Will our leaders really have the courage and vision to save medicare? Will the new health sector leadership team of Wynne/Hoskins/Bell actually open the door to “disruptive innovation” — and finally move beyond the rhetoric of “health reform” over the past decade — and actually take the leveraged actions necessary to actually transform our health service delivery system?
Disruptive innovations cause fundamental paradigm shifts in the way we think and behave in complex adaptive human systems. Instead of tinkering on the edges with simple structural reforms, as we have been doing in Ontario, redesigning our core healthcare delivery system processes at the service delivery level—with a strategic focus on the patient/family experience of care—will create the fundamental shifts that will be required for us to save Medicare, because patient-centred designs are always less expensive.
But bottom-up innovation from our front-line care providers requires top-down liberation from our leaders.
Are we capable of such change? Does the Wynne/Hoskins/Bell Team have the political will to make it happen? Will they in fact shift resources within the system to fund real health system reform? Are our governance Boards, CEOs and LHINs now ready to become catalysts for the patient/family-focused care revolution that taxpayers and voters really do want? Is our community support sector capable of managing growth and transformation at the same time?
All this sounds like “big changes ahead”. But remember, humans don’t like change. In fact, change management scholars tell us that: nine of out ten humans would rather die, than change.
If we are really compelled to change, we usually choose incremental, shallow changes that enable us to maintain the “illusion of control” — and the comforting delusion that we could always go back to the “old-ways of doing things” — if the little incremental changes don’t work out. So the big “structural innovation” of 80 new Health Link structures with Collaborative Governance and Integrated Management Scorecards became for many, a minor pilot project about the 5 percent of “high-users” in their local system.
There are not many Health Links that have actually engaged their partners’ governance boards in the process of holding their CEO’s accountable for the appropriate outcomes that the organization committed to in the Health Link Business Plan. Many Health Link management structures do not have a common Balanced Scorecard and CEOs working together on strategy and strategic alignment.
Finally, Health Links seemed like a major structural change that would facilitate meaningful collaboration at both the Board and management levels, but many are not like that. They are just a “project”, rather than a serious transformation effort.
For the past ten years, the health sector has been traumatized by never-ending incremental changes that were experienced as “unconnected” and “unaligned” as they were developed in their independent Ministry silos by a variety of different ADMs. While without doubt, many good things were achieved over the past ten years, there was no significant systematic change — not in the culture of fear & anxiety that exists in the system.
Hoskins can publish a new Health Sector Strategy Paper with the best of intentions. but if he simply accepts the existing culture, his strategy won’t work. He needs to align the structure, culture and skills of the system.
When deep, fundamental, transformational changes that are irreversible occur, people throughout a complex adaptive system undergo a complete paradigm shift in how they think and behave. The system evolves through the occasional disruptive innovation when everything changes, and then there is no going back to the “good old days.”
So how are we ever to successfully transform our existing healthcare delivery system? When are we going to stop “tinkering on the margins” of structure — and get on with the aligned fundamental reforms that Ontarians want and need?
Using innovation management models previously applied to other industries, Clayton M. Christensen, a Harvard business professor, argues in his book, The Innovator’s Prescription, that the concepts behind “disruptive innovation can reinvent healthcare.”
The term “disruptive innovation“, which he introduced in 2003, refers to “an unexpected new offering that turns the market on its head.” The internet and the personal computer are examples of “disruptive innovations”. They changed everything—and there is no going back to the old ways of doing things.
A few years ago, Christensen told the Annual OHA Convention that disruptive innovators in healthcare aim to shape a new system that places patients and their families at the centre of the delivery system; and, provides healthcare consumers with a high-quality continuum of services that are delivered seamlessly. Mr. Christensen argued that by putting the financial interests of hospitals and doctors at the centre, the current system gives routine illnesses, with proven therapies, the same intensive and costly specialized care that more complicated cases require.
The New York Times suggests that “by creating a continuum-of-care that follows patients wherever they go within an integrated system, care providers can stay on top of what preventive measures and therapies are most effective.” Princeton economist, Uwe Reinhardt, says that in such systems “tests aren’t needlessly duplicated, competing medications aren’t prescribed by different doctors, and everyone knows what therapies a patient has received.”
For years health system critics have suggested that patients/families/citizens/taxpayers have not had a very significant influence on health system reform efforts. Rather, system design issues have been driven mostly by influence, authority, span-of-control issues, roles & scopes for service providers, managers, boards of governance, public servants and “inner-circle” influencers. These issues are of great concern to health system insiders, but of little concern to patients and the larger public—who are actually the “owners” of our healthcare delivery system.
However, we have learned that we do our best, most productive learning in partnership with patients. In an excellent report on patient-centred care, Human Factor: How Transforming Healthcare to Involve the Public can Save Lives & Save Money, researchers Bunt and Harris tell us that “the people who use services, and the staff who deliver services, generally have deep knowledge and understanding about how to make them better.” The authors proclaim that “in the most basic sense ‘patient centred care’ means taking more account of the users of services. There is extensive evidence that this delivers improvements in care delivery, increases in health literacy, and provides valuable feedback and assistance in setting priorities.”
Despite all this, we still don’t really pay much attention to the patient or their families. Unfortunately, “Patient-Centred Care” isn’t a strategy, it’s too often been merely a slogan or empty mantra. The last Minister said it was important so everyone said similar things in their re-written mission, vision and values statements.
“Patient engagement” rather than “experience-based re-design” has become the focus of the systems change efforts. That means we learn how unhappy people are, but we won’t actually do much about it. It has very much been about “optics”. “Patient engagement” makes us look like we care. Sort of like the CQI/TQM fad that was just a box-of-tools, then came the Institute For Health Improvement, the Canadian Patient Safety Institute and Health Quality Ontario and things began to actually improve. “Patient experience design” actually changes the system — and the humans don’t like to change.
While traditional vested interest groups continue to have extraordinary influence over government, new consumer/ public interest groups are now emerging to finally break the log-jam.
The “Changing Of The Guard” at Queen’s Park usually means opportunities for fresh thinking, and a preparedness to take on the deeply-held assumptions about our healthcare service delivery system — that taxpayers and citizens own. If there is to be a power shift for transformation, the patients, rather than the usual service providers and their lobbyists and rather than the same/old inner-circle group think, may finally experience a shift in assumptions.
We never had this unusual combination of Physician Leaders at the top before, but I think the mix of perspectives and insights from Dr. Hoskins, Dr. Bell, Dr. Tepper and Dr. Sinha may produce some break-through thinking about how we can meet the challenges of the next few years. While this considerable Doctor Brain Thrust (perhaps with the usual physician “blind spots”) will no doubt influence the Minister’s thinking, he’ll also gravitate to his own “inner circle” — which will reflect his personal interests, style and priorities.
While Hon. Deb Matthews certainly began to pay attention to patients, I think Health Minister Hoskins may be even more oriented to take the patient/citizens/taxpayer perspective.
So who will be in the new Minister’s “inner circle”? More, the same or different vested interest group insiders — or will patients and health reformers finally get a voice in the future? We have some great spokes-persons for the patient perspective and new voices are emerging with the insights we need.
Sholom Glouberman, President of the Patients Canada, has written a book entitled My Operation, (available at http://www.patientscanada.ca). A very thoughtful blogger on patient issues,. Sholom says that he is optimistic that most healthcare delivery organizations really do want to put the patient and their families at the centre of their service system designs. “They just need encouragement and support to do it,” he says.
The Patients Canada‘s mission is to promote increased patient engagement with healthcare organizations to enhance the voice of the patient. They will be organizing training programs specifically designed to improve the capacity of patients and their caregivers to interact with healthcare professionals. The Patients Canada isn’t the only consumer group to emerge recently. Another is the Canadian Association for People-Centred Care.
Dr. Vaughan Glover is a co-founder of the Canadian Association for People-Centred Health—a grassroots organization dedicated to finding ways to make our healthcare system more responsive to patients and their families. In his book, Journey to Wellness: Designing a People-Centred Health System (available at http://www.capch.ca), Dr. Glover says that the issues in a people centred system are “whether I feel valued, whether I am listened to, whether my needs are met, whether I was presented with all the options for care, and whether I received high-quality service.”
He says “the principle of individuality creates an interesting problem: a patient-centred system must be inclusive enough to support 34 million personalized health systems that are unique to each Canadian and ultimately managed by him or her.” He says that “health is a personally defined balance of mental, physical, spiritual and emotional well-being.”
Their People-Centred Model, places the informed patient at the centre—with access to coaches and support groups, supported by legislation and a system that is managed to be patient/family-centred. While the direction of change in this model is clear, it shifts the focus from the structural issues raised by the existence of the LHINs, to the fundamental issues that go to the heart of purpose: Why does the healthcare system exist?
What is its mission, its purpose for existing? If the answer is: “to serve the patients/families/clients/residents,” then it is important to know what “patient-centred care” really means? There are many definitions for PCC that are offered. NRC Picker, (the company specializing in tracking patient experiences) suggests seven components of patient-centred care:
1. Respect for patient’s values, preferences and expressed needs. This dimension is best expressed through the phrase, “Through the Patient’s Eyes” and the book of the same title. It leads to shared responsibility and decision-making.
2. Coordination and integration of care. This dimension addresses team medicine and giving patients support as they move through different care settings for prevention as well as treatment.
3. Information, communication and education. This includes advances in information and social technologies that support patients and providers, as well as the cultural shifts needed for healthy relationships.
4. Physical comfort. This dimension addresses individual, institutional and system design (i.e. pain management, hospital design, and type and accessibility of services).
5. Emotional support. Empathy and emotional well-being are as important as evidence-based medicine in a holistic approach.
6. Involvement of family and friends. Care giving includes more than patients and health professionals so that the larger community of caregivers are considered.
7. Transition and continuity. Delivery systems provide for caring hand-offs between different providers and phases of care.
While these has been lots of rhetoric about patient-centred care over the past three years, there are very few examples of organizations that are actually re-designing their systems, structures and processes to be more patient-driven. Patient engagement yes, redesign, not so much. So, how could Dr. Hoskins and his new team shift the system’s attention to making real change happen?
My very favorite patient-centred care model is the Nuka Model — developed by first nations people in Alaska. It would be great if our new Minister would go up there a kick the tires of a very real paradigm shift. Rather than the very sincere, but not too effective efforts we’re made here so far. (See Blog On Nuka Model)
We need a “Nuka Mindset Transformation“, rather than an “Ontario Vested Interest Group Power Adjustment“. That’s my best advice.
But what do you think?
If you were briefing our new Minister of Health, how would you rank Patient-Centred Care/Patient Experience as a policy and program priority — what would YOU suggest?
While our Minister may end up sitting through over 100 presentations over the next four or five months, he will not have the benefit of your honest best advice — unless you click here and participate in the Health Leaders’ Survey For Hoskins.
FORWARD THIS BLOG TO COLLEAGUES YOU THINK OUGHT TO PROVIDE THEIR ADVICE TO OUR NEW MINISTER OF HEALTH.