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June 2016 //
Canadian Government Executive /
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The Interview
begins with the proverbial “coalitions of the willing.” Without
them there will certainly be no transformation of anything and
certainly not of Canadian healthcare.
Q:
How has CFHI changed its mandate since you
became the CEO?
The Canadian Health Services Research Foundation was created
in 1996 through a federal government endowment that was sup-
posed to run for twenty years. It had a broad mandate to enhance
the implementation of health services and fund some research.
The main change since my arrival was to completely move away
from research funding. To continue would have made no sense—it
was just duplicating the work of others. When I arrived we did a
tripartite strategic plan focussed on what we considered the most
important goals that would influence healthcare transformation:
patient and citizen engagement (a new area for the foundation),
accelerating institutional change (primarily through our execu-
tive training, the EXTRA program) and policy dialogue.
Q:
CFHI has been in the Executive Training business
for a long time. How did it change?
EXTRA was originally created to increase understanding among
healthcare leaders of how to apply research findings. It was fo-
cused on the individual. EXTRA participants brought with them
change projects. We had not realised that our focus should be on
the change projects themselves and that bringing teams into EX-
TRA made more sense than individuals. Now very senior teams
including VPs Medicine in big hospitals, Directors of Nursing and
ADMs in Health ministries make up our cohorts. You get the idea.
They use the program to achieve change in their organizations.
EXTRA is our Petri dish for innovation.
EXTRA has long been one of very few places where frontline
healthcare people get together to share ideas about improvement
across the country. (There is excellent participation from Quebec
as it has always been a fully bilingual program.)
Q:
So tell me more about these Petri dishes.
Well, right now, we have thirteen “natural experiments” going on
in healthcare delivery. We had RiskAnalytica (a Toronto consult-
ing firm) model out projections to showwhat the benefits would be
if only half of Canadian healthcare institutions made the changes
that five of our EXTRA projects had shown to make a difference.
Their conclusion: $2.1 billion annually.
As we moved away from research funding, there were two other
important opportunities, both of which helped frontline health-
care people and organizations better provide care for patients
with chronic conditions.
The first opportunity was in the North West Territories where
we supported regional healthcare teams to analyze and re-think
(using the EXTRA approach of tailored learning and expert coach-
es) care. The second was the unprecedented all-Atlantic provinces
collaborative on Chronic disease. Through it we met Dr. Graeme
Rocker who had implemented the INSPIRED program modelled
on the UK “Breathless” program for treating COPD sufferers at
home. The program vastly improved their lives. We also dem-
onstrated that care could sometimes be moved successfully out
of the acute care hospital. For every dollar invested, the system
saved $21.00.
However the real “Aha” moment came later when I was chair-
ing a session at Ontario’s Health Achieve in November 2013. One
of our EXTRA fellows, Dr. Marilyn el Bestawi, had demonstrated
a great project. I said wistfully at the end of her presentation:
“Now if only others would do that!” My colleague from the Ot-
tawa Hospital, Heather Sherrard, came up to me and said “Well,
that is unlikely.” “Why?” I asked. “No beta testing” she answered.
The light went on. As former Minister of Health Monique Begin
used to complain, Canada is a nation of pilot projects. CFHI has
proved that does not have to be the case. We embraced beta test-
ing. We call it developing Spread Collaboratives. We have start-
ed to engage with provinces to move from spread to scale. New
Brunswick is the first.
Q:
So how do you move the stubborn world of
Healthcare into adopting new practices?
CFHI identifies well-evaluated innovation and offers the oppor-
tunity to enthusiastic health organizations to adapt and imple-
ment those changes. We create collaboratives with these teams,
modestly fund them to permit some staff rotation and data col-
lection, and support them with coaches and learning modules.
We also carefully evaluate the outcomes for patients and what it
all costs. One spread collaborative drew on years of applied re-
search on patient and family engagement to improve outcomes.
The second collaborative originated with the EXTRA project in
Winnipeg run by Cynthia Sinclair and Joe Puchniak on the re-
duction of inappropriately prescribed anti-psychotics to people
with dementia in long-term care. (We just released the results
of the 56-site implementation in mid-May. They captured the
national imagination. We have done more than forty interviews
in a broad range of media.) Most excitingly, the province of New
Brunswick has decided to scale the appropriate prescribing of
antipsychotics to all nursing homes in the province. The third is
spreading Dr. Rocker’s COPD program. The others are coming
soon.
Q:
CFHI seems really focused on program
evaluation.
Yes we are, and we don’t just talk about it: we actually do it. Data
collection and analysis is an integral part of our programming.
That is why we actually have results to share from the spread of
collaboratives.
I have been a believer of the utility of sensible approaches to
evaluation since the mid-1970s. It must be embedded in program-
ming and actually influence management. Often organizations
collect data routinely but either don’t know how to use it or don’t
have it built into management decision-making. CFHI is showing
that spread and scale of well-evaluated local innovation can be
done and should be done. Innovations start with innovators, peo-
ple who see different ways of approaching problems. Old notions
of giant levers for change applied top-down may work from time
to time (it was a key step to have the state pay for healthcare). But
achieving change in complex systems more and more requires
that good ideas developed locally be tested, altered, spread and
scaled. That does take a lot of leadership—first to develop the idea
and then for someone to see the merit in it and test it in their own
area. I learned a lot about this in my work in international devel-
opment. It applies to healthcare, too.