Director Clinical Governance, Northern Sydney Central Coast Area Health Service Australia
Consider a typical senior management meeting, and how care–which is, after all, the core business–is talked about. Care is typically talked about as delays, costs, issues, liabilities and perhaps, revenue or market share. Its beneficial purpose generally remains implicit. Conversely, consider a typical clinical meeting. Here, the ‘system’ is seen as a block to good ideas and a waste, with its positive role in coordination, resource allocation and system improvement unremarked. Similar fault lines can be observed in quality improvement. Official quality and safety strategies often boil down to exhorting clinicians to "please try to not harm people", rather than a positive view of doing things well. Conversely, clinicians can be reluctant to buy into broad system issues beyond their own immediate sphere of influence or even their own profession.
This divergence matters because, given the link between resource and clinical outcomes, the clinical and managerial cultures must come together if real progress is to be made. The challenge is therefore to recruit the organisation–not just its formal structures, but also its culture and practices–to continuously improve care. Given that one must start with the culture one has, rather than the desired one, the practical problem is how to link subcultures in a common, positive project of improving care.
The quality of healthcare remains highly variable. While excellent results are the norm, the reliability of healthcare processes generally remains low, with unreliability being estimated by the Institute for Health Care Improvement1 (IHI) at 1:10. That is, healthcare processes generally deliver the intended result only nine times out of ten. This estimate is corroborated by the thousands of avoidable deaths and injuries that happen each year, as well as by structured record audits. While there are major exceptions (consider the safety improvements in anaesthesia) even the best health systems perform well below what might be expected.
Technical complexity is necessarily a factor, but as Gaba had noted2, reliability in healthcare is also limited by cultural factors such as lack of accountability, structural secrecy, cultures that blame and, tellingly, the ‘normalisation of deviance’ –the acceptance of poor quality as normal. AHRQ's description of a high reliability organisation–safety as a top-level priority, recognition that activities are error prone, blame-free reporting, development of solutions through collaboration and resources directed to safety concerns3–gives further insights into why reliability remains low.
Improving our capacity for quality and safety is not just a matter of going out and setting up new quality systems. First, there is little evidence that quality interventions as such make a material difference4. While this may reflect the difficulty of demonstrating cause and effect in complex evolving systems, it should give policy-makers a pause before making further large investments. Second, safety culture is a facet of the broader culture, and quality will be best improved by addressing broader cultural issues, in particular, how all participants in the health system, whether clinician, consumer, manager, funding agency or regulator, can collaborate to ensure the right care is delivered reliably in the right way.
While there are exceptions, health services generally remain organised around professional relationships, resource inputs, external reporting lines and historical arrangements. A discourse centred on effective, integrated, efficiently resourced care does not arise naturally in these conditions.
As Degeling and his colleagues have shown5, the major sub-cultures often have conflicting values about important things. For example, most medical clinicians are deeply sceptical of teamwork (unless they happen to lead the team), while nurses generally see teamwork as essential. Similarly, clinical doctors and nurses see quality as a private professional matter rather than belonging in the public domain while managers see (clinicians') quality as a proper matter for the public record. Clinical doctors and clinical nurses generally reject resource constraints as the basis for an individual care decision, while managers are more willing to base decisions on available resources. The key point is that very powerful groups have polarised views on the very issues that must be dealt with if quality and safety are to be improved, namely, teamwork, quality, evidence and the basis of resource allocation.
This dissonance is not theoretical. Middle managers, whether clinical or general, are subjected to pressures from above to avoid patient harm, to conserve money and to retain the workforce. They also experience pressure from below to protect their unit from outside pressure and to procure new resources and opportunities. This can create great personal stress and even alienation amongst the very people whose support is needed to ensure a safe, reliable system. A nurse manager's comment reported in a recent study of a major hospital is revealing:
“. I know a lot of the systems could work a lot better, but they're playing their little party and they've got their little set-up nice so, stepping on toes is not my thing because you know you're not going to get support further up, so why do it? It's just too difficult and it's real shame.” said a Nurse Manager6.
The implications for clinical leaders are profound. Unless middle managers are 'authorised' to lead by both the followership and those 'above', and unless senior management gives consistent support through difficult times, energy is diverted into survival rather than taking the system forward7. The challenge is to engage and recruit divergent cultures in a common task of improving care.
Official strategies aimed at improving quality and safety tend to be couched in what might be called 'anti-negative' terms-for example 'please stop killing / infecting / poisoning / tripping people'. While such approaches play well in senior management and political circles, and indeed close loops on much 'guilty' knowledge (falls reduction, anyone?), they tend to be less than inspiring to clinicians, who soon tire of straining against system limits and top-down mandates. While increased vigilance and error trapping can make safety gains, these are tiny compared to the gains from optimised care systems.
The challenge is, therefore, to move from the ‘anti-negative’, to the ‘positive’, from ‘don’t harm' to ‘let’s do the right thing’. This is more than a rhetorical gesture-to make the transition, it requires a rethinking of who 'we' are, what we manage, and how.
Healthcare nearly can be described in terms of processes-a sequence of actions and events that tend to be repeated in similar circumstances. Typical examples are treatment of community acquired pneumonia, an elective surgical admission or normal childbirth. While such processes have a technical dimension, namely what is done in what order, they also have a social and cultural dimension-the values, expectations and interactions of those involved, whether nurse, doctor, consumer or manager.
It follows that if operations are based on care processes, the various sub-cultures can be linked because it is clear who is involved, in what capacity, using what resources, to what effect, with what variation. Furthermore, a process-based system promotes organisation around the care produced rather than history, profession and resource inputs. Even more fundamentally, the values around which the system is built resonate with those involved: quality discourse can move from a post hoc source of guilt to a prospective responsibility, from 'what went wrong', to 'what must we do right'. This re-orientation is more than sleight of hand. As Quinn points out8, purpose-centred thinking-that is, what must be done to achieve the desired result-can greatly enhance leadership.
While it is simple to state, 'quality and safety are our highest goal', as Marais points out, there is usually conflict between safety and performance goals, and in practice, a choice must be made between optimising performance and optimising safety9. Furthermore, a wide range of external factors affect that choice as also internal influences, ranging from overt politics to mandated targets to the personal ambition of decision makers.
In health services, there are interesting and complex ethical issues surrounding such choices. First, while the careers and reputations of decision makers may be at risk, the lives that are most affected are not usually involved in the discussion, at least at a policy level. Second, at a societal level, the tensions between access to services, quality and funding usually remain undiscussed: unrealistic expectations abound, and quality / performance trade-offs remain implicit. Third, in the absence of a societal consensus and overt policy, the burden of decision-making is typically passed down to clinicians and patients, whose marginal resource decisions are constrained by a system that neither the clinician nor patient feels able to influence.
As Marais points out, the challenge is not to proclaim one goal to the exclusion of others, but to assess the risks and to know how much risk is acceptable.
A simple example from my own organisation is our approach to improving inpatient nutrition. Earlier in-house research had shown avoidable problems with inpatient nutrition, with a significant impact on vulnerable patients. The typical approach in the past has been the 'anti-negative'-one of developing a set of detailed policies and procedures designed to avoid the problem (in this case, malnutrition), with the hope that the staff would have the time, inclination and resources to follow.
The positive approach is subtly, but crucially different. Rather than being a set of error-trapping procedures, the policy comprises a set of positive evidence-based standards, developed in consultation with consumers, clinicians, food service providers, managers and funders. Each standard is a positive statement, such as ‘the ward environment will be conducive to eating’, with a set of subsidiary statements. Of course, extensive subsystems are now being developed (e.g. risk screening) but once again these are couched in terms of positives, rather than negatives.
The approach does not ‘wish away’ constraints on achievement, such as resources. Rather, it allows them to be effectively risk managed. If, for example, a ‘standard’ in the nutrition policy cannot be met, then the risk, which is now known as opposed to be buried, can be formally and accountably managed by acceptance, elimination or control.
Quality, Safety and Improvement requires a supportive culture, but we must get started. We can start with the culture we have to create the one we want. This requires an understanding of our cultures and a practical way to engage them in a shared positive vision of where we need to be.
Philip Hoyle is a Director of Clinical Governance for Northern Sydney & Central Coast Area Health Service. Responsibilities within that role include quality, safety, risk management, policy systems and accreditation, as well as executive responsibility for research and disaster management. Philip's obsession is the prospective design of health systems, so that clinical staff, consumers, managers and funders can combine to ensure the right care is delivered, first time.
1 Nolan, T, Resar R Improving the Reliability of Health Care Institute for Healthcare Improvement, Boston, 2004
2 Gaba, David M : "Structural and Organisational Issues in Patient Safety" California Management Review Vol 43, no 1 Fall 2000
3 AHRQ Evidence Reports, Number 43. Making Health Care Safer: A Critical Analysis of Patient Safety Practices
4 ?vretveit, J What are the best strategies for ensuring quality in hospitals?, Health Evidence Network (HEN) at http://www.euro.who.int/HEN/Syntheses/hospitalquality/20031124_4
5 Degeling, P; Winters, M; Maxwell, S; Coyle, B; Hoyle,P: A Project to Map the Cultural and Psycho-Social Predispositions of Staff in RNSH and to Assess the Implications for Reform University of Durham and Northern Centre for Healthcare Improvement, 2007Degeling Subcultures
7 Degeling, P and Carr “A Leadership for the systematisation of health care: the unaddressed issue in health care reform“ Journal of Health Organisation and Management Vol 18 No 6, 2004 399-414
8 “Entering the Fundamental State of Leadership: Reflections on the Path to Transformational Teaching (An Interview with Robert E. Quinn)." Academy of Management Learning & Education, vol. 4, no. 4, 2005, 487-495.
9 Marais, K Dulac N, Leveson N Beyond Normal Accidents and High Reliability Organizations: The Need for an Alternative Approach to Safety in Complex Systems MIT Engineering Systems Symposium 2004: http://esd.mit.edu/staging/symposium/pdfs/papers/marais-b.pdf