How Hockey Can Save Healthcare

A Principle-Based Approach to Reforming the Canadian Healthcare System

Stephen Pinney, MD

Lulu Publishing, 2016

Reviewed by Chris Carruthers, MD

BOOK REVIEW

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Dr. Pinney is an orthopedic surgeon who graduated from McGill medical school in 1991. He practised academic surgery in the United States until August 2010, when he was recruited as the head of orthopedic surgery at St. Paul’s Hospital in Vancouver. After only two years, he returned to the US. This book reflects his discouragement with the Canadian health care system, his insights, and his suggestions on how to improve it. He uses hockey as an analogy, comparing the principles and commitments required to run a professional hockey team and the health care system.

 

Like a successful hockey team, a successful health care system has to set clear goals, select and use players to achieve the best outcomes, closely measure the results, and make changes, including changes in personnel, based on overall performance. The goals of individual hockey players are subordinate to those of the team. Substituting doctors for hockey players, Dr. Pinney discusses how this is not what is happening in the Canadian health care system.

 

In the five years between Dr. Pinney’s departure from Vancouver and the publication of his book, we have improved in several areas, but because we have not progressed far enough, many of his suggestions remain important today. Although he recognizes that Canadians pay a lot for a mediocre system, he also supports a publicly funded health care system with universal coverage. He does not promote an American-style system, but he does suggest that Canadians look at some of the systemic benefits of that system.

In Canada, Dr. Pinney quickly became frustrated with the barriers to practising efficiently and effectively and with the inability to change the system. One colleague said to him, “After 18 months, you will understand the system and you just need to determine if you can tolerate it for the rest of your career.”

 

He met and worked with other health professionals, but they were also trapped in a dysfunctional system. He highlights fragmented care, absence of valid and useful outcome metrics, and the lack of competition and accountability. He criticizes the fact that patients seeing their family doctor are only allowed one complaint at a time.

 

Dr. Pinney does not hesitate to criticize the medical profession’s shortcomings and resistance to change, which affect the performance of the system. For example, the lack of competition and accountability ensures that poorly performing physicians retain their positions year after year.

 

He also mentions, “lack of clinician input into hospital budgeting was one of the most surprising and disappointing features I observed.” He refers to fragmented payments for titled positions that physicians hold, payments that are often referred to as “shut up” money that buys silence from physicians and allows administrators to be in control. For these and other reasons, he supports physicians developing leadership skills to participate in system change.

 

Comparing health care to hockey, he writes, “There is no head coach to coordinate the team, and if there is a general manager, he or she is likely completely disconnected from what is happening.” He suggests that teams need clear goals and must work together to achieve these patient-centred goals and accurately measure and pay for results. He notes the lack of a single entity with the power to change the system and with accountability, particularly to population health metrics.

 

Dr. Pinney supports bundled payments, which is an effective way of paying for outcomes. This is a trend in the US, but has yet to be introduced in Canada. In Canada, bundling physicians’ payments into an overall payment would be met with significant resistance.

 

In Canada, Dr. Pinney identifies what he calls toll booths. For example, he cites the case where every year the anesthesia department in his hospital stated what days they would be available and what days they could not cover because of vacations. He finds this “toll booth” unacceptable.

 

Another good analogy is the 2 September 1972 Canada–Russia hockey game. Canada was outclassed; the teamwork of the opposing team was what defeated Canada. This loss lead to disruptive innovation in Canadian hockey. It took a generation for the changes to be implemented, but Canada became competitive and won.

 

Some key learning points:

  1. Facilities need to be customer centered.
  2. Competition should drive the performance of healthcare facilities.
  3. Cleanliness is the canary in the coal mine.
  4. Equipment and physical plans must be kept up-to-date.
  5.  Facilities require strong leadership and skilled management teams.
  6. Facilities must be financially viable.” His emphasis on competition is important. This has been contemplated for years in the Canadian system, but only timidly introduced.

 

Finally, a key point Dr. Pinney makes is how change will occur: evolutionary or disruptive. He supports a disruptive approach. Perhaps, we are seeing disruption today, driven by financial reality.

 

This is an excellent book. Chapter 8 is the key chapter that outlines the principles for running a successful health care system in Canada. If you only have time to read one chapter read this one.

 

My disappointment is that it would have been an advantage to the Canadian health care system if Dr. Pinney had remained in Canada to be a champion of change.

 

Author

Chris Carruthers, MD, is a consultant. He was founding president of the Canadian Society of Physician Leaders and the first winner of its award of excellence, which is named after him.

 

Correspondence to: ccmd@rogers.com

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Dr. Pinney is an orthopedic surgeon who graduated from McGill medical school in 1991. He practised academic surgery in the United States until August 2010, when he was recruited as the head of orthopedic surgery at St. Paul’s Hospital in Vancouver. After only two years, he returned to the US. This book reflects his discouragement with the Canadian health care system, his insights, and his suggestions on how to improve it. He uses hockey as an analogy, comparing the principles and commitments required to run a professional hockey team and the health care system.

 

Like a successful hockey team, a successful health care system has to set clear goals, select and use players to achieve the best outcomes, closely measure the results, and make changes, including changes in personnel, based on overall performance. The goals of individual hockey players are subordinate to those of the team. Substituting doctors for hockey players, Dr. Pinney discusses how this is not what is happening in the Canadian health care system.

 

In the five years between Dr. Pinney’s departure from Vancouver and the publication of his book, we have improved in several areas, but because we have not progressed far enough, many of his suggestions remain important today. Although he recognizes that Canadians pay a lot for a mediocre system, he also supports a publicly funded health care system with universal coverage. He does not promote an American-style system, but he does suggest that Canadians look at some of the systemic benefits of that system.

In Canada, Dr. Pinney quickly became frustrated with the barriers to practising efficiently and effectively and with the inability to change the system. One colleague said to him, “After 18 months, you will understand the system and you just need to determine if you can tolerate it for the rest of your career.”

 

He met and worked with other health professionals, but they were also trapped in a dysfunctional system. He highlights fragmented care, absence of valid and useful outcome metrics, and the lack of competition and accountability. He criticizes the fact that patients seeing their family doctor are only allowed one complaint at a time.

 

Dr. Pinney does not hesitate to criticize the medical profession’s shortcomings and resistance to change, which affect the performance of the system. For example, the lack of competition and accountability ensures that poorly performing physicians retain their positions year after year.

 

He also mentions, “lack of clinician input into hospital budgeting was one of the most surprising and disappointing features I observed.” He refers to fragmented payments for titled positions that physicians hold, payments that are often referred to as “shut up” money that buys silence from physicians and allows administrators to be in control. For these and other reasons, he supports physicians developing leadership skills to participate in system change.

 

Comparing health care to hockey, he writes, “There is no head coach to coordinate the team, and if there is a general manager, he or she is likely completely disconnected from what is happening.” He suggests that teams need clear goals and must work together to achieve these patient-centred goals and accurately measure and pay for results. He notes the lack of a single entity with the power to change the system and with accountability, particularly to population health metrics.

 

Dr. Pinney supports bundled payments, which is an effective way of paying for outcomes. This is a trend in the US, but has yet to be introduced in Canada. In Canada, bundling physicians’ payments into an overall payment would be met with significant resistance.

 

In Canada, Dr. Pinney identifies what he calls toll booths. For example, he cites the case where every year the anesthesia department in his hospital stated what days they would be available and what days they could not cover because of vacations. He finds this “toll booth” unacceptable.

 

Another good analogy is the 2 September 1972 Canada–Russia hockey game. Canada was outclassed; the teamwork of the opposing team was what defeated Canada. This loss lead to disruptive innovation in Canadian hockey. It took a generation for the changes to be implemented, but Canada became competitive and won.

 

Some key learning points:

  1. Facilities need to be customer centered.
  2. Competition should drive the performance of healthcare facilities.
  3. Cleanliness is the canary in the coal mine.
  4. Equipment and physical plans must be kept up-to-date.
  5.  Facilities require strong leadership and skilled management teams.
  6. Facilities must be financially viable.” His emphasis on competition is important. This has been contemplated for years in the Canadian system, but only timidly introduced.

 

Finally, a key point Dr. Pinney makes is how change will occur: evolutionary or disruptive. He supports a disruptive approach. Perhaps, we are seeing disruption today, driven by financial reality.

 

This is an excellent book. Chapter 8 is the key chapter that outlines the principles for running a successful health care system in Canada. If you only have time to read one chapter read this one.

 

My disappointment is that it would have been an advantage to the Canadian health care system if Dr. Pinney had remained in Canada to be a champion of change.

 

Author

Chris Carruthers, MD, is a consultant. He was founding president of the Canadian Society of Physician Leaders and the first winner of its award of excellence, which is named after him.

 

Correspondence to: ccmd@rogers.com

Top