Every doctor has seen or done something horrible to an old, dying patient.
Armed with good intentions, we spot a gasping 95 year old and jump into action. We snap open a laryngoscope blade, hoist her jaw into the air and shove in a tube to relieve her “upper airway obstruction”.
Our technical prowess is matched only by our moral purity. But we accomplish something grotesque and wrong.
Doctors must learn to identify sick patients and how to resuscitate them. But these skills cause harm if doctors do not learn what comes between diagnosis and treatment.
Before treatment, we must ask: Why?
Purpose Before Process
A governance expert entertained a large group of doctors in Toronto this weekend. He summarized a graduate textbook on board governance in 40 minutes, for a group who had very little board experience.
It was brilliant, funny and almost useless.
He said, “We must ask, ‘To what end?’ before be dive into minutiae about governance process.”
“New members are most generative at the start. With experience they tend to get attracted to technical solutions.”
In other words, new Board members start out asking good questions, but after they learn about the details and history behind the bylaws, they waste time with minutiae and irrelevance.
He repeated himself: Organizations must address “purpose before process”. We asked questions, laughed and applauded.
As soon as he stopped talking, we started what he said to avoid: We rolled up our sleeves and dove into 6 hours of work on process and detail.
Governance Renewal
Doctors must identify sick patients. It can be very hard to admit that our patient is sick.
But the next step is more difficult.
Before we treat, we must ask, What do we hope to accomplish? Palliative care aims for a different outcome than critical care.
The OMA Board has embarked on governance renewal. We assume the Board believes that it needs change, which takes courage to admit.
Now the OMA should pause and ask, What do we hope to accomplish with governance renewal?
People talk about fixing bad governance. They lecture on improved process. But they struggle to define what is broken and what, exactly, needs to be improved.
If we cannot define success, people will criticize the outcome. If we shoot at nothing, we will hit it.
Reasons for Governance Renewal
Here are a few common problems Boards face:
- Lost touch with membership/shareholders.
- Mission drift.
- Impoverished dialogue / no true debate.
- Rubber stamping decisions.
- Pre-supposed, pre-determined debate.
- Concentration of power.
- Information filtering by a few senior directors.
- Resistance to change.
- Over-reliance on the few ‘big voices’ of very senior board members (“Bullies”).
- Perverse incentives to stay on the Board.
- Directors in continual campaign mode to get elected to committees.
- Blurred lines between Board and Management. Confused Principal – Agent relationship.
- Enmeshed relationships between Board and Management.
- Low psychological safety – directors too scared to speak up.
- Dismissiveness to generative discussion.
- Guffaws, chortling and eye-rolling during debate.
- Extremely low accountability for performance.
- Extremely high accountability around minutiae during crisis.
- Obsession with fiduciary details.
- Conflicts of interest – The attention poured into this issue dwarfs all discussion about every other issue to the virtual exclusion of everything else on this entire list.
Boards need to identify their own issues. A Board must know what it hopes to fix before it starts governance renewal.
Good intentions are not enough.
Change to appease members is not enough.
Technical prowess and great ideas about how to treat governance issues will not help unless Boards have a clear idea of what success looks like before they start.
Every doctor has done or seen something horrible done to a dying patient. It happens because we forget to pause and ask, Why treat this patient?
Dying, gasping patients do not suffer only from upper airway obstruction. Supporting the airway will not fix a death spiral.
Boards with dysfunctional structures will not improve by simply changing the bylaws.
A Board needs to embrace governance renewal with purpose and intention. A Board must know why it needs governance renewal before it changes anything.
Otherwise the Board will change governance just because it can. It will create something grotesque and leave the problems it hoped to fix unchanged.
Shawn – this is fantastic. This is exactly right. The OMA needs to ask why we are pushing for renewal. The OMA needs to understand what the goals for renewal are — before we create a structure to fit what is right now an ill-defined purpose.
Getting an outside expert will not help us find purpose. Only we can do that.
The participants yesterday seemed to reach consensus on one particular goal: give members a say in who becomes the “face of the OMA”. While that is a step in the right direction, it’s one of many steps we need to take before the OMA truly changes.
Well said, Nadia!
And more, I think doctors have a clear sense of what they think about purpose. The OMA has reached out for expert help, but we need the courage to make the changes. And to your point, there are things that experts could not do for us.
I get a bit worried when I hear people dismiss all the experts and advice. But I know you aren’t one of those.
It is exciting to see the Board changing. I look forward to the renewal starting in May.
Thanks for taking time to read and share a comment!
Talk soon,
Shawn
Terrific Shawn.
Each of your Comman Board Problems should spark some reflection. It is key to understand and keep clarity around the Agent – Principal relationship and purpose. The mission of the organization, the strategic plan and the management directive to carry that out must be determined, be clear to all and then given life. The work to achieve that strategic plan can then be supported, guided and debated by governance. ‘Noses in- fingers out’ will solve several of your other issues. I know strategy work gets eyes rolling too. When you have experience in an organization that lives a sound, inspiring strategic plan that grounds the work of management and governance it solves many of these issues.
Courage, clarity in the hard work ahead!
Thank you, Debra!
You make great points about tying in a strategic plan with the mission. In fact, you offer great advice in every single line of your comments: I really hope people take the time to digest what you’ve said here. It comes from your many years of Board experience.
Your underlying message carries positivity and hope. We need that right now for sure.
Great to hear from you. Thanks so much for taking time to read and comment!
Talk soon,
Shawn
Shawn worked palliative care into his blog.
My day is already a success 🙂
🙂
Great to hear it. I did that just for you! 😉
Hello Shawn
The why is so important. In scholarly qualitative research (not the kind that just use a bit of the tools/the ‘how’ without qualitative rigour), first steps include picking a theoretical ‘lens’. The theoretical lens is the ‘why’.
Psychotherapy research says that knowing a particular lens and ‘working it deeply’ as theory and method that forms practice (praxis) is more important than even which lens. However, to not have a clear lens or to just pick ‘tools’ ( the ‘how’) without working deeply from a ‘why’/theoretical base leads to less impactful work.
Now what lens? One thing to know is that there is often an unawares ‘why’ operating if no aware choice has been made. In present day medicine, systems design often comes from the world of business and new managerialism. the same theories that guide automation and assemblyline work in car companies like Toyota. the cost in health though can be great with suicide and death from overwork.
Medicine’s MBAs and MEds often have only the lens of new managerialism taught. However, in am earlier blog, you noted that there were some values in medicine that were not ‘worked’ well in such models, namely ‘relationship’ and ‘autonomy’. Your blog noted that this was obvious in an untheorized way from lived experience. You called for an exploration of ‘the nature of things’. There is a theoretical lens that can support that work of theorizing lived experience which leads to methods such as ‘institutional ethnography’ and ‘situated knowledge’ ( Dorothy Smith, OISE) and ground-up methods (which bring the theory out of the exploration that starts with the people living the knowledge). These methods use ideological lenses of feminism, postcolonialism, etc. those theoretical frames do put autonomy and relationship as central to the theories in terms of their ethics. they lead to understandings of governance and things like conflict resolution that put autonomy and relationship as central.
If we are searching for becoming more aware of the theory that is inherent in our lived knowledge, these are lenses that could be explored. i do believe that using those ways to know our ‘whys’ could help us, and our patients . aftee all, the ‘whys’ of new managerialism seem to lead to ever increasing rates of loneliness in the world (equivalent to a pack a day smoking) when relationship and autonomy is not well represented.
Thank you Shawn.
Wow, Siobhan, you’ve taken this to a much deeper level!
I like your comments about new managerialism. I’ve read about it in the context of government and bureaucracy writ large but not in the sense of how it relates to governance renewal. Very interesting!
You touch on some great ideas; I would be in over my head to comment meaningfully on philosophy behind the epistemology of organizational behaviour without refreshing my reading first. But you’ve offered the inspiration to do so!
Thanks so much for taking time to read and comment. You call for meaningful change, deep change. I hope we’re ready to listen.
Talk soon,
Shawn
Well said Shawn. We need a What question answered before we get to a How question. The old guard are whistling by their own graveyard in ignoring the fundamental question – What is the OMA? What do we want it to be? Until you have those questions answered, you cant start building an organization to fulfill the goals. It makes no sense to waste time to rearrange the deck chairs on the Titanic. We need a direction before we start launching off. It is patently obvious that the old guard don’t want this question asked and they have a new skewed and misrepresentative survey to give them they answers they want. We cannot allow them to bring this agenda to a spring council strategically constructed to not allow any time for this question to be asked. We need action from the membership to stop this process and start asking the fundamental questions where the answers are binding.
Great comment, Ernest.
I agree: We need to ask what we want to accomplish before we ask what tool/structure we need to get the job done.
Having said that, we face an unusual problem. No matter what we want to accomplish, we need a President. At the same time, we have an opportunity to change the structure. It’s easier to change the structure when there aren’t a bunch of people holding positions in the old structure. It will be very interesting to see how we stickhandle out of this one.
You said it best: “We need…[to] start asking the fundamental questions where the answers are binding.”
Thanks for sharing a comment!
Cheers
Shawn
Wow – a long list of problems to address. At the risk of being presumptuous I would like to share a technique I learned several years ago and have used on many occasions (albeit in business). It is often used when developing processes, but I have found that it can work very well in other situations. What I like best is that it provides a framework that helps to bring problems and solutions into focus and facilitates developing an action plan to bring about the desired results. I’m sure it has some fancy name (which I have forgotten) but I simply call it the As Is – To Be tool.
So here is the very much abridged version:
Identify the As Is and the To Be and document them on a flip chart, or something similar. This brings “the gap” into a much clearer focus. Avoid getting into discussing solutions at this point.
Identify what the barriers are to attaining To Be. Document.
Identify what the enablers are to attaining As Is. Document.
Identifying the barriers and enablers helps to determine action items that need to be taken to develop an Action Plan.
This is a very simplified version of the exercise, but I’m sure you get the idea.
With something as complicated as what you are dealing with it may be worth considering a professional facilitator, and possibly a “scribe” to help during the exercise. A facilitator can help to keep discussions on point and avoid going off on several tangents. You may also have to break your list down into more “digestible” segments/sessions and then bring it all together once all the items have been addressed.
When addressing the bylaws of an organization it might also help review the mission/vision statement(s) before starting the exercise and then test the final result of each item to ensure the bylaws are aligned, or at least not at odds with, the mission/vision. Again, this helps with maintaining focus.
You have a big job ahead of you and I wish you much luck in achieving the desired results.
If I could add just one important consideration – develop the best plan you can, one that everyone (or at least most) can live with. The first one may not be absolutely perfect, but that is what Continuous Improvement is for. There will always be something to be tweaked. Things are constantly changing, often things not within your control. But once you have the backbone established, Continuous Improvement techniques can be used to keep your bylaws relevant to changing conditions.
Hey Valerie, what a great tool. Thank you!
This reminds me that there is so much to learn. We really need consultants to help. I also like your call for a facilitator. I’ve almost always appreciated hearing what an outside voice thinks about our problems.
And your advice about a ‘good enough’ plan – brilliant. Agree completely.
Thanks so much for writing such a thoughtful note! Everything you said sounds like it came from years of experience.
Talk soon,
Shawn
Shawn:
Great article as usual.
I agree with Debra: The mission of the organization, the strategic plan and the management directive to carry that out must be determined, be clear to all and then given life.
Unless there is willingness to change the OMA mission statement to serve the interest of its membership instead of for the good of the public, no change in the governance exercise will benefit the physicians and we will forever be in this mess.
Time has changed. Leave protecting the public to the CPSO. OMA should not be run as an old boy club and just play ball with the government. Time to look after the welfare of its members,
then it will survive even without RAND. Sadly I don’t see any such willingness yet. Although I am older( in this business 41 years), I don’t want to belong to this “OLD BOY CLUB”.
I especially like your last paragraph, Michael. Everything you said is great, but your last paragraph hammers it home.
We ARE in a new situation. We have been far too slow to realize that the rules of engagement have changed with this government. We keep thinking that we are talking with a reasonable partner. The OMA must serve its members; it’s the only reason for the OMA to exist.
I agree with you: We do not want to belong to and Old Boys’ Club that exists to be chummy with government.
Thanks for sharing a comment! Great seeing you this weekend, too.
Cheers
Shawn
Taking off from Valerie’s comments, I believe that we have to separate short term goals from long term goals. The representatives have to quickly decide on an interim Executive system. This should not be conflated with the long term goals.
We should not panic about the long term goals. There has not a chance for the recently elected representatives to get together and discuss the various possible paths as we go forward. It does appear from events over the last year that members are asking for major changes at the OMA. It seems silly that the studying of Governance plans have not been put off until the new representatives have had a chance to discuss it. It seems more reasonable that the new “parliament” of the OMA be the one creating the parameters for change at the OMA.
Long term changes need to be thought through carefully and they should proceed logically. Discussions of many details should wait until a new discussion framework is set up. One step will lead to another. We should not panic about the details instantly.
Excellent points, Gerry.
I guess we tend to worry when we see changes, even short term, that might shackle us to something for another 40 years. Members would find reassurance if they knew that they had the power to change again, if things aren’t working out. Regular referenda on important issues keeps us all honest, I think.
“We should not panic about the details…” Well said.
Thanks again for sharing a comment!
Talk soon,
Shawn
Unfortunately, Shawn, The grassroots in our particular Medical Society of District 5, are not interested in Politics and do not participate in much meaningful discussion about their day to day issues-especially those who are not in groups. Most do not go to General Medical staff meetings and Family practice rounds at present are focused on education alone. To my knowledge no one has approached our local MP and do not even know his name. Discussion on how FP’s and Specialists Interact needs to be reviewed(in my opinion) and I think that the medical societies need an almost military organisation in terms of regularity of meetings even if only a few people show up. Right now , in our community, this is not happening and no one is stepping up to the plate indicating a desire to lead in this regard.
Great points, Chris.
I often wonder whether the lack of zeal comes from a lack of power? People need to know that they can make a difference before they get involved. You and I believe that involvement makes a difference in and of itself. Lack of involvement sends a clear message to those who seek to command and control us: Doctors don’t care if they lose their ability to impact their practice environment. Even though we know that doctors care deeply about this, we need to show up to meetings before bureaucrats believe that we care.
You make excellent points about local interaction, referrals, etc. I got the sense, a few years ago, that some ‘leaders’ like it when doctors do not spend too much time talking with each other. Talking leads to rebellion.
I fear that I might have been too negative with this comment. For some reason, despite the beautiful spring sunshine, I am finding it too easy to see the dark side of things today. I’d better stop now… 🙂
Thanks so much for taking the time to read and share a comment! Great to hear from you.
Talk soon,
Shawn
When I got into medical politics, I hoped that I could make a difference. I thought that at minimum I would at least know more about what was going on and tried to arrange for a wider perspective amongst my colleagues.
I ended up instead bitter because Liberals in power in 1986 took pot shots in town meetings at me and other physicians in an unfair way and , like you said, my colleagues didn’t care! If they had cared, I could have gone on, but it became obvious I was working in a vacuum in this particular focus of my medical career. That’s why I gave up Medical Politics. I got hurt. And I wonder if this is the end result in all politics. Maybe that’s why people don’t show up because if you care and you show up, you seem to get hurt. Better to spend time with the family which should have been my main focus in retrospect.
Chris, social media has changed the playing field. I used to think that my political views were unusual and often came to feel that I was an outlier in my thinking. Through social media I was shocked to find that my views were often quite common on so many things.
It is empowering to have allies that can be called upon through your keyboard. I have leaned on them and they have leaned on me. Don’t despair, Chris. You are not alone.
A corollary to my last comment.
If Doctors want to get involved in Politics or even their lives in general, they have to ask themselves 3 questions.
1. What matters to them .How much does it matter?
2.Find out WHO makes them happy and
3.WHAT makes them happy.
And then they are set. Promise!
Thanks for sharing the last two comment, Chris. They help me understand things better. I’ve always wondered why someone, like you, who has so much insight and interest into medical politics was not running for an elected position. You should still consider it.
I, too, have struggled with years of MD apathy. However, everything changed over the last 5 years as the Ontario government attacked doctors. Many are still uninvolved, but no one is uninterested.
You posed 3 great questions. I’ve been asking myself these kinds of questions recently. For your first question, I ask, “What can you not stop thinking about?” As for the other two questions, I know what you mean. I would push back a bit and ask what you mean by ‘happy’. 🙂
Thanks again for taking time to share these comments. Readers love the comments best.
Talk soon,
S