Healthcare Quarterly

Healthcare Quarterly 2(3) March 1999 : 24-30.doi:10.12927/hcq..16546

Communication as a Priority for Success: Lessons Learned through Change at St. Michael's Hospital

Jeff Lozon and Rosemary MacGilchrist


"What we have here is a failure to communicate."
There are few phrases in our language with as much power to change history and alter the shape of events. With these familiar words, battle lines are drawn, relationships break down, partnerships dissolve and dreams are abandoned.

Communication, in all its myriad forms, has enormous implications for healthcare organizations, particularly during these times of unprecedented and accelerated change. If left ignored or given lip service, it can lead to organizational paralysis, resistance to change and a demotivated workforce. When championed and elevated to a status of strategic importance, it can do just the opposite: promote change through understanding; inspire employees, physicians and volunteers; win the support and influence of vital stakeholders; and achieve corporate goals. Both directly and indirectly, the successful application of communication helps us to achieve our common goal as caregivers: provide excellence and quality in patient care, in teaching and in research.

An organization that is absolutely committed to communication is one that demonstrates these key factors:
  • A formal and dedicated communications function with appropriate resources to support a wide range of information media and programs reporting to the most senior levels of the organization.
  • A culture that supports open, honest communication through the presence of credible management spokespersons and a commitment to timely sharing of information and dialogue around key decisions and issues.
  • An environment of participative decision-making and on-going consultation.
  • Regular communication "checks" through staff satisfaction surveys, focus groups and other techniques to take the "pulse" of the organization.
  • Communication principles that are aligned with the organization's mission and values.
  • A disciplined approach to change that always involves a communication plan.

A supportive communications culture is one where success is not measured by how many communication policies or procedures are in place but by how clearly employees understand the organization's mission, by how well they are treated, recognized and respected and by how committed they are to enhancing the value of their employment experience with that particular institution.

St. Michael's Hospital, a Catholic teaching and research hospital in downtown Toronto, has gained many insights into the value of communication during the past seven years. This article provides an overview of the importance of communication throughout the organization's transition process and outlines lessons that can assist other healthcare organizations as they move forward with their own particular challenges and opportunities.

In any kind of organization, communication is a priority for success but in healthcare facilities - high-touch organizations - it becomes a particularly vital component. At St. Michael's Hospital, communication is a key factor in decision-making, in the development of new initiatives and in managing human resource issues. Ongoing communication has become intrinsically woven into our fabric and our culture.

Toronto's "Urban Angel" as St. Michael's Hospital has affectionately been called, is fully affiliated with the University of Toronto and provides leadership in patient care, teaching and research. The hospital was founded in 1892 by the Sisters of St. Joseph to care for the homeless and the poor. This important part of the organization's mission has remained intact, but the work of this downtown hospital has expanded to include an additional focus on treating heart disease, trauma, HIV/AIDS, kidney disease, diabetes and a wide range of services within the inner-city health program.

Hospital facts and figures point out to the organization's key role within Toronto as both a major employer and a vital contributor of healthcare services on two campuses, the Wellesley Central site and the Bond site: 4,500 employees, 25,000 annual inpatient admissions and 385,000 outpatient visits per year.

Change as the Communications Catalyst

St. Michael's Hospital has experienced a level of unprecedented change during the 1990s. The management team and the Board of Directors managed to turn a dramatic financial crisis in 1991 into an opportunity to make choices and changes long before other healthcare facilities were forced to respond to changing consumer expectations, the accelerated pace of technology and significant funding reductions, to mention only a few driving forces.

Here's a chronological snapshot of the major events that have shaped the communication practices at St. Michael's Hospital:

1991 The discovery of a $63 million debt - the largest recorded by an Ontario public institution to that date - threatens the organization's survival.
1991/92 An aggressive program of financial and management restructuring and a new strategic plan, "Shaping Our Future Together," ensures the hospital's stability and provides assurance to the Ministry of Health that the organization can move forward into the future.
1994 The hospital receives funding and approval from the Ministry of Health to build a new facility that will house new operating rooms, intensive-care units, diagnostic laboratories and amenities for patients and staff.
1995 A reengineering project, "Patient Care Journey," streamlines the organization, reengineers processes and systems to make them more efficient and effective, and creates major organizational change for improved patient satisfaction.
1997 The hospital's debt is eliminated.
1997 The first directions from the Health Services Restructuring Commission - the province's restructuring organization - recommend the acquisition of the Wellesley Central Hospital by St. Michael's Hospital. A legal and public relations debate ensues as the former Wellesley Central Hospital challenges the recommendation.
1998 The final directions of the Health Services Restructuring Commission are issued, and it is clear that the former Wellesley Central Hospital will integrate its programs and services with those of St. Michael's Hospital.
1998 The Foundation for St. Michael's Hospital successfully completes a $20 million capital fundraising campaign. Part of the success of this campaign can be attributed to a "rebranding" of the hospital's history as Toronto's urban angel and the communications theme "Help Us to Watch Over You."
1999 A new strategic plan is developed as a focal point for moving ahead with the integration of the former Wellesley Central Hospital with St. Michael's Hospital. This plan includes a culture study, a staff and physician satisfaction survey, a new vision and revisions to the hospital's mission and values to become more reflective of the transition process and the current environment.

A Commitment to Communication

In 1991, the immediate challenges faced by St. Michael's Hospital and its leadership following the financial situation were enormous. Within a few short months, the hospital ensured its continued survival by streamlining operations, embarking on an aggressive recovery plan, appointing a new management team and putting new processes and systems of accountability into place to ensure that such a situation never occurred again. Many of the difficult decisions of this time included bed closures and staff layoffs to reduce expenditures and save money.

These actions crystallized the organization's commitment to communications. If we look back for a moment, before 1991 the communication climate within the organization can best be described as following an unwritten rule about "the need to know." The process was hierarchical and filtered, and as information moved through the chain from top to bottom, the messages lost clarity and consistency. Cross-professional communication was almost nonexistent. The content was sporadic and often inaccurate. A change in the communications climate was brought about by the magnitude of the crisis and the gradual erosion of trust - a "blip" in the communications environment of the organization. The culture of St. Michael's Hospital, founded by the Sisters of St. Joseph, was one that was considered high-touch and high-intensity in the value that was - and still is today - placed on relationships, on respect and on individual dignity. The breakdown in communication during that time demonstrates the impact that a major loss of credibility can have on a communications structure and philosophy.
A year after the crisis, the aggressive strategy began to pay off. The hospital was financially stable and the debt had been reduced by one-third. A strategic plan, "Shaping Our Future Together," was developed following an exhaustive consultative process with key stakeholders. Employees, patients, the community and others were excited about what the plan meant for the future of the hospital. The lines of communication were opening again.

And, in fact, communication was formalized in the 1992 strategic plan because it was identified as an area of organizational priority. Since that time, many communication processes, structures and systems have been put into place, but the single most important factor in successful communication begins with the commitment of the President and CEO and the senior leadership team. It begins with a pledge to share information openly and candidly, to listen to diverse viewpoints and opinions, to minimize confidentiality, to recognize and appreciate those who are working towards the organization's goals and to encourage open and ongoing participation from key stakeholders. This pervasive culture and active participation in the communications process is much more effective than publications, open forums and information-sharing meetings. These tools are crucial, but it is important that they be seen as complementary to the process, and not as the process itself.

With a framework and commitment in place, the communication challenges and objectives of St. Michael's Hospital became strategically linked to the overall goals of the organization. The immediate requirement was to rebuild employee pride and deal head-on with negative media coverage that had shaped public opinion just after the crisis. The goals were to:

  • Demonstrate, through concrete examples and actions, that this was a new St. Michael's Hospital - one that was fiscally responsible, progressive and had changed outdated processes and ways of managing its business.
  • Regain the confidence of key stakeholders, including patients, staff, physicians, donors, the government and the community.
  • Build pride and a sense of optimism in the future among the staff. The former "family-style" atmosphere of the hospital had been threatened and employees felt there had been a breach of trust.
  • Reposition the hospital to internal and external audiences as an organization that could balance two very different but integrated objectives: to achieve fiscal responsibility and sound business practices while maintaining the level of quality patient care that had become the hallmark of this downtown hospital.

In 1998, a full communications and media relations audit - positioned as an important step before the development of our next strategic plan - indicated that these important goals had been achieved. St. Michael's Hospital - Toronto's urban angel - was seen as a leader in healthcare reform, progressive, patient-focused, caring and compassionate. A staff satisfaction survey showed that St. Michael's Hospital had achieved the benchmark among its peers in areas such as communication and recognition of employees. There is still much work to be done in moving towards the new vision and directions of our recently completed strategic plan, but the seeds have been sown and a solid foundation is in place.

Multilayered Communication the Key to Success

Today, St. Michael's Hospital develops and implements communications programs on a number of levels and geared to a wide range of audiences. The communications model is based on sharing and collaboration of key message development across, up, down and throughout the organization's complex layers. The expectation is that the President and CEO of the organization, and the leadership team, will set the communications tone through openness, accessibility and honesty. The President and CEO is engaged in all facets of communication to a broad range of audiences - staff, physicians, volunteers, donors and friends, government and other key influencers. Face-to-face dialogue and discussion is the preferred method of communication within a high-touch organization, although a full range of communications tools and techniques are employed.

Some of the highlights of the organization's commitment to communication include:

  • A repositioning program called "Reform, Recovery, Renewal," which was targeted to both internal and external audiences in 1992 to communicate the organization's turnaround and the directions that had been developed through a new strategic plan. A significant component was an internal communications plan developed following a full communications audit. Equally important, this plan included a new emphasis on proactive media relations to counterattack much of the negative publicity that had arisen from the financial crisis.
  • An emphasis on face-to-face communication programs including ongoing Town Halls (open forums), a Breakfast-with-the-President series, Leadership Forums for managers and a Communications Council. The council brings together representatives from all areas of the organization including physicians, staff, volunteers and union representatives. The group's mandate is to bring forward issues, discuss areas of concern, flag "hot communication topics" and test communication messages and strategies. This approach is being used effectively during the transition process of integrating the programs and services of the former Wellesley Central Hospital with those of St. Michael's Hospital.
  • A heavy reliance on print (identified as a key and preferred source of communication) as part of the comprehensive internal communications plan, including a quarterly feature magazine called Wings, a biweekly publication called NewsBreak, news bulletins, an Intranet site, extensive use of email, bulletin-board displays and regular question-and-answer documents on human resource issues.
  • An aggressive media relations strategy that targets the business and financial press because this audience is the primary source of donations for equipment and technology. There is no other hospital in Canada that has received the quantity and quality of media coverage in the business press as St. Michael's Hospital. Stories on research breakthroughs, positions on healthcare issues and "firsts" in patient care are also marketed to print and electronic media on a regular basis to promote the hospital as an organization concerned about patient care and demonstrating leadership in teaching and research.
  • Development of a new Corporate Identification program, which repositioned the hospital as "Toronto's Urban Angel" through a new logo and graphic standards for all print and audio-visual materials.
  • A communications program developed for the Urban Angel capital campaign, which took this theme one step further with a positioning statement and support materials under the slogan "Help Us to Watch Over You." This campaign raised awareness and financial contributions to support the Foundation of St. Michael's Hospital.

One of the reasons why these initiatives have all been so successful is that they are team-based and developed by experts in many areas throughout the organization. The ownership resides with a committed group of stakeholders through the hospital and supports a key message and underlying principle of our communications efforts. What becomes clearly evident is that communications is not a sole product or responsibility of the Communications department - although clearly this group has some defined accountabilities and goals - but is a responsibility of everyone within the organization. Communication is identified as a core competency of the organization.

Human Resources and Communications: Partners in Change Management

Communications is quite simply about people. In high-touch organizations, the kind of issues that people identify as being crucial are those that add value to their work by helping them to understand the vision and their role in being a part of the big picture. Yet during times of intense change the questions that are the most important and urgent for employees are the ones that are often the most difficult to address. People need and want to know whether they will have a job after reengineering or restructuring, and what impact any job change will have on their role within the organization and on their long-term career. These issues are not always answerable - because we often just don't know the answers - and they become even more complex in a unionized environment.

The Patient Care Journey at St. Michael's Hospital involved a major restructuring and reengineering of processes, patient care roles and support systems throughout our organization. Because of the anticipated change there was a high level of anxiety associated with the rollout of the process. Our organizational response was to immediately form two work groups of representatives from throughout the organization, one for Human Resources issues and the other for Communications issues. There were many other work groups engaged in a high degree of activity, but these two groups worked in close cooperation from the start to develop guiding principles and work plans to guide the process. Our approach was that we would "overcommunicate" if that was what was required, and that we would place significant resources behind the development of a wide range of materials, mediums and tactics to ensure that everyone understood what was happening and the rationale behind the change. That did not necessarily mean that everyone liked the messages they were hearing, but there were abundant opportunities to receive, share and discuss information.

One example of how the partnership between Human Resources and Communications was so effective can be seen in how we addressed changes in job responsibilities - a radical redesign of traditional patient care roles - with our employees. Through ongoing dialogue and shared discussions, it became clear that the traditional roles of employees within St. Michael's Hospital would not sustain the organization into the future. Considerable efficiencies could be gained, improved patient care achieved and the quality of working experiences enriched for our staff.

The role redesign initiative involved the redistribution of responsibilities from traditional positions such as housekeepers, ward secretaries and porters to new positions with a greater scope of responsibility and an improved focus on patient-centred care. Environmental assistants, for example, were involved in a number of tasks such as assisting patients with completing their meal choices, cleaning rooms, delivering messages and flowers and communicating with families on the floors. As a result of the change, employees were enabled to learn new skills and to eventually apply for new positions within the organization as their existing positions were phased out. The process was complex, but Human Resources, Communications and members of the role redesign team worked closely together to ensure that employees understood the process and had the supports they needed to become successful.
Communication messages were developed and disseminated about the value of employees to the organization and our commitment to minimize job loss in keeping with our mission and values. At the same time, visible actions and strategies undertaken through Human Resources initiatives were demonstrating the credibility of these messages.

Seminars in resume writing and interview preparation were offered. A Career Assistance Centre provided guidance and options on career choices both within and external to the organization. Mentors were assigned to assist staff in role playing and rehearsing for interviews. Skills that were crucial to job success - keyboarding and English as a Second Language, for example - were provided to employees to ensure they were equipped to compete successfully for new roles. In short, leadership was "walking the talk," which made the communication messages credible, easily understood and visible. The change was achieved with minimal job loss and disruption.

A strong relationship, mutual respect and a working partnership between the Human Resources and Communications functions are essential for success. In our hospital, this is a clear commitment that has resulted in a number of shared achievements, including the development of recognition programs, a well-publicized performance management system, an attendance improvement program and ongoing staff satisfaction surveys. These efforts were guided to a great extent by Human Resource Principles and Communication Principles - clear statements of intent and purpose that are developed in consultation with employees to ensure their relevance and credibility.

Another successful initiative during the Patient Care Journey was our effort to leverage the power of the rumour mill to advantage. In spite of the best practices in communication, the rumour mill or "word on the street" will always be the most effective source of communication. The trick is to work with this effectively and ensure that the stream of communication through these sources is clear, credible, timely and accurate. To help us do just that, we appointed Communications Captains, the people seen as the informal leadership throughout the organization. These Captains met with the President and CEO regularly, usually during a time when key milestones were reached or decisions confirmed. The goal was to ensure the Communications Captains understood and championed the messages so that they could become ambassadors throughout the organization.

The Captains were treated as privileged receivers of information in that they received communication around key issues on a priority basis. As a result, they were seen by their peers as those "in the know."

Future Communication Challenges

In April 1998, the Health Services Restructuring Commission of Ontario - a government-appointed body with the authority to develop and implement directions for change within the provincial healthcare system - recommended that St. Michael's Hospital acquire the programs and services of the former Wellesley Central Hospital. During the 1998 year, this process required most of the organization's energy, commitment and resources to ensure a smooth and seamless transition for patients, staff, physicians, the community and other key stakeholders. The process has been challenging, and we have learned many lessons along the way.

The challenges have been compounded by the delay in the physical consolidation of the two sites, and at the time of publication it is clear that the Wellesley Central site will remain open until at least August of the year 2000. In spite of this, the transition process is well under way, and the new strategic plan provides clear directions for moving ahead so that St. Michael's Hospital can achieve its vision of being recognized as the finest academic healthcare provider in Canada.

An important first step in our integration process has been the development and implementation of a cultural study. This study - administered through a series of focus groups on both sites and a survey tool - demonstrated that there were more similarities than differences between our two organizations. It also identified gaps where additional communication and work is required to help us move forward proactively in integrating the two organizations. For example, the culture study clearly indicated that there was a great deal of misunderstanding about the meaning and concept of a Catholic hospital, and a comprehensive communications, education and awareness plan has been developed to deal immediately with this important issue.

As we move forward through the integration process, we are using the full range of our communication tools and techniques. We rely on a special "New Directions" newsletter, on Town Halls and on quarterly briefings with managers to get the word out. We have brought a group of representative employees together to act as our issue "touchstones" and to develop a series of Communication Principles to guide our efforts. We are upfront with employees, physicians, patients and the community about the status of the transition and are quick to address changes as they occur. Visibility at the senior management level has been a key priority throughout this process, especially as we are finding again that there are many human resource issues that cannot be definitively answered now but that are causing anxiety for staff.

Lessons Learned

The benefits we have gained from the power of open communication are overwhelming results, acceptance from key stakeholders and the satisfaction that comes from developing ambassadors for the organization. We have proven over and over again that involving a broad range of people in solving a problem or addressing a particular issue provides a much stronger solution than one developed by an exclusive group. Often, the process does become more laborious and time-consuming, but the quality and the creativity of the objectives are worth the extra effort. At the same time, open communication makes for results that are more sustainable because people have a stake in them, are convinced of their ownership and have a strong investment in the results. Acceptance is built in along the way as well as a long-term commitment and a passion to achieve shared goals.

Through open communication, we have created ambassadors for our organization - ambassadors and champions who have been understood, respected and valued throughout the problem-solving process. Committed, excited, passionate people are a greater endorsement of any organization than glossy annual reports, eye-catching advertisements or other mediums. Again, it reverts back to the importance of face-to-face communication in a high-touch, high-intensity environment.

For organizations who are excited about communication and who are committed to results, these are the top lessons in communication learned through seven years of change at St. Michael's Hospital:

  • Build commitment from the top.
    The President and CEO and the senior leadership team of the organization must be prepared to make communication a priority and to ensure that behaviours and actions support the messages being given throughout the organization. The communication must be open, honest, timely and credible. Sometimes that means sharing information before all of the facts are complete or while many questions are still unanswered. Don't be afraid to reveal your vulnerability if you don't have all the answers - this is a risk you will have to take.
  • Layer the organization with your messages.
    Commitment does begin at the top, but from that point on forget about hierarchical communication processes and cascading rollouts, especially in complex organizations such as healthcare facilities and teaching hospitals. Use existing committees to review and receive messages and develop solutions. Target informal ambassadors and leaders to carry the message. Blanket the organization by using all available communication venues and opportunities. Use every chance for face-to-face communication. Supplement dialogue with established traditional tools such as publications and newsletters. Your layers of communication should move up, down and across the organization.
  • Build milestones for participation and consultation at every step of the process.
    Whether you're developing a solution to deal with funding cuts or a high-level strategic plan for the future, make sure there is plenty of opportunity for employees, physicians, volunteers and patients to have their say and input into the process. The outcome will be ownership, credibility and commitment.
  • Demonstrate passion for your message.
    If you don't believe what you're saying, you can't expect anyone else to. Show your excitement and enthusiasm for your message. Keep your language clear and straightforward. Adapt your presentation style to the culture of your organization.
  • Ensure that communications becomes everyone's responsibility.
    A strategic communications professional who understands and can apply the appropriate research, planning and evaluation techniques is necessary and can lead your organization's communications initiatives in a coordinated and effective way. By communicating clear expectations about communication responsibilities and building these into performance management systems, a culture can be sustained that rewards and recognizes effective communication at every level and with every employee.
  • Leverage the power and credibility of your management team.
    Traditionally, middle management has been referred to as the "frozen middle." Our communication surveys indicate that employees prefer to hear important information directly from their managers and that this group has a high degree of credibility. Focused efforts on providing these managers with the time, resources and training can be extremely beneficial and provide a vital link in the communication chain.
  • Build a strong bridge between Human Resources and Communications.
    This partnership, as explained earlier in our article, is integral to success.
  • Communicate as much as you can - and then go back and do it again.
    Use the full range of tools and techniques at your disposal. Our premise is that you can never communicate too frequently or too often. It would be hard to cite an organization that had been challenged because of its emphasis
    on overcommunication.

Many people have been amazed at how well St. Michael's Hospital has survived during this period of constant change while still maintaining good morale among our staff - the special feeling of care and compassion that is the spirit of our reputation as Toronto's urban angel. People truly believe that what they are doing and contributing to our organization makes a difference. By integrating the power of communication into the philosophy and the day-to-day operations of a high-touch organization such as a healthcare facility, we can all make a difference by bringing hope, healing and comfort to those whose lives we touch.

About the Author(s)

Jeffrey C. Lozon has been President and Chief Executive Officer of St. Michael's Hospital since 1992. He is currently on secondment as Deputy Minister of Health for the Province of Ontario. In 1998, he was awarded the CEO Award of Excellence in Communications by the Toronto chapter of the International Association of Business Communicators.

Rosemary MacGilchrist is Director, Communications for St. Michael's Hospital where her responsibilities include communications activities such as corporate identity and positioning, employee communications, media relations and issues management.


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