Right-Sizing Health Systems: The systems-focused Children’s Hospital

Through visionary leadership, health systems focus, population-based approaches, trusting relationships, and creative partnerships, systems-focused Children’s Hospitals create integrated delivery networks purposefully designed to meet the unique needs of children and families. This serves to improve healthcare access, system navigation, and efficiency, and children’s experiences of care and outcomes. 

In this episode of SPARK: Conversations, join host Dr. Katharine Smart as she engages in a compelling dialogue with Alex Munter, CEO of CHEO. Alex shares insights from his extensive experience, highlighting innovative strategies and collaborative initiatives aimed at enhancing healthcare access and quality for children across Canada. This episode offers listeners a deep dive into transformative healthcare leadership, inspiring action towards a more equitable and sustainable future for pediatric care.

Transcript

Transcript: Right-Sizing health systems: The systems-focused Children’s Hospital

Connected by purpose. Driven by passion. This is Children's Healthcare Canada’s SPARK: Conversations podcast series. 

Katharine: Welcome to SPARK: Conversations, Children's Healthcare Canada’s monthly podcast series. SPARK: Conversations is one component of Children’s Healthcare Canada’s SPARK Knowledge Mobilization Program. During the 2024-2025 fiscal year, SPARK: Conversations has been and will be dedicated to Right-Sizing Children’s Healthcare Systems. Thanks to our SPARK: Conversations podcast sponsor, the IWK Health Centre for their ongoing support. I'm your host Dr. Katharine Smart and today I am absolutely delighted to be speaking to have our guest as Alex Munter. He is probably the person who coined the idea of Right-Sizing children's healthcare, so he's here to share his experience and wisdom with us and help us dive deep into what he's learned. 
 
So let’s tell you a little bit about Alex. Alex is President and CEO of CHEO (Children’s Hospital of Eastern Ontario), and has over 25 years of leadership in health and social services. Under his leadership since 2011, CHEO has transformed into a leading digital health institution, significantly improving wait times, safety, and efficiency. CHEO has received multiple accolades, including being named a top workplace and one of the world's best children’s hospitals.

Alex has also led CHEO’s role in pioneering health initiatives, such as the Kids Come First Health Team and the Kids Health Alliance, enhancing regional healthcare connectivity. He has been instrumental in integrating research into clinical care and advancing patient and family engagement.

Before CHEO, Alex served as CEO of the Champlain LHIN and Executive Director of the Youth Services Bureau, contributing to significant improvements in elder care and youth mental health services. He was also a City and Regional Councillor in Ottawa, where he led initiatives in public health, childcare, and senior services.

Alex holds a Bachelor of Social Sciences from the University of Ottawa, a Master of Science from the London School of Economics, and a professional designation as a Certified Health Executive from the Canadian College of Health Leaders. He has been recognized with numerous awards for his community contributions, including the Ontario Francophonie Award and the Queen's Diamond Jubilee Medal.

If this isn't enough, you can go to our website where his full bio is featured, because there's many more things that we could talk about with respect to Alex as well. 
 
 So, Children's Healthcare Canada is on a mission to right-size children's healthcare systems, from coast to coast to coast and across the continuum of care. Children, youth and their families are experiencing long and costly delays for essential and time sensitive healthcare services. We want to explore what this term means in real world context, along with what it's going to take in terms of collective action to change the way systems work, and interact and intersect. So welcome, Alex, we're excited to have you here today.

Alex: Great to see you again, Katharine.

 Katharine: So you have the privilege, or perhaps the challenge of having been the longest serving children's hospital CEO in Canada. So tell us, you know, you've been there since 2011. What have you learned? What is changed during your term? Where do you think we are?

Alex: Well, so, you know, I would answer that question differently today than in 2011. Because I don't think what I didn't realize, in 2011, that we were about to have many years of our system, the children's health system I'm talking about, standing still, in terms of capacity, while demand grew. And so, you know, when I started to about 2018-2019, we actually shrunk in terms of our relative size because of years of budget constraints and budget reductions. But at that same time, of course, we saw growth, population growth, here in Ottawa. Child and youth population is growing nine times more quickly than the Ontario average. And we saw growth in the burden of disease. So, you know, increased prevalence of everything from childhood cancer to diabetes, to colitis and of course, a very significant increases in prevalence in eating disorder, anxiety, depression. So you have kind of a double whammy right, a growing population with increased need. And the organization not growing with that. And so, you know, any healthcare organization, certainly a hospital. You know, think of it as a box. And the urgent, emergent care has to happen, keep coming through the emergency department. Children that need to be admitted, surgery that has to happen. And so that's the first thing that goes into the box. And if the box is too small, what happens is the plan and scheduled care doesn't fit. And so kind of through the course of my first eight, nine years here, right up to really the pandemic, what we were seeing was a very kind of steady, gradual decrease in capacity as there was more and more urgent stuff filling the box. And less room for planned and scheduled care. And then, of course, that really then escalated through 2020-21 When we had periods of closures and cancellations of clinic appointments to surgeries, to diagnostic procedures and more. And so what that led to was by, really, by 2022, in Ontario, and I expect it's not that different from the rest of the country, in the rest of the country. In Ontario, kids were waiting longer than adults for planned and scheduled care across all clinical streams development; rehabilitation, mental health, medicine, surgery, diagnostic imaging. And of course, you’re a pediatrician, you understand what that means. That can change the trajectory of a child's entire life. If diagnosis is delayed, if intervention is delayed, if, you know, if a child needs dental surgery, for example, as a toddler and doesn't get it for 18 months that can affect language acquisition. Children that are having trouble sleeping because of because they need their tonsils out and then waiting a year or 18 months. That's a school year and a half. Children with developmental disabilities needing first of all diagnosis, and then therapeutic intervention, you know, that are you know, those earliest years are gold in terms of of impact, and the you have less impact or slower impact, the later that children get access to care. So I think the big. Because it because that happened bit by bit by bit. It's kind of like, you know, boiling the frog, we didn't quite realize we were being boiled. And I, you know, I started in 2011. And, you know, within a few months of starting the government announced the funding freeze for hospitals, which had not been the case in Ontario, really, in 15 or more years. Right. And, and so, you know, that's. So the I think the big change is, we had a growing problem that we didn't necessarily recognize, quickly enough. The government certainly didn't recognize – the government contributed to. And the big difference now is, we understand there's a problem. You're doing a series of podcasts about resizing – right-sizing, rather, pediatric healthcare. And we're starting to see government respond.

 Katharine: Yeah, I think you've touched on so many things that are important for people to understand. You know, I think the first thing you mentioned, that's so critical is this idea of population growth. You know, I think what's misleading sometimes is because sort of the percentage of children is the population, has been relatively stable, but the actual total number of children is massively increasing. That, you know, when those systems aren't getting bigger, there's a lot more kids needing that care, and also just the fact that cares improved so much that children are surviving much longer with conditions that they didn't before. So that overall impact on the system like you're talking about, I think, is huge. And then so important, I think is that point of, you know, what happens when we don't address things in a timely manner for kids. And some of these things that on the surface maybe don't seem as urgent, you know, become urgent over time, or as you talked about, you know, have those developmental or lifelong impacts that maybe aren't super obvious right up front, and to making those connections, I think, for people, so they understand why these investments are so, so critical, so that children have that opportunity to meet their full potential. So it's wonderful, I think, to see that we're finally shifting into these conversations. And there's this awareness now that we need to really do something about this. And I think that stat that, you know, kids are waiting longer than adults across the board for services is shocking to people. I don't think that's the perception, you know, they don't think that

Alex: no, no. And, that's not a public policy goal. No, like there's nobody in government of any partisan stripe at any level of government that wants that, right. And so, and one of the reasons that happens, and not to get too geeky about the data, but one of the things that happens in Ministries of Health, is they look at population level data, for the whole population. And children are such a small part of the healthcare system utilization, that when you look at the whole picture, what's happening with kids is just swamped by the overall by the bigger picture. And so you might be in a situation where wait times are coming down for surgery, say, for the whole population, but they're actually going up for kids. Just not enough kids, that that would show up at a population level. So one, you know, one of the things I've learned, that's really important for the children's health sector is we do need, we do need data just on kids. Both kids health status, health outcomes and experience of the health system. Because when you do kind of a lifespan approach, you will, from you know, looking at the big picture, you're gonna miss it. And I think that's why I remember talking to Premier Wynn, when she visited CHEO, many years ago, seven or eight, nine years ago. About the fact that the funding formula at the time for hospitals, was actually taking money away from children's hospitals and redistributing it to adult hospitals. But there's so few children's hospitals, that it actually had a big impact on us. There's so many adult general hospitals, that by the time you disperse it, nobody had a benefit over there. And, and she was shocked. She didn't know that. Right?

Katharine: Yes.

Alex: Because it was a detail. Right. So that I think is those of us who, you know, advocate for children's health, we really need to advocate for kids specific data – programs of course and services, but also data tracking. And to your first point, you know, sometimes, I do a lot of fundraising for CHEO, and go to a community group or a service club or something. And, you know, one of the things I do is okay, how much do you think the children's population is growing? And people tend to do like a negative number, it's actually shrinking; is their guess, right? Because we hear a lot about the aging of society, which is absolutely true. And our health system has huge work to do to better support our elders. But, you know, people are always shocked when it was gonna be 1.2 million more kids in 20 years. And there are today so. So if that's like an entire Manitoba.

Katharine: Oh, absolutely. And like you said, right, being absorbed into a much smaller system, because there's only so many children's hospitals. That is population growth. Right. Yeah. It's not spread out the same way that the adult numbers are spread out. So I think that piece, the impact, much like you were talking about, about you pull some funding here, the impact is different. And I think how that gets communicated is so important. And I think your point about data, child-specific data, so that we know what we're talking about important. But I think what you've also been a really wonderful example of, and what I want to ask you a little bit more about is equally important, I think is how we communicate that data and what we know to the public, so that they feel compelled and understand what we're talking about. And even just the term, right-sizing children's health are, like, I know, you're one of the people that sort of, has really done a lot of work on how we communicate these ideas. So tell me a bit about you know, why that term? And what are other, you know, things you found from a communication perspective have been really important to, to actually get this message across to people who maybe don't live and breathe each day like you and I?

Alex: Yeah, and you're right, that, like, keep it simple, right. Like, it's got to be simple and clear. And some of our arguments are complicated, right. So I think we need to, first of all, I think we need to tap into the general goodwill that people have towards children's healthcare. And as per my example, the former Premier, who was genuinely quite shocked that was happening in her own government. There is no public policy objective to reduce access to children's healthcare, even if inadvertently. Public policy often has that outcome. And so I think it's operating on two levels. One of the things I've learned over time and I think one things we've done really well in Ontario, and Children's Healthcare Canada is really building something similar across the country - is sticking together and amplifying our voice because we are a small part of the overall system. So in the Ontario context, there's 150 hospitals. And there's, there's five children's hospitals, right? And so. So the five of us together are more likely to be heard and more likely to have impact than any of us individually. And so the pandemic actually helped with that, because we started, we've always worked together, of course, but we started really working together. In Ontario, so the five children's hospitals, the child and youth mental health centres, and the children's rehabilitation centers, which are called children's treatment centers here in Ontario. We started having a weekly call. And at the beginning, it was about, you know, just really practical things like, you know, visitor policy, PPE, those kinds of things. And then over time, as we compared notes and saw, and it was very apparent very early, that the pandemic was going to have a very significant impact on backlogs of care. And, and so, you know, we started working together to make the case around that. And it took a while, right, it took two and a half years. But then ultimately, we did secure, really, for Ontario, historic, unprecedented investment of $330 million per year, to increase the capacity of hospitals, mental health centers, and children’s treatment centers. And really, we pull that off by sticking together.

Katharine: Yeah.

Alex: And but because, you know, governments are not organized around or rarely organized around populations, right. So if you think of the Ministry of Health in Ontario, but think of the Ministry of Health in any province, you know, there's the doctor section, there's the hospital section, maybe his mental health section, there's a lot of different parts of the Ministry, organized programmatically and for lots of good reasons. But then we show up and say, okay, there's a population of kids. And their needs are interconnected. You know, the impulse of a bureaucracy is to try to slot that into the different into the different columns, and to have us say, which is more important. Right, is surgery more important than rehab? Is community sector, more important than hospitals? And so part of what we have to do is really explain why it's all interconnected. If you invest in surgery, and so we increase our surgical throughput, but you don't invest in outpatient rehab. What happens is the kids who just had surgery, because it's urgent, right, urgent goes first. They get their rehab, and the kids that have been waiting, who also need it, are going to wait even longer. If you don't invest in community-based mental health services, then more and more kids will end up in the emergency department. So here are CHEO, historically, one in four teens in crisis in the emergency department are back within six months. And that's an indicator of lack of community services, their access to those services, I should say. So you need to if you want to make a difference for the emergency department, don't just invest in the emergency department also invest in, for example, community-based mental health services. So kind of making that case. You know, we have to get people's head around it. But I believe we were successful, because we didn't let people divide us. We didn't say the need is greater at this hospital or that hospital, that surgery is more important than rehab. We said this is we've looked at it this is this is the investment that's required. It's required across all the clinical streams. I mean, advocacy, you never get everything you wanted. But we put in a proposal for $371 million and got funded at $330, so that's not bad.

Katharine: No, no, it's incredible. And again, I think what's so powerful about your argument, right, is really that health is an ecosystem, and you can't like divide it up. And I think that's compelling. And I think it's particularly true for children. And I think the other thing we know, you know, for kids that have chronic and complex medical illnesses; they also often have developmental challenges, associated mental health challenges, families that need support, right? It's hard to pull these things apart as the kids are complicated, and they live in complex environments, and those things are interrelated and so are their outcomes. So it makes so much sense. So you know, you've had that success of getting that really historic funding package, which is incredible. Tell us what are some of the things you've implemented, some of the solutions that are happening at your hospital. And what are some takeaways our listeners can have from some of your successes, that they might be able to take to where they're working.

Alex: Yeah, so I mean, it's early days yet, but some of the initiatives that we have been standing up, kind of in the lead up to, you know, to the announcement and then accelerated by the announcement would be things like our One Call One Click Program, which is one way in for roughly 30 child and youth mental health service providers. And so it's one intake, one place to go for intake, I should say. And then from there, case coordination, daily huddles, all referrals from school, other mental health and addictions nurses go into schools that are part of the program, education programs. So the idea is the philosophy is catch and hold, right so that once a kid comes in the door, they don't have to. We'll hold on - we the system, not CHEO, but CHEO and all of our partners, we will hold on to them. And we will figure out where they need to go and what the best services are. And we will coordinate with each other on that, as opposed to making the family do that work. So that's had great momentum.

And it's one of the initiatives of our Kids Come First Health Team, which has taken on a number of things. Everything from community vaccination clinics for routine childhood immunizations. That done I think, so far, and that started in the fall roughly 30,000 doses for kids that just, you know, 80% of them didn't have family physician and so. Making sure that, you know, the threat of infectious disease like measles, and other and other illnesses that are spreading all over the world, that we that we have better immunization. Urgent care clinics in the community, integrating homecare into our service system. And then within the hospital, a lot of investment, you know, in kind of new models of care and really trying to optimize everyone's scope of practice. So we have way more nurse practitioners now for example, which is really helping us the backlog. They team up with physicians. We, you know, interestingly, for many of our mental health programs very, very hard to find psychology. Psychologists to work in hospital. And so how do we build team-based care and optimize other professions when we can't find enough psychologists, for example.

Anyway, like all across the board, and so a lot within the hospital, but really our focus in many ways outside the hospital, right? So for example, in this region, unlike other places in the country, but in this region, there really isn't a lot of pediatric surgery, day surgery, or any kind of surgery. But in this case, day surgery outside of CHEO. And so if we really want to make a dent in surgical backlog, we need to have more ways in, right. And so we've created a reach through Kids Come First, regional pediatric surgical program. We have our first two rural hospitals on board. There's many more lining up to join. That where really it's GP, anesthetists, local anesthetist, the nurses from those hospitals with equipment and training support from us. And then our surgeons go out and so you know, that's a model for increasing capacity. We're thinking in these ways, working with Indigenous communities around priority areas they've identified which particularly are around mental health and developmental services and access to culturally appropriate care and dental care actually. Particularly for Inuit kids. Ottawa having the largest Inuit population in the South and being the referral center for the central part of Nunavut. And so working on that issue, you would know of course, dental surgery is the number one surgery by volume in CHEO and most children's hospitals. So lots of lots of kind of practical, tangible solutions that this investment has expedited.

Katharine: That’s amazing and you know the theme I'm really hearing of the work you're doing right, it's about relationships. It's about building partnerships. It's about thinking outside the box in terms of who can do what. And also what I love, you know, you're at a children's hospital, I work as a pediatrician in a rural community. That idea of how do we work together? So, you know, how do you see the role of the children's hospitals in terms of connecting and working with more regional and rural hospitals in terms of serving children?

Alex: Yeah, totally. So for example, a great example is the regional pediatric surgical program, which our first two sites are in Carleton Place and Brockville. And you know, and we've got many more rural hospitals ready to go. We are engaged in conversations. There are community pediatricians and family physicians who see kids throughout the region. And how we can better support them, both in small ways in terms of access to information, for example, but also in bigger ways in terms of access to resources. And so, you know, really the goal is to build as much capacity as we can, and we are better able to do that because the resources we have then are many other organizations. And, and I think what we have, you know, there's all these kind of unintended negatives and positives that came out of that pandemic. One of the kind of flukes of it all was we, we spent a year. We spent 2019, building the Kids Come First Health Team, getting a governance in place, and partnership agreements and getting to know each other. And then we had a plan to things we want to do things like One Call One Click, but then the pandemic came along. And so then we just had to, we just put our plans away. But we had a structure. So we just started doing things. Isolation centers, getting PPE, respite care for kids with disability, developmental disabilities. Immunization. Like there's some 20 different projects involved in almost all the partners. And so, to your point about relationship, you know, we had a VP here who was an occupational therapist, she would always say, “adults learn by doing not by talking about doing”. And so that the pandemic gives us an opportunity to do. To work together, to get things done. And that really cemented that partnership in a way that probably would have taken longer in a more conventional time.

Katharine: Yeah, that's I think, you know, obviously, so many horrible things about the pandemic. But one positive is it did sort of show us I think that we can change things at scale. I, you know, think about virtual care, and the leaps and bounds we've made there, which I think is another great example, right of how children's hospitals can reach outside of their boundary. And I certainly have that experience connecting with my referral hospital for patients and I know, CHEO would support rural places in that as well, you know, it's another one, right, where we just leapt ahead, what might have been another 10 or 15 years. And that willingness to kind of embrace those learnings to continue to move things forward, I think is one of the thankfully positive changes. And hopefully, we can continue to realize we can do hard things. And I think we sort of learned that and we have to keep challenging ourselves.

So that, Alex, takes me to my final question for you. Just sort of in summary, you know, we've talked about lots of things today, this is an area you of course have a lot of experience. So if you had, you know, the right people in front of you right now, decision makers, and you had 30 seconds to give them your elevator pitch about why right-sizing children's health care should be a priority, now, what would you say?

Alex: Population of children is growing. And that population of children - children are the future taxpayers, caregivers, innovators, healthcare workers. And investing in them is actually not only a wise investment for our society as a whole. It's not only a moral obligation to them, but actually will reduce pressure on the healthcare system later. Because if we can put children on the path to lifelong health, then there'll be working in the healthcare system, not using it services, when they are adults.

Katharine: Thank you for that inspirational thought. I certainly agree with you. So thank you, Alex. It's been - it's always wonderful to see you. It's been a real pleasure speaking with you today and learning from you about your vast experience working in children's healthcare. So thank you for your incredible advocacy. I think you have really with your team moved the dial both in your own institution across Ontario, and there's lots our listeners from across the country can take from your experience and thank you for being a leader in such an important space.

Alex: Thanks, Katharine.

Katharine: So thanks again to SPARK: Conversations podcast sponsor, the IWK Health Center for their ongoing support. That's it for today. Thank you for listening to SPARK: Conversations. To stay up to date on all of our SPARK offerings including the upcoming podcast episodes, visit our website at childrenshealthcarecanada.ca and subscribe to SPARK: News weekly - bi-weekly, pardon me. Biweekly e-bulletin. If you haven't already, like our podcast, tell a friend about it. We love having you here. We love your comments and thoughts. Thanks and we'll see you again next month.