4th Anniversary Lecture by Jean-Louis Denis
12-11-2014
Wifi login: Seminar
Password: TILT2014
Governing for improvement and
innovation in healthcare systems
TILT’s Lecture series
Jean-Louis Denis
Full Professor
Canada Research Chair on Governance and Transformation of
Health Systems
École nationale d’administration publique
November 12, 2014
Highly institutionalized environment &
change + innovation
• “Stressing inertia may be slightly misleading in
that organizations constantly experience
unfolding change. To the institutional school,
however, the prevailing nature of change is
one of constant reproduction and
reinforcement of existing modes of thought
and organization (i.e., change is convergent
change)” (Greenwood & Hinings, 1996: 1027).
“System inertia may thus be a rational response to
interventions that seek to reform when individuals and
organisations have to manage other competing demands. If the
benefits of a reform come at the cost of other important
organisational goals, then organisations and the individuals in
them will necessarily satisfice. In a system that is
over constrained with competing demands, the human attention
and physical resources needed to make a new intervention
succeed are just not available”. (Coeira, 2011 in BMJ)
« Most notable are the constant fiscal pressures resulting from everexpanding
demand and the outsized political influence exerted by the medical
profession because of its control over the quality and terms of health
services. Rather than aiming to secure the basic needs of the public, as is
usually the case with pensions or social insurance, health care policy
invariably states that patients should expect the “best” care available, as
defined by the providers of that care. It is quite a unique situation, especially
when compared with other areas of social protection. In fact,
even if health systems have other characteristics, reform and design must
always entail some kind of cost- control measures, accompanied by various
mechanisms to secure physicians’ cooperation.” (Forest & Denis, 2012: 576)
« In the end, however, the most important questions
might be: Do successful
efforts need to include some form of commitment to
the stability
of the system, in terms of resources, delivery
arrangements, and political
support? Or is reform — real reform — always
disruptive, resulting in a
new architecture of programs, resources, and
incentives, or even a new set
of values and guiding principles?” (Forest & Denis,
2012:579)
Improving clinical practices/delivery can’t be achieved in
a vacuum:« The persistent gap between available
evidence and current practice in health care
reinforces the challenge of finding effective
solutions. Contributing to this current status have
been the complexity of change process,
limitations of research on implementation, and
slow recognition of the critical role of
organizational context ».
(Stetler, C. B., McQueen, L., Demakis, J., Mittman, B.S., 2008)
Overall Ranking
Country Rankings
1.00–2.33
2.34–4.66
4.67–7.00
AUS
CAN
GER
NETH
NZ
UK
US
OVERALL RANKING (2010)
3
6
4
1
5
2
7
Quality Care
4
7
5
2
1
3
6
Effective Care
2
7
6
3
5
1
4
Safe Care
6
5
3
1
4
2
7
Coordinated Care
4
5
7
2
1
3
6
Patient-Centered Care
2
5
3
6
1
7
4
6.5
5
3
1
4
2
6.5
Cost-Related Problem
6
3.5
3.5
2
5
1
7
Timeliness of Care
6
7
2
1
3
4
5
Efficiency
2
6
5
3
4
1
7
Equity
4
5
3
1
6
2
7
Long, Healthy, Productive Lives
1
2
3
4
5
6
7
$3,357
$3,895
$3,588
$3,837*
$2,454
$2,992
$7,290
Access
Health Expenditures/Capita, 2007
Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity).
Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health
Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund
Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and
Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).
Competing hypotheses about
innovation in health systems
Convergence hypothesis
Narrowing set
of options
Multiple
external
contingencies
Pathways
toward
convergence
End result: Innovation??
Path-dependency
hypothesis
Hybridization hypothesis
Hybridization hypothesis
(Tuohy, 2012)
• Windows of opportunities & entrepreneurial
activities within systems and innovation
• Markers of hybridization:
– Changes in the balance of power
– Changes in the mix of control instruments that
govern the exercise of power and in organizing
– Principles that shape public expectations
regarding entitlement to health care and the
functional role of the state
Governing for high-performing
healthcare systems and
organizations
Perspectives on high-performing healthcare
organizations and systems
• Macro perspective: focus on broad system
characteristics (financing, manpower, regulation)
• Micro perspective: focus on programs and the
interventions needed to achieve high quality &
safety results or outcomes
• Meso perspective: focus on strategies and
investments in organizational (and system)
resources to create and sustain high performing
systems – facilitative context
Dynamic of performance and change
in health systems and organizations
• Complementary hypothesis: you cannot choose
only one or some elements and expect high gains
in term of performance (Pettigrew & al., 2003)
• Contextual hypothesis: starting point of a
performance journey will depend on contextual
factors
• Non-linear hypothesis: improvement is not a
discrete event, it is a process that proceed
gradually with unexpected evolution
High-performing healthcare systems
• Comparative study of
three high-performing
health systems:
o
o
o
Intermountain
Healthcare in Utah
Jönköping County
Council in Sweden
South-Central
Foundation in Alaska
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Ten Critical Themes in Transformation
(Baker & Denis, 2011)
Leadership and
Strategy
Quality and system
improvement as a core
strategy
Organizational Design
Robust primary care teams at the
centre of the delivery system
Leadership activities that
More effective integration of care
embrace common goals and that promotes seamless care
align activities throughout
transitions
the organization
Promoting professional cultures
that support teamwork, continuous
improvement and patient
engagement
Providing an enabling environment
buffering short-term factors that
undermine success
Improvement Capabilities
Organizational capacities and skills
to support performance
improvement
Information as a platform for
guiding improvement
Effective learning strategies and
methods to test and scale up
Engaging patients in their care and
in the design of care.
(Adapted from Denis et al., 2011)
LEVERS TO SUPPORT CHANGE AND
IMPROVEMENT
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Three underlying assumptions
• A1: Despite political and structural limitations inherent in any
health system, organizations and front-line workers can
significantly compensate for these challenges and, in doing so,
achieve improvements (and innovation).
• A2: Dollars/Reals alone neither buy all types of desirable
change nor translate easily into improvements.
• A3: Real changes taken at any level of a health system are
those that translate into improvements at the delivery/clinical
level, including behavioural changes of providers and practice,
with the end goal of improving health outcomes and patient
experience.
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Key message I: clinical context
provides a unique opportunity to
improve care and increase the
development and uptake of
innovations
Key message II: Managing and
organizing with healthcare
providers and teams are essential
for health system improvement
and innovation
Challenges for high-performing
healthcare organizations
• Creating unity/consistency in organizations without killing
innovation, entrepreneurship and ability to adapt and
perform
• Creating more synergy between the organizational and
clinical worlds
• Going deeper in the management and organization of
clinical performance (efficiency, appropriateness, quality,
safety of care...)
• Channelling distributed expertise, legitimacy and influence
to support organizational and improvement goals
• Generating effective intermediary process & mediations
across the organization to support organizational and
improvement goals
Four core process and organizational
mechanisms for the engagement of professionals
in improvement initiatives
1) Working on group norms (culture) across the
organizations – social compact!!
2) Receptive /facilitative organizational context
– Effective microsystems at the point of care
3) Leadership as collective and distributed
– Organization and system level promotion of
leadership
4) Team-based organizations and “teamness”:
– Cross-disciplinary contexts
Clinical units (microsystems) as
unique opportunities for
improvement and innovation
By clinical care management systems we mean
approaches (including incentives, accountability
and capacity development issues) to assuring
the design and delivery of effective and
appropriate care through guidelines and
reminder systems (and related methods and
tools) and the development of a
clinical/organizational leadership system that
provides successful support to practicing
clinicians (Baker, Denis, Grudniewicz, Black, 2012)
Key message III: Governing for
healthcare improvements implies
the conduct of large-scale
organizational development in
health care organizations where
providers and managers
collaborate to create facilitative
context.
Four Habits of High-Value Health Care
Organizations (Bohmer, 2011)
• Specification and planning, including the
management of specific sub-groups of patients
• The design of specific infrastructure (e.g., staff,
information, technology) to match the needs of
subpopulations
• The capacity to properly monitor and provide
oversight through process and outcome
measures of care; and
• Strong knowledge management to learn from
positive and negative deviations in outcomes and
care
Elements of Effective CCMS
System Design
& Population
Focus
Leadership
Clinical
Microsystems
Design
Clinician
Leadership
and
Engagement
Knowledge
Management
and Decision
Support
Clinical Microsystems Design
• Most quality initiatives focus on individual clinicians or
professions but microsystem thinking identifies the need to
create clinical teams with clearly defined aims, defined
work processes and information flows and well organized
patterns of work and learning that produce optimal
outcomes
• Clinical microsystems thinking provides a powerful
framework for engaging staff and creating more effective
care environments and has been used by many teams to
assess and improve the care they provide
• But clinical microsystems alone do not provide sufficient
leverage for high performance healthcare systems – which
require both broader system level design (and population
focus), linked with leadership and deployment
Key message IV: Plural leadership is a
fundamental ingredient of highperforming (continuous improvements
and innovation) healthcare systems
and organizations
Four perspectives on plural leadership
1. Sharing leadership for team effectiveness: Team-based
organizations
2. Pooling leadership at the top to lead others:
Knowledge-based organizations
Mutual leadership in groups
Dyads, triads and constellations as joint organizational
leaders
3. Spreading leadership across levels over time: Interorganizational collaboration
4. Producing leadership through interactions: Knowledgebased organizations
Leadership relayed between people to achieve outcomes
Leadership as an emergent property of relations
Denis, J.-L., Langley, A., & Sergi, V. (2012). Leadership in the plural. Academy of Management Annals.
37
Leadership in healthcare systems and
organizations
• Leadership is distributed de facto.
• Main challenges:
– Harnessing leadership potential for health system
change and improvement
– Creating synergies across locus of leadership
(policy, managerial, clinical and community
leadership)
• Creating and sustaining the conditions for
continuous improvement and innovation
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Conclusion
• Improving and reforming healthcare systems is
a challenging task
• The political economy of healthcare systems is
more aligned with inertia than transformation
(at least in the Canadian healthcare systems)
• Clinical governance may represent an
promising option to face system inertia
Some references
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Baker, G. R., & Denis, J.-L. (2011). A Comparative Study of Three Transformative Healthcare Systems:
Lessons for Canada. Ottawa: Canadian Health Services Research Foundation. Available from
http://www.chsrf.ca/Libraries/Commissioned_Research_Reports/Baker-Denis-EN.sflb.ashx
Baker, R., Denis, JL. Medical leadership in health care systems: From Professional Authority to
Organisational Leadership. Public Money and Management, 2011, 31(5): 355-362.
Denis, J.-L., Baker, G. R., Black, C., Langley, A., Lawless, B., Leblanc, D., . . . Tré, G. (2013). Report on
physician engagement and leadership for health system improvement: Prospects for canadian healthcare
systems, CIHR, Expedited synthesis program.
Denis, J.-L., Davies, H. T., Ferlie, E., & Fitzgerald, L. (2011). Assessing Initiatives to Transform Healthcare
Systems: Lessons for the Canadian Healthcare System. Ottawa: Canadian Health Services Research
Foundation. Available from
http://www.chsrf.ca/Libraries/Commissioned_Research_Reports/JLD_REPORT.sflb.ashx
Baker, R., Denis, JL , Grudniewicz, A., Black, C. (2012) Fraser Health: Exploring a Model of Clinical Care
Management Systems, Ottawa: Canadian Health Services Research Foundation.
Denis, J.-L., & Forest, P. G. (2012). Real reform begins within: An organizational approach to health care
reform. Journal of Health Politics, Policy and Law, 37(4), 633–645.
Denis, JL; Gibeau, E., Langley, A., Pomey, M-P, van Schendel, M. (2012) Modèles et enjeux du partenariat
médico-administratif: État des connaissances, Rapport présenté à l’AQESSS.
Denis, J.-L., Langley, A., & Sergi, V. (2012). Leadership in the plural. Academy of Management Annals, 6(1):
211–283.
Stetler, C. B., McQueen, L., Demakis, J., & Mittman, B. S. (2008). An organizational framework and strategic
implementation for system-level change to enhance research-based practice: QUERI Series.
Implementation Science, 3(1), 30.
West, M., Lyubovnikova, J , Eckert , R, Denis , JL (2014) "Collective leadership for cultures of high quality
health care", Journal of Organizational Effectiveness: People and Performance, Vol. 1 Iss: 3, pp.240 - 260
Some questions for discussion I
• What about national culture and its relation to
reform?
• What about professionalism and its
embedded rules, values and social context at
the different layers of HC system and reform?
Some questions for discussion II
• What about the role of technologies in
transforming HC?
Some questions for discussion III
• What about the implications of plural
leadership for (taking) responsibility?