50+ Years on the Front Lines in Health Care

As of this month, I have been doing hospital ward service, night and weekend call for over 50 years. This wasn’t the burden that you might imagine. For one thing, I haven’t had to waste a lot of time asking what worthwhile thing I might do in my life to help people. Doing night and evening call well, in addition to daytime work, has been a big part of the answer.

How could I be helpful? My wife, a former social worker constantly reminds me that courtesy is a great start. I get “a sour look” if she doesn’t like my “tone” when taking the call. Every time I pick up the phone, I try to remind myself that people who call through the night are calling because they are worried. Trying to be friendly and supportive, in spite of the hour, is the first step in reassuring callers that you want to help them with their problem. After hours medical availability has two other advantages. Most people will not call if they know that our team is available should trouble arise. Telephone support, done well, reduces the number of people going to the Emergency Department after hours, which helps lessen the burden for the rest of the hospital staff as well as demand in the broader health care system.

Younger colleagues joining our hospital specialty practice, tend to regard this kind of availability as crazy but with time, most realize that meeting patient’s needs is less work rather than more work. This service is not available to every one of the thousands of patients we see, but our team offers 24/7 response to the smaller group with serious diseases. The fact that we take these calls for this group of children has a subtle dividend. Our availability earns the respect of our colleagues when we need to send patients to the Emergency Department with the additional benefit that ER colleagues can be briefed on relevant clinical issues. All of this results in better communication, faster, safer and more efficient care.

There are also many opportunities to improve care for admitted patients. Hospitals like all organizations have operation manuals spelling out how things should be done according to our administrators. Then, there is “the invisible hospital” - how the hospital actually runs which is understood by the staff delivering care. This includes ward clerks, porters, technicians, allied health professional doctors and nurses among others. Some of the others include the patients of families with chronic diseases.

In airports, these folks are known as frequent flyers. Airline businesses make an effort to structure their services to offer the best treatment to frequent flyers. Most hospitals have patient and family care committees to gather the perspective of these “users” of the system. It’s not always clear that this perspective makes its way back to the boardroom. In fact, it was a really good signal when our hospital administration recently decided to move their office back to the hospital premises from a downtown office building.

Any business owner will tell you that they learn more about the problem in their businesses by doing a “walk about”. They will find out things like, there are insufficient parking spaces, the elevators are slow or don’t work at all. The patients in clinics are asked to wander all over the hospital to get their labwork, x-rays and prescriptions, and directional signage is poor. Administrators who get out of their offices get a chance to chat with employees and patients who well know the real problems of the organization often deeply buried in official reports. It’s a big help if these administrators have had a background working on the front lines of health care.

The further administrators get from the clinics or bedside, the more difficult it is for them to run the hospital well. This principal applies to higher levels of administration as well. Most cities in Canada have decided to rationalize and consolidate care as a way to save money spent on administration. This also means that many of these multi hospital systems have 5-10,000 employees making it challenging for front line workers to correct even minor issues. Some hospitals convene “Town Hall Meetings” where employees can get to know their administrators and their priorities. Hospitals have also responded by adopting Quality Improvement Programs. Quality improvement programs in health care were adapted from the auto industry which faced similar challenges. In the best system, the quality teams meet regularly to go through itemized issues, define a process and document the disposition. It is a bad sign when these programs are run by the administrators focused on “the process” rather than the problems the staff have identified.

There is a law of nature which dictates that the further administrators get from the patient, the more non patient care issues dominate thinking. In Ontario, hospitals report to regional health councils. Governments regularly shuffle the organization to give the appearance that they are doing something without much evidence that these “shakeups” accomplish much. A number of years ago our Regional Health Council decided to do something definitive about the delivery of Home Care. Physicians who hoped to see an improvement were disappointed to see that governments dumbed down service delivered by the best teams to a lower standard.

This can be a special problem when it comes to Federal Government involvement in Health Care. Canadians are understandably proud of being citizens with universal health insurance which is enabled by Federal Government law, partial financial support and the ability to bring the provincial governments together to encourage a national standard in some of their programming.

The downside is illustrated by the recent fiasco involved in the “Axe the Fax” initiative. The Federal Government managed to spend $300 million in a country of 38 million people and completely failed in their objective to get physicians to e-mail prescriptions to pharmacies rather than use a Fax.

I was part of the reference group at the early stages of the initiative. After a year of presentations, our committee of 16 (unpaid) individuals was abruptly shut down without explanation. At my recent annual physical, my family physician showed me how the “shut down” had forced him to go back to sending individual faxes adding hours to his work week. I had never used the system either because it lacked a “feedback loop” telling me that a prescription had been received at the pharmacy. It was especially galling to learn that the CEO of this debacle had been paying himself close to $900,000 a year in salary and benefits.

At another postmortem on our failed billing system integration for 1000 physicians in our regional group, I had to ask several times whether the executive running the program had ever actually tried to use the program himself. I didn’t want to badger him but that’s what it took for him to admit that while he was “the face of the project”, he had never used it himself.

We will never have enough money to meet the growing needs of the expanding cohort of “aging baby boomers” added to the extraordinary needs of a legion of young children who have immigrated from the “underdeveloped world” but we don’t stand a chance unless the hospital planners and administrators get themselves into doctor’s offices, clinics, wards and emergency departments across the country where care is actually delivered.