Leading Change at SJHC and LHSC

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Leading Change at SJHC and LHSC: Burr Under the Saddle or a Grain of Sand in the Oyster : 

Leading Change at SJHC and LHSC: Burr Under the Saddle or a Grain of Sand in the Oyster The transfer of perinatal services at St. Joseph's Health Care Centre (SJHC) to the Women's and Children's Services at London Health Sciences Centre (LHSC), included the relocation of clinical programs, 500 staff and about 40 physicians.

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SJHC's perinatal program had been among the hospital's premier programs and was recognized as a world-class tertiary perinatal program for more than 30 years. The hospital's comprehensive care for newborns included providing care for very sick infants and extremely premature babies.

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The move to LHSC was a source of much concern to key stakeholders, leading scientists and specialists with much negative impact on recruitment, retention and staff morale. The vice-president, acute and ambulatory care at SJHC and the vice-president, women and children's clinical business unit at LHSC were appointed to help prepare leaders throughout all stages of the restructuring.

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On their agenda were the following issues: culture, safety procedures, team conflict, excessive turnover, structure, leadership orientation, among others. Where should they start; and how could they get physicians, patient care leaders and staff to think past six months, given that there are numerous issues that keep them busy on a daily, weekly and monthly basis?

Learning Objective : 

Learning Objective The objective of the case is four-fold: To discuss the difference between transition and change. We would see the critical importance of readiness work. 2) To explore how to lead complex change, which includes change to structures, processes, systems, people and culture. )

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To emphasize the importance of emotional intelligence, and that skills associated with the emotionally intelligent agent of change are a requirement to lead deep and comprehensive change. To understand ways to gain influence as change agents when positions in the organizational structure hold no formal power. Informal power is the cumulative effect of caring and concern for others. These people can make a difference, but are not necessarily leaders.

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Central Issues: Personal Development; Organizational Change; Leadership; Consolidations and Mergers


HEALTH SERVICE RESTRUCTURING COMMISSION Established in April 1996, with balanced knowledge and expertise – made up of representatives from industry and health services with a: Two-fold mandate: to make decisions on restructuring public hospitals in Ontario: and 2. to maker recommendations to the minister of health and long-term care on reinvestments in and restructuring of other parts of the health system and other changes required to support restructuring generally and the creation of a genuine health service system in the province.

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The HRSC attempted to recommend changes that respond to the needs of Ontario’s communities in a cost-effective manner (To do more-and better-with less) HRSC started by the - use of the report by LACTHRC (an earlier committee for restructuring) – as well as several other reports for its analysis of the needed health service reform in London

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- invited individuals and organizations to provide input. - met with board members, administrators, and local politicians, physical and other health care providers to obtain more information and to clarify issues relating to London’s restructuring plans. That’s a good start….. What do you think about that?

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January 1997 report recommended: - options for clinical activities - the areas of governance, reinvestment and manpower adjustment were also made; -cost-savings and capital estimates were provided as well.

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This was to begin a process of coherent, constructive changes, renovations, and modernizations that would strengthen the local health system. The ff key outcomes were envisioned: 1. better quality of care 2. management and administrative efficiency 3. border health system integration 4. affordability of services and 5. accessibility to health service in the community.

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The HHSRC directed St. Joseph’s Care - to plan a low risk pregnancy program for approximately 1,500 births, and - all other services with respect to perinatal health would be transferred to the London Health Science Centre (LHSC - in 1998, a vision for the low-risk birth was created. What was the vision?

Original Vision Abandoned : 

Original Vision Abandoned A clinical panel, under the leadership of Sandra Letton and Margaret Nish, concluded the low-risk birth program should be transferred to LHSC together with the Perinatal Program based on: - clinical implications - potential risks - sustainability and - academic impact


THE TRANSFER OF PERINATAL SERVICE The Implications of the transfer Included the relocation of clinical programs, staff and physicians – more than 500 staff and about 40 physicians, trainees and researchers were involved. The new LHSC facility would house capacity for 6,00 births, 42 neonatal intensive care beds, 70 antenatal among other services.

Profile of the SJHC’s perinatal program : 

Profile of the SJHC’s perinatal program Had been among the hospital’s premier programs and was recognized as a world-class tertiary perinatal program for more than 30 years. Comprehensive care for newborns Did a full range of surgical procedures, with the exception of cardiac surgery. The perinatal transfer was therefore considered a major project.

Concerns of Key Stakeholders : 

Concerns of Key Stakeholders The move to LHSC, where the program would be one premier services, was a source of much concern to key stakeholders, leading scientists and specialists with potential negative impact on recruitment, retention and staff morale.

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The general perception of women who were recent and expectant patients of London's maternal care units was that LHSC and SJHC were good hospitals with specialized areas of operations. But they were suspicious of the motives for changing a maternal care system that seemed to be working well the way it was.

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???? A lot of the sub-specialists that we need re actually off-side, at LHSC, so there’s a lot of travelling back and forth across the city. The ‘what ifs’: What if we find that a certain part of the care model doesn’t really work? What if we don't have enough storage spaces?

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It’s a bit of a stretch sometimes, and it ends up taking a lot of time and individual resources. As a result there is a need for some adaptability within the current design in order to cope with the unanticipated (proactive).


THE CHANGE AGENT Sandra Letton (DJHC) and Ellen Rosen (LHSC) advocated for a new model of organizational development resourcing, to prepare leaders throughout all stages of the clinical restructuring: pre, during and past.

Profile of the Change Agents : 

Profile of the Change Agents Lianne Collins and Rebecca Parkes were appointed as the ‘citywide change agents’. Collins and Parkes had extensive backgrounds and experience working together in change management, leader development and executive coaching in both the public and private sectors and primarily in healthcare.

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Relayed Experience: From 1995 to 1999, and Parkes and Collins had been involved, as external consultants, in the integration of non-clinical services at University Hospitals, and when University Hospitals and Victoria Hospital integrated, they had organized a similar integration at LHSC.

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Collins continues her external consultant role in clinical environments until 2003. Parkes returned to a citywide role in 2000 as part of the clinical restructuring (mandates by the provincial government in 1996) between SJHC and LHSC. Collins joined the citywide clinical restructuring in 2003.

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The first phase of clinical restructuring, Milestone I, included the transfer of 28 clinical programs and services between LHSC and SJHC. Parkes and Collins were reassigned to the second phase of clinical restructuring involving Perinatal Services at SJHC and Women’s and Children’s Services at LHSC in the fall of 2005.

The Main Task : 

The Main Task To establish a readiness for change, in the years leading up to actual transfer.


THE CHALLENGES Fiscal constraints Expanding care requirements Changing demographic in the provider population Established citywide agreement with unions of both organizations Staff of both organizations was anxious about the change and its impact on care delivery, the workplace and the quality of work life.

Challenges - Cultural Differences : 

Challenges - Cultural Differences Governance Size (LHSC was much larger) Leadership structure and existing management systems - SJHC was smaller and therefore more close- knit; it was “relationship-oriented”. - LHSC was perceived to be more task- focused and soiled in its approach.

Challenges - -Faith Base Belief : 

Challenges - -Faith Base Belief SJHC’s embedded processes based on Catholic beliefs; whereas operations at LHSC were secular based: for example, abortions were not performed at SJHC but would be performed at LHSC (the decisions belong to the family and the physicians). It was predicted that the change agents would need to work through the differences in religious beliefs.

Challenges - -Decision Making Process : 

Challenges - -Decision Making Process What will the decision-making process be at the integrated LHSC? Who should decide? How should the transition in decision-making processes be communicated? How would top decision makers manage conflict in opinions and values? How could they create a common language? Policies and procedures, and even the interpretations of the policies and procedures should be agreed upon prior to moving.

Challenges -Leadership Structure : 

Challenges -Leadership Structure Both SJHC and LHSC had a tri-partite mission – patient care, teaching and research. The differences in structure and leadership boiled down to the following: - at SJHC, shared leadership provided a structure and process for involving health care providers in decision making problem solving and improvement activities.

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- At LHSC, the management model and organizational structure was more layered; designed around business units and four leadership layers – top-down.

General Issues : 

General Issues At least one nurse from LHSC was not concerned about the cultural differences. To some it was almost a bit of a joke because they didn’t know when it was going to happen.

Demographics: an Aging Workforce : 

Demographics: an Aging Workforce Staff at SJHC was getting older; a significant number of individuals could elect to retire when perinatal services would transfer to LHSC. Health care landscape in Ontario was faced with a competition for talented health care providers. ??? Real concern among them was that the standard of service could be comprised if a large number of staff could choose to retire.

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What could the leadership at the two hospitals do to retain the best people? How to attract the best health care providers in the new unit, and thereby guaranteeing the highest quality of care and excellence in research and teaching? ??? Could a divided culture in the decision to continue employment or leave the integrated LHSC? Conflicts in patient care terms – composed of SJHC and LHSC staff physicians – could linger for many years.

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The physicians were also highly mobile. There’s the potential for people to leave; on the other hand, if we design it right there’s the potential to really attract people too.

Potential Conflict within Teams : 

Potential Conflict within Teams Conflict could affect team effectiveness and the subsequent level of care received. How would LHSC ensure public confidence in the services it provided? People were equally split between positive and negative reactions to move all high-risk care to LHSC - women who had given birth at SJHC were more likely to have negative feelings, based on a sense of loss of “their” maternity hospital

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- Even those who felt positive about the plan had nagging concerns about the availability of care in a large unit with staff forced to merge. - Women wanted to know that all of the front-line workers physicians, staff midwives – supported the changes involved

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- The ability to deliver safe patient care - Worry about potential conflict in patient care teams. - What can be done about the potential for conflict?

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Individual, personal concerns - The LHSC staff expressed concerns about being overwhelmed by the large influx of SJHC staff. - “How will the transfer affect me?” - People at LHSC were anxious about new knowledge and skill requirements and learning curves for the physicians in less acute, less technical primary and secondary programs.

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- Some people at LHSC did not perceive themselves to be “|the top of the heap”, resulting in worries about their individual status in the new program. - The biggest concern is about personalities and possible power struggles.

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Dr, Roukema had a different perspective: for him SJHC would move in without a change in the way they do their work; “for us it’s not going to be so much of a change in culture, at least with respect to the amalgamation, we plan on taking the organizational model as we have it”.

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For the nurses who are close to retirement their concerns were whether they were going to have their jobs; and whether they were going to get along with nurses at LHSC, some have been working in this area 20 to 30 years.

Managing the Human Side of Change : 

Managing the Human Side of Change Physicians and staff were expected to work in teams, but the values espoused and cultures at SJHC and LHSC were quite distinct. What steps would need to be taken to enable a smooth and safe transition; to create respect and high-performing teams? Need for adequate support and preparation for the transfer of programs, services and people, to achieve the desired outcomes; try and give people as much information as you can. Don’t hide anything from them.

Implications of Union Agreements : 

Implications of Union Agreements Parkes and Collins had to operate with the limitations and conditions of the internal organizational collective agreements with the various unions including citywide unions.

Key Issues in the Agreements : 

Key Issues in the Agreements The citywide agreements were originally constructed and signed at a time when there was a surplus of staff and lay-offs were predicted. The agreements dictated that staff who have elected to transfer can change their mind right up to the actual transfer date and can bump back to their organization anytime within one year following the transfer date.

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During the transfer year union members operates within the collective agreement of their original organization.

Implications of the Agreements : 

Implications of the Agreements It was difficult to finalize the planning for adequate staffing at both organizations when at any time a staff member can reverse his decision. The potential gaps created in staffing worsened the already existing problems of staffing shortages and an inadequate causal pool of nurses. Even when staff chose to transfer there are impacts that need to be managed.

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The resultant unit now has an integrated seniority list from both organizations; a senior member at one organization may find themselves less senior within the integrated team. This change in seniority status had implications for selection of time off, vacations time, and promotions.

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Operating under different agreements during the year of transfer meant differences in pay, scheduling benefits, etc. for nurses working side by on the same shift; this interfered with team integration.

Complacency and urgency for change : 

Complacency and urgency for change The atmosphere at both SJHC and LHSC was very pressure-prompted, dealing with what was urgent and pressing, first. Complacency as an individual’s inability to deal with the feeling of ambiguity and discomfort of a future that was relatively unknown and unpredictable.

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The actual transfer of Perinatal Services to the new LHSC facilities would take place until 2009 but because clinical restructuring, dates and timelines were postponed many times, feelings of skepticism and complacency were generated in leaders, physicians and staff.

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Developing strategies to deal with both feelings of complacency and those of impenitence and urgency proved to be a real challenge for the Parkes and Collins given the timelines were out of their control.

context : 

context Collins and Parkes were cognizant of particular “organizational realities”. They were not part of the perinatal group; they had no formal authority over the medical staff How would they engage the physicians, patient care teams and front-line leaders? Observers described physicians as “not used to seeking approval”. Both hospitals had unions representing nurses. How would Collins and Parkes generate enthusiasm and cooperation from the union leadership?

Task and success factors : 

Task and success factors Their task was to cultivate “leaders” who had the capabilities to obtain buy-in and cooperation from many self-directed and autonomous groups. To be successful, these leaders would need to actively attend to the human side of change and deal effectively with their own, and other people’s feeling and emotional reactions while implementing the complex changes.


HOW TO PROCEED Profile of the change agents Parkes and Collins were selected to lead the transformational project based on their experiences of designing and implementing system-wide change in healthcare systems, as well as the practical experience and learning acquire from earlier transfer.

Limitations of the change agents : 

Limitations of the change agents Parkes and Collins were well aware of what they could influence and what was outside of their control including: - facilities readiness and timelines - dollars available for clinical restructuring - citywide union agreements - launching of other organizational changes

The 3 Pillar Strategy : 

The 3 Pillar Strategy The agents designed a strategy for the current transformation based on three pillars: - leadership - culture - systems integration and alignment Their task was not an easy one. If left unsupported and mismanaged the transfer could compromise clinical outcomes, recruitment and retention of talented providers (nursing, allied health and physicians) and escalate costs

The Way Forward : 

The Way Forward What should Parke and Collins do to ensure that the transfer would not compromise clinical outcomes, recruitment and retention at reduced cost?

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Case Question: What are the key challenges facing Rebecca Parkes and Lianne Collins? What should they do now? Evaluate the pros and cons of all possible alternatives. Personal Question: If you were Rebecca Parkes and Lianne Collins, what would you do now? Why? Additional Class Prep Personal Mission Statements due.

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1) What is your definition of effective leadership? How did you arrive at this definition? 2) What are the characteristics of effective leadership? 3) Describe examples of effective leadership. These can be historical figures, people you know, or people you have observed. They can even be fictional (i.e., from novels, movies, etc.), as long as you can describe them.

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4) Describe the outcomes of effective leadership. What happens that’s special and different when leaders are effective? 5) Have you been an effective leader to date? Why or why not? Illustrate this with examples. 6) What do you need to do to improve your leadership effectiveness in the future?

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