Going Upstream for System Redesign
Lessons from Covid-19 #15
A person walking by the river sees a child in distress floating downstream and calling for help. The brave citizen dives in, rescues the drowning child, and barely makes it back to shore.
A while later, another crying child floats by and is rescued. This happens several more times. Eventually, the exhausted rescuer walks upstream along the riverbank, comes upon someone throwing kids into the river, and puts a stop to it.
“A river watering the garden flowed from Eden; from there it was separated into four headwaters.” (Genesis 2:10)
Upstream is the commonly used word in healthcare as the place to go to prevent and lessen the severity of diseases in individuals and populations.
An example of treating risk factors to reduce the need for more extensive and expensive in-hospital care is used in a book on health care in Canada titled Upstream Medicine (1).
Upstream Medicine deals with protecting against personal high-risk health activities such as smoking and impaired driving. It also tackles social determinants, including inequities in income, education race, gender, and other factors affecting downstream health and quality of life.
There are many downstream responses to Canada’s long-term care (LTC) crisis of excessive deaths during Covid-19. The military was called in to stabilize desperate situations. There were calls for resignations of politicians, administrators, and medical public officers of health. Demands grow for better education, remuneration and job security for LTC staff.
The percentage of Canadians over 65 years of age is increasing so rapidly that a “grey tsunami” of seniors overwhelming the healthcare system is predicted. But geriatrics (the medical specialty of caring for the aging) remains impoverished in Canada.
In Canada adults over age 65 now outnumber children, yet there are over 2500 paediatricians and only 300 geriatricians. (6) Childhood is commonly a season of good health. Geriatric patients’ lifespan may exceed 35 years, with increasingly complex medical and social conditions.
Geriatrics is also the lowest paid medical specialty in Canada. This upstream physician deficiency generated the downstream LTC deficiencies peculiar to Canada.
Over 6,000 have died in LTC homes in Canada from Covid-19, compared to only 29 in Australia (7). Canada is home to 6.6 million people over age 65, while Australia has 3.8 million. Despite its larger population, Canada has 300 geriatricians to Australia’s 620.
One salary scale lists Canadian geriatricians’ salary at $81K, and Australia’s at $175K. These glaring disparities cannot be blamed primarily on government, as the Canadian medical profession is primarily responsible for the proportionate production and remuneration of the Canadian physician and surgeon workforce.
The working hypothesis of this series is that more downstream government oversight and resources devoted to LTC are necessary but insufficient. The solution requires correction of the upstream system design flaw.
This series compares the problem upstream to the person throwing kids in the river. What drove the thrower to throw? What system flaw in Medicare is represented by the thrower? It is proposed that the organizational structure of the health system and its relation to government and other agencies culminated in the Canadian LTC debacle.
What caused Medicare to be structured as hierarchical and bureaucratic structures and why was the system not designed to reflect and enhance the complex adaptive nature of its subject?
Upstream organizational flaws in healthcare systems also have negative downstream effects on other groups. Indigenous Canadians have higher rates of many diseases, reduced life expectancy, higher rates of incarceration, contaminated drinking water, crowded housing and many other problems. This has persisted for centuries despite Medicare.
Within the hospital system, rates of physician and staff burnout is high and increasing. The design flaw has also frustrated efforts towards a national Pharmacare program for years. It perpetuates the prolonged wait times in emergency departments and for scheduled procedures including joint replacements, that have plagued Canada for many years.
In summary, “Every system is perfectly designed to get the results that it gets.”(2)
What should the redesigned system look like?
The working hypothesis identifies an unrecognized comparable of “throwing kids in the river” that occurred in the early days of Medicare. Without correction, solving the many ills of healthcare, the economy and climate stress affecting all of society will fall short of the possible.
The working hypothesis to explain this chronic problem in chronic care is that Medicare itself was conceived and organized in an adversarial, exclusive, competitive and restricted setting, so that integration and inclusivity could not take root and flourish.
It is believed that the hierarchical organizational structure naturally emerging from the battle at the inception of Medicare was the wrong model for a world of complex adaptive systems. It is proposed that changing the upstream organizational structure to one that is itself a complex adaptive system, will enable healthcare and the economy to flourish downstream.
Organizational structure (graphic and demonstrable) and organizational culture (the unwritten way things are actually done) influence each other. Wrong organizational design breeds toxic culture, while appropriate system redesign generates synergy and harmony.
The history of Medicare in Canada is well documented. (3) Systems theory and organizational structure are also perennial topics of research and application. As the coronavirus causing Covid-19 is referred to as novel (one that is new and not previously seen), the system redesign proposed in this series is novel.
When Medicare grew to cover all of Canada and the Territories, as defined in the Canada Health Act (CHA) of 1984, there were five foundational aspirations of the system. These were:
- Universal (to cover all Canadians)
- Comprehensive (to cover all medically necessary services)
- Accessible (no matter where you live, and truly available)
- Portable (among provinces) and
- Publicly administered (through elected governments).
These are praiseworthy, but unattainable within the organizational design in place. Decades of royal commissions, electoral battles, massive cash infusions, and a misdirected battle over private and public care have not cured the shortcomings of Medicare.
Canada spends the largest portion of its gross domestic product on healthcare, yet many health services are excluded.
The defeat of the Saskatchewan doctors in their 1962 strike against the Tommy Douglas government was the upstream event that ended the medical profession’s hope of control of an autonomous health system supported by private insurance plans. Public healthcare was born, and Premier Douglas was voted the greatest Canadian of the 20th century.
The strike outcome was a troubled collaboration between the medical profession and government. Both sides adopted the hierarchical and bureaucratic organizational structures of the day, and remained bound by them, despite an increasingly complex world and society.
Decades later complex adaptive system organizational theory emerged and productive interdependence of the medical profession and government was restricted. While legislatively in control, government is always distracted by the requirement of re-election every four years.
Medicine is a demanding profession. The origin of the deficiencies in Canada’s LTC system begins within the ranks of the medical profession.
The internal hierarchical structure controlling the profession produced a culture in acute care hospitals of excessively long work hours for doctors in training.
Resident doctors laboured for superiors. The 1978 satirical novel The House of God (4) focuses on the psychological harm and dehumanization endured by hospital resident medical staff during their training. The book became informal “required reading” for trainees and residents around the world, and the jargon remains popular.
How did the House of God hospital staff cope with its plight and how does this relate to the ongoing plight of LTC residents?
The lowest patient category in the House of God were those we now see in LTC facilities. They were designated as “GOMERS” for “get out of my emergency room.”
They were old, without clearly defined problems that could be fixed in an acute care hospital. No service wanted them tying up their scarce hospital beds. In House of God, strategies were presented to make the GOMERS someone else’s responsibility.
They would be “buffed,” meaning charts and lab values were dressed up to entice another service to transfer them to their ward. If successful, the process is known as a “turf”. For example, “turf to medicine”. If the GOMER was moved on, only to return later, the event was a “bounce back.”
The stigma of caring for aged patients continues as an unintended consequence of the hierarchical systems that define both the medical profession and government. The working hypothesis includes that a culture of insufficiency pervades the hierarchical healthcare system in Canada.
This results in some patients and providers being considered more worthy than others. This insufficiency, and how to reduce it with system redesign, will be explained more in the chapter discussing the economics of scarcity.
The early church members (representing persons and their component parts) were held together by “ligaments and roots,” of love and concern for every part of the corporate body of the church. In the early church model, the stronger and privileged members supported the weaker and disadvantaged.
The tenuous state of the residents and their front-line providers of LTC facilities in Canada shows that the early church organizational model has not been applied to the modern situation. The model for system redesign now is a modern application of “ligaments, roots and sinews” in the form of an expanded model of human body organ systems interwoven with cross-system services applicable to the stages of life.
Charts comparing organizational models including the path to this proposed redesign will be the subject of two of the upcoming chapters.
The next chapter will be an unplanned venture into an ancient evil still defiling the human race. It has come to the fore during Covid-19. It is a core issue for humanity in itself. It is also a demonstration of the failure of our organizational structures and their role in creating and sustaining systemic global problems.
1.Upstream Medicine. Doctors for a Healthy Society, Edited by Breshnahan,A., Brindamour,M., Charles,C., Meili,R. Purich ,2107
2.Don Berwick, Institute of Medicine
3.Making Medicare: The History of Healthcare in Canada :1914-2007, Canadian Museum of History
- The House of God, Samuel Shem, Richard Marek Publishers, 1978.
- Statistics Canada, released July,2019
- Canadian Medical Association Journal News, May 2,20197.Australia’s Covid-19 successes shine light on Canada’s troubled LTC sector Terence McKenna CBC news , June 13,2020
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