Essays

Essays January 2015

A Paradox to Be Outgrown — Moving From Doing Stuff to Providing True Value

Dr. Brendan Carr and Hugh MacLeod

Dr. Brendan Carr joins me on the “balcony of personal reflection.” Most people would agree healthcare research and innovation are intended to generate knowledge, tools and technologies to improve quality and enhance the patient experience: to take what is inherently “complex” and poorly understood and render it “simple,” safe and clear. If so, then how can it be that as we rapidly advance our collective knowledge and bring new skills, interventions, devices and drugs to bear we in fact contribute to the variation that systematically threatens quality and produces an environment that is ultimately less safe for our patients and staff?

The Ghost of Healthcare Hope emerges…

“I like this conversation. From what I see, denial and complacency are your biggest threats. There is a gap between patient safety and quality outcomes on paper and what patients and families experience. Silence, unawareness, indifference and complacency are the greatest enemies of improvement. A first step to progress is coming to terms with your current reality.

Any economist who persists in believing that healthcare is a market product just like any other has not spent any time as a patient. Patients give up their body and power to an institution and a team of strangers. They have all of the technical knowledge: the patient is on their back and they are scared. Patients are in pain and anxious. They are vulnerable. Often they cannot assert themselves.

Providers view their own time as a precious commodity. Patients make demands of their time. There is a power imbalance that requires adjusting.

There is nothing new in what patients experience — it is the reality of being a patient in a system that struggles to get things right. Perfection is unattainable, but you will never approach perfection unless you commit to settling for nothing less.”

No doubt part of the truth lies in the fact we are generating “stuff” in healthcare at an incredible rate and with that stuff comes a constant stream of change. This reality has been recognized by scholars, health leaders and even the popular press for over a decade, and coincidently health professional training programs have been recalibrated to produce “life-long learners” rather than the fabled all-knowing version that was notional if not the reality of past generations.

Likewise, healthcare organizations large and small have redoubled their efforts in quality: training staff, building better information systems, adopting quality standards, tools and practices, advancing governance practices and enhancing accountability. Indeed if looked at from the perspective of specific quality metrics like AMI mortality, we are winning many battles. Why is it, then, that from the perspective of achieving a safe, reliable and high-quality experience for our patients, we appear to be losing the war? Many authors have made critical comparisons between healthcare and other industries, like banking, where risk is high, information has ballooned, technology has advanced rapidly and industry culture places tremendous value on traditional practices and professional norms.

Hence our embarrassment that the banking industry has successfully transformed personal banking while healthcare, despite making impressive quality gains, is still on the wrong side of the risk-to-benefit curve for so many of our customers. Some would argue rightly that the typical customer interaction in banking bears no comparison to the average healthcare experience. The same is true of frequent comparisons to Starbucks. Healthcare is so much more complex: a typical episode in healthcare is more like a week at an all-inclusive resort than ordering your favorite extra hot, skinny, wet cappuccino with one of those green sticks please. To be fair, the Starbucks comparison is really only applied to going through triage or registering in an ambulatory care clinic. True enough and they do their piece better and with fewer errors than we do ours all the time.

The even scarier thing about healthcare is that each of the individual elements that make up the whole episode present risk from a quality, safety and experiential perspective and, here’s the curve, many of the risks interact in ways that we can’t predict, haven’t studied or don’t have the means to observe and measure. As much as we talk “patient focus” we still behave like we really care about pieces of the whole. Maybe for good reason. We need highly specialized experts who have in-depth understanding of extremely challenging pieces of the puzzle. We need to pursue challenging questions with rigor and discipline. That’s how we grow our knowledge: it’s a beautiful thing. The answer surely isn’t to dial back our improvement efforts and academic pursuits; it must have to do with how we develop the capacity for all of this emerging knowledge in ways that ultimately serve the best interest of patients, or, at least doesn’t create greater risk of harm. Bringing the customer perspective to the table early and often is certainly part of the answer. But there is an equal, if not more compelling, need for a shift on the expert side of the table, which brings us back to the banking analogy.

Consider the nature of the technological innovations that accompanied the personal banking revolution: ATM’s (Automated Teller Machines) and secure online account access. My hunch is that whoever dreamed this up wasn’t trying to improve a piece of the puzzle at the front line. They were trying to transform the complete experience for the customer and reset the bar within their industry using technology that would be reliable, relatively easy to use, and cost less. They were thinking “disruptive innovation” in the Clayton Christensen sense of the word. In contrast, many new technologies and innovations adopted at the front lines in healthcare are “sustaining innovations” in Christensen terms: they actually increase complexity from a technological, process and human factors perspective. Chances are they cost more and increase risk too. Seen through the lens of a randomized, controlled trial they may have clinical efficacy, but are they effective when applied in the real world from the perspective of cost, quality and safety? Experts need to understand that raising the bar on clinical outcomes isn’t the whole picture: we need to reframe our thinking in terms of creating value for our customers, which means considering benefits and unintended consequences, not to mention the costs involved.

So, what was different in the banking world that allowed them to take a more effective path? Some would point to the clarity the industry had when it conceptualized the new personal banking model: a singular focus on enhancing the customer experience, framed within a clear understanding of evolving market and industry dynamics. An unmistakable imperative to achieve greater value for customers and shareholders, a must-do scenario. Most leaders agree the Canadian healthcare system has many of the same imperatives, perhaps with the exception of a singular focus on enhancing the customer experience. How can this be? We all come to work every day wanting to do the best for our patients. Does the fact we operate in a huge monopoly make a difference? Is it a failure of leadership? Is it because the system we defend so loyally is not really a system? Are we measuring the wrong stuff? Is it because we are trying to look at a complex ecosystem through a simple lens?

The answer almost certainly is all of the above, and more. Perhaps to start, we leaders need to be clear about the overarching imperative to achieve better value for patients and the system, and how that means lowering our collective tolerance for poor safety and unintended outcomes. We reflect on a passage from the Art of Leadership by M. Dupree… “The first responsibility of a leader is with others, to define reality, the last is to say thank you. In between the leader is a servant.” We are all servants to those we are here to serve… the patient!

Maybe we need to think about what we measure, particularly when we are introducing new models, tools or technologies, and be intentional about focusing on the overall experience with heightened vigilance about negative impacts.

Maybe we should focus less energy on improving what is and create more capacity to design what should be from the customer’s perspective in the first place: it seemed to work for personal banking.

The Ghost of Healthcare Hope returns...

Every healthcare system is a reflection of its values. What is our National Value Statement? What are Canadians’ core health values? What is the hierarchy of values among professionals? Are all clinical occupations equally valued and integrated into quality improvement culture? Once quality-enhancing tools and techniques demonstrate their value, do we ensure spread within the shortest time possible? To what extent are resource-allocation priorities and decisions focused on value? Do you ask what value behaviour have I tolerated in myself and others that conflict with delivering value to Canadians? My questions connect nicely to a recent article by D. and K. Naylor titled Seven Provocative Principles for Health Care Reform:

  1. Every set of national arrangements involves trade offs among quality, affordability and accessibility.
  2. Although overall healthcare systems are not transplantable, the merits of adopting good ideas from other countries are too often ignored.
  3. Simplicity in legislation and regulation trumps complexity. The more changes that are made concurrently, the greater the risk of unintended consequences.
  4. Every effective healthcare system imposes caps on spending and engages in strategic rationing.
  5. Fairness in finance and access to healthcare is an evergreen objective of health policy makers. However, fairness is seldom defined.
  6. Higher levels of spending do not correlate closely with quality of care but may instead lead to diminishing marginal health benefits.
  7. Transactional micromanagement of healthcare is suboptimal, whether publicly or privately administered.”

A major obstacle to progress is the failure to ask ourselves wicked questions leading to a deep exploration of assumptions we hold and make. Without exploring our assumptions we will continue to be held hostage by our indifference to failure and be unable to reach our improvement potential. Exposing these assumptions can be both uncomfortable and a relief. It is uncomfortable because the conclusions we draw and the beliefs we adopt based on our assumptions often seem to be “the truth” — obvious, acceptable and defensible. They guide us to do and say “the right things.” By engaging people in dialogue, wicked questions invite exploration into inconsistencies in thought that have held us back from achieving our purpose, and can be used to promote a search for local solutions to organizational challenges.

Join my next guest Dr. Graham Dickson in a conversation about healthcare contradictions.

See essays in this series.

See essays from series 2

See essays from series 1

About the Author

Dr. Brendan Carr, President and CEO, Vancouver Island Health Authority
 
Hugh MacLeod, CEO, Canadian Patient Safety Institute

References

Naylor D. and K. Naylor. 2012. Seven Provocative Principles for Health Care Reform, JAMA, 307(9).

MacLeod H. and J. Kitts.  2013. “Shaping Healthcare Alignment,” Longwoods Ghost Busting Essays.

MacLeod, H. 2010. Working Together for Safe Efficient and Quality Care, Canadian Journal of Respiratory Therapy, 48(4).

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