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The Duty to Do Things Differently - Executive Summary

In August 2020, the government of Québec entrusted Commissaire à la santé et au bien-être (CSBE) with a mandate to assess the performance of the health and social services system in managing the first wave of the COVID-19 pandemic, from February 25 to July 10, 2020. This mandate focuses on the provision of care and services to older adults, and on the public health response. It does not assess measures taken to manage subsequent waves of the pandemic.

The final report, entitled Le devoir de faire autrement (The Duty to Do Things Differently), is published in two parts:

  • Part 1: Renforcer le rôle stratégique de la santé publique (Strengthening the Strategic Role of Public Health), deals with the government’s overall management of the pandemic
  • Part 2: Réorienter la gouvernance vers des résultats qui comptent pour les gens (Realigning Governance to Achieve Outcomes That Matter to People), deals with the system’s performance in providing care and services to older adults in residential facilities during the first wave.

In the short term, to address management issues raised during the first wave:

  • Develop and adopt an integrated national strategy to ensure health crisis preparedness
  • Develop a culture of transparency with regard to population health policies and decisions
  • Adopt an outcome assessment system based on recognized international standards to support decision making (clinical, organizational, governance)
  • Plan and regulate the provision of residential services based on expected outcomes and a fair funding model
  • Call for joint solutions.

In the long term, to optimize resource usage, value creation and the sustainability of the public health and social services system:

  • Strengthen the strategic role of public health
  • National plan for a value-based healthcare system.

What happened?

There were 5,718 deaths in Quebec during the first wave of the pandemic (February 25 to July 11, 2020). 4,836 deaths occurred in residential facilities for older adults (CHSLDs, RPAs with or without care units or RI-RTFs). 

In the first wave, 64% of deaths occurred in CHSLDs, even though older adults in these residential facilities represent less than 0.5% of the population

Excess mortality: 

  • Québec-wide: 15%
  • In CHSLDs: 34%

The excess mortality in Québec during the first wave was greater than in other provinces. 

Why did it happen?

The pandemic revealed and exacerbated four areas of vulnerability in the ecosystem of care and services for older adults. 

  1. Management of the healthcare system in times of crisis, revealing that Québec was ill-prepared to face a pandemic. 
  2. The state of care and services for older adults at the start of the pandemic (labour shortage, lack of staff supervision, lack of expertise in infection, prevention and control).
  3.  Deficiencies in the governance of care and services for older adults.
  4. Deficiencies in the overall governance of the health and social services system. 

The root cause of our collective failure during the first wave

For many years now, the Ministry has failed to fulfill its crucial governance role:

  • Attention placed on system operations (activities, resources, care/service volumes, access) and not on outcomes. 
  • The Ministry does not use all the governance levers at its disposal to improve system performance. 
  • Governance shortcomings are an obstacle to developing a care and service model that optimizes healthcare resources to improve population health. 

Most of these issues were known before the pandemic. Recommendations were made. But decisions were not taken to act on them. A change in direction is needed to focus on outcomes and on the value of care and services. 

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