In the summer of 1998, the University Health Network (UHN) faced an acute personnel situation in which an exodus of skilled resources was taking place. The turnover of information management staff was increasing dramatically, and despite best efforts to recruit new employees, the vacancy rate remained at an unsustainable level. This case study reviews both the short- and longterm strategies that were employed to address these issues and to establish UHN as an employer of choice in health information management. Material in this article is based in part on papers presented at HIMSS 2000 and INFOCUS 2000 (Cameron, Claiter and Murphy 2000).

INFORMATION MANAGEMENT AT THE UNIVERSITY HEALTH NETWORK

UHN is one of Canada's largest acute-care teaching and research organizations, with approximately 1,000 beds and a full range of healthcare services in all specialties. The organization consists of four physical sites: Toronto General Hospital, Toronto Western Hospital, Princess Margaret Hospital, and Toronto Medical Laboratories.

Shared Information Management Services (SIMS) is a corporate function reporting to the Chief Information Officer and is responsible for the complete spectrum of information management services. The services include the implementation of an aggressive five-year electronic patient record strategy, as well as the technical support of over 25 major clinical and business applications, 50 interfaces, and network and server systems for all four sites. UHN is a leader in public sector spending in health information management, dedicating approximately 4% of total operating expenditures to SIMS - representing a $30 million annual operating budget and approximately $50 million in capital over the next five years. The scope of information management at UHN is increasing rapidly and demands a talented complement of professionals. Our vision to become an international leader in health information management is largely dependent on our ability to attract and retain the best and brightest employees.

RECRUITMENT AND RETENTION CHALLENGES

By June 1998, SIMS faced an immediate need to fill vacancies that represented over 29% of budgeted staff. Despite recruiting efforts, the turnover of SIMS staff was so high that the vacancy rate remained unaffected. As the healthcare industry began to respond to the impending Y2K remediation efforts, competition with peer hospitals for skilled technical resources fuelled the development of aggressive compensation and bonus incentive programs.

An initial analysis of the costs involved in implementing a compensation-based strategy was completed, revealing that UHN simply could not afford to compete on compensation alone. In addition to being cost-prohibitive, the analysis illustrated the potential for serious internal equity issues if staff were awarded financial incentives based on the "hot skills" of a highly dynamic industry.

The findings were presented to UHN's Senior Management with a proposal to develop a more comprehensive strategy that would attract and retain staff well past Y2K. SIMS received approval to develop a recruitment and retention strategy specific to the health information management environment - a significant achievement in an organization that had historically employed only corporate policies and procedures for human resources initiatives.

SIMS Management initiated the strategy planning by conducting exit interviews and informal surveys to identify the contributing factors in the internal environment. Although departing staff showed an appreciation of the challenging work and positive working relationships at UHN, their complaints fell into four major categories: compensation, workload, career opportunities and professional development. The extent of these issues required a cooperative effort with Human Resources to develop the short-term solutions to stabilize the situation, as well as long-term strategies to create a highly attractive working environment.

COMPENSATION

While other sectors were supporting dramatic salary increases for technically skilled staff, the three-year wage freeze on healthcare salaries had resulted in base salaries that were far below market value. This issue complicated recruitment and retention efforts significantly as the existing staff were grossly underpaid, and internal equity issues surfaced with each new hire. In June 1998, the majority of SIMS staff were squeezed into four salary pay scales with an average annual salary of $46,000 CDN and the highest technical position at $58,700 CDN.

To address the compensation issues, SIMS job classifications and salary ranges had to be aligned with the market to enable ongoing external benchmarking. SIMS management first reviewed a comprehensive listing of information management job outlines from William M. Mercer Limited (1998) to define their position requirements. Using 50 benchmark positions that met or exceeded an 80% match with SIMS positions, the Human Resources team extracted market salary data at the 50th and 75th percentile. As an additional means of validation, the team also surveyed three healthcare organizations and benchmarked against five private organizations.

The analysis clearly indicated that SIMS could not afford to compete at the 75th percentile. Therefore, using the 50th percentile, the salary ranges were adjusted by 3%. More important, the analysis showed that SIMS had to extend the number of salary grades and realign job classifications into appropriate pay ranges. Once the realignments took place, 53% of staff fell below the minimum of pay ranges, and another 43% were between 80 to 96% compa-ratio. (Compa-ratio measures the salary against the salary range for the position. Compa-ratio is calculated by dividing the salary by the mid-point of the salary range and multiplying the result by 100.) Only 4% of staff were compensated at the job rate for their classification. (The job rate is defined as 96% compa-ratio.)

This analysis was presented to UHN's Senior Management, and with their approval, the team established a long-term strategy to ensure appropriate compensation with phased-in salary reviews and adjustments every three months and market analysis reviews and adjustments every six months. The funds necessary to implement these adjustments were derived from vacancies and increased financial investment from the organization.

Between July 1998 and October 1999, the average annual salary increased from $46,000 to $55,600 CDN, a 21% increase, while the highest technical position increased from $58,700 CDN to $84,600 CDN, an increase of 44%. By the end of the third quarter 1999/2000, SIMS had implemented six phased-in salary adjustments, increasing its annual base compensation budget by $625,000 CDN. At this time, the majority of compensation issues had been addressed, as shown by the more appropriate distribution of compa-ratios in Figure 1. Since then, the phased-in salary adjustments have continued, and SIMS is confident that employees are paid appropriately in a competitive pay range.

WORKLOAD

Workload was also identified as a very serious internal issue, as the scope of SIMS services was steadily increasing without a corresponding influx of qualified staff. With a complement of only 57 staff managing the workload of 80, the long-standing expectation of an unpaid 15 to 20 hours in overtime each week to offset the 29% vacancy rate was unsustainable.

In March 1998, the UHN Board approved a new information management strategy, Integrating Care, which established the framework for efforts from 1998 to 2001. However, SIMS still faced organizational expectations to address over 100 approved projects that had been initiated, but not completed, during the tenure of previous leadership. Using Integrating Care as a foundation, the existing 100 projects were prioritized based on the urgency of operational issues, impact on patient care, availability of funding and required technical skills.

A list of ten major initiatives was published in July 1998 as the basis for information management efforts for the following year. Staffing and recruitment plans were developed accordingly to ensure appropriate workload for all staff. At this time, SIMS hired a dedicated recruiter to implement the plans and address the 29% vacancy rate. The recruitment efforts included internal postings, external Internet postings on major Canadian websites, career fairs, print advertisements in both healthcare and mainstream media, recruiting for undergraduate co-op and graduating students, the use of recruiting agencies for management positions and the revision of a recruiting brochure. These efforts resulted in the recruitment of 35 full-time positions over 15 months, averaging 2.33 fulltime equivalents (FTEs) per month (Figure 2).

SIMS also expanded the student recruitment program (coop, summer, internship and graduate) to include nine post-secondary academic institutions. The purpose of this expansion was to hire more students to address short-term project requirements and the high volume of workload. This strategy was very successful because it also met longer-term recruitment requirements as SIMS hired many of these students upon graduation. This effort required the commitment of a .4 FTE to manage the student recruitment program.

Workload management has been further supported through the development of a Project Management Office (PMO). The PMO ensures that information management projects are aligned with corporate objectives, are reflective of the organizational requirements, and that project plans are achievable within the current environment. The application of formal project management processes and approval mechanisms has contributed significantly to workload management and the success of SIMS project implementations.

SIMS has also completed a benchmarking exercise to determine how other hospitals within Ontario are compensating for overtime. In April 2000, UHN compensation policies were rewritten for overtime, on-call, call-back and shift premium, outlining specific implications to SIMS employees. Budget was reallocated to address the requirements created by the new policies.

The success of these workload management initiatives has renewed the organization's confidence in information management efforts, which in turn has positively impacted staff morale.

CAREER OPPORTUNITIES

The exit interviews conducted in the summer of 1998 also identified the lack of career opportunities within SIMS as one of main reasons staff were leaving the organization. Employees indicated that the career path was limited to a job hierarchy focused on a management model. This hierarchy encouraged only those individuals with management aspirations to progress from entry-level positions of Technician and Analyst to Project Leader, then Project Manager, and finally to Manager (Figure 3).

This single stream model limited the more technically oriented staff to a Project Leader position, where most remained until they left the organization. To address this issue, the SIMS job hierarchy was revised to incorporate both a technical and project career stream. The technical stream allows staff to progress from a Senior Analyst to Specialist, and then from a Senior Specialist to Architect. Each step provides opportunities for staff to further develop and utilize their technical expertise (Figure 4).

The project stream allows staff to progress from a Senior Analyst to Project Manager, and then from a Senior Project Manager to Project Director. In this progression, staff manage larger-scope projects and teams, with increased budget responsibility. For those individuals with the appropriate skills and experience, there are also opportunities to advance to an Operational Manager or Director position from either stream.

With the revision of the SIMS job hierarchy, generic job profiles were developed to align SIMS positions with the market and to incorporate standard functional and technical competencies. The generic job profiles were then matched with departmental profiles to create job descriptions.

PROFESSIONAL DEVELOPMENT

Between hospital mergers, budget cuts and Y2K time pressures, management could not provide the time or money that would allow staff to participate in many professional development opportunities. The increased workload and high stress left staff feeling that they didn't have time to attend the few educational programs that existed.

In 1997/98, the professional development budget was distributed without a formal process. The budget was used for course fees, books and conferences within the project management, management, and application support areas. The other technical departments within SIMS had little to no training budget. The limited access to training dollars and the perceived inequity in spending was a major source of dissatisfaction among staff.

As part of a strategic partnership with SIMS, the University of Victoria's School of Health Information Science conducted a professional development survey in October 1998 and February 2000. The response rate of the first survey was only 26%, with the results indicating that 44% of staff believed that SIMS had an interest in their professional development. Staff also indicated the need for a formal orientation to SIMS. By February 2000, the response rate increased to 50%, with 68% of staff indicating that SIMS was committed to addressing their professional development needs. This survey also captured staff interest in various health information management topics.

SIMS introduced a formal orientation program and hospital tour in January 1999. The program was designed to help staff integrate more quickly into the SIMS environment. Since its inception, the program has been evolving based on the feedback from evaluations. It is now scheduled monthly and program materials are available online for both existing staff and new hires.

Since the distribution of the first survey, SIMS has significantly improved the quality and number of professional development opportunities. In fact, 30 health informatics seminars have been offered based on the topics staff identified as relevant to their learning needs. Fifteen employees are enrolled in a Health Informatics Certificate program, sponsored by the University of Victoria and The Michener Institute. Other initiatives have included: team-building workshops, a management development retreat, "Lunch and Learn" seminars where staff share their expertise with colleagues and improved access to the latest research data provided by GartnerGroup. These initiatives have provided opportunities to develop as a team and ensure that staff and management stay current with the latest information management and technology trends.

In the 1999/2000 fiscal year, training funds were allocated to each departmental budget based on 2.7% of compensation. (Compensation is defined as salaries only, and excludes benefits and purchased contract services.) In 2000/01, the allocation increased to 2.9% of compensation for each department. An additional joint budget was established, increasing the overall budget for professional development to 3.8% of SIMS total compensation.

In April 2000, SIMS hired a Development and Education Specialist to coordinate a professional development program and the student recruitment program. A Professional Development Committee has been established to review and approve requests for access to the joint budget. Guidelines for course cost-sharing were developed, and dates have been set for educational grant submissions each quarter. Supporting this process, SIMS Managers have completed professional development plans for all staff. To promote SIMS as a learning environment, all staff who receive funding must present a report of their learning experience for all department members to access.

MOVING FORWARD

The SIMS recruitment and retention strategy has been incorporated into a new line function within the directorate. An operating plan for 2000/01 was completed for the department to sustain the achievements to-date and to further develop the recruiting and retention program. To capture the interest of information management professionals, who may not have considered a career in healthcare, the SIMS recruitment team is developing a multifaceted marketing plan. All promotional materials will share our information management strategy and personnel initiatives in order to develop a positive image in the marketplace. The team will also continue to work with Human Resources to ensure that regular market salary reviews are conducted so that our compensation levels remain competitive. SIMS will be implementing a résumé management system to more effectively evaluate our applicants.

The following plans and programs will be implemented in the next fiscal year:

1. A Summer Flex Hour program will be offered again in 2001. It was first implemented in June 2000 and was very well received.
2. Action plans will be implemented that address the following concerns raised by staff during recent exit interviews:
   • concern for a greater technical knowledge base within SIMS;
   • the lack of mentoring;
   • the need for better orientation to an individual's job; and
   • the need for increased communications between the operational and program departments.
3. A SIMS staff satisfaction survey will be distributed and a staff feedback committee will be established in October 2000. The intention of both plans will be to bring forward any employee concerns that affect staff morale and retention.
4. An employee recognition program and an incentive program will be designed for both of the Operations and Programs teams. SIMS wants to recognize and reward both individuals and teams for their excellent contributions.
5. The Management Development Program will continue to be refined so that we can further develop and retain our leaders.

CONCLUSION

The fundamental shift from a compensation-based focus to a broad recruitment and retention strategy has enabled UHN to establish a competitive environment to attract and retain the best and brightest health information management personnel. SIMS turnover rate has been stabilized and the target staff complement of 80 employees has been far exceeded, with a current complement of over 120 information management professionals (Figures 5 and 6).

This enviable position began with a single principle - to attract and retain quality staff, SIMS cannot and will not compete on compensation alone. While appropriate and competitive compensation is integral to any recruitment and retention strategy, other organizations will always offer better compensation, benefits and bonus programs. Therefore, a more comprehensive approach to recruitment and retention is necessary.

We believe that the lessons learned from this experience have a broad application to other public and private sector organizations:

• Long-term commitment from Senior Management and Human Resources leadership must be secured. Our success has been very much dependent on the recognition that the information management environment is unique and requires creative solutions that the organization may not have employed before.
• The strategies must be incorporated into ongoing budgeting and planning practices to ensure longevity. Our continuous efforts have set expectations within our environment that emphasize human resources planning as an integral component of management and staff members' organizational responsibility.
• Baselines and benchmarks must be established to enable continuous monitoring and evaluation. This is critical to ensure that we are never again responding to a mass exodus and are able to proactively identify and address issues.
• The strategies must be well communicated. It is particularly important to manage expectations and to communicate that a systematic approach will yield steady improvement and not necessarily immediate results.

By ensuring these initiatives are a priority for SIMS, we are confident in our ability to continue to minimize turnover of information management personnel and build the team necessary to meet the challenges ahead.

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