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Organizational adjustments to support a collaborative initiative
Team building and change management
Managing the anticipated changes
The impact of new initiatives may be minimal, but may also have significant implications for team members (including some not involved directly with the initiative) and other services. Implementing a new initiative will always require some organizational adjustments.
Traditional approaches may need to be adapted to make them relevant to providers and consumers working together in new ways and in different settings. A new style of practice may mean changing people's traditional roles, working relationships, responsibilities and reporting relationships, and individuals involved with an initiative are likely to embrace change at different rates.
In many instances, the challenge of managing change is to “unfreeze” what may be longstanding patterns, behaviours and cultural norms; negotiate a transition to new patterns, behaviours and norms; and integrate these changes into the processes, structures and culture of an organization or practice. Managing these changes successfully involves five general steps or tasks:
Analyze the current state of the practice or organization.
Predict the likely consequences of the proposed changes and take steps to manage them effectively and in a timely manner.
Ensure the planning and implementation proceeds in a planned and systematic manner.
Ensure everyone involved is well informed and has an opportunity to participate in all stages of the project.
Address issues that might affect the change process as they arise.
Analyze the current state of the practice or organization including:
Previous experiences with change
The culture of the organization (norms, values, expectations) and the extent to which these may be (perceived to be) threatened by the new change
Current organizational structures and processes and changes required to support the new initiative
External factors that may influence the success of, or be affected by, a new initiative
The adequacy of resources available to support the project
Predict the likely consequences of change
Prior to implementing an initiative, discuss with all team members the potential implications both for the initiative as a whole and for their individual activities.
Predict potential problem areas for both individual team members and the system.
Predict which individuals might resist the proposed changes and why this might be.
Predict the impact of changes on work patterns and loads.
Predict the impact of changes on other services in the community.
Be sensitive to individual as well as collective issues.
Ensure planning and implementation proceed in a systematic manner
Ensure there are clear goals and objectives that are shared with all team members who are involved.
Ensure that the objectives and goals are reviewed at least annually.
Develop a clear plan for implementation of the initiative, including delineation of responsibilities and timelines.
Identify a leader/change manager for the project.
Ensure team members moving into new roles are adequately prepared, trained and supported.
Develop a communication strategy that is two way, i.e., team members have a chance to contribute to decisions regarding the changes, as well as being informed of decisions made by others.
Involve and inform all team members working in the initiative
Ensure team members who will be involved with implementing different parts of the initiative, including the evaluation, are fully informed at each stage of its design and implementation.
Provide opportunities for all staff to review the progress of the initiative at pre-determined points in time.
Inform all individuals and services who are likely to be affected by the initiative as to what is taking place. Meet with them on a regular basis to review what is happening and any impact it may be having.
Address issues as they arise
Make changes as required in organizational structures or processes.
Deal with individuals who might resist these changes on a 1:1 basis.
Reinforce the reasons for making these changes and the consequences of leaving things as they were.
Adjust the pace of change if it is taking the organization longer than expected to adjust.
Clarify new roles.
Preparation of primary health care staff before an initiative begins
All primary health care staff need to be fully informed about the goals and directions of a new initiative and have an opportunity to comment on the design of the initiative or practical issues in its implementation. Issues to be discussed can include:
Who the mental health care providers are and what roles they will play
The goals of the initiative
The limitations of the initiative, i.e., what cannot be done due to resources or time
How the initiative is going to be monitored
Space requirements
Telephone and message-taking requirements
Meeting expectations
Sharing office space
Impact on workloads
Sharing responsibility for care
Potential scope of practice - “who does what” - issues
Preparation of mental health care providers for working in a new initiative
Before they begin work, mental health care providers need to be adequately prepared for what they are likely to encounter, such as:
The role primary health care plays in the health care system
The pace, demands and sometimes unpredictable nature of primary health care
The roles of specific primary health care providers
The most common problems seen in primary health care
The culture of primary health care, including charting
Scope of practice issues
New team members should meet with the existing team before the initiative begins to get to know one another and to be clear about the expectations within the relationship and what each individual is looking for from the other. This can be done either in a single meeting or a series of meetings, at which the following should be covered:
Goals of the new initiative
Limitations of the new initiative
Information required when making a referral
The kinds of cases that may be referred
How information about shared cases should be exchanged
The frequency of contact expected
How brief or lengthy informal discussions during clinical time should be
Whether family physicians and other primary health care providers wish to be interrupted while seeing a consumer
The kind of information that needs to be exchanged to make a decision
How the provider of specialized services will be briefed/prepared by the primary health care provider regarding individuals they are seeing
What should be done if an unforeseen issue arises
How and when cases can be handed back to the primary health care provider
Telephone availability [See Telephone availability section below]
Charting and record-keeping
If more than one team member is being hired or starting at the same time, the orientation can be done together. This can also provide an opportunity for team members to begin to understand one another's skills, perspectives and work styles, particularly if they come from different disciplines.
Telephone availability
If providers of specialized services are only available in the primary health care setting for part of the week, it is helpful if they can be available by phone (if needed) in between visits. Calls by primary health care providers do not usually need to be returned immediately but within the same working day. This offers additional support for primary health care providers when handling complex cases.
Problem resolution mechanism
Ensure that there is a clearly detailed and understood mechanism for resolving problems that may arise. It may be a responsibility that is delegated to an individual or the working group, or to an ad hoc group that may need to be formed depending upon the nature of the problem.
Ongoing review meetings/reports
It is important to ensure that everyone involved with the initiative is kept updated about its progress and has an opportunity to raise specific concerns they might have or problems they perceive. In many instances, this will be done on an ongoing basis through personal contacts. In addition, it is worth providing brief, periodic written updates on the initiative's progress for all staff and holding a review meeting - either as a separate meeting or as part of another initiative meeting - on an annual basis, or more frequently if problems have developed.
Informing consumers
Inform potential consumers of the new service(s) available using printed pamphlets, letters, posters or a combination of all three. The material should clearly outline the services provided, including specific examples, and how to gain access to these services. The name of the mental health care provider and type of service provided can also be posted on the front entrance or in the reception/waiting area of the primary health care setting.
When they are referred to a mental health care provider, consumers should receive specific information in the form of a one-page flyer or brochure outlining the nature of the service, the referral process, expectations (if any) of the consumer and other relevant background information.
Organizational adjustments checklist
Develop a change management strategy.
Prepare primary health care providers and staff.
Prepare mental health care providers.
Negotiate telephone availability.
Build in a problem resolution mechanism.
Consider organization of meetings and reports.
Inform consumers of the new initiative.
Prepare a handout describing the new initiative.
“Things do not change; we change.”
Henry David Thoreau
The planning group needs to ensure that everyone involved, especially those with administrative responsibilities, are aware of the goals and purpose of the initiative and will support these, even if they are not involved on a regular basis.
Change is more likely to be accepted when there is:
A willingness to explore new ideas, perspectives and approaches
An understanding of the rationale for and benefits of doing things differently
A strong, ongoing commitment to implement and sustain change
A plan with clear goals
An identified leader(s) to guide the project
Opportunities to take stock of progress made and adjustments required as the project proceeds
If there is an opportunity, it can be very helpful for staff to visit a similar initiative already underway in order to observe how other clinicians doing similar kinds of work function. They can also discuss with both primary health care and specialized staff ways in which the model can work most effectively and some of the problems that may arise. This provides them with a “real” frame of reference when working in their own setting.
Be clear about liability issues when providing recommendations or advice over the telephone and document these contacts. The primary health care provider can make a notation in the chart/electronic health record which can be co-signed by the mental health care provider at the next visit.