Essays May 2012

Forging Complete Questions to Defeat “The Ghost of Healthcare Despair”

Hugh MacLeod

Feedback received on my January 16, 2012 essay “The Ghost of Healthcare Despair” prompted a follow up encounter and essay.

While ascending the stairs to the balcony of reflection, I was once again confronted by the “Ghost of Healthcare Despair”. Not startled by the presence of this Ghost I commenced to concentrate on the phrases adorning the Ghost’s robe. Phrases such as:  100 great ideas never acted on, wicked questions asked – answers not welcomed; patient centered care – significance of provider interests; independence vs inter-dependence; teamwork count me in - if I am in charge; indifference to failure - I win you lose, I am fine – it is you who must change.

As I proceeded to scrutinize the text on the Ghost’s robe, I reflected on the haunting message the Ghost shared in my first encounter.

“Nowhere am I more powerful than when the right idea is offered by the right people at the right time and yet, it becomes a study or report, and it dies, ending up adorning me in splendid fashion.”

I was quickly brought back to the present when the Ghost shouted with a disparaging smile...

“You are an idealist...I was talking to a colleague Ghost this morning about the numerous networks advancing their own goals and agendas and their seeking preferential access to the policy and funding decision-making process. In addition, we talked about the lack of a clear focus and finish. From the patient, resident, client perspective attempts at redesigning whole systems are focused only on selected fragments that encourage a service delivery system that is provider centric. While policy makers and direct service providers express a desire to improve the patient experience many are challenged on how to execute this goal. Will  entitlement, expectation, and emotion continue to trump evidence? Based on moments of insight adorning my robe, I ask, will the players bail on the needs of society”?   

With that, the Ghost of Healthcare Despair departed with a cynical laugh.

Everyone endures their own special ghost, although similar individuals tend to experience comparable spooks.  Some face a cynical, ’burnt-out woe-is-me’ type.  Others face a ‘stuffed-shirt know-it-all’ with a little Napoleon.  This should come as no surprise when we allow ourselves a moment to contemplate the obstacles at hand. The ghosts before us yield the errors of our ways – looking in versus looking out to be responsive to those we are here to serve.

Arriving at the balcony I began to envision what the world of healthcare delivery could be. Never had the writing of Tommy Douglas been more potent when he said...

“Again and again we would leave some sitting in the hospital waiting room while we went out and borrowed or begged for a few dollars here and there till we’d make up enough to pay the bill.  In some cases I knew people who simply died.  I remember burying a girl fourteen years of age who had died with a ruptured appendix…It was in those days I made up my mind that if ever I had the power I would, if it were humanly possible, see that the financial barrier between those who needed health services and those who gave health services was forever removed.”

Ideals are not merely dry stagnant thoughts.  If they are real, they stem from life and they grant us life. Most people who work in healthcare, dream about what could be.

It is an activity that goes on, usually, in the margins of our mental life.  Sometimes we need to endure a crisis before we take them seriously.  In people who are listening to their own margins, these elements can spark conscious reflection, active moral reasoning and from there can lead to the forging of a complete question.  

When Tommy Douglas ‘made up his mind’, he had come through crisis and I suspect he had been in a state of deep reflection, surrounded by vivid dream images of a better world than the one he was facing.  Out of this state, he hammered out his complete question: ‘how do we remove the financial barrier between those who need health services and those who give health services?’ His question helped reorganize and re-define Canadian society.  

Standing on the balcony of reflection I could hear an echoing of voices and opinions.  Representatives of major health professions making alarming statements like a recent government decision would put 20% of membership out of work and that would be disastrous for the people of the province.  A hospital CEO calling into question the Ministry’s commitment to equitable access because of a funding decision he didn’t like.  Behind me, a health professional stating to a reporter, as if it were fact, that wait times will never come down unless we open the system up to two-tier options.  To my left, I saw an academic using a graph to show that the demographic shifts facing the province would inevitably lead to poorer health care over the next two decades.  To my right, a politician talking about the need for fiscal responsibility to bend the cost curve of healthcare. 

Transfixed by the voices below I began to digest what was being said. I came to the conclusion that the discourse was actually ordinary and a part of a spirited debate. However, interspersed with this content was a thread of negativity, of anger and frustration. The conversation reminded me of a schoolyard taunt, Fight! Fight! Fight! It was a current of destructive energy running through the spirited debates.  None of the speakers seemed to be aware of it but gradually it was drowning out the useful content. In addition, the destructive energy was enabling and fuelling other less scrupulous detractors.  Then it hit me, this is the work of The Ghost of Healthcare Despair. It is the shadow side of the system that has been built up by personal interest and personal agenda. 

The system must learn to look through and respect the organizing power of a new lens to the future. What might that be? I believe the “patient experience” is critically important to our ability to navigate the transition to the future. Meaningful conversation…Ask. Listen.Talk.. can be a vital shift of the healthcare system sense of purpose back to where it belongs.

Nothing takes the EGO out of the room like the voice of the patient experience.  

What are you doing to encourage formal and informal leaders at all levels to hammer out truly meaningful questioning? Everyone is tired of the quick-fix that achieves no real effect.  Probing questioning – including questions about existing authority and cartel structures – these contain the power you need to find real solutions to today’s challenges.  The freedom to ask questions out of honest personal reflection will enable us to outgrow constraints in the current collective approaches to healthcare.

It is really about practicing the science and art of asking a precise and complete question.  The presenting problem is rarely the actual problem.  What do I mean by a ‘complete’ question? Systems can be understood from many perspectives.  Fundamentally, they have three basic components: a pattern that gives form or expresses will; a structure that organizes knowledge; and a practical process that achieves a measurable effect.  These three attributes express the value of consciousness in the healthcare system at any point in time. 

Without exploring our assumptions we will continue to be held hostage to our  indifference to failure, which creates barriers to reaching our improvement potential. By engaging people in honest conversations with complete questions invite exploration into inconsistencies in thought that have held us back from achieving our purpose, and can be used to promote a search for local solutions to organizational challenges. 

So often our Socratic impulse to formulate the tough complete questions succumbs to the status quo.  The thread of new ideas that emerge in a moment are often neglected and lost.  As the Ghost pointed out in my first encounter…

My robes..They are a testament to my many victories!  Each of these documents contains a moment of genuine insight and consensus in the healthcare system when a problem was well defined and a practical, innovative strategy was clearly articulated…but then, it was never acted upon! I have quite a wardrobe.  Each document represents hours of volunteer and paid hours of hard work, often by the best and brightest.  Each document contains someone’s hope that they could make a difference”.

Through discourse and the application of honest conversation, we can work like Plato did to keep the Socratic fire burning.  If that fire is ignited in enough of us, working together, we can find new complete questions that will help us solve any and all problems facing our healthcare system.  

We have libraries filled with advanced healthcare research, we have inboxes filled with quality improvement e-mails, we have board rooms filled with transformative ideas, we have conferences filled with brilliant minds, we receive care improvement insights from the front lines, we have constant churn of policy and we all have patient centered care experiences.

If we want to accelerate change and improve quality and patient safety outcomes on a larger scale, we have to do things differently. We, means all of us. All have either a legal or moral authority to demand and promote quality and patient safety, some have both. Collectively we have the power to make healthcare accountable to the patient, resident and client. It may not always be easy to confront the historical, structural and behavioural barriers. This requires courage to abandon old patterns, structures and processes found to be incompatible with a patient-centered approach, and discipline to resist knee-jerk reactions to mini-crises and fleeting fads.

I leave you with this question, “what is, preventing us from formulating the complete questions essential for a sustainable and “ghost free” healthcare system?”



Susan Lanyon wrote:

Posted 2012/05/06 at 03:14 PM EDT

Great article. Says it all. The analogy of the ghost is helpful to get readers to see what ghost they are holding onto.


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