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.
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.
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.
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!
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