Quebec's Bill 15: yet another 'stupidifying' reform?

Quebec Minister of Health Christian Dubé promised to “shake the pillars” of the health and social services network with his Bill 15, reorganizing how services are accessed. If the past is any indication of the future, this could only be wishful thinking.Yves Couturier (PhD), a professor at the school of social work at the University of Sherbrooke, is interested in the implementation of innovations in the care of elderly patients and in primary care, “two major priorities in Quebec for decades,” he said.With his colleague Louise Belzile, Couturier, also a researcher in health care and social services systems, has published, Stupidité, erreur et apprentissage—Vers des organisations apprenantes en santé et services sociaux ("Stupidity, error and learning—Towards learning organizations in health and social services"). The fruit of their 20 years of experience in the field, the book combines humour tinged with anger, with concrete examples and scientific foundations. The two authors paint a poor portrait of the Quebec health network, a system which demonstrates, according to them, a stubborn incapacity to implement lasting and effective solutions due to “stupidizing processes” at work at all levels.“We develop quality innovations, we demonstrate that we can implement them, but they too rarely produce the expected effects because of a component of stupidity that we do not dare to face,” summarized Couturier, with whom the Medical Post’s French counterpart ProfessionSanté.ca conducted a Q&A, discussing this observation in the light of Quebec’s Bill 15, the stated objective of which is to “make the health and social services system more efficient.” Read: 'You're on your own': Quebec parents grapple with lack of pediatrician followupTo set the scene, what do you mean by “stupidizing process”?It is a set of individual and collective decisions, actions and behaviours that do not respond to any logic and which, in the context of an organization under constraints of human and financial resources, lead its actors to adopt absurd practices. Stupidizing processes lead people to do things wrongly or not seriously. They then have two choices: Fight against it, at the risk of suffering and/or being marginalized, or integrate this stupid practice.Here is a real-life example. Accreditation Canada announced its visit to one of the province's residential and long-term care centres (in Quebec, Les centres d'hébergement de soins de longue durée [CHSLD]) a year in advance. So the staff involved in the cafeteria menu decided to update it (improve its quality). We increased work meetings for 12 months and we decided on a new menu. But once approval was obtained, nothing changed on the residents’ plate, because priorities had changed along the way. It’s good for the image with Accreditation Canada, but in the end, we did it for show, and for the people who participated in the working committee, it’s demotivating.Another example: In 2004, the Quebec Ministry of Health and Social Services (MSSS) decided to adopt the case management for the coordination of home care. The reference framework was to be published in 2017. For 13 years, managers and professionals empirically tried many models, without any guidelines. The idea was burned.Through the framework you present in your book, can we conclude that Bill 15 is a “stupidizing” reform?Overall, yes, and I am quite skeptical about its ability to achieve the objective Dubé is pursuing. However, it would be stupid to throw the 1,300 articles of the bill in the trash. Some are going in the right direction, such as the desire to create a learning health system through better data collection, to adopt a culture of continuous quality improvement or to include a change management dimension, which is too often the fifth wheel of the carriage even though it is essential.Read: Frustration of fragmented careOther positive elements, concerning medical governance, are: the presence of a manager per establishment and the strengthening of the powers of the DRMGs (regional departments of general medicine). But we have left clinicians too much to do, what they want, when they want. One in three medical practices today is inefficient, redundant, or even useless, while we still have a serious problem with accessibility to doctors.Do we really need a new centralizing reform after those of 2004 and 2015? The same logic has been applied three times over time, by the same people at the MSSS who do not rely on science. We should be shown serious evaluations of the reforms of 2004 and 2015 which, have not had any real effects on the ground. Such reforms take 10 years to integrate. This is the third in 20 years. Managers are in adaptation mode all the time. In 2004, they wanted reform. In 2015, they hated it. In 2023, they are resigned and will make do, a posture that is a source of inertia and could derail progress.So is organizational stupidity the fault of managers?No, because overall the MSSS is undermanaged, and Minister Dubé seems to be sensitive to this reality. Managers are overloaded, they have to deal with a multitude of issues and implement a continuous flow of innovations. When we can't do everything or we don't have the human and financial resources, despite the injunctions that come from above, we try to look good, to show that we are moving. We create committees, we choose our battles and end up adopting stupidizing processes. To make matters worse, there is also a lot of turnover among managers. As soon as one of them does his job well, he is promoted and his work is left in place. Then stupidly, his successor tends to deconstruct what has been done before just to make his own mark.Aren’t the shortage of staff and the lack of financial resources an obstacle to more “intelligence” within the network?The problems in the healthcare system existed before the labour shortage. We can even reverse the proposition: It could well be that the labour shortage is, at least in part, a consequence of stupidizing processes. When staff are treated like pawns, when they have poor working conditions, when they are overwhelmed with tasks and meetings, it is demobilizing to see their counterparts in the private sector, who sometimes work on the same floors, have better salaries, less responsibilities and are exempt from committees. We thus create a stupidizing vicious circle that encourages network staff to leave for the private sector. The phenomenon also risks amplifying if we are to believe the researchers and intellectuals who affirm that Bill 15 sets the legal conditions for the privatization of health. If we allow the construction of private hospitals, we will create a breath of fresh air for network employees.Read: Report: Private clinics in Ontario cost the system more and don’t improve careHowever, it is true that the labour shortage remains an obstacle to the implementation of innovations, because adequate training must be constantly provided. If people are trained, for example, in the deprescription of antipsychotics for Alzheimer’s patients housed in CHSLDs (a real case), but due to the turnover rate, three-quarters no longer work there after two years, there is no one trained left—even though everyone agreed that deprescribing is beneficial for patients.What about the impact of health budgets?In part, but it is not an issue specific to Quebec. All health systems in the world are currently struggling. This is part of a public debate needed: What do we want as a society and how do we finance health and social services? Today, we do not have the means to achieve our ambitions, and resources do not keep up with the needs that will increase in the future with the aging of the population. We are always chasing. The government is very proud to have created 2,600 places in its new homes for seniors, but we have 3,500 people waiting for a place in CHSLDs and we know that 6,000 people aged 85 and over will arrive per year. We're not going to hit a wall. We're in the wall! And it was predictable. These 2,600 new places will be of no use. They had to be done, but they will not change the situation. The same goes for home care. We have known for 20 years that we must invest in this, because it is the solution to unclog hospitals. However, in terms of investment in home care, Quebec is the ninth province per capita and there have never been so many elderly people stuck in hospital beds due to lack of home care resources.What is the solution to break the vicious cycle of these processes of stupidification?There is not one solution, but several. We must first establish a culture of quality and promote its continuous improvement. You need management that has the means and time to accomplish its task. To do this, we must slow down the pace of major structural reforms so that people can digest them, and we must attach dedicated resources to all the transformations and innovations to be implemented. Finally, we must adopt a culture that is fair in the face of error. Staff must be able to talk about their mistakes, without fear of judgment or reprisals, to find solutions so as not to repeat them. In learning contexts, such as in the aviation sector, each error is analyzed, we discuss it collectively, we learn from it, we act on its determinants, then we disseminate the results of the analysis to everyone, in order to let everyone benefit from it.Read: Bill prompts call for Quebec to recognize systemic racism in health system

Quebec's Bill 15: yet another 'stupidifying' reform?

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