by Dr Ishma Harford
Measuring the success of a system seems straightforward. Set a goal, and if it is achieved, it was a success. While a somewhat ‘easy’ approach, its one-dimensionality misrepresents the reality.
Achieving an outcome is easy to celebrate, but understanding how it came about offers not only insight into how it may be reproduced and improved, but it uncovers its true cost.
Suppose you task 2 workers to dig a hole. You give them each 3 days and return. At that time, both holes are dug, and thus, from a strictly outcomes perspective, the goal was achieved. But how it was done absolutely matters. If one worker was given a spoon, while the other was given a shovel, then the effort required is immensely mismatched. The cost to you, who paid the same wage to both, appears fixed. But the cost to the worker who was short-changed in his duties is often hidden but matters just the same.
The assumption that the worker with the spoon gets better with practice would be misguided. The wrong tool does not build skill; it wears down the hands of its holder, and every hole costs more than the last. Because both holes were dug, nothing looks wrong. You inspect the holes, not the hands, and for the next task you may wrongly hand out another spoon. The effort to compensate therefore hides the problem that created it.
In healthcare, outcomes are usually the end-all metric of success. But the cost of that success is often obscured. In weaker health systems, where resource burdens and administrative challenges are greater, the greatest compensator is often the human resource.
Even in better-organised systems, this phenomenon exists. In a 2003 United States study, nurses lost about 33 minutes of every 8-hour shift working around missing supplies, broken equipment and inaccurate information, quietly fixing the problem in front of them rather than the system that caused it.
Let’s examine what our spoon analogy could represent in actual healthcare. Acuity describes how much attention and resources a patient needs to achieve the standard of care. Imagine a ward that requires 4 nurses but only has 2. If enough patients are critical and require high-acuity care, our nurses must divide their finite attention between these critical patients and the other duties required while already being disadvantaged by insufficient staffing.
When the most valuable and exhaustible resource must compensate for the structural failures of the system, it creates not only low morale, but the feeling of being undervalued. This breeds a particularly insidious type of distress, where you know what is needed to do the job right, but are disadvantaged with spoons and expected to deliver regardless.
Across the Caribbean, nursing vacancy rates average 40%. The migration of the healthcare workforce is not purely because of financial incentives. It is also because the system’s pressure falls disproportionately on the everyday heroes who do more with less, whose cries remain unheard and whose very wellbeing is the hidden cost of the success the system so narrowly assesses.
The age-old argument that resources are finite invariably holds, and sacrifices must be made. But when the sacrifice is the most valuable resource the system has, and success is touted without understanding its true cost, the spoon gets handed out again.
The dark side of heroism is the hidden sacrifice. When a system cannot function without day-to-day strain and sacrifice, even honour becomes performative. Our heroes cannot lift their heads while they continue to pay the hidden cost and be the fodder for narrow success.
Dr Ishma Harford is a medical doctor and a Commonwealth Scholar who holds a master’s degree in Health Analysis, Policy and Management. The Health Imperative is an educational, non-partisan column about health, the system that delivers it, and all the implications in between.
NOW Grenada is not responsible for the opinions, statements or media content presented by contributors. In case of abuse, click here to report.