Maureen O’Neil has been leading the CFHI since 2008, but she’s been fighting battles in the policy trenches with her signature energy and enthusiasm for decades. She most recently served as President of the International Development Research Centre, Interim President of the International Centre for Human Rights and Democratic Development, President of the North-South Institute, and Deputy Minister of Citizenship, Government of Ontario. She serves on a broad range of boards at the provincial, national and international levels. Patrice Dutil, the editor of CGE, caught up with Ms. O’Neil to talk about leadership in creating a culture of sustained innovation.
Q: You’ve been in leadership positions, and you’ve watched leaders for a long time—what do you think are the greatest strengths in public sector leadership today? What are their greatest weaknesses?
If I think about healthcare, there are many people itching to make changes for the betterment of patient care. For decades we have talked about the social determinants of health. Improving income is key. What is an individual doc to do with that? Well, at St. Mike’s in Toronto there is a real attempt to make sure their patients are getting all their income benefits. And Dr. Ryan Meili and colleagues in Saskatoon have a program called UPSTREAM which actually clothes principles in reality. The re-discovery of the Guaranteed Annual income and the substantial policy work on the topic 40 years ago has engaged public servants (in Ontario) and the social organizations outside government looking for better ways to direct income to poor people. This social engagement and blurring of policy lines takes real leadership and I see it as very positive.
Q: Those examples are rare, though.
They are. The last several decades and have been very difficult for anyone who is inspired by a desire to see a fairer society. The pendulum swing following the 1978 Bonn summit was the beginning. Frankly it has been hard for the ordinary person to see themselves in government policy since. Maybe that is why Trump and Sanders have been having such a run in the US primaries. Even now in Canada we do not talk about poverty. We talk about the middle class. I recently did a bit of research for a conference on basic income and it is sad to see how little progress has been made. The Ken Carter Commission on Taxation concluded (in 1966!) that the tax system placed an unfair burden on the poor. The Senate Commission on Poverty of 1971 concluded that Canada should adopt a guaranteed annual income. Almost 50 years later, we’re still talking about it like it is a new idea! The Royal Commission on the Status of Women and in the early 80s the McDonald Commission on the Economy all came to the same conclusions. I was lucky to have begun a public service career when the fashion was public and social engagement. Searching for evidence was expected, as was engaging in discussion and, if necessary, argument with your Deputy Minister or Minister (as long as you were polite and respectful). I really don’t know now. It seems to me that in Ottawa, and in most provincial capitals, those reflexes might be a little rusty.
Q: So what keeps you optimistic and engaged?
I really do believe a better world is possible. I also believe that it requires relentless effort to change anything. At CFHI with our small budget ($17 million in the face of a $220 billion healthcare spend in Canada) we can make a difference and most importantly we are already showing that good ideas applied, tested and evaluated can be spread by willing imitators and adapters. Patient care will improve and it will likely cost less than now. Change always 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 supposed 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 executive 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 focused on the individual. EXTRA participants brought with them change projects. We had not realised that our focus should be on the change projects and that bringing teams into EXTRA 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: HC in Canada is primarily the responsibility of the provinces.
Yes. Right now, we have thirteen “natural experiments” going on in healthcare delivery. Our research shows where there is ample opportunity to radically improve Canadian healthcare with blindingly simple changes. We had Risk Analytica (a Toronto consulting firm) model out projections to show what 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 healthcare 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 coaches) 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 demonstrated 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 chairing 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 Ottawa 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. 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 testing. We call it developing Spread Collaboratives. We have started 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 opportunity to enthusiastic health organizations to adapt and implement those changes. We create collaboratives with these teams, modestly fund them to permit some staff rotation and data collection, and support them with coaches and learning modules. We also carefully evaluate the outcomes for patients and the FISC. One spread collaborative drew on years of applied research 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 reduction of inappropriately prescribed anti-psychotics to people with dementia in long-term care. (We just released the results of the 56 sites’ 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 anti- psychotics 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 programming 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, people 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 development. It applies to healthcare too.