Monday, September 5, 2016

Solving Healthcare Problems 101, Part II

Who should we turn to if we want smart public policies in health care?

As I noted last time, health care systems, even at the local hospital level, are preposterously complex and interdependent. It's all too easy to lose sight of how changing practice in one place can affect resources somewhere else. Sure, it's not hard to figure out that reserving an operating room for urgent cases might increase wait times for hernia repairs. But that pricey bedside blood test could shave hours off the lab's turnaround time for other tests, or do a better job of predicting who needs a CT scan and who doesn't. In the never-ending quest to contain health care costs, these are policy decisions that can't be ignored but are easy to miss.

Governments tend to tackle these matters in one of two ways: 100% internally, or 100% externally, through a (very well) paid consultant. These approaches are almost always wrong.

When decisions around policy are made inside ministries or large administrative departments, there's almost never a way to determine how those decisions are reached or even who's reaching them. Stonewalling and doublespeak are de rigeur towards journalists and stakeholders alike, and "consultation" is only for show - the policy is more often than not presented as a done deal, with negotiation room for minor tweaking at best. Given the cloistered, hierarchical culture of large ministries, conformity is mistaken for consensus, with the resulting decisions tainted by groupthink.

And consultants? Consultants definitely have a part to play in the public sector. You wouldn't task a team of nurses or doctors with implementing a new e-mail system, nor spearheading a public relations campaign. Even the most gifted health professional has only so broad a range of expertise.

But what do we see instead? Consultants hired to craft and sell staff on strategic plans - whatever that's supposed to mean for a cash-strapped, overcapacity health care facility - or worse, to analyze systems and processes, then recommend ways to change the way staff go about their work.

Let's set aside that most of these business-school schemes have their origins in the manufacture of inanimate objects. Is there anything more insulting to highly educated, front line professionals? To have a total stranger tell them how to work with patients, or what their priorities need to be? Oh, and be paid a good deal more than everyone in the room except perhaps the doctor? Would parents put up with this in schools? Why is it perfectly acceptable practice in a hospital?

In order to properly address a complicated problem, you need a variety of opinions from diverging perspectives. No, not everybody should be invited to the table, but you need representation from people with credibility among their peers. If you want to hire an outside consultant to facilitate these sorts of initiatives, that's a good use of outside expertise. So who needs to be at the table?

Front line workers. If it's a hospital clinic, you need a doctor, a nurse, and a clerical worker. If it's a public health department, you need nurses from the applicable team.

Administration/Management/Government. This is obviously dependent on the situation and the level of the issue being addressed. Even the most basic, sensible ideas around reorganizing services have bureaucratic implications and hiccups to implementation, not only financial. Someone needs to know how the gears turn to decide if a plan is feasible.

Big-picture Perspective. I don't mean the CEO or a Board member, but somebody whose body of knowledge complements those on the front lines. This is someone like a staff epidemiologist or a partnering researcher. There isn't much to be gained from devoting hundreds of man-hours to fix something that isn't a high priority. There's nothing wrong with restricting tanning bed use to prevent skin cancer, but how many lives is it claiming as compared with smoking?

Historical Perspective. Want to understand a system problem? Start with how you ended up in the situation you're in. In many instances - say, a problem in a hospital department - staff will have this knowledge and you don't need an extra person. If it's a major system overhaul - say, restructuring how regional health authorities are funded - there needs to be someone able to tell if the rationale for a policy is still relevant...or if it's nothing more than an accident of history.

Small-picture Perspective. You could convene a meeting with the world's leading authorities on pandemics, the most dedicated nurses on Earth, and the most experienced doctors in their field, facilitated by the most esteemed master of teamwork theory, and still miss the impact of an action plan on individuals. Doctors and nurses rarely see how patients live their daily lives, nor interact with their loved ones outside the exam room. Administrators rarely grasp how scaling back mental health services might land a schizophrenic man on the streets or in jail. These anecdotal effects of policy decisions matter, and often matter more than the big-picture numbers. Where can you find this sort of intimate knowledge to challenge policymakers? Possibly from a patient advocate or ombudsperson, though there's a real risk of antagonism from the word go. Conflict is needed to make sound decisions, but not animus.

Here's a wild idea: invite a freelance journalist to join a task force - someone who might not have answers, but should know how to ask pointed questions, and assemble the facts and details into a coherent narrative or picture. The objective isn't an exercise in media relations, transparency, or spin. Rather it's about getting a wholly different perspective than insiders might possess, a lens on the impacts of health policy decisions that won't be reflected in the numbers. Maybe interviewing users of a needle-exchange program will confirm whether it's working as intended. Maybe a new toy set or white noise machine is lowering the level of agitation in the pediatric waiting room. There are intangible impacts to everything we do in health. Let's look for them in the planning stages instead of putting out fires down the road.

Next time: the nitty-gritty of implementation

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