Lewis: Three words to live by to boost health system performance |
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Lewis: Three words to live by to boost health system performance
There is a slogan from management theory that in three words — one of which is repeated — both explains much of why healthcare in Canada underperforms and prescribes the remedy.
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Slogans and aphorisms are the Swiss army knives of language. Some crystallize common sense: Rome wasn’t built in a day. Some peddle dubious math: Believe you can and you’re halfway there. Others offer useful cautions: Always give 100 per cent, except when you’re giving blood.
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However cogent, amusing, and inspiring slogans may be, they’re not action plans. There are exceptions; Drink Milk is both exhortation and instruction manual, and success is well-defined. Most of life is less straightforward. Healthcare complexity is off the charts.
Yet there is a slogan from management theory that in three words — one of which is repeated — both explains much of why healthcare in Canada underperforms and prescribes the remedy. It sounds Zen-like, something to ponder cross-legged on a mat. It isn’t an implementation plan, but it is central to a good one.
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The mystical phrase is Tight-Loose-Tight, or TLT. Here’s how it applies to health care.
Good public healthcare systems do three things. They articulate what the system is supposed to accomplish (vision and goals). They mobilize and deploy resources to achieve the goals (execution). They measure and evaluate performance, and use the findings to address shortcomings and ensure continuous improvement (accountability).
The vision and especially the goals must be tight: meaningful, clear, concrete, precise, and measurable. As summarized in a pithy quality improvement aphorism, some is not a number, soon is not a time. Tight requires targets, be they maximum wait times for diagnostics, childhood vaccination rates, or percentage of patients able to see a doctor or nurse practitioner within two days. System-wide performance targets filter down to the organizational level. In high-performing systems, the goals are co-designed, broadly endorsed, and drive efforts up and down the organizational chart.
Execution should be loose: once the goals are clear, organizations, units and teams should have considerable latitude to figure out how to achieve them, responsive to local needs and practical circumstances. Experimentation and creativity should be encouraged, supported by real-time performance data. It is management with a light touch: trust the talent, but verify.
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Accountability should also be tight. Performance indicators must be clear and measurable, and the information system must be able to produce both routine and customized reports in real time. Every significant shortcoming should trigger improvement efforts. Every significant success should scale up.
Sadly, Loose-Tight-Loose (LTL) remains the dominant approach in Canada. Governments rarely set precise and ambitious improvement targets for access, health outcomes, harm reduction, or value for money. Goals are often framed as financial commitments (we will spend $100 million more on home care) or increased capacity (we will recruit 200 international nurses). Neither success nor failure is transparently defined, making it easy to declare success and never admit failure.
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Conversely, governments’ grip on execution is too tight. Where goals are too loose, what the system is accountable for is blurry. To compensate, governments often over-manage how the system does its work. Budgets are siloed into rigid categories. Government will swoop in to fix a noisy problem — say a big backlog of patients awaiting an MRI — by adding capacity. More capacity generates more utilization. The more imaging machines there are, the more they will be used. With no analysis of how many scans actually change either diagnosis or treatment, and no targets for the expected yield of important information, these reactive measures may make things worse.
Evaluation and accountability are loose because the goals are loose and incomplete. There are almost never goals for eliminating harmful, zero value, and low-value care. There is a large peer-reviewed literature on how much valuable clinical time is spent on routine and simple tasks and valueless paperwork, but there is neither objective measurement of nor goals for making the best use of people’s time and jettisoning useless work. The public has no access to quality and safety data on individual facilities. Not knowing and not telling are the glue that holds health care federalism together. It is looseness incarnate.
LTL has failed. Governments can declare what the system should accomplish. They can manage how the system does its work; but they cannot do both. TLT brings both role clarity and real accountability. It’s time.
Steven Lewis spent 45 years as a health policy analyst and health researcher in Saskatchewan. Reach him at slewistoon1@gmail.com.
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