Presentation to 6th International Conference on the Scientific Basis of Health Services, 2005, Montreal
How leading hospitals in the
US and Europe achieved
excellence in service quality and sustained it
Dr Glenn Robert, UCL
Professor Paul Bate, UCL
Dr Peter Mendel, RAND Corporation
Funding: The Nuffield Trust, London & RAND Corporation, US
© Paul Bate & Glenn Robert, University College London 2005. All rights reserved. Not to be reproduced in
whole or in part without the permission of the copyright owner
Objective
To re-trace the ‘quality journey’ of 8 high
performing health care organizations in
order to explore the processes that
enabled them to successfully
implement, spread and sustain quality
improvement initiatives
2
Background
The quality lottery: striking variation
between health care organizations
in how successful they are in
implementing and sustaining Q & SI
3
One large study of American
health care quality
Source: McGlynn et al (2003) NEJM, 348, pp. 2635-2645
439 indicators of clinical quality of care
Across 30 acute and chronic conditions
Participants (N=6712) had received 54.9% of
scientifically indicated care
Conclusion:
The ‘defect rate’ in the technical quality of
American health care is approximately 45%
It is probably the same in the UK!
4
Background
• HSR getting better and better at
measuring health outcomes and quality
• Variation between (Jarman) and within
(Adler) health care organizations
• Strong on the ‘what’ but weaker on the
‘why’ and ‘how’
• Most HSR related to quality issues does
not seek to explain the human and
organisational causes of variation
5
Background
• Move from describing to explaining
• Processes and dynamics of
improvement rather than list of ‘key
success factors’
• Ethnographic case studies of
organizations with a history and
reputation for sustained quality
improvement
6
Organizational sample
• United States
–
–
–
–
–
Albany Medical Center (AIDS Treatment Center)
Cedars-Sinai (Emergency Department)
Luther Midelfort Mayo Health System (Critical Care Unit)
San Diego Children’s Hosp. (Allergy & Immunology)
SSM St. Joseph’s Health Center (Intensive Care Unit)
• Netherlands
– Reinier de Graaf Groep (Flow Varicies -- Vascular
Surgery)
• United Kingdom
– Peterborough Hospitals (Radiology Services)
– Royal Devon and Exeter (Orthopaedic Centre)
7
LOS ANGELES
EAU CLAIRE
PETERBOROUGH
DELFT
EXETER
ALBANY
ST. LOUIS
SAN DIEGO
8
Study design
• 15 days fieldwork in each site
• Semi-structured interviews: macroand micro-system
• Direct observation and documentary
evidence
• Draft narrative fed back to key
informants
• Analysed shared narratives and
identified ‘challenges’, ‘elements’
and ‘processes’ that combine to
explain improvement in health care
9
The generic challenges
Despite huge variety similar sets of challenges:
1. Educational (a learning process to support
continual improvement)
2. Political (addressing and dealing with the
politics of change)
3. Cultural (giving ‘quality’ a shared, collective
meaning, value and significance)
4. Emotional (engaging and mobilising people)
5. Structural (organising, planning and coordinating the improvement effort)
6. Physical and technical (supportive technologies
and infrastructure)
10
Solutions to meet these
challenges (elements)
1.
Educational
1.1 A quiet, reflective form of leadership
1.2 Knowledge of ‘hard’ quality improvement methods
and techniques
…
2.
Political
2.2 An agreed ‘compact’ for Q & SI between key interests
2.4 A dispersed, devolved/decentralised authority system
…
3.
Cultural
3.1 A philosophy and mission that highlights top quality
patient care
3.7 An organisation whose image and identity are
inextricably bound up with the concept of
‘excellence in quality’ …
11
4.
5.
6.
Emotional
4.2 Building communities of practice and wider social
commitment to Q & SI
4.6 Emotional involvement in the organisation improvement
effort
…
Structural
5.1 An explicit and formally signed off strategy for Q & SI
5.10 Specialist interlocutor/connector roles with regard to
quality: ‘boundary spanners’ (linking resources, people
and ideas)
…
Physical & technical
6.1 A leadership that is aware of the material and
symbolic/aesthetic importance of buildings and
architecture, and incorporate this into its concept of
service design
6.2 Whether it is free-standing and has control over its own
buildings and space, data and technical systems
…
12
Regulatory
Environments
Professional &
Social Movements
Outer Context
Market & Resource
Environments
Inner Context
Organization
Performance
Organization
Size
Technological
Environments
Organization
Structure
Educational
Structural
Task-centred leadership
Quality strategy & plan
Whole-systems design
Devolved authority
Multi-level leadership
Quality leadership positions
QI governance structure
Quality department/group
QI training programs
Communities of practice
Data & monitoring systems
Results-oriented planning
Enabling Admin role
Boundary spanner roles
Organizational ‘slack’
Pedagogical leadership
Organizational change knowledge
QI techniques knowledge
Knowledge harvesting
Experimentation & piloting
Evidence-based learning
Experience-based learning
Physical &
Technological
Technology/design leadership
Functional design of built env
Aesthetic design of built env
Info technology design
Medical technology design
Locating of built env & tech
Cultural
Values/symbolic leadership
Culture of excellence
Patient-centered ethic
Culture of mindfulness
Group/collaborative culture
Scientific culture
Culture of learning
Formality-savvy culture
Culture of empowerment
Cosmopolitan culture
Long term perspective
Organizational identity
Recruitment
Acculturation
Political
Emotional
Inspirational leadership
Clinical & other change champions
Collective momentum
Professional & social affiliations
Quality as a mission/calling
Emotional commitment
Improvement campaigns
Politically-credible leadership
Clinical engagement
Peer-to-peer relationships
Clinical-Managerial partnering
Empowering staff
Empowering patients
External partnering
13
Regulatory
Environments
Professional &
Social Movements
Outer Context
Market & Resource
Environments
Inner Context
Organization
Performance
Organization
Size
Technological
Environments
Organization
Structure
Educational
Structural
Task-centred leadership
Quality strategy & plan
Whole-systems design
Devolved authority
Multi-level leadership
Quality leadership positions
QI governance structure
Quality department/group
QI training programs
Communities of practice
Data & monitoring systems
Results-oriented planning
Enabling Admin role
Boundary spanner roles
Organizational ‘slack’
Pedagogical leadership
Organizational change knowledge
QI techniques knowledge
Knowledge harvesting
Experimentation & piloting
Evidence-based learning
Experience-based learning
Physical &
Technological
Technology/design leadership
Functional design of built env
Aesthetic design of built env
Info technology design
Medical technology design
Locating of built env & tech
Cultural
Values/symbolic leadership
Culture of excellence
Patient-centered ethic
Culture of mindfulness
Group/collaborative culture
Scientific culture
Culture of learning
Formality-savvy culture
Culture of empowerment
Cosmopolitan culture
Long term perspective
Organizational identity
Recruitment
Acculturation
Political
Emotional
Inspirational leadership
Clinical & other change champions
Collective momentum
Professional & social affiliations
Quality as a mission/calling
Emotional commitment
Improvement campaigns
Politically-credible leadership
Clinical engagement
Peer-to-peer relationships
Clinical-Managerial partnering
Empowering staff
Empowering patients
External partnering
14
Regulatory
Environments
Professional &
Social Movements
Outer Context
Market & Resource
Environments
Inner Context
Organization
Performance
Organization
Size
Technological
Environments
Organization
Structure
Educational
Structural
Task-centred leadership
Quality strategy & plan
Whole-systems design
Devolved authority
Multi-level leadership
Quality leadership positions
QI governance structure
Quality department/group
QI training programs
Communities of practice
Data & monitoring systems
Results-oriented planning
Enabling Admin role
Boundary spanner roles
Organizational ‘slack’
Physical &
Technological
Technology/design leadership
Functional design of built env
Aesthetic design of built env
Info technology design
Medical technology design
Locating of built env & tech
Pedagogical leadership
Organizational change knowledge
QI techniques knowledge
Knowledge harvesting
Experimentation & piloting
Evidence-based learning
Experience-based learning
?
Emotional
Inspirational leadership
Clinical & other change champions
Collective momentum
Professional & social affiliations
Quality as a mission/calling
Emotional commitment
Improvement campaigns
Cultural
Values/symbolic leadership
Culture of excellence
Patient-centered ethic
Culture of mindfulness
Group/collaborative culture
Scientific culture
Culture of learning
Formality-savvy culture
Culture of empowerment
Cosmopolitan culture
Long term perspective
Organizational identity
Recruitment
Acculturation
Political
Politically-credible leadership
Clinical engagement
Peer-to-peer relationships
Clinical-Managerial partnering
Empowering staff
Empowering patients
External partnering
15
RESULTS
So what processes enabled
these health care
organizations to successfully
implement, spread and sustain
Q & SI initiatives?
16
A flavour .. two case studies
Cedars-Sinai, Los Angeles
Peterborough
• 875 beds
• 670 beds (2 sites)
• 6,600 staff and 1,700
• 2,300 wte staff
affiliated physicians
• Acute medical services
• Primary service area
to 280,000 in east of
consists of 2.3 million
England
people ($70m p.a on
• Income of £89.1m in
community outreach)
2001/02
• Major teaching hospital • 3 star Trust 2001/02 and
(UCLA)
2002/03
17
Process mapping method –
Step One
Systematically coded the validated
case narratives for mentions of
processes between elements
18
An example
In this spirit, the hospital decided to hire this physician to
lend clinical background and credibility to the quality
effort [2.1 to 2.2]:
“So he… went around looking at evidence based stuff,
and began to bring to the institution a whole discipline
[3.8 to 5.15] around analyzing process, flow diagrams,
cradle diagrams, privatization approaches,… and we
began to infuse the organization with that approach.
We linked up then with the national demonstration
project later [1.4 to 3.10] becoming the Institute for
Healthcare Improvement, [he] became faculty in the
IHI, as you probably know, and kept us connected with
a network of people who had a growing similar interest
around these kinds of things” [5.10 to 1.4].
19
Process mapping method –
Step Two
Employed social network analysis
techniques to examine and
visualize the patterns of relations
among the organizational
processes for each case study
20
Cedars-Sinai Sub-Process Mapping
C3.10
PT6.6
S5.2
IC1.1
S5.3
S5.1
S5.5
OC1.4
C3.8
S5.4
S5.10
S5.7
P2.3
P2.2
EM4.4
ED1.5
ED1.4
S5.12
OC1.5
EM4.6
S5.6
S5.15
S5.9
S5.13
P2.1
ED1.3
ED1.2
EM4.2
S5.11
C3.6
C3.7
C3.11
C3.2
S5.8
ED1.1
P2.5
EM4.3
C3.5
EM4.1
P2.4
ED1.6
PT6.5
C3.1
PT6.1
C3.14
IC1.2
P2.7
S5.14
C3.12
C3.3
PT6.3
C3.13
PT6.2
EM4.5
OC1.6
IC1.3
ED1.7
Note: Dotted line indicates negative relationship.
OC1.7
Educational
Political
Cultural
Emotional
Structural
Physical/Technical
Inner Context
21
Outer Context
Cedars-Sinai Sub-Process Mapping
C Cosmop
ClinTechn
Supp
TaskLship
OrgSize
WholeSysDes
QStrategy
QLdrs
C Formal
Regulatory
Environment
DecAuth
QIdept
Peer-to-Peer
Profl-Social
Affiliations
EmotInvlv
KHarvest DistrLdrs
DataSys
QI
Training
QGovern
Enabling
Admin
C Science
QTraining
Programs
Pedag
Lship
Values
Lship
StaffEmpw
ICTSupp
PT6.1
QSlackRes
ClinEng
Experm
Plan
Process
Mrkt/Resource
Environment
Bndry
Spans
Patient
Centred
Comm-of
Practice
LearnC
Clin
Champions
OrgChng
Training
LTermC
GroupC
Evid-based
Learning
Org
Identity
QMission
Note: Dotted line indicates negative relationship.
CollMoment
OrgPerf
InspLship
Clin-Mgt Prtnr
CExcell
Socializ
OrgStruc
Techn/Design
Lship
Recruit
Retain
Phys
Aesthetics
CredLship
ExtPrtnr
Social
Mvmnts
Exp-based
Learning
AvailTechn
Educational
Political
Cultural
Emotional
Structural
Physical/Technical
Inner Context
22
Outer Context
Cedars-Sinai Process Mapping
Process
Structural
Cultural
Educational
Political
Emotional
Physical & Technical
Outer Context
Inner Context
Total SubProcess Ties
(#)
80
69
41
30
13
11
4
3
W/in
Process
(%)
30%
23%
5%
13%
15%
0%
25%
0%
IN-ties
(%)
29%
39%
51%
50%
62%
27%
75%
33%
OUT-ties
(%)
41%
38%
44%
37%
23%
73%
0%
67%
Most Central Sub-Processes
Communities-of-Practice, Quality governance systems, Distributed
leadership, Data and monitoring systems, Boundary-spanner roles
Group culture, Values/symbolic leadership, Culture of learning
Clinical engagement
23
Peterborough Sub-Process Mapping
IC1.3
IC1.1
C3.2
PT6.6
ED1.1
P2.1
OC1.5
C3.11
S5.11
C3.5
C3.9
IC1.2
P2.3
S5.6
ED1.5
EM4.1
C3.7
C3.1
S5.5
S5.4
P2.7
P2.5
ED1.2
C3.6
PT6.5
P2.2
S5.7
OC1.6
S5.3
S5.10
S5.8
C3.12
ED1.3
OC1.4
ED1.4
S5.9
W4.3
EM4.6
C3.13
S5.15
P2.4
S5.14
S5.13
ED1.6
S5.2
ED1.7
Educational
Political
Cultural
Emotional
Structural
Physical/Technical
Inner Context
24
Outer Context
Peterborough Sub-Process Mapping
OrgPerf
OrgSize
ClinTechn
Supp
Pedag
Lship
CredLship
Values
Lship
Mrkt/Resource
Environment
LTermC
Comm-of-Practice
GroupC
Peer-to
Peer
InspLship
EmpwC
OrgStruc
LearnC
CExcell
QLdrs
Social
Mvmnts
ExtPrtnr
OrgChng
Training
QIdept
Recruit
Retain
DecAuth
StaffEmpw
KHarvest
Enabling
Admin
Coll
Moment
ClinEng
ScienceC
ICTSupp
DataSys
Clin-Mgt Prtnr
WholeSysDes
BndrySpans
QTraining
Programs
EmotInvlv
DistrLdrs
Experm
Org
Identity
QI
Training
Regulatory
Environment
QSlackRes
QGovern
TaskLship
Exp-based
Learning
Evid-based
Learning
Educational
Political
Cultural
Emotional
Structural
Physical/Technical
Inner Context
25
Outer Context
Peterborough Process Mapping
Process
Total SubProcess Ties
(#)
W/in
Process
(%)
IN-ties
(%)
OUT-ties
(%)
Structural
Cultural
Political
Educational
Outer Context
Inner Context
Physical & Technical
Emotional
52
49
43
26
7
6
6
5
25%
14%
7%
8%
0%
0%
0%
20%
10%
71%
56%
50%
29%
0%
33%
60%
65%
14%
37%
42%
71%
100%
67%
20%
Most Central Sub-Processes
QI facilitating team, Enabling administrative role
Culture of empowerment, Group culture
Empowering staff, Clinical engagement
Experimentation & pilots
26
Comparative Process Mappings
Peterborough
Cedars-Sinai
27
.. and the emotional
“People here aren’t just motivated. This isn’t
their job, it’s a mission, it’s their life, it’s the
cause they’re committed to. For them, it’s
personal.”
(Director HIV AIDS Programme, Albany Medical Centre, New York)
“Perfect care is something we never reach,
but like the North Star, it serves as a beacon
to guide us … Every day Children’s should
strive to be even better than before. Our
physicians, our nurses, and our staff seek to
attain it; our families deserve it.”
(Foreword of the Children’s Agenda, Children’s Hospital and Health
Centre’s strategic and business plan, June 2001)
28
Conclusions
• The generic but variable thesis: ‘many paths
up the mountain’
• Failures and ‘bumps in the road’
• Multi-level, multi-dimensional process based
model of service improvement
• Context and physical/technology factors
important in realising quality but cultural and
structural response of organizations largely
determine whether QI is sustained
• Yes, human and organisational factors are
important – and need to understand ‘how’
and ‘why’
29
Jeopardising change
Lack of a …
Learning process
Political process
Cultural process
Mobilisation
Planning & co-ordination
Physical infrastructure &
technical systems
Can lead to…
Amnesia or
frustration
Inertia
Evaporation
Energy-sink
Fragmentation
Exhaustion
30
For comments and further
information:
g.robert@chime.ucl.ac.uk
31
Organizing for Quality: Journeys
of Improvement at Leading
Healthcare Organizations in the
US & UK
James L. Zazzali, Ph.D., M.P.H., RAND Corporation
Glenn Robert, Ph.D., UCL Medical School
Peter Mendel, Ph.D., RAND Corporation
Paul Bate, Ph.D., UCL Medical School
Funding Sources:
Nuffield Trust, London
RAND Corporation Health Unit, Santa Monica
Copyright, all rights reserved, 2005
Research Objectives
• To present cross-site and cross-national
findings regarding the ability of healthcare
organizations to sustain QI programs and
processes
• To identify best practices in change
management related to the introduction and
implementation of QI
• To approach this with a decidedly
organizational perspective
33
Study Design
• Mixed methods with a multilevel approach
• Interviews with over 100 senior leaders at 11
Health care systems in 3 countries (results
today only for US & UK)
• Site visits to one “high performing”
department within each of the 11 health
systems to observe and interview staff
• Interview data used to construct survey items
• Survey of staff in the “high performing”
departments
34
Organizational Sample
• United States
– Albany Medical Center (AIDS Treatment Center)
– Cedars-Sinai (Emergency Department)
– Geisinger Health System (Rheumatology)
– Luther Midelfort Mayo Health System (Critical Care Unit)
– San Diego Children’s Hosp. (Allergy & Immunology)
– SSM St. Joseph’s Health Center (Intensive Care Unit)
• Netherlands
– Reinier de Graaf Groep (Flow Varicies -- Vascular Surgery)
• United Kingdom
– Kettering General Hospital (Accident & Emergency Services)
– Kings College (Breast Unit)
– Peterborough Hospitals (Radiology Services)
– Royal Devon and Exeter (Orthopaedic Centre)
35
Survey of “High
Performing” Departments
• Survey measured:
– The degree to which 9 key factors related to
sustaining QI efforts were met in the department
– Perceptions of importance of these factors for 5 of
the 9 areas
– The organizational culture of the department
– The respondents’ level of QI training and QI team
experience
– Respondents’ socio-demographic characteristics
• Survey sample
– 477 respondents across 10 sites in the US & UK
– 48% response rate with two mailings
36
Nine Factors Related to Sustaining
QI
•
•
•
•
•
•
•
Organizational slack for quality improvement
Quality resource infrastructure
Availability and use of data
Culture of sharing and learning
Distribution of responsibility
Organizational identity
Senior leaders creating a vision, scripting &
motivating
• Communication and discourse
• Systems perspective/thinking
37
Nine Factors Related to Sustaining QI
• A. Organizational slack for quality improvement
– 1) Our unit provides staff with time and other resources to
work on implementing new ways of improving how we do
things here.
– 2) I have opportunities to visit or interact with people in
other units or outside this organization to bring back new
ideas which might improve how we do things here.
• B. Quality resource infrastructure
– 3) Our unit has access to people who can provide training,
advice and support in quality improvement.
• C. Availability and use of data
– 4) Our unit has easy access to data that is useful for
understanding the processes and outcomes of our work.
– 5) Our unit routinely makes changes based on
measurement of the processes and outcomes of our work.
38
Nine Factors Related to Sustaining QI
• D. Culture of sharing and learning
– 6) People in our unit like to share their ideas and
expertise with one another.
• E. Distribution of responsibility
– 7) My efforts can play an important role in the success
of quality improvement activities in this unit.
– 8) Quality improvement activities can produce
significantly better patient care and outcomes in our
unit.
• F. Organizational identity
– 9) This organization has a mission or purpose that I
strongly identify with.
– 10) This organization has a particular history that I am
proud of.
39
Nine Factors Related to Sustaining QI
• G. Senior leaders creating a vision, scripting &
motivating
– 11) Senior management within this organization know how to
inspire and motivate staff across areas to work toward common
goals.
– 12) Senior management within this organization make improving
the quality of patient care a priority.
• H. Communication and discourse
– 13) People in our unit feel they can freely express their views and
have their opinions listened to.
– 14) There is good communication between our unit and others in
the organization on important issues of delivering patient care.
• I. Systems perspective/systems thinking
– 15) People in our unit really understand how patients move across
departments within this organization.
– 16) There is strong inter-departmental coordination within this
organization.
40
Challenges in Sustaining QI
1.0
2.0
3.0
4.0
4.0
Sr. mgmt. knows how to inspire & motivate staff across
areas to work toward common goals.
*
4.1
3.9
4.4
People in our unit like to share their ideas and expertise
6.0
*
3.8
Opportunities to visit or interact with people in other
units or outside this organization to bring back new
ideas
4.2
*
4.4
There is good comm. between our unit and others on
important issues of delivering patient care
4.2
4.5
There is strong inter-departmental coordination
4.0
US
* denotes p<.05
5.0
*
UK
41
Advances in Sustaining QI
1.0
2.0
3.0
4.0
5.0
6.0
5.3
This organization has a mission or purpose that I
strongly identify with.
4.7
QI activities can produce significantly better patient
care and outcomes
5.2
5.0
My efforts can play an important role in the success
of QI activities
5.2
5.0
This organization has a particular history that I am
proud of.
5.1
5.0
*
*
*
5.0
4.8
People in our unit feel they can freely express their
views and have their opinions listened to
US
* denotes p<.05
*
UK
42
Importance of Factors
Related to QI Sustainability
1.0
2.0
3.0
4.0
5.0
6.0
Training and time for
improving quality of
patient care and service
5.7
5.7
Senior management
makes improving the
quality of patient care a
priority
5.6
5.5
This organization has a
mission or purpose that I
strongly identify with
5.5
5.1
People in department
understand how patients
move across departments
in this organization
5.4
5.3
Access to professional
staff for training, support
and advice on quality
improvement
5.4
5.4
US
* denotes p<.05
UK
*
*
*
43
QI Training & Participation
0
Have you been trained in formal quality improvement principles
and techniques (e.g., principles espoused by Deming or Juran, Six
Sigma, Rapid C ycle, Plan-Do-Study-Act, or other quality
improvement techniques like Process Mapping, Root C ause
Analysis, etc.
Have you ever served on a quality improvement team in this
organization (i.e., a team specifically formed to analyze and
improve the quality of care or service)?
10
20
30
50
60
36
*
11
51
*
15
US (% Yes)
* denotes p<.05
40
UK (% Yes)
44
QI Training
0
5
15
25
30
35
40
45
50
7
33
0
46
Nurses
Total
20
23
Non- c linic al
Physic ians
10
19
36
11
US % Yes
UK % Yes
45
QI Team Participation
0
Non-clinical
10
20
40
50
60
38
7
56
Physicians
17
57
Nurses
Total
30
22
51
15
US % Yes
UK % Yes
46
Differences in
Organizational Culture
Group Culture (teamwork & affiliation)
35.0
30.0
25.0
20.0
15.0
10.0
5.0
Rational Culture (task oriented)
Developmental Culture (risk
taking/entrepreneurial)
0.0
Hierarchical Culture (bureaucracy)
US
UK
47
Conclusions
• These organizations face similar
challenges & successes for QI
implementation and sustainability
• QI training and participation are more
diffuse in the US
• The organizational cultures are different
for the US & UK sites
48
Next Steps
• Multivariate (and multilevel) models of
individuals’ perceptions of key factors
related to sustaining QI and their
importance, predicted by organizational
culture and QI training and participation
• Book presenting case studies and
synthesizing an organizational model of
factors related to QI sustainability
49
Components to a process
model of improvement
Receptive
context
- Outer context
- Inner context
6 generic challenges
63 elements
?? processes
50