One question to test your quality system
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! – 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 ‘every system is perfectly designed to get the results it gets.’ Sound familiar? An oldie, but oh, what a goodie! I’m resurrecting it because it reflects precisely what we’ve found in our research on what makes an effective quality system. Show me the quality manager preoccupations and I’ll predict what’s going on with quality at point of care. If it’s all about compliance, it’s likely that point of care staff see ‘quality’ as an extra set of tasks they must ‘do’ 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’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 – and staff – 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’s just not the way these organisms work. Of course compliance provides significant jigsaw pieces for our puzzle. It’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’ll never complete the ‘high quality care’ picture. If your quality system is mostly about compliance, you’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’ 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’t know what they don’t know about creating consistently high quality care in a complex environment, they’re unlikely to go looking for a person with the skills that can help them to pursue this. If they see ‘quality’ as the mechanics of quality: the audits, incidents, reporting and committees, rather than the point of care purpose, then that’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’re focused on the governance engine room, there’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 ‘good staff are out there doing a great job’, with their successfully ticked compliance activities supporting this. If only that’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 – 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’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’s difficult to imagine a CEO appointing a finance manager on the strength of them ‘being organised’ or ‘good with numbers’.
The pursuit of consistently high quality care is the same – but harder. It requires everything that well-managed finances requires – 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’t create what’s required at point of care. The senior and middle managers’ job in any service is not just to provide a service and get their staff through the day – 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’t achieve that without the whole of the executive, and managers at all levels, having the ‘will and skill’ 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 – 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 – I salute you! And those still thinking about it? Make 2018 the year you make your mark on the ‘great care’ map.
‘Every system is perfectly designed to get the results it gets’: 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.
Juran Institute: http://www.juran.com