Sober second thought about Saskatchewan's healthcare transformation plan

There's many a slip 'twixt cup and lip.

Thanks to Mary "Wet Blanket" Smillie for cooling my ardour over Saskatchewan's healthcare transformation plan.  Here's Mary's comment/sober second thought:

I agree with the parts of the press release you've highlighted, Kishore. I too am excited about the opportunities to shift the focus of health care to the best way to care for people rather than continuing to equate care with visits to a single health professional. The promise of primary care teams with physicians is great. Accessing specialists in a timely way - also great. The promise of no waits for Emergency care concerned me however without us first significantly improving primary care. Without a redesign of primary care, with improvements to coordinating better with specialists, the Emergency wait time targets are unrealistic and may detract us from our focus on getting primary care right.

I absolutely agree.  While the plan looks promising, implementation will be challenge.  Your example is a great one.

Primary care is the bedrock of healthcare, and getting it right will reduce the demand on ERs.  People who are currently using ERs as their default primary care site will have access to a primary care team when they need it.  More people will receive appropriate care for their chronic medical conditions, have fewer acute exacerbations, and therefore have less need to visit the ER.  Primary care redesign will achieve a reduction in ER demand, and thereby contribute to shorter ER wait time.

Attempts to shorten ER wait times without making significant investment in primary care reform may expend unnecessary resources.

But, primary care redesign will take time.   Its effects on ER usage/wait times won't be immediately apparent.  Do we have the patience to let the benefits cascade up through the system?  Which effort makes a better headline?

Cross your fingers, Mary!

Wish granted! Saskatchewan's healthcare plan leads the way

My apologies to anyone who, over the weekend, asked me how work was going.  I probably talked your ear off about this exciting healthcare news: Saskatchewan's plan for transformation and innovation.

This is exactly what I was wishing for 2 weeks ago.

There is so much hope and potential packed into this brief press release that I've been savouring it all weekend.  Many points deserve comment, but for now I'll pick out a couple of doozies.

"Better care, better health, better value".  

Has the Triple Aim ever passed through the lips of the leader of a North American geopolitical unit? (Actually, yes.  Google says (key words "governor triple aim", "premier triple aim") Oregon Governor Kitzhaber (a physician) is a proponent of Triple Aim.  But still, it was a nice piece of hyperbole while it lasted...)

"All people are connected to a care team that includes a family physician".  

I don't want to read too much into this phrase, but I know that the people who write these speeches are mighty careful about their choice of words.  So, I see "care team" and "includes" (rather than "lead by") as significant.

"A five per cent decrease in the rate of obesity in children and youth"

This acknowledges that health care should not solely focus on high-tech, institutional "rescue care".  Tackling childhood obesity will involve all the social determinants of health, such as education, income, and social resources.  Can a tobacco-free Saskatchewan be far behind?

"All people will have access to a specialist and diagnostics within one week"

One week to see a specialist? That's a stretch goal.  And I want in on it!  As the release points out, other systems have achieved this already.  Again, the careful choice of words here doesn't say that a person necessarily needs to see the specialist in person.  They could have a telephone or videoconference consult, or their primary care team could consult with the specialist and then provide specialist-directed care locally.

But, words are cheap, and press releases are priced to clear.  What makes me think that this isn't just rhetoric in advance of the premiers' meeting this week?  I've heard similar lofty goals when Saskatchewan announced its Surgical Initiative.  Giving everyone the option to have their surgery within 3 months?  And making that change within 4 years?  Audacious!

But, as I've had the privilege to work with the patients, providers and administrators involved with the Surgical Initiative, I've seen an absolute commitment to achieving this goal.  Ideas for clinical innovation come from the front-line providers and patients.  Support and resources come from administrators.  Even after one year, the changes were impressive.

So, I'm excited about this new vision because of our track record so far.

You have been warned: Best to steer clear of this topic with me this week.  Unless you've got an hour or so to spare!

Clinicians and administrators need to share the sandbox

Thanks to Trish Livingstone for helping me clarify my thinking on starting quality initiatives at the grassroots level.  Trish (Director, Health System Quality and Efficiency Management for the Government of Saskatchewan) left this comment:

Agreed, Kishore, don't wait for permission - start now! As administrators, we often create barriers but our role should be to facilitate these changes at the front-line by providing support, incentives, opportunities for training, etc. In the words of Berwick, the administration's role should be to "help those who help patients." So, start without us but even better - let's do this together!

You can't go wrong by quoting Berwick!

This comment illustrates the tension between letting front-line workers initiate improvement work and needing some degree of administrative support and coordination so resources aren't wasted and efforts aren't duplicated.  We definitely need to work together and cooperate.

But, frankly, it doesn't feel like an equal relationship (yet!).  I think many clinicians feel that the administrator/manager/director's job is to say "No." Are managers actively soliciting ideas from their staff?  How much time are managers spending walking around the wards, visiting clinics, talking with support staff, or asking clients about their experience?  How much enthusiasm and expertise is being wasted because managers are in meetings with other managers, rather than being available to "help those who help patients"?  How many managers are encouraging their staff to try something and give permission to fail (AKA: learn)?

I had a taste of this earlier in the week.  As part of our clinic's new improvement project (to which I alluded in the last post), I visited nurses at an outpatient treatment clinic.  I wanted to find out if they had any ideas on how we could improve delivery of a certain cancer treatment.  Did they ever have ideas!

I thought I would have to drag suggestions out of them, but instead I found that they were brimming with ideas.  They showed me system dysfunction that I was unaware of.  Plus, they had already been thinking of ways to fix the problems.  But, they had no mechanism (no invitation) to communicate the problems or initiate improvement.

They were thrilled that someone was actually asking for their insights into this part of patient care.

How much missed opportunity exists in wards, clinics and care homes?  How much potential could be tapped by (as Trish says) "providing support, incentives and opportunities for training"?

You're right, Trish.  If we're going to start quality improvement work at the front-line, we need help from administrators.  So, managers and directors, please be part of this grassroots work.  Trish has challenged you to "help those who help patients".  Will you say "Yes" to trying an improvement suggestion rather than waiting for approval from higher up?  Will you weigh the value of attending another regularly scheduled meeting vs. visiting the ward to solicit change ideas from your staff?

Vive la Revolution!

Provinces, schmovinces! This is a chance for front-line workers to shine!

Anonymous left a cryptic comment on my "Feds, schmeds!" post:

"I agree Kishore .... let's start today!"

Silly Anonymous, whatever do you mean? In the post, I exhorted provincial governments to quit relying on the feds for leadership around national healthcare change.  But, I don't have anything to do with the provincial government, so it's not my responsibility to get the process going.

Unless you're suggesting, Anon., that in the same way that provincial governments shouldn't wait for the feds to get the ball rolling, clinicians (and patients!) shouldn't wait for provincial governments to make the first move.  Is that what you're getting at, you closet subversive?

But without funding and administration, how can front-line workers (especially private practice clinicians like our urology group) ever make a significant impact on patient care?  You're probably going to quote Margaret Mead:

"Never doubt that a small group of thoughtful, committed people can change the world.  Indeed, it is the only thing that has."

Alright, Anon., you're on!  As it turns out, we're starting a new improvement project in our office.  While it will involve changes for Saskatoon Health Region policies and staff (as well as our own staff and physicians), we're not waiting for outside permission to get started.  I'll commit to telling the story of our progress in this blog, if you, Anonymous, will commit to spreading the word to front-line workers that we can all start making small changes without waiting for permission from Leaders With Titles.

Deal?

Feds, schmeds! This is a chance for provinces to shine!

Hi, guys! Anything interesting happen while I was away? What? The federal government unilaterally imposed a healthcare funding plan on the provinces? Ha, ha. Sure they did.

Oh, I see they did.

Like many of the provincial finance ministers, I wasn't thrilled with this strategy, but perhaps for different reasons:

• Too much money! Transfer payments continue to increase by 6% annually until 2017.  Then, increases are tied to economic growth.  That much dough is a recipe for whittling at the edges of the status quo, not an incentive for radical redesign of healthcare.

• No airing of dirty laundry! A negotiation process would have been as much about outcomes and accountability as it was about dollars and cents.  We should have had a national, bare-knuckles brawl about the waste, perverse incentives and lack of patient-centredness in our health system. We've been deprived of the chance to let the public have a real say in restructuring healthcare.

• No master plan! If each province takes its no-strings-attached loot bag and hunkers down in its respective corner, we could end up with widely disparate models of care delivery.  We need a national clearinghouse for improvement ideas and innovation so we can learn from each other's experience.

Wait a minute! Who says we need the federal government's permission to do these things?  This is a golden moment for the provinces.  Mr. Harper is going out of town and giving us the keys to the house.  We can fight over the liquor cabinet, or we can pull together.

Some will see a crisis.  Real leaders will see opportunity.

I hope we start hearing their voices soon.