The Role of Health Managers in Workforce Restructuring

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The Role of Health Managers in Workforce
Restructuring

• David Briggs
• University of New England
• ACHSE Seminar 2006
• Managing in a changing environment of corporate
  and financial services.

2
Or

• Or
• what have frogs, bicycles, donkeys thoroughbreds
  and a princess in a pond got to do with health
  managers
• ?
• Some lessons from the experience of Australian
  and NZ health managers
• ?
• An interpretative qualitative study

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Health managers perceptions of the health system

• The overwhelming perception of the participants
  is of a health system that is best described as
  being pre-occupied with constant change while not
  being particularly adaptive and responsive.
  Collectively the sub themes are constant change
  and complexity, bureaucracy, politics and a
  non-adaptive system of parts. This presents a
  reality that the components of the health system
  are just that and that they do not operate
  effectively in a systemised fashion (Briggs 2006)
• The other themes to emerge include the unique
  role', career and learning of health managers
  and the stakeholders
• Three decades of constant change

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Question

• What reasons do politicians and senior
  bureaucrats give for a restructure when
  announcing this fairly regular occurrence?

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Answers

• Create efficiencies and release funds for
  clinical services
• Reduce the number and levels of management
• Make services more responsive to the needs of
  communities

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Question

• Do restructures achieve those objectives
• Change is inevitable and constant
• Does/should restructuring focus on the
  organisational design or service delivery

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Organisational design the views of Australian
health managers

• System design and sense of organisational
  structure is just so relatively unimportant
  compared to having good people. Your good people
  will find networks and find ways to get things
  done. Because a lot of our structures are quite
  evolutionary, kind of backward. (GM04).
• its extremely difficult to get them from our
  health service over to somewhere close to the
  home. It is kind of breaking down the silos in
  other health services as well as dealing with the
  silos that exist here (AH04).
• And a change, to even change one small thing.
  Means that the whole pile of other things that
  flow on from it have to be changed too. So, we
  dont adapt what we dont change (MM03)
• Constant restructuring does not necessarily
  produce effective change or efficiencies
  (Braithwaite et al 2006)
• Keep organisation structures simple and focused
  on service delivery. Form should follow function
  (Zinn Mor 1998)
• Concentrate on people and how to deliver care,
  work in teams with others and with communities
  and clients

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Australian Health Workforce

• Between 1991 and 2001
• Registered Nurses increased by 6
• Enrolled nurses decreased by 21.4
• Carers and Aides employed in health increased by
• 20.3
• Medical Professionals increased by 11.2 (25 of
  GP workforce from overseas)
• Managers increased by 10.1
• Business/computing professionals increased
  by16.9
• Average increase of 10.5 in the total health
  workforce
• There are growing shortages of health
  professionals, particularly doctors and nurses
  and these shortages are increased in rural and
  remote areas.
• Workforce substitution
• Global impact

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Who is correct?

• So as (CE) said you know it should be business as
  usual at the clinical level, it should make no
  difference to how care is delivered and I wanted
  to say to him well if, if thats the case why are
  we doing it. Really, I had to ask, you know, if
  were not making any difference to people or
  peoples experience for the outcomes or the
  clinicians. Why continue to do this? (NM06).

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Complexity

• Higher levels of complexity are seen as reactions
  to changing external parameters prompting dynamic
  readjustment from within the system (Cole 2003
  pp.323-338)
• Workforce is not a passive object, but agent in
  complex turbulent system-both shapes and shaped
  byenvironmental, social and political factors.
  (Mickan 200250)
• Shifting political ideologies in western liberal
  democracies-free market economies, small
  government, economic rationalist and competitive
  reforms.

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Do restructures allow more effective decision
making

• I have to go through, four (4) or five (5)
  layers of people who all have their own thing.
  And theyre away, you know, so, you know it might
  take a, a week to get up to the one person, then
  it might two weeks up to the next person, and
  then you know, whatever(NM06).
• Im being nailed for my budget, theyre being
  nailed for theirs. Everybodys worried about
  whos is going to get costed to who? Um, you
  know, its, its just a barrier (to) integration
  (NM06).

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Complex but not adaptive

• I think organisational changes and restructures
  create a huge amount of destabilisation and
  distractionI think theres huge amount of
  instability and lack of direction that filters
  down through, all the area health services and
  right down to everyone whos providing services
  and right down to the patients( NM04).
• Need to focus on partnerships, networks and
  evolving relationships to find better ways to
  deliver health care

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Lacking power and influence

• I felt like I was the princess of the pond
  with a spoon with all the holes in it, to empty
  the pond and there were these enormous tankers
  down the other end filling it up(OD01).
• and probably I cant put my finger on what, on
  the big difference I make now (AH06).
• youre part of delivering it rather than
  necessarily setting the agenda so to
  speak(MM01).

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Health Management role in change and restructures

• Sensemaking managing people
• Engagement
• Leadership
• Communication
• Decision-making
• Financial management and budgets
• organisational design, strategy, quality, and
  safety

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Health managers engage in sensemaking to manage
change

• I try and make sure I understand the changes that
  are occurring and then I make sure that theyre
  part of everybodys orientation so that we at
  least try and get staff to understand
• really coming back to fundamentals to say ok
  what are we trying to do here and does this make
  sense and how much value does this create and
  having that critical thinking which is so
  important. Its that critical thinking and the
  ability to challenge and think outside the square
  and the ability to just not take things, the
  status quo as is. (NM04).

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Manage self resilience

• I think you also have to learn how to manage
  yourself. I dont think you can actually manage
  people unless you kind of know how to manage
  yourself as well (AH04). You also need to have
  faith in your own ability (GM03) and have
  self-belief, certainly a lot of kind of, sort of
  self-belief would actually be critical and, to
  be personally self motivated and to work in that
  environment it must create a lot of mental
  strength(GM04)
• you definitely have to have that idea of broad
  vision otherwise it becomes very disheartening at
  times.

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Big picture and flexibility

• You do need to be flexible and you do need to
  always have your eye on that bigger picture as to
  what is happening (AH04). It requires the
  ability to change and be flexible and
  accommodating in different situations (NM04).
  Flexibility is the key and having that broader
  picture focus as well, because you dont operate
  in isolation (AH04).

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Sensemaking protection

• does anybody know what we are actually doing, so
  theres that frustration I suppose thats where
  you use your retrospect view to say look, this is
  just the way it works, its up and its down and
  you have got to, sort of, cope (MM01).
• I actually try and use the other clinical
  managers for a sound off and a whinge and try and
  keep the staff stuff off that, so that you dont
  betray that frustration onto the people that are
  actually just doing the work. There is enough
  negativity around without adding to it yourself
  (MM01).

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Resilience - passive acceptance and opportunity-
the story of the hedge
like trimming away at a hedge, and what she does
is that, she keeps trimming away at this huge
hedge, right, and eventually she find a way of,
trimming right through the whole hedge and
create the thing that you need to get through.
And snip by snip, and then eventually you get an
opportunity where you can kind of crash through
(GM04).
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Challenges to change and effective management

• Organisational design
• Professional cultures, structural issues and
  power
• Teamwork individual role, interprofessional
  roles and organisational objectives
• Leadership transformational managing up -
  transitory
• Empowerment requires trust and investment
• Competencies and Capability
• Continuing Professional Development

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Health management role is seen to be unique is
viewed positively and valued

• I work in it because I believe in, that it is a
  public good. I want to make a lasting difference
  actually (AH06).
• Theres an essential value in health management
  in a human sense and in the societal sense both
  in the public and the private sectors. (GM01)
• I love a challenge. And this is a really
  challenging role (NM06).
• really thrilling, like intellectually and
  personally (GM04).

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Continuing Professional Development

• Lifelong Learning
• Networks
• Mentors and role models
• External engagement
• Discipline or Inter disciplinary
• Professional Colleges
• Accreditation
• Journal clubs
• Rural clubs
• Benchmarking and best practice

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• In a sense of thinking about the system, you
  know, you have to think of it like a FROG. You
  know if a frog is just put in water, laughter
  if the water is gradually heated its nice and
  content there but it dies.
• I just wonder sometimes that kind of complex
  nature of the health system, some people are
  quite content to sit in the boiling water, not
  quite realising they are actually in boiling
  water.
• Some people approach it as if it is a bike. The
  idea of a bike is that you can take its parts,
  cut it, join it, weld it back together and it
  will still be a bike.
• You cant do that with a frog!
• People expect that they can dissect the health
  system and cut bits of it off and join bits to
  it, and join it in different ways. Somehow, they
  still expect it to be functioning! (GM04).

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Health managers needs to be capable and
valuedNeed to select train and invest in
thoroughbreds (not donkeys) to make effective
change and to sustain quality health care delivery