Taking the Message Home: Quality and the High Performance Organisation Judith Dwyer La Trobe University

La Trobe Health Management Group 2 The big questions:  What do we really know?  How is quality improved?  How long does it take?  Acknowledging a source: The Evidence for Effectiveness for Quality Initiatives in Human Services: A Critical Review. Russell Renhard, Australian Institute for Primary Care, 2001.

La Trobe Health Management Group 3 Definition Problem: Outcomes not inputs  This is new and difficult  Problems are conceptual –what is a quality outcome?  And practical –who wants to know and what will they do with the information?  Inputs, outputs, structure & process still matter, for both assuring and improving

La Trobe Health Management Group 4 What the literature says  Key finding: –‘Quality initiatives, regardless of scope or focus, are more likely to be effective when used in an organisation that functions according to [CQI] principles and practices. The key determinant of success of a quality initiative, therefore, is not the initiative itself but the nature of the organisation in which it is used’ Renhard,2001.

La Trobe Health Management Group 5 The CQI Organisation  Use of problem-solving methods –based on hard and soft data  Focus on systems and processes –not individuals  Use of cross-functional teams in CQI  Employee empowerment to identify and action improvements  Explicit focus on internal and external customers/consumers

La Trobe Health Management Group 6 Underlying these...  Sustained management support for this way of working  Take home message: Organisation culture, systems and alignment matter -

La Trobe Health Management Group 7 Pictures of the year by NBC Press on!

La Trobe Health Management Group 8 Implication and 2 Qualifications  Narrow quality initiatives in organisations without a structured approach to CQI won’t work  Qualification 1: Some things will work anywhere eg better labelling of medication  Qualification 2: Some things won’t work even in CQI organisations if not done well eg standards not properly developed and accepted

La Trobe Health Management Group 9 Role of government  Quality happens on the ground  Government cannot deliver quality –except of its own operations  Government can encourage, motivate and support

La Trobe Health Management Group 10 Beatings won’t work  Little evidence that punitive approaches are effective –but may suppress useful info (Liang & Storti 2000) –‘Circle of Fear’ - mistake, punishment, micro-management, suppression of data, mistake, punishment………...  Purchasing quality can help –but not as primary strategy

La Trobe Health Management Group 11 How good is the evidence?  Mixed - studies diverse in design and measures - 2 reasons:  Reason 1: Q concept unclear –and therefore how to measure it technical aspects of service delivery?technical aspects of service delivery? consumer and other viewpoints?consumer and other viewpoints?  Reason 2: way CQI is adopted –shift in culture, over time, system development precedes results

La Trobe Health Management Group 12 How is Quality improved?  Traditional Government belief: –figure out the best method ONCE and get everyone to take up new methods now  Traditional Community belief: –figure out the best rules to make sure patients are safe and enforce them now  Traditional Insurer belief: –don’t make mistakes –if you do, find out who’s to blame and punish them

La Trobe Health Management Group 13 Health System Response  Lots of Committees, Enquiries, protocols, procedures, experiments, reports  Many calls for change, everyone agrees on goals, but not methods  Sense that progress is slow, reports are not implemented  Why?

La Trobe Health Management Group 14 One answer  Institute of Medicine Report ‘Crossing the Quality Chasm’ (2001)  Describes system that is wasteful, often redundant, lacking information systems, subject to delays, errors and unnecessary services  Offers 6 key characteristics of ideal health care system

La Trobe Health Management Group 15 6 Characteristics  Safe  Patient-centred  Efficient  Effective  Timely  Equitable

La Trobe Health Management Group 16 No recipes  Authors didn’t provide recipe for improvement  Reason: Complex Adaptive Systems Theory –highly adaptable elements health professionalshealth professionals –small inputs can have large effects –new behaviours constantly - like the weather, not predictable –simple rules can give complex outcomes –‘strange attractors’ - poorly understood values or needs which can be harnessed

La Trobe Health Management Group 17 Complex Adaptive Systems Theory  Compared to mechanical systems thinking –image of throwing a rock to land on a chosen spot calculate and throwcalculate and throw –then throwing a bird need to understand what will make the bird go to that spotneed to understand what will make the bird go to that spot

La Trobe Health Management Group 18 Pictures of the year by NBC

La Trobe Health Management Group 19 Power of Simple Rules  Authors advocate –understand the system and strange attractors –accept that change has to be negotiated with the ‘adaptable elements’, ie can’t be imposed from outside –agree on simple statements of principle, not detailed procedures –suggest 10 simple rules

La Trobe Health Management Group simple rules 1Care based on continuous healing relationships 2Customisation based on patient needs and values 3Patient as source of control 4Shared knowledge and free flow of information 5Evidence-based decision making

La Trobe Health Management Group 21 Simple Rules continued 6Safety as a system property 7Need for transparency 8Anticipation of needs 9Continuous decrease in waste 10 Cooperation among clinicians Source: Institute of Medicine. Crossing the Quality Chasm: a new health system for the 21st century. Washington: National Academy Press, 2001.

La Trobe Health Management Group 22 How long does it take?

La Trobe Health Management Group 23 References  Institute of Medicine, (2001). Crossing the Quality Chasm: a new health system for the 21st century. Washington, National Academy Press.  Liang and Storti (2000). “Creating Problems as part of the ‘solution’: the JCAHO sentinel event policy, legal issues and patient safety”. Journal of Health Law, 33(3),  Renhard The Evidence for Effectiveness for Quality Initiatives in Human Services: A Critical Review. Australian Institute for Primary Care, Melbourne.