited him in the morning, afternoon and evening for more than two hours. There were no in and out privileges for visitors. It was awful, but I felt I had no choice.”

I elicited similar responses whenever I went on to explain the various targets together. It seems that they are high on the list of changes that many patients want to see improved. Listing them together often elicits clear recognition of things that niggle but are rarely expressed.

The list of obvious but relatively unnoticed performance targets that will improve patient and family experience includes

1. A change in the policies surrounding hospital gowns
2. The reduction or elimination of parking fees for visitors and families of patients
3. That there is a chair in the triage position in Emergency Departments for a family member or friend who accompanies the patient
4. That hospitals adopt an open visiting policy so that friends and family members can visit patients any time
5. That all hospital notes are readily available to patients (and whenever possible, their families) so that they can review them at will
6. That food policies in hospital are open to allow and even enable family and friends to bring food from home to patients, by, for example, having a patient and family accessible refrigerator and microwave oven on every hospital unit

These six changes in policy and practice would go a long way to making hospitals more patient and family friendly. We encourage hospitals to adopt them.

Process for developing Key Performance Targets (KPTs), developed by Patients Canada.

Small Changes with Impact: The Third Chair in Triage™

As President of Patients Canada, I’m excited to share the work we’ve been doing on Key Performance Targets (KPTs) with those of you following my blog. It’s a very important project and I invite your feedback and comments. Find more information about Patients Canada on our website.

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Small changes can improve the experiences that patients and families have with healthcare. We have been talking about things like hospital parking and food as areas that are relatively non-controversial but have room for clear and concrete changes that would significantly impact our experiences as patients or family members. We’ve developed these ideas to act as key performance targets (KPTs) that can be used by healthcare organizations and bodies to help improve their care.

These KPTs were identified by listening to patient experiences for many years and discussing them with a panel of patients, family members, providers and researchers to determine how these experiences could be improved. We’re now excited to announce Patients Canada’s Small Changes with Impact initiative – a set of key performance targets for healthcare, informed by patient and family member experiences with the system.

The first of these ideas sets the tone for what we are doing; it is a small change that has not so far occurred to service providers, has only been implemented in hospitals with a well-developed patient voice, and can be seen as a challenge for change in hospitals that have not yet implemented it.

Over the last few years, we have heard hundreds of stories from patients and families who have visited emergency rooms. From them, we learned that most emergency rooms have two seats in the triage office – one for the patient and one for the triage nurse. Over time, it became obvious that a third chair for a family member would be a tremendous help not only for the patient and the accompanying person (often a family member), but also for the triage nurse who could gain that extra insight when making the decision about what to do next.

The Third Chair in Triage™ is our first key performance target. We have been told by the CEO of the Kingston General Hospital, Leslee Thompson, that the third chair has already been installed in their hospital emergency room. Obviously, their Patient and Family Experience Advisors came to the same conclusion that we did.

Our challenge is not only to hospitals, but also to researchers in emergency medicine, regulatory bodies, accreditation groups and others to respond to this minimal intervention. The hospitals can add the chair and researchers can evaluate the impact. After that, regulatory agencies might adopt it as a requirement for accrediting emergency facilities. We believe that this would be an important step forward in making healthcare services more patient-friendly. What do you think?

Next week I will present more key performance targets.

 

™:  The Third Chair in Triage is a trademark owned by Patients Canada.

Redesigning hospital rooms from the patient perspective

Last Friday, an article in the New York Times described the patient rooms in the new University Medical Center of Princeton, New Jersey. The architect is Michael Graves who is in a wheelchair after suffering from meningitis some years ago. He brings a strong patient perspective to the design of the hospital’s patient rooms.

For starters, the rooms are singles; there are no double rooms. Research shows that patients sharing rooms provide doctors with less critical information (even less if the other patient has guests). Ample space is given to visitors because the presence of family and friends has been shown to hasten recovery.

Ditto the big window: Natural light and a view outdoors have been regarded as morale boosters since long before Alvar Aalto designed his famous Finnish sanitarium in the 1930s (a “medical instrument,” as he called it), bragging about curative balconies and a restorative sun deck. (Kimmelman, pars. 12 & 13)

And generally, they look more like hotel rooms than hospital rooms.

It’s less antiseptic, cluttered and clinical than your average patient room, more like what you find in a Marriott hotel, anodyne and low-key, with a modern foldout sofa under a big window; soft, soothing colors; and a flat-screen TV. (Kimmelman, par. 23)

The new rooms also include a bedside-to-bathroom handrail to make it easier for patients to go to the bathroom safely on their own.

Bringing their perspective to the design of hospitals rooms will make a big difference to the experience that patients and families have in hospitals. The hospital in New Jersey is an excellent and concrete example of the difference it makes to consider the patient experience; patient satisfaction ratings are now in the 99^th percentile – not just for the room, but for everything from the food to the care. And staff like working there as well.

In the redesigned room, patients asked for 30 percent less pain medication. According to the article, “Reduced pain has a cascade effect, hastening recovery and rehabilitation, leading to shorter stays and diminishing not just costs but also the chances for accidents and infections” (Kimmelman, par. 6).

This is an excellent example of what Patients Canada has been working towards: including the perspective of patients and their families, and thereby contributing to a better outcome for patients and a better experience for everyone involved.

Kimmelman, Michael. “In Redesigned Room, Hospital Patients May Feel Better Already.” The New York Times. The New York Times Company, 21 Aug. 2014. Web. 25 Aug. 2014.

The College of Physicians and Surgeons and transparency

Last week I was interviewed by the Toronto Star about how the College of Physicians and Surgeons of Ontario (CPSO) communicates with the public when there are complaints about doctors. At the moment, there is almost no reporting about complaints except for when they are very serious. Less serious complaints, even when they are successful, are not made public. The CPSO is trying to be more transparent about its activities and at Patients Canada, we support this. Patients should know more about their activities. And we are interested to know what steps they will take to make their rulings more transparent to patients and the general public.

When the article came out, some friends who are doctors told me that they disagreed with the view that all complaints should be made public because after all, some of them are frivolous or merely mean-spirited, but all can have a bad effect on a doctor’s reputation. And we agree. We do not think that it is necessary to make all complaints public or even to make all the workings of the CPSO entirely open to public scrutiny. However it would be a good idea to let people know if there are recurrent cases of bad behaviour or a litany of justified complaints about particular doctors without any change in behaviour. We know that the CPSO tries to help doctors learn from their mistakes and provides support for them to do this. It would be a good idea to also publicize these efforts and be more transparent about them as well.

As we see it, the change is from an ancient culture where the CPSO was a keeper of professional secrets and the public was never admitted into this inner sanctum. The mystery of medical knowledge was not open to public scrutiny at all because the power of medicine was to some extent dependent on this secrecy. That view of professionalism died many years ago to be replaced by a more responsive and open one. In the old world, doctors applied their professional authority to help patients without much regard for the patient’s perspective. Today, doctors are beginning to partner with their patients to come to shared understanding of health issues and how to deal with them. We expect that it is in this vein that the college is beginning to partner with patients to develop a greater transparency in its activities.

In Nova Scotia, this has gone further. The province is making the medical mistakes registry available online:

According to the government website, making the information public “raises the level of accountability – and demonstrates a commitment to transparency and openness. The goal is to share lessons learned and prevent the event from happening again.”

For the first six months of 2014, 27 serious adverse events were reported. Twenty-one of those incidents resulted in “adverse health effects leading to death or serious disability” while a patient was being cared for at a facility in Nova Scotia, including three incidents where a patient died or was injured after a fall while being cared for by a district health authority or IWK [Isaac Walton Killam Health Centre]. (CBC News)

The publication of these mistakes is not only a sign of increased accountability and transparency. It is a comfort to those who have been harmed and their families. Most often, patients and their families recognize that mistakes and bad experiences can happen, and what they want is for those errors to not be repeated. Making them public can go a long way to averting their recurrence.

“Nova Scotia Medical Mistakes Registry Goes On Line.” CBC.ca. CBC/ Radio-Canada, 14 Aug 2014. Web. 18 Aug 2014.

We liked the hospital but the food was awful

There are many little things that could change to improve our health care experience. So far we have talked about a couple of them – small changes to parking policy and improvements in visiting hours are two excellent examples of how to dramatically improve the experience of patients and family members. All our examples come from what patients tell us about their experience with health care. A growing group of patients, providers and researchers at Patients Canada think about these experiences and work together to discover the very small changes that can improve them.

Food is another example of a problematic area in hospitals. Most satisfaction surveys have found that patients complain about the food far more than they complain about doctors or nurses. And everyone knows that cost constraints have resulted in trying to find more and more efficient ways of producing food for hospitals and long-term care facilities. For many years, hospitals have been working hard to produce less expensive food while maintaining quality. Today, hospitals in Canada spend less than $8.00 per day for food per patient. The quality has been mixed. We noticed that so far hospital food policy has not usually included patients and family members, nor has much of this policy been easily accessible to patients and their families.

In the old days, food could not be brought into the hospital because the hospital provided a scientifically correct diet for patients and interfering with that would slow or even imperil the patient’s recovery. Moreover, the safety standards in hospitals were considered to be significantly more stringent than ones at home, and so a second reason to ban outside food was to avert the risk of poisoning patients.

Even today, many older patients and their families believe that these policies remain in place. Some sneak food in to give to their sick relatives. Others, who are more compliant, do not bring any food at all. One older woman watched her husband lose thirty pounds in a three-week stay in hospital because he said, “I hate hospital food and will not eat it!” However she never considered bringing in food that he did like because she (falsely) assumed that it was not allowed and she was not about to flout hospital rules. Her husband never recovered from his sudden weight loss and died within two years.

Today, most hospitals allow families to bring in food. Often they place restrictions on what can be brought in. Below is a quote from the Mayo Clinic Nutrition-wise blog (Nelson, Zeratsky). Despite the fact that it continues to mention the possibility of “deadly consequences” of not checking if it is safe to feed the patient, it is a pretty good example of current hospital policy about bringing in food.

As much as hospitals try, the food they serve may not meet expectations — especially when people don’t feel well. As a result, you may be tempted to bring a meal or special treat to a loved one in the hospital to show your concern and to help make the person feel better. In your concern, you might not ask if this is safe. It’s important to know that in some circumstances this act of kindness could have unintended and even deadly consequences.

Here are some guidelines that my department has put in place to help people navigate this thorny issue:

• Before you bring food in, check with the nurse, doctor or dietitian. Your loved one may be at risk for infection or may need to follow a very strict diet. In some situations, even normal bacteria in foods (such as uncooked items like fruits or salads) or excess nutrients (such as those containing vitamin K, or unknown substances like gluten or allergens) can be dangerous.
• If you get the OK to bring food in, make sure you prepare food safely. The Department of Agriculture has excellent information on their website about food safety for people who are vulnerable to infection. Throughout the steps of food preparation, it’s important to follow the mantra:
  • Clean. Wash your hands, utensils and cutting boards before and after contact with raw meat, poultry, seafood and eggs.
  • Separate. Keep raw meat, poultry and seafood away from foods that won’t be cooked.
  • Cook. Use a food thermometer — you can’t tell food is cooked safely by how it looks.
  • Chill. Refrigerate foods within 2 hours and keep the fridge at 40 F or below.

• Bring only enough food that can be eaten at one time. Consider single-serve items, such as individual yogurts, packages of crackers and peanut butter, and wrapped cookies. That way there are no leftovers to worry about.
• Don’t store perishable foods in the room. In addition to being unsafe, they can be unappetizing.
• Label all food items. Put the name of your loved one on the food container and the date that the food was prepared. You don’t want your kind intention causing problems for another patient.

This set of policies and the write-up might benefit from a review by patients and their families. Critically, patients and their families should know when food can be brought to recovering patients. Otherwise there might be “deadly consequences” of starving older patients by not feeding them food that they like and are used to eating.

Nelson, J., Zeratsky, K. “Play it safe when taking food to a loved one in the hospital.” Nutrition-wise blog. Mayoclinic.org 28 March 2012. Web. 10 Aug 2014.

Parking policy discussions

At Patients Canada, we try to find very clear and concrete changes that might make the patient experience better. We develop these ideas after listening carefully to the many experiences that patients and families have when they encounter the health care system. Over these last few weeks we have been talking about parking. We pointed out that there was a very big difference between the views of providers and patients about the place of parking policy in health care. We noted some strong opposition to parking charges presented in the Canadian Medical Association Journal, which claimed that charging for parking violates the Canada Health Act because it means health care is no long free at the point of delivery. We noted that although parking is a miniscule part of the hospital budget, it is considered to be an important source of income because it is free of governmental or other restrictions, and allows for a greater flexibility in its use. Some patients do not object to high parking costs because they see them as a contribution to the good work of the hospital.

But still for many patients, parking costs are inordinately high and a significant cost associated with long waits in the emergency room or an appointment to see a specialist or visiting an inpatient. There are lots of ways to reduce the burden of parking in these cases.

Free parking

The most obvious way is the one adopted in Scotland and Wales where parking is free. In Canadian hospitals, this could easily be associated with voluntary donations for parking if people really wish to donate to the hospital. A major donor might be asked to donate to a fund that would provide free parking for all. The parking structure might be named after such a donor who would be appreciated by all those who park in her building. Various modalities can be introduced to decide who to charge for parking and who should get it as part of the hospital service. These discussions of hospital policy might by themselves be instructive and a useful basis for moving forward. In our discussions, we have come up with some ideas, for example: if an emergency room visit takes more than a designated time, free parking chits would be given to patients. These can be paid for from the emergency room budget, or the ER doctors’ joint budget or some other source relevant to ER funding.

Valet parking

In some hospitals, valet parking is offered at a slight fee to a patient with mobility issues so that they don’t have long walks to their appointments. This is an example of making the parking experience better for patients. Another similar service might include providing such valet services at the door of the Emergency Department so that accompanying family members can be right there when the sick person comes in to register.

Subsidized parking

Most hospitals and long-term stay facilities offer reduced rates for parking if there are going to be regular visits over a period of time from family members or others close to a patient. Often this practice is not well enough publicized. In the USA, specialists offer parking chits to their patients. Can this happen here? Might it relate to waiting time before the visit?

As you can see, there is no shortage of ideas about parking. We encourage you to write to us with your ideas of how parking policy can be improved.

A designated parking space for moving in to long-term care

At Patients Canada, patients and those close to them partner with health care providers and others to help improve patient and family experience.

We always begin by receiving and listening to the experiences that patients and families have. In the last several blog posts, we spoke about parking as a good example of a policy area that can have a great impact on our experience with health care. In this post, I’d like to share an example of a change that happened as a result of hearing about such experiences and then working together with Baycrest Centre for Geriatric Care to make its policies more patient-friendly.

The day of moving in to a nursing home is a particularly stressful time for a family. Ordinary house moves are considered to be among the most stressful times in anyone’s life, but the move into a long-term care facility is even more traumatic for the new residents and their spouses and children. Often the processes put in place for nursing homes admissions can add to the difficulty of this transition. At one point in time at Baycrest, the requirements for moving in a few pieces of familiar furniture to make the new room more home-like made things difficult. It was necessary to call at least three days in advance to make an appointment at the loading dock at the back of the complex. Once there, Baycrest provided no cart and no further help because of insurance concerns. It was also required that the freight elevator be used to bring the furniture to the floor.

This procedure had evolved over some years as a result of multiple efforts at cost control and risk reduction. It had not been developed with any intention of making life harder for people moving in. It responded to a whole series of problem cases, such as equipment breakdowns and demanding families. Baycrest, like most institutions, has had many cost containment exercises and the lack of help might have emerged from one of them. The requirement to move furniture without any help from the institution was further complicated by the lawyers’ instruction not to give out the names of short-term light moving companies that were familiar with the facility. No doubt, this was to avert any liability should something go wrong.

Here was a process that was obviously unfriendly to new residents and their families. When it was brought to the attention of senior staff, they agreed that this was “low hanging fruit” and could be an “early win” for the process of improving resident and family experience.

A series of meetings over several months resulted in changed policies that were not significantly more costly nor more risky and vastly improved the experience of new residents and their families. They decided that families would be given the names of light moving companies if they need help moving furniture into the resident’s room. If they wanted to do it themselves, a designated parking spot had been created at the front door for families who were helping a new resident move in. And residents and families were able to call in advance to get the help of a porter.

We can suggest that this policy or one like it can improve a somewhat traumatic experience by recognizing the need to help new residents and their families to easily move their clothing and small pieces of furniture into their new home.

The more general lesson is that changes in small policy areas like these can make a big difference to people and their experience within the health care system. If you have experiences to share or would like to help design them get in touch with us at www.patientscanada.ca.