TRANSFORMATIONAL CHANGE AND THE ROLE OF SOCIAL WORK
by
Brenda MacDougald
BSW, University of Northern British Columbia, 1999
MSW(C), University of Northern British Columbia, 2015

REPORT SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SOCIAL WORK

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
April 2016
© Brenda MacDougald, 2016

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
TABLE OF CONTENTS
Table of Contents ...............................................................................................................................ii
List of Figures ....................................................................................................................................iv
Introduction

....................................................................................................................................1

The Practicum Setting ............................................................................................................2
Learning Goals .......................................................................................................................4
Theoretical Frameworks ....................................................................................................................7
Northern Health Authority .....................................................................................................8
Literature Review...............................................................................................................................11
Integrated Primary Health Care ............................................................................................12
Interprofessional Teams .............................................................................................14
Transformational Change and Leadership .............................................................................14
The Role of Social Work .......................................................................................................15
The Practicum Experience, Critical Review ......................................................................................17
Northern Health’s Transformational Change Process ...........................................................18
Drivers of Change ......................................................................................................19
Provincial Direction .......................................................................................20
Northern Health Executive and Leadership ...................................................21
Physicians and Community Partners .............................................................23
Information Management and Technology....................................................25
Interprofessional Teams .................................................................................28
Organizational Restructuring .....................................................................................29
New Process and Functioning ........................................................................31
Information Management and Technology....................................................34
The Role of Social Work within Transformational Change ..............................................................37

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
The People Side of Change ....................................................................................................38
Leading People through Change ............................................................................................41
Implications for Professional Practice ...................................................................................45
Social Policy Development ........................................................................................48
Working with Physicians ...........................................................................................51
Integrated Primary Health Care Teams......................................................................55
Summary ............................................................................................................................................59
References ..........................................................................................................................................63
Copywrite Permission ........................................................................................................................67

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
List of Tables
Figure 1 Integrated Health Care Support ...........................................................................................2
Figure 2 Northern Health Structure 2015 ..........................................................................................3
Figure 3 Northern Health Authority by Region .................................................................................9
Figure 4 Idealized Northern Health System of Services ....................................................................13
Figure 5 Framework of the Patient’s Medical Home.........................................................................25
Figure 6 Strategic Framework for Health Information Management and Technology .....................27
Figure 7 First draft of Integrated Health Care Oversight ...................................................................30
Figure 8 Future Electronic Medical Record Systems in Northern Health .........................................45
Figure 9 First Nations in the Northern Health Region of British Columbia ......................................48

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
All images within this report are the property of Northern Health. Further reproduction is
prohibited without express permission of Northern Health.

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
Transformational Change in Northern Health; the Role of Social Work
In response to a growing prevalence and impact of chronic disease and with the expected
exponential increase in the population of older people, the medical system in British Columbia
began a shift from an acute response toward a more proactive and 'planned care' orientation (BC
Ministry of Health, n.d.). The Health Authority and the provincial government committed to
working together toward changing the face of health care for patients (Northern Health, n.d.).
The Health Authority, therefore, has undertaken a system change approach toward the provision
of integrated primary health care, where interprofessional teams (IPT) provide holistic care,
using a person centered approach. The process of implementing primary care homes and teams
had already begun, where integrated health care wraps around the individual and their family to
provide more effective and eventually more efficient care to the people living throughout the
health authority. An integrated primary health care team approach was introduced throughout
the Northern Health Authority to ultimately produce better population health outcomes and
improve social and health equity (Canadian Association of Social Workers, n.d.). As they
transform to this new way of delivering service, the entire organization must shift how they do
their work, accommodating new processes and norms, changing how they think about healthcare.
Transformational change is all-encompassing and requires the people involved to actually
change both their behavior and their thinking and attitudes (Tafvelin, Hyvönen, & Westerberg,
2014).
Imperative to the successful transformation of the provision of health care is the need for
leadership that understands and is competent in human relationship and community building.
This practicum experience provided a unique opportunity to glimpse the change process from the
perspective of the Executive leadership within Northern Health. Exploring the role of social

1

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
the Implementation Leads from Public Health and the North East, North West and Northern
Interior Health Areas. The Regional Resource Team worked on cross cutting issues to ensure a
consistent approach to change. The practical experience was under the direction of Mike
Simpson, Executive Lead Community Services Integration & Implementation Division who, in
this corporate environment, provided a unique opportunity to observe change and
transformational leadership expressed with a social work perspective and within the macro level
of the organization. Figure 2 illustrates the organizational structure of Northern Health as of
July, 2016. Care Process Coaches and Practice Support Coaches provided local training and lead
local quality improvement initiatives.

Figure 2. Northern Health Structure, Pre Transformation, 2015

Figure 2. The practicum setting was under the direction of Mr. Simpson, Director/Manager of “Specialized” services (Northern Health, 2015).

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
This was a most opportunistic time to be involved with the organization as they move from the
planning stage to an action phase of a system-wide, transformative change process. As a
practicum setting, the Northern Health resource team afforded an opportunity to explore and
observe the role of social work within leadership positions, having positive influence of people
through an enormous system transformation. At the same time, observing leadership in action
was difficult in that the bulk of the practicum took place during the summer months when many
people take vacation. It was also an unfamiliar and difficult work environment to be a practicum
student, requiring a period of adjustment to learn the environmental language and norms, the
complex history of the change process and details of the planned rollout of integration
throughout the region. The Executive members were not used to having outside learners in their
midst so norms and practices for the learning environment were not yet established. To facilitate
the integration of theory into practice, a daily professional journal was kept to record and reflect
upon learning. It was a place to reflect on the learning topics and other ideas or issues to up
during a practicum experience. This journal was a helpful tool to process and analyze new
information and the daily entries provide concrete examples to illustrate learning and suggest
further exploration.
Learning goals. The overall goal of this practicum experience was to better understand
the role of social work within Northern Health's transformational change to an integrated primary
health model, and evaluate how social work values and ethics influence those being led through
the change process. The motivation for seeking this placement included the reputation of Mr.
Simpson, the practicum supervisor, for his social work ethics and his leadership ability within
Northern Health as well as the opportunity to work in a new environment to explore and apply
social work values and skills. Change management, or the people side of change, is where the

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
role of social work was anticipated to shine. The practicum experience provided an opportunity
to evaluate how social work values and ethics influence a more holistic and broad perspective for
those being led through the change process. This experience offered new opportunities for
positions of leadership, as well as a better understanding of the overall nature of the change and
an opportunity to grow, not only as an employee but as a future leader. The learning within the
practical placement was guided by the following questions:
1. How do traditional social work values and skills of those in Leadership positions affect
their experience leading people through a transformational change process?
2. How do these values and skills compare to those needed to drive transformational
change? How do they connect to leadership skills?
Through observation and discussion, I was successful in reaching my overall learning goals:
1. I gained a better understanding of the role of social work throughout Northern Health's
integrated primary health care.
2. I determine social work skills and abilities associated with promoting and leading active
participation in the change process.
3. I increased my knowledge and understanding of the following:
a. boundary spanning
b. person-centeredness
c. role ambiguity
4. I hope to influence future research into the link between social work values, skills and
abilities and successful transformational leadership.

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
To achieve these objectives I engaged in a variety of activities as outlined below:
1. I read suggested readings from Mr. Mike Simpson, Practicum Supervisor, including
internal documents, both historical and present as well as Kotter’s 2014 book
‘Accelerate; building strategic agility for a faster-moving world’ and Hiatt and Creasey’s
(2012) ‘Change management: the people side of change’.
2. I maintained a daily professional journal about daily events, noting learning topics to
bring up for further discussion with practicum supervisor. I will include this journal in
the submission of my final report and presentation.
3. I observed social workers operating within this change process, noting how their skills
and social work value system promote the change process. I also shadowed a social
worker on the Prince George Team 1.
4. I discussed the contributions of social workers to the systematic change process.
a. I met with Mike Simpson on a weekly basis (or more, as available) to broaden my
perspective and discuss current events of the change process.
b. I completed interviews with social workers in executive positions, leadership
positions, as members of an Interprofessional Team (IPT) and the Executive
Director of the Prince George Division of Family Practice.
5. I joined in the everyday work carried out by the teams within their work setting.
a. I attended IPT planning and coordination meetings and discussions with a variety
of professionals, departments and teams including physicians.
b. I took part in integrated health care training, involving forums for IPTs as well as
a forum with Psychiatrists and physicians.

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
c. I joined the Regional Resource Team to experience the regional scope of the
work.
d. I travelled to Vanderhoof, an hour west of Prince George, to meet with members
of their IPT to discuss current communication issues.
6. I completed specific work tasks to be determined by practicum supervisor.
a. Answering questions generated by the Public Health Nurses and the Primary Care
Nurses forums.
b. Updating various job descriptions to reflect IPTs and the person centered Primary
Care Model (Northern Health, 2012).
Theoretical Frameworks
This practicum experience was influenced by my past experience as a social worker in
the North, my social work perspective, approaches and philosophies involved in working within
the helping profession. As a lifelong resident of Prince George, BC and a current employee of
the University Hospital of Northern BC, I understand the challenges faced by northern workers
and residents receiving services from our medical system and value the generalist approach
needed in my helping practice. As a generalist practitioner, working within a large institution
such as the Northern Health Authority, I work from a structural social work perspective (King,
2008) and approach people from a person centered, strength based perspective (Rice & Girvin,
2010). As a practicum student on the Regional Resource Team, I was introduced to a regional
perspective of an IPT whose role it was to help guide and transform the entire system to a
Primary Care Model (Northern Health, 2012). This regional perspective was emphasized and
my previous helping experiences became interconnected with those of the practicum, influencing
my understanding of what was involved in a structural change of this magnitude. The practicum

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
experience in turn, influenced my work with clients and IPT members, providing a more holistic
approach to both experiences.
The structural perspective of social work, a social change or conflict theory of
oppression, states that societal and structural influences shape the context of our practice (King,
2008). Social problems are understood as an effect of oppressive social constructions, and as
barriers to service, they must be removed (King, 2008). This practicum was approached from
within a structural social work framework (Rice & Girvin, 2010), and was enhanced by working
within the very structure responsible for shaping and directing the systemic change process.
Operating from a Strengths Based perspective (Rice & Girvin, 2010) facilitates people to become
more resourceful, capable and resilient to manage their challenges, accepting that every person,
family, group and community holds the key to their own meaningful change process (Hammond,
2010). The Strengths Based paradigm (Hammond, 2010) also works well with transformational
leadership driving the transformational change process to an integrated primary care approach.
While it may be a struggle to practice from the underlying values, principles and philosophy of
the approach as a starting point of change, it is empowering to actively engage others into the
process while valuing the experience and abilities of the people at the center of it (Rice & Girvin,
2010).
Northern Health Authority. The Health Authority is divided into three Health Service
Delivery Areas: the Northeast, the Northern Interior and the Northwest (see Figure 3). Together,
they are responsible for delivering health care to a population of 350,000 residents, spread
throughout nearly two-thirds of the province of BC, from Haida Gwaii to the eastern BC border,
from the northern BC border and as far south as Quesnel and Valemount. This is an area of

8

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
weather and high travel costs, resulting in physical and social isolation (Peters et al., 2010). The
challenges of British Columbia's demographic and disease trends lead to population health
inequities, requiring a collaborative, Population Health approach (Northern Health, n.d.). The
goal of such an approach is to improve the health of the entire population while reducing health
inequities among specific population groups (Northern Health, n.d.). This approach is also one
of Northern Health's four pillars of their 2009-2015 strategic plans, concerned with the
determinants of health and integrating accessible, high quality health services for Northerners
(Northern Health, 2014).
Northern Health remains steeped within the medical model of care and the traditional
methods of physician compensation. Yet the Health Authority is determined to set a change in
motion to improve access to integrated health services and to measurably improve staff and
physician engagement (Northern Health, 2009). They have changed systems and processes,
continuing to change many historical norms and practices. This affects core guiding principles,
ensuring they shift their approach and deliver health care together, as an organization. As part of
this reorganization at a systems level, Northern Health has chosen to focus on developmental
evaluation based on the innovation driving change (Gamble, 2008). More traditional approaches
work to predict outcomes and focus measurement on goals, while developmental evaluation is
intended to support innovation within a context of uncertainty (Gamble, 2008). Innovation is
necessary with the transformative change underway, as the system is created by the very people
providing care. With transformational change the outcome is unknown, the change is allencompassing (Tafvelin, Hyvönen, & Westerberg, 2014) meaning the outcome is dependent
upon the people working within the system.

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
Moving forward, Northern Health strives to merge the current realities of providing care
within a medical model with a future vision of providing person centered care using a Primary
Care Model (Northern Health, 2012). To begin transforming to new ways of practicing,
Northern Health has taken direction from Kotter’s guide ‘Accelerate’ (2014) a model developed
to drive transformational change in a large, multi-silo organization, where there is a need to
handle challenges fast enough to take advantage of opportunity while maintaining quality care or
‘status quo’. The basic premise of Kotter’s model is to have a dual system, one providing the
reliability and efficiency of the organization to continue with regular operation and the other,
with agility and speed; “Action is opportunity seeking and risk taking, all guided by a vision that
people buy into” (Kotter, 2014). This dual system requires people to make a shift in the way
they do their work, to challenge old systems of operation and look for innovative ways to
change. In addition to Kotter’s (2014) premise of dual systems, Northern Health has also
explored Sharmer & Kaufer's, (2013) model, based on the idea that most learning methodologies
rely on the past for information, and learning for the future requires an inner shift to suspend
judgment and redirect our attention. Transformational change toward a future change, therefore,
requires specialized and skilled leadership, well suited to the values and skills of social work to
help teams shift not only their behavior, but also their thinking and attitude to move forward in a
different direction.
Literature Review
In preparation for this practicum experience, a literature review was conducted using key
terms associated with integrated primary health care, the role of social work, transformational
change, transformational leadership, and interdisciplinary teams. Within primary health care,
person centeredness, community services and case management were explored and the role of

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
the social work included topics of social work role ambiguity, conflict, and subjective wellbeing.
For the purpose of this report, multidisciplinary, inter-professional, and interdisciplinary teams
were also researched. ‘Interprofessional’ implies an exchange of information and skill across the
team over time and Northern Health has changed their language to reflect their future state of
being, knowing it will take time and learning before reaching this level of practice. During the
practicum experience, the concepts of ‘risk tolerance’, change management, group facilitation
skills, and ‘team based care’ were added. All of these concepts were then paired with the context
of northern and remote British Columbia using the search engines SocINDEX with Full Text,
Social Sciences Full Text, PsycINFO, MEDLINE with Full Text, ERIC, and Humanities Full
Text. Finally, Mr. Mike Simpson, practicum supervisor, provided directed readings regarding
transformative change, transformative leadership, primary health care approaches, change
management, and transformational change theory. Often the most recent research was obtained,
especially in the area of system change and integrated primary health care.
Integrated primary health care. Primary health care services begin with the doctor,
who becomes the first and most common point of entry into the health care system (Conference
Board of Canada, 2013) and the primary care home is a place where the family physician
provides patient centered and holistic care through an accessible and coordinated,
interprofessional team approach (Zuril, 2014). Primary health care is basic care provided by a
variety of health care professionals (Zuril, 2014). It is accessible and integrated, concerned with
quality improvement and patient engagement and relies on interdisciplinary care, health
promotion and disease prevention to build capacity within the community (Ontario Medical
Association, 2013). Primary health care is the accepted best practice of providing quality,
person-centered health care in an efficient and accessible manner (Graham & Shier, 2014; World

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK

Health Organization, 2008; Zuril, 2014) and, according to Clapton et al. (2008), primary care
services utilizing an IPT and sharing natural geographies can offer patients less fragmented
services between hospital and community.
The importance of person-centeredness, patient involvement, participation and
engagement of the client is agreed upon by those who have adopted an integrated, primary health
care system (see Ontario Medical Association, 2013). People-centered primary care focuses on
health needs and enduring personal relationships and engages people to become partners in
managing their own healthcare (World Health Organization, 2008). As seen in Figure 4, the

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
person and their family are at the center of care, upheld by the various community and
professional supports, specialty services and acute and tertiary care. This diagram could be
improved by adding standardized communication pathways, showing the need for
communication to travel freely between all parts of this system with from physicians to
community services to acute care.
Interprofessional teams. According to Northern Health, an IPT consists of a variety of
professionals working together, combining their skills to support the holistic total care of the
patient (Zuril, 2014). An IPT may look differently in each community throughout the various
northern regions, depending on the needs of a population and the availability of qualified
professionals. It could either begin with a physician or Nurse Practitioner, then nursing, social
work, mental health clinician and other therapies as deemed appropriate and where resources
allow. Working within this integrated care team approach may also include specialists within a
specific area of medicine such as psychiatry, neurology, or pediatrics (Zuril, 2014). Team
members eventually learn to draw on knowledge from each other while remaining within their
professional boundaries (Zuril, 2014). This is a long process, but when health professionals with
complementary skills come to understand both their own role and those of other professionals on
the care team, operating from a full scope of practice, they begin to move toward shared goals of
improved care practice.
Transformational change and leadership. Over the years, the literature continues to
recognize the positive effects of transforming to a Primary Care Model (Northern Health, 2012),
such as improved organizational performance, innovation and job satisfaction (Fuller et al.,
1996; Lowe et al., 1996 as cited in Tafvelin, Hyvönen, & Westerberg, 2014). Given the scope of
the transformation and the importance of successful and seamless transition, there is a need for

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
this transformational change to have exemplary leadership through the entire process (Bass,
1990, 1997, 1999; Senge et al., 2015; Tafvelin et al., 2014).
The success of transformational change depends, in part, on the ability of the leaders to
ensure professionals on the team remain committed to the vision and clear in their assignment
(Tafvelin et al., 2014). Transformational leadership, a model based on role clarity and
commitment can be applied to systems change where a holistic view combined with the concept
of person-centeredness becomes the core of the transformation (Tafvelin et al., 2014). The
Conference Board of Canada wrote, "A lack of strong organizational leadership is an
underestimated barrier to implementing effective, integrated primary health care teams"
(Drummond, Abbott, Williamson, & Somji, 2012 as cited in Conference Board of Canada,
2012). A systems leader is able to see and appreciate the larger system and shift the focus from
reacting to problems, to proactively collaborating to create the future. They are introspective,
understand resistance, foster reflection and appreciation of the reality of others, all while
integrating the information into their managerial practice (Burghardt & Trolliver, 2010 as cited
in Ring, 2012). The documented positive benefits of transformational leadership demonstrate the
need for specialized and skilled leaders to help people move forward together, creating the
process as they go.
The role of social work. Social workers have been immersed in healthcare since the
early 1900’s responding to the needs created by economic and policy changes, major world
events and public health crises (Kerson & McCoyd, 2013). Social work roles in health care
today continue to be guided by the values outlined in the Code of Ethics, providing a basis for an
identity to the profession (NASW, 2008 as cited in Kerson & McCoyd, 2013). On the integrated
primary health care team, the social worker acts as an adjunct to the medical treatment through

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
care coordination between social and health issues, linking to other disciplines and services, and
playing a key role in assessment and ongoing support with psycho-social issues in a proactive
manner (Canadian Association of Social Workers, 2005). They bring a broader, more holistic
perspective of healthcare and personal wellbeing into the assessment, planning and intervention
phases of care, understanding of the complex interconnections between people, time and place
which shape and affect their current and future state (Heinonen, MacKay, Metteri, & Pajula,
2001). Consideration of a social context to any given situation allows the health care team to
move beyond a biomedical perspective and begin addressing social inequities and structural
issues affecting people needing help (Towns & Schwartz, 2012). Social work has historically
struggled with role ambiguity however, as inaccurate or unclear role definitions within
interprofessional practice leads to significant challenges for both the Social workers and their
primary health care team members (O'Brien & Calderwood, 2010). Interprofessional
collaboration is imperative to securing role clarity and trust, as unclear professional scope of
practice leads to overlapping duties with undervaluing the workers' role and leading to
confusion, frustration and chaos (O'Brien & Calderwood, 2010).
While it is now more common to find Social workers within supervisory positions in
health care, Executive positions within Northern Health remain more closely related to Nursing.
Maintaining competence through adequate supervision, consultation, training, ethical thinking
and at this level of the organization remains difficult (Schmidt & Klein, 2004)with so few
Executives with a social work perspective. Successful transformational leaders create
environments fostering commitment and role clarity to promote a stable organization (Tafvelin et
al., 2014). The same ethically based skills and abilities used to help people in need may translate
into leadership skills and abilities, especially when the task at hand is moving an organization of

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
people through transformative change. “The common thread linking the knowledge, skills and
values of management practice and direct practice is the significant role played by the emotions
that permeate the professional social work domain” (Ruch, 2011, p. 1326).
The Practical Experience; Critical Review
The overall goal of this practicum was to gain an understanding of a transformational
system change process and how social work fits into both Regional Leadership and integrated
health care teams in Northern Health. While the practicum placement allowed a glimpse into the
ideological continuums running throughout the Regional Resource Team, it was also an
invaluable opportunity to both experience and envision social work values, ethics and skills at
work. The practicum experience was unique in that it occurred during the latter planning phase
and early transformation phase of a system wide move to primary care. During this time, the
Executive level restructured their communication and decision making processes to better
respond to the fast-paced change process. As the momentum increases, the organization not only
must adequately respond but also anticipate future organizational needs. The skills and abilities
associated with promoting and leading active participation in this process can be compared to
traditional social work values and skills, demonstrating the potential influence Social workers
have during a transformational change process. The skills involved in group process work can
also be applied to IPTs to improve organizational functioning and team cohesion (Guzzo and
Dickson (1996, cited in Robotham, 2008, and Trevithick, 2005 and Preston-Shoot, 2007, cited in
Pullen-Sansfac on and Ward, 2014).
Further restructuring to include the entire system was yet to come. By the end of the
practicum experience, many communities were scheduled to transition in September, 2015 with

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
the goal to complete initial structural transition throughout the regions by spring, 2016. While the
practicum took place on the cusp of the actual transition, there was much planning and
anticipation of the movement on the ground and throughout various departments of the
organization. Looking back over the four-month placement during the slower summer months,
this time was the calm before the storm. Much maneuvering was occurring behind the scenes of
the change process, with little movement actually occurring toward primary care practices to
clients. For instance, discussions between various unions and Northern Health Human
Resources are closed and take time. How to best reorganize the Executive structure and function
are also closed conversations.
Northern Health’s transformational change. The transformational change process
began long before this practicum experience so it is important to provide a historical context to
the current systematic shift and the rationale behind Northern Heath’s direction of change. In
2008, the BC Health Officer outlined eight strategic initiatives, including integrated primary
health care to respond to the complex issues involved with population health inequities (World
Health Organization, 2008). The Northern Health Authority began consultations with northern
British Columbians in 2009 to better understand what primary health care meant to individuals,
communities and professionals within those communities (Northern Health2, n.d.). They began
the implementation of interprofessional primary care teams in three prototype communities and
by 2011, Northern Health identified the need to standardize ongoing physician engagement and
integrate a clinical information system for sharing client information. In 2012, the model for
integrated and accessible primary health care services in Northern Health was developed to be
integrated, patient centered and more accessible (Northern Health2, n.d.). As of 2014, Northern
Health’s 7,000 staff members operated 25 acute-care facilities, 14 long-term-care facilities, and

18

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
many public health units and offices providing specialized services (Northern Health, 2014). Six
integrated primary health care teams operate throughout the Northern Health region with
approximately 20 more teams to be implemented by 2016. The first six sites lead tremendous
system changes, from the development of the integrated primary health care teams and
standardized processes, to new documentation processes (Northern Health, n.d.). The
implementation of interprofessional team based care to support primary care will focus on the
following conditions: one or more chronic diseases; mental health and addiction issues; frail
elderly; prenatal and early child health; and child and youth complex care needs (Northern
Health2, n.d.). On average, across the regions, these populations combined make up
approximately 10% of any given physician’s panel of patients (Northern Health2, n.d.). Many
forces must come together at all levels of the organization and Government to drive this
transformational change, working together to balance capacity with client need. These efforts
are expected to result in continuous, coordinated and comprehensive care for people and their
families, reduce waiting lists, pressure on emergency rooms and create an overall more
sustainable health care system (Northern Health2, n.d.).
Drivers of change. The direction for change began with the World Health Organization’s
(2008) promoting system transformation by directing improvements to the overall accessibility
of services and supporting the need to systematically provide care for people throughout their
lifespan. The drivers of this movement stem from both external and internal forces; from the
current political will of the province, to workers who develop and standardize processes with the
IPTs. Change of this magnitude requires many people in different systems to work together,
reaching beyond their traditional roles and boundaries to create something different. They must

19

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
then align and balance unique needs across the Health Authority with their capacity to provide
quality service.
Provincial direction. The Primary Health Care Charter directs the health care system
through the transition of creating a person centered comprehensive and integrative system to
improve the quality of care for lower health status populations and those who experience gaps in
care (World Health Organization, 2008). In 2010, British Columbia implemented a sector-wide
strategy called the Innovation and Change Agenda. This document provides an overarching
framework for coordinated action, laying the foundation for strengthening primary care
practices, meant to drive meaningful change across the health system, by setting strategic and
operational priorities for the delivery of health services (British Columbia Ministry of Health,
2014). A shared plan of action and a patient-focused vision for the health system are critical to
successful change. As the Ministry responds to the health of the Province, Northern Health must
be ready to respond to the Ministry and it is therefore essential to maintain a good relationship
with the Ministry of Health and respond to requests as needed (M. Simpson, personal
communication, June 1, 2015). This need to be responsive was demonstrated in May, 2015, as
the opposition party focused on the health care section of the provincial budget in the BC
Legislature. The Executive Leadership was formerly requested to make themselves available to
respond as quickly as possible to any questions posed by the Opposition. It was considered an
urgent matter as the Minister of Health would not answer questions posed to him until receiving
a formal response from Northern Health. Despite best efforts to provide pertinent details ahead
of time, there is always the possibility of unanticipated questions, taking priority over day to day
operations (M. Simpson, personal communication, June 1, 2015).

20

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
The BC Ministry of Health declared change management and the implementation of the
strategy to be an ongoing challenge as there is still work to do in regard to buy-in from health
authorities and other partners (Ministry of Health, 2014). The Ministry (2014) have therefore, set
eight priority areas for service delivery action, beginning with a shift from a culture of being
disease-centered and provider-focused to a model of patient centered, primary care. This shift
will include IPTs working with physicians within the community. Another such priority,
discussed during the practicum was to standardize communication pathways between primary
and specialist treatment while focusing on IPTs to provide better linkages to community health
care (British Columbia Ministry of Health, 2014). All eight priority areas are reflected in
Northern Health’s vision moving forward into integrated primary health care and will be
prioritized and implemented as a part of the transformation.
Northern Health executive and leadership aligns with the Province to promote the change
process by providing communication, timelines, direction and mandates to the entire
membership, while setting organizational priorities. The current model of information flow
begins with implementation, driven by the three regional Chief Operating Officers, who each
have an implementation team from their region. This model allows autonomy in different
regions but adds complexity to the change process as a whole. Regional leaders must separate
their local Health Service Delivery Area’s needs from the organization’s regional needs, as
disconnection from the overall vision of the organization may cause competing priorities within
the regions. The role of the Resource Team is to provide resources and support across the
regions to have local needs met. They ensure regional considerations are escalated to the
regional leaders for consideration. The Workforce Transition Plan describes the process and
means by which employees move from the current to future state. Aligning structures to ensure

21

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
all pertinent pieces come together and following workforce transition plans will require a cultural
shift from within the organization, including not only how processes occur, but also questioning
why processes are used. The organizational executive must lead by example and reorganize
themselves, changing their own culture to allow more innovation and risk tolerance. Decisions
must be made quickly enough to keep up with the organizational shift.
Boundary spanning, or networking with other organizations or partners, link the
organization with other sources of information within the environment (Mull, 2014). It
encourages innovation by bringing together different perspectives and knowledge, while
remaining within their scope of practice (Mull, 2014). There were many examples of this
practice experienced during this practicum, some of which are identified throughout this report.
The Resource Team was comprised of people from a variety of key disciplines and departments
across the regions, all stepping away from their main work to provide their ideological
perspectives and expertise to help drive the change process forward. Before the move toward
integration, the members of the Resource Team had not worked together across their separate
silos and did not understand each other’s roles and responsibilities. They learned from each other
at the table, discovering how their many disciplines align within the larger system, providing
clarity and enabling a collective and unified move forward.
The involvement of the affected unions continues to have an enormous impact on the
change process, as it takes time to ensure fairness and safety for the many workers.
Communication with the entire Northern Health membership are significantly affected during
this time as it is customary to refrain from communicating with workers while negotiating
unionized positions. The multitude of managers must be made aware and understand early on,
the business reasons for change and feel secure about future change to their role to enable them

22

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
to portray this confidence to the work force. They are the leaders with the most direct and
therefore influential effect on the workers providing services. It is imperative the organization
develop and maintain trust amongst the employees during this time of change, despite the
difficulty with minimal information flow. Once the union talks end, the communication can
resume.
Physicians and community partners. Over the last year, Northern Health has been
working to advance co-leadership between physician and administrative leaders, recognizing the
existence of shared responsibilities. Medical staff and administrative leaders were consulted to
endorse the shared functions for their respective roles within the Northern Health Executive &
Northern Health Medical Advisory Committee, the Regional Medical Advisory Committees and
the Medical & Administrative Leaders. Co-leadership between medical and administrative
leaders is an important factor in achieving Northern Health’s mission of providing exceptional
health services for Northerners. Physicians throughout the organization have been involved in
creating this change, including assessing chronic disease management service pathways to and
from the primary care homes and restructuring the mental health and addictions process,
specifically with psychiatry and primary care physicians. The practicum setting allowed a
glimpse into important boundary spanning with physicians and strategic alliances at the
organizational level. For example, a physician sits on the ITS steering committee (among
others), spending time and energy informing the electronic medical record structure changes
across the northern regions. Several doctors demonstrate a stepping away from the traditional
roles to drive the change process, encouraging innovation in others by bringing together different
perspectives and knowledge; all while remaining within their scope of practice (Mull, 2014).
This involvement brings a rich historical perspective as well as a macro lens to the issues and

23

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
considerations surrounding implementation of a Primary Care Model (Northern Health, 2012).
These physicians take an active hands-on approach, attending meetings, forums and travelling
throughout the regions to converse directly with doctors in the area. One Physician has
embraced the co-leadership model to focus on physician engagement and orientation to
teamwork, touring with the Chief Operating Officer to areas in the regions not yet on board with
the change process. This physician has been actively engaged with primary care in his own
integrated practice and was a part of the move to primary care from the beginning. He
understands the historical discord between physicians in the North and is skilled at talking with
doctors in a straight forward manner, cutting through the emotional discord and distrust to get
right to the heart of an issue (M. Simpson, personal communication, June 17, 2015). He admits
to preferring to be invited to a community to have an honest conversation rather than an
informational forum, engaging in two-way dialogue (P. Murray, personal communication, June
17, 2015). He understands the need for physician autonomy, especially in the more remote
regions where they have already established ways of carrying out their business (P. Murray,
personal communication, June 17, 2015).
This interprofessional team approach to driving change also required the ability to work
closely with the physicians within the community and community services. Municipalities and
regional districts across the North partnered with Northern Health and Divisions of Family
Practice to work on issues important to the community to improve overall health and wellbeing.
Divisions of Family Practice began in 2009 with an idea to bring physicians together for a
collective voice in healthcare, especially at a local level (Family Practice, 2011). There are
currently 34 Non-Profit Divisions of Family Practice agencies in BC, all separate entities,
supported by a central office (Family Practice, 2011). In Prince George, every local physician is

24

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
as needed. An Electronic Medical Record (EMR) establishes a common, integrated and
complete clinical information system with standardized administration functions, in which
information and standardized data can be easily shared and collected (British Columbia Ministry
of Health, 2015). The strategic framework illustrated in Figure 6 captures how ITS will support
the transformation of the health system (British Columbia Ministry of Health, 2015). It
highlights the key implications of the three strategic priorities for ITS and the three areas which
must be addressed in order to provide an effective response. A key component to the ability to
provide care in this new way is due, in large part to the ability of team members to access a
common electronic medical record (EMR), including the person’s entire care plan. A person’s
care plan, an integrated plan addressing a patient's social and health care needs is contributed to
by all disciplines and typically stored, maintained and managed within the primary care home
(Mosby's Medical Dictionary, 2009 as cited in Zirul, 2014). Access extends from physicians and
other specialists in the community as deemed necessary and the IPT. The Province of BC will
focus their ITS efforts on connecting health information systems “across the continuum of care”,
including EMR systems, clinical information systems and provincial eHealth systems (BC
Ministry of Health, 2015). It is recommended to expand the use of Telehealth including
videoconferencing to use in recruitment, retention and professional development and to support
regional networks across rural and remote communities to improve quality of health data (British
Columbia Ministry of Health, 2015).
While ITS does not drive the change process per se, their capacity has a great impact on
when and how health care work is carried out and how data is collected and used. The business
side of the organization drives the transformational change timelines and ITS drives the
alignment and timing of the transformation. For instance, ITS work plans are divided quarterly,

26

TRANSFORMATIONAL CHANGE AND SOCIAL WORK

27

Figure 6. Strategic framework for health information management and technology

(British Columbia Ministry of Health, 2015).

so they demand the entire system also follow this schedule to some degree. It becomes
imperative to keep ITS up to date with community timelines and service needs during the
transition. Leadership and ITS work together, weighing different perspectives and needs
throughout the system and ITS delivers what is asked of them, basing their priorities on those of
the Executive of Northern Health. Change management support and the overall timelines also
have a significant need to align with ITS for training, to ensure IPT skill competencies and ITS
orientation and training move smoothly. Much pressure is involved in balancing Northern
Health’s priorities and timelines with their capacity to respond to and anticipate community
and/or team readiness to move forward. The recent structural changes within the Executive have
left ITS concerned as to how they will continue to receive clear direction and priorities, and how
they would proceed with determining priorities as the rate of change quickens and expands

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
across the Authority. This exemplifies the extent to which change in one area of the system will
have an impact upon other areas of the system and not only needs direction but ongoing change
management support.
Interprofessional teams, once developed, situated and trained, have an opportunity to
build capacity and skill of their own to provide seamless and quality, person centered care.
Although many processes will be provided to them from the prototype communities, there is
much room for developing unique/local process to provide more efficient and helpful service to
people. A culture of creativity must be developed and then maintained among the workers who
are the most affected by the changes; a complicated balance to achieve. People are now
expected to take an active role in developing new systems and processes, all focused on the
person receiving services. Changing process can be a daunting task for some and values are an
essential component of risk management when faced with uncertainty (Chase, 2015). Thinking
about building processes in a person centered way can be challenging, especially when it means
thinking about healthcare in an entirely new way. For instance, while working together on a
future state pathway map, a ‘box’ was added to the flowchart to accommodate the current reality
of waitlists for the IPTs in Prince George. A team member objected to the assumption of
waitlists citing this as old system thinking. Instead, she argued, a future state of providing
holistic and efficient care in a person-centered way can assume that the current waitlists are a
part of the transition process and not a future reality. If people plan for a system with no
waitlists, the system will find ways to bring this new perspective to fruition. If they plan for
waitlist, they will remain the reality. Other challenges involved shifting focus to place the
person’s needs before the needs of the organization and truly include the person or client as an
active participant in driving their care. These examples all require a shift of culture for both

28

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
workers and people receiving service, and require the need for ongoing learning of new roles and
new skills. Time and space must be made for people to figure out how they will move forward
in their role, and how they will manage their own environments within the IPTs. Beyond the
standardized tools and procedures, it is left to the individual teams to evolve to be more efficient
and effective. The goal is to encourage workers to remain in their positions long term, thereby
stabilizing the entire system. People bonding together through collective problem solving and
over time, establish routines, and develop feelings of ownership, pride and a sense of
accomplishment. This will help create the change in attitude.
Organizational restructuring. Northern Health’s systematic management was
traditionally built to minimize risk. People and work streams are in siloes to produce efficiency
and reliability. In Northern Health, communication historically travelled from the top of the
organization to the bottom and back up again, but rarely across the separate silos. Information
was typically provided or reintroduced to the Executive by way of formal process such as
briefing notes, meant to inform and open dialogue. Discussion then contributed to either a
decision to request further information, undertake or deny the request. The process was repeated
until it was successfully resolved or dropped altogether. This structure is slow to move,
communicate or make change (Kotter, 2014) and in response, Northern Health is changing their
model of care across their three regions. As the move progresses, communication and problem
solving will be unique to the regions and often fast paced. The model of person centered care
must balance standardization with autonomy, allowing regions and remote areas to be unique in
their approach to change.
Restructuring creates a culture of change and growth throughout the organization. In
August, 2015, the role and function of the Integrated Health Care Steering Committee and the

29

TRANSFORMATIONAL CHANGE AND SOCIAL WORK

30

Current VS future
(Creating a network)

NH
Executive

Operations
Traditional
hierarchy
responsible for
implementation

NH
Executive

IHC
Steering
Committee

Operations
Traditional
hierarchy
responsible for
implementation

IHC
Steering
Committee

IHC
Network
IHC
Resource
Team

Figure 7. First draft of Integrated Health Care Oversight
Figure 7. (Northern Health, 2015)

Regional Resource Team was reviewed and Northern Health moved toward a structure that
would allow decisions to be made more quickly and more often at the local or HSDA level.
Having three distinct regions within the Northern Health Authority allowed a greater degree of
local operation and decision-making for individual health facilities, however it also left Health
Service Delivery Areas (HSDA) limited autonomy in structure and process. Depending upon the
needs and capacity in their area, this had the potential to create competition and animosity

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
regarding attention of Regional Leadership. The goal is to create the best balance to allow
autonomy within the regions without compromising person centered care practice. Among the
many examples of successful partnerships, one such model of excellence can be found in the
Southcentral Foundation, an Alaska Native-owned, nonprofit health care organization serving
nearly 65,000 Alaska Native and American Indian people (Southcentral Foundation, n.d.). As a
suggested reading, this website provided a historical overview of how their system came to be
and person centered philosophies worth incorporated in our own experience. In 1999, an
agreement was signed to take over ownership and management of the Alaska Native Medical
Center, instituting a system-wide transformation of care (Southcentral Foundation, n.d.).
Working from the premise that Alaska Native people are in charge of designing and delivering
health care, their vision included a Native Community that enjoys physical, mental, emotional
and spiritual wellness (Southcentral Foundation, n.d.). Their mission is unique in that it
combines the mission and vision of Southcentral Foundation with the Alaska Native Tribal
Health Consortium (Southcentral Foundation, n.d.).
New process and functioning. The structure proposed to and accepted by Northern
Health’s Executive in September, 2015 consists of the Executive Committee, Steering
Committee, HDSA Implementation committee and finally HSDDA Networks (see Figure 7).
This working copy, as of July 17th 2015, shows how people within Northern Health have been
organized differently (see Figure 7) with different scopes of practice. For example, the Steering
Committee reduced their core membership and is now the Leadership Rapid Action Team, found
within the IHC Network. Their role is to oversee the strategic implementation plan, addressing
issues related to the implementation, structural changes, interim solutions and change
management, bringing people to their table for discussion and input as needed. The meetings,

31

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
chaired to ensure people are working from within the new framework, entail weekly ‘huddles’
for 30 minutes to help keep pace with the changes to date. Since the Leadership Rapid Action
Group is working without agendas or formal minutes, a tried and tested ‘standing items’ format
was applied to enable the priorities of the organization be met. This format allows such items as
change management to be addressed on a regular basis. As the team oversees the identification
of barriers, it ensures solutions are proposed, tried, monitored and documented. In addition, they
oversee decisions regarding standardization and variation, capturing processes to enable
comparability and regional resolutions. Plan, Do, Study, Act (PDSA) cycles travel from a Team
Lead to their Health Service Administrator, and then to the regional Chief Operating Officer.
Any items with a regional impact, such as a mental health service pathway are forwarded to the
Leadership Rapid Action Team for removal of barriers and decisions before moving forward
with standardization of processes. Transitioning to the new system, this communication pathway
will change to pursue PDSA cycles occurring ‘as needed’, moving through the system, only
going as far as necessary to be resolved. Throughout this process, people have also been tasked
with asking questions to thoughtfully disrupt old processes and patterns of thinking, and
celebrate by communicating successes to the whole of the organization.
The Resource Team stopped their current format and reorganized as a part of the
Regional Integration Networks (See Figure 7). The networks (see Figure 7) are a newly
developed entity, meant to identify barriers and issues experienced by the IPTs, proposing
solutions with a focus on innovation and creativity. They propose change to functions, processes
and roles, to redesign services while focusing on the needs of the IPTs and the people receiving
services. They then review results of rapid improvement cycles to determine areas to standardize
and share regionally. This restructuring is important to support the rate the change will occur

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TRANSFORMATIONAL CHANGE AND SOCIAL WORK
once the entire health authority becomes involved.

Again, it is important for this group to

disrupt old processes while attending to ‘work-arounds’ and rationales in pursuit of quality
integrated care. Further networks (see Figure 7) will evolve by common topic or locale and
although it has yet to be determined who will make up any given network, one will be created to
ensure the flow of information from the Health Service Delivery Area Integration Networks to
the Rapid Action Team (personal communication, July 17, 2015). In line with this structure
change, there was a recent direction for regional leads to make emergent decisions as needed at
an HSDA level while moving forward with implementing integrated teams. Decisions being
tracked at this level will be assessed for standardization or ‘lessons learned’ before forwarding to
the Network to determine the impact to the rest of the organization. This new structure differs
from the ‘army’ Kotter (2014) describes, as there may not be sufficient ‘champions’ within all
levels of Northern Health with enough power, influence or both to drive the culture to change.
The new system loses much of the flavor of Kotter who sees the networks as having members
from across the levels of the organization and driven by the bottom up (Kotter, 2014). If the
culture does not shift, however and this group does not feel they have the power to make
decisions, the system has the potential of becoming even more bogged down (Kotter, 2014). As
stated by Mr. Simpson (personal communication, July 17, 2015), every organizational structure
can succeed and every structure can fail, depending on the people running it. The players also
have to be inspired to take risk, be innovative and create the
process for themselves (Kotter, 2014). Change is driven by the people embedded in the change
process and will require great support to transition in a positive and helpful manner.

33

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
Northern Health’s Executive recognized their system of responding was slowing the
process down and recreated their communication and decision making process to be more nimble
in their ability to react and make key decisions more quickly. The Chief Operating Officers and
local Health Service Areas became more empowered to make decisions in order to move the
work forward in a community. The project leads were enabled to focus more time, resources
and attention on operational implementation at their local level, to be a resource to the networks,
pulling new teams together and liaising with the Regional Lead Rapid Action Team for support.
One challenge includes to managing, tracking, testing and standardizing processes across the
Health Authority. Another challenge involves the necessary culture shift within all levels of the
organization. The current shift of structure and processes, in response to their inability to meet
the current needs, shows a level of commitment from Northern Health to respond to the everchanging environment. Once the system has moved to a model of integrated primary care,
Northern Health may no longer have the same silos or divisions of care, but precisely how the
system will look or operate will be an evolving process, dependent upon the actions and hard
work of the people working within the change process.
Information management and technology services and systems within Northern Health
have grown and changed over the years, resulting in different and only partially connected
systems across the health sector. According to British Columbia Ministry of Health (2015), a
strategic challenge affecting transition to integrated care is the multiple, loosely connected
clinical information systems and a lack of provincial clinical information standards (British
Columbia Ministry of Health, 2015). Recommendations from the Ministry include establishing a
sector-wide health information exchange and governance to oversee and guide ITS
transformation in all areas of health to prioritize the standardization of clinical processes and

34

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
exchanges of health information (British Columbia Ministry of Health, 2015). There is currently
little standardization across the Health Authority in regard to the multiple Electronic Medical
Records. These EMRs are used by a variety of departments in a variety of communities across
Northern Health, all with their own particular systems of providing care, keeping records and
sharing information. The information is ‘owned’ by the electronic medical record, necessitating
formal sharing agreements to ensure Northern Health access to share pertinent medical
information as needed for continuity of care purposes.
The main ITS concerns moving forward include mandatory reporting requirements and
how best to share information, including remote access capabilities, all while ensuring the
system is functional and secure throughout the entire Health Authority. All 26 communities
throughout Northern Health will be using a clinical documentation exchange system to securely
transfer information as necessary. The current care plan within MOIS, the Primary Care EMR,
was designed for physician use and is not yet adequate for team use, as it lacks a holistic, team
perspective. Northern Health is committed to ‘upgrade’ to better meet the needs of the IPT, but
must first see the entire Health Authority up and running with a basic, yet compatible electronic
medical record. Any upgrade to include such items as a better care plan will wait to be
addressed after all communities throughout the health authority are transitioned.
The size and complexity of this change process will result in a long transition period.
This system will be built over the next 3-5 years, yet the transformative change is occurring now,
leaving ITS concerned with both the scope of the work yet to be done. Timing is extremely
important as ITS can only focus on one priority at a time, their capacity is limited, and they must
be given direction from the organization before they can begin to move. There are limitations to
what ITS and their suppliers are capable of delivering and a concern that once communities

35

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
begin to transition, they will be inundated with ITS requests without proper direction to
prioritize. They also must balance their creativity with the management of priorities,
standardizing the use of MOIS across the regions. The drawbacks to this approach is that it is
labor intensive and includes risk associated with mandatory reporting requirements, duplication
of reporting, and mandatory statistic gathering for the BC Government. For example, Northern
Health Mental Health and Addictions have chosen to duplicate their charting in order to maintain
their other mandatory reporting requirements built into their current EMR until an alternate
system is built to accurately capture the date. This will slow down the entire process of
integration but will enable the change process to continue.
Northern Health has long been grappling with standardizing their electronic medical record
system throughout the Health Authority at the cost of losing mandatory reporting requirements
or creating duplication of charting for workers. By August, 2015, Northern Health remained in
conversation with the Ministry of Health and other governing bodies as to how to manage all
mandatory reporting requirements. The implications of making choices now that for years to
come, will dramatically affect the manner in which information is collected, shared and used can
be an overwhelming prospect. Eventually the decisions must be made and the consequences
lived with. By the end of the practicum, Northern Health had finalized the decision to transition
to Medical Office Information System (MOIS) and/ or Integrated Community Clinical
Information System (ICCIS) (now renamed Community MOIS) (See Figure 8). These two
electronic medical record systems are already being used by many physicians in the Health
Authority and are compatible with each other. Meeting physicians where they are at currently
encourages engagement and ‘buy-in’ to the change process which is integral to facilitate moving
forward together as a health authority. The success of this complex transformational change

36

TRANSFORMATIONAL CHANGE AND SOCIAL WORK
process relies on the electronic medical record systems being aligned for reporting, information
sharing and privacy needs. The three regions are unique in their approach to the change process
and every community unique in their capacity to provide health care to the local population.
The Role of Social Work within Transformational Change
The Role of social work is at the heart of this report and at the very nature of creating
transformational change relies on the values, skills and abilities, inherent to social work. By
participating in the change management process, I was able to confirm there is a legitimate place
for social work in the executive and leadership environments. My real growth in awareness and
insight however, was how closely aligned our traditional social work values, beliefs and skills
are with those skills and abilities needed to successfully drive transformational change. It is
imperative to understand the change process and the effect a change of this magnitude has on
people, whether within Northern Health, independent physicians and the people they serve.
While cultural values and beliefs have a significant impact on the outcome of transformational
change (Kotter, 1985 as cited in Schein, 1992), the ability to adjust to a cultural change,
including resistance to that change can affect the outcome (Spiker & Lesser, 1995; Waddell &
Sohal, 1998 as cited in Schein, 1992). Relationships between people are an important vehicle for
change (NASW, 2008) and strengthening relationships will promote and restore the wellbeing of
individuals, families, social groups, organizations and communities looking to achieve optimum
psychological and social functioning (Social Workers Act, 1998). There is a distinct need to
bring people together, to create integrated teams with workers who are currently entrenched in
separate silos to promote the person centered perspective (Pullen-Sansfacon and Ward, 2014).
Facilitating change in practice requires an informed, caring, value based social work skills and
cohesive leadership at all levels (Littrell, 2011). Social workers can contribute to the IPT by

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drawing upon group work principles, formed by the values and culture of social work and crucial
to successful team cohesion (Gray et al., 2008 as cited in Pullen-Sansfacon and Ward, 2014).
The People Side of Change. According to Hiatt and Casey, (2012), managing the
people side of change includes competency in leadership, allowing the organization to respond to
changing conditions to enable growth and profit. The structure of the system will be developed
by the organization, but how the care is delivered and how workers choose to build their new
environments will determine the ultimate outcome of the transformation. In some cases, people
will physically move to a new location and begin training to work within their full scope of
practice necessitating a need to let go of old process and create new, more person centered
approaches. For most people, this will require a mental shift, letting go of traditional ways and
embracing a new approach and focus. Learning new interventions will require training or
retraining to reach full scope of practice also requires a mental shift. To move the change
forward, the culture of the people throughout the organization must first align and then adjust.
For those entrenched in their way of practicing the existing medical model this is a difficult
endeavor. Change can be difficult to cope with and people often require help and support to
manage the necessary shift in thinking and attitude. Helping people to think and act in a person
centered manner is a role meant for social work as it is founded on and informed by a specific
value base (IFSW, 2000), influencing how people think about providing person centered care is
value driven. Restructuring the entire system is imperative to successfully changing how people
provide care and approach their work. Changing processes and clarifying new roles allows
people to become excited about creating a new and better way of providing services. It is an
opportunity to engage people to be an active participant but if this group does not feel they have

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the power to make decisions, the culture will not shift, and without a culture shift, the system has
the potential of becoming even more bogged down (Kotter, 2014).
Change management requires understanding both internal and external aspects of the
change process and must be managed as people are led through a transformational change
process. A key point to consider while changing structure is to answer the question “Will this
better serve the people?” and according to Simpson, if the answer is ‘yes’, then the work
focusses on resolving barriers by providing testing to move forward toward standardization
(personal communication, June 2, 2015). To ensure movement in the right direction, rapid
responses is required while shifting concentration to include not only ‘what’ is done, but also
questioning ‘how’ and ‘why’ it is important. This takes a person centered approach with
openness to applying different processes. Altering how people think about care in a person
centered way requires a culture change from the medical model to the Primary Care Model
(Northern Health, 2012) and will require strong direction and leadership of the organization.
Just before the practicum placement began, the Resource Team and other leaders
attended the ADKAR Change Management Training where they separated change management
from project management clearly in their minds. They realized their own ‘change management’
was not getting enough attention, often left to compete with other projects or priorities. Thinking
of the change management side of issues was a different perspective for most people, a
‘mechanical’ process not yet integrated into practice. Questions generated from the symposiums
and forums for Public Health Nurses, Primary Care in the North East, Mental Health and
Addictions and Psychiatry exemplify the need for change management with the workers directly
impacted by the changes. Issues can be generalized into the following categories;
What/how/when will this affect me and my job/role/function, how will we get to the idealized

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state, and what exactly will that look like when we get there? People want answers as to how the
new system will operate in the future. When reviewing questions generated by the various public
forums, there are people working in the system feeling uninspired and powerless to evoke
change. While many agree with the need for a primary care model, there is concern about how
the change will affect them directly in their future work. Fear and uncertainty can be quelled
with reassurance and providing accurate information. The task of providing answers to the
questions helped me to understand the nature of people’s trepidation for the future. It was
challenging to provide an informative answer that fit within the key messages provided by
Northern Health Executive. I tried to use positive language that was clear and concise, not easily
misunderstood. Reflections on the Public Health Nurse symposium held in April, 2015, was a
great example of the type of feedback Nurses were looking for. This response was factual,
informational and genuine. Not only did it outline a future plan, but it was acknowledged that
people’s comfort with the current state and fear of the unknown future may cause “excitement,
apprehension or resistance”. This identified how everyone will be at different levels of
‘readiness’ for change, normalizing the issue and empathizing with people’s fears, while
promoting confidence and commitment to a vision of integrated health care services, where
together, everyone will learn as they go. Once the Labor union discussions began however, and
despite workers most affected by the change calling for more detailed communications from
Northern Health Leadership, the organization, as per protocol, must refrain from direct
communication with any staff member about the planned changes until discussions are complete.
The representatives agreed to provide this information to staff after all the individual discussions
with those affected workers have occurred, leaving the general workforce to speculate. This halt

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on open communication causes increased discomfort and fear, and people begin to imagine the
worst with limited communication but will improve in time.
Change begins with people and relies on people to be successful. There is a place for
traditional social work values and skills to promote people to make positive movement forward
through, what often is a difficult time managing change. We can all appreciate having people in
our midst who can really listen to us and guide us toward exploring different perspectives and
accepting new ways of thinking and doing. This speaks to people working at all levels of the
change process, from those providing direct services to people receiving care, and those at the
top Executive levels of the organization. The change will forever impact how we do our work
within the IPT environments. This is an opportunity to encourage person centered philosophy
and practice, throughout all levels of the organization. While assisting with the rewriting of the
various IPT job descriptions, I had the opportunity to edit the wording to person centered
language, adding strength based statements and ensuring team based care was reflected
throughout. The language used in these documents are important, specifically to emphasize a
person centered perspective, forever shaping how people approach their work.
Leading People through Change. Leadership and Management, while both essential,
are different and the difference not always well understood. Management helps organizations
produce reliable, efficient and predictable results and involves planning, budgeting, and
providing policies and procedures to guide action, and measure results (Saleeby et al., 2014). On
the other hand, leaders create an environment to promote and host conversations, inspiring
innovation and solutions to emerge (Saleeby et al., 2014). They can be found throughout many
situations and levels of the organization. In Northern Health, transformational leadership begins
in the Executive and Leadership levels. This transformation to a new approach to health care

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requires strong transformational leadership to help move the entire system though this
formidable process. Positive attitudes with a genuine belief in the direction of the organizational
change must permeate all teams throughout the regions, further complicated considering the
unique geographical and population factors affecting medical service delivery in the northern
regions of British Columbia (Peters et al., 2010).
The current confusion and angst amongst Northern Health workers regarding when and
how primary care is going to unfold causes stress that can be felt throughout all levels of the
Northern Health system. The main challenges of the organizational leaders include guiding
workers to shift their thinking, actions and attitude, moving them from “ego-system awareness”
or a focus on the individual, to an “eco –system” reality of the organization (Sharmer & Kaufer,
2013). The people within an organization must realize they are a part of a larger system and
begin to understand the issues from a broader perspective (Senge et al., 2015). Transformational
leadership theory focuses on the collective of the society, where the leader influences the team
through the use of charisma, having a vision and inspiring intellectual stimulation regarding the
well-being of others, the organization, and society (Bass, 1999). As an example of
transformational leadership, Mr. Simpson, Practicum Supervisor, has an ability to set the tone in
a room, allowing a safe place for people to bring their perspectives to the table, probe deeper
discussion, all while pulling information together to provide a broad, shared vision for all. He
used light humor and his interactions have a way of putting people at ease, instilling a sense of
humanity and therefore trust to the moment. Ms. Gunn, Vice President, Primary and Community
Care and Clinical Programs, admires Mr. Simpson’s (practicum supervisor) ‘gift’ of being able
to coach people to move toward innovative new world solutions, allowing them to begin at a
novice stage, supporting them to build their competence and confidence (meeting

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communication, May 22, 2015). Transformational leadership must also be strong enough to
resist people continuing to work in traditional ways. Systems have been there a long time and
resistance to changing any process is apt to occur. It demands an open mind and heart to respond
to rigid assumptions and agendas (Sharmer & Kaufer, 2013) as well as an ability to create space
for people to come together, learn and explore through generative conversation, allowing the
collective wisdom to emerge (Senge et al., 2015). While resistance to change is a normal
response, successful management of the people side of change enables growth and profit (PullenSansfacon and Ward, 2014). Mr. Simpson’s group process skills demonstrated this when he
reworked the meeting agenda to maintain control over the direction the discussion went with the
Psychiatrist forum.
The Executive Committee of Northern Health strives to use a model of participatory
leadership as an organizational change concept (Saleeby et al., 2014). This approach engages
key team members to be architects in the process to create the future of the organization (Saleeby
et al., 2014). Just as the people receiving care are active members of the team in team based
care, so too are Northern Health team members active in their change process. People have to
rely on each other to do a good job and allow mistakes to happen, but it is difficult for people to
take the risk of losing information or not doing things ‘right’ the first time. Some professionals
are concerned about how information will travel back and forth with the proposed system, others
with how the information will be tracked across the region and still others, by the overwhelming
volume of workload anticipated. Roles are becoming more unclear and people are looking for
direction, unsure of the future. This uncertainty is understood as a by-product of the change
process, yet is difficult to manage as people may lose sight of the value in their work. (Senge et
al., 2015). Leaders in Northern Health have been formally reassured to encourage innovation

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and creativity as they enter into this phase of redesigning how care and services are provided.
Giving people direction, but also the permission to do things differently is important in such a
traditional setting (Senge et al., 2015). Strong, supportive relationships are of utmost importance
to maintaining a profound commitment to a holistic perspective about health and over time, these
mentoring relationships will nurture similar thinking and behavior in others (Senge et al., 2015).
Managers are looking for cultural support and development to enable them to create
space for everyone to do things differently, to help move their workers through the change
process. Two common barriers to team based care, experienced by current interdisciplinary
teams include change management and communication, due, in part, to difficulty with the
coordination of change throughout the regions and the required shift in cultural norms. Restraints
on open communication during union discussions had an immediate impact on those providing
services, leaving people unsure of the direction forward.
According to the Guidelines for Ethical Practice (2005), Social workers function to
improve policies, procedures and practices, informing administrators of their ethical
responsibilities. They encourage employers to remove barriers to ethical practice and strive to
promote effective teamwork and communication. Change management and communication are
areas where Social workers have training and experience, if not within transformational change,
then within helping field. Social work has the fundamental helping skills transferable to assist
those workers around them to adapt to change and promote good communication at all levels.
There is also a place for Social workers at the head of the table to be reaching beyond those who
share social work values and perspectives, to engage those with different values and viewpoints
(Elizabeth J. Clark, NASW News, 2007 as cited in Scott and Scott, 2011).

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Implications for professional practice. Northern Health Authority is going to be under
tremendous pressure during what could be a very long transition period and the need for Social
work value driven support is vast throughout the organization. The creation of new ways of
working in a generalist manner requires systematic retraining and ongoing support, to both
upgrade skill and to adjust to the changes experienced by teams. Prototype communities continue
to report stress and uncertainty, six years into their process, still grappling with how to form their
team to work in a cohesive and beneficial manner. Working closely with physicians as part of
Figure 8. Northern Health Future Vision of Integration Community Clinical Information Systems

Figure 8. Northern Health Future Vision of Integration Community Clinical Information Systems,
comparing past and future structure. The dark arrow depicts how the flow of information has the ability to travel
between silos. ICCIS quickly became renamed to “Community MOIS”.
Northern Health, 2015

the integrated team is new and uncertain for everyone involved. Both team members and
physicians need support to build meaningful relationships and systems of doing business

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together. Many details must come together over three vast regions with people working together
toward a new way of doing business. Movement forward must be slow and thoughtful, with
adequate plans in place to both understand and respond to resistance at all levels, as at no time
can care be compromised.
Despite the need for person centered care being integral to the successful health care
system, few health providers are properly prepared or trained in this area, leaving a gap between
policy and service delivery (World Health Organization, 2008). Doctors and Nurses are trained
to respond to medical issues based on a medical model of care, and although they realize the
need for this psycho/social piece of treatment, they may not have the skill set to manage these
aspects of the holistic approach. They may also be restricted by time and space, or lack a
connection to the community resources. The ability to rely on a Social worker to complete this
piece of care is ideal, yet access to social work can be problematic, especially within the outer
regions, where access to resources and skill capacity vary widely (Schmidt & Klein, 2004). The
teams working in the Lakes District, for instance, have had no access to social work for some
time, leaving important work to fall to other team members to resolve (Raquel, personal
conversation, August 7, 2015). This is an important gap to understand for that region. A social
work perspective would help teach and model the values and ethical thinking behind providing
value driven person centered care and could assist this region with group cohesion and
relationship repair.
The application of social work skills in group dynamics and communication are useful in
dealing with such challenges as resistance and are transferable to apply to team work (Guzzo and
Dickson (1996, cited in Robotham, 2008, and Trevithick, 2005 and Preston-Shoot,2007, cited in
Pullen-Sansfac on and Ward, 2014). Other skills observed, inherent to social work training

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include active listening skills, relationship building and motivation skills and responding to
resistance. Resistance to change impacts the moral climate within the organization and the
values and culture of the organization, impacting the reaction to change (Danisman, 2010). It is
important to also consider social work skills and values as being connected to information and
technology systems. Social workers can play an integral role in learning how to properly use
information technology accessible to them, not only to provide good data, but as a vehicle to
drive personalized and ethically based care forward. The potential for improved information
technology, according to Simpson (personal communication, August 7, 2015), could begin to
have a diagnostic function, identifying groups of individuals or communities with needs that
require an educational approach to change behavior and improve health. In time, it will be useful
to provide enough clinical information to guide the intervention or treatment of the individual,
addressing health in general, including mental health (M. Simpson, personal communication,
August 7, 2015).
In thinking about the skills needed to respond to the people within the transformational
change process, I am struck by how closely interpersonal skills, inherent to social work, can be
translated throughout the various levels of an entire Health Authority. I have begun looking
differently at any meeting as a ‘group’ and watching for value driven, interpersonal interventions
working alongside the business style or medical model of running meetings. I have gained more
confidence in asserting my skills within a team or management arena instead of simply in a client
setting. There is a legitimate role for my value driven clinical skills to be used effectively within
any interprofesional team and particularly for leadership positions supporting people through a
major change process. IPTs will be springing up all over Northern Health and social work has a
part to play in supporting people along the way. It is imperative that social work values and

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48

skills are represented at all levels of the organization as social work also has a role to play in
policy and practice development. The policy change to working within a person centered care
model is just one example of where social work values, ethics and skills are invaluable to foster
in those providing direct care.
Social policy development. Northern Health's boundaries encompass a wide variety of cultures
and norms, including the many First Nations territories (See Figure 9) and several remote

Figure 9

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communities with limited access to services. There is continued interest to address the wide
variety of challenges and adopt strategies to improve access to health care in rural and remote
communities but Northern Health’s capacity to respond to the unique needs of these
communities is limited. Further research is needed to establish the best paths forward to ensure
strong, unique approaches to people living and working in these remote northern regions. The
Innovation and Change Agenda provides an overarching framework for coordinated action,
laying the foundation for the establishment of a First Nations Health Authority to close health
gaps for Aboriginal peoples. Comparing the Northern Health mandate, mission and values with
those of First Nations Health Authority, the latter is much more focused on person centered care
versus focusing on service/performance. It uses ‘us and we’ language in context of ‘people’,
measuring outcomes by way of the people’s health and satisfaction with services. Northern
Health is dedicated to patient centered care and is looking to others who can help lead them in
their work with collaborating with aboriginal people within the Health Authority.
Northern Health is actively studying this system for their future plans with partnering
more formally with the local First Nations. The current systems, while not yet working formally
together, do co-exist and both Northern Health and the Non-profits are learning from each other
in hopes of future information sharing and cohesive, team based care. Nak’azdli, a non-treaty
First Nation of 700 members on Reserve, next to Fort St. James is a current example of a First
Nation working alongside Northern Health. Using a not for profit model, Nak’azdli has created
its own Health Centre with a Nurse practitioner, two Nurses and visiting professionals, with
many volunteers coming together to help their system work. Another example of a not-for-profit
structure is in Hazelton, BC where the United Church owns the patient data of the agency
providing the services. To formalize any true partnerships or sharing agreements in these

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outlying and remote areas, there must first be a balance agreed upon between autonomy and
standardization. With First Nations leading the way, the place for social work will arise again
once this journey to partnership is pursued and developed.
Community based services compliment and augment the integrated primary health care
approach by providing specialized and targeted services (Clapton et al., 2008), yet community
agencies are also not yet a part of Northern Health’s transformational change. This is recognized
as an important aspect to add on in the future. When information can be more freely shared
amongst coordinated and integrated services, people will experience a higher quality of person
centered care that is more efficient and easier for the person to navigate (Clapton et al., 2008).
Here in northern British Columbia, social workers are often generalists, used to resolving service
gaps as they arise and are a natural fit to lead this work as they often already have a connection
to resources within their community and have a culture of navigating all systems available to
them. As a long-time resident of Prince George, with a strong background in the Non-Profit
Sector, it is important for me to provide knowledgeable leadership to the future inclusion of
community partners. Information sharing with these agencies would further enhance the quality
of care provided and help build our community together
The review of research of an integrated primary health care team approach, conducted by
Northern Health, show that IPTs are both effective and cost effective. A deeper review and
assessment of the dynamics of dispersed teams and leadership qualities involved in
transformational change is necessary for teams to flourish (Allen & Vakalahi, 2013). Little is
known still, specific to the role and effect of organizational leadership and managerial decision
making within interprofessional practice (Conference Board of Canada, 2012), leaving a need to
capture organizational data to assess team functioning at all levels, as well as the impact on

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health and economic outcomes. In shifting this culture of the organization, there is a need to
question decisions and rationale along the way, thereby encouraging new ideas and innovative
solutions while creating new processes. This will require a genuine passion for the work and an
ability to engage people in a manner that instills trust and confidence to try new approaches.
Social work could have a positive effect on policy development, ensuring person centered
practices and the people side of change is prioritized.
Working with Physicians. Physicians are a key component to the success of this
transformative change and moving to a model of patient centered care relies heavily upon the
leadership of physicians. In the letter addressed to Terry Lake, BC’s Minister of Health, Premier
Clarke (2015) highlights the mandate of the Ministry of Health 2015-16 and includes the
following direction:
“Work with the Doctors of BC, College of Physicians and Surgeons, College of
Registered Nurses and the Association of BC Nurse Practitioners, to continue to
strengthen primary care access for British Columbia patients across the province
including the addition of new physicians and Nurse practitioners”.
Knowing when and how to engage with physicians is fundamental. Each region is
protective over what they are doing and doctors and others want to be consulted ‘with’ not
directed ‘to’ (P. Murray, personal communication, June 7, 2015). The team is reminded to be
aware of ‘top down’ communication and direction, to listen carefully to the communities and to
be respectful of their current service patterns and trends (P. Murray, personal communication,
June 7, 2015). There is a continued need for Physician ‘champions’ throughout all levels of the
system, who can help translate information from the Executive, to and from physicians. While

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their involvement is integral to changing the system, physicians bring their own level of power,
adding to the complexity of the current changes (L. Holland, personal communication, August
12, 2015). There is a persistent, re-occurring struggle to balance local and professional
autonomy with the need for standardization across the organization. To balance flexibility with
standardization, both within and outside Northern Health, integrated primary health care services
work in partnership with the Divisions of Family Practice, who commit to supporting physicians
until they are ready to join the systematic change to integrated primary care (O. Godwin,
personal communication, August 13, 2015). According to the Executive Director of Divisions,
Ms. Godwin, being a Social worker plays a strong role in the position of leadership within the
Divisions (O. Godwin, personal communication, August 13, 2015). Bringing fundamental social
work values and systems thinking to her present work promotes change to happen more quickly
and efficiently, as she uses her group facilitation and conflict resolution skills to resolve
interpersonal and team tensions. (O. Godwin, personal communication, August 13, 2015). The
Executive Director sees another struggle involving physicians and Nurses, who often find
themselves responding to perceived notions of their power and authority and the cultural norms
within the health care discipline (Conference Board of Canada, 2012). The medical model,
rooted in hierarchy and formal processes, becomes especially problematic with respect to Nurses
and their relationship with doctors (O. Godwin, personal communication, August 13, 2015).
These norms are deeply entrenched and can be detrimental to the working relationship and team
environment, causing tension and animosity (O. Godwin, personal communication, August 13,
2015). This relationship dynamic is in need of healing, or team based care may be in jeopardy
(O. Godwin, personal communication, August 13, 2015). According to Godwin (2015), there is
a role for social workers to help team members to “unpack” their historical issues and explore a

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healthier understanding of their roles and expectations, to demystify them and move past these
historical issues.
Primary health care services, the first and most common point of entry into the health
care system (Conference Board of Canada, 2013), yet physicians are often unprepared and
untrained in addressing the wide scope of needs people present with. These might include the
psychological and social aspects of care, and the broader health issues such as child welfare,
homelessness, and poverty (Canadian Association of Social Workers, n.d.). On the current
integrated teams, social workers help physicians take on these ‘soft skill’ interventions, adding
value to the Physician’s practice, given their expertise in navigating the financial, social, and
mental health and addiction systems, both within the health authority and within the local
communities.
Just as physicians are imperative to integrated primary care, Psychiatrists are key
members in the redesign of Mental Health & Addictions services. As integrated primary care
teams are being asked to take an active role in developing the system as they go, Psychiatrists are
being asked to help with the process of determining function of the IPT specialty services.
Clinical pathways for people and information to travel from primary care homes to Psychiatry,
MH&A specialized services and back again must be defined and processes standardized,
including any screening and assessment tools. The Psychiatrists generally see the benefits of
primary care, but have grave concerns for their most seriously ill people falling through the
cracks of this model. This particular group of Psychiatrists is resistant to the proposed changes
and shares a history of protecting specialty services. Providing good leadership to this strong
voice is imperative, as the system is already moving forward with change so the time for
negotiation is past and time for planning and creating has arrived. The Mental Health and

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Addiction open forum held August 6, 2015 was an important first step to begin to engage this
group of professionals and find ways to work together to change the system. The process of
hosting this forum was informed by Mr. Mike Simpson, a social worker with extensive training
in such areas as group dynamics and group facilitation. Such skills in leadership and group
dynamics were invaluable in directing the conversation and understanding the issues from
multiple and differing perspectives to one big picture. For example, in the planning stage the
agenda was reframed to allow speakers to discuss ‘how’ the system will be built, instead of ‘if’
or ‘why’ the change is occurring (M. Simpson, personal communication, June 2, 2015).
Knowing the historical context of a group provided crucial information to move this group
forward. The forum was chosen to be professionally facilitated to remove Northern Health
Executive from directly telling the Psychiatrists what to do and instead encourage open and
honest dialogue to move forward together (M. Simpson, personal communication, August 6,
2015). In this case, it made better sense to approach this meeting as an informational session,
providing informational updates of how they are moving through changes, rather than trying to
buy the group into a concept which is already adopted (M. Simpson, personal communication,
August 6, 2015). Maintaining a tight agenda, with an unbiased facilitator allowed group
members an opportunity to have their concerns heard, minimize backlash and promote cohesion
with the broader perspective. Generalizing the same particular message as the other specialty
services including chronic disease, reminds the group they are part of the bigger picture of
change occurring across the entire NHA (M. Simpson, personal communication, August 6,
2015). This perspective shift is important as the culture of the system must move to one of
integration, sharing information and becoming truly person centered instead of system centered.

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Integrated primary health care teams. Professional team based care works with
individuals and their families who are respected as integral to the change process, through
partnership and collaboration, improving patient experience, provider satisfaction and long term
cost sustainability (Northern Health, 2015). As workers move from the current model of care
into interprofessional primary health care teams, they will become a part of a community based
team, supporting a physician’s practice. One such team in Prince George is situated in an old
elementary school, where Northern Health offices provide a home base for the current and future
IPTs. As teams form in different locations throughout the health authority, office and primary
care home space must be found and secured, before designing systems to accommodate a shared
electronic medical record and with remote access. Near the end of the practicum, I had the
opportunity to shadow an IPT social worker who is a part of a seasoned interprofessional team,
leading the way in the change process. I saw the team in action, joining their morning ‘huddle’ to
review new referrals and discuss any complex issues. I heard the different perspectives and ideas
shared amongst the nurses, the occupational therapist, the mental health clinician and the social
worker and experienced the value of hearing different views. After a morning huddle, she
travelled to a doctor’s office downtown and conducted interviews and counseling sessions to
their identified panel of people. As I joined her in her work, I observed the generalist nature of
her role and was able to think about the language we used in the job descriptions and how it fit
well with the expectations and realities of the role. During the one morning, I saw her involved
in assisting clients with a variety of social, financial and legal issues while navigating several
systems. While this particular team is strong and functional, the social worker admitted that the
anticipated organizational shifts are making them nervous about how they will be affected by the
system changes.

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A challenge of implementation across a vast region is designing a team approach that
makes sense for different local communities. IPTs will look vastly different throughout the
Northern Health Authority, depending on individual community size, location, capacity and
need. Health care workers living in the smaller, more remote communities are applying this
integrated primary health care approach to their community within the realities of their resources,
assets, skills, cultural norms and geographic location. For an example of complexity and
resourcefulness, consider Tumbler Ridge, where Public Health services are now shared with
Chetwynd. Remaining true to integration, these two small communities had to find the capacity
to fill the public health role in both communities. The team has discovered and is testing unique
‘work around’ solutions for sharing resources and information. Despite the long distances and
limited physician ‘buy-in’, the role is being shared between the two remote communities.
The pilot communities in Prince George, Fraser Lake and Fort St. John have been
working within the new way for six years or more, paving the way for the current
transformational shift for the remainder of the Health Authority. The teams are tired and often
frustrated with the barriers they face within leadership, and have lost some trust that their work
will be meaningful to those changing in the future. They continue to experience times where
resolution to their barriers was much too slow, and in response, communication returned to the
old systems. The team needs rapid answers to their questions, regular updates and to trust that
their hard work will be used to inform future work. They worry that the processes they worked
so hard to develop will be changed in the standardization process. During this practicum
experience, it was necessary for Executive leadership to respond rapidly to the concerns of the
Lakes Region, to build rapport and to actively listen to their concerns. This personal interaction
will help resolve issues, demonstrate trust and openness to share. Once the alliances built and

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trust developed with those in that region, others will see how the new network system can
operate, and begin to trust in the new processes. According to Simpson (personal conversation
August 7, 2015), trust is not something to build, but must be earned through action. It is not
enough, therefore to change the system. People must also be invited and supported to partake in
the new way, so trust can begin to develop and spread.
Given the sometimes vast shift in scope of practice, many staff will experience a
completely new way of providing care and will often have to update their competencies in
certain areas. Some staff will be affected vastly more than others and despite having to learn
new process; the provision of care must remain both seamless and coordinated. This will
produce tremendous stress throughout the system that will require ongoing interpersonal
management over a long period of time. One pilot team has struggled to work through many
challenges and still describe their teams as in the ‘storming’ stage of development (Tuckman &
Jensen. 1997). This team worked very hard to build and reorganize their systems to manage the
workload but never did benefit from having a social worker on the team. This means the team
and the whole region have been left with inadequate social work perspective and intervention to
support the changing medical model of care. Lack of role clarity, trust and overlapping skills can
cause chaos within a team and without clear boundaries, people may perceive and project
hierarchy of importance and/or power (Conference Board of Canada, 2012). Role ambiguity was
certainly prevalent throughout the questions resulting from the public health forums. Most
concerns and fear revolved around a lack of understanding their new future role within primary
care teams and what they would be expected to do within their scope of practice. The reality is
that the system is changing and people will learn and develop new ways as they go, making the
end result dependent on the people working within it their ability to manage and shape it. This

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prospect is overwhelming for some and exciting for others, so support must be available to those
struggling to cope. Understanding the need to be a true stakeholder in the change process is at
the core of traditional social work and is person centered. Relationship and team building skills,
fundamental to group facilitation and counseling are a part of fundamental social work skills.
Building trusting relationships relies heavily upon the skill of active listening, setting aside
personal values and concentrating on what must occur to provide better care to the people
receiving services.
Social work has much to offer both the integrated primary health care teams as well as
the transformational change process to shift the way healthcare is both viewed and delivered
within the Northern Health Authority. Their experience and expertise benefit, not only their
immediate teams, but the transformational change process as a whole, influencing the next
generation of leaders to come. Truly changing how care is provided, allowing the person to be
the leader in their own care will take strong leadership and role modelling. As a social worker,
the challenge of leading people through a cognitive and behavior shift sounds exciting but
managing the push back and resistance to change will be a daunting task. As a leader, it will be
important to encourage teams to shift their thinking, culture and behavior to provide integrated,
person centered care. Without these shifts, people will quickly revert to practicing in old ways.
According to Mitchell et al. (2013), the skill and reliability with which team members work
together is fundamental to the success of team-based care. Mitchell et al. (2013) describes
honesty, discipline, creativity, humility and curiosity as the personal values, necessary for
individuals to function effectively within the team. Kotter (2014) discusses the importance of
deep listening, trust and collaboration throughout the relationships within the team. According
to Tafvelin et al., successful transformational leaders create environments fostering commitment

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and role clarity to promote a stable organization, while support among co-workers enhances the
effects of transformational leadership ( 2014). The role for social work speaks for itself. Strong
fundamental social work skill such as group facilitation, understanding group dynamics, conflict
resolution and communication promote change at both a transformative level as well as within
the very team surrounding the person receiving services.
Summary
The creation and implementation of a transformational change to how healthcare is
provided throughout an entire Health Authority is extremely complex and difficult to study in its
entirety. Transformational change is slow moving, taking years to fully incorporate throughout
the system. This practicum took place on the cusp of full implementation throughout the
regions. Northern Health has now embarked on the next steps in their change process, applying
an integrated primary health care approach to rural and remote regions of northern BC and
expanding all existing primary care systems. The scope of the change process and the individual
needs of communities and regions make this a daunting task for any organization, and given this
time of initial action, the process began to move more quickly. The higher level systems within
the organization, in response, changed their structures and process to accommodate the faster
rate of change than they were previously able to manage. This structure may not go far enough
however, to facilitate the necessary culture change toward community based and client centered
care. There is a need for more of an ‘army’ of champions throughout the system, with either
power or influence (or both) to drive the change forward in a person centered manner (Kotter,
2014). It will be interesting to see if the momentum continues as Kotter (2014) describes and if
the current system can be nimble enough to respond to barriers as they arise. The culture must
also now shift to allow middle managers to be free to be innovative and creative in their response

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to change, refraining from operating in the old silo system. This cultural shift will influence and
support the front line where the care is being provided.
There are many intertwined mechanisms that drive change of this nature forward, with
different approaches and perspectives regarding how the move should transpire. The people side
of change can be affected with organizational priorities overriding change management, yet
change doesn’t just ‘happen’, change begins and ends with people. To move an organization
forward in a systematic way, new process and function will occur and workers must feel safe
enough to take risk and learn to trust one another. Despite having skilled people working on the
ground, it will still require time and space for them to adjust to their roles on the IPTs, leaving a
variety of opportunities for social work to have influence over how the medical model transforms
into a more client centered, helpful and efficient system. Employee resistance to change is
directly tied to organizational norms and culture, trying to preserve how things are and have
always been inpacting the success or failure of change efforts. (Duff and Hurtley, 2012). It is a
difficult task to engage individual people to commit to systematic change; to shift their thinking
from being about them personally, widening their perspective to empathize with others. It will
take strong, supervisory role models throughout the system, brave enough to risk better systems
with innovative solutions. Team dynamics will play a big role in how integration moves
forward.
Social work has an integral role in helping the people. Pullen-Sansfaçon and Ward
(2014) contend that social work in general is well suited to the task of transforming culture.
They can assist people to embrace change and to take an active role in improving the level of
care provided to the population. Applying social work principles to change management will
support the workers as they shift their entire culture, questioning why systems are in place and

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finding new processes to create more client centered systems. Client centered values drive the
guiding questions about how transformational leadership skills and attributes compare to
traditional social work values and skills. Social work values and insights are an asset to any
change process, and can be especially effective when applied to transformational leadership
roles. Social work has a significant role to play in all levels of the organization and in many
capacities during a transformational change. The implications for professional practice are far
reaching, throughout all levels of the organization. The skills applied to support necessary
culture shifts to create person centered care can be positively influenced by social work values
and ethics. This practicum experience allowed but a glimpse into an enormous system change yet
clearly demonstrated the unique and integral position social workers must contribute to the
success of an endeavor of this magnitude.

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