Dealing with change: EHPs face new challenges when hospitals merge
Dealing with change: EHPs face new challenges when hospitals merge
Problems include combining EHSs and helping employees cope
Recent changes in the health care industry have set off an avalanche of hospital mergers, which presents a special set of problems for employee health practitioners. Not only must they face consolidation of their department with one or more others, but they also must assist other hospital employees in handling the change-related uncertainties that produce illness, low morale, decreased productivity, higher absenteeism, and turnover.
From 1980 through 1994, at least 512 hospitals were involved in about 250 mergers or consolidations, according to the American Hospital Association (AHA) in Chicago. Bill Erwin, an AHA spokesman, says the number actually may be much higher.
What are the unique challenges EHPs must grapple with when their hospital merges or consolidates with others? The process might feel like settling the Balkans conflict, as one EHP describes it, but those who are working through the process emphasize the important role of employee health practitioners in that time of rapid change. (For more details, see the first-person account on p. 18.)
In October 1994, Good Samaritan Hospital and two Bethesda hospitals -- all in Cincinnati -- merged,
forming TriHealth, Good Samaritan/
Bethesda Hospitals. Kathleen W. VanDoren, RN, BSN, COHN, Paralegal, went from being
manager of employee health and workers' compensation at Good Samaritan to a position called
coordinator of employee health services for the group, although she does not supervise the Bethesda
EHPs.
Her first hurdle was adjusting to the elimination of her middle management job and the appointment of another person as manager of employee health and workers' compensation for all three hospitals.
"I had applied for the new management position, but did not get it," says VanDoren, who also is executive president of the Association of Occupational Health Professionals in Healthcare in Reston, VA. "I wondered what qualifications they were looking for that I didn't have -- all of the things you wonder when you don't get a position."
VanDoren now sees a bright side, however. "I've come to realize the fact that I'm not responsible for all three hospitals, which means I can really concentrate on improving the department at Good Samaritan, plus I can also contribute to the other two employee health departments in improving their areas," she says.
Emphasis on streamlining services
Another change involved a sharp increase in the number of employees. The merger swelled the ranks from about 2,900 at Good Samaritan to 7,800 in the combined system. Although each hospital has its own EHS, employees transfer back and forth, and VanDoren's department handles services that the other two do not.
Some of those services may not survive, though. Employee health staff are meeting twice monthly to "see what we have to do vs. what is a nice benefit" for employees, VanDoren says. "We all put our ideas on the table with much tact, present what we've developed, how we do things, and let the new manager work with all three areas and have the responsibility to decide what we're going to do."
The goal is for all three departments to "mirror" each other, she adds. Forms are being standardized, and some services will likely be eliminated. "The emphasis is on streamlining services to provide employees the benefits they need and to comply with governmental regulations."
Education programs may be cut. Immunization programs also are under scrutiny. VanDoren's employee health department already has lost a part-time registered nurse in the reorganization.
Facing such sweeping changes brings a feeling of uncertainty. "Whenever you're trying to streamline services or mirror other departments, individuals come into it with a feeling of apprehension," she says. Concerns include: "Is something going to be eliminated? Will it be my job or my area? Will there be so much change that I won't know my own department? Is hospital A taking over hospital B?"
Defensive feelings also emerge. Having initiated all of the EHS's policies and procedures, health screenings, rehabilitation programs, medical case management, and computerization, "you can begin to get very defensive" in the face of change, VanDoren notes. "But I try to keep an open mind. There's going to be change whether you like it or not."
Try to be part of the process, she advises, and be willing to consider the different way others do the job.
"Maybe they really have a better way. Maybe we'll have to scrap the way all three hospitals are doing it and come up with a fourth way," she says.
The process often is "painstaking," she adds, requiring patience, negotiation, tact, and diplomacy. "Sometimes it feels like trying to get Bosnia and Croatia together, but you have to keep an open mind and be enthusiastic about the changes. We have so much to offer together, so many resources, so many departments and services."
Having a positive outlook is especially important for EHPs, who must help other hospital employees cope with new stresses. On some days since the merger almost twice as many employees have reported to the EHS, many with vague complaints. "We sit with them and let them talk," VanDoren says. "Many are afraid of losing their jobs."
Employee counseling needed
Phyllis K. Stebbins, RN, manager of employee/occupational health for Huntsville (AL) Hospital, reports similar employee problems. Although the merger one and a half years ago -- which added 1,200 employees to the 3,000 in Stebbins' facility -- went smoothly, she and the other EHPs provided a lot more counseling in the first year.
"People were still afraid they were going to be laid off," she says. "We had a lot more upset stomachs and a lot more headaches. Often the physical complaints were not physical at all. We spent much more time in a counseling role. The best thing we did was to learn to say, 'Wait, you're here today; you were here yesterday. There's no reason to feel you won't be here tomorrow. You are a vital part of the hospital's function. We've gained beds; we've gained patients. So how can we do that with less personnel?"
For Stebbins, her hospital's acquisition of a smaller hospital was less traumatic because she already knew the employee health nurse in the other facility.
"We had a rapport already," Stebbins notes. "We were just within a few blocks of each other and had shared policies over the years."
Nevertheless, the two departments were dissimilar in many ways, and since Stebbins' facility had acquired the smaller one, the other EHS came under her supervision.
"We tried to do that very gently and slowly to make everybody feel very worthwhile and welcome. We had to get along really quickly, and we did. We meshed our two departments well," she says. "We had interaction with every [employee] because the way we're set up, employees don't get their annual raise unless they have been to employee health to get TB skin testing and immunizations such as hepatitis B. They did not do that up the street."
Employees can receive services at either facility's EHS. This is advantageous for TB skin testing, for example, because employees "have twice the opportunity" to have their tests done, she says.
Record keeping was perhaps the biggest hurdle. Because Stebbins' EHS provided more services than the smaller hospital's program, "our records seemed to be more complete than theirs," she says. "Their charting system was different from ours, too."
Stebbins admits that at first, she probably had "the same fear that everybody else in this building and the other building had: 'Uh-oh, are there going to be layoffs?' That is the fear all across the country whenever there's a merger, but none of my fears came true," she states.
Administrators had told her about the merger and the reasons for it, as well as what kinds of questions she could expect from employees. "They were correct," she says. "If you have good administrative support, you can get through almost anything."
"During a merger, many employees are left, understandably, questioning their futures with the new organization," says Christopher Cimino, president of Human Resources Services (HRS) in Chicago. "This insecurity is especially evident among middle managers, who are most often the victims of downsizing because of the duplication of management functions that occurs during a merger."
When health care organizations merge, confusion often arises over which policies, practices, and programs will remain and which will be discontinued, he adds. Decisions should be made early in the merger and then communicated consistently during the process and after its completion; otherwise, "employees will be left confused and upset."
'Rightsizing' new in health care
A recent unpublished HRS survey of 40,000 health care employees uncovered the following facts: Employee satisfaction with new policies declines an average of 14% after mergers; the perception of job security decreases 25%; and 80% of workers perceive the restructured management to be less concerned about them or quality than about company finances.1
Understanding why their hospital is merging or "rightsizing" (a euphemism for downsizing) helps calm employees' fears and apprehensions, says consultant Donald N. Lombardi, PhD, principal partner with the Center for Human Resources/InterVista in Mt. Arlington, NJ. Lombardi, a psychologist, has worked with more than 190 health care organizations and hospitals in reorganizations and is the author of Stress in the Health Care Environment (Ann Arbor, MI: Health Administration Press; 1990) and Handbook for the New Health Care Manager (Chicago: American Hospital Association; 1993).
"The biggest problem with rightsizing is that people in health care are just not used to it," he says. "Since the 1920s, hospitals and other health care facilities have been in a constant state of growth. Also, for years there was no competition among health care institutions."
Now, with the proliferation of health maintenance organizations and preferred provider organizations, people have more health care choices.
Hospitals are rightsizing due to competition, as well as hospitals' tendency to "over-hire and over-staff" their facilities in the 1970s and 1980s, Lombardi says. In addition, the shift from inpatient to outpatient services means shorter patient stays, which in turn means fewer staff are needed.
"That means less constituents for an employee health component," he says.
Employees need to understand these factors and know they are part of a national trend, not something that is happening just to their hospital.
"They need to understand that, in the long run, it might be beneficial to hospitals because technology is not going to go backwards; people will spend less and less time in hospitals," he adds. "A lot of employees think [a merger or rightsizing] is going to be a precursor to the hospital closing. But that's not true. I tell managers to tell their [staffs] that people will always look to their local health care institution to be at the forefront of health care the same way people look to the public school system to educate their kids. The fact that most hospitals are seen as public trusts will be their saving grace."
The 'us and them' mentality
The issue of turf protection often arises when employee health or hospital departments must combine, Lombardi notes. He suggests the following graphic solution:
"Draw a big circle and label it 'CP' for customer patient. Then draw a circle within it and label it 'ORG' for organization. Next, draw a circle within that one and label it 'D' for department. Last, draw a little one in the middle and label it 'I' for individual."
The drawing illustrates "spheres of influence," he explains, and it shows that priorities have to be established from the outside in. "Individuals in health care organizations have to understand that the first priority is the customer patient, the second is what is good for the organization, and the third is for the department to help make it happen relative to the organization."
Battles between individuals within departments about how they've always done things is "'us and them' stuff that has no relevance," Lombardi states. "The patient is 'them,' and the entire organization is 'us.' The best way for individuals to ensure they will maintain their jobs is to order priorities from the outside in."
Lombardi maintains that organizations include three types of employees. About 20% of the staff are "superstar types who would run through the wall if they thought it was for the good of the hospital or patient." About 70% are "steady" people who like their job and where they work.
About 10% don't like anything, however. "In times of crisis, unfortunately, these people are very skilled in getting a lot of air time," Lombardi says. "They'd rather talk problems than solutions, they love to dredge up the past, and their favorite pronouns are 'me' and 'I.' But those days are gone."
When managers fail to provide leadership in times of change, those detracting people fill the void. To prevent this, he suggests five rules to silence such people because "there's nothing in there that they like to do":
* Nobody is allowed to state a problem without immediately proposing a solution. If the problem is putting two employee health components together, what would be the best way to enact the merger of those services?
* Focus on the future, not the present or the past.
* There is no such thing as "us" and "them" anymore. "Us" is the total entity of the department.
* Use the circle diagram to set priorities. Use a 20-point system: If a policy or idea is good for the patient, it gets 5 points; if it's good for the organization, it gets another 5 points; if it's good for the department, another 5 points; and if it helps the employee health practitioner do his or her job, give it another 5 points.
* Lastly, to maintain your department or position, think creatively about how you can "sell" your services, Lombardi advises. Stress the benefit your department provides to the organization vs. the risks and expenses.
Head off the 'FUD' phase
Human resources consultant and organizational psychologist Thomas A. Atchison, EdD, president and founder of Atchison Consulting Group in Oak Park, IL, works exclusively with health care employers. He says "re-engineering" (or downsizing) in health care often is being done "in a very mean-spirited way" that ignores the impact on employees.
"I think we're going to look back on this as one of the worst things we've ever done in health care. Re-engineering has to be done, but not in the way it is being done," he states.
Atchison says he knows of hospital managers receiving e-mail messages asking them to report to human resources to be fired, and of employees being called into meetings only to have final paychecks handed to them.
"Mergers and consolidations have only one objective: to get cost out of the acute side of health care. That's the only reason they're doing it. It's not so much what we do, but how we do it that makes the difference. It can be done in a way that irreversibly damages your human capital or in a way that maximizes the potential of the remaining human capital," says Atchison, author of Turning Health Care Leadership Around (San Francisco: Jossey-Bass; 1990).
He suggests using focus groups to gain employee input into the process of change and plans for the organization's future. If this is not done, the result will be widespread employee fear, uncertainty, and doubt -- the "FUD phase," according to Atchison.
Slashed tires and gunshots
"The fears are primitive and serious," Atchison says, such as the fear of losing one's livelihood and being unable to take care of one's family. "The uncertainty is, 'Will I have a job? What will it look like?' Many of the doubts have to do with the leadership of the organization and whether it will be competent. It's a trust issue," he explains.
When employees are left out of the process, "some kind of travesty" can take place. He has heard of hospital administrators' tires being slashed and the windows being shot out of CEO's homes.
"If you put people in a situation where they have no recourse, they will hurt you, either passively or aggressively," Atchison says. "If [employers] don't start incorporating the human condition into their change processes on the front end, we will see a very bad situation. When [employees] are treated badly, they feel justified in sabotage, in not working very hard, in stealing things. However, if they are made to feel like part of the future, then they won't hurt themselves or the company and will want to participate in the company's vision."
EHPs might start to notice increased illness and accidents, high absenteeism, turnover, substance abuse, insomnia, eating disorders, personal problems, and other stress reactions among employees, all symptomatic of a more "passive-aggressive" internalizing of FUD, he says.
Atchison advises EHPs to "get in front of the power curve" and form small focus groups to allow employees to vent their feelings and "discharge some of the energy they're internalizing."
Otherwise, "sit and wait for the dysfunctionality to fall into your lap, and then you're essentially doing therapy in a situation where it might not have much impact. By the time people get into the FUD phase, it could be too late unless you're a psychiatrist," he states.
Reference
1. Sherer JL. Corporate cultures: Turning 'us versus them' into 'we.' Hospitals & Health Networks 1994; 68:20-27. *
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