Hospital System Assessment & Redesign for a New Millennium

Key Implications for Decision Makers

  • The introduction of a code of conduct during hospital amalgamation had a very positive effect on the organization.
  • Education opportunities are a key form of support during amalgamation.
  • More time is needed for middle-managers to give support to staff during the transition process. Both participants noted managers were too busy to do it.
  • Succession planning programs would help shape future leaders within the organization.

In general:

  • Harms from hospital integration are seen as short-term difficulties: inconveniences for patients, anxiety and stress for staff, pressures on budgets, and increased costs.
  • Change is constant and affects the entire organization, from physical moves to leadership changes. Constant change brings with it chaos and stress, which must be acknowledged and dealt with in order to make the organization effective.
  • Improving (or at the very least preserving) high-quality patient care is the most important issue for everyone in the organization, and this improvement needs to remain a central focus of and the main reason for the change.
  • Chaos/stress, culture, voice, support, and context are key elements of a model titled Managing Transitional Chaos that depicts the hospital integration process. This model looks at the process of integration, representing it as involving many fluid, inter-connected concepts.

Recommendations for addressing organizational change and the resulting chaos and stress include:

  • providing constant communication in the organization;
  • acknowledging, appreciating, and understanding different work cultures during amalgamation and working towards easing amalgamation;
  • providing ample and appropriate support throughout the change process to make the transition easier for staff; and
  • acknowledging, addressing, and seriously considering external forces affecting the organization under change (for example, nursing shortages, workloads, etc.).

These recommendations are interconnected and must be considered simultaneously rather than as isolated parts.

Executive Summary

In 1997, Ontario's Health Services Restructuring Commission ordered the Sudbury region's three hospitals to merge. The integration process caused a great deal of instability and anxiety in the Sudbury healthcare system. Currently, hospital services are still delivered at three sites, while a new hospital is being built on one of the former sites.

There is little evidence or information on how integration works in a northern, non-teaching referral centre that serves both rural and urban populations. As well, there are few studies on what managers and policy makers perceive to be the benefits and harms of healthcare mergers. This research project developed an evidence-based model to be used by managers and policy makers, both in the Sudbury region and in other similar jurisdictions throughout Canada.

Data were collected through semi-structured interviews at three times during the integration process. Three groups of people were interviewed each time: decision makers, care providers, and care recipients (that is, patients and their families).

The participants identified the key themes of constant change, and the chaos and stress change causes, which affect both the organization and its individuals. Change, as identified in the interviews, was not limited to physical moves; it was broader, covering leadership changes as well. Throughout the study, all people believed the hospital was operating in a continuously chaotic environment, and there was uncertainty for the future and frustration due to construction delays.

Besides constant change, chaos, and stress, a number of other significant themes were identified by the study:

  • Patient care was central in the discussion of restructuring. Many positive changes which occurred in the delivery of care and in the philosophy of patient care were highlighted. Although there were not any improvements by the end of the study, a number of participants stated that the quality of patient care was maintained during the transition period.
  • Voice includes perceptions around communication, input, and decision-making. Though all stakeholders agreed there can never be enough communication, they had different ideas about the best way to communicate.
  • Culture encompasses both the informal and the formal rules that govern the organization; in other words, the ways of "being" and the ways of "doing." Staff saw the standardization of policies and procedures across all three sites as a main concern, but there was also concern about the effect of merging three different organizational "ways of being."
  • Support involves three main issues: educational opportunities for care providers; leadership support in terms of decision-making; and financial resources.
  • Hope for the future showed mixed results. At different interview times, participants were either hopeful for the future or uncertain about the final outcome. Most participants felt there would be dramatic improvements once everyone was working at one site. However, the care providers and patients expressed uncertainty about this.
  • Participants identified many recurring contextual issues/external factors that added to the complexity of the integration process. These included professional shortages, financial resources, and government policy.

Specific strategies for improving the amalgamation experience included introducing a code of conduct, maintaining or increasing education opportunities, earmarking specific time for busy middle managers to give support to staff, and implementing succession planning programs to help shape future leaders within the organization.

Change is traditionally depicted as a linear process that moves from pre-existing conditions through the implementation process to stabilization. However, the data from this study suggest that the integration process is dynamic, characterized by constant change, and marked by repeating periods of normalcy and chaos. The proposed Managing Transitional Chaos model is a different way of examining and understanding integration, representing restructuring as a circular process with inter-connected concepts that could change from one moment to the next. Patient care, as the priority of the organization, is at the core of the model, encompassed by a state of transitional chaos that affects and is affected by voice (communication and input in decision-making), culture (processes used to operate the organization, procedures or standards of professional practice, codes of conduct, beliefs, and values), and support (leadership, education, and financial resources), all within the context of external factors (ministerial directives and human and financial resources). These concepts are inter-connected and are the main elements affecting integration and increasing stress among stakeholders.

Challenges around and strategies to cope with each of the key concepts are identified. Strategies for managing chaos include assessing the environment to determine challenges around support, voice, culture, and context. Strategies for increasing voice include using multiple ways to seek input, participate in planning, disseminate information, increase public awareness, and gain commitment and involvement. Strategies for considering the cultural implications of merging existing organizations include jointly developing and implementing standardized ways of "knowing" and "doing," using best practice guidelines, and standardized ways of measuring quality of patient care. Strategies for ensuring there is support for staff include providing adequate resources (human and material) throughout the process and ensuring that support (educational, leadership, and financial) is flexible, personalized, and appropriate for the situation and the context based on an assessment of the organization's needs. Strategies for managing external forces include considering implementing an evidence-based workload measure.