Insights January 2013

Shaping Canadian Healthcare Alignment

Hugh MacLeod and Dr. Jack Kitts


Today, on the balcony of personal reflection I am joined by Dr. Jack Kitts, a leader with a track record of progress. We start with the premise that redesigning the Canadian healthcare system with its complex organic properties, powerful interest groups, political game playing for votes, is more challenging than the transformation of the auto sector, housing sector and the financial sector combined. Why? Well as a start we make the assumption that somehow there is actually a “system” that can be reformed, transformed, re-designed and aligned to improve quality and safety. While we all use the language of “healthcare systems”, the truth is, we do not have a system of services that have been designed to work together to create an intentional outcome.

The component parts of an automobile have been designed and aligned together to produce an intentional outcome: you can drive somewhere. What is the outcome of our non-system of unaligned component parts in our healthcare sector?

We are interrupted mid-conversation by a now familiar voice. It is the voice of the critic. Like one of Scrooge’s ghosts, its aim is to shock us into consciousness.

“You just don’t get it…A lack of political will is one of the major reasons dramatic and sustained healthcare reform and redesign has not occurred.  Politicians are too timid to make significant changes to the healthcare system because of perceived political risks. Even worse, the redesign changes would take more than one term to implement, requiring sustained focus and long term commitment to new ideals. The attention spans of self-serving politicians prevent the restructuring and increased accountability you dream about.”

In Canada, we have hundreds of healthcare networks, regions, institutes, councils, agencies, think tanks, foundations, etc. In addition, we have thousands of independent health service delivery agents – each doing their own thing independently, rather than as interdependent operations.  In reality, rather than a “system”, what we have is a set of publicly-financed federal, provincial and territorial insurance plans. 

If you look at the Canadian healthcare map, you will see an aggregate of isolated institutions. The problem is that most health system leaders at the governance and managerial levels view themselves as “governors or managers” – not as “system architects or system designers” focusing on the public interest, as well as their organization’s interest.

The role of government should be that of an architect, through the creation of sound healthcare policy not as a manager. The delivery system on the other hand should be an “accountable” operator and innovator within the architecture set up by the government. This is a very different way of thinking about a service delivery system that has traditionally been designed by politics, not evidence about what works. This has for many, created a status quo mindset as the preferred route in healthcare.

In addition, there is no single “Game Book” outlining the steps to follow to guarantee successful reform. Why?  Because every province/territory has its own history, plurality, community, state of readiness and most importantly degree of courageous leadership.

The ongoing global financial challenges have raised new conversations in corporate board rooms about return on investments, outcome not outputs, consumerism, ethics, codes of conduct, public transparency, baseline measurements, quality improvement, risk management, third party validation, rewards and consequences, etc. Why do we lobby hard to maintain the status quo when it comes to healthcare? What are we afraid of losing? How many healthcare related organizations, both private and public, thrive off the lack of transparency, consumer value consciousness, accountability for costs, tracking and reporting to the public on health outcomes including safety vs. health outputs?

Data paints an alarming picture.  Implications of provincial and regional variations in healthcare spending suggests that a significant % of current healthcare spending is devoted to services that provide no apparent health benefit and in fact, may be harmful. Therefore, new questions need to be asked.  Are we using our money wisely?  What are the health outcomes for the investments?  Why do we have such a variance in care, spending and outcome by province, by geographic area? The architects need to ensure that the assumptions underlying their long term plans reflect both the real economics of the market and the healthcare performance outcomes of the provider organizations.   If you agree there is no "status in the quo"…can deeper government involvement possibly get you the things you want like universality, accessibility, without compromising the good things like choice and access? Are these two really reconcilable or are these the trade-offs?  Are we willing to make them?

Every Healthcare System is a reflection of its “Values”. What is our National Value Statement?  What are Canadians’ core health values? What is the hierarchy of values among professionals? Are all clinical occupations equally valued and integrated into quality improvement culture? Once quality enhancing tools and techniques demonstrate their value, do we ensure spread within the shortest time possible? To what extent are resource allocation priorities and decisions focused on value? Do we ask ourselves what value behavior have I tolerated in myself or others that conflict with delivering value to Canadians?

These questions, connect nicely to a recent article by David and Karline Naylor titled “Seven Provocative Principles for Health Care Reform”

  1. Every set of national arrangements involves tradeoffs among quality, affordability and accessibility.
  2. Although overall healthcare systems are not transplantable, the merits of adopting good ideas from other countries are too often ignored.
  3. Simplicity in legislation and regulation trumps complexity. The more changes that are made concurrently, the greater the risk of unintended consequences.
  4. Every effective healthcare system imposes caps on spending and engages in strategic rationing.
  5. Fairness in finance and access to healthcare is an evergreen objective of health policy makers. However, fairness is seldom defined.
  6. Higher levels of spending do not correlate closely with quality of care but may instead lead to diminishing marginal health benefits.
  7. Transactional micromanagement of healthcare is suboptimal, whether publicly or privately administered.

A major obstacle to progress is the failure to ask ourselves wicked questions leading to a deep exploration of assumptions we hold and make. Without exploring our assumptions we will continue to be hostage to our indifference to failure and be unable to reach our improvement potential. Exposing these assumptions can be both uncomfortable and a relief.  It is uncomfortable because the conclusions we draw and the beliefs we adopt based on our assumptions often seem to be “the truth” -- obvious, acceptable and defensible.  They guide us to do and say “the right things.” By engaging people in dialogue, wicked questions invite exploration into inconsistencies in thought that have held us back from achieving our purpose, and can be used to promote a search for local solutions to organizational challenges. 

Next Week’s Guest on the Balcony of Personal Reflection: T. Closson in a conversation titled “Accountability for Performance”. 

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 of Canadian Patient Safety Institute. Dr. Jack Kitts is President and CEO of the Ottawa Hospital


Naylor D, Naylor K, Seven Provocative Principles for Health Care Reform, JAMA, 2012 Vol 307, No.9
Macleod H. Lewis S. Asking the Unaskable – Thinking the Unthinkable, Healthcare Quarterly. 2012. Vol.15 No.1
MacLeod H. We Have A Perfect Storm-Let’s Use It. HeathcarePapers. 2011 11(3) 


Lou Mann wrote:

Posted 2013/02/25 at 09:36 PM EST

A very insightful and honest appraisal of current alignment challenges and opportunities. Agree now is time to begin surfacing wicked questions to challenge outdated assumptions held.


Rob Robson wrote:

Posted 2013/02/26 at 10:28 AM EST

A wonderful start with your oppositional metaphor comparing the healthcare system to the automobile. They are both systems but radically different in their nature, with healthcare being complex, open, and adaptive and automobiles being slightly complicated, closed, and mechanical. So it is not surprising that the techniques to influence change must be different for different systems.

Excellent observation about there being no single "Game Book". In fact, complex adaptive systems (CAS) can never be fully controlled or planned or even aligned, but we can learn how to influence the way they evolve. And studying other complex systems is a great idea (one that we are quite hesitant to adopt in healthcare) and this study should not be restricted to healthcare systems only.

The question of "mal-alignment" that you have identified is an important characteristic of the Canadian healthcare CAS. Unfortunately the solution to this is not to be found in the automobile metaphor where wheels can and are routinely "balanced and aligned".


If only we could find the right place to take Canadian healthcare for a tune-up and re-alignment!!


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