Organizational Change in Healthcare with Special Reference to Alberta

Key Implications for Decision Makers

Policy Makers

To encourage the successful implementation of health system change, policy makers should explicitly recognize the tension between the need for both provincial standards and local variation, and the time and intensive human effort required to accomplish change.

Senior Leadership of Regional Health Authorities

Middle-level managers play an important role in implementing system change, encouraging front-line workers to adopt change and facilitating change at upper organizational levels. Yet these managers are assuming so much of the responsibility for implementing change that they are burning out in the process. To ensure the health system retains and develops strong middle management capacity, these individuals need to be given immediate support, including sufficient time and resources.

We observed pockets in the health system that implemented desired change through leaders' cultivation of capacity for building positive work relationships, articulating the principles or significance of people's efforts in changing, and providing cross-level system support needed for change implementation. These pockets showed us that it is important for more areas of the health system to cultivate this kind of capacity for changing.

Change Leaders of All Levels in the Organization

To accomplish desired change, it is critical to pay attention to the less remarkable, less visible, but nevertheless quite significant and essential, everyday "change work." This involves capitalizing on opportunities, proving the value of changing, and altering or creating symbolic forms, such as classifications and principles that support change. It is also important to celebrate small wins that consolidate gains in change while energizing continuing efforts.

To encourage professionals to change behaviour, it is useful to draw on multi-faceted approaches such as explanation, encouragement, or creating circumstances and systems that make it easier for professionals to implement change, or more difficult not to change.

Researchers and Decision Makers

In embarking on a program of research, researchers and decision makers can meet their individual and joint needs by discussing not only the content of the investigation but also the relational foundation of the proposed collaboration. What are the mutual benefits to each of being involved in the research? How and when will research findings be shared? What relational practices can be implemented to enhance the quality of the collaboration and research outcomes? As a result, they can plan to work collaboratively on actions that contribute to the research process.

Executive Summary

The need to effectively implement organizational change is of strategic importance for healthcare leaders as they face continuing pressures to reform healthcare. Yet this task is far from straightforward. The most carefully developed plans for change can disintegrate during implementation, disrupting the lives of people who work in health organizations as well as the service delivery they manage and provide. In addition, organizational research points to the difficulties associated with implementing system change into well-established organizations such as those in the healthcare sector. Research has determined, for example, that as patterns of work become established and taken for granted, they become highly resistant to change. Research has also shown that significant change often originates in events external to the organization, such as mandated regionalization in the case of healthcare.

Although prior research has advanced knowledge about why organizations do not change and the importance of external origins of change, it provides only limited understanding of the internal and contextually situated processes that people undertake to produce organizational change. In this five-year (July 2000 - December 2005) research program, through our decision-maker partners, we were able to gain a close look at how people accomplish change in health organizations through their persistent and everyday efforts. As a result, we have been able to generate knowledge on implementing change that contributes to extant organizational theory and provides insight for decision makers undertaking health reform at the organizational and system levels.

Our program of research consisted of two phases.

In phase 1 (July 2000 - June 2003), as a team of researchers and decision makers, we identified four key areas of change to investigate; these initiatives were being implemented in different parts of the Alberta healthcare system at either provincial or regional levels and were relevant for our decision-maker partners. We closely followed the changes of healthcare regionalization, transforming the delivery of continuing care, primary healthcare reform, and introducing the nurse practitioner role . We focused on understanding the "everyday" work of implementing change as undertaken not only by top management, but also by middle managers and front-line staff. By examining the real-time work involved in producing these changes, our research disclosed and explained how individuals accomplished organizational change, articulating the micro-processes, practices, and symbols created and used in implementing desired change.

In phase 2 (July 2003 - December 2005), we investigated two cross-cutting themes: restructuring organizational units and altering provider relationships . Earlier analyses had suggested that change initiatives in these areas were more difficult to implement because they required individuals to alter established practices and re-interpret their professional and/or organizational identities.

We briefly sketch the four change initiatives and two cross-cutting themes below.

  • Project #1: Healthcare Regionalization . In 1994, the Alberta government regionalized the delivery system by creating 17 new geographic entities called regional health authorities. In 2003, a second phase of regionalization reduced this number to nine. We investigated the relationship between regionalization and changes in healthcare delivery, attempting to understand how structural changes affected service delivery. Our analyses show the importance of cognitive change in accomplishing regionalization. Briefly, through regionalization, the government mandated a significant structural change to the system and used a coercive approach to push through the first stage of implementation. From this point forward, it was critical that key actors in the system changed their way of thinking about how the system should function and how they would relate to each other. One way key actors resolved differences was to develop co-operative working strategies at the front line, even though they maintained fundamental disagreements at the system level. These disagreements continued to be represented in different stakeholder perspectives about regionalization.

  • Project #2: Transforming the Delivery of Continuing Care . Continuing care is a major component of the health system, providing ongoing health services for the elderly and clients with special needs. Our analyses of regional planning documents showed that regions differed in their response to this provincial reform, based in large part on the proportion of elderly in the population served. Investigations of implementing this policy over a four-year period in the East Central Health region and another region's long-term care facility showed that transforming the delivery of continuing care requires attention to both the structural redesign of care and the cultural principles that provide the significance for proposed changes. Middle managers consistently articulated principles honouring choice and control and worked persistently with front-line supervisors to translate the new cultural principles into practice. Front-line supervisors worked every day with staff to change routines and cultivate new care practices that realized the desired culture. Senior managers co-ordinated principle-based relationships among community and staff.

  • Project #3: Primary Healthcare Reform . Primary healthcare has been a priority across Canada . While many studies point to physicians as cost-drivers and resistors of change, our investigations of an innovative primary healthcare partnership strategy in the Calgary Health Region found that their input and support facilitated reform efforts in primary healthcare. Although top management provided guidance and support, decisions about how to implement new trategies for primary healthcare were left to middle managers in collaboration with service providers. We also found that learning to provide services in new ways was facilitated by drawing on dynamic capabilities already existing within the organization. In particular, learning occurred through experimentation, and the use of pilot projects provided a mechanism for encouraging creative approaches. This organization-wide approach to learning through experimentation required significant managerial involvement, especially in managing the tension between the unrestricted development of local initiatives and organizational needs for guidance and control.

  • Project #4: Introducing the Nurse Practitioner Role . The number of Alberta nurse practitioners has grown from approximately 15 in 2000 to 130 in 2005. A large percentage of nurse practitioners work in Capital Health, and for this project we partnered with this health authority. Based on our interviews, meeting observations, and archival data of the introduction of this new role, we developed a model of change that explains how embedded actors, in this case nurse practitioners, legitimize the new role through their use of three micro-processes of change: (1) use every available opportunity to advance the change initiative; (2) carefully fit the desired new way of working into established organizational structures and systems; and (3) consistently prove the value of the innovation to others. We also found that nurse practitioners and their managers engaged in a change strategy of "small wins" that celebrated accomplishments while providing a platform that energized continuing efforts. In related research, we found that middle managers made important contributions to the change process by assisting with the reallocation of tasks that occurred with the addition of the nurse practitioner role. These managers provided guidance that helped team members develop new working relationships with the nurse practitioner, and they kept a focus on the advantages of introducing nurse practitioners that was critical in moving through the disruption of integrating a new team member.

  • Cross-Cutting Theme #1: Restructuring Organizational Units . This theme examines cultural dynamics in restructuring. The first project identified how a reciprocal dynamic between culture and positive work relationships creates a type of resilience or capacity for a system and its members to endure conditions of extreme change. Cultural symbols not only shape individuals' capacity to develop positive organizational relationships, but positive relationships keep symbolic forms alive and re-infuse them with meaning and significance. These relationships become a life-enriching and energy-producing resource that broaden individuals' repertoires for dealing with change and help them reframe difficult experiences from helplessness and lack of control to hope and purposeful action. The second project examined the merger to form the new David Thompson Health Region. A first set of analyses disclosed innovative cultural practices in merging that call upon prior region and local unit strengths to develop policies and business processes. These practices include flexible application of policies within general standards and consistency expectations; intensive relational work early on for colleagues from various locations to get to know one another; and cross-cutting task committees that bring together members from different prior regions, locations, and sectors of the new region. The third project involves comparative analyses of identity dynamics in merging, with collaborators from the University of Montreal and its HEC business school. Drawing on data from healthcare mergers in Alberta and Quebec , we are examining "identity work," the strategies in dealing with merging that individuals use to alter their own and others' identities, and that managers use to construct a new organizational identity.

  • Cross-Cutting Theme #2: Altering Provider Relationships . Joining with collaborators at the University of Lethbridge , we conducted comparative analyses of change initiatives (introducing nurse practitioners, reforming long-term care, reforming primary healthcare, and restructuring the rural physician clinic) oriented to institutionalizing new ways of working in health organizations. Our analyses found that in each initiative, key actors at the organizational, group, and individual levels identified new valuable practices and took purposeful actions in an attempt to spread these practices throughout their organization. We identified the role of institutional change champions and found that they invested heavily in the process. They used three complementary approaches as they attempted to influence the institutionalization process: they managed the meaning of the desired changes; they focused attention on desired changes; and they created physical situations that encouraged people to try the new ways. We suggest that the role of institutional change champion is critical to the long-term success of organizational change initiatives. Currently, there is more attention given to entrepreneurial activities (developing new ideas and experimenting) but to implement changes and gain widespread acceptance, a longer-term, more nuanced and patient agent of change is required. Through our focus on actions designed to spread change rather than initiate it, we draw attention to a critical component of the overall change process.