Pandemic and the need for agility

1- The Long-term care facility carnage

Of all Canadian provinces, Quebec is the hardest hit by the COVID-19 pandemic. On a global scale, its death rate is only surpassed by Italy and the UK. At the national level, by comparison, its death rate is 35 times higher than British Columbia. Most of its victims are elderly citizen, living in long term care facilities called CHSLD in Quebec.

The constant news coverage of the pandemic has brought to light the horrific reality of the living (and dying) conditions in some CHSLD. A few points of interest;

• This is unfortunately not a situation unique to Quebec. The military (who are helping in many provinces) have just published a report documenting similar conditions in Ontario’s long-term care facilities.

• Residences for the elderly in Quebec can bear many different names (CHSLD, RPA, RI, RTF, Etc.) they can also be either privately run or managed by the provincial government. None of this seem to be a factor to differentiate the amount or quality of care provided to the elderly. For this reason and to increase readability, within the confine of this article, the acronym CHSLD will include all the various type of residence for the elderly.

• The impact of the pandemic on the quality of life of residents is highly variable among CHSLD. Some of them have taken extraordinary measure early on and have successfully prevented an outbreak of COVID-19 (CHSLD Stanstead). Others will undergo several investigations including criminal one. (CHSLD Herron)

• These poor living conditions have been denunciated for at least 10 years; it is not new. What is new is the fact that so many deaths without any human dignity have occurred in such a short time frame. This in turn created a publicly stated political desire to resolve this situation permanently.

The challenge is therefore to define the best approaches, both short and long term, that would permanently improve the quality of life in Quebec’s CHSLD. Can agility contribute to the success of these initiatives? In the next section we will look at what was done short term and in a situation of urgency. The following section will cover what is considered for the longer term once the state of emergency is over.

2- Short term initiatives

Agility, this ability that few organizations possess to be able to adapt to new realities and very quickly offer a good or service now required. This ability is essential in time of crisis.

The Quebec government launched several short-term initiatives that broadly respect the following 4 concepts of agility;

• The product (or service) does not have to be perfect. In the Agility mindset you release a “minimally viable product” as quickly as possible in order to capture an opportunity (or prevent further deterioration in this case). The product is made better over time by a continuous improvement process

• Creating experiment to learn.

• Using empirical data instead of data from a predictive model.

• Entitlement to make good faith error and the ability to replace what was put in place with a better solution.

To confront the urgency created by a large number of deaths in CHSLD, prime minister Legault decided to address the chronic issue of lack of personnel in these institutions. That first step to address the quality of life problem was delivered with relative agility as illustrated below;

• Rather than using traditional recruitment channels, Premier Legault decided to make a public address on television to find 10,000 volunteers to take a course to become “préposé aux bénéficiaires” (an experiment). Response to that personal plea was overwhelming.

• That solution is not perfect. Creating a new category of job and a new salary grid caused serious frictions with labor unions and other employees who are now asking for a comparable salary review. However, the opportunity to improve the quality of life was seized and the improvement process already started.

• A good faith error was committed by premier Legault when he promised full time job to all who would take the course. The prime minister has admitted this oversight and is working in correcting this situation.

This is but one example among many as examples of agility abound. 2 initiatives are worth special mentions. What distinguish these initiatives is the fact that they were already started before the COVID-19 pandemic started. Approval cycle that are measured in years were reduced to a few weeks in both cases.

• The pandemic made face to face meeting impossible and working remotely an obligation at a university hospital (CHUM) and everywhere else. A request for a collaboration tool (Microsoft Teams) had been made 18 months earlier. The benefits of these tools are well documented and widely available in most large corporations but progress in getting approval were slow. Microsoft Teams was implemented within a week once the pandemic was confirmed.

• Telemedicine has been in the work for almost 10 years. The initiative was always hitting bureaucratic red tape, resistance to change and doubts about technological solution. All the sudden, within a few weeks, it is up and running. It took only a few weeks to put in place but it will help the population for several years to come.

3- Longer term initiatives

Many initiatives aiming to increase the quality of life for the elderly are currently under study. One of them is considering reducing the number of peoples in CHSLD by keeping the elderly at home for a longer period of time. This in turn requires a robust home care organization. In Quebec, home cares are provided by “Centres Locaux de Services Communautaires“(CLSC).

It is not yet possible to analyze the agility of these implementations because these initiatives are not yet started. What is possible is to review what was done successfully elsewhere in the world in similar circumstances.

Buurtzorg operate in the Netherland. It was created in 2006 as a non-profit organization. in 7 years, it grew to 7000 employees and provided 66% of home care in that country.

Buurtzorg achieved this by leveraging the power of small, self managed teams (10 to 12 nurses). Combining this with a very flat corporate structure they are the picture of corporate agility. Decisions are made at bedside not centrally. This combination of factors has resulted in saving of a few billion Euro per year for this country health care system. As a bonus speed at which care are delivered as well as patient and nurses satisfaction have all increased substantially.

This organizational experience has been replicated in several counties and at various scale, notably in Ontario. Results achieved during these experiments were frequently much better than what the previous hierarchical structure could deliver. The main lesson from the Buurtzorg experience is that economies are available without sacrificing the patient or the nurses.

4- Conclusions

• Faced with a state of emergency the government of Quebec has demonstrated an ability to act rapidly and in an adaptive manner in the short term. The health system of that province is familiar with Lean/Agile methodologies having delivered several initiatives in these frameworks a few years ago. Unfortunately, severe funding cuts from the federal government since 2016 and a few restructuration were devastating to their agile transformation.

• An institution confronted by an emergency has no choice but to act with agility (quickly and adaptively). Those who don’t frequently disappear all together. Once the state of emergency removed will it be possible for the Quebec health system to maintain and grow their agility? There is nothing intrinsic that would prevent it but many constraints exist. If we look at this in the context of an increase of home care by CLSC for instance;

  • Lack of resources (financial, material, human, etc.) In fact, the very same shortages that created the CHSLD situation.

  • A return to year long approbation cycles

  • Resistance to changes and bureaucratic processes

  • Inflexibility of the current structure

On a more positive note there are a few real-life examples of large hierarchical and bureaucratic institution that have successfully adopted agile practices. The US army provide such an example. General Stanley McChrystal in his book “team of teams” illustrate how agile principles were successfully used during the war in Afghanistan.

• Lastly, a word of caution. Software, for all of its wonder, is not a solution for a poor work organization or deficient processes. Trying to resolve these issues with software only lead to deceptions.