Previously we talked about the need for a safety culture throughout the health care delivery system. At the patient and their direct provider level we discussed the need for information, and the ability to consider different options so that the appropriate choice is made by the patient in the pursuit of their care goals.
We are going to talk about “system managers” in this posting. Clearly there are many levels of managers in every system, accentuated further when the system is consolidated and under political oversight and control. It goes almost without saying that the closer the decisions get to the politicians at the top, the greater the risk becomes that short term political priorities drive decisions, rather than keeping patient and provider safety top of mind. Often the result also has the messaging “do as I say, not as I do.” When this occurs, no “safety first” culture can exist and everyone inside and around the system is at more risk and genuine improvement initiatives stall or fall back.
The best way to illustrate some of the results of these kinds of decisions is to relate to you, real life examples of what been happening.
A person was diagnosed with cancer and was faced with an aggressive surgery put forward as the treatment by the specialist they were referred to. A second opinion was sought and a different option was provided with a less aggressive surgery and treatment. For the patient, this option had an acceptable chance of maintaining a more satisfactory quality of life.
The first specialist refused to allow the second option to occur and the frustrated patient went so far as to consider legal action to attempt to gain the opportunity to choose the second specialist. Luckily for the patient, circumstances changed for the first doctor, taking him away from the province and making him unavailable for some time. The second doctor was then able to do the surgery. The reason the patient chose this route was because they were satisfied with the safety of that choice and it provided the opportunity to maintain an acceptable quality of life for them. At last report this patient remains happily cancer free and enjoying life.
This well-informed patient was initially denied the ability to make their own choice for their treatment and the benefit/risk associated with that choice. We don’t know what this doctor’s reasons were but his disregard for the patient and their choices was unacceptable. It is also clear that there are no policies that effectively insure that the patient has the ability and the right to make their own choice.
A young lady with juvenile diabetes was able to take part in some very early trials of islet implants in Edmonton. It was valuable research and the treatment worked well for her and had a dramatic positive impact on her quality of life. This care team kept very close contact with her and expected to follow her care requirements well into the future. She got married and started her family in another province. When the time came to get her renewal treatment back in Edmonton it was denied. The team was fully prepared and committed to continuing her care, however in her neighbouring province of residence, there was a similar speciality practice starting up. That province refused to allow her to go back to her care team but instead told her that the only option was to go to the new provider.
She offered to pay for the cost of the surgery in Edmonton but even this was refused, apparently tangled up in inter-provincial government policies. Clearly, these policies are not written with the priority of safety and care of individual patients in mind.
The new provider put her on a long wait list. This not because of being too busy with these operations but because he was not very active. In turn, this meant that the supply of islets made available to him was very limited. When the treatment did finally get done, it was much more painful and significantly less satisfactory. She is now living with some negative impact on her health and quality of life as a result. She continues to be denied the opportunity to return to her first and preferred care team.
Surely if government leaders are going to walk the talk of “patient centred” this should not happen. It would be much safer (and more efficient) to have patients able to make the choice to remain with their care team that they know and respect, regardless of location.
A few years ago, it was decided to take over the ambulance services in rural Alberta and centralize the management of it all. In our local rural communities we had an excellent ambulance service, primarily staffed and operated by dedicated long term community members. These teams were often complimented when emergency patients were taken to major centres for specialized care.
My brother had the onset of severe abdominal pain and his wife drove him to the local hospital designated by the system to be for his care. There it was determined that he needed to be transferred to an urban hospital with more diagnostic equipment. The transfer could not take place by ambulance though, because all of the local ones had been called away to respond to centrally determined needs elsewhere. His wife then drove him to that hospital herself. On arrival they had to sit for hours in the emergency department because “transfers” can only be done by ambulance. This meant he had to start from scratch to get “admitted” through the emergency department there. By the time this was achieved that Friday evening, many of the staff and specialists had left for their weekend. Monday morning he was operated on. In addition to removing the ruptured gall bladder, he had to undergo the extra treatment necessary clean up his affected abdominal cavity.
I believe the decision to centralize the ambulance management was not done with the full scope of safety for patients in mind. It likely was done to relieve some pressure in a larger urban centre at the expense of others. There was no public consultation nor explanation of how the safety of patients would be better handled or at least maintained by this centralization decision. The outcome clearly is that patient safety was not properly considered and it has been compromised in our communities. The knock-on effects of not having a system in place to accept transfers from one hospital to another of a patient with an appropriately identified emergency condition does not prioritize the patient’s safety either.
Bigger is not better for patient care, nor is it better for provider care. I believe that the political drive to huge hospitals is more about the politics of putting dollars in larger population centres than it is for the people that need care or for their providers’ well being. Focus should be to maximize effective and efficient care and that is not forcing everyone into a concentrated area. Is it any wonder that patients have a greater than 1 in 30 chance of contracting an infection when admitted to today’s larger hospitals? The decision to go big means all manners of illness are placed in the same location at close proximity to each other and treated by a commonly located team. If a restaurant or a restaurant chain had this frequency of food borne illness, the provincial health system’s inspectors would very quickly and publicly shut them down. Patient and provider safety is not top of mind when decisions are made to build huge legacy hospitals in major urban centres.
The money taken from the rest of the province to create them reduces the other areas’ ability to provide accessible care in much the same way as the ambulance example above.
If we look more closely at the providers and what is expected of them by the big system managers, more examples come to mind about misplaced priorities. New doctors go through a “right of passage” of sorts, when they are expected to work very long hours at the later stages of their training. While afterward, many joke about the challenges they faced, there is no doubt that this compromised the ability to function at the high level that is necessary to insure the best and safest work with patients. In virtually all other professions that have the responsibility for the public’s safety, (and the responsible individual’s own safety as well) this kind of work environment is against the law and the employer would be fined or face tougher penalties.
This same situation occurs with some of the shift work patterns for nurses. When Daylight Savings comes and goes each year, as members of the public the media tell us about the risk of increased accidents on our roads, and the degradation of performance at work and yet nurses regularly work shift patterns that are much more challenging to adjust to than a single hour change forward or back twice a year. The requirements switching from days to nights and back again in a short period of time cannot be very good for the health and safety of the nurses involved, or the patients they are expected to care for.
It is not clear to us whether this work pattern is the result of the government’s or the nursing union’s negotiating position but either way, it is not what could be described as a practice that has either the patient’s or the individual nurse’s safety at top of mind.
How do these policies and these practices get established and even more important, how are they perpetuated in systems that proclaim repeatedly that they are “patient centred”? Why, when good and dedicated people recognize the opportunity or need for system improvements, do they often find it so difficult and often impossible to get enough support to make things better? In other sectors, where safety culture is top of mind for everyone involved, it is a different world. Safety is absolutely the top priority and those who bring forward ideas or actions for improvement are recognized and honoured for what they do. We need to learn from this and to do what it takes to instill and maintain a true safety culture in health systems.
What we talked about here are just a few examples that show what happens to the system’s leadership, and its culture, when operating inside a monopolistic system overseen by politicians. Short term and longer term safety considerations get lost in the pursuit of political priorities, often biased toward population dense areas. Another strong impact is the pervasive political risk aversion against improvement and innovation (“stability” in politic-speak) if it has any potential perceived negative consequences to the big players involved.
What is it going to take for the fundamental changes to be made? We will talk about some of the initiatives that are being worked on and additional ideas in our next post.