Thursday, September 19, 2013

Alberta Health Services–In Need of a Cranial Defibrillator

When Alberta Health Services announced on September 10th that they were initiating a significant reorg of upper management as an initial step to providing better services to patients, partners and stakeholders, many people forwarded the report to me proclaiming it was either the best or worst report they had ever seen.

Upon examination of the report, I must confess one thing.

Without facts and data, how can you tell if it is either?

The report opens with its guiding principles (quoting verbatim):

  • How does this organization and structure further AHS in providing high quality service to Albertans, and secondarily in providing teaching and research opportunities to advance the future of health care in Alberta and beyond?
  • How does AHS provide teaching and research opportunities to advance the future of health care in Alberta and beyond?
  • How to ensure there is effective and enhanced collaboration between AHS and the Ministry of Health.
  • Serve as a roadmap for moving forward.

A very worthy but very broad set of principles, I thought, especially for an organization as wide, as deep, as complex and as important as Alberta Health Services is. 

The report then explains some of the symptoms that prompted the need for a study in the first place, including but not limited to (quoting verbatim):

  • The current organizational design could be improved to more directly support a mandate of putting the emphasis on service to people.
  • It is anecdotally reported that the structure is confusing to navigate for patients and the general public.
  • Community leaders have also expressed concerns that it is unclear who they should turn to inside the organization with local health delivery concerns.
  • There is more emphasis on corporate functions and responsibilities as opposed to clinical functions.
  • Each layer of the organization should demonstrate added value to AHS’s mission.
  • People should want to work in AHS, not simply be employed there because there is no other option.
  • It is not always apparent how AHS works complementary to and in support of the Ministry of Health.
  • It has been my observation that some staff in the organization frequently spend more time than is likely necessary or productive on process and crisis response including the preparation of briefing notes, background documents, media statements, etc.
  • Decision making activity and communication planning have to be focused on people and the overall mandate of the organization.

Whew … that’s a long list and quite an endeavor to undertake.

But then the report has a myocardial infarction.

It immediately proposes a new org chart, based on the principles of:

1. The primary focus is providing health care services to Albertans and secondarily to support teaching and research.

2. Working collaboratively with stakeholders and partners is essential to a continuously high performing health system

3. Any additional layers in the organization structure need to be justified on the basis they are adding value to the organizational objectives.

To jump to the end result without explaining how one got there is like watching the first five minutes of a movie and the last five minutes, leaving the audience to ask “What in the heck just happened here?”.  The producer and director know but that’s not helpful to the audience.

There is not a shred of data that demonstrates how the symptoms were measured nor how the org chart (and the associated firing / reorg of 5 / 75 people respectively) addresses the symptoms in a measurable “how do we know this solves them” way.

To justify the miracle cure, the report goes on to reference textbook-like quotes such as:

It is important here to distinguish between leadership and management – the two are not the same. AHS has a multitude of managers. Leaders, as distinguished from managers or bosses, are people who inspire others to be the best they can be. Someone others look up to as role models. Leadership requires courage, vision, and likeability.

Collaboration and cooperation with key stakeholders is critical moving forward.

For the record, leadership is not merely made up of people who inspire others to be the best that they can be or whom people look up to as role models. The Dalai Lama is a leader to many by this definition but probably wouldn’t have the foggiest idea how to run a health care system.  However, to get into a more valid definition would be to inundate you with more textbook quotes. :-)

The report then goes on to say that there will be reviews of strategy in the areas of:

  • IM/IT strategy
  • People strategy
  • Research strategy
  • Patient centred care strategy

But is the cart before the horse here?

I would posit that the strategies in these areas be examined first as part of a holistic “who are we, why are we here, who do we serve and how do we do it” review and then make appropriate org changes in order to maximize investment, execution and results in each of these areas. 

Perhaps some type of backward induction or backcasting process (click here for an example), starting backwards from a desired end goal to the present to determine optimal capital, processes, human resources, roles, rites, rituals, rewards, etc., could be used to create a baseline.  Existing attributes and processes could then be overlaid over these “theoretical optimums” to determine deviations from optimal, adjustments could be made, etc.  Very complex …. but very effective …. very measurable …. and very transparent.

      Otherwise, the completion of the studies planned within AHS (some of which use less effective “forward looking” processes or the even less effective, very subjective “justification” models) may require undoing / redoing the org changes that were just made.  In other situations, people may find that these studies become tainted as they become an exercise of “Ok – now how do we make these strategies fit into the present org chart even though the org chart should be changed to accommodate these strategies?”.

      How do I know what processes some groups are planning to use?  Read The Coffee Shop–The New Source of Privacy Leaks to find out.

      Then we have other worrisome ideas.  When I attended the Alberta Economic Summit in February past as I described in The Alberta Economic Summit and Tough Decisions, this suggestion was put forward:

      Heather Smith, President of the United Nurses of Alberta, suggested that many problems in Alberta’s economy would automatically be solved if we had more public servants – that bigger is always better. 

      So given all of this, it seems odd to invent a new leadership structure before one has all the data to understand what it is they are leading.

      The Bottom Line

      In the real world, leaders strive to run their organizations such that the organization becomes:

      • the investment of choice
      • the employer of choice
      • the provider of choice

      When a service is mostly a government monopoly (with some exceptions), it is difficult to accomplish these objectives and provide incentive to team members to accomplish such ideals.

      That’s not a call for a private competitor to Alberta Health Services.  It is just an observation of human realities and the fact that we are often at our best when facing competing forces.

      Goldilocks and Data – Not Too Much Or Too Little

      Add to this the complexity that when it comes to informing the electorate as to what one is doing to improve a government-provided service, one walks a fine line between informing the voter and overloading them (if the voters even care about the details).

      However, if we do things in the wrong order or in absence of sufficient data, it is difficult to determine whether the actions chosen will produce the desired outcomes.

      Add to that the fact that if we don’t demand supporting data (and full transparency in general) or pay attention to who really benefits as I mused about in Government and the Death Spiral of Status Quo, then we will never know if the right choices were made at all.

      And then we will never know if the cranial defibrillator being applied to Alberta Health Services is saving it or killing it.

      <rubbing the paddles together>


      In service and servanthood,



      When it comes to portraying something as salvageable or not, I recall with amusement, Monty Python’s “Dead Parrot Sketch” (warning: strong language).


      I’m not suggesting that AHS is not salvageable because it is a great organization, staffed with great people and it must be saved.  It just needs a little strategic and tactically intelligent assistance to help it reach its ultimate potential.

      However, I’m not certain that a report filled with little data is going to move the ball in a manner that serves the people, the organization or the government in a measurable, known-outcome way.

      However, to the uninitiated, it does have a sense of “feel good”, I suppose … a feeling that “things are happening”.

      Unfortunately, “feel good” is like writing a prescription for pain killers when someone has a broken foot while omitting the need to put a cast on the foot.  It kills the pain for now but potentially leaves the patient lame for the rest of their Life or needing much more expensive treatment options in the future.

      Addendum 2 – Past Performance

      I am on public record three times for reporting privacy breaches by AHS staff and AHS staff (including people responsible for monitoring such breaches) are aware of this. 

      However, no one has ever contacted me to specifically ask what was revealed, by whom and in what manner was privacy contravened.  I wonder if such a lack of urgency (something that a business would get on top of immediately to protect their interests) is indicative of the sense of urgency to be expected in the upcoming reviews.  I hope not.

      Addendum 3 – Competency

      I have received a fair number of emails asking me to describe my thoughts on the overall thoroughness of the report and the competence of the author (Ms. Davidson).  While it is obvious from this blog that I find the report to be disappointing, other opinions that I might offer don’t add to a constructive dialog that would benefit the process of enhancing AHS and the services it offers.

      There is an intriguing event currently developing at the Trillium Health Centre where Ms. Davidson served as President and CEO until December of 2011.  Trillium has recently announced that 3,500 patients are facing potential health concerns as a result of the misinterpretation of mammograms and CT scans by one doctor for the period from April 2012 to March 2013.   I wonder if Ms. Davidson had any input into the processes there (with its supposed checks and balances) that allowed this issue to take place, given that it began a few months after she left. 

      She was also a senior official with the Canadian Red Cross when the tainted blood scandal was being resolved in the late 1990’s according to this bio but curiously omitted from her LinkedIn profile.


      What would she have learned from these incidents that the people of Alberta could benefit from as a result of these incidents?

      Mistakes happen. 

      What we learn from them matters.

      What we share with others matters more.

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