In this turbulent time for health care in Quebec, it is crucial that we establish a clear vision of the steps we need to take to make our health care system a model of quality, accessibility, and safety, and one that we can count on for the long term. As part of the search for solutions, I offer a series of three articles. This first one sketches a portrait of the current situation and describes the symptoms of profound affliction within our system. The second will conceptualize an ideal future situation, i.e., a system in continuous equilibrium. The third will draw on evidence to support a potential avenue to achieve the desired result.
KEY WORDS: health care system, Quebec, accessibility, costs, clinicians, managers, common goals, co-management
Patients using Quebec’s health care system can’t help but notice an abundance of undesirable traits: wait lists, inefficiencies, incidents, accidents, lack of communication, and more. However, by attempting to treat these symptoms in isolation, without bringing to light their underlying causes, we risk taking a firefighter’s approach, continually trying to put out fires and living in a state of perpetual frustration as new situations crop up here and there. Top
Maintaining this management style is very much a choice; we also have the option of adopting a more scientific, more reasonable, and much calmer approach, similar to the diagnostic method of clinicians. By treating the undesirable effects of the system like the symptoms of a disease, we will be able to explain them with a single deep etiology. Only then will we be able to prescribe a cure and apply it appropriately.
When our fellow citizens fall sick, they want to know that they can rely on a high-quality health care system that is not only accessible and safe, but also sustainable. Not only do they want a system that evolves with their values, but they also want to be proud to call that system their own.
This is why they charge decision-makers with the double task of both treating and preventing disease. It also explains why they are shocked when results are lacking. In fact, any patient entering the system anywhere in the province can easily observe that Tim Horton’s restaurants across Quebec have a better mastery of the ABCs of management than publicly funded health care facilities. And since they are funding those services with their taxes, they feel that they are not getting their money’s worth. Until very recently, physicians were held in high esteem by the citizens of Quebec; indeed, it was thought that our doctors played a key role in the organization of care. Moreover, our population was under the illusion that physicians and managers had a certain control over spending. The reality, however, is quite different. In fact, the gulf separating physicians and managers is extremely wide. Top
Two parallel worlds
We, the doctors and managers of the health care network, essentially share a common goal. We all work “for the patient” to the best of our abilities and knowledge. However, the dilemmas we face and the perceptions we have of our obligations with respect to the health care system often diverge.
Managers’ duties and the scope of their work are effectively defined by the Ministry of Health and Social Services, which must consider both access to care and the budgetary framework. Managers, thus, endeavour to achieve accessibility while optimizing costs. They regularly update their employer by submitting structured reports, and they offer recommendations for their boards of directors according to allocated budgets. These workers are intimately aware that the needs of each individual patient must harmonize with those of the population at large. In fact, consideration for the health of the population is a part of the continuous discourse of health care administrators across the province.
For their part, physicians naturally concentrate on the patient who requires immediate attention. As the physician–patient relationship is at the heart of the practice of medicine, it is natural that clinical physicians prioritize the patient they are currently treating. All the more so when we remember that, by taking the Hippocratic oath, the physician pledges allegiance to the patient and the profession, and not to the cost of clinical activities. Top
In medical school, future physicians learn to recommend the best that science has to offer to their patients. Because advances in medicine and pharmacology have been much more rapid over the last few decades, physicians hasten to treat the diseases they encounter by applying increasingly precise and specialized science. Moreover, given that they are generally not trained in finance or health economics, physicians dedicate their time and attention to the patient in front of them, who needs treatment right then and there. The patient, thus, receives appropriate medical care.
The concept of population-based responsibility has recently made headway in Quebec. It is not yet well ingrained across the health system, but it appears that the impact physicians could have on the health care system, as well as their involvement in management, may well increasingly extend beyond their relationship with their patients. In fact, it will be become more and more obvious that the needs of any one patient must be weighed against a vision that privileges the health of populations. Therein lies the dilemma for clinicians. Top
As clinicians feel much more responsible for their patients than for the population in general, they take for granted that managers will ensure that patients are sent to them at the right time. However, in Quebec’s current health care system, it is not at all unusual to hear statements like: “I made my diagnosis and I submitted your request for admission, but the institution did not provide the operating time necessary for your surgery to take place as soon as possible,” or “If I had a nursing/IT/administrative assistant, the system would run more smoothly and you would receive better care.”
Moreover, clinicians generally have relatively little knowledge of the administrative aspects of care and feel more responsible for the quality of the medical procedure than for the management or cost of care. They offer recommendations to their Board of Directors through their establishment’s Council of Physicians, Dentists and Pharmacists. These recommendations are based on quality of care and do not take into consideration either financial impact or subsequent waitlists for the population. From their perspective, this is a completely normal state of affairs. In fact, for them, the worst case scenario would be that their patients are unable to benefit from the latest scientific advances because of budgetary constraints. Top
Furthermore, physicians have no responsibility to the institutions themselves, but are instead responsible to the province through their union affiliation and professional organization. This means that their responsibilities are more of an ethical and moral nature than specifically territorial or administrative.
Clinicians’ expectations of managers, i.e., that they will ensure that the right patient is at the right place at the right time, are simply not officially formulated. Managers attend to their work while making recommendations to their Board of Directors. They are accustomed to the fact that clinicians prioritize their patients over budgetary constraints. Thus, managers fulfill their mandate as best they can while under no perceived obligation to either consult clinicians about their decisions or even keep them informed.
Thus, health care managers and clinicians are on completely different wavelengths. Worse still, they work in parallel structures under conflicting priorities. It follows that even if board members want patients at their particular institution to have access to better care, they must often choose between clinical recommendations and budgetary constraints. Top
Resolving the dilemmas of managers and clinicians requires careful comparison of their underlying nature. After all, experts working in the same field very likely face similar problems.
First, let us note that clinicians and managers are faced with rather distinct realities. Clinicians spend most of their practice time with individual patients. Managers, on the other hand, have to deal with questions about system costs, for which they are accountable.
However, when we examine the accessibility side of the problem more closely, we find that managers and physicians share similar concerns: on the one hand, clinicians feel more and more responsible for the needs of the community, while on the other, managers are responsible for waitlists.
It is, thus, on the issue of accessibility that managers and physicians are now beginning to draw closer together. Even if we have a long way to go, there is a glimmer of hope for the physician–health care manager comanagement approach currently catching on here and there across the province. Top
Principles of the solution
Many dilemmas confront all players in the system, whether we are clinicians, managers, or users of the system.
As we will see in the next article in our series, a solution to our current predicament must take a direction based on four principles:
The approach must be patient centred and clinically based. To achieve this, we must base care objectives on the needs of individual patients by setting our priorities on a clinical basis.
The main objective is to improve the flow of patients through all trajectories of care simultaneously. By identifying which task or resource creates the longest wait times for the most patients in the system and by improving the synchronization of resources, we can quickly reduce wait times without using additional resources.
Continuous improvement of the system to balance the flow of patients is of vital importance. Balancing the flow of the system is very different from balancing its capacity. We often make the mistake of confusing these two factors when we try to improve the health care system. We need to identify the most frequent causes of interruption in patient flow to eliminate them as rapidly as possible.
The elimination of local optimization measures is essential when improving many interacting chains of activity. Otherwise, local optimization will continue to interrupt the flow of patients through the system and stall the continuous improvement process.
Any and all solutions must simultaneously:
Create an ever flourishing health and social care system
Rapidly improve the quality, safety, and timeliness of patient care
Rapidly improve the affordability of care
Not create more complexity for staff
Furthermore, for comanagement teams to understand each other and work in a coherent fashion, clinicians must accept the responsibility of making care more affordable and managers must agree to help improve the quality of care. Together, these two professional bodies must work to improve the accessibility of care. The common goal of all these objectives is to encourage the free circulation of patients through the system.
The primary objective of health care is to have fewer and fewer people using the system for the simple reason that they have less and less need for it. In fact, in Quebec, citizens have been loud and clear in their call for policymakers to focus on prevention to decrease the number of sick people. These efforts must necessarily come from the government as a whole and not just the Ministry of Health and Social Services. Top
And, yet, Quebec’s health care system is in an unprecedented state of turmoil.
When they venture into the system, people do not always find the high-quality, accessible, safe, and sustainable system they expect. Clinicians and managers often have parallel perspectives and modus operandi that barely enter into dialogue with each other. The time has come to put forward a solution that is patient-centred and clinically based, a solution that will facilitate patient flow through all care trajectories within a continuously improving environment. This solution must simultaneously eliminate local measures of optimization which impede system fluidity and cloud focus. We will be able to assess the success of this solution by measuring the improvement of care, the capacity to pay, and the creation of a sustainable environment that does not create more complexity for health care workers.
Ruth Vander Stelt, BA, MD, CMFC, MM, is a family physician practising in the Pontiac region of western Quebec. She has also served as president of the Association médicale du Québec.