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Nusrat Farhana’s Story: Dissecting Healthcare Competitiveness in Canada

June 22/2021

By Françoise Makanda, Communications Officer at DLSPH

What causes Canadian hospitals to compete amongst themselves with no paying clients?

Under the supervision of Dean Adalsteinn Brown, Nusrat Farhana spent the last six years understanding what drives hospitals to compete through the Ontarian and Albertan healthcare systems.

“If you don’t understand why hospitals behave the way they do, you do not know how to create a culture that is conducive to high quality,” says Farhana who will be graduating with a PhD from the Institute of Health Policy, Management and Evaluation’s Health Services and Research.

Nusrat Farhana

Alumna Nusrat Farhana

Despite public funding, healthcare systems compete on service volume, donations, research activity, human resources, and branding. Good branding help hospitals tout their specialized services, research activity and equipment, which then attracts highly skilled physicians and donations.

Donations are vital for equipment purchases. Capital campaigns require a ten per cent investment from donors and hospital before breaking ground. It’s a loop, says Farhana. “From the perspective of a hospital CEO, it makes sense to be able to provide something that patients value but otherwise wouldn’t be there.”

Hospitals may receive extra perks like special attention from their respective ministry. Also, if a highly specialized service is offered in two separate provinces, they will compete for the same patient group.

A hospital struggling to get patients will be under threat and will compete. Its leadership may even collaborate with a competitor to maintain viability.

“You won’t be viable as a clinical program because you won’t have the operational efficiency and you won’t have the clinical competence to run your program,” she says, “you won’t get away with being a poor performer for too long, especially when everyone’s eyes are on you.”

Competition has unwritten rules. For instance, systems abide by the ‘no talent poaching’ rule, says Farhana: “Although it may happen, it’s usually not in leaders’ ethics.” Not all competition is funding focused—good performance management culture begets good quality care which leads to healthy competition, she adds. The competitive drive on high quality or specialized care and research for instance can be intrinsically altruistic.

In Alberta, Farhana says there is a drive for quality with a good performance management culture. “If they do better on quality, it pushes others to do the same. Quality driven by performance management culture drives behavioural change.”

Ontario is renowned for being the hub of innovation says Farhana but it should push for a stronger quality-driven culture of care. Since 2012, health system funding reform has focused on volume as well as cost-per-weighted cases as indicators of access and efficiency. Clinical quality may suffer, although she observes that the competition culture needs further examination.

“Our funding structure is still focused on wait times as it being an indication of quality. We’re still focused on cost-per-weighted cases and wait time. We still have not taken a close look at how we can create a relentless drive for things like mortality, safety, care coordination, and adverse events.”

Farhana would like to see a new performance management culture in Ontario which will encourage stakeholders to monitor metrics over time. This will allow them to consistently address quality and induce behavioural change.

The vivacious Bangladeshi-born researcher understands the importance of healthcare. “You’re blessed if you come from a well-off family. Otherwise, you could die of something quite simple. Education is the only way to go. Health care is a luxury.”

Her parents instilled in her the value of hard work. They left Bangladesh when she was sixteen to live in New Zealand. At 19 years old, she moved by herself to Canada. “I needed to see more of the world,” she says.

Farhana built her network from scratch. She studied neuroscience and psychology at U of T, followed by Master of Public Administration at Queen’s, and finally landed on health system design. A part of her wanted to nurture and another wanted a challenge.  “It’s a profound responsibility to be able to think of health-care performance. It’s a privilege to be able to think along that line and It’s a huge endeavour to be able to take on that role.”

Farhana needed a supervisor for her PhD in healthcare performance management but the same name kept popping up. “Who is this Adalsteinn Brown person? I asked myself. I was not aware of the weight of his name.”

At the time, Dean Steini Brown was IHPME’s director. After briefly meeting with him in March of 2014, Farhana had found her supervisor. When she would casually mention her supervisor’s name “I would get the biggest eyes and eyebrows shot up to the sky ‘oh my God, are you serious?” and I was like either something is really wrong with this person, or I am in luck.”

“As intellectually stimulating it may be, PhD is a long-enduring journey,” she shares. To help graduates, she founded the IHPME Peer Support mentorship program. She admits that she needed support at times from Brown.

“I made it clear to him whenever I needed him. He was almost my therapist for a while, I am grateful for absolutely everything he kindly granted me,” she says of her supervisor.

“There was very much of a ‘we and us.’ That really helped me get through this many milestones over these many years. He respects the people around him. He listens very, very closely, very emotionally intelligent and very calm, no matter what goes wrong.”