It is Friday, 4 p.m., the chest infection that you have nursed for a week is not getting better and has you weak and sick. You call your family doctor’s office; a recorded message says “call telecare, go to an afterhour’s clinic, or go to the Emergency Department.”
None of those is a good option that will lead to optimum care. A common outcome from a call to Telecare is that at the end of the call there is encouragement to go to the Emergency Department. When that advice has been heeded, what could take 10 minutes of professional time has always taken many, many hours. Sitting in a waiting room when I should be home in bed with prescribed medical therapy is not an attractive option.
Presentation at an After Hours clinic will possibly get you medical care, but each operates differently, some with a “wait and take your chances”, others where you call to make an appointment, while still others require you to go to the clinic in person to get your name on the list after which you may be seen a few hours later. And in no case does the after-hours clinic have access to any of your records, particularly of medications you may be on or to which you may be allergic, or, better still, what antibiotic worked for you the last time!
In writing this column, I am working from an office in Augusta, Georgia where I see Prompt Care, Primary Care, and Urgent Care usually within a 5 minute drive of my office! And when you go to Urgent Care with flu-like symptoms or other symptoms, the receptionist calls up our records from the hospital on the computer and can tell right away what hospital and emergency visits you have had, what clinical interventions you have had, results of diagnostic tests. You can get routine lab testing on the spot along with some imaging scans. You can be out and back home with any essential medications within an hour!
Each of these facilities, including Emergency Departments, advertises time to wait and Time to Care, the latter being the measure of efficiency. Each facility seems to take great pride in the lowest possible “Time to Care”. Why is that?
Unlike the New Brunswick urban system, the method of payment to physicians and clinics is dependent on customer (patient) satisfaction; as with buying cars or fast food, there is a doctor and patient financial relationship that recognizes that while the service provider has time pressures, so do I as the patient. I need to get home to heal; I need to get back to work as quickly as possible.
This is a sharp contrast with the semi-socialized system that seems to direct primary care in New Brunswick. In our system, we have the blessing of not having to worry about whether there is a co-pay charge or whether our insurance has somehow lapsed or whether the treatment is covered. Most of what we need for life sustaining care is available with the presentation of the Medicare care.
In our system, we are patients but there is no buyer-seller relationship; strictly doctor-patient, professional, mysterious, wonderful in many ways. But the waiting times, the delays, the inability to see our records, the inability to check diagnostic test results. This is 2020 and New Brunswick is supposed to be an IT leader……but not in health.
My friends in Augusta have access to a portal at which they can obtain on the internet their full hospital medical record, results of diagnostic tests including lab results. And a new resident in the area can find a family doctor pretty much the same day. And the discovery of a bad gall bladder can be fixed on the same day as its discovery!
That all costs money, my critics will say. That undoubtedly is true but more importantly it requires understanding that service providers have their first duty to their customer, the patient. Jim Sinegal, founder of Costco, makes the point that organizational success in dealing with customers is all about culture. That is why employees happily remain with Costco for years when other retailers experience turnover.
Then it requires vision of a system that places the interests of the patient at the centre and builds services and systems that ensure efficient and effective care. It also requires a commitment to putting the people with the best training, experience and skill in charge of essential programs.
We could build these patient-centred systems in New Brunswick. It will never happen as long as we keep violating the key principles that make the system patient-centric. When all is said and done, what makes this system so much more efficient is customer focus whereas in New Brunswick, until now, our system has largely been driven by the convenience of service providers. This relates to office hours, access to care, weekend care both in the community and in the hospital. Every service provider needs to start their work day by asking one simple question: if I were treating my parents today, how would my service be different?
In using the American health system analogy, we get immediately to the issue of cost and certainly when we hear tales of six figure invoices for what we deem to be routine surgery that is sobering. And when we hear about the large number of “charity cases” and persons without coverage that too is sobering. Just adopt the principles and apply them to New Brunswick.
For instance, the first thing that I learned many years ago studying some excellent centres is that the physician community plays a huge role in governance! By having physician and nursing leaders embedded in the governance structure, or even leading it, there is a better than average chance that policies and strategic directions of the organization will go down better with the professional community.
Another key element is reliance on efficient information systems, driven in the US by the critical billing system. Being able to get access to records and test results on line is huge.
The focus on getting patients processed efficiently with a minimum of delay is another feature that requires physicians and administrators to work very closely together. Both benefit because of the way the system is financed whereas in Canada the compensation and reimbursement models tend to present a wedge between physician practice and hospitals.
Another stunning feature is that staff functions at full scope of practice: LPNs, RNs, Nurse Practitioners, Nurse Anaesthetists, Family Practice Nurses and more. This stands as a serious contrast with New Brunswick where rivalries, inter-professional angst still is strong. This feature alone is a great roadblock to patient-centred care.
In examining other health systems, the Organization for Economic Cooperation and Development ranks the US and Canadian systems as the lowest amongst 10 western world countries. So we would not want to blindly parachute elements of one system over another. We should, however, have the courage to acknowledge that for all of our excellence in New Brunswick we can be so much better for our patients by doing some things that other systems have already shown to be effective. That starts with putting the patient at the centre and building programs around them, not around the convenience of service providers.
Ken McGeorge,BS,DHA,CHE is a retired veteran health care CEO, part time consultant and columnist with Brunswick News.
True to their promise from last fall, the Higgs government has succeeded in capturing the attention of New Brunswickers around health reform. The announcement of what is referred to as a plan that includes major changes to small, rural hospitals was the second step. The actual first step was the announcement of the expansion of Nurse Practitioner appointments within the health authorities on January 27.
Anyone involved in the health reforms of 1992 knows that a frontal attack on rural hospitals is a formula for certain push-back, speaking mildly. My friends and I remember well the fact that despite the logic, people on the ground were interested in only one thing: will my doctor be able to look after me and my children when we are sick particularly at night or on the weekends.
It was difficult enough in 1992 when 55 hospital boards were dissolved in favor of creating 8 regional hospital boards. But now you have a population for whom that is forgotten and the power of social media. Social media can win and lose elections!
The aftermath has been predictable with local MLAs taking real heat at a time when election talk is in the air and rural seats are critical. Dwight Eisenhower said: “Farming looks easy when your plough is a pencil and the cornfields are a thousand miles away.” And so it is with those who would initiate health care reform. From Fredericton the world looks vastly different than it does at 2 a.m. in Plaster Rock!
It is clear by now that the provincial government is intent on shaking things up in New Brunswick and most New Brunswickers think it is about time! Many issues face the Premier and his government that have been the topics of angst in the electorate for decades including municipal reform, the performance of the education system, infrastructure, extremes in labor relations, economic and jobs development.
So where do you start? It is a challenge for government hanging onto minority status. A strong majority status is to be preferred when wading into major reform for many of the reasons already mentioned in previous commentaries. The commencement of major reform in 1992, difficult as it was, was made much easier with Mr. McKenna’s huge majority and lack of social media!
But make no mistake; the public is looking for leadership on this very complex and challenging file and the Premier and the Minister of Health have both made it clear that they have some great plans in mind.
So just where do you start?
In last week’s column we outlined steps to set the stage for major change in large organizations. Having dealt with determining priority and forces of support and opposition, we concluded that with such a complex, highly political system, it is imperative that government “strike while the iron is hot.” In other words, there are times when the electorate is just ready to support change in its cherished programs and reading the mood and readiness is critical.
The electorate has been calling for change in health care in New Brunswick for over a decade but the messages have not been clear. Government response and public desire have often been on opposite sides of the street. While the public has wanted an improvement in the Ambulance system and its life-saving services, governments snarled it up with issues of which is not where the mood of the public was. They want their loved ones attended to as quickly as possible.
The modern hospital has become the centre of much attention here and across the world. These are not facilities to be treated as yet another office building nor retail outlet. Lots of things happen in hospitals that can, and often do, attract some unsavory characters to the premises!
I remember calling one of my colleagues several years ago and in mid-conversation, he said: “gotta let you go; terrorists are in our ICU”! This was not North America but could be.
I remember getting an urgent call from our Post Partum unit one day when the nurse said a husband was there brandishing a revolver! I also remember countless stories of persons coming while intoxicated to our emergency department, sometimes for treatment of injuries, sometimes to sleep it off.
My staff often had to deal with persons with major psychiatric problems that manifest in belligerence and serious aggression. There have been cases reported of babies abducted from post partum and nursery areas in some cities.
On Tuesday, the New Brunswick Health Authorities issued a document that is mostly aspirational in terms of future directions for health care services. The document did, however, get specific as it relates to rural “hospitals” and noted the conversion of beds to “chronic care” and announced changes to the way emergency health services will be offered in small, rural facilities. Understandably, those living in rural communities are expressing visible concern if not anger.
And why not? They, for the most part, enjoy a level of primary care services that exceeds the expectations of those of us living in urban New Brunswick. The family doctors who provide care in many of these local communities offer their patients a totally personal level of care without the significant delays that are typical in urban health care. With access already to a level of superb primary health care services, the thought of losing some elements of that service is too much for them.
If I were driving health care reform, this would not be the hill on which I would want to die because the actual cost savings, relatively speaking, are not significant.
Premier Higgs recently said what many thoughtful people have expressed for years; the news report made it sound like he was blaming MLAs for issues in economic progress in New Brunswick. And social media then picked it up and had concerns expressed about language and culture. Pity the poor public that is reliant only on sound bytes and headlines.
Health Care Reform is a topic that is discussed in many important places in New Brunswick; in government, in educational sessions, in association meetings, by the Medical Society, in Think Tanks, and at Tim Horton’s. The fact that the current expression is Health Care Reform suggests that the problems and issues are not simply cosmetic and that they need a major push to change! It also suggests that established methods are failing us, and they are. Read more here
Clinical Laboratory Consolidations in New Brunswick
The Minister of Health has given the green light to inviting proposals to plan a consolidation of Clinical Laboratory Services in New Brunswick. Great idea for all the right reasons!
In 1962 I was allowed each Friday afternoon to visit the Lab at the Yarmouth Regional Hospital where the Chief Technologist was a personal friend. I learned the basics of how hospital labs work, learned how to do Haemoglobin tests with a hand-held device, and learned how to use pipettes and test tubes. That was sufficiently fascinating that I determined to choose Medical Lab Technology as a career. Later in my development my career path changed but the memories remain!
In the 1980’s, visionaries in Ontario could see the impact on health care that would be brought by new technologies and computerization together with predicted labor supply issues and consolidation of hospital and health programs. So we saw the beginnings of the development of large central labs springing up in the population centres. This enabled highly expensive, state of the art equipment to be consolidated where it could be used around the clock, seven days per week. Read more here
Each year in New Brunswick the Department of Health publishes physician payments from Medicare, the responsible thing to do from a public accountability perspective. Physicians constitute a highly respected profession in which the public invests enormous trust in their practice and professional activity. That the majority of their professional billings come from the provincial government through the Medicare Branch suggests that public disclosure is essential. As a principle, all who draw income from the public purse should have their government-paid compensation fully disclosed.
The numbers reported in December 2019 had some unique characteristics because for the first time a family doctor was the leader in Medicare billings, reported at nearly $1.7 million. The public has come to anticipate billings by high-earning specialties in that range, but this was the first time for a family physician. The CBC report went on to note that this was the first year that a female physician led the earnings list. Read more here
Health Care Reform in New Brunswick: some tips for policy-makers
The provincial government has sent many signals promising that we would see major health care reform in New Brunswick in January 2020. So what will it look like really?
Regionalization of hospitals in 1992 was the last time that the health care system in New Brunswick was truly shaken up. It is true that the two health authorities were formed long after that but the public hardly noticed except to note that there was a division between French and English. Read more here
Nursing Homes: What is the Assessment Process All About and Why do health authorities want to control it?
In recent weeks, much has been said in public discourse about acute care beds occupied by seniors who are awaiting “placement in a nursing home.” Horizon Health Authority says that 31% of their acute beds are occupied such patients. This, of course, renders these beds inaccessible for post operative care or medical emergency care.
In the long term care system, the nursing home is, by a factor of 40%, the most expensive option for accommodation and care. Many people could be managed at home if the system were organized with proper supports tailored to the individual needs for home care. Others, perhaps up to 40%, could be cared for in Special Care Home facilities. Many of the Special Care Homes in NB provide a superb level of accommodation and care for elders including those with physical and mental challenges. Read more here
The Case for Conditions on Binding Arbitration
Listening to union leaders, be they CUPE or others, one would get the impression that the employer, in the current case, the Nursing Home Association and Government, is being rather stingy in looking at salary rate increases. When numbers like 1% or 2% or 5% over 5 years are thrown around they mean little to the average voter or citizen of New Brunswick.
What goes into a collective agreement is complex and challenging for employers who have to administer it fairly. What often happens in negotiations is that there is a push in early bargaining sessions to get through the narrative of the contract then leave compensation rate increases as the flash-point for government to deal with. Then it gets into the public arena and the public might be tempted to join the chorus of “they are hard-working people, just give the small increase and get this over with.”
Read more here
Labor Legislation Needs a bit of Human Service Reality:
Being a union member and the right of unions to strike are both essential elements in our democracy. I have been a member of a union and was actually an entry-level worker in health care when CUPE was originally organizing in New Brunswick. Throughout my career of 5 decades I have seen and worked with the best and worst of what collective bargaining brings to the health care environment. Read more here
Listening to the People: the lost art in politics?
In 1970, early in my career of administering hospitals, George Labovitz, one of the premiere consultants and motivational speakers in health care, made a huge impression on me and colleagues. I recall to this day that he taught us young health executives: listen to the people! It sounds so simple and most in leadership would say they do that. The truth is learned when you listen to employees in the coffee room or the café or hear their response to these columns!
Labovitz told us how he often is called into large organizations to help them solve organizational and people problems. In one such instance, he got most of what he needed for his consulting report, for which he was paid a good fee, by sitting in the cafeteria talking with employees! With humor, he told about getting from one employee a pretty accurate diagnosis of the organization’s issues to which he responded: “have you told anyone about this? If not, don’t! I need it for my report!” Read more here
Tinkering Will not resolve health and long term care issues:
The health and long term care system in NB has been so lacking in provincial focus and direction for so long that no amount of tinkering will fix it! The system, in economic terms, represents 50% of provincial spending and employs or is the main source of income for tens of thousands of New Brunswickers. That the system is at a “choke point” should come as no surprise to any who seriously understand the system for this has been predicted for decades. The problem has been, over many years, that the decisions to shift and reorganize the system, in the last 25 years, have been made largely at political level where decision-makers cannot possibly have sufficient understanding to understand the long term impact of short term decisions. Read more here.
Ask people around town and inevitably the overcrowded Emergency Department and issues at the Primary Care Level loom large in conversation. It has long been established that the overcrowding in the Emergency along with the long waits are not only unnecessary but entirely preventable. Yet it goes on with no apparent light at the end of the tunnel particularly for elders.
The government of NB announced in 2017 an investment of $200 million in new construction and renovations at the hospital and the project is well underway with large steel framing visible from the highway. It is a building from the 1980’s and is in need of some upgrades. But would you not think that one of the main construction elements would be the creation of a facility to eliminate the Emergency Department overcrowding? Do we have any hope that there is some solution out in the community medical practice world that is destined to fix this problem? Read more here
Since the late 1990’s calls have been repeated to “bring nursing homes back to the Health Department” in New Brunswick. The reason is that in the eyes of planners, it seems so simple: “all those elderly folks waiting for placement in Nursing Homes, mostly in highly expensive hospital beds…… they could be in a nursing home if we just had control of them!”
That is simply uninformed reasoning, simplistic logic and New Brunswick’s health and long term care is in the disarray that it is because since the mid-1990’s, knee-jerk, simplistic logic has been applied to this incredibly important and expensive two portfolios. Primary Care has not advanced much, Emergency Services are still over-run with non-emergencies, access to specialty care continues to get worse, and doctor’s office automation stalled, Alternate Level of Care patients continue to grow. Knee-jerk administration of the province’s most expensive and complex resource is not wise.
So my caution is simply that NB avoids another knee-jerk strategy based on false assumptions and ill-informed counsel. Read more here
Health Reform Requires Strength and Great Information:
The proposed transfer of nursing homes to the Department of Health or to the Health Authorities is a mistake of the highest order! Nursing homes are important elements of the Long Term Care System. They have progressed a long way from the old days of crowded facilities with bad smells. Several nursing homes in NB are now recognized internationally as leaders in Long Term Care and could teach us all a lot about eldercare. Read more here
In 2016 the NB Council on Aging listed creation of a provincial Dementia Strategy as a top priority for government. Prior to the council meetings, there had been periodic calls from the Alzheimer Society and other knowledgeable leaders in the system for such a strategy for the province.
The reason for the push from care delivery persons and families is that the growth of Dementia (there are at least 85 different forms of which Alzheimer’s is the leading one) is rapid and placing incredible stress on Emergency Departments, family doctors’ offices, the long term care system, and, most importantly, caregivers.
The Alzheimer Society of NB estimates the cost of treating this disease is $479 million per annum and by 2029 it will rise to $1.042 Billion. In the first six months of this year, the Society received 405 new clients and that is less than half of the known new cases being managed in New Brunswick in some manner. Read more here
Adding More Seats in university nursing programs is no solution to the “crisis in nursing staffing”
In his article in the Telegraph Journal on Friday, October 18, 2019, Michael Robinson reveals that prior to the budget cuts in the university nursing faculties, the UNB had pitched the province with an idea it believed would solve the nursing shortage crisis. He examined a flurry of attempts by the UNB administration to convince government that the solution to the nursing staffing crisis was to add a large investment to expanding faculty and class size in the RN programs at UNB.
In the exchanges of emails, it was revealed that the university proposed major expansion in enrollment levels with a cost estimate of $14,000 per student as the solution to graduating more nurses qualified to write the registration examinations. This proposal was to take the number of seats from 488 to 800 by 2025/26 adding significant increase in budget in addition to what had been approved in 2005/6 for the expansion of class size. Read more here
Missing Two Major Steps in a Three Step Long Term Care Process: why does all the energy go to the most expensive option?
In all the discussion of those poor seniors occupying Acute Care Beds, one rarely, if ever, hears discussion of all the options? Instead, when discussion does take place with the family doctor about the next stage in care, the conversation invariably commences with “perhaps it is time to be considering a nursing home.”
This conversation is repeated over and over dozens of times each day across the province as doctors and discharge planners try their best to help families come to terms with one of life’s most challenging decisions. Read more here
In his final offer to CUPE as published in the TJ last week, Premier Higgs offered a percentage wage increase to be tied to a reduction of two days in the contractual allowance for sick time. Employee absenteeism in the health care system is not just a problem; it is a costly part of what is wrong with what has been described as an ailing health system in New Brunswick. The total cost of absenteeism across the health and long term care system in New Brunswick would be in the $100’s of millions annually if calculated properly.
The sick time allowance in any collective agreement or institutional personnel policies, contrary to widespread myths, is that it serves as an insurance plan designed to ensure that employees cash flow is protected when they are seriously so they can remain at home, or hospital, without fear of losing pay. In the private sector, many employers provide little to no similar benefit but good employers will take steps to protect their employees. A small business operator recently told me that she pays for 2 sick days per annum. Others pay less, others pay more generously as an employee retention tool. Read more here
In all the responses received to my columns from professionals and the public, this is the question that keeps recurring and breaks my heart. As recently as this morning I was asked that question, again, by a retired health professional NB. The same question arose in discussions at two public speaking engagements. These are intelligent citizens of New Brunswick who vote, pay taxes, and not system abusers at any level. Read more here
Health Reform Issues: What the People Say
The need for reform of the health system on several levels is beyond dispute and the public is well aware of many elements that require serious modernization. Many such issues have been documented in previous commentaries here.
In the September 10 edition of Brunswick News publications, Premier Higgs sent the warning of tough calls to be made in Health Care in NB. This can be interpreted as a warning shot across the bow. Next we could expect some changes to be outlined later either in the legislature or in a future budget or Throne Speech.
Many years ago I learned the value of MBWA, a concept not taught in MBA programs but learned early by executives with great instincts. Management by Walking Around is what has given us Costco, for instance, one of the most successful and dramatic innovations in retail in generations. Founder Jim Sinegal could be seen visiting many outlets in a single day, talking with people, getting feedback, giving feedback and encouragement. Read more here
In the September 10 edition of Brunswick News publications, Premier Higgs sent the warning of tough calls to be made in Health Care in NB. This can be interpreted as a warning shot across the bow. Next we could expect some changes to be outlined later either in the legislature or in the budget.
Then public policy expert Donald Savoie released his book that outlines Canadian democracy in peril. Governments have gotten a long way from listening to the people.
The need for reform of the health system on several levels is beyond dispute; the public is well aware of many elements that require serious modernization. Many such issues have been documented in previous commentaries here. Read more here
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.