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Context: An evidence base that addresses issues of complexity and context is urgently needed for large-system transformation (LST) and health care reform. Fundamental conceptual and methodological challenges also must be addressed. The Saskatchewan Ministry of Health in Canada requested a six-month synthesis project to guide four major policy development and strategy initiatives focused on patient- and family-centered care, primary health care renewal, quality improvement, and surgical wait lists. The aims of the review were to analyze examples of successful and less successful transformation initiatives, to synthesize knowledge of the underlying mechanisms, to clarify the role of government, and to outline options for evaluation., Methods: We used realist review, whose working assumption is that a particular intervention triggers particular mechanisms of change. Mechanisms may be more or less effective in producing their intended outcomes, depending on their interaction with various contextual factors. We explain the variations in outcome as the interplay between context and mechanisms. We nested this analytic approach in a macro framing of complex adaptive systems (CAS)., Findings: Our rapid realist review identified five "simple rules" of LST that were likely to enhance the success of the target initiatives: (1) blend designated leadership with distributed leadership; (2) establish feedback loops; (3) attend to history; (4) engage physicians; and (5) include patients and families. These principles play out differently in different contexts affecting human behavior (and thereby contributing to change) through a wide range of different mechanisms., Conclusions: Realist review methodology can be applied in combination with a complex system lens on published literature to produce a knowledge synthesis that informs a prospective change effort in large-system transformation. A collaborative process engaging both research producers and research users contributes to local applications of universal principles and mid-range theories, as well as to a more robust knowledge base for applied research. We conclude with suggestions for the future development of synthesis and evaluation methods., (© 2012 Milbank Memorial Fund.)

Traditional health care is fragmented, marred by quality and safety defects, with a failure to provide evidence-based care, and huge and unjustifiable variations in practice. There is abundant evidence that traditional means of delivering health care are obsolete. Concerns are deepening about persistent and widening gaps in health status that health care cannot overcome. Increased spending on health care has never definitively solved the problems of access, quality, or equity. Non-medical determinants of health indicate that the solutions to health problems lie mainly outside health care. The current financial crisis may create the urgency and courage to both eliminate the fundamental problems in health care delivery and reduce health disparities.

This year's Health Care in Canada report prepared by the Canadian Institute for Health Information profiles what is changing, and what is not, in Canada's healthcare system, including a selection of findings related to this year's focus topic: primary healthcare.

The Mazankowski Report is ingenious in design. It is in fact a report in three movements. It begins with a well-modulated analysis of internal reforms needed to improve the system, generally harmonious with the prescriptions of other national and provincial reports. Its financial analyses are composed in a more ominous minor key. Its defining moment is a jarring ideological crescendo that may turn out to be its legacy in the Canadian healthcare debate.

Interpretation: Members of Saskatchewan district health boards supported the general goals of health care reform and believed that changes already undertaken had been positive. There were few major differences in views between appointed and elected members and between provider and nonprovider members. However, tensions related to authority and representation will require resolution. [ABSTRACT FROM AUTHOR]

Looks at the status of the health care system in Canada. Allegation that the country's health care system as of 2004 is unsustainable; Identify the areas of the country's health care system that are performing excellent; Suggestion on how to tackle the problems or flaws of the country's health care system.