How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England

Core elements of excellent hospital leadership: lessons from the five top-performing hospitals in China

Substantial evidence indicates that leadership plays a critical role in an organization's success. Our study aims to conduct case studies on leadership attributes among China's five top-performing hospitals, examining their common practices. A semi-structured interview was conducted with 8 leaders, 39 managers, 19 doctors, and 16 nurses from the five sample hospitals in China. We collected information from these hospitals on the role of senior leadership, organizational governance, and social responsibility, aligning with the leadership assessment guidelines in the Baldrige Excellence Framework. Qualitative data underwent interpretation through content analysis, thematic analysis, and comparative analysis. This study adhered to the consolidated criteria for reporting qualitative research guidelines for reporting qualitative research. Our study revealed that the leaders of the five top-performing hospitals in China consistently established "Patient Needs First" as the core element of the hospital culture. Striving to build world-renowned hospitals with Chinese characteristics, the interviewees all believed strongly in scientific vigor, professionalism, and cooperative culture. The leaders adhered to a staff-centered approach, placing special emphasis on talent recruitment and development, creating a compensation system, and fostering a supportive environment conducive to enhancing medical knowledge, skills, and professional ethics. In terms of organizational governance, they continuously enhanced the communication between various departments and levels of staff, improved the quality and safety of medical care, and focused on innovative medical and scientific research, thereby establishing evidence-based, standardized hospital management with a feedback loop. Meanwhile, regarding social responsibility, they prioritized improvements in the quality of healthcare by providing international and domestic medical assistance, community outreach, and other programs. To a large extent, the excellent leadership of China's top-performing hospitals can be attributed to their commitment to a "Two-Pillared Hospital Culture," which prioritizes putting patient needs first and adopting a staff-centered approach. Furthermore, the leaders of these hospitals emphasize hospital performance, operations management, and social responsibility.

The characteristics of leadership and their effectiveness in quality management in healthcare - A systematic literature review and a content analysis

Effective quality leadership is identified as a critical factor for organisational success. Leadership style has an important role in the implementation of quality management. This systematic review describes the characteristics of leadership in quality management in healthcare, and analyses their association with successful or unsuccessful quality management by using content analysis. Papers published in peer-reviewed journals between 2011 and June 2023 were selected by exploring the Abi/Inform, Business Source Complete, Cinahl, Pubmed and Web of Science electronic databases. Altogether 3014 records were found. PRISMA-protocol was used for selection of studies. 12 original and three review articles were included. Six leadership characteristics were identified that were linked to successful or unsuccessful implementation of quality management. The six categories were strategic, knowledge-oriented, value-based, supportive, participatory and communicative leadership. Supercategories and subcategories of successful and unsuccessful implementation are described. The results can be used to identify the leadership characteristics that promote successful quality management in healthcare organisations. In education for leaders and managers, attention should be in the characteristics and style of leadership and their impact on the effectiveness of quality management.

Using Healthcare Failure Mode and Effect Analysis in prospective medication safety risk management in secondary care inpatient wards

OBJECTIVES

The evaluation and improvement of medication management processes is an essential part of preventive medication risk management strategies in hospitals. The aim of the present study was to identify and analyse risks of a new electronic medication management process and to suggest improvements to manage the identified risks in a secondary care hospital.

METHODS

The electronic medication management process of four wards at the Lapland Central Hospital, Finland was evaluated by Healthcare Failure Mode and Effect Analysis (HFMEA). The multidisciplinary HFMEA team consisted of five experts who identified the failure modes and rated their hazard scores (scale of 1-16). In addition, the patient safety incident reports of the hospital were used for identification of failure modes. Safety recommendations were identified, prioritised and implemented with a follow-up evaluation.

RESULTS

The team identified five phases in the electronic medication management process. Altogether, 35 potential failure modes were found, with eight being classified as the most severe (hazard score >8). The given recommendations (n=15) concerned improvements to the electronic medical record (EMR) (n=8) and to the work processes of the wards (n=7). Only two of the recommendations were fully implemented, and five were under development or partly implemented after a 15-month follow-up period.

CONCLUSIONS

For identifying risks associated with electronic medication management and for compiling related safety recommendations, triangulation of different risk identification methodologies is recommended. When implementing electronic medication management, appropriate patient identification in medication administration should be ensured together with EMR development. Systematic efforts should be made for the effective implementation of the safety recommendations. Further research is warranted to explore barriers to implementing safety improvements, especially in small healthcare units in rural areas.

Board talk: How members of executive hospital boards influence the positioning of nursing in crisis through talk

Talk by members of executive hospital boards influences the organizational positioning of nurses. Talk is a relational leadership practice. Using a qualitative-interpretive design we organized focus group meetings wherein members of executive hospital boards (7), nurses (14), physicians (7), and managers (6), from 15 Dutch hospitals, discussed the organizational positioning of nursing during COVID crisis. We found that members of executive hospital boards consider the positioning of nursing in crisis a task of nurses themselves and not as a collective, interdependent, and/or specific board responsibility. Furthermore, members of executive hospital boards talk about the nursing profession as (1) more practical than strategic, (2) ambiguous in positioning, and (3) distinctive from the medical profession. Such talk seemingly contrasts with the notion of interdependence that highlights how actors depend on each other in interaction. Interdependence is central to collaboration in hospital crises. In this paper, therefore, we depart from the members of executive hospital boards as leader and "positioner," and focus on talk-as a discursive leadership practice-to illuminate leadership and governance in hospitals in crisis, as social, interdependent processes.

Hospital governance accountability structure: a scoping review

INTRODUCTION

Hospitals, as complex organizations with clinical, financial, and social functions, face different barriers to providing high-quality and safe services at reasonable costs. Various initiatives have been carried out in hospital governance to improve quality, safety, and accountability. This research aims to identify the structures and dimensions that make hospital governance accountable.

METHODS

The research used Arksey and O'Malley's scoping review framework to examine the research literature on hospital governance structure and accountability. The literature review included PubMed, Web of Science, Embase, Scopus ProQuest, Google search engine, and Google Scholar databases from 2010 to 2023. Data were analyzed using the content analysis method.

RESULTS

Excluding unrelated and duplicate sources, 40 articles and reports were included in the study. The studies were reviewed and analyzed based on organizational type, type of source, year of publication, objectives, and key findings. Accountable governance features were extracted from the selected articles and reports. The four main themes include inclusive governance, commitment to accountability, planning for accountability, and autonomous governance. Thirteen subthemes were extracted from the study literature.

CONCLUSION

Various initiatives have been implemented regarding the reform of the governance structure of public hospitals in different countries. Many of these reforms aim to improve financial and clinical accountability. The study results could be used to identify the structures and dimensions that make hospital governance accountable.

Organizational attributes that contribute to the learning & improvement capabilities of healthcare organizations: a scoping review

BACKGROUND

This study aims to explore and identify the organizational attributes that contribute to learning and improvement capabilities (L&IC) in healthcare organizations. The authors define learning as a structured update of system properties based on new information, and improvement as a closer correspondence between actual and desired standards. They highlight the importance of learning and improvement capabilities in maintaining high-quality care, and emphasize the need for empirical research on organizational attributes that contribute to these capabilities. The study has implications for healthcare organizations, professionals, and regulators in understanding how to assess and enhance learning and improvement capabilities.

METHODS

A systematic search of peer-reviewed articles published between January 2010 and April 2020 was carried out in the PubMed, Embase, CINAHL, and APA PsycINFO databases. Two reviewers independently screened the titles and abstracts and conducted a full-text review of potentially relevant articles, eventually adding five more studies identified through reference scanning. Finally, a total of 32 articles were included in this review. We extracted the data about organizational attributes that contribute to learning and improvement, categorized them and grouped the findings step-by-step into higher, more general-level categories using an interpretive approach until categories emerged that were sufficiently different from each other while also being internally consistent. This synthesis has been discussed by the authors.

RESULTS

We identified five attributes that contribute to the L&IC of healthcare organizations: perceived leadership commitment, open culture, room for team development, initiating and monitoring change, and strategic client focus, each consisting of multiple facilitating aspects. We also found some hindering aspects.

CONCLUSIONS

We have identified five attributes that contribute to L&IC, mainly related to organizational software elements. Only a few are identified as organizational hardware elements. The use of qualitative methods seems most appropriate to understand or assess these organizational attributes. We feel it is also important for healthcare organisations to look more closely at how clients can be involved in L&IC.

TRIAL REGISTRATION

Not applicable.

Evaluating quality improvement at scale: A pilot study on routine reporting for executive board governance in a UK National Health Service organisation

BACKGROUND

Quality improvement (QI) in healthcare is a cultural transformation process. We explored how routine reporting could be developed to aid visibility of the process for QI governance.

METHOD

A retrospective evaluation of QI projects in a large healthcare organisation was conducted. We used an online survey so that the data accrual process resembled routine reporting to help identify implementation challenges. A purposive sample of QI projects was targeted to maximise contrast between projects that were or were not successful as determined by the resident QI team. To hone strategic focus in what should be reported, we also compared factors that might affect project outcomes.

RESULTS

Out of 52 QI projects, 10 led to a change in routine practice ('adoption'). Details of project outcomes were limited. Project team outcomes, indicative of capacity building, were not systematically documented. Service user involvement, quality of measurement plan, fidelity of plan-do-study-act (PDSA) cycles had a major impact on adoption.

CONCLUSION

Designing a routine reporting framework requires an iterative process to navigate data accrual demands. A retrospective evaluation, as in this study, can yield empirical insights to support development of QI governance, thereby honing the implementation science of QI in a healthcare organisation.

Consumers' and health providers' views and perceptions of partnering to improve health services design, delivery and evaluation: a co-produced qualitative evidence synthesis

BACKGROUND

Partnering with consumers in the planning, delivery and evaluation of health services is an essential component of person-centred care. There are many ways to partner with consumers to improve health services, including formal group partnerships (such as committees, boards or steering groups). However, consumers' and health providers' views and experiences of formal group partnerships remain unclear. In this qualitative evidence synthesis (QES), we focus specifically on formal group partnerships where health providers and consumers share decision-making about planning, delivering and/or evaluating health services. Formal group partnerships were selected because they are widely used throughout the world to improve person-centred care. For the purposes of this QES, the term 'consumer' refers to a person who is a patient, carer or community member who brings their perspective to health service partnerships. 'Health provider' refers to a person with a health policy, management, administrative or clinical role who participates in formal partnerships in an advisory or representative capacity. This QES was co-produced with a Stakeholder Panel of consumers and health providers. The QES was undertaken concurrently with a Cochrane intervention review entitled Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation.

OBJECTIVES

1. To synthesise the views and experiences of consumers and health providers of formal partnership approaches that aimed to improve planning, delivery or evaluation of health services. 2. To identify best practice principles for formal partnership approaches in health services by understanding consumers' and health providers' views and experiences.

SEARCH METHODS

We searched MEDLINE, Embase, PsycINFO and CINAHL for studies published between January 2000 and October 2018. We also searched grey literature sources including websites of relevant research and policy organisations involved in promoting person-centred care.

SELECTION CRITERIA

We included qualitative studies that explored consumers' and health providers' perceptions and experiences of partnering in formal group formats to improve the planning, delivery or evaluation of health services.

DATA COLLECTION AND ANALYSIS

Following completion of abstract and full-text screening, we used purposive sampling to select a sample of eligible studies that covered a range of pre-defined criteria, including rich data, range of countries and country income level, settings, participants, and types of partnership activities. A Framework Synthesis approach was used to synthesise the findings of the sample. We appraised the quality of each study using the CASP (Critical Appraisal Skill Program) tool. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. The Stakeholder Panel was involved in each stage of the review from development of the protocol to development of the best practice principles.

MAIN RESULTS

We found 182 studies that were eligible for inclusion. From this group, we selected 33 studies to include in the final synthesis. These studies came from a wide range of countries including 28 from high-income countries and five from low- or middle-income countries (LMICs). Each of the studies included the experiences and views of consumers and/or health providers of partnering in formal group formats. The results were divided into the following categories. Contextual factors influencing partnerships: government policy, policy implementation processes and funding, as well as the organisational context of the health service, could facilitate or impede partnering (moderate level of confidence). Consumer recruitment: consumer recruitment occurred in different ways and consumers managed the recruitment process in a minority of studies only (high level of confidence). Recruiting a range of consumers who were reflective of the clinic's demographic population was considered desirable, particularly by health providers (high level of confidence). Some health providers perceived that individual consumers' experiences were not generalisable to the broader population whereas consumers perceived it could be problematic to aim to represent a broad range of community views (high level of confidence). Partnership dynamics and processes: positive interpersonal dynamics between health providers and consumers facilitated partnerships (high level of confidence). However, formal meeting formats and lack of clarity about the consumer role could constrain consumers' involvement (high level of confidence). Health providers' professional status, technical knowledge and use of jargon were intimidating for some consumers (high level of confidence) and consumers could feel their experiential knowledge was not valued (moderate level of confidence). Consumers could also become frustrated when health providers dominated the meeting agenda (moderate level of confidence) and when they experienced token involvement, such as a lack of decision-making power (high level of confidence) Perceived impacts on partnership participants: partnering could affect health provider and consumer participants in both positive and negative ways (high level of confidence). Perceived impacts on health service planning, delivery and evaluation: partnering was perceived to improve the person-centredness of health service culture (high level of confidence), improve the built environment of the health service (high level of confidence), improve health service design and delivery e.g. facilitate 'out of hours' services or treatment closer to home (high level of confidence), enhance community ownership of health services, particularly in LMICs (moderate level of confidence), and improve consumer involvement in strategic decision-making, under certain conditions (moderate level of confidence). There was limited evidence suggesting partnering may improve health service evaluation (very low level of confidence). Best practice principles for formal partnering to promote person-centred care were developed from these findings. The principles were developed collaboratively with the Stakeholder Panel and included leadership and health service culture; diversity; equity; mutual respect; shared vision and regular communication; shared agendas and decision-making; influence and sustainability.

AUTHORS' CONCLUSIONS

Successful formal group partnerships with consumers require health providers to continually reflect and address power imbalances that may constrain consumers' participation. Such imbalances may be particularly acute in recruitment procedures, meeting structure and content and decision-making processes. Formal group partnerships were perceived to improve the physical environment of health services, the person-centredness of health service culture and health service design and delivery. Implementing the best practice principles may help to address power imbalances, strengthen formal partnering, improve the experiences of consumers and health providers and positively affect partnership outcomes.

National statutory reporting: not even ticking the boxes? The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020

INTRODUCTION

Regulation through statutory reporting is used in healthcare internationally to improve accountability, quality of care and patient safety. Since 2017, within the National Health Service (NHS) in England, NHS Secondary Care Trusts (NSCTs) are legally required to report annually both quantitative and qualitative information related to patient deaths within their care within their publicly available Quality Accounts as part of a countrywide patient safety programme: The Learning from Deaths (LfDs) programme.

METHOD

All LfDs reports published between 2017 (programme inception) and 2020 were reviewed and evaluated through a critical realist lens, quantitatively reported using descriptive statistics and qualitatively using reflexive thematic analysis.

RESULTS

In 2017/2018, 44% of NSCTs reported all six statutory elements of the LfDs reporting regulations, in 2019/2020 35% of NSCTs were reporting this information. A small number of NSCTs did not report any parts of the LfDs regulatory requirements between 2017 and 2020. Multiple qualitative themes arose from this study suggesting problematic engagement with the LfDs programme, erroneous reporting accuracy and errors in written communication.

CONCLUSIONS

The LfDs programme has, to some extent, reduced variation and improved consistency to the way that NSCTs identify, report and investigate deaths. However, 3 years into the LfDs programme, the majority of NSCTs are not reporting as required by law. This makes the validity of National statutory reporting in Quality Accounts within the NHS in England questionable as a regulatory process.

The Special Measures for Quality and Challenged Provider Regimes in the English NHS: A Rapid Evaluation of a National Improvement Initiative for Failing Healthcare Organisations

BACKGROUND

There is limited knowledge about interventions used for the improvement of low-performing healthcare organisations and their unintended consequences. Our evaluation sought to understand how healthcare organisations in the National Health Service (NHS) in England responded to a national improvement initiative (the Special Measures for Quality [SMQ] and challenged provider [CP] regimes) and its perceived impact on achieving quality improvements (QIs).

METHODS

Our evaluation included national-level interviews with key stakeholders involved in the delivery of SMQ (n=6); documentary analysis (n=20); and a qualitative study based on interviews (n=60), observations (n=8) and documentary analysis (n=291) in eight NHS case study sites. The analysis was informed by literature on failure, turnaround and QI in organisations in the public sector.

RESULTS

At the policy level, SMQ/CP regimes were intended to be "support" programmes, but perceptions of the interventions at hospital level were mixed. The SMQ/CP regimes tended to consider failure at an organisational level and turnaround was visualised as a linear process. There was a negative emotional impact reported by staff, especially in the short-term. Key drivers of change included: engaged senior leadership teams, strong clinical input and supportive external partnerships within local health systems. Trusts focused efforts to improve across multiple domains with particular investment in improving overall staff engagement, developing an open, listening organisational culture and better governance to ensure clinical safety and reporting.

CONCLUSION

Organisational improvement in healthcare requires substantial time to embed and requires investment in staff to drive change and cultivate QI capabilities at different tiers. The time this takes may be underestimated by external 'turn-around' interventions and performance regimes designed to improve quality in the short-term and which come at an emotional cost for staff. Shifting an improvement focus to the health system or regional level may promote sustainable improvement across multiple organisations over the long-term.

Knowing, relating and the absence of conflict: relational leadership processes between hospital boards and chairs of nurse councils

Purpose

This study aims to enhance understanding of the collaboration between chairs of nurse councils (CNCs) and members of executive hospital boards (BM) from a relational leadership perspective.

Design/methodology/approach

The authors used a qualitative and interpretive methodology. The authors study the daily interactions of BM and CNCs of seven Dutch hospitals through a relational leadership lens. The authors used a combination of observations, interviews and document analysis. The author’s qualitative analysis was used to grasp the process of collaborating between BM and CNCs.

Findings

Knowing each other, relating with and relating to are distinct but intertwined processes that influence the collaboration between BM and CNC. The absence of conflict is also regarded as a finding in this paper. Combined together, they show the importance of a relational process perspective to understand the complexity of collaboration in hospitals.

Originality/value

Collaboration between professional groups in hospitals is becoming more important due to increasing interdependence. This is a consequence of the complexity in organizing qualitative care. Nevertheless, research on the process of collaborating between nurse councils (NCs) and executive hospital boards is scarce. Furthermore, the understanding of the workings of boards, in general, is limited. The relational process perspective and the combination of observations, interviewing and document analysis proved valuable in this study and is underrepresented in leadership research. This process perspective is a valuable addition to skills- and competencies-focused leadership literature.

The Implementation of Improvement Interventions for "Low Performing" and "High Performing" Organisations in Health, Education and Local Government: A Phased Literature Review

BACKGROUND

There is limited understanding about whether and how improvement interventions are effective in supporting failing healthcare organisations and improving the quality of care in high-performing organisations. The aim of this review was to examine the underlying concepts guiding the design of interventions aimed at low and high performing healthcare organisations, processes of implementation, unintended consequences, and their impact on costs and quality of care. The review includes articles in the healthcare sector and other sectors such as education and local government.

METHODS

We carried out a phased rapid systematic review of the literature. Phase one was used to develop a theoretical framework of organisational failure and turnaround, and the types of interventions implemented to improve quality. The framework was used to inform phase 2, which was targeted and focused on organisational failure and turnaround in healthcare, education and local government settings. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to guide the reporting of the methods and findings and the Mixed Methods Appraisal Tool (MMAT) as a quality assessment tool. The review protocol was registered with PROSPERO (CRD: 42019131024).

RESULTS

Failure is frequently defined as the inability of organisations to meet pre-established performance standards and turnaround as a linear process. Improvement interventions are designed accordingly and are focused on the organisation, with limited system-level thinking. Successful interventions included restructuring senior leadership teams, inspections, and organisational restructuring by external organisations. Limited attention was paid to the potential negative consequences of the interventions and their costs.

CONCLUSION

Dominant definitions of success/failure and turnaround have led to the reduced scope of improvement interventions, the linear perception of turnaround, and lack of consideration of organisations within the wider system in which they operate. Future areas of research include an analysis of the costs of delivering these interventions in relation to their impact on quality of care.

Implementing a novel programme for nurses and allied health professionals to develop capacity for evidence-informed clinical practice

Background

Nurses and allied health professionals (AHPs) require skills and support to access, appraise, interpret and use research evidence in clinical practice. We describe the process of designing and implementing the Evidence in Practice (EiP) programme at a UK hospital.

Methods

Key stakeholders were engaged to identify learning needs and priorities in appraising and implementing research evidence. To address these, we designed a multi-strategy bespoke programme of activities.

Results

The programme comprised the development of (a) a visual summary of a research paper, (b) five skills development masterclasses and (c) a six-month mentoring scheme to develop and implement plans for translating evidence into practice.

Discussion

The programme overcame many of the traditional barriers (lack of access, skills and time) to increase engagement of nurses and AHP staff in accessing, reviewing and using evidence in clinical practice.

Conclusion

With clinical leadership support, it is feasible to use a multi-strategy approach to promote and enable nurses and AHPs to use evidence in clinical practice.

Perceived Burden Due to Registrations for Quality Monitoring and Improvement in Hospitals: A Mixed Methods Study

BACKGROUND

Quality indicators are registered to monitor and improve the quality of care. However, the number and effectiveness of quality indicators is under debate, and may influence the joy in work of physicians and nurses. Empirical data on the nature and consequences of the registration burden are lacking. The aim of this study was to identify and explore healthcare professionals' perceived burden due to quality registrations in hospitals, and the effect of this burden on their joy in work.

METHODS

A mixed methods observational study, including participative observations, a survey and semi-structured interviews in two academic hospitals and one teaching hospital in the Netherlands. Study participants were 371 healthcare professionals from an intensive care unit (ICU), a haematology department and others involved in the care of elderly patients and patients with prostate or gastrointestinal cancer.

RESULTS

On average, healthcare professionals spend 52.3 minutes per working day on quality registrations. The average number of quality measures per department is 91, with 1380 underlying variables. Overall, 57% are primarily registered for accountability purposes, 19% for institutional governance and 25% for quality improvement objectives. Only 36% were perceived as useful for improving quality in everyday practice. Eight types of registration burden were identified, such as an excessive number of quality registrations, and the lack of usefulness for improving quality and inefficiencies in the registration process. The time healthcare professionals spent on quality registrations was not correlated with any measure of joy in work. Perceived unreasonable registrations were negatively associated with healthcare professionals' joy in work (intrinsic motivation and autonomy). Healthcare professionals experienced quality registrations as diverting time from patient care and from actually improving quality.

CONCLUSION

Registering fewer quality indicators, but more of what really matters to healthcare professionals, is key to increasing the effectiveness of registrations for quality improvement and governance. Also the efficiency of quality registrations should be increased through staffing and information and communications technology solutions to reduce the registration burden experienced by nurses and physicians.

What Does a Systems Approach to Quality Improvement Look Like in Practice?

Universally improving healthcare systems is difficult to achieve in practice with organisations implementing a range of quality improvement (QI) approaches, in varying and changing contexts, and efforts ranging from project-based improvements to whole system change. This study aimed to identify how organisations overcome the challenges to improving the quality of the services they deliver. Drawing on the eight challenges from the ‘Quality and Safety in Europe by Research (QUASER) hospital guide, we assessed eight cases reported by the UK-based regulator Care Quality Commission as improving their performance. A thematic analysis of these secondary data established that all eight challenges had been addressed or considered in varying degrees. Education and physical and technological challenges seemed less prominent than developments made to address other challenges such as developing leadership, structure, and culture to support improving quality. This paper relies on the analysis of secondary case data and one framework to assess improvement efforts. Further research is required to consider other models and frameworks and to collate longitudinal data to capture the dynamics and increasing the maturity of improving healthcare systems in practice.

Board level “Picture-Understanding-Action”: a new way of looking at quality

Purpose

The purpose of this study is to present a quality improvement approach titled “Picture-Understanding-Action” used in Ireland to enhance the role of healthcare boards in the oversight of healthcare quality and its improvement.

Design/methodology/approach

The novel and practical “Picture-Understanding-Action” approach was implemented using the Model for Improvement to iteratively introduce changes across three quality improvement projects. This approach outlines the concepts and activities used at each step to support planning and implementation of processes that allow a board to effectively achieve its role in overseeing and improving quality. This approach matured over three quality improvement projects.

Findings

The “Picture” included quantitative and qualitative aspects. The quantitative “Picture” consisted of a quality dashboard/profile of board selected outcome indicators representative of the health system using statistical process control (SPC) charts to focus discussion on real signals of change. The qualitative picture was based on the experience of people who use and work in health services which “people-ised” the numbers. Probing this “Picture” with collective grounding, curiosity and expert training/facilitation developed a shared “Understanding”. This led to “Action(s)” from board members to improve the “Picture” and “Understanding” (feedback action), to ask better questions and make better decisions and recommendations to the executive (feed-forward action). The Model for Improvement, Plan-Do-Study-Act cycles and a co-design approach in design and implementation were key to success.

Originality/value

To the authors’ knowledge, this is the first time a board has undertaken a quality improvement (QI) project to enhance its own processes. It addresses a gap in research by outlining actions that boards can take to improve their oversight of quality of care.

Ethnographic research as an evolving method for supporting healthcare improvement skills: a scoping review

BACKGROUND

The relationship between ethnography and healthcare improvement has been the subject of methodological concern. We conducted a scoping review of ethnographic literature on healthcare improvement topics, with two aims: (1) to describe current ethnographic methods and practices in healthcare improvement research and (2) to consider how these may affect habit and skill formation in the service of healthcare improvement.

METHODS

We used a scoping review methodology drawing on Arksey and O'Malley's methods and more recent guidance. We systematically searched electronic databases including Medline, PsychINFO, EMBASE and CINAHL for papers published between April 2013 - April 2018, with an update in September 2019. Information about study aims, methodology and recommendations for improvement were extracted. We used a theoretical framework outlining the habits and skills required for healthcare improvement to consider how ethnographic research may foster improvement skills.

RESULTS

We included 283 studies covering a wide range of healthcare topics and methods. Ethnography was commonly used for healthcare improvement research about vulnerable populations, e.g. elderly, psychiatry. Focussed ethnography was a prominent method, using a rapid feedback loop into improvement through focus and insider status. Ethnographic approaches such as the use of theory and focus on every day practices can foster improvement skills and habits such as creativity, learning and systems thinking.

CONCLUSIONS

We have identified that a variety of ethnographic approaches can be relevant to improvement. The skills and habits we identified may help ethnographers reflect on their approaches in planning healthcare improvement studies and guide peer-review in this field. An important area of future research will be to understand how ethnographic findings are received by decision-makers.

Countries' experiences in reforming hospital administration structure based on the Parker and Harding model: A systematic review study

In recent years, many reforms have been made on the structure of hospital administration, most of which are proposed by Parker-Harding models. Therefore, the purpose of this study is to systematically review global relevant experiences in reforming the hospital governance structure with emphasis on the Parker-Harding model. Required information was collected using keywords autonomization, corporatization, privatization, decentralization, reform, hospital autonomy, governance model, and structural reform in databases such as EMBASE, PubMed, Scopus, SID, MagIran, and other resources. Information on the subjects under study was collected from 1990 to 2020. The content extraction method was used for data extraction and data analysis. Thirty-nine sources were included in the study. Results of searching for relevant evidence on a variety of hospital governance models (government, board, corporate, and private) based on the Parker-Harding model in four categories including strengths (31), weaknesses (30), outcomes (26), and interventions (21) are outlined. In this study, strengths, weaknesses, outcomes, and corrective interventions were presented for different models of hospital administration that could be used by healthcare policymakers. Also, According to the results of this study, governmental model less recommended.

Analysis of the Structure of Public Hospitals Administration in Iran: A Qualitative Study

Background: Public hospitals account for approximately 80% of the health system resources while producing only 20% of the public sector's output. Objectives: This study aimed to analyze the current administration structure (strengths, weaknesses, solutions, and proposed models) of Iranian public hospitals. Methods: This study is qualitative research with a phenomenological approach. The required data were collected using semi-structured interviews with 58 national experts in the field of hospital management who were selected based on the purposive sampling method. Data were analyzed using the conventional content analysis method. Results: Nine main themes and 34 sub-themes were identified in the weaknesses. The strengths contained four main themes and 16 sub-themes. The proposed solutions had five main themes and 22 sub-themes, and the proposed models from the experts' points of view were composed of four main themes and six sub-themes. The important weaknesses were low commitment and motivation, poor financial management and budgeting, and centralized decision-making and management. The strengths included strong infrastructure, extensive service delivery, government support, and positive social functions. The most important proposed solutions were complying with the requirements of structural reform, development of related assessment indicators, public-private partnership, payment system reform, delegation, manpower management, hospital organizational structure, and reform of the tariff system. Finally, the model of the Board of Trustees, while maintaining government ownership but observing the legal requirements of this structure, was the main suggestion of experts on reforming the structure of the administration of public hospitals in Iran. Conclusions: According to the expert’s opinions, the current structure of Iranian public hospitals has many problems. Managers and policymakers can make the necessary corrections based on the solutions and models proposed in this study.

Health boards' governance of quality and risk: quality improvement agenda for the board

Purpose

This study explores key governance, leadership and management activities that have impact on quality, risk and safety within Australian healthcare organisations.

Design/methodology/approach

Current non-executive directors (n = 12) of public and private health boards were interviewed about contemporary approaches to fiduciary and corporate responsibilities for quality assurance and improvement outcomes in the context of risk and safety management for patient care. Verbatim transcripts were subjected to thematic analysis triangulated with Leximancer-based text mining.

Findings

Boards operate in a strong legislative, healthcare standards and normative environment of quality and risk management. Support and influence that create a positive quality and risk management culture within the organisation, actions that disseminate quality and risk broadly and at depth for all levels, and implementation and sustained development of quality and risk systems that report on and contain risk were critical tasks for boards and their directors.

Practical implications

Findings from this study may provide health directors with key quality and risk management agenda points to expand or deepen the impact of governance around health facilities' quality and risk management.

Originality/value

This study has identified key governance activities and responsibilities where boards demonstrate that they add value in terms of potential improvement to hospital and health service quality care outcomes. The demonstrable influence identified makes an important contribution to our understanding of healthcare governance.

Impact of the Norwegian National Patient Safety Program on implementation of the WHO Surgical Safety Checklist and on perioperative safety culture

Objectives

Our primary objective was to study the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. Secondary objective was associations between SSC fidelity and safety culture. We hypothesised that the programme influenced on SSC use and operating theatre personnel’s safety culture perceptions.

Setting

A longitudinal cross-sectional study was conducted in a large Norwegian tertiary teaching hospital.

Participants

We invited 1754 operating theatre personnel to participate in the study, of which 920 responded to the surveys at three time points in 2009, 2010 and 2017.

Primary and secondary outcome measures

Primary outcome was the results of the patient safety culture measured by the culturally adapted Norwegian version of the Hospital Survey on Patient Safety Culture. Our previously published results from 2009/2010 were compared with new data collected in 2017. Secondary outcome was correlation between SSC fidelity and safety culture. Fidelity was electronically recorded.

Results

Survey response rates were 61% (349/575), 51% (292/569) and 46% (279/610) in 2009, 2010 and 2017, respectively. Eight of the 12 safety culture dimensions significantly improved over time with the largest increase being ‘Hospital managers’ support to patient safety’ from a mean score of 2.82 at baseline in 2009 to 3.15 in 2017 (mean change: 0.33, 95% CI 0.21 to 0.44). Fidelity in use of the SSC averaged 88% (26 741/30 426) in 2017. Perceptions of safety culture dimensions in 2009 and in 2017 correlated significantly though weakly with fidelity (r=0.07–0.21).

Conclusion

The National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture.

Implementation of a Quality Improvement Roadmap in the Department of Internal Medicine of an Academic Medical Centre in Singapore

Background: Clarity in directions and constant engagement efforts are crucial to implementing high-quality interventions in Quality Improvement (QI) initiatives. It underpins the success to achieve impactful improvement, effectiveness of interventions through clinical leadership and project sustainability. Our objective was to implement a QI roadmap to improve QI participation of specialists and to clearly align projects and stakeholders to achieve departmental priorities and goals.

Methods: Baseline measurement of Department of Internal Medicine (DIM) specialists involved in QI projects was performed. Root cause analysis and prioritization was conducted to determine the interventions. Series of interventions to address challenges faced by stakeholders to ensure congruency of directions that included collective learning sessions, planning of communication, and documenting progress with checkpoint meetings were carried out. A survey was conducted before and after interventions.

Results: QI projects' participation rates of DIM specialists increased to 82.6% from 26.3% with an increase in uptake in leadership roles from three to nine specialists within the 12 months. The perception survey showed a positive shift in attitudes with greater ease in applying QI tools and concepts, with an increase of 25.7% in 2020 as compared to 2018. With the ease of completing QI projects, DIM specialists became more confident after intervention at 63.2% compared to 42.1% before and also regarded the department to be much stronger in QI culture with an improvement of 51.2%. DIM QI strategic themes model was borne from developing the core focus areas of the departments in order to align existing and prospective QI projects to the established themes.

Conclusion: Department-specific goals and priorities with dedicated interventions are important in driving the interest and ownership to initiate QI projects that align to solve operational problems. The ease in creating the strategic themes model targeting key performance indicators and matching QI projects to the relevant themes, lowers activation barrier and promotes spread due to its simplicity to create and use for communication.

The role of professional elites in healthcare governance: Exploring the work of the medical director

Medical leaders occupy a prominent position in healthcare policy in many countries, both in terms of the governance of quality and safety within healthcare organisations, and in broader system-wide governance. There is evidence that having doctors on hospital boards is associated with higher quality services. What is not known is how they have this effect. Analysing data collected from observations, interviews and documents from 15 healthcare providers in England (2014–2019), we elaborate the role of medical directors in healthcare governance as ‘translation work’, ‘diplomatic work’, and ‘repair work’. Our study highlights the often enduring emotional effects of repeated structural changes to clinical services. It also contributes to theories of professional restratification, showing the work of medical directors as regional ‘political elites’, and as ‘corporate elites’ in publicly-funded healthcare systems.

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Medical Directors affect quality through translation, diplomatic, and repair work.

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Medical Directors are regional ‘political elites’ on the frontstage and backstage.

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Some Medical Directors are ‘corporate elites’ aligned with organisational interests.

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Service change has enduring emotional effects that can negatively affect quality.

Institutional use of National Clinical Audits by healthcare providers

RATIONALE, AIMS, AND OBJECTIVES

Healthcare systems worldwide devote significant resources towards collecting data to support care quality assurance and improvement. In the United Kingdom, National Clinical Audits are intended to contribute to these objectives by providing public reports of data on healthcare treatment and outcomes, but their potential for quality improvement in particular is not realized fully among healthcare providers. Here, we aim to explore this outcome from the perspective of hospital boards and their quality committees: an under-studied area, given the emphasis in previous research on the audits' use by clinical teams.

METHODS

We carried out semi-structured, qualitative interviews with 54 staff in different clinical and management settings in five English National Health Service hospitals about their use of NCA data, and the circumstances that supported or constrained such use. We used Framework Analysis to identify themes within their responses.

RESULTS

We found that members and officers of hospitals' governing bodies perceived an imbalance between the benefits to their institutions from National Clinical Audits and the substantial resources consumed by participating in them. This led some to question the audits' legitimacy, which could limit scope for improvements based on audit data, proposed by clinical teams.

CONCLUSIONS

Measures to enhance the audits' perceived legitimacy could help address these limitations. These include audit suppliers moving from an emphasis on cumulative, retrospective reports to real-time reporting, clearly presenting the "headline" outcomes important to institutional bodies and staff. Measures may also include further negotiation between hospitals, suppliers and their commissioners about the nature and volume of data the latter are expected to collect; wider use by hospitals of routine clinical data to populate audit data fields; and further development of interactive digital technologies to help staff explore and report audit data in meaningful ways.

Communication and leadership in healthcare quality governance

PURPOSE

The importance of hospital board engagement in the work of governing healthcare quality has been demonstrated in the literature. Research into influences on effective corporate governance has traditionally focused on board architecture. Emerging research is bringing to light the importance of governance dynamics. This paper contributes to emerging research through highlighting how communication and leadership underpin effective engagement in governing healthcare quality.

DESIGN/METHODOLOGY/APPROACH

A comparative case study of eight Australian public hospitals was undertaken involving document review, interviews and observations. Case studies were allocated into high- or low-engagement categories based on evidence of governance processes being undertaken, in order to compare and contrast influencing factors. Thematic analysis was undertaken to explore how communication and leadership influence healthcare governance.

FINDINGS

Several key components of communication and leadership are shown to influence healthcare quality governance. Clear logical narratives in reporting, open communication, effective questioning and challenge from board members are important elements of communication found to influence engagement. Leadership that has a focus on healthcare excellence and quality improvement are aligned and promote effective meeting processes is also found to foster governance engagement. Effective engagement in these communication and leadership processes facilitate valuable reflexivity at the governance level.

PRACTICAL IMPLICATIONS

The findings highlight the way in which boards and senior managers can strengthen governance effectiveness through attention to key aspects of communication and leadership.

ORIGINALITY/VALUE

The case study approach allows the exploration of communication and leadership in greater depth than previously undertaken at the corporate governance level in the healthcare setting.

Mapping clinical governance to practitioner roles and responsibilities

Purpose

While clinical governance is assumed to be part of organisational structures and policies, implementation of clinical governance in practice (the praxis) can be markedly different. This paper draws on insights from hospital clinicians, managers and governors on how they interpret the term “clinical governance”. The influence of best-practice and roles and responsibilities on their interpretations is considered.

Design/methodology/approach

The research is based on 40 in-depth, semi-structured interviews with hospital clinicians, managers and governors from two large academic hospitals in Ireland. The analytical lens for the research is practice theory. Interview transcripts are analysed for practitioners' spoken keywords/terms to explore how practitioners interpret the term “clinical governance”. The practice of clinical governance is mapped to front line, management and governance roles and responsibilities.

Findings

The research finds that interpretation of clinical governance in praxis is quite different from best-practice definitions. Practitioner roles and responsibilities held influence practitioners' interpretation.

Originality/value

The research examines interpretations of clinical governance in praxis by clinicians, managers and governors and highlights the adverse consequence of the absence of clear mapping of roles and responsibilities to clinical, management and governance practice.

Guardians of public interest: the expectation and experience of non-executive directors in National Health Service commissioning boards in England

PURPOSE

The purpose of the study is to examine how Non-Executive Directors (NEDs) in the English National Health Service (NHS) commissioning bodies experienced their role and contribution to governance.

DESIGN/METHODOLOGY/APPROACH

Semi-structured interviews were conducted with a purposive sample of 31 NEDs of Primary Care Trusts (PCTs) and 8 Clinical Commissioning Group (CCG) NEDs. Framework analysis was applied using a conceptualisation of governance developed by Newman, which has four models of governance: the hierarchy, self-governance, open systems and rational goal model.

FINDINGS

NEDs saw themselves as guardians of the public interest. NEDs' power is a product of the explicit levers set out in the constitution of the board, but also how they choose to use their knowledge and expertise to influence decisions for, as they see it, the public good. They contribute to governance by holding to account executive and professional colleagues, acting largely within the rational goal model. CCG NEDs felt less powerful than in those in PCTs, operating largely in conformance and representational roles, even though government policy appears to be moving towards a more networked, open systems model.

ORIGINALITY/VALUE

This is the first in-depth study of NEDs in English NHS local commissioning bodies. It is of value in helping to inform how the NED role could be enhanced to make a wider contribution to healthcare leadership as new systems are established in the UK and beyond.

Developing a Next-of-Kin Involvement Guide in Cancer Care-Results From a Consensus Process

Background

In hospital cancer care, there is no set standard for next-of-kin involvement in improving the quality of care and patient safety. There is therefore a growing need for tools and methods that can guide this complex area.

Objective

The aim of this study was to present the results from a consensus-based participatory process of designing a guide for next-of-kin involvement in hospital cancer care.

Method

A consensus process based on a modified Nominal group technique was applied with 20 stakeholder participants from 2 Norwegian university hospitals.

Result

The participants agreed on the 5 most important priorities for hospital cancer care services when involving next-of-kin. The results showed that next-of-kin stakeholders, when proactively involved, are important resources for the patient and healthcare professionals in terms of contribution to quality and safety in hospitals. Suggested means of involving next-of-kin were closer interaction with external support bodies, integration in clinical pathways, adjusted information, and training healthcare professionals.

Conclusion

In this study, we identified topics and elements to include in a next-of-kin involvement guide to support quality and safety in hospital cancer care. The study raises awareness of the complex area of next-of-kin involvement and contributes with theory development and knowledge translation in an involvement guide tailored for use by healthcare professionals and managers in everyday clinical practice.

Implications for Practice

Service providers can use the guide to formulate intentions and make decisions with suggestions and priorities or as a reflexive tool for organizational improvement.

Medical leadership: boon or barrier to organisational performance? A thematic synthesis of the literature

OBJECTIVE

The influx of management ideas into healthcare has triggered considerable debate about if and how managerial and medical logics can coexist. Recent reviews suggest that clinician involvement in hospital management can lead to superior performance. We, therefore, sought to systematically explore conditions that can either facilitate or impede the influence of medical leadership on organisational performance.

DESIGN

Systematic review using thematic synthesis guided by the Enhancing Transparency in Reporting the synthesis of Qualitative research statement.

DATA SOURCES

We searched PubMed, Web of Science and PsycINFO from 1 January 2006 to 21 January 2020.

ELIGIBILITY CRITERIA

We included peer-reviewed, empirical, English language articles and literature reviews that focused on physicians in the leadership and management of healthcare.

DATA EXTRACTION AND SYNTHESIS

Data extraction and thematic synthesis followed an inductive approach. The results sections of the included studies were subjected to line-by-line coding to identify relevant meaning units. These were organised into descriptive themes and further synthesised into analytic themes presented as a model.

RESULTS

The search yielded 2176 publications, of which 73 were included. The descriptive themes illustrated a movement from 1. medical protectionism to management through medicine; 2. command and control to participatory leadership practices; and 3. organisational practices that form either incidental or willing leaders. Based on the synthesis, the authors propose a model that describes a virtuous cycle of management through medicine or a vicious cycle of medical protectionism.

CONCLUSIONS

This review helps individuals, organisations, educators and trainers better understand how medical leadership can be both a boon and a barrier to organisational performance. In contrast to the conventional view of conflicting logics, medical leadership would benefit from a more integrative model of management and medicine. Nurturing medical engagement requires participatory leadership enabled through long-term investments at the individual, organisational and system levels.

Special Measures for Quality and Challenged Providers: Study Protocol for Evaluating the Impact of Improvement Interventions in NHS Trusts

Background: Healthcare organisations in England rated as inadequate in terms of leadership and one other domain enter the Special Measures for Quality (SMQ) regime to receive increased support and oversight. There is also a ‘watch list’ of challenged National Health Service (NHS) providers at risk of going into SMQ that receive support. There is limited knowledge about whether the interventions used to deliver this support drive improvements in quality, their costs, and whether they strike the right balance between support and scrutiny. The study will seek to determine how provider organisations respond to these interventions, and whether and how these interventions impact organisations’ capacity to achieve and sustain quality improvements over time.

Methods: This is a multi-site, mixed methods study. We will carry out interviews at national level to understand the programme theory underpinning the interventions. We will conduct 8 NHS case studies to explore the impact and implementation of the interventions that form part of the SMQ and challenged providers programme. We will use a conceptual framework based on models of organisational readiness for change and draw on board maturity research for implementing quality improvement. We will also review the use of quantitative metrics and data for tracking the progress of improvements in quality of care and sustainability upon leaving SMQ, as well as the costs and benefits of the interventions through a cost-consequence analysis (CCA).

Discussion: High-quality interventions that successfully support struggling healthcare organisations are essential and an issue that is an international concern. Our study will allow a greater understanding of the programme theory, impact, and staff views and experiences of the SMQ and challenged providers regime. Formative feedback will be reported to key stakeholders.

Understanding how front-line staff use patient experience data for service improvement: an exploratory case study evaluation

Background and aim

The NHS collects a large number of data on patient experience, but there are concerns that it does not use this information to improve care. This study explored whether or not and how front-line staff use patient experience data for service improvement.

Methods

Phase 1 – secondary analysis of existing national survey data, and a new survey of NHS trust patient experience leads. Phase 2 – case studies in six medical wards using ethnographic observations and interviews. A baseline and a follow-up patient experience survey were conducted on each ward, supplemented by in-depth interviews. Following an initial learning community to discuss approaches to learning from and improving patient experience, teams developed and implemented their own interventions. Emerging findings from the ethnographic research were shared formatively. Phase 3 – dissemination, including an online guide for NHS staff.

Key findings

Phase 1 – an analysis of staff and inpatient survey results for all 153 acute trusts in England was undertaken, and 57 completed surveys were obtained from patient experience leads. The most commonly cited barrier to using patient experience data was a lack of staff time to examine the data (75%), followed by cost (35%), lack of staff interest/support (21%) and too many data (21%). Trusts were grouped in a matrix of high, medium and low performance across several indices to inform case study selection. Phase 2 – in every site, staff undertook quality improvement projects using a range of data sources. The number and scale of these varied, as did the extent to which they drew directly on patient experience data, and the extent of involvement of patients. Before-and-after surveys of patient experience showed little statistically significant change. Making sense of patient experience ‘data’ Staff were engaged in a process of sense-making from a range of formal and informal sources of intelligence. Survey data remain the most commonly recognised and used form of data. ‘Soft’ intelligence, such as patient stories, informal comments and daily ward experiences of staff, patients and family, also fed into staff’s improvement plans, but they and the wider organisation may not recognise these as ‘data’. Staff may lack confidence in using them for improvement. Staff could not always point to a specific source of patient experience ‘data’ that led to a particular project, and sometimes reported acting on what they felt they already knew needed changing. Staff experience as a route to improving patient experience Some sites focused on staff motivation and experience on the assumption that this would improve patient experience through indirect cultural and attitudinal change, and by making staff feel empowered and supported. Staff participants identified several potential interlinked mechanisms: (1) motivated staff provide better care, (2) staff who feel taken seriously are more likely to be motivated, (3) involvement in quality improvement is itself motivating and (4) improving patient experience can directly improve staff experience. ‘Team-based capital’ in NHS settings We propose ‘team-based capital’ in NHS settings as a key mechanism between the contexts in our case studies and observed outcomes. ‘Capital’ is the extent to which staff command varied practical, organisational and social resources that enable them to set agendas, drive process and implement change. These include not just material or economic resources, but also status, time, space, relational networks and influence. Teams involving a range of clinical and non-clinical staff from multiple disciplines and levels of seniority could assemble a greater range of capital; progress was generally greater when the team included individuals from the patient experience office. Phase 3 – an online guide for NHS staff was produced in collaboration with The Point of Care Foundation.

Limitations

This was an ethnographic study of how and why NHS front-line staff do or do not use patient experience data for quality improvement. It was not designed to demonstrate whether particular types of patient experience data or quality improvement approaches are more effective than others.

Future research

Developing and testing interventions focused specifically on staff but with patient experience as the outcome, with a health economics component. Studies focusing on the effect of team composition and diversity on the impact and scope of patient-centred quality improvement. Research into using unstructured feedback and soft intelligence.

Funding

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

The impact of leadership churn on quality management in Australian hospitals

Purpose

The purpose of this paper is to explore the relationship between frequent turnover (churn) of the chief executive officer (CEO), quality manager and members of the governing board with the management of quality in eight Australian hospitals.

Design/methodology/approach

A mixed method three-year longitudinal study was conducted using validated quality system scales, quality indicators and focus groups involving over 800 board members, managers and clinical staff.

Findings

There were unexpected high levels of both governance and management churn over the three years. Churn among CEOs and quality managers was negatively associated with compliance in aspects of the quality system used to plan, monitor and improve quality of care. There was no relationship with the quality of care indicators. Staff identified lack of vision and changing priorities with high levels of churn, which they described as confusing and demotivating. There was no relationship with quality processes or quality indicators detected for churn among governing board members.

Practical implications

Governing boards must recognise the risks associated with management change and minimise these risks with robust clinical governance processes.

Originality/value

This research is the first that we are aware of that identifies the impact of frequent leadership turnover in the health sector on quality management.

Translating research on quality improvement in five European countries into a reflective guide for hospital leaders: the 'QUASER Hospital Guide'

OBJECTIVE

The aim was to translate the findings of the QUASER study into a reflective, dialogic guide to help senior hospital leaders develop an organization wide QI strategy.

DESIGN

The QUASER study involved in depth ethnographic research into QI work and practices in two hospitals in each of five European countries. Three translational stakeholder workshops were held to review research findings and advise on the design of the Guide. An extended iterative process involving researchers from each participant country was then used to populate the Guide.

SETTING

The research was carried out in two hospitals in each of five European countries.

PARTICIPANTS

In total, 389 interviews with healthcare practitioners and 803 hours of observations.

INTERVENTION

None.

MAIN OUTCOME MEASURE

None.

RESULTS

The QUASER Hospital Guide was designed for leadership teams to diagnose their organization's strengths and weaknesses in the eight QI challenges. The Guide supports organizational dialogue about QI challenges, enables leaders to share perspectives, and helps teams to develop solutions to their situated problems. The Guide includes extensive examples of QI strategies drawn from the data and is published online and on paper.

CONCLUSIONS

The QUASER Hospital Guide is empirically based, draws on a dialogical approach to Organizational Development and complexity science and can facilitate hospital leadership teams to identify the best solutions for their organization.

Understanding corporate governance of healthcare quality: a comparative case study of eight Australian public hospitals

Background

Patients are sometimes harmed in the course of receiving hospital care. Existing research has highlighted a positive association between board engagement in healthcare quality activities and healthcare outcomes. However, most research has been undertaken through surveys examining board engagement in a limited number of governance processes. This paper presents evidence of a comprehensive range of processes related to governing healthcare quality undertaken at the corporate governance level. This provides a more detailed picture than previously described of how corporate governance of healthcare quality is enacted by boards and management.

Methods

A comparative case study of eight Australian public hospitals was undertaken. Case studies varying is size and location were selected from two Australian states. Data collection included a review of key governance documentation, semi structured interviews with board members and senior management and an observation of a board quality committee meeting. Thematic analysis was undertaken to identify processes related to key tasks in governing healthcare quality.

Results

Two key tasks in the corporate governance of healthcare quality, evaluating healthcare quality and overseeing quality priorities, were examined. Numerous processes related to these two tasks were found. Case studies, while found to be similar in engagement on previously identified processes, were found to differ in engagement in these additional processes. While generally low levels of engagement in processes of overseeing quality priorities were found, cases differed markedly in their engagement in evaluating healthcare quality processes. Additional processes undertaken at some case studies represent innovative and mature responses to the need for effective corporate governance of healthcare quality. In addition, a group of processes, related to broader governance taskwork, were found to be important in enabling effective corporate governance of healthcare quality.

Conclusion

The work of governing healthcare quality, undertaken at the corporate governance level, is redefined in terms of these more detailed processes. This paper highlights that it is how well these key tasks are undertaken that is important in effective governance. When processes related to key tasks are omitted, the rituals of governance may appear to be satisfied but the responsibility may not be met. Boards and managers need to differentiate between common approaches to governance and practices that enable the fulfilment of governance responsibilities. This study provides practical guidance in outlining processes for effective corporate governance of healthcare quality and highlights areas for further examination.

Using patient experience data to develop a patient experience toolkit to improve hospital care: a mixed-methods study

Background

Patients are increasingly being asked to provide feedback about their experience of health-care services. Within the NHS, a significant level of resource is now allocated to the collection of this feedback. However, it is not well understood whether or not, or how, health-care staff are able to use these data to make improvements to future care delivery.

Objective

To understand and enhance how hospital staff learn from and act on patient experience (PE) feedback in order to co-design, test, refine and evaluate a Patient Experience Toolkit (PET).

Design

A predominantly qualitative study with four interlinking work packages.

Setting

Three NHS trusts in the north of England, focusing on six ward-based clinical teams (two at each trust).

Methods

A scoping review and qualitative exploratory study were conducted between November 2015 and August 2016. The findings of this work fed into a participatory co-design process with ward staff and patient representatives, which led to the production of the PET. This was primarily based on activities undertaken in three workshops (over the winter of 2016/17). Then, the facilitated use of the PET took place across the six wards over a 12-month period (February 2017 to February 2018). This involved testing and refinement through an action research (AR) methodology. A large, mixed-methods, independent process evaluation was conducted over the same 12-month period.

Findings

The testing and refinement of the PET during the AR phase, with the mixed-methods evaluation running alongside it, produced noteworthy findings. The idea that current PE data can be effectively triangulated for the purpose of improvement is largely a fallacy. Rather, additional but more relational feedback had to be collected by patient representatives, an unanticipated element of the study, to provide health-care staff with data that they could work with more easily. Multidisciplinary involvement in PE initiatives is difficult to establish unless teams already work in this way. Regardless, there is merit in involving different levels of the nursing hierarchy. Consideration of patient feedback by health-care staff can be an emotive process that may be difficult initially and that needs dedicated time and sensitive management. The six ward teams engaged variably with the AR process over a 12-month period. Some teams implemented far-reaching plans, whereas other teams focused on time-minimising ‘quick wins’. The evaluation found that facilitation of the toolkit was central to its implementation. The most important factors here were the development of relationships between people and the facilitator’s ability to navigate organisational complexity.

Limitations

The settings in which the PET was tested were extremely diverse, so the influence of variable context limits hard conclusions about its success.

Conclusions

The current manner in which PE feedback is collected and used is generally not fit for the purpose of enabling health-care staff to make meaningful local improvements. The PET was co-designed with health-care staff and patient representatives but it requires skilled facilitation to achieve successful outcomes.

Funding

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

Qualitative process evaluation of the Perioperative Quality Improvement Programme (PQIP): study protocol

INTRODUCTION

The Perioperative Quality Improvement Programme (PQIP) is designed to measure complications after major elective surgery and improve these through feedback of data to clinicians. Previous research suggests that despite the significant resources which go into collecting data for national clinical audits, the information they contain is not always used effectively to improve local services.

METHODS AND ANALYSIS

We will conduct a formative process evaluation of PQIP comprising a multisited qualitative study to analyse PQIP's programme theory, barriers, facilitators and wider contextual factors that influence implementation. The research will be carried out with the PQIP project team and six National Health Service (NHS) Trusts in England, selected according to geographical location, type of hospital, size and level of engagement with PQIP. We will include one Trust which has not expressed interest in the PQIP for comparison and to explore the role of secular trend in any changes in practice. We will use semi-structured interviews (up to 144 in Trusts and 12 with the project team), non-participant observations (up to 150  hours) and documentary analysis. We will track the lifecycle of perioperative data, exploring the transformations it undergoes from creation to use. We will use framework analysis with categories both from our research questions and from themes emerging from the data.

ETHICS AND DISSEMINATION

Ethical approval has been granted from the University College London Research Ethics Committee (ref 10375/001). Permissions to conduct research at NHS Trusts have been granted by local Research and Development offices in coordination with the Health Research Authority. We will follow guidelines for data security, confidentiality and information governance. Findings will be shared at regular time points with the PQIP project team to inform the implementation of the programme, and with participating NHS Trusts to help them reflect on how they currently use data for improvement of perioperative services.

Designing and pilot testing of a leadership intervention to improve quality and safety in nursing homes and home care (the SAFE-LEAD intervention)

OBJECTIVE

To describe the design of a leadership intervention for nursing home and home care, including a leadership guide for managers to use in their quality and safety improvement work. The paper reports results from the pilot test of the intervention and describes the final intervention programme.

DESIGN

Qualitative design, using the participation of stakeholders.

METHODS

The leadership guide and intervention were designed in collaboration with researchers, coresearchers and managers in nursing homes and home care organisations, through workshops and focus group interviews. The pilot test consisted of three workshops with managers working on the leadership guide, facilitated and observed by researchers, and evaluated by means of observation and focus group interviews with the participants. The analysis combined the integration of data from interviews and observations with directed content analysis.

SETTING

Norwegian nursing homes and home care services.

PARTICIPANTS

Managers at different levels in three nursing homes and two home care services, coresearchers, and patient and next-of-kin representatives.

RESULTS

The managers and coresearchers suggested some revisions to the leadership guide, such as making it shorter, and tailoring the terminology to their setting. Based on their suggestions, we modified the intervention and developed learning resources, such as videos demonstrating the practical use of the guide. Evaluation of the pilot test study showed that all managers supported the use of the guide. They adapted the guide to their organisational needs, but found it difficult to involve patients in the intervention.

CONCLUSIONS

A participatory approach with stakeholders is useful in designing a leadership intervention to improve quality and safety in nursing homes and home care, although patient participation in its implementation remains difficult. The participatory approach made it easier for managers to adapt the intervention to their context and to everyday quality and safety work practice.

How organisations contribute to improving the quality of healthcare

Naomi Fulop and Angus Ramsay argue that we should focus more on how organisations and organisational leaders can contribute to improving the quality of healthcare

What should be in hospital doctors' continuing professional development?

OBJECTIVE

To ask those most affected by continuing professional development for senior doctors - patients, other professional groups and doctors themselves - what it needs to encompass.

DESIGN

The nominal group technique.

PARTICIPANTS

Six groups of between seven and nine members (n = 49). Separate groups were held for nurses and therapists (n = 9), patient representatives (n = 8), medical directors (n = 8), consultants (n = 8) and medical trainees (n = 7). An additional group consisted of 'Darzi Fellows' (n = 9), trainee doctors who were undertaking a leadership fellowship.

SETTING

Groups were held at the Royal Society of Medicine in London.

MAIN OUTCOME MEASURES

Priorities for the content of continuing professional development for senior hospital doctors, ranked in order of importance. Themes derived from analysis of group discussions.

RESULTS

We present the ranked priorities of different groups for what should be included in continuing professional development for senior hospital doctors. Analysis of group discussions identified the following three themes: developing and supporting the system of care; changes in the way medicine is practised; and personal wellbeing and caring for colleagues.

CONCLUSIONS

The implication of our findings for providers of continuing professional development is to consider the balance of content. Doctors and other healthcare professionals need to keep up with scientific advances and technical developments. But in addition, they need to be adept at working with the system changes required for translation of research into practice, the development of new ways of working, and for the organisational changes that underpin continual quality and safety improvement.

Structuring ambiguity in hospital governance

This empirical, multicase research into developing governance structures highlights the strategies of four Dutch hospitals to strengthen their governability. The hospitals studied choose to commit themselves to duality as their starting point for structuring governance arrangements. All of them create positions of doctors and managers that are based on consensual decision making and common responsibility, in this way structuring governance at hospital level and unit level. Interestingly, they consciously choose to create ambiguous positions keeping formalization by rules and job descriptions low. Efficacy of dual hospital governance depends heavily on personal strength, mutual understanding, and trust of the incumbents, which offers new chances for governability but also harbors vulnerability to hospital governance.

What's the problem with patient experience feedback? A macro and micro understanding, based on findings from a three-site UK qualitative study

Context

Collecting feedback from patients about their experiences of health care is an important activity. However, improvement based on this feedback rarely materializes. In this study, we focus on answering the question—“what is impeding the use of patient experience feedback?”

Methods

We conducted a qualitative study in 2016 across three NHS hospital Trusts in the North of England. Focus groups were undertaken with ward‐based staff, and hospital managers were interviewed in‐depth (50 participants). We conducted a conceptual‐level analysis.

Findings

On a macro level, we found that the intense focus on the collection of patient experience feedback has developed into its own self‐perpetuating industry with a significant allocation of resource, effort and time being expended on this task. This is often at the expense of pan‐organizational learning or improvements being made. On a micro level, ward staff struggled to interact with feedback due to its complexity with questions raised about the value, validity and timeliness of data sources.

Conclusions

Macro and micro prohibiting factors come together in a perfect storm which provides a substantial impediment to improvements being made. Recommendations for policy change are put forward alongside recognition that high‐level organizational culture/systems are currently too sluggish to allow fruitful learning and action to occur from the feedback that patients give.

Physician Burnout: Resilience Training is Only Part of the Solution

Physicians and physician trainees are among the highest-risk groups for burnout and suicide, and those in primary care are among the hardest hit. Many health systems have turned to resilience training as a solution, but there is an ongoing debate about whether that is the right approach. This article distinguishes between unavoidable occupational suffering (inherent in the physician's role) and avoidable occupational suffering (systems failures that can be prevented). Resilience training may be helpful in addressing unavoidable suffering, but it is the wrong treatment for the organizational pathologies that lead to avoidable suffering- and may even compound the harm doctors experience. To address avoidable suffering, health systems would be better served by engaging doctors in the co-design of work systems that promote better mental health outcomes.

Next level of board accountability in health care quality

Purpose The purpose of this paper is to offer six principles that health system leaders can apply to establish a governance and management system for the quality of care and patient safety. Design/methodology/approach Leaders of a large academic health system set a goal of high reliability and formed a quality board committee in 2011 to oversee quality and patient safety everywhere care was delivered. Leaders of the health system and every entity, including inpatient hospitals, home care companies, and ambulatory services staff the committee. The committee works with the management for each entity to set and achieve quality goals. Through this work, the six principles emerged to address management structures and processes. Findings The principles are: ensure there is oversight for quality everywhere care is delivered under the health system; create a framework to organize and report the work; identify care areas where quality is ambiguous or underdeveloped (i.e. islands of quality) and work to ensure there is reporting and accountability for quality measures; create a consolidated quality statement similar to a financial statement; ensure the integrity of the data used to measure and report quality and safety performance; and transparently report performance and create an explicit accountability model. Originality/value This governance and management system for quality and safety functions similar to a finance system, with quality performance documented and reported, data integrity monitored, and accountability for performance from board to bedside. To the authors' knowledge, this is the first description of how a board has taken this type of systematic approach to oversee the quality of care.