The dangerous 'Everyone comes to work to do a good job' belief

The South Australian Independent Commissioner against Corruption (ICAC) report: ‘Oakden – A Shameful Chapter in SA’s History (Feb, 2018) discusses ‘systemic failings in processes and oversight that allowed events at the Oakden facility to occur for more than a decade…’  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 ‘a disgrace’ 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 ‘care stocktake’, whatever sector you’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’t grab the opportunity to make positive changes as a result of the lessons from this, and other associated inquiries,  the Oakden residents’ suffering was all for nothing.

Everyone’s out there doing a good job…
I want to focus on one aspect of the findings, related to this quote from the report: ‘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….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.’

This sort of statement is made in just about every inquiry into poor care, and I’ve become interested in the ‘why’ behind this – because although we know the issue, it’s far from fixed.  The relevant report recommendation for the purposes of this discussion is No.3: ‘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…and the expectations and responsibilities imposed upon each member of staff…’

There it is – 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 – isn’t responsibility the cornerstone of clinical governance?

I don’t often see the practice of personal responsibility prioritised in most health services. We talk about it – but real action is often headed off at the pass by the ‘good people come to work to do a good job’ statement, often followed by ‘everyone here is responsible for quality.’  I’d bet good money on the fact that both these statements were regularly heard around Oakden – 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:
    Clarifying and agreeing specific personal roles in providing safe and high-quality care
    Providing the management and systems support to assist staff every day to enact that role and fulfil their responsibilities
    Effective processes, based on a ‘just’ 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 ‘quality improvement’ 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 ‘forcing functions’, 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, ‘many staff thought that Oakden was a dumping-ground for those staff needing performance management.’ There we go on the merry-go-round of suboptimal care; put poor performers into challenging services and…hope? – 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’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 ‘new knowledge’ 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 – and those who just come to work to do a job.  All staff need daily, active, focused support – from leaders, managers and systems – to be their best.

Weak management = weak care quality 
I don’t think we really believe this ‘new knowledge’ 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’t. I suspect that ‘everyone comes to work to do a good job’ is a stronger belief – even when we know it isn’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’d avoid if you were a patient.  We know where the poor performers are; which service they are sent to ‘retire’ (if we can’t get them out on ‘gardening’ leave) – if indeed we try to manage them at all.  (And too often the ‘retirement’ plan is a job in the quality and safety unit, which in turn perpetuates weak quality systems…sigh.)

I get it.  The more senior the manager the more ‘up and out’ 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’t pick up issues of neglect) and generally keeping the organisation looking good. That’s a big part of their job.

Unfortunately, in the rough and tumble of all this – and make no mistake, these jobs are not for the faint-hearted – point of care can get lost.   It seems everyone is working around the care, rather than on it. There’s no line of sight between decision makers and what consumers experience. This is particularly so if an organization hasn’t clearly defined the quality of care they want to create every day – 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 ‘staff come to work to do a good job’ mantra fills the vacuum, and it’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’ effectiveness I’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’ desks, and discussed ad infinitum in committees, I’ve never seen ‘turn our managers into high performing superstars as a matter of urgency’ 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 ‘management’ is too hard, or too boring, or too political, or too ‘soft’ to tackle?  Perhaps clinicians just don’t get the critical importance of management skills and competence in the same way they do clinically. Or we just don’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?: ‘we must be good because we’re us!’  It’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’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’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 – which is understandable when you remember that ‘everyone comes to work to do a good job’ – 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’s really going on at the bedside. From the report:

‘The committee process was too cumbersome to be effective…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…the committee structure was dependent upon the effectiveness of the person chairing the committee.’

For now, I’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 ‘matron’ was all-seeing – and emulate it in a modern context. I’d clone you if I could.  In the absence of that option? – I’m waiting for the robots.