Allied health and organisational structure: massaging the organisation to facilitate outcomes.
This paper discusses the professional issue of changes to the organisational structure of the allied health service, at Auckland District Health Board (ADHB) as it has impacted upon physiotherapists. It traces the initial steps of a journey on which ADHB hospital-based allied health professionals embarked to support a vision of interdisciplinary and client centred work practises for all professional groups. While this project leveraged learnings from existing experience and literature, ADHB's scale, organisational culture and the limited timeframe created unique problems and solutions.
A significant change management process was undertaken for hospital-based allied health staff, to restructure the work environment from the traditional single discipline departments to a mixed model of an allied health division supported by a clearly defined professional leadership structure. This work is contextualised within the New Zealand health-care environment and the organisation, providing a model of allied health structure that supports the individual professional disciplines as well as positioning allied health professionals to further develop interprofessional skills to meet complex consumer health needs. Mueller J, Neads P (2005). Allied health and organisational structure: massaging the organisation to facilitate outcomes. New Zealand Journal of Physiotherapy 33(2) 48-54.
Key Words: Allied health, organisational structure, interdisciplinary teams, physiotherapy, management of change
Changes in health care are driven by financial, political, economic and social factors. Consumers are changing: increasing life expectancy; the ability to access a wide variety of health and lifestyle information from sources such as the internet; and the increasing complexity and chronicity of illness caused by the approaching retirement of the baby-boomer population bulge have led to demands for increased quantity and quality of health care. Consumers expect health professionals to communicate and collaborate on decisions about their health care and are becoming increasingly vocal when this does not occur.
These demands cause educators, policy makers, managers and leaders to re-evaluate how health practitioners are taught and how clinicians are organised around the patients to offer them high quality and coordinated care. "The complexity of patient care has contributed to an increased awareness that effective interdisciplinary teams may help reduce costs by reducing service duplication and minimising unnecessary interventions" (Hall and Weaver, 2001, p. 872).
Organising an allied health workforce: a review of teams and interprofessional practise
Increasing emphasis on professional collaboration to maximise health gain is inextricably linked to the need to be more responsive to consumers (Biggs, 1997b; Greenwell, 1995; Storrie & Manthorpe, 1997). Law and Boyce (2003) consider implementation of an integrated decentralised model, with allied health working within an interprofessional team challenges allied health to adopt more collaborative practices. Teams are becoming larger as patient complexity increases, with multidisciplinary teams developing in the 1940's (Julia & Thompson, 1994). Since the 1970's interdisciplinary teams have emerged (Gibbs & Teti, 1990). Interprofessional teams exist in many settings (Wolf, 1998) and often health professionals are members of several teams (Caldwell & Atwal, 2003). A key feature of effective teams is that the collective output is greater than the sum of the individual efforts as a result of synergy (Castro et al, 1994; Manion et al, 1996). This collaboration of professionals enables something to be achieved that could not be achieved alone (Biggs, 1997a). New Zealand Council of Health Care Standards (1997) endorses interprofessional practice, moving to holistic service-wide standards with organisation-wide standards on assessment and planning of care: "there is a multidisciplinary approach to planning care appropriate to the client/ patient/resident and contemporary professional practice" (Standard 3, p. 8).
Health care professionals have a range of education, specific skills and competencies. A profession's body of knowledge is key to delineating and describing the profession (Higgs & Titchen, 1995). Biggs (1997a) considers that an interprofessional environment clarifies roles and responsibilities so that service priorities and obligations can be decided (Tucker et al, 1999). Interprofessional teams deliver comprehensive, holistic services, while reducing service gaps (Biggs, 1997a). Teams bring different skills to meet patient need and improve safety as multiple inputs of specialist expertise are provided in the context of a shared goal (Biggs, 1997a; Ovretveit, 1995).
Benefits of interdisciplinary environments include: sharing skills, expertise and knowledge; and development of mutual understanding, enhancing relationships (Tucker et al, 1999). Sharing reflections with other professionals enhances relationships as areas of competence stand out, allowing concerns about power and authority to be relinquished (Horder, 1992). Boundaries must be removed if an interdisciplinary service, centred on quality patient care is to emerge (Koerner, 1993) and mutual respect is essential (Caldwell & Atwal, 2003).
Caldwell and Atwal (2003), MacKay et al (1995) and Wilmot (1995) identify problems and barriers faced by interdisciplinary teams. These include: different ideologies or different goals; unequal power held by different disciplines; and dialogue through documentation rather than conversation. Role overlap and confusion is a problem as is occupational status (both real and perceived) and distrust of other groups' perspectives. Professions' different histories and politics represent different social and moral principles. Identifying these problems is the first step to addressing them.
Organisational Structure in Health Care: a review of structural changes
As health care organisations respond to environmental pressures and increasing demands on acute care services, organisations restructure to manage clinical service delivery and improve patient outcomes. The literature covers changes to allied health organisational governance structures that have occurred since the early nineties (Astley, 2000; Boyce 2001; Compton, 1997; Dawson, 2001; Globerman, 1999; Law, 1999; Law & Boyce, 2003; Lopopolo 1997, 1999; Michalski et al, 1999; Ovretveit et al, 1981; Robinson & Compton, 1996 and Wake-Dyster, 2001).
Robinson and Compton (1996) identified challenges when reviewing the move from a physiotherapy department at John Hunter Hospital, Australia to a unit dispersement model. Physiotherapists had dual reporting responsibilities to: a programme manager for clinical and line management; and a director of physiotherapy for professional input. Although physiotherapists benefited from increased input into management and decision making, challenges arose from loss of budget and management control, reducing positional power and giving other services control.
Lopopolo (1997; 1999) reviewed hospital restructuring changing the role of a small team of (eight) physical therapists in acute care. There was: a shift from centralised to de-centralised department; cross-training of physical and occupational therapy assistants; increased focus on staff productivity; work on patient treatment and staff interaction to maintain professional identity (Lopopolo, 1997). The study concluded that: "decentralisation of physical therapy services had a profound effect on patient care delivery and professional interaction" and "Therapists have assumed greater and more demanding roles in the delivery of patient care while knowledge and information sharing have increased, and these changes have the potential to benefit caregivers and patients" (Lopopolo, 1997, p. 932). Furthermore, the emphasis needed to be maintained on professionalism in order to shape practice (Lopopolo, 1999). The Australian allied health reforms are well documented, with Boyce (1991) identifying five different models of allied health organisation implemented across Australia over two decades. The impact of these models is analysed by Law and Boyce (2003).
THE ORGANISATIONAL CONTEXT
In 1999, New Zealand's publicly funded health care system was re-organised into District Health Boards having responsibility for all health-care needs of their population, from "cradle to grave". ADHB is the third largest district health board in the country located in central Auckland, responsible for total health-care needs of approximately 370,000 local consumers. ADHB is New Zealand's largest public hospital provider, providing a significant proportion of New Zealand's tertiary services.
Over the past five years ADHB has been going through a major redevelopment and organisational change programme to improve facilities, merging four separate hospitals into one integrated acute hospital (946 resourced beds) and a separate ambulatory care facility. By the early 2000's, the provider arm had a significant financial deficit. To reach breakeven by 2006/07, redesign of business processes and staff re-organisation was needed. Two key programmes were implemented to accommodate this. The Change Programme team redesigned business processes to improve patient flows and reorganised clinical staff to deliver high quality clinical care while the Building Programme focussed on building a major tertiary hospital and migrating patients, services and staff to the new facility. The Building Programme completed contemporaneously with the Change Programme implementing business process and staff changes into the new Auckland City Hospital between May 2003 and October 2004. The management structure was also significantly reduced. Figure One shows ADHB's current functional structure.
[FIGURE 1 OMITTED]
Historically there was a range of staffing structures in place for allied health practitioners (AHPs) at ADHB. Physiotherapy had three single-discipline hospital and outpatient-based physiotherapy teams ranging from five to forty full time equivalents (FTEs). Physiotherapists were also employed in four multidisciplinary teams: in the community, hospital and a stand-alone rehabilitation facility. When AHPs reviewed their structure in 2000 it proved challenging to gain consensus on a solution. There was much discussion regarding who should manage allied health, similar to the Australian experiences described by Law and Boyce (2003). An area of clear agreement was that allied health needed a stronger voice within the organisation, achievable by representation at senior management level. There was no agreement on a new structure for practitioners and services. The final recommendation was that a Director of Allied Health (DAH) position be created. This was agreed by the executive team and the position was filled in October 2002.
Organisational Allied Health Review
The DAH completed a review of allied health services and presented key findings and proposed plan to the Executive Team in February 2003. Five key issues were identified, including an urgent need to restructure hospital-based allied health services in preparation for the opening of the new hospital in October 2003 and professional leadership, communication and clinical practice issues. Other issues included: absence of information profiling the workforce; lack of clarity and consistency of organisational structure and reporting lines; and the relationship between ADHB and the union.
THE CHANGE PROCESS FOR HOSPITAL-BASED ALLIED HEALTH PROFESSIONS
The Restructuring of Hospital-Based Allied Health Services
Many of the challenges identified in previous allied health restructuring initiatives (Astley, 2000; Boyce, 1991; Boyce, 2001; Dawson, 2001; Law & Boyce, 2003; Lopopolo, 1997; Robinson & Compton, 1996; Wake-Dyster, 2001) were present within ADHB, as well as additional unique factors, including:
* Impacting nearly 200 FTE's, significantly more than has been reported to date (Astley, 2000; Boyce, 2001; Dawson, 2001; Lopopolo, 1997; Wake-Dyster, 2001);
* Limited time available before migration into the new hospital (eight months);
* The barriers of the internal culture including:
** Disbelief from clinicians that their views would be heard and considered;
** Lack of collaborative union involvement;
** Staff change aversion after the ongoing Change and Building Programmes; and
** The competition between four hospitals that did not support collaboration, standardisation or integration of either business processes or clinical practice.
To overcome these obstacles and ensure practitioners would respond to the change demands and clinical environment of the new hospital, the DAH proposed a restructure of hospital-based allied health services. This was presented to affected staff and their union in April 2003. Notably 36% of the total allied health workforce was included in the proposed restructure. The proposal documented the relationships between the proposed realignment and the need for interdisciplinary allied health teamwork.
During the two week consultation period with affected staff, the union and other key stakeholders, the proposal was widely discussed with 35 written and 23 oral submissions. There was a high response rate from physiotherapists as they were the largest single discipline affected. Generally, they were wary of the move to interdisciplinary therapy teams. The smaller disciplines saw the move as an opportunity to redress historical power imbalances they perceived within the old departments. Positive feedback from all disciplines and services included: strong support for a centralised hospital-based allied health service reporting to a single Service Manager; strengthening of interdisciplinary practice and standardisation of senior allied health roles. Feedback consistently identified: a lack of profession-specific leadership; professional competency issues; a lack of proof that interdisciplinary teams work in acute care; and concern about the time line. Speech language therapists and occupational therapists were concerned about the number of senior roles for their professions.
In May 2003 the staff and union received the finalised plan, incorporating feedback and including the implementation process. Responses to frequently asked questions were circulated to all affected staff. The plan included:
* Appointment of part-time implementation Project Coordinator;
* Move from discipline-specific to interdisciplinary therapy teams and change of team members for occupational therapists, physiotherapists, and speech language therapists;
* A move to interdisciplinary therapy team structure timed to coincide with the physical move to new office space combining open plan, meeting rooms and individual/shared office space; and
* Discipline-specific Professional Leader roles.
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The Implementation Plan
Project work commenced as outlined in Figure Three below. The professional leadership work-stream was led by the DAH, with senior practitioners leading other work-streams.
[FIGURE 3 OMITTED]
The Changing Road Map during Project Implementation
During the course of the project, specific achievements included:
* The Model of Care work-stream agreed significant practice change for AHPs working in a 45 bed acute assessment unit. The lead practitioner became responsible for initial patient assessment. An assessment tool was developed (now being used in other areas of the hospital) including screening questions for four allied health disciplines. This had two benefits: patients were not repeatedly asked similar questions; and appropriate intervention(s) were identified and implemented promptly. The key to success was the collaboration across disciplines developing both a model of care and a tool to implement it.
* The Physiotherapy Weekend and On-Call Service was reviewed as each hospital had separate physiotherapy weekend and on call services in place. Criteria for referral varied and the seven day per week facility mandated change. Negotiation with staff and union lengthened this process. The change to employing staff on Tuesday to Saturday or Sunday to Thursday was a significant shift from employing staff Monday to Friday and incurring overtime rates, thereby reducing overall costs.
* The Professional Development Review enhanced interprofessional learning while continuing to value and provide discipline-specific learning, despite historically different departmental budgets for staff development. Continued refinement of the standard application process and agreed benefits per person ensured all physiotherapists had equitable access to the available funds.
* The part-time Clinical Educator role for Auckland Hospital physiotherapy staff was re-scoped to a Clinical Educator role for all hospital-based therapists coordinating management and delivery of: orientation; induction programmes; interprofessional training; and development. This was perceived as a resource loss by the ex -Auckland Hospital physiotherapists but as gain by other physiotherapists and their therapy colleagues.
* Human resource issues delayed implementation of therapy team leader roles.
The new organisational structure and creation of interdisciplinary therapy teams for hospital-based services created three key points of difference for ADHB compared to other models (Law & Boyce, 2003).
An Organisational Model for Hospital-Based Allied Health Services
ADHB moved from a variation of the classical departmental model to a mixed allied health division model. Pure models of organisation structure are rarely implemented in health care and ADHB has chosen a variation of option four outlined by Law and Boyce (2003), a mixed model of an allied health division supported by a clearly defined professional leadership structure.
The model below (refer Figure Four) has retained budget, management and professional responsibility for allied health professions within the control of allied health, while grouping therapy staff into interprofessional teams around similar patient cohorts.
[FIGURE 4 OMITTED]
The Director of Allied Health role for ADHB is organisation-wide, reports to the CEO and has professional and strategic leadership responsibilities for approximately 531 FTEs including hospital-based, ambulatory and outpatient services, community physical health, mental health and regional public health services. In contrast to DAH roles in the Australian public health system (Boyce, 2001), the DAH role at ADHB does not have budgetary authority or day-to-day management responsibility. The ADHB provider arm has a matrix model of management, with all clinical staff managed within clinical service teams and three senior medical, nursing and allied health professional roles (refer Figure Five) provide executive leadership, strategic direction and leadership of the clinical governance framework.
[FIGURE 5 OMITTED]
The Allied Health Service Manager reports to the General Manager for Clinical Specialty Services with financial, contractual, human resource and operational accountability for 190 hospital-based FTEs, closely resembling the DAH roles described in Australian literature. Inpatient AHPs benefit from having a manager with an allied health background, understanding their professional and cultural perspectives. Six Team Leaders provide leadership, financial management and operational responsibility for the individual teams (up to 40 FTEs).
A key component of feedback from the professions was the need for clearly defined professional leadership so that individual professional needs could be met within an interprofessional environment. A professional leadership structure was implemented to provide profession-led strength, recognising the need for discipline-specific leadership and development to contribute to: operational and strategic planning; research; clinical education, individual staff development; and contribute to development of profession-specific quality clinical services (Figure Five). These roles balance the need for professional learning and socialisation with interdisciplinary and client centred work practices for all allied health professional groups, maintaining professional networks internal and external to ADHB.
The Introduction of the Health Practitioners Competence Assurance Act (2003)
The introduction of the Health Practitioners Competence Assurance Act (2003) required registered health professionals to move to a competency-based annual practicing certificate with different requirements for each professional group. Feedback from staff and managers supported development of a professional governance and leadership model. This became an essential component of the new allied health organisational structure.
Hospital-based allied health services at ADHB have responded to the changes required to facilitate service delivery and improve clinical services to consumers within the new hospital. Strong communication and true consultation allowed the introduction of interdisciplinary allied health teams on an unprecedented scale. It has been important to provide the ability to continue to grow and develop the individual professions (such as physiotherapy) while strengthening and facilitating the collective organisational requirements of allied health, the concept originally discussed in Blayney and Fitz (1990).
The introduction of a mixed model of an allied health division supported by a clearly defined professional leadership structure achieves the organisational goals of: a cost-effective, integrated allied health service; delivers high quality clinical care to patients using interdisciplinary teams; while continuing to develop individual professions. The model will evolve however, but needs to remain focussed on structures that deliver best outcomes for both the consumers with complex health needs and the professionals that deliver their care. For physiotherapists, the challenge is in the workplace. We need to be prepared for change but also contribute to ensuring that change is sensible and successful. We must understand these global demands, evaluate proposed organisational structures and service delivery models, and contribute to the change processes. We can improve service delivery and clinical outcomes for consumers without compromising the goals of the profession.
We would like to acknowledge all the allied health professionals who have been involved in and working through these organisational changes, particularly the occupational therapists, physiotherapists, social workers and speech language therapists now based at Auckland City Hospital. Thank you also to Carol Piper (PSA Organiser for ADHB) for her support of the staff while working through these changes, Pip Anderson for her assistance with formatting and Ian Rowe for his invaluable contribution editing this paper.
* ADHB has implemented a large-scale change to the organisational structure for hospital-based physiotherapists, moving from single discipline to interdisciplinary therapy teams
* Strong communication and true consultation is essential for any management of change on this scale to be successfully implemented
* It is imperative to continue to grow and develop individual professions (such as physiotherapy) while strengthening and facilitating the collective organisational requirements of the allied health professions
* The introduction of a mixed model of an allied health division supported by a clearly defined professional leadership structure will continue to evolve while remaining focussed on delivering optimal outcomes for both consumers and professionals
* Physiotherapists need to be prepared for change and also participate in ensuring that change is sensible, successful and able to be evaluated
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ADDRESS FOR CORRESPONDENCE
Janice Mueller, Director of Allied Health, Administration, Level 5, Auckland City Hospital. Private Bag 92024, Auckland. Email: firstname.lastname@example.org
Director of Allied Health, Auckland District Health Board
MNZSP, MNZCP, MBA (Dist)
Allied Health Manager, Auckland City Hospital, Auckland District Health Board
MNZCP, MNZIHM, MHSc (Hons)