Insights August 2014

Back To The Future – What Have We Learned About Ourselves

Hugh MacLeod


Reflected on two recent essays. First, by Steven Lewis titled: “Ontario spent $119 Million to Get Doctors to Increase Cancer Screening Rates. It Didn’t Work. That’s Good Newsand a second essay by Mark Hundert, Chris Helyar and Tom Closson titled: “The Hidden Waste in Ontario Healthcare”.

Six key messages:

  • Appealing to and rewarding what’s worst in us will often bring out what’s worst in us.
  • Cynical target-chasing can, if you work at it become the new normal.
  • If you think behavior and motivation are explained entirely by money, you don’t get it.
  • Need to change focus from efficiency to appropriateness of care.
  • Tremendous variations in outcomes. Time to take another look at funding formula to ensure it is consistent, and evidence outcome based.
  • Are we fulfilling our stewardship role to those we are here to serve.

The two essays prompted me to dive into my archive of essays and speeches on the themes of: behaviour, people gifts, variance and leadership. What follows is a presentation to the Health Care Leaders Association of BC on March 12, 1999. As you read the presentation, reflect on where we are today.

“It has been said by many that we live in extraordinary times.  A new vision of healthcare is slowly evolving. It seeks to leave behind the historical patterns of silo organizations and command-control hierarchies.  This new vision is a healthcare system not just used, but owned by, co-created with, and responsive to the community in which it operates. 

The new vision embodies a system in which health care providers, regardless of organizational affiliation or scope of practice deliver; appropriate, safe, efficient, and quality driven patient-resident-client focused services.  It is a system that is affordable and accessible, with its quality built on the talent of multi-disciplinary teams.

Management becomes more focused on self-management in a team setting. Relationships are fundamentally different, with public and patient centrally valued and active participants. They have the information and tools they need to pursue wellness and are encouraged to ask questions to test assumptions held. Patients and Families will not be content to be nameless and faceless victims of system failures. Citizens as owners of the healthcare system (taxpayers) expect and deserve nothing less.

I assume many of you here today share this vision – indeed, who could oppose it – but articulation is far easier than implementation. This is often referred to as the “knowing-doing gap”. We all know more than we need to about achieving quality outcomes. It is now imperative that we transform what we know into what we do. Very bright people work in healthcare; some are intellectually gifted. We collectively can change the future.

We have created libraries of books, studies, research papers, and commissions on healthcare transformation and what the future holds.  We have a glimpse of what the future holds:  an aging population and workforce combined with a significant change in the ethnic and linguistic character of society.  In addition, the pace of change combined with the introduction of new drugs and new technologies will continually test our human capacity to deliver safe quality care.

Enough talking, reading and studying - it is time for a sense of urgency. We need aggressive and committed action from care providers, management, executive leadership in health care organizations; and from government. Committed action will be anchored by, prudent and future focused policy to drive expectations, with leadership action from above and below.  

Indeed, we are at a social, economic, emotional and philosophical, healthcare crossroad. In this emerging scenario of accelerating healthcare change, complexity and uncertainty, an effective healthcare leader needs to understand and act with self-confidence and a sense of personal mission, purpose and direction.

A new healthcare vision, and purpose will enable us to see the future clearly, while reuniting us with the roots of wisdom that we have left behind.  It requires us to put behind and outgrow once and for all the mindsets, attitudes and behaviour that has split us off from this wisdom.

For me, good leadership is valuing leadership.  It has its roots in the mentoring we received as children, the parenting that served us on our journey of maturity and personal growth.  My mother validated me as a person, provided feedback that built me up instead of knocking me down, reduced my fear, affirmed my importance, presence and role in the family system,

She took joy in the value of my contributions, however small, and acknowledged the importance of others and treated them with honor.  It was a time of process and valuing. For me, this is an image of what Value LEADERSHIP is all about.

Unfortunately, in many work places the conditions in which employees find themselves in are the real cause of care breakdown.  Many employees feel that they have ended up in workplaces that see them as cogs in machines, as disposable, of little value.  They are unclear of the present and fear the future.

From a friend:  “Something happens to a number of people on their way to work…they transform… They operate in a command and control hierarchy.  If they acted in their social family network as they do at work, they would have no friends.” 

We need to pause and remind ourselves that, within our context, within our organizations we have all the gifts we need to move forward. Every individual has the capacity to contribute to healthcare transformation. Every individual that is part of the system carries the seeds of success: skills, talents, potentialities and enthusiasm. Unfortunately for many front line care providers and patients the same seeds also contain too many intellectual, emotional and systemic barriers. Leaders – all of us – need to take action and nurture the growth of those seeds that will allow for a connected system.  

Far too often, organizational culture – its customs, traditions, and practices – play out in day to day power and political relationships. We need a new conversation and critical appraisal of how patient-resident-client focused we really are.  We have to be clear about the difference between responsibility and accountability.  Unfortunately, many parts of our health system still hold onto our traditional command-and-control systems, structures and processes, where accountability means finding someone to blame.  

Real accountability is about honouring commitments and working in a caring and effective manner.  It is about learning, truth, change and growth. It is not about fear and punishment. 

Collectively we must look the truth in the face. There is no greater enemy of improvement than indifference to failure. The challenge for all is to lead, manage, guide and coach others through a transformation process.  This goes much deeper than tinkering with structure and adopting the right rhetoric. 

It is a sustained effort to embed appropriate high quality patient experience as a defining imperative that permeates both individual behaviour and organizational culture. To improve performance, organizations must overcome varying degrees of systemic, cultural, and individual barriers. 

Leaders have an obligation to identify and nurture the people with courage and discipline to drive improvement and change. They create healthy environments for the dedicated people who self-select to work in healthcare. 

Healthier workplace environments increase the resiliency, adaptability, creativity, satisfaction, morale and productivity of individual workers, leading to safer care.  The added bonus is that healthier workplaces end up costing the system and the tax-payer less.

Our biggest mistake is failing to demand more from governance, and senior leadership. For example, lack of real attention and action to local, regional, provincial and national variations in practice including lack of serious evaluation from a behavioural perspective, becomes a recipe for substandard care.

We need to stop convincing ourselves that the remedy is more money, more technology, more staff and look within ourselves and our organizations for the courage to change.

We all use the term “continuum of health care”, what about a reframing to “continuum of interaction and connection” involving those we rely on to deliver the service to patients / residents.

Robert Putnam, author of “Systems Thinker” uses the following example to reinforce the importance of understanding interaction and connection.

The essential value of an automobile is that it can take you from one place to another.  No single part of the automobile – a wheel, an axle, a carburetor, can do that.  An automobile is not the sum of its parts, it is the product of their interaction.”

Interaction brings growth – change, commitment, and values shared. If you want followers you have to give people reasons to follow.  After all, healthcare organizations are organic structures, patterns of energy, webs of relationships, conversations and decisions between people. What keeps the patterns alive is the valuing of people – the spirit and oxygen of healthcare organizations. Values and ethics guide the development of relationship patterns. We need to understand our values and those we work with…widespread organizational change begins with individual change.

Daniel Goleman author of Emotional Intelligence, puts it this way:

The single most important factor in maximizing the excellence of a group’s product was the degree to which the members were able to create a state of harmony…as knowledge based services and intellectual capital become more central to corporations improving the way people work together will be a major way to leverage intellectual capital, making a critical competitive difference.”

Two Key Questions For You To Reflect On:

  1. How does a healthcare organization grow if its employees are not growing? Worse still, if their learning potential is crippled by the organization that employs them.
  2. Whose job is it to fix it?

I began by referring to my roots as a child and the leadership of my mother.  I end this presentation by sharing with you my most important leadership lesson, from my grandfather.

“Keep your eyes open and alert.  Look through and around the obvious.  Practice listening to hear, after all you do have two ears and one mouth.  Never tell anyone what you can do, show them. By your actions you get to create your freedom. Life is about a journey; enjoy the sunrises and sunsets.” June 13, 1966 

When you think of a great teacher or mentor who inspired you, what comes to mind? Do the memories bring up images of someone you trusted, someone who took time for you, who challenged the assumptions you held, who was passionate about your interests?  You can probably see this trusted guide or mentor who fired you up.

As Leaders, now it’s your turn to ignite others.

Today and every day, you as leaders can disrupt the Status Quo. There is NO Status in the Quo!

Thank you

Here we are in 2014, fifteen years later. What do we have to celebrate? What gaps still exist? How do we close them? What role does Government, Board, CEO, Care Provider, Patient and Family play? A quote from Pogo…”We Are Surrounded By Insurmountable Opportunity.

Back to the two essays referenced earlier, I offer a new framing and context. Let’s make safety of staff and patients-families-clients the number one goal. Let’s be transparent and account for the cost of poor quality in the system. Let’s change the high return on investment (ROI) from advocacy, strategic communications, politics and lobbying to high return (ROI) for quality and safety.

I close with a reflection. In 1999, Americans learned that 98,000 people were dying every year from preventable errors in Hospitals. One can only guess at what the staggering number would be for preventable harm not leading to death. According to a recent (2013) study from the prestigious Journal of Patient Safety, four times as many people now die from preventable error, as many as 440,000 a year. Preventable errors, now claims the third spot in leading cause of death. On the healthcare workforce side a recent study from Truven Health Analytics, formerly the Healthcare business of Thomas Reuters, reports that hospital employees are less healthy than the general workforce and cost more in healthcare spending. They found hospital employees are more likely to be diagnosed with chronic conditions like asthma, obesity and depression, and were 5% more likely hospitalized. These workers spent 9% more in healthcare costs than the general public. What’s wrong with this picture…a healthcare industry that purports to care for people but ends up being third in the US in terms of creating unexpected deaths and has a workforce that is less healthy than the general workforce. What would the Canadian picture look like? Have we become desensitized to numbers. One preventable death is personal, thousands become a statistic. Are we now accepting safety statistics as a cost of doing business?

About the Author(s)

Hugh MacLeod is CEO Canadian Patient Safety Institute.

References A New Evidence based Estimate of Patient Safety. 


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