Episode 07: In conversation with Dr. Brendan Carr

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As CEO of an organization that is situated in one of the fastest-growing communities in the province, Brendan is excited about the richness of that community and the importance of never losing focus on the delivery of quality, safe care.

Today, your host Ellen Gardner, Communications and Marketing at HIROC, speaks with Brendan Carr, President and CEO of William Osler Health System.

He had always wanted to be a physician, but Brendan Carr’s educational journey started in business when he acquired an MBA. That experience – and time as a commanding officer in the naval reserve – taught him the value of situational leadership and the power of leading through influence and seeking different perspectives and ideas from those around him. That belief has been reinforced as a healthcare leader, where he feels the best ideas and chance for impact come from the end user.

The opportunity to work in different healthcare systems across the country before coming to Osler has kept him curious and engaged. Brendan is acutely aware of the growing pressures on our healthcare system and the importance of not letting the drive towards greater efficiencies be done at the expense of quality and safety.


Ellen Gardner: Good morning, I'm Ellen Gardner. I work in marketing and communications at HIROC. And today we have the good fortune of speaking with Dr. Brendan Carr, who is the President and CEO of William Osler Health System. Welcome Brendan.

Brendan Carr: Thank you. Good morning.

Ellen Gardner: Where did you grow up, Brendan?

Brendan Carr: I was born in Windsor, Ontario, and then moved to Toronto when I was little. We lived around the Toronto area until I was about 12 or 13, and then my family moved to Cape Breton. I lived in Cape Breton for four or five years and then my family moved to Dartmouth, Nova Scotia where I went to high school and then eventually went to university. And so I spent most of my life on the east coast of Canada, but I was actually born in Southern Ontario.

Ellen Gardner: Okay. Well, that might explain why you've managed to work in practically every part of Canada – you’ve worked on the west coast and the east coast, and you moved back to Ontario. So how does the experience of living in all those different parts of Canada affect the way you see the healthcare challenges in this region?

Brendan Carr: I think it reflects just my curiosity, and part of what I get charged up about is learning about what we're doing. And so the opportunity to work in different systems has really been about experiencing it firsthand. There are certainly some takeaways. The systems across the country are struggling with very similar issues for sure – be those issues how we're dealing with the changing demographics of our population, the complexity of our patients, the changing demand as well as changes in terms of technology, consumer expectations, all that kind of stuff. And I would say with absolute clarity that the simple structural integration is entirely insufficient in terms of actually delivering on integration. That, at the end of the day, even in large systems that are designed structurally to create an integrated model, it still comes down to clarity of purpose, to clarity of focus, to alignments of all the different elements, it's still an ecosystem. It's still a very organic model, and it still requires the fundamental relationships to be in place to drive quality and to really focus energies on improving care.

One of the reasons I came here was that as we were doing work on the west coast to try to understand how we could make advances in terms of hospital to home or health links types approaches. Some of the best examples are here in Ontario, in what would be considered a non-integrated system. And so there is a learning there, which is the structure can help, but it's not all that matters.

Maybe with a bit of a critical lens, what I would say is I don't know that any system across the country has managed to address the issue of alignment of accountability and incentives across the entire system, including primary care, and all of the community elements. I think we haven't been able to see the fruition of integration because really without that alignment, it's really, really hard. The notion of accountability and clarity, I think is really hard to achieve.

So if you look at that same question from another perspective, in different jurisdictions there are different models. There are public models, there are public/private models that do achieve a very different level of integration. And I don't think it's the structural construct. I think it is the alignment of incentives and accountability. If you look at some of the high-performing organizations in the States for instance, the Cleveland Clinics, the Mayos, it's not really about the business model. It's about the fact that whatever they're doing, everybody that's coming to work every day, be it a physician or a nurse or another staff member or a leader, there's clarity around their goals and objectives, where their focus is. And their incentives are all moving in the right direction or in the same direction.

I think you can achieve that in public systems, in regional systems, in other systems. But I think it’s challenging to achieve in a purely fee-for-service system. I think that would be the one thing that most people would probably agree on.

Ellen Gardner: How much do you actually look at other systems, Brendan? In other words throughout your career, how important has it been for you to say, "You know what, this is what I've seen and it's actually working, so can we try and apply some of that here?"

Brendan Carr: I think it's hugely important and I think it's really the fundamental role of senior leaders in the system. I guess my opening position would be I love the public healthcare system. As a physician, I love what we do. And now as somebody who is a senior leader, I can no longer hide behind the fact that I'm not a senior leader. I feel also responsible for what we do or don't achieve as a system.

Brendan Carr: It's an interesting paradox in healthcare where so much of the care that we deliver every day, we're increasingly trying to understand how we should bring evidence into practice, how we should standardize, how we should do all those things. But, when it comes to the leadership of the system, for some reason we still think that we have to make it all up ourselves, right? And it's not getting us where we need to go and I think it's not being accountable as leaders. In healthcare, so much of the local conditions do matter in terms of what we actually achieve for patients. So it's not as simple as saying, well they were able to do this in this place, let's just take that and try to do it here.

I think the leadership question is to be curious about what they achieved, what were the elements or the fundamentals of it, and then ask the question so what could that look like in our environment?

Ellen Gardner: So you've been back in Ontario and at Osler for nearly a year. I just wonder what accomplishments are you proud of during this time? What do you feel you've been able to change and improve?

Brendan Carr: I would have to start by saying, I think I joined an organization that was very well-run and an organization that I think has accomplished a lot in the last ten years. So this was not a fixer-upper for me. I didn't have that sense when I joined this organization. I think what I've contributed to the most in the last year – it’s just been a year – is starting to establish clarity around what ‘the next’ is going to be for this organization.

And we've done that through a strategic planning process. We've done that through looking at our leadership structure and asking questions like what structure makes sense in terms of where we think we need to go as an organization and as a system. So, I think my biggest contribution has been more at the level of this organization has made a lot of progress in ten years; now where do we need to bring our focus to get to the next level?

The other thing that I'm really excited about is William Osler exists within a very interesting community, within a very interesting demographic. I think my favorite part of my job is actually getting to know and try to understand who the people are that we serve. Who is our community, and the richness that is in that. And there is such richness here. It's really gratifying.

Ellen Gardner: When you started in the position here, in your opening message you talked about, "As a physician in emergency medicine, I am passionate about the patient experience and the delivery of safe quality care." At HIROC, we are all about safe patient care, reducing adverse events. What has been the toughest part about fulfilling that commitment?

Brendan Carr: I think that is the toughest part for an organization like Osler, and many of our peers are experiencing this. This is maybe going to be a little bit pointy, but as health systems across the country we have been very focused on trying to find internally efficiencies (code for cost savings). And the reality is, from a quality perspective and a safety perspective, there is a tipping point between efficiency and safety.

As leaders we also have to own up to the fact that there are times that we're driving our systems for efficiency at the expense of safety, or quality. And it's actually the thing that I'm most concerned about as a leader to tell you the truth, because just being able to move people through is not sufficient. But I think because of many of the pressures that have been on our systems, we've been very focused on trying to do that.

At the same time, like in William Osler, we have one of the most rapidly growing populations in the province. When organizations go through significant growth phases, one of the greatest risks is that you take your eye off the individual quality for every patient because you're so focused on just bringing new services on stream, getting new physical systems working properly. And, it's almost like there's a risk that there's a degradation of quality because you're just focused on the volume and trying to deal with that.

I think we've had some very honest conversations about that as an organization. At William Osler, one of our main focuses over the last few years has been on this notion of getting back to basics with respect to quality. And I think that that's just a nod to the fact that for an organizations like ours, particularly organizations that are growing quickly, there's a lot of demands, there's a need for a drive towards efficiencies.

We really need to be very conscious and deliberate about surfacing quality and safety in those conversations and making sure that we're not doing things for the sake of efficiency that create risks for safety. I think that is a fundamental challenge for leaders in healthcare today.

Ellen Gardner: Can you give me an example of how you are making sure that the efficiency doesn't overlook the patient safety element? How are you doing that?

Brendan Carr: Yes. We were having this conversation at our senior table yesterday. So a good example would be, this organization spent I think 157 days in code gridlock last year. That's almost every other day, we were in what we would define as an extreme over-capacity situation, where by definition you have patients that you're doing your best to meet their needs. But I think we would have to recognize that just by virtue of that, of the volume, of that overcapacity environment, that there is inherently some degradation and some risks. Right?

We might not be able to change that for every single patient, but there are things like never events that we can keep clearly in focus. And I think that we as an organization should be very clear that we would want every practitioner in this organization to know that if we're in one of these extreme over-capacity situations and they're looking after a patient, that they would understand that if they were ever approaching a situation where they felt that their patient could be at risk of one of these never events, that the never event would always trump anything else, and that they would take whatever action they needed to take to ensure that that didn't happen.

Ellen Gardner: A key element of your leadership style Brendan has been to involve the public, and I think you want to ensure that the public and patients' families have input in the development of hospital services and programs. So why is that important to you?

Brendan Carr: To me this is also one of the real fundamentals. I'll give you three quick examples. Number one is making sure that we need the public's voice and we need our patient's voice to understand the things that really matter to them. So at Island Health in British Columbia we had created large community councils. In the northern part of the island, we imagined that we would go there and be focusing on particular kinds of care processes. When we sat down with the people in that community, what we understood very quickly was the thing that they saw as the single greatest barrier to care was accessibility.

Over a period of years, we ended up developing a local volunteer led bus that would actually get people to the healthcare services. That was a single most important thing that we could do in that community that was entirely driven by the citizens who are the patients and it probably had the most impact of all the things we could have done. And we would've never gotten to that as health leaders because we wouldn't have thought of transportation as something that was within our purview.

The second thing would be making sure that the way we develop services is actually meeting the needs of our patients. I remember in Halifax, we were doing some work to try to streamline our mental health services and there was a community program that was doing great work. I think the story goes something like this – there were clients coming into this mental health service, and essentially it was taking an entire day for them to work through multiple appointments.

We had the great idea that we could streamline that and max pack all of their interactions into an hour and a half. So we did this, and what we started hearing from our patients after the fact was that their satisfaction actually declined. What we didn't understand was it for those clients, the experience of coming, taking the day, and interacting was actually for some reason important to them, and it contributed to the experience that they were achieving. Our drive was around efficiency and what we thought was making things better for patients.

But in fact, the way it was received by the patients was that this is not as good as the way it used to be. I've now got all this time and I don't know what to do with my time. Whereas before, the cadence just worked better for them.

So making sure that the way that we're doing things is actually achieving the desired effect. I think it's really important. This is the third one – I love our system and I love what we're doing every day. And I'm more clear today than I've ever in my life that what we're doing and the way we're doing it is just not sufficient. As leaders, I think one of our greatest failures is that our focus has been largely on trying to achieve change through improving what we're doing today. I think we need to let our patients in and listen to other perspectives – patients and communities, so they can actually help us to understand how we can fundamentally do things differently that would actually be better.

I think that we just have to acknowledge that for those of us that are working in healthcare that are of this system, we have natural limitations because of our worldview. Our greatest opportunities for change, like creating real value and real impact, have to be co-created. And it has to be using design principles that are actually driven by the end user, not people who think they understand care process and are trying to design what they think would be good for the end user.

Ellen Gardner: You started out in your life as wanting to be a physician or thinking about medicine, and then you take a bit of a detour. You got an MBA.

Brendan Carr: Yes.

Ellen Gardner: So did you ever as you started down that business path think, "Oh, I like business. I could stay in this world"?

Brendan Carr: Absolutely. I did actually. I had always thought about doing medicine. I went to business school and when I finished my MBA, a very good friend of mine who went into dentistry said, "You're applying to medical school now. Right?" I really was enjoying (business school). And the way that I think about it is, this is a long time ago and high school was pretty binary. You either did science or you did something else. I don't know, because all I did was science! And when I went to business school, I got this opportunity to study economics, and organizational development, and operations research.

Literally, I felt like my brain had just exploded. It was amazing to see the world through different lens. When you actually take micro and macroeconomics, you start to have a sense of how the world works in a different way. And so it was powerful for me because it just opened up a whole different perspective in terms of how to look at the world and how to understand systems. And I think fundamentally I'm a systems kind of person. And so I've really enjoyed that.

For a heartbeat, I was thinking maybe I'll just keep doing this. And then my buddy poked me and said, "You always wanted to do medicine." I said, "Yeah that's right. I did." So I applied to medical school and I was fortunate enough to get in.

Ellen Gardner: But did you work in management at all? Did you work in the business world or you mainly studied it?

Brendan Carr: No, I studied it. However, I had the really great fortune of becoming a naval reservist when I left high school, and it was totally fortuitous. I was fortunate to go into officer training, and so I trained as a Mars officer in the Naval Reserve, and did my watch keeping certification and spent summers when I was going to university, either as a training officer, a navigation officer, and ultimately as the commanding officer of a small training platform, a small ship that was training other people to do navigation and stuff. My earliest memories of applying management or leadership skills was as a 24-year old captain, as a junior officer on a small vessel that had a crew of probably six or eight people, and their average age would have been 15 years older than me.

My earliest leadership memory is that working in very hierarchical environments, it was immediately apparent to me that if I tried to lead through authority as a 24-year old lieutenant, that was not going to really be successful for our crew and for what we were there to do. Situational leadership was one of the earliest things I learned, and the power of leading through both influence and just engaging the people around you, and how great ideas come out of that. I think my very earliest lesson in leadership was as a junior officer in the military. And it was about non-hierarchical leadership.

We all have our own natural tendencies or strengths, and I certainly think I lead better when I'm in engaging others. I have no problem as a leader being vulnerable saying, "Okay, I don't have all the answers," or, "I'm not sure that I'm understanding this well," or, "Does anybody else have any ideas on this?" That's when people light up. People in healthcare want to be successful. They want to do what's right for our patients. And so I think as a senior leader, when you create those doorways for people, they go through them and awesome things happen.

Ellen Gardner: That does sound like it's become an important quality for you in a leader, that you need to be able to involve people in the decisions. So being able to say, "I don't have the answers," has probably helped you.

Brendan Carr: I think so. And I think personally it's been a really good thing. I credit my wife with teaching me this because she pointed out to me a long time ago that wasn't the way that I was! But in seriousness, why does this leadership style matter today? It matters today because of what we were talking about a few minutes ago, which is if we thought what we were doing today was sufficient, it was getting the job done and we were all good, then fine. Go ahead and just carry on. That's not my belief. My belief is that we need to love this system, and we need to love it enough to let it evolve into where it needs to go.

I think we have to open ourselves, to be a learning organization. That would be a common phrase where it's not about just doing what we're doing today better, but it's actually saying part of our mission as an organization is going to figure out how to do new things and how do we learn to do new things? If it's really a new thing, there is no leader who can stand up and say I got it. You actually have to be open to this notion that okay, we're going to have to figure this out.

So either I can go away and try to figure it out myself, or I can try to unlock the greatest potential we have as an organization, which is all the great people that come here every day who have different perspectives and different ideas, and who are passionate about what we're doing. That's where the opportunity is for us. And so I think as leaders, we have to lead in a way that allows that capacity to be unlocked as a system.

Ellen Gardner: One of the things I was struck by was a reflection you had on the fact that it was your bedside experiences that really have informed your style as a leader. You're running a very large complex, growing urban organization. How do you stay in touch with that? Is that a very difficult thing to do to?

Brendan Carr: One of the things I loved about coming to Ontario and coming to Osler is it's actually more manageable where I can actually on any given day be at all of our sites. So I can have a presence there. I mean the large regional systems in this country, if you think about Alberta or think about Nova Scotia, even in BC where Island Health was one of five geographic regions, our geography covered the entire island to Vancouver Island. It was a six-hour drive from tip to tip and not to mention the Gulf Islands and things like that. It's really challenging in large regional systems for senior leaders to stay in touch because it's just a function of geography and scope, and things like that.

And the risk in that is that you lose contact with the people who you're serving, what matters to them, and the actual day-to-day experience that those people are having. We think about some of the great disasters in healthcare, like the mid-Staffordshire, where we know that one of the things that happened was the senior leadership team lost touch with their teams, their staff, and with their patients. It's not simply about appearing to be present. It's not just a tick box. You actually have to find ways to be able to observe, to interact, to ask questions.

The challenge as a senior leader is oftentimes when you walk through a hallway, especially when you're known as a leader, it's really hard to be able to do it in an authentic way, right? People try be their best in that. And so you really have to work at it. I think you just have to be out and around. I think it's about making contact with people. So if I'm standing in the lineup at Tim Horton’s, I'll have a conversation with a family member about what brought them to the hospital. And through that I sometimes get a little bit of a sense of how's your experience. Likewise with staff members.

I think about our emergency department. Like many organizations, we have a very busy emergency department. So if our emergency department has a really busy 24 hours or week, or month, you want to go down and pat people on the back and say good work. What we need to be doing though is going down there when they're not so busy and actually spending time, paying attention, and talking to them in those non-extreme situations – how are you as a team thinking about quality, how are you thinking about the patients? We tend to do it when things are extreme because we feel like we should show up. I guess we should, but I don't think that that's enough. I think that it really needs to be more. People need to know that what I'm really interested in is not just that they can deal with volume; I really want to know how they're thinking about the quality that they're delivering, the experience that they're creating, what are the things that are getting in their way.

Leadership rounding and huddles are some really well-developed approaches to this that just need to become part of the way that we do our work.

Ellen Gardner: Do you spend a lot of time yourself passing along your life lessons to someone else on your team?

Brendan Carr: Yes, for sure. Development is an active process for us as a team. That's something that people commit to when they join this team. That looks like coaching and mentorship individually. I've had a coach through most of my leadership career, and I would argue that coaching is something that I think is sometimes not well understood. Sometimes we think about coaching as when somebody has a deficiency, we're going to coach them up.

Brendan Carr: I think of it more as if we're really committed leaders and leading self is such an important dimension of leadership. It's very hard to do that yourself. Having somebody who is outside of yourself who can help guide you and can just ask you questions about yourself and help you to know yourself better. I find that incredibly important. I spend time with other leaders and I also spend a lot of time just having coffee with people.

I try to be as open as I can to young aspiring leaders in particular who are trying to figure out their own journey. It's the closest thing to direct patient care that I get to do now, which is to sit down with a young bright person and just listen to them and sometimes give them guidance. Sometimes it's just giving them reassurance and letting them know that you're on the right track and the work that you're doing is really valuable. It's very rewarding to do that.

Ellen Gardner: You must have a lot of pressures on you. How do you prioritize your time Brendan?

Brendan Carr: On any given day, it's challenging. I think one of the things I've learned is that there is a point in leaders' development where they have to own the fact that as a leader, I'm responsible for deciding how I'm going to spend my time. I have to make choices because I will never be able to do everything that there is a demand for and I just need to own that. I need to have some comfort with saying I'm not going to get everything done or be able to do everything that everybody would like me to do. I do have to have my own sense of priorities, and I think we all have to learn to do that.

If I fill my schedule with meetings from seven or eight in the morning until 6:00 at night, I can do that for stretches of time. But I'm fooling myself if in doing that, I think I'm actually delivering the value to this organization that I was brought here to deliver. The value that I deliver requires some time for reflection, introspection, to try to make sense of this complex environment. So it's actually okay as a leader to create something, like time when you can do this. To all my colleagues who say,"Yeah, well I do that at 4:00 in the morning when I'm getting on my stationary bicycle," I say awesome.

I would invite people to consider that the time and energy, and the quality of time and energy that we put into what is probably the most important work that we do, should be deserving of some of our best energy. And, maybe that's at 4:00 in the morning or 11:00 at night. I don't know. But for me it's not. I like to get on my bike early in the morning, but I'm pretty clear that that time is really for me to try to actually, if anything, clear in my mind, maybe meditate a little bit. And really be investing in me because I know that that's going to carry me through the day kind of thing, yeah.

When we talk about patient experience, what is that? It's the human experience that people are having. As leaders we set the tone. We might not believe it, but truly how we show up to work every day is important. If we show up as people and as human beings and as people who are living our lives, dealing with all the same stuff that they’re dealing with and are trying to do our best, I think that has a huge impact, and it plays out in our organization. That's how we get to humanizing the experience for patients.

Ellen Gardner: We've seen you and Catherine Gaulton our CEO, and Cathy McNeil together and you seem to be so aligned in your leadership style. What is it? Is it an accident that you guys think alike?

Brendan Carr: I don't think it's an accident at all. We grew up together to be honest with you. So Catherine, Cathy and I, we became senior leaders in the same organization together. I think we've had the benefit of not just spending time together, but working through challenging problems together. And I think that I certainly have benefited from Catherine and Cathy as friends and as colleagues hugely in terms of shaping me and many other people obviously. Our CEO at the time was Chris Power, who is the CEO of the Canadian Patient Safety Institute. So, I think we had a very special team. And under Chris's leadership, we had real clarity around our focus.

Ellen Gardner: Do you have any memories of some great advice that you received that has carried you through your life?

Brendan Carr: Absolutely. So I think the first advice was something that I learned myself that I referred to earlier, which was that don't confuse authority with leadership. And that great leaders seldom have to lead with authority. Great leaders inspire people, they create clarity, they create focus. They create a sense of urgency and accountability, and they unlock the discretionary energy that people have that if they come to work every day, they may or may not bring it. And great leaders just get people to actually want to really, really be invested in what they're trying to accomplish. So that's one thing that I think has been my greatest learning and I would share with people.

I think personally, training as a physician, you spend a good 10, 12 years getting to the point that you are an expert, right? And you almost have to back yourself out of that a little bit. Seriously, my wife helped me with this. You might be an expert in emergency medicine, which means if you've got a patient in a trauma room, along with the entire team that's there, you clearly have expertise. Don't confuse that with always knowing what's the right thing to do. Or don't confuse the fact that you're a smart person who’s been able to take on different challenges and do that. It doesn't mean that you're always right, that you will always have the best ideas, that other people don't have ideas that are really important.

So I think the other thing as a physician coming into leadership has really been, it's actually been about listening and it's really been about undoing a lot of the things that my medical training trained me to do, which was to think critically. That stuff is really important in that clinical care process. But when it comes to really understanding people, our system, how we need to change and how we support change, I think actually being curious and seeing other people as whole and inherently believing that other people have capacity and have ideas. Those would be the two things I would share.

Ellen Gardner: Thank you Brendan. A real pleasure learning about your leadership and your medical journey.

Brendan Carr: Oh, thanks Ellen. I really, really appreciate it and I've enjoyed it, so thanks so much.