Archive for category Policy

Andrea Horwath has a Complaint about the Health Care System.

For my American friends and readers, we’re having a provincial election here in Ontario. Since health care is deemed a provincial responsibility (though funded extensively by the federal government), it’s naturally a hot topic of discussion. At the televised leader’s debate a couple of days ago, New Democrat leader Andrea Horwath managed to step in it, just a little, by suggesting Emergency Department staff at Hamilton General Hospital treated her son inappropriately or even incompetently after he injured his elbow skateboarding. “He went to an emergency ward in my community,” she said. “They didn’t do anything for his fractured elbow. They sent him home, said it doesn’t really need anything, they can’t afford a cast, and go home and somebody will help you figure out how to put a sling on it.”

Unlike St. Joseph’s Health Care Centre in Toronto, which took a pasting in the Toronto media after an elderly man made allegations of abuse, Hamilton General pushed back:

Despite her clarification Wednesday, some hospital staffers felt Horwath’s comments were unfair, said Jeff Vallentin spokesperson for Hamilton Health Sciences.
“All I know is there are lots of folks (working here) concerned about the comments … some feel it’s an unfair representation of the hospital.”
He added that no one has made an official complaint about Leonetti’s visit to the ER.

[SNIP]

The hospital’s chief of emergency medicine would not speak on the specifics of the Horwath case, but said it is common for elbow fractures not to be put in a cast.
Dr. Bill Krizmanich works in emergency at McMaster University and said there are many degrees of fracture, from a hairline to a full-out break, and each is treated differently. The elbow is a very complicated joint because of its range of movement and the treatment depends on the severity of the injury.
The most common elbow injury from skateboarding is a radial head fracture, which normally heals permanently in about four to six weeks with very few future problems.
“In those, we don’t splint and we don’t cast. It heals on its own … (and) early mobilization of joints is helpful.”

At the end of it all, Andrea Horwath walked backed her comments, somewhat: her intent, she claims, wasn’t to attack staff but to highlight systemic problems. “The example,” she says, “was meant to illustrate that people are disappointed with the service they’re getting at the hospitals. In the event, it turns it turns out Horwath was not even with her 18-year-old son during the visit; her retelling of the story was at best second-hand — and 18-year-olds are not known for taking direction well.

I guess, to be charitable, Horwath was trying to personalize a complex issue, i.e. validating through personal anecdote reports of poor care at Ontario hospitals. Unfortunately, the leader of the party of the Left managed to fall into the  trap of repeating the same tired meme (ironically!), beloved of right-wing politicians and pundits that Canadian public health care is The Pit From Whence Few Return Alive.

We all have stories of poor treatment by health care institutions, and I am sure this is a commonality of both Canadian and American health care systems. My own story relates to being seen in the ED of Belleville General (I was passing through) presenting with sudden onset of severe headache. I was treated badly by the Emergency physician who plainly thought I was some drug-seeking tourist from The Big Smoke. (The nursing staff, I hasten to add, were superb and professional.)

But anecdotal evidence, while having the power of making the complex real and personal, is also the worst kind of evidence. It’s pretty difficult to generalize conclusions from anecdotes. Even if Horwath’s story is true and my story is true, you can’t point to a larger conclusion, as Horwath does, that “people disappointed with the service they’re getting at the hospitals.”  It’s logically faulty. In any case, the larger point it isn’t actually true, and illustrates nicely the problem of using anecdotal evidence for anything: more often then not you’re going to be caught with your pants down. Statistics Canada has the data.

Patients very or somewhat satisfied with health care services, by region, 2007

Source: Statistics Canada. Patient satisfaction with any health care services received in past 12 months, by sex, household population aged 15 and over, Canada, provinces and territories, occasional (CANSIM Table 105-4080). Ottawa: Statistics Canada, 2008

In Ontario, 86% of people were either very or somewhat satisfied with the health care received. Is there room for improvement? Absolutely, and I am a bit worried about the gap between “somewhat” and “very”, which the StatsCan study does not elaborate upon. If we’re going to talk reasonably about health care reform, let us at least speak rationally, and use evidence and best practices. Bashing health care agencies and professionals isn’t helpful, especially when (I suspect) large number of health care professionals are sympathetic to the New Democrat message.

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Are Nurses Resistant to Change?

The obverse of Rob Fraser’s post — “Are Nurses Innovators?” — over at Nursing Ideas. When I commented on his post, I thought that innovation among nurses is hampered by institutional and cultural factors, indifferent leadership and the unfortunately prevalent equivocation of innovation with negative changes to nursing work life and patient care standards. When many nurses hear the word “innovation”, frankly, they run the other way. The suspicion of innovation is so ingrained among bedside nurses that even when change can be demonstrably shown to improve patient care, resistance is almost always fierce and very frequently successful.

My classic story about resistance to change and innovation involved some telemetry nurses at the hospital way up North where I was first employed. The manager of the telemetry unit decided that the nurses there ought to be able to read cardiac monitors: the telemetry packs were actually monitored in the ICU. The advantages should be obvious: faster response to potentially lethal cardiac arrhythmias, real time correlation of symptoms, and for the nurses, gaining skill and knowledge to enhance their practice and patient care — greater satisfaction for all and decreased mortality and morbidity. Win for everyone. And the hospital was going to pay for tuition and time so each RN could take Coronary Care I!

What could possibly go wrong?

My spies tell me that even after 12-odd years the nurses on Telemetry still can’t read monitors. There and in other places where I have worked, nurses invariably presented the same reaction to change: No, not on my life, over my dead body. “Can’t do it” is the default position. The reasons given are almost always unchanged: will increase workload and therefore compromise patient care, don’t have the time, not given enough support, has not been communicated well: no, absolutely not, won’t do it, can’t do it.

I’ve thought about this failure of innovation frequently since. I’m not persuaded that using sophisticated strategy, i.e. engaging informal leaders, building consensus, getting buy-in or any of that would have made much difference. In my mind, the reasons for resistance are complex. Many nursing leaders, managers and hospital administrators fail to appreciate how deeply scarring the last couple of decades have been on the nursing profession. Massive cuts to nursing staff in the 90s (and ongoing in some places), increasing patient acuity and workloads, ever-decreasing ancillary services all have left an atmosphere of malaise and mistrust. Hospital administrators treat nurses and nursing as a human resources problem to be managed and disciplined, only slightly above the kitchen staff in the institutional pecking order. In such circumstances — in the hierachical, authoritarian model of management which has be the ne plus ultra of nursing culture, lo these many years — there is bound to be pushback to any innovation. It’s reflexive. And sadly, I don’t think it’s an exaggeration to state bedside nurses have been mostly right. Examples of hospital administrators and managers pissing on nurses in the name of innovation are legion.

So if top-led innovation is difficult, what about innovation from the front lines? Even harder, in my judgement. In the first place, innovation and creativity are not highly sought-after characteristics for front line nurses — though they should be. Innovation is never found on job descriptions. (I suspect — and I would love to hear from nursing managers on this point — that nurses who think too deeply are probably viewed as undesirable and more likely to cause trouble. Though if I were a manager, I would probably take the opposite point of view.) Secondly, managers and administrators (and bedside nurses themselves) tend to view innovation as a management function. If you’re a front line nurse, and you have an idea or read a study that would improve practice in your unit, the sad fact is that you will get very little traction unless your idea is already on management’s radar. Your peers will be unlikely to view your ideas as positive and will often actively try to undermine you. Managers are usually unwilling to engage in a process of change that involves much more than moving a linen cart from A to B if it involves negotiations with other departments: they have to pick their battles too. At the end of it all, who needs the aggravation?

Which leads me to my third point: institutional inertia. Let me provide an example. Some years ago, at a previous employer, I was involved in an ad hoc committee to revise the nursing assessment forms for the emergency department. The old forms were frankly useless, and we were quite excited about being the opportunity to create positive change for ourselves and our colleagues. (The fact we were so excited, actually, speaks volumes.) We worked very hard, and came up with some very presentable forms. Then the “approval” process kicked in. First the forms had to clear both the Manager and the department Nurse Educator. Then the physicians group had to approve them, because, apparently, mere nurses were incompetent to create forms for their own use. Then the manager’s manager would have to have a go at them, and then would send them around to various other interested parties and committees for approval, including the Housekeeping Manager(!) and the quarterly meeting of the Pharmacy and Therapeutics Committee (because, apparently, lowly nurses know nothing about deciding how to document medication properly), and finally to the all-powerful Medical Advisory Committee for final approval, because doctors are so much more smarter than nurses, especially when it comes to charting. Interestingly, the physicians had final say over nursing documentation.

Almost needless to say, the process broke down somewhere between the Nurse Educator, who promised to take our lovely forms forward, and the initial physician approval. They simply fell off the plate. But apart the inevitable breakdown in process, the interesting thing to note about this tale of disillusionment is that apart from the initial burst of creativity, nurses had no real control over the innovation, instead relying on the (sometimes) dubious expertise of others for validation and approval. Again, this speaks to how seriously, or not, nursing innovation is made and developed in practice. The conclusion one comes to, if you are among the 80-odd per cent of us in front line practice, is not much, who cares, and why bother. I don’t doubt nurses are innovators, at all levels, and I don’t think nurses are inherently resistant to change. But creating a culture and providing the leadership where nursing innovation is valued and rewarded — it clearly isn’t now — will require a revolution in thinking and practice — from hospital administrators and managers to the bedside. It’s maybe time to think about how we as nurses can do this — because ultimately, it’s about the future of our profession.

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Channelling the Minister of Health

Was working on this yesterday and planned to post this morning:

I see via Twitter and Rob Fraser that Toronto East General Hospital is about to whack 120 nursing positions in an effort to control costs, and Peterborough Regional is similarly eliminating 121 positions to rein its whopping $26.8 million deficit. Under provincial law, hospitals are not permitted to run deficits.

Is it relevant to point out that (for example) Robert Devitt, President and CEO of Toronto East General pulled down a salary of $441,347.40 in 2009? Which was increased from 425,001.20 in 2008?

Some, I guess, would argue no. Salaries have to be high to compete with the private sector. They work hard, and earn their cheese. And so on. Very well. Why don’t we mimic the private sector and tie salaries of senior hospital management to performance? Make some simple metrics, related to mortality and morbidity, fiscal accountability and patient satisfaction, and base salaries on these?

You can plainly see I was working myself up to a snarkfest on bloated upper management salaries, general wastefulness, sloth, meetings to plan meetings, catered lunches and so forth — all at the cost of patient care. But the wind was taken out of my snippy sail when I saw this in the Globe and Mail this morning:

Ontario to link hospital CEOs’ pay to quality of care

Minister calls move a ‘vote of confidence’ in local governance of hospital

[snip]

[The] government is beginning by targeting hospital CEOs, 14 of whom made more than $500,000 last year. While the so-called Excellent Care for All Bill is not expressly designed to lower salaries and bonuses for top executives of the province’s 154 hospitals, compensation could go up or down depending on performance, Health Minister Deb Matthews told reporters Monday.

“I am concerned about compensation generally in the health-care sector,” she said, “but this bill does not address those concerns.”

Rather, Ms. Matthews said, the new rules would make executives accountable not just for the fiscal health of their hospital but also for how effectively they put patients’ needs first. This includes reducing rates of infection among patients and the number of patients who are discharged from hospital and then re-admitted. Medical errors would be reported directly to patients and hospital executives – a practice already in place in large teaching hospitals.

[snip]

Clearly there is an explanation for this bizarre and eerie coincidence. Either the Ministry of Health has gained access to my WordPress account, and is secretly developing government health care policy based on my absurd and incoherent ramblings, or else the she is reading my thoughts.

I prefer the latter scenario.

We're psychically linked!

I can now place my fingers to my forehead and start channelling: “Deb Matthews, Deb Matthews, cull 20% of hospital managers. They won’t be missed.” Or “Deb Matthews, Deb Matthews, legislate a 4:1 nurse to patient ratio.” Or “Deb Matthews, Deb Matthews, ban the pig slop that passes as food in Ontario hospitals and make them serve proper nutritious meals.” Or “Deb Matthews, Deb Matthews, amend the Registered Health Professions Act to give nurses the authority to do their jobs properly.”

Anyway, I have go. Tin foils hats are on sale at Canadian Tire. I don’t want her reading my mind all the time.

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Pooped

No Health Care for You --- and No, We're Not Bigoted Creeps Either

Was going to write about the niqab and the new Quebec law denying government services to anyone wearing it, which presumably includes health care (basic human rights anyone?) but I’m too tired to write much of anything today today. I’m coming off three night shifts — which don’t usually wipe me, but having The Ankle (which feels like someone’s been beating it with a bat this afternoon) is a real drag.

So I’m going to take some drugs, put up the leg, and watch television till my brain turns to zombie goo.

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Some Stoned and Possibly Ill-Advised Thoughts on the Ontario Budget

My semi-annual quasi-political post, written on Tylenol 3s, in case you didn’t know it.

The provincial budget was brought down yesterday — for my American readers, means the provincial government’s fiscal plan for the coming year — and there’s some almost good news for hospitals and some bad news for nurses. The semi-good news: there’s going to be a 1.5% funding hike for hospitals across the province, instead of the 0% funding increase the government had mooted. The bad: a pay freeze for all in the public and near-public service, which would, ahem, include nurses and other health care professionals. In practical terms, the province has said it will honour increases in current contracts — RNs are actually due for an increase on 1 April — and the province-wide contract for hospital nurses expires in March 2011, meaning the impact won’t be felt until negotiations between the Ontario Nurses Association and the Ontario Hospital Association are completed sometime next year.

As I’ve noted before salaries of nurses (and other HCPs) are often targeted as “excessive” — the (unstated) reasoning being that somehow nurses’ salaries aren’t commensurate with their skill level — we’re just nurses, after all. Tim Hudak, the Tory party leader, has gone so far to suggest that opening the contracts and slashing our salaries is the prudent route to fiscal responsibility. (No mention, of course, that his salary be cut, either — or the unmitigated disaster the Tories inflicted on the health care system the last time they had their incompetent hands on it.)

I should say that RNs have good salaries: with a small amount of overtime, I topped out over 88k last year, with full benefits and four weeks vacation. Well paid, yes, but most RNs I know would say we’re not nearly paid what we’re worth, given what we’re responsible for and what we’re required to know to provide safe and competent care. If you have any doubt, do you want your IV started by me or by the porter?

There is, to be a sure, a lot of waste and room for new efficiencies. Two quick thoughts — no doubt more would come, except I’m fairly whacked on Tylenol 3s:

1. Managerial positions have proliferated like bacteria in a warm, moist environment in most Ontario hospitals, with little discernible improvement, to my eyes anyway, in patient care or outcomes.

2. Hospitals waste literally millions of dollars every year in consultants’ fees, again to no apparent effect — I would like to see published, sometime, the aggregate sum spent on consultants in province’s hospitals.

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Ankle Update: able to put a little weight — just a little, mind — on my foot this morning. Biggest problem: getting up in the night to pee and falling over the dog, crutches and all.

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Human Papillomavirus

An eye-catching post title, no? Some interesting results of a study on the HPV vaccine, and a valid point:

The quadrivalent vaccine against human papillomavirus (HPV) types 6, 11, 16, and 18 (Gardasil, Merck & Co) results in statistically significant reductions of HPV-associated genital diseases, such as warts and cervical dysplasia, in young women who receive it, according to the final analysis of 2 randomized placebo-controlled efficacy trials.

The HPV vaccine also statistically significantly reduces Pap test abnormalities, procedures such as colposcopy, and definitive cervical therapy, compared with placebo, report the study authors, led by Nubia Muñoz, MD, from the National Institute of Cancer, in Bogota, Colombia

[snip]

Dr. Ault suggested that healthcare systems should see a return on their investment in the vaccination in the coming years. In the United States, for example, there are annually “several hundred thousand cases of cervical dysplasia” and “millions of abnormal Pap smears,” he said. “We should see a big reduction in these costly items in the next few years,” Dr. Ault argued, referring to diagnostic and therapeutic care related to such clinical events.

[snip]

Agent of Wrath?

For those of you who don’t live in Ontario, the provincial government has offered the vaccine free on a voluntary basis to Grade 8 girls since September 2007. There was (and is) considerable controversy about the programme, i.e. that teenage girls are suddenly going to run amok because the vaccine “sends the message” condoning teenage sexual activity, an idea wrapped up in some literally mediaeval notions (I use the word in its exact sense) about female sexuality and disease being the wrath of God for sinful behaviour. Funny such attitudes still exist in 2010, yet there it is. I would have to say, on that count, that the evidence of Divine intervention in the form of human papillomavirus is rather lacking. In any case, an example how preventative health care saves money, stops disease and saves lives.

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Punish the Nurse

I know this case as been making the rounds of the health care blogs, so if you’ve seen it before, you can perhaps safely ignore this post.

For everyone else, do you know what happens when nurses get all uppity and ethical and report a physician for breaches of safe practice? You get arrested and threatened with ten years’ imprisonment:

When veteran nurse Anne Mitchell wrote a confidential letter last year to the Texas Medical Board, complaining about a doctor she thought practiced shoddy medicine, she assumed it would be anonymous.

Instead, Dr. Rolando Arafiles Jr. fired her after reporting her to the local sheriff — a former patient and admirer of the doctor — for maliciously ruining his reputation.

Police in Kermit, Texas, searched Mitchell’s computer and found the letter, then charged her with “misuse of official information” in her role at Winkler Memorial Hospital, a third-degree felony in Texas under an abuse-of-power statute.

Today, 52 and out of work, Mitchell could face 10 years in prison for doing what she believed was her obligation under the law — to report unsafe medical practices.

Arafiles had, among other things, sutured the rubber tip of a glove to a crushed finger in order to protect it, and performed a skin graft in the Emergency Department which subsequently (and unsurprisingly) failed. In that wasn’t enough, Arafiles was flogging his own herbal remedies, consisting of white grape juice, to his patients on the side while providing treatment.

The second day of the trial proper was yesterday, and was full of interesting information. According to a local account, it turns out the arresting sheriff, who was so full of love and admiration for the good doctor, was selling the herbal supplement on side. And, incredibly, the physician himself thinks diabetes has no impact on wound healing.

It’s an unfortunate confluence of corrupt local politics and hospital complicity — the administration where Arafiles worked was fully aware of his shortcomings and refused to act — in a toxic culture of entitlement, where if things go wrong, and accountability is demanded, you blame the nurse. In the end, you have to wonder who needs to be on trial.

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Even in Disaster, Breast is Best

Another consideration on the disaster in Haiti. The International Lactation Consultant Association points out the worst thing you can do is send infant formula:

Interventions to protect infants include supporting mothers to initiate and continue exclusive breastfeeding, relactation for mothers who have ceased breastfeeding, and finding wet nurses for motherless or separated babies. Every effort should be made to minimize the number of infants and young children who do not have access to breastfeeding. Artificially fed infants require intensive support from aid organizations including infant formula, clean water, soap, a stove, fuel, education, and medical support. This is not an easy endeavor. Formula feeding is extremely risky in emergency conditions and artificially fed infants are vulnerable to the biggest killers of children in emergencies: diarrhea and pneumonia.

As stated by UNICEF and WHO, no donations of infant formula or powdered milk should be sent to the Haiti emergency. Such donations are difficult to manage logistically, actively detract from the aid effort, and put infant’s lives at risk. Distribution of infant formula should only occur in a strictly controlled manner. Stress does not prevent women from making milk for their babies, and breastfeeding women should not be given any infant formula or powdered milk.

The trouble is, the intuitive response would be to send formula. It would help some poor infant, somewhere. Better than doing nothing, right? Unfortunately, in cases of disaster, a strictly utilitarian response is necessary, in order to save us, and more importantly, to save the people we are purporting to help, from our best impulses to do good.

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War is Hell. And Bad for Your Health.

Some interesting articles in the current issue of The Lancet (registration required to read some of the articles, sorry — but worth it) on the effect of war on health, and how these impacts on health are continually minimized. When we as nurses think of threats to health and well-being, we tend to think of things like smoking or diet, without considering larger systemic problems. Like war. Too inconvenient and challenging, maybe: war is an accepted instrument of foreign and domestic policy in every first world nation. We consume time and energy in our public discourse convincing ourselves that war is necessary evil, and even glorifying the carnage, while at the same time minimizing its very real and human impacts. As a culture, we like war.

And maybe as nurses being concerned with health and well-being, should challenge the culture a bit on this one?

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The Lancet also published in the same issue a scathing editorial regarding the humanitarian response to the Haitian earthquake:

We have repeatedly drawn attention to the fact that when viewed through the distorted lens of politics, economics, religion, and history, some lives are judged more important than others—a situation not helped by the influence of news media, including ourselves. This regrettable situation has resulted in an implicit hierarchy of crisis situations further influenced by artificial criteria, such as whether disasters are natural or man-made. . .

. . .The Lancet has been observing aid agencies and NGOs for several years and has also spoken with staff members working for major charities. Several themes have emerged from these conversations. Large aid agencies and humanitarian organisations are often highly competitive with each other. Polluted by the internal power politics and the unsavoury characteristics seen in many big corporations, large aid agencies can be obsessed with raising money through their own appeal efforts. Media coverage as an end in itself is too often an aim of their activities. Marketing and branding have too high a profile. Perhaps worst of all, relief efforts in the field are sometimes competitive with little collaboration between agencies, including smaller, grass-roots charities that may have have better networks in affected counties and so are well placed to immediately implement emergency relief.

Given the ongoing crisis in Haiti, it may seem unpalatable to scrutinise and criticise the motives and activities of humanitarian organisations. But just like any other industry, the aid industry must be examined, not just financially as is current practice, but also in how it operates from headquarter level to field level. It seems increasingly obvious that many aid agencies sometimes act according to their own best interests rather than in the interests of individuals whom they claim to help. Although many aid agencies do important work, humanitarianism is no longer the ethos for many organisations within the aid industry. For the people of Haiti and those living in parallel situations of destruction, humanitarianism remains the most crucial motivation and means for intervention.

No further comment seems necessary.

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In Praise of Canadian Health Care, Warts and All

I’ve been following the American health care debate, somewhat — it’s like watching a slow-motion train wreck, except less fun. The chances of any substantial legislation passing appears now to be derailed for another 20 or 30 years, or maybe forever, because it’s hard to imagine a more auspicious conjunction of the political stars. So Americans must now make themselves believe (again) they have the best health care system in the known universe, with infant mortality rates higher than Cuba, and Canadians can still retain their annoying moral superiority about our system, which frankly, has vast swaths of suckiness. Just ask any Canadian RN or physician.

And yet. Maha at Call Bells Make Me Nervous posted this:

Several shifts ago, I was assigned to an area with five rooms. In one of the rooms was a homeless man who was being treated for cellulitis and hyperglycemia. He was eventually discharged to a community care centre where home care nurses would take over. After the room was scrubbed clean, another patient was brought into the room. The second patient was a fairly well known celebrity. I thought that it was remarkable that two people with completely opposite socioeconomic backgrounds were treated in the same hospital, in the same room by the same team of doctors and nurses. The Canadian health care systems may have its problems, but it was nice to see it actually working as intended.

And also this comment on another post of mine by At Your Cervix gave me pause for reflection: her boyfriend potentially faces an expensive course of IV treatment for an MRSA infection. Maha points out that for all of the flaws in our system, there is equality of access. At Your Cervix worries about cost. Here, you would go on Home Care, with RNs visiting you daily.

I’ve worked in both systems. The bottom line is that unless you have gobs of cash and/or a gold-plated health insurance scheme, American health care will suck you dry and spit you out.

I am often severely critical of our health care system for wastefulness and stupidity. As we all should be. Money spent on exorbitant management salaries, consultant’s fees, catered lunches, duplication, inefficiencies and all the rest undermines public trust and confidence in the system, and worse, is money directly taken out of front-line patient care. It is inexcusable.

Yet I would take our system over the American without thinking about it twice. The reason: in terms of crude outcomes, like infant mortality, five-year childhood mortality, life expectancy, cost as a percentage of GDP, access to primary care and the like, the Canadian system consistently outperforms the US. And everyone is covered, without exception. We can argue about the middle and particular cases, like wait times for hip replacements or time to cancer treatment. But we also tend to forget (sometimes too conveniently) that health care in the US is rationed as well. Forty or fifty million people, depending on what statistics you hear, go without insurance, and millions more are grossly underinsured. Here you wait for elective orthopaedic surgery.

The point remains: overall, Canadians are actually pretty healthy. Despite our socialized, horrible, bureaucratized, death-panelized system.

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