Longwoods Blog

by Ted Ball


If a community governance board takes as their mandate “to act the best interests of the patients, families, and communities served by the organization,” then they really need to be at the dialogue tables that are determining the design of the community’s healthcare delivery system for decades to come.

In my judgement, however, the state of health-sector governance competence has sadly decreased significantly over the last few decades. 

When I compare observations with other seasoned governance coaches working in the Ontario healthcare sector, our collective consensus is that perhaps only 30 percent of governance boards in the sector are actually adding value to their organization or to the community. 

Within that group, my “coaches corner” group estimated that only 10 to 15 percent of them are actually providing considerable value by truly representing the voices of patients, their families, and staff as they work in a synergistic partnership with their CEO to approve the strategic directions that will drive the organization to achieve their shared vision.

The select few boards that are seen to have added considerable value to their organizations are those that utilized measurement and strategic tools like the balanced scorecard for tracking progress on issues such as patient safety, seamless patient experience, high-quality care, compassionate care, and, improving patient, staff, and physician satisfaction rates. 

It has been demonstrated time and again that when boards put a spotlight on key issues and follow up with wicked and probing questions—without blame—they will, over time, drive an incremental shift and improvement in their organization’s outcomes.

Despite the fact that this is unquestionably the ideal, my panel of seasoned governance coaches estimate that about 70 percent of today’s governance boards actually add little or no value to their organizations. Unfortunately, they just create work.

To make matter worse, the informal panel of governance coaches estimate that 5 to 10 percent of that 70 percent group of “non-value-adding” boards includes boards they consider to be essentially dysfunctional. These boards in fact generate negative impacts—often fear and anxiety—on their organization’s service performance. 

I suspect that this assessment does not sit well with lots of people, but it is, I am certain, true. At the same time,  it is a situation that can be turned around—if that is the will of governance boards.

To bring about this shift, boards need to learn more, communicate better, mobilize, and take their stewardship role more seriously.

Most healthcare governance boards have been taught by their centralized lobby groups—and perhaps even lectured by governance lawyers—that their primary duty is to the best interests of the organization, yet the paradigm shift required by collaborative governance is to place the larger public interest of the “patient-owners” above the more narrow self-interests of the individual organizations.

This is another example of the “51/49” relationship that makes the organization’s interests the top consideration. While silo and system interests are about equal, when push comes to shove, the silo’s interest should rule. But essentially, they are about equal.

So, what is the local system design process that boards need to get involved with?

Ontario Health and Ontario Health Teams

Most people think that launching the new Ontario Health corporation and replacing Local Health Integration Networks (LHINs) with OHTs were all Tory ideas. They were not. When the Tories walked into office in June 2018, the public servants gave them their best advice on “how to dynamite the existing system”—which actually appealed to some of Ford’s advisors in the early days of their tenure as a government. “Blowing stuff up” seemed like a great strategy for the new government.

Without having much understanding of the existing system’s design, the newly elected Ford government bought most of the public servants’ recommendations (see the secret MOHLTC report released by the NDP). The main features of their advice were (a) getting rid of LHINS—which really meant getting rid of LHIN boards and keeping the staff; (b) creating a “super agency” made up of most of the MOHLTC branches and about twenty agencies—such as Cancer Care Ontario (CCO), Health Quality Ontario (HQO), LHINs, and Gift of Life—and re-branding them corporately as Ontario Health.

Doing this type of high-level provincial environmental scan is important, but governance boards that are serious about their mandate to represent citizens and patients also need to be aware of the dynamics among their local OHT CEOs. 

Many contacts across the system report that many OHTs are experiencing or have experienced a distrustful, competitive environment in which survival, fear, and self-interest are the paramount forces at play. In communities where this is the case, the community governance boards may not have an accurate understanding of how their paid CEOs are actually behaving.

Is it possible that something as important as poor OHT CEO relationships can remain unknown to governance boards? Could the board have so little awareness of the environment and dynamics in which their community is operating?

Stories about the early days of OHT development suggest that the relationships between the acute care hospitals and the community agencies are often strained. We now understand that the strained relationships may have come about because the hospitals were originally led to believe that the Ford government wanted the hospitals to run the delivery system. Their lobby, the Ontario Hospital Association (OHA), had consulted closely with the public servants who wrote the system redesign proposal for the new Tory government. Hospitals were told that the new government wanted the hospitals to manage the delivery system—as set out in the secret MOHLTC report to the new government.

In several communities, however, institutional and community healthcare services operate as collaborative partners and the hospital CEOs are not pining to be local healthcare super-bosses because their boards hired them as the hospital’s CEO, not the system CEO.

There are also a few examples of OHTs where the relationships were and are very strong—usually in smaller rural communities—where personal egos are less often at play and there is a deep culture of collaboration. But these OHTs only represent perhaps 10 percent of all the OHTs in the province.

So governing boards need to understand that there could be strained relationships between the CEOs within an OHT. If that is the case, the entire OHT-building effort over the next several years could become a big time-wasting power-game that would end with the deterioration of that delivery system in five or six years from now.

That should not be acceptable.

Collaborative Governance Design

Over the twenty years that I have worked as a governance coach, the knowledge and best practices in the governance field has evolved from a narrow legalistic focus in the 1970 and 1980s. As it engaged with the fields of organizational science, it first embraced the Carver model, which impressed on everyone the distinct roles of the CEO and the board of governors. Then came the policy governance model, the modified policy governance model, the generative governance model, and then the balanced governance scorecard. These were all evolutionary improvements in the field of silo governance.

But with OHTs, we need a governance model for a group of independent organizations that are in a formal,  interdependent relationship. That model is called “collaborative governance.” It is a system or network-wide governance methodology that focuses on ensuring that all the partners are integrated at the CEO and board levels to create the following outcomes:

•  Each OHT system member retains their existing community governance board, whose role or function is to hold the CEO accountable for agreed-upon outcomes at both the silo and system levels. This is what it means to be “independent” and “interdependent” at the same time.

•  Health-service-provider (HSP) CEOs form an OHT strategy team (one member, one vote) that selects a Lead CEO from among themselves to serve in “stewardship” capacity.

• The Lead CEO has an OHT Office of Strategy Management with a VP for Finance and Resource Allocation; a VP for Organizational Development and HR; and a VP for Digital and eHealth Services.

• In these integration exercises, governance boards of silos discover over their journey that all board members across the continuum share the same mission: “to represent the best interests of the “owners” of their organizations. They also discover that the silos have the very same “owners”.

• Each OHT system member sends their board chairs and vice chairs to attend a Vision and Outcomes workshop with all of their OHT CEOs and a few others to launch into the new era, starting by developing a shared vision for the Ontario Health Team and generating the outcomes that will flow from their vision as set out in the top two quadrants  of the four-box Kaplan and Norton best-practice balanced scorecard—that is, patients/customers, and finance.

•  When an OHT-member HSP board has accepted the OHTs system balanced scorecard, they need to determine, with their CEO, what specific outcomes in the OHT system scorecard their CEO will be held accountable to the board for achieving.

• From then on, in addition to holding their respective CEOs accountable for outcomes in their organization’s balanced scorecard, they would then also include the additional outcomes in the OHT system balanced scorecard.

•  Unless an organization has a particular problem that would require the CEOs priority attention, all CEOs in the collaborative governance system would invest 51 percent of their time, energy, and commitment to achieving the outcomes that they are accountable for in their silo, and 49 percent of their time, energy, and commitment to their system accountabilities.

• This collaborative governance design means that all the existing community governance boards would also expand their oversight horizon as  governors. They would now be asking wicked and probing questions of their CEO on both their system-accountabilities and their silo-accountabilities.

How Can HSP Governance Boards Add Value?

Based on lessons learned from successes and failures in implementing integrated delivery system designs, I would suggest the following to community governance boards:

1.     SUPPORT THE CEO—your CEO is going flat out on pandemic crisis management and dealing with numerous complexities, so back off pandemic issues management and provide them with looser restraints and more flexibility.

2.     HELP GENERATE THE OHT’s “SHARED VISION” OF THE FUTURE SYSTEM—use Zoom conferences with fellow board chairs, vice chairs, and CEOs to create an initial integration of the OHT’s shared vision and the outcomes/results that would flow from the realization of the vision.

3.     EXPAND THE CEO ACCOUNTABILITY AGREEMENT—extend the agreement beyond accountability for the silo outcomes to also include accountability for the appropriate system outcomes contained in the OHT’s balanced scorecard.

4.     BRING IN COLLABORATIVE GOVERNANCE—stop being just a “silo board of governance” and start also being a “system board of governance” by holding the CEO accountable for system outcomes—in addition to the silo-outcomes—while taking shared governance oversight for the wellbeing of the whole delivery system by asking the CEO wicked and probing questions about system issues as well as the usual silo issues.

5.     DEVOLVE AUTHORITY OVER RESOURCE ALLOCATION—boards need to stand united on the principle that each OHT’s strategy team of health service provider CEOs must be responsible for the multi-year allocation/re-allocation of resources among the OHT’s members. Each respective board will hold their CEO accountable for achieving the outcomes that result from their allocation decisions.

Boards should send a delegation to meet with their MPP and tell them why they need to advocate for the devolution of authority over resource allocation within each OHT.

Stewardship for Our Communities

In his book Stewardship: Choosing Service Over Self-Interest, author Peter Block says that “the fire of intensity of self-interest seem to burn all around us. We search so often in vain to find leaders who we can have faith in. Our doubts are not about our leaders’ talents, but about their trustworthiness….we are unsure whether they are serving their institutions or themselves.”

To a significant extent, narcissism and self-interest have become the norm within the leadership of the Ontario healthcare system over the past fifteen to twenty years—although it has improved somewhat since the arrival of the Ford government.

Humble is “in” now. Narcissism is more contained. “In service to the people” is increasingly reflected in the actions taken by Doug Ford—and starting to be noticed in some CEOs as a good leadership trait.

But our well-intentioned community governance boards need to be asking themselves some wicked and probing questions about their current governance role in the midst of the pandemic while, at the same time, the future local healthcare services delivery system is being designed by forces and interests that do not include community governance boards whose role is to represent the community’s interests.

Here is a wicked question: if the Ontario Health Team system transformation is such a big deal in the history of Ontario healthcare—as Minister Christine Elliott has said—then why do most community governance boards know almost nothing about it?

The handful of OHTs in which a critical mass of governance board members and HSP CEOs are aligned on transforming their delivery system need to understand that simply inserting the minimum STRUCTURAL specifications will not result in success. Find out next week how they could succeed.

Permission from Transformation Lessons Learned

ABOUT THE AUTHOR: “Ted is a world-class resource for providing insight and intelligence to understanding and solving complex challenges. If there was something important, but impossible to do, he is the first one I’d call.” —Art Frohwerk, former lead at Disney Imagineering Corporation.

This entry was posted on Thursday, February 18th, 2021 at 1:12 pm and is filed under Longwoods Online.