Addressing the Opioid Crisis with Interprofessional Collaboration

Word cloud of keywords related to spine. muscle and joint pain and the opioid crisis, including: Spine, Muscle & Joint Pain, MSK Pain, Low Back Pain, Manual Therapy, Addiction, Pain Management, Mental Health, Prescriptions, Co-ordinate Care, Collaboration, Interprofessional, Families, Economic Impact

Among its consequences, the COVID-19 pandemic is an unplanned experiment in what it means to have reduced access to care. Sadly, while it’s occurring, Ontarians’ need for care is rising. This increased need is not directly related to COVID-19 but because of it.

Pandemic’s impact on patients

Ontario Medical Association president Dr. Adam Kassam recently advised that due to restrictions during COVID-19’s three deadly waves, “more than one health care service was not performed for every Ontario resident this year.”[1]

This hugely diminished access to care affected primary care, emergency departments, as well as regulated health care professionals, such as chiropractors, registered massage therapists and physiotherapists, who could have provided relief.

As mentioned in my last post, the pandemic’s demands on essential workers and added stress was high, increasing their risk of injury and need for care. Those in labour-intensive roles also had to keep working in less-than-ideal conditions and in moving to makeshift home offices, knowledge workers faced new challenges. These pandemic-driven demands, stress and challenges exacerbated back pain and other spine, muscle, joint and related nervous system or neuromusculoskeletal (nMSK) conditions.

And as musculoskeletal (MSK) conditions and related pain account for the largest share of global disability burden,[2] there’s no doubt reduced access to care impacted many Ontarians with these issues.

In fact, our members have told us of patients who turned to or increased their use of pain management medications to compensate.

Opioid-related deaths increased by more than 75 per cent

Tragically, the fallout of reduced access to health care and other services is notably evident in the number of monthly, opioid-related deaths in Ontario, which rose by 79.2 per cent between February and December 2020.[3]

Some of these fatalities are pandemic related. Others are indicative of the ongoing crisis. For example, almost one third of opioid-related deaths among employed individuals comprised those in the labour-intensive construction industry both before and after the pandemic started.

More than 50 per cent of opioid users have reported back pain

What may come as a surprise to some is that back pain has been reported in more than half of regular opioid users.[4] It’s also one of the most common diagnoses emergency and family physicians cite for prescribing opioids.[5]

And even though many patients are prescribed opioids for pain, a 2016 systematic review and meta-analysis found that opioid medications provide modest, short-term pain relief for people with chronic back pain but evidence of long-term efficacy is lacking.[6] Fortunately, there’s alternatives.

Manual therapy: a medication-free alternative for low back pain

Over the past 10 years, research has demonstrated that treatments chiropractors provide, such as spinal manipulation and therapeutic exercise programs, can relieve low back, neck, shoulder or other MSK pain. Also, the type of care chiropractors provide is now globally recognized as an evidence-based first and second-line approach for low back pain.[7]

In fact, the 2017 Canadian Guideline for Opioid Therapy and Chronic Non-Cancer Pain recommends therapies without medication, such as spinal or joint manipulation and therapeutic exercise, for treating back and neck pain, as well as knee osteoarthritis, fibromyalgia and severe headaches/migraines. Similarly, Health Quality Ontario suggests that making better use of non-medical treatments to manage acute and chronic pain will reduce the number of people who end up using opioids for the long-term.

This means Ontario’s health care system now has a recognized option for treating low back and other spine, muscle and joint pain, aside from opioids. But this option hasn’t been utilized to its full capacity. This shortfall is due in part to the complexity in the public and private pay components it requires to help all patients, including those most vulnerable.

Success of Ontario’s Primary Care Low Back Pain program

For an extended period, Ontario has monitored utilization of the health system with a goal to appropriately move care from acute care settings and emergency departments into the community. So, successive governments focused on strengthening primary care and interprofessional teams as a way of bringing leading practice and efficient health care models to Ontario.

With the knowledge that MSK conditions could be managed in the community, our association advocated with the provincial government to include chiropractic care in the primary care models it was developing at the time.

These efforts led to it funding seven Primary Care Low Back Pain (PCLBP) pilot sites across the province in 2015. Under this model, interprofessional primary care teams were formed to deliver efficient, co-ordinated and integrated care to vulnerable patients with low back pain via MSK experts, such as chiropractors.

Successful outcomes followed and 83 per cent of patients surveyed after receiving MSK care at one PCLBP pilot site said they now rely less on medication, including opioids, to help manage their low back pain.[8] And the PCLBP program continues today.

However, evolution of the community-based model of care has generally seen primary care models focus on disciplines funded by the public health care system – limiting chiropractors’ potential to bring relief to more patients.

OCA’s Opioid and Pain Reduction Collaborative

With the growing awareness of the opioid crisis, there is a desire for all levels of health care professionals, as well as governments to decrease the burden it creates and research what’s causing it. That research reveals significant links to MSK pain and that, for example, these conditions presenting in emergency departments contribute to patients’ initial access to opioids.

So our Board of Directors had the foresight to prioritize the opportunity for chiropractors to help solve the opioid crisis.

Subsequently, we partnered with the Centre for Effective Practice (CEP) to create the evidence-based Opioid and Pain Reduction Collaborative (‘Collaborative’). It’s designed to help chiropractors, or other manual therapists, co-ordinate a plan of care with patients and their prescribing health care professionals toward the end goal of them successfully reducing their opioid use.

Our solution includes the CEP-developed Manual Therapy as an Evidence-Based Referral for Musculoskeletal Pain clinical tool. It’s designed to inform physicians and nurse practitioners with the best available evidence.

Another key part of this solution is a script to help chiropractors start a conversation with a patient about reducing their opioid dependency. Most importantly, this script enables chiropractors to do so while staying within their professional scope of practice. We also offer fillable forms to help chiropractors share care plans with prescribing health care professionals.

Why interprofessional collaboration is imperative

But chiropractors can’t do this on their own. Interprofessional collaboration is imperative because MSK disability that’s related to opioid dependency involves much more than the pain of sitting or standing for long periods of time. It affects all aspects of a patient’s life, including their work, social interactions, family life, mental health and finances.

Spine, muscle and joint experts, such as chiropractors, can target the cause of the MSK pain and connect to affected areas of the patient’s life. Patients, primary care providers, as well as often social workers and other health care professionals, are also essential for the depth and expertise they bring to the complexity of a patient’s situation.

And to achieve the best outcomes, all care team members who the patient wants connected to their care plan should be aware of what’s happening at each stage.

So, as the patient’s mobility improves, it’s important for their care team to understand what the chiropractor’s next steps are in their plan of care. This understanding helps ensure the physician or nurse practitioner reduce their medication at an aligned pace or closely monitors the patient’s medication, if they are taking on a greater amount of exercise.

This close connection among the care team is needed to ensure the patient’s overall goals, such as reducing dependence on opioids, strengthening their mobility or improving their ability to stay at work, are met.

I believe patients also recognize the value of collaboration, as our research has found many are frustrated with the lack of communication and coordination among health professionals who care for them.[9] 

Key challenge: communicating across public and private care disciplines

One of the challenges we face is communicating across disciplines and at the right points in time. As we move into post-pandemic recovery, we know the publicly funded system will be under tremendous pressure to catch up and with enhanced interprofessional communication, chiropractors can help.

So, for example, when a physician refers a patient to a chiropractor or a chiropractor reaches out them to discuss a patient’s plan of care, it’s important for them to agree on:

  • What the early weeks of care look will look like
  • When they’ll circle back with each other

This is a watershed moment for all of us to come together to change the outcomes for Ontarians who depend on opioids to relieve their MSK pain.

Health care community’s response to OCA’s Collaborative

This urgency coincides with a growing interest among family health team providers to know what’s going on with their patients’ care – whether it’s from a chiropractor or another health care professional outside the publicly funded system.

There’s a recognition that an increasing number of patients choose to see chiropractors or health care professionals who are not within the public pay system.

We’ve heard about an increasing number of family physicians and nurse practitioners asking about chiropractic care and providing information about the kind of care practitioners can deliver outside the bundled care systems. And again, with a focus on interprofessional care, they want to be engaged in these conversations.

Not surprisingly, the CEP clinical tool has been accessed more than 2,500 times since the Collaborative launched in June 2020 and some of our members have cited favourable feedback from physicians they’ve shared it with.

How the Collaborative will help Ontarians and Ontario

This collaborative approach empowers public and private health care professionals to achieve better patient outcomes for many Ontarians.

Once we reach a critical level of adoption, we expect to see more Ontarians moving, healthy and able to be a committed part of our workforce.

If we can provide the best MSK care at the right place, which is often outside hospitals, we’ll also help enable our health system to efficiently address the pandemic’s backlog of patient needs. Then our publicly funded system can devote its resources to priorities, such as cardiac and cancer care, that can’t be delivered elsewhere.

Finally, I think there’s an opportunity to further explore the co-ordination of care between the public and private pay system for evidence-based, well-established pathways of care. And low back pain would be one of those.

We know more than 70 per cent of Ontarians have extended health care benefit coverage through their workplace and the impact MSK conditions indirectly have on employers.[10] I think there’s an opportunity to leverage these benefits for the greater good, in terms of how they’re covered.

How can you help?

We launched the evidence-based Collaborative’s tools to our members in 2020 and are providing additional supports, such as this podcast series, to advance their implementation.

You can help by encouraging prescribing physicians and nurse practitioners to use this CEP tool and apply this approach to collaboratively help solve this opioid crisis.

I welcome your thoughts and feedback.

(Please note, this blog will be taking a break in August so you can enjoy your summer but it will be back in September with a focus on extended health care insights.)


[1] Kassam, A. (2021, July 4). Doctors’ focus on ‘missing patients’ is just first step in leading the pandemic recovery. Toronto Star.

[2] Vos, T., Lim S.S., Abbafati C., et al. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the global burden of disease study 2019. The Lancet, 396:1204–22.

[3] Gomes, T., Murray, R., Kolla, G., Leece, P., Bansal, S., Besharah, J., Cahill, T., Campbell, T., Fritz, A., Munro, C., Toner, L., Watford, J. for Ontario Drug Policy Research Network. (2021) Changing Circumstances Surrounding Opioid-Related Deaths in Ontario during the COVID-19 Pandemic.

[4] Deyo, R.A., Von Korff, M., Duhrkoop, D. (2015). Opioids for low back pain. Thebmj. (350):g6380

[5] Borgundvaag, B., McLeod, S., Khuu, W., Varner, C., Tadrous, M. and Gomes, T. (2018). Opioid prescribing and adverse events in opioid-naive patients treated by emergency physicians versus family physicians: a population-based cohort study. CMAJ Open. 6(1): E110-E117

[6] Shaheed, C.A., Maher, C.G., Williams, K.A., Day, R., McLachlan, A.J. (2016). Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 176(7):958-968

[7] Foster, N.E., Anema, J.R., Cherkin, D., Chou, R., Cohen, S.P., Gross, D.P., et al. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 391(10137): 2368–2383.

[8] Primary Care Low Back Pain Pilot Evaluation: Final Report.

[9] Partnership4BetterHealth, OCA Patient and Family Advisory council.

[10] Environics Research, as commissioned by the Ontario Chiropractic Association. (2019). Attitudes of Ontarians Toward Chiropractic Care. 13

Chiropractic Care During COVID-19

The role of chiropractic care in this pandemic

Chiropractor Dr. Amy Brown treating frontline nurse during COVID-19.
Chiropractor Dr. Amy Brown treats one of many frontline nurses during the COVID-19 pandemic, as explained in our Better Health in Any Space feature.

This is my first blog post since joining the Ontario Chiropractic Association (OCA) as CEO. I’m proud to lead an organization that represents 80 per cent of chiropractors in Ontario. This is an outstanding profession of regulated health care professionals, who are respected and valued by their patients.

This appreciation is even more evident as we continue to navigate the challenges of a global pandemic.

Pre-COVID-19, patients value their chiropractors

Long before COVID-19, we commissioned an Environics study on Attitudes of Ontarians Toward Chiropractors in June 2019. We learned that 26 per cent of Ontarians received chiropractic care, up from 20 per cent in 2016 – across regions, age, gender, education and income levels.

This study also told us Ontarians see chiropractors as trusted, competent and ethical health care professionals. In fact, more than seven in ten patients rated their chiropractic care experience as good or great.

COVID-19 has reinforced these findings, demonstrating the multi-pronged value of chiropractic care, while prompting the evolution of virtual care delivery.

Supporting frontline essential workers during COVID-19

During this pandemic, frontline health care and other essential workers have emerged as the heroes. At the best of times, spine, muscle and joint (musculoskeletal) injuries have been cited as the leading category of occupational injuries among health care workers.1 And sprains and strains account for 44 per cent of all lost-time claims across occupations in Ontario.2

The demand for essential workers to sustain COVID-19 efforts imposed longer shifts, increased stress and made redeployment to unfamiliar sites a frequent reality. Those extra pressures increased the risk of injury among frontline workers and the need for spine, muscle, joint and related nervous system (neuromusculoskeletal) care to help treat or avoid them.

Many of our members, such as Dr. Amy Brown, a chiropractor who practises at Coronation Chiropractic, Massage & Physiotherapy in Cambridge, experienced a spike in nurses seeking chiropractic care during the pandemic. Fortunately, chiropractic care was approved to deliver essential services for emergency, acute and urgent care during Ontario’s first lockdown period and could meet this increased need.

And chiropractors continue to provide care to help those on the frontline – from truck drivers to bakery workers – to keep working during the pandemic.

More than a year into COVID-19, it’s been a gruelling marathon for frontline workers. And Ontario chiropractors continue to treat essential workers’ neuromusculoskeletal issues and support the province’s COVID-19 efforts. They also continue to treat Ontarians working from home, who never thought their sofa or dining table would serve as their office for months on end.

Alleviating Stress on Emergency Departments

While hospital emergency departments (EDs) strain to care for patients with COVID-19, the system needs other options for people with back pain.

Data tells us that in a given year, more than 400,000 patients visited EDs in Ontario with musculoskeletal disorders, including arthritis, bone and spine conditions, among others.3 But as many as 97 per cent of emergency patients with back pain are not admitted and are sent home.4

Chiropractors are experts in assessing, diagnosing and treating many of these types of musculoskeletal conditions in the community. They also provide the type of care recommended as first and second-line approaches for low back pain.5

In delivering this direct benefit to patients during the pandemic, chiropractors continue to help reduce unnecessary visits to hospital EDs that are urgently needed for patients suffering from COVID-19.

Growth of Virtual Care Delivery

During this pandemic, patients continue to seek treatments for chronic care. So, with guidance from our regulator, the College of Chiropractors of Ontario (CCO), many chiropractors began offering virtual care.

Patients responded favourably to this treatment option. It enabled those with ongoing needs to continue their care plan, while minimizing the risk of spreading or contracting COVID-19.

Fortunately, insurance providers also adapted and included virtual care in extended health care benefit plans. Four out of five patients rely on their employer’s plans for chiropractic care.

To help our members safely deliver permitted services during the initial 2020 shutdown and beyond, we provided them with the ongoing information and resources they required. We also formed a return to practice working group and collaborated to provide them with a toolkit to support their safe return to patient care.

Recently, we were honoured to receive an Ovation Award of Excellence for COVID-19 Response & Recovery Management and Communications from the International Association of Business Communicators’ Toronto chapter, recognizing this work.

Some of my colleagues in other health care fields asked: “How can chiropractors deliver care without hands-on, manual therapy?”

The answer is that chiropractors develop a comprehensive treatment plan. Hands-on therapy, such as manipulation of vertebrae or other joints, is one type of treatment provided. Chiropractic care also includes customized, therapeutic exercises, patient education and self-management strategies, such as positions of relief.

Ongoing Value of Virtual Care

Even with most clinics open, virtual care continues to prove advantageous to many patients, such as those with compromised immune systems or other health concerns. It’s also valuable for those who have mobility issues or transportation challenges that may be worse during the pandemic.

Chiropractors are also combining virtual and in-person care to provide patient-centred solutions. Medical history, discussing patient expectations, education and coaching are completed virtually while in-person visits for treatments foster optimal patient experience and outcomes.

The Future of Chiropractic Care in the post-pandemic world

In my next post, I’ll talk about another crisis affecting Ontarians before, during and after COVID-19 – the opioid crisis and our strategy to help address it.

I look forward to our collective future in Ontario during and long after this pandemic.


1. Ngan, K., Drebit, S., Siow, S., Yu, S., Keen, D., and Alamgir, H., (2010). Risks and causes of musculoskeletal injuries among health care workers. Occupational Medicine. Volume 60 (Issue, 5). 389 – 394.

2. WSIB (2019), Schedule 1 – By the Numbers, 2019 WSIB Statistical Report. Common Characteristics of allowed lost time claims in 2019 (infographic).

3. MacKay C., Canizares M., Davis A.M., Badley E.M. (2010) Health care utilization for musculoskeletal disorders. Arthritis Care & Research. 62(2). 163-169.

4. CIHI (2017-2018) NACRS Emergency Department Visits and Length of Stay.

5. Foster, N.E., Anema, J.R., Cherkin, D., Chou, R., Cohen, S.P., Gross, D.P., et al. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 391(10137). 2368–2383.

3 Ways Boards and CEOs Can Shun Scandal and Sustain a Positive Culture

Businesswoman leading collaboration session with postit note board, possibly engaging the Board and CEO.Boards and CEOs bear enormous responsibility for the well-being of their organization’s people. In turn, organizations rely on fully engaged and motivated employees to deliver on their mission. Much is written about how ‘trust’ affects each employee’s engagement. Employees should be able to trust their organization to provide a safe environment that evokes pride and provides ample support for them to thrive in delivering quality work to the communities they serve. Employees are also expected to share values aligned with their organization and to come to work each day prepared to do the best they can. Informed leaders know that most employees share this goal. So when employee performance goes amiss, it’s frequently because the culture, including the systems, processes and tools, impedes their success.

Leadership creates culture. To build a culture of trust, ‘walking the talk’ as boards and CEOs is imperative.

The rising number of harassment incidents recently making headlines is a wake-up call for all boards and CEOs. Sadly, in numerous cases, the issues were known and ignored. Employers’ responses to these incidents are also alarming. For me, it raises the question: What is the priority for boards and CEOs?

To mitigate media exposure crises, contracts are usually abruptly terminated but what about long-standing workplace harassment issues employees face each day? What’s the impact to emerging leaders who may view the way senior members (leaders or staff) behave as the way to lead or get ahead?  What message does it send to employees? Does it suggest inappropriate behaviour is ok, as long as you can get away with it, but if you’re caught, you will be fired? These characteristics don’t belong in organizations that espouse to be just, caring, learning and innovative.

When harassment issues emerge, we should ask: What kind of governance and leadership processes might have mitigated damage to the organization, its employees and stakeholders?

In my previous post, I addressed the relationship between the board and the CEO, how to ensure each can simultaneously fulfill their role in harmony through meaningful conversations, particularly generative dialogue, learning and a united workplan.

Boards and CEOs need this harmony to meet their key mandate: To advance the organization’s mission. This mandate includes protecting and growing the organization’s assets. To achieve this mandate, the board must provide effective board governance oversight and the CEO must efficiently manage the organization.

At the heart of this accountability is managing our most important assets – the employees who deliver on our organization’s mission.

Sustaining Trust

Here are 3 ways boards and CEOs can work together to support our employees and sustain a culture of trust:

#1. Seek out the story behind the data –

Boards monitor performance indicators to gain insight. This must include setting performance goals and monitoring indicators that relate to culture and people practices, such as employee engagement, turnover, sick time and grievances. Data only gives us part of the picture. Its complement is insight into the story behind the numbers.

You uncover this story through generative dialogue with the CEO. To work effectively, we must give board members opportunities to use their intuition and judgement to ask the CEO probing questions.

Boards and CEOs must also be open to feedback from all stakeholders. A leading practice in performance assessment is the 360° feedback process. This can be cumbersome and the traditional process alone is outdated in today’s dynamic environment.

With social media and rapid learning cycles, we can connect this process to more dynamic feedback loops. CEOs can gain more dynamic feedback and insight through tactics like trusted blogs, town halls and webinars. Board members should seek opportunities to connect with the broader stakeholder community, gain feedback on their organization’s reputation and how it looks from the outside. Employees also talk about their work environment and their experience reflects how the organization interacts with its stakeholders.

If boards and CEOs listen, while connecting internally and externally, they can’t be blindsided by a longstanding, toxic work environment.

#2. Watch employee interactions throughout the organization

Boards and CEOs must have visibility into the work environment and how employees interact at different levels. How the CEO engages with senior staff, how executive team members support committees or communicate in board meetings often indicates how these leaders interact with the entire organization.

From the governance level, CEOs and boards can also look at internal relationships by participating in key events, such as recognition ceremonies, learning sessions or celebrations. When board members observe how employees and leaders interact, they discover context behind the data presented to them. CEOs must also make it their priority to spend time with all teams to get insight into rapport or tensions between management and employees.

#3. Prioritize and structure HRs’ role appropriately –

Human Resources (HR) must directly report to the CEO. This structure enables HR to advise the CEO and give the board the support it needs to deliver on people practices oversight and the organization’s culture.

We must also remember the HR function is not responsible for the culture. Culture is the role of the CEO. However, we expect HR  to ensure all leaders and employees have the tools they need to apply leading practices to their work and fulfill their roles. Equally important, it must be a strategic partner in ensuring the work environment enables its people to create the best outcomes for the organization. This role includes having: policies that protect employees who come forward with complaints; processes and standards for investigating these complaints; and learning best practices so that everyone knows their responsibilities. The board must provide oversight to ensure these appropriate policies are in place and reassessed, as required.

Caroline showing leadership with three other people participating in CN Tower Edge Walk
Toronto’s CN Tower has created a safe environment that fosters the trust visitors like myself need to attempt its Edge Walk. CEOs and boards must also create a safe workplace with a culture that gives employees the support they need to thrive.

There are no quick fixes to transform a contentious or negative culture. A long-term commitment to applying these 3 ways to foster the well-being of an organization’s people will start the journey.

Now is a good time to reflect on the past year, take stock of your organization’s culture and make plans to strengthen your long-term commitment to its people or most important asset.

What steps will you take in the new year to sustain a positive culture built on trust?  What needs to change, if anything?

I look forward to your thoughts on this subject.

Best wishes for the holiday season and for a positive 2018!

How CEOs and Boards Can Leverage 3 Keys to Soar in Unison

Leading Board of Directors meeting - with strong CEO as insight from Caroline BreretonIn my previous post, I identified 3 keys to enable successful leadership, outlining the leadership challenges Boards of Directors and CEOs, Presidents or Executive Directors face. Having served on and chaired Boards of Directors, as well as been accountable to one in my CEO role, I’ve lived the challenges and rewards.

Like ballroom dancers, boards and CEOs must find ways to cooperatively lead together and deliver on their accountabilities, without stepping on each other’s toes. Boards should only delve into operations when necessary and CEOs must appear to welcome detailed questions, even when they don’t.

Each party must develop a trusting, productive relationship with the other and clear accountabilities for the organization to flourish. If the relationship is not optimal, the entire organization flounders, as the CEO and management team struggle to meet new or unclear expectations from the board.

In the public and not-for-profit sectors, boards complete the accountability cycle back to funders and residents. And if you work in these sectors, you know how complex they are.

Patience runs thin for slower progress on strategies, when either the board or CEO changes. Boards organically change when their membership changes. Each cycle brings a renewed need to focus on the relationship and accountabilities as new board members offer their unique contributions. Yet sometimes boards and CEOs forget to put the necessary supports in place to ramp up quickly to a productive working relationship.

To successfully choreograph this dance, here are traditional and new approaches that have helped me leverage 3 keys: Listening, Learning and Leading, from both sides. I invite other CEOs and boards to retrace these steps as they forge their own paths to success.

Listening – From Meaningful Conversations to Generative Dialogue

An essential part of listening is having meaningful conversations so that we can uncover what’s really important.

Boards of Directors govern, while the CEO manages the organization. Yet both provide leadership to enable success, must meet specific accountabilities and make tough decisions.

Board decisions relate primarily to fiduciary and strategic issues. Understanding the context is essential for good decision-making and sometimes requires insight into operations. Structured reports and information can help but can only go so far. Meaningful conversation on issues fosters greater understanding. Coined by William Isaacs, as ‘Generative Dialogue,’ this kind of conversation is gaining more traction with some boards but is not yet common practice.

Generative dialogue mode enables the board and CEO, with their senior leadership, to delve deeper into an issue without overstepping each other’s accountabilities. Each party understands that the time spent on a topic must focus on listening to issues from all perspectives around the table.  The goal of the process is to reach a shared understanding of the context, before the decision is made.

One way I’ve found to achieve this goal is through scheduling educational sessions on topics of strategic or fiduciary importance prior to the board meeting and ideally a month or so before the decision must be made. This process allows board members to digest the information and complement their understanding with other reading/information before the decision-making meeting. In the limited time boards have together, we need to ensure they have what they need to effectively fulfill their role.

Learning – Using 360 Dynamic Feedback to Adapt, Grow and Thrive

Adapting what we know to the context of each scenario we land in is critical. Board members bring diverse skills from their professional and personal experiences and this diversity gives the board strength. However, applying these skills to board governance is different. For example, the way performance indicators are presented in one organization may not apply in another but they may work perfectly for a particular board and CEO. If you have an experienced information management professional on your board, they will apply the ‘nose in’ and ‘finger out’ concept, by asking questions to understand meaning and action plans without telling the CEO how to do their role.

Giving directors formal opportunities to learn about governance helps them adapt their knowledge to your board’s specific context. It is also important for the CEO to have a strong foundation in governance. Even better is learning together to create a shared understanding of best practices in governance.

Either way, learning through dynamic feedback is crucial. Good governance practices include the annual board survey, meeting evaluations and in-camera debriefs without the CEO to discuss board performance. These tactics may generate improvements to board process and even change the CEO and the management team’s expectations in a way that better supports the board or its priorities.

I think there’s another performance enhancing feedback process we usually miss:  Capturing how the CEO and senior management experience the board’s impact and effectiveness. CEOs change less frequently than boards but new board members change the context of the board/CEO relationship.

In welcoming feedback from the CEO and management team, boards role model the principles of continuous learning, which help us all grow.  To be effective, both parties should probe for tough feedback and follow through to make sustainable improvements. I believe we need to optimize the board/CEO relationship so that both can co-create the best future for the organization they serve. Then, at the centre of a successful public or not-for-profit sector organization, you’ll find a Board Chair focused on improvements and learning, as they adeptly share the CEOs feedback with their board

Leading – Uniting Leaders through Clear Expectations and a Solid Workplan

The Board Chair’s leadership makes or breaks the board’s effectiveness. While not always recognized as leaders, the Board Chair’s role determines the success of the board/CEO relationship. Their leadership must start with authentic intention and a genuine desire to serve the organization through their role. Of course meeting management, relationship building, communications and conflict management expertise make the Chair’s contributions even more effective.

Through its succession planning process, the board should define these skills as imperative and support aspiring chair candidates’ efforts to enhance these skills, during their tenure as members.

On the other hand, the Chair holds the CEO accountable for access to effective staff support to deliver on the board’s responsibilities. In setting expectations that the board will have good practices for doing its work, the Chair signals respect for the CEO.

Sounds wonderful but how do you achieve this balanced leadership? One tool I’ve found indispensable for making the CEO and board relationship most effective is having a comprehensive, annual workplan that:

  • Aligns with the organization’s strategic priorities
  • Fulfills its fiduciary responsibilities
  • Builds in generative dialogue time
  • Addresses the responsibilities of the board’s one employee: the CEO, President or Executive Director (through performance assessment, compensation and succession planning)
  • Accommodates its own governance processes (policies and procedures, board succession planning and board development)
  • Supports stakeholder engagement

Once developed, this workplan should serve as a central blueprint for the board’s work and the support needed from the CEO.

Boards play a central role in accountability. I’ve had the invaluable experience of seeing a community-based board step up to an enormous challenge and ensure that the organization it served flourished, even under extreme external forces.  This is how I’ve worked to master the dance between the CEO and board.

What works for you? I welcome your thoughts on these approaches to strengthen governance and the board/CEO relationship.

3 Keys to Make You a Successful Leader

Keys to effective leadership: listening, learning and leadingLeadership has been fundamental to our accomplishments for as long as we have shared stories of our successes and failures. Coordinating work or rather making the best use of an organization’s assets and the skills of its people, along with engaging everyone to advance a better future, drives us as human beings.

So why is effective leadership for positive change so challenging?

Frequently we hear people express their dissatisfaction with leadership. It’s hard to recall anyone writing about the thousands of exceptional leaders we have in the public or private sector. We tend to focus on the few outlier examples, positive or negative.

Different stakeholders express their expectations of leadership from their varied vantage points.

  • Clients/Patients/Customers no longer tolerate organizations that do not engage effectively with them, understand their needs and make a difference to their lives. We need to identify which principles guide our interaction with these priority stakeholders, particularly as this is our reason for being in health care or a service industry.
  • Employees are seeking a different work experience. The workplace is filled with different generations but it’s time to stop labelling them. Yes, we need to understand trends but each employee brings a unique contribution and their own expectations within a multigenerational team. In her “Body of Work,” Pamela Slim describes a workforce who sees their work and personal lives aligned with their drive, passion and values. How will we learn to lead in this environment? My experience in public service and complex environments, such as health care, suggests that it’s crucial for leadership to enable this alignment. This alignment creates a culture that retains talent, which is essential to success in any service or care industry.
  • Boards of Directors are challenged to understand a dynamic environment where they are expected to have their “nose in” but “fingers out” of the business. Can boards deliver on their accountabilities without duplicating the management function? Stakeholders are quick to lay blame if the organization fails to deliver on its mandate, as we have seen time and again. Balancing the governance accountability with the management/CEO role requires leadership in itself.
  • Funders expect their constituents to be satisfied. However, we have just begun to scratch the surface of understanding, through dialogue and big data, what constituents expect. How will we rapidly gain a better understanding so that we can be strategic and thoughtful about the changes we implement?

In previous posts, I have shared my teams’ successes, from working in a complex health care environment. These learnings also apply to other settings.

In upcoming posts, I am going to focus on what I believe are the important considerations for leaders to succeed in their roles. As Ontario’s employee demographic shifts during the next 10 to 15 years, leaders will need to get much better at rapidly learning how to effectively lead others and employees will need to ramp up their ability to collaborate.

I believe the following three attributes are keys to success, which I will focus on in upcoming posts

  1. Listening to gain insight – In my last post, I shared my perspective on how important listening is to our work with patients and families. A key part of listening is having meaningful conversations so that we can uncover what’s really important to our patients, so that we are in a better position to meet their needs. These listening strategies and approaches can effectively guide engagement with other stakeholders. I will explore how these strategies and approaches can improve interactions with boards, funders, residents and employees.
  2. Learning to adapt what we know to the context – Learning is a skill that must be mastered by individuals and organizations. In his book “Getting Everything You Can Out of all You’ve Got,” Jay Abraham addresses the issue of how to avoid the costly learning curve. He recommends we master the ability to borrow success practices from other industries and then apply them to ours. We need to understand that there are well established, proven ways to work with people to deliver what they as individuals need. The methods can be transferred. It’s coordinating the intervention or support and its outcomes that are unique to each individual. “Agile” is a term used frequently these days to describe how organizations learn and improve. It also describes the culture and leadership practices of successful organizations.
  3. Leading with authentic intention – In any business/sector/enterprise, leadership is essential to deliver on the mission or mandate its stakeholders set. In a guest Leadership Lab column I wrote for the Globe and Mail earlier this year, I described ways a leader can engage with their stakeholders to steer their organization through complex change.

Leaders will be successful if they listen and learn and apply that learning with their skills to lead an organization.

Recently Andre Picard wrote in the Globe and Mail about Dr. Philpott’s move from the health file to Minister of Indigenous Services. He listed the strengths she brings to her new, even more complex role. Among those strengths are many that all leaders need today. Most significantly for me he noted that: “her unofficial title will certainly be Minister of Social Determinants of Health.” Given our success locally incorporating this perspective into our strategies, I am excited to observe how this will impact outcomes for our Indigenous People and other areas of our health services. She will continue to “Listen, Learn and Lead.”

Please watch for upcoming posts where I will explore these three critical attributes.

What do you think about these three attributes? I’m particularly interested in hearing how, as leaders, we can more effectively lead multigenerational teams. What challenges do you face?