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)
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.
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.
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:
- Change the doctor’s orientation toward him/herself and toward nurses in general;
- 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.
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.
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.
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