How Do We Get More Local Decision-Making In Health Care?
Posted October 12, 2018
The government is completing its plan to replace the QEII Health Sciences Centre structures at the VG site. That is an expensive, but perhaps necessary, choice. A quicker and much less expensive initiative would be to rebuild the management structure that operates it and the rest of the Nova Scotia Health Authority.
A common refrain from candidates for the Progressive Conservative leadership, and many others, is the need for much more local decision-making in health care. They are describing a real problem.
To better understand why the current structure does not work, consider an example where it does.
An acutely ill patient arriving at the QEII emergency department receives excellent care from a remarkably diverse group of health professionals. As described in an October 3rd op-ed by Dr. Kirk Magee, each member of the team has a clear role and the expertise to perform it.
It does not matter that the doctors, nurses, paramedics, technicians, and others all have different bosses. They know that the patient’s immediate outcome will be entirely determined by the people in the room. Teamwork comes naturally, given both the urgency and clarity of the situation.
Most health care is not like this. It involves systemic delivery of various diagnostic procedures, resulting treatments, and follow-ups to see if they are working. After our acutely ill patient’s emergency room visit she will be told to come back for periodic tests, and she will get used to waiting in line.
Those doing the tests are, at best, loosely connected to those who will respond to the results. They are all part of a big machine.
The Nova Scotia Health Authority has 23,400 employees in 135 locations and works with more than 2,500 physicians charged with every aspect of adult health care other than maternal. It is big and complex.
No organizational structure would be perfect, but some approaches are better than others. It is hard to find much to like about the present one.
The facilities are divided into four zones, each having an Operations Executive Director. Bizarrely, each reports to a different Vice-President. Those Vice-Presidents also manage separate hierarchies in each zone for things like Mental Health, Diagnostic Imaging, Continuing Care, Pathology and Laboratory Medicine, and Perioperative Services.
Adjacent to all of this is another hierarchy of doctors, some with responsibilities within their zones, and others with province-wide responsibilities for programs of care.
Imagine the players who would be needed to make a decision that might improve the way health care is delivered in one of our regional hospitals. Unlike the ER team who are gathered in one room, it is unlikely that the necessary participants would all be found in the same county. This is not a recipe for nimble and responsive decision-making.
A better structure would vest as much authority as possible in the zone leaders, who would all report to the same executive. Ideally, that would include the senior physician leaders in the zones.
Independent care facilities such as continuing care and perhaps mental health could be kept outside the scope of the zone leaders.
For support services such as laboratories and diagnostic imaging, there should be a central function providing broad policy direction, but beyond that the leaders of those functions should view it as their role to support the zone management in making prompt sensible choices.
Changes such as those announced about hospitals in Cape Breton, or more recently the QEII Health Sciences Centre, are fundamentally political choices. They would still be made in the same way as they are today.
The new QEII facility will entirely replace three aging facilities at the VG site and will add a few dozen beds. It will also bring together functions that were previously separated.
The advantages for both patient care and research were highlighted by Dr. Drew Bethune, medical director of what will be the consolidated cancer treatment centre. As with our emergency room example, having the people necessary for cancer-related decisions working at the same location makes for more timely and effective decision-making.
Sources have told me that a revision to the NSHA organizational structure is in the works. There is considerable room for improvement.
A key test of the revision will be the extent to which decision-making authority within regional and community hospitals is expanded.
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