Part Two – Addressing Tab 13

When leadership gets too far ahead of those they are leading, or are not visible enough in their leadership process, those who are being led will react. In order to be successful despite breaking this rule, one must be a “visionary leader” whose past successes have earned exceptional trust from those being led. Steve Jobs comes to mind when discussing successful visionary leaders.

And sometimes, vision and past success still isn’t enough. Consider Moses, who, after leading a successful rebellion and escape, and who apparently had a direct line to the Almighty, was faced with opposition after spending a mere 40 days out of contact receiving the mother of all governance documents on Mount Sinai.

The biggest problem with the contents of Tab 13 is that this ambitious project was assumed by the Board to be 100% their responsibility. Once that premise was accepted, and with all good intentions, the Board simply got too far ahead of Council and members. Will Rogers is quoted as saying about leadership: “If you’re riding’ ahead of the herd, take a look back every now and then to make sure it’s still there.” I’m not sure that Council was ever back there to begin with.

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I have had multiple conversations with Board Directors to suggest that if this was not the intention, now is the time to take a step back, include Council and other interested members in dialogue, and make sure all the pieces of the governance puzzle fit together solidly. We will find out what kind of approach the Board as a whole will take sometime between now and the end of Council this weekend. And luckily, we have an opportunity to be heard regarding how things might move forward. My hope is that the Board uses the time set aside on Friday and Saturday to engage with Council and provide some insight into the approach taken so far. My hope is that the changes proposed, where they impact directly on Council, membership and things like elections and appointments, are put in abeyance until a coherent plan for the whole organization can be developed.

In the meantime, how can we frame the big issues raised by Tab 13? What questions do we think are most important? For me the main question that came out of my reading of Tab 13 was: “What role should Council adopt in the future?”

How can we reconcile the roles of Board and Council, or: Is the tail wagging the dog?

I have already pointed out the contradiction between our bylaws, which state that Council is the governing body of the OMA, and the Board Charter, which states that  the Board “is the highest decision making authority within the organization with the exception of the duties of the Council.” Unfortunately, the development of the Board Charter went hand in hand with bylaw changes that reduce the duties of Council. In the tired old bylaws regarding Council that remain, the duties of Council include electing Assembly Board Directors and the Chair and Vice-Chair of Council, and appointing the auditor. Otherwise, the bylaws state that Council can decide anything that a general meeting of members can decide. Which is pretty much anything.

So to sum up, the Board is the highest decision making authority within the organization with the exception of the other highest decision making authority. Meaning that the Council is the highest and the Board is next highest.

How can we make sense of this? Tab 13 has shown quite clearly that there are duties for which the Board should be the final authority. Ensuring that the organization is following all laws and regulations governing it, ensuring that appropriate financial controls are in place to mitigate the risks of embezzlement and other corruption, ensuring that the CEO (and staff as a result) is competent and performing adequately for the good of membership, ensuring that programs are meeting the needs of members and are of good value, ensuring that the organization does not take on unreasonable risk that would threaten its existence.

Corporate duties for a corporate Board.

Following from that, then, is the concept that non-corporate duties should fall to a non-corporate structure: Council.

This, if valid, should actually increase the duties of Council. And increase the responsibility of Council to be more than a biannual gathering to discuss general issues.

Duties that might fall to Council could be:

  • approval of health system policy
  • approval of public relations strategy
  • approval of government relations plans
  • approval of research goals
  • approval of communications plans
  • approval of new programs or discontinuation of old programs

Policy committees that currently report to the Board would instead report to Council. Approved plans would be forwarded to the Board for resource management (financial and human resource) and risk management assessment and to ensure the plans are legal. The only reason for the Board to return these policies to Council would be if significant issues arose in any of these corporate domains.

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I think that the closest corporate structure to ours is that of a municipality. Municipalities elect Councillors to represent citizens in running the affairs of the city. Most Councils then have a Board or General Committee which is made up of Councillors and other appointees which assume the roles that we are describing for our Board. But the governance structure is clear: Councillors represent citizens and, with the use of various committees, direct the priorities and policy decisions of the city. The Board serves Council, not the other way around. The “independence” of the Board (that the Board doesn’t make decisions based on constituency loyalties) is ensured by having a majority of members be independent of constituency responsibility, by having them appointed based on their skill set. They may not even be physicians, but could be professionals with experience in serving on Boards who can help the Board itself be more efficient. (There is a legal obstacle to having non-members be Directors, but there are ways around this.) The minority would be elected by members and could provide oversight and insight for Council.

When you think about the “independence” of Board Directors currently, you can see where the gap in accountability is. If someone is making policy decisions on behalf of members, shouldn’t he or she be accountable for these decisions? When the Board makes an unpopular decision, how can members hold Directors accountable? Since Board deliberations are confidential, and Board Directors under the new Charters would be forced to publicly support even those decisions they advocate against, where should members or Council direct their concern? At the entire Board? Every time? Without even knowing whether a decision squeaked through by a slim margin or was overwhelmingly approved, how do members know if there is any point in asking the Board to reconsider?

How many current committees (at least the ones that are still relevant) are actually doing Council work? A group such as the Uninsured Services Committee provides policy advice for the benefit of members. This committee inexplicably reports to the Board, despite the fact that the work of this committee is not “Board work.” The Board should review it’s recommendations to ensure compliance with law, regulation, financial prudence and risk management, but it’s recommendations should be brought to Council directly for approval. Council should determine the committee’s mandate and membership and assess it’s effectiveness.

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These are just a few thoughts, but the intent is to highlight the importance of defining a role for Council within the overall governance structure. Whether we maintain a twice-a-year Council and tilt committee appointments in favour of more regular member involvement, or whether we attempt to capitalize on the new era of connectedness by forging a more social, modern Council, we need to choose between simply changing to a model that might not apply well to our organization, or innovating a solution that moves us forward stronger.

I have met many people over the last two years being involved with the grassroots and with the OMA. Most of them I met “virtually” long before I ever met them. I have collaborated with some people that I have never met in person. Multiple conversations about OMA policy are going on simultaneously right now on social media and online collaboration platforms. Some of these conversations have been going on for a year or more. Some people contribute more to these conversations than others, some contribute a lot to one conversation but less to others that they monitor because they are interested in learning. These platforms provide a safe space for discussion and promote member engagement in the discussion of OMA policy. So why should we not take the next step and use these to promote member engagement in the actual production of OMA policy?

Innovating would mean, however, that Council has to take a more comprehensive look at how it functions and how it is structured. It would be a revolutionary shift in our governance. But it could ensure that our representative organization is maintained and strengthened, providing more people with the ability to provide meaningful contributions to the OMA.

The Board governance changes have handed Council, Board and membership a huge opportunity to examine, discuss, question and debate the future of our organization. I think that changes in OMA Council and the Board could spur innovation, not merely change. The Board has produced a huge volume of change in Tab 13. Much of this is sorely needed, especially the defining of the duties of Board Directors and the Board itself. But we really should consider if we want “change” to stifle “innovation” or to facilitate it.

 

 

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Demystifying “Tab 13”

Tab 13:

Do you blame me for just calling the Board of Directors Report to Council on the Work of the Board Charter and Work Plan Task Force just plain old “Tab 13?” This is the place assigned to the report in the Council Binder for Fall Council, and there is probably not a more fitting position for this report to be in than number 13. Not because it is a bad report, or even a dangerous report. It is just unlucky because some of the work contained within is just a few steps too far ahead of where Council and members are with respect to OMA governance.

It’s unlucky, because it contains a lot of good, hard work done by an obviously determined group of Board Directors and OMA Staff, work that is obscured by poor presentation, a lack of guidance for the uninitiated, and some stark changes from the status quo that seem to come out of left field.

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But there is nothing to be afraid of, really. Council should, as it usually does, approach unfamiliar changes with caution and really commit to understanding the changes that are being recommended by the Board. I do not feel that the Board is trying to “pull a fast one” on Council, or mislead Council in any way. I feel the Board is trying to improve upon current OMA Board governance, and in doing so, make the organization better. Clarifying “who does what and how” will make us a stronger organization. But these roles and duties must be understood by an informed Council, and any reservations that Council has must be resolved before changes that affect Council take place.

For the benefit of members who are interested but overwhelmed and for Council delegates who will have to consider Tab 13 on November 24 and 25, I would like to try to demystify the documents, from the point of view of someone who was not involved in their production and who has had the same opportunity to wade through them as any OMA member. Some of the post hoc guidance from members of the Task Force, while well-meaning, make too many assumptions based on their own intensive exposure to governance education, that we should understand what they understand. And a few hours of group learning on the day before Council comes too late and will be too superficial to instill the same level of understanding and insight on the Council floor.

I would like to present my impressions of Tab 13, and in a separate post, present some suggestions regarding how Council might respond to its content. Again, I would like to state that even though these notes identify possible problem areas and concerns, my impression is that these changes are being recommended by a Board that is trying to make lasting positive change to the OMA. We just need to help with our own insights and points of view.

Breaking Down Tab 13:

Here is the good news: It is not necessary to read through the 229 pages of Tab 13. I will outline the important bits and what you need to know and suggest where you might want to focus and what you might be able to skim, scan or (gasp) skip.

Introductory Section:

This section (pages 1-6) starts off promisingly, but after the second paragraph of page 2, starts to wander off into minutiae that are detailed later in the documents.

There are details regarding the new Board Committees that have been developed and the current committees whose mandates are no longer relevant. Unfortunately, the rationale given for many of these changes is only that the governance expert recommended the changes and that the changes represent “best practice.” There isn’t really an explanation as to why the changes are important to our specific organization, or an outline of the problems these changes are expected to solve. If this were merely an overview that was to be supplemented by more detail later, this would be understandable. Unfortunately, this is not the case, and the reader is left with these questions unanswered.

(I believe this is a problem in presentation, not that there are no good reasons for the changes. By relying on information to come much later, at Council or the day before, the Task Force misses the opportunity to provide the concepts necessary to understand the changes early on, allowing confusion and apprehension to take hold.)

The bottom line regarding the committees is that all of the committees prescribed in the current OMA bylaws will be eliminated. Their functions will be assumed by Board Committees, except for the Committee on Committees, whose functions will largely be assumed by a Board Subcommittee that reports to a Board Committee. These Board Committees will not be listed in the bylaws, allowing their composition, terms of reference, and existence to be changed by the Board without requiring passing a  Council motion.

Finally, the bylaw changes necessary to implement the changes are listed. The details are difficult to follow in isolation from the bylaws themselves, which are reproduced later in the report, so not necessary to read at this point. The one point that is interesting, and not highlighted in Tab 13, is that Bylaw Article 9:1 remains unchanged: “The governing body of the Association … shall be the Council of the Association.” Something to keep in mind while considering all of the other information, and to which I will return later in the discussion.

Charters:

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There are three types of Charters that have been produced by the Task Force, and thankfully none of them end up with the OMA stranded on a deserted island. These Charters are basically the instruction manual for the various bodies and positions within the Board structure. Each Charter outlines the purpose, duties, responsibilities, skills and qualifications, activities and expectations of the person, position or group. They are designed to give involved people, and curious members, an accurate and detailed overview of who does what and how. There is one Charter for the Board as a whole, a series of Charters for specific Board positions and the CEO and Secretary, and a series of Charters for specific Board committees.

The good news is that these Charters are exhaustive. This is welcome information for those of us who made incorrect assumptions about what the Board and its members do, and what their authority is. It is clear that these Charters are the result of huge investments of time and energy, and that much thought was put into the details within.

The bad news is that many of the charters are very similar to each other in content, a point you may not realize until you have slogged through several of them. Hopefully the outline below will help guide you, but it does not take the place of the Charters themselves.

The Board Charter:

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One of the two most important documents in Tab 13 is the Board Charter (the other being the Charter for Individual Board Directors). The 14 pages are thorough, and like the other Charters, are written in plain English, not bogged down with legalese. It also sets the format for the Charters of the various Board committees established later on. I feel it should be read in its entirety by all Council delegates and anyone interested in what the Board does and how it works, particularly those who struggle with the concept that the Board works “for the good of the corporation,” and whether this means that it may possibly work counter to what is felt to be the “good of members.”

The first paragraph of the Board Charter states that the Board is the “highest decision making authority within the organization with the exception of the duties of the Council.” This is confusing. If the Council is the governing body of the OMA, according to bylaw 9:1, how is the Board the highest decision making authority? What is the difference between being the governing body and the decision making authority? More on this later.

My take-aways from the Board Charter are:

  1. The Board’s duties and responsibilities are clearly being focused on the “corporate” side of the OMA. The primary role is to oversee the running of the business side of the OMA.

I see the OMA as three main entities: The first entity is the “business” aspect of the OMA: providing services to members such as running OMA Insurance, providing legal advice, enhancing the “brand” of physicians in society, taking in dues and allocating that money to the various activities of the organization. For the purposes of this entity, the Board acts like any corporate Board, assessing the quality of work done by the CEO and his or her staff, ensuring that funds are spent wisely and legally, assessing risks to the organization including reputational risk, and importantly, being responsible and accountable for the above.

The second entity is the OMA as the negotiating body for physicians, as enshrined in the Representation Rights Agreement. It is the Board’s duty to ensure that this agreement is followed and that negotiations represent the best possible outcome for the profession as a whole. It is the Board’s duty to recognize when the RRA needs to be renegotiated for the benefit of members. These duties do not appear specifically in the Board Charter, but perhaps they should.

The third entity is the OMA as the political organization representing physicians’ collective values and hopes for the future as it pertains to the practice of medicine and to the health care system that we work within. As difficult as it is to represent physicians’ collective anything, if the OMA is going to be a relevant representative of members, somehow the organization needs to be able to establish a coherent platform for what physicians’ work should look like, what payment schemes should be promoted, how the health care system should evolve to best serve members and our patients, and what priority we should place on these and other issues.

The Board Charter talks about the Board being responsible, with the CEO, for developing the organization’s Strategic Plan and long-term goals as embodied in the Mission, Vision, and Values statements. Within these generally broad statements and their interpretation, lay the specifics about what the OMA will stand for politically.

It is interesting that the Board Charter, in its thorough detailing of Board duties, does not assign the development of OMA political policy to the Board, but implies only the idea that policy must fit within the Strategic Plan. How policy is set is not detailed here.

2. The Board Charter sets out a number of operating principles that apply to the rest of the Board structures. You might as well read these now, so you can skip over them multiple times later on.

These principles include how meetings will be run, what information will be provided to committee members and when, how a committee’s expectations will be communicated to support staff, how minutes of meetings will be distributed, etc.

3. The Board is responsible for oversight of the OMA’s finances, strategy, risk management, and the oversight of the CEO’s duties, performance, decisions, compensation, administrative plans and policies.

Largely this responsibility is carried out by the Board Human Resources and Compensation Committee, which brings its recommendations to the full Board for approval. Overall, the Board is tasked with oversight of the entire organization, either directly, or via the CEO and the OMA staff under his direction.

4. The Board has approved the concept that Board Directors must be “independent,” meaning that they do not represent a constituency within the OMA and do not hold a leadership position with any identifiable group within the OMA. They also may not be in an employee position or contractual position with the OMA.

So while constituencies elect Board Directors, the Directors are not responsible to the constituency that elected them. This is nothing new, but by outlawing the simultaneous holding of a Board and Council or constituency position, the Board has underscored this distinction. This is not to say that Directors are not responsible to members as a whole. And these Charter documents insist that Directors accept the fact that they are accountable to members for the performance of the OMA and it’s divisions and staff. How that accountability is enforced is not specifically mentioned in the charter, and more on that later as well.

5. The Board is responsible for all of the elements of OMA Board governance structure and practices. Note the specific identification of Board governance. The Board and it’s subsidiary committees are tasked with the following for all Board committees and the Board itself:

  • determining the desired qualifications for members
  • identifying and encouraging possible candidates who meet those qualifications
  • determining the selection process for committee membership
  • determining all of the above for CEO committees at the request of the CEO
  • determining which Board Directors sit on which committees
  • officially calling for nominations for the positions of Board Director, President-Elect (and President if required) (I have had varying opinions given to me regarding the item “inform the Districts and Council regarding the preferred criteria and skills for the election of Directors” – does this mean the general criteria and skills or specific criteria and skills the Board feels it needs added at any particular time? The latter possibility is problematic, as it may allow the Board to unduly influence elections.)
  • ensuring that all nominees for positions understand the duties and responsibilities, etc. for the position
  • complete management of all Board committees and Board Charters
  • assessing the effectiveness of all Board committees and members of committees and the Board itself
  • ensuring that Directors and committee members are adequately educated so that they can fulfill their duties
  • recommending to Council whether the Director who is President-Elect should not succeed to the position of President

So everything was going so well. Now I wish I hadn’t boldfaced that last one. Let’s get it out of the way, because we have bigger fish to fry. There is no explanation about this item (officially item 5(b)25 of the Board Charter). There are no details about how and why the Board might decide to make this recommendation. And there are no corresponding bylaws that would allow the President-Elect not to succeed as President unless 75% of Council voted to completely remove the President-Elect from the Board. The Board can recommend to Council anything it wants, including the removal of any Board Director. The Board has also, through Bylaw changes to be looked at later, given itself the authority to define the qualifications for being a Director and to remove any Director (through an unspecified mechanism) who does not meet those qualifications. So why the need for 5(b)25? And why isn’t it part of the OMA bylaws in addition to the Board Charter?

The more significant and ubiquitous changes that arise from this section are the decision to remove certain committees from being governed by the OMA bylaws and the decision to remove Council and non-Board members from some traditionally mixed committees. Some bylaw-specified committees are eliminated altogether, including the Committee on Committees, which was partially filled by election from Council in the past and will now be filled by appointment by the Board to the General Nominations Subcommittee.

Why the change and what difference does it make? The Board feels that responsibilities that fall within the Charter of the Board should be managed solely by the Board. Board governance, the financial affairs of the organization, the appointment to Board committees and the evaluation of the CEO and the strategic plan should, as Board responsibilities, be carried out by the Board and decided upon by the Board. There is also the fact that as Board Directors, they are externally responsible for these items as well, and must ensure that they are carried out legally and in accordance with regulations or they are able to be held personally liable.

And that is all well and good, but what isn’t clear is why having a minority number of non-Board members on some of these committees would harm the ability for those committees to meet their mandates or increase Board members’ liability. In addition, the organization stands to gain significantly from non-Board member participation on these committees, by being able to provide an outside view of decisions being contemplated, and more importantly, by helping to train and identify future candidates for Board or other positions within the OMA. It is not enough to say “well if you like corporate finance so much, just get elected to the Board and you can be on the Finance and Audit Committee.” The OMA membership includes many physicians with particular talent in human resources, finance and governance. Not everyone can make the huge commitment needed to be a Board Director. Why would we not want to take advantage of non-Board members’ skills on these committees?

And why, if the Council is the governing body of the OMA, would we not want Council to have some insight into the decisions being made by these Board committees? How does one justify the removal of the governing body from the actual governing?

6. Finally, the Charter concludes with statements regarding the “Governance Culture” on the Board.

These sentiments are repeated in every charter and basically boil down to each member of every body understanding their accountability, pulling together with the other members to carry out their duties, committing to acting in the interests of the OMA in corporate matters and in the interests of the membership as a whole in other matters, and fostering a positive, collegial, inclusive and respectful environment for Board Directors and staff, and accepting that the information being provided by experts on OMA staff is credible and reliable. The last statement is interesting, as it deals with a situation that has been not uncommon lately, where committee members have been at odds with advice being given by staff. How exactly committee members will be able to question data or reports given to them without contravening this principle is unclear.

I have not touched on everything in the Board Charter. I do suggest you read it through and think about your own questions and needs for clarification.

Individual Director’s Job Description:

The comparatively slim Individual Director Charter sets the mold for the specific job descriptions for positions such as President, Committee Chair, etc. What we have to realize when reading them is that these are corporate positions with corporate responsibilities and accountabilities. That once a Director is elected, they no longer “belong to” the constituency that elected them. They have no particular individual responsibility to Council or members other than to act in the collective best interests of the OMA corporation (the business, negotiations and political entities) in carrying out their duties. This new job description does not even include the obligation to meet with members of the constituency that elected them, though I have yet to encounter a Board Director who avoided meetings with members.

So is this good or bad? Does this change the way we think about Directors? Is there anything new here? Is there anything unique about OMA Board Directors that does not apply to Board Directors of any other corporation?

What else appears to have changed?

  • The job description outlines specifically that Directors are expected to adhere to standards regarding preparedness for meetings, attendance at meetings, participation on a Board committee, conflicts of interest and ability to understand, to a reasonable degree, corporate finance. Further, the expectations regarding conduct in meetings and when in contact with OMA staff or senior management are outlined. How to resolve conflicts within the Board and communicate concerns about other Directors or staff are listed. Again, it is stated that OMA experts should be relied upon in good faith. Directors are also expected to adhere to the OMA Directors’ Code of Conduct and OMA Spokespersons Policy, neither of which are provided in Tab 13.
  • A slight but significant change in the policy of “Board solidarity” has been made. In the past, while Board Directors were not allowed to publicly oppose a decision made by the Board, they could refrain from publicly supporting the position. This was seen in the 2016 TPSA debate. The new job description specifies that Directors must be “demonstrably committed” to board approved decisions. A footnote clarifies that “being ‘demonstrably committed’ means that you ‘publicly support’ and do not publicly oppose, disparage, question or denigrate the approved motions, resolutions and decisions of the Board. This is a distinct departure from previous. It leaves a Director with only one option in the face of a Board decision that he or she feels she cannot support on moral, ethical, or other personal grounds, or if he or she feels that the Board has been misled or misinformed. That sole option is resignation from the Board. I’m not sure that we need to have unanimity on our Board in order for it to reach valid decisions, even on the most important issues. Acquiescing to a majority or consensus decision should be sufficient. Forcing a Director to publicly make statements that he or she does not believe, forcing a Director to feel dishonest in his or her communication, this is not something that I can support. This clause should be revisited by the Board. It may prevent innovative thinkers from joining the Board and may cause a number of resignations when we least need them, during a period of high tension such as when a PSA is presented to members with a recommendation.
  • Section 4 of the job description is entitled “Director Termination and Resignation,” although it has nothing to do with resignation. This section allows the Board to remove a Director who is not carrying out his or her duties and also refuses to undertake corrective action. Similarly, a Director who is not attending meetings could be removed. Directors who are removed would not be allowed to run for re-election for two years. Giving the Board the ability to remove Directors elected by other bodies (Council or Districts) is unusual. Keep in mind that vacancies on the Board can be filled by the Board with any member from the constituency or even outside the constituency, (even though traditionally an informal poll is held to inform the Board of members’ wishes). Also keep in mind that all Board meetings are confidential, so members will not know the reasons behind the removal of the Director they elected. There are no details as to how the decision to remove a director will occur – majority vote? unanimous vote? Board Chair decision? In the absence of the powers granted in this section, however, what can a Board do in order to rectify a serious problem with one of its elected members? Perhaps the issues should be brought forward to the constituency that elected the Director in the first place. Perhaps, instead of changing the bylaw to allow the Board unlimited authority to alter the makeup of the Board itself, we should make it easier for a constituency to recall it’s Board Director(s) and remove and replace them? Otherwise, we are 100% acknowledging that once elected, a Board Director has no connection to his or her constituency whatsoever, and that the only enduring representation that members have to any governing body is that of their Council delegates. And by acknowledging that, we must consider Council in a different light than previous. More in part 2.

Specific Director Charters

These Charters, for the President, Chair of the Board, President-Elect and Past President outline the expected duties and responsibilities for these positions. In broad strokes, the President is the voice of the OMA, the Chair is the voice of the Board in communicating with the CEO and is responsible for the function of all Board committees, and the President-Elect is an apprentice-type position and is automatically the Chair of the Governance and Nominating Committee. The Past-President role includes chairing the Nominating Sub-Committee but is not a member of the Executive Committee and is expected to only contribute to Board discussions as the final speaker. I think this is in recognition that this would be the third year of office for this person, who has not faced his or her electorate throughout that time. The Past-President may also carry out special assignments as needed. Each of these Charters specifies in detail the responsibilities of the positions, of which the Chair of the Board actually seems the most onerous.

Concerns:

  1. The Chair of the Board is a huge job, stretching on for seven pages compared to the President’s four. I wonder if a Vice-Chair position should be considered in order to share the load and encourage good succession planning. If the job of Board Chair is so onerous as to be unsustainable, we will lose the ability to attract high quality Directors to the position.
  2. The President-Elect’s automatic appointment as Chair of the Governance and Nominating Committee seems contrived, as if to give the President-Elect something to do. Since the President-Elect will be expected to take on the public speaking duties the following year, I would have hoped to see some of those responsibilities incorporated in the President-Elect role. We have to recognize that the President-Elect’s election by Council will be more dictated by his or her ability to publicly represent the OMA than his or her ability to chair an important committee or his or her knowledge of governance issues. Everything that is being done regarding Board committees seems to be pointing toward increasing the competence of the organization and choosing the best people for each job. Automatic appointments fly in the face of this wisdom. It also ensures that the Chair of Governance changes every year, something that may not be ideal.
  3. Similarly, the Past-President’s automatic appointment as Chair of the Nominating Sub-Committee is potentially problematic. Also, I am not sure that we should be constraining debate at the Board by limiting the participation in Board discussions by someone who may have much to offer.
  4. There is mention in the President’s Charter of a “Board Sanction, Discipline and Removal Policy,” but this policy is not produced for Council or potential candidates for the Board to review.
  5. Without seeing the OMA Spokespersons Policy, these Charters make it clear that the President is going to be the sole spokesperson for the OMA. I feel that we should be playing to our representatives’ strengths, and that the President should be the spokesperson in the situations in which he or she is best suited to carry out that responsibility. If we have a President who is great at giving speeches but not great at answering interview questions, and a President-Elect who is the opposite, why not utilize them both? We may not always be as fortunate as we are this year.

Committee Chair Charters:

These are essentially the same as the Board Chair charter, limited to the scope of the committees involved. Important to read if you are a Committee Chair or sitting on one of these committees.

CEO Mandate:

This document lists the duties and responsibilities of the CEO in six pages, divided into sections for Strategy, OMA Programs, Finance, Administration, Human Resources, External Affairs, Compliance with laws and regulations and Board interactions. The CEO is the conduit between the OMA staff and the Board and is accountable for the performance and effectiveness of the OMA organization. Nothing really new here, but interesting to see the breadth of duties assigned to the CEO to delegate or carry out.

Throughout all of the above Charters and Job Descriptions, it is explicitly stated that the job of the OMA Board leadership is focused on governance and stewardship of the OMA and not on the details of how Board and Committee decisions will be taken from concept to action. If the Board feels that this activity is not happening effectively, it is the CEO to whom the Board turns. It is the CEO who bears the responsibility of making the necessary changes to improve OMA operations, and it is the CEO who is accountable if these changes are not successful.

New Menu of Board Committees:

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The Board Charters develop a new menu of committees from which the Board can choose when establishing a new committee. These are not the only committees that the OMA can create, as Council has the authority to strike groups of its own. It is unclear if there are any Council committees currently in existence, as no list of committees has been released by the Board with the current documents. So let’s assume that all current committees will be either discontinued (I have an aversion to the term inexplicably preferred by the Board, “sunset” or “sunsetted”), or converted to one of the newly defined groups. While only presented as a footnote in Tab 13, these definitions are important:

  • A “Board Committee” is a committee created by the Board, consisting entirely of Board members and reporting directly to the Board.
  • A “Board Sub-Committee” is a committee created by the Board which reports directly to a Board Committee and whose Chair must be a member of the Board. Other members of a Board Sub-Committee do not have to be members of the Board.
  • A “Board Task Force” is a committee created by the Board which reports directly to the Board. Members of a Board Task Force do not have to be members of the Board.
  • An “Advisory CEO Committee” is an OMA committee authorized by the Board to report, through the CEO, on selected topics of interest to the Board. No member of the Board should serve as a member of an advisory CEO
    Committee, except the President.

You can see that the designation of the committee is very important to understanding its membership and reporting requirements. Currently, the only known committees are as follows:

Board Committees: Governance and Nominating Committee (GNC), Finance and Audit Committee (FAC), Human Resources and Compensation Committee (HRCC) and the Executive Committee (EC).

Board Task Force: Board Charter and Work Plan Task Force, Negotiations Task Force.

Board Sub-committees: Nominating Sub-committee (from GNC), Pension Sub-committee (from FAC)

Advisory CEO Committee: Member Communications and Public Affairs Advisory Committee (MCPAAC).

Other existing committees will undergo transformation to one of the four committees above, with change in membership as necessitated by the type of committee it becomes. The Relativity Review Committee, for example, has a Board Director as its current Chair. Unless it becomes a Board Sub-committee, that chair should change. How committees earn their designation appears to be at the discretion of the Board, which creates all except the Advisory CEO Committees.

The Committee Charters are dense documents thanks to the inclusion of basic principles of function and behavior of every committee and committee member. The Board Committees (the “Big Three” excluding the EC) have huge mandates and heavy workloads. You can scan these by looking for the sections called “Terms of Reference” and “Duties.” I wonder if the mandates may turn out to be more than can be managed and if this will result in more committees anyway. (I also wonder about the combining of the Budget Committee and Audit Committee into one Finance and Audit Committee. Usually these functions are felt to be best carried out independently.)

The aim of the changes to committee structure is supposed to be the removal of Board Directors from influencing the recommendations of all committees, allowing Council members and regular OMA members a greater influence over these recommendations. Given that aim, it is confusing that all of the committees except for the Advisory CEO Committees can still have Board Directors as members. Sub-committees will have a Board Director as chair, since the work being done by Sub-committees relates closely to Board Committee work. Members of Sub-Committees and Task Forces do not have to be Board Directors, but nothing prevents the Board from appointing Directors to these bodies. So, if these changes are meant to ensure that the Board does not unduly influence the work of Task Forces and Sub-committees, perhaps better safeguards against this should be entertained.

Ultimately, the recommendations of all of these groups flow through to the Board for approval. There is no clarification as to the basis by which the Board decides to approve recommendations. From the Board Charters, it is clear that the Board would not and should not approve recommendations that would expose the OMA to legal or financial risk. But what about “reputational risk?” What if a committee recommends an action that the Board feels could adversely affect the reputation of the OMA and its members? Who determines if such a risk is acceptable or not? Who actually governs the OMA?

To illustrate this issue: Currently, the health care system is in crisis, partly due to an imbalance between the need for service and access to that service. (Let’s not argue about the nature of that imbalance.) Let’s say the OMA were to strike a committee of some sort to investigate alternatives and make recommendations regarding changes that might help to correct this imbalance. And let’s say that committee recommends that the OMA advocate for the introduction of a hybrid public/private model for health care system funding. How will it be decided what to do with this recommendation? Who should decide? The Board is caught between advocating for members (if the recommendation means that this change is necessary to safeguard members’ ability to provide good care in a sustainable system) and mitigating risk to the OMA, including reputational risk. Council, on the other hand, has representation from all districts and sections, and has the ability (and obligation) to obtain feedback and represent the views of the majority of members. Council is aware of the reputational risk, but may not come to the same conclusion as the Board regarding the magnitude of that risk and its implications for the future. More about this in part two as well.

Who will sit on these committees (except for Board Committees)? The selection criteria for each committee is listed and seem to aim pretty high. The criteria may screen out members who have an interest but no experience in the committee’s work. It will be mainly the work of the Negotiations Sub-committee to recommend the membership of Board groups. And unlike the previous Committee on Committees process, the Board will choose all members of this Sub-committee.

One other exclusion from involvement on these committees is that members of a Section or District executive will not be allowed to sit on Sub-Committees or Task Forces. I’m not sure this is ideal, as the executive of a Section or District usually has the best overview of the issues confronting that constituency. It would be strange to have, for example, an Emergency Room Overcrowding Task Force without involving any member of the executive of the Section on Emergency Medicine.

Also of likely interest to Council members is item 3(hh) in the GNC Charter which restates that the committee can recommend to the Board that the President-Elect should not succeed to the position of President, but goes further to state that this committee could nominate another Director to be President. Since the Board Directors will no longer be members of Council, they cannot, according to the bylaws, nominate anyone to be President or President-Elect at any time, since it is clearly stated in the bylaws that Council elects the President-Elect and if necessary, the President. I think that in the large volume of writing encapsulated in Tab 13, there will invariably be errors. The second part of 3(hh) is likely just that and should be removed. (Okay, I admit that this item may only have been of interest to Council members with a bylaw fixation. Guilty as charged.)

Finally, it is good to know that all committees and Task Forces will be expected to perform a self-assessment of their performance, roles and responsibilities. I am sure that Council and/or members would be happy to provide feedback to these groups as well, and perhaps soliciting such feedback should be added to the Charter sections related to the assessment of these bodies.

Board Secretary Mandate:

The Secretary of the Board was converted to an administrative role when the Executive Committee changes occurred at Spring Council 2017. This position is now held by an OMA staff member, but as a party to Board meetings and function, the duties are outlined in Tab 13 for completeness.

Board and Committee Workplans:

Monopoly-Pass-Go

These documents, from page 95 to 181 inclusive, can be safely skipped. If you end up on one of these committees, you will become familiar with its workplan. Suffice to say that it is a good thing that each group will at least attempt to slot in all of its duties and responsibilities on a timeline in advance. It will also help to determine which committees are simply too overloaded to fulfill all of their duties and allow for some duties to be delegated effectively.

Changes to the OMA Bylaws:

So here is your chance to read the OMA Bylaws. Again.

Okay, it is not necessary to read all the bylaws. The changes highlighted in red are necessary to align the Bylaws with the changes instituted in Board governance.

  • District and Assembly Board Directors will cease to hold their Council delegate position when they take on their Board position. District Board Directors will no longer sit on the District Executive.
  • District Nominating Committees have been eliminated from the Bylaws. The Nominations Sub-committee will assume the work of recruiting and promoting the opportunities of running for Board Director positions in all Districts and Assemblies. The explanatory notes at the beginning of Tab 13 stated that the rest of the duties of the District Nominating Committees would remain intact, however the revised bylaws strike all mention of these committees and their duties. Therefore, it is unclear if District Nominating Committees, which do important work in helping encourage members to consider running for District and Branch Society positions, will continue on, but just outside the governance of the OMA Bylaws.
  • The duties of the auditor, and references to the standing committees mentioned in the Bylaws (Audit, Budget, Nominations, Central Tariff and Committee on Committees) are removed as these duties (except for Tariff, which may continue) will be assumed by the Board Committees and Sub-committees.
  • New Bylaw 10:2:3 is as follows:

The Board of Directors may establish qualifications and eligibility requirements for holding the office of director. The Board of Directors may remove from office any director who ceases to meet a qualification or eligibility requirement for holding office as director.

I think this is somewhat problematic as mentioned earlier, and is deserving of more discussion with Council.

End of Part 1

Hopefully, this outsider’s guide will have helped you wade through Tab 13. Part 2 is a look at how all of this may impact on members, Council delegates and Council as a body. It will hopefully stimulate some thinking and discussion about the substance of the Board changes, the timing of their roll-out, how Council could recommend adjustments to some of the changes and develop changes of its own, and hopefully some ideas about how all of this could lead to a stronger, more unified organization.

coming soon

 

 

 

 

 

 

 

 

It’s the Most Wonderful Time of the Year…for OMA Wonks Like Me!

Yes, friends, it’s THAT time of the year, the time that OMA elves and pixies start to quiver with anticipation. It’s Pre-Council Season, and Father OMA is putting lots of goodies under the (insert festive totem here).

happy whatever

Fall Council 2017 is shaping up to be full of interesting and association-changing items, but we won’t get too many details until next week sometime, when the “Council Binders,” (now in pdf format), are released to OMA Council delegates. This OMA governing body of almost 300-members has the ultimate authority over the strategic direction of the organization, guided by its 25-member Board. Readers may be aware that 50% of the Board, and the entire Executive, is now made up of new representatives, most of whom took their positions as part of the wave of renewal that occurred last year, after a non-confidence motion led to the resignation of the previous Executive. Council itself was similarly renovated, with many new delegates elected in the most highly contested elections the OMA has likely ever seen.

This Council meeting is the second opportunity for this new Council to give direction to the organization, after Spring Council saw the complete revision of how the OMA President is elected and a reduction in size (and power) of the Board Executive, among other governance changes. At Spring Council, the direction given to the Board and the organization was clear – more changes need to be made to ensure the OMA is effective, responsive, responsible to members and democratic. Motions directing these changes that were passed at recent Council meetings include:

  • one motion at Fall Council 2016 requesting that a full and independent review of the operations of the OMA be undertaken.
  • one motion at Spring Council 2017 successfully indicated that Council delegates want to continue to play a meaningful role in ensuring fair and responsive governance of the OMA by being directly involved in Governance leadership.

Many members’ motions put forward for consideration at Spring Council were unable to be debated due to time limitations Many of these, as well as new motions will likely surface. But members’ motions may not be the most interesting part of Fall Council.

OMA President Shawn Whatley, speaking on his “President’s Tour” in Ottawa, informed those gathered that the OMA Board will be presenting the results of their Governance Review, in which the number of Board committees will be reduced, and the responsibilities of many committees will be devolved to member-led working groups. As well, Dr. Whatley informed attendees that the Operational Review of the OMA, conducted by independent consultants from Deloitte, will also be shared at Council. In addition, details about the OMA’s newly developed public relations campaign will be shared and discussed. Other items for discussion at Council are similarly significant: how is the Relativity Review Committee faring with the longstanding and thorny issue of fee equity? How are negotiations going? What will be our association’s response to the ongoing rollout of Bill 41, which was vehemently opposed by the organization? What is the status of the federal tax changes?

On the surface, this is what progress at the OMA should look like. Members speak, Council advocates, the Board strategizes and the OMA organization delivers.

Unfortunately, I suspect Council delegates, and members at large, have reason to suspect that there will be some lumps of coal in place of the presents that they are anticipating.

Lump #1: Governance Review

governance word cloud

Regarding governance, (insert glazed eyes here), delegates are going to have to keep their eyes and ears open. An afternoon session on the day before Council has been unexpectedly scheduled to introduce delegates to the governance changes proposed by the Board.

A three-hour education session on a single topic, when the entire Council meeting is only 14 hours, should indicate to delegates that something big and unfamiliar is about to happen.

As a frame of reference, at Spring Council, there was no “education session” on governance. Nonetheless, the entire Presidential election system was rewritten, including changes to who votes for the President and who can run for President, the elimination of the six-member Executive in favour of a three-member Executive, and a change to how the Chair of the Board is elected. Within the various motions required to make these changes, there were areas of dispute and discussion, and even an unexpected attempt by the Board to circumvent the recommendations of the Governance Committee.

The presence of non-Board members on the Governance Committee, and astute members of Council, ensured that stealth changes to the election process did not take place. The events that took place led to the approval of a Council motion stating that the Governance Committee should be a group selected by both the Board and Council, and should report to both bodies as a “hybrid” committee.

And all this change, lengthy discussion, and debate occurred during Council, all without any “education session” prior to Council.

So, what can we expect this time? How will the organization respond to the governance debates at Spring Council? And what will the three hours of “education” lead to? Will the OMA follow consultant-driven governance changes at the cost of losing its member-driven organization? And what purpose does Council serve if the Board doesn’t follow through on Motions?

Surely, if the Board is recommending sweeping changes to OMA Governance, it is important that delegates fully understand what they are being asked to approve. The OMA’s governance consultant has been quite open in expressing his opinion that the Board’s involvement in OMA committees should be reduced to a small, but extremely influential number of committees.

Does any of this sound familiar?

One might ask: will delegates and Council still have a role to play on important committees that determine how the organization is governed, how it spends the mandatory dues it collects, what kind of public image and advocacy for members it undertakes? Are we headed back to a system where a small number of Board members populate the most influential seats? Where we lose the delegates’ voices and create a new echo chamber? Did we come through all of the recent electoral renewal only to have newly engaged members and delegates shunted to “advisory” task forces because only the Board seemingly can see “the big picture?” And who will choose members to populate those advisory committees?

The most significant and transformative changes that have occurred at the OMA recently have come about as a result of grassroots members challenging the way things get done at the OMA. If you like Shawn Whatley being our President and you like Nadia Alam being our next President, realize that the changes that allowed this to happen would not have been possible with a Governance Committee made up solely of Board Members. The thought would never have crossed their minds. The changes necessary to elect Shawn Whatley would not have been in place in May, and only the Board would have decided who to crown as president from among themselves. Strong and motivated representation on the OMA Governance Committee ensured that the changes occurred, and occurred in a timely way.

Meanwhile, the OMA has been without a Governance Committee for the last six months. Despite there being more work to be done, particularly with respect to issues related to the Single Election Period, the committee was disbanded after Spring Council. The reasons for this were never adequately communicated to non-Board committee members.

It is essential that oversight of the OMA’s governance, finances, communications, and external policies and priorities not be left solely in the hands of a small insular group on the Board. And I look to some of the newly elected Board members themselves to rein in any such inclination. If you are a delegate, please attend the governance education session, but be wary of education masquerading as indoctrination.

Lump #2: Operational Review

iceberg corp

Delegates to Fall Council 2016 may recall the infamous “forensic review” of the events surrounding the General Meeting of Members (GMoM) that occurred in August 2016 regarding the even more infamous 2016 TPSA. Price Waterhouse Coopers (PWC) was retained on September 1, 2016, to perform a review of the events that led to the GMoM. The PWC report was on at least one occasion described as a “forensic review” but in fact was nothing of the sort. In fact, it wasn’t a review of anything other than the chronology of events that occurred from July 1 to August 16, 2016. After keenly awaiting this report, Council delegates were presented with a version of it on the eve of Fall Council 2016, and a revision at Council the next day. Delegates, and subsequently members, were gravely disappointed in this report, whose terms of reference seemed to be purposely defined to avoid the presentation of any new information whatsoever. And that took almost three months to compile and almost didn’t get finished in time for Council to review it.

Delegates to Fall Council 2017 have been promised better. A wide-ranging Operational Review was commissioned early in the mandate of the current Board, sometime after Spring Council. Almost six months have passed. As noted above, this report was promised to be available at Fall Council.

We seem to be in for more disappointment this year. The Council agenda, released on November 6, lists “Operational Review: Status Update” as one item to be discussed during one hour, along with four other reports.

So, it’s not done; why should we be terribly bothered?

I feel it is important for the leadership of an organization to not only hire good consultants when necessary but also to make clear to those consultants the timelines that the association and its members require. It is important to ensure that the work is done expediently, that everyone at the association is cooperative, and that the results get clearly and honestly communicated to Council and members in a timely fashion. Many engaged members and delegates have been aware that all is not rosy at the OMA, that challenges exist, and problems exist, that the organization has not been as effective as possible in advocating for and representing members. The organization seems hesitant, requiring members and representatives to apply pressure to obtain action. No organization is perfect, and members need to know where our problems are and what solutions are suggested.

Do we want a thorough review? Absolutely. Should such a review take place in less than six months? Most definitely.

How are we to interpret the delay of completion of this work? Is it due to a lack of clear expectations of the consultants, and if so, why did this happen again? Is it that the problems are worse than expected, requiring even time than expected, and if so, is there nothing that we can get started on now rather than months from now? Was there adequate cooperation with the review process, and if not, why not? When will a final report be ready, and how will this be shared with members? Will it be shared? If not, surely members are entitled to wonder why their money is being spent on secret internal reports.

The operational review should highlight areas in which the organization excels in addition to areas in which it is weak. Why deprive members of the knowledge of excellence within their organization?

And why is the OMA not keeping a promise to produce this report that was made only three weeks ago by Dr. Whatley in Ottawa?

lump of coal

I think two lumps of coal are enough for any family to put up with, and hopefully, there will be no other carbonaceous surprises for us at Council. I look forward to meeting up with the people I have come to know at Council and through Social Media. And I look forward to leaving Council with a stronger organization and a sense of renewed collective purpose.

Season’s Greetings to all!

funny-seasons-greetings

The Morneau-Trudeau Tax Changes Will Cost Us All

I am a physician, practicing community-based palliative care in Ottawa. I am not incorporated, but I stand firmly in support of my colleagues who are advocating against the proposed changes envisioned by Minister Morneau and Prime Minister Trudeau. The unfairness of these changes, which will penalize my colleagues and others who made use of a completely legal vehicle to finance things such as capital expenses, maternity leave, and retirement planning, is clear. The fact is that the use of Private Corporations was not a “grey-area” and was actually encouraged by governments. It is clear that Mr. Morneau and his Finance Department staff felt they were targeting a group of people who, regardless of their actual financial health, could be portrayed as “one percenters.” They are now finding out that the bullseye at which they were aiming has expanded in size to include just about anyone who owns their own business in Canada.

 

But let’s take it a step further. Given the reach of private enterprise in Canada, we all, all citizens, are going to be paying for this tax. I only hope that businesses would have the courage to be transparent about it. When you receive a bill at the local family-run restaurant, I would like that bill to read:

  • Food/drink:        $40.00
  • MTS*:                   $ 4.00
  • Subtotal:              $44.00
  • HST:                       $5.72
  • Total:                     $49.72

                                                                *MTS: Morneau-Trudeau Surcharge

Because that cost will be there. When that entrepreneur looks at his or her finances, and realizes that their savings is no longer going to be sufficient for them to sell or hand to business off to family when they planned, that they may never achieve the financial independence that years of crushing hard work and risk should reward them with, something has to give. Small business owners, who early on in their careers are the last to collect earnings, having gone through the growing pains and sleepless nights wondering if they will be successful, have earned the right to an appropriate income. Given the choice between delaying retirement for five years and raising prices, they will do the latter. Given the choice between standing pat or expanding their business, with its attendant risks and costs, they will do the latter, and raise prices to fund this expansion.

 

My pets’ veterinarian has been in the process of building a new clinic to replace the old outdated building he has been in for many years. As expected, prices have gone up. He is still a bargain, in my books, and I understand that my pets will benefit if they need more than routine care. This is not a tax, this is money going to support a business I need and that I value. But the next hike in rates may be solely due to the fact that our veterinarian can’t afford to keep all his employees while saving for other future improvements to the clinic. That he can’t afford to keep all his equipment maintained while saving responsibly for his retirement. So in order to maintain service, he will have to institute a surcharge, thanks to Mr. Morneau and Mr. Trudeau.

 

What will the Morneau-Trudeau Surcharge amount to? Hard to say. But it will be real. And it won’t provide any direct benefit to those who are going to be asked to pay it – consumers, you and me. It will reduce our federal deficit somewhat, but not as much as Mr. Morneau’s staff hopes. Because some businesses will not raise prices. They might be already in a fight for their lives against big box stores, big box restaurants, multinational professional services companies, massive public corporations. They might have customers who simply cannot afford to pay more, businesses who operate in low socioeconomic regions or who have existing contracts to honour. They might be unable to charge more because they are constrained to one or few payors, such as doctors.

The fact is that these businesses, the ones who cannot pass on the cost of the Morneau-Trudeau Surcharge to their customers/clients/patients may simply do what Mr. Morneau and Mr. Trudeau hope – that they “pay a little more.” But many more will decide to “cut a little more” instead. So a bit longer wait for your food because there are less wait staff. A bit less stock on the shelves at the corner store. A bit more likely to reach voicemail than a person when you call your doctor’s office, and a bit longer to get a call back. Some people will lose their jobs or have hours cut back, causing a drop in income tax revenue. Businesses may simply close, reducing tax revenue at all levels of government. These are real consequences and real people being affected. And none of them, not the employees of the businesses, not the owners, not the clients/customers/patients, none of them are “one-percenters.”

 

So don’t let Mr. Morneau and Mr. Trudeau fool you into thinking this is about the “rich paying a little more.” This is a shell game. This is your money. You paid tax on it when you earned it, you will pay “a little more” when you spend it. You even get to pay HST on the whole amount, including the Morneau-Trudeau Surcharge. Wealthy, middle class, blue collar, working poor, or unemployed, we will all pay.

Reconciliation and lasting forgiveness needs two parties, and time

Shawn Whatley published a recent blog post: Can Doctors Rebuild a Working Relationship with Government?

The photo from 2015 that originally accompanied this blog post was interesting. In 2015, North and South Korea almost came to open warfare after the deaths of two South Korean soldiers in the DMZ between the two. The two governments eventually sent high ranking insiders to negotiate a way out. BBC Korea, correspondent, Steve Evans, analyzed the situation:

Each side is represented by two members of the inner circle of the leaderships in Pyongyang and Seoul.

The difficulty is that they cannot even agree on the facts of the events which led to the current state of heightened tension.

It started when two South Korean soldiers were seriously injured by landmines in the so-called Demilitarized Zone between the two countries.

South Korea said North Korea planted the mines; North Korea said that was absurd.

Both sides say the other then fired the first shot in the artillery barrages.

The talks will not diminish the fierceness of the rhetoric between the two halves of Korea, but they may find a way for both sides to walk away safely from a dangerous situation before it explodes.

South and North Korean officials during their meeting at the truce village of Panmunjom in the Demilitarized Zone (22 August 2015)

From Wikipedia:

As a reaction to the August 4 landmines, South Korea resumed playing propaganda on loudspeakers near the border. In 2004 both sides had agreed to end their loudspeaker broadcasts at each other. North Korea threatened to attack those loudspeakers, and on August 20 North Korea fired a rocket and shells across the border into Yeoncheon County. South Korea responded by firing artillery shells back at the origin of the rocket. There were no reports of injuries on either side. Following threats of war from the North, and various troops movements by both North and South Korea and the United States, an agreement was reached on August 24 that North Korea would express sympathy for the landmine incident in return for South Korea deactivating the loudspeakers.

 

I don’t think I have to detail what has gone on in the short years since this photo was taken. Today’s headlines regarding North Korea/South Korea relations are as follows:

 

“South Korea proposes military talks with North Korea to ease tensions”

“Kim Jong-un may have more plutonium than anyone thought”

“There’s no chance of reunification for North and South Korea”

“America says it is prepared to use military force against North Korea”

 

Shawn’s blog asks the question: Can we forgive the Ontario Government? And when any commenter on Facebook says that this is difficult or unlikely, the author asks a straw-man question: “Given all that, is there ANY way you might consider working with them? What would it take? If they seriously changed direction, would you try to work with them?”

 

Shawn is asking if we are ready to forgive and I say most would say “no”. Simple, and understandable. Other than some vague assurance that Shawn gives that Premier Wynne wants peace with the doctors (how exactly has she “signalled that she wants to rebuild a relationship with doctors”), while somehow her Minister and Deputy Minister of Health do not, doctors have seen no indication that this government understands the damage it has caused to the relationship between doctors and government and the impact this has had on patient care. Lost opportunities to improve the delivery and quality of health care in Ontario caused by intransigence, disrespect and pursuit of what seems to be an anti-doctor (and pro-every other health care provider) agenda have burned any trust that doctors have that the current government wants to put care before ideology, and responsibility before self-aggrandizement.

 

It is not the “satisfying joylessness” of anger that sustains the current dispute between doctors and government. Doctors are not “refusing” to forgive the government. Doctors are not expecting “a tear stained face clutching hat in hand.”

 

Rather, it is the “joylessness” of our relationship with government that is pushing doctors away from engagement of any sort with government, that is pushing them to work as hard as necessary, but no more than that, that is making doctors feel helpless in the face of the overwhelming power of the government bureaucracy industry. Rather, it is the government that is “refusing” to forgive doctors for wanting to continue to practice for the benefit of their patients, rather than for the benefit of micromanagers and senseless meeting-goers in the LHINs, sub-LHINs and sub-committees of sub-LHINs. Rather, it is increasingly the voices and faces of doctors that are tear-stained with the frustration of seeing patients suffer and die due to government incompetence, and patients who we see “clutching hat in hand,” begging for better access to treatment.

 

So are we now seeing the Ontario Government “expressing sympathy for the landmines” they laid over the last 5 years, in exchange for the OMA “turning off the loudspeaker?”

 

If I am not mistaken, binding arbitration assures us that a PSA will be reached prior to the next election, either through negotiation alone or via mediation and possible arbitration. However this PSA is portrayed by the government, even if generous to doctors, we must continue to advance our advocacy for our patients and the system and we must insist on a system that is sustainable from a financial and workload perspective for physicians in order to ensure its viability. A PSA may ensure what and how we are remunerated, but it will not ensure that the government fund and organize health care effectively and efficiently. If the PSA gives a boost to the fee for a total joint replacement but the government reduces O.R. funding to hospitals, how would this help anyone?

 

So there is no reason not to applaud new funding and new programs to improve health care. But we must remain resolute in defending the existing programs from the ongoing erosion that has occurred. We must remain willing to ask the hard questions and make the difficult points such as the simple connection between underfunded home care, lack of LTC space, and hospital overcrowding leading to unsafe work conditions and less than ideal quality of care. When a major Ontario newspaper, the Ottawa Citizen, publishes article after article after article over a two week period relating the poor environment in many LTC homes, this is an gift for doctors to stand up and say “We care about LTC, we see its connection to the entire health care system, and fixing the problems there will yield benefits everywhere in the system. We are ready to assist and if the government will only listen, patients will benefit.” Instead, we have two infographics about wait-times, a blog about forgiveness, and not one single quote from one single doctor in page after page of health care reporting.

 

Shawn, a person or organization that truly regrets its actions behaves in certain ways. These include: acknowledging the action, acting in a way opposite to that action, understanding the magnitude of the action, correcting the action if possible, refraining from repeating the same action given the opportunity, among others. And these behaviors must be done willingly, not because they would be inevitable (like BA) or untenable (like further unilateral cuts).

 

I am willing to have my Association negotiate with the government. Just as the North and South Koreans sat down and negotiated. But I want my Association to understand who they are negotiating with. I want my Association to put in place the situation where the government can start to behave like a partner. Over the next PSA, the government of whatever party is in power has the opportunity to demonstrate its interest in being that partner or in building the next big missile to aim at doctors. And that government has the opportunity to understand that doctors will always stand up for our patients and our ability to provide the care they need. Ongoing positive messaging about the shortcomings in our system is not like offensive loudspeakers aimed at the government, it is advocating for the humanitarian work that we do every day as doctors. We must continue and intensify this while we observe the government’s behavior over the term of the next PSA.

Champlain CCAC rations patients’ personal care in their dying days

I am a General Practitioner practicing in Community Palliative Care in Ottawa. I, and several other physicians working in this field in Ottawa, see patients every day in their homes and at hospice. We care for people in the final stages of illness, to ensure comfort for them and for their families and caregivers. While our services are in constant demand, and sometimes patients have to wait for our care, I have always felt that we in Ottawa and the Champlain region provided a high level of palliative care.

For the last month or two, the Community Care Access Centre, or CCAC, has had to start rationing access to Personal Support Worker, or PSW, services, even to palliative patients. This year, they have seen an unprecedented increase in both the number and complexity of patients being referred for home care services. In order to meet their fixed budget, they have had to reduce access to Personal Support Services, such that most patients are having to be put on a wait list and wait up to weeks or even months to access this service that allows them to maintain their dignity at home by helping them get dressed and undressed, help them prepare a meal, help them bathe and use the toilet. Yet patients are being told there isn’t enough money in the budget to provide this care.

This affects even patients on the palliative caseload. It means that terminally ill patients are being denied assistance with bathing and personal care until they are so weak and unwell that they are essentially bedbound. And even then, some remain on wait lists.

Palliative patients have limited energy to use every day. If they spend it on bathing themselves, dressing themselves, etc, that means they have less energy to be awake and interact with family and friends, less energy to read or watch TV, less energy to enjoy even looking out the window. Often, their caregivers are elderly and have medical or physical issues that prevent them from assisting with personal care. Sometimes these patients live alone. Exceptions have been made, but not frequently enough. Dying patients are suffering because the government will not fund CCAC adequately. And transferring CCAC responsibilities to the Local Health Integration Networks will take these sorts of decisions even further from the patient and the bedside.

Also, hospital inpatients being discharged also join the waitlist, sometimes resulting in dangerous situations at home when patients don’t have the necessary supports. Even patients who already have PSW services may lose these if they are admitted to hospital for more than 14 days. We recently had a patient be discharged too early so that he would not lose access to his PSW, which was absolutely essential for his care.

At the same time, hospices are also stretched to the limit, causing them to tighten admission criteria.

Wait-listing introduces an unpredictable factor into end of life care planning that cannot be allowed to continue. Patients and families need to know that the support is going to be there when they need it. To do otherwise is cruel to patients and families and goes against our commitment to improve palliative care in Canada and Ontario.

The wait-listing is a result of the CCAC being overbudget on PSW services (not just palliative PSW services). This is due to three factors: PSW wages have gone up, and deservedly so; demand for PSW services has increased beyond expectations due to earlier hospital discharge and the general aging of the population; and the complexity of patients being cared for at home has increased dramatically, meaning more people at home need higher level of service to be maintained at home.

So there is currently a two-tier level of care in chronic and palliative home care. One tier for people who can afford to purchase more services to serve their needs, and another tier for people who have no choice but to wait for service, and suffer in the meantime. All because the government continues to increase bureaucracy and limit funding for patient care. Nothing in Bill 41 will alleviate the suffering of patients going without personal care in Champlain region.

My patients deserve to end their lives in comfort, in their own homes if they desire, and with the dignity of having their personal needs met. My patient who looks forward to sitting in her favorite chair, looking out her window at her garden, should not be told to just stay in bed because we can’t afford to get her the help she needs to get into that chair and back into bed. My patient who has always prided himself on getting dressed “like a normal person” each day, should not be told to stay in his pajamas because his dignity is not worth enough to our provincial government. My patient who would rather get assistance to use a bedside commode than use a diaper in bed, should be given that option as long as it remains feasible. My patients should not feel that they are an undue burden on their family by seeing them struggle with providing their care.

If we are serious and honest about improving the care of the dying and terminally ill, we must be serious about funding the personal care that palliative patients require. We must root out the waste that exists in the layers of bureaucracy, not just in the CCAC, but in the LHINs and the Ministry of Health, whose growth has well out-stripped the funding for palliative care in Ontario.

palliative-tree

 

Time to Clean House?

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As many of you were, I was saddened and somewhat angered by the news of Shawn Whatley’s resignation from the OMA Board today. Saddened because he has given so many of us an insight into the workings of our Association and a perspective from someone who has not only worked within the organization but who also sees where it can improve and change for the better. His blog and other writing is what has inspired many new physician leaders, including me, to get involved in shaping the future of the OMA.

I am angered as well, however. With Shawn’s resignation, many members have lost what they see as their voice on the Board. Board members, once elected, serve the members of the association as a whole, not their own particular constituency. This means that appealing to my District Directors has little impact if they feel that my opinions of views do not reflect the membership’s needs or wishes. The problem is that the Board of Directors has so infrequently asked for my advice as a member or indeed as a delegate, that I have no confidence in their ability to know that their actions work for the good of the membership. The most obvious example of this was the TPSA and the admitted failure of the Board to consider that membership might reject it.

But I do not want to dwell on the past. The present and the future are of much greater concern. Members who have followed Shawn’s blog and writings know pretty much where he stands. They also have the ability to have a two-way, open and public conversation with him through commenting on his blog. Shawn always responded to every comment, something that I have always felt was an exceptionally effective way to build on the conversations. In contrast to Shawn’s communications, the communication from the Board is limited to the carefully worded and parsed emails from the President that rarely give any insight into the thinking and discussion at the Board, and simply lay out the path that the Board has decided to take on any issue. The other communication conduits have been Town Halls, both electronic and in-person. I have yet to hear anyone comment that they were satisfied with these experiences, as these generally are non-candid affairs meant to verbalize pre-prepared speaking points.

So I am angry that the distance between members and the Board seems to be growing, not shrinking. Even though I am involved on my section executive and on the Governance Committee, I have witnessed the Board’s apparently insatiable need to be in control of everything. Health City Kingston needed to be examined with a fine-tooth comb to root out any unsanctioned advocacy. Rallies and Town Halls attended by members were labelled as partisan despite invitations to all political parties. Member communications have been held up until they became irrelevant. Even the Governance Committee’s plans to develop a plan to examine and reform the structure of the Board Executive, while completely within the scope of this committee, has to be “sold” to the Board before proceeding to inform members of this initiative and get member input.

I keep coming back to the question – Why did Shawn Whatley resign? Why now? Looking back, it is clear that Shawn (and others?) was likely not in favour of submitting the TPSA to members. Did he resign then? No. He didn’t resign when the Board hired Navigator to sell the TPSA to members. He didn’t resign when Navigator’s tactics bordering on harassment took place. He didn’t resign when the Board was admonished by Justice Perell prior to the GMM. He didn’t resign when the Executive did not step aside in the wake of the TPSA vote. I can only imagine how difficult it would have been to sit through all of these decisions, knowing that they were the wrong decisions, knowing that they were damaging the Association and the relationship with members, and still hanging on so he could do what little he could to represent members. So Shawn has resigned now, and there is no obvious reason that we know of that this happened. However, we can be safe to assume that either he could no longer stomach going along with whatever plan was now being agreed to at the Board, or worse, that whatever it is that the Board has decided to do, it is worse than the TPSA, worse than Navigator, worse than legal antics, worse than ignoring a 2/3 vote against an agreement that the Exec continued to defend even after the GMM, and continuing to consider that they had a mandate to represent members.

What happened? What is it that the Board has approved that Shawn could not even hold his nose and accept? I think members need to know. I think members have a right to know. And with that knowledge, I think members have a right to decide if the Board is truly acting in their best interest. I can only assume that Shawn provided the Board with a letter of resignation. If the Board feels truly blameless in his decision to resign, they should release his letter of resignation, with his consent, so that members can decide for themselves whether Shawn’s resignation reflects merely a personal decision that enough was enough, or if there are even more concerns of which members have a right to be aware.

Much attention lately has been focused on the Executive. In my opinion, however, assessing the Executive’s fitness to serve is not enough. Members, through Council, have a right to assess the ability of any Board member to continue to serve in the membership’s best interests. Council has a right to hear what the issues were that lead to Dr. Whatley’s resignation. If things have become severely dysfunctional and the Board’s business has been distracted by such a degree that a Director had to resign, then the Board’s fitness to serve members has to be brought into question.

With all due respect to the Coalition, the Executive doesn’t appear to be the whole problem. Today’s events shine a new light on that suggestion. The problems with the OMA governing bodies seem to go deeper. While a GMM may consider the motions brought forward by the Coalition, I fear that the real work needs to be done by Council, which has the authority and responsibility to remove any Board Members who are not performing their duties adequately.

I call on the OMA Board to address the reasons for Dr. Whatley’s resignation, release his letter of resignation and allow members to fully understand the events leading to this. Without this clarity, we can only assume that something egregious was about to happen or has happened. Without this clarity, the members will have no idea if we should still have hope and trust that the Board can fulfill it’s duty to members. In either of these cases, motions for removal of every remaining Board member would be in order, with notice of same being given as per OMA Bylaw 10:5:4:

The Council may, by a resolution passed by at least two-thirds of the votes cast at a meeting of the Council of which notice specifying the intention to pass such resolution has been given, remove any director or officer from office before the expiration of his or her term.”

There is no precedent for mass removal of Board Directors. One suggestion would be to appoint an interim Board made up of representative of the District Executives or members they nominate. This would be a caretaking enterprise until new elections to the Board can be held. Let’s face it: the government would be foolish to negotiate with our current leadership, who have shown themselves to be so out of touch with members. And members would be foolish to trust this group to present an adequate TPSA for ratification.

If there are Board members who feel that there is an alternative path to a positive outcome, I would be interested in hearing about it. Silence on this issue now will only ensure that a debate at Council will have the last word. For the good of the Association, for the good of members, for the good of our patients and our ability to contribute to shaping the health care system moving forward, we must have this discussion.

Is it time to clean house and move forward? I guess that depends.