Queensland Health Case Study Analysis

Queensland Health Crisis

1) What factors might be affecting the job performance of clinicians at Queensland Health?
There are varied approaches to responding to this question (noting that the question does not
as for suggestions on improving performance)! since it is recognised that there is an
interconnectedness bet"een individuals! the teams#groups "ith "hich the$ associate and the
additional requirements of organisation% &rganisations themselves are sometimes referred to
as open s$stems "hich transform human and ph$sical resources received (a transformation
process) from their environment into goods and services that are then returned to the
environment% The organisation's requirements to engage "ith e(ternal staeholders through
alliances or partnerships! then further connects the performance of individuals to the
requirements of the e(ternal environment% &"ing to this interconnectedness! job performance
can thus be influenced at the level of individuals (influences such as personalit$! motivation!
e(pectanc$ and cultural bacground)! groups#teams (influences such as team roles!
communication! group si)e! equit$! tas! cohesion and management approaches)!
organisational structure and culture and the e(ternal environment (such as demands b$
marets! alliance partners)% With this in mind and for the sae of simplicit$! the discussion "ill
begin "ith reference to a job performance equation (1) and "ill focus ostensibl$ on the job
performance at the individual level (the clinicians)% *ubsequent questions in this e(amination!
consider interventionist strategies that impinge on performance%
+ob performance , attributes ( "or effort ( organisational support (1)
Considering each variable in the equation in conte(t of the information provided in the case
stud$! the +ob performance of clinicians is better understood-
.ttributes-
Clinicians see themselves as dedicated! professional and committed to providing the
best possible care for patients and other customers (info from internal revie")
Culture of bull$ing and intimidation from upper management on those "ho see to
point out problems! as for mone$ to help department
Too much paper"or! "here admin staff "ors / am01pm hospital hours! "hile
clinicians ma$ be required to attend to patients 23 hours#da$ 0 so clinicians are
required to carr$ the administrative overload in the off hours rather than concertedl$
practicing medicine%
Wored long hours "ith clinician staff shortages ! feelings of being underpaid "ith
little access for professional development (to improve health care)
4age 1
*ome clinicians are from countries "ith different standards and education levels!
"hich potentiall$ compromises the s$stem as good clinicians sometimes tae on
increased "orloads to cover deficiencies%
Wor 5ffort-
6n the off hours (outside of /am to 1 pm) clinicians often tae on e(cessive
administrative duties to cover for administration staff "ho "or conventional
hours% This requirements appears to be consistent "ith the organisational norm 7
"hich is to meet budgetar$ requirements and so in the process! clinicians
inadvertentl$ are required to tae on tas that might often fall outside of the role
that the$ are primaril$ emplo$ed to do%
Clinicians have to deal "ith more patients than is reported! o"ing to the culture of
secrec$ "here "aiting list statistics have been hidden form public scrutin$ under
the justification of patient confidentialit$% The revie" estimated that in fact almost
118888 people "ere "aiting for a consultation "ith a specialist is a public
hospital and that about 21888 of those "ould actuall$ require surger$%
4ossibl$ have to cover and help those clinicians from other countries that ma$
not have the sill set! no"ledge! or e(perience to be able to practice in .ustralia
to the level of care e(pected%
9imited resources have clinicians engaging "ith net"ors across jurisdictions to
ensure that levels of patient care are upheld "here possible%
&rganisational *upport-
:rom the top do"n the focus of the organisation is on budget! even if it means
possibl$ distorting the true position of the organisation%
Clinician's complaining are faced "ith intimidation and bull$ing%
There is a complete lac of support from the organisation from the top do"n! "ith
ever$one just "atching their o"n bac! "hile maing sure that political agendas
are represented%
The culture is entrenched since this has transgressed a number of successive
governments%
The factors outlined thus far tend to e(acerbate lo"er job performance and stress! "hich often
culminates in burn out! sic da$s! stress! and poor retention% While man$ of the staff ma$ have
the attributes required to generate the performance required! this case suggests that "or effort
(leading to burnout) and organisational support ("hich undermines performance) are the biggest
issues in terms of "or performance% The culture portra$ed "ould be adversel$ affecting
clinician motivation levels and therefore their "illingness to perform% .lso the case suggests that
the opportunit$ to perform is not necessaril$ given to all staff members due to poor job design
and a destructive culture%
4age 2
Wor effort is directl$ related to the motivation levels of staff "hich "ere not helped b$ the
centralised decision maing culture at Qld Health % 4resumabl$! this has meant that clinicians
have little influence over decisions "hich directl$ affect them! including the need to have to pic
up the administrative slac%
:urther! job performance requires value congruence bet"een clinician and organisation% This
apparent absence is a source of cognitive dissonance! "hich "ill further deter job performance%
;alues after all! create attitudes that predisposes behaviour! including job engagement%
<eliefs and values .ttitudes <ehaviour
Create that predispose
The lac of organisational commitment! "ill negate +ob *atisfaction and lo"er job performance
=ltimatel$! high levels of motivation "ill lead to"ards improved job performances% .lthough
needs theories of motivation are not al"a$s supported empiricall$ (such as >aslo")! Herberg's
t"o factor theor$! "hich has mi(ed empirical support! can e(plain job performance of clinicians
as it pertains to the current case stud$% :ocussing on h$giene factors (can either satisf$ or
dissatisf$ "orers)! it is evident that there are a number of h$giene factors that are leading
to"ards job dissatisfaction and therefore undermining job performance% 9eading to levels of
often e(treme dissatisfaction are factors such as relationship (supervisor$#management)! peers
(having to tae on increased "orloads at times associated "ith lo"er trained foreign clinicians)!
"or conditions and compan$ polic$#administration (requirements of additional administrative
duties and having to endure culture of bull$ing! etc)% While these factors are b$ no means
e(haustive! the$ lend "eight to"ards diminishing job performance%
:urther! in considering process theor$ (?oal setting and vroom e(pectanc$ theor$) further
facets that ma$ elude to deteriorating job performance are e(posed% ?oal setting requires some
e(pectation that tas effort "ill lead to tas performance% *ince clinicians are often e(cluded
from managerial decisions! it can onl$ be assumed that participation in tas efforts are
compromised% With feedbac probabl$ largel$ being directed to"ards budgetar$ targets!
performance is further compromised% The e(pectation that clinicians are required to do more
"ith less might also deteriorate tas performance since goals "ill be become difficult to achieve%
;room's e(pectanc$ theor$ also highlights the possible uncoupling of effort to performance (50
:) and performance to outcomes (40&)% The 50: e(pectanc$ is undermined b$ a lac of trained
emplo$ees! selection of people "ith required competencies (eg foreign poorl$ trained doctors)!
lac of role clarification (clinicians becoming administrators)! insufficient resources and
4age @
insufficient feedbac% 40& outcomes are compromised "ith budgetar$ performance indicators
being possibl$ more valued than patient care outcomes%
9astl$! the organisation is a large politiciced beauracrac$% The Theor$ A practices adopted b$
management is not inclusive of the participation and empo"erment of clinicians that is required
for them to achieve high performance% This! coupled "ith inappropriate organisational support
(including structure and culture)! e(cessive "orloads! incongruence of values! the motivational
dissatisfiers and curtailment of motivating factors 7 are all factors that appear to be adversel$
effecting the job performance of clinicians at Queensland Health%
4age 3
2% What shared values! beliefs and behaviours have impacted upon Queensland Health's
culture? What steps "ould $ou suggest to improve the culture?
To anal$se the culture a first step "ould to be use Cultural Web%
Cultural Web can be used to understand the current culture and its issues%
Stories-
Hiring of +a$ant 4atel a surgeon "ho had lost his =* licence to practice medicine but
being able to practice medicine in .ustralia% There "ere man$ people tr$ing to report
their concerns based on his behaviour but nothing "as done%
The practice of suppression! in "hich he claimed at least one former health minister has
been instrumental! had encouraged Queensland Health staff to act in a similar fashion
=nderperforming staff not dealt "ith or being promoted
Rituals and Routines-
over0bureaucratise! secrec$! bull$ing and intimidation! from top do"n%
BHistor$ of a culture of concealment "ithin and pertaining to Queensland Health' due to
inherited behaviour from former health minister%
Claims of patient confidentialit$ to cover discrepancies on true si)e of "aiting lists! etc%
To continue the false idea and thought the health s$stem "as doing fine and on budget!
that there "ere no problems%
9oo after $ourself#department (ever$ man for themselves)
Control System-
4age 1
5(ecutive Cirector of Health *ervices is responsible for D8E of Queensland Health's
resources% >inister of Health is the ultimate leader of the organisation%
The core value of the organisation "as Bthe budget' and it "as used as a control s$stem%
The ?overnment% The use of one person "ho "as in charge of D8E of the resources for
the "hole organisation% The$ decided "ho and "here those resources "ould be
allocated%
Hierarchical decision process
Fon0collaborative
Fo accountabilit$
Organisational structures-
Classical class structure made up of support staff! nurses! clinicians! specialists! admin!
managersG augmented b$ top class structure of e(ecutive! and government%
<ureaucratic funnelled up to three )ones and a central office
5(ecutive Cirector of Health *ervices 7 control D8E of resources
>inister of Health 7 the top%
9ac of cooperation! trust bet"een teams 0 B*ilos'
>anagers out of touch "ith needs of front line staff
Power Structures-
D8E resources controlled b$ 5(ecutive Cirector of Health *ervices% H6f 6 am at the
director0general level and the ministerial staff "ant to vet and read the ne"sletters 6
"asn't to send to m$ staff! in the end 6 just lose interest in sending ne"sletters to m$
staff%
Ieluctance to share information across silos%
>anagers did not encourage0staff participation in problem solving! did not engage "ith
staff and did not properl$ manage non0performing staff%
:ailure of leaders! managers and supervisors of dealing "ith comple( problems! did not
engage their staff! did not properl$ manage non0performing staff
>inisterial staff needs to vet internal ne"sletter from Cirector to hospital staff%
<udget integrit$ centred managers at a modest level that there's not much point asing
for more mone$ and not much point raising the problem! self0regulating po"er negative%
Symbols-
bureaucrac$! government! and the s$mbolic roles of doctors! nurses! specialists! support
staff
This cultural "eb is a good "a$ to brea apart all of the facets of the problem but to tacle these
issues but looing on ho" to improve the overall culture $ou first see that- in Tucman's group
d$namics%
4age J
Within Queensland health is supported b$ three )ones and a central corporate office% These
hierarchical la$ers of decision maing did not support a responsive and efficient health s$stem%
The centralised and hierarchical structure contributed to the frustration of staff and customers
(patients and others)% >an$ *taff felt angr$! frustrated and resentful to"ards senior managers
and some reported e(periencing bull$ing and intimidation "hen seeing more funding to deliver
patient care% The report sho"ed Ban entrenched and negative culture of bull$ing! threat!
intimidation! coercion and retribution on the one hand and of secrec$! blaming and avoiding
responsibilit$ on the other% This culture is in no doubt one of the reasons surgeon +a$ant 4atel
had not been dealt "ith earlier b$ management even though there "ere concerns reported to b$
the staff% This level of secrec$ enforced all the "a$ do"n from the ministr$ in hiding the real
numbers of "ait times! surgeries! etc% Ieinforced this culture of non0reporting and no
accountabilit$%
6n the belo" t"o diagrams it appears that the culture in the Healthcare s$stem specificall$ the
patient facing ones are continuall$ stuc and repeating the storming section% The culture just
doesn't build cohesion%
4age K
To start $ou need to brea the c$cle of bull$ing! secrec$ and intimidation% Lou need to
empo"er those "ho no" something is "rong and give them a voice and place to do so% Lou
need to increase protection of those people "ho choose to mae their concerns public
("histleblo"ers) and $ou need to create a separate central bod$ to oversee public interest
disclosures% These "ere alread$ recommended to the government but the premier 4eter
<eattie rejected the suggestions% The culture has to change all the "a$ at the top in the
government and the$ also have to be held responsible% There needs to be a change to the
overall reporting structure in the organisation! create a flatter structure% ?ive departments ! and
clinicians more autonom$ over budget "ithin certain guidelines%
:or e(ample if a clinician rules that a >I6 or catscan is "arranted ma$be there are K criteria
that "ould allo" this to happen "ithout an$ oa$! that the$ have to sign off and be responsible%
That the$ ma$ be onl$ to have a certain amount of quota per month based on those criteria and
if either the criteria isn't met or the$ are the over their quota then there direct supervisor "ould
have to approve and be responsible% The$ ma$ have a certain amount of quota or guidelines on
top! but it "ould help put conte(t to those incidents of over budget and also give responsibilit$
bac to those on the front lines that have to mae split decisions in regards to care! but also at
least be budget conscious%
This e(ample is a good place to get input from all aspects of the group "ho "ould be involved in
the decision process and ma$ come up "ith better guidelines or processes that in turn give
them more empo"erment! motivation and job satisfaction% 6t has alread$ been said that staff
are all dedicated to giving the best possible care to patients! so the$ should allo" them to do so
"ithin reason and balance%
<$ using the belo" process-
The <usiness Control 4rocess
4age D
.s the organisations flattens out and allo"s the shift from being budget driven and hiding the
numbers! that $ou allo" the truth to come out! and allo" those in the trenches to help develop
and empo"ered to change happen% That this process is continuous and if the ultimate goal is
for better health care "ith conservative vie"s in regards to the budget! as long as $ou include
the different departments in the change it "ill help%
+ob enrichment (pg 1J2) Her)berg's principles of job enrichment
Principle Motivators involved
1. Remove some control while
retaining accountability
Iesponsibilit$ and .chievement
2. Increase the accountability o
individuals or their own wor!
Iesponsibilit$ and recognition
". #ive a person a complete natural
unit o wor! $module% division%
area and so on
Iesponsibilit$! achievement and recognition
&. #rant additional authority to
employees in their activities
Iesponsibilit$! achievement and recognition
'. Ma!e periodic reports directly
available to the wor!er rather than
to the supervisor
Iecognition
(. Introduce new and more diicult
tas!s that the individual has not
previously handled
?ro"th and learning
). *ssign to individuals speciic or
specialised tas!s+ enable them to
become e,perts
Iesponsibilit$! achievement !recognition and
advancement
4age /
&n a smaller scale $ou "ould also have to address the culture of leaders! managers and
supervisors often failed to deal "ith comple( situations! encourage staff participation in problem
solving! did not engage "ith staff and did not properl$ manage non0performing staff% To do this
managers have to be taught that its their responsibilit$ to do these things and ma$be start
instituting M46's (Me$ 4erformance indicators)% That after a difficult case the$ should debrief the
staff involved and loo at "a$s the$ could improved on the case even it "as good or bad% That
allo"ing the staff to learn from this onl$ increases their job satisfaction and motivation for the
ne(t case to come through% .lso "hen dealing "ith non0performing staff it gives the manager a
chance to help improve their sills (if it's a confidence thing)! or identif$ missing sills (need
more training)% 6f $ou sho"ing an interest in all staff this onl$ improves group cohesion!
motivation! job satisfaction! decreases stress! increases retention especiall$ if $our the teaching
them ne" sills! increasing their no"ledge base% .ll of these items discussed increases
various motivators that "ill onl$ improve the overall culture "ithin the group%
*ample core job characteristics for enriched and un0enriched jobs-
-nriched .n/enriched
S!ill 0ariety Cecided o"n strateg$ for
performing tas and changed
strateg$ at "ill
Were provided "ith e(plicit
instructions for tas to
perform and strateg$ to use
(e%g% Bfirst! open letter)
1as! Identity :ormed into groups of tenG
performed all necessar$
operations on a certain
proportion of customer
requests
.s an individual! performed
just one of these operations
on all requests
*utonomy Chose length and timing of
breas% 4erformed o"n
inspections at intervals the$
determined
5(cept for breas! sta$ed at
"orplace throughout the
da$% Had "or periodicall$
checed b$ inspectors
2eedbac! *a" productive posted on
scoreboards at end of each
da$
Ieceived no specific
information about
performance level
When looing at the current jobs if the$ are either enriched or un0enriched
S!ill variety 7 is more un0enriched from the ver$ top of directors "ho can't release internal
memos "ithout government scrutin$ and so doesn't send an$ internal information an$more% .ll
the "a$ to clinicians "ho are driven b$ maintaining budget constraints and hiding proper
statistics of actual "ait times! surger$! etc and are bogged do"n b$ the sheer mountain of
admin stuff "ithout the proper support or time%
*utonomy 3 =n0enriched 7 again fro decision maing taen a"a$ up to the top! as "ell as
pressure from government bod$ overseeing critical decisions% Core value of the s$stem is
Bbudget constraint' "hich has shaped the entrenched culture% 4eople are not free to mae the
right decision for the good of the patient for fear of being bullied! threatened! etc%
4age 18
2eedbac! 3 =n0enriched 7 There is no feedbac "ith in a culture of Bsecrec$! bull$ing!
intimidation! etc'% Fo one treats the concerns for improper care let alone praising good care%
.nother item to brea the culture after flattening out is to increase cross0communication and the
most important aspect of cultural change "ould be to build trust bet"een the people maing up
the multi0disciplinar$ teams that are integral to providing healthcare services% The report said
the culture could onl$ improve! if there "as participation in team problem solving! a redesign of
the "orplace! s$stems improvement and a focus on the patient "hen maing decisions about
care%
4age 11
Question @
6n order to sustain an engaged and productive "orforce! apart from cultural intervention! "hat
other processes could Queensland Health emplo$? >ae recommendations for alternative
interventions% =se relevant &< theor$ to support recommendations%
6n order to sustain an engaged and productive "orforce $ou need to address certain aspects
about the job "ithout specificall$ looing at the culture%
+ob *atisfaction is the degree to "hich an individual feels positivel$ or negativel$ about "or%
T"o factors strongl$ related to job satisfaction are organisational commitment and +ob
involvement%
The culture at Qld Health maes both of these attitudes hard to achieve% :irstl$! staff are not
involved in the decision maing process and have felt anger! frustration and resentful to
managers% *taff could be described as having an 5(ternal locus of control 7 people feeling as
though "hat happens to them is out of their control% There also seems to be evidence of
>achiavellianism of managers "ho manipulate others purel$ for personal gain to meet budget
or avoid reprimand%
The case tals about Bsilos' built around occupational groups and a distinct lac of trust or
team"or% 6t is hard for an emplo$ee to feel part of an organisation "hich has this t$pe of
culture! "hen there is lac of information sharing around the organisation "hich reinforces those
negative aspects of the organisation! and is continued to be reinforced of "orload and budget
constraints%
>eglino :rame"or decribes four values those are especiall$ important in the "orplace%
.chievement
Helping and concern for others
Honest$
:airness
*taff values "ere not considered% Ieport (done b$ the healthcare s$stem) found in general
personnel "ere dedicated! professional and committed to providing the best possible care for
patients% 6t suggests that majorit$ of staff have values described b$ >eglino and "ere being
neglected b$ the Qld Health management%
Without acceptable levels of +ob *atisfaction there is not going to be sufficient "or effort and
thus job performance "ill be reduced% This can result in absenteeism! high turnover! lo" morale
and stress as has been seen in the case%
Within the top nine "or0related values (C +amieson and + &'>ara! >anaging "orforce) these
appear to be the most effect b$ the current situations%
1% Iecognition for competence and accomplishments
2% Iespect and dignit$
@% 4ersonal choice and freedom
4age 12
3% 6nvolvement at "or
1% 4ride in one's "or
D% *elf0development
&ne aspect to loo at is job design in itself-
4ob design
The four basic approaches to job design (simplification! enlargement and rotation! and
enrichment) have provided vital insights into the comple(it$ of effective job design% Collectivel$!
the$ are an important platform for later theorists% Ho"ever! the common factor underl$ing these
approaches is that the$ are Bstatic'G that is! the$ assume that all individuals "ill respond in the
same! positive manner to these approaches% The$ fail to recognise the Bd$namic' nature of
individual behaviour 7 "hich "orers can! and "ill respond in a variet$ of "a$s to the
implementation of an$ innovative job design approach%
The job characteristics model
1% *ill variet$ 0 the degree to "hich the job requires an emplo$ee to undertae a variet$ of
different activities and use different sills and talents
4age 1@
2% Tas identit$ 7 the degree to "hich the job requires completion of a B"hole' and
identifiable piece of "or (that is! it involves doing a job from beginning to end "ith a
visible outcome)
@% Tas significance 7 the degree to "hich the job is important and involves a meaningful
contribution to the organisation or societ$ in general
3% .utonom$ 7 the degree to "hich the job gives the emplo$ee substantial freedom!
independence and discretion in scheduling the "or and determining the procedures
used in carr$ing it out%
1% +ob feedbac 7 the degree to "hich carr$ing out the "or activities results in the
emplo$ee obtaining direct and clear information on ho" "ell the job has been done%
Critical ps$chological states-
5(perienced meaningfulness in the "or
5(perienced responsibilit$ for the outcomes of the "or
Mno"ledge of actual results of the "or activities
These are important in job retention of emplo$ees "ho could be overstressed! over"ored! etc%
>oderators are- job0design moderators
?ro"th0need strength 7 the degree to "hich a person desires the opportunit$ for self0
direction! learning and personal accomplishment at "or% 6t's similar to >aslo"'s
esteem and self0actualisation and .lderfer's gro"th needs% 6f doctors "ere to conduct a
debriefing after hard successful or unsuccessful cases this "ould help all those involved
to gro"%
Mno"ledge and sill- needed for performance in an enriched job are predicted to
respond positivel$ to enrichment% The debriefing further helps "ith "ere to teach ne"
sills! reinforce old sills or those "ho are lacing more training% 6t also re0enforces "ith
those the good job that the$ are doing%
Conte(t satisfaction- e(tent of ho" much a emplo$ee is satisfied "ith salar$ levels!
supervision and "oring conditions% These de0briefings are good indicators for all
involved on the job that the$ are doing% 6t lets them no" over the "hole conte(t of their
job satisfaction%
The organisation is going to have get more clinical staff and the$ should provide more fle(ible
and famil$0friendl$ "or arrangements! fair remuneration! and ongoing opportunities for
professional developments% :or e(ample-
:or admin staff and even nurses $ou could have them "or /am to /pm shifts and onl$ "or @
da$s on and three da$s off! rotation schedule to mae sure that the administration "or for the
doctors is being done and the$ can practice medicine% 6t is a longer shift but the$ get more time
off and so in turn more time to spend "ith their ids% This might appeal to some "ho then "ould
could have cut do"n on da$care costs if the$ have a partner! as the$ "ould have fe"er da$s
"oring but the same hours% .lso nurses might be inclined to this as it "ould also give them
more time "ith their famil$ "hile also ma(imi)ing their times "ith patients and minimi)e an$thing
missed in shift s"apping%
4age 13
Coctors $ou might do three shifts of Kam to @pm! @pm to 11pm and 11pm to K am% .t all of
those shifts $ou "ould still get the opportunit$ to spend time "ith $our famil$! and the$ "ould
rotate this% This is one e(ample of a fle(ible "or arrangement that man$ people are striving for
a "or balance lifest$le%
Lou can also institute +ob rotation! for e(ample! a nurse ma$ be rotated on a monthl$ basis!
looing after geriatric patients one month! surgical patients the ne(t and rehabilitation patients
each third month%
While job rotation ma$ decrease efficienc$ because people spend more time changing! it can
add to "orforce fle(ibilit$% *taff can be moved from one job to another% This is often the
primar$ purpose of job rotation% ;ertical loading is a e$ aspect of job enrichment%
To help sustain an engaged and productive "orforce $ou should first follo" the steps for
leadership change% 6 "ould first separate the reporting structure and have someone "ho is not
elected at the top! can be still accountable from the government standpoint but the minister of
health can't be the leader as there are political and other factors to his decisions that having
nothing to do "ith the "elfare of the healthcare s$stem%
This follo"s the *teps for 9eadership Change from Motter (2882)%
1. -stablish a sense o urgency
2. Create a guiding coalition
". 5evelop a vision and strategy
&. Communicate the change 0ision
'. -mpower broad/based action
(. Create short/term wins
). Consolidate gains and produce more change
6. *nchor new approaches in the culture

6f "e loo at . T$polog$ of Change strategies from Ce(ter Cunph$ N Coug *tace (1//8) "e can
consider the strateg$ "hich best fits for Qld Health%
The$ require a transformational over an incremental change% There is support for change "ithin
the organisation and collaboration "ill be vital to changing the culture and implanting successful
strategies% Ho"ever due to the urgenc$ caused b$ the anger and fear of bullied emplo$ees a
more directive#coercive mode made be required%
:or these reasons Qld Health reall$ need a combination of a Charismatic transformation and
Cictatorial Transformation%
6ncremental Change
*trategies
Transformative Change
*trategies
Collaborative#Consultative
modes
1% 4articipative
evolution
=se "hen organisation is in
fit but needs minor
adjustment! or is out of fit but
time is available and e$
interest groups favour
2% Charismatic
transformation
=se "hen organisation is out
of fit! there is little time for
e(tensive participation but
there is support for radical
change "ith the organisation%
4age 11
change%
Cirective # coercive modes @% :orced evolution
=se "hen organisation is in
fit but needs minor
adjustment! or is out of fit but
time is available! but e$
interest groups oppose
change
3% Cictatorial
transformation
=se "hen organisation is out
of fit! there is not time for
e(tensive participation and
no support "ithin the
organisation for radical
change! but radical change is
vital to organisational survival
and fulfilment of basic
mission
:rom this case as a public sector organisation "ith man$ undercurrent and entrenched ideals
$ou "ill need to use a combination of a charismatic transformation as "ell as Cictatorial
transformation%
The first is because "ith the organisations trac record $ou "ill need to get ever$one involved in
the change to effectivel$ re0build bac trust! and there is support for radical change% Lou need
the Cictatorial transformation because there "ill be great resistance from those "ho are
comfortable "ith the status quo and $ou "ill need to change that or $ou "ill lose all credibilit$
"ith those "ho are in support of the change%
%
With the organisation is in such disarra$ $ou "ould start in step 1- "ith comments about
Q9C Health%
-stablish a sense o urgency
a% Core Challenge- ?et people out of the buner and read$ to move% This means
that the "hole organisation has to be shaen up that change is coming and the$ need
to be on board
b% Cesired Fe" <ehaviour- 4eople start telling each other O9ets go! "e need to
change things%O That there is an increase from all levels of the Health care s$stem
change is under"a$! their is an increase in energ$ and motivation to change%
Step 2 Create a guiding coalition
b% Core challenge- get the right people in place "ith the trust! emotional
commitment and team"or to guide a ver$ difficult change process% Lou "ould need
to build this and include ever$one from nurse manager! biomedical engineers!
doctors! janitorial! ever$one "ith a vested interest in the "hole process (the best
ideas come from the least e(pected source)
c% Cesired ne" behaviour- a group po"erful enough to guide large change that
"ors "ell together (creating solid cross departmental and organised groups is
important to create cohesion and respect across the organisation%) 6f it seen
throughout that ever$one has a voice! and is treated equal! then that attitude "ill help
to spread through the organisation
Step " 5evelop a vision and strategy
c% Core Challenge- ?et the guiding team to create the right vision and strategies to
guide action in all of the remaining stages of change% This requires moving be$ond
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number crunching to address the creative and emotional components of vision (mae
sure that budget isn't the focus but better healthcare! although $ou can't discount
budget conservatism in light of the ?:C)
d% Cesired Fe" <ehaviour- The guiding team develops the right vision and strateg$
for the change effort 7 ver$ important as this "ill continue to have increase scrutin$
from all members of the organisation and to help "ith bu$ in to the change%
'. Communicate the change 0ision
d% Core Challenge- ?et as man$ people as possible acting to mae the vision a
realit$
e% Cesired Fe" <ehaviour- 4eople begin to bu$ into the change and this sho"s in
their behaviour
(. -mpower broad/based action
e% Core Challenge- Iemove e$ obstacles that stop people from acting on the
vision
f% Cesired Fe" <ehaviour- >ore people feel able to act! and do act! on the vision
). Create short/term wins
f% Core Challenge- 4roduce enough short0term "ins fast enough to energise the
change helpers! enlighten the pessimists! defuse the c$nics and build momentum for
the effort
g% Cesired Fe" <ehaviour- >omentum builds as people tr$ to fulfil the vision "hile
fe"er and fe"er resist change%
6. Consolidate gains and produce more change
g% Core Challenge- Continue "ith "ave after "ave of change! not stopping until the
vision is a realit$ 0 no matter ho" big the obstacles
h% Cesired Fe" <ehaviour- 4eople remain energised and motivated to push change
for"ard until the vision is fulfilled
7. *nchor new approaches in the culture
h% Core Challenge- Create a supporting structure that provides roots for the ne"
"a$s of operating
i% Cesired Fe" <ehaviour- Fe" and "inning behaviour continues despite the pull
of tradition turnover of change leaders! etc%
Iecommendations "ould be for an a head of the healthcare that "ould not have D8E control
over available resources that that control "ould be released incrementall$ do"n% That there
"ould be guidelines and budget amounts per area in the healthcare% That doctors "ould have
the autonom$ to mae decisions about tests! care! treatment if certain criteria is met! and if not
then it "ould be up to their superior! "ith the same scrutin$% That the budget "ould be rela(ed
but still criticall$ "atched to see "here adjustments have to be made and "here it "ent over!
those "ho are responsible held accountable to provide the conte(t to the over amount%
That these changes to the budget control! decision maing has to be looed at "ith The
<usiness Control 4rocess
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1) That the standard is set
2) Lou measure the output (chec to see the budget! usage of resources across
organisation)
@) Compare budget across organisation! compare resource use (>I6! catscan! surger$!
etc)
3) *ee "here adjustments need to mae "ith consideration of conte(t
1) 5ither the standard changes to accommodate! outputs get changed or ever$thing
remains status quo
The point to this process that it is a ongoing process that is monitored b$ the top ("ithout
government involvement) and then revie"ed b$ independent revie" board that then reports
findings to the government and the top level of the Healthcare ?roup! to eep it honest! true
and correct%
There also has to be an &busbudman "ho "ould deal "ith complaints from outside the
organisation (patients) as "ell as confidentialit$ of internal staff! the$ "ould have the autonom$
to investigate and then report t their findings and "hat the organisation should do%
The$ should also be doing research on "hat patients feel about their care "hen the$ sta$ in the
hospital% 5ver$thing from cleanliness! admin staff (checing in)! to nurses! doctors! etc% This
gives a snapshot from the patients' e$es "hat areas that ma$ be perceived performing "ell but
in the e$es of the patient not performing "ell at all% This "ould be an independent revie" and
could be used to point out areas "ithin the job criteria or the overall process and strategies that
need improvement%
.s discussed earlier debriefings are important after all t$pes of cases and "ere earlier
discussed%
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