Get Political to Improve Care

Parliament-OttawaIf you want to transform your hospital to improve patient service, get ready to fight, uphill, against every disincentive in our current system.

Very few reasons exist for hospital administrators, doctors, nurses, or the Ministry of Health to have patients seen and treated promptly.

This post summarizes Step 10, in No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments.

Get Political

High functioning teams play in the same direction, at the same time. Canadian hospitals have staff playing at cross-purposes:

  • Hospitals lose money for seeing more patients.
  • Doctors earn more for seeing more patients.
  • Nurses get paid the same no matter how slow (or fast) they work.
  • See blog on Canadian Chaos.

No one talks about incentives and control inside the system.

Deal With Unions

71% of public employees belong to a union versus 17% in the private sector. Unionization rates are over 90% for hospitals in Ontario.

Provider unions have grown imperious. Management fears them. See Are Unions Killing Healthcare?

There are 3 rules in healthcare:

  1. Always do what’s best for patients.
  2. Always do what’s best for providers.
  3. Never confuse #2 with #1.

Everybody has to work a little harder, and care for more patients today, than they did in the past.

Unionists are taught from the cradle that nurse to patient ratios take priority over patient needs.

Unions resists process change, if there is any chance that the change might negatively impact union members. Patient benefit is secondary.

Discuss Funding After Governance

People believe that our bloated healthcare system centres on debate about funding vs. spending, or supply versus demand.  But it is neither of these.

Whether money comes from taxes collected by government, or taxes collected by insurance companies, the issue is not about money.

The debate must shift from how money comes in to who is control of how money gets spent.

Everyone demands accountability from the system, but no one gives the people inside the system the freedom or authority to truly control outcomes.

There too many self-interested stakeholders with narrow agendas.

The status quo survives on compromise consensus.

Problem With Salaried Administrators

Most administrators care more about losing their job than pursuing radical innovation for patients.

Administrators spend years working to get promotions into senior leadership. Hospitals give administrators little incentive to tackle the toughest problems.

In a bureaucracy-driven system, leaders focus on being slightly better than their peers, but never to be outstanding.

The risks of true innovation are too high.

Milton Friedman said that bureaucrats risk two choices with innovation:

  1. They can block something beneficial, but no one will ever know.
  2. They can approve something harmful. Then everybody knows, and the administrator loses his job.

Most bureaucrats choose #1.

Problem With Clinical Administrators

Just because you spent time as a clinician does not mean you understand how other clinicians think. We cannot lump all clinical training together.

When we look at healthcare with untrained eyes, we might think that nurses, respiratory therapists, and physicians do basically the same things.

They all see patients, travel around the hospital, and record their findings in charts, while discussing treatment plans.

This is like saying everyone in IT is basically the same. To the untrained eye, computer scientists, IT repairmen, and website developers basically do the same thing: they work in high-tech.

No one would ever fill a senior IT leadership team with only website developers. They would never assume that such an unbalanced team could champion IT excellence.

In health care, we assume anyone who spent time working with direct patient care should be able to run the hospital.

It’s simply not true.

CEOs who hang around the nursing station will never really know what it means to think like a nurse. CEOs who have watched physicians work will never understand how physicians think.

We Need Doctors in Leadership

See blog posts:

And stop talking about engagement. We need true partnership.

What Our challenge Is Not

Conscientious providers get tied in knots worrying about the healthcare system.

We’ve done this for decades and it must stop. Until leaders focus solely on patient service, the system will not improve.

The time for political conscientiousness has passed. Emergency providers are on their own.

If government wants to decrease emergency department use, they need to redesign the system so patients are attracted to seek care elsewhere.

It is not for EM workers to bear the responsibility of rationing care for the whole system.

What Our Challenge Is

Patients need humanity and compassion with every clinical interaction.

The most important outcomes for patients are often qualitative, subjective, and impossible to measure.

We need to learn to articulate what medicine is. It must be hard. It needs to be tough and complicated to capture everything we do for patients.

Narrow-minded medicine makes patients secondary.

We need tough-minded leaders with diverse backgrounds and training who are committed to putting patients before budgets, politics, and ideology in order to sort out the Canadian chaos in healthcare.


This gives you a sense of the last chapter of No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments. Thanks for checking it out!

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4 Replies to “Get Political to Improve Care”

  1. I certainly don’t claim to know the inner workings of hospitals or even doctors’ offices, but I know just from experience as a patient that you are sooo right. I applaud your courage in being so open and honest when few are willing to do so. I do notice more and more doctors speaking out lately. It is unfortunate that our government and bureaucrats have made it necessary.

    1. As always, I sure appreciate you taking time to read and share your thoughts!

      You are right. The cost of calling for change often over shadows the desire to ask for it.

      Best regards,


  2. Shawn,

    I don’t think I’ve come across anyone past year 2 of med school that gets as enthusiastic as you can about this stuff. I’m going to challenge you here, though. What is it specifically you’re looking for in a politically active doctor? Are you hoping to see better leadership at a departmental/institutional level or at the system level? Or both (which I presume is your wish)? Where are we supposed to find these leaders, other than the ones who step forward? Considering all the other professional and personal demands we have, is it fair to expect political acumen (never mind action) from doctors?

    More importantly, to what end? “Better patient service” is a pretty nebulous concept, open to as many interpretations as there are stars in the sky. If we start going overboard with performance metrics, how do we account for the patients that simply don’t get better? I think of my own experience at a CHC. We had sky-high patient satisfaction survey results, from the most pitiful members of our society no less–addicts, assault victims, schizophrenics–but the LHIN refused to compromise on its obsession with getting our volumes up. Serving more people can also “count” as better patient service, even though it most certainly isn’t. I suspect such amorphous definitions of quality is one reason why people in health care look to self-interest as a default course of action.

    Call me overly crusty if you must, but broad-based innovation in health care also seems to create as many problems as it fixes. I can think of no more a perfect example than Primary Care Reform aka capitation for FPs. This vaunted ideal was championed for years by some of the most prestigious docs out there, including EBM guru and would-be MP Dr. Gordon Guyatt. Of course, the primary care reform ideal eventually evolved rather messily into the FHO model that has received scathing reports on behalf of provincial auditors, as effectively paying doctors not to see patients. Dr. Hoskins and the esteemed DM (Dungeon Master?) Dr. Bob Bell have used observations of abusers of the FHO model as a political bludgeon, to erode public faith in the profession, and stonewall efforts to get back to the negotiating table.

    Politics may be the art of the possible, but it’s also war by other means.

    Frank Warsh

    1. Frank, what a thoughtful note! I cannot do justice to all the points you raise.

      When I say ‘politically active’, I do not mean capital ‘P’ Political. I mean we need to think about power structures, and what motivates powers to act in the ways they do. For instance, unions representing lab technicians will no doubt regale us with the dangers of point-of-care testing, and especially self-testing. While the technology exists, and its price drops each year, it will be an incredible battle to get point-of-care testing into hospitals and clinics without guaranteeing that it does not lead to fewer jobs for lab techs and nurses. So, we need to understand political power struggles before we can advocate for what seems like obvious improvements to patient care.

      So, how do I get involved?

      Utopian designs are wonderful: they offer cut and dried solutions and ways to be involved. “Do X, and we will achieve Y.” “All doctors should just use EMR and the patients would no longer suffer.”

      Real life is not so simple. I suggest that we each get involved in a tiny corner of the system that interests us. You already have something that you care about, and pay attention to, without anyone begging you to do it. That’s where you start. Perhaps, you take issue with meaningless metrics about volumes. I bet if you dig into it, you would find that someone benefits from increased volumes, someone else wants to legislate volume restrictions, and so on. Find the power struggle, the political point.

      Finally, you noted that I seem a bit obsessed with this issue. You did not say that; you were too kind. I AM enthusiastic about this, but probably to a fault. The more I read about politics, healthcare legislation, power, and control, the more I struggle to stay calm. It feels like I see Vesuvius shaking but must remain calm when discussing the possibility that it might erupt.

      Thank you SO much for reading and taking time to share a comment. Readers love to read the comments even more than the main post.

      Best regards,


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