News and views from the President/CEO

Colleagues

I'm continuing my efforts to meet more of you in your own workplace, or at least onsite.  In the last couple of weeks I've visited a number of facilities across the province: Oyen, Brooks, Bassano, Edson, Mayerthorpe, Whitecourt, Slave Lake and High Prairie.  Thanks everyone for making me feel welcome. 

There was probably not a single place I visited where people didn't come forward with suggestions for change and improvement.  You see all around you areas where we are ready for change, but there is a recognition that what needs to be done will take time.  Although this year we have a much better budget outcome than last, we can't do everything in any one year. 

As you know Premier Stelmach has set our objective to be 'the best performing, publicly funded, health care system in Canada'.  We've got a good base, but with still a long way to go.  For example, public funding per age/gender-adjusted population is greater in Alberta than any other province.  Yet our life expectancy is below the Canadian average. 

Last year we articulated our Strategic Direction (remember the wheel?), which outlined 20 strategic priorities and associated targets.  We won't achieve those targets by sitting on our hands: we have to take purposive action to change what we do and how we do it.

Our repositioning to become the best is being managed through five Transformational Improvement Programs (or TIPs as they are becoming known), three of which are about transforming clinical services and two are about building an internal foundation to support a merged AHS.  The TIPs are constantly evolving and we would welcome your ideas about what additional actions ought to be thought about.  Please email your thoughts to TIPs@albertahealthservices.ca.

The three clinical TIPs deal with the critical aspects of the healthcare system: primary care, access and seniors care.

Building a primary care foundation, the first TIP, recognizes the fundamental importance of primary care to the healthcare system.  By definition, primary care should be the gateway, the entry point, the first point of contact.  The whole healthcare edifice depends on a solid primary care foundation. For example, people are admitted to hospital when they can't get primary care in a timely way.  So our ambition here is to improve access to primary care so that every Albertan will have a responsible primary care physician and healthcare team.  We need to develop new approaches to primary care to make this happen.

The second TIP, improving access, reducing wait times, is designed to address the reality that too many people are waiting too long for secondary care.  This year we are placing priority on improving access to emergency departments and undertaking foundational work to improve access to elective care. This work will focus on the entire patient experience: from referral, to treatment, to discharge. It will require us to develop new, integrated service models that are focused on the patient.  Our responses this year (and over the course of the plan), recognize that improving access to secondary care means addressing needs in the primary care or seniors system as well.  We need to focus on the interdependencies in the continuum of care.

Improving choice and quality for seniors is our third TIP.  Alberta is growing and aging. In 20 years time one in five Albertans will be seniors.  Seniors are now waiting too long in hospitals and in the community for access to seniors' accommodation.  In many parts of province seniors have no choice in the type of accommodation that is available in their community: 75% of our seniors beds are in long-term care, suitable and necessary for the most dependent, but not right for everyone.  Over the next decade we aim to add about 900-1,000 new seniors' beds every year, with most of them being supported living.

The two internally focused TIPs relate to enabling our people to achieve excellence in providing health services and enabling one health system.  The former is about providing our staff, physicians and volunteers with the education, information and supportive work environment needed to provide safe, high quality health care to those we serve.  This will include a strong focus on enhancing engagement, devolving decision making, developing a culture based on our organizational values and providing an organization conducive to innovation and the ability to respond flexibility to service needs..  The latter TIP, colloquially called 'the merger TIP', is about getting all the decision and support infrastructure functions right.  It's about one payroll system, one general ledger and so on.  But it goes further than that, for example, looking at the data infrastructure across the province making sure that we describe and count in the same way.  It is about ensuring we as an organization, and every manager, has the basic tools to help us become (collectively and in every constituent part), 'the best performing, publicly funded, health care system in Canada'.

The TIPs are not just a one-week wonder.  They build on the hard work you're already doing and celebrate progress we have already made in many areas. They will guide us over the next five years.  They will inform our priorities for budget allocations.  But each year will have targets to be achieved that year, and each year we will refine the plan in the light of experience.  Again your thoughts and reflections will help us here.

I invite you to join the discussion on Insite. There, you'll find an introductory video and more information about each of the TIPs, including actions we're taking and what we hope to achieve by 2015. You also have the opportunity to comment and have your say.

This plan sets an exciting agenda for us for the next five years.  Albertans will see better health services over that period.  We will see a stronger and healthier organization. I'm looking forward to it, and I trust you will enjoy the journey to get there.

Best wishes,

Stephen

Colleagues,

Workforce engagement

The engagement and satisfaction levels of Alberta Health Services' workforce, including employees, physicians and volunteers, is critical to our success as an organization and our ability to deliver safe and high quality healthcare to Albertans. The recent poor performance on the workplace engagement survey stimulated action by Executive including requirements for senior leaders to develop and implement workplace engagement strategies and the creation of a Workforce Engagement Working Group. That Group has now developed a draft Workforce Engagement Plan, identifying actions to be initiated or implemented over the next 12 months to improve workforce engagement.

These are organizational-wide initiatives, designed to complement initiatives at a local level.

The Plan identifies five broad areas of action:

·  Develop our people
·  Enhance internal communications
·  Encourage local autonomy and ownership of decisions 
·  Enhance workforce recognition 
·  Promote our vision

As part of the consultation on the draft, we'll be holding two chat rooms on August 16th and 18th. Details of how to hook in are available here.

You can also comment in writing by sending your thoughts to ahs.engage@albertahealthservices.ca by August 23, 2010. 

The census

There has been a good deal of public controversy recently about how the next Canadian census is to be conducted. Essentially, the Federal government is proposing to eliminate the mandatory long form questionnaire that a proportion of Canadian households were required to complete and collect these data by implementing a voluntary survey instead.

There are real implications of this proposal for Alberta Health Services. The short census form will continue to collect basic demographic information like number of people in a household and their ages.

The new voluntary long questionnaire will contain questions similar to those in the previous mandatory form but the voluntary nature of the instrument means that detailed information about the population we serve will now be collected only from those who are especially motivated to respond.

What does this mean for us and why am I concerned?

If we are to plan for health services we need good information about both what the population is like now (to respond to current needs) and how the population is likely to evolve over time. We also know that health service use varies by factors such as income, country of birth, employment status, and other social and economic realities. So putting these two issues together, we need to have accurate and longitudinal data about these factors which influence health status and/or health system use. If information on these factors is only collected on a voluntary basis we will suffer from what statisticians call response bias: that some groups may not complete the voluntary survey and, more importantly, we won't know to what extent there is under-reporting in these groups. This will mean that it will hinder our planning efforts and also make it very difficult to track changes in population health status over time.

The Canadian census has included information on these population groups for decades and thus provides a good baseline to track changes and project into the future. The census has provided the denominator in calculating rates for population health tracking.

So you can see there are real implications for us. The census is conducted under strong legislation to protect privacy but when designing data collections (and the census is no exception) one always has to balance intrusion with the need for the relevant data.

A personal issue

In September of last year the Edmonton Journal published an article about me entitled 'Nurses fight with Duckett long term battle'. The article was based on a 'quote' from a nursing academic: 'Stephen Duckett is well known for his time in Australia for being at loggerheads with nursing groups and professional therapists'.

I have a thick skin but this statement particularly annoyed me. It was not true, it was highly damaging to my reputation and it has no foundation in fact. Unlike many of the other criticisms of me or my decisions, which generally are expressed as opinions which are difficult to challenge, this one was phrased as an assertion of fact. I immediately approached the Journal requesting an apology and the immediate (verbal) response was that 'the Journal doesn't apologize'. Since then I have engaged in extensive correspondence with the Journal with the aim of getting an apology or retraction.

Initially the Journal offered to print a response from me. I was loath to pursue this course of action as it had the potential to reignite the story, of benefit to the Journal but not to me. I subsequently submitted a response, substantially the same as this blog post which they refused to publish.

If a newspaper is to make a serious allegation like that made in the article, it should be verified or triangulated.

Contrast the Edmonton Journal story with one about me in a free weekly in Calgary (Fast Forward Weekly). Here the journalist spoke to Heather Smith from the United Nurses of Alberta (UNA).

Ms Smith, to her credit, reported that I had a good reputation with nurses in Australia. The reverse of what the Edmonton Journal reported. Given the gravity of what was being claimed, a mere phone call to UNA may have disproved the claim.

Even the Journal's own records could have been checked. Edmonton Journal journalist Sheila Pratt did a major piece about me some time ago.

She contacted a number of people in Australia as part of that, some of whom were quoted in the paper. If there were any inkling of bad relations and bullying of nurses it is likely that would have been reported to her and probably incorporated in her piece. But nothing is mentioned.

Finally, the academic allegedly quoted (Dr Donna Wilson) denies saying anything of the kind. In a letter to me Dr Wilson said:

I did not make this statement nor did I intend to convey this message. I am not aware of any published evidence that would support the statement. It is my view that during the interview I was perhaps misunderstood and ultimately misquoted. This statement does not reflect my views and I apologize for this misunderstanding. I would ask the Edmonton Journal to provide for this clarification to ensure that my words do not lead to any further misunderstanding.

To my disappointment but consistent with its original position, the Journal refused to publish Dr Wilson's letter.

To be fair to the Journal, it claims that Dr Wilson did indeed make the statements. I have, of course, no way of knowing who is correct here but, to some extent it is irrelevant whether or not Dr Wilson made those statements. My point is, the Journal should have checked claims such as those before publishing them.

The Alberta Press Council has established a Code of Practice, the first two items of which are as follows:

Accuracy

1. It is the duty of the newspapers to avoid publishing inaccurate or misleading statements and further, it is the duty of newspapers to correct promptly, and with due prominence, significant inaccuracies or such misleading statements.

Opportunity to reply

2. It is the duty of newspapers to allow a fair opportunity for reply when reasonably called for.

Individuals and organizations should be given a fair and reasonable opportunity to reply to a personal attack or criticism.

I have endeavored to seek a reasonable response from the Journal consistent with the Code but to no avail. The Press Council has indicated it will not rule on this issue because of the time that has elapsed since the original publication.

The Journal, I think, would see itself as a responsible publisher but in my view the way it has treated me in this matter does not reflect well on it.

Stephen

Colleagues,

My blog last week focused on the 'big picture' changes related to the 2010/2011 budget. Today let's talk about the changes underway on the frontlines of health care - the changes being led by you.

I hesitate to say that the 'winners' of the Action Your Ideas initiative have been selected. On the face of it, Action Your Ideas was about identifying operational efficiencies and cost-savings and so on.  More importantly, it was about creating an opportunity to demonstrate that ideas from all parts of our organization are valued and important. So it was always much more than just a contest.

Six ideas have been identified from more than 700 submissions from staff and physicians. The awards range from $250 to $500 and five of these will be implemented, another is being investigated further for implementation down the road. For more information, please read the Action Your Ideas story on Insite.

Two things struck me.  First, I was encouraged that many of the 700 submissions were already in the works, a good reminder that we often know what needs to be done, and many of the changes that were underway were seen by others as a good thing too.  Many ideas related to initiatives that achieved multiple objectives, such as reducing costs, saving energy and reducing our environmental footprint  - truly thoughtful, far-reaching, 'big picture' thinking.

Secondly, the submissions show real understanding of the complexities of health care and pride in your work.  I enjoyed learning more about how things works 'on the ground' and hearing in your own words a sense of commitment to care.  Ultimately efficiency and cost-saving are freeing resources to improve quality and patient care. After many weeks of focus on the budget, I found this personally very rewarding and inspiring. Thank-you.

Wrapping up Action Your Ideas took longer than expected, in part because we wanted to make sure that we could act on all of the successful submissions. But let's not think of this as the end, but rather the start. As I noted in my last blog, this year's budget is much different than last year's. We made tough decisions and in large part because of the province's five-year funding commitment, we have turned a corner.  Much the same is true of staff engagement. Last year we were necessarily focused on the immediate need to address budget pressures. We are in a much better position now to engage our staff in new and important initiatives rolling out of the Transformational Improvement Programs,  for example.

Last year, we lived up to a commitment to minimize adverse impact on access and quality. We also identified the need to put much greater emphasis on staff engagement - this year we are following through on that commitment as well.

The engagement plans senior leaders were charged with developing following the Workforce Engagement Survey are now being collected. I look forward to reading these and trust (and expect) that they will have a positive impact on your work areas. These plans should reflect your input and leaders' commitment to engagement, and will be part of their performance agreements.

The Workforce Engagement Working Group has been established and includes 12 AHS employees and physicians, who work at all levels and areas in the organization. This group will meet throughout the summer and will recommend to AHS executive an organizational workforce engagement strategy by Sept. 30. This strategy will include at least two major engagement initiatives for 2010/11.

I invite you to view my blog today in video format and I look forward to your comments.  - Stephen

Colleagues,

Earlier today, the Board approved our 2010/11 Budget.  This is a very different budget from last year.  Last year was tough.  We faced tough priority decisions about how we could bring our spending into line with the financial targets set by the province. For 2009/10 I promised that, in addressing our difficult financial situation, we would have two priorities:

1. Minimize adverse impact on access and quality
2. Minimize compulsory lay-offs

That is what I promised to do.  That is what we did.

I'm proud of what we in Alberta Health Services achieved last year.  We all stepped up to the plate.  Managers looked to new strategies that would help us achieve the budget targets.  All staff tightened their belts, covered vacancies, reduced the use of non-essentials, reduced professional development time.  We couldn't have done it without you going that extra mile.  So thank-you.

I know it was hard.  Some might say too hard, with a cost to all of us. But remember, Alberta and Alberta Health Services were facing the worst global economic crisis since the Great Depression.  

In the face of this, we went after efficiencies, we tightened up on recruitment, we deferred some projects.   So how did we fare in 2009/10 compared with the prior year?

First, in terms of services.

On the positive side, in 2009/10 we actually opened beds!  The number of open beds at the end of 2009/10 was about 2 per cent more than at the beginning with the biggest increase occurring in seniors accommodation.

Alberta Health Services Beds by Type 

But not all is positive. The number of acute beds only marginally increased, not enough to keep pace with increasing demand.  The consequence is there for all to see: waiting times for elective procedures are still too long and our emergency departments are overcrowded with too many people waiting too long for care.

What about staffing?  Well you heard rumours that there were going to be thousands of lay-offs, creating anxiety for you about your jobs.  You also read that we had imposed a staffing freeze.  And no matter how many times we said there was no freeze, that we would minimize lay-offs, the rumours persisted.

Well, now we can look at the facts of what happened over 2009/10. 

View larger image

On March 31, 2010, we employed 2 per cent more staff than a year earlier.  Some of that was due to our assuming responsibility for emergency medical services and shows up in the big increase in 'other health professionals', but taking that into account, we probably increased staff in other areas by 1 per cent, in one of the most difficult years in memory in health services delivery.  We went up in staff numbers last year, not down.

There were stories too that Alberta Health Services was becoming a big bureaucracy.  The numbers give the lie to that.  We reduced management and administrative staffing by 5 per cent.  This happened at all levels.  The number of Vice Presidents and above for example, declined from 144 in the 12 predecessor entities to 79 in Alberta Health Services.

We made progress on lots of other fronts too.  Take research for example.  We published a new strategic direction for research.  In that we said we wanted Alberta Health Services to be a research friendly place, to facilitate research.  So in 2009/10 we set the ground work for that.  We are on track so that by the end of this year we will have what I call mutual recognition of research applications.  If someone wants to do research involving both Edmonton and Calgary or rural hospitals, for example, they will no longer have to get two or more separate approvals.  This is a massive change and I'd like to thank all those who have worked to make it possible.  It demonstrates that there are real, tangible benefits for researchers in the creation of Alberta Health Services.

So although it was a tough year we still managed to move our agenda of improving access, quality and sustainability forward.  Not as much as any of us wanted, but so be it. I'd like to thank all of you for your work, your dedication in that difficult environment.

But that was then, this is now.

The 2010/11 budget is very different.  Why?  Because we now have a five-year funding plan announced by the Government earlier this year.  The five-year funding plan pays off our deficit, brings us up to our end-of-year spending level and gives us 6 per cent more in 2010/11.  It gives us 6 per cent more next year and the year after that too.  Then 4.5 per cent for the remaining two years. A seismic shift and it shows that the government has confidence in us.

This increase still requires us to manage and set priorities.  Remember in the past, health costs used to go up by ten per cent a year. But it now sets us achievable budget targets.  And with those budget targets we have service targets.

We've carefully reviewed all our spending patterns and the 2010/11 budget approved by the Board provides a new, solid foundation going forward.

What do I mean by that?

First, every position currently needed to deliver an ongoing clinical program is now fully funded.

Secondly, because we have allocated budgets right down to the Manager level, we can give managers the responsibility and accountability to manage within those budgets and enable them to work within those budgets without facing undue administrative hurdles.  

We have therefore abolished the vacancy management program effective immediately.  This means that a Manager in most cases can now approve replacement of a vacancy in any existing position without further approvals up the line.

Thirdly, we have approved filling of a number of new positions.  The budget provides for about 450 new positions to be filled across the organization.

We will also move on restoring professional development funding and recognizing the tremendous contributions our colleagues have made and are still making.

Moving Forward

But that is all about us, how we work internally.

What does it mean for Albertans, the people we serve?

There are two big things we are doing in this budget.

We are starting on a five-year program to increase dramatically the number of seniors beds in the province - more than 4,000 over the next three years.

2010/11 sees the first installment of this. There will be at least 1,100 more continuing care beds, more than 3,000 over the next three years. In other words, at least 1,000 more beds a year for the next three years.

This represents an increase in capacity of more than 8 per cent, which should facilitate a significant reduction in seniors waiting at home or in a hospital to get access to a seniors place.

The second priority is addressing waits in emergency departments.  The expansion in seniors' beds is critical to this as that will help us address the hospital 'back up' problem: people backed up in hospitals in acute beds when it would be better for them if they were in seniors' accommodation.

The acute beds we free up by reducing those waiting for seniors' beds will become available to people who are backed up in emergency departments waiting for a hospital bed.

In addition, as previously announced we are opening two Medical Assessment Units, one in Calgary and one in Edmonton, to improve flow from emergency departments.

These are our service priorities for 2010/11.

For more details, please view the 2010/11 budget package online.  If you are interested, please join one of the telehealth sessions tomorrow when I will answer your questions about the budget. 

If we fix the problem of people awaiting placement and people waiting in emergency departments in 2010/11 that will be huge.  It will provide real and demonstrable benefits to Albertans. 

And that is what we all want to see.

So although the budget might be seen as being about money and how we spent it, the budget is really about our priorities.  It's about delivering better access and better quality to Albertans.

This is what we are all about. It's why we work in health care, it's what motivates us.

I think 2010/11 is going to be a good year for us and all Albertans.

Thank you. 

Stephen

Colleagues,

Next Tuesday the Board of Directors will review the proposed 2010-2011 budget. This week I'm preparing a 'video blog' so that I can post and share details of the budget with you immediately after it is approved by the Board. The day after, Wednesday June 30th, I invite you to join me at one of the telehealth sessions to talk more about the budget and answer your questions.

This two-way communication is extremely important to me for a few reasons.  It is part of our overall commitment to workforce engagement, letting you know, as soon as we can what we are doing and why. 

The budget approval will also mark another watershed for Alberta Health Services.  Every budget is an exercise in priority setting, but as I've said in the past, we are facing far fewer difficult decisions than contemplated just a few months ago because of the new funding agreement with the province. Today, even as Alberta emerges from a severe global recession, we are proposing to increase significantly investment and growth in many areas.  It has been a couple of years since we were able to say that with real confidence.

Patient Advocacy

I'm an enthusiast for the role of advocacy in improving health care, and was a high profile advocate for a number of health-related causes in Australia. I also chaired the Board of a non-government welfare agency which was at the forefront of advocacy for social justice, working with and for its clients.  The health professions in Australia have a long and distinguished record of advocacy, at all levels. The Royal Australasian College of Surgeons, for example, can claim credit for significant reductions in road trauma through its advocacy, and there has also been much succesful advocacy at local levels, improving pedestraian safety with campaigns for traffic lights for example,  

There is also the difficult issue of internal versus external advocacy.  Internal advocacy is something that many nurses and other health professionals do on a small scale every day for their patients: seeking an urgent consult, arguing for a better piece of equipment. I don't know of a single leader in this organization (or for that matter any organization in which I've worked), who doesn't believe that investing more resources in their area would lead to improved access and/or quality.  And, for the most part they are right.  We face huge demands and resources are limited, forcing priority choices.  Health leaders know this reality, know that they have to think not only of the needs in their area but balance this against the pressures they know their colleagues are facing, and they temper what they say.

There has been some question as to Alberta Health Services' position on advocacy, partly because of infelicitous wording in our original Code of Conduct and partly because we adopted the wording in new contracts for physicians which read as if advocacy was inappropriately constrained.  (As an aside, that wording was imported, without change, from the contact used by one of our predecessor organizations). 

The new Code of Conduct has made our position much clearer and is supported by a new draft communications policy.  I'd like to thank everybody who has taken time to provide feedback on the proposed new  policy. Posted a few weeks ago, it will go to the Board for final approval later this year after the consultation phase winds up this month. The policy and opportunity for feedback is posted at http://insite.albertahealthservices.ca/1635.asp.

A letter, signed by Dr. Christopher Doig, President of the Alberta Medical Association, Dr. Trevor Theman, Registrar of the College and Physicians and Surgeons of Alberta, and me, reinforced our commitment to advocacy and was posted on the AMA website last week. It's brief, so I'll reprint it here in its entirety:

Patient advocacy is one of the most important ways in which health care can be improved.  The Alberta Medical Association (AMA) stands behind any physician who advocates on behalf of his or her patients.  Similarly, the College of Physicians and Surgeons of Alberta (CPSA) and Alberta Health Services (AHS) also strongly support and encourage patient advocacy.

For its part, AHS does not regulate, restrict, or direct the personal views or opinions of individuals, provided they have clearly identified that they are not speaking as representatives of AHS.  AHS asks, however, that comments made on behalf of AHS with respect to policy, planning and related issues be made by the appropriate administrators and officials.  Administrators and other physician leaders have a duty to the organization not to make comments publicly that might be prejudicial to AHS or create a conflict of interest position with AHS.  Administrators are, after all, speaking on behalf of AHS.

Practically speaking, how can this be achieved?  The answer is remarkably simple: By being honest, fair, transparent, accountable and professional (see http://www.cpsa.ab.ca/Libraries/Res_Messenger/M137.pdf).  It is often more effective, and certainly courteous, but not mandatory, to first advocate internally.

Advocacy sometimes leads to negative public reaction.  However, if a physician feels that it is necessary to advance the interests of patients, then he or she should do so and this is consistent with the values and principles of Alberta Health Services, the College of Physicians and Surgeons and the Alberta Medical Association.

Although this letter was addressed to physicians, the same arguments and principles apply to everyone.  I'd be interested in your thoughts on this.

Total Compensation Program

Another major initiative rolling out next week is the Management and Out of Scope Total Compensation Program. Senior leaders started to receive details today, and over the next couple of weeks, your managers will provide the information and have conversations with those of you in this group.  

As you know, this has been a long and extremely complex process, involving market surveys to develop the grids, a review of 8,000 positions, discussions with leaders to allocate positions, develop standard titles and so on. All of this was a necessary first step in harmonizing the very different compensation arrangements of the 12 former health entities.  Often overlooked is the fact that this work is also focused on recognizing the value of the work and contributions of staff.   This process has not been cost neutral, partly because many of you have taken on new and additional responsibilities, but partly reflecting the different starting points in the predecessor entities.

This is a good investment for many reasons. The new salary grids make it possible to map career paths for the future, because greater stability and an ability to plan are as important to you as individuals as they are to us as an organization.  So this is not simply an administrative exercise in corporate organization.  It is long-term commitment to work with you as individuals and support the choice you have made to be and stay with Alberta Health Services.

For that reason the process will not end next week. We expect there will be many questions as the work and the allocations are fine-tuned. Initially, please ask questions of your managers and HR advisors. If you require more information, a dedicated phone line will be in operation starting June 28. The number for this line will be posted on Insite.  In the meantime, a comprehensive list of Frequently Asked Questions has been posted on the Compensation webpage and will be updated as the need arises.

Final thoughts

We are now seeing the results of a tremendous amount of work from across the organization come to fruition on the budget, health plan and many other initiatives. A series of related access and quality announcements will be made in the weeks and months ahead.

I cannot say it often enough: Thank-you. All of these advances are a direct result of your dedication. I look forward to hearing from you next week.

Stephen  

Colleagues,

I've been pretty occupied over the last few weeks working on our 2010/11 budget. This goes to the Board later this month.

As you know, the provincial budget for 2010/11 significantly increased funding to Alberta Health Services. We are now in the process of working out how this will flow out across the organization. Obviously we don't have unlimited money, so we'll still have to make priority choices, but, let me tell you, developing this budget is a much more pleasant task than the same task last year!

I noticed on the weekend that 20 days have passed since my last blog was posted on May 21; this means that no more posts are accepted. My blog has become an important mechanism for you to air issues and frustrations. So, it's important to keep the ability to post alive.

As you know, this blog gets a lot of hits. The blog stats show hits of well over 100,000 per month, and 1,685,257 (to be precise) hits so far through the end of May.

I've been intrigued about how many of the hits were internal and how many external. The last blog provided a natural experiment. You might recall that my last blog was about the two-year anniversary of the announcement of the merger of regional health authorities, patient advocacy and opportunities for engagement. I uploaded the blog on Friday May 21, just before the long weekend. On that day there were 3,375 hits. I know there are staff who check every day, but that number includes external people who have an alert for when new blogs are posted. That was the Friday before a long weekend.

On that Saturday there was a front page story in the Calgary Herald which mentioned the blog, an encouragement for external hits. There were 719 hits that day, and hits hovered around that level for the rest of the long weekend. Tuesday we sent out an all-staff email drawing attention to the blog, we got more than 20,000 hits that day, with more than 10,000 hits the day after. If we assume all the hits before the all-staff email were external, and all the ones after that were staff and physicians, we can conclude that more than 30,000 of you read the blog, or more than a third of our staff and physicians, in less than a week. A remarkably high incidence! By the way, almost 1,700 comments have been posted since the blog was launched. 

Thanks for this and I hope the blog continues to be useful to you. It certainly is for me. In the next few weeks I'll be using the blog to provide you with more information on the budget. Stay tuned.

Best wishes,

Stephen

Colleagues

This year marks the two-year anniversary of the announcement of the merger of regional health authorities, and the three predecessor provincial entities (Alberta Alcohol and Drug Abuse Commission, Alberta Mental Health Board and the Alberta Cancer Board).  Alberta is not the only place where similar consolidations have occurred over the last few years.  Typically the arguments for these consolidations include the importance of addressing equity, reducing competition and improving efficiency.  All three of these have occurred with the merger here in Alberta.  To take an example which has been in the news recently, provision of cataract surgery was much greater per head of population in Edmonton than it was in Calgary. This discrepancy was highlighted by the merger and we are now taking steps to equalize service levels.  In terms of a nonclinical example, security services were very unevenly distributed across Alberta, and recent changes in this area have led to the introduction of security services in northern Alberta. 

The new structure has brought together into the same reporting line services in Edmonton and Calgary, leading to greater cooperation and collaboration in solving common problems.  We no longer have cities and towns around the province bidding against each other to recruit new physicians.

Are we there yet?

Obviously the first couple of years of the merger have been somewhat turbulent.  The economic environment has certainly not been friendly.  The world (most notably North America and Europe) continues to face a very serious   global financial crisis.  This obviously impacted on Alberta including oil and gas prices, which in turn impacted the Government of Alberta flowing onto the financial situation of Alberta Health Services. 

No surprise therefore that early in our career as a new organization we faced a significant budget challenge.  The good news is that as the recovery is proceeding so too there has been a turnaround in the financial position of Alberta Health Services.  This year's budget gives us funding stability for the next five years, funds us at the rate we were spending in 2009/10, and gives us a 6% increase over last year.  A very different situation from what we were facing late last year.  We still have a long way to go because the uplift in funding is below the traditional level of funding in Alberta so we still have challenges ahead of us, still have priorities to set, but we can now look forward with much greater confidence than we have had in the past.

A most unusual event

Early last week, most unexpectedly, I was admitted to hospital for what turned out to be a sudden and severe viral illness.  I was really, really sick and taken to Foothills Medical Centre in an ambulance.    It caused me to reflect on a number of issues.  First, that all of us are vulnerable and we never know when any of us will need the people, resources and services of Alberta Health Services.  I received superlative care in that crisis situation and it is interesting to reflect on the number of people who were involved in that care.  The obvious ones are the doctors in the emergency department and on the ward, including the doctors called in for consultation, the nurses, the medical imaging technologists and many others.   Some of them I remember but unfortunately I have no recollection of many others who were caring for me because of the state I was in.

It was some of the little things that were done that stick in my mind.  The food services person, for example, who made sure that I had something to eat even though I hadn't ordered anything and hadn't been there at the right time (I should pass on my compliments about the cauliflower soup which was the only thing that appealed to me at the time). 

Obviously I was known to many people I came in contact with but there were others who didn't know me.  I remember especially those who engaged me as a real person rather than as a number or a person in a dreadful gown.

Of course good care like I received happens every day in Alberta Health Services.  Every day, people are providing care of this kind, doing little and big things for people at their most vulnerable.

Opportunities for engagement

Alberta Health Services is currently identifying its key priorities for the next five years and formulating a Health Plan.  You were recently asked to be involved in this and I would encourage as many of you as possible to provide input.  Already many of you have and your participation is valued. Only one day after the Health Plan survey launch, the website had logged  4,765 Visitors.

Your perspective is also valued in our Total Safety surveys. The Workplace Health and Safety Culture survey (for staff, physicians and volunteers) will provide a baseline from which to assess priority initiatives and opportunities to enhance and support safety, wellness and health in AHS workplaces. The Patient Safety Culture survey (for staff and physicians) results will form part of the Quality Performance Roadmap for the Effective Organization Standards.

As part of greater efforts to build a culture of engagement, a Workforce Engagement Working Group will be established to help develop the organization's engagement strategy. This is a great opportunity for those wanting to promote a positive and satisfying culture in our organization. The Terms of Reference for this group as well as the Expression of Interest form are available on Insite. Deadline for application is May 28, 2010.

Patient Advocacy

The Alberta Health Services Board recently approved a proposed new Communications Policy to address concerns about the ability of staff and physicians to publicly comment in both their official capacity as AHS administrators and leaders, and when speaking as patient advocates. The draft policy is now open for feedback, questions and comment through June 11, before going back to the Board later this year for final approval.

Many staff and physicians have multiple roles, as both administrators representing and speaking on behalf of Alberta Health Services, and as advocates for patients on a wide range of health matters. Alberta Health Services supports and encourages both roles and makes it clear in the proposed policy that: "Consistent with the AHS Code of Conduct, AHS does not regulate or restrict public comments of staff or physicians speaking as private citizens."

The policy seeks to balance private views with organizational responsibilities, by allowing and encouraging people to speak in both capacities by first making it clear when they are speaking personally or on behalf of AHS.

When speaking on behalf of AHS, individuals "have a duty to the organization not to make public statements that would put them in a conflict of interest with AHS. AHS individuals speaking in leadership roles in an official capacity on behalf of AHS have a duty to the organization not to make public comments that are, or may be, prejudicial to AHS."

But this does not restrict their views when advocating for patients expressing personal views. In this way, having first indicated when they are speaking as representatives of AHS on behalf of the organization, or as individuals expressing a private opinion, staff and physicians can speak in either capacity. The Code, approved by the Board earlier this year, is based on the AHS principles of respect, accountability, transparency and engagement. We think the proposed policy reflects our commitment to these principles. 

Best wishes to all

Stephen

Colleagues,

I have now been to nine employee engagement sessions, meeting with more than 1000 staff at hospitals and other sites big and small, in order of the meetings: Sheldon M. Chumir Health Centre, Peter Lougheed Centre, Rockyview General Hospital, University of Alberta Hospital, Royal Alexandra Hospital, Red Deer Regional Hospital, Drayton Valley Hospital and Care Centre, Didsbury District Health Services,  Strathmore District Health Services.  Attendees came from other sites/services to those places and from all parts of the organization. Other members of the executive have also been making the rounds. I would like to thank all the staff, physicians and volunteers who have taken time to attend these meetings. From my perspective the meetings have been very positive in the sense that attendees have been open, honest and direct with their feedback and comments. I think we have truly seen and heard all of our values of respect, accountability, transparency and engagement at play here.

What has been good about this from my perspective is that practically all of the questions and comments have been couched in terms of things we can actually do to change and make this organization a better one for us all. There have been practical suggestions and practical examples of things that could make a material difference to the working life of the people who raise these issues.

As expected, some of the problems we face (not all) were associated with the very difficult budget situation we had last year. I'm not saying that the budget caused low morale, but rather that some of the actions we took had an impact on morale. We faced the budget situation by centralizing decision-making: We tightened up on purchasing and we implemented the vacancy management plan. This reduced the autonomy of frontline managers and had a direct impact on the day-to-day work of many people throughout the organization.  I heard loud and clear in these feedback sessions that this impact on autonomy contributed to the survey results. Another example related to staff development: Again, because of the budget situation, we were really tight on approvals for professional development. For professionals who strive to keep abreast of advances in their areas of expertise, who want to grow and ensure that they are doing their best, this was a bitter blow. It is also frustrating for staff who might have to deal with broken equipment, and having to scrounge or wait for everyday items needed to care for patients.

So our response to the engagement survey must address these issues. In the weeks ahead we will roll out updates throughout the organization, assigning decision rights to managers which will allow them to recruit staff and to purchase relevant items within their approved budget. This is not a trivial task because managers need to be able to monitor how much they've spent and how much money they've got left to spend, and our information systems may not yet be up to that task.  

Anyway these are not the only things that need to be done. We're still collating the suggestions, both written and verbal.

As I've said, all of the vice presidents and site leads will need to develop their own draft employee engagement action plan by June 30 and to implement one strategy from that by December 31. Those local action plans will feed into and inform a provincial action plan to be completed by September 30. We'll also look for an opportunity for the Alberta Clinician Council to comment on these strategies.

Again I'd like to thank you for your contributions so far and I look forward to more feedback over the next few weeks.

On another matter, the Board has been reviewing the Communications Policy to ensure its alignment with our values and the Code of Conduct, in particular clarifying our policy on public comment.  I'll be releasing a new draft policy for consultation next week.

Finally, those of you who are Calgary-based will probably see media reports later today about a legal intervention we've taken today (see our news release).  Basically, we're intervening in bankrupcy procedings which are underway against Health Resource Centre, a private surgical facility which provides public orthopaedic surgery under contract to us.  What we are doing is seeking appointment of a 'receiver' to manage HRC so that the orthopaedic surgery undertaken at HRC can continue uninterrupted.  Although we can pick up additional orthopaedic surgery in our existing facilities, we are best able to meet the needs of our patients - who are our first priority - if HRC continues to operate.  Later this year we will be opening additional operating rooms and beds in the new McCaig tower. This will provide a significant expansion of surgical capacity as required within the public sector. 

Stephen

Colleagues,

Just two weeks ago, I passed my one-year anniversary here at Alberta Health Services. I've survived temperatures at -46°C, and, in fact, on one of the days when the temperatures were like that, I was out and about visiting hospitals so I really noticed the cold. But, as much as people talk about it, and boast, as I now can, about their experiences, Alberta isn't all about the weather! In my year here I've visited much of the province, albeit seeing relatively little of the sights: mostly I see insides of hospitals and other health facilities. We are also just at the start of the new financial year and so we're in the midst of budget preparations. So what you'll get in this blog is a bit of looking back, and a bit of looking forward. This year I'm determined to meet more of you and learn and know more about your communities.

As I've said on a number of occasions, we are living through the largest merger in Canadian history. Other mergers might have involved more capital and a higher profile across Canada, but we are certainly engaged in the merger involving the largest number of staff. Alberta Health Services is the largest health care organization in Canada, the largest employer in Alberta and the fifth or so largest employer in the country. We've got to remember, though, that the principal criterion against which we want to be judged is not size, but rather quality. The Premier has set us an ambitious goal: to be the best performing publicly funded healthcare system in Canada. We're committed to getting there.

The merger is complex. Twelve predecessor entities were merged, and we also took over direct provision of ground emergency medical services in many parts of the province. The new legal entity was only created on April 1, 2009, although the merger was announced in May 2008. So, we're less than two years into the merger. Many experts in this area suggest that mergers take about four years to be implemented.

We entered 2009 with significant challenges. You'll recall back when the 2009 budget was announced that I spoke in my blog about the budget challenge we faced. That was huge. But we've done remarkably well on that. We've achieved significant back-office savings; savings that position us well for 2010. I'd like to thank all of you who worked so hard to achieve those savings and set the scene for moving forward. 

In my first few months, I moved quickly to stabilize the formal structure of the organization, to establish a strategic vision, and to get started on the budget savings. The merger represented a sea-change in the direction for the organization of health care in Canada, and people from all over the country are watching us closely. The good news is we're already beginning to see some of the benefits of the merger, in the sharing of ideas and what economies of scale can do. 

Just last week, for example, the Board met in Lethbridge, and the Board agenda reflected how the merger is helping the people in Lethbridge and the rest of the province. The Board approved a parkade at the hospital. As you know, our policy on parking is that it must be self-sufficient. Users of the parkade will pay market rates. But even so, the Lethbridge parkade would not have been viable by itself. It only became viable because we are assessing self-sufficiency on a provincial, rather than local basis. An example of Lethbridge benefiting from the merger.  

The Board also considered an implementation strategy relating to seniors' accommodation. Our new policy was informed by the very good work that was done by the former Chinook Health Region. An example of the good ideas from the south being shared with the rest of the province, and a direct benefit of the merger.

We've still got more to do in articulating the vision, embedding the values, making sure budget targets are met and so on, but I feel pleased with how much we've done in these areas.

Importantly, we're starting some really exciting and innovative work that will lead to improvements in the care we deliver and how we deliver it.  Examples are the care transformation project (starting at the University of Alberta Hospital) and our work on seniors' accommodation and primary care.

Not all went well in that first year, though. In terms of our service to Albertans, our response to H1N1 attracted a lot of criticism. I've already outlined some of the constraints we were under, so I won't belabour the point here, but I'd like to reiterate what I said at the time. I was really pleased and proud of the way the men and women of Alberta Health Services put all else aside and devoted themselves to protecting and providing care for Albertans. 

We enter the 2010 budget year in a quite different environment from how we started 2009. As you know, the province has fundamentally shifted the financial parameters within which we work. Whereas in 2009 we were given an extremely difficult budget target, 2010 is merely going to be hard. The impact on my daily work is profound: three or four months ago my days mainly involved meetings to discuss really difficult budget choices. I was dreading 2010, as, quite frankly, we were facing even more really difficult decisions. But the provincial government has changed our fiscal envelope for the better. Our budget deficit for 2009/10 will be paid off by the province, meaning that we don't have to make additional reductions in 2010/11 to fund that. They've also given us budget certainty into the future, with a 6% increase this year and for the next two years, and 4.5% for the two following years. This means we can make long-term plans, but it doesn't mean we can go easy on budget control.  In the past, we were growing at 10% to 11% a year, so we must continue to be fiscally responsible stewards of public money. We'll have to continue to make hard choices, but those choices will be about where we might have investments, what health services might be best for Albertans in improving health status, access and quality. Last year, the challenge was to achieve a balanced budget while protecting access and quality. We now face a different and much more pleasant question: how best to improve access and quality using the increased funds we now have and the savings we achieved in 2009, which can now be partially re-invested in services rather than being used to reduce debt.

Earlier this year, we circulated an employee engagement survey, with responses received over the period January 27 to February 15. I said at the time quite candidly that I wasn't looking forward to the results. We proceeded with the survey, though, because we wanted an honest read of where the organization stood, and we wanted a baseline before the start of 2010/11.  We've got the results now and they're mixed, but overall not good.  I think that's partly to do with the timing, as the survey was done before we had our budget certainty, when staff were unsure of how we would meet the budget targets (a position I was in, too), and there was uncertainty and rumours about layoffs. So I wasn't surprised when I saw the results. 

I'll just give you the headline numbers here, with more detail coming out next week as we start our consultations. The company who did the survey for us compared our results with other organizations in their data set, which provides a benchmark for us. In terms of overall engagement, their main summary measure, 35% of Alberta Health Services staff responded favourably compared to a benchmark of 76%.  As I said, not good.  This overall engagement score had a number of subcomponents:

- Were you proud to tell others that you work for AHS?  41% were favourable compared to 88% in benchmark organizations;

- Were you optimistic about the future of AHS? 29% versus 76%;

- Did your job provide you with a sense of accomplishment? A better result, 68% versus 79%.  Still leaving room for improvement, though. 

In terms of some of the other scores, you were asked whether the senior leadership sets ambitious but realistic goals. Only 30% of you thought we did, compared to 63% in benchmark organizations. I suspect this is an example where the environment and the budget challenge had a significant impact. We had a huge budget task that you probably thought was not possible to achieve. Hopefully, if the survey was redone today, we'd see a positive change because of the positive budget news. On related issues, you were asked whether you had trust and confidence in our ability to achieve goals, and marked us poorly (28% favourable versus 67% in benchmark organizations).  Similarly on whether we act consistently and do as we say, 28% versus 56%.

The feedback about your immediate supervisor was somewhat better but still not as good as the benchmark (61% versus 73% as a summary score). Performance feedback was similar:  46% versus 63%.

An interesting characteristic of the AHS results was the high percentage of "neutral" responses, which may indicate that survey participants are undecided or are still taking a wait and see disposition with AHS.

So where do we go with all this? Each of your vice-presidents and people in similar roles received a copy of the results for their area of responsibility yesterday. I have asked them to share those results with you in face-to-face meetings to the extent possible. All of us in the senior leadership will be spending time over the next few weeks getting out and about in the organization meeting with groups of managers, staff, and physicians to discuss the results of the survey and to listen. 

You'll appreciate that what we've got here is survey data. We need to put some flesh on those numerical bones and supplement the quantitative data with rich qualitative data. So what I want from the VPs is to marshal your feedback about what you think we should do to help change this organization for the better. We're also going to conduct some focus groups to assist with a drill down of the data at the end of next month. That feedback will provide the basis for an Action Plan for this whole organization. I've committed to complete the Action Plan by the end of the summer.

We had a fairly low response rate in the survey, but I'd like to thank all of you who took the time to complete the survey. As I said, the results aren't really a surprise to me, but they do give us a good quantitative benchmark to provide a basis against which we can measure improvement.

2009 was a difficult year for me in all sorts of ways. But I found Alberta Health Services to be the most supportive organization in which I have ever worked. Senior staff and the Board have been really personally supportive, expressing real concern in the face of some tough times. (Of course the Board had a mixed role in that they are my boss as well). I would like this organization--and me personally--to be as supportive for you as it has been for me. That is where I want the Action Plan arising from the survey to lead us.

Best wishes,

Stephen

P.S. Following a request in a comment on a previous blog entry, we'll publish blog stats every month.

Colleagues

You will recall that back in January I posted a blog called,  "First do no harm, Part 1".  That blog was about the importance of providing a safe environment for our staff.  Since then we've done a lot of work on occupational health and safety and this will continue to be a priority of mine.  I am planning to include in my 2010/11 performance agreement and in the performance agreements for all senior operational staff, targets about reducing our disabling injury rate. 

The reason that blog was titled "Part 1" was that I always intended to write a second blog about the importance of providing a safe environment for patients.  I'm following up today because of the recent release of the public report relating to incidents at Alberta Children's Hospital.

We know from a study by Baker and others*  that, on average, one out of every 15 patients who are admitted to a Canadian hospital experience an adverse event.  The hospitals sampled in that study included hospitals from Alberta and there is no reason to expect that the Alberta data would be any different from the average reported in that paper. 

The old paradigm about patient safety was that adverse events were relatively rare and when they did occur, it was because somebody slipped up.  Adverse events were seen as being caused by some individual who was at fault.  Our new understanding is that adverse events are common (as shown in the Baker et al study) and that there are a whole host of antecedents which contribute to adverse events.  So in contemporary analyses of adverse events, we tend to focus on system factors, each of which contributes to the incident.  This is not to say there are not some occasions when individuals clearly are at fault and the single cause, but this is relatively unusual. 

So a lot of the new thinking about patient safety is that we should try to learn from mistakes: that we should strive for continuous improvement in how health care is delivered.  This in turn means that we need to know about mistakes and lapses and that people who see mistakes or make mistakes (or near misses /close calls) feel safe about reporting those incidents.  So this highlights the importance of developing a "just and trusting culture" so that people feel it is safe for them to come forward and disclose what happened; that they trust the organization will look at this from a learning rather than punitive perspective and that they will be treated fairly. 

Staff come to work wanting to do a good job.  They all want to do their best.  But sometimes things go awry.  This can be devastating for the staff involved and of course for the patients.  So we want to minimize the likelihood that this happens, we want to maximize the number of incidents that we hear about.  For this to happen we need to have a just and trusting culture right throughout Alberta Health Services.  Incidentally, this is also why we took so much care to ensure that the public report on the Alberta Children's Hospital incident did not identify the staff involved.  As it turns out one of the units involved had taken significant efforts to create a just and trusting culture within the unit. 

I cannot stress enough how important it is to emphasize and create a just and trusting culture.  Not only is it important because we want to learn from our mistakes but the earlier we find a mistake, the better chance there is that corrective action may be able to be taken.

We need to be careful though, that in protecting the staff involved we don't get complacent.  We must truly learn when things go wrong.  We must be up to demonstrating that we have implemented change to prevent a reoccurrence.  We have to be open and honest with ourselves and with our patients so when we discover that something went wrong, we need to tell our patients about it.  This can be hard.  Our patients come into hospital thinking that they will only get the best.  They don't expect things to go wrong.  But in my experience, patients welcome this honesty and particularly welcome it when we say we will do everything we can to make sure the same thing doesn't happen to anybody else. 

I'm passionate about trying to improve the quality of what we do.  We need to make it easy for everyone to participate in the improvement endeavour.  If we want to reduce that 1-in-15-number, we've got a lot of work to do.  I know lots has already been done in Alberta, but we've still got lots to do.  But, as they say, a journey of a thousand miles must begin with a single step.  That first step involves all of us, watching, reflecting, learning.

Thanks

Stephen

* Baker, G. R., P. G. Norton, et al. (2004). "The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada." CMAJ 170(11): 1678-1686.

Colleagues

The Olympics are over now, the airports clogged up by returning spectators and athletes.  Millions of Canadians were engrossed by the spectacle, the drama, the finger-gnawing excitement, and the thrill of the win.  You really feel for some of the athletes who did not take home medals, having been trained, psyched up, and watched by others under the glare of the media.

While I was writing this I learned that over 80% of Canadians watched the thrilling hockey final.  A serious and culturally important event for Canadians: I heard a discussion on the radio mid-Olympics about whether it was more important to win the men's hockey gold or the overall medal tally. I don't know what that answer is. I do know that just being in the Olympics is a tremendous achievement for any athlete, but on Sunday afternoon only one goal really mattered, so to speak.  

I have learned this winter that hockey is to Canadians what 'footy' is to Australians*. So I was not surprised when lots of your colleagues initially streamed videos of the Olympics, demonstrating their enthusiasm for the Olympics, but unfortunately, and unbeknownst to them, to the detriment of the performance of our computer systems.

We should all also congratulate our colleague, Susan O'Connor, from Foothills Medical Centre, who was a member of the women's curling team which won Silver in another competition that went right down to the wire. As for the other sports, from a personal perspective, I must say I had never realized there were so many different ways to get down a mountain so quickly. 

As you know one of Canada's goals for this Olympics was to "Own the Podium." This was understood to mean dominating the medal tally.  Halfway through the games, though, the Canadian Olympic Committee acknowledged that this goal would not be achieved.  There were lots of comments in the media about this.  But the medal tally picked up, and Canada won more gold than any other country.  This then was redefined as the goal, and owning the podium became an ultimately successful quest for gold. 

And why not?  I started to think about whether and when it was legitimate to redefine goals.  I started thinking about 'expectations,' goals and targets.  When should we be able to revise them?  What should be the consequences?  How do you set them in the first place?

For goals to be meaningful, they have to balance 'stretch' and achievability. If there is no stretch target (e.g. a continuation of the previous trend or otherwise soft), they have no real meaning.  On the other hand, if the stretch is too great, they demotivate and encourage gaming, fudging and fraud. 

Goal setting is playing an increasingly important role in health care.  With our new five-year funding agreement, we will need to negotiate performance goals with Alberta Health and Wellness.  What will we need to deliver on with our funding increase?

Many countries are introducing a kind of pay for performance ('P4P' in the literature) as part of the design of health system funding formulae.  The idea is that hospitals, health care plans, physician practices should get additional funding for superior quality or health-improving performance (plans that achieve higher levels of immunization performance being one example).  Here in Alberta, as we develop activity-based funding for long-term care, we will also be introducing a pay for performance element, as a supplement to the principle that resources should go where health care needs and costs are greatest. In other words, dollars should follow patient needs.  The design of our funding formula for long term care will demonstrate a balance across our three objectives of access, quality and sustainability.

In this case, because every hospital and long-term care centre is different, 'performance' means achieving the goal of meeting the unique needs of patients. This will require us to identify quality metrics, performance against which will attract additional funding to support greater patient needs. Quantifiable measures of health system performance are complex to develop, but not impossible.

All this is not rocket science, as they say.  Developing performance metrics for organizations or systems builds on what we do everyday when we plan a project with our colleagues or team.  We sit down and talk about what we want, what's achievable, what will change and make things better for our patients, and we evaluate our progress.  Thinking again about getting down those mountains quickly, there are lots of ways to get to the same end point.  People can be very innovative in how they get there and we at Alberta Health Services should nurture and encourage that same creativity and pursuit of innovation as we work toward our goals.

So is it any different for Alberta Health Services or a hospital or a seniors' residence? Maybe so, maybe not.  The goals are certainly bigger, more complex, involving teams and system change.  Take our emergency department goals.  Achieving improved emergency department performance means we have to improve the speed of consultations from inpatient physicians.  But their reward system lies outside the ED, so it's a bit harder but still needs to be done.  Improving transfers to the wards is another necessary strategy.  So waiting time in ED quickly becomes an issue for the whole hospital.   Simple goal, complex strategies.  All we can do is express the goal clearly and not lose focus.

But ED performance, indeed hospital performance as a whole, is affected by the outside environment, literally.  A bad winter ups the flu presentations and clogs up the ED.  So we're back to the Olympic problem, is it legitimate to revise goals about ED performance in winter? 

So what about flu?  Should we revise our targets about waiting times in ED or for elective surgery if there is a bad winter?  Shouldn't we have worked out by now when winter comes, every year, and be ready for it; have immunised staff, have other strategies ready to swing into action?  So we're back to how we set the targets in the first place.  Were they sensible?  Did they take into account some inevitabilities, like winter? Of course - we adapt and adjust and rise to the challenge. But I think the onus is on us to set sensible targets taking into account the foreseeable.

Are we going to revise our goals? Yes. We should do this on an annual basis.  Look back at how far we've got, make course corrections, think about implementing new ideas and so on. 

So back to the Olympics.  Sometimes just being in the race is a pretty good achievement, but it sure is nicer to be up there and achieve your goal.

Best wishes

Stephen

* I mean the real game: Australian Rules football.  If you meet an Australian, especially one from the southern states, ask them to explain why Collingwood ('the Mighty Pies') is the greatest footy team every seen on this planet.

I invite you to view my blog today in video format and I look forward to your comments.  - Stephen

Due to high demand, this video may take some time to load.  Your patience is appreciated.

View video 

Below is the text of my video presentation today.

Colleagues

The provincial budget brought down this afternoon represents a dramatic change for Alberta Health Services, and indeed creates an important precedent for the rest of Canada.  There are four big differences between our pre-budget situation and where we are today. 

First, the Budget provides us with our funding envelope for the next five years.  Not only do we know our budget for 2010/11, we know our budget for the four years after that. 

Because of this funding certainty we can redouble our efforts to improve access and quality. We will be able to deliver more for Albertans.  We will be able to demonstrate more easily our commitment to patient care and the values that bring us together as an organization - values that go to the heart of what matters to our patients, our colleagues, our families and friends.

 I wouldn't want to sit around for hours in an emergency department waiting room waiting to be seen.  I wouldn't want to face unreasonable delays for cancer treatments, or to wait in pain for a knee replacement.  But that is what is happening to some of our fellow Albertans, and we can change this.

A budget is a means to an end, and starting today we have greater ability to achieve our goals of access and quality and sustainability than we have had since Alberta Health Services was formally created.

Think back to last spring.  We didn't know our budget until after the start of the financial year.  If you recall, my first response to the 2009/10 budget (headed "Budget blues") acknowledged that things were tighter than 2008/09, but I wasn't sure just how much tighter.  We couldn't present our financial plan to our Board until June, a quarter of the way into the financial year. Most other health services in Canada are still in that same boat.

Getting a budget late means you start late in planning and implementing the necessary changes.  It means you have less time to implement things.  It almost inevitably means you end up with a deficit. 

In contrast, with today's announcement, we know now what our funding will be five years down the road. This is a first in Canada. We now have a much longer time frame to plan, to consult, to implement.  It also means we can more easily plan major innovations and initiatives that might take two or three years to provide a return.  

The second big difference is that we have a clearer process for setting the budget and a better understanding of the government's parameters.  When we submitted our proposal for funding certainty to the government late last year, we framed our request based on external factors: projections of economy-wide inflation and our estimates of the impact of the growth and aging of the population.  The government has accepted that approach. This means that the government is now able to say back to us, "We have funded you for inflation. We have funded you for growth and aging of the population, now make sure you meet that growing demand and ensure that Albertans are able to access high quality services in a timely manner."  I'll come back to that point later. 

The government has also said, "We recognize there is a backlog of issues and we want you to fix that, so we are going to provide additional funding for the first three years of the funding period." This additional funding means we can focus more on doing what we do best: providing high quality, cost- effective, universal health care. 

The third big difference is that the government has agreed to pay off our accumulated debt.  As you know, we expected a deficit this year because we knew that we just couldn't do all the necessary changes in time to allow us to reduce our spending rate without compromising health care. We could have reduced costs more quickly, but we were not prepared to do that. We were able to live by our commitment to focus on non-clinical cost savings.

Government funding rules allow us to borrow to run a deficit but we must have a deficit reduction plan.  Just like a household credit card, what you borrow you must pay back!  With interest! So we were looking at $1.3B accumulated debt at the end of the 2009/10 financial year, $400M or so from 2008/09 and $900M from 2009/10.  We would have gone into 2010/11 having to find about $900M in savings in 2010/11 to adjust our current spending rate back to government funding levels plus a further $450M to pay back the debt over three years.

So, if the old budget model had continued, we'd have to find more and more savings -  not just to live within our allocated budget, but also additional savings to pay back money borrowed in previous years.  To achieve these savings we'd have to reduce our spending levels more and more. 

The 2010/11 budget decision to take over our debt means that we don't have to cut services to make those debt repayments.

The fourth big difference is that the government has adjusted our base budget to take into account our current level of spending, so where we start 2010/11 is where we finish 2009/10.  This is dramatically different from the 2009/10 budget where we entered 2009/10, with a spending rate about 10% up on 2008/09 but a budget increase of 6%.  We had to play catch up just to stand still!

So far so good.  But remember historically we have increased our spending by 10% a year. The new 5-year funding agreement does not provide for that level of funding growth so we'll still have to watch our pennies and not expect to receive additional funds in future years.  In fact, I'll go further: if we want to fund innovation and new types of services, we'll have to work smarter so we can make sure we meet future demand.  This will include new strategies and investments in areas such as primary care.  More on that in the next few months.  We'll have to work to improve our productivity and ensure our new labour agreements are both fair and affordable.

It is not enough to use this stable funding to simply balance the budget: we are also accepting responsibility for improving the health system and for ensuring we get best value for health care funding, which means continuing to be both more efficient and more innovative.

I know 2009 was a tough year. We really squeezed hard on spending.  Many of you have raised concerns about the restrictions involved, especially in terms of the vacancy management system.  But by doing that, by achieving those large savings though vacancy management, we are that much better positioned going into 2010/11.

Together we have booked about $700M savings for 2010/11, which is about six or seven per cent of our total budget. Or, to put it in context, about as much as it costs to run a major urban hospital for an entire year. It is important to remember that this is a budget going forward  from today, and that we must ensure we capture and annualize these savings. 

Many of you feared that the savings we were looking for in 2009 were going to be like the early-mid 1990s.  I said all along that they would not be like that and now we have assurance that this will be the case.  To achieve this it has been just hard grinding slog: a few dollars shaved here, a million from procurement there, each manager looking carefully at whether that vacant position really needs to be filled or agonizing about position elimination  I'd like to thank all of you for your contribution to meeting the goals government set for us. 

The result of all that hard work behind the scenes is now clear.  I promised you that I would minimize layoffs, and that's what I've done.

Albertans will know from their everyday experiences with the health system whether we are meeting their expectations.  But I want to go further.  Our values say we need to be accountable and transparent and we are already turning those words into action.  We already publish more data about our performance than Albertans have ever seen and we are committed to publishing even more.  With the budget announcement we should go even further. 

I've already spoken to the independent Health Quality Council of Alberta about jointly developing 15 or so quality measures which they will monitor and publish on an annual or twice yearly basis.  We'll use those same measures as part of our internal accountability process (together with additional ones of course) and we'll commit to publishing them ourselves as well.  These measures will supplement (or potentially replace) measures included in our recently endorsed quality dashboard.  We will also consult with our Health Advisory Councils, all of which are now up and running, about how we should judge our performance in a way that is relevant to consumers.  And we'll seek advice from the newly-established Alberta Clinician Council as well.

We are moving quickly. In terms of specifics, I've also already asked our staff and physicians to look at ways in which we might immediately reduce dramatically the backlog for elective procedures such as hip and knee replacements and cataract operations. I'll release more details in the next week.

Finally, what does it mean to you?  As I said, 2009 has been a hard year.  I'm not looking forward to the staff survey results, as we've  had to make some tough and unpopular decisions to live within our budget.  These results though will be a baseline and I trust we'll see significant improvement in future surveys. 

There have also been unfounded rumours about massive clinical staff layoffs around the corner, and these can now be laid to rest.  That uncertainty is now behind us.  

Instead, let's look ahead.  The new five-year funding provides budget increases in line with the expected impact of population growth and ageing.  That means we can plan for growth in services over this period, so we can better meet the needs of the population we serve.

 I'd like to conclude by thanking you all for staying with us though this difficult time.  As I said in my annual report to you late last year, I was hoping that in 2010 I could say:

"Look, we've done a lot of this budget work, and now what we want to be on about is improving care for Albertans, improving health standards of Albertans, improving the flow of patients through our system so we can address the waiting list problems and emergency departments and so on."

Well, we have reached a turning point and know that we can say 2010 will be very much like that.  Our job now is to show Albertans real improvement in access and quality.  Providing care and improving services is why you and I work in the health sector, it's what we do best.  We now have an unparalleled opportunity to do this.  I wish you well as we work together on that goal.

Thank you.

Colleagues,

The Hippocratic injunction that we should first "do no harm" was written in the context of our duty of care to our patients.  But it should apply with at least as much force to our duty of care to ourselves and our co-workers in health care.  

This blog is about a tragic on-the-job fatality, and what we must do about it.  One of our colleagues, Sheldon Miller, head gardener at Medicine Hat Regional Hospital, died last November while performing routine maintenance on a tractor.  Last week I met with Sheldon's family and his workmates and later made a Telehealth address to maintenance workers at 93 sites across the province.

I'm asking all of you today to join me in setting and reaching a clear goal: zero injuries.  I am asking you to look after your colleagues. If you see them engaged in risky activities please draw that to their attention.  Please raise issues with your managers or supervisors if you think there are workplace hazards that make the work unsafe.  Don't continue to work in unsafe environments.  We truly must ensure that when you come to work, you know that the workplace is safe.

All of us have a role here.  Your expectation, my expectation, and your manager's expectation should be that you will not suffer an injury while you are at work.  You owe it to your colleagues, you owe it to your families, and most importantly, you owe it to yourself. It is the right thing for us to do, and there is ample evidence to support the need to strive for zero injuries.

Unfortunately Sheldon wasn't the first health care worker to die in a workplace incident in Alberta.  Alberta Employment and Immigration reports that there has been about one fatality each year in the health industry in Alberta for the past five years.

The health care industry is a dangerous one.  Occupational health statistics show that in 2008, for example, the health industry in Alberta had 3.23 lost-time claims per 100 worked person years, and 4.1 disabling injury per 100 person years.  The long term claim rate is more than 50% above the Alberta average (1.88) and the disabling injury rate is relatively high as well.  One thinks of mining, for example, as a dangerous industry, but the long-term claim rate in that industry is 0.66 in 2008 and the disabling injury rate is 2.92, much less than health care.  

Within the health care industry, long term care facilities had a markedly higher lost-time rate (5.1 per 100 person years) relative to the rest of the sector.  Occupational health and safety is improving in most industries, but the rate of improvement in health care is slower than other industries and in some cases we are going backwards (e.g. the hospitals' long term lost-time claim rate went up between 2007 and 2008).

The vast majority of the lost-time claims and disabling injuries relate to sprains, strains and tears (about 2/3 of incidents) but in some cases there are fatalities.

This is not acceptable, and clearly management has a major role here.  We need to make sure that our workplaces are safe, that you have the equipment, the hoists, the lifts that you need to avoid strains, that we have designed the work flow so that repetitive injuries are avoided.  As a leader in the organization I need to be monitoring where there are "hot spots" so that I can direct action to eliminate the hazards that cause the injuries so that we can make the zero injury expectation a reality.

How we will get there will be guided by our new Strategic Plan for Workplace Health and Safety.  The Strategic Plan has three main components:

1. That management and staff are committed to maintaining a strong culture of employee health, safety and wellness.

2. That there is consistent application of proven workplace health and safety management principles across the organization.

3. That we develop and align workplace health and safety professionals in the organization to enhance service and facilitate further adoption and development of workplace health and safety competence among leaders.

The Workplace Health and Safety Strategic Plan was presented to the Human Resources Committee of the Board earlier this week.  The Committee has asked that the Strategic Plan be referred to the full Board for discussion and indicated their clear support for strategies which emphasize the importance of ensuring a safe workplace.

We can and will do better.  Our target is that we should not have any occupational injuries.  Sheldon Miller's death should be the last one in Alberta Health Services. 

On a somewhat related matter, I would remind you that we are in the field with our  Workforce Engagement Survey.  I urge you to go to the website and complete the survey. The more responses we have, the more we can be sure that we are truly tapping into the opinions of staff about how we can improve their work environment.

Best wishes,

Stephen

Colleagues,

To help put the developments of the past few days around the bed plan and Alberta Hospital Edmonton in perspective, I'd invite you to revisit my Annual Report blog posted on December 11th.  What I said then was:

So, what I'm hoping is that as we move into 2010, we'll be able to say "Look, we've done a lot of this budget work, and now what we want to be on about is improving care for Albertans, improving health standards of Albertans, improving the flow of patients through our system so we can address the waiting list problems and emergency departments and so on."

And this is going to be a major aspect of my work over the next 12 months.

I'll say again what I said then - what we are all about and what we have always been about - is improving the access, quality and sustainability of healthcare in Alberta, and in so doing, improving the health status of our fellow Albertans.

This week's decisions will make that all the easier. 

I'd also like to say this again: You are doing a great job and 2010 is promising to be a watershed year for Alberta Health Services.

Times change. The situation we face today is not the same as that which we faced last fall, and, I would argue, recent changes are for the better.  

We've worked hard on managing recruitment, with consequent savings.  We've made a lot of progress on the back office savings too.  We've now locked in somewhere between $600 million and $700 million of savings for next year already. 

So, we will be able to go further in 2010 on access and quality, and quicker than we had anticipated.

Best wishes,

Stephen

Colleagues

I, like many of you, have been deeply affected by the horror of the Haiti earthquake.  Many staff and physicians across Alberta Health Services have stepped up and asked what we can do to assist the people of Haiti struggling to recover from this week's earthquake.

For a start, Alberta Health Services will make accommodations in terms of scheduling and staffing to make it possible for individuals and organizations to provide assistance quickly.  This will be coordinated through your manager, director or vice-president.  A number of organizations exist with the expertise and national and international contacts to provide relief assistance and we encourage staff and physicians interested in volunteering to work with these established organizations if they are not already doing so.

Alberta Health Services is also setting up a single point of contact to use our purchasing power to provide corporate rates for medical supplies, which includes drugs. This will be coordinated through Contracting, Procurement and Supply Management.  If you have any questions, please contact Steve Bowers, ED, Procurement & Operations at steve.bowers@albertahealthservices.ca, 780.342.0174, or the Call Centre at 1-877-595-0007. For HR information, Mona Sikal, Senior Lead in Employee & Labour Relations at mona.sikal@albertahealthservices.ca, 780.426.8503. 

Based on past experience with international disaster relief and the reality of chaos on the ground in Haiti, both individuals and organizations will find it useful and important to align with organizations with experience in disaster relief.  A dedicated web page is being created to provide information on various aid organizations. (Note: it's not there yet)  Those who are already part of relief efforts will be able to provide information to be added to this page,  http://www.albertahealthservices.ca/relief.asp by sending it to web.team@albertahealthservices.ca. The page will be developed over the weekend as information comes in. It will include information on how to make donations and the page will be updated regularly.

I know that many people have offered to provide their personal support and this is appreciated.

Decisions on patient transfers to Alberta will need to be made with provincial and federal guidance from Alberta Health and Wellness, Health Canada and Immigration authorities.  That said, we recognize the urgency and would like to provide the support detailed above in the short term.

Let me conclude by saying thank-you to those who can provide support in whatever form - in this and in all cases where we in the developed world can show leadership and compassion. It all makes a difference.

Stephen

Welcome to my first annual report to staff.  This is the text I used in my video presentations today.

I understand that there's been a technical glitch so some of you didn't see the first announcement on these talks on November 30th.  This should be fixed by the next time I do this.

My intention is that we have two of these reports a year.  One in mid-year around June and one around the end of the year.  In addition to my blog, this will be one of my regular ways in which I will communicate directly with you - the men and women of Alberta Health Services.

I'm sitting here in my office in Edmonton, experiencing my first Alberta winter.  People forewarned me about what to expect, but I must admit that the -30 degree weather we've had over the last few days is a bit difficult to get used to.  I'm also looking forward to having a break at Christmas, going back to Australia to see family and friends and the plus 30 they are experiencing at the moment.

Alberta Health Services is a large organization, the largest employer in Alberta, the fourth or fifth biggest employer in Canada, and the largest health services provider in Canada so in terms of communicating everything that is going on, despite our best efforts, it's hard for you to know what I am thinking, and what other members of the Executive are thinking.

One of the ways in which I've attempted to be clear about where we're going and what I am thinking, is through my blog and we have about 100,000 hits on the blog every month.  I've also had over 1,000 comments on the blog, and certainly that is one of the ways I've tried to tap into some of the issues that you are concerned about.  I know it's not a random sample of you, the staff, but I certainly use it to find issues which are of concern to at least a subset.  And that's useful for me, so please keep on commenting to help me in my role and hopefully, by doing so, help address the problems you are facing.

Today I want to look back over what Alberta Health Services has done since we were created in May 2008 and look forward into the future.  For those of you interested in numbers, Alberta Health Services is now an organization which is 575 days old.  I've been with you for just under half of that period now, 260 days or so.  So from my perspective, I'm about a quarter of the way through my first 1000 days!

We've achieved a lot in that time and you should be proud of what you've done. Not everything has gone well and I'll come to that in a minute.  But if you think back I think we can say there's been three major themes so far in Alberta Health Services' existence. 

A critical theme in the first year or so was the need to maintain access, quality and safety during a period of significant organizational change. 

You are living through the largest merger in Canadian history.  We are the largest employer in Alberta and one of the largest employers in the country. And bringing together 12 organizations with very different cultures, very different processes, very different organizational systems, is a significant challenge.

Overlaid on all of that is our assumption of responsibility for ambulance and emergency health services in the province.  With that, we've brought into our organization staff from a range of other employers.

This first period might be described as safeguarding health care in Alberta during this time of transition.

But we've moved on from that passive and reactive mode into one which is about building the foundations for the new Alberta Health Services, and this is a second, parallel theme of this initial period.

We have spent a lot of time and a lot of effort consolidating and optimizing the back office functions, bringing together the disparate IT systems, the various HR systems and so on.   And there remains much work to do in these areas.  I learned the other day that we now have the third biggest email network in Canada. This system stuff goes on behind the scenes and patient care goes on at the same time. 

Another major theme that's been happening over the last year or so has been addressing the budget challenges. As you know we've got a significant hurdle ahead of us.  I've made no secret about that, and I've talked about it since I was first appointed and the provincial budget was announced.

But we've done a lot since then. 

If you think about it, every day we've brought down our spending rate significantly, and we've already put in place savings which next year will save us somewhere between $650 and $700 million.  In other words, every day someone in the organization identifies an additional $2 million of annualized savings.  That's a lot of work - a lot of very good ideas are going into this.

But we've still got budget challenges in front of us.

As an aside, I'd like to thank all of you who responded to the Action Your Ideas initiative.  We've had around 500 responses to date, and we're evaluating them now.  The responses are still trickling in.  Clearly there's a lot of energy and ideas out in the organization and we want to be able to tap into that, so we can provide better care to Albertans. 

You don't have to be Einstein to realize that not everything has gone well this year. 

Some particular events stick in my mind. 

The initial roll out of H1N1 for example resulted in long queues.  Now, think about the experience that meant for Albertans. Some people had to wait hours and hours in the queue.  I wouldn't have liked that.  Some people were turned away from the queues, and some were turned away again the next day.   Again I wouldn't have liked that to happen to me or my family.

So obviously, we didn't meet Albertans' expectations in that first week.

Now I'm on record as saying that one of the things that contributed to the lineups was that public sentiment in terms of vaccination changed prior to that week.  Polling initially indicated that only 40% of Albertans wanted to be vaccinated, then the public learned of the first deaths resulting from H1N1 and the demand for the vaccination increased to about 75-80% of the population and we were overwhelmed.  Unfortunately, the number intending to be vaccinated seems to have dropped back to the expected levels. 

That first week, we vaccinated almost 300,000 Albertans and in retrospect, the number of people being vaccinated in one week, in fact, should be a cause for celebration.  The process was poor but the outcomes were good.

So, although as I said we didn't live up to Albertans' expectations, there was something to be proud about.  Importantly, we learned from that first week, made big changes and the second and subsequent weeks went much better.

Over all, I think our response to H1N1 has been good.

There have been several highlights:

- Establishing the influenza assessment centres was really innovative and went really well.

- We also set an ambitious target to vaccinate 70% of health care workers in two weeks which we achieved - a remarkable accomplishment.

- Our ICU, intensive care unit, response was also well planned and went well.

- A lot of you stepped up to the mark and worked really hard, really long hours, every day including the weekends, and that has paid off in terms of the vaccinations.

- We've now vaccinated more than a million Albertans. Again, something to be really proud of.

- And we are seeing in the statistics that our expected rate of hospitalization is lower than we predicted, and I think that might be in part due to the large number of people that have been vaccinated.

So we are actually protecting Albertans from this pandemic. You are keeping people healthy, and saving peoples' lives.

There are other things that didn't go well and I've reflected on them a lot - and looking forward to doing things better next year.

Looking back, I think we can be proud of what we've done in a number of areas.  Across the whole organization, we've kept up with providing a good level of service to Albertans over this period.  We've also made some major savings.

So moving on to next year, we have the organization in place now - not perfectly and I'll come to that in a minute, but this means we're able to issue budgets to the various organizational units so we will go into 2010/11 able to give managers throughout the organization a budget that will help them with long-term planning and stability.  And we'll also be able to say to them these are our performance expectations, these are the things you need to achieve, so you know how much money you've got and you know what you need to achieve. Everyone can have a better sense of what needs to be done.  This in turn means we can relax some of our centralized controls.  So I anticipate that we will be phasing out the vacancy management system come the start of the next financial year, April 1st.

As I said right at the start of addressing the budget challenge, we will do everything we can to avoid compulsory layoffs.  And the way we're doing that is through two main strategies: vacancy management and voluntary retirements.

About 2% of the people eligible for voluntary retirement have put up their hands. At this point we haven't accepted very many of those, because our first priority was to make sure we had the staff to deal with H1N1, but as we move out of that phase, we'll be turning our mind to voluntary retirement in the near future.  This has meant we are able to keep our commitment about minimizing compulsory layoffs and that still is our expectation.   know through my family experience the pain of a compulsory layoff and it is something I want to avoid if at all possible.  I'll not promise that there will be no compulsory layoffs - but we will be really trying to minimize them.

Protecting our existing workforce though, comes at the expense of being very tight on recruitment.  This in turn means that we are tight on recruitment of new graduates that are coming from schools of nursing and other health professions.  I would dearly love to increase the number of new grads we take, as these people are our future and we need to make sure we've got a sustainable workforce into the future. And I hope we'll be able to increase our rate of employment for these new graduates in the coming years.  But it's going to be a tough time for a couple of years.

The creation of the new organizational structure has meant we're doing a lot of work slotting people into the new structure, assessing all the new jobs and so on.  

I'm conscious of the fact that I made commitments to those of you who are management and exempt staff that we'd have that done by now and we haven't.  In part because of H1N1, but that's not the only reason, in part it was a bigger task than we anticipated, and we still have a lot of work to do on it.  I apologize for not having met that commitment, but we are now confident we'll have all of the job assessment and alignment processes complete for the management and exempt staff by the start of the next financial year, April 1 2010.

Although we've still got these budget challenges in front of us, we need to acknowledge that there's more to life than budgets.  As I've said time and time again, we've got three goals - access, quality and sustainability - not just one.

So, what I'm hoping is that as we move into 2010, we'll be able to say "Look, we've done a lot of this budget work, and now what we want to be on about is improving care for Albertans, improving health standards of Albertans, improving the flow of patients through our system so we can address the waiting list problems and emergency departments and so on."

And this is going to be a major aspect of my work over the next 12 months. 

One of the sobering facts that we face in Alberta is that a kid born in our province today can expect to live about a year less in terms of a healthy life than a kid born in other Canadian provinces.  And at the same time, after you adjust for age and gender, we're spending about $500-$600 more per person per year than the average Canadian province. 

So we ought to be able to do so much better.  We ought to make sure that in the future, kids born in Alberta have a better healthy life expectancy than kids in other provinces, and this is going to take a major effort not only in making sure our hospital care is good and there is good access, but more importantly, in making sure that our primary care system is working well and we're addressing population health needs across the province.

We've also got more to do in building the trust of Albertans in Alberta Health Services.  There's a lot of criticism of us in the media - a lot of it unfair I think.   They ascribe all sorts of motives to us which are quite unfounded.  But rather than react to that, we are going to do a better job in 2010 of talking more about what we ARE doing, and what it means for our patients and clients. 

In summary, what we are all about is improving the access, quality and sustainability of healthcare in Alberta, and in so doing, improving the health status of our fellow Albertans.  I think we're well placed to do that - to do a great job of doing that.  I'm looking forward to the challenge that 2010 will bring.

This year has been a tough one, not only because of H1N1 and budget issues, but the implementation of a new organization and everything else.  You, the men and women of Alberta Health Services and your physician and other colleagues, should be proud of your achievements.  You've continued giving the best care, the best in keeping people healthy, the best service in support of those providing direct care and other services.  I'd like to thank you for that.  It's been hard but you've done great things for the Albertans we serve, the people who live with us in our community.

I'm taking a break over the Christmas period, a bit of a refresher in a sense, and I'm of course looking forward to that.  I hope you have that opportunity as well, but in any event, I wish you the joy of this season and thank you for all that you've done.

If the technology works, we should now be able to take questions.  I'm not going to be able to answer all questions that you have - but we're developing a mechanism, where I can respond to all the questions you raise.

Now - over to you...

Since I started this Blog on 28 March I've made 18 posts (this is the 19th), had over 800,000 hits, and over 1,000 people have posted comments. On average we seem to be getting 100,000 hits on the Blog per month. What is on the Blog (both on the main Blog posts and the responses) is written by me and is meant as a way of communicating with you, the men and women of Alberta Health Services.

The Blog is an open one in the sense that it is hosted on the Alberta Health Services external site, so obviously the messages can be read by a wider audience. But that is not its main purpose. Communication lines in an organization as large as Alberta Health Services can become quite long and messages can be distorted. That is one of the reasons I want you to be able to hear directly from me what decisions are being made, the directions we are going in, and so on.

As I said, we have now had more than a 1,000 comments posted in response to the Blog or in response to other people's comments. I read all of the comments that are posted and try to respond to all of them as well. The Blog rules specify that because this is a Blog for Alberta Health Services staff, only comments with an Alberta Health Services email address will be posted publicly. I am a bit more lenient than that and also have posted a comment from a Convenant Health email address, "Alberta Health Services" is taken to include our subsidiaries. Comments which do not have an Alberta Health Services address are not uploaded. This means that you need to let me know who you are. This information need not go any further as you can use nicknames, initials for your public description.

Almost all of the comments that are posted from an Alberta Health Services email address are uploaded. There is probably only a handful (less than five) that haven't been uploaded since the Blog started and I have generally sent an email to the person who posted explaining why not, and how they went outside the Blog rules.

From my perspective the comments are extremely valuable and provide an opportunity for me to hear directly the views of staff on decisions we make.  As you can tell by reading the comments, not everybody likes every decision we make, but management is not a popularity contest! Managers have to balance competing interests and/or competing objectives. It's the manager's job to weigh the issues and work out which path is most likely to take the organization forward, in our case in terms of access, quality and sustainability. Sometimes it's easy, and you can achieve all three with a single decision. In other cases there is a balance. One of my friends once said that management is about choosing which problem you want to be left with!

Back to blog issues. As some of you know, I have asked line managers to follow up some of the issues you have raised directly with you. If you have raised issues and I haven't responded please feel free to raise them again. When I started the Blog I was a bit concerned whether I would have the time to do regular posts, read and respond to comments. As you know I generally respond every few days, although sometimes it takes me up to a week to respond to the comments. But as I said this is an important mechanism for two-way communication, so please keep reading and commenting.

On another matter, we've had a few comments about the material that was posted on the College and Association of Registered Nurses of Alberta (CARNA) website purporting to be a summary of remarks that Andrea Robertson (Senior Vice President, Nursing Strategies) and I made to a nursing leadership forum recently. The "summary" was inaccurate. A couple of other attendees at the forum have called us to state that the summary does not accord with their recollection of the event either. Click on the following link to read our response and request to CARNA, where we asked them to take down the material.

Finally, I'm continuing my travels, most recently to Leduc and Devon.

Best wishes,

Stephen

Colleagues

If this second wave of H1N1 is a twelve-week pandemic as clinical leaders  project, we are one-third of the way through, so I wanted to touch base with you and thank you for what you have done so far in responding to this dramatic challenge.

Unfortunately, we got off to a rocky start with the vaccination line-ups.  We have been criticized for allowing people who weren't in high-risk groups to queue up for vaccination.  It is easy in hindsight to be critical of that decision: it led to inappropriately long waits and we should have been better at line management earlier.  But with all due respect to our critics, these issues need to be considered in the context of the results you achieved. We're moving very quickly, faster than other provinces, which means we are protecting Albertans sooner. I'm proud of that and all of you should be as well.

Public sentiment toward vaccination changed rapidly following the high profile, tragic deaths of several young people early in the second wave.   Initial polling, which showed 40 - 49% of Canadians wanting to be vaccinated, converted into polling that showed 75 - 80% wanted vaccinations, almost a doubling of demand more or less overnight.  We were overwhelmed, with the visible consequences.

The stop-start nature of the vaccine supply is also causing significant supply-demand pressures.  I have teleconferences almost every afternoon where we talk about how much vaccine we have left, how much we expect to get next week and so what  groups we can vaccinate, given expected supply, relative need and estimated size of the group.  Last week the vaccine line-ups were more or less non-existent, partly because a lot of people were vaccinated in the first week, partly because of phasing in the eligible groups, and partly because Albertans are staggering their attendance at the clinics but principally because of your good work in staffing, managing and supporting the clinics. I know that it can be stressful for those of you who have to make quick clinical judgments about eligibility in the line ups. Rest assured I will support you when you make those judgements in good faith.

Next week we should finish the roll-out of vaccination to all the high-risk groups and so we should be looking to expand to the rest of the population as soon as we can. But again how we roll out this next stage  is going to be limited by how much vaccine we receive.  This is not in our hands.

We are now seeing the impact of H1N1 on our hospital beds and intensive care units.  We have done some modeling of what a twelve-week epidemic would look like and the impact on ICUs and hospital beds is slightly greater at this stage of the epidemic than we projected. Our ICU Surge Capacity plan, and our prior purchase of additional ventilators, is allowing us to open additional ICU beds, and deploy staff, as needed, when needed, and where needed.

But we are still only a third of the way through the pandemic and I expect things to get tougher over the next few weeks, especially in terms of demand on hospitals. We will therefore need to start re-allocating resources to a clinical area or service if patient volumes and / or staff illness require us to do so. This is called the selective prioritization activation level in our pandemic plan.

The pandemic has been a mobilizing experience for Alberta Health Services.  I sent an email to one of our administrative staff yesterday and got a reply back which was something along the lines of, "I'm helping out in the Emergency Operations Centre and H1N1 is my highest priority and so I may not be able to address this issue.  Please contact so and so etc."  I was tremendously heartened by that sort of auto reply.  H1N1 is the highest priority for this organization and it is so good to see so many stepping up to the plate.

It's also good to hear that the public is recognizing the good work you're doing.  This week I heard the story of the gentleman who bought dozens of roses and handed them out to staff in the Calgary clinics, and of others who are providing other tokens of their appreciation.

I would like to join them and emphasize how grateful I am that so many of you have gone so far beyond what can be expected of you to help Albertans weather this crisis.

Thank you for everything you are doing for all Albertans.
 

Stephen

Colleagues

An issue which occasioned much comment earlier this year was the new Alberta Health Services' Code of Conduct.  Although based to some extent on the Codes used by our predecessor organizations, it attracted a great deal of criticism for being overly prescriptive and impinging on democratic rights.  In part as a result of that criticism, and in part because of our processes for regular review, we sought the views of staff on the Code and received a lot of feedback.  The Governance Committee and the Board agreed to a redraft of the Code.  That redraft is taking shape and we are now ready to seek further comment. My aim is to finalize the new Code this year by taking it to the December 3rd Board meeting, for implementation in the New Year.  That necessarily means the time line for the second round of consultation will be short, but no less important.

The new draft takes a quite different approach from the one developed last year, which was restrictive and focused on rules rather than our organization's values.   Since the current Code was developed, we have approved a new Strategic Direction for the organization with a new set of values (respect, accountability, transparency and engagement) and it makes sense for a new Code to take those new values into account.  Similarly, we had few organization-wide policies in place when the Code was first written, and as a result the Code covered much detail which is now appropriately covered in Human Resources and other policies.   So the new draft looks quite different from the old.  It is 'principles-based' and provides a guide to our actions and decisions, rather than delineating precise rules. 

But don't get me wrong.  This is still a document which guides acceptable behavior; the Code is an important document which will help to set the 'tone' and culture of Alberta Health Services, how we interact with patients, clients, the community and how we interact with one another - again based on the values we have adopted.   As described in its introduction:  "Our Code is based on both rights and responsibilities. It protects and guides equally all of those who are part of, or work within our health system. It recognizes the challenges we face, the high standards expected and needed of us, and the paramount importance of our shared duty to the people we serve."

The new draft is now posted online, please click here to view.  I'd appreciate it if you would take the time to look at it and send your feedback (positive or negative) by Nov. 11 directly to Noela Inions, Ethics and Compliance Officer, via e-mail at complianceofficer@albertahealthservices.ca .

Thanks,

Stephen

Colleagues

This week marked my 200th day in Alberta, an opportunity to reflect on progress.  Much has been achieved: we have introduced and populated a formal structure for the organization (including recruiting highly talented people to the executive team); set a strategic direction; introduced regular financial reporting, accountability and budget targets; set new standards for public reporting and accountability; and started the journey to fiscal health.  All this has been achieved in an environment of intense public scrutiny.

In terms of getting out and about, last week I visited Wetaskiwin and Ponoka Hospital and Care Centre, meeting about 100 staff, then on to Rimbey to celebrate the opening of the new hospital wing.  I've now visited about one third of our acute care sites across the province.

But of course, there is still much to be done.  The 2009 - 2010 budget targets are still a challenge and we have set ambitious goals for improvement in access to care for this year.

Action Your Ideas

Many of our budget strategies so far have been developed by the leadership of the organization.  In some circumstances the budget planning has involved tough decisions about the need to reduce staffing levels, preferably through the vacancy management process and voluntary retirement.

But I know from the comments made in this Blog that many of you have lots of ideas about how we should go about achieving our savings targets.  I also know that some departments have already had meetings to seek your ideas about where we should be looking for savings.  As I said in my speech to the Canadian College of Health Service Executives last month, I see part of my job as a leader as being to "liberate you to think and act creatively."  And I now want to put my money where my mouth is.

Even though we have done a lot already in terms of the savings we have locked in, the remaining budget challenge is still big. So what I am now seeking is your creativity and your ideas about how we should find further savings.  So starting today we have set up a website for staff and physicians to put forward their ideas for cost savings.  We are looking for ideas to come forward before December 4, 2009.  Every idea will be acknowledged and evaluated.  If we don't proceed with it, we will tell you why and of course give you an opportunity to revise and enhance it.

I invite you to work with your manager, leaders and team to submit your cost-saving ideas to us. I also ask that you consider ways that your unit or department can become more cost-effective by reviewing your daily tasks, processes, resources and work environments.

So we are looking for good ideas which are going to help us save money.  All the ideas you submit will be evaluated by a multi-disciplinary team as we go along but you are asked to talk to your managers or senior physician leaders to get an initial reaction to your ideas.

The ideas that are proven to involve some significant cost savings will go into a draw to win one of several prizes.  The prizes we are proposing  are

·        one of two customized weekend packages that interests you such as a skiing get away or horseback riding;

·        one of two $500.00 gift cards that can be used for the store or business of your choice; and

·        one of five customized team packages that interests your team such as going to a sports event, dinner theatre or having a team luncheon. 

To demonstrate my own commitment to this, I have agreed to pay for these prizes personally.

We will provide regular updates as we evaluate the ideas that come forward, including featuring staff and physicians who have submitted some of the best cost-saving ideas in future editions of the Connect newsletter as well as inviting them to co-author an entry about their idea on my blog.

I am hoping that this program will generate some really exciting ideas to help us achieve our targets.  I'd encourage you to participate in this exciting initiative.  Let's see how many bright ideas come forward which help to position us better for the future.

Best wishes,

Stephen

Colleagues

My travels around Alberta continue.  Since my last blog I've been to Fort McMurray, Calgary, Red Deer, Bonnyville (to sign an agreement about First Nations' health), Cold Lake, Vulcan, Carmangay, Okotoks and Black Diamond.  One of the interesting things about the Cold Lake visit was that we have people there filling corporate office roles, including our provincial Director of Patient Concerns.  It caused me to reflect on how technology (emails, even telephones) allows us to be "location independent", that central coordination can occur from any point in the province, and that, for better or worse, our office is as close as our mobile/cell phone/blackberry!

I've given quite a few talks in my travels and these are available on my home page. Most importantly, I've made commitments to our Foundations that money raised locally will stay local, outlined our approach to rural health issues  (more on this to come as our rural health planning framework is finalized later this year) and described our first thinking on new processes for clinician engagement.  The clinical engagement framework has been developed to ensure the expertise and experience of physicians, nurses and allied health professionals will inform patient and population issues, improve clinical practice, patient outcomes, quality and patient safety, and strategic planning.

The Fort McMurray trip was for the monthly Board meeting (although we took time to meet with people from the local community and tour the hospital as well).  Amongst other things, the Board noted the feedback on the Code of Conduct and that we would be undertaking a revision of the Code.  We will probably have a redraft of the Code available for a quick consultation commencing late October.  We aim to take the revised Code to the December Board meeting.  Speaking of the Code of Conduct, I've now been formally asked to respond to a complaint against me referred to in the previous blog entry and have done a first draft of my response.  This will be submitted to the Ethics and Compliance office some time in the next week or so.

 Alberta Hospital Edmonton

Alberta Hospital Edmonton has been much in the news of late so I thought I should provide you with an update on where we are with this.  

The high-level Implementation Team that was struck last week has begun its work, with its first meeting on Tuesday of this week.  As the team gets up to speed I have taken the opportunity to reiterate what I said right at the start of this process:  not a single patient will be moved unless and until we have somewhere for that patient to go.   That was my commitment then, it remains my commitment today.  Obviously, though, our message wasn't getting through.  It is for that reason that I welcomed the Premier's initiative, and the opportunity to create a pause in the process that, from my perspective, will ensure that we stay true to the commitment.

I have also offered the view that the move toward "mainstreaming" (co-locating mental health beds in general hospitals) and, where it is right for the patient, more community-based treatment, have been world-wide trends for some time now and are well supported in the literature. Not surprisingly, there have been calls in the past for mental health services in Alberta to pursue these same directions.  The issue then becomes, what is the best, safest way of getting there?  What must we do to ensure that any move is demonstrably in the best interest of patients?  

Review by the Implementation Team can help here.  The Team has a number of members with strong mental health patient advocacy backgrounds, so you can be sure that anything we do will be evaluated from that perspective. The depth of experience on this team makes the standard that much greater: they bring a wide variety of perspectives, as in order to be effective, the committee needs that broad base of viewpoints.

The creation of the new team will also assist in documenting where we are and where we want to go.  That in itself will be a good thing as I think part of our problem was that we weren't clear enough about what we were proposing.  Rumour, gossip and fear found a niche in which to fester in the absence of clarity.   But why weren't we clear and explicit?  Unfortunately because we were doing what we had been accused of not doing: consulting.  Back in August we set a broad direction of mainstreaming and then began consulting on the details.  Over the ensuing period much has been fleshed out but there is still more to do.  The creation of the Implementation Team will add insight, experience and advice to provide a clearer path.  

So bear with us folks.  Our work, and that of the Implementation Team is a work-in-progress, with a necessarily high degree of uncertainty based on the fact that we are genuinely interested in engaging with clinical leaders and key community stakeholders.

There is still a lot of work to be done on finalizing which beds might go where, what space is available in the acute units, what renovations need to be made to make them suitable, how long the renos will take, what clinical teams/groups will move where  and so on.  This will all take time and so I can't say that tomorrow, or next week, or next month these patients will move on this particular day.  At this stage, I can't see any moves taking place this year but we should be able to start some of the moves in the first half of 2010, again based on the best interests of our patients.

What I can commit to is what I've said from the start: no patient will be moved unless and until there is a bed for them to go to.  The new Implementation Team will now guide all of this work, so we will have to show them the details of our proposals before any patient is moved.  This level of accountability may help to give assurances to the skeptics that we were serious when we made the commitments about this whole process, commitments that I'm happy to be judged against.

Best wishes

Stephen

Colleagues

A Code of Conduct complaint about me has attracted a lot of publicity and commentary.  The complaint is being investigated by the Board of Alberta Health Services quite independently of me and how it will play out is not in my hands. 

I am serious about supporting ethical behaviour in the workplace and am totally opposed to bullying.  To describe my efforts to discuss frankly some of the issues we face as bullying is unfortunate.  I recognize the use of hyperbole in debating issues, but we should be careful about using terms such as bullying, which may weaken our ability to recognize and address real bullying when it occurs.

For the record, as I have said on a number of occasions, nurses are now and forever will be an essential component of the health and hospital workforce.  I respect and value their contribution and look forward to continuing the discussion.

Best wishes

Stephen Duckett 

Colleagues

Just a quick update and thanks to all those who have commented.  Tuesday was a record for blog hits - over 30,000 - with a further 16,000 yesterday.  I would have liked for you all to hear about the details of our proposals at pretty much the same time as our official release, but unfortunately that didn't work out.  I'll try better for next time!

There's been a lot of commentary in the media already, some based on what is actually going to happen, some based on some fantasy of the commentator.  Let's be clear about what is happening.  First, people who no longer need acute care but are occupying acute beds because they are able to be cared for in a community space but can't find one will be able to get one. (And so we hit the Quality button).  Secondly, there is a net increase in the number of beds effectively available for acute care, admittedly only a net increase of 60 beds, and sure I would have liked more, but 60 is 60.  (And so we hit the Access button).  And at the same time as improving access and quality we save some money (and hit the sustainability button).

You'll appreciate that this has been a pretty busy week for me and I apologize for not being able to respond to all the comments.  I'm also tied up for the rest of the week so I thought some generic responses might help in the short term.

First, I really appreciate those of you who have said kind words about the blog.  I sincerely believe in transparency and I want to make sure you know where I'm coming from on important issues.  You may not always agree with me (at least that is also clear!) but you should know that I will not hide anything from you, palatable or not.  If you disagree with my comments or ideas, feel free to say so. 

If you look back over previous blogs and some of my speeches you'll have seen some themes, about Alternate Level of Care patients, about attempting to avoid lay offs, which were repeated in this week's decisions.  Think back to a few months ago when I implemented the vacancy management program.  Again, lots of criticism.  But think about it now.  Every person we haven't hired is a layoff avoided.

A number of you asked some similar questions: why the differences between Edmonton and Calgary and why no mention of rural.  Well, in part the Edmonton vs Calgary differences are about starting in different places.  Edmonton has Alberta Hospital Edmonton and Calgary doesn't.  Also a bit of an insight into how the numbers came about.  On the one hand we had to be able to identify how many Alternate Level of Care patients there were in each hospital.  That put a cap on the number of patients who could be transferred out.  We also had to identify how many community facilities had beds coming on stream in the next couple of years.  Don't forget, for this strategy to have any credibility we needed to be able to point to real beds in real places that we would fund.  Not empty promises.  I have said many times that we weren't moving anybody until they had a place to go to.  Anyway, both sides of these equations were different between the two cities and so we ended up with the different numbers.  Nothing nefarious I assure you.

 What about rural?  I acknowledge that we have the same problems of inappropriate bed use in both large regional cities and in smaller rural centres.  But back to the Edmonton vs Calgary equations.  Yep, we have one side, the patients who shouldn't be there, but we don't have the places for them to move to.  We aim to develop/stimulate about 10,000 additional community places over the next 5-7 years as part of the Seniors' Action Plan we are developing.  As those places come on stream we could look at similar strategies in other places, as I've said previously this will occur with local consultation.  But, unfortunately, without beds I can point to, I can't do the same sort of thing, desirable as it may be in terms of better accommodation for those stuck in hospital beds.

 Anyway, thanks for all your comments.

 Best wishes

 Stephen

Colleagues,

Unfortunately, in terms of my travelogue I haven't got anything more to report.  I have stayed close to Edmonton over the last couple of weeks as we transit from summer into the fall.  The Board and its sub-committees are back now, with lots of papers about tracking our progress and moving the policy agenda forward.

As you know from my last blog, I had been planning to release both performance data about how Alberta Health Services is tracking and how my variable pay (aka 'bonus') will be calculated.  Unfortunately this was all a bit delayed, principally because we needed to get the data right and in a form which is comprehensible to you and the general public.  All of this will be uploaded today and should be available at 6 PM on our publications page http://www.albertahealthservices.ca/205.asp.

But the thing that has consumed most of my time for the last couple of weeks has been addressing our budget.  I have said right from the start that we face a significant budget challenge.  We won't be able to achieve all the savings necessary this financial year and so we have adopted a multi-year approach.  We must position ourselves so that we go into the next financial year with the savings strategies in place or at least locked in for implementation in the first few months of the financial year.  This has been an incredibly difficult task, to put it mildly.  If we didn't care about access and quality then achieving savings would be easy, but that is not where we start.  We have obligations to Albertans and indeed it is important to recognize that most of you work in the health system because you feel an obligation and a calling to be, directly or indirectly, part of providing high quality services.  Achieving the sustainability goal whilst improving access and quality is difficult, and designing a strategy to do that has taken a lot of time.

You will be aware that in many of my talks and in some of my blog comments I have referred to the issue of so-called "alternate level of care" (ALC) patients, patients who no longer need the intense care that an acute hospital can provide but can't get access to a bed in the community such as in a long term care or supportive living facility.  Think about it: these patients are not getting the support they require.  Sure, if they need acute care, they will get it and get good acute care, but the staff of acute care facilities like working with acute patients, they are trained to work with acute patients, that is their skill.  For a person who doesn't need acute care, that skill is wasted.  More importantly, acute care staff may not have the skills to help build and maintain a person's independence, and they won't be oriented to meet the different needs of such a person.  So we are not providing the best quality of care for that person.

Having alternate level of care patients in our acute facilities also means we are moving backwards on our sustainability agenda.  Our acute wards are staffed to meet acute care needs, not long term care needs and so there is a very different staffing profile and obviously very different costs.  We've already recognized this issue to some extent by 'cohorting' Alternate Level of care patients in some of major hospitals.  But even here, we haven't adopted exactly the same staffing profile as if the patients were in community facilities and the physical design of the ward is nothing like what we would see in community facilities.   So we can save money by moving alternate level of care patients to services in the community.  That one action helps us progress in terms of both quality and sustainability.  To the extent we keep acute beds staffed and open, it also helps us with our access agenda.  It is this thinking that has underpinned a lot of our work over the last few months, thinking about how we can improve quality, how we can improve access and how we can improve sustainability with the one policy initiative.

A particular example of this has been Alberta Hospital Edmonton.  Alberta Hospital Edmonton also has its alternate level of care patients who would be better accommodated in community based facilities of a kind similar to long term care or supportive living facilities.  So a couple of weeks ago we announced this broad general direction of moving patients from Alberta Hospital Edmonton into the community.  As I have remarked on a previous blog this has been (deliberately or otherwise) misinterpreted as suggesting that people would be moved without adequate supports.  Nothing could be further from the truth.  In my view the new services that will be used to support people leaving Alberta Hospital Edmonton will mean that their quality of life will be significantly improved.  We are now putting the final touches on this constellation of initiatives which I will be announcing later this week.  I have been criticized because of the approach we have adopted to managing this change process.  As you know we announced a broad general direction with a commitment about ensuring that services would be in place before any patients were moved, but no specifics as we were going to flesh out the specifics following consultation with staff and physicians. The alternative would have been to finalize and announce details without consultation, an approach which I suspect would have attracted even more criticism.  When we announced the broad direction for Alberta Hospital Edmonton we had some thoughts about the mix of services that we would need to provide to meet the commitment I had made. What has come back to me following that consultation is significantly better than what we started with.  Not just fine tuning and marginal tinkering, but significantly better, with a whole new service suggested.  So despite the criticism about this approach, I am committed to continue to consult on implementation of our proposals.

These decisions are designed to take us forward in terms of access, quality and sustainability.  None of this will be easy.  Over the next couple of years patients will move from one location to another, which means that the need for staff support for them will also move from one location to another.  The staff we need in the new facilities will be staff skilled in promoting or maintaining independence of these patients, not meeting their acute care needs, so we will need to reprofile our staffing.  As you know we instituted the vacancy management program a few months ago and have also announced a voluntary retirement program.  Both of these are designed to minimize the number of compulsory layoffs that might be associated with these changes. We are not currently looking at lay-offs and we will not consider lay-offs unless and until it becomes absolutely necessary.  Any rumours or statements you have heard to the contrary about layoffs this week for example, are wrong, misleading and mischievous.  By the end of this week you will know whether my denial or the person from whom you heard the rumour spoke truth.  Please bear that in mind the next time you hear a rumour from that source.  I am committed to being transparent with you, and to the extent possible I will ensure you hear things from me first, not via the media.

I know these last few months have been hard: uncertainty creates anxiety.  The possibility of job losses is still with us.  Many of you have told me in your blog comments that it is easier to just pack up and leave Alberta.  Many of you don't have that opportunity, or you want to continue working with us.  I would like to thank all of you who have stayed with us in this difficult time.  I know it's hard and it will continue to be hard for a little while yet as we identify whether our vacancy management and our voluntary retirements will mean that we can meet our budget targets.

But let's remember how we got into this situation.  The province is in deep financial trouble.  Although the price of oil seems to be recovering, the price of natural gas is extremely volatile. It is my hope that the provincial budget will be healthier next year and healthier the year after that as well.  We have to ensure that the changes we are making now position us well for when the province returns to financial health. We will then be well placed to say: "we made our contribution in the hard times, there are still additional health needs out there and unfortunately we had to put them on hold during the hard times, we're out of that now and here is our list".  Alberta's financial fundamentals are sound and so the good times will return.  I am convinced that the decisions we are taking today will help position us well for that future.  So thank you for bearing with us.  

Click here to read the news release: 2009-2012 performance measures and CEO access and quality improvement targets posted

Best wishes,

Stephen

Colleagues

We passed an important milestone last Thursday: 500,000 hits on the blog since we first posted on 28 March.  We've also had more than 600 comments posted.  Thanks everyone for reading it and a special thanks to people who posted comments, I hope the interchange is productive and useful.

Since my last blog I've continued my own personal "Travel Alberta" program, visiting Grande Prairie (again), Beaverlodge, Fort Saskatchewan (see my speech on pandemic preparedness), High Level, and Fort Vermillion.

One of the things I have been intrigued about since my arrival in Alberta is an obsession in the media with my salary, the nature of my contract, and the nature of my potential performance bonus.  Generally, people quoted in the media speak with an air of authority and certainty about the nature of my contract.  So for example, one commentator asserted that I have an annual contract and that I am on a very short string with a contract renewed annually.  It begs the question: Why would I have left a good job in Queensland, uprooted my family, and bought a house in Edmonton for a job that might only last 12 months?  To put the record straight, I have a long-term contract with Alberta Health Services.

Similarly it is regularly asserted that the sole criterion for my bonus is Alberta Health Services' financial performance.  Again this is a furphy. (Another Australianism, meaning an erroneous or improvable story.  If you check on Google you'll find that it derives from the name of the manufacturer of water tanks used in the First World War where people stood around exchanging gossip and rumours).

Think of the context within which I work.  We went through an extensive development program for Alberta Health Services' Strategic Directions over the last few months, the Board endorsed the Strategic Directions document at its June meeting, and we released it a few days later.  The Strategic Directions document emphasizes that Alberta Health Services is pursing three key goals:  Access, Quality and Sustainability. Three goals, not one.  These goals encompass eight areas of focus including improving access, decreasing waiting times and so on.  I have taken these three goals and these eight areas of focus as the basis for the performance targets that I have negotiated with the Board and which will form the basis for calculating my bonus.

In fact my bonus will be pretty evenly balanced over the three goals of Access, Quality and Sustainability.

What we are on about in Alberta Health Services is to provide access to good quality care and treatment, and good preventive services, to the people of Alberta.  That is our raison d'être.  However, we need to do that in a way which is financially sustainable.  And so my performance bonus and the organizational strategic directions involve this balance across the three domains.

The Executive Committee was involved in the development of my performance agreement and a significant proportion of their bonus will be based on the achievement of my bonus: that is they will be locked into the same balance of goals across access, quality and sustainability.  Other components of their bonus will be based on specific goals related to their areas of responsibility and the extent to which they exhibit the organizational values of respect, accountability, transparency and engagement.  I would expect that the bonus arrangements of their direct reports will reflect a similar mix of domains.

I have given copies of my performance agreement targets to senior leaders in the organization and so they will begin to drift down the organization over the next little while.  I will also release the details of the bonus arrangements, and post them on our website, later this week.  We will also start releasing information about key aspects of Alberta Health Services' performance, such as progress against our access targets, number of patients admitted to our hospitals and so on.  We've been slow in releasing these data because we needed to make sure they were correct.  The different regions had used different definitions and different ways of collating data which meant that, despite a spurious air of accuracy, the data were not compatible and didn't allow accurate or fair comparisons.  Over time, as we continue our work on data integrity, I hope to expand the information we release into the public domain.

Another planet?

As an aside, when I mentioned to one of my colleagues that I would shortly release the full details of my bonus arrangements publicly she challenged me on that and said, "do you mean everything?" and I said, "yes."  She looked at me as if I had come from another planet and pointed to the criteria for levels of the bonus and asked again, "everything?" and I said again, "everything." She looked astonished and I looked at her quizzically.  She just said that this is not something that had ever been done before.  I pointed out that this is consistent with our value of transparency.

But she is not the only person who seems to think that I come from another planet.  I have been amazed at the continuing xenophobia associated with my appointment.  Canada has a reputation in Australia of being very open and welcoming to migrants, indeed my impression is that Canada seems to do that better than Australia.  I am constantly surprised therefore at the number of comments made in the media (especially by bloggers) about the fact that I am an Australian and that a Canadian should fill this job.

Australia and Canada share a common heritage and our health systems are in fact quite similar, albeit with some significant differences.  Australia's Medicare arrangements were based on Canada's and the two key economists who developed Australia's Medicare spent time working in Canada.  If I recall correctly, some Canadians were hired to work at the most senior levels in Australia as part of the early implementation of Medicare (then called Medibank).  The late Anne Crichton, a friend and former professor at the University of British Columbia, entitled a monograph comparing the two health systems "children of a common mother." *

But back to where I started.  According to one poll,"significant majorities of Canadians feel that Medicare (85%), two official languages (73%), peacekeeping (69%), and the CBC (60%) are essential characteristics of the country".  (To some extent, Australia's Medicare holds the same iconic status).  So it's no surprise that Albertans are watching closely how we go in improving health care in this province.  I'm absolutely convinced that it is possible to make headway on wait times and seniors care and so on while balancing the budget over a reasonable period of time. We cannot do everything all at once, but we need to get on with the job.  We also need to demonstrate that we are going forward, and that we are serious about achieving the ambitious goals we have set for ourselves, so hence our commitment to publish information to allow the public to track our progress.

With best wishes,

Stephen

* Anne Crichton (1998) Children of a common mother: a comparative analysis of the development of the Australian and Canadian health care systems to 1995 (Australian studies in health service administration no. 83) School of Health Services Management, University of New South Wales.

Colleagues

I hope you've all had a relaxing and refreshing Summer break.  As you'll know, we've got challenging times ahead of us.

Since my last blog I've continued my "Travel Alberta" program, most recently to Lethbridge and on to Pincher Creek to look at a really good model of service integration in a rural setting.  On Tuesday, I gave a speech at the Calgary Rotary Club called Life in a Cold Climate: Managing Canada's Biggest Merger, about our directions and some of the challenges facing us.  A copy of this speech is available here.

The Budget

We continue to work on the budget.   In my second blog post back in April, I talked about the "budget blues."  I mentioned that "we had quite a big task ahead of us," and so this proved.  Although we got a 6% or so increase in funding, this is not enough to meet our current spend.  The Board at its June meeting approved a budget for Alberta Health Services in 2009-2010 which was framed as involving $250M of budget savings, growing on an annualized basis to $650M.  This budget meant we would have to borrow significantly to balance in 2009-10 and would leave a gap of somewhere between $500M and $700M in 2010-11, assuming that we would achieve a funding  increase of 5.8% in 2010-11 and be fully funded for the opening of the new facilities which come on stream in that year.  A big task indeed! 

Over the last few months the Executive and senior staff have been working on identifying ways in which we can save that money.  Steps to rein in expenditures include our vacancy management program, which has tightened up on external recruitment.  My goal in all of this is to minimize potential layoffs.  We have made significant progress on identifying areas of savings, and one of the most outstanding has been the work done in procurement.   Here we look to make around $200M of savings in a full year, and we are on track to achieve that.  Those sorts of savings can only be achieved as a result of the work done, not only by the procurement folks, but by people throughout the organization who are thinking about how to standardize the products we purchase, and improve distribution of products.  We might even be able to increase our saving estimates through our collaborative work with British Columbia.  There are further savings to be achieved in back office functions.  We are looking to rationalize our multiple payroll systems, multiple HR systems, multiple IT systems and so on to achieve further savings. 

But we are aiming not only to minimize layoffs but also to ensure that service delivery is protected.  One of the examples I have talked about in the past few weeks is how we could achieve savings and improve quality at the same time, specifically mentioning patients occupying acute beds who don't need to be there - the so-called "alternate level of care" patients. If you think about it, once an acute care episode is finished, a hospital bed is a silly place for a person to be. The environment is noisy, not the least bit home-like and so on.  It is far better for that person to be in a more home-like environment, quieter, in more comfortable surroundings, than to occupy an acute bed.  It also helps us with our sustainability goal.  We staff a hospital bed for people with acute needs, the nursing staff are trained and oriented to look after people in acute need.  People in residential care have different health needs and different expectations (and rights) about maintaining their own independence.  So part of what we need to do is to open additional residential care beds, so that we can move those alternate level of care patients out of the acute facilities, thus achieving a saving and a quality improvement at the same time.   That sort of an approach is going to be a cornerstone of our budget strategies and we are now looking at these sorts of strategies across the province.  These strategies need to be carefully phased so that to take account of when residential care facilities become available. More on this soon.

This approach is also central to our thinking about Alberta Hospital Edmonton.  When I visited there earlier this year staff talked about "ALC patients" and after asking a few questions I realized there were the same issues at Alberta Hospital Edmonton as in our other acute facilities: people who are occupying acute beds with nowhere more appropriate to go.  Again, any downsizing at AHE has to be accompanied by appropriate accommodation or services being established in the community. Our commitment to our patients is clear: No hospital spaces will be closed unless and until community-based beds and services are in place.  We are currently consulting with staff at Alberta Hospital Edmonton on what appropriate services might look like.  Unfortunately the to-and-fro you see in the media on this issue is the result of our desire to consult on what is appropriate care for the people who might be moved, so we can't be more definitive about what the next steps might be.  I'd invite those who question the decision not to redevelop Alberta Hospital Edmonton to remember that if the hospital were to continue in its current form - a care model out of touch with contemporary best practice - there would be a need for a massive redevelopment.  Such a redevelopment is not currently on the approved and funded capital program and it seemed to me to be dishonest to keep pretending that such a development would happen.  I recognize that there are concerns about whether or not the community spaces will be created. To that I say: Watch us.

These sorts of strategies are in fact not enough to achieve our budget goals, so we need everybody in Alberta Health Services to put on their thinking caps to identify different ways of achieving savings.  I will be shortly writing to senior staff in the organization seeking ideas where they can develop saving strategies specific to their local organizations, zones or hospital facilities.  A number of you in your blog comments have pointed out areas of inefficiency across the organization, including comments from people who are not working to their full scope of practice. So as we issue budgets to zones and facilities we will be setting targets for further saving strategies.

But in preparing our budget strategies we must always have in mind the Strategic Directions of the organization.  We have set ourselves ambitious targets about improving Access, Quality and Sustainability.  So any saving strategies must not impact on the access and quality goals of the organization as we have articulated them in the Strategic Directions.  We have committed to improving access and quality and so I'll be looking to saving strategies and other organizational arrangements which help us achieve those ambitious targets.

Albertans have a reputation for innovation and a "can do" attitude.  It is my hope that we can harness this energy, this innovation to come up with bright ideas which we can use to achieve our budget targets and improve service for Albertans.  I have asked the three "hospital" Senior Vice-Presidents and the Zone Vice-Presidents to schedule regular discussions about different ideas that are coming forward so that there can be sharing across the organization.  That is how we can use the benefit of a single provincial organization to make sure there is learning across the province and that the bright ideas of one part of the province are able to be implemented in another. 

I am confident that with this sort of initiative we'll be able to demonstrate leadership across Canada in innovation in service delivery.

With best wishes,

Stephen

Colleagues

My recent travels around Alberta have taken me to Fort McMurray (with a side trip out to the oilsands), Vegreville and Lamont.  I was talking to someone recently who mentioned that I had probably seen more of Alberta than he had, a person who was Alberta born and bred.  But despite the fact that I have visited most of the larger centres in Alberta, I still don't really feel I know those cities and places well.  Certainly on my trips I try to understand the economics of the community, what it is that drives and sustains employment in those places, what are the seasonal rhythms and so on.  I still have a long way to go in that regard.  My trips typically involve arriving at an airport and a drive to a local health facility or office block, not much chance to see the scenery!

I've also recently had a quick trip back to Australia.  As some of you will know I continued on a major national Commission looking at reform of the Australian health and hospital system after I was appointed here in Alberta.  This meant I spent  most Tuesday nights participating by distance in the Commission meetings which were typically held on Wednesdays, Australian time.  The Commission submitted its report on the 30th June and the Australian Prime Minister released it on July 27, 2009.  He invited the ten members of the Commission to dinner at his official residence, the Lodge, on the 26th July, not something that happens everyday in your life so I went back to Australia just for the dinner and the launch and then straight back home.  The Commission's Report is available at http://www.nhhrc.org.au/.

What struck me about all of this was the similarities of the problems that are facing Canada and Australia.  I have also been reading some articles comparing the Canadian and the U.S. health care systems, certainly the U.S. is quite different from Canada and Australia but in a way they are facing similar problems of ensuring access, quality and sustainability, to use Alberta Health Services' terms.  Indeed, I am not aware of a health system in the world that is not facing the same challenges.

I mentioned in my previous Blog that we are working assiduously on preparing for the H1N1 epidemic and its impact on us as we enter the winter months.  As part of our preparation, I organized a teleconference between  Dr. Gerry Predy, our Senior Medical Officer of Health, Dr. Dave Megran, the Senior Physician Executive, me, and former colleagues in Melbourne, Australia who are coming out of their winter months.  We had about an hour on the phone asking them questions about the impact on ICU and hospital staff absenteeism, what they did about school closures, N95 masks and so on to learn from their insights into how they managed this epidemic.

We thought this interchange was extremely valuable, providing us some insight to help us in our preparations and the Australians also thought the occasion to reflect was valuable.  I am going to organize a similar teleconference with my former colleagues in Queensland in the next few weeks to tap into their experiences as well.

All of this emphasized for me the importance of learning from others, of  keeping our eyes and ears open to new ideas, new approaches to how we do things.  We often get set in our ways and think that what we've done in the past is the way things must work in the future.

We are facing a number of challenges both in the immediate term (the budget for example) and also the longer term (the increasing importance of chronic disease, dealing with issues of prevention) and we will need every skerrick (n. Australian. a small piece, a bit) of Alberta innovation to enable us to address these issues.  Alberta innovation will be facilitated the more we look to lessons from other places and the bright ideas that they have had.

The establishment of Alberta Health Services should also help in cross-pollination of ideas from one part of the province to another.  I know, for example, that there is considerable sharing of ideas occurring right now about budget strategies.  One that I'm particularly interested in is how we can improve the quality of care for people who no longer need to be in an acute facility but can't find a place in long term care or designated assisted living.  If we can help these people be accommodated more appropriately we may be able to improve both quality and sustainability simultaneously, and potentially access as well.

Research Plan

Some of you will be aware that we have been thinking a lot about how we can improve Alberta Health Services' participation in research.  We have had an external review of our approach by Drs. Lorne Tyrrell and Roger Palmer (copy of their report is available at http://www.albertahealthservices.ca/190.asp ) and are currently working out both how we respond to that report and how we position ourselves better to make Alberta Health Services a research friendly organization.  Engagement and research by clinicians will position us better for the future in a number of ways.  First, it will ensure that the clinicians themselves are up to date with the latest knowledge and treatments that can help us meet the health care needs of Albertans.  Secondly, a research-friendly environment can be very stimulating and will help us attract the best and brightest in the world.  In order for us to be a research-friendly organization we need to change some of our processes, we need to know how much our commitment to research is, we need to be accountable for our research investments and we need to set priorities about how we make our investments.  A draft research directions document is currently out for consultation with information about the consultation available on the above page (on the same page you'll also find our strategic outline for quality and patient safety http://www.albertahealthservices.ca/files/org-patient-safety.pdf).

The New Structure

We are well on our way to implementing the new structure with further rolling out of new positions occurring almost every week.  I am aware that this is a frustratingly slow process for those of you affected by it.  However we are a very large organization, with about 90,000 staff, and the implementation of this structure is certainly taxing us in terms of the number of positions for which expressions of interest need to be called, applications fairly judged, and appointments made.  Necessarily, positions are filled sequentially by hierarchical level.  Different parts of the organization are proceeding at different paces in this regard so that we can move as quickly as efficiently possible.

Finally, I'd like to thank all those who jumped in to assist following the disaster at the Big Valley Jamboree.  This involved people from right across the province offering assistance, clearing EDs and so on.  A good example of collaboration and dedication.

With best wishes,

Stephen

Well I'm back, after a relaxing 2 ½ weeks in France.  As some of you would have read in the media, I kept in touch with events happening back here.  Despite this, when I was driving back into the office on Monday morning I felt like I had been away for a month.  A lot happened while I was away and obviously we've got a big agenda over the rest of this financial year.

Helipads

Just before I went on holidays, I approved closure of eight helipads across the province.  This decision was based on a belief that Transport Canada had set a deadline for us to be compliant with "new" aviation regulations.  This belief was unfounded and the helipads in fact did not need to be closed.  The Board Chair, Ken Hughes, has already apologized to the Alberta community for this decision and it is obviously one which I deeply regret.  I am currently reading through piles of material about how this advice came to be given to me.

The response to the decision clearly shows that Alberta Health Services has a long way to go in rebuilding our credibility.  I will be carefully reviewing the background to the decision over the next week to identify what lessons there are for us in that process.  It is important though for me to stress that none of the people involved (myself included) had any nefarious intent.  This decision was not part of a plan to downgrade rural services but rather was driven by a false belief that we had little choice in this, given what was perceived to be externally imposed requirements. But more of that when we have finished the review of the decision process.

Code of Conduct

A Code of Conduct for Alberta Health services, to replace similar codes in predecessor organizations, was developed in 2008, endorsed by the Board in January 2009 and rolled out in subsequent months.  It was also distributed widely throughout Alberta Health Services in printed form just before I went away and attracted some criticism in blog comments.  A number of organizations have also weighed in with their comments and suggestions. 

As is often the case, the more eyes that are cast over a document like this, the more suggestions for changes you receive.  I read somewhere that we all have a very strong inherent desire to amend/alter/edit the written word.  When I looked at the Code I also thought of ways to refine it.  For example, I think we need to make it clear that nothing in the Code prevents a member of Alberta Health Services staff from reporting criminal activity to the police.  But if I continue with that example does an employee have any obligation to tell anyone in Alberta Health Services before they take such action?

We have established a position of Ethics and Compliance Officer (and appointed Noela Inions Q.C. to that role) to provide an alternate mechanism for reporting (separately from line management) to allow confidential internal disclosures.  A confidential report from Noela Inions is a standing item on the agenda of the Governance Committee of the Board and all management staff (other than Noela) are excluded from that component of the meeting so that she can report directly to the Board about any activity which she comes across which warrants high level oversight.  This safeguard is important and we need to make it more widely known.   We've also got an external disclosure service which can be used (see the relevant policy - Safe Disclosure Policy PDF).
 
It is my intention to take recommendations for changes to the Code of Conduct to the Governance Committee and subsequently the Board meeting in September to take account of the feedback received to date since the Code was made widely available.

Refining the Code of Conduct is a specific case of a general issue, namely that we need to make clear that Alberta Health Services' policies are living documents i.e. that in addition to formal review of the policies every three years that if it is clear that a policy needs amending before a scheduled review, there should always be the potential to do this.  Obviously we don't want to review policies on a daily basis but we need to have a process where staff can identify areas where policies may need some revision.

If any of you have any comments or suggestions for change to the Code, they can be provided to Noela via e-mail at complianceofficer@albertahealthservices.ca or noela.inions@albertahealthservices.ca. If preferred, your comments can also be provided in confidence via the external reporting line at 1-800-661-9675.

Comments should be provided before August 14th in order for them to be taken into account for advice to the Governance Committee and subsequently the Board meeting in September.  If it appears that there is extensive interest other options for inviting feedback such as a post implementation consultation survey may be considered. 

Hospital Performance

In my last blog I discussed a decision I made about releasing the names of individual hospitals to the Fraser Institute so that they could publish a "report card" on Alberta hospitals.  This decision attracted some criticism in the media, and the last blog included a poll on this issue.  3,513 people replied to the poll with about 65% indicating that the names of individual hospitals should have been released, about 30% replying that the names should not have been released and about 5% being undecided.  I would like to thank those who responded for taking the time to complete the poll.  Clearly I am not alone in questioning the value of publications of this kind.  Interestingly the media reportage of the Fraser Institute publication constantly referred to the performance of hospitals in the present tense, failing to acknowledge the point that these data were about 2 ½ years old representing the situation well before Alberta Health Services came into existence and demonstrating the complexity of how release of information about performance should be handled.  As I indicated in the previous blog I will be giving some thought over the next few months to how we can be more transparent about reporting hospital performance in the future.

H1N1

You will appreciate that in addition to being concerned about the incidence of H1N1 in Alberta and Canada generally, I have also been following Australia's experience with H1N1.  H1N1 hit Canada in our Spring, and we didn't experience its full impact.  It's now winter Down Under and I am keeping contact with my former colleagues in Australia to see what we can learn from their experience.  But in the meantime I want to assure staff that we are very concerned about the potential impact of H1N1 on Alberta.  I have established a small executive sub-committee consisting of Dave Megran, Chris Eagle and Pam Whitnack to coordinate our response to H1N1, with Dave, who has a background in infectious diseases, taking single leadership responsibility for this.  The executive now has a standing item on H1N1 where Dave, Chris and Pam can report back on issues as they arise.

Although there are specific issues about H1N1, and the preventive strategies that are relevant here (e.g. use of N95 masks), in our focus on N95 for example we should not forget the use of universal precautions:

Taking these precautions is something that can be done today whether or not you have been fit tested for the N95 mask.

One of the lessons we learned from our experience with H1N1 earlier this year, is the importance of communication and to that end we are expanding the information for Health Professionals on the H1N1 page of  the Alberta Health Services website. The new information will be posted by Friday 24th July as an additional means of communication with you.

Strategic Directions

The final board-endorsed version of the Strategic Directions for Alberta Health Services was released while I was away.  I would encourage you to look at this document which sets out our priorities and some quantitative performance indicators for the next three years.  Certainly this document will be guiding my own priorities over the next six months.

One of the things that is important about the document is that it shows that, contrary to the view sometimes conveyed, we don't have one simple overarching goal of budget performance, but that we are striving to improve access and quality of care as well.  Our performance is not going to be judged on a single dimension: the public rightly expects us the address access problems in the health care system and, as taxpayers, they expect us to do that within the funding allocated by government.  This will be a big challenge for us but I am sure, drawing on the innovation for which Albertans are famous, we will be able to achieve the fairly tough goals we have set for ourselves.

Best wishes,
Stephen

We are still rolling out the new structure, with more positions being filled on a daily basis.  With each new appointment, greater clarity and certainty emerges.  Further announcements of appointments and refinements to the structure will be uploaded on June 30.  After that marginal changes will continue to be made (as would be the case in any large organization) but they'll be uploaded as they occur, no more single big day of changes/announcements.  Not every important issue facing Alberta Health Services has a designated person on the top levels of the chart, in part because we've tried to align the structure with our priorities as articulated in the Strategic Directions, a draft of which you have seen, the final version is going to the Board next week.

As I've previously acknowledged, there are costs in this transition:  there are fewer positions than there were before and that means hard decisions have to be made.  We are trying to ensure that our decisions are fair and in line with our values, that we treat everyone with respect and that our processes are transparent.  We are still working through some of the details, including ensuring clarity in the roles of the central strategy groups and the operations people.

The change we are going through is big, probably the largest merger in Canada's history as we have about the same annual revenue as PetroCan and Syncrude, but more staff!  The rolling out of the new structure creates the changed reporting lines and the new, province wide integrated functions which are what a merger is.

With the rolling out of the new structure, we are now beginning to act like a normal organization with meetings being held between the executive and the senior operation leaders and a meeting this week in Calgary with the senior leaders from all parts of the organization.  From my perspective this went extremely well, with leaders from across the organization seeing each other face to face for the first time and displaying a remarkably positive esprit de corps.

See Alberta...

Since the last blog, I've done yet more travel, to Calgary, Red Deer and twice to Grande Prairie, once to accompany the Minister for a meeting with Mayors and Reeves and one to meet the Western Cree Tribal Council.

The Red Deer visit was one of the last of my familiarization tours.  I also met there with Mayors and Reeves from Central Alberta, responding to their request following leak of a memo from the previous David Thompson Health Region about repurposing of a number of small hospitals.  Basically my message was that we at Alberta Health Services do not have a list of hospitals to close, repurpose or whatever.  But what I also said was that change is inevitable.  The commitment we have made is to work with local communities to ensure that our health services meet changing local needs.  A copy of my speech is on the web here.

Our Values...

I'd like to share with you a difficult decision I had to make recently that challenged me in terms of living our values.  As many of you would know, the Fraser Institute publishes an annual report comparing "outcomes" of hospitals.  The Institute wrote to me seeking permission to use the names of the relevant hospitals in their report. So here was an opportunity to demonstrate both accountability for our outcomes and transparency.

But I also needed to reflect on whether publication of data in this form truly would represent accountability.  Clearly, publishing misleading (or out-of-date) information does not represent or facilitate real accountability.  The information used by the Fraser Institute is the most recent it can obtain from the Canadian Institute of Health Information, but it is still two years old, based on the experience before Alberta Health Services was formed,  and there is no reason to believe that it represents the contemporary situation at the relevant hospitals .  In fact, there is some evidence from the United States that historic performance is not a good predictor of current performance, and we would be doing a disservice to any person who made a treatment-location choice based on the published information.  Conversely, hospitals which were not identified as poor performers based on the historic data, may now be experience a run of adverse outcomes.  There is now a substantial literature on the use, strengths and weaknesses of "report cards" with no consensus on the way forward.  Although a few years ago I was a supporter of publishing these sorts of data, I've since changed my mind, at least in terms of publishing using the method adopted by the Fraser Institute  (see my article on this issue here).

So, if you don't publish death rates and so on what do you do?  Different hospitals and other facilities do indeed have different outcomes, are more or less diligent in adopting clinical processes which contribute to outcomes of care and are more or less rigorous in learning from poorer outcomes.  We must indeed be accountable for the safety and quality of the care we provide.  I think this means we have to acknowledge that mistakes happen, be open about investigating and learning from mistakes and be able to demonstrate that we have learned from these mistakes/events.  This is what I think the public would want.  So if we publish data it must be relevant and timely and in the context of demonstrating what we have done about any issues identified.  We in Alberta Health Services therefore need to develop a way of doing all that and that will be a priority of mine.  So does the Fraser Institute approach of naming hospitals help any of that?  Does it demonstrate any sense of organizational learning?  I think not.

Given all of that, I ended up saying no to the Fraser Institute's request (see my letter), a decision the Institute has criticized (see here).  What do you think?  Was I right or wrong?  What would you have done?  To vote about releasing the names of individual hospitals and their rates of adverse outcomes, see the poll below.

 Bon voyage

Finally, like many of you, I'm about to take a holiday.  It's been pretty intense over the last three months since I arrived and a break will do me good.  I'll be back in late July.  I know it has been a difficult time for many as we've moved to the new structure and I'd like to thank you for your perseverance.  Have a nice break :-)

Best wishes,
Stephen

P.S. I've also published another article on a critical challenge facing the health system available from the link below.  The publisher won't let me publish a pdf on an open web site so if you would like a pdf of this or the other articles, please email AHSCorp@albertahealthservices.ca and we will send you a copy.

Duckett, S. (2009).  "Are we ready for the next big thing?"  The Medical Journal of Australia  190(12):687-688
http://www.mja.com.au/public/issues/190_12_150609/duc10283_fm.html

Colleagues

My last blog attracted over 20,000 hits. Understandable, given the topic was the new structure.  I can understand the angst and the concern.  As I pointed out in the background paper, structural change can create uncertainty amongst affected staff.  I tried to minimize this by moving blocks of staff, changing reporting lines rather than creating new groups.  Unfortunately, because the previous, enabling structure had not been fully populated, this involved more change than I had anticipated.  We've tried to move quickly, though, to give certainty as soon as possible.  This also positions us to address the big tasks we have ahead of us (especially the budget).  We have now updated the organization charts to reflect appointments (including acting appointments made to date).  Our goal is to have all management and supervisor positions filled by end of June.

One of the most contentious decisions was that related to how allied health staff would report in the new structure (importantly some allied health staff had more clarity than others:  nutritionists, for example, report via the Food Services line through to Clinical Support Services).

As I proposed in comments on the blog over the long weekend, I held Town Hall meetings in Edmonton and Calgary to listen to the views of our allied health staff on this issue.  We needed to move quickly on this issue as positions are being posted as we are debating the most appropriate reporting lines.  We were also testing the capabilities of the new organizational structure as I wanted to invite all affected  allied health staff which in turn meant we needed to have appropriate, up-to-date, mailing lists for these staff.  This didn't work out as well as I had hoped.  Many staff didn't get notified in time (or at all).  You will appreciate that staff only began working on this issue on the Tuesday morning after the long weekend, with the objective of having locations organized by the Wednesday or Thursday.  It was remarkable that so much was done in so short a time and I would like to thank the telehealth people and the administrative staff involved for their efforts in this regard.  I would also like to apologize to those of you who didn't get notified in time to attend the events.  The issue of those locations which couldn't participate in a two-way dialogue on the Wednesday is more complex.  Unbeknownst to me, there was heckling at some of the remote locations.  Because this involved offensive language all the mikes were disabled.  In contrast, on Thursday we had two way communication with participants from a number of sites (including Slave Lake, and Edmonton again!).  In all I think more than 500 allied health staff participated and were able to express their views.

Common themes from the comments related to the need to group allied health together in rural areas or suffer problems relating to small fractional appointments across different program areas.  The need for a professional reporting structure, especially for new staff, was also argued i.e. that program management might work well for an "expert" practitioner but others, who need support and mentoring in terms of development of their professional skills, would not easily receive that monitoring under program management.

There was not unanimity of views on this issue nor would I expect that.  As I indicated in one of my posts, there are trade offs and strengthening one set of links automatically weakens others.  I would have thought that was pretty obvious, although I note that not all shared my view on that.

Betty-Lynn Morrice did a sterling job in synthesizing the 100 or so emails that she received on this issue, the views expressed at the Town Halls, and consultations with hospital Senior Vice Presidents and Zone Vice Presidents.  The Executive has now considered all this (twice!) and the organization charts now on the web reflect the outcome of those decisions (see Organizational Chart).  A document outlining the new arrangements in more detail is also on the web (see Allied Health Structure Document).

Although we have generally adopted  "departmental"  rather than "program" management, you will see that we have not done so uniformly.  Contexts in rural Alberta and Edmonton and Calgary are somewhat different and this is reflected in different organizational arrangements.  We have also taken account of size of teams and historic reporting arrangements, again not uniformly.  Of course this decision won't please everybody but I think it is a sign we listened to the arguments presented in the various fora.

As I have stressed, each approach to management has strengths and so whichever path we followed comes at some cost.  We are therefore proposing to adopt processes to mitigate the weakness of the path adopted.  For example, we will need to ensure that the service level agreements (at a structural level) and performance appraisal process (at an individual level) encourage and reward program team functioning and responsiveness in those situations where we have proposed departmental management.  We are also proposing "professional practice leads" to address some of the weaknesses inherent in program management.

Finally, I would like to thank those of you who adopted a light or neutral tone to you responses.  I got a chuckle from a few of them, thanks.

Many of the responses assumed I had made up my mind even though I had told you I hadn't.  There's nothing much I could say in response to those comments as I felt it would be better to just let the process run its course and people could judge me by my actions not my words.

Looking back over the comments, there are quite a few of the "quick to judge" variety, which suggests that we have a long way to go in building trust between front line staff and those of us in management roles.  Something else for me to work on over the next few months.

Further explorations in Alberta

I spent May 21 and 22 in Calgary with both internal and external meetings.  The fact I was scheduled to be there overnight made it possible to have the Calgary Town Hall meeting with allied health staff.

I also participated at a conference in Banff on the evening of the 22 May and took the opportunity to spend a weekend in that delightful location.  Last week I spent two days in Grande Prairie as part of the Board meetings and had a chance to visit a quite innovative "community village" which involves a collaboration with a number of non-government organizations. The "Committee of the Whole"  (the Board in another guise) considered a number of issues, including the Budget.  Basically, more work needs to be done here and so still not much certainty, I'm afraid.

Last Sunday I walked with my family in the Alberta Health Services sponsored Little Big Run in Edmonton.  We've done the equivalent for several years in Brisbane, but the weather there was about 15 degrees C warmer.  It was good to see the full age range including energetic 4 and 5 year olds pulling parents and grandparents behind them!  It was also good to see AHS staff doing their part:  the EMS on stand-by, the staff at the Weight wise kiosk, even the person in the Princess Alex T-shirt who doubled back to pick up a drink cup that had missed the bin!  Our times weren't the fastest, nor was our 5km route the longest, but it was a great family and exercise-oriented morning.

Vacancy Management

From the feedback I am receiving the vacancy management process is a cause of some concern to some of you.  I would like to reiterate my position.

First, I have directed that if any unit wants to fill a position which was not occupied in the first quarter of this year (January - March) or is a new position, then my personal approval needs to be obtained.  This is to ensure that the Board's interim expenditure plan, i.e. the approval to spend in the first three months of this financial year (April - June) at a level no greater than the last quarter of the last financial year (January - March), is implemented.  The purpose of the interim expenditure plan is to ensure that we moderate our expenditure as we prepare our budget.  We spend more than $30 million per day so it is important to introduce tight financial discipline as soon as possible to enable us to meet our budget targets.

The second type of approval required is where a unit seeks to advertise a position externally.  Here approval from a member of the Executive is required.  As you know we have a significant budget challenge before us.  A very large proportion of our spend is on staff, so meeting our budget challenge forces us to look at the number of staff we employ.

In a typical year we recruit between 6,000 and 7,000 staff.  Some of this is churn i.e. casuals and people joining and leaving the organization for a short time, but the more we can restrict external recruitment and the more we can fill positions internally, the more we mitigate the need for layoffs to meet our budget requirements.  Layoffs are a very undesirable strategy and I will be doing everything in my power to minimize the use of layoffs and conversely maximize the use of natural attrition as part of our budget strategy.  I know from personal (family) experience that layoffs have real personal consequences for those affected and I think it is very important that we manage our recruitment and our budget processes to minimize their likelihood.  I know that, from the perspective of an individual unit, you think this might be unfair and that it inhibits your ability as a manager to manage your staffing profile, but it seems to me that some short-term inconveniences in this regard are justified as we move quickly to prepare our budget strategy.

Recent Speeches & Interviews

I have recently given an interview on CBC Radio about aspects of the organizational structure.  I have attached a link to that interview if you are interested. (CBC link)

I have also given a speech to a seminar on making difficult choices put on by the Institute of Health Economics.  Sometimes over the last few days I feel I could have filled up the whole conference with some of the choices I have to make!  For better or for worse, my paper is written in dry economic language, as befits an economics conference.  I have also made that speech available for anyone interested.  Amongst other things it outlines my views about priority setting in the health sector, how Alberta Health Services might be engaged in priority setting and the place of activity based funding.  I would welcome any comments on the speech from those who can wade their way through it.

I've also attached a link for a paper of mine which has been recently published which provides some comments on the relationships between the health and education sectors.

Duckett, S. (2009). "Interdependence of the health and education sectors in meeting health human resource needs." Healthcare Papers 9(2): 30--34.

With best wishes,

Stephen

Colleagues,

More tripping around this week, with an Executive retreat on Thursday and Friday.  We did a lot of good work (at least from my perspective) on aspects of the new formal structure and forcing ourselves to think strategically, getting above all of our day-to-day imperatives. It was interesting how often we came back to some of the ideas in the plan: the three big goals of access, quality and sustainability; the values of respect, accountability, transparency and engagement (not all at once, but reaffirming from time to time the importance of one or other of these in the way we work) and also the eight areas of focus.

I also was able to participate in the long service awards celebration for staff from the Edmonton area.  These events are both fun and important.  We should do more about celebrating our achievements, and those of our staff.  As I said in my opening remarks, what is it about health care that so many of us decide to join and stay in this industry a long time, often in the same work place. Part of it obviously is that we meet a great group of people that we're happy to spend our working days with, but part of it too is that we get a personal reward in terms of helping others.  This applies with equal force to those who provide clinical care to patients and to those (like me) who are there to support that care.  Certainly making a difference to our society through improving the health system is a big motivator for me. 

Giving certainty

One of the constant messages I got when I've visited your places of work and went to other meetings is that we need to get on with it!  Too many people said to me that they didn't know where they fitted in the organization, that they didn't know who to go to if they had an issue and so on.  It was a surprise to me that the formal structure had not been elaborated to connect the top levels (which we can all see on the Alberta Health Services web page) to everyone else in the organization.  That has been one of my priorities.

The previous structure was described as 'enabling', presumably with the connotation that this was just to get us going.  I've released today a new formal structure that will take us forward. The top levels are on the web today, by Friday you'll be able to see many more levels so you should have clarity about where you fit in.  If you don't, please raise it with your supervisor or, if necessary, with me. I've also released a background document to set out the rationale for the approach I've adopted and how I see the new formal structure working.

You'll see that the new formal structure is innovative in that it abolishes the divide between those who sit in a corporate office and those who have responsibility for operations.  Before I arrived, the approach in place in Alberta Health Services was that one member of the executive had over 80% of staff reporting to them, with the rest not quite relegated to mere onlookers but certainly quite divorced from the day-to-day reality of the front-line issues. All members of the executive in the new approach will have both operational and strategic responsibilities; this will bind us together and increase the extent to which we are able to hold each other accountable. 

The new approach will mean that, say, the five zone Vice-Presidents will now report to five different members of the executive. This doesn't mean we are recreating five autonomous primary and community care delivery entities. Although I expect the zone Vice-Presidents to function with quite broad bands of delegated authority, the zones will all be part of one organization, functioning within one operational policy and strategic framework. Over time, we'll be developing more explicit 'Alberta Service Models', our single approach to design and implementation of the care approach across Alberta. Although not advocating a one size fits all approach, we want to ensure equity across the province and that the best evidence-based ideas and approaches are shared and implemented so that all our services can be the best in Canada, if not the world.

Developing these 'service models' will be collaborative, potentially in each instance involving people from the front line, people with research experience in the relevant area who can bring that perspective, consumers, people with skills in costing the implementation and so on. When the new approach comes to the executive, there will be one champion who was responsible for the development of the new approach, but there will be other members of the executive who will have responsibility for the implementation of that proposed new approach. That responsibility will give them a much greater ability to critique (and improve) the proposals put before us.

Anatomy and physiology

I've generally used the term 'formal structure' to describe the organization chart, a term I picked up from one of my lecturers way back when I was doing my Master of Health Administration, don't ask how long ago that was, suffice to know it was, unfortunately, last century.  I've used the term 'formal structure' deliberately because what is on the chart is really just the anatomy, the bare bones if you will, of how Alberta Health Services will work.  The background document describes some of the cross cutting groups that we will establish to get the new structure to work. But even these aren't all that will be necessary to be a fully functioning, top performing organization.

Every organization needs an 'informal structure' (to use my lecturer's term*), the physiology to go with the anatomy - I hope we won't see too much pathology though! In addition to the groups outlined in the background document, we'll obviously see other temporary or permanent groupings emerge.

One of the values we identified in the plan was 'engagement', taken to include clinician, consumer and colleague engagement. Obviously we'll see local structures for both consumer and clinician engagement develop over time, but I'd like to stress the importance of colleague engagement in this blog. It is important that we engage our colleagues where appropriate before we make decisions. Many decisions we make impinge on someone else or would benefit from advice and consultation. We should make sure we do this as appropriate. No, I don't mean to take away individual decision rights, I'm a firm believer in single unambiguous line accountability. In fact, I want to expunge the term 'matrix management' from our lexicon! I don't want staff to be uncertain about whether to look left or upward on the matrix to know who is in charge. There must be one person who is in charge of any one situation:  for each issue, for each employee, for each operational policy area there should be clear line accountability. Similarly, when I go on holidays I don't sit around thinking wistfully of all the committees I could have attended. If it's your idea of a fun way to spend time, maybe I could give you the name of someone who can help you. What I do mean though, is that we have to recognize, maybe strengthen the notion that we are part of a bigger team, that our colleagues in different parts of the organization can help us. Phone calls, quick catch-ups over coffee are important ways in which we engage our colleagues, in addition to a quick meeting to share and discuss. So it's a balancing act, founded on relationships of trust. No analysis paralysis, for sure everyone wants an oar in, with all care and no responsibility, but we are a team and we need to make sure all members of the team have appropriate involvement. In what I call footy, the aim is to be a champion team rather than a team of champions! Each player has strengths - some mighty kickers (long and accurate), some run really fast, some can jump really high to catch the ball - you need all of these skills to win the game. But what helps you win is to blend that all together. In footy they don't have a committee deciding at each minute of the game what to do: they've trained well, worked out who can do what and know instinctively who to involve, when and how. So too with us.

There is a tension between line accountability and 'colleague engagement', one we'll all have to manage.  How it works out will evolve over time.  But I think the new formal structure creates healthy tensions to help us move forward on our critical tasks, task which are so important to Albertans and, as I said above, are why we are here.

Best wishes

Stephen

* See J.W. Hunt (1972) The Restless Organisation Wiley, Sydney.

Colleagues

On the move

I've been continuing my trips around the province, this week Westlock and Lethbridge, the latter for a Board meeting. I'm beginning to understand differences in challenges between the heavily resource dependent places (Fort McMurray being the best example), and those which also have an agricultural base. I'm also getting to hear (and see) for myself some of the challenges you face.

On the home front, the good news is there is a home front: I've bought a house so weekends won't be spent driving around Edmonton looking at possibilities. We move in in June, there may be a little gap before our furniture arrives, but better that way than the other way around!

Budget blues

I've already written about the tough budget we face. As we delve into the budget framework more deeply, the news isn't any better. As you may know, I've instructed all operating units to live, in this first three months of the financial year, within the same budget envelope as the last three months of the last financial year. Unfortunately, this won't be enough to balance our books in 2009-10 and more will have to be done. The executive is busily working on this with the aim of putting something before the Board Audit and Finance Committee in early-mid May.

In the meantime, we'll have to tighten our belts further. So I've put further brakes on external recruitment (no Virginia, this is not a freeze. Read my lips: Brakes, not stop). Essentially, there'll need to be more senior approval of all external recruitment action.

The plan

The good news is that not all my energy has been spent on worrying about money. I've also spent time thinking about our strategic direction. I've floated some of my thoughts in previous blogs so thanks again for all those who lodged comments, they've been helpful. It's pretty obvious that a Strategic Plan ought to be a high priority. How can you develop a budget strategy without knowing what's important and what's not? Similarly with the organizational structure, something else I've been working on and will soon share with you. 

Anyway, we've now released the new consultation document on this. A lot of it will be familiar to readers of my blog. We've settled on four values: respect, accountability, transparency, engagement. The three big goals of access, quality and sustainability should also be familiar to you. But it's all out for consultations so it's up to you to say whether they resonate with you.

What we've done is expand on the three big goals, into eight areas of focus. What does 'access' mean? To some extent it's obvious: do something about waiting lists, improve the chance of getting a family doc, and so on. But what we've also said is that we should measure our progress on that. And we mean it. (Remember we say we believe in accountability?) So we've proposed some measures of progress.

Plan shapes actions

It's my hope this document will have real meaning across the organization. It will certainly shape how I spend my time: I propose 'deep dives' into each of the eight areas of  focus over the next month or so (after I've finalized the budget). I'm also proposing accountability agreements with each of the Zone VPs and the facility leads. These annual documents will record the budget and key targets, including any zone/facility plans relevant to each of the areas of focus. The provincial plan will thus shape thinking and action at all levels of the organization. The plan itself is just one page, so apologies to all of you who (sadly wanting a life), love to read long plans that look impressive on your bookshelf. The plan is out for consultation with staff and stakeholder groups. A pdf version for printing is available at AHS Strategic Plan and an online, interactive survey with questions is available at  AHS Strategic Consultation. Please use that latter version as it will help us collate responses.

Anyway, all this relates to the plan as we've devised it, just talking amongst ourselves (Board members, exec, Joan McGregor and team and me). Now it's your chance to tell us whether or not we got it right. Please do.

Best wishes,

Stephen

Colleagues

Settling in

I've just finished week 4, and I'm still standing!  I'm still settling in though, getting around the province.  I went to Medicine Hat Monday, where I had a lovely welcome from assembled staff.  Thanks to all of you.  I'm going to Fort McMurray Monday, although unfortunately my visit there has to be cut short because I'm meeting with the Minister later that afternoon back in Edmonton.  But I'll make another trip soon.   I'm spending quite a bit of time on the road (e.g. last week in Calgary 2 days in addition to the visit to what I now know as The Hat), but I feel this is still necessary to get a better feel of what is going on outside my office and to pick up on issues.

Spare time is taken up with house hunting and settling in to Edmonton.  Everybody is making me feel very welcome, and that's not only people from Alberta Health Services.  My daughter has started at school  and is enjoying it.  Speaking of my daughter, my fiercest critic, she has pointed out that my reference to bursting into song with the slogan 'We are one' probably makes no sense to you.  It was an allusion to a song (well known at least to me) that goes:

We are one but we are many
And from all the lands on earth we come
We share a dream and sing with one voice
I am
You are
We are Australian

I'll spare you the vocal rendition but, as you can see, it's an Australian song.  Apologies, although it probably won't be the first comment I make which will be lost in translation.

Current priorities

In terms of my priorities, I'm still focusing on budget issues. It's just as well I wasn't too detailed in my immediate budget response, as further detailed work on the allocation suggests the like with like increase allocated by government is closer to 5.8% rather than the 6% we thought on budget day.  Anyway, the detailed analysis and preparation of a response is still going on.  We haven't made any decisions or even made any recommendations to the relevant subcommittee of the Board.

I'm also working on the new formal organization structure, trying to respond to the plea I've heard loud and clear that you want some certainty, you'd like to know to whom you report and where you fit in.  I've developed a sketch, building on what is here already: the zones, the groupings of facilities and so on.  But we need to do some detailed work to connect the dots.  To have meaning to all of you we don't just need the top few levels, but we have to outline the whole thing.  I expect to finish this in the next fortnight (n. Australian word meaning '2 weeks').

Both the budget response and the formal structure are being informed by my third main priority, work on the strategic plan for Alberta Health Services.  It's critically important that we set our budget priorities in the context of thinking about where we want to go, lest we make short term decisions that position us poorly for the longer term challenges we face.  Similarly, the formal structure needs to be designed to facilitate our strategy and be consistent with our values.

I've been doing a bit of road testing of the plan over the last week in presentations I've made and I've also tried out bits and pieces in this blog and responses to comments others have made.

Proposed values/principles

One of the things I've been doing a lot of thinking about is the set of values we should live by.  Alberta Health Services' values should inform everything we do, including the design of our organization.  Values or principles are important in all organizations but are particularly important in the health sector.  Health is a values-driven industry.  Many of us chose to work in this sector because of our values and the personal return we get from helping others in need.

As I've said, I've tried out some of my thoughts previously but I'm settling on proposing to you that we express what we live by in terms of 4 broad principles: respect, accountability, transparency and engagement.

Importantly, these shouldn't be mere words, and will only have meaning if they become deeds.  That is, we should see these values in behaviours and an expectation that we live the values should be in all our position descriptions (including mine).  So what behaviours might we see if we live these values?  Take respect for example.  This should be exemplified in a number of ways: we should value each other and each client as individuals; we should be compassionate; we should treat our patients/clients, and our colleagues, with dignity, fairness and respect their confidentiality; we should be sensitive to diversity and we should recognize the contributions being made by others.

So that one little word unpacks to some really important concepts and behaviours.  If we did all that, all day, every day, everywhere, our patients/clients would have a much better experience, as would we as staff.

Anyway, we need to do some similar work thinking through and articulating the other words.  My aim is to finalize that and the other elements of the plan to release it later this month for you to comment on.  We're also thinking about ways  to make it easy for you to give feedback on the draft, possibly using electronic means so it's not only people in the big centres who will get a say.  Incidentally, I'm hoping you won't have to wade through a huge tome to get an idea about the proposed strategic direction: we aim to have a relatively short document, hopefully able to be summarized in one page and remembered by us all!

Best wishes

Stephen

P.S.  There are still lots of comments being posted in response to the previous blogs.  I read all entries, and try to respond every now and again.  In order to make it easier for others to keep track, we'll close off responses to the first blog soon and set a rule that responses to earlier blogs close off 14 days after I post.

 Colleagues

Today is Day 2 of Week 3!  Not sure how the clock works for the 30-day plan.  Are weekends in or out?  Whatever, I'm almost half-way into the first 30 days.  I'm still on a learning curve about Alberta and the intricacies of how the predecessor organizations worked. All necessary as I want to build on the good stuff that's out there.  Just because 'we are one', doesn't mean that we throw the baby out with the bathwater.  Also 'we are one' doesn't mean we are one homogeneous blancmange.  We are a diverse bunch, with different training, different experiences, different roles, serving a heterogeneous population.  As a few people said in response to my first post, remember there are lots of roles that are necessary to keep Alberta Health Services afloat, not just those which require health professional qualifications. 

Speaking of the blog, there's been a huge response, I think over 35,000 hits, with over 150 comments.  I read all the comments and, as you know, attempt to respond from time to time.  This is a moderated blog and all but a handful of comments have been uploaded.  Uploading takes a bit of time as one of us has to go in and read and post your thoughts.  Just because your comments don't appear instantly, doesn't mean they won't appear in the next day or so.  This is all a learning experience for me, so bear with us.  We've formalized the blog rules with this link http://iblogs.albertahealthservices.ca/ceo/page/policy.  In response to one post, we've added RSS feeds to help you keep track of what is going on.

I was in Calgary for two days last week (Rockyview and Foothills), and also took some time out to visit services in Edmonton, between last week and this I've been to UofA Hospital, Glenrose and Royal Alex, together with a number of aged care facilities.  I'm going to Grand Prairie on Thursday, Medicine Hat Monday.

One of the things I've been working on is the 3 year plan.  In its current form it's structured around the three big goals I've spoken about (access, quality and sustainability), with a number of 'areas of focus' to make it real.  One of my 30 day goals is to get a draft out to staff to look at before we finalize.

The Budget!

But the most important thing I've been turning my mind to is how we respond to today's budget.  The global economic crisis is clearly playing its way through into how we in Alberta Health Services work.    Even before I arrived, I was aware that, like Queensland where I used to work, the Albertan economy is exposed to resource prices.  I understand that for every $1 reduction in oil prices, the Alberta government loses an estimated $200m of revenue.   Alberta Health Services represents 20% of the provincial government budget, so it's not a surprise that the winds of change affect us directly.  Over the last five years, health spending has increased an average of 10% per year. Today's budget allocates us a 6%  increase on a like with like basis, pretty good compared to other areas of government, but a signal that the ways of the past have to change.   Over the next few days our Finance staff will be meeting with Ministry staff to work through the details of what's in and what's not in the budget.  There looks to be some opportunities here, with a move toward a more global allocation, giving us more flexibility to set our priorities in an integrated way and to get rid of the administrative detritus associated with highly specific and tightly constrained grants.

But a global budget increases our responsibility: we have to address the ongoing consequences of last year's overspend, the full-year costs of last year's newly opened facilities and the costs of facilities to come on line this year.  There is also the challenge of the inexorable rise in health costs, faster than inflation.  And it's up to us to make the choices and set the priorities for our spending. 

This means that we have a big task ahead of us if we are to live within our means.  So things are going to be tighter this year.  How much tighter?  We don't yet know.  Over the next few weeks we will be reviewing our currently foreshadowed spending levels to see how we should respond to the new budget envelope.  Clearly, we'll need to do things very differently if we are to come in on Budget at the end of fiscal 2009.  But we've got a good start already.  The integration will give us some opportunities to reduce duplication and to streamline our processes.  Being one organization means we can compare and contrast more easily; to look at differences in how we do things between one end of the province and the other.  We can also benefit from making it easier for services and facilities to learn from each other to improve efficiency and/or service outcomes.

But the reality is there's a big gap between a 6% increase and our historic growth of 10%.  We can't afford to pretend that it's going to be business as usual.  We are going to have to work much smarter.  We'll need to look very carefully at everything we do:  Is this process (investigation, administrative hurdle or wait) necessary for the care this patient needs?  Why are our costs higher than the hospital up the road?  Could the care this patient needs be delivered closer to home in a lower cost setting? And so on.

Change can be painful.  Breaking out of the comfort of the old ways can be difficult.  But change can also be fun.   We want to be at the fun and creativity end of the response to change opportunities; using our ingenuity and prairie practicality to get the best bang for the bucks we've been allocated.

So we've got a lot of work ahead of us to put some flesh on the bone of our response to the budget before I can say what the precise implications are.  I don't want to say one thing today and another a few weeks in when we've done the detailed analysis required.  The time line I have in mind is doing some detailed work over the next few weeks, then a broad proposal to the Board Audit and Finance Committee for a meeting in mid-May and the Board meeting in late May.  We then, of course, need to do detailed work on the strategies, and get sign off from the Minister/Ministry where appropriate.  This will take much of June.

As you know, the Board has endorsed an interim expenditure plan for the April-June period, with spending at the January-March levels.  The timeline outlined above should enable us to allocate 2009 budgets to operating units to come into effect on July 1.

I'll keep you posted as I get further information or we make any decisions.  In the mean time, please be wary of scaremongering, gossip and rumours.  Although gossip is often the way some spend time over coffee, what you hear is more than likely to be untrue.  Take what you hear with a grain of salt, but don't put the salt in your coffee and you'll have a better day.

Best wishes

Stephen Duckett

Colleagues

I'm writing this at the end of my first week in the new job.  First, I'd like to say thank you to everyone who has made me so welcome, there's been lots of kind messages - both verbal and written - and invitations to meet or visit.  I will be trying to get around to learn a bit more about Alberta, both in terms of the geography and the issues that need to be addressed.  But, there are only so many hours in the day so please accept my apologies in advance if I can't get to you in the nearish future.

In lieu of direct contact, I'm going to try a blog to let those of you who are IT literate know more about my thoughts, proposals and activities.  I've not done a blog before, nor read many of them, so I'd welcome feedback on what you find interesting (or not). My aim is to blog every two - three weeks.  I'll also look at the responses and may be able to reply to individual comments or to groups/themes. 

Not screaming

There was a story in the Calgary Herald this week which ended:

Maybe Stephen Duckett is smart enough to fix all this.  On the other hand, once he gets a good look at the system, he might just run away screaming.

Sure there are some big issues we need to address, but we must remember that for the vast bulk of Albertans, the health system provides access to good care without breaking the bank- either personally or as taxpayers.  So I'm not in the mood to run away screaming, at least yet! 

But we've got to face the fact that there is an agenda ahead of us.  Obviously one of the things I've got to do quickly is stabilize the organizational structure.  There are two tasks here: filling the second line to provide permanent leadership and ensuring that there are clear lines of accountability for everyone.  As you know, Chris Mazurkewich, our new Chief Financial Officer starts in mid-April and we've just completed interviews for the Corporate Services position.  I'll be moving on the other senior vacancies next.  I'll also try to move on structure quickly, aiming to reduce reporting lines. I don't see a massive shake-up as in my view fiddling with structures doesn't necessarily lead to improved patient care.

Where next?

My agenda for the next few weeks will involve more out and about, I've already been to Red Deer (just for a Board meeting though), and I'll be spending two days in Calgary next week.  But I'll also be starting some work on the Alberta Health Services Plan.  We're supposed to have that completed by April 1, we won't get there though. There are many potential organizing frameworks for the plan: Vision 2020, the Alberta Quality Matrix for Health (http://www.hqca.ca/assets/pdf/Matrix.pdf), and the three goals previously identified by the Board (Access, Quality and Sustainability).  I like the simplicity of the three goals - I can remember them easily and I think they capture the things we ought to be on about.  I'd welcome feedback on whether others share that view.

We also need to do some work on the values for the organization.  To date, I've emphasized the process values of transparency, accountability and participation, but we also need to have something about recognizing and treating each other as humans (staff-staff, staff-patient, patient-staff).  I'm not sure what the predecessor organizations did on this, nor what might be a set of values that would resonate with staff.  Again, I don't want a long list as if they are to be meaningful we should all remember them (and live by them).

Looming over the horizon is the Budget.  We don't have the final numbers yet so there's not much I can say about it at this stage.  At its Red Deer meeting, the Board approved an interim expenditure plan which allows us to spend for the next three months at the same rate as the last three. It's important to me that we deliver on our commitments so I'm putting in place processes to ensure we live within that approval.  Although we formally only become one organization on the first of April, a lot of work has been done over the last ten months to harness the benefits of the integration.  We'll need to speed that up if we are to improve access and quality in a sustainable way.

Thanks again for making me welcome and please feel free to respond.

Stephen Duckett