Making Healthcare Work: Principles, Rules, Actions

For those unfamiliar with the Canadian situation, (mostly) US-based corporations are lobbying furiously to get our governments to abandon Canada’s public system and replace it with a US-style, two-tier, system, despite the fact that the US system provides most Americans (excluding the rich, overprivileged elite) with demonstrably poorer health care (Mike’s books have substantial data to back this assertion up), and are much less efficient and effective (health care costs consume 15% of US GDP compared to 9% in Canada, although millions of Americans are uninsured or underinsured, and the bureaucracy of the US system is stifling, with paperwork consuming as much as 40% of spending, far more than in Canada, to the point the NYT recently moaned that many Americans were so overwhelmed by the bureaucracy of the system that it was interfering with the quality of the care they receive).

The reason for this lobbying is obvious and self-serving: Big Pharma and Big Medicine make substantially higher margins selling into the American system, and they want to con Canadians into believing that they should want such a system as well. So waiting times (although comparable to those in the US) are trotted out as evidence that Medicare is broken and the government is necessarily less capable of running a healthcare system than greedy private corporations. The con is working — the Conservative party in Canada and in Alberta, always willing to help generous foreign corporations line their own pockets in return for fat campaign contributions — is helping out with the misinformation campaign. So Mike has to focus much of his attention to countering the lies with hard facts, and his wise advice for improving the effectiveness of the Canadian system through innovations (most, ironically, borrowed from American community experiments) have received pathetically little public attention. The media dumb down the debate to “public vs. two-tier private” systems (Canadians consistently and overwhelmingly prefer the former, despite the money spent to try to convince them otherwise), and, except for the short-lived Romanow report (which most governments praised, but clearly don’t understand, as they have implemented few of the recommendations other than committing more money to the system), there has been almost no discussion of how to make the system even better.

Mike’s newest book, Prescription for Excellence: How Innovation is Saving Canada’s Healthcare System (the choice of “is saving” rather than “could save” was presumably deliberate), is his latest attempt to bring attention to some of the practices that have been applied in various communities around the world, and which, if adopted by Canadian communities, could put an end to any doubts that Canada’s system is a world class model for other countries.

Notice the focus is on communities. What Mike is calling for is sharing of information and best practices, and coordination of community-based healthcare initiatives, not massive centralized systems. He understands that networks work much better than hierarchies, but laments the lack of effective community-based networks in healthcare worldwide.

The book lays out the principles and rules for effective healthcare established by the US National Institute of Medicine’s groundbreaking 2001 Crossing the Quality Chasm report:

Principles: Health care should be:

• Safeóavoiding injuries to patients from the care that is intended to help them.
• Effectiveóproviding services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse).
• Patient-centeredóproviding care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
• Timelyóreducing waits and sometimes harmful delays for both those who receive and those who give care.
• Efficientóavoiding waste, in particular waste of equipment, supplies, ideas, and energy.
• Equitableóproviding care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

Rules: Health care processes should be redesigned in accordance with the following ten rules:

1. Care based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits. This rule implies that the health care system should be responsive at all times (24 hours a day, every day) and that access to care should be provided over the Internet, by telephone, and by other means in addition to face-to-face visits.
2. Customization based on patient needs and values. The system of care should be designed to meet the most common types of needs, but have the capability to respond to individual patient choices and preferences.
3. The patient as the source of control. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them. The health system should be able to accommodate differences in patient preferences and encourage shared decision making.
4. Shared knowledge and the free flow of information. Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information.
5. Evidence-based decision making. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.
6. Safety as a system property. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.
7. The need for transparency. The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the systemís performance on safety, evidence-based practice, and patient satisfaction.
8. Anticipation of needs. The health system should anticipate patient needs, rather than simply reacting to events.
9. Continuous decrease in waste. The health system should not waste resources or patient time.
10. Cooperation among clinicians. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care.

Mike builds on these principles and rules to suggest specific improvements to Canada’s health-care system, at the community level, in each of these eight critical healthcare system stress points:

• Treatment for the terminally ill
• Treatment for chronic illnesses
• The role of home and continuing care
• The role of long-term care
• Illness and disease prevention and emergency preparedness
• Access to caregivers, and patient-caregiver teamwork
• The role of drugs
• Dealing with wait times

The recommendations are extensive, well-considered, practical, innovative, not difficult to implement, and illustrated with examples of where they have been successfully used.
Now all we need is to get communities networked together and working on these recommendations, and sharing their experiences with other communities. While the nature of the different regulatory and organizational environments between countries must be considered, the challenges of the system and the needs of patients and caregivers are similar everywhere, and there are extraordinary opportunities for communities to learn and help each other worldwide.

The biggest challenge, it seems to me, is the lack of autonomy of the community-based heathcare providers and systems, their ability, once they have had ‘aha’ moments and identified improvements they intuitively know will work, to actually implement them, free from top-down and bureaucratic interference. Nothing could be more discouraging than knowing what you need to do, and not being allowed to do it. That, and, for Americans, dealing with the infuriating and pervasive Moral Hazard Myth.