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  • Writer's pictureDr. Sandor Demeter

Transforming Health Care in Manitoba or “The Fine Art of Muddling Through”

The views and opinions expressed in this op ed are my own and do not necessarily represent the opinions of any organization, agency, or other entity that I have been, am now, or will be affiliated with.

I have been a health care provider for almost four decades across four provinces, with the last two decades in MB. I have observed less than ideal health care transitions across the board. However, the public deserves to know what is happening in MB because, frankly, we suck at it.

In my own Department (Diagnostic Imaging – HSC) we have two Director vacancies which have been unfilled for over two years and one Director position unfilled for over a year. Interim or “acting” responsibilities have been bestowed to existing managers who are operating in an environment of prolonged uncertainty. Shared Health (SH) Senior Management has not shared the proposed organizational plan leaving staff and managers uncertain about what their roles will be.

Holding employees in limbo for over two years in unconscionable. It is hard to be an effective innovative leader when you are held hostage in prolonged transition states. Essentially you just “hold down the fort” until you know what the ultimate plan is and what your role will be.

I wonder if what is happening in my Department is a microcosm of the bigger picture in Shared Health?

Here are historic examples of poorly executed health care transition planning in MB.

Over the last two decades the Canadian trend has been to move from local to more central models of health care delivery. Both local and central models have their pros and cons, but these will not be discussed here.

The Winnipeg Regional Health Authority (WRHA) was formed ~ 1997 with Health Sciences Centre becoming an operating division of the WRHA in 2001 and being governed by the WHRA board. However, a policy decision was made to allow the other hospitals (e.g. St Boniface Hospital, Victoria General Hospital, Misericordia Health Centre, Grace General Hospital, Seven Oaks General Hospital, and Concordia Hospital) to be governed by their own faith based boards while still being funded through WRHA. The Grace and Victoria hospitals became owned and operated by the WRHA in 2008 and 2013, respectively.

Diagnostic Services Manitoba (DSM) was formed in 2002 and operated clinical laboratory services across the province and diagnostic imaging (e.g. CT and MRI) outside of WRHA.

The creation of WRHA and DSM resulted in a disjointed system that some described as a “half-pregnant mess”. Imagine trying to harmonize and coordinate services across multiple hospitals, and in the case of DSM, across multiple Health Regions, each with their own governance board with varying priorities and philosophical bents.

A good example of this fragmentation is that St Boniface Hospital (SBGH) is involved with WRHA’s Palliative Care Program but is not involved with the SH Medical Assistance in Dying (MAID) program.

For background, MAID had its origins in February 2015, when the Supreme Court of Canada ruled in Carter v. Canada that parts of the Criminal Code needed to change to satisfy the Canadian Charter of Rights and Freedoms. The parts that prohibited medical assistance in dying would no longer be valid. The Supreme Court gave the government until June 6, 2016, to create a new law.

In June 2016, the Parliament of Canada passed federal legislation that allows eligible Canadian adults to request MAID.

On February 24, 2020, the Minister of Justice and Attorney General of Canada introduced An Act to amend the Criminal Code (medical assistance in dying) in Parliament, which proposed changes to Canada’s law on medical assistance in dying. The final amended legislation was given royal assent on March 3, 2021.

SBGH took a faith-based position that it would not permit MAID in its institution which resulted in patients being transferred out of hospital to receive MAID services. One less than ideal patient transfer created sufficient angst amongst the SBGH Board that they voted to allow on-site assisted dying in “rare circumstances”. The decision was overturned two weeks later after the Catholic Health Corp. of Manitoba intervened by adding 10 new members to the SBGH Board to tip the majority balance in their favor. (CBC report)

This is an example where the MB government of the day did not have the political will to fully harmonize the delivery of publicly funded health care resulting in a fragmented health care system where “faith based” institutions could impose their values on patients who may not share the same perspectives.

Shared Health (SH) emerges.

One of the mantras going around during the formation of SH was that the MB health care system was “broken”, and that SH would “fix the broken health care system”. It is interesting to note that the executive team appointed to - “fix the health care system”, were the same executives who were responsible for managing the “broken” health care system. There is literature which explores the pros and cons of keeping the CEO post organizational transformation but keeping the whole executive team, especially by direct appointment, is unusual and noteworthy.

On June 28, 2017 the MB Minister of Health, Seniors and Active Living Minister (Goertzen) started the ball rolling on why health care transformation was needed by opining “Manitoba’s health-care system is complex and siloed, with eight independent organizations each doing their own planning, standard setting and service delivery in relative isolation of one another,” said Goertzen. “This is neither efficient nor effective and has been identified as a major impediment to improved access to quality health care and our ability to manage costs in a sustainable way.” (News release)

The journey to implement SH, previously called Shared Health Services, has been a long and winding road and we are still on the journey.

Compare the SH transition time lines to AB who collapsed their nine Regional Health Authorities and three government agencies into one agency, AB Health Services, in about a year (One province, one healthcare system: A decade of healthcare transformation in Alberta). Such transitions are not without push-back and criticism. Saying this, AB cannot be criticized about stretching their transition out over a prolonged period of time or doing it in a painful piecemeal manner.

The closure of the ERs at Concordia Hospital (CH) and Seven Oaks General hospital (SOGH) was a long drawn out process with “vague” communication about timelines (WFP April 29,2019). The Government of the day brought in their consultant (Dr. David Peachy) to review the hospital reorganization plans. Peachy concluded that the plan was still sound, but the timelines needed to be extended and he shared that he met with many stakeholders, including the Manitoba Nurses Union (MNU), who agreed with his position. The MNU was "absolutely shocked" and stated he misrepresented their position (WFP May 10, 2019).

Shortly after this, and to further add to staff anxiety, the government changed its mind part way through the process and changed the proposed CH walk-in-clinic to an urgent care centre. This left WRHA scrambling on how to staff the urgent care centre (CBC May 22, 2019).

Apt quotes form the afore referenced CBC article:

The sudden change has left hundreds of employees in limbo.

Employees who would have lost their jobs with the ER shutdown, or bumped employees with lower seniority to remain at Concordia, are now unsure of their standing.

I can imagine many of CH health care workers had already decided to retire, change career or bump/transfer into another health care facility.

Another sad example of poor transition planning was the closing of Nuclear Medicine (NM) services at SOGH. The closure was a prolonged death by a thousand cuts. It started with the NM gamma camera, which takes pictures for NM studies such as bone or heart scans, starting to breakdown on June 25, 2018. There was hesitation, and delays, in fixing the camera as management did not want to spend money for a department that was going to close at some unspecified future date (but soon?). This led to limiting the NM studies that could be done at SOGH. The result was longer imaging times for some patients and needing to transfer some SOGH in-patients to other hospitals for NM studies they could no longer be done in-house.

The SOGH NM camera continued to deteriorate until declared out of service on August 20, 2018. NM staff were kept at SOGH to close shop.

Unfortunately, there was a disconnect between coordinating the closing of NM and breast cancer surgery services at SOGH.

The current standard of care is that most women undergoing breast cancer surgery have a NM sentinel lymph node (SNL) study prior to surgery. This involves injecting a small amount of radioactive material into the skin of the breast to help the surgeon find and remove the first arm pit lymph node, i.e., the sentinel node, which drains the breast. This helps to determine if the cancer has spread to the arm pit without having to take out every lymph node and reduces complications such are swelling post-surgery.

A NM gamma camera is not needed for this procedure. As such, it was alarming to hear that SOGH management, despite being fully informed about the situation, would not allow the NM technologists to continue to provide NM SLN studies while breast cancer surgeries were still being provided at SOGH. The last breast cancer SLN procedure at SOGH was on Sept 7, 2019. After this date women having breast cancer surgery at SOGH had to first go to a different Winnipeg hospital to get the NM SLN injection and then drive to SOGH for the surgery. This was totally unjustified given that NM staff did not transfer out of SOGH until mid-October, and one could attend to SOGH for this procedure on an ad hoc basis.

What part of this was “patients first”?

WRHA/SH asked clinicians for feedback on the effects of health care transformations. I wrote up and submitted the SOGH NM saga and its impact on breast cancer patients. I did not get a response or even an acknowledgement of my concerns. I followed up asking for a response – I got nada!

So much for consulting and responding to the concerns of those on the front lines; just rhetoric and window dressing.

One of the missions of SH is to provide “Provincial Services”.

Has it “harmonized” the delivery of health care services, or has it created a more fragmented scheme?

SH delivers (with some exceptions) the following services: lab outside of the private Dynacare lab, diagnostic imaging (DI), MAID, breast health, mental health and addition, all clinical services at Health Sciences Centre.

SH does not directly deliver services at the other WRHA or provincial hospitals except for lab and DI services within these institutions. It also does not provide services currently being delivered by Cancer Care Manitoba (CCMb) which is truly a provincial service.

In the end, we now still have RHAs, including WRHA, and CCMb with their own executive teams and boards. We also now have SH, with its own board and slate of executives, who provide some service directly and others (e.g., lab and DI) within other institutions.

I will let you decide if MB’s feeble incremental approach to harmonizing health care services has resulted in better and more cost-effective health care delivery or to continued incremental muddling resulting in a perpetual “half-pregnant” mess.

I know that we are all in the middle of managing and responding to the COVID pandemic and COVID fatigue. In anticipation of the argument that: we are in the middle of a COVID pandemic so of course planning and implantation are delayed. MB’s health care transitions pre-dated COVID and the COVID pandemic is a poor excuse for ineffective health care transition by managers who have been at work throughout the period, especially when they do not have front line clinical care duties.

To conclude I want to return to the original message that ineffective change management has real negative effects on staff. Change fatigue is as real as COVID fatigue.

Change battle fatigue is the result of many elements such as past failures plaguing the minds of employees and the sacrifices made during the arduous change process. When a transformation is poorly led, fatigue can set in quickly. (Forbes)

“The Fine Art of Muddling Through” quote source (Linblom)

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