Editorial - Vol 4, No 8:  Leadership and the Management of Change in Clinical Settings

...Continued

"A tale of two cities - and two hospital cultures - management of complex organisational and clinical change" was presented by Mr Mark Flowers, Chief Executive Officer of Healthcare Hawke’s Bay (HHB). He has been with the organisation since 1993, having previously worked with the Hawke’s Bay Area Health Board as Community Health Manager. He firstly had the role of Surgical Services Manager and chaired the task force that established the Hawke’s Bay Regional Hospital. In 1995 he became Development and Planning Manager on a full-time basis, responsible for the planning and implementation of the regional hospital and related projects. This included all aspects of the planning for, construction of, communication within and change management within the hospital.

The Hawke’s Bay in 1993, when Crown Health Enterprises were being established, had a number of low-standard, inefficient, wrongly-sized hospitals that were unsuitable for their required purposes. Secondary health care performance was inefficient and quality standards were inadequate.

The decision was taken to bring together in Hastings the hospital specialist teams and equipment from around the region and to provide all other health care services through community services. This provided an opportunity to rebuild the organisation’s structure.

The new structure was built on a "hub and spoke" model, with Hawke’s Bay Hospital in Hastings as the "hub" and service centres, the spokes, in rural areas and Napier (refer slide 3). It was intended that iwi health care providers and general medical practice services be included within this model.

Flowers referred to a "blizzard of considerations" (refer slide 4) that had to be dealt with in establishing the new organisation. There were staffing and union issues related to an obvious downsizing. A ceiling set by Treasury meant there were financial constraints. Possible future developments had to be considered in order to plan effectively. Other considerations included clinical issues, community attitudes, design issues, political pressures, customer service issues, change processes, cultural concerns and health sector norms. Alongside all of these considerations, a high level of clinical services had to be maintained during the changeover period.

In addition, the change itself caused enormous levels of anxiety for some staff.

Issues related to clinical involvement included difficulties reaching consensus on complex issues, often under pressure of deadlines, in the public gaze and in a litigious environment, and arriving at mutual visions of the future.

In these circumstances, the facilities and practical things easily became the "battleground". It proved extremely difficult to get doctors to lead positively, with a clear picture of the complexities and issues, and to provide the time for them to do so.

Flowers described how a combination of external drivers (eg, consumerism and technology developments), internal drivers (eg, inefficiency and clinical safety issues), and a patient-focused care philosophy drove a shift to clinical pathways, process re-engineering, facility re-design and "patient-focused operating systems" (refer below). These changes generally result in enhanced performance: high quality clinical outcomes, operating efficiency, reduced costs and staff and customer satisfaction (refer slide 11).

Patient-focused care aims to increase direct patient care time, improve continuity of patient care, minimise patient movement throughout the hospital, empower staff to respond more immediately and comprehensively to patient needs, improve staff job satisfaction and professional development, and tailor ward facilities to the needs of patients. This is achieved by decentralising patient services, cross-training and encouraging multi-skilling of ward-based teams, simplifying high volume processes, grouping together patients with like needs and developing multi-disciplinary clinical pathways.

Flowers described four dimensions of change: procedures/systems, leadership, team and individual. He noted that, most often, most effort is directed to the dimension of procedures/systems when, he believes, it should be directed to the latter three dimensions.

Flowers summarised the situation in the Hawke’s Bay today, which now has one hospital and three health centres, most of which are accredited. He noted there are now reduced bed numbers, reduced average length of patient stay, an increased percentage of day-stay surgery, discharge planning, a reduction in forms and improved documentation and redesigned processes.

[View Mr Flowers’s presentation, A tale of two cities - and two hospital cultures - management of complex organisational and clinical change]

"The management of change in complex settings" was a presentation by Professor Michael Powell, Professor of Health Management and Associate Dean (Research), University of Auckland Business School.

Powell is also Director of the Masters in Health Management and the Advanced Health Leadership Programme. He has been involved in research, teaching and consulting in the New Zealand health sector since the 1993 reforms. He has particular interest in the areas of governance, organisational change, clinical leadership and professionals in management roles.

The various changes in the New Zealand health sector have often meant changes to structures but have ignored other elements of an organisation:

Health reforms in New Zealand have focused on the "anatomy" of the health system rather than the "physiology" (let alone the psychology!).

Powell recommends a systems view, and reviewed a "four-frame" approach that considers the following four elements (Bolman and Deal, in Reframing Organizations, 1997):
  • Structural;
  • Human resources;
  • Political;
  • Symbolic.

In his description of this "systemic" approach to organisational change, Powell highlighted references in other Forum presentations that fell into each of these categories.

The structural frame is usually the starting point for much organisational change but organisations often do not look beyond it to other perspectives. The focus is on roles, responsibilities and reporting relationships. New information and financial systems are set up to fit these new systems.

Powell noted examples raised in the Forum presentations that fit into the structural frame (refer slide 5). These included tiers of management, formal quality control, clinical leaders in line management roles, flat structures, etc.

Examples raised in the Forum presentations that fit into the human resource frame (refer slide 7) included activities that addressed training needs in health management, professional development activities, etc. Cultural differences were considered in the Forum presentations but there was little discussion of individual differences.

The political frame considers health care organisations as political entities. It accounts for the complexity associated with such factors as multiple stakeholders, negotiations and bargaining, and the fact that there are usually winners and losers from change.

Concepts of culture clashes between doctors and managers, "revolutions" in health care management and clinical leaders as "union reps" referred to in Forum presentations fit into the political frame (refer slide 9).

The symbolic frame takes into consideration such items as the different meanings of change to different groups and the importance of rituals and ceremonies. The change leader’s role is to develop and present new meanings and visions.

Concepts of different subcultures, eg, caring versus curing, and a shift from treating illness to maintaining wellness referred to in Forum presentations fit into the symbolic frame (refer slide 11).

Powell reviewed the central elements, the leadership challenge and the leadership image for each frame (refer slide 12). For example, within a structural frame, central elements include new units, new roles and new reports. The leadership challenge is to align the structure externally and internally and the leadership image is that of an architect. However, in a political frame, central elements are winners and losers and persuasion. The leadership challenge may be to build alliances and recognise differences and the leadership image is that of an advocate or facilitator.

Powell concluded by summarising the usefulness of the four-frame model which offers a systems approach to change. The model encompasses most elements of the change process. It provides a framework for the review and analysis of change problems, which brings other frames to bear on a problem, which, otherwise, may have only been considered from one perspective. The model should be used flexibly and organically rather than mechanistically.

[View Professor Powell’s presentation, The management of change in complex settings]