"If You’re Riding a Horse and It Dies …" A Commentary on Health System Transformation through Research Innovation
In the words of Goethe, “Knowing is not enough; we must apply. Willing is not enough; we must do.” If health services and policy research is to be a major driver of health system transformation, the conditions for creating that change platform need to be initiated today. It is clear that we need a different approach to the way in which we develop and utilize evidence and the paper by Tamblyn et al. (2016) provides us with four strategic priorities that could help us find our way. There is no silver bullet that would awaken us to a transformed system. But we have long studied the problems and continue to arrive at similar solutions. It’s time to stop talking and, together, take action. If you’re riding a horse and it dies, simply get off and try something new. In this commentary, there is general agreement with the directions proposed, but they will not be enough to create sustainable change unless leaders are willing to work to create a culture where answers to relevant research questions are adopted, spread and scaled within their healthcare organizations.
I was once given a wonderful book by a dear colleague entitled, If You’re Riding a Horse and It Dies, Get Off, by Jim Grant and Char Forsten (1999). It is about the education system, but I found that it had many similarities to healthcare. The story is set in 1918 and depicts a man riding into a town, when his horse suddenly drops dead. People come from miles around offering suggestions by which the dead horse could be revived, such as getting a bigger whip, visiting places that ride dead horses, a more experienced driver, assembling a committee, team riding, more money, federal assistance, and the list goes on. Sound familiar? Finally, someone has a bright idea and says, “If you’re riding a horse and it dies, get off and try something new.” And in comes the car!
As I read the paper, Health System Transformation through Research Innovation, I thought of this book; not because it felt like the wheel was trying to be re-invented but because there seemed to be emerging clarity that somehow the worlds of researchers, decision-makers, care providers and patients needed to be joined in a fresh, new way to move healthcare toward the transformation that it requires to be a safe, highly effective and efficient system. We’ve studied the dead horse long enough! Let’s take what was great about riding a horse and build on it, but try something new.
Some of the good things about being engaged in healthcare as long as I have are that you get to learn from your mistakes, see what works and doesn’t work and come to understand that there is no silver bullet – no one thing that will transform the healthcare system on its own. In this complex environment, I believe that many complementary initiatives will be required to bring about the necessary changes, and we must solve these issues collaboratively if we are to be successful. Research is, and will continue to be, an enabler to provide the evidence required to effect change. The four strategic priorities outlined in the paper are all valid contributors to creating the necessary knowledge for change to happen. But simply acting on these priority areas will not have the desired result if we don’t pay attention to creating the climate for change that is required to bring these initiatives into being. In the field of patient safety, the evidence is clear that, despite our best efforts, patients continue to experience preventable adverse events in hospitals and the community at an alarming rate. What we have come to learn is that, although hugely important, it is not enough to focus on specific clinical interventions to improve patient safety. Leadership is required to create a culture of patient safety so that the lens of safety is applied to all that takes place. This is not dissimilar to research innovation. Developing researchers who can work in a learning system is an excellent idea, but without creating learning systems in which they can work, we will be no further ahead. So, although I support the objective of training and funding a new generation of scientists, we will need to start today to begin the journey toward a learning system.
In June 2000, I had the opportunity to hear a futurist talk about a digital world where people enter their homes and a computer detects heart rate, blood pressure, oxygen saturation levels, air quality, etc. and is able to connect with the physician’s office to change medications, make appointments and counsel people on steps they need to take to remain healthy. And by then, this technology was already available for use. Yet, in 2016, we have not been able to mainstream these concepts. The strategic priority two, eHealth, that is outlined in the paper, is an essential component of moving forward in healthcare, so why are we so slow to act on what’s available to us today? During my tenure as CEO of Capital Health in Halifax, it was not that we didn’t see the value or necessity of moving in this direction. Our clinicians were the first to tell us that they were frustrated with the lack of easily retrievable data to assist them in providing high quality care. We met with many vendors who had what appeared to be great products and seemingly easy solutions to assist us in turning data into useable information to inform diagnosis and care. Yet, our hands were tied as we waited for provincial solutions and the necessary resources to invest in the technologies at hand that never seemed to materialize. And, with precision medicine at our doorstep, the healthcare system is poorly positioned for uptake. Our industry partners are frustrated with the inability to co-design and implement IT solutions in Canada. I believe that this eHealth strategy, creating health innovation communities to develop, integrate and evaluate eHealth solutions is a solid way forward.
There is no conference, conversation or service delivery planning happening today that doesn’t touch on our aging population and the potential effect on our healthcare system. Many innovative ideas are being fostered throughout the country, but with little scale and spread. Perhaps additional research is needed in this area, but why can’t we simply learn from what is already happening around the world to enhance current programs or try new approaches? Learning from this paper that only 0.3% of research funding nationally has been dedicated to scaling and spreading of ideas as well as change management, was disturbing but eye opening. There are so many great initiatives happening in this country in small pockets that are rarely evaluated and are even more rarely spread and scaled. It is disappointing to me that this area did not surface as a priority for research innovation, as I believe it could assist us greatly in learning from each other across the country.
And last but not least, health system finance. Funding and sustainability as a strategic priority is a much-needed focus. As an example, I once heard a family physician saying that she had no idea how many patients with diabetes she had in her practice, and that she had never received any tangible evidence, through data, of whether or not she was providing good care. What were her outcomes? She had no idea about what was cost-effective in her practice and what wasn’t. The same can be said for most healthcare systems in this country. We know the rolled-up figures for providing care but, generally speaking, we have no idea about what procedures cost us, where we get good return on investments, what are lost leaders, etc. Few organizations have developed robust case-costing systems that provide them with real-time knowledge of how they are spending their scarce dollars. What other industry would work this way and survive?
And are we incenting the right behaviours? In countries where health outcomes are improving and spending reducing, payment models have evolved to reward outcomes and performance. The fee-for-service model has been long gone, but in Canada remains alive and well. There is no question that new reimbursement models are required if we are to improve health outcomes in a sustainable system. This priority has merit and will provide much-needed information for decision-makers. Hopefully, there will be the courage required to implement the necessary changes.
In conclusion, I think that overall, the direction that the Institute of Health Services and Policy Research is heading is a sound one. However, the expected impacts will not be achieved without complementary work on creating the culture to embrace these changes with a focus on helping people through the change process. Leadership is required to be engaged in a significant way on this journey along with a solid partnership with patients and families. And the missing link so often is turning the new knowledge generated through research into useful information that helps effect change. Let’s create models that not only study questions relevant to the field but also have a component of adoption, scale and spread that is so sorely lacking on many fronts. Perhaps partnering with interested leaders to develop a learning health system that can receive scientists who have the necessary skills to work in these new environments would be a great start in demonstrating to the country how science and practice, harmoniously, can lead to improved healthcare and outcomes. And, as the strategic priorities are implemented, we need to look to the “unusual suspects” for the change that it required to propel us forward, like partnerships with industry, utilizing the expertise available to us through organizations such as CADTH and Canada Health Infoway, and engaging patients to help us define their needs to better manage care.
In the words of Goethe, “Knowing is not enough; we must apply. Willing is not enough; we must do.”
About the Author(s)Chris Power, MHSA, President and CEO, Canadian Patient Safety Institute, Edmonton, AB
Grant, J. and C. Forsten. 1999. If You`re Riding a Horse and It Dies, Get Off. Peterborough, NH: Crystal Springs Books.
Tamblyn. R., M. McMahon, J. Nadigel, B. Dunning and E. Drake. 2016. “Health System Transformation through Research Innovation.” Healthcare Papers 16(Special Issue, September): 8–19. doi:10.12927/hcpap.2016.24719.
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