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Evidence based management
Abstract
Although waiting to witness flamingos in flight is a great improvement on pigs, I believe Hadridge and Pow (JRSM 2008;101:7–11)1 understate some of the issues to be addressed before the NHS flock can take to the air. Their exhortation to have more confidence and curiosity, become more connected and show more compassion would seem worthy enough, but their strategy for inducing the cultural change required to ‘sort out’ the health system stops short of describing meaningful action below the layer of high level organizational leaders. This may be an unfortunate emphasis, as previous calls for studies to increase our improvement effectiveness have highlighted issues associated with the inverted power structure of healthcare organizations and the need to explore and understand this dynamic.2
In contrast to Hadridge and Pow, though sharing similar objectives, Keroack and colleagues3 describe how they developed and used a composite index of quality and safety, based on patient-level data and the six attributes of an ideal health system articulated by the US Institute of Medicine: safe, effective, timely, efficient, equitable and patient-centred.4 Keroack et al. looked in depth at 79 US Academic Medical Centres and identified a distinctive set of behaviours and organizational practices which were uniquely associated with the top-performing hospitals. Although themes identified by this group have clear echoes with Hadridge and Pow's ‘four Cs’, the work of Keroack et al. might help further NHS organizational quality improvement in at least two important ways. First, by describing an approach that produces robust evidence supporting the value of specific operational practices it helps address the increasingly heard call for evidence-based management. Second, by encouraging the pursuit of improved healthcare through interventions at levels deeper than senior leadership, it brings a focus to the interface between those in service-line clinical leadership positions and front-line workers. Having experienced healthcare improvement efforts from the perspective of a Medical Director, Clinical Director and front-line clinician, I suspect that effective engagement at this interface may be a crucial factor if NHS improvement is to spread its wings.
Introduction. Objective: to assess the efficacy of controlled release OROS MPH (Concerta®) in children with attention deficit/hyperactivity disorder (ADHD) previously treated with immediate release methylphenidate (MPH IR).
Leaders of academic medical centers (AMCs) are challenged to ensure consistent high performance in quality and safety across all clinical services. The authors sought to identify organizational factors associated with AMCs that stood out from their peers in a composite scoring system for quality and safety derived from patient-level data.
A scoring method using measures of safety, mortality, clinical effectiveness, and equity of care was applied to discharge abstract data from 79 AMCs for 2003-2004. Six institutions (three top and three average performers) were selected for site visits; the performance status of the six institutions was withheld from the site visit team. Through interviews and document review, the team sought to identify factors that were associated with the performance status of the institution.
The scoring system discriminated performance among the 79 AMCs in a clinically meaningful way. For example, the transition of a typical 500-bed hospital from average to top levels of performance could result in 150 fewer deaths per year. Abstraction of key findings from the interview notes revealed distinctive themes in the top versus average performers. Common qualities shared by top performers included a shared sense of purpose, a hands-on leadership style, accountability systems for quality and safety, a focus on results, and a culture of collaboration.
Distinctive leadership behaviors and organizational practices are associated with measurable differences in patient-level measures of quality and safety.
VIEWPOINT Reform of health-care systems in the past decade has been driven by ideas such as public/private partnerships, managed competition, managed care, and integrated care. These abstractions betray the grand nature of ambitions harboured by reformers. Faced with funding pressures on the one hand, and failures of service delivery on the other, policymakers have entertained radical solutions in the hope they will lead to improvements in health-system performance. In practice, reform has generally fallen short of both rhetoric and expectations, leading to reappraisal of the strategies pursued and a search for new policies. The failure of radical solutions stems in part from their limited effect on clinical practice. Improvement of the performance of health care depends first and foremost on making a difference to the experience of patients and service users, which in turn hinges on changing the day-today decisions of doctors, nurses, and other staff. Reforms based on ideas like managed competition and integrated care might have some effect on clinical decisions, but in professional organisations like hospitals and primary-care practices, many effects on decision-making exist. In these organisations, policies initiated by health-care reformers have to compete for attention with established ways of working and other imperatives, which may result in a gap between policy intent on the one hand and delivery on the other. A key feature of professional organisations, as Henry Mintzberg noted over 20 years ago, 1 is that professionals have a large degree of control. As a result, the ability of managers, politicians, and others to influence decisionmaking is more constrained and contingent than in other organisations. Thus, ways have to be found of generating change bottom-up, not just top-down, especially by engaging professionals in the reform process. This includes recognition of the importance of collegial mechanisms in professional organisations and the role that leaders from professional backgrounds themselves can have in bringing about change. Mintzberg’s insights into the nature of professional organisations have been reinforced by studies of the effect of quality-improvement initiatives in healthcare organisations in several countries, and we now draw on findings of these studies to explore the challenges entailed in improvement of performance.
This article argues that the NHS is destined to experience repeated mistakes, continued low morale and political instability unless leaders at all levels pay serious attention to four fundamental aspects of culture which are largely absent in today's health system - confidence, curiosity, connectedness and compassion. While a focus purely on structural change will fail to cultivate the corporate spirit needed to challenge and motivate staff to really care, serve and succeed, investing in the appropriate values and behaviours offers the prospect of a widespread and potentially rapid transformation.