Denos Health Management

Job Redesign in Change Management

2011-10-28T12:38:14Z

Economic pressure and the cost of healthcare world-wide are factors that a hospital manager must continually focus on in providing effective and efficient care to patients. Increase in costs on all fronts often necessitate that positions are consolidated or changed to fit better with the provision of care and saving on expenses.

Job Redesign

Functional flexibility is a concept that advocates job redesign as a method to improve organizational performance. “The re-organization of work and the redeployment of staff associated with the implementation of functional flexibility are likely to have significant implications for the employees and managers involved” (Desombre, 2006, para. 1 [1]). Job redesign will focus on enhancement of services through a holistic approach by increasing the number of skills to a job description and reducing the number of employees required to fulfil all tasks.

Collection of Information

Successful redesign of a job requires the person assigned to the task to collect all available information on the current job and work environment (Hayman, 2008 [2]). This task includes current job descriptions, documents pertaining to the different tasks assigned to the job, databases, minutes of meetings, duty rosters, employee behavior, and outcomes of tasks. Another important aspect of this preparatory phase is observation of workers during their daily routine. Movement and work studies provide valuable information on the workflow and productivity of staff members in their current roles. Observation of interaction between employees among themselves and with patients and associated activities provides good insight of the efficiency of the current job specifications. Meetings with staff and informal conversations about their expectations of the job are good sources for planning job redesign.

Job Analysis

Job analysis is the process of considering all the aspects of the new or redesigned job by breaking it down into job elements, the level of autonomy of the worker, the knowledge, skills, and abilities required to perform the job, and the behavior required from the employee (“Job Analysis, Design, and Evaluation,” 2004 [3]). The job analyst considers physical abilities required to perform the newly designed job as well as all the individual tasks necessary to complete each job function, which in turn relates to a specific outcome.

Other Factors and Job Redesign

Work environment.

The job analyst considers and evaluates the current work environment, the proposed work environment of the new job, and the psychological impact of these changes. The changed job will affect organizational culture, interrelationships between workers and the relationship between the worker and supervisor (Ingersoll, 2002 [4]). The physical environment may also change when the employee performs tasks in areas that he has not worked before.

Socio-technologic environment.

The new job may involve new work groups and technological components unfamiliar to the worker. The job analyst analyzes the potential impact these changes may have on the perceptions of the employee and co-workers in the new environment, and adjusts specifications to the job design that will enhance the smooth interaction.

Cross training and skills set.

Job redesign implies additional skills required for performing the job. Comparison of the current skills sets as determined in the job analysis and the skill required for the new job, provide information on required training for the employee. The designer of the new job must consider the length of time and basic requirements for training in the scope of implementation of a new job. The job analyst gives careful consideration to the abilities of current employees to master the additional skills required successfully.

Workload.

Job redesign is often the product of improving productivity and efficiency of workflow and quality in the organization. Theoretical planning results in a grouping of skills and tasks that may fit together perfectly, but the job designer has to consider workload. The intent of the new job is to improve workflow, without making the outcomes impossible to reach because of an unmanageable workload.

Work Processes and Expected Performance

Job Evaluation

The organization evaluates the newly designed job in terms of education required, level of responsibility of the employee, working conditions and the skills required to perform the new tasks (“Job Analysis, Design, and Evaluation,” 2004). Job evaluation results in the hierarchical ranking of the job in the organization and could lead to salary adjustments.

Motivational Factors

The job analyst will develop processes to evaluate the possible impact of motivational factors on job satisfaction or dissatisfaction and ways to manage these factors after implementation of the new job. The application of a motivational model such as Maslow's Hierarchy of Needs will improve the rate of success (Liebler, 2008 [5]).

General Work Processes and Performance

The organization must carefully consider all processes involved in migrating employees to a newly designed position. Training sessions for new skills, orientation in the new environment, performance evaluations throughout the implementation phase, and good communication with the employee are extremely important for a smooth transition. The job designer must develop in- process and outcomes indicators for all the processes associated with implementation of the new job. Processes must include the impact of new jobs on the organization and on co-workers who have to interact with the employee in the newly designed job.

The Learning Organization

The changes proposed through redesign of jobs can cause stress in an organization. The management of the organization can reduce stress and make employees and different levels of the management structure much more adaptable and flexible to adjust to change, but implementing and promoting the principles of a learning organization. Peter Senge describes the principles of implementing a learning organization (Smith, 2001 [6]).

Systems Thinking

Systems-thinking is the process of focusing on the whole, rather than the individual parts and encourages the employee and organization to consider the interrelations between various functions. A health care organization is a combination of dynamic processes and tasks that integrate to provide a good outcome for patients. Job redesign must focus on the whole system and not just the individual tasks performed by an individual. Once employees see the bigger picture and how the new design fits into the whole system, understanding will improve and encourage all staff to embrace change and achieve success.

Personal Mastery

Just like the organization must focus on systems and the whole, so must management encourage employees to look at themselves and continually develop toward goals and purposes they choose. Personal mastery can enhance the individual's sense of achievement and expansion of personal vision. Personal learning forms the building blocks for organizational learning and expands individual capacity.

Mental Models

Each individual has a mental picture and deeply engrained perception of the organization and world. The principle of learning teaches individuals to look at their surroundings with an open mind and to expand their view and perception of the world. An employee who masters the concept will be able to reshape actions and decisions and enhance the process of improvement and change.

Building Shared Vision

Employees who embrace the idea of a learning organization and open their minds to new ideas and systems thinking will start to understand the purpose and destiny of the organization. Through open communication with colleagues and management and good guiding principles provided by the organization, employees will build a shared vision for the organization. The organization will collectively work toward achieving the goals set out by leadership.

Team Learning

Team learning builds on the previous concepts and develops conversational and collective thinking skills. Team learning enhances the ability to become greater than the sum of the individual team members' talents. Through the development of skilful listening, observation and discussion, the team works toward achieving its objectives, create something new, or build new relationships in the organization.

Intra-organizational and Inter-organizational Communications

The successful implementation of redesigned jobs in the organization is highly dependent on intra- and inter-organizational communication that occurs. Change not only requires good planning and design but also how management communicates these decisions (Richardson, 1996 [7]). Communication must occur on all levels of management and must be clear and contain all the necessary information. Employees must have the opportunity to communicate upward to ensure that all relevant concerns and problems reach management.

The organization must regard implementing change such as newly designed job as a quality improvement project and the organization must use its approved performance improvement model. FOCUS PDCA is an example of a performance improvement model. Communication must include the new process flows, anticipated quality of services, decision-making processes, and the new hierarchy of the job. Management must communicate clearly all the aspects and employees who will be affected. Lewis (2000) found that communication is central to the prediction of planned outcomes in the implementation of a change process.

Job Satisfaction

Zeffane (1994 [8]) concluded that task variety, participation in decision-making, certainty about future directions and perceived work performance were central to job satisfaction. A well designed job description that clearly indicates tasks and expectations from the employee is imperative for job satisfaction. Each task or group of tasks must indicate the outcomes expected from the employee, so that they can work toward the specific performance indicator. A variety of closely related tasks will keep the employee interested in the job, but avoid distraction and loss of focus. Orientation and training for the new job is very important, as the employee needs to feel safe and well prepared for the new position.

Employees who experience an increase in perceived job control and an increase in better utilization of their skills and development will experience higher job satisfaction (Morrison, 2005 [9]). Job satisfaction directly relates to fulfilling the Maslow Needs Hierarchy. Careful consideration of all the factors in the design process will contribute to job satisfaction. The manager of the employee must do frequent performance evaluations through active participation of the employee. The employee will have the opportunity to raise problems or concerns with the job, which in turn will assist the manager to adjust the job description when necessary. An organization that seriously addresses employee concerns will notice increased job satisfaction. Employee satisfaction surveys among the category of employees with redesigned jobs will provide good feedback regarding the challenges of the new job. The manager must provide feedback to employees on the survey and prove that concerns are addressed.

Conclusion

The redesign of jobs is a typical example of change management. The organization that implements the concepts of a learning organization through systems-thinking has a better chance of success. The organization must plan every step of the process in detail and consider all aspects of the new job. Management must plan and execute clear and effective communication throughout both organizations efficiently. Leadership of the organization must control the process through constant evaluation of the organization to ensure job satisfaction.

[1] Desombre, T., Kelliher, C., Macfarlane, F. & Ozbilgin, M. (2006). Re-organizing work roles in health care: evidence from the implementation of functional flexibility. British Journal of Management 17, p. 139-151.

[2] Hayman, B, Wilkes, L. & Cioffi, J. (2008). Change process during redesign of a model of nursing practice in a surgical ward. Journal of Nursing Management 16, p. 257 – 265.

[3] Job Analysis, Design, and Evaluation. (2004). Encyclopedia of Applied Psychology.

[4] Ingersoll, G. L., Wagner, L., Merck, S. E., Kirsch, J. C., Hepworth, J. T. & Williams, M. (2002). Patient- focused redesign and employee perception of work environment. Nursing Economics 20(4), p. 163-170.

[5] Liebler, J. G. & McConnell, C. R. (2008). Management principles for health professionals (5th ed.). Sudbury, Massachusetts: Jones and Bartlett Publishers.

[6] Smith, M. K. (2001). Peter Senge and the learning organization. The Ecyclopedia of Informal Education.

[7] Richardson, P. & Denton, D. K. (1996). Communicating change. Human Resource Management 35(2), p. 203-216.

[8] Zeffane, R. (1994). Job satisfaction and job redesign: findings from Australia. International Journal of Comparative Sociology 35(1-2), p. 137-242.

[9] Morrison, D., Cordery, J., Girardy, A. and Payne, R. (2005). Job design, opportunities for skill utilization, and intrinsic job satisfaction. European Journal of Work and Organizational Psychology 14(1), p. 59-79.

RAISING THE STANDARD OF NURSING CARE IN BENGHAZI

2011-09-22T14:03:23Z

Benghazi Medical Center is a 1200 bed, tertiary care, academic hospital that received its first patients in September 2009. The hospital serves the eastern part of Libya, and receives referrals from general hospitals and primary care facilities. DENOS Health Management was contracted by the Libyan Ministry of Health to manage the facility since its opening.

Nursing care at inception

Prior to the arrival of DENOS, the Ministry of Health recruited nurses from the Philippines, India, Bosnia, Serbia and Ukraine. Local Libyan nurses were also appointed in various positions. DENOS appointed a Chief Nursing Officer, Deputy Nursing Officer – Clinical and Deputy Nursing Officer – Training, and tasked them with evaluating nursing services at the BMC, and provide an action plan to improve services.

Evaluation of nursing services

Language Barrier

One of the major obstacles identified was a major deficiency in effective communication among nursing staff and between nursing staff and other health care professionals. Most Libyan nurses could only read, write and speak Arabic, and nurses from Eastern Europe had a very limited knowledge and use of English. This posed a serious threat to patient safety and treatment protocols, as hardly any notes were made in the patient's Medical Record.

Different schools of training

The variety of countries of origin led to different applications of nursing care and treatment. No standardization existed, and in many cases, care was counter-productive. Levels of training and skills were also varied from highly skilled to very little experience and knowledge.

Teamwork

Hardly any teamwork existed. Staff formed informal groups based on language, country of origin and religion, and due to a variety of backgrounds, the divide among staff grew. The barriers for effective teamwork were numerous, and had to be addressed for effective nursing care.

Methods of evaluation

The senior nursing team used DENOS language tests to determine the level of English proficiency. Depending on the results, nurses were classified in different groups, so that targeted remedies could be applied. DENOS standardized competency tests were translated into the major foreign languages (including Arabic) and nurses were subjected to an examination. Based on previous experience and qualifications, each nurse had the opportunity to write two tests based on knowledge. Translators were available to assist during examinations, to ensure that nurses had the best possible opportunity to reflect their skills.

Findings

English language proficiency

90% of Philippine nurses were highly successful in passing the English tests. 72% of Indian nurses passed, and only 2% of the Eastern European and Libyan nurses managed to score above the pass rate. In some cases, no questions were answered. Nurses were categorised on their English proficiency, and different levels of English Foreign Language courses were suggested and implemented.

Clinical competence and skills levels

Nurses wrote tests designed for different nursing disciplines, and based on outcomes, were placed in units and sections. Nurses who failed their tests were given the opportunity to write a test in a different discipline. All candidates that failed with less than 10% below the pass rate, were allowed to do self-study and return for follow-up tests a week later. Failures with more than 10% below the pass rate, were assigned to proctors in various disciplines, and were not allowed to practice without supervision, until written and clinical (practical) competencies were passed.

Other observations

A serious lack of nurses in disciplines such as ICU, Cardiac, Paediatrics and Scrub existed, and proposals for specific training courses were tabled. The same scenario existed for supplementary services such as CSSD, wound care and chemotherapy. The serious lack in qualified, experienced registered nurses led to the decision to create a new level of care giver, so that qualified staff can concentrate on clinical duties.

Implementation of action plan

English language classes were presented to nurses, and only the use of English was permitted in written clinical documentation and for communication among professionals. This encouraged staff to learn the language, and practice the use as much as possible. Different levels of training exist, and nurses completed the courses in tandem. After the first year, a major improvement was noted, which encouraged other staff to pull through and become English proficient.

Theoretical and practical training courses were presented for ICU, Cardiac Care, CSSD and Scrub Nurses, and certificates were issued to successful candidates. The programs continue on a rotation basis, and new nurses are accepted in new cycles. The courses proved to be so successful, that negotiations started with the local nursing school to offer combined classes and practical sessions.

A caregiver course was developed. Staff members in non-clinical positions, but with prior experience in hospitals, were allowed to apply. After a series of interviews, 50 initial candidates were selected, and started the caregiver course. Within the first six months, 35 successful candidates were awarded certificates, and are now fully engaged in the provision of services to patients.

MERGING OLD AND NEW ORGANIZATIONAL CULTURES

2011-09-22T13:58:44Z

An organization that considers bringing in a management company to oversee the day-to-day operations of a health care facility faces a difficult decision. They have to weigh up the costs associated with an external management company, the effects it will have on the local staff, and the impact of change on the community to the obvious benefits of bringing in expertise that will lead to higher productivity, cost savings, improved performance, quality and patient safety. The aspect of adding a group of foreigners to the local mix brings with it challenges to improve services and cost effectiveness but also angst and insecurities among staff. The values and cultures of the two groups are different, and the typical resistance to change exists. The key to a successful organization is to build a new, single culture and identity.

Mission, Vision and Values

Employees of any organization associate with the mission, vision, and value statements of the organization, and follow the code of conduct of the organization. Informal organizations exist among staff members, and combined with the formal organization structure, are the building blocks of the organizational culture. Immersing a new management into an existing organization necessitates the review of the core documents of the organization to reflect the combined mission, vision, and values of the new entity. Ensuring that employees take part in the formation of the new core documents will go a long way in building loyalty and a shared sense of belonging.

Hofstede's Model

In a study to discover the impact of a merger on the culture of an organization, Hofstede (Shaw, 2002) identified six dimensions of cultural differences between organizations. The framework provides good reference of the perceptions of employees from two different organizations, and depending on the structure of each organization, each dimension plays a role of varying importance.

Process-oriented versus results-oriented.

This dimension relates to performance measurement and outcomes. The organization in which goals and performance measurement are unclear, the focus will be process rather than results and will have major impact on the combined culture of the new organization.

Employee-oriented versus job-oriented.

Traditionally, organizational cultures either focus on the person or on the task. The ideal situation is to have a proper balance between the two poles, and employees from an organization in which emphasis was on the individual will perceive neglect in the new structure.

Parochial versus professional orientation.

This dimension relates to the extent to which employees perceive the involvement of the organization in their personal lives. In professional-oriented organizational cultures, the organization values the competence of employees and their personal lives are left out of the equation.

Open system versus closed system.

In closed organizations, the newcomers perceive isolation and not welcomed within the new organization within a short time. Employees perceive the organization as secretive and non- communicative, and change toward a united culture will take much longer to achieve.

Loose control versus tight control.

The degree to which the organization exerts control on employees with regard to dress- code, time-keeping, and cost control has a large impact on the culture of the organization. A newly formed organization has to balance the importance of welcoming employees from a previously loosely controlled environment into the new with the need to control and set the new standard of work performance.

Normative versus pragmatic.

The new organization must balance its focus on market share and cost containment with its principles and ethical values. The main reason for management contracts is the increase in effectiveness and cost containment, and employees from an organization that was extremely pragmatic in its view may perceive the new organization as sacrificing principles.

Impact of the New Culture on Employees

Leadership of the organization has to have a clear merger strategy that takes all the dimensions of cultural change into account. Management carefully plans the design for integration of the organizational cultures and must include specific plans for response to the impact and reactions of employees, continuous performance, and the impact on patient care (Sonna, 2000). If high ambiguity between the two cultures of the organizations exists, the employees will initially be demoralized, distrust management, and experience increased patient incidents (Lee, 1990). Leaders on all levels in the new organization must find common grounds for the informal cultures that exist, and highlight shared values and principles. Employees who experience an increase in personal value from the merger will emerge as change agents for the rest of the organization.

Combination of the Workforce

Communication

Effective and frequent communication with staff is imperative to establish a cohesive workforce on departmental level and to ensure good patient outcomes. The manager must provide opportunity to staff members from both hospitals employed in the department to provide input and continually promote two-way communication. Employees must be part of the decision-making process and should perceive that they are heard. The organization must employ change management principles throughout the process of integrating the two groups of employees, and it is important for the manager to identify change agents among the group. Change agents are part of the group and not management and could be very successful in changing perceptions.

Group Identity

The manager must establish a group identity among staff members in the department. Employees must conform to the new corporate identity as soon as possible by wearing the same uniforms, identity badges, and sharing work shifts and responsibilities. The manager must encourage group discussions on the effect of a new management and monitor progress of the process informally or through employee satisfaction surveys, even on departmental level. The manager must immediately address all concerns raised during these discussions or surveys, or elevate these concerns to the next level when appropriate. Staff members' sense of belonging will increase when issues are addressed and the group accepts the responses.

Competitiveness

Competitiveness may often lead to improved performance because employees need to prove that their methods of doing things are better than the other. The manager must pay special attention to work practices from both groups of employees and encourage employees to find the best solution based on evidence-based practice. Establishing new procedures based on the experience from both groups of employees will build a common organizational culture. Employees will eventually buy-in to procedures of the other organization if one process proves to be superior to the other.

Trust

The manager must never underestimate the power of trust. Organizational charts depict the hierarchical structure of an organization, but it is the human network that does the job (Kleiner, 2002). In a high trust culture people speak freely and provide their opinions of the organization, quality, safety, satisfaction for staff and patients, and ways to improve. Employees, who may not even appear on the organization chart, play crucial networking roles in instilling trust, cooperation, and a unified culture.

The New Organization System

The management builds the new organization on the principle of “Systems Thinking” (Brown, 2008). The organization functions as a macro-system, and each unit and department as a micro-system. The organizational chart represents the new system but the system consists of all the interrelationships among its key components, such as process flows, attitudes and perceptions, quality of services, decision-making, and hierarchy. The organizational chart reflects single leadership positions for systems such as finance, human resources, medical and nursing leadership, operations, and quality and risk management. Each location will have support departments to manage the day-to-day business of the organization, but the organization centralizes the main functions, rules, and regulations. This new structure standardizes procedures and practices and prevents duplication of services. The new structure provides ample opportunity for senior staff positions and strongly supports cost saving and improved service delivery.

Conclusion

Change is always difficult, no matter how much managers read and understand the concept. The implementation of a new management structure has a severe impact on staff morale and management has the obligation to approach the situation with much sensitivity and consideration for all employees to establish successfully a single organization with a shared mission, vision, and values. Strong communication channels and involving employees on decision-making on unit level will ensure unity. A new, cost-efficient organization with improved patient care delivery will emerge when management dedicates time to the process of change.

References

Brown, J. A. (2008). The healthcare quality handbook (23rd ed.). Pasadena: JB Quality Solutions.
Kleiner, A. (2002). Karen Stephenson's quantum theory of trust. Strategy + Business (29). Retrieved from http://www.netform.com/html/s+b%20a...
Lee, J. R. (1990). The perceived consequences on a veterans administration psychiatric hospital of its merger with a veterans administration general medical and surgical hospital. Abstract, University of LaVerne. Retrieved from EBSCOHost database.
Liebler, J. G. & McConnell, C. R. (2008). Management principles for health professionals (5th ed.). Sudbury, Massachusetts: Jones and Bartlett Publishers.
Shaw, J. (2002). Tracking the merger: the human experience. Health Services Management Research 15(4), p. 211-222. Retrieved from EBSCOHost database.
Sonna, E. (2000). A case study of a hospital merger: process and outcomes. Abstract, Indiana University School of Nursing. Retrieved from EBSCOHost database.