TM5541: Managing Effective Health Programmes

Reorienting Health Services Towards More Holistic Care

Assignment Three

Samantha Leggett 10/28/2011Word Count: 3409 (excluding references and footnotes)

SN: 12494652 Samantha Leggett

Contents Page

1: Introduction: What does a health promoting health care setting look like? 3-4

2: Strategic planning and management activities to facilitate the successful

reorientation of health services 4-7

3: Potential barriers to effective change 7-11

4: Promoting acceptance of change 11-13

5: Training considerations 13-14

6: Conclusion 15

7: Appendix A 16-17

8: References 18-21

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TM 5541: Managing Effective Health Programmes

Assignment Three

Reorienting health services towards more holistic care

1: Introduction

Amnesty International (2006) and Oxfam (2010) have performed comprehensive reviews of

health service provision for survivors of intimate partner violence (IPV) and their families in

Papua New Guinea’s National Capital District (NCD). It has been found that although services

exist to support survivors of IPV they are fragmented, under resourced and lack the

coordination and capacity to be truly effective. Very little exists in the way of awareness raising,

prevention strategies, dedicated immediate medical care, or to address behaviour change.

In light of the gravity of the IPV landscape in NCD and the disheartening local maternal and

child mortality and morbidity statistics1, the Papua New Guinea (PNG) National Department of

Health (NDoH) has proposed a move towards centralising care to a ‘one-stop’ family support

centre. The centre will be attached to the main antenatal and child health clinics in NCD;

provide a more holistic service for families affected by IPV; and will also ensure that early

detection, screening, prevention and health promotion activities reach a wider section of

society. The new service will effectively be working towards becoming a health promoting

health care setting which will provide better infrastructure for health improvement.

1 The Maternal Mortality Ratio in PNG ranks at 470:100,000. Outside of sub-Saharan Africa it is one of the highest in the world

and remains the highest in the Pacific region (UNFPA, 2009. Monitoring ICPD goals: selected indicators. Retrieved from:

http://www.unfpa.org/swp/2009/en/pdf/EN_SOWP09_ICPD.pdf)

Infant mortality in PNG is 52:1000 ranking it around the 45th worst country out of 222 (World Health Organization, 2011. Global

health Observatory Data Repository Country Statistics. Retrieved from: http://apps.who.int/ghodata/?vid=15600&theme=

country; CIA, 2011. The World Factbook. Infant Mortality. Retrieved: https://www.cia.gov/library/publications/the-world-

factbook/rankorder/2091rank.html)

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This paper will first explore the concept of a health promoting health care setting in order to

contextualise the change in service delivery. Within the concept of change management the

following areas will then be explored: strategic planning for successful change; barriers to

change; promoting change and managing staff resistance; and training considerations to aid

reorientation of healthcare services.

A health promoting health settings’ primary goal should be to achieve health gains for its

community (Radoslovich & Barnett, 1998). A health promoting setting will, instead of solely

focusing on repairing ill health and the medical model, also focus upon the social, political and

individual contextual factors that influence health (WHO, 2007a). The Northern Territory

Government (1999) advocate that a health promoting health setting should provide a focal

point for primary, secondary and tertiary health promotion activities (see Appendix A for

examples of primary, secondary and tertiary health promotion activities related to IPV).

Further, a health promoting health setting is one which creates alliances with other settings,

consumers and the community (Radoslovich & Barnett, 1998); many initiatives are fully

effective only when there is broad collaboration between multiple actors (Swedish National

Institute of Public Health (SNIPH), 2006).

A health promoting health setting also has the potential to be an important knowledge base.

Knowledge of unique local conditions, disease prevalence and potentially contributing factors

for example, if made available, can contribute to an issue (such as IPV) or disease being tackled

on a national, regional and local level (SNIPH, 2006).

2: Strategic planning and management activities to facilitate the successful reorientation of

health services

Strategic planning determines end goals and identifies strategies for accessing, allocating and

managing resources to achieve these. Strategies may be seen as the tools containing the means

with which to achieve a goal (Wasilewski & Motamedi, 2007).

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Jahn (2008) and Wasilewski & Motamedi (2007) state that strategic planning must be a process.

However Heward et al assert that processes can only be used as guides as no one organisations’

behaviour can be predicted, meaning that change will not occur in an orderly sequential

process. Change is seen as complex, is often multi-faceted and is influenced by the environment

from its broadest level of external structure and social and political constructs, through to its

teams and individual staff members. Organisational uncertainties and dynamism are also

contributors (Heward, Hutchins & Kelleher, 2007; Wasilewski & Motamedi, 2007).

Zuckerman (2006) identifies ten best practices in strategic planning, nine of which are relevant

to healthcare and are discussed below:

1. Establish a unique, far reaching vision that is clearly articulated. Strategic planning

should have clear and obtainable goals. It should also be cost effective and this must be

clearly articulated (Wasilowski & Motamedi, 2007). Alexander (2006) argues that one of

the most pertinent challenges with this practice is keeping the vision alive and relevant

in order to engage employees who work within a short-term operational frame of

reference, typically from day-to-day.

2. Attack critical issues. Zuckerman (2006) highlights that sometimes, a plethora of issues

are addressed rather than prioritising the most important ones. This is sometimes

aggravated further by a failure to clearly specify what the exact problems are that the

organisation is trying to address. Critical issues identified for action must be made

explicitly so that resources can be allocated to the areas where they will yield the

greatest returns. Alexander (2006) points out that limiting the focus of practice has not

traditionally been a strength of health care organisations. It is asserted that a culture

that allows flexibility and thrives upon change should be nurtured.

3. Develop focused, clear strategies-a clear means to a tangible end. Such strategies must

incorporate contingency plans and recognise likely barriers and constraints. The end

must be tangible so that it is possible to measure progress, make adjustments during

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the process and facilitate accountability. It is asserted that healthcare organisations

must increase the rigor and sophistication of their strategic planning practices

(Zuckerman, 2006).

4. Achieve real benefits-benefits should be measurable and could be related to cost

effectiveness, operations or meeting community needs (Zuckerman, 2006).

5. Organise pre-planning-Zuckerman (2006) states that a failure to prepare the

organisation and its leaders adequately for the strategic planning process may result in

planning efforts straying off course early or losing momentum. Before the strategic

planning even begins, objectives should be identified, the process should be described, a

schedule prepared, roles and responsibilities of organisational leaders should be defined

and strategic planning facilitators should be identified. This information should then be

communicated to all stakeholders before the rest of the process commences. Jahn

(2008) warns that solely mandating change will not be successful, the whole process

requires to be led; individuals need to be guided and included.

6. Structure effective participation –the scope and extent of participation required across

the range of stakeholders should be considered at the outset in order to maximise

effective participation throughout the process. Key participants should be identified as

should where their contributions will be needed. Participative mechanisms are also

important, e.g. interviews, surveys, focus groups, task forces and review meetings

(Zuckerman, 2006). If strategic planning is undervalued, sufficient resources will not be

provided and the process of reorientation will be compromised (Wasilewski &

Motamedi, 2007). Alexander (2006) challenges that the more expansive and inclusive

the process, the more challenging the task of maintaining a narrow focus and

establishing a limited number of strategic priorities.

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7. Think strategically-Zuckerman (2006) advocates that a highly skilled and experienced

facilitator should be utilised to ensure that a forward thinking and creative orientation

characterises the planning process.

8. Manage implementation-Zuckerman (2006) recognises that many organisations,

although they achieve successful strategic planning, report that they experience failure

at the implementation phase of reorientation. Five keys to successful implementation

are suggested: communicate the plans’ priorities; assign responsibilities and hold

individuals accountable for progress; ensure that the right people with the right skills

are involved; ensure that the plan is meaningful and real to all stakeholders; and

establish and utilise a structured monitoring and evaluation system. These facets are all

highlighted in the previously suggested priorities.

9. Manage strategically-Zuckerman (2006) states that strategic planning should be neither

episodic nor just ongoing, but interrelated in a continuous manner. Strategic

management is characterised by continuously evolving plans; sustained, managed

implementation; finance and operations integrated with planning; and day-to-day

management with a strong strategic orientation. Alexander (2006) purports that this

aspect subsumes all nine others and is the absolute key to effective strategic planning in

healthcare; organisations employing strategic management will become demonstrably

more innovative and able to embrace change.

3: Barriers to successful change

Key resisting factors or barriers to changing established practice or an existing service can

prevent or impede the change process in all organisations (National Institute for Health and

Clinical Excellence (NICE), 2007). An understanding of the cultural, political and historical

contexts within an organisation to barriers facing successful change, their complexity and

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interrelatedness is therefore required in order to be able to develop and implement a

successful strategy for reorientation.

The barriers to change that confront each change process present a mixture of generic and

unique obstacles (Post & Altman, 1994) and the key contributors are as follows:

Poor communication- Managers have been criticised for using poor or manipulative

communication strategies to discuss plans with clinical staff for the proposed change to

a service (Post and Altman, 1994; Woollard, Lewis & Brooks, 2003). However, poor

communication within all layers of a healthcare system is also implicated (Heward et al.

2007).

Acceptance, beliefs and perceptions- Individual beliefs and attitudes heavily influence

organisational culture and group norms. These, in turn, have an effect upon both

individual and collective acceptance of change, beliefs about it and perceptions of it

(Heward et al. 2007). A person’s belief in their own ability to adopt a new

behaviour/way of working has an impact upon whether attempts are made to

implement change (NICE, 2007). Some individuals may not believe that better patient

outcomes will be achieved with a change in service, or will perceive that the personal

costs are too high; perceptions of benefits versus costs (personal, institutional, practical

and financial) will likely play a major determining role in the acceptance of, or resistance

to change (Yeatman & Nove, 2002). An increase in workload; change in work focus

(Yeatman and Nove,2002); whether the change reflects key individual values (Post &

Altman, 1994) and a perceived lack of power to effect change (Heward et al.2007; NICE,

2007) are examples of issues that will be considered.

Awareness, knowledge and experience- evidence demonstrates that often, a lack of

awareness of, or familiarity with, the most up-to-date and effective practice/guidance in

specific areas impedes change. If the knowledge is there, it may be that how the service

needs to change, or the most effective methods of implementation are unknown (NICE,

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2007). Woodhouse (2000) demonstrates that clinicians become frustrated by a lack of

access to usable information. Awareness and knowledge are also greatly influenced by

past experience of change and a previously positive experience can rally group

commitment to the cause. Conversely a previously negative experience can foster staff

resistance and present facilitators with the challenge of trying to achieve consensus

within a group whilst dealing with outspoken objectors to change (Ely, 2001; Post &

Altman,1994; Woollard et al.2003)

Skills- for effective change to happen, individuals not only need to know what needs to

change, but also how best to competently and effectively carry out the

activities/behaviours needed to implement change (NICE,2007). Without these skills,

another barrier to effective change arises. Woollard et al. (2003) stress the magnitude of

the task of managing change within a culture where staff choose to perform poorly

within existing programmes.

Practicalities-practical barriers can involve a lack of resources or personnel, or

difficulties in establishing service delivery (for example in this instance, perhaps due to

the vast number of actors involved in IPV services in NCD- many also have other remits

besides IPV-see Oxfam, 2010). In some cases the configuration of services or the

infrastructure of the organisation may need to be altered to allow for change to happen

(Heward et al. 2007; NICE, 2007).

Financial considerations could also be considered a practical barrier to successful

change: there may be pressures on funding allocations or significant implementation

costs coupled with resource constraints (NICE, 2007; Post & Altman, 1994; Woollard et

al.2003); irregular payment of staff wages may create job insecurity and a subsequent

reluctance in staff to assume additional responsibilities (Ely, 2001; Woollard et al. 2003).

Government workers in Papua New Guinea do not earn a salary commensurate with the

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cost of living, particularly within NCD; many have no choice but to live in settlements on

the fringes of the district without access to power, potable water or sanitation. It is

known that it is not uncommon for salaries to frequently be in arrears-consequently

employees only sporadically turn up for work and often, when they do, create minimal

output (personal communication, June 18, 2011- J Kemp, ODI Fellow, PNG National

Department of Planning; N Vellodi, ODI Fellow, Central Bank; A Rosewell,

Epidemiologist, WHO; M Leggett, environmental consultant, Office for Climate Change

and Development, GoPNG).

Significantly, the current workforce may be insufficient to fulfil existing service

requirements (e.g. replacement of ageing workforce and day-to-day workload), let alone

fulfil initiatives such as a major service reorientation. This information is particularly

pertinent in light of a service that is fragmented, grossly under developed, under

resourced and without any leadership (Woodhouse, 2000).

Time constraints- change takes time and continued momentum is required for success

(NICE, 2007). Ely (2001) points out that time constraints will impact at all organisational

levels and NICE (2007) challenge leaders to consider what other changes may be

happening within an organisation in addition to one’s own programme and any service

changes that may be required because of it. Ely (2001) acknowledges that with minimal

existing organisational upheaval more positive changes can occur.

Woodhouse (2000) stresses that the time taken to complete new and additional

documentation, particularly if it is unstructured, not standardised and duplicated,

should not be underestimated as a key barrier to change when staff are weighing up

costs versus benefits. Maintaining change in the long term is also another practical

difficulty; key members of staff may leave or priorities may shift which means that it

could be difficult to maintain any changes that have been introduced (NICE, 2007). Al-

Motlaq, Mills, Birks and Francis (2010) highlight that it is important to recognise that

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primary health promotion activities will increase the workload of the already

overstretched nursing and medical teams. It is found that often secondary and tertiary

models of health promotion are incorporated into service delivery but that primary

health promotion has to take a back-seat to curative services due to human resource

and time constraints.

A lack of active commitment from and involvement of managers, administrators and

politicians- Heward et al. (2007) assert that a clear consistent vision of the change

process is needed for actors at all levels to maintain motivation. A lack of clarity or

consistency in vision will only serve to lower team morale and subsequently motivation

to contribute towards change (Ely, 2001). Support from non-clinicians is seen as

essential-commitment has to be as much at political and administrative levels as at

middle management and clinical levels (Woodhouse, 2000). Woollard et al.(2003) found

that the main barrier to change was seen to be the attitude of middle managers, who, it

was felt were the least well informed of the staff groups

4: Building acceptance of and managing resistance to new approaches to service delivery

Woollard et al. (2003) recognise that because of its nature, the thought, process and outcome

of change has the potential to create stress and fear in all those involved. It is seen as

particularly challenging in the healthcare arena due to the complexity of relationships between

the wide range of stakeholders (NICE, 2007). Gardner et al. (2011) acknowledge that strategies

need to be adapted for use at different organisational levels in order to implement change

successfully. The literature suggests that excellence in communication and a high level of staff

involvement are the key driving forces to building acceptance of and managing staff resistance

to change. Information sharing and the direction of engagement are also important

considerations.

Post and Altman (1994) assert that information sharing is the key solution to disengaged

personnel. Yeatman and Nove (2002) advocate that the engagement of a range of health centre

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staff (e.g. managers, clinicians and administration staff) and at a broader programme level

(researchers, policy and programme managers and service providers) is a critical component to

a successful change process. At the initial stages of discussing reorientation and strategic

planning Jahn (2008) recommends having as much supporting evidence to hand as possible. If

information is scientific and evidence based, it will help to form a more persuasive argument for

the service reorientation. It is also recommended that other supporting data is available and

relevant, for example cost-benefit analyses for the health service, practitioner and community;

and case studies of previous successes.

Jahn (2008) emphasises that an initial meeting such as this may also be seen as the ideal

opportunity for politicians, managers and the ‘on the ground’ workforce to discuss the

reorientation and strategic processes. This helps to build critical mass and consensus in addition

to creating ownership and a higher level of commitment to change. Ely (2001) purports that

further on in the process, excellence in practice should be rewarded on a regular basis;

providing feedback will serve to increase morale. This could be done through regular staff

meetings; notice boards; or regular newsletters for example.

Post and Altman (1994) suggest that throughout the planning and reorientation process,

communication is treated as critical business practice and that ‘champions’ are created at all

levels. Woollard et al. (2003) add that a persuasive and coherent argument must be formulated

and presented to the workforce in order to try to overcome resistance to new ways of working.

The value of shifting the focus of the service to a more holistic and health promoting way of

working needs to be communicated clearly to staff (SNIPH, 2006) and the benefits to self and

the community served must be emphasized (Woollard et al. 2003).

Maximising staff involvement in the change process has also been identified as critical in

assisting staff to recognise the need for change and to develop a sense of ownership (Woollard

et al. 2003; Yeatman & Nove, 2002). Jahn (2008) recommends that all stakeholders must be a

part of the strategic planning and change process from the beginning, warning that people

don’t like to be ‘blindsided’ by change at a point down the line. The earlier in the process

individuals are included the less the likelihood of resistance.

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Finally, the importance of creating a balance between top-down and bottom-up strategic

planning and change management is emphasized in the literature (Cashmore, Noller, Ritchie,

Johnson & Blinkhorn, 2011; Dexter & Price, 2007; Zuckerman, 2006). Leadership should provide

high level direction and guidance but planning should focus upon the key workers and be driven

up, rather than down the organisation. Dooris (2009) and Zuckerman (2006) assert that this

approach has many benefits: it allows broader based, more substantial and more meaningful

participation in the planning process; fosters creativity, innovation and empowerment; and

leads to greater implementation success.

5: Training considerations

The capacity to effect change is needed at individual, program and organisational levels

(Yeatman & Nove, 2002). Heward et al emphasise the importance of capacity building at a

senior level in order to aid understanding of health promotion concepts and orientation. Ely

(2001) asserts that new knowledge and skills gained from an educational programme must be

relevant if they are to be valued and utilised at any level.

Redfern and Christian (2003) emphasize the crucial role of project leaders to the success of the

change process and suggest that to achieve competence in change management, training

content should include: reviewing literature on evidence based practice, managing change,

auditing practice, developing evidence-based guidelines, research methods, data analysis,

ethical issues and research presentation skills. It is stressed that regular (e.g. 3 monthly)

training updates and reviews should be conducted in order to help maintain momentum.

Dexter and Price (2007) advocate the role of a practice based educator as an agent of change,

asserting that the position should also incorporate an element of counselling. It is asserted that

education takes an individual away from unquestioning conformity to social (or workplace)

norms whilst attempting to instil a sense of personal responsibility for learning.

At the organisational level support for health promotion needs to be integrated into the policies

and procedures of an organisation. Yeatman and Nove (2002) state that formal training of

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health care staff in relevant health promotion knowledge and skills alone is insufficient to

achieve enduring change. Supportive organisational structures are required to reinforce

knowledge and skills gained during staff training and enable them to be applied. It is asserted

that organisational capacity building also needs to incorporate the management of competing

demands on staff to address state and local health priorities. This is in addition to dealing with

wider issues brought about by limited public health budgets and staffing constraints.

Woolard et al. (2003) suggest that technical difficulties can often be overcome by well designed

operating procedures, policies and processes. If people lack skills and are unable to synthesise

and conceptualise information, the availability of a protocol to work by is often unbeatable.

Such guidance, it is purported, will also help to combat wide variances in practice. Cashmore et

al. (2011) stress that building upon established policies and practice and trying to work with

aspects of a service that are already proven effective, rather than completely changing

everything, are less likely to meet resistance. Redfern and Christian (2003) demonstrate that

adherence to guidelines was consistently identified as a mechanism associated with improved

change outcomes.

NICE (2007) outline that where training is required to ensure the skills to implement change,

time may also be needed to assimilate the new skills and practice them. Support from peers or

mentoring is seen as a useful commodity at any level. Individual abilities, interpersonal skills

and coping strategies will also affect how easy or difficult it will be for individuals to learn new

skills and will of course, influence the time taken to learn them. Cashmore et al. (2011) suggest

regular team meetings as an aid to building capacity (for example from discussing case studies)

and maintaining motivation.

Worryingly, Redfern and Christian (2003) discovered that time constraints were repeatedly

cited as a barrier to change happening throughout the training process. Staff demonstrated

commitment to the cause but found that they didn’t have the time to implement the necessary

changes at the current level of staffing and job requirements despite training, peer support and

regular follow up. This finding is especially pertinent to a potential reorientation of services for

intimate partner violence within Papua New Guinea’s National Capital District.

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6: Conclusion

A service that is largely reactive to a significant public health issue, such as intimate partner

violence, and that does not incorporate all three aspects of health promotion, such as that

found by Amnesty and Oxfam for survivors of IPV in NCD, can never be truly effective or reach

its fullest potential in serving the community.

This paper demonstrates that the essential facets of service reorientation are inextricably

intertwined and complex. However, with thoughtful strategic planning, an awareness of the

barriers and facilitators to effective change and comprehensive and fully supported training at

all levels of an organisation, the reorientation of a health service towards becoming a health

promoting health setting is achievable.

7: Appendix A

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Examples of primary, secondary and tertiary health promotion activities related to intimate

partner violence (IPV) within the context of Papua New Guinea

Within a public health framework primary prevention of IPV means reducing the number of

new instances of IPV by intervening before any violence occurs. Primary prevention relies on

identifying the risk and protective factors for IPV and action to address these (WHO, 2007b).

Within the PNG context primary health promotion activities might include: policy changes to

promote human rights, gender equity, a reduction in alcohol related harm or a reduction in

child maltreatment; judicial reform to end impunity for perpetrators; public awareness and

advocacy campaigns which incorporate participatory methods, particularly with men and boys;

and strengthening data collection and research activities in order to raise awareness of the

extent and gravity of the situation. Highly visible public health campaigns that challenge social

norms regarding violence, gender roles and relationships may also be effective but the

importance of effective monitoring and evaluation programmes is also highlighted (WHO,

2007b).

The focus of secondary health promotion is on responses that tend to happen after IPV has

occurred, often with the aim of reducing the likelihood of future incidences (Cohen, Davis &

Graffunder, 2005; WHO, 2007b). Such interventions might include screening activities to aid

early detection of the issue; working with known perpetrators to stop their use of violence;

safety planning for women living in situations of ongoing violence; improved access to relevant

services and shelters; and risk reduction strategies for women to use to prevent the completion

of an act of violence (WHO, 2007b).

Tertiary health promotion refers to treatment and rehabilitation from the pathophysiological

and psychological consequences of IPV after it has occurred (Cohen et al., 2005). Such activities

might include the administration of post exposure prophylaxis for HIV and other sexually

transmitted infections; emergency contraception to prevent unwanted pregnancies;

counselling; medical or surgical interventions to treat injuries (e.g. broken bones, wounds); and

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follow up activities (e.g. ongoing counselling, HIV testing etc). Ongoing work with known

perpetrators may also be included (Oxfam, 2010).

8: References

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