Qmentum uarterly - Accreditation Canada

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www.qmentumquarterly.com
mentum
uarterly
Quality in health care
DECEMBER 2008 VOLUME 1, NUMBER 2
Governance
and Leadership
Publications Mail Agreement No. 40045878
Contents • Governance and Leadership • Volume 1, Number 2
Q
mentum
uarterly
Quality in health care
Introduction
Good Governance and
5. Promoting
Effective Leadership
Wendy Nicklin
Responsibilities:
6. Reshaping
A New Vision for Health Care Boards
Pamela C. Fralick
to Help in the Governance Journey
10. AJamesResource
R. Nininger
Out for the Wave:
14. Watch
The Evolving Role of Board Governance
Jean Morrison
Relations: Effective Leadership
17. Dynamic
in Complex Environments
Thomas G. Philpott
Health: A New Organization
20. Eastern
with a Unique Approach to Governance
Joan Dawe
Governance in Ontario:
30. Hospital
The Challenge of Change
Maureen A. Quigley & Graham W.S. Scott
Qmentum Approach to Health
33. The
Care Governance: The Changing
and Diverse Landscape of Health
Care Governance in Canada
Brian Schmidt
for Quality
38. Leading
Maura Davies
Canada’s New
41. Accreditation
Governance Framework for Health
Care Organizations and Systems
Jean-Louis Denis, Marie-Pascale Pomey, François
Champagne, Ghislaine Tré & Johanne Préval
In Closing
Wisdom
46. Sharing
Gilles Lanteigne
Quality Improvement: How Governance
26. Beyond
Standards are Promoting Health Care Reform
and Improving Performance in the Middle East
Fadi El-Jardali
Qmentum Quarterly: Quality in Health Care is the product of a partnership between Accreditation Canada and Les éditions du Point.
Les éditions du Point is a specialized publisher. One of its journals, Le Point en administration de la santé et des services sociaux, is intended for health
professionals and administrators and has been published for five years.
Les éditions du Point’s publications target administrators, managers, and professionals in the health network. The publications are intended as tools
for information, support, professional development, and continuing education, as well as for reflection, analysis, and expression. While remaining
very close to the concerns of the targeted readership, the publications are also guided by national and international thinking.
3
Governance and Leadership • Volume 1, Number 2
Q
mentum
uarterly
Quality in health care
Qmentum Quarterly: Quality in Health Care is an avenue for sharing expertise, innovation, and
leading practices across Canada. The publication provides a forum for health and social services organizations that are committed to learning about and improving quality and patient safety.
Publisher
Normand Bouchard
Managing Editors
Erin Guthrie and Suzanne Perron
Produced in consultation with
Accreditation Canada
Wendy Nicklin
President and Chief Executive Officer
Gilles Lanteigne
Executive Vice-President
and Chief Operating Officer
Donna Anderson
Vice-President, Strategic Communications
and External Relations
Liane Craig
Director, Strategic Communications
Contributors to this edition
François Champagne, Maura Davies,
Joan Dawe, Jean-Louis Denis, Fadi
El-Jardali, Pamela C. Fralick, Gilles
Lanteigne, Jean Morrison, Wendy Nicklin,
4
James R. Nininger, Marie-Pascale Pomey,
Thomas G. Philpott, Johanne Préval,
Maureen A. Quigley, Brian Schmidt,
Graham W.S. Scott, Ghislaine Tré
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Wendy Nicklin
President and Chief Executive Officer
Accreditation Canada
Introduction
Promoting Good Governance
and Effective Leadership
T
he theme of this issue is Governance and Leadership. With the launch of Accreditation Canada’s
Qmentum Accreditation Program, the previously
combined Leadership and Partnerships standards
were separated into dedicated standards for governance and
for leadership. This division recognizes the critical trend that
emphasizes the heightened importance of the role of boards.
It also came about at the request of clients and surveyors who
stated that there was a blurring of the roles of governance
and leadership in the previously merged standards.
The new standards reflect greater specificity and rigour. In
particular, the standards for both governance and leadership are strengthened in the areas of quality and patient
safety. The governing body and the leadership team are integral in setting the tone and creating the culture necessary
to provide quality and safe care within an organization, a
fact which several of our contributors also recognize.
We are pleased to bring you a diverse range of authors and
articles in this issue. On the topic of leadership, Maura
Davies writes about her experience as the leader of a health
system and shares examples of quality in action in her
region. Thomas Philpott offers an inspirational article for
leaders based on his discussion with Dr. Arthur Porter,
Director General and CEO of the McGill University
Health Centre.
Jean Morrison reflects on her years in health administration
as both a leader and a board member and considers how the
roles have evolved over time. Joan Dawe writes about her
region’s governance renewal process, which resulted in a
modified policy governance approach, and the process used
for their community health needs assessments.
As winter begins to settle in across
Canada, I am pleased to bring you the
second edition of Qmentum Quarterly.
Feedback from the first edition was
positive and it is our intention to
continue to keep you informed about
relevant and timely knowledge and
initiatives that contribute to improving
the quality of health care.
Fadi El-Jardali provides us with an international perspective
by taking a look at how accreditation is improving the
governance of health care organizations in the Middle East.
Closer to home, Maureen Quigley and Graham Scott discuss
the changes that have taken place in health governance in
Ontario in recent years.
Pamela Fralick of the Canadian Healthcare Association
reviews the research on the link between patient safety and
governance, and discusses the role of governance on quality
and patient safety. James Nininger of the Community for
Excellence in Health Governance talks about the previous
lack of investment by health care organizations in governance
and leadership, and describes some of the new and innovative
resources that are now available.
Looking inward, Brian Schmidt summarizes how Accreditation
Canada’s new Qmentum governance standards were developed
as well as the process that organizations undergo when using
the governance standards. Jean-Louis Denis et al. provide an
in-depth article on the specific work that went into the development of the governance framework with its five core functions of governance and its link to the governance standards.
Organizations that have gone through Qmentum have found
the new governance component actively draws the board of
directors into the accreditation process, a significant change for
board members. Indeed, Qmentum supports all health care leaders to exercise their important responsibilities more effectively.
Until next time…
5
Pamela C. Fralick
Reshaping Responsibilities:
A New Vision for Health Care Boards
One of the most intriguing challenges
— and opportunities — in shaping
today’s health system is how to make
full use of the experience and skills
of boards of directors. The governing
board may be the least known and most
underutilized tool in efforts to address
issues such as quality of patient care
and safety.
6
M
uch is expected of a board of directors. In terms
of governance, a board is the link between the
public who receives the services and the hospital
management who delivers them. The American
Sarbanes-Oxley Act in 2002 emphasized the governance
responsibilities of a board of directors. Beyond setting organizational goals, monitoring productivity, and ensuring executive accountability, the board of directors is expected to reflect
public interest, be a forum for citizen engagement, and
promote transparency and accountability. Board members
have thus assumed a greater role and responsibility for the
direction of the organization and are held more accountable.
Along with management, boards make vital
decisions, choices, and judgments regarding where to reduce resources, increase resources, or eliminate programs and services
entirely to meet the needs of the population
more effectively. They also have to safeguard
patient safety, as well as make decisions on
when and how to disclose issues affecting
patient care and safety.
Governance, Management, Accountability and Shared Responsibility. This document outlines a set of principles in relation
to governance, management, and accountability of the health
system. This was followed in late 2005 with a round table to
discuss the inevitable challenge of integrating these principles
into health system practices across the country.
Most recently, Accreditation Canada (2008) has taken the
significant step of identifying Standards for Sustainable
Governance in response to “system-wide changes in structures
for health care delivery, and the increasing need for public accountability.” One of the five key functions of governance is
identified as “demonstrating accountability”.
Charging boards, either formally or informally, with the enormous task of safe“The pursuit of
guarding patient safety is one thing. How
they choose to execute this task is quite
excellence is not a
another. There does not yet exist an
spectator sport.”
extensive body of literature to help organizations do so, and current research being
CHA National Roundtable on
undertaken by Dr. Ross Baker et al. sugHealth System Effectiveness,
gests that efforts to improve governance as
December 2005
it relates to quality and patient safety in
The report, To Err is Human: Building a
Canada are still in the early stages in many
Safer Health System (Kohn, Corrigan,
institutions and facilities. His work, once
& Donaldson, 2000), published by the
released, will be informative and instructive for boards of all
Institute of Medicine of the National Academy of Sciences,
health organizations.
was a very public acknowledgement of the scope of problems
within the American health system. It boldly identified the
Two additional initiatives undertaken this year may help
nature of the issues, and prescribed clear steps to change the
boards grapple with this emerging challenge. The first is the
culture that led to and sustained poor practices. Governance
U.S.-based Institute for Healthcare Improvement campaign,
was included as a priority piece of the puzzle.
“Get Boards on Board,” designed to uncover best practices in
augmenting the governance role on the issues of quality and
This report opened the floodgates. Shortly thereafter, the
patient safety. The campaign urges boards to
Institute of Medicine’s Committee on Quality of Health
Care in America produced another pivotal book, Crossing
the Quality Chasm: A New Health System for the 21st Century
1. Set specific aims to reduce harm; make “an explicit, public
(2001). More than just commentary on the problems of the
commitment to measurable quality improvement”.
day, the authors provided a how-to guide for creating a more
2. Get data and hear stories to establish transparency and put
transparent and accountable health system. Again, the role of
a “human face” on harm data.
the board was identified as a key player in shaping the system
3. Establish and monitor system level measures that are conof the future.
tinually updated, made known to the entire organization,
and publicly released.
Yet despite the fact that these publications riveted public and
professional attention on quality, patient safety remains an
4. Change the environment, policies, and culture to disclose
ongoing and unresolved issue. One in 13 patients in Canadian
adverse events, support those who are harmed, and resolve
health care facilities experiences some type of adverse event,
issues that contribute to that harm.
according to The Canadian Adverse Events Study (Baker,
5. Learn more about how “best-in-the-world” boards work
Norton, et al., 2004).
with executive and medical leadership to reduce harm.
Canada has been somewhat late both in addressing patient
6. Establish executive accountability for clear quality improsafety issues and in acknowledging the board’s role in promotvement targets (Conway, 2008).
ing patient safety and quality of services. Following the creation
Secondly, in March 2008, the Canadian Patient Safety
of the Canadian Patient Safety Institute in 2003, health system
Institute (CPSI) announced the release of the Canadian
leaders began addressing the critical nature of the board role in
Disclosure Guidelines. These represent nearly two years of
effecting change. For instance, in 2004, the Canadian Healthconcerted effort by representatives from key national organizacare Association (CHA) partnered with the CCAF-FCVI Inc.
tions, including physicians, nurses, pharmacists, other health
to produce Excellence in Canada’s Health System: Principles for
7
care providers, and patients. The
national guidelines are intended
to assist and support health providers, inter-professional teams,
organizations, and regulators in
developing and implementing
disclosure policies, practices,
and training methods across
Canada. CPSI underscores
that “Ultimately, these guidelines symbolize a commitment
to the patient’s right to be informed if they are involved in
an adverse event, by promoting
a clear and consistent approach
to disclosure, emphasizing the
importance of inter-professional
teamwork, and supporting learning from adverse events” (2008).
References
Accreditation Canada. (2008).
Sustainable governance standards.
Qmentum program 2009 (ver. 2).
Ottawa, ON: Author.
Baker, G.R., Norton, P.G., Flintoft,
V., Blais, R., Brown, A., Cox, J., et al.
(2004). The Canadian
adverse events study: The incidence
of adverse events among hospital
patients in Canada. Canadian Medical
Association Journal, 170, 1678–1686.
doi:10.1503/cmaj.1040498.
Canadian Healthcare Association
(CHA), & CCAF-FCVI Inc. (2004).
Excellence in Canada’s health system:
Principles for governance, management,
accountability and shared responsibility.
Ottawa, ON: Authors.
The following advice is for
organizations and boards as they
go forward on their governance
journey:
1. Work towards influencing the process
by which governments appoint board
members, such that required attributes/
competencies for the work of the organization, including patient safety, are
taken into consideration.
2. Seek board members with expertise in
the areas of quality and patient safety
(where the board member selection
process permits recruitment).
3. Ensure your board has a quality care/
patient safety committee or structure
to probe these matters beyond simple
questions.
4. Allocate appropriate resources to ensure
boards have the training and expertise
to ask the needed questions.
5. Challenge current notions on board
functioning, such as the interpretation
of the operational/governance divide
and remuneration of boards.
The decisions faced by boards and management are a delicate balancing act which
encompasses accountability, transparency,
patient safety, and quality/quantity of services delivered. The National Healthcare
Leadership Conference, organized jointly
by the Canadian Healthcare Association
and the Canadian College of Health
8
Service Executives, has purposefully selected “Accountability in Health System
Leadership: The Balancing Act” as its
theme, reflecting the importance of this
issue in today’s environment. This event,
which will be held June 2009, will provide
a provocative opportunity for all health
leaders to further debate the role of boards
in effecting change in the way we address
patient safety and quality of services.
Finally, boards of directors are just one
agent of change and they cannot act
alone. The effectiveness of a health
system is the outcome of a shared partnership among governments, trustees,
and executives. All must do their part to
sustain the momentum towards higher
levels of governance, accountability,
transparency, and patient safety.
Pamela C. Fralick, MA, is the President
and CEO of the Canadian Healthcare
Association following seven years as CEO
of the Canadian Physiotherapy Association.
Ms. Fralick served nine years on the board
of directors at the Centre for Addiction and
Mental Health (CAMH), including three
years as Board Chair. Ms. Fralick also
acts as Chair of the Health Action Lobby
(HEAL), a coalition of 36 national health
associations and organizations.
Canadian Patient Safety Institute.
(2008). Canadian Disclosure Guidelines. Retrieved September 22, 2008,
http://www.patientsafetyinstitute.ca/
Disclosure.html
Committee on Quality of Health
Care in America, Institute of
Medicine. (2001). Crossing the quality
chasm: A new health system for the 21st
century. Washington, DC: National
Academy Press.
Conway J. (2008). Getting boards on
board: Engaging governing boards in
quality and safety. Joint Commission
Journal on Quality and Patient Safety,
34, 214–220. Retrieved from http://
www.ihi.org/IHI/Topics/LeadingSystemImprovement/Leadership/Literature/GettingBoardsonBoard.htm
Institute for Healthcare Improvement.
(n.d.). Get boards on board. Retrieved
September 22, 2008, from http://
www.ihi.org/IHI/Programs/
Campaign/BoardsonBoard.htm
Kohn, L.T., Corrigan, J.M., &
Donaldson, M.S. (Eds.). (2000).
To err is human: Building a safer health
system. Washington, DC: National
Academy Press.
James R. Nininger
A Resource to Help in the
Governance Journey
The effective governance of our health
care organizations is of paramount
importance to you and to me. Understanding why this is important is not
difficult — making it happen is much
more of a challenge.
T
he money we spend on our health care system is
enormous. The health care sector is by far the most
costly of public services delivered in Canada. Total
spending was estimated to be $148 billion in 2006,
representing 10.3% of GDP — the highest level in 31 years
(CIHI, 2007). If recent trends continue, one study showed
that provincial government spending on health care will consume more than 50% of total revenues in six of 10 provinces
by 2020 (Skinner & Rovere, 2006).
Personal health status and the state of health services are
continuing top-of-mind issues for Canadians. Citizens want
to be assured they will get timely access to the quality care
10
they need. For this to happen, it is imperative for the health
sector to exhibit a high level of effective organizational
performance. There is not another sector of the Canadian
economy or area of public policy for which effective
governance is more critical.
Why then is it that until recently, the governance and leadership of our health care organizations have not been a priority?
Here are some possibilities. Some suggest that the complexity
of the delivery system has made it difficult to come to grips
with effective governance. Even basic fundamentals such as
lines of accountability and responsibility are often thorny and
difficult to understand. Others offer the
view that ministries of health have not been
focusing on governance as one of the ingredients for the effective delivery of health
care services, even though many thousands
of individuals across the country volunteer
their time to make health care better in
their communities. Still others claim that if
there was only enough money, there would
be no problems in health care at all!
Leading organizations
invest in being well
governed and being
well led.
There is perhaps another reason. Health
care organizations have been slow to invest
in building their governance and leadership
competencies, particularly when compared with leading
private sector organizations. Investments in these two critical areas have not kept pace with overall investments in the
delivery of care. As well, there has been a reluctance to learn
what other organizations are doing and to share best practices.
My experience as the CEO of the Conference Board of
Canada, as well as subsequent involvement on the boards of
two large publicly traded companies, has made it clear to me
that leading organizations invest in being well governed and
being well led. They spare no effort in searching far and wide
for best practices on their journey of continuous improvement.
We should expect no less from our health care organizations.
The good news is that the areas of health care governance
and leadership have received increased attention in recent
times. A number of provinces, such as British Columbia and
Saskatchewan, have invested in these two areas on behalf of
health care organizations. Accreditation Canada has recently
launched new governance standards as part of their accreditation process. The Governance Centre of Excellence of
the Ontario Hospital Association now offers extensive
educational programs for their members. The Canadian Patient Safety Institute is focusing on the role of the
board in quality of care and patient safety as are a number
of the provincial quality councils. The Canadian Health
Leadership Network (CHLNet) has brought attention to
the importance of health care leadership at all levels.
Increasing numbers of health care organizations are
demonstrating their commitment to governance and leadership. I have served as a judge for the Conference Board of
Canada/Spencer Stuart National Awards in Governance
program for the last eight years and it is encouraging to see
the number of health care organizations that are applying for
awards. In fact, the overall winner in the first year of the awards
was the Capital Health Authority in Edmonton, and last year
Bloorview Kids Rehab received an honourable mention.
Yet much more needs to be done. Health care organizations
have to adapt to dramatic changes in their environment.
Changes brought about by new provincial legislation, restructuring of health care organizations, increasing awareness and
involvement by citizens regarding health
care issues such as wait time guarantees,
and accountability pressures all point to
the need for enhanced governance and
leadership. It is disconcerting when we
read about instances where financial and
patient care problems have occurred that
point to poor governance and leadership.
A Resource to Help
in the Journey
Clearly, health care organizations and
national/provincial health organizations
need to increase their investment in their governance and
leadership practices. For this reason, a group of individuals has
been working together since January 2007 to build a resource
that will help meet this need.
The initiative is the Community for Excellence in Health
Governance (CEHG), which can be viewed at
www.myhealthboard.ca or www.gouvernancesante.ca.
The Vision of CEHG is “Better Governance, better health.”
The Mission is “Excellence in health governance through the
web-based sharing of the latest ideas, information, resources,
tools, and innovative practices.”
The main features of the website are located in the following
“rooms”:
n
The Resource Centre, when fully developed, will contain
information on Canada’s health care system and extensive
information on health governance. It will include tutorials
on governance, emerging governance issues, a repository
of governance policies and practices, and a section where
members can share Member Practices and/or peer reviewed
Innovative Practices. The Innovative Practice material is
being identified in partnership with Accreditation Canada.
n
The Lounge is a meeting room designed to allow members
to communicate with each other and share information.
The Lounge is the place for discussion forums on specific
topics and for specific types of users, for members to ask
questions of others via chat rooms and video conferencing,
and for governance thought leaders to host blogs.
n
My Boardroom contains all the tools to coordinate the
activities of a board of directors. It is a secure online
portal accessible only to members of a specific board.
It allows board members to receive their board and committee packages, to communicate with each other, and to
manage board meetings.
n
My Office is a member’s control centre on the CEHG
website. It allows members to personalize their site,
manage their multiple board commitments, and consolidate various types of information.
11
Current Status of the Project
The website is now being beta tested by a number of health
care organizations and national/provincial health organizations. Considerable work needs to be completed in populating
the Resource Centre with governance material and practices.
Our goal is that the beta testing will be completed by spring
2009 and the site available for broad use shortly thereafter.
As the Community will belong to its members, organizations
interested in helping with the beta testing phase of the project
or helping in other ways (such as providing Member Practices)
are encouraged to contact us through the website.
Funding for the Community
The Community is a membership-based organization, and
health care organizations and national/provincial health
organizations will be invited to join once the website becomes
fully operational. A membership fee guide is under development. Additional funding is being sought from the federal and
provincial governments, corporations, and foundations.
Initial funding for the project came from McGill University
Health Centre, through the support of Dr. Arthur Porter, CEO
of MUHC. Two provinces, Manitoba and Saskatchewan, and
a number of other organizations supplemented this funding.
Beta testing of the CEHG website is expected to be completed by
spring 2009 with the site available for broad use shortly thereafter.
my
boardroom
Oversight of the Community
The development of CEHG is a major undertaking. An
extensive amount of consultation has taken place as well as
a large market research study conducted by Harris/Decima
earlier this year. Both clearly indicated the need for CEHG by
health providers across the broad spectrum of the Canadian
health industry.
For too many of us governance is overly complex, almost
a black hole. One of the purposes of CEHG is to explain,
simplify, and enlighten. The Community for Excellence
in Health Governance is designed to make a major breakthrough in health governance by increasing the ability of
trustees, executives, and medical leaders to share insights,
compare experiences, and converse on important issues. Such
a breakthrough is necessary if the boards in our health sector
are to play a major role in leading us to a better future.
12
LOUNGE
resource centre
The Community has been incorporated as a not-for-profit
organization and its development has been overseen by a small
board of directors. A number of advisory groups have been put
in place including an advisory council of prominent governance experts, a health governance panel, and an editorial
advisory committee. Information on all of these groups can be
found on the website.
Conclusion
MY OFFICE
The CEHG website offers a unique interface, with the main features
of the website located in various “rooms.”
James R. Nininger, PhD, is the Chair of the Board of the
Community for Excellence in Health Governance. He was
President and CEO of the Conference Board of Canada from
1978 to 2001, and is involved in a number of boards in the
public and private sectors.
References
Canadian Institute for Health Information (CIHI). (2007). Health Care
in Canada 2007. Ottawa, ON: Author.
Skinner, B.J., & Rovere, M. (2006). Paying More, Getting Less 2006:
Measuring the Sustainability of Public Health Insurance in Canada.
Vancouver, BC: The Fraser Institute.
Jean Morrison
Watch Out for the Wave:
The Evolving Role of Board Governance
The evolution we are seeing in the role of
health boards causes me to reflect on my
30 years in health care and more specifically my years in health administration.
My health administration education taught
me that boards that oversaw the delivery
of health services were responsible for
setting an organization’s strategic direction,
monitoring progress towards achievement
of the direction, and monitoring the
overall performance of the organization.
That sounded pretty clear, so you can only
imagine my surprise 18 years ago when
I first started attending board meetings!
14
I
n my early experience with the boards I had the opportunity to observe and work for, board members spent a lot of
time monitoring the financial position of the organization
and approving the contract awards and recommendations
put before them. There was a great deal of focus on building
maintenance, construction, and capital equipment purchases.
Put simply, boards seemed to spend a lot of time counting the
money, but little time focused on the product we delivered,
namely health services or the results of our work. The focus
of the board was made evident by who participated in board
meetings. I saw boards that required the Chief Financial
Officer to take part in all board meetings, but the people
responsible for the health programs were not required to
attend, and sometimes not allowed to attend.
I have to say I was rather disillusioned. It seemed to me that
there were a lot of things that my administrative colleagues felt
were not the business of “The Board” that I felt should be the
main concerns of the board. My academic preparation had led
me to truly believe in the principle of public administration
and public input into health services planning and monitoring. In my mind, boards should have been playing a key role
in determining what the health organization was doing and
monitoring how well it was done. When I became a chief
executive officer, I provided more and different information to
the boards I worked with than many of my colleagues did, but
I only touched the tip of the iceberg in terms of providing the
right information at the right time.
I have grappled with the role of boards both as an administrator
and as a board member on a number of not-for-profit boards. I
currently chair the Governance Committee for Accreditation
Canada’s board of directors. On this board, as with the other
boards I am on, we regularly debate whether we are doing our
work or getting into the weeds and doing management’s work.
I have lived through the see-saw of governance models, from
sometimes no clear model, to traditional models with board
committees, to Carver with no committees, and back again.
Well, the pendulum has continued to swing and now I find
it has started to pass me by. I have come to this awareness
gradually as I have been swept into the current drive for improved quality in health care delivery. Over the past five years,
I have spent a great deal of time focused on current quality
methodologies and factors that lead to improved quality, safety,
and transformed health care delivery agencies. The work done
by the Institute for Healthcare Improvement, the Canadian
Patient Safety Institute, and the Health Quality Council of
Saskatchewan have become regular reference points for me.
One of the factors that have been identified as key to becoming
a high performing organization is the leadership of the board
and executive management. What does that mean in terms of
the role of the board? A background paper by The Institute for
Public Administration of Canada (IPAC) defines a very clear
picture for the role of the board (Adamson et al., 2007). IPAC
stresses the need to be focused on the interests of the owners
and the customer — in other words the public we serve —
A board’s fiduciary
responsibility is broader
than ensuring financial
integrity, and those of us
in management will learn
how to support and assist
boards to fulfill that role.
and to truly assess both
financial and nonfinancial information
to understand and push
the organization’s performance.
The
Institute
for
Healthcare Improvement is more explicit
in their description of
the board’s role in qua­
lity and patient safety:
The Board’s work relating to patient safety takes many forms:
setting goals for organizational improvement; building the
business case for patient safety in which patient safety goals
are integrated with the organization’s strategic goals and
business plan; reviewing data related to key organizational
metrics; reviewing adverse event reports and root cause
analyses; providing resources for improved infrastructure,
education, and staffing; and holding management
accountable for addressing patient safety issues (Botwinick,
Bisognano, & Haraden, 2006).
In my experience, the board’s role was not nearly this broad. Its
role had been focused on providing the resources for quality improvement, as recommended by management, and sometimes
having a small role related to setting goals for organizational
improvement. The fallout following large corporate scandals,
primarily in the United States, has caused board members to
review their role, the role of boards as a collective, and their
method of operation. There has been an increase in board
education, and as board members change, there is a continual
revisiting and rewriting of board policy and methods of operation based upon the expertise that joins the board.
Most recently I was stunned by the suggestion that board members should take part in safety walk-arounds. Actually, I heard
of this practice a couple of years ago in the United States and
15
thought, “It can’t happen here, our system
is different”. Well, it is coming!
Board performance, like
member you always need to be clear about
your role and responsibilities. Ask
questions until you understand what you
are being told, and work to ensure you
receive information that allows you to be
confident your organization is delivering a
quality product.
I have always been a manager who visits
the performance of any
care delivery sites, talking with staff and
organization, needs to be
patients. Over the last three years, this type
continually assessed and
of activity has taken on a new life in our
health region. All senior leaders now take
improved. It will change
part in walk-arounds and gather specific
At the same time, I would caution that we
as the situations change
information. We are working to systemmust be careful how we as board members
and as the personalities on react to individual pieces of information
atically analyze the information collected
the board change.
in the walk-around so it can inform
and anecdotes. Boards need to use a vaour ongoing planning and monitoring.
riety of methods to monitor performance.
I must say that initially this was not a
When setting out on this journey, boards
very comfortable experience for senior leaders without clinical should know what they are looking for, how they are going
backgrounds, but it has become easier over time.
to collect the information, and how they are going to use
the information once they receive it. From my perspective, a
To think that board members would take part in walk-arounds board walk-around provides one piece of information collected
is a little more difficult for me to grasp. Is this okay from through direct observation. Boards embarking on walk-arounds
a privacy and confidentiality perspective? Do board members need to identify why they are doing the walk-around,
have the background to understand what they are seeing? What determine what information they are attempting to collect,
will board members do with the information? If the board is and understand how that information will be integrated into
out there talking with staff and patients, what’s my job? The their overall monitoring framework.
questions I have about boards taking part in walk-arounds are
many of the same questions that managers who reported to I expect all not-for-profit boards will continue to grapple with
me had when I would visit sites and that I had when it was the role of the board versus the role of management. There
proposed that our whole senior leadership team take part in will continue to be tension about who is leading and who
walk-arounds. I can now tell you from experience that our is following. While tension between a board and management
executive walk-arounds are going well.
may be uncomfortable, some tension is not a bad thing. It keeps
us alert, it keeps all of us pushing to improve, and most
This new place, with boards getting more involved in moni- importantly, it keeps us honest.
toring the clinical performance of organizations, is not always
a very comfortable place. Boards that have more information If you are thinking that I am way behind the times in my unask more questions. It is sometimes uncomfortable being asked derstanding of the evolving role of boards, congratulations for
pointed questions that do not have easy answers, or even worse, being on top of the wave. And for those who do not have a
that you do not know the answer to. When I think back to my clue what I am talking about, good luck and make sure you are
early belief that boards were not involved enough in moni- holding your breath—the wave is here!
toring the care we provide, it causes me to reflect on the old
saying: “Be careful what you ask for, you might get it”.
Jean Morrison, RN, BScN, MN, MHSA, is Vice President,
Performance Excellence and Chief Nursing Officer for the
Regardless of all my misgivings, as a leader I do believe we are Saskatoon Regional Health Authority. Jean has a unique
going in the right direction. A board’s fiduciary responsibility combination of nursing, academic, and administrative skills and
is broader than ensuring financial integrity, and those of us in experiences gained during 31 years of involvement in the health care
management will learn how to support and assist boards to field throughout Saskatchewan and Canada.
fulfill that role. There is no perfect model to follow to know
what non-financial information to give a health board or how
References
to put that information together. It is our job to work with our
boards to develop reports that are understandable, provide
Adamson, B., Ball, T., Caplan, E., Cheesbrough, G., Moore, K.,
trends over time, include comparisons or benchmarks to
& Sékaly, G. (2007). How can local healthcare governance survive?
similar organizations, and allow our boards to determine if the
Background paper for the Healthcare Leaders’ Dialogue on Governance
organization is achieving the goals that were set.
Renewal. Toronto, ON: The Institute of Public Administration of
As a board member, my belief is that there is no perfect model
for board operations. Board performance, like the performance
of any organization, needs to be continually assessed and
improved. It will change as the situations change and as the
personalities on the board change. Just remember, as a board
16
Canada.
Botwinick L., Bisognano M., & Haraden C. (2006). Leadership
guide to patient safety [White paper]. IHI Innovation Series.
Cambridge, MA: Institute for Healthcare Improvement.
Thomas G. Philpott
Dynamic Relations: Effective Leadership
in Complex Environments
What is the definition of a strong leader?
Stephen Covey, the celebrated author of
The 7 Habits of Highly Effective People,
says it is a person who inspires others by
communicating to them their worth and
potential (2004, 2007). The Honourable
Arthur T. Porter, Director General and
Chief Executive Officer of the McGill
University Health Centre, feels that
leadership can also be seen from a more
personal perspective. This article is a
reflection of a recent discussion with
Dr. Porter.
Leaders versus Managers
Great leaders are not afraid of pursuing their vision. This is a
fundamental difference between a manager and a leader. A
true leader is prepared to take critical risks. A manager, on the
other hand, may take risks on a daily basis, but not to the same
extent as the leader whose broader, more strategic risks can
make or break the person’s career.
A manager learns to manage risk and opportunity, whereas a
leader must have the capacity to lead the organization with an
overarching vision. Sometimes leaders have to make choices
that may result in losing their job, such as in a merger. Such
high-stake decisions require focus on the organization’s immediate health and stability, but also the vision to consider all
elements that make up the competitive landscape of the future.
This is not to say that a manager cannot lead an organization effectively. There are many excellent managers.
Moreover, some organizations are perfectly suited to someone
who is more of a manager in style than a leader. For a complex
academic health centre, however, a strong leader at the
top, supported by effective managers, is essential due to the
challenging and constantly evolving environment.
Leadership Style and Crisis Management
The most important aspect of effective leadership is staying
true to your own personal style. Some leaders are focused on
the minutiae, while others function by consensus, and still
others employ a charismatic style by leading from the front.
If you try to be something that you are not, your leadership
potential will never be realized.
A leader must simplify the issues, communicate effectively,
and develop an agile team that embodies the attributes of effectiveness, efficiency, and loyalty. Loyalty must be mutual.
The team must feel that that leader is willing to take the blows
when the going gets tough. This will inspire the team to
remain loyal to that leader during difficult times.
In a crisis, there is a strong temptation for a leader to begin
micromanaging. This is a big mistake. A leader must stay high
above the swirling clouds and turbulence to continue to see
17
the big picture and make strategic moves. The moment a leader
begins to micromanage, perspective and the horizon are lost.
decisions, much like the
leader making a tough call
regarding a merger.
The CEO and the Board
A CEO needs to have a good board and a strong relationship with its members. This does not mean that it need be
a harmonious relationship; in fact, there is such a thing as
healthy tension. Due to the differences and strengths within
a board, the nature of the relationship will change over time
and between boards. This relationship is thus a dynamic one
and fixed rules do not apply. Every CEO has a unique style,
as does each board. Therefore, the ensuing relationship must
mould itself.
The nature of the relationship will often depend on the
strength of each of the two forces. A strong CEO will have the
tendency to want to make all the leadership and management
decisions. Another CEO may let the decisions drift towards
the board. Even the seating arrangements can reveal the
nature of the relationship. A CEO who sits on the side during
a board meeting is a very different CEO from one who sits
next to the Chair.
The Role of the Board
A board should provide a positive venue for sounding, advising, and questioning. Similar to the Senate, it is a source
of sober second thought. While some CEOs might like
to approach the board with a problem and seek a solution, a
strong leader will tend to bring a “straw man” solution to the
board. Board members will critique it and flesh out the details,
and the result is often a complete and better solution.
In terms of the division of directing and managing, a publicsector hospital board is quite different and more complex than
private-sector boards as there are fiduciary duties that are often
poorly understood in both theory and practice. Some board
members feel, for example, that they should have greater access to information and use their position to represent the constituency from which they may have been appointed, which
may create confusion in their execution of duty. As a result
of this environment, the board becomes more parliamentary
in nature. Yet board members must understand that, once
appointed, their duty is to the board and the organization, not
to a constituency.
At the same time, it is important for the board to allow the
leader to lead. There isn’t time to have every decision made
or vetted by a committee. In Good to Great, Jim Collins does
not include much discussion on the board (2001) and there
is a reason for this: An aggressive leader will not spend much
time consulting with the board, but will be careful to do so for
the right issues at the right time. This ensures the board is used
effectively and efficiently.
This also means that strong leaders must live with the
consequences of their actions and be willing to make difficult
18
The Right
Attitude
The worst thing for a CEO
to have is a “must retire
here” attitude. If you want
an organization to fulfill
its promise, you must be
prepared to take risks. If
Dr. Arthur T. Porter
you are always operating
with retirement in the back
of your mind, you won’t be willing to make the decisions that
will force the organization to stretch beyond its perceived
capacity.
In addition, a leader should always look for the strategic advantage in any given situation. There are very few circumstances you
will find yourself in that are truly negative. Much like Aikido,
you can often win a tough battle through apparent submission.
The trick is to remain above the swirling clouds as the tempest
rages below and to keep the horizon always in view.
Thomas G. Philpott, MBA, MHA, is Public Private Partnership Programme Manager at the McGill University Health Centre
(MUHC) and a board member of the Community for Excellence
in Health Governance. He holds a Master of Business Administration from the Richard Ivey School of Business and a Master
of Health Administration from the University of Ottawa. While
with the MUHC Executive Office, Mr. Philpott acted as liaison
with the MUHC board, as well as Project Director of the
Community for Excellence in Health Governance.
The Honourable Arthur T. Porter, P.C., MD, is the Director
General and CEO of the McGill University Health Centre, and
President of the RUIS McGill. In addition, he serves on a number
of boards, including Air Canada and the Munder Funds. Most
recently, Dr. Porter was appointed to the Government of Canada’s
Privy Council and the Security Intelligence Review Committee.
References
Collins, J. (2001). Good to great: Why some companies make
the leap...and others don’t. New York: Harper Collins.
Covey, S.R. (2004). The 7 habits of highly effective people:
Powerful lessons in personal change. New York: Free Press.
Covey, S.R. (2007). The leader formula: The 4 things that make a
good leader. Retrieved October 5, 2008, from
http://www.stephencovey.com/blog/?p=6
Joan Dawe
Eastern Health: A New Organization
with a Unique Approach to Governance
Eastern Health, with more than 12,000
employees, 720 physicians, and 2,500
volunteers, is the largest integrated
health authority in Newfoundland and
Labrador, serving a regional population
of 293,000 and providing unique provincial programs and tertiary care services.
As an academic health care organization,
it also has distinctive roles in education
and research.
Background
History
Formed on April 1, 2005, from the merger of seven health
care organizations, Eastern Health offers the full continuum of health and community services within its 80 sites
including hospitals, health care centres, long-term care facilities, and community care settings. In September 2007,
Eastern Health successfully participated in its first regional
accreditation survey using Accreditation Canada’s former
Achieving Improved Measurement (AIM) standards.
Governance
Eastern Health’s authority to govern was delegated by
the Government of Newfoundland and Labrador and is
20
outlined in specific legislation including the Regional
Health Authorities Act (2006) and the Transparency
and Accountability Act (2004).
While the provincial government assigns governing
boards the responsibility to govern the organization,
the Minister of Health and Community Services ensures
that the government’s fiscal and policy responsibilities
are fulfilled. These roles are clearly defined in the regional health authority legislation.
In appointing boards of trustees, the provincial government
has recognized that boards must address a diverse array of
complex issues and challenges, including:
n
achieving a balanced approach to
governance that recognizes the dual
accountability to the government and
the public
n
maintaining quality and standards of programs and services within the fiscal ability of the province
n
responding to increased needs and expectations
n
performance-based planning and reporting to the government and the public (Transparency and Accountabili­ty
Office, 2005)
There was a strong commitment and determination by trustees to seize
the opportunity of a
changing environment
and adopt a governance
process that would create
a meaningful value-added
role for the board.
In assuming the responsibility for establishing Eastern Health,
the 18 volunteer-member Board of Trustees accepted the significant challenge of creating a complex, fully integrated organization and the need to bring financial stability and sustainability to a system that had incurred a substantial debt. Within
months of its appointment, the board was also confronted
with a number of very serious issues related to health human
resources, physical capacity, and hormone receptor testing for
breast cancer. Consequently, trustees realized they needed
to think and act in new ways to meet the dual demands
for services and greater accountability. Traditional “business
as usual” ways of governing were no longer acceptable.
While the board of trustees recognized that it existed to serve
both the people of Newfoundland and Labrador and the provincial government, there was a view that direct accountability to the community served might indeed be the most critical aspect of that accountability.
With this backdrop, the board began exploring models of
governance that would direct its activities to produce the best
results for the people it served. From the outset, there was a
strong commitment and determination by trustees to seize the
opportunity of a changing environment and adopt a governance process that would create a meaningful value-added
role for the board. A considerable amount of time was spent
discussing trustee experiences and reviewing current practices,
national accreditation standards, and literature on governance
(CCHSA, 2005; CHA & CCAF-FCVI Inc., 2004; Carver,
2006).
The board selected a modified policy governance approach
to accommodate the organization’s unique circumstances,
which increased the board’s sense of owning the model. This
approach was a major shift in thinking and practice. Trustees
considered the implications of separating policy from implementation and the possible dangers of the board being forced
into a vacuum. They wondered if they would have the
information necessary for effective governance and how they
could be assured the strategic plan was being implemented.
These concerns were addressed with a commitment to imple-
ment a monitoring system, which required
information from both internal and external sources confirming that all of the policies and strategic directions were being
carried out. In addition, regular compliance statements from the chief executive
officer would be required. Any areas of
variance were to be adequately explained
and action plans for remediation were to
be developed where necessary.
One of the appeals of the policy governance
model was its policy framework. The
board recognized that its policy development job was critical to the organization’s
success and sustainable governance. These policies—written
statements of the board’s values and perspectives—would
contain all of the board’s direction and instruction to Eastern Health. Policy governance would enable the board to play
more significant leadership and advocacy roles on behalf of
the people served, with emphasis on the following:
n
clearly distinguishing the role of the board from the
executive
n
being more proactive, with emphasis on planning and
priority setting
n
having an outward vision rather than an internal preoccupation
n
strengthening relationships with stakeholders
n
defining ends policies (the reason the organization exists
and the desired outcomes the board wants the CEO and
staff to achieve) and executive limitations (conditions,
actions, and decisions that the board considers unacceptable)
n
having mechanisms for monitoring and evaluating
the board’s work, its performance as a team, and ongoing
professional development
n
evaluating CEO performance against all board executive
limitations and ends (Carver, 2006; Oliver, 1999)
The complexities of creating a new organization were enormous. In addition to paying attention to finances, the board
recognized the need to make quality and safety priority areas
and to support the CEO in creating a culture of quality improvement. Planning, quality and safety, and finance subcommittees were appointed to help the board achieve its work.
During the first year of the board’s mandate, trustees devoted a
significant amount of time and effort completing a mandatory
comprehensive orientation program. Carol Gabanna,
an accredited facilitator in policy governance, was engaged
to provide educational sessions for trustees and the executive.
She also conducted workshops on the development of policies on governance process, board/staff linkage, and executive
21
limitations. The full participation of trustees in orientation
and governance education illustrated the high degree of
commitment of all board members and ensured they clearly
understood their roles, responsibility, and accountability.
Taking an ends approach to governance was contrary to our
traditional learning about the nature of board deliberations.
However, the development of ends policies during this past
year and the use of regular monitoring reports on policies
have brought a level of comfort to the board in assuring
accountability for Eastern Health. All policies have been assessed and modified to reflect the changing environment. The
board of trustees is still at an early stage of implementing its
policy governance approach and like any change, it involves
discipline, perseverance, and motivation.
As she prepared for her presentation at the National Healthcare Leadership Conference in Saskatoon earlier this year, Joan Dawe surveyed
Eastern Health’s Board of Trustees and CEO to ask for their views on
the governance approach. Here are their perspectives:
Board of Trustee Observations
n Provides a clear separation of governance and operations.
n Provides a greater sense of direction.
n Requires board members to be well prepared for meetings,
to be open to diverse views, and to be able to stand together
once a decision is made.
n The board’s willingness to be available for community meetings has been a plus as it keeps us in touch with the “ownership” of the organization.
n Monitoring reports enable me to be more accountable.
n Executive limitations set boundaries for the CEO without
binding the person’s hands. This process has built-in accountability, thoroughness, and transparency.
n Many opportunities for board education and development.
Demanding in terms of time and energy, but has been necessary and productive.
n Requires a change in thinking to focus on outcomes instead
of processes — very positive shift. Makes it easier to measure
performance and improvement.
President/CEO Observations
n Clearly outlines the role of the board and the role of the
CEO.
n Requires a new way of thinking and interacting with the
board.
n Creates a “healthy tension” between the board and the
CEO—meaning the board can expect CEO accountability for the ends within the executive limitations set by the
board, and the CEO can expect board accountability with
respect to its governance process.
n Requires executive/board education and ongoing coaching
regarding the process, and the development of monitoring
reports acceptable to the board.
n Requires a concentrated focus on outcomes, but with an acceptance that board members can ask for information at any
time to help in their understanding of the operations of the
organization.
n Evolving as both the board and the CEO better understand the policy governance process.
22
Reflections
Strategic Plan
The policy governance approach supported by the Regional
Health Authorities Act and the Transparency and Accountability Act guided the development of Eastern Health’s first
strategic plan. Eastern Health Strategic Plan: 2006–2008 clearly
defines the values, mission, vision, and strategic issues of the
organization. When combined with the operational plans, the
strategic plan helped move Eastern Health towards achieving
its vision of “Healthy People, Healthy Communities”. The
plan was developed with input from government, community
representatives, staff, physicians, and other partners in the
delivery of quality health and community services. This
information was combined with data collected from several
administrative sources. Annual performance reports are
submitted to the Minister of Health and Community Services
and tabled in the House of Assembly.
One of the major developments arising from the strategic
planning process was the commencement of communitybased health needs assessments throughout the Eastern Health
region. These assessments provided the board with evidencebased knowledge about the communities served. The process
documented here has been used quite effectively in both the
Burin Peninsula and Southern Avalon areas and will continue
to be used in subsequent needs assessments throughout the
Eastern Health Region.
Burin Peninsula Community Health Needs Assessment
In June 2005 at a public meeting on the Burin Peninsula, the
board announced its intent to conduct its first needs assessment
using a “determinants of health” approach. It is widely accepted
that making improvements to the health and well-being of
people must go beyond the delivery of health care services.
A steering committee composed of Eastern Health staff was
used to oversee the needs assessment process. To assist the
steering committee, a community advisory committee consisting of people from the Burin Peninsula was established. This
committee provided advice and feedback on the process and
outcomes of the assessment.
Qualitative and quantitative data were collected from primary and secondary sources. Qualitative data were collected
through 20 focus groups, 24 key informant interviews, and
486 telephone interviews. Eleven written submissions from
the public were also received. Quantitative data were compiled from several administrative databases and other sources
of secondary data.
The needs assessment report, Navigating the Way Together
(Eastern Health, 2006), resulted in 35 recommendations targeting priority issues identified through the needs assessment
and validated by both the steering and advisory committees.
The report was released at a public meeting in June 2006. With
the board’s acceptance of the recommendations, it committed
The region of Newfoundland and Labrador served by Eastern Health.
to monitor their implementation and to publicly provide a complete account of the progress on all recommendations in two years. Highlights of
the report were distributed to all households, physicians’ offices, health
facility waiting rooms, and libraries throughout the Burin Peninsula.
In June 2008, the two-year status report was released to health and community service providers, community leaders, and the general public
(Browne et al., 2008). Ongoing work to address the issues raised in the
needs assessment has been substantial.
Some of the significant advantages of the needs assessment process
included the degree of engagement and the extent of involvement in
health and community services decision-making by communities. These
have led to stronger partnerships between the community and the board
of trustees. Board values and policies concerning community capacity
building, strategic leadership, outward visioning, being proactive, and
being accountable to the people served were very much reflected in
this initiative.
23
References
Accreditation Canada. (2008). Strengthening governance through accreditation
[CD-ROM]. Ottawa, ON: Author.
Board of Trustees of Eastern Health.
(2006). Eastern Health strategic plan:
2006–2008. Retrieved from http://
www.easternhealth.ca/publicreports.
aspx?d=2&id=107&p=51
Browne, L., et al. (2008). Navigating
the way together: Burin Peninsula
two-year report. Retrieved from http://
www.easternhealth.ca/publicreports.
aspx?d=2&id=107&p=51
Navigating the Way Together resulted in 35 recommendations targeting priority issues.
Highlights of the report were distributed to all households, physicians’ offices, health
facility waiting rooms, and libraries throughout the Burin Peninsula.
The value of community engagement
is best reflected in the comments of one
of the community advisory committee
members: “The whole process and results were a real eye opener for me”, said
Lisa Slaney, Executive Director of Grace
Sparkes House. “Usually, we have our own
understanding of something and we talk to
our circle of friends about it and we have
one perspective. The great thing about this
needs assessment was that it came from
the people of the Peninsula; it wasn’t from
one group. Participating on the committee
made me realize that we need to consider
the needs of the whole community — the
whole of the Burin Peninsula — to make
it a viable, healthy community. Health is
not just about the services at the hospital.
I found it to be very enlightening... I think
the needs assessment has had an impact
on the community. The process was very
comprehensive and the needs were identified. It’s two years later and I can see a
difference” (Browne et al., 2008).
Conclusion
The Board of Trustees has the ultimate
responsibility and accountability for the
stewardship of Eastern Health. Its job
is to decide policy and strategy, monitor performance, listen to stakeholders,
and be accountable for the organization.
Recently I had the opportunity to view
24
Accreditation Canada’s new CD-ROM
on governance (2008) and I was pleased
to see our direction and approach to
governance is much in keeping with the
2009 Qmentum sustainable governance
standards.
Since its appointment in April 2005, the
board, despite being confronted with a
number of very serious issues, has invested considerable time and effort in establishing a new, unique approach to governance to help it fulfill its responsibility
and move the organization towards its
vision of “Healthy People, Healthy Communities”. Trustees are truly committed
to a belief that in the long run, as surely
as excellence is Eastern Health’s goal for
client, patient, and resident services, excellence begins with governance.
Joan Dawe, RN, BA, CHE, is Chair of
the Board of Trustees of Eastern Health in
Newfoundland and Labrador. She has an
extensive career in nursing, health administration, and policy, and was Deputy
Minister of the Departments of Health and
Social Services with the Government of
Newfoundland and Labrador. She was the
recipient of the 2001 Public Service Award
of Excellence in Newfoundland and
Labrador, and the 2004 recipient of the
Canadian Healthcare Association Award
for Distinguished Service.
Canadian Council on Health Services
Accreditation (CCHSA). (2005).
Leadership and partnerships standards.
CCHSA’s accreditation program (6th ed.).
Ottawa, ON: Author.
Canadian Healthcare Association (CHA),
& CCAF-FCVI Inc. (2004). Excellence in
Canada’s health system: Principles for governance, management, accountability, and
shared responsibility. Ottawa, ON: Authors.
Carver, J. (2006). Boards that make a
difference: A new design for leadership in
nonprofit and public organizations.
San Francisco: Jossey-Bass
Eastern Health. (2006). Navigating the
way together: Burin Peninsula community
health needs assessment. Retrieved from
http://www.easternhealth.ca/publicreports.
aspx?d=2&id=107&p=51
Oliver, C. (Ed.). (1999). The policy governance fieldbook. San Francisco: Jossey-Bass.
Regional Health Authorities Act. (An act
respecting the delivery of health and community services and the establishment of regional
health authorities.) (2006). St. John’s, NL:
Queen’s Printer.
Transparency and Accountability Act.
(An act to enhance the transparency and
accountability of the government and government entities to the people of the province.)
(2004). St. John’s, NL: Queen’s Printer.
Transparency and Accountability
Office. (2005). Excellence in governance:
A handbook for public sector bodies (Rev.
ed.). Retrieved from the Government of
Newfoundland and Labrador’s Executive
Council’s website: http://www.exec.gov.
nl.ca/exec/cabinet/transacc/pdf/Excellence_Gov.pdf
Fadi El-Jardali
Beyond Quality Improvement: How Governance
Standards are Promoting Health Care Reform and
Improving Performance in the Middle East
Quality of care is now prominent on
the government health policy agendas
of several Middle Eastern countries. A
study conducted in 2000 by the World
Health Organization revealed that there
were no accreditation programs in the
Eastern Mediterranean (WHO, 2003).
Since then, some countries in this region
have embarked on the development and
implementation of accreditation programs (El-Jardali, 2007).
W
hile many countries in the region still do
not have national accreditation programs,
more hospitals are realizing that accreditation contributes to improving the quality of
care. It also enhances the public’s confidence in the hospital and improves business and prestige, particularly when
the hospital is privately owned. Over the last five years,
many health care organizations (particularly hospitals)
26
in several countries in the region have been seeking international accreditation from recognized bodies such as
Accreditation Canada. This article will examine how the
impact of international accreditation goes beyond quality
improvement practices and how governance and leadership accreditation standards for hospitals are improving
overall performance and promoting health care reform in
several Middle Eastern countries.
Health Care in the Middle East
In the Middle East, accreditation is becoming a critical part of
a market-driven, consumer-focused health care system. The
demand for improving, managing, and controlling quality in hospitals has been escalating in many Middle Eastern
countries. While organizations in many oil-rich countries in
the region have sufficient resources, there is recognition that
success in delivering high quality services is dependent not
only on the availability of adequate resources but also on the
optimum use of those resources.
There is a greater need than ever to ensure
that hospitals do things effectively and
maintain a high standard of quality and
safety. Public awareness of quality and safety
issues in the region has been increasing over
time. Furthermore, poor quality has become
a threat to health care organizations and
systems. There is pressure on governments
and providers to set up effective health systems that are based on quality management
and patient safety principles.
responsible and accountable for the health system’s direction
to ensure that population health needs are met (Duca, 1996;
Mintzberg, 1997; Fennell & Alexander, 1989; Stolzenberg,
2000). Governance standards put emphasis on developing a clear direction and objectives for the organization,
building knowledge by assessing needs and gathering data
and information, developing the role of executive officers
and senior management, understanding the importance of
strategic planning, building and maintaining positive relationships with stakeholders, and promoting accountability
and outcome-based management.
While organizations in
many oil-rich countries
in the region have sufficient resources, there is
recognition that success
in delivering high quality
services is dependent not
only on the availability
of adequate resources but
also on the optimum use
of those resources.
The health systems of several countries in
the region are in a fragile and developmental stage. For example, primary care, tertiary
care, long term care, and home care are
fragmented and the continuum of care is
lacking. Many health care organizations
and systems operate without a strategic plan
or sufficient planning. The use of data is limited. Governance
and accountability are problematic, particularly when authority, resources, and information are not well coordinated in a
public/private system of health care delivery.
Historically, the role of governance and management has
been blurred in the region’s health care organizations. Many
hospitals in the Middle East are private entities owned by
hospital corporations or family businesses, but only some of
them are governed by a board of directors. In some cases,
the hospital owner or the CEO plays the role of the board of
directors. In other cases, the board of directors consists of a
small team of family members or business people. The board
exercises authority, direction, and control over the hospital.
In many cases, the role and responsibilities for governance
and management are not defined, leaving grey areas in terms
of functioning. These grey areas create a series of challenges
related to the board–management relationship, particularly
when it comes to exercising authority in the organization.
The Role of Governance Standards in
Health Care Reform
Literature notes that effective governance is the conscientious exercise of authority by stakeholders who are
Governance standards are helping health
care organizations move from traditional
“command and control” governance structures towards a new governance process.
These new structures promote openness,
engagement, and management based on
performance-based targets and measures
to ensure accountability in meeting the
hospital’s strategic objectives and the
health needs of clients.
In addition, governing boards of some
hospitals are becoming involved in strategic planning exercises and in representing the needs and expectations of clients
and stakeholders. Such involvement may
reflect greater pressure for hospitals to
perform better. Evidence shows that the
involvement of the governing board is positively associated
with a hospital’s net income, and that engaging the governing board in the strategic planning process for hospitals is
associated with better performance (Kaissi & Begun, 2008).
A recent study shows that commitment, support, and governance and leadership are associated with better quality in
hospitals that undergo accreditation (El-Jardali, Jamal,
Dimassi, Ammar, & Tchaghchaghian, 2008).
Many hospitals in the region are currently undergoing
Accreditation Canada’s accreditation process. In this context,
it is becoming evident that standards promote the understanding of the role of governance and leadership in hospitals in
addition to promoting accountability. Standards help
to clarify the range of board responsibilities which include
sharing data; ensuring and monitoring the quality of hospital services; monitoring the effectiveness of the hospital’s
manage­ment; analyzing information and the needs of clients
and stakeholders; ensuring the fiscal integrity and longterm future of the hospital; ensuring the flow of information
in and out of the organization; offering opportunities for
stakeholder engagement and interactions with the external
environment; and steering a strategic planning process by defining the purposes, principles, and objectives of the hospital.
27
The standards are
a very important role in
allowing
hospitals
defining “what” needs
to realize that they
to be done in terms of
Governance standards
are not entirely selfquality and safety and
are helping health care
sufficient, and that
are steering manageorganizations move from
they need to engage
ment in terms of “how”
traditional “command
other
stakeholders
to do it.
and health care orgaand control” governance
nizations. Hospitals are
structures towards a new Conclusion
increasingly starting
governance process.
Accreditation is not
to realize that they are
only a tool for improvaffected by the wider
ing quality in organicontext. In short, govzations but it also has
ernance and leadership standards are helpthe
potential
to
become
a powerful tool
ing boards and management move from a
for
reforming
health
systems.
The current
“hospital loyalty” mindset to having a
picture
and
outlook
seem
very
promising
community conscience by being socially
when
it
comes
to
the
significant
contriresponsible. There are many instances
bution
of
Accreditation
Canada
at the
where hospital boards are promoting
international
level.
There
is
a
need
for
partnerships and engagement in order to
empirical
research
to
evaluate
the
impact
garner informed input from communities
of Accreditation Canada’s involvement
and not only stakeholders.
in Middle Eastern countries. With more
organizations in the region planning to
Governance and leadership standards are
undergo accreditation, one can expect
promoting health system planning, fosterthat health care systems will start to
ing service integration and coordination
have a clear direction and achieve better
among different components of health
outcomes.
care (e.g. primary care, tertiary care,
long term care), and putting emphasis
on population health and wellness and
greater accountability. All of these can
help promote health system reform in
the long term.
Through its accreditation program
based on the assessment of practice with
an emphasis on clinical performance,
measurement, and reporting, Accreditation Canada is playing an important
role in broadening the base of hospital
governance. Governance standards are
improving accountability, creating a
culture of reporting and transparency,
driving quality improvement practices, and
reforming health systems in the region.
Boards in accredited institutions in the
Middle East are now more involved in
quality assessment and patient safety issues. While the current reality is far from
ideal in terms of accountability and reporting to citizens about health status,
needs, and outcomes, it is clear the
accreditation standards are compelling organizations to assume more responsibility
and vigilance. Hospital boards are playing
28
As the demands of health reform for accountability for costs and quality as well as
for actionable information become more
widespread, accreditation could assume a
pivotal role in ensuring that such data are
regularly collected, analyzed, and used for
decision making. With the expansion of
the scope of governance, measurement,
and reporting in Accreditation Canada’s
new Qmentum program, the discussion
about accreditation as a tool to promote
health systems reform at the international
level will become more prevalent.
Fadi El-Jardali, MPH, PhD, is an Assistant Professor and Chairman at the Department of Health Management and Policy
at the American University of Beirut. He
also works with Accreditation Canada as
an International Accreditation Consultant
for the Middle East and North Africa region.
He has worked with the Ontario Ministry
of Health and Long-Term Care, Health
Canada, and the Health Council of Canada.
He was an Executive Hospital Director and
has also served on many national and international advisory and steering committees.
References
Duca, D.J. (1996). Models of governance and leadership. In Nonprofit
boards: Roles, responsibilities, and
performance (pp. 3-16). New York:
John Wiley & Sons.
El-Jardali F. (2007). Hospital
accreditation policy in Lebanon: Its
potential for quality improvement.
Lebanese Medical Journal, 55, 39-45.
El-Jardali, F., Jamal, D., Dimassi, H.,
Ammar, W., & Tchaghchaghian,
V. (2008). The impact of hospital
accreditation on quality of care:
Perception of Lebanese nurses.
International Journal for Quality in
Health Care, 20(5), 363-371.
Fennell, M.L., & Alexander, J.A.
(1989). Governing boards
and profound organizational change
in hospitals. Medical Care Research
and Review, 46 (2), 157-187.
Kaissi, A., & Begun, J.W. (2008).
Strategic planning processes and
hospital financial performance.
Journal of Healthcare Management,
53(3), 197-209.
Mintzberg, H. (1997). Toward
healthier hospitals. Health Care
Management Review, 22(4), 9-18.
Stolzenberg, E.A. (2000).
Governance change for public
hospitals. Journal of Healthcare
Management, 45(5), 347-350.
World Health Organization (2003).
Quality and accreditation in health
care services: A global review.
Retrieved from http://whqlibdoc.
who.int/hq/2003/WHO_EIP_
OSD_2003.1.pdf
29
Maureen A. Quigley
Graham W.S. Scott
Hospital Governance in Ontario:
The Challenge of Change
Hospital governance in Ontario is currently
undergoing significant change arising from
several factors: the increased focus on good
governance practices in both the public and
not-for-profit sectors, new realities in the
legislative environment, and new expectations for board oversight and public reporting related to quality of patient care and
patient safety. Based on our experience in
both voluntary hospital-initiated governance
renewal processes and those which have
been directed as a result of government
“supervision” or investigation, we believe
that this is an unprecedented time of
challenge and change for hospital boards
in Ontario.
The Evolution of Hospital Governance
The expectations of governance in the Ontario hospital
sector have changed profoundly since Medicare was
established in 1970. In the first two decades of Medicare,
boards functioned primarily as community fundraisers and
advocates for government funding. Directors were selected for
community stature, philanthropic contributions, and connections with government and the business community. Directors
saw their primary responsibility as “lending their name” and
providing financial support. Hospital administrators, as they
were then called, dominated hospital strategy, with the boards
taking little interest in the business, strategic direction, or
decision-making of the organization.
In 1992, the Ontario Minister of Health commissioned a
review of the Public Hospitals Act, which was first proclaimed
in 1931, to address the “vastly changed nature of health care
and of the hospital, the increasing complexity of hospital management and operations, and the movement toward
Portions of this article are reprinted with permission from the April 2006 edition of Director, published by the Institute of Corporate Directors (www.icd.ca).
30
a more accountable and better managed
These pressures have resulted in numerous
provincial health care system”. The review
operational reviews ordered by governcalled for “all hospital boards and other
ment or more recently by Local Health
stakeholders [to] have a common unIntegration Networks, the appointment of
The Ontario hospital
derstanding of what is meant by hospital
an unprecedented number of hospital susector has been
governance and of the distinction between
pervisors, and formal voluntary governance
confronted with
governance and management...and for a
reviews in a number of hospitals. While in
clear definition of hospital accountability to
several instances significant weaknesses in
significant governance
its patients, the public, and the government”
hospital governance and accountability
challenges over the
(Steering Committee, Public Hospitals Act
have been exposed, on a more positive
past decade.
Review). Regrettably, the recommendations
note, it has precipitated an increased focus
of the Public Hospitals Act Review were
on governance best practices throughout
for the most part not implemented. At the
the Ontario hospital sector.
same time, the concept of “governance” as a
learned art or skill began to develop currency in the hospital
Spotlight on Good Governance Practices
and broader not-for-profit sector through the work of governance theorists such as John Carver (1990).
In 2004, the Ontario Hospital Association (OHA) identified governance renewal as one of its strategic priorities and
In the private sector, there was a similar awakening to the
jointly commissioned with the Ministry of Health and Longconcept of governance as a defined function of the board of
Term Care (MOHLTC) a report on hospital governance and
directors. This function required the fulfillment of specific
accountability (Quigley & Scott). In late 2004, the OHA
roles and responsibilities and associated skills and competenestablished the Governance Leadership Council, a bluecies. The 1994 Toronto Stock Exchange report Where Were
ribbon panel of predominantly private sector leaders in corpothe Directors? was the seminal work which triggered a
rate governance, to advise on the application of governance
series of corporate governance guidelines issued by regulabest practices in the hospital sector. Under the auspices of the
tory bodies and corporate governance watchdogs in the deGovernance Leadership Council, the OHA released its Guide
cade that followed. These corporate governance guidelines
to Good Governance in October 2005, which provides sample
led to a renewed focus on governance in the not-for-profit
tools and templates to be used by hospital boards in reviewing
sector, which generated reports including Building on Strength:
their governance policies and practices. With the guidance of
Improving Governance and Accountability in Canada’s Voluntary
the Governance Leadership Council, the OHA also launched
Sector (Broadbent Panel, 1999) and Reaching For Excellence:
the Governance Centre of Excellence which now provides
Governance and Performance Reporting at The Princess Margaret
extensive continuing education to hospital and other health
Hospital Foundation (PMHF & CCAF-FCVI Inc., 2001).
sector directors and trustees.
A catalyst for governance renewal in the Ontario hospital sector was the amalgamation directions issued to many hospitals
across the province from 1996 to 2000. The new boards of
the amalgamated hospitals quickly learned that they had to
focus on reform of their governance structures and processes
and develop new governance policy frameworks in order to
effectively govern these complex, newly merged multi-site
organizations.
While most amalgamated hospitals engaged in governance
renewal in the late 1990s, the majority of other hospitals had
little or no incentive to update their governance policies or
practices. Consequently, the Ontario hospital sector has been
confronted with significant governance challenges over the
past decade. These challenges are a consequence of an outdated Public Hospitals Act, new accountability requirements,
a subsequent shift in governance and accountability relationships from the Ministry of Health and Long-Term Care to
Local Health Integration Networks, and significant financial
challenges in the face of increasing public expectations and
demands for service.
Concurrent with these provincial initiatives on governance
best practice, Accreditation Canada (then known as the
Canadian Council on Health Services Accreditation) began
developing a new accreditation program for health sector organizations. The Qmentum program includes new standards for governance and a governance functioning tool
to assist boards in addressing “growing demand for excellence in governance practice” and “the increasing need
for public accountability” (2008). The standards and
governance functioning tool, which were implemented
in 2008, further raised the bar in governance practices
throughout the Canadian health sector.
The New Legislated Realities for Hospital
Boards
The bar has been raised even higher for health governance
in Ontario as a result of two pieces of legislation that have
profoundly altered the accountability requirements in both
the hospital and the broader health sector. Bill 8, the
31
Commitment to the Future of Medicare Act,
and Bill 36, the Local Health System Integration Act, have imposed unprecedented
new accountability obligations on the
boards of directors of Ontario’s hospitals
and other health service providers. As a
result of this legislation, hospital boards
have been challenged to meet new standards of governance and demonstrate
greater accountability to the public for
quality of care and to taxpayers, government, and private donors for strong financial stewardship. Specifically, the board is
now required by law to enter into a signed
hospital services accountability agreement with the Local Health Integration
Network and to establish a performance
agreement with the CEO which is aligned
with the hospital services accountability
agreement. There are legislated penalties for non-compliance, including fines
imposed on the CEO, which became
applicable in 2007 but have not yet been
implemented. Across the hospital sector,
this legislation has already triggered much
greater attention towards rigorous performance measures and regular performance
monitoring by the board against the
accountability agreement. The legislation has also created some concern about
board and individual director liability in
the event of non-compliance.
The Board Role in Quality
and Patient Safety
Increased attention to performance
moni­toring at the governance level has
also been accelerated by the annual Hospital Report, a joint initiative of OHA and
MOHLTC. The Hospital Report compares
clinical performance across hospitals
through the availability of increasingly
sophisticated and comprehensive performance data from the Canadian Institute for Health Information and other
sources. This ability to compare hospital
performance on a broad basis is placing
considerable new pressure on boards to
defend their performance. For example, as
a condition of funding, individual hospitals in Ontario must now report publicly
on wait times for designated procedures,
resulting in the ability to compare performance across hospitals. New regulations
were recently introduced requiring public
32
reporting on hospital-acquired infections
effective September 2008. The combination of these developments has resulted in
an unprecedented expectation for board
oversight of hospital performance. As a
consequence, directors are not only being
held accountable for their performance
but are giving much greater attention to
enterprise risk management, including
reputational risk arising from suboptimal
performance.
These new requirements for board oversight of quality and patient safety have
also challenged directors to satisfy themselves with the quality and reliability of
performance information and to engage
in more rigorous questioning of management and clinical leadership, while at
the same time respecting the separation
between the board’s governance responsibilities and management’s operational
responsibilities.
In conclusion, Ontario hospitals have
been significantly challenged by fundamental changes in the expectations of
governance. Yet while there are substantial hurdles that many boards and indeed
CEOs are struggling with as they address
the new expectations, there are also
strong signs of significant commitment to
improvements in governance.
Maureen A. Quigley, BA, MSc, Health
Strategies Facilitator and Advisor, Maureen
Quigley and Associates Inc., has extensive
experience working as a facilitator and advisor
on health governance and policy matters with
health sector organizations in Ontario including hospitals, community care access centres,
Local Health Integration Networks, and the
Ministry of Health and Long-Term Care.
Graham W.S. Scott, C.M., QC, is President
of Graham Scott Strategies Inc. and Counsel
to McMillan LLP. He is a consultant in health
care and has worked in association with
Maureen Quigley of Maureen Quigley and
Associates Inc. on major health projects. He
is Chair of the Canadian Institute for Health
Information and AllerGen NCE and serves on
other health care based boards. He is currently
Supervisor of Kingston General Hospital.
References
Accreditation Canada. (2008).
Sustainable governance standards.
Qmentum program 2009 (ver. 2).
Ottawa, ON: Author.
Carver, J. (1990). Boards that make
a difference: A new design for leadership
in nonprofit and public organizations.
San Francisco: Jossey Bass.
Commitment to the Future of Medicare Act
(Bill 8). (2004). Retrieved September 23,
2008, from Service Ontario’s e-Laws
website: http://www.e-laws.gov.
on.ca/html/statutes/english/elaws_
statutes_04c05_e.htm#BK0
Local Health System Integration Act
(Bill 36). (2006). Retrieved September 23,
2008, from Service Ontario’s e-Laws
website: http://www.e-laws.gov.
on.ca/html/statutes/english/elaws_
statutes_06l04_e.htm
Governance Leadership Council. (2005).
Guide to good governance. Toronto,
ON: Ontario Hospital Association.
Panel on Accountability and Governance
in the Voluntary Sector (Broadbent
Panel). (1999). Building on strength:
Improving governance and accountability in
Canada’s voluntary sector. Ottawa, ON:
Voluntary Sector Roundtable.
Princess Margaret Hospital Foundation
(PMHF), & CCAF-FCVI Inc. (2001).
Reaching for excellence: Governance and
performance reporting at The Princess
Margaret Hospital Foundation. Ottawa,
ON: Authors.
Quigley, M. A., & Scott, G. W. S. (2004).
Hospital governance and accountability
in Ontario: A report for the Ontario
Hospital Association. Toronto, ON:
Ontario Hospital Association.
Steering Committee, Public Hospitals
Act Review. (1992). Into the 21st
century: Ontario public hospitals (ES 1-3).
Toronto, ON: Queen’s Printer.
Toronto Stock Exchange, Committee
on Corporate Governance in Canada.
(1994). Where were the directors?
Guidelines for improved corporate governance in Canada. Toronto, ON: Author.
Brian Schmidt
The Qmentum Approach to Health Care
Governance: The Changing and Diverse Landscape
of Health Care Governance in Canada
The recent introduction of Accreditation
Canada’s Qmentum program is bringing
new knowledge and innovation to our
national health services accreditation
program. These innovations are supporting the development of a culture of caring,
patient safety, and quality patient care
through the work of individual health
care organizations.
T
his spirit of knowledge and innovation has also been
brought to the important work of health care
governance, which oversees and strategically supports,
guides, and enables high quality patient care while
reflecting the values of the communities served.
The mechanisms for the assessment and review of governing bodies within health care accreditation have undergone
significant change over the last twenty years. The ClientCentred Accreditation Program (CCAP) of the mid-1990s
featured a separate set of accreditation standards for governing
bodies. With the Achieving Improved Measurement (AIM)
program in 2001, health care governance and leadership
standards were integrated to reflect both the unique and related responsibilities of governance and management. This
integration had many positive features as well as challenges in
fully engaging the governing bodies in governance-related
standards compliance work. Written responses to the governance-related standards were sometimes drafted by a member
of the management team.
Over the period of time the AIM accreditation standards were
in place, the structure of the health care system in Canada
continued to change, but even more radically than before.
Substantial increases in the cost of delivering health services
brought a new level of scrutiny to the health care systems in
every province. Concerns over quality and risk management
heightened. As a result, governments’ expectations of governing bodies changed, where accountability for both effective
management of resources and patient care outcomes were put
on the same high plane.
Changes were often radical, with regionalization or further
aggregation of smaller regions over historical boundaries.
We now see the extreme of one or two health authorities per
province, and other provinces considering further aggregation
over very large regional boundaries. Some health care organizations in Canada now live in the world of nine- and
ten-figure budgets, with nearly 25,000 staff (Fraser Health,
2008; Vancouver Coastal Health, 2008).
33
Ensuring that the patient is first will always be the focus of
health care governance. It is, however, a more complex business. Mergers, outsourcing, complex financing and contract
management, patient care and enterprise risk management,
and human resource management are common features of
board of directors’ meetings.
Our health care system has enjoyed the benefits of scores of
capable and committed volunteer governors. This still exists
but in many larger organizations, different skill sets and commitments of time are being expected. An increasing proportion
of governing body membership consists of smaller corporatestyle boards, influenced by government-approved members or
directly appointed members (who may also be remunerated)
with corporate governance experience.
Changes to the Accreditation Process for
Governing Bodies
The Qmentum program has responded to the significant
variations, expectations, and complexity of governance
processes in all sectors of the health care system, both small
and large. Previously combined standards for governance
and management (Leadership and Partnerships) have been
separated, while maintaining coherence between the two.
The development of the Qmentum governance standards was
initiated through a rigorous conceptual, theoretical, and best
practice analysis of governance in health care organizations,
led by Dr. Jean-Louis Denis and his team at the University of
Montreal. Denis and his colleagues (2005) created a framework for the analysis of governance practices in health care
organizations. They identified a number of models that each
play a part in supporting the complexity of governance in
the health care system. A synthesis of the strengths and
weaknesses of these models gave rise to the development of a
governance framework based on a set of five core functions:
n
34
the acquisition, production, and assessment of knowledge that is appropriate to support the design and
implementation of broad and long-term goals, and to
guide organizational adaptation
n
the creation of long-term goals for the organization,
as well as a vision and values that guide its own governance and the actions of the organization
n
a set of processes to ensure the board’s internal development, the development of the organization, and
the provision of sufficient resources in order to support
the achievement of the vision
n
the identification and support of a range of relationships
with external and internal stakeholders, including the
chief executive officer, in order to contribute effectively
to the achievement of long-term organizational goals
n
the elaboration of appropriate processes to control and
monitor the performance of management and the organization in order to contribute to organizational adaptation
and the cohesiveness of organizational culture
Following this initial work, Denis and his team (2006) created
a set of specific standards for each of the five core functions, as
well as a general standard to guide the role of the board in the
practice of governance. Importantly, the work also involved
creating understanding of how various governance models
and philosophies can influence the development of each of
the core functions.
As discussed previously, many governments have created organizational models and governance frameworks that differ
widely and continue to change. Whether these models focus
on concentrated authority, stakeholder integration and
involvement, or distributed and shared responsibility, the new
Qmentum governance standards have been designed to
accommodate this changing landscape. The standards are not
prescriptive of any specific model of governance.
A recent article in Canadian Healthcare Manager describes the
difficulty in achieving organizational stability due to the
almost predictable rate of health care restructuring in
Canada. Hylton (2008) comments on the belief of knowledgeable observers that major restructuring can be followed by
at least five to ten years of instability while new organizations
are put in place and new roles and decision-making processes
are defined. The construct of the new Qmentum standards are
an important support for governing bodies and senior management in navigating their way through these transitions.
The Application of the
Qmentum Governance
Standards in Health Care
Organizations
Arising from the five core functions, the
broad subsections within the governance
standards relate to
Ensuring that the patient
is first will always be
the focus of health care
governance.
1. developing a clear direction
2. building knowledge through information
3. supporting the organization to achieve its mandate
4. maintaining positive relationships with stakeholders
5. being accountable and achieving sustainable results
6. functioning as an effective governing body
The subsections contain standards reflecting these governance
roles and responsibilities.
Each member of the governing body completes a selfassessment by addressing questions relating to the first five
subsections. In each case, they evaluate the level of compliance they believe the governing body has achieved in each
area. The collated results of the comple­
ted surveys lead to board discussion that
will support the board’s work in evaluating
its effectiveness as a whole, identifying
strengths, and creating plans for improvement. Many boards may continue to
supplement this evaluation work with independent board self-evaluation exercises
which delve into board operations and
governance in more detail.
Another feature of Qmentum is the governance functioning tool which is designed
to address the sixth subsection. The questionnaire evaluates
the effectiveness of the organization’s governance structure
and the efficiency of its governance processes. Questions
on membership, training, decision-making processes, and
performance are completed individually by board members.
The governance functioning tool applies to most organizations, with the exception of small, private organizations that
do not have boards. Organizations submit this governance
data to Accreditation Canada once during the three-year
accreditation cycle.
While the standards review and governance functioning tool
completion is only required once in the accreditation cycle,
boards may find it useful to complete the governance functioning tool annually or at an additional time of their choosing.
Periodic review of the standards is also a beneficial activity.
Support for Boards of Directors of Health
Care Organizations
Evaluation of a board’s compliance with the standards in areas
such as strategic planning and direction, mission development,
external communication, and board membership needs to be
placed into the context of its specific role and responsibilities
articulated by its federal, provincial, or territorial government;
denominational; or private sector interest. Many boards may
also have contractual relationships with other boards that will
adjust the context of the board’s self-evaluation. There is no
“right way” in the accreditation program for how the organization is to be governed and operated — only compliance with
standards.
The Qmentum standards for health care organizations and
the governance functioning tool are intended to strengthen
governance practices, as well as provide mechanisms for identifying continuous improvement of governance processes. Some
provinces also provide their own best practice guidelines and
expect the boards of public bodies, including health authorities, to provide evidence of compliance with the guidelines.
In British Columbia, the Board Resourcing and Development
Office (2005) of the provincial government administers the
guidelines (which are largely complementary to Accreditation
Canada standards) and reporting on compliance. They also
offer useful references on broader aspects of governance functioning.
Board members will also be interested in the inclusion of new
standards related to the development of an ethics framework
to guide ethical behaviour, and new standards on patient safety culture.
In addition to the board working with their new standards,
surveyors will want to examine the board’s knowledge, strategic involvement, and how it oversees the implementation
of the Required Organizational Practices, a key component
of the organization’s quality and risk management program.
Board members will be engaged in some of the discussions as
particular tracers are followed at the time of the on-site
survey. (A tracer is the method used by surveyors during an
on-site survey to evaluate administrative and clinical processes.) Early feedback is positive from boards that have been
part of a Qmentum survey process.
36
Other provincial and national organizations provide excellent
support in the area of board continuing education and director
development. The Ontario Hospital Association (OHA) is
perhaps unique among non-profit organizations in the extent
they provide support and services to health sector boards of
directors. Along with their annual Health Care Governance
Forum, OHA’s Governance Centre of Excellence provides an
ongoing array of best practice continuing education programs
and certifications. The Institute of Public Administration
of Canada also offers programs. In their Healthcare Leaders’
Dialogue on Governance Renewal in January 2008, presenters
tackled some of the current issues relating to transition and
restructuring in the health care system. The Institute of
Corporate Directors also provides support to increasing
numbers of governors from the health care sector.
Accreditation Canada
care system, whether
and the newly crea­
public or privately
ted Community for
owned. The analysis
There is no “right way”
Excellence in Health
and interpretation of
in the accreditation
Governance (CEHG)
standards relative to
program for how the
have recently joined
the diversity of health
organization is to be
together to create the
care governance is key.
Health Governance
Accreditation Canada
governed and operated
Panel (HGP). The
is supporting the de— only compliance with
panel is composed of a
velopment of surveyors
standards.
group of board memand boards in achieving
bers, executives, and
excellence in gover­
thought leaders who
nance across Canada.
bring experience and
Ongoing evaluation of
insight into the process of governance.
the application of the governance stanThe HGP’s draft terms of reference (2008)
dards is occurring.
includes activity in the areas of
Speaking as a member of Accreditation
n Identifying leading practices based on
Canada’s Accreditation Program Advicriteria established by Accreditation
sory Committee, the Qmentum program
Canada.
has exceeded my expectations. The new
program not only reflects best practices,
n Strengthening the quality and conbut is delivered as a continuous cycle
tent of the CEHG website at www.
in a quality improvement program-like
myhealthboard.ca to provide reformat. For governing bodies interested
sources and organizational support for
in value for money and results, accreditaboard development and organization.
tion will no longer be seen as an add-on,
n Developing strategies to support
but as a complementary and important
board development, particularly
component of the quality improvement
in areas where governing bodies in
culture that health organizations are cregeneral may be experiencing chalating. Boards will also have support from
lenges with certain accreditation
peers across the country. Speaking as a
standards. Strategies will include
surveyor, discussions with the governing
supporting the focused ongoing edubody will be more relevant and focused
cation of surveyors, and identifying
on their critical role, while still respecting
emerging issues in the health care
their important partnership with managesystem that may have an impact on
ment. And finally, speaking as a user of
the interpretation or application of
the Qmentum program, Qmentum will
the governance standards.
provide more direct and relevant involvement of directors, and an overall higher
level of satisfaction with the accreditation
The CEHG has also recently created an
experience.
affiliation agreement with the Institute of
Corporate Directors.
Brian Schmidt, OD, MSc, FCCHSE,
Accreditation Canada is committed to
is the Senior Vice President, Provincial Serensuring and supporting good governance
vices, Population and Public Health at the
in health care organizations as an underProvincial Health Services Authority of BC.
pinning of organizational performance.
He is an Accreditation Canada Surveyor,
Through the new Qmentum accreditation standards and the governance funcmember of the Accreditation Program Advitioning tool, governing bodies will have
sory Committee, and member of the Health
the opportunity to evaluate their funcGovernance Panel. Brian is a Clinical Assotioning against best practices, celebrate
ciate Professor in the Department of Health
their leading practices, and work together
Care and Epidemiology at the University of
on opportunities for improvement. The
British Columbia and current Chair of the
standards accommodate large and small
organizations in all sectors of the health
Health Care Leaders Association of BC.
References
Accreditation Canada. (2008)
Draft terms of reference for the health
governance panel. Unpublished.
Board Resourcing and Development Office. (2005). Governance
and disclosure guidelines for governing
boards of British Columbia public
sector organizations (“Best practice
guidelines”). Retrieved from the
Government of British Columbia’s
Ministry of Labour and Citizens’
Services website: http://www.lcs.gov.
bc.ca/brdo/governance/corporateguidelines.pdf
Denis, J.-L., Champagne, F., Pomey,
M.-P., Préval, J., & Tré, G. (2005).
Toward a framework for the analysis of
governance in health care organizations
and systems. Montreal, QC:
Canadian Council on Health
Services Accreditation.
Denis, J.-L., Pomey, M.-P.,
Champagne, F., & Tré, G. (2006).
The functions of governance in health
care organizations: Definition, process
and standards. Montreal, QC:
Canadian Council on Health
Services Accreditation.
Fraser Health. (2008). About us.
Retrieved October 14, 2008, from
http://www.fraserhealth.ca/
AboutUs/Pages/default.aspx
Hylton, J. H. (2008, March).
Applause, please! Canadian
Healthcare Manager. 22.
Vancouver Coastal Health. (2008).
About us: VCH by the numbers.
Retrieved October 14, 2008, from
http://www.vch.ca/about/numbers.
htm
37
Maura Davies
Leading for Quality
How do we achieve excellence in
health care? How do we create high
performance health systems? What does
it take, as leaders, to inspire and enable
our staff to do their best for the patients
and communities we serve? This is the
challenge for health system leaders.
38
I
n the not too distant past, the role of a CEO was viewed
by many as ensuring a balanced budget, maintaining
public confidence, and promoting positive relationships
with key stakeholders, including the board, government,
medical staff, and major donors. Responsibility for ensuring
quality of care was often viewed as the purview of the
medical staff, independent contractors who reported directly
to the board on quality of care issues through the Medical
Advisory Committee. Although senior leaders focused on
operational issues, little if any time was spent monitoring
organizational performance other than financial statements.
the point of care for patients and clients, by paying attention
to these environmental factors, leaders do their part in
ensuring quality, now and in the future.
One of the most challenging roles of the CEO and other
senior leaders is influencing the culture of our organization.
Organizational cultures tend to be well embedded and
not easily changed. Although most health organizations
proudly post their core values on letterhead, websites, and
signs throughout their facilities, these words may or may
not actually represent the real values and related beha­
viours within the organization. In my health region, we have
Thankfully, times have changed. As President and CEO of
recently launched a renewal of our core values through a caman integrated health system employing approximately 12,000
paign called “Our Values in Action”. With the help of many
staff, I am personally responsible for ensuring that systems and
staff and patients, we have developed written material and a
processes are in place to ensure the quality and safety of our
wonderful video (created by one of our talented People Stra­
care. Our strategic plan includes specific goals and objectives
tegies staff) that translate our values of Respect, Compassion,
related to quality and safety. Our senior team and board
Excellence, Collaboration, and Stewardship into a code of
regularly review a dashboard of quality indicators that
conduct. We are inviting all our staff, physicians, and volunmeasure and monitor our performance relateers to renew their commitment to these
tive to established targets or standards.
values and the behaviours they represent.
The preliminary response to “Our Values
Investments in
What is the role of senior leaders in relation
in Action” has been astonishing, as people
learning for our staff and embrace the opportunity to help us transto quality? Can we really influence the quali­
ty and safety of services provided by others?
form our organizational culture and our
other investments to
Should we be held accountable for things
care and work environments. That culture
create healthy, joyful
we cannot control? Accreditation Canada’s
includes a commitment by every one of us
workplaces are essential
new Qmentum standards for an Effective
to do our very best.
to help us recruit and
Organization provide direction regarding the role of senior leaders in achieving
The third subsection of the Qmentum
retain highly skilled and
excellence. Notably, Qmentum includes a
standards for an Effective Organization
motivated staff.
separate set of governance standards, which
relates to the role of leaders in the allocahelp differentiate the role of the governing
tion of resources. Health system leaders
body relative to management.
make very difficult decisions about
allocating resources that are often insufficient to meet the
As senior leaders, a large part of our role is monitoring and
needs and expectations of those we serve. These decisioninterpreting the internal and external environment. This
making processes need to be fair and transparent. As part
means maintaining perspective of the big picture and seeing
of our commitment to quality, we also need to demonstrate
how changes in the political, economic, technological, or
that we are efficiently and effectively using the resources we
social environment may affect our communities and our
have. With health care costs now comprising more than 45%
organization. For example, how do public expectations of
of some provincial budgets, governments and taxpayers are
better access and customer service influence how we organize
quite appropriately asking tough questions about the value for
and deliver services? How do changes in government policy
money invested in health care. We know that there are many
direction affect us? How do provincial, national, and internainefficiencies in our health systems, and increasingly we are
tional economies affect our costs and funding?
turning to lean design and quality improvement methods from
other industries to help us enhance quality while reducing the
In the longer term, what trends are emerging that we need to
cost of care.
be aware of and proactively address? For example, how will
changing demographics affect the need for long term care,
A large part of the role of leaders is enabling and supporting
home care, and chronic disease management? What oppordirect caregivers to provide excellent care. Positive outcomes
tunities are provided by having a more computer savvy popuare not achieved in isolation from the human resource
lation in terms of innovative approaches to communications
management, information systems, and physical infrastrucand service delivery? How will we meet the needs of an aging
ture required to support that care. In our efforts to manage
workforce? Do we truly understand the health status of our
health care costs, many organizations, including my own,
community, including the health disparities between neighhave underinvested in the support systems that
bourhoods, and how can we and our community partners close
enable better quality care. We know that electronic health
those gaps? Although these issues may seem far removed from
records and other information systems will enhance the safety,
39
We are not alone. Health
system leaders across
Canada and the world
are constantly striving to
do their part to provide
the inspirational leadership
that will help create high
performance organizations.
coordination, and efficiency of our care.
We know that investments in learning for
our staff and other investments to create
healthy, joyful workplaces are essential to
help us recruit and retain highly skilled
and motivated staff. We know that many
of our aging buildings pose tremendous infection control risks and are not conducive
to the patient and family-centred care environments. Our role as leaders is to work
hard to provide the infrastructure needed
to achieve positive patient outcomes.
The expectations of leaders in relation
to organizational excellence continue to
evolve. At times they can seem quite overwhelming. From
time to time, when things go wrong, you may question your
effectiveness as a leader. I know I do. But then I am rejuvenated by wonderful examples of quality in action. Recently, I
was inspired by staff who took it upon themselves to arrange
telehealth to connect one of our very ill patients with her
daughter’s wedding. I was impressed by a report from a clinical
leader who responded to my request to examine high readmission rates for a specific surgical procedure by providing a
detailed analysis of the cases and the changes he and his
colleagues are making to improve the quality of their care. I
was heartened by the team who have recruited and supported
more than 100 new nurses from the Philippines who are joining our care teams across the region, bringing with them a
youthful joy that is contagious. I am encouraged by the gains
made by our cardiac care team who has achieved amazing
results in implementing “Perfect Care” for their patients.
We are not alone. Health system leaders across Canada and
the world are constantly striving to do their part to provide
the inspirational leadership that will help create high performance organizations. We often learn from one another. Recently, more than 200 colleagues from across Saskatchewan
and I met with leaders from Jönköping County in Sweden,
who shared with us their success in creating one of the leading health systems in the world. Through an ambitious and
40
exciting initiative, Quality as a Business Strategy (QBS),
funded by our Ministry of Health and led by our provincial
Health Quality Council, these Swedish leaders and other
amazing, generous international leaders will work with us to
ensure our organizational plans, processes, leadership development, quality improvement systems, and quality measures
are aligned to achieve high performance. My region’s QBS
leadership team is excited as we embark on our quest to be
the best possible.
Leading for quality is no longer viewed as a minor role for
senior leaders. It is our job. It is why we are here. For me, it
is a personal mission: one that I believe is shared by leaders
across Canada who are committed to making a real difference
in the quality of our care and the performance of our Canadian
health systems.
Maura Davies, BSc, BEd, MHSA, FCCHSE, is the President
and Chief Executive Officer of the Saskatoon Health Region.
Maura has over 35 years experience in health care as a clinical
dietitian, educator, and senior executive. She is a board member
for the Canadian Patient Safety Institute and a surveyor for Accreditation Canada. In 2007, Maura was selected as one of the
Top 10 Women of Influence in Saskatchewan by Saskatchewan
Business Magazine and one of Canada’s Top 100 Most Powerful
Women by the Women’s Executive Network.
Jean-Louis Denis
Marie-Pascale Pomey François Champagne
Ghislaine Tré
Johanne Préval
Accreditation Canada’s New
Governance Framework for Health
Care Organizations and Systems
In 2005, Accreditation Canada invited
a research team from the University
of Montreal to develop a governance
framework and governance standards for
health care organizations. To develop the
governance framework, we conducted a
broad literature review on governance
in the fields of management, public
administration, and the social sciences.
Two types of works were found: scientific literature, which focused on theory,
and normative writings, which provided
practical advice without explicitly
addressing the logical foundations of
the prescriptive systems they propose.
We are grateful to Accreditation Canada for supporting this research and to Jennifer Petrela for her editorial assistance.
41
B
oth the scientific and the normative approaches have
merit. In the best of circumstances, scientific analyses
guide the elaboration of a logical model that supports
good governance. When normative products are based
on sound experiential knowledge, they can become crucial
when translating that model into standards and criteria for the
accreditation of governance practices in real-life settings.
Broadly speaking, governance refers to “the conduct of collective action from a position of authority” (Hatchuel, 2000).
A multi-dimensional concept, governance originated in the
field of corporate management where it has been defined as
the nature of the relationship between the organization and
its owners (Harding & Preker, 2003) or the relationship between shareholders and upper management. Recent studies of
corporate social responsibility have expanded the concept of
governance (Porter & Krammer, 2006). Since the early 1990s,
there has been an increased focus on governance in the public
sector. In this sector, as in the non-profit context, governance
refers to the relationship between an elected or a designated board and the institution’s management. In recent years,
findings on problems with patient safety (Kohn, Corrigan, &
Donaldson, 2000; Baker & Norton, 2002) and quality of care
(IOM, 2001) have stimulated growing interest in improving
governance capacity within health care systems.
The governance framework identifies five core functions of governance:
generating intelligence, formulating
mission and vision, resourcing and
instrumentation, managing relationships, and controlling and monitoring
(see Figure 1). The actualization of each
of these functions varies depending on
which of the following three alternative
governance models are being used: the
agency model, the stakeholder model,
or the stewardship model.
n
42
The stakeholder model sees organizations as voluntary
communities in which all interests must be considered
equally to avoid organizational dysfunction (Collett,
2004; Kuhn & Shriver, 1992), and the board’s main
purpose is to serve as a vehicle for coordinating stakeholders’ interests (Evan & Freeman, 1988). The idea
that the board should involve key stakeholders to support and enrich its policies is based on this model.
n
The stewardship model is based on altruistic assumptions
about individual behaviour and presumes a relatively
consensual view of organizational environment, i.e.
a low level of goal conflict among actors (Davis et
al., 1997; Armstrong, 1997). The stewardship model
recognizes that collectivistic or pro-organizational
behaviours have greater utility for individuals than
self-interested behaviours do. Board and senior leadership develop a cooperative relationship within this
model and pursue the same goals.
Figure 1. The Governance Framework
Improved
Adaptation
Governance
Functions
Generating
intelligence
n
Formulating
mission and vision
n
Resourcing and
instrumentation
n
Managing
relationships
Reactivity to needs
System integration
Innovation and learning
Responsiveness to social
trends and requirements
n Resource acquisition
n Organizational legitimacy
n
n
Controlling and
monitoring
n
The agency model of governance hypothesizes a fundamental conflict between the goals of the board and senior
leadership, and organizational members (Davis, Schoorman,
& Donaldson, 1997). Within this model, the objective is to
ensure that sufficient control is maintained over organi-
Improved
Population
Effectiveness
n
n
n
Strengthened
Culture and Values
n
n
n
Organizational climate
Workplace health
Concern for organizational
fairness
Improved
Stakeholder
Satisfaction
Sustainability
The Governance
Framework
n
Production Process
Governance and management have
complementary roles in organizations.
The main focus of governance is on
adaptation to the external environment. The focus of management is on
operational issues (but not exclusively). It is expected that both governance
and management influence organizational performance.
zational members who are pursuing their own “selfinterest”. The board as the owner of the organization
has a hierarchical relationship with senior leadership
and organizational members.
Strengthened
Institutional
Development
The Five Core Functions
Generating intelligence, the first core function, refers to know­
ledge acquisition, knowledge production, and assessment of
the appropriateness of knowledge. It guides organizational
adaptation and promotes organizational cohesiveness related
to culture and values. Intelligence is a stock of knowledge
constituted to support the design and impleapplication generate trust and cooperation
mentation of broad organizational goals. In
among the social actors concerned.
the agency model, intelligence principally
By providing values and
refers to information that enables the
Managing relationships, the fourth function
information on innovaorganization to exercise control. In the
of governance, refers to the attention paid
tive ways to organize
stakeholder model, intelligence relates to
to critical entities by the governing body
work, governance
information that allows users to create a
to foster a close connection between the
credible and sensitive map of stakeholder
organization and its environment. In the
functions can contribute
positions and expectations (Mitchell, Agle,
agency model, critical relationships are
to strengthening the
& Wood, 1997). In the stewardship model,
as a set of relations between
cohesiveness of organiza- understood
intelligence emphasizes information about
the organization’s principal(s) and its
tional culture and values. agents. Relationship management unfolds
values and expectations used to create
opportunities for learning and to foster
in hierarchical contexts characterized by a
innovation geared towards social responsilack of trust among the parties involved.
bility. All three models hold that generating intelligence plays
In the stakeholder model, managing relationships entails
a critical role in the organization’s ability to construct a
working with a wide set of evolving entities that may express
plausible vision of its future and to evolve towards that vision.
legitimate views on the organization’s future. Strategies to
manage relationships among these entities should be adapted
Formulating mission and vision, the second function of goverto the relative power, legitimacy, and urgency of stakeholder
nance, refers to the development of the organization’s raison
demands (Mitchell et al., 1997). In the stewardship model,
d’être and its prospective long-term vision. To a certain exrelationships are managed according to the principle of inclutent, this function resembles the policy perspective developed
sion, which means maximum integration of entities (individuals,
by Carver (1997). Again, it varies within the frameworks of
groups, and organizations) independent of their power or their
each of the three models of governance. In the agency model,
ability to voice their positions. This view is fundamentally
formulating mission and vision emphasizes short-term goals
different from the stakeholder model, which focuses on well(or at least the interests of the owners of the organization) as a
constituted entities.
core constituent of the organization’s mission and vision. The
stakeholder model posits that a viable mission and vision are
Controlling and monitoring, the last function of governance,
based on a workable compromise between the expectations of a
refers to the organization’s ability to recognize the level at
variety of legitimate stakeholders. And the stewardship model
which its policy goals have been achieved and to adjust its
sees mission and vision in terms of long-term and broadly
operations accordingly. This function is contingent upon the
altruistic ideals, such as the democratization of an organizaother four governance functions. Together, the generation of
tion or system or the survival of institutions that enhance
intelligence, the clarity and credibility of the organization’s
social well-being.
mission and vision, the supply of resources and proper instruments, and their integration into a set of significant relationResourcing and instrumentation, the third function, refers to
ships form the basis for controlling and monitoring activities.
the provision of the means by which the organization and its
This view of controlling and monitoring accords with the
members may achieve the goals (mission, vision) set by the
emphasis placed on accountability by normative works on
governing body. Resourcing emphasizes the need to align the
governance (Carver, 1997; Pointer & Orlikoff, 2002).
supply of resources with the resources needed to achieve broad
policy goals. Instrumentation focuses on the generation of apAgain, the ways in which controlling and monitoring are
propriate policy instruments (e.g. incentives, systems for monibalanced and achieved differ according to the governance
toring and control, contracts [Salamon, 2002]) to support the
model invoked. The agency model focuses on hierarchical
achievement of policy goals. In the agency model, resourcing
control within a system of sanctions and predesigned rewards.
and instrumentation ensure the sufficient transfer of risk from
The stakeholder model monitors key stakeholders’ prefe­rences
principal to agent without compromising policy goals, which
and expectations to maintain organizational legitimacy and
in this case are related to owners’ interests. The stakeholder
ensure that the organization is not confined by a particular
model suggests that resourcing is achieved by strategically coset of demands and interests. And the stewardship model
opting a network of actors and that instrumentation is selected
monitors the organization’s achievements with regard to social
not only for its effectiveness in achieving policy goals but also
trends, expectations, and values. It also pays attention to
for its acceptability to stakeholders. The quest for acceptabi­
control to ensure that collective resources do not deviate from
lity may involve the use of various types of instruments. This
the fundamental purposes for which they were intended.
model also asserts that policy instruments should be designed
and implemented to document stakeholders’ strategic posiThese five functions of governance are interdependent and
tions and legitimacy (Mitchell et al., 1997). The stewardship
co-evolve according to a dynamic of mutual adjustment. The
model, meanwhile, suggests that resourcing and instrumentagovernance framework posits that the actualization of the five
tion are appropriate and effective if their distribution and
core functions influences levels of organizational and systemic
43
adaptation, as well as the cohesiveness of the organization’s
culture and values (Sicotte et al., 1998). Adaptation is defined as responsiveness to needs (e.g. expectations, shifts in
disease patterns), the ability to integrate various organizational
and system components, responsiveness to broad social trends,
achievement of a sufficient level of innovation and learning, acquisition of requisite resources, and maintenance of legitimacy.
Adaptation is a multi-dimensional concept and it stands to reason that a mix of the three governance models increases the odds
that a health care organization or system can adapt successfully.
But the five functions of governance do not only address the
interplay between the organization and its environment. They
also involve the generation of po­licies that guide managerial actions across the organization’s internal boundaries. By providing
values and information on innovative ways to organize work,
governance functions can contribute to strengthening the cohesiveness of organizational culture and values.
Enhanced production processes, better adaptation, and a
strengthened culture will directly and indirectly influence
three broad organizational goals for the performance of
health care organizations and systems: improved population
effectiveness, deeper stakeholder satisfaction, and enhanced
institutional development.
n
Population effectiveness refers to the alignment of
patterns of service delivery with the population’s
evolving expectations and needs. It corresponds to
the organization’s position regarding the market of
care and services and to the viability of that position.
n
Stakeholder satisfaction refers to the perceptions of legitimate stakeholder groups of the organization’s ability to
respond fairly to their preferences and expectations.
n
Institutional development refers to the growth of the
organization’s resource base and its social fabric in order
to maximize cohesiveness and the ability to face ongoing,
evolving challenges.
A high level of achievement of these three goals will increase
the sustainability of health care organizations and systems
because the goals in question focus not only on resources but
also on relational and legitimacy issues that are fundamental
to the evolution of organizations within complex environments, including health care systems.
Links Between the Framework and
Accre­ditation Canada’s Governance
Standards
Accreditation Canada’s Qmentum accreditation program invites
health care organizations to assess their governing body (board
of directors) separately from management. The Qmentum
governance standards are rooted in best practices gleaned from
governance literature, environmental scanning, and feedback
from Accreditation Canada clients and surveyors.
44
To develop the governance standards, the research team first
reviewed the literature and various theoretical frameworks.
Next, focus groups with French and English stakeholders
across Canada were organized by Accreditation Canada.
Participants included board members, governance experts,
representatives of health care associations, and members of
professional groups. They expressed their opinions, not only
on the model but also on the proposed standards, to help
adjust the standards to their own context. After reviewing the
focus group results, Accreditation Canada decided to complement the standards with a governance functioning tool that
addresses board modes of functioning. The standards and the
governance functioning tool were pilot tested in both French
and English institutions to determine their applicability. After
validation, they were incorporated into Qmentum.
Conclusion
Accreditation Canada’s decision to consider governance as distinct from management dovetails with the idea that institutions
are accountable for their actions. Better coordination between
high-level governance and healthy, optimal management will
result in institutions that meet expectations for accountability
within the population and policy makers and will foster the
development of a proactive approach to offer the most relevant
and safest services possible.
Jean-Louis Denis, PhD, is a full Professor with the Department of
Health Administration at the University of Montreal and Director
of the Interdisciplinary Health Research Group (GRIS). He holds
a Canadian Health Services Research Foundation/Canadian
Institutes of Health Research Chair/Professorship on the transformation and governance of health care organizations. He is
currently pursuing research on primary care, the regionalization
and integration of health care, and the role of scientific evidence
in the adoption of clinical and managerial innovations.
Marie-Pascale Pomey, MD, PhD, is a Professor with the Department of Health Administration at the University of Montreal. She
is also a Research Associate with the Interdisciplinary Health
Research Group (GRIS), and Chair of Governance and Transformation of Health Care Organizations at the University of
Montreal and the Ottawa Health Research Institute. She is currently part of a research team, funded by the Canadian Patient
Safety Institute and the Canadian Health Services Research
Foundation, investigating the governing body’s role in increasing quality and safety in health care organizations.
François Champagne, PhD, is a full Professor of health care
management, health policy, and health care evaluation with the
Department of Health Administration at the University of Montreal.
He is also a Researcher with the Interdisciplinary Health Research
Group (GRIS) at the University of Montreal. His current research
interests are in the areas of strategic management, interorganizational
networks, integrated delivery systems, organizational performance,
and the use of evidence in management.
Ghislaine Tré, MD, MHA, is a PhD candidate in public health
specializing in health care management. She is a Research Officer
for the Interdisciplinary Health Research Group (GRIS) at the
University of Montreal. Her fields of interest are patient safety,
management practices, and governance in the health care system.
Johanne Préval, MSc, is a Research Officer for the Interdisciplinary Health Research Group (GRIS) at the University of
Montreal. She has a Master’s Degree in Health Services Administration from the University of Montreal. Her fields of interest are health
care organization performance, quality improvement and patient
safety, governance, and health care systems.
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Sicotte, C., Champagne, F., Contandriopoulos, A.-P., Barnsley, J.,
Béland, F., Leggat, S. G., et al. (1998). A conceptual framework for
the analysis of health care organizations’ performance. Health Service
Management Research, 11, 24–48.
45
Gilles Lanteigne
Executive Vice-President and
Chief Operating Officer
Accreditation Canada
In Closing
Sharing Wisdom
Leadership and governance set a crucial
tone in any environment. In health care
there is pride in innovation, and an
obligation to learn from the experience
of others. As we come to the end of our
Governance and Leadership issue, we
hope that in sharing the knowledge and
wisdom of our contributors, you are able
to apply a theory or practice that will
help you in your own work.
L
ooking ahead, the theme of the next issue of
Qmentum Quarterly is Worklife. It is widely recognized that the health care environment is one of
the most difficult to work in. For this reason, the
concept of quality of worklife is central to Accreditation
Canada’s Qmentum Accreditation Program. Qmentum defines worklife as “supporting wellness in the work environment.” Articles will include a submission from the Qua­
lity Worklife – Quality Healthcare Collaborative, of which
Accreditation Canada is a national partner, as well as an
article from Accreditation Canada on Qmentum’s Worklife
Pulse Tool.
Before then, Accreditation Canada will be holding a web­
inar on January 15, 2009, on improving quality and safety in
health care by changing the work environment of health care
providers. Dr. Graham Lowe, one of Canada’s foremost experts
on worklife, will discuss the results of his research conducted
in Alberta on the role of health care work environments in
shaping a safety culture. A sample of the employers involved
in the research will speak about how they used the evidence to
inform decision making in their organizations and the results
of those actions. Listeners will be able to ask questions and
participate in a discussion on creating and maintaining safety
cultures. For more information on the webinar, please visit
Accreditation Canada’s website at www.accreditation-canada.ca
under Learning and Development.
While on the topic of sharing wisdom, I would also like to tell
you about the new International Society for Quality in Health
Care (ISQua) accreditation/external evaluation research
website that Accreditation Canada is hosting. Given the
increasing amount of accreditation-related research, this website was created as a means for research to be coordinated and
shared more effectively. It is a tool for collaboration and information transfer that will assist in the exchange of research,
understanding, and knowledge of accreditation effectiveness.
I invite you to visit www.isquaresearch.com to help us increase
the value of this site by posting your own research as well as
browsing the research featured.
We would like to thank all those who contributed to this issue.
As always, we welcome your feedback and invite you to share
with us your suggestions or ideas for future themes.
Together we are making great strides!
If you would like to make changes to your subscription information, please contact:
Sylvie Anne Turgeon n Subscriptions and Customer Service - Les éditions du Point
Tel: 514 277-4544, ext. 241 n Toll-free: 1 888 832-3031, ext. 241 n E-mail: [email protected]
46
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