Royal Perth Group Proposal for an Allied Health Leadership and Governance Framework May 2015 Version 1.8 Prepared by South Metropolitan Population Health Unit
Project Control Group Name Dr Aresh Anwar Jodie Chamberlain Joel Gurr Marani Hutton Project Manager Kate Gatti Belinda Whitworth Position/Title A/Executive Director, Royal Perth Group (RPG) Deputy Executive Director RPG Director, Fiona Stanley Hospital Area Allied Health Advisor, SMHS Executive Director, South Metropolitan Population Health Unit Manager, Non-admitted Services Reform Team, Population Health Version Control No Date Nature of change(s) 1.6 18 May 2015 Draft document submitted to the Project Control Group (PCG) 1.7 20 May 2015 Revised version following PCG 1.8 5 June 2015 Revised version following feedback from PCG 1
Contents 1.0 Key Points... 3 2.0 Context... 4 3.0 Purpose... 4 4.0 Scope... 4 5.0 Methodology... 5 6.0 Current RPG allied health service models... 6 7.0 Principles... 7 8.0 Critical Success Factors for an Allied Health Service... 7 9.0 Allied health leadership and key roles... 9 10.0 Governance and Structure... 11 11.0 Transition and Change Management... 18 12.0 Considerations for next steps (summary)... 18 13.0 References... 19 Appendix 1:... 20 25 Allied Health and Health Science Professionals represented by... 20 The Office of the Chief Health Professions... 20 Appendix 2: Australian Allied Health Organisational Models... 21 2
1.0 Key Points This review was commissioned to provide options for a leadership and governance framework for Royal Perth Group (RPG) allied health. The overall governance of RPG is outside the scope of this review. To achieve a RPG allied health integrated leadership and governance framework attention to the internal culture of the RPG is required to bring two strong and traditional work cultures together. Allied health, in this review, refers to Physiotherapy, Occupational Therapy, Social Work, Dietetics & Nutrition, Speech Pathology, Podiatry and Clinical Psychology. It is acknowledged that other allied health professions, programs or service may be considered within the RPG allied health structure. Royal Perth Hospital is a tertiary hospital, recently downsizing from the largest tertiary hospital in Western Australia, to a 450 bed tertiary hospital. Some of the significant changes include workforce reduction and transfer to other sites and revised service models and profiles. Bentley Hospital is operating as a secondary specialist hospital. The majority of services are mental health and aged care/rehabilitation. Mental health operates within a program management model. There are also currently limited surgical and maternity services. The proposed options for consideration are based on an evaluation of current literature related to allied health service delivery structures, the mapping of RPG purchased activity and service profiles. RPG allied health interview and survey data informs the overall report. The proposed options are also based on Bentley hospital services aligned to RPG Service 1 and Service 3 and that Service 3(mental health) operates within a program management model. A proposed transition to any of these options would require as a priority a workforce build and costing with RPG human resources and finance staff. A recommendation that a RPG Director of Allied Health position be created and recruited to via an open and competitive process. The position will report directly to the Executive Director, Royal Perth Group and will provide strategic and operational direction for allied health at an organisational level. Proposed changes to the RPG allied health leadership and governance framework will require: change management support; the establishment of positions and recruitment for key roles in accordance with the human resource principles and public sector standards; classification assessment of new/changes in positions; the establishment of governing committees and groups following appointment of leadership positions. Once the preferred allied health structure is approved the clinical team structure and operational arrangements will be formulated. There are a number of interdependencies with the RPG structure that will inform this work. 3
2.0 Context South Metropolitan Health Service (SMHS) has undertaken significant reconfiguration, transition and reform across sites that have impacted on clinical service activity, staffing, service and funding models. The future of health care delivery is increasingly inter-professional and dependent upon high performing clinical. The Royal Perth Group (RPG), Royal Perth hospital and Bentley Health Service, moved to service streams (service 1-4) in 2012. This model enables more clinicians to be invested and involved in leading clinical services and supports the requirement to deliver services within an activity based funding (ABF) affordable state. The change in governance has been fully implemented at the Royal Perth Hospital and further work is required to align and integrate the functions and services of Bentley Health Service to the RPG model. It is within this context that RPG has identified the allied health professions for review and realignment within its new service profile. 3.0 Purpose This paper presents a leadership and governance framework for allied health professions to achieve an integrated allied health service with effective points of intersection with the nursing, medical and organisational leadership structures. It is recognised that allied health professions have a significant role and are major contributors to the delivery of high quality health care and health outcomes for patients across the care continuum. Allied health professionals must be in a position to lead and fully participate in the diverse clinical that function across services streams and multiple sites. This framework will align with the organisational governance structure, vision, accountabilities and reform of RPG. 4.0 Scope There are 25 allied health and health science professions within WA Health, supported by the Office of the Chief Health Professions Office (see appendix 1). For the purposes of this review the in-scope allied health services are the departments of the following professions: Physiotherapy Occupational Therapy Social Work Dietetics and Nutrition Speech Pathology Podiatry Clinical Psychology 4
5.0 Methodology The South Metropolitan Population Health Unit was commissioned by the A/Executive Director of RPG to undertake the RPG Allied Health Review. The Project Control Group met regularly throughout the review process and was provided with regular updates and results. An examination of current literature on allied health models and structures was undertaken using published literature search engines and follow up of relevant reference lists. Learnings from the literature have been used to inform the review and report. The results have been summarised in a table available as part of the supporting documentation. The RPH and BHS allied health workforce builds were reviewed and clarification sought from allied health directors on the rationale and construct of both staffing numbers/levels and structures. Job description forms of contemporary allied health leadership positions were reviewed to inform potential positions, duties and responsibilities relevant to a RPG allied health structure. As with all information gathered this informed the review and report. Structured face-to-face confidential interviews were held with allied health directors, directors of nursing, heads of departments/service coordinators/coordinators, service directors and key managers. The questionnaire aimed to elicit information on the current state of allied health organisational structure, principles of allied health, communication/reporting and potential future governance structures. All interviewees were invited to provide additional comments at the end of the interview which many contributed; in addition some participants provided further information by email. An online survey was also developed using Survey Monkey and distributed via the allied health director/heads of department to all allied health staff in scope for this review. The survey was distributed to a total of 280 staff and completed by 151 (54% response rate). In addition to multiple choice format an open ended comments section was included and completed by the majority of respondents. As with the interview questionnaires the survey included questions on current site structures (both individual sites and RPG), reporting, communication and principles of allied health. Information about allied health leadership and governance collected from the interviews and online survey has been de-identified and summarised in a supplementary document. This information is presented in key themes with implications for organisational development. It is envisaged it will be used to guide and facilitate a change management process should a decision be made by the RPG executive to reform the leadership and governance of allied health. De-identified staff feedback received from interviews and survey monkey has also been collated and provided to the PCG. This report is for the Project Control Group (PCG). 5
6.0 Current RPG allied health service models The current RPG allied health services are delivered through a division of allied health with a historical reporting line through to the Director of Clinical Services. Allied health professionals within mental health programs are program managed with professional governance provided by general Heads of Departments at BHS (see Figure 1). Figure 1 Royal Perth Group Allied Health Current Structure Mix of 3 models: traditional medical, division(b) & unit dispersement Executive Director RPG Deputy Executive Director RPG RPG Service Streams BHS General Manager (Dept of ED) Service 1 RPH A/Director Allied Health Service 2 Service 3 Service 4 BHS A/Director Allied Health RPH AH HODs x 5 RPH HOD Podiatry RPH Clinical Psychology BHS AH HOD x 5 Senior Coordinator x1 Coordinator x 1 RPH AH clinicians in clinical RPH AH clinicians in clinical RPH AH clinicians in clinical RPH AH clinicians in clinical BHS Allied Health clinicians in clinical BHS Allied Health clinicians in clinical Professional and/or operational Professional management only Information gathered in interviews with key allied health staff identifies issues to be addressed in the new leadership and governance structure: Potential duplications and gaps in allied health leadership. Different governance structures within and across sites. A mix of Heads of Departments/Senior Coordinators/Coordinators in situ across sites with inconsistencies in job descriptions, roles and responsibilities. Different approaches between sites in determining workforce build to deliver services as set out in the SMHS Purchasing Plan. Within integrated organisational structures allied health professions are more likely to be managed by other disciplines than any other health professions (e.g. nursing or medical). Therefore, formal system wide processes are required to communicate, prioritise and act on allied health issues throughout all levels of the organisation and regardless of line management professional differences. 6
Working effectively in dual reporting service models was reported by all professions (nursing, medical, allied health) as an issue in all aspects of work. For example, effective communication, decision making, priority setting, management support and skills in interdisciplinary team management, clarity of roles and responsibilities, parity of leadership opportunities across disciplines and HR. There are different baselines in services across RPG from which to transition services to a new leadership and governance model. 7.0 Principles There are generally accepted guiding principles for allied health services and leadership structures that focus on patient care and service goals, professional, management and operational accountability, career development and leadership (Mueller Janet). The RPG allied health professionals interviewed identified the following as most important: Support service delivery and patient care that ensures role clarity, enables interprofessional practice and is reflective of best practice. Facilitate patient centric care and incorporate the following service goals: o Timely care and decision making o Efficient care o Effective care o Appropriate care o Patient centric o Evidence based Have clear lines of professional governance and operational accountability A central strategic and operational Director of Allied Health be established and maintained. In addition it is recognised that ideally, allied health services: are delivered to patients at a time appropriate in the patients care journey; enable patient flow within the services of the RPG; enable patient flow between acute, rehabilitation, primary care and mental health services offered by the State government or at the interface with the nongovernment and private sector and; create sustainable and ABF affordable allied health services at RPG into the future. 8.0 Critical Success Factors for an Allied Health Service Critical factors to shape the change process and create an effective and efficient allied health service are identified in Jones & Jenkins (2006). These include: A critical mass of staff with a range of expertise to deliver comprehensive patient care and provide staff development in all specialties. 7
A service that facilitates cross-organisational working and integrated care pathways. Allied Health Professional (AHP) specialists available to develop clinical services and the skills of junior staff to deliver a high standard of clinical care. Equal standards of care and eligibility for service users in all areas. Comprehensive CPD, education and training, staff rotations and student placements. Cross-service facilitation of support for therapy assistant workforce. Optimum use of ICT, including uniform data collection, analysis and performance reporting. Managers with the authority to deliver a service that contributes to the strategic direction of the organisation. Uniformity of clinical governance management and procedures. Structures and systems that make effective and efficient uses of resources and facilitate cross-boundary team working. Flexibility to deploy staff with specialist knowledge and skills to the full diversity of services based on variable demand. 8
9.0 Allied health leadership and key roles The allied health professions guiding principles are inclusive of ways to support and develop leadership. The following diagram (figure 2) provides examples of key roles that build allied health leadership throughout the organisational structure. Figure 2: Examples of Allied Health Leadership Roles OT Physiotherapy Social Work +/- +/- Executive Tier Executive Director Allied Health or Director of Allied Health Position Service Stream Tier Allied Health Heads of Service Positions Speech Pathology Podiatry Clinical Psychology +/- Department/Centres/Units Tier (within service streams) Allied Health Coordinators (qualification in an AH discipline) +/- Senior Coordinators +/- Coordinators +/-Head of Departments (Profession specific) Dietetics +/-Professional Leads AH clinicians in multidisciplinary clinical AH clinicians in multidisciplinary clinical AH clinicians in multidisciplinary clinical *Perform clinical governance function for each profession where this is not delivered by other positions Current literature notes allied health leadership is strengthened by dedicated positions in each tier of the organisation (Government of South Australia, 2013). The functions of each tier are described below. Executive Tier (Director of Allied Health) (HSU G12-14) Provides advice on allied health matters to the Executive Director of the organisation. Accountable for allied health credentialing, practice standards, ethics, education, research and establishment budget. Accountable for planning, development and maintenance of systems to support the clinical and professional practice of allied health staff. Manages the risk and development aspects of allied health professional matters and advise on relevant policy and planning issues. Responsible for the overall management of an Allied Health Division where applicable. 9
Represents allied health on Strategic Executive and Operational Committees. Overall, responsible for leadership, collaborative and inclusive culture, change and reform. Service Stream Tier (Heads of Service) (HSU G11) Allied health strategic planning for Service Stream. Translates operational planning to service delivery with Service Stream management team. Provides operational management and/or clinical governance for. Budget holder of allied health for stream portfolio. HR recruitment of allied health professionals within stream. Heads of Departments (HSU P3-P6) Current primary profession leadership role. Manages profession specific supply across the matrix of service. Receives FTE establishment and manages an agreed FTE establishment. Advancement of the profession (albeit siloed and competitively). Profession specific credentialing. Rostering Clinical education and training needs. Research Allied Health Senior Coordinators/Coordinators (HSU P3/4) (specialty not ward) Day to day operational management of allied health professionals within specialty areas. Immediate go to person for day to day operational issues. Liaises with professional leads regarding performance and professional service issues. Professional Leads (HSU P4) Profession specific advancement (expanded scope of practice, Allied Health Assistant models). Credentialing and scope of practice requirements for the profession. Professional issues as they arise. Clinical education and training requirements. Research. These positions are also currently resourced at Fiona Stanley Hospital and should be considered in an allied health structure: Director Allied Health Education and Training: clinical education and training for allied health Director Allied Health Research Business management support 10
10.0 Governance and Structure The literature describes a variety of Australian allied health models and ways to organise the allied health workforce across health services (see Appendix 2). Three models are described and could be feasible given the current RPG organisational structure: Option 1: Allied Health Division Model: See appendix 2 (c) Option 2: Allied Health Integrated Decentralisation Model: See appendix 2 (a) Option 3: Allied Health Integrated Decentralisation Model: See appendix 2 (b) These options are presented diagrammatically below, (figures 3-5) for consideration as an appropriate RPG allied health governance structure. The benefits and limitations of each option are listed based on a summary of literature on Australian allied health structure and organisation and feedback from interviews. All options assume BHS operates within Service 1 and Service 3. Critical success factors should be taken into account when considering an allied health structure option. 11
Option 1: Allied Health Division Model (c) Figure 3 Royal Perth Group Allied Health Governance Option 1 Allied Health Division Model (c) Executive Director RPG Division of Allied Health Director Allied Health RPG Service 1 RPG Service Streams Service 2 Service 3 Service 4 Profession managed allied health departments AH clinicians in clinical AH clinicians in clinical AH clinicians in clinical AH clinicians in clinical Professional and operational Professional only Key Points: A Division of Allied Health is led by a Director of Allied Health across the RPG The Director of Allied Health has oversight of: * Clinical governance, safety and quality * Education and professional development * Workforce and service redesign Research Clinical data, outcomes and information to inform performance Allied health professionals within the Division managed by Head of Departments with delegated responsibility to senior discipline coordinators, with the exception of Service 3. Service 3 operationally manages the allied health clinical with professional governance via the Division. Professional and operational governance via the Division of Allied Health. Consideration of leadership position to support BHS and across site support. Benefits Clear strategic allied health leadership and pathways for operational and strategic management. Allied health is led by allied health and accountable for its business +/- budget. Allied health is perceived within the organisation as a united collaborative single service provider. Minimises dual lines of reporting (service 3 only) Limitations Adds reporting line for Executive Director. No allied health leadership at service stream tier. Director of Allied Health must be skilled in inter-professional management/ collaborative leadership to manage professions with parity. May not support fully integrated teamwork or inter-professional teamwork at the frontline. For service 3: program managers must be 12
skilled in inter-professional management/collaborative leadership to manage professions with parity. Dependent on effective dual reporting/management approaches. 13
Option 2: Allied Health Integrated Decentralisation Model (a) Figure 4 Royal Perth Group Allied Health Governance Option 2 Integrated Decentralisation Model (a) Director Allied Health RPG Executive Director RPG RPG Service Streams *Professional lead(s) required for any profession when professional governance is not insitu (eg via AH Head of Service or within a team) Service 1 Service 2 Service 3 Service 4 Multiprofessional AH Teams Multiprofessional AH Teams Multiprofessional AH Teams Multiprofessional AH Teams Operational only Allied Health Heads Coordinators Operational management AH Teams Professional only Allied Health Heads of Service (1 position may manage 1 or more streams) Key Points: Director of Allied Health at executive level, reporting to Executive Director. The Director of Allied Health has oversight of: * Clinical governance, safety and quality * Education and professional development * Workforce and service redesign Research Clinical data, outcomes and information to inform performance Allied Health Head of Service (at Service Co-Director level) for professional management across one or more streams (in line with Nurse Manager). Allied Health Heads of Service work directly with Service Co-Directors and Service Nurse Managers to provide service level strategic planning and patient flow; +/- Budget responsibility for AHP s within service stream. Allied Health Coordinators operationally manage multi-professional allied health generally across clinical specialty/ units. Professional leads provide professional governance. Benefits Limitations Senior allied health leadership through the service level of the organisation is supported by an executive tier. Professional leads (& for example Director of Education and Training) maintain and build professional competence. Allied health services can be packaged to Adds reporting line for Executive Director Interprofessional approaches to patient care are dependent on trust and collaboration between allied health, nursing and medical professions that must be built through a whole of 14
provide a cost effective means of service delivery. Embeds allied health clinicians in the clinical for multidisciplinary teamwork. Allied health resource provides clinical leadership, team clinical performance and succession planning. Supports emerging roles of allied health assistants and extended scope of practice for clinicians. organisation approach. Dependent on strong inter-professional management approaches. Cost of leadership positions would need to be found from within current single discipline hierarchies. Not well evaluated to date to determine full benefit of the model. 15
Option 3: Allied Health Integrated Decentralisation Model (b) Figure 5 Royal Perth Group Allied Health Governance Option 3 Integrated Decentralisation Model (b) Director Allied Health RPG Executive Director RPG RPG Service Streams Service 1 Service 2 Service 3 Service 4 Professionally Managed AH Heads of Department Multiprofessional AH Teams Multiprofessional AH Teams Multiprofessional AH Teams Multiprofessional AH Teams Professional & Operational Allied Health Heads of Service (1 position may manage 1 or more streams) Key Points: Director of Allied Health at executive level, reporting to Executive Director. The Director of Allied Health has oversight of: * Clinical governance, safety and quality * Education and professional development * Workforce and service redesign * Research * Clinical data, outcomes and information to inform performance Allied Health Head of Service at Service Co-Director level provides strategic, +/- budget responsibility for AHPs across one or more streams. Allied Health Heads of Department operationally manage and professionally govern single discipline allied health professionals across clinical units and specialties. Benefits Limitations Senior allied health leadership through the service level of the organisation is supported by an executive tier. Professional Heads of Departments maintain and build professional competence and supply staff to deliver services. Allied health services can be packaged to provide a cost effective means of Adds reporting line for Executive Director Additional cost of Head of Service at Co- Director level to be met from within existing allied health structures. Inter-professional approaches to patient care are dependent on trust and collaboration between allied health, nursing and medical professions built through a whole of organisation 16
service delivery. Embeds allied health clinicians in the clinical for multidisciplinary teamwork. Supports emerging roles of allied health assistants and extended scope of practice for clinicians. No dual lines of management. approach. Day to day operational management can be onerous on the professional Heads of Department 17
11.0 Transition and Change Management The implementation of a new leadership and governance structure for the RPG allied health professions will require a clearly articulated transition and change management process. Commitment from the RPG executive to provide leadership and engage with all health professions, not just allied health professions, to assimilate new structures and manage change is critical. Both RPH and BHS have strong and different traditional cultures. Royal Perth Hospital has operated, until recently, as the largest tertiary hospital in Perth and there is a robust sense of pride and ownership. Bentley, as a secondary hospital is focussed on community services, and has invested in its own strong sense of identity, promoting unity and confidence in its service delivery. Due to the significant changes in service delivery with the closure of Shenton Park Campus and downsizing with the commissioning of Fiona Stanley Hospital, RPH has been operating in change mode for a number of years. For Bentley Health Service there have been a number of changes in governance models in recent years, which survey feedback indicates have not been well managed. To date the inpatient and mental health service profile has remained largely unchanged, however non-admitted services have been unbundled with the view to changing service models. Given the strong cultures and ownership at individual sites, significant investment should be made early and over the transition period to build on existing areas of site staff engagement, to harness the energy and highly skilled workforce at both sites in the case of a new RPG allied health leadership and governance model. Supplementary documentation detailing the findings from the online survey and interview results is provided to inform the change process. 12.0 Considerations for next steps (summary) Formalise RPG governance structure, including role of Bentley Hospital Engage Change Management service (consultant) Develop a human resource plan to manage the change in Allied Health structure Approve the new Allied Health (AH) structure Create Director of Allied Health position Create an innovative AH leadership group from RPG sites and draw on broader allied health leadership group across SMHS and training and research organisations. Review RPG allied health activity profile, workforce and budget subsequent to governance structure and service delivery decisions Clinical team structure and operational arrangements for the allied health structure will be formulated once the allied health structure is in place. There are a number of interdependencies with the RPG structure that will inform this work. 18
13.0 References Allied Health Clinical Governance Framework - Qld - 2013 http://www.health.qld.gov.au/ahwac/html/clin-gov.asp Allied Health Best Practice Governance Framework - NSW Health Education and Training Institute - October 2012 Policy Paper: Australia s workforce of allied health professionals - AHPA - March 2013 http://www.heti.nsw.gov.au/resources-library/allied-health-best-practice-governanceframework/ http://www.ahpa.com.au/portals/0/representation/ahpa_policy_paper-workforce- March_2013.pdf Allied Health Review Background Paper 19 June 2014 http://www.together.org.au/files/4814/0624/6678/allied_health_review_- _Background_Paper_-_19_06_2014.pdf Establishment of a central Adelaide local health network allied health leadership structure Government of South Australia - November 2013 http://www.cpsu.asn.au/upload/industrial/proposed%20calhn%20allied%20health% 20Restructure.pdf Managing and Leading in the Allied Health Professions, Jenkins and Jones (Chapter 4) Radcliffe Health 2015 http://www.radcliffehealth.com/sites/radcliffehealth.com/files/books/samplechapter/706 8/04_jones%5B6%5D-50180100rdz.pdf 19
Appendix 1: 25 Allied Health and Health Science Professionals represented by The Office of the Chief Health Professions Audiology Bio Medical Engineering Clinical Perfusion Clinical Psychology Dietetics Exercise Physiology Medical Imaging Technology Medical Librarian Medical Science Medical Physics Neurophysiology Technology Nuclear Medicine Technology Occupational Therapy Orthoptics Orthotics and Prosthetics Pharmacy Physiotherapy Podiatry Psychology Radiation Therapy Respiratory Science Sleep Science Social Work Speech Pathology 20
Appendix 2: Australian Allied Health Organisational Models Model Executive Lead(s) Management of allied health Traditional Medical Model Medical Director or Director of Clinical Services Within a clinical services directorate: profession managed departments (eg OT Dept; Physiotherapy Dept) Allied Health Division Model (a) Allied Health Division Model (b) Allied Health Division Model (c) Option 1 Unit Dispersement Model Integrated decentralisation model (a) Option 2 Integrated decentralisation model (b) Option 3 Integrated Divisionalisation Model (not yet published, RA Boyce 2015) (M Hutton 2015) Executive of a Medical Division Executive of a Medical Division Director Allied Health (Head of Division of Allied Health) reports to Executive Director Clinical managers of clinical subunits Both Service Co-Director (operational) & Director of Allied Health/Allied Health Heads of Service (professional) Director of Allied Health for both professional and operational Executive Director of Allied Health Within the medical division: Rotating chair of Allied Health Profession managed departments Within the medical division: Director of Allied Health Profession managed departments Within a Division of Allied Health: Profession managed departments Professions are dispersed across clinical subunits (eg cancer care; ED). May report through a team leader Eliminates professional management Professional leads for professional when clinical governance is not provided by existing position/person. May or may not include a Director of Allied Health Allied health Heads of Service lead multiprofessional allied health service. Teams are generally matched with the clinical units across the organisation. Allied health Heads of Service lead multiprofessional allied health service. Teams are generally matched with the clinical units across the organisation. Allied Health Directors in Divisions/Programs manage including Heads of Departments of professions. AH Directors report to executive in the divisional structure. This is an integrated network model with over 400 FTE in allied health. Programs are mature and supported by an internal matrix of allied health services. 21
This document can be made available in alternative formats on request for a person with a disability. Department of Health 2015