REVIEW and thoughts on: Chronic Condition, Jeffrey Simpson
Working from the hypothesis that “to appreciate where we are, it is worth revisiting how we got here,” this book includes a thorough review of the history of the Canadian Medicare system. This was very instructive to me, although some will be more familiar with these developments. Some of the important elements that stood out for me were:
1 – “Fee-for-service” for providers (specifically doctors) is well baked into the system
2 – Hospitals are a distinct and well-developed part of both the infrastructure and of the system
3 – Even though the Canada Health Act allows non-government service providers, the word “private” complicates any discussion because it conjures up “US-style,” “two tier,” and other terms that garner very emotional responses.
Simpson provides a thoughtful comparison of our system with those of England, Sweden and Australia. This illustrates how no one has a perfect system, but there are systems that perform much better than ours does. He suggests that low public awareness as to the mediocrity of results from the Canadian system (by OECD standards) is a big part of the problem. Maybe people are fine as long as we are not as bad as the US. Politicians certainly benefit from the misperception both in reducing panic of a looming crisis and in hiding any province-to-province comparison that could identify comparative laggards.
According to Simpson, continuing to throw money at the current system is a complete waste of resources and is an admission that funders do not understand the dire situation that we have created. The big thing at stake is what he calls “vertical equity” meaning that the status quo puts an unfair burden on future generations. (He uses “horizontal equity” to describe how the system treats people in terms of access and care at any given time.)
The big recommendations are threefold:
(1) Doctor and nurse unions have to stop being rigid in protecting compensation. Fee-for-service usually means that “how much” you get paid is a function of “how much” you work. Again, there is no clear answer but Simpson relays the challenge of how, for example, reducing wait times leads to rising costs because more patients are being served.
(2) Hospitals need to be allowed to do what they do well, and cease to provide ALC-type services that are both of insufficient quality and of exorbitant cost.
(3) Drug expenses have to come down. He suggests a national drug plan based on CPP.
Each of these avenues takes on a very specific and very powerful interest group: unions, hospital administration and pharmaceutical companies. All tough rows that need to be hoed.
I enjoyed the read, and it got me thinking about how much of the eventual solution will come from strong leadership in small areas that can start some momentum. Actions and results at lower levels can help to build the various beachheads that need to be established for more comprehensive systematic changes to bring sustainability and “vertical” equity.
As long as I have been active in the business world (and paying attention), “providing solutions” has been part of normal business language. This is not a measure that I endorse, but a Google search for “business solutions” garners 10 times more results than does a search for “business problems.” (For what it’s worth, bing.com turns up 270 million for the former, and 300 million for the latter. Is Microsoft onto something here?)
Tom Blackwell (National Post Health Care columnist) writes last month about the trends to bring Toyota-like efficiency into hospital and health-care environments. The successes are clear and are often demonstrated in reduced wait times and higher through put. Both of these offer defense to such criticisms as “you can’t treat people like automobiles” because you can treat processes like processes.
One of the perspectives that Mr. Blackwell introduces is that of consultant Tim Hill, who works in the implementation of such programs. His criticism is that, as the worm turns toward “everybody’s doing it,” clients may not be getting the value that they should (or, as Hill puts it, “A lot of health care facilities are getting ripped off.”). Needless to say, the eHealth initiative in Ontario has raised the level of scrutiny on consultants to the health-care industry, including perhaps myself and Mr. Hill.
Accountability for “providing solutions” has always been a tricky one for consultants and service providers. How many software executives would take payment from the efficiencies their product generates? Or how many advertising executives would link compensation to the sales impact of a campaign? With a larger understanding of shared interests, consultants can be encouraged to try to “solve the problem” rather than simply “provide the solution.” This may override the obvious tension of the pay-the-least vs. charge-the-most divide. Again, both sides need to be reasonable.
The bigger challenge is where “the problem” stretches beyond the area of the organization that hired the consultants. The natural temptation for any service provider is to give the client “what they want,” which may not be the solution they need. To use Mr. Hill’s example, the hospital may get the rigour of Lean processes (that they asked for!), but some important underlying issues remain unsolved.
Managing the tension of collaboration is possible when there is an understanding of the shared interests. This likely means that: (1) the customer is not always right; and (2) for consultants, there are no one-size-fits-all solutions… but we all knew that already.
THIS ORIGINALLY APPEARED IN THE MARCH NEWSLETTER OF THE CANADIAN SUPPLY CHAIN SECTOR COUNCIL (www.supplychaincanada.org)
En route to a meeting this morning, I found myself listening to CBC Radio One’s The Current and a discussion of flu preventation/pandemic preparedness. Today’s discussion explored mandating flu vaccines for health care workers. One expert, Dr. Alison McGeer, the Director of Infection Control at Mount Sinai hospital in Toronto, makes the very general comment, “Nobody likes to be told what to do.” As it turns out, this may be the biggest issue in play for this particular discussion.
Complementing Dr. McGeer’s insight, was New York State Health Commissioner, Dr. Richard Daines, whose state has adopted mandatory flu vaccinations for those in the system who come in regular contact with patients. The scientific evidence appears to be compelling, and demonstrates the correlation between vaccinated health care workers and reduced impact of flu on society. Neither doctor relied solely on the scientific evidence because both, I assume, realize they are up against a less rational “you can’t make me” reaction to the word “mandatory” (or “forced,” if you want stronger reactions).
Their counter arguments were excellent, and I am curious whether or not this came through media training, or simply understanding how to diffuse a particular line of questioning. Here are two examples of note (paraphrased):
Dr. McGeer, in response to concerns about limiting freedom of choice: “If you are a pilot with a heart condition, you are not given the choice to continue to fly.” (Score more points for the analogy!)
Dr. Baines, in response to concerns about over applying the rules: “We have reasonable people in our institutions; they will implement this in a reasonable way.”
In contrast, I think that the support given by Linda Haslam-Stroud is the President of the Ontario Nurses Association was very weak, suggesting the idea is good, but stressing that choice is important without much support. I am not sure if this was a lack of media training/preparation, or if it is simply much more difficult to support the “you can’t make me” side of this argument.
Interestingly, in New York and other areas that adopt this practice wholeheartedly, the people can retain their right to choose, with the choices being (1) get a vaccine and keep working, or (2) don’t get a vaccine and take some unpaid time off. So, you see, “you can’t make me” is indeed correct!
Yesterday afternoon, I had the pleasure of listening to Michael Porter speak about value-based strategy in the health care system. (Since then, two people have asked me, “Who is Michael Porter?” Answer, for non-MBA types: “He is the Wayne Gretzky of business strategy.” Think 1980s and substitute Harvard Business School for the Edmonton Oilers.)
Having previously only read Porter, I was delighted at his level of passion and engagement with the audience. From the second to front row, I got a great view of all he did well. I would argue that this was not entirely necessary. As I mentioned to a fellow attendee: when your name is Michael Porter, with that particular crowd, you could count on the audience doing some work to understand you.
My take on the top-level was likely the same as everyone else’s. The current system is not set up to allow practitioners or patients to succeed. Too many people are asked to do the impossible. (That those in the system continue to do toil is a comment on very human-centric motivations!) The answer is to let people/system pieces excel in very specific areas. The success of niche players in business (Apple specializing in “cool,” Wal-Mart doing “cheap,” and Starbucks continually polishing their “experience” are all well-known examples). There is a German health centre that specializes in “headaches.” That is the future of health care.
We all have our “things” and Porter’s is “value-based competition.” Given that my “thing” is “getting the right ideas implemented,” I smiled (then cringed) when Porter glossed over the need for a “broad consensus” required to implement any of these changes. He quickly alluded to all the egos that prevent people from “stepping back and thinking rationally, ” and half-heartedly urged any board members in the audience to use their influence to champion attention to patient-outcome value.
I am unsure if others picked up on the importance of this point. It is a huge barrier to the right conversations ever beginning. Porter is right that it has to start somewhere: indeed, it has already begun. “Broad consensus” may be a challenge, but a good dose of “couldn’t this be WAAAY better” from various places in the system can help. I will continue to try to do my part. Intolerance is good.
In work that I do with clients, the situations with the lowest return on time/energy (ROTE) consistently involve communications with those who don’t “get it.” “Getting it” and “not getting it” creates very strong in/out-group perceptions. “It” can take a number of different forms, and usually, I am on the outside looking in. I will hear, for example:
- THEY don’t get that a for-profit model can fit in health care.
- THEY don’t get that Canada is a different market from the U.S.
- THEY don’t get that they are losing the chance at more business down the road by being so contentious now.
My job is to help them to help the other side to “get it.” It can work, but not all the time. Recently, I fear, I was the one who was likely being accused of not “getting it,” which, honestly, is new for me. I actually pride myself on being able to see both sides of things, in most instances. As I understand, and tell my clients, when you are involved, things become less visible. On top of that, it can be completely unclear who is right.
For example, imagine those who did not want to give the automotive Big Three any U.S. Government funds.
For them, the situation is clear:
The Big Three (THEY) don’t get that the model is broken and more money is only prolonging their ultimate demise.
For those supporting a loan/bailout, it is equally clear:
The U.S. Gov (THEY) don’t get that we just need a bridge loan. Weather this storm, and we are set up for long-term success.
One of those positions is right, but only time will tell.
My recent challenge is bringing my “soft-skills” orientation into a “tech-savvy” environment in a discussion about creating value in information sharing and collaborating. Quite predictably, one of us is “not getting” that if and how people use any tool–not to mention the relationship between the parties–will dictate a large degree of effectiveness. Perhaps the other of us is “not getting” that in the future, personal relationships, perceptions and things like “the benefit of the doubt” have little or no role in the workplace.
One of those positions is right, but only time will tell.
There is a risk in oversimplifying issues to the point of a binary explanation (e.g. this or that). The temptation to oversimplify is obvious when presenting the issue to a wider audience who likely have yet to pay attention to the issue: descriptions become easier (e.g. it’s like this OR it’s like that), and encouraging agreement and disagreement is more likely (you are with us OR you are against us). The inherent danger is that these oversimplifications take deeper root.
Such binary identification with words is described as religious attachment to the resistance to “private” involvement in Canada’s health care system by Robert Ouellette of the CMA. At some point, an argument was being made that a 100% public system (conceivably the “Canadian” system) was superior to a “free market/services to the wealthy” system employed (conceivably the “American” system). “So it really is pretty simple,” goes the explanation to those whose decision/votes one is trying to woo, “You either support a Canadian system, or we risk deteriorating into, well, you know what.”
This type of positioning may be necessary to garner support for a cause, but when the binary support can cloud the issue. In Alberta, Ralph Klein famously put forward the “Third Way” after clearly describing the other two alternatives, one being unacceptable, the other impossible. But the same forces of binary division happen when you talk about the an “Alberta solution” vs. an “Ontario solution.” The required changes in the health care system are not about Alberta vs. Ontario, Canada vs. the U.S. or private vs. public; it is about finding a manageable way to meet the growing strains on the system.
Words are necessary to describe these things, but there has to be a tolerance for ambiguity of language along the way. To commit to a strategy, you have to describe the path, but “this or that” language has to be avoided for fear that it does take root. In winning people over, it is tempting to simplify language, but some things will never be simple. Health care is one of those things; so is government and economic policy. Is anyone prepared to get specific on the “change” that either McCain or Obama will bring? Likely not until January.
Today’s Toronto Star has an interesting take on a bill regarding apologies that is currently being considered at Queen’s Park. The bill apparently frees a doctor to say “sorry” for a mistake or outcome, without the fear of having the apology brought into court as an admission of guilt. It is an intriguing proposal, which promises to reduce the number of cases that go to court, because an apology may be all the person needs to forget and move on.
This flavour of apology resembles decaf coffee and light beer: all the good, with none of the bad. The problem is that–and coffee- and beer-drinkers know this–it can’t be the same.
Recall in April 2001 when a U.S. spy plane crashed in China, the Chinese authorities cried out for an apology. What they got was a declaration that the U.S. was “sorry that it happened.” I was living in Japan and the time, working as a translator, and remember the discussion about the translation: “See, he said ’sorry” to them.” True, and somehow he managed not to apologize. Such are the nuances of international diplomacy.
Here, however, we are all speaking English. This bill could do one of two things to exchanges where doctors have to convey bad news to patients.
#1 – Doctors who are genuinely sorry with the result (even though they surely explained the risks going in) can relax and communicate to a fellow human being that they really wish it could have worked out better.
Note: this has the potential to ring very hollow, even if the intent is true.
#2 – We will see a rise in no-risk lip-service apologies designed to quiet a patient who might otherwise fight back and demand retribution from the system that failed to beat the odds, or at least cover the spread, in a medical procedure. (This is the provincial NDP’s position, as I understand it.)
I think that the benefits from scenario #1 will outweigh the cynical suspicions of #2, so it is a good development. I also think that it is too bad that we have to split the individual apology from the institutional apology. Either way, we lose a bit of the human element, but we all have to minimize the downside. This may be a smart trade off that leads to a better working system.Another option might be for doctors to preface apologies by saying, “The opinion I am about to express comes from my individual feelings, and in no way reflects those of this institution or my profession.”
I just got back from Japan.
Jet lag always gives me time to contemplate, and the near 180 degree nature of Tokyo/Toronto time zones usually guarantees at least two day/night reversals on either side of my trip. This very early August morning proves mornings are indeed shortening, at least until that wondrous day in October when “Fall back” gives a brief reprieve from wake-up darkness. Due to my recent travels, my contemplations turned to a discussion that I once had in a Japanese class around a newspaper article that proposed the introduction of “daylight savings” to Japan (”sunny time” as the article tagged the North American phenomena).
“People in Japan would never agree to ’sunny time’ because we work long enough as it is,” came my teacher’s summary. What on earth is the link between moving dawn until after 5AM and working even longer hours? After diligent effort and multiple paraphrasing to erase any doubt of a missed nuance, I grasped the link: There is an understanding in the Japanese workforce that you cannot leave work before dark. Darkness is by no means an indication that you can go home (or, more commonly, out for beers with your co-workers), but sunlight is not to be encountered on your homeward commute. My notion of “end of day” may also have slid because many of my “foreigner-friendly” jobs (i.e. teaching English, translating to English, etc.) had mid-morning start times.
That this conversation took place in a language class made it natural for me to suspect I was actually misunderstanding, which made me genuinely open to really understanding the core issue. I am not sure I would probed to the same extent had the conversation taken place in English (or had my Japanese been better!). What we had was a fundamental difference in beliefs. For me, daylight savings time could mean getting in a full-round of golf after work, or bike riding with the kids after dinner. To my Japanese teacher, and potentially to Japan’s average working Taro, the clock change was like watching the “fall back” time change while working the night shift… but for everyday of the summer!
Fundamental differences don’t fall easily, and that is exactly why daylight savings time will never be implemented in Japan. But given the absence of evidence the change breeds the promised energy efficiency, is Japan really worse off?
Fundamental differences are at the heart of the proposal to limit a physicians rights to exercise moral judgement in delivering medical care. Some life and death issues (beginning and end) cannot be driven by science and rationality, but instead fall prey to fundamental beliefs (aka: morals) that may conflict with legislation. When this is the case, and when operating within the laws of the land, it is most realistic to have patients find doctors who share (or at least don’t oppose) the fundamental belief in question. The trade off should be seeing that doctor OR getting the medical treatment in question.
NOTE: The case may be different in rural areas where the supply and demand dynamics are different.
If you really like daylight savings time, you shouldn’t live in Japan. Conversely, if you really like Japan, you had better be flexible about Springing ahead and Falling back. No one can have both. Patients are not different.
There is a rigour to Lean thinking that can appear supremely cold and calculating. However, its unwavering focus on “what the customer sees as value” should curry favour with those who are receiving (e.g., paying for) the end product, which ideally equips companies to look after their people and their environment. Welcome to the triple bottom line.
See… it’s not all about the relentless pursuit of cost savings.
There are some very real inefficiencies (waste, or “muda”) that can be rid from any system with this approach. This may be part of the reason we are seeing such approaches embraced in non-traditional areas, including the service industry and, yes, health care.
The Flo Collaborative
The Flo Collaborative kicked off in September 2007 in order to examine and improve the flow of care in
Not surprisingly, many initiatives that offer the possibility for “quick wins” target frontline staff who are actively engaged in their current standard processes. Andrew Ward, Senior Manager at the Erie St Clair CCAC, worked on the pilot project in
Assessing and Influencing Authority
Asked about lessons learned in getting the all-important “buy-in” from “naysayers,” Andrew sees great potential in gaining involvement from the beginning. He says that it is well worth the initial investment in time to determine who has informal authority, in addition to those with formal authority. “No process change is made in a vacuum,” he explains. “Many things must be considered prior to making an adjustment in staff workflow.” Project leads and others within the team need to feel involved in order to want to share information.
There are some natural barriers that people can hit if they take a “business” approach to anything related to health care. Nonetheless, there are some significant improvements to be gained from a systematic approach, such as that with the Flo Collaborative. Like in any change initiative, it is ever so important to unlock the knowledge of the frontline by enabling good two-way communication. Andrew concludes, “By taking the time and identifying team members of formal and informal authority from the beginning, process changes will yield higher and more sustainable outcomes.” Don’t be mistaken: just because it’s soft, doesn’t make it easy.
This originally appeared in the June 2008 e-Newsletter for the Canadian Supply Chain Sector Council (www.supplychaincanada.org).
I had the very good fortune of hearing Deepak Chopra speak at the conference of the Ontario Association of Community Care Access Centres (OACCAC) this week. He was speaking to a room of various individuals involved in the delivery of health care at a community level, but his messages were wide sweeping.
According to Dr. Chopra, the trend toward well-being is the single biggest trend in the world today. He extrapolated to include economic well-being and environmental well-being, in addition to personal well-being. In short, people want the best end result to complex situations that include many interdependencies. In order to overcome the challenges of today, thus achieving well-being, we need to speak in non-violent metaphors. This demands a paradigm shift.
He navigated an impressive range of topics and, perhaps playing to his audience, spent a significant amount of time discussing biological and neural happenings. I say “perhaps playing to his audience” because he spent time as well on quantum physics.
The key message was indisputably focussed on the best way to bring about the best change. Given the state of the health care system–and that Ontario’s Minister of Health and Long-Term Care recently changed–the forum was a good one. The talk was teeming with fascinating insight and inspiring stories, but one of the most tangible pieces of advice that he shared was around leadership. Although Deepak Chopra leads a session on the Soul of Leadership at the Kellogg School of Business, the advice was accessible and applicable to all who were there… a “Micro Leadership” message, if you will.
Effective leaders do two things, according to Dr. Chopra: (1) self reflect to self understand; and (2) remain open to opportunity. (Although he says many leaders mention luck, he defines “luck” as opportunity meeting preparedness.)
Clearly if everyone adopted this line of thinking, things would be easier. Although many hung on his every word (and bought the book after), not all were or will be able to embody or sustain this approach. Those who do, have a responsibility to (1) focus on the greater good and (2) look for ways to merge opposing interests with those of the former. Tough work, to say the least. Here are but two applications from follow on sessions that I attended:
1. Dr. Joshua Tepper from Ontario Health Force spoke about opportunities and necessity to have medical schools and colleges breed practitioners with cross-discipline awareness. What better way to find new opportunities than to have more people working together. The functional disciplines will have to be very comfortable with one another and secure in themselves to be open to this. You can imagine all the reasoning for not collaborating: what is they start doing our work? who decides if we don’t agree?
2. Jeff Dolweerd discussed a LEAN case study underway the Central CCAC. The rigorous focus on value from the client’s perspective identifies clear ways to create value more effectively. In a situation where supply is staff and demand is uncertain, the answer lies in getting people to work more flexibly, both with hours and job roles. Sounds simple, until you run into a union mindset (like this one), which may not be able to open up to possibility. (Not to suggest that privatization is the answer; it is definitely a possibility!)
I thoroughly enjoyed Deepak Chopra’s talk and it set a perfect tone for the rest of the day, in my opinion. Not everyone will “get” or will be able to follow his prescription to lead. For those that do, given that we are very emotional beings, it may be tough to stay that course. According to Chopra “there is a creative solution to every problem.” I have cast doubt on that thought on this blog, but I have pause to reconsider now. It is there; we are all tasked to find it.
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