Incursion into the heart of Santé Québec

Photo: Graham Hughes archives La Presse canadienne «Le Devoir» a pu assister à une réunion de tous les p.-d.g. du réseau de la santé québécois.

Le Devoiris today publishing an excerpt from a book to be published in spring 2025 by Somme toute/Le Devoir. The book, written by Pascal Mailhot and Marie-Michèle Sioui, traces the history of the health network, from the birth of health insurance to that of the Santé Québec agency. The former political advisor and the journalist interviewed nearly thirty personalities from all political backgrounds. Through reforms and crises, they take a cross-eyed look at significant periods in the history of health in Quebec, including the COVID-19 pandemic, which they experienced on both sides of the political wall. In this second part: all the senior leaders of the health network take stock of the budgets and the 500 actions they must carry out.

There are Teams meetings where colleagues joke and tell each other about their weekend. And then there are those of the Santé Québec management committee.

On the screen, the faces of all the presidents and CEOs (CEOs) of the CISSS and CIUSSSs of Quebec appear in small boxes. In a very exceptional manner, we are allowed to attend the deliberations of the leaders of these sprawling structures, which manage health care in each region of Quebec.

On this morning of November 6, the gears of the machine seem rather well oiled. The CEOs dive without delay into the brain of the mammoth that is the health network in Quebec. Their universe is contained in a series of Excel spreadsheets. In total, 52 people log in this way every Wednesday.

The President and CEO of Santé Québec, Geneviève Biron, opens the meeting. She lists four priorities. “Refocus on the core business,” “take care of our world,” “do better with what we have,” and “address the causes of the problem, not the symptoms,” she lists. In short: work to make the public sector more attractive, promote a better work-life balance, mobilize teams where it counts, establish predictable budgets, question ways of doing things, be more efficient, use new technologies, involve user committees more, achieve economies of scale… A vast program.

Ms. Biron then keeps a low profile. The financial concerns of CEOs, in this context of budgetary tightening, permeate the discussions. The strategies put in place to keep patients as far away as possible from hospitals and their emergency rooms too.

Photo: Valérian Mazataud Le Devoir Genevieve Biron, Director of Santé Québec

The assistant vice-president of Santé Québec, Robin Marie Coleman, takes control of what she calls the “strategic steering room.” It is a virtual environment composed of dashboards, performance indicators, project monitoring and “issues.” The numbers scroll at a frantic pace on the screen, testifying to the incredible complexity of a network that never sleeps.

Senior executives dive into an almost parallel universe, with its own dimensions of space and time. Even the health system’s calendar doesn’t work like it does in the ordinary world. It divides a 12-month year into 13 periods, which are counted from P1 to P13.

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Tight budgets

Ms. Coleman reveals that CEOs will see a first model of the Votre Santé portal in December. The application, a digital gateway for all primary care, is an election promise of the CAQ. It should finally see the light of day in the spring of 2025. Until now, it seemed lost somewhere in the Ministry's organizational chart. “It's going so round in circles,” a source told the Journal de Montréal in June.

The CEO of the CIUSSS de l’Est-de-l’Île-de-Montréal, Jean-François Fortin Verreault, points out that this application is linked to the GAP, the “front-line access window,” a service for the more than 2.3 million Quebecers who do not have a family doctor. “We still had significant budget cuts,” he warns. A specialist in organizational development, the boss has a quick mind. Information seems to circulate at high speed in his head. The budget tightening, announced to the CEOs a week earlier, will have repercussions on the network’s ability to meet needs. “Several of you have received letters. […] We will have to be vigilant about access results,” warns Ms. Coleman. Bruno Petrucci, of the CISSS de la Montérégie-Est, raises the same red flag. “The cuts, the [compressions], we wonder how we are going to support that in a sustainable way,” he says, concerned.

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The tables scroll across the screen. You have to squint to read the fine details, and strain your ears to decode the language, punctuated by acronyms. Care becomes “PEC”. Home care, “SAD”. Patient-based financing, “FAP”. The vocabulary, aggregated in sentences that sometimes take on the air of mathematical formulas, testifies to the complexity of the issues being addressed. The CEOs do not need subtitles to understand each other. They break down the complex problems submitted to them and navigate with ease in this ocean of data and abstract concepts. Still, even an outside eye can see that some indicators are in the red.

One voice rises above the fray: that of Santé Québec’s executive vice-president of operations and transformation, Frédéric Abergel, whose long experience in the network commands respect. His message is clear. “The primary intention is not to go green. It’s to have impact and results. We are no longer in an accountability model where you have to do a “check” because you have 100%,” he insists.

Mission: 500 actions

Together, the network’s top managers are working on 500 actions. Without a plan, it would have been 1,200, jokes Mr. Abergel. He invites the CEOs to focus their efforts on those that will bring the most significant results. “Often, small actions bring big impacts. One of my wishes is that we move from a philosophy in our network where we are very focused on the efforts we have made to instead move towards the impacts we have—if possible with less effort, even,” he emphasizes. In other words, take key actions in specific sectors, rather than spreading ourselves thin in all directions.

The discussion is particularly lively around the famous dashboards, these measurement tools dear to the Minister of Health, Christian Dubé. The length of stay on a stretcher, a crucial indicator, is the subject of particular attention. “You've managed to stabilize the indicators, instead of seeing the gaps keep increasing,” Coleman said, emphasizing the importance of recognizing even small victories.

In terms of results, the mammoth produces exploits that sometimes seem… anachronistic. At the CISSS de Laval, CEO Jeanne-Evelyne Turgeon emphasizes that she has — “finally!” — been able to stop the production of hospital cards. “It speeds up, and by a lot, the time it takes to register in the emergency room,” she observes. Not only were the plastic cards not environmentally friendly, they also constituted an obstacle to patient care, she specifies. Which just goes to show that sometimes all it takes is a tiny grain of sand to jam a gear.

Photo: Jacques Nadeau archives Le Devoir The length of stay on a stretcher, a crucial indicator, is the subject of particular attention.

At the heart of the beast, resistance sometimes seems harmless. But the domino effect it creates is not. At the CISSS du Bas-Saint-Laurent, CEO Jean-Christophe Carvalho is working hard to speed up the movement of patients from the hospital to long-term care centres (CHSLDs). “Every time we move forward, we discover a new blocker,” laments the cardiologist. The previous week, the problem came from the pharmacists. They are unable to provide seven-day-a-week on-call, which is necessary for transfers to take place on weekends. “We are adjusting to provide remote support, so that the user goes to the CHSLD, even if it means we can complete the admission afterwards. But it’s not done…”, he says with a nervous laugh. Through “corporatism,” he dares, some people also block the arrival of pharmacists with a bachelor's degree in hospitals. “But it would help me in the regions,” he emphasizes.

$429 per day at the hospital

In the middle of the “strategic steering room” is what Ms. Coleman calls the “act, response/action wall.” A small box on a highly publicized file appears. “Billing issue when a patient refuses to leave short-term care,” we read there. The short text refers to an article from Devoir, which revealed in April 2023 that the CIUSSS de l’Estrie was charging $429 per day to users who refused to leave the hospital to go to a residential or rehabilitation centre.

In the table, the path that this file has taken is summarized in a few points. The assistant deputy minister asked to put an end to this practice, but the CEOs believe they did not receive a “clear message.” Confusion reigns. Santé Québec launched a survey in September, but ten institutions have still not responded. In the network, practices “are really divergent.” On the screen, the exercise appears strictly accounting, far from the human angle put forward by the media.

The financial losses, since the establishments no longer charge fees to patients who refuse a transfer out of the hospital, are in the millions of dollars. The hospitals find themselves deprived of thousands of places, we read in the document. Financial year report ? “Follow-up in progress with the VP Finance team of Santé Québec and the DGFARB,” is written at the bottom of the box. The DGFARB ? The “Direction générale du financement, de l’allocation des ressources et du budget”…

The file will evolve “favorably,” Ms. Coleman assures the CEOs. “It is still a very, very political file. We must be extremely careful and be well supported in relation to the direction that we are going to communicate,” she adds, sibylline. Santé Québec is monitoring variables to improve access. She sees it as a way to measure her impact on people's lives.

Good moves and humans

Ms. Coleman regains her enthusiasm when it comes to encouraging her colleagues to share their successes. “Raise your hand!” she says. Maryse Poupart, from the CISSS de la Montérégie-Centre, announces the addition of 96 additional places in accommodation, with the opening of a new seniors’ home — which officials could not help but rename “MDA MA” (for “seniors’ homes and alternative homes”), when the concept was precisely intended to humanize the nomenclature of care facilities.

In the Outaouais, a specialized nurse practitioner clinic is preparing to open its doors. Bruno Petrucci, from the CISSS de la Montérégie-Est, welcomes the implementation of a new patient orientation service — the REOGOP counter — which helps relieve pressure on the Saint-Hyacinthe emergency room by redirecting around twenty people each day to more appropriate resources.

The day after this virtual meeting, Jean-François Fortin Verreault welcomes us into his office at Maisonneuve-Rosemont Hospital, on boulevard de l’Assomption. Over a cup of coffee, the CEO wants to demystify the previous day’s meeting. “It’s not theoretical, it’s not abstract notions,” the manager asserts, showing the various indicators scrolling across his screen. “Behind each piece of data, there are real patients being treated. There are real humans behind the figures on staff retention rates or mandatory overtime.”