Taking the Message Home: Quality and the High Performance Organisation

1
Taking the Message Home Quality and the High
Performance Organisation

• Judith Dwyer
• La Trobe University

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.

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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

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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.

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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

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Underlying these...

• Sustained management support for this way of
  working
• Take home message
• Organisation culture, systems and alignment
  matter -

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Press on!
Pictures of the year by NBC
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Implication and 2 Qualifications

• Narrow quality initiatives in organisations
  without a structured approach to CQI wont work
• Qualification 1 Some things will work anywhere
  eg better labelling of medication
• Qualification 2 Some things wont work even in
  CQI organisations if not done well eg standards
  not properly developed and accepted

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Role of government

• Quality happens on the ground
• Government cannot deliver quality
• except of its own operations
• Government can encourage, motivate and support

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Beatings wont 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

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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?
• consumer and other viewpoints?
• Reason 2 way CQI is adopted
• shift in culture, over time, system development
  precedes results

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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
• dont make mistakes
• if you do, find out whos to blame and punish them

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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?

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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

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6 Characteristics

• Safe
• Patient-centred
• Efficient

• Effective
• Timely
• Equitable

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No recipes

• Authors didnt provide recipe for improvement
• Reason Complex Adaptive Systems Theory
• highly adaptable elements
• health 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

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Complex Adaptive Systems Theory

• Compared to mechanical systems thinking
• image of throwing a rock to land on a chosen spot
• calculate and throw
• then throwing a bird
• need to understand what will make the bird go to
  that spot

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Pictures of the year by NBC
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Power of Simple Rules

• Authors advocate
• understand the system and strange attractors
• accept that change has to be negotiated with the
  adaptable elements, ie cant be imposed from
  outside
• agree on simple statements of principle, not
  detailed procedures
• suggest 10 simple rules

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10 simple rules

• 1 Care based on continuous healing relationships
• 2 Customisation based on patient needs and values
• 3 Patient as source of control
• 4 Shared knowledge and free flow of information
• 5 Evidence-based decision making

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Simple Rules continued

• 6 Safety as a system property
• 7 Need for transparency
• 8 Anticipation of needs
• 9 Continuous 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.

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How long does it take?
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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), 263-85.
• Renhard 2001. The Evidence for Effectiveness for
  Quality Initiatives in Human Services A Critical
  Review. Australian Institute for Primary Care,
  Melbourne.