Insights November 2013

Alignment: A Misunderstood Concept

Hugh MacLeod

The conversations on this crowded “balcony of personal reflection” confirm that for an organization or a network of organizations to be successful, each of their interdependent parts must be designed to operate in sync with one another – and with the overall provincial policy and strategy direction. Or to say it another way, a smooth operating system is not the product of a series of isolated actions – but from orchestrating the right combination of interactions.

However, “alignment” is not a concept that is particularly well understood in our healthcare model. Rather than aligning the components of culture, skills, structure and strategy – the actual requirements for alignment – we tend to focus almost exclusively on the component of “structure.” This is what Peter Senge referred to as a “mental blinder.”

Suddenly, the Ghost of Healthcare Consciousness appears and offers the following:

“The traditional response to poor performance in healthcare has been to perpetually shuffle the internal organizational boxes, rather than aligning the integrated components that would attain the desired results. If you wish to distance yourself from the same reoccurring mistakes from the past, your provincial healthcare leaders, along with your local organizational leaders, need to master the art and science of system alignment and organizational design. If you don’t like the results that are currently being yielded, you must alter your approach. You need to understand each resulting outcome is deeply embedded in the system design from which it stems.

“As a noun, alignment refers to the degree of integration of an organization’s core systems, structures, processes and skills; as well as to the degree of connectedness of the people to the organization strategy. As a verb, alignment is a force like magnetism. It is what happens to scattered iron filings when you pass a magnet over them.”

While Canadians are saying that they love our healthcare system, the fact is that our current methods of organizing and delivering care are incapable of satisfying the expectations of patients and their families. In part, this disconnect stems from the science and technologies involved in healthcare – the knowledge, skills, care interventions, devices and drugs – have advanced more rapidly than our ability to deliver them safely, effectively and efficiently.

It is recommended to visualize and utilize four key leverage points to advance the patient safety and quality agenda:

  1. Front Line Service Providers: Quality is ultimately in the hands of those who actually deliver care. Their performance is heavily dependent on their knowledge, skills and attitude. It also depends on how they define themselves as professionals – their values, aspirations, organizational ethos, information-seeking behaviours, sense of stewardship over resources and interprofessional comfort levels. Ultimately, providing quality care is contingent upon front line workers having the tools and ability to decipher current quality levels and comprehend the existing relationship between individual roles and outcomes. Only through development can individuals begin to resolve the inefficiencies found in the status quo. 
    Those organizations, and those jurisdictions, that invest in the skills development of their people, perform best. It’s really that simple. Yet in tough economic times in the past, the health sector has always cut staff development budgets first – as if investing in our people was just a “nice to do,” rather than “essential to our success.”
  2. Governance: How organizations behave is also significantly influenced by how they are governed. Governors indicate how serious quality issues are taken through their priorities, the information they receive, the decisions they make and the actions taken to ensure quality is a core value embedded within their organization. Do Boards clearly narrate the adoption of quality improvement practices as a core expectation? Do they drive improvement beyond the requirements of government and external accreditation, regulatory and licensing bodies?
    Boards of governance exist to represent the interests of the “owners” of the organization. Wherever Boards are active and involved in quality, their awareness and effort are seemingly echoed throughout the organization. Where Boards are dysfunctional, outcomes on all major indicators are low, including quality.
  3. Leadership and Management: Since the day-to-day work of the healthcare system is transactional, the quality of care depends significantly on how front line healthcare delivery is managed. The role of governance is to establish quality as a core organizational value and to hold executives accountable for performance.  CEOs and managers carry out quality-related mandates by motivating, prioritizing, measuring, coaching, supporting and celebrating excellence while adhering to a comprehensive strategy.
    We need CEOs who see the next five to ten years as an opportunity to “leave a legacy” – a once-in-a-lifetime opportunity to create something of real value for their community. Five years from now, a critical mass of our existing health system leadership will retire. What qualities should we be looking for in the next generation of healthcare leaders? That is a question Boards must begin asking now.
  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 inquiry, which teaches: “Whatever you celebrate, pay attention to and reward, you will get movement.”

Our reality is made up of interconnecting circles of complex activity. But, we are conditioned to see and think in straight lines. What we are able to see depends on what we are prepared to see. What do you see? Begin by asking: “What do patients, residents and clients need, and how can healthcare respond?”

I close with a comment posted by Rob Robson on the essay, “Shaping Canadian Healthcare Alignment”:

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

It is time for new conversations with new thinking. Join next week’s conversation titled:“A Different Way of Thinking

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, CEO Canadian Patient Safety Institute Patient, Husband, Father, Brother, Grandfather Concerned Citizen.


The Canadian Patient Safety Institute (CPSI) exists to raise awareness and facilitate implementation of ideas and best practices to achieve a transformation in patient safety. We envision safe healthcare for all Canadians and are driven to inspire extraordinary improvement in patient safety and quality. To address many of the challenges mentioned in the essay above, the Canadian Patient Safety Institute – with partners – has tools and resources, please contact


MacLeod, H. 2011. “A Call for New Connectivity.” Longwoods HealthcarePapers 11(2).
Senge, P. 2006. The Fifth Discipline. Doubleday, New York.
Robson, R. 2013. Comment posted on essay: “Shaping Canadian Healthcare Alignment.” Longwoods Ghost Busting Essays.



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