Provincial Health Services Authority (BC)

  • John Andruschak, Vice President and Consolidation Lead, Pathology and Laboratory Medicine, Provincial Health Services Authority, Vancouver, British Columbia 

Change Management Meets Political Reality: Lab Reform in the Lower Mainland of British Columbia

There are two primary reasons for undertaking lab reform in British Columbia’s Lower Mainland (LM): to ensure patients continue to have access to quality diagnostic testing; and to secure a fiscally sustainable service delivery model. These two reasons have directed attempts at laboratory reform in British Columbia for the last 28 years. In order to make the changes to lab service delivery, physicians responsible for the various sections of the lab must be involved in the process to help describe how to make the changes in a manner that assures patient safety and that correct diagnosis, treatment or prognostic decisions continue to be made for the patient.

Meaningful engagement by physicians can be confounded by a number of factors that Change Agents must not only be cognizant of, but have put strategies into place to either eliminate or neutralize their impact. Within the lab LM consolidation project comprehensive risk assessments, mitigation and communication plans were developed and reviewed with leadership to provide assurance that stakeholder concerns would be recognized and addressed. When the lab physicians rejected the change plan – which was the expected response to the action – a show of resolve did not materialize and resistance was not mitigated. Physicians explained their actions as not being resistant to change, irrational, or unsupportive merely for the sake of non support, but as a deep expression of concern over the patient's or the organization’s viability despite clear evidence that the current laboratory system had significant deficiencies that were potentially harmful to patients and frustrating to treating physicians. While Change Agents are usually portrayed as undeserving victims of irrational and dysfunctional responses by the change recipient, it is also quite possible they have in fact contributed to the occurrence as a direct result of their own actions. (Ford J. et al, 2008 p362)

The literature is clear in describing the need to appreciate the cultural differences in gaining physician engagement and recommend a change management approach which recognizes the “expert culture”, which, in turn, is supported by the stature given to the physician on the health care team. As the change agent I had two choices: build stronger relationships, or get another expert to present the contrarian opinion. As the leader of the lab project team, both tactics were employed as well as several other key change management strategies: involving the lab clinicians in the change process; providing incentives to facilitate the desired behaviours; communicate, communicate, communicate; recognizing expert culture and securing early adopters. However, there were three primary factors that precluded these established change management practices from being successful.

1. Activation of the political agenda (the visit to the Member of the Legislative Assembly or MLA) when change agents failed to use the negotiated and established processes to attempt change to physician practice. The Physician Master Agreement clearly articulated that change in practice or service delivery was a matter for consultation between the British Columbia Medical Association (BCMA) and the Ministry of Health (MOH), not the Health Authority, in this case the Provincial Health Services Authority (PHSA) or individual physicians (i.e. pathologists providing lab services).

2. The resignation of the Premier of BC midterm and the subsequent drive by MLAs to arrive at a new leader generated a number of political cycles where there was extreme sensitivity to any controversy or issue which would result in the BCMA not being on side.

3. This political dynamic created a circumstance where it was not possible to impose consequences for non compliance for fear of the issue being externalized to debate in the public domain. This had always been an identified risk, but the identified mitigation strategy of moving to a legislated solution was not actionable.

For the last three years in order to carry out this intervention, I have been searching fruitlessly for the “holy grail” of physician engagement and questioning the change management literature in both its relevance and applicability to large system change (e.g. with regard to laboratory services consolidation). However, when engagement did come in the form of the Lab Reform Committee, it came as a result of a negotiated agreement between the MOH and the BCMA. In the last seven months, initiatives were identified that would improve quality, provide a new service delivery paradigm and provide the opportunity for significant fiscal savings. This was achieved because the political level was able to facilitate engagement by being very clear that a consequence of the proposed legislation would have the affect of removing control for governance, funding and operations from the BCMA: thus a real and meaningful consequence to not participating. The election is occurring at this time of writing but execution of many aspects of the original lab consolidation plan is occurring and the MOH has made lab reform a broad health authority goal which the HA board chairs must agree to meet.