Social Work in Restructuring Hospitals: Meeting the Challenge

Globerman, Judith, Davies, Joan MacKenzie, Walsh, Susan, Health and Social Work

In an effort to improve efficiency and effectiveness, internal hospital restructuring is occurring on a massive scale in North America. There is extensive literature on restructuring models in health care that describe the reorganization of bureaucratic organizations (Fogel, 1989; Weber, 1991) and patient-focused or patient-centered hospitals (Brider, 1992; Jirsch, 1993; Lathrop, 1993; Sidky, Barrable, & Stewart, 1993; Tidikis & Strasen, 1994; Wakefield et al., 1994), program management models (Charns & Tewksbury, 1993; Harber, 1994; Jirsch, 1993; Morris, Stuart, Monaghan, & Alton, 1994), and matrix organizations (Clement, 1988). The literature also describes models of management and staff deployment that use shared governance (Eichelberger, Behl, Lees, Peterson, & Taylor, 1994; Fitch, 1994; McMahon, 1992; Peterson & Allen, 1986a, 1986b; Porter-O'Grady, 1993) and cross-training and "multiskilling" of staff (Sidky et al., 1993) and that will improve organizational effectiveness, efficiency, and the quality of patient care (Morris et al., 1994).

Morris and colleagues (1994) summarized several categories of reasons for restructuring hospitals. The most prominent reason cited in the literature involves an increased interest in focusing on the patient and family and organizing care so that they are the center of all activities (Wakefield et al., 1994). As described by Jirsch (1993), the goal is to have "patients ... regarded as organizational customers" (p. 28) so that the system is more accountable to clients or customers with resultant improved care. Economics, cost control, and fiscal restraint are also frequently cited as reasons for restructuring (Henderson & Williams, 1991). A third category of explanations relates to the organizational management literature, which emphasizes worker empowerment, control over the workplace, and the need to re-evaluate assembly-line thinking (Bolton & Gordon, 1994; Hammer & Champy, 1993). Finally, with the defragmentation of the patient, a move away from assembly-line health care, and a return to holistic care, evaluation opportunities are enhanced, and one can evaluate the effectiveness of patient care.

The most comprehensive description of the various organizational models is that offered by Charns and Tewksbury (1993). According to their continuum, hospitals are shifting from hierarchically organized functional organizations that are organized with discipline-specific departments with different functions (for example, social work) to flattened organizations that are integrative and in which disciplines are allocated to programs. Thus, at one end of their continuum are traditional, bureaucratic, pyramidal organizations with distinct departments that are independent and autonomous. In the middle of the continuum matrix organizations are lodged, where professional staff are equally responsible to their department and director or to their program or patient care unit and program director. At the far end of the continuum lies pure program management, where discipline-specific, functional departments such as social work or physiotherapy are eliminated and professional staff are hired, supervised, and evaluated by and completely accountable to their programs. The program management model, in theory, places professionals in programs in which they have greater autonomy and responsibility for their decisions and actions, thus effectively eliminating middle management and discipline-specific supervisory-level staff. With the flatter hierarchy and discipline-specific staff integrated in programs, there is an expectation of "results-oriented management" (Morris et al., 1994) and systems thinking (Senge, 1990).

Because of their interest in focusing on the patient and controlling costs, hospitals are engaged in reorganization activities that are frequently referred to as "shifts toward program management." Among professional staff, these changes have resulted in anxiety and concern about patient care and job security. In an effort to understand the experiences of social workers undergoing hospital restructuring, we conducted an exploratory survey with a sample of hospital social workers in the province of Ontario.

METHOD

Research Design

An exploratory telephone survey was conducted with 12 senior social workers at a group of hospitals undergoing restructuring in Ontario to understand their experiences of the effects of restructuring on the organization and delivery of social work services. We were interested in the issues related to social work and the strategies the social workers devised to manage their work lives. Because of the lack of data about social workers' experiences of reorganization - the issues they identify as important to the social work role and the strategies they select to manage change (Globerman & Bogo, 1995) - the interviews followed a semistructured qualitative interview guide and were largely interpretative. The goal was to identify themes and patterns in relation to issues and strategies in hospitals restructuring from functional to program management models.

Sample

A number of criteria were considered in the selection of hospitals for the telephone survey to ensure a heterogeneous sample. These included geographic region of the province, size of community, size of hospital, type of hospital, teaching versus nonteaching hospital status, and language and culture of the region. The type of reorganization model was also considered in that we chose to eliminate amalgamated or amalgamating hospitals from the sample. This decision was based on the belief that amalgamation was driven by principles different from reorganization toward program …

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Publication information: Article title: Social Work in Restructuring Hospitals: Meeting the Challenge. Contributors: Globerman, Judith - Author, Davies, Joan MacKenzie - Author, Walsh, Susan - Author. Journal title: Health and Social Work. Volume: 21. Issue: 3 Publication date: August 1996. Page number: 178+. © 1999 National Association of Social Workers. COPYRIGHT 1996 Gale Group.

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