A policy framework to support culture change in hospitals Pieter Degeling

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A policy framework to support culture change
in hospitals Pieter Degeling
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Culture
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(No Transcript)
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Levels of culture

• Rules and practices enacted in the course of
• resource allocation
• exchange relationships
• social control
• conflict management and resolution
• social integration
• socialisation
• Shared attitudes, values and beliefs that are
  embodied in action in ways that
• makes social interaction possible and
• Materialises and reinforces personal identity
• Basic assumptions and legitimating ideology
• about the way the world is and/or ought to be,
• that are regarded as natural and necessary truths
  in society,
• that set the agendas within which action can
  take place and
• set the limits of actors personal identity

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Culture as the mutual constitution of structure
and action
ENABLES CONSTRAINS

• Culture
• Taken as given
• Values
• Attitudes
• Beliefs
• Rules

STRUCTURE
ACTION
EMBODIES RECREATES
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Ethnographic findings on the cultural composition
of hospitals
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Culture Change

• From what? to what?
• Desired culture tends be defined in terms of
  desired outcomes rather than its constituent
  elements
• No Blame Culture
• Learning Culture
• Safety Culture
• A client centred culture

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CHIs embarrassing conceptual void about
culture, structure and methods
STRATEGIC CAPACITY Patient focus
Leadership Direction and Planning
RESOURCES PROCESSES Processes for
Quality Improvement Staff focus
?
RESULTS Patients experience and outcomes
Use of Information
Learning, Innovation and Improvement
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Some indicators of culture in health care
organizations

• Enacted practices and rules that signify an
  acceptance or rejection of
• Interconnections between the clinical and
  resource-usage dimensions of care
• The need to balance clinical autonomy with
  transparent accountability
• The systematisation of clinical processes
• The power sharing implications of the
  multidisciplinary nature of clinical work

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Questionnaire design

• Respondents views on
• acute health care issues
• strategies for addressing hospital resource
  issues
• their professional autonomy
• scope and limits of their accountability
• causes of clinical practice variation
• factors affecting their clinical practice
• interconnections between the clinical and
  resource dimensions of care
• forms of knowledge which should be used in
  setting clinical standards
• management models appropriate for improving the
  overall performance of clinical units

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Sample
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Study Findings

• differences between respondents best explained by
  their occupational background
• these differences occur on four dimensions, two
  of which explain 91 of the variances

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The Two Dimensions were

• personalized vs socially abstracted approaches to
  clinical work organization
• individualistic vs collective concepts of
  clinical work performance

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Professional Subcultures Across Country
Comparison
Emphasis on financial realism and transparent
accountability
Individualistic concepts of clinical work
Systematised concepts of clinical work
Emphasis on clinical purism and opaque
accountability
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Summary of Professional Cultures
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Medicines individualistic culture

• Equivocal about interconnections between
  clinical/ resource dimensions of care
• Deny need to balance autonomy/ accountability
• Deny team-based power sharing care
• Deny systematisation

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Nursings equivocal culture

• Equivocal about interconnections between
  clinical/ resource dimensions of care
• Equivocal about need to
• balance autonomy/ accountability
• Support team-based care power sharing
• Some support for systematisation

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General Management

• Accept interconnections between clinical/
  resource dimensions of care
• Accept need to balance autonomy/ accountability
• Ambivalent about team-based power sharing
• Accept systematisation but not sure of methods

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Stability of professional archetypes
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Mapping the culture of health care organisations

• Questions
• One culture?
• Multiple cultures?
• What then of the organisational culture of
  individual hospitals?
• An unresolved plurality that is masked by the
  claim that we are all here for the patient.
• Lots of issues that cant be talked about
• Misrepresentation, obfuscation and performance
  salving dissimulation are institutionally
  necessary truths
• Collusion around forgiving accountability

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In Summary Reform is Producing

• Stasis
• Erosion of Trust
• Gouldners Vicious Cycle of Control
• Danse Macabre

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• Stasis
• Culture eats strategy for breakfast every
  morning
• Berwick 2000

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Ethnographic findings on the cultural composition
of hospitals
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Clinical Product Line Model late 1980s
Intermediate Products
Final Products
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Stasis
Intermediate Products
Final Products
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Erosion of Trust and Affiliation

• Respondents
• assessments of the management style of their
  hospital
• Affiliation with the hospital

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Respondents Assessments of Hospital Management
Style





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Respondents affiliation with their hospital
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Anxiety and Depression within Hospital A
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Policy responses to Stasis

• Tensions between
• Initiatives with developmental potential
• Increasing top-down surveillance
• if a little control doesnt work
• Then perhaps a lot more will

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The short term imperatives of the electoral
cycle has reinforced tendencies toward top-down
surveillance

• Coming in on Budget
• Waiting lists
• Targets
• Political noise
• Safety and risk reduction
• Quality
• Hence hospital management has focused on issues
  management rather than the substantive content of
  clinical work

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• How this plays-out is illustrated in the
  implementation of Clinical Governance in the UK

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The policy settings for quality modernisation
Source Dept of Health 1998
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Stated Aims of Clinical Governance

• Clinical Governance will integrate
• financial control
• service performance
• clinical quality
• through
• organisational wide responses
• application of local professional self regulation
• Scally and Donaldson 1998

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Implementation

• Most Hospitals met requirements placed on them by
  strengthening existing systems dealing with
  matters such as
• clinical audit,
• quality improvement
• They established additional silos for other
  issues they now needed to report and
• Established a committee structure signifying the
  presence of a co-ordinated approach.

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Result An issues focussed model of clinical
governance
TRUST/MANAGEMENT BOARD/CEO
CLINICAL GOVERNANCE SUB-COMMITTEES
Clinical governance infrastructure dominated by
traditional retrospective and reactive oriented
silos (risk, claims, complaints, audit, health
and safety)
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Evaluation

• The model met the formal requirements placed on
  hospitals.
• But
• Was ill-suited to set-in-train processes that
  would change the organization and performance of
  clinical work along lines consistent with the
  intention of reform

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In summary

• A hospitals clinical work continued to be
  conceived and spoken about as an
  un-differentiated aggregate.
• The failure to disaggregate into specific patient
  categories meant that efforts to improve quality,
  clinical effectiveness and efficiency were
  pursued via a number of top-down reporting
  structures
• These structures retrospectively gathered data on
  generic issues such as quality, risk, safety and
  patient satisfaction.

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The fragmented depictions of care that resulted

• Could not encompass the diversity of clinical
  work that is entailed in treating a patient with
  a fracture or, supporting a patient in self-
  managing their asthma.
• This undermined the relevance of clinical
  governance for many medical, nursing and allied
  health staff and
• Led them to regard CG as
• adding to their paperwork
• bolstering the inspectorial character of
  managements interest in clinical work.

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• An Alternative Approach

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Demmings Principles

• Effective organisations are those that are
  organised and managed to support their key
  production processes
• Within effective organisations multi-disciplinary
  production teams are supported by systems that
  enable them to self-manage their work
• The work of multidisciplinary teams usually
  involves a range of interconnected processes
• Problems in these processes are the main source
  of shortfalls in quality and efficiency that
  undermine both organisational effectiveness and
  worker satisfaction

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Demmings principles cont.

• Understanding variability in the key processes
  that affect the work of a multi-disciplinary team
  is the starting point for improving quality,
  efficiency and worker satisfaction
• Accordingly, effective organisations are
  characterized by the structures and methods they
  use to
• focus on the key aspects of their production
  processes and
• make these amenable to process control to the
  benefit of improved efficiency and quality

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The essential features of an alternative model
are

• A product-output focused hospital organization
  structure
• A method for documenting the specifics of
  clinical production for nominated high volume
  case types
• A clinical production focused accountability
  structure

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On structure

• Introduce structures that will enable hospitals
  to operate as multi-product service
  organisations
• Whose work is pursued through multi-disciplinary
  product line departments
• that are organised around specific high volume
  treatment outputs such as
• treatment of fracture (orthopaedics).
• normal deliveries and caesarean sections
  (obstetrics),
• treatment of hypertension and angina
  (cardiology),
• treatment of pneumonia and COPD (respiratory
  medicine) and

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Product focused hospital organisation structure
Intermediate Products
Imaging
Pharmacy
Path.
Hotel services
Hip ICP 1
Hip ICP 2
Final Products
Knee ICP 1
ICP 1
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• Method

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A method that for each high volume case type

• describes the sequence of diagnostic and
  therapeutic events whose occurrence of
  non-occurrence will significantly affect quality,
  cost and outcome.
• prospectively costs the care that will be
  provided and in so doing defines the cost
  indicators that will be used to judge efficiency.
  
• prospectively defines the quality and outcome
  indicators that will be used to judge
  performance.

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Characteristics of Integrated care pathways
Clinical Pathway
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Characteristics of Integrated Care Pathways

• Systematically developed written statements
• That incorporate the views of clinicians
  (medical, nursing, allied health) patients and
  managers
• About the agreed sequence of diagnostic and
  therapeutic events whose occurrence or non
  occurrence will significantly affect, quality,
  outcomes and cost

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A number of provisos

• ICPs are not immutable documents setting out
  inviolable treatment regimens.
• The existence of a pathway does not obviate
  clinicians responsibility to make clinical
  judgements and to tailor care according to their
  assessment of the clinical needs of individual
  patients.
• Thus clinical variation remains a to be
  expected (in the sense of an often required)
  feature of clinical practice.
• The matter at issue is what a clinical team can
  learn from these variations and how they can
  systematize this learning.
• Accordingly, when the care process varies from
  that described in the pathway, the reasons for
  the variance are recorded and become the focus of
  structured across-profession conversations
  described above.

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High volume case types how many pathways?

• Within a 600 -700 bed DGH in the NHS
• Emergency admissions account for 53 of all
  inpatient episodes and 83 of all bed days
  consumed within the Trusts
• 40 HRGs (of 603) account for 46 of emergency
  admissions and 42 emergency generated bed days
• 40 HRGs account for 60 of in patient elective
  episodes and 40 of elective bed-days, and
• 40 HRGs account for 84 of day elective episodes
• 10 HRGs account for 98 of all maternity and
  births admissions and 97 of maternity and birth
  bed days

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Why high volume case types?

• High volume case types are those for which
• Pathways will produce the biggest bang for the
  buck as we strive to improve
• Efficiency
• Effectiveness
• Quality
• We can generate valid data for statistical
  analysis

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• A clinical production focussed
• accountability structure

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A clinical production focussed accountability
structure

• Put clinical production at the centre of
  hospital management accountability
• Establish a clinical production council as the
  peak clinical production management body for the
  hospital
• Task of this body to monitor and improve
  condition and/or treatment specific clinical
  production processes of individual clinical
  production units, i.e how we do hips or normal
  deliveries,
• Signifies a shift in emphasis
• from a concern for issues management and
  meeting performance targets
• to a concern for the detailed composition of
  clinical work for particular patient categories.
  

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Clinical Production Focused Accountability
Structure
Hospital Management Board
Clinical Production Council
ORTHOPEADICS DEPARTMENT
Hip Replacement Type 1
Knee Replacement Type 1
Hip Replacement Type 2
Fracture Type 2
Facture Type 1
Each condition/treatment specific report
includes data on evidence, cost outcomes,
clinical effectiveness, quality, safety, adverse
events, variance, complaints/claims
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A clinical production focused accountability
structure that

• Specifies the accountability of heads of
  clinical units, on a case type by case type basis
  for units performance on
• The evidence-base of pathways
• Observed variability in clinical practice
• Clinical outcomes
• Quality,
• Safety and adverse events
• The volume of cases treated
• projected costs vs. actual costs.

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In other words a structure that will re-focus
clinical unit management

• From input and issues focused management
• Budgets
• Waiting lists
• Political noise
• To detailed management of clinical work
• Condition specific pathways for high volume case
  types
• Evidence based
• Across discipline setting co-ordination
• Quality
• Outcome
• Efficiency (technical and allocative)

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A policy framework to support culture change
in hospitals
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A clinical production focussed management system
Clinical Production Focussed Accountability
Structure
Method
Clinical Production Focused Org Structure
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In other words establish a policy framework that
will support structures and methods

• That will encourage multi-disciplinary teams to
  monitor and improve their performance by asking
  questions such as
• At what points and to what extent did the care we
  provided for patients with this condition vary
  from that outlined in the clinical pathway?
• What caused these variations?
• Is our clinical practice informed by evidence and
  national guidelines?
• In which cases were variations caused by non
  clinical factors such as variability in clinical
  practice and/or organisational and systems wide
  factors?
• To what extent have these variations affected
  the experience of patient, quality, safety, risk,
  clinical effectiveness and technical efficiency?
• How will we go about improving our performance in
  respect of both the clinical quality and
  technical efficiency?

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• Culture Change

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Culture as the mutual constitution of structure
and action
ENABLES CONSTRAINS

• Culture
• Taken as given
• Values
• Attitudes
• Beliefs
• Rules

STRUCTURE
ACTION
EMBODIES RECREATES
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The how of culture change

• Evidence from a range of settings and policy
  domains strongly suggests that the point of entry
  for culture change is at the action/practice
  segment of the cycle
• In other words what is required are policies that
  will support the introduction of structures and
  practices which embody the culture we are looking
  for
• recognise interconnections between clinical and
  resource dimensions of care
• balance autonomy with accountability
• reinforce the team-based nature of service
  provision
• systematise clinical work processes

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• Some Evidence of Culture Change

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Evidence of cultural shifts among medical managers
Emphasis on financial realism and transparent
accountability
Individualistic concepts of clinical work
Systematised concepts of clinical work
Emphasis on clinical purism and Opaque
accountability
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Some other evidence on emerging changes in
medical culture suggest that room for manoeuvre
on clinical work focussed management may be
increasing
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Assessment of propositions that clinical
practice should not take account of resource
constraints
Doctor
Doctor Manager
Manager
Nurse Manager
Nurse

Positive Disagree with proposition
Mean factor score
Negative Agree with proposition
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Assessment of practices that would facilitate the
systematisation of clinical work
Doctor
Doctor Manager
Manager
Nurse Manager
Nurse
Positive Reject practices
Mean factor score
Negative Support practices

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Assessment of a model of clinical unit management
that underwrites medical ascendancy and
emphasises management role in resource acquisition
Doctor
Doctor Manager
Manager
Nurse Manager
Nurse
Positive Reject model
Mean factor score
Negative Support model

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Assessment of models of clinical unit management
that emphasise the managers role in bringing
about improvement oriented team building
Doctor

Doctor Manager
Manager
Nurse Manager
Nurse
Positive Reject model
Mean factor score
Negative Support model

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Standards should be based on self referenced
knowledge
Doctor
Doctor Manager
Manager
Nurse Manager
Nurse
Positive Reject model
Mean factor score
Negative Support model
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These (albeit preliminary) indications of shifts
in medical and nursing culture suggest an
emerging basis for establishing the social
authority of clinician managers in introducing
clinical work focussed management systems
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Clinical product focused management as a medium
for enacting culture change
Transparent Accountability
Clinical/Resource interconnections
Clinical Product focussed Management System
Shared multidisciplinary power
Clinical work systemisation
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So what are we waiting for?