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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 24-October-2003, Vol 116 No 1184

Improving quality: maintaining the momentum
Gerald Moss
The ‘Quality and patient safety’ movement in New Zealand has gained momentum1 through the enthusiasm resulting from the recent 3rd Asia Pacific Forum on Quality Improvement in Health Care, publication of the report ‘Improving quality’,2 and the announcement of many quality awards both nationally and locally. The actual implementation of quality initiatives – that is to say ‘change management’ – and demonstration of success will depend upon maintaining this momentum. This immediately raises issues around leadership and culture change in a complex adaptive system,3,4 and around effectiveness and evaluation.5,6 Quality and Safety in Healthcare – a relatively inexpensive journal also online at http://www.qshc.com – contains a wealth of interesting, informative and relevant material around these issues.

Clinical governance

In 1997 the concept of ‘clinical governance’ was introduced into the UK National Health System7 as an approach to quality improvement that supported ‘joined-up-ness’8 of new and established quality-improvement initiatives. This systems approach not only aimed to improve effectiveness through integration of these activities but also drew attention to the interdependence of the system components – each component had effects upon the other components, and was in turn affected by what happened in the other components.
This approach to quality improvement, albeit with local adaptation, has been strongly promoted in the Australian context, and moderately so in New Zealand. The importance of clinical governance lies in the acceptance of the concept by clinical and allied health professionals and the opportunity to learn from the enormous amount of published research coming out of the UK.
A new report from the National Audit Office (NAO) on the implementation of clinical governance in the NHS is both timely and informative.9 It identifies significant barriers to further improvement, including lack of time and resources, cultural difficulties, lack of strategy and lack of expertise in particular components. There are also concerns over continuing professional development, largely caused by workload or organisation of working commitments, which conflicts with training. The report concludes that progress in implementing clinical governance is patchy, and varies between trusts, within trusts and between the components of clinical governance. Overall, the key features of the better-performing organisations are quality of leadership, commitment of staff, and willingness to consider doing things differently.

Leadership

There is no shortage of books on leadership and courses offering training in leadership; however, there is little information on the effectiveness of these and for whom they are targeted. This issue may be addressed in New Zealand as a result of the formation of the Leadership Institute, an initiative of the University of Auckland Business School, in February 2003. It will have a national focus to harness the energy, ideas and momentum of the Knowledge Wave 2003 Leadership Forum.
Clearly leadership from the top – that is from the Minister of Health and through district health board (DHB) chairs and CEOs – is of paramount importance, but ‘leadership should be researched as a process that can occur throughout organisations, and not just from people at the senior end of the hierarchy.’10 Those who feel unable to develop themselves as leaders could become excellent supporters; support is a resource that leaders require.

Culture change

A healthcare organisation consists of a myriad of subcultures, each unique with different histories, perspectives and collegial loyalties along with proud and protective attitudes around their respective departments. When proposing change, administrators should remember that one size does not fit all.11–14 A further consideration is the matching of hierarchical management and professional models of patient care. An inclusive approach, where there are opportunities for communication, where communication is two-way, where people’s opinions are valued and where patience is a virtue, is likely to be conducive to success.
The ‘quality manager’ is involved in leadership, the development of skills, and the provision of resource amongst other duties. The situation is New Zealand is similar to that in Australia, namely poor support on the part of organisations for these professionals and a lack of opportunities for their own professional development, education and training.15

Patient safety

The boundaries between the various elements of clinical governance are poorly defined and there is a great deal of overlap; indeed, the underlying principle of clinical governance is that of integration and joined-up-ness. However, the term ‘patient safety’ draws attention to the burden of adverse events16 and the growing interest in clinical risk management. Part of the hoped-for change in healthcare is the development of ‘open disclosure’ when things go wrong and of a blame-free culture in which mistakes can be disclosed and the management of risk improved.
The current environment in respect of the law in healthcare tends to focus on the need to attribute blame before compensation can be awarded, even if simply to address a serious outcome in which negligence played no part. This tendency is a major concern as it works against the development of a blame-free culture.17
The NAO report indicated that, although the recording, collation and review of data were performed well, performance was weak as regards training in risk management and in moving from identifying measures to improve quality to taking action.9

Implementation

Much research has been conducted around the implementation of research-based evidence in clinical practice and is relevant to change management in healthcare generally. Success factors identified include strong evidence, supportive opinion leaders, integration within a committed organisation, context analysis, professional involvement, good project management, and careful understanding of the local context.18 Implementation should be seen not as rational and linear (political model) but as a negotiated and uncertain process enacted locally within clinical groups and based on tacit knowledge.19
The characteristics associated with the successful implementation of quality and excellence in healthcare share, in particular: strong leadership, involvement, empowerment, customer focus, teamwork, trust, effective information transfer, and organisational commitment.14
Increasingly, healthcare professionals have been required to do more with less, and management professionals have been burdened with pressures over quantity and cost to the relative exclusion of quality and safety.20 Failure to provide adequate resources after having raised enthusiasm and commitment is likely to be counterproductive and bring momentum to a halt. Generally, staff point to the lack of time as a barrier to implementation, but it is also a barrier to reflection and evaluation. How will they know how they are doing?
The requirements for successful implementation of complex change have been enumerated along with indicators of failure associated with the lack of each one.21 For example, the requirements are vision, skills, incentive, resources and an action plan. If all are present, change will probably occur. Where there is no vision confusion reigns; where there is no skill anxiety results; if there is no incentive change will be gradual at best; lack of resources leads to frustration; and if there is no action plan false starts may be expected.

Knowledge management

Systems within healthcare organisations depend upon:
  • information – which must be accessible in a timely manner;
  • knowledge – which tends to diffuse poorly across boundaries;
  • learning – which often does not appear to happen.21
The art and science of marketing have received little attention in healthcare. Part of these are a requirement for providers to ‘know the customer’; knowing the customer is important in change management, and in successful consumer involvement.
Medical librarians and information technologists are becoming key players (as health informationists) in knowledge management and could become even more effective through opportunities for engagement with clinical and management professionals.
Organisations might be encouraged through the Wave Project to share expertise, and use economy of scale, for example in the provision of comprehensive and coordinated education and training of a high standard for quality managers.
A universal understanding of complexity in healthcare (the subject of a series of articles in the BMJ) will greatly enhance the likelihood of successful implementation of change. It is not about agreeing that healthcare is complex, it is about understanding that healthcare is a complex adaptive system in which, for example, one observes the rich interaction of components and not just the system’s structure, in which history and the environment interact in a non-linear way, and in which emergent behaviour cannot be predicted.4 Such understanding encourages inclusiveness and helps an organisation to make sense of itself.

Evaluation

‘Evaluation is an integral component of quality improvement and there is much to be learned from the evaluation of small-scale quality improvement initiatives at a local level.’22 Quality improvement programmes consume considerable resources and may have significant consequences, yet little is known about whether or not they are effective and the reasons for this.23 It does not make any sense to plan an intervention without an intention to evaluate its effectiveness; planning the evaluation should be part of planning the intervention. ‘Those planning and reporting evaluations of quality improvement should do so in the context of a systematic review. Similarly, those planning quality improvement activities should consider the results of systematic reviews when doing so.’24 Although the literature supports the development of evaluation-informed25 and evidence-based26 management in healthcare, reviews confirm that use of appropriate research is sub-optimal.27

Making it happen

Progress in the development of quality improvement in healthcare has been slow and incremental. In order to build and maintain momentum, to the point where the snowball becomes an avalanche, it is necessary to reach a ‘tipping point’ or critical level, the requisites for which may be summarised below:
  • key people, such as ‘connectors’ or network people, ‘mavens’ who are curious and knowledgeable, and ‘salesmen’ or super opinion leaders;
  • the packaging or marketing of information – described as the ‘stickiness factor’ – which grabs attention and makes an impression;
  • the power of context, which includes forming groups of a manageable size, allowing true engagement, a deep understanding of the context, and meticulous planning.28

How are we doing?

Recommendations from the NAO for trusts in the UK9 are based on evaluations of progress so far in that context. At present, such data are not available in the New Zealand context although evaluation would indicate what has or has not worked, why this is so, and where resources might be most usefully applied. The NAO-recommended activities will be well established in some New Zealand DHBs but, just as in the UK, implementation is likely to be patchy. These recommended activities are:
  • the review of information requirements;
  • the development of systems of internal reporting on quality;
  • the maximisation of the benefits to be derived from clinical audit;
  • support for continuing professional development;
  • benchmarking of key clinical governance initiatives;
  • agreement on action plans, timetables and priorities.
One thing cries out above all else: leadership.
Author information: Gerald Moss, Consultant in Clinical Governance, Christchurch
Correspondence: Dr Gerald Moss, 29 Rubens Place, Christchurch. Email: gerald.moss@clear.net.nz
References:
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