Monday, September 29, 2014

On Poking the Bear

On occasion, I have blogged about my workplace – about the frustration and angst of being where I am at. In short, I have “poked the bear”, I don’t know if “the bear” reads my blog – the bear might, parts of the bear probably do. I have also “poked the bear” more directly, via a book review in the divisional newsletter and the intranet and to that end, the bear has responded somewhat in mixed ways. Granted, the direct pokes are perhaps a little more diplomatic than some of what can be found on this blog. To date the bear hasn’t taken a swipe at me, although I have at times thought that it might.

However, my experience has sold me on the power of writing, and more broadly on the power of blogging and other social media (twitter, facebook) to affect change (both personal and social). It was not until I started pouring my thoughts and ideas out in a way that others might read and respond to that the challenges I was facing started to become surmountable in real and tangible ways. It is a way of speaking the name that should not be spoken; a way of peeling back the fa├žade of a challenge to identify and explore what is beneath the surface and from there to think about how that challenge might then be overcome. The beautiful thing about blogging, about allowing those who read my blog to respond either via comments or through email – is that the door is then open for collaboration.

I recognize that my current situation is not sustainable in the long-run; that it results in a longing for something more. The writing is clearly on the wall. The culture as it has evolved, and who I am are not compatible and a consequence of that has been profound disengagement. Writing is my coping mechanism – and beyond that it is a tool to affect change, it builds a path from where I have been, to where I am at, to where I will be.

So I recognize that I might be “poking the bear” – but when I think of the alternative, of keeping the part of me that might best benefit from building new roads and bridges private – it seems as though it is a reasonable risk to take. Further, I have learned that skeletons in closets haunt their owners, whereas those on display have tremendous tuition value. Because of blogging, my closet is bare – and paths to a better future are being built

Tuesday, September 23, 2014

A Canada without Compassion Comes at a Tremendous Cost

The capacity for compassion, the ability to see each other through, rather than to see through each other is perhaps the one thing that sets Canada apart from many other nations in the world. It is a culture of being there for one another – of lending a hand-up when times are rough, and of sharing in success when times are good. It is a culture of true leadership. For decades, compassion has shaped Canada’s public policy at all levels of government, municipal, provincial and federal. For decades, Canada has been a leader in health and social policy – Canada has demonstrated the power of compassion to overcome the most significant of challenges.

As such, as a Canadian – the move away from compassion as a core value, as a way of being, should be seen as being deeply disturbing. It should be seen as a move away from a culture that has enabled many great successes, towards a strategy of every man, woman and child for themselves, a strategy that will ultimately lead to a Canada that is far less than what it is capable of doing and being. The loss of compassion among Canadians, and particularly among those who are our leaders is nothing short of heartbreaking.

The underfunding of public systems of health and education, and an unwavering focus on the second dumbest idea ever – “Taxpayer Value”, is at its core a demonstration of a lack of compassion for others and in particular a lack of compassion for those who work in the public service and those who rely on the services it provides. High-quality, high-performing public health and public education systems need to be a priority and they need to be based on a compassionate view of those they employ and those they serve – they need to embody the hand-up that they are capable of being.

Is it compassionate to have wait times that effectively deny access to care in order to manage budgets and at the same time prohibit people from their own resources to expedite their care to mitigate the costs of their illness and or disability?

Is it compassionate to deny access to adequate compensation to those harmed by medical error?

Is it compassionate to have students who are the most in need of resources the least able to access the resources needed – is it compassionate to fund every student in every school district similarly, when the availability and effectiveness of PACs varies substantially?

Is it compassionate to treat the children of Canadian mothers and foreign fathers differently from the children of Canadian fathers and foreign mothers with respect to their access to healthcare?

A Canada without compassion, is a cold and heartless country – a country that turns its back on tremendous potential and as a result pays a huge opportunity cost. A Canada without compassion, will struggle – as those in their time of need are abandoned, and in turn, those previously abandoned turn their backs on the needs of others. A Canada without compassion will be unable to overcome the challenges it confronts – it will condemn some of its citizens to poverty, others to pain and disability. It will fail to enable and empower its citizens to contribute what they are capable of, in favour of ensuring that those who are lucky enough to avoid adversity will keep a little more money in their pockets.

Sadly, I feel that stories, like that of this Ottawa family – are about to be more common place, and sadder yet, the comments that follow it seem to reflect a loss of compassion among Canadians that is nothing short of heartbreaking.

Sunday, September 14, 2014

Alternate Level of Care - Not a Silver Bullet to Fix Healthcare Woes

Alternate level of care (ALC) patients are often the scapegoats to what ails the healthcare system. They are accused of being overly expensive bed blockers who use up more resources than they need and prevent somebody who needs a higher level care from accessing those services.

I would argue that the system does not adequately understand the issue of alternate level of care patients, that alternate level of care patients might not use as many resources as they are accused of using, and that if the system addressed the problem of ALC it does not follow that access to healthcare, and in particular a reduction in wait times to care would follow.

First, the system does not adequately understand the issue of alternate level of care patients. It should be noted that all patients who are not "acute care" patients are "alternate level of care" patients. This would include patients who are admitted and waiting for a procedure (pre-procedure ALC), as well as patients who are "well enough" to be discharged but cannot be discharged because of inadequate post-discharge care environments. The problem of pre-procedure ALC is not the same as the problem of post-procedure ALC but rarely are the two kinds of ALC looked at separately. Typically, when people think of "bed blockers", they are thinking of patients who are adequately recovered from their illness or surgery to be discharged but cannot be discharged because they still require some level of care, or their home environment is inappropriate. Some of these patients will not need a permanent placement in a long-term care home, but rather need a place where they can recover further before returning home or are waiting for home care or informal care providers to be available to provide for their needs. At any rate, the needs and reasons that those patients are ALC needs to be better understood before leaping to the conclusion that building more long-term care facilities is the solution to the problem.

Second, on the issue of cost it is erroneous to assume that the "average cost" of a hospital day is the appropriate cost to attribute to an ALC patient. The average cost of a hospital day is an aggregate number that reflects the costs of "high needs" patients and "low needs" patients - it is all of the costs of hospitals divided by all of the hospital days. The mere existence of a patient in a hospital does not attract spending on that patient. It is absolutely ridiculous to think that an ALC patient is as resource intense as a patient who is within the first 48 hours post-surgery, or who is acutely ill, yet - declaring that an ALC patient costs the same as these other patients is often what happens in the hand-wringing over ALC. If it takes 5 nurses to care for 20 acutely ill patients, those same 5 nurses might be able to care for 50 "alternate level of care" patients, or perhaps nurse aides are adequate to address their needs. Further, it may be desirable to have some "less resource" intensive patients in the mix as it provides for a bit of a break. Do we really want a system where nurses are working at the limits of their capacity, all the time? What might that mean for rates of medical error? What might that mean for rates of nurse burnout? What might that mean for rates of occupational injuries among nurses? It is even imaginable that having these patients in hospital might be the most efficient way to address their needs under some circumstances. In short - do not expect resolving the ALC problem to save as much money as is often estimated. If the ALC problem were adequately addressed we would see the average cost per patient day increase, not decrease.

Lastly, because governments set health budgets, even if the beds were available in hospital - it is a heroic assumption to think that the number of procedures performed would increase by any substantial amount. To the extent that money is actually saved and could be reallocated to provide access to care, some additional surgeries might be performed. However, the increase in access is likely to be far less than what is often imagined - just because a bed or an OR is available in the public system does not mean that it will be used. Unless governments are willing to spend more on healthcare, they will simply reduce the number of beds "staffed and in operation" or will close OR's to manage budgets.

Wednesday, September 10, 2014

One Year From Now: First School Days

A Year From now my daughter will be heading to her first days of kindergarten - she will start her academic journey. As a parent, I know she already has some tremendous advantages, and that if she needs any help along the way that we will do what we can and what needs to be done to ensure that she is able to reach her potential. Our plan was to send our children to public school, at least for their elementary years. We have every confidence in the curriculum. We have every confidence in the ability of public school teachers to inspire learning - we know that there are many dedicated individuals who work tirelessly every school day and every other day to not only do their job, but to do it well. We appreciate the diversity in public school classrooms and feel that it is a benefit to our children.

However, the dispute between the BCTF and the Government, now has me asking some questions about the school system, about how it works, and about how it might be in a state of dysfunction going forward. It has me questioning whether or not the public school system is "healthy" - if it is a place where teachers feel they can innovate and practice to the fullest of their abilities? A place where all students have their needs met? It has me questioning the statistics that the "outcomes are the best in the world" and wondering if those statistics are subject to a kind of statistical slight of hand. Not that the statistics are wrong, just that they fail to tell the full story or have been subjected to cherry-picking. I am wondering about the culture of the public school system - about the relationship between those who teach and those who manage the system.

And I am left with a sense of trepidation and dread.

I fully support a universally accessible, public education system that performs well and meets the needs of the students it serves - but, I have a hard time coming to the conclusion that the system in British Columbia is where it needs to be in order to be a system that performs well, and meets the needs of the students it serves. A system where there is little gap between what the people who work in the system are capable of and what they actually achieve. I am very worried, that given the rhetoric and propaganda, the posturing, and the statistics - that what should be, is and will be, very different from what my daughter and son will actually experience if they go to public school.

First, I have serious concerns about the adequacy of funding in the school system. I know on a per-capita basis student funding has increased at a rate that is slightly ahead of inflation. However, that statistic hides a lot of details and in isolation actually says very little about whether or not that level of funding is "adequate". It fails to take into consideration changes in the composition of the population being served. Are there more high-needs students being served? Are there more students who are facing food insecurity or home instability? How has technology changed, is the system expected to deliver the same things it did 10 years ago, using the same tools? A proxy for adequacy is to look at the funding in other jurisdictions (again a lot of nuances, but in a pinch it will do) - and in British Columbia public school funding as 2010/11 was about $750 less per student per year than the Canadian average. Further, there is some argument to be made that funding all public schools equally at a per student level leaves a lot to be desired in the way of equity as schools in "better-off" neighbourhoods may have a much easier time suplementing their budgets than schools in economically disadvantaged areas. As a result, public funding might be adequate in some areas and inadequate in other areas. However, unlike in health, there is little measurement of the supplemental spending, the private spending, in education.

Second, in terms of outcomes and what is measured, again there are a lot of nuances and considerations to be made. The catchment school that my children would attend, has good outcomes. It also is in a very middle to upper middle class neighbourhood. Consequently, the students who attend might not be grappling with some of the challenges to learning that other students face. There might not be as many who are learning english as a second language. There might not be as many who face food insecurity. There might not be as many in adequate housing. There might be more students with parents who hold post-secondary credentials. There might be less unemployment. There might not be as many with absentee parents. There might not be as many who struggle with the tab for school supplies or field trips. There might be more parents willing to engage tutors to imporve academic performance. The students might be more likely to have a regular family doctor and to have thier health needs met. There might be more parents willing to chip in to fill the gaps in the budget for class room supplies. There might be fewer students waiting for psych-ed assessments simply because their parents have expedited access by paying out of pocket. As a result, the funding that follows students as having special learning needs might be more likely to be available, simply because a greater share of those students will have been identified. (I do not believe the government publically reports how many students are on the wait list for psych-ed assessments and what their average wait time is). In short, the outcomes observed are not entirely a result of what was done within the context of the school system.

Lastly, and perhaps my biggest area of concern - is the state of the relationship between those who manage the school system (government and administrators) and those who are on the front lines - the teachers. I have come to the conclusion that high-performing organizations are able to return exceptional results with the resources they have because they focus on two things: (1) empowering their staff to work to the fullest extent of their capabilities; and, (2) meeting the needs of their customers. There does not seem to be a whole lot of collaboration. There does not seem to be a whole lot of respect. There does not seem to be a lot of trust. There does not seem to be a focus on students and what they need from the education system (which might not be the same thing in all areas). There does not seem to be genuine leadership. There seems to be a lot of ideology, and a lot of frustration. That is not a recipe for innovation - that is not a recipe for "being the best" by any length of the imagination.

When I think of what the public school system should be capable of doing, particularly in a developed country with adequate resource to fund it, there is not a doubt in my mind that it would be more than adequate to meet the needs of my daughter or any other child in British Columbia. However, now less than a year from the time that my daughter will enter the "school system" - I sit very apprehensive. I suppose I could consider myself fortunate that if push came to shove, private school would be an option for us, but there again it disturbs me that the government would benefit from that decision with a substantial savings from not having to meet its full funding obligation with absolutely no requirement to redirect the money saved into the public system. Again, it seems wrong that there is an incentive for the government to encourage parents to opt out of the public system.

Tuesday, September 2, 2014

The Paradox of Taxpayer Value

Something awful happens when a business focuses its resources on achieving shareholder value. Things are done that improve the bottom line, but risk the long-run viability of the business. Before long, it’s a lean mean business machine that is unable to deliver because of high staff turn-over and abysmal customer satisfaction. Without the right staff, and without a demand for product, the writing is on the wall. It’s not that shareholder value is not important, it is – but rather that, the road to shareholder value is paved with having the right people to do the right things, and having a product or service that customers want, that meets their needs. Shareholder value is a happy side-effect to being successful in business, and paradoxically, when companies focus on shareholder value instead of the things that lead to business success, companies fail.

Despite clear indications that focusing on shareholder value leads to corporate dysfunction and failure – the parallel concept in government, “taxpayer value” has grown to be the dominant focus. The focus is on achieving the lowest possible tax rates – both corporate and individual. Unfortunately, a focus on “taxpayer value” will lead to the same dysfunction that it yields in the corporate world. There is reason to believe that the road to “taxpayer value” is paved by having the right people do the right things, and providing high-quality services that meet the needs of the public.

The relentless focus on “taxpayer value” has resulted in a situation where there is a lot of frustration – and seems to be leading to a situation where the government struggles to attract and retain the best and brightest and seems to be struggling to provide high-quality services that meet the needs of the public (particularly in the healthcare and education sectors). The government seems content with a command and control philosophy – even though, it seems that the world has shifted towards collaborate and innovate. I do not believe, absent a shift in thinking and a change in course, that this will end well.

If companies can shift their thinking and recognize that the road to shareholder value is paved by focussing on their human resources and their customers – why can’t government be capable of a parallel shift in thinking and recognize that the road to taxpayer value is paved with employee engagement and services that meet the needs of those who use them? There is nothing in particular about government that makes collaborate and innovate impossible - rather, all that is needed is the courage to do so, and the commitment to the public service and those it serves.