Ducas,
Gottschalk, Cohen-Baker
This article is distributed under a Creative Commons Attribution
License: https://creativecommons.org/licenses/by/4.0/
Abstract: Since 1993, the University of Manitoba (UM),
Winnipeg area hospitals, the Winnipeg Regional Health Authority
(WRHA), and the Manitoba Health Department have engaged in a series
of agreements that have changed access to knowledge-based
information for health professionals. These agreements gradually
transferred the management and delivery of library service from
hospital libraries to the UM Libraries. This paper describes the
historical evolution in health information access in Winnipeg,
subsequent revolutionary changes that resulted in the Health
Sciences Libraries Service Model, and the devolution of the model
following serious challenges. Its rebirth as the WRHA Virtual
Library is discussed with factors that may impact the new service
model.
Introduction
Library programs and services are products of
their environments. Political, educational, structural, and
technological factors at play within individual provinces reflect
the relationships that governments develop with health sciences
libraries and their clients, typically health professional schools
and health care practitioners. [1,2].
Manitoba has one major city, Winnipeg; one MD/Ph.D. granting
institution, the University of Manitoba (UM); one faculty of
health sciences, and one significant health sciences library, the
UM Neil John Maclean Health Sciences Library (NJMHSL). These
particulars shaped a unique “made in Manitoba” solution for the
delivery of library services to the health care community in the
province. This paper describes the events that led to the
evolution of health information access in Winnipeg, subsequent
revolutionary changes in these services, and their eventual
devolution due to an array of significant challenges.
Part 1: Evolution
The Early Years of Starts and Stops
Manitoba has a history of delivering centrally
supported, knowledge-based information services to health
professionals. The UM’s original Medical Library was established in
1920, when the College of Physicians and Surgeons of Manitoba (CPSM)
gifted their library to the University with a legal agreement
stating “The College members would have at all reasonable hours,
access to the said library and all addition hereto” and that “the
privilege which is at present enjoyed by out-of-town members of the
medical profession of receiving books by post….Shall be continued
and shall apply to all additions to the Library” [3]. In the 1970s and 1980s, the Head of the
Medical Library, Audrey Kerr, spearheaded programs to coordinate
delivery of information to medical professionals. In 1975, CPSM
granted funds to the Medical Library for library services to rural
physicians. In 1976, the Medical Library Extension Service was
inaugurated with an Extension Librarian. Although the program was
heavily used and valued by CPSM members, funding ceased in 1993.
Mandate changes required CPSM funds to be used only “to expand
programs for which it was directly accountable in the areas of
licensure, standards of medical practice, and discipline” [4].
In 1980, the Manitoba Health Libraries
Association (MHLA) established a Task Force on Shared Services to
review the provision of health information and to investigate ways
in which it could be improved and expanded through cooperative
programs and services [5]. The Task Force
recommended the “appointment of an area coordinator to maintain
existing shared services that have been developed by MHLA; and to
provide technical service back-up to the member libraries and
reference services including Medline” [5].
In 1983, in response to these recommendations and with one-time
funding from the Winnipeg Foundation, the Winnipeg Health
Information Network (WHINET) pilot project was launched. The
18-month WHINET project was successful but as permanent funding
could not be secured, it was abandoned. [6]
In September 1988, the Manitoba Association of
Registered Nurses (MARN) closed its library because the library was
under-used and MARN could not budget for materials, technology, or
staffing. MARN members were told to use hospital libraries or the
MHLA network of libraries. Nurses in Winnipeg and Brandon hospitals
had access to some resources but nurses in rural areas were left
without services. Not only were nurses underserved but library
services for rural hospital administrators and allied health
personnel were nonexistent. In 1989, Ada Ducas, then the Director of
Educational Resources at the Health Sciences Centre (HSC), laid the
groundwork to establish the Manitoba Health Information Network
(MHINET) to meet the information needs of nurses and health
administrators. Presentations were made to the Manitoba Health
Organizations Inc. (MHO) and MARN. MHINET was approved as a two-year
demonstration project by both organizations and the HSC [7]. The role of MHINET was to meet the
information needs of Manitoba nursing professionals, hospitals
administrators, and allied health professionals. MHINET services
delivered through the HSC Library Services department included a
toll-free number; access to book and journal collections in the UM
Medical and HSC libraries; reference and consultation services;
computerized literature searches; and a current awareness service.
The MHINET demonstration project was very
successful and MARN agreed to continue funding the service for nurse
members and it operated from 1989 to 2003. In 2001, the passage of
The Registered Nurses Act, changed MARN’s mandate to a regulatory
body. With the establishment of the College of Registered Nurses of
Manitoba (CRNM) funding for MHINET was discontinued despite a report
outlining the benefits and value of the MHINET service [8]. By this time, the MHO had been replaced
by the Manitoba Health Department, which was also not interested in
funding the service. In 2003, MHINET services ceased.
These promising starts and stops to the provision
of library services demonstrated that sustained and ongoing funding
was critical in order to improve information access for health
professionals in Winnipeg and across the province.
Factors
Leading to Change
a.Technological
In the 1980s and 1990s, technological,
educational, and political factors triggered new thinking around
information access for health professionals. Winnipeg hospital
libraries ranged from a state-of-the-art facility located in a
research centre to basement rooms with inadequate staffing and
collections. Limited coordination of library services was a concern
noted in a 1998 MHLA position paper: “Better coordination of health
sciences information resources has also been hampered by the
diversity of mandate, governance and funding amongst libraries” [6]. Despite these challenges, MHLA
developed a number of initiatives such as the publication of the Selected
Books and Journals for Manitoba Health Care Facilities in
1979-80 and, as early as 1978-79, the Serials Holdings of Member
Libraries [9]. This computerized
union list included locations of 800+ journal titles held by sixteen
hospital and health libraries in Winnipeg and Brandon. Additionally,
staff of the HSC Library Services maintained a card catalogue of
books held in Winnipeg’s hospital libraries.
However, technology was rapidly changing with the
introduction of service delivery methods such as DOCLINE and the
Internet. In Winnipeg, only the three hospital libraries staffed
with professional librarians, were integrating technology into their
services and had adequate collection budgets: the HSC, St. Boniface
General Hospital (SBGH) and Deer Lodge Centre. Smaller hospital
libraries (Victoria, Seven Oaks, Grace, Concordia, Misericordia, and
Riverview) were disadvantaged as they had part-time library
technicians, inadequate collections budgets and limited access to
new technologies. In 1995-96, an MHLA ad-hoc committee conducted a
survey to determine technical and financial resources needed to
implement DOCLINE in Winnipeg hospital libraries and found that
several libraries had no computer equipment or Internet access [6]. Outside of Winnipeg, the state of the
hospital libraries was worse.
b. Educational
New education needs were also driving change. In
1988, MARN supported a resolution “That by the year 2000 the minimal
educational preparation for entry to practice of nursing be the
successful completion of the MARN approved baccalaureate degree in
nursing” [10]. In 1996 all the nursing
diploma schools in the hospitals were closed and nursing education
moved to the UM and Red River College. With nursing programs moved
to postsecondary institutions, hospital libraries shifted focus from
assisting nursing educational programs to supporting nurses on
clinical rotations as well as clinical care.
Medical students in Winnipeg had traditionally
performed their clinical placements in the two large teaching
hospitals, the HSC and the SBGH. As medicine became more
specialized, the large teaching hospitals became acute care centers.
To provide students clinical access to a range of illnesses, a more
distributed education model was adopted. More clinical placements
were scheduled for community hospitals offering primary and
secondary care. As a result, hospital libraries needed clinical
materials for rotating medical students and other health care
professionals.
In the 1990s, health care professionals found
both new technologies and increasing quantities of published
scientific literature daunting [11]. The
need for training in information retrieval was pressing because many
practitioners did not have the skills to find recent and accurate
information. As McKibbon and Walker-Dilks [12]
pointed out many were not even aware that their skills were
deficient and little information literacy instruction was being
delivered in hospital libraries.
c. Political
Political changes in the management of the healthcare system were
also being implemented. In the early 1990s, regionalization of
health services was sweeping the country. On May 14, 1992, the
Manitoba Minister of Health issued the report “Quality Health for
Manitobans – The Action Plan” [13].
Subsequently, Manitoba Health began decentralizing decision-making
processes to Regional Health Authorities (RHAs). Thirteen RHAs were
established including two in Winnipeg. In 2000 the two Winnipeg RHAs
merged to form the Winnipeg Regional Health Authority (WRHA).
To achieve overall cost-effectiveness, the RHAs
adopted a program management model. A basic principle of program
management was to decant decisions to the least complex, most
competent unit. Services not deemed primary functions (e.g. patient
care) of the RHAs were evaluated and contracted to more appropriate
agencies. Library services were considered non-primary functions.
The newly formed RHAs had many challenges facing them and were aware
that health professionals needed access to evidence-based
information.
Similar technological, educational, and political challenges were
being experienced across the country. A number of provincial
initiatives emerged that focused on coordinating library services
for health care providers working outside universities. Health
Science Information Consortium of Toronto was “founded in 1990 out
of a desire to strengthen the relationship between the University of
Toronto Libraries and the libraries of health care institutions
affiliated with the University's Faculty of Medicine” [14]. In the mid-1990s, the Health Knowledge
Network (HKN) in Alberta initiated the provincial shared purchasing
of electronic resources and the University of British Columbia’s
Woodward Biomedical Library was managing teaching hospital libraries
in the Vancouver area. The time was ripe for similar changes in
Manitoba.
Part 2: Revolution
The opening of the NJMSHL was a major catalyst
for change in Winnipeg health library services. Its construction
provided the initial infrastructure for service coordination.
Changes to the administrative structure for the delivery of
healthcare within Winnipeg also stimulated the expansion of library
services across the city.
Single Health Library for UM and HSC
A new medical library for Winnipeg had been
planned since the 1970s and medical leaders repeatedly pushed for
formal collaboration between area hospital libraries and the UM
Medical Library. In the 1980s negotiations began between the Faculty
of Medicine and HSC. HSC is the province’s largest teaching hospital
and is located adjacent to the UM Health Sciences Campus
(Bannatyne). A concerted effort was made to construct a new building
which included a library to support both the Bannatyne campus and
the HSC. HSC donated the land for the new building, the Brodie
Centre.
In 1993, a formal agreement was signed between
HSC and the UM integrating HSC Library Services into the future
NJMHSL. The NJMHSL officially opened on June 5, 1996. As part of the
merger, the HSC library technicians and librarian were given the
option of transferring to the UM Libraries (UML). Funding was given
for staff to manage three satellite collections – a Pediatrics
Collection in the Children’s Hospital, a General Hospital Collection
in the General Hospital, and a Psychiatric Collection in the Psych
Health Centre. As a result of the successful merger, health
professionals at the HSC had the best of all worlds - access to a
world class university health science library and on-site clinical
collections.
St. Boniface Hospital Library Joins UM Libraries
In 1997, the SBGH, the city’s second largest
teaching hospital, approached the UML requesting that its library
become a NJMHSL satellite. It was well staffed with two professional
librarians and 5.5 library assistants. Hospital administrators
realized that they could not match the technology and resources of
the UML. After a two-year negotiation, the SBGH Library became a
unit of the NJMHSL. The technicians and librarians also transferred
into the UML joining either the Association of Employees Supporting
Education Services (AESES) or the University of Manitoba Faculty
Association (UMFA) bargaining units.
Victoria General Hospital Joins UM Libraries
In the mid-1990s, the Victoria General Hospital
(VGH) was staffed with a library technician and ran a networked
version of MEDLINE. Under former hospital leadership, the VGH
Library was stripped of print materials because the perception was
that most relevant medical information was available on the
internet. The VGH Library limped along for a number of years until a
professional librarian was hired in the library technician’s
position. Although the hospital did not increase the materials
budget, the librarian offered a higher level of service. When the
librarian left in 1998, he wrote a report with a number of
recommendations including that the VGH commit to hiring a
professional librarian [15]. In August
1998, a new VGH CEO approached the UML and requested an assessment
of the library. The assessment [16] led to
an invitation from VGH for the UML to manage library services. In
April 1999, negotiations were concluded, and an agreement was signed
which included funding for a .5 librarian, a .5 technician, and
library materials. Both positions were brought in as UML employees,
and it was agreed that additional VGH funding would be provided in
due course to increase staffing and library resources.
The Subsidiary Affiliation Agreement – Libraries
The success of these agreements inspired other
Winnipeg hospitals to advocate for similar arrangements. Senior
management within the Winnipeg region was aware of the library
service agreements negotiated between the UML and the three
hospitals. Separate negotiations were considered time consuming and
not representative of the program management approach. In 2000, the
newly formed WRHA approached the University and requested an
agreement covering library services for all Winnipeg hospitals.
The Subsidiary Affiliation Agreement –
Libraries was written and signed in 2000 by the University and
WRHA [17]. The Agreement addressed the
philosophy of library services (i.e. a program management model) and
stipulated service assessments be conducted for each Winnipeg
hospital and health care centre. WRHA senior management made library
services for the three remaining hospitals (Concordia, Seven Oaks,
and Grace) a priority. Each library was assessed with a view to
transferring management to the NJMHSL but hospitals could opt out.
As with the earlier assessments, reports were written considering
differences in funding, staffing, collections, and technology at
each facility [18,19,20]. Completed
assessments were reviewed by the University, the WRHA and the CEOs
of each hospital. The service assessments were the basis of a final
agreement. One-time baseline funds were transferred from the
Minister of Health to the Minister of Education and then to the
University and the UML. This ensured that the hospital libraries and
services were funded through the UM. The implementation of this
agreement changed the fundamental structure of both the hospital
libraries and the NJMHSL. A joint UM/WRHA Library Program
Liaison Committee (LPLC) was established to provide oversight and to
ensure that individual and joint obligations were met. The LPLC was
structured to function at high level within both the UM and the
WRHA. It was co-chaired by the head of the Health Sciences
Libraries, who reported to the University Librarian, and the
Executive Director of Research and Applied Learning, a physician,
who reported to the CEO of the WRHA. Membership in this committee
included the UM President (or their representative), the University
Librarian, and representatives from the WRHA clinical departments
including medicine, nursing, and allied health. The committee met
regularly, and reports were sent to them throughout the year. The
committee was also asked to make presentations to the WRHA
Leadership Council. The LPLC worked well at keeping everyone
appraised of developments and changes. The WRHA was very supportive
as evidenced by funding new stages of the program.
Grace, Seven Oaks, and Concordia Hospitals Join UM Libraries
In 2002, the Grace, Seven Oaks, and Concordia
Hospital libraries became satellites of NJMHSL. Each satellite had
core budget requirements ensuring they would have annual funding
for:
One FTE librarian and FTE library technician
A monograph budget of $10,000 at each location
A serials budget (variable at each location) transferred to a
central fund for journal acquisition
A technology budget of $10,000 at each location
A supplies budget of $4000 at each location
An administrative budget for the UML
One full-time UML IT staff member to support all locations
The WRHA insisted that no existing library staff lose their
positions– and no one did. Meetings were held with human resources
departments in each hospital, hospital unions representing library
staff, and the UM AESES bargaining unit. Although pensions could not
be transferred to the University’s fund, seniority was maintained.
All five hospital libraries and the NJMHSL became known as the UM
Health Sciences Libraries (HSL).
Library Services for WRHA Community Services and Long-Term Care
Senior management in the WRHA recognized that
staff working outside the hospitals also required library services.
The WRHA subsequently asked the UM to consider consolidating the
three health centre libraries focused on rehabilitation and
long-term care. As a result, the Deer Lodge Health Centre,
Misericordia Health Centre and Riverview Health Centre libraries
became part of the HSL. A separate agreement was not required for
this development, but a report was requested. The report, Library
Services for Long Term Care in the Regional Health Authority,
included details on staff, funding, resources and services [21]. The preamble of the initial Subsidiary
Affiliation Agreement – Libraries also included a Schedule C
listing the names of thirty-five personal care homes, fourteen
community health agencies, and fourteen mental health agencies that
should be considered for future library services. Providing service
to the personal care homes was included in the Library Services
for Long Term Care report and funding was provided by the WRHA
[21].
No additional negotiations took place for the community health
agencies and mental health agencies listed in Schedule C. In a Letter
of Agreement - Library Services, written by the CEO of the
WRHA in 2008, the issue of service to the community and mental
health agencies was addressed [22]. This
letter included a paragraph which stated that “the WRHA and the
University further agree to work collaboratively to pursue a
provincial license relating to access to electronic health
databases, articles and communication networks”. The HSL had the
capacity to provide services to these organizations because a low
number of service requests were anticipated. Hospital librarians
became responsible for services to specific community-based health
facilities. Services to these facilities included access to the UML
collection, literature search requests, document delivery, and
training. An Amending Agreement was drafted by WRHA which
would have seen the term “WRHA Hospital” replaced by the term “WRHA
Organization” and would have included the community agencies and
mental health agencies. The Amending Agreement was never
signed by the University Librarian, a fact of critical importance in
later developments.
Health Sciences Libraries 2004-2014
By 2006, all the WRHA hospitals and health care
centres had been integrated into the UML and the HSL was structured
as follows:
The NJMHSL is part of the UML structure
One main academic health sciences library – the NJMHSL - that
also served the largest teaching hospital, HSC
Five hospital libraries – Seven Oaks, Victoria, St. Boniface,
Grace, and Concordia
Three health centre libraries – Deer Lodge, Riverview, and
Misericordia
Outreach services to:
o WRHA Corporate Office, WRHA
community area offices, and ACCESS Centres (centres providing
primary care and
family services)
o Community health and mental
health agencies (twenty-eight in total)
o Thirty-five personal care
homes
The staff complement included 10.5 academic librarians and 9.5
technicians. To ensure that librarian workload was distributed
evenly and that all areas of the city were effectively serviced,
eight access points were recognized as outlined in Figure 1.
In addition to the HSL service network, a few other developments
rounded out the provision of library services to the WRHA. The WRHA
Corporate Office was not originally considered in the Subsidiary
Affiliation Agreement - Libraries but there were staff located
in these offices conducting research and writing health policy often
in collaboration with UM faculty. A 2005 study revealed that more
librarian support was needed and the HSL reconfigured existing
staffing so that a .5 librarian position provided support to the
Corporate Office [23]. In addition, a
subsequent proposal to the CEO of the WRHA requested funding to
cover some staffing shortfalls. The Misericordia Health Centre
librarian position was extended to a full-time appointment with the
view that this position could also provide services to community
health agencies in Point Douglas, Inkster and the Downtown area. An
additional librarian position was added to the SBGH Library to
provide assistance to the community agencies and liaise with the UM
Family Medicine program at SBGH.
Figure 1: WRHA Community
Areas & Associated UM Health Libraries
Success with the HSL Service Model
Between 1995 and 2015, many consortia
were established, and agreements signed between hospitals and
university health libraries across the country [1, 2]. The UM HSL Service Model was unique
in Canada because all, both teaching and community, hospital
libraries in the city were integrated and became satellite libraries
of the UML. In retrospect, a number of critical factors facilitated
this development:
Support for the initiative came from the highest levels
of the University and WRHA;
A Master Affiliation Agreement had already been
negotiated between the University and the WRHA serving as an
umbrella under which subsequent agreements could be established;
Knowledge-based information was largely print based, and
agreements were simpler to negotiate because at the time
publishers’ electronic licenses were less of a factor;
Early successes with the HSC and the SBGH resulted in
champions and supporters who encouraged the WRHA to look at
extending the model throughout Winnipeg;
The model supported the WRHA’s strategic goal of developing a
“learning organization with a strong safety culture and timely
access to accurate and relevant information to support decision
makers” [24];
The WRHA was committed to implementing a program management
approach for the delivery of services and the Agreement
was an example of one that worked.
UML and WRHA administrators developed relationships over a
long period of time resulting in consistent planning and
development. There was buy-in from hospital CEOs and no
institution was forced to participate;
A reasonable amount of funding was requested with recommended
operational and staffing standards. The Minister of Health
approved and cooperated with the Minister of Education to
transfer funds to the University.
The development of the HSL Service Model was not rushed. The model
included taking the time needed to consult staff at all levels of
the various organizations; gathering information; and making
strategic plans. Frequent meetings were scheduled to reassure
affected staff that their concerns and contributions were being
taken seriously. Time was spent with the existing hospital library
staff to discuss the gains and benefits of collaboration. Staff were
asked to concentrate not on what they had lost but to recognize the
tension between centralized and decentralized services. Everyone
cooperated in crafting a set of guiding principles to establish an
overall plan of service delivery, resource acquisition, and staffing
for the region. In the smaller libraries, service was paramount, but
the opportunity to become part of a larger health libraries system
offered increased access to of resources and technology for clients.
The model incorporated the best of both worlds. All of these factors
were enhanced by good timing, hard work, persistence and luck.
Assessments of the HSL Service Model 2006, 2011, and 2013
Three large surveys were undertaken
over the years, to ensure that the HSL was providing the services
that clients wanted and to assess service quality. An initial WRHA
Library Satisfaction Survey was conducted in 2006. The health
administrators who participated indicated satisfaction with the HSL
services and resources. In 2011, the HSL participated in the Value
of Library and Information Services in Patient Care Study
funded by the National Library of Medicine [25].
The HSL was one of only four Canadian sites in a group of 56. This
survey was a replication of the landmark Rochester study [26] and reconfirmed that “information
obtained from a library had an impact on patient care” [25]. In 2013, the initial 2006 survey was
replicated but distributed more widely to health care professionals
across the region [27]. About 1,000
healthcare providers participated in the survey with 57% (570)
having used HSL services. The results demonstrated that
administrators, managers, and healthcare professionals rated online
databases and online journals more highly and used them more
frequently than point-of-care tools. The most highly used and highly
ranked library services were librarian-mediated literature searches,
document delivery, and the ability to link to full-text journal
articles. These results were echoed in the many qualitative comments
from respondents stating how the services saved time and made them
more efficient. Assessments revealed that the model was working to
support health providers throughout the region.
Part 3: Devolution
The organizational structure set in place allowed for the effective
and efficient functioning of the HSL. Despite this, the many
successes of the HSL Services Model were offset by significant
challenges that led to radical changes. Factors that contributed to
the changes were recognized early in the development of the model.
These included: electronic access to resources; creation of a unique
category for WRHA employees in the integrated library system (ILS);
license requirements limiting access for WRHA employees; issues with
baselined funds; and librarian academic appointments. Unanticipated
factors included political change; shifts in the philosophy of
academic library service to the community; and limitations in
lifespans of agreements between organizations. Electronic Access to Resources
The Agreement between the UM and WRHA was
written when print collections dominated and services in the
hospital libraries were focused on reference assistance; mediated
literature searches; faxing of journal articles; mail delivery of
books and audiovisual materials; and basic instruction on MEDLINE,
CINAHL, and the internet [17]. Few had
heard of Google.
Although this may seem naïve today, the
original Agreement granted WRHA staff online access to UML
electronic resources only if they visited a hospital
library. This agreement was adequate at the time because there were
few e-journals, no e-books, and PubMed had become freely available
online. Most publisher licences allowed for “drop-in access” to UML
online resources. Electronic journals were just starting to emerge
and large-scale licensing of electronic products was in its infancy.
WHRA nurses, allied health professionals, and other hospital staff
without academic appointments were considered drop-in users.
Physicians with admitting privileges in Manitoba hospitals had
academic appointments with the University giving them access to all
UML resources.
Licensing of online resources became more
of an issue as resources rapidly migrated online. WRHA staff were no
longer considered “drop in” users and publishers began demanding
expanded licenses from the UML. The Agreement was unclear
and the wording that appeared under article 3.1.c, Obligations of
the University, stated [17]:
…grant to the WRHA Medical
Staff and to staff of the WRHA working within the head office of
the WRHA, the WRHA Head Office Staff and to all staff of WRHA
Participating Hospitals access to all library facilities and
related services established, by the University, from time to
time, in the WRHA Hospital Libraries, on the same terms and
conditions as said library
facilities and related services are made available to the
University’s staff and students.
More importantly item 3.1.d.iii stated “Access to the online
catalogue and the full line of electronic services via the UML
computer networks” [17]. Under these
terms, the UML was obligated to provide access to its online
resources to WRHA “head office” and all Winnipeg hospital staff.
Creating a Unique Category in the ILS
Issues with the Agreement and
electronic access were further compounded by the category assigned
to WRHA staff in the ILS. The UM ILS was available in all the
Winnipeg hospital libraries. WRHA staff were given special borrower
cards that permitted searching of the ILS; borrowing of UML print
materials; and logging into hospital library computers to access UML
licensed databases and the internet. Early in the evolution of the
HSL Library Services Model the Head of the UM HSL Library Services
Program recommended the addition of a unique category for WRHA staff
so they could be easily identified and access to electronic
resources restricted, as needed. The recommendation was not
implemented by UML administration.
As a result, WRHA staff were registered in
the UM Faculty/Staff/Student category and automatically had full
access to all UML electronic resources. The WRHA Senior Executive
and staff were repeatedly reminded and they acknowledged that
offsite access to UML electronic resources for WRHA staff was not
part of the Agreement and that access could be lost at any time. In
recognition of these licensing difficulties, the UML began
negotiating access for WRHA staff. In some cases, vendors added the
WRHA staff with little or no additional cost. In other cases, the
costs were prohibitive since the WRHA had over 28,000
employees.
In 2012, the WRHA was informed that only staff
working in the hospitals and the Corporate Office building would be
covered in licensing agreements for electronic resources. This
decision left many WRHA staff without access to resources on which
they had become reliant. This have and have-not scenario caused
resentment amongst staff. There were many complaints to the WRHA
leadership. Eventually a new University Librarian (UL) would revisit
the issue as the UM faced a period of fiscal restraint.
Academic Appointments
Librarian staffing presented an additional
problem. At the UM, librarians hold academic appointments. When
librarians were hired they were eligible for continuing appointments
with a variety of benefits including research leaves. The University
of Manitoba Faculty Association Collective Agreement (UMFA
Article 21) states that librarians are able to take a full year of
research leave for every six years worked [28]. The hospital
libraries employed 10.5 UML librarians. This meant that as many as
two librarians per year could be on research leave. In hindsight,
provisions should have been made in the Agreement for
invoicing the WRHA for the cost of leave replacement librarians.
Initially the UML covered the costs but as time went on budgets were
increasingly strained and new UML leadership could not justify them.
After a review by UM Human Resources in 2013, it was determined that
new hospital librarian hires would be offered “contingent
appointments” and ineligible for research leaves.
Funding of the HSL Library Services Model
Similar to the issues with online access,
the entire funding model gradually became problematic. The original
Agreement obligated the WRHA to transfer one-time baseline
funds to the University for the provision of library services. The
flow of the one-time funds was from the Minister of Health to the
Minister of Education and then to the University budget. The
understanding of baseline funding hinged on the definition in
university documentation that indicated this meant permanent ongoing
budget amounts for the UML [29]. It was
assumed that once the WRHA money for library services became
baselined to the University that the hospital libraries became
University libraries and, going forward would receive the same
increases as all other departments.
And, in fact, that is the way the UML
managed the hospital libraries until 2008. However, there was no
stipulation in the Agreement that once the money was
baselined to the University that they were obligated to provide
yearly increases. University funding comes from many sources
(Manitoba Education and Training (MET), tuition and related fees,
ancillary fees, sales of goods and services, investments, and other
grants from the Province of Manitoba and the Government of Canada).
Of all these funding sources, only the allocation from MET has a
negotiated annual increase. Since the operating grant from MET
represented approximately fifty-nine percent of UM total operating
revenues, the baseline funding from the WRHA to the UM eroded while
salaries and acquisition budgets increased.
In retrospect, the baselined funds issue
should have been a red flag to everyone negotiating the Agreement,
but most specifically to University administrators and legal
advisors. Years later, senior administrators in the WRHA stated that
the Agreement could have had provisions built into it which
would have seen the WRHA provide yearly increases for cost-of-living
adjustments, salary increases, and journal cost increases. It would
have been easier for the UML and WRHA to obtain funding from
Manitoba Health during the years that the New Democratic Party (NDP)
was in power (1999 to 2016). However, the University did not request
these increases and they became an issue when UML leadership
changed, and finances became increasingly constrained under a
Progressive Conservative (PC) government.
Political and Financial Change
In 2017, several changes took place that
necessitated a change to the Agreement. The PCs were elected
in 2016 and introduced a deficit reducing budget. The WRHA was told
to cut eighty-three million dollars from its operating funds. At the
same time, the WRHA staff who did not have access to UML electronic
resources were putting pressure on the WRHA administration to
negotiate electronic access to health-related resources. This would
necessitate a change in the license agreements and additional costs.
Given the cuts demanded by the government, the WRHA was not in a
position to increase the budget for HSL Library Services.
The UM was also experiencing budget cuts
and, in 2016, the institution embarked on a redesigned budget model.
The new budget model changed the way funds were transferred to
faculties encouraging them to become more creative in generating
income. UM faculties generated income by establishing articulation
agreements with universities in other countries to attract
international students and also by establishing new graduate
programs with higher tuition fees. The UML administration had fewer
options for generating income but viewed contracts and affiliation
agreements for library services as possibilities.
Because of the PC government’s austerity
platform; the UM budget redesign; and the UML’s new interest in
generating income, the WRHA and the UM revisited the Agreement.
Philosophy of Service
University Librarians (ULs) have different
philosophies of service. Their views, experiences, and financial
environments impact the extent to which they are willing to
implement external agreements. Three ULs were part of the lifespan
of the HSL Service Model. The UL in 1990 – 2009 had an inclusive
view of library services and believed the UML was a provincial
leader in information delivery. They also understood that the Agreement
benefited UM staff and students working and learning in Winnipeg
healthcare facilities.
The UL in 2009 – 2014 was faced with the
electronic access issues and a different financial reality. Their
risk management response was to limit access to electronic resources
for the WRHA staff. Up until 2015, the health sciences librarians in
both the hospitals and the University worked collaboratively to
provide services to UM faculty and students and to WRHA staff. This
was a fluid and reciprocal environment in which the hospital
librarians participated in delivering training sessions to
university faculty and students and the university librarians
assisted with literature searches for WRHA staff.
The UL in 2014 – 2018 implemented a strict demarcation between the
support provided to the “academy” and the external support provided
to WRHA staff. They also advocated for a shift in services from
mediated to self-service. Both these changes radically altered the
HSL Services Model [30].
In addition to the above, other issues
contributed to the changes. The UL who served from 1990-2009 was
fully committed to maintaining the structure as it had been
developed. The two subsequent ULs did not fully support the purpose
and shared vision of the HSL Library Service Model [31], as the people who developed it. There
may also have been the perception of an imbalance of power wherein
the WRHA received the greater benefits while the UML incurred the
greater risk [32].
Agreement Lifespans
Do agreements have a lifespan? [33,34] Probably. Some agreements come to a
close; others evolve, while others are resurrected after a number of
years under different but similar mandates. For example,
Saskatchewan Health Information Resources Program (SHIRP) changed
from a provincial partnership to a University of Saskatchewan
program [35]. In Manitoba, a number of
library agreements came to a close over the years. For example, the
College of Physicians and Surgeons Extension Service
agreement for rural doctors negotiated with the former UM Medical
Library lasted seventeen years. Similarly, the Manitoba Health
Information Network (MHINET) agreement with Manitoba
Association of Registered Nurse lasted thirteen years. In total, all
of the agreements with the hospitals and WRHA lasted about twenty
years. Given the complexities of the environment and the various
pressures under which it operated, the HSL Library Services Model
made a significant contribution to healthcare provision in Manitoba
[27].
A New Model – The WRHA Virtual Library
As these factors converged and the
HSL Library Services Model devolved, a new service model was needed.
On January 1, 2018, the UL officially announced that the eight WRHA
hospital libraries would be closed, and the service transitioned to
a new service, the WRHA Virtual Library. The savings from hospital
library closures and staff reductions were used to purchase licenses
for electronic resources specifically for the WRHA.
The staff complement for the new
service model included four librarians and four library technicians
who continue to be located at the NJMHSL [30].
No librarians or technicians lost their jobs during this transition
as they were reallocated to vacant positions within the UML. One
librarian, the WRHA Electronic Services Librarian, was relocated to
the Fort Garry Campus, with three librarians and four technicians
providing the services formerly delivered by twenty people. Unlike
the old model, the WRHA Virtual Library Services was not managed by
the Head of the NJMHSL but instead an Associate University Librarian
(AUL) overseeing all UML contracted services.
The evolving library service continues to
have successes and challenges [30]. Although the WRHA sought
electronic access for all 28,000 employees, this is not yet a
reality. The original Subsidiary Affiliation Agreement – Libraries
stipulated WRHA staff would be given access to all UML resources,
whereas the new WRHA Virtual Library portal provides access to
freely available online resources and a select suite of subscription
resources.
Discussion
Access to evidence-based health information and
library services for healthcare providers has long been a
challenging issue in Canada. Major barriers identified by the
Canadian Health Libraries Association (CHLA/ABSC) to establishing a
national solution included: the fact that healthcare is a provincial
responsibility; the costs of establishing a new body to coordinate a
virtual library; and the costs of acquiring evidence-based resources
[37]. For over a decade, the CHLA/ABSC
attempted to address the issue nationally. From 2000 to 2008,
stakeholders across the country were consulted culminating in the
funding and creation of a Canadian Virtual Health Library in 2010, a
project that lasted approximately two years [38].
Meanwhile across the country, various provincial initiatives
developed, some still extant and developing, some devolved.
Winnipeg’s HSL Library Services Model and new WRHA Virtual Health
Library offers lessons for existing and future services.
a. Agreements
While cooperation between universities and
government agencies seems like a “win- win” proposition, this paper
reveals their fragility and complexity. The fact is that agreements
are “living” documents and need monitoring and revision to remain
relevant. High level communication between the UL and the senior
administration within the WRHA was lacking in the latter years of
the HSL Library Services Program. Changes in leadership on both
sides contributed to a loss of continuity in understanding the
history of the relationship and a commitment to the Agreement.
Additional mechanisms, such as a requirement for a biennial review
of the Agreement, could have been written into the Agreement
to ensure long-term sustainability and to allow library services to
evolve gradually.
b. Long term Fiscal Planning
While funding had been addressed in the early
stages of the development of the Agreement, unforeseen
internal and external financial challenges eventually had an impact
on the service. A consistent reexamination of the Agreement
including regular reviews by the financial departments of each
organization would have provided snapshots that anticipated
budgetary problems.
c. Evolving Nature of Evidence-Based
Healthcare Information
The HSL Library Services Model as originally
conceived, involved librarians providing mediated searches and
reference consultation service. The services were heavily used as
evidenced by a 2015 analysis of the searches performed by the HSL
librarians. From 2004 to 2010, approximately 19,000 searches were
conducted with each search taking an average of 85 minutes [39]. Although many WRHA staff also had
online access to a variety of evidence-based resources during this
time, they preferred mediated services because it saved them time
and they received a quality product. As evidence-based medicine
products incorporate more algorithms and artificial intelligence,
the need for mediated searching for day-to-day information seeking
becomes less necessary [ 40,41,42]. The
need for research support for systematic reviews or broader
investigations of changes to support patient care within the
healthcare system still remains. This support continues to be
provided by librarians in the WRHA Virtual Library [30].
d. Recentralization of Provincial Healthcare
Services
Experiments with decentralization through
regionalization continue, with some provinces reducing the number of
regions, others recentralizing delivery. For example, Alberta has
become one large health region and has developed library services,
the Knowledge Resource Service, for the healthcare providers across
the province [43]. Manitoba is also
quickly moving towards a single regional health authority, Shared
Services. These organizational shifts require continuous
reconfiguration of library service delivery and point to a different
model for the provision of information services for healthcare
providers. Integrating evidence-based health information into
provincial electronic health records is the future [41]. As things currently stand, this type
of access cannot be delivered by a university academic library
system. It might be reasonable to integrate knowledge sources into
electronic health records through provincial regional models or
perhaps a consortial membership model. However, electronic record
linkage to knowledge sources is still under development, with
evidence of success still needed.
e. Ongoing Need for National Access to
Evidence-Based Healthcare Information
The provincial challenges underscore that
national access to evidence-based healthcare information continues
to be fragmented. Within each province, differing sets of products
and services are available to healthcare providers and varies by
profession. National associations like the Canadian Medical
Association and the Canadian Nurses Association attempt to
compensate for this differentiation by offering their members access
to various evidence-based resources. Some health care providers
(e.g. Physician Assistants) belong to associations who do not have
the financial resources to offer their members such benefits.
Studies have shown that better and more cost-effective decisions are
made when healthcare providers have access to high quality evidence
at the point of care [25]. A recent drive
for a national Pharmacare Plan underscores yet again the need for
some kind of national access to a suite of relevant evidence-based
healthcare tools including drug/pharmaceutical databases.
Conclusion
From the early evolution of health library
services in Manitoba, a confluence of factors resulted in the HSL, a
revolutionary library service model that served Winnipeg health
professionals for nearly 20 years. Part of this success was the
inextricable link between the UM and WRHA clinical programs with one
medical school adjacent to one large provincial hospital located in
one major city. The HSL library services to the WRHA have devolved
since 2018 due to recognized and unanticipated factors. However, a
new WRHA Virtual Library model has emerged. Data will be gathered
and analyzed as the service develops. Time will tell if it is
meeting the needs of Winnipeg healthcare providers but the lifespan
of agreements, long term financial planning, the evolving nature of
evidence-based health information, the recentralization of
provincial healthcare services, and the ongoing need for a
pan-Canadian access to evidence-based health information may be
factors in its future.
Statement of Competing Interests No competing interests declared
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