News and views from the President/CEO

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.