Abstract
Addiction and Mental Health Services of Kingston, Frontenac, Lennox, and Addington is emerging from years of fractured leadership and operational experiences to a new era of promise—with lessons learned along the way. A case study of change and innovation describes the journey Addiction and Mental Health Services of Kingston, Frontenac, Lennox, and Addington has been on since 2020, including making a transition from a Chief Executive Officer to a Joint Executive Leadership model to meet organizational needs, and adopting an approach to governance that is collaborative and integrates existing stakeholder governance representatives to mirror the current provincial Ontario Health Team vision of service.
Introduction
Addiction and Mental Health Services of Kingston, Frontenac, Lennox, and Addington (AMHS-KFLA) provides mental health and addictions services to clients within the local and provincial health system. It is responsible for the delivery of a complex set of services to support people with serious mental illness or addiction needs. The Government of Ontario funds it as part of the overall health system.
Addiction and Mental Health Services of Kingston, Frontenac, Lennox, and Addington is an agency experiencing a transformation, following a period with significant challenges. The Agency provides meaningful services to its clients, is resilient in the face of change, and possesses a spirit of courage to innovate and continually improve.
Research methodology
An analysis of current literature on models of leadership was conducted and applied where applicable in the work of the organization.
Background/historical context
In the past six years, AMHS-KFLA has experienced significant leadership changes and challenges. Table 1 illustrates key issues and change points during this period, with a chronological summary of key events and context for the current culture and environment. A more detailed summary of the table is included in Appendix A. 1 Please see the references at the end of this article for information on all appendices.
For a full job description approved by the board on January 27, 2021, for the Joint Executive Leadership, see Appendix D 2
Many of the changes over the six years were imposed from outside the organization. Since 2015, AMHS-KFLA has had six different Chief Executive Officers and has experienced significant financial challenges. It underwent a restructuring of its service model twice and experienced a difficult layoff process resulting in a reduced staff complement and a change in the administration model three times. In turn, this led to four different internal service structures and considerable turnover of finance, human resources, and information services staff.
The journey
The current phase of AMHS-KFLA’s organizational recovery and stabilization began July 1, 2020. The authors—Director Client Services, Director Operations, and Supervisor—embarked on this journey together.
Internal forces for change
Staff change fatigue
Anecdotal evidence from conversations with staff revealed they were having change fatigue due to frequent changes in leadership between 2015 and 2020. The absence of stable leadership notwithstanding, there was a compelling vision, mission, values, and strategic direction.
Loss of CEO and board
In 2018, the AMHS-KFLA Board of Directors and CEO were dismissed, sending a shockwave through the organization that was still evident in July 2020. The staff remaining in leadership and frontline positions felt they were on a ship with an uncertain direction. With the full authority of the board and CEO, the funder engaged a supervisor. The supervisor made changes in leadership and operations to address the financial crisis. This took the form of significant staff layoffs, an update and change in service delivery models, and disposing of property assets. The supervisor’s work was completed in June 2020 and a second supervisor—one of the authors of this article—continued making changes beginning on July 1, 2020.
External forces for change
Partners/Stakeholders
The perception of key stakeholders up to July 2020 was that AMHS was an island unto itself and uninterested in being part of an integrated health system. Partner organizations had little trust in AMHS leadership, and some felt the services were of inferior quality. It was important to address these perceptions head-on to restore AMHS as a key partner in care. AMHS leaders demonstrated a keen commitment to collaboration and integration and appreciated that working with system partners would enhance outcomes for clients.
Ontario Health Team
In 2017, Ontario Health announced a shift in direction from Local Health Integration Network lead services to a new model called Ontario Health Teams (OHT). Ontario Health Teams are developing over time. Their goal is to improve health services for all Ontarians by promoting and focusing on coordination, standardizing performance, measuring results in the context of the Quadruple Aim, 3 and integrating funding and accountability with re-investment in frontline care and digital support. Guidance and details on the OHT model were provided by the Ministry. 4
In July 2020, the Frontenac Lennox and Addington OHT (FLA-OHT) was in its application phase. Its guidance and work influenced the second supervisor’s thinking and approach. The supervisor joined the FLA-OHT Steering Committee, intending to bring AMHS into a conversation about an integrated health system.
COVID-19
Along with the OHT initiative, the COVID-19 pandemic forced the AMHS leadership to change how services would be offered. The pandemic created new opportunities and relationships with external partners to collaborate on solving a common problem in the community—homelessness of people with addictions and mental health needs. Organizations worked in partnership to provide self-isolation for homeless persons testing positive or experiencing COVID-19 symptoms.
Challenges converted to opportunities
Moving forward
By July 2020, AMHS-KFLA needed to achieve stability. The way to begin was to begin rebuilding the organization with the leadership team and staff in place at that time. The focus of the journey as it moved forward centred on embracing the corporate values of compassion, innovation, excellence, and accountability. In addition, there was a commitment to implement the three strategic directions: to lead and support system change, create an ideal individual experience for clients, and be a transformational organization that contributes proudly to a responsive addiction and mental health support system. 5 See Appendix B for the complete strategic plan, vision, and mission.
The leadership team incorporated “The Five Strategies to Support Your Employees Through a Crisis,” by Wei Zeng. 6 The five strategies are show appreciation; provide individualized support; involve employees in decision making; entrust employees with new responsibilities; and designate time and space for team building.
In addition, each leader participated in facilitated training to learn coaching methods to enable them to perform the jobs they were hired for. 7 When leaders put their coaching approaches into practice, all five strategies were leveraged. This became another platform for new and transformed relationships with partners.
In their research, Milner and Milner point out nine principles of the coach approach: listening, questioning, giving feedback, assisting and goalsetting, showing empathy, letting the coachee arrive at their own solutions, recognizing and pointing out strengths, providing structure, and encouraging a solution forward approach.
Milner and Milner’s research revealed that leaders were best at listening before the coach training and, following coach training, their listening skills improved by 32.9%. The research also showed that leaders struggled with recognizing and pointing out strengths, and letting the coachee arrive at their own solutions. 8 The experience of AMHS-KFLA staff mirrored this research. Putting the coach approach into practice represented a change for some of the leaders and for the staff they led.
Stabilizing AMHS-KFLA was critical in order to move from the negative experiences of the previous six years to a more positive future. Given the situation, the focus needed to be both internal and external. Leveraging the tools and resources of LEADS Canada, LEADS in a Caring Environment framework 9 for leadership in healthcare, each member of the leadership team completed a mapping exercise. The goal of this exercise was to determine where leaders needed to enhance existing relationships or build new ones within or outside the organization. The LEADS tool for the mapping exercise can be found in Appendix C. 10
Figure 2 identifies clearly where AMHS-KFLA needed to focus to build an integrated health system and be part of the FLA-OHT. Developing trustworthy relationships with the various partners and stakeholders was key.
For a detailed time line listing of events see appendix A.
Excerpt from Addiction and Mental Health Services of Kingston, Frontenac, Lennox, and Addington (AMHS-KFLA) mapping exercise results. 11
Executive leadership and governance were essential in building stability in the organization. Various options were evaluated, including amalgamating AMHS-KFLA with or becoming a subsidiary of another service provider. After weighing the pros and cons of what would be best for the organization, a decision was made to keep AMHS intact as a separate organization within the health system and recruit a board and appoint a joint executive leadership rather than hire a new CEO.
The potential impact of a new CEO on the organization was another important consideration for the Supervisor. In his article “Why Transformation Efforts Fail,” 12 change management expert John Kotter highlights the need to anchor changes into the corporation’s culture. He also describes the risks associated with changing top leadership in the midst of a transformation, especially if they do not identify with the new approach.
Joint Executive Leadership
The Joint Executive Leadership consists of the Executive Director, Client Services, and Executive Director, Operations. These positions report jointly to the Board of Directors with equal responsibility and replace the need for a Chief Executive Officer. The rationale for this approach is two-fold. First, it brings stability to an organization that has experienced so much change. The Joint Executive, although new to the organization in 2020, provides a stabilizing influence and consistent leadership into the future. Second, it prepares the organization to move into whatever the new FLA-OHT structure may be.
In the article by Gerzema and Johnson “Is CEO a Two-Person Job,” they state “trial and error have taught us four basic rules to position co-CEOs for success. Pick the right partner; set expectations; define roles and responsibilities and distribute authority but not responsibility.” 13
The shaded area in Table 1 displays the responsibilities the Joint Executive share equally in reporting to the board. The non-shaded area displays their individual responsibilities.
Collaborative governance board
In Collaborative Governance of Public Health in Low- and Middle-Income Countries: Lessons from Research in Public Administration, author Kirk Emerson defines collaborative governance as “the processes and structures of public policy decision-making and management that engage people across the boundaries of public agencies, levels of government and/or the public, private, and civic spheres to carry out a public purpose that could not otherwise be accomplished.” 14
Based on direction from the OHT, a decision was made to recruit a collaborative governance board to mirror what the FLA-OHT governance might look like. The AMHS-KFLA Board consists of nine members recruited through a targeted process. Recruitment focused on appointing one board member from each of the current boards of Kingston Health Sciences, Providence Care, and Kingston Community Health Centre; and one board member each recruited from AMHS Client Family Advisory Council, Queen’s University Faculty of Medicine, Indigenous public, primary care, Francophone, and public at large.
The AMHS-KFLA Board governs under the Addiction and Mental Health—KFLA, Ontario Corporation Bylaws. In keeping with the FLA-OHT work and the overall direction of Ontario Health, experienced board members were recruited who have a passion for oversight of AMHS-KFLA as part of an integrated health system and who are familiar with the addiction and mental health work of system partners.
The current AMHS-KFLA Board was formed in December 2020 and commenced its duties in January 2021. Although AMHS had previous boards, the latest board was positioned as a new chapter in the organization’s history. To that end, AMHS-KFLA Board reviewed, updated, and approved its governing by-laws and policies.
Evaluation joint executive leadership
The Health Services and Policy Research Institute at Queen’s University has been engaged to facilitate a process to evaluate the Joint Executive Leadership model in the fiscal year 2021 to 2022. The approach to the evaluation is collaborative. An Evaluation Working Group is established with participation from the AMHS Board, leadership team, managers, and frontline staff. The evaluation will seek to answer one overarching question, guided by two sub-questions: Is the co-leadership model effective? How and in what ways is Joint Executive Leadership being experienced by the Board of Directors, leaders, managers, and staff? And, are the leaders’ knowledge, skills, and abilities compatible with the Joint Executive Leadership model?
Data will be collected through targeted interviews, surveys, and logic model and stakeholder mapping. The goal of the evaluation is to learn from what has worked and what has not with this leadership model so that adjustments can be made to optimize organizational performance. The hope is that this unique leadership model will have provided the stabilizing influence that the organization and partners have been seeking.
Collaborative governance development evaluation
Given the AMHS-KFLA Board is new and comprises members from existing boards, the approach to evaluation is by establishing a Board Assessment Tool. Data will be collected from the board through individual interviews. The information gathered from the question “what will success look like at the end of year one?” will inform the board development plan. In the future, metrics will be identified to measure board performance.
Lessons learned
An environment scan through conversations with internal staff and external community stakeholders informed an understanding of the previous six years and the importance of listening and hearing the experiences of those who were interviewed. The authors accepted the results of the scan at face value. The past could not be changed, and the best place to focus was on the here and now.
The Joint Executive Leadership and Supervisor worked closely together, made decisions collaboratively, and kept each other well informed on issues, processes, and opportunities. The external health system landscape was evolving and changing. In their work, it was important that the Joint Executive Leadership and Supervisor keep this in mind to ensure AMHS, despite its past, was part of the process. Being intentional about what relationships to cultivate internally and externally was important. Minds were changed one conversation at a time and new directions were set and actions to address issues were taken. Building on the organization’s existing foundation and focusing on the vision, mission, values, and strategic directions, AMHS-KFLA began to stabilize. COVID-19 created opportunities to provide services in a new and different way, and stakeholder relations were enhanced to solve issues facing the community in a collaborative setting.
The authors learned the value of implementing the five domains of LEADS in a Caring Environment as a tool for transformation, 15 paying particular attention to the Achieve Results domain to Set Direction and Take Action to Implement Decisions. Based on research and leadership experience, the authors put into practice 10 action leadership skills that powerful leaders use to make decisions and achieve results: hire the right people, hold people capable that within them they have what it takes to make a decision, lead rather than manage—people want to be led not managed, use the coach approach to leadership, listen and reflect on what you are hearing, celebrate successes and learn from failures, build a culture of innovation, set clear direction, inspire action, and model the way—walking the talk. Implementing these skills made a significant contribution to AMHS-KFLA’s transformation.
For AMHS-KFLA, the change journey continues with renewed energy and focus. The board, staff, and leadership remain client centred and committed to the agency and its mission, including innovating and supporting an integrated health system.
