Dr. Kevin Smith: People Want the Context of ‘Why’

Cover art for episode 57 of Healthcare Change Makers with Dr. Kevin Smith

(Access show transcript) UHN’s CEO Dr. Kevin Smith doesn’t back away from the difficult questions: how is the hospital addressing burnout and turnover in their nursing population, the risks and potential of AI in healthcare, and investment in Canadian health research. But he’s also invigorated by the commitment his teams have to their patients and to each other, and the pride they take in working for a world-leading organization like UHN.

Show Summary

Today’s guest is President and CEO of University Health Network, Canada’s largest academic health sciences centre. Dr. Kevin Smith pursued his education in Canada, the U.S. and Great Britain, studying psychology, science, public policy and medicine.

If Kevin's had a frustrating day, one of his best experiences is talking to young people who are enthusiastic and filled with hope. He says the system is in good hands with the generation in training today.

Open forums and site visits are a regular part of Kevin’s life at UHN, and he sees the challenging questions he gets as a sign of a healthy culture. In fact, when he feels the news is too positive, he’ll precipitate a tougher conversation, asking people to tell him what they are scared of, and what’s not going as well as it should.

Mentioned in this episode

Transcript

Imagine you could step inside the minds of Canada's healthcare leaders, glimpse their greatest fears, strongest drivers, and what makes them tick. Welcome to Healthcare Change Makers, a podcast where we talk to leaders about the joys and challenges of driving change and working with partners to create the safest healthcare system.

Ellen Gardner: Welcome to Healthcare Change Makers, a podcast produced by HIROC. I'm Ellen Gardner with Michelle Holden and Philip De Souza. Today's guest is President and CEO of University Health Network, Canada's largest academic health sciences centre.

Kevin Smith pursued his education in Canada, the US, and Great Britain studying psychology, science, public policy, and medicine. Before moving into healthcare leadership roles, Kevin worked as a medical educator. He still teaches at the Rotman School of Management and the De Groote School of Medicine at McMaster.

Open forums and site visits are a regular part of Kevin's life at UHN, and he sees the challenging questions he gets as a sign of a healthy culture. In fact, when he feels the news is too positive, he'll precipitate a tougher conversation, asking people to tell him, "What are you scared of, and tell me what's not going well as it should."

Ellen Gardner: Welcome, Kevin. It's great to have you on Healthcare Change Makers. I want to start by asking if anything in your upbringing prepared you for leading Canada's largest healthcare organization?

Kevin Smith: It's a great question that I've never been actually asked before. I grew up in a little town in Eastern Ontario called Prescott. Very small, at the time it was about 5,000 people. Now, it's much less than that. So small town living meant you were very much involved in your community, where you looked after each other, you knew your neighbours. It was some years ago now.

I think my parents very much had a huge, huge impact on myself and my two sisters. My mother was a Brit by birth, my father Canadian of United Empire Loyalist background. So the expectation, from both of them, duty was very important in our home. You had a responsibility to do something if you took it on.

Very compassionate, so if people in our community needed help, compassion was important. Education and particularly science. My father was an engineer by background and interestingly as an industrial engineer, efficiency was something else that he would kind of drill into us in a good way. And respect, everybody deserved respect. People who were not as fortunate as we were, it was very important to recognize how fortunate we were and help others. And I think that's probably the small town Canada mentality of the generation. I was born in the mid-'60s and that was certainly what I felt loudly and clearly.

Ellen Gardner: So you grew up in a small town, but you left that small town probably to go to university and now you find yourself in a huge city. So you probably have a little bit of those small town roots still in you.

Kevin Smith: Those of us from small towns I think never escape those wonderful small town roots, so for sure, keep those and treasure them.

Ellen Gardner: UHN nurses and the healthcare system in general are experiencing complex challenges and most notably high provider burnout and turnover. UHN wants to address those challenges and essentially create a future that nurses want to be part of. So the hospital has just set out a five-year plan for reimagining the way nurses will be supported and celebrated. Kevin, can you talk about the plan and how it came to be and what are some of the elements in that plan?

Kevin Smith: I actually think this is the challenge of our generation in healthcare and that will be adequate health human resources with appropriate quality of work life, not only in Canada or Ontario or Toronto, but literally around the world. And so, as an academic health science centre, people who believe and fervently support research, our first step was go to literature, and there is a significant literature on quality of work life and nursing. My comments would apply to nursing, but also to all of the allied health professions as well.

I think the most important initiative, our Chief Nursing Executive, my colleague Pam Hubley, was very wise in ensuring that this collaboration plan was done with and for nurses and nursing colleagues. So I think what's really important was we started off with a listen: what are nurses frustrated by, what do nurses come to work to do, and how are we stymieing them in the system. How do we build up a future where nurses say, "I want to be part of that, I want to lead that," including creating many more leadership opportunities for nurses, who are by all means and experiences, leaders within our healthcare system every day.

I think at UHN, because of the unique nature of what we do and the peer group that we are fortunate to be in as a top 10% of hospitals in the world, we also need to think about positioning nurses and UHN as global leaders in their profession, in their disciplines. And that means expanding the role to include education, research, innovation. In a way looking a bit more like medicine has in the past in terms of career trajectory, career opportunities, professorships, research fellowships, postdoctoral studies, all of those things that I think has supercharged medicine. We need to create a similar path based on what we heard from our nurses.

And then, I think the other really important piece of this is creating a work experience to meet the multi-generational and diverse workforce that exists in Toronto. We are very diverse in terms of the number and generational breadth of people who work as nurses at University Health Network. And then, add to that with the great fortune of living in the world's most diverse city, we have diversity of professions, diversity of cultures, diversity of religion, and every possible manner. We are so fortunate to have that in Toronto.

And our workforce should look like those we serve, so increasingly being sensitive to what does that look like. If I'm a nurse who was educated in the Philippines as an example, how is that different and how do I bring those skills together while keeping that which you treasure as a nurse trained in the Philippines and marrying that to those things that we know are going to be good for patients and each other at UHN.

So I think the other is really looking at how we'll also extend nurses and others, but particularly nurses. And in many parts of the world when nurses are unavailable, we've looked at are there technicians, are there technologists, are there other unregulated providers who can extend the nurse's reach while taking his or her workload down a bit?

And for sure, because UHN is the only hospital in Canada that is privileged to have a health professional college within it, the Michener Institute for Education at UHN, I think it's incumbent on us to invent some of those new professions and also create some job progression for folks like our PSW colleagues who are often the heroes of the healthcare system. Last but not least, it's really about creating a team environment where nurses really feel valued and equal members of the team, and I think we're doing well. We can always do better.

Ellen Gardner: The fact that you've got the Michener Institute and you want to expand the resources and really engage nurses in a different way, has that been successful in terms of attracting a new population of nurses? Because I know there's a shortage of nurses, so are you finding that those nurses are there and that there's work being done on bringing them into the hospital?

Kevin Smith: We have reversed the drain in terms of losing more nurses than hiring, so that's the good news. The bad news is we're still seeing the number of nurses who leave us highest in the first two years of nursing. And as one of the most acute and highest intensity hospitals in the country, we've also gone back and looked at what can we do to better support those nurses, particularly who are early in their career trajectory in looking after very, very sick and complex people. And a large portion of that is making additional investments in mentorship, bringing back some of those recently retired senior nurses, not to do direct nursing care, they've decided that they've had enough, they've had a great career and were ready to make the transition out of direct nursing.

But to our great pleasure, many of these remarkable nurses are willing to come back and are willing to support their young colleagues and mentor them through those first couple of years in highly intense, highly acute settings where no one wants to feel that they can't turn to a senior colleague for help and support when you're looking after such sick people. That's also allowed us to adapt and transform the stresses and the agility within the team and rotate people in a way that allows their quality of work life and mental health and physical health to be prioritized as well.

Ellen Gardner: You started your career in medical education and I know that that's a big part of UHN. So before moving into leadership roles, education was your life and you still teach at the Rotman School of Management and the De Groote School of Medicine at McMaster. Since you started teaching, what do you notice about medical education that's different? What's changed with the students who are in your classrooms today?

Kevin Smith: Yeah, it's a terrific question, and like all generations, today's generation of learners across the health disciplines, including medicine, look like and respond to the priorities of their generation. I came from McMaster, which was the founding school of problem-based self-directed medical education in the '70s. I wasn't there then, but the founders, people like John Evans and Fraser Mustard and John Bienenstock and luminaries of that ilk, they really completely revolutionized the traditional curriculum to a problem-based self-directed learning model, kind of a Montessori for medicine, if you want to make it quick and catchy.

But I think then as now, we are seeing students with a massive social conscience, who are much more aware of population health and well-being than perhaps in the early days when I first started out, when we were very focussed on disease treatment, we're swimming upstream and students are asking about disease prevention.

Students are recognizing that your genetic code, while important, is no more important than your postal code. And we've known this for many, many years, but poverty, deprivation, early childhood trauma are among the most impactful issues on lifelong health. And I think learners today are extremely attentive to a policy framework of how we change well-being and that will result in changing healthcare.

I think students of today in the health professions, including medicine, have expectations of a great learning experience and I'm happy to hear and see them speak up when the learning environment isn't giving them what they want or need. They are more than ever mindful of quality of work life and appropriate work-life balance, which is I think superb. They're also in search of systemness, I'm not sure if that's a word, but they're very passionate about not being lone rangers on their own trail, treating an individual patient as an individual provider. And it's very important to them that it is a team experience.

And last, I would say both for themselves because we see a much, much, much more diverse population of learners and we see our patients becoming more diverse as a country of immigration. So equity, diversity, inclusion, are very important and vocal within the learner community today.

So I think we are in very good hands when I deal with young people. If I've had a frustrating day, one of my best experiences is going and talking with young people who are enthusiastic and filled with hope and filled with hopefulness that the system is in good hands with the generation in training today.

Ellen Gardner: That's great to hear. I'm sure you feel fortunate to have had your medical education in McMaster because I always knew McMaster was a different kind of medical school. And it's interesting how now it's really seen as a leader just in terms of the kind of medical education that students want today.

Kevin Smith: Absolutely. Well, really changed the world, right? Literally when Harvard became a medical education environment that recognized that we need to move to problem-based learning, they came to McMaster to learn about how do you do problem-based learning? And then, of course, it's just literally rippled around the world and is now permeating many, many other disciplines, law and other important disciplines. And I think the more we recognize that the better educational interventions look like the world in which practitioners will evolve, the more rewarding and the less jarring it is when one leaves education and moves into the workplace.

And we are seeing over and over again the importance of that transition that many young people who are leaving health professional training or business training or engineering training, if the move from learning to doing is less traumatic because they've had that experience throughout their training, it makes the stress for the individual dramatically different and frankly, the work environment a much more relaxed and enjoyable place.

The most important thing we do in education is learn how to learn, and there is no possible way a health professional could today learn all of the knowledge that exists. It is literally, doubling every four to five years in terms of new knowledge. So what is important is do you know how to get the information that informs you as practice evolves? Do you know how to engage with patients to talk with them about what their health objectives and outcomes are?

Gone thankfully are the days where I'm the doctor and I'll tell you what to do and you should do it. It is now learning how to engage with a patient about what their goals are, the issues of their quality of life, and what outcomes are acceptable to them.

Ellen Gardner: That's a good bridge to my next question about a new project at UHN that's looking for ways to integrate patient stories into clinical care. And the basis of this research is seeing what happens when educators move away from deliberate practice approach to encourage people to just have a more integrated approach, and really that's more about a thoughtful, deeper approach, asking more questions. Is that the way you see it?

Kevin Smith: I do. When I look back on my career and particularly as I've moved from working within first a medical school, then a hospital, then a health system, and now a health network. It really does change your lens. When you're managing a broader continuum, you're thinking about solutions differently. So if your responsibility is limited to when the patient enters the door of a hospital and when the patient leaves the door of a hospital, you can do a reasonably good job or as good a job as possible that flow permits within those walls. When you look and say, "This is about the entire continuum of care, this is about the entire experience of care for the patient and family and the provider community," then you think about wrapping care around both the patient and family and the provider at points of transition.

And when we talk to patients about when are they often most disappointed or frightened or feel adrift, particularly in complex or chronic health conditions, it is the points of transition where we often let them down. They'll hear from their primary care physician, you should expect this to happen, and then it may not happen, which of course makes the patient quite anxious. Then, they may hear from someone in the hospital things that they should expect. And if they don't happen in the way they've been described, again, we've weakened the confidence and frankness for the patient, and then again, at points of discharge into home care and other very challenging time and for some of our patients onto palliative care and long-term care.

So we have really embraced the model that says integrated care is about invisible points of transition both for patients but also for providers. So that making those handoffs easy and we're all patients, so you and I know as a patient, we actually don't really care who the provider works for, who signs their pay cheque. What we care about is am I getting the care and access and communication, and communication, number one, with our patients who say, "When do I feel adrift when I can't reach someone to talk to me about what I'm worrying about, when I can't find out why something that I expected to occur isn't occurring?"

So about 12 years ago, myself and a number of colleagues came together to embrace the concept of integrated care and said, "We're going to remove the barriers between the various levels of care and eradicate the view that we look after only one piece. We must look after end-to-end care." And it was some of the things extremely simple like a single telephone number to call throughout the care experience that you could actually get a person to talk to. The opportunity to have a standardized approach to care.

So for example, if you had something like congestive heart failure, that we'd know if your failure was exacerbated, well, what's the next step rather than having to track down a cardiologist, having preplanned that in a digital care path that would say, "We're going to change your meds because you appear to be having an exacerbation." We don't need to in an urgent situation, call someone. We've planned for these contingencies, we've worked with pharmacists, we've worked with physicians, we've worked with respiratory therapists, and we have the plan in place and we share it with you.

The other odd thing about medicine is we often feel a bit anxious about sharing the care plan because what if we don't do it exactly that way? Patients are fantastic quality assurance experts. No one is more interested than they are in whether or not they're getting the care they were promised. So I would say now that that process of care, that integrated care model is evolving into digital health, where we take what we're doing with maybe simple technologies and begin layering in some of the unbelievable digital health opportunities that truly allow us to take this on steroids and supercharge it for very large populations and use things like artificial intelligence and big data. I think that truly will be revolutionary in the practice of medicine.

Ellen Gardner: In a talk I heard you give a few years ago, Kevin, you talked about how Canada, really we should be proud that we can compete with any science enterprise in the world. U of T is in the top five medical schools in the world, and UHN is part of that family. And I know one of your personal missions is to push for more investments in science and innovation. You talk about investments in health as having the highest rate of return of any investment. So I know that you talk about this a lot, are you seeing those investments happening now or is this something that Canada still needs to get up to speed on?

Kevin Smith: I actually think that Canada has lost ground of recent, and I completely respect that the prime minister and the finance minister federally have many competing demands, especially after COVID. But when you look at the world's leading economy, science-based economies, and especially challenging when one lives next to the largest spender on R&D, the United States, it's very worrisome. So the National Institutes of Health, the equivalent of Canada's Canadian Institute for Health Research spends about 55 times more than we do. Based on our population, we should see that more like 10 times more than we do if we're going to remain competitive.

I think in the days of old, we thought about research for the sake of research. I think now we need to recognize that research is the lifeblood to a knowledge-based economy. Research is the lifeblood of commercialization in Canada, which leads to manufacturing in Canada, which leads to high quality jobs in Canada. It also leads to the development of services and goods, in our case, perhaps drugs, medical interventions, medical supplies that Canadians can get first if we're those leading research institutions as we are currently in which to maintain.

So for me, I think we have to help reframe the discussion that research investment isn't just about people in labs and pointy heads thinking about esoteric questions or intellectually stimulating questions, but people who actually build our economy.

The other piece we often don't talk about is at University Health Network, last year we spent $550 million on research, almost all of which went to people. And those are great jobs, and I don't mean for traditional academic researchers, physicians, scientists, and basic scientists, but they're staff, the technicians, the technologists, the unbelievable number of redevelopment and building projects that our construction sector has been put to the task of creating. Those are great jobs, unionized jobs, jobs that pay well and highly, highly skilled builds so that we have among the best people in the construction sector as well as the scientific sector.

So I think we have some responsibility to help our political and policy makers better understand research is the lifeblood of the future economy. It is the lifeblood of high qualified personnel. It is the lifeblood of building a civil society. And at the moment, we are falling behind. China as an example, is dramatically increasing the spending in research, much larger population, similar to many other G-15 countries outperforming Canada research investment. We really have to worry about reentering that brain drain we saw of the '80s, where people were being sucked out of Canada to other environments. I really worry about that.

I also worry about the fact that we don't really have a clear strategic plan that enunciates nationally where will Canada be among the best in the world, and I'm a biased individual. I know that that should be in life sciences. I know that that should be in science and medicine, but when you look at the whole STEM, science, technology, mathematics, engineering, there are so many opportunities for young Canadians and for immigration. We wish to be 100 million people by the turn of the century. If that's going to happen, we need to be a place for those high-quality jobs based on research.

Ellen Gardner: Is that something that can be turned around fairly quickly making these kinds of investments or you think we're looking at many years of trying to catch up?

Kevin Smith: I suspect it will take a great deal of political and public service will. It'll also take a great deal of passion from the electorate. One of my disappointments is when I think about elections of late, we had one in Alberta yesterday, I didn't hear, nor do I hear at the federal, provincial or municipal level, the discourse and the demand for discourse around health and research at a public policy level. What will the next Prime Minister of Canada's commitment to preservation of a universally accessible healthcare system look like and feel like? What is our dream for research and how will our political leaders enunciate that? And frankly, if Canadians don't demand to know the positions of leaders who wish to take on the big chair, then it'll be very difficult to hold those leaders to account.

Now, we have some responsibility in the field where we are at times too divided over that investment. So I think we have some work to do as do our elected and public policy officials. I don't think it's a one-time fix. We tried that when last we made some significant investments. It can't be bolus followed by an arid desert for years, then a bolus followed by another dry period. It needs to be not unlike the United States, an annual investment in research that keeps pace both with population growth and with inflation, as well as some very targeted areas where we know, for example, artificial intelligence, Canada is endowed with some of the brightest minds in the world. It is arguably the next industrial revolution. Why would we not wish to translate that into strong economic performance in Canada and beyond?

Ellen Gardner: Since you started in the CEO position at UHN, AI has made huge inroads and you certainly know that, and it's making a huge difference in healthcare. So I see that there are now many courses related to AI and medicine offered by the Michener Institute. I'm interested in how it's been received inside the organization. I know there's probably been a lot of re-training and can you say it's generally been embraced by the staff?

Kevin Smith: Absolutely. I would say there is a thirst for this to occur. Like every innovation curve, there are the leading adopters, and I think those are who we're hearing from now, the people who are wildly enthusiastic, the 20% who want to be two-standard, three-standard deviations above the mean, and just love this. As it becomes more normalized and standardized, I'm sure we'll see those folks who are a little bit below the mean, who have some struggle with change. But the vast, vast, vast majority of people, including patients, are absolutely astounded by the opportunity that this offers.

I think we've also gotten over, I see no sense of fear of being replaced by technology or artificial intelligence. I see people embracing that artificial intelligence working with humans can dramatically improve the healthcare and science experience and result. So I am wildly enthusiastic about that.

I also would say Michener and other educational offerings throughout UHN, people are overwhelmingly signing up for this. They're so excited about the opportunity, and because we're so fortunate to have remarkable scholars here who are leading the edge, leading edge on AI, people like Bo Wang and Mike Brudno and the list goes on, who are a bit agnostic to the discipline. Doesn't matter to them if the data is from cardiology or respirology or psychiatry or surgery.

Our approach, as you know, has been one of collaboration recently. We in the Mayo Clinic, Sheba Medical Center in Israel, Albert Einstein in Brazil, Mercy Health System in the USA have come together to really foster the data behind glass approach that allows us to keep our data but share the aggregation of data and begin looking at, for example, if you were in an ICU or I was in an ICU today and we put the coordinates of all of the data that's being measured and there are thousands and thousands of data points per day for an ICU patient, and it identified that you or I had a number of the features of the last 100 people out of millions of patients encountered that went on to have a complication.

We can intervene early, we can prevent that complication, and that obviously better for the patient, better for efficiency, better for cost, but most importantly better for outcome. So I think there is just such an excitement both in learning, and again back to the Michener, many, many environments, places like UHN are also saying, "Gee, we've never done this before.” Part of our structure is credentialing physicians to say they're competent to do things when there are brand new things like AI-aided practice.

We actually need the ability for educational institutions to say, "You are competent to undertake this work just as we did 15 or 20 years ago in robotic surgery." As robotic surgery came along, we needed to tell boards of hospitals who grant privileges, doctor X is in fact competent to practice robotic surgery and has gone through an educational intervention that ensures that they are up to the standard of Canadian practice.

Ellen Gardner: One of the things you do is you make a point of making site visits and UHN is such a vast network of hospitals and departments. And can you tell us a little bit about what it's like? Give us a feeling for one of these walkthroughs that happens when you go on a site visit?

Kevin Smith: Unfortunately, COVID interrupted one of the more pleasurable parts of my job, which is to go and talk to the people and the patients who are doing the work and receiving care and the scientists. And now recently of course, we're able to do so again safely. Nursing week has just passed. So myself and Pam, our chief nursing executive, have done a lot of rounding in the last few weeks and it is so invigorating again to see the team camaraderie, the commitment that teams have to their patients and to each other to a person. We heard them talk about what a great team they work on in their various units. Because UHN is such a vast place across acute care, long-term care, chronic care, rehabilitation, primary care, you name it, we're in it.

But it was fascinating to go and well, of course, people are tired and a bit stressed and everyone would love it if we had a few more nurses and a few more doctors and a few more environmental service colleagues to lighten the loads of many hands, they were so positive about what was happening in their program and so proud of being part of a world-leading organization like UHN. Now, I wouldn't for a moment want to suggest to you that we don't have hundreds of opportunities for continued improvement, and many of those great colleagues pointed out, here's what we're doing really well. But equally importantly, maybe more importantly, they also pointed out where could we do better? What would make a difference and to a person they started with our patients, what would be better for our patients and then what would be better for our team.

And losing connection to that communication, direct communication in my opinion, changes the organization from being focused on quality, safety, quality of work life, the patient experience to kind of administering a healthcare system, which I have no interest in doing. I think we're here to continuously improve the patient experience and the quality of work life experience for the remarkable staff who we’re fortunate to attract and retain.

I think the other really exciting part was seeing the diversity of team UHN. There are few places in the world in part because of the nature of our community, such a diverse city, but also because of our partnership with the University of Toronto. There's virtually nowhere on earth where you could find the same concentration and breadth of clinical and academic expertise. And we can bring people together from across literally every discipline. And I don't mean simply the traditional medical disciplines, but engineering, the arts, music, like many remarkable solutions that will be found in transdisciplinarity and interdisciplinarity. And it's so exciting to me when we see that kind of team form and those kinds out of the box solutions that truly brings the best of every discipline to the table and our patients and staff can benefit from that.

Ellen Gardner: You probably get a very different view of things when you do those visits just from, yes, as you say, seeing the diversity of people and different disciplines, and there's a lot of excitement around that. I just wonder if you ever get any difficult questions or unexpected questions coming out of those visits?

Kevin Smith: Oh, for sure. During COVID, one of the things I'm proud of is we had, we're one of the hospitals in maybe the world, but certainly the country, that had one of the most active communication systems. So we had open forums that anyone at UHN could join or frankly beyond, at least twice a week in the early days. And oftentimes, they were forums where we didn't have answers to the questions, like will we have enough supplies? Well, in the early days, we didn't know that. When will we get a vaccine? We didn't know that. Are some of the rumors about the vaccine, negative rumors about vaccine true? Doesn't appear to be, but that will require scientific investigation and that takes time.

So many, many questions then particularly out of fear, understandable fear because we'd seen such devastation in Europe, Southern Europe, and even New York, where we thought the first wave would be about shortage of ventilators. It came down to like most pandemics, really public health measures, gowns, masks, gloves, and social isolation. But we didn't know that at the time. So many of those, can you give me assurance questions.

Now, I would say the anxiety of course is will we have the resources that we need to catch up and will we have the people to attract? I think frankly at the moment, it's less about the money. Our government has been robust in investment, particularly during COVID. But as you know, if you have many, many vacancies of nurses, we can only ask nurses to work so much before we dramatically impact their well-being and quality of life.

I would say the majority of questions now is how will we balance the needs of our patients who we all feel profoundly committed to serving and as quickly as possible, especially in those diseases where they might be life-threatening in the longer term or your quality of life could be irreparably changed, but equally not make those people who provide that care ill from overwork.

So many, many challenging questions and I take that as a healthy culture at UHN. If you have an open forum or go into an environment and people aren't as the leader of the organization asking you some of those tough questions, we will often precipitate that. If it's been too, shall I say, a positive conversation, "Tell me what you're scared of, tell me what you're worried about, tell me what's not going as well here as it should." And that permeates from our board who also asks us to not spend time or all of our time on celebration, but on how can we be better, how can we improve what we do, how can we be and remain a top decile hospital in the world in every measure of success.

Ellen Gardner: I just wonder, Kevin, about, you had to answer a lot of questions you didn't know the answers to, and what changed for you in your personal leadership style going through that, what did you learn about yourself during that time?

Kevin Smith: You know what? I've been reflecting on that one a bit, like what's changed and what have I learned? I think one can never communicate too often, especially at times of stress and fear. It's okay more than okay to say, "I don't know the answer to that question. Here's what I do know and here's why I'm led to the following belief and here's the expertise." I think, and I include myself in this category. I think in days of old perhaps when I started out, there'd often be a request that would go up the pipe to "the leadership." And you might get a yes or no answer, yes you can, or no you can't. And I don't think that's an acceptable model any longer. I think if the answer is yes or no, people want the context of why, why did you say yes or no to that decision or to that direction. And I think people want much more accountability and transparency.

They also want frankness. So I'm grateful that some of my more dogged colleagues during the pandemic would push and say, "You know what? Kevin, that sounds a bit too political an answer. Give it to me straight. I really want to know what you think." And more and more and more, I believe that trying to give people straight, honest, simple answers is the right thing to do. Even if that answer is, "I don't know the answer to your question, but here's how I'm thinking about the problem." Very helpful.

The other piece I think is, and we're doing this more and more and more often in engaging people in what they think the right thing to do for the organization is. We made a very early decision on mandatory vaccination, which I know to this day not everyone agreed with, but we transparently said, "We are a science-based organization, we are responsible for the protection of staff and patients, and we must do everything possible to create the safest healthcare environment." And unquestionably that led to we need to make vaccination a responsibility.

That unfortunately saw a few colleagues leave University Health Network who disagreed with that decision, but the overwhelming majority of people and then the number of emails that I got as the first hospital in the country to make that decision absolutely demonstrated to me that it was the right thing to do.

I guess the last part to your question is we all get it wrong sometimes, I more than most. And people are extremely forgiving if you're humble about taking the wrong decision and being open to reversing that decision if it isn't the right one, or it doesn't enjoy followership where appropriate. Now, followership can be a bit overrated as well. I don't think we're open to debate on should we create the safest environment possible for patients. Our mission calls us to that, the needs of the patient come first. But beyond that, we're Canadians and negotiation is always welcome in areas where it doesn't put people at risk.

Philip De Souza: Kevin, I really appreciated how at the start of the podcast you talked about your family and I wrote the word down values like you talked about duty, compassion, and respect. And I just wanted to say admire that. And I also admired a little further on, you talked about when you are dealing with the, let's say the up and coming learners in healthcare, and you really spoke the words you used all about inclusiveness and hope, transparency, openness and learning. And then, I talked to myself, we're so fortunate, Ellen, Michelle, and I, we get to talk to, and Abby and Marc, a variety of leaders from across the country almost every month. And when I tell my friends or my family, I told my mom last night, "Oh, we're talking to you tomorrow." And she's like, "Wow!" And she was so amazed. She's like, I always wonder that, I'm like, "Oh yeah, these are just regular people." They're in charge of hospitals.

Kevin Smith: Mr. Churchill had the best saying, and I said my mother was a Brit and we spent many of our summers in Britain as children and visited frequently our extended family, my grandparents. And I love Mr. Churchill's not complimentary statement, “He's a humble man with a lot to be humble about.” And what I think we all have to be blindfold. We all have something to learn and we all have something to teach, but nobody has all the answers.

Philip De Souza: You must get lots of people who have misconceptions about, you and of course, all the amazing healthcare leaders across the country and who run huge healthcare organizations and help the system keep moving. So I guess my question, what's one question you received or a misconception or as you talk to those, to the up and coming learners who come through your hallways – a question that made you chuckle or that made you laugh or wonder like, "Oh, people have this perception of leaders." Is there one that has come your way that just brought a smile to your face?

Kevin Smith: And I can tell you one that brings a frown to my face.

Philip De Souza: Oh, okay.

Kevin Smith: Let me tell you that, and then while I'm blathering, I'll think about one that brings a smile to my face.

The one that brings a frown to my face is people who believe that those who are in leadership positions would ever think that money was more important than patients. And there'll be times when certain people will have the assumption that people in jobs like mine think more about the budget. Of course, I have a responsibility, a fiduciary duty, as does the board, to be responsible with public dollars and to live within our economic means. But money's just a tool and it's a tool to undertake exemplary healthcare, wonderful education of tomorrow's scientists and providers, and of course looking after people through research, education, and clinical care. So my blood always gets a little boily when someone says, "Well, I know you're really concerned about the bottom line." I'm concerned first about caring for patients, and then I'm concerned about whether we use our resources responsibly. So that I guess that would be the blood boiler.

The chuckle I think is maybe at times a misperception about how healthcare is funded, that you'll see people think that, well, you're doing more whether you need it or not because you make money at it. And it's quite understandable, people don't understand the economics of healthcare in Canada where we are, for example, globally funded on some things and our docs get paid on a fee for service, however much you do, you get paid for. And hospitals have the opposite funding model which says, we'll only pay you to do this number.

So, you'll occasionally get a bit of a chuckle when you're looking to recruit somebody and they'll say, "Well, if I come and I do more surgery for you, I'll generate you a whole bunch more money." And I chuckle and say, "No, you'll generate you a whole bunch more money, but they'll generate the hospital a whole bunch more expense."

So it is as is so often the case, understanding the incentives, fiscal and otherwise. It's a very complicated sector and few sectors and most of our board who are often business people are always a bit astounded when they come to realize physicians in Ontario's hospitals, Canadian hospitals are privileged, they're not employees. So they're allocating your resources, but they don't actually work for the hospital. They bill the government separately. And you know what? Working through that and making sure that we're aligning the interests of the funder, the interests of the patient, the interests of the provider, that's a daunting needle to thread some days.

The glass is half full. And for those of us, when I was in Hamilton, we had a mission in different parts of the world, including Haiti, started by the Sisters of St. Joseph of Hamilton. And one only needs to go to any part of the less economically advantaged world than ours and even large parts of the economically advantaged world to realize how fortunate we are to be in Canada, to have a Canadian healthcare system that is a top, UHN is a top hospital in the world, one of the top 10 hospitals in the world if you believe Newsweek. It's the only hospital on that list that says it doesn't matter who walks through the door, they'll get the same standard of care. And when you go elsewhere, even to remarkable and wealthy countries, that isn't true.

Philip De Souza: Absolutely. I'm so happy you ended off our formal part of our conversation with that. That's such a great way to end off and I'm going to pass it back to Ellen for the lightning round.

Kevin Smith: Okay. The lightning round. Great. I'm looking forward to the snapper.

Ellen Gardner: If you could spend the weekend in any city, which would you choose?

Kevin Smith: The first city that came into my mind is London. I know it well. I love it. I enjoy wandering it. I lived there for a while so I know I could see friends. The old adage, when one tires of London, one tires of life, I really feel that way about that wonderful city.

Ellen Gardner: What's the best or worst piece of career advice you ever received?

Kevin Smith: The best piece of career advice I ever received was love what you do, and if you have more days not enjoying going to the office or wherever you work, then days that you do, then you need to move on. Don't stay in a place where you are not finding joy and enthusiasm and stimulation. And equally, even if you love the topic, if you're not working with people who bring out the best in you and you bring out the best in, it is actually about having fun and doing good work and seeing results. So I think that's probably the best advice, that and focus and finish.

The other for me has always been particularly coming from an academic background, we can ponderously study, and you know what? At some day, you have to move from study to act and do and get results. You can't wait for perfection. So when you've got enough to go, go, and make things happen, and if things aren't improving, then readjust your plan quickly.

Ellen Gardner: How do you tend to feel looking back on your teenage years?

Kevin Smith: I have to confess, I'm not a big looker back. I love looking forward, but you know what, my life has been a privileged life. So if I look back now, I think of them as good years. I grew up in such a small town. I think when I intellectually remember it, I think that there were times when I thought, oh, it's boring here and I wish we lived in a bigger city. And you'd see things on TV, the few TV channels that you had in those days that looked so exciting.

And now, I look back with gratitude that, you know what, it was a simpler time and place to grow up and it gave you a kind of rootedness. It’s not that we all didn't have struggles as teenagers, the normal struggles, I kind of chuckle at them now and think, man, I wish I had the problems that I thought were insurmountable and devastating as a teenager today. But you know what, that's life, and I think most teenagers have that feeling. I look at teenagers of today and think, wow, they have a way more complicated, difficult life than I had.

Ellen Gardner: What books are on your nightstand right now?

Kevin Smith: You know what? I'm reading a book right now called The Match King, and it's about a financier who was a complete charlatan, who came from Sweden. And many of the flaws in our economic situation today are completely rooted in some of the craziness that he precipitated. Kreuger was his name. He precipitated on Wall Street just before the great crash in the '20S. I also just finished reading an Ann Rice book. So I love historical fiction, I love biographies and autobiographies. Kind of love, if the topic takes my interest, I like reading about it.

Ellen Gardner: Final question, what's your go-to when you need a creative boost?

Kevin Smith: My go-to when I need a creative boost is actually a day with my university buddies. And I don't mean just my friends that I grew up with in university, but people who work in universities and academic hospitals and just to say, "You know what? I'm frustrated and I need your wisdom and your thoughtfulness and critique and a good laugh as well."

Ellen Gardner: Well, thank you so much, Kevin. It's been such a pleasure speaking with you. Just really enjoyed having you on our program today.

Kevin Smith: Pleasure's all mine. Thank you for the privilege of chatting with you.

Ellen Gardner: You have just been listening to our interview with Kevin Smith, President and CEO of University Health Network. For more information about HIROC and to listen to past episodes of Healthcare Change Makers, go to our website hiroc.com. Thank you for listening.

Thank you for listening. You can hear more episodes of Healthcare Change Makers on our website, hiroc.com, and on your favorite podcasting apps. If you like what you hear, please rate us or post a review. Healthcare Change Makers is recorded by HIROC's communications and marketing team and produced by Podfly Productions. Follow us on Twitter at @HIROCGROUP or email us at communications@hiroc.com. We'd love to hear from you.