speech: reflections on 20 or so eventful months

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Reflections on 20 or so eventful months

Speech by

Dr Stephen Duckett

Foundation President and Chief Executive Officer

Alberta Health Services

to

Alberta Health Services Senior Leaders

6 December 2010



1

Id like to thank you all for joining me here to mourn, celebrate and move on. We live in different

realities. Mine is a future primarily outside AHS, yours within. Our realities overlapped for 20 short

months, a time when we achieved an enormous amount which is to be celebrated. But also a time cut

short and for me it is appropriate to mourn the might-have-beens, and the agenda that I hope will be

continued. But we all also need to move on, to the next stages of our lives. Many of you are good

friends and I hope I can catch up with you from time to time, to share laughs and adventures. But many

of you dont know me well. And I want to take this opportunity to give you a better understanding of

who I am, what I did and why.

Im going to give a formalish talk, partly to avoid too many tears! What I want to do tonight is say my

piece, not in real time youll be pleased to know. Because of my former role Ive been constrained in

what I can say, especially so this year. Im a free person now and can reflect on our achievements and

missed opportunities more directly.

So to begin at the beginning.

Joining Alberta Health Services

I was appointed in January 2009, Ive told some of you the trials and tribulations of the short-listing

video interview on the Friday (Australian temperature at +40, the other end of the line in Calgary at -40),

the 2 day drive back to Brisbane from my holiday, the haircut, the flight, arriving in Calgary on the

Monday night and an hour or so later being rotated around three tables at dinner with the board. A

foretaste of the pace at which I would be working in AHS.

Another aside. In the interview I was asked if Id any media experience. I answered yes but I didnt

expect thered be much exposure in this job. The Board basically rolled around laughing and I realized

Id made yet another mistake in the interview.

Although the internet age means people can find out a lot about who you are, I wanted to make my

values clear, so thered be no risk that Id be asked to do things I wouldnt want to do. Given the

governments previous history on Medicare1, in my first meetings with Ken Hughes as Board Chair and

Minister Liepert in that interview week, I told them that I would not do anything that would undermine

the Canada Health Act. They both accepted that position and honoured it. I see myself as a friend of

Medicare with a small f. The capital F folk go much further and want to end private delivery, putting

almost all physician practices out of business2. Not a position I can support.

So shortly after the announcement of my appointment, but while I was still in Australia, I got this phone

call from Ken Hughes and Don Sieben, chair of the Audit and Finance Committee, telling me that theyd

just become aware of the need to do a significant financial correction, dimensions still unclear but

certainly north of $1B. Imagine my feelings. I thought I was going to a well endowed health system!

1http://www.thecanadianencyclopedia.com/index.cfm?PgNm=TCE&Params=M1ARTM0012159

2To be precise, according to their website

(http://www.friendsofmedicare.org/default.asp?mode=webpage&id=52) they are opposed to a parallel system of

for-profit delivery, with no mention of any exclusion for physician practices.



2

Anyway, an interesting introduction to AHS and one which gives the lie to those who said I was

appointed simply to do budget cuts. Ive said subsequently to Ken Hughes that I should sue them for

misrepresentation in not informing me about the financial situation as part of my recruitment. In

return, he pointed out that for misrepresentation to have occurred they would have had to know how

bad the problem was when they appointed me. And they didnt of course as the oil and gas price

collapse was just occurring.

But then I arrived here. Lorinda, Joyce and others had taken the trouble to speak to my former staff in

Queensland to find out my likes and dislikes. To make things easy for me. To make me feel welcome.

And that set the tone for me inside Alberta Health Services. This has been probably the most supportive

organization I have ever worked in. You have all been welcoming. Tolerating my quirks, Australianisms,

different sense of humour. But really caring for me in the tough times, and weve had a few. For the

record when I say you, I dont only mean you, the leaders in this room, but you, the others with whom

Ive worked at all levels of the organization, and the Board too.

There was less tolerance outside AHS. The media created a Stephen Duckett I didnt recognize,

portraying me as a one-dimensional budget cutter, a portrayal that still continues3. Yet my main work

and achievements in Queensland had been about access and quality, the other two goals of AHS!

Paradise lost?

An early challenge I faced was the issue of AHS legitimacy. When I arrived there were still many (inside

and outside AHS) who lamented the demise of the predecessor entities, and they looked back on the

good old days when everything was perfect. Everything AHS did was bad and not up to the standard of

the previous region, board, Commission. But as Ive said in previous presentations4, all was not rosy.

Alberta spends more per capita (adjusted for age and sex) than other Canadian provinces, and gets less.

Male and female Albertans have a shorter health adjusted life expectancy than the Canadian average.Albertans who get cancer dont live as long as people from Ontario.

All this using data from before AHS was formed.

Investment decisions have over-emphasized acute provision at the expense of seniors care. In contrast

to other provinces, Alberta reduced per capita spend on non-acute facilities over the last decade. Is it

any wonder that our acute facilities had to become de facto seniors housing, contributing to the

systemic problems that have created the problems in emergency care?

And emergency department performance in both Edmonton and Calgary has been getting steadily

worse over the last decade, achieving the eight hour standard for admitted patients about 60% of thetime in the first few years of the decade to around 25% now. Neither level acceptable of course.

3

http://www.edmontonjournal.com/health/interim+Alberta+health+board+boss+will+focus+better+service+engagi

ng+staff/3890943/story.html4

Most notably to this forum, the Board, zone planning days for the Calgary, Edmonton and North Zones and at a

University of Alberta conference (http://www.economics.ualberta.ca/boom_and_bust_again.cfm)



3

And there was significant variation in practice between different parts of the province, different

admission rates, differences in length of stay. Little was done to learn from these differences, different

definitions were used across the province and there was no effective benchmarking. The effects are still

with us: it takes a day longer to treat a person with a stroke in Edmonton than it does in Calgary, same

for hip replacements. This consumes excess bed days and effectively reduces access in Edmonton.

This perception that the predecessor entities were perfect was achieved by aggressive media

management, restricting transparency, duchessing key commentators, and in some former entities, by

having a Mr Fix-it whose role was to respond to external pressures, including manipulating waiting lists.

Unfortunately for me, these strategies were not consistent with either my values or those of AHS.

Achievements

You know only too well what it was like when I started. No functioning formal structure. No financial

reporting system. No strategic direction. We addressed all that quickly.

But that is not what Im most proud about. You all led teams that have started change in a myriad of

areas. Ill only highlight a select few tonight but there are lots5.

I think the single greatest achievement is how you are working together for the benefit of Albertans.

There are hundreds of examples of how youre sharing ideas, one learning from another. My experience

with the workplace engagement group, people in all sorts of roles, from all parts of the province was

very rewarding and I think we can already see the turn around in engagement as a result of that work.

I think the work weve done on emergency access is a good example and one I was particularly proud to

be part of and would like to write up. Introducing new ideas into Alberta to improve flow: the medical

assessment units, for example. Work on tehse started back in 2009. The workshop I convened, leading

to the driver diagram, leading to a coherent set of medium and long term initiatives involving zones and

hospitals and others. A problem which has been around for ten years is not going to be fixed in ten

weeks or indeed one year, despite all of our best efforts, but I think we are seeing early signs of

improvement. So I plan to claim some credit if we see a turn around by mid next year!

In 2009/10 we had a big budget challenge and all stepped up to the mark, and continue to do so.

Bringing the budget under control involved hard work. But work that was and is essential if Medicare is

to be sustainable. If the 10-12% growth rates experienced in Alberta in the past had continued, there

would have been increasing questioning of the fundamentals of Medicare, to the detriment of all of us.

So lots was done to address the challenge. Take procurement: here we saved hundreds of millions of

dollars by standardizing and using our purchasing power. This was not just a CPSM achievement, but

involved countless people from across AHS contributing and adjusting their practices for the common

good.

5Ive also addressed some of our achievements in two papers which are in press: Getting the foundations right:

Alberta's approach to health-care reform forthcoming in Healthcare Policy and Second wave reform in Alberta

forthcoming in Healthcare Management Forum.



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Our incipient Enterprise Risk management framework is already attracting positive comments from

other provinces.

Developing modern, province-wide medical staff by-laws.

Weve done a lot on moving toward interprovincial equity in clinical and non-clinical areas. Take cervical

cancer screening for example. Different regions had different policies and priorities with respect to

invitations and reminders. Capital Health didnt put the same value on this as Calgary Health Region,

with the result that screening rates are appreciably lower in Edmonton (69.6%) compared to Calgary

(74.3%), an issue we are now addressing.

Expanding security coverage in the province on a cost-neutral basis in a new service model is another

example of improved service equity.

Developing Canadas first electronic provincial drug formulary that other provinces now want to buy.

This was only possible because we were one provincial organization, of a size to support the specialized

staff needed to do this.

Developing a coherent, evidence-based approach to workforce planning which looks not only at supply

but affecting demand.

Replacing more than a dozen different funding schema for long term care by an equitable, provincially-

consistent, activity based funding approach is another major achievement. There are currently huge

variations in what we pay for care (after standardizing for the needs of residents) and the incentive on

facilities until now has been to take the least dependent rather than the most dependent resident,

contributing in part I think to our problem of long stay Alternate Level of Care patients in our acute

hospitals.

Tighter and better contracting for services is yet another example. At least having contracts is a start, in

contrast to the Villa Caritas contractual mess we inherited from Capital Health or the hand shake deals

of another region. As you know I support having private delivery within a publicly funded health system.

Our aim should always be to ensure that our service contracting is for the benefit of patients, to improve

access, to garner innovation, to improve efficiency so we can get more access for our dollars. This

means we need good contracting, activity based funding helps this. But we must also aim for contracts

which are tight in terms of price and/or an expectation of an efficiency dividend with volume growth.

Still a work in progress Im afraid but at least we know what to do.

The best service contracting example is in ophthalmology in Calgary. Here we commissioned anacademic paper to give advice about what best practice in contracting might look like. And the answer

came back, not at all like what you are doing6. So we went to tender and got a significant price

reduction: we proposed to spend the same money as had been previously allocated but with 20% more

patients treated. A win you would think. But politics intervened. The ophthalmologist-entrepreneurs

who had misread the tea leaves and tendered too high complained to the Minister that somehow an

6http://policyschool.ucalgary.ca/files/publicpolicy/Dranove_Capps_Dafny_ONLINE.pdf



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the fact that the budget parameters were set by government and our job was to live within the budget

government set.

The media suffered a similar blind spot when Minister Zwozdesky was appointed and overturned our

proposed bed closures, seen as a major setback for me. Only one journalist picked up the budgetary

implications: that if the beds werent being closed, AHS must be going to get a funding increase in thebudget to pay for it all. So the media looked only at the surface, failing to see the underlying dynamics.

This funding increase was a significant achievement for me and for AHS.

And so good came out of it all. The Government dramatically changed our financial parameters, and put

us on a secure, long term financial footing. The first time any provincial government has done anything

like that in Canada. The five year funding agreement is fair, but requires significantly tighter financial

discipline than exercised by the previous entities with their average 10% increases in spending per

annum. It transformed my working day where every meeting was about progress on budget strategies

to be freer to thinking about investment strategies, investment strategies which are now beginning to

show dividends.

Long term secure funding, with reasonable but not excessive growth rates within which services must

manage, is an essential for Medicare to survive. Those of us who support Medicare should be arguing

for that in all provinces and nationally.

The media

My relationship with the media was fraught from the start. Partly because of Canadian-Australian

cultural differences (people werent ready for direct speaking), partly because of the perceived

perfection of what went before.

The media along with politicians only see the short term, and often fail to connect the dots. The

immediate deadline and the quick attribution of blame drive the story. This means that short term wins

or decisions are all important, and crowd out any real consideration of the long term. One example will

suffice. Building on published comments from three physicians, I attempted to open up the issue of

social disparities and social determinants citing significant differences in life expectancy in higher status

neighbourhoods in Edmonton versus lower status9 10

.

The immediate media response was to close the debate down, essentially with the simplistic suggestion

that all one needed to do was open a new urgent care centre11

! What is needed in that neighbourhood

is better primary care, not more patch-up services, and beyond that, employment opportunities and a

range of social supports, housing and so on.

9

http://www.capitalhealth.ca/NR/rdonlyres/egeta3vsclkaagarxdaazp6l3vvcu7pfos7a6i7xiby6t765d5opnrxsm6b6xxt

znn5xmounqbkux5nj3zgcp6wwbdb/Poverty+and+Health+in+Edmonton+Nov21.pdf 10

http://www2.canada.com/edmontonjournal/news/letters/story.html?id=30ec58a5-fa59-42bf-b6dd-

e7b382c4783011

http://www2.canada.com/edmontonjournal/news/cityplus/story.html?id=847f5d81-19bf-40b9-a486-

d2d7f2ed427c



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But I dont want to demonize the media. The job of the journalist is to write stories. Conflict is better

than no conflict. And theyll get little encouragement to think of the long term interest of Albertans.

Journalists, as with the Alberta public, have been socialized to be skeptical of public officials. They didnt

believe that community services would be established to facilitate the redevelopment of mental health

services in Edmonton because the same promises had been made and not kept before. And anewcomer with no track record in the civilized world (aka Canada) could certainly not be trusted.

The same with other reform initiatives. Previous strategies to address health care deficits had generally

been to spend more, what Ive referred to as an Oliver Twist strategy12

. Anything that amounted to

doing things differently and/or more efficiently must be inherently wrong.

The role of the Chief Executive Officer

The job of CEO of Alberta Health Services is unique in Canada. AHS is the largest health care provider in

Canada by a factor of three, with 90,000 staff the largest employer in the province (and in probably

every town or city in the province). AHS operates in a politically charged environment.

My job actually involved multiple separate jobs:

y Managing the 2009/10 budget challenge (and for 2010/11 the continuing need to exercise tight

financial discipline)

y Getting the merger underway (incidentally, Canadas largest merger in terms of staff,

undertaken with no preparatory time!)

y Putting the foundations of a unified and integrated provincial system in place

y Leading the transformation to position AHS better for the future.

Many of you have highlighted to me another of my roles, teacher. Ive received more than one hundred

farewell emails. Some from people I hadnt met, some from people who I met only fleetingly. Some

very moving. Thank you for that. But one theme from many of them is how much people learned from

me (the implication was they learned positively!! I trust I got that right). People said similar things

about me when I left Queensland. Thank you for that, this means a lot to me and it also leaves

something behind which I hope will lead to improvement in the services you provide or manage and in

your working life.

The CEOs unique role, though, is to set directions. To be planning for 5, 10, 20 years out. Thinking

about what the system ought to look like and what we need to put in place now to get there.

Transformation, though, is not just one big decision. Its not just setting a direction. Its also the

hundreds of little decisions that are necessary to operationalize the transformation. Decisions that you

made, sometimes seeking my counsel, I guess back to that teacher role too.

We have set ambitious goals13

, but goals which in my view are achievable. But only achievable if we do

things differently: not more of the same but transform the organization with LEAN and other quality

12http://www2.canada.com/edmontonjournal/news/letters/story.html?id=30ec58a5-fa59-42bf-b6dd-

e7b382c47830



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improvement initiatives. Redesign services to deal with the different workforce of the future. Build on

what we know works in other countries, or elsewhere in Canada. We must be open to new ideas if we

are to succeed. And this is part of what I think I brought to AHS. Please dont lose that.

Its not only in Alberta where change is needed. Health care in Canada needs to be transformed

dramatically if it is to be sustainable, an issue Ill return to later.

And we were transforming. AHS is a large organization so change takes time but we were beginning to

turn the corner and I am confident that the paths we established will show dividends in the next six to

twelve months.

Several people have said to me that I had the worst job in Alberta. I dont think so. Working with you

on our multiple agendas, seeing the progress we were making, puzzling out what to do and how to

improve access and quality for Albertans was challenging but fun.

I cannot deny, though, that the job was exhausting and stressful. It took a toll on my health and on my

family. Costs that the external world doesnt see or care about. So here Id like to thank my partner andour daughter for what theyve put up with over the last 20 months. A dad/partner away from home too

much, and when he was at home, often in his study. But also to thank them for the support they gave

me over that period and in the last couple of weeks.

To some extent the work load in the job was unsustainable in the long term. 75-80 hour weeks Monday

to Friday, more work on weekends is hard on anyone. All that in the public glare makes it worse.

I was watching TV last week and complained about the lack of good programs to watch. Sarah pointed

out that Id had no time for week night TV since being here.

So there are positives from all this, and you get to see one last polarity diagram14

. Maybe you can helpme manage this polarity by keeping me informed and inviting me to join in celebrations of successes!

So the last couple of weeks have been hard for me, I made a silly mistake and my role here ended. But

from a personal point of view it may, in the end, be good. It is certainly a better way to slow down than

a heart attack!

All of you are working too hard. A few weeks ago I wrote to you all about work-life balance, as I said, I

was somewhat hypocritical given where I was but its still something that has to be addressed.

I mentioned just now that weve set ambitious goals in our 5 year plan. Some responses to the plan

called for peoples jobs to be on the line if the goals were not met15

. That type of call leads to twopotential consequences: first, next time you wont be as ambitious in your goal setting, with Albertans

being the poorer. Secondly, severance arrangements need to be revisited. At present the executive

13The governments version is here http://www.health.alberta.ca/documents/Becoming-the-Best-2010.pdf

14Johnson, B Polarity management: identifying and managing unsolvable problems HRD Press 1996

15http://www.edmontonjournal.com/health/Alberta+unveils+health+plan/3906386/story.html



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essentially has one year severance entitlements. If there is to be a higher risk of dismissal, then there

have to be greater protections.

Cookie incident

And now some words about the cookie incident.

First, I want to acknowledge upfront that I made a mistake.

I have tried to be open and direct in my responses to the media. But for the last few months media

advice from government was for me to be less accessible.

On the Friday morning of the cookie incident I was subject to the same line of advice: that I was not to

make any comments following the meeting AHS had convened. Dr Eagle was designated as the AHS

spokesperson. Media reporting of the incident has generally been along the lines that I refused to

comment about what we were doing about emergency department long waits.

However, the most significant story that day was about comments made by Dr Sherman, then still

Parliamentary Assistant to the Minister for Health and hence a person with an important role in the

provincial government on health policy. I suspect the reason for the advice to keep me away from the

media was the expectation that I would be asked questions about Dr Shermans comments. Indeed, this

proved to be the case with questions such as:

y What do you think of Raj Shermans criticism of AHS . . .

y Do you have a response to some of the criticisms that MLAs are directing to AHS.

So the emdia was really after comments from me about political not health issues. I have always

attempted to be totally honest and upfront in my dealings with the media, including about AHS

performance. Under my leadership, AHS increased its transparency and plans are afoot to be even moretransparent, publishing a broader array of data. I have also acknowledged publicly that health care

performance has not been good. I have said a number of times, on the record, that Albertans are

waiting too long for care.

But I led internal efforts within AHS to improve wait times in emergency departments. These started in

the Spring of this year when the provincial government reversed our budget situation so that instead of

needing to find significant savings, we were able to make investments. Remember this was way before

the emergency department physicians sent their email.

I prioritized development of seniors accommodation (which frees up acute beds to allow a quicker flow

through the emergency department as well as improving quality for the seniors affected) and other

strategies related to improving emergency department performance. These strategies are now having

an impact.

So, I would have been quite happy to talk about our performance in this area, but was advised not to.

AHS had a media briefing scheduled for half an hour or so after I left the hotel.



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Every time: back to the quality agenda, and the role of the clinical networks. We need to redouble our

efforts to improve quality of care, including through development of a just and trusting culture.

Au revoir

To do all this we need to learn to manage in a different way. As Ive said time and time again, we dont

want more of the same. We have to learn new skills, new ways of doing things. Get ideas from othercountries, even Australia! So this was indeed an emphasis of my time with you. To help position Alberta

better for the challenges ahead by facilitating experimentation, and innovation, pointing out

alternatives, encouraging you along the way. Or at least thats my perception.

I want to thank you all for being with me on this journey. The executive, a fine and talented team who

gave me incredible support, worked incredibly hard on creating AHS. Thank you. My immediate staff,

who helped and protected me in so many ways. Who made life easy for me in lots of little (and big)

ways and looked after me at work, going beyond what could be reasonably expected. Thank you.

Everyone in this room, who laughed and worked with me. And people not here who shared in our

struggles. Thank-you all. And again, an enormous thank you to my partner and our daughter.

Ive got a number of regrets. Not seeing all of Albertas Big Things is one. Nor the gopher museum. At

this stage we look like well be staying in Edmonton for a while yet so maybe a future opportunity!

Which also means that Ill have an opportunity to stay in contact with you. You who have been so

supportive, so helpful, such good people to work with, so dedicated.

But my biggest regret is not being alongside you so much for the next stages of this journey. We have

the foundations in place to do truly wondrous things. Please continue to do them.

Thank you and au revoir

Stephen

speech: reflections on 20 or so eventful months

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