Government & policy
SSHA riddled with problems,
operational review finds
TORONTO – An independent review of Ontario’s Smart
Systems for Health Agency (SSHA), commissioned by the provincial
government and SSHA, has found the organization operates with inadequate
strategic planning and project management, poor levels of service
delivery, governance and accountability problems, little measurement of
return-on-investment, and low levels of customer satisfaction.
According to Deloitte Consulting, which conducted the review, the value
of SSHA’s accomplishments against a $458 million investment over the
last four years (including the current year plan) is difficult to
Nevertheless, the 100-page operational review asserts that SSHA could
and should play an important role in Ontario’s eHealth strategy. It also
emphasizes, however, that major improvements will be necessary before
Ontarians can be assured that investments in the agency are resulting in
The following text consists of extracts from the report, which can be
SSHA has been operating in a fluid and complex business environment
without formal strategic direction from the Ministry. As a consequence,
it has been unable to develop a concrete and detailed strategic plan.
This situation has made it difficult for SSHA to establish its business
priorities and to meet client and stakeholder expectations. Despite
these issues there is overriding support within the broader healthcare
community for a provincial agency such as SSHA, dedicated to providing
eHealth solutions. In fact, the need for an effective eHealth Agency is
expected to increase in the emerging eHealth strategy.
Consultations with clients and stakeholders determined that the SSHA
brand is not well regarded. Much of the client dissatisfaction with
SSHA’s service is warranted, although the Agency has also faced
criticism about issues that fall outside of its mandate. This is a
reflection of the nebulous understanding about SSHA’s role and core
business within the broader healthcare community. Clients and
stakeholders do not distinguish the Agency from the Ministry especially
since the Ministry acts as funding provider, oversight manager and
client. The broader healthcare community has a range of views on the
role that an improved SSHA should play. The spectrum of roles spans from
strictly a secure infrastructure provider to a full-service Electronic
Health Record (‘EHR’) developer, integrator and operator. The brand and
reputation of SSHA can be improved over time, but only through a more
disciplined adherence to fewer approved priorities. SSHA can no longer
attempt to be ‘all things to all people’ in the eHealth sector, and at
the same time deliver on key commitments.
SSHA has not demonstrated its value proposition to clients. The initial
infrastructure deployment by SSHA has been complete since 2003. The
Agency has been slow to shift its focus from deployment to operations
and service excellence. It has not articulated a standardized product
and service catalogue with associated pricing that can be compared to
the market. The scope expansion inFY04/5 from seven priority areas to
the inclusion of client business solutions has tested the capacity of
the organization. It has eroded focus on achieving operational
excellence within its core products and services. The result has been an
unfocused array of clients, products and services that reflect a
legitimate desire to utilize deployed assets, but lack a clear
commitment to client service and outcome measurement. In a client
focused organization, stakeholder committees and user groups would be
formed. Client relationships would be supported by service-level
agreements (SLAs) and performance reporting.
The advantages afforded by an agency construct have been diminished by
SSHA operating more as a Ministry division than an independent operating
entity. The current legislation (Regulation 54/05) under the Development
Corporation Act restricts the Agency to Ministry-based annual funding as
part of the Results Based Planning (‘RBP’) cycle used by the Province.
This leaves the Agency susceptible to operational and tactical direction
from the Ministry that blurs overall accountability for results. Revenue
collection from other sources is prohibited under the Act, yet
opportunities exist for joint funding, or cost recovery of services that
are being left unrealized. Enabling legislation specific to SSHA is
required to support a multiyear funding model with an annual
accountability agreement, allowing SSHA to operate more like a transfer
payment agency than a division of the Ministry.
The Agency has made significant progress in addressing its founding
mandate and business purpose, namely the introduction of secure networks
and data centres. However, there is a considerable way to go before
value will be realized from the enabling infrastructure. SSHA has
installed over 1,700 circuits to connect public hospitals, CCACs, public
health units, physicians, and other provincial healthcare providers. The
Agency has provisioned two data centre facilities. The result is an
ability to host its current 19 applications in a highly available
environment. However, significant questions exist relating to the
effectiveness of certain decisions and the value obtained from
The Agency has faced substantial challenges with respect to the rate of
user adoption as well as security architecture methods and expectations.
Adoption of secure email as a means of transmitting electronic health
information has not met Ministry and SSHA expectations. Of the 60,000
secure email boxes that have been installed since 2003, only one-third
mailboxes are in active use. The Agency does not report on whether the
sites in use are for the purposes intended, and has not established a
position regarding the future of this program.
Similarly, there are issues to overcome with respect to access to a
secure eHealth environment. The initial vision of PKI certification of
end users has proven to be problematic (e.g., only a fraction of the
initial investment has been deployed). In order for the province to
leverage value from its investment in a secure eHealth environment,
issues regarding user adoption and security will need to be addressed.
There is a need to incorporate the lessons learned from previous
investment decisions into future plans.
Since cost information by product, service or client has not been
maintained historically (nor has performance measures) it is not
possible to assess the cost/benefit of past investments. It may also be
too early to assess the value of these investments as the healthcare
sector has been slower to adopt electronic information management than
other sectors. Management recently identified several areas where
performance must be improved to ensure control over operational,
financial and client service practices. The Agency has also identified
the need for substantial performance improvement in its core business of
network and data centre operations. However, progress in these areas has
been too slow.
The current financial management regime is inadequate to ensure the
cost-effective execution of a $145 million expenditure plan for FY06/7.
The primary concern is the lack of an effective, centralized,
controllership function required to instill financial discipline,
control and education across the Agency.
Financial management practices have been inadequate to manage the
increasing size and complexity of the organization. We did not find
evidence of inappropriate use of funds, although it was not part of our
mandate to conduct a detailed review of financial controls. While recent
improvements have been made, strengthening SSHA’s management and
accountability will require the elevation of financial management on the
corporate agenda. In response to these challenges, the Agency will be
adding the position of Chief Financial Officer (CFO) to the executive
The Agency faces management, performance and organizational capacity
issues which must be addressed in the short term. SSHA lacks the
rigorous operational and financial planning required to function
effectively. In October 2005, the Agency began to implement a new
planning process and to develop its first integrated project plan. A
resource planning and forecasting process was introduced in October
2005, but has not yet evolved to a consistent, repeatable, Agency-wide
Project management capability is insufficient given the complexity of
the eHealth field. There is still no single, integrated project
management methodology across the organization. The organization
structure also needs to be strengthened. The current structure is
unnecessarily complex and does not reflect leading practices for
Information Services providers.
At the request of the Ministry, SSHA has also been dealing with a
transition from a consultant-based to an employee-based organization.
Because this transition took place in parallel with capacity building
activities, SSHA had difficulty managing the significant degree of
change and acquiring appropriately skilled staff. This has led to a
skills gap in some areas such as business and financial management.
Fundamentally, the culture of the organization needs to change to one
that is customer focused, deliverable-oriented, and able to partner
effectively with the Ministry and other health sector stakeholders.
SSHA does not have a clearly defined strategy. SSHA does not have an
overarching documented strategy that defines the organization’s
development over the next 3-5 years, including its strategic goals and
objectives. The business plan, with divisional goals and output-based
accomplishments, is a mechanism for obtaining annual funding, and cannot
be used as a substitute for a comprehensive strategy.
Recently the SSHA Strategic Planning and Communications Committee, led
by the Board Chair, submitted a short-term proposed strategy and plan to
the Ministry. While this initiative is a good first step, the current
status of this proposed strategy remains unclear as it is not formally
approved by the Ministry. Therefore, the overall strategic direction for
SSHA remains unclear. As such, maintaining focus will continue to be a
challenge for the organization. Until a stable, clearly articulated
eHealth strategy is defined and approved by the Ministry, SSHA will
continue to face changes in its strategic direction and mandate which
will impact operational and service performance. The relationships
between strategy and governance documents, including gaps in
Performance measurement is not linked to strategic outcomes. A
performance agreement has not been documented between the Ministry and
the Agency. SSHA’s current corporate balanced scorecard is not tied to
its business plans (including financial and operational plans). To
improve alignment, a new performance management initiative to develop a
corporate balanced scorecard and associated divisional scorecards was
launched in early 2006.
At the time of this report, this initiative is still in its early stages
and its full impact will be difficult to assess until FY06/7 fiscal year
end. In general, the Ministry, SSHA clients and other stakeholders are
seeking more timely and consistent reporting, including qualitative and
quantitative information on performance and the Agency’s contribution to
overall health system performance.
Management decision-making processes have been inadequate to effectively
steer the Agency. Strategic decisions regarding fundamental services,
major scope changes or the addition of new projects are not
well-documented. In the past, in-year changes in direction at short
notice have created additional resource and funding pressure on SSHA.
In 2005, a new ‘funneling process’ was put in place to formally evaluate
change requests or new project requests made by the Ministry or by SSHA.
Each project is now required to go through feasibility and business case
analysis before a go no-go decision can be made. All scope-change
decisions must now be approved by the SSHA Board and the Ministry in
writing. This is a very important, recent improvement in internal
decision making, and reflects recognition on the part of the Agency that
decision-making at the Ministry and the Agency has been ad hoc and
uncoordinated, leaving stakeholders unclear as to the priority and rate
of progress of various initiatives.
The recently implemented business and operational planning process (Q3
FY05/6), as well as the funnelling process are allowing SSHA executives
and the Board to begin to make more informed decisions. These decisions
must be ratified by the Board and submitted to the Ministry via the
business plan document for approval. Variances from the business plan
are reviewed on a monthly basis. Decisions regarding variances must also
be approved by the Board and documented in the Board meeting minutes.
Tactical decisions are made during regular weekly status meetings
between project leads and the Executive Committee.
The Executive Change Management committee, supported by a director-level
group facilitates the resolution of resource and scheduling conflicts
between projects and divisions. Additional forums for decision making
include a monthly, full-day SSHA Executive meeting for a comprehensive
review of project and budget status; a quarterly, full-day SSHA
Executive meeting to review the annual budget; and a monthly SSHA Board
Meeting where key decisions are ratified.
With these mechanisms in place, the Agency will be better equipped to
assess progress against approved plans and to stay focused on the
achievement of formal commitments. In late 2005, formal meetings between
SSHA management and the eHealth Office were instituted, which has
resulted in more structured communications between SSHA and the
The governance model has not encouraged the degree of partnering and
collaboration required to deliver complex eHealth solutions. The
principal governance relationship has been between the Ministry and SSHA
management. The predominant focus is on budgeting, monitoring and
control from a central planning perspective (e.g., eHealth Office).
At the same time, the Agency serves a number of clients within the
Ministry (e.g., program owners) for whom solutions are being delivered
by SSHA. These program owners often set the terms and conditions under
which SSHA interfaces with the end-users of its services (e.g. health
system providers). The result is that SSHA management is often faced
with competing or contradictory demands from policy setters, program
owners, funding managers, and users of its services. This reinforces a
relationship between the Ministry and SSHA that is based on operational
negotiation and control rather than collaboration.
It also leaves end-user customers unclear as to their role in priority
setting. The Ministry, not having received the level of reporting it
asked for from SSHA, has placed increasingly tight controls on the
Agency, thereby inhibiting its operational independence.
Administratively, the MOU between MOHLTC and SSHA is outdated and does
not reflect the broader scope and accountabilities in the amended
regulation. This leads to multiple interpretations of the mandate adding
to confusion about SSHA’s role.
In 2005, the lack of a stable SSHA Board led to a governance gap that
impacted decision-making over several months. As such, the FY06/7
multi-year business plan is not formally approved in writing by the
newly instituted Board and Ministry. The introduction of a new Board for
SSHA offers the opportunity to establish a more collaborative
environment between the Agency and the Ministry. There is also a need to
establish increased autonomy for the Agency to effectively build
meaningful service relationships with the end-users of its eHealth
A clear accountability agreement with measurable targets and results
does not exist between SSHA and the Ministry. Well-defined expectations,
deliverables and measurable performance targets have not been
established and documented by the Ministry for SSHA. For example, an
annual accountability agreement with specific performance expectations
has not been part of the governance model. This makes it difficult to
assess the true performance of SSHA relative to expectations. As a
result, the actual or perceived value of SSHA’s accomplishments against
a $458 million investment over the last four years (including current
year plan) is difficult to assess. Outcomes have also not been defined
by the Ministry for the Agency, making it difficult for SSHA to
understand the end-state of a project or initiative and work towards
that state. The result has been a task-based approach to project
The Agency and the Ministry have different indicators and tools for
measuring SSHA’s results. The new SSHA balanced scorecard has been
strengthened over previous versions to include four categories – Client
Perspective, Internal Perspective, Learning and Growth Perspective, and
Stakeholder Perspective. Some basic metrics are in place. SSHA is in the
process of researching other technical and financial metrics. Divisional
scorecards are at the early stages of development in the eHealth
Solutions Division and the CIO’s office. Many traditional metrics used
for network and data centre management are not in place. The Ministry
has also asked SSHA to report on four areas – Quality, Client
Satisfaction, Pace of Delivery and Cost. The SSHA and Ministry
performance measures and tools need to be aligned to a common set of
agreed upon targets. A formal request for SSHA to present a performance
scorecard to the Ontario e-Health Council in early 2005 has not been
done to date.
The current legislation restricts SSHA from operating effectively as an
arms length agency. SSHA operates like a division of government with its
involvement in the RBP process, reliance on funding envelopes and
working with holdbacks for in-year funds. Consequently, the Ministry
(through the eHealth office) and central agencies are overseeing,
reviewing and commenting on the financials and operations of SSHA at a
By comparison, a transfer payment agency (such as Cancer Care Ontario or
a major hospital) would operate with greater Board and management
accountability for performance against approved strategies and plans.
Such a structure could provide a number of benefits to SSHA including:
the ability to carry-forward approved project funds into next fiscal
year where legitimate issues had resulted in project delays; the
potential to obtain revenue from clients for certain services where it
has been proven economical to do so and performance targets are not
compromised; and, the ability to enter into long-term, performance-based
partnering relationships with industry or other stakeholders to leverage
expertise and resources beyond those existing within SSHA.
Products and services lack clear, detailed definition. The lack of a
detailed, standardized product and service catalogue leads to confusion
about the scope and scale of SSHA’s offerings. Clients are unclear about
the products and services provided by SSHA. In response, the Agency has
started to develop detailed descriptions of the products and services it
provides. Product descriptions for ONE Network and ONE Hosting are more
clear and thorough than for ONE Mail, ONE ID, ONE Support and ONE Pages.
The Agency has not yet progressed to a product and service catalogue
with clearly stated service standards.
Client dissatisfaction with SSHA service levels is high. SLAs are not
consistently defined or implemented with all clients. As a result,
customized agreements are in place for most clients. Standardized client
reporting against SLAs is minimal to non-existent. Management dashboard
tracking of service level targets for incident resolution has only been
in place for a few months (e.g. IS Enterprise Services Reports).
Service level performance is currently only managed for high-priority
incidents. While some clients were appreciative of the efforts and
service quality provided by individual SSHA employees, overall feedback
from clients on service levels has been highly critical. Clients must
deal with multiple SSHA or vendor contacts for service or technical
issues. Clients find this confusing and are unsure of the escalation
path for their complaints. SSHA has recently established a client
service manager role to mitigate such issues.
Network and data centre costs can be more tightly managed. Network costs
account for 22%of the FY06/7 operating budget. The budget for network
operations has been increasing by 10% year over-year. The Agency is
establishing a new network contract (currently in negotiations) that
will become operational in 2007, with the objective of containing the
growth of network costs. The two data centres constitute 20% of the
FY06/7 budget, with facility rental expenses being the most significant
contributor to data centre costs. The current proliferation of racks in
the data centre may result in escalating facilities costs if the Agency
does not take measures (e.g. server consolidation) to reduce the
existing rate of floor space consumption.
SSHA created the eHealth Solutions Division (eHSD) to assist the broader
healthcare community in developing and deploying applications. This
division recently has taken on the responsibility of client service
management. The division is comprised of dedicated project resources and
resources that spend a portion of their time on operational and
maintenance activities. SSHA is in the early stages of developing client
reports but has not developed a definitive approach to such reporting.
User groups or client councils have not been part of SSHA’s approach to
managing client and stakeholder relationships.
Users’ expectations of SSHA often do not align with its actual mandate
and capabilities. With one or two exceptions, external stakeholders were
unable to provide a reasonably accurate list of SSHA’s products and
services. Interviewees consistently stated their belief that the
products and services they expect from SSHA are vital to delivering on
their government-mandated responsibilities and objectives. These
objectives include such things as: improved access to healthcare,
progress against the provincial wait time strategy, improved health
outcomes, and cost containment.
With the constant push by government to create greater integration
across the Ontario healthcare system, stakeholders view SSHA as a key
enabler for their specific technology needs. There is broad support for
a provincial eHealth agency to promote integration and economies of
scale. At the same time, stakeholders are frustrated by what they view
to be slow progress with eHealth in Ontario. The lack of alignment
between external stakeholders, the Ministry and SSHA has been
exacerbated by performance issues and by SSHA’s limited engagement of
stakeholders in processes that define Ministry and SSHA priorities and
As a result SSHA’s products and services are perceived to be
ineffective. This has resulted in some client organizations moving ahead
with their own technology solutions, security protocols and eMail
systems. In time these standalone client projects may have serious
implications for the overall eHealth environment and SSHA’s future role.
There is a perception that quality of products and services delivered by
SSHA is poor. Stakeholders generally expressed dissatisfaction with the
quality of SSHA’s products and services. They find varying degrees of
quality and consistency in SSHA’s provision of basic infrastructure
needs, network and connectivity services, as well as secure eMail.
Numerous examples were provided relating to the lack of system
availability, long turn-around times on requests for service, lack of
bandwidth and lack of warnings or communications during system
down-time. Other frustrations include:
• While SSHA employees are perceived to be technically proficient, they
demonstrate little business acumen. This translates into an inability to
understand client issues, manage client expectations and describe SSHA
products and services in a meaningful way.
• SSHA is perceived as rigid and inflexible by many clients.
• The inability of SSHA to describe how SSHA measures and reports on its
• Most users do not have Service Level
Agreements, mainly because the process to agree on
SLAs is too complex and long and where SLAs are in place, no
feedback/reporting on it is done.
• SSHA’s communication and general engagement with stakeholders is
insufficient for them to feel satisfied that the Agency values client
Stakeholders recognize that some of SSHA’s operational problems can be
explained by the lack of maturity within the organization. They also
realize that the lack of a clear mandate contributes to SSHA’s
difficulties with operational planning and that SSHA’s execution of
activities is shaped by the Government’s policies and priorities.
However, on balance, our consultations with external stakeholders
highlighted the widely held perceptions that SSHA:
• Offers products and services that are relatively ineffective;
• Delivers products and services inefficiently; and
• Does not measurably contribute to the efficiency of the healthcare
This has led to an erosion of confidence. Restoring credibility requires
a concerted effort by the Agency.
To address the increased importance of the Agency in the future Ontario
eHealth agenda, a number of recommendations for improvement and an
associated implementation plan have been developed. Given the increased
urgency for substantive progress with eHealth in Ontario, an aggressive,
Agency-turnaround plan is required. As such, the high-level
implementation plan included in this Report calls for the fundamentals
to be implemented by March 31, 2007. Fiscal year 07/8 will also be
required to fully implement the required improvements. The Ministry
needs to own the eHealth program and be engaged at the level of making
strategy, policy, and program decisions, and work with the Agency to
implement appropriate solutions.