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	<title>QualityBites Blog</title>
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	<description>&#39;QualityBites&#39; is a selection of posts from my monthly QNews bulletin.  If you&#39;d like to receive QNews in your inbox every month, click on &#39;Free Quality Assessment Tool&#39; above.
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<link>https://www.qualityworks.com.au/qualitybites-blog/one-question-to-test-your-quality-system_264s78</link>
<title><![CDATA[One question to test your quality system]]></title>
<description><![CDATA[Here&rsquo;s a simple question to ascertain if your organisation is on the road to consistently high quality care.

What does your organisation&rsquo;s quality system manager/team spend most of their time doing?
]]></description>
<content><![CDATA[What does your organisation&rsquo;s quality system manager/team spend most of their time doing?

No doubt many of you were hoping for something more inspirational; perhaps a question about culture or unveiling the secrets of data and reporting. But! &ndash; before you abandon this article, think about it for half a minute. The answer to this question is loaded with information about the quality of care your organisation provides.

Why? Because &lsquo;every system is perfectly designed to get the results it gets.&rsquo; Sound familiar? An oldie, but oh, what a goodie! I&rsquo;m resurrecting it because it reflects precisely what we&rsquo;ve found in our research on what makes an effective quality system. Show me the quality manager preoccupations and I&rsquo;ll predict what&rsquo;s going on with quality at point of care. If it&rsquo;s all about compliance, it&rsquo;s likely that point of care staff see &lsquo;quality&rsquo; as an extra set of tasks they must &lsquo;do&rsquo; and that quality is something different to their interactions with consumers.

A compliance-based quality system does not promulgate the mindset or behaviours required to provide consistently high quality care. Even if managers and staff are using compliance intelligently and applying it to improve, you might have safe, accessible care, in partnership with consumers, as these are the areas targeted by compliance requirements. No complaints if you&rsquo;re achieving these consistently with every consumer, of course. But beyond these there will be gaps in your high quality experience jigsaw puzzle. Gaps that consumers &ndash; and staff &ndash; would rather not be there, such as care appropriateness and effectiveness, and coordination and integration of care.

Consumers and staff cannot live by compliance alone.

It is impossible, in the complexity of health and aged care, to provide consistently high quality care through compliance alone in a complex health or aged care organisation; it&rsquo;s just not the way these organisms work.   Of course compliance provides significant jigsaw pieces for our puzzle. It&rsquo;s not an either/or. But without the box top that provides the organisational view of what consistently high quality care looks like, designed by consumers and all levels of staff; and an executive-led strategy for making it the reason people come to work every day, you&rsquo;ll never complete the &lsquo;high quality care&rsquo; picture. If your quality system is mostly about compliance, you&rsquo;ll have wins in some areas, but will not create an organisation that provides consistently high quality care as business as usual.

Executives will get exactly what they prioritise 

The quality manager and team role often reflects the executives&rsquo; understanding of what a quality system should deliver. This is a big statement, especially as this understanding is often linked to funding and political requirements, rather than a clear and consistent vision of what boards and executives want to achieve for their consumers. It seems that these external expectations have narrowed over the past decade as we seek to plug the safety gaps we lived with for too long.  Our focus has zig-zagged from clinical outcomes to compliance audit; from safety and risk to consumer participation, in no apparent order.

The potential of the quality systems manager role appears to be restricted by the knowledge of those doing the hiring. If boards and executives don&rsquo;t know what they don&rsquo;t know about creating consistently high quality care in a complex environment, they&rsquo;re unlikely to go looking for a person with the skills that can help them to pursue this. If they see &lsquo;quality&rsquo; as the mechanics of quality: the audits, incidents, reporting and committees, rather than the point of care purpose, then that&rsquo;s what it will be. From my perspective this is a significant contributor to the slow pace of improvement and change in the quality of the care health and aged care services; while we&rsquo;re focused on the governance engine room, there&rsquo;s no-one on the bridge steering the ship towards a designed destination.  So we are blown about by the winds of fad, fashion and funding, and a lot of the hard work and good intent gets lost in the sea of confusion.

Consistently high quality care is harder to achieve than a balanced budget

Our research into what makes an effective quality system highlights this. Too often the board and executive beliefs about the quality of care are overly optimistic, because &lsquo;good staff are out there doing a great job&rsquo;, with their successfully ticked compliance activities supporting this. If only that&rsquo;s how it worked! Our complex organisations are as far away from that as Pluto is from the Sun. Consistently high quality at point of care is an ongoing challenge, every bit as tough as keeping the budget in the black &ndash; and look at the focused work that goes into that. Finance plans, systems, budgets, committees, lots of board and executive time, training for managers, reporting, accountability. It&rsquo;s viewed as a vitally important and ongoing pursuit, requiring knowledge and technical skills across the board and executive, with specialist expertise in the finance team. It&rsquo;s difficult to imagine a CEO appointing a finance manager on the strength of them &lsquo;being organised&rsquo; or &lsquo;good with numbers&rsquo;.

The pursuit of consistently high quality care is the same &ndash; but harder. It requires everything that well-managed finances requires &ndash; and more. In the same way as managing the budget happens, managing the quality of care is a line management responsibility. The quality systems manager provides systems and technical support, as the finance manager does, but they can&rsquo;t create what&rsquo;s required at point of care. The senior and middle managers&rsquo; job in any service is not just to provide a service and get their staff through the day &ndash; but to provide a high-quality, well managed service. This bit is not an optional extra, but fundamental to consumers receiving consistently high quality care. All consumers receiving consistently high quality care requires a whole of organisation approach; and you can&rsquo;t achieve that without the whole of the executive, and managers at all levels, having the &lsquo;will and skill&rsquo; to deliver it.

Our research indicates that both the understanding and messages around this are very mixed. Most clinical managers and staff would like more help with understanding how their consumers are travelling &ndash; beyond the constraints of accreditation and other external compliance. Achieving both compliance and support for clinicians to progress their standard of care can be done. But it requires a strategic, planned and systematic approach that embraces both standardisation and clinical judgement; responsivness and proactivity,  to achieve a defined view of high quality care for every consumer.

To the consumers, boards, CEOs, executives, quality systems managers and bureaucrats out there valiantly striving beyond compliance to create a strategic and comprehensive great care experience &ndash; I salute you! And those still thinking about it? Make 2018 the year you make your mark on the &lsquo;great care&rsquo; map.

References

&lsquo;Every system is perfectly designed to get the results it gets&rsquo;: variously attributed to Arthur Jones, W. Edwards Deming, Paul Batalden and Donald Berwick.

Leggat SG, Balding C (2017) A qualitative study on the implementation of quality systems in Australian hospitals. Health Services Management Research, Volume: 30 issue: 3, page(s): 179-186, August, 2017.

http://journals.sagepub.com/doi/10.1177/0951484817715594

Juran Institute: http://www.juran.com
]]></content>
<guid isPermaLink="true">https://www.qualityworks.com.au/qualitybites-blog/one-question-to-test-your-quality-system_264s78</guid>
<pubDate>23 Dec 2018 08:23:00 GMT</pubDate>
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<link>https://www.qualityworks.com.au/qualitybites-blog/why-quality-language-is-killing-quality_264s85</link>
<title><![CDATA[Why quality language is killing quality]]></title>
<description><![CDATA[WHAT&#39;S THE ISSUE? 

What&#39;s wrong with this sentence?

&#39;We ensure that our staff provide safe, high quality and person centred care.&#39;
]]></description>
<content><![CDATA[If I never read a sentence again like that it will be too soon.  But I know I will. Over and over. These words, and the many others like it lurking in strategic plans and annual reports and quality frameworks, have played a starring role in slowing progress with improving the quality of care in health and human services.

At this point many of you will be thinking that I need a holiday.  What on earth could be so wrong with this perfectly fine looking sentence?  This, or something like it, may even feature in your own documents.

The problem is, when you deconstruct it, it doesn&#39;t make much sense.  And words that don&#39;t make sense have little power to inspire the common understanding and action required to create consistently high quality care.

Health and human services have been in a dance with the language of quality from the beginning. Ever since &#39;quality assurance&#39; became a thing, we&#39;ve shuffled between language that described what we were trying to do and what we were trying to achieve without ever really coming to grips with what we were trying to say.  I know! - I was guilty of it for many years.  For one thing, most of us didn&#39;t have enough knowledge to use the right language - it seemed any old words would do and everyone put their own interpretation on them and we bumbled along. That lack of deep understanding, coupled with a constant stream of jargon associated with new improvement fads, meant that we were butchering the language of quality like a tourist with a week of night school local dialect under their belt.

Which is why the sentence above, if we were to utter it in &#39;qualityland&#39; where everyone spoke fluent quality, would attract serious eye rolling, sighing and a few laughs from the locals.

Technically, &#39;person-centred&#39; and &#39;safe&#39; are dimensions of quality care, so adding &#39;quality&#39; as a component of quality care makes no sense.   It&#39;s a bit like describing the components of a car engine as &#39;cylinders, radiator and engine.&#39;  Apart from keeping us stuck in senseless jargon, these types of sentences also allow people to claim &#39;quality&#39; care when it doesn&#39;t exist, because it&#39;s something that doesn&#39;t need to be further defined, or can&#39;t be defined. It just &#39;is&#39;.  So people can point to mediocrity and call it &#39;quality&#39; - and who&#39;s to argue? And these kinds of quality statements do nothing to help the staff  who are charged with  providing the care to fully understand exactly what it looks like and means to them, so they are unlikely to make it happen.  My other beef with the sentence is the &#39;ensure&#39;: very little ensures anything in a complex system; once again, sounds great, but creates a complacency that if we say it, somehow it&#39;s already done.

One day I realised that by persisting with this language, I was not only confusing other people, I was confusing myself.  So I started to have a good look at the language of quality, eventually settling on something I could work with, even if no-one else could.  You can see this in my books and videos.

It&#39;s not too late...

We all know how powerful language is in developing shared understanding, influencing opinions and shaping behaviours.  Language is evolving all around us: sometimes it seems to be change for the sake of it, and sometimes we can see the benefit to the way we frame and think about things, such as not assuming that a medical doctor we don&#39;t know in a story is a &#39;he&#39; for example. It seems like such a little thing to say &#39;she - or he&#39; - but it immediately reminds us that the days of assuming all doctors are men are gone - mostly -  and that the power that goes with being a doctor is no longer vested only in men.

In the same way, we can  - and must - evolve the language of quality in health and human services. Around about one score and five years ago, from my reckoning, the word &#39;safety&#39; entered the &#39;quality&#39; lexicon and immediately became the alpha term.  It didn&#39;t matter how many frameworks and papers were published describing quality care as the sum of a number of dimensions; the shock of finding out that we provided unsafe care sent &#39;safety&#39; directly to the top of the dimensions charts for so long that many of the other dimensions faded away. I&#39;ve said many times that this is perfectly understandable, considering that prior to that safety hadn&#39;t been widely discussed, reported on or addressed as a specific issue - what happened in the hospital stayed in the hospital. So &#39;safety&#39; definitely needed to assert its place and receive the attention it deserved. 

But as so often happens in human services, the pendulum swung too far - and with it the language. People started referring to &#39;safety&#39; when they really meant more. And over time, safety became quality, and a whole generation of healthcare professionals and managers grew up thinking that managing risk, reporting incidents and meeting standards was essentially all there was to &#39;quality&#39;.  Access and efficiency were taken care of via funding requirements and, later, &#39;consumer focus&#39; entered the fray.  Effectiveness, appropriateness and integration got lost in all but a few organisations.
]]></content>
<guid isPermaLink="true">https://www.qualityworks.com.au/qualitybites-blog/why-quality-language-is-killing-quality_264s85</guid>
<pubDate>20 Jan 2019 05:30:00 GMT</pubDate>
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<link>https://www.qualityworks.com.au/qualitybites-blog/four-excerpts-from-39the-point-of-care39-book_264s81</link>
<title><![CDATA[Four excerpts from &#39;The Point of Care&#39; book...]]></title>
<description><![CDATA[What happens when a new CEO is given 6 months to fix a health service riddled with quality problems?  Drawing on my first two &#39;technical&#39; books, my research into effective quality systems and many years in the quality and clinical governance trenches, this &#39;business fiction&#39; tells the story of one CEO&#39;s quest to take a health service from ordinary to extraordinary.  But not everyone wants to go with her... 
]]></description>
<content><![CDATA[EXCERPT 1

Carol pointed to the slide. &quot;Good managers are critical to this because they can point everyone in the same direction and build teams that work to their strengths to create Great Care. These managers - and the and quality teams that support them - must be equipped with the skills they need to play their role in providing great care. At the very least they should have a working knowledge of complexity, change, resilience and measurement. They should know how to get the best out of people in a challenging environment and understand how to work with consumers to create positive experiences and outcomes. People aren&#39;t born with this knowledge, nor do they necessarily acquire it on their rise through the ranks. Basically, if we want great care, we have to develop great managers.&quot;

Carol paused as she clicked to her final slide, emblazoned with the KVHS Great Care logo, and many photos of KVHS consumers, staff and committee members.

&ldquo;And where has all this left us? Just before this session I received a text containing our state DHHS results.&rdquo; A hush descended over the audience. All that work and commitment.

Did it make a difference?...

EXCERPT 2

Pari&rsquo;s face was creased with indignation. She glanced around the table. Kristen looked too surprised for words. Anton was slumped in his chair reading the article on his tablet, while Jeff sat bolt upright, ready for action.  Elena was grim-faced, giving nothing away.  Carol&rsquo;s face was flat and expressionless. She put the paper down and clasped her hands in front of her knuckles white.

&ldquo;How dare they portray Carol as a bad manager trying to cover up problems with a fad, when in fact she&rsquo;s doing the exact opposite!&rdquo; Pari exclaimed, crossing her arms defiantly.

Kristen recovered her powers of speech. &ldquo;WHO is giving them the information? It&rsquo;s time to get it stopped, once and for all. Not only is it untrue, but if it continues it&rsquo;s going to kill any hope of embedding GC. I know some people who are already using the bad press as an excuse not to participate, and this is just a boost to their cause. And we&rsquo;ll never win back the community&hellip; oh, no!&rdquo; She slapped her forehead dramatically. Our next Great Care community workshop is next week. It won&rsquo;t be a happy crowd!&rdquo;

&ldquo;It&rsquo;ll be OK,&rdquo; Jeff reassured her. &ldquo;It gives us an opportunity to counter the &lsquo;Leader&rsquo;s&rsquo; rubbish, at least.  As for who is doing the leaking, they may just have slipped up by providing so much detail.&rdquo;

&ldquo;What do you mean?&rdquo; Pari uncrossed her arms and leaned forward, intrigued.

&ldquo;Well, by my reckoning, it&rsquo;s got to be someone who&rsquo;s actually attended a GC workshop,&rdquo; replied Jeff. &ldquo;There are details about Great Care in that article that could only have been gleaned from being there in person.&rdquo;

&ldquo;That&rsquo;s around 150 people across 10 workshops now,&rdquo; said Pari, quietly.

&ldquo;That&rsquo;s not too many.&rdquo;  Jeff shuffled impatiently in his chair.  &ldquo;Pari, can you get us the workshops lists?  There can&rsquo;t be too many people there who are disaffected enough to take this risk. We should be able to narrow it down without too much trouble.&rdquo; Pari nodded. &ldquo;I  know your strategy has been to address this quietly and not give it much oxygen, Carol,&rdquo; he continued, glancing at his silent CEO.   &ldquo;And at first I agreed with you. But it hasn&rsquo;t worked.  Someone is playing with us and it&rsquo;s time to confront it head-on.&rdquo;

&ldquo;And we have social media!&rdquo; Anton announced, fingers flying over his tablet. &ldquo;Don&rsquo;t worry, just the usual haters who are happy that today&rsquo;s &lsquo;Leader&rsquo; has given them something else to attack. Nothing worth our attention.&rdquo;

&ldquo;You haven&rsquo;t said much Elena,&rdquo; continued Jeff, who was on a roll, responding to the crisis with typical ED physician vigour.  &ldquo;There must be some dissatisfied nurses. There usually are.&rdquo;

&ldquo;Well, seeing as they make up the biggest slice of the staff, you should expect that there will be more unhappy nurses than other staff,&rdquo; responded Elena testily, lips pursed. &ldquo;And what about allied health and non-clinical staff?&rdquo;

Pari gazed at her thoughtfully. She wasn&rsquo;t sure that Elena&rsquo;s heart was really in what she was saying, whereas the other Executive Team members were stirred up and ready for action.

EXCERPT 3

Carol completed her analysis of the KVHS results in the Department of Health&rsquo;s performance report and sat down.

&ldquo;How did we get into this situation?&rdquo; Chris Bowman-West, the Quality Committee chair, and nurse-turned-lawyer, was struggling to conceal his frustration.

The other Board members on the Quality Committee looked at the Executive Team, who looked down at the table. Nancy sat in silence.  This was Chris and Carols&rsquo; show &ndash; for now.

&ldquo;It&rsquo;s not just the consumer and staff satisfaction we need to worry about is it?&rdquo; Andy Bidwell, chair of the Consumer and Community Partnerships Committee, pointed at the screen showing the KVHS performance results summary.  There are problems with clinical care there as well.&rdquo;

&ldquo;I meant the &lsquo;whole&rsquo; situation,&rdquo; said Chris.  &lsquo;Consumers, staff, care, everything.  KVHS has always prided itself on providing excellent care; it&rsquo;s been a strategic objective as long as I can remember.  And the Board was always led to believe that it was an operational reality.&rdquo;

&ldquo;We do provide excellent care.&rdquo; Elena looked up defiantly.  &ldquo;Every health service has its up and downs. No-one can expect us to be perfect. But we have very good, hard-working staff, and no-one at KVHS comes to work to do a bad job.&rdquo;

Carol regarded her CNMO thoughtfully, wondering why she would make such potentially career-limiting statements in this situation.  With a shock she realised that this was no evasive smokescreen.  Elena really believed what she was saying.  Carol winced inwardly.  So much work still to do to get everyone on the same page, she thought, knowing that Elena was not going to enjoy the next slide in her presentation.

&ldquo;Well,&rdquo; continued Chris, &lsquo;whilst I&rsquo;d like to believe that, Elena, I think we&rsquo;ve avoided the hard facts for too long.  At least now we know where we are. As Carol has now had enough time in her role to get a good feel for the issues, I&rsquo;ve asked her to put together her thoughts on how we got here.  I believe we need to understand where you are and why, before we work out how to get where we want to go.  Our plans must be based on the reality of how we got here in the first place, or we could make the same mistakes.  Carol?&rdquo;

Carol clicked to the next slide which was headed up &lsquo;Clinical Governance Warning Bells&rsquo;.  &ldquo;I&rsquo;ve got a mental list of clinical governance &lsquo;warning bells&rsquo;, that I&rsquo;ve developed over many years in the healthcare game. Some of them are also discussed in the relevant literature. When I hear a bell ring, my antennae go up, because I know there&rsquo;s a fair chance that there&rsquo;s a poor care issue lurking. Maybe not across the whole organisation, but generally one or more of these warning bells indicates that consumers may be getting a raw deal somewhere in the service.  These bells have been ringing in my ears ever since I got here, so I thought they&rsquo;d provide a good framework to look at the organisational issues that either have been or currently are likely contributing to our poor results.&rdquo;

The group studied the list silently.  Every item had a red tick next to it.


	Hierarchical culture with little point of care staff power or recognition, which can manifest as a culture of fear and staff reluctance to speak up
	Institutional, isolated and inward looking culture, unwilling to learn from elsewhere (long standing Board/exec members with little role evolution)
	Board and Executive unwilling to hear bad news
	Lack of specific clinical leadership at each level of the organisation, and deliberate and ongoing teamwork development, for the provision of safe, quality care
	Weak S&amp;Q reporting format and content, and lack of active response to data and feedback
	Lack of robust review of clinical practice; and assumptions by clinicians that monitoring, performance management or intervention is the responsibility of someone else
	Tolerance of sub-standard care: problems are long standing and known by many stakeholders but not acted on
	Lack of consumer participation in their care and little interest shown in consumers&rsquo; interests; with decisions made to meet the needs of the organisation and staff over care safety and quality
	Quality system based on compliance with standards with limited service and care improvement beyond standards&rsquo; requirements and reaction to things that go wrong
	Building works, budget issues, major restructure, rapid demand growth
	CEO lacks requisite S&amp;Q improvement knowledge to lead point of care excellence
	CEO and Board chair are at loggerheads or collude to withhold information from the rest of the Board and Executive.


Chris broke the heavy quiet around the table.  &ldquo;This Board has been content for far too long to accept the good news stories and not probe too far into the murky stuff.  Well, it&rsquo;s time to dive into the murk. OK, Carol, give it to us straight, and don&rsquo;t pull any punches.&rdquo;

EXCERPT 4

On the Monday morning after the Executive Team planning session, Rosie bustled in and set a pile of &lsquo;non-urgent&rsquo; messages in Carol&rsquo;s in-box.  &ldquo;How did it all go?&rdquo; she asked.  As usual, she didn&rsquo;t stop while Carol replied, but busied herself with changing the flowers.

&ldquo;Surprisingly well, thanks Rosie.&rdquo; Carol stopped to admire Rosie&rsquo;s deft flower arranging. &ldquo;We&rsquo;ve got a ways to go but there&rsquo;s definite progress.  We learned some useful skills and committed to some good decisions. Now the hard work continues.&rdquo;  She picked up the message on top of the pile and read it.  &ldquo;What&rsquo;s this one from the National Rural Health Association?&rdquo;

&ldquo;Oh!&rdquo; Rosie actually stopped what she was doing. &ldquo;That&rsquo;s good news. Just after you left for the executive planning workshop, the Association called and &ndash; wait for it &ndash; asked if you&rsquo;d be willing to be the closing speaker for the annual conference, to talk about how you&rsquo;ve turned KVHS around.  No-one from Kinsley Valley has ever been asked to give a keynote address at the conference, so it&rsquo;s a real honour!&rdquo;

Carol opened her mouth to respond, but Rosie continued hurriedly.  &ldquo;Of course I said I&rsquo;d check with you but that I was sure you&rsquo;d say &lsquo;yes&rsquo;.  You&rsquo;re going to have so many good stories about KVHS to tell with everything that&rsquo;s going on. We haven&rsquo;t seen this much action for years!&rdquo;   She stopped and peered at Carol.  &ldquo;You don&rsquo;t look as pleased as I thought you would. Is something wrong? I thought I was doing the right thing.&rdquo;

Carol immediately assembled a smile and slipped it on.

&ldquo;I am pleased - that you are so proud of Kinsley Valley, Rosie.  And of all the hard work everyone is doing. I&rsquo;m just not sure that there will be enough good news stories by the time the conference is on.  Isn&rsquo;t it just before the state election?&rdquo;

&ldquo;Yes, in about four months.  And you will have lots of good stories to tell, I&rsquo;m sure of it.&rdquo; Suddenly Rosie noticed she had stopped moving and went back to continue with the flowers.  The staff will be so proud that the whole country will hear about Kinsley Valley.  Lots of them will be able to attend as this year it&rsquo;s being held at the Woodside conference centre, only three hours away: just down the road! Year after year we&rsquo;ve had to hear CEOs from other rural health services blow their trumpets. The &lsquo;Mountain Health Care&rsquo; CEO has done that closing address three times in the past seven years.  Their care may be average but their self-promotion is outstanding.&rdquo;

Carol regarded the normally positive Rosie with interest, surprised at her intensity.

&ldquo;The staff really need something to brighten them up,&rdquo; Rosie said. &ldquo;This past year has been such a grind. If you can&rsquo;t do it, no-one can.&rdquo;

Carol rolled the idea around her mind and felt the familiar lead in the pit of her stomach. She did not entirely share Rosie&rsquo;s optimism.  As nice as it was to be asked, and to hear Rosie&rsquo;s enthusiastic endorsement, Carol knew that concrete improvements might not have emerged by then.  After everything the health service had been through, they didn&rsquo;t need to add public embarrassment at a conference to their list.  It was too big a reputational risk.

She shook her head. &ldquo;Sorry Rosie,&rdquo; she said as she sat down and picked up her phone.

&ldquo;Carol. We need this.&rdquo; To Carol&rsquo;s surprise, Rosie&rsquo;s normally cheery voice wavered.

 
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<pubDate>23 Dec 2018 08:37:00 GMT</pubDate>
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<link>https://www.qualityworks.com.au/qualitybites-blog/from-helpless-to-helpful-let39s-get-proactive-about-great-care_264s73</link>
<title><![CDATA[From helpless to helpful - let&#39;s get proactive about great care.]]></title>
<description><![CDATA[Learned helplessness is discussed a lot in healthcare. I&rsquo;ve heard it blamed for every ill from staff not speaking up for safety, to allowing chronic poor care to go unchallenged. From my perspective it is a key contributor to average or poor care. Too often I see or hear of situations where staff know that things need fixing but don&rsquo;t feel they can do anything about it, or have lost the will to aim for anything other than mediocrity.
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<content><![CDATA[However! The theory of helplessness being learned turns out to be a furphy. One of the original researchers in this area, Martin Seligman, has taken another look and concluded that learned helplessness is &lsquo;the default mammalian reaction to prolonged bad events.&rsquo; So, staff who have been bullied,  managed by strict command and control managers, or constantly discouraged from excelling or contributing their ideas, over a prolonged period, may suffer &lsquo;passivity and heightened anxiety&rsquo; because it seems it is the human condition to retreat in the face of these situations, for the purpose of self-preservation. So not so much learned, but automatic.

Feel a bit helpless now to do anything about helplessness?  Fortunately there is some good news as well.  The later research also gave some substantial clues on how to re-wire helplessness.  Apparently, hope is the kryptonite! Some people are naturally hopeful and optimistic and so avoid falling into helplessness, even when they experience situations where others succumb and give up.

But we don&rsquo;t have to depend entirely on people&rsquo;s internal optimism to overcome mediocrity. We can make a decision to actively cultivate hope in people to short-circuit helplessness.  Managers have the power to show that there can be a better way, or day, and that staff are valued contributors to making this happen.

These are salient lessons in the context of leading quality, and fit nicely with other related research that tells us that job satisfaction is reliant on staff feeling their role allows them to experience purpose, meaning, mastery and autonomy and acknowledgment.  Apparently the drive to create meaningful connections by helping others is also a key motivator, which should give us a significant advantage in healthcare, but clearly, we&rsquo;re not yet using it to its full potential. It seems that helping staff to build these drivers into their roles will repay leaders in spades: less helplessness, more proactivity,  better care.

But take a look at these role characteristics.  Each of them presents a challenge to the hierarchical and command and control human services environment.  I&rsquo;m reminded of the many conversations I&rsquo;ve heard in health services over the years when it comes to supporting staff to provide good care. Purpose: shouldn&rsquo;t they know what their purpose is and get about it?  Meaning: they get paid, don&rsquo;t they? Mastery: no, we don&rsquo;t want them to use their improve their skills or use experience and judgement &ndash; something might go wrong. And who do they think they are, anyway?  Autonomy: they can&rsquo;t just do what they like! I&rsquo;m the boss! Acknowledgment: they&rsquo;re professionals, why do they need a reward?

These conversations demonstrate a stubbornly persistent old school view of how organisations should work. But if this were the ideal organisational model for providing care, we wouldn&rsquo;t have the problems we do. Command and control creates a whole lot of unmotivated staff and learned helplessness, blocking the initiative and proactivity required to create great care every day.  So the very changes that will support great care are those that are the most threatening to the current management mindset and processes.  Where managers feel confident enough to provide these conditions for their staff to thrive, so does care. Where they&rsquo;re not, it doesn&rsquo;t.

With research consistently demonstrating the efficacy of supporting staff to thrive, not just survive, perhaps it&rsquo;s time for this to become a key tenet of improving care safety and quality.  Supporting these changes will require quality leaders to shift their own mindset and skills, and those of the managers around them.   Not an easy task!  But it&rsquo;s an essential step in our pursuit of great care.  So much effort goes into developing new protocols, standards, systems and training, but not so much into the people who must work with them.  In the end, staff belief in their contribution to creating greatness may be a missing link to improvement success.

Isn&rsquo;t it worth putting a little effort into developing this as well?

 
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<pubDate>23 Dec 2018 08:10:00 GMT</pubDate>
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<link>https://www.qualityworks.com.au/qualitybites-blog/when-we-hear-what-we-wish-we-hadn39t_264s80</link>
<title><![CDATA[When we hear what we wish we hadn&#39;t]]></title>
<description><![CDATA[Recently on a plane I pricked up my ears to this conversation  &ndash; roughly paraphrased &ndash; going on behind me:
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<content><![CDATA[Passenger A: &lsquo;Bob&rsquo;s just out of hospital again.&rsquo;

Passenger B: &lsquo;How is he?&rsquo;

Passenger A: &lsquo;They stabilised him and changed his medications, so he seems much more comfortable. Not sure I&rsquo;ll be able to convince him to go back there next time though.&rsquo;

Passenger B: &lsquo;Really? What happened?&rsquo;

Passenger A: &lsquo;Oh, you know, the usual.  Nothing too bad &ndash; it&rsquo;s just that he&rsquo;s getting sick of it.  They got his name wrong on the bracelet again and we had to complain long and loud to get it fixed.  I know our name isn&rsquo;t the easiest to get right &ndash; but that&rsquo;s no excuse.  Of course this meant that we had all sorts of fun and games with medications and tests &ndash; the staff listened to us even less than usual because half the time they thought Bob was someone else or they couldn&rsquo;t find him in their records. It&rsquo;s a miracle something didn&rsquo;t go wrong.

&lsquo;And those staff!  Some are nice but most of them don&rsquo;t give you the time of day. So how good the care is depends on who&rsquo;s on.  He even had a fight with the weekend physio this time.  I don&rsquo;t know what that was about. There was the usual drama with trying to work out when he&rsquo;d be discharged &ndash; this was really tricky for me &ndash; as you know I&rsquo;m travelling all over the place for work at the minute.  And I wasn&rsquo;t able to get in to see him every day because I&rsquo;ve been away so much &ndash; and when I did, he didn&rsquo;t look &ndash; or smell &ndash; very clean &ndash; said he hadn&rsquo;t had a proper wash since he was admitted &ndash; but surely that can&rsquo;t be right.  And the food!  Anyway, it&rsquo;s a pain, because the clinical care is good, and it&rsquo;s close to home &ndash; but Bob is very unhappy with everything else about it.  He thinks the sicker he gets, the worse they&rsquo;ll treat him as he won&rsquo;t be able to stick up for himself.  I don&rsquo;t know what we should do.&rsquo;

Passenger B: &lsquo;Have you talked to the GP?&rsquo;

Passenger A: &lsquo;Yes, but she thinks that it&rsquo;s all fine because they manage his condition well &ndash; she doesn&rsquo;t understand how important all the other stuff is to him. Oh good &ndash; food.&rsquo;

At this juncture, our snack was served and their conversation turned to airline food &ndash; also interesting but perhaps not a topic for QualityNews &ndash; although not unrelated to healthcare quality and this story.  (How was she rating the airline snack compared to Bob&rsquo;s hospital fare, I wondered?  And how different is the relative importance of food in both settings?)

What&rsquo;s your response to Passenger A?
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<pubDate>23 Dec 2018 08:28:00 GMT</pubDate>
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<link>https://www.qualityworks.com.au/qualitybites-blog/plan-to-be-great-not-just-to-survive_264s79</link>
<title><![CDATA[Plan to be great - not just to survive]]></title>
<description><![CDATA[The start of another year &ndash; and people are planning.  If you&rsquo;re reading this, you&rsquo;re probably developing an improvement plan for the year. &ndash; or thinking about it!
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<content><![CDATA[An improvement plan should be a simple task, but it&rsquo;s easy to  over-complicate it. Basically, you want to know: Where are we now? Where do we want to be X months/years from now? How will we get there? The tricky bit is often in the &lsquo;Where do we want to be?&rsquo; question. Quality improvement destinations can be hard to conceptualise, so we often end up describing what processes we want to have in place, rather than the destination we want to reach as a result. This is a bit like planning a holiday by making a list of all the things you have to do: packing, working out who will look after things while you&rsquo;re away, identifying the mode of transport and the activities you&rsquo;d like to include &ndash; without identifying where you&rsquo;re going. You may get organised and experience some fun activities, but do you end up in the best possible place?

Many quality plans are elaborate &lsquo;to do&rsquo; lists. These are satisfying to tick off as they&rsquo;re accomplished, but difficult to assess in terms of what difference all those tasks made. Quality programs can become three or four year groundhog cycles &ndash; lots of work and effort going into essentially the same tasks, showing the same results on monitoring graphs year after year. Without a clear idea of how you want thing to be different as a result of all those tasks &ndash; great consumer experience; positive staff attitudes and actions; strong organisational reputation; inspirational Board leadership &ndash; the tasks on your to do list become ends in themselves. And another year of hard work and frustration passes with the old challenges &ndash; staff and executive engagement, data collection and reporting, sustained change, meeting standards &ndash; just getting more challenging.

So always start your quality planning by first identifying and describing your desired destination for consumers and staff &ndash; in concrete, specific terms &ndash; and work out from there the processes and actions you need to get you there.
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<pubDate>23 Dec 2018 08:26:00 GMT</pubDate>
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<link>https://www.qualityworks.com.au/qualitybites-blog/ten-leadership-practices-for-great-care_264s77</link>
<title><![CDATA[Ten Leadership Practices for Great Care]]></title>
<description><![CDATA[&lsquo;If it doesn&rsquo;t happen in habit, it doesn&rsquo;t happen.&rsquo;

I&rsquo;m not sure who to attribute this quote to &ndash; possibly Steven Covey. If he didn&rsquo;t say it, he should have!  But whoever it was, I&rsquo;m a fan of this idea.  What&rsquo;s this got to do with the first QualityNews for 2017? As regular readers will know, I like to kick off each new year with something &ndash; a goal or challenge &ndash;  that inspires action to make care better at the end of the year than it is at the beginning.   This year, I&rsquo;m challenging you to master and implement 10 leadership practices that will kickstart your quality system, turbo charge your clinical governance and transform your consumer experience.
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<content><![CDATA[Most human services boards, executives and managers see themselves as quality leaders.  which is just as well, because they are! On my travels, however,  I see the same quality leadership mistakes over and over; usually made by well-intentioned people who think they&rsquo;re doing the right things, or don&rsquo;t realise they&rsquo;re doing the wrong things. As a result, they put time and energy into creating  lots of OK care, some terrible care, and occasionally, some great care. But occasional great care is not what we want, nor what consumers need.

The feedback from the Quality Intelligence Quiz in 2016 was also clear &ndash; &lsquo;we want to understand this stuff better!&rsquo; So over summer I sat down and listed the key leadership problems that I see &ndash; (which are also commonly discussed in the literature) &ndash; and gathered together my resources based on research and experience of what works over many years, to see if I could sort out some practical suggestions for more effective quality leadership practice (yes, my idea of a summer holiday good time.)  What should leaders do &ndash; consistently &ndash; to get a better return on their investment of time and energy? What started out as a plan to kick off QualityNews  2017 with a list of quality governance warning bells (which will happen in a future edition) morphed into something quite different.

What emerged was the &lsquo;Ten Practices of Great Care Leaders&rsquo; (with thanks and acknowledgement to Steven Covey for the concept.)  We talk endlessly about the importance of leadership in creating safe, high quality care  &ndash; and everyone nods sagely &ndash; but what does this mean in terms of every day actions?  There&rsquo;s some things that should be done, regularly and well, that will result in greater staff engagement in care creation and improvement; and some things that should not be done &ndash; ever &ndash; as they have the opposite effect.

Whether you&rsquo;re an old hand or an emerging leader, these practices apply to you! Use your leadership time more wisely! Challenge yourself, your board, executive, committees and department heads to stop doing the negative things and start doing the useful things.  Commit to creating new leadership habits by the end of 2017: maybe all ten, maybe just one. Even a small change gets you started on the path to achieving the great care you want your service to be known for.

The Ten Practices of Great Care Leaders

1. Make the pursuit of greatness a shared purpose across your organisation
It&rsquo;s not enough just to say we provide &lsquo;excellent/amazing/best in the world/best in the known or unknown universe care&rsquo;.  To claim it you have to prove it.  And to prove you do provide high quality care, and not just say that you do, you must define exactly what high quality care looks like at the interface between care giver and care recipient, and know how many consumers experience it.  This takes grit, determination, clever planning and relentless action &ndash; all with your staff and consumers. &lsquo;Hoping&rsquo; that care is great is not a strategy. &lsquo;Trusting&rsquo; that everyone out there is doing a great job is not a measure.  The pursuit of greatness must be meaningful to what staff do every day, or it will remain a boardroom dream. Work with your staff and consumers to create a model that shows &ndash; on one page &ndash; exactly what &lsquo;greatness&rsquo; means for every one of your consumers, and the specific roles everyone in your organisation plays in pursuing it.  If front line staff and managers don&rsquo;t find the model relevant and helpful to their work, revise it with them until it is. Make it so clear and straightforward that it also passes the &lsquo;take home test&rsquo;; that is, when you test it on your family, they don&rsquo;t run screaming from the room, afraid they will otherwise die a slow death from boredom, confusion or sheer ridiculousness.  If your staff and family say &ndash; &lsquo;yep, that makes sense, get on and do it&rsquo;, you&rsquo;re on a winner.  If they also say &lsquo; looks great &ndash; let me at it!&rsquo;, you&rsquo;ve hit the jackpot. Patent it immediately and get on the international speaking circuit.

2. Pursue greatness with aspiration and realism
Over-confidence about the quality of care experienced by your consumers is the biggest of the big red flags when it comes to effective quality governance. Yes, set an aspirational goal to achieve great care for every person, every time and pursue it with gusto.  But be realistic about what it takes to get there.  Doing anything consistently well in a complex system such as your organisation is hellishly difficult, because of the sheer number of factors involved, and the way they react with each other.  Just like the road system, achieving a good day takes more than good people, trying hard.  More than committees, reporting and rules.  It requires great people, surrounded by great systems, actively supported every day by great leaders.   Creating quality care is a dynamic pursuit, not set and forget. There are many boulders on the road to great care; don&rsquo;t pretend they&rsquo;re not there. Actively seek them out and get about blowing them up, and be on the lookout for new ones.

3. Know thy consumer as thyself
Be insanely curious about what goes on for the people under your roof/your care. Remember that there are human beings with real feelings, in some sort of physical/psychological pain, on the receiving end of your organisation&rsquo;s services. They are not some sort of mysterious avatar.  What they want is what you want. To be treated with courtesy and compassion.  To know what&rsquo;s going on in a way they can discuss with their loved ones.  To be as physically and psychologically comfortable as possible. To be given real choices, where possible,  that take their lives and families into account. Treatment that gets the job done. Consistent, accurate messages about their progress. Not to be harmed. Focus your quality and governance systems on achieving these things, starting with an honest assessment of how well they are done now. If I came into your service as an &lsquo;undercover&rsquo;  consumer, to what extent would I experience these things? Would it depend where I was in the service?  What shift I presented to?  Who was on? Remember, one day it will be you, or a member of your family. You&rsquo;ll be grateful, when you&rsquo;re on the receiving end, if the service you end up in read this in 2017 &ndash; and acted on it.

4. Stop &lsquo;doing&rsquo; quality
&lsquo;Doing quality&rsquo; makes no sense.  When staff say they are &lsquo;doing&rsquo; quality, this is not a good sign.  Usually it means they see &lsquo;quality&rsquo; as a series of tasks they would really rather not be doing, rather than the experience they&rsquo;re creating for consumers.  Using this term is cementing a negative mindset about the whole process of improvement. There are only two verbs associated with quality: you&rsquo;re either creating great quality care &ndash; or you&rsquo;re supporting someone else to create it.  That&rsquo;s it. This also goes for &lsquo;having&rsquo; clinical/quality governance. Let&rsquo;s get a bit more energy into the equation: &lsquo;We govern for great care&rsquo;.

5. Understand that &lsquo;Everyone is responsible for quality&rsquo; probably means that no-one is
If &lsquo;everyone&rsquo; is responsible, that means there are plenty of other people to fix a problem.  Which means it&rsquo;s not my problem. Unless individuals understand their specific role in creating great care (and receive specific support for that role) they are unlikely to enact it. Here&rsquo;s a challenge: aim to get a critical mass of staff in your organization answering the &lsquo;who is responsible for the quality of care in your organisation?&rsquo; with: &lsquo;I am &ndash; and let me tell you exactly how&rsquo;.  Embedding that change in understanding alone will transform the quality of your care and consumer experience.

6. Hold a blowtorch to jargon and fads
Einstein said: &lsquo;If you can&rsquo;t explain it simply, you don&rsquo;t understand it well enough&rsquo;. Conceptually, the pursuit of quality care should be simple, but is often over-complicated. Quality is created by the people who provide and experience the care. Tools and methods are only as good as they help people create great care together. This is the test of any quality system, tool or method.  Confusing and annoying these people by waving shiny things with unintelligible names at them is not a smart strategy.  Staff will judge you on your ability to make the process for creating, monitoring and embedding great care simple, relevant and helpful, not on your command of quality-ese. As with any tool, &lsquo;new&rsquo; is not always &lsquo;improved&rsquo; &ndash; and sometimes it is.  The really skilled people are the ones who can sort this out: &lsquo;will this new tool or approach help or hinder us in out pursuit of great care?&rsquo; Under the layers of jargon and fancy wrapping, most quality tools and methods exist to help you plan, detect, implement, streamline or measure. Choose the tools &ndash; old and new &ndash; that help you do these things in the easiest most effective way, explain them in plain language, and your staff and consumers will thank you.

7. Remember that people support what they help create
Designing new policy, processes, rules and training without the people who are charged with their implementation, and expecting positive engagement and sustained change, is a path to madness and despair.  On the bright side, this commandment also reminds you to seek the people who are creating great care and acknowledge them.  Focusing on the things that go wrong doesn&rsquo;t inspire people to do them right.  Seeking and learning from the good stuff is every bit as important as fixing the bad stuff. Find the amazing thing people are creating in your service and spread them like mad.

8. Live the truism:&rsquo; Information drives understanding, but feelings drive action&rsquo;
To engage people in creating great care, hit them with the facts, and then get out of your head and paint the human picture that shows the need for change. There&rsquo;s a reason that car ads spend their precious expensive minutes more on feelings than facts. If you can get both the &lsquo;Oh, that&rsquo;s interesting&rsquo;, response to the facts, and a &lsquo;Wow, we should do something about that!&rsquo; gut response, you&rsquo;re at least 78%* more likely to have enthusiastic participants in the change. (Well, a lot more likely.)

9. Ask three defining questions at every meeting
So many graphs, so much paper.  What did your latest quality-related meeting achieve? Did it get you closer to achieving your purpose? Or was it a procession of process, a cavalcade of compliance, with the impact on point of care concealed in the mists of mediocrity? [OK, enough alliteration.] Put all that information and time to work!  At the end of every meeting ask &ndash; and answer &ndash; As the result of this meeting:

Are we on top of our risk and poor care hot spots?

How well are we supporting staff to achieve great care for every consumer?

Are we clear about the actions we will take to progress great care for every consumer between now and the next meeting?

10. Lead with Quality Intelligence
We&rsquo;re not born with the knowledge required to lead the creation of great care. Improving safety and quality is a technical specialty, requiring Quality Intelligence: a specific set of knowledge and skills. But it&rsquo;s easy to fall into the trap of thinking the bureaucracy of quality is all there is to creating high quality care.  Leaders work hard to put in place governance systems, care processes, committees, compliance, improvement activities, measures and reporting.  But these are just supporting structures. The quality of the consumer experience hinges on people: the motivation and ability of managers and staff at point of care to create consistent greatness from the chaos of complexity.  This requires leaders to understand how to create consistently safe, great care within the complexity of their organisations. They must develop the right organisational mindset, define great care and support staff to implement the right actions to achieve it, based on the reality of the challenge. They must point everyone in the same direction, and build teams that display resilience and proactivity.  Systems must be designed to support and guide great practice, and an accurate picture of progress towards great care painted with robust measures. Leading the human side of quality requires leaders who go beyond the bureaucracy of quality to develop a deep understanding of what this really takes.
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<pubDate>23 Dec 2018 08:21:00 GMT</pubDate>
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<title><![CDATA[Data, data everywhere - but is it telling us what we need to know?]]></title>
<description><![CDATA[Data, data everywhere&hellip; some of it useful for improving care, some of it not and a whole lot in between. Never before have health services collected, studied and discussed so much data about care safety and quality&hellip;and yet, the mindset and strategy required to make this a useful exercise are often missing. 
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<content><![CDATA[The health services in my part of the world are about to be supplied with more and better data, courtesy of a recent state-wide review of quality and safety. This is a good thing, if course &ndash; but if that&rsquo;s all it took to create great care, well&hellip; The way data are reported, and the mindset of those who rely on reports to govern the quality of care, determine whether the hours spent preparing and discussing the information are worthwhile, or wasted. In my experience there are five (at least) distinct data report types at the highest levels of governance that differently influence how governing bodies respond to the information, and the impact on care. Which one is yours?
The Work of Art: the report presentation is so dazzling and multi-factorial that the board just sits back and admires it. Anything that looks this impressive must be good! And any quality manager and executive who can produce it must know what they&rsquo;re talking about. No need for scrutiny. The result? A superficial understanding of the quality of care and a false sense of security. May lead to nasty surprises and lack of understanding and appropriate response when a sub-optimal care issue bursts the bubble.

The Terminator: a relentless focus on the things that go wrong. The emphasis is on key risks and compliance breaches. The board doesn&rsquo;t realise there are many other aspects of care that are equally important to monitor, discuss and improve. The result? Many blind spots about the true quality of care, and other issues of importance to consumers and clinicians are ignored. Key risks may be well managed, but there&rsquo;s little significant improvement in overall care.

The Rinse and Repeat: the same stuff is reported over and over and over&hellip; useful or not, often with more or less the same &lsquo;average&rsquo; results. Data are used for reassurance that everything is OK, rather than to inform a drive towards excellence. The board may be frustrated, but not know how to ask for a broader view of the quality of care provided, or for significant improvements to be made. The result? Mediocre care may be seen as acceptable or normal, and a narrow view of what constitutes high quality care is perpetuated.

The Politician: reporting is designed to draw board attention away from results that indicate that all is not well. &lsquo;Nothing to see here &ndash; and if there were, we&rsquo;d have it under control.&rsquo; Frequently accompanied by &lsquo;boards should stay out of operations&rsquo;. The result? May contribute to catastrophic failures, severe harm and generally poor care, and associated dereliction of governance duty.

The Action Hero: reporting is organised to inform and guide the action required to achieve and maintain high quality care. Action heroes know they can&rsquo;t save everyone at once, and the data are crafted to help the board prioritise precious resources to maximise impact where it counts &ndash; at point of care. As with all action heroes, sometimes action is taken precipitously, or not where it&rsquo;s needed, particularly if the action hero is employed without their trusty &lsquo;understanding of variation and complexity&rsquo; side-kick. The result? A shared and balanced view of the components of high quality care, are actively monitored, managed and improved; with occasional reactive and wasted actions which don&rsquo;t help anyone improve anything.
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<pubDate>23 Dec 2018 08:20:00 GMT</pubDate>
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<title><![CDATA[Does your quality system detect neglect?]]></title>
<description><![CDATA[Does it? And &ndash; if you&rsquo;re running an acute healthcare service, how long could a consumer go without being offered a wash? These questions have been exercising my mind lately, as I see more and more quality systems focused on risk and compliance, with a bit of improvement thrown in to meet accreditation standards. And reactive risk and compliance at that. Of course standards must be met and risks managed &ndash; but driving and supporting the whole consumer experience requires more than that. Imagine the elements that would be missing from other people-related industries such as hotels and aviation if they only met technical standards and managed risks.
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<content><![CDATA[We&rsquo;ve evolved risk management to identify and name key risks, such as pressure injuries and consumer identification, so we can detect, report and count when these things go wrong &ndash; and do something about it. This has transformed staff understanding of risk and the need to manage it to prevent harm. But instead of taking this process and applying it to other aspects of care, we seem to have plateaued.

It&rsquo;s time to move on!  &ndash; to getting the care basics right &ndash; consistently. There&rsquo;s no doubt that this happens in every organisation &ndash; in pockets. But very few health or aged care services are confident of it happening for every person, every time. What if we applied the same focus to this as we do to risk?; identify the basic care components that need to go right, increase staff understanding of why they&rsquo;re important, work them into the fabric of daily routines, and detect and report when they are not happening.

Many people say that basic care components are &ndash; or should be &ndash; self-evident, so we don&rsquo;t need to be explicit about identifying them. Well, we used to say that about risk and harm too; before the Quality in Australian Healthcare Study showed us that we didn&rsquo;t know as much about the scope of harm &ndash; and why it was happening &ndash; as we thought we did.

We don&rsquo;t need to develop key care components from scratch of course. It seems to me that the US Institute of Medicine (IOM) got it right all those years ago by identifying the dimensions of healthcare quality: safe, effective, patient-centred, timely, equitable, and efficient.  Interestingly, these were expressed as aims for every healthcare episode, not just dimensions. They are meant to be proactive guides.

Many of you will know that if you ask the right questions of any audience &ndash; healthcare professional, manager or consumer &ndash; about what&rsquo;s important in a health or aged care episode, they identify these dimensions. Not in these words at first &ndash; generally, they&rsquo;ll describe the actions within each of these dimensions that they want from a healthcare experience. Safety is a critical dimension, of course &ndash; but, interestingly, actions related to effectiveness are almost always discussed first, closely followed by issues describing responsiveness to the individual. Continuity and integration of care, seldom seen in current quality systems, also features in what people want from their healthcare. Discussions about aged and community care identify the same dimensions, but the actions within them differ, relative to the sector.

What&rsquo;s this got to do with a quality system detecting neglect? Everything! Lately, I&rsquo;ve taken to asking workshop audiences and quality managers one critical question to ascertain where their quality system is up to:

&lsquo;Would your quality system detect and prevent a Mid Staffordshire &ndash; like decline into poor bedside care and neglect of patients in your organisation?&rsquo; (see http:www.midstaffspublicinquiry.com/)

This turns out to be a great question because it makes people stop and think &ndash; &lsquo;would it?&rsquo; If your quality and risk system relies mostly on incident reporting and accreditation, the honest answer is probably &lsquo;no&rsquo;.   Clinically-related accreditation standards certainly help &ndash; such as the National Safety and Quality Standards in Australia, as they set a high bar for key clinical processes, requiring changes in staff behaviour and proactive monitoring and review.

Mid Staffordshire showed that good care is about much more than this, however. We know staff are pressured, rushed and, at times, frustrated with their jobs.  This environment favours task completion, rather than care. Things get missed and corners cut in the complexity and the rush. But which ones? Would your quality system detect if patients weren&rsquo;t eating and drinking? Being washed and taken to the bathroom? Having their pain relieved? Understanding what was happening to them? Feeling respected and consulted? Being treated according to best available evidence?

Some people respond that their death review process picks up a lot of issues. And done well, it does. After the event, unfortunately. Is this process working to identify care issues as well as technical clinical issues, however? I wonder how much general &lsquo;poor care&rsquo; contributes to preventable deaths.

My motivation for wanting health and aged care services to be as focused on components of care as they are on key risks is mostly about improving the consumer experience. But that&rsquo;s not all. For me, it&rsquo;s also about health, aged and community organisations having the satisfaction of moving beyond monitoring and reacting, to achieving their potential for doing good. It&rsquo;s about healthcare professionals and quality managers enjoying being proactive and making a real difference. I&rsquo;m not seeing as much of that as I used to. Many quality managers, in particular, are looking more like administrators that technical experts. This does not make for great job satisfaction, as evidenced by the revolving door of people moving in and out of quality roles (which in turn, does not build a solid base of technical expertise&hellip;)

Have a think about your bedside/chairside care, beyond clinical standards. Are the key components and expectations of basic care clearly defined with staff? Have consumers had input into what&rsquo;s important to them? Are you proactive in detecting care &lsquo;slippage&rsquo;? Or do you only know when it turns into a complaint, or you hear about it at the local supermarket, or in the press? How does your organisation respond?   Sighing about the staff? Or developing a better system of care that guarantees the basics of care for every consumer?

Oh &ndash; and how long can consumers go without a wash in the acute sector? Can&rsquo;t answer that unequivocally. But so far the record is eight days.
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<pubDate>23 Dec 2018 08:19:00 GMT</pubDate>
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<link>https://www.qualityworks.com.au/qualitybites-blog/the-dangerous-39everyone-comes-to-work-to-do-a-good-job39-belief_264s74</link>
<title><![CDATA[The dangerous &#39;Everyone comes to work to do a good job&#39; belief]]></title>
<description><![CDATA[How would you like a report into an organisation you are associated with to be called &lsquo;A Shameful Chapter&hellip;&rsquo;?  No, me neither.  And yet this is now the case for many people who are, and have been for the past decade or so, associated with the Oakden Older Persons Mental Health Service (Oakden facility); with the release of the latest in string of reports on suboptimal care at the service.
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<content><![CDATA[The South Australian Independent Commissioner against Corruption (ICAC) report: &lsquo;Oakden &ndash; A Shameful Chapter in SA&rsquo;s History (Feb, 2018) discusses &lsquo;systemic failings in processes and oversight that allowed events at the Oakden facility to occur for more than a decade&hellip;&rsquo;  Many of you will know the story.  With regret I write that it is not an unfamiliar one in health and aged care.  Care was poor or absent, the facilities were described as &lsquo;a disgrace&rsquo; and complaints and improvement mechanisms designed to detect and fix problems were ineffective.

There are many issues in this report worthy of discussion and learning.  I hope that your organisation is taking the opportunity to use the report findings to do a &lsquo;care stocktake&rsquo;, whatever sector you&rsquo;re in.  We know that, in the complexity of human services, the standard of care is not set and forget; it goes up and down in response to changes in the many interdependent factors making up care delivery. Everyone can benefit from a regular care quality reality check. If the whole human services sector doesn&rsquo;t grab the opportunity to make positive changes as a result of the lessons from this, and other associated inquiries,  the Oakden residents&rsquo; suffering was all for nothing.

Everyone&rsquo;s out there doing a good job&hellip;
I want to focus on one aspect of the findings, related to this quote from the report: &lsquo;The problem was the regime that existed that enabled the Oakden facility and its operations to deteriorate to such an extraordinarily poor state, and to operate in that way for such an extended period of time without any meaningful intervention&hellip;.for this reason I think this report ought to be considered by all public officers in positions of authority, irrespective of the agency within which they are employed.&rsquo;

This sort of statement is made in just about every inquiry into poor care, and I&rsquo;ve become interested in the &lsquo;why&rsquo; behind this &ndash; because although we know the issue, it&rsquo;s far from fixed.  The relevant report recommendation for the purposes of this discussion is No.3: &lsquo;The CE (of the Department of Health and Ageing) and the CEOs (of the Local Health Networks) implement a structure to routinely remind all staff working at a treatment centre of the management structure in place at the centre; the assignment of responsibilities&hellip;and the expectations and responsibilities imposed upon each member of staff&hellip;&rsquo;

There it is &ndash; the thing I would wave my wand over if I only had one spell, because it would transform care in an instant: personal responsibility for the quality of care provided to consumers.  This is a critical but often overlooked ingredient in all instances of poor care, and seldom discussed in depth at conferences or in scholarly articles about clinical governance and fixing care problems.  And yet &ndash; isn&rsquo;t responsibility the cornerstone of clinical governance?

I don&rsquo;t often see the practice of personal responsibility prioritised in most health services. We talk about it &ndash; but real action is often headed off at the pass by the &lsquo;good people come to work to do a good job&rsquo; statement, often followed by &lsquo;everyone here is responsible for quality.&rsquo;  I&rsquo;d bet good money on the fact that both these statements were regularly heard around Oakden &ndash; as they are in most human services. But these beliefs are dangerous; not only do they give us a false sense of security, but they excuse senior and middle managers from doing the hard yards (and within the politics and constraints of most organisations, they are hard yards) required to create and maintain the personal responsibility and accountability of every one of their staff, by:
&#xF0D8;    Clarifying and agreeing specific personal roles in providing safe and high-quality care
&#xF0D8;    Providing the management and systems support to assist staff every day to enact that role and fulfil their responsibilities
&#xF0D8;    Effective processes, based on a &lsquo;just&rsquo; culture,  for calling staff to account and implementing the responsive action required when accountability falls down.

If these were a given, quality and safety systems and clinical governance would be able to get on with the proactive job of supporting staff to drive and lead the pursuit of consistently high-quality care for consumers. But without the personal accountability component in place,  quality and safety systems end up as spotters and rescuers; focused on identifying poor care and trying to do something about it.  Ironically, most of the &lsquo;quality improvement&rsquo; remedies that are put in place via extra training, policy and process change, or projects to introduce new practice are doomed precisely because they require personal responsibility to be properly implemented.  In the end, except for systems, equipment and IT-related &lsquo;forcing functions&rsquo;, most quality and safety improvement relies on the people who must work with the change wanting, and being equipped, to fulfil their accountability for the quality of care they provide.

The degree of difficulty increases exponentially when, as the report goes on to say, &lsquo;many staff thought that Oakden was a dumping-ground for those staff needing performance management.&rsquo; There we go on the merry-go-round of suboptimal care; put poor performers into challenging services and&hellip;hope? &ndash; that good care will result.  I know, think about it and your head spins and your ears buzz.   In any other high-risk industry we&rsquo;d have gone out of business years ago.

Everything about this indicates services that are organised primarily around the needs of managers and clinicians, rather than consumers. This is where healthcare has come from, of course: great, committed people, doing great work as the foundation of great care.  But, although a cornerstone of great care, we now have &lsquo;new knowledge&rsquo; that tells us this is not enough.  We know, from two decades of data and inquiries and learning about how to create safety in complexity, that everyone can have a bad day; be skewered by a weak system,  overwhelmed by volume, or just make a basic human error.  This applies to the people who come to work to do a good job &ndash; and those who just come to work to do a job.  All staff need daily, active, focused support &ndash; from leaders, managers and systems &ndash; to be their best.

Weak management = weak care quality 
I don&rsquo;t think we really believe this &lsquo;new knowledge&rsquo; however. Dumping the poor performing staff in a facility with the most challenging and vulnerable residents, who need those staff to be skilled, competent and above all caring, is a pretty big indication that we don&rsquo;t. I suspect that &lsquo;everyone comes to work to do a good job&rsquo; is a stronger belief &ndash; even when we know it isn&rsquo;t always true. We accept this contradiction with an ease born of learning at the knees of our predecessors.  We grow up with it. Everyone in an organisation knows that mistakes are made, that care quality goes up and down and which service you&rsquo;d avoid if you were a patient.  We know where the poor performers are; which service they are sent to &lsquo;retire&rsquo; (if we can&rsquo;t get them out on &lsquo;gardening&rsquo; leave) &ndash; if indeed we try to manage them at all.  (And too often the &lsquo;retirement&rsquo; plan is a job in the quality and safety unit, which in turn perpetuates weak quality systems&hellip;sigh.)

I get it.  The more senior the manager the more &lsquo;up and out&rsquo; they are expected to be; aware of the corporate office or Department surveillance and  funding imperatives; fitting 20 patients into one bed whilst hitting the KPIs; preparing reports for high level committees (much of which is about care safety and quality, ironically, but often a narrow view that doesn&rsquo;t pick up issues of neglect) and generally keeping the organisation looking good. That&rsquo;s a big part of their job.

Unfortunately, in the rough and tumble of all this &ndash; and make no mistake, these jobs are not for the faint-hearted &ndash; point of care can get lost.   It seems everyone is working around the care, rather than on it. There&rsquo;s no line of sight between decision makers and what consumers experience. This is particularly so if an organization hasn&rsquo;t clearly defined the quality of care they want to create every day &ndash; in concrete terms, with the assistance of consumers and staff, and made achieving it a strategic, business and value priority.  In the absence of this, the &lsquo;staff come to work to do a good job&rsquo; mantra fills the vacuum, and it&rsquo;s easier for busy managers to just focus on their jobs, assuming that others are out there doing theirs.

In the research into quality systems&rsquo; effectiveness I&rsquo;ve been involved with over the past three years, this was a consistent theme. Even in the face of evidence to the contrary, in the form of the many reports on incidents and safety issues crossing managers&rsquo; desks, and discussed ad infinitum in committees, I&rsquo;ve never seen &lsquo;turn our managers into high performing superstars as a matter of urgency&rsquo; recommended as a remedial action. Yet this would fix a lot of common care problems.  It seems to me that we propose just about anything but, in a series of repeated workarounds. Why? Because &lsquo;management&rsquo; is too hard, or too boring, or too political, or too &lsquo;soft&rsquo; to tackle?  Perhaps clinicians just don&rsquo;t get the critical importance of management skills and competence in the same way they do clinically. Or we just don&rsquo;t prioritise it:  we accept that poor care is part of what we do, employ some quality improvement, and move on. Is it just a bad case of cognitive bias and over-confidence on the part of the senior managers?: &lsquo;we must be good because we&rsquo;re us!&rsquo;  It&rsquo;s probably a mix of all of these. Bottom line though:  expecting strong quality of care in services with weak managers shows we healthcare types to be not as smart as we think we are.

Can&rsquo;t the quality system fix it?

Of course, quality and safety systems that detect and fix poor care are important.  But ultimately they are only an aid to providing consistently high quality care for those charged with making it happen.  And it&rsquo;s so easy to just go through the quality motions. Many of these systems appear to be in place because they are required for accreditation &ndash; which is understandable when you remember that &lsquo;everyone comes to work to do a good job&rsquo; &ndash; so why do we need all this other stuff apart from accreditation?  It can all look good on paper but not paint a picture of what&rsquo;s really going on at the bedside. From the report:

&lsquo;The committee process was too cumbersome to be effective&hellip;but it also suffered from the further defect that complaints and reports were not the core business of the committees but were matters that were incidental to their business. Whilst the committees that were in place were in theory appropriate, in practice they were ineffective&hellip;the committee structure was dependent upon the effectiveness of the person chairing the committee.&rsquo;

For now, I&rsquo;d like to finish by thanking those of you out there who are doing the hard yards of equipping your managers for their critical roles, because caring for consumers really does come first. Who do define high quality at point of care and align your organisations around achieving it for and with every client, consumer, resident and patient (and a special shout-out to those using the strategic quality system to do it!)  Who understand that high quality point of care is a function and outcome of a chain of line managers, right from the top, populated by skilled and supported people. You remember what it was like when &lsquo;matron&rsquo; was all-seeing &ndash; and emulate it in a modern context. I&rsquo;d clone you if I could.  In the absence of that option? &ndash; I&rsquo;m waiting for the robots.

 

Reference:

https://service.sa.gov.au/cdn/icac/ICAC_Report_Oakden.pdf
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<pubDate>23 Dec 2018 08:16:00 GMT</pubDate>
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<link>https://www.qualityworks.com.au/qualitybites-blog/my-new-book-the-point-of-care-is-now-available_264s69</link>
<title><![CDATA[My new book: The Point of Care is now available!]]></title>
<description><![CDATA[Looking for an easy way to build your quality leadership knowledge and skills?  In The Point of Care, I take organisational improvement from the dry and technical topic it can be and embed it in the story of a health service trying to make a difference against the odds and against time. 
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<content><![CDATA[Carol Mathewson has a problem. Lots of them, in fact.  As the new CEO of Kinsley Valley Health Service, she&rsquo;s taken over the helm of an organisation that ranks last in the state for both consumer and staff satisfaction. She loves a challenge&mdash;but having just six months to get those results out of the basement is more of a challenge than she bargained for. Her Executive Team is divided, many staff are resistant to change and there are players inside and outside of the organisation willing her to fail.

This is a story that anyone in health and human services can relate to, and can help get the key players in your organisation about what a quality system is, and what it can do for your consumers, your staff, your organisation -  and you!

And it&#39;s not just a story; all throughout are my best tools, tips and models for creating consistently great care in your organisation, including: leadership, change, planning for great care, implementation, improvement, staff engagement and cultivating the right mindset for the best results.  

Anyone in a leadership role in a health or human services organisation, responsible for providing a great service, will relate to and be able to apply The Point of Care lessons and tools. 

I hope it helps you in your quest to create great care with your consumers.
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<pubDate>01 Dec 2018 04:31:00 GMT</pubDate>
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<link>https://www.qualityworks.com.au/qualitybites-blog/is-your-quality-system-road-leading-you-to-greatness-or-are-you-stuck-in-the-compliance-carpark_264s67</link>
<title><![CDATA[Is your quality system road leading you to greatness? Or are you stuck in the compliance carpark?]]></title>
<description><![CDATA[Here&rsquo;s a simple question to ascertain if your organisation is on the road to consistently high quality care.
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<content><![CDATA[Here&rsquo;s a simple question to ascertain if your organisation is on the road to consistently high quality care.

What does your organisation&rsquo;s quality system manager/team spend most of their time doing?

No doubt many of you were hoping for something more inspirational; perhaps a question about culture or unveiling the secrets of data and reporting. But! &ndash; before you abandon this article, think about it for half a minute. The answer to this question is loaded with information about the quality of care your organisation provides.

Why? Because &lsquo;every system is perfectly designed to get the results it gets.&rsquo; Sound familiar? An oldie, but oh, what a goodie! I&rsquo;m resurrecting it because it reflects precisely what we&rsquo;ve found in our research on what makes an effective quality system. Show me the quality manager preoccupations and I&rsquo;ll predict what&rsquo;s going on with quality at point of care. If it&rsquo;s all about compliance, it&rsquo;s likely that point of care staff see &lsquo;quality&rsquo; as an extra set of tasks they must &lsquo;do&rsquo; and that your care quality is comprehensively parked.

A compliance-based quality system does not promulgate the mindset or behaviours required to provide consistently high quality care. Even if managers and staff are using compliance intelligently and applying it to improve, you might have safe, accessible care, in partnership with consumers, as these are the areas targeted by compliance requirements. No complaints if you&rsquo;re achieving these consistently with every consumer, of course. But beyond these there will be gaps in your high quality experience jigsaw puzzle. Gaps that consumers &ndash; and staff &ndash; would rather not be there, such as care appropriateness and effectiveness, and coordination and integration of care.

Consumers and staff cannot live by compliance alone.

It is impossible, in the complexity of health and aged care, to provide consistently high quality care through compliance alone in a complex health or aged care organisation; it&rsquo;s just not the way these organisms work.   Of course compliance provides significant jigsaw pieces for our puzzle. It&rsquo;s not an either/or. But without the box top that provides the organisational view of what consistently high quality care looks like, designed by consumers and all levels of staff; and an executive-led strategy for making it the reason people come to work every day, you&rsquo;ll never complete the &lsquo;high quality care&rsquo; picture. If your quality system is mostly about compliance, you&rsquo;ll have wins in some areas, but will not create an organisation that provides consistently high quality care as business as usual.

Executives will get exactly what they prioritise 

The quality manager and team role often reflects the executives&rsquo; understanding of what a quality system should deliver. This is a big statement, especially as this understanding is often linked to funding and political requirements, rather than a clear and consistent vision of what boards and executives want to achieve for their consumers. It seems that these external expectations have narrowed over the past decade as we seek to plug the safety gaps we lived with for too long.  Our focus has zig-zagged from clinical outcomes to compliance audit; from safety and risk to consumer participation, in no apparent order.

The potential of the quality systems manager role appears to be restricted by the knowledge of those doing the hiring. If boards and executives don&rsquo;t know what they don&rsquo;t know about creating consistently high quality care in a complex environment, they&rsquo;re unlikely to go looking for a person with the skills that can help them to pursue this. If they see &lsquo;quality&rsquo; as the mechanics of quality: the audits, incidents, reporting and committees, rather than the point of care purpose, then that&rsquo;s what it will be. From my perspective this is a significant contributor to the slow pace of improvement and change in the quality of the care health and aged care services; while we&rsquo;re focused on the governance engine room, there&rsquo;s no-one on the bridge steering the ship towards a designed destination.  So we are blown about by the winds of fad, fashion and funding, and a lot of the hard work and good intent gets lost in the sea of confusion.

Consistently high quality care is harder to achieve than a balanced budget

Our research into what makes an effective quality system highlights this. Too often the board and executive beliefs about the quality of care are overly optimistic, because &lsquo;good staff are out there doing a great job&rsquo;, with their successfully ticked compliance activities supporting this. If only that&rsquo;s how it worked! Our complex organisations are as far away from that as Pluto is from the Sun. Consistently high quality at point of care is an ongoing challenge, every bit as tough as keeping the budget in the black &ndash; and look at the focused work that goes into that. Finance plans, systems, budgets, committees, lots of board and executive time, training for managers, reporting, accountability. It&rsquo;s viewed as a vitally important and ongoing pursuit, requiring knowledge and technical skills across the board and executive, with specialist expertise in the finance team. It&rsquo;s difficult to imagine a CEO appointing a finance manager on the strength of them &lsquo;being organised&rsquo; or &lsquo;good with numbers&rsquo;.

The pursuit of consistently high quality care is the same &ndash; but harder. It requires everything that well-managed finances requires &ndash; and more. In the same way as managing the budget happens, managing the quality of care is a line management responsibility. The quality systems manager provides systems and technical support, as the finance manager does, but they can&rsquo;t create what&rsquo;s required at point of care. The senior and middle managers&rsquo; job in any service is not just to provide a service and get their staff through the day &ndash; but to provide a high-quality, well managed service. This bit is not an optional extra, but fundamental to consumers receiving consistently high quality care. All consumers receiving consistently high quality care requires a whole of organisation approach; and you can&rsquo;t achieve that without the whole of the executive, and managers at all levels, having the &lsquo;will and skill&rsquo; to deliver it.

Our research indicates that both the understanding and messages around this are very mixed. Most clinical managers and staff would like more help with understanding how their consumers are travelling &ndash; beyond the constraints of accreditation and other external compliance. Achieving both compliance and support for clinicians to progress their standard of care can be done. But it requires a strategic, planned and systematic approach that embraces both standardisation and clinical judgement; responsivness and proactivity,  to achieve a defined view of high quality care for every consumer.

To the consumers, boards, CEOs, executives, quality systems managers and bureaucrats out there valiantly striving beyond compliance to create a strategic and comprehensive great care experience &ndash; I salute you! And those still thinking about it? Make 2018 the year you make your mark on the &lsquo;great care&rsquo; map.

References

&lsquo;Every system is perfectly designed to get the results it gets&rsquo;: variously attributed to Arthur Jones, W. Edwards Deming, Paul Batalden and Donald Berwick.

Leggat SG, Balding C (2017) A qualitative study on the implementation of quality systems in Australian hospitals. Health Services Management Research, Volume: 30 issue: 3, page(s): 179-186, August, 2017.

http://journals.sagepub.com/doi/10.1177/0951484817715594

Juran Institute: http://www.juran.com
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<pubDate>27 Nov 2018 04:22:00 GMT</pubDate>
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