| Lewis, Steven |
| Somewhere around 2050, the last registered nurse without a university degree will ride off into the sunset. Manitoba had gamely held out as the last province to retain the diploma option, but it, too has thrown in the towel. Raising entry-to-practice credentials (ETPC) in health disciplines is the new pandemic. Among recent developments: |
Sounds sensible, right? Let's examine what we've learned about this phenomenon over the years[i]. First, no one can pin down where raising the ETPC starts. Many have looked, and more knowledgeable and savvy people than I cannot trace a change back to its origins. The best guess is that the movements begin in faculty lounges or around the board tables of professional associations. While we don't know how the credential upgrade begins, we know how it doesn't. Employers never demand increased ETPC; on occasion they explicitly oppose it. No one has ever produced evidence that those practicing with the about-to-be-abandoned credential were harming the public. Governments never instigate the changes. Second, increasing the credential does not necessarily mean more training. Take the therapies. Until recently, you got to be a physiotherapist by taking a 4-year university degree in, sensibly, physiotherapy. Now you take a 2-year master's program following an undergraduate degree in anything. Same with OT - my brilliant and talented niece got her MSc on top of her architecture degree, consisting of about a year in the classroom and a year of practical experience. We are to take it on faith that we get a more capable entry-level therapist in half the time it used to take, armed with a degree that sounds more advanced. Nursing has been even more artful. First, it bid adieu to an intensive, roughly 23-month diploma program in favour of the 4-year, but less jam-packed baccalaureate program. The degree students actually spend less time in practice settings during their training. The transition to a degree-only program predictably reduced the numbers of graduates. Employers and governments grew alarmed at forecasts of a 100,000+ shortage of RNs on the horizon. No worries, responded the universities. We've got a solution. Presto - there are now 11 programs across the country that will give you a nursing degree on top of, say, a fine arts degree in 2 years! Follow the bouncing ball: two years wasn't sufficient to turn out a competent entry-level nurse fifteen years ago, but now it is again. Excellent. (Advice to students: demand a master's degree for your troubles, just like the physios and OTs. Of course, this would confuse regulators, irk nurses with 4-year baccalaureate degrees, and cause riots among nurses with real master's degrees. The physios and OTs had the good sense to eliminate the undergraduate option altogether.) Third, at least in some jurisdictions, universities, wielding their academic freedom, have acted with remarkable vigour to satisfy professions' aspirations for increased ETPC. The University of Saskatchewan - my alma mater and annual recipient of my donations, in case this essay prompts it to withdraw my degrees - decided on its own not to enrol a new class of physiotherapy students a couple of years ago, as part of its campaign to adopt the MSc as the ETPC. It somehow forgot to notify the government or obtain its permission, although it invoked the Cool Hand Luke defence. One might think the Premier or Minister of Advanced Education might have called up the President to inform him that this ringing exercise of institutional autonomy suddenly made a few million dollars vanish from the university's budget. Nah; bygones. Fourth, the ETPC movement has created subtle changes in the meaning of advanced degrees. I believe the technical term is "phoney baloney." These so-called professional master's degrees and doctorates require none of the rigour, research, or external scrutiny that used to be hallmarks of advanced education. While purveyors of these degrees acknowledge that they are different in important respects, they know full well that the public makes no such distinctions. The biggest assault on standards is where the advanced degree sits on top of an undergraduate degree in a different discipline. The master's-level PT and OT training has to be basic because no one has any grounding in the subject matter prior to entry into "graduate" studies. Fifth, no one seems to know or care about the practical consequences of raising ETPC. People will disagree about the wisdom of the nursing conversion, but shouldn't we at least be curious about the consequences? (I'm not picking on nursing here; it's just that nurses outnumber the other professions combined, so the implications are huge.) For example:
But, one might counter, even if the ETPC changes were in a sense unnecessary, there are worse sins than overeducating the health care workforce. Not so fast. One of the reasons professions raise ETPC is to increase their status and credibility in the academy. They do this in part by developing complex theory and creating specialized identities. Merging these identities into unified interprofessional teams is a challenge under any circumstances; even stronger and more fragmented identities forged in longer education programs will hardly make this easier. Furthermore, graduates with higher credentials will expect to work at a higher level and many will be disappointed and bored by the everyday but important work of patient care. All that said, there is no definitive proof that increasing ETPC has been a colossal mistake. I'm saying merely that it might have been, but we know embarrassingly little about the consequences. And if we're going to require more education for health care newbies, we need to debate the form that education should take. Too many practitioners know nothing about the social determinants of health, health systems, policy, economics, and the arts of citizenship. Maybe they need to broaden their educational horizons rather than deepen their discipline-specific identities. That nurse with a BFA and a two-year nursing degree may indeed turn out to be admirably educated for the challenges of working in a variety of contexts. But let's not confuse that prospect with the ETPC essential to making health care better. ------------------------------------------- [i]Before I get into the analysis, full disclosure: as a public representative on the Canadian Nurses Association Board of Directors in the early 1990s, I cast the lone vote against what was then known as the BN 2000 resolution. For the past 6 years I have sat on the federal-provincial-territorial Coordinating Committee on Entry to Practice Credentials (we have a gift for catchy titles). So I have been around this topic for some time, and while it cannot compete with my obsession with baseball statistics, it ranks right up there among my day job preoccupations. |
Thursday, November 5, 2009
Degrees of Separation: Do Higher Credentials Make Health Care Better?
Wednesday, October 21, 2009
What Elinor Ostrom can Teach Healthcare
| by Neil Seeman |
| Remember the "tragedy of the commons"? I learned the concept in first-year economics class at Queen's University - not in real economics class, but in the dorm room. The cleaning staff fluffed the pillows and vacuumed the carpets each Monday. Students would raze the place over the ensuing days. By Thursday the place was a pigpen. |
| We undergraduates lived the tragedy of the commons. Acting independently in our own self-interest, we destroyed the shared but limited resources of the common area: the pull-out sofa bed for out-of-town guests; the dart board; the ping pong paddles. In the hierarchy of student needs, these things ranked very highly; yet we ruined them. Why so? More typically referenced examples of the tragedy of the commons tend to involve natural resources, like fish. If everyone in a village who fishes has equal rights to eat out of the same lake, human behavior (even if everyone in the village is kind-hearted) will lead inevitably to a disappearance of stocks. How do we regulate this? Thanks to the influential article by the late biologist Garrett Hardin in Science in 1968, the paradox of the "tragedy of the commons" - Hardin used the example of herders sharing a common plot of land and then eroding its value due to individual self-interest - has flummoxed economists for the last 50 years. The tragedy-of-the-commons problem is highly relevant to not-for-profit hospitals and public sector healthcare: how do we align collective self-interest to support public goods? Elinor Ostrom, 76, one of this year's Nobel Laureates in Economic Science (shared with Oliver E. Williamson), devoted her career to cracking this riddle. A researcher at the University of Indiana and Arizona State University, Ms. Ostrom's work as a "collective action scientist" well preceded what we now call "good governance". Just as intriguing as her research is the way she went about attacking the problems she sought to solve. Practical EconomicsEconomist David Henderson has described Ms. Ostrom's Nobel as a victory for "practical economics" as opposed to abstract formulas. Public reaction to her award, as measured by my quick sentiment analysis on Twitter, the social network, has been highly positive (try this: log on to Twitter, and search for "Congrats" and "Ostrom"). (Compare this to negative sentiment, and shock, registered in response to President Obama's Peace Prize win.)Lost in the media parade over Ms. Ostrom on account of her being the first woman to win the economics Nobel has been her work itself. ("The important thing about Lin Ostrom," 2002 Nobel laureate Vernon Smith said, "is not that she is the first woman to win the prize but that she richly deserved it.") Ms. Ostrom challenged the tragedy of the commons as an absolute rule, and, upon reviewing dozens of governance case studies, discovered cases of communal ownership in poor regions that worked smoothly - i.e., where people's interests in the "commons" were aligned, and as a result the common resources did not disintegrate. Among the case studies she uncovered that worked were those that had a manner of property rights system in place, despite the lack of private ownership in the resource itself. This led her to propose a series of rules for governing commonly pooled resources. These included the idea that rules should clearly define: who gets what; good conflict resolution methods; that people's obligations to keep the resource in good condition be proportional to the benefits they reap from the resource; that monitoring and punishing be done by the users or someone accountable to the users; and that users should be allowed to participate in setting and modifying those rules. The Power of the Case StudyOne lesson to be had from Ms. Ostrom's work is the power of case studies. Her practical case-study approach and field work led her to attack the paradox of the tragedy of the commons methodically, and in ways that economic theory never could.In real life, Ms. Ostrom found, the tragedy of the commons theory did not unfold the same way all the time. She examined user-managed fish stocks, pastures, woods, lakes, and groundwater basins. Some common resources were overused and depleted, but some were managed well. She set forth her findings in her 1990 book, "Governing the Commons." What is the secret to successful management of the commons? "One of the most important factors is whether local people monitor each other," Ms. Ostrom said in a news conference after her award was announced. "Not officials, locals. I'm not denigrating that officials can do something very positive. But what we have ignored is what citizens can do, and the importance of real involvement of the people involved…". This, to me, sounds like a good argument for involving every responsible citizen who consumes publicly funded health care to formulate its ethics and rules. In a word: engagement. About the Author Neil Seeman is a writer, and Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College at the University of Toronto. |
Monday, August 10, 2009
The End of Healthcare Consultese?
By Neil Seeman
A new motion passed unanimously by the British Medical Association urges the NHS to scrap management jargon. For example, physicians have been asked to use “patient” and ditch “client” and “service user.”
People who thirst for plain English in healthcare and in all service sectors – I count myself among them – have been losing this battle. In a journal article in 1994, Richard Peck described the then-“adjectival All-Star” of healthcare: “seamless.” He wrote: “Virtually no one attending a healthcare conference in the ‘90s will avoid hearing the word “seamless” at least a few times. It is the Holy Grail of would-be managers of the healthcare system, an ideal: patients moving effortlessly from one level of care to another, as necessary and without a hitch – without doubt, without misadventure …”.
Fifteen years later, “seamless” still reigns. According to the British Medical Association, management-speak dehumanizes health professions: “performer” (aka “doctor”); “efficiency savings and disinvestments” (aka “budget cuts”); and “service user” instead of “patient.” The UK-based Plain English Campaign promotes clear language in all public communications, noting that language confusion among doctors and patients can be a life-or-death issue.
The Plain English Campaign states: “Since 1979, we have been campaigning against gobbledygook, jargon and misleading public information. We have helped many government departments and other official organizations with their documents, reports and publications. We believe that everyone should have access to clear and concise information in plain English.”
Some NHS hospitals and trusts have received the Plain English Campaign’s annual Crystal Mark for clarity, while other institutions have been shamed with its opposite, the “Golden Bull” award. The Campaign’s medical writing course teaches “writing short sentences; using bullet points; being ‘active’ not ‘passive’; and using verbs to emphasize action.” Sessions feature lessons on how to craft hospital appointment letters and patient information leaflets.
What People Want
There are legitimate arguments against so-called “plain language”: sometimes what is straightforward to one is offensive to another (e.g., the word “blind”); hence words such as “non-sighted” emerge. Language, especially English, is like an arctic floe – slow and serene, and then disruptive. This year Miriam-Webster added many jargon-laden words that address concerns about the environment (carbon footprint), medicine (cardioprotective), pop culture (flash mob), and, in particular, online activities (sock puppet, vlog, webisode).
Given the natural drift of language, especially in healthcare, can we learn from patients to determine which words they prefer? I think so.
We can learn from online analytics – looking at the actual language people use every day – found in millions of postings scattered on the World Wide Web. When talking about their real healthcare experiences, people describe themselves as “patients” about five times more frequently than as “consumers”; and people call themselves “consumers” about seven times as much as they call themselves “clients”.
Most of the objections to the word “patient” seem to come from academics who decry the supposed paternalism associated with the word; or from those who prefer “consumer” on principle – they don’t like the “medical model” of health. My interpretation: Regular people overwhelmingly prefer “patient”.
This is just one example, and not scientific. (For what it’s worth, this approach seems to confirm small studies. In one such study, 75% of 133 people in community care preferred to be called “patient” by their GP – vs. “client” or “service user”. In another study, the author surveyed 101 people attending a back-pain clinic and found that 74 preferred “patient.”)
Words such as “client” and “consumer” and “service user” have been thrown about in conferences and vision statements for many years, but they don’t stick with the public. When a word doesn’t stick, we should shelve it.
It would be helpful if dictionaries would expunge stale meanings with the same vigour with which they embrace new ones year after year. Then, perhaps, the experience of patients everywhere might be a bit more seamless.
About the Author
Neil Seeman is a writer and Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College at the University of Toronto.
A new motion passed unanimously by the British Medical Association urges the NHS to scrap management jargon. For example, physicians have been asked to use “patient” and ditch “client” and “service user.”
People who thirst for plain English in healthcare and in all service sectors – I count myself among them – have been losing this battle. In a journal article in 1994, Richard Peck described the then-“adjectival All-Star” of healthcare: “seamless.” He wrote: “Virtually no one attending a healthcare conference in the ‘90s will avoid hearing the word “seamless” at least a few times. It is the Holy Grail of would-be managers of the healthcare system, an ideal: patients moving effortlessly from one level of care to another, as necessary and without a hitch – without doubt, without misadventure …”.
Fifteen years later, “seamless” still reigns. According to the British Medical Association, management-speak dehumanizes health professions: “performer” (aka “doctor”); “efficiency savings and disinvestments” (aka “budget cuts”); and “service user” instead of “patient.” The UK-based Plain English Campaign promotes clear language in all public communications, noting that language confusion among doctors and patients can be a life-or-death issue.
The Plain English Campaign states: “Since 1979, we have been campaigning against gobbledygook, jargon and misleading public information. We have helped many government departments and other official organizations with their documents, reports and publications. We believe that everyone should have access to clear and concise information in plain English.”
Some NHS hospitals and trusts have received the Plain English Campaign’s annual Crystal Mark for clarity, while other institutions have been shamed with its opposite, the “Golden Bull” award. The Campaign’s medical writing course teaches “writing short sentences; using bullet points; being ‘active’ not ‘passive’; and using verbs to emphasize action.” Sessions feature lessons on how to craft hospital appointment letters and patient information leaflets.
What People Want
There are legitimate arguments against so-called “plain language”: sometimes what is straightforward to one is offensive to another (e.g., the word “blind”); hence words such as “non-sighted” emerge. Language, especially English, is like an arctic floe – slow and serene, and then disruptive. This year Miriam-Webster added many jargon-laden words that address concerns about the environment (carbon footprint), medicine (cardioprotective), pop culture (flash mob), and, in particular, online activities (sock puppet, vlog, webisode).
Given the natural drift of language, especially in healthcare, can we learn from patients to determine which words they prefer? I think so.
We can learn from online analytics – looking at the actual language people use every day – found in millions of postings scattered on the World Wide Web. When talking about their real healthcare experiences, people describe themselves as “patients” about five times more frequently than as “consumers”; and people call themselves “consumers” about seven times as much as they call themselves “clients”.
Most of the objections to the word “patient” seem to come from academics who decry the supposed paternalism associated with the word; or from those who prefer “consumer” on principle – they don’t like the “medical model” of health. My interpretation: Regular people overwhelmingly prefer “patient”.
This is just one example, and not scientific. (For what it’s worth, this approach seems to confirm small studies. In one such study, 75% of 133 people in community care preferred to be called “patient” by their GP – vs. “client” or “service user”. In another study, the author surveyed 101 people attending a back-pain clinic and found that 74 preferred “patient.”)
Words such as “client” and “consumer” and “service user” have been thrown about in conferences and vision statements for many years, but they don’t stick with the public. When a word doesn’t stick, we should shelve it.
It would be helpful if dictionaries would expunge stale meanings with the same vigour with which they embrace new ones year after year. Then, perhaps, the experience of patients everywhere might be a bit more seamless.
About the Author
Neil Seeman is a writer and Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College at the University of Toronto.
Tuesday, August 4, 2009
Bird Flu, Mad Cow Disease, and other Biological Plagues of the 21st Century
Andrew Nikiforuk
On October 17, 2004, a Thai smuggler wrapped the two small crested eagles from Tibet in cotton cloths. Then he placed each bird into a 60-centimetre (24-inch) wicker tube, making sure the raptors had room to breathe. With the tubes hidden in his hand luggage, the avian transport boarded Eva Airways Flight BR0061 from Bangkok to Vienna, along with 128 other jet-setters.
The smuggler was on a business trip. A Belgium falconer had ordered the birds for $17,000 and the avian entrepreneur had promised to make the delivery in Antwerp. But a random drug check at Zaventern airport in Brussels uncovered the illicit cargo. Given that bird flu had already killed 32 peasants and chicken handlers that year as well as millions of chickens and 83 tigers at Thai zoos, customs officials quarantined the birds and tested them. When both eagles proved positive for H5N1, authorities slaughtered 700 parrots and canaries in quarantine facility. Authorities then tracked down the smuggler (importing diseased species is not a crime) and put him in an isolation ward at the Antwerp University hospital for four days. The veterinarian who tested and killed the infected eagles developed conjunctivitis, a common flu symptom, just two days later. Doctors put his entire family on anti-viral drugs. "We were very, very lucky," admitted Renee Snacken at Belgium's Scientific Institute of Public Health in Brussels. "It could have been a bomb for Europe."
See: More.
On October 17, 2004, a Thai smuggler wrapped the two small crested eagles from Tibet in cotton cloths. Then he placed each bird into a 60-centimetre (24-inch) wicker tube, making sure the raptors had room to breathe. With the tubes hidden in his hand luggage, the avian transport boarded Eva Airways Flight BR0061 from Bangkok to Vienna, along with 128 other jet-setters.
The smuggler was on a business trip. A Belgium falconer had ordered the birds for $17,000 and the avian entrepreneur had promised to make the delivery in Antwerp. But a random drug check at Zaventern airport in Brussels uncovered the illicit cargo. Given that bird flu had already killed 32 peasants and chicken handlers that year as well as millions of chickens and 83 tigers at Thai zoos, customs officials quarantined the birds and tested them. When both eagles proved positive for H5N1, authorities slaughtered 700 parrots and canaries in quarantine facility. Authorities then tracked down the smuggler (importing diseased species is not a crime) and put him in an isolation ward at the Antwerp University hospital for four days. The veterinarian who tested and killed the infected eagles developed conjunctivitis, a common flu symptom, just two days later. Doctors put his entire family on anti-viral drugs. "We were very, very lucky," admitted Renee Snacken at Belgium's Scientific Institute of Public Health in Brussels. "It could have been a bomb for Europe."
See: More.
Monday, July 27, 2009
Unintentional Observations about Poker and Pandemic Planning
Two weeks ago. Visit my own clinic and am stopped at the front door, separated from staff by a two metre glass wall. Questions. "Do I have a fever, cough or sore throat?" Signage reinforces the interrogator. "No". A sanitizer dispenser is right in front of me. "Please clean your hands and go on in." I am monitored as I follow her instructions.
One week ago. Visit the lab at my own clinic. Its a repeat performance. Stopped at the front door I was separated from staff by a two metre glass wall. Questions. "Do I have a fever, cough or sore throat?" Signage reinforces the interrogator. "No". A sanitizer dispenser is right in front of me. "Please clean your hands and go on in." I am monitored as I follow her instructions. Consistent. I appreciate the diligence.
Yesterday. Accompany an adult to a three-physician practice. No signage, no sanitizer, no questions. Doctor shakes my hands and we chat. He joins the patient in his office. I wonder about the patient who just came out of his office.
Yesterday. Accompany the same adult to a lab - one of many outlets of a very large corporation. Lots of pandemic related signs -- I count at least three on the counter alone -- saying: Stop - Clean Your Hands. One sign asks about symptoms: If you have a cough or shortness of breath (especially if new) - please report and wear a mask. At least 22 other people walk in while I wait. Just two people use the obvious bottle of sanitizer. The crowd includes a young father with a three-day-old child. The visit, the father tells me later, is for the child. No preferential treatment provided. No one from staff asks any one any questions about their general health. Or their throats or coughs. No one is monitored to see if they sanitize their hands. One lab technician is wearing a plastic face shield. Two others are not. Everyone who enters stands in front of the signs to announce their arrival and is told to take a "number" -- a piece of plastic about the size of a Bicycle Poker Card. Everyone does. The baby is in arms as dad holds the card. [Gee they are beautiful at that age and dad is doing a pretty good job despite her fussiness.]
One man (about 75 years old) sits and waits, keeps coughing one of those deep gurgling coughs. He tries to stifle them and turns his face to the right. Now his seat mate is in the direct line of fire. A few times he puts his right hand to his mouth as he coughs. In this same hand he is holding his "poker card." His plastic poker card. When his number comes up he walks to the counter and returns it to the card dispenser - ready for the next patient. Glad he didn't leave before the baby arrived.
Beside me is a play area for children. It's mostly full of red, yellow and green blocks but no children. Good thing. I can imagine where each one of those blocks would be if there were children in there. I silently dub this the little spittle flu box.
The patient with me is done. We leave and decide to walk down the stairs. The elevator is half full. Full enough. No need to play the odds.
Share your own stories here.
One week ago. Visit the lab at my own clinic. Its a repeat performance. Stopped at the front door I was separated from staff by a two metre glass wall. Questions. "Do I have a fever, cough or sore throat?" Signage reinforces the interrogator. "No". A sanitizer dispenser is right in front of me. "Please clean your hands and go on in." I am monitored as I follow her instructions. Consistent. I appreciate the diligence.
Yesterday. Accompany an adult to a three-physician practice. No signage, no sanitizer, no questions. Doctor shakes my hands and we chat. He joins the patient in his office. I wonder about the patient who just came out of his office.
Yesterday. Accompany the same adult to a lab - one of many outlets of a very large corporation. Lots of pandemic related signs -- I count at least three on the counter alone -- saying: Stop - Clean Your Hands. One sign asks about symptoms: If you have a cough or shortness of breath (especially if new) - please report and wear a mask. At least 22 other people walk in while I wait. Just two people use the obvious bottle of sanitizer. The crowd includes a young father with a three-day-old child. The visit, the father tells me later, is for the child. No preferential treatment provided. No one from staff asks any one any questions about their general health. Or their throats or coughs. No one is monitored to see if they sanitize their hands. One lab technician is wearing a plastic face shield. Two others are not. Everyone who enters stands in front of the signs to announce their arrival and is told to take a "number" -- a piece of plastic about the size of a Bicycle Poker Card. Everyone does. The baby is in arms as dad holds the card. [Gee they are beautiful at that age and dad is doing a pretty good job despite her fussiness.]
One man (about 75 years old) sits and waits, keeps coughing one of those deep gurgling coughs. He tries to stifle them and turns his face to the right. Now his seat mate is in the direct line of fire. A few times he puts his right hand to his mouth as he coughs. In this same hand he is holding his "poker card." His plastic poker card. When his number comes up he walks to the counter and returns it to the card dispenser - ready for the next patient. Glad he didn't leave before the baby arrived.
Beside me is a play area for children. It's mostly full of red, yellow and green blocks but no children. Good thing. I can imagine where each one of those blocks would be if there were children in there. I silently dub this the little spittle flu box.
The patient with me is done. We leave and decide to walk down the stairs. The elevator is half full. Full enough. No need to play the odds.
Share your own stories here.
Monday, June 8, 2009
Why consultants use PowerPoint … and other pearls of wisdom from 26 years in the healthcare management consulting industry.
Neil Seeman interviews Neil Stuart . . .
Why consultants use PowerPoint …
With a newly minted PhD in health policy from Brandeis University, Neil Stuart joined Price Waterhouse as a fresh-eyed consultant in 1983. “It seemed like a good place to be for a short while – I’d learn a lot and maybe figure out how I could get a ‘real job’.” Twenty-six years later he would emerge as one of Canada’s most respected strategic advisors and health policy visionaries. The world of consulting has changed dramatically since 1983, Neil Stuart recently told a large gathering of former colleagues, clients, and mentees upon his retirement from IBM Canada’s healthcare consulting practice. (We would have needed a Hubble-powered fisheye lens to jam every well-wisher there into a single photograph).
1. How would you define the business of “healthcare consulting”?
Neil Stuart: “Any consulting to health care organizations that in some ways is about the business of health care or health care delivery – assisting with studies, plans, reviews, evaluations, solving problems, designing or implementing new approaches.”
2. What sorts of character traits make somebody well-suited to the healthcare consulting business? Who is not suited for it?
Neil Stuart: “To be a good consultant, exceptional analytical, problem-solving and communication skills are essential. But the thing that really distinguishes a great consultant from the rest is an ability to see things from the client’s perspective to understand their issues – the consultant who really figures out what the client is looking to deal with and focuses their energies and imagination on this. In my experience, one of the most common scenarios for consulting jobs getting off track is when a consultant gives a client something they did not ask for or sets out to solve the wrong problem.
If someone is the kind of person who already has the answer or who is “on a mission”, they might find consulting a frustrating path to take.”
3. How has the business changed over the last 25 years – for the better, and for the worse?
Neil Stuart: “The big consultancies have become much more sophisticated with well developed consulting methodologies and more refined tools for running their business. Twenty-five years ago, consultants were more likely to be ‘flying by the seat of their pants’. The contracts and scale of projects have grown too. A lot more of the work is related to information technology. Twenty-five years ago much of what consultants did was advisory in nature, e.g. reviews that led to recommendations. Today, there is much more hands-on work with bigger projects where consultants are involved in building and implementing large solutions and helping to manage associated change processes.
With bigger consulting projects, bigger teams and bigger practices, the roles in these consulting practices have become more specialized – with some individuals focused just on selling consulting work, some on project management, some on change management, some on process redesign, some on IT architecture and so on.”
4. How do these changes affect how and when healthcare organizations should hire consultants?
Neil Stuart: “Health care organizations need to be clear on why they need the help of a consultant. Is it for an independent or expert opinion? Is it to do a job for which they lack the specialized resources internally? Is it because they are in ‘trouble mode’ and need outside help? There are many different kinds of consultants and consulting skill sets. Health care organizations should make sure they are clear on what they are looking for and be sure to hire the consultant or consulting team that can meet their needs. If in doubt, would-be clients should check with others who have used consultants recently for similar work and learn from them.”
5. How do you respond to the critics of healthcare IT consulting who complain about some projects going over-time and over-budget?
Neil Stuart: “More often than not these situations could have been avoided if there was greater clarity on the project requirements. It is true that some times when consultants are competing to win projects, they can over-promise. This is where the client has to be crystal clear on what they are looking for and what they are contracting for.
In the case of IT related projects, it is really important that there be a clear focus on the health care benefits of the IT. There must be meaningful business reasons for introducing new IT. The health care leaders (not just the people in the IT group) must be involved in and driving these initiatives. They have to believe that health care itself will be improved by the IT. And as the IT solutions are being designed, built and implemented there must be an overriding emphasis on realizing these health care benefits.
Ontario is currently poised to try a very different approach to procuring large e-health solutions. They are looking to Infrastructure Ontario to help channel such procurement through consortia that include the IT vendors and consultants, but also include a party who will finance the project. They have called this approach Alternative Financing and Procurement (AFP). It offers a way of addressing many of the risks traditionally associated with big IT initiatives.”
6. In all your years as a trusted advisor to healthcare leaders, what qualities do you think make the best leaders shine?
Neil Stuart: “Vision, an ability to inspire their team, a grasp of the critical strategic issues – all have to be at the top of this list. Many of these qualities touch on being able to anticipate new opportunities and mobilize organizations to prepare for the future.”
7. What qualities make for dysfunctional healthcare leadership?
Neil Stuart: “Maybe the biggest pitfalls lie in becoming too focused on the narrow interests of one’s own health care organization and losing sight of what is good for patients and what the bigger health care system needs to be taking on.”
8. Why do consultants use PowerPoint presentations so often? Will the madness end?
Neil Stuart: “You have a point – no pun intended. PowerPoint has been a great tool to help consultants quickly summarize their analyses and findings and pull together a presentation. But PowerPoint can also be a real handicap if people rely on decks that are just an amalgam of slides originally prepared for other purposes. And there are some downsides in getting caught presenting from slides someone else has prepared. PowerPoint is often a used as shorthand to frame a richer, more detailed story. The presenter has to have the story and if they don’t, PowerPoint will not give it to them.”
9. What was your best experience as a management consultant and leader in the industry?
Neil Stuart: “Consulting gives one an opportunity to assist client organizations at some of their most exciting and formative moments, as well as sometimes their most vulnerable moments. Consulting can sometimes give one an opportunity to contribute to breakthrough changes and real innovation. This can be very fulfilling. But the consultant’s role is often beneath the radar. It will always be the executives in the health care organizations, or sometimes government, who own the initiative and deservedly wear the success.”
10. Would you recommend consulting as a career or even a career step for a young professional entering the health care world?
Neil Stuart: “Absolutely, I can think of no other place a fresh MBA or MHA graduate could go where they could get the same variety of experience, the insights, the chance to be part of so many innovative projects, to be in an environment that so values learning, and (if they are good) to move ahead so fast.”
Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College, University of Toronto.
Neil Stuart may be reached at: neil.stuart@sympatico.ca
Wednesday, June 3, 2009
This Just In: Systems Designed to Fail, Fail
By Steven Lewis
First there is the disaster that comes to light long after the fact. Then there is the inquiry. Then there is the scathing report that meticulously unearths the causes of the disaster. Then there is the apology (they’re allowed now – it’s the law!). Then there is restitution. Finally there is the commitment: never again. And then the same thing happens, somewhere else, again, and again, and again.
Canadian medicine – it is quite different in some other jurisdictions – is organized around four fundamental premises. First, doctors are highly trained professionals whose license to practice needs no expiry or renewal date. Second, initial certification exams are reliable guarantors of lifelong competence and consistent, high quality practice. Third, it is both unnecessary and unsporting to subject the autonomous judgments of professionals to rigorous and regular scrutiny. Fourth, professional self-regulation is the ideal mechanism for preventing harm.
To quality improvement and harm reduction experts in every other industry, these premises are not merely dubious, but laughable. Yet they persist in medicine, and the inevitable result is that people get hurt. Radiology and pathology are high-stakes diagnostic professions where errors can kill. When massive failures occur, as in the Newfoundland and Labrador breast cancer testing debacle of 1997-2005 (!), or the Charles Smith forensic pathology fiasco of 1981-2005 in Ontario (!), the root causes turn out to be depressingly pedestrian. That’s what makes them as pathetic as they are tragic.
Even more damning is the repetition. The lid has just come off Quebec’s breast cancer diagnostic breakdown. Saskatchewan is cleaning up after a pathologist who may have put thousands of people at risk over 5 years. It will cost millions of dollars to have every one of his 70,000 images reread out of province, and perhaps tens of millions to settle the malpractice claims (the notorious Regina lawyer Tony Merchant has already launched a class action suit). The only difference between these jurisdictions and those so far untouched by the contagion is that the time bombs are on different schedules.
Despite the repeated revelations of system errors that demand system solutions, nothing has fundamentally changed to guarantee safer health care and prevent the birth of gestating misadventures. When push comes to shove, the right to practice shoddy medicine trumps public safety; no one gets to cancel the flight or shut down the assembly line without definitive proof of repeated incompetence. A health region or regulatory body that moves aggressively to suspend a practitioner pending investigation of suspicious results will be harassed and condemned for violating due process. The first reflex will not be to acknowledge the problem or seek mentorship; it will be to lawyer up. The medical association with go to bat to keep the practitioner in the saddle. Physicians and others in the know who would not send their own kids to an incompetent colleague either can’t or won’t stop yours from ending up in his care.
It’s not just a conspiracy between the guilds and the law; it’s a systematic failure to manage risk. Built in redundancy, rigorous peer review, structured continuing education, and mandatory recertification are cornerstones of safety. The higher the stakes, the greater the need for vigilance and tightly organized quality control systems. Geographically isolated professionals are obviously at risk, and many will fail without carefully designed, reliable supports in place. But everyone needs audit, feedback and peer support to perform reliably over time. In medicine it is well-documented that performance declines with age. The response to this chilling reality has been to let the chips fall where they may – the pathology of denial.
The Saskatchewan case is especially instructive. There were suspicions about the radiologist’s competence 3 years ago. With the regulatory noose tightening around his neck, he volunteered to go for remedial education. No educational program in western Canada stepped up to the plate. After he spent 3 months at McMaster, the Saskatchewan College received a perfunctory and brief report on his progress and skills that it rejected as inadequate. He returned to practice, and on the evidence to date, his interpretation of every 20th image may have put someone at risk.
The system is designed to fail, and it must be redesigned to succeed. The solution is not to expect physicians to look furtively over their colleagues’ shoulders and snitch to the authorities. The remedies must be systemic, obligatory, and woven into the fabric of medical education, ethics, and organization. Among the obvious requirements are:
- Mandatory review of randomly drawn samples of diagnostic interpretations. The frequency and intensity of the scrutiny should be commensurate with the complexity of the practice, known error rates, and the consequences of mistakes.
- A formal, standardized protocol for addressing competency problems. The first signs of problems should trigger mandatory supervision and intensified case reviews until performance is demonstrably up to snuff.
- Beyond certain thresholds of error, automatic suspension followed by the launch of a remediation algorithm.
- Specific additional support, review, and continuing competency assurance procedures for isolated practitioners.
- Transparent reporting to the public of performance results.
It is delusional to believe that everything is now out in the open, with nothing more to uncover. It’s not just the outliers who cause harm; because medicine is so fraught with unjustifiable variations in practice, it is certain that the errors resulting from “satisfactory” practice far outnumber the misdeeds of the visibly incompetent. The graveyards are filled with anonymous victims whose stories will never surface in a public inquiry. Until professionals take their collective obligations seriously and embrace a culture of safety, prevention will fail, detection will be late, and the victims will pile up. If they view peer review, recertification, and remediation as violations of sacred entitlements, sleepwalking through mandated processes won’t accomplish much.
Sad to say, for radiology and pathology our salvation may come from machines. It is foreseeable that computerized pattern recognition software will be able to diagnose more accurately and consistently than specialists in all but the most unusual of cases. If that day comes, we can be sure that these highly reliable machines will be programmed to self-diagnose and identify anomalies in their own findings and performance at regular intervals, and will be examined, refurbished, and re-tested according to strict protocols. In other words, we will treat them and their needs with care and respect, governed by the duty to put patients first. Too bad that we don’t do the same for fallible diagnosticians and their victims.
Subscribe to:
Posts (Atom)
Posts
