Tuesday, March 23, 2010

How do you change a culture?

I recently finished my second book on Theory of Constraints - this one on health care "We All Fall Down". Absolutely fabulous.

While it has made me more optimistic, the challenges of working in a dysfunctional culture, one filled with mistrust and fear frequently seem insurmountable.

I frequently discuss the issue with senior leaders in the organization and am told that I should just accept the culture and learn to work within it.

As an individual, how do you change a culture?

Monday, March 15, 2010


The “capacity” of acute care hospitals is often reported to be overwhelmed, particularly in Canada and public funded hospitals. To some extent this is true. Too much healthcare need is created by a population that frequently does not place “health” as a priority. But, even when people do, they run into healthcare providers that have very little interest in preventive medicine or addressing negative health behaviors. And when people do get listened to and the healthcare provider does something about it, frequently the healthcare provider gets it wrong (such as not following recognized best practices) or the persons does not follow the advice (but, motivating personal change and the skills lacking in healthcare providers to facilitate this is a completely different subject).

So, right now, too many people are trying to get into acute care hospitals, whether it be for urgent needs (e.g., via an Emergence Department) or to receive “elective” surgery and get off one of those much maligned wait lists.

But the ability to acute care hospitals is not just stress by too much demand, it is also constrained by not enough “output”. And, in acute care, “output” is our ability to discharge patients … either as “cured” or “recovered” or to a lower cost of care. In fact, most patients in acute care are discharged to a lower cost of care setting, such as home care or rehabilitation settings… the ability of hospitals to cure patients or discharge them fully recovered is largely a misconception. Publicly funded hospitals simply cannot afford to wait for patient to “get better”. While hospitals try to focus on getting the patient “well enough”, I’d like to make one very significant point…

… We are not very good at discharging patients and the healthcare systems do not put enough resources to facilitating discharge.

The proof… many acute care hospitals have move to 7-day per week staffing models for physical therapy and have improved availability for other allied health professions, particularly occupational therapy and social work…. And the results have been significantly shorter lengths of stay. How has this been achieved? These three professions place a key role (no, make that THE KEY ROLE) in rehabilitation and facilitating discharge planning. No disrespect towards nursing, but comparisons to what PT, OT, and SW do towards rehabilitation and facilitating discharge simply does not compare to what nursing views as its role in rehabilitation and discharge, and the outcomes do not compare (in fact, relying on nursing to facilitate rehabilitation and discharge planning may INCREASE a patients length of stay and increase the total cost of care).

If you believe discharging patients is a constraint that limits a hospitals capacity, then the reasonable decision is to invest in the allied health professionals to optimized length of stay and get patients out of acute care faster.