Insights (Essays)

Insights (Essays) October 2013

Toyota, Air Canada and Best Western Hotels are not ERs

Hugh MacLeod

When we are accustomed to an elevated vantage point, such as the viewpoint gained by the “balcony of reflection,” it can become a habit to ignore some of the exhaustive and complex interactions care providers perpetually participate in. Therefore, it is vitally important to occasionally leave our accustomed perches and join the countless patients, families and care providers at ground level; to walk onto the playing field of healthcare and witness events as they actually unfold. Words, reports and conversations often fail to recount or explain the many difficult occurrences that transpire daily. If we truly wish to gain a greater comprehension of the indications or manifestations that perpetuate the adversities with our current system, we must first understand what takes place within our walls. 

I was recently reminded of the great importance, and the many insights that can be obtained, when being present at ground level. My wife and I had just returned home from vacation when she began feeling ill. Her sudden onset of discomfort prompted us to visit a large teaching hospital nearby. Like many of the emergency wards across the country, this ER was beyond full. In addition to the common chaos, I counted five patients with police escorts, observed crowded work spaces framed by storage and stacking of equipment and supplies, overheard continuous orders for multiple tests and watched the continual shuffling of patients via porters. Most important of all, I watched the tireless efforts of care providers as they dealt with many unruly and distracting patients and family members. I have a fond admiration for the job care providers perform and the thankless circumstances they navigate. In the end, this impromptu visit showcased the complexity of the hospital system.

The Ghost of Healthcare Consciousness appears and offers the following:

“The relationship between people is what makes the absolute comparison between healthcare and aviation, automobile production and hospitality inappropriate. Yes, there is much to learn from aviation, automobile production and hospitality services, but compared to healthcare they are elegantly simple in character and complexity. If aviation, automobile production and hospitality services are checkers, healthcare is multi-dimensional chess. I urge all senior decision-makers, planners, policy makers, theory experts and tool kit designers to spend time on the wards, have conversations, see and feel what it is really like. Any economist who persists in believing that healthcare is a market good just like any other has not spent any time as a patient or a family member of a patient.”

After experiencing weeks of travel, hotels and hospitality prior to my wife’s hospital admittance, it was easy to identify the disparity between healthcare service delivery and air travel, hospitality and automobile manufacturing industries.

All airline pilots, and co-pilots, have extensive checklists that are applied in every circumstance. They do not interface with the passengers and they do not customize their service to address the uniqueness of each of the passengers on board. In fact, the pilot and co-pilot are formally protected from all contacts and interruptions. There is also a substantial technocratic and automated proportion to their work. I am by no means discrediting the professionalism and expertise of pilots, but commercial airliners do literally fly themselves most of the time. There are many elements healthcare can learn from aviation, such as the absence of hierarchy in making safety decisions, standardization of equipment and supplies, simulation exercises, the importance of data, and the optimal use of technology, but we must not attempt to implement complete frameworks from industries that scarcely correspond with healthcare. When we look at the human component on an auto assembly line, we learn that these individuals are aided by the latest in technology and robotics. They are assemblers of parts. Day after day they assemble the same parts, in the same order, at the same time, to create the same car. The work is predictable, not complex. To create greater productivity, effectiveness and efficiency, including quality and output, they have two choices: eliminate assembly line steps with new technology or create a new assembly line. There is no human interaction with the customer or the purchaser of the service. They do not change the line due to politics and the flavour of the month. Yes, we can continue to learn great lessons from LEAN but LEAN by itself is not enough. We must think differently, as we are fundamentally different. Healthcare providers are not just numbers at a production station; they are not robots devoid of desire, compassion and creativity. They perform their roles with a personal blend of art and science built on patient experiences.

In the hospitality business, unruly or distracting behaviour is not accepted. In fact, security will usher customers off the premises when they become unruly or obnoxious. They uphold this practice to protect their business and their reputations. After all, the hospitality industry works endlessly to cater to, protect and pamper their desired customers, while eliminating any element that may potentially ruin a prized customer’s experience and/or jeopardize profits. Yes, observations about healthcare not wanting some customers back is a significant distinction. However, healthcare organizations are going to be judged on the customer experience of all who present through its doors regardless, and therefore the focus on the patient experience overall is still going to be critical.

The Ghost of Healthcare Consciousness re-appears and offers:

“Your healthcare system is open to all who come through the doors. You are not in the market segmentation business driven by profit through exclusive care insurance plans like many private hospital corporations. As you witnessed, patients who present at the hospital are complex, not predictable, and often not stable. 

Hospital service/care is complex, organic and team-based. A patient during his/her ER stay could receive care support and diagnosis from many different care providers. The providers use a blend of science, art and intuition/personal experience, and their way of doing and interpreting instruction. While many are taught the theory of quality and patient safety in the classroom, they are also influenced by the practices and preferences of their senior peers. 

With the arrival of new technology, drugs, procedures, treatment plans and the drive to increase throughput, hospitals have unpacked the patient body into specialty and sub- specialty care, not an auto assembly line. With the push and demand for new technology, new drugs, new procedures, new processes and new approaches to speed up the service line (in-out of hospital), it is becoming difficult to say who is responsible for the patient. In the airline industry, air traffic controllers keep an eye on the planes and ensure that they never set adrift. How do patients come and go? You need to create a new picture.”

Three recommendations for your consideration: 

  1. The lessons learned from other industries should be considered an additive to what is developed by involving stakeholders within the healthcare organization.
  2. We not only need to strive for scientific and technocratic excellence, we must also pay attention to the relational and behavioural side of healthcare. 
  3. Spend time to understand what reality is like at the patient and care provider interface.

A posting by Robert Pental on the essay “Can an Organization Grow If Its People Are Not Connected?” says it all:

“I am not someone you would normally see on this balcony of personal reflection. No, the place for me as a floor nurse would be closer to the lighting booth in the theatre of healthcare. A place where you not only watch the performance but have the added feature of being intimately part of the production. A place where you learn that some lights, or in my case, call lights, take priority over others. A place where you know the production is so massive, more complex, interdependent and co-related than any one person should reasonably believe they are able to explain, let alone fully comprehend. 

As a result, time on this balcony of reflection seems a welcome reprieve, but of course the ghost of healthcare despair knows no bounds. A ghost that for me is not a disembodied theatrical prop in the wings off stage; no, the ghost of healthcare despair is very real to me, a ghost that at times it could be said that I feed. Not by personal preference, mind you, but nonetheless nourish. I will never been proud of this fact, and attempt with each and every performance to eliminate it, but sometimes, some areas take priority. So when it calls, I go. When it speaks, I listen. And when I listen. I take as my accountable share the view from its sullen and lugubrious eyes and make no attempt to shield its cold wizened hand from my own.

“This system, if you want to call it that, is in tatters. No one comes when I call. I waited hours in that emergency room for what, this... this... you call this a room? 

“I can’t even hook up the T.V. How am I suppose to watch my hockey? This place stinks. 

“You're not even a real nurse. You’re a man. Why aren’t you a doctor? And where is the doctor? I need to see him. NOW. 

“This “system” cares nothing about me, only about cutting corners and making money for big wigs and forcing me to look after myself when it should be you looking after me. I pay your wages, I’ll have you know.”

So on and on the ghost goes, but what it may not realize is that in its despair is a message of what is also needed for those able to see. What is that silent message weaved into its phantasmal shroud? Well, it is not about how we are going to fix things and when it will be done. No, because like the Dickens’ ghost of despair these essays are indebted to, the ghost of what is yet to be, any and all of our futures are unclear. So that may be what the ghost is requesting is we let compassion be our guide and decency for everyone take the lead. 

Why? Because sometimes certain lights need to take priority over others."

And what about behaviours and relationships? Join next week’s conversation titled: “Creating a Complete Picture.” 

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, CEO of the Canadian Patient Safety Institute, patient, husband, father, brother, grandfather and concerned citizen


MacLeod, H.B. 2010. “Working Together for Safe Efficient Quality Care.” Canadian Journal of Respiratory Therapy Winter Vol. 46.4.

Pental, R. 2013. Posted comment on the essay: “Can an Organization Grow If Its People Are Not Connected?” Longwoods Ghost Busting Essays. 


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