Guastalla hospital, Italy: Fostering employability
In February 2000, Guastalla hospital set up an organisational improvement project in association with the trade unions representing the healthcare sector. The project focused on redesigning the work organisation and integration of diverse professional profiles around the same working process, improving cooperation and mutual learning, minimising vertical hierarchy and segmentation, improving the quality of care and service and eliminating lead-times and inefficiency.
The hospital of Guastalla is a part of the Local Area Health Company (AUSL; Azienda Unità Sanitaria Locale). Since 1994, the Local Health Units in the province of Reggio Emilia have been a single-care structure. The company is situated in the centre of the Emilia-Romagna region and runs five hospitals: in Correggio, Scandiano, Castelnovo Monti, Montecchio and Guastalla. The total workforce of AUSL is about 3,700 employees. Guastalla hospital has 504 employees: 104 senior doctors (of whom 38 are women) and 400 nurses, technicians and other job profiles (of whom 335 are women) and covers a population of 65,000 inhabitants. About 50% of the employees are aged between 30 and 50. In the hospital of Guastalla, the union structure is made up of six representatives (of whom three are women). Union density is about 50%. The interaction between the management and the employee representatives is a constant factor, as they have a meeting almost weekly to discuss any new developments.
Description of the initiative
In February 2000, the public health agency (AUSL) of Reggio Emilia and the health care workers’ and doctors’ unions joined together to start an organisational improvement project in the Guastalla hospital, as Guastalla represents a strategically important context for the services provided by AUSL. To turn this improvement venture into reality, the social partners decided to seek the collaboration of a research institute specialised in labour. The intervention was organised into three closely interconnected main steps. The first stage – long-term scenario development – implies the identification of a goal(s) strategic for the organisation at that exact moment, the imagination of a scenario and a back-casting process where the actors are committed to identifying and creating the right premises and conditions for achieving the planned goal.
In the short-term scenario, through communication and consensus research tools (such as work groups, information and actor involvement), the actors are asked to design a feasibility plan and an action plan. Finally, the implementation phase is carried out by a partnership of actors willing to implement actions and changes in order to achieve the agreed scenario.
Particular attention was paid to experimentation in order to define modalities of intervention on work organisation processes and to promote greater integration and collaboration among the vertical sectors. Collaboration between vertical sectors was established in the initial phases by setting up a working group comprising professionals, management representatives and unions, all coordinated by the research institute. Work then began with the aim of valuing the professionals better, listening to them, developing their ideas and making them participants in an organisation that depends on each individual’s potential. The study of the dynamics and characteristics of a health services organisation are indeed indispensable for proceeding with the identification of problems, the adoption of actions for improvement and successful quality management.
The project focused on:
- redesigning work organisation and the integration of diverse professional profiles around the same working process;
- improvement in cooperation and mutual learning;
- redesigning work organisation and reducing vertical hierarchy and segmentation;
- organisation of activities according to flows;
- improvement in the quality of care and services;
- reduction in lead-times and inefficiency.
The partnership created between management, trade unions and the workforce is formalised in an agreement between the hospital management and the union representatives around the premises and scope of the project, methodology and activities. In this specific case, two agreements were signed: one by the physicians’ union and the other by the public employees’ union. The agreements focused on the reorganisation of productive and working processes; the increase in process efficiency; the improvement in the quality of services and working conditions; and participation in the dialogue, negotiations and change processes. The involvement of the union representatives was particularly relevant in order to legitimise the process and guarantee the operative management of the project.
Some difficulties occurred due to tense relationships between partners, political elections, change in the hospital management, etc. However, the tense relations between the social partners, especially between management and unions, were managed through meetings, often promoted by the consultants.
Finally, a four-month period was devoted to developing many different projects in work organisation change. The work was managed by groups of employees, self-organised and coordinated by an internal leader. Specific projects were planned to improve relations between the hospital and external organisations devoted to administrative and policy management, e.g. Direzione AUSL Reggio Emilia, territorial medicine and other services. The proposals gathered were aimed at creating a coordinating body to study and assess the performance levels and services of the health structures at a regional/local level. Furthermore, communication and integration between different departments had to be formalised.
AUSL has always paid much attention to training measures. In 2005, it delivered 501 training courses for a total of 88,000 training hours. The annual courses cost about EUR1 million, of which EUR260,000 is for the external courses (EUR34,000 for Guastalla hospital alone). The internal courses are mainly focused on new procedures or guidelines (evidence-based medicine). In order to map all the skills, AUSL created a specific database through which to find qualified employees (mainly doctors) to be used as internal trainers.
The involvement of all the operators allowed the company to grow, taking advantage of all the acquired competencies. The real change was the adoption of a participatory methodology. The consent of the employees and an analysis of the situation were essential for the project development.
Two main topics were mentioned during the organisational analysis and addressed in the organisational development phase:
- the level of intra-organisation integration, mainly based on informal mechanisms and the relationships of actors, needed to be formalised and addressed;
- the inter-organisation integration between the hospital and external environment needed to be improved.
Five years after the project began, the basis for activities carried out in 2005 has been linked mainly to three factors:
- The certification process that Guastalla hospital began at the end of 2004. The organisational improvement project has contributed to the certification process, both by stimulating the work of a group of health care professionals from different fields and by strengthening the collaboration between health care professionals working in the hospital and others working throughout the territory.
- The beginning of restructuring and enlargement works at the hospital.
- The computerisation of wards. ICT was introduced to improve information availability and knowledge.
More opportunities for dialogue have arisen between the hospital and the territory and important projects have been undertaken on care continuity and on discharge of patients for care at home. The project has been a methodological basis for training initiatives on organisational change. Until now, AUSL organised two programmes of training courses, called ‘winning team’ (squadra vincente), in which different professionals come together in order to express their viewpoints on how to deal with organisational changes. Each programme consists of a three-day training course (eight hours a day) and involves 20 employees (doctors, nurses and clerks). With the support of consulting agencies, AUSL has also provided a specific training course on organisation change for head physicians and managers.
Exemplary and contextual factors
The organisational improvement project, involving management, trade unions and the workforce, increased the integration of the employees and the mobility among the departments and different units of the hospital itself. The project helped the Guastalla hospital to deal with diverse issues, such as the responsibility of operators in the process, participation in the decision-making process and dialogue among diverse professional profiles within the same ward and belonging to different wards.
Maite Tapia, Volker Telljohan, Fondazione Istituto per il Lavoro, Bologna