Wednesday, December 3, 2008

Transforming Healthcare Organizations

Transforming Healthcare Organizations

Imagine you are a member of a hospital's executive team, having just left a meeting in which you and other members discussed the possible introduction of an ambitious Computerized Physician Order Entry (CPOE) system. Around the conference table you and others questioned whether CPOE would be the most effective way to realize your hospital's commitment to patient safety. Other issues that were raised included whether clinicians would support or resist the change, whether staff would have sufficient skills, where to begin, affordability and whether to proceed incrementally or with a "big bang." While there was much disagreement with respect to each of the issues, there was near unanimity around two important decisions - CPOE would be implemented and you would be the executive responsible for the system's design and implementation. This article, based on the experiences of a multi-site hospital, and drawing on past research on organizational change, provides a Four-Stage model to help change leaders in healthcare. Although relying on Toronto's University Health Network to illustrate the change model, the model is intended to speak to change leaders implementing various types of complex changes in all healthcare organizations.

To read the complete article click here

Friday, November 7, 2008

Dear Mr. Harper: Try a Post-Partisan Approach to Public Health Policy | Neill Seeman Essay

November 4, 2008

Dear Stephen,

In 2001, we worked on a historic legal challenge to expand free speech in this country. We fought so-called election “gag laws” (enacted federally in 2000) that limit spending by third party groups – of all ideological persuasions – during political campaigns. Although our arguments failed at the Supreme Court of Canada, this was a popular cause – applauded by many legal, academic, and media commentators across the political spectrum.

Under our line of reasoning, organizations opposed to, say, seal hunting should be constitutionally entitled to advertise during elections to promote their cause. The current law, one might argue, creates a "two-tier" system, where political parties are free to advertise during an election campaign within certain limits, yet third parties are silenced.

Building up to that landmark legal challenge, you reached out to people from a variety of political camps. Yet today, some members of the media and academia unfairly characterize you as intolerant of views that differ from your own; I know this to be untrue. Given your passion for the airing of different political views – the same passion that led you to doggedly challenge Elections Canada’s limitations on third party spending during campaigns – I have a suggestion on how to show global leadership during your new mandate: Pursue a postpartisan approach to the creation of effective public health policy.

As I argue in the current special edition of HealthcarePapers focused on obesity, “post-partisanship” is unlike “bipartisanship”. Bipartisanship is horse-trading – in its best incarnation, this means crafting patchwork legislation that allows all sides to feel satisfied that some thread of their vision or ideological essence found its way into law. The process plays to ego, not good policy.

In its worst incarnation, bipartisanship is merely rhetoric on the campaign trail, and nothing more. On the other hand, “postpartisanship”, a vision of politics championed by Governor Arnold
Schwarzenegger of California and New York Mayor Michael Bloomberg, is a more sophisticated decision-making model that breathes life into novel policy ideas to yield maximum, lasting impact.

In HealthcarePapers , I apply the vision of post-partisanship – elucidated in the book Radical Middle: The Politics We Need Now by Marc Satin – to health policy. I argue that the 10 political principles of post-partisanship Satin describes are ideally suited to public health, since public health policy-making, such as anti-obesity initiatives or mental health improvement strategies, necessarily requires long-term, multi-sector solutions that are enabled by strong legislative supports. Representatives wedded to a long-term public health cause also need to sustain lasting relationships across party lines in order to buttress the original legislation with interim evaluations, re-investments and other policy supports. Herein lies one of the practical benefits of a post-partisan approach to decision-making.

As noted by Satin, the 10 post-partisan principles are as follows:
1. Relationships are as important as convictions.
2. Criticism needs to be well-balanced by self-criticism.
3. There must be an overriding commitment to dialogue and deliberation.
4. There must be an overriding commitment to diversity of opinions and perspectives.
5. Compromise is not the only endgame.
6. Be simultaneously creative and practical.
7. Demonstrate a penchant for big ideas.
8. Support a bias for action.
9. Demonstrate concern with values and principles.
10. Have a long-term vision.

I believe that these 10 principles can provide the basis for a priority setting public health policy model that will temper political self interest. Under this vision, diverse decision-makers can come together from the outset of planning and policy debate; decision-makers can feel free to disclose their competing interests; and validated analytical techniques can be used to select the most innovative, unbiased and criteria-based ideas from among all those considered.

Post-partisan decision-making, in advance of landing on any final policy proposal, allows multi-sector partners to select weighted solution criteria (a process formally referred to as multi-criteria decision-making analysis). The process enables a neutral, independent commission with assigned legislative power (comprised of members nominated by all parties) to identify the cognitive and partisan biases that may have inadvertently crept into any final, recommended policy solutions.

This process can serve innovation. As the global financial crunch tightens its noose on governments, we require innovation in the service of better value. Public health is a good place to start. Unlike other domains of health care policy (such as hospital management), both the federal and provincial governments have constitutional jurisdiction over key areas germane to public health.

Federal constitutional authority extends to “peace, order and good government” and all matters not explicitly assigned to provincial authority. The Department of Health Act provides a federal mandate to protect against the spread of disease, to provide surveillance, to guide public health research (e.g. via the Canadian Institutes for Health Research) – and to advance the physical, mental and social well-being of Canadians.

Stephen: You have the unique opportunity to make post-partisanship the new culture of Parliament. A first step might be to create a multiparty committee of independent members from across Canada charged with designing the weighted criteria by which potentially high-impact public health policies should be assessed prior to design and implementation. The criteria might include: estimated policy magnitude; the effectiveness, if known, of current interventions; the ability to effect change in the near- and long-term; and cost effectiveness.

We are in an era of zero-sum budgeting and fiscal challenge while tackling the steady, unyielding onslaught to our health care system from increasing rates of chronic disease such as diabetes, cancer, heart disease and asthma. Governments face a stark choice: innovate; or implode, borrowing against the future and creating further intergenerational inequity in order to sustain the health care system.

The good news is that you will not be the first to embrace postpartisanship. And we have seen dividends come from such an approach in the arena of public health. Consider that Gov. Schwarzenegger’s state has witnessed a dramatic percentage decline in teen pregnancy rates. This is especially impressive since it occurred during mass migration to the state of sub-populations with very high teen pregnancy rates such as those seen outside of California.

California’s ambitious plan to curb teenage pregnancy – as with the governor’s new leadership in the battle against childhood obesity through mandated school physical activity- and healthy-lunch initiatives – would never have taken place but for Mr. Schwarzenegger’s continued openness to opposing viewpoints.

Like any other political model, post-partisanship is just a suite of ideals that will only succeed if elevated to a science. In the pursuit of more innovative and cost-effective public health interventions, you possess the skills to make the approach work. This is the kind of politics Canada’s health system needs now.

Neil Seeman
Senior Resident in health system innovation
Massey College at the University of Toronto,
Adjunct Professor of Health Services Management
Ryerson University.
In 2001, legal and policy advisor to Prime Minister Stephen Harper
in Harper v. Canada (AG)

Tuesday, October 21, 2008

Blogger: Dashboard

Blogger: Dashboard

High Performing Healthcare Systems: Delivering Quality by Design. Toronto: Longwoods Publishing.

Longwoods has just launched the book "Systems" -- full title is High Performing Healthcare Systems: Delivering Quality by Design. It has its own blog, See:

Here is part of
Foreword to the Book

Citation Information
Brown, A. 2008. "Foreword." High Performing Healthcare Systems: Delivering Quality by Design. 9-10. Toronto: Longwoods Publishing.

Quality remains one of the great trade-offs in Canada's healthcare system. Every person working in the system agrees with the importance of quality, and many make it an explicit part of their personal and professional missions. Today, for example, when confronted by clear evidence of poor quality in their own practices and organizations, clinicians and administrators rarely question the validity of the information and they respond quickly to solve the problems identified. At the same time, however, most clinicians and administrators believe that large-scale improvement is unaffordable.

Although quality continues to rise in importance, and nearly every study published identifies room for improvement, something stops us from achieving the high quality we desire. The work of G. Ross Baker - who led the Quality by Design initiative and, with Peter Norton, the landmark study on patient safety in Canada - lays out the challenge clearly. Every day in Canada's healthcare system preventable errors arise in hospitals, long-term care facilities and physicians' offices. These errors lead to extra costs, poor health and, in many cases, avoidable deaths. Yet the pursuit of safety and quality remains the something extra that many of the people working in our system can follow up on only at the end of a busy day. . . . .

Tuesday, October 14, 2008

Longwoods eLetter October 14, 2008

Longwoods eLetter October 14, 2008
Home | About Us | Subscriptions | Contact | Healthcare JobSite | Sign up here for Longwoods FREE eLetter

“I witnessed a true force for systems understanding and change—not an economist or an accountant, but a research- and quality-oriented physician moving far beyond the traditional healthcare finance textbooks of the time” Rick Roger, Senior Editor, Healthcare Policy and former CEO, Vancouver Island Health Authority, commenting on the new book: High Performing Healthcare Systems || Delivering Quality by Design. Order here.
  1. From Canadian Press: Key promises in the federal election campaign, with projected costs where applicable and available. Click here.
  2. Longwoods' roving contributor and democracy revivalist Steven Lewis: caught up with the five political party leaders in their post-televised debate debrief at an undisclosed location near Toronto. For the unabridged interview click here.


PROFILE of two new books. Available Free Online.
SYSTEMS [the book] Six authors including author and editor Dr. Ross Baker announce that . . .
On October 15, 2008, Longwoods will launch the book Systems (full title: High Performing Healthcare Systems || Delivering Quality by Design) Made possible by a grant from the Ontario Ministry of Health and Long-Term Care, the project team visited seven systems around the world that met their criteria – attributes that range from equity to efficiency.

If you would like an electronic copy of the book we will send you one on October 16, 2008. Free. Please click here to order.

. . . and this just in
“Perhaps, I wondered, by looking at the nature and structure of games, I could gain valuable insights about my own life and how to live it.” From: “Unlearning.” A new book by Dr. Alejandro R. Jadad. Click on the link and learn more ... including access to free digital copies.

Longwoods Publishing would like to welcome Sodexo Healthcare and Price Waterhouse Coopers to the Longwoods HealthcareBoard.

They will be joining our other corporate members: 3M Healthcare, Accenture, AGFA, Baxter, Borden Ladner Gervais (BLG), Cerner, CGI, Courtyard Group, Clarity Healthcare-Consulting Cadre, Emergis, HayGroup, HP Canada, Healthtech, IBM, Johnson and Johnson Medical Products, Medtronic, McKesson Canada, Microsoft,, Philips Healthcare, Ray & Berndtson, Roche, SAS, Strata Health.

The Longwoods HealthcareBoard members enable us to present new ideas, policies and best practices essential to healthcare management, practice, education, research and motivation. It is a measure of their support for learning. In return Longwoods creates opportunities for our corporate partners to showcase their products and systems in our journals and on our website and opportunities for corporate representatives to meet key clients and prospective clients.

For information on becoming a member contact Matthew Hart

Healthcare Quarterly, in collaboration with the Canadian Patient Safety Institute and other national sponsors, is pleased to announce a fourth issue of Patient Safety Papers for publication in Spring 2009. This follow up to the first three issues will again provide real-time overviews of patient safety initiatives from the field and research projects on important patient safety topics.

Guest Editor, Professor G. Ross Baker, Department of Health Policy, Management and Evaluation at the University of Toronto invites organizations and/or individuals to submit papers and case studies with a particular emphasis on contributions that highlight Canadian or comparative efforts to measure or improve patient safety. Descriptions of demonstration projects and interventions would be welcomed along with strategies for engaging patients and clients in improving safety.

Please submit abstracts or summaries of no more than 200 words to Dianne Foster Kent, Editorial Director, Longwoods Publishing, no later than Friday, November 7, 2008. Submissions will be reviewed by the editorial team and a selection of authors will be invited to prepare full manuscripts for publication.


This issue of the journal Electronic Healthcare:Vol. 1 No. 1 2001 is made available at no charge courtesy of Accenture. For the editorial by Dr. Michael Guerriere, click here: The Editor's Focus: It's Leaving Here Just Fine. Other authors include: William Pascal, Tom W. Noseworthy, John A. McAllister and Dan Bader, Carla Gregor, Brian Gamble, Camille Orridge, Pat Rich, George Blake, Denis Protti and KLAS. Read the complete issue online, download and save the papers, send them to colleagues. Effective until midnight October 28, 2008.

This issue of the journal Healthcare Policy / Politiques de Santé:Vol. 1 No. 2 2006 is available at no charge courtesy of CIHR. For the editorial by Dr. Brian Hutcheson, click here: Researchers' Role in Policy Decision-Making: Purveyors of Evidence, Purveyors of Ideas? Other authors include: John N. Lavis, Huw T.O. Davies, Russell L. Gruen, Kieran Walshe, Cynthia M. Farquhar; Robert G. Evans; Trisha Greenhalgh, Jill Russell; Catherine Pope, Nicholas Mays, Jennie Popay; Rick Roger; Jonathan Lomas; John N. Lavis; Aleksandra Jokovic, Jennifer Frood, Kira Leeb; Anton Hart; Marjorie MacDonald, Sandra Regan, Heather Davidson, Rita Schreiber, Jane Crickmore, Lesley Moss, Janet Pinelli, Bernadette Pauly; Mark Crawford; Claudia Sanmartin and Nancy Ross; Kyle Whitfield, Susan Wismer; Sanober S. Motiwala, Shamali Gupta, Meredith B. Lilly, Wendy J. Ungar, Peter C. Coyte. Read the complete issue online, download and save the papers, send them to colleagues. Effective until midnight October 28, 2008.

  • Send your transitions, news and innovations to (Let your communications VP know.)
  • Ever wonder what happens to all those eLetters? Stay tuned here. (This page has its own search engine)
  • Ever wonder where we keep all the transitions we report? Click here.
  • If you received this eLetter from a colleague, sign up for your own issue. Click here.

Learning Opportunities:
  1. October 19-21, 2008: Vancouver BC. Innovation in HealthCare: Passion to Progress. Leaders from all areas of health care and related industries will attend this two-day conference focusing on leadership, systems change and sustainable outcomes. Confirmed to speak are, Hon.George Abbott, Dr. Richard Heinzl, Roger Martin, Tod Maffin, Stan Davis, Jeremy Gutsche and Rex Murphy. For more information, click here.
  2. Wednesday, October 22, 2008 – Breakfast with the Chiefs. Toronto. Matt Anderson, CEO - Toronto Central LHIN. Location: Health Sciences Building, Room 610, 155 College Street, University of Toronto, Toronto. Register here.
    Sponsors: ACAHO, Accenture, Cerner, CGI, Healthtech, HP Canada, HPME, University of Toronto, IBM, McKesson Canada, Ontario Hospital Association, Philips Healthcare

    Breakfast with the Chiefs: registration requirements: some very fine print
    Do you work at a publicly funded organization? If so, you must hold a current personal subscription for at least one Longwoods journal. This covers attendance for the full season. This year’s speakers include: Dr. Alan Hudson, Matthew Anderson, Dr. Adalsteinn Brown, Dr. Ross Baker, Dr. Vivek Goel, Dr. Michael Guerriere, Ida Goudreau, Cliff Nordal, Murray Martin and Dr. Mary Ferguson-Pare. If you are not a subscriber click here first. If you are a subscriber register here.

    Registrants from private sector organizations, foundations and associations must be registered members of the Longwoods HealthcareBoard. If you are not sure of your status and want more information please contact Matthew Hart at

Monday, October 13, 2008

Unlearning. A book by Dr. Alejandro R. Jadad (not reviewed)

Dr. Alejandro R. Jadad writes:
"I just published my first non-medical book, entitled "Unlearning", which I am using to explore the impact of combining online publishing, social networking and the notion of "Freeconomics".

The book can be downloaded for free or purchased at:

I hope you enjoy it. Feel free to share it with anyone you think might find this interesting.


Here is an excerpt:
I still remember my maternal grandfather quoting
[Benjamin] Franklin’s words:

“For Life is a kind of Chess, in which we have often points
to gain, and competitors or adversaries to contend with, and in
which there is a vast variety of good and ill events, that are, in
some degree, the effects of prudence or the want of it.”

Many years later, when I was in my late teens and already
a medical student, my grandfather’s image and Franklin’s
words came to me suddenly, while I was playing as the
captain and goalkeeper of my university in-door soccer team.
I could see the entire field from under the goalposts and was
shouting instructions to my teammates. I suddenly felt like
the King on a Chessboard, being the target of the opposing
team, unable to move from my box and hoping that my
teammates would follow my commands. I also realized that, at
the same time, in my life outside the pitch, I was a
dispensable pawn at the hospital where I was training as an
intern, with little control over my future. It was my superiors,
not me, who would decide where and when I would work, and
what role I would play in the war against diseases. I replayed
the words from Franklin’s essay and realized that I could
easily replace the word Chess for game, making his
statements even more prescient:

“Life is a kind of game, in which we have points to gain,
and competitors or adversaries to contend with, in which there
is a variety of good and ill events, that are, in some degree, the
effects of prudence or the want of it”.

At that moment, feeling like a piece on a board, I started
to suspect that not just Chess, but all games in general, are
much more than enactments of life. They may be signaling to
us, constantly, that life itself is a game.

This thought set me on a path that proved to be much
more challenging and exciting than I could have ever

Perhaps, I wondered, by looking at the nature and
structure of games, I could gain valuable insights about my
own life and how to live it.

Sunday, October 12, 2008

Federal Election 2008: Interview with Party Leaders + commentary. Steven Lewis.

Longwoods' roving contributor and democracy revivalist Steven Lewis: caught up with the five party leaders in their post-televised debate debrief at an undisclosed location near Toronto.

Interviewer Steven Lewis: As usual, health care is front and center in this election. [Leaders look at each other quizzically, and leaf furiously through their briefing books.] Medicare is in crisis. The system hangs in the balance. What will you do as Prime Minister to strengthen this icon of Canadian identity?

Gilles Duceppe: I'm not interested in being Prime Minister, and health care is provincial jurisdiction. Next question…

Jack Layton: More doctors, more nurses, catastrophic drug coverage-

Stephane Dion: More than more doctors and way way more nurses than the NDP, and definitely more catastrophic drug coverage-

Elizabeth May: So you've finally got the Green message.

Layton and Dion: What do you mean?

May: Your platforms are all recycled. I salute you.

Stephen Harper: Let me be Prime Ministerial here. The Liberals almost killed Medicare by shoveling money at the problems with no success. We've invested wisely and got results. Especially more doctors and nurses.

Dion: But you're just continuing to do what we started in the Health Accords.

Harper: That's in the past. We've shown the kind of leadership the provinces want.

Duceppe: I agree with that. Write the cheques and get out of the way.

Harper: Exactly. But when we write the cheques with no conditions, the provinces deliver because we clearly respect the Constitution. That's the genius of the Conservative approach.

Interviewer Lewis: How many more doctors do we need. Medical school enrolment has practically doubled in the last 5 years-

Layton: What the hell?

May: I'm just new here. How could I have known that?

Harper: No way. They're nowhere to be seen. My own doctor is retiring.

Dion: Where's my briefing book?

Interviewer Lewis: It's a fact, almost double. They'll be graduating soon.

Layton (recovering quickly): Not enough. Should be quadruple.

Dion: Quintuple!

May: Gentlemen, harness yourselves. It's the wrong focus. We need to reduce smoking through education and taxes.

Harper: Let me again show the wisdom of Prime Ministership. If you raise taxes, people get anxious. Anxious people smoke. It's the only pleasure they have left once you've taken away their jobs in the oil patch. The Green Party may want young people to start smoking. We don't. In fact, we want to put young offenders in jail.

Duceppe: It's not the federal government's business. Smoking is under Section 92 of the Constitution Act.

Layton: The New Democrats have always respected Quebeckers' right to smoke without interference from Ottawa.

Harper: Our record speaks for itself. We're the ones who relieved the provinces of the intolerable burden of reporting to Canadians on how they spent the billions of new federal funding and what they accomplished. We got rid of the nanny state and overbearing federalism that threatens the very fabric of Canada. When Canadians pay their taxes to Ottawa, they want the money to go back to their own provinces with no meddling. Except they have said, very clearly, that they don't want it spent on safe injection sites.

Dion: Mr. Harper, you didn't get rid of the nanny state, you got rid of the nanny. No child care, no support for families.

Layton to May (aside): Did Dion actually get off a good one?

Dion: And also Mr. Harper, we started writing cheques with no accountability, and you stole our policy and claimed it as your own. I wish I could say I was surprised-

Duceppe: We have nothing to fear but fear itself.

Harper: That's another one of my lines Gilles. Politicians shouldn't plagiarize-

May: Is it always like this when you guys get together? I feel like drinking the hemlock.

Harper (indignant): If I were your husband, I'd take it!

Interviewer Lewis: Please, let's get back to health care. What will you do to close the technology gap?

Dion: My government will put an MRI in every hospital in Canada with more than 8 beds.

Harper: Our plan goes way beyond the Liberal broken promises. We'll put a CT scanner in every 7-11.

Layton: There you go again. Private care for the rich-

Harper: The scans would be paid for publicly.

Layton: Yes, but as a private, for-profit facility, the 7-11 will try to sell Canadians extras they don't need, like Pepsi and shrink-wrapped porn-

Duceppe: Ottawa has no place in the depanneurs of Quebec.

Layton: -so our plan is to open state-run convenience stores with CT scanners, ultrasound machines, generic drugs, sigmoidoscopies, all publicly funded.

Dion (aside): Mon dieu, that's good. Why didn't my dream team think of that that? Saboteurs….

May: Our plan is to build green roofs on every hospital. Solar panels will power the MRIs.

Interviewer Lewis: Let's turn to catastrophic drug coverage. Romanow called for it. The provinces were all for it, with leadership from Ottawa. Canadians need it. Where is it?

Dion: We're committed to it. It's in our platform.

Interviewer Lewis: But the Liberal government could have done it years ago. It could have made it a condition of the Accord and earmarked money for it.

Layton: Shame! Broken promises! Liberals, Tories, all the same, all the time.

Duceppe: Stephane, I agree with you. All the Liberal health care policies are catastrophic.

Harper: Good one Gilles.

Duceppe: You can use that in your speeches. Not that you need permission…

May: Time to move on, gentlemen. It's the environment, stupid. Clean it up, ban GMOs, put away the car, get Canadians moving, and everyone's healthier. More health, less health care.

Layton (aghast): Elizabeth, where' the leadership in that? If everyone's healthier, what will all those new doctors and nurses do? You're out to take away their livelihood. Just like I've always said, scratch a Green and there's dark Tory blue underneath. It's a neo-con job.

May: Jack, with respect, you need an exorcist. Your head spins faster than Linda Blair's.

Dion: We have the plan for the future. We're going to tax the doctors and nurses and administrators for providing excessive health care. They will charge the patients more money. We will give patients a tax cut to pay for the health care. So everyone will pay more and everyone will use less. Less for more - that's the Liberal health care solution. Just like the carbon tax.

Interviewer Lewis: Prime Minister, what do you think?

Harper: I'd like to hear more from Stephane. Keep going.

Layton (barely able to contain himself): Did you say you're going to charge people for medically necessary services?

Dion: My proposal is revenue neutral.

Duceppe: My Quebec includes the Canada Health Act. Did I really say that?

Layton: Our position is, we should never have gone in, and we should get out now.

Harper: We will be out by 2011, that's a guarantee.

May: What's this got to do with Afghanistan?

Harper: Elizabeth, we're talking about health care. I guess you're too new to understand.

Dion: Let me remind you, the Liberals were always for getting out of health care. Mr. Chretien started it, by cutting transfer payments. Mr. Martin finished the job, adding tens of billions of dollars with nothing expected in return. That's 21st century leadership.

Duceppe: I find myself agreeing with the three of you who won't be Prime Minister and the one who will. With federalists like you, who needs to separate? Did I really say that?

Interviewer Lewis: So let's wrap this up. What's your key health care message for Canadians, and how is your health care platform different?

May: We're going to strengthen publicly financed health care, write cheques, and invest in upstream health care.

Interviewer Lewis: So you'd do what every health care report has advocated for twenty years.

May: Yes. Like I said, recycling is good. Not as good as cycling, but still good.

Layton: We're going to rescue publicly financed health care from the hidden privatization agenda of the Liberals and Tories, write cheques, and make Bay Street pay for more doctors and nurses.

Interviewer Lewis: So what is that hidden agenda?

Layton: Don't be obtuse. It's hidden, so how would I know? But it's very, very bad for kitchen tables.

Duceppe: We're going to hold the government accountable for writing big cheques with no conditions, so Quebec can accept the cheques, deny the federal government has contributed anything, and participate when we feel like it in Pan-Canadian initiatives.

Interviewer Lewis: How is that different from what every other province does?

Duceppe: We are a nation, obviously.

Dion: We're going to restore Ottawa's role in national health care--

Duceppe: You mean Pan-Canadian. You can't say national.

Dion: I can so say national. National. National. National national national.

Harper: We are committed to further increases in transfers with no conditions and allow the provinces to experiment, innovate, and improve.

Interviewer Lewis: With the economy heading south, where will you get the money?

Harper: Some will come from the tar sands, and the rest from cutting the fat out of cultural spending. You can read all about it in our platform.

ALL: What platform?

Interviewer Lewis: Thanks to you all. It's a great day for democracy.

Thursday, October 9, 2008

Longwoods eLetter October 7, 2008

Longwoods eLetter October 7, 2008
Home | About Us | Subscriptions | Contact | Healthcare JobSite | Sign up here for Longwoods FREE eLetter

“I wouldn't rush to say that this is the nail in the coffin of public health care.'' Prof. Terrance Sullivan commenting on the availability of Wait Time Insurance.
Steven Lewis Interviews Party Leaders in Election Mode 2008. Click here.
FEATURED PRESENTATION: Improving Access-the Governance Challenges
Dr. Alan Hudson is Lead of Access to Services/Wait Times for the Health Results Team, Ministry of Health and Long-Term Care. He was recently appointed as Chair of eHealth Ontario. This presentation was made at Breakfast with the Chiefs in the Imperial Room held Tuesday, September 16, 2008.


Ever have to write a recruitment ad for a healthcare leader? Find lots here.

Urgent Care Centres: is this a model for Canada? Here are some references: (Search for more)

  1. Emergency Department and Walk-in Clinic Use in Models of Primary Care Practice with Different After-Hours Accessibility in Ontario
  2. Features of Primary Healthcare Clinics Associated with Patients ... When the usual clinic is not readily available, the ER may be the principal alternative for both minor and major urgent care needs
  3. Missed Opportunity: Patients Who Leave Emergency Departments ... What are the characteristics that may increase the risk of patients leaving EDs before being seen.
  4. Quarterly Letters: A Response to Stories about Wait Times for ... At a hospital level, the need for urgent care and diagnostic testing is being accomplished well
  5. Organizing Primary Care for an Integrated System: Urgent care would be provided by the members of the physician group on a 24-hour -a-day/7-days-per-week basis

Salary Disclosure 2008 (Disclosure for 2007):

  • Hospitals and Boards of Public Health (Ontario). DOWNLOAD PDF. This category includes Ontario Hospitals and most Boards of Public Health
  • Ministries (Ontario). DOWNLOAD PDF. This category includes Ontario’s Ministry of Health and Long-Term Care
  • Crown Agencies (Ontario). DOWNLOAD PDF. This category includes Ontario’s Local Health Integration Networks (LHINs)

B.C. Heath Authorities (Report for Fiscal Year April 1, 2007 – March 31, 2008. Includes salary disclosure)

Other Health Employers (Fiscal Year April 1, 2007 – March 31, 2008 includes salary disclosure)

Coming to OHA HealthAchieve2008? The Job Bulletin Board has new Career Opportunities. Just like at the Laundromat. Organizations who want to post their job opportunities can contact Susan Hale.

A new model for Magnet Hospitals. Download PDF. The fount of knowledge and expertise for the delivery of nursing care globally: flexible, and constantly striving for discovery and innovation. they will lead the reformation of health care; the discipline of nursing; and care of the patient, family, and community.

Healthcare Quarterly, in collaboration with the Canadian Patient Safety Institute and other national sponsors, is pleased to announce a fourth issue of Patient Safety Papers for publication in Spring 2009. This follow up to the first three issues will again provide real-time overviews of patient safety initiatives from the field and research projects on important patient safety topics.

Guest Editor, Professor G. Ross Baker, Department of Health Policy, Management and Evaluation at the University of Toronto invites organizations and/or individuals to submit papers and case studies with a particular emphasis on contributions that highlight Canadian or comparative efforts to measure or improve patient safety. Descriptions of demonstration projects and interventions would be welcomed along with strategies for engaging patients and clients in improving safety.

Please submit abstracts or summaries of no more than 200 words to Dianne Foster Kent, Editorial Director, Longwoods Publishing, no later than Friday, November 7, 2008. Submissions will be reviewed by the editorial team and a selection of authors will be invited to prepare full manuscripts for publication.


This issue of the Journal of Nursing Leadership Volume 16. No. 3. Read about nursing leadership in medical circles. Made available at no charge courtesy of Accenture . Read the complete issue online, download and save the papers, send them to colleagues. Effective until midnight October 21, 2008.

The following issue of the journal HealthcarePapers Vol. 4 No. 1 2003 | Leadership Development is available at no charge courtesy of McKesson. Read the complete issue online, download and save the papers, send them to colleagues. Effective until midnight October 21, 2008.

Friday, July 4, 2008

The Conference Board Answers Steven Lewis by Anne Golden

We at the Conference Board of Canada are avid readers of Longwoods publications and newsletters. We were very surprised after reading the essay prepared by Steven Lewis that appeared on the July 1 e-letter. His essay, titled The Conference Board: Rank Amateurs with an Agenda?, left us perplexed by its snarky and unprofessional tone, its limited ability to appropriately interpret the data presented in the summary, and its poor understanding of benchmarking methodologies—which, by the way, is one of the Conference Board’s core competencies. We have been involved in benchmarking projects for over a decade, and have been hired for our benchmarking expertise in countries such as Australia and Ukraine.

As Mr. Lewis appropriately pointed out, we did not release a full-scale report. What was released on June 30 is, in effect, an executive summary. However, the methodology and list of indicators are included on the website (under Methodology and Details and Analysis, respectively). The rankings and a full analysis of each indicator will be added to the website in September. At that time, a section will be added to the methodology with full details on data sources.

When the Conference Board talks about “health” in the report card, we are talking about “health status”. It is therefore appropriate to make recommendations about the factors that affect our health status—such as the health care system and lifestyle choices. The purpose of the health category in the Report Card on Canada is to assess the health status of average Canadians. We have chosen to include and rank diseases that are the top burdens in Canada. We think that this approach is more appropriate than ranking diseases which do not affect many Canadians. So, for example, we do not include mortality due to malaria. While it may be a health burden in many countries, it is not in Canada.

Mr. Lewis was puzzled by results from Italy (A) and Denmark (D) given that the two indicators he pointed out (life expectancy and infant mortality) were on opposite ends of the scale. Having him be more thorough to review the list of indicators on the web site under Details and Analysis, he would have seen that in addition to life expectancy and infant mortality, there are eight other indicators. Denmark does worse, relative to Italy, on six of these indicators.

Mr. Lewis rightly pointed out that our inclusion of heart disease in a sentence about the increasing rates of chronic diseases, like diabetes, was incorrect. We have made a correction to the website.

We agree with Mr. Lewis that there is undoubtedly an alignment between progressive democratic systems and health outcomes, and we have done work on this subject. However, this report only focused on the examination of 10 health status indicators. In this phase of the research we did not analyze the factors influencing this ranking. However, this will be the purpose of an upcoming phase of this project after the September release.

We also agree with Mr. Lewis that primary health care reform is essential if we want to make a difference—we raised this issue in last year’s report card. Primary health care reform will undoubtedly be referred to again when we expand on the Overviews in the September full release. The Conference Board has been consistently supportive of the publicly-funded health care system and a strong supporter of primary health care reform. In fact, we have provided support to federal and provincial governments over the past few years to advance primary health care in this country and primary health care issues have been studied in depth in several other Conference Board publications. For Mr. Lewis to suggest otherwise is irresponsible and disrespectful.

We are the foremost, independent, not-for-profit applied research organization in Canada. We are objective and non-partisan and we do not lobby for specific interests. Our only agenda is to improve the health of Canadians. The Report Card on Canada clearly states that its overall goal is to assess Canada’s quality of life relative to peer countries, and that “Most Canadians would agree that without health, quality of life is severely compromised.” All of our work in the health care field has one goal—to improve the health, and by extension the quality of life, of Canadians. We are proud of our achievements and firmly believe we are contributing to a better Canada. By exposing Canada’s weaknesses, we aim to bring increased focus to these areas for improvements.

Anne Golden is President and Chief Executive Officer of The Conference Board of Canada.

Thursday, July 3, 2008

The Conference Board: Rank Amateurs with an Agenda? by Steven Lewis

[For the full Conference Board report click here.]

The Conference Board of Canada has published a summary that ranks Canada's health (or is it healthcare, or is it both) as 9th best out of 16 selected rich countries (the least rich is Italy, where the food, wine and climate are so good that it is hard to imagine why anyone so blissfully located would even notice a little less purchasing power). We get a B. The aforementioned Italy, along with Japan, France, Sweden and Switzerland, get As. In a shocking upset, the Americans beat somebody - in this case, get this, Denmark. According to a recent UK survey reported on 60 Minutes, far from being melancholy, the Danes are the happiest people on earth, even though their life expectancy trails ours by 3 years and Japan's by 4.5. Maybe they're too happy to notice. Maybe they have other priorities, like universally free post-secondary education.

As for the A-list, there are two Axis powers (Italy and Japan), and two - Switzerland and Sweden - that stayed out of WW2 (well, 3 if you count France). All 5 are rather social democratic, but so is Denmark. By contrast, joining Denmark on the D-list are Ireland, the UK, and the US. We get a B, but grudgingly, and the Board notes ominously that we are in danger of tumbling to a dreaded C.

Teasingly, the Conference Board released its ranking but not a full-scale report that, one hopes, will, at its promised release in September, reveal the methods, assumptions, and data on which it is based. In polite company this would be termed peculiar; in academic circles, irresponsible and even contemptible; in most of the media (Longwoods of course excepted), as a gift headline story requiring no further work. Based on essentially no information, can we make sense of the Board ratings and rankings?

Tellingly, there are confusions. The lead sentence in the summary is, "Given increasing rates of diabetes and heart disease [this latter is false by the way], Canada has no choice but to adopt a new business model for health care that focuses on both preventing and managing chronic disease." From that a sentient reader would infer that the Board is rating and ranking our health care system. But half-way down, the summary says, "It is important to keep in mind that this grade assesses the overall health status of Canada's population; it is not intended to rank the health-care system (italics mine)." So what's with the new business model for health care if health care isn't being evaluated?

If it's health we're examining, let's look at health. Of the 16 chosen countries, Canada ranks 2nd on life expectancy and 11th on infant mortality - the most commonly used composite measures of health. The Board is alarmed by our relatively high heart disease and escalating diabetes-related mortality rates. OK, but logically, if we're living longer than everyone but the Japanese and if our tickers and pancreases are letting us down, our other organs must be thriving. We have to die of something (perhaps confusion is a leading cause of death at the Board). Why weight some causes over others? There might be a defensible reason, but let us in on it before assigning a number.

Let's compare Italy (A) with Denmark (D). Italy is 7th on life expectancy and 15th on infant mortality rate. Denmark is 15th and 8th respectively. So if we're rating health, not health care, why are these countries at the opposite ends of the scale? The answer, I suspect, is that the Board is conflating elements of both health and health care in its method, and come September we might discover precisely how.

The confusion compounds when we look at the Conference Board's prescriptions for success. The Board correctly points out that the top-performing countries have progressed by addressing the non-medical determinants of health, among them listing: environmental stewardship; health promotion; education; early childhood development; income, and social status. By its own assessment then, social democracy seems to be the pathway to population health, but the Board pointedly refuses to go there. The solutions are "a new business model for health care," "greater receptivity to innovative technologies and health-care delivery systems," better information technology and "new approaches to prevention and management."

I'm a pretty harsh critic of our health care system and advocate a major overhaul. Like the Board, I'm all for investing in health information systems, managing chronic diseases better, and improving accountability. But like anyone familiar with a vast population health literature and a basic understanding of the law of diminishing returns from health care, I know that these measures will not reduce health disparities or greatly improve overall health status. The Board summary is silent on the one element of health care that might make a difference: primary health care reform. Instead it offers up the standard industry tonics of more and fancier gadgets and coded calls for privatization.

Might the Conference Board have an agenda other than improving the health of Canadians? When think tanks promote new business models for health and innovative delivery systems as solutions to problems that on their own analysis originate elsewhere, look for the method in the apparent madness. It's usually a call to feed the beast - the diagnostic imaging and drug manufacturers, the private sector management contractors, the advocates of private and parallel health care systems. It's perfectly legitimate to tout these reforms, but at least do it forthrightly and explain why Canada should choose this route rather than the broader health-enhancement strategies pursued successfully by others.

I'm new to the rating and ranking game, but in the spirit of the Board, I'll give it a go.

Transparency of method: F
Plausibility of ratings and rankings: D
Awareness of factors affecting health: A
Internal coherence: F
Likelihood of prescriptions improving health: F

I'm glad to have the Conference Board in the population health choir, but sad to see its accurate understanding of why some countries are healthier than others dissolve into shilling for industry and solutions destined to raise costs, misallocate resources, and miss real opportunities to make a difference.

Wednesday, July 2, 2008

Big cancer bills covered

The Ontario government is set to spend an additional $50 million for greater access to three expensive cancer drugs, sources told the Toronto Star.

Of the three, Avastin may be the best known to Star readers thanks to a front-page story published two years ago yesterday. Reporter Tanya Talaga introduced readers to Esther Hart, a mother of one who succumbed to colon cancer in April 2007 at the age of 39.

Tuesday, June 24, 2008

An Institute of Continuing Health Education: An Idea Whose Time Has Come?

From the Editor-in-Chief of Nursing Leadership, Dorothy Pringle, OC, PhD:

In a recent issue of the Canadian Medical Association Journal, the editor called for the establishment of a Canadian Institute of Continuing Health Education (Hébert 2008). The primary concern behind this proposal is dissatisfaction with the current funding of continuing medical education (CME) and its consequences in terms of quality of the educational products and the confidence physicians have in them. The majority of CME is funded by pharmaceutical companies; as reported in the editorial, in 2006, of the $1.45 billion spent on accredited CME in the United States, 60% came from drug companies (Fletcher 2007). The editor maintains that while Canadian statistics are not available, there is no reason to believe the situation is any different in this country. The caterpillar in this cornucopia of riches is that the pharmaceutical companies do not provide this funding from the goodness of their hearts. To quote from the editorial: "In effect, the industry focuses primarily on treatments and treatment-related issues at the expense of the larger therapeutic picture, including quality of care and patient safety not involving drugs, determinants of health, prevention and health promotion and other modalities of treatment" (Hébert 2008: 805).

Perhaps the most surprising and welcome observation in the editorial is that "the current system focuses on physicians rather than on interdisciplinary teams. A team-based perspective is essential if our goal is to improve quality of care rather than market share" (Hébert 2008: 805).
As a nurse, more than once I have scanned opportunities to take a Caribbean cruise and receive hundreds of points towards some continuing education target or other. If I were a physician, a drug company would subsidize my trip. In the middle of February, at -20°C, the ethics and value of such an opportunity might well take a backseat to the possibility of sun and fun. I also recall that a couple of years ago I was surprised when a physician colleague questioned the $150 registration fee for a conference sponsored by an organization in which we are both members. He then admitted that he was not used to paying a registration fee because drug companies subsidized most of the meetings he attended. I was not sympathetic, and he acknowledged the underlying problem.

Nursing has not had to deal with control of nurses' continuing education by the pharmaceutical industry. In fact, at times we have looked with envy at the largesse available to medicine to sponsor conferences and hold workshops that, in the vast majority of cases, has not been available to us. I believe that envy has diminished as evidence-based healthcare has taken root and the potential for tainted evidence via the pharmaceutical industry has been identified and acknowledged.

But what about nursing's continuing education enterprise? It's big, diverse, sponsored and delivered by many different sources, unregulated and variable in terms of quality and relevance. It ranges from superb to trivial. Nurses may get continuing education from their employer, from a local college or university, through their professional organization, from specialty nursing and medical organizations or from private educational organizations, to name just some of the sources. A nurse's employer may dictate and provide some continuing education to ensure that its employees are informed of and prepared to deliver new approaches to care in the workplace. A professional organization may offer programs that have obvious value to large sections of their membership. Continuing education divisions of colleges and universities conduct surveys to identify individual courses and programs, such as palliative care, pain management, elements of administration and more, that are of interest to many nurses.

Essentially, the onus is on the individual nurse to determine her or his continuing educational needs and to find sources to meet them. As one might expect, some nurses aggressively and systematically seek out what is available, assess quality and select wisely. Others wait for education to come to them and live with whatever quality they get, while still others use a hit-and-miss approach.

The CMAJ editor believes that continuing education is too important, relative to high-quality patient care and patient safety, to be left to the vagaries of the marketplace and the influence of Big Pharma. According to him, it should concentrate on improving practitioners' performance and thus patient clinical outcomes and quality of care. Continuing education should "focus on themes and topics based on the needs of patients or health professionals; make greater use of a broad range of proven, effective adult learning techniques; include all health professionals, be affordable, accessible and where possible, integrated into clinical practice" (Hébert 2008: 805). To achieve this, he proposes the creation of an Institute of Continuing Health Education that would, among other things, set guidelines and standards, identify gaps, develop and promote interprofessional educational opportunities, develop effective ways of educating health professionals, integrate this education into clinical practice and serve as a clearinghouse for continuing education for all health professionals.

This seems like a good idea in so many ways, perhaps even one whose time has come. However, before elbowing to the front of the line to endorse it, we need to consider a number of things. Nurses' continuing education, while not organized systematically, is not subject to "taint" as CME has become. Do we want national oversight and organization? What indicators are there to suggest we need the organization, standard setting and accreditation that is being proposed? Do we agree with the description of continuing education described in the editorial? I believe nursing holds a more inclusive view that goes beyond the improvement of clinical practice as the only objective. A strong element within nursing continuing education focuses on administration and leadership. The intention ultimately is improved patient outcomes, but these are attained indirectly, through better management of nursing resources. Also, some nurses who do not hold degrees want credit towards degrees from their continuing education undertakings; indeed, some universities have arranged their continuing education offerings to articulate with degree requirements. Would this type of continuing education meet the criteria the proposed institute might set?

The basic questions are: How would such an institute improve upon what is available now? and, Who would pay its operational expenses? From my perspective, the interprofessional element is the most appealing part of the proposal. As we creep towards true interprofessional team-based care (which I acknowledge is flourishing in some settings and has yet to emerge in many others), and as research multiplies the knowledge base of all the health disciplines, it is clear that much of what health professionals need to know to provide care should be learned together. This interrelatedness does not negate the unique aspects of care that each discipline would continue to teach and learn on an intradisciplinary basis. The popularity of interprofessional conferences in cardiology, cancer, aging, neurology, nephrology, bioethics, etc. speaks to the joint interests of the disciplines and practitioners who work together to plan the conferences, present papers at them and participate in the discussions. This is a great base on which to build. The funding is quite another challenge, and one that is not addressed in the editorial. Clearly, the pharmaceutical industry is not an option, unless these companies would be prepared to make a no-strings-attached donation!

The CMAJ editor suggests that the Canadian Academy of Health Sciences (CAHS) take on this challenge and begin discussions with stakeholders. Here I must declare a conflict of interest, as I am a fellow of CAHS and an executive on its board. Nevertheless, I think continuing education is a topic that the interdisciplinary academy is well suited to tackle. It has a number of instruments at its disposal to explore the issues and present a range of options with their strengths and weaknesses.

Nursing should welcome this suggestion from the CMAJ. It raises an important opportunity for all the health disciplines to consider. Thank you, Mr. Editor.

Monday, May 26, 2008

Community Engagement. Later is better.

By Anton Hart

My most memorable NIMBY experience occurred a few years ago. The fury of it all makes it seem like yesterday. I went to a meeting organized by members of my community who were aggrieved by the imminent arrival of a methadone clinic. The crowd literally spilled out onto the sidewalk of a local bar made available for the proceedings. Several doctors – clinic affiliates – were there, ostensibly to engage the community. After the chair and a local lawyer laid out the “facts,” the games began. For the next two hours or so not a rational thought surfaced, not a constructive word was spoken. The local representative on city counsel tried but was generally shouted down. The crowd went home in a highly excited mood to prepare their tar and feathers to ride the principals and politician out of town and so protect their neighbourhood. The raging battle spilled out into the kitchens, living rooms and local eateries. Even the local church found its voice a few days later when the Reverend Canon Christopher King, Senior Pastor of Little Trinity Church, wrote that “the church looks to Jesus as the one who shows us how to bring healing and transformation to hurting people and into communities. . . . He never compromised their safety by his healing, transforming work with social outcasts.” And so, the pastor reasoned, no clinic should come to his church’s back yard. Or, in this case, across the street.

On the other hand, the doctors at the meeting accused the crowd of not caring and putting their hard-earned home equity and personal welfare ahead of the dire needs of patients – who were also members of the community. The local blogger described it this way: “Tabarnouche! One would think, reading some of this, that the Gaping Gates of Hell were open and inhaling local residents in droves.”

Clearly, community engagement was not working.

This is not a new story. It is repeated often where we find the public fearful and frustrated when it has collectively determined that a cause, event or thing will destroy them. In this case, the clinic’s patients were presumed to be social outcasts who would threaten the neighbourhood and members of a church congregation. The mantra is, “build it anywhere – but not in my community.”

Let me report that this situation has since resolved itself to a dull roar, and postulate that it could now benefit from continued community engagement. These notes are a reflection of what subsequently happened and the application of some recent learnings. See what you think.

In the first place, neither the clinic nor the local politicians nor the government of the day engaged the community to ask them if and how and when they would like a methadone clinic in their community. They knew what the answer would be. Street smarts told them to stay under the radar. But the politicians also understood the need for the clinic in this community and even supported its owners in their search for a suitable building. Not fully succeeding in this limited goal they left the operators of the clinic, more or less, to their own devices. This, says journalist Malcolm Gladwell, is a process where the doing comes before engagement. And, I add, it is a demonstration that “doing” is more important to social change than any awareness campaign or pre-implementation community engagement. It is a demonstration that if you are in a position of power you can effectively begin the process of change. By doing. Consultation and awareness do not in themselves constitute change and, in fact, they accomplish nothing, says Gladwell. If anything, awareness (or community engagement) is the final stage of social change. That’s where it can have impact. Engagement is then designed specific to the goals set out. It is educational. But the doing will already have been done.

And so, in this community, the clinic went ahead. It weathered some unpleasant treatment from members of the community, a little extra attention from the media and from some vigilant cops keeping an eye on things. Today, the operators are keeping the place clean, enforcing rules to ensure a quiet operation and are going about their business without fanfare. As this was unfolding the Minister of Health (Ontario) commissioned a task force to take a close look at Methadone Maintenance Treatment across the whole province – prompted only in part by matters in his own riding. In response, the residents and business association – my neighbours – prepared and presented a thoughtful brief to the task force. Residents were given an opportunity to speak, and they gave heartfelt commentary. In the local blogger’s words, “Community residents presented their concerns in a dignified and reasonable way.” The advice was cogent, and the residents were heard. Some of the subsequent recommendations from the task force reflected the residents’ submission. In response, the provincial government set in place a province-wide program to improve communications, training, counselling, community engagement and other related services, and the city is working with the clinic to better integrate its operation with the neighbourhood. I know for a fact that the Minister made an unscheduled stop at the clinic – without fanfare.

The engagement shouldn’t stop here. It needs to be ongoing, and the mechanisms are available. Some members of the community stay in touch with the clinic owners, and the owners know where to find them. Some obvious exterior improvements have been slow to come about, hampered by city bureaucracy and some lethargy from the clinic’s operators. It’s a concern near the top of a neighbourhood’s list. Both the clinic and the city need to get on with it. (The same could be said for other businesses on the block.) The cops report little or no related crime and include the clinic in their rounds. In the meantime, new condominiums, new restaurants and new stores are all coming to the neighbourhood – unfazed by the operation of a methadone clinic with a stormy past. Real estate values are up. A few nay-sayers still want to be heard, but the neighbourhood’s silent optimists are drowning them out.

David Bornstein, who has studied social change and written about it, says that people who want to change the world are obsessively driven to succeed; they are, therefore, good listeners; they build good teams; they pay close attention to their environment; they stay focused on long-term goals but continually adapt to changing environments; and they are always looking for new opportunities to grow and innovate. By adopting this attitude, the local parliamentarian, the local councillor and the renewed rate payers’ group can improve this community, serve the sick and maybe even bring the church onside – or invite the Salvation Army to start a counselling service. The task force was strong on the need for counselling and community support. That presents an opportunity for continued community engagement.

In the end, I went back to the local blogger for a comment, and found that he had just posted a report that “research shows supportive housing has no effect on property values or crime rates. And, as in earlier studies, it showed initial community opposition disappeared once the homes opened.” Now’s the time, I add, for community engagement to ramp it up. Later is better.

Some of these thoughts come from the book, How to Change the World, by David Bornstein (Oxford University Press, 2004). They also reflect my notes taken during a debate between journalist Malcolm Gladwell and philosopher Mark Kingwell on the merits of awareness and engagement in the process of social change (May 13, 2008 on the campus of the University of Toronto).

Anton Hart is publisher of a range of healthcare publications from Longwoods Publishing Corporation, a member of a number of boards engaged in social change and the Chair of Ontario’s Methadone Maintenance Practices Task Force, which tabled its final report in March 2007. Contact:

Taking Community Engagement Seriously: How to Find Good Ideas and Make Them Stick

By Neil Seeman

IN THE LAST TWO YEARS, “community engagement” was mentioned more than 5,400 times in international newspapers and government and corporate press releases. Compare that to 1998-2000 when “community engagement” came up 111 times. What’s behind the new fashion in community engagement (a.k.a. “stakeholder engagement”), and does it work?

Community engagement (in my view) means developing and enhancing public participation in change: the more vigorously you engage stakeholders, the more you will understand their legitimate issues, misconceptions and potential resistance to change. Your solution will not only therefore be more effective, you will enjoy better “buy-in” for implementing new initiatives.

“Community engagement” is a concept that William E. Connolly, the Johns Hopkins political theorist, might consider an “essentially contested concept” : wide agreement exists on the virtues of the notion, but argument arises about what it means or what it aims to achieve. In some organizational contexts, extensive community engagement can reflect a culture of risk aversion (a.k.a. “buck-passing”) to the community; or political posturing (“hearing out the stakeholders,” with no follow-through). The exercise of consulting the community can be meaningless. Lacking intelligent oversight, the final result of expensive and time-consuming public engagement sessions is often a long list of complaints, unanswered questions, and unfulfilled wishes. The ensuing report makes it seem that everything (and, therefore, nothing) is a “priority”.

But sometimes – and let’s not kid ourselves, this is rarely done well – community engagement can bring about real, lasting innovation (though this “suitcase” word , too, needs definition). Why do some experiences in community engagement achieve greatness result while others remain an exercise in futility?

Before embarking on the engagement exercise, many fail to ask fundamental questions: Do community members offer better insights than those who have studied the issue; or are the “experts” themselves bound by conflicts (e.g., wanting research funds to evaluate new, untested programs rather than being keen on implementing proven solutions)? In some situations – e.g., improving access for the community – stakeholders offer profound insight and are in the ideal position to design solutions. When the solution needs to be adopted by the community to be effective (e.g., the use of walking trails or bike lanes to support increased physical activity), community engagement is critical. In other situations, community “stakeholders” come to the table with their stakes dug in. The concern may not be the bias itself, but leaving it undeclared.

To help illustrate the appropriate role for stakeholders, my IBM colleague, John Soloninka, has identified the following taxonomy of problems, and their related engagement goals :

Problem | Goal of Engagement

Complex problem needing expert solution
Engage stakeholders for input on what the problem is and possible solution elements, but do not ask them for the entire solution

Complex problem that only those on the front line know how to solve
Engage front line in designing the solution

Problem for which there is wide variation in opinion, and no “objectively” right solution (i.e., one based on values)
Engage in societal values definition

Problem for which there is poor general understanding of the facts among the general public, and many special interests legitimately or illegitimately driving misperception
Engage for education, and how to manage perceptions (this may be misinterpreted as paternalistic, and communications must therefore be managed delicately)

Once the right scope for community engagement is defined, there are two errors in logic that can trip up the initiative. These errors badly disrupt the progress of innovation.

First, it is a fallacy that all new ideas are of equal merit; secondly, more voices do not necessarily lead to better ideas. Ideas have to be sifted and weighed, and that takes serious effort.

The trouble with innovation in health care (or in any other sector) is that it’s not tangible; it cannot be measured easily – and its success cannot be easily predicted. When thinking about innovation, people often make an “attribution error,” welcoming an idea that is familiar because it fits well with traditional values of the culture or the organization. True novelty at first feels “foreign” and, therefore, is frequently rejected.

Gary Hamel of the London Business School finds this problem widespread among corporate executives today, and has compared the current state of business innovation unfavourably to the early 20th century era of Fredrick Winslow Taylor, who pioneered new ways of managing business, or to later 20th century examples such as the Toyota Production System or total quality management. In my view, this attribution error is exaggerated in healthcare, an expert-driven industry where there is a high degree of deference to yesterday’s opinion as the best model for tomorrow’s.

It is for these reasons that community engagement gatherings sometimes keep re-inviting the very same people who came to the previous session, usually the most outspoken and best mobilized groups, and measure the supposed success of the enterprise by the number, rather than the quality, of ideas generated.

Just as corporations generally tap into the creative potential of a very small proportion of their talent pool, health care leaders run the risk of enlisting only a small segment of their stakeholders when they try to generate innovative ideas. Insufficient resources are invested in marketing and recruitment efforts to get the right people to the table. More intelligence needs to be harvested to identify and quantify the good ideas – the ideas that have real promise of improving quality of life or another outcome of interest.

The problems of group idea-generation have been well-documented in the organizational context. Amy Edmondson of the Harvard Business School finds that corporate teaming exercises – often designed in good faith to be representative of a diversity of skill-sets and knowledge, typically break down in three ways. First, depending on who else is there, people may be too afraid to share information. Second, some people may be naïve about others’ self-interests, eliciting argument rather than generating ideas. Third, some people, all too aware of competing interests, withhold information. These problems can be overcome by an effective moderator and by group exercises such as role play where, for instance, the group is divided into fact-providers and Devil’s Advocates, and then roles are exchanged.

A greater challenge – especially in a tight funding environment – is inviting the right people (rather than just more people) to the sessions, and then synthesizing the best ideas.

Social networking tools online are instructive here. IBM, which launched its open “Innovation Jam” process in 2006 , posted White Papers and internal strategy documents online, inviting public comment using blogs. Customers, suppliers, and family members of employees provided input into IBM’s corporate strategy. Wired magazine has dubbed this approach “crowdsourcing.” The message here is to take risks and invite “competitors” and customers to the table; in the health care context, this might mean involving representatives from neighbouring hospitals, regions, private industry, and from government.

Once the ideas are generated, how are the best ones selected? Remember that idea generation and mobilization – the focus of any communication engagement – is just the first stage. In Crafting Organizational Innovation Processes, Kevin Desouza and colleagues dub the second stage “advocacy and screening”. They observe that corporations have more success when this process is transparent and standardized. The third stage is experimentation; this stage assesses the sustainability of ideas for a particular organization at a particular time. The fourth stage is commercialization or market testing – in a public health care context, this might mean “client feedback” – to analyze the costs and benefits of rolling out the innovation. Finally, the last stage is diffusion and implementation: gaining company-wide buy-in. In health care, this last stage means championing the idea internally and externally.

All this is to say that successful community engagement is more than just a cocktail party bringing together the usual suspects. It requires significant effort to find the right people – i.e., targeted message campaigns to historically unrepresented voices. It requires transparent analytics – such as statistical forecasting tools and correlation analyses to assess the anticipated impact of new ideas on outcomes of interest to corporate strategy. It then requires piloting; returning to the community to gain feedback on the ideas selected; and, finally, pursuing a corporate strategy in order to “own” the idea publicly.

Innovation is like a glow-worm, easier to see from far away, long after someone else has thought of it. If it weren’t hard, it wouldn’t be worth it.

Neil Seeman, JD, MPH is a Managing Consultant and Researcher at IBM Healthcare and IBM Global Business Services in Toronto. He is a writer and adjunct professor of health services management at Ryerson University. His research focuses on governance and social networking tools in healthcare. He is currently writing a book about obesity and community. He may be reached at: