The new health sector leadership team of Wynne/Hoskins/Bell has just arrived amid some every bad news: “Ontario does not have a health system that is among the best in the world“.
Nope. Not anymore. In June the Commonwealth Fund released their latest comparison of health systems in 11 developed countries. Next to the United States, Canada has now been rated the second-worst healthcare delivery system in the developed world. We were last for overall quality; effective care; timelines for access; patient-centredenss; and, we scored second-last on efficiency.
This new study—which ought to be a wake-up call to all healthcare leaders — said that our health system is characterized by “long-waits; poor management of chronic conditions like diabetes; poor coordination of care; and, failure to involve patients in decisions about their care.” The Commonwealth Fund examines 80 indicators of performance, many of them based on patient surveys.
Over the past decade, Canada has dropped our rank from third place, to 10th place — now just ahead of last place United States. Any healthcare leaders in Ontario who are still protesting that “we have a great healthcare system”, and that the only solution is “more money”, should finally be kicked to the side in this debate and told: “Liar, liar, pants on fire”.
At the same time as we were having poorer and poorer operational performance over the past ten years, we were investing more and more money from both our federal and provincial governments — proving conclusively, that “more money”, does not mean that the system will be improved — if all we do is just “spent more money”.
But while Canadians have poured billions and billions of additional dollars into our healthcare delivery system in order to “fix it for a generation,” as former Prime Minister Paul Martin promised, the fact is that what health reformers were warning about (i.e. “more money” in a poorly designed, bureaucratic and wasteful system will not “fix” it). In the end, almost all the health system reform money — $81 billion — was spent by the provinces on wage increases for healthcare professionals. So taxpayers did not get the “safe”, “efficient”, “high-quality”, “patient-centred system” that they paid for.
Today, while “saving money” has become an important motivator in the U.K., in the United States, healthcare customers are becoming much more demanding as consumers. They want an integrated service delivery system that is designed to meet their individual needs. The issues here are about “system design”, rather than “tougher management controls”.
If our new Minister, Hon Eric Hoskins, were to get really serious about patient-centred care — way beyond the current rhetoric about “patient engagement”, we could indeed transform our delivery system to be more like the world famous Nuka Model: with its very real Customer/Owner orientation built into the macro-design of the system. (See Blog On Nuka Model)
At the macro-system design level, this is the kind of paradigm shift we really, really need in Ontario.
At the patient service delivery level, leading-edge organizations are moving beyond the “patient engagement” phase to embrace the new discipline of experience design based on the science of a human experience. Art Frohwerk, a systems engineer and human factors expert, who once headed up the Show/Ride Engineering at Disney Imagineering has devoted the last 20 years of his life adapting experience design methods to the patient/caregiver/family experience in the United States.
“Patient Experience Design” incorporates many disciplines — including the best of TQM/CQI/Lean Thinking/Strategy Mapping/Scorecarding/Kaizen/Emotional Intelligence and the collective intelligence of patients, nurses, doctors, families, staff and even Board members. Experience design fundamentals include: being relevant, engaging, flow and adapting.
Redesigning systems, structures and processes within an organization, or across the local delivery system — from the perspective of the patient is an example of what we mean by the term: disruptive innovation. Imagine if a hospital, a community service or a Health Link partnership structure was configured within a framework that viewed the patient as a “whole person” — rather than as just “something to be fixed”. Imagine intentionally designing the patient experience in a partnership with care providers, patients and families.
For the most part, our systems, structures and processes were never designed from the patient perspective. This transformational methodology simply liberates front-line healthcare providers to work in partnership with patients and families to pro-actively design the systems, structures and processes from the patient perspective.
Frohwerk, the world-leading developer of patient experience design methodologies, says: “using the tools of experience design not only helps us have a shared focus on the patient, but causes us to visualize how we can each contribute in often little ways. Then, it’s like Appreciative Inquiry—folks go back to work, and just start doing better things.”
In such a place, care would be personal and proactive— anticipating the patient’s needs, reducing risk, improving efficiency—all with the empathic intention to improve healing, in body, mind and spirit. With such care, the patient understands the purposes and procedures of treatment. This understanding reduces anxiety, fear and uncertainty. Importantly, it increases self-confidence and promotes patient compliance with the healing process.
In such a place, the inherent need for teamwork with a shared focus — and with better connected and flexible processes — improves the experience of nurses, doctors, other health professionals, technicians and administrative staff, as well as patients and their families. Such improvements in turn produce the results that every healthy organization needs: greater job satisfaction, and higher staff retention rates. All that, because the system was redesigned to place the patient at the centre.
Organized by the principles and insights of the Science Of Experience Design, healthcare service delivery organizations are much better able to meet their financial objectives—because relevant processes are cheaper to run, and lead directly to improved predictability and higher patient loyalty.
Frohwerk’s world-leading experience design methodologies include the Storyboard and the Master Process — which he first developed 20 years ago while leading teams designing the way to deliver new levels of guest experience at new Disney attractions.
The Master Process ensures that all the things that an organization did that worked well (i.e. balanced scorecard, lean thinking, quality improvement initiatives, etc.) is retained, strengthened and aligned with the new innovation being introduced. Storyboarding doesn’t replace things that are working, it integrates and aligns with them to create synergy.
The Experience Design Storyboard is a unique tool with the ability to create insight and organize ideas and information in a way that process design, and lean thinking alone cannot. It’s used by teams of healthcare service providers, patients and families to set the stage for seamless processes, integrated systems, appropriate roles, useful measures and strategy implementation.
Experience Design Storyboarding also combines the leading-edge disciplines of visualization, storytelling, process workflow, experience design, system design, scorecarding, lean thinking, Kaizen, and addresses emotional, social, and spiritual issues as well. The deliverable is an imaginative, graphical representation of the activities, issues and mechanisms — at an “altitude” that enables broad, yet specific patient/family-focused issues to be addressed.
The process of Storyboarding for design is much more than just brainstorming, telling stories, sending out surveys, or hosting focus groups to ask what an experience should be. It creates a setting to bring customers, leadership, and cross-sections of staff together in different forums to discover, invent and test the “story” of the patient experience.
Changing a healthcare service provider organization and shifting the healthcare delivery system from a provider-focus, to a patient-focus, requires a major behaviour change within the healthcare delivery system. To change our behaviour, we need to change how we think about our realities.
What’s great about Storyboarding is that it generates fast change that is never resisted because the people who live with the design, designed it themselves.
The new leadership team of Wynne/ Hoskins and Bell need to appreciate that the scale of these changes requires much more than “good will” and exhortations from our leaders. It requires a strategic focus and a disciplined process for actually redesigning the system and the patient experience — as well as taking the leveraged actions required to align the core systems, structures, incentives and processes to be “patient-centred”.
If you really want to change how the healthcare services delivery system performs, you’ve got to look at how it is designed. As Peter Senge says: “Every system is perfectly designed to achieve the outcomes it produces. If you want different outcomes, you need a different design.”
This is not about taking a very badly designed system and making it friendlier with volunteers to cheer-up patients as they travel across a poorly-designed system. This is about dealing with a poorly-designed system and re-designing the system in partnership with patients and families.
Transforming a system with ingrained behaviours and traditional “ways-of-doing-things” will not be easy. Health system knowledge expert Steven Lewis points out that “the way patients and providers (and the system as a whole) interact is a product of history, circumstance, psychology, social norms, identities, and other factors that together define the nature of the relationship.”
What are the “ingrained habits of behaviour” that need to be overcome?
Hoskins and his advisors will gain insight from Lewis’ paper “Making Patient-Centred Care Real: The Road To Implementation,” where he says that while the theory of patient-centred care is straightforward, implementation is not. Lewis sets out the following challenges for those who want to shift to patient-centred care. He says:
- On many levels the nature of the relationships is inherently unequal. Patients are by definition dependent on their providers for help (otherwise they wouldn’t need to see them) and providers have more knowledge (most of the time).
- Much of the time, patients are in some degree of pain, discomfort, or anxiety. They are not at their peak; they are vulnerable. In such circumstances, they often have reduced capacity to assert themselves and take control of their care.
- Status and other hierarchies come into play. Often providers are more highly educated than patients, particularly older generations. There is a tendency to defer to credentials and the other attributes of status that accrues to providers, notably but not exclusively doctors.
- Providers—again, physicians in particular—are not inculcated with a culture of service. They see patients as fundamentally different from customers. They view their own time as a precious commodity (which it is) and organize their practices around its most efficient deployment. Their basic question is not, “what does the patient need to have a good experience,” but rather, “what do I need to do to cope with demands.”
- It is difficult to imagine a system fundamentally different from the one we know. Our behaviour is conditioned by our expectations, which are conditioned by how things are and have been. It is even more difficult to change when one does not know what is possible.
- There are risks (real or perceived) inherent in trying to change power relationships and models of communication and behaviour. Alienating a provider on whom one depends is obviously problematic. Where the relationship is intermittent, it may not be worth risking even if there is some dissatisfaction with what one has.
These are all trusts that must be addressed if we are to succeed.
So, how will “health reform” be any different this time? Will it be run out of a Secretariat at Queen’s Park? Will it have lots of rules and regulations? Will innovation be allowed in a risk-averse bureaucratic environment?
In order to go beyond the simple structural reforms of the past, our healthcare system needs the disruptive innovation of patient/family-focused care — a transformation process that has the best chance of producing deep, sustainable change in our healthcare delivery system. That’s the kind of impact that Hoskins needs if he is to succeed in “changing the patient experience”. He needs to hear what it is like today on the front-line of care delivery — and how it needs to fundamentally change. He needs to understand the science of a human experience, and what will be required to change the experience of Ontario’s patients.
In his book, Deep Change: Discovering the Leader Within, Robert Quinn distinguishes deep change from incremental change—the type of change we usually talk about. Quinn describes “incremental change” as the typical result of rational analysis and planning. There is a desired goal, and specific steps to reach that goal. Incremental change is usually limited in scope and is reversible. As it does not disrupt our past patterns, we can return to the old way if the change does not work out.
Therefore, during incremental change we feel that we are “in control.”
So instead of a Health Link being a transformation structure — with real structural changes like collaborative governance and an integrated management scorecard — it just becomes a minor operational Pilot Project for the 5% of high-users. While finding better solutions for the 5% is essential, how are we using these insights to re-design the system? What caused this potential “winner” to sub-optimize as “incremental change“?
In contrast, “deep change” requires new ways of thinking and behaving. It is not a check-box “To Do Project” that needs to be monitored and approved by important people at Queen’s Park. It is change that is major in scope, discontinuous with the past, and generally irreversible. The deep change effort distorts existing patterns of action and involves taking risks — in an environment that has unfortunately become very fearful and risk-averse. Deep change requires people to be working to surrender the “illusion of control”, and engage in innovation to design real change in the system.
Today, if you suggest to a CEO that there may be an innovative solution to their problem, the word “innovation” usually means “risk” — and not many senior managers teetering on the brink of retirement are gung-ho innovators and risk-takers in this environment. Will this change with Hoskins?
Ministers, Deputies and Premiers can certainly cause change — if that is really their intention. But this usually involves stopping some stuff, and starting new stuff. It involves thinking differently, and doing things differently. Is that what is going to happen? Is there going to be change?
What would happen if LHINs, for example, actually allocated more resources to health service organizations that are patient/customer/people-focused; and fewer resources (i.e. real budget cuts) to organizations that don’t produce acceptable results on their key performance indicators? If healthcare organizations made money — and lost money — on their patient satisfaction scores, trust me, patients will notice the difference in their experience.
I believe that if Health Minister Hoskins and our provincial and local LHIN leaders were to make the financial incentives on such a patient-focused strategic direction very clear, the system will shift overnight. CEOs, senior managers and community boards of governance who understand the emerging incentives will drive the patient/family-focus revolution — if the incentives exist.
No doubt some will warn our new Minister that “such measures are going to create chaos in the system”. No doubt some of the various “vested interest groups” and “power players” will suggest to the media, or to Opposition Parties, that change is unnecessary — or unfair.
Publicly, citizens and the media will observe the unfolding reports of budget increases and budget decreases for local service providers that are based on performance measures that reflect the opinions and evaluations of consumers. If this is an open, fair and transparent process that rewards healthcare service provider organizations for “good performance,” rather than “good optics” and actually punishes “poor performance,” I believe that the public — and the media — will be very supportive of this type of transparent process and outcomes.
I also have faith that many local community governance Boards will seize the opportunity to lead their organizations into what Dr. Vaughan Glover calls “people-centred care.” In northern and rural Ontario, governance and managerial leaders need to be thinking about the concept of “Health Hubs” that meet the needs of their population.
Quality and safety issues — as well as accessibility issues — need to be front and centre as our rural and northern communities design their local health and health-related social services to meet the emerging needs of their communities.
Once health system transformation, and the disruptive innovation of patient-centred care actually take hold — perhaps within the next there years — it will never return to the “good old ways of doing healthcare;” and we will have a better, higher-quality, safer and less expensive healthcare delivery system. Such a scenario could unfold in 24-months, if the Minister wanted it.
The Wynne/ Hoskins/Bell Team need to carry on the patient-centred direction started by Hon. Deb Matthews mid-way through her tenure as Minister Of Health.
If your organization wants to build your internal capacity to design the patient experience, click here for a brochure that outlines a one-day workshop for teams to learn about Patient Experience Design Storyboarding.
FORWARD THIS BLOG TO COLLEAGUES YOU THINK SHOULD ADVISE OUR NEW MINISTER ON “HOW OUR HEALTHCARE SYSTEM COULD TRANSFORM”.