With some 3,300 members, 21 chapters and over 50 corporate partnerships spanning the full range of Canada's healthcare system, the Canadian College of Health Leaders (CCHL) has a mission to develop, promote, advance and recognize excellence in health leadership. Through a code of ethics, lifelong learning, credentials, leadership awards and robust advocacy agenda, the CCHL has contributed to Canada's health policy and performance since 1972. Any review of its membership uncovers an impressive cadre of names synonymous with Canada's brain trust in healthcare. Ray Racette, President and CEO of CCHL since 2008, is an example of that leadership acumen and commitment. With a BSc in life sciences from Queen's and Masters in health administration from Ottawa, Ray's ascension though leadership included postings in Ontario, the Northwest Territories and Manitoba, with the latter culminating as President and COO of the Victoria General Hospital within the Winnipeg Regional Health Authority. Ray holds a CHE designation from CCHL and received its Leadership Award for Manitoba in 2005. Ken Tremblay spoke with Ray this Fall.

HQ: As CEO of the CCHL, you are a leader of leaders …

RR: I'm really fortunate to be leading the college. What I bring to my role are diverse leadership experiences and that I've been a member of the college for my entire career, even as a student. Now, I have the fortunate opportunity to deliver on our new vision that includes advancing leadership and shaping health systems. Capable leadership is a fundamental asset for the development of health systems: not just for today but also for tomorrow. The need for leaders has never been as critical as it is now.

HQ: Canada's healthcare system has to be a very challenging leadership environment. What issues are keeping your members up at night?

RR: We have never been in a more complex period of change. That alone is tough, but there are others: the pressure of ongoing and multi-year funding cuts; the challenge of downsizing things you can no longer afford and the impact on people, programs and organizations; and, the need for improvement and accountability to meet targets. These are very stressful and challenging times. There is uncertainty over structural changes such as those in Nova Scotia, Manitoba and Alberta. Even Ontario, which is not regionalized, is likely to face some form of structural change. These changes are daunting because they impact how organizations are governed and managed.

We have an ageing workforce with widespread retirements spanning all the professions, including leadership. That's a particular challenge: a large group of boomers are entering retirement age without a sense of when and how this will unfold. Some [organizations] have recognized that they could lose 50% of their staffing over the next five years!

Lastly, there is a lack of a clear vision for the health system in most provinces. Leaders are left wondering what changes they actually have discretion over and which ones they don't. That tends to freeze people from moving on things that they might be able to do simply because they're not sure if they can.

HQ: Given that, what are the emerging leadership skills essential for success in these times?

RR: Self-management is important, being resilient, remaining optimistic and not dwelling on negative issues, especially those you can't control. Being curious. Staying personally healthy is important given the tremendous amount of pressure and uncertainty leaders face.

Being transparent in decision-making, especially with so many tough decisions that need honest and forthright discussion. High engagement is extremely important. The improvement agenda requires that you know how to build an environment of collaboration and cooperation amidst high expectations and pressures to get things done. People within the organization need to want to contribute, thus the need for a more distributive leadership model versus command and control. Engagement across the organization ensures a voice for all levels of the organization in terms of what's important.

Leaders need a systems perspective in terms of achieving the Triple Aim objectives. Leaders need to look beyond geography and sectors and consider system investments. They need to be visionary and have a sense of direction. Often, they try to do too many things and lose focus. Being courageous. It's not easy making decisions that are tough and controversial but still need to be made. Being able to champion a change so that you can stand behind it, support it even when it starts going sideways, requires courage. Lastly, leaders need to build relationships and partnerships and networks and to create trust. That is particularly important for systemic change: How do you build the trust and partnerships as enablers for what needs to be done?

HQ: The college's membership structure includes chapters spanning the country's various jurisdictions and governance structures. How has provincial variation in system design affected the leadership acumen and skills needed for success?

RR: The issue for leadership is that extensive restructuring by the government negatively impacts leadership capacity, organizational health and decision-making. Alberta lost so much good talent in their changes that it is still struggling with how to actually lead change in Canada's biggest health system. These changes can be quite disruptive and, even though they're intended to achieve benefits, the reality is that the evidence is equivocal.

In provinces with regional structures, leadership roles have mandates and spans of control far beyond what you would find in a hospital setting. They often span a sector and offer unique challenges and opportunities in terms of the broader system. Where you might be a director of a facility laboratory in Ontario, a lab director in Alberta might oversee services in the entire province and even the private sector. These emerging roles are much larger than those experienced in traditional career paths; we haven't trained people for the scale, scope and geography of models like Alberta Health Services. These structures introduce new challenges for leaders: how to communicate effectively, how to make decisions and how to engage physicians who tend to be connected locally yet must function within bigger structures.

HQ: Leadership is not an intuitive suite of skills and many feel that more clinicians need to be prepared for leadership in the system. How do you think we need to engage the clinical side of the house for the system challenges we face in Canada?

RR: The elephant in the room: our current approach to physician reimbursement presents an enormous challenge to leaders trying to operate on a systems basis. If we look at countries and systems that are outperforming us, physicians are a part of the system in terms of how they're compensated and how they're organized, e.g., primary care at the hub of the system. In Canada, we're struggling with this. Even if we accept it as a constraint we can't necessarily control, there are many things we can and need to do to engage physicians because we cannot make substantive changes without them being on board.

Some of the things that I would suggest: make sure we focus on a common goal, i.e., the patient and patient-centred care; recognize clinical knowledge as an asset for change management and decision-making; understand the impacts of change on a clinical practice; create supportive cultures and find ways to involve them in decision-making; develop physician champions who can engage their colleagues; and be sensitive to their time and clinical obligations so that they can become involved. It's certainly doable and, in my experience, engaged physicians are a tremendous group to work with.

HQ: Given the CCHL's advocacy agenda, what are the top issues you are advancing to Canada's policy makers? What do we need to keep or change to deliver on the promise of Canada's healthcare delivery model?

RR: For our recent National Health Leadership Conference and a session called the Great Canadian Healthcare Debate, we asked leaders across the country to identify the policy issues most important for us to advance as a college. We received about 50 policy briefs and, with an expert group outside the college, reduced that number to 10. Our National Health Leadership Conference debated several and, in the end, three issues were viewed as the most important and highly valued to advance to government and system: increase in funding for mental health; the use of electronic health records (no modern health system is performing well without one); and a national pharmaceutical strategy.

There were some other issues identified as important because they could be done tomorrow if we chose to do them. One is mandatory screening for frail elderly to support patient and family engagement in decision-making and clinical care. We could move on that tomorrow and substantially improve our performance across the country. Similarly, we could choose an integrated approach to palliative care that could support much better patient/family involvement in end of life care.

HQ: Healthcare providers via their associations and unions number in the tens of thousands; your college represents about 3,300 professionals. How do you get your message to the public as we debate healthcare's Triple Aim of better access, lower cost and better outcomes?

RR: We access the public through the quality of our membership and the work that they do. The work we do in terms of developing leaders and improving their leadership contributes to the effectiveness of our members as leaders. A lot of the things we do in governance and leadership hit the public that way. Going directly to the public is an area that we're just getting into, e.g., the Great Canadian Healthcare Debate and it generated substantive media coverage.

Another example is our work with HEAL where we released a consensus statement in December 2014 called The Canadian Way – Accelerating Innovation and Improving Health System Performance. In that document, we endorsed the Triple Aim as an important framework for performance improvement and innovation for our health system. Through the consensus statement, we engaged federal, provincial and territorial governments and the media about how we move the system forward as we advance the Triple Aim agenda.

HQ: The perennial bogeyman of healthcare in Canada is the private sector, a constituency that the CCHL has embraced through partnership. What are your views on how these national and global companies are shaping the performance of Canada's healthcare system?

RR: Our traditional view of industry has been too narrow; we've tended to view them as suppliers and procurement models have tended to focus on supply chain/commodity pricing when the broader value might include partnering for innovation and access to new technology. From a college perspective, we engage with industry because the traditional perspective undermines the substantive value they bring. There's no question that the private sector is the major research and development engine for innovation and new technologies. Many of the improvements and changes we need are in their product pipeline or readied for market through R&D funding. Secondly, these companies have a worldview of health systems, as many have global reach and operate in health systems around the world. They enrich the discussion and sponsor innovation for the Canadian system based on results in other countries. That perspective is essential when we consider how to improve our system.

HQ: One of the quirks of Canada's national performance is healthcare's assignment to 14 provincial and territorial jurisdictions with their variable uptake and outcomes with issues like e-health, pharmacare, chronic disease management and sustainability. When you meet colleagues across the country, what's their take on Ottawa taking a greater role in driving pan-Canadian solutions?

RR: The idea that the federal government should have a key [pan-Canadian] role has been a challenge for federal governments. An alternate view would be the need for collaboration among all levels of government and, particularly the federal government, to commit to building and sustaining relationships with the provinces and territories so that we can focus on improving our health system. I can't imagine any progress without the federal government being at the table with the provinces and territories.

Countries that are outperforming Canada, such as constitutionally similar Australia or those in Scandinavia, are performing better because they found a way to develop a national agenda. Our challenge is that we do not have a funded, collaborative structure that supports governments working together. While a working group with the Council of the Federation generated and shared a lot of ideas among its members, few were actionable without the requisite enablers.

As a college, there are four key areas where we think federal leadership is important. One is the ageing of our population and limitations of the Canada Health Act to cover services in home care, long-term care, home-based technologies, etc. We remain focused on "insured services" as being hospital care and physician services; we don't have a modern view of what should be insured, and this gap undermines our ability to develop consistent quality of care across the country. There's no way we can have an approach to prescription drugs without the provinces being highly engaged and strong federal leadership. Supporting the spread of health innovation is a major role for the federal government by virtue of its funding and research capabilities and role in disseminating innovation across the country. Countries doing better than us have a coordinated national approach to funding health innovation. Lastly, funding for infrastructure, modern hospitals, the electronic health record, etc. are key mandates that the federal government can leverage through their power and overarching leadership.

HQ: When you talk to your counterparts in other countries, what common themes or challenges surface?

RR: There's a global consensus that the Triple Aim objectives are an important focus. The United States has a unique challenge with an overhaul of their health insurance system. The United States is improving quickly under the Obama administration despite the rhetoric and media coverage. Accountable care organizations are a novel way to transform how these massive organizations work across the entire health systems. They're also looking at alternative ways of paying for health professionals. There is a massive decline in the number of fee-for-service physicians in the United States, and they're moving into a large number of new models of delivery and payment.

All countries are struggling with ageing and chronic disease management; managing the complex needs for the elderly and end-of-life care are priorities everywhere. While we sometimes worry about our system, even countries that are doing relatively well wonder if they have it right. Everywhere, funding models are moving to outcome-based models, and we are experimenting with such changes in Canada too. Sweden, for example, funds all surgeries as fixed/bundled payments. So, while we may have some catch-up to do on some of these topics, our agenda is not unique relative to other countries.

HQ: You've been at the college since 2008. What have been the highs and lows of your tenure? Any lessons learned, likes or dislikes that may be of interest to our readers?

RR: It was interesting to move to the association side from the hospital and regional side. I have really enjoyed the experience of working within the association environment, and the opportunity to work nationally and globally is a real privilege and honour.

It's mostly highs! We have a small staff: they're excellent, hard-working and very committed to supporting members. I've really enjoyed the opportunity to meet members and people from all across the country and gain an exposure and a connection with them. We've seen significant change since my arrival: new models of lifelong learning like e-learning and e-mentoring. We revamped our governance structure, and all of our internal structures and how we work have all changed. We've expanded the number and nature of our external relationships. Membership has expanded from 2,800 to around 3,300. We modernized our certification program and even our journal went from paper to online. The LEADS in a Caring Environment Framework has become the dominant leadership development framework in Canada, a success that has been both rewarding and humbling.

The major challenge is that we have to operate as a business and our funding is 100% activity-based. We have to earn revenues through the year and that, of course, works as a variable, impacting our staffing and capacity. Our aspirations to continually improve the college put pressure on us to deliver new mandates in new ways. It has forced us to expand our capacity through partnerships, networks and by leveraging the strengths of others.

HQ: What advice would you give to those contemplating a leadership role in healthcare in Canada?

RR: If you really want to have a challenging and dynamic career that requires commitment, ongoing learning and self-management, etc., you probably won't find a more complex industry. I have spent my whole life in this industry and I still love it. But it's not for the faint of heart.

It's a great career choice for younger people. New opportunities will come with new delivery models and, as the boomers exit, even more opportunities will open. In terms of value to the public, it's the most important public service you could be involved in. You can make a difference as a leader. Those of us who have been in leadership for a long time have been able to advance agendas, and new leaders will make improvements by virtue of their energy, knowledge and the people you work with. It's an exciting career and one that brings a lot of personal value and rewards.

HQ: Thank you.

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