Category: System

Don’t Worry, Be Happy betrays deep wisdom in a simple package. Of course, we cannot be happy by telling ourselves to be so.

The song’s brilliance lies in redirecting our focus. It distracts us from real tragedy and makes us smile.

We do not become happy by focusing on happiness. We find happiness by looking for something else. Happiness sneaks up on us as a by-product of the search.

Quality by Design

System planners manipulate behaviour. For example, product placed at eye level sells more, and kids eat less junk food if cafeterias place healthy options first. Systems influence quality. Check out: Nudge: Improving Decisions About Health, Wealth, and Happiness.

System thinking pivots on fascination with The System. It cares much less about individual people inside the system. System thinking solves many problems. But people have uncanny skill at cheating systems, sometimes without even trying.

Babysitting Quality

WestJet treats its pilots like big boys and girls. WestJet does not babysit its front line professionals.

Same thing in university. Many students feel shocked that professors have no interest in spoon-feeding like teachers did in high school. Students soon develop responsibility for their own performance, or fail by mid-term.

Many students form study groups to clarify issues and encourage each other toward higher marks. For them, study groups work.

The Root of all Quality

Medicine is about people, not things. No amount of planning for quality and safety gets around individuals making decisions. And people make decisions for many reasons. Rules, reward, values, concepts, fear of punishment and social pressure can all influence our decisions.

Individual behaviour determines quality, and everyone wants to control it. Government controls rewards; regulators control rules and punishment; educational colleges promote concepts and values (e.g. CanMEDS).

But they all miss the glue that holds these together: relationship. Relationship trades on all spheres of influence.

Professional Relationships

Social structure, stability, and power come from small groups of connected individuals.

Groups of two to four physicians, who meet together regularly to discuss cases, share concerns, and offer support to each other, would create a culture of quality. Community doctors rounding on their in-patients used to meet like this all the time.

NOTE: Groups would need to rotate members every year or so. Quality would suffer if small groups of low performers met together for years.

If system planners wanted to do something really radical, truly innovative, they might encourage small, autonomous groups. Clusters of physicians could keep each other encouraged, accountable and passionate about quality and innovation.

Small groups would out-perform anything that a central authority could put in a guideline or regulation. Physicians who meet and talk together could apply cutting-edge research and knowledge to immediate patient needs. No central authority could ever come close to regulating that kind of service and care.

Small autonomous groups of physicians would make most current regulation redundant, almost comical.

Culture builds from the ground up. Leaders need to nurture, recruit, and develop outstanding culture creators, but ultimately leaders hand over the growth of culture to individuals.

Subversive Groups

Small teams are subversive. By their very nature they have ideas that will not be identical to those held by leadership. This makes some leaders panic.

Any intermediary power, or organization, that forms between the individual and the state, threatens Leviathan. Weak leaders worry about autonomous small groups.

Many large hospitals have gone out of their way to make the doctors’ lounge smaller or less accessible. They do not want doctors talking with colleagues. But informal groups form the basis of culture, society itself.

Square Pegs in Round Holes

Mandating group practices will not build culture. Doctors might organize groups for financial advantage, attend required meetings, but never enter into the relationship building required for culture. Meetings do not create culture. Relationship does. Government cannot build or mend local relationships with practice reform.

Quality does not flow from measurement, rigour, and reporting. These things identify gaps and quantify improvements. They can influence change, but they do not deliver quality per se. We need to learn how to get quality and not just identify when it’s there.

Quality: a Meta Result

Quality, like happiness, comes by focusing on something else. It comes with effort. But quality is more of a second order, meta-result that starts with culture built on relationships.

Blunt regulation, arbitrary legislation, and unilateral action obliterate culture. They drive doctors to despair, to sing Don’t Worry, Be Happy.

photo credit: bobbymcferrin.com

We find money for things we value. A fool parts with his money for little value in return.

But price-value mismatch makes most of us shop for a better deal. When we find what we need for less than we expected to pay, no amount of pecuniary anxiety can stop us.

Apple iPhone 6 $800

Hunter Boots Women’s Original Nightfall Pull On Rain Boot $320

Xbox 360 Wireless Racing Wheel $7,716

Compact Brushless Hammer Drill/Brushless Impact Combo $500

Montegrappa Horse 2014 Fountain Pen $28,995 (!)

CPSO – College of Physicians and Surgeons of Ontario

At a round-table on self-regulation last year, two things stood out:

1 – Doctors’ anger at the CPSO

2 – Doctors’ devotion to self regulation

The CPSO is debating whether it’s a good time to raise dues for Doctors.

Maybe some people just enjoy watching doctors suffer. As new graduates field calls from their lenders, working doctors face > 30% net cuts by 2017, and as our glamorous, new Prime Minister seeks to emasculate professional corporations, the CPSO ponders increasing dues. It feels out of touch by half.

Dr. Rob Stern agreed to share the letter he wrote to the CPSO as one of many who spoke up:

Dear CPSO,

I find it doubly shameful regarding your fee increase for 2016.

Initially, we are asked to increase dues paid to you when many members are facing anywhere up to 20% or more in fee cuts due to the unilateral action by the Ministry of Health/Ontario.  You should also be tightening your belts and doing more with less as your membership has been experiencing.

Secondarily, we are asked for our opinion, but advised to “MAIL” in our feedback rather than providing our opinions online.  It is almost as if you folks are making it difficult for us to send in feedback and hope you don’t get too many negative opinions to justify your increase.  It is not clear that your “discussion forum” is being taken into advisement by the CPSO or is simply a forum to vent our frustrations to fellow members.  I hope you are taking comments there seriously as I am not sure I have seen a positive response there as yet.

Shame on you for your fee policies and pathetic attempts at providing “objective opinion feedback” from members.

..Dr. Rob Stern

cpso #60770

Dr. Stern’s comments reflect many others on the CPSO website.

But doctors’ anger about the CPSO goes beyond dues. It hinges on the CPSO mandate and how the college carries it out (see CPSO portrays doctors as untrustworthy – gated).

We need to ask what the CPSO is trying to achieve and whether it’s the best way to achieve it.

Doctors support governance by our peers but roil at nontransparent collusion with government. The CPSO exists largely unchanged, even after Justice Corey thrashed the “devastating” Medical Review Committee (MRC) in 2005. Many of the same senior leaders still hold court.

Long before we relied so much on regulation and legislation, doctors adjusted behaviour based on peer feedback: weekly case conferences, morbidity and mortality rounds, or time spent in the doctors’ lounge debating conundrums.

Since talking with friends went out of fashion, we now rely on random CPSO audits from ‘peers’ every 10 years. Despite horror stories, most go fine (gated link).

But even monthly CPSO peer chart audits — done by people doctors do not know or trust, using secret methods and ambiguous feedback — would never match the value of doctors talking together.

Old docs used to mentor younger ones. Both learned in the process.

Doctors support the rule of law – common law, not the continental variety.  A jury of our peers judges us best. Secret police or self-appointed judge-jury-and-executioners do not promote high performance or enthusiasm for patient service.

Regulation does not inspire excellence and innovation. Regulation strangles creativity and progress. Like salt, a pinch of regulation improves the mix, but too much ruins everything.

Doctors bristle at the price of regulation inside the CPSO monopoly. It might encourage doctors to shop for a better deal.

photo credit: Amazon.ca

Scouts pick pro athletes in high school. Agents pick winning manuscripts. Even backyard gardeners pick weeds out of a sea of identical shoots.

Experts in all fields identify winners and losers.  Why is it so hard with government programs?  Every year we hear about new programs or structures that promise to fix healthcare like Local Health Integration Networks, Health Links, and Health Care Connect.

Each wave of politicians feels the need to create a splash of new programs that cost more than anticipated and deliver less than hoped. How can we choose great government programs without it feeling like playing the Ontario Pick 3 lottery?

Les Vertesi, in his book Broken Promises, wrote that government programs fail because they:

1. Assume a new and large bureaucracy.
2. Assume people will do as told.
3. Ignore unit value and only focus on total cost (usually large).
4. Avoid mentioning incentives.
5. Forget about customers, or treat them like widgets on an assembly line instead of agents with choice.

How to pick a winning government program

Using Vertesi’s comments, we can draft a tool to help us sift out winning government programs. All programs should:

A) Add no new bureaucracy.

Great businesses find ways to build new programs that use existing management. Unless politicians are vigilant, even circumspect, bureaucracy bloats and spawns. We need money for patient care, not more paper-data-regulation-reporting. At the very least, new bureaucracy should eat up a tiny part of the budget.

B) Assume individual freedom.

People break rules. Rules get misunderstood. New programs should build these assumptions into their design. We do not live in a 1950s, rule following society. Leverage rebellion into the design. Inspire rule-breaking to benefit patient care.

C) Report costs per patient.

For example, how much does it cost to deliver a baby? Does the cost change if a midwife delivers versus a physician? Reporting annual earnings of midwives alongside doctors creates a festival of envy. It does nothing for patients. Instead of talking about program costs, government should share unit costs.

D) Align clear incentives.

Every schoolboy knows that people respond to incentives. And every schoolgirl knows that money is only one of many incentives. Failed programs pretend incentives do not work. They tack them on as an afterthought or align them in opposite directions.

For example, outpatient chronic care programs often pay doctors for each patient seen. They pay nurses whether they see patients or not. And they pay hospitals less for seeing more patients (hospitals often close outpatient clinics to save money).

Soldiers follow orders, but civilians need aligned incentives.

E) Consider people, not things.

Vertesi suggests we have soup kitchen healthcare. A small group of people makes the soup and decides how much everyone else gets. The rest of us line up for our fair share. But some people cannot eat soup. Patients come with needs that often defy tick-boxes. They choose to seek care where it works for them, and then they decide whether or not to follow instructions.

Progressive

Our current government lusts for change.

• The Price-Baker report tells us to think of patients like children in a school district. They should enroll with their local clinic, no choice allowed.
• The New Graduate Entry Program limits new doctors to earning less than some nurses, after overhead, with rigid productivity rules.
• In the next few weeks, we expect a promised ‘white paper’ from the government on healthcare reform. Will it add bureaucracy and cost? Will it discuss incentives, patient choice and unit cost?

Government could ask doctors and nurses about basic criteria that every new program must address; like a surgical checklist, except for government.

Asking frontline providers about new plans before implementation might increase the chance of picking a winning government program. But then, they’d have to ask.