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Speech by Dr Stephen Duckett Foundation President and Chief Executive Officer Alberta Health Services
Alberta Health Services Senior Leaders
6 December 2010
I d like to thank you all for joining me here to mourn, celebrate and move on. We live in different realities. Mine is a future primarily outside AHS, yours within. Our realities overlapped for 20 short months, a time when we achieved an enormous amount which is to be celebrated. But also a time cut short and for me it is appropriate to mourn the might-have-beens, and the agenda that I hope will be continued. But we all also need to move on, to the next stages of our lives. Many of you are good friends and I hope I can catch up with you from time to time, to share laughs and adventures. But many of you don t know me well. And I want to take this opportunity to give you a better understanding of who I am, what I did and why. I m going to give a formalish talk, partly to avoid too many tears! What I want to do tonight is say my piece, not in real time you ll be pleased to know. Because of my former role I ve been constrained in what I can say, especially so this year. I m a free person now and can reflect on our achievements and missed opportunities more directly. So to begin at the beginning. Joining Alberta Health Services I was appointed in January 2009, I ve told some of you the trials and tribulations of the short-listing video interview on the Friday (Australian temperature at +40, the other end of the line in Calgary at -40), the 2 day drive back to Brisbane from my holiday, the haircut, the flight, arriving in Calgary on the Monday night and an hour or so later being rotated around three tables at dinner with the board. A foretaste of the pace at which I would be working in AHS. Another aside. In the interview I was asked if I d any media experience. I answered yes but I didn t expect there d be much exposure in this job. The Board basically rolled around laughing and I realized I d made yet another mistake in the interview. Although the internet age means people can find out a lot about who you are, I wanted to make my values clear, so there d be no risk that I d be asked to do things I wouldn t want to do. Given the government s previous history on Medicare1, in my first meetings with Ken Hughes as Board Chair and Minister Liepert in that interview week, I told them that I would not do anything that would undermine the Canada Health Act. They both accepted that position and honoured it. I see myself as a friend of Medicare with a small f. The capital F folk go much further and want to end private delivery, putting almost all physician practices out of business2. Not a position I can support. So shortly after the announcement of my appointment, but while I was still in Australia, I got this phone call from Ken Hughes and Don Sieben, chair of the Audit and Finance Committee, telling me that they d just become aware of the need to do a significant financial correction, dimensions still unclear but certainly north of $1B. Imagine my feelings. I thought I was going to a well endowed health system!
http://www.thecanadianencyclopedia.com/index.cfm?PgNm=TCE&Params=M1ARTM0012159 To be precise, according to their website (http://www.friendsofmedicare.org/default.asp?mode=webpage&id=52) they are opposed to a parallel system of for-profit delivery, with no mention of any exclusion for physician practices.
Anyway, an interesting introduction to AHS and one which gives the lie to those who said I was appointed simply to do budget cuts. I ve said subsequently to Ken Hughes that I should sue them for misrepresentation in not informing me about the financial situation as part of my recruitment. In return, he pointed out that for misrepresentation to have occurred they would have had to know how bad the problem was when they appointed me. And they didn t of course as the oil and gas price collapse was just occurring. But then I arrived here. Lorinda, Joyce and others had taken the trouble to speak to my former staff in Queensland to find out my likes and dislikes. To make things easy for me. To make me feel welcome. And that set the tone for me inside Alberta Health Services. This has been probably the most supportive organization I have ever worked in. You have all been welcoming. Tolerating my quirks, Australianisms, different sense of humour. But really caring for me in the tough times, and we ve had a few. For the record when I say you, I don t only mean you, the leaders in this room, but you, the others with whom I ve worked at all levels of the organization, and the Board too. There was less tolerance outside AHS. The media created a Stephen Duckett I didn t recognize, portraying me as a one-dimensional budget cutter, a portrayal that still continues3. Yet my main work and achievements in Queensland had been about access and quality, the other two goals of AHS! Paradise lost? An early challenge I faced was the issue of AHS legitimacy. When I arrived there were still many (inside and outside AHS) who lamented the demise of the predecessor entities, and they looked back on the good old days when everything was perfect. Everything AHS did was bad and not up to the standard of the previous region, board, Commission. But as I ve said in previous presentations4, all was not rosy. Alberta spends more per capita (adjusted for age and sex) than other Canadian provinces, and gets less. Male and female Albertans have a shorter health adjusted life expectancy than the Canadian average. Albertans who get cancer don t live as long as people from Ontario. All this using data from before AHS was formed. Investment decisions have over-emphasized acute provision at the expense of seniors care. In contrast to other provinces, Alberta reduced per capita spend on non-acute facilities over the last decade. Is it any wonder that our acute facilities had to become de facto seniors housing, contributing to the systemic problems that have created the problems in emergency care? And emergency department performance in both Edmonton and Calgary has been getting steadily worse over the last decade, achieving the eight hour standard for admitted patients about 60% of the time in the first few years of the decade to around 25% now. Neither level acceptable of course.
http://www.edmontonjournal.com/health/interim+Alberta+health+board+boss+will+focus+better+service+engagi ng+staff/3890943/story.html 4 Most notably to this forum, the Board, zone planning days for the Calgary, Edmonton and North Zones and at a University of Alberta conference (http://www.economics.ualberta.ca/boom_and_bust_again.cfm)
And there was significant variation in practice between different parts of the province, different admission rates, differences in length of stay. Little was done to learn from these differences, different definitions were used across the province and there was no effective benchmarking. The effects are still with us: it takes a day longer to treat a person with a stroke in Edmonton than it does in Calgary, same for hip replacements. This consumes excess bed days and effectively reduces access in Edmonton. This perception that the predecessor entities were perfect was achieved by aggressive media management, restricting transparency, duchessing key commentators, and in some former entities, by having a Mr Fix-it whose role was to respond to external pressures, including manipulating waiting lists. Unfortunately for me, these strategies were not consistent with either my values or those of AHS. Achievements You know only too well what it was like when I started. No functioning formal structure. No financial reporting system. No strategic direction. We addressed all that quickly. But that is not what I m most proud about. You all led teams that have started change in a myriad of areas. I ll only highlight a select few tonight but there are lots5. I think the single greatest achievement is how you are working together for the benefit of Albertans. There are hundreds of examples of how you re sharing ideas, one learning from another. My experience with the workplace engagement group, people in all sorts of roles, from all parts of the province was very rewarding and I think we can already see the turn around in engagement as a result of that work. I think the work we ve done on emergency access is a good example and one I was particularly proud to be part of and would like to write up. Introducing new ideas into Alberta to improve flow: the medical assessment units, for example. Work on tehse started back in 2009. The workshop I convened, leading to the driver diagram, leading to a coherent set of medium and long term initiatives involving zones and hospitals and others. A problem which has been around for ten years is not going to be fixed in ten weeks or indeed one year, despite all of our best efforts, but I think we are seeing early signs of improvement. So I plan to claim some credit if we see a turn around by mid next year! In 2009/10 we had a big budget challenge and all stepped up to the mark, and continue to do so. Bringing the budget under control involved hard work. But work that was and is essential if Medicare is to be sustainable. If the 10-12% growth rates experienced in Alberta in the past had continued, there would have been increasing questioning of the fundamentals of Medicare, to the detriment of all of us. So lots was done to address the challenge. Take procurement: here we saved hundreds of millions of dollars by standardizing and using our purchasing power. This was not just a CPSM achievement, but involved countless people from across AHS contributing and adjusting their practices for the common good.
I ve also addressed some of our achievements in two papers which are in press: Getting the foundations right: Alberta's approach to health-care reform forthcoming in Healthcare Policy and Second wave reform in Alberta forthcoming in Healthcare Management Forum.
Our incipient Enterprise Risk management framework is already attracting positive comments from other provinces. Developing modern, province-wide medical staff by-laws. We ve done a lot on moving toward interprovincial equity in clinical and non-clinical areas. Take cervical cancer screening for example. Different regions had different policies and priorities with respect to invitations and reminders. Capital Health didn t put the same value on this as Calgary Health Region, with the result that screening rates are appreciably lower in Edmonton (69.6%) compared to Calgary (74.3%), an issue we are now addressing. Expanding security coverage in the province on a cost-neutral basis in a new service model is another example of improved service equity. Developing Canada s first electronic provincial drug formulary that other provinces now want to buy. This was only possible because we were one provincial organization, of a size to support the specialized staff needed to do this. Developing a coherent, evidence-based approach to workforce planning which looks not only at supply but affecting demand. Replacing more than a dozen different funding schema for long term care by an equitable, provinciallyconsistent, activity based funding approach is another major achievement. There are currently huge variations in what we pay for care (after standardizing for the needs of residents) and the incentive on facilities until now has been to take the least dependent rather than the most dependent resident, contributing in part I think to our problem of long stay Alternate Level of Care patients in our acute hospitals. Tighter and better contracting for services is yet another example. At least having contracts is a start, in contrast to the Villa Caritas contractual mess we inherited from Capital Health or the hand shake deals of another region. As you know I support having private delivery within a publicly funded health system. Our aim should always be to ensure that our service contracting is for the benefit of patients, to improve access, to garner innovation, to improve efficiency so we can get more access for our dollars. This means we need good contracting, activity based funding helps this. But we must also aim for contracts which are tight in terms of price and/or an expectation of an efficiency dividend with volume growth. Still a work in progress I m afraid but at least we know what to do. The best service contracting example is in ophthalmology in Calgary. Here we commissioned an academic paper to give advice about what best practice in contracting might look like. And the answer came back, not at all like what you are doing6. So we went to tender and got a significant price reduction: we proposed to spend the same money as had been previously allocated but with 20% more patients treated. A win you would think. But politics intervened. The ophthalmologist-entrepreneurs who had misread the tea leaves and tendered too high complained to the Minister that somehow an
open, transparent bidding process was unfair and successfully enlisted the media in their cause. And a new process was cobbled together. But at least we kept the lower price. Let me tell you this. I have listed this as a success. I think we made the right decision then and faced with the same facts I d support the same decision again. If I have to weigh up the interests of a handful of business people who misjudged the tender process against the interests of hundreds of patients who would now get treated quicker, I know what side I d always come down on. We have also set the scene for better intra-provincial cooperation, signaling the end of the medical arms race between Edmonton and Calgary. We ve got new mechanisms for intra-provincial learning: the Alberta Clinician Council and the clinical networks. Although these are still nascent organizations, which need nurturing and validating, we are already seeing the good work that can come from them (e.g. the work of the Bone and Joint network in developing protocols and introducing clinical benchmarking). I d also like to list our attempted reform of mental health services in Edmonton as an achievement, although there are certainly lessons here as well. Villa Caritas opens a month today. Some of the most vulnerable in our society will be moving into modern facilities, next door to a major acute hospital rather than in an isolated institution on the outskirts of the city. Like Christopher Wren s epitaph7, look around Villa Caritas and look around the multi-bedded rooms out at Alberta Hospital Edmonton and you will see the difference. You will see the environment in which care ought to be provided. Although we only achieved part of the reform, reform I still believe is necessary, those in the new facilities will be beneficiaries of this forever. My take home lesson was that I took on too much. I should have proceeded one step at a time. I also was not ready for the most disgusting media campaign I ve seen in my career. A media campaign where people who were supposed to care for the mentally ill attempted to scare the populace about how dangerous it would be for people with mental illness to be treated in nearby acute hospitals or in the community. That kind of stigma harms patients and harms mental health services by keeping them stigmatized and isolated. Perhaps our biggest achievement has been the Five Year Funding agreement, negotiated at the end of 2009. October 2009 was a terrible time for me. What we faced then was the reality that we most likely couldn t meet our payroll later that financial year8. During 2009 we had to tighten our belts. We had to set priorities. We said we would minimize layoffs and protect access to services. And we kept that promise. I m proud of that. The media s role was interesting at this time. All the cuts were AHS fault (usually mine). Not once did the media link back to
http://www.famousquotes.me.uk/epitaphs/14.htm: LECTOR, SI MONUMENTUM REQUIRIS CIRCUMSPICE (Reader, if you seek his monument look around you.)
the fact that the budget parameters were set by government and our job was to live within the budget government set. The media suffered a similar blind spot when Minister Zwozdesky was appointed and overturned our proposed bed closures, seen as a major setback for me. Only one journalist picked up the budgetary implications: that if the beds weren t being closed, AHS must be going to get a funding increase in the budget to pay for it all. So the media looked only at the surface, failing to see the underlying dynamics. This funding increase was a significant achievement for me and for AHS. And so good came out of it all. The Government dramatically changed our financial parameters, and put us on a secure, long term financial footing. The first time any provincial government has done anything like that in Canada. The five year funding agreement is fair, but requires significantly tighter financial discipline than exercised by the previous entities with their average 10% increases in spending per annum. It transformed my working day where every meeting was about progress on budget strategies to be freer to thinking about investment strategies, investment strategies which are now beginning to show dividends. Long term secure funding, with reasonable but not excessive growth rates within which services must manage, is an essential for Medicare to survive. Those of us who support Medicare should be arguing for that in all provinces and nationally. The media My relationship with the media was fraught from the start. Partly because of Canadian-Australian cultural differences (people weren t ready for direct speaking), partly because of the perceived perfection of what went before. The media along with politicians only see the short term, and often fail to connect the dots. The immediate deadline and the quick attribution of blame drive the story. This means that short term wins or decisions are all important, and crowd out any real consideration of the long term. One example will suffice. Building on published comments from three physicians, I attempted to open up the issue of social disparities and social determinants citing significant differences in life expectancy in higher status neighbourhoods in Edmonton versus lower status9 10. The immediate media response was to close the debate down, essentially with the simplistic suggestion that all one needed to do was open a new urgent care centre11! What is needed in that neighbourhood is better primary care, not more patch-up services, and beyond that, employment opportunities and a range of social supports, housing and so on.
http://www.capitalhealth.ca/NR/rdonlyres/egeta3vsclkaagarxdaazp6l3vvcu7pfos7a6i7xiby6t765d5opnrxsm6b6xxt znn5xmounqbkux5nj3zgcp6wwbdb/Poverty+and+Health+in+Edmonton+Nov21.pdf 10 http://www2.canada.com/edmontonjournal/news/letters/story.html?id=30ec58a5-fa59-42bf-b6dde7b382c47830 11 http://www2.canada.com/edmontonjournal/news/cityplus/story.html?id=847f5d81-19bf-40b9-a486d2d7f2ed427c
But I don t want to demonize the media. The job of the journalist is to write stories. Conflict is better than no conflict. And they ll get little encouragement to think of the long term interest of Albertans. Journalists, as with the Alberta public, have been socialized to be skeptical of public officials. They didn t believe that community services would be established to facilitate the redevelopment of mental health services in Edmonton because the same promises had been made and not kept before. And a newcomer with no track record in the civilized world (aka Canada) could certainly not be trusted. The same with other reform initiatives. Previous strategies to address health care deficits had generally been to spend more, what I ve referred to as an Oliver Twist strategy12. Anything that amounted to doing things differently and/or more efficiently must be inherently wrong. The role of the Chief Executive Officer The job of CEO of Alberta Health Services is unique in Canada. AHS is the largest health care provider in Canada by a factor of three, with 90,000 staff the largest employer in the province (and in probably every town or city in the province). AHS operates in a politically charged environment. My job actually involved multiple separate jobs: y y y y Managing the 2009/10 budget challenge (and for 2010/11 the continuing need to exercise tight financial discipline) Getting the merger underway (incidentally, Canada s largest merger in terms of staff, undertaken with no preparatory time!) Putting the foundations of a unified and integrated provincial system in place Leading the transformation to position AHS better for the future.
Many of you have highlighted to me another of my roles, teacher. I ve received more than one hundred farewell emails. Some from people I hadn t met, some from people who I met only fleetingly. Some very moving. Thank you for that. But one theme from many of them is how much people learned from me (the implication was they learned positively!! I trust I got that right). People said similar things about me when I left Queensland. Thank you for that, this means a lot to me and it also leaves something behind which I hope will lead to improvement in the services you provide or manage and in your working life. The CEO s unique role, though, is to set directions. To be planning for 5, 10, 20 years out. Thinking about what the system ought to look like and what we need to put in place now to get there. Transformation, though, is not just one big decision. It s not just setting a direction. It s also the hundreds of little decisions that are necessary to operationalize the transformation. Decisions that you made, sometimes seeking my counsel, I guess back to that teacher role too. We have set ambitious goals13, but goals which in my view are achievable. But only achievable if we do things differently: not more of the same but transform the organization with LEAN and other quality
improvement initiatives. Redesign services to deal with the different workforce of the future. Build on what we know works in other countries, or elsewhere in Canada. We must be open to new ideas if we are to succeed. And this is part of what I think I brought to AHS. Please don t lose that. It s not only in Alberta where change is needed. Health care in Canada needs to be transformed dramatically if it is to be sustainable, an issue I ll return to later. And we were transforming. AHS is a large organization so change takes time but we were beginning to turn the corner and I am confident that the paths we established will show dividends in the next six to twelve months. Several people have said to me that I had the worst job in Alberta. I don t think so. Working with you on our multiple agendas, seeing the progress we were making, puzzling out what to do and how to improve access and quality for Albertans was challenging but fun. I cannot deny, though, that the job was exhausting and stressful. It took a toll on my health and on my family. Costs that the external world doesn t see or care about. So here I d like to thank my partner and our daughter for what they ve put up with over the last 20 months. A dad/partner away from home too much, and when he was at home, often in his study. But also to thank them for the support they gave me over that period and in the last couple of weeks. To some extent the work load in the job was unsustainable in the long term. 75-80 hour weeks Monday to Friday, more work on weekends is hard on anyone. All that in the public glare makes it worse. I was watching TV last week and complained about the lack of good programs to watch. Sarah pointed out that I d had no time for week night TV since being here. So there are positives from all this, and you get to see one last polarity diagram14. Maybe you can help me manage this polarity by keeping me informed and inviting me to join in celebrations of successes! So the last couple of weeks have been hard for me, I made a silly mistake and my role here ended. But from a personal point of view it may, in the end, be good. It is certainly a better way to slow down than a heart attack! All of you are working too hard. A few weeks ago I wrote to you all about work-life balance, as I said, I was somewhat hypocritical given where I was but it s still something that has to be addressed. I mentioned just now that we ve set ambitious goals in our 5 year plan. Some responses to the plan called for people s jobs to be on the line if the goals were not met15. That type of call leads to two potential consequences: first, next time you won t be as ambitious in your goal setting, with Albertans being the poorer. Secondly, severance arrangements need to be revisited. At present the executive
The government s version is here http://www.health.alberta.ca/documents/Becoming-the-Best-2010.pdf Johnson, B Polarity management: identifying and managing unsolvable problems HRD Press 1996 15 http://www.edmontonjournal.com/health/Alberta+unveils+health+plan/3906386/story.html
essentially has one year severance entitlements. If there is to be a higher risk of dismissal, then there have to be greater protections. Cookie incident And now some words about the cookie incident. First, I want to acknowledge upfront that I made a mistake. I have tried to be open and direct in my responses to the media. But for the last few months media advice from government was for me to be less accessible. On the Friday morning of the cookie incident I was subject to the same line of advice: that I was not to make any comments following the meeting AHS had convened. Dr Eagle was designated as the AHS spokesperson. Media reporting of the incident has generally been along the lines that I refused to comment about what we were doing about emergency department long waits. However, the most significant story that day was about comments made by Dr Sherman, then still Parliamentary Assistant to the Minister for Health and hence a person with an important role in the provincial government on health policy. I suspect the reason for the advice to keep me away from the media was the expectation that I would be asked questions about Dr Sherman s comments. Indeed, this proved to be the case with questions such as: y y What do you think of Raj Sherman s criticism of AHS . . . Do you have a response to some of the criticisms that MLAs are directing to AHS.
So the emdia was really after comments from me about political not health issues. I have always attempted to be totally honest and upfront in my dealings with the media, including about AHS performance. Under my leadership, AHS increased its transparency and plans are afoot to be even more transparent, publishing a broader array of data. I have also acknowledged publicly that health care performance has not been good. I have said a number of times, on the record, that Albertans are waiting too long for care. But I led internal efforts within AHS to improve wait times in emergency departments. These started in the Spring of this year when the provincial government reversed our budget situation so that instead of needing to find significant savings, we were able to make investments. Remember this was way before the emergency department physicians sent their email. I prioritized development of seniors accommodation (which frees up acute beds to allow a quicker flow through the emergency department as well as improving quality for the seniors affected) and other strategies related to improving emergency department performance. These strategies are now having an impact. So, I would have been quite happy to talk about our performance in this area, but was advised not to. AHS had a media briefing scheduled for half an hour or so after I left the hotel.
I should have stopped and said no comment etc and I acknowledge that my continued cookie remarks made it appear that I might not have cared for the situation many Albertans face in emergency departments every day and the good work that the men and women of Alberta Health Services do every day. That is not my view and I regret deeply that I came across that way. I was caught unprepared for the media chase and responded poorly. My mistake. But I trust you now see some of the constraints I was under. Making Medicare sustainable One of my goals at Alberta Health Services was to show Canada (and the world) a new health system which was sustainable. This is still one of my goals, but for now, it will probably be by writing about what needs to be done. But this will build on what we were setting in place here. To give you a taste, what we need to do is ensure that: The right person enables the right care in the right setting, on time, every time. Yes I know it de-emphasizes the prevention agenda, but that needs to be dealt with separately. Each of these words is important. Right person: you know my obsession with full scope of practice, doctors doing what doctors should do, RNs likewise etc. To understand the dimensions. The government has committed to funding universities and colleges to graduate 2000 RNs per annum, a commitment not kept incidentally. What we need is an additional commitment to train 1000 health care aides annually. Then we d see some workplace transformation. Enables: we are facing a chronic disease tsunami. So we shouldn t be thinking about what we do as treating patients , with all that it connotes of treater doing something to treatee. Rather we need to talk about enabling care, supporting the person with chronic disease to manage their care, supporting their family or carers in that endeavor. Our work on the Interactive Continuity of Care Record (horrible title), is absolutely fundamental to this. Right care: here the clinical networks have a role in identifying best care, developing protocols and benchmarking performance. Right setting: We should be aiming to support care in what I call the least restrictive alternative. At home if possible through services coming into the home, or via telephone consults (including HealthLink), and in community settings. This requires a transformation of the Alberta mindset which still seems to me to equate health care progress with more acute beds. A better place to start is to assume an acute admission is a failure, of prevention, of available alternatives. Not always true I know, but as I said, a better mindset. On time: The access agenda, which needs to be supported by transparent and regular reporting. Not yet possible in Alberta in many areas (e.g. elective procedure waits).
Every time: back to the quality agenda, and the role of the clinical networks. We need to redouble our efforts to improve quality of care, including through development of a just and trusting culture. Au revoir To do all this we need to learn to manage in a different way. As I ve said time and time again, we don t want more of the same. We have to learn new skills, new ways of doing things. Get ideas from other countries, even Australia! So this was indeed an emphasis of my time with you. To help position Alberta better for the challenges ahead by facilitating experimentation, and innovation, pointing out alternatives, encouraging you along the way. Or at least that s my perception. I want to thank you all for being with me on this journey. The executive, a fine and talented team who gave me incredible support, worked incredibly hard on creating AHS. Thank you. My immediate staff, who helped and protected me in so many ways. Who made life easy for me in lots of little (and big) ways and looked after me at work, going beyond what could be reasonably expected. Thank you. Everyone in this room, who laughed and worked with me. And people not here who shared in our struggles. Thank-you all. And again, an enormous thank you to my partner and our daughter. I ve got a number of regrets. Not seeing all of Alberta s Big Things is one. Nor the gopher museum. At this stage we look like we ll be staying in Edmonton for a while yet so maybe a future opportunity! Which also means that I ll have an opportunity to stay in contact with you. You who have been so supportive, so helpful, such good people to work with, so dedicated. But my biggest regret is not being alongside you so much for the next stages of this journey. We have the foundations in place to do truly wondrous things. Please continue to do them. Thank you and au revoir
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