Researcher on Call

Researcher on call

Conference of 18 June 2008

Introduction

The Réseau des soins de santé de qualitéand the Canadian Health Services Research Foundation are pleased once again to be associated with the Researcher on Call initiative.

Researcher on Callis an interactive series that brings together researchers and decision makers to discuss a key topic in the healthcare field. This conference call in French will focus on optimizing management of the healthcare workplace. I am honoured to welcome our two speakers, Chantal Viens, full professor with the Faculty of Health Sciences at Université Laval and lead researcher in the ProActif project, as well as Nicole Labrie, Director of HôtelDieu SaintJoseph inSaintQuentin, New Brunswick. Allow me to give the floor to Dr.Chantal Viens.

Presentation by Chantal Viens – Pro-Actif

We first must ask the question, “What is the relevance of this ProActifprogram?” ProActif, as you can see at the top of the slide, refers to participatory and evaluative research program to optimize workplace management: application of knowledge, transfer of expertise, innovative interventions and training of transformational leaders. You can understand that such a programentails not just me but also many other partners, from the Association québécoise des établissements de soins de servicesetde santé and from the Ministère de la Santéetdes Services sociaux,as well as very accomplished researchers to support and mentor this team of researchers, practitioners and decision makers.

Thus, our first project,for which I will be presenting various results in a moment, truly targets the training that managers would like to obtain to properly launch these organizational transformations.

The second project, which involved a participatory and evaluative researchaction, entails some 30 investigative projects in four provinces:Ontario, Quebec, Nova Scotia and New Brunswick. Later, our friend Nicole will talk to you about what is happening in New Brunswick. We genuinely wanted to examine the promising practices and totry to identify the scenarios, approaches and solutions so we could disseminate them and then generalize them to a large group of people.

You will understand that having found and identified this knowledge, we now must disseminate it. So the thirdprojectinvolves truly looking at how to disseminate and transfer this knowledge. We also realized that there is an absolute need for managers who serve as “work organization coaches” to mentor people. This brings us to the next slide, because this is one of that findings that effectively updated this third project.

Slide5 shows the results of our first project, at least a synthesis of the results, which confirm that it is truly worth the effort to develop evidence that will be accessible tomanagers. This is what we checked with managers in our questionnaires:Does conducting work organization project management actually require evidence? People told us:yes, we need evidence; then themanagers told us that they understand theevidence, referred to the evidencein most of their cases, had access to it, and used theevidence, but… and that is where it gets truly interesting – while they do use it, they reported that they make particular use of knowledge obtained from their colleagues and of the experience of their colleagues. You can now see the full relevance of the third project for having coaches as work organization champions to mentor them with the various tools we have developed.

I will now hand you over to my colleague, NicoleLabrie, who is going to explain her projectinNew Brunswick.

Presentation by Nicole Labrie

Thank you very much, Dr.Viens. I am pleased to tell you about this wonderful experiment that actually began three years ago. In Authority 4, we hadmajor problems in surgery, with claims that our unit harked back toVietnam, with major problems affecting the safety and qualityof our patient care.

The atmosphere was characterized by a total lack of any sense of belonging on this team, which made daily work on the team very difficult.

There was also high level of staff instability. Many staff working in this unit had no position linked to the unit. Thus, in the morning, a person might work with one assistant, then the next morning, with another assistant. And teamwork was already challenging enough.

The schedules were also challenging. Staff may have had responsibility over two or three consecutive relays for the 25patients in a unit. So there was a great deal of instability related to data-gathering, which could lead to major errors.

We’ll now look at Slide 8.I In our project, we had identified very specific objectives: maximize the role of each practitioner by optimizing his or her basic training, adopt a care delivery model, then optimize multidisciplinary team work by factoring in the daily operation of the physical facilities. To achieve this, we actually began with training. We obtained training from Mr.Bédard on reorganizing care and services. All managers in Authority 4 were able to attend this training, a key component for following the best practice in organization of care. A team was identified with a head nurse as mentor. A mentor for us is a person who oversees the integration of new graduates and new staff into the care units. I personally served on the team. We had truly taken the time to develop a logic framework, our communications plan, and our very specific timelines, which were subsequently approved by the piloting team. That team was very important for us, because it was a senior team, which made many decisions and provided administrative support,and because its composition served as a guide to proper orientations, sound planning and effective co-ordination.

We then expanded our team in the unit itself with a nurse, an assistant and a clerk. These people joined the team on a volunteer basis.

Chantal Viens

I think we could allow the people listening to us to ask any questions they may have. Mylène, would you like to handle the question period?

Mylène

Yes. Thank you, Chantal. So thank you very much forthese very interesting presentations. We are now ready to start the interactive period.

Question period

Q.I have a question for Ms.Labrie. I believe you said that the absenteeism rate dropped in the first year, after which it rose. Do you have any plans to address this or did I understand correctly?

R.<Nicole Labrie> Yes, you understood correctly. There was an improvement in the year following the reorganizationwhile in the past year we are again seeing an upward trend. What we did was to truly go back and reassess the workload in the unit, and we found that at certain times of day, we still needed to add staff to handle the load. Unfortunately, we had an administrative reorganization of health care in New Brunswickthat led us to slow down our reassessment a little, but we must also look at the generational trend, which also affects attendance. We actually have to look at it from another angle. Regional Health Authority 4 did add a person responsible for studying attendance. With that person, we can actually see whether there is room for improvement in our reorganization as well the effect on attendance.

R.<Chantal Viens> If I may add, Nicole, there is a factor I found excessively strong in our institution. This allowed us to introduce a measurementthat I have difficulty implementing in the other provinces. You established a workload measurement with the graph, and each day, you quantify your graph. You know when you’re at 93, 97percent and we noticed that when you exceed 93percent to 97percent of the intensity of care, that we were under that and there were indicators that began to be able to… because the lengths of stay, oops!, began to be able to lengthen, and absenteeism could rise. In the graph that you produced, I found that this allowed for a good staff mixand staff skills, to determine whether we chose the right person to perform the right intervention.This was a great strength, because work intensity measurements are not very popular because they are not effective in capturing everything. The approach you used, and in particular, Nicole, the way you managed it, is an exemplary measurement. Thetool may have its shortcomings, but you have made up for these by looking at each activity to ensure that we have them all. In addition, what you did for each activity was to examine what can be done by whom, so that allowed you to look at yourgraph: oops!, your absenteeism is rising. You look at whether this is linked to intensity – or is it anew generation effect? This lets us start to identify the indicators specifically to determine what is causing the shift in a given moment. Then, there are the studies by LindaO’BrienPallas that tell us that when we exceeded 85percent, we began to see a slight shift in our indicators to the negative side. Your people confirmed that in reorganizations, we could go as high as 93, 95percent, but beyond that, we truly began to see problems.

So I just wanted tell people that you had this tool which, in my opinion, was relevant and should be applied to other settings.

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