Micro Organizational Behaviour

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 Ontario health care. Two Ontario hospitals acted as pilot sites for projects under the Flo Collaborative, working with the regional Local Health Integration Networks (LHIN) and Community Care Access Centres (CCAC). The overall “flow” of care crosses several different organizations; for example, a client/patient moves from admission into a hospital medical unit, receives treatment and care within the hospital, and then transitions from the hospital to receive an appropriate level of care. The approach for improvement includes “The Model for Improvement,” Lean methodology, Six Sigma Tools, and PDSA cycles.

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 Windsor between his CCAC and the Hôtel-Dieu Grace Hospital. He explains, “Often times, staff are well aware of shortcomings within the process but remain silent in expressing their ideas for improvement.” He adds that now, because of the Flo Collaborative, staff have greater opportunities to discuss and try new process changes. Often resistance to change is common in such improvement projects; however, Andrew still found an appetite for the improvements: “Many times we overlook that the frontline has lived with their current system inefficiencies and that they want the change, as well.” As with other change efforts, people have to feel comfortable contributing their individual insight to realize the overall process improvements.

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.

In working with a client recently, a hospital nurse relayed a situation to illustrate some of the conflicts that can arise between staff. The loose details are as follows: a patient is recovering in hospital and begins to feel nauseous in the middle of the night. The nurse records a prescription for Gravol on the chart. The following dialogue ensues during the doctors rounds:

Doctor: Who prescribed Gravol for this patient?

Nurse: I did; he was nauseous.

Doctor: Listen, I prescribe meds for patients, OK?

Nurse: (either out loud or internally) It’s Gravol! The patient was nauseous, and you weren’t around. Would you rather I let the patient vomit on themselves while I wait for you to come around and prescribe Gravol?

Behind this conflict, there may be several issues (interpersonal history, sleep deprivation, emotional strain of the job, frustration at poor handwriting, etc.). One of the issues may well be that this particular doctor does not respect the nurses full ability to provide insightful medical care. If the nurse suspects or understands this to be the doctor’s orientation, he/she has two options:

1. Change the doctor’s orientation toward him/herself and toward nurses in general;
2. Work around the orientation to get the right treatment for the patient.

The nurse pursuing Option 1 may face this interaction:


Doctor: Who prescribed Gravol for this patient?

Nurse: I did; he was nauseous.

Doctor: Listen, I prescribe meds for patients, OK?

Nurse: Gravol does not need a prescription. Since the patient is not allergic to Gravol, it was the best and safest answer. I am in a position to make that call.

Doctor: No you are not. Doctors make decisions.

Nurse: With all due respect, my training gives me the expertise to make this decision. This can allow you to focus on more serious issues. You would be my first contact if I had any uncertainties. With this patient, I believe this was the right approach.

Doctor: Doctors make decisions.

Nurse: …


The nurse pursuing Option 2 may find this:


Doctor: Who prescribed Gravol for this patient?

Nurse: The patient was nauseous; I suppose I should have written “nausea” on the chart instead of “Gravol,” but because the patient has had Gravol before, I didn’t see a problem.

Doctor: Just give me the information; I will make the decision, OK?

Nurse: Sure.

From the outside, it is objectively wrong and a misallocation of resources for nurses (or any other participant in a system) to not be allowed to make full use of their training and expertise. Although in selecting Option 2, you are enabling that misallocation, you are saving your time and energy with a work around solution. It is a trade off.


In a very real sense, objectivity allows you to pick your battles. You have the option, in some cases, of steering away from the “let me change your mind” conversation and still get the “right” outcome. It is a tough turn to take, but often an easier and faster resolution.

If you have read my blog before, please pardon me while I explain this question in view of not getting the “benefit of the doubt” from others reading this. I have worked in and with a wide range of health care organizations. As a citizen of Ontario with children, a spouse, siblings and parents in the province, I have a vested interest in the current and future system reforms working. I see a greater possibility for success if the right kind of collaboration takes place so that the right people are able to make the best (not easiest) decisions.

With that context, understand my sincerity in asking “What is it with doctors?”

In my writing and my client work, in- and out-group dynamics come up a lot. Doctors are perceived as a very specific constituency in the system… with good reason. The extent to which this perception stands is fascinating:

At lunch recently with a fellow consultant in the health care system said to me: “We seek to inform the doctors, but all we hope is that they don’t actively resist the work we are doing.” Working with a hospital group recently, the historic specter of the doctor vs. nurse divide reared its head. An academic mentor of mine with whom I consulted before launching my practice suggested: “It won’t work if you don’t get the docs on board, and I don’t think you will.”

There are a number of reasons why doctors could view themselves as very removed from the system: degree of training, stature that crosses most/all cultures, different employment structure with the hospital/community system, etc. But do they see themselves as that different? Some may, some may not.

If I were a doctor, I think that I would be proud of my accomplishments, and I might develop an ego. I also might think that it is my job to make decisions and may actually not appreciate what I perceive as challenges from other staff (RNs, RPNs, etc.) who (although they are only trying to help) are trying to make those decisions for me. What if they are wrong? If I were time starved, as many doctors are, I may not be able to take the time to “soften” my message or think about the “how” of my communication skills.

If doctors are removed from the workings of the system, they can take responsibility to “engage” more. If they don’t those working around them can accept the out-group reality and behave accordingly. The right information to save and prolong lives can still get through. Like many things, it is easiest if both sides work together. Some doctors will; some won’t or can’t. It is the latter group that could tip the scale one way or the other. As some of the tougher reforms come through, it will be interesting to see if the perception (and reality) of doctors change.

This week’s Longwoods newsletter (www.longwoods.com) lists instances of LHINs “starting to show some muscle” in enforcing balanced budgets for hospitals. The tally of resolved vs. delayed agreements from the London, ON, area is on the Longwoods Healtcare Blog. There is specific mention of a resolution, whereby the South East LHIN lent one of its area hospitals the shortfall to balance the budget for 2008; and of a conflict, whereby the North West LHIN and the Thunder Bay Regional Health Sciences Centre dig in on there competing positions.

The people working in these negotiations must feel like Gary Sinise in Apollo 13 when he is trying to simulate the landing procedure while not exceeding an unprecedented voltage level. In the movie (and the real story), he does it, which provides more evidence that the impossible is attainable when we work together.

What if the impossible is really impossible?

I can guarantee you that the word “impossible” has come up in the discussions and negotiations between Ontario’s hospitals (legally bound to budgets) and funders (LHINs whose job it is to enforce this accountability). I am equally certain that, in the end, some of the things deemed “impossible” were so in actuality, while others were not. The only way to separate the two is discussions (apparently still ongoing in Thunder Bay) that remain open and solution-focussed amid a cloud of rising tension. This is no mean achievement.

Unfortunately, “out-of-the-box” solutions are not always there, but they won’t even be entertained if there is a breakdown in the shared goal, which is getting a sustainable health care system in place. If a situation is truly unmanageable, then there is a responsibility to find a solution together. It demands a different approach than traditional “us vs. them” negotiations. A healthy dose of mutual trust will be necessary for resolutions or re-evaluations.

I am intrigued by the cost savings at Quinte Health Care from implementing third-party (Murphy Walsh) consultant recommendations for improved quality of life for nursing staff. Such experts can add tremendous value in honing systems. Of course, time tells whether the dollar return on these efficiencies will help with the budget shortfall. People also have to embrace the changes, and time also tells whether the changes are actually workable for the staff. One hopes that there is a peppering of “sell” in the “tell” for any change required.

Tom Blackwell raises a the dynamic of the “right to choose” in this piece on canada.com. The question is: who gets to decide what is best for a sick child: parents or doctors? I think we can all take comfort that the situations where this sort of dispute escalates to the Children’s Aid Society are “rare,” and needless to say, “emotional.”

Both doctors and parents, one can assume, have the best interest of the child at heart. But it may be more complicated than that: I recall hearing commentary on an instance in Vancouver–raised in the above article–whereby the parents of sextuplets refused blood transfusions because their Jehovah Witness faith did not allow the procedure. The commentary (I will try to find the source; you will have to trust me for now) was that in such instances, loving parents need to be legally forced, because it allows them to save the child, while also saving religious face.

If, in fact, both parties are focussed on what is truly best for the child, both are responsible and accountable. Parents need to be ready to make their case with more than just “this is what we want” or, worse “this is what our child wants.” With all due respect, it should not take a psychiatrist to determine that a child is unfit to determine the cancer-fighting procedures that they will receive. The medical profession must be granted some degree of trust and authority to make these decisions for people. This sort of latitude should be granted, but also needs to be earned.

Information is everywhere, and Google could probably help find a source to support that a diet of raw vegetables beats chemotherapy or that alternative care in Mexico will be more effective than Ontario hospital care. If these sources of information are being given the nod over what the doctor says, the doctor has some “selling” to do. Understanding the real concern takes time, and usually requires (1) creating a relationship of trust and (2) asking questions. Did the doctors do this? Did they have the time? the skill? Not everyone is going to take a doctor’s word as gospel; nor should they.

Medical research and past results are not the only forms of evidence, but will only be effective if the other party is listening. Fostering a dialogue can get people to open up to some grim realities. It must be a horrible decision to pick between a grueling medical procedure that might help, and a less extreme treatment that almost certainly won’t. That decision, however, should not be the parent’s, and definitely shouldn’t be the child’s!

You can’t take politics out of the health care system, which would suggest that George Smitherman gets some latitude in his public commentary, as do all politicians. Who takes politicians comments at face value? At some point, however, the gamesmanship and negotiation-style posturing will get in the way of achieving a sustainable system. This position receives support from Dr. Yoel Abells in his column in today’s National Post. Dr. Abells rightly scolds Minister Smitherman for using a confrontational approach to negotiating funding with hospitals. The basis for the criticism is that the Minister is picking fights that the LHINs—the funding messengers—are going to have to finish.

NOTE: If you are asking, “What’s a LHIN?” as many a layperson will, visit www.lhins.on.ca for details on the newish player in Ontario health care.

I wish that more people shared Dr. Abells’ perspective; he is in the community and in a hospital. He also takes enough interest in the solution to share his views with the public. I think that his arguments are valid, but I believe that assigning blame defeats the purpose of any health care reform.

Previously, I have written about the movie Apollo 13 (here): is there any clearer example of necessity mothering invention? Ed Harris’ statement “Failure is not an option” is taken as gospel. This type of collaboration (us and us; not us vs. them) fosters true innovation. Making the most of the available resources gets beyond the status quo gamesmanship whereby hospitals grumble in March about under funding only to be topped-up in April for by a government looking for political points.

The LHINs are at the front lines of reform. Granted, posturing from the Minister and his office doesn’t help the situation, nor do tactics from hospitals. Both will have to reach across the fence for things to work for the long term. Time will tell if the LHINs gain enough credibility to broker these handshakes.