Bill Tholl, President and CEO of HealthCareCAN
Talent Management Conference
Many thanks to Drs. Margaret Steel and Robin Walker for the invitation to be here today and for their leadership. I also want to recognize the leadership, locally and nationally, of many others here today, including Dr. Mike Strong…incoming chair of AFMC; Dr. Gillian Kernaghan…co-chair of CHLNet…and, of course, Dr. David Hill…member of the HealthCareCAN Board and co-chair of our VPs Research Roundtable.
I’ve been asked to share with you this morning my thoughts around health leadership in general and then, in particular, around collaborating in leading change.
My plan is to begin by spending a few minutes reflecting on the first 100 days of our new federal government and how the new PM and his team are doing so far with the “sunny ways” approach to leadership given the ever-increasing complexities of healthcare. I will then spend some time describing what I see as the nature of Canada’s great health leadership challenge: treating what I call the “Canadian Condition”.
Then, using the “by health, for health” LEADS leadership framework that many of you will be familiar with, I will share with you how it can be used as a change leadership tool…using the metaphor of carpooling in terms of forming and sustaining networks…such as SWAHN here in London…as well as strategic alliances/coalitions/partnerships nationally such as the Canadian Health Leadership Network or CHLNet.
I’ll wrap up by giving you a sense of where the health policy agenda appears to be going and what HealthCareCAN, working with others, is doing to help shape that agenda.
Before doing so, let me say just a few words about HealthCareCAN: the “national voice of Canada’s hospitals and regional health authorities”. (See one pager in your package).
“Sunny Ways”: So far so good?
Turning then to the “sunny ways” to better health and healthcare, you will all recall a freshly minted Prime Minister invoking the words of Wilfred Laurier from 150 years in underscoring that our new government will do things differently. The concept is intended to empower all of us to make Canada a better place. It also marks a new, more collaborative and cooperative approach to working with other First Ministers and to working with stakeholders.
Based on the first 100 days, including the Ministers of Health meeting last week, I would say the verdict is: so far so good…and let me tell you why.
Let’s begin by reflecting on the federal election and the federal “real change” health agenda that helped get the Liberal party elected with an unexpected majority government (See two-pager in your package).
As you all know, it was the second longest elections in Canadian history…78 days; three times the normal writ period. (Longest was apparently in the late 1872…89 days.) This allowed for a broad range of major policy issues to be debated, discussed and distilled…the economy, foreign policy, tax policy, energy policy, child care policy, environment, etc.
Once again, however, health and healthcare did not receive a lot of air time in any of the leaders’ debates or on the campaign trail. This is not unusual. Despite the fact that polls before and during the federal election indicated that worries about healthcare continue to rival jobs and economy for Canadians, it received minimal discussion or debate.
As Jeffrey Simpson points out in his book Condition Critical, Medicare is still seen as the “third rail of Canadian politics”…touch it and you die. No Minister of Health in living memory, for example, has ever gone on to become Premier or Prime Minister. Or, as André Picard recently reminded us, former premier Smallwood once famously remarked: “I have never had a conversation on healthcare that didn’t lose me votes!”
That said, health and homecare did find their way into the Liberal platform. There is, for example, a firm commitment to work with the provinces and territories to negotiate a new, multiyear Health Accord. This was reiterated in the Governments Speech from the Throne.
Deputy Ministers met last December in Toronto and Ministers met just last week in Vancouver to begin to put “sunny ways” to the test in terms of negotiating a new, multi-year Health Accord (Note: provide some personal reflections on Health Accords 2003 and 2004).
The marching orders for Minister Philpott, at least in terms of basic building blocks for a new Health Accord, are pretty clearly laid out in her mandate letter, which essentially mirrors the platform commitments, but with some more specifics.
Looking at the campaign commitments, there are four basic building blocks for a new accord. They are: (1) expanded homecare programs, with a particular focus on helping provinces address the growing challenges around palliative care and with a promised $3 Billion over 4 years; (2) expanding access or coverage to out-of-hospital pharmaceuticals; (3) Increasing the availability of high-quality mental health services for Canadians who need them and the establishment of an Expert Committee to work with the Mental Health Commission of Canada. And (4) scaling up and spreading innovations more quickly.
I want to focus this morning on this fourth element of the plan and the leadership in research and innovation that will be required to spark the transformational change that our healthcare system requires. Nothing less than a concerted, collaborative effort that focusses on the needs of patients and their families will overcome what, in a recent national editorial co-authored with Carol Herbert, we call the Canadian Condition. What is it?
The Canadian Condition can be described in short as our irresistible urge to constantly reinvent the wheel and put the interests of providers ahead of those of patients. One of my former bosses, Monique Bégin, is fond of describing Canada as the “land of many pilot projects” when it comes to healthcare. A colleague recently went so far as to say Canada has more health-related pilots than Air Canada!
Our editorial points out that there are no shortages of exemplary practices across Canada. We have over 6000 of them in our “Innovation Sensation database”. But the structures and processes simply don’t exist to scale them up and spread them out in any effective or reliable way.
Among the key finding of the Federal Advisory Panel on Healthcare Innovation, chaired by Dr. David Naylor, were that Canada’s healthcare system has aged badly and, that “pockets of extraordinary creativity and innovation dot the Canadian healthcare landscape”. But, due to the fragmented nature of our healthcare system, “we are caught up in a vicious cycle with slow deployment”.
While there were over 40 well-considered recommendations in the final report of the Naylor panel, cutting across five major themes, two overarching recommendations garnered much of the public attention.
First, new machinery: the Panel recommended consolidating three of the existing dozen or more C-agencies and establishing a Healthcare Innovation Agency of Canada.
Second new money: making a critical distinction between research and innovation, the Panel recommended that the federal government invest, ramping up over time, up to $1 billion per year in a new Healthcare Innovation Fund. This would be on top of the CIHR’s current $1B per year.
The final report was released…some would say deep sixed on July 17th…a Friday afternoon… at 2 pm right after Premiers had their semi-annual meeting in Newfoundland. It was immediately declared by Jeffrey Simpson as “DOA”. And, it very well might have been, except for the results of the October 19th
Just in advance of the Ministers’ Vancouver meetings, the January 19th headline in the Globe and Mail declared that “the Liberals were reviving the “zombie report”’. In the article, our new federal health Minister, Dr. Jane Philpott, declared that she is a “huge fan” of the report, which is full of some “fantastic ideas”.
(Explain “Naylor lite” if time permits.)
I want to also acknowledge some of the excellent work that was done by Premiers going back to 2012 and the creation of the Health Care Innovation Working Group, which was co-chaired by Premiers Ghiz and Wall. The Working Group was established following the previous federal government’s “take it or leave it” approach to negotiating a new Accord, when the ten-year 2004 Accord came due. (Testimonial to the leadership of “Surf and Turf” and the release of “Innovation to Action” report in July of 2012).
As everyone now knows, Canada’s international ratings in terms of overall health system performance have slipped badly over the past 10-15 years. In fact, we rank 10/11 according to the 2014 Commonwealth Fund report (Mayor Rudy Giuliani story…time permitting). This gradual decline was, in fact, acknowledged by Ministers in Vancouver along with a commitment to work together to turn the rankings around.
When asked by the media about the rankings, I suggested that if Canada could find the means to collaborate to more effectively scale up and spread our leading practices across this country we would be back in the top five health performing nations in the world within the next five years. These include collaborations such as working together here in SW Ontario to create a fully integrated EHR/EMR system that has been identified by Canada Health Infoway as a model.
Or, to take another example, the collaboration across University Ave between Mount Sinai and UHN, and the leadership by Dr. Andrew Morris to develop an AMR stewardship program that was recently featured at the G7 Health Ministers Meeting.
As Dr. Naylor has pointed out in various presentations, if the UK can go from zero to hero over 10 years according to the same Commonwealth comparison, so can Canada!
Carpooling our way to better health and healthcare
So, where does the LEADS framework come in and how can we carpool our way to better health and healthcare. (Explain LEADS briefly as a leadership model and as a change model). Chapter 8 of our book on LEADS focusses on the “D” in LEADS or Developing Coalitions and it starts with the quote:
If you want to travel fast, travel alone. If you want to travel far, travel together.
– African Proverb
In the spirit of “sunny ways”, we are all looking for ways to work better together. And, there are any number of ways to come together: strategic alliances, value networks, coalitions, strategic partnerships. They can be formal or informal. They can be aimed at advocacy, capacity building, service delivery, product development or information sharing. But in all cases, be ready to sacrifice reaction time and control.
Based on the research that I have been involved with and my experience (e.g. recently completed case study on Canadian Health Leadership Network and cross-case analysis for a four year CIHR funded study into leadership and co-authoring the book on LEADS). I would also offer you the following as general preconditions for forming any such collaboration.
First, as John Kotter suggests, the first of eight steps to leading change is to either take advantage of or create a burning platform. Or, as Rahm Emmanuell, former Chief of Staff for President Obama said: “Never let a good crisis go to waste”. So it is, for example, in terms of mental health and plight of Canada’s first nations.
Second, the external threat of not working together has to exceed the internal threat of working with others: mutual gains, mutual interests must be clear and compelling. As I said, losing some time and some autonomy are often the price you pay for working together.
Third there has to be some pre-existing sense of trust among the key players or partners: relationships always come ahead of task orientation.
And, finally, “reciprocity”, by which I mean that all the partners, has to have some skin in the game and all have to think about giving as well as taking. If all the partners take more than they give, the network or partnership inevitably dies or never really gets off the ground.
Assuming these preconditions exist, how does the metaphor of carpooling help us describe how coalitions or collaboratives can work for you?
So, once we have basically got to know one another and established some trust, if I were to ask you to carpool with Bill, what’s the first question you might ask…PAUSE…Where are you going? What’s the destination? Because if we agree to carpool and you want to go back to Niagara on the Lake from London and I want to go to Sarnia…one of us is going to be very disappointed when we hit the 401! Using the LEADS framework, successful coalitions have a very clear focus on “achieving results” the shared destination or a shared preferred future state (use “fencepost” imagery if time permits).
In the case of negotiating a new Health Accord, there needs to be a very clear and compelling vision for a better future for healthcare. We’ve suggested to Minister Philpott as part of a coalition (G-4)…that we need to set the goal of being in the “top 5 health systems in the world in the next 5 years by scaling up and spreading”.
Now that we agree on the destination for carpooling I would feel obliged to tell you that I like to speed. I like to get to that preferred future in a hurry. If you are a white knuckle rider, you probably don’t want to ride with Bill. In terms of a coalition or partnership this is where you need to check to ensure you share the same values…openness, honesty, surprise free…the biggest road bump by far in causing carpools to fail is the big surprise (give example). You need to set these expectations down formally and call your partners if you think these core values are being breached.
In the case of various coalitions working together to shape the new Health Accord…more is not necessarily merrier. There are limits and with the addition of each new carpooler, you risk watering down the message or clouding the “ask”. Dissonant messaging allows decision-makers to pit one constituency against another. Strive to put all your “begs” in one “ask-it”!
Turning to the third test of successful carpooling: We have agreed on the destination and want to get their sooner rather than later. We might then agree to share in the driving, share in the gas and, if you’re driving with Bill, share in the speeding tickets! You need to be clear who’s doing the driving. Again formal agreement on risk sharing is often warranted, especially where trust in new found.
The metaphor here is that you need to consciously assess the risks…financial, legal, and, most often over-looked, your reputational risk. As an organization and as an individual, you only have so much political capital to expend. You want to use it as judiciously as you can and avoid tarnishing it in any way (HSFC cookbooks example, if time permits).
The fourth test or screen for successful carpooling is to share the roadmap. Err on the side of sharing too much information, not just to mitigate surprises but also to anticipate that detour or that accident on the road, when you may want to call upon your navigator to help find an alternative route or avoid construction.
Finally, when we arrive at our destination, Bill will not claim credit for having done all the driving or paying for all the gas. Remember, credit is infinitely divisible…and like your mother taught you and me, it is always better to give than receive.
So, in summary, successful collaborations, like carpooling, requires:
- Sharing same destination;
- Sharing same values;
- Sharing risks;
- Sharing information; and,
- Sharing credit.
Using the principles of carpooling, we at HealthCareCAN are working both on our own and as part of several collaboratives or strategic alliances to help shape both the federal policy agenda and the next Health Accord.
So, for example, we are working as part of G-4…with Canada’s doctors, nurses and pharmacists…to help move the yardsticks on an IT plan in support of a pharma strategy for Canada and in terms of focussing attention on the needs of the frail elderly. We are also working as part of the Health Action Lobby or HEAL to promote integrated patient care as recommended by the Naylor Panel.
As a general rule, issue-specific, time limited coalitions tend to have more success than those that have multiple destinations or continue once success has been realized (or not). Players change. The agenda can change. And, of course, the economic or political conditions can and do change. And, you can always “renew your vows” if there is another opportunity to work together.
Stabilizing the traumatized health research patient
(Tuckman’s “forming, storming, norming, performing” Team H10)
Having spent some time on innovation and innovative approaches to working together, I now focus on one of the key issues concerning the health research community here in London and right across Canada. It is, the lack of adequate core funding and the significant reforms taking place at the Canadian Institutes for Health Research.
I’m not sure how many people in this room are familiar with all of the issues or have a strong interest in health research…show of hands?
In short, we know that the CIHR base budget has been frozen since 2010. We also know that, for a number of reasons, the number of grants submitted has increased by over 50% since 2010…resulting in the success rate dropping sharply from 22.5% to just 14.8%.
In addition, because of the funding freeze, the percentage cut to the budgets for funded grants has gone from about 17% to over 25%.
Perhaps most worrisome of all, we have seen the percentage of grants submitted by Emerging Clinical Investigators …those under the age of 35…that are funded drop from about 10% to just 3.4%.
This erosion of funding has been accompanied by wholesale reforms to CIHR peer review system and streamlining of funding programs, consolidated now under Foundation and Project grant schemes. This has further been destabilizing the research community.
In short, if health research were a patient, it has been severely traumatized over the past five years. We have just formed a new collaborative…we call it “H10”, comprised of the top ten research-based hospitals and regional authorities from across Canada…to work together and , for example, with the Council of Academic Hospitals of Ontario of CAHO, to first stabilize the patient and then help transport the patient forward.
We are still going through the carpooling screens to ensure that we share the same destination. We are, I believe, all looking first and foremost for restorative funding in the spring federal budget that would add $150M back into the A-base of CIHR to recoup inflation. We are also looking for a one-time only Transition Fund of $50M over two years to ensure that investments in young clinical investigators and emerging health research disciplines (e.g. aboriginal health research) are not lost.
Viewed over the longer terms, CIHR is still a tremendous success story. However, we continue to work with CIHR leadership to restore trust and confidence that seems to have waned between researchers and the CIHR.
Summing up: From carpooling to rockships
To sum up, I believe that we need to embrace the “Sunny Ways” to better health and health care. We have a federal government that cares again about healthcare. We have a federal Health Minister and at least 7 other rookie health ministers who appear to have adopted a Team Canada approach to health reform, but they need our help to re-engineer our healthcare system…scaling up and speeding up innovations in the system. Engagement of the health provider community and patients will be critical.
We will all have to find ways to work better together, to look for opportunities to carpool in the best interest of patients and their families.
To close by mixing metaphors, in 1984 John Kingdon described the complex processes of shaping public policy as akin to launching a rock ship.