The critical role of managers as quality leaders OR Where the top down and bottom up approaches to improvement meet.

Imperatives for improvement External: External: »Quality in Australian Health Care Study (1995) »Pollies’ attention »Question of internal vs external regulation »Comparisons with OH&S, airlines, nuclear power plants etc »High profile cases such as Bristol, King Edward, RMH, Nhill and Camden/Campbelltown »Increased publicity re problems/adverse and sentinel events »Led to…….

Focus on –Accountability –And –Safety

Big quality-related expectations in many areas: Clinical governance (accountability, culture, leadership) Clinical governance (accountability, culture, leadership) Management of risk (known problem areas, systems improvement, human factors) Management of risk (known problem areas, systems improvement, human factors) Open disclosure Open disclosure Safe staffing Safe staffing Credentialing Credentialing Education Education Consumer participation Consumer participation

But they’ve done it in other industries… Airlines Airlines Nuclear power Nuclear power Gas and oil Gas and oil OH&S OH&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 powerto Focus on roles, communication and systems improvement. Focus on roles, communication and systems improvement.

Clinical Governance “Clinical governance is the system by which the governing body, managers and clinicians share responsibility and are held accountable for patient care, minimising risks to consumers and for continuously monitoring and improving the quality of clinical care.” (ACHS 2004).

Clinical governance means accountability for quality FromBoardroomtoBedside!

Why is quality improvement difficult to implement and maintain in health care? Health care: complex processes; complex processes; unpredictable outcomes; unpredictable outcomes; life and death issues life and death issues Health 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 goals diverse goals

Why is quality improvement difficult to implement and maintain in health care? (cont.) Health 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 consumers uncertain relationship with patients as consumers

Why is quality improvement difficult to implement and maintain in health care? (cont.) 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 environments not well adapted/integrated for individual environments

How do we go about achieving QI? Monitoring and measurement Monitoring and measurement Education Education Standards, policies and procedures Standards, policies and procedures Systems review and development Systems review and development Improvement projects Improvement projects Credentialing Credentialing “Less lofty” methods “Less lofty” methods

But… Improvement of health care performance ‘hinges on changing the day-to-day decisions of doctors, nurses and other staff’ (Ham, 2003)

How do we do this? Middle Management is a bridge between the visionary ideals of the top and the often chaotic reality of those on the front line of business – and the key to continuous improvement (Nonaka and Takeuchi, 1995).

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

RVEEH Middle Manager project Action research-based case study of 35 middle managers Action research-based case study of 35 middle managers (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 the QI Program? Driving Forces Agree with QI goals Agree with QI goals Professional obligation Professional obligation Adds creativity to role Adds creativity to role Encourages problem-solving Encourages problem-solving Opportunities to build skills Opportunities to build skills Enjoy being involved in activities Enjoy being involved in activities Improves things for patients & staff Improves things for patients & staff Restraining Forces No time QI process hard to follow Lack of QI skills Not fully supported or empowered Not enough feedback Does not improve inter- department communication

The top five enablers – to be involved in change and improvement 1. More time in the day 1. More time in the day 2. More resources 2. More resources 3. Education and training 3. Education and training 4. More evidence of improvements 4. More evidence of improvements 5. More support from management 5. More support from management

The RVEEH top ten motivators 1.QI improves things for patients 2.QI improves things for staff 3.QI allows me to be creative and innovative 4.QI is a professional obligation 5.QI assists in problem solving 6.Belief in the goals of QI 7.Job description includes QI 8.QI enables me to learn new skills 9.Senior management involvement (pressure/commitment) 10.QI Improves interdepartmental relations

RVEEH Project What were the middle manager values? What were the middle manager values? »Providing safe and effective care »Contributing to patients achieving positive outcomes »Running an efficient service »Running an effective service »Being part of a respected health care organisation »Ensuring the patients’ encounter with my service 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. 12 months after the first middle manager survey, significantly more people strongly agreed that: I feel supported in my role by senior management I feel supported in my role by senior management I feel empowered by senior management to assist the hospital achieve its goals I feel empowered by senior management to assist the hospital achieve its goals I am asked to be accountable for my contribution to the hospital's goals I am asked to be accountable for my contribution to the hospital's goals I have a degree of ownership of the RVEEH QI and Accreditation programs I have a degree of ownership of the RVEEH QI and Accreditation programs The process for meeting EQuIP and QI requirements is simple and easy to follow The process for meeting EQuIP and QI requirements is simple and easy to follow

Significantly less people strongly agreed in the second 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: showing initiative in problem solving and service delivery is encouraged at RVEEH; showing initiative in problem solving and service 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 roles. QI adding innovation and creativity to middle manager roles. (fits with literature) (fits with literature)

Significant in the second survey but not the first Staff participation in team activities is encouraged Staff participation in team activities is encouraged Providing patients with the best possible care is the most important issue at this hospital Providing patients with the best possible care is the most important issue at this hospital Plus the other significant improvements

Measures of Involvement Organisational (5 levels of organisational CI implementation) Organisational (5 levels of organisational CI implementation) »Organisation moved from Level 2 to Level 3-4 on the Bessant et al 1-5 scale Individual departments (1-5 scale for each department): Individual departments (1-5 scale for each department): »2001 : 50% scored 3 or more »2002 : 95% scored 3 or more

So what was achieved? Middle manager attitudes, values, motivators and enablers were identified and incorporated into the model Middle manager attitudes, values, motivators and enablers were identified and incorporated into the model Middle managers felt more: Middle managers felt more: »supported by senior managers in QI »ownership of the QI program »confident about the QI process Middle managers felt less: Middle managers felt less: »that QI assisted them to be creative, innovative and problem solving »that QI facilitated ease of communication QI implementation level increased QI implementation level increased

Senior and Middle Manager leadership role in laying the foundation for staff to take ownership of change and 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 consistent with the vision and values and translating it into implications for change and improvement *Clarifying the strategic direction/clinical governance/quality program relationship consistent with the vision and values and translating it into implications for change and improvement *Clarifying and supporting individual job accountability and requirements so that employees can carry out processes effectively and see their contribution to the overall strategy *Clarifying and supporting individual job accountability and requirements so that employees can carry out processes effectively and see their contribution to the overall strategy *Developing a plan with willing innovators, comprising short term projects, and empowering and equipping them to implement it *Developing a plan with willing innovators, comprising short term projects, and empowering 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 structure, policy and role change *Support and guide through the inevitable setbacks and embed improvements via structure, policy and role change