HSA helps put the brakes on program management

The Report: April / May 2000 vol.21 num.2

by PAM BUSH and REBECCA MAURER

HSA members in the Capital Health Region have helped put the brakes on a plan by their employer to introduce an extreme form of program management.

The plan, championed by CEO Tom Closson, would have seen the elimination of key departments such as physiotherapy, social work and respiratory therapy. Instead, paramedical professionals would have belonged to one of nine program areas and would have reported to a program leader, in most cases, a nurse.

"The obvious problem with this form of program management is that it eliminates any opportunities for clinical supervision, professional guidance or support," says HSA President Cindy Stewart. "Not only is this damaging to our members sense of professionalism, it is potentially damaging to patient care."

Val Avery, District Representative for the Capital Health Region, agrees. "Meeting after meeting, we told senior management that their plans to dismantle departments would lead to fighting between programs for staff and resources," she says. "Our members were also very concerned about the loss of clinical supervision and career laddering."

To voice their opposition, members in the CHR attended many of the department meetings where Closson outlined his plans for program management. Members spoke passionately about the impact that program management would have on paramedical professionals education systems and sense of collegiality.

This effort finally paid off in early February when the CHR announced that they would not proceed with plans to eliminate hospital departments "at this time." Officials from the CHR say they are still committed to the objectives of program management, but recognize the many problems associated with the dismantling of departments. They say this shift is not connected to the announcement only weeks prior that Closson is leaving the CHR to take a position in Ontario.

Avery says while members are very pleased that the health region took HSAs concerns seriously, they dont believe they are out of the woods just yet.

"We have to remain vigilant," Avery says. "We have reason to believe that despite Mr. Clossons departure, there are other senior managers in the CHR who have this model in mind."

For this reason, Avery says HSA will continue to oppose any measures that threaten the collective agreement or undermine the structures that support paramedical professionals.

"There is no doubt that the team concept is important," Avery notes.

"But I dont think that we need to move to a fully decentralized model. We can continue to deliver excellent care without removing support systems for paramedical professionals."

-• the allegiance to a program management model may result in a decline in the commitment to identification with the profession, possible compromises with the standards and value stances of the professional, a lack of support of informal collegiality that may have served as a source of positive reinforcement for occasionally overburdened or even demoralized professionals, or a further devaluation in the status of the profession." ... The Impact of Hospital Restructuring on Social Work Services: The Case of Sunnybrook and Womens College Health Sciences Centre, Jospeh H. Michalski, Ph. D., Elizabeth Creighton, M.S.W., and Linda Jackson, M.S.W., October, 1998.

What is program management?
Program management, also known as "patient-focused care," involves the reorganization of services into "programs." Exactly how services are divided varies from region to region. For example, while the Capital Health Region planned to introduce nine programs, the North Shore Health Region has decided on six.

Other features of program management, which may or may not be incorporated into the model at any particular facility, include:

Whether a facility or health region adopts some or all of the features of a program management model depends on a variety of factors, including the size of the facility/region, the type of service that is provided and management style.

This explains why reactions to program management can vary from facility to facility. In some regions, measures normally associated with program management have been introduced with minimal disruption. However, in extreme cases, program management includes the elimination of departments and the support systems upon which paramedical professionals rely.

Murray Shaw, a steward at Vernon Jubilee, has experienced the consequences of program management first hand. He says that with the elimination of departments, there are no opportunities for paramedical professionals to participate in planning decisions. This point was illustrated when his health region recently opened a multi-level care unit in their extended care facility.

"Patients are transferred there when they no longer need acute care services, but arent yet ready to go home," Shaw explains. "But because there is no longer a social work department, planning for the new unit took place with no input from social workers ... even though we are the people who do the work to make sure that services are in place when these patients go home."

Why are so many health care administrators experimenting with program management?
Some health care administrators tout program management as a solution to many of the ills of our health care system. They argue that it will improve the quality of care for patients, empower staff, create strong partnerships between doctors and other staff, and improve the linkages between hospital and community care. They also claim it will make health care delivery more cost-effective.

-Some people describe program management as the flavour of the month, but as far as Im concerned its not a flavour, its a bad taste." ... Debra Gillespie, Chief Steward, Juan de Fuca Hospital

There is little, if any, credible evidence to show that program management will achieve the results that administrators claim. In fact, where independent research has been conducted, it shows that the opposite has been the case.

In 1997, the Hospital Management Research Unit of the University of Toronto conducted a longitudinal study looking at the restructuring process at Sunnybrook Hospital in Toronto. The study concluded that "global levels of patient satisfaction with in-patient acute hospital care have not changed markedly since 1992 [when program management was implemented]."

The conclusions are even more damning when it comes to the impact on health care professionals. The reports says "employees •express decreased satisfaction with many areas of their work and work environment. Specifically, staff wanted their needs considered in policy decisions, and open and honest communication from senior leaders."

The Sunnybrook study was conducted when program management was still in the implementation stage. Since then, the hospital has realized that professional practice issues require significant attention, and has appointed a Professional Advisory Council Chair to oversee the hiring of "professional practice leaders" who will address clinical, education and research needs for the decentralized professions.

The same situation occurred at the University of Alberta hospital, which also eliminated professional departments. Six months ago, the hospital finally recognized the problems associated with program management and created positions for "practice leaders" to address professional issues.

-HSA will oppose any measures, in any health region, that compromise the integrity of our professions." ... Cindy Stewart, HSA President

Another Sunnybrook study that looked specifically at the impact of program management on social work found a decrease in the amount of time spent on education and professional development (from 7.2 per cent in 1995 to 4.3 per cent in 1997), and no increase in the amount of time spent on research (one per cent). The study notes, "thus an irony emerges in that while knowledge continues to be touted as a key resource in program-managed care facilities, the actual time spent engaged in education and research activities appears to have declined in this particular setting."

The study further notes that the hospitals restructuring effort involved cutting the social work staff from 36 full-time and six part-time social workers in 1994, to 30 full-time and five part-time social workers in 1997. This included the termination of the positions of "chiefs" within each profession.

The study says that the implications for the loss of leadership roles are clear. "Social workers have no profession-specific advancement opportunities in a program-managed hospital. Those social workers interested in leadership opportunities must pursue these positions outside the profession, typically in competition with nurses and other disciplines for a small number of leadership or management roles. The social worker who values and desires a mentoring role, clinical consultation, teaching students and pursuing research projects may not find these opportunities to be as available in the program-managed environment."

-There is no question that our members made a significant contribution by speaking out against this plan whenever they could. And HSA made it clear that we would use all resources available to us to protect our collective agreement." ... Ron Ohmart, HSA Labour Relations Officer for the Capital Health Region

Not surprisingly, the study concludes that while the hospital has realized some positive objectives of program management ... including more time spent on direct patient care and less time spent on administrative duties ... "the findings do not support the literature on patient-focused care which implies that staff should experience a high level of job satisfaction working within this model of organizational design." In fact, the study confirmed that social workers had "a heightened sense of isolation from other social work colleagues following restructuring" and that "over time, social workers views about program management became increasingly negative."

Research in other jurisdictions
Stewart says research done in other provinces simply confirms what HSA members have been reporting for years.

"Health regions in BC should be taking a very careful look at facilities where program management has been tried and rejected," says Stewart.

"Rather than wasting thousands of dollars experimenting with program management, they should learn from the mistakes made by health administrators in other jurisdictions. More importantly, they should listen to the concerns of health care professionals who actually deliver the services."