Jean-Louis Denis Full Professor Canada Research Chair on Governance and Transformation of Health Systems École nationale d’administration publique November 12, 2014 Governing for improvement and innovation in healthcare systems TILT’s Lecture series
Highly institutionalized environment & change + innovation “Stressing inertia may be slightly misleading in that organizations constantly experience unfolding change. To the institutional school, however, the prevailing nature of change is one of constant reproduction and reinforcement of existing modes of thought and organization (i.e., change is convergent change)” (Greenwood & Hinings, 1996: 1027).
“System inertia may thus be a rational response to interventions that seek to reform when individuals and organisations have to manage other competing demands. If the benefits of a reform come at the cost of other important organisational goals, then organisations and the individuals in them will necessarily satisfice. In a system that is over constrained with competing demands, the human attention and physical resources needed to make a new intervention succeed are just not available”. (Coeira, 2011 in BMJ)
« Most notable are the constant fiscal pressures resulting from everexpanding demand and the outsized political influence exerted by the medical profession because of its control over the quality and terms of health services. Rather than aiming to secure the basic needs of the public, as is usually the case with pensions or social insurance, health care policy invariably states that patients should expect the “best” care available, as defined by the providers of that care. It is quite a unique situation, especially when compared with other areas of social protection. In fact, even if health systems have other characteristics, reform and design must always entail some kind of cost- control measures, accompanied by various mechanisms to secure physicians’ cooperation.” (Forest & Denis, 2012: 576)
« In the end, however, the most important questions might be: Do successful efforts need to include some form of commitment to the stability of the system, in terms of resources, delivery arrangements, and political support? Or is reform — real reform — always disruptive, resulting in a new architecture of programs, resources, and incentives, or even a new set of values and guiding principles?” (Forest & Denis, 2012:579)
Improving clinical practices/delivery can’t be achieved in a vacuum: « The persistent gap between available evidence and current practice in health care reinforces the challenge of finding effective solutions. Contributing to this current status have been the complexity of change process, limitations of research on implementation, and slow recognition of the critical role of organizational context ». (Stetler, C. B., McQueen, L., Demakis, J., Mittman, B.S., 2008)
Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity). Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009). AUSCANGERNETHNZUKUS OVERALL RANKING (2010)3641527 Quality Care4752136 Effective Care2763514 Safe Care6531427 Coordinated Care4572136 Patient-Centered Care2536174 Access6.553142 Cost-Related Problem63.5 2517 Timeliness of Care6721345 Efficiency2653417 Equity4531627 Long, Healthy, Productive Lives1234567 Health Expenditures/Capita, 2007$3,357$3,895$3,588$3,837*$2,454$2,992$7,290 Overall Ranking Country Rankings 1.00–2.33 2.34–4.66 4.67–7.00
Competing hypotheses about innovation in health systems
Convergence hypothesis End result: Innovation?? Pathways toward convergence Narrowing set of options Multiple external contingencies
Hybridization hypothesis (Tuohy, 2012) Windows of opportunities & entrepreneurial activities within systems and innovation Markers of hybridization: – Changes in the balance of power – Changes in the mix of control instruments that govern the exercise of power and in organizing – Principles that shape public expectations regarding entitlement to health care and the functional role of the state
Governing for high-performing healthcare systems and organizations
Perspectives on high-performing healthcare organizations and systems Macro perspective: focus on broad system characteristics (financing, manpower, regulation) Micro perspective: focus on programs and the interventions needed to achieve high quality & safety results or outcomes Meso perspective: focus on strategies and investments in organizational (and system) resources to create and sustain high performing systems – facilitative context
Dynamic of performance and change in health systems and organizations Complementary hypothesis: you cannot choose only one or some elements and expect high gains in term of performance (Pettigrew & al., 2003) Contextual hypothesis: starting point of a performance journey will depend on contextual factors Non-linear hypothesis: improvement is not a discrete event, it is a process that proceed gradually with unexpected evolution
High-performing healthcare systems Comparative study of three high-performing health systems: o Intermountain Healthcare in Utah o Jönköping County Council in Sweden o South-Central Foundation in Alaska 19
Ten Critical Themes in Transformation (Baker & Denis, 2011) Leadership and Strategy Organizational Design Improvement Capabilities Quality and system improvement as a core strategy Robust primary care teams at the centre of the delivery system Organizational capacities and skills to support performance improvement Leadership activities that embrace common goals and align activities throughout the organization More effective integration of care that promotes seamless care transitions Information as a platform for guiding improvement Promoting professional cultures that support teamwork, continuous improvement and patient engagement Effective learning strategies and methods to test and scale up Providing an enabling environment buffering short-term factors that undermine success Engaging patients in their care and in the design of care.
23 (Adapted from Denis et al., 2011) LEVERS TO SUPPORT CHANGE AND IMPROVEMENT
Three underlying assumptions A1: Despite political and structural limitations inherent in any health system, organizations and front-line workers can significantly compensate for these challenges and, in doing so, achieve improvements (and innovation). A2: Dollars/Reals alone neither buy all types of desirable change nor translate easily into improvements. A3: Real changes taken at any level of a health system are those that translate into improvements at the delivery/clinical level, including behavioural changes of providers and practice, with the end goal of improving health outcomes and patient experience. 24
Key message I: clinical context provides a unique opportunity to improve care and increase the development and uptake of innovations
Key message II: Managing and organizing with healthcare providers and teams are essential for health system improvement and innovation
Challenges for high-performing healthcare organizations Creating unity/consistency in organizations without killing innovation, entrepreneurship and ability to adapt and perform Creating more synergy between the organizational and clinical worlds Going deeper in the management and organization of clinical performance (efficiency, appropriateness, quality, safety of care...) Channelling distributed expertise, legitimacy and influence to support organizational and improvement goals Generating effective intermediary process & mediations across the organization to support organizational and improvement goals
Four core process and organizational mechanisms for the engagement of professionals in improvement initiatives 1)Working on group norms (culture) across the organizations – social compact!! 2)Receptive /facilitative organizational context – Effective microsystems at the point of care 3) Leadership as collective and distributed – Organization and system level promotion of leadership 4) Team-based organizations and “teamness”: – Cross-disciplinary contexts
Clinical units (microsystems) as unique opportunities for improvement and innovation
By clinical care management systems we mean approaches (including incentives, accountability and capacity development issues) to assuring the design and delivery of effective and appropriate care through guidelines and reminder systems (and related methods and tools) and the development of a clinical/organizational leadership system that provides successful support to practicing clinicians (Baker, Denis, Grudniewicz, Black, 2012)
Key message III: Governing for healthcare improvements implies the conduct of large-scale organizational development in health care organizations where providers and managers collaborate to create facilitative context.
Four Habits of High-Value Health Care Organizations (Bohmer, 2011) Specification and planning, including the management of specific sub-groups of patients The design of specific infrastructure (e.g., staff, information, technology) to match the needs of subpopulations The capacity to properly monitor and provide oversight through process and outcome measures of care; and Strong knowledge management to learn from positive and negative deviations in outcomes and care
Elements of Effective CCMS Clinical Microsystems Design Knowledge Management and Decision Support Clinician Leadership and Engagement System Design & Population Focus Leadership
Clinical Microsystems Design Most quality initiatives focus on individual clinicians or professions but microsystem thinking identifies the need to create clinical teams with clearly defined aims, defined work processes and information flows and well organized patterns of work and learning that produce optimal outcomes Clinical microsystems thinking provides a powerful framework for engaging staff and creating more effective care environments and has been used by many teams to assess and improve the care they provide But clinical microsystems alone do not provide sufficient leverage for high performance healthcare systems – which require both broader system level design (and population focus), linked with leadership and deployment
Key message IV: Plural leadership is a fundamental ingredient of high- performing (continuous improvements and innovation) healthcare systems and organizations
Four perspectives on plural leadership 1. Sharing leadership for team effectiveness: Team-based organizations Mutual leadership in groups 2. Pooling leadership at the top to lead others: Knowledge-based organizations Dyads, triads and constellations as joint organizational leaders 3. Spreading leadership across levels over time: Inter- organizational collaboration Leadership relayed between people to achieve outcomes 4. Producing leadership through interactions: Knowledge- based organizations Leadership as an emergent property of relations Denis, J.-L., Langley, A., & Sergi, V. (2012). Leadership in the plural. Academy of Management Annals. 37
Leadership in healthcare systems and organizations Leadership is distributed de facto. Main challenges: – Harnessing leadership potential for health system change and improvement – Creating synergies across locus of leadership (policy, managerial, clinical and community leadership) Creating and sustaining the conditions for continuous improvement and innovation 38
Conclusion Improving and reforming healthcare systems is a challenging task The political economy of healthcare systems is more aligned with inertia than transformation (at least in the Canadian healthcare systems) Clinical governance may represent an promising option to face system inertia
Some references Baker, G. R., & Denis, J.-L. (2011). A Comparative Study of Three Transformative Healthcare Systems: Lessons for Canada. Ottawa: Canadian Health Services Research Foundation. Available from http://www.chsrf.ca/Libraries/Commissioned_Research_Reports/Baker-Denis-EN.sflb.ashx http://www.chsrf.ca/Libraries/Commissioned_Research_Reports/Baker-Denis-EN.sflb.ashx Baker, R., Denis, JL. Medical leadership in health care systems: From Professional Authority to Organisational Leadership. Public Money and Management, 2011, 31(5): 355-362. Denis, J.-L., Baker, G. R., Black, C., Langley, A., Lawless, B., Leblanc, D.,... Tré, G. (2013). Report on physician engagement and leadership for health system improvement: Prospects for canadian healthcare systems, CIHR, Expedited synthesis program. Denis, J.-L., Davies, H. T., Ferlie, E., & Fitzgerald, L. (2011). Assessing Initiatives to Transform Healthcare Systems: Lessons for the Canadian Healthcare System. Ottawa: Canadian Health Services Research Foundation. Available from http://www.chsrf.ca/Libraries/Commissioned_Research_Reports/JLD_REPORT.sflb.ashx http://www.chsrf.ca/Libraries/Commissioned_Research_Reports/JLD_REPORT.sflb.ashx Baker, R., Denis, JL, Grudniewicz, A., Black, C. (2012) Fraser Health: Exploring a Model of Clinical Care Management Systems, Ottawa: Canadian Health Services Research Foundation. Denis, J.-L., & Forest, P. G. (2012). Real reform begins within: An organizational approach to health care reform. Journal of Health Politics, Policy and Law, 37(4), 633–645. Denis, JL; Gibeau, E., Langley, A., Pomey, M-P, van Schendel, M. (2012) Modèles et enjeux du partenariat médico-administratif: État des connaissances, Rapport présenté à l’AQESSS. Denis, J.-L., Langley, A., & Sergi, V. (2012). Leadership in the plural. Academy of Management Annals, 6(1): 211–283. Stetler, C. B., McQueen, L., Demakis, J., & Mittman, B. S. (2008). An organizational framework and strategic implementation for system-level change to enhance research-based practice: QUERI Series. Implementation Science, 3(1), 30. West, M., Lyubovnikova, J, Eckert, R, Denis, JL (2014) "Collective leadership for cultures of high quality health care", Journal of Organizational Effectiveness: People and Performance, Vol. 1 Iss: 3, pp.240 - 260Lyubovnikova, J Eckert Denis
Some questions for discussion I What about national culture and its relation to reform? What about professionalism and its embedded rules, values and social context at the different layers of HC system and reform?
Some questions for discussion II What about the role of technologies in transforming HC?
Some questions for discussion III What about the implications of plural leadership for (taking) responsibility?