“Saving medicare” is going to be a very tough assignment for our new Minister and Deputy Minister of Health given the state of Ontario’s economy. But while there are certainly many things that are not working well in our misaligned healthcare services delivery system, and while it’s true that our delivery system needs to undergo a fundamental transformation, there are in fact many examples of wonderful cost-effective innovations that really work well in our healthcare system today.

What we need to do is uncork the bottled-up innovation within the system, and, we need to re-invent healthcare delivery — by spreading these innovations. Instead of stifling everyone with endless rules/regulations and MOHLTC administrative control processes, we need to liberate the wisdom and know-how in the system.

What the Hon. Eric Hoskins, our new Minister of Health needs to understand is that the knowledge and wisdom on “how to fix the healthcare delivery system” is at the frontlines of care delivery — as close to the patient as possible. Yes, we have some smart and capable policy-makers, and several high-performing silo-organizations, but the healthcare services delivery system has not changed after 10 years of what we were told was “health reform”.

While hundreds of millions were spent of these reforms, it is difficult to see the impact of all these various health reform initiatives. Over the past decade there were some minor, as well as significant improvements — but we don’t have any transformational shifts that have taken place.

Real system reform — like the concept of devolving authority and accountability deeper into the delivery system — has been vigorously resisted by our public service for ten years. They don’t want to give up “control”, or even the “illusion of control”. Health Ministers Smitherman, Caplan and Matthews did not succeed in implementing their government’s legislation on local empowerment. They each spoke passionately about reforming the health system, but nothing changed — other than the law.

The fact is, over the past ten years, our Health Ministry successfully prevented devolution to the Local Health Integration Networks, and, as a consequence, most, or many people, believe that our LHINs are sub-optimal because they never actually had the ability to be successful. I think the “smart fix” now would be to implement “devolution”, and task each LHIN with the responsibility to fund their own Integrated Health Service Plan,either with frozen budgets — or perhaps, even with less money in future years.

If it’s true that there is 30% waste in our $50 billion delivery system, and that the government is compelled to find $12 billion in savings in the next three years, don’t you think that some of the required savings ought to be removed from the healthcare budget over the next few years, if there is indeed “waste”?

If it’s true that years two and three of the Wynne Government’s tenure are projected to be fiscally challenging — particularly when our federal government ends its transfer payment boost in 2016 — then prudent grassroots health system leaders will be including these calculations into their future planning scenarios.

Saving money in the health system isn’t going to be easy.

An old adage from a former Deputy Minister of Health was: “you can’t have a war with both the OMA and the OHA during a single term in office. Each government must pick one to go to war with.” While it sounds like cynical advise, if you look back over the years, it seems that each government had a fight with either doctors or hospitals during their term. But the easy life — when the government only had to fight with one of them, is over. The world has changed. Over the next four years the OMA and OHA will not be hearing a lot of good news from our provincial government.

However, no government has ever faced the tsunami of debt that the Government of Ontario must now contend with, as our total provincial debt approaches $300 billion — and, as our interest payments on the debt are now stretching beyond $11 billion annually.

That’s $11 billion in interest payments every year — at an historically low rate of interest!

A one percent hike in interest payments will cost taxpayers an extra $3 billion annually.

Nevertheless, eleven billion dollars in interest payments on our debt is more than we currently spend on education, training, colleges and universities annually. With a structural deficit, a stagnant economy, and the emerging reality of increasing interest payments on our massive $300 billion debt, we are most certainly going to be in “big trouble” within the next few years.

Big trouble.

Moody’s Investors Service’s recent public sector debt report pointed out that “while California’s debt burden was 50% of their total revenues in 2012-2013, Ontario’s net direct and indirect debt is 226% of consolidated revenues.”

Several weeks ago Moody’s indicated that Ontario is currently  undergoing a credit review that is expected to be completed shortly. Last week they downgraded our condition from “stable” to “negative“. To top off this bad news, the federal government has unilaterally reduced transfer payments to Ontario by $640 million — half of which was for health care.

While this seems to be difficult for some public sector leaders to comprehend, I know that mature groups like the OHA and OMA know in their gut that the government faces a solid brick wall on the province’s drastic financial circumstances. They know we have got to work on solutions — together. They know that the status quo cannot survive.

By Christmas or New Years, Minister Hoskins will no doubt lay-out his high-level strategic directions for the healthcare sector based on input form the Ministry of Finance and, designed to address each of the key challenges we face — including our financial realities. His strategic plan may also empower the healthcare delivery system to transform themselves — as patient-centred, high-quality, seamless services across the delivery system.

Ministers traditionally take the lead on the policy development front — with lots of support from the public service: from their personal staff; with input from LHIN Boards and CEOs; and, from the interest groups that they engage with.

So how will Hoskins build on the “health reform policy”, “lessons learned” from the past? How will he begin to build on the many successful innovations that already exist in isolated places throughout our healthcare services delivery system? How will he build on the solid footing of so many excellent world-class services?

Given our new Minister’s grassroots orientation, I suspect that his role over the next four years may be — to become “The Voice of the Patient” — while holding his multiple other perspectives as a doctor, an academic, social justice advocate, etc. He recently said that his top priority is to “improve the patient experience”.

If Hoskins were to come out with his Health Sector Strategic Directions by January, it would be very effective if he then invested three-months in February, March, April making a provincial tour — hosted by each of the Local Health Integration Networks — to explain his strategy paper to health service providers in each LHIN.

It would be wonderful if the new Minister invested a day or so in each of the 14 LHINs and get a chance to visit/see a number of these wonderful innovations at the local level. He would certainly gain real insights into what is/isn’t happening at the operational level where care is being delivered. He needs to see and hear about “what’s working, and what’s not working, across the province”.

While a provincial tour would enable Health Minister Hoskins to discover some wonderful new directions to invest in, over the next year or two of his expected four-year tenure, he will only have access to money from the savings he can get out of system improvements in “quality” and “safety” in the longer term — and in the short-term, by actually re-allocating money in the system. As a activist Minister, he will need lots of internal savings to pay for new grassroots innovation projects. Or, he could listen to the “inner circle” and the “vested interests”, and just maintain as much of the status quo as possible.

Historically, the Liberals have said: “we’re putting a protective blanket over the healthcare and education budgets — because that reflects our values.” The problem is, in the healthcare sector, about 30 percent of our expenditures do not “add value” — and are in fact wasted spending that could be both redeployed, and used in part to pay down our $300 billion provincial debt.

But if the Wynne Government were to continue to maintain a “protective blanket” over our healthcare budget, we would be irresponsibly protecting a great deal of the waste in our $50 billion health budget. What kind of “values” would those be, when the consequences are that government would then need to cut very effective programs outside the healthcare budget –including programs and supports that are in fact part of the “determinants of health”?

We could actually end up reducing “social supports” for children in the Community and Social Services’ budget — in order to “protect healthcare spending”. And then, because we would  fail to adequately address the determinants of health, we will end up spending even more on treating the outcomes from the increased burden of illness among poor children that we were too short-sighted to prevent.

So, by “protecting the Ministry of Health’s budget”, we could paradoxically end up with a sicker society that cuts other Ministers’ programs like breakfast programs. That does not sound like the values of the Wynne/Hoskins/Matthews government that Ontarians elected.

In political systems, money flows not to where evidence says it is required, but to those who have political “power”. This is our existing system. That’s why our Health Science Centres and large community hospitals fill their boards with top business and social elites. Once a group has power and money, they naturally become dedicated to maintaining the status quo.

In rational economic systems, money flows to where there is the greatest return-on-investment (ROI). We do not have a rational system in healthcare.

The problem is that while today’s budget puts issues on hold for this year, next year, and three years after that, the health system is expected to be implementing big changes. But that’s not really how our existing system functions and behaves.

Dr. Hoskins will discover that our system encourages “spin-doctoring communications”, overt political behavior, and focusing on our narrow self-interests — rather than on the public interest. Public servants even ask interest groups to focus their submissions to align with the government needs — not their community’s needs.

In the current model, “the health system is in service to the Ministry”. Perhaps under Hoskins, “the Ministry will be in service to the system”. That would certainly be transformational! But we need change in how our LHINs and Health Links structures think and act as well.

In the future, we need local decision-makers who will develop the capacity to take on a much more evidence-based approach to our policy development, and to our strategic investments in healthcare that will also enable us to achieve significant ROIs, and to actually save money!

For example, for every $1.00 we invest in community-based mental health services and supportive housing, we save $2.17 in unnecessary costs in our emergency departments jails and courts. The previous government had no interest in such sound investments. They really seemed much more interested in “flashy” issues like the MARS Project, and the e-Health Program, than on sad, little mental health issues at the community level.

Making change is not easy. Normally, in political systems, if you move to reduce spending in those areas where people have “power”, there will be major “push backs” — sometimes with the underlying threat of more public battles. While the OHA says they support further investments in community care, they have never suggested that growth in community care should be funded by redeploying resources from acute care to community services.

While the political rhetoric of the past ten years has been about “transformation”, the actual reality has really been about maintaining the “status quo”.

So, how will our provincial government behave in a fiscally responsible way — while actively perusing their progressive agenda? This is the Red-Tory debate.

I think Premier Kathleen Wynne may yet emerge as our next modern-day Bill Davis — a Red-Tory Premier who always “pushed the envelope” to create a more equal, more just, and fairer society — while creating the environment for wealth creation and job growth, and ensuring the very prudent and ethical management of public resources.

That’s what people want from the Wynne Government — open, honest, fair processes that improve our public serves. To do that in healthcare means a fundamental transformation, rather than the on-going optical illusions and empty rhetoric.

With the Hon. Deb Matthews assigned to achieve cost savings, it will be impossible for her old Ministry to bring her new spending plans. She knows there is waste in the system, and that the system needs to be redesigned to be more efficient.

In the past, the Liberal government certainly talked about “population health” — and rhetorically Smitherman/Caplan and Matthews stated that they intended to “shift resources to community care” — but there is still little real evidence that there is any significant transformational shift in resources from institutions to community services — or from “treatment” to “prevention” programs. Those were Ministerial “Wishes”, rather than a strategy to shift resources.

So, “transformation” needs to be more than just noble rhetoric, and a new Secretariat. There needs to be focused action. What is the “transformation”? What should transform? That’s for Health Minister Hoskins to decide over the next several months. He needs to decide the what, and, how of the changes that are going to happen.

A good place to start? How about the “devolution of authority to the local level” — to provide the community empowerment promised by the original legislation that was passed nine years ago — but never acted on? The legislation passed under Health Minister Smitherman foresaw that LHINs would, one day, actually need to be “shifting resources” within their local service delivery system to meet their community’s unique needs. That certainly would have been transformational!

However, we’re still stuck with the same/old status quo, because Queen’s Park expanded their mandate over the past 10 years as they held on to the jobs, and the power to do resource allocation centrally in MOHLTC silos — while our political and bureaucratic leaders would babble-speak about “transformation” and “integration” for everyone else — and while staying in their own silos, and constantly making incremental changes that keep operational people busy “shuffling on the margins”, and “cutting on the edges” of the system.

As we move ahead, we really should stop wasting everyone’s time, creativity and good will on “hospital mergers”, and “munchkin mergers”? We need real, fundamental patient-centred reform. That fundamental reform should involve devolving spending authority to the local level — within a transformed and re-skilled LHIN system. We need to push control down into the system — right to the patient.

Minister Hoskins ought to let communities decide for themselves how to allocate the healthcare spending envelope for their community — as they address their unique needs, with either the same, or increasingly fewer resources, all with a set of provincial standards. That means transforming, rejuvenating and empowering the LHINs — as well as empowering Health Links; empowering our very capable operational managers; empowering our brilliant front-line care providers; and, empowering “patients as partners”.

The knowledge, know-how, wisdom and the insights into “what to do”, and “how to do it”, is in the hearts and minds of the people in the health care services delivery system — at the Health Link and LHIN-levels — and at the front-lines of patient care services. It’s in the hearts and minds of patients and their families. People are brilliant.

So, what do you think we need to succeed? What should Hoskins pay attention to? What should be “let go of”?

Here is your chance to share your best thinking with the new Minister & Deputy as they begin the process of determining the new strategic directions for the Ministry over the next four years. Click on Health Leaders’ Survey On Advice For Hoskins.

Most people in the health sector breathed a sigh of relief when Ontario voters rejected the Tories — and with them, several seriously ill-conceived policies on the healthcare sector.

However, as I and others have consistently pointed out, it did not matter who won the provincial election, because, whoever formed the government would be faced with what is: a truly unsustainable system for delivering healthcare services.

While nobody in the provincial government today ever talks about “the discipline of the marketplace“, trust me. It’s coming. Ontario is in big trouble, and we are about to pay through the nose for it over the next three or four years.

Credit rating agencies analyze the ratio of provincial debt to revenue to gage each province’s capacity for managing debt — just as a bank examines our ability to pay the mortgage on our homes. What the government will be hearing these days isn’t good news.

Moody’s Investor Services says that Ontario has by far the highest ratio of any province — where our debt now amounts to 238% of our revenue. As a result, they just adjusted our status from “stable” to “negative”. That means the cost of borrowing money is going to increase for Ontario’s taxpayers.

A credit rating drop predicted to come within weeks — combined with a 1% hike in interest rates — can easily cost Ontario taxpayers another $4 or $5 billion in additional interest charges — on top of the $10.6 billion in interest payments we’re already paying today.

The new Ontario budget — which the people of Ontario voted for in the election — adds billions more to our existing $300 billion debt. However, the government has promised to reduce the deficit by at least $4 billion a year — for the next three years. People are asking: if 55% of our provincial expenditures are on wages, who is going to contribute to the $12 billion in “required savings” over the next three years? Whose ox will get gored?

Since it is estimated that up to 30% of our $50 billion healthcare expenditures are wasted, the healthcare budget will no doubt be under pressure — certainly in next year’s provincial budget.

Addressing these financial realities for our healthcare system, will require our provincial leaders to demonstrate unprecedented vision and courage. People truly want our leaders to succeed in transforming our healthcare system to be more customer-focused — with higher quality, and more effectiveness.

The people of Ontario did make a choice in the election: they want their government to be “force for good in their lives”. They are counting on our leaders to “fix” our healthcare service delivery system — including getting rid of waste, and reallocating resources to where they are needed.

But will Kathleen Wynne, Eric Hoskins and Bob Bell be visionary and courageous enough to cause those types of transformational changes over the next two, three and four years? Will they in fact lead our healthcare system through a fundamental transformation from caterpillar to butterfly — or, will they simply continue with the same/old tired health reform rhetoric that certainly seemed sincere out of the mouths of the last three Ministers — but never really materialized?

Where is all the “health reform” we already paid for?  The numerous examples of real innovation that I have seen came from local leadership and front-line wisdom — not from a costly government program. These issues will be the focus of my future blogs — as our new leaders hopefully seize control of the agenda.

I expect that Minister Hoskins will produce high-level strategic directions for the healthcare service delivery sector within the next six months — perhaps by next January.

In the meantime, I think our new Minister will be listening very carefully to what the various self-interest groups and patients’ groups within our healthcare service delivery system have to tell him about creating a better, more effective healthcare delivery system — for less money. As a passionate reformer and advocate for the little guy and the weak, he will also be “open to new ideas” from groups that have not traditionally had easy access to the Health Ministry’s inner circle of power and influence.

With the “Changing of the Guard” at Queen’s Park comes the possibility that old paradigms and ways of thinking will end. A new Premier, Minister and Deputy certainly generates hope for a fundamental mindset and cultural transformation. While “Changing the Guard” at Buckingham Palace is a very precise and disciplined process, at Queen’s Park, we encounter a very messy, complex, adaptive human system of interrelationships that are driven primarily by power, money, status and ego.

Changing all of the key power players at once creates a highly threatening environment to the status quo — and to those who thrived in the former regime and benefited from the lack of transparency.

However, the countervailing force against the existing status quo is Kathleen Wynne — with a very different grassroots perspective than her predecessor — who loved the high-tech and “big IQ” projects; Eric Hoskins, a social justice Rhodes Scholar, who, as a passionate reform-oriented  policy-wonk, has now been handed an historic opportunity to actually save medicare from collapse; and, the Minister’s key-person, Bob Bell, a self-described “healthcare rink-rat”, who, as Deputy, will oversee the implementation of the new government’s evolving policies for improving mental health services, reforming the primary care service delivery system, and finally getting in the illness prevention business.

This is the group that will be accountable for successfully transforming healthcare within the next four years. But will they succeed? Will this new leadership group actually “think-outside-the-box”? Will they reach beyond the same old tactics, to generate the actual transformation of the delivery system at the local level?

How will our new leaders — with their fresh perspectives — respond to the initial round of briefings that they will get at the same/old, same/old MOHLTC, and from the same/old vested interest groups?

In addition to the “inner circle” of interconnected friends, the formal Government Structure of the MOHLTC will also be experiencing high-levels of anxiety. Will they be able to survive the leadership shift? Will they win the new guys over? There’s lots at stake! Jobs. Money. Power.

Over the past decade, MOHLTC was able to grow and thrive as they responded to the opportunities provided by numerous scandals to expand their “control” over the healthcare service delivery system from their Bay Street offices in downtown Toronto. Despite the government’s own legislation to create LHINs, and downsize the MOHLTC, the number of Assistant Deputy Ministers in fact grew over their first two terms from 5 to 14 — each with multiple new branches seeking even more things to “control”, and more people to “command”.

The assumption in our current health system design is that we need a centralized bureaucracy to provide the operating system with templates/processes/regulations that require extensive monitoring to ensure compliance with what Queen’s Park says. However, will Hoskins/Bell /Wynne stick with that assumption — that our delivery system needs to be micro-managed from Queen’s Park? Does the new team believe that because Queen’s Park puts forward the “illusion of control”, that they actually have any control?

It would be prudent for the new leadership to remember that the MOHLTC is itself a narrow self-interest group that does not always operate in the public interest. While the initial briefings for the new leadership team will no doubt feature a predominant underlying theme of the compelling need to “protect the status quo”; and, to maybe consider some additional “minor tinkering” that essentially leaves MOHLTC intact — in control — and continue to be unaccountable for the system chaos they create.

Nevertheless, the pressure for fundamental transformational change will be significant — and time will be of the essence.

The Wynne/Hoskins/Bell Team cannot afford to wander about for the next two years contemplating, “what we should do differently?” If they are going to demonstrate progress by the next election — four years from now — they need to start sooner than later. They need to set out high-level strategic directions within five or six months — perhaps by next January/February, 2015.

Along with their policies and priorities, they need an interlocking set of mission statements that clarifies everyone’s roles over the next four years: the role of the MOHLTC; of the LHINs, of governing boards and CEOs, and the roles of the Health Service Providers.

People who want to see changes in roles/authority/mandates, need to communicate their best thinking to the Minister now.

Some groups will understand and really “get” that this next six months provides a time-limited opportunity to think creatively about how our public services ought to be re-invented.

Formal Vested Interest Groups — including the OMA, OHA, RNAO, AOHC, OACCAC, etc — will be up-dating and re-aligning their self-interests with what they perceive the new power players want to hear. The more reform-oriented interest groups like Patients Canada, Association of Ontario Health Centres, RNAO, Canadian Mental Health Association, the Ontario Community Support Association and several others, could be welcomed into the evolving “inner circle” of influencers as the generational leadership evolves and transforms in partnerships with the new leadership team.

The more traditional lobby groups will also be tarting up their most recent policy papers, advocacy positions, and, in some cases, their “vision” for how Ontario’s healthcare system should be organized and managed. This, I think, will be time well-spent. These high-level strategies will almost certainly capture the attention of a scholarly policy-wonk like Eric Hoskins.

Policy Papers — like the ones created just before the election by RNAO, and by the OACCAC — are focused on the “big picture” — with an emphasis on how the system could be changed and improved. Hoskins has to address the big questions these groups raise.

Joining the debate about the design of our future system will be another powerful self-interest group that will be anxious to maintain the status quo: the CEOs of the Health Science Centres — who could potentially be faced with steep spending cuts over the next four years with a Premier and Minister who are strongly oriented to shifting to community care, primary care, mental health services, health promotion and chronic disease management.

Some Health Science Centres have already undertaken the exercise: how would they downsize by 5% if they had to? Some are exploring how to make money from “medical tourism”, and other revenue-generating ideas.

While there has been some negative gossip over the early summer about how our new Deputy, Dr. Bob Bell, may be limited by a rigid “University Ave Lens/Perspective“, paradoxically, our new Deputy could in fact become a countervailing force — as he grapples with his role of implementing the government’s priorities on: primary care reform, mental health service expansion, health promotion/illness prevention — and, improving the patient’s experience across the delivery system.

We don’t know where our Deputy is heading yet, but he clearly signed-on for “big changes” in our delivery system. The key issue of devolution may rest on the final report of the Standing Committee Of The Legislature that conducted hearings across Ontario to learn about what the system believes needs to happen with LHINs, CCACs and HSPs.

It will be interesting to learn about their insight on how the government could improve on this initial attempt at local empowerment through the Local Health Integration Networks. What will they recommend?

Our most recent Leadership Survey @ TedBall.com found that 76% of health system leaders believe in some devolution/local empowerment — but with many calling for the transformation and re-skilling of the LHINs. But will the status quo still win?

If the choice is between saving our healthcare system through local empowerment, and downsizing the Ministry of Health, it will also be interesting to see where our public sector unions stand on that question. Former Health Minister Deb Matthews will be drawn into this debate about “Saving Medicare” vs. “Saving MOHLTC” in her key role on spending controls and dealing with the public sector unions.

Remember 19 unions spent $9 million in the final week of the campaign on ads saying: “Don’t vote for Hudak“. How will the government respond to their election allies? Or, will they actually opt for real health system reform, and topple the Ministry in favor of local empowerment — while being fair and generous to its employees?

There will be no end of complex and messy challenges for the new leadership team. The issue will be their preparedness to actually step away from the status quo, and the same/old same/old solutions and “fixes-that-fail” in order for them to take focused leveraged actions that will propel our health services delivery system into transformation, as we shift from caterpillars to butterflies. Real transformation, not rhetoric.

While consumer empowerment is the ultimate goal, our leaders need to start empowerment earlier in the food chain — by empowering the LHINs to liberate HSPs, and by Health Links to implementing their local health system improvement agendas, while HSPs empower their front-line healthcare service providers to re-design the patient experience in their silos.

It will be interesting to see what LHINs do in response to the arrival of the new Minister.

The LHINs could potentially become the new Minister’s “eyes & ears” on the delivery system — like their DHC predecessors. They could also be the Deputy’s “window on the delivery system”. However, the LHINs have historically been strongly influenced by the MOHLTC staff, rather than having strong relationships with the Minister’s Office. Will Hoskins embrace LHINs as his “agents” in local communities?

Since their establishment, the LHINs have mostly been silent on the “devolution” issue — as three Ministers, two Deputies and four ADMs ignored the legislation empowering the MOHLTC to devolve spending authority from Queen’s Park to local communities. The idea was to “empower the LHINs” to  fund their own Integrated Health Service Plan for their community. Some LHIN leaders have spoken up, but most have been silent.

So the question is: will there be a serious effort to transform, re-invent and re-skill our public services, or, are we going to continue on our long slide from a healthcare system that ranked third place in the world just ten years ago, to having now slipped to 11th place — behind the US, and behind most major developed countries?

Pulling us out of this rut and leading strategy implementation bureaucratically will be the new deputy Minister and his three Associate Deputies — Susan Fitzpatrick, Helen Angus and David Hallett — with Fitzpatrick basically operating as the COO of the Ministry.

Will this MOHLTC Executive Team become “out-of-the-box thinkers”, or are we up for more of the “same/old, same/old”? Most people seem optimistic, but time will tell.

While Dr. Eric Hoskins is still an unknown quality, the fact is that the very survival of Medicare in this province, and in this country, is now in his hands. He didn’t ask for this job, let’s hope he, his Deputy and the Executive Team at MOHLTC do well.

I don’t know anybody who doesn’t truly wish our new leaders the very best. We need them to be successful. When they succeed, we all succeed. We each need to ask: how can we help the Minister and Deputy be successful? We also need to hold them accountable for the results they produce. They are in stewardship to the system.

Within the next 100 days — to six months — we will learn whether Mr. Hoskins and his aligned team will embrace the status quo/the inner circle/and the same/old namby-pamby empty rhetoric about health reform, or, if indeed — as I predict — our new reform-oriented Minister will actually lead the fundamental paradigm shift required to re-invent and transform how our existing health and health-related social services are delivered — perhaps just-in-time for the next election, perhaps even with Dr. Hoskins heading to the polls as leader of his party in 2018.

There are a number of successful Health Ministers who have sought their party’s leadership — several successfully. They say: “Here is what I accomplished in healthcare, imagine what I could do as Premier.”

So Hoskins, and the staff he puts in place, will indeed be open to new ideas — and to new ways of seeing old problems. They have the very important task of “saving medicare and transforming healthcare” ahead of them.

Nevertheless, for the most part, over the next few months our new leaders will be encouraged at numerous briefings to maintain as much of status quo as possible — with only some “minor tweaks”. So how would YOU advise the new Minister? Here is your chance to join with perhaps a hundred or more other leaders to communicate your best advice — anonymously.

Health Leaders’ Surveys @ TedBall.com have provided the 1,500 to 2,500 readers who reviewed them each time with important insights from the 150-200 leaders who invest 10 minutes to provide anonymous briefings to Minister/Deputies/decision-makers/health system leaders.

So, share your wisdom/insights with Hon. Eric Hoskins by clicking on and completing the Anonymous Health Leaders’ Survey.

FORWARD THIS BLOG AND SURVEY LINK TO COLLEAGUES YOU THINK OUGHT TO PROVIDE THE NEW MINISTER WITH THEIR “BEST THINKING” ON THE HEALTH POLICY AGENDA.

Over the next two or three years, our healthcare system will be forced to undergo a fundamental transformation that will generate a great deal of mistrust and acrimony as 5% to 8% of total spending is removed. So how can your organization prepare for the real truth about the future of our health are delivery system?

Trust will be key in the emerging environment of rapid transformation.

In his book Trustworthy Government, David Carnevale describes trust as “an expression of faith and confidence that a person or an institution will be fair, reliable, ethical, competent, and nonthreatening”.  Trust has also been explained as having faith that someone is able to, and wants to control their “dark side” as it would affect oneself or others.

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

Trust is social capital.  It reduces conflict, improves communication, eases cooperation, enhances problem-solving, reduces stress, enables people to realize more satisfactory relationships, amplifies organizational learning, an advances change.  Trust is a positive mindset.  It needs to be restored in organizations”.

All organizations have behaviours and issues that are “undiscussable”. That is, everyone in the organization is aware of a recurring dynamic or situation that blocks individuals and the organization from achieving desired outcomes and reduces effectiveness.  However, no one will openly discuss the situation, or even articulate its existence.  The unspoken decision to ignore or pretend to be unaware of the undiscussable is reinforced the longer the tacit agreement of silence is maintained.

Beyond the silos, within the power dynamics among the Health Link CEOs, and among the LHIN leadership, there are issues which everyone very carefully manages to avoid.

People within an organization and within a delivery system begin to engage in what Chris Argyris, in his book Overcoming Organizational Defenses, calls “organizational defensive routines“.  These routines are basically avoidance strategies.  They are ways of by-passing errors, ignoring difficult issues and problems, and saving face (for yourself or a colleague).

While defensive routines help us to feel secure and in control in the short run, they ultimately erode our sense of well-being and the health of the organization.  By masking the dynamics of the situation, defensive routines keep undiscussables underground, and legitimize error and unacceptable behaviour.

From his study of organizational defensive patterns, Argyris warns that the longer the situation continues, the greater the sense of malaise, hopelessness, and cynicism exists.  The malaise leads to distancing and blaming behaviours, mediocre performance, and, finally, blow-ups at the individual and organizational levels which destroy the capacity for learning, efficiency and effectiveness.

Surfacing undiscussables and exploring them without blame or defensiveness requires a great deal of courage and skill.  Two exercises, “Undiscussables,” and the “Left and Right Hand Column” offer some guidance for teams seeking to unveil and learn from taboo topics.

However surfaced, people find that undiscussables often turn out to be critical factors in solving problems, propelling them toward their vision, or developing their collective ability to learn.  Over time, as more open communication develops within the organization, the fear, blame and judgment that feed undiscussables and defensive routines will be replaced with trust and a commitment to generative learning.

“Telling the truth” will only become a common practice in organizations when there is a “safe environment” or culture that supports this norm.  People need to consciously create safety for one another by being open to learning, and by their determination to “seek to understand”, rather than to judge. This concept is critical to the well-being of individuals, teams and organizations.

I strive to “tell the truth” in my blogs. Often not “the whole truth” — because it is too often very negative. I try and explore positive issues and point to examples of success — while telling as much of the truth that I know.

A fundamental commitment to the truth is a difficult way to live. It may set you free, but it won’t make you rich. Nevertheless, it is essential for authentic learning, empowerment, partnership and stewardship.  By “commitment to the truth”, we do not mean that we are seeking the final word on an issue.  There is not one external objective “truth”.

Our understanding of reality is influenced by the assumptions, mental models and experiences that we hold deep inside.  A commitment to the truth requires our relentless willingness to reflect on and surface the ways we limit or deceive ourselves from seeing the bigger picture.  Continually being open to different understandings of why things are the way they are, demands that we practice honesty with ourselves.

It also demands that we are honest with those around us.  Constructive, honest feedback is essential for learning.  Communicating anything less than the truth is a common defensive behaviour that is intended to protect ourselves or others.  Like all defensive routines, however, deception and avoidance prevents learning and hinders human growth and potential.  By committing to the truth, we are collectively able to let go of assumptions and mental models that have held us back, and open ourselves to learning.

This “commitment to learning” and seeking the truth is intimately tied to an organization’s commitment to end secrecy.  In his book, Stewardship:  Choosing Service Over Self-Interest, author Peter Block states that organizations built on a foundation of empowerment support the idea of full disclosure.

Arguing that knowledge is power, Block supports giving complete information and telling the truth all the time.  This position requires “training all employees so as to create business and customer literacy.  Full disclosure and full information are the rule, so that people understand the consequences of the decisions that they are making”.

He goes on to write that “full disclosure means to openly discuss bad news and difficult issues.  No protecting or positioning allowed.  The more sensitive the issue, the more it needs discussing — especially in groups.”

The number of “undiscussables” we have in the health system is really incredible. I openly question why MOHLTC was allowed to avoid the “will of the Legislature” that passed a law that enabled devolution of authority over spending.

An example of an “undiscussables” is that MOHLTC failed to implement this provision of the law, in order to save/protect their own jobs. It has been estimated that 70% to 80% of MOHLTC jobs would vanish with devolution, and that modest growth and skills for allocating resources would be required in the LHINs.

While the MOHLTC does not have veto power formally, nobody is stopping them. There is no devolution. Period.

We express our trust in our institution by the amount of information we allow to become public.  The bureaucratic notion of telling people only on a “need-to-know basis” is how patriarchy maintains its grip.  Full transparency and disclosure also requires that people do their own communicating.  If our goal is to “tell the truth”, we do not need professionals to tell us how to get our message across.”

An “empowered organization” requires individuals who are deeply committed to the truth.  Block’s notion of stewardship suggests that we hold in trust the well-being of some larger entity — our organization, our community, the earth itself.

Block says that to hold something of value in trust calls for placing service, ahead of control. It means we no longer expect leaders to be in charge, or out in front.  We search, so often in vain, to find leaders that we can have faith in.  Our doubts are not about our leaders’ talents, but about their trustworthiness.  We are unsure whether they are serving their institutions or themselves”.  By modeling the values of stewardship, service and trustworthiness, leaders can steer their organization toward vibrancy and health and commitment to achieving the shared organizational vision.

A “commitment to the truth” is also essential to establishing real partnerships within and amongst organizations.  Block describes how traditional hierarchical structures based on uneven power relationships between bosses and subordinates make it difficult and unsafe to tell the truth.  Bosses must pretend to know all the answers, since that is what is expected of someone in their position.

In turn, employees must strive to hide mistakes and areas that could be improved — so as to avoid being blamed by their “superiors”.  By redistributing power within organizations to create true partnerships, we are able to create an environment in which people feel less vulnerable, and are therefore more honest with each other.

It can get even more complicated in structures like Health Links — which is a structure that requires CEOs who normally pull apart, to begin to pull together. To avoid one another, and to avoid the truth about the need for true collaborative action, many Health Link CEOs have simply turned over the responsibility for this little “pilot project” to middle management. They don’t intend to use Health Links as a platform to transform their system.

The fact is that the effort behind many Health Links is mostly about the 5%, rather than how the CEOs will transform the design of systems, structures and processes — based on what they are learning from the 5% of high users.

So, the truth is, many Health Links are compliant, but few are heading for transformation, but that itself becomes an “undiscussable”.

No matter whether our concern is with learning, empowerment, stewardship or partnership, a “commitment to the truth” begins with deep personal commitments from the people at the top — senior management and the board.  Block believes that what is true, is known to each of us — that we all have the knowledge and answers within us.

He writes, “the spirit demands an inward focus,” needing reflection, dialogue and clarity about our own intentions.  Looking externally at the commitment of others diverts us from taking responsibility for our own choices and actions.

To affirm the spirit, we need to ask ourselves what has meaning for us, what we most desire and believe in.  Spirituality, or “the process of living out a set of deeply held personal values and honoring forces — or a presence greater than ourselves — requires that we be committed to the personal truth that lies in each of our hearts.”

In his book, Trustworthy Government, David Carnevale explains the importance of participative processes for building high-trust, cooperative and high performance organizations.

He writes, “participation elevates feelings of personal efficacy by granting staff more control over their work lives.  Involving employees means trusting them with information, power, authority and responsibility.  They interpret their enhanced control over the conception and execution of their work as expressions of confidence, and they respond accordingly. Trust is a reciprocal attitude”.

Carnevale concludes, “the message is clear.  Trust and high performance are impossible if the organization deals with employees just in terms of their work roles, puts up defenses that impair free expression, uses manipulative methods to motivate workers to do what it wants, and attempts to control everything and everyone. Staff who are suspicious and cynical become absorbed in self-protective practices.  They are less likely to take risks, to speak out when it is called for, to question ideas that need examination, to participate during meetings, or take a chance that a fresh approach might be the answer to a problem.  They fear speaking truth to power. ”

“Who, after all, is going to expose themselves to risk or commit to an organization that weakens their sense of efficacy, or threatens their very existence?  Who identifies with a system that keeps them small?”

FORWARD THIS BLOG TO COLLEAGUES WHO DON’T WANT TO WORK IN A SYSTEM THAT KEEPS THEM SMALL.

This blog provides a thinking exercise about what we need to do to make our future healthcare system come into existence.

Scroll down and read the left, and then right-hand column about our current reality in our first curve healthcare system, and about what it will be like when we achieve our vision of the future — when we reach the second curve healthcare system over the next three years.

When you finish reading the right-hand column about what it will be like, your job is to think about what Leveraged Actions (maximum impact for minimum effort) would be required to propel us from where we are (current reality), to where we’re going (emerging vision).

There are five key perspectives that must be considered when planning for a fundamental transformation: Customer/Patient/Citizen, Financial, Structural/Value-Creating, and Skills & Capacity perspectives. So, what would need to happen in order to propel us towards the emerging vision?

FORWARD THIS BLOG ONTO ANY COLLEAGUES YOU THINK MIGHT BENEFIT FROM THINKING ABOUT THE TRANSFORMATION AHEAD.

I had that experience when three children, ages 12, 14 and 16, made a presentation to the Systems Thinking in Action Conference in San Francisco.

The Systems Thinking Conference organized by Pegasus is an annual learning event at which Peter Senge, author of The Fifth Discipline, and 800 systems thinking practitioners from business, education, health care, government, and academia gather to learn about what people are discovering from their experiences with organizational and whole system transformation.

While I usually leave this four-day learning event refreshed and excited about the incredible breakthroughs in applied systems thinking that are being achieved by learning organizations from over 20 countries around the world, this time I was simply filled with a warm sense of optimism for the future.

While there were more than 50 workshops to choose from, I was attracted by the presentation title:  Starting Early:  How K-12 Students are Becoming Systems Thinkers.

The workshop program outline for the conference read: “As more and more businesses recognize that skill in systems thinking is  an essential element of basic management literacy, they not only seek knowledgeable recruits, but also look for ways to build internal capability. Learn how one school   district has organized  to teach teachers  and  students  alike  how to use systems thinking and systems dynamics, as three public school students and one of their system dynamics mentors share some projects and the tools and techniques they have used.”

As someone who teaches systems thinking skills to adults, I was most intrigued by the following line in the brochure: “Long before they become the sought-after leaders of tomorrow, these students are cultivating the mental models and skills required to make decisions and take effective action based on deep understanding of the dynamics of the systems that will affect their lives and their work.”

As a parent of two children, I’m deeply concerned about the confusion, chaos and frustration being experienced by the education system.  I worry that while my children will be living in the knowledge economy, they are still being trained for the industrial era.

While I was keen to see children who have had systems thinking training from the start, I was also energized by the hope expressed in the program outline. While there were a few other workshops being conducted simultaneously, the course description screamed out at me the words “kids” and “hope”. 

In my imagination I visualized a world in which everyone was able to explore their own and other people’s thinking while they worked co-operatively together to continuously improve the world around them.  That’s the ultimate promise of the knowledge economy where integrative holistic thinking replaces linear silo-thinking.

But to successfully shift from the industrial society to the information economy will require a fundamental change in the way we think and behave.  In the new economy, because knowledge will expand very rapidly, we must also be able to accelerate the rate at which we learn.

Systems thinking and system dynamics are a set of skills and tools that enable teams of people to tap into their collective intelligence and solve complex problems.  Many would say that such skills and competencies are essential for survival in the information economy.

The seminar started with a highly informative explanation of how the Catalina Foothills School District in Tucson Arizona implemented a fully integrated approach to systems thinking and systems dynamics within individual classrooms, the school and the district itself.  Project manager Joan Yates explained that two important reasons for their success were that the change process was “bottom-up” and highly participative.

After we heard from the grown-ups at the workshop, we had the most extraordinary opportunity to hear and experience clarity of thought from three children who had been learning and practicing systems thinking since Grade Five.

The audience — veterans from learning organizations, business people, teachers, college professors, leading consultants, public policy professionals and leading industrialists — sat spellbound at what often felt like real wisdom coming from the children.

“I’m 52-years old and have been trying to learn more about systems thinking from the experts at this conference, but I’ve learned more about systems thinking from these young people than from any of our top speakers,” said one woman in the audience at the end of the students dialogue.

These young people showed us how they apply systems thinking tools and techniques in their school work — in analyzing literature; in understanding lessons in history; in learning about chemistry; and for examining contemporary issues facing American society.

A 16-year old young woman showed us how she used the Escalation Archetype from causal loop diagrams to analyze the historical lesson learned from a colonial conflict between the British and the French. 

“It’s a reinforcing loop”, said the young woman, “they had to find a way to break the pattern to end the conflict.”

While the escalating causal loop diagram is not difficult to understand intellectually, we could tell that this young girl really did understand the nature of a behavioural dynamic that sucks the life out of many adult-run organizations today.

Adults often have difficulty recognizing repeating patterns of escalation that won’t end until someone breaks the pattern.  That’s the archetype that was in place throughout the arms race between the U.S. and the U.S.S.R., and it’s a common pattern of thinking and behaviour in most human organizations and systems today.

I kept reflecting on these circumstances as I listened to these Arizona children who naturally recognize patterns of behaviour over time, and understand the consequences of not breaking the pattern.  That filled me with real hope for a better world.

A teacher in the audience responded:  “Wow, this is really great!  But do you kids ever use stuff outside the classroom?”

“Sure,” the children responded as they gave several examples of how system archetypes appear as realities in their daily lives.

Imagine children — like these ones — who automatically recognize that behaviours like “dissing” in the schoolyard will lead to greater conflicts.  They break the pattern because they  understand that nobody ever really “wins” from escalating conflicts.

The image of a whole generation who are able to see a bigger picture and avoid repeating past patterns of flawed thinking and behaviour certainly energized me.

In the field of organizational transformation and whole system change, adults who have been schooled in traditional linear thinking styles often struggle to see the common patterns of behaviour — the “fixes that fail,” the “shifting the burden,” and each of the archetypes that characterize organizational life. 

The audience — rooted in their own experience of how difficult it is to change the way we think and behave — were clearly moved by what they were experiencing during our dialogue with the children at this workshop.

These kids were different.  Their thinking was not fragmented and linear, it was holistic and integrated. These children actually thought in terms of behaviour-over-time.  They quickly saw patterns in complex systems.  They spoke in terms of relationships of effect between variables — instead of explaining who or what was at fault, or where the “blame” belonged.

These kids were thinking through the lens of dynamics tools with ease.  They were thinking — without the mental blinders of linear thought processes — and comfortably accessing their multiple intelligences.

It would be wonderful to have these children sit down with the warring factions in the education sector and draw causal loop diagrams that explain the dynamics of escalation and why everyone will lose unless someone changes the pattern.

As someone who has spent the last ten years helping adults “learn” systems thinking, the experience of listening to these children was really encouraging.

In my experience, many adults find it difficult to “un-learn” the assumptions that have formed the underlying structure of thought in the industrial age. We continue to hold mental models of reality that are deeply embedded in our linear, mechanistic thinking patterns and habits.

Leaders throughout much of society continue to cling to Newtonian assumptions that prevent them from seeing a larger picture of reality — or from seeing the leveraged actions that would actually achieve the objectives that they say they are attempting to achieve.

When we are trapped in our fragmented and linear thinking patterns, we continue to respond with “quick-fix” solutions: downsizing, restructuring, re-engineering, mergers, centralization.  These were the responses that made sense when the dominant worldview was rooted in the assumptions of the industrial age. Nevertheless, it is the fragmented thinking style we learned in school.

That’s why our leaders in healthcare are so attracted to industrial methodologies like TQM/CQI, re-engineering and lean thinking — each linear thinking styles that fail to grasp the truth about complex, adaptive, human systems.

That’s why the MOHLTC is organized in fragmented silos — where the actions in one part of the ministry create unintended consequences for another.

That’s why when you are so firmly planted in your silo, you cannot see the integrated service delivery system that taxpayers believe they have purchased with their taxes.

Where breakthroughs have occurred in recent years, systems thinking skills, techniques and tools were used by adult learners as filters that allowed them to see a richer interpretation of reality and enabled them to discover the key leverage points in their systems. 

But these children from Tucson very comfortably and quite naturally saw the world’s complexity as patterns.  They understood the systems that they live in as organic living systems that can be better understood by analyzing their dynamics and inter-relationships.

You could sense how these children thought differently.  How they could cut through complexity, and see the real issues with clarity.

In his book, Seeing Systems, Barry Oshry points out that we humans spend our lives in systems: the family, the classroom, the team, the organization, etc.  He says that when we don’t see systems, “we fall out of the possibility of partnership with one another; we make up stories about one another; we become antagonists when we could be collaborators, and we become strangers when we could be friends.”  The children that we saw at this workshop had developed the capacity to “see systems” with clarity.

The Catalina transformation happened as both a bottom-up/top-down process — because a critical mass of people shared the vision for a fundamental transformation. By “transformation”, we mean the process by which a caterpillar becomes a butterfly.

What did I learn at this workshop with the children?

I learned that successful transformations in the education sector –like the healthcare and corporate sectors — need to be bottom-up, not just top down.  It was the Arizona teachers themselves — often inspired and facilitated by principals — who led the transformation.

But mostly I learned — or I had a glimpse of — how clearly children can think and act when they continuously apply systems thinking tools, techniques and practices in their schoolwork and in their lives.  I got that understanding where it matters: my heart, not my head.

That’s why I’m feeling more confident about the future of humanity.

This blog was originally published by Managing Change, Winter, 1999. Since then, Ted’s children became “system thinkers” and today, fifteen years later, they are thriving as young adults. The Ontario education and health systems are not doing quite as well. FORWARD THIS BLOG TO PEOPLE YOU HOPE WILL SPREAD THE WORD ABOUT THE POWER OF SYSTEMS THINKING.

At the bottom of this blog is a chart that sets out the design of accountability in the LHIN/Health Link health service delivery system model for Collaborative Governance.

In the Collaborative Governance Model, health service providers (HSPs) shift from their silos into a systems approach to governance and accountability.

From the perspective of a health service provider organization, the accountability system includes up to three components:

The Strategic Balanced Scorecard — the four-box framework that sets out the organization’s Board-Approved strategy — including the methodology for tracking progress.

The Service Accountability Agreement With The LHIN — that sets out the organization’s expected outcomes and alignment with the Integrated Health Service Plan which — if best practices were followed — reflects a “fair business bargain” agreed to by the LHIN and HSP. The Service Accountability Agreement will also reflect the Accountability Agreement between the LHIN and the MOHLTC; and, where appropriate,

The Health Link Business Plans contain the newest set of accountabilities that Boards of organizations that have joined a Health Link must add to the other two sets of accountabilities. While the lead partner in the Health Link is accountable to the LHIN, each partner’s board, and their CEO, are accountable for achieving their part of the agreed-upon outcomes.

The chart at the end of this blog also outlines how formal Accountability Agreements between Boards and their CEOs (as well as Chief-of-Staffs in hospitals) reflect the input from those three sources: the internal organizational scorecard; the agreed-upon Health Link outcomes; and, the outcomes required in their Service Accountability Agreement with the LHIN and the local Integrated Health Services Plan.

It shows how the CEO’s Accountability Agreement (and the Chief-of-Staff’s Agreement) drive both the Managerial Accountability Agreements, and the Medical Chiefs’ Agreement in hospitals. Best practices suggests that everyone’s accountabilities — and the “supports they require in order to be successful” — are explicit, fair and balanced.

The Balance Governance Scorecard’s four-box framework can provide a method to check on the degree of alignment that there is in your system of cascading accountabilities.

The chart below outlines the accountability architecture, from the perspective of a single HSP. From a “system perspective“, we need each of the HSP’s governance boards to hold their CEO’s accountable for each of these three perspectives.

They are no longer just a silo board, they need to think and act like a “system board” on behalf of the whole community.

The key assumption of the Collaborative Governance model is that Boards exist to represent the interests of the “owners” of the organization — not the narrow interests of the organization itself.

So, in addition to holding the CEO accountable for the outcomes in the Board’s approved organizational scorecard, a best practice Collaborative Governance Board would also monitor progress on the LHIN’s service agreement — as well as the appropriate components of the local Integrated Health Services Plan (IHSP); and, the agreed-upon business plan outcomes from their Health Link.

That’s the basic architecture of the Collaborative Governance Model.

For the most part, the people currently talking up the concept of “Collaborative Governance” really only mean that collaboration is a “good thing”. It’s a nice value, rather than an aligned pragmatic accountability system design for governance. In this simple worldview, collaboration is “good” and, as such, ought to be practiced.

But the concept of “Collaborative Governance” must become more than just a “good intention” and a “nice value”, it must be intentionally designed and aligned to actually work to create collaboration at the CEO/Management/and at clinical levels — where integration really counts.

Collaborative Governance needs to be intentionally designed to be an antidote to “silo governance”. It enables silos to be part of the network system. It is intended as a force for integration — if the Boards of Health Links partners would meet together periodically to ask the “wicked” and “probing questions” on behalf of the community: the “owner” of the entire healthcare services delivery system.

When HSPs were just silos, governance boards only held their CEO’s accountable for outcomes in their silo. Today, a major feature of Collaborative Governance is that while Boards exist to ensure good management in their silo, as Health Link Partners, and as members in a common LHIN, they are equally and mutually accountable for improved outcomes in their local healthcare services delivery system as well.

So in the future, Boards would hold their CEO’s accountable for both system-level, and silo-level outcomes. That’s the key leverage point for Collaborative Governance: the integration of system & silo accountabilities. It’s the traction that makes integration actually occur at the Health Link level without setting up yet another “super-board” to govern the whole local system. Nevertheless, Collaborative Governance needs to be much more than just a “good intention”.

The “lead” Health Link partner organization has been entrusted with one million dollars of taxpayers’ funding to support the development of the partners’ agreed-upon action plan. Some of the more strategic CEO-led Health Links (vs. the more operational ones), will be developing Health Link Balanced Scorecards that spell out the “cause-and-effect linkages” between the Customer/Patient/Client outcomes; the Financial outcomes, the Process outcomes, and the Learning & Growth outcomes in their scorecard.

As everyone will discover, when you’ve seen one Health Link, you’ve seen one Health Link. They are a real mix of relationships. Nevertheless, leadership surveys @ TedBall.com demonstrate a very respectable amount of optimism that Health Links will in fact succeed in their mission to transform their local delivery systems.

While concerns have been raised that some Health Links see themselves as a pilot project for the Top 5%, rather than a structure to achieve better integration of services for the whole community — based on the “lessons learned” from the “Top 5% Group”, who consume 66% of all our resources.

For organizational structures to succeed, they need to be designed and aligned to succeed.

However, for whatever reason, Queen’s Park has failed to be very clear about the governance of Health Links, or about how accountability would work. Why? They believe that saying nothing about governance and accountability means they are promoting a “low rules” environment, and that people should feel free to innovate.

So, without a macro-framework for alignment, it will now be up to the 80 individual Health Links to design and align themselves to work as an integrated health services delivery system. Collaborative Governance provides a framework and practices to enable alignment within each Health Link.

The advent of Health Links as formal partnerships — with formal accountabilities — ought to trigger the governance boards of the Health Link Partners to get together — perhaps a couple of times per year — to review the progress being made together by “the partners” in the network.

By bringing the Health Links Partners Governance Boards together to review their local delivery system’s progress; and to explore how the partners could transform the patient experience as they travel across the continuum-of-care; communities, through these boards, could be able to hold “stewardship” for the local health services delivery system’s transformation journey.

As “stewards” for the well-being of their community, our governance Boards need to stretch their minds ahead to 2015 and beyond. They need to understand that there will in fact be significantly fewer resources available for healthcare services immediately after the election. Some organizations could face 10% cuts in their budget, while others will be required to manage rapid growth and expansion.

There will also be a pressing need to re-allocate resources within the existing healthcare delivery system to meet the emerging needs of each unique community. Who is going to do that job?

Governing boards would need to acknowledge that their CEOs manage in toxic, blame-oriented regulatory environments driven by fear and anxiety that starts at Queen’s Park and spreads throughout the healthcare services delivery system. Boards need to explicitly liberate their CEOs to be innovative and creative as healthcare system executives, and as the organization’s strategic and operational leader accountable for silo and system outcomes approved by the Board.

The beliefs and convictions of Ontario’s health sector leadership was captured in the recent health issues survey @ TedBall.com during March Break.

On the question of “Devolution Of Authority” (for allocating resources) to the LHINs, 30% of respondents said they were “very supportive”; another 21% were “supportive”; and a further 25% said they had “some support, with adjustments”. That’s 76% of health system leaders who want devolution. That’s a significant stance that should not be ignored.

Only 13% of respondents were “opposed to the devolution of authority” to the LHINs.

With the arrival of a new Deputy Minister in June, and the expected report of the Legislative Committee studying the original LHIN legislation, there is an opportunity to tag the LHINs with the task of re-allocating fewer resources across their delivery system using provincial standards and their Integrated Health Service Plan as guides.

I very much doubt that the next government really wants to put Queen’s Park in charge of downsizing budgets at the local level — or in charge of re-allocating resources from acute care to community care, based on evidence and population need. That’s the point at which politicians say: shouldn’t the decision about the allocation of resources be a local decision, rather than a centralized bureaucratic decision?

The emerging challenge for Health Link Partner Boards and their CEOs, is: how quickly they can prepare for major transformational change over the next year or more — while funding still remains somewhat stable — as long as we are in “pre-election mode”.

While the next election could actually be as far away as a year from now — and perhaps even to the end of the legislated mandate in 2015, people who have been “putting things off until after the election”, should be asking themselves: why are you waiting? Are you a political candidate, or a healthcare leader?

So, now would also be a good time for Health Link Governance Partners to engage in conversations about Collaborative Governance design — before the financial crunch comes after the election. Smart people, smart communities will be getting their ducks in a row now.

Unfortunately, many LHINs and Health Links may actually wait until their community is in a horrible crisis before moving to action. Some will hold true “stewardship” for their community, and take action much earlier. Today, perhaps 20% to 30% of our healthcare delivery system has actually achieved a state of “readiness for transformation”.

There are a number of LHINs that are currently already engaging their HSP governance boards about governance, and about the concept of Collaborative Governance. But given that 70% of all major large-scale change efforts fail, it is very possible that only 30% of our Health Links will actually succeed in the end. That may be the case in some LHINs.

There are mixed reports on the behaviors and operating assumptions of our 14 LHINs. Respondents to our recent March Break Health Leaders’ Survey had a distinct pattern.

40% said they had “little” to “no confidence” that LHINs would contribute to the success of the Health Link Program. That is a significant level of negative judgment about our existing LHINs, and their capacity to support transformation.

32% of Ontario healthcare leaders said they have “some confidence” that LHINs will help the Health Links initiative to succeed. 28% said they had “high” to “great” confidence that these local integrated health systems would succeed. That’s 60% who have some degree of confidence that LHINs would help the Health Links succeed. Form a change management perspective, that’s a solid critical mass going forward.

But if Health Links are to become the “transformational” vehicle that Queen’s Park claim they are, the partner CEOs and senior managers need to be liberated by the governors to develop the strategy and a plan for aligning the structures, culture and skills of the partnering organizations to create a better more seamless experience for patients.

If every Board told their CEO that among their highest priority is the creation of a “seamless experience” as patients and their families move across the continuum-of-care in their community, we would achieve the integrated system taxpayers are demanding. The foes of local governance say that these silo-boards are in fact urging their CEOs to build a self-serving empire at each organization.

That could be true in 10% to 15% of “old-school cheerleader boards”.

Today, in addition to each Board holding their CEO’s accountable for system and Health Link outcomes, Collaborative Governance design could also include an aligned structure for regular quarterly meetings of Health Link Board Chairs/Vice Chairs in order to review the overall Health Link Scorecard, and to engage in generative dialogues on high-level strategic directions for the Health Links Partnership.

Notice I’m not advocating for a new layer of Health Link System Governance. Collaborative Governance is about the self-organizing capabilities of systems. It is not about new structures. It’s about new conversations, and new behaviors.

Of the three governance modes of Strategic/Fiduciary and Generative, the Collaborative Governance Partners’ Council needs to focus primarily on being “generative“.

On behalf of the “owners” of our healthcare delivery system, they should invest perhaps four days per year asking “wicked” and “probing” questions that will help management uncover the strategic directions required to achieve the vision for a more integrated delivery system, that improves the patient experience, and achieves the goal of improved health status of the population served.

Health Links need to become learning communities, and the governance boards need to play a role in facilitating learning, in their organizations, and across the sector.

The challenge: Queen’s Park seems to be totally perplexed by governance and best practice governance concepts — including their own incredible track record of actually implementing “worst practice” governance models at the Family Health Team level. In addition, a number of key people in the Queen’s Park inner-circle of policy influencers are “anti-governance”. This is the “Fewer Boards are Better” camp.

The “fewer boards are better” advocates apparently do not accept the research from Canadian Patient Safety Institute (CPSI), and from Institute For Health Improvement (IHI), that suggest that properly trained governance boards can actually add significant value towards improving health quality, patient safety and the patient experience.

The anti-governance advocates don’t acknowledge these points. They simply say that silo-governance causes system fragmentation. They say the solution is to just “get rid of them”.

As always, there is some degree of truth in the anti-governance group’s charges. Some governance boards — particularly our Health Science Centre Boards, and sometimes boards of smaller hospitals — do push their CEOs to be silo-centric, rather than system-centric.

All the Minister of Health, (or even the LHINs) need to do is “call them out on it”, when Boards are being silo-centric.

So far, this anti-governance sentiment has only manifested itself as neglect from Queen’s Park. The problem is, if Health Links fail because there was not a best practices approach to governance and accountability, who will be accountable? Would that be the Minister’s, or the MOHLTC’s responsibility to ensure that the program they designed actually works?

The answer is: it’s both.

While these are still early days, we are now entering into our second year with the Health Links program. What are we learning? What’s working? What’s not?

The best current examples of emerging Collaborative Governance in Ontario is at the North Simcoe Muskoka LHIN — led by Board Chair, Bob Morton; and at the SELHIN, led by Board Chair, Donna Segal. People should access their slide deck presentations from their upcoming April 28th OHA Workshop presentations to understand their respective approaches to Collaborative Governance.

While these slide-decks outline the logic of the approaches being taken by the NSM LHIN and by SE LHIN, the glue that actually holds their process together is trust, ownership and commitment. Trust enables true collaboration, and, with practice, synergy.

In the Collaborative Governance Model, if Board Chairs, Vice-Chairs and Committee Chairs of Health Link partner boards were to meet three or four times per year as the HSP governors, they could monitor the systems’ evolving progress, and explore potential leveraged actions that would propel the whole system forward — the wonderful world of continuous improvement and strategic learning.

We have yet to get accountability design right in our healthcare system.

So, in this “low rules” environment — where government has no clear views on governance and accountability for Health Links — health system leaders should take some time to think about it: how could your organization better integrate the multiple outcomes for your organization — and for the larger system at the LHIN and Health Link levels?

Think about it as you review the chart here: Collaborative Governance: Accountability System Alignment.

FORWARD THIS BLOG TO COLLEAGUES INTERESTED IN THE ART & SCIENCE OF ACCOUNTABILITY ALIGNMENT, AND THE NEED FOR DESIGNING COLLABORATIVE GOVERNANCE FOR HEALTH LINKS AND FOR LHINS.  

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

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

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

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

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

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

Last month in Vancouver, at the Patient Experience West Conference hosted by The Strategy Institute, I had the delightful experience, for a second time, to a very inspiring presentation by an Alaskan first nation’s organization in the person April Kyle — an energized, inspirational HR professional who told us wonderful stories about “what’s possible” in a health service delivery system.

April also presented at last year’s AOHC Annual Conference on “People-Centred Care”, where the CHCs had two presentations from the Southcentral Foundation in Alaska on their now world-famous “Nuka Model”. They have engaged in a large-scale transformation process that has enabled them to move beyond “patient-centred” care and “people-centred” to something much richer, deeper.

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

That is a very different healthcare system than our somewhat paternalistic version where we think “patient engagement” is an end-product, rather than a step in the redesign process.

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

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

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

• A 50% reduction in urgent care and ER utilization;
• A 53% drop in hospital admissions;
• A 65% drop in specialist utilization; and,
• Customer and staff satisfaction rates over 90%.

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

• The hub of the system is the family;
• The interests of the Customer-Owner drive the system to determine what we do — and how we do it;
• Customer-Owners are “active partners” in their care, and, in decisions about their care;
• Relationships between the Customer-Owner, the family, and health service providers must be fostered and supported;
• Emphasis on wellness of the “whole person”, family, and community including; physical, mental, emotional, and spiritual wellness;
• Population-based systems and services;
• Intentional whole system design to maximize coordination and minimize duplication;
• Outcome and process measures to continuously evaluate, learn and improve; and,
• Services are financially sustainable and viable.

April presents multiple perspectives and insights into the transformation process that their integrated health services providers underwent to become truly “customer-owner” driven.

So, why does Southcentral succeed? How do they live by these Operating Principles? How do they get such great performance results? How did they become such a “great placed to work”?

There seems to be three main reasons: 1. The macro organizational design of their healthcare service delivery system; and, 2. The common language & frameworks for the staff to talk about, plan for, and implement change to the way they deliver services to their people. And, 3. An aligned culture (thinking & behavior) that flows from the other two.

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

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

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

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

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

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

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

When we listened to the powerful stories about Southcentral’s transformation journey from April Kyle at the recent Vancouver Patient Experience West Conference, we could understand the galvanizing forces that has enabled their 1,500 staff to build a much better system that is well beyond just “patient-centred”. Indeed, it appears that these mental models are truly embedded in their organizational DNA. It is who they are. Who they are being.

“Among our highest corporate priorities”, says April, “we invest in the development of our people with extensive learning workshops, coaches and mentors.” Best practices suggested investing 1% to 5% of payroll budget on learning and growth of people.

Sometimes it means un-learning.

“We learn as little kids how to pick up a stone, throw it and hit the target, April told the gathering.” “But we are not throwing stones, we’re throwing birds… and the birds clearly have a mind of their own. We throw them towards the target, but they then head off towards the direction that they want to go in.”

Conference participants learned how Southcentral created a fully-integrated healthcare and support services delivery system that has been designed to provide high-quality, seamless care that is customer/client patient-focused, and cost-effective.

How did they do that? By learning about working with “thinking birds”. April’s presentation outlines how Southcentral is a learning organization that has learned from their best mistakes, forgiven and moved on to the next level.

What are the first steps? Towards a patient-centred system?

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

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

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

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

• Patients and family members would participate in rounds;

• Medical records would belong to patients;

• Shared decision-making technologies would be used universally;

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

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

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

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

Health Links partner teams that want to succeed in their quest to become “patient-centred”, also need to address both their clients’ “expressed needs” — as well as their “latent needs”.

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

Experience-based design Storyborading techniques and tools are methods used way to surface these critically important “latent needs” — in the co-design process with patients/family/staff.

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

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

Governance Boards of Health Link Partnerships ought grasp the importance of an integrated collaborative approach to the success of their organization as a collaborative partner. Collaborative partnerships won’t happen in the absence of designing and aligning collaborative governance strategies, structures, cultures and skills.

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

Smart Health Links will ensure that their individual governance boards are fully engaged in “failure prevention strategies”, at the same time as they are advancing the components of the strategies that will lead to the overall success of their collaborative efforts.

I’m holding an assumption that governance boards of Health Link Partners want their individual silo to be a highly collaborative member of the Health Link the organization has joined and signed-off on a Business Plan in which the LHIN will hold the lead partner accountable.

Boards of Health Links Partners can learn from the Nuka ‘Customer-Owner’ Model as they provide collaborative governance on behalf of the “owners” of their organization, rather than the narrow self-interests of their silo.

Updated blog from March 25, 2013.

FORWARD THIS BLOG TO COLLEAGUES WHO ARE INTERESTED IN THE ‘CUSTOMER-OWNER’ MODEL FROM ALASKA FIRST NATION.

The new vested self-interest group in town is called “Patients Canada” – the newly-transformed Patients’ Association of Canada, headed by their wise and thoughtful President, Sholom Glouberman.

Patients Canada is the product of the learning done by hundreds of people engaged in generating “patient stories” and deeper insights into the patient experience over the past four years. Glouberman has attracted a clump of highly talented people skilled at developing things like patient satisfaction/patient experience indicators.

He also meets with governmental officials, and healthcare service providers, to explain: “what patients want”.

 “We know the system will be changing dramatically over the next few years. We’re simply saying the patient perspective needs to be at the table as the new system is designed”, says Patients Canada‘s President.

“We’re interested in improving the healthcare system, and we’re interested in working with providers to do that. We don’t see ourselves as an isolated group arguing only for the patient perspective”, says Glouberman. His point: when patients win, everybody wins — healthcare professionals, administrators, boards, politicians, taxpayers.

“The most critical system change that needs to happen is the development and provision of health and social supports required by a rapidly growing population, with the various stages of chronic diseases. And the greatest savings we can make for this population is to provide support and treatment for them and their caregivers at home — in order to avert hospitalization or institutionalization,” says Glouberman.

Recent studies show that about 40 percent of people destined to go into very expensive institutions can be maintained at home — which would of course be of greater benefit to seniors’ physical and mental health.

While “aging at home” is often perceived as an option only for the wealthy, it is actually more cost-effective: the cost of homecare services for one day averages out to $55 compared to $1,000/day for a hospital bed, or at least $130/day for a long term care bed.

Glouberman explains, “This means that we need more care in the community — not only by primary care doctors, but also by nutritionists, pharmacists, physical and occupational therapists, and any other folks who can support patients and their family caregivers.”

Glouberman  has recruited former Deputy Minister of Health,  Michael Decter to serve as Patients’ Canada new Board Chair. Decter says,” My interest is to see emerging and reforming health care services informed in their design by the voices, insights and wisdom of patients. The needs and realities of the patient experience in an era of chronic disease need to come to bear more powerfully than they have historically. Now and in the future patients are far more participants than passive recipients of care. I am delighted to be part of Patients’ Canada because of the practical  and pioneering work of Sholom Glouberman and his colleagues.”

Along with Glouberman and Decter, Dr. Vaughan Glover, the President of the Canadian Association for People-Centred Health, also pushes for a very different kind of healthcare delivery system. Nevertheless, despite very clear messages from Decter/Glouberman/Glover, we still seem confused about what to do in a system that is bloated with data, but starved of wisdom.

So, just where is the community health services development vision that will guide the shift from acute care to community and primary care at either the provincial or local level? There are no such comprehensive plans to my knowledge, and there does not seem to be any pragmatic focus on developing the capacity of the community sector to expand to meet the challenges of our seniors population.

As long as shifting from acute care, to primary care, as the “hub of the system” is just a talking point in the Transformation slide-deck, the status quo is not in danger, if they just can keep everyone talking.

That does not mean we are doing nothing. We are doing “stuff”. But it is mostly unleveraged and underwhelming. The MOHLTC continues to focus their energy and attention on the “one-size-fits-all solutions”, like the Ideas From Utah Program, and by seeking the views of the traditional vested interests power groups that I have named in my blogs on Queen’s Park (i.e. the OHA, OACCAC, AOHC, RNAO, the OMA).

That’s not a negative comment about the Wynne Government. All governments — from all political parties — seem to dedicate themselves to protecting the status quo. I don’t know why, but they do.

People who were kinda hoping that Health Links might cause the unleashing of innovation at the local level, are now reporting that numerous HSP CEOs don’t really seem to see this as an opportunity to “transform the delivery system”. That’s not an agenda that they have truly embraced at this point. They see Health Links as a one-off pilot project about the top 5% of users. They are not working to transform the system. They think all the hype about transformation is mostly just bunch of gobblygook from babble-speaking insiders who profit from reform rhetoric. “This too shall pass,” say the long-timers who have learned how to fake compliance.

While MOHLTC officials tend to get caught in the interest group’s various lobby campaigns, they ought to pay very close attention to what the Minister is saying.

The Hon. Deb Matthews, currently under pressure from a ground-swell of unhappy clients and staff of the CCACs, has branded herself the “Patient-Centred/People-Centred Health Minister“. Her leadership on this strategic theme is having an impact as many health service provider organizations scramble to become more “patient, and people-centred”. It’s clear this is her passion. By selling the concept of “patient empowerment”, the Minister has also paved the way for a “new voice” among the interest groups.

The Minister of Health has made a revolutionary suggestion. She suggests we ask the patients what they think. But this is a big complex game. No doubt there will be new jobs for Directors of Patient Engagement — just like there were Directors of TQM/CQI in another buzz-word era. But will any of this PR rhetoric from MOHLTC result in any improvements? Is it possible that the patients could win?

Patients Canada and its dedicated bank of talented volunteers are stepping up to change the existing DNA of our healthcare services delivery system. They have put together a brain-thrust to develop the essential set of patient indicators — which will no doubt be adopted as the accepted standard across the province, much like Ottawa Ankle Rules.

As the “Health System Design War” heats up, there is a new player in town with patient indicators saying: “BUT THIS TIME, THE PATIENTS MUST WIN!”

But will they win? I sure hope so, but those fires of self-interest burning all around us are now clearly out-of-control and largely ignored by a critical mass of very nice leaders who continue to hope that it will soon be their turn in the inner-circle and the “big bucks”.

While those who have power and money can be expected to be aggressive in their efforts to maintain the status quo, it’s actually too late.

The bottom-up consumer revolution has arrived on the shores of our teetering healthcare delivery system. Bye, bye status quo!

FORWARD THIS BLOG TO PEOPLE YOU THINK WANT THE PATIENT-CENTERED REVOLUTION TO SPEED UP.

Political scientists studying interest group politics often start with an assumption that the “top of the food chain” in interest group politics has to be the Ontario Medical Association.

The initial assumption is that this rich and powerful lobby group runs circles around the government. However, the actual record over the past twenty years indicates that the OMA does not have a “winning track record” in their relations with government.

The truth is doctors tend to be politically naive about the cut and thrust of political dynamics. To start with, physicians are not even aligned as a group. So it has been hard for the OMA to be the “single voice of doctors”, when they are often fragmented.

The problem is: we will never successfully transform our healthcare system, until and unless our doctors are happy.

Nevertheless, it is hard to generate any sympathy for physicians among the other healthcare interest groups. Indeed, there have been a number of cases where government has gained the “upper hand” when the Ontario Hospital Association has publically opposed the OMA — and urged the government to undertake measures the doctors oppose.

While we’ve had many examples of “divide & conquer” politics among healthcare interest groups, these incidents become embedded in our culture, and in weakening relationships.

If our goal is to transform the system, we need these vested interest groups to collaborate and partner with one another. However, the challenge — following the expected election this Spring or next Fall — will be transforming our healthcare delivery system, with fewer financial resources.

Because our doctors are very well paid following the significant increases they negotiated with the McGuinty Government, the assumption is: they are the “big winners” in the resource allocation game.

Most people remember the series of generous increases over the past 10 years — forgetting the virtual wage freeze that lasted for much of the ’90’s. In the last set of negotiations, the result — on average — was that most doctors have experienced at least a 5% reduction in their income. It could have been, and still might get worse, once the election has been settled.

The top strategist for the OMA today is former Deputy Minister of MOHLTC, Ron Sapsford. While Ron certainly sees the “big picture” from his comprehensive perspective, his mandate is to represent the narrow interests of the doctors — who have experienced higher than average wage increases for over a decade, but who still feel undervalued, unfairly treated, and poorly paid.  

Indeed, “physician unhappiness” has become a major impediment to healthcare transformation throughout our healthcare system. “What are we going to do about our grumpy doctors”, is all too common a question/concern expressed right across the province.

We talk about the need to be honest and open with patients about tough issues like end-of-life planning. Well, we also need to talk to our doctors about what’s at stake over the next few years for the very survival of our public healthcare system. The system cannot be successfully transformed without the full involvement of physicians in the design, planning and implementation phases of health system transformation.

What we know from past experience is that “more money” does not make physicians happy. We’ve tried significant annual increases every year for the past ten years, and it does not work. More money has never solved our “physician unhappiness” problems.

Given that the government does not have any more money anyway, perhaps now is the time to address the underlying reasons for such widespread grumpiness on the part of the medical profession.

As everyone on the ground-floor of healthcare service delivery knows, physician behavior and attitude has a huge impact on both the quality of health service delivery, and on the level of job satisfaction for the rest of the health services team. We need “happy doctors” to produce an environment where the whole healthcare team can collaborate to achieve the great care, and good service, that taxpayers believe they have already paid for over many years.

As the system transforms over the next three to five years, nurses and other health professions will no doubt see jobs shift to the community sector — perhaps at lower pay. Physicians ought to understand that rather than “more money” for OHIP fees, we really need to save as many RN and allied health care jobs as possible.

How about some empathy from physicians for our non-medical health professionals!

Our anxiety-ridden service delivery system really can’t afford to have the OMA and the government at logger heads again over money for increased physician payments — we know how that nasty fight ends. It won’t be pretty.

Given that there is no money, can we stop the mean spiritedness, and switch to the “Happiness Agenda” for doctors; to the “Better Experience & Quality Agenda” for patients; and to the Determinants Of Health & Equity Agenda for the high-cost, at-risk populations?

The fact is, we need physician brain-power fully engaged in the on-going design and planning of our local health service delivery systems, at the Health Link operations level; and at the LHIN planning level; and, at the provincial policy level. We will never run a good healthcare system without meaningful physician engagement in the overall planning operations and policy process. We need physician brainpower — and we need positive and collaborative attitudes.

In recent years, the OMA has invested in a rigorous leadership development program which is beginning to produce a new generation of physician leaders at the local health care service delivery level. As the Health Links are being set up, there are numerous examples of young, smart doctors taking an active role in shaping our primary care system.

Dr. Jonathan Kerr of Belleville Ontario, is one such emerging community physician leader who graduated from the OMA’s leadership development program. The South East LHIN brought Jonathan on as their Primary Care Physician Lead. “He has got great listening skills and he builds trust and commitment among each of the people he works with”, says one observer.

Dr. Brent Elsey with the Barrie Family Health Team is another “next generation physician leader” who is really exciting physicians and connecting to everyone on teams throughout the North Simcoe Muskoka LHIN about the benefits of more integrated approaches to primary care.

In the Central West LHIN, Dr. Frank Martino is the Primary Care Lead. He is the current President of the Ontario College of Family Physicians. Observers say Frank is another “emerging physician leader” who really connects with other physicians — as well as with everyone else on the multidisciplinary partner’s team.

While the next generation is “getting ready” to provide enlightened and visionary local leadership for primary care reform and health system transformation, physicians as a group are too often chronically unhappy. But poking sticks at them in the fee negotiations is not a particularly smart strategy. Engagement and meaningful involvement is the very best strategy. The challenge is the “level of cynicism” that exists on both sides.

While everyone pays attention to the issue of physician incomes, the fact is organized medicine invests considerable efforts to improve health, and improve the healthcare system. Doctors have to work in this system, so they want to make it better too.

Currently the OMA is working closely with the Ontario Quality Council to develop quality-based procedures. They are active partners on the “Choosing Wisely Campaign” which encourages physicians to think about the value of tests which are of lower value, or, perhaps unnecessary for some patients — potentially saving hundreds of millions of dollars. The OMA is also placing priority on the electronic medical records with their aggressive e-agenda — which has now resulted in over 9,000 physicians with electronic records.

If we’re looking for insights that will determine the design of Ontario’s emerging system, the OMA certainly has compelling insights that must be considered when primary care — rather than acute care — is the centre of the system.

While it is true that many physicians still demand no further reductions in income, the fact is that many understand the province’s financial realities and are supporting the OMA to help create a better health system for everyone.

Hopefully the OMA Board and Council will be able to convince rank-and-file physicians that it is in their very best medium and long-term interests to help create a better healthcare delivery system — rather than just fight for an even richer pay packet for doctors — which can only end in what economists call, “The Tragedy Of The Commons“.

The “Tragedy of the Commons” is a systems thinking archetype that illustrates one of the common mistakes in designing complex adaptive systems: combining perverse incentives for individuals or silos in systems — where system health and survival actually requires cooperation and coordination of effort.

The archetype is named after an essay by ecologist Garret Hardin that explains how a tragedy occurs over the use of a “common pasture” — where the villagers of a community graze their livestock, and where the incentive structure is designed to reward everyone for increasing the size of their livestock herds. In such environments, greed is the normal response.

Over time, the common pasture is bare dirt, all the livestock die, and the villagers starve-to-death. That’s what we are heading for right now in Ontario: another “Tragedy Of The Commons“.

Prime Minister Paul Martin Jr’s $40 billion, 10-year, 6 percent annual increases “Fixed-For-A-Generation Health Sector Reform Fund”, was almost all spent on wage increases for healthcare professionals. While some of the money went to improved services, most went to improved wages for healthcare professionals.  

The Canadian Institute For Health Information reports that half of the money from the six percent annual increases went to physician fee increases — which went up an average of 3.6 percent each year, for ten years. Unionized nurses and hospital staff improved their wages by an average of 3.4 percent per year — “way better” than anyone else did over that same period.

So all that money — which was to be spent on changes that would “fix healthcare for a generation” — just turned into greatly improved wages and gold-plated pensions for health professionals. Not higher quality services. Not services that are more “patient-centred”, or even “safer” care. Just better wages and pensions.

Now we’re broke, and the healthcare system still needs to be “fixed“!

Let’s hope that our doctors roll up their sleeves and press on with the work they have started — and let’s hope that government and the delivery system meaningfully engages our doctors in efforts to truly transform our healthcare services delivery system.

Next week I’ll address the emerging Patients’ Lobby.

FORWARD THIS BLOG TO PEOPLE YOU THINK WANT TO BUILD POSITIVE RELATIONSHIPS WITH PHYSICIANS AND ORGANIZED MEDICINE. 

Over at the headquarters of the Registered Nurses’ Association Of Ontario (RNAO) on Pearl Street, a counter-strategy is evolving about how to deliver primary care and support services to meet the needs of our population with evidenced-based best practices. Their process includes looking at the evolving system through a lens that enables the full scope-of-practice of RNs, while also expanding the use of Nurse Practitioner-led Clinics and exploring concepts like the “Care Co-ordinators” in the delivery of primary care services. 

Over the past five years, the RNAO has conducted a number of very effective and influential advocacy campaigns for health system reform on such vital issues as primary care, air quality, health promotion and the transformation and expansion of community care services. All of these advocacy campaigns reflect the heart-felt values of their nurse members.

They have produced some top-notch, values-based, leading-edge public policy and nursing practice guidelines in their published reports: “Client-Centred Care”, “Facilitating Client-Centred Learning” and “Strategies To Support Self-Management In Chronic Conditions”.

These paradigm-shifting perspectives — all presented with compelling, solid evidence — are now starting to have an impact on the thinking of a number of key people/groups in the healthcare sector.

For their part, the RNAO argues that much of our CCAC costs are for “unnecessary bureaucracy”. They suggest relocating the Case Managers to primary care settings to save what they say is $160M annually in administration costs. While more streamlined administrative costs is one part of the RNAO’s goal, they say they are primarily focused on quality patient care, and evidence-based best practices.

Says RNAO CEO Doris Grinspun, “We are proposing that the CCACs evolve into moving the case managers that they currently have — 3,500 of them — directly to work in primary care to actually support patients in the community. Then, evolve the rest of the CCAC administration into the LHINs to actually provide health system planning for all the services, including primary care, and including home health care.”

Over 150 RNAO members will descend on Queen’s Park on February 27th for their annual Nurses’ Lobby Day. Nurses are now advocating for their three-year plan, Enhancing Community Care for Ontarians (ECCO) which proposes that interprofessional primary care organizations — such as Community Health Centres (CHC), Nurse Practitioner-led clinics (NPLC), Aboriginal Health Access Centres (AHAC) and Family Health Teams (FHT) — expand their reach and role over the next three years, with the support of a temporary LHIN-led Primary Care Transitional Secretariat to organize local geographic primary care networks.

The RNAO’s ECCO model proposes that by 2015, primary care organizations should provide complete care co-ordination and health system navigation for all Ontarians — including the referral for home health care and support services, thus eliminating the need for CCACs.

Current Registered Nurse (RN) case managers and care co-ordinators working within CCACs, would transition to the primary care setting and contribute their high level of expertise and system knowledge to provide dedicated care co-ordination and health system navigation to Ontarians with the most complex care needs. The remaining population will receive care co-ordination from a combination of existing primary care RNs, non-RN case managers/care co-ordinators and other qualified primary care providers.

So, by the end of Nurses’ Lobby Day, most MPPs will have had a quality one-on-one conversation with a passionate and articulate RN (from their riding) who will explain how the RNAO’s ECCO model benefits patients.

Having worked with nurses on strategy and operational issues for the past 20 years in the Balanced Scorecard development process with hospitals and CCACs, I think I have a fairly good understanding of their values, beliefs and passions.

Today, RNAO really does reflect their rank-and-file members. That’s why they have grown from 17,728 members in 2002, to 36,000 voluntary members by 2013 — an increase of 103 percent.

So, here is an organization with remarkable staff and board leadership. Even if you don’t like them because they are mostly focused on the nurses’ perspective, these guys really have learned how to be effective in our complex political/policy environment.

They do something very important: they speak “truth to power” and, as a result, they have real influence on how decision-makers think about the key healthcare issues.

Feisty RNAO CEO Doris Grinspun — who along with her President and thousands of engaged members of RNAO speak out passionately on behalf of the nursing profession. Indeed, Grinspun has become a major force for evidence-based health policy and for best practice reform initiatives that would truly benefit patients — while at the same time — enhancing the full scope-of-practice of RNs. She tells it like it is — the whole truth. As a result, all three political parties listen respectfully to Doris, and to the RNAO’s message.

Other groups are critical of the RNAO’s razor focus on just nurses — rather than on the whole healthcare team. However, most are very aware of the rising influence of nurses. The hard, cold, political fact is that our three provincial party leaders want to reach out to this significant voting block of 115,000 Ontario RNs and their families. So they listen carefully to Doris because she is a passionate, values-focused advocate who can, and will, mobilize these nurses politically.

As we witness the traditional “dances of the dinosaurs” with hospitals and doctors, another very entrepreneurial and highly strategic force for progressive health policy reforms has been unleashed by the Ontario Association Of Community Health Centres, under the leadership of Adrianna Tetley, their hard-working, highly-strategic, bottom-line CEO.  

Originally set up under Bill Davis’ “Red Tories”, Community Health Centres had an initial mandate to serve “at risk” populations — particularly the poor. However, the holistic, more integrated approach to primary care was seen as the model that would ultimately emerge as a focal point for primary care service delivery, while grand-fathering many of the solo GPs over however many decades it would take.

The long-term plan in the early ’80’s was to incrementally grow the CHC sector, and to measure its performance for gradual expansion into middle class communities. Thirty years later, we still only have 77 CHCs serving just 4 percent of the population. That’s because McGuinty and the OMA favored Family Health Teams to CHCs.

Tetley has the good fortune of representing a sector that produces excellent health outcomes —  in a fairly cost-effective manner. The CHC sector ought to have a bright future because of their high patient/client satisfaction rates — which are directly related to their fully-integrated, multidisciplinary team approach to holistic primary healthcare services.

AOHC places a lot of emphasis on building the internal capacity of CHCs to be excellent at quality, service and the patient/client experience. As a result, today there are many more examples of administrative excellence and high quality healthcare services — along with compassion, caring, commitment and love.

That’s why CHCs are becoming a “high-performing” component in the healthcare services delivery system. Addressing the CHCs at their annual meeting, Deb Matthews said: “What you do is not just the right thing to do for people in need, it is the right economic choice for the government to make.”

Recent studies by the Institute For Clinical Evaluative Studies (ICES) demonstrated that the CHC Primary Care Model is by far the best performer among all of the other primary care models. They even take the sickest — 32 percent of CHC clients have multiple diagnosis. Another study by Elisabeth Bruyère Institute, found that CHC model provides “superior services in chronic disease prevention and management, as well as superior health promotion services”.

Hello? Isn’t that what we will need more of in the future?

In terms of health system transformation, if primary care is to become the “hub of the system“, CHCs need to be a key strategic sub-sector that ought to grow by at least 8 percent  per year for the next three years — to achieve at least 24 percent growth (prior to reducing hospital budgets) as the government makes good on their commitment to “shift resources to primary care, and to the community sector”.

This “parallel system” would only co-exist for a short two to three-year transition period. That means that health system operating costs will be much more expensive in the initial set-up, and start-up phases of transformation. For a brief period, we would have both the developing community sector, and the hospitals (frozen at “0”), in full operation — until the appropriate community services are fully in place — and only then reducing the institutional budgets within each community’s Integrated Health Service Plan.

However, the realities of minority government — now, and after the next election — means that nobody is actually planning the “transformation” in any sort of strategic way.

Yes, that’s right. There is no plan. Surprise! Welcome to Ontario. We don’t have a plan for the future.

I told you, people with weak stomachs need to avoid observing two things: the making of sausage, and the making of public policy — because there is a lot of crap in both those products.

So the government mostly just “talks” transformation policy — and sincerely hopes for it to occur one day — while maintaining as much of the status quo as possible, for now. When you are in a minority government situation, its smart politics to be on both sides of the Status Quo/Fundamental Transformation debate.

Nevertheless, beyond the “politics of survival” for the Spring Budget 2014, is the whole ugly truth about the province’s true economic circumstances — and the realities of both pending funding cutbacks, and the pressing need for the reallocation of resources between the institutional and community sectors.

In the meantime, the OACCAC in its fourth policy paper, “launching the conversation”, has suggested that the government contract out their policy responsibility to a Commission or “Committee Of Experts” who would report after the election — so the current government can say: “It is being studied”.

But that won’t work. In the next election, voters will want to know from each political party: Do you support user fees, and means-tested private pay for home care services, or not?

And, if not, how do you propose to pay for expanded homecare services: by reducing some of the estimated 30% waste in our $48 billion system; by shifting resources from acute care services to home and community support services, or by some combination of these?

Next week I’ll tell all about the Doctor’s Lobby.