Like our Premier — who attended Harvard University for a week — I too spent a week in1989 “studying at Harvard” with a group of healthcare reform radicals led by an unknown professor/physician named Don Berwick – who went on to become the acknowledged healthcare quality guru on our planet.

Berwick and his team were breaking new ground way back then. They came armed with dozens of “tools”, “frameworks” and “quality processes” borrowed from Deming’s work with Japanese manufacturers. Unfortunately, the first generation of healthcare quality learners all seemed to go out and start consulting companies that sold fancy TQM Workshops with CQI Tool Boxes — instead of being focused on what Berwick actually taught us: which was “a different way of thinking”.

The repeating pattern we have experienced over the past two decades is that the healthcare sector has been borrowing ideas and processes from the manufacturing sector wholesale — and implementing them as “flavour-of-the-month” solutions.

Most self-respecting hospital CEOs back in the ‘90’s went out and hired a Director of TQM/CQI and ran “expert-led”, “bums-in-seats” seminars for front-line workers — where everyone learned why they could not do their job without a pareto diagram and a fish-bone diagram.

Sadly, the idea of education and skills development for the front-line care providers turned into a scam because most people did not understand that what Berwick, Deming, Shwerhart and Juran taught was that the quality improvement movement was about a different way of thinking, it wasn’t about the tools. The tools were a process that ought to enable people to see the “same/old” issues with fresh lenses.

For two days later this month, Berwick is bringing together the faculty and students from 25 years ago to participate in a 25th anniversary quality conference called Improving Skills For Tomorrow’s Healthcare: The Experts Perspective (April 30th – May 1st).

In the advance video promotion for this gathering back at Harvard, Berwick points out that “a lot has changed in the 25 years since the Institute for Health Improvement founders built on the work of Deming, and applied the science of improvement to the healthcare sector”.

IHI trained 10,000 people as QI leaders in the first ten years of its existence. This work has spread over the past ten years and has been systemized as quality improvement curriculums – often on a state-wide basis — targeted to hospital middle managers who are then responsible for engaging their front-line workers using these improvement tools.

Groups like the OHA have also cashed in on this lucrative “bums-in-seats” educational workshop business — by teaching green and black belts for lean thinking, along with other courses. From the private sector, the Studer Group has created a powerful quality training program which a number of Canadian hospitals have used to create real improvements.

But most of the training packages around today are still stuck in “old-school” quality tool training. Rather than being pragmatic, they tend to have a strong academic bent that leaves front-line staff cold. Why? Because left-brain manufacturing processes that promise to “save money” does not really motivate care providers.

Today, Berwick acknowledges that back in the early days of IHI, and the beginning of the TQM/CQI movement, we (believe it or not) did not even think about the one diagnostic tool that today fundamentally changes the whole equation: the patient!

Interesting how “old school quality” didn’t see the patient as a potential source for solutions — or even for meaningful measurement.

“We also didn’t understand ‘systems’ back then”, says Berwick. “We didn’t understand hospitals as systems, or local community services as a ‘system of services’ that somehow ought to fit synergistically together.”

Since the early days of borrowing manufacturing quality tools and processes, we’ve learned a great deal about the behaviour of human systems that people like Margaret Wheatley, Herbert Wong, Barry Oshry, and Dee Hock refer to as “complex, adaptive systems”. But we no longer do 1980’s-type “bums-in-seats” academic theory training. We’ve learned from these limitations, discovered the power of collective intelligence, and moved on.

The Health Council of Canada’s new report, “Which Way To Quality?” traces the Canadian version of the TQM/CQI craze in the early 2000s with the Canadian Adverse Events Report in 2004, and demonstrates our progress in each province since that time.

Today, in Saskatchewan, for example, they are using Hoshin Kanri, a lean-based approach to planning — with some right-brain components — that involves identifying a common vision, setting goals, tracking progress towards those goals, and changing direction as required. This is the “learning-by-doing” model borrowed from the manufacturing sector that has had some success in places like the Virginia Mason Health System in Seattle.

“Using a ‘top-down’ and ‘bottom-up’ approach, Hoshin Kanri incorporates feedback from people working at all levels of the healthcare delivery system. However, best practices tells us that each organization, and each cluster of organizations (in a LHIN, or Health Link) require a customized approach that reflects the unique idiosyncrasies of the complex human system that needs to move forward.

We certainly won’t successfully transform our healthcare system by pushing everyone in the province into a classroom to learn how to use manufacturing tools for quality that have achieved some success in another healthcare system in some far-off place.

Successful health quality transformation will depend on local leadership, and the appropriate next step for each cluster — not centralized control with a “one-size-fits-all” approach to quality training.

While someone may have uncovered “the best Grade Eight Math Curriculum in the world”, if you are in Grade Three, or Grade Twelve, it is sub-optimal. Thankfully, Queen’s Park has abandoned their traditional belief in the “one-size-fits-all” philosophy of the past.

The Health Council of Canada reports that “many leaders talked about the need to change the healthcare culture to one in which people understand that quality improvement is ongoing and is part of their everyday work. Several stressed that it is important for leaders to set priorities and a clear direction for quality improvement initiatives to avoid change fatigue and burn out.”

One leader interviewed said “everybody is so busy doing what they are doing. No one seems aware that as a system, we’re not addressing what we need to be addressing. Culture change is required to get that discipline.”

The issue isn’t about the need to have the very same “tools” and curriculum. It’s actually about how we think. The fact is we’re ingrained in fragmentation — where we automatically always beak off the various pieces from the whole into isolated and incomplete parts.

The wonderful thing about the Health Links are that they are designed to look at the patient experience cross-functionally along the continuum-of-care. So instead of examining the experience silo by silo, participants are asked to address the “whole picture”, rather than the “sum of the individual parts.”

Art Frohwerk, the inventor of the Patient Experience Design Storyboarding Methodology being adopted by leading-edge healthcare organizations says “fragmentation causes us to lose context, optimize one part and sub-optimize others, and is the basis for the profound world of ‘missed connections’ in healthcare.” He says, “it is the missed connections that cause high-cost, poor results and bad human experiences – for both the patient, and the caregiver.”

Peter Senge explains that “from a very early age we are taught to break apart problems, to fragment the world.  This apparently makes complex tasks and subjects more manageable, but we pay a hidden, enormous price.  We can no longer see the consequences of our actions; we lose our intrinsic sense of connection to a larger whole.” When we try to “see the big picture”, we try to reassemble the fragments in our minds, to list and organize all the pieces. 

But, as physicist David Bohm says, the task is futile — similar to trying to reassemble the fragments of a broken mirror to see a true reflection.  Thus, after a while, he says, “we give up trying to see the whole altogether”. Today many people who work on healthcare can’t see “a system of care”, because there isn’t one. Health Links Teams will discover this when they ask patients and their families about their experience with the delivery system.

When we give up the illusion that the world is created of separate, unrelated forces, we can then build Learning Organizations — organizations where “people continually expand their capacity to create the results they truly desire; where new and expansive patterns of thinking are nurtured; where collective aspiration is set free; and, where people are continually learning how to learn together. “

In such organizations, people no longer compete with one another.  There are no longer the traditional silo wars between departments or factions.  People are working cooperatively and collaboratively together to integrate the component parts into a coordinated whole. 

Integration is the opposite of fragmentation.  Learning how to think in an integrated, holistic way involves a struggle to overcome our traditional, fragmented ways of thinking.  Systems Thinking shows that small, well-focused actions in the right place can produce significant, enduring improvements.  By contrast, traditional fragmented thinking focuses on symptomatic fixes — not underlying causes.

This doesn’t mean Quality Tool Training is bad. Of course it will do some good – as it did in the late ‘80’s, and throughout the 1990’s. But, hey we’ve learned a lot since then. We actually know the limitations of last generation’s tool-based QI training programs.

They tend to be more about teaching, than about learning.

They tend to be more top-down, than bottom-up. More didactic, than participative. More expert-led, than collective intelligence. More about politics/optics, than about fundamental transformational change. More about the process, than about achieving results.

Peter Senge says “in place of our traditional fragmented ways of thinking about the world, we can learn the skill of systems thinking – the ability to see the whole picture, of seeing interrelationships rather than things, and of seeing patterns of change rather than static fragmented snapshots.”

Adult learning methodologies suggest that each cluster of Health Link organizations need to evolve their own unique blend of what is already working for them locally right now – along with several new ideas that “fit” their unique circumstances.

In the ‘90’s, the leading-edge organizations that opted for “transformation” over “re-engineering” experienced performance surges – while 70% of re-engineering projects that were rolled-out top-down, failed. Lean thinking projects in healthcare achieve similar results.

So, unless we change how we think, we will always produce the “same/old” results. If the Health Links choose to evolve and adapt the new stuff, they could succeed. If they import old school expert-led theory-based tool training, they may flounder and fail to move beyond their fragmented silos.

Next week’s blog: “Health Coaches Innovative Program For True Patient-Centred Care”.

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“Linkets” are new-born Health Link partners who have actually been connected to one another all along, but are just now – like the baby in the crib on their back at the moment they discover that they actually own the hand dancing in front of their face – becoming aware of themselves as a “system” of services with common patients, as well as common “owners”.

Remember watching the total delight babies experience when they make that exhilarating discovery that the hand is theirs? While toilet training and connecting to the world around them are among the vital first priorities of baby humans, communications and understanding are the next highest priorities for our species.

It is the same for human organizations as they evolve and develop.

Health Links will require some time and space to form and to develop. Margaret Wheatley said of complex adaptive human systems, “when a system is failing, or performing poorly, the solution will be discovered within the system — if more and better connections are created.”

In Finding Our Way: Leadership In Uncertain Times, Wheatley says that “the solution is always to bring the system together so that it can learn more about itself from itself. A troubled system needs to start talking to itself, especially to those it didn’t know were even part of itself.” For Health Links partners to communicate effectively, they need to learn and practice a skill called “dialogue”, and an art called “listening”.

Is it possible that the new Health Links partners have in fact been talking past one another for years — in their determined attempt to be “independent”, at the expense of their interdependence. While the war of independence has been won by the silos, the people who “own” the silos lost.

My mentor Herbert Wong of Quantum Solutions used to tell me: “if we are going to be effective transformation coaches, we need to understand and honor the two most compelling needs that the humans have: our need to be independent, and, our equally compelling need to be part of a larger group, a community, a family, a team.”  

We seek connected independence and interdependent autonomy. Got it? We’re a paradox!

While Health Links provides the opportunity to satisfy the need to be part of a larger community and a larger purpose, the collective efforts will collapse in utter failure — unless we can listen to one another, talk to one another, and value one another as partners, collaborators & colleagues — all working on behalf of the patients and the “owners” of our healthcare delivery system.

So, what is this vital survival skill called “listening”?

To listen fully means to pay close attention to what is being said beneath the words.  You listen not only to the “words”, but to the very essence of the person speaking.  You listen not only for what someone knows, but for who they authentically are – for who they are “being”.

Generative listening is the art of developing deeper silences in yourself — so you can slow your mind’s hearing to your ears’ natural speed; and so you can hear beneath the words to their meaning. We tend to take listening for granted, assuming that “hearing” is the equivalent of “listening”.  However, while hearing is a function of the ears, listening requires the involvement of the mind.

Indeed, listening is an active process — not just a passive reception of sounds.

At its heart, committed listening is based on our intent to “seek to understand”.  In Principle-Centred Leadership, Stephen Covey writes that when we seek to understand another, “we need to give full attention, to be completely present.  Then we need to empathize — to see from the other’s point-of-view, to ‘walk in their moccasins’ for a while.”   

Covey says “we tend to take listening for granted, assuming that hearing is the equivalent of listening. While hearing is a function of the ears, listening is a function of the mind.”

While the five disciplines of a learning organization (Personal Mastery, Mental Models, Shared Vision, Team Learning and Systems Thinking) are all critically important, the skill of dialogue is essential. Indeed, Health Links that intentionally practice dialogue will be the ones that succeed in achieving their outcomes.

Dialogue is the same skill Premier Wynne calls “conversations”.

It is a reflective learning process in which group members seek to understand one another’s points-of-view and deeply held assumptions.  With its roots from the Greek dialogos (dia means through and logos means the word), dialogue is a process of “meaning making through words.” Through this mode of communication, people learn how to think together, thereby developing collective meaning and shared understanding. 

To engage in true dialogue participants must be willing and competent to engage in committed listening, inquiry, and the suspension of their assumptions. This involves attending to others who are speaking, inquiring into and seeking to understand their beliefs, values and mental models without judgment, and articulating our own assumptions, leaving them available for all (including ourselves) to question and explore. 

In the Fifth Discipline Fieldbook, William Isaacs sets out what he thinks are the three key conditions for the successful Practice of Dialogue.

The first condition is: suspending our assumptions. Isaacs says that he collective commitment to suspending assumptions requires participants to set aside, for a time, their perceptions, feelings, judgments and impulses, and monitor carefully their own internal experience.  In the process of “suspending assumptions”, individuals are better able to see their own assumptions as they can be held up, compared and contrasted to the assumptions of others. 

Isaacs’s second condition for dialogue is that participants be willing to regard one another as equal colleagues — all equally committed to achieving deeper insights and learning.  Only by interacting as colleagues, as equals, will the group create the trust that is required for the surfacing of assumptions.  It takes a lot of trust for individuals to reveal the uncertainty, tensions or conflicts in their reasoning, and the meaning we have assigned to what we observe. Teams must create a “safe environment to tell the truth.”

Isaacs’s third condition for dialogue is to use a facilitator within the small groups who will “hold the context” of dialogue.  As Peter Senge notes in The Fifth Discipline, “in the absence of a skilled facilitator, our habits of thought continually pull us toward discussion, and away from dialogue.  This is especially true in the early stages of developing dialogue as a team discipline…We believe in our own views, and want them to prevail.  We are worried about suspending our assumptions publicly.  We may even be uncertain if it is psychologically safe to suspend ‘all assumptions’.” 

While the “skill of dialogue” opens up the conversation to explore the whole reality, at some point, decisions need to be made – which are best done using another key skill call “discussion”. The challenge is to stay in dialogue long enough to get all the facts and all the perspectives on the table.

Discussion is a way of organizing collective efforts in critical thinking so as to arrive at decisions that stay made.  Skillful discussions display rigorous critical thinking, mutual respect, weighing of options, and decision-making that serves the group’s vision, values and goals.

Too often these core skills are missing from our discussions.  Ineffective, unskilled discussion can resemble a verbal combat, participants hurl ideas at one another, as the discussion turns into an unskilled debate. 

When this happens, the team has overshot useful advocacy for ideas and landed in a place of listening only for logical fallacy and arguments to “beat down” the ideas of others. The frame is one of “win/lose”, “point/counterpoint”. 

In human groups, this breakdown in communication often leads to withdrawal and/or aggression — where the opinions of the loudest, most persistent or most “powerful” win.  In such situations everyone loses and decisions are often of poor quality.  Not all perspectives or alternative viewpoints are considered, relationships are often damaged, and decisions lack group commitment and, therefore, sustainability. 

The Latin roots of decide mean to “kill choice,” and the purpose of discussion is in fact to eliminate some ideas from a field of possibilities, while the stronger ideas remain. 

Cognitive conflict, or dissonance, can be a rich source of information and ideas, leading to innovative new solutions for complex problems that we have had difficulty resolving in the past.  Indeed, the purpose of discussion is to honour and resolve cognitive dissonance — while minimizing affective dissonance. 

Discussion is about ideas, perspectives and opinions — not about the people who hold opinions or have different ideas.  We are not judging or evaluating the people who hold the ideas — just the ideas themselves. 

For Health Links to succeed, cross-functional meetings to explore reality, and to plan actions, need to be designed to ensure that all participants are aware of the structure of the dialogue/discussion process. Among some of the Health Link partner organizations are people who are involved in organizational development. Most of these professionals can teach these skills. So there are dialogue coaches within each Linket.

The best advice for Health Links start-ups is: slow down, get connected, build trust, get all the information and deep understanding of the relevant issues though dialogue, gain a comprehensive understanding of the outcomes the Health Link is committed to achieving and then engage in decision-making discussions as you learn and adapt to what you discover, and to what emerges.

Next week’s blog: “FRAGMENTATION: Unless We Change How We Think, We Will Always Produce The ‘Same/Old’ Results”.

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There ‘s a story about President Lyndon Baines Johnson emerging from the White House onto the lawn in the Rose Garden where there are two helicopters warming up. 

“Your helicopter is over here sir”, says the spiffy young uniformed cadet as he snaps to salute his Commander-and-Chief. “Son,” says LBJ with his sun-beaten crinkley face smiling broadly, “They are all my helicopters.”

Like the US President’s helicopters, the people of Ontario own all the component parts of our healthcare delivery system. Patients’ organizations today are saying to the provincial government and to healthcare service providers “we own all the healthcare provider organizations, and we have an expectation that these various component parts of our healthcare services delivery system will collaborate to address our holistic needs.”

Imagine a healthcare delivery system were the patients and clients are treated like they “own” the place. There are in fact such large-scale change systems currently under construction.

The Institute for Innovation & Improvement defines Large-Scale Change (LSC) as “the emergent process of moving a large collection of individuals, groups and organizations toward a vision of a fundamentally new future state, by means of high-leveraged key themes, distributed leadership, massive and active engagement of stakeholders, and mutually-reinforcing changes in multiple systems and processes, leading to deep changes in attitudes, beliefs, and behaviors that sustainability becomes largely inherent.”

Since Health Links are Ontario’s attempt at large-scale change, health system leaders will no doubt be interested what a successful health system transformation looks like — and what can we learn from others who have already gone down this path?

At last June’s AOHC Annual Conference on “People-Centred Care”, the CHCs had two presentations from the Southcentral Foundation in Alaska on their now world-famous “Nuka Model”. (Check out their website – these guys have truly transformed their healthcare delivery system). They have engaged in a large-scale transformation process that has enabled them to move beyond “patient-centred” care and “people-centred” to something much richer, deeper.

When any one of Southcentral’s 150,000 clients come to one of their hospitals or clinics, they are thought about (mental model), treated as (process design), and referred to as “Customer-Owners”.

That is a very different healthcare system than our somewhat paternalistic version.

Like the challenge facing each Health Link, Southcentral had to redesign the patient journey to become “person-focused”, not “provider-focused”. The Nuka Model of healthcare delivery is all about thinking and behaving differently – a fundamental transformation producing excellent balanced scorecard outcomes — and very satisfied owners.

“In our process redesign, we transferred control of the system to the people who are receiving the services and are using the expertise of our professionals to help them make decisions”, says Southcentral’s Jana Towne. “That is a very different mindset than just being a customer or patient. The Nuka system of care transcends the organizational boundaries because it includes our community, our partners, our stakeholders – all those things, all together,” she told conference delegates.

So what could Ontario’s Health Link leaders and facilitators learn from the experience of health system re-design teams from the first nations’ peoples in Alaska? I think we could learn how — through their Customer-Owner Redesign Process — they were able to achieve:

• A 50% reduction in urgent care and ER utilization;

• A 53% drop in hospital admissions;

• A 65% drop in specialist utilization; and,

• Customer and staff satisfaction rates over 90%.

Why did Southcentral’s integrated healthcare delivery system achieve such dramatic performance improvements as a result of their large-scale change learning journey? Health Link early adapters ought to reflect on the NUKA SYSTEM’S OPERATING PRINCIPLES that include:

• The hub of the system is the family;

• The interests of the Customer-Owner drive the system to determine what we do — and how we do it;

• Customer-Owners are “active partners” in their care, and, in decisions about their care;

• Relationships between the Customer-Owner, the family, and health service providers must be fostered and supported;

• Emphasis on wellness of the “whole person”, family, and community including; physical, mental, emotional, and spiritual wellness;

• Population-based systems and services;

• Intentional whole system design to maximize coordination and minimize duplication;

• Outcome and process measures to continuously evaluate, learn and improve; and,

• Services are financially sustainable and viable.

So, why does Southcentral succeed? How do they live by these Operating Principles? How do they get such great performance results?

There seems to be two main reasons: 1. The macro organizational design of their healthcare service delivery system; and, 2. The common language & frameworks for the staff to talk about, plan for, and implement change to the way they deliver services to their people.

On the design side, I would say that Nuka reflects many of the characteristics of Chaordic Design conceived by Dee Hock, the founder and CEO Emeritus of VISA International. Dee Hock said: “By Chaord, I mean any self–organizing, adaptive, non-linear, complex system, whether physical, biological, or social, the behaviour of which exhibits characteristics of both order and chaos or, loosely translated to business terminology, cooperation and competition.”

In addition to macro design and philosophy, the Nuka Model also relies on Southcentral’s 1,500 staff to share a “common language” and to use “common frameworks” that enable them to think collectively about their future, plan for it, and implement the changes required to achieve their vision.

When I review the smashing successes Quantum has been involved with in the United States and Canada in the organizational and whole system transformation business over the last twenty years, the key to all these successful transform projects was the customized transformation curriculum that was presented by the organization’s own leaders that provided the common language and frameworks for talking about, planning for, and implementing change.

Similar to the Quantum’s learning-by-doing model, at Southcentral, all employees come together for 3-Day training workshops led by the CEO and senior team — who strive to “practice what they are preaching” about being “open-to-learning”. As a Learning Organization, they get their people to better understand themselves, and their own individual learning styles — because they have learned that the more self-aware people are, the more empathic they become. Leaders in organizations undergoing transformation need to be empathic.

Human organizations (where 90% of people would rather die than change) that are undergoing a fundamental transformation, need common frameworks to talk about themselves, and about the organization, as everyone undergoes even more unrelenting changes. For the humans, change is often hard, messy work.

If Health Links are to succeed in the medium and longer term, they need to invest some time and attention to front-end developmental dialogues that build momentum and trust in the short-term. Nobody is under the gun to succeed quickly, or before the next election occurs. This is not a race. Health Links need to “slow down, in order to speed up the transformation process”.

Each Health Link now has a plan approved by their LHIN – which the partners will continue to refine and adjust as circumstances evolve and shitstorms happen in their dynamic little complex adaptive human system. The key challenge ahead will be: Strategy Execution. How will the Health Link partners implement change? How can they become one of the 30% of Links that will succeed? What can we learn from the “lessons learned” in Alaska?

When we listened to the powerful stories about Southcentral’s transformation from April Kyle and Jana Towne at AOHC’s 2012 Annual Conference, “People-Centred Care: Are We There Yet?”, we could understand the galvanizing forces that has enabled their 1,500 staff to build a much better system that is well beyond just “patient-centred”. Indeed, it appears that these mental models are truly embedded in their organizational DNA.

“Among our highest corporate priorities”, says April Kyle of Southcentral, “we invest in the development of our people with extensive learning workshops, coaches and mentors.”

While the Alaska Nuka System is way beyond just “patient-centred”, most of the U.S. healthcare system is just now being impacted by their renewed drive for quality and patient-centredness. While Ontario is starting to move, there is a lot emerging in this field in the US where, for example, they have developed some initial models/programs for Patient Advisory Councils as well as proven patient-centred design methodologies adapted from Disney’s Imagineering Corporation.

So the patient revolution is now underway.

In his article, “What ‘Patient-Centered’ Should Mean: Confessions Of An Extremist”, Don Berwick, the US quality guru, proposes his definition of patient-centred as: “the experience of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care.”

Berwick says that in the hospital sector his definition would mean:

• Hospitals would have no restrictions on visiting – no restrictions of place, or time, or person – except restrictions chosen by, or under the control of, each individual patient;

• Patients would determine what food they eat, and what clothes they wear in hospitals (to the extent that health status allows);

• Patients and family members would participate in rounds;

• Medical records would belong to patients;

• Shared decision-making technologies would be used universally;

• Operating room schedules would conform to ideal queuing theory designs aimed at minimizing waiting time, rather than to the convenience of clinicians;

• Patients physically capable of self-care would, in all situations, have the option to do it; and,

• Patients and families would participate in the design of healthcare processes and services.

So that’s a good place to start – the hospital sector. Building on this initial thinking from Berwick, Health Links partners ought to determine what “patient-centred/client-focused” actually means in the homecare sector, the primary care sector (FHTs, CHCs, solo-docs, etc) and in the community care sector (mental health, public health, etc).

Health Links partner teams also need to address both their customers’ “expressed needs” — as well as their “latent needs”.

“Expressed Needs” are the needs patients/clients/families can articulate because, they (a) know what they are getting now; and, (b) they know what they want instead. Their all-important “Latent Needs” are needs patient/families have, but because they don’t know about what they need, they can’t express it. So they can’t ask for it directly, because they simply don’t’ know.

Experience-based design Storyborading techniques is one way to surface these critically important “latent needs” in the co-design process with patients/family/staff.

Health Link leaders and facilitators who are open to doing things differently will find some thought-provoking new ways of looking at and thinking about the “same/old”, “same/old problems” from the insights of thought leaders like Dee Hock, Barry Oshry, Margaret Wheatley and Peter Senge, and from the “lessons learned” from such remarkable organizations like the Southcentral Foundation’s Nuka Model, and from Ontario’s own Children’s Treatment Network in York/Simcoe regions (check my Feb 11^th blog post “Learning From Our Past Successes”).

While no doubt each Health Link has the capability within the staff and leadership to successfully achieve the goals that the local partners have committed to, the fact is experience teaches us that there will be a 70% failure rate for large-scale healthcare transformations like re-engineering, mergers, TQM/CQI, program management, etc. That reality ought to have some people feeling a little bit “at risk” as they begin their learning journey forward.

Many people will be focused on how to be among the 30% of Health Links that will succeed. The Southcentral Foundation’s transformation journey suggests that alignment on the basics like vision/values, and the ability to engage the whole workforce in the strategic change process of their large-scale change project, are some of their critical success factors.

To maximize the chances of success, Health Link partners should review the literature on what happens in the first two stages of team development: the Forming Stage and the — Storming Stage. How will the Health Link partners get through the dynamics of the first two stages in order to get to the Norming Stage, and ultimately to the Performing Stage?

Smart Health Links will be engaged in failure prevention strategies at the same time as they are advancing the components of their strategy that will lead to the overall success of their collaborative efforts. There will be no need to worry about Performing, if the Health Link can’t successfully go through the Forming & Storming stages. 

So what skills will the Health Link require to get through those human dynamics? See next week’s blog: “Survival Skills For Transformation”.

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Nineteen Health Links – or “Linkets” – have now been officially born.

Wow! Remember the look on your baby’s face when they finally discovered that the hand waving in front of their eyes was actually their hand – and they could control it!

That is a truly gleeful moment… “mine!”, “mine!” say their beaming faces, twinkling eyes and giggling/snorting noises.

If we were to drop all the references to the official governmental language about the “mission of Health Links”, rock bottom: what the heck are they? While they are a loose federated structure of local health service providers who have come together for a defined purpose, the actual answer is: relationships, relationships, relationships. Health Links are a set of relationships. If that sounds simple, it isn’t. These are complex adaptive human systems – and humans are messy.

As the newly-born Health Links partners begin their collaborative learning journey together, they need to think about organizational, system and service delivery design from the perspective – the lens – of complex, adaptive human systems. They need to come together and undergo a developmental learning journey to reach full maturity as a system of independent organizations working interdependently together in a whole new voluntary structure that is designed to focus on the patients.

While the folks I was working with at Quantum Solutions in Austin in the 1990’s were the leading-edge designers of systems thinking tools for complex integrated system design and leveraged thinking for whole system transformation, we were always trying to learn from others to discover what they were learning — so we could incorporate the very best insights into the organizational and system transformation tools we were developing.

At the annual Systems Thinking In Action Conference with Peter Senge and 800 of his closest followers, I first encountered an amazing organizational design innovator called Dee Hock. I mention him because the moment I learned the “structure” of a Health Link, I thought of him — and his creative thinking about organizational and whole system design.

Dee Hock wanted to create an organization that existed on the boundaries: between “control”, and “chaos”. He called it the “chaordic organization” and applied it to the company of which he was CEO, a newly-formed corporation in the credit card business in the late ‘60’s called VISA.

VISA is in fact simply a platform upon which willing participants like the CIBC, Air Canada and a consumer can align as a “partnership” to do business together. Today, over 23,000 financial institutions around the world engage in 7.2 billion transactions that exceed $650 billion annually using this partnering platform.

So the organizational design structure of VISA is an “enabling structure” for business transactions between willing partners who come together in a variety of relationships, and combinations of relationships.

Among the organizing principles of a chaordic alliance that he outlines in his book, “The Chaordic Organization: Out of Control and Into Order” are:

• It must be equitably owned by all participants. No member should have intrinsic preferential position. All advantage must result from individual ability and initiative.

• Power and function must be distributive to the maximum degree. No function should be performed by any part of the whole that could reasonably be done by any more peripheral part, and no power vested in any part that might reasonably be exercised by any lesser part.

• Governance must be distributive. No individual, institution, and no combination of either or both should be able to dominate deliberations or control decisions.

• It must be infinitely malleable yet extremely durable. It should be capable of constant, self–generated, modification of form or function without sacrificing its essential nature or embodied principle.

• It must embrace diversity and change. It must attract people and institutions comfortable with such conditions and provide an environment in which they could flourish.

In speaking about the challenge he was given to solve the credit card industry crisis in the late ‘60’s, Dee Hock said “It was beyond the power of reason to design an organization to deal with such complexity, and beyond the reach of imagination to perceive all the conditions it would encounter.”

“Yet,” observed Dee Hock, “evolution routinely tossed off much more complex chaords with seeming ease. It gradually became apparent that such an organization would have to be based on biological concepts and methods. It would have to evolve — in effect — to invent and organize itself.” So, here we are again with this idea of “self-organizing systems” and how complex human systems are adaptive.

The great thing about chaordic organizational designs is that they simply facilitate whatever combination of relationships want or need to occur. When I, as a consumer, use my VISA card, I engage my bank, the CIBC, a merchant like the Bay who wants my business, and Air Canada — who will give me loyalty points for their airline when I use my Aerogold VISA card.

The senior teams and massive administrative structures at Air Canada, CIBC and the Bay are not involved – except for the original decision to form a partnership. That’s the stage most Health Links are at right now. If they have followed best practices, partners in the initial nineteen Linkets will be deeply committed to the outcomes and processes that they just submitted in their Health Links Business Plan that they developed collaboratively together.

Those Health Links that succeed over the next 12-18 months will be those that engage and empower their clinicians, and their clients, in the patient experience co-design process. The lesson here for senior managers is: set the stage, and liberate the people. Hold an “assumption of competence”, and supply the “supports required” for them to be successful. Seems simple enough, but, with the humans involved, it is complex.

The bottom-line measurements of success and failure for Health Links are largely about: the patient/client experience. While the senior executives who run the delivery system will need to know about the progress being made, this work is actually about what transpires between patients/clients & their families and their direct health service providers.

So this core process isn’t about the “big bosses”. Once a Health Link is up and running, it is really about how front-line care service providers along the continuum impact on patients; and, it’s also about the middle managers who can remove barriers and provide a variety of “just-in-time” supports to ensure success.

So it isn’t just the top bosses of the Link Partners who have to change how they think and behave. The whole combined organization of partners (including front-line workers and middle managers) across a continuum-of-care needs to shift how they think about who they are; who they serve; who they are related to; and, how they could shift their thinking and behavior to improve the patient experience – and, therefore overall organizational performance.

While many of those lean thinking projects are actually showing important numerical improvements, the truth is, while health care service delivery and manufacturing have some common elements and some valuable techniques like “Kaizen”, healthcare really is profoundly human, and manufacturing is considerably less so. Human dynamics are in fact the life-blood of complex, adaptive human systems. We need to move beyond lean, to achieve true transformation.

A fellow by the name of Barry Oshry is another organizational scientist who has addressed the complex human dynamics of organizational life from whom our Health Links can learn some important insights about the challenge before them. Oshry says that within and across each of the organizations in a Health Link, there are fundamentally four separate “spaces”: the top space, the middle space, the bottom space, and, the customer space.

People in the “top space” function as shapers of the organizations; people in the “middle space” function as integrators; people in the “bottom space” function as producers. The “customer space” includes the internal customers within each HSP – as well as the primary customers: patients/clients/families/residents.

Oshry says the conditions of “the space” we’re in can be so powerful, and so constant that we tend to respond to them without awareness or choice. It’s like being fish in a fish tank. They are blissfully unaware they are surrounded by water — their movements are all just mindless reflexes adapted for their environment.

This is what Oshry calls the “Dance of The Blind Reflex” where people respond blindly and reflexively to the conditions of the space they are in. So, it is important to understand the conditions of the spaces across each Health Link partner organization.

The conditions of the Top Space are responsibility and complexity.

Top healthcare executives deal with many difficult issues simultaneously that have tremendous impact on the overall success of each individual organization. The “blind reflex” to this condition is to suck up responsibility, and feel burdened and overwhelmed.

To cope with these feelings of being overwhelmed in a dangerous, risk-adverse, blaming environment, tops differentiate – they develop areas of specialty and responsibility.

Guided by a mental blinder Peter Senge calls “the illusion of control”, tops seek to grab hold of their chunk of responsibility. Ultimately, they get stuck in their private turfs: “this is my territory, and that is yours”. To a great extent, all of this is understandable. If you are a highly paid VP or Director of specific organizational turf, you “guard-your-turf”—and, as a result, sub-optimize the system.

If our top people allow Health Links to become about “turf”, they will absolutely fail.

Below the top space is the place where the middle managers hang out. Oshry says the condition of the Middle Space is diffusion.

Middle managers are constantly being pulled in numerous directions by the many needs of their subordinates and their bosses – as well as by the needs of the patients/clients and families. Oshry calls them the “torn middles”.

The “blind reflex” to their condition is to disperse – middles move away from each other and out toward the individuals who are pulling them. They ultimately feel very alienated from one another, very isolated, very stuck.

System designers need to be aware that’s what it is like — within each organizational silo — so imagine how unaligned the middles are across the boundaries of all the various Health Link partners.

But if they fail to integrate cross-functionally — at the hand-off points — they will certainly not succeed in improving the patient experience. What middle managers along the continuum do can make or break a Health Link. If they are trapped in traditional command and control cultures, they will not succeed.

The condition of the Bottom Space, according to Oshry, is vulnerability.

People in the bottom space always feel threatened by the various dynamics that drive the behaviors of the organization’s leaders – the “bosses”. There is also lots of media attention to how we can no longer afford our healthcare system.

Fear and anxiety are often the dominant emotions in healthcare workplaces. The “blind reflex” to this condition is to coalesce. That’s why bottoms draw together to form a “we” – the oppressed we. Oshry says that people in the bottom space feel “oppressed, ignored, unrecognized and mistreated. They experience negative conditions that are created by bosses, and then hold the tops and middles responsible for the ills for the system.”

They experience “blaming down”, and participate in “blaming up”.

But Health Links are all about front-line care providers across the silos working collaboratively together to design better patient/client experiences for the top 5% of system users. That means mobilizing the “bottoms”.

While the LHINs had the Integrated Health Service Plan process to mobilize the “tops”, Health Links is a process that has been designed to mobilized the “bottoms” — and achieve significant system improvements by integrating the “middles” cross-functionally within their own organizations and across the system’s hand-off points.

System design teams and work teams in the Health Links will gain critical insights from Barry Oshry’s book, “Seeing Systems: Unlocking The Mysteries Of Organizational Life” — which after understanding all the internal dynamics, points out quite bluntly how the people in the “customer space” live in a world of neglect.

The success of Health Links will only occur when the delivery system partners shift how they think and behave. So, how can the tops, middles, bottoms and, customers deal with the condition of their space?

The challenge of the top space to overcome, or master, is differentiation and fragmentation, Oshry urges that tops lead shared visioning processes that engage the whole system — and that they step up to be in “stewardship”, rather than being in “control”. While life would become easier and work more enjoyable, the ingrained dynamic in the tops is to seek either actual control, or the “illusion of control”.

To overcome dispersion, Oshry says that the middles need to integrate cross-functionally and operate as “system integrators” who will provide others with informational support and the resources to achieve the results required.

Over the past twenty years I have come to understand that the most leveraged combination of actions we can take to integrate organizations – like the Health Links – is to 1. Integrate the middle managers cross-functionally; 2. Liberate the front-line (“bottoms up!”); and, most importantly, 3. Empower the people who actually “own” the system: the patients/clients/residents.

Next week’s blog: “Nuka: The Customer-Owner Model”.

FORWARD THIS BLOG TO COLLEAGUES WHO ARE INTERESTED IN HEALTH SYSTEM DESIGN & DYNAMICS.

I had an amazing birds-eye view into the possibilities of “patient-centred care” in the acute care hospital of the future when I went along as part of a delegation from the Patients’ Association of Canada, and another consumer group called “Patient Destiny.”

At the end of a truly mind-boggling presentation about the new Humber River Hospital, Alies Maybee from the Patients’ Association, along with Kevin Leonard and Sandra Dalziel of Patient Destiny left the Boardroom (where I had spent the previous two hours sipping water and being excited), and we walked to the foyer at the entrance to the hospital.

No doubt I was wearing some degree of anxiety on my face as my head swiveled around trying to spot the men’s room.

“May I help you sir?”, said this little woman carrying a broom and dust-pan. “Are you looking for something?”, she said with a warm, welcoming smile.

“Men’s room”, I replied. “Come this way,” she said cheerfully, as she led the way in her bright blue smock around a corner and down the hall until she stood in front of the door to the Men’s Room. “Here it is sir.” she beamed at me.

I walked over to her and said, “Thank you so much. I really felt that you actually went out of your way to welcome me as a visitor. I actually felt really welcomed.”

She had no idea that I had just emerged from listening to Humber River Hospital CEO, Dr. Rueben Devlin for a two-hour, comprehensive briefing on how his new hospital was going to be the ultimate in being “family and patient-centred”. After hearing about all these exciting plans and visions for a revolution in customer service, we witnessed the cleaning lady at Humber River Hospital practice the type of behaviour in the hall that the CEO is preaching in the Board Room. That’s called alignment.

Check it out. Something important is happening here that many hospitals can learn from.

Devlin is an interesting guy. He has been fascinated his whole life by futurology – by learning about “what’s next?”. Now he is engrossed in actually creating the future of patient-centred acute care hospital services.

If you have not seen the billboards across the Toronto skyline, or seen the Toronto Sun and Global and Mail inserts, Humber River Hospital (which will open in 2015) will be the centre of a paradigm-shifting digital hospital transformation and the “reinvention of patient care”. Their campaign makes some very big claims.

The fund-raisers at their Foundation call it “North America’s First Digital Hospital.”

Our two patients’ groups were visiting the existing Humber River Hospital because we wanted to learn first-hand what all the fuss is about. We’re a pretty savvy group. We have conducted several site visits to assess patients programs across the province. If all you have is a spin-doctored optical illusion, we will know. Our team understands “value”, from a patient/family perspective.

Patient Destiny — led by Kevin Leonard and Sandra Dalziel – has been the leading advocates for patient access to their medical record and enabling patients who want to become true partners in their healthcare. Alies Maybee is a technology professional from the Patients’ Association of Canada who investigates and studies enabling technology for patients. While our patient delegation carried a good understanding of the future of healthcare technology, the “Humber River Revolution” story amazed and excited each of my technology-savvy colleagues.

“This is really world-leading, a thoughtful pulling together of proven technologies as the bedrock for the acute care hospital of the future,” says Alies Maybee. “I hope hospital leaders kick the tires and check out if the ‘lessons learned’ at Humber provide any insights for them.”

When it opens in 2015, the new Humber River Hospital will be lean, green and patient-centred. People who know Rueben Devlin talk about his passion for environmental causes (his green energy initiatives save operating dollars for reinvestment in patient care), his passion for efficiency and sound financial management, and, his singular mission to be on the leading-edge of patient-centred acute care.

“Care is going to be revolutionized in ways we only once dreamed of – or enjoyed while watching the myriad of science fiction-based films and TV shows”, says the Toronto Sun insert. “From automated registration kiosks, to patients accessing their hospital appointments from the comfort of their smart phones, iPads or home computers; to automatic sensors checking patients’ vital signs for nurses – Humber will be the leading all-digital hospital in North America,” says the literature.

To learn about what the world’s best had to offer patient-centred digital healthcare, “we toured what most agree is ‘one of the leaders’ in Oslo, Norway”, Devlin tells us. “We wanted to learn how to build a better tomorrow– not a bigger yesterday”. He told us that the new Humber River Hospital will change the patient experience significantly.

Devlin exudes excitement, commitment and passion when he talks about the thinking, insights and sweat equity that have gone into their evolving vision for their future hospital. “Everything we do is from the perspective of the patient and family. We call it ‘people care’ and that’s what our patients and families really want.”

Devlin says that “the digital technology not only enables rapid diagnosis and improves accuracy, it lets doctors and nurses do what they do best – caring and healing.”Every inpatient room at the hospital will be a “smart room” with a bedside control terminal that allows patients to set the environment of their room, adjust the lighting, make video-calls, access the internet and review their own medical charts and test results.

Eighty percent of all inpatient rooms will be single-bed with space for a family member to spend the night. They will engage families and fully welcome them. The positive effect of having family as an integral part of the care is well understood and accommodated for in the Humber River Hospital Model.

In the new hospital, instead of miles of corridors, depending on the nature of your treatment, you’ll enter through one of nine “portals of care”. Instead of a grand entrance, it will be like arriving at the airport where your airline is located. Then, once inside, there’s one-stop registration and a walk of no more than 30 feet to your clinic.

Devlin and his system design team invested a lot of time understanding the needs of patients, staff and physicians. Knowing that a happy, energized, committed and competent team produce high patient satisfaction rates, they looked at things like “sneaker time” – the time that nurses spend walking around the ward and incorporated into the design a reduction of this travel time – which puts nurses more often at the side of patients.

The design of patient units could have increased “sneaker time” from 5.4 km per shift, to 11.6 km per shift — if they did not think through the design. With help from the GE Hospital of the Future Team, the hospital’s final design combined with technology actually decreases sneaker time by 18.3%.

While “caring for the caregivers” is a smart strategy, the new Humber River Hospital is attempting to deal with a number of systemic patient complaints and stated preferences that challenge hospitals everywhere.

Things like: when a healthcare worker enters a patient’s room, screens will display the name and profession of who has arrived in the room. Electronic records of each patient-interaction will be recorded. These innovations address a number of historical concerns of patients. While many of these technology tools are great, I love their plan for their fully integrated patient information system.

Humber will have a single electronic source for each Patient’s Medical Record. All patients and caregivers will have instant online access to everything from a patient’s clinical and laboratory and diagnostic imaging, to pharmacy orders in the hospital or at home.

“Other tools that we will use to keep patients safe”, says Devlin, “include bar coding to ensure the right drugs get to the right patient at the right time; voice recognition technology for more accurate charting — as well as the latest in infections disease control, and a digital centre to monitor all building functions.”

While I am not a techy, Kevin Leonard of Patient Destiny – a passionate patient techy –turned to me as we were leaving the Boardroom and said: “If they implement each of the components of their plan, we will have one of the best global examples of effective patient-centred care right here in Ontario.”

Alies Maybee from Patients’ Association of Canada says: “This hospital promises to set the new standard in providing patients and their families with a much better patient experience”. While Devlin has his primary focus on acute care delivery, he says that significantly more emphasis needs to be placed on primary care and home care. “Acute care may be a smaller part of the evolving system”, says Devlin, “but it is still vital to community needs.  In fact the success of acute care facilities is dependent upon all of the other parts of the system working well.  Acute care facilities are an expensive place to have patients who could and should be cared for either at home or in other facilities.”

While significant thinking time ought to be invested in designing our home support, community care and primary care services, we also need to think about the future of acute care — and what the “Humber River Patient Revolution” means.

Dr. Rueben Devlin – and perhaps maybe 15% of CEOs approaching retirement within the next few years – are what I call a “legacy-seeking leaders”. People like him work night and day doing their level best to leave something behind for the next generation that’s a little better than the hospital/medical system he experienced as a physician, a hospital CEO, and as a patient and a family member himself. Legacy-seekers tend to have very full days filled with new possibilities.

Devlin is a very lucky guy. What an innovative process he is conducting. What a gift to the community. What a showcase to the hospital industry. What a safe place for patients. What a great place to work for the cleaning lady who loves to be hostess at a place with which she is very proud to be associated. And, what a wonderful legacy this CEO has provided us to learn from.

Thank you Dr. Devlin.

Next week’s blog: “THREE LEVERAGED HEALTHCARE TRANSFORMATION STRATEGIES”.

FORWARD THIS BLOG TO COLLEAGUES WHO ARE INTERESTED IN HEALTH SYSTEM REFORM.

The disruptive innovation introduced by Health Links is the bottom-line focus that has been placed on the “patient/client experience” across the continuum-of-care. That is the focus of the health sector transformation strategy of the Wynne Government. These are the key outcomes they will measure.

In a Special Report On Health Sector Transformation that I wrote for MANAGING CHANGE in 2010, I said that “disruptive innovations in healthcare will aim to shape a new system that places patients and their families at the centre of the delivery system and provides healthcare consumers with a high-quality continuum of services that are delivered seamlessly.”

The Tories’ new Health Care Policy Paper also places a major emphasis on “patient-centred care” and “consumer choice” — but their primary strategy is to create another new health system structure with the hospitals in charge. Nevertheless, it seems to me, that whether you are in a Health Link today or not, the healthcare system (no matter what party forms the next government) is going to be putting increasing “value” on the indicators measuring quality and customer service satisfaction.

That’s certainly the focus for these first 19 Health Links that are being established.

So how will we know when Health Links have succeeded? According to the Transformation Secretariat, the goals to be obtained include:

• All complex patients will be attached to a primary care provider and have coordinated care plans developed;

• People will have same-day/next day access to their primary care provider;

• There will be a reduction in time from primary care referral to specialist appointment — as well as reduced time from referral to home care visit;

• There will be primary care follow-up within 7 days of discharge from an acute care hospital;

• There will be a reduction in the ALC rate to 9% or less; and,

• An increase in self-reported satisfaction with healthcare services.

In addition, Health Minister Deb Matthews has been ask Health Links to focus on improving the patient experience – starting with the top 5% of health system users.

What our Health Links will soon discover is that improving the personal experience of patients and their families will require not simply redesigned patient/client service delivery processes – but a transformed healthcare culture as well.

“Culture” is about how people think and behave. However, in a command and control culture that starts with Queen’s Park holding LHINs accountable for outcomes over which they have no control, and then LHINs holding Health Service Providers (HSP) accountable for outcomes over which they have no control, usually end up one-way or another creating a highly defensive posture in front-line caregivers who feel a need to avoid blame. CYA (Cover Your Ass) strategies tend to prevail in such environments.

While this may be “normal behavior” in bureaucratic environments, it makes most healthcare professionals a tad uncomfortable. You understand empathy, and its place in designing the patient experience. Best practice patient-centred care design engages patients and providers in the design process. So, for healthcare service providers, empathy is key.

Empathy is the ability to imagine yourself in someone else’s position and to intuit what that person is feeling. It is the ability to stand in others’ shoes, to see with their eyes, and to feel with their hearts. Empathy isn’t sympathy – that is, feeling bad for someone else. It is feeling with someone else — sensing what it would be like to be that person.

Since people’s feelings are not always put into words, we must be able to read non-verbal cues, such as facial expressions. People with high levels of emotional intelligence can read “body language” – which is 70% of a person’s “communications”.

To be empathetic, it is necessary to be self-aware. When we are self-aware, we are in touch with our own emotions, and therefore are more able to read others’ feelings.

In his book, A Whole New Mind: Why Right-Brainers Will Rule The Future? Daniel Pink says “empathy is a stunning act of imaginative derring-do, the ultimate virtual reality: climbing into another’s mind to experience the world from that person’s perspective.” Indeed, empathy is an essential part of experience-based design because system designers must put themselves in the very being of whoever is going to experience a care process or service.

People exploring the various options for measuring patient-centred care should also reflect upon measuring the ten suggested Guiding Principles For Patient-Centred Care.

These are:

1.      Care is based on continuous healing relationships.

2.      Care is customized and reflects patient needs, values and choices.
 
3.      Families and friends of the patient are considered an essential part of the care team.
 
4.      Knowledge and information are freely shared between and among patients, care partners, physicians and other caregivers.
 
5.      Patient safety is a visible priority.
 
6.      The patient is the source of control for his or her care.
 
7.      All team members are considered caregivers.
 
8.      Care is provided in a healing environment of comfort, peace and support.
 
9.      Transparency is the rule in the care of the patient.

10.  All caregivers cooperate with one another through a common focus on the best interests and personal goals of the patient.

So, while we are pretty good at generating these sorts of high-level principles, we can’t seem to be able to create the reality? How can we change the “patient experience”?

Art Frohwerk, the “father” of Patient Experience Design Methodologies points to the fact that “there is no system”. He says, “specialty advances and growth in healthcare have inadvertently contributed to the vulnerability of the overall system.”

As a result, healthcare has three unmet deficiencies. These are:

• Fragmentation – treating parts, versus the system, thus sub-optimizing the whole.

• Missed Connections – learning gaps, creating risk and aggravation.

• Being Reactive – which always costs more than being proactive.

“These critical deficiencies are the foundation of today’s serious cost and performance problems”, says Frohwerk. “It is our focus on the patient experience that will help us see and correct the design of these system challenges.”

Art believes that the goals set for Health Links are achievable. However, he says a “system approach” is required – a new paradigm, and a new set of lenses for seeing, as well as new habits of behavior. “They need to figure out the system – driven by the intended patient experience – then, orchestrate the mechanisms to pull it together”, says Art.

Having devoted the past fifteen years of his life applying the same tools that he invented to create the “customer experience” at Disney Theme Parks around the world, Art says “healthcare is an eco-system of people, places, science and tools.” His experience design process fundamentally transforms the patient and provider experience.

Advice to Health Links: the partners need to understand the whole ‘big picture’ before diving in to “fix” a single part – because every part is, in some way, interdependent with another. Optimizing one area, will undoubtedly sub-optimize other areas.

Frohwerk says that the teams recruited to the Health Links project need to understand the science of a human experience by understanding four fundamentals:

• How can we be relevant to the whole patient, the whole person …not just the physical, medical… not just the doctor or nurses needs… focus on the whole person…

• How do we engage with the patient/client?  …not just when we need to…

• How do we adapt to the moment and adapt the system over time?  …every other industry is working to master this…

• How do we create flow?  …here is where we find enormous disconnects and fragmentation – they are egregious.

About the discipline of experience design, Art says “we need to inventory, scene-by-scene, what we call the ‘story of the customer,’ — including the resident/client/patient/family/taxpayer and, the community.

It is more “people-centred”, than “patient-centred”, when you engage the teams of frontline care providers — along with patients and families — using a unique Experience Design Storyboard to collect insights from all influencers on the patient/client experience.  This helps them see what’s important in the moment, and to recognize positive cues and negative cues as a set of interdependent issues – from the perspective of the “whole person”..

Art says, “This will give us a record of ‘what’s important’, and the patterns to draw from across the continuum-of-care.  This enables us to better anticipate people’s needs and to be able to see unique variations. And, it enables us to address negative cues, and design for positive cues.”

The Storyboard structure and process for seeing and discovering the whole truth of the patient experience creates the conditions for what Margaret Wheatley calls a “self-organizing solution”.

I have seen how the “Storyboarding Methodology” helps people visualize what an entire service experience will “look like”, “feel like” and “be like” as Art Frohwerk unfolds the wrap-around-the-room set of panels depicting each chapter, scene and stage that the group created through their storytelling dialogues together in the patient experience design process.

While the initial stages of this redesign process enables people to “slow down”, at some point, it is “time to speed up”. In the top-down world of strategy execution, these are called “leveraged actions”. In the bottom-up world of experience design, they are called “catalytic triggers”: the proven key leverage points that accelerate change in complex adaptive human systems.

We need both leveraged actions and catalytic triggers to succeed. Otherwise, you are left with a set of good intentions, going nowhere.

Successful transformation depends on an organization’s ability to identify the most leveraged actions that would create “maximum impact, for minimum effort”, or, “biggest bang for the buck”; etc.

Systems thinking guru, Peter Senge, describes “leveraged actions” as small, well-focused actions that can produce significant enduring improvements if they are in the right place. For example, the “trim tab”, or small “rudder on the rudder” of a ship would be a good metaphor for leverage. This tiny trim tab is what makes it easier to turn the rudder, which in turn makes it easier to turn the ship.

The most leveraged actions (i.e. “biggest bang for the buck” or, “maximum impact for least effort”), for creating a “patient-centred care revolution” in Ontario, would include:

• Governance Boards of Health Links partners that are prepared to re-invent and transform themselves to become focused on quality, safety and the patient experience as a partnership of health service providers. Such boards will model for staff that they can transform and connect across the continuum too;

• CEO’s of Health Link partners who demonstrate commitment to becoming true Learning Organizations that engage the collective intelligence of their organizations to develop and execute the necessary strategic changes – while learning from the “best mistakes” in on-going improvement processes;

• Facilitative managers across the Health Links partners who are mandated to “drive out fear” in their organizations. They build trust and emphasize collaboration, learning, continuous improvement and personal growth;

• Health Link Partners that liberate their frontline care providers to utilize patient experience design using a common language and set of frameworks for talking about, planning for, and implementing complex change. However, creating individual and systemic clinical pathways for the top 5% of health system issues does not require much time by CEOs, VPs, LHIN staff, etc. It requires clinical co-ordination and judgment. It requires a supportive/innovative environment that unleashes the capacity of the system to transform itself.

• LHINs and public servants at Queen’s Park who are wise enough to “keep out of the way” — while providing whatever “supports” are required to ensure that the Health Links, and their managing partner, succeeds.

So, there you have it: empathy from front-line care providers working in partnership with patients/clients; some experience design science; and, some leveraged actions on the part of decision-makers can combine synergistically to truly transform the patient/client experience. That’s the goal of the Health Links, and the vision of the 14 Integrated Health Service Plans across the province.

Next week’s blog: “THE HUMBER RIVER PATIENT REVOLUTION”.

FORWARD THIS BLOG TO COLLEAGUES WHO YOU THINK MIGHT BE INTERESTED THE ART & SCIENCE OF PATIENT EXPERIENCE DESIGN.

Change management scholars warn us against making structural change without addressing the skills of the organization, the culture of the organization, or the strategy that drives it. They say that until and unless strategy, structure, culture and skills are aligned, there will be no transformation. Just grinding noises and angry, frustrated people.

Health Links are a voluntary structure in which health service providers — from across the continuum – agree to collaborate to improve healthcare services for the top 5% of health system users. But is a Health Link a transformation mechanism, or an interim step in a larger process to put primary care and patients at the centre of the healthcare services delivery system? That would be a genuine transformation of the existing system: from caterpillar to butterfly.

While “transformation” might sound romantic and exciting, what I have learned over the past fifteen years is that  it is not for the “faint-of-heart”.

Herbert Wong and Ken Moore of Quantum Solutions of Austin Texas were my teachers and mentors when I was learning about “organizational” and “whole system transformation” in the early 1990s. They understood that the soft stuff was the hard stuff.

Their premise – rooted in Quantum physics – is that organizations, sub-systems and whole systems have the very same qualities as the natural world. What they, and writers like Margaret Wheatley, in her book Management And The New Science, call “complex adaptive systems” – a very different way of understanding reality.

However, at its core, our very traditional health care system hangs onto a paradigm that there is “one right answer”, and we can find it by copying the same methodologies and structures that have had some traction in the manufacturing sector. Our assumption has been: healthcare services are a lot like the manufacturing business.

So, we’ve had methodologies like TQM/CQI, restructuring, right-sizing, re-engineering, program management, and lean-thinking – all borrowed from the manufacturing sector. At the same time, we’ve also had several decentralized structures: DHCs, local Ministry Offices, LHINs, and now Health Links.

We’ve had lots of experience testing out different manufacturing methodologies and structures. So, what we have learned over the past 30 years is that large scale transformation projects fail 70% of the time. There is also lots of literature around that demonstrates the type of holistic approach that works 30% of the time. But changing thinking & behaviour isn’t something the health system wants to do. We like to do things like we have always done them.

Change is hard. Very hard.

While the health sector has traditionally embraced the Newtonian belief in “one right answer”, “order through hierarchy”, and that “one-size does fits all”, there has always been a countervailing force that contains true insights like: two opposite things can in fact be true at the same time. It’s called a “paradox”. And in the real world, there are paradoxes everywhere.

So, how could healthcare executives learn to “think differently”? That’s a challenge in an industry where the system designers, funders and managers who are in control mostly believe that there is “one right answer” which can be found with linear problem-solving methods. They hold assumptions about human organizations that are simply not true.

This mindset says that we can either have a system with “controls”, or one where “innovation” leads to messy inconsistencies. We can have a system designed for “stability”, or one that is designed to “adapt to constant change”. We can have a system that has “top-down controls”, or one in which there is “bottom-up empowerment”. A system that has “consistency”, or one with great “variability”.

These are thought of as choices. The question is: why do we think we need to choose one of these options? Why “either/or”? Why not both?

Successful transformation leaders are those who comfortably embrace paradoxes like these. They design and lead organizations and systems that have prudent and sufficient “controls”, as well as significant support for “innovation”. These organizations and systems have “stability”, as well as constant “continuous change”. They have “consistency”, as well as “variability”.

The realization that no solution is found either in taking a stand on these opposites, or in balancing them, opens up the possibility of a higher level of perception — which integrates or synthesizes both, and renders a fatuous choice between them unnecessary.

When I speak with Art Frohwerk, the guy who invented the Experience Design Storyboard Methodology at Disney Corporation’s Imagineering Division – the method that has been now adopted world-wide for patient experience design – we compare notes, findings, experiences, and insights. Art combines his training in engineering and psychology to achieve breakthrough thinking about the design of human systems.

While we both know examples of good outcomes from applied lean thinking in the healthcare sector, in most, or at least many cases, this manufacturing sector methodology — while providing some initial gains and benefits  – too often ends-up in the long-run being ineffective in solving the real complexities of healthcare service delivery.

Asking front-line staff to focus on “waste” produces a different culture than one that asks staff to focus on the “patient experience”.

Frohwerk says: “too often lean manufacturing approaches fool us with measures of efficiency by streamlining out ‘waste’ in what we physically do. However, too often it just speeds up a mess of misalignments and missed connections”.

“With complex, adaptive systems like healthcare, lean thinking does not ask us what  really needs to be done, or how to better connect all parts of the system”, says Art. “It is great as a left-brained analytical tool. However, we are in a world of front-line care providers where there is as many ‘left-brainers’ as ‘right-brainers’. So we can end up doing harm if we always push left-brain solutions”.

Rising above all the fragmentation of reform efforts, Art sees the “big picture” of system design from the perspective of the patient experience, and all the factors that go into that experience. “Lean, TQM, Kaizen, Electronic Medical Records, Generative Governance, Digital Healthcare Technology, Patient-Centeredness and all the other great silo advancements need to be integrated together”, says Art Frohwerk.

“A true systems approach is needed first”, he says. “First, figure out the system – driven by the desired patient experience – then, orchestrate the mechanisms to pull it together. That’s how you successfully apply the concepts of patient-centre care design.”

Art Frohwerks’s Patient Experience Design Methodologies enable people to easily see that healthcare is in fact an eco-system of people, places, science, and tools, rather than fragmented components of a machine. He says “we need to see the ‘whole picture’ before we dive-in and fix any part—because every part is, in some way, interdependent with one another”.

“Optimizing one area will undoubtedly sub-optimize other areas”, says Art. “We need to understand and embrace the science of ‘systems thinking’, and the art of ‘systems sensing’, and imbed these in our personal and management belief systems – our culture.”

Unfortunately, too often government tends to point in opposite directions at the same time saying things like – “be innovative”, but “don’t take chances doing new things” — and “be sure to follow the prescribed templates, and ensure compliance with the project management plans”. Talk about being trapped between a rock and hard places. How can innovation emerge in the process-obsessed world of the scandal-plagued, blame-oriented healthcare sector? It can’t.

Linear, bureaucratic, rules-based thinking will simply not work when innovation is required.

In the quantum physics world, just as it is possible that sound can be both a wave and a particle at the same time, it is possible that our healthcare system can have prudent controls, and be innovative; customized, as well as standardized and systematized. It can be independent and interdependent – all at the same time.

In the top-down, fear-driven, command & control culture that starts at the Ministry of Health and invades the whole hierarchy in the healthcare sector, the normal response is: “Pick a side. It must be one, or the other.” Or, “What do the rules say?”

Systems Thinking is a way of thinking about, and a language for describing and understanding the forces and interrelationships that shape the behaviour of systems and the people in them. Senge said that “the act of systems thinking lies in seeing through complexity to the underlying structure generating change”. He points out that “systems thinking does not mean ignoring complexity. Rather, it means organizing complexity into a coherent story that illuminates the causes of problems and how they can be remedied in enduring ways by designing effective changes in the right places of a system to bring about the outcomes, or results, you need and want.”

Health Links need to ensure that the partners develop and apply systems thinking skills, and are operating from a common set of assumptions when they explore how the 5% of healthcare service “high users” can have a dramatically different patient experience.

What the Transformation Secretariat at Queen’s Park knows is that when the Health Links focus on the patient experience across the continuum, they will not only improve the patient experience, they will save money – experience tells us that as much as 30% can be saved using patient-centred care design methodologies.

When the Wynne Government is compelled to deal with our provincial financial realities in their Spring budget, I believe that healthcare leaders across Ontario may be forced to shift from dealing with the existing complicated nature of the challenges facing healthcare, to dealing with the full complexity of whole system transformation. So we really do need to shift our current thinking and behaviour — from fear and anxiety, to seeing new possibilities.

We need to “let go” of our need to survive and instead focus our energy and talents on our need to transform – “from caterpillar to butterfly”.

In Finding Our Way: Leadership For Uncertain Times, Margaret Wheatley explores the nature of complexity. She says “social insects, bird flocks, schools of fish, human traffic jams, all exhibit well-synchronized, highly-ordered behaviors. Yet these sophisticated movements are not directed by any leader. Instead a few rules focused at the local level lead to a coordinated response.”

Wheatley, Wong and Moore were each learning about successful transformations that focused on building the internal capacity for transformation by liberating people within an organization, and within a system of organizations that tap into their collective intelligence to design the required changes. Each of them talked about how human systems are “self-organizing”.

In Wheatley’s book, she says, “self-organizing systems have the capacity to create for themselves the aspects of organization that we thought we, as leaders, had to provide. Self-organizing systems create structures and pathways, networks of communication, values and meaning, behaviors and norms.”

She says, “in essence, they do for themselves most of what we believed we had to do for them. Rather than thinking of organization as an imposed structure, plan, design, or role, it is clear that in life, organization arises from the interactions and needs of individuals who have decided to come together.” Wheatley points to the recurring mistake – which is imposing plans and designs on the system. Today, Health Minister Matthews and her Transformation Secretariat seem to be avoiding that mistake – so far.

Health Links are designed to be self-organizing — with Queen’s Park and the LHINs promising that their only role is to remove barriers, supply modest resources (up to $1 million based on the Business Plan), and hold people accountable — through the LHINs — for their agreed-upon patient-centred and quality results.

It’s hard to believe that Queen’s Park does not have yet another “one-size-fits-all” solution that controls the micro-direction of each Health Link — under the false assumption that all they are each at the same stage of development. However, it looks like MOHLTC may have finally kicked their control/micro-management addiction. Three cheers!

But this has not been how Queen’s Park has historically thought and behaved.

Over the past three years, the McGuinty Government’s unrelenting barrage of rules, regulations, protocols, and RFP processes were a wild pendulum swing that occurred as a result of their need to deflect blame for the e-health and Ornge scandals. Today, small armies of bureaucrats now guard our virtue on RFP processes – while causing significant overall increases in administrative costs, for very questionable benefits, and, as a result, the painful death of innovation in the health sector.

However, the fact is the only way we are going to get out of the bind we are in is with innovation. But, innovation means taking risks – and you can’t take risks in a risk-adverse environment — where rules and regulations replace judgment.

My sense from Hon. Deb Matthews, and from the Transformation Secretariat, is that there is an increasing shift away from centralized micromanagement and demands for conformity to rules. Indeed, they are saying “tell us what ‘useless rules’ are getting in your way.”

This is a major shift in thinking on the part of Queen’s Park and some LHINs – where the ingrained culture of command and control normally produces a dynamic of micro-management. The pressures at Queen’s Park — and on the LHINs — are all about “risk-avoidance” and “blame-avoidance”. That is the message that they hear loud and clear.

With Health Minister Matthews taking an active leadership role in health system reform, and the launch of the Health Links as “self-organizing”, it now looks like there just might be a health system transformation of some kind. Stay tuned…

Next week’s blog: “Redesigning The Patient Experience Requires Empathy — As Well As The Science For Complex System Design”.

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It isn’t easy being a leader during periods of transformational change. We have had very few leaders who really get what deep transformational change requires of leaders and followers. My dear friend Michel Lalonde got it.

Michel was among my first teachers from the “real world” of healthcare service delivery where citizens and healthcare providers meet. He introduced me to what lean thinkers today call “gemba” – where the real nitty-gritty world of service delivery exists. While I could read learned articles from a number of academic teaching hospital CEO’s, I met my first real-world  “gemba instructor” from the delivery system when he was CEO of Hawkesbury General Hospital in the early 1990’s. Michel Lalonde was unusual compared to the other hospital CEO’s who were getting to the 10th floor of the Hepburn Block at Queen’s Park, where I had worked as Chief-of-Staff to Health Minister Larry Grossman.

He didn’t tell us he needed more money. Instead, he talked about how a focus on quality was making his hospital more efficient.

Indeed the research community had discovered in the late 1980’s that quality-driven re-designs often produced 30 percent cost reductions. He also had a profound respect for the wisdom of the front-line worker.

He believed his people were smart and talented. He trained and coached his managers to practice team learning and to learn how to tap into the collective intelligence of teams throughout the hospital. He was constantly learning how he, as the CEO, and how his managers could be more “in service to” the care providers – who he said enabled them to actually fulfill their hospital’s mission: their very purpose for existing.

In the early 90’s, this was called “a paradigm shift” in managerial thinking. Michel’s approach challenged traditional practices and ways of thinking. While his colleagues respected him, I don’t think a lot of them really understood where he was coming from. In my view, while there are some extraordinarily good CEO’s in the system, the sector is very slow to change. Michel was always focused on “how to make things better, now, and in the future.”

Michel wanted to learn everything he could about the various emerging management fads like: TQM/CQI; re-engineering; systems thinking; performance management – because he understood how these types of approaches created benefits and challenges for healthcare workers and managers. He asked a lot of questions about aspects of these methodologies that impacted on how people think and behave.

In the early 90’s at Learning Organization conferences and workshops in both the United States and in Canada, I was learning about  “what worked” and  “what didn’t work” in the leading-edge efforts to accelerate change in organizations by applying adult learning methodologies using simple systems thinking tools and practices like  “dialogue” and  “after action review” to generate  “lessons learned.”

While there were great breakthroughs that occurred, the recurring pattern in the stories about transformation was that people would change for a while, and then return to the “good old days and ways of doing things.”

Michel often talked about his struggles with “sustainability of change” at HGH as they underwent their first transformation into Total Quality Management (TQM) and Continuous Quality Improvement (CQI). His intitution about what influences sustainability is now backed up by recent research demonstrating that 40% of Ontario healthcare organizations have difficulty maintaining continued use of best practices – after they are formally introduced and explained to all stakeholders.

Michel knew how people’s behaviors are like organisms in an eco-system: they have an inexorable urge to survive.

In his book, Think Better: An Innovator’s Guide to Productive Thinking, Tim Hurson points out what Michel already knew: which is that humans will do anything to maintain our habits and ways of thinking. He says “no matter how dysfunctional the present, no matter how sensible the reasons for change, most people and organizations would rather wring out the old, than ring in the new.” He says that the “old behaviors are hard to kill. As a result, even the most well-intentioned and well-conceived change initiatives simply won’t stick.”

As fellow soldiers in the war to achieve sustainability of positive changes, Michel and I had lots of discussions about “the nature of humans” and how to get change internalized in people’s brains – as well as in their systems, structures and processes. In those days, we were both trying, failing, but learning a little more about how it might be possible to achieve sustainability for the large-scale change initiatives we were involved with.

I learned a lot from his practical real-world insights as a CEO in learning dialogues over about a four or five year period. At the time I was being exposed to the leading edge thinking of a team of about thirty people engaged in developing, testing and improving a series of systems thinking-based tools for strategic/leveraged thinking; organizational alignment and emotionally intelligent leadership development.

The book, Stewardship: Putting Service Before Self-Interest, perfectly describes Michel Lalonde’s mindset and way of  “being” in the world. Because he always openly engaged in self-reflection, Michel’s observations about the challenges he faced would inevitably include his own critical self-examination of his role: his strengths, his vulnerabilities – what else he could have done. He always asked: how can I improve?

I believe that it was his deep self-awareness that made Michel so empathic towards others. If he could recognize some potential flaws, it was because he had some firsthand experience with those types of mistakes himself. He didn’t judge people by their mistakes, he simply led them – with compassion and understanding – to another place, usually a better place.

In his first bout with cancer, Michel stopped working 90 hours a week and dropped to under 30 hours. He selected four or five highly leveraged activities and liberated his people to work in teams improving quality.

That’s how Michel “managed” HGH: by holding an assumption of competence, being deeply committed to quality, and by practicing dialogue to tap into the organization’s collective intelligence to discover what to do.

While many hospital CEO’s dominate their Boards (some say that governors are sometimes “led around by the nose”), Michel wanted “more value” from his Board. He engaged his Board in discussions about policy governance issues, seeking to get his Board to really understand the distinction between his role and theirs.

He firmly believed that healthcare organizations needed strong and effective Boards that are prepared to “push the envelope” on behalf of their community – and by holding the CEO accountable for quality-of-services and a balanced budget.

He brought governance guru John Carver to Hawkesbury and sent members of his Board to training sessions in the United States that focused on the Board’s duty to serve the “owners” – and to become a source of what Michel called “generative governance.”

Michel trained his bosses to become more effective at governing the hospital in ways that reflected community wisdom and needs.

Physicians at his hospital were not lobbying Board members to see things “their way.” While some of the circumstances of the doctors no doubt caused some friction with administration, and perhaps the Board; it was clear how much managers & physicians at this hospital truly held one another in high regard.

Respect was palpable. Michel’s role was to operate as a “connector” across the system – between people and groups.

This was easy for him because he was a natural systems thinker. He focused on the “whole system”: frontline caregivers, managers, physicians, boards, health authorities and the “owners” – who were the people of Eastern Ontario in Champlain LHIN, and the citizens of the province.

While Michel constantly dealt with people who were often firmly rooted in their silos, he saw the “inter-connectivity” in everything.

He always comfortably walked through all the silos to address the heart of the matter. He ignored the “boundaries” and focused on what needed to happen to improve service quality. He thought deeply about what combination of “leveraged actions” would propel his organization forward to the next level.

While warm, fuzzy and charming, Michel had a rigorous bottom-line mindset – which was why he felt more at home with private sector CEOs in Conference Board of Canada conferences than with his fellow hospital CEO’s at the Ontario Hospital Association’s education programs. Yes, he wanted high-quality, compassionate care, but he equally wanted “value-for-money” for taxpayers dollars.

While Michel certainly had an impact on Hawkesbury and Champlain District, his leadership style and “way of being” also impacted on the larger provincial system.

When the government decided to devolve power from Queen’s Park to local communities, Michel Lalonde agreed to come out of retirement to serve as the first Chair of the Champlain LHIN – where he continued to coach his community to adopt best practices in governance, management and administration. In this role he encouraged and cajoled the health system leaders to collaborate to deliver high-quality care for the people of Champlain District.

While he was always deeply engaged in activities that would transform the system in Champlain District, what Michel knew was that if we are ever to succeed in transforming our healthcare delivery system, we will need a pipeline of talent that will build on the progress made.

His last several years were spent as Resident-in-Chief at the University of Ottawa’s Masters in of Health Administration Program. Molding the health system leaders of the future: creating the leadership pipeline that he knows will be required if we are to succeed in transforming our healthcare services delivery system. And that is his true legacy.

Three years ago, surrounded by his family, Michel Lalonde passed away peacefully on February 19th, 2010, at Elizabeth Bruyere palliative care unit after a heroic battle with cancer.

As I reflect on the Michel Lalonde that I knew – my teacher from Gemba – I imagine what he would be saying as we reflect on our progress towards implementing the 3^rd iteration of each community’s Integrated Health Services Plan — developed by all of the health service providers funded by the LHIN. In addition, one or two groups within each LHIN will also be implementing the new Health Links Model that focuses on patient-centred clinical care plans for the top 5% of health system users… with more planned.

I imagine that he would be smiling and nodding wisely, saying:  “Just get on with it. Make the future happen now. You already know what to do – and how to do it. So just do it.”

Next week’s blog: “Successful Transformation Means Changing How We Think & Behave”.

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The new Health Links are both a structure and a process.

They are a voluntary structure composed of Health Service Providers (HSPs), from across the continuum-of-care, who agree to be accountable to the LHIN for a set of strategic outcomes related to improved patient experience/satisfaction and quality indicators.

However, from another perspective, they are also a process that mobilizes health service provider partners to focus on achieving some bottom-line outcomes for the top 5% of health system users through the development of coordinated care plans for all complex patients.

So Health Links are a process designed to spark collaboration among system partners to achieve some agreed-upon outcomes for patients. In order to succeed, this process requires a lot of dialogue among the partners, and among these patient populations to understand the issues — followed by some very focused action steps to improve care for a population that consumes 66% of the resources in healthcare. That’s how you cause health system mobilization and that’s how you engage patients in the design of their care.

So, does the Ontario healthcare system need a mobilization strategy at this point, and is Health Links the right strategy?

The fact is that we have now had three iterations of Integrated Health Service Plans over the past eight years, but we have not seen a lot of strategy execution and health reform implementation. While people have done a good job making incremental improvements and refining their local plan with their LHIN, Health Links could become the spark that ignites the mobilization of clinical staff to help redesign the delivery system across organizational boundaries in partnership with patients.

Evidence from successful transformations in health care suggests that: if you create a good clinical plan for each patient — and patient populations — the quality-of-care will go up, and the cost will go down. How do we know this approach will work? Is it true that patient satisfaction and quality-of-care can go up, while costs go down? In fact, we know it can.

While Ontario has spent hundreds of millions of dollars over the past 20 years conducting what Queen’s Park has called “health system reform”, we don’t seem to have retained a lot of the “lessons learned” from our various successes and failures along the way.

The Ministers, Deputies, ADMs and DHC/LHINs/Local Office staff frequently change, and each new generation of leaders pulls together to “make major changes to the system” — without much insight from past health reform efforts. Each generation ends up with yet another “structural quick-fix-that-fails” to deliver on the promised reforms which have always included higher-quality, cost-effective and patient-focused care.

However, much can be learned from the many successful innovations that we have undertaken in the name of “health system reform” in the past. One such group that the Health Links can learn from is: the Children’s Treatment Network (CTN) in York/Simcoe.

Since only 30% of large-scale transformations ever succeed, Health Links leaders will want to know what it was that CTN did to achieve extraordinary results – from the perspective of patients/clients and their families — as well as from taxpayers, who now get more and better services, for less money.

Like the Health Links, the Children’s Treatment Network brings together a number of diverse players, including seven active care hospitals, two CCACs, four school boards and over 30 independent agencies. So how can a diverse set of partners gain a common understanding of what they agree to achieve together? How can they get aligned?

While the Health Links partners are bound by the Business Plan that they developed together collaboratively, at the Children’s Treatment Network, they are bound by three key agreements: a Memorandum Of Understanding (MOU) — which contains high-level commitments to the network vision, mission and philosophy of partnership; an Information Sharing Agreement – which sets out the responsibilities for data stewardship by each of the partners using an agreed-upon shared electronic record; and by Service Agreements – which are contained in 20 contracts for the delivery of clinical services. Similar agreements are in place for CTN’s shared back office supports and leased space among the partners.

These three key formal agreements are the product of many conversations, and a lot of planning.

You might be imagining the CTN as a large organization occupying a lot of space to deliver all these complex services to over 5,000 families. However, CTN is a unique dispersed service model, with a small corporate structure and services spread across the organizations that are involved in delivering services to this “high/complex needs” population cohort covering Simcoe County and York Region.

In terms of scale, for only about $12 million annually, CTN mobilizes 82 FTEs in 20 host partner organizations to provide high-quality personalized rehab/clinical services for children with autism, developmental disabilities, dual diagnosis, and long-term rehabilitation needs – including specialized medical, communication, PT and OT services.

Think about that. You may know of parents of children who require very high levels of health system services just to provide them with some fairly basic support. These chronically ill children certainly fall into the category of the “Top 5% of Health System Users”.

If you know families in these circumstances, you’ll be familiar with the fact that often one parent quits their job to become a full-time facilitator, communicator, case manager, recorder and advocate for their child. Eighty percent of these families are affected by divorce. Parents of chronically-ill children lead very difficult lives.

As our first generation of Health Links go about exploring who their heavy health services users are, and what they are experiencing as patients/clients, they will uncover some amazing stories about how our fragmented healthcare services delivery system makes for absolutely horrible experiences for chronically ill people.

I work as the pro bono consultant for the 500,000 Ontarians who have environmental-related illness (FM, ME, MCS). This very unhealthy population cohort utilizes primary care physicians at eight to ten times the rate in the rest of the population. Why? Because there isn’t a patient-centred “system” to provide them with the complex set of health and social support services that they need. So they keep seeking help for their illnesses as they get sicker and sicker.  Taxpayers spend hundreds of millions — and these folks receive terrible healthcare services at great cost. It is a horrible situation.

It was MPP Kathleen Wynne who convinced the Ministry of Health to invest $250,000 to create a Business Case for a patient-centred system of services that this high-use population needs to better meet their total healthcare needs, vs. the existing very expensive, poor-quality primary care services that they experience today.

The Association of Ontario Health Centres (AOHC) is now conducting the study. I believe that they could end up projecting that we can save as much as $300 million annually, if this population had an actual service delivery “system” – as close-to-home as possible. One that provides the health and social support services required to dramatically increase quality-of-care, while significantly reducing costs. Now that’s transformation.

However, looking for the high volume/high-cost users also can’t be allowed to become a “blame the patients” exercise by healthcare providers.

It is true that there are some individuals (maybe .01%) – the so-called “frequent flyers” — who utilize healthcare services inappropriately. However, the Health Links will soon uncover chronically-ill population cohorts who are bounced around the delivery system (like those with environmental illnesses), because there really isn’t a “system”. There are only well-intended health service providers operating in rigid silos — where most core processes are designed for healthcare providers, not patients.

Health Links will follow patients across those silos, by focusing on “the patient journey” across the continuum-of-care. That’s what CTN does. So, what did they learn?

Here are 10 critical success factors at CTN, that Health Links ought to think about:

•  Shared Vision & Purpose – CTN invested many hours engaging their partners from across the continuum of services in Facilitated Dialogues, doing Mind Maps, and participating in Open Space Conferences with service providers and parents — where the client/parent was the focus for designing a better health services delivery system for these children.

• Patient/Client-Centred Design – before he even hired his senior management team, the first CTN CEO, Bob Morton (now Chair @ NSM LNIN) brought together front-line service providers, middle managers and families to design the service delivery system. These cross-functional middle managers and front-line service providers partnered with patients and their families to design the service delivery system at CTN.

• On-Going Family Engagement – CTN produces high-levels of client/family satisfaction because of its deep commitment to family engagement. The input of families is essential to the successful outcome of their children’s Single Plan Of Care — and ensures that parents and family members are welcome partners in the planning and delivery of CTN services.

• Service Delivery Team – with the client/family, teachers, principals, healthcare professionals delivering specific services. This team can meet together and online to engage in case management and service planning dialogues that address client/family issues and circumstances.

• Single Plan-Of-Care – is developed for each client. The plan is the product of the collective intelligence of the whole service delivery team, in conjunction with the parents.

• Shared Electronic Record – with data, team member comments, up-dates for all to see and know about the client and their family. CTN says this was a critical success factor in creating patient-centred care. And, what makes the record really innovative is that team members from health care, education and community organizations document in the shared record – CTN has addressed privacy and consent issues that are often seen as barriers to multiple sectors using a shared record.

• Capacity-Building & Co-Ordination – as CTN moved from planning to strategy execution, they focused on building people’s capacity to learn how to collaborate better. CTN provides Team Facilitators through ongoing support of care plan coordinators, families and professionals who all participate in training and education programs that provides them with more capability to work inter-professionally as equal partners — equally focused on providing the best outcomes for the child and family.

• Management Alignment – the initial work to mobilize middle managers and front-line service providers to collaborate with parents has continued with a structure that involves all partners with members of the CTN’s Executive Team’s Management in evaluative, monitoring, planning and quality improvement processes. Today, CTN CEO Louise Paul and her staff provide strategic direction, stewardship, coaching and love to the collective efforts of a very large and complex web of interconnections producing extraordinary results.

• Enlightened/Best Practice Governance – from the beginning, the CTN Board has been in stewardship to the staff, and to the service provider partners, in order to support them in their innovative efforts to improve care and support for these families.

• Enlightened/Public Servants – CTN was fortunate to have two outstanding public servants who, in the true spirit of “serving the public”, embraced the problem of 5,000 poorly served families in York/Simcoe who required high levels of support just to manage. Michael Klejman from the local office of MOHLTC and Graham Constantine of the DHC linked arms with local CCAC CEOs in York and Simcoe, and with local Boards of Education Directors and others to ensure that these families got the services that they needed — through enhanced collaboration – rather than building a “Bloorview Children’s Hospital” for the two regions north of Toronto.

While Graham and Michael are retired, they continue to be “in service” to their public purpose files — by serving as volunteer Board members and coaches to the Children’s Treatment Network.

These two are not alone. There is a remarkable group of extraordinary former public servants out there – Mary Catherine Lindberg, Darwin Kealey, Michael Innes, Bob Morton, Dan Burns, Jeff Quirt, Donna Segal, Scott Dudgeon and many other true “public servants” who continue to contribute their wisdom, coaching and mentoring on the issues that are so dear to their hearts, and indeed, part of their very purpose.

Speaking of purpose, Klejman and Constantine ought to have a real sense of fulfillment in terms of their very positive impact on the quality-of-life of thousands of people who are impacted by chronically-ill children throughout York and Simcoe Regions. When you review the data on customer satisfaction, and the heart-felt stories and comments of parents whose lives have been transformed because of CTN, you really get why these integration efforts are so essential; and what the outcomes can be when health providers shift the focus from provider-focused processes, to process focused on patients and their families.

Prior to 2006, these families described their experience as “frustrating, fragmented, confusing and overwhelming”. Finding services, battling waitlists, travelling long distances, briefing numerous professionals from different sectors on their child’s history and coordinating services from multiple agencies were just part of their day-to-day tasks. When Health Links Partners discover the “high users” in their system, they will discover people in similar circumstances.

In CTN’s case, often one parent has to quit their job to be facilitator, communicator, case manager, recorder and advocate for their child. If you know people in these terrible circumstances, you’ll be familiar with the fact that 80% of these families are further torn apart by divorce. These are difficult, hard lives that they lead.

The Children’s Treatment Network’s bottom-line challenge was to produce better outcomes for kids and families — by bridging service gaps, bringing more critically needed services closer to home, and breaking down silos to create a true service delivery “system” that can provide family-centred, coordinated care efficiently and effectively.

Network partners today include over 60 healthcare, education, recreation and social service organizations that have joined together so they can take a team approach to each child’s care — at home, at school and throughout the community.

While Health Links are not as diverse or complex as the CTN’s multiple partners, their success story suggests that diverse partners from across the service delivery system can in fact succeed — when they are truly focused on the needs of the patient/client, and not on the organizational turf of the healthcare service provider organizations, or on the preferences of professionals.

Next week’s blog: “My Teacher From Gemba MICHEL LALONDE”.

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As part of the final “legacy actions” taken by former Premier Dalton McGuinty just before Christmas, the MOHLTC announced the first 19 Health Links – which are voluntary partnerships of healthcare providers who agree to accept shared accountability to achieve a number of measureable outcomes for patient/client satisfaction, and for making quality improvements in the delivery of services — from a patient/family perspective.

Will Health Links continue under Premier Wynne, or under a Tory or NDP government? The answer is: why not?

These new voluntary structures will not only design a much better patient experience for the top 5% of healthcare service users, it could also end up saving taxpayers up to $2 billion a year – maybe more.

Sounds good! How will it work? MOHLTC says that Health Links will be accountable to the LHINS – the same as for all health service providers. They say that while Health Links will initially be voluntary, overtime, the entire province would be in one of these “voluntary partnerships” that set targets and collaborates with partners across the continuum to achieve specific outcomes.

Health Links are integrated healthcare delivery systems where primary care and patients are at the centre. The current buzz says there maybe 70 Health Links in the future. However, there is no timetable for the next round. When they are ready to start, they can start. All they need is a Business Plan.

Healthcare providers in the Health Links are to put agreed-upon collaborative initiatives in place that will allow for measureable, positive impacts on the quality and experience of patient care. Much to the cheers of organized patients’ groups, the government uses language like: “improvements in the patient experience”. Health Minister Matthews has truly branded her tenure as Minister of Health as “patient-centred” and “quality-focused”.

The government’s framework and principles for Health Links also indicates that there will be “joint” or “shared” accountability for achieving these bottom-line patient experience results. However, we know that 70% of all major change initiatives fail. So how could Health Links ensure that they will in fact succeed?

Health Links partners would be well advised to follow “best practices” for organizational and whole system transformation. In 18 months from now, we know that the most successful of the initial 19 projects will be those who engaged their front-line healthcare service providers, middle managers (as well as patients & families) in the redesign of the patient journey – the clinical plan.

Evidence suggests that if they collaborate with one another utilizing the tools and practices of Learning Organizations (i.e. the practice of dialogue, systems thinking, collective intelligence, team learning, cross-functional integration and empowerment of middle managers, and front-line service providers, as well as the application of Experience Design Methodologies), they will indeed succeed in transforming themselves, their services and the patient/client experience.

So what does a diverse group of partners within each Health Link do to ensure that they do succeed?

First of all, Health Links won’t be successful, unless they build trust among the partners and among health service providers. In his book, Trustworthy Government, David Carnevale describes trust as “an expression of faith and confidence that a person or an institution will be fair, ethical, competent and nonthreatening”. Unfortunately, surveys measuring employee trust in the healthcare sector have demonstrated increasing levels of disbelief and mistrust within and between organizations.

Carnevale writes that many people go to work “with guarded, suspicious, and cynical attitudes. They have lost faith in their organizations. Their hopes and expectations have been mismanaged. The costs of mistrust and cynicism are high. These emotions corrode organizations and destroy high-performance.” The loss of trust is a loss of system power in organizations. Trust is an integrative mechanism – the cohesion that makes it possible for organizations to accomplish extraordinary things.

Health Link Partners need to embrace this concept of “trust as social capital”. Carnevale said “trust reduces conflict, improves communication, eases cooperation, enhances problem-solving, reduces stress, enables people to realize more satisfactory relationships, amplifies organizational learning, and advances change.”

In the UK, where their healthcare delivery system has been undergoing transformational change over the past three years, organizational scientists have been learning about what happens in low trust healthcare environments that are undergoing a fundamental transformation.

In an August 2012 article in the Ashridge Business School Journal, the authors found that in low trust environments in the NHS, managers reported the following range of responses:

• Criticism and suspicion of other organizations and professional groups. For instance, senior clinicians would continuously question and challenge managers’ intentions behind decisions and oppose their proposals for change.

• Opposing changes based on a cynical interpretation of the motives of those proposing them or because they perceived the changes to be imposed upon them. For instance, one clinician stated: “We must accept it even though we do not believe in it.”

• Passive opposition to changes, such as failing to complete tasks on time, not responding to requests for information or general apathy and low commitment to changes.

The Ashridge Business School Journal’s article also suggests that in the UK health system “heightened anxiety and distrust also amplified covert political dynamics as individuals seek to protect their interests by forming coalitions and hiding feelings or opinions that are not considered expressible in public, spreading gossip and misinformation and manipulating data to present information in a favorable manner.”

Is it possible that covert political dynamics are will be at play in some of the Health Links projects? Do you think maybe in some? If they are, what we know from experience is that when political dynamics increase, trust levels go down. As trust goes down, failures increase.

Since we don’t want many failures among the Health Links, how do we build trust?

Trust starts with how the top leadership are behaving. Is Queen’s Park creating Health Links as a political strategy, an optical illusion — or are they really actually sincere about the better/cheaper care outcomes for patients and taxpayers that they are promising?

While there may be some good reasons to be cynical about Health Links, there are much better reasons to believe that these initiatives can and will act as a catalyst for organizations to collaborate on achieving the type of patient-centred outcomes that are listed in each community’s Integrated Health Service Plan, and now in each Health Link’s Business Plan.

There is no question that each Health Link can succeed, but will they? What does the Readiness Assessment conducted on each Health Link tell us? Are these organizations really ready for transformation? What can they learn from their own “best mistakes” of the past? How could LHINs and Queen’s Park support these efforts?

Successful transformations have top-down and bottom-up components. We need Health Minister Matthews providing high-level top-down visionary leadership that encourages the bottom-up revolution. We need CEOs, governance boards and senior managers liberating our front-line service providers to transform the delivery system.

The Balanced Scorecard Collaborative’s research on the healthcare sector indicates that only 10% of organizations ever actually execute their strategy successfully. Among the list of barriers to strategy execution in the health sector is: only 5% of the workforce understands the strategy. Hello? Will each of the Health Links fully engage their front-line care providers – as well as patients and families — in this service redesign project?

To succeed, we need to pull people together across the Health Link Partners to plan the clinical & non-clinical delivery of patient-centred care across the continuum. The “patient/client experience” can be mapped by front-line workers and patients using Storyboarding Methodologies — which are much better aligned with the culture and mindset of the health services sector, than the lean thinking/six sigma methodologies of the manufacturing sector.

While both of these approaches can save up to 30% in costs, “Looking For Waste” is simply not as an inspiring mission for front-line healthcare workers as “Improving The Patient Experience”. While the “hard approach” may work best in the manufacturing sector, the “soft approach” really does work best in healthcare.

Health Link Partners also need to have a common understanding of this term “partnership”. Best Practice Guiding Principles For Partnership, include:

1.      Shared Vision & Agreed Process:  The partners need to evolve a shared vision (picture) of what the end-product will look like, and how the process should be designed to achieve high-quality, patient-centred care.

2.      Partnership Equality:  Health Service Providers (HSPs) must strive to create an authentic partnership and promote partnership behaviour and practices.  Partnership means to be connected to one another in a way that the power between the participants is roughly balanced.  Partnership acknowledges our absolute interdependence. Partners ought to select a lead partner to serve as the “managing partner” in service to the others to support collaboration, and to be accountable to the LHIN for achieving the outcomes.

3.      Independent & Interdependent – self-governing independent health service provider organizations are also interdependent as they serve the same client as they travel across the continuum-of-care.

4.      Learning Organization:  The partners must strive to think, behave and act as a Learning Organization — what Peter Senge calls “a group of people who are continually enhancing their capacity to create the results they want.”

5.      Dialogue:  Partners practice the skill of dialogue.  In dialogue everyone truly listens to each other, treats each other with respect and works together to build on each other’s thoughts and ideas — rather than being focused on scoring points and winning arguments.  In dialogue, complex issues are explored and different views are presented as a means of discovering “new ways of seeing old problems.”

6.      Team Learning & Systems Thinking:  Successful partnerships utilize team learning skills to develop ideas in which the whole is greater than the parts that each contributes — and by using systems thinking to discover solutions to the complex problems. Teams of front-line workers and middle managers tap into their collective intelligence as they redesign the delivery system in partnership with their customers.

7.      Joint & Mutual Accountability.  Each partner is responsible for achieving the overall outcomes of their Health Link’s Vision — as well as their individual agreed-upon outcomes.  Accountabilities for each partner need to be listed, measured and documented – including each of the “supports required” to successfully achieve the outcomes expected of each partner.

8.      Avoid Dominance.  Participants in the partnership will not attempt to “control” the relationship.  While there may be a “Partner In Charge” (51% vs. 49%), the partners strive to behave as though there is a 50/50 responsibility for achieving the agreed-upon outcomes.

9.      Diversity:  Partners will achieve high levels of creativity by including people who have a diversity of perspectives, opinions, experiences and beliefs.  Best practice partnerships celebrate diversity and seek to utilize it for innovation. Partners are both independent and interdependent – at the same time.

10.  Right to Say “No”.  Partners each have the right to say no.  Partnership does not mean that you always get what you want.  It means you may lose your argument, but you never lose your voice.

Best practices also would suggest that to succeed, the health service provider partners need to select the right “lead partner”, or “managing partner”, who would be well-advised to operate as though they have 51% — while all the other partners hold a 49% share of the responsibility & obligations for the Health Links.

“Politics” ought never play a role in the selection of the managing partner. It is a simple exercise: What are the functions that need to be done? Who has the capacity to perform these functions? Is the “lead partner” prepared to be held accountable to the LHIN for the Business Plan outcomes promised? Are all the partners agreed on the selection of the “lead” partner?

If the “lead partner” is the “managing partner”, does everyone understand what that means? Everyone needs to have a common understanding of: how the Lead/Managing Partner be “in service” to the other partners? It is essential to get these understandings nailed down and agreed to among the partners and with the LHIN. The MOHLTC is flowing “up to $1 million” to each Health Link Lead Partner to support the implementation of the plan that the partners have each signed-up-for.

Ultimately, to succeed, the Health Links partners also need to know how to design systems, structures and processes for “Joint Accountability” and “Shared Accountability”. They need to develop accountability processes and practices that are rooted in best practice mutual accountability structures and processes.

However, Health Links won’t get anywhere — until and unless the health service provider partners have a shared vision across the continuum-of-care at the governance, management and staff levels. At its simplest level, a Shared Vision is the answer to the question: “What do we want to create?”

Peter Senge describes the concept of a Shared Vision in his book The Fifth Discipline.  He writes, “A shared vision is not an idea.  It is, rather, a force in people’s hearts, a force of impressive power.  It may be inspired by an idea but once it goes further – if it is compelling enough to acquire the support of more than one person – then it is no longer an abstraction.  It is palpable.  People begin to see it as if it exists.  Few, if any, forces in human affairs are as powerful as a shared vision.”

While there is much to learn from our past failures of health reform, for the next few blogs, I’m going to focus on some really amazing “innovators” who have indeed found ways to successfully serve chronic high-users of the health system — with better, more effective care, at less cost.

Next week’s blog: “Learning From Our Past Successes”.

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