Health system decisions in Alberta lack guidance from strong vision, values, principles or evidence

In late March, Alberta Health Services (AHS) discontinued maternity services in Banff’s Mountain Springs Hospital. This decision fell out of a regional planning process. It resulted in public outcry, demonstrations, media attention and a pending judicial challenge; it prompted both a Healthy Debate article and webchat.

The economic impact of this decision on the AHS budget is microscopic, and relatively few maternity patients will ultimately be affected.  But it does prompt a very important question: What is the AHS decision-making framework for decisions that alter health care services provided to communities?

I believe that such decisions should be guided by a provincial vision for health care and by an appropriate set of health system values and guiding principles, and that they should ultimately be made through a decision-making framework characterized by a focus on evidence, a commitment to patient-centredness and slavish devotion to quality.

An effective vision unambiguously and passionately proclaims why the organization exists and what it stands for. It is a powerful leadership tool and can be used as a lens through which to examine important decisions.

The vision statement of AHS reads: “to become the best performing publicly funded health system in Canada.” Each reader can decide for themselves if this statement unambiguously and passionately proclaims why Alberta’s health care system exists and what it stands for. However, it was not referenced throughout the planning process for maternity services in the Bow Valley Corridor, and I doubt it played a meaningful role in guiding the clinical service decision that was ultimately made.

Guiding principles, informed by a vision and a set of values, can be precious assets. In times of stress and turmoil, they can light the way, ensuring that important decisions are never made arbitrarily or thoughtlessly. A values-based set of guiding principles can stand as a bulwark against the temptation of political expediency.

Was the Banff decision regarding relocation of maternity services informed by an appropriate set of values and guiding principles? It is arguable whether the final decision honoured AHS’ stated values of transparency, safety and accountability. The question of whether the decision was in keeping with AHS’ guiding principles is complex, since these principles reference neither a commitment to clinical quality nor the use of best-evidence in decision-making.  Absent these elements, how could they possibly inform any important decision regarding health service delivery?

The framework that was employed for the Banff maternity services decision is outlined in an August 2012 AHS planning document. It contains data regarding the health of the population, currently available services and providers, and the population that accesses them. It also describes the provider and community engagement processes that were employed and how attention was paid to risk analysis and assignment of accountability for action.

However, the document is silent on matters that I believe are essential to a decision to relocate maternity services. These include:

  • The specific ‘evidence-base’ for this decision
  • Details regarding the nature of any and all quality and patient-safety concerns that exist, and how they will be managed
  • How the decision demonstrates a commitment to patient-centredness
  • Exactly how much money will be saved and how these savings will be used
  • How the decision may affect the present and future availability of doctors and nurses in Banff
  • The impact of these decisions on the attractiveness of Banff as a place to live
  • The risk of other unintended consequences

Equally problematic is how such decisions are being communicated to Albertans.

AHS officials interviewed about the maternity services decision responded with talking points. One representative said that “the decision was based on patient care and patient care needs,” while the Executive Director of the Banff Mountain Springs Hospital opined that “the decision was the best thing for patient care and for quality and safety.” Should not the citizens of Banff have been provided concrete information regarding the manner in which the final decision took into account each of the considerations listed above?

I’ve focused on one small health care service delivery decision affecting one small Alberta community, but I’ve done so because it’s a ‘canary in the coal mine’. This is a time of significant directional change in health service delivery in Alberta. Right now, health system priorities identified by AHS are being turned into specific decisions that will affect how health care services are being provided in areas such as palliative care, home care, continuing care, chronic disease care and health care in remote and rural communities.

How are these decisions being made? I believe that each should be driven by a powerful, compelling system vision, that each should be observably aligned with an appropriate set of health system values and guiding principles, and that operationally, where it matters most, each decision should be evidence-based, patient-focused and quality-driven.  If these criteria were met, every decision affecting health service delivery would be easy to explain to Albertans. This is not the case today.

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1 Comment
  • Dave Kennedy says:

    I am trying to contact Dr. Bear. I was a student at U of T, Faculty of Medicine, class of 1978, who did his clerkship at St, Mike’s Hospital.
    I have a question about a review article he penned in the CMAJ, published in Jan. 1979. I have used this article for years and wonder if he would have any updates. I want to recommend it to medical students I teach at UBC Okanagan campus.
    Dave Kennedy MD FRCP (Anaes) retired


Robert Bear


Dr. Robert Bear is a former Professor of Medicine at the University of Toronto and the author of Sorrow’s Reward, a novel set in a dialysis unit.  He blogs on health care at sorrowsreward.com.

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