Transforming a Library Service within a Provincial Healthcare Organization: Forging a New Path

Introduction: Prior to 2011, libraries within Alberta Health Services (AHS) operated using a variety of selfdetermining service models across 19 locations. Evaluation of library services demonstrated significant gaps in service delivery and access to resources, cost inefficiencies, and variation in library service standards across the province. National and international trends reflected ongoing library closures and challenges in demonstrating library contributions to organizational goals and improvements in health information literacy. Description: In January 2011, all AHS library services were aligned under the Knowledge Management Department to capitalize on the natural fit between libraries as conduits to evidence and knowledge management practices that support the use of evidence in practice. The mandate was to develop enterprise-wide library resources and services to support clinical decision-making and quality patient care under the umbrella of the Knowledge Resource Service (KRS). A Business Case for Library Services Optimization guided this initiative. Outcome: KRS is now a focal point for access to, and expertise in, healthcare information resources and services. Organization-wide evaluations conducted in 2011 and 2014 show increased user satisfaction, while utilization analytics reflect continued growth. Discussion: The KRS Optimization Initiative was a proactive, internally driven effort to extend library services and resources beyond the traditional library space, streamline ‘back-office’ functions, and allow staff to contribute to organizational initiatives. The path has been winding, yet lessons learned include the value of dedicated staff, teamwork and maintaining a focus on improving service for all AHS staff and clinicians.


Introduction
Alberta Health Services (AHS) was created in 2009 with the vision of one fully integrated healthcare system providing equitable and high-quality services to all Albertans. This integration brought together 108,000 employees who work at 650 facilities across the province providing care to 4.2 million Albertans [1]. Library service 1 , offered in 19 locations, varied significantly across the province: in 1 region it was externally contracted, in some regions libraries were 1 Library service refers to all services outlined in Standard 4 of the Standards for Library and Information Services in Canadian Healthcare Facilities [2] as well as reference and consultation. operated by regional health authorities, and in yet other regions it was non-existent. Overall, existing libraries functioned independently with no standard service practices and limited resource sharing. Following the amalgamation of AHS as a single, provincial health organization, all healthcare libraries in Alberta were re-aligned under the newly established Knowledge Management (KM) department. This reorganization capitalized on the natural fit between libraries as conduits to information and the healthcare practitioner's need to improve healthcare performance and outcomes.
Following broad stakeholder consultation and a review of the literature, Business Case: Library Service Optimization (2012) was developed [3]. All library-related systems within AHS (including contracted service agreements, partnerships, and business processes related to licensing) were included within the scope of the AHS Library Optimization Initiative ("The Optimization Initiative"). A single, unified library service was envisioned as a focal point for access to expert healthcare information services and resources.
The Optimization Initiative identified 5 principles that would guide decision-making and direction: • Create equitable access to resources and services across AHS and affiliated organizations • Provide seamless, efficient operations with a focus on value-added services • Enable lifelong learning for AHS staff through evidence literacy capability building and skill development • Support evidence-informed decisions at the policy and patient care level • Support patient and family access to high quality evidence where appropriate The Optimization Initiative was developed to address AHS needs and to build a highly valued, future-oriented library service. It imagined a library service that is financially sustainable yet adaptable to the changing knowledge needs of a geographically dispersed healthcare workforce. A literature review undertaken in 2011 [4] (and updated in 2015 and 2017) highlighted common issues and themes in the special library environment including: the imperative for libraries to demonstrate value to the organization [5][6][7]; challenges in access for rural/remote users [8,9]; integration with knowledge management departments to turn knowledge into action [10][11][12]; and utilizing technology to access evidence [6,8,13,14]. Knowledge for Healthcare: A Development Framework (National Health Service) clearly articulates the role libraries can play in fostering lifelong learning, research, and evidence-informed practice [15]. Embracing technology is emphasized as a key solution to address information needs and positively impact patient care [16]. The literature mirrored the concerns and desires felt within AHS libraries while emphasizing that successful transformation could be achieved when library professionals develop the next iteration of their service rather than wait to have a solution imposed [5]. Guided by the literature and stakeholder input, The Optimization Initiative reinvented library services to become a core support and driver for the success of the newly established AHS organization.

Phase I (2012 -2014)
The Optimization Initiative was planned and implemented in 3 distinct phases.
The first phase leveraged the service model developed by an externally contracted library service, adapting processes and structures to fit the larger AHS context. All library staff (including contracted staff) participated in work streams that informed and directed operational decisions.

Name change
One of the first and most important changes was the introduction of Knowledge Resource Service (KRS) as the new name for AHS Library Services and its contracted service providers. The choice of name was intended to communicate a single, unified service, and to better reflect the work that we do as part of the KM department. It also signaled a deliberate decision to move away from a traditional concept of "library" as being tied to a physical space, which was important within our geographically dispersed organization and set the stage for introducing the online virtual library [5].
Website and single point of access To better meet our users' needs, a single KRS website was developed to replace the separate regional AHS library and contracted services' websites. With the launch of the KRS website came the introduction of a centralized request intake system for all KRS services [17,18] using Springshare's LibAnswers platform. This system allowed KRS staff to provide library services (literature searching, document delivery, book/AV holds and reference and consultation) anywhere in the province, which also led to the development of service standards and evaluation processes to support a provincial and centralized model. The website also brought all licensed and open access e-resources together, facilitating easier and more equitable access for our users.

E-resource consolidation
Leading up to the development of the website as a single access point, it was critical to consolidate the various existing regional electronic licenses into a core collection of clinical reference resources for AHS. Consolidation produced a cost savings due to reduced duplication, which was then reinvested in new resources. This was a huge undertaking given that in the past libraries operated with their own collections budget and principles. Once an inventory was collected, we worked with individual vendors and as members of a licensing consortium to negotiate new licenses based on the guiding principle of equitable access for all AHS staff.

Phase II (2015)
With the single access point for library services and resources completed, Phase II focused on the consolidation of business processes to create efficiencies and address the increase in service requests from healthcare providers across AHS.
Centralized collection management In Phase II, KRS moved to a centralized enterprisewide collection management model, which entailed a shift in thinking from localized print collections to one provincial library collection distributed amongst various sites. This required reconfiguration of print acquisition, decision-making and maintenance processes, with dedicated Collections staff providing oversight to all aspects of collection management. This change achieved 2 goals: coordinating collection management and freeing librarian time for direct service.
Contracted library services brought in-house As services and resources came together under the provincial model, the business decision was made to move all contracted service library sites in-house under AHS management, including human resource agreements, budgets, service philosophy and all aspects of library operations. This transition was complex, and involved developing a new KRS website within AHS, migrating catalogue records, and transitioning staff from one organization to another with as little disruption as possible. Staff transitions proved to be quite challenging during a time of financial restraint and hiring freezes across the public sector in Alberta.

Library closures and consolidation
Coinciding with organizational budget mitigation activities, and aligning with the goals of The Optimization Initiative, KRS permanently closed 2 libraries in Calgary and 1 in Grande Prairie, mainly because provincial staffing levels did not allow continued operation of the current complement of sites while still maintaining quality service. Two of these libraries were staffed by a single person; 1 library was determined to have lower usage statistics, required extensive renovation and was required for clinical purposes by the facility. Books and journals from these libraries were weeded and(or) redistributed amongst remaining libraries, and the library space was repurposed by the hospital facility for identified clinical needs.

Introduction of online learning modules
While the closure of libraries and reorganization of services posed many challenges, we also achieved exciting milestones in service provision; during this period we created Evidence at Your Fingertips, an online series of pre-scheduled, synchronous evidence literacy courses. This series of classes are taught virtually over Skype for Business software and are available on a regular basis with 3 semesters throughout the year. As our users are located mostly outside of facilities with library staff, and as users in general expect and require training to be more easily accessible online at their point of need [19][20][21], this was a critical aspect of creating a sustainable model for evidence literacy capacity-building within the organization.

Phase III (2016)
The final phase of The Optimization Initiative was informed by the success of earlier phases. Centralized access to resources and services meant increased requests for service and new roles for library staff, including chat or virtual desk responsibilities, virtual document delivery, and expansion of online teaching sessions. Decisions therefore focused on finding efficiencies to support library staff in direct service delivery.

Development of service directions
To aid decision-making and to ensure ongoing success after the close of The Optimization Initiative, the KRS Strategic Service Directions were developed. The 4 Strategic Service Directions were: • Enable Easy Discovery and Access • Enhance Evidence-informed Decision Making • Create "Just-in-Time" Learning Environments • Build Centres of Excellence to Enrich Learning and Collaboration In 2017, an additional Strategic Service Direction was added, Incorporate a Client-Centred Focus [22].

Library consolidations in Edmonton and South Zones
Aligned with the strategic service direction of "building centres of excellence to enrich learning and collaboration," a review of remaining library locations was initiated. The goal was to create hubs of library staff in fewer physical library spaces, thus supporting collegial collaboration and support in service delivery. To ensure that decisions were evidence-based and fair, a variety of criteria and methods for review were employed, including: • Library gate count • Circulation statistics • Interviews with KRS staff, other Canadian health library leaders and facility administrators • A literature review • Facility profiles (including a collection description, special user base served, professional specialties on site, accessibility, and special activities or offerings of the library) Other factors considered were library aesthetics, ease of staff management and the presence of, or potential for, an optimal library "footprint" (i.e. computer access, study and print collection space, workstations for KRS staff and the potential for training space.) Upon review, 4 sites were closed (2 in rural and 2 in urban locations), and staff and collections were consolidated at remaining libraries. An existing library was simultaneously upgraded by adding an enhanced print collection aligned to clinical services within that facility.

Outcomes
Evaluation during and after completion of The Optimization Initiative demonstrates positive changes to access, service delivery and user capacity. Unfortunately, a direct before-and-after comparison of service and access statistics is not possible due to inconsistent data collection between different library systems. Results from a 2011 review of AHS Library Services, a 2013/2014 user survey, and current statistics from Springshare LibAnswers and our integrated library system form the basis of the following outcomes: • The streamlined website has increased ease of access for users. In 2011, 17% of respondents (46 out of 271 respondents) felt that information on the library's website(s) was too difficult to access, in comparison to only 4% (8 out of 210 respondents) by 2014 [23]. [4, Springshare LibAnswers RefAnalytics statistics]. This increase is likely due to greater ease of making online requests, back-end efficiencies resulting from the centralized request intake system, and increased staff time for direct service provision as a result of site consolidations.
• Online chat has been well received by users as a valuable service. In 2017, 95% of chat users who rated their chat session (194 of 209 users) rated their experience as good or great, and user comments confirm those ratings: "Support I received had my question answered in less than 2 minutes. Excellent service for AHS staff!" (Springshare LibAnswers chat transcript.) • Evidence literacy training was provided primarily in-person in 2011 which made it difficult to reach users located outside of urban centres [4]. By 2017, KRS staff responded to 304 requests for training and reached 1,625 session attendees, which would not have been possible without a robust online education curriculae and the ability to provide as-needed training using Skype for Business. • With greater access to services and resources, users have shown that they are finding the right information to guide their clinical and strategic decision-making. In 2014, 96% of survey respondents (n=518 respondents) said the information they received from KRS was relevant and accurate and 94% said the information provided new knowledge. Additional measures highlight the value of KRS in supporting clinical decision-making and policy development, as reported elsewhere [24].

Discussion
Equitable access to high quality evidence for health care providers across Alberta, seamless operations, and evidence literacy capacity-building were the guiding principles on which we built a single provincial library service. The KRS website revolutionized and streamlined operations and increased our reach significantly, especially to rural users. Equitable access to a core suite of resources and services is now available to all AHS healthcare practitioners. Restructuring collections management created efficiencies as it freed up time of other KRS staff to focus on core business and user services. From a management, technology, and user perspective, moving to a unified system has been very successful, allowing KRS to nimbly respond to emerging organizational priorities.

Lessons learned
The lessons learned relate to the overarching initiative and its success within a large, complex organization, rather than the specific deliverables and tasks of transforming a library system. Support from leadership and partners (academic institutions and consortia) was critical for the success of the initiative, especially strong advocates within the organization who believed in the vision for AHS. These leaders knew that access to and use of evidence is essential to success in the knowledge intensive healthcare industry. Resource sharing with external partners and licensing consortiums enabled fiscal efficiencies by offering a broader collection at limited cost. Internally, KM colleagues, AHS-supported change management practices and the Employee and Family Assistance Program provided support during times of change fatigue.
The value of change management cannot be overemphasized when undertaking a radical transformation in library services. The Optimization Initiative called upon strong leadership skills to be sensitive to staff needs and feelings. At each phase staff struggled with change fatigue; site closures in particular required compassionate communication.
Clear and frequent communication is another key factor for success. Often we faced the question of "why change?" Communications had to be understandable, transparent and inspirational to reinforce direction and curb the flow of misinformation.
Being part of a large organization means that external factors can impact the best laid plans. During the time of this initiative, AHS (and Alberta in general) was significantly impacted by an economic downturn, a devastating wildfire and changes in organizational stability. It was important to be empathetic regarding external factors which impacted staff resiliency and ability to cope with change. Planning and implementation needed to be flexible and responsive and reinforce overarching goals.

Future directions
Current work in KRS is focused on further enhancing services to provide even more value to the organization and our users. This includes the refinement of the service delivery model along with the continued articulation of our strategic service directions. In collaboration with our KM colleagues, we are actively involved in organization-wide initiatives such as the implementation of a provincial electronic health record, leadership development programs, and clinical research opportunities. KRS is also working with other departments to facilitate and encourage use of mobile devices and online healthcare applications to find information at the point of care. Our focus remains on providing a world-class information service to clinicians in support of providing the best care to Albertans.