Longwoods Blog

by Ted Ball


As I said in my previous essay, it is my judgment that our public healthcare delivery system will significantly deteriorate on indicators of quality, safety, and accessibility across the province within five to six years unless the Ford government empowers local communities to allocate resources for healthcare services through their Ontario Health Teams (OHTs).

Mr. Ford should no longer allow healthcare systems at the OHT local community level to be designed and micromanaged—top-down—by the centralized bureaucratic elites at Queen’s Park. Throughout the pandemic, the Premier has seen firsthand how razor-focused the public-service healthcare officials are on being “control process–oriented,” rather than “outcome and results–oriented.”

Unlike the previous Liberal government, and unlike our public servants, Doug Ford knows there is wisdom at the local level and in the frontlines of care delivery. He knows that the answers to some of the most perplexing challenges facing our healthcare delivery system are in the hearts and minds of our frontline care providers.

But that bottom-up capacity, capability, and wisdom needs to be liberated. Are the MOHLTC and Ontario Health in the liberation business? No, liberation would be a disaster for the command-and-control power addiction among our public servants.

Instead of demanding more of his public service, our Premier—possibly suffering from “Patty Hearst/Stockholm syndrome”—clearly listens to the internal, inner-circle echo-chambermaids and advisors who have been telling him that what the healthcare system really needs are billions more borrowed dollars to maintain the existing delivery system. They have persuaded the Premier that this would be a prudent investment—or that Trudeau is so desperate to be loved again that he will fall for it. But he didn’t, so far.

The Premier and his Minister of Finance really need to cross-examine their advisors in the public service who claim that the healthcare system needs more money. If they get their hands on billions of additional tax dollars, will Ontario Health or the MOHLTC commit to achieving province-wide, high-quality, integrated health system transformation?

No. They won’t. Not unless something changes soon.

My assessment is that Ford is going to be in big trouble at the midpoint of his second term because that is when most of our eighty OHT health systems will begin to measurably deteriorate in terms of quality, safety, effectiveness, efficiency, patient satisfaction, and seamless services.

This will happen because, in my best judgement, most of the OHTs will not succeed in designing an integrated delivery system for their communities over the next two to three years. I am convinced that most OHTs will simply fail to successfully integrate and their community boards will haplessly watch it happen.

Sadly, it will just be a matter of doing too little, too late.

In this essay I will endeavour to provide some pragmatic suggestions based on lessons learned from designing and implementing integrated healthcare delivery systems to the twenty to thirty OHT leadership teams that are genuinely determined to achieve system transformation.

I learned about integrated healthcare-delivery system-design methodologies, processes, implementation challenges, and effective accelerator strategies in the early 1990s from my mentor, Herbert Wong, the founder and CEO of Quantum Solutions of Austin, Texas. Herbert had an R&D team of about forty people who were inventing tools and frameworks for designing complex, adaptive human systems and developing strategy execution processes to mobilize senior and middle managers, as well as frontline care providers, to implement their strategies—all based on systems thinking.

By the year 2000, however, what appeared to be true in the health-sector world of “change practitioners” was that at least 70 percent of all attempts at large-scale change in healthcare systems and healthcare organizations ended in failure. Only about 30 percent ever succeeded at TQM/CQI, re-engineering, lean thinking, and local system integration, and only 10 percent of system mergers were successful.

Failure in large-scale change is not only extremely expensive—it uses billions of taxpayers’ dollars—but, for the people mobilized behind the new great effort to improve the system, the frontline people recruited to dream the dream of a better system, it is terribly demoralizing. The organizations themselves can, and often do, atrophy for years afterword.

So the folks at Quantum Solutions set out to discover more about why some leaders/organizations/communities failed to achieve improved integrated systems and why others succeeded. Their findings—presented at a couple of annual Systems Thinking Practitioners’ Conferences and refined after feedback by other practitioners in the field—were called the “minimum specifications for success” in designing, implementing, and managing Integrated Delivery Systems (IDS). They are the opposite of the “low rules” approach.

In my many blogs posted at TedBall.com, I avoided stipulating what I thought should be done. Instead, I posed the wicked questions that leaders need to think about. While I have always resisted prescribing a checklist of the most leveraged actions a community could take, the following are nine suggested minimum specifications that each Ontario Health Team should discuss:

😷  Strategy Development and Execution

The CEOs of the OHT member/partner organizations need to be put in charge of strategy development and strategy execution by their respective boards. CEOs are the “chief strategy officers” in their own organizations and when they come together as a group of equal partners, they then become the “system strategy team” for the OHT.

An OHT strategy team is responsible for developing and executing aligned strategies to achieve the outcomes in the OHTs System Balanced Scorecard.

The best-practice balanced scorecard from Kaplan and Norton is the best tool/framework for both strategy development and strategy execution that we have access to in the healthcare sector. The four-box strategy framework is driven by the top two quadrants: CUSTOMER (patients, families, and communities) and FINANCE (the leveraged use of resources and strategic budgeting).

The OHT System Strategy Team—made up of the partner CEOs—ought to meet weekly for three or four hours to determine how to achieve the outcomes in their system scorecard by identifying the actions required in the bottom two enabling quadrants: VALUE-ADDED PROCESSES (the design of systems, structures, and procedures to achieve the customer and financial outcomes) and LEARNING AND GROWTH (what new skills or capacities are required to design the value-added processes).

😷  Lead CEO vs System CEO

Rather than using the suboptimal collaboration model of an imposed “System CEO,” OHT Strategy Teams that are determined to succeed should instead select a “Lead CEO” from within the team.

This Lead CEO would be mandated to provide stewardship to the Strategy Team and their respective boards, and be the single point of contact between the OHT and the MOHLTC/ Ontario Health. The Lead CEO can be terminated by the strategy team—that is, unless they operate as a true “servant-leader” of the OHT’s healthcare service delivery system.

But the Lead CEO will need some pragmatic help from three VPs who will work together in their own stewardship role. These are:

(a) an OHT VP of FINANCE who is the fundholder for bundled OHT system payments and is knowledgeable about evidence-based decision-making, with responsibility for overseeing the devolved allocation of resources linked to the OHT’s balanced scorecard strategies;

(b) an OHT VP of ORGANIZATIONAL DEVELOPMENT/HR who is responsible for building the internal capacity of staff across the delivery system to use common language and frameworks for designing and integrating systems and processes—such as quality and safety methodologies; lean-thinking principles; and patient-experience design methodologies—with all the latest tools and procedures for aligned strategy execution across the OHT healthcare service providers (HSP); and,

(c) an OHT VP for DIGITAL/IT and eHEALTH SERVICES, headed by a person who can facilitate the effective and efficient integrated digital health strategies needed to transform healthcare delivery in the post-COVID era.

In this collaborative governance model, while the Lead CEO is a servant-leader for the group, each of the CEOs on the OHT strategy team needs to devote at least 51 percent of their energy and time to ensuring that they achieve the outcomes they are accountable for attaining in their silo scorecard. The remaining 49 percent of their energy and time will be invested in ensuring that they successfully reach their OHT’s local-system balanced-scorecard outcomes.

This 51/49 balance redefines the role of CEOs. It is an essential paradigm shift in which healthcare CEOs are no longer just “silo CEOs.” They are now taking another step up in the hierarchy to become “health-system executive CEOs.”

😷  Shared Vision Alignment Post-Pandemic

Without a powerful shared vision for the future system, no OHT is going anywhere.

OHTs intent on succeeding should devote four to five hours generating an initial shared vision for their OHT or, in this emerging “experienced pandemic” environment, a refreshed vision for the healthcare services provided by the OHTs in the post-pandemic era.

In addition to all the OHT CEOs involved in the visioning process, the member HSPs should have both their board chairs and vice chairs present at this initial half-day collaboration and partnership-building visioning exercise. These citizens represent the interests of the community as opposed to the self-interests of the providers. They are the “patient-owners” whose purpose is to hold their CEOs accountable for outcomes in the patient/community/taxpayers’ interests. The delivery system—and the individual HSPs—all belong to the citizens of Ontario, the patient-owners of the whole system.

Along with the board/management group generating the initial OHT shared vision, it would be prudent to also include a few primary care physicians from community health centres (CHCs) and family health teams (FHTs); medical chiefs-of-staff of hospitals; and, the OHTs local medical officer of health.

The purpose of the exercise is to generate an agreed-upon vision—a picture of the future—that the OHT will bring to fruition within the next two to three years. We all know that, as systems scientist Peter Senge has said, “Few, if any forces in human affairs are as powerful as a shared vision.”

At the end of this visioning day, the final exercise would be to generate the projected outcomes and results that arise from the implementation of the shared vision that the participants have created together. Those are in the top two quadrants of the balanced scorecard—the CUSTOMER quadrant and the FINANCIAL quadrant.

😷  The OHT Balanced Scorecards

The Lead CEO’s role is to support the OHT strategy team at their weekly half-day meetings as they generate strategies and come up with the right combination of leveraged actions to propel the OHT toward their shared vision for the future.

Developing the first iteration of the OHTs balanced scorecard could take forty hours of CEO discussions over three months. When it is completed, each CEO should present the OHT local system balanced scorecard to their respective boards of governance.

😷  Collaborative Governance and CEO Accountabilities

Community governance boards exist to represent the best interests of the communities, patients, and families that the healthcare provider organization serves by holding their CEOs accountable for the agreed-upon outcomes that are in the public interest—they serve as the patient-owners.

The 51/49 governance model—in which each partner HSP maintains their current organizational governance oversight as well as a shared-system governance oversight and shared CEO accountabilities for the larger system—is called collaborative governance.

In designed collaborative governance, as each HSP community governance board approves their OHT’s balanced scorecard, they can then enter into an expanded accountability agreement with their CEO so that their responsibilities cover both of their roles—first, as the chief executive officer of their organization, and then, as an OHT strategy team member with additional, specific, system-wide accountabilities.

Similarly, community governance boards would not only provide oversight for a single organization, they would now—with this paradigm shifting governance design—also provide oversight and stewardship to the larger healthcare delivery system by holding their respective CEOs accountable for the appropriate system outcomes.

Collaborative governance is a design that holds CEOs accountable for accomplishing outcomes internally—within their organization—and externally—within their local service delivery systems.

😷  Primary Care Is The “System Hub” of the OHT

Ontario Health Teams need to be designed as “patient-centric.” I am not using the term patient-centric the way Queen’s Park does, as an adjective, but as a crucial design feature. That’s why primary care services—CHCs and FHTs among others—need to be the hub of the OHTs delivery system. That is a major shift from the current system design in which hospitals serve as the hub of the delivery system.

The resources for patient navigators, mental health nurses, social workers, and so on need to be placed within primary care settings where there is a community board of governance to oversee the expenditure of hundreds of millions of taxpayer dollars in the public interest.

😷  Integrating OHT Middle Managers Cross-Functionally

Middle managers within the OHT member organizations are the key leverage point for mobilizing aligned change across the service delivery system. They should meet monthly for half a day—perhaps in smaller logical groups—to connect the system together as a system.

Start with lessons learned from the pandemic and suggested solutions.

Then, with organizational development support, task the OHTs cross-functional teams of middle managers to determine how to implement patient-experience design processes across the delivery system—co-designed with patients, families, and frontline care providers—to create a seamless, high-quality, safe, experience across the continuum of care—the very heart of why OHTs exist.

😷  Open-Space Conference for Frontline Workers

The Balanced Scorecard Collaborative studied why so many healthcare organizations failed to execute their strategies. They found that, where they failed, only 5 percent of their workforce actually understood or even knew about the strategy.

Unless strategy is connected to the frontline, nothing different will happen.

Each Ontario Health Team would be well-advised to host at least ten separate four to five-hour (Zoom-enabled) “open space conferences”—a methodology for generating the collective intelligence and wisdom of frontline care providers, and for connecting people throughout the delivery system.

Each self-organizing online dialogue conference needs to involve the whole system, represented by a selection of about thirty-five to forty people.

Ten such open space conferences would make it possible for up to four hundred people from across the delivery system to spread positive and optimistic communications—peer-to-peer—about the positive changes that are coming.

😷  Local System Design Requires “Owners” Input

As discussed, governance boards exist to represent the best interests of the owners of the organization—the patients, families, and communities they serve.

Board members need to wake up—and step up—to their role as stewards for their communities.

This issue of local health system integration design truly is an issue of governance and stewardship. The fact is that, currently, our community boards of governance are not involved in the critical decisions about the design of each local system. There is no community governance input.

Why is that?

We need our healthcare community governance boards—and their 10,000+ board members—to invest their insights, community values, and wisdom in the design of their community’s Ontario Health Team to ensure that the OHTs do not re-create another “provider-centric” system design.

Published with permission from Transformation Lessons Learned

ABOUT THE AUTHOR: “Ted Ball is a brilliant systems thinker, and the best intelligence gathering resource Ontario has. But, what is uniquely exquisite about Ted, is his non-nonsense attitude, honesty, and integrity to share information generously and widely. Working with Ted is at once inspiring, stimulating, and fun!” —Dr. Doris Grinspun, CEO, RNAO.

This entry was posted on Thursday, February 18th, 2021 at 1:08 pm and is filed under Longwoods Online.