Optimizing physician leadership and engagement in two Canadian provinces: a journey of discovery
Graham Dickson, PhD
The first part of this paper describes the rationale for optimal physician leadership and engagement and the recommendations in the Canadian Society of Physician Leaders (CSPL) white paper pertaining to “what provincial medical associations can do” to optimize this. The second reports efforts being made in British Columbia and Saskatchewan to realize the spirit of the CSPL recommendations. Both projects are efforts of co-creation: doctors and non-doctors, building health systems of the future, but creating them together. The third part outlines achievements and lessons of discovery learned along the way that they — and other jurisdictions of a similar wont — can integrate into their journey.
KEY WORDS: physician leadership, engagement, Saskatchewan, British Columbia, system design, communication, dyad structure, facility engagement, evaluation
In 2017, the Canadian Society of Physician Leaders’ white paper entitled “Accepting our responsibility: a blueprint for physician leadership”1 argued for improvement in the level of physician leadership and engagement in Canada’s health care system. Two years later, progress commensurate with its recommendations has been made in Saskatchewan and British Columbia.
Optimal physician leadership and engagement: what is it, and why is it important?
A partnership with physicians is necessary to achieve the highest quality of patient care in modern, changing health systems.1-4 The CSPL white paper outlines how doctors can achieve optimum physician leadership and engagement to ensure that reforms are in the best interests of patients. But what is meant by the term, “optimum physician leadership and engagement”? “Physician engagement refers to the active and willing participation of physicians in local, regional, and provincial efforts to improve health in Canada” (p. 6).1 Top
Recommendations at the provincial level were as follows:
We recommend that provincial ministries and medical associations take steps to:
Two case studies: Saskatchewan and British Columbia
Under the leadership of their medical associations, and in partnership with their ministries of health, BC and Saskatchewan have engaged in the challenge of increasing physician leadership and engagement, and their approaches reflect the letter and spirit of the CSPL recommendations. Top
The vision for the desired future health system for Saskatchewan is Better Health, Better Care, Better Value, and Better Teams for Saskatchewan People.5 In early 2016, a working paper dedicated to exploring the future physician role in a redesigned and integrated patient-centred health care system6 was enthusiastically received by the SMA’s Representative Assembly. SMA leadership was given the mandate to pursue these ideas with their counterparts in the Saskatchewan Ministry of Health (SMOH).
In July 2016, the SMOH and SMA held a two-day “visioning session,” where vigorous dialogue ensued, highlighted on the second day by a cry of frustration from a member of the SMA: “Why do you [representatives of the ministry] think we [the doctors] are so powerful, but we feel so powerless?”
The session ended with the following statements of agreement endorsed by all present at the meeting — representatives of SMOH, SMA, the Saskatchewan College of Medicine, Health Quality Council, and regional health authorities7:
Since this vision session, the partners have held two years of dialogue and action to achieve an optimum level of physician leadership and engagement in Saskatchewan’s health care system. These efforts had to run in parallel with health reform priorities of the Saskatchewan government, such as amalgamation of 12 health regions into one.8
Advancing physician engagement and leadership in Saskatchewan continued in two streams: a local, physician-led demonstration design project and physician participation and leadership in “single-region” transition efforts.
As part of the physician-led demonstration design project, the SMA president and CEO communicated regularly with SMA membership about the nascent design project, through written updates, verbal presentations, and discussions at local medical association meetings and the SMA’s semi-annual Representative Assembly (Bonnie Brossart, CEO, SMA, personal communication). Top
In March 2017, a learning session was held with the original participants in the 2016 visioning session. Medical and policy leaders from Kaiser Permanente in the United States were invited to talk about the actions they employed to achieve a physician partnership approach to service delivery. Dialogue about what might work or be customized to work in Saskatchewan ensued and was shared broadly with SMA members.
The demonstration project was initiated in the former Prince Albert Parkland Health Region (now part of the Saskatchewan Health Authority) to engage almost 140 doctors in co-design of how the physician community could work with the local administration. These issues included
This project was designed to be led by local doctors so that they would “own the work” (Dr. Joanne Sivertsen, past-president, SMA, personal communication, April 2018).
Following the Kaiser Permanente learning session, local physician and administrative leaders from the former Prince Albert Parkland Health Region signaled their interest in exploring a new care model. In November 2017 following local discussions, a survey was prepared by the SMA and SMOH to determine physician interest; more than 70% of physicians responded. A desire for physician-led design was evident: a large majority of respondents indicated that physicians should have a greater role in system design and that innovative approaches designed by physicians would improve health care quality and outcomes. Top
At about the same time, a small, dedicated group of seven Prince Albert physicians took on a more focused role in advancing these ideas and ambitions with their colleagues to discern: “What will make or break it for you in participating in this project?” Several local physicians committed to learning more about the Patient’s Medical Home framework and Ontario and Alberta’s primary care reform efforts.
All of these preparatory sessions and discussions led to a design event in late October 2018, where physicians, health care providers, administrators, ministry bureaucrats, patient and family advisors, and community leaders came together to articulate “a more specific and detailed expression of a new model of health care delivery that describes governance and organizational design structure, leadership, data and analytics, and compensation models that will improve care and the experience for Prince Albert and area citizens and improve the work experience of health care providers.”9 Top
In the other stream — physician participation and leadership in single-region transition efforts — initially there was a risk that the restructuring process might slow down a focused effort at improving engagement practices. However, from the outset the decision was made to engage physicians in redesign and implementation in a manner that reflected the spirit of the agreements discussed in the July 2016 visioning session.
Physicians became central to the provincial regionalization process in three ways. First, two physicians became part of the provincial transition team. These doctors played an instrumental role not only in informing transition efforts and strategies, but also in communicating progress on the transition to their medical colleagues, most frequently in local, face-to-face meetings. Second, a physician advisory group was established, consisting of 25 physicians from all areas of the province. This group met every six weeks throughout the transition process, and most of their recommendations were implemented. Third, a dyad structure in which physicians were partnered with non-physician administrators was adopted province-wide.
In keeping with the journey metaphor, achieving optimum physician engagement in Saskatchewan is an ongoing process of discovery, relationship building, and commitment. A great start has been made; yet a sustained effort over time is needed to achieve the desired goal (Brossart and Sivertson, personal communication).
On 1 April 2014, Doctors BC signed a Memorandum of Understanding Provincial Engagement (MOUPE)10 with the BC Ministry of Health and six region CEOs, to commit to “and be mutually accountable for strengthening and clarifying their relationship with physicians at provincial, regional, and local levels” (p. 1). More specific goals were to:
The MOUPE offered a 5-year (expires 2019), $63 million fund to support facility-based physicians and their relationship with the health authority at their site. “Facility Engagement is a provincial initiative that originates from the Physician Master Agreement. It aims to strengthen relationships and engagement between health authorities and facility-based physicians, to improve their work environment and the delivery of patient care.”11
In a 2013 membership survey, Doctors BC had identified a high degree of aggravation with respect to doctors’ perceived lack of influence and voice in hospitals. Health authority representatives (physician leaders and non-physicians) agreed to improve communication and physician input into decisions affecting patient care and the quality of the working environment.
To operationalize the fair distribution of funds and to ensure that they were dedicated to the goals of improving physician facility engagement, the Specialist Services Committee (SSC) — a joint clinical committee with physician and ministry of health/health authority representation — was tasked with overseeing the program, defining the conditions under which funds would be distributed and administered, and determining how the overall project would be evaluated. The SSC is housed at Doctors BC and headed by Dr. Sam Bugis, a well-respected surgeon. Top
The approach to facility engagement was to revitalize an existing structure in the hospital: the Medical Services Associations (MSAs). As the collective voice of doctors at a hospital, many MSAs were struggling to find a role or have any influence. Infrastructure was created that allowed a transfer of funds to each MSA reflecting the size of the hospital and the number of doctors. Criteria for obtaining funding were developed.12 Facility engagement liaisons support MSAs and health authority leaders and facilitate conversations between them.
A third initiative was an independent formal evaluation led by a team from the University of British Columbia. In 2018, four years into the initiative, the formal evaluation is a year away from completion. However, numerous factors suggest that significant progress is being made. “If the point of the exercise is to have doctors speaking more meaningfully with each other, and with the health authority, we are seeing significant progress” (Dr. Sam Bugis, chair, Specialist Services Committee, Doctors BC, personal communication). At the time of writing, 73 facility engagement initiatives are up and running and all health authorities are involved.
Progress appears to be a result of two factors: physicians have taken up leadership roles in their facility; and health authority leaders (physicians and non-physicians) have moved meaningful change forward in their institutions. In many instances, doctors are also working better together to fix what they might otherwise have seen as someone else’s problem. Top
These two cases were chosen because they were very clear efforts to enhance physician engagement and leadership. Although they are very different in approach, there are some common elements that promote ongoing success.
After four years of effort in the case of Doctors BC and two years by the SMA in Saskatchewan, both groups refer to the initiative as a journey, not an event. Both projects are efforts of co-creation: doctors and non-doctors, building health systems of the future, but creating them together. As long as the trust generated at the beginning of the two projects can be maintained, progress in relationship building will continue. Trust is the lubricant for engagement, and optimal physician engagement is doing it, experiencing it, learning from it, and ultimately enjoying the process, rather than the outcome. Top
1.Van Aerde J, Dickson G. Accepting our responsibility: a blueprint for physician leadership in transforming Canada’s health care system. White paper. Ottawa: Canadian Society of Physician Leaders; 2017. Available: https://tinyurl.com/y4t4uepn (accessed 31 May 2018).
2.Marchildon G. Physicians and regionalization in Canada: past, present and future. CMAJ 2017;189(44). DOI: 10.1503/cmaj.171237
3.Integrated leadership for hospitals and health systems: principles for success. Chicago: American Hospital Association and American Medical Association; 2015. Available: https://tinyurl.com/yxs3khr2 (accessed 1 Dec. 2015).
4.Denis JL, Baker GR, Black C, Langley A, Lawless B, Leblanc D, et al. Exploring the dynamics of physician engagement and leadership for health system improvement: prospects for Canadian healthcare systems. Regina: Saskatchewan Ministry of Health; 2013. Available: http://tinyurl.com/hzag2wc (accessed 20 Nov. 2015).
5.Plan for 2018-19. Regina: Saskatchewan Ministry of Health; 2018. Available: https://tinyurl.com/y44gjrm5 (accessed 21 October 2018).
6.Patient and family advisor program. Regina: Government of Saskatchewan; 2015. Available: http://tinyurl.com/jotqvgq (accessed 20 Nov. 2015).
7.Creating a vision for health care in Saskatchewan and the role of the physician: report on proceedings. Unpublished report. Regina: Saskatchewan Ministry of Health and Saskatchewan Medical Association; 2017.
8.Abrametz B, Bragg T, Kendel D. Optimizing and integrating patient-centred care: Saskatchewan Advisory Panel on Health System Structure report. Regina: Saskatchewan Ministry of Health; 2016.
9.Update and discussion: Prince Albert demonstration project. Unpublished report. Saskatoon: Saskatchewan Medical Association; 2018.
10.Memorandum of understanding: provincial engagement. Victoria: Government of British Columbia; 2014. Available: http://tinyurl.com/juqzehf (accessed 17 Nov. 2015).
11. The facility engagement initiative. Vancouver: Doctors BC; 2016. Available: https://tinyurl.com/yy6mc74d
12. Supporting facility engagement. Vancouver: Doctors BC; 2016. Available https://tinyurl.com/y2dnbddm
13. Saxena A, Davies M, Philippon D. Structure of health-care dyad leadership : an organization’s experience. Leadersh Health Serv 2018;31(2):238-53. DOI: 10.1108/LHS-12-2017-0076
Graham Dickson, PhD, is senior research advisor to the Canadian Society of Physician Leaders.
Correspondence to: firstname.lastname@example.org
This article has been peer reviewed.