Medicare vs. Patient Care

i_love_medicare_stickerConference participants wore ‘I Love Medicare’ pins in Calgary.

Nietzsche might ask

Do you love medicare because patients benefit, or do you love medicare because you benefit?

Do you love ‘free care’ more than patient care?

People can care more about the idea of universal health care than they do about the care patients receive.

They deny data showing

long waits

poor patient outcomes

lack of access

lack of coordination

high cost


lack of control

provider frustration

Their solutions focus on

more control

more funding

more rationing

more cuts to salaries > 100k

more patient education to divert access

They would rather fight for a failed system than fight for improved patient care.


n. An arrogant, stubborn assertion of opinion or belief

dog-ma-tism n.

1. positiveness in assertion of opinion especially when unwarranted or arrogant

2. a viewpoint or system of ideas based on insufficiently examined premises

Medicare dogmatism will guarantee mediocrity at best.

We need a system that:

puts patients’ needs first

makes patient experience central to funding

gives patients great access

offers patient choice

guarantees quality care (Quality should be a given)

demonstrates business excellence

attracts the best leaders

rewards great outcomes; not mediocrity

aligns incentives for every provider

rewards grass-roots provider innovation

gives control to health-care experts

This can happen in a publicly funded system, but it will never happen if people resist change.

We need to stop thinking that health-care is so special, complicated and unchangeable.

Do we love medicare more than patient care? Can we have an adult conversation about change?  What do you think?

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Personality Conflict: An Excuse Great Leaders Never Use

Sibling RivalryDon’t ever:

Tell someone complaining of chest and upper abdominal pain: “It’s just gas.”

Tell someone feeling short of breath: “It’s just anxiety.”

Dismiss workplace conflict with: “It’s just a personality conflict.”

Carl Jung first wrote about personalities and conflicting opposite types.  The famous Myers-Brigg’s personality test uses pairs of opposites:





But the concept of conflict gets twisted to explain all persistent conflict between two people.  Why do we think personality conflict can explain so much?

Did Churchill and Hitler have a personality conflict?

Are personality conflicts holding back world peace?

Dr. Russel Watson says personality conflicts are not the true source of conflict in the work place.  He describes personality:

“The word itself is complex…unique constellation of one’s consistent behavioural tendencies…Terms used instead of ‘personality’ include: type; behavioural style; preferences; traits; and temperament, among others…closely describe work behaviours…how one does their job, or goes about their normal day-to-day activities.”

Instead of personality conflicts, Watson suggests that we fight over value conflicts:  differences in ideology.

“While behavioural style describes how one does their job, Values illuminate why one does their job, ie, their wins, drives, and rushes as they perform their duties.”

Lencioni tells us to ‘mine for ideological conflict‘ in his book, “Death by Meeting”.  He says we need to debate how our ideas differ or meetings are a waste of time.

Wrestling with conflicting ideas and values seems odd to a post-modern leader.  Post-moderns put weight on opinion, context and environment; everyone’s opinions are equally valid; you just have to be tolerant and get along.  We’ll dig into this in another post.

Do you find yourself relying on ‘personality conflict’ to explain difference of opinion?  Are you avoiding the hard work of digging into the real issues? I’d love to hear what you think by clicking Leave a Reply or # of Replies below.  Thanks!

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Are Unions Killing Healthcare? Should We Fire Them or Add More?

MP900341718Unions helped improve working conditions in the mid-19th century industrial revolution.  But what have they done for PATIENTS lately?

Unions did great things for manufacturing, but have they done ANYTHING to improve service?

In a publicly funded healthcare system, does it make ANY sense to have unions?  Don’t government jobs already have good salaries and benefits?

Have unions improved anything for patients?

Have they increased efficiency?

Customer service?




Do unions improve anything other than salaries and benefits for their MEMBERS?  Are unions all about protecting seniority instead of promoting skill?  Are all unions the same, or do some care about something other than themselves?

Jeffrey Simpson writes in ‘Chronic Condition‘, that governments can’t “…break union rules that make surgeries happen to fit the convenience of providers instead of patients…” (p. 41).

In a world of evidence-based decision making, is there any proof that unions add value for patients? 

Unions drive up wages and create MANY extra layers of bureaucracy in hospitals just to manage union issues.  A platoon of nurse leadership and human resources staff spend hours managing unions.  Not employees . . . unions.  Would the public support the extra costs of dealing with unions? 

Increased wages, increased hospital costs, patient access decreased…

We need reform based on patient need.

We need to measure outcomes and hold unions accountable.  We need to look at the total cost of unions to healthcare and have them find efficiencies.  We need to examine the impact unions have on patient mortality and morbidity due to unions refusing care unless wages go up or work effort goes down.

Unions exist for themselves.  Unions do not exist for patients.  This has to change.

Should we empower hospitals to get rid of unions or expand them?  Do you have evidence showing that unions benefit patient access to care, quality, and customer service?  Please leave a comment by clicking Leave a Reply or # of Replies below.  Thank you!

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Patient Flow into Buckets or Patient Flow into a Funnel?

bucketsNurses and doctors think patients belong in buckets.

Not literal buckets; buckets of care: primary care bucket, emergency medicine bucket, inpatient bucket…

How do we know providers believe in a bucket concept of care?

They tell patients they’re in the wrong bucket!

They tell patients to get out of the bucket!

They tell patients to go to a different bucket next time they need care.

Hilton hotels suggests staff should be empowered to handle ANY issue that arises for guests during their stay.

What happens in healthcare?

Sorry, ma’am.  You’ll have to go somewhere else for that.

Sorry, sir.  I don’t have time to discuss that with you.  The ED isn’t the place for that kind of problem.

Subtitle:  And don’t come back next time!

Funnel of Care

Patients should seek care where THEY choose.  How they choose and how we can help them make a great choice will be discussed in another post.  For now, once patients present with a concern – no matter where they present – we should be prepared to help to whatever extent we can.  Sending them away with a dismissive, “This isn’t an emergency” is unacceptable.

The funnel starts where patients choose to access care.  The funnel continues to more and more specialized care until patients get what they need.

With bucket-thinking, we expect patients to make their own clinical judgment.  Then, we berate them for poor clinical judgment:

“Why didn’t you go see the family-doc/walk-in-clinic/anywhere-else?”

But without clear, available access, patients are forced to attend the ED.  EDs refer patients to their family docs for follow-up far more than family doctors refer to the ED.  Referral patterns have reversed.  We could make the ED a referral only facility like an ICU – no entry without a referral letter.  Family Docs and clinics would need advanced access, longer office hours, basic resuscitation equipment…

System issues force patients to seek care wherever they can get it.  It’s our job to help them when they get there; not send them away.

What do you think?  Would you want your family to be sent away from the ED?  Is that safe?  Is it good customer service?  Click Leave a Reply or # of Replies below.

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5 Ways to Reduce Healthcare Spending on Emergency Departments

MC900434829ED visits are growing.

ED costs are growing.

If the ED was a bakery, we could send customers away at the front door when the pastries were gone.  Some still suggest this dangerous practice.  Here are 5 better ideas that will work.

5 Ways to Save $$ on EDs

1. Increase access to imaging and labs.  A patient can’t wait weeks to find out whether the lump in her breast is a cancer or headache is a tumour.  Patients come to the ED even though they’d often rather go anywhere else.

2. Provide clinics for ‘in-between’ patients (CTAS 3).  On a scale of 1 to 5, CTAS 3 patients aren’t dying but have more than a sunburn.  These patients needs tones of care and investigations.  A few are acutely ill, but most suffer from chronic issues.  Either give them direct access to clinics, or let emergency physicians send patients directly to specialty clinics (same day appointments).

3. Get admitted patients out of the ED.  Admitted patients get horrible care in the ED and cost the most, by a very wide margin. ED care costs more than ward care.  Get admitted patients were they can get the care they need: up to the wards!

4. Don’t transfer dying patients to the ED who never wanted to come to the hospital in the first place (signed advanced directive).

5. Close EDs.  In Canada, we close rural EDs and refuse to expand the size or number of EDs to keep pace with population.  It’s a terrible option for customer service, but it does save money. 🙁

What do you think?  Click Leave a Reply or # Replies below.

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ED Efficiency: High Acuity vs. Volume

MP900182789Myth survives as common knowledge. Healthcare sages propagate emergency department (ED) efficiency myths like:

“If the ED only saw ‘true-emergencies’, ED crowding and costs would improve.”

“Many patients don’t need to be in the ED.  We would save money by sending them somewhere else.”

The myth of High-Acuity, ‘true-emergency’ EDs assumes:

1. It’s possible to educate patients to go elsewhere.

2. Patients have somewhere else to get care.

3. Staff can safely tell who is a ‘true-emergency’ and send all others elsewhere.

4. Low-acuity patients crowd the ED and shouldn’t be there.

5. We can save money by decreasing low acuity ED visits.

Myth Busting

1. Patients attend the ED for access, not because they are stupid.  Most patients don’t need education.

2. Patients come to harm if sent elsewhere. (JAMA)

3. Low-acuity patients do NOT crowd the ED.  They cycle through quickly.  Sick, admitted patients crowd the ED.

4. Marginal costs for minor patient complaints are minuscule:  pennies compared to the cost of keeping the ED open.

High Acuity

‘True-emergencies’ don’t trickle in one at a time.

‘True-emergencies’ often present in batches.  In larger EDs, three critically ill patients often present at the same time, and most providers can recall a time when 4 critically ill patients showed up within minutes.  Each critically ill patient requires up to 4 nurses, a physician, a respiratory technician, and more.

ED Efficiency Killer

Why do governments close low-volume EDs even if they have money to keep them open?

Small EDs often have many hours when they see very few patients.  An acute care resource running at anything less than full capacity wastes money.  Idleness equals waste; it kills efficiency.  

ED Efficiency Solution

Consider a trauma room. Most hospitals keep one or more operating rooms open (staffed), at great cost, to manage trauma or emergency surgery.  Idle trauma rooms are expensive. Hospitals can recover some cost by managing non-emergent cases, especially if the team has already been called in and a suitable admitted patient awaits surgery.

Eliminate idleness to increase ED efficiency.

Hospitals recover cost and gain efficiency by using the trauma room for less urgent, non-trauma patients!

Even IF there was a way to figure out which patients were ‘true emergencies’, EDs large enough to manage all the ‘true emergencies’ in a community would stand idle much of the time at HUGE cost.

EDs recover cost and gain efficiency by seeing less-acute patients.

Mythical ‘High Acuity’ EDs never match the efficiency of a high volume ED. 

How do you approach efficiency in your ED?  How would you deal with ED idleness if you could identify and safely send away all the non-true-emergencies?

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87 Ways to Block Patient Flow Improvements

Blond Boy CryingChange stretches us.

Even good change – getting married, having a baby, retiring – is tough.

In our department, we’ve had a ton of change to improve patient flow, and we’ve heard a ton of complaints.

Here’s a few:

  1. You’re moving too fast.
  2. You’re moving too slow.
  3. What’s taking you so long to get moving?
  4. I wasn’t at the meeting.
  5. I wasn’t invited to the meeting.
  6. You had the meeting without me!
  7. You have too many meetings.
  8. I’m tired of going to so many meetings.
  9. No one asked for my opinion.
  10. You already asked for my opinion.
  11. You should talk with those of us who do the real work.
  12. You shouldn’t listen to whiners from the front line.
  13. You should consult outside experts.
  14. We don’t need experts telling us how to do our job.
  15. You’re too idealistic.
  16. You’ve lost your ideals.
  17. You can’t see the big issues.
  18. You can’t see the details.
  19. Why improve what’s  already better than most?
  20. This place has gone to hell.
  21. But look what we stand to lose!
  22. You have too many details unanswered.
  23. Your proposal is too detailed.
  24. It’s too complicated.
  25. It’s too simple.
  26. It will never work here.
  27. It’s never worked anywhere else.
  28. It takes too much time.
  29. I have nothing to do now.
  30. I’m underutilized.
  31. It takes too much energy.
  32. What are you not telling us?
  33. Your emails are too long; you tell us too much.
  34. You don’t expect us to believe that’s why you’re doing this, do you?
  35. Your data is biased/skewed.
  36. You collect the wrong data.
  37. Your data is anecdotal.
  38. Let me tell you a story I heard…
  39. You should work more clinically; you spend all your time in the office.
  40. You work too much clinically; you should spend more time in the office.
  41. This seems to be all about special treatment for XX providers.
  42. What’s wrong with special treatment for YY providers?
  43. Why should we treat patients as family?
  44. Just because I get special treatment for my family doesn’t mean other patients should get it too.
  45. We might miss one sick patient.
  46. These patients aren’t sick; they should wait.
  47. These patients could all be seen in a walk-in clinic.
  48. These patients need a nurse, a full set of vitals, an ECG, and an acute bed STAT.
  49. One bad outcome is enough to stay the way we were.
  50. It costs too much.
  51. This would work if we spent more.
  52. You are asking us to do someone else’s work.
  53. Someone else is stealing my work; I’m going to submit a union grievance.
  54. There’s no infection control.
  55. We don’t need to see infectious patients so quickly; they can wait.
  56. It’s too stuffy.
  57. It’s too breezy.
  58. There’s too much paperwork.
  59. There’s no paper for notes.
  60. There’s no privacy.
  61. I need more people around to feel safe.
  62. There are too many people.
  63. We need more nurses/doctors/patients/support in the same space.
  64. I feel disconnected from other staff.
  65. I don’t like working shoulder to shoulder with other staff.
  66. It feels like you aren’t supporting the team.
  67. It seems like you only support the X team.
  68. You’re dividing the X team.
  69. I’ve done this for decades.  I don’t need to change a thing.
  70. Those new guys are out of date.
  71. It’s the wrong focus.
  72. You just want to be famous.
  73. Why don’t you spend time on what really matters?
  74. You are out of touch.
  75. You sound like a corporate pawn.
  76. All you care about is X metric.
  77. You just want to undermine Y group of workers.
  78. This sounds like what failed last time.
  79. Are you saying we aren’t working hard enough?
  80. You don’t know what you’re talking about.
  81. If you just changed X, you wouldn’t  need to do this.
  82. You know, this will never work.
  83. We need to give more power to the people actually doing the work.
  84. This is embarrassing.
  85. I used to be proud of working here.
  86. I wouldn’t send my family here; I’d send them to the terrible hospital down the road.
  87. Why can’t you admit this is a stupid idea?

Kotter discussed many of these in  “Buy In”.  He suggests that there are 4 main attacks:

  1. Fear Mongering
  2. Death by Delay
  3. Confusion
  4. Ridicule/Character Assassination

Kotter proposes the following response:

  1. Invite attacks
  2. Respond with clear, simple common sense
  3. Respect always; never fight
  4. Focus on the audience
  5. Prepare for attacks

Change cannot be blocked.  Leadership is change.  Time changes things even if leadership will not.  Patients have benefited from disruptive innovations in our ED, and our whole team proudly wears the scars we earned through it.

How have you responded to change?  Does this list sound familiar?  Click Leave a Reply or # of Replies below.

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