Friday, December 12, 2008

Cup Holder Conundrum

Over the last few days, many of you watched, as I did, the Pan-Canadian Broadcast of IHI's National Forum. The keynote speeches weren't very cheery.

Don Berwick looked downright ticked off. Change isn't progressing fast enough for his liking. I suspect that most people involved in quality improvement share his frustration. Dr. Berwick imagined 2 letters that he would write, for his daughter to open 20 years from now. One letter presumes that the quality agenda will flourish over the next 2 decades. The second letter is an apology: Sorry we let the nay-sayers beat us down. Sorry we couldn't budge the inertia of groups with a vested interest in the status quo. Sorry that you're paying the price 20 years from now.

John Kitzhaber – ER physician and former Oregon governor – made a passionate appeal for reforming the US healthcare system before it becomes financially unsustainable. His perspective is purely American, but in the current economic situation, Canadians should take notice as well.


It made me think of automobile cup-holders.

North American automakers have been pilloried as they plead (and make not-so-veiled threats) for a financial bailout. GM has made an astonishing mea culpa: We acknowledge we have disappointed you. Whether or not you think they are sincere (GM gets savaged in some of the comments below the article), some of their admissions could just as easily come from the healthcare industry.

  • At times we violated your trust by letting our quality fall below industry standards
  • See the Institute of Medicine's To Err is Human: Building a Safer Health System. Healthcare has some quality issues.

  • We also biased our product mix toward pick-up trucks and SUVs.
  • We lavishly commit resources to "Cadillac" acute care of conditions that often result from lifestyle choices. Perhaps we should be "taking the bus" of preventative health care.

  • And, we made commitments to compensation plans that have proven to be unsustainable…
  • Fee-for-service rewards delivery of more services. Overuse is a quality defect.

We also plead for more resources. And occasionally get pilloried for it.

Now for the cup-holders...

Many drivers "consider the design, location and number of cup holders in a vehicle to be one of the most important attributes influencing their vehicle purchase." Considerable effort has gone into the design of cup-holders that will accommodate a variety of cups and be accessible, yet unobtrusive. Like certain aspects of Clinical Practice Redesign, it's about ergonomics.

But, a gas-guzzling behemoth SUV with a beautifully-designed cup-holder is still a gas-guzzling behemoth SUV. The cup-holder is an elegant component in a fundamentally flawed system.

When we try, in our Advanced Access project, to tweak our work flow, are we deluding ourselves? Are we refining the cup-holder while the broader system lurches down the highway, belching smoke and blowing gaskets? Would the energy put into local projects be better invested lobbying for a radical system overhaul?

I hate self-doubt just before the holidays.

See you in the New Year!


  1. Originally posted by Heather 12/15/08 8:00 AM

    I love and appreciate all of your thoughts. So how do we change it????

  2. Originally posted by Maura Davies (Saskatoon Health Region) 12/15/08 8:00 AM

    Kishore, never doubt that the changes you are making at the micro level are making a difference. Don Berwick, IHI and lots of research on quality and safety tell us that we need to work on multiple fronts (micro, mezzo, macro). The changes you are making to your practice are having influence far beyond your office. By modelling physician leadership for quality and safety and sharing your stories, you are helping us make the cultural changes that are required for larger system transformation. I was fortunate to attend IHI in person this year as part of a very keen group of Saskatchewan health care professionals. One of the most significant learnings for the team from the Saskatoon Health Region is that our region and others throughout the province are on the right track. Sure we have lots more to do and it is very challenging work, but we have all the ingredients for success. We need to do a better job of telling our stories and celebrating those successes, such as the work you are doing, to transfer the knowledge we have gained and to give us that added boost when the going gets tough. I wish you continued success in 2009.

  3. Originally posted by Lori 12/15/08 11:45 AM

    Very interesting commentary regarding health care and the auto industry. In the end it comes down to who has peoples’ senses engaged. We see consistent images of need for specialty services in acute care and outside of visions of starving children in Africa there is little in the way of prevention - that is as engaging. I guess it comes down to that maxim of 'follow where the money is going' to help sort this situation out. It comes down to issues of control as well. The design of physicians being in the trump position for all aspects of health care does not lend to a wholistic system redesign in regard to prevention - a team approach is best. One aspect of Berwick's presentation was how he touched on the issue of aggressive acute care for people who are perhaps more in need of palliative or quality of life care - everyone dies. This is an issue that crosses the entire life span, not just for older people. To begin addressing this area of health care is beginning to tread on sacred ground.

  4. Originally posted by Phyllis 12/15/08 1:00 PM

    I think Kishore has hit the nail on the head. We need a whole new approach to how we do health care. The preventative bus has been talked about at least since I went to University (graduation 1975), but not acted on in any substantive way. I do not work in public health either so am not being self serving. Along the way we can't ignore the quality improvement part for the pieces.

  5. Originally posted by Doug Robertson 12/17/08 9:15 AM

    Thanks for your insights, Kishore! I hate self-doubt, too (especially before the holidays). But doubt is wisdom's midwife, and a precursor to change. Kipling wrote that we should "make allowance" for doubt (in “If”). I wish more of us had a healthy doubt for the status quo! Thank you for your example. Please, don't doubt your influence in our quest for quality. (And, without doubt, I expect you'll enjoy your holidays!)