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Akmal A, Podgorodnichenko N, Greatbanks R, Zhang JA. Does organizational readiness matter in lean thinking practices? An agency perspective. INTERNATIONAL JOURNAL OF OPERATIONS & PRODUCTION MANAGEMENT 2022. [DOI: 10.1108/ijopm-05-2021-0331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeExtant research documents the importance of lean thinking for organizations, however, as prior research has largely focused on hard lean practices, but little is known about the effects or the significance of soft lean practices. This research attempts to address this issue by examining how soft lean practices enhance organizational lean readiness, and in turn increase the success of lean implementation.Design/methodology/approachThis research adopts a single case study design in a small-medium enterprise livestock feed manufacturing organization, and investigates the period from late 2011 through the end of 2019 covering two attempts at lean implementation – an initial failed attempt followed by a successful introduction of lean within the case organization. The research analyzes interviews with 29 managers and employees from all organizational levels and departments within the case organization. Secondary data including organizational documents and performance measures and metrics were also incorporated into the research design.FindingsDrawing on agency theory, the authors advance a principal-agent interaction perspective to conceptualize organizational lean readiness – specifically, the authors consider the “state or condition” of four agency factors (goal conflict, information asymmetry, risk aversion and length of relationship), and explore if these four agency factors can be utilized as proxies for organizational readiness for lean implementation. The authors identify the formation of a shared vision and identity within the organization as an effective mechanism through which soft lean practices enhance organizational lean readiness. Finally, the analysis offers an understanding of how the long-term success of lean implementation is improved by the introduction of soft lean practices as a prerequisite to create organizational readiness for the implementation of hard lean practices.Originality/valueThe study is unique in the sense that it empirically links agency theory and the role of soft lean practices in developing organizational lean readiness in a small-medium enterprise context by defining the ideal state of four agency factors as proxies for organizational readiness.
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Coulden A, Chortis V, Smyth T, Salahuddin S, Hanif W, Ghosh S. A quality improvement project reducing adverse events and improving adherence to guidelines surrounding VRIII usage. BMJ Open Qual 2022; 11:bmjoq-2021-001612. [PMID: 35393291 PMCID: PMC8991048 DOI: 10.1136/bmjoq-2021-001612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 03/19/2022] [Indexed: 11/24/2022] Open
Abstract
Variable rate intravenous insulin infusions (VRIII) are frequently used in hospitals and incorrect use can lead to electrolyte imbalance, hypoglycaemia and adverse outcomes. The Joint British Diabetes Societies (JDBS) published guidelines in 2014 and recommended the use of a balanced fluid as substrate. There was no published data to demonstrate the superiority of this fluid in reducing adverse events. This quality improvement project aimed to review the existing practice at our Trust in accordance with JDBS guidelines. We predicted introducing this fluid would reduce adverse events and demonstrating this was a prerequisite condition from our Trust Medicines Management Committee to approve its long-term availability. We carried out an audit of our practice in 2015, at which time the JBDS recommended fluid (0.45% sodium chloride/5% dextrose with 0.15% potassium chloride) was not available in our Trust. Our VRIII guideline was re-written with recommendation for use of the balanced fluid, after procurement from pharmacy. Our primary areas for improvement as highlighted from the 2015 audit were correct substrate prescription and rate reduction of hypokalaemia (potassium <3.5 mmol/L) and hypoglycaemia (glucose <4 mmol/L) during VRIII use. Analysis of the pre-intervention (December 2016) and post-intervention (September–November 2017) data showed a significant increase in correct fluid use; 11% pre-intervention to 76% post-intervention (χ2, p<0.0001). The number of hypoglycaemic events per VRIII reduced from 0.73 (±1.78) to 0.28 (±0.84) (p<0.05) peri-intervention. Similarly, the number of hypokalaemic events per VRIII reduced from 0.15 (±0.54) pre-intervention to 0.05 (±0.25) post-intervention. There was also a significant reduction in number of VRIII episodes associated with a hyponatraemia event from 26% at baseline to 12% post-intervention (p<0.01). Some of these marked improvements were not sustained at 1-year post follow-up. We reduced adverse outcomes with a substantial net-cost saving during this period, through implementation of new and accessible guidelines, trust-wide education programmes and posters to raise awareness.
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Affiliation(s)
- Amy Coulden
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK .,Institute of Metabolism Systems Research and Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK.,Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vasileios Chortis
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Institute of Metabolism Systems Research and Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK.,Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Theresa Smyth
- Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sofia Salahuddin
- Institute of Metabolism Systems Research and Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK.,Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Wasim Hanif
- Institute of Metabolism Systems Research and Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK.,Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sandip Ghosh
- Institute of Metabolism Systems Research and Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK.,Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Willetts G, Nieuwoudt L, Olasoji M, Sadoughi N, Garvey L. Implementation of a Registered Undergraduate Student of Nursing (RUSON) program: The nurses’ perspective. Collegian 2022. [DOI: 10.1016/j.colegn.2021.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Flynn R, Mrklas K, Campbell A, Wasylak T, Scott SD. Contextual factors and mechanisms that influence sustainability: a realist evaluation of two scaled, multi-component interventions. BMC Health Serv Res 2021; 21:1194. [PMID: 34736470 PMCID: PMC8570000 DOI: 10.1186/s12913-021-07214-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 10/21/2021] [Indexed: 12/04/2022] Open
Abstract
Background In 2012, Alberta Health Services created Strategic Clinical NetworksTM (SCNs) to develop and implement evidence-informed, clinician-led and team-delivered health system improvement in Alberta, Canada. SCNs have had several provincial successes in improving health outcomes. Little research has been done on the sustainability of these evidence-based implementation efforts. Methods We conducted a qualitative realist evaluation using a case study approach to identify and explain the contextual factors and mechanisms perceived to influence the sustainability of two provincial SCN evidence-based interventions, a delirium intervention for Critical Care and an Appropriate Use of Antipsychotics (AUA) intervention for Senior’s Health. The context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic guided our research. Results We conducted thirty realist interviews in two cases and found four important strategies that facilitated sustainability: Learning collaboratives, audit & feedback, the informal leadership role, and patient stories. These strategies triggered certain mechanisms such as sense-making, understanding value and impact of the intervention, empowerment, and motivation that increased the likelihood of sustainability. For example, informal leaders were often hands-on and influential to front-line staff. Learning collaboratives broke down professional and organizational silos and encouraged collective sharing and learning, motivating participants to continue with the intervention. Continual audit-feedback interventions motivated participants to want to perform and improve on a long-term basis, increasing the likelihood of sustainability of the two multi-component interventions. Patient stories demonstrated the interventions’ impact on patient outcomes, motivating staff to want to continue doing the intervention, and increasing the likelihood of its sustainability. Conclusions This research contributes to the field of implementation science, providing evidence on key strategies for sustainability and the underlying causal mechanisms of these strategies that increases the likelihood of sustainability. Identifying causal mechanisms provides evidence on the processes by which implementation strategies operate and lead to sustainability. Future work is needed to evaluate the impact of informal leadership, learning collaboratives, audit-feedback, and patient stories as strategies for sustainability, to generate better guidance on planning sustainable improvements with long term impact. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07214-5.
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Affiliation(s)
- Rachel Flynn
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Alberta, T6G 1C9, Edmonton, Canada.
| | - Kelly Mrklas
- Strategic Clinical Networks™, Provincial Clinical Excellence, Alberta Health Services, Calgary, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, T2N 4N1, Calgary, Canada
| | - Alyson Campbell
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Alberta, T6G 1C9, Edmonton, Canada
| | - Tracy Wasylak
- Strategic Clinical Networks™, Provincial Clinical Excellence, Alberta Health Services, Calgary, Canada.,Faculty of Nursing, University of Calgary, T2N 4V8, Alberta, Canada
| | - Shannon D Scott
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Alberta, T6G 1C9, Edmonton, Canada
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Radcliffe E, Kordowicz M, Mak C, Shefer G, Armstrong D, White P, Ashworth M. Lean implementation within healthcare: imaging as fertile ground. J Health Organ Manag 2021; ahead-of-print. [PMID: 33047577 DOI: 10.1108/jhom-02-2020-0050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to understand the barriers and enablers to lean implementation as part of an imaging quality improvement programme from a socio-cultural perspective. DESIGN/METHODOLOGY/APPROACH An in-depth 33 month ethnographic study, using observation and qualitative interviews, examined the process of lean implementation as part of an improvement programme. FINDINGS Implementation of lean was more successful compared with other reports of lean in healthcare settings. Key enablers of lean were high levels of multidisciplinary staff involvement and engagement; the professional credibility of facilitators and clinicians as early adopters, all within a wider culture of relatively strong inter-professional relationships in the imaging department. These enablers combined with the more routinised and standardised nature of imaging pathways compared to some other acute specialties suggest that imaging is fertile ground for lean, linked to the manufacturing origins of lean. PRACTICAL IMPLICATIONS When introducing lean within healthcare settings, special attention needs to be paid to the specific healthcare context and the existing cultures of inter-professional relationships. Fostering an improvement culture and engagement with training, together with adequate financial resource, are a key to contributing to the level of acceptability of an improvement tool such as lean. ORIGINALITY/VALUE This ethnographic study, bringing together rich multi-source data, has provided a detailed insight into the cultural workings of the process of lean implementation within a complex healthcare system.
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Affiliation(s)
- Eloise Radcliffe
- Faculty of Health Sciences, Macmillan Survivorship Research Group, University of Southampton, Southampton, UK
| | - Maria Kordowicz
- Lincoln International Business School, University of Lincoln, Lincoln, UK
| | - Caroline Mak
- Department of Population Health Sciences, King's College London, London, UK
| | - Guy Shefer
- Department of Population Health Sciences, King's College London, London, UK
| | - David Armstrong
- Department of Population Health Sciences, King's College London, London, UK
| | - Patrick White
- Department of Population Health Sciences, King's College London, London, UK
| | - Mark Ashworth
- Department of Population Health Sciences, King's College London, London, UK
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Huikko-Tarvainen S, Sajasalo P, Auvinen T. Just a leader? Leadership work challenges and identity contradiction experienced by Finnish physician leaders. J Health Organ Manag 2021; 35:195-210. [PMID: 34159766 PMCID: PMC9136864 DOI: 10.1108/jhom-10-2020-0421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose This study seeks to improve the understanding of physician leaders' leadership work challenges. Design/methodology/approach The subjects of the empirical study were physician leaders (
n
= 23) in the largest central hospital in Finland. Findings A total of five largely identity-related, partially paradoxical dilemmas appeared regarding why working as “just a leader” is challenging for physician leaders. First, the dilemma of identity ambiguity between being a physician and a leader. Second, the dilemma of balancing the expected commitment to clinical patient work by various stakeholders and that of physician leadership work. Third, the dilemma of being able to compensate for leadership skill shortcomings by excelling in clinical skills, encouraging physician leaders to commit to patient work. Fourth, the dilemma of “medic discourse”, that is, downplaying leadership work as “non-patient work”, making it inferior to patient work. Fifth, the dilemma of a perceived ethical obligation to commit to patient work even if the physician leadership work would be a full-time job. The first two issues support the findings of earlier research, while the remaining three emerging from the authors’ analysis are novel. Practical implications The authors list some of the practical implications that follow from this study and which could help solve some of the challenges. Originality/value This study explores physician leaders' leadership work challenges using authentic physician leader data in a context where no prior empirical research has been carried out.
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Affiliation(s)
| | - Pasi Sajasalo
- School of Business and Economics, University of Jyväskylä, Jyväskylä, Finland
| | - Tommi Auvinen
- School of Business and Economics, University of Jyväskylä, Jyväskylä, Finland
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Taylor S, McSherry R, Cook S, Giles E. Exploring the emotional experience of lean. J Health Organ Manag 2020; ahead-of-print. [PMID: 33169587 DOI: 10.1108/jhom-01-2020-0002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE This research aims to contribute to the literature on Lean implementation in healthcare by studying the emotional experiences of the relevant actors related to a Rapid Process Improvement Workshop (RPIW) in a UK healthcare context. The purpose of this study was to go beyond what people think about Lean and towards an exploration of their subjective, emotional and "feeling" experience and whether that emotional experience influenced Lean implementation. DESIGN/METHODOLOGY/APPROACH A phenomenological and symbolic interactionist qualitative case study was undertaken. Data related to participants' emotional experience were collected through non-participant observation and semi-structured interviews. Data were analysed using thematic network analysis. FINDINGS This paper provides novel insights into the emotional experience of Lean as experienced through an RPIW. The findings reveal that participation in an RPIW is much more than a technical process. It influences how people feel about themselves, is based on relationships with others, and requires mental, physical and emotional effort. All of these factors influence engagement with, initiation of and sustainability of the RPIW. RESEARCH LIMITATIONS/IMPLICATIONS A new conceptual framework for the planning and implementation of RPIWs has been developed. However, because of the chosen research approach, the results may lack generalisability. Therefore, researchers are encouraged to test the framework and proposed practice implications. ORIGINALITY/VALUE Despite emotions being an integral part of individual and social everyday life, emotional experience has not been studied in relation to Lean. This study is the first to explore emotions in relation to Lean, with implications for practice as to how RPIWs are managed with a new framework for implementation being proposed.
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Affiliation(s)
| | | | - Susy Cook
- Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
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Williams B, Hibberd C, Baldie D, Duncan EAS, Elders A, Maxwell M, Rattray JE, Cowie J, Strachan H, Jones MC. Evaluation of the impact of an augmented model of The Productive Ward: Releasing Time to Care on staff and patient outcomes: a naturalistic stepped-wedge trial. BMJ Qual Saf 2020; 30:27-37. [PMID: 32217699 PMCID: PMC7788216 DOI: 10.1136/bmjqs-2019-009821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 11/20/2019] [Accepted: 02/27/2020] [Indexed: 11/24/2022]
Abstract
Background Improving the quality and efficiency of healthcare is an international priority. A range of complex ward based quality initiatives have been developed over recent years, perhaps the most influential programme has been Productive Ward: Releasing Time to Care. The programme aims to improve work processes and team efficiency with the aim of ‘releasing time’, which would be used to increase time with patients ultimately improving patient care, although this does not form a specific part of the programme. This study aimed to address this and evaluate the impact using recent methodological advances in complex intervention evaluation design. Method The objective of this study was to assess the impact of an augmented version of The Productive Ward: Releasing Time to Care on staff and patient outcomes. The design was a naturalistic stepped-wedge trial. The setting included fifteen wards in two acute hospitals in a Scottish health board region. The intervention was the Productive Ward: Releasing Time to Care augmented with practice development transformational change methods that focused on staff caring behaviours, teamwork and patient feedback. The primary outcomes included nurses’ shared philosophy of care, nurse emotional exhaustion, and patient experience of nurse communication. Secondary outcomes covered additional key dimensions of staff and patient experience and outcomes and frequency of emergency admissions for same diagnosis within 6 months of discharge. Results We recruited 691 patients, 177 nurses and 14 senior charge nurses. We found statistically significant improvements in two of the study’s three primary outcomes: patients’ experiences of nurse communication (Effect size=0.15, 95% CI; 0.05 to 0.24), and nurses’ shared philosophy of care (Effect size =0.42, 95% CI; 0.14 to 0.70). There were also significant improvements in secondary outcomes: patients’ overall rating of ward quality; nurses’ positive affect; and items relating to nursing team climate. We found no change in frequency of emergency admissions within six months of discharge. Conclusions We found evidence that the augmented version of The Productive Ward: Releasing Time to Care Intervention was successful in improving a number of dimensions of nurse experience and ward culture, in addition to improved patient experience and evaluations of the quality of care received. Despite these positive summary findings across all wards, intervention implementation appeared to vary between wards. By addressing the contextual factors, which may influence these variations, and tailoring some elements of the intervention, it is likely that greater improvements could be achieved. Trial registration number UKCRN 14195.
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Affiliation(s)
- Brian Williams
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Carina Hibberd
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Deborah Baldie
- Division of Nursing, Queen Margaret University Edinburgh, Musselburgh, East Lothian, UK
| | - Edward A S Duncan
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK
| | - Andrew Elders
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Margaret Maxwell
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK
| | - Janice E Rattray
- School of Nursing and Health Sciences, University of Dundee, Dundee, UK
| | - Julie Cowie
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Heather Strachan
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK
| | - Martyn C Jones
- School of Nursing and Health Sciences, University of Dundee, Dundee, UK
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Onyura B, Crann S, Freeman R, Whittaker MK, Tannenbaum D. The state-of-play in physician health systems leadership research. Leadersh Health Serv (Bradf Engl) 2019; 32:620-643. [DOI: 10.1108/lhs-03-2019-0017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
This paper aims to review a decade of evidence on physician participation in health system leadership with the view to better understand the current state of scholarship on physician leadership activity in health systems. This includes examining the available evidence on both physicians’ experiences of health systems leadership (HSL) and the impact of physician leadership on health system reform.
Design/methodology/approach
A state-of-the-art review of studies (between 2007 and 2017); 51 papers were identified, analyzed thematically and synthesized narratively.
Findings
Six main themes were identified in the literature as follows: (De)motivation for leadership, leadership readiness and career development, work demands and rewards, identity matters: acceptance of self (and other) as leader, leadership processes and relationships across health systems and leadership in relation to health system outcomes. There were seemingly contradictory findings across some studies, pointing to the influence of regional and cultural contextual variation on leadership practices as well entrenched paradoxical tensions in health system organizations.
Research limitations/implications
Future research should examine the influence of varying structural and psychological empowerment on physician leadership practices. Empirical attention to paradoxical tensions (e.g. between empowerment and control) in HSL is needed, with specific attention to questions on how such tensions influence leaders’ decision-making about system reform.
Originality/value
This review provides a broad synthesis of diverse papers about physician participation in health system leadership. Thus, it offers a comprehensive empirical synthesis of contemporary concerns and identifies important avenues for future research.
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Sarre S, Maben J, Griffiths P, Chable R, Robert G. The 10-year impact of a ward-level quality improvement intervention in acute hospitals: a multiple methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
The ‘Productive Ward: Releasing Time to Care’™ programme (Productive Ward; PW) was introduced in English NHS acute hospitals in 2007 to give ward staff the tools, skills and time needed to implement local improvements to (1) increase the time nurses spend on direct patient care, (2) improve the safety and reliability of care, (3) improve staff and patient experience and (4) make structural changes on wards to improve efficiency. Evidence of whether or not these goals were met and sustained is very limited.
Objective
To explore if PW had a sustained impact over the past decade.
Design
Multiple methods, comprising two online national surveys, six acute trust case studies (including a secondary analysis of local audit data) and telephone interviews.
Data sources
Surveys of 56 directors of nursing and 35 current PW leads; 88 staff and patient and public involvement representative interviews; 10 ward manager questionnaires; structured observations of 12 randomly selected wards and documentary analysis in case studies; and 14 telephone interviews with former PW leads.
Results
Trusts typically adopted PW in 2008–9 on their wards using a phased implementation approach. The average length of PW use was 3 years (range < 1 to 7 years). Financial and management support for PW has disappeared in the majority of trusts. The most commonly cited reason for PW’s cessation was a change in quality improvement (QI) approach. Nonetheless, PW has influenced wider QI strategies in around half of the trusts. Around one-third of trusts had impact data relating specifically to PW; the same proportion did not. Early adopters of PW had access to more resources for supporting implementation. Some elements of local implementation strategies were common. However, there were variations that had consequences for the assimilation of PW into routine practice and, subsequently, for the legacies and sustainability of the programme. In all case study sites, material legacies (e.g. display of metrics data; storage systems) remained, as did some processes (e.g. protected mealtimes). Only one case study site had sufficiently robust data collection systems to allow an objective assessment of PW’s impact; in that site, care processes had improved initially (in terms of patient observations and direct care time). Experience of leading PW had benefited the careers of the majority of interviewees. Starting with little or no QI experience, many went on to work on other initiatives within their trusts, or to work in QI at regional or national level within the NHS or in the private sector.
Limitations
The research draws on participant recall over a lengthy period characterised by evolving QI approaches and system-level change.
Conclusions
Little robust evidence remains of PW leading to a sustained increase in the time nurses spend on direct patient care or improvements in the experiences of staff and/or patients. PW has had a lasting impact on some ward practices. As an ongoing QI approach continually used to make ongoing improvements, PW has not been sustained, but it has informed current organisational QI practices and strategies in many trusts. The design and delivery of future large-scale QI programmes could usefully draw on the lessons learnt from this study of the PW in England over the period 2008–18.
Funding
This National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sophie Sarre
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
| | - Jill Maben
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | | | - Rosemary Chable
- Training, Development & Workforce, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Glenn Robert
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
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11
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Onyura B, Crann S, Tannenbaum D, Whittaker MK, Murdoch S, Freeman R. Is postgraduate leadership education a match for the wicked problems of health systems leadership? A critical systematic review. PERSPECTIVES ON MEDICAL EDUCATION 2019; 8:133-142. [PMID: 31161480 PMCID: PMC6565666 DOI: 10.1007/s40037-019-0517-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE There have been a growing number of leadership education programs for physicians. However, debates about the value and efficacy of leadership education in medicine persist, and there are calls for systematic and critical perspectives on medical leadership development. Here, we review evidence on postgraduate leadership education and discuss findings in relation to contemporary evidence on leadership education and practice. METHOD We searched multiple databases for papers on postgraduate leadership development programs, published in English between 2007 and 2017. We identified 4,691 papers; 31 papers met the full inclusion criteria. Data regarding curricular content and design, learner demographics, instructional methods, and learning outcomes were abstracted and synthesized. RESULTS There was modest evidence for effectiveness of programs in influencing knowledge and skills gains in select domains. However, the conceptual underpinnings of the 'leadership' training delivered were often unclear. Contemporary theory and evidence on leadership practice was not widely incorporated in program design. Programs were almost exclusively uni-professional, focused on discrete skill development, and did not address systems-level leadership issues. Broader leadership capacity building strategies were underutilized. A new wave of longitudinal, integrated clinical and leadership programming is observed. CONCLUSIONS Our findings raise questions about persistent preparation-practice gaps in leadership education in medicine. Leadership education needs to evolve to incorporate broader collective capacity building, as well as evidence-informed strategies for leadership development. Barriers to educational reform need to be identified and addressed as educators work to re-orientate education programs to better prepare budding physician leaders for the challenges of health system leadership.
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Affiliation(s)
- Betty Onyura
- Centre for Faculty Development, Faculty of Medicine, University of Toronto, St. Michael's Hospital, Ontario, Canada.
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada.
| | - Sara Crann
- Department of Psychology, University of Windsor, Ontario, Canada
| | - David Tannenbaum
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
| | - Mary Kay Whittaker
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
| | - Stuart Murdoch
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
| | - Risa Freeman
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
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Harvey CL, Baret C, Rochefort CM, Meyer A, Ausserhofer D, Ciutene R, Schubert M. Discursive practice - lean thinking, nurses' responsibilities and the cost to care. J Health Organ Manag 2018; 32:762-778. [PMID: 30299224 DOI: 10.1108/jhom-12-2017-0316] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to explore the literature regarding work intensification that is being experienced by nurses, to examine the effects this is having on their capacity to complete care. The authors contend that nurses' inability to provide all the care patients require, has negative implications on their professional responsibility. DESIGN/METHODOLOGY/APPROACH The authors used institutional ethnography to review the discourse in the literature. This approach supports inquiry through the review of text in order to uncover activities that remain institutionally accepted but unquestioned and hidden. FINDINGS What the authors found was that the quality and risk management forms an important part of lean thinking, with the organisational culture influencing outcomes; however, the professional cost to nurses has not been fully explored. RESEARCH LIMITATIONS/IMPLICATIONS The text uncovered inconsistency between what organisations accepted as successful cost savings, and what nurses were experiencing in their attempts to achieve the care in the face of reduced time and human resources. Nurses' attempts at completing care were done at the risk of their own professional accountability. PRACTICAL IMPLICATIONS Nurses are working in lean and stressful environments and are struggling to complete care within reduced resource allocations. This leads to care rationing, which negatively impacts on nurses' professional practice, and quality of care provision. ORIGINALITY/VALUE This approach is a departure from the standard qualitative review because the focus is on the textual relationships between what is being advocated by organisations directing cost reduction and what is actioned by the nurses working at the coalface. The discordant standpoints between these two juxtapositions are identified.
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Affiliation(s)
- Clare Lynette Harvey
- School of Nursing, Midwifery and Social Sciences, Central Queensland University , Mackay, Australia
| | - Christophe Baret
- The Institute of Labour Economics and Industrial Sociology (LEST - CNRS), Aix-Marseille University , Aix en Provence, France
| | - Christian M Rochefort
- School of Nursing, Faculty of Medicine and Health Sciences, University of Sherbrooke , Quebec, Canada.,Research Centre, University Hospital Center of Sherbrooke (CHUS) , Sherbrooke, Canada.,Research Centre, Charles-LeMoyne Hospital, Longueuil, Canada
| | - Alannah Meyer
- School of Nursing, Eastern Institute of Technology, Taradale, New Zealand
| | | | - Ruta Ciutene
- Faculty of Social Sciences, Kaunas University of Technology , Kaunas, Lithuania
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Abstract
OBJECTIVE This study examined a 6-month follow-up of a regional evidence-based practice (EBP) fellowship program and the predictors of EBP adoption at hospital units. BACKGROUND The immediate beneficial effects of a regional EBP program are known, but the medium-term effects are not certain. METHODS A matched pretest/posttest study was conducted using a mailed questionnaire 6 months after the completion of a 9-month regional EBP fellowship program among 3 annual cohorts of participants. RESULTS Statistically significant improvements in the mean scores of EBP beliefs, EBP implementation, and group cohesion were found (P < .05). Of the 47 participants who completed their EBP projects, more than three-quarters reported EBP adoption at their own hospital units, and EBP beliefs were a positive predictor of EBP adoption (odds ratio, 1.12; 95% confidence interval, 1.02-1.22; P = .017). CONCLUSIONS The outcome improvements continued 6 months after the fellowship program, and strong EBP beliefs predicted EBP adoption in the participants' units.
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Boak G, Dickens V, Newson A, Brown L. Distributed leadership, team working and service improvement in healthcare. Leadersh Health Serv (Bradf Engl) 2017; 28:332-44. [PMID: 26388221 DOI: 10.1108/lhs-02-2015-0001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to analyse the introduction of distributed leadership and team working in a therapy department in a healthcare organisation and to explore the factors that enabled the introduction to be successful. DESIGN/METHODOLOGY/APPROACH This paper used a case study methodology. Qualitative and quantitative information was gathered from one physiotherapy department over a period of 24 months. FINDINGS Distributed leadership and team working were central to a number of system changes that were initiated by the department, which led to improvements in patient waiting times for therapy. The paper identifies six factors that appear to have influenced the successful introduction of distributed learning and team working in this case. RESEARCH LIMITATIONS/IMPLICATIONS This is a single case study. It would be interesting to explore whether these factors are found in other cases where distributed leadership is introduced in healthcare organisations. PRACTICAL IMPLICATIONS The paper provides an example of successful introduction of distributed leadership, which has had a positive impact on services to patients. Other therapy teams may consider how the approach may be adopted or adapted to their own circumstances. ORIGINALITY/VALUE Although distributed leadership is thought to be important in healthcare, particularly when organisational change is needed, there are very few studies of the practicalities of how it can be introduced.
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Affiliation(s)
- George Boak
- Business School, York St John University, York, UK
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15
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Enslev Jensen B, Anne Found P, Williams SJ, Walley P. Improving the efficiency and effectiveness of ward rounds. INTERNATIONAL JOURNAL OF QUALITY AND SERVICE SCIENCES 2016. [DOI: 10.1108/ijqss-05-2016-0039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Ward rounds in hospitals are crucial for decision-making in the context of patient treatment processes. However, these tasks are not systematically managed and are often extended due to missing information or equipment or staff unavailability. This research aims to assess whether ward rounds can be structured more efficiently and effectively from the perspective of patients and staff.
Design/methodology/approach
This mixed-method approach examines the ward rounds conducted in three units within a haematology department of a major Danish hospital. Baseline measures were collected to capture the value of the ward round described by patients and staff. The information on patient and equipment flows associated with a typical ward round was mapped with recommendations for improvement.
Findings
Staff aspired to deliver a good-quality ward round, but what this meant was never articulated and there were no established standards. The duration of the ward round was unpredictable and could take 6 hours to complete. Improvements identified by the team allow the ward rounds to be completed by mid-day with much more certainty.
Research limitations/implications
This research provides an insight as to how ward rounds are conducted within a Danish haematology department.
Practical implications
The research has implications for those involved in ward rounds to reduce the time taken whilst maintaining quality and safety of patient care.
Social implications
This research has implications for patients and their families who wish to spend time with consultants.
Originality/value
Previous research has focused on the interactions between doctors and nurses. This research focuses on the operational process of the ward round and presents a structured approach to support multi-disciplinary teams with a focus on value from the patient’s perspective.
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16
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Tistad M, Palmcrantz S, Wallin L, Ehrenberg A, Olsson CB, Tomson G, Holmqvist LW, Gifford W, Eldh AC. Developing Leadership in Managers to Facilitate the Implementation of National Guideline Recommendations: A Process Evaluation of Feasibility and Usefulness. Int J Health Policy Manag 2016; 5:477-486. [PMID: 27694661 DOI: 10.15171/ijhpm.2016.35] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 03/27/2016] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers' leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention's potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation. METHODS Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a four-month leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention. RESULTS Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation. CONCLUSION Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers' behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations.
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Affiliation(s)
- Malin Tistad
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.,Department of Physiotherapy, Karolinska University Hospital, Stockholm, Sweden.,Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Susanne Palmcrantz
- Department of Physiotherapy, Karolinska University Hospital, Stockholm, Sweden.,Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Lars Wallin
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.,Department of Physiotherapy, Karolinska University Hospital, Stockholm, Sweden.,Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Anna Ehrenberg
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.,Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Christina B Olsson
- Department of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Swede.,School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Göran Tomson
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Lotta Widén Holmqvist
- Department of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Swede.,Mörby Academic Primary Healthcare Center, Stockholm County Council, Stockholm, Sweden
| | - Wendy Gifford
- International Health Systems Research, Departments of Learning, Informatics, Management, Ethics and Public Health Sciences, Karolinska Institutet, Solna, Sweden
| | - Ann Catrine Eldh
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.,Department of Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
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McGahee A. Sustainability of Innovations. Part II: Exemplar of Addressing Sustainability Factors in the Development and Implementation of an Evidenced-Based Practice Improvement Project. Res Theory Nurs Pract 2016; 30:4-9. [PMID: 27024996 DOI: 10.1891/1541-6577.30.1.4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Chambers LL. Factors for sustainability of evidence-based practice innovations: Part I. Res Theory Nurs Pract 2015; 29:89-93. [PMID: 26062287 DOI: 10.1891/1541-6577.29.2.89] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Sales A. Nurse staffing matters: now what? BMJ Qual Saf 2015; 24:241-3. [DOI: 10.1136/bmjqs-2015-004050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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20
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Hamilton J, Verrall T, Maben J, Griffiths P, Avis K, Baker GR, Teare G. One size does not fit all: a qualitative content analysis of the importance of existing quality improvement capacity in the implementation of Releasing Time to Care: the Productive Ward™ in Saskatchewan, Canada. BMC Health Serv Res 2014; 14:642. [PMID: 25547227 PMCID: PMC4279911 DOI: 10.1186/s12913-014-0642-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 12/09/2014] [Indexed: 11/10/2022] Open
Abstract
Background Releasing Time to Care: The Productive Ward™ (RTC) is a method for conducting continuous quality improvement (QI). The Saskatchewan Ministry of Health mandated its implementation in Saskatchewan, Canada between 2008 and 2012. Subsequently, a research team was developed to evaluate its impact on the nursing unit environment. We sought to explore the influence of the unit’s existing QI capacity on their ability to engage with RTC as a program for continuous QI. Methods We conducted interviews with staff from 8 nursing units and asked them to speak about their experience doing RTC. Using qualitative content analysis, and guided by the Organizing for Quality framework, we describe the existing QI capacity and impact of RTC on the unit environment. Results The results focus on 2 units chosen to highlight extreme variation in existing QI capacity. Unit B was characterized by a strong existing environment. RTC was implemented in an environment with a motivated manager and collaborative culture. Aided by the structural support provided by the organization, the QI capacity on this unit was strengthened through RTC. Staff recognized the potential of using the RTC processes to support QI work. Staff on unit E did not have the same experience with RTC. Like unit B, they had similar structural supports provided by their organization but they did not have the same existing cultural or political environment to facilitate the implementation of RTC. They did not have internal motivation and felt they were only doing RTC because they had to. Though they had some success with RTC activities, the staff did not have the same understanding of the methods that RTC could provide for continuous QI work. Conclusions RTC has the potential to be a strong tool for engaging units to do QI. This occurs best when RTC is implemented in a supporting environment. One size does not fit all and administrative bodies must consider the unique context of each environment prior to implementing large-scale QI projects. Use of an established framework, like Organizing for Quality, could highlight the distinctive supports needed in particular care environments to increase the likelihood of successful engagement. Electronic supplementary material The online version of this article (doi:10.1186/s12913-014-0642-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jessica Hamilton
- Health Quality Council, Saskatchewan, 241-111 Research Drive, Saskatoon S7N 3R2, Saskatchewan, Canada.
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