HEALTH PRINCIPLES MAKE SENSE, CONFERENCE DECIDES

Meeting in Ottawa, the National Roundtable on Health System Effectiveness used as its starting point the principles developed jointly by the CHA and CCAF in 2004 (Excellence in Canada's Health System: Principles for Governance, Management, Accountability and Shared Responsibility). Using the principles as a framework, the participants examined real-world health system practices currently occurring in provinces and territories across Canada.

They concluded that the adoption and implementation of the principles across the health system would be a valuable step in improving health system effectiveness, and should move forward as soon as possible. To advance this process, the CHA created an External Advisory Panel on Health System Effectiveness.

CCAF Executive Director Michael Eastman participated in the Roundtable, first by presenting the CHA/CCAF principles to the conference, and then by summarizing the presentations on actual applications of the principles. He also accepted an invitation from CHA to serve on its External Advisory Panel, along with Wendy Nicklin, President and CEO of the Canadian Council on Health Services Accreditation and Heather Reichert, Chief Financial Officer, Manitoba Health and co-chair of the F/P/T Advisory Committee on Governance and Accountability, among others. CCAF will keep members informed as this initiative progresses.

In this Update article, Sharon Sholzberg-Gray, President and Chief Executive Officer of the CHA, speaks with Michael about the Principles for Governance, Management, Accountability and Shared Responsibility.

Sharon Sholzberg-Gray: One of the attractions for the CHA in working with CCAF on this project is that CCAF has had previous experience dealing with both the health sector and the use of principles.

Michael Eastman: Our collaboration with the health sector goes back many years. In 1987, we published a document called Accountability and Information for Cost-Effectiveness, which explored the potential for comprehensive auditing in hospitals. Our 1998 publication Governance Check-up was the result of a joint project with the Canadian Council on Health Services Accreditation. It provided a set of ideas and diagnostic tools designed to respond to the interests of hospital board members and their executives.

In 2002, we published a document called Reporting Principles: Taking Performance Reporting to a New Level. This was a major product of our multi-year Public Performance Reporting Program. It recommends nine principles to help organizations improve the usefulness and credibility of their public reporting.

Because of our experience with these projects, we saw collaboration with the CHA as an excellent opportunity for CCAF to advance our vision for excellence in public sector governance, management and accountability.

Sharon Sholzberg-Gray: Why do you find the use of principles to be a valuable approach?

Michael Eastman: CCAF believes principles provide a framework to support decision-making and against which to assess progress. Shared principles provide common ground for stakeholders to work successfully together to address mutual objectives.

In an environment of complex accountability relationships, different stakeholder groups will naturally come to the table with different approaches and different perspectives. If these differences are also accompanied by different sets of principles - especially if these principles are implicit - the resulting tension can impede progress and foster inertia.

Our organizations worked together to identify, and make explicit, overriding broad principles that can represent shared ground among all health sector partners and the public.

Michael Eastman: That's right. The first five principles provide guidance on governance, management and accountability, and focus on what needs to be achieved for the health system to realize excellence. They relate to five key areas of responsibility of the leaders who govern and manage the health system and its component elements:

• Strategic direction
• Leadership and resource capacity
• Risk management
• Public accountability and involvement, and
• Ethical management.

The remaining six principles address how partners in the health system can work together effectively to achieve the goals reflected in the first five principles.

Michael Eastman: Principle one addresses the responsibility to provide strategic direction. It states that:

“Canada's health system is best served by coherent direction, informed decision-making and clear goals that are shared among those responsible for making decisions.”

All parts of the system should agree on what has to be achieved and how their work in unison contributes to the shared goal. This requires governments and other stakeholders to work together to ensure goals are realistic and adequately resourced.

“The health system's ability to achieve its strategic direction depends on having the necessary leadership and resource capacity.”

Leadership is critical to a system's capacity to perform. Other key resources include people, structures, processes, finances, equipment, technology and information.

Capacity is always limited. Health system partners must share in the responsibility for aligning public expectations, goals and available resources.

The third Governance, Management and Accountability principle relates to risk management. It states:

“Health system partners need to understand, explain and manage the risks associated with providing or not providing a particular health service.”

Risk and control are key issues for governance at all levels. For example, the health system is grappling with issues around quality and patient safety. Those responsible for governance should ensure that management has effective risk-control strategies in place.

The fourth principle of this group of five addresses public accountability and involvement.

“Health system partners need to demonstrate commitment to public transparency and accountability. They do this by explaining to, and involving the public in, what they plan to do, how well the system is performing, and the implications of both.”

At each level within the health system, the public needs to hear about decisions made, the results stemming from those decisions, and the implications for other aspects of the system.

A key challenge here is determining how well the system is performing. In this context, a valuable tool could be the use of system effectiveness indicators - developed, measured and reported jointly.

The final principle for governance, management and accountability addresses ethical management.

“Health services need to be managed within a framework of articulated ethics and values that is communicated and understood within organizations and across the system.”

Leaders throughout the system, including those working directly with the public, are responsible for putting values into action, and need to know and understand those values.

Sharon Sholzberg-Gray: The remaining principles deal with sharing responsibility within the health system. How would you summarize the six of them?

Michael Eastman: First of all, I might note that they are based on CCAF research into accountability arrangements between provincial governments and those who receive transfer payments. They are amended to reflect the health care context, and they focus on the following issues:

• Roles and responsibilities
• Relationships among health system partners
• Governing bodies
• Plans and budgets
• Information, and reporting on performance, and
• System integrity.

I'll go through them briefly one by one:

The first principle in this group, or number six overall, states that:

“Health system partners need to understand their roles and responsibilities - and governance and management arrangements and practices need to be in place to support the effective discharge of their duties.”

Governments, as the higher-order organizations in the accountability relationship, have a special responsibility to communicate their expectations to the rest of the system regarding governance and management. They, as well as trustees and managers, must understand who is responsible for what.

When responsibilities are shared, all parties need a sense of ownership in the strategic plan, and a clear process for coordinating efforts.

The next principle reads:

“The conditions under which one partner gives direction to another need to be clear to all parties. Mechanisms for giving direction, and the conditions under which they are used, need to be explicit and understood by all parties.”

Canada's health system is extraordinarily complex and interdependent, making inter-organizational coordination and accountability a large and ongoing challenge.

Sometimes, for policy reasons or in emergencies, one partner may be required to direct the priorities or operations of another. The conditions under which one partner may direct another should be clear in advance, as should the channels through which such direction is given and validated.

The next principle, the third of six in the second set of principles, deals with those responsible for governing health organizations, that is, trustees, directors or governors. It states:

“The processes for appointing or electing individuals need to be predictable, easy to understand and transparent, and result in effective governing bodies.”

The composition of a governing body will significantly influence its approach to its responsibilities. Its composition also influences the way it connects to the local community and other stakeholders and will likely influence its perceived legitimacy.

Principle nine says:

“Procedures for approving plans and budgets need to be clear and respectful of the legitimate interests of all parties.”

Number 10 reads:

“Health system partners should have the information they need to fulfill their respective roles and responsibilities. The principles and standards for providing information and reporting on performance also need to be clear and understood.”

Formal reporting provides structure, an overall context, reference points and opportunities to bring out patterns and add interpretation to data. Reporting principles and standards help ensure the utility of reported information and allow for fair comparisons and benchmarking.

The final principle deals with the integrity of the health system. It states:

“Health system partners need to set clear conditions and criteria governing their respective rights and responsibilities. They also need to provide for validation of the performance information reported by and to each other.”

The first point here is that those charged with governance of the health system and its many parts have a responsibility to maintain the system's integrity and ensure that it advances the public good.

The second point deals with the responsibility of reporting organizations for the integrity of the information they report. To support this responsibility, accountability arrangements should provide for independent, objective and authoritative confirmation of their formal reports.

Sharon Sholzberg-Gray: At our conference, we agreed that health system participants should verify the performance of their organizations against the principles, as the final principle suggests. Based on CCAF's experience with principles, do you think this would be a useful approach?

Michael Eastman: Yes, definitely. At the same time, I would encourage them not to get hung up on the precise wording of the principles, but instead to focus on the concepts behind the words.

Similarly, I would suggest that health system organizations review and adjust the principles from time to time. As we all know, priorities change, and these principles should change to reflect evolving priorities.

Sharon Sholzberg-Gray: Finally, as a member of our External Advisory Panel on Health System Effectiveness, what advice would you have for moving this initiative forward?

Michael Eastman: I would suggest that the next step would be to spread the word throughout the health system about the principles and how to implement them. This could be done through some kind of knowledge transfer and capacity development initiative.

At your December roundtable event, you had participation from a number of stakeholders who could contribute to such an effort. Off the top of my head, I would include the Institute on Governance and the Canadian Council on Health Services Accreditation in such initiative. CCAF would be pleased to work with these organizations and others to develop an informational program on principles for governance, management, accountability, and shared responsibility in the health sector.

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