Insights (Essays)

Insights (Essays) April 2013

Trapped in the Future

Hugh MacLeod and Martin Vogel


Good day, I am joined on the balcony by Martin Vogel, a leader calling for national change. We start our conversation on the theme that while Canada has historically been a world leader in health service delivery, over the past two decades, we have seen a steady decline in our relative performance when compared to other industrialized nations, on a whole range of key health and health system indicators. While our per capita spending is ranked number five, too many of our outcome measures rank between 25 and 30 out of 32 OECD countries. Many of our existing systems, structures and processes are deeply rooted in the assumptions of the early days of Medicare, over 50 years ago. The fact is that a modern healthcare system must adapt to the realities of the knowledge economy, the age of technology and a culture of patient empowerment.

For their own part, healthcare workers embrace evidence-based practices. In addition, successful healthcare organizations are not isolated and disconnected from their partners within their community. They are part of, and act as, an integrated system – where the owners and the customers are one and the same. While there is no doubt in our mind that there are a number of leaders who really do understand this, we have not been able to make the transition.

If we are open to change, then we must be open to learning from others and instituting their successes. We must also be open to seeking and exploring a range of possibilities that we may not have thought about before. When we stick to the same old mental models, we come up with the same old solutions, which inevitably fail us again ... and again. This dynamic is called “fixes-that-fail.” Much has been written about the healthcare system’s addiction to “fixes-that-fail” and their corrosive impact – which is cynicism among boards, managers and front line staff. When we are cynical, we do not hold much respect for one another. Cynicism grows when we realize that we have seen this game before, and we have learned what it takes to extract the result that we need in an often threatening, and highly political, environment. In the past, we have expended enormous amounts of energy and resources focusing on the same two “fixes”: a focus on finances and structural changes. If we know these “fixes” don’t work, why are there still so many devotees for these particular mental blinders? Why do we not put in place functional governance structures, adopt a shared vision and instill a culture of continuous quality improvement across the healthcare sector?

Suddenly, the Ghost of Healthcare Despair appears and shouts:

“You two are idealists: What were the unintended outcomes of closing acute care beds before expanding community-based services? Did you produce the outcomes that the evidence predicted would happen? Did you learn from the previous re-engineering era, where the system focused primarily on financial accountabilities, and failed to take into account the larger perspectives of the customer’s care experience and the health of the community? Did you not consider the design of internally misaligned processes, and the capacity of staff to implement continuous change and improvement? What have you learned about systems, structures and processes that provide the “illusion of control” and the “optics of accountability,” without any real control, and no real accountability for the results you produce? Have you studied what happens to the morale of front line healthcare providers, who are knowledge workers in the true sense of the word, but find themselves trapped in horribly outdated, command-and-control systems, structures and processes that breed fear and anxiety, and entrench a culture of blame avoidance? Don’t you know that a compliance model, rather than a commitment model, for large-scale system change in healthcare has never yielded sustainable results?”

With that encouraging note, the Ghost disappears.

Deming, the father of the total quality management movement, taught us that 93% of all the problems he had ever encountered in complex organizational systems were the result of poorly aligned systems, structures and processes; and that only 7% of the time was the problem attributable to the people.We have system design problems. It is the way that we designed the system with service delivery models, and with funding and financing models that can no longer support the new and emerging health and healthcare needs of society. The incentives in the healthcare system today cause the behaviours that we experience, and our health system performance has suffered. People whom we have met across the system are talented and well-motivated leaders who are producing suboptimal results in a dyslectic and chaotic system.

We need to act as a unified system, to design a system of functional integration across the continuum of care, that is built to achieve its intended outcomes for the owners and customers of the system: the people of Canada. But, each and every time the system faces these sorts of high-level macro design issues, we fragment and entrench in our traditional silos and engage in protectionist behaviour. We do this in spite of best practice wisdom about managing complex change. It seems that the will to change is simply not there. For whatever reasons, we have become stuck in an either/or debate. Consumer demand for a system of seamless services has been pitted against one of independent governance and management.

So now we have a breakthrough question we would like to ask: why can’t we have both?

Why can’t taxpayers and healthcare consumers get all the benefits of a functionally integrated, seamless system of services, as well as the considerable benefits we can potentially get from independent governance and management? Think about it. Why can’t we have both? Breakthrough questions are intended to go after the assumptions that we are holding. My question is: why are we holding an assumption that the issues we face are about independence versus interdependence. The paradigm shift here is for leaders to embrace a simple paradoxical truth: we can be interdependent and independent, at the same time, if we design for it. We can do this through integration rather than by assimilation.

If it is true that a critical mass of health system leaders believe that, with the resources at our disposal, there is no reason why Canadians should not have the best health and healthcare in the world, and if they are passionate about restoring this system to its former status, then we can and will succeed. But only if we don’t get stuck in the same old ways that we have always led and managed the system over the past two decades, and more.

Let us ask:

  • How will political leaders change so that health systems can function, operate and be managed free of political interference? So that patients are put first and not third; coming in after politics and finances?
  • How will ministries change, so that they are “in service” to healthcare organizations, rather than maintaining some empty and temporary illusion of control?
  • How will healthcare governance change, so that the formal structures truly represent the owners and customers of their organization, and not merely the narrow interests of their silo, or the narrow interests of some of the more powerful stakeholders within the silo?
  • How will managers within local delivery systems collaborate with their community partners to ensure that consumers actually experience the seamless system of integrated care, which they rightly deserve, at the service delivery level?
  • How will we develop the internal clinical and administrative management capacity of our vice-presidents, directors and managers to co-lead and to manage both strategic change and professional performance?
  • How will we achieve the right balance of authority, autonomy and accountability so that we actually achieve measurable improvements to our healthcare system over the next three to five years?

Changing the system means changing the system. Change management scholars tell us that, unless it is simply more tinkering on the edges and playing on the margins, at the beginning of every journey towards systemic change at least 30% of the partners will be opposed to the change. It would be normal that some of us will get stuck fighting the same old wars, the same old ways. Healthcare executives, health professionals, public servants and front line staff have all developed their careers in a silo-centred bureaucratic model of healthcare delivery that has always been driven by the tug-of-war and power struggles between service providers, administrators, managers, elected government officials and civil servants.

Today, we have a rare opportunity to stamp out cynicism by building trust, demonstrating respect and by being open to learning from one another. We can do this by focusing on achieving real improvements in the care experience for healthcare consumers, by respecting and empowering the people who deliver these services and we can do this at a lower per capita cost. If we are not prepared to change, there will be consequences to the taxpayers and healthcare consumers that we exist to serve.

Next Week’s Guest on the Balcony of Personal Reflection: S. Jarvis in a conversation titled “The Winds of Change and Gathering Storms.” 

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 Author(s)

Hugh MacLeod is CEO of Canadian Patient Safety Institute. Martin Vogel is Vice President of the Canadian Medical Association


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