1

Royal Perth Group

Allied Health Leadership and Governance Framework

Supplementary Information

June 2015

Version 1.0

Prepared by South Metropolitan Population Health Unit

2

Project Control Group

Name Position/Title

Dr Aresh Anwar A/Executive Director, Royal Perth Group (RPG)

Jodie Chamberlain Deputy Executive Director RPG

Joel Gurr Director, Fiona Stanley Hospital

Marani Hutton Area Allied Health Advisor, SMHS

Project Manager

Kate Gatti Executive Director, South Metropolitan Population Health Unit

Belinda Whitworth Manager, Non-admitted Services Reform Team, Population Health

Version Control

No Date Nature of change(s)

1.0 12 June 2015 Draft document submitted to the Project Control Group (PCG)

3

Contents

1.0 Introduction ........................................................................ 4

2.0 Key Themes ....................................................................... 4

2.1 Allied health leadership and governance ........................... 4

2.2 Responsive services .......................................................... 6

2.3 Leading change, engaging staff ......................................... 8

2.4 Communication .................................................................. 9

2.5 Working with dual lines of reporting ................................. 10

2.6 Clinical education, training and professional support ....... 11

2.7 Inter-professional teamwork ............................................ 12

3.0 State and National Drivers of Change .............................. 13

4

1. 0 Introduction This supplementary information from the interviews and online survey with allied health staff is provided to inform the change management should a decision be made by the Royal Perth Group (RPG) executive to reform the leadership and governance of allied health. Structured face-to-face confidential interviews were held with Directors of Allied Health (DAHs), Heads of Departments (HODs), Allied Health Senior Coordinators (SCs) and Coordinators (COs), Service Co-Directors (SCDs), Directors of Nursing (DONs) and General Manager (GM). The interview questionnaire aimed to elicit information on the current state of allied health organisational structure, principles of allied health, communication/reporting and potential future governance structures. All interviewees were invited to provide additional comments at the end of the interview which many contributed; in addition some participants provided further information by email.

Feedback from staff is presented below under the following key themes: 2.1 Allied health leadership and

governance 2.2 Responsive services 2.3 Leading change, engaging staff 2.4 Communication

2.5 Working with dual lines of reporting

2.6 Clinical education, training and professional support

2.7 Inter-professional teamwork A discussion of the findings and potential implications for organisational development and change management is provided for each theme in section 2.0. Consultation with the Chief Health Professions Officer, Department of Health provided insight into the state and national drivers for change for allied health professions. These are described in section 3.0.

2.0 Key Themes

2. 1 Allied health leadership and governance Executive Tier Position

All DAHs/HODs/SCs/COs wanted an allied health leadership position situated in the executive tier of the organisational structure.

All interviewees at BHS wanted to maintain the allied health leadership position (currently BHS DAH 0.5FTE) on site at BHS and its executive functions.

All SCDs/DONs/GM supported an allied health leadership position at an executive level. They each held different views for governing allied health as a whole.

5

Line Management of HODs/SCs/COs

The majority of the HODs/SCs/COs wanted to maintain current reporting lines ie through DAH(s) or in one case the SCDs.

A small number of HODs/SCs/COs did not perceive benefits in reporting through the DAH, based on the current functions of the DAH role.

Line Management of Allied Health Teams

All DAHs/HODs/SCs/COs preferred the allied health teams to report (currently directly or dual) through the HODs/SCs/COs.

The SCDs/DONs/GM held differing views on whether the professions should be line managed by a HODs/SCs/COs structure. Clinicians being managed fully through the service stream and clinical team/specialty/program were described as an alternative to the current structure of HODs/SC/COs, assuming appropriate clinical supervision arrangements were in place.

Director Allied Health

Most HODs/SCs/COs perceived the DAH positions could deliver more strategic allied health functions including: cross-department leadership strategies; strong strategic capability (ie strategic planning for allied health and as a contributor to RPG planning); strong clinical knowledge of the business of all departments in its remit; system development for interdisciplinary decision making; engagement of all departments with parity; stakeholder engagement; provision of expert allied health advice to executive; and contemporary professional development of the allied health workforce.

The HODs/SCs/COs perceived the benefits of the current DAH positions were: communication of information to/from executive; development of business cases; and representation of allied health at some executive forums.

Governance Functions

The DAHs/HODs/SCs/COs described the important governance function of their roles, being: provision of senior clinical expertise; clinical professional supervision; profession specific advice; professional judgement to best allocate resources to meet clinical demands; workforce management and development.

All SCDs/DONs/GM discussed a range of improvements that could be made to the current governance of allied health services.

A common theme from SCDs/DONs/GM was difficulty getting timely, detailed and accurate information about the current allied health workforce and services (eg workforce data; budgets; changes to contracts; operational issues; human resources; governance; roles and responsibilities).

One comment by an executive staff member was that allied health as a whole can be experienced more as ‘a separate entity’ in the organisation rather than part of the integrated clinical service. This has become evident at the ward level where conversations to improve clinical services may not automatically include

6

allied health. Often the right people have to be brought together in a meeting at another time.

One of those interviewed suggested that to achieve an integrated service with structural change may require extensive change management and risked the perception of devaluing staff. Other strategies suggested were: valuing and engaging staff for their knowledge/experience; building teamwork; partnerships; and focusing on cultural change.

Implications for organisational development and change management

A leadership and governance model for allied health needs to balance the immediate priorities of service delivery while moving toward the RPG vision for integrated clinical services within each of the streams across both sites. While an allied health leadership position in the executive tier is in principle well supported for RPG there are diverse views and preferences about the best model to govern allied health services. The governance model should maximise allied health’s capacity to operate in partnership with nursing and medical services within the streams. Due to diversity of views amongst staff on governance, any structural change will require strong leadership by the executive team and clear communication of how allied health services will function and strengthen the RPG service stream model. Parity with the nursing and medical structures should generate a platform for allied health to be part of the integration of clinical services across the whole organisation. There is clearly an opportunity to establish a Director of Allied Health position in the executive tier and in the context of the service stream model at RPG. The job description should reflect contemporary national benchmarks of similar positions. In particular, the position will need to provide strategic allied health leadership, management and advice to the Executive Director RPG and deliver tactical support to the Service Stream Co-Directors via the allied health workforce.

2.2 Responsive services DAH/HODs/SCs/COs accountability

The DAHs/HODs/SCs/COs perceived an important aspect of their role was to deliver a responsive patient service with a highly skilled team. Flexibility to meet the daily surges in clinical activity and demonstrating accountability for this was a key theme. There were differences in how each HODs/SCs/COs prioritised services.

Benefits of current structure

At both sites a number of DAHs/HODs/SCs/COs perceived that the current governance structure delivered flexible allied health services despite lean

7

resources. At RPH, departments had adapted to new FTE/workforce builds and described successfully using new staff rotations to manage surges in activity.

Highly skilled clinicians with extensive experience in multiple specialties were seen to strengthen the capability of departments to respond to increased service demand.

Barriers to delivering flexible services

SCDs/DONs/GM described challenges in providing a responsive and flexible service. For example, unclear and overly complex allied health FTE allocation at BHS need redesign; FTE allocation that governs the placement of allied health staff in clinical areas; loss of FTE and skilled staff that impacts multiple clinical areas; small allied health departments (eg speech pathology; dietetics, clinical psychology; podiatry) not receiving an FTE allocation where there is a service need (eg mental health - speech pathology; dietetics); a perception of more commitment to the business of the large departments (ie physiotherapy; occupational therapy; social work) compared to small departments.

SCDs/DONs/GM described challenges at ward and specialty level in accessing allied health staff at critical points in the patient’s journey. For example, Service 3 requires the capacity to provide crisis management for patients which works best with occupational therapists and psychologists present during ward rounds. An allied health service 7 days per week was considered important for mental health services. Service 1 requires interdisciplinary teams at the frontline and perceived benefits in more allied health staff being ‘embedded’ within clinical teams.

Benefits of reconfiguration

SCDs/DONs/GM perceived that the reconfiguration had offered good opportunities to improve interdisciplinary services to date. Examples included the new approach to triage patients in the community rehabilitation service; ortho-geriatric services where allied health is part of the team; and the RPG diabetes service. Interdisciplinary teamwork was perceived as a flow-on benefit of these projects.

Administrative functions

DAHs/HODs/SCs/COs considered a review of the administration functions of roles was necessary. Some departments operate without dedicated administrative support and many HODs operate ROSTAR, taking attention away from clinical work. Human resource systems were described as onerous and lengthy and made backfill of staff unachievable in a short time frame with approval processes in some cases taking over 6 weeks.

Implications for organisational development and change management The above feedback may suggest that flexible service delivery models enable the management of rapid changes in clinical activity across the different service areas. Both the SCDs/DONs/GM and DAHs/HODs/SCs/COs want allied health staff placed

8

in the areas of highest need whilst maintaining core services. Both groups also expressed frustration when it was perceived that this wasn’t happening. In a tight fiscal environment with clinical pressures, flexible service delivery commands the best use of a finite resource. In the service stream model, decision making about how and where allied health FTE is best used (ie priority setting) needs a team approach between the professional HODs/SC/COs, SCDs/DONs/GM and business managers. The allied health structure has not changed since the introduction of the RPG service streams in 2013 and as such allied health are continuing to operate as disciplines within a departmental model. This does not appear to promote integration and consideration needs to be given to how allied health resources are allocated within service streams and teams to maximise the clinical capacity and meet the workload demand. Smaller departments may be less visible in all clinical areas as they have a small workforce providing services across multiple specialties. Any change to allied health leadership and governance would need to strengthen the capacity of all leaders to better manage clinical activity. The workforce build, review of administrative functions of HODs/SCs/COs and the establishment of business rules for prioritising services within streams or across departments could add value.

2.3 Leading change, engaging staff Executive Support

The DAHs/HODs/SCs/COs were asked about the type of support from executive that assists them to manage their departments and lead change. More engagement between executive, allied health leaders and their teams was a key theme across all areas.

Suggested improvements included routine formal meetings with executive members and opportunities to collaborate on service improvements.

One of the executive leaders described supporting allied health by 'unblocking issues' and leading change through conversations with the right people.

Engagement with Executive

The DAH/HODs/SCs/COs acknowledged that it was not practical for each department to have a representative at all executive/senior meetings. In this context, the HODs/SCs/COs relied on strategies that engage all departments with rigour and parity which was perceived as currently not working well.

Departments that perceived low engagement with executive and the wider organisation described their experience as ‘insular’ and were concerned they ‘didn’t know what they didn’t know’ about RPG business.

Building the knowledge of executive staff on each allied health service was also suggested.

9

Information from Executive

Many HODs/SCs/COs perceived that timely information and feedback from executive was not easy to access. They wanted quality information, with directives clearly communicated and where appropriate the opportunity to discuss consequences and plan together the best path forward. In Service 1, dashboard meetings with Service Co-directors and HODs were perceived as working well for reporting.

Nursing, Medical and Allied Health

Stronger relationships between allied health, nursing and medical teams were described as essential to improve patient flow and streamline services with timely allied health input.

Implications for organisational development and change management

SMHS and RPG have undertaken significant reconfiguration and reform that has influenced and changed the way services are delivered. It is noted this ongoing reconfiguration has resulted in some “change fatigue”. However, there is continued opportunity to strengthen engagement as part of routine business as well as during change and reform.

2.4 Communication Lines of communication

Communication was a key theme in discussion about the current allied health leadership and governance structure. The governance lines of DAHs to HODs/SCs/COs at both sites were perceived as a clear line for relaying information up/down tiers at each site. BHS interviewees in particular valued the communication pathway from DAH to the GM located on site.

The lines of DAHs to HODs/SCs/COs were perceived as less effective for communication on complex issues; interdisciplinary collaboration; prioritisation/ problem solving issues across services; and recruitment of senior staff. One interviewee described this as “more layers in the organisation equals more dilution of the message”.

A number of HODs/SC/COs stated that would like more opportunity to contribute to strategic issues both through the DAH and by direct involvement.

Communication by HODS/SCs/COs with allied health teams

Open door management was consistently described by HODs/SCs/COs as the best path to quickly resolve pressing operational/clinical issues within their own teams. A small number of HODS/SCs/COs liaise with the equivalent HODs/SCs/COs across sites for professional support.

10

Suggested improvements for organisational communication included:

Early dissemination of information as it often influences decisions at the department level;

Transparent communication, participation in decision making, timely information and in-person communication were perceived as helpful at BHS.

Maintain currency of email distributions lists and include HODs/SCs/COs in messages where staff are managed by dual reporting.

Involve the right professional HODs/SCs/COs for decision making.

Better strategies across the whole organisation to manage allied health services issues that arise in any forum/committee/meeting or through any reporting line (ie via DAH/service streams/GM BHS).

Implications for organisational development and change management Based on the above information it appears that the current reporting lines between the DAH and the HODs/SCs/COs provide limited opportunity for allied health HODs/SC/COs to engage in the wider business of the organisation and with the service stream leaders. The establishment of a new DAH position with a contemporary designed JDF would address many of the above concerns through leadership, engagement and reform of the allied health services. There would be benefits in defining communication pathways for key shared goals/targets ie via Service Streams and/or via DAH.

2.5 Working with dual lines of reporting Uncertainty

Governance via dual lines of reporting was perceived with a degree of uncertainty. Issues raised were consistent across all professions (ie nursing; medical and allied health) and in service 1, 3 and 4.

Roles and responsibilities Service 3

The need for further clarification about the responsibilities of the program managers and the HODs/SC/COs was raised. Although the roles and responsibilities of HODs/SCs/COs and program managers are documented with some departments these were perceived as not working clearly in practice.

Many perceived that engagement and communication with program managers as their large workloads made them difficult to access.

Interdisciplinary leadership

The development of leaders’ capability to manage interdisciplinary teams and

work with all professions with parity was a key theme to making dual lines of

11

reporting work. Similarly it was reported that some staff are experiencing confusion and unclear information at times about lines of accountability.

Evaluation

Evaluation of the dual lines of reporting model at RPG was requested. Implications for organisational development and change management This feedback may indicate that staff are still adapting to working with dual lines of reporting and adjusting to the Service 3 program management model which is in early stages of implementation. Making dual lines of reporting work on a daily basis is critical to the success of the service stream model. When not working well, dual lines of reporting may result in: staff confusion, poor accountability; duplication of communication (ie staff giving the same feedback to multiple leaders or vice versa); reactive communication and the issue not getting resolved. With a new leadership and governance model for allied health there is an opportunity to re-examine dual lines of reporting across all professions. This should include clarity around roles and responsibilities that will easily be understood by staff. Similarly, managers will need to set clear boundaries on their role and those of support staff in this context.

2.6 Clinical education, training and professional support

No dedicated budget

Both DAHs/HODs/SC/COs and SCDs/DONs/GM considered it important to improve clinical education and training for allied health. Unlike medical and nursing staff, the allied health workforce at RPG does not have a dedicated education and training budget. It was acknowledged that BHS had made progress by allocating a small budget over recent years. A disconnect between training and the needs of the service streams was also noted.

The DAHs/HODs/SCs/COs indicated that wherever possible staff are supported through study leave or work time to attend training and conferences that are relevant to their job.

Backfilling

It was reported that often staff do not undertake professional development through SMHS because their role cannot be backfilled or there is too much work to distribute among the remaining staff while they are away.

12

Upskilling staff

The workforce pool of clinicians with experience for specialty services was perceived as relatively small. Finding suitable staff quickly for temporary cover was raised as a challenge in both high acuity and rehabilitation services.

While new graduates may be available they need significant upskilling before being used for backfill in many services.

Many HODs described upskilling staff across several specialties in response to this issue. This was perceived as helpful but not entirely solving the problem.

More specific clinical training for allied health, interdisciplinary training with RPG staff and leadership training was requested.

Consistent positive feedback was received from staff about the leadership courses offered by the Department of Health.

Professional support and supervision

Less experienced HODs/SCs/COs reported informal mentoring by more experienced HODs/SCs/COs at RPG.

Professional support could be enabled more by the health service through sharing of resources, visiting clinicians and opportunities for job rotations.

One executive staff member described issues of approval process for professional supervision as prolonged and required formalisation.

Implications for organisational development and change management A quarantined budget and dedicated clinical training and education resources for allied health is clearly indicated. A workforce development strategy for allied health could be the responsibility of the Director of Allied Health.

2.7 Inter-professional teamwork Positive about working interprofessionally

Most interviewees perceived interprofessional teamwork as positive and that there is good opportunity at RPG. Some perceived that “we already work interdisciplinary on the wards” however there was little evidence presented of interprofessional practice beyond such an example.

Barriers to participation

Many HODs would like to do more strategic work in this area (eg via committees) but are limited by time and other priorities.

Others considered this function was currently undertaken by the DAH and that they were not given opportunity to participate directly.

13

It was also perceived that the physiotherapy profession was over-represented in interprofessional forums to the exclusion of the other allied health professions.

Allied Health Heads of Department Meetings

The allied health HOD meetings were described as primarily for reporting. Several suggestions to change to a dynamic facilitation style for meetings would allow more equitable collaboration, problem solving and team decision making.

Implications for organisational development and change management Interdisciplinary teamwork goes beyond simply working among staff of different disciplines, sharing case notes and case conferencing. Feedback from staff indicates that there is already a positive view of interdisciplinary team work at RPG. There are opportunities to harness this energy and build competencies within and across teams/disciplines towards a functional interprofessional service delivery model.

3.0 State and National Drivers of Change Consultation with the Chief Health Professions Officer at the Western Australian Department of Health provided insight into the key drivers influencing the allied health and the health science professions, both state and nationally. In particular, the discussion focused on the professions and governance, Australian health workforce reforms, sustainable workforce and change management. The information affirms the opportunity for RPG to consider contemporary redesign of allied health services. It was noted also that the allied health professions lack the same industrial relation protections as nursing and medical professions. Consequently, this workforce may be more at risk of reduction than other professions during organisational reforms. The benefits of building an allied health workforce based on service need were reinforced. Professions and Governance 25 professions (specified callings) are currently within the Chief Health Professions

Officer remit with a trend toward an increasing number of health science professions.

This list includes both registered and self-regulating professions. The implication for

health services is to plan for an expanding number of allied health and health

science professions with increasing governance requirements. Interestingly, this

workforce is considered accessible and not in the same supply crises as nursing and

medical.

14

Allied Health Models/Structure

Australian research by Rosalie A Boyce was discussed as helpful for understanding

different allied health models and structures used in Australian health services.

Evaluation of new allied health models, such as at FSH, is recommended.

Director of Allied Health

A Director of Allied Health position is in situ in all area health services in WA. These

representatives meet monthly with the Chief Allied Health Professions Officer at the

DOH Allied Health Council.

The positions were set up to function strategically and provide a voice for allied

health at executive. The roles benefit from contemporary leadership styles (ie

collaborative/authentic leadership) and an extensive knowledge of clinical practice.

Recruitment to such a leadership position aims to attract the best person for the job

from multiple professions, rather than a person representing a specific profession.

Interprofessional Governance

Interprofessional governance (ie being managed or managing a staff member of a

different professional background) is increasingly occurring in health service

structures. Examples in WA include WACHS, FSH and RPG mental health program

management. In these cases clinicians have a management line and a

clinical/professional supervisory line. It is imperative in such structures that clinicians

have ready access to discipline specific expertise.

Leadership Training

Collaborative leadership is an emerging area of practice and is helpful for changing

the way teams work. The leadership program offered by the DOH has had close to

200 participants and has been successful in supporting new ways of working,

particularly with young clinicians. There is an intention to continue to provide

leadership training opportunities in the future.

Primary Health and Reform

Given the reform in primary care with the establishment of the Primary Health

Networks, there may be opportunities to work collaboratively at the hospital and

primary care interface.

Sustainable Workforce

For allied health services, workforce models that may offer more sustainability

include allied health professionals supervising a workforce of allied health assistants.

This model operates on the premise that clinicians maximise time on clinical work at

full scope of practice (and where indicated expanded and advanced scope of

practice). Allied health assistants add to the integrated care model by assisting with

therapeutic and program activities. Work is progressing across Australia on scope of

practice for professions and allied health assistants.

15

Partnerships with Education

Partnerships between health services and universities/training organisations were

also discussed. It will be in the interest of health services to strengthen relationships

with education to drive workforce reform and better manage teaching, training and

research. There are already examples of hospitals working with specific universities

to create allied health research centres.

Australian Health Workforce Policy

Health Workforce Australia (HWA) extensively documented the challenges facing the

health workforce and the transformations required to meet the rising demands of

health care, specifically: build workforce capacity; boost productivity and improve

workforce distribution. During its tenure HWA injected new programs in workforce

and training. Many of these initiatives directly influenced some of the allied health

professions (eg in retention, simulated education and interprofessional practice). The

essential functions of Health Workforce Australia were transferred to the

Commonwealth Department of Health and Ageing in 2014. The key areas of work

remain a priority for health services to progress.

16