Taking the Message Home: Quality and the High Performance Organisation Judith Dwyer La Trobe University

Taking the Message Taking the Message Home: Quality and the Home: Quality and the High Performance High Performance OrganisationOrganisationJudith DwyerJudith Dwyer

La Trobe UniversityLa Trobe University

La Trobe Health Management Group

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The big questions:The big questions:

What do we really know?What do we really know? How is quality improved?How is quality improved? How long does it take?How long does it take? Acknowledging a source:Acknowledging a source:

The Evidence for Effectiveness for Quality The Evidence for Effectiveness for Quality Initiatives in Human Services: A Critical Initiatives in Human Services: A Critical Review.Review. Russell Renhard, Australian Institute Russell Renhard, Australian Institute for Primary Care, 2001for Primary Care, 2001..


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Definition Problem: Definition Problem: Outcomes not inputsOutcomes not inputs This is new and difficultThis is new and difficult Problems are conceptualProblems are conceptual

– what is a quality outcome?what is a quality outcome?

And practicalAnd practical– who wants to know and what will they do who wants to know and what will they do

with the information?with the information?

Inputs, outputs, structure & process still Inputs, outputs, structure & process still matter, for both assuring and improvingmatter, for both assuring and improving


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What the literature What the literature sayssays Key finding: Key finding:

– ‘‘Quality initiatives, regardless of scope or Quality initiatives, regardless of scope or focus, are more likely to be effective when focus, are more likely to be effective when used in an organisation that functions used in an organisation that functions according to [CQI] principles and practices. according to [CQI] principles and practices. The key determinant of success of a quality The key determinant of success of a quality initiative, therefore, is not the initiative itself initiative, therefore, is not the initiative itself but the nature of the organisation in which it but the nature of the organisation in which it is used’ is used’

Renhard,2001.Renhard,2001.


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The CQI OrganisationThe CQI Organisation Use of problem-solving methodsUse of problem-solving methods

– based on hard and soft databased on hard and soft data

Focus on systems and processesFocus on systems and processes– not individualsnot individuals

Use of cross-functional teams in CQIUse of cross-functional teams in CQI Employee empowerment to identify and Employee empowerment to identify and

action improvementsaction improvements Explicit focus on internal and external Explicit focus on internal and external

customers/consumerscustomers/consumers


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Underlying these...Underlying these...

Sustained management support for this Sustained management support for this way of workingway of working

Take home message: Take home message:

Organisation culture, systems and Organisation culture, systems and alignment matter -alignment matter -


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Pictures of the year by NBC

Press on!Press on!


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Implication and 2 Implication and 2 QualificationsQualifications Narrow quality initiatives in Narrow quality initiatives in

organisations without a structured organisations without a structured approach to CQI won’t workapproach to CQI won’t work

Qualification 1: Some things will work Qualification 1: Some things will work anywhere eg better labelling of medication anywhere eg better labelling of medication

Qualification 2: Some things won’t work even Qualification 2: Some things won’t work even in CQI organisations if not done well eg in CQI organisations if not done well eg standards not properly developed and standards not properly developed and acceptedaccepted


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Role of governmentRole of government

Quality happens on the groundQuality happens on the ground Government cannot deliver qualityGovernment cannot deliver quality

– except of its own operationsexcept of its own operations

Government can encourage, Government can encourage, motivate and supportmotivate and support


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Beatings won’t workBeatings won’t work

Little evidence that punitive Little evidence that punitive approaches are effectiveapproaches are effective– but may suppress useful info (Liang & but may suppress useful info (Liang &

Storti 2000)Storti 2000)– ‘‘Circle of Fear’ - mistake, punishment, Circle of Fear’ - mistake, punishment,

micro-management, suppression of micro-management, suppression of data, mistake, punishment………...data, mistake, punishment………...

Purchasing quality can helpPurchasing quality can help– but not as primary strategybut not as primary strategy


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How good is the How good is the evidence?evidence? Mixed - studies diverse in design and Mixed - studies diverse in design and

measures - 2 reasons:measures - 2 reasons: Reason 1: Q concept unclearReason 1: Q concept unclear

– and therefore how to measure itand therefore how to measure it• technical aspects of service delivery?technical aspects of service delivery?• consumer and other viewpoints?consumer and other viewpoints?

Reason 2: way CQI is adoptedReason 2: way CQI is adopted– shift in culture, over time, system shift in culture, over time, system

development precedes resultsdevelopment precedes results


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How is Quality How is Quality improved?improved? Traditional Government belief:Traditional Government belief:

– figure out the best method ONCE and get figure out the best method ONCE and get everyone to take up new methods noweveryone to take up new methods now

Traditional Community belief:Traditional Community belief:– figure out the best rules to make sure patients figure out the best rules to make sure patients

are safe and enforce them noware safe and enforce them now

Traditional Insurer belief:Traditional Insurer belief:– don’t make mistakesdon’t make mistakes– if you do, find out who’s to blame and punish if you do, find out who’s to blame and punish

themthem


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Health System Health System ResponseResponse Lots of Committees, Enquiries, Lots of Committees, Enquiries,

protocols, procedures, experiments, protocols, procedures, experiments, reportsreports

Many calls for change, everyone Many calls for change, everyone agrees on goals, but not methods agrees on goals, but not methods

Sense that progress is slow, reports Sense that progress is slow, reports are not implementedare not implemented

Why?Why?


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One answerOne answer Institute of Medicine Report ‘Crossing the Institute of Medicine Report ‘Crossing the

Quality Chasm’ (2001)Quality Chasm’ (2001) Describes system that is wasteful, often Describes system that is wasteful, often

redundant, lacking information systems, redundant, lacking information systems, subject to delays, errors and unnecessary subject to delays, errors and unnecessary services services

Offers 6 key characteristics of ideal health Offers 6 key characteristics of ideal health care systemcare system


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6 Characteristics6 Characteristics

SafeSafe Patient-centredPatient-centred EfficientEfficient

Effective Effective TimelyTimely EquitableEquitable


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No recipesNo recipes Authors didn’t provide recipe for improvementAuthors didn’t provide recipe for improvement Reason: Complex Adaptive Systems TheoryReason: Complex Adaptive Systems Theory

– highly adaptable elementshighly adaptable elements• health professionalshealth professionals

– small inputs can have large effects small inputs can have large effects – new behaviours constantly - like the weather, new behaviours constantly - like the weather,

not predictablenot predictable– simple rules can give complex outcomessimple rules can give complex outcomes– ‘‘strange attractors’ - poorly understood values strange attractors’ - poorly understood values

or needs which can be harnessedor needs which can be harnessed


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Complex Adaptive Complex Adaptive Systems TheorySystems Theory Compared to mechanical systems Compared to mechanical systems

thinkingthinking– image of throwing a rock to land on a image of throwing a rock to land on a

chosen spotchosen spot• calculate and throwcalculate and throw

– then throwing a birdthen throwing a bird• need to understand what will make the bird need to understand what will make the bird

go to that spotgo to that spot


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Pictures of the year by NBC


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Power of Simple RulesPower of Simple Rules

Authors advocateAuthors advocate– understand the system and strange understand the system and strange

attractorsattractors– accept that change has to be negotiated accept that change has to be negotiated

with the ‘adaptable elements’, ie can’t with the ‘adaptable elements’, ie can’t be imposed from outsidebe imposed from outside

– agree on simple statements of principle, agree on simple statements of principle, not detailed proceduresnot detailed procedures

– suggest 10 simple rulessuggest 10 simple rules


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10 simple rules10 simple rules

11 Care based on continuous healing Care based on continuous healing relationshipsrelationships

22 Customisation based on patient Customisation based on patient needs and valuesneeds and values

33 Patient as source of controlPatient as source of control

44 Shared knowledge and free flow of Shared knowledge and free flow of informationinformation

55 Evidence-based decision makingEvidence-based decision making


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Simple Rules continuedSimple Rules continued

66 Safety as a system propertySafety as a system property

77 Need for transparencyNeed for transparency

88 Anticipation of needsAnticipation of needs

99 Continuous decrease in wasteContinuous decrease in waste

10 Cooperation among clinicians10 Cooperation among cliniciansSource: Institute of Medicine. Source: Institute of Medicine. Crossing the Quality Crossing the Quality

Chasm: a new health system for the 21st century.Chasm: a new health system for the 21st century. Washington: National Academy Press, 2001.Washington: National Academy Press, 2001.


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How long does it take?How long does it take?


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ReferencesReferences Institute of Medicine, (2001). Institute of Medicine, (2001). Crossing the Quality Crossing the Quality

Chasm: a new health system for the 21st century.Chasm: a new health system for the 21st century. Washington, National Academy Press. Washington, National Academy Press.

Liang and Storti (2000). “Creating Problems as part Liang and Storti (2000). “Creating Problems as part of the ‘solution’: the JCAHO sentinel event policy, of the ‘solution’: the JCAHO sentinel event policy, legal issues and patient safety”. legal issues and patient safety”. Journal of Health Journal of Health Law,Law, 33(3), 263-85. 33(3), 263-85.

Renhard 2001. Renhard 2001. The Evidence for Effectiveness for The Evidence for Effectiveness for Quality Initiatives in Human Services: A Critical Quality Initiatives in Human Services: A Critical Review.Review. Australian Institute for Primary Care, Australian Institute for Primary Care, Melbourne.Melbourne.

Documents

Taking the Message Home: Quality and the High Performance Organisation Judith Dwyer La Trobe University