The Times, Theyre Not AChangin Fast Enough and Far Enough

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The Times, Theyre Not A-Changin(Fast Enough
and Far Enough)

• St. Elizabeths Health Care
• 100th Anniversary ConferenceToronto, March 7,
  2008
• Steven LewisAccess Consulting Ltd. Saskatoon SK

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Major Themes

• Whats the problem do we need transformation
  change or is it just rhetoric?
• The scale of change are we sufficiently
  ambitious?
• The pace of change are we going fast enough?
• What accounts for Canadas inertia problem?
• Can we do anything about Canadas inertia problem?

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In Praise of Voluntary, Incremental Change and
Modest Improvements
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(No Transcript)
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Why I Have Nothing To Say On That Subject

• Primary health care people get evidence-based
  care about half the time
• Chronic diseases 70 of Canadian health care -
  are poorly managed
• As many as 9000 people die needlessly in
  hospitals every year
• A 60 increase in real per capita health spending
  in a decade has not solved wait time problems
• The healthcare workforce is aging, morose, and
  fragmented
• People suffer when we get it wrong

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The Larger World

• Politics and democracy
• Environment
• Inequality
• The rise and fall of civilizations
• Identities

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Lessons

• Recognizing a genuine crisis is what
  distinguishes civilizations that succeed from
  those that dont
• Acting well in isolation can produce devastating
  unintended consequences
• Civilizations that seem to be at the apex of
  their powers can decline rapidly
• We need a new sense of collective vision, action,
  accountability to save the planet (literally)
• Fragmented excellence and depth are easy
  ingenuity is hard
• Demonstration is easy spread is hard

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The Big Solutions that Dominate Canadas
Health Care Discourse

• More doctors
• More nurses
• More money
• IT/EHR
• More machines
• Higher credentials for entry-to-practice
• Safer Healthcare Now!
• Quality Improvement
• Payment for performance

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Do We Have Enough Doctors?

• Conventional wisdom no
• Some peculiar facts
• Cities with high doctorpatient ratios have as
  many people who cant find a doctor as those with
  low doctorpatient ratios
• We have as many doctors per capita as a dozen
  years ago providing more services
• There appears to be no relationship between the
  supply of doctors and population health status

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Source Univ. of California Atlas of Global
Inequality, http//ucatlas.ucsc.edu/spend.php
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Do We Have Enough Nurses?

• Projections of 100,000 shortage in coming decade
• Many unfilled vacancies
• But
• Nurses spend about a 50 of their time doing
  professional nursing
• Confusion about which tasks can be done by which
  personnel category
• Could it be that we have a shortage of nursing
  but not a shortage of nurses?

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The Solutions of High Performing Systems

• More measurement and intelligence, real-time
• More accountability
• More (or at least better) management
• Close beds, open clinics
• Tools and techniques
• Work to maximum capabilities

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Canada
Singapore
Malta
Source Univ. of California Atlas of Global
Inequality, http//ucatlas.ucsc.edu/spend.php
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Lessons

• More may cause as many problems as not enough
• Doing is not the problem thinking creatively is
  the gap
• Innovation is not the problem spread is
• Mistaking no correlation for causation (money and
  health status HHR supply and outcomes) is even
  worse than mistaking correlation for causation
• It is Canadian to be incrementalist, but
  incrementalism may not work in all circumstances

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Is Canada Uniquely Learning Disabled?

• Grip problem
• Too weak a grip on principles (at times)
• Too strong a grip on structures and policies
• Federalism problem
• Ottawa reduced to being a cash cow and a source
  of perpetual inflation
• Provinces that fail on their own reluctant to try
  to succeed together
• Anarchy problem
• OK to practice well or poorly
• OK to get poor or excellent value for money

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Identities Is Holding On Holding Us Up?

• Origins, cultures, and loyalties both root us and
  divide us
• It is very hard to distinguish without judging
• Many healthcare identities work against
  client-centeredness and coordination
• Professional identities buttressed by theory
• Institutional identities aspiring to unique
  cultures
• Sectoral loyalties and competitions
• How do we achieve holistic, integrated service
  where identities are parochial?

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So The Real Problems Are.

• Ingenuity the capacity to assess the root cause
  of a problem and apply the most relevant and
  effective solutions
• Courage the ability to do what we know needs to
  be done in the face of opposition
• Expectations we settle for too little

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Things to Watch Out For

• Understand the problem before rushing to a
  solution
• Do not mistake a values and interests problem for
  a technical or knowledge transfer problem
• Always have both an innovation and a spread
  strategy we typically forget the latter
• Dont make people miserable with small change
  when you can make them miserable with big change
• Watch what the academy is doing is it an
  incubator for innovation or a bastion of
  conservatism?
• Track and develop intra-organizational values
  never assume that everyone agrees

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Citizenship and Better Health Care

• Health care in Canada is a matter of political
  economy
• The problem of health care in Canada is as much
  civic and democratic as it is technical
• We know how to do things better we just have a
  problem of scale and spread
• Organizations that understand that improvement is
  civic work in a political context will achieve
  the best marriage of policy and practice

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Completely Invalid Inferred Estimate of
ActionTalk Ratio in Four Countries
In selected leading organizations
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Contact Information

• Steven Lewis
• Access Consulting Ltd.
• 211 4th Ave. S.
• Saskatoon SK S7K 1N1
• Tel. [phone]
• Fax [phone]
• E-mail Steven.Lewis_at_shaw.ca