Organizational journeys to CLAS, Part II: Challenges and successes for implementation

ODABIDAMAGEWIN

“Odabidamagewin” is an Oji-Cree term which denotes “those who are our leaders.” Thus “Odabidamageg” is the approach to governance and leadership which SLMHC has adopted.

The Sioux Lookout MenoYaWin Health Center (SLMHC) is the primary Referral Hospital for the First Nations in North Western Ontario Canada. Our mandate is to improve the delivery of health services and the health status of our service population through:

·         Enhancing health services available to our northern communities
·         Building a new hospital in Sioux Lookout

SLMHC is also establishing itself as an Ontario “centre of excellence” in First Nations health care. We meet the needs of patients who historically have been serviced by other facilities in Northwestern Ontario and Manitoba. This culturally focused and designed health center promotes healthier lifestyles and helps to reduce some of the extreme disease incidence rates currently experienced.

The SLMHC catchment area services a population base of 30,000 people living in Sioux Lookout and 31 other communities. With the exception of Sioux Lookout and 3 proximate communities, the service area is vast, remote and isolated. It covers an area of 385,000 square kilometres (148,000 square miles), representing nearly one third of Ontario’s land mass.
More than 80% of the service population are First Nations people, most of who live in isolated circumstances. The only connections to hospital-based services for most of them are by telemedicine or by air. Consequently more than 80% of our patients arrive by air whether for ambulatory or inpatient services. 
For the most part, the hospital services had always been provided to these people without so as even a cursory consideration of their world view and their particular situations. This disregard for them was essentially a result of Government policies that governed them from the early 1900’s. As a result these people became highly marginalized and apathetic. In this context the Federal Government erected hospital that became known as the Indian hospital. On the other hand the Provincial Government ran a different hospital facility, among the First Nations people this was always known as the white people’s hospital.  As you can imagine such a public policy environment did not always produce good relations between the native people and the non-native people.

As a result of this demographic profile and makeup it became evident earlier on that direction and management of this new hospital needed to be different from your usual mainstream health care institutional leadership and management practices. What is striking and innovative about the experience in meeting this need is the way it was done. The management of the SLMHC focused not on the mainstream models of organizational governance and how they could be effectively implemented instead they chose to explore the dominant client base and their governance systems. For the most part, the governance systems of the First Nations of the area have evolved to entrench processes which are outlined in the Indian Act (a Federal Government policy outlining a governance system for First Nation communities). Nevertheless most of them have also opted to maintain the pre-Indian Act custom of including elders in their governance systems. Why is this?

• It produces stability in the community governance processes
  
• It passes on the wisdom of the elders to future generations
  

The elders who participate in these governances are very well versed in the ways of human relations. They have come to know that the principles behind human relations and behaviour never really change from one age to another. From this knowledge and awareness, they are able to figure out what advice to give in any given situation. This advice often proves to provide ways of maintaining of positive relationships.
The management and leadership of SLMHC recognized that to facilitate the sense of ownership of the hospital by the First Nations people as “their hospital” they would have to find a way to emulate or reflect the governance systems of these First Nations people.  Establishing an Elders Council would accomplish this. As a by product of this decision SLMHC’s organizational management system was enhanced.
In addition, the SLMHC recognized the governance process was to be different in how the board of directors conducted their business. The members came there with a clear understanding that they were there to represent particular interests. Rather than insisting the board members be selected on based on their related skills and experience only, SLMHC decided to reflected this reality. A description of this follows.

BOARD OF DIRECTORS

SLMHC is governed by a board of directors appointed on a “proportional representation” basis: 2/3 Anishnabe, 1/3 non-native.   The board also includes two physician representatives and an elder/healer.

Representational Appointment:  Board appointments are representational, and are not specifically “skill-based”.   Appointments are made by the Board after consultation with First Nations or sponsoring organizations.
Blended Model:  Board operates on a “blended model” versus a “governance model” or “management model” borrowing characteristics typical of both “chief and council” and conventional “hospital board” constructs.
Integrated Board:  The board operates successfully as an “integrated” board versus the nominal representation, liaison, consultative, advisory, constituency, caucus, or similar approaches tried by other organizations across Canada which have a mix of Aboriginal and non-Aboriginal members. 
CHALLENGES AND LESSONS LEARNED
Getting the First Nations community to become true partners in this social experience has been a challenge but recognizing their ways and culture and building these into the organizational culture has turned SLMHC into a success story.

1. The elder’s council has been very effective in guiding the SLMHC in developing programming that increases the quality of health services to the First Nations people. This has had the effect of engendering a sense of ownership of the organization by the First Nations people.
   
2. The elder’s council has brought stability to the SLMHC’s relationship to the First Nations political leadership.
   
3. The participation of the First Nations board of directors has increased.
   
4. The degree to which the board is “integrated”: First Nation members are not just advisory, consulted or token  - the interests of all people of the service area are represented
   
5. The Board now consistently achieves a quorum.
   
6. Board self-evaluations show 100% of Board members feel that Board time is well spent.
   
7. Decisions are made by consensus - only 2 decisions in 5 years have required a caucus, and only 1 has split along racial/ethnic lines: neither was problematic.
   

The path taken by SLMHC means many different things but for many people living in the area serviced by SLMHC it means that the very best of western medicine comes together with the ancient medicines and the healing practices to equal quality and compassionate health care.