It's one thing to identify a problem, another to solve it.
In my last post, I worried that one of our hospital wards was about to undergo an expensive renovation without a full exploration of the alternatives. The stated motivation for the renovation is to expand surgical bed capacity to accommodate an increased volume of procedures. The increased volume results from the Saskatchewan Surgical Initiative goal of offering surgical dates within 3 months of booking by 2014.
My concern is that spending this money on renovations supports the status quo. It will give a false sense of accomplishment and quell the urgency to implement innovative solutions that hasten postop recovery, so as to reduce the need for hospital beds.
Now that I've convinced myself of the huge opportunity cost of investing in bricks and mortar rather than process improvement, I feel compelled to act. (Curse you, Conscience!) But, what to do? In a big organization like Saskatoon Health Region (SHR), decisions are made from the top down. Once resources are committed to a significant project like this, positions are entrenched and minds unlikely to change. I might as well just keep my head down, do my own work, and keep my nose clean until retirement. Right?
That's a victim mentality. I reject it. I may not be able to influence all the decisions that I would like to, but if I remain passive, I will influence none of them. The victim mentality is a self-fulfilling prophecy: If you think you can't, then you are right. (attrib. Henry Ford).
Where to start?
With myself, of course. Have I understood the whole situation? Have I jumped to conclusions? First, I need to talk to the administrators charged with the daunting task of matching surgical volumes and bed capacity. I need to hear their side of this story.
What can I contribute to finding a solution? I can bring a clinical perspective. I can suggest what improvements can be implemented within a reasonable time. I can have conversations with my medical and surgical colleagues in ways that are generally inaccessible to non-clinicians. I can bring knowledge of and experience in using improvement techniques. I can bring a mile-wide stubborn streak.
Then I need to understand how to engage administrators in the quality agenda. Oooh, snap! That phrase usually reads "engage physicians in the quality agenda" and is spoken by administrators. I hate the implications of the phrase and I'll bet administrators don't like it pointed at them either. I've griped in previous posts that, doggone it, physicians are already "engaged" in the quality agenda, and that healthcare leaders need to remove the obstacles that prevent us from achieving our goals. Maybe there's a similar situation with administrators.
What if, contrary to what many clinicians believe, administrators actually are interested in improving the quality of care, and there are obstacles in their path also? What are the obstacles?
Insufficient current clinical knowledge is a significant impediment. While many administrators have a clinical background, they may not have up-to-date information on the latest techniques in perioperative care and surgical techniques that can speed patient recovery. They may not know what is possible to achieve.
Daily operational pressures crowd into the time needed to deeply contemplate solutions to complex problems. A manager explained to me last week that "bed rounds" - a meeting of most the hospital's managers - happen twice a day. Twice a day! These managers are just trying to keep their heads above water. How can they possibly free up the time to be innovative?
Goals and objectives are set by administrators at the next level up in SHR's hierarchy. If senior leaders set a goal of increasing surgical volumes, and give very tight timelines to achieve that goal, then managers and directors will grasp at the first, most obvious solution. While they may have considered other options (see the last post), they may reject them as too unwieldy or time-consuming. It may be more expeditious to spend lots of money, and build our way out of this problem.
I can help with the clinical information, but for each of the other obstacles, SHR's senior leaders will have to remove the barriers the managers and directors face: overwhelming operational responsibilities that consume cognitive resources, and perverse incentives that lead us to deliver greater volumes of status quo rather than the exceptional care of which SHR is capable.