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How leading hospitals in the US and Europe achieved excellence in service quality - and sustained it Dr Glenn Robert, UCL Professor Paul Bate, UCL Dr Peter.

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Presentation on theme: "How leading hospitals in the US and Europe achieved excellence in service quality - and sustained it Dr Glenn Robert, UCL Professor Paul Bate, UCL Dr Peter."— Presentation transcript:

1 How leading hospitals in the US and Europe achieved excellence in service quality - and sustained it Dr Glenn Robert, UCL Professor Paul Bate, UCL Dr Peter Mendel, RAND Corporation Funding: The Nuffield Trust, London & RAND Corporation, US © Paul Bate & Glenn Robert, University College London 2005. All rights reserved. Not to be reproduced in whole or in part without the permission of the copyright owner Presentation to 6th International Conference on the Scientific Basis of Health Services, 2005, Montreal

2 2 Objective To re-trace the quality journey of 8 high performing health care organizations in order to explore the processes that enabled them to successfully implement, spread and sustain quality improvement initiatives

3 3 Background The quality lottery: striking variation between health care organizations in how successful they are in implementing and sustaining Q & SI

4 4 One large study of American health care quality Source: McGlynn et al (2003) NEJM, 348, pp. 2635-2645 439 indicators of clinical quality of care Across 30 acute and chronic conditions Participants (N=6712) had received 54.9% of scientifically indicated care Conclusion: The defect rate in the technical quality of American health care is approximately 45% It is probably the same in the UK!

5 5 Background HSR getting better and better at measuring health outcomes and quality Variation between (Jarman) and within (Adler) health care organizations Strong on the what but weaker on the why and how Most HSR related to quality issues does not seek to explain the human and organisational causes of variation

6 6 Background Move from describing to explaining Processes and dynamics of improvement rather than list of key success factors Ethnographic case studies of organizations with a history and reputation for sustained quality improvement

7 7 Organizational sample United States –Albany Medical Center (AIDS Treatment Center) –Cedars-Sinai (Emergency Department) –Luther Midelfort Mayo Health System (Critical Care Unit) –San Diego Childrens Hosp. (Allergy & Immunology) –SSM St. Josephs Health Center (Intensive Care Unit) Netherlands –Reinier de Graaf Groep (Flow Varicies -- Vascular Surgery) United Kingdom –Peterborough Hospitals (Radiology Services) –Royal Devon and Exeter (Orthopaedic Centre)

8 8 ALBANY PETERBOROUGH EXETER DELFT ST. LOUIS SAN DIEGO EAU CLAIRE LOS ANGELES

9 9 Study design 15 days fieldwork in each site Semi-structured interviews: macro- and micro-system Direct observation and documentary evidence Draft narrative fed back to key informants Analysed shared narratives and identified challenges, elements and processes that combine to explain improvement in health care

10 10 The generic challenges Despite huge variety similar sets of challenges: 1.Educational (a learning process to support continual improvement) 2.Political (addressing and dealing with the politics of change) 3.Cultural (giving quality a shared, collective meaning, value and significance) 4.Emotional (engaging and mobilising people) 5.Structural (organising, planning and co- ordinating the improvement effort) 6.Physical and technical (supportive technologies and infrastructure)

11 11 Solutions to meet these challenges (elements) 1.Educational 1.1 A quiet, reflective form of leadership 1.2 Knowledge of hard quality improvement methods and techniques … 2.Political 2.2 An agreed compact for Q & SI between key interests 2.4 A dispersed, devolved/decentralised authority system … 3.Cultural 3.1 A philosophy and mission that highlights top quality patient care 3.7 An organisation whose image and identity are inextricably bound up with the concept of excellence in quality …

12 12 4.Emotional 4.2 Building communities of practice and wider social commitment to Q & SI 4.6 Emotional involvement in the organisation improvement effort … 5.Structural 5.1 An explicit and formally signed off strategy for Q & SI 5.10 Specialist interlocutor/connector roles with regard to quality: boundary spanners (linking resources, people and ideas) … 6.Physical & technical 6.1 A leadership that is aware of the material and symbolic/aesthetic importance of buildings and architecture, and incorporate this into its concept of service design 6.2 Whether it is free-standing and has control over its own buildings and space, data and technical systems …

13 13 Educational Physical & Technological Structural Political Cultural Emotional Task-centred leadership Quality strategy & plan Whole-systems design Devolved authority Multi-level leadership Quality leadership positions QI governance structure Quality department/group QI training programs Communities of practice Data & monitoring systems Results-oriented planning Enabling Admin role Boundary spanner roles Organizational slack Pedagogical leadership Organizational change knowledge QI techniques knowledge Knowledge harvesting Experimentation & piloting Evidence-based learning Experience-based learning Values/symbolic leadership Culture of excellence Patient-centered ethic Culture of mindfulness Group/collaborative culture Scientific culture Culture of learning Formality-savvy culture Culture of empowerment Cosmopolitan culture Long term perspective Organizational identity Recruitment Acculturation Inspirational leadership Clinical & other change champions Collective momentum Professional & social affiliations Quality as a mission/calling Emotional commitment Improvement campaigns Inner Context Outer Context Organization Size Organization Structure Organization Performance Market & Resource Environments Professional & Social Movements Regulatory Environments Technological Environments Politically-credible leadership Clinical engagement Peer-to-peer relationships Clinical-Managerial partnering Empowering staff Empowering patients External partnering Technology/design leadership Functional design of built env Aesthetic design of built env Info technology design Medical technology design Locating of built env & tech

14 14 Educational Physical & Technological Structural Political Cultural Emotional Task-centred leadership Quality strategy & plan Whole-systems design Devolved authority Multi-level leadership Quality leadership positions QI governance structure Quality department/group QI training programs Communities of practice Data & monitoring systems Results-oriented planning Enabling Admin role Boundary spanner roles Organizational slack Pedagogical leadership Organizational change knowledge QI techniques knowledge Knowledge harvesting Experimentation & piloting Evidence-based learning Experience-based learning Values/symbolic leadership Culture of excellence Patient-centered ethic Culture of mindfulness Group/collaborative culture Scientific culture Culture of learning Formality-savvy culture Culture of empowerment Cosmopolitan culture Long term perspective Organizational identity Recruitment Acculturation Inspirational leadership Clinical & other change champions Collective momentum Professional & social affiliations Quality as a mission/calling Emotional commitment Improvement campaigns Inner Context Outer Context Organization Size Organization Structure Organization Performance Market & Resource Environments Professional & Social Movements Regulatory Environments Technological Environments Politically-credible leadership Clinical engagement Peer-to-peer relationships Clinical-Managerial partnering Empowering staff Empowering patients External partnering Technology/design leadership Functional design of built env Aesthetic design of built env Info technology design Medical technology design Locating of built env & tech

15 15 Educational Physical & Technological Structural Political Cultural Emotional Task-centred leadership Quality strategy & plan Whole-systems design Devolved authority Multi-level leadership Quality leadership positions QI governance structure Quality department/group QI training programs Communities of practice Data & monitoring systems Results-oriented planning Enabling Admin role Boundary spanner roles Organizational slack Pedagogical leadership Organizational change knowledge QI techniques knowledge Knowledge harvesting Experimentation & piloting Evidence-based learning Experience-based learning Values/symbolic leadership Culture of excellence Patient-centered ethic Culture of mindfulness Group/collaborative culture Scientific culture Culture of learning Formality-savvy culture Culture of empowerment Cosmopolitan culture Long term perspective Organizational identity Recruitment Acculturation Inspirational leadership Clinical & other change champions Collective momentum Professional & social affiliations Quality as a mission/calling Emotional commitment Improvement campaigns Inner Context Outer Context Organization Size Organization Structure Organization Performance Market & Resource Environments Professional & Social Movements Regulatory Environments Technological Environments Politically-credible leadership Clinical engagement Peer-to-peer relationships Clinical-Managerial partnering Empowering staff Empowering patients External partnering Technology/design leadership Functional design of built env Aesthetic design of built env Info technology design Medical technology design Locating of built env & tech ?

16 16 RESULTS So what processes enabled these health care organizations to successfully implement, spread and sustain Q & SI initiatives?

17 17 Cedars-Sinai, Los Angeles 875 beds 6,600 staff and 1,700 affiliated physicians Primary service area consists of 2.3 million people ($70m p.a on community outreach) Major teaching hospital (UCLA) A flavour.. two case studies Peterborough 670 beds (2 sites) 2,300 wte staff Acute medical services to 280,000 in east of England Income of £89.1m in 2001/02 3 star Trust 2001/02 and 2002/03

18 18 Process mapping method – Step One Systematically coded the validated case narratives for mentions of processes between elements

19 19 An example In this spirit, the hospital decided to hire this physician to lend clinical background and credibility to the quality effort [2.1 to 2.2] : So he… went around looking at evidence based stuff, and began to bring to the institution a whole discipline [3.8 to 5.15] around analyzing process, flow diagrams, cradle diagrams, privatization approaches,… and we began to infuse the organization with that approach. We linked up then with the national demonstration project later [1.4 to 3.10] becoming the Institute for Healthcare Improvement, [he] became faculty in the IHI, as you probably know, and kept us connected with a network of people who had a growing similar interest around these kinds of things [5.10 to 1.4].

20 20 Process mapping method – Step Two Employed social network analysis techniques to examine and visualize the patterns of relations among the organizational processes for each case study

21 21 Cedars-Sinai Sub-Process Mapping Educational Political Cultural Emotional Structural Physical/Technical Inner Context Outer Context IC1.1 C3.1 C3.10 C3.11 C3.12 C3.13 C3.14 C3.2 C3.3 C3.5 C3.6 C3.7 C3.8 ED1.1 ED1.2ED1.3 ED1.4 ED1.5 ED1.6 ED1.7 EM4.1 EM4.2 EM4.3 EM4.4 EM4.5 EM4.6 IC1.2 IC1.3 OC1.4 OC1.5 OC1.6 OC1.7 P2.1 P2.2 P2.3 P2.4 P2.5 P2.7 PT6.1 PT6.2 PT6.3 PT6.5 PT6.6 S5.1 S5.10 S5.11 S5.12 S5.13 S5.14 S5.15 S5.2 S5.3 S5.4 S5.5 S5.6 S5.7 S5.8 S5.9 Note: Dotted line indicates negative relationship.

22 22 Cedars-Sinai Sub-Process Mapping Educational Political Cultural Emotional Structural Physical/Technical Inner Context Outer Context OrgSize CExcell C Cosmop LTermC Org Identity Recruit Retain Socializ Values Lship Patient Centred GroupC C Science LearnC C Formal Pedag Lship OrgChng Training QI Training Experm Evid-based Learning Exp-based Learning InspLship Clin Champions CollMoment Profl-Social Affiliations QMission EmotInvlv OrgStruc OrgPerf Regulatory Environment Mrkt/Resource Environment Social Mvmnts AvailTechn CredLship ClinEng Peer-to-Peer Clin-Mgt Prtnr StaffEmpw ExtPrtnr PT6.1 Phys Aesthetics Techn/Design Lship ICTSupp ClinTechn Supp QStrategy Bndry Spans Comm-of Practice Plan Process QGovern QSlackRes DataSys TaskLship WholeSysDes DecAuth QLdrs DistrLdrs QIdept QTraining Programs Enabling Admin Note: Dotted line indicates negative relationship. KHarvest

23 23 Cedars-Sinai Process Mapping

24 24 Peterborough Sub-Process Mapping Educational Political Cultural Emotional Structural Physical/Technical Inner Context Outer Context IC1.1 PT6.6 S5.10 S5.11 S5.13 S5.14 S5.15 S5.2 S5.3 S5.4 S5.5 S5.6 S5.7 S5.8 S5.9 ED1.1 ED1.2 ED1.3 ED1.4 ED1.5 ED1.6 ED1.7 IC1.2 IC1.3 PT6.5 OC1.4 OC1.5 OC1.6 C3.1 C3.11 C3.12 C3.13 C3.2 C3.5 C3.6 C3.7 C3.9 EM4.1 W4.3 EM4.6 P2.1 P2.2 P2.3 P2.4 P2.5 P2.7

25 25 Educational Political Cultural Emotional Structural Physical/Technical Inner Context Outer Context OrgSize ClinTechn Supp BndrySpans Comm-of-Practice QGovern QSlackRes DataSys TaskLship WholeSysDes DecAuth QLdrs DistrLdrs QIdept QTraining Programs Enabling Admin Pedag Lship OrgChng Training QI Training KHarvest Experm Evid-based Learning Exp-based Learning OrgStruc OrgPerf ICTSupp Regulatory Environment Mrkt/Resource Environment Social Mvmnts CExcell LTermC Org Identity Recruit Retain Values Lship GroupC ScienceC LearnC EmpwC InspLship Coll Moment EmotInvlv CredLship ClinEng Peer-to Peer Clin-Mgt Prtnr StaffEmpw ExtPrtnr Peterborough Sub-Process Mapping

26 26 Peterborough Process Mapping

27 27 Comparative Process Mappings Cedars-SinaiPeterborough

28 28.. and the emotional People here arent just motivated. This isnt their job, its a mission, its their life, its the cause theyre committed to. For them, its personal. (Director HIV AIDS Programme, Albany Medical Centre, New York) Perfect care is something we never reach, but like the North Star, it serves as a beacon to guide us … Every day Childrens should strive to be even better than before. Our physicians, our nurses, and our staff seek to attain it; our families deserve it. (Foreword of the Childrens Agenda, Childrens Hospital and Health Centres strategic and business plan, June 2001)

29 29 Conclusions The generic but variable thesis: many paths up the mountain Failures and bumps in the road Multi-level, multi-dimensional process based model of service improvement Context and physical/technology factors important in realising quality but cultural and structural response of organizations largely determine whether QI is sustained Yes, human and organisational factors are important – and need to understand how and why

30 30 Jeopardising change Lack of a … Can lead to… Learning processAmnesia or frustration Political processInertia Cultural processEvaporation MobilisationEnergy-sink Planning & co-ordinationFragmentation Physical infrastructure & technical systems Exhaustion

31 31 For comments and further information: g.robert@chime.ucl.ac.uk

32 Organizing for Quality: Journeys of Improvement at Leading Healthcare Organizations in the US & UK James L. Zazzali, Ph.D., M.P.H., RAND Corporation Glenn Robert, Ph.D., UCL Medical School Peter Mendel, Ph.D., RAND Corporation Paul Bate, Ph.D., UCL Medical School Funding Sources: Nuffield Trust, London RAND Corporation Health Unit, Santa Monica Copyright, all rights reserved, 2005

33 33 Research Objectives To present cross-site and cross-national findings regarding the ability of healthcare organizations to sustain QI programs and processes To identify best practices in change management related to the introduction and implementation of QI To approach this with a decidedly organizational perspective

34 34 Study Design Mixed methods with a multilevel approach Interviews with over 100 senior leaders at 11 Health care systems in 3 countries (results today only for US & UK) Site visits to one high performing department within each of the 11 health systems to observe and interview staff Interview data used to construct survey items Survey of staff in the high performing departments

35 35 Organizational Sample United States –Albany Medical Center (AIDS Treatment Center) –Cedars-Sinai (Emergency Department) –Geisinger Health System (Rheumatology) –Luther Midelfort Mayo Health System (Critical Care Unit) –San Diego Childrens Hosp. (Allergy & Immunology) –SSM St. Josephs Health Center (Intensive Care Unit) Netherlands –Reinier de Graaf Groep (Flow Varicies -- Vascular Surgery) United Kingdom –Kettering General Hospital (Accident & Emergency Services) –Kings College (Breast Unit) –Peterborough Hospitals (Radiology Services) –Royal Devon and Exeter (Orthopaedic Centre)

36 36 Survey of High Performing Departments Survey measured: –The degree to which 9 key factors related to sustaining QI efforts were met in the department –Perceptions of importance of these factors for 5 of the 9 areas –The organizational culture of the department –The respondents level of QI training and QI team experience –Respondents socio-demographic characteristics Survey sample –477 respondents across 10 sites in the US & UK –48% response rate with two mailings

37 37 Nine Factors Related to Sustaining QI Organizational slack for quality improvement Quality resource infrastructure Availability and use of data Culture of sharing and learning Distribution of responsibility Organizational identity Senior leaders creating a vision, scripting & motivating Communication and discourse Systems perspective/thinking

38 38 Nine Factors Related to Sustaining QI A. Organizational slack for quality improvement –1) Our unit provides staff with time and other resources to work on implementing new ways of improving how we do things here. –2) I have opportunities to visit or interact with people in other units or outside this organization to bring back new ideas which might improve how we do things here. B. Quality resource infrastructure –3) Our unit has access to people who can provide training, advice and support in quality improvement. C. Availability and use of data –4) Our unit has easy access to data that is useful for understanding the processes and outcomes of our work. –5) Our unit routinely makes changes based on measurement of the processes and outcomes of our work.

39 39 Nine Factors Related to Sustaining QI D. Culture of sharing and learning –6) People in our unit like to share their ideas and expertise with one another. E. Distribution of responsibility –7) My efforts can play an important role in the success of quality improvement activities in this unit. –8) Quality improvement activities can produce significantly better patient care and outcomes in our unit. F. Organizational identity –9) This organization has a mission or purpose that I strongly identify with. –10) This organization has a particular history that I am proud of.

40 40 Nine Factors Related to Sustaining QI G. Senior leaders creating a vision, scripting & motivating –11) Senior management within this organization know how to inspire and motivate staff across areas to work toward common goals. –12) Senior management within this organization make improving the quality of patient care a priority. H. Communication and discourse –13) People in our unit feel they can freely express their views and have their opinions listened to. –14) There is good communication between our unit and others in the organization on important issues of delivering patient care. I. Systems perspective/systems thinking –15) People in our unit really understand how patients move across departments within this organization. –16) There is strong inter-departmental coordination within this organization.

41 41 Challenges in Sustaining QI * * * * * denotes p<.05

42 42 Advances in Sustaining QI * * * * * denotes p<.05

43 43 Importance of Factors Related to QI Sustainability * * * * denotes p<.05

44 44 QI Training & Participation * * * denotes p<.05

45 45 QI Training

46 46 QI Team Participation

47 47 Differences in Organizational Culture

48 48 Conclusions These organizations face similar challenges & successes for QI implementation and sustainability QI training and participation are more diffuse in the US The organizational cultures are different for the US & UK sites

49 49 Next Steps Multivariate (and multilevel) models of individuals perceptions of key factors related to sustaining QI and their importance, predicted by organizational culture and QI training and participation Book presenting case studies and synthesizing an organizational model of factors related to QI sustainability

50 50 Components to a process model of improvement 6 generic challenges 63 elements ?? processes - Inner context - Outer context Receptive context


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