Saturday, March 28, 2015

First, Know Yourself

I have spent a lot of time thinking about work in the past 8 months - about what I needed to work a life I can live, about what I wanted to be "when I grow up". It has been a difficult process - one that has made conversations about what I plan on doing with myself difficult ("I'm still thinking about that" seeming like a wholly inadequate, albeit very honest, answer) and as a result, I have been stuck in a bit of a transactional rut, work-wise. That rut where I do my job and I do it adequately but where work is not a source of incredible satisfaction in my life. That rut, that's actually very stressful for me (because of who I am) - where I really did not know what I wanted, or at least had no concrete ideas on how I would get there. That rut that even made doing an adequate job of my resume difficult if not impossible. That rut that made it next to impossible to plan or work towards something without some more concrete kind of idea about what that something is. That rut that is wholly unproductive and uninspired. That rut where I worried that the activities that actually were bringing me a great deal of satisfaction and enabling me to cope would result in either discipline or termination. I had some ideas that I wanted to align who I was, with what I do; I wanted to be fully present in my work and I wanted some larger things to work towards - but those ideas had not crystallized in a way that I could effectively communicate to others - others I would need to bring onboard with any plans.

I needed to know myself, I needed to reflect on the conditions that would drive a productive and satisfying work life for me and I needed to go about finding or creating those conditions.

I know I do not want to live a life of leisure - having the day at my command would not be enough. I need my days to not only be under my own control, but I also need them to be productive. I also know that being an economist is part of who I am - not practicing economics, remains unfathomable, it needs to be part of what I do. Equally, I know I am a writer - writing needs to be a part of what I do. Further, I know I need variety and I need to be creative in the work I do. I like work that I have not done before - I like applying my skills in new areas and perpetually growing the things I know about. I particularly like developing ideas and fostering communities - I like engaging others, "I think out loud" and thrive on respectful discussion. I find hierarchy soul crushing - the relationships with my supervisors or those I work with or for need to be collegial and constructive - I need to work in an environment where there are ideas about what needs to be accomplished (and ideally where I have helped to shape what those things are) - but where I am largely left to explore how that is to be done. I need to be able to be innovative. I need deadlines - but little else, the less structure, the better. Work needs to reflect and be a part of who I am. That is now the direction I am going in.

In the last week, I have been able to do what I could not in the months before. I have been able to articulate what I want to be "when I grow up" - I have found the drive that has been absent for many years, and am making not just steps but strides in my life. To paraphrase an old song - life these last few months has not given me much of what I thought I wanted, but it has given me what I truly needed. Life finds a way - a way of slowly teaching a person that they can not change who they are, that sometimes even changing where you are is beyond your control, but that there is almost always a way forward.

Life in the next few months will be busy - busy preparing for the transition. Busy making plans. Busy getting things done. I'm a pretty happy person at this moment (despite what is a daunting workload in the months to come) - and am hopeful that if I just focus on doing good work, that the money will follow (after all, there are obligations to meet).

At this moment, I also have an incredible amount of gratitude - for those who have made where I am at now possible. You know who you are, and thanks.

Friday, March 27, 2015

Sewing a Parachute

Since Friday, I have been sewing a parachute. Crafting an exit strategy with fervent energy - an exit strategy not just out of the ministry, but out of government entirely. I am on the brink of leaving the organization - because, my work and who I am often seem in conflict; because my strengths go unused; because I don't feel like I can be who I am; I don't feel like I can bring and apply my passion to my work; I don't feel like I can shape my work; I don't feel like I can explore ideas; I don't feel like I can be innovative. I feel frustrated; I feel anxious and stressed (and half-wonder, could this blog ever get me fired?); I feel like I cannot be innovative; I feel like I can not "Think Big" at work; I feel like I am not in control of the work I do, how I do it or what becomes of it; at the very least I feel misunderstood.

And yet - when I think about what I am passionate about - when I think about what is needed, I can not help but think that my organization needs me, needs people like me to get past the hard bits to a place where they can be at work and be who they are and bring everything to the table because nothing less than everything will do.

I am passionate about a healthcare system that works for the people it serves.

I am passionate about being engaged and heartbroken at the disengagement prevalent in the organization at this time.

I am passionate about truly good policy.

I am passionate about writing - and good writing in particular.

I am passionate about thinking big.

I am passionate about building bridges.

I am passionate about learning.

I am passionate about transparency.

I am passionate about engaging people in a discussion of ideas and true collaboration.

I am passionate about evidence informed decisions making.

I desperately want the work I have done outside of work, to match the work I do at work.

I want to work a life worth living - where I am productive because work is not work, but a part of who I am.

Yet, I am sewing a parachute...while part of me yet still, hopes I won't need it.

Saturday, March 21, 2015

From Here to There

We have an engagement problem at work. It is well known. The last workplace environment survey (WES) results demonstrated our division had sunk to the lowest scoring work unit in the entirety of the Ministry. At one time, it had one of the highest scores. The impact is acutely felt. As such, I had some hope when the Deputy Minister put out a call for expressions of interest to co-chair an employee engagement forum, there was just one catch: subject to supervisor approval.

I am not a person who believes that any problem can be solved by denying that it exists in the first place. Further, my door has been open and I have had an open ear to my colleagues. I have also written a book review in our divisional newsletter on a book that seems 'on-track' for solving these kinds of problems (Dan Pontefract's Flat Army: Creating a Connected and Engaged Organization). I have given voice to the concerns I have heard at meetings. I have also undertaken a project that resulted in art being hung in the halls - halls that had been barren for a decade. I want work to be a better place, I truly do - so I figured I should throw my hat in the ring.

As such I was greatly disappointed when my supervisor came into my office on Friday to tell me that she was withholding approval of my application to Co-chair the forum. Not so much because she wanted to, but rather because the Executive Director felt there might be workload issues, and more tellingly that "I may express negative opinions with respect to the situation in our division". I wish I could say that it was completely unexpected, but it really wasn't as the executive director has demonstrated that she is far more concerned with how things look, than with how things are. Yet another indication of where the culture of my workplace is at - and how unlikely it is to change anytime soon.

This is the painful part - the part where the relationship has been long-dead, the part where whatever bits I once loved have long since withered, the part where it is clear there is not going to be some miraculous turn around. This is the part where I have to take into account my strengths and the work I could be doing instead. This is the part where I must dig deep - think hard, and hope that in 25 years I will look back and know I made the right choices even though they were hard and uncomfortable and risky.

Tuesday, March 17, 2015

The Modern Day Malthusian Catastrophe: Healthcare Sustainability

The foundation of most healthcare expenditure projections is that the patterns observed in the recent past will continue into the foreseeable future. Patterns of health care use remain the same. Patterns of disease remain the same. Patterns of health care delivery remain the same. More sophisticated models incorporate some change, but again, it is based on the assumption that the rate of change in the future will be the same as the average rate of change in the past. In short, most projections (at least those beyond the next five years) will be almost comically incorrect. They paint a Malthusian Catastrophe in the making - where access to healthcare is limited and costs associated with providing healthcare are astronomical.

These projections paint a picture of a health system that is wholly unsustainable - a picture where the vast majority of public resources are gobbled up by an ever more hungry healthcare system. Gobbled up by providers demanding ever more pay. Gobbled up by patients demanding ever more marginal and incremental increases in longevity or quality of life that come at an ever increasing costs. Note - in the story that is currently told about healthcare and its future, both patients and providers are villains.

In these projections - the future is some ominous place where things go from bad to worse. In these projections, waitlists grow and costs increase.

However, it should be noted that in these projections, the critical assumption is that the status quo will prevail.

Given that the projections are likely painfully correct if the status quo does prevail, the challenge is in developing and fostering a system that embraces change and innovation, rather than stagnation. If a system sees change as a threat rather than an opportunity - the Malthusian Catastrophe becomes more likely. If the system embraces change and the idea that it is possible that more can be done with the resources available, or that the capacity to pay for more can be expanded, then the Malthusian Catastrophe is averted.

The way our system is structured, it has assumed that the way healthcare has been delivered in the past (physicians and hospitals), and the way it has been demanded in the past is the way it should be and will be delivered in the future. It has limited capacity to embrace change and innovation. It ignores the patient and their role, at its own peril.

It is poorly structured to adopt practices that move healthcare from being delivered by doctors and in hospitals - in part because there are large cost-shifting realities. Our system covers almost all medically necessary services provided by physicians or those services provided in hospitals, but little coverage is provided for dentistry, pharmaceuticals, or other practitioners. As such, even if a pharmaceutical becomes the more effective treatment modality, there is an incentive for patients to choose the less effective or efficient modality simply because doing so is free, whereas the alternative might incur potentially large out-of-pocket expenses. Pursuing the "better level of care" - with things that often turn out to be preventative or prophylactic but incur out-of-pocket expenses becomes the domain of those with the resources to do so - and the gap in health status between the top 5 percent and the bottom 5 percent widens. This speaks to the need for the system to be far more comprehensive in its view of what is, or is not "healthcare" that is to be covered or subsidized.

It also speaks to the unspoken trade off between equality and equity that has been made. Everyone is equal - meaning all those with bad hips are served equally badly, while all those with heart attacks or cancer are served equally well. As a result, the level of satisfaction with the system largely depends on whether or not you happen to have your specific needs met adequalty and that largely depends on what those needs are and whether or not they have been deemed worthy of adequate resources. A poor man who happens to need pharmaceuticals is just as screwed as the well-to-do in need of a new hip - neither has their needs met and might be better served by a system that would cover the pharmaceuticals of the poor man and permit the rich man to spend his own money to get access to a new hip.

Monday, March 2, 2015

The Invisible Hand of Things Done Well

Choosing the right goal is perhaps the most important thing an organization or individual can do. It will guide what is done or not done. It will illuminate the path to incredible success, or will lead down a rabbit hole of misery where the difference between what is, and what is possible grows instead of diminishes.

When it comes to healthcare, it must be wondered, “Do most of our problems stem from a relentless focus on the wrong goal?” In healthcare in Canada there has been a relentless focus on the dollars spent – all the while, the dollars spent grow and the outcomes do not get appreciably better. All the while, longer wait lists. All the while more disability and suffering seems apparent. All the while, the difference between where we want to be and where we are seems an ever increasing chasm. All the while, our rankings in international reports on the healthcare systems continue to drop – going from being a lead system, to being mediocre, to, now almost last place.

Providers in the system do not seem overly pleased, nor for that matter do patients – further, successive governments are repeatedly chastised for failing to perform. Nobody is happy – and yet despite our obsession with the healthcare system and its costs, nothing seems to get better and many things seem to get worse.

It is depressing and frustrating – how is it a country with so much can perform so poorly when it comes to healthcare? How could we have lost so much ground in comparison to other countries?

The thing is that when things are done well – a simply incredible thing happens, almost always what is possible aligns with what is, and the cost of doing it is minimized. If something can be done better, for less – better for less happens. By focussing on doing better, on better meeting the needs – and then focussing on doing so more efficiently, a kind of evolution happens. It happens in cars. It happens in computers. It happens in almost everything – so why does it not happen in healthcare in Canada?

The answer is quite simple, the pursuit of “better” was consumed by the pursuit of “cheaper”. Imagine if a company failed to invest in making its products better. Failed to spend the money now, to reap benefits later – focussed on the short-term, on maximizing profits for shareholders. It would not be long before that company would fail, before competitors would simply outperform. Likewise, in healthcare – for far too many years there has been a relentless focus on doing things cheaper. Steady increases in the budget have seemed extravagant, but the truth is they obscure the demands of keeping pace with a growing and aging population. The focus has not been on doing “better” for quite some time, and looking forward at budget increases of less than 3 percent in the years to come, it is unimaginable that there will be a shift in focus to doing things “better” for quite some time. “Better” costs money – at least initially, and that is not something that the system seems willing to invest at this time – by focussing on being lean it is growing ever fatter.

Imagine for a moment, if “better” became the focus instead of the dollars spent. If the focus shifted to the things that really mattered, things like minimizing suffering, minimizing the impact of disability, minimizing death, and maximizing patient satisfaction. To solving the very real problems faced by patients. Further, what would happen if the way things were done shifted – from top down to bottom up? What if we harnessed the knowledge of those who do things, to do those things better? What if we smashed the healthcare hierarchy and fostered an eco-system instead?

Would the invisible hand of things done well happen in healthcare – could we have healthcare that is both better AND cheaper?