Is sane management possible in a crazy world?

Most people benefit from healthcare. However, Canadians remain dissatisfied because too often we receive faulty care and delayed care, not supported by evidence. Browman and colleagues relate successful efforts to introduce evidence-based care. They show that strong champions can be effective even in insane environments. The collaborative approach suggested is moving and thoughtful. Sharing between knowledge and financial stewards, including the use of stories, is especially valuable when financial stewardshipis not possible because we lack information about the local outcomes of care. Goodwill between stewards is especially necessary when there are few external incentives to provide excellent care. In healthcare good deeds are punished, not rewarded. Canadian governments fail to regulate healthcare because of the conflict of interest arising when the same group not only regulates care but also functions as insurer, governor, administrator and evaluator. We need radical change to eliminate the perverse incentives and bizarre management practices that bedevil our healthcare system and impede the use of evidence. Fundamental changes in organization and evaluation proposed by the Halifax Chamber of Commerce and the Kirby and Mazankowski committees will help. Separating the functions of insurer, administrator, evaluator and regulator is ethical and necessary.