A comprehensive approach to effectively engage physicians during a hospital closure: Using the physician engagement model

34 Healthcare Management FORUM Gestion des soins de santé – Winter/Hiver 2006

ORIGINAL ARTICLE

AbstractIn 2003, St. Vincent’s Hospital (SVH) closed its doors. The authors investigate the

involvement of the medical staff in the successful closure of SVH using the

Physician Engagement (PE) Model. This 10-strategy model is based on engage-

ment, communication, education and support. Results were gathered by surveys,

unstructured interviews and meetings. Data suggested that engaging physicians in

the process was favourable, particularly by using the PE model. Six recommenda-

tions are given to assist administrators/decision-makers in future closures.

RésuméEn 2003, le St. Vincent’s Hospital (SVH) a fermé ses portes. Les auteurs examinent

la participation du personnel médical dans l’exécution de la fermeture du SVH à

l’aide du modèle d’engagement du médecin (EM). Ce modèle en dix stratégies se

fonde sur l’engagement, la communication, l’éducation et le soutien. Les résultats

ont été recueillis par enquêtes, entrevues non structurées et réunions. Les don-

nées suggèrent que l’engagement des médecins dans le processus a été favorable,

particulièrement en utilisant le modèle d’EM. Six recommandations sont for-

mulées afin d’aider les administrateurs/preneurs de décisions dans les fermetures

à l’avenir.

ince the late ‘80s, hospitals worldwide have been closing.1,2 In Canada,as a result of recent provincial health care restructuring, there havebeen hospital closures, particularly in Ontario,3-5 British Columbia,6

Saskatchewan7 and Newfoundland and Labrador.8 These closureshave negatively affected staff and the community, for example, stress

and burnout have been well documented in staff after a closure;9-11 therefore,obtaining further input from these groups has been acknowledged.9,10,12-15

There is, however, a paucity of research on the impact of closures andconsolidation of services on physicians.1,3,16-18 What has been shown is thathospital closures cause demoralization, stress and anger in medical staff,particularly when they are not included in the change process.1 This in turncan affect professional efficacy, quality of work and patient outcomes.

Despite these negative consequences, no prior research has examinedsuccessful strategies on effectively engaging medical staff in a closure.Researching techniques of engaging other key stakeholders, including thecommunity, patients, nurses and support staff, is limited. McLellan et al.have detailed their multifaceted approach on educating and supportingstaff during an Ottawa hospital closure.4,17 Preliminary results of their evalu-ation indicated a positive result in having a multifaceted approach.

Ajay Puri, MHA, is a ResearchCoordinator for the Centre forHealthy Aging at Providence,Vancouver, B.C. His research interestsinclude health service and policyresearch and vulnerable populationsresearch with a focus on visibleminorities and the elderly.

Taj Bhaloo, MHA, is an AdjunctProfessor in the Department of HealthCare and Epidemiology, Faculty ofMedicine, University of BritishColumbia and also is the Director forthe Centres of Innovation, threeresearch-based centres, at ProvidenceHealth Care, Vancouver, B.C. Herresearch and professional interestsinclude health system serviceredesign, with a focus on care for theelderly.

Toby Kirshin, MHA, is the Leader ofMount Saint Joseph HospitalTransformation and InfectionPrevention and Control at ProvidenceHealth Care, Vancouver, B.C.

Akber Mithani, MD, is a ClinicalAssociate Professor in the Departmentof Psychiatry, Faculty of Medicine,University of British Columbia, andalso the Vice-President responsible forthe Centres of Innovation, MSJTransformation and InfectionPrevention and Control at ProvidenceHealth Care, Vancouver, B.C. Hisresearch interests include health sys-tems service and outcomes researchas well as research in the fields ofgeriatric psychiatry and medicine.

S

A comprehensive approach to effectivelyengage physicians during a hospital closure:Using the physician engagement model

by Ajay K. Puri, Taj Bhaloo, Toby Kirshin, and Akber Mithani

Healthcare Management FORUM Gestion des soins de santé – Winter/Hiver 2006 35

A COMPREHENSIVE APPROACH TO EFFECTIVELY ENGAGE PHYSICIANS DURING A HOSPITAL CLOSURE: USING THE PHYSICIAN ENGAGEMENT MODEL

In 2003, Providence Health Care (PHC), Canada’s largestCatholic-based non-profit health care provider, closed one ofits sites, St. Vincent’s Hospital (SVH). This was in order tohandle ongoing pressures of health care cuts, gain cost effi-ciencies and to continue PHC’s commitment to the commu-nity. The closure did not face the same resistance as didmany other facilities across Canada in similar circumstances.Throughout the change, the administration engaged partici-pation of its physicians by using a model to incorporatethem into the process.

The objective of this study was to conduct an initial exam-ination of using a multifaceted engagement strategy (i.e., thePE model) for involving physicians during a hospital closureand consolidation process.

MethodsSite characteristics

Opened in 1939, SVH (Heather Site) was a communityhospital situated in Vancouver, British Columbia. SVH wasan 81-acute bed and 75-residential bed facility. It had justover 350 medical staff and 400 nursing and other staff. PHCoverall had approximately 1,000 medical staff at the time ofclosure. In Vancouver, there were four other hospitals servic-ing the population, two are operated by PHC, Mount SaintJoseph (MSJ) and St. Paul’s Hospital (SPH).

Description of the hospital closureA Site Changes Implementation Team (SCIT) was estab-

lished to manage all aspects of the closure. PHC’s MedicalAffairs department led the physician component of the clo-sure and worked with all other departments to ensure a suc-cessful closure. The closure was announced to staff in April2002 and was completed by the end of March 2004. Most of

the planning and ongoing communication with the medicalstaff occurred one year prior to closure.

What occurred? • Acute services transferred to MSJ and SPH (e.g., anesthe-

siology, lab and radiology).

• 155 in-patients relocated to other PHC sites.

• 210 Full-Time Equivalents (FTEs), mainly nursing staff,transferred to MSJ and SPH.

• Approximately 67 job losses occurred due to the closure(non-medical staff).

• 75 Residential Care Beds, 2 Surgical Beds and the UrgentCare unit were divested.

Physician engagement (PE) model The PE model incorporated 10 strategies to engage physi-

cians (Figure 1). The main thrust of these strategies was tofully engage, communicate with, educate and support thephysicians throughout the process (prior, during and post-closure) and at every level: individual, group and organiza-tional. Throughout the closure process, physicians wereencouraged to provide feedback on all aspects of the closureto better facilitate the transition. The administrationensured it was proactive, consistent, interactive and trans-parent throughout the change process. These strategies weredeveloped by the Medical Affairs department and were guid-ed by PHC’s values of spirituality, integrity, stewardship,trust, excellence and respect.

Figure 1. Physician engagement model.


Puri, Bhaloo, Kirshin, and Mithani

Individual level1. “Open door” policy: The Medical Affairs department

had an “open door” policy to welcome questions orconcerns at any time. This opportunity was given to allmedical staff and was done informally. This included e-mail and telephone correspondence and one-on-onemeetings with the VP of Medical Affairs. A direct tele-phone number was also publicized should physicianshave questions about the process.

2. Personalized letters: Letters from the VP Medical Affairswere sent to each physician discussing the closure andthe resources available should they require furtherinformation.

3. Access to counseling: A counseling service, theEmployee and Family Assistance Program (EFAP), wasmade available to physicians. EFAP provided confiden-tial telephone and in-person counseling to any physi-cian, 24 hours a day, free of charge.

Group level4. Medical affairs and CEO open forums: Four physician-

specific open forums were scheduled with the VP ofMedical Affairs across PHC’s hospital sites. Three CEOopen forums were arranged and medical staff and stafffrom all sites were invited to attend.

5. Team building sessions: Each affected department wasencouraged to have team building sessions with allphysicians and staff post-closure.

6. Leadership and SCIT meetings: Associate departmenthead/physician leader meetings were held every 1 to 2months for updates. In addition, presentations on theclosure were made at the Medical Advisory Committeeand Expanded Leadership Forum meetings. Physicianleaders and department heads attended both thesemeetings. Lastly, selected physician leaders were invit-ed to join program and planning meetings arranged bythe SCIT.

7. Medical staff newsletters: Medical Affairs Update newslet-ters were distributed monthly by mail, fax and e-mail toall SVH medical staff from spring 2003 to the closure.The newsletters followed a similar format: updates onthe closure, contact information for the VP MedicalAffairs and counseling service information.

Organizational level 8. Involvement of senior medical staff: Medical Affairs

worked extensively with the senior medical staff,including department heads, physician program direc-tors and physician leaders, to gain their insights andfeedback on the process. The senior medical staff werealso encouraged to discuss the closure with their peersand to further engage them throughout the process.

9. External communication: Letters were sent to all physi-cians and other referral sources across the provinceprior to the move, indicating that SVH would be closingand that the medical staff were relocating.

10. Communication strategy: Medical Affairs and theCommunications department used a transparent andconsistent message of sharing the vision of the changeand setting a timeline for the closure. Information wasshared in an open, frequent, honest and timely manner.It was emphasized that the closure was part of a largervision of PHC: a renewal of its service to the communi-ty. The closure was initially communicated as a consoli-dation process, not a closure, as closures have negativeassociations attached to them. This message was con-sistently emphasized for at least two years leading upto the closure. In addition, the SVH site will be redevel-oped as an “aging in place” residential care facility, andthis was communicated for a full year prior to the clo-sure.

Study designThree approaches were used to investigate how physicianswere effectively engaged: (1) post-closure surveys, (2) post-closure interviews and (3) the number of physicians wholeft PHC as a result of the closure.

1. Post-closure surveysAn 11-question survey was mailed to all physician leadersat SVH post-closure and an independent coordinator notinvolved in the process collected the data. Open-ended andmultiple-choice questions were asked in three areas: com-munication, leadership support and on the overall process.Data were collected six to nine months after closure. Thesurvey was initially sent out in the summer of 2004, but dueto the absence of many participants, it was again sent outin the fall of 2004. Those who could not complete the sur-vey were contacted by telephone. Open-ended answerswere grouped into common themes and analysis was con-ducted using SPSS software, Version 12.0.

2. Post-closure interviews A series of unstructured interviews and meetings were heldby Medical Affairs six months post-closure with the physi-cians in all affected programs, departments and divisions toinvestigate how they viewed the closure process, whetherthey felt engaged and if so how, and to identify any unre-solved issues. There were a total of 25 meetings that includ-ed one-on-one interviews with individual physicians as wellas focused program, department and/or division meetings.Responses were reviewed and common themes highlighted.

ResultsResults of the closure overall

There was an 88.5% response rate to the survey (n = 26, 23of 26 physician leaders responded, 6 by telephone) and alldepartments at SVH were interviewed. From the survey, 74%



of the physicians felt the process went smoothly and/or waswell organized and planned (17/23). Four respondents feltindifferent and only two felt the process was unsatisfactoryand could have been more supportive of physicians. From thephysician planning perspective, 74% indicated nothing elsecould have been planned better (17/23). Of those who indi-cated that improvements could be made, individual respons-es suggested further education on how departments wouldbenefit from the change, more administrative support to helpcoordinate the closure, and special attention to departmentsthat were more affected than others by the closure.

Interview data revealed findings similar to the survey. Ahigh number of responses reported that physicians felt ade-quately informed about the closure and that they were givenreasonable education, communication and support through-out the process. In addition, the interviewees stated that thetransitions for each of the departments went relatively welland there were no major post-closure issues reported at thetime of interview. The issues common to most intervieweeswere that the process itself was quite stressful and that ittook them time to get used to the new environment. Also,having additional physical space was an issue as there wereno opportunities to grow at the new locations.

Lastly, no physicians were identified as leaving the organ-ization as a result of the closure process.

Results from the physician engagement modelAll the medical staff were engaged in at least one strategy

and it was reported that some found certain strategies orcombinations of strategies useful during the process.

Individual levelFrom the interviews, physicians felt that having the “open

door” policy made them feel more involved and supported inthe process as they were able to openly communicate anddiscuss their concerns with the administration by e-mail,telephone or in person. Having a transparent and engagingadministration was also found to be important. Surveyresults indicated that 91% of physicians found the in-personmeetings with the VP and Leader of Medical Affairs useful(20/22). In addition, 84% believed there was sufficient sup-port to deal with the process (16/19).

Group levelOver 25 physicians attended the first medical staff open

forum and there were 130 attendees at the first CEO openforum. There was a decline in the turnout for later forums,and interviewees indicated that this was because those whodid not attend were already well informed about the processand therefore attending such forums would not be necessary.Interview results suggest that the forums were beneficial asthey allowed an opportunity for open dialogue, to have vari-ous questions answered, and to have the process furtherclarified.

The survey indicated that team building sessions wereheld in 57% of the respective departments (13/23); 72% of therespondents indicated they attended the sessions (13/18)

and of those 86% found them useful (12/14). The respon-dents suggested these sessions should have focused moreon pragmatics and had a greater physician attendance.

The medical staff appreciated being invited to the leader-ship and SCIT meetings as they provided an opportunity towork alongside staff and administrators and to be a part ofthe decision-making process. As for the newsletter, surveyresults indicated that 82% found it useful (18/22), and inter-view results also supported the usefulness of a physician-specific newsletter as it addressed their concerns specifically.

Organizational levelFrom the interviews, the physicians appreciated having

senior medical staff available to talk with and involved in thedecision-making process. Of the physician leaders whoresponded to the survey, 71% were clear about what wasexpected of them during the closure process (15/21).Interview respondents indicated that having letters sent outby the Communication department to referral sources wasbeneficial as the messaging was honest and allowed for astandardized message to be conveyed externally. From theinterviews, many physicians were appreciative of having acommunication strategy that provided them with informa-tion, which was disseminated well in advance, frequentlyand consistently.

DiscussionThe results of this initial investigation support using a

multiprong engagement model that focuses on includingphysicians during a hospital closure and consolidationprocess. Physicians at SVH indicated that by implementingthe Physician Engagement Model, they were effectivelyengaged, educated, supported and communicated with. Theclosure also did not impact the retention of physicianresources, which further supported the model’s use.

Previous research has shown the negative impact of clo-sures on physicians, particularly when they have not beeninvolved in the decision-making process.1,3, 6-18 Blair reportsthat fewer than 10% of the medical staff at ShaughnessyHospital, located in Vancouver and closed in 1993, felt thatthe closure was handled well.16 Blair also indicates that theclosure “caused long-lasting divisions among MDs” as thephysicians were not able to express their views through theprocess and were not welcomed or supported by physiciansat other hospitals. By incorporating the medical staff into theclosure process, as the present findings indicate, physiciansfelt more satisfied with the closure process.

As the PE model uses various modes and levels ofengagement and addresses physicians from the individual,group and organizational level, it certainly increases physi-cian participation at every level. Having these 10 strategiespremised on engaging, educating, supporting and communi-cating with the medical staff, helped relieve physician anxi-ety and addressed their concerns. The direct connection withthe administration was also valuable, particularly being ableto communicate with them at any time and to have the sup-port of the senior medical staff.


Puri, Bhaloo, Kirshin, and Mithani

Since no comparable studies on strategies that engagemedical staff during a hospital closure have been publishedand studies examining strategies that engage other staff arescarce, this paper builds on the recommendations madefrom what relevant information is available. Previous litera-ture has recommended the use of the strategies either indi-vidually or in a combined approach as in the case of the PEmodel.1,4-6,11 McLellan et al. investigated a similar multifac-eted approach of educating and supporting nursing staff dur-ing an Ottawa hospital closure that showed promisingresults.4,17 In addition, the authors showed that a communi-cation strategy that was consistent and frequent was foundto be quite successful and this is further supported by thecurrent study.

Recommendations From the findings of this study, the following recommen-

dations are suggested when considering a hospital closureor consolidation of services.

1. Ensure physician involvement: Involve physicians in thedecision-making process from the very beginning andallow them to discuss the change and provide feedbackthroughout the process. In addition, have the MedicalAffairs department lead the process of engaging themedical staff, as the needs of the physicians can bespecifically addressed.

2. Utilize the physician engagement model: When working withphysicians during a significant change, it is recom-mended that the PE model be implemented. Themodel can be modified to suit the needs of physiciansat other organizations as long as it is a multifacetedapproach that engages them at the individual, groupand organizational level, and is based on engagement,communication, education and support.

3. Have an “open door” policy. Having the administrationavailable on request and being transparent and sincereabout the process are important factors for engagingphysicians in a successful closure. In addition, the in-person meetings further the physicians’ accountabilityfor their respective areas.

4. Use frequent and consistent messaging. Having a high fre-quency of clear and direct messaging at all levels of theadministration was found to be useful. Being open,honest and timely is key to successful communicationplanning.

5. Engage senior medical staff. Working with senior medicalstaff to talk with their colleagues about the change isparticularly important in reducing the anxiety associat-ed with a closure and allows for further involvement ofthe medical staff.

6. Give timely notice. As soon as the final decision has beenmade to close or consolidate services, an announce-ment should be made to all physicians and staff with-out delay, and a plan put in place to receive input fromall affected groups. Having the announcement made atthe outset of the process minimizes rumours andallows the affected stakeholders a chance to beinvolved in the decision-making process.

Limitations As there were no comparison or baseline data to investi-

gate how the physicians felt prior to the closure, it is difficultto conclude whether the PE model changed their reactions.In addition, the small sample size of the survey and respons-es collected solely from physician leaders may also limit thegeneralizability of the findings. However, combined with thequalitative results (interviews and meetings with all physi-cians), it enables support for the model and the recommen-dations suggested.

Future research As this study was an initial evaluation exploring the PE

model, health service researchers need to give the model fur-ther attention. Empirical, controlled studies are needed toreplicate and expand the findings of this study, includingcost-effectiveness, more quantitative data, randomized con-trol trials, having multisite comparisons and/or controlgroups.

In addition, the PE model should be investigated in othersystem-wide changes that affect medical staff, for example,changes to fee and compensation schedules, decision-mak-ing for new programming, and working with inter-profession-al teams.

Future studies should investigate similar multifacetedmultilevel engagement models in other stakeholder groups(e.g., non-medical staff, housekeeping, food services, othercontracted-out services, community, and patients) during ahospital closure or consolidation process.

ConclusionThis study examined how to effectively engage physicians

during a hospital closure. It is suggested that a multifaceted,multilevel approach, comparable to that of the PE model, beimplemented when working with physicians as it can facili-tate a successful hospital closure.

AcknowledgmentsThis study was supported by Providence Health Care. The authors

would like to thank Dr. Tina Wu, Dr. Jean-Francois Kozak, Shaf

Hussain, Laurie Smyth and all the medical staff who participated

in the data collection for their assistance.

References1. Valent P. The human costs to staff from closure of a general

hospital: An example of the effects of the threat of unemploy-

ment and fragmentation of a valued work structure.



Australian & New Zealand Journal of Psychiatry 2001;35:150-

154.

2. Jaklevic MC. Hospital closure pace still high. Mod Healthc

2001;31:22-23.

3. Gray C. Will hospital closures mean physician unemployment

in Ontario? CMAJ 1997;156:1614-1616.

4. McLellan T, Petricic J, Grant S. Where do we go from here?

Preparing staff for hospital closure through education and

support. Healthc Manage Forum 1999;12:48-49.

5. Baumann A, O’Brien-Pallas L, Deber R, Donner G, Semogas

D, Silverman B. Downsizing in the hospital system: A restruc-

turing process. Healthc Manage Forum 1996;9:5-23.

6. Van der Wal R, Bouthillette F, Havlovic SJ. Recommendations

for managing hospital closure. Healthc Manage Forum

1998;11:12-24.

7. Liu L, Hader J, Brossart B, White R, Lewis S. Impact of rural

hospital closures in Saskatchewan, Canada. Soc Sci Med

2001;52:1793-1804.

8. Way C, Gregory D, Doyle M, Twells L, Barrett B, Parfrey P.

Health care provider outcomes during and shortly after acute

care restructuring in Newfoundland and Labrador. J Health

Serv Res Policy 2005;10 Suppl 2:S2:58-67.

9. Greenglass ER, Burke RJ. Hospital restructuring and burnout.

J Health Hum Serv Adm 2002;25:89-114.

10. Greenglass ER, Burke RJ. Stress and the effects of hospital

restructuring in nurses. Can J Nurs Res 2001;33:93-108.

11. Havlovic SJ. Coping with downsizing and job loss: Lessons

from the Shaughnessy hospital closure. Canadian Journal of

Administrative Sciences 1998;15:322.

12. Johnsson J. Community concerns stall hospital closure.

Hospitals 1989;63:18,20-2.

13. Burke RJ. Survivors and victims of hospital restructuring and

downsizing: Who are the real victims? Int J Nurs Stud

2003;40:903-909.

14. Burke RJ. The ripple effect: It’s time for health care leaders to

address staff concerns following restructuring. Nurs Manage

2002;33:41-42.

15. Burke RJ, Greenglass ER. Effects of hospital restructuring on

full time and part time nursing staff in Ontario. Int J Nurs

Stud 2000;37:163-171.

16. Baer N. As hospitals shrink, consolidate or close, physicians

are swept up in the turmoil. CMAJ 1996;155:1166-1169.

17. Saunders D, Bear R, Triska O, et al. Understanding the impact

of the consolidation of surgical services in a major integrated

health region. Ottawa, ON: Canadian Health Services

Research Foundation;2003.

18. Ritchie DC, Mor V. The impact of the closure of Harvard

Pilgrim Health Center of New England on primary care physi-

cians: Implications for quality of services. Medicine and

Health, Rhode Island [serial online] 2005;88:179.

Setting high standards for health leaders since 1984

Certified Health Executives are dedicated professionals, committed to life-long learning and better able to lead in the 21st century.

Certification is rapidly becoming recognized as the national standard of professionalism in health leadership and is a preferred criteria for employers when recruiting for senior positions.

For more information on applying for the only Canadian professional health designation, visit www.cchse.org or contact us at 1 800 363-9056.

Documents

A comprehensive approach to effectively engage physicians during a hospital closure: Using the physician engagement model