There is a growing sense of optimism about the future of our healthcare system that has set in since the election in June. But for many, it is still somewhat difficult to overcome the sense of cynicism that began to increase over the past several years as our provincial government increasingly sought to exert more and more “controls” and micro-management efforts over our healthcare services delivery system.
From RFP designs that discourage innovation and promote risk-averse thinking and behavior; to project managementitis as a replacement for strategic thinking; to worst practice Accountability Agreements that attempt to hold people and HSPs accountable for things over which they have no control; the healthcare delivery system and its leaders have been treated with incredible disrespect by people and processes that “health reformers” and “change-agents” bristle over.
Nevertheless, today, even despite a vastly more threatening financial environment, many of Ontario’s healthcare leaders seem increasingly optimistic about the health system’s — and the government’s — ability to actually transform our healthcare system. This is the health system’s “reservoir of good will”. We want and need our leaders to be successful — or we should.
While there is still a healthy skepticism about the future of the sector, the arrival of the Wynne/Hoskins/Bell team seems to have produced a genuine sense of optimism that there will be “fresh eyes” on “old files” — with the same, or similar vision and values.
Operational healthcare leaders who are feeling less threatened by the external environment now have the opportunity to look inward — at their own organizations and their own local delivery systems — and ask: what can we do to improve? Governance boards of health service providers — representing the “owners” — need to ask: how can we behave as both a silo board, and a delivery system collaborative board?
This exploration is for those who, as Robert Greenleaf stated in his essay, Trustees As Servants: “are dissatisfied with their present roles, and have a strong urge to do the best they can, so that they will venture to make a wholly new role for themselves with only the vision of the possibility of greatness to guide them.”
Using a systems perspective, operational and governance leaders really need to focus on leveraged approaches that examine systems, structures, roles, and how the local delivery system is designed and functions — rather than falling into blaming and finger-pointing.
By encouraging ongoing, open, honest conversations about the distinct contributions of the CEO, the Board, the LHIN and HSP system partners, we can create strong, integrated and accountable organizations and local delivery systems that can move strategically toward the achievement of both their silo and system missions and visions — just as the “owners” would want.
The “owners” — who are the taxpayers of Ontario, and the citizens of each community — actually own all the silos. Silo boards need to evolve to also become system boards at the same time. They need to tell their CEO that their focus should be 51% on their silo, and 49% on the system.
Instead of being silo Kings and Queens, CEOs would be able to emerge as Health System Executives who are skilled collaborators. They also need a partnership with their Board, where the Board is the “managing partner” (51%) — and they are the executive partner with 49%.
Shortly, we will enter a period where Boards and CEOs will experience significant financial pressures and significant internal and external tensions related to the new Minister’s Strategic Change Agenda, currently under development.
CEOs and their Boards need to ask themselves: Do we have a “safe environment” in which the Board and CEO can speak the whole truth? Can you be truthful with the LHIN, and with the MOHLTC? Can we challenge our Health Link partners? Or, are you trapped in an unsafe political environment dominated by the dynamics of blame and blame-avoidance?
Our reality is that in today’s chaotic and ever-changing environment, Boards and CEOs do not spend much time thinking about, planning for, or engaging in effective governance processes. We are so busy attending to micro-issues and reacting to today’s crisis, that most organizations fail to engage in direct conversations about the respective leadership roles that the Board and CEO need to play in order to achieve the intended purpose of the organization, and the intended purpose of their Health Link Business Plan and the LHIN’s Integrated Health Service Plan.
Under the Wynne/Hoskins/Bell leadership team, there will also be a strong focus on quality, safety, the patient experience — all with real measurements that focus the attention of Board and staff as they engage in their learning journey together.
Organizations that have successfully transformed themselves were able to undergo profound change — because they redefined themselves as Learning Organizations – and were able to develop new approaches to leadership: servant leadership, stewardship, adaptive leadership, and systems thinking.
One of the reasons for rising optimism in the healthcare sector is that not all organizations are stuck. In fact, many are doing very well. Indeed, at least 25 to 30 percent of Health Service Providers are actually thriving today — producing higher-quality care, better results, more satisfied patients and happier staff, than ever before. In each successful CCAC/hospital or agency case example, you will find a best practice board of governance that holds their CEO accountable — for both silo and system outcomes.
However, such dramatic shifts in performance require a very different approach than our traditional models of command and control governance, managerial leadership and strategy implementation.
The Wynne/Hoskins/Bell Healthcare Leadership Team may yet emerge as servant-leaders — who provide their support by removing barriers, and empowering HSPs, CEOs, LHINs, and the MOHLTC to mobilize to achieve truly fundamental patient-centred change.
The delivery system has been very uncomfortable with the degree to which “narrow self-interests” have been a dominant behavior that is thriving and doing very well in Ontario today. People sense that Wynne/Hoskins/Bell, in contrast, seem to be “in service” to the system.
In his essay, The Servant As Leader, Greenleaf wrote: “The servant-leader is servant first… It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead… the difference manifests itself in the care taken by the servant – first to make sure that other people’s highest-priority needs are being served.”
According to Greenleaf, the best test, and the most difficult to administer is: “do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants? And, what is the effect on the least privileged in the group: will they benefit, or, at least, not be further deprived?”
Organizations that have successfully transformed their governance and management processes are often those that have rooted their thinking in a systems perspective, and tapped into the collective intelligence of their people. Rather than falling into finger-pointing and blame – which too often characterizes Board/CEO relations, and silo/LHIN relations – Board members and senior staff, the HSP and the LHINs need to dialogue openly and honestly about how the design of their systems, structures, incentives and processes are producing the current results that are being achieved as we slide from 3rd place, to second last out of 11 health systems in the developed world.
Hello? We need large-scale change if we are going to save a system that is continuing to decline at faster and faster rates.
When an organization has decided to redesign their systems and structures, the skill and discipline of systems thinking is an essential tool. Systems thinking is a knowledge economy skill that enables teams to discover the key leveraged actions that will propel the organization or a local integrated delivery system towards its vision, and towards achieving the outcomes and targets that they set out in best practice strategy implementation frameworks like Balanced Scorecards and system design tools like the “Storyboard“.
Peter Senge, author of The Fifth Discipline, calls systems thinking “the cornerstone of the learning organization”. Systems thinking is a practical and useful tool in our discussion of Board/CEO/Staff relations. With the skill of systems thinking, we step back from particular events to look at emerging patterns – to see the “bigger picture”. As fallible human beings, we often rush to decisions without a clear understanding of why a particular problem has emerged. The practice of systems thinking ensures that reflection and dialogue on patterns – not events – occur before decisions are taken.
For example, what began as an important equity gesture during the election, the government announced an increase in wages for our lowest paid PSW’s working in our community support and homecare sectors. But due to a lack of systems thinking, the entire sector is now experiencing significant trama — just when we need them stabilized, energized, confident and ready for growth.
While it is true that there is an overall sense of optimism in the health sector, in those areas where PSWs are employed, organizations are experiencing complete disbelief in how the government is disregarding the hardships caused by poorly thought-out policies.
While government officials talk about “systems” and “lack of systems”, too often there is in fact no demonstrated ability to actually apply systems thinking to public policy implementation — a skill requirement that seems to still be lacking. As Senge put it, “the art of systems thinking lies in seeing through complexity to the underlying structure generating change”. Indeed, the ability to recognize and understand an organization as a system of interrelated parts — where each part impacts the whole — is an essential step in system design.
The skill of systems thinking enables us to avoid the “unintended consequences” of little mistakes (like the wording of the PSW announcement) in order to see the longer-term consequences of flawed-thinking — and the command-and-control attitudes expressed by the statement: “we are going forward anyway”.
At the Queen’s Park and LHIN-Levels, leaders need to acknowledge that by refusing to stop the jet-boot implementation of the PSW wage increase, and honestly addressing the “unintended consequences” of their actions, this strategically important sector may be unable to respond over the next few years to the emerging demands for vastly increased services in the homecare and community support sectors.
If we are to succeed in transforming healthcare, the MOHLTC and the LHINs need to understand “systems” and “systems thinking” better. Perhaps the new leadership team of Wynne/Hoskins/Bell can now demonstrate that on the PSW file…soon.
At the Health Link Level, individual HSP governance boards also need to take responsibility for representing the “owners” — the citizens who pay for and receive services from our delivery system, and from the silo they are governing. This would be a major shift for organizations that have too often become “cheerleaders” for their individual silo — rather than providing governance oversight for “the delivery system”.
If a silo board member understands that 51% of their focus ought to be on their silo, and 49% on the system that impacts on their silo, then they will be better able to represent the “owners” — who own all the silos, and have higher-level concerns about the patient journey across the continuum-of-care.
We need systems thinkers, servant-leaders and people who can hold the “bigger picture” of the dynamics in this complex, adaptive system.
At the Health Service Provider Level, Boards also need to focus on the “bigger picture”.
Ronald Heifetz, who teaches at the JFK School of Government at Harvard University, uses the image of the balcony and the dance floor to illustrate the importance of the different vantage points for leaders. He notes: “Because Board members are more emotionally distant from the day-to-day action of the organization, they often are in a better position to see things from a balcony perspective. They can observe the whole of the dance floor without getting caught up in the dance. In the knowledge economy organizations must develop the capacity to change quickly to adapt to constantly changing environments.”
Heifetz says “trustee wisdom comes from its broad focus. While staff must pay attention to the trees, trustees can look at the whole forest.” Given the temptations which the Board has to leave the balcony (“we just want to have one dance”), they are challenged to dialogue about how they can stay on the balcony and feel secure there. From the balcony they can see “the big picture” and the “whole system”.
The problem is even when we get a Board that can see the “big picture” from a “balcony perspective”, too often they are limited by perverse worst practice structures and practices put in place by the Queen’s Park brain thrust.
For example, in our existing structures:
- The MOHLTC controls the LHINs through worst practice Accountability Agreements that typically contain outcomes over which LHINs have no control.
- LHINs in turn hold HSPs accountable for outcomes that they often have no control over either.
- At the operational level, Boards are very often confused about what they should actually hold their CEO accountable for achieving. In the past, some told their CEO to simply “win big” for their silo, rather than for the system.
- And, as a consequence of all the above, people in the delivery system experience blaming and engage in blame-avoidance dynamics to protect themselves.
But stable governance Boards representing the best interests of their community — and following best practice governance — can still be sub-optimized by the “worst practice behaviors” of the MOHLTC/LHIN on issues like accountability design.
After a scandal-riddled decade in the top ranks of our healthcare system, many Boards and CEOs now find themselves in a very traditional command and control fearful relationships – rather than one that is defined by interdependence, collaboration, innovation and partnership. The mindset, style and culture of “control” starts at the top — and then works its way through the delivery system. Indeed, this is a system focused mostly on processes, rather than a focus on results.
The massive over-reaction of government bureaucracy to their own internal scandals has placed the whole delivery system into mindless, bureaucratic rules and control processes that are diverting patient care resources to support the CYA (“cover-your-ass”) activities that have stifled innovation and creativity on the bureaucratic altar of Risk Avoidance.
According to this bureaucratic mindset, the solution to system fragmentation isn’t Collaborative Governance or Integrated Management Scorecards among the Health Link partners — but rather “getting rid of all those citizen/community boards” that they claim are merely cheerleaders for the narrow self-interests of their silos.
In today’s complex environment, our silos are increasingly understood to be part of a larger delivery system. Boards can no longer simply hold their CEO’s accountable for outcomes in their silos’ Balanced Scorecard, they have also signed-off on a Service Accountability Agreement with the LHIN; and they have, or soon will sign-off on a Business Plan Collaborative Agreement with their Health Link partners.
But how many governance Boards today are actually holding their CEO’s accountable for both their system and silo outcomes? If Boards have no interest in how well their organization is doing at achieving their Health Link commitments; or, if they have no interest in being a collaborative player in their Local Health Integration Network’s Integrated Health Service Plan, and their Service Accountability Agreement; then they really are not acting in the interests of the people who “own” their organization, and the whole service delivery system (i.e. the people of Ontario).
The good news for the Wynne/Hoskins/Bell Healthcare Leadership Team is that Ontario already has a critical mass of HSPs who really do get all this — and are absolutely at a state of “readiness for transformation”. We’ve had a few false starts that were more PR-oriented, than solid transformative public policy. And, we have an urgent clean-up in the PSW aisle — where significant amounts of good-will are now being squandered.
In the short-term (next 12-24 months), our current circumstances would suggest that perhaps 30% — maybe even 40% of HSPs — will surge forward in their own successful transformation. But without Collaborative Governance Structures and Integrated Health Link Scorecards, the success rate among Health Links transforming the patient experience across the continuum-of-care could very well only be 20% to 25%. That’s a 75% to 80% failure rate for those who like to keep score.
Failure is certainly avoidable — if we acknowledge the need for transformational change, and if the Ontario Government makes the right policy choices in the months and years ahead.
So, what are the right policy choices — from your perspective as a healthcare leader? What would you tell our new Minister as he prepares his Ministry’s renewed Strategic Directions? What should his priorities be?
Last chance to participate in the (click here) Health Leaders’ Survey For Hoskins.
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