I have been wandering along woodland trails wondering about hospital structure since my realization (stated in the last post) that I was not invested in even the existence of health authorities, let alone invested in implementing what they authorized. This was tempered by my realization that I am invested in the existence of Tatamagouche, and also in even more hard to define entities like ‘my practice’ and ‘my patients’. The wan/won-daring made me want to see a way forward, to be a part of effective management of the entities that exist and are important to me. To not sacrifice that which I care about for the cause of making a point about systemic dysfunction.
To find a way to function better, it is important to make an inventory of how things function now. Presently there are 5 main pathways that hospitals and institutions use to decide and act
1. Contractual. Much of what actually happens in a hospital is under the umbrella of a contract. A contract is an agreement between parties saying that A and B will each provide a defined service to the other. Generally in health care A, the practitioner, provides a set of services, called deliverables, and B, the government or health authority, provides payment.
A contract works best when the services are clearly defined. The problem with many government contracts is that only one side, the payment side, is clearly defined. The practitioner side is often deliberately open to interpretation because there is so much variation in place and patient needs and expectations that a very specific contract would probably be applicable to one practice, or even to only a couple of patients in that practice. This leads to frustration from both sides. Practitioners may feel that they are doing different and more work than the contract seems to implicate, while the government may feel that the practitioners are not meeting the spirit of the contract. The only thing that doesn’t change is the pay, which cannot be changed.
This means that changing contracts is unwieldy and glacial. Because everyone knows this, the wording becomes more and more nebulous and the ‘deliverables’ become more and more open to interpretation. I presently am working under a 1 year trial contract that I signed 9 years ago. If you read that contract you would have absolutely no picture of what my job looks like. The one thing you would know from it is how much I am paid. As a result, contracts are essential but do not provide leadership or action.
2. Commensalism. A commensalism relationship occurs when 2 organisms or entities use each other for mutual gain. The well known example is the birds that eat the parasites off the hippo’s hide. The hippos and birds are not committed to each other. They do not have a common goal. They tolerate each other and use each other. As soon as any personal gain is realized, the relationship ends. Hospitals have deals like this. Perhaps the simplest to describe is the relationship between a hospital and a surgeon. An operating room without a surgeon serves little purpose, and a surgeon without an OR serves little purpose. Surgeons and hospitals have a long commensalism history. They need each other and use each other, but they are not (generally) committed to each other. If one party isn’t realizing the other’s goals, the relationship ends. This is not to say that surgeons lead entirely utilitarian lives or work in such a calculated fashion, but the OR-surgeon relationship is largely commensal.
This relationship has a long history and is largely successful, and ‘gets things done’, but it is about as possible to create a new commensal relationship in a hospital as it is in the savannah. They happen through evolution, not by design.
3. Collegial. This is an agreement between people who know each other. They have a relationship based on mutual respect and an understood concept of temporal equity. This means, practically, that I may call a specialist whom I trust for help in a ‘beyond the contract’ type of encounter with the understanding that they can trust me to receive a similar request in the future. New health care workers and patients have little understanding of the degree of care that happens in such encounters.
While these arrangements often ‘get things done’, there are a couple of problems with collegiality as a problem solver in hospitals. First, collegial relationships take time to form, respect takes time and trust of reciprocity takes time. This means that new practitioners (and their patients) can be at a disadvantage. Second, collegiality only exists between those who have a shared experience. For practitioners, it is greatest for those whose job is most like your own and then extends to include, to varying degrees, all those who are involved in direct patient care … but it abruptly ends there. There is no collegiality in hospitals between providers and administrators. This is partly due to a lack of (perceived and real) respect, and a lack of history of reciprocity.
Unfortunately, because of these issues, some specialties are removing collegiality from the patient care process. The surgical pain managements come to mind (neurosurgical pain referrals, joint replacements). These are now arranged through soulless forms and middle-person mediated questionnaires. This is being done in the name of patient equality but I believe is leading more to patient estrangement.
4. Contextual. These are decisions that happen because of an exceptional circumstance. In certain contexts, the health system recognizes that practitioners will move outside their contractual and established routines to do something different. Pretty much everything Covid related in hospitals has been done contextually. The system can manage this well on occasion but the understanding is that this is a rare ask or tell. If it keeps happening then the context is the every day and the system will need to recognize that and make contractual changes to match.
For example, in my previous post I wrote about bed pressures. If the bed manager says every week that there is a severe overcrowding crisis that requires a contextual response, the practitioner will respond by going beyond the contract and respond contextually once or twice. After that it no longer sounds like a crisis and sounds more like an every day reality that should be addressed as such. And context should go both ways. Practitioners should, rarely, be able to present a plea to request a contractual exception. But it shouldn’t happen recurrently, or the contract should be changed.
5. Collaborative. These decisions happen together with all those affected. A group plan is developed to manage a new problem. An agreement is made that this will be considered part of the contract, even if not in writing. The groups that are collegial create plans within their circles. The plan is implemented. Such a system sounds ideal, and it might seem that since I have put it last, it is seen to be the solution to most issues. In fact it is not. It is a time consuming and frustrating process that can involve multiple meetings simply to decide on how to meet. The smaller the group, the better it works.
Recently in Tatamagouche, the hospital reopened as an urgent care center as we did not have the staff who were committed to running an ‘all-comers’ ER. It was agreed locally that the community would benefit from an urgent care centre if the alternative was nothing for those patients without a family doctor. We had 2 meetings in Tatamagouche and many calls and emails and developed a workable solution in 7 days. Everyone in the collegial circle in our community was ready to go. It took a further 8-10 weeks to work its way through all the collaborative meetings before it could be implemented. This is typical of collaborative decisions. Often great ideas are developed but the momentum for change has long waned by the time the meetings are all done.
It is useful, when in the midst of a decision or negotiation, to recognize what kind of deal is happening as this allows the participants to talk and think in the same way about the problem. I think that part of the bed pressure issue is that the bed manager is viewing the problem as a collegial request and the local practitioners are seeing it as a contextual crisis that has lost its ‘one-off’ identity. Recognizing this may lead to more fruitful and less fraught future discussions. This is almost certainly true for many of the negotiations that we face at work and in life.
My next post will look to a new way of negotiating, perhaps a way forward.
