Editor’s note: This is the first in a series of monthly columns on leadership in health care from CHLNet, which represents more than 40 health organizations.
This month’s Top Three focuses on the issue of leadership and transformation. We regularly use the term “transformation” to describe what needs to happen to health care. Many of the demands emerge in discrete elements of the health-care system: i.e., digital transformation; transformation of the long-term care system; transformation of mental health service delivery; public health transformation; supply chain transformation; and healthy workforce transformation. Yet, all these interconnected sub-elements of the larger health system are often pursued as if the changes desired in them are isolated from other sub-systems. When they impact patients, families or citizens, the impact is cumulative, such as in terms of their demands on behavioural change.
These three articles illustrate the true challenge of transformation, and the need for leaders to see it not as simply a cumulation of changes, reforms, innovations or Plan-Do-Study-Act (PDSA) continuous improvement cycles but as a process of collective people change, regardless of the role one plays in health care. The importance of leading from a place that recognizes the changes demanded of others is key to success.
Article 1 defines transformation as “the emergence of an entirely new state, prompted by a shift in what is considered possible or necessary, which results in a profoundly different structure, culture or level of performance.” That definition suggests a scope and breadth of change that is often not the focus on individual sub-system changes. It also requires – according to the authors – broad organizational and individual leadership capable of large system change that is often lacking in health care today.
Article 2 is an editorial from the Healthcare Policy Journal in 2021 that outlines policy changes facing federal, provincial and territorial health-care budgets in Canada. It is notable in that it discusses the policy-making environment as a consequence of COVID and some of the challenges inherent in it. Germane to the transformation theme is that it describes a multiplicity of desired arenas for policy change. Notably, one that CHLNet has identified as ‘fundamental’ to the survival of the health system – a psychologically healthy workforce – is not one the authors include.
Article 3 applies what I would call a “people systems” leadership viewpoint. Using the example of the need to “transform” national and international food systems, it states as a premise that a people-systems leadership approach is needed because it is applied, “in situations where we deal with complex wholes that comprise of multiple entities, processes and interactions, that result in a range of outcomes which we may consider more and less desirable… (there is) … diversity between actors in the way they view the system and the different purposes and interests they have for participating in it.”
Article 1: Capability building for large-scale transformational change: learning from an evaluation of a national programme. BMJ Open Quality.
Summary: This article presents an evaluation of the Virtual Academy of Large-Scale Change (VALSC) established to support England’s National Health Service (NHS) in implementing its ambitious Long Term Plan that will require a sustained program of transformational change on a scale perhaps not hitherto seen in the NHS.
VALSC was developed to build capability in health and care system teams involved in transformation or redesign programs. Results suggest that it has helped build capability for large-scale change in terms of learning, behaviour change and impact.
Article 2: Post-Pandemic Transformation of Healthcare Delivery in Provinces and Territories. Healthcare Policy.
Summary: While this editorial was written prior to the Omicron wave of late 2021 and 2022, it’s remarkable to see the relevance of the challenges the author articulates for health care. The author cites the many new policies, procedures and physical spaces used to deliver health care during the pandemic. He then asks: “As reopening unfolds, some of the significant challenges facing the federal government, provinces and territories are these: What new practices and behaviours should be retained in the post-pandemic era? How will the changes be paid for?”
He identifies short-term challenges such as trade-offs between supporting changes in long-term care or reducing surgical backlogs. He argues that “the public voice will be particularly raw,” suggesting that health policymakers will have to pay greater attention to citizens and families as well as advocacy groups. He also suggests, among other things, that governments that have nurtured in-house expertise in health systems analysis – compared to those who have hollowed them out – will be in a much better place to respond to post-pandemic challenges. Two key ingredients are needed: data and the expertise to make sense of the data.
Additional articles he summarizes refer to behavioural and budgetary challenges in “the COVID-19-induced challenges of engaging with patients.” These include: medical malpractice insurance and required reform; aggregating family physician data across provinces and territories; reforming specialist physician incentives and payment models; the rapid adoption of telehealth in primary care; the alternative level of care in Ontario; and finally, the implementation of coordinated and integrated care for medically complex children in the same province.
These challenges – and myriad others – comprise the landscape of the many dimensions of health-care transformation.
Article 3: How food systems change (or not): governance implications for system transformation processes. Food Security.
Summary: This paper argues that supporting food system transformation requires more than science-based understanding and analysis of how components in the system interact. The authors argue that changing the emergent properties of food systems (what we call food system synthesis) is a socio-political challenge that is affected by competing views on system boundaries and purposes, and limited possibilities for central steering and control. They point to different traditions of “systems thinking” that emphasize particular types of interventions for achieving system change and argue that food systems are best looked at as complex and multi-dimensional.
This implies that leaders need to move beyond rational engineering approaches and instead anticipate and accommodate inherent social tensions and struggles in processes of changing food system dynamics and outcomes. Through a case study, they demonstrate that a multi-level perspective (MLP) on system transformation is useful in understanding both how food system transformation has happened in the past and how desirable transformations are prevented from happening today.
Based on such insights, they point to key governance strategies and principles that may be used to influence food system transformation as a non-linear and long-term process of competition, negotiation and reconfiguration. Such strategies include the creation and nurturing of diversity in the system, as well as formation of discourse coalitions. Such governance interventions imply a considerable re-orientation of investments in food system transformation as well as a rethinking of the role that policymakers may play in either altering or reproducing undesirable system outcomes.
All three articles are from the point of view of leadership for change – and transformation – inherent in people-systems like health care. If we do not have the capabilities to facilitate, or at least guide our actions with an appreciation for the demands they put on people to “transform” their component of the system, we are not dignifying the challenge of health-care transformation.
CHLNet is a social enterprise of 40+ organizations called “network partners” who gather around health leadership. Part of its work is to share emerging leadership practices for 21s century care. Visit www.chlnet.ca to learn more.