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Lessons of Leadership with Dr. Jonathan Irish: The Success Story of Cancer Care Ontario.

Posted on March 12, 2020

Lessons of Leadership with Dr. Jonathan Irish: The Success Story of Cancer Care Ontario.

Yael Bensoussan, MD, FRCSC: Resident Physician, Otolaryngology – Head & Neck Surgery, University of Toronto; MSc (Candidate) Institute of Health Policy, Management and Evaluation.

In the midst of a major healthcare restructuring in Ontario, I had the chance to meet with Dr. Jonathan Irish, a head & neck cancer surgeon at the University Health Network. Dr. Irish was a pioneer in establishing wait time standards, benchmarks and reporting in Ontario in the early 2000s. He oversaw a process of linking funding to quality improvement initiatives in cancer surgery; a process that continues today, improving access to high quality care. We talked about health care leadership and mentorship, particularly in today’s healthcare environment. Here are a few lessons I have learned while discussing his incredible journey at Cancer Care Ontario.

(YB: Yael Bensoussan | JI: Jonathan Irish)

Lesson # 1: How to become a healthcare leader. “Great leaders will evolve into greater leadership positions. If you find great mentors, they will bring you onto their journey.”

YB: How did you become a healthcare leader?

JI: “I was a young surgeon who was interested in clinical epidemiology. When I was considering an application for a master’s degree in clinical epidemiology in the mid-1980s and particularly linking outcomes with quality of life I was greatly discouraged to do so.  I was told that it was “nursing research”. It wasn’t very popular at that time. So, I did my master’s degree in molecular biology, I graduated, and opened my lab. I didn’t feel I was thriving in that role because to succeed in that field, you need to be a full-time researcher, and I was a surgeon and it was difficult to compete when I had only 2 days of protected research time and no infrastructure support. In 1993, Princess Margaret Hospital underwent a big transformation project. The Princess Margaret commissioned KPMG, the consulting firm, to help develop and lead the project. They needed clinical leaders and although I was very junior in my career I was offered a 6 months secondment to help with the project. I was looking for a new challenge, and although I knew it would mean reduced income for a while, I jumped on the opportunity. This project gave me the opportunity to work with great healthcare leaders at the PMH and professional consultants at KPMG. This was the first time I was recognized as a young healthcare leader. In 1999, the position of chief of surgical oncology position became available at UHN. I was 40, the youngest candidate, but the most enthusiastic. I was selected and had the immense privilege to work under Dr. Alan Hudson, who was President and CEO of UHN, and Dr. Bob Bell, who later also became President and CEO of UHN and then Deputy Health Minister and many other leaders and mentors. You will learn that great leaders always evolve into greater leadership positions. If you find great mentors, they will bring you onto their own journey.” 

Lesson # 2: How to introduce a healthcare innovation. “There was a perfect storm. We used a healthcare disaster to create an opportunity.” 

YB: How did that lead you to your journey at Cancer Care Ontario?

JI: “In 2003, Alan Hudson was appointed as President of Cancer Care Ontario. At that time, it was an agency mostly focused on medical oncology and radiation therapy. Dr. Hudson was asked to reorganize the agency and improve wait-times for cancer services. Dr. Hudson also wanted to increase the surgical focus in the organization particularly since wait times for cancer surgery were abysmal. They needed a “surgical wait-time guy”. I remember a phone call from Bob Bell in December 2003 and he said “Alan is going to give you a call to take a job with CCO and oversee cancer surgery wait times for the province…don’t say no” …great mentors will pull you up. Within a few months, we had established target and benchmarks for cancer surgery in the province and were moving towards collecting wait times for every patient undergoing cancer surgery in the province and reporting it on a monthly basis by region, hospital and by type of surgery that the patient was having. Pretty transformative."

YB: How did your team convince the government to massively invest in improving surgical wait-times?

JI: “Well, there was a perfect storm. We took the opportunity offered to us by a disaster – wait times for cancer diagnosis and treatment were atrocious. Almost simultaneously, the alarming numbers made the front page of the Toronto Star and the New York Times, who’s headline mocked the Canadian Healthcare system’s access to care. To solve the problem, we had to engage our colleagues…our fellow surgeons as well as other stakeholders including patients. We first had to establish priority levels as well as time to surgery guidelines and standards. It was a huge endeavor.  We also had to understand that there was no high-level evidence for establishing wait time targets so really the targets were driven by consensus and common sense and, of course, guided by what evidence was available.  In the background of all of this a Wait Time Information System was created which collected “near real time” wait times for all hip replacements, knee replacements, cataract surgery and cancer surgery across the entire province.  This allowed us to report wait times for each region and each hospital with performance data to drive quality care improvement for cancer patients.

And then came SARS. The hospitals closed down for 6 weeks, and the surgical wait times for cancer treatment sky rocketed. The government needed to invest in surgical volumes that would reduce wait times in an environment where wait times were already too long.  There was a perfect storm. We used a healthcare disaster to create an opportunity. Cancer Care Ontario received 3 million dollars to purchase incremental cancer surgery volumes to improve wait time to surgery after SARS in Toronto. By then, we had the perfect set up to measure access to care in the province with the programs we had implemented…but we also know that wait times would ultimately be reduced so critical to our strategy was that the contracts that we established with hospitals was not just to perform the surgery but to report on quality and quality improvement for cancer surgery…in other words our mission was to improve ACCESS TO CARE AND ACCESS TO QUALITY CARE.   Every single dollar was spent to not only improve wait times but to improve the quality of care.

Another major initiative linked to this was to establish “centres of excellence” or as I now like to call it “centres of experience” for high complex cancer surgery.  We regionalized cancer treatment in thoracic surgery and later HPB surgery and now in head and neck, gynaecology and sarcoma surgery to make sure patients were directed to expert teams in “centers of experience”.  We also recognized that while this process moved “patients to quality” for complex cancer much more important was “moving quality to the patient” for more common cancers.  So, measuring quality of care performance in areas like prostate cancer, breast cancer and colorectal cancer was much more important, and we implemented the reporting of surgical quality metrics such as margins, lymph node retrieval rates and many other metrics that were directed in consultation with opinion leaders throughout the province.  As time went on the outcomes on both the access to care and the quality side of the ledger were so good that our investment went from 3 million dollars and peaked around 80 million dollars and finally CCO now oversees in partnership with the Ministry a 460-million-dollar budget linking volumes, access and quality of care."

Lesson #3: How to implement a healthcare innovation. “It’s called the herd effect. If you can get 70% of people going in the right direction, the rest will follow.” 

YB: Once you had the support from the government, how did you convince the surgical community?

JI: “At first, there was certainly some resistance from the surgical community when we implemented the quality reports. But I truly believe that all healthcare professionals want to give the very best care to their patients and want to better themselves.  I think we understood that health care providers often do not know how they are performing or what their target is, and they don’t know how they are performing in comparison to their peers.  So, understanding that “the most competitive animal in the medical kingdom is often the surgeon” and by a surgeon knowing their performance in comparison to his or her peers can have a profound effect on performance…something that I would call the “herd effect”. We also harnessed the “herd effect” by identifying opinion leaders in the community to help us implement the changes. If you can get 70% of people going in the right direction, the rest will follow.  We understood that quality improvement did not occur in the boardrooms of CCO but rather in all of the communities in Ontario.  We understood the importance of establishing opinion leaders or “champions” in each clinical area in each of the regions and they became the “herd leaders”. Another key was not to create a punitive atmosphere by publishing individual data, we only shared regional data at first and published hospital or individual data only upon request by the hospitals or surgeons themselves. A punitive approach would have led surgeons to choose healthy patients and “easy cases” to get better reports, which is why we were always reluctant to share reports publicly.”

Lesson#4: How to delegate leadership. “Quality of care improvement doesn’t happen on University Avenue. It happens in the chemo suite in Thunder bay, on the OR table in Timmins... it happens locally.”

YB: How do you think Bill 74 – The People’s Health Care Act will impact the mandate of Cancer Care Ontario?

JI: “As you know, the recent reform of our healthcare system has merged many agencies including Cancer Care Ontario into one agency--Ontario Health. I understand that the objective is to reduce cost by reducing redundancy of various administrative and management positions. I think that this objective is a commendable one. What worries me, is the operationalization of this change. While this is all in transition currently many of our cuts to date have included our public reporting of quality metrics and our regional leaders for surgical oncology who were responsible for overseeing local “Communities of Practice” and leading local quality improvement initiatives in our regions and in our hospitals.  Perhaps this will be just temporary as we transition into a new and larger agency, but I just hope we do not lose our ability to make an impact at the local level and that we do not lose the momentum and many of the things that we have moved forward over many years. That would be sad. What we need to understand, is that quality of care improvement doesn’t happen on University Avenue. It happens in the chemo suite in Thunder bay, on the OR table in Timmins, in the emergency department at North York Hospital. It happens locally. As healthcare leaders, we should not dictate standards and assume that the community will follow. Leadership is about training other leaders, who can report the reality of their regions and have an impact locally.”

Lesson#5: How to impact quality of care at a larger scale. "As a surgeon, I impact a few patients lives per day. A good healthcare leader can affect millions of patients at a time." 

YB: What is the next step for you in your healthcare leadership journey?

JI: “For now, I would love to continue being a surgeon, a clinician, and continue to really love the system management role that I play in our health care system.  I could potentially see myself investing more in a systems management position in the future. As a surgeon, I impact a few patients lives per day. I really believe that a good healthcare leader can affect millions of patients at a time. In that sense, I hope to have the chance to take part in the new Ontario Health system in the next few years."

To learn more about…

Dr. Jonathan Irish: https://www.ahns.info/public-profiles/jonathan-irish-toronto-ontario/, https://www.uhnresearch.ca/researcher/jonathan-irish.

Cancer Care Ontario: https://www.cancercareontario.ca/en/cancer-care-ontario/about-us.

Bill 74- The People’s Health Care Act: https://www.ola.org/en/legislative-business/bills/parliament-42/session-1/bill-74.

Wait times for surgery in Ontario: https://www.hqontario.ca/System-Performance/Wait-Times-for-Surgeries-and-Procedures.

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