After further reflection on last week’s essay, “Toyota, Air Canada and Best Western Hotels Are Not ERs,” I felt compelled to expand upon my observations from my ER visit. To those at the ground level, my personal insights may be deemed unremarkable, but for those at arm’s-length from the ER, this may serve as a reminder of the many pervasive obstacles that are experienced by care providers on a daily basis.

Each ER room, along with every 24-hour period, yields its own distinctness, but I suspect my personal observations while visiting the ER are common events that are experienced with great repetitiveness. After a 14-hour stint, my survey of the ER and the individuals and care providers within it left me with a series of gripping images. These incredible images have captured my ground level perspective.

The Ghost of Healthcare Consciousness appears and offers the following:

“If you are truthful with yourself, you have recognized that the images we often attempt to paint don’t always mirror the reality in which we find ourselves … Like photographers, healthcare leaders at all levels must make choices. They must choose what to focus on. They must choose what exists within their frame. They must continually learn to be better. They must learn new technologies and new settings. They must continue to see differently. In order to capture the perfect image, they must make continual adjustments and attempts. Vowing never to stop until their image mirrors their vision. We must continue to learn from the images that capture our progression, even the images that represent the ugliest side of healthcare. It is through dissecting the displeasing elements that plague us that we are able to move beyond them. The healthcare system is much deeper and more complex than any highlight reel will ever depict.”

I couldn’t agree more; it is essential that we understand our negatives so that we can convert them into positives. In order to capture a complete image, we must come to understand the components that contribute to the whole. Allow me to share with you the five images that depict my recent ground level perspective along with a new set of questions derived from them.

Image One – Key Social Determinants of Health at Play

A significant number of the ER visitors presented with mental health, drug and/or alcohol issues. Furthermore, due to the instability of some of the individuals within this specific patient group, a significant portion of them was unruly, demanding and intrusive. In conjunction with this disruptive behaviour, I saw a few of the individuals arrive handcuffed and with police escorts. Being within earshot of the conversations between these patients and their doctor and/or nurse, I learned that many of these individuals were habitual ER returnees. Sadly, none of these patients can, or will ever be, completely healed by an ER visit.

The elderly also made up a significant percentage of ER visitors. For the elderly, the most common difficulty appeared to be their inability to remember information. Many elderly patients were unable to recite their telephone number or address, let alone the medication they were on. Some of these elderly patients also seemed to be unsure of, or disconnected with, the entire screening, testing and follow-up process. It was clear that those unable to remember their contact information would also be unable to keep up with the medical information extended to them.

Lastly, the ER was comprised of an ethnic mix. It was apparent that a lot of information from both sides – patient and doctor – was lost due to an inability to communicate. For some, the English language was difficult enough to comprehend; never mind the often confusing language of healthcare.

Image Two – Distractions and Transitions

Once my wife and I made it through the ER door, I witnessed a flurry of activity that was fused with distraction and multiple handoffs. Just inside the ER door was a holding area with eight chairs, though some patients apparently felt more inclined to walk around than to sit. Across from the holding pen was the nursing station. On the other side of the nursing station were examination beds, treatment chairs and supplies stations. Needless to say, very close and crowded conditions for all. Access to personal cell phones was permitted in the holding area, which leads to a multitude of voices talking over each other. In some instances the conversations overheard were completely revolting, to say the least. Combine the obtrusive phone conversations with the rudeness and aggressive behaviour of certain patients and you begin to wonder what the impact these distractions have on the busy and dedicated ER staff. Do these constant distractions and variables impact quality and safety for those who have arrived in need of immediate help? 

Image Three – Our People, Our Champions

There are significant variations in age cohorts and significant gender differences by profession. There are three categories of employment: full-time, part-time and casual. Therefore, the blend of these categories changes from unit to unit, shift to shift and hospital to hospital. On top of that, there is an ever changing and growing ethnic/cultural mosaic. The physician community is made up of independent private contractors not hospital employees who, by and large, do not sign results-based quality of care contracts. Nurses and other paramedical employees who meet position requirements use seniority to choose shifts, work areas and units. Healthcare employees are on sick leave, workers’ compensation and long-term disability more than in any other business (statistics show that these numbers are double that of all industries). Healthcare has the biggest and fastest growing number of Sick, LTD and WCB claims along with claims on prescription benefit plans related to stress and anxiety. The majority of management staff works the day shift Monday through Friday.

A footnote – a recent US study found that healthcare spending is 9% higher for hospital employees than it is for the general public. The study also suggests hospital employees are more likely to be diagnosed with chronic conditions like asthma, obesity and depression and were 5% more likely than the general population to be hospitalized.

Image Four – Healthcare Culture 

Healthcare is one of the most complex organic structures ever created and with such complexity comes power struggles, opposition and suffocation. Think about the traditional top-down leadership model and its hierarchy of power and the professional practice/turf issues that surface on a daily basis. Think about the top-middle-bottom spaces in continuous change with the latest flavour of the month (often driven by ever changing politics). Think about middle managers with their huge scope of practice, significant numbers of direct reports, and how they are squeezed daily by top and front line expectations.

In many regional and provincial structures, senior leaders and managers, including human resources, quality and safety officers, work in a corporate environment apart from where care is provided daily. Claims of staffing shortages, extreme occupancy rates and related workload challenges continue to surface along with extended work days where 12-hour shifts and excessive overtime have become routine. Lastly, there continues to be a serious lack of professional development within healthcare due to its quick removal from all budgets. When compared with other industries, development programs for healthcare workers fall far behind. It seems as though we often forget about our greatest asset: our people.

Image Five – Characteristics of Healthcare Management

Having created images regarding the people and culture in healthcare, I began thinking about the characteristics of healthcare management. We at times fall into a leadership trap. We often read about, study and bring management concepts from the private sector to healthcare without talking about how our characteristics and our context are different. Decisions are very susceptible to political influence and not necessarily in the best interest of the patient population. Incentives are frowned upon and seen as inappropriate by the public for public sector employees. Managers in healthcare are seen as civil servants. A “one size fits all” approach is often more reassuring to civil servants and politicians which negatively affects innovation and creativity. The highly political environment unfairly highlights problems and rarely acknowledges successes that can be leveraged. With error a scapegoat must always be found.

The ministry, our policy setter and funder, and the civil service are risk-averse due to the political consequences of all actions. This approach to policy making slows the decision process and the subsequent delays often miss leverage opportunities. Many are conditioned to see and act in linear lines and yet the entire system is dynamic, operating within circles of sub-systems. The media also plays a major role in a public health system because of its ability to influence political decision-making.

We must continually capture and interpret healthcare images in order to acknowledge and ask new questions. As Margaret Wheatley, author of Finding Our Way, says: “When a system is failing or performing poorly, the components must come together to learn more about itself, from itself.”

Leadership guru, Peter Senge, frames it another way: “By coming together in an open and honest dialogue, we can integrate our fragmented individual snapshot perceptions to bring focus into a more complete and accurate representation of a shared reality.” 

To bring a new focus and find the “Way”, here are just a few critical patient experience questions to keep asking over and over again:

  1. What is the shared vision we are working toward? What is our starting point? What beliefs and assumptions do we hold? Who needs to be part of this work? Is anyone missing?
  2. Is the meaning of this work still clear? Is it changing? Are we becoming more truthful with each other? If not, why not? Is information becoming more open and easier to access?
  3. Where are we using control? Collaboration? Innovation? What are we learning from working and adapting within confusion and chaos? What do we want to become?

The value of this practice of asking questions was evident at the beginning of the customer revolution. Interviewing customers and incorporating their perspectives became a potent force for stimulating organizations to new levels of quality, service and innovation. That’s what the evolving plan for transforming healthcare should be about: developing a deep understanding of the things people want and need, both in the whole of their healthcare journey, and within each and every care interaction. 

It is necessary to create a comprehensive and integrated system of care that is shaped by and driven with the active involvement of many, including patients, families and communities. Such change must combine the rich wisdom and experience of people in the system with the imagination and passion of patients. 

Positive action will build trust between employees and leaders and between organizations and the communities of people they were created to serve. Great healthcare starts with a Question – ASK. Great healthcare requires an open mind – LISTEN. Great healthcare requires a responsive heart – TALK. 

A passage from the essay “Conditions Leaders Influence”:

“Before leaders can see the future state as a vivid visual image, we have to get to know and understand the underlying values, beliefs and attitudes held. The old expression you cannot see the forest for the trees must take on a new meaning. Leaders need to see the trees, not to mention the spaces between and the surrounding flora and fauna. What would happen if we changed the picture by having leaders spend dedicated time talking to patients and families and staff where care and services are actually produced? … It is a big transition from being knowledge experts conveying wisdom of their many years of experience to becoming visible, present leaders whose greatest skill is asking the right questions. When was the last time the CEO put on the greens and spent time in the operating room? When did the director of home care actually accompany a community therapist in a home visit in the inner city? When did the vice-president responsible for materials management spend time in the warehouse understanding processes? How often do leaders spend time in areas that are not their direct responsibility or participate in quality improvement outside their personal portfolio?”

To achieve a new vision, the current and future leaders, from all parts of the healthcare system, must come together. Not merely to manage the change or to cope with it, but to allow collective dialogues to create new perspectives. Perspectives that will build the kind of quality and safe patient care we all push so hard to actualize. To participate in this vision, leaders will need to hold an intuitive and emotional identity with healthcare, with the patient. It was through such human resolve that healthcare organizations and institutions came about. It will be through such human resolve that they will change and transform!

Everything we do is about enhancing the patient experience, so let’s begin a conversation with patients and families. Join next week’s conversation titled: Three Patient and Family Voices: Dare to Dream, Listening to Me and Stop Tiptoeing Around What Matters.

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

Hugh MacLeod, CEO Canadian Patient Safety Institute, Patient, Husband, Father, Brother, Grandfather … Concerned Citizen


The Canadian Patient Safety Institute (CPSI) exists to raise awareness and facilitate implementation of ideas and best practices to achieve a transformation in patient safety. We envision safe healthcare for all Canadians and are driven to inspire extraordinary improvement in patient safety and quality. To address many of the challenges mentioned in the essay above the Canadian Patient Safety Institute with partners has tools and resources. Please contact


“Hospital Employees Are Less Healthy, More Likely to be Hospitalized than the General Workforce.” Truven Health Analytics Study2012.

Wheatley, M. 2005. Finding Our Way – Leadership for an Uncertain Time. Berrett-Koehler Publishing INC, San Francisco.

Senge, P. 2006. The Fifth Discipline. Doubleday, New York.

MacLeod, H. and M. Davies. 2013. “Conditions Leaders Influence.” Longwoods Ghost Busting Essays. 

Levine, D. 2013. Presentation on Healthcare Management. Seniors Quality Leap Initiative, Montreal.