Much of the talk about health reform in Ontario still continues to be about “structure” — or, as some call it: the “Who gets to be the boss debate“? This isn’t about: how do we design a seamless experience across the continuum-of-care? This isn’t about: how to create a vertically integrated service delivery system that provides “seamless patient experiences”?

That’s because “structure” in Ontario’s health system is always about “control”, rather than “service”. We’ve had local Ministry Offices, District Health Councils, LHINs, and more recently, Health Links. “Structure” has never been about: how do we design the system to better serve our patients and taxpayers? In a bureaucratic/political system, “who is the bossman” is a question that usually trumps being “patient-centred” — or, at least that’s what it was like before Hoskin’s “Patient First“, and the new and improved world of Health Link II.

While tinkering with “structure” on its own can sometimes actually reap a few short-term benefits, most of the restructuring exercises undertaken by Queen’s Park over the years only addressed the symptoms of dysfunction — not the root causes. If we are to successfully transform our healthcare services delivery system, we need deep fundamental change — not more time-consuming, non-leveraged planning/restructuring exercises that are only about power and authority.

From the 30 percent of successful transformations, we have learned that fundamental change needs to be intentionally designed and enshrined at both the organization and system levels — if we are to actually succeed in creating a better, higher-quality, more customer-focused healthcare delivery system.

Experience with successful transformations at the Organizational-Level indicates that the more effective silo-interventions include:

- Developing Adaptive Leadership/ Stewardship/ Facilitation Skills within senior and middle managers at regular learning workshops – so they can lead and manage the organizational transformation, system integration, and alignment projects;

- Investing 1% to 5% of payroll budget on the Learning & Growth of Managers – so that they can build the internal capacity to transform the existing system using Balanced Scorecards, design thinking and systems thinking for talking about, planning for, and executing strategic change;

- Shifting Organizational Culture from “command and control” to teamwork/ collaboration/ collective intelligence/ emotional intelligence. “Transformation” means shifting from decisions based on power politics and inner-circle vested interests currently being practiced, to evidence-based, customer-focused decisions within a Learning Organization;

- Developing — or renewing — each organization’s, and each Health Link’s, SHARED VISION of the future — using mindmapping techniques with HSP leaders to achieve alignment across the delivery system, and within each organization;

- Renewing Governance, in alignment with the evolving system – with major focus on quality/customer/ staff/ stakeholder satisfaction at the organization level, as well as on collaborative governance at the Health Link partnership level. Boards need to hold their CEO/COS accountable for both system and silo-outcomes;

- Engaging Management, Medical Chiefs, Board and Staff in on-going Balanced Scorecard Development, Strategy Execution & Strategic Learning Dialogues that tap into their collective intelligence — so that they can generate strategies that will align the organization to achieve improved performance and enhanced integration at each organization;

- Linking Strategy to Operations and Linking Managerial Accountability Agreements to the organization’s board-approved strategic outcomes — at both the system and silo-levels;

- Focusing on Quality & Safety – which in the end, will also lead to cost savings through greater efficiencies (rule-of-thumb: when you focus on quality, you save 30% of costs) that can be learned from Health Quality Ontario;

- Designing The Patient Experience – using Experience-Based Design Storyboards to design real change within silos and across the continuum, rather than just focusing on the very shallow dive called, “patient engagement”;

- Linking To Delivery System Partners – by working collaboratively with Health Link partners and with fellow HSPs across the LHIN to implement the IHSP (Integrated Health Service Plan) in their community — in addition to their own Balanced Scorecard; and,

- Aligning Structure/ Culture/ Skills to the strategic outcomes of the organization, and the local LHIN and Health Link network.

At the Local (LHIN) and Provincial System Levels (MOHLTC), there are numerous combinations of leveraged actions that are required for our healthcare service system to succeed. These include:

- Articulate High-Level Provincial Transformation Strategy – providing high-level strategic direction and liberating LHINs, Health Links and HSPs to transform themselves at the local level in each community. Dr. Eric Hoskins has started this high-level strategic direction with his Empire Club “Patients First” Speech.

- Redesign Economic Incentives — and align them to reward patient satisfaction scores, and quality outcomes, rather than funding provider activities and volumes. Hoskins has said he would start by introducing “bundled payments” that will shift from paying for provider activities, to patient outcomes/satisfaction.

- Provincial Leadership Alignment — means that the Minister, Deputy Minister, MOHLTC public servants, LHIN Board/Staff, HSP Boards and Staff are all operating from a “Shared Vision” for our provincial health system to provide high-quality, timely care at the organizational and service delivery level.

- Devolve Resource Allocation Authority To LHINs — as set out in the LHIN Legislation ten years ago, but never acted on by the government because it meant down-sizing MOHLTC. While operational health leaders want local empowerment, they also want the LHINs to transform, before any devolution takes place.

- Implementing each of the existing Health Link Business Plans — which means local partners need a scorecard for their Health Link, as well as a clear plan for who is accountable for the outcomes promised in their Business Plan. It also means that the Governance Boards of HSPs in the Health Link Partnership need to practice Collaborative Governance – and to hold their respective CEO’s “feet to the fire” on system outcomes, as well as for their usual silo-outcomes.

- Implementing each LHINs Integrated Health Service Plan (IHSP) – instead of making up yet another “new plan” for 2020, use the old plan to decide what “leveraged actions” need to be taken to implement the existing plan by 2016-18 — updated to include the Minister’s Patients First Action Plan & Mandate Letter issues and themes.

- Put The Focus On Quality And Safety – which is the role of Health Quality Ontario and its leader, Dr. Joshua Tepper. Quality improvements can often save 30% of costs.

- Encouraging The Development Of Vertically-Integrated Delivery Systems – like the Mount Sinai Health System composed of Circle-Of-Care/Bridgepoint/Sinai; and, like St. Joseph’s Health System a vertically integrated service delivery system of services in Hamilton; as well as a number of rural and northern vertically integrated delivery systems/health hubs that are emerging as bottom-up community collaborations.

- Designing a “system” for Home & Community Support Services/And For Chronic Disease Management – including testing, homecare, self-care support and education. Such a system needs to be patient-driven, rather than interest group & provider-driven.

- Expanding the role of Case Management to improve coordination & communication among the organizational silos, and healthcare providers (54% of Ontarians are not confident that patient care is properly coordinated: Change Foundation/ Pollara). Is case management the individual citizen’s best friend, or, are they just an invaluable tool for hospitals to be “in control” of clearing their beds?

- Implementing A Universal Palliative Care Program – with funds reallocated from acute care services, where too many people go to die in $1,000 per day high-tech, specialized environments, because of a lack of community-based palliative care programs — which 70% of Ontarians would prefer — at a fraction of the cost.

- Increasing Mental Health Spending from the current 5% of total health sector spending, to the 9% recommended by the National Mental Health Commission. Mayor John Tory says he intends to utilize his political capital with Premier Kathleen Wynne to get adequate funding for mental health. In Toronto, there are 8,900 people on the supportive housing wait list. An investment of $30 million a year in rent supplements, and housing allowances, would enable us to house and support just over 4500 homeless people living with mental illness; and,

- Implementing an e-Health strategy with the Consolidated E-Health Fund (set aside by Queen’s Park) to provide all Health Links with common IT solutions.

The “mental blinder” that has historically impaired our health system leaders is the “structural-quick-fix”. But deep meaningful change will only occur in complex human systems when the right combination of changes occur at the HSP/Health Link/LHIN and provincial levels.

Structure” is like the DNA of an organization, or system. Whatever you design into it, produces the outcomes. So we need to shift our thinking about the design of the systems, structures and processes that would integrate a health and support services system at the community, or Health Link level. “Who should the boss be” ought to flow from the answer: who can manage a system of services?

To succeed, fundamental, integrated, aligned, transformational change is required.