Longwoods eLetter October 7, 2008

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“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.

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ESSAY
Steven Lewis Interviews Party Leaders in Election Mode 2008. Click here.

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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.

• The video presentation. Click here.
• Supporting materials provided by Dr. Hudson. Improving Access-the Governance Challenges (PDF).
• Supporting materials from the editors of Longwoods. Recommended Reading (PDF).
• Sponsors: ACAHO, Accenture, CGI, HP Canada, HPME - University of Toronto, IBM, McKesson Canada, Ontario Hospital Association, Philips Healthcare.

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OFF THE CUFF

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 longwoods.com 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)

• Fraser Health Authority (PDF)
• Interior Health Authority (PDF)
• Northern Health Authority (PDF)
• Provincial Health Services Authority (PDF)
• Vancouver Coastal Health Authority (PDF)
• Vancouver Island Health Authority (PDF)

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

• Providence Health Care (PDF)
• Mount St. Mary's Hospital (PDF)
• St. Joseph's General Hospital (PDF)
• Greater Vancouver Community Services Society (PDF)

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.

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PATIENT SAFETY PAPERS - CALL FOR SUBMISSIONS | DEADLINE NOVEMBER 07, 2008
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.

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FREE ISSUES

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.

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.

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.

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.

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.

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.

Notes
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: ahart@longwoods.com

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.

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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: neil@ca.ibm.com

De-Regionalizing Alberta

The Road to Reform or Collateral Political Damage?
And then there was one.

by Steven Lewis

Last Wednesday (May 14, 2008), 12 boards governed Alberta’s 9 health regions, and the province’s mental health, cancer, and alcohol and addictions programs. A day later they were all replaced by the Alberta Health Services Board (AHSB). Alberta is the second province to eliminate RHA boards – PEI (population 140,000) was the first. New Brunswick is down to two. The Alberta solution is nothing if not Canadian: when in doubt, restructure.

Why this, and why now? Recent Alberta politics explain the timing. Premier Ed Stelmach was the surprise winner in the Conservative leadership race last year over heir apparent (and previous Calgary RHA Board Chair) Jim Dinning. Widely expected to suffer serious electoral losses in the recent election, Stelmach won a massive majority. This conferred a license to make a clear and dramatic statement as a means
of putting a new face on government and bidding a final adieu to the Klein-Calgary era.

The why is more interesting. Regionalization as originally conceived was intended to devolve authority from the provincial level while consolidating it at the local level. In no province was devolution as thoroughgoing as envisioned. Political accountability proved difficult to devolve, so governments continued to have to answer for alleged regional missteps. Over the years most provinces have repatriated authority from the regions, retaining control over major decisions such as facility closures and earmarking funds for specific purposes. But RHA boards do experiment and innovate, reach out across sectors, have mechanisms for responding to local concerns and preferences, and advocate for their regions.

So what, in the government’s view, is the trouble with regionalization? In April Health & Wellness Minister Ron Liepert said that a new governance model was needed to improve management. Perhaps the new regime sees the regions as vocal irritants always clamouring for money. Perhaps it was an accumulation of perceived sins, from the instrument sterilization cock-ups in East Central to the very public complaints of underfunding by the Calgary RHA leadership prior to and after the election. Structural reform does not guarantee improved access, better quality, or greater efficiency. Moreover, restructuring takes its toll on leadership and creates anxiety among the troops. It succeeds only when it is part of a coordinated, substantive plan to change the system’s culture, incentives, and accountability.

The creation of the AHSB is the first of a promised three stages of changes to be announced by December 15, 2008. The most concrete commitments thus far are to train more doctors, extend the ban on trans fats in restaurants and get rid of junk food in schools. Whatever the merits of these measures, they are hardly transformational, and none requires taking regionalization apart.

That leaves de-regionalization and its prospects for success. The key questions are:
• Will the promised Community Health Councils be acceptable substitutes for the RHA boards or dismissed as toothless imitations of the real deal? They are to be appointed by the AHSB, raising obvious questions about their independence and capacity to advocate and criticize. British Columbia had a two-tier system in the 1990s, with local community councils mandated to advise the RHA boards. The public had more connection to and confidence in the community councils than the RHA. The government eliminated the tension by getting rid of the community councils.
• What will become of the population health agenda? Reducing health disparities is intersectoral work that takes place at the neighbourhood and community level. One of the unsung triumphs of regionalization has been the education of boards about the non-medical determinants of health and the importance of addressing the root causes of ill health. Can a single provincial board even begin to understand and pursue a population health agenda in the face of the predictable preoccupation with access, wait times, drugs and technologies? Will the system stake its future on a highly
medicalized, technology-focused view of health? Who will champion prevention and health promotion, and back up rhetoric with dollars?
• How will the voices of the marginalized be heard? It’s daunting enough to get the attention of an RHA board, let alone a single provincial authority working out of Edmonton.
• If the model retains regions as administrative units, how much authority and flexibility will accrue to the executives? To what extent will they be able to reallocate funds and experiment with new approaches? Existing CEOs, several of whom have national and international reputations, have been given until April 2009 to find other work. Will this capacity find meaningful roles in the new era or will the province find itself with a severe executive talent shortage?
• The new board reports directly to the Minister. Will the Minister (and the ministry) set out a broad set of expectations and accountabilities and let the board operate with considerable autonomy – almost like a Crown Corporation – or will the leash be short? Will the power lie with the AHSB or with the Minister and Deputy?

All should clarify in the coming months. The first move shows no lack of courage: poking a stick in the eye of 125 politically well-connected board members and the communities they represent is a calculated act of disharmony. If there is leftover boldness to apply to the substantive issues, there are some intriguing possibilities. Imagine the AHSB with a mandate to achieve:
• A fully functional, interoperable, standardized electronic medical record within 2 years.
• A health human resources plan that optimizes the roles of all providers, with expanded roles for nurses, pharmacists, and therapists.
• The full integration of physicians into the system with a focus on primary health care.
• The removal of all of the perverse incentives in the system that drive up costs and stand in the way of equitable, high quality care.
• A brave, evidence-based, cost-effective approach to drug purchasing and prescribing.
• A real reduction in health disparities between the well-off and the disadvantaged.

In a jurisdiction truly committed to reform, the restructuring would be the warmup act to a genuine transformation agenda. Alberta’s health regions have arguably been leaders in quality improvement, health information technology adoption, and primary health care renewal. With the stroke of a pen a great deal of innovation capacity and experience has been cast aside. Nothing in the public communiqués to date suggests that anyone has thought very deeply about the risks and consequences of the dismantling. The challenge for the government and the AHSB is to get out of the gate with some creative policies and progressive decisions.

Without some early and tangible wins, the memory of May 15, 2008 may linger longer and deeper in the public consciousness than its architects ever imagined.
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Steven Lewis is President, Access Consulting Ltd., Saskatoon, Adjunct Professor of Health Policy, University of Calgary & Simon Fraser University and a member of the editorial advisory board for the journal Healthcare Papers | Steven.Lewis@shaw.ca

Electronic Med Records Are Worth the Privacy Risk

From the Wall Street Journal Blog of November 29, 2007, 9:06 am
Poll: Electronic Med Records Are Worth the Privacy Risk
Posted by Jacob Goldstein

On the subject of electronic medical records, regular folks appear to agree with the health-wonk elite.

Yes, electronic records make it tougher to keep patients’ records private, most people said in a new poll from the WSJ Online and Harris Interactive. But the risk is worth it, because the records can also decrease errors and reduce health costs, according to a majority of respondents.

Overall, 60% of 2,153 respondents said the benefits of electronic medical records outweigh the risks; 63% said electronic records can significantly decrease the frequency of medical errors, 55% said they can significantly reduce costs, and 51% said they make it more difficult to ensure patients’ privacy.

A couple other interesting findings: 76% of respondents are confident that the doctor always “has an accurate and complete picture” of their prior medical history (we suspect a survey of docs would yield a less confident response to this one). And only 1% of respondents said they use a personal health record stored on the Internet — demonstrating that there’s plenty of room for growth in the ambitious personal-health Microsoft and Google are working on.

Health Blog Question of the Day: Do the benefits of electronic medical records outweigh the privacy risk? If so, what can be done to get more doctors to go electronic?

Balanced hospital budgets approved by South West LHIN (Ontario)

LONDON, ON, May 1 /CNW/ -
The South West Local Health Integration Network (LHIN) Board of Directors reviewed and approved Hospital Service Accountability Agreements (H-SAAs) for 16 hospitals yesterday for the fiscal year 2008/09 and 2009/10.

The following hospitals submitted balanced budgets for 2008/09 and 2009/10:
• Alexandra Hospital (Ingersoll)
• Alexandra Marine & General Hospital (Goderich)
• Hanover District Hospital
• Huron Perth Healthcare Alliance: Clinton Public Hospital, Seaforth Community Hospital, St. Marys Memorial Hospital, Stratford General Hospital
• Listowel Wingham Hospitals Alliance: Listowel Hospital and Wingham Hospital
• London Health Sciences Centre
• Middlesex Hospital Alliance: Four Counties Health Services (Newbury)
• South Bruce Grey Health Centre
• South Huron Hospital Association (Exeter)
• St. Joseph's Health Care, London
• St. Thomas-Elgin General Hospital
• Woodstock Private Hospital

The Board extended the budget negotiation period for four hospitals:
• Grey Bruce Health Services
• Middlesex Hospital Alliance: Strathroy Middlesex General Hospital
• Tillsonburg District Memorial Hospital
• Woodstock General Hospital

The review of H-SAAs at yesterday's Board meeting marks another step in an evolving process that began last fall when hospitals submitted the first draft of their annual plans. The South West LHIN will now work with the 16 hospitals to implement their annual plans and introduce a process to further assist the four hospitals that have not yet balanced their budgets.

"The completion of 16 agreements is an important milestone for our LHIN and for the communities served by our hospitals," says Tony Woolgar, chief executive officer of the South West LHIN. "We are continuing to work closely with the four hospitals that have not yet balanced their budgets and we are confident that they will be able to do so.

"The process for hospital budget development and approval this year is quite different than in the past and our hospitals have risen to the challenge, recognizing that it provides a solid foundation for system planning and performance improvement as we move forward," adds Woolgar.

QUICK FACTS

The 2008-2010 Hospital Service Accountability Agreement (H-SAA) process marks the first hospital budget negotiation between Ontario's 14 LHINs and hospitals. Hospitals are required to balance their budgets under the Local Health System Integration Act, 2006. Signed by the boards of directors of both hospitals and their LHIN, H-SAAs hold hospitals accountable for operating within a balanced budget and maintaining agreed upon service levels.

Ontario's LHINs have an accountability agreement with the Ministry of Health and Long-Term Care. For information on the South West LHIN's Ministry-LHIN Accountability Agreement, visit the "Accountability" section under "About our LHIN" at www.southwestlhin.on.ca

The South West Local Health Integration Network (LHIN) is a crown agency responsible for planning, integrating and funding more than 150 health service providers, including hospitals, long-term care homes, mental health and addictions agencies, community support services, community health centres, and the South West CCAC. Established under the Local Health System Integration Act, 2006, as one of 14 LHINs across Ontario, the South West LHIN operates an annual health care budget of $1.8 billion. The South West LHIN covers an area from Lake Erie to the Bruce Peninsula and is home to almost one million people.