Changing staff culture in hospital groups

A major challenge for the Saolta University Health Care Group (Grúpa Ollscoile Cúram Slainte) was how to change staff culture from being hospital-oriented people to being Group-oriented people, Mr. John Shaughnessy, Director of HR with the Group told a meeting of HMI West. Maureen Browne reports.

Mr. John Shaughnessy
Mr. John Shaughnessy

A major challenge for the Saolta University Health Care Group (Grúpa Ollscoile Cúram Slainte) was how to change staff culture from being hospital-oriented people to being Group-oriented people, John Shaughnessy, Director of HR with the Group told a meeting of HMI West.

In providing an overview of the Group and how it had progressed so far, he identified the challenges it faces, the governance arrangements it is putting in place, how it proposes to implement the Clinical Directorates, the priorities it has identified and the Human Resources issues of most significance.

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He said the scale of the operation was daunting when the basic facts were laid out:

  • Saolta served a population of 820,000 stretching from Donegal to Galway, to the midlands and it covered 32 per cent of the geographical area of the state.
  • It managed six hospitals over seven sites with 1,979 beds and provided services directly to six counties and indirectly to a number of others.
  • The Group’s Management Team oversaw a spend of €752 million and, with 9,146 staff, it is one of the largest employers in the country – 4.5 times larger than Google and Medtronic, four times bigger than Dell, three times bigger than HP, twice the size of Intel, Boston Scientific and Pfizer and slightly larger than Ryanair.

“Our vision is to provide better access to care, to achieve the highest standard of quality, consistency and uniformity in care, to deliver cost effective hospital care in a timely and sustainable manner and to encourage and support clinical and managerial leaders”.

He said the first CEO, Bill Maher had a goal to develop the group into a Foundation Trust, which meant changing the way the organisation delivered services and ultimately earning independence, for example to borrow money against the collateral they had in hospitals, and then to compete for work under the proposed commissioning scheme.

In terms of how funding arrangements for the acute sector were evolving, he highlighted the potential that the Money Follows the Patient model saying – “Saolta ran a deficit of over €50 million last year. We are piloting ‘Money Follows the Patient’ in shadow format in UHG for the past couple of years. If we had been paid on this basis last year, UHG would have had a €1 million surplus instead of a large overspend”.

“If we had been paid on this basis last year, UHG would have had a €1 million surplus instead of a large overspend”.

The challenges Saolta faced included Group integration, establishing the Board of Directors, embedding the governance and leadership arrangements, developing a performance management culture, overcoming the Human Resource and financial challenges, meeting access targets and implementing the National Clinical Programmes.

On the issue of trolley waits and lengthening waiting lists, he indicated that capacity was a challenge in the region. “Even with 1,900 plus beds, there are a range of issues that add complexity to both acute and community service delivery including a demographic profile that has a high proportion of an ageing population living in largely rural areas, many isolated and living alone”.

He said Saolta had a clear direction of travel and he indicated that “Our vision is to provide better access to care, to achieve the highest standard of quality, consistency and uniformity in care, to deliver cost effective hospital care in a timely and sustainable manner and to encourage and support clinical and managerial leaders”.

“We want to integrate training, teaching, research and innovation to expand horizons and boundaries. We have a management development approach for our clinical directors which will help ensure high standards of governance, both clinical and corporate. We want to recruit and retain high quality staff in all our hospitals. This is a particular challenge in relation to medical and specialist nursing grades in some sites. We have three succession management programmes either complete or underway for multi-disciplinary staff along with a nursing and midwifery management development programme, to fill the gaps left by years of under-investment in staff development. We are working on a development programme for clerical staff also and will continue to redress the development deficit over the coming years”.

Mr. Shaughnessy outlined the management structure of the Group.

“There is a Board of Directors to whom the Group Executive is accountable. While it doesn’t yet have a statutory foundation, the order of business between the Group Executive and the Board is formal and is developing into a model which will transition into the statutory format when the legislation is enacted. The Board was established on a competency basis by the then Health Minister, Dr. James Reilly, and differs from the traditional political profile of many state Boards. Our lay directors bring experience, knowledge and expertise to the table and are not encumbered by political baggage. Chaired by Dr. John Killeen, the Board meets ten times a year, rotates the venue across each site and has four public meetings each year. The Board does not have legislative authority but is in a position to influence and persuade national decision-makers”.

 “An average of 47 people per month seek assistance in dealing with stress and stress-related issues so we need to take a proactive approach rather than just a reactive one to self-care”.

The Executive supporting the development of the Group consisted of the Chief Executive Officer, Chief Finance Officer, Chief Clinical Director, Chief Operating Officer, Group Director of Human Resources and Chief Director of Nursing and Midwifery.

An Executive Council consisting of the above, the Clinical Directors (CDs), the General Managers from each hospital, the Chief Academic Officer, the Head of Corporate Development and the Dean of the Medical School made all policy decisions for the Group.

There were four Group CDs – Medicine, Perioperative, Diagnostics and Women and Children’s services, and they were evolving to ultimately take responsibility for all clinical services on all sites. This structure was based on the Clinicians in Management model predicated on responsibility, authority and accountability transitioning to the CD management team away from the traditional site-based structure. To enable this transition, there would be a Project Team and Lead which would clearly define roles, responsibilities, authority and accountability. All staff would be assigned to a Directorate governance unit and a budget would be assigned to cover all aspects of the Directorate’s business. This would happen via an Implementation Plan which would incorporate ongoing risk assessment to ensure robust effective and safe structures. The Directorates would work to the Group’s service plan targets and would have a set of Key Performance Indicators to improve quality, drive performance and ensure efficiency.

There were a number of key committees which were central to decision-making:

  • An Employment Control Committee to address recruitment from a group perspective and decide on which replacement and new posts would be filled.
  • An Estates Group to look at all aspects of infrastructure and address applications around capital projects.
  • A Finance Committee to address all finance business throughout the Group.

“In keeping with the recommendations of the Higgins Report, which is the blue-print for the establishment of the hospital groups, we have an academic partner, NUI Galway. We have also established partnerships with the Northumbria Foundation Trust (UK) and the North Shore Jewish Health Care Group (USA) to facilitate learning from organisations which have already walked the path of change”.

Mr. Shaughnessy said that some of the current objectives of Saolta were to:

  • Implement the Group’s Strategy over a five year period.
  • Meet waiting list targets for OPD, Adult Inpatient, Children Inpatient and Scopes.
  • Seek solutions to ED issues and meet the national targets for trolley waits.
  • Complete Phase 1 of the North West Cardiology Review.
  • Implement the Money Follows the Patient model of funding.
  • Implement the branding strategy and develop a user-friendly website.
  • Develop and launch an Information and Communications Technology Strategy.
  • Maximise collaboration with the Community Healthcare Organisations,
  • Review the Orthopaedic and Urology Networks and Emergency Departments.
  • Implement the HR Strategy.
  • Implement the Group Quality and Safety and Clinical Audit governance structures.
  • Deliver a Group Workforce/Recruitment/Retention Plan to facilitate proactive recruitment.
  • Deliver key capital projects (new Ward block in UHG and PHB, new ED in UHG, Medical Academies in SRH and MGH for example)
  • Work proactively with Unions to promote strong employee relations.
  • Further develop Succession Management Programmes,
  • Achieve financial breakeven.,

On the HR front, he said there hasdbeen steady progress in reducing absenteeism across the Group. “Our 12 month running average is 4.17% compared to 4.65% nationally (Acute Services). Saolta was below 4% for four successive months at the end of 2014. Our 3.37% absence in October 2014 was the first time the Group dipped below 3.5% and throughout 2014, the trend in the Group is linearly downwards with quarterly averages going from 4.55% in Q1, to 4.30% (Q2), 3.92% (Q3) and 3.75% (Q4). The 12 month running averages for each hospital continue to steadily decrease and we have marked this pattern with a poster campaign in each hospital highlighting progress on both public and staff notice boards.”

He said wear and tear on staff was manifesting itself in work-related stress and mental illness (there were 15,285 fewer WTEs nationally than in October 2007 while activity had increased year on year). “Ten per cent of our absence is certified as stress-related. Workload, management style, organisational changes and restructuring are all factors in the current absence profile. Peer absence increases risk to staff in moving and lifting patients so musculoskeletal injuries feature prominently. We have a physiotherapist available one day a week in UHG to whom staff can self-refer and we believe it will help us keep more staff on duty. We need to provide a support service for pregnant staff, particularly in relation to back care (12.4% of absence in GUH in November was pregnancy-related). There is a need to increase investment in the Employee Assistance and Occupational Health Programmes as early identification of at-risk employees is critical.

“We have achieved much with 13.4% fewer staff available to us when compared to 2009. This has been done through generating more awareness, auditing and hard data. But there is a need to improve Employee Support and Staff Wellbeing Services. There is only one person employed to provide support in the areas of stress management, developing resilience, managing worry and managing anger. An average of 47 people per month seek assistance in dealing with stress and stress-related issues so we need to take a proactive approach rather than just a reactive one to self-care”.

The HR Strategy set out the blueprint for change – improved staff attendance, formal performance management and a constant search for efficiencies being examples of some of the goals agreed. Saolta undertook an Employee Engagement Survey to consult with staff on a range of issues, some of which informed the HR Strategy.

As a Group which had committed to the Healthy Ireland policy, Saolta had produced a three year implementation plan for the Group. Fifty nine priority actions had been identified and the aim was to bring about organisational change to improve the health and wellbeing of staff, patients and communities. The Implementation Plan was ambitious, taking a multi-faceted approach to improving the health of staff, visitors and service users. The commitment of the Group’s Executive Council and the Health and Wellbeing Division had facilitated the allocation of resources and funding for the implementation of the plan.

As for the future, he said, “Saolta must keep driving forward on as many fronts as we can. We will continue to keep the patient front and centre in all of our actions and support our staff to the best of our ability”.