Saturday, December 20, 2014

The McNeil Report - Condition Critical at the BC Ministry of Health

Health is a mission critical portfolio in government - it consumes two out of every five tax dollars spent in the province of British Columbia and faces incredible challenges in the years ahead as increased demand for health services taxes the resources available to meet those demands. It is not trite to say that in order to have a health system that meets the needs of those living in this province, the organization that is responsible for leading the entire healthcare system can not be dysfunctional. Organizational failure at the Ministry of Health will have critical consequences with respect to the Ministry's ability to meet the demands of its mandate. Even an organization that is marginally functional will result in tremendous opportunity costs moving forward. The Ministry needs to be an organization that exemplifies high performance - it needs to demonstrate the kind of culture and workplace that delivers exceptional results for the resources that it has at its disposal. It needs to be a place that attracts (and retains) the best and brightest - a place where that talent is recognized and used to its full potential. A place where people are supported to be their best.

As such, anyone who reads Marcia McNeil's report into the 2012 firings at the Ministry of Health should be deeply concerned and worried about the organizational health (or lack there of) of the Ministry - and the scars that remain from those events. Anyone who reads that report, should be asking themselves about the current state of the organization and its culture. Should be asking about the critical work that needs to be done to repair and rebuild to get the organization from where it is at (after an honest assessment about where that may be), to the place where it needs to be.

The McNeil report paints an awful picture of an organization that lacks integrity. It paints a picture of an organization that prematurely comes to conclusions and then goes on a hunt for the evidence to support those conclusions. It paints a picture of an organization that intimidates those who work for it. It paints a picture of an organization that will do anything to appease the public, even at the expense of its own people and its ability to do the work it must do. It paints the picture of an organization that is reluctant reflect on its own actions and take actions to repair the damage. It paints a picture of an organization, where people point the finger at other people, rather than be held accountable for what was done. It paints the picture of an organization with a culture of "fear and anxiety".

Now ask yourself, is that the kind of organization that is going to attract and retain the best and brightest? Is that an organization that is going to empower its people to do what needs to be done - to speak up when something needs to be said? Is that an organization capable of handling conflict? Is that an organization that will drive engagement? Is that an organization that is going to be high-performance? Is that an organization that exemplifies leadership?

The McNeil report has been criticized for being too narrow in scope - for failing to answer the critical questions of who made the decision to terminate and why. It is true that there are a lot of questions that remain unanswered (questions that deserve answers and an independent inquiry). However, the picture that is painted by the report should not be ignored for what it does show is a horrifying scene of an organization that is in need of drastic intervention, an organization that is in critical condition.

Sometimes a long, hard look in the mirror and an honest assessment about where things are at is all that is needed to start on the road to a better place. Sometimes much more is needed.

Monday, December 15, 2014

From Flubber to Firm - Hopes for 2015

I had hoped that by this time I would be preparing to venture on a new chapter in my life career wise. That I would be aligning who I am with what I do. That my plans for the months ahead would be more concrete - and that I would be excited about the work that was to come in the months ahead.

It is not that steps have not been made, they most certainly have - but that rather than the concrete I had hoped for, I have flubber (for those who do not know, flubber is a Newtonian solid made of school glue and a mixture of water and Borax, in short homemade silly putty). I have to accept that getting to a place where I do good work, that matters (and for which I am paid adequately) - is more of a process. I have to accept that going from where I am at, to where I ultimately want to be will take more. More time. More blog posts. More learning. More relationship building. More thought. More patience.

As such, I have been trying to make the most of where I am at. Identifying the bits and pieces at work that I can work towards changing (and working towards those changes), giving voice to what might otherwise go unheard, and doing good work, even when there are significant barriers to doing so. I know that in the long run, I likely will not remain where I am at - and hopefully by next New Years I will be several steps closer to where I want to be in my career (or perhaps will have made that next step a reality). I am also hopeful that when I leave where I am at - that maybe as a result of the things I do between now and then that I will have contributed to rebuilding a better workplace than the one that welcomed my return from maternity leave in September 2013.

What 2014 has brought is clarity - a clarity of purpose, and clarity around what the next chapter of my work life might look like. Clarity around the things I need in order to be satisfied with the work I do. Clarity around the things that seem to be causing me dissatisfaction.

So as I look forward to 2015, I am still excited about the work in the months ahead (work outside of work, and work at work to rebuild a better workplace). I will spend 2015 doing the more that needs to be done and perhaps when 2015 draws to a close, I will be starting that new chapter in my life career wise. A chapter that aligns who I am with what I do, a chapter filled with purpose, a chapter focussed on doing good work that matters, that makes the time spent working time that is well spent.

Friday, November 28, 2014

On Dr. Danielle Martin's 3 Big Ideas

I actually think that Dr. Martin and I might have a lot in common. We are both passionate about healthcare. We both believe that Canada’s public health care system could do a lot better when it comes to serving the needs of Canadians who rely on it. We both believe that timely access to medical care should not be reliant on a person’s wealth. We both believe that social determinants of health (things like income, education and housing) drive health outcomes and the use of the healthcare system – and that by addressing those issues significant improvements in the health and well-being of Canadians could be realized. We are both young women with well-informed opinions (hers developed in the context of being a physician and my own developed as a result of being a health economist and first hand experiences as a patient) and a willingness to debate those opinions publicly.

Dr. Martin believes that a single-payer system that has a monopoly on medically necessary care is critical. Further, she believes the system could be salvaged if just 3 big ideas were implemented – National Public Drug Coverage, Less is More, and a Guaranteed Income Supplement.

In contrast – I have come to the conclusion that the single-payer system and how it is structured is a very big part of the problems that seem endemic to our system and that no idea is “Big Enough” to salvage it, and absent structural change that the most promising “Big Ideas” are simply not feasible. I believe there’s a reason why every other first-world country in the world with a universal public health system that out performs Canada’s also has a parallel private system that also provides medically necessary care. Single-payer is simply one of those ideas (like communism) that is nice in theory, but in practice and in the context of a complex reality fails to deliver the best outcomes and leaves many suffering the very real consequences of the system’s inadequacies.

Dr. Danielle’s first “Big Idea” is National Public Drug Coverage for the top 20 drugs used to treat chronic conditions in Canada. It is nothing short of shameful that Canada does not include pharmaceuticals as part of its public health system – particularly given that pharmaceutical therapy has become the cornerstone of effective medical care for many conditions. It is also shameful that the approach to pharmaceutical policy in Canada is a provincial/federal/territorial patchwork quilt. It is true that bulk buying the most common drugs would save the system money, and that providing access to those drugs would likely improve adherence among those for whom cost is the primary reason for lack of treatment adherence. National coverage of the top 20 pharmaceuticals would be a good start.

However, that is all this particular “Big Idea” is; a start. It is nowhere near big enough to actually remedy the larger problems and the larger reality that Canada’s health system is a patchwork quilt of practice and policy that is far from comprehensive. The fact that Canada runs more than a dozen different health systems (each province and territory effectively administering its own system, plus the systems run to address the needs of first nations, prisoners, members of the military, etc.) – is a massive waste of resources in and of itself. Further, while the lack of pharmaceutical coverage is lamentable, other big voids include the absence of coverage for dentistry and the services of many para-health professionals (psychologists, chiropractors, massage therapists, physiotherapists, etc.) and the absence of comprehensive coverage for long-term care. If we want a public health care system that is truly functional and comprehensive – the multitude of public systems would be collapsed into a single federal entity, and the system would be expanded to be truly comprehensive in nature to include pharmaceuticals, the services of para-professionals, and long-term care.

Dr. Danielle Martin’s second “Big Idea” is less is more. This idea is aimed at limiting the number of tests and procedures that are of questionable value or duplicative in nature. In retrospect there are a lot of things that happen in the health system that prove to be of little value, in retrospect there are things that are done that perhaps should not be done. In a perfect world – and even in this imperfect world, it is hard not to say that doing some things less would save the system money and not result in worse outcomes, in some cases, doing less might even result in better outcomes (for example the prescription of unnecessary antibiotics that lead to resistant strains of bacteria). This idea is alluring in its simplicity and echoes the environmental movement to reduce, reuse, and recycle in order to stretch what is available to the limit of its potential.

However, the idea of “Less is More” is deserving of scrutiny, particularly in healthcare. Born out of “Less is More”, are care protocols that exhaust conservative options first, denial or delay of access to diagnostic testing and denial or delay of access to treatment. The first thing to understand, is that healthcare decisions are not made retrospectively. There is no “way-back” machine to turn back time and make a different choice if the choice made proves to have been the wrong one – and for some the “less is more” will exact a terrible human toll. Further, patients are a diverse group of individuals with a diverse range of preferences and a diverse tolerance of risk. Not all patients want to wander through the conservative options first. Not all patients are going to be satisfied with denial and delay of access diagnostics or treatment. “Less is More” as a philosophy has the potential to deprive patients of informed choice and decision making with respect to their own bodies and has the potential of moving the system further away from being patient centred. Too many patients in Canada have already borne the brunt of “Less is More”, of having doctors put the needs of the system ahead of the needs of the patient – and absent any alternative route for patients to access, seems like an unjust infringement of rights that should be contested.

Dr. Danielle’s third big idea is a guaranteed income supplement. Poverty is highly correlated with levels of poor health. If you do not have an adequate income, you may not eat an adequate diet, you may not have access to adequate housing, you may not be able to make investments in your own skills to improve your chances in the labour market. Dr. Danielle’s answer is a straight-up hand out to the poor. She proposes that the tax system be used to directly transfer wealth, and that doing so will address the ills that poverty causes. Doing so will make the problems of inadequate housing, inadequate education and inadequate nutrition simply disappear.

However, this is another idea that is deserving of scrutiny and more than cursory thought. Simply giving money to the poor is attractive in its simplicity. It is what is done every time you walk down the street and give the panhandlers change. However, it neglects the reality that poverty is a symptom of underlying problems, many of which are not solved by a hand-out and for some, money may make those problems worse (in the case of addictions). It is also a bit of a “cop-out”, instead of trying to understand and address the causes of poverty and impacts on those impoverished, society buys itself out of the responsibility to be compassionate, the responsibility to give the impoverished a hand-up rather than a mere-hand out. Further, doing so would negatively distort individual decisions with respect to the development of skills, participation in the labour force, and other life choices. If the cost of making poor decisions is lowered, inevitably more poor decisions may be made. Further, it may generate even greater levels of disdain for those who are impoverished – particularly as significant tax increases on those who have made “good decisions” would be used to subsidize a share of the poor who are poor as a direct result of “bad decisions”. Merely giving money does not translate into better housing, better nutrition, better education and social integration. Canada needs to do the hard work in this area and truly get a handle on understanding poverty and its underlying causes as the solution is unlikely to be a mere hand-out. After all, it’d be a shame to spend all that money, and still have to contend with the results of inadequate nutrition, inadequate housing, inadequate education, and inadequate social integration – when that money could have been used to provide better nutrition, better housing, better education, and better social support. Good medicine is treating the underlying causes of disease and disorder, rather than ameliorating only the symptoms.

Big ideas are most definitely needed if we are going to get to a place where a truly comprehensive, universal public health system that meets the needs of Canadians is to be achieved, the biggest of which is the acceptance of the idea that it does not need to be a single-payer monopoly on medically necessary care.

Wednesday, November 26, 2014

Unintended Consequences: Information Resources Squandered

Freedom of Information and Protection of Privacy (FOIPPA) legislation was not intended to hamstring data scientists and policy workers. It was not intended to cause a culture of fear that inhibits the pursuit of knowledge in the public’s interest. It was not intended to cause the sharing of data and information to grind to a near halt. It was not intended to squander resources to ensure adherence to the letter of the law. It was not intended to result in the gutting of capacity to do valuable research on the efficacy and safety of drugs.

Yet, those are the very real unintended consequences – consequences that are difficult to cope with and understand unless you have attempted to grapple with them first hand.

When it comes to data and government’s use of data – many in British Columbia and Canada are in the dark about how it works and why it critically matters. Many are incredibly fearful of the use of their personal information, and the words “Data Privacy Breech” often elicit a tremendous fear of identity theft. Further, personal medical information is sensitive information that needs to be kept confidential as it has the potential to negatively impact an individual’s personal life. Protection of privacy and the mitigation of risks associated with sensitive personal information needs to be a priority. Those trusted with access to that information have a responsibility and a duty not to violate the privacy of individuals by accessing information to satisfy “personal curiosities” as was recently the case in Vancouver Island Health Authority ( or to sell that information for personal gain as was the case in Ontario a little while ago when a Rouge Valley Centenary Hospital clerk sold the information of birthing mothers to financial companies (

The collection of data (either directly or indirectly), use and disclosure of that information are all governed by FOIPPA legislation – collection, use or disclosure that does not meet the needs of the legislation are subject to significant sanctions including termination of employment, substantial fines or even jail time.

So what does that mean?

It means that every time Ministry A wishes to link individual record level data with Ministry B or to share information with the health authorities, there has to be a Privacy Impact Assessment (PIA) and an Information Sharing Agreement in place. As a result significant resources are used to undertake Privacy Impact Assessments and to draft Information Sharing Agreements. As a result, far less information sharing between different organizations that are publicly funded occurs than what might be optimal, simply because sharing data is an onerous activity. As an example, consider a program that is being tailored to improve upon the health status of “at-risk” families. It is suspected that families who receive welfare, families who are newly arrived, families who have a history of domestic violence, families who have low income are “at-risk” of poor health outcomes. However, much of the needed information is not collected by the Ministry of Health – but is collected through a variety of other ministries and organizations including Revenue Canada, the Ministry of Justice, the Department of Corrections, the Ministry of Social Development, the Ministry of Children and Families, etc.. Much of that information was not collected with the purpose of evaluating or developing health policies or programs. As such, even though “the Government” collects the information, it might be severely limited in the sharing of that information and its use and at a minimum would need to undertake a Privacy Impact Assessment and enter into one or more Information Sharing Agreements. If it is an outside researcher needing the information there would significant costs (thousands of dollars) and delays in the production of information. This would need to happen not just once, but for every project that requires information to be shared between ministries or outside researchers – and every project would have to specify the use and disclosure of the information collected.

Further, it means that once those charged with analysing the information have the data in hand – they are limited in the kinds of analysis and explorations that they may undertake. They are able to undertake the analysis for which they have been granted permission under the Privacy Impact Assessment and the Information Sharing Agreement (or via other legislation) only. Unfortunately, this often means that there is a tremendous opportunity cost that is incurred.

As an analogy, imagine for a moment, that a chef has been given the ingredients for a meal, but rather than enabling and empowering the chef to make the “best meal possible” with the ingredients that they have been given, the chef has also been given a precise recipe to follow and have been told that if they deviate from that recipe that they will be fired. If the chef wants to do something different with the ingredients that they have been given (and retain their job), the chef must first submit a revised recipe to their superior and only after that recipe has been approved by a joint board will the chef be allowed to make the revised dish – however, when the chef has suggested revisions to the recipe before, the suggestions are often dismissed out of hand either because of lack of time, or fear that the chef will produce something that is not palatable.

Imagine what that does for innovation?

Imagine what that does for job satisfaction?

Imagine how hard it would be to keep the best and brightest interested in public data?

Imagine the difference between what is done and what could be done?

Those who work with health data need to be empowered and enabled to make the most of the information resources that are available. They need to be free to explore the data and to make potentially profound discoveries about how the public can be served better. There needs to be a better way to protect the privacy and interests of individuals without sacrificing the potential to develop, implement and evaluate the policies and programs that are publicly funded.

Working with data is not just a science, it is also an art – and unless we are willing to enable and empower those who work with data to make the most out of the information resources available – the gap between what is and what could be will remain.

Wednesday, November 19, 2014

Focussing on the cost of health care won't make it sustainable

The sustainability of the health care system is a legitimate concern - worthy of attention and actions to ensure that it remains capable of meeting the health needs of the population in the decades to come.

Unfortunately, the conversation around sustainability as it relates to the healthcare system is often limited to the cost of providing healthcare. The focus is on saving the system money - almost by any means feasible. The focus is on demand management. The focus is on doing the things that will cost the least amount of money to do, or alternatively, choosing to save money by doing less, doing nothing or denying or delaying access.

There is no end of angst when people (some highly educated and informed) look at the historical patterns of health care use and growth in health care costs and apply current forecasts of population and forecasts of costs. The conclusion that things will go from bad to worse, is an easy conclusion to reach. If a person applies a pessimistic view to the trajectory of general levels of health and well-being (the consequences of less than optimal lifestyles) - a grey picture becomes darker still. However, it is folly to look at the future in this way - can you imagine if people viewed other industries similarly, with a view that how things are done will be the way that things will continue to be done and that demand would simply outstrip supply (note: such an approach does sound somewhat familiar with respect to worries about the food supply).

Almost paradoxically, by focussing on the money (on "taxpayer value"), on the cost of care - the sustainability of the system itself is being jeopardized, opportunities to advance the health and well-being of the population are being foregone, and things very likely will go from bad to worse.

By focussing on the money - policy makers put blinders on and are subject to thinking in the short-term, managing this year's budget and next year's budget - and perhaps if the government is newly elected maybe the budget 3 or 4 years down the road is taken into consideration. The ability to truly consider impacts for a generation or more is limited. The long-term view is abused to inspire "chicken-little" thinking. As such an investment in health that might take a decade (or more) to "pay-off" is likely to be foregone in favor of investments that have pay-offs in the short term. As such, short-term cuts to access become appealing because they improve the budget that is on the immediate horizon - the budget that becomes so central at the time of the next election. Cuts that impact a small group of people are chosen in order to please the majority of taxpayers with promises to keep expenditures "in-check". All the while, undertaking the business of healthcare, becomes ever more frustrating (and unsustainable) to both patients and providers, as innovation becomes an unintended casuality and provider burnout becomes an unintended side-effect of short-sighted cost-cutting.

However, consider for a moment, what might happen if the focus were to shift away from "taxpayer value" and towards a system intent on pleasing those who use it (patients), by doing what can reasonably be done to improve the health and well-being of patients. A system that truly values patients, and those who provide services to those patients. A system that is compassionate enough to understand that health needs often have soci-economic causes. Think about the kinds of wide-angle thinking that might be fostered - the kinds of innovation that might come to fruition.

If we desire a "sustainable health-system", the first step is fostering a shift in thinking and shift in focus, and to believe that "taxpayer value" will follow as a side-effect. I conceed, it is a radical leap to be made - but a critical one if true sustainability is the goal.

Perhaps, as some measure of evidence of the potential for this kind of shift, consider the results businesses have been able to achieve by making similar shifts. Consider the businesses that have shifted their thinking away from "shareholder value" towards delighting their customers - notable examples include WestJet, Telus, and Apple and in contrast, organizations who have refused to make similar shifts. Is there any real evidence that thinking a parallel shift in thought applied to public systems is foolish?

Monday, November 17, 2014

The Dawn

I will be blunt, in the year and a bit since I returned from maternity leave I have spent most of that year wanting to leave behind the place I have gone to work to for the past decade. I have spent most of that year frustrated and floundering. Most of that year stressed. Most of that year disengaged at best. Often quietly angry by the lack of what once was.

I have gone through 3 supervisors as a result of re-orgs in the past year.

The overall vacancy rate on our floor hovers around 30 percent (nearly 40 percent of all cubicles are empty and 10 percent of offices).

The vast majority of halls have remained as they have been for the past 10 years – barren expanses of cream.

The effects of the 2012 scandal continue to reverberate through the organization.

The scores of the Workplace Environment Survey had sunk to new lows and our branch, had gone from a group with some of the highest scores in the ministry to the group with the lowest scores in the ministry.

On a personal level, a good chunk of the time since my daughter was born has been a struggle (as illustrated by countless posts on this blog). As a result, it has required a great deal of effort simply to tread water, and to get back to a place where I feel that I can once again make headway on the things that I care about. For most of the past four years it was not possible to think about where I wanted to go, when as a consequence of what happened I was stuck on where I had been.

Then there was a dawn of sorts.

In the past 4 years I had not just “tread water”, I had not just kept my head above the level (although often times it had felt that, that was all I was intent on doing), I had made a difference. People had read my blog and for some what I had wrote resonated, for others I was allowed to help them achieve their goals or to better navigate the system, my perspective on the health system had shifted, my perspective on my work had change; I had built new bridges. I was once again at a place where I felt that I was able to not just “tread water” but to move forward in meaningful ways. I am at a place where I feel that I have learned a great deal of very important lessons, and that working to apply those lessons has a great deal of potential, even where I currently am at.

I could “abandon ship” – and indeed, if the right opportunity materialized, a position where the purpose of the position and my purpose and passions aligned, I would. However, in the interim, I could make where I am at, a better place. I could do what is feasible to align my work, my purpose and my passions. I could do things to improve upon the empty walls in the halls, I could do things to shift thinking, I could help others navigate towards being happier here (or elsewhere), I could make where I was at a place where at the very least, the little voice that says “This is not a place I want to be,” shifts, and says, “This could be a place where I’d want to be, if…” and then set about doing those things that will transform this place a little bit each day.

So 14 months after coming back from Maternity Leave, I’m finally, settling in, my boxes are unpacked and the cardboard has been taken to recycling and I’m making where I am at a place where I can do good work, that matters – a place where the difference between what is and what could be, gets a little smaller each day.

Ready. Set. Go. This is the starting line.

Tuesday, November 11, 2014

Cost versus Quality: Focus on What Matters

Money. It is a distraction from focusing on what matters. What happens when a business makes making a profit, it’s only reason for being? What happens when a government makes exceptionally low tax rates it’s only reason for being? In both cases, the organizations quickly forget why they exist in the first place and begin to make decisions that jeopardize and limit the potential of their organizations to do good (even great) work, that matters.

I’ll be blunt, saving the taxpayer an extra $100 or even $1,000 a year, is not going to motivate the kinds of public servants the province needs to innovate, to effectively run its programs and to deliver exceptional taxpayer value (services bought for the money spent). Similarly, making money for the shareholders of a business, likely will not be able to inspire employees to bring their “A” game to the office, day in and day out. A nameless, faceless shareholder or taxpayer simply fails to inspire and meet a deeper need for meaningful work. Even if those working are objectively paid well for the work that is done.

Meeting a deeper need for meaningful work is what enables people to go above and beyond, is what makes a difference between a job done well, and a job done exceptionally well. Finding passion and purpose in the work that is done, unleashes the potential to do not only good things, but, amazing things. People who have passion and purpose in the work they do, do not work 9 to 5, they work 24/7/365 because their work fills an intrinsic need beyond just paying the bills. A need to know that what a person has done matters, that it makes a meaningful difference to lives of others.

That’s not to say that the work that is done should be done without thinking about the financial impact of undertaking the work (resources are not unlimited), or that employees should be wasteful in their use of resources. Rather, it is to say, that in the long run focusing on what really matters is likely to yield much better outcomes.

Applying this thinking to the health system, think about the kind of system that results from focusing on the cost of care (taxpayer centered) versus the kind of system that results on focusing on the quality of care (patient centered).

If the costs of care become the focus, then what is in the best financial interest of the system becomes the priority when making a decision. In a system focused on cost, there is rationing of care. In a system focused on cost, there is a need to control information and decision-making, there is a need for “gatekeepers” and collateral damage becomes an acceptable cost of doing business. In a system where cost of care is what matters, even the needs of providers might be neglected. In a system focused on cost, it is not about what is possible, it is about what is affordable. A system focused on costs sacrifices the needs of both patients and those who provide services in order to appease the taxpayer – it sacrifices the great in favor of the mediocre.

If the costs of care are taken as a given (as much resources are used as are needed to meet needs), then the focus shifts to what is in the best interests of the patients and what is in the best interests of those delivering the services to patients. Information is no longer feared and hoarded. Innovation is embraced. There is no need for care rationing and there is a great incentive for shared decision-making. Further, the work becomes intrinsically meaningful as it becomes about making life better for others, and in particular about making life better for patients. The pursuit of better care and better outcomes becomes the goal. The possible is unleashed.

To highlight the difference between these two approaches, consider the work of Elizabeth Holmes and her company Theranos. In a system focused on costs of care, her work could be seen as a threat, as it opens the door to demands for health services that would otherwise be deferred or go unneeded. In a system focused on quality of care, her work becomes a tremendous opportunity to avoid bad outcomes from ever materializing in the first place. A system that might cost more, but might also deliver far more for the dollars spent.

So what matters, really?

Monday, October 27, 2014

The Continuing Saga of Sam

Last week, I wrote of our houseguest Sam*. My cousin – who has drifted out to the coast, and who it seems is adrift in life. After a week of somewhat anaemic searches for housing, going out Friday night, which led to a Saturday morning that had me discovering pee on my living room floor at 7 am – I went to my cousin’s room to find Jayla (who I let out), but no Sam. I texted my cousin:

“I just cleaned Jayla’s pee off of the floor – not cool.” I called my aunt, asking her to offer to my cousin to take Jayla until he could find a job and a home that would accommodate having a pet. She agreed to talk to my cousin.

My cousin responded more than an hour and a half later by text “Shit on my way home walking.”

At which point, I again went to look in on Jayla, and thought that the room smelled, to discover the source of the smell on the bedroom floor.

I texted my cousin again, with a picture of the offending matter (a rather large turd), “and now this”. To which he responded by text, “God dam,” “I’ll find a place to go tonight can I still do some work for you today or no?”.

My husband and I had discussed how we should respond to the situation, we texted back “Look, you and Jayla can stay tonight, but Jayla has to go by the end of day tomorrow, you can stay until the end of the month.”

The dog was making the housing search near impossible, and what was evident was that my cousin’s lifestyle seemed incompatible with being a responsible pet owner at this time. I was hoping, that perhaps if Jayla was not part of the current situation, that maybe my cousin would be able to do the things that need to be done – things like finding steady work and stable housing. More than anything I wanted my house back, my cousin had been there a week and the stress was starting to build in a number of ways.

At mid-day Sunday, Sam indicated he had found a place, a room that was available immediately in a Condo on a bus route and across from a mall with a middle-aged room mate who worked in the oil patch half the time and was okay with the Jayla. It had seemed as though a minor miracle had happened and that my cousin would soon (in the next 48 hours) be in a place of his own.

On Monday, I asked Sam what his plan for moving was and he said he was paying the rent and the damage deposit, getting keys cut and signing forms, and that he could move Tuesday.

Tuesday, I bought my cousin a moving out gift – a laundry basket filled with a set of towels, some pajama bottoms and a t-shirt, laundry soap, soap and personal grooming supplies. I printed a stack (30) of his resumes and the forms for the Medical Services Plan. He indicated his girlfriend, Mel* who he intended to move out with, was not well, and that he’d move out on Wednesday instead. The gift nearly brought Sam to tears.

Wednesday, I bought Jayla a dog license at lunch. A little after 6, I texted my cousin, “What’s your plan?”

To which he texted back, “Just out with Mels* for din din.” Mels, is his girlfriend, they’ve known each other for all of two months, and for some reason or another, think that it is a good idea to move in together. Not the choice, I’d make, but it’s not my choice to make.

I replied, “OK, do you want a ride to your new place with your stuff tonight?”

He replied “I’ll ask Mels now.”

And then there was nothing, for more than two hours at which I point I texted again, “What’s the plan?” and, fatefully, “Does Lola need to be let out?”

My cousin texted back, “Yes, just one last time,” and “Is it ok if I spend one last night I just feel unsafe without a lock on the door for my girl.” I had gotten the distinct impression, that despite my cousin’s wanting his girl to move in with him, that she did not share the same desire, but was perhaps unwilling to clearly communicate that with him.

I texted my cousin back with the picture of a throughly soiled bed.

“I’m too late – Lola has made a mess of your bed. We can pick up a lock for your door tonight.”

The message though, seemed not to connect, and my cousin texted again asking to stay one more night, to which I texted back, “Your dog has pissed and defecated on your bedding, there is no bedding on your bed and it will be at least 4 hours before it will be cleaned.” I was doubtful the bedding was anything less than ruined, thankful a waterproof mattress protector had saved the mattress, however, I was truly at my limit. I needed my house back.

The message finally seemed to get through, and he responded, “Omg I’m so sorry I’ll be home soon, I’ll pack my stuff.” He and Mels arrived by cab 20 minutes later – I calmly greeted them at the door and said I’d give them a ride to where they would stay that night. I placed a hook and eye lock I had found in the basement with his belongings. He gathered his stuff and we loaded it and Jayla into the car. I drove them to their friend’s place, he ordered Pizza on the way. I dropped them off and wished him well and drove home.

The next day, I texted my cousin and invited him for dinner on Sunday. I had felt somewhat bad about how the move out had gone, and wanted to let my cousin know that he was still welcome as a guest. On Saturday, I texted him further and indicated we could pay him for the work that he had already done, and that if he could come around two in the afternoon that there would be about two hours of work that could be done. He agreed.

Sunday came. Two o’clock came, and went. Then three. Then four, and then at half past four, my cousin showed up with Mels and Jayla in tow. My husband, tired of waiting for my cousin to arrive, had taken the kids out for a walk. He arrived back – and briefly exchanged niceties, asking if there was a reason Sam was late and could not text or call. Sam, being Sam, answered vaguely. It did not go over well. My husband, left to cool off at his office. My cousin, claimed to need to get keys from his landlord, but that he’d be back later. I started on dinner. Not knowing who was or was not going to be eating, I made dinner for four adults and two kids.

Sam later texted to say that he had gotten scammed on his place and was out both cash and a place to live. I advised him that my husband was willing to help, and that he should call the cops. Sam indicated that he did not want to bug us.

Dinner was ready at half past six. I ate alone with the kids.

This morning, I wrote Sam an email –

Sam –

I have no doubt that at the moment your life is not easy. The work that is available to you at this moment is not overly stable or secure, offers little in the way of benefits, and the pay is minimal. This past weekend we offered you a couple hours of work at $20/hour - and you show up 2.5 hours late with no prior text or warning that you intended to be late. You claim to have been scammed on your room - and are out both money and accommodations, and Mr. W has offered to assist you legally in that regard, but you do not want to "bug us". The reality is that at this moment your life as an adult is at ground zero. There is no easy road forward, the choices you make will either lead to an easier and more comfortable life that will afford stability and satisfaction; or, alternatively will lead to a life that is harder yet, plagued by poverty and insecurity and littered with regret.

Over the past couple of weeks, I have had an opportunity to get to know you and I see tremendous potential for you to make a good life for yourself that is filled with the love of family and friends and the rewards of hard work and dedication. You have an engaging personality, the kind of personality that makes friends easily and leads others to want to lend you a hand in helping you to achieve your goals. You are socially gifted. You are physically fit and capable of hard work. Further, you have the advantage of time – you are young enough to create nearly any future you want. At your core you are a good person who is capable of doing well in this world.

You have people who believe in your ability to do well and who are willing to help you help yourself in making a better life. You have people in your life who want to see you succeed – who want to help you up when you stumble and who want to cheer you on when you are doing well – do not take that for granted.

With that said, I would like to offer the following advice:

1. Do not get caught up on your past. Your past is the result of previous choices that were made, and the parts of your past that you regret offer up an opportunity for you to learn how to do better in the moment, and in the future. Let your past enable you to build a better future – do not let it condemn you to a life of struggle.

2. Do not get caught up on your shortcomings or the challenges that you are confronted with. Everyone has shortcomings and everyone is confronted by challenges in their lives. Those who succeed find ways to overcome their shortcomings, ways to compensate for their failings. Those who succeed carefully reflect on the areas of their lives in which they need to do better, and then undertake to improve or compensate in those areas. Further, there is no shame in seeking guidance on how to overcome your shortcomings.

3. Be accountable, to both yourself and others. Be aware of when you have failed either yourself or those in your life, acknowledge the failure and take steps to remedy it. Do not step away from your responsibility to either yourself or to others.

4. Value and respect your relationships with others – as they are, and always will be, your greatest asset and the source of much satisfaction in your life. Try to see others through to the degree possible and resist the urge to see through others. Do what you say you are going to do, and treat others with the kind of respect you'd expect to receive from others.

5. Look for and capitalize on opportunities that move you closer to the kind of life you want for yourself. With each choice you make, ask yourself if that choice moves you closer to or further away from the life you want for yourself in a month, a year or five years from now. With each relationship you have, ask yourself if that relationship moves you closer to or further away from the life you want for yourself – if a relationship is causing you to move further away from your goals, consider fixing it or moving on. If a choice is likely to move you further away from your goals, make a different choice.

6. Seek to be a role model. There will be those who will look up to you – who will see what you do, and the challenges you overcome – demonstrate the kind of life that you would want someone you love to lead. Lead the kind of life you would want your niece or nephew to lead, the kind of life you would want your son or daughter to lead.

7. Strive to rely on yourself and be confident in your ability to do so. Be aware of your attitude towards yourself and about your own capabilities. Seek to rid your vocabulary of the word “can’t” and instead focus on the “can”.

With that said – think about what you want for yourself in a year from now, and in five years from now and start moving towards it. We'd like to keep in touch with you and support you in making good life choices - but we will not support you in continuing to make poor life choices.

This is your life, now lead it.

Much love and kind regards,

The W Family

P.S. The following is a link to the Residential Tenancy Branch who may be able to assist you in your dispute regarding your room.

Mr. W. has also offered his assistance - carefully consider whether or not you want to forego that.

P.P.S. Please find the following information on housing/shelters in Victoria - as much as we'd like to help you out further in the way of housing, we do not want to support you in continuing to make poor life decisions, and these programs may be better able to assist you.

Threshold Housing Society: , , and the referral form:

Out of the Rain Youth Shelter (pet friendly)

Our Place:

Coolaid Society:

Again, as much as it may pain you to do so - seriously ask yourself whether or not your lifestyle at this time is compatible with having a dog - and whether or not you can adequately meet her needs. Having a dog is a choice - one that might be moving you further away from your goals, or alternatively adjust your lifestyle and place meeting her needs as a priority in your life.

P.P.P.S. We have a cheque for you for the work that you have done - let us know when you'd like to pick it up, or alternatively, if you'd prefer email money transfer, that too is doable.

*Names have been changed to protect identities.

Wednesday, October 22, 2014

On The Road to a Healthier, Happier Mrs. W

At the beginning of October, Mr. W and I went away on a mini-vacation. A welcomed get away to Seattle, where we indulged in sleep, and food, and drink, and shopping - and yet more food and drink. The shopping was needed in part because in the year since returning to work (economists are desk jockeys), my pants had grown tight and there were very few pairs that actually fit. I had hoped that a year after my return to work, that more of my pants would fit, rather than fewer. The scale confirmed what the pants were telling me - I was just 10 pounds lighter than I was when I was 9 months pregnant with my daughter, a full 15 pounds heavier than when I returned to work. I had joined the two-thirds of the population who are either overweight or obese in Canada - with a BMI squarely in the overweight category. I had also noticed that my blood pressure that was historically low/very-low had creeped up to normal levels over the past year (in years past it would be 95/50 - and was last clocked at 125/65).

I resolved that I had to do something different and the sooner I did, the sooner I'd be on a better path. Further, having had developed gestational diabetes with my daughter, and having a father and grand parents who have developed Type II diabetes - I know that I am at an elevated risk of developing Type II diabetes over the next decade.

I had all kinds of reasons to be out-of-shape. My work environment is stressful. The kids limit the amount of time I have to work out and get exercise. My husband does the cooking. I was mildly depressed. I'll get fit after I change jobs, or after Wyatt starts kindergarten and life is more accommodating of doing so.

I knew whatever I did had to be compatable with where I am at now, and that waiting for other circumstances to align to do something might come at a steep cost in terms of my health (if the last year had brought 15 pounds and a 30 point increase in blood pressure, where would I be in 5 years?). So I thought about what I could change to get to a healthier place and have been pursuing the following strategy for the past 17 days:

*I have abstained from drinking alcohol - I wasn't a "Big Drinker" before, but 5-7 glasses of wine/beer and the occasional Martini over the course of a week has a way of adding up. I have decided that when I reach my interim goal, I might reintroduce wine to my diet - which has been surprisingly motivating.

*I have eliminated creamer/milk from my coffee and have grown accustomed to drinking it black.

*I gave my husband a cooking holiday and have taken over most of the food preparation.

*I bought a FitBit($99) and installed its app (FREE) - initially I bought a black one, and three days later, just long enough to fall in love with it, it got lost. So my current FitBit (another $99) is grey/blue and in Sharpie I have written my phone number.

*I started weighing my food (bonus use for the kitchen scale we already have), and journaling what I ate via an app on my iPhone (MyFitnessPal - FREE). Because the app counts calories for me, can add calories for the activity tracked by my FitBit and sets a calorie goal for the day staying on track has been pretty easy. As a bonus - because of the nutritional information the app provides me I have a better understanding of where my diet falls short and the impact of small changes (like substituting baked yam fries for fries). I have found that I can eat a very large volume of food that is hunger satisfying within the calorie goal if I focus on eating non-starchy vegetables (most veggies are calorie cheap), some fruits (melons, apples and berries are also colorie miserly choices), and proteins, choosing whole grains (quinoa is now a staple), limiting dressings and sauces and avoiding refined flours and added sugars. Chocolate bars and desserts aren't "out-of-bounds" but when faced with the choice of having such a treat and feeling hungry later, I have changed the choice I make. I've said good-bye to the pain-au-chocolat, and have opted for Hazelnut Chocolate Chia pudding instead (125 mls of Chocolate Hazelnut Almond Milk mixed with 15 grams of chia seeds and allowed to set for 45 minutes). This has meant packing a lunch - and has had the pleasant bonus of avoiding the $10-12 lunch expenditure each day.

*I got a FitBit Aria ($130) - a wifi scale that links up with the FitBit App and MyFitnessPal and allows for tracking trends over time. As a bit of a surprise, the Aria also lets you spy on non-registered users of your scale (guest users)...

*I committed to 10,000 steps a day (a walk at lunch time usually is enough to get there) and a Boot Camp (45 minutes, 3 days a week - cost $120 for 4 weeks/12 sessions).

Seventeen days (and $450)in, and I'm starting to notice more energy, better mood, looser pants, more money (as spending on booze and lunches has been slashed - I anticipate the sunk costs will be recouped in less than 3 months as I estimate a $25 saving in food costs and $20 saving in booze costs per week - $180 per month) and have dropped nearly 5 pounds. I'm looking forward to a more enjoyable ski season and am hoping that most of the changes that have been made can be sustainable over the longer term.

Thursday, October 16, 2014

The Category is: Early Twenty-Somethings

Today’s post is a bit of a divergence – it has nothing to do with healthcare, maternity care, or my workplace. Today’s post is about our unexpected, hopefully short-term, houseguest.

On Friday, I got a phone call from my Aunt – who still lives in my hometown. Her eldest son (early twenties) has decided that it was time to leave the family home and moved out to the coast in June and has been living between the Victoria area and Salt Spring Island. He has been doing cash jobs (general labour stuff) and crashing at acquaintances. In July he was involved in a car accident, and briefly went back to Alberta for medical care, but returned to the coast in September.

“Are you around this weekend?” she asked.

“Well, sort of yes and sort of no – we will be around Friday but not until after 9 as we have a Thanksgiving dinner to go to, and we have the other two kids this weekend and were planning on being away Sunday night to go to a Thanksgiving dinner in Lake Cowichan.” I replied. It was going to be a busy weekend with a full-house. The dinner in Lake Cowichan was later cancelled.

“Well, would it be at all possible for Sam* to stay with you guys this weekend. I am kind of desperate, he has nowhere else to go.” Rock meet hard place.

The thing is, it’s not just Sam, but Sam and his dog “Jayla”*- a completely sweet purebred English Bulldog, but a dog none-the-less. The thing is, when it is just us our house is pretty full as we are trying to sleep train the toddler & preschooler and doing so is immensely easier when they can sleep in separate rooms and when the older kids are with us, there really is no spare room. The thing is between my job, my other job and my husband’s job and the kids – we were already red-lining. Having guests is one thing, having an unemployed early twenty-something, young man and his dog stay with next to no notice is quite another. Particularly, an early twenty-something young man who I barely know – I moved to the coast nearly 18 years ago now and my cousin might not yet have been in school when I did so. I have seen him all of a handful of times in the years since – and, had sparingly kept in touch with his mother. But he is family, it is Thanksgiving, and there was nowhere else for him to go.

“I guess so.” I replied.

So on Friday night my cousin (tattooed and pierced) and his dog arrived, after we had retired for the night, he parked his defunct Moped and trailer in our carport. We left a towel and some soap on his bed, and a note directing him and Jayla to the shower. I awoke the next morning unable to find my laptop – he had taken it from the dining room table and it was open beside him as he slept. I found myself mildly annoyed.

He slept late on Saturday. When he woke, and we spoke it was clear – my cousin had no work, no home, no money, no reliable transportation and no plan. He offered to make-do and crash at a friend’s house for the rest of the weekend, we offered for him to stay as he was already settled even though it would mean having my step-daughter bunk with her little siblings. The last thing we want is for our place to be a revolving door for my cousin, and we are hoping that when his stay with us is over, he will only be an invited guest (for dinner or the like) from time to time.

On Saturday, we took his resume (it clearly needed formatting and editing) and formatted and edited it – “So what year did you graduate high school?” I asked.

“I didn’t graduate, I need Science 12. Dumb, I know.” He replied.

I could not help but think, who in 2014, does not finish at least high school? Victoria is a University town, so there’s no shortage of young people looking for work. The lack of high school would put my cousin at a strict disadvantage.

“So do you have any other training? Like Food Safe or Serving it Right, or anything really?” I asked.

“No” – he replied succinctly.

“You might want to consider getting your GED or doing the course by correspondence as a high school diploma would really open some doors.” – I continued, half knowing that at some point, probably years down the road that he will need to come to that conclusion himself, and that no amount of well-intended “advice” will convince him at this time.

The resume done and emailed to him, I was hoping to find him actively scouring the internet for work. Nope, he was cruising Facebook. I was irritated.

I did a load of his wash (it is doubtful that our laundry machine has ever had such a challenge before, and in a house with toddlers and a dog, that is saying something).

On Sunday he again slept late – my husband waking him and reminding him that people without jobs and homes should not be sleeping in and asking him help with some chores around the house. He happily and diligently helped with the chores. He then tried to get his moped to work – switching the fuel in it and playing with the wires. He and his parents bought it the week before and needed to get it running, which it was, but since then had yet again had a mechanical failure. The back brake was also not operational. The Moped is 40 years old – and for the time being should not be considered reliable (or safe for that matter) transportation.

“Do you have a helmet?” I asked.

“No” he replied .

“You know you’ll probably get a ticket for riding it without a helmet.” I added – while thinking, you know, without a helmet if you only wind up with a ticket and not a brain injury, you would be lucky.

“I know – almost got a ticket the other day.”

It seeming clear that finding work quickly would be wishful thinking without some help, it is also clear that steady work and the money that comes with it are likely pre-requisites to finding a place that Sam can call home. Further, finding a home for Sam, is an absolutely priority – if not for Sam, for myself and our family - so my husband forwarded the revised resume to an acquaintance of his who runs a temporary labour company for blue collar workers. Luckily, the acquaintance was able to find work at a construction site that started on Tuesday. So far, he has worked hard and diligently and it is looking likely that the crew he is working on might employ him directly. At least with work and a legitimate paycheque, his chances of finding a roof over his head would be greatly improved.

Wednesday morning I went to give my cousin a ride to his co-worker’s to car pool (as was discussed the night before), as we had planned the night before only to find his room empty, his hard hat on his bed and his work boots on the floor. No note was to be found.

I texted him – and he explained that he went to his colleagues place earlier and would rent his equipment for the day. I let him know that not doing what you say you are going to do earns no brownie points around our house. I found myself, again, irritated.

So at least my cousin had work. But still, no home and he seemed to be making only cursory efforts at finding a home. It is Thursday – and I think he has only looked at less than a handful of places (maybe 3). On Tuesday I sent him a dozen links to listings. Yesterday, I started emailing and texting a few on his behalf. Today, I wrote an accommodations wanted ad on his behalf. If by the end of the weekend there is no headway on the home-front (Victoria’s rental market is insanely tight and having a dog in tow does not make it any easier), I will be requiring him to apply to a program directed to housing otherwise homeless youth and helping them with life skills.

Don’t get me wrong, my cousin is a sweet kid, as is his dog, he seems to be reasonably hard-working, has an outgoing personality and he does not smoke – he gets on with the kids, however, he is still an early twenty-something with all that comes with that territory. Including all kinds of things that not being an early twenty-something and being an entirely different kind of early twenty-something when I was – I am likely to find at a minimum irritating. He needs to be an early twenty-something somewhere else, and the less I know about it, probably the better – as it is entirely likely, that withholding judgement on the choices he makes might be beyond my capacity.

On that note – know of an available and affordable suite or somebody looking for a roommate in the Greater Victoria area (even a sublet would be fine)? Please drop me a line or two...please.

*Sam – not their real names, pseudonyms are being used.

Friday, October 10, 2014

Get it, Got it, Good

It's easy to see judgement of the choices women make - often by other women. Look no further than the mommy wars. Look no further than the question whether or not women should have the right to a cesarean section. Look at the right to access an abortion.

Sometimes the judgement is downright militant. There seems to be a need - not only to control our own lives, but then to extend that control to others. A need to have our own choices reflected back in the choice of others. A need to pressure others to make the same choice.

The pro-lifers with placards outside of women's health clinics are bullies - seeking to shame women away from their choice. The lactivists who seek to shame women into breastfeeding. Those who look to those who work outside of the home with disdain - and those who look to those who stay home with an equal amount of disdain. All of them are bullies.

It is not healthy.

It is an act of seeing through other women, rather than seeing women through.

Today, Malala Yousafzai became the youngest winner of a nobel peace prize - she is quoted as saying "A girl has the power to go forward in her life and she is not only a mother. She is not only a sister. She is not only a wife, but a girl should have an identity." Malala gets it.

A while ago, Suzie Barston and Kim Simon started the #ISupportYou movement. Suzie and Kim get it.

Similarly, Dr. Walker Karraa, founded Stigmama to start to peel away the many layers of stigma associated with mental illness, particularly among mothers. Dr. Karraa, gets it.

In her speech to the UN on the need for men to also be feminist, Emma Watson demonstrated that she gets it.

Lastly, in my own home town, I came accross another woman who seems to get it. Celtie Lou - gets it.

They get that we need to see women as people, fully people: nothing less. They get that we need to be secure enough in our own choices to allow other women to make their own choices even when they are different from our won. They get that we need to support and empower women - understand what the real needs are, and then work to meet those needs. We need to respect each other. We need to see each other through, rather than seeing through each other. What's more, is that these women understand that it's not enough to just get it - and what is remarkable and amazing, is these women understand the need to help others get it too. They are doing good work.

Imagine for a moment the world, if more women got it. If more people got it. Truly got it. Imagine the communities, imagine the mountains that could be climbed and the challenges that could be overcome.

Now ask yourself, what can you do to help others get it? Go do that. It is good work.

Tuesday, October 7, 2014

Small Steps in the Right Direction

This past week, something critical to the functional health of the BC Ministry of Health as a workplace, happened. Something that might signal a real turning point and a shift towards rebuilding the organization from the cultural damage that resulted from what was for many of those involved, an entirely disproportionate and inappropriate reaction to the circumstance.

Minister Lake, and Deputy Minister Stephen Brown issued an apology to the family of Mr. McIsaac. Further, there has been a committment to reviewing what happened in 2012 to learn from it and to revise policies and procedures to ensure that a similar situation will be handled better and more appropriately in the future.

Mr. McIsaac, was a co-op student who, 3 days from the end of his work term was fired from his position at the ministry along with 6 other staff. Subsequently, an investigation (which cost no less than $3.4 million) determined that there was not actually an breach in data security and largerly cleared the staff in question.

It is not easy to take responsibility for a mistake - particularly a mistake that happened as the result of another person's actions or inactions. The minister and deputy minister that were heading the ministry in 2012 have since moved on. As individuals, the current minister and deputy minister are not to blame for what happened in 2012. However, it demonstrates real leadership to recognize the responsibility the organization has for what happened in 2012, to recognize the need to learn from what happened, and to take steps to repair the damage that was done.

The events of the past week, are small steps in the right direction. It is unfortunate that such steps were not taken proactively - happening only after a very public appeal from the family for an apology. However, there is an opportunity to be proactive about the next steps that are taken - and for the sake of the Ministry, and the family of Mr. McIsaac and the others involved in the scandal, I hope the next steps continue in the right direction and adequately address what still needs to be done.

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.

Sunday, August 31, 2014

Ethics and Single Payer Healthcare

Ethics can be described as the art of doing the right things for the right reasons. Recently, a family doctor (Dr. Brcic) writing for the Tyee claimed that private for-profit healthcare in BC had egregious ethics because the finances of for-profit care were obscure, accessibility of for-profit care was limited, and that individuals coping with pain and illness were vulnerable.

However, in claiming that the ethics of for-profit care are egregious, it would be a large error, an egregious one, to assume that the ethics of single-payer care are any better. Perhaps what is striking and often ignored are the numerous ways in which conflicts of interests and breaches of ethics occur because of the single payer system and how it is structured.

First, by prohibiting competition in the healthcare sector for medically necessary services and being the sole provider of those services, government is in a conflict of interest. It has a political interest in making it look like the system performs well. It has a financial interest in limiting the amount of money spent on services provided. It has both a political and financial interest in limiting accountability for medical error and system failures. It is fair to say that many measures of the system are cherry picked to demonstrate good performance or obscure poor performance. The system does not measure real wait times. The system does not measure care demanded but not received. The system takes credit, for things that are likely the result of other socio-economic changes. Holding the system to account for medical error, or even medical malpractice is notoriously difficult in Canada. Is it particularly ethical that a person wanting cosmetic surgery likely faces a much shorter wait time than a person in need of pelvic floor repair? Is it particularly ethical that a consumer who buys a faulty car likely has more recourse than a victim of medical error?

Second, by making doctors accountable for system sustainability it puts doctors in an unenviable position of being in a conflict of interest when it comes to the best interests of individual patients versus the best interests of the system. Doctors need to be able to focus on the needs of their patients without worrying about the needs of a system.

Third, a single-payer system often results in an arbitrary violation of an individual’s right to medical autonomy. Rather than a person being in charge of what is done, and when, the system determines which choices are available and controls access. If a service is medically necessary, an individual is at the mercy of the system and the system’s assessment of the importance of the condition and accessing treatment. The system assumes (wrongly) that all individuals affected by a condition are impacted in the same way and fails to adequately reflect the wide variety of circumstances that individuals contend with. Further, because of the political nature of a single payer health system, conditions that have a high degree of stigma, or that affect few individuals may have a difficult time jockeying for a fair share of the resources needed. Is it particularly ethical to withhold access to treatment options and care, when the resources are available (upwards of 16 percent of specialists in Canada are unemployed, and more are likely under-employed), simply because public tax money is unavailable, but private resources are available? Is it particularly ethical to deny an individual the right to make medical decisions for themselves, because those decisions do not conform to the decisions the average taxpayer would make?

It is perhaps important to remember that politicians are not always renowned for their ethics, and it is an egregious assumption to declare that doctors are willing to abandon their ethics in favor of profit in a private system.

Wednesday, August 27, 2014

The Fine Art of Feedback - A Lesson for Fraser Health

Feedback is a gift - those who provide it are being brave in doing so, they are providing an insight into not only want went wrong (or conversely well) but how to do better in the future. It's not easy to tell someone else or an organization that they failed you. When a person provides feedback, they do so in the hope that someone else will not be failed in the same way. They do so in the hope that by being open - by exposing themselves, that they can affect positive change. They do so in the hope that their words do not fall on deaf ears.

The easy thing to do, is to defend against the criticism. People and organizations receive feedback as a threat - a threat to their viewpoint. Further, it is difficult to admit that what was done or not done caused real harm to another person. It is difficult to admit that change is neccessary. Particularly difficult when the organization or individual is heavily invested in their point of view or way of doing things.

This past week, Fraser Health got the gift of feedback. The articles, on Today's Parent, and iVillage and comments on those articles are a treasure trove of information that can be used to do better - to provide quality care to all moms, to learn.

However, rather than take the gift as an opportunity to do better, to initiate changes to better serve moms, Fraser Health took the easy way out in their response. Which basically reads like - the choice is yours as long as your choice is the same one we'd make for you, which is to breastfeed, unless it's absolutely not a physical possibility.

So what's the problem?

The problem is that the health and well being of ALL women at a time of exceptional health vulnerability (not just physical health vulnerability, but also mental health vulnerability) needs to be supported. The problem is that a health authority can not just say that they are available to support the needs of those who make the choices they deem to be the 'right' choices. A health authority can not just substitute ideology for quality care and neglect the needs of those who either cannot or choose not to breast feed. The problem is that the right to do what one pleases with ones' own body is sacred and that those choices need to be made out of free will, not coercion.

The problem is that health care provision should never come with a big heaping helping of unjustified guilt and shame, as that generates stigma and undermines quality care.

So what would be the right response, in this situation? How could Fraser Health make the most of the gift of feedback that they've been given?

The right response would be to acknowledge that real harm has resulted from the policy - harm that Fraser Health is committed to remediating. The right response would be to include those who have been brave enough to call out Fraser Health in it's approach to new moms to develop a new approach to infant feeding. The right response would be to develop an infant feeding strategy that treats grown women, new mothers, like adults and respects their right to decide what to do with their own bodies. The right response would be to commit to support all women in the provision of quality healthcare during pregnancy, childbirth, and the year post-partum and to encourage feedback, and to use that feedback to do better.

Fraser Health via twitter has indicated that they are reviewing and would like to talk and has asked for my contact information.

I am hopeful they are now willing to listen, and will ultimately find their way to doing the right thing.

Tuesday, August 26, 2014

Infant Feeding Declarations: A Violation of Quality Care

Quality care begins with an unwavering commitment to meeting the needs of patients by providing informed consent and collaborating on care plans in a spirit of shared decision making. That means working with patients to understand what matters to them, it means providing the benefits and risks of the options available, and it means respecting their decisions. Stigmatizing certain decisions does nothing to promote health and well-being of any patient – including mothers.

As such, it is disturbing to see quality care take a back seat for some new mothers in British Columbia as health authorities fail to support all new moms in what is perhaps one of the most health challenging times of their lives. Specifically, the “Infant Feeding Declaration” that is being hoisted upon women is a reprehensible violation of the duty owed to these women as patients, a duty to provide the care that best meets the needs of mothers and their babies, a duty to provide informed consent, and a duty to foster shared decision making.

In the “Infant Feeding Declaration” women are told of the benefits of breastfeeding and the risks of formula feeding. Further, they are asked to make a promise about their future actions regardless of the circumstances they might ultimately face. Imagine being told that by feeding formula you are providing your child with less than the best start in life – and the additional guilt that is brought on by the feeling that you “broke a promise”. Imagine the stigma associated with even admitting that you happened to use formula.

How does any of that contribute to good care?

Frankly, Fraser Health, and any other health authority in British Columbia or elsewhere deserves to be told that treating patients in this way – new mothers, grown women- is wrong and needs to end. All mothers deserve support as they begin motherhood - all new mothers and their babies deserve informed consent and shared decision making. All new mothers deserve to feel that they can be honest about how they feed their children with their care providers – and that means health authorities should provide care and hold the judgement.

I encourage you to tweet (@FraserHealth) or email them and let them know you think they’ve gone to far. Demand better!

Monday, August 25, 2014

The Irony of Insisting That "Patients Must Demand Better Care"

Ever read the statistics on Malpractice suits in Canada? Maybe peruse the reports from the BC Patient Care Quality Office? Read up on the incidence of medical error? Maybe you have read the latest Commonwealth Fund report on healthcare in Canada – you know the one that places Canada second to dead last among OECD countries in terms of health system performance? Are you at all familiar with who the patients who use the health system actually are? Are you familiar with how the system is structured?

There are those who insist that patients are the ones who should be responsible for changing the healthcare system – that patients should demand better care. It is a shame that those who take this stance have not really given much thought to the reality of being a patient. It is a shame that they seem to have neglected that it is one thing to “Demand Better Care” and quite another to have the demand that is made, heard and then actually result in “Better Care”. It is a harsh truth that there are patients who have been “Demanding Better Care” – in whatever ways they can – but that many of these patients find that their demands are met with the same indifference that the demands of a toddler asking for a non-existent popsicle are met with.

It is all well and good to think that patients should have the ability to demand better care, and that those demands should result in meaningful and positive change. But the reality is that the system is designed in such a way, that the patients are the people ‘in the system’ whose voices are least likely to be heard but who are impacted most when the system fails.

Think about it – think about the resources at the disposal of the government. Think about the organization of doctors, nurses and healthcare providers. Think about the knowledge of “the system” that these other parties to the system have. Think about the levers available to affect change in the system – and exactly how few of them are available to patients. Now think about the reality of facing a health challenge – and then having the burden of “Demanding Better Care” hoisted upon your shoulders when you are at the mercy of the system.

As it currently stands, patients in Canada are in a position where they have tremendous potential to affect meaningful change, but until those who are in control of the system meaningfully empower patients to affect that change, they remain unable to do what they are being called upon to do.