New article on making quality systems more useful and effective drivers of high quality care

Health service staff do not see their organisation's quality system as a useful support for providing good care.  So what are we going to do about it?  Read our research findings in the attached pdf article, published in Health Services Management Research, August 2017.

Quality-systems-implementation-article-HSMR-Leggat-and-Balding-2017.pdf Quality-systems-implementation-article-HSMR-Leggat-and-Balding-2017.pdf (143kB)

Ten Leadership Practices for Great Care

Great care for every consumer is not set and forget - you have to work at it! Here's 10 leadership practices that will help guide your organisation to care greatness.

Tools, Tips and Links Resources

Models, examples, checklists, articles and information to help you take your quality system - and your care - from good to great.

Cognitive Bias Codex

An excellent reminder that humans are flawed beings - and that our thinking is not as perfect as we think.  Very helpful for identifying the mind boulders that block our path to creating safe, quality care.

Creating Great Care in Complex Systems Resource List

Helpful information for creating safety and quality in complex systems

Amalberti, R, Vincent, C, Auroy, Y and de Saint Maurice G (2006) Violations and Migrations in Health Care: A Framework for Understanding and Management. Qual Saf Health Care. December 15 (Suppl 1):i66–i71. (Accessed November 2010)

Balding C (2015) Leading a strategic quality governance system online course.

Balding C (2012) '5 Essential Skills for 21st Century Quality Managers.'  InTech Open Access

Balding C (2011) The Strategic Quality Manager:  A Handbook for Navigating Quality Roles in Health and Aged Care.  Arcade Custom, Melbourne.  Available as a handbook or ebook from:

Dekker S (2011) Drift Into Failure – From Hunting Broken Components to Understanding Complex Systems. Ashgate Publishing Company, UK

Flin R, O’Connor P, Crichton M (2008) Safety at the Sharp End – A Guide to Non-Technical Skills. Ashgate Publishing, UK

Lillrank P, Liukko M (2004) Standard, routine and non-routine processes in healthcare.  International Journal of Health Care Quality Assurance; 2004; 17, 1; ABI/INFORM Global pg. 39

Meadows DH (2008) Thinking in Systems – A Primer. Sustainability Institute, USA

NHS (2016) Developing people, Improving care. a national framework for action on improvement and leadership development in NHS funded services. NHS, UK.

NZ Health Quality and Safety Commission (2016) From knowledge to action: a framework for building qulaity and safety capability in the NZ health system. (Health Q&S Commission, NZ.

Plsek P, Wilson T (2001) Complexity Leadership and Management in Healthcare Organisations. BMJ, 323, no.7315, pp. 746–49

Weick KE, Sutcliffe KM (2007) Managing the Unexpected. John Wiley and Sons Inc, USA

The six achievements of an effective quality system.

Checklist for a hard working quality system.

Quality systems can and should do so much more for health, aged and community services than they do.  Why?  Partly this is becuase many boards and executives don't understand the potential of their quality system, and how it must be running like a well oiled machine to drive great consumer care and experiences within complex environments.

 Click on the pdf below for the six acheivements - and the corresponding components required to make them a reality in your organisation.

Strategic-Quality-System-Logic-one-pager.pdf Strategic-Quality-System-Logic-one-pager.pdf (1MB)

Characteristics of high performing health services 2016

How does yours stack up?

High-performing-health-services-2016.pdf High-performing-health-services-2016.pdf (392kB)

QualityNews: Djerriwarrh Health Service CG Failure

In QualityNews November 2015 I responded to the Djerriwarrh Health Services clnical governance falure, resulting in the deaths of seven babies.  Click on the attachment to read my take on why we shouldn't need any more reminding about why leadership and vigilence are critical to patient safety.

QualityNews-November-2015.pdf QualityNews-November-2015.pdf (336kB)

A Strategic Quality System


The 'SQS'  Model: Laying out the essential elements of effective quality systems that support great consumer experiences.  

An effective quality system must have Purpose: a definition of a great consumer experience; People: who are guided to develop the characteristics required to create great care; and Pillars of quality governance: systems that are only as good as they support staff to provide the desired consumer experience.

This is the basis of my book 'Create a Great Quality System In Six Months: A blueprint for building the foundations of great consumer experiences', which leads you through a month by month detailed plan for building and implemeting this quality system to get great results.

Follow the steps and create great care!   Find out more here.

SQS in Action

Western Health, a large multi-campus teaching health service in western Melbourne, implemented the Strategic Quality System two years ago.  They were looking for somethng that would bring all their good improvement work together, identify their gaps and focus more completely on their consumers.  Here's an overview of their progress a year later.

Western-Health-Best-Care-Overview.jpg Western-Health-Best-Care-Overview.jpg (217kB)

The Quality System Maturity Scale.

Where is your organisation on The Quality System Maturity Scale? Use my scale to start a conversation about the health and effectiveness of your current quality system - and to plan how you'll evolve it to create even better care and experiences for consumers.

Organisational Quality System Maturity Scale

Maturity Level


1. Informal


  • Driven by lone ‘champions’ with an interest in improvement.
  • Lack of systematic approach: random improvement activities based on minimal and poor data.
  • Managerial response to quality problems largely dependent on staff ‘trying harder’.
  • Limited staff input into identifying problems and improvements.  

2. Compliance


  • Focus on compliance with external/funding requirements.
  • Problem based and reactive approach with minimal systematic collection or analysis of data on key issues.
  •  ‘Doing quality’ is staff code for auditing and other data collection with little impact on consumer care.
  • ‘Quality’ seen as the responsibility of the quality manager. 

3. Reactive


  • Focus on risk management and compliance with accreditation and other external requirements.
  • Systematic tracking of key indicators, consumer feedback and incident reporting.
  • Evidence of some system improvement and follow up.
  • No agreed change and improvement model in use. 
  • Reliance on policy change and education as key change tools.
  • Leaders are developed to improve safety.

4. Proactive Improvement

  • Quality system is a key component of clinical/quality governance system, with plans for improvement at organisation-wide and local levels.
  • Lack of common and uniting goals with the improvement program comprising a series of (possibly unrelated) monitoring, improvement and redesign projects.
  • Minimum dataset reported across all quality dimensions.
  • Data analysed and reported through organisational levels to the governing body, with evidence of effective systems improvement as a result.
  • Strategies in place for developing leaders to engage staff in improvement across the dimensions of quality, with some consumer input.

5. Strategic


  • The desired quality of the consumer experience at point of care is defined with staff and consumers, and achieving it is a strategic priority.
  • The organisational quality plan is designed and systematically implemented to create the defined quality consumer experience, through developing people and improving systems.
  • Roles and responsibilities at all levels of the organisation for creating the quality consumer experience are described and supported.
  • Governance systems are owned by the governing body and executive team and designed to support staff to create the quality consumer experience.
  • An agreed and consistent model for change and improvement is in use. 


Developing Strategic Quality Governance: Five Actions for Boards


Describes five key actions Boards can - and should - take, to develop strategic quality governance that makes a real difference to consumers.  

Available as a pdf document - see below.

(This is the text of an article that appeared in Australian Ageing Agenda, May 2015.)

Board-Role-Strategic-Quality-Governance-final-2015.pdf Board-Role-Strategic-Quality-Governance-final-2015.pdf (628kB)

Change Reality Check - list

Sometimes its easier to hope that change will go well than face the fact that there are boulders along the path to success.  But if you don't identify and move the boulders, staff that are subject to the change are likley to look for another path; and before you know it, you're leading a change that noone else is following.  Slippage and erosion are part of change in complex systems; but this is accelerated when the change is not a good fit in the first place.

Here's some tough questions that, answered honestly, will help you build a realistic picture of what you're dealing with and the chance of success.  Better to know before you embark, when you can work with the staff to do something about it, than hope for the best and spend months rescuing a change that doesn't take, is circumnavigated, or actively thwarted.

Change Reality Check-list - answer 'yes' to two or more of these and you still have some work to do  - with those involved - to tailor your change for maximum success and sustainability:

  • Was the new process developed separately from those who will implement it?
  • Do those who are using the new approach have doubts about its usefulness?
  • Are the associated rules and protocols easy to violate?
  • Are extra rules required to comply - without removing 'old' rules?
  • Are extra resources required to comply?
  • Are there negative side effects of implementation felt by other services/departments?
  • Does it conflict with other policies and/or priorities in certain situations?
  • Does it work better for some shifts, or parts of the service, than others?

(Adapted from Amalberti, R, Vincent, C, Auroy, Y and de Saint Maurice G (2006) Violations and Migrations in Health Care: A Framework for Understanding and Management. Qual Saf Health Care. December 15 (Suppl 1):i66–i71.)

Five Favourite Change for Improvement Books

My Five Favourite ‘Incredibly Useful Change for Improvement’ Books

These are my current ‘go-to’ books for understanding and making change for improvement in complex organisations. They live in the real world and are full of useful explanation, practical solutions and tools for making process and culture change a reality. 

Byham, W (1993) Zapp! Empowerment in Health Care.  Fawcett, USA.

Connors R, Smith T (2011) Change the culture, Change the game.  Penguin Books, New York, USA.

Heath D & C (2011) Switch: How To Change Things, When Change is Hard. Random House Business Books, USA.

Kotter J (2014) Accelerate: Building Strategic Agility for a Faster-Moving World. Harvard Business Review Press, USA.

Lencioni P (2012) The Advantage: Why Organizational Health Trumps Everything Else in Business. Jossey-Bass, USA.

Generic National Standards presentation for Boards and Executives 2013

This generic presentation for Boards and Executives can be used as a basis for your presentations - don't forget to adapt it to your service and make sure you're confident with the content - do your homework so you'll be able to answer those tricky questions!

Sign up for my monthly newsletter (in the right hand column of this page)  to receive ongoing tips and info on effective implementation and staff buy-in.

Nat_standards_and_governance_Boards_and_Execs_2013_generic_Balding.pdf Nat_standards_and_governance_Boards_and_Execs_2013_generic_Balding.pdf (832kB)

Presentation from the 'Cathie and Cathy' Workshop at the AAQHC Conference 2012

AAQHC_Workshop_Bedding_Down_the_Basics_2012_CO_and_CB.pdf AAQHC_Workshop_Bedding_Down_the_Basics_2012_CO_and_CB.pdf (3MB)

Handy Books & Articles

These links, books and articles are useful and practical  references for quality managers, and cover the essential components of quality systems management – well worth getting hold of to build your professional development library.

Recommended Reading

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 1, 2017.​

Provost L and Murray S (2011) The Healthcare Data Guide.  Jossey Bass, USA.

The Health Foundation (2011) Quality Improvement Made Simple:  What every Board should know about Quality Improvement.  The Health Foundation, UK

Swanick and McKimm (eds) (2011) ABC of Clinical Leadership. BMJ Books.

Bridges W (1997) Managing Transitions.  Addison Wesley Publishing Company, USA.

Weeks C (2010) Handy Hints for the Novice Conference Presenter.  The Junction, Australia.

Frankel A, Leonard M, Simmonds T, Haraden C, Vega K (eds) (2009) The Essential Guide for Patient Safety Officers.  Joint Commission on Accreditation of Healthcare Organisations and Institute for Healthcare Improvement, USA.

Classen et al (2011) ‘Global Trigger Tool’ Shows that Adverse Events in Hospitals may be Ten Times Greater than Previously Thought. Health Affairs, vol 30, no 4

Balding C (2008) From Quality Assurance to Clinical Governance. Australian Health Review, vol 32,no 3. pp.383–91