Health Governance

It’s been over 10 days since I last blogged – time to catch up a little.

On January 16, 2008 we held a very successful conference on Health Care Governance renewal that focussed on the changes being implemented in Ontario. Ontario is in the process of implementing a “made in Ontario” regional model that integrates health services by region under what are called Local Health Integration Networks or LHINs in acronym. The job of the LHIN is to integrate all health services in a given geographic region – home care, long-term care, hospitals, mental health, etc. Unlike BC or Alberta, the model in Ontario has meant the elimination of the local level of governance (health provider Boards). The model therefore includes local governance, a LHIN governance structure (there are 14 LHINS in Ontario) and the Ministry of Health and Long-term Care at the apex.

These changes in structure mean that there is a tremendous amount of transformation of the system that has to occur – changes in the management of the system; in the governance of the system; in the interaction between the players; in the way that the Ministry of Health interacts with the system; etc. A lot of change!! The conference brought together Board members and senior management from a wide variety of health care providers, LHINs, Community Care Access Centres, etc to talk about how to start changing governance and management to ensure the integration of the system and the strategic alignment of the system.

We have created a new section on the IPAC website that is dedicated to health care – by health care I mean the management and governance issues related to health care (not clinical issues!). We will be expanding this section over the next few years as we continue to work in helping ameliorate health care management and governance in Canada. Check out this new section – there are two ways to get there: Look under “Key Initiatives” or look for Health Care under the “Research” section of the website.

Nuclear Fallout

Have you been following the saga of the AECL reactor located in Chalk River? This is an interesting case of the independent regulatory function bumping up against politics.

Thomas Walkom of the Toronto Star says it best...here is the linkhttp://license.icopyright.net/webprints/Njk4MTc0.html

The Politics of Public Money

On January 10, 2008 I had the pleasure of being on a panel with David Good from the University of Victoria who has just published a new book under the auspices of the IPAC Book Series in Public Management & Governance. It is entitled “The Politics of Public Money – Spenders, Guardians, Priority Setters, and Financial Watchdogs inside the Canadian Government.”

The session was co-sponsored by the Toronto Regional Group of IPAC and by the IPAC National Office and very well attended (over 80 registrants).

David’s book is a comprehensive review of the evolution of the budgeting process at the Federal level. The forces at play that he describes – the interaction between the four key players in the budget process – spenders, guardians, priority-setters and watchdogs – are also relevant to other levels of government and provide the “lay” reader with an appreciation and understanding of the forces at play. It is a good way to describe the modern budget framework that has evolved in Canada. As he also notes, there are a myriad of other forces both public and private that affect these four players and the dynamics of their interaction.

To quote David’s book: this framework “helped us to see the uneasy balance among the competing budgetary objectives – determining fiscal aggregates, allocating resources, and achieving efficiency in the management of expenditures. In terms of budget outcomes – controlling total expenditures, linking expenditures to priorities and ensuring efficiency in expenditure and avoiding financial mismanagement – we see that it is rare that the government can achieve simultaneously high scores in all three areas. Instead, as government focuses its limited attention and scarce resources on one, it gives less priority to another, sometimes with significant and undesirable consequences.”

The budgetary process is one in which scarce resources are allocated amongst a broad range of seemingly worthy programs and priorities. The dominance of one of the player (guardian versus spender) over another is determined in large part with the particular fiscal circumstance that the government finds itself in as well as the public mood or politics. The periods of relative success of guardians are those when the economic and fiscal circumstances of the government were such that priority-setters had no choice but to make fiscal considerations paramount. We see this at the federal level in the mid-1990’s and in provinces around that time and also later. The era of having acceptable deficits has ended and the public expectation was of a balanced budget. This was reflected in the retrenchment that one saw in governments of all political stripes across Canada.
The stresses at the provincial and municipal levels are greater in that they are more directly responsible for direct service delivery – health care, education, social services, etc.

The emergence of the financial watchdog – Auditors General – has greatly impacted the budgetary process and the public perception of that process. The new accounting rules promulgated by the Public Sector Accounting Board (PSAB) and enforced by Auditors General have changed budgeting in Canada and new upcoming rules will further change the budgeting process. I will comment more about this in a forthcoming post on my blog.

This book is a must read for anyone interested in the budgetary process in Canada and also for those who want to understand how to impact that process. Kudos David!!

Happy New Year

Another year is over – 2007. Wow, it went by really fast. It seems that time moves faster the older we get. I still remember reading the book “1984” by George Orwell and thinking that it was a long time in the future. The date has come and gone, and hopefully the Ministry of Truth is not on the horizon, though sometimes you have to wonder.

You are probably wondering where I am going with this train of thought. Well, my thoughts are in Africa as I read what is happening in Kenya. In December 2006, I had the wonderful opportunity of attending the annual conference of the African Association for Public Administration and Management (AAPAM -http://www.aapam.org/ ) in Arusha, Tanzania. It was my first visit to sub-Sahara Africa and I learned much at the meeting and I especially enjoyed meeting the dedicated public servants from across Africa, including Kenya. IPAC has been active in Africa for over 15 years, helping governments develop their public service. We actually have a project in Kenya that is focussed on Human Resources and Results Based Management. I am not enough of an expert to pontificate on who is right or who is wrong in the current conflict in Kenya, but I do know that unless all the population is actively and positively engaged in building their society cleavages will occur. We have seen this in many countries around the world and throughout history – it is not only an African phenomena. Historically, think back to the French Revolution or the American Revolution. More recently, think about the fall of the communist system in Eastern Europe. I do not mean to equate the level of democracy in Kenya to these situations, but merely to make the link that a democracy cannot function effectively and endure if a large portion of its population is economically disenfranchised. It is only by assisting countries in building their civil society that we can ensure economic prosperity for citizens.

In Iowa today, the state is holding the first of the Presidential caucuses. It is an example of democracy at its grassroots. People are gathering in living rooms, gyms, etc to debate and to vote for their choice for the presidential nominee for their party. This small group of voters will have an inordinate impact of the US Presidential race. Guess we will have to wait to see what this all means and if one candidate emerges with the Big Mo’ to take them all the way to their convention.

IPAC Leadership Conference - Part 2

So where was I……..In my last post I gave you a synopsis of two of the major speeches on the first day of the Leadership Conference. The second day (Friday) began where the first day left off.

The first speaker of the day was John Furlong, CEO of VANOC – the Vancouver Olympics organizing committee. For those who have been hibernating – this is the 2010 Winter Olympics. What can I say about his speech – you should have been there. It was a tour de force! Amazing, animated, funny, entertaining and unforgettable. The task that the organizing committee is gargantuan. It is the equivalent of holding 3 SuperBowls a day for 17 straight days! It also requires that the organizing committee mobilize the resources of the city, the province and the country. As Mr. Furlong said, it is Canada that is on display during these 17 days and his job is to make Canadians proud and to make the world appreciate the hospitality and ability of Canada. His organization will grow from a handful of people at the start to about 700 now to 50,000 by February 2010. Imagine the leadership it takes to grow an organization that quickly and to that size, all the while knowing that no one will have a job in the organization at the end of the Olympics. At the same time, the organization must maintain its core values and ethics as it grows. Mr. Furlong learned about leadership on the sports field as captain of his football club in Ireland. He said that for him leadership is finding a way to ensure the success of your teammates.

In the afternoon, in one of the break-out sessions, I had the pleasure of listening to the newly appointed Ontario Secretary of Cabinet, Shelly Jamieson. When we invited Shelly to speak she was (and still is, until January 7, 2008) the Deputy Minister of Transportation. The announcement of her appointment was made on Thursday afternoon – a few people asked me if I knew something when we invited her to participate in our conference. The answer is…sometimes it is good to be lucky!!

Shelly was on a panel with James Ridge, Deputy City Manager of Vancouver and Sheldon Levy, President of Ryerson University. James gave an insightful talk about what life is like for a senior leader in the municipal order of government – a “jack of all trades”. He described the 50 disparate business lines that municipalities are responsible for – from emergency management to cemetery operations, from garbage collection to transit, and from social programs to public health. His main message was leaders have to trust subordinates and delegate decisions and that the leader’s job is to shape the culture of the organization and ensure its ethical underpinnings. Sheldon laid out the transformation that is occurring at Ryerson University that is only possible through collaboration. For him, leaders must be a guide, a mechanic, an enabler, a promoter and a journalist. As a guide you must be able to bring people to share a common vision; as an enabler you must be able to listen and to help great things happen; and as a promoter you have to act as the booster for the organization.

Shelly focused on two aspects of leadership – 1) the ability to attract and retain good people and 2) maintaining a work-life balance. She emphasized that a titles does not make you a leader. Shelly spoke of the demographics impacting not only government but also society as a whole. In order to attract the right people to the right job at the right time, she stressed the need to articulate a value proposition – this is not how much you are paid, but rather the ability of the organization to accommodate the interest of its employees. Employees are looking for learning and developmental opportunities; they want an organization that communicates meaningfully with them; and want visible and accessible leaders. In terms of work/life balance, Shelly spoke about the ability to set boundaries and that it is a personal responsibility to do so. She spoke about the importance of respecting others by starting meetings on time and the requirement for leaders to be authentic.

The closing speaker of the Leadership Conference was Senator Romeo Dallaire, retired Lieutenant General in the Canadian Armed Forces who commanded the United Nations Forces in Rwanda in 1994. If you have not read his book, “Shake Hands with the Devil: the Failure of Humanity in Rwanda”, I encourage you to do so. The book has been made into a movie, starring Roy Dupuis as Romeo Dallaire. Here is the clip of the movie:
http://www.youtube.com/watch?v=CaHAXnOGj9k

Senator Dallaire spoke eloquently and movingly about how the world has changed and how we must change as well. It is the only talk that I have ever heard where the speaker quoted such a mix of people: Yogi Berra, Richard Nixon, George Patton, and Henry Mintzberg! He spoke about Wisdom – the ability to anticipate; Unity of Effort – the ability to lead people from the front; Strength – the ability to be pro-active and to take risks; and Aim – the ability to select and maintain an objective. He spoke about the Code of the Feudal Knights – “Without Fear and Above Reproach” and how it should apply today. I cannot do justice to his talk. Senator Dallaire was generous with his time answering questions from the audience, autographing copies of his book and having his picture taken with participants (like me!).

click here for pictures!

There is so much more that I can talk about. This was a great conference. If you missed it, we will be posting the presentations on our website. More importantly, this was the first of our “Annual” Leadership Conferences. Don’t miss the next one!!