Longwoods Blog

by Ted Ball

BEYOND STRUCTURE—HOW THE “SOFT STUFF” IS REALLY THE “HARD STUFF”

When they discuss integrated delivery system (IDS) design, most people only focus on issues of structure. Although structure is critically important in the system design field, the fact is that whatever you design into the system is what produces the outcomes. So, if we see poor access to services, climbing numbers of preventable patient deaths and injuries, gaps in services, and patients experiencing a complete lack of continuity of services, look at the system structure. It has been designed to produce exactly those outcomes.

And, as the saying goes, “If you don’t like the results, change the design.”

From a system designer’s perspective, structure is much more than the organization chart—it also includes functional, structural, and work process design; decision-making, accountability, and empowerment; information flow and transparency; rewards and incentives; and, strategic budgeting.

In creating a successful integrated delivery system, what we call structure—the “hard stuff”—accounts for at least 51 percent of the basis for success. Ontario Heath Teams (OHTs) must first get their structure right before looking at other factors.

Here are five recommended minimum specifications for the structural components of an effective integrated delivery system.

🎖REGION/GEOGRAPHY—To be a truly integrated healthcare delivery system, the boundaries must conform to current patient-flow patterns based on the Institute for Clinical Evaluative Sciences (ICES) data. These regions have been called sub-regions, sub-LHINS (Local Health Integration Networks), and Health Links regions. Not all OHTs conform to ICES patient-flow data­—some follow the classic provider-centric model created by managerial staff agreements.

🎖OHT STRATEGY TEAM—The OHT CEOs need to form a strategy team of equal partners to develop a course of action for implementing the OHT’s shared vision. To accomplish this, the team will then develop a best-practice four-box Kaplan and Norton balanced scorecard and each CEO will engage their respective boards in ratifying or improving the CEO’s recommended OHT system scorecard.

🎖DEVOLUTION OF AUTHORITY OVER THE ALLOCATION PROCESS—Because the Health Service Provider (HSP) organization CEOs are the ones who are being held accountable for results, they need to be empowered to allocate the OHTs total resources to reflect their evolving multi-year system reconfiguration plan.

The first principle of accountability is: “You cannot be accountable for anything over which you have no control.”

🎖LEAD CEO VS SYSTEM CEO—The OHT strategy team will select a lead CEO who can guide the OHT strategy team as a “servant leader” practicing stewardship services. Rather than having all the HSP CEOs report to a single system CEO, the CEOs should continue to report to their only real bosses—their community governance boards.

🎖OFFICE OF STRATEGY MANAGEMENT AND STRATEGIC LEARNING—This office exists to ensure the implementation of strategy across the new integrated delivery system. The lead CEO will employ an OHT VP of finance; an OHT VP of organizational development (OD) and (OD) and human resources (HR); and a VP for digital and eHealth services.

While each of these five minimum structural specifications are essential for the effective implementation of an integrated delivery system, there are also some equally important non-structural minimum specifications that OHTs must follow if they intend to be successful.

Non-Structural Minimum Specifications

In addition to the five structural minimum specifications outlined above—the hard stuff—there are four proven best practices that acknowledge the fact that complex adaptive systems are profoundly human in nature—this is the “soft stuff”—which account for at least 49 percent of the critical success factors.

Here are four key leveraged actions to enhance an OHTs chances of success on the soft side:

1.   Invest 1 percent of the OHTs total payroll budget in transformation skills development and capacity-building for intact teams.👍

No Ontario Health Team will succeed in achieving its outcomes and vision until and unless there is a critical mass of senior and middle managers, and cross-functional design teams that have acquired “transformation skills.”

Among the 70 percent of organizations that failed at large-scale change processes were organizations and systems in which less than 5 percent of the staff had provided input or even understood the strategy.

Among the 30 percent that were successful were those that invested in developing the internal skills for transformation—particularly among cross-functional groups of senior and middle managers, and high-performance work-process design teams.

Reporting to the lead CEO on this should be the OHT VP of organizational development and HR, who would work with a team of OD learning facilitators to provide workshops designed to build capacity on systems thinking; team learning; facilitation; leadership and coaching; lean thinking; and quality assurance practices and processes—TQM/CQI and patient quality and safety procedures and methodology.

The OHT VP of organizational development needs to ensure that all HSPs share a common language and common frameworks for talking about, planning for, and implementing complex change across the multiple organizations that currently tend to talk past one another because they share different mental models, training, and experience.

2.   Shift organizational culture—starting at the top👍

“Culture” describes an organization’s typical way of thinking and behaving, as well as its norms, values, language, interpersonal behaviours, behavioural expectations, and leadership styles. This basic set of assumptions influences what the organization pays attention to, what things mean, how to react emotionally to what’s going on, and what actions to take in various kinds of situations.

Sadly, healthcare culture in Ontario has morphed over time from a predominantly bottom-up caring culture to an increasingly top-down bureaucratic one. This is very evident in the extent to which the Ministry itself—along with the Ontario Medical Association (OMA), the Ontario Hospital Association (OHA), and others—operates as a collection of fragmented and competitive vested-interest groups.

In their recommendations to the newly elected Ford government, the MOHLTC urged the new government to appoint a hospital CEO—whom they had selected—to head each of the thirty new command-and-control entities that they called Ontario Health Teams.

Deputy Minister Helen Angus said repeatedly that what she needed in a new delivery system was “a single point of accountability”—a dream system in which, instead of weak-kneed citizen boards pretending to hold their CEOs accountable, the “super-agency” Ministry employees from the old MOHLTC would actually be able to hold those CEOs accountable. At least that was the dream.

While her plan was not fully accepted, it gives us some understanding of the cultural assumptions that infuse the thinking and behaviour of the MOHLTC—and most likely Ontario Health, the “new” organization made up almost entirely of people indoctrinated by the old Ministry and then transferred over and re-branded as part of the new entity.

Indeed, the MOHLTC has historically celebrated traditional command-and-control culture, calling it “accountability.” But when the MOHLTC uses that term, they do not really mean accountability, they mean blame.

Accountability is very different from blaming, which means “to find fault with, to censure, revile, or reproach.” Blaming is an emotional process that seeks to discredit the person or organization being blamed. As Marilyn Paul, a scholar in the field of accountability, explains, “blaming is more than just a process for finding fault. It is often a process of shaming others, and searching for something wrong with them…. Blaming generates fear and destroys trust. When we blame, we often believe that other people have bad intentions or lack ability. The qualities of blame are judgment, anger, fear, punishment and self-righteousness.”

Blaming culture, Paul argues, causes further dysfunction in an organization because “where there is blame, open minds close, inquiry tends to cease, and the desire to understand the whole diminishes.”

When people in a command-and-control, bureaucratic organizational culture work in this kind of atmosphere, they naturally engage in defensive routines, covering up their errors and hiding their real concerns.

In healthcare, accountability practices ought to be the highest priority and, perhaps, the most leveraged action that the board of Ontario Health could take right now. If boards were to direct a shift from blame to real accountability, and if that shift were properly designed and executed, it would change the way people think and behave.

“A focus on accountability recognizes that everyone may make mistakes or fall short of commitments,” writes Marilyn Paul. “Becoming aware of our own errors or shortfalls, and viewing them as opportunities for learning and growth, enables us to be more successful in the future…. Accountability therefore creates conditions for ongoing constructive conversations in which our awareness of current reality is sharpened and in which we work to seek root causes, understand the system better, and identify new actions. The qualities of accountability are respect, trust, inquiry, moderation, curiosity and mutuality.”

While blame and blame-avoidance are the driving forces in the old MOHLTC bureaucracy, as well as among the vast majority of employees of the re-branded Ontario Health, a careful examination of the background of the key people on the senior management team and board of governance of Ontario Health gives us cause for some optimism that these particular leaders will understand, pragmatically, what needs to be done. They understand Change Management 101.

They will, however, discover that their new organization is in fact saddled with a sick blame and blame-avoidance culture that has historically infected the entire healthcare delivery system from CEOs to middle managers. 

The board of Ontario Health urgently needs to require their senior management team to engage in leading-edge methodologies to shift their organization’s culture from its blame-orientation to a truly accountable organization.

The board needs to hold their CEO accountable for achieving a fundamental culture shift from the traditional thinking and behaviour of the old management philosophy to one of stewardship, servant-leadership, and adaptive transformational leadership.

3.   Develop stewards and adaptive leaders across the system👍

So what is the leadership culture in the healthcare sector?

Traditional command-and-control styles of leadership have focused on having personal power and authority over others. This style of leadership has been reserved for a few key individuals whose role has been associated with the behaviours of control, direction and “knowing what is best for others.”

However, this current style of narcissistic leadership does not support an empowered, accountable, and responsible workforce—the type of workforce required to build and maintain a flexible, innovative, dynamic, and successful organization or system.

If the mandate and purpose of Ontario Health is to ensure that the OHTs and their individual members are successful in achieving their outcomes, then they need to get out of the micro-management, command-and-control model and shift instead to a new mandate that eliminates barriers and providing the supports necessary for each OHT, and each HSP, to be successful.

Managing the delivery system is the role of accountable health-system CEOs, not Ontario Health, nor the old Ministry. Ontario Health’s role is to ensure that all OHTs and HSPs are successful.

Ontario Health needs to ask each employee: How does what you do add value to people in the healthcare services operating system? The question the board of Ontario Health needs to ask is: Do we really need this activity if it does not support OH’s reason for existence—i.e., making OHTs and HSPs successful?

This should result in a significant reduction in the number of employees at Ontario Health. The Ontario Health employees that remain—with this value-added mission—need to embrace and practice adaptive leadership.

In his seminal work, The Practice of Adaptive Leadership, Ron 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 of people to face hard problems and take responsibility for them.”

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

It also means orchestrating conflict rather than quelling it. Indeed, conflict can become a tremendous source of creativity.

As Heifetz says, leaders in the midst of adaptive transformative change must be able to “artfully guide people through a balance of disorientation and new learning…. Leaders need to hold the group at 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 also goes hand-in-hand with the concept of stewardship, which author Peter Block defines as “the willingness to be accountable for the well-being of the larger community or organization, by operating in service, rather than in control of those around us.”

In hierarchical systems, Block points out, leadership has come to be associated with behaviours of control, direction, and knowing what is best for others. This, however, disempowers people, limiting their confidence and willingness to contribute fully to the wellbeing of the larger community or organization.”

Being in stewardship also requires courage—the courage to stand up for what is right.

“The fire and intensity of self-interest seem to burn all around us,” Block argues. “We search in vain to find leaders we can faith in. Our doubts are not about our leaders’ talents, but about their trustworthiness. We are unsure if they are serving their own silo, or themselves.”

Should the board decide to hold their CEO accountable for a fundamental culture shift at Ontario Health, the senior management team, like the board, has a number of executives who have successfully participated in, or even led, a culture shift at an Ontario healthcare organization.

When CEOs of HSPs finally start to live in a safe environment, free from worries about being blamed by a bureaucratic process, and when they begin to feel that Ontario Health exists to actually help them be successful, then they can connect to their OHT CEO colleagues to work as equals in developing and executing the strategies that will enable their OHT to achieve its shared vision.

When that happens, the CEO’s direct reports will be part of a true learning organization—an accountable learning organization.

4. Each OHT must be designed as an accountable learning organization👍

Nobody in an OHT today has ever designed an integrated delivery system (IDS) that was specifically designed to meet the unique needs of their community.

So, everyone is just going to have to start learning how to do it … by doing it.

If that is the assumption that the OHT’s leadership starts with, their approach should reflect some degree of humility, of curiosity, and a sincere willingness to see the existing realities from new perspectives.

They need to become much more open to learning, open to thinking differently. This is not part of our health system’s existing anti-learning culture.

Systems scientist Peter Senge describes a learning organization or learning community as a “group of people who are continually enhancing their capacity to create the results they want.” He believes that healthy organizations are managed with the objective of liberating and using employee know-how to improve work processes.

If OHTs are managed with the objective of liberating and emancipating frontline healthcare providers and staff, they will require a very different philosophy of organization and job design, communications, and labour-management relations. They will need to develop and support participatory methods and processes that reduce the climate of fear and allow staff the necessary peace of mind to fully engage in their work without all the “gotcha” games played by command-and-control systems, structures, and processes.

Traditional bureaucratic organizations and systems are dominated by the need for control and conformity. They assume that workers are incompetent and that executives are untrustworthy, therefore they need to be carefully micromanaged and controlled. 

This, in turn, creates high degrees of mistrust, defensiveness, and fear—all of which undermine learning and seriously suboptimize one’s work life.

Without trust, an OHT will fail. Restoring or building trust is perhaps the most vital leveraged action that governance boards can take. The cost of the mistrust and cynicism that has been generated by the historical behaviours of the centralized bureaucratic governing style is very high.

These powerful emotions—mistrust, fear, cynicism, and feeling victimized—have corroded our healthcare organizations. They make high performance difficult, create unstable work environments, and, as a result, have led to thousands of preventable deaths and harmful accidents.

People need to work in environment that builds trust rather than destroying it.

Trust is an integrative mechanism. It is the cohesion required for people to come together to accomplish great things. Trust is social capital. It reduces conflict, improves communication, eases cooperation, enhances problem-solving, reduces stress, amplifies organizational learning, and advances positive change.

Our problem today is that—in an environment of mistrust, cynicism, and chaos—our frontline staff become suspicious and cynical, increasingly absorbed in self-protective practices to avoid the blame/shame game spawned by Queen’s Park and delivered by managers wherever there is a weak CEO.

At the root of the problem is how Queen’s Park plays games with the concept of accountability—by which they really mean blame. Their role is to decide who is to blame.

But, as discussed above, accountability is very different than blaming—finding fault with, censuring, reviling, reproaching. When the bosses blame, they are often shaming others and searching for something wrong with them. The hallmarks of blame are judgment, anger, fear, punishment, and self-righteousness.

Ontario Health Teams, their CEOs, and their governance boards all need to recognize that the Ontario healthcare system has reached a very unhealthy stage of development and we urgently require deep change—deep change as distinguished from the traditional incremental change practiced by Queen’s Park’s current “slow boiling frog” methodology.

Incremental bureaucratic change from Queen’s Park is usually presented as though it were the product of rational analysis and planning—with a great deal of PR, marketing, and branding techniques thrown into the mix. It is usually limited in scope and is reversible. It does not disrupt past patterns, so we can return to the old ways if the change does not work out.

With incremental change, we feel as though we are actually still in control.

In contrast, deep change requires new ways of thinking and behaving. It is change that is major in scope, discontinuous with the past, and generally irreversible. Indeed, deep change efforts—like OHT local healthcare services’ system designs—reconfigures the existing patterns of thinking, behaviour, and action. And, it involves taking risks.

Deep change for OHTs would require Queen’s Park to surrender the illusion of control that they cling to so tightly. It requires CEOs to stop being so frightened of healthcare bureaucrats and speak openly with their boards about the threats they are facing—threats that prevent them from being driven only by their accountability agreements with their boards.

Deep change requires CEOs to dig into their sense of professionalism as managers, to speak truth to power, and to cease their fear-generating behaviours. To successfully transform, adaptive leaders need to invest in the skills of their people and reshape their OHTs into true learning communities.

Moving Beyond Structure to Human Leverage

While all the components of structure that I listed at the beginning of this essay are absolutely essential—lesson learned: whatever you design into the system produces the outcomes achieved—the fact is that there are a bunch of key human, or soft, factors that turn out to be just as important as the structural minimum specifications.

The soft stuff includes such non-structural influences as the skills that people have to transform the organization; learning organization culture—or how people think and behave; leadership styles; stewardship; disruptive governance; and best practices for accountability and empowerment.

Organizational transformation coaches and hands-on leaders who have undergone a fundamental organizational or system transformation will tell you: THE SOFT STUFF IS THE HARD STUFF….

. . .because the humans are a f*** of a lot of work.

Published with permission from Transformation Lessons Learned

ABOUT THE AUTHOR: “Ted Ball cuts through the clutter with quick wit and keen intellect, focusing on the true levers of transformational change. His articles are a must-read for anyone working to improve the system.” —Shirlee Sharkey, President and CEO, SE Health

This entry was posted on Thursday, February 18th, 2021 at 1:16 pm and is filed under Longwoods Online.