​Health and Long-Term Care Reform: Whatever Happened to Sound Organizational Principles

I remember his voice from 60 years ago when Prof. Arnold Cook lectured beginning business students, and I was one, on the principles of what makes for a good organization that grows and develops.  The principles of clear accountability, shared vision, strong leadership have been my guiding principles in large and small organizations that I have directed over the last half century.  The organizations that grow and survive have shown that Prof. Cook was absolutely correct, and some of them are outlined in Good to Great, the classic Jim Collins book that describes what it takes to take an organization from “good” to “great”.

Transpose that basic thinking then to health and long-term care in New Brunswick and think, for a moment, of the issues that have caused so much nasty public discussion in recent years, particularly the last three.

Start with hospitals.  As the major provider of health services in regions in the province, they are said to be one of the most complex organizations in our society.  Why is that? 

Historically, in conventional hospitals, you would have a board of directors who were legally charged with the responsibility for all that goes on in the name of the hospital.  This includes such challenging things as recruiting the right physicians to the community to provide services based, in some measure, at the hospital.  How does a Board composed of local business people or professionals know how to recruit physicians and how to engage them in the hospital in a manner consistent with legal and accreditation requirements?  In those hospitals, by regulation and consistent with by laws, they would have a Medical Advisory Committee.  These committees typically consisted of physicians in good standing in the hospital.  This committee, in most hospitals, was very influential in advising on programs and policies governing everything from admissions to operation of the emergency department or the operating room. 

Some physicians actually came to believe that the Medical Advisory Committee “managed the hospital.”  But by law they were “advisory to the Board and Administration”, yet rarely would either take a position that is inconsistent with the Medical Advisory Committee. 

For the most part, physicians are not paid by the hospital and the old rule of thumb was that 80% of the cost of running a hospital was driven by the pen of the physician!  So, 80% of the cost of operation of the hospital is driven by professionals for whom there is no accountability to an authority group or person.  Books have been written on this complex set of relationships, the point of which is that in hospitals the lines of accountability are quite inconsistent from what you would find in Costco, GE, or any others of the large major organizations that dominate the economy.

Similarly with the powerful and influential nursing profession, while hospitals typically have a Director of Nursing or Chief of Nursing who has a daunting set of responsibilities for fiscal and quality results, on the front lines the persons who supervise care activity are members of the nurse’s union so that in executing any leadership duties, there is, by definition, a split loyalty to the employer and the union.

And with hospitals, the accountability issue becomes even vastly more challenging when you superimpose a method of appointment of boards and CEOs that is driven not by considerations of excellence in service but in party politics.  Service excellence does require clear lines of accountability from the owners thru the board to the providers of service at the bedside.  In New Brunswick, we have had a governance system for health authorities in which boards not only do not have direct authority in clinical and programmatic matters but they do not appoint the chair of the board nor do they appoint and measure performance targets for the CEO.  As mentioned in previous commentaries, this model is fraught with breakdown in clear lines of accountability and responsibility and serves to explain why it has been so difficult to get traction on key issues in the health authorities.

You will find similar lapses in the chain of accountability in the long-term care sector in which the system is regulated by the Department of Social Development.  It is a large department with wonderful personnel, all of whom honestly want to succeed and see services run smoothly.  In one part of the long-term care system, there are community boards elected in accordance with facility by laws and who function with limited direction and training.  Their mandate is, amongst other things, the appointment of a CEO and, with the CEO, a Director of Care. 

Under the Nursing Homes Act, there are regulations that guide the organizations and there is, also, a funding mechanism that has been shown to be outdated for years.

The balance of the long-term care system is governed under the Family Services Act which was not designed for long term and eldercare.  The oversight and regulation are conducted by another division of the department in which policies and standards are developed then given to regional offices who serve as the inspectors and monitors of compliance with the Family Services Act.  Those who regulate regionally are accountable thru a system to one departmental senior official that is not in the same division as the official that is responsible for creating standards.

This large component of the long-term care system (home care and special care) is larger than the nursing home sector and is owned and managed by over 400 separate organizations who do incredible work under very difficult circumstances.

So, if government actually were to state a goal of Excellence in Long-Term Care, and I hope they will, the current disconnects in accountability make it virtually impossible to achieve traction in any reasonable time.  There is no clear path from vision to execution.  That is not a criticism of people for they all are terrific.  But it is an observation on a system that has grown for a long time without focus. 

When things go wrong in health and long-term care what typically happens, in the absence of clear accountability, the fingers come out and the blame game starts.  Over and over, we have seen that in recent years.  The Accountability confusion has created serious role ambiguity so that often regulators seem confused on the question of “is our job to regulate or is it to manage?”

If we are serious about wanting great quality, person-centered service in health and long-term care, steps must be taken to fix the accountability and associated role ambiguity conundrum.  That will take some commitment and understanding but avoidance simply perpetuates what has caused the public so much grief in the last two decades. 

Who?  What? Where?  When?  How?  These are some of the foundational questions of clarifying, and fixing, accountability.

And the people appointed to some new governance body for the health authorities need to be schooled in organizational behavior and dynamics, creation of organizational excellence.  If they don’t ask those questions, they don’t understand and should not be part of a governance model either for health or long-term care.

Professor Cook was right as was Jim Collins:  excellence is borne from sound organizations that have strong leadership and clear accountability.  Without that we sentence ourselves to more of the same.
​
Ken McGeorge,BS,DHA,CHE is a retired career health care CEO, part time consultant, and columnist with Brunswick News; he is the author of Health Care Reform in New Brunswick and may be reached at [email protected] or www.kenmcgeorge.com
​