Royal Ottawa Health Care Group

Ken Shepard  Now our next speaker is also in the healthcare area, and it's George Weber. And George Weber is a fully engaged, committed CEO who was once Secretary General, president of the International Red Cross, still advisor there. And so for him to be on our he's been our Secretary-Treasurer for quite a while. For him to be on meetings, he's flying off here, flying in here, having meetings in New York, ducking. And he's still so passionate about Requisite that he's been on the board for quite a number of years and is active, he's engaged and gives good advice. So we love that kind of commitment. George is also unusual in that he's worked with Ron Capelle as a consultant in using RO in three organizations over many years. I thought that makes an interesting story. Okay, so with that, can I introduce Georgia and Ron?

George Weber   Ken, thank you very much for that very kind introduction. I recall what my grandfather once said, that he said, praise is like perfume. Sniff it, but don't swallow it, meaning that you're only as good as your last achievement. So it's a constant era of achievements day by day. Anyways, a little bit expands on what Ken said about my background. So I've been a Chief Executive officer for 32 years, so it kind of dates me. And I've run four different organizations over that period of time. And I'm currently in post. I'm currently the President and CEO of the Royal Ottawa Healthcare Group, which I'll introduce more formally, set the context a little later on. And three of the four organizations I've used requisite organizational principles and practices. The first one, I hadn't been introduced to it when I was first a CEO back in, back in 1983. And so it's been about a 20-year journey using Ro. And throughout this journey, Ron Capelle from Capelle Associates has been by my side throughout this whole period. So beyond being a professional colleague, he's become a close friend also too, and has helped me out of some very, very difficult situations, which we'll describe in a minute. So kind of following what was suggested to us by the organizers of the conference, we're going to kind of have a TED format and we're not going to show any PowerPoints. We're going to just talk and we're going to have a dialogue. We're going to set some context. And then Ron's going to ask me a serious question, a little bit like Warren. And I'm going to reinforce some of the points that John just gave about dealing particularly in the healthcare situation as we go forward. And again, dealing with three. And we're just going to touch the surface in all these three organizations. And hopefully, afterwards, we can have A Q&A and a little bit of dialogue on some of the challenges or certain areas that you would like a little bit more in-depth description on. So the three organizations that I have headed and currently one heading is first is the International Federation of Red Cross Red Crescent Societies in 94. I was appointed and took over in December of 92 but we started the design work back in 94. It's part of the International Red Cross Red Crescent, then the Canadian Dental Association which was quite a different organ, a different type of organization in 2000 and then currently the Royal Ottawa Healthcare Group which I took over in 2007 and started working on design and RO in 2008. And in each of those organizations, I was newly headed as part of the organization. In terms of the International Red Cross, I was the first Canadian ever to head that organization. It had been headed by many other nationalities before that period of time. Maybe, Ron, I'd turn it over to you to say a few words also too great.

Ron Capelle  Basically, as George said, in each one of these situations and going over the 20-year period the process was somewhat similar. We would come in and work with George and his group in doing an assessment. They'd make decisions on what they wanted to do and then we'd work with George and his group. In terms of implementation, I'm not going to talk about how we do assessment or how we do implementation. Tomorrow morning I'll be doing a keynote and I'll talk about both of those things. But at this point in time it's more the interest of these three organizations and their success of them. In two of the three organizations we also came back and did an evaluation. So not only were these interesting in themselves but George also had an interest in the evaluation and to determine on a little more objective basis what the outcomes were and whether they made a difference or not. So with that preamble then what I'm going to do is more or less interview George about these three. We'll go through each one successively. So we'll start with the International Federation of Red Cross and Red Crescent Societies. And as George said, this work started in 94. And George, I wonder if you could, if you could talk a little bit about the organization and why you decided to do something related to organization design.

George Weber   So I took over in December of 92 and of course had a year to kind of do my own assessment during 93 and in 1994 just a little bit about the International Federation. It is the largest humanitarian network in the world today. At that point, it consists of 149 National Red Cross Red Crest Societies and the central body responsible for directing and coordinating international humanitarian assistance and improving the capacity of national societies to take care of their own humanitarian activities in their own country. At that time we had about 5000 employees, about 300 at headquarters and the rest spread around in about 16 regional delegations and 50 country delegations. They were responsible for coordinating the activities of about 298,000 staff, and over 100 million volunteers, and aiding and assisting about 233,000,000 people worldwide at that point. Also, too, the Federation was directly responsible for assisting about 15 million people in 94. We also operated, which is a little bit more complicated, adding to complications. We operated in four languages. English, French, Spanish and Arabic. And we had 92 different nationalities working for us. 92. Big number. Tough when you're dealing with different operating cultures and trying to deal with RO and bringing these principles and translating things of this nature. So, why? Well, the main thing is that when I arrived, the gap between supply and demand was growing in 94, just remember, we were dealing with Rwanda and the consequences of the Rwanda conflict. There were hundreds of thousands of refugees in Tanzania and the Congolese and conflict all over the place. And we were dealing with the major situation in Yugoslavia, the breakup of the armed conflict in Exhugoslavia. Then we had many other operations that the media didn't talk about because those were the two focus points at that point. And we could see that the world was evolving and there was a real gap between supply and demand. And the complexity of the operations was increasing. In addition, along the way, the number of national societies was getting better things. And they didn't want the Federation to do the actual work. They wanted to support and to coordinate. And so the national societies were improving their capacities along the way, and the numbers were increasing. And so we had to customize the different services to each different country. So it was changing and evolving. The volume of information requiring specialization was increasing exponentially at that point, too. More demand for accountability, and transparency with the donors. And we were dealing in a VUCA world. You've heard this term before, VUCA, a volatile, uncertain, complex and ambiguous world. And it was increasing in leaps and bounds. And I also should say, when I took over, the organization had drifted. They had only an acting a chief executive for about a year and a half before I even got there. So again, when things happen, silos start the form and all the rest of it because the acting doesn't always take the same decisions that a permanent CEO would at that point. Great.

Ron Capelle  George, could you talk about a couple of highlights of the change process? There were some interesting, unique, I think relatively unique factors in terms of what changed and how that happened.

George Weber   Well, I think let me maybe deal with some of the success factors and then something that was unusual about the situation.

Ron Capelle  Great.

George Weber   Clearly. And I think this is kind of boilerplate man anybody that's gone through this kind of change process before, and particularly using Ro, it was important to have a strong internal team that will kind of lead the change made up of Frontline. We used people from top management all the way down to Frontline folks as part of internal teams and task forces supplemented again by Ron and his team who came in, who provided the outside knowledge and content urging and the methodology and all the rest of it. And having those teams, the external and internal teams, working together and being harmonious was a critical success factor in kind of moving it forward. When you're dealing with a worldwide organization, it's all about communication over communication. We know this is kind of boilerplate. You got to kind of and again operating in four languages and I speak three of the four, so we're getting around and the CEO's got to be up in front and center running around and dealing with not only with the headquarters in Geneva but around the world in terms of the delegations. And one of the things that you're dealing with in an emergency relief organization is the constant need to re-energize the process. When we were doing this change process the analogy would be painting the side of a destroyer at full battle stations in stormy waters, just imagine that people are focused on getting relief, trying to work at lives and this and that and you're trying to change and put structure into the organization. It's not always easy, takes a little bit longer and then you've got the barrier of multinationals working with people from all different cultures in terms of trying to get them to understand the stiff and they just don't have the knowledge and the background, the management experience to be able to deal with it. So the other thing that we did too that was unusual about this situation is that while we were trying to reorganize, we were also trying to develop a new strategic plan. So normally you do these things sequentially, you have a plan, strategic plan, and business plan, and then you kind of align your organization to deal with it. Well, we did in parallel and it can be done, it's difficult, but we did it in parallel. And I guess in terms of what was also unique is that there was so much compression in our organization we realized right away with Ron's help that we needed to move from a stratum five organization to a stratum six. There was just too much compression and so we moved from a stratum five to a stratum six was really an unusual situation and kind of dealing with that and then lining up the people just.

Ron Capelle  To add to what George said. It was the first time I'd been in a situation where strategy and design were being done at the same time and it was very interesting and it does work and it's a very interesting Iterative process. And in fact, what we found was that design drives strategy almost as much as strategy drives design. It's very much an Iterative process and if you have two groups that work together effectively, one can do that. I just want to add as well in terms of what George said in terms of moving from Stratum Five to Stratum Six, people now talk there's now a word for it. It wasn't a word back then. The word is upshifting. And what we found going in was that a Stratum Five organization was not sufficiently complex. It needed to be stratum six. These folks were dealing with the United Nations and all kinds of other large, complex, high-level organizations. And you've got to be able to operate at the same level. You don't want to be outgunned when your people meet with the other folks in terms of deciding these kinds of issues on a global basis. So the complexity was critical. Just one other question on that, George. The other piece that was kind of interesting was that if you could comment on that in terms of the functional alignment, you were clear about the strategy, but then in terms of the functional organization, it was really disparate and it wasn't organized in terms of the disaster response, on the one hand and the national society focus on the other. Could you comment a little bit on that?

George Weber   Yeah. And it's clear because there was a bit of a mixed system, a hybrid system before, and we did carve out total disaster relief, coordination and direction as one grouping, one division and the other division, national society cooperation and development. And of course, then you have to have cross-functional accountabilities related to that. The other issue, other big issue related to all of this too, is that given that the country and regional delegations were run by the disaster group, and when the disaster occurred, you had to have appropriate cross-functional accountabilities. In terms of the headquarters and with the appropriate people, the headquarters and the, you know, debating as who's in charge and with the specialization like that. Does the doctor report to the doctor in Geneva, or does they report to the doctor at the head of the regional or the country delegation? So you constantly had that kind of battle to kind of fix along the way too, which got fixed during this process.

Ron Capelle  Great, thank you. George was there for a number of years. He wanted to come back to Canada, came back, and had a position as the head of the Canadian Dental Association, so this would be in 2000. And this was a very different type of organization than the one he was in previously. And maybe, George, you could talk a little bit about what that situation was and what some of the challenges you had coming in.

George Weber   Well, the only one thing, I just want to go back to the Federation because there's a better outcome, which is the most important outcome for me along the way. Is that the ability? Back in 94, we talked about taking care of 15 million Beneficiaries, and in 99, five years later, we were able to take care of 30.2 million Beneficiaries. And for me, that was a real achievement to kind of be able to deal with that kind of narrow the gap between supply and demand which is a very, very important achievement for that organization at that time. Well, my reentry into Canada and I had to come back because for family reasons I won't get into it. So my reentry job was with the Canadian Dental Association which was a completely different, a much smaller organization. It was an organization responsible for representing the interests of the 19,000 dentists in Canada and kind of advancing the profession plus also promoting optimal oral health. We had a small I went from 5000 people to 60 people. And although it did have substructures accreditating bodies and we also set up a for-profit high-tech company. So quite a different situation. And so I was moving from the interesting thing, I moved from a level six down to a level four, a stratum four. And that was quite challenging intellectually, which I'll get into in a moment and I'll get into why I brought in RO at that point.

Ron Capelle  Yeah, on that one as well. George, why did you decide to do something with the organization design and what did you see as some of the key success factors in that situation?

George Weber   So I was a new hire and this was a little bit more a traditional approach because they had had a strategic plan. So it was really at that time they just finished strategic planning when I got there. Although the organization, again had been drifting, the CEO had been acting there for a year and so it was again, doing it sequentially, had a plan. So it was a matter of aligning the people to deliver on the plan. There had also been an internal KPMG report on the organization that was very highly critical in terms of effectiveness and efficiency in the organization. And there were some retirements and departures. So it made it a little bit easier to then use that opportunity to bring in Ro. And in terms of being a small organization, one of the success factors was we were able to and given they were all in one location, it was much easier to do RO because you could engage everybody. All the staff were involved in this with an internal team, same thing. External consultants working with an internal team and so on. Communication. So communication was easier because I walked around and saw everybody within an hour. So it was a much easier operation. The only thing unusual about that situation was that it was just a type of not-for-profit being that you can do RO even in a professional membership organization. And the results were better staff satisfaction, the members were happier and we were on a better financial footing too, along the way. So it was kind of a small interlude between two really big jobs.

Ron Capelle  It's a really interesting situation. We've had this in another case with a client going from a six to a four on kind of a temporary basis. And you kind of predict that there'd be a disconnect that you wouldn't provide the direction that was necessary. But one of the things you find is that if you understand this well enough and you understand what the problems are, you can sometimes mitigate some of the and I think in terms of George in that situation one of the things he did was he mitigated some of the risks in terms of getting down deeper to provide some of the direction that was necessary. The other thing is that the temptation in that kind of case, and we've seen it in these situations, the other temptation is that you're going to apply your full capability and you're going to overly complicate this organization. This is a nice stratum four organization. You don't want to overcomplicate it with all kinds of wonderful stratum six thinking. We had another situation with an executive who moved from being a Stratum six deputy Minister to running a Mint, which was a Stratum Four situation. And in that particular case, she really needed to resist setting up all kinds of future stuff going out ten years, which would have just driven people crazy. So I think in terms of both of those challenges that George had in that particular case, they were both difficult and both well, I should admit though.

George Weber   Ron, you probably know this, is that I did do some stratum five and six. It got me into trouble with the organization because I did come up with some futuristic thinking. We're 1015 years away. Dentists were saying, no, I just want to know where my next dollar is coming from here and keep the dentist out of Medicare in Canada. Forget about all this futuristic stuff, we're not interested in that. We want to know what you're doing for me today. So it did get me a little bit anyway.

Ron Capelle  That's good.

George Weber   Some of the thinkers of the group loved it, but you know, the majority happened, right?

Ron Capelle  So then in 2008, George moved to the Royal Ottawa Healthcare Group. And George, could you maybe talk a little bit about what that organization is and in that particular case, why you decided you wanted to do something on organization design?

George Weber   And I'll pick up on some of the things from John because I was faced with the same situation that John was with one of the worst performing hospitals in the national health system in the UK. So the Royal Ottawa Healthcare Group that I was brought in in a crisis fashion as an acting CEO, theoretically for six months because I had another job to go back to in Geneva. But they asked me to do this job for six months and then they hired me permanently. Royal Ottawa is one of the four standalone specialized mental health facilities in eastern Ontario with three different campuses. We take care of about 35,000 patients yearly, have over 660 beds, both community and inpatient beds, and have an employee workforce of about 2000, including a couple of hundred doctors. And doctors in Canada, unlike other places, are not employees, they're independent contractors for the most part. So it makes it interesting when you're bringing RO into all of this too, having these two separate lines. We also had a charitable foundation, a research institute, and given that we were an academic health science center, not only did we care, we do teaching, and of course do research and advocacy in terms of why we brought in our role. I came in and the organization was in crisis. In Ontario, and in other parts of Canada too, when an organization is in crisis, the Minister of Health has the right to put a supervisor in, fire the board, and fire the senior management team. And we were at that stage where the press was hammering because we were the first P Three hospital open in Canada, a private-public partnership. So some of all our hotel services were being run by the private sector. So they were all mixed when you talked about outsourcing too. The private sector is part of our management team, so it's a little bit different. And we were the first in the P Three hospital to open and it had its challenges. And the unions were jumping all over us about that. And they were in major financial difficulty and they had a leadership vacuum. Four out of the six top leaders, and vice presidents had left, either been fired or left. And they fired. Of course, the board fired the CEO and brought me into a crisis situation to deal with it so that they wouldn't be fired by the minister and a whole new board was brought in. So I was faced with a mess at that point. So the first job doing like John was to really kind of put your finger in the dike, deal with all the stuff that you had to deal with, put in temporary management to hold to kind of try to stabilize the organization. And then I asked Ron to come in, let's do a proper assessment here and then move in with George.

Ron Capelle  In that setting, what did you see as some of the key success factors and what did you see as some of the things unusual about that situation?

George Weber   Well, in this one here, again, it was clear that you needed really sustained CEO leadership. And this is where the CEO had to get really involved with, given the former one had been fired, was never around, and all the rest of it where you had to have done a lot of walking around and see, there was a lot of CEO involvement in terms of helping to kind of stabilize the situation and getting the organization ready to be able to deal with RO and convincing the management team because it hadn't been done. And when you have the doctors and the senior management constantly saying, well, has it ever been done in any other hospital? They're constantly looking, show us the comparators, always show us the comparators. We don't believe this is something for the private sector. So a lot of convincing had to be done to a lot of skeptical, very bright people who were skeptical about kind of the Iro methodology or practices. So a lot of work had to be done right at the front to be able to deal with that gain. We set up the same thing, a strong internal team, a very bright person, one of our high potentials took over as part of the internal team to kind of help drive this with external support from Iran and his team. But also along the way, since it was a highly unionized environment, over 80% was unionized. I also set up a kind of advisory group that was made up of union and frontline people who were brought into the tent learning, and teaching the methodology along the way so that they could also help us to kind of advocate where we were going with this situation. They met every couple of months and the internal team would report to them in terms of what they were doing how they were doing it and what the next steps were. And that was very, very important. Had this group of advisory group made up of frontline folks along the way. I will also say that the institution itself was ready since it had drifted for a couple of years. The staff was ready for some strong leadership and wanted to know really, where are we going and let's have some clear leadership as opposed to the siloed thinking and operations that we found that was unusual. Again, it's a multisite done in a hospital. It's rare that these things are done in hospitals, but it was done in the hospital. Highly unionized, although that's not different than many other cases a lot of you people have dealt with. But also at the same time, again, we did like in Geneva, we also were not sequential in terms of having a strategic plan and then aligning the organization. We did the strategy and the design in parallel at the same time, which was unique.

Ron Capelle  Okay, great. Anything else on that George, before we move to outcomes?

George Weber   No, I think that's all.

Ron Capelle  Okay, great. Could you talk about the outcomes then? There were a couple of different measures of outcomes in this particular case. Could you talk a little bit about that, please?

George Weber   Yeah. Clearly, we're a Stratum Five organization and that was made very clear in terms of dealing with the Stratum levels. What was really remarkable was the independent work-life studies in terms of 2008, where the baselines with the employees, and how they felt about the organization. For example, only 15% trusted the organization. At the end of 2010, 45% trusted the organization. And now it's even higher. At that point it's in a unionized environment where there's a lot of cutbacks in healthcare in Canada where hospitals are being, and particularly in Ontario, leaving in a zero environment. So it's a tough financial picture. So a lot of employees and unions don't trust you and like that. But we were able to move that trust factor, which is critical in terms of also putting an RO. We reduced employee absenteeism. We had a proper plan put into place with targets and indicators starting to use much more data-driven decision-making, which is very, very important along the way. And one of the big things in healthcare and particularly in the hospital sector is the incredibly high spans of control. What has happened in Canada and maybe in other areas, is that in order to protect patient care, middle management has been stripped out because you tend to want to protect the frontline folks, the caregivers and management. So we had managers, frontline managers, responsible for 100 and 2140 people at times. And we were able to bring the spans at control down to a more reasonable amount, still too high because you're running a 24/7 operation, but within our budgetary constraints. So we were able to find some redundancies in some areas in terms of dealing with the gaps that we were able to free up some positions to be able to put some more managers back in. Because hospitals, particularly in Ontario and in Canada, are probably some of the most overregulated institutions that you can find in Canada today. And so when you're overregulated, there's more people doing throwing regulations every time there's an incident, government puts in more regulation and you've got to have the administrative structure to be able to teach the front line and bring them up to steam on these regulations. It's very difficult when you got when you're managing 100 and 140 people and you got to do performance reviews on them and all the rest. So that was, I think, a major achievement. And of course, dealing with cross-functional relationships, again, fixing NEPA, but it's still a work in progress, I would say. It never changes. It's like maybe Leah always said, it's a semicolon and you constantly work it because of the turnover and things of this nature and changing environment, so that you constantly have to work at this.

Ron Capelle  George, could you also, in terms of outcome, take a look at a couple of things. One was the manager-direct-report alignment, a kind of pre-post, and the other was how the organization did on recommendations.

George Weber   Yeah, so the manager frontline folks alignment was at 20% when I think when we first the assessment was done and at the end of the implementation of the design, it was up to 97.5%, which was a real achievement.

Ron Capelle  The other one was the 30 recommendations.

George Weber   Yes, with 30 suggested recommendations. And one of the things that we did in order to re-energize the process, which I always think. You always kind of have to re-energize the process after a year and a half, two years of trying to move forward on it. We had 30 suggested recommendations. The senior management team had accepted all the recommendations. And at that point, about a year and a half in, we were, I think 30, think about 25. 30% had been fully implemented, another about another 60, 70% had been partially implemented and pretty well implemented today, now in 2014.

Ron Capelle  Great, thank you. I just want to underline one of the points that George made, the manager-direct-report alignment and span of control is critical, as we know. In hospitals in particular, there are these budgetary constraints. So you've got these high spans, but you can't add people in. So what we were able to do is find some mid-level positions that were individual contributors and have them start to manage people at the next level down. So without adding bodies to the organization, it was possible to add management horsepower and reduce the spans of control in the organization. So that was an interesting constraint that the group was able to get around in terms of making significant improvements in that area. So in terms of our comments, this wraps up that piece. What we'd like to do is open the floor for questions.

Gerry Kraines   I'm wondering if you guys can talk about two things in particular that are related to healthcare, maybe specific to Canada or one is the role of the physician, the physician leader, and how they fit into the management operating system. And the other one is the challenge that the unions impose on structure and restructuring and those kinds of efforts. I wonder if you guys could just comment on those two.

Ron Capelle  Great. So one part of the question is physicians, and the other part of the question is unions. George, could I turn that over to you, please?

George Weber   So, in Ontario and other parts of Canada, under the Public Hospital Act, physicians are not employees of hospitals, although in some cases now, and that is slowly changing. Now they are coming along in low numbers, but they are given privileges to operate in the hospital. In Ontario, physicians are the only ones who can at this stage, although nurse practitioners are gaining this right also, but physicians fundamentally are the only people allowed to admit and discharge inpatients in hospitals. So you need doctors on board. But the doctors having privileges and not in the kind of the management line, one has to operate with them a little bit differently. Although they are part of the teams, we do have a chief of staff who is part of the staff, and they would have a couple of assistant chiefs under them. And they kind of manage and lead the physicians. And the chief of staff reports to me for the quality work but also has the right to report directly to the board on the quality, the quality of care. So it is very difficult when a physician is misbehaving, so to say, in quotation marks, to get rid of the person because then you've got to withdraw the privileges. And to withdraw privileges is meaning, is taking away their ability to work. So it's a very difficult and convoluted process to get them to manage their behaviour, although that is slowly changing. Now we've been able to put performance reviews in for all the physicians and through clinical directors, heads of the program, which are funded partly through our global budget, so they work partly for the corporation. So it's slowly changing. But it's still challenging in that these are independent contractors that work for, that have privileges in our facilities and they are critical to any Ro. You got to bring them on board. Also, too, because they have so much influence in terms of how a team functions, a clinical team functions together and who they also have an influence in terms of the staff mix and skill mix, in terms of who they want to help to take care of the patient because they're ultimately accountable for the care of the patient. So they have to be brought on board. And they're not always and they're very skeptical about anything because they're used to having evidence base and show me the evidence. Show me the proof that this works. Show me the proof. This is going to make a difference to the clinical outcome of my patients by doing all this reorganization. So it's a constant challenge and that's why sometimes it takes much longer to convince some of these in a hospital sector to do RO because of all the convincing and work that you have to do to prove to them that this is going to make a difference. And we've overcome that. In terms of a union, it's the same thing. Unions are skeptical, but they see it as a way of downsizing because you have financial difficulties, you're bringing in RO practices and you're going to whack all of us and you're going to change all this. And we got all these privileges and we have these positions and these are the job that they do and all it can be done. But again, it's a lot of work in terms of because these unions are very, very powerful and the doctors have their own union also too. And the nurses in particular are very, very powerful and our largest workforce in the hospital sector are nurses and the unions are very, very powerful and any change has got to be negotiated up to the ying yang in order to bring this in. So it's a lot of work to do Ro, but it proves its worth and it is an excellent methodology, even for hospitals, notwithstanding some of these barriers that you've got to overcome.

Ron Capelle  Good. Thank you, Gerry.

Gerry Kraines    First of all, congratulations to both of you. I think this is groundbreaking work bringing RO into healthcare. And I'm very impressed and very humbled by what you've done. Most of the work that we've done with healthcare has been at the top two or three levels of the hospital and the medical staff. And we're increasingly being asked to look down the hospital organization. And what I have not been able to resolve in my own mind are the span of control between a nursing manager at level three and 60 RNS at level two. Because I cannot in my own mind see how a level three manager of nurses can be held accountable for the effectiveness of 60 nurses. And so for me, that represents a fracture. I don't have an answer for it, but a fracture in the accountability system. How have you thought about that? How have you resolved it? I'm really very interested. We know that the argument is usually, well, they're professionally trained, they're professionals, they don't need to have the supervision. But in any other organization, you might have an engineering department and a manager of engineers will probably not have a span of control of more than ten or twelve. And now we're dealing with lives at stake. How do you resolve that issue of an accountability system?

Ron Capelle  Do you want to take it first?

George Weber   I'll take it second, Gerry. That is the most difficult part. And it's not only just dealing with level threes, dealing with the level twos, it's also dealing with the level ones in terms of trying to deal with savings. One of the things we did do is to ensure what level twos would do, because level twos were doing a lot of level one work. So we had to get that right and to ensure that level twos were made sure that the work was done at the proper level was the first thing. So the next thing was that we had to have certain level twos and dealing with level ones and dealing with and supervising level ones and level threes, dealing with level twos. And clearly, the spans of control are in our place now. They're anywhere from 40 to 50. And it's not perfect. That's why we do performance reviews in terms of dealing with the people every two years instead of every year. You can't do when you're running 24/7 people, you can't do it every year. There are just too many people when you're running 24/7 operations. So we've taken a couple of the steps, and it's not perfect, and it's something that's still a work in progress. We haven't yet got that right, in my view.

Ron Capelle  So if I could add to that, it's a great question, and I think you've really kind of nailed the fundamental issue, I think, in terms of the outcome. The outcome, on the one hand, is suboptimal. On the other hand, it's better than it was before. And I know you agree with that in terms of your experience as well, Gerry. In terms of the changes what you tend to find going into a healthcare organization is that you've got the head nurse of the ward or whatever term you want to use for it, and that person's accountable for everyone. Well, if you start to look at the positions, there are some fundamental differences or should be between a stratum two nurse and a stratum one nursing assistant or registered nursing assistant or practical nurse. There are a whole bunch of different titles. So these should be more stratum two roles. These should be more Stratum one roles. The stratum three head of the unit is accountable for all. And of course, you've got that gap so that you get really suboptimal work from those folks at a stratum one level because of that gap. So one of the changes is to put in a stratum two manager for those stratum one folks. So that was part of a positive change. The other thing that we haven't done yet, and we actually did this analysis, we've done this analysis, I guess 15 or 20 times, but we haven't done it here. In terms of task analysis, what tasks are people doing? What we found is that professionals, we have 19 studies now, and professionals spend about 50% of their time doing lower-level tasks. You could pay someone less money to do just as well. The potential annual cost savings works out to about $10,000 per professional. If you look at and we don't have a study on this yet, but if you look at what the registered nurse does, who should be a stratum two physician, my hypothesis would be that somewhere around half the work is probably stratum one tasks that could be done by someone at a lower level. And so we're hoping at some point to be able to do a study like that. And it's ironic because on the one hand, healthcare is really constrained in terms of funding, but on the other hand, this is such a fundamental issue that goes right across healthcare and hasn't been dealt with yet. So I'm really hoping that we will have an opportunity perhaps with George to do some research on that and provide some data in terms of what my hunch is, is a tremendous opportunity to make healthcare better and also significantly reduce the costs.

Speaker E If you could repeat my question.

Ron Capelle  Yeah, thank you. So what Gerry is basically saying is that in terms of that broader span of control, in terms of the three two, it really is excessive in terms of being held accountable and in terms of providing effective managerial accountability and work. And we would agree at suboptimal Gerry's suggesting that maybe through the RO methodology, one could go to the policymakers in terms of saying, look, you think you're saving a lot of money, but in fact, here are some of the issues with that. Good point we need to wrap up. Ken's giving me the kind of get-off-the-stage sign. So thank you very much for your attention and questions. 

Thank you, George. 

Thank you, Ron.