mardi 18 octobre 2011

Leadership in health care

This piece was written for my classmates in the course Economic social and cultural rights in Canada and the global south, given by The Social Justice Commitee :

The leadership market in health care :

How are leaders made and evaluated?  

1. Privately-funded lobbies to feed the media

Years of pressure on the media from self-professed economic think-tanks have reshaped the political thinking in Quebec. I never suspected until last year that renowned institutions like the Fraser Institute provided biased information : they are regularly quoted in the media and so they must be reliable, right? Actually, no. Organizations like the Fraser Institute and the Institut Économique de Montréal present themselves as non-political but they are actually lobbies that promote non-debatable ideas to the media. Intelligence is out. Popular surveys and privately-funded research are in.

I became acquainted with the propaganda of the Fraser Institute in the Fall of 2010 when the Chamber of Commons discussed the long-form census.  It appears that the actions of the Harper government had prompted the Chief statistician of Statistics Canada to resign. Incidentally, if I had to make a list of governmental institutions that are efficient, leading-edge and essential to our democracy, Statistics Canada would be very near the top of my list. The honorable Tony Clement was the minister in charge of Statistics Canada at the time and when I enquired about the disdain showed to statisticians, he gave me a cryptic answer, which is unacceptable given his executive intrusion into the running of Statistics Canada. After some research, it turns out that the arguments he used were identical to those found in a paper from the Fraser Institute.

Political figures appear to rely on private institutes for their decision-making in the same mistaken belief I had that the media are doing their due diligence when verifying sources. Why no one protested over the years, I cannot fathom. The end result is the adoption by the media, the population and the political class of ideas tailored for their particular tastes and escaping independent academic scrutiny.

2. The accreditation market in the health care sector

My current interest lies in the Quebec health care system. It was essentially nationalized in the sixties and seventies and still works quite well to this day. Médecins québécois pour le régime public (MQRP) believe that large chunks of it are in danger of being privatized. The experience in Quebec has shown that, given proper funding, an empowered public sector can provide universal coverage to the population. However, power and funding have suffered from gradual erosion, to the point that lobbies can successfully persuade politicians that the public sector is a bureaucratic money-pit. The obvious fix of retaking the power that was lost to lobbies is not currently feasible given the complacency of the media. The political class is therefore stuck with the idea that there is a widespread crisis of leadership across the whole public health care system, an idea that prompts it to create new levels of administration to make sure that everything stands up to scrutiny. This in turns fuels the critics who denounce excessive bureaucracy.

This sets the table for the accreditation of everything connected to administration in the health care sector. Accreditation from a recognized organism was originally conceived as a certification intended to inform consumers. However, we now have a de facto monopoly in Accreditation Canada. Accreditation Canada is a not-for-profit organization and it itself undergoes an accreditation process provided by ISQua, the International Society for Quality in Health Care. ISQua is the world leader for accreditation in health care administration. Here follows an exerpt from Charles D Shaw's paper : «Toolkit for Accreditation Programs».

The project to develop a Toolkit for Accreditation Programs was initiated in 2001 by ISQua, the International Society for Quality in Health Care, following discussions with colleagues at the World Bank also at the World Health Organization, and in response to requests coming to ISQua.

A clear need was expressed for a straightforward tool for implementation in a nation state or health care system. This would be an aid for accreditation providers and would also meet the requirements of funding agencies such as the World Bank, intergovernmental organizations such as the WHO, and individual countries considering the development of a national program.

Canada does not have a national program because health is a provincial responsibility. However, every province has implemented a public health care system and Quebec has dutifully followed the Toolkit and made accreditation mandatory (licensing) for its governing bodies. For reasons of efficiency, all public bodies are now using Accreditation Canada as their provider.

Another excerpt from Shaw, followed by a comment from Australia :

Historically, accreditation aimed for voluntary, professionally-driven continuing improvement. But since the mid-1990s, new and existing programs have increasingly become mechanisms for accountability to the public, and to regulatory and funding agencies. And they have progressively aligned themselves to statutory mechanisms.

“It would be naive to believe accreditation does not have a role in informing decisions on what hospitals should remain and what hospitals should reduce services, re-structure or close.” Australia

3. The evolution of accreditation in Quebec

The idea of participating in an accreditation process may hold fears. Shaw identifies the following : sanctions for shortcomings, loss of staff morale if denied accreditation, misuse of performance data, gaining accreditation and then losing it when standards get more demanding. According to Shaw :

If the program’s aims are clear, those who stand to gain or lose from it are easy to identify. Traditional, profession-driven programs have tended to build links with regulators and consumers, thus becoming more accountable and transparent. More recently, programs have been increasingly influenced by commercial providers and insurers. And lately, there has been active support from government. (My underlining)

The discomfort felt in Quebec stems precisely from the growing influence of commercial providers. Having implemented a successful public sector, Quebec has no tradition of consumerism in health care. Therefore the newly introduced commercial lobbying feels awkward and counter-productive.

The programs are not clear and the threat of privatization, however unlikely, is hard to dispel. I would very much like to hear the honorable Minister Yves Bolduc speak on this subject and clarify the intentions behind the changes he made to the composition of administrative boards. I am somewhat apprehensive of the pressures that I feel will be exerted in the federal-provincial negotiations that will take place in 2013-2014. The following statement sure feels like trouble in light of the unclear aims of accreditation in Quebec and the severely restricted funding of the public health sector :

« Un moyen fondamental d'améliorer les soins de santé est d'assainir les milieux de travail des employés de ce domaine. Aussi est-il inacceptable de financer, de gouverner ou de diriger des établissements de santé malsains tout autant que d'y travailler ou d'y recevoir des soins. » (Coalition pour la qualité de vie au travail et des soins de santé de qualité, 2006)

4. Message for the Honorable Dr. Yves Bolduc

You did not take the opportunity of the Commission parlementaire on bill 127 to explain the motivation behind the administrative reform that it introduced. At least not to the satisfaction of the participants and not to mine. I'm a nice guy so instead of bad-mouthing you, I am running for one of the two seats on the Conseil d'administration that are reserved for the population of my Centre de santé et des services sociaux. My vision is the betterment of health care in Quebec. My mission is to improve knowledge. My values are honesty, kindness and friendship. What are yours?

François Genest, 18 octobre 2011

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