Establish a shared purpose, guiding principles and unifying framework to coordinate our mission. Canadian healthcare leaders, providers, and organizations should adopt the Quintuple Aim framework as the overarching goal of health system redesign. Health system planners should understand population needs, determine which services best meet those needs, and resource them appropriately. Provincial Ministries of Health should implement patient care accountability frameworks that incorporate accountability zones, program expectations and performance targets. Health planning and design should be entrusted to an independent public entity at arm’s length from government, to reduce the impact of election cycles on health system decisions. Canadian policymakers should learn from international health systems, while upholding publicly-funded healthcare and the Quintuple Aim. Ministries of Health and Health Authorities should assure all Canadians access to primary care, prioritizing those in greatest need. Reliable access to primary care will help emergency systems focus on their core mission. Governments must support unified digital health integration to facilitate data access and information-sharing among patients, care providers, researchers, and communities. Principles of Justice, Equity, Diversity, and Inclusion (JEDI) should be embedded in healthcare planning, delivery, and evaluation at all levels. Provincial health ministries should catalyze system redesign by creating adaptive, integrated care clinical networks that prioritize patient and population needs. When system factors compromise care, EM must engage with healthcare leaders to avoid simplistic responses to complex problems and to encourage system innovation.

Optimize the number, distribution, capability, connections, coordination and workforce of emergency departments and other access points. Provincial Health Ministries should establish Emergency Care Clinical Networks (ECCNs) to coordinate clinical service and HR planning, operational guidance, and quality improvement initiatives. ECCNs should oversee categorization, standardization (facilities, equipment, required competencies) and integration of EDs and other emergency care access points. ECCNs should establish and support team-based care, creating complementary roles and responsibilities to serve patient needs. Health Ministries and authorities should provide the necessary funding for team building, including regional simulation programs. Emergency care systems should work with EMS agencies to implement and evaluate pre-hospital coordination centres and “expanded scope” EMS concepts. Provincial governments should implement a needs-based, behaviourally-influenced, iteratively-updated physician resource planning model (e.g., the Savage Model).

Implement accountability frameworks, defining accountability zones, program expectations and performance targets. Healthcare leaders should use defined performance measures to monitor care gaps and determine whether these are best addressed through new capacity, enhanced efficiency, or reallocation of existing resources. Where the gap/root cause is capacity, they must advocate for new resources; where it is inefficiency or misallocation, they must facilitate change. The Minister of Health must hold all hospital/health authority CEOs accountable to on-average bed occupancy levels of 85% to reduce emergency departments being used units to hold admitted patients. Facilities should implement demand-driven overcapacity protocols to be activated when pull systems are failing and access block is compromising care delivery. Overcapacity protocols should also bridge the hospital-to-community transition. Provincial governments should immediately invest in aging-at-home options and Alternate Level of Care (ALC) transition capacity to expedite hospital outflow, mitigate acute-care access block, and improve quality outcomes. Hospitals must publicly report ED performance in relation to CAEP ED access and flow targets, as articulated in its 2013 position statement on overcrowding and access block.

Integrate and fund disaster preparedness throughout the system. All healthcare facilities must have a formally tested plan for surge capacity. A system that is near or at 100% occupancy cannot, by definition, cope with surges. The plan must include a constant level of bed redundancy which must consist of real beds—staffed but unoccupied—as opposed to theoretical bed expansion above the existing census. Competency in disaster response must be validated though structured cyclical auditing, established as a requirement for healthcare facility accreditation and integrated into routine evaluation. Preparedness planning must be integrated and uniform across all levels of the health system and allow for mutual aid across all levels and jurisdictions. Education and training in disaster preparedness should have dedicated annual funding to achieve and maintain competency. All disaster planning must consider vulnerable segments of the population including those with special needs and challenges.

Adapt to a changing world, within and beyond medicine, by becoming a learning health system (LHS). CAEP, in conjunction with university departments and divisions of emergency medicine, should develop a pan-Canadian EM research network, to coordinate researchers and facilitate interdisciplinary collaborations that prioritize the most urgent and impactful patient and population needs. Emergency physicians should embrace leadership and stewardship roles in digital health, to ensure that the best innovations are promulgated and that precious public resources are not diverted to non-value-added activities. Emergency physicians, through their national and provincial organizations, must be knowledgeable in the population health effects and health system impacts of climate change events (e.g., wildfires, floods), and participate in public and professional education, and advocacy. EM training programs should include public affairs, policy and advocacy in their teaching, as part of a health systems science (HSS) curriculum, to advance understanding of the broader context in which EM operates and nurture the next generation of systems change leaders. EM training programs should address the impact of social identity in the healthcare setting and foster opportunities for productive interaction among specialties, to establish teamwork and shared goals as integral parts of professional identity development.