FSFHG Allied Health Model Review

Transcription

1 FSFHG Allied Health Model Review June 2017 fsh.health.wa.gov.au fh.health.wa.gov.au FSFHG Allied Health Model Review Report, version 1 Allied Health, Fiona Stanley and Fremantle Hospitals Group Version date: June 2017

2 Contents Acknowledgements 1 Acceptance and Approval Executive Summary Background Models of Allied Health Traditional Medical Model Allied Health Divisional Model Unit Dispersement Model Integrated Decentralised Model Fiona Stanley Hospital and Fremantle Hospital Allied Health Aims and Objectives of the Review Project Objectives Desired Project Outcome Constraints Methodology Allied Health Questionnaire Allied Health 1:1 Interviews Allied Health Focus Groups Questionnaire medical and nursing Medical HoS Focus Groups External Stakeholders Patients Results Considerations / Biases Participants Results by Theme (In)efficiency Professional Support Professional Oversight Know the Business Inter-professional Practice A Voice for Allied Health AH Education Team Patient Care Other Issues 33

3 4.5 Car-parked Issues Proposed Models Current FSFHG Allied Health Leadership Costs Error! Bookmark not defined. 5.2 Option A Allied Health Divisional Model Description Roles and Responsibilities Strengths, Weaknesses and Risks Indicative Cost Error! Bookmark not defined. 5.3 Option B Integrated Decentralised Model Description Roles and Responsibilities Strengths, Weaknesses and Risks Indicative Cost Error! Bookmark not defined. 5.4 Option C Current FSH Model Expanded Description Roles and Responsibilities Strengths, Weaknesses and Risks Indicative Cost Error! Bookmark not defined. 5.5 Option D Service Dispersement Description Roles and Responsibilities Strengths, Weaknesses and Risks Indicative Cost Error! Bookmark not defined. 5.6 Critical Success Factors Recommendations Appendices Appendix 1 AH Questionnaire Appendix 2 AH Leadership Team 1:1 Interview Template Appendix 3 Questionnaire (medical & nursing) Template Appendix 4 - Results by Stakeholder Allied Health Staff FSH Allied Health Staff at FH Allied Health Leadership Team FSH Allied Health Leadership Team FH Medical Heads of Service Nurse Unit Managers Nursing Executive 69

4 7.4.8 FSFHG Co-Directors Patients Appendix 5 - Clinical Psychology / Neuropsychology Appendix 6 - Abbreviation List Bibliography 74 Contact 76

5 Acknowledgements The contribution of the Allied Health staff of FSFHG and all other stakeholders who gave their time and considered opinion to the review process is acknowledged. Acceptance and Approval Author Katrine Nehyba Signed Project Manager FSFHG Allied Health Model Review Date 19/06/2017 Accepted by Kellie Blyth A/Director Allied Health FSFHG Project Advisory Board Janet Zagari Co-Director, Service 1 FSFHG Project Advisory Board Tim Leen A/Co-Director, Service 4 FSFHG Project Advisory Board Kate Gatti Executive Director, Clinical Service Planning & Population Health, SMHS Project Advisory Board Signed Date Signed Date Signed Date Signed Date Accepted by Paul Forden Executive Director FSFHG Project Advisory Board Signed Date 1

6 1.0 Executive Summary This report describes the main findings of a review of the Allied Health organisational structures at Fiona Stanley Hospital (FSH) and Fremantle Hospital (FH). The review was undertaken over a three month period in The main aim of the review was to evaluate the current models under which Allied Health is structured at FSH and FH, with the aim of identifying the strengths and weaknesses of each; and to subsequently deliver an options paper outlining different models of AH organisational structure for FSFHG to inform a decision around a preferred option. Allied Health at Fiona Stanley Hospital currently operates under a unique matrix design, with professional and operational leadership devolved to different members of the management team. Allied Health at Fremantle Hospital operates under a profession-managed model, in a traditional departmental structure with a single point of leadership and individual professional governance. The consultation process for this review included over 370 Allied Health staff, as well as medical, nursing and other stakeholders throughout WA Health, inter-state and internationally. The main areas of concern identified by the participants are listed below: Allied Health staff value a work environment that provides them with a sense of professional support, and in which there is strong advocacy for their profession. This was perceived to be lacking for a significant number of the FSH participants. There is strength in a united Allied Health voice, which should be developed in addition to and not at the expense of a sense of individual professional identity. It is beneficial to have identifiable points of contact for non-allied Health stakeholders, who can provide inter-professional representation of Allied Health issues. There are inefficiencies within and between the two models of Allied Health as they currently operate. This has caused significant frustrations for Allied Health staff at both sites. The report describes the results of the consultation process, and proposes four Allied Health leadership models for consideration. 2

7 2.0 Background 2.1 Models of Allied Health A review of the literature (2, 3, 15, 17, 23) identified four main models of Australian allied health (AH) organisation Traditional Medical Model individual profession-managed departments reporting to a medical director or Director of Medical / Clinical Services was commonplace in the 1990s before the AH professions merged as a collective CEO Director Medical Services Director of Nursing Deputy Director Medical Services Medical Organisation Nursing Organisation Dietetics Head of Department Physiotherapy Head of Department Dietetics Staff Physiotherapy Staff Medical Staff Nursing Staff 3

8 2.1.2 Allied Health Divisional Model individual profession-managed departments, reporting to a Director of Allied Health Director of Allied Health (DAH) reports direct to the Executive is a commonly used AH structure nationally CEO Director of Allied Health Director Medical Services Director of Nursing Dietetics Head of Department Physiotherapy Head of Department Medical Organisation Nursing Organisation Dietetics Staff Physiotherapy Staff Medical Staff Nursing Staff 4

9 2.1.3 Unit Dispersement Model individual professions are dispersed amongst clinical units individuals or groups of professionals are employed by the constituent clinical units of the hospital management of the professions is dispersed throughout the organisation s clinical unit structure cohesive capacity for a whole-of-organisation voice for either the professions or collective allied health is difficult, because of the fragmentation of services through the organisation and lack of agility of professions across services is an infrequently used AH structure. Is currently seen in some mental health service directorates. Has been tried and reversed in some organisations. 22) (1, 17, CEO Manager Clinical Unit 1 Manager Clinical Unit 2 Manager Clinical Unit 3 all staff all staff all staff Dietetics Social Work Psychology Dietetics Social Work Physio Speech Pathology Dietetics Social Work Physio OT 5

10 2.1.4 Integrated Decentralised Model founded on a structure of co-existing individual profession management and team management supports individual professional discipline identities with a decentralised approach to team-based service delivery, which promotes collaborative practice is relatively common outside of WA Health with international examples in New Zealand This image is taken from Law & Boyce. (15) 2.2 Fiona Stanley Hospital and Fremantle Hospital Allied Health Fiona Stanley Hospital (FSH) is the newest tertiary public hospital in Perth, Western Australia. It opened in 2014 and is a 783-bed facility in the South Metropolitan Health Service (SMHS) which offers medical and surgical services, emergency care and specialist services for adults and children in a modern, state-of-the-art environment. The hospital is also home to the State Adult Burns Unit, the State Rehabilitation Service, a comprehensive cancer centre and a mental health unit. Fremantle Hospital (FH) is a 300-bed specialist hospital in SMHS which provides aged care, mental health, rehabilitation, planned surgery and specialist medical services. In 2016 governance of the two sites merged to become the Fiona Stanley Fremantle Hospital Group (FSFHG), however AH operates under two different organisational structures. Allied Health at Fremantle is structured in an AH divisional model, with uni-discipline leadership of professional departments via a Profession Manager (PM), who holds both professional and operational accountability. Following the merger with FSH, an 6

11 AH Head of Service (AH HoS) was implemented at FH. The PMs report to the AH HoS, who reports to the DAH. Staff are managed within their profession. Allied Health at FSH is structured so that operational management and accountability are separated from professional leadership and strategic management. Allied Health professionals are organised around like-patient groups, in alignment with the hospital s service streams. Staff are managed by an AH Coordinator (AHC), who in turn reports to an AH HoS. The AHC and AH HoS roles have accountability for the operational activity of the AH staff in their services. A Professional Lead (PL) is appointed for each AH discipline these positions have no managerial authority over the staff in their discipline. The PL role is strategic and includes advising on professional standards and practice, and advocating for the profession. 7

12 The following professions are included in AH at each site: FSH Allied Health FH Allied Health Aboriginal Hospital Liaison Service (provide a cross-site service) Allied Health Assistants Audiology Clinical Psychology & Neuropsychology Dietetics Exercise Physiology Occupational Therapy Pastoral Care (provide a cross-site service) Physiotherapy Podiatry Social Work Speech Pathology Dietetics Occupational Therapy Physiotherapy Podiatry Social Work Speech Pathology 2.3 Aims and Objectives of the Review This project has four main drivers: 1. A commitment was made during FSH Commissioning that the AH model would be reviewed two years after opening (in October 2014). 8

13 2. The Fiona Stanley Fremantle Hospital Group (FSFHG) organisational structure will change from four to five service streams at the start of the financial year. 3. An intent to align the operational and strategic models for AH services across Fiona Stanley Hospital (FSH) and Fremantle Hospital (FH) as they currently operate according to two different organisational structures 4. A financial imperative to reduce expenditure across AH as directed by FSFHG Executive. The anticipated benefits of this review include, but are not limited to: enhanced collaboration across AH at FSH and FH; improved efficiency and effectiveness of AH services across sites; and insight into perceptions of the AH model at both sites Project Objectives A review of the current models under which AH is structured at FSH and FH, with the aim of identifying the strengths and weaknesses of each. The delivery of a report outlining different models of AH organisational structure for FSFHG. The models presented must include costing detail sufficient to inform the decision around implementation of a preferred option. Options presented should also provide a clear additional rationale and supporting evidence for the recommendations Desired Project Outcome The presentation of options for a FSFHG AH organisational structure that, if implemented: best supports service delivery and safe patient care; improves service and communication efficiencies within AH; ensures role clarity, facilitates inter-professional practice and is reflective of best practice; aligns with the FSFHG organisational structure and the move to five directorates; and is consistent in approach across FSH and FH Constraints Funding: there is no possibility to release funds for an external review, or budget for additional resources or administrative support for the project. Timeframe: is non-negotiable. Resources: 1.0 FTE project manager for three months, temporarily redeployed from internal AH FTE. 9

14 3.0 Methodology A mixed-methods approach was used for this review, meaning that both qualitative and quantitative data was collected. This allows validation of findings from different sources, and elaboration of the findings of one approach with data from another approach. A mixed methods approach has been used in other reviews of AH (6, 11, 16, 20) structures. The following methods were used: Stakeholder Method/s FH AH staff Questionnaire Focus Group FSH AH staff Questionnaire Focus Group FH AH Leadership Team 1:1 Interview Questionnaire Focus Group FSH AH Leadership Team 1:1 Interview Questionnaire Focus Group FSH NUMs Questionnaire + discussion FH NUMs Questionnaire + discussion FSH / FH nursing executive Questionnaire + discussion Medical HoS Questionnaire Focus Group Other stakeholders (non- FSFHG) Patients Telephone interviews Review of complaints and compliments Participation in all aspects of this review was voluntary. 3.1 Allied Health Questionnaire A previously published questionnaire was adapted to suit the needs of this review. Braithwaite & Westbrook (6) surveyed staff attitudes towards a clinical directorate structure that had been introduced into an Australian hospital 3 years prior. The full version of the questionnaire is published and the authors state this paper makes available a comprehensive and validated instrument for assessing attitudes to [Clinical Directorates] across a range of dimensions. The questionnaire was adapted to meet some local requirements some questions were discarded, and others were added. The questionnaire was also adjusted for four groups of recipients: FSH staff, FSH Leadership Team (LT), FH staff, FH LT. All 10

15 questions are closed-ended, with no opportunity for comments. This was deliberate as the burden of analysing additional qualitative data would have been too great for the scope of this review. The focus groups (described in section 3.3 below) were the opportunity for staff to provide commentary. The questionnaire was distributed electronically via SurveyMonkey, with a two-week period in which to complete it. Please see Appendix 1 for the questionnaire template. 3.2 Allied Health 1:1 Interviews All members of the Allied Health Leadership Team (AHLT) at FSH and FH were invited to an interview lasting up to 1 hour. This was a semi-structured interview based on a core group of questions. Responses were typed directly into a Word document which was reviewed with the participant during and at the conclusion of the session. This enabled the verification process to be conducted concurrently with data collection, which was important for efficiency of the project. These interviews followed the SOAR format Strengths, Opportunities, Aspirations, Results. Please see Appendix 2 for the interview template. 3.3 Allied Health Focus Groups All AH staff and the AHLT were invited to attend one of a series of focus groups. The aims of the focus groups were to present initial results for staff to have an opportunity to provide comments and feedback (in later focus groups) for ideas of different models to be discussed Four focus groups were offered to FH staff; one to FH LT; six to FSH staff; and three to FSH LT. In addition, staff were advised that they could request a focus group for their team outside of the scheduled ones; this resulted in four additional focus groups. The focus groups were semi-structured. Relevant results were presented to each group, for example the FH staff were shown an extract from their questionnaire responses; the FSH LT were shown collated results from the interviews and their questionnaire responses. Participants were able to provide feedback or comments at any time. Participants were able to see results from other groups if they wished. FSH and FH staff were also asked to rate potential benefits of a cohesive AH model (one model at both sites). Possible benefits - for example cross site collaboration on QI, research and service improvement projects; cross site rotations - were generated in the 1:1 interviews with the LTs and were printed on sheets of paper. The participants were given sticky dots and asked to place a dot on the piece of paper if they agreed that it was an advantage. In the later focus groups proposed ideas for AH models were presented and discussed. This did not occur in the initial focus groups because they weren t yet prepared. 11

16 3.4 Questionnaire medical and nursing Opportunities for consultation with groups of medical and nursing stakeholders were brief. This included - 15 minutes at a Hospital Executive Committee Plus (HEC+) meeting - 10 minutes at the Nursing & Midwifery Executive Committee (NMEC) meeting - 15 minutes at a FSH and a FH Nurse Unit Manager (NUM) forum. The data collection method chosen for the HEC+ meeting and NUM forums was multiple-choice questions, because opportunity for comments and discussion were limited. The HEC+ meeting utilised TurningPoint technology, the NUM forums a paper-based tool. The NMEC meeting was an opportunity to ask open ended questions and generate discussion to expand on the results obtained in questionnaires. The questionnaires asked participants to respond to statements about the outcomes of the AH model at FSH or FH. For example It is helpful to have one point of contact with AH (i.e. AHC) to resolve service issues (FSH only) and AH can get the right staff in the right place at the right time (both sites). Please see Appendix 3 for the questionnaire template. 3.5 Medical HoS Focus Groups Four focus groups were planned with medical HoS from specialties which were identified as having greater involvement with AH services. The focus groups were semi-structured around the following core questions: Is there any difference in your working relationship with AH at FSH compared with other sites? Is it easy to collaborate with AH on service issues? Have you noticed any effect of the AH structure on the AH staff who work in your clinical team? If the model was to change, what, if anything, would be important to maintain? In addition, medical HoS were offered a 1:1 interview if they were unable to attend a focus group, and six interviews were conducted, following the same format as the focus groups. 3.6 External Stakeholders Information was sought from external stakeholders about other AH models. These were unstructured interviews each was different depending on the information sought by the project manager. Stakeholders included Allied Health Directors and Heads of Department at other Perth metropolitan hospitals, as well as inter-state representatives and recognised experts. 3.7 Patients Information was requested from the FSFHG Patient Liaison Service about complaints and compliments received relating to AH services for a 12 month period. 12

17 Comparison of the broad nature of this type of feedback was made between FSH and FH. 13

18 4.0 Results Results are presented here according to the main themes identified in the review. A description of the results by stakeholder group is presented in Appendix Considerations / Biases It is worth considering the following when reading the results: Almost all of the AHLT positions at FSH and FH are on contracts which expire in People in the LT may have a vested interest in avoiding change. Attendance at focus groups was voluntary, therefore a self-selection bias may have occurred. There may be a higher representation of people who are unhappy with the current situation. For example: I never come to workshops or things like this, but I wanted to come to this one because I think this model is just ridiculous. The halo effect: I like (or dislike) this part of it therefore I like (or dislike) all of it. For example: The fact that we haven t got a space for our department is rubbish. I want to go back to a departmental model. The affect heuristic: I like (or dislike) this aspect of it, therefore I think it is (or isn t) working well. For example: I like my job. I think the model works and it would be a shame to change it. What you see is all there is: the notion that people form impressions and judgments based on the information that is available to them, without considering all the other information that isn t available to them. For example: The data shows that we are happy it seems pretty clear that the Freo model has to stay. Surely they couldn t change us to the FSH model now. 4.2 Participants The questionnaire was completed by 370 allied health participants (76%) across both sites. Questionnaire Participants n = 370 FSH Leadership FH Leadership FSH Staff FH Staff 14

19 Method of Consultation with AH Number of participants Percentage of stakeholder group Questionnaire 240 FSH staff 60% 66 FH staff 85% 24 FSH LT 80% 8 FH LT 89% AHLT 1:1 interviews 29 93% Focus Groups (18 were conducted across both sites) 6 FH LT 66% 14 FSH LT 58% 67 FSH staff 17% In addition, the following FSFHG staff were consulted 22 medical HoS at HEC+ meeting 16 nurse executive at HEC+ meeting 11 medical HoS at focus group or interview 48 nurse executive (NUM or Nurse Director) 5 Co-Directors Consultation outside of FSFHG included: Directors of Allied Health and senior AH managers at other Perth hospitals Senior managers in community AH services Dr Rosalie Boyce Allied Health representatives (managers or directors) from hospitals outside of WA Health The FSFHG Director of Allied Health was not included in consultation, as she was a member of the Project Advisory Board. 4.3 Results by Theme Themes were generated by content analysis of the data this type of analysis aims to describe the characteristics of the data (In)efficiency The FSH Allied Health Leadership Team reported that multiple conversations and consultation occur in the current FSH model in order for decisions to be made. For 15

20 most of the FSH participants, this consultation was perceived as duplication of effort and work, and therefore inefficient. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% There is duplication of management effort in this model FSH LT FSH Clinicians FH LT FH Clinicians Disagree Unsure Agree An example that was given was a staff member calls in sick to the AHC. The AHC needs to find a staff member to replace them. There is no one in their service who is available so they ask the other AHCs if there is any capacity within their teams. A potential staff member is identified but it is not clear if this person has the necessary skills in the required clinical area. The AHC asks the PL. The Allied Health Leadership Team participants were all asked in their 1:1 interviews What do you think needs to change in order to improve the model of AH here?. The most frequent response given at FSH was the need to reduce inefficiency. For example: Multiple conversations are required to make small things happen (AHLT FSH, interview #5) It s too hard to get anything done because there is too much consultation (AHLT FSH, interview #2) This situation is potentially compounded by a lack of clarity regarding roles and responsibilities within the FSH LT. 16

21 The roles and responsibilities of everyone in the leadership team are clear to me - FSH LT Agree Unsure Disagree The roles and responsibilities of everyone in the leadership team is clear to me - FSH staff Agree Unsure Disagree For the majority of AH staff at FSH it is not yet clear who does what in the Leadership Team, and who to go to with particular issues. A small number of the FSH LT perceived the discussion and collaboration that the model necessitates as an advantage. They believe it added integrity to processes and decision making. The consultation holds people to account,...like an in-built system of checks and balances... and means that multiple points of view are considered. 17

22 There are lots of people involved in the same process, like performance reviews. But you can t do without them. You could lose a valuable contribution. (AHLT FSH, interview #3) Fremantle Hospital participants did not perceive inefficiencies in their model. They considered it more efficient to report to a sole decision maker the Profession Manager because it results in quicker decision making. The AHC and HoS roles in the FSH AH model are intended as a source of efficiency for consultation with external stakeholders. They are meant to be easily identifiable and readily accessible points of contact for all Allied Health issues within either a specialty team or a service stream. A number of stakeholders reported that one point of contact is helpful: 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% It is helpful to have one point of contact with AH to resolve service issues (HEC+ results) Medical Nursing Disagree Unsure / did not respond Agree It s helpful to have that one point of contact. I ve got traction on projects involving AH here that previously were going nowhere. It s easier here. (Medical HoS, FSH) The AHC role is very valuable because they understand [the clinical area]. I don t want to have to negotiate with a physio head of department and an OT head of department. (Medical HoS, FSH) We are not missing out by not having a HoD for Physio, OT and SW at every meeting (FSH Co-Director) 18

23 Conversely, this aspect of the FSH AH model was perceived to be complex and inefficient by others: The structure adds complexity. If there s an issue with physio on the ward, I ll go to the senior physio to sort it out. But should I have gone to the AHC first? And because it s a physio issue am I meant to get the PL involved as well? It seems over-replicated (NUM, FSH) A quicker response time would help. The HoS or AHC goes and consults with the relevant PL, which is great, you get a considered response, but sometimes this takes too much time (Co-Director) It s hard to find someone who knows what s going on over there. I try to call to get an answer about an issue and I get bounced around from the co-ordinator to the PL to the HoS (AH LT FH, 1:1 interview #14) A source of inefficiency reported by FSH AH staff was reporting to a line manager (AHC) who isn t from their profession, or doesn t understand their profession. Participants reported that this can create difficulties, which are perceived as inefficient, and at times frustrating. It takes too much time to explain issues and deal with the AHC. You have to explain everything because they don't have baseline professional understanding and knowledge. (AH staff, FSH FG #8) Day to day work would be much more streamlined if we were in any other model (AH staff, FSH FG #2) It s so much easier and quicker talking to someone who understands you. (AH staff, FH FG #1) SUMMARY: The majority of respondents from the FSH Leadership Team reported inefficiencies within the current leadership structure due to involvement of multiple people and multiple conversations in order to make a decision. Allied Health staff at FSH perceive duplication of management effort and reported inefficiencies in liaising with a manager if the manager does not understand their professional contribution. A single point of contact with AH was found to be beneficial for non-ah stakeholders, but this role may not be functioning optimally in the current FSH structure. 19

24 4.3.2 Professional Support The perception that staff are not receiving enough professional support in the FSH model recurred in all modes of consultation. Several reasons were proposed to explain this lack of a profession-specific manager perception that the PL role is disempowered lack of contact with colleagues within the profession a lack of a departmental space (see Car-Parked Issues) Staff reported that a profession-specific manager would be better able to support them than an inter-professional manager. This was reported by FSH AH staff, and also from some external stakeholders, for example: Regardless of how helpful or friendly the AHC is - they don't understand. We need support from a senior clinician within our profession. (AH staff, FSH FG #6) AH staff don t have a rewarding professional support network here [at FSH], because they have generic AH leadership. (Medical HoS, FSH) Staff at FSH also reported a sense of professional isolation because of a lack of contact with colleagues from their profession. I have enough contact with colleagues from my profession - FSH staff Agree Unsure Disagree In contrast, only 3% of FH staff disagreed with this statement. Some of the commentary from FSH staff includes: 20

25 I think a lot of us are experiencing professional isolation. I can go a long time without seeing another [person from my profession]. (AH staff, FSH FG #8) You don't know who your colleagues are. There are other [e.g. physios] who I've never met. There is no opportunity for incidental contact or ad hoc conversations. (AH staff, FSH FG #1) Clinicians consistently feedback that they would prefer to be under a departmental model, because they aren t working closely with [their colleagues] across the whole site. This affects caseload management. There aren t opportunities for incidental contact with other [e.g. OTs] to facilitate workload. (AHLT FSH, interview #7) The sense of professional isolation is compounded by factors that are not related to the model. It was recognised by participants that there are other factors which limit the ability to interact with AH staff at FSH, for example the size of the campus, and a busy workload. While many FSH staff felt that the model had lessened contact with their professional colleagues, some participants commented that the model had also created a disconnect between them and their medical and nursing colleagues. The model is making us mingle with people we have nothing to do with, and taking us away from our medical and nursing team. (AH staff, FSH FG #9) In contrast, some senior AH staff reported that professional support was less important to them than the relationships with their colleagues in the clinical team, and that the FSH model enhanced this. As a senior I am more interested in relationships with the people I work with. It It's a not as important for me to connect to all the other people in my profession. I have more contact with the AH, medical and nursing staff I work with here. (AH staff, FSH FG #4) The questionnaire asked staff to respond to the statement I feel connected to my profession. 21

26 100 I feel connected to my profession - FSH staff % Agree Ex Phys PC CP / NP Pod AHA PT OT SW Diet SP The FSH results show that some professions do have a sense of professional support. Exercise Physiology and Podiatry are smaller professions who are, for most of the time, co-located in the same area i.e. gym or outpatient clinic. Clinical Psychology / Neuropsychology (CP / NP) participants reported that as a team they have put a lot of work into developing a sense of intra-professional connection. They recognised that a lack of support from colleagues was a potential problem in the FSH model, and have implemented strategies to manage it: for example there is a weekly CP / NP lunchtime get-together. This meeting is prioritised in a busy caseload, because it is recognised as a valuable opportunity to talk with colleagues and gain professional support. Dietetics and Speech Pathology felt least connection to their profession. This may be explained by having a relatively small number of FTE spread across the campus. Fremantle Fremantle staff reported that they felt well supported by colleagues within their professions, and were not experiencing professional isolation. 22

27 I feel connected to my profession - FH staff Diet SP PT OT SW % Agree Fremantle staff stated: I like having a workspace where you can bounce ideas off a colleague. I like crossing paths with people from the same profession. (AH staff, FH FG #3) There is a lot of support and understanding here. (AH staff, FH FG #2) There are a number of potential reasons for this greater sense of professional support at FH: the AH organisational model FH is an established hospital with an established culture FH is a smaller hospital with fewer staff therefore more likely to know colleagues the presence of a departmental space (see Car-parked issues). SUMMARY: There was a strong perception at FSH that the AH model does not offer enough professional support nor opportunity to connect with colleagues from within the profession. This is potentially a greater issue for junior staff than seniors. There are some geographic differences between the two sites which help create a sense of support at FH and isolation at FSH, however there are other factors at FSH which contribute to a sense of not enough professional support. One profession has actively sought ways to address this, with success Professional Oversight Concerns were raised at FSH regarding a potential lack of clinical oversight. Several reasons were identified as possible causes of this: 23

28 AHC role is busy with day-to-day operational management, and does not have time to spend on the floor observing clinical practice and acting as a clinical expert PL role is removed from operational aspects of practice and is not directly aware of clinical workload inter-professional line management - AHCs do not have clinical understanding of all of the professions in each of their specialty teams, and what best practice looks like for each clinician Concerns raised regarding this include: Concern 1. Inability to move staff easily in order to have the right staff in the right place at the right time Example The ops team don t have the understanding of their staff skill mix, who can do what within the profession, so they can t move staff to cover leave. (AHLT FSH, 1:1 interview) 2. The creation of service silos The AHC doesn t have cross-service visibility. We ve created service silos which reduce efficiency and runs the risk of inequity in patient care. (AHLT FSH, 1:1 interview) 3. Clinical risk You can t be aware of what s happening clinically when you aren t line managing people. There is an element of risk in that risk to clinical practice and safety & quality. (AHLT FSH, 1:1 interview) Examples of inter-professional management exist elsewhere in health for example in RITH, WACHS and in some Eastern States examples. In consultation with external stakeholders, the following factors were reported which contribute to successful inter-professional oversight: managing a small team (i.e less than 12) managing a team of senior clinicians all RITH professionals are P2 seniors with experience frequent team meetings are held where clinical care is assessed against whether the patient is achieving their goals. Fremantle This concern was not raised by FH participants. SUMMARY: 24

29 It is not clear that there is adequate oversight of clinical practice at FSH. The main reasons attributed to this were absence of profession-specific line management, and the development of service-silos Know the Business Participants in this review considered it important to be able to talk with someone in AH management who has understanding and knowledge of the relevant area. At FSH, this is someone in an inter-professional role. At FH, it is a profession manager. For external (non-ah) stakeholders the key factors when liaising with AH were that the person has an understanding of the clinical area, and that the interaction was efficient. Some stakeholders preferred the FSH model, and others did not. It s good to have one person who understands all about [this area]. (Medical HoS, FSH) I need someone [in AH management] who understands the business of [e.g. orthopaedics]. Generic management can be OK as long as they understand the clinical area. (Medical HoS, FH) I want to go directly to the key person, not have an intermediary person who liaises with others and comes back with an answer later. (Medical HoS, FSH) I would prefer to deal with clinicians directly. (Medical HoS, FSH) For most of the AH participants, however, it did matter whether their line manager was someone from their profession. Fremantle AH staff were more satisfied with the support from their line manager than FSH staff. 25

30 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% I have enough support from my line manager FH staff FSH staff Disagree Unsure Agree There could be many reasons for this, however feeling understood was identified as an important contributing factor. I want a manager from the profession who understands me (AH staff, FH FG #4) Being managed by someone outside the profession works at a high level but not at a clinical level. They can't provide operational guidance. (AH staff, FSH FG #9) If the AHC doesn't have experience in your clinical area they can't provide clinical advice. This can cause issues with patient safety. (AH staff, FSH FG #9) We need a supervisor who knows what we are doing. We need someone with an understanding of our clinical work. Someone from our profession. (AH staff, FSH FG #4) We report to someone who is not from our profession and they can't offer consultancy or advice or professional support. (AH staff, FSH FG #8) This is potentially less of a concern for experienced staff. Some of the senior FSH AH clinicians mentioned that it didn t matter that their line manager wasn t from their profession: 26

31 Your Professional Lead doesn't know everything about the profession. Even in the old model I couldn't get clinical support from them. (AH staff, FSH FG #9) I get good support from my AHC. The model allows them the time to get to know each person when they don t move on quickly. (AH staff, FSH FG#6) SUMMARY: It is important to all stakeholders that they are in contact with an AH manager who understands their business. For external stakeholders (non-ah), this means a person who understands the clinical area. For the majority of AH participants, this means someone from the same profession Inter-professional Practice One of the proposed advantages of the FSH AH model is that it would promote interprofessional practice (IPP) within AH. Staff at both sites reported that they were practising inter-professionally. Statement % Agree FSH % Agree FH I know that all the AH staff who I work with have a good understanding of what I do I am confident describing the work that other AH professionals in my clinical team do, and how it helps the patient I feel connected to the other AH staff who work in the same clinical area as me Fiona Stanley Hospital There was feedback from external stakeholders that IPP was occurring at FSH to a greater degree than at other hospitals, for example: 27

32 It seems more cohesive at FSH. When [we] ring someone - we get the sense that the FSH staff member knows what the patient s goals are not only from their profession but also from the other professions. It feels like FSH is doing this better than other hospitals. (Stakeholder external to FSH) This new model is fantastic. Allied Health are working together as a unit, whereas at [previous hospital] it was fragmented. (Medical HoS, FSH) Communication and collaboration in [my clinical area] has strengthened compared to when we were at [previous hospital]. (NMEC, FSFHG) Not sure if it is the model or the physical environment but I feel that AH are working more inter-professionally here than at [previous hospital]. This is helped by the fact that they share an office and gym space. (Medical HoS, FSH) You can speak to any member of the AH team at FSH and they know what the others are doing. At Fremantle you need to go to each of the individual professions. (NMEC, FSFHG) A smaller number of participants were not convinced that the FSH AH model had resulted in IPP: I think Allied Health have always worked inter-professionally. This model doesn t add to our IPP, but it does take away from professional oversight and support. (AHLT FSH, interview #17) Staff are working in an inter-professional team but they aren t doing true interprofessional practice. (AHLT FSH, interview #21) Don t think AH is actually being any more inter-professional than anywhere else I ve worked. (FSH Co-Director) Fremantle Hospital Participants from Fremantle commented that IPP was occurring within AH at that site: The FSH model was sold as something that would promote IPP. Where is the evidence that this isn t happening well enough in other sites?...multidisciplinary teamwork is happening here and always has. (AHLT FH, interview #12) There is a long established history at FH of inter-disciplinary and multidisciplinary collaboration. There are strong ties between the different Some departments FSH participants and between believed the clinical that the teams. model did (AHLT not FH, aid IPP, interview for example: #25) 28

33 There are factors which encourage IPP which are independent of the organisational structure of AH. For example at FSH: co-location in shared AH offices an IPP education program offered by the AH Education Team And at Fremantle Hospital: positive role-modelling of IPP established culture that encourages inter-professional working. SUMMARY: The perception of most AH staff at both sites is that IPP is occurring. There were positive comments from non-ah staff that AH were demonstrating greater interprofessional practice at FSH. The extent to which IPP may or may not actually be occurring at either site was not objectively measured in this review A Voice for Allied Health One of the aims of the current FSH model was that it would strengthen the inclusion of Allied Health within the organisation at an executive level to influence strategic planning. Having a DAH at an executive level was perceived to be valuable in achieving this: Having the DAH at executive is useful. (AH staff, FSH FG#6) The only part of this model I wouldn t want to lose is having the DAH at executive. (AH staff, FSH FG #2) It s a huge bonus for AH voice in the organisation. Irrespective of the AH model this position should remain (AHLT FSH, interview #11) Having the DAH position represented at executive is positive. It gives us a voice in the organisation. But we don t need this specific AH model to do that. (AHLT FSH, interview #17) Allied Health participants at both sites felt that AH had a voice in their organisation. Fremantle staff were able to attribute this to their model, whereas FSH participants were less certain of the effect their model has on this. 29

34 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% The FSH/FH model is helping AH to be visible and have a voice in the organisation FSH LT FSH staff FH LT FH Staff Disagree Unsure Agree The AH HoS role was recognised as an important contributing factor at Fremantle Hospital. SUMMARY: The DAH position was uniformly recognised as a strength of the AH model, and something which had given AH a voice in the organisation AH Education Team The AH Education Team was initially only resourced and available at FSH. Since the FSFHG merger it is now a cross-site service. The prevailing view at FSH was that this service that adds value. The Leadership Team participants were all asked in their interview What are the strengths of the AH model? The Education Team was the most frequent response at FSH. The questionnaire also provided opportunity for participants to provide feedback on the Education service: The AH Education Team is a useful resource - FSH LT Agree Unsure Disagree 30

35 The AH Education role improves my ability to access education and training - FSH staff Agree Unsure Disagree Several reasons were described to explain this: the Education Team are a source of expertise that has improved the quality of education provided in AH they have improved access to education and training for AH staff they perform tasks (such as staff and student orientation) that free up clinicians to do patient care they perform tasks (such as co-ordination of mandatory training) that improve efficiencies in the leadership team. Fremantle AH participants were less certain of the value of the AH Education team. Thirty-seven percent of the Leadership Team agreed that it was a valuable resource, and 38% of staff felt that it improved their ability to access education and training. External stakeholders (non-ah) at FSH reported that collaboration with the AH Education team has resulted in successful inter-professional education delivery and is an example of effective AH, medical and nursing collaboration. SUMMARY: The Education Team was perceived as valuable resource, more so by FSH participants than FH participants Patient Care Some feedback was received about the impact of the different AH models on patient care. The questionnaire provided an opportunity to respond to the statement The FSH / FH model is working for patients. Fremantle Hospital participants were more positive about this than FSH. 31

36 100% The FSH / FH AH model is working for patients 90% 80% 70% 60% 50% 40% 30% Disagree Unsure Agree 20% 10% 0% FSH LT FSH staff FH LT FH staff The graph shows that FSH participants were less certain that the FSH AH model is having a positive impact of patient care. This was explored further in the individual interviews with the AHLT on both sites. They were all asked the question Does the structure support AH to provide the best solutions for patients? Fremantle participants almost unanimously responded Yes. Reasons included: it promotes development of the profession and leads to best practice able to manage one profession in one place by one person flexible and responsive can get the right staff member in the right place at the right time staff satisfaction Fiona Stanley leadership team respondents were more divided in response to this question. There were 11 comments suggesting no, nine suggesting yes, and four uncertain. Reasons provided as to why the FSH model does not support AH to provide the best solutions for patients include: Professional Lead doesn t have appropriate clinical oversight can t get right staff in right place at right time: more difficult to move clinicians around because of service silos and operational staff not understanding professional skill mix staff aren t happy day to day caseload allocation is more difficult negative selection is occurring: good staff are leaving because they are dissatisfied with the model cuts to clinical staff FTE Reasons why the FSH AH model is supporting patient care: 32

37 collaboration within clinical teams, demonstrating IPP AH clinicians always put patient care first integrated team have excellent clinicians doing an excellent job the different roles within the FSH leadership team AHC, PL, HoS, Education allow clinicians to focus on clinical care and patient service Some external stakeholders (Medical Heads of Service and Nursing Executive) commented that the FSH AHLT structure is expensive, and they would prefer to see resources directed to clinical FTE than management FTE. The current model is expensive. We are meant to be patient-centric and should have a functional, effective and lean model. We need to fund patient care as a priority, not management. (Medical HoS, FSH) SUMMARY: The impact of the model on patient care was not objectively measured in this review. The predominant perception at FH is that their model supports staff to provide quality care. FSH respondents identified some barriers to this, in particular staff satisfaction, less flexibility in moving staff, and concerns with clinical oversight. 4.4 Other Issues Other topics raised during consultation, however less often that those which formed the themes described above, include: flat structure and lack of succession planning at FH for management positions not enough P3 positions in all professions, across both sites P3 positions at FSH are de-skilled because they do not have any non-clinical responsibilities FSH AH HoS role is over-burdened with HR processes (e.g. contract management) and does not have enough time to dedicate to leadership the FSH model does not align with WA Health IT systems, which are profession-based this creates inefficiencies the extent of change that is occurring in AH is destabilising and having a negative effect on staff morale one size doesn t fit all FSH model needs to be more flexible to enable individual professions to do what best suits them, rather than fit into a generic AH approach need more support for AH research leadership of safety and quality is lacking FSH AH staff share offices and therapy spaces, which helps to create a strong clinical team FSH AH leadership team are co-located in an office, which helps to share knowledge and different perspectives AHC role has oversight of an inter-professional team, and is able to drive a shared vision of service improvement and patient care for the specialty team 33

38 In addition, a summary of results organised via stakeholder group is presented in Appendix Car-parked Issues These issues were raised several times by stakeholders during the consultation process. They are presented for information only and are considered out of scope in relation to the aims of this review. Allied Health departmental space A room or rooms dedicated just to that profession e.g. the Social Work Department. staff at FH would like to maintain their departments. They mentioned that these spaces provide the opportunity to: communicate with colleagues; have incidental conversations which support patient care; gain professional support; and have a central location to store profession-specific resources. some staff at FSH would like to gain a departmental space, for the same reasons mentioned above. Allied Health funding being allocated to specialty areas Some Medical Heads of Service mentioned that they would like the funding / FTE / establishment for Allied Health to belong to their clinical area, for several reasons: it is a risk that AH FTE is not secure to their clinical area. The medical HoS do not have the ability to protect the FTE, for example when there are reductions, and are concerned about the implications of this for clinical care in their area e.g. length of stay. some professions are better suited to being in the medical / specialty team. Separating AH has diluted the collaboration and communication between the medical, nursing and AH professionals. would like dual reporting lines: AH reporting to the medical Head of Service for clinical care and the Professional Lead for professional needs. More FTE More AH clinical FTE is required: several medical HoS and NUMs mentioned that they need more AH FTE within the clinical area to facilitate patient care and enable service improvements to occur it was suggested that the FSH AHLT is expensive and the cost might be at the expense of providing direct clinical care would be better to redirect some of that expense to increase clinical FTE, to enable patients to have access to care 34

39 5.0 Proposed Models Based on the results of the review, feedback from stakeholders, review of current practice in other hospitals and a literature review, four potential models for AH are proposed. The following questions are available for consideration when assessing competing alternatives for AH structures. (18) 1. Does the structure have support for professional practice leadership and team-based service delivery? 2. Does the structure have the internal flexibility to enable rapid response to peaks in service demand across the organisation? 3. Is allied health leadership embedded in the corporate level and the operational level to enable meaningful and joined-up participation in planning, service development and workforce management? 4. Is there single point accountability for professional services, and operational services? 5. Does the organisational approach show how those who are served by allied health can have meaningful engagement? 6. Does the structure have mechanisms for supporting excellence in clinical practice, education, research and innovation? NOTES The Clinical Psychology / Neuropsychology team at FSH requested that their position in AH be considered in conjunction with this review. Please see Appendix 5. The costing information are base salary costs only (from 1 st July 2017). Costs do not include: o annual leave loading, o long service leave provision o superannuation; or o area support o corporate operations o site support o clinical overhead. Allied Health FTE in Mental Health is excluded (unless otherwise indicated), on the assumption that this will be transferred to Mental Health in the new financial year. 35

40 36

41 5.2 Option A Allied Health Divisional Model 37

42 5.2.1 Description Allied Health divisional model. There is an Allied Health division and a range of professional departments or services within it. It offers profession management of professional resources, and the ability via a Director of Allied Health to co-ordinate and develop organisational-wide service priorities and systems. A DAH has overall strategic and operational accountability for AH services, has a budget, and reports directly to Executive Roles and Responsibilities Director of Allied Health Provides executive leadership, management and governance for the Allied Health service within FSH. As a member of the FSH senior management team, contributes to the achievement of FSH and SMHS performance objectives through the development and implementation of strategic and operational plans, policy and service improvement strategies. Models collaborative leadership and facilitates inter-professional relationships across allied health, nursing and medical professions Represents the health service in the community setting, addressing professional, academic and operational issues Liaises with other agencies, both public and private, as well as community groups and individuals, in order to ensure that AH services are responsive to changing needs Head of Department Responsible and accountable for all aspects of the profession specific service and resource Manages the human, financial and infrastructure resources of the service Develops, implements and updates clinical standards of care, policies and procedures Develops and coordinates the Safety, Quality and Risk activities Optimises professional expertise Provides performance management, professional supervision and education, with links to AH Education Director Deputy Head of Department Supports the functions (described above) of the profession Head of Department 38

43 5.2.3 Strengths, Weaknesses and Risks Strengths Operational- and professional accountability focussed service under the overall leadership of the DAH Single point of contact (DAH) for senior executives Integrates operational and professional accountability of all AH practitioners Accountability and responsibility are clear reduced confusion and duplication Structure supports professional practice leadership Staff are line managed within their profession Provides staff with a sense of professional support and advocacy An AH subculture is fostered Provides clear point/s of responsibility for clinical oversight Structure supports excellence in clinical practice, education and research Staff mobility and agility: easy to move staff can get the right person in the right place at the right time Complements FSFHG service stream structure profession services are provided across the service streams Support of new graduates and experienced clinicians Succession planning opportunities within professions Smaller professions (Exercise Physiology, Audiology, Allied Health Assistants) could be aligned under the governance of larger professions (see Option B) to further increase efficiencies and decrease costs Significant cost saving compared to current FSFHG model Weaknesses Perception of a lack of single points of contact for each specialty team for stakeholders. This can be mitigated by portfolio representation e.g. the head of CP/NP is the point of contact for Mental Health and attends the Service 5 meetings etc. Requires a collaborative approach from the professions and there is a loss of dedicated FTE focussed solely on strategy Allied Health is viewed as disparate, multiple identities that operate as singlediscipline professions Smaller departments have reduced critical mass due to smaller FTE and their issues may be marginalised. This can be mitigated by aligning with larger professions as described above Potentially encourages a siloed professional approach Limited team-based service delivery focus 39

44 Risks Profession cultures remain separate and distinct. Discipline boundaries create silos, which in turn perpetuates individualistic thinking and behaviour, and inappropriate competition, at the expense of the patient/consumer 40

45 5.3 Option B Integrated Decentralised Model 41

46 5.3.1 Description Integrated decentralised model. A DAH has overall strategic and operational accountability for AH services, holds a budget and reports directly to Executive Professional identity, management and governance underpin this structure Requires AH professionals to adopt collaborative practices and provide teambased care through an intra-divisional matrix There is team representation and oversight of inter-professional practice via a nominated (or resourced depending on the team) Team Leader Smaller professions (Exercise Physiology, Audiology, Allied Health Assistants) are aligned under the governance of larger professions Roles and Responsibilities Director of Allied Health as per Profession (e.g. Dietetics) Manager as per Heads of Department description in and promote cross-structural working and inter-professional practice through collaboration and consultation with other members of the AHLT Deputy Manager (Profession) as per (Profession) Coordinator As per Profession Manager, however recognising that the profession is significantly lower in FTE and service reach Reports directly to a Profession Manager (eg Coordinator Exercise Physiology reports to the Physiotherapy Manager) Team Leaders A senior therapist from any profession who acts as an IPP Champion, promotes collaboration and cohesion within the clinical team at the specialty level and undertakes any administrative functions required at a team level. Point of contact at a specialty level for external stakeholders interface with the NUM and medical HoS for service issues as required This could be a nominal position with no additional FTE, or may be resourced e.g. 0.1 FTE via backfill 42

47 the Team Leader reports to an appropriate Profession Manager, for example the surgical Team Leader could report to the Dietetics Manager. This further encourages cross-structural oversight at the leadership level. Attends relevant service stream meetings to provide a collective AH subspecialty view Strengths, Weaknesses and Risks Strengths Integrates operational and professional accountability of all AH practitioners Operational and professional accountability focussed service under the overall leadership of the DAH Less line reports to DAH than option A and current model Allied Health is viewed as a single, united health service stakeholder A sustainable AH subculture (profession community) is fostered Ability to manage activity and staff agility across services and streams (easy to move staff can get the right person in the right place at the right time) Ability to co-ordinate and develop organisational wide service priorities and systems. Operational and strategic resource is combined which may improve efficiency and communication Team structure is focussed around consumer needs, rather than a profession s needs Strong foundation of professional governance ensures professional practice leadership and subsequent patient safety Builds on existing strong foundation of IPP as described in the review. High quality and innovative patient care is provided by teams with diverse professional backgrounds Maintains an IPP focus and promotes cross-boundary working Accountability and responsibility are clear reduced confusion and duplication Staff are line managed within their profession but AHLT and Team Leaders model inter-professional practice Team Leader approach and deputy arrangement allows succession planning and career structure Team Leader supports the goals and outcomes of the team, rather than the discipline, and promotes collaborative practice Structure supports excellence in clinical practice, education and research Medical and nursing leaders have clear go to AH roles for relevant communication Provides clear point/s of responsibility for clinical oversight at a profession level Complements FSFHG service stream structure and multi-professional teams are allocated within streams and specialty areas 43

48 Significant cost saving compared to current FSFHG model Weaknesses Perception of a lack of single point of contact. This can be mitigated by service portfolio representation e.g. the Physiotherapy Manager can represent acute care and attend Service 1 meetings A loss of dedicated FTE focussed solely on strategy Risks Change resistance within organisation. This can be mitigated by change management strategies and a building of a cross site, cross profession AH community 44

49 45

50 5.4 Option C Current FSH Model Expanded 46