SHA’s Strategic Influence: Current State and Future Goals

Simon Health Authority (SHA) provides multiple services across a large area, serving over a dozen cities. Services include acute care (i.e. hospitals), home health, and residential care. Simon Health Authority also has partnerships with private organizations such as community doctors and affiliated societies that provide care to almost two million people in the region.

A complex delivery system results in a complex structure. SHA is organized as a matrix around its 17 care delivery programs (Western Management Consultants, 2014). Each program is independent with its own budget, service plan, and Program Medical Director (PMD). As well, each site has its own leadership, including its own Executive Director.

The Caretakers’ review of SHA identified its strategic priorities, namely: leadership, planning, workloads, programs, and culture.

Quality of care begins with the board of directors and trickles down to frontline staff. SHA believes in the power of great leadership and its relationship to effective teamwork. Strong leadership across the organization keeps employees focused on achieving the organization’s goals.

Good leadership also recognizes the value of people development. Their theory is by developing and training employees to perform at a higher standard they will provide a higher standard of care. SHA provides education and training both on site and online. Educating and training cultivate a culture of pride and workmanship.

SHA leadership also believes in effective planning and organizing. Leadership closely monitors resources to ensure they are used where needed most. SHA believes building capacity is improving primary and community care and making it accessible to all through patient-specific programs.

Finally, SHA leadership values people, whether they are employees or clients. SHA employees say, “everyone values everyone else” (Yerema & Leung, 2018) All employees need to be treated with the same dignity, respect and care extended to the patients.

Culture

     SHA’s organizational culture is a patient-focused organization where employees work well together. The Authority wants to foster a culture of improvement throughout the organization to encourage a “can-do” attitude. Therefore, providing essential programs, education, and training to support the movement, make an incremental improvement to affect the organization positively. “Organizational culture is an idea in the field of organizational studies management which describes the psychology, attitudes, experiences, beliefs and values (personal and cultural values) of an organization” (Schein, 2009). Organizational culture encompasses the collective values and behaviors contribute to the psychological social environment. The differences in the culture relate to a different management team and can be manipulated and altered depending on leadership and employees. “The organizational culture should be cascaded to all the staff in the organization so that everyone within the organization understands the importance and to ensure that they own the process of success” (Kiptoo & Mwirigi, 2014, p.190). Therefore, the dimension of the organizational culture will affect its alignment and mind-sets to obtain more positive influence on the current cultural situation. “A cultural shift needs to occur where all staff work to a full range of competency, in a team-based model of care, to support complex patients ‒ including those with episodic, short-term and longer-term care needs”(British Columbia Ministry of Health, 2017, p.10).

Newspaper Article

Simon Health Authority (SHA) is at the forefront of discovery and new technologies. As the most extensive health authority in Canada, it is the place where people want to be.  Our people make us better, which is why we invest in our people. It is an exciting time at SHA as we are experiencing a time of massive growth. In the last year, our clientele has tripled. The growth has caused us to expand and to offer new services to meet this demand for healthcare.  Compassionate care is our passion. We love what we do and are proud of our people.
At SHA we believe in bringing the highest standard of care to all our patients. We are the future of healthcare. We are committed to the development and growth of our people. Presently we have online courses offered to staff development through our company-wide intranet. Our goal is to offer on-site education and training for the professional development of our staff. We currently own and operate 12 hospitals. There are 206 hospitals right now in our province. In future, we would like to increase the number of hospitals and facilities under our ownership. We believe the SHA model of care has the power to transform healthcare. We have over 6,000 volunteers who provide 400000 hours of service annually. Currently, we support 16000 seniors through home health services and residential care facilities (Fraser Health, 2018). In the future, we would like to make all healthcare services accessible to all seniors. In addition, we plan to expand the services we offer to seniors including housekeeping and transportation.

SHA’s motto is “better health, best in health care” (Fraser Health, 2018). At SHA, we are always on the cutting edge of new technologies and methodologies. There is also a new study or project on the go. Right now, there are over 250 active research studies being done to help us keep above the curve. The University of British Columbia Medical Journal regularly publishes our research. We trials everything in our home sites and garner success. Once a project is successful, we mirror it at all other sites. Collaboration and innovation are the keys to our many successes.
SHA is the health authority with the largest population in the province. We care for 1.8 million people every year. We have a strong staff contingent with over 25000 employees and over 2000 physicians (Fraser Health, 2018). The communities we serve are from Massachusetts Bar to Robert City. We love what we do and we are privileged to serve our communities to the best of our ability.
Our primary goal is to bring compassion and purpose to every interaction we have with patients. Patients are our partners in care. We rely on coalitions and partnerships with many other organizations for the highest quality of care. These partnerships help us plan, develop and improve the services we offer. At SHA we care for each patient as if they were family.  Come to SHA where we put the care back into healthcare!

Competencies

Building Trust

Reddy (2018) defines trust as

…freedom given to all those working in the company to do what they want to do, experiment with their ideas for the benefit of the company. Another way of defining trust is having trust in the employees and the employer that they will work for the benefit of the company.

Currently, SHA suffers from trust issues. Employees are unable to express themselves completely as the core management committee (Western Management Consultants, 2014) does not believe in them. They feel suffocated while working and adversely affects the patient-organization relationship. Decreased morale leads to gossip, a lack of credibility, and working to achieve personal gains. The quality of patient care is compromised when employees feel bound by rules and lose the freedom to express themselves. As quality decreases, trust decreases and ultimately results in fewer patients.

Further, the health authority has trust issues with its external partners, such as the Ministry of Health. Complaints included a lack of trust in information provided, a lack of rationale behind submitted budgets, and errors in the provided information. (Western Management Consultants, 2014). The desired future goal is having an independent environment, allowing new ideas, “transparency, authenticity” (Seay, n.d.) and also excellent patient care. Patients will endorse SHA to other people as a result of developing great trust.

Possible steps to improve trust include:

• Employee engagement – Making them part of the company
• Communication of goals – “Communicates the goals of the company to the people working at the lower level, then this brings a sense of trust amongst the employees, the employees will have the feeling of belonging to the company” (Reddy, 2018).

Managing the Political Landscape

Political behavior are “activities to acquire, develop, and use power and other resources to obtain one’s preferred outcomes when there is uncertainty or disagreement about choices” (Hughes, Collarelli-Beatty, & Dinwoodie, 2014). Also, Bolander (2011) states “political landscape starts from the top. Whoever leads your organization will not only form the landscape but also influence the rules (more on that later). The political landscape is the formal hierarchy, informal hierarchy and alternative hierarchies that link the political players together.”

SH has issues with political behavior. Western Management Consultants (2014) found many sites stuck with a culture of permission seeking – they needed to impress the appropriate authorities to get approvals. So, the desired future goal as stated by Ferris, Davidson, and Perrewe (as cited in Hughes et al., 2014) is “note the importance of trust, credibility, and apparent sincerity as a cornerstone of political skills” and also not allowing any type of “favoritism” (Bolander, 2011) by the community. However, Hughes et al. (2014) note the pervasiveness of politics, calling it a “natural part of the strategic leader’s life”. They also note political behavior as appearing to be self-serving. Finally, they pose this question: “How can [leaders] influence others effectively, given the reality of organizational politics, while maintaining their credibility and remaining authentic?”

Manktelow et al. (n.d.) advise leaders to take the following steps to achieve the desired goal and to adapt to manage this political landscape:

Build Connections – Try to be friendly with everyone but don’t consider developing a personal relationship, be certain to base it on consent, to avoid any suggestion of illegal or inappropriate influence, and to never break confidentiality.

Develop people skills – Reflect on your emotions, what prompts them and how you handle them. Learn to listen carefully as people like people who listen to them.

Analyze the organization chart – Office politics often circumvent the formal organizational structure. So, sit back and observe for a while, then map the political power, rather than people’s rank or job title.

Understand the informal network – Watch closely to find out who gets along with whom, and who finds it more difficult to interact with others. Look for in-groups or out-groups. Notice the basis of connections whether it is friendship, respect, or something else.

Be Brave but not Naive – It is better not to run away from bad politics. The opposite can be more effective. Try to understand the goal, so that you can avoid or counter the impact of negative politicking.

Boundary Spanning

SHA’s board of directors has relationships with the Ministry of Health, the divisions of family practice, independent practitioners (contractual relationship). The programs have direct responsibilities to their executive directors,  Program Medical Directors (PMD), and Site leadership (site directors). Other stakeholders have an impact on the organization like customers, strategic patterns, community, governments and regulating bodies. Executives may consider their organization’s relationship with the external world as more reactive to what happens in the environment.  “Strategic leaders who are working to ensure an organization’s sustainability in the ecosystem cannot ignore the importance of influencing that ecosystem” (Hughes et al., 2014, p.152).

van Meerkerk and Edelenbos (2018) indicate “the importance of boundary spanning for networking performance and trust building in governance networks.” Boundary spanners are organizational members who play a key role in these governance networks. They are engaged in building sustainable relationships between relevant organizations in their organizational’ s environment (van Meerkerk & Edelenbos, 2018). Their focus is on the effect of boundary spanning behavior; for instance: team performance (Ancona & Caldwell, 1992), absorptive capacity (Ebers & Maurer, 2014), innovation (Tushman, 1977), network performance (Van Meerkerk & Edelenbos 2014).

Boundary Spanning

occurs at the periphery of organizations where the outer membrane allows for permeability for organizational actors to look out and others to look in. This can facilitate coordinated activity where new structures are forged to enable the sharing of resources and joint decision-making (Williams 2012).

“These actors are the boundary spanners and through their roles in “information exchange” (van Meerkerk & Edelenbos, 2018). They enhance trustful relationships, engage in boundary-spanning activities that cross, weave and permeate many “organizational boundary settings” (van Meerkerk & Edelenbos, 2018) that can influence the strategic planning at multiple levels in the organization.  Planning within SHA occurs at multiple organizational levels like program levels, stakeholders, and the Ministry of Health.

SHA board meetings “have a highly structured agenda that does not allow for directors to engage in creative, ‘upstream’ thinking; it is much more practical, therefore, to ask questions about what has presented rather than test assumptions, conclusions, and options” (Western Management Consultants, 2014). Currently, the board does not provide their members with the needed information ahead of the time to review and develop their thought and questions. There is limited opportunity for the board to interact with the senior medical leadership in professional affairs and quality issues (Western Management Consultants, 2014). When SHA considers boundary spanning, it should contemplate the importance of working together. Kaplan and Norton (2001) noted: “Most of these strategy-focused leaders found that their most important challenge was communication of their strategy to those whose job it was to implement it” (p.8).

SHA can enhance its boundary spanning by improving “communication amongst programs at each site so that site staff understand program plans and any potential impacts to other areas/programs on site”. (Western Management Consultants, 2014). SHA must gain the hearts and minds of all their middle managers, technologists, frontline employees, and back-office staff. It needs to develop their visions of what success would look like and the outcomes they want to achieve. SHA’s objectives have to align with organizational capabilities and capacities for making change. SHA should let their employees find innovative ways to accomplish the strategic mission. If SHA can effectively communicate its vision and strategy, it can achieve its desired objectives.

Hughes et al., (2014) delineate communication trust as the trust of disclosure, the willingness to share information in a timely manner, admit mistakes, tell the truth, keep confidences and give and receive constructive feedback open dialogue when challenges happen (p.163).
Strategic influence is expansive: exist in an environment of cross-cultural work, it requires virtual team interacting with other virtual teams, building bridges across diverse groups and expand beyond organization (Hughes et al., 2014).  Strategic leadership involves collaborative learning. The strategic leader must create a climate where they not only exert strategic leadership themselves but also encourage strategic leadership from others. Creating such a climate allows ideas for strategic thinking to come forward.  Leaders must carefully consider their definitions of strengths and competencies (Hughes et al., 2014, P.155). Marzano, Carss, and Bell (2006) note that “a combination of informal, team building events and meetings/workshops are important for enhancing mutual understanding, stimulating cross-boundary interaction.” In the same line, Ansell and Gash (2008, p. 558) note “face-to-face dialogue is at the core of the process of breaking down stereotypes and other barriers to communication.”

Therefore, weaving and integrating the differences between the groups to create interdependence will have a positive impact on the boundary spanning behavior. Leaders can do the following:

1. Define teams to create safety and provide them with resources, time, and space needed to develop cohesiveness unit.
2. Clarify boundaries to accurately differentiate the work of different organizational members.
3. Facilitate the exchange of information and viewpoint across the organizational lines.
4. Build a social network across the organization for people to get to know each other on personal levels.
5. Encourage the uniqueness of each group and synergies between them.
6. Bring groups together in emergent, new directions to cross-cut boundaries and enable reinvention. Create an environment where deeply held values, beliefs, and perspectives are open to change (Hughes et al., 2014, p.179).

Involving Others

One of the most important competencies across SHA is involving others. People in positions of high authority tend to keep ideas, decisions and new agendas among themselves. This leads to fewer new approaches for building a strong organization and also leads to front-line employees losing interest as their freedom is compromised.
The goal is to support employees to help see themselves as part of the organization (Stark, 2010). This increases enthusiasm for working more efficiently which turns to extra patient care and benefit for the organization.
The involvement of employees is achieved by building trust on employees on behalf of the manager to share information, Forgiveness on mistakes thinking employees are learning and patience as involving others decreases the efficiency and instantaneous decision making.

As stated by Stark (1998), “Involvement is worth the risk. It results in associates who are dedicated, committed, and who produce greater results…both in quality and in profits…than a group of associates who are not involved. You will be satisfied with the long-term results” (p. 318). Involving others also includes those outside the organization. Doing this will create closer linkages between community members and their health services (Western Management Consultants, 2014). Western Management Consultants (2014) praise SHA’s actions, saying “The extensive effort to involve partners and communities in the planning, delivery and alignment of services is noteworthy” (p. 18).  

Connecting at an Emotional Level

Hughes et al. (2014) say “Strategic direction, alignment, and implementation require tremendous amounts of persistence and effort, demanding commitment from the heart. Therefore, demonstrating other’s value by involving them in the process, will help to engage people’s hearts (p. 184).

SHA connects with their employees at an emotional level (Western Management Consultants, 2014). A “can-do attitude” is part of the culture. Managers describe their staff as passionate, caring people who are dedicated to patient care.

SHA’s employee engagement levels are in line with other health authorities, but are poor overall. Managers feel supported but cannot give frontline employees a similar level of support (Western Management Consultants, 2014). Surveys from frontline employees showed a ratio of engaged to actively disengaged staff at 1:1. Gallup (as cited by Western Management Consultants, 2014) call a ratio of 4 engaged to 1 actively disengaged staff as a “tipping point”.

One way to improve emotional connection is to link personal aspirations to the aspiration of the organization (Hughes et al., 2014, p. 186). Hughes et al. (2014) use Torstar CEO Prichard as an example. He managed to unite diverse arms of the same organization to see a common vision and to commit to the well-being of the organization as a whole. Similarly, Western Management Consultants (2014) recommend engaging staff in finding solutions to their own problems, as “increasing engagement motivates people”.

Building and Sustaining Momentum

Hughes et al. (2014) expound the importance of building and sustaining momentum and its impact on strategic influence. They acknowledge the danger of daily tasks derailing the focus on long-term goals and encourage leaders to maintain forward movement. They recommend setting appropriate expectations, celebrating successes, and sending consistent messaging.

Unfortunately, SHA needs improvement in building and sustaining momentum. Currently, managers and frontline staff feel overwhelmed by multiple initiatives and a lack of implementation support (Western Management Consultants, 2014). Staff feels stuck in a culture of firefighting, unable to proceed with proactive measures (Western Management Consultants, 2014). Further, staff notes the lack of a “coordinated, intentional and continual improvement program”. (Western Management Consultants, 2014).

McChesney, Covey, & Huling (2012) refer to the whirlwind as “the massive amount of energy that’s necessary just to keep your operation going on a day-to-day basis”. This energy expenditure denies resources to what McChesney et al. (2012) call the wildly important goals. They recommend leaders focus on one to two goals “that will make all the difference” (McChesney et al., 2012).

SHA recognizes a need for improvement in focus – there are over 1000 initiatives (many inactive) spread across all programs (Western Management Consultants, 2014). One employee, speaking for SHA, said: “strategy is deciding what not to do”. (Western Management Consultants, 2014). Having inactive initiatives, many due to an apparent failure of improvement, may further hinder SHA’s ability to build and sustain momentum. Hughes et al. (2014) say “people in the organization often interpret a lack of immediate success as failure, and this interpretation is a key threat to building momentum and expanding the stretch of influence”. (p. 191) Hughes et al. (2014) suggest setting out clear expectations, as initiatives could take three to five years to produce meaningful results. They further suggest a celebration of small successes as the organization proceeds with the initiative, to show progression and a reward for the effort.

Finally, clear communication is vital to this competency, as with many other operational dimensions. Feltner, Mitchell, Norris, & Wolfle (2008) say “communicating clearly and effectively by deploying a range of different techniques to solicit support from others can help bring about effective change.” Employees need reinforcement and reminders on the purpose and desired outcomes of each initiative. Further, leaders need to limit or even hinder “potentially distracting messages from being communicated” (Hughes et al., 2014).

Organizational Structure

Galbraith (2014) would describe SHA’s organization design as a mixed model, leaning more towards the divisional model but also containing elements of the conglomerate (pp. 166-168). SHA’s “divisions” are the care delivery programs, but SHA also considers each site as a unit, resulting in an organizational matrix. The individual programs connect with each other as a person proceeds through the continuum of care, from hospitals to outpatient care and possibly through to home care and long-term care.

The Caretakers do not believe SHA needs to drastically change its organizational structure. Having a purely divisional organizational structure built around programs would not address regional and site-specific pressures, and vice-versa. Having a pure conglomerate of unrelated business would not make sense, as all health care falls within the aforementioned continuum of care. Instead of changing the organization structure, The Caretakers feel more should be done to span the horizontal boundaries separating sites and programs. Kelly & Penney (2011) note improved outcomes for patients when hospital care managers and home care liaisons collaborate and have good relationships. Further, Smith & Treschuk (2018) note the dangers of fragmentation in post-hospital health care for individuals with complex chronic conditions.

Process changes may help overcome the “silo” effect in health care. For example, improved data access to all health care providers should “promote more efficient, safer, and higher-quality care” (Glaser, 2011). Western Management Consultants (2014) noted the failure of community-oriented programs to plan jointly with other groups such as Residential Care and physicians.

Another change could come from addressing group dynamics. Kriendler, Dowd, Star, & Gottschalk (2012) remind us of people’s tendency to form in groups, resulting in a dynamic of “us” vs. “them”. Western Management Consultants (2014) present an example of this dynamic with managers and non-managers. The Caretakers recommend changing the dynamic of “us vs. them” to “we”; in other words, align individual goals to the organization’s mission and vision (Wakeman, 2014).

Conclusion

SHA, like many organizations, values strategic influence. SHA currently has processes and structures in place to best use its relationships and influence among its employees and with its partners. Current development requires an understanding of leadership, organizational culture, collective beliefs and experience for producing the outcomes for direction, alignment, and commitments. However, SHA also has areas for improvement regarding strategic influence. This analysis of SHA’s current state and future plans will hopefully show assist SHA with continuous quality improvement and expanded strategic influence moving forward.

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