Medicine, management, and modernisation: a "danse macabre"?

Harnessing a clinician-led governance model to overcome healthcare tribalism and drive innovation: a case study of Northumbria NHS Foundation Trust

PURPOSE

Healthcare tribalism refers to the phenomenon through which different groups in a healthcare setting strictly adhere to their profession-based silo, within which they exhibit stereotypical behaviours. In turn, this can lead to deleterious downstream effects upon productivity and care delivered to patients. This study highlights a clinician-led governance model, implemented at a National Health Service (NHS) trust, to investigate whether it successfully overcame tribalism and helped drive innovation.

DESIGN/METHODOLOGY/APPROACH

This was a convergent mixed-methods study including qualitative and quantitative data collected in parallel. Qualitative data included 27 semi-structured interviews with representatives from four professional groups. Quantitative data were collected through a verbally administered survey and scored on a 10-point scale.

FINDINGS

The trust arranged its services under five autonomous business units, with a clinician and a manager sharing the leadership role at each unit. According to interviewees replies, this equivalent authority was cascaded down and enabled breaking down professional siloes, which in turn aided in the adoption of an innovative clinical model restructure.

PRACTICAL IMPLICATIONS

This study contributes to the literature by characterizing a real-world example in which healthcare tribalism was mitigated while reflecting on the advantages yielded as a result.

ORIGINALITY/VALUE

Previous studies from all over the world identified major differences in the perspectives of different healthcare professional groups. In the United Kingdom, clinicians largely felt cut off from decision-making and dissatisfied with their managerial role. The study findings explain a governance model that allowed harmony and inclusion of different professions. Given the long-standing strains on healthcare systems worldwide, stakeholders can leverage the study findings for guidance in developing and implementing innovative managerial approaches.

If It Is Complex, Let It Be Complex - Dealing With Institutional Complexity in Hospitals Comment on "Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?"

Waitzberg and colleagues identified strategies that managers and physicians in hospitals apply to reconcile dilemmas between clinical and economic considerations. Contributions that actually acknowledge the institutional complexity of hospitals and describe how to deal with it are rare. This comment explains the reason behind the institutional complexity in healthcare organizations and argues that institutional complexity is a good foundation for a well-functioning and sustainable healthcare, as long as we are able to deal with this complexity. This point underscores the importance of their contribution. However, even if the identified strategies on how to reconcile and balance different, competing demands are important, they are not easy to apply in practice. First, the strategies require frequent and high-quality interaction between different actors adhering to different institutional logics. Second, even when the strategies are applied successfully, it is difficult to make them sustainable since they rest on a fragile balance between competing logics. However, these are important avenues for future research for researchers who want to follow the route of Waitzberg and colleagues.

Clinicians' psychological empowerment to engage in management as part of their daily work

PURPOSE

The purpose of the article is to analyze how physicians and nurses, as the two major health care professions, experience psychological empowerment for managerial work.

DESIGN/METHODOLOGY/APPROACH

The study was designed as a qualitative interview study at four primary care centers (PCCs) in Sweden. In total, 47 interviews were conducted, mainly with physicians and nurses. The first inductive analysis led us to the concept of psychological empowerment, which was used in the next deductive step of the analysis.

FINDINGS

The study showed that both professions experienced self-determination for managerial work, but that nurses were more dependent on structural empowerment. Nurses experienced that they had competence for managerial work, whereas physicians were more ignorant of such competence. Nurses used managerial work to create impact on the conditions for their clinical work, whereas physicians experienced impact independently. Both nurses and physicians experienced managerial work as meaningful, but less meaningful than nurses and physicians' clinical work.

PRACTICAL IMPLICATIONS

For an effective health care system, structural changes in terms of positions, roles, and responsibilities can be an important route for especially nurses' psychological empowerment.

ORIGINALITY/VALUE

The qualitative method provided a complementary understanding of psychological empowerment on how psychological empowerment interacted with other factors. One such aspect was nurses' higher dependence on structural empowerment, but the most important aspect was that both physicians and nurses experienced that managerial work was less meaningful than clinical work. This implies that psychological empowerment for managerial work may only make a difference if psychological empowerment does not compete with physicians' and nurses' clinical work.

Expanding nurses' authority - Physicians' and nurses' attitudes

AIM

To examine and compare the attitudes of physicians and registered nurses regarding extending nurses' authority.

DESIGN

This was a comparative quantitative study, which used a questionnaire that examined the attitudes of nurses and physicians regarding expanding nurses' authority.

METHODS

The study comprised a sample of 134 nurses (62.7%) and physicians (37.3%), who filled out the self-report questionnaire that included sociodemographic data and questions designed to examine the participants' attitudes and perceptions on expanding nurses' authority. The general reliability of the questionnaire was Cronbach's α = 0.931. Participants were sampled through the convenience-snowball method.

RESULTS

Differences were found between the attitudes of physicians and nurses to expanding nurses' authority. Nurses tended to be in favor, whereas physicians tended to be against (t(86.29) = 7.713; p < 0.05). Nurses' attitudes are also more positive specifically to procedures related to drug administration (t(132) = 6.894; p < 0.05) and resuscitation (t(132) = 2.974; p < 0.05), compared to physicians.

CONCLUSIONS

Nurses have more positive attitudes toward expanding nurses' authority than physicians do, specifically toward drug administration and resuscitation. Further study is proposed to identify factors which affect the physician-nurse relationship and attitudes on a large scale through a qualitative study.

The Usability of the Preliminary ICF Core Set for Hospitalized Patients After a Hematopoietic Stem Cell Transplantation From the Perspective of Nurses: A Feasibility Study

Background: A hematopoietic stem cell transplantation (HSCT) has a major impact on the functioning and perceived quality of life of patients. To describe the functioning of patients, a preliminary set of 53 categories of the International Classification of Functioning, Disability and Health (ICF) as relevant for HSCT patients has been selected earlier by a Delphi study. For the implementation of this preliminary ICF core set for patients after HSCT in clinical practice, a feasibility study was requested.

Methods: A feasibility study was conducted in an explanatory mixed-methods research design. Qualitative data were collected cross-sectionally by semi-structured interviews based on specific topics related to feasibility regarding the use of the preliminary ICF core set for HSCT patients from the perspective of nurses (five in ICF-trained nurses and five regular, untrained, nurses). Quantitative data, were collected longitudinally by using a mobile health application based on ICF in which the ICF trained nurses registered HSCT patients' functioning.

Results: Qualitative analysis indicated that using the preliminary ICF core set is practical and acceptable for providing information about the functioning of HSCT patients from the perspective of nurses. In addition, nurses indicated a demand for this information due to its impact on multidisciplinary meetings and clinical decision-making by involving relevant aspects of the functioning of patients. Management support, trained staff, and designated time to focus on functioning are mentioned as requirements for successful implementation. Quantitative analysis demonstrated that the most used 30% (n = 17) ICF categories are included in the preliminary ICF core set for HSCT patients (n = 24). Energy (b130) was the most used ICF category. Family relationships (d760) was the most frequently and highly positively associated ICF category.

Conclusions: From the perspective of nurses, the preliminary ICF core set for HSCT patients is feasible and relevant in gaining information regarding functioning. Applying this preliminary ICF core set for HSCT patients in the anamnesis and the nursing consultations contributes to this information. Further research is needed to look at the perspective of other professionals and HSCT patients themselves.

Personal values among first-year medical and nursing students: A cross-sectional comparative study

BACKGROUND

Collaboration in healthcare is essential but differences in personal values can be a potential source of disagreements between physicians and nurses.

OBJECTIVES

The purpose of this study was to verify if and to what extent there were divergences in the personal values profile between medical and nursing students at the beginning of their education and training. A second aim was to explore gender differences in personal values.

DESIGN

This is an observational cross-sectional study.

SETTINGS

This study was conducted at one University in northern Italy.

PARTICIPANTS

We compared the personal values of 393 first-year medical students with those of 403 first-year nursing students.

METHODS

The Portrait Values Questionnaire-40 was administered and analyses of variance were performed to assess degree group and gender differences in terms of personal values.

RESULTS

Medical students scored significantly higher than nursing ones on values related to dominance over others and personal success. Female students significantly outscored males on personal values that reflect other-oriented and social focus, whereas male students obtained higher scores than females on personal values related to personal and selfish orientation.

CONCLUSIONS

Schwartz's Theory of Basic Human Values may be a valuable theoretical framework for interprofessional education to promote a common reflection on personal values held by medical and nursing students since the early years of study.

Involving clinicians in management: assessing views of doctors and nurses on hybrid professionalism in clinical directorates

BACKGROUND

Hybrid professionalism is one of the most effective ways to involve clinicians in management practices and responsibilities. With this study we investigated the perceptions of doctors and nurses on hybridization in clinical directorates (CDs) in hospitals.

METHODS

We investigated the attitudes of healthcare professionals (doctors and nurses) towards eight hospital CDs in the Local Health Authority (LHA) of Bologna (Emilia Romagna, Italy) 6 years after their implementation. We used a validated questionnaire by Braithwaite and Westbrook (2004). Drawing on Palmer et al. (2007), we added a section about the characteristics of department heads. In all, 123 healthcare professionals in managerial roles completed and returned the questionnaire. The return rate was 47.4% for doctors and 31.6% for nurses.

RESULTS

Doctors reported an increase in clinical governance, interdisciplinarity collaboration, and standardization of clinical work. Hybridization of practices was noted to have taken place. While doctors did not see these changes as a threat to professional values, they felt that hospital managers had taken greater control. There was a large overlap of attitudes between doctors and nurses: inter-professional integration in CDs fostered alignment of values and aims. The polarity index was higher for responses from the doctors than from the nurses.

CONCLUSION

The study findings have implications for policy makers and managers: mission and strategic mandate of CDs; governance of CDs, leadership issues; opportunities for engaging healthcare professionals; changes in managerial involvement during the COVID-19 pandemic. We also discuss the limitations of the present study and future areas for research into hybrid structures.

The Care Process Organization Triangle: A Framework to Better Understand how Clinical Pathways Work

Clinical pathways, also known as care pathways or integrated care pathways, are used worldwide to make care processes transparent and organize care around patient needs. Although this is in international use, it is still unclear why pathways sometimes work and sometimes do not. To better understand how pathways work, there is a growing need for paradigms or organizing concepts. Different quality and health-care management gurus have developed frameworks to better understand how certain processes or methods work. This paper will provide an overview of several frameworks and integrate them into Donabedian's Structure–Process–Outcome configuration. In view of this configuration, the care process organization triangle was developed. In this paper, we will describe the three cornerstones of this triangle by integrating the literature on clinical pathways. The care process organization triangle is only one model, but as Deming described it: ‘Some models can be quite useful’.

Health service planning and sustainable development: considering what, where and how care is delivered through a pro-environmental lens

The aim of the present paper was to review the opportunities currently available to health service planners to advance sustainable development in their future-facing roles within health service organisation. Critical challenges and enablers to facilitate health services planners in adopting a pro-environmental lens are discussed.

Oncology communities of practice: insights from a qualitative analysis

Background

A community of practice (cop) is formally defined as a group of people who share a concern or a passion for something they do and who learn how to do it better as they interact regularly. Communities of practice represent a promising approach for improving cancer care outcomes. However, little research is available to guide the development of oncology cops. In 2015, our urban community hospital launched an oncology cop, with the goals of decreasing barriers to access, fostering collaboration, and improving practitioner knowledge of guidelines and services in cancer care. Here, we share insights from a qualitative analysis of feedback from participants in our cop. The objective of the project was to identify participant perspectives about preferred cop features, with a view to improving the quality of our community hospital's oncology cop.

Methods

After 5 in-person meetings of our oncology cop, participants were surveyed about what the cop should start, stop, and continue doing. Qualitative methods were used to analyze the feedback.

Results

The survey collected 250 comments from 117 unique cop participants, including family physicians, specialist physicians, nurses, and allied health care practitioners. Analysis identified participant perspectives about the key features of the cop and avenues for improvement across four themes: supporting knowledge exchange, identifying and addressing practice gaps, enhancing interprofessional collaboration, and fostering a culture of partnership.

Conclusions

Based on the results, we identified several considerations that could be helpful in improving our cop. Our findings might help guide the development of oncology cops at other institutions.

Prevalence and use of clinical pathways in 23 countries – an international survey by the European Pathway Association

Objectives

To give an overview on the use and prevalence of clinical pathways.

Design

Cross-sectional descriptive study.

Study participants

European Pathway Association (E-P-A) contact persons in 23 countries.

Results

Clinical pathways, also known as critical pathways or integrated care pathways, have been used in health care for 20 years. Although clinical pathways are well established, little information exists on their use and dissemination around the world. The E-P-A has performed their first international survey on the use and dissemination of clinical pathways in 23 countries. At present, pathways are used with a minority of patients, mainly in acute hospital trusts. Our survey showed that clinical pathways were predominantly viewed as a multidisciplinary tool to improve the quality and efficiency of evidence-based care. Pathways were also used as a communication tool between professionals to manage and standardize outcome-oriented care.

Conclusions

There is a future for the use of clinical pathways, but there is a need for international benchmarking and knowledge sharing with regard to their development, implementation and evaluation.

Health care clinicians' engagement in organizational redesign of care processes: The importance of work and organizational conditions

The Swedish health care system is reorienting towards horizontal organization for care processes. A main challenge is to engage health care clinicians in the process. The aim of this study was to assess engagement (i.e. attitudes and beliefs, the cognitive state and clinical engagement behaviour) among health care clinicians, and to investigate how engagement was related to work resources and demands during organizational redesign. A cohort study was conducted, using a questionnaire distributed to clinicians at five hospitals working with care process improvement approaches, two of them having implemented Lean production. The results show that kinds of engagement are interlinked and contribute to clinical engagement behaviour in quality of care and patient safety. Increased work resources have importance for engagements in organizational improvements, especially in top-down implementations. An extended work engagement model during organizational improvements in health care was supported. The model contributes to knowledge about how and when clinicians are mobilized to engage in organizational changes.

Developing Canadian physician: the quest for leadership effectiveness

Purpose The purpose of this study is to discern the physicians' perception of leadership effectiveness in their clinical and non-clinical roles (leadership) by identifying their political skill levels. Design/methodology/approach A sample of 209 Canadian physicians was surveyed using the Political Skills Inventory (PSI) during the period 2012-2014. The PSI was chosen because it assesses leadership effectiveness on four dimensions: social astuteness, interpersonal influence, networking ability and apparent authenticity. Findings Physicians in clinical roles' PSI scores were significantly lower in all four PSI dimensions when compared to all other physicians in non-clinical roles, with the principal difference being in their networking abilities. Practical implications More emphasis is needed on educating and training physicians, specifically in the areas of political skills, in current clinical roles if they are to assume leadership roles and be effective. Originality/value Although this study is located in Canada, the study design and associated findings may have implications to other areas and countries wanting to increase physician leadership effectiveness. Further, replication of this study in other settings may provide insight into the future design of physician leadership training curriculum.

Uptake of mandatory outcome measures in mental health services

Aims and method

The collection of results of a specific outcome measure, the Health of the Nation Outcome Scales (HoNOS), is mandatory for mental healthcare providers in the National Health Service in England. Not all providers collect HoNOS data and coverage varies widely. This paper explores, by means of interviews with clinicians and policy makers and econometric analysis of HoNOS data, the barriers and incentives to the uptake of HoNOS and outcomes more generally, and the key characteristics associated with providers who do undertake HoNOS.

Results

The main barriers to the collection of outcomes involve a lack of adequate feedback mechanisms, a lack of perceived clinical relevance and poor information technology infrastructure. Econometric results show HoNOS collection is associated with providers who produce high-quality data.

Clinical implications

Initiatives should focus on putting systems in place to encourage feedback mechanisms for clinicians.

The doctor-manager relationship

The different cultures of doctors and managers and the impact of these on their working relationships are described. A historical resumé tracks organisational change, the evolving nature of the relationship and the stresses it engenders. The phenomenon of scapegoating and an approach to managing risk is explored. Vignettes describing familiar problems, with suggested strategies for analysing them and resolving difficulties, are presented.

Translating concerns into action: a detailed qualitative evaluation of an interdisciplinary intervention on medical wards

OBJECTIVES

To understand how frontline reports of day-to-day care failings might be better translated into improvement.

DESIGN

Qualitative evaluation of an interdisciplinary team intervention capitalising on the frontline experience of care delivery. Prospective clinical team surveillance (PCTS) involved structured interdisciplinary briefings to capture challenges in care delivery, facilitated organisational escalation of the issues they identified, and feedback. Eighteen months of ethnography and two focus groups were conducted with staff taking part in a trial of PCTS.

RESULTS

PCTS fostered psychological safety-a confidence that the team would not embarrass or punish those who speak up. This was complemented by a hard edge of accountability, whereby team members would regulate their own behaviour in anticipation of future briefings. Frontline concerns were triaged to managers, or resolved autonomously by ward teams, reversing what had been well-established normalisations of deviance. Junior clinicians found a degree of catharsis in airing their concerns, and their teams became more proactive in addressing improvement opportunities. PCTS generated tangible organisational changes, and enabled managers to make a convincing case for investment. However, briefings were constrained by the need to preserve professional credibility, and staff found some comfort in avoiding accountability . At higher organisational levels, frontline concerns were subject to competition with other priorities, and their resolution was limited by the scale of the challenges they described.

CONCLUSIONS

Prospective safety strategies relying on staff-volunteered data produce acceptable, negotiated accounts, subject to the many interdisciplinary tensions that characterise ward work. Nonetheless, these strategies give managers access to the realities of frontline cares, and support frontline staff to make incremental changes in their daily work. These are goals for learning healthcare organisations.

TRIAL REGISTRATION

ISRCTN 34806867.

Money's (not) on my mind: a qualitative study of how staff and managers understand health care's triple Aim

Background

The “Triple Aim” – provision of a better care experience and improved population health at a lower cost – may be theoretically sound, but paradoxical in practice as it forces together the logics of management and medicine. The aim of this study was to explore how staff and managers understand the change imperative inherent to the Triple Aim and the mental models underlying their understanding.

Methods

This qualitative study builds on thirty semi-structured interviews conducted with managers, nurses, midwives, medical secretaries, and physicians at a department of Gynecology and Obstetrics in Denmark who successfully cut costs through staff and bed reductions and, from what we can ascertain, maintained care quality. Mental models were articulated from a content analysis of the interviews.

Results

Staff and managers identified with the different dimensions of the Triple Aim along classic professional divides, i.e. nurses and midwives focused on patient experience, physicians on health outcomes, and manager on all three. Underlying these, we found four mental models. The understanding of change was guided by a Professional ethos (inner drive to improve care) and a Socio-political discourse (external requirement to become more efficient) mental model. The understanding of economics was guided by a You-get-what-you-pay-for and by a More-bang-for-the-buck mental model. A complex interplay could be discerned between all four, which led staff to see the Triple Aim as a dilemma between quality and economics and a threat to clinical care and quality, whereas managers saw it as a paradox that invited improvement efforts. Despite these differences, managers chose a change strategy in line with staff mental models.

Conclusions

The practical challenges inherent to the Triple Aim may be symptomatic of the interactions between the different mental models that guide staff and managers’ understanding and choice of change strategies. Pursuit of quality improvement in the face of financial constraints (the essence of the Triple Aim) may be facilitated through conscious exploration of these empirically identified mental models. Managers might do well to translate the socio-political discourse into a change process that resonates with the mental models held by staff.

Is medical perspective on clinical governance practices associated with clinical units' performance and mortality? A cross-sectional study through a record-linkage procedure

Objective:

Assessment of the knowledge and application as well as perceived utility by doctors of clinical governance tools in order to explore their impact on clinical units’ performance measured through mortality rates and efficiency indicators.

Methods:

This research is a cross-sectional study with a deterministic record-linkage procedure. The sample includes n = 1250 doctors (n = 249 chiefs of clinical units; n = 1001 physicians) working in six public hospitals located in the Emilia-Romagna Region in Italy. Survey instruments include a checklist and a research-made questionnaire which were used for data collection about doctors’ knowledge and application as well as perceived utility of clinical governance tools. The analysis was based on clinical units’ performance indicators which include patients’ mortality, extra-region active mobility rate, average hospital stay, bed occupancy, rotation and turnover rates, and the comparative performance index as efficiency indicators.

Results:

The clinical governance tools are known and applied differently in all the considered clinical units. Significant differences emerged between roles and organizational levels at which the medical leadership is carried out. The levels of knowledge and application of clinical governance practices are correlated with the clinical units’ efficiency indicators (bed occupancy rate, bed turnover interval, and extra-region mobility). These multiple linear regression analyses highlighted that the clinical governance knowledge and application is correlated with clinical units’ mortality rates (odds ratio, −8.677; 95% confidence interval, −16.654, −0.700).

Conclusion:

The knowledge and application, as well as perceived utility by medical professionals of clinical governance tools, are associated with the mortality rates of their units and with some efficiency indicators. However, the medical frontline staff seems to not consider homogeneously useful the clinical governance tools application on its own clinical practice.

Reorganising hospitals to implement a patient-centered model of care

Purpose

– The purpose of this paper is to understand how the introduction of a patient-centered model (PCM) in Italian hospitals affects the pre-existent configuration of clinical work and interacts with established intra/inter-professional relationships.

Design/methodology/approach

– Qualitative multi-phase study based on three main sources: health policy analysis, an exploratory interview study with senior managers of eight Italian hospitals implementing the PCM, and an in-depth case study that involved managerial and clinical staff of one Italian hospital implementing the PCM.

Findings

– The introduction of the PCM challenges clinical work and professional relationships, but such challenges are interpreted differently by the organisational actors involved, thus giving rise to two different “narratives of change”. The “political narrative” (the views conveyed by formal policies and senior managers) focuses on the power shifts and conflict between nurses and doctors, while the “workplace narrative” (the experiences of frontline clinicians) emphasises the problems linked to the disruption of previous discipline-based inter-professional groups.

Practical implications

– Medical disciplines, rather than professional groupings, are the main source of identification of doctors and nurses, and represent a crucial aspect of clinicians’ professional identity. Although the need for collaboration among medical disciplines is acknowledged, creating multi-disciplinary groups in practice requires the sustaining of new aggregators and binding forces.

Originality/value

– This study suggests further acknowledgment of the inherent complexity of the political and workplace narratives of change rather than interpreting them as the signal of irreconcilable perspectives between managers and clinicians. By addressing the specific issues regarding which the political and workplace narratives clash, relationship of trust may be developed through which problems can be identified, mutually acknowledged, articulated, and solved.

Doctors as health managers: an oxymoron, or a good idea?

Purpose

The purpose of this paper is to review the current literature and summarises the benefits and limitations of having doctors in health management roles in today’s complex health environment.

Design/methodology/approach

This paper reviews the current literature on this topic.

Findings

Hospitals have evolved from being professional bureaucracies to being managed professional business with clinical directorates in place that are medically led.

Research limitations/implications

Limitations include the difficulty doctors have balancing clinical duties and management, restricted profession-specific view and the lack of management competencies and/or training.

Practical implications

The benefits of having doctors in health management include bottom-up leadership, specialised knowledge of the profession, expert knowledge of clinical care, greater political influence, effective change champions to have on-side, frontline leadership and management, improved communication between doctors and senior management, advocacy for patient safety and quality, greater credibility with public and peers and the perception that doctors have more power and influence compared to other health professionals can be leveraged.

Originality/value

Overall, there are more benefits than there are limitations to having doctors in health management but there is a need for more management training for doctors.

Projections of specialist physicians in Mexico: a key element in planning human resources for health

Projections are considered a useful tool in the planning of human resources for health. In Mexico, the supply and demand of specialist doctors are clearly disconnected, and decisions must be made to reduce labour market imbalances. Thus, it is critical to produce reliable projections to assess future interactions between supply and demand. Using a service demand approach, projections of the number of specialist physicians required by the three main public institutions were calculated using the following variables: a) recent recruitment of specialists, b) physician productivity and c) retirement rates. Two types of scenarios were produced: an inertial one with no changes made to current production levels and an alternative scenario adjusted by recommended productivity levels. Results show that institutions must address productivity as a major policy element to act upon in future contracting of specialist physicians. The projections that adjusted for productivity suggest that the hiring trends for surgeons and internists should be maintained or increased to compensate for the increase in demand for services. In contrast, due to the decline in demand for obstetric and paediatric services, the hiring of new obstetrician-gynaecologists and paediatricians should be reduced to align with future demand.

Perceptions of trust in physician-managers

PURPOSE

The purpose of this paper is to explore the dual role of physician-managers through an examination of perceptions of trust and distrust in physician-managers. The healthcare sector needs physicians to lead. Physicians in part-time managerial positions who continue their medical practice are called part-time physician-managers. This paper explores this dual role through an examination of perceptions of trust and distrust in physician-managers.

DESIGN/METHODOLOGY/APPROACH

The study takes a qualitative research approach in which interviews and focus group discussions with physician-managers and nurse-managers provide the empirical data. An analytical model, with the three elements of ability, benevolence and integrity, was used in the analysis of trust and distrust in physician-managers.

FINDINGS

The respondents (physician-managers and nurse-managers) perceived both an increase and a decrease in physicians' trust in the physician-managers. Because elements of distrust were more numerous and more severe than elements of trust, the physician-managers received negative perceptions of their role.

RESEARCH LIMITATIONS/IMPLICATIONS

This paper's findings are based on perceptions of perceptions. The physicians were not interviewed on their trust and distrust of physician-managers.

PRACTICAL IMPLICATIONS

The healthcare sector must pay attention to the diverse expectations of the physician-manager role that is based on both managerial and medical logics. Hospital management should provide proper support to physician-managers in their dual role to ensure their willingness to continue to assume managerial responsibilities.

ORIGINALITY/VALUE

The paper takes an original approach in its research into the dual role of physician-managers who work under two conflicting logics: the medical logic and the managerial logic. The focus on perceived trust and distrust in physician-managers is a new perspective on this complicated role.

How professional identity shapes youth healthcare

PURPOSE

The primary care sector is experiencing considerable change. How change and uncertainty are accommodated by the professional identity of medicine has not been examined. The purpose of this paper is to address the youth healthcare as an exemplar as this field is often a source of uncertainty for general practitioners (GPs).

DESIGN/METHODOLOGY/APPROACH

Using heterogeneity sampling, 22 GPs participated in focus groups to explore perceptions of youth healthcare, factors that help and hinder it, and training needs. Analysis of the research material was guided by a theoretical model on professional identity.

FINDINGS

GPs described tensions that challenged their professional identity - the challenges of working with young people and their complex issues, the extent to which youth healthcare sits within the purview of general practice, and the scope of training required. These tensions appeared to destabilise professional identity. Some participants had customised their identity by enriching understandings of and approach to general practice. Participants also reported work customisation as a way of managing the complex demands of the general practice role. Deepened insight appeared to bolster perceived capacity to support a complex patient cohort. Research limitations/implications - Participants are not representative of the primary care sector - furthermore, the methodology limits the generalisability of the findings.

PRACTICAL IMPLICATIONS

To bolster youth health, mere clinician training is insufficient. Youth health requires explicit support from governments and training providers to be incorporated into the healthcare landscape.

ORIGINALITY/VALUE

This study extends current research on professional identity by examining youth healthcare within the changing context of primary care.

Patient assessment within the context of healthcare delivery packages: A comparative analysis

BACKGROUND

Due to an increased focus on productivity and cost-effectiveness, many countries across the world have implemented a variety of tools for standardizing diagnostics and treatment. In Denmark, healthcare delivery packages are increasingly used for assessment of patients. A package is a tool for creating coordination, continuity and efficient pathways; each step is pre-booked, and the package has a well-defined content within a predefined category of diseases. The aim of this study was to investigate how assessment processes took place within the context of healthcare delivery packages.

METHODS

The study used a constructivist Grounded Theory approach. Ethnographic fieldwork was carried out in three specialized units: a mental health unit and two multiple sclerosis clinics in Southern Denmark, which all used assessment packages. Several types of data were sampled through theoretical sampling. Participant observation was conducted for a total of 126h. Formal and informal interviews were conducted with 12 healthcare professionals and 13 patients. Furthermore, audio recordings were made of 9 final consultations between physicians and patients; 193min of recorded consultations all in all. Lastly, the medical records of 13 patients and written information about packages were collected. The comparative, abductive analysis focused on the process of assessment and the work made by all the actors involved. In this paper, we emphasized the work of healthcare professionals.

RESULTS

We constructed five interrelated categories: 1. "Standardized assessing", 2. "Flexibility", which has two sub-categories, 2.1. "Diagnostic options" and 2.2. "Time and organization", and, finally, 3. "Resisting the frames". The process of assessment required all participants to perform the predefined work in the specified way at the specified time. Multidisciplinary teamwork was essential for the success of the process. The local organization of the packages influenced the assessment process, most notably the pre-defined scope of relevant diseases targeted by the package. The inflexible frames of the assessment package could cause resistance among clinicians. Moreover, expert knowledge was an important factor for the efficiency of the process. Some types of organizational work processes resulted in many patients being assessed, but without being diagnosed with at package-relevant disease.

CONCLUSION

Limiting the grounds for using specialist knowledge in structured health care delivery may affect specialists' sense of professional autonomy and can result in professionals employing strategies to resist the frames of the packages. Finally, when organizing healthcare delivery packages, it seems important to consider how to make the optimal use of specialist knowledge.

Occupational closure in nursing work reconsidered: UK health care support workers and assistant practitioners: A focus group study

In healthcare, occupational groups have adopted tactics to maintain autonomy and control over their areas of work. Witz described a credentialist approach to occupational closure adopted by nursing in the United Kingdom during the 19th and early 20th centuries. However, the recent advancement of assistant, 'non-qualified' workers by governments and managers forms part of a reconfiguration of traditional professional work. This research used focus groups with three cohorts of healthcare support workers undertaking assistant practitioner training at a London university from 2011 to 13 (6 groups, n = 59). The aim was to examine how these workers positioned themselves as professionals and accounted for professional boundaries. A thematic analysis revealed a complex situation in which participants were divided between articulating an acceptance of a subordinate role within traditional occupational boundaries and a usurpatory stance towards these boundaries. Participants had usually been handpicked by managers and some were ambitious and confident in their abilities. Many aspired to train to be nurses claiming that they will gain recognition that they do not currently get but which they deserve. Their scope of practice is based upon their managers' or supervisors' perception of their individual aptitude rather than on a credentialist claim. They 'usurp' nurses claim to be the healthcare worker with privileged access to patients, saying they have taken over what nursing has considered its core work, while nurses abandon it for largely administrative roles. We conclude that the participants are the not unwilling agents of a managerially led project to reshape the workforce that cuts across existing occupational boundaries.

The impact of an integrated medical leadership programme

Purpose

– The purpose of this paper is to determine the impact of an integrated Medical Leadership Programme (MLP) on a cohort of participating specialty doctors and the NHS services with which they were engaged.

Design/methodology/approach

– This was a qualitative study designed to obtain rich textual data on a novel training intervention. Semi-structured interviews were conducted with participating MLP trainees at fixed points throughout the programme in order to capture their experiences. Resulting data were triangulated with data from extant documentation, including trainees’ progress reports and summaries of achievements. Recurring discourses and themes were identified using a framework thematic analysis.

Findings

– Evidence of the positive impact upon trainees and NHS services was identified, along with challenges. Evidence of impact across all the domains within the national Medical Leadership Competency Framework was also identified, including demonstrating personal qualities, working with others, managing services, improving services and setting direction.

Research limitations/implications

– Data were drawn from interviews with a small population of trainees undertaking a pilot MLP in a single deanery, so there are inevitable limitations for generalisability in the quantitative sense. Whilst the pilot trainees were a self-selected group, it was a group of mixed origin and ability.

Practical implications

– The study has provided valuable lessons for the design of future leadership programmes aimed at doctors in training.

Originality/value

– Identifying the effectiveness of an innovative model of delivery with regard to the Medical Leadership Curriculum may assist with medical staff engagement and support health service improvements to benefit patient care.

Health care managers learning by listening to subordinates’ dialogue training

Purpose

– Middle managers in health care today are expected to continuously and efficiently decide and act in administration, finance, care quality, and work environment, and strategic communication has become paramount. Since dialogical communication is considered to promote a healthy work environment, the purpose of this paper is to investigate the ways in which health care managers experienced observing subordinates’ dialogue training.

Design/methodology/approach

– A qualitative study using semi-structured interviews and documents from eight middle managers in a dialogue programme intervention conducted by dialogue trainers. Focus was on fostering and assisting workplace dialogue. Conventional qualitative content analysis was used.

Findings

– Managers’ experiences were both enriching and demanding, and consisted of becoming aware of communication, meaning perceiving interaction between subordinates as well as own silent interaction with subordinates and trainer; Discovering communicative actions for leadership, by gaining self-knowledge and recognizing relational leadership models from trainers – such as acting democratically and pedagogically – and converting theory into practice, signifying practising dialogue-promoting conversation behaviour with subordinates, peers, and superiors.

Research limitations/implications

– Only eight managers participated in the intervention, but data afforded a basis for further research.

Practical implications

– Findings stressed the importance of listening, and of support from superiors, for well-functioning leadership communication at work.

Originality/value

– Studies focusing on health care managers’ communication and dialogue are few. This study contributes to knowledge about these activities in managerial leadership.

Mobilising identities: the shape and reality of middle and junior managers’ working lives – a qualitative study

Background

Social identities shape how individuals perceive their roles and perform their work. Yet little is known about the identities of various types of NHS managers and even less about how they may influence how they carry out their work to achieve effectiveness.

Objectives

To chart the work of middle and junior clinical and non-clinical managers; to describe how their identities are constructed and shape the performance of their roles; to explore how they mobilise their identities to achieve effectiveness.

Design

Qualitative research.

Setting

Two large English hospital trusts.

Participants

Data consisted of 91 semistructured interviews with four primary categories of managers [junior clinical (JC), junior non-clinical (JNC), middle clinical (MC), and middle non-clinical (MNC)], shadowing of a small subsample, observations of meetings. For some analyses the four categories were broken down into finer-grained ‘work groups’. The data were analysed both qualitatively, using the constant comparative method, and quantitatively, using the method of ‘quantitising’ (the numerical translation of qualitative data).

Results

Respondents’ identitiesas managerswere not particularly strong. Results reveal a more nuanced and widely spread portrait of the ‘reluctant manager’ than hitherto reported. The picture ofwhat managers dowas complex and multifaceted. On some dimensions, such as ‘span of responsibility’, ‘span of control’ and cross-site working, internal variations by ‘work group’ indicate that comparisons between the four primary categories were not particularly meaningful. Variety was added to by internal diversity even within ‘work groups’. Analyses ofself-reported effectivenessrevealed that ‘hard’, demonstrable measures of performance (‘transactional effectiveness’) were important to all four categories of managers; however, many were also concerned with ‘softer’ indicators involving enabling, supporting and developing a team (‘processual effectiveness’). Many felt ‘processual effectiveness’ fed ‘transactional effectiveness’. It was also regarded as a form of effectiveness in its own right that could be compromised by undue attention to ‘transactional effectiveness’. Across all categories respondentsmobilisedbothmanagerial identitiesand ‘other’ professional identities (e.g. nurse, doctor, accountant or scientist) for effectiveness. Although mobilisation capacities of ‘other’ identities were fairly explicit,managerialidentity often appeared ‘in disguise’. There was a tendency to refer to experience or tenure within the organisation as a resource to influence others and to cite ability to communicate as their personality trait, yet this implies skilled knowledge of organisational context. Equally, identifying, for example as a ‘people person’, encompasses a raft of management skills such as the ability to translate specific demands placed on their subordinates by the organisation in terms that are clear and meaningful. The research also revealed that the ‘mobilising capacities’ of the ‘facets of identity’ of the various ‘work groups’ were subject to identity constraints arising from others ‘above’, ‘below’ and ‘laterally’, as well as from the wider organisation (such as culture, resources) and their workload. For clinical managers, it was also constricted by juggling clinical and non-clinical work within time constraints.

Conclusions

Many respondents struggled with their identities as managers. Given that a strong identity is associated with uncertainty reduction and employee strengthening, more work is needed to improve how positive identities can be fostered both among managers themselves and amongst those with whom they interact. To fully comprehend the relationship between self-perceived identities and how managers carry out their work it is recommended that future research gives attention not only to variation across but also within primary categories and work groups.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Managing between the agendas: implementing health care reform policy in an acute care hospital

PURPOSE

This paper aims to assess administrative and clinical manager stances on health system reform. Understanding these stances will help to identify cultural differences and competing agendas between these two key health service stakeholders and contribute to developing strategies to improve organisational performance.

DESIGN/METHODOLOGY/APPROACH

A qualitative methodology was used comprising in-depth open-ended interviews conducted in 2007 with 26 administrative and clinical managers who managed clinical units.

FINDINGS

This paper provides empirical insights into the ways that administrative and clinical mangers conceive of their managerial roles in relation to health care reform and performance improvement in health services. The findings suggest that developing a hybrid clinical manager culture as a means to bridge the gap between administrative and clinical manager stances on reform objectives, while possible, is not yet being realised.

RESEARCH LIMITATIONS/IMPLICATIONS

The research has relevance for health services that are experiencing organisational transformation. However, its location in one health service limits the generalisability of findings to other sites. Further research is needed to assess the opportunities for a hybrid culture to emerge as well as its effect.

PRACTICAL IMPLICATIONS

While attention is predominantly directed to clinician groups as a key stakeholder in implementing health reform policies, this paper has implications for how administrative managers also structure their roles and responsibilities to create an organisational climate conducive to change. This will include strategies to support clinical managers to make the transition from a predominantly clinical, to a clinical managerial, orientation.

ORIGINALITY/VALUE

This paper addresses a significant problem in health service governance, namely the divide between the value stances of dual hierarchies. This problem is only now gaining prominence as a significant barrier to health reform.

Exploring a "community of practice" methodology as a regional platform for large-scale collaboration in cancer surgery-the Ottawa approach

Pressing challenges have forced health care providers to rethink traditional silos and professional boundaries. Communities of practice (cops) have been identified as a means to share knowledge across silos and boundaries. However, clarity sufficient to enable their easy and uniform reproducibility is lacking, leading to a gap between cop conceptualization and implementation. This paper explores a cop structure and outlines a framework that is adaptable, measurable, and implementable across health disciplines in a regional cancer surgery program.

Hospital restructuring and physician job satisfaction: an empirical study

The adoption of clinical directorates through the internal reconfiguration of hospital organizations has been one of the most widespread restructuring interventions in many Western European countries. Despite its extensive adoption, a lack of knowledge remains on the analysis of how this reorganization affects professionals' job satisfaction. This paper contributes to the debate on clinical directorates by exploring how the structural characteristics of newly adopted organizational models influence physician's job satisfaction. More than 300 physicians in 18 clinical directorates in the Italian National Health Service were surveyed regarding their overall job satisfaction following the introduction of departmental arrangements. Survey results were then linked to another survey that classified newly adopted models according to the criteria used to merge hospital wards into directorates, by recognizing "Process-integration", "Specialty-integration" and "Mixed-integration" types of directorates. Our findings show that structural aspects of change significantly influenced overall job satisfaction, and that a physician's openness to experience moderated the adoption and implementation of new clinical directorates. Specifically, results demonstrate that physicians with high openness to experience scores were more receptive to the positive impacts of change on overall job satisfaction. Implications for how these findings may facilitate organizational shifts within hospital settings are discussed.

Exploring types of individual unlearning by local health-care managers: an original empirical approach

Background

The ability of health-care managers or organisations to adapt and respond to change is vital if they are to succeed in the contemporary health-care environment. Change involves the learning of new behaviours and giving up, or abandoning, some established ones – more formally defined as unlearning. However, research on unlearning is lacking. This original exploratory study investigates UK NHS health-care managers' engagement with behavioural unlearning and cognitive unlearning, and also considers the related concept of fading. The study also investigates the impact of individual unlearning on participating health-care managers' decision-making.

Research questions

(1) To what extent do health-care managers engage with the process of unlearning and what impact does the engagement with this process have on health-care managers' decision-making? (2) What are the barriers and enablers that influence the engagement of health-care managers with the process of unlearning? (3) To what extent does the health-care setting affect the level of engagement with the process of unlearning by health-care managers?

Methods

The study investigated these questions through an examination of the academic literature. Several management (Business Source Complete, Emerald), psychological (PsycINFO), health (MEDLINE) and education [Education Resources Information Center (ERIC)] electronic databases were searched for English-language articles that were published between January 2000 and March 2012. The literature provided the basis for original exploratory research that investigated local health-care managers' experiences of unlearning. A case study approach was adopted for empirical data collection, using qualitative interviews to investigate experiences of unlearning in two secondary care NHS trusts (an acute trust and a mental health trust). A total of 85 episodes of unlearning were identified from a purposive sample of 29 health-care managers. The sample participants varied in terms of clinical/non-clinical background, type of department/unit and length of time as a manager.

Results

The findings show that the health-care managers who participated in this study engaged with unlearning and fading. The engagement is triggered through either an individual experience or a change event. There was little evidence to indicate that health-care setting or professional background had a strong influence over health-care managers' engagement with unlearning, although this finding is limited by the exploratory nature of the study, sample size and range of settings examined. Participants identified a variety of barriers to individual unlearning including personal behaviour and staff resistance to change. Enablers such as personal skills, attitudes and relationships were more commonly cited than organisational enablers such as policies, procedures and work circumstances. The findings also suggest that unlearning does influence the decision-making of health-care managers, encouraging a more discovery-orientated approach.

Limitations

This study has a number of limitations. It is an exploratory study involving a small number of participants drawn from two NHS trusts, which limits the depth of insight that it can provide regarding specific aspects of unlearning processes. Further, because of the relatively low numbers of participants in our study, the findings provide limited insights regarding theextentto which managers engage with processes of unlearning across different health-care settings and theimpacton their decision-making. Finally, the study is able to provide only a limited interpretation of the nature of fading, although the empirical data do provide evidence that fading should not be conceptualised as a type of individual unlearning.

Conclusions

The study has enhanced the theory of individual unlearning by reconceptualising existing unlearning models and developing a new typology that distinguishes between four separate types of individual unlearning. The findings demonstrate that health-care managers who participated in this study engaged with unlearning processes and that this engagement impacted on their decision-making processes. After engaging with individual unlearning, several managers moved away from idea imposition approaches to decision-making in favour of more discovery-focused approaches, which have been reported in academic literature to be more successful. Future work that investigates a greater number of health-care managers' experiences of unlearning in a wider range of settings is necessary to establish the significance of health-care setting to individual unlearning experiences and provide greater generalisability to the findings of this study.

Funding

The National Institute for Health Services and Delivery Research programme.

Is management essential to improving the performance and sustainability of health care systems and organizations? A systematic review and a roadmap for future studies

Recent studies have highlighted the importance of management in the health care sector. Positive correlations have been found between clinical and economic performance. Although there is still controversy regarding what kind of management and which managers should lead health care organizations and health systems, we now have interesting evidence to analyze. Starting with a systematic review of the literature, this article presents and discusses the streams of knowledge regarding how management can influence the quality and sustainability of health systems and organizations. Through the analysis of 37 studies, we found that the performance of health care systems and organizations seems to be correlated with management practices, leadership, manager characteristics, and cultural attributes that are associated with managerial values and approaches. There is also evidence that health care organizations run by doctors perform better than others. Finally, we provide a roadmap that indicates how the relationship between the management and performance of health systems and organizations can be further and more effectively investigated.

Why risk professional fulfilment: a grounded theory of physician engagement in healthcare development

The need for trans-professional collaboration when developing healthcare has been stressed by practitioners and researchers. Because physicians have considerable impact on this process, their willingness to become involved is central to this issue.

OBJECTIVE

This study aims to gain a deeper understanding of how physicians view their engagement in healthcare development.

METHOD

Using a grounded theory approach, the study developed a conceptual model based on empirical data from qualitative interviews with physicians working at a hospital (n = 25).

RESULTS

A continual striving for experiences of usefulness and progress, conceptualized as 'striving for professional fulfilment' (the core category), emerged as a central motivational drive for physician engagement in healthcare development. Such experiences were gained when achieving meaningful results, having impact, learning to see the greater context and fulfilling the perceived doctor role. Reinforcing organizational preconditions that facilitated physician engagement in healthcare development were workplace continuity, effective strategies and procedures, role clarity regarding participation in development and opportunities to gain knowledge about organization and development. Two opposite role-taking tendencies emerged: upholding a traditional doctor role with high autonomy in relation to organization and management, clinical work serving as the main source of fulfilment, or approaching a more complete 'employeeship' role in which organizational engagement also provides a sense of fulfilment.

CONCLUSION

Experiencing professional fulfilment from participation in healthcare development is crucial for sustainable physician engagement in such activities.

Managing boundaries in primary care service improvement: a developmental approach to communities of practice

BACKGROUND

Effective implementation of change in healthcare organisations involves multiple professional and organisational groups and is often impeded by professional and organisational boundaries that present relatively impermeable barriers to sharing knowledge and spreading work practices. Informed by the theory of communities of practice (CoPs), this study explored the effects of intra-organisational and inter-organisational boundaries on the implementation of service improvement within and across primary healthcare settings and on the development of multiprofessional and multi-organisational CoPs during this process.

METHODS

The study was conducted within the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester-a collaborative partnership between the University of Manchester and local National Health Service organisations aiming to undertake applied health research and enhance its implementation in clinical practice. It deployed a qualitative embedded case study design, encompassing semistructured interviews, direct observation and documentary analysis, conducted in 2010-2011. The sample included practice doctors, nurses, managers and members of the CLAHRC implementation team.

FINDINGS

The study showed that in spite of epistemic and status differences, professional boundaries between general practitioners, practice nurses and practice managers co-located in the same practice over a relatively long period of time could be successfully bridged, leading to the formation of multiprofessional CoPs. While knowledge circulated relatively easily within these CoPs, barriers to knowledge sharing emerged at the boundary separating them from other groups existing in the same primary care setting. The strongest boundaries, however, lay between individual general practices, with inter-organisational knowledge sharing and collaboration between them remaining unequally developed across different areas due to historical factors, competition and strong organisational identification. Manipulated emergence of multi-organisational CoPs in the context of primary care may thus be problematic.

CONCLUSIONS

In cases when manipulated emergence of new CoPs is problematic, boundary issues could be addressed by adopting a developmental perspective on CoPs, which provides an alternative to the analytical and instrumental perspectives previously described in the CoP literature. This perspective implies a pragmatic, situational approach to mapping existing CoPs and their characteristics and potentially modifying them in the process of service improvement through the combination of internal and external facilitation.

The European quality of care pathways (EQCP) study on the impact of care pathways on interprofessional teamwork in an acute hospital setting: study protocol: for a cluster randomised controlled trial and evaluation of implementation processes

Background

Although care pathways are often said to promote teamwork, high-level evidence that supports this statement is lacking. Furthermore, knowledge on conditions and facilitators for successful pathway implementation is scarce. The objective of the European Quality of Care Pathway (EQCP) study is therefore to study the impact of care pathways on interprofessional teamwork and to build up understanding on the implementation process.

Methods/design

An international post-test-only cluster Randomised Controlled Trial (cRCT), combined with process evaluations, will be performed in Belgium, Ireland, Italy, and Portugal. Teams caring for proximal femur fracture (PFF) patients and patients hospitalized with an exacerbation of chronic obstructive pulmonary disease (COPD) will be randomised into an intervention and control group. The intervention group will implement a care pathway for PFF or COPD containing three active components: a formative evaluation of the actual teams’ performance, a set of evidence-based key interventions, and a training in care pathway-development. The control group will provide usual care. A set of team input, process and output indicators will be used as effect measures. The main outcome indicator will be relational coordination. Next to these, process measures during and after pathway development will be used to evaluate the implementation processes. In total, 132 teams have agreed to participate, of which 68 were randomly assigned to the intervention group and 64 to the control group. Based on power analysis, a sample of 475 team members per arm is required. To analyze results, multilevel analysis will be performed.

Discussion

Results from our study will enhance understanding on the active components of care pathways. Through this, preferred implementation strategies can be defined.

Trail registration

NCT01435538

To adopt is to adapt: the process of implementing the ICF with an acute stroke multidisciplinary team in England

Purpose: The success of the International Classifcation of Functioning, Disability and Health (ICF) depends on its uptake in clinical practice. This project aimed to explore ways the ICF could be used with an acute stroke multidisciplinary team and identify key learning from the implementation process. Method: Using an action research approach, iterative cycles of observe, plan, act and evaluate were used within three phases: exploratory; innovatory and refective. Thematic analysis was undertaken, using a model of immersion and crystallisation, on data collected via interview and focus groups, e-mail communications, minutes from relevant meetings, feld notes and a refective diary. Results: Two overall themes were determined from the data analysis which enabled implementation. There is a need to: (1) adopt the ICF in ways that meet local service needs; and (2) adapt the ICF language and format. Conclusions: The empirical fndings demonstrate how to make the ICF classifcation a clinical reality. First, we need to adopt the ICF as a vehicle to implement local service priorities e.g. to structure a multidisciplinary team report, thus enabling ownership of the implementation process. Second, we need to adapt the ICF terminology and format to make it acceptable for use by clinicians.

Implementing performance improvement in New Zealand emergency departments: the six hour time target policy national research project protocol

BACKGROUND

In May 2009, the New Zealand government announced a new policy aimed at improving the quality of Emergency Department care and whole hospital performance. Governments have increasingly looked to time targets as a mechanism for improving hospital performance and from a whole system perspective, using the Emergency Department waiting time as a performance measure has the potential to see improvements in the wider health system. However, the imposition of targets may have significant adverse consequences. There is little empirical work examining how the performance of the wider hospital system is affected by such a target. This project aims to answer the following questions: How has the introduction of the target affected broader hospital performance over time, and what accounts for these changes? Which initiatives and strategies have been successful in moving hospitals towards the target without compromising the quality of other care processes and patient outcomes? Is there a difference in outcomes between different ethnic and age groups? Which initiatives and strategies have the greatest potential to be transferred across organisational contexts?

METHODS/DESIGN

The study design is mixed methods; combining qualitative research into the behaviour and practices of specific case study hospitals with quantitative data on clinical outcomes and process measures of performance over the period 2006-2012. All research activity is guided by a Kaupapa Māori Research methodological approach. A dynamic systems model of acute patient flows was created to frame the study. Consequences of the target (positive and negative) will be explored by integrating analyses and insights gained from the quantitative and qualitative streams of the study.

DISCUSSION

At the time of submission of this protocol, the project has been underway for 12 months. This time was necessary to finalise both the case study sites and the secondary outcomes through key stakeholder consultation. We believe that this is an appropriate juncture to publish the protocol, now that the sites and final outcomes to be measured have been determined.

Leadership collaboration during health reform: an action learning approach with an interagency group of executives in Tasmania

Objective. To use an action learning approach to encourage a group of executive leaders, responsible for the implementation of a state health reform agenda, to consider the leadership required to drive improvement in healthcare services. Methods. Based on an assertion that knowledge is co-produced and that deliberative and structured conversation can be a mechanism to drive change, an action learning approach was used to facilitate an interagency group of executive leaders, responsible for the implementation of a state health reform agenda, who were encouraged to consider the leadership required to drive improvement in healthcare services. Results. It was difficult to assert how the group contributed specifically to the implementation of the health reform agenda but individuals gained insights and there was informal resolution of institutional tensions and differences. The method may provide new knowledge to the reform process over time. Conclusions. Getting the participants together was challenging, which may reflect the reality of time-poor executives, or a low commitment to giving time to structured and deliberative informal dialogue. Further work is required to test this thesis and the action learning approach with other parts of healthcare workforce.

How hospital leaders implemented a safe surgery protocol in Australian hospitals

OBJECTIVE

To analyse the strategies used by hospital leaders to improve compliance with the 'ensuring correct patient, correct site and correct procedure protocol'. While following such a protocol saves lives according to an international study of the World Health Organization safe surgery checklist, promoting compliance in hospitals has proved to be a regulatory challenge.

DESIGN

SETTING AND PARTICIPANTS

Using a qualitative research design and 'responsive regulation' theory, this study explored implementation strategies used by hospital leaders in 20 Australian public hospitals. Semi-structured interviews were conducted with 72 informants to analyse how front-line leaders improved compliance with the safe surgery protocol in their hospitals.

INTERVENTIONS

Implementation analysis of the safe surgery protocol.

MAIN OUTCOME MEASURES

The use of implementation strategies located on a 'responsive regulation' pyramid.

RESULTS

Informants identified many strategies used to improve protocol compliance typically beginning with persuasion. Supportive strategies were located on a regulatory pyramid beginning with softer interventions: persuade, enlist leaders, train, remind, relax protocol requirements, redesign hospital systems and reward compliance. In response to low and slow compliance, many hospital leaders switched to a pyramid of escalating sanctions: direct, delegate, monitor, publicly report, reprimand and penalize.

CONCLUSIONS

A multiplex problem requires graduated and multiplex regulation. Hospital leaders proved to be responsive regulators in applying both multiple supports and sanctions that improved compliance over 3 years. These experiences with protocol implementation illustrate the multifaceted challenge of health sector regulation and offer lessons for embedding future patient safety solutions.