The critical role of managers as quality leaders

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

2. Imperatives for improvement • 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…….

3. Focus on • Accountability • And • Safety

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

5. But they’ve done it in other industries… • Airlines • Nuclear power • Gas and oil • OH&S • All high risk, complex and filled with experts! • Focus on efficiency and expert power to • Focus on roles, communication and systems improvement.

6. 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).

7. Clinical governance means accountability for quality From Boardroom to Bedside!

8. Why is quality improvement difficult to implement and maintain in health care? Health care: • complex processes; • unpredictable outcomes; • life and death issues Health professionals: • tribal; • autonomous experts; • interested in technical outcomes; • distrust zealots; • ambiguous relationship with management; • many languages and dialects • diverse goals

9. Why is quality improvement difficult to implement and maintain in health care? (cont.) Health care organisations: • professional/machine bureaucracies; • conservative and slow to change; • complex politics; • management vs clinical decision-making; • staff melting pot; • process oriented; • uncertain relationship with patients as consumers

10. Why is quality improvement difficult to implement and maintain in health care? (cont.) Quality and Safety programs: • variety of tools and approaches; • jargon; • management driven; • team oriented; • imprecise measures; • not well adapted/integrated for individual environments

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

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

13. 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).

14. 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.

15. 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?”

16. RVEEH Middle Manager project • Action research-based case study of 35 middle managers (allied health & nursing) Focus Groups Literature review Objective Measures Middle Managers’ Survey Develop Model Re- Survey Implement model, observe and re-adjust Problem solved !

17. Driving Forces Agree with QI goals Professional obligation Adds creativity to role Encourages problem-solving Opportunities to build skills Enjoy being involved in activities 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 What do Middle Managers think of the QI Program?

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

19. 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

20. RVEEH Project • 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

21. 2. Education and Information 3. SM and MM Agree Accountability Innovators 5. MM Operationalise QI Program 4. QI Planning • Supported by SM • Team/Communication process • Short-term projects demonstrating results • Review, evaluation and learning • • - 1. Senior Management Commitment and Involvement A MODEL FOR A MIDDLE MANAGER - DRIVEN QI PROGRAM • Basic skills for al • Just in time specific training • Different methods and adult learning • Information flow up, down and around the organisation • SM and MM in collaboration • Incorporates values and strategic goals • Tailored to local needs • Priorities agreed by MM • Senior managers (SM) and middle managers (MM) agree role • Senior managers empower and resource middle manager involvement • Clear goals for involvements set • 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

22. 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 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 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

23. Significantly less people strongly agreed in the second survey that: • 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; • staff being proud to work at RVEEH; • QI being a worthwhile use of time and • QI adding innovation and creativity to middle manager roles.   (fits with literature)

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

25. Measures of Involvement • 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): • 2001 : 50% scored 3 or more • 2002 : 95% scored 3 or more

26. So what was achieved? • Middle manager attitudes, values, motivators and enablers were identified and incorporated into the model • Middle managers felt more: • supported by senior managers in QI • ownership of the QI program • confident about the QI process • 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

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