Tackling Organizational Change in Health Information Management: Two Canadian Experiences

David Thompson, MHSc, and Karen Adams

Introduction

Health information management in Canada has been undergoing significant changes in recent years. This paper presents two examples of how organizational change is taking place in two distinct jurisdictions in the country. The experience of St. Michael's Hospital illustrates how organizational change management is an important component of systems implementation, while the experience of Fraser Health Authority in British Columbia exemplifies how large-scale systems changes in the delivery of healthcare require organizations to respond with structures that support their new organizational context.

History of St. Michael's Hospital

St. Michael's Hospital is a Catholic academic healthcare provider, fully affiliated with the University of Toronto, established in 1892 by the Sisters of St. Joseph to care for the sick and the poor of Toronto's inner city. Since that time, the hospital has preserved this commitment to compassion and excellence, while evolving into a center for innovation in patient care, teaching, and research.

A leader in inner city health, as well as a major tertiary referral center, St. Michael's Hospital has more than 550 inpatient beds, extensive outpatient clinics and is downtown Toronto's designated trauma center for adults.

Context for Organizational Change

St. Michael's is currently involved in a three-year information management project to develop and implement a fully integrated, enterprise-wide patient care management technology system. By 2006, there will be one main source for patient information with fully integrated applications and databases.

The need for an effective change management component when implementing systems that redefine the way people work has been well documented. This finding is not exclusive to healthcare organizations and is true of almost any organization that implements an organization-wide change. However, systems implementations and their acceptance by clinical staff within Canadian hospitals are perhaps more complex than most due to a variety of factors:

• The recent impact of external factors in depleting the organization's energy and resources (that is, SARS)
• Questionable tolerance for change among various stakeholder groups
• Pivotal role of non-employees (that is, physicians) in making this project a success
• Organizational risk associated with potential for lost productivity during implementation

Applying an organizational change management process from planning through implementation reduces business risk and improves the odds of achieving the intended benefits and return on investment. A four-phased process for managing organizational change is being applied during the implementation of the patient care information management system at St. Michael's Hospital.

The Change Process

The first two phases, Building the Foundation for Commitment and Getting Agreement and Setting Direction, require time to build commitment and a willingness to maintain flexibility. The new or improved relationship between the stakeholders will foster a shared examination of the alternatives available to the organization. By having carried out a joint assessment of the readiness to proceed, St. Michael's has built a foundation for commitment that will make it easier to enter the next phase.

The second phase of the change process begins and ends with obtaining agreement from the key stakeholders about how the process is proceeding. This is the start of the commitment to work together, and there is an acceptance at this point of a joint responsibility on the part of the key stakeholders to engage in the next steps. During this phase, change structures are established, detailed needs are specified and a vision of what the changed organization will look like and how it will function begins to emerge. The foundation that was built in the previous phase begins to be cemented into place by commitments, structures, and philosophies that all those involved are committed to support.

Upon the completion of this phase, appropriate structures will be in place to proceed with the detailed changes to the organization's function. A vision of what the future organization will be like will have to be developed. Specific needs to work towards will be established. The endorsement of the key stakeholders reinforces the existence of a high commitment work organization.

In the third phase, Making Changes, the change process moves on to the detailed process of analyzing existing and intended operations and designing and implementing alternative arrangements to put the changes in place. Too many organizations begin the change process at this phase without going through all the earlier stages. Almost all initiatives that begin at this phase fail, some almost immediately, because neither trust, commitment, nor understanding of the future have been developed. In this phase, the change process moves on to the detailed process of analyzing existing and intended operations and designing and implementing alternative arrangements to put the changed organization in place. Design and redesign must incorporate the input of the people who will actually do the work that is being redesigned. Some design processes are accomplished through the normal organizational structure; others through parallel structures of steering committees, design, and implementation teams or workgroups. Organizational structure, support systems, people (knowledge, training, and skills), clear role and responsibility definitions and formal and informal interrelationships between the key stakeholders are some of the key elements the design process must deal with.

Implementation is a comprehensive process within the third phase and involves considerable detail where such is necessary, but which constantly leaves some flexibility for future change and for the fact that learning systems constantly evolve. This phase ends with implementation, but since implementation is interdependent with organizational analysis and design/redesign, it is clear that making changes is a continuous process.

The fourth phase of the change process, Keeping it Going, refers to the need to sustain what has been accomplished and to continuously monitor progress to ensure that the different targets and goals and ways of organizing are being adhered to. Sustaining change is at least as difficult as initiating and implementing it in the first place. However, it's a different process from that involved in Making Changes. It usually calls for different ways of working, different approaches, and sometimes the responsibility for sustaining the change process may shift to different people.

The change process model described here reflects a process that is long in duration. At St. Michael's Hospital, significant investment has been made in the first two phases of this organizational change process. This will ensure the success of the system and clinical process changes, but it also creates the alignment of the organizational fundamentals-- work, people, structure, culture and values that will be necessary to achieve clinical transformation and hence true sustainability.

History of Fraser Health

On December 12, 2001, the Fraser Health Authority was formed when the former Fraser Valley Health Region, South Fraser Health Region and Simon Fraser Health Region were amalgamated. Fraser Health Authority (or Fraser Health as it is commonly known) was one of six health authorities in British Columbia created when the provincial government announced the redefinition of health authority boundaries in British Columbia. Of the resulting six health authorities, five have geographic areas of responsibility while the Provincial Health Services Authority has responsibility for the administration of provincial programs.

Fraser Health covers the area in British Columbia from Burnaby in the west to Boston Bar in the east. There are 12 directly managed acute care facilities in Fraser Health along with a number of affiliated and contracted facilities. Services are provided to the 1.5 million residents in Fraser Health, along with those who access Fraser Health from outside its boundaries. These services include public health services, acute care services, mental health services, and continuing care services. The annual operating budget of Fraser Health is approximately $1.6 billion with services delivered by approximately 20,000 staff. There are approximately 1,950 physicians with privileges at facilities within Fraser Health.

Developing the Organization

Following the creation of Fraser Health, a commitment was made to have the organization structure in place by mid-April 2002. An interim Senior Administration structure was put in place very quickly and was fine-tuned early in 2002 to create the permanent structure. Each of the members of the Senior Administration then went about creating their administrative structures. From the beginning of Fraser Health, Health Information Services has been part of the portfolio of the Vice President Corporate Services and Chief Financial Officer. There were some different titles for Health Information Services in early iterations of the Fraser Health organization chart, but the title Health Information Services was developed to include Health Records, Registration (Admitting), Information Analysis and Security, and Switchboard Services. By early 2002, it was decided that Health Information Services would be part of the Chief Information Officer's portfolio along with Technical Services and Information Systems Services. The Chief Information Officer was appointed in early 2002. He quickly posted the positions for the three directors for the three distinct areas in his portfolio. By April 2002, the three directors had been appointed.

Each of these three areas then went about developing their own organization structures. Administration for Fraser Health had deemed that any positions of a Manager, Director, and above had to be posted prior to being filled. At the beginning of May 2002, four manager positions in Health Information Services were posted. These were Manager, Health Records--Fraser North; Manager, Health Records--Fraser South; Manager, Registration Services, and Manager, Information Analysis and Security.

There were some subsequent reorganizations in Fraser Health that resulted in some title changes to the Managers in Health Records and the Registration Services Coordinators. By the end of May 2002, three of the four Health Information Services managers had been selected. For Health Records, the appointment of the managers completed the organization structure as the Health Records Coordinators at individual sites were already in place. For Registration Services, it was necessary to post the position of Registration Services Coordinator for Fraser South and Fraser East as there was no one in this position. In creating the organization structure for Fraser Health, it was necessary to create an organization structure that supported all of Fraser Health by effectively utilizing existing budgets. This meant the reallocation of funds from one area of Fraser Health to other areas to ensure a consistent organization structure.

In the early days of Fraser Health, it was evident that some decisions needed to be made about the Information Analysis and Information Security area, as there was some over-lap between this area and another area of the organization called Integrated Analysis and Evaluation. By the beginning of August 2002, the Directors of Health Information Services and Integrated Analysis and Evaluation had come to an agreement that Integrated Analysis and Evaluation would recruit for a Manager of Information Analysis and that Health Information Services would recruit for a Manager of Electronic Health Information Privacy. The result would be that the Clinical Data Analysts in Health Information Services would report to the new Manager of Information Analysis. The coding function remains within Health Information Services and it has been recognized that there needs to be a strong working relationship between the Manager of Information Analysis and the Health Records group.

Why Not Organize Based on Process?

The Health Information Services structure that was designed for Fraser Health is fairly traditional. The structure is based on a mix of corporate functional responsibilities and geographic responsibilities (see Exhibit 1). There was some thought to developing an organization structure based on processes (for example, transcription, records management, data collection, registration, switchboard), but it was felt that Fraser Health could only move to this type of process-based structure when consistent information systems were in place across Fraser Health to support an integrated process.

EXHIBIT 1

Health Information Services

Health Information Services is made up of approximately 386 FTEs and a budget of slightly more than $231 million.

Benefits and Challenges

The formation of Fraser Health has had some significant benefits for Health Information Services:

• Sharing of resources across Fraser Health. We have been able to create six corporate resources to support systems and data quality.
• We have been able share similar issues that we all faced in the former health regions on a broader scale and to work toward shared solutions.
• Groups, such as the Clinical Data Management Group, have been formed to look at Health Records data standards across Fraser Health.
• We have been able to build on existing information systems investments, such as Meditech and Dictaphone, to expand these systems across Fraser Health at a lower incremental cost by building on existing investments.
• The establishment of the position of Manager, Electronic Health Information Privacy reinforces our work in the area of developing the electronic health record and ensuring that our house is in order with respect to personal information privacy.

There have also been some significant challenges:

• The Clinical Services Directional Plan for Fraser Health has resulted in role definitions for some of our acute care sites, which has had an impact on the delivery of services on those sites.
• We have been faced with the need to implement some significant cost reduction strategies that have had an impact on Health Information Services.
• We have all had to learn to work together and to be conscious of not imposing our old way of doing things on others.
• It has been a time of at least three reorganizations with each one having an impact on Health Information Services.
• The list of ideas and priorities far exceeds our available resources. There are many good ideas that need to be acted upon, but the achievable list of priorities is much smaller than the great ideas.

Priorities

Health Information Services has identified some immediate priorities for the near future, including:

• Implementation of an integrated abstracting system for Fraser Health. This was completed in 2003.
• Integration of the existing Dictaphone dictation systems in Fraser North and Fraser South and expansion of the system to Fraser East. This ongoing.
• Playing an active role in the Meditech Migration strategy for Fraser Health. This is ongoing.
• Implementing consistent practices and processes for core functions in Health Information Services (for example, release of information, coding, chart tracking, Registration).
• Developing a directional plan for Health Information Services.

The past three years have been very exciting for Fraser Health. What is described in the preceding paragraphs is only a sample of the changes that have taken place since the formation of Fraser Health. We have gone from three separate and distinct health regions to an integrated health authority. An organization structure for Health Information Services has been created to ensure the effective provision of services within Fraser Health and to be a leader in British Columbia and the nation. With our significant organizational changes behind us, we can move forward to address our priorities and to reach our goals within the context of Fraser Health.

Summary

These two examples of organizational change highlight the important role that Health Information Management plays in today's dynamic healthcare organizations. It highlights the need to manage change at both the project level and at the organizational level when attempting to craft a structure to support the delivery of health information services.

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