Does your quality system detect neglect?

Does it? And – if you’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 – 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.

We’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 – 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’s time to move on!  – to getting the care basics right – consistently. There’s no doubt that this happens in every organisation – 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’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 – or should be – self-evident, so we don’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’t know as much about the scope of harm – and why it was happening – as we thought we did.

We don’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 – healthcare professional, manager or consumer – about what’s important in a health or aged care episode, they identify these dimensions. Not in these words at first – generally, they’ll describe the actions within each of these dimensions that they want from a healthcare experience. Safety is a critical dimension, of course – 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’s this got to do with a quality system detecting neglect? Everything! Lately, I’ve taken to asking workshop audiences and quality managers one critical question to ascertain where their quality system is up to:

‘Would your quality system detect and prevent a Mid Staffordshire – like decline into poor bedside care and neglect of patients in your organisation?’ (see http:www.midstaffspublicinquiry.com/)

This turns out to be a great question because it makes people stop and think – ‘would it?’ If your quality and risk system relies mostly on incident reporting and accreditation, the honest answer is probably ‘no’.   Clinically-related accreditation standards certainly help – 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’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 ‘poor care’ 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’s not all. For me, it’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’s about healthcare professionals and quality managers enjoying being proactive and making a real difference. I’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…)

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’s important to them? Are you proactive in detecting care ‘slippage’? 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 – and how long can consumers go without a wash in the acute sector? Can’t answer that unequivocally. But so far the record is eight days.

Using quality data to drive a successful mission

Monitoring – and Response.

Data, data everywhere… 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…and yet, the mindset and strategy required to make this a useful exercise are often missing. 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 – but if that’s all it took to create great care, well… 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’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’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’s little significant improvement in overall care.

The Rinse and Repeat: the same stuff is reported over and over and over… useful or not, often with more or less the same ‘average’ 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. ‘Nothing to see here – and if there were, we’d have it under control.’ Frequently accompanied by ‘boards should stay out of operations’. 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’t save everyone at once, and the data are crafted to help the board prioritise precious resources to maximise impact where it counts – at point of care. As with all action heroes, sometimes action is taken precipitously, or not where it’s needed, particularly if the action hero is employed without their trusty ‘understanding of variation and complexity’ 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’t help anyone improve anything.

Ten Practices for Great Care Leaders in 2017

‘If it doesn’t happen in habit, it doesn’t happen.’

I’m not sure who to attribute this quote to – possibly Steven Covey. If he didn’t say it, he should have!  But whoever it was, I’m a fan of this idea.  What’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 – a goal or challenge –  that inspires action to make care better at the end of the year than it is at the beginning.   This year, I’m challenging you to master and implement 10 leadership practices that will kick start your quality system, turbo charge your clinical governance and transform your consumer experience.

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’re doing the right things, or don’t realise they’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 – ‘we want to understand this stuff better!’ So over summer I sat down and listed the key leadership problems that I see – (which are also commonly discussed in the literature) – 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 – consistently – 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 ‘Ten Practices of Great Care Leaders’ (with thanks and acknowledgement to Steven Covey for the concept.)  We talk endlessly about the importance of leadership in creating safe, high quality care  – and everyone nods sagely – but what does this mean in terms of every day actions?  There’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 – ever – as they have the opposite effect.

Whether you’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’s not enough just to say we provide ‘excellent/amazing/best in the world/best in the known or unknown universe care’.  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 – all with your staff and consumers. ‘Hoping’ that care is great is not a strategy. ‘Trusting’ 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 – on one page – exactly what ‘greatness’ 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’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 ‘take home test’; that is, when you test it on your family, they don’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 – ‘yep, that makes sense, get on and do it’, you’re on a winner.  If they also say ‘ looks great – let me at it!’, you’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’t pretend they’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’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’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 ‘undercover’  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’ll be grateful, when you’re on the receiving end, if the service you end up in read this in 2017 – and acted on it.

4. Stop ‘doing’ quality
‘Doing quality’ makes no sense.  When staff say they are ‘doing’ quality, this is not a good sign.  Usually it means they see ‘quality’ as a series of tasks they would really rather not be doing, rather than the experience they’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’re either creating great quality care – or you’re supporting someone else to create it.  That’s it. This also goes for ‘having’ clinical/quality governance. Let’s get a bit more energy into the equation: ‘We govern for great care’.

5. Understand that ‘Everyone is responsible for quality’ probably means that no-one is
If ‘everyone’ is responsible, that means there are plenty of other people to fix a problem.  Which means it’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’s a challenge: aim to get a critical mass of staff in your organization answering the ‘who is responsible for the quality of care in your organisation?’ with: ‘I am – and let me tell you exactly how’.  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: ‘If you can’t explain it simply, you don’t understand it well enough’. 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, ‘new’ is not always ‘improved’ – and sometimes it is.  The really skilled people are the ones who can sort this out: ‘will this new tool or approach help or hinder us in out pursuit of great care?’ 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 – old and new – 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’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:’ Information drives understanding, but feelings drive action’
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’s a reason that car ads spend their precious expensive minutes more on feelings than facts. If you can get both the ‘Oh, that’s interesting’, response to the facts, and a ‘Wow, we should do something about that!’ gut response, you’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 – and answer – 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’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’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.

Good luck! Get the summary version of Ten Great Care Leadership Practices here.

When we hear what we wish we didn’t.

Recently on a plane I pricked up my ears to this conversation  – roughly paraphrased – going on behind me:

Passenger A: ‘Bob’s just out of hospital again.’

Passenger B: ‘How is he?’

Passenger A: ‘They stabilised him and changed his medications, so he seems much more comfortable. Not sure I’ll be able to convince him to go back there next time though.’

Passenger B: ‘Really? What happened?’

Passenger A: ‘Oh, you know, the usual.  Nothing too bad – it’s just that he’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’t the easiest to get right – but that’s no excuse.  Of course this meant that we had all sorts of fun and games with medications and tests – the staff listened to us even less than usual because half the time they thought Bob was someone else or they couldn’t find him in their records. It’s a miracle something didn’t go wrong.

‘And those staff!  Some are nice but most of them don’t give you the time of day. So how good the care is depends on who’s on.  He even had a fight with the weekend physio this time.  I don’t know what that was about. There was the usual drama with trying to work out when he’d be discharged – this was really tricky for me – as you know I’m travelling all over the place for work at the minute.  And I wasn’t able to get in to see him every day because I’ve been away so much – and when I did, he didn’t look – or smell – very clean – said he hadn’t had a proper wash since he was admitted – but surely that can’t be right.  And the food!  Anyway, it’s a pain, because the clinical care is good, and it’s close to home – but Bob is very unhappy with everything else about it.  He thinks the sicker he gets, the worse they’ll treat him as he won’t be able to stick up for himself.  I don’t know what we should do.’

Passenger B: ‘Have you talked to the GP?’

Passenger A: ‘Yes, but she thinks that it’s all fine because they manage his condition well – she doesn’t understand how important all the other stuff is to him. Oh good – food.’

At this juncture, our snack was served and their conversation turned to airline food – also interesting but perhaps not a topic for QualityNews – although not unrelated to healthcare quality and this story.  (How was she rating the airline snack compared to Bob’s hospital fare, I wondered?  And how different is the relative importance of food in both settings?)

What’s your response to Passenger A?

Leadership under pressure

I’m fascinated by what makes leaders tick – particularly in the challenging and messy world of health and human services where nothing is easy. My new interview seriesQualityTalks – endeavours to get inside the heads of leaders, with many different roles and perspectives, to find out.  Many thanks to all those who gave feedback on the interview with psychologist Julie Warnock – seems the concept of respect among staff fostering respect  for consumers made quite an impression!

In this new interview, hear Jacque Phillips, CEO of Numurkah District Health Service, discuss what goes through a leader’s mind when flood waters are lapping at the door of her hospital.  Subsequent to this interview, Jacque was awarded OAM for services to the township of Numurkah before and after the floods.   A great yarn and – as always –  lots to learn.  Enjoy – and tell me what you think!

Healthcare Leadership from the other side of the bed – Julie Warnock

Listen to my interview with Julie Warnock, an organisational psychologist who develops leaders in many different sectors, including healthcare.  Struck down by a sudden illness, Julie got to experience healthcare leadership first hand over four weeks and two campuses of the same h…

Source: Healthcare Leadership from the other side of the bed – Julie Warnock

Plan to be great – not just to get things done.

The start of another year – and people are planning.  If you’re reading this, you’re probably developing an improvement plan for the year. – or thinking about it!

An improvement plan should be a simple task, but it’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 ‘Where do we want to be?’ 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’re away, identifying the mode of transport and the activities you’d like to include – without identifying where you’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 ‘to do’ lists. These are satisfying to tick off as they’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 – 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 – great consumer experience; positive staff attitudes and actions; strong organisational reputation; inspirational Board leadership – the tasks on your to do list become ends in themselves. And another year of hard work and frustration passes with the old challenges – staff and executive engagement, data collection and reporting, sustained change, meeting standards – just getting more challenging.

So always start your quality planning by first identifying and describing your desired destination for consumers and staff – in concrete, specific terms – and work out from there the processes and actions you need to get you there.

What’s your great care destination in 2016?