From the Editor-in-Chief
Our Healthcare "System" – What System?
In recent months, several colleagues and friends have recounted personal experiences to me about their dealings with the healthcare "system." Prompted by their stories, my professional work of late and a personal experience of my own, I have spent many hours contemplating the "non-system" nature of our healthcare "system." Our collective experiences belie some common themes suggestive of results from a hypothetical qualitative study focused on the lived experience of the family members of those who need Canadian healthcare services. The themes might read as follows: (1) looking for guidance in navigating the system, (2) continuously filling the gaps to ensure continuity of care and information, (3) struggling to find adequate post–acute care supports and (4) staying vigilant to ensure a safe passage for me, my loved one or both of us. Of course there are likely many other themes that might emerge from these and your own experiences, but addressing these might be a place to start, if not fundamental to creating a well-functioning system.
Have you ever thought about the defining characteristics of a system? The term denotes "a set of things working together as parts of a mechanism or an interconnecting network" (Oxford Dictionaries 2010). Similarly, another definition suggests that a system is "a complex, unified whole comprised of interacting, interrelated, or interdependent elements" (The Free Dictionary 2010). As a further extension to these definitions, systems may also be "interacting bodies influenced by related forces, forming a network especially for the distribution of something" (Merriam Webster 2010). Healthcare delivery, perhaps? Our healthcare "system" is undoubtedly a complex whole and a network of interrelated components designed to resolve problems of the human condition. But is it truly a system?
A "non-system" may be defined as one that lacks effective organization. Do we have a healthcare system that is effectively organized to support the needs of Canadians, in particular, providing health services in an integrated manner? How ironic that in the previously cited dictionary (Merriam Webster 2010) the word non-system is preceded by the word non-support and immediately followed by non-target. For example, is the "system" sufficiently supportive and targeting the needs of an aging population with a preponderance of chronic diseases yet who want to stay out of institutions? This segment of our population is growing rapidly and is often highly vulnerable, with a variety of needs. But it is definitely in need of a system of services that are truly connected. Further, the aged Canadian – whom we all eventually see in the mirror – is taking the rap for a lot of the bottlenecks and backlogs in the system. How fair is that, when the system is not adequately connecting the dots between providers and services to keep the channels open?
Let's consider whether the prevailing silo models and structures of present-day clinical services delivery will ever lay claim to being a "system." This is not to suggest that all parts of the system are broken. We have innumerable, pre-eminent, excellent clinicians, many high-performing healthcare organizations and numerous innovative ideas being tested in the field – not to mention many superb leaders at every level struggling daily to address the fiscal and operational challenges. But we spend far too much time and money filling the cracks, when perhaps what we really need is a facelift. We need to think about new models, roles and processes that are focused on getting the constituent parts to work in accord. A true system cannot have insular subsystems that only sometimes work well together.
Regarding the elements of our "system," what becomes clear on reflection is that we need to put the core elements of what defines a "system" into the delivery of healthcare. The "system" is in desperate need of reinvention. So many times, we hear of individuals being unaware of the various services and support options available to them in the community. For those of us who work in the system, we usually know where to find and get what we need, but for outsiders it's the luck of the draw. Hence, I imagine a system that provides guidance to users on the most appropriate venue from which to seek specific services – a user's guide, or perhaps a roadmap to the healthcare system. In the interim, perhaps we need to create a navigator role that guides and supports individuals through the mire of available supports and services, and ensures that their needs and wishes, respectively, are met and considered.
Also, let us consider how to address the often-cited breakdown of communications between providers and the lack of information continuity among sectors of care. Clinicians, in particular, lament the considerable gaps in the information exchanged across the trajectory of care. This insufficiency is frequently compounded by undue delays in the transmission of information, resulting in a less than complete, if not dated, reflection of an individual's needs. At this juncture, I must quell my need to launch into a rant about the slow progression to adopt integrated electronic health records across the country. Alas, such clinical hand-offs could be so enhanced with the adoption of computerized documentation tools that are standardized and integrated throughout each provincial jurisdiction, if not across the country.
While always proud of my colleagues and nursing heritage, there are times, as a nurse, that I feel ashamed of the healthcare "non-system." Increasingly, the presumed "system" of healthcare delivery lacks the qualities of what one might deem to be an acceptable level of service. The lack of a well-functioning system translates into communication gaps, discontinuity of information, poor integration of services, discontinuity of care, an overall fragmented experience and people falling through the cracks. You are all well aware of the inherent dangers lurking amid all those disconnected processes. Indeed, the disconnects continue to result in higher than necessary costs, redundant diagnostic testing and insufficient supports when and where they are needed, not to mention the endemic problems of ER wait times and increasing numbers of alternate level of care (ALC) patients consuming acute care resources. We spend inordinate amounts of time obsessing with fixing ER wait times and addressing the issue of ALC. In my humble opinion, as in classic systems theory, it would behoove us to consider the implications of addressing the system inputs and outputs differently.
For decades, community-based care has received short shrift in health system funding. Although articulated many times over the last few decades, the need to shift our gaze away from acute care to the community remains. Given the evidence related to the social determinants of health (e.g., poverty) and the inevitable health sequelae (e.g., diabetes) leading to significant costs compounded over time, it seems targeted community and social supports make infinite sense. Considering the provision of proactive, preventive and intervening services outside hospital emergency departments – and, by the way, by health professionals other than physicians – is imperative. Also essential to a real system of healthcare is the provision of alternatives for recovery from acute episodes of care. We need more investments directed to integrated support services for those recovering from post-acute conditions, managing chronic diseases, contending with the challenges of aging and for those caring for aging, dying or chronically ill family members. There are some who believe that the answer to our system woes lies in the creation of more long-term care beds. But we don't need more institutions; we need a system of healthcare services that supports Canadians in their homes and communities.
Lynn M. Nagle, RN, PhD
About the Author(s)
Lynn M. Nagle, RN, PhD, Editor-in-Chief
The Free Dictionary. 2010. Retrieved December 11, 2010. <http://www.thefreedictionary.com/system>.
Merriam-Webster Dictionary. 2010. Retrieved December 11, 2010. <http://www.merriam-webster.com/dictionary/nonsystem>.
Oxford Dictionaries. 2010. Retrieved December 11, 2010. <http://oxforddictionaries.com/view/entry/m_en_gb0839190#m_en_gb0839190>.
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