Growing a culture for quality improvement- whose quality interests does the manager promote?

1. Growing a culture for quality improvement- whose quality interests does the manager promote? Rod Perkins Senior Lecturer in Health Management, School of Population Health, University of Auckland and Business Leader, Mental Health & Addiction Services, Bay of Plenty DHB

2. My objective • To offer managers and those with an interest in organisational life some pointers to engaging with clinicians around performance management • Managers are interested in organisations and their welfare • Clinicians working at the coalface generally aren’t

3. People view organisations differently Some see them- • being like machines • as complex systems • Communities of work etc Where every one is pulling in the same direction I see them as • Places of contest where those at the top have different interests from those at the coalface- acknowledging that those at the coalface, sometimes cohabit the top

4. Values Different Leadership Roles Strategic direction Ideologically driven Strategic development Professionally driven Best practice

5. We’ll return to this later

7. Summative and formative indicators The literature considers performance indicators as broadly relating to either internal or external control and accountability. There are two axes: • The source of control • Internal or external • The nature of resultant action • Positive, supportive and formative or • Negative, punitive or summative

8. Adapted from Tim Freeman’s Using performance indicators to improve health care quality in the public sector: a review of the literature, Health Services Management Research 15, 126-137, (2002)

9. Types of indicators Different Leadership Roles Strategic direction Summative Strategic development Formative Best practice

10. What do we mean by good performance? • The points of emphasis change over time • Sometimes the emphasis is on- • Economy • Efficiency • Effectiveness • Outputs • ‘quality’ outcomes • Social results

11. Griffith et al “Use several hundred measures & benchmarks to provide each responsibility centre with multidimensional measures of performance Baptist Hospital Inc aggregates more than 75 measures to 14 for governance reporting. Report promptly and often publicly; important performance measures are reported daily, biweekly and monthly so that managers and most employees know exactly where they stand”

12. Indicators: Hospital & Health Services in the late 90s

13. Indicators: Examples indicators used to monitor DHB performance in 2007

14. Seen one of these?

15. Maybe this? Maybe this?

16. maybe?

17. What place do these have in performance management? • I think they’re fine for school children- younger ones • But they have the potential to damage credibility • e.g. a hospital in the UK with a hospice adjacent was reported to have a higher death rate than like size hospitals and got a in a league table • But expect to see more public disclosure of performance and the challenge to us is to make sure that performance tables are meaningful and compare like with like

18. We must be critical • We should never get a smiley face for an average length of stay that is lowest in the league unless other factors are also taken into account e.g. readmission rates • Epidemiologists use meta-analysis in their search to understand cause and effect relationships • Managers need to critically appraise their use of indicators to determine whether they are pointing to the performance domains they are wanting to identify

19. Quality in Healthcare 101 • Good structure leads to good process and good process leads to a good outcome Structure Process Outcome • When we understand the relationship between process and outcome, we’ll often favour measuring process, remembering of course that it is always outcome that we’re interested in

20. Returning to the different interests of those in the system

21. Health of the Nation Outcome Scale (HONOS) • Is a set of 12 scales, each one measuring a type of problem commonly presented by patients/clients in mental health care settings. A completed HoNOS score sheet provides a profile of 12 items measuring behaviour, impairment, symptoms and social functioning • It is a numerical record of a clinical assessment but does not replace clinical notes or any other records. It is intended that it becomes an integral part of a minimum data set

22. The use & potential for misuse of HONOS • Clinicians or case managers complete a HONOS after a client visit • Advocates of HONOS say that it informs clinicians about how well their clients are doing. Some clinicians say that they don’t need HONOS- they can figure it out for themselves • Advocates of HONOS also say that it can be a powerful tool to assist managers and in resource allocation decisions….. • And when you aggregate the results, HONOS can inform the Minister about whether the mental health of the Nation is improving

23. Values Different Leadership Roles Strategic direction Ideologically driven Strategic development Professionally driven Best practice

24. Lessons for managers • Don’t use information generated at the grass roots against the interests of those at the grass roots • Talk up the goals and ambitions of the organisation you work for to achieve clinician buy-in, but don’t bull shit • Promote the use of performance indicators when you are confident that they are valid and can be collected reliably • Take care in the use of smiley faces and sad faces- remember they are part of managerial (& political) discourse, not professional discourse • Remember …data collection relies on the goodwill of clinicians and is thus susceptible to manipulation, particularly when reward and censure depend on results (Audit Commission, Aiming to improve the principles of performance measurement, London, 2000)

25. The Revolution in Hospital Management John R Griffith, Kenneth White and David Bernd. Jnl of Healthcare Management; May/Jun 05