How Do You Spell Accountability?

Posted on November 26, 2010 by susanonthesoapbox

It’s all over the news.  Dr Duckett has been fired over the cookie incident.  This was a decision of his employer, the AHS Board, not the Health Minister, even though:

  • the AHS Board reports to the Health Minister
  • the Board wanted to wait two weeks to see if the public furor would die down but Zwozdesky directed it to act immediately because waiting two weeks wasn’t going to accomplish anything—probably true if he’d already decided to fire the man
  • Ken Hughes, Board Chairman, was quoted as saying “The minister made his directions clear to us.  That was one of the important considerations that we took into account.” 
  • three AHS Board members resigned

But, as the Premier said when this mess started, he couldn’t discipline Dr Duckett because it was up to the AHS Board, not the Premier, to take action.  In other words, the Premier and by extension, the Health Minister, are not accountable for this decision.

So let’s talk about something the government is accountable for—providing decent health care for Albertans.  The Legislature has been locked in debate for 18 solid hours on various amendments to Bill 17, the Alberta Health Act.  The most significant amendment was proposed by Dr Raj Sherman.  He wants to add maximum ER wait times to the Act:  4 hours for standard patients and 6 hours for seriously ill or injured patients with both targets to be met 95% of the time. Dr Sherman’s targets come straight out of the Canadian Association of Emergency Physicians Position Statement on ER overcrowding published in 2007.  The 2007 position statement restates an earlier one published by the CAEP in 2000.  Obviously the problem of overcrowding and how to rectify it has been around for a long time.

Why is Minister Zwozdesky fighting this amendment?  He’s given three reasons:

  • If you include a target for ER wait times then what’s to stop others from demanding legislated wait times for cancer care, eye surgery, access to continuing care and the like?  This is the floodgates argument–you let one target in the door and before you know it they all come pouring in.  But what’s wrong with opening the floodgates in a measured fashion to add new targets as the health care system stabilizes?  Wouldn’t that ensure quicker access to treatment?
  • Including the amendment is not practical because it would make the Act unresponsive to new improvements and, to quote the Minister, “What are you going to do?  Bring that act [into the Legislature] every few months for changing, for updating, [and] go throuugh the whole rigamarole of yet another debate?  Many pieces of legislation require a high degree of flexibility in order to respond to a changing environment.  That’s why the government passes regulations.  If the Minister is fussed about putting the targets into the Act, he can expand the Lieutenant Governor in Council’s power to pass regulations under section 12 to include regulations relating to wait times.  It’s heartening to note that section 14 requires the LGC to get public input before any regulations are changed, except in the case of an emergency.
  • The amendment would invite even more lawsuits.  This is puzzling because I don’t know who the Minister is trying to protect from those nasty lawyers.  It’s not the government because the government is immune from litigation or prosecution by virtue of the Legislative Assembly Act.  It’s not the hospitals or doctors because they are already exposed to medical malpractice litigation under common law.  Adding a legislative target won’t change tort law.  It certainly has no impact on contract law.  So who’s the Minister protecting?

And what does the Health Minister recommend as a solution?  Another policy.  Something that sounds impressive on paper but is of little use when it comes to getting results.   So how do you spell accountability?  Well, it’s definitely not spelled Z-w-o-z-d-e-s-k-y.

Posted in Alberta Health Care, Politics and Government | Tagged | 2 Comments

A Christmas Present?

Posted on November 23, 2010 by susanonthesoapbox

What a bizarre week!  Dr Sherman, the junior health minister, fired off an incendiary email to his fellow MLAs blasting the Premier and Cabinet for their inept management of the ER wait time crisis—and was kicked out of caucus.  Dr Duckett finally pulled together 100 clinical leaders for a brainstorming session aimed at reducing ER wait times.  The team produced a set of ER protocols and was just about to unveil them when Dr Duckett side tracked the process by refusing to answer the media’s questions because he was eating a cookie.  Dr Duckett offered a public apology but the damage was done, the cookie incident went viral and it’s highly likely that Dr Duckett will be going home very soon.

Meanwhile Minister Zwozdesky has taken a different tack.  Apparently tired of the continued attacks on ER wait time targets, he’s promised Albertans a Christmas present.  He made this promise in the Legislature—twice.  On Nov 15 he said “I have given Alberta Health Services until Christmas to come up with the improvements that we need to see.”  On Nov 18 he added “…there are some overcrowding issues in emergency rooms in some cases, and we’re addressing those.  There is a plan, and there will be even more progress between now and Christmas.” 

The Health Minister even put his wait time targets on the record (which is helpful given how many times they have been revised downward).  He told the House:  “…for the larger hospitals, including…Edmonton and Calgary…45 per cent of the people should be in and admitted within eight hours by the end of this year.  Secondly, they are also to be discharging 70 per cent of the people who do not require an overnight stay within four hours.  Both of these targets, it’s important to note, will actually be increases from actual results.  (That last part is reassuring given that the definition of a “target” is a goal to shoot for, an improvement over actual results, otherwise all you’re left with is the “status quo”.)

Interestingly, Minister Zwozdesky’s Christmas promise ties into an approach advocated by Dr Sherman who cites the UK experience where the number one accountability measure for the entire health system is a metric based on ER wait times for admitted patients.  That’s because every other health service feeds into the wait time for admitted patients in the emergency department.  In Dr Sherman’s words, “It’s not an emergency problem; it’s a system problem”.  This view is shared to a degree by Dr Taft (Member for Edmonton-Riverview) who says that long wait times in emergency rooms “…are a kind of indicator of how the health system, at least the hospital side of the health system is running generally.” 

How will these wait time reductions be achieved?  Presumably by implementing the ER protocols unveiled by Dr Duckett’s team of clinical leaders just after the cookie incident.  The protocols set out thresholds which, when reached, require immediate action to reduce wait times.  Think of it as surge protector.  Once the threshold is reached the patient is moved out of ER.  However it’s not clear where the patient is going because the success of the protocols is dependent on the addition of 81 new beds—49 in Edmonton and 32 in Calgary.  These beds will be opened over the next three months.  In other words, unless a miracle happens, Minister Zwozdesky will miss his newly revised ER wait time targets and instead of a present in our Christmas stockings we’re going to find a lump of coal.

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Dr. Duckett’s Bad Hair Day

Posted on November 14, 2010 by susanonthesoapbox

This has been a bad week for the AHS and Dr. Duckett.  On Wednesday the AHS posted its actual performance against target performance for ER benchmark wait times.  You’ll recall that the benchmark wait time is 4 hours for treatment/discharge and 8 hours for treatment/admission.  The AHS said it would meet the 4 hour benchmark 80% of the time and the 8 hour benchmark 48% of the time—or did it?  The targets keep slipping downward.  Hardly surprising since the actual performance numbers (also posted on Wednesday) indicate that some hospitals met these targets only 20 to 30% of the time.

So this is where it gets interesting.  When Health Minister Zwozdesky heard that the AHS had released the wait times and targets he said the release was premature and was only part of the package of performance measures the AHS were developing.  According to Don Braid (Nov 13 Herald) in the space of 8 hours–between 10 a.m. and 6 p.m.—the original sentence setting the March 2015 benchmark target at 90% was in the release, disappeared and then reappeared.

It made me wonder whether Dr. Duckett was having a bad hair day.  In an article in The Medical Journal of Australia  (MJA 2009: 190(12) 687-688) Dr. Duckett reflects on his 35 year career in health care in Australia.  He voices a concern that the health care sector has failed to tackle the fundamental challenge which results when an aging boomer population refuses to wait meekly for health care.  He discusses macro changes (things like activity-based funding for hospitals) and micro changes (like internal organizational processes which are controlled by hospital managers and staff).  He wraps up his comments with the following thought:  “Of course, no health care system can guarantee perfect care and perfect outcomes for individual patients.  It is inevitable that some health professionals will have a ‘bad hair day’—the result of activities the night before, work pressure, momentary distraction in thinking about issues at home or behaviour of their work colleagues.  Even the best intentioned health professional can make a mistake.  But it is these micro interactions that determine the patient experience, and tomorrow’s patients will expect more from their encounters and will be less tolerant of practices of the past”.

It would appear that on Wednesday Dr. Duckett had a “bad hair day”.  AHS staff responsible for setting benchmark targets weren’t clear on what the targets were and PR staff weren’t sure whether they should be posted.  Then to make matters worse, Dr. Duckett failed to communicate with his boss, Minister Zwozdesky, who was clearly steamed about the “premature” release of the ER wait times and improvement targets.  Add to this the fact that Dr. Duckett’s personal performance targets for 2010/2011 set the ER wait time benchmark for 2015 at 2 hours not 4 hours for treatment/discharge and 4 hours not 8 hours for treatment/admission.  Minister Zwozdesky says he’s concerned about AHS lowering the targets and says he’d like to see the targets “…a little higher than the fingers can reach…” but setting Dr. Duckett’s personal targets twice as high as the AHS public targets creates confusion not alignment.     

If we could just get Health Minister Zwozdesky and Dr. Duckett to work on the “micro interactions” between themselves and settle on a consistent set of targets, maybe we’d all stop having bad hair days.

 

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Who are you going to call? (Ghostbusters!)

Posted on November 7, 2010 by susanonthesoapbox

Sometimes the problem of Alberta’s failing health care system seems insurmountable.  Like a tangled ball of yarn I wonder where does it start—ER waiting times, shortages of acute care beds, adding long term care beds—and where does it end?  It feels like we’re stuck in the movie Ghostbusters waiting for the guys in hazmat suits to show up with nuclear powered vacuum cleaners to save us.  But unlike the hapless citizens of New York City we do know who to call—Health Minister Zwozdesky.  He said as much in the Legislature on February 23, 2010.  In response to a question about dissatisfaction with the decision to centralize all decision-making power in the Superboard Mr. Zwozdesky replied:  “Mr. Speaker, people at the local level have every opportunity to speak to their MLAs to bring those issues forward.  They have every opportunity to speak with their local health advisory councils…They have every opportunity to pick up the phone and call my office.”    

So on Oct 27, 2010,  I did.  But instead of exercising my “opportunity” to call Mr. Zwozdesky I sent him an email with a cc to my MLA.  Mr. Zwozdesky ignored my letter but my MLA responded the next day and asked if he could table the letter in the Legislature.  It was tabled on Nov. 1, 2010 after an intense Q & A period in which MLAs from all parties (except the Conservatives, of course) continued to press the government on what it intended to do about the health care crisis.

It’s now Nov. 7—still no word from Mr. Zwozdesky, not even a computer generated non-response which, honestly, is all I expected.  I also wrote to Premier Stelmach—deafening silence on that front as well.

Nevertheless, I urge you to exercise your “opportunity” to use this communication channel if you have any concerns about the government’s progress on fixing the health care system.  Mr. Zwozdesky can be reached at edmonton.millcreek@assembly.ab.ca.  If you don’t know who your MLA is (I didn’t) check out the link here.

So who are you going to call?

Posted in Alberta Health Care, Politics and Government | Tagged | 1 Comment

Why we’re here

Posted on November 3, 2010 by susanonthesoapbox

The purpose of this blog is to share information about the health care system so that we can become effective advocates for change.  I intend to post everything I can find on this topic.   A good place to start is the letter that ignited this issue when it was leaked to the press—the letter from Dr. Paul Parks to Health Minister Zwozdesky.  It’s attached here.  Dr. Parks summarizes the problem in one sentence:  “The severity of the ongoing emergency department/system overcrowding cannot be understated:  currently our provincial urban EDs (Emergency Departments) have more than 50% of their acute care beds occupied and blocked, on a 24/7 basis, by EIPs (admitted Emergency In-Patients).”  He argues eloquently for immediate intervention on the part of the Government in order to avert the “catastrophic collapse” of the emergency care delivery system.

So what has the Government said in response?  Health Minister Zwozdesky talks about a 5 year funding commitment and a 5 year action plan.  He also refers to a 4 prong health care plan.  Sounds impressive, but what does this really mean.  I intend to track down these documents and post them.  While I’m at it I want to find out more about the Superboard, who are the board members, what is their experience and compensation?  In addition, we all know that the Conservative Party held its annual convention last weekend.  They debated and passed a number of resolutions—did they pass any health care resolutions, if so what were they?

These are questions I want answered.  What do you want to know?

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Alberta’s Failing Health Care – An Introduction

Posted on October 31, 2010 by susanonthesoapbox

ER doctors have documented 322 cases where patients received substandard care in Alberta’s emergency rooms over the last 2 years.  These cases are real people–our husbands, wives, parents and children–who have suffered and in fact died as a result of the overcrowding in the emergency rooms because 50% of the ER beds are occupied by patients who have been admitted but can’t be transferred to the wards.

Premier Stelmach, Health Minister Zwozdesky and the head of the AHS Superboard, Dr. Duckett, have been aware of this crisis for over 2 years because Dr Paul Parks, the head of Emergency Medicine, has documented the failure of the ER system and has pleaded and advocated on our behalf.  In Feb 2008 Stelmach pledged to address the situation immediately, Duckett received a billion dollars to improve the system (it got worse) and Zwozdesky has been empathetic but ineffectual.

So where are we now, 2 years later.  Worse off than we were before.  Dr Parks warned Zwozdesky in his letter of Oct 18, 2010, that the overcrowding problem has worsened and “…we anticipate the potential catastrophic collapse of timely emergency care delivery”..

Here’s how the government and the AHS responded:

  • Stelmach says “We have acted” (Herald Oct 29/10). “We’re seeing progress. Sure, we’re having our challenges.  Refining a health-care system isn’t easy”. (Herald Oct30/10)  True, but he’s known about this problem for over 2 years and the “progress” he’s referring to has made the situation worse, not better.  Stelmach also refers to a new 5 year funding commitment to the health superboard which will put more money into the system, train more people and add more continuing care beds.  But he doesn’t tell us how much money will be earmarked for this  endeavour, where it is coming from, when it is coming, who gets it, or even who makes these decisions.
  • Stelmach offered the following additional help (Oct 29/10 Herald) — a Health Care Charter and a patient advocate.  The Charter will not entrench the target benchmarks aimed at reducing wait times and the advocate will report directly to Minister Zwozdesky, who has been remarkably unresponsive to date.  This solution is meaningless.
  • Zwozdesky has set up administrative goals in the form of bonuses to be paid to senior administrators for achieving performance objectives.  One of these performance objectives is a target benchmark of no more than a 4 hour wait from the time a patient arrives in ER until he’s treated and sent home and no more than an 8 hour wait before they’re given a bed in another ward.  In order to achieve the 8 hour target AHS has been told to speed up bed openings by discharging patients to make room for in-coming ER patients.  He’s also admitted that these benchmarks, which are already “informally” in place, are only being met 20 to 40 percent of the time.  Did the senior administers “informally” receive a 60 to 80 percent reduction in their bonuses last year?

Yes, this is a complex problem, and yes, we need to address long term issues, but promising to provide funding with no idea of how best to use it and setting meaningless targets with no accountability on the part of the very people who are charged with the responsibility of providing decent health care to Albertans is not the answer.

Incidentally, we already have a patient advocate.  His name is Dr. Paul Parks.

Posted in Alberta Health Care | Tagged | 4 Comments