Essays April 2013
The Winds of Change and Gathering Storms
Today I am joined on the balcony by Sheila Jarvis, a leader who focuses on the importance of culture. We have a myriad of issues facing healthcare in Canada and they swirl around us like gathering storms. Healthcare’s funding demands continue to build while chronic disease management overwhelms the system at its focal point, acute care hospitals. Patients, especially baby boomers, gather information online like no previous generation. Armed with knowledge, they become more astute medical consumers who demand patient-centred care. Healthcare workers, meanwhile, want a larger say in solving problems created by a lack of system alignment. As the pressure builds and the storm gathers we hear from a familiar voice, the Ghost of Healthcare Despair:
“All I see is tinkering here … wasted breath … look at the record – studies, papers and strategies filled with genuine insight and practical, innovative solutions – never acted upon. I have a library of them. Each document represents hours of volunteer and paid hours of hard work, often by the best and brightest. Each document filled with hope and answers and changes to come. All ignored.”
Given the gathering storms around healthcare, it is time for an open and honest conversation about our current realities. Time to leverage patient safety as an unprecedented opportunity to redesign the healthcare services system. In order to realize the goals of Canada’s Healthcare Quality Agenda, what will be more difficult: The challenge of keeping up with scientific discovery, or the challenge of changing human behaviour? That may seem like an odd question. Obviously, scientific progress is essential. But so is behaviour change. Health professionals and health-system managers need to take change as seriously as they do scientific discovery. How many healthcare-related organizations, both private and public, thrive off the lack of transparency, consumer value consciousness, and accountability for costs, tracking and reporting to the public on health outcomes, including safety vs. health outputs?
Three observations come to mind. First, the healthcare system must be organized around patient groups, not hospitals. In an environment characterized largely by chronic disease, this is the only reasonable way to coordinate and integrate care delivery. Second, politicians shouldn’t debate individual cases. They should get objective advice based on sound evidence and leave the doing up to the managers.
Third, fixes often fail because a final plan becomes a negotiated settlement at the lowest common denominator. Instead, the focus should be on common areas of real value creation: transparency, reduction of variation, greater coordination across the continuum, use of evidence and obligations of the citizens themselves not to abuse the system or their personal health status, etc. This will raise necessary conversations and questions about bilateral accountability.
To achieve the promise of the future, change will be required at several levels: Changes in our personal behaviour, changes in our institutional cultures and changes at the level of our healthcare systems. Leadership must create the conditions for positive change in multiple healthcare settings, and must ask some serious questions:
- Do we avoid action that may or may not succeed?
- Do we play it safe with easily attainable goals?
- Do we treat vision and mission as noble ideas, without everyday action to demonstrate them?
- Do we bury or spin bad news – suppress truth and avoid transparency – even though the information might provide a compelling case for change?
- Do we fear the risk of losing control? Do we need to be the recognized leader?
- Do we put on blinders about the damage to patients, staff and families?
- Do we truly listen to the patient? Are patients engaged in our new directions?
- Do we congratulate ourselves based on short-term results made at the expense of long-term sustainability?
- Do we over-focus on the next big job and our need for increasing status?
- Do we ask ourselves: “Can I really do this? Should I have been better prepared?”
- Do I have the will to prove to myself and others that I can measure up? What behaviour have I tolerated in myself or others that can no longer be tolerated, given my full commitment to patient safety and quality of care?
Based on moments of personal reflection, as leaders, we can undertake our key responsibility, which is to create the conditions within the healthcare system to solve today’s challenges. Leaders must continually ask: “How can we, as leaders, meaningfully tap into and create a culture that encourages the expression of intellect, passion, commitment and experience by all levels of the delivery system to make real change that satisfies healthcare consumer needs and expectations?”
The fact is that for an organization, or a network/system of organizations, to be successful, each of their interdependent parts must be designed to operate in sync with one another – and with the overall strategy. A smooth operating system is not the product of a series of isolated actions – but from orchestrating the right combination of interactions.
However, “alignment” is not a concept that is particularly well understood in our healthcare delivery system in Canada. Rather than aligning the components of culture, skills, structure and strategy – the actual requirements for system alignment – we tend to focus almost exclusively on the component of “structure.” Unfortunately, the traditional response to poor performance has been to shuffle the internal organizational boxes, rather than align all of the integrated components that would achieve the results required. If we are to stop repeating the same mistakes of the past, our healthcare system leaders at the macro level, and our organizational leaders at the local and operational level, need to master the art and science of “system alignment” and “organizational design.” If we don’t like the results that we are currently producing, we need to understand that the outcomes of every system are embedded in its design.
While Canadians are saying that they love our healthcare system, the fact is that today our current methods of organizing and delivering care are unable to meet the expectations of patients and their families. In part, this is because the science and technologies involved in healthcare – the knowledge, skills, care interventions, devices and drugs – have advanced more rapidly than our ability to deliver them safely, effectively and efficiently. It’s time for a mindset change.
Changing mindsets is about more than changing minds, it is also about bold and truthful conversation. Let’s listen in on a conversation with Dr. Don Berwick, a respected patient safety and quality champion, who was asked: “What does competition mean in healthcare?” His response: “More hospitals that compete with each other. More providers with ingrained turf to compete with each other. More pharmaceutical companies competing for market share. We set up a war. Wait a minute, let’s talk about the patient. The patient does not want a war.”
We need CEOs who see the next five to 10 years as an opportunity to “leave a legacy,” a once-in-a-lifetime opportunity to create something of real value for their community. In five years from now, a critical mass of our existing health system leadership will retire. What qualities should we be looking for in the next generation of healthcare leaders? That’s a question Boards need to be asking right now.
A dramatic convergence of social, economic, demographic and technological forces have brought healthcare to a threshold of a perfect storm. To brace ourselves against this storm, we suggest that we begin with self-reflection to understand how we are connected within both our local and larger communities. We need to understand the system not as a structure, but as relationships – and we need to play our roles as architects, aligning and designing a better system. We need to make sure we create a mindset of sustainability – where our collective productive energy does not go to waste.
Our reality is made up of interconnecting circles of complex activity. But, we are conditioned to see and think in straight lines. What we see depends on what we are prepared to see. What do you see? What we know for certain is that healthcare people are capable of brilliance. We know the answers are within the hearts and minds of the people in the healthcare system. The answers to the dilemmas you face are within your own organization – in your front line healthcare providers, managers, boards and patients.
Standing on the balcony watching the storms, with a little bit of effort, we can see the sun shining through. The sun takes the form of family and patient faces. With all the challenges faced by the healthcare system, the light in the sky is the input and involvement of families and patients in redesigning and reconfiguring the system to meet their needs.
As leaders in the healthcare system, we know we are not alone in our desire to improve the system. Actively partnering with the people who use our services to make the entire system better is critical. We need to let go of the anxiety that sometimes comes with bringing patients to the table with us.
A strategic coming together in a new adult conversation on system alignment using the dimension of quality as a focus and leverage point can offer a humanistic, unifying theme to chase off the Ghost of Healthcare Despair. Let’s always return to these questions: “What do healthcare patients, residents and clients need, and how can the system respond?”
Next Week’s Guest on the Balcony of Personal Reflection: J. Shamian in a conversation titled “People: The Most Important Organizational Asset.”
Click here to see the First Series of Ghost Busting essays.
Click here to see essays from the Second Series: The Ghost of Healthcare Consciousness.
About the AuthorHugh MacLeod is CEO of Canadian Patient Safety Institute. Sheila Jarvis is President and CEO of Holland Bloorview Kids Rehabilitation Hospital
Gilber G., B. Balik. 2010. “The Beautiful Lie.” Hospitals & Health Network Digital Magazine.
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