We are told that the Ontario healthcare delivery system is on the precipice of a “fundamental transformation”. Is that a “good”, or “bad” thing?

Our Health Minister, the Hon. Eric Hoskins, and his Deputy, Dr. Bob Bell, are very up-beat in their presentations about the future direction of our emerging healthcare services delivery system. They are also very clear about their intentions: they would like to be seen to be doing something they say is: “patient-centred“, “integrated“, “more efficient“, “high-quality“, “transparent” and, “accountable“. They want people to get the “right care, at the right time, by the right provider“.

So that certainly doesn’t sound terrible.  Indeed, many of us are quite keen to see such a transformation of our healthcare delivery system. If all those things actually happened, as you can imagine, things would really have to change in our healthcare delivery system. The status quo would simply not survive. Innovation and learning would flourish — because the system would be pushed to change and adapt.

But change and innovation are not something that bureaucratic systems are very good at. It is certainly not something governments usually want because, real change can mean political instability. That’s why governments tend to invest their efforts and talents in managing the “optics” of issues. Most Ministers and Deputies are under pressure– from the Premier’s Office and Finance — to “keep a lid on it”.

Indeed, my first-hand observation about the “Institution of Government” — under all three political parties — is that government (both political and bureaucratic) — is actually there to maintain as much of the status quo as possible. That’s their mission as government: maintain the “status quo”.

While some may think I’m being way too cynical; from my perspective, I’m simply telling the truth, as I have experienced it. As a recovering political scientist and Ministerial Advisor, I have observed up close that those who have “got” power and resources, have absolutely no intention of losing their resources and power to munchkins — who don’t have an existing power base; don’t really know how to influence government decisions; and, have never invested the time and resources required to achieve any personal or political linkages to the “inner circle” of influence at Queen’s Park. These are the people who are collectively working at shaping the design of our future healthcare services delivery system — and, in so doing, are creating the next generation of “winners” and “losers”.

People with power and resources are the ones who can invest significant time and effort engaging with political and bureaucratic officials. That’s why they made it into the “inner-circle”. They invest a great deal of effort working collaboratively with public servants, Minister’s staff/Premiers’ Office — and sometimes hiring professional government relations firms for help with strategy, communications, and political connections — as they set out influencing government thinking and public policy direction.

The “munchkin agencies” are just struggling to keep up with their patient workload, and their crushing reporting demands!

Of course, while the government-of-the-day — under all three political parties — has always sought to maintain and protect the status quo, they each have also proclaimed that they were being “patient-centred”, “patient-focused” and “more-efficient”. But is that really true? Are our governments really there to “protect the status quo”, or do they actually exist to “advance the cause of patients and taxpayers”? This is a Wicked Question, not a cynical question.

I think the answer will reveal that the status quo usually prevails; that change is almost always very incremental; and that there is little about our existing system that is either “patient-centred”, or “responsive to taxpayers”. I see numerous examples of this. Take palliative care, as an example.

In 1982, government polls for the Bill Davis government told us that 50 percent of the population preferred to die at home, surrounded by friends and family — with professional care and support services for families that did not want overly-medicalized, or high-tech hospital interventions for their loved ones. So, we started investing in home-based palliative care and hospitals.

Today — despite 40 years of growing taxpayer and health consumers support for expanded palliative care services in the community and at home — we still have only one in three patients with chronic illness who actually ever receive palliative care services. Patient-centred? Don’t think so! “More efficient”? Nobody seems to care.

Nevertheless, while two-thirds of us will not be able to gain access to the palliative care services we need and want, in a recent survey, 70 percent of hospitalized patients said they preferred “comfort measures” over high-tech, life-prolonging treatments. The question is: Why can’t taxpayers get what they want?

While there is no doubt that each successive government has claimed to be very supportive of comprehensive palliative care services, there always seems to be “no new money available at the present time”, or, only enough for incremental growth. The cold fact is that no government has been prepared to reallocate resources from acute care expenditures related to dying patients, to expanded community-based palliative care services. So the status quo survives — despite each of the very sincere statements from Health Minister Of-The-Day, that they “intend to expand the availability palliative care”; and despite the compelling business case for these less expensive services, there is never any significant growth.

In fact, it has only been on a few occasions when we have the required political and bureaucratic courage and alignment necessary to achieve “evidence-based decisions” — that disrupt the status quo, and produce real change. The rest of the time, public policy is too often about “power elites”, “inner-circles”, and “vested-interests” — who are all fully engaged in influencing and/or benefiting from decisions about public policy and strategic direction.

In the real world of healthcare politics, our Minister and Deputy Minister co-habit a shark tank where vested interests of all kinds seek their time and attention. So who our Ministers and Deputy spend their time with — will most certainly shape their thinking about “health system reform”.

So, what are the vested interest groups and inner-circle advisors clamoring about? Do any of their priorities reflect the patient/public interest — or are they all simply self-interested?

If there was alignment between Hoskins/Bell and Wynne on creating a Universal Palliative Care Program for the people of Ontario, it would certainly happen. But given all the various pressures they are under, who is pushing them for it? Do you think they have as many dialogues with Patients Canada, as they have with the Ontario Hospital Association and Ontario Medical Association? If they only listen to the power elites, to the vested interest groups, and to Queen’s Park’s inner-circle, it will not happen — because there is really nothing in it for any of them.

Even when the politicians clearly say they “want it to happen”, it does not happen.

Maybe if The Beer Store provided palliative care, they might finally convince the government to provide this “universal service” — as a succession of provincial Health Ministers from all three parties have talked about, but never provided.

FORWARD THIS BLOG TO COLLEAGUES WHO WOULD BE INTERESTED IN SEEING A UNIVERSAL PALLIATIVE CARE PROGRAM FOR ALL ONTARIANS.  

While our provincial government has been saying they are in the midst of “transforming” our health system, it is important to know that 70% of all large-scale transformations fail — so learning how the 30% succeeded is very important!

The Balanced Scorecard Collaborative says that the most common reason for failures in Balanced Scorecard transformation case histories is a “lack of commitment/alignment at the top” – that is, among the executive leadership of the organization. The challenge is, while our senior healthcare managers are well-paid, they are often very cynical about the so-called “health reform agenda” that has pre-occupied Queen’s Park and the LHINs for a decade.

In the healthcare sector, this increasing cynicism requires operational leaders to shift from reactive crisis management, to proactive strategy development and strategy implementation. It requires governance and managerial leadership to be “in service” to those who actually deliver healthcare services to the citizens/owners and taxpayer/patients.

At the operational level, how can a CEO create such a fundamental shift in the thinking and behavior of their top management? Professional leadership coaches and change management scholars would emphatically say that it must start with a commitment by the CEO to model change and learning themselves.

The strategic decision to become a “Learning Organization” means that CEOs need to learn how they can lead and manage such an organization. They need to learn more about how they can be developmental coaches and facilitators. They need to determine how they will personally model learning, growth and change.

That means “learning-how-to-learn.” It means understanding adult learning methodologies/learning styles, and developing their own capacity to be developmental facilitators and coaches to their senior team members and to their middle managers.

While external coaches and facilitators can “add value” to such a process, it is essential that the Balance Scorecard process be led by the CEO. Others can help, but unless the CEO leads it, the gains will only be incremental, the pace will be very slow, and the changes are not likely to be sustainable.

In the meantime, there can be hundreds, sometimes thousands of employees, awaiting strategic direction and leadership from the top. How will that direction come?

By investing at least two-days-per-month in strategy dialogues, a traditional Senior Management Team which is focused primarily on operations, can be transformed into a High-Performance Strategy Team that has the capacity to actually lead and manage the organization’s transformation journey. The challenge for senior managers is: how they will change their relationships with their direct reports? How do they liberate and guide people to achieve the results required?

Organizations that produce superior results with Balanced Scorecards are often those where the middle managers have transformed themselves from command and control in organizational silos, to a new emphasis on developmental facilitation for integrated, cross-functional high performance teams. This new skill for developmental facilitation is different from basic facilitation. In developmental facilitation we teach skills and empower the team to generate solutions.

Experience tells us that middle managers will not transform until and unless their bosses have authentically transformed – and are themselves modeling the thinking and behavior that middle managers are expected to exhibit for front-line workers.

This is a major challenge for CEOs: how to develop the capacity of their senior and middle managers to be highly strategic and capable of leading and managing others through a transformative learning experience in which the entire system is designed to be patient-centred.

From the CEO’s perspective, since their own success is dependent upon the success of each of their direct reports, they clearly have a major stake in seeing that each of their senior managers will be successful at achieving the outcomes for which they are accountable. After all, when the CEO’s direct reports are successful at achieving their outcomes, the CEO is successful. And, when the CEO is successful at achieving a balance of outcomes – everybody wins.

In a best practice Accountability Agreement process, each executive selects outcomes, themes and measures in the BSC that they helped develop – and then list what they will be accountable for achieving. They also list the supports that they require to be successful; and, what they believe should be the consequences of success and failure on themselves.

The key to this best practice design is achieving the right balance of empowerment and accountability. “The most common reason for BSC failure is lack of commitment/ alignment at the top – among the executive leadership of the organization.”

Barry Oshry, author of Seeing Systems: Unlocking the Mysteries of Organizational Life explores the organizational dynamics of complex, adaptive systems and the conditions of three “spaces” in organizations: the top space, the middle space and the bottom space.

A key leveraged action for successful balanced scorecarding requires the integration of middle managers into cross-functional teams. Their role needs to shift from day-to-day operations within a silo, to being developmental facilitators and coaches of cross-functional high-performance teams.

The condition of the middle space is “diffusion” according to Oshry. He calls them the “torn middles” – because they are constantly being pulled in numerous directions by the many needs of their subordinates in the bottom space, and by the demands of their bosses in the top space.

Middle managers, trapped in their silos, often feel isolated from one another. Hospital Culture Survey Results also tell us that they feel alienated, lonely and fearful of being blamed. To survive in such toxic work environments, middle managers and senior managers often engage in what Chris Argyris calls “defensive routines”.

In Overcoming Organizational Defenses, Argyris explores defensive behaviors and organizational patterns. He explains that these routines are designed to “cover up” or by-pass inefficiencies and ineffectiveness in our organizations. He identifies defensive routines as “errors of design” which he says are at the heart of organizational effectiveness. He says that if organizations and their people are to thrive, defensive routines must be surfaced and reduced.

Many CEO’s understand what it is like to live in a “threatening” environment, rather than a “innovation” environment. Threats come from above: from Queen’s Park, from the LHIN, from their Board. In such environments, people learn how to “fake compliance” and “avoid truth”.

In such environments, “politics” and “gaming” begin to dominate the “inner-circles” of power, creating “winners” and “losers” — none of which has any impact on the core business of the organization, and yet, preoccupies the energy and attention of leaders at all levels.

The CEO also needs to bring together their senior team with middle managers to engage in strategy development, organizational alignment and strategy implementation dialogues on an on-going basis. In organizations that achieve accelerated change, the CEO and Strategy Team often spend at least one-day-per-month with middle managers on strategy dialogues — in addition to their own 2-days-per-month as a Strategy Team.

Best practices suggest that these dialogues should be designed as “learning-by-doing” workshops — on a “just-in-time” basis — at which the CEO and the Strategy Team members tap into the collective intelligence of the middle managers — as they determine the organization’s evolving strategy, and select the indicators that will measure their progress.

Perhaps the CEO’s greatest vulnerability today is the growing alienation of front-line healthcare providers. While the CEO must survive in an increasingly threatening external environment, internally, direct service providers are less and less prepared to experience “yet another management fad” that past experience tells them will fail.

The best CEOs are those whose primary strategic goal is to provide the type of support that front-line care providers need to ensure high-quality, safe services which patients and their families rank highly. But there might not be a lot of those.

I was surprised at the results of the Health Leaders’ Survey @ TedBall.com that ranked “patient-centred care” and “improving the patient experience” as 13th out of 17 priorities. In contrast, I am certain these would be the number one priority of front-line care providers.

That is why CEOs need to lead a bottom-up transformation in which middle managers provide support and coaching to front-line care providers who can redesign the core and support systems structures and processes to be patient-centred and family-focused.

In the post-SARS/Ebola-era, our healthcare providers also face a wide-range of deeply complex emotions related to their own personal and family safety. If they are to succeed, CEOs and their management teams must understand that their organization is profoundly human. They need to understand their organizations not as a series of fragmented organizational component parts that make up the whole, but as a network of human relationships. In the healthcare system today, many of these relationships require healing to take place.

Organizational scientist, Barry Oshry, describes the condition of the front-line worker as “vulnerable”. From the healthcare provider’s perspective, various forces in the organization and in government provide constant threats to their security and quality-of-life. Oshry says that the “blind reflex” to this condition is to coalesce or combine together.

Oshry says that people in the bottom space often feel “oppressed, ignored, unrecognized and mistreated”. They experience negative conditions and they hold management and governance primarily accountable for many of the problems that they experience. They experience “blaming down” by management and governance, and participate in “blaming up”.

People in the so-called “bottom space” draw together to form a more powerful “we”. However, all too often people in the bottom space do not hold themselves personally accountable for how their own behavior and attitudes may be contributing to the deterioration of their quality-of-work life.

In a transformed organization, front-line service providers take responsibility for their condition and the condition of the organization. They pull together as a positive force for change and improvement. They are empowered to control and coordinate their own work; and, they participate in the development and implementation of the organization’s strategy through the BSC cascading process.

The truth is that the answers to healthcare’s most complex problems can be found in the hearts and minds of the people who deliver services to patients and their families.

Liberating the “bottoms” and integrating the “middles” is how Learning Organizations successfully transform to achieve their outcomes.

Below is a chart that outlines the conditions, reactions and solutions to the challenges faced by people in the Top, Middle and Bottom Spaces in your organization.

“Accountability” is a word that is loaded with meanings that strike fear in the heart and soul of our health care system. That’s because it has come to mean: “Who is to blame?” And, “how should they be punished?”

So why are we surprised when the outcome of this approach is blame-avoidance, blame-shifting, cover-ups, in-fighting, defensive behaviors, anti-learning dynamics and the cause of even further dysfunction in a health system that has already been diagnosed as being among “the least healthy work environments in the country”.

When things are not going well, the first question seems to be: who is to blame?

We already know the “unintended consequences” of these types of systems, structures and processes. The whole focus is on blame and blame-avoidance – rather than on accountability for achieving measurable outcomes that may be perfectly reasonable and very desirable.

Accountability is very different than blaming – which means: “to find fault with, to censure, revile, reproach.” Blaming is an emotional process that seeks to discredit the blamed.

But when people work in an atmosphere of blame, they naturally engage in defensive routines – covering up their errors, and hiding the real issues that need to be dealt with – if the performance of our health system is to actually improve over the next few years.

When our energies are focused on finger-pointing, scapegoating, and denying responsibility, the effectiveness of our entire health care system – and the organizations and people who work in it – suffers.

Marilyn Paul, a scholar in the field of organizational accountability says that a blaming culture causes organizations to become dysfunctional because “where there is blame, open minds close, inquiry tends to cease, and the desire to understand the whole problem diminishes.”

Within the healthcare delivery system, our existing blaming culture generates fear and destroys trust. When we blame, we attempt to prove that others must have had bad intentions, or lack ability. The qualities of blame are “judgment, anger, fear, punishment and self-righteousness”, according to Paul.

In contrast, accountability emphasizes keeping agreements and performing tasks in a respectful manner. It is all about learning, truth and continuous improvement. Is that not what we really need in our health care system today? Are we now ready to learn from our past mistakes? Are we really prepared to change?

Experts like Marilyn Paul advise us that “a focus on accountability recognizes that everyone may make mistakes or fall short of commitments. Becoming aware of our own errors or shortfalls, and viewing them as opportunities for learning and growth, enables us to be more successful in the future.”

Errors, shortfalls and mistakes can of course take place at any point in the system: how provincial public servants designed a particular policy or program; how operational managers implemented a program; how teams of health professionals were organized within systems, structures and processes to deliver the services; or, whether or not service provider organizations are aligned at the service delivery level.

Paul says that “accountability creates conditions for ongoing constructive conversations in which our awareness of current reality is sharpened, and in which we work to seek root causes, understand the system better, and identify new actions.” She lists the true qualities of accountability as: “respect, trust, inquiry, moderation, curiosity and mutuality.”

In my practice as an Organizational Transformation Coach, here are the SIX PRINCIPLES OF ACCOUNTABILITY that we use for our best practice toolkit/accountability process:

1. You can’t be accountable for anything over which you have no control.

An Accountability Agreement must be a “fair business bargain”. It is a personal promise to achieve measurable results. But a person can’t keep their promise if circumstances beyond their control change.

That makes sense, doesn’t it? If a CEO is being held accountable for improving staff/physician moral, and their provincial government is engaged in highly emotional disputes with unions and physician organizations, how can the CEO be held accountable for the results that such an atmosphere will produce?

However, the CEO should certainly be accountable for demonstrating improved outcomes with their own organization’s unions, staff and physicians that they are able to achieve from the processes that they put in place to achieve their measurable results locally.

If a manager is being held accountable for an outcome that can only be achieved if a certain barrier is removed – like the lack of a skills development program, or the lack of equipment or specialized technology – and nobody removes the barrier, why should they be expected to be accountable?

How can they possibly deliver on their promise if they are not given the support they require to succeed? Best practice Accountability Agreements list the “supports required” to achieve the outcomes for which a person is willingly accountable. If they don’t get the support they need, they can’t be held accountable. It’s that simple.

That’s where this concept of “mutual accountabilities” comes into play.

At the operating level, a manager with an Accountability Agreement must be able to hold his or her boss accountable for providing the “supports” they mutually agree are required to successfully achieve their outcomes.

An Accountability Agreement is therefore a tool for people to mobilize the support they need to make them successful. It’s a manager’s best friend, not their worst enemy! Between the provincial governments and the agencies and institutions they fund, there also needs to be an explicit and “fair business bargain”.

In Ontario, it starts with a “worst practice” Accountability Agreement between the MOHLTC, and each of the 14 LHINs. It is “worst practice” because it holds the LHINs accountable for outcomes over which they have no control. However, many LHINs then hold HSPs accountable for outcomes over which they also have no control either. This begins the “blame-avoidance shuffle” — a dance that every health executive learns in order to survive.

So we either keep up the advanced “gaming skills” of our senior healthcare executives, or we change how the game is played — by redefining “accountability“.

“Accountability” holds a prominent place in the Health Minister’s Mandate Letter. If the Wynne/Hoskins/Bell Team redefine “accountability” for the health sector, we’ll end the “blame-game” – and, we will shift our cultures towards the way true Learning Organizations think and behave. The second key principle for best practice approaches to accountability:

2. Accountability for outcomes means that activities/efforts and processes are not enough.

Think of the mindset shift required here. Our health care system is characterized by a complex set of rigid bureaucratic processes designed in separate silos holding different assumptions.

The truth is that our fragmented health care system is the product of isolated silos within our Health Ministry. The real focus of the existing system is on the rules, regulations and bureaucratic processes – not on achieving outcomes. That is what bureaucratic organization do: they focus on process, not on outcomes.

Best practices would suggest that “holding people accountable” should only be done in the context of clearly defined outcomes or results. These outcomes must be understood and adjusted regularly to reflect new realities as they emerge in a constantly changing and chaotic environment.

Not only must everyone understand what is expected of them and why, they must also have the necessary resources, conditions and skills to achieve the outcomes for which they are being held accountable. Is that not a reasonable and “fair business bargain?”

In a best practice accountability process, no one is given points for “following the process”. The only thing that counts is getting the results — bottom-line measurable results.

If the process design does not produce the results required, we need to change the process. Better yet, we need to design processes that are focused on achieving the results that are required – right from the start!

The third principle:

3. Accountability for results requires real empowerment — as well as room for personal discretion and judgment.

This principle would require another paradigm shift for the health sector: the principle is about the reality of “balancing empowerment and accountability”. Not the empty rhetoric that has contributed to the growing cynicism of our front-line health care providers, but real empowerment.

While the health care sector is clearly part of the knowledge economy, many continue to live with industrial-age assumptions about the “need for command and control”.

The assumption in other modern knowledge-based industries that rely on skilled professionals is that the solutions to their most complex and perplexing problems are within the hearts and minds of the people who work in the system.

Smart organizations that are thriving in the knowledge economy invest between 1% and 5% of their payroll budgets on developing the skills of their people to work in high performance teams solving organizational problems and dilemmas by tapping into the collective intelligence of the people in their system.

The fourth best practice principle on accountability design is:

4. Accountability must be dynamic: outcomes and targets change as circumstances change.

While most people would agree that this seems perfectly reasonable, the existing rigid bureaucratic culture of health care – from the Premiers on down to the front-line nurse – is about inflexibility.

In the existing system, we are given every incentive to focus on the process, rather than the outcomes. Indeed, Queen’s Park and most LHIN have created a very Process/Project Management Culture in the health sector; rather than an Innovation/Results-Focused Culture. The Wynne/Hoskins/Bell Team can change this by redefining accountability.

Best practice Accountability Agreements are flexible. When circumstances change, accountabilities change. The focus is on what needs to be done to ensure that a person is successful.

The fifth key principle for accountability system design is:

5. Accountability and stewardship for the organization belongs to everyone.

Management guru Tom Peters has said that health care systems, structures and processes are the most complex organizational designs ever conceived by humans. But most of our core design assumptions are rooted in the old industrial model.

Systems thinking, chaos theory and quantum physics\ have all contributed greatly to our emerging understanding of the health care sector as a complex adaptive system. Each part of the system impacts on the performance of the other parts of the system. We know that.

When there is insufficient home care services within a community, elderly people get trapped in acute care beds – and then we get back-ups in our emergency departments.

When that happens, the resulting headlines seem to compel many of our politicians to invest even more money in hospital emergency services, rather than on the root cause of the key system design problem: an under-investment in community care.

Despite the fact that all parts of the health care system are “inter-connected”, we’ve organized ourselves into rigid silos and departments which we attempt to “manage” through traditional bureaucrat control mechanisms – where we solve issues within each silo – often without any apparent concern about its impact on the other parts of the system.

So when government leaps in to “fix” Health Links, or “fix the CCACs and home care”, if they have not thought through the “unintended consequences” of their actions, many people could pay a very high cost for poor public policy.

Best practice accountability processes include integrating the Accountability Agreements cross-functionally – across the organization, and across the delivery system. That way people truly understand how their actions impact on others; and why we need to ensure that we are working synergistically together within our organizations, and with all parts of the system.

At the front-line of the delivery system, care providers are very good at integrating across the delivery system when they are focused on serving the best interests of the family and patient. It’s higher up that needs a more strategic approach.

Having line-managers from each of the Health Link partners integrating their Accountability Agreements cross-functionally can lead to the creation of the collaborative work plan to make the agreed-upon system changes and process redesigns happen.

The sixth and final principle for designing accountability systems is:

6. Accountability is meaningless without fair and appropriate consequences.

For all the fear and anxiety that our existing hierarchical, command-and-control accountability processes produce in people, the truth is that there really isn’t much of a focus on the actuall consequences – just the “threat” that maybe “something bad” could happen.

In their book, Accountability: Getting a Grip on Results authors Klatt, Murphy and Irvine point out that “Accountability is not about assigning after-the-fact blame. Rather, it’s about providing before-the-fact incentives for success — and room for decision-making, risk-taking and growth.”

They state that “consequences may be positive or, negative, but either way they need to be fair. They are not punishing or under-handed. Finding out what went wrong in a situation is essential for preventing the recurrence of problems.”

As the Wynne/Hoskins/Bell Team approach the 6-month mark of their four-year mandate to transform our healthcare delivery system, they will very shortly be making leveraged changes that will begin to shift the DNA of the system. Their commitment to changing the status quo will require them to make deep and meaningful changes to the existing system.

Among the most leveraged shifts that they could make is to: redefine accountability!

NEXT WEEK MY BLOG IS: “THE CEO-LED/BOTTOM-UP HEALTHCARE TRANSFORMATION”.

As the political debate about the meaning of “accountability” heats up, what healthcare leaders know is that in their sector, accountability is really about: “who is to blame?” From the Minister of Health, to the triage nurse, the entire system is driven by a culture and a set of ingrained behaviors of “blame” and “blame-avoidance”.

In systems and organizations that are blame-oriented, “blame-avoidance”, “politics” and “budget gaming” can consume up to 30% of the productive capacity of managers.

The truth is that these human dynamics in our healthcare system have created circumstances that are unfair and unsafe for everyone. In such environments, change, innovation and learning are very difficult to achieve. Retrenchment and cover-up would be the “normal” human response to these conditions.

But, is it possible for an organization to escape this pervasive healthcare culture?

The evidence says “yes”: when an organization strives to become a learning organization, and undertakes a learning journey in which they tap into their collective intelligence to transform themselves.

While leadership is key, change management scholars also tell us that a necessary condition for organizational and whole system transformation is having a common language and common framework for talking about, planning for, and implementing change.

In the healthcare sector, each of the stakeholders hold very different “mental models” of reality. Even basic assumptions on the meaning of the words that are used do not mean the same things to everyone.

A best practice Organizational Balanced Scorecard, LHIN-Level Scorecard, or Health Link Scorecard provides provincial governments, governing Boards, Health Link Partners and CEOs with a common accountability framework for coordinated strategy development and implementation. This best practice framework provides us with the four balanced perspectives of: Finance, Customer, Value-Added Processes, and Learning & Growth Enablers (see diagram at end of blog).

By adapting a best practice version of balanced scorecarding, and redefining accountability, healthcare organizations within a Health Link region would have a common methodology for managing change, improving collaboration and executing strategies that are in the public (i.e. the owners’) interest.

In our system, Governance Boards of HSPs have Performance Agreements with the LHIN. These set out high-level outcomes that need to be achieved – in return for the public funding that they receive. But the Board’s purpose is to represent the best interests of the “owners”; and, to hold management accountable for achieving outcomes that will be different in every organization – because everyone’s circumstances are different.

But, in addition to their silo-outcomes, Health Service Providers also have “system outcomes” for which they are accountable. These are contained in the Health Link Business Plan, and in their Performance Agreement with the LHIN which will incorporate each LHIN’s Integrated Health Service Plan (IHSP).

But what model will our macro healthcare system design be with the Wynne/Hoskins/Bell Team? A patient/system focus, or silo and hospital-centric focus? Will we intentionally shift from an acute care focused system to one in which primary care and the patient is in the centre? Will we end up with centralized bureaucratic control, or, with a customer-driven and community-focused model?

Best practice system and organizational design tells us that “every system is perfectly designed to produce the outcomes it produces.” We have designed a hospital-centric system for the benefit a many stakeholders — none of whom are patients.

If we want different results, we need to redesign the system. The uncertainty about “what direction” we are going in as the system is redesigned produces a turbulent, chaotic and unsafe environment for everyone.

Provincial governments have a key role in how they design the macro systems, structures and processes in our healthcare delivery system. In Reinventing Government, Gaebler and Osborne say that governments should empower citizens — by pushing control out of the bureaucracy, and into the community.

That has not been the direction of our provincial government — which has now bulked up from 5 to 16 ADMs to enable the MOHLTC to micro-manage such things as “approving local business plans” of local Health Links — which are also approved by the LHIN.

The problem with our current micro-management design: there are no cases where centralized controls and rigid bureaucratic rules have produced local innovation and customer satisfaction. Hello? Should we not be dismantling this top-heavy bureaucracy?

Gaebler and Osborne advise governments to “measure the performance of their agencies, focusing not on inputs, but on outcomes. They should be driven by their goals – their missions – not by rules and regulations. They should decentralize authority, and embrace participatory management.”

If the MOHLTC and some LHIN officials who may have adopted a “command and control” culture were to shift their thinking and behavior to facilitation and collaboration, the system would stabilize, and then focus on the most appropriate changes that will be required to transform and improve the healthcare delivery system.

Our new Premier, Minister and Deputy need to ask themselves: what are we doing differently than the former Premier/Minister/Deputy? If they are following the same assumptions, they will produce the same/old, same/old results.

Governments and policy wonks love branding and re-branding exercises, but calling a program “2.0” does not, by itself, produce different results.

In addition to poorly designed policies from Queen’s Park, Boards of healthcare organizations are also increasingly being exposed as one of the many factors that are contributing to what the public increasingly believe is “poor management” of our healthcare system. That does not necessarily mean that our governors are of poor quality. Indeed, we don’t have “bad”, or “incompetent” Boards, we mostly have governance processes that do not reflect best practices.

It is the design of the “governance system” that needs fixing – not the governors or trustees. It is the existing lack of clarity that creates uncertainty and confusion, not the competence of those who are serving their communities through their governance role.

In a true Learning Organization, one of the fundamental principles of accountability is: “you cannot be accountable for anything over which you have no control.”

If CEOs are to be accountable for achieving the results that their Board wants for their community, then they need to be backed up by managerial systems, structures and processes that are designed to ensure that they are successful. They also need to be supported by provincial policies and incentives that will enable them to succeed.

If governance boards exist to represent the interests of the “owners” of their organization, they will note that the “owners” they represent, are also the “owners” of each of the other healthcare provider organizations in their community. In other words, the “owners” hold a “system approach”. They own the whole system — and they need it to function collaboratively. So, to represent their interest, is to take a “system perspective” — while being in stewardship to their own individual organization.

That’s what a best practice BSC process provides to CEOs, their Boards and government officials: a methodology for successfully managing complex strategic change. Governing Boards can play a key role in shifting the system — if they are prepared to model change themselves.

In his introduction to Board Work: Governing Healthcare Organizations, Stephen Shortell points out that “incremental improvement in Board structure, composition, skills or processes will not do the job. What is needed is a total rethinking of the governance concept and the implications that this holds for healthcare governance work.”

In the healthcare sector, combining the Collaborative and Generative Governance Models with Balanced Scorecarding and best practice Accountability Agreements — would allow such a “total rethink” to happen. However, some very practical advice: if an organization is to have a fair chance of succeeding, Boards must give their CEOs the time and space to develop their proposed Organizational Balanced Scorecard with their senior and middle managers – before locking into what the Carver and Pointer/Orlikoff Models call the Board’s “ends policies”.

While MOHLTC and some LHINs may represent a “threatening force”, rather than an “enabler”, helper or supporter; governance boards can choose to be coaches/mentors to their CEOs and intentionally create an environment in which innovation can flourish — as a direct counter-veiling force to the external threats.

Given that poor alignment between the Board and management often results in organizational dysfunctionality, it is very much in the interests of the Board — and the CEO — to commit to creating both an Organizational BSC, and a Balanced Governance Scorecard that outlines how the Board will “add value” to the achievement of the organization’s strategic outcomes.

Given the recent Minister Of Health Mandate Letter, it is clear that the Wynne/Hoskins/Bell Team does not intend to maintain the status quo. Change is going to happen at many levels of healthcare services delivery system. Since the system is fully inter-connected, policy-makers must look for the “unintended consequences” of their policy shifts.

Boards and CEOs also need to be prepared to invest the time and effort required to design what may be a very different relationship with each other to manage through the major changes ahead. They need to determine just how they will change their relationship and governing practices as we go through system and organizational transformation.

Accelerated and sustainable change is possible in organizations where the Board and CEO are engaged in a partnership to achieve the outcomes (“ends”) set by the Board. A partnership is a relationship of equality. However, in this model it is clearly understood that the Board is the “managing partner”. In effect, it can be thought of as a relationship in which the Board holds 51%, and the CEO holds 49%.

While it is clear who the boss is in this model, and it is understood that the Board has a duty to hold the CEO “accountable for outcomes”, the best results are achieved when Boards and their CEOs behave as though they have a 50/50 responsibility to achieve the outcomes that they set out in their Organizational BSC.

In addition to their Organizational Balanced Scorecard outcomes, CEOs also need to be held accountable for their “system” outcomes contained in their Health Link Agreement, and in their Performance Agreement with the LHIN.

Where Boards have also embraced concepts like Peter Block’s “stewardship” and Ron Heifetz’s “adaptive leadership” as core principles for governance, the focus of the Board is on: how they can contribute to ensuring that their CEO is successful.

After all, when the CEO is successful… everybody is a winner!

Today, we have a remarkably compliant system that provides high rewards for a sub-group of stakeholders and produces terrible results for patients and taxpayers. How can this be fixed?

In Carverguide: The CEO’s Role Under Policy Governance, John Carver points out that “an effective board relationship with the CEO is one that recognizes that job products of the Board and executive are separate.” He says: “effectiveness calls for two strong, totally different responsibilities. Either party trying to do the other’s job is interfering with effective operation. It is not the Board’s job to save the CEO from the responsibilities of their job, nor is it the CEO’s job to save the Board from their responsibilities of governance.”

While Organizational Balanced Scorecards and Balanced Governance Scorecards provide managers and Boards with frameworks and methodologies for achieving greater clarity on their distinctive roles, the real key to success is a commodity that is often in short supply in the healthcare system: trust.

In Trustworthy Government, David Carnevale describes trust as “an expression of faith and confidence that a person or an institution will be fair, reliable, ethical, competent, and non threatening”. All too often, however, work organizations destroy their employees’ trust. This is certainly the case in our healthcare system today.

If the Board does not trust the CEO, none of this can work. The flip side of this same issue is: whether or not the CEO can actually trust their Board. As Carver says, “CEOs have long been accustomed to Boards checking performance against unstated and unclear criteria. They are used to Boards that sometimes undermine the CEO’s authority by intruding into sub-CEO levels of the organization and even by directly countering the CEO’s instructions. CEOs are also accustomed to Boards failing to protect them and their staff from renegade, intrusive individual Board members.”

Below is a best practice Balanced Scorecard setting out the top two quadrants for the Customer and Financial “strategic outcomes”. The bottom two quadrants are the “enablers” of Learning and Growth and Value-Added Processes. The fuel tank is, of course the Learning & Growth quadrant.

NEXT WEEK MY BLOG WILL BE ON “REDEFINING ACCOUNTABILITY IN THE HEALTHCARE SECTOR IS AN URGENT PRIORITY FOR THE WYNNE/HOSKINS/BELL TEAM”.

I want to acknowledge — and celebrate — the 150 people who have gathered here tonight at the first annual fundraiser in the memory of two extraordinary young people — Geoff and Sophie — as well as other children and families who have experienced mental health crisis.

Tonight is different.

By your attendance here tonight, at this first annual dinner; by your attendance at next year’s fund-raiser; and by attending these memorials in the years to come; “suicide prevention” and “children’s mental health” will finally get on the radar screens of politicians, policy-makers and healthcare administrators.

Your presence here says to them, and to yourselves that:

• You want action on the mental health file.
• You want significantly increased spending on mental health research, and on mental health treatment knowledge.
• You want more collaboration across the system — children’s mental health; adult mental health; community mental health support services, acute care services, addictions, and suicide prevention programs — so that we finally get some synergy from these existing fragmented investments.
• And, you want more appropriate financial investments in mental health — I’m going to suggest at least a 6% increase in spending each year, over the next four years to turn this system around.

My own introduction to the mental health file happened in the early ’80’s, while I was a policy-wonk working for the Bill Davis Government.

I had done Energy Policy, and helped craft Ontario’s Industrial Strategy when — and, as happens from time-to-time — my Minister was shuffled to the healthcare portfolio — and I’m his Chief-of-Staff and Senior Policy Advisor, who doesn’t know anything about healthcare issues.

When cabinet shuffles take place — it happens the moment the Minister is sworn into office. So I scrambled over to the Ministry of Health… up to the 10th Floor of the Hepburn Block at Queen’s Park… where the elevators open up onto a beautiful glass and impressive wood paneled reception area.

When I arrived, the person at the reception desk — who knew I was on my way over to see our new offices — said to me: “Too bad they had the cabinet shuffle during the full moon. This is when all the crazy people show up.”

I said: “Who shows up?” She said: “Crazy people.”

You mean “customers”, I said. I told her: “if any of our ‘customers’ show up, I’d really like to talk to them”

Within an hour a young man, maybe 29-30 years old appeared at the Minister’s Office and was brought immediately in to see me. “What’s on your mind?”, I asked him.

Turns out, he is a dissatisfied customer from our Queen’s Street Mental Health facility. He said he didn’t think we knew what we are doing in the healthcare system, and that the way we behaved was actually dangerous and harmful.

He said he had trained as a concert pianist… had had a nervous breakdown… and had been treated with electric-convulsive shock therapy against this will… and now he does not remember how to play the piano.

He told me that his life no longer had a purpose. His reason for “being” was to be a concert pianist — and now he doesn’t know what his purpose is for being here.

That 15-minute meeting was my introduction to a file called “Mental Health Misadventures“.

Thoughts of that young man have haunted me for years. We no longer make mistakes like that with electric-convulsive shock therapy. We now know when, and how, to use this technique.

However…we now make a new set of horrible mistakes with psychotherapy drugs… and we continue to learn from to horrible unintended consequences of some of these drugs.

Mistakes? Lack of treatment knowledge about what to do? Inadequate, underfunded services? Lack of coordination and integration to meet the needs of people and families who need help, support and cures? These are the harsh real-world realities of our mental healthcare system today.

So we owe it to Geoff, Sophie and to this one-time concert pianist — and to the many other children and families affected by suicide — that we “fix” our desperately underfunded and uncoordinated mental system — in order to provide people who need help, with the type of supports they need.

So, what should we be investing in?

We already know that there are excellent school-based mental health programs that have reduced suicidal thoughts at some school boards.

We know that embedding mental health professionals in emergency departments — or in primary care settings — appear to successfully reduce suicidal behavior.

There is also excellent evidence that psychotherapies, such as cognitive behavior therapy, can effectively treat depression — which is a high-risk for suicide attempts.

We know that all parts of our mental health system — acute care, community care, suicide prevention programs, research, and mental health human resources — all need significantly more funding.

The fact is, we have learned more about the human brain in the past five years, than we knew in the previous 50 years. Indeed, today we have scientific experts who are beginning to talk boldly, and very optimistically, about a “cure” — for a variety of illnesses like depression, anxiety, and other mental health conditions.

Up until now, mental health advocates have been simply too timid to say publically that they intended to “fight for cures” for mental illnesses, for fear of creating false hopes among those affected.

But today, it is time to say it out loud — we have had enough advances over the past five years to say: “a cure for mental illness is a plausible dream.”

Research has identified in the human genome that certain genes are at risk for mental illness.

While there are still no diagnostic bio-markers — such as a blood or salvia test to diagnose mental illness — many believe such breakthroughs are in sight.

So, there is hope for a cure. But we all need to be in stewardship to this struggling system to fan these flickering flames of hope. That’s why we are here tonight. This isn’t an ordinary fund-raiser for a good cause.

This evening is the start of something new. This event is an emphatic statement — from a whole community that has gathered together here tonight to assert a deep commitment to children’s mental health — in memory of Sophie and Geoff, and the many others who have experienced mental illness.

Windsor can become the example of leading-edge mental health services — because that’s who you are!

I spent 18 months working night and day on the Essex County Health Care Reconfiguration Project back in the early ’90’s. I know Windsor. Windsor has always been a unique and deeply caring community. For years you have had the highest per-capita donor rate for charitable causes in Canada.  Even in recessions, Windsor always rallies to the cause. This is a wonderful caring community.

Despite significant and historical underfunding of your local healthcare delivery system, Windsor has also always demonstrated a flare for leadership and innovation in healthcare service delivery.

In the late ’70’s and early ’80’s, it was Windsor who led the way on the development of palliative care and hospice programs. You are the leaders in Canada, and Ontario.

You can also lead the way on mental health reform.

The money raised this evening is going towards a very unique innovator in the field of children’s mental health: Maryvale.

While Maryvale is 90 years old, having been founded by the Sisters of the Good Shepherd in 1929, today it is a leading example of a fully-integrated approach to children’s mental health services.

While it is a Children’s Mental Health Centre, for the past 14 years, Maryvale has been the site for 6 acute-care mental health beds allocated to Windsor Regional Hospital — and won the Ontario Hospital Association’s “Best Of The Best” innovation awards for a few years ago.

Maryvale’s culture and operating style is all about what our health and social service agencies need to learn: how to provide true partnerships in care. That’s what it takes to be the “best of the best”.

When you listen to the consumer complaints about our children’s and adult mental healthcare delivery system, they are often about “fragmented” and “uncoordinated” services.

“There is no system!” say frustrated families.

That’s why Maryvale strives to be integrated with other care partner services across the delivery system.

Maryvale’s partnerships include active, synergistic, collaborative working relationships with:

• The Greater Essex County District School Board — who provide two teachers for the students admitted to, and discharged from, these six crisis beds.
• The Windsor Regional Hospital, who provide the services of 6 Child Psychiatrists.
• The Hotel Dieu-Grace Hospital which through the Regional Children’s Centre is providing leadership as the “lead agency”, on fundamentally transforming mental health services in this region.
• And, Maryvale partners with their funder, the Local Health Integration Network.

I’m so happy Gary Switzer, the LHIN CEO and Dr. Tam Doey and Dawn Maziak, the mental health leads could be here this evening. These three people have a lot to do with the really exciting mental health strategies that are beginning to emerge from your LHIN.

Windsor has in fact already become somewhat of a “mental health Mecca“.

Since 2002, Windsor has gone from only 11 psychiatrists, to 37 today. With seed-funding and engagement, the mental health sector is now beginning to collaborate on exciting and innovative solutions to mental healthcare services for the people of this region.

One really exciting project that has just received LHIN funding is the development of a Suicide Assessment Tool with Alive Canada, with input and training from mental health workers across the region.

So there is real “hope” for the future.

The first hope I have is that: we are capable of learning.

We must.

There are 800,000 children in Canada who have at least one mental health issue — the most common of which are anxiety disorders, attention deficit/hyperactivity, conduct disorder, depression and substance abuse.

What is shocking — absolutely shocking — is that only 1 in 4 of these children will receive the mental healthcare they need.

We don’t have a viable “system” of services for children’s mental health. We don’t have good linkages across the mental health support services within communities. It is shameful.

Canada’s suicide rate is third highest in the industrialized world — with 8% of young people attempting suicide each year… and 15% admitting to it.

Suicide is now the second leading cause of death among young people 15-25 years of age.

While most young people pull through these agonizing and turbulent times, because we have a horribly inadequate treatment system, we end up with an extraordinary burden of mental illness in our society — because we fail our children.

Indeed, 20% us of will require mental health services at some point in our lives.

Twenty percent! Think about it. This is the single biggest illness burden we have in our society. But because we keep it “in-the-closet”; and because we continue to “cover-it-up”; we still won’t make adequate investments in our mental health care services — because it is simply not a recognized priority.

Yes, it has become fashionable now that several high-profile business, sports and entertainment stars have leaped “out-of-the-closet” and spoken-out on depression and mental illness. Community acceptance and support is certainly growing.

But it is still not yet a significant healthcare system priority. While it may not be a spending priority, mental health care, and the lack of it, costs taxpayers deeply — very deeply.

The cost of mental illness to the Canadian economy is $50 billion a year. Over 500,000 Canadians per week miss work for psychiatric reasons. The cumulative cost to the economy over the next 20 years is $2.5 trillion.

Policy-makers and public spending priority-setters need to take off their mental blinders and get a clearer picture of these realities. The fact is that the burden of mental health is more than 1.5 times all cancers — and more than seven times that of all infectious diseases.

Under Health Minister Larry Grossman, after hyper-ventilating mental health spending, we got mental health expenditures up to 11.3% of our total healthcare spending in Ontario. Today that has declined to just 5%, as other priorities grew more rapidly.

The National Mental Health Commission has called for a mental health budget target of 9% of total health spending.

So we need the province to contribute considerably more funds — at least 6% per year, for the next four years — would be reasonable catch-up target for re-deploying resources from investments with little to no return, to these proven mental health interventions.

While it would be wonderful if society was to react with compassion, love and support for those people and families who are struggling with mental health issues, the fact is that the straight business case for investment in mental healthcare is so compelling.

Recent studies tell us that the lack of community-based supports for the mentality ill is the top cause of much higher costs in our emergency departments, police forces and the provincial courts. Mental illness is now the highest cost-driver on all the other components of our healthcare delivery system.

Our National Mental Health Commission tells us that for every $1.00 we invest in community mental health supportive housing, we will save $2.17 in cost avoidance in hospitals, jails and courts. We get back more than double our investment!

Think about that.

Rather than understand the need to spend money, to save money; as a society, we have had simply failed to step-up and re-deploy resources within the system.

We have failed to do the right thing.

After more than 30-years of observation of all three political parties in power, and having carefully followed at least 12 different Ministers of Health over that period, there is a trend that emerges.

What we have had — from time to time — is a Mental Health Ministerial Santa Claus who appears, and for some reason, makes mental health their personal priority, and then we get traction until they are shuffled to another portfolio, and then again, years of neglect.

In my introduction, you heard about my old boss — Larry Grossman — and what he did in his brief tenure as Minster of Health to put the mental health sector up there with the other less common, but more acceptable illnesses — like cancer, diabetes and heart disease.

But Larry was not the only Minister who ever championed mental health. Murray Elston, Elinor Caplan, Frances Lankin and David Caplan each in turn became “Mental Health Santa Clauses”, during their tenure as Minister.

In my comments tonight, I want to say why there is still hope for the mental health file — and one of my main reasons for hope is our emerging political leadership.

I believe that the Hon Eric Hoskins could be the next “Ministerial Mental-Health Santa Claus” for the sector.

This is a values-based politician who, when he ran for the leadership of his party, decided that his pitch to the delegates at the convention would be more appealing with a promise that, if he became Premier, he would “fix” the mental health care system.

Wow! That is different.

Today, our recently-minted Minister of Health is backed-up by a very compassionate Premier — who deeply gets issues like stigma — and consistently responds to disadvantage groups like the mentally ill, the homeless and the poor.

The Premier has now put mental health among the top priorities for both the Minster of Health — to make significant improvement to adult mental health services; and for the Minister of Youth and Children — to proceed with a fundamental transformation of our children’s mental health care system.

We could very well be on the precipice of major breakthroughs in mental healthcare investments. But we need to hold their feet to the fire.

The question is: Why is mental health still such a low priority for our society — and therefore for government funding?

Historically, I think the answer is: cultural and systemic stigma and fear about mental illness.

However, the TV commercial that Aisha spoke about in my introduction called, “My Dad Got Sick Last Year“, generated extraordinary responses from people.

The truth is we live in a very compassionate society. Given the chance, people come forward and tear away the smoke-screen of stigma. But politicians have not shifted the funds to respond meaningfully.

That’s why we all have to come back here next year… and the year after that. It is our collective obligation to change this system. And we can change the system.

I’m going to close my comments this evening by showing a brief high-impact video that speaks to the issues of “hope”.

My mentor, Herbert Wong, always used to say “innovation takes place on the edges of systems — where the challenge of scarce resources, can only be overcome by thinking-outside-the-box.”

You can’t get “more on the edge” in this country than Newfoundland; and you can’t get “more on the edge” of Ontario, than then city of Windsor.

The video I’m going to show you is a wonderful message of hope from the Newfoundland CMHA, to the people of Windsor. You will hear a powerful message to all of us.

That message is: “We Can Change The System.”

It also has a power message to the family, friends and neighbors of Sophie and Geoff and all those who have lost a child because of mental illness, which is: “Everything, Is Going To Be All Right.”

Because we are going to fix it!

[Play Video: Newfoundland CMHA]

What do you think? Could community governance help save Medicare, or are they part of the problem?

The Premier’s mandate letter to the Hon. Eric Hoskins seemed to take pains to avoid acknowledging the existence of local Community Governance Boards in our healthcare services delivery system. Ignoring the traditional platitudes about “voluntary governance” and “citizen engagement”, she tells the Minister to partner with “administrators, healthcare providers and patients” in the development of our future system.

Is it just me, or should reference not have been made to our volunteer healthcare governance boards — who exist to represent the interests of the “owners”? Quite frankly, we have been seeing this coming for awhile. In 2007, I wrote a Backgrounder Paper for a Conference on Governance Renewal, entitled: “How Can Local Governance Survive?”

Back then, at the end of their first term, the McGuinty Government’s circle of advisors were beginning to openly question the value of independent community governance. When they first arrived in office, the Liberals had received a highly critical confidential report on hospital governance by forensic accountant Al Rosen.

Despite Mr. Rosen’s devastating critique about the lack of accountability in our system, the government of the day — under Health Minister George Smitherman’s leadership — decided to maintain a macro-system design that continued to retain independent local community governance — a key feature of the government’s devolved health system plan, as laid out in the legislation creating the Local Health Integration Networks.

Their original concept was to maintain “independent governance”, within an “interdependent service delivery system ” — where the Health Service Providers (HSPs) would be held accountable for agreed-upon outcomes in their Service Accountability Agreements, by their Local Health Integration Network, rather than Regional Health Management Authorities.

From an organizational and system design perspective, the paradox of independent HSPs operating within an interdependent system — with linked accountabilities; integrated management system scorecards; and, supported by Collaborative Governance processes and practices, can definitely work — if they are designed and aligned on both their system and silo outcomes.

But two problems had emerged by the end of the Liberal’s first term in office. Following Minister Smitherman’s departure, despite passing their legislation on devolution, in order to keep their jobs, the MOHLTC simply failed to devolve spending and allocation authority to the LHINs. Their self-preservation and self-interest was to maintain the old system — where Queen’s Park decides how/where to spend the money, and the centralized administration in Toronto gets staffed-up to play an ever-expanding role in the micro-management of each local healthcare services delivery system across the province.

So, instead of following the new law, and devolving authority to local communities, the MOHLTC grew from just 5 ADMs when the LHIN legislation was passed at Queen’s Park, to today’s 15 ADMs — and the many more micro-managers and template designers that have been hired over the past ten years to expand their “command” and “control” over the service delivery system out of their different silos at Queen’s Park.

While each LHIN continued to produce regular Integrated Health Services Plans (IHSPs) for their network of Health Service Providers (HSPs), they were never actually empowered to implement their community’s IHSP. Central planners at Queen’s Park also sought to micro-manage the delivery system at the local level — by creating worst practice command & control Accountability Agreements between Queen’s Park and each LHIN. This was done so that Queen’s Park could not be blamed when things go wrong.

But imposed Accountability Agreements in which people are “held accountable” for things over which they have no control, are called “worst practices”. Nevertheless, our LHIN Boards and their CEOs never objected to these worst practice accountability agreements when they were first imposed. Now this blame-avoidance way of thinking and behaving is ingrained in their DNA.

While LHINs are in law governed by Community Boards Of Governance, in practice, LHINs have not emerged as “the Minister’s eyes & ears on their local delivery system”, but rather, more like a line-authority to the Ministry — and as some say, “an extension of the Ministry” — but still with an independent and accountable Community Governance Board, that is also empowered in law to provide strategic direction to the LHIN, and to the HSPs that they fund.

All these complexities could be made to work together synergistically, if it weren’t for the political dynamics of the various interest groups.

However, as governance has gone under repeated attacks, not many people have come to the defense of Boards — including Boards. CEOs have also been largely silent — which is strange because they only have their Boards as a “buffer” between themselves and the bureaucracy. While there has been mostly silence in the midst of governance criticism, the Ontario Hospital Association has capitalized on the growing criticism — by opening up a new revenue-generating business called the “Governance Centre Of Excellence“.

They package and market one-day governance seminars targeted to individual board members on a large variety of fragmented governance topics, by numerous “governance experts”. These one-day/one-off workshops are designed for individual participants from many organizations, rather than for an intact Board that is undertaking an intentional in-depth governance renewal program.

But the bottom-line test is: has the quality and effectiveness of independent community governance improved in Ontario — or not — since the creation of the OHA’s “Governance Centre Of Excellence“? It would seem… not yet.

Here we are in 2014 — seven years since my original paper — and the voices of discontent about the quality and effectiveness of healthcare governance across the province have grown even louder, despite the thousands of governors who have sat through “how to” workshops at the Centre Of Excellence.

So, what is the future of healthcare governance now? Was the absence of any reference to healthcare governance in the Premier’s letter a “good”, or a “bad” thing? Am I being over-sensitive about the exclusion of community governance from the Minister’s Mandate Letter, or is community governance actually at risk?

While there is a tiny lobby for patient-centred governance reform and several advocates for generative governance, the loudest, best-connected lobby — with the most momentum — is the “Fewer is Better” group. They are convinced that the real problem in our health system isn’t the “poor quality” of our community governance boards — they think that there are: “just too many Boards”.

In the months ahead, these advocates will be pushing for lots of mergers in the munchkin community health and social services support sector to achieve their goal of “fewer boards” — under the assumption that merged organizations are cheaper and better. The advocates offer no evidence for their claim that “Fewer is Better“; and, they simply shrug-off the hard-evidence that hospital mergers in the 90’s did not ever result in “more efficient”, or “higher-quality” organizations; and, they ignore vital issues like the potential loss of hundreds of millions of dollars in volunteer-time.

There is also some support for Tim Hudak’s proposed Hospital Hub & Spoke Model — where the hospital’s governance membership expands to include the CCAC, the LHIN, and other service provider/spokes within a region. These hospital sector and Regional Health Authority advocates say that the community sector’s governance ought to be replaced with our better-managed and governed hospitals. While the acute care hub and spoke model advocates say “fewer is better” for Boards, they also say “bigger is better” for expanded hospital hubs.

Their arguments also have no data to back them up.

On the other hand, there are a number of emerging examples of self-organized clusters of service providers who are evolving interesting new local health & community support system designs they call “Rural Health Hubs“. These diverse local system designs have emerged bottom-up over many months and sometimes years of dialogue and discussion at the local level. These are organizations who are responding to their unique environments in similar, yet very different ways.

Indeed, there is lots of evidence that says that in complex adaptive systems, bio-diversity leads to thriving, self-organizing environments — where innovation flourishes. But the community governance board critics say that “silo-boards get their CEOs to fight for a bigger piece-of-the-pie for their silo — rather than playing nicely and collaboratively with their peers to design and manage a better healthcare services delivery system.”

These critics suggest that most Community Governance Boards simply act as “silo-cheerleaders” for their organizations — and that despite a decade of criticism about Boards failing to generate accountability in their organizations, they say that most boards have still not improved their accountability systems, structures and processes — yet another a key priority listed in the Minister of Health’s initial Mandate Letter from the Premier.

While there is lots of evidence that says governance can play a valuable role in creating a better system focus on quality, safety and the patient experience, unfortunately, many of the legitimate criticisms that have been leveled at governance have not been adequately addressed in the past ten years. So, which way should we go: generate another wake-up call for local Community Boards to create Collaborative System Governance in their Health Links, or, merge community health service providers into single-board/single-CEO Hospital Hubs? Which way should we go?

Normally, before major structural changes are made, there is some sort of public debate. So, let’s start talking about “our future health system”.

Where do you stand on these issues? Should Community Governance in our health sector be transformed, reduced, or eliminated? If you think governance should be transformed — rather than reduced or eliminated — what can you do to advance the health reform agenda in your community? Major assumptions that some are holding about governance need to be surfaced and openly discussed — at the Health Link level — among local Boards, and among senior managers/CEOs within a local community.

Topics at these Community Dialogues On Healthcare Governance ought to include:

• What is each Board’s role in a redesigned system?
• Who does each Board “represent”?
• Who are the “stakeholders” that the Board needs to consider?
• How can each of the Boards govern their silo — while also holding their respective CEOs accountable for appropriate “system outcomes”?
• How can Boards across the delivery system ensure that their organization is focused on improving quality, safety, and, the patient experience — particularly at the “hand-off points” within HSPs, and across the continuum?
• How can Boards support collaboration and provide strategic direction to CEOs on developing a Health Link System Balanced Scorecard?
• How can each Board utilize their Health Link System Scorecard in their Integrated Accountability Process with their respective CEOs?
• Without alignment on outcomes across the system, and without common frameworks and metrics, there will be no change. So, how can each Board, and their CEO, develop/renew their CEO/Board Accountability Agreements — in ways that incorporate best practices for balancing accountability and empowerment for the CEO/Chief-of-Staff — as well as for senior and middle managers — for both their silo and system outcomes?

There are clearly several major strategic issues at stake here. What will our new system “be like” and “look like”? Boards of Governance, within local communities, need to step-up to address these critically important macro system design issues. If people want Medicare to survive, they need to take action at the community level to create the required changes. But do our Boards understand what is at stake here?

A high-level Roadmap — rather than a vision — is being used to guide the unfolding of our future healthcare system. The Wynne/Hoskins/Bell Team will be guided by an initial Minister’s Mandate Letter that says the evolving system must be “patient-centred”; “transparent” and “accountable”. These are certainly the right strategic directions for our healthcare delivery system. Now leaders need to focus on how to deliver on these themes.

The Institute for Health Improvement (IHI) refers to this type of model as: “an overall system design where every aspect of the system must revolve around the patient – where the patient and family, in partnership with the system, drive everything.” The future could be promising…we just might even get it right.

So, what’s the big deal about governance boards not being mentioned in the Mandate Letter? Perhaps it was just an oversight… or maybe simply a comment on the current “status” of Community Governance in Ontario. Nevertheless, we really ought to have our community governance people — who represent the “owners” (citizens, patients, taxpayers) — at the table. They also ought to be the Minister’s and the Premier’s “best friends” — who can provide the required local leadership as the system transforms.

Hopefully, the exclusion of governance in the Premier’s Mandate Letter will be a “wake-up call” for Boards to become more relevant to the future.

I personally don’t think that there will be a lot of support for the Anti-Community Governance Lobby. I can’t see a circumstance where MPPs or Cabinet Ministers would say: “Great idea — getting rid of local community governance” — or supporting the idea of reducing the number of boards because “there are just too many of them.”

That does not mean there should not be any mergers of health service provider organizations over the next few years. To be very clear, I’m not opposed to mergers. I trust the Wynne/Hoskins/Bell Team and our Local Health Integration Networks to actually encourage mergers — where it improves services, or saves money.

However, “Mergers” are not a method that should be taken lightly — since about 80% of mergers fail. Steve Lurie’s paper Getting To Integration provides important insights on why the merger failure rates are so high — and how to get in the 20% Club for “successful mergers/integrations”.

As for the “Fewer is Better” lobby, they really need to check out the research conducted by the Canadian Patient Safety Institute (CPSI) demonstrating that properly skilled and educated community governance boards have a proven capacity to have a significantly positive impact on patient care — quality, safety and satisfaction. If that’s true: Why would we want fewer Boards?

What if our focus was “better governance” — where silo-focused Boards are actually transformed? In Collaborative Governance, for example, each silo-board at the Health Link Partnership level would hold their respective CEOs accountable for: (a) outcomes in the organization’s silo-balanced scorecard; (b) outcomes in the Health Links approved Business Plan and Scorecard; and, (c) the service outcomes listed in their Accountability Agreement with the LHIN — including appropriate delivery system objectives in the Integrated Health Service Plan. Collaborative Governance is often viewed as the better and wiser route to enhanced system integration than the single/Board/CEO option.

It is the Wynne/Hoskins/Bell Team’s mission to mobilize the hearts and minds of the system to actually transform into the high-quality, patient-centred, transparent and accountable integrated health services delivery system that they are seeking to create over the next four years. Recent surveys @ TedBall.com indicate that most healthcare leaders are optimistic that the combination of our new Premier, Minister and Deputy have the capacity, values and courage to lead our healthcare system in the right direction.

But as capable and competent as the Wynne/Hoskins/Bell Team may be, they can’t save the healthcare delivery system all by themselves. They need several dollops of community courage, vision and leadership to emerge at the grassroots community level. People need to step up, and help in this common cause for “best practice health system transformation”.

Community Governance can help, by demonstrating leadership, and by agreeing to transform themselves — as their local delivery system is transformed. In Board Work: Governing Healthcare Organizations, authors Pointer and Orlickoff have argued that for governance to effectively lead healthcare into the future, new mindsets, structures and skills will be necessary. They point out that “effective governance is not a happy accident. Rather, it is the result of an integrated process of planning, coordination, implementation and evaluation”.

They say that “when a Board is governed by chance or tradition, (or simply reacts to whatever situations arise), it abdicates its responsibility for leadership and contributes to organizational atrophy.” If Boards in Ontario are to continue to survive, they need to decide on their role and function in a transformed system.

IF YOU THINK INDEPENDENT LOCAL COMMUNITY GOVERNANCE BOARDS OUGHT TO JOIN THE DEBATE ABOUT THEIR FUTURE — SEND THIS BLOG TO SOMEONE YOU KNOW IN HEALTHCARE GOVERNANCE.

Wow! Invest a few minutes reviewing the results of this summer’s Health Leaders’ Survey as the readers @ Ted Ball.com provide their “best advice” to our new Minister, Hon. Eric Hoskins, and to Deputy, Dr. Bob Bell.

The 200 healthcare leaders participating in our survey included CEOs and Board Chairs/ Board Members — from hospitals, CCACs, community agencies, homecare providers, the LHIN Boards/Staff, MOHLTC officials, politicians and their political staff; healthcare associations, health professional organizations, and numerous healthcare professions’ regulatory bodies.

You will see in our survey how these health system leaders describe the healthcare environment and assess the relationships between HSPs — and government — in very blunt, to-the-point terms.

Doctors Bell/Hoskins are lucky. Survey participants clearly want our new Minster and Deputy to succeed. This is a survey in which participants offer up their best advice on priorities, strategic direction and structure.

Read the heart-felt outpouring of advice to our new Minister of Health — based on the wisdom gained from the “School-Of-Hard Knocks”; and, from their best advice about health system priorities and strategic directions.

As you read these results, I ask that you reflect on this question: since it is very rare for Ministers & Deputies to actually step up and solve all the problems that we face in the health sector: What could your Board do; what could your CEO and Senior Team do; what could middle managers do to align themselves and what could you do to address these issues?

Click here for: Health Leaders’ Survey Results.

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.

FORWARD THIS BLOG TO COLLEAGUES YOU THINK WANT TO BETTER UNDERSTAND THE EMERGING ENVIRONMENT.

The new health sector leadership team of Wynne/Hoskins/Bell has just arrived amid some every bad news: “Ontario does not have a health system that is among the best in the world“.

Nope. Not anymore. In June the Commonwealth Fund released their latest comparison of health systems in 11 developed countries. Next to the United States, Canada has now been rated the second-worst healthcare delivery system in the developed world. We were last for overall quality; effective care; timelines for access; patient-centredenss; and, we scored second-last on efficiency.

This new study—which ought to be a wake-up call to all healthcare leaders — said that our health system is characterized by “long-waits; poor management of chronic conditions like diabetes; poor coordination of care; and, failure to involve patients in decisions about their care.” The Commonwealth Fund examines 80 indicators of performance, many of them based on patient surveys.

Over the past decade, Canada has dropped our rank from third place, to 10th place — now just ahead of last place United States. Any healthcare leaders in Ontario who are still protesting that “we have a great healthcare system”, and that the only solution is “more money”, should finally be kicked to the side in this debate and told: “Liar, liar, pants on fire”.

At the same time as we were having poorer and poorer operational performance over the past ten years, we were investing more and more money from both our federal and provincial governments — proving conclusively, that “more money”, does not mean that the system will be improved — if all we do is just “spent more money”.

But while Canadians have poured billions and billions of additional dollars into our healthcare delivery system in order to “fix it for a generation,” as former Prime Minister Paul Martin promised, the fact is that what health reformers were warning about (i.e. “more money” in a poorly designed, bureaucratic  and wasteful system will not “fix” it). In the end, almost all the health system reform money — $81 billion — was spent by the provinces on wage increases for healthcare professionals. So taxpayers did not get the “safe”, “efficient”, “high-quality”, “patient-centred system” that they paid for.

Today, while “saving money” has become an important motivator in the U.K., in the United States, healthcare customers are becoming much more demanding as consumers. They want an integrated service delivery system that is designed to meet their individual needs. The issues here are about “system design”, rather than “tougher management controls”.

If our new Minister, Hon Eric Hoskins, were to get really serious about patient-centred care — way beyond the current rhetoric about “patient engagement”, we could indeed transform our delivery system to be more like the world famous Nuka Model: with its very real Customer/Owner orientation built into the macro-design of the system. (See Blog On Nuka Model)

At the macro-system design level, this is the kind of paradigm shift we really, really  need in Ontario.

At the patient service delivery level, leading-edge organizations are moving beyond the “patient engagement” phase to embrace the new discipline of experience design based on the science of a human experience.  Art Frohwerk, a systems engineer and human factors expert, who once headed up the Show/Ride Engineering at Disney Imagineering has devoted the last 20 years of his life adapting experience design methods to the patient/caregiver/family experience in the United States.

“Patient Experience Design” incorporates many disciplines — including the best of TQM/CQI/Lean Thinking/Strategy Mapping/Scorecarding/Kaizen/Emotional Intelligence and the collective intelligence of patients, nurses, doctors, families, staff and even Board members. Experience design fundamentals include: being relevant, engaging, flow and adapting.

Redesigning systems, structures and processes within an organization, or across the local delivery system — from the perspective of the patient is an example of what we mean by the term: disruptive innovation. Imagine if a hospital, a community service or a Health Link partnership structure was configured within a framework that viewed the patient as a “whole person” — rather than as just “something to be fixed”. Imagine intentionally designing the patient experience in a partnership with care providers, patients and families.

For the most part, our systems, structures and processes were never designed from the patient perspective. This transformational methodology simply liberates front-line  healthcare providers to work in partnership with patients and families to pro-actively design the systems, structures and processes from the patient perspective.

Frohwerk, the world-leading developer of patient experience design methodologies, says: “using the tools of experience design not only helps us have a shared focus on the patient, but causes us to visualize how we can each contribute in often little ways. Then, it’s like Appreciative Inquiry—folks go back to work, and just start doing better things.”

In such a place, care would be personal and proactive— anticipating the patient’s needs, reducing risk, improving efficiency—all with the empathic intention to improve healing, in body, mind and spirit. With such care, the patient understands the purposes and procedures of treatment. This understanding reduces anxiety, fear and uncertainty. Importantly, it increases self-confidence and promotes patient compliance with the healing process.

In such a place, the inherent need for teamwork with a shared focus — and with better connected and flexible processes — improves the experience of nurses, doctors, other health professionals, technicians and administrative staff, as well as patients and their families. Such improvements in turn produce the results that every healthy organization needs: greater job satisfaction, and higher staff retention rates. All that, because the system was redesigned to place the patient at the centre.

Organized by the principles and insights of the Science Of Experience Design, healthcare service delivery organizations are much better able to meet their financial objectives—because relevant processes are cheaper to run, and lead directly to improved predictability and higher patient loyalty.

Frohwerk’s world-leading experience design methodologies include the Storyboard and the Master Process — which he first developed 20 years ago while leading teams designing the way to deliver new levels of guest experience at new Disney attractions.

The Master Process ensures that all the things that an organization did that worked well (i.e. balanced scorecard, lean thinking, quality improvement initiatives, etc.) is retained, strengthened and aligned with the new innovation being introduced. Storyboarding doesn’t replace things that are working, it integrates and aligns with them to create synergy.

The Experience Design Storyboard is a unique tool with the ability to create insight and organize ideas and information in a way that process design, and lean thinking alone cannot. It’s used by teams of healthcare service providers, patients and families to set the stage for seamless processes, integrated systems, appropriate roles, useful measures and strategy implementation.

Experience Design Storyboarding also combines the leading-edge disciplines of visualization, storytelling, process workflow, experience design, system design, scorecarding, lean thinking, Kaizen, and addresses emotional, social, and spiritual issues as well. The deliverable is an imaginative, graphical representation of the activities, issues and mechanisms — at an “altitude” that enables broad, yet specific patient/family-focused issues to be addressed.

The process of Storyboarding for design is much more than just brainstorming, telling stories, sending out surveys, or hosting focus groups to ask what an experience should be. It creates a setting to bring customers, leadership, and cross-sections of staff together in different forums to discover, invent and test the “story” of the patient experience.

Changing a healthcare service provider organization and shifting the healthcare delivery system from a provider-focus, to a patient-focus, requires a major behaviour change within the healthcare delivery system. To change our behaviour, we need to change how we think about our realities.

What’s great about Storyboarding is that it generates fast change that is never resisted because the people who live with the design, designed it themselves.

The new leadership team of Wynne/ Hoskins and Bell need to appreciate that the scale of these changes requires much more than “good will” and exhortations from our leaders. It requires a strategic focus and a disciplined process for actually redesigning the system and the patient experience — as well as taking the leveraged actions required to align the core systems, structures, incentives and processes to be “patient-centred”.

If you really want to change how the healthcare services delivery system performs, you’ve got to look at how it is designed. As Peter Senge says: “Every system is perfectly designed to achieve the outcomes it produces. If you want different outcomes, you need a different design.”

This is not about taking a very badly designed system and making it friendlier with volunteers to cheer-up patients as they travel across a poorly-designed system. This is about dealing with a poorly-designed system and re-designing the system in partnership with patients and families.

Transforming a system with ingrained behaviours and traditional “ways-of-doing-things” will not be easy. Health system knowledge expert Steven Lewis points out that “the way patients and providers (and the system as a whole) interact is a product of history, circumstance, psychology, social norms, identities, and other factors that together define the nature of the relationship.”

What are the “ingrained habits of behaviour” that need to be overcome?

Hoskins and his advisors will gain insight from Lewis’ paper “Making Patient-Centred Care Real: The Road To Implementation,” where he says that while the theory of patient-centred care is straightforward, implementation is not. Lewis sets out the following challenges for those who want to shift to patient-centred care. He says:

• On many levels the nature of the relationships is inherently unequal. Patients are by definition dependent on their providers for help (otherwise they wouldn’t need to see them) and providers have more knowledge (most of the time).
• Much of the time, patients are in some degree of pain, discomfort, or anxiety. They are not at their peak; they are vulnerable. In such circumstances, they often have reduced capacity to assert themselves and take control of their care.
• Status and other hierarchies come into play. Often providers are more highly educated than patients, particularly older generations. There is a tendency to defer to credentials and the other attributes of status that accrues to providers, notably but not exclusively doctors.
• Providers—again, physicians in particular—are not inculcated with a culture of service. They see patients as fundamentally different from customers. They view their own time as a precious commodity (which it is) and organize their practices around its most efficient deployment. Their basic question is not, “what does the patient need to have a good experience,” but rather, “what do I need to do to cope with demands.”
• It is difficult to imagine a system fundamentally different from the one we know. Our behaviour is conditioned by our expectations, which are conditioned by how things are and have been. It is even more difficult to change when one does not know what is possible.
• There are risks (real or perceived) inherent in trying to change power relationships and models of communication and behaviour. Alienating a provider on whom one depends is obviously problematic. Where the relationship is intermittent, it may not be worth risking even if there is some dissatisfaction with what one has.

These are all trusts that must be addressed if we are to succeed.

So, how will “health reform” be any different this time? Will it be run out of a Secretariat at Queen’s Park? Will it have lots of rules and regulations? Will innovation be allowed in a risk-averse bureaucratic environment?

In order to go beyond the simple structural reforms of the past, our healthcare system needs the disruptive innovation of patient/family-focused care — a transformation process that has the best chance of producing deep, sustainable change in our healthcare delivery system. That’s the kind of impact that Hoskins needs if he is to succeed in “changing the patient experience”. He needs to hear what it is like today on the front-line of care delivery — and how it needs to fundamentally change. He needs to understand the science of a human experience, and what will be required to change the experience of Ontario’s patients.

In his book, Deep Change: Discovering the Leader Within, Robert Quinn distinguishes deep change from incremental change—the type of change we usually talk about. Quinn describes “incremental change” as the typical result of rational analysis and planning. There is a desired goal, and specific steps to reach that goal. Incremental change is usually limited in scope and is reversible. As it does not disrupt our past patterns, we can return to the old way if the change does not work out.

Therefore, during incremental change we feel that we are “in control.”

So instead of a Health Link being a transformation structure — with real structural changes like collaborative governance and an integrated management scorecard — it just becomes a minor operational Pilot Project for the 5% of high-users. While finding better solutions for the 5% is essential, how are we using these insights to re-design the system? What caused this potential “winner” to sub-optimize as “incremental change“?

In contrast, “deep change” requires new ways of thinking and behaving. It is not a check-box “To Do Project” that needs to be monitored and approved by important people at Queen’s Park. It is change that is major in scope, discontinuous with the past, and generally irreversible. The deep change effort distorts existing patterns of action and involves taking risks — in an environment that has unfortunately become very fearful and risk-averse. Deep change requires people to be working to surrender the “illusion of control”, and engage in innovation to design real change in the system.

Today, if you suggest to a CEO that there may be an innovative solution to their problem, the word “innovation” usually means “risk” — and not many senior managers teetering on the brink of retirement are gung-ho innovators and risk-takers in this environment. Will this change with Hoskins?

Ministers, Deputies and Premiers can certainly cause change — if that is really their intention. But this usually involves stopping some stuff, and starting new stuff. It involves thinking differently, and doing things differently. Is that what is going to happen? Is there going to be change?

What would happen if LHINs, for example, actually allocated more resources to health service organizations that are patient/customer/people-focused; and fewer resources (i.e. real budget cuts) to organizations that don’t produce acceptable results on their key performance indicators? If healthcare organizations made money — and lost money — on their patient satisfaction scores, trust me, patients will notice the difference in their experience.

I believe that if Health Minister Hoskins and our provincial and local LHIN leaders were to make the financial incentives on such a patient-focused strategic direction very clear, the system will shift overnight. CEOs, senior managers and community boards of governance who understand the emerging incentives will drive the patient/family-focus revolution — if the incentives exist.

No doubt some will warn our new Minister that “such measures are going to create chaos in the system”. No doubt some of the various “vested interest groups” and “power players” will suggest to the media, or to Opposition Parties, that change is unnecessary — or unfair.

Publicly, citizens and the media will observe the unfolding reports of budget increases and budget decreases for local service providers that are based on performance measures that reflect the opinions and evaluations of consumers. If this is an open, fair and transparent process that rewards healthcare service provider organizations for “good performance,” rather than “good optics” and actually punishes “poor performance,” I believe that the public — and the media — will be very supportive of this type of transparent process and outcomes.

I also have faith that many local community governance Boards will seize the opportunity to lead their organizations into what Dr. Vaughan Glover calls “people-centred care.” In northern and rural Ontario, governance and managerial leaders need to be thinking about the concept of “Health Hubs” that meet the needs of their population.

Quality and safety issues — as well as accessibility issues — need to be front and centre as our rural and northern communities design their local health and health-related social services to meet the emerging needs of their communities.

Once health system transformation, and the disruptive innovation of patient-centred care actually take hold — perhaps within the next there years — it will never return to the “good old ways of doing healthcare;” and we will have a better, higher-quality, safer and less expensive healthcare delivery system. Such a scenario could unfold in 24-months, if the Minister wanted it.

The Wynne/ Hoskins/Bell Team  need to carry on the patient-centred direction started by Hon. Deb Matthews mid-way through her tenure as Minister Of Health.

If your organization wants to build your internal capacity to design the patient experience, click here for a brochure that outlines a one-day workshop for teams to learn about Patient Experience Design Storyboarding.

FORWARD THIS BLOG TO COLLEAGUES YOU THINK SHOULD ADVISE OUR NEW MINISTER ON “HOW OUR HEALTHCARE SYSTEM COULD TRANSFORM”.

Will our leaders really have the courage and vision to save medicare? Will the new health sector leadership team of Wynne/Hoskins/Bell actually open the door to “disruptive innovation” — and finally move beyond the rhetoric of “health reform” over the past decade — and actually take the leveraged actions necessary to actually transform our health service delivery system?

Disruptive innovations cause fundamental paradigm shifts in the way we think and behave in complex adaptive human systems. Instead of tinkering on the edges with simple structural reforms, as we have been doing in Ontario, redesigning our core healthcare delivery system processes at the service delivery level—with a strategic focus on the patient/family experience of care—will create the fundamental shifts that will be required for us to save Medicare, because patient-centred designs are always less expensive.

But bottom-up innovation from our front-line care providers requires top-down liberation from our leaders.

Are we capable of such change? Does the Wynne/Hoskins/Bell Team have the political will to make it happen? Will they in fact shift resources within the system to fund real health system reform? Are our governance Boards, CEOs and LHINs now ready to become catalysts for the patient/family-focused care revolution that taxpayers and voters really do want? Is our community support sector capable of managing growth and transformation at the same time?

All this sounds like “big changes ahead”. But remember, humans don’t like change. In fact, change management scholars tell us that: nine of out ten humans would rather die, than change.

If we are really compelled to change, we usually choose incremental, shallow changes that enable us to maintain the “illusion of control” — and the comforting delusion that we could always go back to the “old-ways of doing things” — if the little incremental changes don’t work out. So the big “structural innovation” of 80 new Health Link structures with Collaborative Governance and Integrated Management Scorecards became for many, a minor pilot project about the 5 percent of “high-users” in their local system.

There are not many Health Links that have actually engaged their partners’ governance boards in the process of holding their CEO’s accountable for the appropriate outcomes that the organization committed to in the Health Link Business Plan. Many Health Link management structures do not have a common Balanced Scorecard and CEOs working together on strategy and strategic alignment.

Finally, Health Links seemed like a major structural change that would facilitate meaningful collaboration at both the Board and management levels, but many are not like that. They are just a “project”, rather than a serious transformation effort.

For the past ten years, the health sector has been traumatized by never-ending incremental changes that were experienced as “unconnected” and “unaligned” as they were developed in their independent Ministry silos by a variety of different ADMs. While without doubt, many good things were achieved over the past ten years, there was no significant systematic change — not in the culture of fear & anxiety that exists in the system.

Hoskins can publish a new Health Sector Strategy Paper with the best of intentions. but if he simply accepts the existing culture, his strategy won’t work. He needs to align the structure, culture and skills of the system.

When deep, fundamental, transformational changes that are irreversible occur, people throughout a complex adaptive system undergo a complete paradigm shift in how they think and behave. The system evolves through the occasional disruptive innovation when everything changes, and then there is no going back to the “good old days.”

So how are we ever to successfully transform our existing healthcare delivery system? When are we going to stop “tinkering on the margins” of structure — and get on with the aligned fundamental reforms that Ontarians want and need?

Using innovation management models previously applied to other industries, Clayton M. Christensen, a Harvard business professor, argues in his book, The Innovator’s Prescription, that the concepts behind “disruptive innovation can reinvent healthcare.”

The term “disruptive innovation“, which he introduced in 2003, refers to “an unexpected new offering that turns the market on its head.” The internet and the personal computer are examples of “disruptive innovations”. They changed everything—and there is no going back to the old ways of doing things.

A few years ago, Christensen told the Annual OHA Convention that disruptive innovators in healthcare 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. Mr. Christensen argued that by putting the financial interests of hospitals and doctors at the centre, the current system gives routine illnesses, with proven therapies, the same intensive and costly specialized care that more complicated cases require.

The New York Times suggests that “by creating a continuum-of-care that follows patients wherever they go within an integrated system, care providers can stay on top of what preventive measures and therapies are most effective.” Princeton economist, Uwe Reinhardt, says that in such systems “tests aren’t needlessly duplicated, competing medications aren’t prescribed by different doctors, and everyone knows what therapies a patient has received.”

For years health system critics have suggested that patients/families/citizens/taxpayers have not had a very significant influence on health system reform efforts. Rather, system design issues have been driven mostly by influence, authority, span-of-control issues, roles & scopes for service providers, managers, boards of governance, public servants and “inner-circle” influencers. These issues are of great concern to health system insiders, but of little concern to patients and the larger public—who are actually the “owners” of our healthcare delivery system.

However, we have learned that we do our best, most productive learning in partnership with patients. In an excellent report on patient-centred care, Human Factor: How Transforming Healthcare to Involve the Public can Save Lives & Save Money, researchers Bunt and Harris tell us that “the people who use services, and the staff who deliver services, generally have deep knowledge and understanding about how to make them better.” The authors proclaim that “in the most basic sense ‘patient centred care’ means taking more account of the users of services. There is extensive evidence that this delivers improvements in care delivery, increases in health literacy, and provides valuable feedback and assistance in setting priorities.”

Despite all this, we still don’t really pay much attention to the patient or their families. Unfortunately, “Patient-Centred Care” isn’t a strategy, it’s too often been merely a slogan or empty mantra. The last Minister said it was important so everyone said similar things in their re-written mission, vision and values statements.

“Patient engagement” rather than “experience-based re-design” has become the focus of the systems change efforts. That means we learn how unhappy people are, but we won’t actually do much about it. It has very much been about “optics”. “Patient engagement” makes us look like we care. Sort of like the CQI/TQM fad that was just a box-of-tools, then came the Institute For Health Improvement, the Canadian Patient Safety Institute and Health Quality Ontario and things began to actually improve. “Patient experience design” actually changes the system — and the humans don’t like to change.

While traditional vested interest groups continue to have extraordinary influence over government, new consumer/ public interest groups are now emerging to finally break the log-jam.

The “Changing Of The Guard” at Queen’s Park usually means opportunities for fresh thinking, and a preparedness to take on the deeply-held assumptions about our healthcare service delivery system — that taxpayers and citizens own. If there is to be a power shift for transformation, the patients, rather than the usual service providers and their lobbyists and rather than the same/old inner-circle group think, may finally experience a shift in assumptions.

We never had this unusual combination of Physician Leaders at the top before, but I think the mix of perspectives and insights from Dr. Hoskins, Dr. Bell, Dr. Tepper and Dr. Sinha may produce some break-through thinking about how we can meet the challenges of the next few years. While this considerable Doctor Brain Thrust (perhaps with the usual physician “blind spots”) will no doubt influence the Minister’s thinking, he’ll also gravitate to his own “inner circle” — which will reflect his personal interests, style and priorities.

While Hon. Deb Matthews certainly began to pay attention to patients, I think Health Minister Hoskins may be even more oriented to take the patient/citizens/taxpayer perspective.

So who will be in the new Minister’s “inner circle”? More, the same or different vested interest group insiders — or will patients and health reformers finally get a voice in the future? We have some great spokes-persons for the patient perspective and new voices are emerging with the insights we need.

Sholom Glouberman, President of the Patients Canada, has written a book entitled My Operation, (available at http://www.patientscanada.ca). A very thoughtful blogger on patient issues,. Sholom says that he is optimistic that most healthcare delivery organizations really do want to put the patient and their families at the centre of their service system designs. “They just need encouragement and support to do it,” he says.

The Patients Canada‘s mission is to promote increased patient engagement with healthcare organizations to enhance the voice of the patient. They will be organizing training programs specifically designed to improve the capacity of patients and their caregivers to interact with healthcare professionals. The Patients Canada isn’t the only consumer group to emerge recently. Another is the Canadian Association for People-Centred Care.

Dr. Vaughan Glover is a co-founder of the Canadian Association for People-Centred Health—a grassroots organization dedicated to finding ways to make our healthcare system more responsive to patients and their families. In his book, Journey to Wellness: Designing a People-Centred Health System (available at http://www.capch.ca), Dr. Glover says that the issues in a people centred system are “whether I feel valued, whether I am listened to, whether my needs are met, whether I was presented with all the options for care, and whether I received high-quality service.”

He says “the principle of individuality creates an interesting problem: a patient-centred system must be inclusive enough to support 34 million personalized health systems that are unique to each Canadian and ultimately managed by him or her.” He says that “health is a personally defined balance of mental, physical, spiritual and emotional well-being.”

Their People-Centred Model, places the informed patient at the centre—with access to coaches and support groups, supported by legislation and a system that is managed to be patient/family-centred. While the direction of change in this model is clear, it shifts the focus from the structural issues raised by the existence of the LHINs, to the fundamental issues that go to the heart of purpose: Why does the healthcare system exist?

What is its mission, its purpose for existing? If the answer is: “to serve the patients/families/clients/residents,” then it is important to know what “patient-centred care” really means? There are many definitions for PCC that are offered. NRC Picker, (the company specializing in tracking patient experiences) suggests seven components of patient-centred care:

1. Respect for patient’s values, preferences and expressed needs. This dimension is best expressed through the phrase, “Through the Patient’s Eyes” and the book of the same title. It leads to shared responsibility and decision-making.

2. Coordination and integration of care. This dimension addresses team medicine and giving patients support as they move through different care settings for prevention as well as treatment.

3. Information, communication and education. This includes advances in information and social technologies that support patients and providers, as well as the cultural shifts needed for healthy relationships.

4. Physical comfort. This dimension addresses individual, institutional and system design (i.e. pain management, hospital design, and type and accessibility of services).

5. Emotional support. Empathy and emotional well-being are as important as evidence-based medicine in a holistic approach.

6. Involvement of family and friends. Care giving includes more than patients and health professionals so that the larger community of caregivers are considered.

7. Transition and continuity. Delivery systems provide for caring hand-offs between different providers and phases of care.

While these has been lots of rhetoric about patient-centred care over the past three years, there are very few examples of organizations that are actually re-designing their systems, structures and processes to be more patient-driven. Patient engagement yes, redesign, not so much. So, how could Dr. Hoskins and his new team shift the system’s attention to making real change happen?

My very favorite patient-centred care model is the Nuka Model — developed by first nations people in Alaska. It would be great if our new Minister would go up there a kick the tires of a very real paradigm shift. Rather than the very sincere, but not too effective efforts we’re made here so far. (See Blog On Nuka Model)

We need a “Nuka Mindset Transformation“, rather than an “Ontario Vested Interest Group Power Adjustment“. That’s my best advice.

But what do you think?

If you were briefing our new Minister of Health, how would you rank Patient-Centred Care/Patient Experience as a policy and program priority — what would YOU suggest?

While our Minister may end up sitting through over 100 presentations over the next four or five months, he will not have the benefit of your honest best advice — unless you click here and participate in the Health Leaders’ Survey For Hoskins.

FORWARD THIS BLOG TO COLLEAGUES YOU THINK OUGHT TO PROVIDE THEIR ADVICE TO OUR NEW MINISTER OF HEALTH.