Essays February 2018

A Healthcare BHAG

Ron Kaczorowski


In his book “Good to Great” Jim Collins describes a huge and daunting goal as a BHAG – Big Hairy Audacious Goal. A BHAG serves as a unifying focal point of effort, galvanizing people and creating team spirit as people strive for the finish line. It captures the imagination and grabs people in the gut1. So what does all of this have to do with healthcare?

Longwoods Publishing recently published an op-ed essay by Abhi Mukherjee describing his vision of an “un-hospital” that provided for his perspectives of tomorrow’s healthcare system and, for me, a great example of a BHAG. How would his vision, the un-hospital BHAG, captivate the imagination and galvanize people to create a network of trained professionals working with the community and actively engaged in keeping the population healthy2. A vision well worth careful reflection.

The level of healthcare spending in Canada amounts to more than $242 billion dollars, according to the latest data published by the Canadian Institute of Health Information (CIHI). Too high of a proportion of those healthcare dollars are sometimes spent on unnecessary care and/or services. Our health systems throughout Canada remain deeply rooted in the traditional “pay-for-service” model, where providers and professionals are encouraged to offer more treatments rather than better treatments. This approach needs to change.

As much as I applaud Mr. Mukherjee’s vision and emphasis on prevention and home care services, I don’t think it is necessary to go as far as transforming our healthcare system by creating “Wellness Network Teams”.  A lighter version of this model has been tried in a few countries, with limited success, and has demonstrated only modest benefits for the elderly population (people over 75).

Instead, I truly believe that our system needs to shift towards value-based healthcare (VBH). In a nutshell, a VHB system would better align the incentives between all stakeholders involved, as payments would depend more on outcomes and quality of care than volume of services provided. VBH is a win-win-win situation, since patients, providers and payers would benefit from the improvements generated by such a new model.

Of course, there are some critical conditions under which such a transformed system would work. A VBH model relies on the principle of shared responsibility. On the one hand, providers would have to be held accountable for patient outcomes and be rewarded for achieving measured quality improvements and/or cost savings. On the other hand, patients would need to be engaged in the decisions pertaining to their treatments and health. Patient engagement implies that they would be given care specific options between a diversity of providers, be they public or private, and that they would be provided with all the needed information to make informed decisions.

With a VBH model, it is obvious that methods and tools will have to be implemented for measuring, sharing and reporting outcomes. What quality indicators will be measured, how these will be collected, shared between involved stakeholders, reported to the general public, and tied to the reimbursement payments, are all questions that will have to be answered before implementing such a model.

This would require a detailed situational analysis of today’s service-based healthcare system with inputs, workflows and outputs. Simple in concept, but difficult and complex to perform due to the many silos of provider networks and the multitude of services that are provided. Included in this approach would be the identification of the distinct value-based requirements from the community of healthcare stakeholders. But if other countries have started to succeed in implementing such a fundamental reform, so can we.

The more daunting component of transitioning to a VHB system is to the change management required. But as long as we can correctly identify the most appropriate people that should be involved, and as early as possible in the process, those change champions can be influential collaborators in the change management process.

Also, let’s not forget that our present healthcare system has been many decades in the creation and has many positive attributes, which should not be overlooked or simply cast away. Too often, change management practices have thrown out the baby with the bath water.

For this part of the process I return to “Good to Great” and the concept behind the “flywheel effect”. The “flywheel effect” is both an image and a process. The image is that of a large 5000 pound metal wheel being rotated on an axis as fast and as long as possible3. The initial force required to start to move such an object is tremendous, but once in motion, requires less and less force. The process is to make sure that you have exerted the right amount of force, or in this case, collaborative and sustained process improvements, to continuously have the flywheel in motion for the required change momentum.

As we are all aware, healthcare is not a flywheel. It does, however, have a long history of valuable services delivered by dedicated professionals by means of a number of different processes along the continuum. To stop the present day healthcare momentum to a new or different healthcare system, like an un-hospital, would require tremendous momentum to slow it down before it can stop and redirect the flywheel to a new direction.

A final consideration is not to stop the present healthcare flywheel, but slowly, through evidence-based change management, steer it towards the desired goals. The advantage would be that you would not lose the positive attributes of our present healthcare system, but through a more collaborative approach, achieve the many small meaningful wins required for change. These wins would be delivered in a patient-centric approach where the community of healthcare stakeholders (providers, payers and patients) could experience the positive outcomes that would be delivered.

Well implemented, a VBH reform would better align incentives to our desired healthcare system and would most certainly produce interesting outcomes. Those outcomes could be the guiding principles and roadmap to an enhanced patient-centric healthcare system. 

To people like Abhi Mukherjee, continue to pursue your visions, but understand that the impossible just might take a little longer.


1. Collins, J. 2001. Good to Great. Why Some Companies Make the Leap...And Others Don't. HarperCollins: 202.

2. Mukherjee, A. 2017. “The Case to Build “Un-Hospitals” in Ontario.” Essays. Longwoods Publishing.  

3. Collins, J. 2001. Good to Great. Why Some Companies Make the Leap...And Others Don't. HarperCollins: 164-178. 

About the Author

Ron Kaczorowski is the President of SecurLinx (IBO), Managing Director of Mareka Alliances and the former Chair of the Kensington Health Centre. He can be reached at



Abhi Mukherjee wrote:

Posted 2018/03/03 at 10:02 AM EST

Thank you Ron Kaczorowski for continuing the conversation. Compliments on a well thought-out op-ed essay.

I believe that the single-payer system in Canada enables us to do the following:
a. We can choose how we would like to spend the $242 Billion that we annually spend on healthcare today, i.e. we can choose to spend it upstream on prevention or downstream in treatment

b. The de-identified macro data belongs to us- the Canadian taxpayers. We can choose to share this, learn from this and potentially monetize it for global research at an unprecedented scale.

I acknowledge your comment “A lighter version of this model has been tried in a few countries, with limited success, and has demonstrated only modest benefits for the elderly population (people over 75).” You suggest a VBH system where payments to healthcare providers would be based on patient outcomes and quality of care, rather than volumes treated. There is merit to this concept and I am encouraged that the VBH model is being matured by various thought-leaders. My only contention is that we are still thinking in terms of patients and outcomes. My humble submission is that healthcare dollars should be spent on maintaining the wellness of healthy people so that they do not become patients (or the eventuality is delayed).

If we, as Canadians, feel that our collective good health and wellness is a priority, we will find a way to accomplish it. I feel passionately that the “un-hospital” system should not be “an impossibility that will take longer”, but rather, it is a vision that we must bring to fruition sooner than later. In the process, we will create a nation that others around the world will look up to.


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