Alberta

Lessons From the Formation of Alberta’s Single Health Region (Alternate Title: Blurred Lines)

“At its core, health is about people… complex interactions among many individuals and organizations, requiring effective working relationships…(which) depend on people respecting each other’s roles and responsibilities, understanding how they relate to each other, and committing to work collaboratively towards shared goals.” – Alberta’s Health Task Force Report, 2012

The Saskatchewan government is amalgamating our twelve provincial health regions into one super-region, which we’ve recently learned will be based out of Saskatoon

As with pretty much everything else Saskatchewan does, Alberta did it first. In 2008, then-Premier Ed Stelmach slashed the number of health authorities in Alberta from nine to one, which came to be known as Alberta Health Services (AHS).

“Moving to one provincial governance board will ensure a more streamlined system for patients and health professionals across the province,” said Ron Liepert, Minister of Health and Wellness at the time, in a media release.

And then all hell broke loose.

Let me be clear that I’m not against a Saskatchewan super-region, but I think there’s value in taking an in-depth examination of the clusterf**k lessons learned next door, so we are at least up to speed on what we don’t want to see happen here.

“Having a single government monopoly responsible for the purchasing, the provision and the evaluation of the system simply isn’t working. We’re getting worse and worse service.” – Danielle Smith, leader of Alberta’s Wildrose Party, 2010

In February 2012, four years after the amalgamation was announced, Alberta’s Health Quality Council (AHQC) released a report on that province’s emergency rooms, cancer surgeries and physician advocacy. It wasn’t pretty, detailing dangerously long ER waits, a culture of “fear and alienation”, and political interference.

In response to the ongoing crisis, the Alberta Health Quality Council recommended the formation of a Health System Governance Review Task Force (Task Force) with the mandate to explore how AHS governance could be strengthened.

The Task Force’s report was submitted to Alberta’s Health Minister at the end of December 2012, but wasn’t released to the public until months later.

“In its analysis the HQCA noted that recent restructuring of Alberta’s health system had led to blurred lines of authority and accountability, and that well-defined roles were needed for major players in the health system.” – Alberta’s Health Task Force report, 2012

The Task Force made 10 recommendations based on three almost-absurdly elementary themes:

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AKA “Know your job and do it properly.”

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IOW, everybody play nice.

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Doctors are fairly important to, you know, healthcare.

With those three statements firmly entrenched by Captain Obvious, the Task Force went on to make ten recommendations to cure what was ailing the AHS.

First, however, it outlined the challenges and lessons-learned from its extensive review of the amalgamation, including:

  • Amalgamating the Alberta health system into a single health authority resulted in instability and confusion about roles and responsibilities of major players in the system;
  • that the shift to a single Alberta health authority was a massive, complex undertaking, which should have included meticulous change management and deliberate decision-making processes about how to distribute responsibilities and integrate assets, functions and people – unfortunately, it didn’t;
  • the purpose of Alberta’s Ministry of Health, which used to play a role in coordinating regional health authorities, fundamentally changed when it began dealing with a single authority, creating unique challenges – ie. healthcare issues were routinely funneled to the Minister’s office, regardless of their nature, location or severity;
  • decision-making was too centralized, reporting relationships were not clear and delegation of authority was not broad enough;
  • there had to be a strong working relationship in order for the system to work – but that didn’t mean meddling; the Government of Alberta was overly involved in the operations of its single authority, and the board was too involved in day-to-day management;
  • Stability was elusive, due to turnover in personnel at all levels and frequent changes in the senior leadership;
  • While efforts were made to engage physicians in helping lead and shape the new health system, they remained relatively disengaged.

This is all troubling for Saskatchewan, especially given the lengths we’ve seen this government go to lately to isolate and give total power and control to Ministers over public services like education.

Perhaps, then, the first of the ten recommendations the Task Force made for Alberta’s single authority may be the most significant in terms of how it applies to Saskatchewan:

“1. That the Minister of Health confirm his commitment to deliver health services through a health authority, Alberta Health Services, overseen by a board …. (and) the AHS Board be given the necessary autonomy to carry out its delegated authority, supported by a clear mandate and governance framework.”

Autonomy.

Just like there is no way elected officials should be meddling in the education curricula of our children, nor should they influence or direct the operational side of healthcare.

2 & 3. “That the authority conferred on the AHS Board…be confirmed by the Minister as the primary building block for an integrated health system…the Minister and the AHS Board adopt a procedure for the recruitment and selection of new board members that is competency based, non-partisan, transparent, follows best practice and is followed on a consistent basis.”

This is about solid structure while avoiding politics and patronage. It’s about the Minister backing off and leaving the operations of the AHS up to the Board, via the CEO. Most importantly, it’s about ensuring that board is chosen based on important and obvious factors, not political-stripe, favors or friendships.

Are you listening SaskParty? Because one need look no further than some of this province’s health regions (ahem – Saskatoon’s) to see that the latter is exactly what is going on right now.

“4. That the CEO be given the autonomy required to execute the Health Plan, and be held accountable for meeting its performance targets.”

There’s that word again – autonomy. Are we sensing a pattern here yet?

“5. That AHS ensure its structure, expertise and resources are appropriately balanced across the continuum of health services… reflected in appropriate visibility, oversight and reporting. Decision-making needs to be as close to the patient, resident or citizen as is feasible.”

Seems like a competency-based, non-partisan and transparent Board should be able to figure that out pretty quick.

6 & 7. “That the Minister and Ministry clarify Alberta Health’s role and responsibilities as a leader in providing strategic policy direction, setting standards and providing assurance to the health system…Alberta Health develops on behalf of the government a long-term, high-level strategic framework for Alberta’s health system… (and) ensure its organizational structure, resourcing and core competencies align with its clarified role and responsibilities.”

So the Health Minister’s and Ministry’s job is not to micromanage – it’s to provide leadership to the Authority on the broad issues of roles and responsibilities, strategic policy, standards of healthcare and the assurances that those can be met.

In turn, the Health Authority’s job is to get down to business – once advised what their job is, make a plan and then get on with it.

“8. That every effort be made by the Minister and Alberta Health to support AHS achieving the targets set out in the Health Plan, and that clear protocols be put in place to communicate and support any material changes to the Health Plan if these become necessary.”

Communication and change management.

I got my first corporate job when I was 22 – prior to that I worked in retail. I remember marveling (and truthfully, I still do) over the fact that the corporate environment is nothing more than Kindergarten for grownups. There are the bullies and super-smarts, the introverts and extroverts, the leaders and the followers. It doesn’t take much to make someone burst into either tears or a tantrum, and if routine is broken – if change is inflicted – it’s like the world freaking ended.

Most corporate environments, especially those involving complex operations or logistics, have stringent change management processes. The first step is usually submitting some form of Change Request or Order, which is then sent around to the relative departments for analysis, and then discussed at a Change Management Meeting, and then it’s denied or approved, then a plan is zzzzzzzzzzzz – sorry, where was I?

Yeah, I don’t love the corporate environment.

But even I know that when this process breaks down – when someone doesn’t open their email and properly read the Change Request, or doesn’t attend the meeting, or just refuses to comply with the Change if it’s approved – the ripple effects can bring the whole machine to a grinding halt.

So the point of Recommendation 8, IMO, is that the Minister or Ministry shall not impose Change willy-nilly on the singular authority, which will already be enduring all kinds of Change-hell as it is, and will be for years.

I mean, whatever – you can be optimistic. I’m being a realist… mark my words, the Saskatchewan health region amalgamation will equal years of Change-hell.

“9. That the leadership of the health system establish processes that reinforce a culture of collaboration between AHS and Alberta Health… Establishing governance mechanisms to facilitate problem solving and decision-making at the system level… Implementing the Working Together Action Plan… Capacity building throughout the system to encourage, enable and recognize collaborative work. That relationships throughout the Alberta health system be based on the same culture of collaboration.”

Blah blah blah blah blah BLAH BLAH.

Everything in Recommendation 9 is fancy corporate-consultant speak for “don’t be assholes”.

Cause let me tell you one thing I know for sure: you can establish culture processes, mechanisms, plans and capacity all day long – if employees don’t want to collaborate, problem solve or otherwise act like grownups, they won’t.

(And is it just me, or does a “Working Together Action Plan” sound like either one of Stephen Harper’s ad campaigns, or a segment on Sesame Street?)

“10. That AHS continue to develop and implement strategies to engage physicians, and in collaboration with physicians, identify current behavioral barriers that hamper the effectiveness of its policies and structures and the two-way communication necessary for success.”

Doctors are important, and even if you don’t like them, you have to work with them.

Here’s the bottom line – the resounding success or catastrophic failure (make no mistake, there will be no middle ground) of the new Saskatchewan Health Authority hinges on one factor alone: its people.

From the very top to the very bottom, everyone has to work together, get along, co-operate, embrace the change, follow the plan…

Are you a glass half empty or glass half full kind of reader? Cause that’s going to determine how you feel about that statement.

The report sums things up nicely with this:

“Effective working relationships depend on people respecting each other’s roles and responsibilities, understanding how they relate to each other, and committing to work collaboratively towards shared goals. Effective governance lies at the heart of these arrangements.”

If this move had been initiated five, or even two years ago, I might have had the faith in this government to pull off a massive merger dependent on respect, understanding, commitment and collaboration.

Not anymore.

Here’s to hoping the Saskatchewan government takes every word of advice they can get from Alberta – or at least from Captain Obvious – about how to, or not to, amalgamate health regions.

For those of you who care, I’m Tammy Robert. I’m a writer, but pay the bills consulting in media and public relations. Email me anytime at tammyrobert@live.ca

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4 replies »

  1. I think its right beside the uni – outside he ram’s lockeroom (ie. that field right beside where the gym is).

    rob

    Like

  2. The first truly insightful analysis of this issue in the media. This will be an issue unmitigated dumpster fire. It will not save money or make services better, especially for small communities. Why focus resources in Kindersley when I can spend every dime in Saskatoon or Regina. Sheer population drives those decisions.

    Most stories have focused on all the administrative costs that will be saved. Won’t happen. The decision will be neutral at best.

    Because now everyone involved in the system (including the Ministry of Health) is going to have to travel to Saskatoon or call Saskatoon to get anything done. Also, it’s not like those people were just sitting around doing nothing. Suspend your disbelief for one moment. Most “bureaucratic fat cats” are actually hard working people who spend their days managing budgets, contracts and employees, collaborating with others to solve problems to make the system better. Did we need all of them? Maybe not but it’s not like anyone was sitting around getting their nails done. The functions that people were serving still need to be done. Hiring freeze and position cuts today but tomorrow people will realize “hey we can’t actually handle the work load” and more people will be hired on.

    Also Because health care is actually local. You need to be in person to do it. No cutting of administration can do that. You still need to physically see your doctor or speech path or nutritionist.

    In addition our system deals with a whole bunch of private providers (ie. doctors) who get paid by the public system but still operate like small businesses. How does this move improve communications with them?

    Finally, how long has it been since we amalgamated school divisions? A long time. But there are still aspects of them like contracts with teachers that are more reflective of the old system than the new. Why? Because it’s really hard to change those things. Not because there’s no will but because sorting it out is a messy ugly business. Those sorts of challenges will exist long after the super health region comes into being.

    Frankly the only smart thing the government has done on this is to decide NOT to amalgamate school division and cause a dumpster fire across the ENTIRE human services.

    Like

    • Great link Brian 👍”The report outlined reasons the current system doesn’t work: the structure is fragmented; the relationship between the department of Health, Alberta Health Services and medical professionals is disconnected; and doctors and other health-care professionals don’t share information.”

      None of these issues will be addressed by creating one health region.

      Like

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