The critical role of managers The critical role of managers as quality leadersas quality leaders

OROR

Where the top down and Where the top down and bottom up approaches to bottom up approaches to improvement meet.improvement meet.

Imperatives for improvementImperatives for improvement External:External:

» Quality in Australian Health Care Study (1995)Quality in Australian Health Care Study (1995)» Pollies’ attentionPollies’ attention» Question of internal vs external regulationQuestion of internal vs external regulation» Comparisons with OH&S, airlines, nuclear power plants etcComparisons with OH&S, airlines, nuclear power plants etc» High profile cases such as Bristol, King Edward, RMH, Nhill High profile cases such as Bristol, King Edward, RMH, Nhill

and Camden/Campbelltownand Camden/Campbelltown» Increased publicity re problems/adverse and sentinel eventsIncreased publicity re problems/adverse and sentinel events

»Led to…….Led to…….

Focus on Focus on

– Accountability Accountability

– AndAnd

– SafetySafety

Big quality-related expectations in Big quality-related expectations in many areas:many areas:

Clinical governance (accountability, culture, leadership)Clinical governance (accountability, culture, leadership)

Management of risk (known problem areas, systems Management of risk (known problem areas, systems improvement, human factors)improvement, human factors)

Open disclosureOpen disclosure

Safe staffingSafe staffing

CredentialingCredentialing

EducationEducation

Consumer participationConsumer participation

But they’ve done it in other industries…But they’ve done it in other industries…

AirlinesAirlines Nuclear powerNuclear power Gas and oilGas and oil OH&SOH&S

All high risk, complex and filled with experts!All high risk, complex and filled with experts!

Focus on efficiency and expert power Focus on efficiency and expert power

toto

Focus on roles, communication and systems improvement.Focus on roles, communication and systems improvement.

Clinical GovernanceClinical Governance

““Clinical governance is the system by which the Clinical governance is the system by which the governing body, managers and clinicians share governing body, managers and clinicians share responsibility and are held accountable for patient responsibility and are held accountable for patient care, minimising risks to consumers and for care, minimising risks to consumers and for continuously monitoring and improving the quality continuously monitoring and improving the quality of clinical care.” of clinical care.”

(ACHS 2004). (ACHS 2004).

Clinical governance means Clinical governance means accountability for qualityaccountability for quality

From From Boardroom Boardroom to to Bedside!Bedside!

Why is quality improvement difficult to Why is quality improvement difficult to implement and maintain in health care?implement and maintain in health care?

Health careHealth care:: complex processes; complex processes; unpredictable outcomes; unpredictable outcomes; life and death issueslife and death issues

Health professionalsHealth professionals:: tribal; tribal; autonomous experts; autonomous experts; interested in technical outcomes; interested in technical outcomes; distrust zealots; distrust zealots; ambiguous relationship with management; ambiguous relationship with management; many languages and dialects many languages and dialects diverse goalsdiverse goals

Why is quality improvement difficult to Why is quality improvement difficult to implement and maintain in health care? implement and maintain in health care? (cont.)(cont.)

Health care organisationsHealth care organisations::

professional/machine bureaucracies; professional/machine bureaucracies; conservative and slow to change; conservative and slow to change; complex politics; complex politics; management vs clinical decision-making; management vs clinical decision-making; staff melting pot; staff melting pot; process oriented; process oriented; uncertain relationship with patients as consumersuncertain relationship with patients as consumers

Why is quality improvement difficult to Why is quality improvement difficult to implement and maintain in health care? implement and maintain in health care? (cont.)(cont.)

Quality and Safety programs:Quality and Safety programs:

variety of tools and approaches; variety of tools and approaches; jargon;jargon; management driven; management driven; team oriented; team oriented; imprecise measures; imprecise measures; not well adapted/integrated for individual not well adapted/integrated for individual

environmentsenvironments

How do we go about achieving QI?How do we go about achieving QI?

Monitoring and measurementMonitoring and measurement

EducationEducation

Standards, policies and proceduresStandards, policies and procedures

Systems review and developmentSystems review and development

Improvement projectsImprovement projects

CredentialingCredentialing

““Less lofty” methodsLess lofty” methods

But…But…

Improvement of health care Improvement of health care performance performance ‘hinges on changing ‘hinges on changing the day-to-day decisions of doctors, the day-to-day decisions of doctors, nurses and other staff’ nurses and other staff’

(Ham, 2003)(Ham, 2003)

How do we do this?How do we do this?

MMiddleiddle M Management anagement iis a bridge s a bridge between the visionary ideals of the top between the visionary ideals of the top and the often chaotic reality of those and the often chaotic reality of those on the front line of businesson the front line of business – – and the and the key to continuous improvement key to continuous improvement

((Nonaka and TakeuchiNonaka and Takeuchi,, 1995) 1995)..

Three predictors of middle management and Three predictors of middle management and staff involvement in change and improvement staff involvement in change and improvement activitiesactivities

•the extent of support from their direct senior manager;

•a belief that the organisation will experience outcomes of value from the activities;

•training in the tools of change and improvement.  

Research questionResearch question

““How can hospital middle managers’ How can hospital middle managers’ involvement in quality improvement be involvement in quality improvement be enhanced, and, if this is achieved, does enhanced, and, if this is achieved, does this positively affect implementation of this positively affect implementation of quality improvement activities in quality improvement activities in hospitals?” hospitals?”

RVEEH Middle Manager projectRVEEH Middle Manager project

Action research-based case study of 35 middle managers Action research-based case study of 35 middle managers

(allied health & nursing)(allied health & nursing)

Focus Groups

Literature review

Objective Measures

Middle Managers’ Survey

Develop Model

Implement model, observe and re-adjust

Re- Survey

Problem solved !

What do Middle Managers think of What do Middle Managers think of the QI Program?the QI Program?

Driving ForcesDriving Forces Agree with QI goalsAgree with QI goals

Professional obligationProfessional obligation

Adds creativity to roleAdds creativity to role

Encourages problem-solvingEncourages problem-solving

Opportunities to build skillsOpportunities to build skills

Enjoy being involved in activitiesEnjoy being involved in activities

Improves things for patients & Improves things for patients & staff staff

Restraining ForcesRestraining Forces No timeNo time

QI process hard to followQI process hard to follow

Lack of QI skillsLack of QI skills

Not fully supported or Not fully supported or empoweredempowered

Not enough feedbackNot enough feedback

Does not improve inter-Does not improve inter-department communicationdepartment communication

The top five enablersThe top five enablers – –to be involved in change and improvementto be involved in change and improvement

1. More time in the day1. More time in the day

2. More resources2. More resources

3. Education and training3. Education and training

4. More evidence of improvements4. More evidence of improvements

5. More support from management5. More support from management

The RVEEH top ten motivatorsThe RVEEH top ten motivators1.1. QI improves things for patientsQI improves things for patients2.2. QI improves things for staffQI improves things for staff3.3. QI allows me to be creative QI allows me to be creative

and innovativeand innovative4.4. QI is a professional obligation QI is a professional obligation 5.5. QI assists in problem solving QI assists in problem solving 6.6. Belief in the goals of QIBelief in the goals of QI7.7. JJob description includes QI ob description includes QI 8.8. QI enables me to learn new skillsQI enables me to learn new skills9.9. Senior management Senior management involvement involvement

((pressurepressure/commitment)/commitment)10.QI Improves interdepartmental relations10.QI Improves interdepartmental relations

RVEEH ProjectRVEEH Project

What were the middle manager values?What were the middle manager values?» Providing safe and effective careProviding safe and effective care» Contributing to patients achieving Contributing to patients achieving

positive outcomespositive outcomes» Running an efficient serviceRunning an efficient service» Running an effective serviceRunning an effective service» Being part of a respected health care Being part of a respected health care

organisatiorganisationon» Ensuring the patients’ encounter with my Ensuring the patients’ encounter with my

serviceservice is positive is positive

• SM leads culture of improvement•SM provides strategic direction for QI plan•SM empowers and resources MM to be involved•SM and MM managers collaborative on QI planning and review

• Senior managers (SM) and middle managers (MM) agree role• Senior managers empower and resource middle manager involvement• Clear goals for involvements set

• SM and MM in collaboration• Incorporates values and strategic goals• Tailored to local needs• Priorities agreed by MM

••

-

• Supported by SM• Team/Communication process• Short-term projects demonstrating results• Review, evaluation and learning

• Basic skills for al• Just in time specific training• Different methods and adult learning• Information flow up, down and around the organisation

2. Education and Information

5. MM Operationalise QI Program

A MODEL FOR A MIDDLE MANAGER - DRIVEN QI PROGRAM

1. Senior Management Commitment and Involvement

4. QI Planning

3. SM and MM Agree Accountability

Innovators

Comparison of results between surveys. Comparison of results between surveys. 12 months after the first middle manager survey, 12 months after the first middle manager survey, significantly significantly more people strongly agreed that:more people strongly agreed that:

I feel supported in my role by senior managementI feel supported in my role by senior management

I feel empowered by senior management to assist I feel empowered by senior management to assist the hospital achieve its goalsthe hospital achieve its goals

I am asked to be accountable for my contribution to I am asked to be accountable for my contribution to the hospital's goalsthe hospital's goals

I have a degree of ownership of the RVEEH QI and I have a degree of ownership of the RVEEH QI and Accreditation programsAccreditation programs

The process for meeting EQuIP and QI requirements The process for meeting EQuIP and QI requirements is simple and easy to followis simple and easy to follow

Significantly less people strongly agreed in the second Significantly less people strongly agreed in the second survey that:survey that:

it is easy to communicate across the organisation.it is easy to communicate across the organisation.

Significant in the first survey but not the second: Significant in the first survey but not the second: showing initiative in problem solving and service showing initiative in problem solving and service

delivery is encouraged at RVEEH; delivery is encouraged at RVEEH;

staff being proud to work at RVEEH; staff being proud to work at RVEEH;

QI being a worthwhile use of time and QI being a worthwhile use of time and

QI adding innovation and creativity to middle manager QI adding innovation and creativity to middle manager roles. roles.

    (fits with literature)(fits with literature)

Significant in the second survey Significant in the second survey but not the firstbut not the first

Staff participation in team activities is Staff participation in team activities is encouragedencouraged

Providing patients with the best possible Providing patients with the best possible care is the most important issue at this care is the most important issue at this hospitalhospital

Plus the other significant improvementsPlus the other significant improvements

Measures of InvolvementMeasures of Involvement

OrganisationalOrganisational (5 levels of organisational CI (5 levels of organisational CI implementation)implementation)

» Organisation moved from Level 2 to Level 3-4 Organisation moved from Level 2 to Level 3-4 on the Bessant et al 1-5 scaleon the Bessant et al 1-5 scale

Individual departments (1-5 scale for each Individual departments (1-5 scale for each department):department):

» 2001 : 50% scored 3 or more2001 : 50% scored 3 or more» 2002 : 95% scored 3 or more2002 : 95% scored 3 or more

So what was achieved?So what was achieved?

Middle manager attitudes, values, motivators and enablers Middle manager attitudes, values, motivators and enablers were identified and incorporated into the modelwere identified and incorporated into the model

Middle managers felt more: Middle managers felt more: » supported by senior managers in QIsupported by senior managers in QI» ownership of the QI programownership of the QI program» confident about the QI processconfident about the QI process

Middle managers felt less:Middle managers felt less:» that QI assisted them to be creative, innovative and that QI assisted them to be creative, innovative and

problem solvingproblem solving» that QI facilitated ease of communication that QI facilitated ease of communication

QI implementation level increasedQI implementation level increased

Senior and Middle Manager leadership role in laying Senior and Middle Manager leadership role in laying the foundation for staff to take ownership of change the foundation for staff to take ownership of change and improvement activitiesand improvement activities

*Defining the vision and values in conjunction with staff*Defining the vision and values in conjunction with staff

*Clarifying the strategic direction/clinical governance/quality program relationship *Clarifying the strategic direction/clinical governance/quality program relationship consistent with the vision and values and translating it into implications for change consistent with the vision and values and translating it into implications for change and improvementand improvement

*Clarifying and supporting individual job accountability and requirements so that *Clarifying and supporting individual job accountability and requirements so that employees can carry out processes effectively and see their contribution to the employees can carry out processes effectively and see their contribution to the overall strategyoverall strategy

*Developing a plan with willing innovators, comprising short term projects, and *Developing a plan with willing innovators, comprising short term projects, and empowering and equipping them to implement itempowering and equipping them to implement it

*Review, recognise, reward and provide resources and time*Review, recognise, reward and provide resources and time

*Support and guide through the inevitable setbacks and embed improvements via *Support and guide through the inevitable setbacks and embed improvements via structure, policy and role changestructure, policy and role change