May 27

The health care “system”.

You know, language is powerful. We throw the word “system” around in relation to our health care in such a way as to assume that it actually exists, a “system” of health care. Webster’s online dictionary has 15 different variations of the definition of system, but the jist is this: “a group of independent but interrelated elements comprising a unified whole; … the whole scheme of created things regarded as forming one complete plan or whole”. Umm…if that’s a system, then that’s not what we have in health care in Alberta.  Now, we have the independent bits, and a whole bunch of created things…but we don’t do a great job of interrelating or integrating these things into a complete plan, or a unified whole—not even close. At least not yet.

To be fair, I do believe we are trying to get there.  Many people, myself included, have been really involved in projects focused on improving access to health care services for patients—getting people the help they need, when they need it. You know, we have made some progress in Alberta, especially in getting people better access to a family physician—but wow– do we ever have lots of work to do, and we sure do have to get beyond the project stage! When you are on the other side of the desk as a patient, or have a family member there– you understand really quickly how un-system like our “system” really is. I have two people in my family with chronic conditions. Neither one has experienced anyone sitting down, and really listenening to the multifaceted nature of the problems they are experiencing as related to the chronic health problem, in the context of their lives. As a result, they sort of lurch along, managing the best they can, getting in for short appointments when they have flare ups (often times with other practitioners because they can’t get in to see their own physician or team), and bearing almost total responsibility for connecting all those disparate dots of treatment when they next see their own doc…because with all the miracles of the computer age…providers still don’t communicate with each other very well. Providers don’t THINK like they are part of a system of health care, a system that should be anchored around the patient’s health experience and need. They think of their piece of the puzzle, and sadly, that’s often where it stops. All too often it falls to the patient (or the patient’s relatives) to tie all the pieces together—and guess what—they forget things because they are sick, and tired, and often desperate for help—help when they need it, not in weeks, or months. And, it isn’t JUST about QUICKER access (although that’s important too), it’s about building a SYSTEM. Connecting the disparate parts and addressing the desperate need.

Just to illustrate: a quick story. A ER nursing manager that I know truly understands the interconnected nature of systems—she knows that the folks who show up in ER with serious health problems often have had the system break down for them in terms of access to primary care—better access there may have prevented the problem from getting to this point. Then, she knows the system has broken down again when these folks wait hours, or even days in the ER for an inpatient bed. Several months ago, she attended a workshop on improving patient flow through the emergency department. Teams from all over the country proudly showed results where they have shaved “two full minutes” off procedures in the ER, or got patients from the waiting room to a gurney in the ER an hour quicker. Now, as this manager related this to me she shook her head and asked: what good is a quicker procedure when the patient hits the wall when a bed is needed? And what are we doing to prevent the need for the procedure in the first place? 

Until we actually and authentically start to THINK LIKE A SYSTEM, we will keep perfecting the parts and leave the patient holding the glue.


  1. Jerry Macdonald

    “… I have two people in my family with chronic conditions. Neither one has experienced anyone sitting down, and really listening to the multifaceted nature of the problems they are experiencing as related to the chronic health problem, in the context of their lives.…” Shannon, this role is exactly what I and my colleagues in the AHS North Zone Chronic Disease Management (CDM) portfolio do on a daily basis. I believe that in your neck of the woods, there are nurses in just this same role; indeed, before the formation of AHS, the CDM programming in Chinook Health Region was the “shining light in the sky” for our Peace Country Health CDM management. Now AHS is trying to bring uniformity to CDM services around the province.

    CDM province-wide is also offering the Stanford University Chronic Disease Self-Management programme; this series of layperson-led, structured small-group workshops focuses on the challenges of living with a chronic health condition. They are not disease-specific; instead they deal with those issues that are common to most chronic illnesses: fatigue, medication management, emotional issues, etc. If your family members have not yet taken advantage of this programme, I would suggest they do so.

    Best Regards.

    1. Shannon

      Yup, you are right about that Jerry–the former Chinook has and is doing some terrific work here, that’s for sure (and there are other places in the province where strides are being made as well). As a matter of fact, I used to lead the programs you are talking about. Here’s the thing though. The system still does not act like a “system”. Many of the approaches taken in the province are what the improvement gurus call “carve outs”, so the person is referred out to a program, or sees a special provider, (usually with a delay) rather than having that CDM care integrated into their central health care relationship with their primary care team. It’s the integration piece that’s the most difficult, and the most lacking in the system. In my experience, it still falls mainly to the patient and family to do the integration piece, to tie it all together. Now, when I said we are getting better at things, I think there are pockets where the integration happens quite well–in spite of the lack of good electronic documentation systems to support it. For example, the heart failure network. This is a specialty CDM program, with very highly trained nurses providing evidence-based HF care to very sick folks. The approach they have taken in the Network is to build capacity in the patient’s main primary care team to provide much more of this care within the context of that team–instead of the traditional approach of receiving patients who have been referred “out” to the program when there are signs of difficulty. That team is seeing some amazing outcomes (was just discussing this with some of their nurses the other day actually)–and is a good example of integration. So, are we doing some good things? Absolutely–but we have a long ways to go to a patient-centred “system” of support for folks with chronic illness.

  2. Cheryl Andres

    There is some great work happening in pieces across the province – i so agree. The problem is, as you state Shannon, its happening in pieces without a true vision of what it needs to look like cohesively in the end. I do believe the problems we are having are a result of the “system” being a series of pieces versus a true “system” of care and support. We talk about team but we don’t walk the talk very well often past the walls of our own program, hospital unit, or office. As a result we work to improve things where we live only to hit walls if the patient requires anything outside our immediate team, program, or office. Until we learn to work together to improve flow of services for the patient across the various settings we won’t see a true “system” of care. Its truly about getting down to the needs of our patients versus our needs as providers. I do think with that will come improved outcomes and improved costs to the “system”. Of course I’m a bit of an idealist and there are lots of good things happening out there despite not being ideal. However, we don’t seem to truly “get” what direction we need to continue to head to truly improve things for our patient and instead keep pouring good money after bad by making the same mistakes over and over again with little result in “system improvement”. My two cents. Loved your thoughts – well written!

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>