Circles vs. rectangles

In my office hangs a cityscape of Montreal, with the focal point being the landmark Orange Julep. It’s unusual shape, and bright colour distinguishes itself from any other building in Montreal – or the province for that matter. To me it is symbolic of change: when everyone else is building rectangles, sometimes you have to look at things in a different way, and build a circle.

Last Friday, I was fortunate to find myself in a room filled with “circle” thinkers. Some brilliant health care minds from across North America congregated at a morning-long conference to discuss the future of healthcare delivery.

The ideas discussed didn’t focus on quick fixes, but rather long-term steps that can be taken to improve our health care and social services ecosystem for decades to come. It was aptly pointed out, that with proper organization, integration and coordination, systems flourish and benefit not only the patient, but us all.

Additionally, we looked at how to better adopt population health management into our integration strategies and support front line clinicians in aligning their practices. Those presenting weren’t just reciting their wish list, but instead were sharing the success they’ve had in building such networks, and what is required to sustain them as high reliability learning organizations.

Change, as we know, doesn’t happen overnight. It takes time, dedication and a genuine desire to be better. It doesn’t come from policy change; it is far more complex than anything written on a piece of paper.

What kept coming back, competing with this notion of change, was how it’s easier to do what we’ve always done. It feels safe. Instead of accelerating improvements, one often delays them.
If we follow this methodology, we’ll end up living in a world of rectangles. Instead, let’s keep trying to build circles.

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Over the last couple of months, the daily headlines have consistently focused on the stories of refugees who are making their way into Canada, whether by plane, train or the now high-profile Roxham Street in Champlain, New York.

Regardless of how a refugee or asylum seeker enters our country, many end up in the excellent care of our staff at the Regional Program for the Settlement and Integration of Asylum Seekers (PRAIDA). I want to take a moment to publicly single out the work of this supportive, informative and, in some cases, life-saving program, and its dedicated staff. Our nurses, doctors and allied healthcare professionals provide health care and social services to those who have seen and survived incredible horrors. In many instances, they have even been separated from their loved ones for long stretches of time.

I am fortunate to have been born and raised in Canada, and I can barely imagine the struggles experienced by those seeking PRAIDA’s aid. For this reason, I am proud that we can be the light at the end of a long road for those in need.

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Global exchanges

One of the great benefits of working in healthcare is having the opportunity to meet other professionals who have a willingness to share insights and trade knowledge. The result: improvement isn’t limited to one site, but is experienced all over.

For example, I’m fortunate to have had some wonderful exchanges over the past 10 days during a visit to Clalit, the largest HMO in Israel. I’ve had the pleasure of learning first-hand about their triumphs and setbacks, and how the lessons that they learned can benefit our network.

As I prepare to return home, I’m especially encouraged by the health care system focus of Clalit,and their clear determination and commitment to putting patients and users first, especially by providing care anywhere and at any time!

As well, the facilities that I visited are at the vanguard in IT and supply chain management. We, too, are focused on these fields, but we are definitely behind and need to play catch-up quickly in order to remain competitive and to sustain our drive for excellence. Looking at Clalit it is encouraging to know that a clear path to continued improvement can be mapped out.

Though 8,000 kilometers separate Canada from Israel, we face many of the same challenges. And, like us, the Israelis are privileged to have excellent staff members, who understand the importance of usercentric care. Throughout our sessions of give and take, one key fact predominated: only by working together—within facilities, within networks, through global alliances—can we continue to improve the healthcare landscape for all.

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With spring break starting this week, and many families taking off to Disneyland I fondly recall my first visit to the Magic Kingdom – 84 acres of rides, restaurants and entertainment, a fantasy land for young and old. And yet, among the throngs of people was a sense of controlled chaos, and a general feeling that this was one well oiled machine.

My fascination and admiration for the theme park stayed with me long after I’d removed the Mickey Mouse ears. The notion of putting the client first, and making sure they had the best experience, was one that has resonated with me both as a physician and administrator. The experience was inspired – from the single Disney card that provided access to all parks, to the unified vision that employees endorse. The results benefit customers and staff alike.

Now, as leader of the CIUSSS West-Central Montreal, I’m trying to invoke the wise words of Walt Disney himself as we look to the future of health care:
“First, think. Second, believe. Third, dream. And finally, dare.”

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My vision for the creation of a McGill Health Network

On October 19, at the behest of the Minister of Health and Social services and in his presence, I outlined the concept of creating an integrated McGill Health and social services network before a room full of representatives of all McGill University related health and social service institutions. The Gazette reporter was also present. The text of my presentation was widely circulated by the Ministry to all stakeholders as part of a consultation undertaken by Dr. Arvind Joshi at the request of the Minister. In that context, I recently took the initiative of summing up the content of this presentation in a letter distributed to all employees of our CIUSSS with a view to enabling them to have an informed understanding of my vision.

My proposal of re-establishing director general positions in major institutions is specifically linked to the creation of a fully integrated McGill health and social services network, an integrated system more fully adapted to the needs of the population. The question is not about “undoing” the present networks, I never said or implied anything of the sort, but about evolving to another type of organization. Bill 10 is predicated on the need to establish networks of care by bringing together institutions under the direction of integrated health and social service centres. In my view we now have the opportunity to move forward and advance quality and access by bringing the two CIUSSS and the MUHC together in an integrated system covering the full range of services people require. This would call for different governance and organizational structures.

What we have today are two CIUSSSs and the MUHC, all under the McGill University umbrella, all serving the same population, but operating independently from one another. Patients need to go from one to another to get all of the services they require, and they have to adapt to each institution, rather than the institutions adapting to their needs, as they should. Services and patient files are often duplicated and fragmented.

We can do much better. We have the technology, the resources, the know-how, the competence required to create a seamless integrated health and social services system where patients entering from any service point would be directed to the nearest available resource required by their condition. This is the essence of the concept of creating truly integrated health and social services systems focused on access, value and quality for the user. It is the direction in which health and social services are moving throughout North America.

Describing this concept, I said the following on October 19:

“In such a network consisting of a substantial territory and population, and encompassing the complete range of operations with an operating budget of some 2.5 B$ it would be necessary and desirable to empower decision-making at the operational level in order to be responsive to local needs and circumstances in a timely manner. In this regard, in my vision I believe there should be director generals in the major institutions in order to ensure that these local considerations are managed according to the needs of the community level.”

As for the councils of physicians, dentists and pharmacists (CPDP), local CPDP sub-councils are possible under Bill 10. In fact, we have created them in our CIUSSS and they work well. They are effective and the preoccupations of each establishment are taken into account. I said all of this in my October 19 presentation, clearly stating that this feature should be carried over in the McGill network concept.

To be clear, in an integrated McGill health and social services system, our current establishments would continue, they would have local management, but they would also have common standards of care and performance. The focus would be on the user and the obligation of the system to enable them to move through it seamlessly.

Our healthcare institutions must adapt to changing times. These are vitally important matters that require informed, in-depth discussion. I welcome any opportunity to further this discussion.

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A voice on the inside

Health care is so ubiquitous and ever-changing that the latest news pops up on TV, on Facebook, in the newspaper—practically everywhere you look. But those voices come from the outside, not the inside.

I’d like to introduce a new voice to the mix—my own, a voice on the inside. Every Monday, I look forward to sharing my thoughts and reflections with you about the healthcare landscape, what we’re doing to improve it, and what lies ahead for us.

My reflections will be about us—the patient, the resident, the caregiver—and what inspires us all to keep going. As the great Vince Lombardi once said, “Perfection is not attainable, but if we chase perfection, we can catch excellence.”


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A historic moment in the life of the Jewish General Hospital

Dear members of the JGH community,

Needless to say yesterday, January 24, was an historic moment in the life of the Jewish General Hospital. Not only for the hospital, our patients, the community and the healthcare network, but notably for those of us who were privileged to participate in the movement of patients into Pavilion K.

In inaugurating Pavilion K, we finally harvested the fruits of seeds of imagination, persistence, resilience and community fellowship, that had been planted some eight years ago. Truly, we were reliving what the founders of the original hospital must have experienced when they first opened the doors to the public in 1934.

Today, we are the pioneers laying the foundation for the future of health care in our community. So remember this day- it is the day each of you will have made your own bit of history.

The teamwork that characterized the move was nothing short of awesome. The passion, the energy and sheer devotion of individuals coming together to make common cause was truly emotional and endearing for many of us. It reminded me of a symphony orchestra whose members are different from one another, but who are orchestrated together for a collective undertaking- one that is involved in making a distinctive contribution, so that each can say, “I helped to make this happen.” And truly, each and every one of you made an invaluable contribution.

A special thank you to Joanne Côté and her Transition Team. Seeing them in action yesterday was like watching a pair’s team of figure-skaters gliding through their routine in effortless fashion. I would also like to take this opportunity to thank all those who came in on their day off to volunteer to make the move the success that it was.

It’s been said that if you want to create a group with a sense of collective identity and shared purpose, get them to build something together. This transforms them by their own efforts. John Ruskin wrote, “The highest reward for a man’s toil is not what he gets for it but what he becomes by it.”For those who participated yesterday in the patient move, for those who dreamt the dream, for those who unleashed their imaginations for design ,and for those who nurtured the construction project through its birth pangs, thank you on behalf of our patients and the entire JGH community.

Finally, one might ask how do you build an organization that can endure? What is the formula for this? The answer is that lasting companies reinvent themselves. With Pavilion K, the JGH has indeed reinvented itself and we are well poised to venture forth into the future with confidence and faith that we will continue to build on the legacy of 81 years going from strength to strength.

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The perfect (transformational) storm

We are in the midst of a storm. The transformation of the healthcare system and of health care delivery will undoubtedly leave in its wake an entirely new world.

It is a time of transition. As writer Erica Brown has said, at times of transition, we are neither here nor there. It can be hard to believe that temporary difficulties are only temporary. If we believe that transitional places are permanent, we are no longer on a journey of transformation; we are stuck in a place of frustration. Confusing transition with destination adds needless layers of anxiety. The future will only look like the present if you do not allow it to look like anything else.

Making this transformation is not a single step and will not occur overnight. It will require restructuring how healthcare delivery is organized, measured, and reimbursed and this is what Law 10 is all about.

There is no longer any doubt about how to increase the value of care. The question is, which organizations will lead the way and how quickly can others follow. Moreover, this transformation must invariably come from within. Only physicians and the organizations providing services can put in place the set of interdependent steps needed to improve value, because ultimately value is determined by how medicine is practiced.

In health care, the days of business as usual are over. Around the world, every healthcare system is struggling with rising costs and uneven quality despite the hard work of well-intentioned, well-trained clinicians. Healthcare leaders and policy makers have tried countless incremental fixes, but none have had much impact.

Its time for a fundamentally new strategy.

At its core is maximizing value for patients. That is, achieving the best outcomes at the lowest cost. We must move away from a healthcare system organized around what physicians do and toward a patient-centred system organized around what patients need. We must shift the focus from the volume of services provided- physician visits, hospitalizations, procedures, and tests- to the actual outcomes achieved. And we must replace todays fragmented system, in which every local provider offers a full range of services, with a system in which services for particular medical conditions are concentrated in health-delivery organizations and in the right locations to deliver high-value care.

What are the pressures driving hospitals and other healthcare institutions to improve accountability and the integration of their services? These can be summarized as follows:

  1. The aging patient (and provider) population that will continue to shift significantly throughout the next decade
  2. The need to enhance care coordination during hospital-to-home transitions. This has consistently shown beneficial effects on cost and care quality, requiring healthcare network leaders to focus on care after patients leave the hospital
  3. Political pressures are compelling hospitals and care systems to provide efficient and optimal patient care
  4. Hospitals need to serve multiple patient populations effectively- management of population health is crucial

What are the issues that will drive transformation? These include:

  1. Increasing pressure on all healthcare organizations to become more efficient, and new payment models are critical to any improvement
  2. Lowering costs over time is essential for long-term financial sustainability
  3. New models of care emphasizing coordination across hospitals and care systems, other providers and the community are essential for quality improvement
  4. The quality of care must improve at a faster rate

In our new healthcare network for West-Central Montreal, where is our focus now? The new team is concentrating on:

  1. Aligning the hospital and all community partners, physicians and other providers across the continuum of care
  2. Utilizing evidence-based practices to improve quality of care and patient safety
  3. Improving efficiency through productivity and financial management
  4. Developing integrated information systems

In the words of Dolly Parton, “Storms make trees take deeper roots.” Once we find ourselves on the other side, we will be in a stronger position; our partnerships will be cemented and any obstacles will have been blown down. I am facing this storm, with you and for you.

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Nursing: past, present and future

This is Nurses Week. What a wonderful opportunity for us all to acknowledge the incredibly important role our nursing colleagues have in the care of our patients and clients, and to recognize their significant contribution to the strengthening of the social fabric of our caring community. 

Although the origins of nursing predate the mid-19th century, the history of professional nursing traditionally begins with Florence Nightingale. Nightingale, the well-educated daughter of wealthy British parents, defied social conventions and decided to become a nurse. The nursing of strangers, either in hospitals or in their homes, was not then seen as a respectable career for “well-bred” ladies. In a radical departure from this view, Nightingale believed that well-educated women, using scientific principles and informed education about healthy lifestyles, could dramatically improve the care of sick patients. Moreover, she believed that nursing provided an ideal independent calling full of intellectual and social freedom for women, who at that time had few other career options. 

Fast forward to today… 

We are in the midst of a tremendous transformation of the health care and social services sector. Just about everything we have taken for granted for years- even decades, is crumbling, and at a pace that is really somewhat breath-taking. This is not a bad thing. It has been a long time coming. 

Bringing our new CIUSSS to life is just one part of this transformation. However, the most fundamental of changes will be driven by technology that will permit us to effect the right types of interventions in the right places at the right time in ways we could only dream of even a few short years ago.

The excitement building around mobile health (mHealth) is increasing at an exponential rate. The technologies! The access to care! The consumer involvement! The clinician (nurse, allied health professionals and physician) tools! There are so many exciting possibilities offered by mobile health in the hospital and the community, and I think this is the next challenge and opportunity for Nursing. Most often on the front lines of patient care, nurses are the people using the technologies, facilitating the access, involving the consumer, communicating with physicians, and therefore, it’s imperative that they are directly involved in the creation of mHealth. Excluding nurses from the front-end development and deployment of technologies will result in wasted time and money, as technologies can only be successful with the early input from end users. 

Although the delivery of healthcare is in a state of creative chaos in today’s healthcare delivery environment, the one facet that is consistent is the nurse. As mHealth grows and becomes the standard of practice, it will be vitally important for nurses to be engaged in the development of these new delivery models. I for one look forward with great anticipation to observe how the core values of Nursing- human dignity, integrity, autonomy, altruism and social justice, will be applied to these new challenges.

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A new beginning blooms

As I sit in the still of the night to compose this blog entry, I am struck by the symbolism of the week at hand. April 1st marks the official start of operation of our new CIUSSS du Centre-Ouest. Rather than this conjuring up thoughts of April Fool’s Day, I would prefer to think that the date was chosen because it is the start of the new fiscal year! But then again…

This is also the beginning of spring, a time when things begin to blossom and to grow anew. So too with our new organization, which is finally being brought into the world after some rather prolonged birth pangs.

Of course, this time of year is also associated with the holidays of Easter and Passover. It is interesting that the Last Supper served the dual purpose of venerating Passover, the escape of Jews from slavery in Egypt, and the establishment of a new religion, Christianity. So too, the creation of our CIUSSS, in particular, represents a coming together of these rich community heritages. The greatest contributions to the world of both traditions can be summarized in five words: memory, optimism, faith, family and responsibility.

As we move forward together to bring the vision of our integrated network of care to life, we should always be guided by these words and remember that we are charged with both a responsibility to the past and a commitment to the future.

Over the coming weeks, I look forward to meeting as many staff from our network as I can, and together beginning the task of building the future of health care and social services in the west-central territory of Montreal.

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