Sunday, February 28, 2010

Collateral damage

If you work in Saskatchewan healthcare, Budget Day, March 24th, may be an early April 1st for you. We’ve been living high on the potash hog, but no longer. The government has been dropping broad hints about holding the line on healthcare spending. And with fixed costs increasing, “holding the line” really means “cutting back”. We immediately think of job losses, program shutdowns and spending freezes. But the most profound and prolonged impact of budget cuts will come from the least heralded casualty: Quality improvement.

With healthcare spending (rumored to be) capped at a 3% increase, and layoffs already starting in some health regions, it’s only a matter of time before someone opines “We need to work smarter”, or “We need to do more with less”. Nice slogans, but it’s not going to happen in a climate of financial restraint and job-security anxiety.

Saskatchewan has the capability to provide exceptional healthcare. The Patient First review, while outlining many of the deep flaws in the system, also told the stories of patients who received exceptional care. By definition, exceptional care required providers to go above and beyond what the system would routinely provide. The system in which we work constrains the level of care that we can provide. It needs to change.

Individual providers - nurses, doctors, physiotherapists, pharmacists, housekeeping staff and all the other people who provide health care - are rarely the problem. We want to give the best care we can to our patients – our neighbors, friends and family. Marshall McLuhan said “There are no passengers on spaceship Earth. We are all crew.” The same idea applies to healthcare. Although we often draw an arbitrary line between patient and provider, we’re all just an icy sidewalk or a Big Mac away from becoming healthcare clients. We all want to improve the system, even if it’s for purely selfish reasons.

So, how will we improve the care we provide? Perhaps through traditional methods like seminars, on-the-job mentoring and reading journal articles. Regardless of how we go about it, improvement requires individual effort, time and resources. But, individual effort can only take us so far. Coordinated efforts to improve the broader system pay greater dividends, and also require greater investment.

In Saskatoon Health Region, there are many quality improvement (QI) initiatives underway - Electronic Health Records, Quality as a Business Strategy, Patient and Family-Centred Care – to name a few. But these efforts are largely still in the planning stages, and haven’t been rolled out to staff and patients. They creep along underneath the radar. And, as such, are prime targets for the budgetary axe.

It almost makes sense to cut QI initiatives. Canceling meetings frees up the time of busy administrators and managers. Conferences and workshops cost money that could be directed toward patient care. And what’s the point in developing an Electronic Health Record strategy when the provincial government isn’t going to fund it in the near future? If any of these arguments seem convincing to you, then welcome back to the bad old days when QI work was just a garnish on the meat and potatoes of providing clinical services.

Even if the QI budget isn’t actually cut, crisis management distracts us from improvement work. As a recent example, preparing for the H1N1 flu “crisis” became a priority in the health regions, resulting in several month’s of cancelled quality improvement project meetings. Planning layoffs and program cuts will be even more time-consuming.

I’ve heard suggestions that the economic downturn will be very short-lived and that potash revenues will soon rebound. If we hunker down, put QI on hold for a year, then start up again, we won’t have lost much, right? Wrong.

While we can dust off the QI projects and start again where we left off, the irretrievable opportunity cost will be staff engagement. In “Seven-year Itch”, I whined about how impatient I was getting at (my perception of) the slow progress on the QI front. If current projects screech from glacial to full-stop, it will be extremely difficult to convince staff, and especially physicians, to re-engage once the budget freeze is over. Salaried SHR employees will be back, certainly, but what about those of us who work at QI projects in addition to running our full-time, fee-for-service clinical practices? Only the most ridiculously committed enthusiasts (AKA suckers for punishment) will step up for a second round.

Cutting resources to QI work will cement the status quo. And the status quo is like keeping your money under your mattress – inflation keeps chipping away at its value.

So, just give healthcare a 10% budget increase, and everything will be fine, right? Wrong again. Budget cuts squash change, but the current method of funding rewards painfully slow improvement. In the same way that the care we provide needs to improve, we need to change the methods we use to implement those improvements. We need strong incentives to promote change. We need clear direction from political leaders.

Here’s a surgeon’s politically naïve take on the problem:

Gangrene is a serious infection. It needs prompt treatment to save life and limb. Administering antibiotics may buy some time, but the patient needs radical surgery.

An inexperienced surgeon is tempted to trim away a little of the gangrenous tissue, not wanting to damage healthy tissue, and hoping to save the patient disfigurement. And so, the infection persists, and the patient returns to the operating room for more extensive surgery, now further weakened by the infection.

Our patient has the best chance for recovery in the hands of an aggressive surgeon, who cuts deeply – sometimes to the astonishment of those observing – until healthy tissue is widely exposed. Some healthy tissue must be sacrificed, to ensure thoroughness. Our patient will need plenty of care and attention to promote healing, but he will survive.

So, maybe we need deeper budget cuts. Timid budget restrictions encourage administrators to nibble away small pieces in each department. As I noted above, some novice observers are surprised at the extent of surgery needed to excise gangrene. But, the same observers would be rightly horrified if the surgeon began to cut away tissue from body parts unaffected by disease.

So go ahead with deeper cuts, but offer to make up the difference through targeted funding. Clear direction and strong incentives from politicians and governing boards will direct administrators to make deep, yet appropriate changes. Require health regions to measure and produce outcomes around quality and patient experience. Fund efforts to achieve those outcomes. Insist on prompt timelines. Encourage cooperation between regions. Recognize that positive change requires significant investment.

Don’t waste a good crisis. Save this patient.


  1. Hi Kishore - another great post! And again, I have to agree with you (ooh I hate it when the surgeon is right).

    Many of today's leaders in healthcare quality point to a major financial crisis as an underlying motivating factor for making the transformative changes that took their systems from good to great (a "change or die" event). Utah's Intermountain Health and Virginia Mason in Seattle are two such systems that quickly pop into my head but there are many others.

    I vote for having us face a significant budget cut BUT allocating 50% of the cut amount to be invested back into those things that are necessary for us to truly change how we do things. My initial ideas are QI and Lean training and infrastructure, a bed flow management system, and IT/Data warehousing that allows us to actually monitor and measure what our processes and outcomes, both clinical and financial, are.

    (and I fully recognize its a lot easier to advocate for a budget cut when you and I , as physicians, are fairly recession-proof. However this doesn't change the fact that we are facing a major opportunity here to actually do better and be better than we currently are.)

    See you in the OR!

    Susan Shaw

  2. I say it again, we have our own Atul Gawande in our midst.