Ensuring Transparency, Accountability and Clarity
Report of the Board of Directors
February 22, 2009
Ensuring Transparency, Accountability and Clarity
For over 50 years the Canadian Mental Health Association, Ontario Division (CMHA, Ontario) has been committed to bettering the lives of those living with mental illness and their families. Our vision: “mentally healthy people in a healthy society” has provided the guiding beacon for who we are and what we stand for as CMHA.
Over the past few years, the Ontario government has initiated a transformation process that changed substantially how health services are delivered in Ontario. This has caused all community mental health stakeholders1 to re-think and transform their organizations to adjust to these new realities. The Board of CMHA, Ontario is focused on implementing our strategic plan (2007-2010) that sets the direction for our current and future efforts. In this report, the Board of CMHA, Ontario lays out some of the changes that must be made to our organizational structures, processes and business practices to fulfill our vision, strategic directions and accountabilities.
THE CHANGING ENVIRONMENT
For all organizations, change is a constant. CMHA, Ontario has been evolving and re-aligning itself in response to the changes in the understanding of (community) mental health and with the evolution of Ontario’s health system. New expectations of public sector (transfer payment) agencies have been established and new working relationships have been implemented. CMHA, Ontario needs to continue to evolve to ensure it fulfills its responsibilities to its stakeholders.
CMHA, Ontario, like many health organizations, is a complex organization that must balance its obligations and its various stakeholder needs to be successful. As stakeholder expectations change, they can and do cause tension when necessary responses by CMHA, Ontario challenge the status quo. It is vital that the rationale for changes at CMHA, Ontario be well communicated so that stakeholders can understand and support what needs to be done. CMHA, Ontario is committed to open and frank dialogue on the changes being proposed.
As the MOHLTC takes on its stewardship role, it has led to significant declines in its internal resources dedicated to community mental health planning and policy development. Unlike other responsibilities transferred to the LHINs, the resources dedicated to these functions have diminished in real terms. The result is a substantial risk to community mental health stakeholders that continued objective and effective, broad based policy development and system planning will be jeopardized. This is particularly troubling as it coincides with mental health finally gaining recognition as an issue on the public agenda.
The environment that impacts CMHA, Ontario’s work has been transforming as well. Several years ago, CMHA began to strengthen its capacity in the areas of policy development; applied research and knowledge transfer to better fulfill its accountabilities to the Ministry of Health and Long Term Care. At the same time, CMHA has continued to fulfill its accountabilities as a Division of CMHA with respect to CMHA nationally and to its local branches. Considerable efforts have also been directed to working collaboratively with other sector stakeholders; e.g.; the “Partnership” with the Centre for Addictions and Mental Health (CAMH), the Ontario Federation of Community Mental and Addiction Programs (the Federation) and Addictions Ontario (AO), Ontario Peer Development Initiative [OPDI] and Ontario Association of Patient Councils [OAPC]). Many other working relationships have also evolved.
CMHA, Ontario’s Multiple Mandates
CMHA, Ontario has three distinct areas of accountability that need to be acknowledged and addressed. It is accountable to:
CMHA, Ontario must be transparent in its actions in fulfilling its accountabilities for each of these mandates. For many good reasons and influenced by historical realities, these accountabilities, in some instances, have become intertwined. To move forward, as a system leader for community mental health, we must address these accountabilities more distinctly than at present.
Accountability to CMHA:
CMHA, Ontario charters its branches in Ontario and signs a branch agreement that lays out mutual responsibilities. Ontario Division has implemented many practices that address these responsibilities to the branches (Executive Directors’ Network, Provincial Branch Forum, etc.) and seeks and receives advice and input from the branches on many matters. The significant source of funding for these activities are the annual fees paid to CMHA by the branches to maintain their charter. As well, by similar agreement, it has mutual responsibilities with CMHA, National and Ontario Division works collaboratively with its sister divisions across the country.
Accountability as a Registered Charity:
As a registered charity, CMHA, Ontario must abide by governing legislation and be accountable to donors for money raised. The Canada Revenue Act allows charities to offer “their direct knowledge of social issues to public policy” with the caveat that this information must be well balanced i.e.; not interest-based and be provided to benefit society and enhance the public good. This accountability limits the role of CMHA as an advocate across its accountabilities.
Accountability to the Ministry of Health and Long Term Care:
CMHA, Ontario receives the majority of its funding from the MOHLTC. This funding is to provide system-wide support for policy analysis, applied research and knowledge transfer for community mental health in Ontario.
The process of delineating accountabilities is not about reducing our commitments but rather increasing transparency of our actions and improving performance. For example, CMHA, Ontario will continue to work collaboratively with its branches and National with respect to matters pertaining to the charter and agreement. Similarly, CMHA, Ontario will work cooperatively with National and the other CMHA Divisions on issues of mutual, pan-Canadian importance.
To be more transparent and inclusive, CMHA, Ontario will seek to implement more consultative processes in carrying out its applied research, policy development and knowledge transfer activities in meeting its obligations as a MOHLTC transfer payment agency. Beginning in 2010, these will be laid out in our Service Accountability Agreement.
Bringing a System Focus
The business practices that Ontario Division has used to address its various accountabilities have left considerable confusion in some stakeholders’ minds about our priorities and purpose. Often there has been little visible separation in our work between accountability for our CMHA roles and our accountabilities to the MOHLTC. We have involved branches directly in our system level policy and research work. We do seek input beyond the CMHA branches but the balance and process have not always been viewed as equitable. Typically, we have relied upon outside sources such as the Partnership or individual Partnership members to coordinate policy input on our behalf. This can be interpreted as undervaluing other community mental health stakeholders input or perceived as giving preferred status to CMHA branches in our work. We have been told that current consultation processes reinforce the perception that CMHA is undertaking its own work rather than working on behalf of the whole field.
Working with other provincial organizations is both necessary and desirable. They are important stakeholders and should provide guidance and advice to CMHA. But CMHA must do better in reaching out and involving all relevant stakeholders in its projects. Not doing so could be viewed as contrary to its MOLHTC funded role and compromise CMHA, Ontario’s accountability as an objective provider of policy advice and research.
The Integration of Mental Health and Addiction Sectors
The shift in policy focus by the MOHLTC and the LHINs has added another complexity to CMHA’s work. Concurrent disorders have been addressed by the MOHLTC through programs developed and funded in community mental health agencies. Most of the LHINs and the MOHLTC have chosen to address the full spectrum of community mental health and addictions as a single sector when undertaking its policy and resource allocation decisions. For CMHA, Ontario this poses a special challenge.
If the MOHLTC and LHINs are looking for integrated policy and planning advice, how does CMHA, Ontario respond to this request? Ontario Division does not have specific expertise or credibility in addiction service planning, policy or service delivery. There is no corresponding organization to CMHA, Ontario that has been funded by the MOHLTC to undertake policy development, research and KT work for the addictions field. The Federation, Addictions Ontario and CAMH all have specific roles in the addictions field. The former two are member based associations while CAMH is a service provider that has a substantial academic and policy focus as well. There remains a gap in the policy development field for community-based addiction services and this makes coordinating comprehensive mental health and addictions policy advice more difficult.
Deciding how best to proceed will take further investigation and discussion by the Board and senior management with other stakeholders (e.g.; MOHLTC, Federation, AO, LHINs, CAMH).
Implementing changes that will enhance transparency, accountability and clarity of CMHA, Ontario’s activities will take time and considerable dialogue with key stakeholders. Implementation will require an explicit communications and stakeholder engagement strategy.
Partnerships, Alliances and Collaboration
Some of Ontario Division’s relationships have grown out of opportunities as they have presented themselves [e.g.; ‘The Partnership’, OHPA, OMAKEN]. Others have developed from our specific accountabilities [e.g.; Executive Directors’ Network, Provincial Branch Forum]. CMHA, Ontario must retain good working relationships with all of its key stakeholders but the mechanisms and relative resource priority assigned to each of the current relationships must be evaluated against our strategic directions and our specific accountabilities. We must also seek out and build new relationships that move the organization forward. This may include working with new academic or other research/policy organizations or international organizations.
A key criterion for deciding on specific alliances is how they help CMHA, Ontario fulfill its accountabilities and better influence needed improvements in community mental health.
Communications is a cornerstone of CMHA, Ontario’s activities. In January of this year, we approved our first strategic communications plan. An important aspect of this plan is promoting understanding of CMHA, Ontario as a provincial leader in applied research; policy development and knowledge transfer for the betterment of consumers and families and the community mental health system. At present, CMHA utilizes many different communication vehicles but the look, feel, messaging and content of the work is not well coordinated. Although each communication vehicle may be effective in the narrower context in which it was developed, it is time to review and revise communications processes to align with our strategic communications plan and our strategic directions.
CMHA National/Divisional and Branch Accountability
The affiliation and ongoing ‘family’ relationship with CMHA National, Divisions and Ontario branches enriches CMHA, Ontario in many important ways. Ontario Division must continue to support these relationships as a distinct accountability.
CMHA, Ontario/MOHLTC Accountability
CMHA, Ontario needs to better align its applied research, policy development, knowledge transfer and communications processes to leverage and enhance its ability to improve community mental health policies and programs. This will require specific actions to integrate our priorities with those of the MOHLTC, LHINs, other government initiatives (e.g.; poverty reduction, mental health promotion) and other stakeholders.
CMHA, Ontario Accountability as a Registered Charity
We have been fortunate to have the ongoing financial support of many individuals who have given us donations to further the work of CMHA. These donations have funded many initiatives that rely solely on the generosity of our donors. There is the opportunity to use this support strategically and to leverage its impact by better integration of our planning across all our activities.
Organizational Actions to Improve Transparency, Accountability and Clarity
Like many health organizations, CMHA, Ontario operates several distinct ‘businesses’ under a single governance umbrella. Therefore, it is incumbent upon the Board to evaluate its own structures and operations to ensure it functions effectively. This requires a thorough review of the Board processes arising from our charter, by-laws, policies, legal and relational obligations and to make changes as necessary to maximize the organizations overall effectiveness. The Board has already taken several steps in this direction through its adoption of a new governance model [Results Based Board] and a review and renewal of all its board policies. In addition the Board will:
Attachment 1: Relationships and Accountabilities
CMHA, Ontario and Its Branches: Scenario
Currently, the CMHA, Ontario Board is elected by the ‘members’ of CMHA. The members are defined by by-law as the members of the branches. Ontario Division may have its own members but they are non-voting. In addition, the Board has ex-officio representation through the Chair of the Provincial Branch Forum, Chair, Ontario Consumer and Family Council and a representative of the Executive Directors’ Network.
CMHA, Ontario will establish a Branch Council with representation from the volunteer and management components of the branches. The Council will be chaired by a member of the CMHA, Ontario Board who will also serve as a member of the Executive Committee. The CEO of CMHA, Ontario will serve as the secretary to the Council. The Council will be responsible for recommending to the CMHA, Ontario Board the annual workplan and funding allocations in support of the branches.
The Council will also be responsible for conducting an annual assessment of the effectiveness of the branch support activities and recommending any changes or special assessment required to provide extraordinary support services.
The branches submit fees annually to CMHA, Ontario as part of the branch/division agreement. The fees have been unchanged for over 25 years. The fees collected are used in part to help meet Ontario’s fee obligations to CMHA, National and to support such activities as the Executive Directors’ Network, Provincial Branch Forum, ED teleconferences, position paper development and other events (e.g.; employment support meeting).
The effectiveness of the current support channels have not been assessed for quite some time. The evaluations have indicated that changes may be worthwhile but this needs to be determined through a joint effort of the Division and Branches.
Establishment of a Branch Council will ensure ongoing support for the branches that is targeted to their changing needs. It will also ensure that the voice of the branches and their support needs are represented at the Board and Executive Committee table.
By moving to this approach, accountabilities and funding priorities are more transparent.
Attachment 2: Relationships and Accountabilities
CMHA, Ontario and the MOHLTC: Scenario
The MOHLTC contracts with CMHA, Ontario to undertake policy development, applied research and knowledge transfer activities on behalf of the community mental health sector. As of April 1, 2010, the accountabilities for these functions will be articulated through a Service Accountability Agreement. At present, CMHA, Ontario reports on its activities through the budget and operational planning process.
CMHA, Ontario will institute a number of changes to ensure its work includes and is seen to include all relevant stakeholders in its MOHLTC funded work. Changes will be required at the governance and operational levels.
The CMHA, Ontario by-law will be reviewed and amended to allow for broader participation in the nomination and election of the Board. Changes will provide for voting membership privileges by CMHA branches and members of CMHA, Ontario. Through its nominations process, CMHA will seek board members that reflect the skills required and the breadth of community mental health stakeholders; e.g.; consumers, family members, providers, academics, policy makers, etc.
A position paper will be developed by the Board to reflect this future state and will examine such issues as:
The position paper will be used to seek input from stakeholders and then amended and implemented.
At the operational level, changes will be implemented to broaden the input of stakeholders throughout the applied research, policy development and knowledge transfer process. For example, expert panels will be established at the outset of a project to guide and to advise on project design and methodology, analysis, consultation and recommendations.
Other communication techniques such a policy forums, electronic communities of interest, blogs, etc can be adapted to bring more ideas and input into CMHA’s work. Joint/collaborative projects can also enhance the quality and scope of projects undertaken.
Several key environmental shifts (described in the body of this report) must be addressed if CMHA, Ontario is to fulfill its accountabilities to the MOHLTC and to effectively implement its strategic directions. Such changes will allow for broader representation and counter current criticisms of insularity and bias that have been levied against our work.
By changing its practices, CMHA, Ontario will be impacting its existing relationships. Changes will need to be very clearly explained so as to avoid confusion and concerns of other stakeholders.
It will be important to begin the change process at the operational level in fiscal 2009/10 so as to gain experience and acceptability prior to negotiating the first service accountability agreement for 2010/11.
Attachment 3: Relationships and Accountabilities
CMHA, Ontario and Community Mental Health Stakeholders: Scenario
CMHA, Ontario is funded to undertake policy development, applied research and knowledge transfer activities on behalf of the community mental health sector. There has been criticism that CMHA, Ontario’s operational and decision-making processes provide inequitable input from all interested stakeholders. It has been stated that its work favours the CMHA branches. Policy advice provided by CMHA, Ontario is sometimes seen as its advice and not being representative of the field as a whole.
CMHA, Ontario will institute a number of operational changes to ensure its work includes and is seen to include all relevant stakeholders in its MOHLTC funded work. Changes will be required at the strategic and operational levels.
At the strategic level, the CEO will establish a policy and research advisory council with no less than 50% non-CMHA membership. The council will meet at least twice a year to review and guide the research and policy priorities for recommendation to the CEO.
On an operational level, expert steering committees representing key stakeholder groups will be established for each policy and research project. The steering committees will help develop the terms of reference for the project, provide advice on methodology, review findings and develop project recommendations.
The final report of the steering committee will be submitted to the CMHA, Ontario Board by the CEO.
The proposed approach begins to address the issues of equitable involvement and brings clarity to the intention of the work to reflect the literature and the views/best practice of the whole field. The potential weakness in this approach is that the final decision-making rests with a board that is elected and may be seen to be exclusively reflective of CMHA branches only.
For the purposes of this paper, Stakeholder refers to a person or organization that has a specific interest in and is affected by the actions of another person or organization.