The complexity of the Health Link challenge seems to be waking up the systems thinkers among us. At conferences I attend, they are coming out of hiding and getting actively engaged in talking about “designing a better delivery system.” Wow! An environment that is “safe” for systems thinkers.

Oh, those poor lonely systems thinkers.

I remember going to Peter Senge’s Systems Thinking In Action Conference every year for about ten years. These were gatherings of about 800 people — from all over the world, and from multiple disciplines and perspectives. Everyone was sharing what we were learning in the field of “applied systems thinking”.

Participants — including myself — found it almost therapeutic to be among such a mass of people who think the same way as they do. Systems thinkers don’t do very well in a world governed by rigid rules, mandatory processes, common templates and the “one-size-fits-all” assumptions of those who seek to control, or to maintain the “illusion of control”.

When you learn about the critical success factors present in the 30 percent of organizations that successfully transformed, the most common is: systems thinking skills.

As Senge says, “Systems thinking does not mean ignoring complexity. Rather, it means organizing complexity into a coherent story that illuminates the causes of problems and how they can be remedied in enduring ways.” It also means designing effective changes in the right places in the system — the key leverage points within a complex adaptive human system as set out in such systems thinking design tools as the Strategic Alignment Model.

The phrase “system sensing” serves to remind us that perceiving a system is not merely an intellectual exercise: it involves giving validity to intuition, people’s senses and instincts, as well as measurable data.  Systems sensing is about following hunches and curiosities.  A wide variety of systems whisper to us everyday, requiring our keen sensitivity and attentiveness to their signals.  Systems typically do not start screaming until they are in crisis.  At that point, desired adjustments require far more time and money.

Systems sensing involves feeling, naming, and exploring the dilemmas we find ourselves in daily.  These dilemmas are typically entered into unintentionally and unknowingly.  Unearthing and inquiring with compassion into these dilemmas can, over time, cultivate deeper understandings.  Holding a systems perspective, or “holding the whole,” means recognizing that apparent opposites can be true, staying curious and patient with inquiry until the whole system in which these opposites can “make sense” is revealed.  Helping people discover and learn about the systems they perpetuate involves practice — asking, and receiving questions in ways that value the relationship with the learner — exchanging questions from the heart as well as the mind.

A person cannot develop the discipline of systems sensing without practicing compassionate and passionate inquiry of themselves and others.  Perhaps our habits of communicating have become a kind of prison for us.  Our “skilled incompetency” in asking questions maintains the very defenses we need to eliminate if we are to learn together.  In the absence of questions exchanged in genuine curiosity, our ability to generate shared insights and meaning is undermined.

To the extent that expert models persist, systems sensing, which requires going within, as well as outside for answers, cannot be realized.  Systems sensing values everyone’s contribution because everyone has a unique perspective from living in the system.  A system can never be fully perceived with just one pair of eyes and ears.  One person’s biases tend to filter out vital information.  It is only with multiple, often divergent perspectives that the rich diversity of a system can be adequately represented.  The ability to accept different points of view is present in community and desperately needed for us to develop the collective organs of perception which can more adequately represent a whole system.

System Thinking is a way of thinking about, and a language for describing and understanding the forces and interrelationships that shape the behavior of systems. The discipline of systems thinking enables us to see beyond the structures and barriers to the underlying processes that are driving system behavior.

Just before he died, Deming changed his old 80/20 Rule to 93-7. He concluded that 93% of the time he encountered dysfunctional systems, they were due to bad organizational design and alignment, while only 7% of the time the problem was due to “people problems”. But half the time that there were “people problems”, the root cause was actually a lack of skills and training. So, real people problems are actually only 3.5% of the problem.

While Deming said this 30 years ago, MOHLTC, the LHINs, our HSP’s CEOs, and our silo governance Boards continue to blame people for sub-optimal performance. Other than our addiction to structural “fixes-that-fail”, we don’t normally apply systems thinking to system design.

That’s because our so-called “system designers” are not designing systems that work, rather, they are simply focused on power — i.e. who should be “the boss” — and design around that decision. What the Minister of Health as asked for is “people-centred” system designs.

While we know that “change is hard”, we must understand that barriers to organizational and system change are not immutable forces of nature — they are human designs and creations. Over the years, many people — through governments led by all three political parties — have engaged in constructing these barriers based on their assumptions, expectations, habits and desires.

Leaders — in government/LHINs/management of HSPs/Governance — need to be prepared to start the process of altering the DNA of the delivery system. But because every Health Link, every LHIN and every HSP is different, the changes required, the sequence of the journey, the realities of local circumstances will require bottom-up, not top-down solutions.

Health Links that will succeed will be those who become true Learning Organizations.

Peter Senge describes a Learning Organization as “a group of people who are continually enhancing their capacity to create the results they want”.   He believes that the building of learning organizations requires basic shifts in how we think and interact. It is an exercise in personal commitment to being open to learning.  Without communities of people who are genuinely committed, there is no real chance of moving forward.

According to David Carnevale, author of Trustworthy Government, one of the key differences between learning organizations and traditional controlling organizations “is that deeply ingrained defensiveness so characteristic of low-trust, traditional bureaucratic organizations that undermines necessary learning.  Trust expedites learning.”

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”.

It is discouraging for front-line care providers to learn through the media about “connected consultants” who pocketed millions in untendered contracts, and about the whole Ornge scandal that costs taxpayers more millions, and about the bottom-line pay packets to some of our senior hospital managers.

The rampant entitlement mentality among senior managers and bureaucrats has created a genuine lack of respect in our healthcare hierarchy.

How do we shift that dynamic?

Carnevale says that “healthy learning organizations are managed with the objective of liberating and using employee know-how to improve work processes.  The emancipation of employee know-how is enabled through a different philosophy of organization and job design, communication patterns, labor-management relations, participatory methods, and other processes that reduce the climate of fear and allow staff the necessary psychological peace of mind to fully engage their work”.

Charles Handy, a scholar in the field, supports Carnevale’s position.  He argues that learning organizations must be built on an assumption of competence — meaning that each individual can be expected to perform to the limit of his or her competence, with the minimum of supervision.

Traditional bureaucratic organizations are dominated by the need for control and conformity — assuming that workers are incompetent and therefore must be carefully managed.  In turn, this creates high degrees of mistrust, defensiveness and fear — all of which undermine learning.

In learning organizations, the assumption of competence is supported through the encouragement of curiosity, creativity and innovation.  The people who deliver the organization’s customers are encouraged to use their know-how to improve work processes.  While successes are a cause for celebration, Learning organizations must also accept and forgive mistakes as part of the learning process.  They must be open to learning from their “best mistakes”.

A learning organization must be built on trust, togetherness and a sense of true community.  Few, if any, of the problems organizations face nowadays can be handled by one person acting alone.  The need for togetherness, or team learning, both to get things done and to encourage the kind of innovation that is essential to any growing organization creates the conditions for trust.

Trust, in turn, improves togetherness and creates a culture and a community in which learning can flourish.

At this stage of the development of Health Links, the partner CEOs and senior teams will either be taking their skills for collaboration to a new level, or settle into their entrenched same/old silos with no real attempts to shift thinking and behavior as the partners redesign the patient experience as they journey across the continuum-of-care.

Art Frohwerk, the inventor of the Experience Design Storyboard — which is now used extensively in leading-edge organizations to “design the patient experience” — says that in a silo-based system, patients are abandoned and mostly on their own as they journey across the continuum from hospital to home care, to chronic care, to nursing homes and palliative.

Storyboarding can be used to follow the patient journey across the health services delivery system, in order to address how the patient experience can be improved.

However, at a higher level of altitude from the patient’s clinical experience is the organizational design that produces the results that are being achieved.

A best practice systems thinking-based model for achieving organizational alignment is the Strategic Alignment Model (see below) that simply teaches us that in order to achieve your mission/vision/outcomes, you need to align the components of Structure, to the strategy; the components of Culture to the strategy; and, the components of Skills to the strategy.

Successful transformation occurs when the interdependent parts are designed to operate in sync with one another — and with the organization’s/Health Link’s strategy.

Successful transformation will not result from a series of isolated actions, but from orchestrating the right combination of interactions.

FORWARD THIS BLOG TO PEOPLE YOU THINK WOULD BENEFIT FROM A BLOG ON SYSTEMS THINKING AND SYSTEM DESIGN.

In a Health Link structure, it is the “lead partner” who has agreed to serve as the “managing partner” or “administrator” for the voluntary partnership of health service provider organizations. They have agreed to be accountable to the LHIN — for the overall success of achieving the outcomes that have been promised in the LHIN and MOHLTC approved Health Link Business Plans.

Of course, it is not only the managing partner who has to worry about success. In this first wave of 25 Health Links, each of the HSP’s senior teams — and their Boards — will of course be concerned with being among the 30 percent of organizations who will actually succeed at achieving their Health Link‘s promised outcomes. These guys really don’t want to fail.

However, the truth is: nobody has ever done a “Health Link” before, and the partnering organizations need to be willing, open and ready to learn together, and to discover together, just how to achieve their outcomes. I notice that I annoy some leaders when I point out that only 30% of Health Links will actually succeed. But evidence clearly teaches us to expect a 70% failure rate for TQM/CQI, merger, re-engineering, lean thinking, Balanced Scorecarding, etc.

While nobody wants to fail, people have to remember: this is also not a “game of perfect”. Health Minister Matthews says: “Dream. Imagine. Then strive to make it happen.” I like that.

People must be open to learning how they — and everyone else — can improve. If humans are involved, it means that in many cases, people will also have to “forgive” one another for past circumstances. If people can’t forgive past hurts, there will be no trust, and no learning.

What we know from past experience over the last twenty-years of reform efforts that the health sector has a variety of learning disabilities that causes us to sub-optimize our efforts.

So, what are the learning disabilities that Health Link leaders – and the managing partner organization – will want to address? In his essay “The Challenge of Stewardship: Building Learning Organizations in Healthcare“, Alain Gauthier lists Five Learning Disabilities common to the healthcare sector that could present serious barriers to the successful transformation of Health Link partners.

These include: the high levels of fear and anxiety in the system; the lack of a shared vision at the system delivery level; the fragmented service delivery processes; the fact that the system is silo-based, and provider-focused; with managers and organizational leaders who are too often driven by ego, rather than being “open to learning”; and, confused governance, and therefore confusion over the strategic direction.

1. High Level of Fear & Anxiety

Gauthier points out that fear and anxiety among healthcare workers and frustration and anger among physicians have produced organizations that are emotional molotov cocktails — driven by the blame and blame avoidance dynamics that have become ingrained in healthcare’s hierarchical command and control structures — and ways of “being” (culture).

In the current rules-based, process-focused, project management culture, the people who gravitate towards positions of power are “gate-keepers” who enjoy being in command and control. In an innovative, entrepreneur environment, people who gravitate towards to positions of power are the coaches and liberators of talent.

While only Tim Hudak ever seems to address our horrible financial realities, at some point soon, the Liberals must address the “whole truth” about our true financial circumstances. We also have to face head-on the emerging probably of institutional job loss, without sufficient growth in the community sector, and the distinct prospect for thousands of RN’s facing salary reductions — if they are fortunate enough to even land jobs in the community sector.

Shame on us for not equalizing wages for hospital and community nurses ten or fifteen years ago. Shame on us for not pushing RNs to their full existing scope-of-practice.

Now there is no money, and while it sometimes seems like the system is in denial, there are in fact many, many deeply worried people. How are we going to address these difficult and complex issues in acceptable and intelligent ways? How are we going to deal with fear at the core of our delivery system? In the Drucker Foundation’s Leader-to-Leader periodical, Larraine Segil’s essay “Leading Fearlessly” points out that fear is damaging. It causes insecure behavior that can run from defensiveness and negativity to paranoia and operational paralysis.

“If an organization breeds fear, it soon slides into corporate sclerosis. Process is used to create a series of hurdles – not for the purpose of learning, or the validation of ideas and projects – but rather as a means for denying innovation and slowing change”, according to Segil. So are Health Links in an entrepreneurial model, where people are aligned on a shared vision and where innovation is encouraged? Or, are they to be a bureaucratic model, where making up and following rigid rules and sticking with prescribed norms is the way to go?

Deming said, if we chose to change, our first priority must be to “drive out fear“.

That means getting a better grip on the appropriate balance between both the “entrepreneurial” and “bureaucratic” models. We need to liberate talent to solve problems, but we need to measure and account for our performance.

Health Links do need to create internal structures and decide on processes/methodologies to achieve at the clinical level what they have agreed to achieve. LHINs need to behave as “shepherds” & “coaches” –true helpers — keeping in mind that Health Links are accountable to the LHINs for bottom-line results.

As “liberators of talent”, senior and middle managers across the Health Links need to provide emotionally intelligent leadership that drives-out-fear, creates a supportive learning environment, and ignites innovation and learning. My hope is that the spirit of Deb Matthews words are filling the hearts and minds of MOHLTC and LHIN officials — as well as everyone at the operational level.

In the early developmental phase of the “Linkets“, we need to keep in mind, these new organizations are just now at the forming stage of team development. The key here is the creation of a “safe environment” — an environment where relationships are built, and trust is strengthened at the clinical level, middle managers’ level, as well as at the senior management level.

The challenge to overcome is the so-called “abuse syndrome” — where MOHLTC creates a command and control, blame-oriented Accountability Agreement with LHINs, who, in turn, engage in commanding and controlling relationships with their HSP’s – who in turn, repeat the pattern on down to the front-line care provider — generating a culture throughout the system that is characterized by fear & anxiety.

Fear and anxiety injected into healthcare operating systems causes dysfunctionality that can be measured in error rates and failure in 70% of cases.

Best practices and the “lessons learned” from whole system transformation efforts suggest that we should expect that 30% of Health Links will emerge with the leadership and the strategy required to actually transform. And, as we always say: it starts with “vision”.

2. No Shared Vision

Alain Gauthier points to the health sector’s well-known addiction to what system thinking scholars call the “Fixes-That-Fail” system dynamics archetype. This recurring pattern is used in order to get by each successive crisis.

In Ontario, our “structural quick-fixes-that-failed”: include: DHCs, local MOHLTC offices, some LHINs… and maybe now some of the 75 to 80 Health Links– if they are allowed to become unaligned structures, where HSPs find it difficult to collaborate.

Mr. Gauthier says of healthcare bureaucracies: “they have practiced cost-shifting, implemented across-the-board cost cuts, forced mergers, and engaged in restructuring without understanding the consequences of their actions.” He says, “when they are confronted by new challenges such as outcome measurements, they look at reengineering, continuous improvement teams and visioning as just another wave of ‘quick-fixes’ – without realizing the philosophy and organizational alignment that these approaches imply.”

You will have noticed that under stress, our healthcare sector typically tends to exhibit one of two different behaviors: (1) immediate action, as in response to a system crisis like SARS; or, (2) bureaucratization, by drawing processes out for so long, they finally disappear –while providing policy-makers and operational managers with the temporary “illusion” that “everything’s under control”– because we have a “very tight process”.

The problem is: neither of these habitual “normal responses” will produce a successful transformation. Instead of grasping for the next structural-quick-fix, Health Link partners need to slow down, get in alignment, and develop the shared vision of the partners through extensive dialogue.

In the case of North Simcoe Muskoka, their community has had an intensive four-year dialogue among the health service provider partners to create a shared vision they call “Care Connections“.

The Dufferin Area Health Link brought together fifty people last May — including the CEOs, senior staff, physicians, LHIN Board & Staff and Governance Boards of the member partners in their Link — to develop a “shared vision” using Mindmapping techniques. Rather than the classic visioning to wordsmith a “Vision Statement“, Headwaters CEO Liz Ruegg wanted to have the first iteration of their Link’s vision to be the product of people’s passion and imagination. This technique is great for groups of 25 to 75. (Click to see Mindmapping Workshop evaluation & brochure)

Of course while it is great that the North Simcoe Muskoka and Dufferin Area Health Link have a top-down shared vision from the Boards and senior managers, if they don’t also facilitate a bottom-up vision for seamless high-quality services, the top-down vision will not likely come true.

To work, shared visioning must be both a top-down, and bottom-up exercise.

Unless there is mobilization at the front-line of care to create a better system, patients and taxpayers will just get the “same/old” fragmented services delivery by a new brand — called “Health Link“.

In their health system research, the Balanced Scorecard Collaborative discovered that where transformation strategies failed, less than 5% of front-line healthcare workers even knew what the vision was.

There are a whole range of methods for tapping into the collective intelligence of cross-functional teams across the entire continuum-of-care. Change practitioners call it “The Whole System/In One Room” – maybe 200-300 people from all levels – including 50 patients and family members who will cause the dialogue to “get real” by their very presence in the room and in the break-out groups.

While I have personally tested half-a-dozen Large Group Intervention Methodologies, I think the most appropriate method for Health Link partner dialogues at this early stage of development is called the “Systems Thinking Unconference” – an off-shoot of Open Space Technology.

If you want to know more about how to extract collective intelligence from large groups, you can go to “ABOUT US” on this website– where you’ll find Misha Glouberman, who has taken Open Space & Unconference methodologies to a new level of art. Misha and I collaborate to combine systems thinking with collective intelligence.

Getting 250-300 people to explore a “focused question” — using a systems thinking design tool as a lens that requires everyone to see the “whole system” and its key leveraged components — will lead to transformational thinking from the group. I believe our unconventional unconference methodology is the very best way to generate trust, collective intelligence, fellowship and commitment to action.

By looking at the Health Link through the lens of a systems thinking tool for system alignment, and tapping into the collective intelligence of a mix of stakeholders (e.g. patients/families, front-line staff, middle managers, board members and LHIN planners), people will design systems that work.

People interested in the type of report an Open Space or Unconference can produce can review the report generated by 150 physicians and 150 primary care non-physicians facilitated by Sholom Glouberman and myself. (Click on Primary Care Reform In Alberta: Open Space Report)

If you are interested in how to tap into the collective intelligence of Health Link  middle managers and front-line staff, Large Group Interventions Technologies is a great book by Bunker and Alban that can also provide you with a number of interesting of methods for tapping into the collective intelligence of your system. But I really think the System Thinking Unconference works best. Trust me. I know it might seem scary, but handing over control actually works!

3. Fragmented Organizational Designs & Processes

Gauthier points out that “most healthcare organizations are highly fragmented — where an extreme degree of specialization is compounded by very different “mental models of reality“. This is equally true of Health Link partners.

Among the traditional polarizations that he addresses in his essay are: primary care practitioners vs. specialists; physicians vs. nurses; administrators vs. clinicians; clinicians vs. support services; acute vs. non-acute care; and, institutional vs. public health/community-based care and home care. That is a lot of polarizing perspectives!

In our fragmented and often dysfunctional healthcare system today, we design both the macro healthcare system, and the internal organizational systems/structures/processes at the service delivery level, as a series of poorly connected silos– where patients/clients experience the opposite of “flow”. The result: consumers experience gaps-in-services, a lack of co-ordination, as well as increasing rates of clinical errors –particularly at the “hand-off” points, right across our service delivery system.

Over the past several years, significant efforts/resources has been invested (by mostly the hospital sector where 1 in 13 patients are harmed, and where 25,000 people a year die in a preventable accidents) in quality and safety programs. But hospitals and CCACs, home support services, etc are all at different stages of development on these measures. Now the challenge is: how can the partners come together on a quality/safety & patient experience agenda?

Without a common language and framework for thinking together, experience tells us that many of the professions across the silos will simply “talk past each other” – holding onto completely different assumptions, beliefs and mental models about their shared circumstances — their Shared Reality.

Without a shared understanding of the realities that must be faced, and without a Shared Vision for the whole delivery system; organizations and healthcare professionals will simply remain within their silos – with little understanding of how each silo impacts on the other — or even how other silos impact on them.

As we move into the Fall, a number of Health Links are just now organizing Dialogue Workshops and Visioning Workshops – engaging Health Link senior managers, Board members and frontline caregivers from across the partnership to talk about what they want to create together. Many of the Health Link presentations I have seen emphasize that the partners are still just now actually getting to know and understand one another.

That’s a good way to start! Strategically, it’s called: “Slow down, in order to speed up.”

Today, there is lots of churning going on. Lots of organizations are just now in the process of “getting ready” to deliver on the commitments they made in their Health Link Business Plan. Some are just now taking baby steps as Linkets. Some are changing quickly, and significantly to adjusting to emerging budgetary realities. Others are now exploring their strategic options at internal Board/Staff Partners’ Retreats.

But let’s be clear: this is the “lull before the storm”.

After a very brief 6-month start-up period, the Health Link Transformation Program was officially launched on May 15th with 25 Health Links now in their initial development phase. The rate of change will no doubt soon pick up. But measurable progress will only be made when a critical mass of managers across the Health Link partners can see “the big picture” – from multiple perspectives – rather than simply seeing the same old fragmented pieces of the puzzle.

So, after ten months of intensive Health Link development, what have we got? Do we have front-line workers who “see the big picture”, and are working towards it, or, do we have the same/old fragmented pieces of the puzzle — the MOHLTC has invested $1 million in start-up funds to support each of 25 new organizations. The successful Health Links will be those who invest that money in skills development.

In Back to Basics, Gordon Dryden provides the following advice to those who are drowning in complexity. He says:”Remember jigsaw puzzles: they’re much easier when you can see the whole picture first”. “Seeing the whole picture” can only happen when we “let go” of the mental blinder: “My reality is the reality.”

Only then can we open our minds and hearts to “seek to understand” the perspectives of others.

4. Silo-Based & Provider-Focused vs. Customer-Focused & Person-Centred

“All systems are perfectly designed to produce the outcomes they achieve. If you want different outcomes, you need to design a different system,” is how my mentor, Herbert Wong would always put it.

Many of the existing systems, structures, processes and incentives continue to encourage healthcare organizations within a local delivery system to focus on their independence, rather than facilitate or encourage interdependence.

This is why our health care system is so crazy-making! There isn’t significant alignments for on-the-ground, pragmatic strategic change that matches the rhetoric for health system reform. If Health Links are only focused on operations at the clinical level, and not on the design of the system, they will simply continue to remain silo-based and provider-focused.

While the provincial government officials often lectures the healthcare sector on the need for integration, coordination and cooperation, the fact is that their own core designs and Ministry silos actually entrench fragmentation, competition and political behaviour as the principle means of survival and growth in our healthcare system.

At the governance level, Gauthier points to “the lack of deep relationships with the community as a larger system” as the ultimate outcome of our existing fragmented designs. So, are our Health Link partner Boards there to represent the interests of the “owners” of their organizations– while fully understanding the perspective of all stakeholders. Or, are they there to represent their silos’ best interests?

Boards of health service providers have signed-off on a Business Plan that outlines what their Health Link will accomplish, but to what extent do they ask “wicked”, and “probing” questions about the transformation plan at each Health Link? If Health Service Provider Boards don’t shift their attention from their silo’s performance, to the system’s performance, patients will be experiencing the same old silo-dyslexia.

If boards are to foster innovation in their organizations, they should practice Generative Governance, learn about their potential to improve quality and safety — as well as enhancing the patient experience.

If Alain Gauthier has accurately described the “larger picture”, and the true context in which healthcare organizations operate, it should not be surprising that there is some confusion, a lack of focus, and unbalanced approaches at both the governance and managerial levels of delivery system. That confusion, and this lack of alignment, is going to be deeply felt on the front-line of the system as the delivery system transforms.

If that’s the case: Boards need to slow down, engage in dialogue, and build on each member’s ideas — until new solutions or possibilities emerge.

If the “Fewer is Better Tribe” of advocates (who want to get rid of governance boards) lose their battle for merger mania, then community governance boards could end up playing a huge role in shifting the healthcare service delivery system — simply by changing their focus on their silos, to holding management accountable for being system/customer/and person-focused.

Boards also have a role in building trust — in their organizations, and in their Health Link Partnership. If you are a board member, please be open to thinking differently. You can help drive real change, when you are also open to change and to whole system transformation.

According to David Carnevale, author of Trustworthy Government, one of the most detrimental aspects of traditional controlling organizations “is a deeply ingrained defensiveness characteristic of low-trust, traditional bureaucratic organizations that undermines necessary learning. Trust expedites learning.”

Carnevale says that “healthy learning organizations are managed with the objective of liberating and using employee know-how to improve work processes. The emancipation of employee know-how is enabled through a different philosophy of organization and job design, communication patterns, labor-management relations, participatory methods, and other processes that reduce the climate of fear and allow staff the necessary psychological peace of mind to fully engage their work”.

In true Learning Organizations, the assumption of competence is supported through the encouragement of openness, transparency, curiosity, creativity, innovation and stewardship. Middle managers and teams of front-line healthcare providers need to be provided with systems, structures and processes that will enable them to use their know-how to improve work processes.

5. Confused Governance

In the past, individual silo boards were encouraged to see their role as cheerleaders for their silo’s growth and their sector’s growth. The boards thought their role was to advance the cause of their silo — rather than the interests of the “owners” of the silo — the citizens of their community.

We know that dysfunctional relationships between governance and management often leads to dysfunctional relationships everywhere in the system.

Gauthier points to the confusion that occurs when “Board members have been mostly driven by somewhat narrow financial considerations, and have not consistently expressed the voice of the community.” In the past, when the provincial government focused their primary attention on the financial quadrant of the Scorecard, the unintended consequence was for Boards to “let go” of the other perspectives: the customer outcomes, the quality and safety measures, the internal processes, and the learning & growth enablers for staff.

Now the Minister has been very clear that Health Links are about “improving the patient experience”, and about “improving quality”.

While there are wonderful examples of leading-edge governance boards who have significantly shifted their governance style towards “generative governance“, we also have examples of boards making very meaningful contributions as they focus on “quality” “safety“, and on the “patient/client experience“.

Where Boards have dutifully focused their CEO’s attention on finance alone – without the balance – the typical strategies brought forward by management, and approved by boards were: reengineering, downsizing, and reorganization of the silos.

If you read my various blogs on the quality of board governance in Ontario’s health system — you will know about how dysfunctional board behaviors in hospitals, CCACs, LHINs and community agencies I wrote that at least 15% of health care governance boards – according to my anonymous “Panel of Governance Coaches.” — are dysfunctional.

But today, in the chaos, are voices of influence saying “We need fewer boards, fewer organizations.” This seems to be the new “structural-fix-that fails”.

I don’t agree with the “fewer is better” crowd.

If the Canadian Patient Safety Institute (CPSI) is correct: that Boards can add significant value to patient safety, quality and the patient experience when they are designed to do so; then why would we want fewer of them?

In a complex adaptive system that is thriving, you will find bio-diversity. Been snorkeling on a barrier reef?  Bio-diversity enriches everything. Heard the expression “teaming-with-life”?

The lean left-brainers will argue that a single board for all the Health Links partners will somehow lead to all sorts of wonderful things. But it would just be another “structural-quick-fix-that-fails” — and it would certainly lead to several years of sustained chaos.

When we add right-brain to our left – known as “whole brain thinking” – we can see how the multiple perspectives of governors from different organizations would provide a more holistic view of the patient/client journey along the continuum-of-care.

When the Public Health Units and health-related social support services are included in the mix of HSPs from the LHIN, then the question can be asked: How can each silo-governance board “add value” to the achievement of their Health Links goals & objectives?

If these are indeed the five learning disabilities of the health sector, then the prudent response would be:

1. First, drive out fear. Develop the internal capacity to transform. Become a safe, supportive, collaborative environment. Invest in just-in-time capacity-building for transformation. Become a learning organization.

2. Abandon the “structural quick-fixes” and tap into the collective intelligence of the system and fully engaging the patient/family perspective to the redesign of services.

3. Let go of “silo perspectives”, and focus on the patient/client’s whole journey across the continuum and develop a System Balanced Scorecard. Align economic incentives to reward quality outcomes and patient satisfaction rates.

4. Shift from “provider-focused” system design to a “patient/client-focused design” – and liberate front-line workers to engage in patient experience design — with Storyboarding methodologies.

5. Fewer isn’t better! But how governance is practiced needs to evolve to embrace a “larger accountability” for integration across the delivery system – not just governance for their silo. Governance transformation is essential. Click on Governance Matters.

6. Develop a Health Links System Scorecard with CEO & Managerial Accountability Agreements that are designed to achieve the results sought at the unit/department/organization & system levels.

7. Trust in the wisdom of people!

While I always worry about the perception that I’m crying: “wolf!”, I really do know what it takes to succeed in “transforming” — the extraordinary organizational/human journey that is the equivalent of moving from caterpillar to butterfly. I’ve been in the “transformation business” for twenty years. It is our business to know how and why 30% of organizations succeed at a specific change methodology called “transformation“.

The fact is that organizational and whole system transformation means “big change” — not a great environment for humans.

Such environments often feel chaotic and dangerous for top management, and for front-line workers. Middle managers mostly feel “torn” between their bosses, who want wonderful outcomes, and the realities faced by front-line care providers — who must live inside systems, structures and processes that aren’t designed or aligned to deliver on the outcomes required/needed by either patients or staff.

The truth is that people become fearful and anxious in such conflicted, stressful, no-win environments — where people get blamed all the time. Health care services are in fact one of the more toxic work environments in Canada, according to tracking studies on 14 Industries over 10 years.

Authors Cooper & Sawaf, in their book Executive EQ, suggest that we “reflect on the amount of time and energy we spend on protecting ourselves from others we do not trust, on avoiding problems we do not discuss, remaining silent and going along with decisions we disagree with, instead of being open to exploring and acting on opportunities and insights that spring from our emotional intelligence”.

Think about it. Think about the waste in human energy! These health sector cultural issues really must be addressed. People need to live and function in safe, supportive environments — not the stressful and threatening environment we experience today.

The authors define “emotional intelligence” as “the ability to sense, understand, and effectively apply the power and acumen of emotions as a source of human energy, information, connection and influence”.  E.Q. is what drives and inspires us towards living out our core values and our purpose in life.

Challenging the commonly held assumption that emotions are either “good” or “bad”, Cooper and Sawaf make the point that emotions “serve as the single most powerful source of human energy, authenticity, and drive that can offer us a wellspring of intuitive wisdom.”

Daniel Goleman’s two block-buster books, Emotional Intelligence, and Working with Emotional Intelligence have profoundly contributed to our understanding of the extent to which our emotions — our feelings — impact on our thinking.

By slowing down the process, by practicing reflection, by thinking about our thinking, and by striving to know ourselves and those around us better, we can come to learn how we can become more integrated — as individuals, as a system of individuals, and, as a service delivery system focused on patients who need our support and care.

The feedback and information that emotions provide us with can be extremely important, powerful and productive.  The key is to have developed our E.Q. to the extent that we learn to acknowledge and value core feelings, in ourselves — and others — and to respond to that information appropriately.

“It is this feedback – from the heart, not the head – that ignites creative genius and intuition, keeps us honest with ourselves, shapes trusting relationships, clarifies important decisions, provides an inner compass for life and career, and guides us to unexpected possibilities and breakthrough solutions”, says Goleman.

Researchers and change management practitioners carefully explore “what went right” in the 30 percent of cases where organizations, and networks of organizations, successfully transformed. Are you interested in “what worked”, and “what didn’t work”? If you are, you can learn how to squeeze into the 30% Club for Successful Transformation.

Experience tells us that the leaders at most Health Links will attempt re-invent the wheel — and then, after 24 to 36 months of painful struggles, land squarely in the 70% Club Of Failed Transformations. It is always interesting to watch decision-makers dismiss the knowledge about best practice transformation. They confidently deny that there will be a 70% failure rate among Health Links.

“Oh, such negativity! Tisk. Tisk. You should stop being so negative,” is a common response I hear. But, sorry folks, these are the facts: only 30% of large-scale transformations ever succeed — TQM/CQI, downsizing, mergers, re-engineering, lean thinking — all experienced 70% failure rates. Why would that be different for the 80 Health Links?

Right off the bat, we remind people what they are told in Change Management 101: that they will not go very far without a “Shared Vision”. We show them the data on the cases where health system transformation failed — which indicates that less than 5% of front-line workers actually understood the vision, or even knew about it. Are people really hearing that? I don’t think so. Do you?

Look around, how may Health Links are obsessed with forging a “Shared Vision”? How many are engaging the front-line to work in partnership with patients/clients/families to design a better more patient-focused services system?

See what I mean? Trust me. We will indeed see 70% failure rates in Ontario — because experience tells us that most will never take the time to engage people in creating a Shared Vision — or follow any of the other essential elements and critical success factors for leading and executing a successful transformation.

I find it interesting that one of the common elements among the organizations that have successfully transformed is the great sense of “togetherness”, or sense of true “community” that gets created through the start-up phase of their transformation journey. We know from the literature, and from deep experience, that as an organization transforms, people become more authentic, and more caring towards one another. People get connected — as people. They feel better understood, supported, respected and valued.

The greatest transformations have taken place in organizations, or systems of organizations that have become Learning Organizations — with a mindset and discipline for continuous improvement, discovery and innovation.

Such shifts do not occur overnight. It takes enlightened and adaptive leadership at both the Health Link CEO-level, and within each organization in the partnership.

The process is accelerated when a critical mass of people within an organization are on a personal journey of change. They become more aware of themselves, and better understand the impact they have on others. Best practices suggests that a critical success factor for transformation is the “modeling of emotional intelligence” by the leadership of the organization, and by the leaders of Health Link Partnership.

In Primal Leadership, Daniel Goleman points out that while most people recognize that a leader’s mood – and how he or she impacts the mood of others – plays a significant role in any organization, emotions are often seen as “too personal” and “un-quantifiable” to talk about in a meaningful way.

But research in the field of emotion has yielded important insights into not only how to measure the impact of a leader’s emotions, but also key insights into how the best leaders have found effective ways to understand and improve the way they handle their own, and other people’s emotions.  Understanding the powerful role of emotions in the workplace sets the best leaders apart from the rest – not just in tangibles, such as better bottom-line results and the retention of talent; but also in the all-important intangibles, such as higher morale, motivation, commitment and innovation.

This emotional task of the leader is primal – that is, first – in two senses:  It is both the original, and the most important act of leadership, according to Goleman.

In the modern organization, this primordial emotional task – though by now largely invisible – remains foremost among the many jobs of leadership: driving the collective emotions in a positive direction — and clearing away the smog created by toxic emotions.  This task applies to leadership everywhere — from the boardroom, to the point-of-care.

Quite simply, in any human group the leader has maximal power to sway everyone’s emotions.  If people’s emotions are pushed toward the range of enthusiasm, performance can soar; if people are driven toward rancor and anxiety, they will be thrown off stride.  This indicates another important aspect of primal leadership:  Its effects extends beyond ensuring that a job is well done.  Followers also look to a leader for supportive emotional connection – for empathy.

All leadership includes this primal dimension, for better or for worse.  When leaders drive emotions positively, they bring out everyone’s best.  We call this effect “resonance”.  When they drive emotions negatively, leaders spawn “dissonance”, undermining the emotional foundations that let people shine.  Whether an organization withers or flourishes depends to a remarkable extent on the leaders’ effectiveness in this primal emotional dimension.

What concerns me when I think about introducing the front-line of healthcare service providers to the Health Link paradigm is: what is the existing level of resilience in the healthcare delivery system? Our system has been through a lot over the past ten years: re-engineering/mergers/lean thinking/ etc. healthcare governance should be seeking to discover: Are people at your organization becoming “change fatigued”? Is everyone ready for even more “big changes” — from caterpillar to a butterfly?

I’m always amazed at how resilient and dedicated our front-line care providers are.

While I am sometimes not popular with senior managers for saying so, almost all organizational and whole system transformation failures, failed at the top — where life at the top of the health sector can be both brutal and rewarding.

I’m fascinated that researchers have traced resilience — the capacity to re-cover from adversity — to a network of brain regions and the production of certain chemicals in the brain. Resilience relies on neural circuits governing fear, reward and social and emotional regulation — all going down in a chemical soup that can be altered by the CEO, and by other leaders, when they shift their behaviors intentionally.

Sure, I know: easy to say, harder to do.

Resilience is the ability to modulate and constructively harness the stress response. A person can boost his or her resilience with strategies that include: reframing, enhancing positive emotions and connecting with others. Success on transformation will absolutely hinge on “resilience”. Set backs are part of any endeavor — and those who react to them productively, will make the most progress.

However, bottom-line: our experience after 20 years in the “organizational transformation business” teaches us that the 30% of successful organizational transformations are caused by certain leadership styles: adaptive, primal, and generative. That’s why we teach these models/skills/ and “ways of being”. We show leadership teams how to create a “safe environment” for transformational change.

Critical to building “resilience” is the capacity to face fears, experience positive emotions, search for adaptive ways to reframe stressful events and poor relationships.

Resilient people thrive when leaders are primal.

Making primal leadership work to everyone’s advantage lies in the leadership competencies of emotional intelligence:  how leaders handle themselves and their relationships.  Leaders who maximize the benefits of primal leadership drive the emotions of those they lead in the right direction.

For the most part, the brain masters the competencies of leadership – everything from self-confidence and emotional self-management to empathy and persuasion – through implicit learning.  But strategies for community building and for building emotional intelligence has to be deliberate.

The very best tool I have ever seen/experienced for successful personal and organizational transformation is a framework for emotional intelligence, a powerful tool called Personalysis^®. This is a remarkable framework and tool that has helped numerous organizations as they underwent their fundamental transformations.

I believe it works as well as it does because, paradoxically, the root to empathy, and to empathic leadership, is through self-awareness. Time and again we learn: the more you understand yourself, the more empathic you become.

A few years ago, when I had to write a chapter of a book on the topic of “Organizational Transformation“, at the publishers expense, I actually got to test five competitive emotional intelligence frameworks to confirm my personal experience over 15 years: that the Personalysis^® Framework is the very best tool of its kind.

This type of framework and language is absolutely essential to enable senior and middle managers to go through the chaos of transformation with such a personal grounding tool that enables them to use the methodology, language and frameworks in ways that facilitate transformation in very supportive ways. If you are thinking about getting a Personalysis® Report, call me at 416-581-8814.

Try it. It will provide extraordinary value and insights.

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The big search for who is in the 5 percent of “high-users” of healthcare services has found that mental health and addictions clients are among the highest right across the province. It makes sense that they show up as “high-cost generators” in other parts of the system. We’ve known about the underfunding for mental health for years.

It seems that the only time anything improves for the mental health sector is when — from time to time — a Minister of Health steps in, and simply makes it happen. Poof! The Minister can be like the fairy godmother, when they decide something is a priority.

While I often rant and rave about politics in healthcare, the fact is “values” and “political beliefs” drive both health policy, and directly influences how our health services delivery system behaves.

Because of my background and experience as a speech-writer for Ministers of Health from all three political parties, I always focus on people’s values. “Values” were certainly what drove Health Minister Larry Grossman in the early 1980’s, when I served as his Chief-of-Staff.

Respect, compassion, dignity, human rights, and community service were values that were instilled in Larry by his family from the start. Larry would recall how, as a young boy waking up each morning, he would hop out of bed and tiptoe around refugees who had been taken in for the night by his parents in the aftermath of 1956 Hungarian Revolution. He understood what was expected of him: he was to “add value” to the world by being in service to the communities of which he was a part.

When he arrived as Minister of Health in 1981, Grossman was clearly a star cabinet minister in the government of Bill Davis. As Minister of Industry, he had been innovative and bold in his efforts to support the transformation of Ontario’s economy from its traditional industrial base to the underpinnings of what has now evolved into the knowledge economy.

As a cabinet minister, Grossman was visionary, highly strategic and courageous. He was determined to make a difference in the world that he inherited.

By his third day as Minister of Health, Grossman had exchanged his pinstriped suits for blue jeans and a T-shirt as he toured Parkdale with ex-psychiatric patient activist, Pat Capponi – who today is a successful Canadian writer.

Pat Capponi did not give Mr. Grossman a nice safe ministerial tour. In the late 1970s, the provincial government had closed thousands of institutional psychiatric beds – in part due to budget constraints, in part due to changing treatment patterns – but they had no, or very few, support programs in the community.

Releasing thousands of patients with only a packet of pills and a pat on the bum had produced a major crisis in downtown Toronto. Deplorable living conditions and what coroner juries called “death by therapeutic misadventure” were the results of government policies that had no vision and no strategy for the traditional “poor cousin” of Ontario’s health care system: the mental health care sector.

Shaken by Pat Capponi’s real-world tour of Parkdale’s Kafkaesque boarding houses, and by his conversations with the ex-psychiatric patients he met, Grossman vowed he would transform the provincial mental health system – and in particular, provide dignity, respect, and meaningful support for those who needed it, where they needed it.

As he dug deeper and learned more about mental health issues over his first several months at the Ministry of Health, Grossman began to develop a much more comprehensive approach that was based on the advice of the mental health reform advocates that he surrounded himself with.

Steve Lurie, Aileen Meagher, Brian Davidson, Mary Ellen Polak, Ron Ballantyne, Dr. Tyrone Turner and numerous front-line support workers collaborated with Grossman and his staff to craft policies and programs that would enable the system to evolve to meet the changing needs of the people it was intended to serve.

Within 18 months of his arrival at the Ministry of Health, Grossman had a new Mental Health Act focused on patients’ rights; a Psychiatric Patient Advocate Office; a major commitment to develop supportive housing for people with chronic mental health issues; an expansion of community-based mental health and support programs that sky-rocketed from $17 million per year to $75 million in just 18 months; a strategy for the devolution of the Provincial Psychiatric Hospitals; and, a commitment for $100M in capital to replace the old Whitby Psychiatric Hospital with Ontario Shores.

In the olden-days, that was a lot of money — and a lot of rapid change.

But what Grossman understood was that money and laws alone would not “fix” the system: what was needed was a fundamental shift in the way we think about mental health – within the mental health system itself, and among the public.

For the public, Grossman, through his partnership with the provincial arm of the Canadian Mental Health Association, sponsored large-scale award-winning radio and television commercials that appealed for public support for the reintegration into the community of fellow citizens who had experienced a mental health problem.

Grossman understood that the real struggle for shifting attitudes would be in the mental health care system itself – among administrators and mental health professionals. That is why he placed special emphasis on the role of the Psychiatric Patient Advocate Office (PPAO) as the key leverage point in the system. Grossman wanted the PPAO to have a profound impact on the culture (thinking & behavior) that had evolved within the system.

“Our challenge,” said Grossman, “is to change the very culture of the system. We need to help administrators, professional practitioners, and Ministry of Health officials to change the way in which they think about mental health and patients’ rights.”

So, here we are – 30 years later. Did the Psychiatric Patient Advocate Office achieve its intended purpose? Has supportive housing proven effective? Did the community mental health sector rise to the challenge? Did it build the internal capacity to transform, grow and evolve? Did the provincial psychiatric hospitals successfully devolve and evolve? Did Larry Grossman’s values-based mental health sector reform strategy work?

As someone who worked with Mr. Grossman on his various strategic initiatives, I feel close enough to his thinking to say that if Larry were alive today, he would be very proud of how the mental healthcare sector has indeed transformed to become more patient-focused and more effective.

But I can also with some confidence predict that if Larry were with us today, immediately after applauding and celebrating everyone who had contributed to the very real successes of the mental health advancements, he would ask the following probing questions: “Are we as consumer/survivor-focused as we ought to be?” “Are we truly accountable for designing and delivering services that are grounded in the perspectives of consumer/survivors?”

Grossman understood in his head, heart and gut why supportive housing needed to be a major part of mental health reform. Today, we have about 173,000 people living with mental illness who are vulnerably housed or homeless. The wait list in Toronto alone is over 5,000 — which means a 2-3 year wait for housing if you are homeless!

The provincial auditor has called for Ontario to develop more supportive housing. We now know that for every $2 spent on high needs individuals, $3 are saved in reduced hospital and justice system costs. That’s a real good R.O.I.

In the community sector, an ACT Team (Assertive Community Treatment) and rent supplement costs just $21,000 per year — compared to $100,000 to keep someone in a hostel; $140,000 to keep someone in a jail; and, less than 10% of the cost of one year of hospitalization. Hello? Why aren’t we expanding these proven programs?

On a recent tour of an example of a “fully-integrated mental health services support system” at CMHA Durham — I saw the impact of systems thinking and innovation that can occur at the service delivery level of community mental health. CEO Linda Gallacher and her team have developed a stunning example of integrated community services that addresses people’s needs in a high-quality cost-effective way that also prevents costs elsewhere in the system.

Here is a model!

According to the Canadian Institute of Health Information one admission to hospital for bipolar disorder or schizophrenia can cost between $8,000 and $12,000 — while case management costs just $6,000. Case management can also reduce hospitalizations by 50%, according to the Community Mental Health Evaluation Initiative studies.

Given what the government has now just learned from the first 25 Health Links about the numbers of mental health and addictions patients in the top 5 percent of health system users, there is now a clear and compelling business case for the sector to grow by at least 4% per year, for the next 3 years. That is, 12% over the next three years.

If Grossman were alive today, his values of service, and his attention to evidence, and to business case assessment, would have him saying bluntly: “we are just not doing good enough.” What we need, he would say, are “leveraged investments” in community supports and housing. He could make the business case to cabinet as to why we need to shift resources in the healthcare system from institutions, to community services.

While all that chaos builds up, and as the OHA seeks to find a new CEO to lead the hospital sector’s vision for our future health system, is it still possible to increase some community health service delivery budgets, when there is such overwhelming pressure to decrease spending?

That’s where Ministers come in. They can make it possible. In mental health, for example, an investment of just $160 million per year would add less than 1/3 of 1% to health spending annually — and it would generate cost savings in the medium term, due to reduced hospitalizations.

Best practices suggest that community support services need to be put in place first, and then shift resources out of the hospital sector.

Tory health critic Christine Elliott – who is Deputy Leader of her party, and a passionate advocate for mental health – says “we are currently operating our health system on an outdated, reactive model based on acute episodes of illness. We need to transition to a twenty-first century model-of-care. In their policy paper, the PC’s commit to “treat mental health as equal in importance to physical health.”

Having lived though 7 years of minority government under the Government of Bill Davis – in which Ontario was also undergoing massive deindustrialization as a result of the Free Trade Agreement – I know that the pressure on our Minister of Health is to “keep a lid on it”. It is the Ministry and Minister’s job to “keep a lid on healthcare — with no new money.”

But you really can’t “keep a lid on”. Indeed, that is in fact bad strategy.

Pressure will be coming from the hospitals and the doctors over the next few years of minority government to at least maintain the existing funding. While the government talks about “shifting from institutional to community-based service delivery”, the funding shift really has not happened yet, and the OHA have yet to develop and roll-out their advocacy campaign. Interesting times ahead.

What is needed today on the mental health file, is a dollop of “Ministerial vision and values”. How about it Deb Matthews? You have demonstrated a passion for eveidence-based decision-making. Why not invest 4% more per year over the next three years by redeploying resources from institutional care, to highly leveraged sectors like community mental health, home support, illness prevention, Community Health Centres, independent living and supportive housing?

These strategic investments of 12% over the next three years would certainly produce significant cost savings for our total system, in the medium and longer-term — and it will also help to off-set the impact of lower hospital budgets.

What is missing is a cohesive plan for the next three to five years that shifts resources to the community by first flowing money to the community to build their services, and then — and only then — reducing hospital budget. Without such a plan, at the local LHIN-level, the status quo remains entrenched, or consumers get caught in the gap. What are required for our healthcare system to succeed is vision, a strategy, and courage.

If Larry Grossman were still with us, he would remind us of the core values that must drive our thinking and behaviour – the values of respect, compassion, dignity, community service, and human rights. Then he would explain to us how in fact … we could be doing much better!

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There are several transformation journeys going on in Ontario right now — as individual Governance Boards, HSP managers, primary care providers and LHINs engage in the process of transforming every health service provider, and every citizen, into a Health Link partnership/membership. We are ultimately heading for 80 local integrated delivery systems (IDS), or as we call them in Ontario, “Health Links” across our 14 LHINs.

That’s a big change! How are you going to do when the system transforms?

Successful Organizational Transformation involves a fundamental redesign of each Health Link organization, and, the local service delivery system as a whole:  the Strategy, Structure, Culture and Skills of the system. These need to be designed and aligned to achieve transformation. If we don’t do things differently, we will all be doing the “same old thing”.

So, rather than tinkering on the edges with downsizing, re-engineering and lean thinking methodologies, organizational transformation involves the re-invention of the delivery system and each organization within it — focused on outcomes; rooted in values of patient-centred service; and, driven by the mission and vision of the organization and system.

Organizational Transformation is a process in which organizations and partnerships of organizations fundamentally rethink and transform the way they are managed, governed, structured and operated.  It’s about transforming from caterpillar to butterfly.

In her book “Transformation Thinking,” Joyce Wycoff describes transformation as “a miracle waiting to happen.  It’s the result of thinking that goes ‘outside the dots’.  It’s what makes an organization grow and flourish – moving beyond barriers to creativity and change”.

Organizational Transformation assumes that there is not a single rigid model or template for what an organization or a local system should become — only some proven processes that enable organizations to recreate themselves. We also have some knowledge of “best practices” for “what works”, and “what doesn’t”, in organizational re-design, and from the “lessons learned” from applied patient experience design methodologies and processes.

While you can’t go into this thing blind, LHINs and Health Links need to avoid at all costs the “one-size-fits-all” approved solutions from the hierarchy. These have always produced mass failures.

Two basic skills that will be required for a successful organizational and system transformation are: Systems Thinking and Dialogue.  Systems Thinking teaches us to see things in wholes, rather than in fragmented pieces.  For successful organizational transformation, people must understand their organization as an integrated system.  Changes to an organization’s culture, structure, strategies and skills must therefore be balanced and aligned to achieve the Shared Vision of what you want to become.

During a Health Link transformation journey, people must also learn and practice open, honest dialogue.  Dialogue is a skill that enables people to listen and learn from one another. People need to learn to listen deeply to each other — seeking to understand one another’s individual realities and hopes for the future. For transformation to succeed, we must work to build on each other’s thoughts and commit to transforming our personal behaviour and our organizational culture to become more respectful, trusting, and supportive of each other.

People within and across organizations within a Health Link must also work cooperatively together to develop a Shared Vision (click to see Mindmapping Workshop evaluation & brochure) of what they want to become, and to find the solutions and strategies that will enable them to achieve their vision.

Perhaps most importantly, each Health Link partner/leader needs to be committed to embarking on a personal journey of change.  Deep experience in the transformation business has taught us that organizations cannot transform, until and unless the people in them undergo a personal journey of change.  It is through changing our own mindsets and behaviours that we will be able to transform into the organization and into the local service delivery system you really have to want to become — your organization’s, and your Health Link’s Shared Vision for the future.

The components (or streams) in an organizational or whole system transformation over the next 24 to 36 months include:

The Leadership Journey:  Boards of Directors, CEO’s and their senior management teams need to generate an initial vision through dialogue
and mindmapping; commit to being stewards of the vision; facilitate the development of a shared vision across the organization; learn how to “design for outcomes”; and plan and implement an aligned Balanced Scorecard for each organization, and for the Health Link’s integrated delivery system. And, they need to develop a system of best practice Accountability Agreements that links everyone in management to the strategy.

Health Link leaders across the continuum-of-care need to find ways of “letting go” of the ingrained habits of silo management, and instead, embrace collaborative & collective intelligence.

Without being in a crazy rush to “get things done” at the beginning, best practices suggests that the CEOs of Health Link Partners ought to spend two-days per month together in strategy dialogues to develop a Health Link System Scorecard – with aligned scorecards for each component part. If lots of work got done between CEO meetings, they could get their service delivery system operational in 9 to 15 months at each Health Link.

Governance Renewal: Silo boards of Health Link Partners need to engage in dialogues about how to blend system and silo governance together. Boards need a wake-up call: their communities need them to “add value” on behalf of the “owners” of our healthcare delivery system. However, boards will need to transform themselves to achieve this.

Accountability Agreements: With a Health Link System Scorecard in place, the CEOs of the silo partners will be able to work together to develop integrated Accountability Agreements for the silo partner Boards to consider. All silo Accountability Agreements with senior and middle managers need to be adjusted to reflect the Health Link System Scorecard.

Capacity-Building for Transformation: There will be no transformation — until and unless a critical mass of people within an organization have the skills required for transformation. No skills means no transformation. Health Links need custom-designed, internal leadership-led (external coaching is fine) capacity-building programs for senior, middle managers and front-line workers on transforming their system. Essential skills for adaptive leaders who take their people on a transformation journey includes: dialogue, team learning, leveraged thinking/strategic thinking, systems thinking, lean thinking, patient experience design, balanced scorecarding, strategy execution — as well as organizational design and system alignment know-how.

Culture Shift:  Culture is about how an organization thinks and behaves.  Organizational transformation requires a fundamental shift from traditional, bureaucratic, command and control environments to one that reflects personal responsibility and accountability, a learning mindset, and a true sense of “stewardship” for the organization.  While culture is often considered a “soft issue”, in reality, it is a “hard issue“.

Best practices suggest that a Culture Shift Strategy – facilitated by middle managers — can be a critical success factor in creating acceleration for the change journey among the Health Link Partners. Middle managers — with external expertise and support — could design a culture shift capacity-building program that would cascade through every organization — facilitated by middle managers.

Accelerated Learning:  Cascading the organization’s Balanced Scorecard and the Health Link System Scorecard is a capacity-building process that requires developmental facilitation and coaching skills for both senior and middle managers. Holding “Unconferences” (click to see Systems Thinking & Collective Intelligence Workshop design) — with 200-300 patients, front-line service providers, middle managers, board members, will lead to much deeper commitments to transformation.

Structural Redesign:  As organizations transform, as people learn new skills, they will learn to continuously redesign and adjust their design, decision-making, and information systems, as well as the rewards and incentives it utilizes to achieve their strategic outcomes. But structure must be aligned with culture, skills and strategy, and it must focus on making the system “patient-centred”.

Read my blog on the Strategic Alignment Model if you really want to understand the art and science of system alignment. Power players always focus on structure first so they can decide: “Who is the boss?” Instead, our system design needs to focus on: “How do we serve the patients/taxpayers?”

High Performance Patient Experience Design Teams:  Redesign teams acquire systems thinking skills, knowledge of design tools, dialogue and team learning skills — as they become increasingly more autonomous and empowered. Patient experience design methodologies like storyboarding will facilitate a bottom-up contribution by patients, families and care providers to moving forward with patient-centred and patient-driven re-designs. But none of this can happen without significant investments in building the internal capacity to transform.

Best practices suggests investing 1% to 5% of payroll budget on “just-in-time”, custom-designed, learning-by-doing support for transformation. At all cost, avoid the one-siize-fits-all top-down academic curriculum.

Strategic Alignment:  Tops need to learn the art and science of continuously aligning strategy, structure, culture and skills within a strategy development process — driven and guided by feedback from the front-line of the organization.

Government’s strategy has been to focus the attention of integration at the service delivery level in the Health Link roll-outs taking place in over 25 communities today. “Alignment” would mean that management and governance would need to be aligned to the integration goals at the service delivery level.

Boards really ought to be leading the charge for system alignment — if they really want a better local healthcare system!

Scope-of Practice: Allowing RNs to perform their full scope-of-practice requires the OMA/RNAO/MOHLTC to agree on processes and a timetable to ensure that nurses perform functions that reflect their existing scope-of-practice. This will improve quality and reduce costs as integration is designed across the continuum.

Human Resources: Successful organizations will have partnerships with unions/workers that develop “win/win” HR plans that reflect the vision, the values and the strategy of the organization/Health Link. Question: is the Health Link the employer for all the employees of the individual silos?

Many failures (among the 70% of organizations that failed to transform) point to the inability of management and labor to forge beneficial “win/win” solutions as the root cause for why, in the end, everybody lost. Will we crash and burn again? Or, will a critical mass of Health Links and LHINs learn how to succeed?

Management and union leaders absolutely must “let go” of their old paradigms that defined their relationship in the past, and instead, engage as true partners with a powerful shared vision for the future. The big issue will be the one we did not do 20 years ago — equalize hospital and community wages. Today, it is, no doubt, unaffordable.

Project Management:  Transformation teams need to learn skills for project management, utilize planning tools/methodologies and create non-bureaucratic, learning-oriented processes that guides the transformation journey. People should be careful not to allow project management tools and methods to be the “driver”, instead of support to the project’s objectives.

Strategic Communications:  Open, honest, two-way communications that include: CEO Reflections Newsletter, Town Hall Meetings, Reflections Dialogues, Learning Events, Voice Mail, E-Mail/Websites, Surveys, Focus Groups, Evaluation and Open Space or Unconferences are all essential activities for success.

Evaluation: Transformation is a learning journey. Health Link leads should arrange with their silo partners to conduct common organizational assessments continuously in order to evaluate progress through surveys, reflective dialogues and formal organizational learning tracking systems.

As organizations and each local system transforms at the Health Link level, they will begin to change in significant and meaningful ways — in terms of the atmosphere/environment — who is included, the ethos or feeling, people’s outlook, the values people practice, and the sense of community support that exists for transformation.

The chart below indicates how these underlying environmental factors change at the Beginning, Mid-Point and the final Transformed State. I have included my thoughts on the worldviews and assumptions about the organization transformation journey, and each of the paths in the chart.

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I met my friend Dennis Pointer in the ’90’s. We both had a passion for discovering how to make Integrated Delivery Systems (IDS’s) work.

I was working with Herbert Wong and Ken Moore of Quantum Solutions of Austin Texas on how to liberate organizations and systems to redesign themselves. Back then we called it “organizational” and “whole system” transformation. But the Ontario healthcare system was only buying something called “re-engineering”.

While Herbert Wong was the total health & support system transformation implementation “How To” expert, the intellectual leader of the IDS movement was Steven Shortell.

Shortell defined an Integrated Health Care Delivery System as “a network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population served.”

Now, really, does that not sound like a Health Link?

You will know Dennis Pointer’s name from the Pointer-Orlikoff Model of Governance outlined in their widely-practiced governance processes in their best-selling book: Board Work. This is the “gold-standard” in most of the world of health governance.

I began a ten-year learning discovery journey with Dennis Pointer on the topic of integrated healthcare governance. He was the author of a very relevant article in Frontiers of Health Services Management, entitled “Loosening The Gordian Knot Of Governance In Integrated Health Care Delivery Systems“.

Pointer and his colleagues said, “because of the unique position of boards, governance is potentially the ultimate integrator.”

The article explores the key issues that need to be addressed on system governance. Dennis would want more clarity on the high-level goals that government wants to achieve. The role and function of the LHIN (devolved/or not), the role of HSP Boards as governance for their silo and as a system partner focused on the patient/client experience, all need greater clarity.

Pointer says that because IDS’s are “accountable for enhancing the health status of the population and integrating the functioning of a diverse network of organizations.” He says that in a multi-organizational system, the responsibilities of governance must undergo a significant shift: from responsibility for treating illness, to responsibility for improving the health status of the population.

“If the system is truly interested in improving community health status, it must interact with public health and other social agencies in the community it serves”, says Pointer. “The system and its governance must shift from an illness-based paradigm, to one that focuses on the health of the community.”

Imagine that! For $47 billion annually on health spending, we would actually get improvement in our health status.

Pointer says that for each of the HSP partner boards, there would also be a need for a significant shift: from responsibility for an organization, to a responsibility for an integrated network of organizations. From a focus on the interests of the silo, to a focus on the interests of the patients and citizen-owners.

“Governance must lead the system toward full integration while being willing and able to transform itself in the process,” says Pointer. But most organizations are trapped in the same/old governance courses that seem — based on experience — to encourage maintaining of the status quo.

“With systems thinking and a clearly articulated mission statement, Board members can prioritize the interests of the system, as defined by the mission, above the interests of the component parts/members,” says Pointer.

While all this transformation stuff is marking noise, things seem like “business as usual” at the OHA’s Centre of Governance Excellence. It isn’t like the OHA is opposed to transformation, it is just they are caught in the business of running lucrative governance workshops that are about the status quo vs. mobilizing boards to actually transform themselves and their local service delivery system.

Pointer says partner boards “will have to determine which governance structures, functions and practices are to be retained, while at the same time redesigning and/or replacing those that may be suited to one stage of system development, but not another.

Pointer’s experience certainly matched our hands-on transformation coaching role in both Canada and in the United States. He gets us to focus on four dimensions. These are:

Control: whether governance of the system is centralized, or decentralized; a single board, or multiple boards.

Structure: the configuration of, and relationships among, the system boards, subordinate boards, and/or advisory bodies.

Composition: the basis on which members of the system board are selected. Should membership if the system board be representative of system components?

Functioning: nature of the functions performed by boards and advisory bodies; and, in decentralized arrangements, how such functions are shared by system and subordinate boards? How should governance functions be shared among system and subordinate boards?

Pointer says that each of these dimensions are moving parts that shift over time — as lessons are learned, and as people discover “what works”, and “what doesn’t work”. He says younger systems — like our newly established 25 Linkets — grow and change at a rapid rate: components are added and corporate structures undergo constant alteration. He says all aspects of the system — including its governance — will undergo constant metamorphosis.

Pointer says “in young systems, we would expect to find control, structure, composition and function in a state of constant flux.” He says “such flux is the result of a system’s attempt to achieve alignment between the incentives, contingencies and constraints presented by the external environment, and the system’s key strategic, structural, and operating characteristics. As systems mature, they eventually achieve some degree of equilibrium. At that point, governance form becomes more stable”, advises Pointer.

The problem is: Health Links are first and foremost about the patient/client experience. While governance can play a positive role, they would become dysfunctional through constant re-invention, system energy will end up being invested in the wrong stuff. The question is: How are Governance Boards going to successfully support the transformation of their health and support services delivery system — when most Boards are badly stuck themselves?

If you want to think about how Boards could “add value” and get “unstuck”, read my friend Dennis Pointer’s paper Loosening The Gordian Knot Of Governance In Integrated Health Care Delivery Systems.

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While for many of us the excitement around “person-centred/people-centred/patient-centred” is new, there have been people in our healthcare system fighting for these very practical, and yet profound changes, for years.

Two such health system reformers are Duncan Sinclair, founding member, and Dr. Vaughan Glover, the President of the Canadian Association for People-Centred Health (CAPCH). Glover says “too often ‘people-centred’ is a term used for its political popularity — with only a vague idea that it means designing our health services delivery system in a fundamentally different way.”

He says that “the concept of people-centred health is a radical idea that health, healthcare, and our healthcare system, should put people first.” In his book Journey to Wellness, Glover explains that it is based on the reality, that “each person manages and is responsible for their own health. More specifically, ‘people-centred’ means taking each piece of the health system puzzle, and ensuring it is responsive to, and respectful of, the perspectives of patients.”

Ultimately the goal of “people-centred care” is to enable proactive partnerships. “Its value,” says Glover, lies in the fact that “not only does the demonstrated cost of illness care fall, which it does, but population health and well-being also increase — and in the long run, total system costs decline.”

“Real system reform means embracing a system model in which the person – supported by skilled and credentialed professionals – works in partnership alongside their trusted network of confidences to support them”, says CAPCH’s President. While Glover and his organization have advocated for this concept of “Health Coaches” since 2005, one highly innovative organization is now actually delivering such programs.

The Ottawa Regional Cancer Foundation has taken an active role in the development and provision of person-centred, community-based cancer care — through an innovative, comprehensive approach referred to as “Cancer Coaching“.  Cancer Coaches are part of a multidisciplinary team of health and wellness professionals — with a background in oncology.  Coaches work one-on-one, or in groups with cancer patients and/or family members or caregivers.  Coaching is offered as a complement to existing cancer treatments and is provided without medical referral.

Cancer Coaching provides navigation assistance to improve access to health care; helps improve patient/clinician communication; and provides information, support and practical guidance to help people cope with the challenges of cancer.  The objectives of Cancer Coaching are to improve patient satisfaction, quality-of-life and quality-of-care as well as both physical and psychosocial health outcomes. It does this by facilitating empowerment and sustainable behavior change.  Ultimately, Cancer Coaching serves to enable cancer patients to become engaged, active participants in their own health care – just what the Minister of Health has been suggesting.  Cancer Coaching is both part of the continuum of cancer care, and, a facilitator of the process.

Cancer Foundation CEO Linda Eagen says “our model of care focuses on the whole person, not the disease. It is personal and individual.” She explains that patients are assisted in identifying their particular needs which may be influenced by a number of factors such as:  the individual’s social context (i.e., cultural traditions, personal preferences and values, family situation, social circumstances and lifestyle); the specific point in the cancer experience; the type of cancer; and, the treatments available.

Working collaboratively with their Coach, patients develop their personal “I Can Plan”. Through information, support and skills development, they are encouraged and assisted to move toward those goals.  Through the processes of empowerment and supported self-management, patients learn how they can be their healthiest – how they can live well with cancer.

Here is a good example of what Health Minister Deb Matthews was talking about when she urged health service providers to: “Dream. Imagine. And make it happen“.

While the original coaching framework of the Survivorship Centre is based on the Australian model, Eagen and her team have engaged in a rigorous continual improvement process – and are now on their twelfth iteration of their unique “Cancer Survivor Coaching Model”.

Coaching is delivered at the Cancer Foundation’s Maplesoft Centre for Cancer Survivorship:  a community-based setting on Alta Vista Dr. in Ottawa — at which I visited last year with Sholom Glouberman, and the Patients’ Association of Canada, as we investigated local examples of “patient-centred care”. Since opening their doors in November, 2011, nearly 1300 patients, caregivers and family members have been coached.

The core element of the coaching model is individual coaching — which provides cancer patients and their primary caregivers with one-on-one personalized care.  Coaches work with patients to help identify the areas of need and interest that are relevant and important to them.  Appointments are structured to help set goals, assess levels of motivation and readiness and to establish a customized health plan.

Coaches also help anticipate and overcome any foreseeable barriers.  Based on their individual goals and needs, Maplesoft clients may then decide to explore other services offered by the Foundation — including group coaching or a variety of complementary programs.  The coaches are also able to assist their clients to access other resources available in the community.

Group coaching is designed to bring together cancer patients and caregivers at “like stages” in their cancer journey.  It provides individuals with an opportunity to work with others who are sharing similar challenges and to benefit from each other’s experiences and knowledge.  Examples of the group coaching programs available include:  Coping with Cancer; Wonders and Worries for kids whose parents have been diagnosed with cancer; Caregiver Group; Cancer Survivorship and Work; and Next Steps.

As a complement to individual and group coaching, a variety of programs and services are offered by means of comprehensive programs, weekly drop-in programs and healing therapies.  These complementary programs focus on health and well-being; addressing the client’s physical, emotional, spiritual and psychological needs — and offer the opportunity to explore forms of alternative care on a trial basis.  The current roster includes more than 30 programs, workshops and services.

In addition to its coaching and complementary programming, the Cancer Foundation has established partnerships and collaborative arrangements with other likeminded agencies and organizations to improve access to cancer resources and support.  These partners and collaborators offer some of their services at the Maplesoft Centre.  The Cancer Foundation has become a “hub for cancer survivorship”.

What we know is that Cancer Coaching is working. Participant satisfaction surveys indicate:

• 81.6% of respondents reported being  “much better”, or “better” able to cope with life;
• 81.7% were “much better”, or “better” able to keep themselves healthy; and,
• 81.4% were “much more”, or “more” able to help themselves.

Johanne Levesque, Vice President, Survivorship Care and Professional Practice at the Cancer Foundation explains, “The Maplesoft Centre that we have created is a healing place where cancer patients and survivors can try new things in a ‘safe environment’, develop new skills and the confidence necessary to manage their disease”.

In the words of some participants:

• “Through this unique coaching program, I have been empowered to better manage my diagnosis … When cancer takes so much from you, knowing that you are part of a network that empowers you is a huge asset.”
• “I have experienced renewed energy, greater stress management and a willingness to engage in activities again.”
• “The Center has helped me to realize how I play an important role in my own health and to take control of my life.  When I was diagnosed with cancer I felt that my life was being controlled by the cancer.  Now I feel back in control.  I exercise regularly, follow a healthier diet and know that the Center is there to help when and if I need it again. ”

Through coaching, the participants in Ottawa’s Cancer Survivorship Centre become informed, active and engaged in their treatment and their wellness.  The patients’ report that their quality-of-life and quality-of-care have improved.

Based on these self-reported benefits, it is predicted that Cancer Coaching will have a tangible and quantifiable impact on a number of important measures including:  increased treatment compliance and adherence; reduced disease and treatment-related symptoms; increased length of survival time and/or time to recurrence; and more appropriate utilization of health care resources (e.g., accessing acute care for symptom management).

Ultimately, such outcomes would have a significant impact on the efficiency and sustainability of our over-burdened health care system. MOHLTC really ought to fund a Business Case Proposal for this concept/initiative.

Linda Eagen says the Maplesoft Centre is striving to be “an incubator for cancer survivorship innovation. We are an example of patient-centred, community-based health care; based on action-oriented translational research; including program development as well as delivery; and professional development.”

The Foundation will soon to evaluate the impact of their Coaching Program on patients, and on the health care delivery system. They are also building relationships with stakeholders in industry to facilitate the up-scaling of the model by means of an e-coaching platform. They also intend to develop a training and credentialing program for Cancer Coaches.

It took a decade of lobbying to get the MOHLTC to recognize palliative care as a “healthcare service”. Will it take that long for Queen’s Park and the LHINs to build on what we have learned from Ottawa’s Cancer Coaches?

Can you see how these simple, low-cost concepts for a more “people-centred” approach might work in other circumstances? Think about it. We could dramatically improve the patient experience and significantly decrease costs – for very small investments in Health Coaches.

Next week’s blog: “Health Link System Governance In A Decentralized Delivery System”.

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In the ‘90’s, Michel Laonde, the CEO of Hawkesbury Hospital (later the Board Chair of Champlain LHIN) and I brought together the key stakeholders interested in creating an Integrated Delivery System (IDS) from the Ottawa area to spend a day with Peter Block, author of Stewardship: Choosing Service Over Self-Interest.

In those days, because of leaders like Dr. Wilbert Keon who had written a major paper on Integrated Delivery Systems as CEO of the Ottawa Heart Institute, and other local health system leaders in the Champlain District who were keen on the IDS concept, there was a real appetite for innovation, but we needed grassroots leadership to make it happen.

Why? Quite frankly, many leaders were still stuck in their silos — defending their turf & perks. Twenty years later, we can talk about the high-level goals of Health Links, but how can they achieve these goals? What type of leadership do we need to make it happen?

Peter Block is one of those people who can have a profound impact on people simply by engaging in authentic dialogue about the group’s vision — and how they could provide the leadership required for a fundamental organizational and system transformation in their unique circumstances.

We all came away from our one-day encounter with Peter Block as strong advocates for the concept of “stewardship”. Block defines Stewardship as “the willingness to be accountable for the well-being of the larger organization by operating in service, rather than in control of those around us.  Stated simply, it is accountability without control or compliance”.

Block redefines authentic leadership as “stewardship”.  He says that leadership has come to be associated with behaviors of control, direction and knowing what is best for others.  It implies that someone up there in the hierarchy is responsible for our well-being.

“This disempowers employees”, says Block, “limiting their confidence and willingness to contribute to the well-being of the organization.”  Instead of expecting to control people, Block believes that organizations must turn to a new approach to governance — a partnering of empowered people, rather than patriarchy.

The underlying value of stewardship is about deepening our commitment to service — a word we use, but don’t always live.  Authentic service is experienced when:

• The primary commitment is to the larger community;
• Each person joins in defining purpose and deciding what kind of culture the organization developed as well as what they will become;
• There is a balance of power; and,
• There is a balanced, fair and equitable distribution of rewards/shared benefits.

Block goes on to explain that stewardship is about being accountable – and it’s about placing ownership and control of work processes close to the core work.  It is about redesigning the social architecture of an organization by exploring ideas about:

• Reintegrating the managing and doing of work.
• The redistribution of power, purpose and privilege;
• The differences between stewardship and leadership;
• How staff functions and professional turf interfere with partnership, participation and total quality improvement efforts; and,

Block says that in most organizations, “the fire and intensity of self-interest seems to burn all around us.  We search so often in vain to find leaders we can have faith in.  Our doubts are not about our leader’s talents, but about their trustworthiness.  We are unsure whether they are serving their institutions or themselves.  And when we look at peers, our neighbours, and ourselves, we see so much energy to make sure we each get our entitlements”. He says, “the antidote to self-interest is to commit and to find a cause much bigger than ourselves.”

Health Minister Deb Matthews says that what is bigger than ourselves is transforming the system to preserve it. If people are just in this for themselves, the larger public purpose will not be achieved.

Are the fires of self-interest burning in your Health Link? Or, does the managerial and governance leadership work colalboratively to serve and to support others to succeed — by removing barriers, and by providing the appropriate, just-in-time supports to achieve the outcomes for which people are being held accountable. Are the leaders across the system aligned on a shared vision?

Organizations that practice Stewardship, Block explains, will succeed by choosing service over self-interest, and by a far-reaching redistribution of power, purpose and compensation. Without this, little change will result.

Can there be a transformation of our health system, without first having a transformation in how we “do leadership”? What will that leadership transformation journey be like?

To replace the traditional management tools of “control” and “consistency”, healthcare organizations need to offer partnership and choice at all levels, to their staff — as well as to their clients/patients/customers.  Individuals who see themselves as “stewards” will choose responsibility over entitlement, and they will hold themselves accountable to those over whom they exercise power.

The transformation is from “Bosses” to “Coaches“.

Block proceeds to demonstrate how applying the concept of Stewardship will radically change all areas of organizational governance and management. He says we need to reintegrate the managing of work with the doing of work.  No one should make a living just watching, measuring or defining what is best for other human beings. Managers must “add value”. Everybody manages, and everybody does real work.

Robert Greenleaf, another relevant leadership scholar, echoes Block’s preferred leadership style with what he calls the “Servant-Leader”. He says: “the servant-leader is one who is a servant first.” So, the bosses are “in service” to those who report to them, not the other way around.

In The Servant Leader Within, he wrote, “it begins with the natural feeling that one wants to serve, to serve first.  Then conscious choice brings one to aspire to lead.  The difference manifests itself in the care taken by the servant — first to make sure that other people’s highest priority needs are being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants?”

The words “servant” and “leader” are usually thought of as being opposites.  When two opposites are brought together in a creative and meaningful way, a paradox emerges. The words servant and leader have been brought together to create the paradoxical idea of servant-leadership.  The basic idea of servant-leadership is both logical and sensible.  Since the time of the industrial revolution, managers have tended to view people as objects; institutions have considered workers as cogs within a machine.

While these leadership styles need to be part of the mix, I think that the transformation of Ontario’s healthcare delivery system into 75-80 Health Links will require what Ron Heifetz calls, “Adaptive Leadership“. He says that the test of true leaders is in how they respond to adaptive problems — those problems that challenge us to learn an entirely new way of being and doing.  Most crises in human systems can’t be solved with an easy technical fix — they are adaptive problems.

Nonetheless, people usually want leaders to respond with a “quick-fix”, and many leaders, eager to please, and to “show-their-stuff”, respond accordingly — by taking the problem on their shoulders, and coming up with a solution that typically alleviates a symptom — not the underlying problem.

Heifetz points out that “a major pitfall of leadership is assuming that somehow you’re the one who’s got to come up with the answers, rather than develop the adaptive capacity, the capacity of people, to face hard problems and take responsibility for them.”

Adaptive Leadership means raising tough questions, rather than providing answers; it means framing the issues in a way that encourages people to think differently, rather than laying out a map of the future;  it means co-creating with people their new roles, power relationships, and behaviors, rather than orienting them in a new direction and giving them a big push.

It also means orchestrating conflict, rather than quelling it.  Conflict is a tremendous source of creativity. Heifetz says that leaders in the midst of adaptive change must be able to “artfully guide their people through a balance of disorientation and new learning.  They need to hold the group in an optimal state of tension and disequilibrium that stimulates a quest for learning, without jarring people so much that they simply aren’t able to learn.”

Adaptive Leadership — along with Stewardship and Servant-Leadership — clearly go hand-in-hand:  adaptive leaders are acting in the interests of the whole organization when they refuse to play Superman and solve problems for others (thus taking the glory on themselves), when they recognize that the success of the organization requires them to nurture people toward acting and thinking in entirely new ways.  Viewed in this way, the terms are synonymous, each puts a different slant on this new form of organizational leadership.

Health Link partner boards and Health Link senior managers need to make an intentional decision to transform their leadership paradigms to Stewardship/Servant-Leadership and Adaptive Leadership, if they want to succeed. How might this happen among the Health Link CEO’s and senior teams?

First, Boards and CEOs of Health Link partners need to engage in deliberate conversations their shared vision about whether or not they are engaging in a transformation — and what that means — in terms of changing how the Board governs and changing how the CEO and senior team leads. What specifically will change? When will they transform? How will they execute their strategy?

Think about it. Maintaining the same leadership paradigms, means maintaining the status quo – while talking rhetorically about “transformation”. This must change — if the emerging vision for Health Links is to be realized. Remember: a caterpillar transforms into a butterfly. What will transformation do to you?

In their recent essay on Organizational Connectivity, Hugh MacLeod and Graham Lowe say that “when front-line staff are not effectively managed, when they don’t feel supported and valued, and when the leaders of their own organization are not modeling collaborative and respectful relationships, how can we expect them to excel in patient care or service delivery?”

Good question! The answer is: Leadership Transformation.

Next week’s blog: “HEALTH COACHES: An Innovative Program For Providing Truly People-Centred Care”.

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Will Ontario really shake-off the entrenched bureaucratic control of our health system?

In a bureaucracy, hierarchy is the central devising principle. Work roles are narrowly defined and a premium is placed on impersonality in relationships, control is maximized, efficiency is prized, secrecy is a virtue, and means — rather than ends — receive the attention and glory.

While Health Links are regulated by a traditional control-oriented government bureaucracy, the countervailing force here is Health Minister Deb Matthew’s commitment at the May 15th Ways & Means Conference: “I have your back. Go ahead, dream, innovate and make it happen! We trust you.”

Normally, bureaucracy does not operate on trust. Traditional bureaucracy attempts to make trust irrelevant by external standards that deny the internal norms upon which trusting social relations must rely.

Think about it. Every aspect of bureaucracy denies the significance of creating social capital like trust. It is the rules that must be trusted, the procedures and templates that confidence is placed in, it is process, not results, that count; and, it is the legal authority of the “superior institution” that one’s faith is placed in. There are hierarchies everywhere. To prevent anyone from being innovative, the government even has a list of Vendors of Record to help safely guide our actions and thinking.

David Carnevale says, “bureaucracy is a monument to institutionalized mistrust and emotional control.” While the Hon. Deb Matthews’ liberating speech at the Ways & Means Conference suggests we could be in a new era of “de-bureaucratization”, these are ingrained habits and ways of being. The Transformation Secretariat certainly has an enlightened approach, but the truth is: change is hard.

However, our healthcare delivery system can’t transform without the MOHLTC and LHINs also transforming. Everyone needs to transform — or nothing is changing.

Health Links are Ontario’s attempt at a “Galilean Shift“. Science students will remember that Galileo’s heliocentric revolution moved us from looking at the earth as the centre around which all else revolved – to seeing our place in a broader pattern in which Earth, and all of the other planets, actually revolve around the Sun.

The Sun in our healthcare delivery system are: the patients/clients, and, the “owners“. That is, the people of Ontario, and the citizens of each local community.

In the systems world-view of complex adaptive systems, we shift from seeing the component parts of systems, to seeing the “whole” picture. This is called “systems thinking” and “whole brain thinking“.

The more left-brain analytic approaches address complex situations by breaking everything down into its components parts – and then studying each component in isolation, and then synthesizing the components back into a whole again.

Peter Senge, author of the Fifth Discipline, says that “for a wide-range of issues, there is little loss in assuming a mechanical structure and ignoring systemic interactions. But for the most important problems, linear thinking is ineffective.”

Problems like healthcare costs — or how to improve quality and patient satisfaction — resist piecemeal, analytic approaches that are theory-based, rather than experience-based, evidence-based, and, pragmatically-based.  We live in a world that is more like humpty dumpty, than a jigsaw puzzle: “All the King’s horses, and all the King’s men, can’t put the system together again.”

Senge says “our enchantment with fragmentation starts in early childhood. Since our first school days, we learn to break the world apart and disconnect ourselves from it. We memorize isolated facts, read static accounts of history, study abstract theories, and acquire ideas unrelated to our life experience and personal aspirations.”

He points out that, “economics is separate from psychology, which is separate from biology, which has little connection with art. We eventually become convinced that knowledge is accumulated bits of information and that learning has little to do with our capacity for effective action, our sense of self, and how we exist in our world.”

Rather than practicing integrative medicine – which assumes our body parts are actually interconnected with cause & effect relationships – we have a focus on “specialists”, and we tell primary care doctors that they can only change a fee for one body part per visit.

Today, fragmentation is the cornerstone of our healthcare delivery system – with acute care, primary care, long-term care, community care, home care, mental health, health promotion and illness prevention all operating under separate assumptions and rules.

Driving the fragmentation in the delivery system is the equally fragmented Ministry of Health & Long Term Care. Ironically, the word health has the same roots as the “whole” (the old English hal, as in “hale and hearty”). Like people, organizations and systems of organizations can get sick and die if they are not flexible enough to withstand change.

Health Links need to design themselves for flexibility, rather than what traditional command and control bureaucracies want – -which is the “illusion of control“, provided by the many rules, templates and common curriculums in the rigid belief that “one-size-does-fit-all.”

Given the complexity, ambiguity and unpredictability in our rapidly changing environment, if they are to succeed, Health Links need to be designed for adaptability — rather than stability.

Adaptation occurs by changing the “rules” of interaction among the system’s component parts. New rules of interaction emerge through the accumulation of new experiences and dialogues among the partners. People are smart. They will find their way, if they connect, and if they collaborate and focus on the design of the system, and the design of the organization in the system.

Using the Strategic Alignment Model as a framework, how would you realign the components of Structure(design, decision-making & accountability, information systems, rewards/incentives and strategic budgeting); with the components of Culture (norms, values, language, behavior, leadership, stewardship); and with the components of Skills (technical, analytical, people organizational, communication) to achieve the Health Links outcomes?

If this new collaborative partnership is to be transformational, it must also alter how each of the Health Link partners are “being“. When they change how they are “being“, it reverberates at many levels and spheres within each of the organizations, and across the partners. This produces changes at the very core of our health and social support services system.

So where do you start to make fundamental change — now that the Minister/Ministry have provided us with the “low rules” innovative construct of the Health Links?

Our recent Health Leaders’ Vital Issues Survey indicated at least 60% of participants are “on board” with Health Links already. That’s a critical mass!

So, what should happen next?

The highest authority in every Health Service Provider is the Board of Governance. The Minister of Health – through the MOHLTC, and their crown agencies, the LHINs – provide the provincial standards and regulations, local planning at the LHIN level and the appropriate aligned incentives to achieve the policy goals of the government. But it is the governance board that approves the strategic directions.

A key question I am asked is: what is the role of Health Links Partner Boards in the governance of the partnership of HSPs in each of the 75-80 communities and 14 LHINs across Ontario?

The Ministry and the Minister have been silent on this point so far. If our government wants fewer organizations to emerge from the Health Link process, they are not saying so — at least not while there is a minority government still in place.

Governance Boards need to be alert to the debate about whether or not our healthcare delivery system would benefit from “fewer boards” doing same/old governance; or, whether now is the time to transform governance — so that it actually does “adds value” to our healthcare delivery system.

The choice is between “Hack & Slash“, or “Transformation“.

The Canadian Patient Safety Institute says that when properly structured and led, governance boards can significantly influence improved performance on: safety, quality and patient/staff/physician satisfaction. If boards can indeed be organized to achieve these important and valuable goals, why would we want to get rid of them?

The “Hack & Slashers” have a perspective that I call the “Fewer Is Better Tribe“. These are the people who always focus on issues of structure and power and tend to provide their deep policy analysis on Twitter. They think the Munchkin Agencies should all merge, and that hospitals ought to run the whole service delivery system.

I’m a member of the “Bio-Diversity Tribe“. We believe that transformed generative governance boards could actually “add value”, and lead to more patient-centred innovations in our complex, adaptive healthcare delivery system. We have a great deal of evidence to prove that it is not true that “fewer is better”. Indeed, there is lots of evidence that proves diversity enriches us. That does not mean “no mergers”. There should be mergers wherever it benefits the patient or taxpayer.

On the management side, the lead partners need to create Health Link-Level Scorecards — that are ultimately the product of the collective intelligence of service providers within each partnership. Scorecards and Strategy Maps would enable organizations within each local Health Link to collaborate and implement the co-ordinated changes required to achieve better outcomes/results for the patients.

At the HSP’s level, in redesigning themselves to improve in each of these priority areas, healthcare organizations in each Health Link need to look at their functional design (what it does); their structural design (who does what); and work process designs (how work is done). But the real disruptive innovation that successful Health Links will introduce is Patient Experience Design Methodologies that liberate and engage front-line service providers — and patients/families — in redesigning these processes to be patient-centred.

To achieve dramatic gains, old ways of thinking about “managing” and “organizing” healthcare organizations need to be abandoned. The successful ones “change the way they think” about their challenges, and develop a shared vision for what the solutions could be.

Dufferin-Area Health Link lead, Liz Ruegg, CEO of Headwaters Health Care, set out the focus of their Link at a one-day Health Link partners’ visioning workshop: “It’s all about building a health care system that ensures patients get the care they need, closer to home, when they need it most”, she told the group.

But what did that mean? What was the group’s “vision” of the future? What did they want to create? About 50 local leaders composed of Board Chairs, CEOs, senior staff, and physicians, from healthcare service agencies across the Orangeville-Dufferin region met for a full day — along with LHIN Board and staff — to engage in collaborate dialogues to create their emerging vision — using a technique called Mindmapping.

Mindmapping was developed by Tony Buzan in the ’70’s to capture a groups’ ideas through dialogue in order to create a “picture of the future that we seek to create”. At the Dufferin-Area Health Link visioning conference 94% of participants rated their experience of mindmapping as “good” to “excellent”. One participant wrote on their evaluation, “Mindmapping meets everyone’s way of thinking — not intimidating. It was fun.”

Peter Harris, Board Chair at Headwaters Health Care Centre says that the governance boards of Health Link partners ought to “step out of their everyday independent way of  thinking and approach this from a different perspective.” He says Health Links truly presents an opportunity to come together and innovate to put patients first”.

Dufferin-Area Health Link Partner, William Osler Health System CEO, Matt Anderson, said, “It was great seeing governance leaders spending a whole day where they did not focus exclusively on their hospital, CCAC, home support agency, or their CHC. They had to hold a ‘whole system’ perspective, rather than just their silo. That was helpful.”

Health Links Partner Boards and Health Links CEOs need to remember that the defining characteristics of a system is that it cannot be understood as a function of its isolated component parts. System leaders also need to understand that the behavior of the system doesn’t depend on what each part is doing – but on how each part of the service delivery system is interacting with the rest.

See the Evaluation & Reflections Survey results @ Dufferin-Area Health Link Visioning Day Evaluation.

Next week’s blog: “Health Links Will Need The Right Mix of Stewardship Servant-Leadership and Adaptive Leadership If They Are To Succeed”.

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

Peter Senge describes “mental models” as “the images, assumptions and stories we carry in our minds of ourselves, other people, institutions and every aspect of the world.”

Mental models act like the mirrors in a carnival funhouse – they frame and subtly distort our vision, determining what we see and how we understand things.

Because we all live inside complex, dynamic systems that are constantly evolving, it is only natural that we develop “mental maps” or “mental models” to help us make sense of the ever-changing world and navigate our life journey.

The problem is many people have a mental blinder called “my reality is the reality” — which often means we cannot see the larger reality of the whole truth. Our mental models become blinders.

Henry Mintzberg’s “Doers” and “Helpers” framework (see June 5^th blog) provides “mental maps” that represent a transformed delivery system – with a fundamentally different DNA in which there are people who do the work, and some people whose purpose is just to help. If the “Helpers” thought or behaved like “bosses”, we would have a top-down, command-and-control, one-size-fits-all system.

Clearly, the Health Link’s local health and support services system isn’t like that. They are designed to be transformative. “Dream. Imagine. Make it happen,” says Health Minister Deb Matthews.

“Doers” and “Helpers” are mental models that enable us to understand our role, and what to expect. Another paradigm shifting framework is the “Bosses Vs. Coaches Mindset”, which is rooted in the beliefs that we hold – because it is our beliefs and assumptions that drive our thinking and behavior.

Take a moment to reflect on the following points about transforming the practice of healthcare management — from “Bosses” to “Coaches”. Here are the transformational mindset shifts required:

• Bosses believe in controlling others through the decisions they make; coaches believe in facilitating others to make decisions as well as empowering them to implement their own decisions.
• Bosses believe that they should talk at people by telling, directing, and lecturing; coaches believe in engaging in dialogue with people by asking, requesting, and listening.
• Bosses believe that their job is to push people or drive them; coaches believe that they are there to lift and support people.
• Bosses believe they know the answers; coaches believe they must seek the answers.
• A boss triggers insecurity through administering a healthy dose of fear as an effective way to achieve compliance; a coach believes in using purpose to inspire commitment and stimulate leveraged creativity.
• Bosses believe that their job is to point out errors; coaches believe that their job is to celebrate learning.
• A boss believes in solving problems and making decisions; a coach believes in facilitating others to solve problems and make decisions.
• A boss believes in delegating responsibility; a coach believes in modeling accountability.
• Bosses believe in creating structures, rules and procedures for people to follow; coaches believe in creating a vision, and promoting flexibility on how to achieve it.
• Bosses believe that their power lies in their knowledge; coaches believe that their power lies in their ability to help bring the best out of people.
• A boss believes in focusing on the bottom line; a coach believes in focusing on the process that creates the bottom-line result.
• A boss believes in doing things right; a coach believes in doing the right things.

As you can see, “Bosses” are “Doers”. They also take on “burdens”, and protect the front-line from the “whole truth”. Hard job: being a boss. Very hard. In a transformed system, bosses become coaches and “Helpers”. It is an easier job — the hard part is “letting go of control”, or letting go of the “illusion of control”.

Queen’s Park — and some LHINs — need to become comfortable with “letting go of control” and empowering Health Links to self-organize to achieve the outcomes listed in their approved Business Plan. How can MOHLTC and LHINs become coaches to HSP? How can senior managers become coaches to middle managers, and how can middle managers be in service to front-line care providers?

Coaches are indeed “Helpers”. They find ways to “add value” with the appropriate support that enables the “Doers” to succeed. Coaches also function with a set of beliefs and assumptions. Are your own beliefs aligned with the Coach’s Credo that says:

• Self-knowledge, and being self-aware, makes people more empathic, as well as more emotionally intelligent.
• People are inherently good and want to contribute.
• People support the changes and commitments they create and freely make — not the ones forced on them.
• Unnecessary control is resented; people prefer to be “led”, rather than “managed”.
• People are doing the best they can with what they know and are aware of at any given moment.
• People make mistakes, but most do not set out to make mistakes on purpose.
• People really do want to improve.
• Mistakes can be framed positively, as learning opportunities for everybody on the team.
• Most people’s limiting beliefs about their capacities and capabilities keep them from accomplishing more than they do.
• Outside input is most helpful when it is actually wanted.
• Coaches can build strong, trusting relationships by being open and honest in owning and disclosing their own thoughts and feelings.
• People’s feelings must not be ignored — a holistic view of people allows one to see the “whole person”, in all domains of their life.
• People appreciate clear, honest feedback delivered in a straightforward manner.
• A safe, supportive, team-based collaborative environment produces synergy and innovation.
• Leaders need to be “in service to” their people, not in “control of” them.
• A boss’s job is to remove barriers, provide the supports required to be successful, and hold people fully accountable for the outcomes — results — for which they have the “supports required” to be successful.

If you too hold these assumptions, and a critical mass of people in your organization also holds these, or similar assumptions, you will want to become a Learning Organization.

Peter Senge describes a Learning Organization as “a group of people who are continually enhancing their capacity to create the results they want”. He believes that the building of learning organizations requires basic shifts in how we think and interact. It is an exercise in personal commitment to being open to learning.  Without communities of people who are genuinely committed, there is no real chance of transformation.

According to David Carnevale, author of Trustworthy Government, one of the key differences between learning organizations and traditional controlling organizations “is that deeply ingrained defensiveness so characteristic of low-trust, traditional bureaucratic organizations undermines necessary learning.  Trust expedites learning.”

I love what Carnevale says. He says that “healthy learning organizations are managed with the objective of liberating and using employee know-how to improve work processes.  The emancipation of employee know-how is enabled through a different philosophy of organization and job design, communication patterns, labor-management relations, participatory methods, and other processes that reduce the climate of fear and allow staff the necessary psychological peace of mind to fully engage their work”.

Traditional bureaucratic organizations are dominated by the need for control and conformity, assuming that workers are incompetent — and therefore must be carefully managed.  In turn, this creates high degrees of mistrust, defensiveness and fear — all of which undermine learning.  Sounds a lot like our current environment, doesn’t it?

A Learning Organization must be built on trust, togetherness and a sense of true community.  Few, if any of the problems organizations face nowadays can be handled by one person acting alone.  Energy and wisdom emerges from a sense of togetherness, and the skill of team learning — to get things done; to encourage the kind of innovation that is essential for transformation; and, to create the conditions required for trust to develop.

Trust, in turn, improves togetherness and creates a culture and a community in which learning can flourish, innovation can emerge, and collective intelligence can surface. In such environment, people feel connected to purpose, and as a consequence, lead much more fulfilling lives.

Could the new Health Links be like that? Will the collaboration that takes place around this initial population cohort (the top 5%) ultimately lead to a transformed way of thinking, doing and being?

While it may be still too early to tell, the Health Link reports and slide-deck case history presentations I have seen — and one partner retreat I have facilitated — has me feeling fairly optimistic that this initiative just may succeed. I know 40% of you are saying “yeah, sure Ted, we’ve been here before”. But have we? Or, is this actually our last opportunity to preserve our healthcare delivery system through transformation?

Is this our cause, our purpose? Are we ready for a transformation that starts by make a change in ourselves, a change in our own thinking and behavior? Can we shift from “Bosses” to “Coaches“? Can we shift our behavior as a “Helper” or a “Doer”?

If we can, we can transform — and therefore preserve our healthcare system.

Next week’s blog: “THE GALILEAN SHIFT IN HEALTH SYSTEM DESIGN AND STRATEGIC ALIGNMENT”.