Healthcare Quarterly

Abstract

While there is an opportunity to learn and build on experiences in other Canadian jurisdictions, Local Health Integration Networks in Ontario (LHINs) differ in a fundamental and important way from Regional Health Boards (RHBs) in other jurisdictions. Whereas other jurisdictions dissolved most provider boards and "integrated" them directly into the regional structure, LHINs have been established without dismantling the traditional power or governance structures (within or outside the Ministry of Health and Long-Term Care). Furthermore, a clear decision was made in Ontario to maintain voluntary, independent governance for all provider organizations, including hospitals, long-term care facilities, community health and support services, and mental health service providers.

The 14 LHINs are completing their first year of operation, in which they have been actively engaged in getting to know their communities and developing their first Integrated Health Services Plan (IHSP) for their catchment area. The Local Health System Integration Act, 2006 (Section 16) states that "a local health integration network shall engage the community of diverse persons and entities involved with the local health system about that system on an ongoing basis, including about the integrated health services plan and while setting priorities."¹ This legislated requirement has created a new dynamic in Ontario's healthcare landscape. The challenge currently being faced by all LHIN Boards is how to ensure appropriate and effective involvement of healthcare providers and the public in their work. In fact, finding the "right" mechanisms to engage with stakeholders - both individually and at an intersectoral level - and to obtain meaningful input as a result of this engagement is essential to ensuring not only effective decision-making of these Boards, but also, their very legitimacy. As they embark on their journey to integrate health services at the local level, there are some important questions to be asked by LHIN Boards:

• Have Regional Health Boards (RHBs) in other provinces found effective ways to engage intersectoral involvement of providers in their work?  
• What kind of investment is required to develop effective communication processes that will create opportunities for networking and exchange between LHIN Boards and providers/public?  
• What can Ontario learn from the experiences of others?

The Need for Engagement

A key goal underpinning the establishment of LHINs is to improve the coordination and integration of the system of health service delivery at the local level. Successful community engagement (i.e., provider and public participation) is seen by the government and the LHINs as essential for realizing this goal. Initially, engagement strategies have been implemented to support LHINs in the development of their Integrated Health Services Plan (IHSP) that will identify priorities for health services integration within each LHIN. Subsequently, in the implementation phase of the IHSP, engagement will be critical to build support for the steps required to close the gap between the LHINs' defined priorities and the current organization of services.

"Workable" strategies and tools are needed to initiate and sustain dialogue between Boards and providers and the public. Mechanisms developed will need to be open to those who have immediate interests in healthcare reform (e.g., healthcare providers, healthcare managers, patients) and those who have more diffuse interests and are distant from the day-to-day activities (e.g., citizens, taxpayers) (see Dubois 2004).

What Can Ontario Learn from Others?

While many jurisdictions across the country have devised a variety of structures and processes to "engage" providers (and the public) in their work, doing so effectively remains an ongoing challenge. (Table 1 provides a summary of some of the strategies and tools that have been used by RHBs in some provinces to build relationships with intersectoral provider groups.)

[Table 1]

Based on a cursory review of the literature and feedback received from individuals involved in the work of RHBs in other jurisdictions, some important themes can be identified regarding strategies and tools for building relationships between RHBs (i.e., at the governance level, as opposed to management level) and intersectoral groups of providers.  

Rationale/Objectives for Engagement of Stakeholders  

1. The strategies and tools (i.e., structures and processes) used by RHBs to engage stakeholders in their work have been dependent on their objectives for consultation/input. The most common objectives for soliciting involvement arise from the need for RHBs to

• strengthen involvement of key "system" leaders in the work of their Board (sometimes in response to expectations included in Legislation/Regulations)
• provide forums for broader consultation and an expanded level of input into the work of the regional "entity"
• involve the broader community in identifying needs and setting priorities to make healthcare planning and decision-making more responsive to population needs
• solicit advice on specific issues/proposed changes
• improve coordination and integration of services (particularly primary health services with other parts of the health system)
• build an understanding of service changes that could impact a community
• demonstrate the organization's accountability to the public
• manage public expectations
• promote shared ownership of the work of the RHBs in their role as a successful "manager, coordinator and/or integrator" of health services.

Strategies and Tools Used by RHBs to Engage Stakeholders

2. There has been significant variation in the types of strategies and tools used by RHBs to liaise/interact with intersectoral provider groups (and the public) both within and across jurisdictions. Some of the most common structures/processes have included

• consultations/focus groups
• community advisory groups
• public board meetings
• open forums  
• annual reports  
• representation of community/provider members on Board committees  
• regular "customer" feedback surveys
• use of the media (i.e., open-line talk shows) (see Quigley and Nickoloff unpublished).

3. Some regions have relied more on the use of existing forums (formal and informal) in communities to share information and consult on health service issues.

4. Some regions have used "targeted" community consultation initiatives² utilizing a range and variety of approaches such as focus groups, public meetings/forums, stakeholder-specific interviews and written submissions. These consultations are used in situations where time and budget permit and the Board determines

• there is potential for a significant impact on health services in a community or a group of communities
• the proposed issue will impact the strategic direction of the health authority; and  
• there is an opportunity to influence a decision.

Participants may include the general public, care providers and community leaders.

5. During their early days of regionalization, some provinces did not feel the urgency to achieve stakeholder involvement (or secure intersectoral collaboration across providers groups) because of the "exclusion" of many specialized services (i.e., cancer and mental health³) from the responsibility and control of RHBs.

6. In some provinces, regions have developed formal frameworks outlining processes for involving stakeholders in RHB activities. For example, the Calgary Health Region developed a Public Participation Framework. The Vancouver Island Health Authority published the VIHA Public Participation Framework. These frameworks help determine the level of participation being sought and are dependent on a variety of factors such as the degree of public interest, the complexity of the issue, the risks to the organization, the budget and timing. The various levels of public participation are shown in Figure 1.

[Figure 1]

Best Practices in Engagement

7. Experiences in other jurisdictions confirm that finding the "right" structure(s) to engage communities in the work of RHBs has been "helpful" but in and of itself is not sufficient to ensure horizontal integration. Two key challenges that have arisen in engaging communities in promoting stronger integration across sectors have included

• ensuring that health services communities don't "wander" from health authority priorities and strategic directions
• developing expertise and resources in community development and relationship building as a primary role for RHB administrators (see Light).

8. The Quebec Regional Agency is an interesting and new model. The system is being "heavily managed" with hospitals negotiating/bidding to do specific volumes of activity based on tight targets that have been established in key areas (e.g., cancer surgery, radiation therapy, hip/knee surgery, day surgery/day procedures, cataracts). Monthly reports are provided to the [regional] Agency. Providers know what is expected and are held responsible and accountable for reporting on volumes (through monthly reports and quarterly meetings). These efforts are resulting in balanced budgets.

Challenges and Limitations  

9. In some Canadian jurisdictions, stakeholders feel they have had less input into the healthcare system in their area since hospitals came under the governance of RHBs. In Nova Scotia, for example, a Minister's Task Force on Regionalized Health Care (Government of Nova Scotia 1999), which was mandated to analyze the current state of regionalization and to study its strengths and weaknesses, found that

• there is a general perception that community representation at the regional level is inadequate
• regionalization is widely misunderstood, with both providers and consumers believing that its main goal has been to cut costs
• deficiencies such as physician and nurse shortages, bed reductions and long waiting times have been attributed to regionalization.

10. Finding ways to go beyond the "traditional circle" of academic and organizational experts has been a key challenge facing most regions in involving providers and/or the public in their work. Professionals tend to dominate the decision-making process, and research and past experience provide little supportive evidence that healthcare quality has been improved. These conclusions are based on a review of studies that conducted literature searches, provided expert opinion or presented results from surveys that researched participants' perceptions (see Zena Simces 2003).

11. "Restoring" the morale, involvement and support of the physician community has been a significant challenge confronting many RHBs. In B.C., for example, physicians reported that they were frustrated with the current regional funding system and were consistent in their lack of support for increased RHB influence over healthcare fund allocations and/or physician payments (see British Columbia Medical Association 2003).

Effectiveness of Stakeholder Involvement

12. Finding ways to engage providers and the public in the work of RHBs has been only part of the challenge. A bigger challenge has been to engage them in a decision-making process in a meaningful manner and in a way that is "comfortable" for them. Experience in other jurisdictions has found that citizens are willing to make decisions about principles, values, client satisfaction and to provide input related to service delivery, but are less willing to make decisions about planning and setting priorities, distributing funds and managing services (see Zena Simces 2003). In fact, as the complexity of devolved decision-making becomes clear, "the community" tends to favour assigning authority to traditional decision-makers (i.e., elected officials, experts and the provincial government) (see Abelson et al. 1995).

13. In local, national and international settings, the public (patient/patient groups) has contributed to the planning and development of healthcare services across a range of service areas and levels, but the impact of this involvement on the quality and effectiveness of health services is undetermined (see Abelson et al. 1995). Past experience, as reflected in the literature, suggests that there is no empirical evidence that the current mechanisms - boards of governance and advisory councils - adopted by governments to enhance citizen participation, accountability and responsiveness in healthcare decision-making are likely to be effective.

Conclusion

Given Ontario's unique approach to regionalization, it is difficult to find models from other jurisdictions that can provide guidance in achieving a collaborative governance relationship between LHINs and provider organizations. However, the variety of strategies and tools for community engagement used by RHBs in other Canadian jurisdictions, albeit executed largely at the operational levels, can assist LHIN Boards in determining approaches for engaging the community in their work and differentiating the respective roles of the LHIN Board, LHIN management and Provider Boards and management as part of the overall engagement process.

Based on the findings from other jurisdictions, the most significant challenges for LHINs in Ontario will be to undertake a process of community engagement which enables those who have input to be comfortable in their role within the decision-making process and to actually achieve value-added input to the LHIN in establishing and implementing the Integrated Health Services Plan.

During this first round of community engagement, LHINs have focused on soliciting general perspectives from the broad public and health service providers on what is important in terms of regional health service priorities. However, as the LHIN mandate evolves to actually setting priorities and allocating resources-based on these priorities, community engagement will need to take on a different focus in which LHINs shift their attention to "selling" (as opposed to soliciting) ideas for change and building support for their IHSPs both with provider organizations and the broader communities within their catchment areas.

Following the submission of their IHSPs to the Minister, it will be important for LHIN Boards to step back and assess the extent to which the processes used to engage the broader public and health service providers and the actual advice received have added value in their decisions on priorities for health services integration. Furthermore, as the approach to community engagement has varied across LHINs, it will also be important to share the learnings across LHINs to help refine subsequent processes for community engagement and to identify future target audiences.

About the Author

Maureen Quigley, of Maureen Quigley & Associates Inc., specializes in the facilitation of planning and change management processes in the Canadian healthcare sector. As part of her practice in health sector governance, she advises LHINs and health service providers on collaborative governance relationships and facilitates dialogue between LHIN and provider Boards of Directors.

Beverley J. Nickoloff is an independent consultant. She has extensive experience in policy and program development, strategic planning and network development in the healthcare sector.  

Corresponding Author:
Beverley J. Nickoloff,
BA (Hon), BEd, MHSc
90 Roslin Avenue, Toronto, Ontario,
M4N 1Z2, Phone: 416-484-4523,
E-mail: bev.nickoloff@sympatico.ca

Acknowledgment

An initial version of this paper was prepared for the Chairs of the LHIN Boards in February 2006. The authors would like to acknowledge the following individuals who shared their perspectives on "engagement" in a regional health system: Ann Casebeer, Associate Professor, Health Sciences - Centre for Health and Policy Studies, Community Health Sciences, University of Calgary; Janet Davidson, Chief Operating Officer, Vancouver Coastal Health Authority Formerly, Assistant Deputy Minister of Health for the Province of Alberta; David Levine, CEO, Montreal Health Authority (Agency for the Development of Health and Social Services); Hume Martin, President & CEO, Rouge Valley Health System (Formerly, Chief Regional Officer with the Calgary Health Region and Executive Director of the Alberta Children's Hospital); Richard Musto, Deputy Medical Officer of Health, Calgary Health Region; Hugh Scott, President & CEO, The Scarborough Hospital (Formerly, Executive Director of the McGill University Health Centre).

The views expressed as well as any errors in the manuscript are those of the authors.

References

Abelson, J., J. Lomas, J. Eyles, S. Birch and G. Veenstra. 1995 (August 14). "Does the Community Want Devolved Authority? Results of Deliberative Polling in Ontario." Canadian Medical Association Journal. 143(4): 421-42.

British Columbia Medical Association. 2003. Policy Papers - Regionalizing Health Care Budgets in BC. Retrieved July 21, 2006. http://www.bcma.org/public/news_publications/
publications/policy_papers/RegionalizingHealthCareBudgets
/ExecutiveSummary.asp;.

Calgary Regional Health Authority. 2000. Strengthening Community Action: Framework for Health and Wellness. Prepared by Bretta Maloff and Yvette Penman, Calgary Regional Health Authority. Retrieved July 21, 2006. http://www.calgaryhealthregion.ca/hecomm/
comdev/pdf/SCAFrameworkFulldoc.pdf.

Dubois, C.A. 2004 (November). Implementing Primary Healthcare Reform: Strategies to Align Stakeholder Support. Summary of the Discussions from a Seminar Organized by the Canadian Health Services Research Foundation's Primary Healthcare Network.  

Government of Alberta. 1994. Regional Health Authorities Act.

Government of Nova Scotia. 1999 (July). Minister's Task Force on Regionalized Health Care in Nova Scotia - Final Report and Recommendations.

Levine, D. 2005. "A Healthcare Revolution: Quebec's New Model of Healthcare." Healthcare Quarterly 8(4): 38-46.

Light, P. "Organizational Design and Integration: A Case Study of a Canadian Health Authority." Retrieved July 21, 2006. http://www.integratedcarenetwork.org/
publish/articles/000050/article_print.html.

Ontario Ministry of Health and Long Term Care. Local Health System Integration Act, 2006.

Quigley, M. Collaborative Governance and Community Engagement. Presentation to the OHA Conference on Community Engagement, June 26, 2006.

Quigley, M. and B. Nickoloff. (unpublished). "Rethinking Regionalization: Can Regionalization Assist in Addressing the Challenges Facing the Ontario Health Care System?" Background paper prepared for the Ontario Ministry of Health and Long-Term Care.

Quigley, M. and G. Scott. Building Collaborative Governance with LHINs: Setting the Framework for a Collaborative Governance Model. Presentation at the OHA Conference on Local Health Integration Networks, April 28, 2005.

Quigley, M. and G. Scott. Advancing Collaborative Governance: A Potential Framework. Presentation to Local Health Integration Network Board Chairs, February 22, 2006.  

Vancouver Island Health Authority. 2003 (August). Public Participation Framework for the Vancouver Island Health Authority (VIHA).  

Zena Simces & Associates. 2003 (May 27). Exploring the Link Between Public Involvement/Citizen Engagement and Quality Health Care - A Review and Analysis of the Current Literature. Prepared for Health Human Resources Strategies Division Health Canada.   Retrieved July 21, 2006. http://www.hc-sc.gc.ca/hcs-sss/
pubs/care-soins/2003-qual-simces/
2003-qual-simces-1_e.html.

Footnotes

1 Local Health System Integration Act, 2006, Section 16(1). On March 28, 2006, the Local Health System Integration Act (LHSIA) was presented to the Lieutenant Governor in Council and received Royal Assent. The ministry is currently developing the regulations and operational policy needed to support the implementation process.

2 Key benefits: involve a high level of public participation; provide valuable information to inform strategic directions. Drawbacks: require
significant time commitments from all involved; expensive

3 These are sectors that traditionally have required much intersectoral collaboration.