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For example, several studies have demonstrated that including advanced practitioners in primary care medical homes allows practices to expand panel sizes [ 7 , 8 ]. Choices about staffing, therefore, can have enormous implications for productivity, making assumption about the demand for certain health professions a moving target.
We know from the literature reviewing the hospital restructuring of the s that workforce change management faces many challenges. The critiques of this era were many, but chief among them, according to Walston and colleagues, were the following: goals for change were not clear, too many changes were implemented too quickly, there was a lack of communication with employees, a lack of engagement with physicians and unions, there was a poor understanding of the local site differences by management leading to a one-size-fits-all approach, and, lastly, that training needs were not anticipated [ 9 ].
In a review of the international literature on workforce planning and development WFPD , Curson and colleagues suggest that the problem goes deeper. They argue that workforce policies lack the capacity to respond to new demands for system change [ 10 ]. The reason, they point out, is that most workforce planning do not take account of political dynamics among the range of stakeholders outside the control of human resource administrators, be they at the organizational or the policy level.
It is with these critiques in mind that we are interested in understanding how two leading health systems in the United States, with a historic commitment to developing and retaining their workforce and to managing change through labor-management partnerships, are responding to the demands of the post-ACA environment. The aim is to explore how they are determining what changes are needed and how they are implementing those changes in practice.
Their experiences may provide insights for other organizations, as well as for policymakers charged with ensuring that the healthcare workforce is able to meet population needs. Our first case focuses on Kaiser Permanente KP , an integrated system that has historically served the employer market on the West Coast.
It has been at the forefront of systems that emphasize value over volume and among the organizations most advanced in the use of HIT to improve the patient care process. In addition, KP has one of the most successful models of labor-management partnerships LMP in the nation.
The second system is the Montefiore Health System, headquartered in the Bronx, NY, an organization with almost 20 years of experience with shared risk contracts with payers.
Like KP, they have extensive experience with care coordination, they are in the process of expanding to new markets, and they have a LMP. The objective of this study is to go beyond descriptive groupings of health workforce changes to explore the dynamic processes and interactions by which staffing models emerge.
To frame our inquiry, we draw on the literature on health workforce planning and development and the theory of loosely coupled systems LCS [ 11 ]. For the purposes of this paper, we define WFPD as the macro level processes and practices that enable the system to change and adopt new staffing arrangements and respond with timely and appropriate education, training, and certification programs.
Schrock has suggested that WFPD policies span the continuum of skill formation, employment networks, and career advancement [ 12 ]. This means not simply examining the supply and distribution of personnel in different categories but also understanding educational and training pathways, management of performance, and the regulation of working conditions.
Dussault and Dubois argue that the traditional approach to WFPD is a linear, sequential, and protracted skill formation process through which healthcare providers hand off demand projections to education institutions and certifying bodies that in turn, supply the requisite workforce [ 13 ]. Weick reasons that this form of sequential task interdependence induces rule-based action and cognitive processes that are not equipped to tackle ambiguous problems like providing a skilled workforce for care models that are in a constant state of flux [ 14 ].
This and other complex, non-routine problems require controlled cognition or slow, deliberative, and explicit thinking that is more often associated with reciprocal interdependence coordinated by an iterative process of negotiation and mutual adjustment among relatively autonomous units and subsystems.
Dussault and Dubois describe an alternative approach that is emerging in healthcare that coordinates the efforts of a diverse range of institutional actors through adaptive processes that respond to specific, local political, economic, cultural, and social contexts where healthcare is delivered [ 13 ].
This approach is understood as a political exercise in which values and differences are made explicit, compromises are made, and actions are justified. Orton and Weick further suggest that there is a need to move beyond the traditional focus on static organizational elements, like structure, resource allocation, and technology, and turn instead to a focus on the dynamic relationship among them [ 15 ]. The focus of this approach is on hierarchy and interdependence among elements within and between organizations and how variability in these features enables different operational strategies and responses to shifts in the external environment [ 17 ].
In tightly coupled systems, individual units and organizations are linked together through formal structures and procedures and they respond to change through centralized control mechanisms that reduce variation and close the system off from the effects of external forces. In loosely coupled systems, on the other hand, the links among the components are weak and a high level of autonomy exists among the interdependent parts of the system [ 20 ].
While the variation in the way similar functions are organized and managed may make it difficult to integrate activities, theorists argue that it enables flexibility and openness to change in the environment [ 15 ].
According to the theory of LCS, all systems are both tightly and loosely coupled because there is variation in how subunits are linked and rely on each other coupled —as well as in the number and strength of their connections lose or tight [ 15 , 17 , 21 ].
Therefore, any subsystem may be closed to outside forces to ensure for stability tight , while another subsystem may remain open to outside forces to enable flexibility loose [ 15 ]. This paradoxical nature of LCS makes it difficult for researchers to conceptualize and study [ 16 ], yet we would suggest that its application to the US healthcare system during this period of intense transformation holds explanatory potential.
Healthcare systems are simultaneously being asked to expand coverage and access, while being financially incentivized to extend the continuum of care to address the social determinants and provide ongoing care management.
Further, we submit that the effectiveness of the transformation occurring in healthcare today may hinge on new, more adaptive methods to prepare the healthcare workforce to perform in a more complex system of care, where job tasks, team interactions, and work locations are continuously changing.
We use a case study design to explore how two major health systems undergoing significant system transformation are managing the process of workforce change. We selected Kaiser Permanente KP and Montefiore because they are well known for their innovative approaches to integrating healthcare yet they are significantly different from each other with regard to their organizational histories, structures, and patient populations.
We conducted site visits to both organizations in the spring and summer of , conducting interviews with 8—10 people at each site including executives, human resource managers, the heads of innovation and care coordination programs, and union and LMP representatives.
Some interviews were held in group settings, while others were individual. We also conducted planning and follow-up phone calls with some of the participants. Interviews were taped and transcribed. We also reviewed current organizational documents, including training plans, reports, and collective bargaining agreements, as well as prior studies on each system [ 9 , 22 , 23 ].
Data analysis proceeded through several steps. First, the research team conducted a review of each case, including the historic development of the system and significant drivers of change, as well as the strategies, structures, and resources informants reported as being central to the competiveness of the system and the sustainability of the workforce in the post-ACA environment. To support this analysis, the research team developed a series of inductive and deductive codes, which we used to extract relevant data from the case documents and interview transcripts.
Next, the researchers jointly analyzed the coded data to developed individual case profiles. These profiles were validated by key informants from each case. Finally, we conducted a constant comparative method to identify cross-cutting themes and principles to explain the workforce planning and development strategy emerging within the two systems. Kaiser Permanente KP was established in as a comprehensive medical system for the workers and their families at Kaiser steel mills and shipbuilding facilities across California and in Portland, OR.
The KP unions played an instrumental role in this expansion by helping KP market to unionized employers in areas where the company had a presence. A key feature in this model is that physicians are employed by KP. The national program office includes a variety of support functions, including human resources, labor relations, information technologies IT , finance, and patient care services nursing.
At the time, KP faced competitive pressures leading executives to demand deep union concessions. In response, many of the KP unions offered the company a choice: continued harsh labor-saving tactics and escalating labor strife, including a strike, or a partnership to address the fiscal crisis and improve the quality of care at KP.
The company agreed to the partnership [ 24 ]. The governance structure consists of the LMP Strategy Group, with one representative from each of three sectors: Physicians, Management and Labor, and each region maintains its own tripartite LMP council. Hawaii is not part of the partnership, and not all KP unions are involved in the partnership, most notably absent is the California Nurses Association. KP also has a network of functional units to support the design and management of change and WFPD strategies.
The LMP staff is integrated into these units, and labor representatives are highly engaged in their activities. These units include the following:.
Unit-based teams UBT are natural work groups of frontline workers, physicians, and managers who solve problems and enhance quality. KP is well positioned to grow in a post-ACA era in which policies to advance integration has proliferated. KP leadership knew that they needed to understand the implications of this shift in demand and have held focus groups with their newest members.
Results have led the company to reorient business strategy around three priorities, as follows:. Because the individual market is more price sensitive than the group market, there is a heightened awareness that they must reduce the cost of care in order to continue to expand in this market.
At the same time, new healthcare consumers expect more value or increased and enhanced services, and this is driving a number of efforts focused on the care experience. Three strategic initiatives have emerged in response to these drivers.
It emphasizes affordability targets, meeting rising customer expectations, and transforming care. Vision is an ongoing initiative to understand what healthcare consumers will look like and how KP can position itself to meet needs in a rapidly changing healthcare market. It develops care models and offers strategic road maps to guide planning and change. Health information technologies are central to this strategy, including the use of social media to keep its members informed and healthy and new mobile technologies to enhance staff communication and reporting.
Remote diagnostic tools will also be more available to patients for common ailments like strep throat, to allow self-testing and more rapid recoveries. In the next 5 to 7 years, they see increased use of remote monitoring technology, sensors, and virtual care, as well as health analytics to enhance the nurse role in triage and care management [ 23 ]. Its goal is to design a new ambulatory care delivery model aligned to the principles of consumerism. They now view these tools as necessary but insufficient.
A regional HR leader described the change:. So, at first…we forecasted membership growth, utilization, supply, turnover, retirement, we looked at the local labor markets, we connected with a university for economic analysis of the projected nursing workforce, and the fluctuations around the economy. And then we realized that most forecasting is based on the previous year, or the previous three, or the previous five years, projecting forward.
So, it really started in to , we have been trying to get a movement towards a kind of qualitative approach to understanding change. The LMP, which was further strengthened in the National Agreement, has several mechanisms that integrate labor and innovative WFPD strategies into the strategic change processes. This open exchange results in accommodation, as illustrated by the Employment and Income Security Agreement EISA , which stipulates that any innovation or change at KP must include a plan for retaining the effected employees.
A second LMP mechanism consists of the negotiated programs to support innovation and the implication of change for the workforce. The national agreement delineates the mission and values of joint programs, sets aside funds, and directs LMP staff and company to consistently integrate the programs across all KP regions.
Examples of these national efforts include Total Health , which advances wellness, health, and safety in the workplace; unit-based teams , which identify quality improvement and cost containment solutions at the ground level; and the National Taft-Hartley Education and Training Trusts , described above.
Lastly, an important characteristic of the LMP governance and planning structures is that it is holistic and aims to permeate every level of the system. In theory, every manager has a designated labor partner with whom they are encouraged to engage in strategic and operational decisions that affect the workforce. Both sides report that this works better in some regions than others, but where it does work, they say that the engagement is ongoing and includes strategic decisions that affect not only the workforce but also the future direction of the company.
Jobs for the Future, an initiative in the Southern California region, illustrates how these mechanisms work together to integrate labor and WFPD strategies into the strategic change processes at KP. Rather than focus on the contentious questions of workforce impacts, the committee first set out to develop a holistic view of the redesign new care models, technologies, facilities, etc.
Though the HR lead reported that some labor and management participants fell into traditional roles and knee-jerk reactions, he observed that these positions quickly gave way as the committee became more engaged in the processes to redesign the care models and workflows. Next, the committee developed a rigorous methodology to assess the impact on jobs and formed LM subcommittees to apply the method to the redesign of specific work areas. Each of these new roles transgresses existing occupational, as well union boundaries and jurisdictions.
The difference between the new with the old approach to labor relations managing change at KP are explained by the HR leader as he reflected on this project:.
So they go to the bargaining table, and the labor person has only been told that there is either going to be a layoff, or a change in jobs, and we are doing this because of the need for affordability, or because we need to cater to the customer. They are like, what!!??? There is a big disconnect between the innovators planning this change and the bargaining with unions to implement downstream workforce implications.
Interestingly, a union representative also sees her role as an intermediary in the broader change processes at KP:. Where are you going to lay-off people? And where do you want to grow, right? Put it on the table, take the consequences….
I try to get everyone to put their issues on the table and work it out…. Several informants talked about the continued resistance of some business units and regional operations to the new WFPD approach. While informants view the LMP as a powerful mechanism for managing the impacts of change, involving workers who are represented by unions outside the LMP and the large number of exempt employees in KP almost half of the workforce is challenging.
Who sets the priorities, allocates the resources, and oversees the initiatives? The fluid fiscal environment and constant innovation are expanding the role of finance in strategic change and workforce decisions.
Informants did not challenge the need for more fiscal control; their concern was over the episodic nature and the short-term time horizon of the financial decision-making process. Several informants expressed the need to figure out how to bring workforce initiatives to scale and spread innovations, like the Jobs of the Future, to other regions.
They believe that a deeper understanding of the knowledge, skills, and methods that underlie the emerging WFPD model might help spread innovation in KP. The organization has a long history of seeking out capitation and other forms of risk-sharing agreements.
Twenty years ago, Montefiore executives formed an Integrated Provider Association IPA , which encompassed its salaried physicians, as well as community-based, voluntary private-practice physicians, and approached private payers with a request to develop risk-sharing contracts.
While Montefiore experienced some losses during the early days of managing these agreements, they pushed ahead, understanding that the change would take time and that returns would be realized only when there were higher volumes of covered lives.
From the beginning, this active pursuit of value-based contracts has been supported by a subsidiary called a Care Management Organization CMO , which developed a robust care management infrastructure with the explicit objective of understanding and addressing the upstream determinants of health.
A focus on patients with high medical expense and high risk of hospital and emergency department utilization by interdisciplinary care management teams has generated savings that that are reinvested in the delivery system.
The CMO supports this care model with a robust WFPD infrastructure that includes a comprehensive competency map for all key CMO workflows supported by a wide range of training programs to ensure employees are prepared with the required skills. For example, HR stations a HR person in every department whose role is to understand the local culture and help HR anticipate and support change.
This sensing function also enables HR to ensure the engagement of labor in planned changes. Regionally, Montefiore also has a long history of labor-management partnership through its participation and leadership in the SEIU Training and Employment Fund. The fund, which was established in to provide education and job training programs for healthcare workers, is the largest joint labor-management training organization in the United States.
Since its formation in , SEIU has established a total of nine funded initiatives, of which Montefiore contributes to five, that cover three main areas:. Training and upgrading : There are two training and upgrading funds one specific to RN and one general that work with Montefiore and union leaders to identify high-demand skills and occupations and develop training programs in response. It includes counseling and tutoring, adult basic education and pre-college preparation programs, and an array of college education benefits to support workers in attaining college degrees in healthcare-related occupations.
Job security : An additional fund provides a safety net and rapid re-employment services for laid-off workers, who receive priority employment from hundreds of healthcare institutions in the NYC area.
Labor-management initiatives : This fund seeks to increase worker voice in the planning and implementation of efforts to increase quality care, patient satisfaction, and operational effectiveness. It supports technical assistance on the development of joint governing structures and training in joint problem solving around quality and performance issues.
The funds are financed by collective bargaining contributions, with employers contributing 0. PPS are providers that form partnerships among major public hospitals and safety net providers, with a designated lead organization for the group. Barnabas Hospital SBH. A major focus of DSRIP is to develop strategies to realign, redeploy, and retrain the healthcare workforce across the provider networks within broad regions throughout the state. All care will be managed, and the number of contracts with HMOs will be dramatically reduced from 17 to 7—10 plans.
The strategy has so far resulted in the outright acquisition or other partnership arrangements with nine hospitals, several of which are in the Hudson Valley, a region that is largely exurban, dominated by solo practices, and radically different from the Bronx in terms of patient demographics. In addition, Montefiore views its engagement in DSRIP as an opportunity to expand its model to a broader continuum of care in the Bronx as well as in the Hudson Valley. This has multiple implications for its approach to WFPD.
Third, early discussions among partners in the PPS suggest a commitment to relocate any displaced workers from partner organizations in the PPS to avoid unemployment. An HR leader described the change:. Whereas in years past we focused on our own employees and attracting top talent, now we are also interested in folks in the community and their future, and how to get them interested in a health care profession…We are partnering with schools, and building health care curriculums…And we have a greater focus on development and education of our community partners.
A core feature of this effort is a competency map that specifies what each worker needs to know and do and identifies curriculum pathways for each of the 80 clinical and non-clinical roles in the CMO. One informant shared that the map enables the CMO to scale up training and target delivery throughout the growing continuum of care. The CMO model has both loose and tight elements. The loose characteristics include the placement of facilitators in the CMO units to listen and support people in developing the skills and knowledge required to continuously improve the model.
There is also an educational council comprised of representatives from throughout the system that helps ensure frontline input into learning needs and evaluation of training programs. Its tightening mechanisms include standardizing some elements of training to help spread the care coordination model to the new Montefiore and the PPS partners.
The partners addressed this gap in this one-time bridge program with the inclusion of a care management module. Since then, the parties have worked together to revamp the curricula to better prepare nurses for care management and care coordination careers—which include courses on the broader institutional changes in healthcare and changing care models.
The nature of labor relations at Montefiore maybe best illustrated by the way in which CMO managers described problems redefining jobs and job titles. But to get a new title is hard. Despite these challenges, HR leaders described their relationship with labor as being based on mutual trust and collaboration. There is a lot of cross cutting comparison that we need to do. CMO leaders say a key challenge is ensuring that its standards are maintained as the number of organizations involved in the continuum of care expands through the DSRIP process.
DSRIP anticipates that, over time, hospitals will reduce the number of beds or close shrink and that ambulatory-, home-, and community-based care will grow. Workers will need to be retrained to move into these new settings within PPS. Despite what is largely a story of successful relationships, Montefiore informants were frank about the challenges ahead that concern them.
The first is a reflection of the need for continued maturation of the labor partnership. In particular, the lack of flexibility in renaming and redefining jobs has been an impediment to change and expansion plans. Currently, these jobs are different in their design and function, based on where the work is performed in a very broad spectrum of care coordination.
Historic interests and political dynamics have in part shaped these varied roles. There are deep differences over how to integrate CHW, e. The third challenge regards the spread of the model to the Hudson Valley. This model is in part reliant on a large system that can move workers affected by change in one facility to new roles and locations in the expanding continuum of care.
It remains to be seen whether there are the workforce relationships and mechanisms that will facilitate such processes in this suburban and exurban area of the state.
Though KP and Montefiore are very different systems, each mounting a different strategic response to the ACA, they share a common understanding of the centrality of the workforce in any delivery system change process.
This is reflected in a series of common themes that emerged in relation to our central study questions: how are these systems determining what changes are needed, and how they are implementing change in practice?
Below, we identify five broad themes present in both systems and discuss in the context of the theory of LCS. We then extrapolate the principles in each that may be relevant to other health systems and to broader issues of workforce policy and practice.
The first theme common to these case studies is that both organizations have a set of strong core values and a centralized vision with regard to their goals. Extensive engagement of labor in change decisions, coupled with the integration of innovation units into the change projects, helps to ensure that these values and vision are key factors in determining the needed change in KP. More recently, participation in the Health Exchanges has led to the adoption of additional values centered on the ideas of consumer convenience and affordability.
These new values are also informing the current cycle of innovation and change in the company. At Montefiore, the core value of population health not only directs internal change, it underlies its efforts to build extensive external partnerships aimed at improving the entire continuum of care in the region. Regardless of whether WFPD is focused on current employees or the external pipeline of people who need jobs, Montefiore informants view these investments as part and parcel of a population health strategy.
Weick [ 11 ] and Burke [ 17 ] argue that large-scale, institutional change, like that occurring in healthcare today, requires a high degree of cooperation that is difficult to achieve among the many semi-autonomous subunits and organizations in LCS. Burke suggests that shared values help remind people why the system exists in the first place, while a centralized vision contributes focus within the dynamic complexity of LCS.
In both cases, we see that their historical and cultural context is key to understanding how they integrate WFPD activities into ongoing change processes. The emerging principle, then, is that the situation determines what type of adaptive WFPD is possible in the first place. This means that WFPD is not just a technical exercise; it must also appraise the political, economic, cultural, and social dynamics within specific contexts in which healthcare takes place [ 13 ].
To be effective, the process must consider the multiplicity of values that drive healthcare and WFPD decisions [ 13 ]. The second theme that emerged in both cases is the commitment to transparency with regard to the goals and criteria for making decisions about changes and to an early dialogue with stakeholders, in particular labor, around the best way to organize the change.
In both systems, we see an institutional commitment to early collaboration with labor and other key partners throughout the change process. In KP, the national agreement and the investment in the LMP have resulted in a highly integrated system of corporate governance that involves labor in strategic decisions on every level of the company, from the UBT to national strategic planning efforts. The sharing of sensitive corporate information and performance data is essential to making these efforts work.
Greater emphasis on transparency and early dialogue between Montefiore and SEIU, its largest union, was observed in external efforts to close gaps in the labor market and in their mutual engagement in the DSRIP planning process.
The expansion of the one-time nurse bridge program to create a new curriculum to prepare nurses for care coordination roles is an example of how joint leadership resulted in improvements to the WFPD infrastructure in the region. The theory of LCS suggests that transparency and early dialogue are highly functional change mechanisms, because they open the process to many different interests and vantage points required for sense making [ 25 ].
In addition, these mechanisms create shared leadership, which is more effective than hierarchical leadership when seeking to tighten connections within a LCS [ 17 ]. An emerging principle then is that WFPD is integrated with strategic and operational planning processes. Moreover, from a change perspective, efforts to integrate are seen as boundary defining and boundary spanning, which is a political process that requires ongoing negotiation and mutual adjustment [ 17 ].
With these concepts in mind, this principle suggests that WFPD is a dynamic process of negotiation and mutual adjustment among semi-autonomous subunits in a LCS that seeks to integrate the workforce into the change processes within firms, as well as, as we shall discuss below, to align internal change with the system-wide skill formation goals and activities of WFPD institutions.
The third theme is changes often emanates from innovations to workflow that emerge from an analysis at the unit level and then take into account competing interests across the system. This is in contrast to change defined based on existing jobs and organizational structure or simply an analysis of who currently does what.
The innovation model in Montefiore also starts with an analysis of the optimum work design at the unit level, as opposed to the current workflows and job structures. It identifies the range of knowledge and skills that are required for coordination across the continuum of care, and it delineates what every occupation group needs to know and do to support the care model.
This tool ensures that the required expertise is available across the entire system, while it also enables the customization of curriculum pathways for each role and individual in the CMO. There are several emerging principles here. The first related once again to integration, as discussed above. But in addition, we see principles of both a holistic approach and an approach that is adaptive to changing demand. The holistic principle implies the consideration of the whole system of professions and occupations, as opposed to each profession having its own distinct role, training structure, and regulatory mechanisms.
Dussault and Dubois posit that a traditional siloed approach in healthcare hinders the implementation of policy and complicates the change process, particularly when new, multidisciplinary models that require a high degree of interdependence among many different professions are required [ 13 ].
A related principle is that adaptive WFPD must be responsive to changing demand. Both systems have concluded that the traditional linear approach to WFPD is necessary but not sufficient. Their adaptive approaches begin with a focus on the demand for healthcare and try to account for the macro shifts and trends as well as the internal political dynamics affecting the health system and its workforce [ 13 ]. In the complex setting of healthcare today, this requires a highly participative decision approach that accounts for many perspectives that is also supported by accurate, robust, and accessible data that can account for the large and growing number of variables that affect the demand for care and the supply of the workforce [ 10 , 13 ].
New methods are also required that can utilize the new so-called big data systems to model the efficacy of possible care models and WFPD scenarios [ 10 ]. These changes are consistent with the proposition of Bechun and Glick, who argue that institutional changes can set into motion new patterns of coupling within organizations as they respond to the changing environment. The sports retailer recognizes that skills are a driving force to adapt to changing circumstances.
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|Cummins power generations||Moeness M. This review analyses various approaches to health workforce planning and presents the Six-Step Methodology to Integrated Workforce Planning which highlights essential elements in workforce managenent to ensure the quality of services. This was described as an analytical process to develop a strategy to close the click required to make each new role successful. Connection successful! Finally, WFPD is generativeresulting in new resources and capacity for innovation. Planners need to take into account the potential effects and outcomes of new policies and practices when making suggestions to ensure that short-term solutions do not mask long-term and reoccurring issues. A https://elegancegroupe-49.com/caresource-medical-transportation/1678-how-technology-has-changed-the-way-healthcare-professionals-access.php on patients with high medical expense and high risk of hospital and emergency department utilization by interdisciplinary care management teams has generated savings that that are reinvested in the delivery system.|
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