Healthcare in Ontario: What Has the System Learned?
SARS was my introduction to public service in the Ontario healthcare system. It was an incredible learning experience filled with genuine heroism, courage and love at the front line and numerous examples of stewardship within the governance, managerial and public service leadership at the top of the system.
Throughout the past six months, I have engaged in hundreds of dialogues with board members, front-line staff and senior managers. The consensus view of the leadership of Ontario's healthcare system is consistent - "after SARS, the healthcare system will never be the same again."
In many ways SARS unmasked some painful truths about our existing system. Throughout the crisis we had to face head-on the unintended outcomes that flow from a healthcare delivery system designed as a series of unconnected silos. We have used the language of "service fragmentation," "lack of coordination" and "silo orientation" for years. SARS made us face the consequences of our current fragmented system designs. Hospitals, community care access centres, community-service providers and public health units all discovered that individual silos can be dramatically impacted by other silos. It is an interconnected system, not a collection of independent silos, even if the connections are poorly designed.
While the current component parts of the system were never intentionally designed to create synergy, coordination and cooperation, individual leaders across this system pulled together - despite the disincentives and the barriers.
I think we succeeded because on a very human level, we were able to combine our collective intelligence to solve real problems. Many people and organizations achieved remarkable results through actions that were executed within accelerated time frames. In the midst of all this, I discovered many people who were going through this experience with a "third eye" - an eye that focused on the underlying systemic issues that were being exposed on a daily basis as we moved through this crisis.
Healthcare leaders I talked with throughout the SARS crisis were asking some very probing questions about system design; about roles and responsibilities; about accountability and empowerment; and about the need for fundamental strategic changes that will enable us to move forward.
Is this different than in the past? I think so. I heard leaders raising issues that go to the very heart of the assumptions upon which our healthcare system designs of the past were based. Having a critical mass of the system's leadership at a point where they are determined to actually change the system is perhaps the silver lining in the SARS cloud.
This is a rare moment in the history of our healthcare system. We have the opportunity to reflect not only on the lessons learned from SARS, but on our past lessons learned about health system crisis management captured in a variety of studies from Romanow to Kirby and from emerging examples of best practices.
The key question that leaders need to address is a simple one: How should the system respond to future challenges? While the question may be simple, the issues it raises are complex.
We must look closely at things like organizational culture, effective collaboration, system relationships and our ability to change and learn. And we must examine these issues through indicators like crisis frequency, staff confidence and public satisfaction.
I feel certain that as we move forward from now, our healthcare system will achieve higher levels of patient/resident satisfaction; improved quality of care; and improved cost effectiveness, as well as high levels of staff satisfaction.
Why am I so optimistic? What I can see, from my limited but all-inclusive vantage points, is a deep commitment among healthcare leaders to the shared values of meeting the healthcare needs of the communities they serve and improving the quality of work life of our front-line-care providers.
A key asset, and core capability of our organizations is "know how" which resides in people. We must continue the "people capacity" conversations that took place during SARS. We know that people within the system contain the seeds of all the required skills, talents and potentialities, as well as the intellectual, emotional and systemic barriers to their planting. People disconnects will lead to passive-aggressive behaviour that creates and consumes negative energy, a sense of hopelessness, squanders public funds through inefficiencies and above all defeats any vision of creating a patient/resident-centred system.
Too often, creative solutions to healthcare challenges are opposed by a fortress mentality that equates change with threat, shifts in priorities as cutbacks and internal and external collaboration with a loss of control. Change requires discipline to resist knee-jerk reactions and courage to separate old patterns and structures and processes which are no longer useful to a healthcare system that is being compelled to change. Bottom line, the modern healthcare system must adapt to the realities of the knowledge economy.
Healthcare workers are knowledge workers. Healthcare organizations are not isolated and unconnected to their partners within their community. They are part of an integrated whole, with the same owners and the same healthcare consumer base. While there is no doubt in my mind that there is a critical mass of leaders who really do "get this," and yet others see it as threatening to the traditional silo-orientation and the status quo.
What are the threatening buzzwords that upset some people? "An integrated system"? "Better coordination"? "System synergy"? Customer-focused"? "Seamless services"?
Why is this stuff scary?
If we are authentically open to change, then we must be open to learning … open to seeking and exploring a range of possibilities that we may not have thought about before.
In closing, as we reflect on the lessons learned from SARS, leaders need to have the courage to let go of the existing mental models and ways of thinking. Instead of thinking and acting as isolated silos under siege, governance and managerial leaders can chose to see themselves through another lens - a lens in which organizations see themselves in relationship to a local health services delivery system, community partners in the delivery of care. It is about coexistence and having the courage and conviction to do what is right.
I leave you with this question: Can you see a "system"? Can you see how you can in fact have independence and interdependence at the same time?
About the Author(s)
Hugh MacLeod is Ontario's Assistant Deputy Minister of Acute Services with responsibility for the Emergency Health Services Branch and Hospitals Branch.
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