Combining resources, combining forces: regionalizing hospital library services in a large statewide health system

Abstract

After a reduction in full-time equivalents, 2 libraries in large teaching hospitals and 2 libraries in small community hospitals in a western US statewide health system saw opportunity for expansion through a regional reorganization. Despite a loss of 2/3 of the professional staff and a budgetary decrease of 27% over the previous 3 years, the libraries were able to grow business, usage, awareness, and collections through organizational innovation and improved efficiency. This paper describes the experience—including process, challenges, and lessons learned—of an organizational shift to regionalized services, collections, and staffing. Insights from this process may help similar organizations going through restructuring.

The libraries in the Oregon region of Providence Health & Services (PH&S) found themselves at a turning point with the departure of their two library managers. With the decision to replace the two librarians with a regional director of libraries, the groundwork was laid for a re-visioning of library services in the entire region. This case study describes the steps undertaken to bring the new vision to life.

The notion of combining library staffs and resources into regional or system-wide bodies is not new to hospital librarianship. In their 2006 article, Thibodeau and Funk found that 1989–2006 “survey data support[ed] reported trends of consolidation of hospitals and hospital libraries and additions of new services” 1. Yet a literature scan conducted in 2014 revealed no articles describing such transformation processes in hospital libraries. While lacking in descriptive studies of the centralization of health system libraries, the literature did provide some examples of integrating specific services 2–10. The review of literature reinforced the authors' belief that sharing the PH&S experience would be useful to other health system libraries working to improve and expand services, while facing staffing and budgetary challenges.

BACKGROUND

Established in 1856, PH&S is a not-for-profit Catholic health care system with locations in Alaska, Washington, Montana, Oregon, and California 11. The libraries discussed in this paper are located in the Oregon region, where PH&S is the largest health care system in the state 12. Consisting of 8 acute care hospitals, multiple clinics, and a large physician group, PH&S Oregon employs 18,205 people, staffing 1,671 acute beds 13. The physical libraries consist of 3 in the Portland metropolitan service area (2 large teaching hospitals and 1 small community hospital) and 1 community hospital library in Medford.

With the loss of the 2 library managers in Oregon, PH&S administration decided that the organization and reporting structure of the Oregon libraries would be rearranged. Due to a hiring freeze, it was determined that the 2 library manager positions would not be filled and instead a new position—director of regional library services—would be established to oversee all of the libraries in Oregon. A new position description was created, 2 candidates were ultimately interviewed, and the internal candidate was selected. When that person, the remaining professional librarian, stepped into the director position, a 0.85 full-time equivalent (FTE) librarian position was left unfilled. This resulted in an overall loss of 1.85 FTE professional library staff (a 65% reduction) through the reorganization. The paraprofessional FTEs were not affected by the reorganization, and the nonlabor budget costs were not adjusted at this time.

STRATEGIC PLANNING

Led by the library director, the strategic planning process began with conversations with key stakeholders across the region: senior leadership, physicians' group representatives, graduate medical education, pharmacy, nursing, quality improvement/patient safety, rehabilitation, business development, research, and health plans. Individual meetings of thirty to sixty minutes gave stakeholders an opportunity to share their feelings about the current state of library services as well as thoughts on areas for growth or improvement. From these information gathering sessions came overall themes that were consistent across disciplines and institutions:

• ▪lack of awareness of what was available through the libraries or, in some cases, that the libraries even existed
• ▪uncertainty of how to access resources
• ▪complaints that it was too difficult to access resources, especially remotely
• ▪requests for more online resources
• ▪requests for more training opportunities

These comments did not come as a surprise but rather reinforced service and access gaps that the library staff knew of. That they were widespread across the breadth of disciplines and institutions only further highlighted the need to address these issues in the strategic plan.

A literature review and environmental scan were performed, and a strengths, weaknesses, opportunities, and threats (SWOT) analysis was developed 14, 15. These, along with the stakeholder interviews, provided the basis for the strategic plan. The strategic priorities were defined to align with those in the current institutional strategic plan. The language and layout used mirrored the design of the institutional plan. This demonstrated a clear awareness of the direction that the organization hoped to be heading and, at each point, showed how the library directly supported and promoted these goals in its own work.

REORGANIZATION AND REPORTING STRUCTURE

Figure 1 illustrates the reporting structure changes that resulted from the reorganization of library services. The fragmentation inherent to the location-specific library model was replaced with a unified service and a streamlined organization. From four separate libraries, one team was born.

Figure 1.

Reporting structure before and after reorganization

The team approach

A new team approach to providing service was implemented with the creation of the regional department. Historically, the four libraries worked independently and did not provide coverage for each other. That meant that some staff had to work as solo service providers, while others had to cover all library services for extended periods during coworkers' time off. The team approach enabled more efficiency and productivity, created less isolation for the staff working alone at smaller sites, increased opportunity for learning from each other, and encouraged collaborative process improvement.

All library staff members were set up with Microsoft Lync, software that provides videoconferencing, desktop sharing, and instant messaging. A SharePoint Team Site was set up to serve as one unified point to store standardized policies and procedures and to share documents. Cross-training took place, and job descriptions for the medical library specialists were adjusted to allow mobility between the Portland-area libraries. This assured consistent coverage during staff time off or scheduling conflicts, as well as support through heavy workloads.

Regional and hospital library emails that all staff have access to were created, so that users had one place where they could send requests that could then be delegated to the appropriate staff member. This shifted individual responsibility to a shared one, based on location, and ensured that all requests would be answered in a timely fashion. It was a relatively seamless transition for patrons: staff members could still provide the personal touch that library patrons desired but now had increased support from the rest of the team.

From hospital-based to regional library services

The re-visioning of the PH&S Oregon libraries led to a shift from hospital-based services to region-based service. There had long been some collaboration between the libraries at the two teaching hospitals—for example, shared purchasing of some large e-resources (Lippincott Williams & Wilkins Total Access, Ovid MEDLINE, CINAHL)—but collection development, services, and policies or procedures were hospital specific. While the libraries had technically always provided service to employees throughout the region, resources were not licensed for this coverage nor was outreach intentional or broad. A deliberate focus on providing information equity to all medical staff and employees, independent of location, required changing the format of resources offered, as well as the way services were provided and how staffing was utilized.

To ensure the same high-quality service for all patrons, work began to standardize policies and procedures. The standardization process allowed the library to uncover best practices and provided an early opportunity for staff members to work together and build relationships.

After identifying gaps and areas of discrepancy, library staff began collecting a standardized set of statistics to more accurately and uniformly capture a picture of the libraries' services and the user population across the region. This enabled the library to better document its value, distribute workload, and identify opportunities for increased outreach.

Collection management

Collection management was significantly affected with a shift to a regional model. A directive to serve geographically disparate patrons required a shift from print to electronic resources. Coordination of the multiple collections was necessary to identify gaps and duplication of resources.

Print journal titles were reduced by 80% in the first year. The 2 large libraries saw a reduction from approximately 240 print titles each to 40. The following year, print titles saw a further cut to approximately 25. Titles were considered for print retention for the following reasons: key titles that patrons liked to browse (e.g. New England Journal of Medicine, JAMA, Lancet), titles that were not available electronically or through multisite licenses, and titles from publishers that had an electronic licensing model not deemed acceptable by the library director or legal department.

At the outset, there was some concern that the library might encounter resistance to the shift from print to electronic-only journals, but the concern seemed to be largely unfounded. While the library continues to have some patrons looking for a print edition, the general response has been overwhelmingly positive as access has been dramatically increased and the quality of document delivery articles has improved with digitally born articles versus scanned print copies.

As previous electronic resources were licensed for one to three sites only, a move to a regional statewide model required new contract negotiations and multisite license agreements. The library worked through a third-party subscription vendor, and the process took significantly longer than in previous years. Most publishers do not provide standard pricing models that cover multisite licensing, and therefore, individual publishers had to be contacted to request a quote for the majority of titles. Many publishers did not see this as a renewal process, thus new contracts needed to be signed and sent through the legal department and contract negotiations, all of which extended the normal time of the journal renewal and purchasing process.

As electronic access was greatly expanded, the price for multisite licensing saw a dramatic increase in cost, in some cases as much as 10 times what the libraries had previously been paying. Despite this and the mandate to increase access and service, the combined library budgets had a 27% percent decrease from the 2011 to 2013 fiscal year. Cost reductions were made in part by reducing duplicate print titles as well as duplicate subscriptions across institutions, which ultimately allowed the addition of 100 electronic titles as well as expanded site access to the e-titles to which the libraries already subscribed.

Technology

Updating the libraries' technology approach was necessary in the new regionalized service model. A single website, which reflected this new approach, was developed. Informal surveys were conducted during training sessions, meetings, and outreach presentations in order to create a website that was responsive to library users' needs. It was determined that users wanted a simple, graphic, “one click” interface that would lead them directly to the desired service. Those specifications informed the design of the main library website.

Two other areas that were identified as challenges were remote and mobile access to library resources. The interface available to the users at the time was slow, unreliable, and not optimized for mobile access. The library worked closely with information technology (IT) to introduce virtual private network (VPN) access, with library services highlighted on the landing page. The VPN access also allowed for a mobile-optimized selection of library services and databases.

The finishing touch in the technology upgrade was the introduction of a discovery tool. In response to user requests for a single search box, the library selected the EBSCO Discovery Services (EDS) tool. Built to encompass the majority of the library's resources, EDS searches the online public access catalog (OPAC), journals, databases, and free web resources. Although point-of-care resources are not integrated in the search, a bank of icons to those resources and pre-populated queries offer a simple way to search across all materials. The new EDS search box became the centerpiece of the library page.

Library space

The strategic plan also addressed the issue of physical space, which is an ongoing concern for hospital libraries all over the country 16. Library space is often looked at by hospitals as space that could be better used by cost-generating entities. The possibility that the libraries may one day be forced to give up space was considered, and preemptive planning was done with this in mind.

Some reduction of space is not necessarily seen as a negative, especially in the large teaching hospital libraries. The shift from print to electronic materials does mean that, going forward, less physical space will be needed to house books and periodicals. Furthermore, duplicate print holdings at the four libraries could be eliminated, and remaining holdings redistributed in order to reduce holding space at one or all of the libraries, if needed. Built in the era of print, the libraries do not currently meet the space or design needs of contemporary patrons. The majority of the footprint is taken up by shelving and storage furniture. A useable twenty-first century library requires more space for computers, study space with outlets for laptops, and collaborative space. Giving up physical footprint in the future in exchange for a library with a modern more useable design would be seen as a positive.

Marketing and outreach

An important component of the successful transition was the library's marketing and outreach campaign. In view of the extensive changes, it was important to reassure users that the quality of service would not suffer, while at the same time reaching out to the PH&S community across the state to convey the message that the regional library would serve their needs as well. A marketing campaign designed to reach users in formal and informal settings was put into place. The results exceeded expectations. The increases in search and document delivery requests from a broad spectrum of users documented the effectiveness of employing diverse marketing tools.

RESULTS

Despite a loss of 2/3 of the professional staff and a budgetary decrease of 27% over the previous 3 years, the PH&S Oregon libraries were able to grow business, usage, awareness, and collections through organizational innovation and improved efficiency following regionalization. Initial usage statistics from the first year of regionalization showed an average monthly increase of 48% in literature search requests (from 707 to 1,043) and 12% in document delivery requests (from 12,618 to 14,136), demonstrating successful outreach and an increase in internal efficiency, as FTE was not adjusted to match increased business.

DISCUSSION

The regional library system in Oregon and the success of the transition is seen as a model for regionalizing services and responsiveness to organizational change. It is being used as a model for the broader centralization of the five-state health care system and Swedish Health Services. The PH&S libraries in Oregon were able to come together as one team and expand services and collections to provide better and more equitable service throughout the region. While the team experienced challenges on the road to integration, the collaborative spirit of the staff, the strategic planning process employed by the regional director of libraries, and the engagement of the library stakeholders in redesigning services greatly aided the process. To provide excellent service and to remain relevant to their host organizations, hospital libraries have to pool resources, both human and physical; stay alert to the needs of their users; and proactively tailor their collections to assure equitable, timely access.

Biography

Heather J. Martin, MISt, AHIP, heather.martin@providence.org, Director of Regional Library Services, Providence Health & Services, Oregon, Providence Portland Medical Center, 4805 Northeast Glisan Street, Portland, OR 97213; Basia Delawska-Elliott, barbara.delawska-elliott@providence.org, Health Sciences Librarian, Providence Health & Services, Oregon, Providence St. Vincent Medical Center, 9205 Southwest Barnes Road, Portland, OR 97225