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Decades of restructuring hurts morale of Alberta’s health care professionals


This is the second of a two-part series on Alberta’s health care restructuring. This article examines the impact of constant change at the highest levels of administration on those who work within the health care system.

Alberta Health Services (AHS) is the largest health care delivery organization in Canada. AHS provides health care to nearly 4 million Albertans across the province, and employs a work force of over 96,000 staff.

The current organization of AHS is the result of two decades of organizational change.

In 1994, Premier Ralph Klein removed local hospital and provider organization boards and set up health regions. After a series of changes to the health regions, they were replaced by AHS in 2008. Over the past six months there has been more change. In June, the entire board was fired over a political dispute, and an Official Administrator was put in place. Two weeks ago, Dr. Chris Eagle, who held the role of President & CEO over the past 3 years, resigned.

Read more of the Healthy Debate analysis of  Alberta’ health care restructuring here.

Research on the impact of health care restructuring

Research suggests that health services restructuring impacts health care professionals on the front lines of patient care.

The negative impact of hospital restructuring on nurses has been well-established, although studies have not been done on how  larger health system restructuring affects front line providers.

About a decade ago, a series of studies were published based on surveys of over 40,000 nurses from over 700 hospitals in the United States, Canada, England, Scotland and Germany. The study found nurses reported higher rates of burnout and dissatisfaction when they worked in hospitals that had undergone major restructuring and organizational change.

Around the same time, researchers in Alberta were asking similar questions about the impact of hospital restructuring on nurses. They noted that “a decade of restructuring and downsizing placed prolonged pressures on the nurses of Alberta.” Surveys of the province’s nurses found that in hospitals where restructuring had taken place, nurses reported higher rates of emotional exhaustion and unmet patient needs.

Sean Clarke, a nursing Professor and researcher at McGill University was one of the lead authors on a study of 40,000 nurses. He suggests “as governments try to restructure to get the health care system they want, health care workers on the ground can feel like the victims of these changes.”

Healthy Debate spoke with Alberta health care providers and former AHS administrators to learn about how recent restructuring has affected them, and their jobs. Most of them agreed to speak with us on the condition that their identities remain anonymous.

‘Change fatigue’

Our conversations with these individuals found that they felt health system restructuring has led to ‘change fatigue’ among staff. Change fatigue was often described by health care providers as feeling more apathetic, less engaged in the system and confused about who is in charge.

Lloyd Maybaum, a Calgary psychiatrist who has been critical of recent changes within AHS suggests that decades of change have led to this disengagement.

“The morale hasn’t been good for a long time. Everyone has change fatigue. People throw up their hands, saying ‘I am going to focus on treating patients, I want to see patients and be done’” he says.

A nurse who works outside Calgary notes “it becomes exhausting to try and keep up with all of the changes.” She says “instead of being able to focus on patient care the distractions are making us wonder if we’ll have jobs tomorrow and with all the changes you aren’t quite sure who is doing what.”

Confusion about who’s in charge

The current reorganization of AHS, is aimed at ‘streamlining’ senior management to better support patients and staff. This includes the reduction in senior AHS positions from 80 to 10. Janet Davidson, lead author of the report that recommended the move, was recently appointed as the Deputy Minister of Alberta Health.

Davidsons’ report emphasizes that AHS is a large, complex organization and cites anecdotal reports that AHS’ “structure is confusing to navigate for patients and the general public and it is not unknown for staff to not know who they report to or who they can go to for assistance and support.”

While Davidson’s report prescribes more change to streamline accountability and responsibility, many health providers questioned the logic of more change.

Lloyd Maybaum says “you can’t get anything done” in an atmosphere of ongoing instability and change. With people leaving roles or reassigned elsewhere, he says that those remaining have challenges working effectively in such a turbulent environment. “They don’t know where the authority to make decisions lies” he says.

An Edmonton physician we spoke to agreed with Maybaum, saying that recent changes to AHS senior leadership leave those remaining “paralyzed by indecision.”

This physician noted that changes leave front line staff and managers asking who they report to, and who is responsible for their organization or region. “I can’t tell you who is in charge of the hospital I work at right now” she says.

A former AHS administrator characterized the mood across AHS as “chaotic”, where staff are scared and uncertain of what changes will come next. “If it’s not your boss, it’s your boss’s boss, and all the way down the line” he says. Further, he adds that all of these changes have staff thinking “why did they get walked out the door? And what does it mean for me?”

Difficulties in planning for the future

Constant changes to decision makers and organizational structure impact the ability of health care providers to access resources and information needed to plan ahead.

A Calgary physician says “I think anyone who is doing planning, in a leadership role or not, needs stable ground to plan on.” But he notes that “the ground is always changing here, making it difficult to plan beyond the immediate future.”

Bill Anderson, an Edmonton radiologist notes “with constant restructuring – it seems to be a time of change for change’s sake, where very little forward strategic thinking about the system happens.” He says “everyone is trying to figure out what their job in the next model will be and you lose another year of improving the system and population health… all of those broader questions get put on the back burner while we figure things out.”

Lloyd Maybaum says that the latest changes also influence how health care providers access and deal with system administrators. “No one knows who will have a job and who doesn’t” he explains, adding “I don’t know who will be here next week.”

Concerns about accountability

While Davidson’s report is aimed at reducing administration, some expressed concerns that further changes will compromise accountability.

“In the old system we were familiar with the bureaucrats” says one Edmonton physician, noting that “they’ve made it so big that nobody actually knows what’s going on.” According to this physician, constant administrative churn means that “[administrators] come into an area, learn it and achieve short term goals, though a year down the road when it blows apart, there is a total lack of accountability for decisions being made.”

However, the health care professionals interviewed were sympathetic to the difficulties facing administrators and managers working in this unstable environment. “As difficult as it is for us, I think it is even more difficult for administration and higher level management” said a Calgary physician. She notes “the latest changes have been very dispiriting for the management I work with.”

According to one former AHS administrator, “the higher up you are in the system, the more unnerving [recent changes] have been.” She explains that “people don’t want to make decisions because they fear retribution.”

Health professionals are disengaged

Along with challenges in making long-term plans due to constant restructuring, health professionals felt they were not consulted when changes were made.

Reflecting on two decades of restructuring, one Calgary physician says “I think physicians have been disengaged for a long time … whenever there is change, physicians don’t seem to be consulted, and management is left behind to pick up the pieces.

An Edmonton physician said “when you see [restructuring] time and time again, and new things happening without input on it … you realize your input won’t have much effect so you then become disengaged.” This physician said that in response to consistently being left out of decision-making processes, physicians stop “putting in efforts by serving on committees etc.”

While all health care professionals noted that they take pride in the care that they provide to patients, they feel disengaged from the system in which they provide this care.

Desire for excellence in spite of instability

In spite of the concerns outlined about the impact of restructuring, health care professionals expressed that they are trying to provide the best quality care possible to Alberta’s patients.

Sean Clarke says that “change is going to be an undeniable element of working in health care” and that “educators, managers and professional leaders have a huge role in helping promote resilience in health care workers.” Management researchers suggest that leaders can look to the research evidence for guidance when trying to mitigate the affects of changes within their organizations.

A physician working outside of Calgary says “I think that things can be better, but people are functioning on the ground, and [health care providers] all have good intentions and similar motivation and it all works well despite the changes.”

Others highlighted their belief that Alberta has historically been a leader within Canada in health system innovation, but this is no longer the case.

Bill Anderson argues “some of Alberta’s health regions were leading the country in many areas – and provincialization put us back many years.” He believes “we were starting to dig ourselves out and get going, and doing good provincial things” when further changes were then made to AHS.

“People used to look to us as leaders” he says, “but with all the change people are looking at us with raised eyebrows asking ‘what’s going on there?’”

What should AHS and Alberta Health do differently with this latest round of restructuring?

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8 comments

  1. Gerald A. Evans

    I am struck, yet again, how the authors of reports criticizing provincial health systems, ultimately end up in important positions in the organizations they castigate. In the AHS case Janet Davidson, ends up appointed as a deputy minister running the very organization she reported on. In Ontario in 2006 , one of the principal authors of a review of the Ontario Drug Benefit Program, ended up being appointed as Assistant Deputy Minister and first Executive Officer of the revamped Ontario Public Drugs Program.

    Hopefully, I am incorrect in speculating that the ambitions of bureaucrats might be driving all these myriad changes to provincial health systems.

  2. Robert Bear

    Interesting article on health care in Alberta. For me, the article begets 3 questions. Question #1: In this supposedly free and democratic jurisdiction, why are so many interviewees afraid to have their names attached to their comments? Question #2: Data exist on the optimum size of organizations from a management perspective. How do these data on achieving management excellence align with AHS and its 96,000 employees? Question #3: %featured%Widely accepted principles of effective change management exist. These principles include staples such as: making a strong case for change, developing a Guiding Coalition of key stakeholders, communicating effectively and incessantly, achieving some early wins and building on them. Has the Government of Alberta employed any of these in the engineering of the changes it has imposed upon its health care system?%featured%

    • D. John Hooper

      When the governance of health care is under a provincial monopoly, there is no freedom to speak.

      If you anger AHS in Lethbridge, you angered them in Edmonton too. There are no safe havens to turn, or alternative systems to work in, without emigrating from the province.

      This is the problem.

      Centralized health care amalgamation destroys competition, advocacy and patient/physician choice.

  3. David Harrigan

    Very interesting and accurate article. My only concern is that other than one anonymous nurse, there is no discussion of, or comments by any of the more than 96,000 employees of AHS.
    There is more to health care than physicians.

    • Karen Born

      Thanks for your comment David. Your criticism is appropriate and was certainly a challenge that we grappled with in writing this article. We did contact about 2 dozen people with interview requests for this story – many of whom were non-physicians and worked in front line care, management and administration for AHS. The majority of these individuals either declined to be interviewed, or did not respond. Many said that they were not comfortable speaking with us in the current climate. Our sense was that physicians were more willing to be interviewed because they are slightly more independent from AHS than say, a salaried administrator. Even then, most requested to be quoted anonymously.

      • David Harrigan

        Thanks for the response. How sad. That pretty much says it all about morale.

  4. Peter G M Cox

    This and the preceding article on AHS reorganisation are very disheartening to those of us who have had any extensive exposure to Canadian healthcare as “users”. While restructuring “mania” may be particularly acute in Alberta, the “symptoms” of doctors and nurses being disenchanted and disengaged (and “muzzled”) are evident across the country – and they have unusually high rates of stress-related complaints, absenteeism and staff turnover, at least partially as a result. From my experience they also do a remarkable job of keeping the system functioning as well as it does under the circumstances.

    However, Canada has one of the highest levels of per capita spending on healthcare in the World with consistently poor results in international comparisons (WHO, OECD, Commonwealth Fund, Euro-Canada Consumer Health Index). Why is this? I believe it has much to do with the organisational structure:-

    In the Euro Health Consumer Index 2012 report the author(s) opined that “one important net effect of the (Netherlands) healthcare structure would be that healthcare operative decisions are taken, to an unusually high degree, by medical professionals with patient co-participation. Financing agencies and healthcare amateurs such as politicians and bureaucrats seem farther removed from operative healthcare decisions … than in almost any other European country. This could in itself be a major reason behind the (Netherlands) landslide victory in the EHCI 2012. Looking at the results of EHCI 2006-2009, it is very hard to avoid noticing that the top consists of dedicated Bismark countries (those with insurance organisations that are organisationally independent of healthcare providers) … Large Beveridge systems (those where financing and provision are handled within one organisational system) seem to have difficulties at attaining excellent levels of customer value.”

    This view seems to be borne out by the philosophy of the Mayo Clinic which I understand attribute their success in providing the best care to every patient through integrated clinical practice by keeping frontline doctors in charge of how the hospital operates.

    It is also supported by a large and growing body of evidence from the business world that success is at least partially the result of employee involvement in the decisions which affect customers (rather than “command and control” structures which may produce short-term success but do not have long-term resilience).

    I would suggest that, if we are to reorganise healthcare (and it seems the need to improve our comparative performance makes this imperative), we should be looking at how the more successful countries’ arrangements achieve the results they do AND EMULATE THEM.

  5. Name (required)

    doctors run their own clinics and run them making huge profits. why not =let them run our hospitals.. we could save billions in health care costs and have excellent health care. maybe they can make sure hospitals have a policy.that all hospital staff speak english only in hospitals..make english mandatory also with contract woker.

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