Out beyond the ideas of wrongdoing and rightdoing there is a field. I will meet you there.
Rumi
By Annamarie Fuchs, Creator
Partners in Health | Conversations.
Over the past year at www.partnersinhealth.ca we’ve been talking about building trust in the healthcare system as a means to stabilize, protect, and to transform healthcare. We’ve discussed the concept of ‘trust’ as the primary enabler for ensuring the delivery of excellent and reliable healthcare. Creating a system that supports and delivers exceptional person-centered care is everyone’s goal. One way to achieve that is to build a governance framework that is integrated in a direct line of sight from elected ministry officials and bureaucrats to operational executives and ultimately (and most importantly) to the clinical leaders who live and work at the coal face – in those places where Albertans receive care from providers.
In the past few months, we’ve seen what appears to be a growing chasm between the values and expectations of clinical providers and those of ministry officials. Trust appears to have become non-existent. More recently we heard an announcement from the Chief Medical Officer of Health (CMOH) where we were told that COVID-19 surveillance, testing, and restrictions would end shortly. Testing will be available only for people who require physician or hospital intervention.[1] Then, on August 4, the CMOH “apologized for causing fear or anger over Alberta’s plan to lift COVID-19 measures.”[2] In that article she is quoted as saying “We will not eliminate COVID, which means we need to learn how to live with it…As vaccine coverage has changed the nature of the province-wide risk of COVID-19, it is time in my opinion to shift from provincewide extraordinary measures to more targeted and local measures.” Our Premier and Health Minister quickly responded by assuring Albertans that the lifting of restrictions had been the CMOH’s idea, and they agree with her plan.
Our clinical providers and leaders however, reacted swiftly and since then the media (and social media) world has been rabid with their concerns, anger, frustration, and disappointment. A group of 10 physicians from the Edmonton zone explained that government decision makers are ignoring the advice of Health Canada, the Centers for Disease Control and Prevention and the World Health Organization. On Friday July 30, a group of 125 people, most of whom are physicians, protested the government’s decision.[3] Leaders such as the AMA’s President also weighed in[4] against the decision as did other leaders from across the country.
So how did we get here? How is it that across the board, leaders and providers seem to be so completely out of sync with each other? If they’re not, it’s not clear to the rest of us. There’s no doubt that our ministry officials and the CMOH have their reasons for the decisions they made to halt COVID-19 tracking, tracing, testing, and isolating. There’s also no doubt that our clinical providers also have solid reasons for rejecting that decision as reckless. This is merely one example of many of the contradictions in decision making that have plagued Alberta’s health system for some time. So how do we create an accepted and common framework for governance in this province that blends the values, expertise, and expectations of clinical leaders and providers with ministry officials that is also informed by Albertans? Let’s look at governance.
What is Governance?
The Institute of Governance (www.iog.ca) describes governance as the way in which society and groups organize to make good decisions. Decision making in ‘good governance’ must be legitimate. It must be based on a solid strategic direction. There must be clear plans and expectations that allow the execution of those plans so that everyone is accountable to ensure that the organization’s goals, objectives, and values are demonstrated through consistent action. It must perform effectively, be transparent, accountable, inclusive, and equitable.
What is corporate governance?
Corporate governance[5] in healthcare is associated with the decision making, oversight, and responsibility for financial decisions and investment, human resources, information technologies, security, policy, adherence to legislation, and more. Each of these artifacts influence and are expected to facilitate the support needed for clinical activities such as patient care, development of practice standards and performance expectations, procedures, identification of infrastructure requirements and so on. In healthcare, our ministries of health and our health system boards of directors operate essentially within a corporate governance model.
Governance leaders set the organizational agenda for any organization and they are accountable to ensure adherence at every level from senior executives to the providers on the ground. This is particularly vital in healthcare because we’re talking about human lives! There must be an absolute line of sight between decisions associated with fiscal responsibility, policy, and performance to every clinical setting where excellence in achieving patient safety, experience, and outcomes alongside provider experience are both expected and enabled.
What is Clinical Governance?
Clinical governance is a system for creating accountability to manage and to improve standards of clinical practice and identify the resources needed to deliver services to Albertans. And good clinical governance exists when clinical accountability is integrated with administrative (or corporate) accountability in a continuous performance and quality improvement cycle.[6] The objective of good clinical governance is to bring people together in a way that bridges all clinical activities and decisions in order to deliver high-quality care.
Integrating Governance in Healthcare
When corporate governance is integrated with clinical governance in a trust-oriented environment, clinicians are enabled to lead strategies designed to improve care quality and patient experience within each of their clinical settings. Government agencies (ministries of health for example) will specify to clinical leaders what the performance expectations are, but the role of the provider is ultimately to make the decisions necessary to ensure and to safeguard the delivery of high-quality care and safety for all patients.
Blending good clinical governance with corporate governance is a means to bridge all responsibilities and accountabilities into a framework that acknowledges the expectations of both while ensuring accountability by both to each other. Leaders in both camps need to acknowledge the fragmentation that currently appears to exist and work to align ALL decisions alongside the needs of Albertans based on both strong clinical evidence and good fiscal responsibility.
Final thoughts – for now
As Albertans we can’t have everything. We rely on a publicly funded[7] health care framework. We live in tough economic times, and we must also live within our means. It’s a delicate balance. But that doesn’t mean that corporate decision makers should ever ignore the expertise of and opinions of a range of clinical experts to achieve their ends, nor should clinical experts try to manipulate leaders by crying foul when they don’t like a particular decision. Nevertheless, if scientific evidence supports a decision, that decision must be informed by the representative opinions of everyone, particularly those front-line clinical providers who are directly accountable to Albertans for the health services they require. And frankly, each of us should be advocating for the person-centered healthcare system we all desire instead of leaving all advocacy efforts to our already exhausted providers.
But here’s where the rubber meets the road. Do we have consistent, accountable, and integrated governance in Alberta’s health system? That’s a question for you to ask yourself and your MLA. If we do, I would suggest that it’s not readily obvious. If we don’t, we should expect more from our leaders. We should demand that they do the hard work of creating a trust-based integrated governance system that hears from all participants and finds ways to meet in the middle. If what you’re hearing in the media doesn’t coincide with your expectations of our healthcare leaders, you might have found your answer.
[1] Hunt, S. & Fedor, T. No quarantine for COVID-19 after August 16: Alberta set to end restrictions. July 28, 2021 @ 7:04 pm. Updated July 28, 2021 @ 9:27 am. https://calgary.ctvnews.ca/no-quarantine-for-covid-19-after-aug-16-alberta-set-to-end-restrictions-1.5527222
[2] Smith, A. The Canadian Press. https://globalnews.ca/news/8085772/alberta-covid-19-hinshaw-ease-measures-op-ed/ August 4, 2021 @ 12:58 pm. Updated August 5, 2021 @ 9:07 am.
[3] Herring, J. Protesters rally against Alberta COVID-19 changes as Canada’s to doctor airs concerns. https://calgaryherald.com/news/local-news/albertas-covid-19-plan-could-have-ripple-effects-across-canada-top-doctors July 30, 2021.
[4] The Canadian Press. AMA head concerned over government lifitng COVID restrictions. July 30, 2021 https://www.timescolonist.com/sports/commonwealth-games/2.3244/alberta-medical-association-head-concerned-over-government-lifting-covid-restrictions-1.24347708
[5] https://www.boardeffect.com/blog/role-governance-healthcare-organizations/
[6] Duvalko, K.M., Sherar, M., & Sawaka, C. Creating a system for performance improvement in cancer care: Cancer Care Ontario’s Clinical Governance Framework. Cancer Control, October 2009, Vol 16, No 4.
[7] https://www.canada.ca/en/health-canada/services/health-care-system/canada-health-care-system-medicare/canada-health-act.html
