Cornell University International Healthcare Conference 11 th - 12 th May 2010 Staff involvement as a matter of life and death? Participative governance and the Hospital of the Future project Peter Totterdill Joint Chief Executive UK Work Organisation Network Visiting Professor Kingston University

The UK Work Organisation Network A coalition committed to shared knowledge, collaborative action and policy advocacy the future of work and organisations closing the gap between leading-edge practice and common practice

The UK Work Organisation Network Health Sector experience includes: Action Research European Hospital Network NHS Improving Working Lives programme Hospital of the Future project in Ireland

How can we create a system of governance that leads to sustainable quality improvement in hospitals?

Integrated governance Corporate Governance cost effectiveness transparency accountability Clinical Governance patient safety risk assessment learning from incidents patient satisfaction

Integrated governance Regulation or innovation?

Quality assurance without quality improvement? compliance distortion of management effort authoritarian control

Innovation in hospital work organisation: an under-utilised resource? quality of patient care mortality risk and patient safety cost effectiveness quality of working life

“Organisations with mutually reinforcing... practices achieve superior performance as their collective impact is greater than the sum of individual measures.” Teague, P., (2005) What is Enterprise Partnership? Organization 2005; 12; 567

South Maasland Hospital, The Netherlands

A conceptual model of partnership and governance in hospitals QUALITY OF WORKING LIFE PERFORMANCE INDICATORS Values, commitment, recruitment, retention Indicators as a tool for reflection and improvement Patients as active partners in the care process PATIENT EXPERIENCE Macro Systems

A conceptual model of partnership and governance in hospitals QUALITY OF WORKING LIFE PERFORMANCE INDICATORS Values, commitment, recruitment, retention Indicators as a tool for reflection and improvement Patients as active partners in the care process PATIENT EXPERIENCE Macro and Micro- Systems

A conceptual model of partnership and governance in hospitals QUALITY OF WORKING LIFE PERFORMANCE INDICATORS Values, commitment, recruitment, retention Indicators as a tool for reflection and improvement Patients as active partners in the care process Partnership & involvement PATIENT EXPERIENCE Macro and Micro- Systems

A conceptual model of partnership and governance in hospitals QUALITY OF WORKING LIFE PERFORMANCE INDICATORS Values, commitment, recruitment, retention Indicators as a tool for reflection and improvement Patients as active partners in the care process Job design & teamworking PATIENT EXPERIENCE Macro and Micro- Systems

A conceptual model of partnership and governance in hospitals QUALITY OF WORKING LIFE PERFORMANCE INDICATORS Values, commitment, recruitment, retention Indicators as a tool for reflection and improvement Patients as active partners in the care process Knowledge distribution PATIENT EXPERIENCE Macro and Micro- Systems

A conceptual model of partnership and governance in hospitals QUALITY OF WORKING LIFE PERFORMANCE INDICATORS Values, commitment, recruitment, retention Indicators as a tool for reflection and improvement Patients as active partners in the care process SELF-DIRECTION & DISCRETIONARY EFFORT CREATIVE SPACES LEARNING & DEVELOPMENT Job design & teamworking PARTICIPATIVE GOVERNANCE Partnership & involvement Knowledge distribution PATIENT EXPERIENCE Macro and Micro- Systems

Hospital of the Future Project What are the principal obstacles and dilemmas which hospitals face in securing effective governance and quality improvement? And what can be done to overcome them?

Seven hospitals studied University Hospital Galway Adelaide and Meath Naas General Hospital Waterford General Hospital St Luke’s Kilkenny National Maternity Hospital Beaumont Hospital

We identified many participative initiatives which are improving patient care and hospital performance.

But there is no systemic approach, either at hospital level or national level, to implementing the practices that we know work.

A conceptual model of partnership and governance in hospitals QUALITY OF WORKING LIFE PERFORMANCE INDICATORS Values, commitment, recruitment, retention Indicators as a tool for reflection and improvement Patients as active partners in the care process SELF-DIRECTION & DISCRETIONARY EFFORT CREATIVE SPACES LEARNING & DEVELOPMENT Job design & teamworking PARTICIPATIVE GOVERNANCE Partnership & involvement Knowledge distribution PATIENT EXPERIENCE

Partnership & involvement  A better IR climate.  Some superb examples of high involvement innovation.  Only a few hospitals spreading partnership practices systematically, and with only partial success.  Widespread medical indifference to the potential of other staff to make an enhanced contribution to governance and quality improvement.  Trade union role often weak and unfocussed.  A better IR climate.  Some superb examples of high involvement innovation.  Only a few hospitals spreading partnership practices systematically, and with only partial success.  Widespread medical indifference to the potential of other staff to make an enhanced contribution to governance and quality improvement.  Trade union role often weak and unfocussed. A conceptual model of partnership and governance in hospitals

PERFORMANCE INDICATORS Job design & teamworking  International evidence and local examples demonstrate that teamworking increases staff engagement & enhances patient care.  The dissemination of team-based practices depends on individual medical consultants, not on evidence of clinical effectiveness or patient safety.  Effective teamworking needs sustained organisational support.  Many managers fear staff empowerment.  International evidence and local examples demonstrate that teamworking increases staff engagement & enhances patient care.  The dissemination of team-based practices depends on individual medical consultants, not on evidence of clinical effectiveness or patient safety.  Effective teamworking needs sustained organisational support.  Many managers fear staff empowerment. A conceptual model of partnership and governance in hospitals

Knowledge distribution  Staff engagement in governance is sporadic  Widespread persistence of a climate of fear perpetrated by some managers & clinicians.  Some excellent examples of continuous improvement and innovation at local level, but systemic approaches at hospital level hard to find.  Staff and frontline unions are an underused resource in managing crisis.  Staff engagement in governance is sporadic  Widespread persistence of a climate of fear perpetrated by some managers & clinicians.  Some excellent examples of continuous improvement and innovation at local level, but systemic approaches at hospital level hard to find.  Staff and frontline unions are an underused resource in managing crisis. A conceptual model of partnership and governance in hospitals

UNION Risk Committee Clinical Directorate STAFF Quality Committee Partnership Committee UNION EXECUTIVE TEAM Local Forums Local Forums Multi-Disciplinary Clinical and Service Teams The dis-integration of partnership and governance

Clinical Governance Committee STAFF EXECUTIVE TEAM UNION TRADE UNION ALLIANCE UNION Beyond the fragments Clinical Directorate Partnership Committee Local Forums Local Forums Local Forums Local Forums Multi-Disciplinary Clinical & Service Teams

The Role of Partnership Committees Strategic Policy Industrial Relations Improvement & Innovation Proposition: a Partnership Committee working to its full potential is located at the centre of the triangle.

Challenges The problem of voluntarism Quality assurance without quality improvement? Regulation or animation?

External validation has been a valuable and valued tool for bringing people together around shared interests across occupational and functional divisions. There is a high risk of a narrow focus on compliance rather than on achieving sustainable improvement. There is a fear that the emerging system of central regulation will seek “one size fits all” compliance rather than resourcing local innovation.

Regulation alone does not bring about sustainable change but may only secure compliance with audit requirements. However given the right circumstances regulation can create the conditions for sustainable and meaningful change.

What is to be done? Formulating clear and actionable recommendations involving all stakeholders A process of shared learning