Insights January 2013

Courage A Rare Competency

Hugh MacLeod and Senator Michael Kirby

From the pen of the publisher

This is the launch of penned theatre by Hugh MacLeod who also plays the role of editor and discussant. The idea just appeared to him one late and awesome night. A few trial essays were so well received that we welcome the opportunity to keep the theme alive and . . .well, just a little mysterious and paranormal. Add your comments if you don’t mind a visit from the past. No flash photos in the theatre, Please. 

I am joined on the balcony by a respected champion of change, Senator Michael Kirby. No major public policy arena in Canada is more in demand of courageous leadership than healthcare. What do we mean when we talk about leadership? We believe strong leaders share a number of key characteristics: Insight, initiative, influence, impact and integrity.

Courageous leaders are able to look at complex situations, gain clarity and determine a course of action. They are willing to go first. They do not sit on the sidelines waiting for a change in circumstances. Strong leaders do not ask others to do what they are unwilling to do themselves. They lead by example. Strong leaders are able to inspire people to willingly follow their ideas. They are able to create real and lasting change. They make a difference.

It must also be said that strong leaders are anchored by values and principles that guide their actions. Yes, we recognize there are critics. More to the point, there are cynics, like the one we call the Ghost of Healthcare Despair.

“What I see is leaders hesitating to take definitive action,” says our not-so-friendly ghost. They need more time. Things are never quite ready. Their complaint about inadequate resources is a chorus across the country. The fix is more people and more money, they claim. They refuse to take responsibility. It is always someone else’s problem.”

From all the research, papers, commissions and studies emerge some common themes: Market competition for high volume; relatively simple procedures; incentives to transform care delivery services; greater emphasis on primary care as gatekeeper and promoter of healthy living; improved regulation, reality in much our the current regulation is out of step with the current environment. For the healthcare system to be effective, the focus needs to shift from money inputs to care outcomes; on being patient-first not provider-first. 

In truth, there is broad consensus on what needs to be done. However, there is no consensus on how to do it. We are not short of insight, initiative, influence, impact and integrity. We are short on the willingness to turn these into action.

All parts of the system wait for other parts to propose change. When the proposals come, they criticize those that ask them to behave differently. Internal politics in healthcare prevent system change. Why should anyone pay attention to those of us in leadership positions? Who are we? Are leaders just a special interest group? Are leaders really interested in change, or more about protecting turf and status quo? Are leaders truly beholden to the greater good? Do we work for the patient-resident-client — the people we serve? Or, are we focused on our own silo, and our own self-interest?

No matter what leadership position we occupy, sooner or later we are going to be put to the test. To handle this circumstance — a test of past complacency, current certainties and leader’s conscious or unconscious ambitions — our leadership metal may require tempering. Part of the tempering, or humbling, can only come from an honest reflection with self. Questions need to be asked to focus leaders on accountability, self-reflection, honesty and purpose. Which questions? Examples include:

  • What do you want to create and contribute to the healthcare system, as an individual, a team and as an organization?
  • What is your vision of achievement?
  • What does achievement look like?
  • What will it take from you to do it? What are you doing right now to reach your vision?
  • What is hampering you? What are you afraid of losing?
  • What might you gain by doing something differently?

Suddenly out of nowhere the Ghost of Healthcare Despair appears again

“You should be talking about real life examples requiring new thinking and courageous leadership. Virtually all healthcare leaders and health ministers say that they care deeply about mental health, particularly child and youth mental health.  Yet even though they say they care, not much changes.”

Today only about one out of every five children or youth with a mental health problem gets any professional treatment.  A child or youth needing psychiatric help waits a year or more before seeing a psychiatrist.   Most importantly, psychological counseling services are a superb example of the two tier healthcare system that politicians of all parties say they despise.

Currently,  if any Canadian needs psychological counseling services they must pay for it out of their own pocket or wait to see a psychiatrist.  Hence the children of upper income Canadians get immediate treatment, while the children of those not so well off wait for twelve months during which the child’s mental health problem considerably worsens.

Many of the children who do not get treated do badly as a student, or end up, as adults, on social assistance, or even worse, end up in jail.  All these outcomes are significantly more expensive to governments than the outcomes if the child had received counseling services when their problem was first diagnosed.

As we considered the issues facing healthcare transformation we visualize four key leverage points:

  1. Front Line Service Providers: Quality is ultimately in the hands of those who actually deliver care. Their quality performance is dependent on their knowledge skills and attitudes, their beliefs about current levels of quality, their sense of the roles they play in quality, and their perception of the status quo. It also depends on how they define themselves as professionals – their values, aspirations, organizational ethos, information-seeking behaviours, sense of stewardship over resources, and inter-professional comfort levels. 
  2. Governance: How organizations behave is also significantly influenced by how they are governed. By their priorities, the information they receive, and the decisions they make, governors signal how seriously they take quality issues -- and what they are prepared to do to ensure that quality is a core value and set of practices in their organizations. Do boards make it clear that the adoption of quality improvement practices is a core expectation? Do they drive improvement beyond the requirements of government and external accreditation, regulatory and licensing bodies?
  3. Leadership & Management: Since the day-to-day work of the healthcare system is transactional, the quality of care depends significantly on whether and how front line healthcare delivery is managed. The role of governance is to establish quality as a core organizational value -- and hold executives accountable for performance. CEO’s and managers carry out the quality related mandate by designing for quality and by motivating, prioritizing, measuring, coaching, supporting and celebrating excellence.
  4. Government Context: We need our public servants and political leaders to be really passionate about quality improvement. Quality improvement requires both ground-up commitment and activity, and top-down policy direction and accountability. Indeed, the most leveraged action that provincial governments could take would be to “celebrate quality”. This wisdom comes from the field of appreciative enquiry, which teaches: “whatever you celebrate, pay attention to and reward, you will get movement”

Next Week’s Guest on the Balcony of Personal Reflection: M. Davies in a conversation titled “Conditions Leaders Influence”. 

Click here to see the First Series of Ghost Busting essays.

Click here to see essays from the Second Series: The Ghost of Healthcare Consciousness.


About the Author(s)

Hugh MacLeod is CEO Canadian Patient Safety Institute. Senator Michael Kirby has demonstrated over his impressive public service career that leadership is about courage.


MacLeod, H.B. We have a Perfect Storm – Let’s Use It, 2011 Healthcare Papers, 11(3)



Rob Simpson wrote:

Posted 2013/08/01 at 02:05 PM EDT

Beyond the excellent points made, we also have to set our minds to stopping the introduction of further harm. While governments and others increasingly are becoming engaged in new mental health initiatives, Ontario is dramatically expanding gambling by introducing 29 new casinos. This will cause substantial harm not only to gamblers, but also to their families and communities. Government simultaneously claims to protect health while introducing harm, a classic application of doublethink. As for courage and leadership, no one being funded by government or in its employ is speaking out - the realistic fear of retribution silences all.


Rob Robson wrote:

Posted 2013/08/01 at 05:08 PM EDT

It is passing strange that the leader of the country's Patient Safety Institute can co-author a useful commentary on leadership without even mentioning the concept of safety - the goal of reducing preventable harm. The question of courage is indeed paramount. Nobody is talking about the deplorable and unacceptable situation in Canada with respect to preventable harm. There is no evidence that the situation described in the Canadian Adverse Event Study, published in 2004, has changed - that 1 out of every 13 patients admitted to an acute care facility in Canada will experience an adverse event associated with significant harm including death. Unless we talk about the situation we will never change it - truly courageous leadership will speak truth to power and promote discussion with the broad public - who often will have innovative suggestions for solutions. The evidence that quality improvement automatically leads to patient safety and reduced harm is very thin indeed.


Anton Hart wrote:

Posted 2013/08/02 at 11:36 AM EDT

This series has generated +100 comments. Most of them sent directly to the author. The rest of us would like to join in the fun. Comment here and consider it published. (comment from the publisher)


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