400846 Building Organisational Capacity in Health Care
School of Nursing and Midwifery | Autumn 2017
LEARNING MODULE 3
Postgraduate
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⦁ Table of Contents
Table of Contents 2
Table of Essential Readings 3
Table of Activities 4
Module 3. Improving organisational performance 5
3.1. Introduction 5
3.2. Objectives 5
3.3. Improving organisational performance 5
3.3.1. The Learning Organisation 6
3.3.2. Theories and concepts underpinning organisational performance improvement 9
Measuring Organisational Performance and Effectiveness 15
3.4. Leadership in Capacity Building and Performance Improvement 23
3.5. Case studies in Building Organisational Capacity 25
Summary 26
Additional Readings for Module 3 27
References for Module 3 29
⦁ Table of Essential Readings
MODULE 3
Reading 3.1 12
Baars, I.J., Evers, S.M., Arntz, A. & van Merode, G.G. (2010). Performance measurement in mental health care: present situation and future possibilities. International Journal of Health Planning Management, 25, (3), 198-214 12
Reading 3.2 13
Isouard, G., Messum, D., Briggs, D., McAlpin, S. & Hanson, S. Improving Organisational Performance. In Harris M.G. & Associates. (2006). Managing Health Services: Concepts and Practices. Sydney: Mosby Elsevier. pp. 349 – 380. 13
Reading 3.3 15
Finkelman, A.W. (2006). Teamwork and motivation. Leadership and management in nursing. Pearson/Prentice Hall. pp. 200-223 15
Reading 3.4 21
Marquis, B.L. & Huston, C.J. (2015). Leadership roles and management functions in nursing. Theory and application (8th ed.) Philadelphia: Lippincott, Williams & Wilkins. Pages 363-380 21
Reading 3.5 27
Greenfield, D. (2007). The enactment of dynamic leadership. Leadership in Health Services, 20, (3), 159-168 27
Reading 3.6 27
Son, C., Chuck, T., Childers, T., Usiak, S. Dowling, M., Andiel, C., Backer, R., Eagan, J. & Sepkowitz, K. (2011). Practically speaking: Rethinking hand hygiene improvement programs in health care settings. American Journal of Infection Control, 39:716-724. I27
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⦁ Table of Activities
Activity 3.1 12
Activity 3.2 12
Activity 3.3 12
Activity 3.4 13
Activity 3.5 14
Activity 3.6 19
Activity 3.7 19
Activity 3.8 22
Activity 3.9 24
Activity 3.10 24
Activity 3.11 26
⦁ Improving organisational performance
⦁ Introduction
Health care systems are under pressure from many stakeholder groups to improve organisational performance and the quality and safety of care delivered to their communities. The media constantly draws attention to waiting lists, a lack of resources in particular health services, errors and incidents and the physical and emotional damage suffered by consumers in the health care system. This results in constant demands for government(s) to use their powers to ‘fix the problems’. In most countries it is not possible to just keep increasing the amount of money available for health care and so the challenge is to work differently and creatively to improve the performance of a system that is already under severe pressure to perform. Walburg, Bevan, Wilderspin and Lemmens (2006) ask the question that is on everyone’s mind:
‘How can we meet the needs and demands of increasingly empowered ‘consumers’, contain costs, incorporate ‘evidence-based’ modes of working, and re-motivate health care professionals – and all at the same time?’ (p.xv).
Case studies from ‘high performing’ organisations demonstrate that it is possible to improve the performance of health care systems with the critical success factor being effective people management practices (Isouard, Stanton, Bartram, Thiessen & Hanson, 2006) and of course, exemplary leadership. West at al. (2002, cited in Isouard et al., 2006) found in their research in the United Kingdom that in order to link people management with improved performance in hospitals there were three key components including training and development, performance appraisal and feedback and effective teamwork. Managers and leaders require quite specific competencies in order to work through people to achieve organisational performance improvement and improved patient outcomes.
This Module examines the theories and concepts underpinning organisational performance, discusses issues related to measuring organisation performance and effectiveness and leadership for capacity building and performance improvement.
⦁ Objectives
On completion of this module students will be able to:
⦁ Explore the relationship between effective change leadership and improving organisational capacity and performance.
⦁ Outline leadership strategies required to mobilise and engage stakeholders in continuous organisational development and performance improvement in health care.
⦁ Improving organisational performance
According to Walberg et al. (2006) managers and leaders in today’s health care systems have a very broad brief related to change management and performance improvement. They need to be able to ensure that day-to-day operations are delivered in an effective and efficient manner; they need to undertake business analysis and benchmarking and work with, and motivate staff to change and improve systems and services within their own departments or facilities, and they need to engage with the organisation as a whole to develop strategies, systems, structures and processes that will improve performance to meet the needs of the community in the future (Legge, Stanton & Smyth, 2006). In many organisations to date ‘performance’ has been understood and measured in very narrow terms including financial indices and budgets results, increases in access and throughput and improved efficiency. The difficulty, according to Halligan (2006, cited in Walberg et al. 2006), is that these measures and terms ‘are not meaningful to patients, or healthcare professionals’ (p.xiii) and they often also have little to do with improving patient or health outcomes. The role of the leader and change agent in the health care setting today is to ensure that clinical practice has a real focus on performance management and improved outcomes for patients and communities and this focus needs to be communicated in terms and measures that that are meaningful for all of the stakeholders.
While most health care professionals are familiar with quality improvement methodologies and are involved in quality improvement initiatives and projects, the results of these efforts are generally seen at the local team, ward or department level and are aimed at improving systems and processes related to patient care at the local level. Professionals undergo training and credentialing, facilities are accredited, new methodologies such as Six Sigma or ISO standards are adopted to improve the quality of care but despite all of this very good quality improvement activity there are still major performance issues within organisations and health systems. According to Walburg et al. (2006, p. 2) the ‘Health care systems are still characterised by variations in clinical care, lack of responsiveness to user’s needs, waste, delays and financial challenge’. These authors are of the opinion that it doesn’t matter how well-meaning individual managers and health care professionals are in relation to improving their practice ‘the isolated application of quality of care ‘tools’ in the form of projects, certification...has had its day’ (Walburg et al., 2006, p.3). Efforts need to be system-wide, integrated and aimed at improving the outcomes of care delivered to the patients (Walburg et al. 2006), rather than just concentrating on improving systems and processes.
The next section attempts to bring together issues related to change, organisational development and improving organisational performance by introducing the concept of the learning organisation and by examining models which can be used by managers and clinical leaders to discover new ways of working and learning together to achieve change and growth within their organisations.
⦁ The Learning Organisation
In the previous section on change management Johnson’s (2009) quote was used to illustrate the point that we need to conceptualise change differently – as something positive rather than negative! We need to begin to see it as the norm and as a positive concept that can help us deal with new challenges as they arise (Kelleher, 2002). As Johnson (2009) suggests the goal should be that change is not seen as an initiative or a project but as a continuous cycle of improvement that has no actual beginning, middle or end. To quote Johnson (2009, p. 295) ‘the objective being to create a learning organisation, that continually reinvents itself, based on external and internal forces’.
The concept of the learning organisation is not new with Kelleher (2002) providing a history which shows that it goes back to the 50’s and 60’s. In 1990 Peter Senge wrote his influential book The Art and Practice of the Learning Organisation in which he argued that a learning organisation has five distinct dimensions, or disciplines, ‘which create an environment in which organisations become more dynamic and its constituent parts share common goals’ (Kelleher, 2002, p.2). We understand what is meant by ‘learning’ (new knowledge, skills and attributes) but what is meant by the term ‘the learning organisation’? Many health care professionals would say that they work in a ‘learning organisation’ because they hold weekly in-services and get conference leave – but those learning events cannot guarantee that learning takes place, that workplace behaviours change or that services improve.
The debate about learning organisations recognises that while individuals are programmed to learn, organisations are not generally as adept at learning as those individuals (Carroll & Edmondson, 2002). Leadership is essential to the development of a learning organisation in terms of providing a supportive environment, establishing a shared vision, building relationships and developing a culture where not only are knowledge and skills constantly improved, but people discover the importance of strengthening teams and finding better ways of working together towards the organisational goals (Carroll & Edmondson, 2002). It is crucial that groups and teams engage in learning as they listen to each other, discuss options, solve problems, evaluate solutions (Kelleher, 2002) and strive to continuously improve their practice. As Kelleher (2002) says – ‘team working’ should not be mistaken for ‘team learning’. This is especially so in relation to patient safety and quality of care issues where the leaders need to provide time and opportunities for knowledge management, information flows and learning about the organisational systems and supports required for individuals and groups to report and learn from errors and incidents, ‘rather than blaming individuals and suppressing information when bad events occur’ (Carroll & Edmondson, 2002, p 55).
Peter Senge talks about the five disciplines (personal mastery, mental models, shared vision, team learning and systems thinking) which represent approaches that an organisation needs to take to develop what he calls the ‘three core learning capabilities’ of working teams, what Senge (2006, p. Xiii) calls ‘the fundamental learning units in an organisation’. The three core learning capabilities are:
1) fostering aspiration,
2) developing reflective conversations, and
3) understanding complexity.
Senge (2006) likens these capabilities to a three legged stool – if any of one of them is missing the stool would not stand up. The following table has been compiled from Johnson (2009) and Senge (2006) as a way of summarising the five disciplines and the core learning capabilities for working teams.
Table 2.3 The Learning Organisation – (Johnson, 2009; Senge, 2006)
CORE LEARNING CAPABILITIES FOR TEAMS
Core Capability Learning Disciplines Description
Fostering aspiration Personal Mastery
Learning to develop and expand personal capacity to create the results we desire and an organisational environment where all members are encouraged to learn and develop. It is about clarifying values and personal vision, focusing energies, developing patience and seeing reality more objectively, life-long learning
Shared Vision Building a vision and commitment to a shared future – setting goals for the team to create that future, along with the principles and guiding practices required to achieve the vision.
Reflective conversations Mental Models
Mental models are assumptions that we have about the world that guide our actions and decision. Often we are not aware of their impact on our behaviour and thinking. Working with these mental models involves reflection, clarification and being open to the scrutiny and influence of others.
Team Learning Team learning starts with suspending assumptions and using conversation, collective thinking and collaborative action to improve the performance of the team and the individual members. Team learning is the basis of organisational learning.
Understanding complexity Systems Thinking A way of thinking about, describing & developing an understanding of the forces and interrelationships as well as the behaviours of the systems in which we work. Helps groups bring about change in those systems for the benefit of the whole.
If you have the time and the opportunity Peter Senge’s (2006) The Fifth Discipline: the art and practice of the learning organisation is a very good resource for people interested in improving organisational learning.
⦁ Theories and concepts underpinning organisational performance improvement
Often doctors, nurses and allied health personnel have a number of clinical indicators and quality improvement processes in mind for improving quality (structures and processes) while the top management has a different set of strategic goals, objectives and measures on their agenda for improving performance including access, throughput, budget measures and outcome (Walburg et al., 2006). The efforts to improve quality and safety of care and outcomes for patients within organisations are not always integrated, nor necessarily focused on the same priorities and objectives (Walburg et al., 2006) and may lack a sound theoretical basis.
In the 1990’s evidence started to appear that showed the extent of patient safety issues in the Australian health care system and many other countries were finding the same issues. The Safety and Quality in Australian Health Care Study (Wilson Runicman, Gibberd, Harrison, Newby &Hamilton, 1995) showed the extent of hospital admissions that were associated with potentially preventable adverse events which resulted in significantly increased length of stay in hospital, significant increases in morbidity, disability and even death resulting from health care management (Wilson, et al. 1995).
A major report called To Err is Human: Building a Safer Health System from the Institute of Medicine (IOM) in 1999 drew attention the fragmentation of the system and the harm that was being done to patients in the health care system. According to the Institute for Healthcare Improvement in the United States of America health care systems were in need of radical change in relation how they perform – ‘the status quo was no longer acceptable’.
⦁ Performance Improvement versus Quality Improvement
Like all of the concepts discussed in this Unit, there are a number of different definitions related to performance improvement in health care. Isouard, Messum, Briggs, McAplin and Hanson, (2006b) quote the IOM definition of organisation performance improvement as
...a continuing (and evolving process) - based in a context of shared responsibility and accountability for health improvement – for (1) selecting and using a limited number of indicators that can track critical processes and outcomes over time and among accountable stakeholders: (2) collecting and analysing data on those indicators; and (3) making the results available to inform assessments of effectiveness of the intervention and the contribution of accountable entities (IOM, 1997, cited in Isouard, et al., 2006, p.351).
You can see from this definition that the key to performance improvement depends upon setting standards, selecting appropriate criteria, undertaking measurement over time and assigning responsibility and accountability for continuous improvement. According to Berwick, Brent and Coye (2003, p.I30) for continuous quality improvement to occur, measurement is necessary but not sufficient. They give the example of measuring your golf score each week but not necessarily improving your game over time! The point they make is that it is very important to understand the link between performance measurement and performance improvement (Berwick, et al. 2003).
In looking at the terms related to quality and performance improvement Berwick et al. (2003) state that ‘organizations and individuals achieve improved performance, guided by measurement, through changing the processes of work’ (p. I35). These approaches to change include:
⦁ Quality control – undertaking work to make care processes stable, reliable and conforming to standards
⦁ Quality improvement – making changes to care processes that improve efficiency, reduce costs and increase performances to new levels (setting new benchmarks)
⦁ Quality design – working to design totally new work processes, products and services (rather than just improving them incrementally).
To quote Berwick, et al. (2003, p. I35)
To improve performance, organizations and individuals need the capability to control, improve, and design processes, and then to monitor the effects of this improvement work on the results.
Performance ‘management’ implies that action is taken to make strategic changes and improvement, and it can be at the level of individual capability (performance appraisal, feedback and ongoing development); processes improvement (implementing new or improved processes to correct deficiencies) or at the organisation level where the executive team or a performance improvement consultant works with key stakeholders to implement a corporate quality improvement strategy which focuses on improving the outcomes of care, rather than the just the inputs, processes and outputs that are generally more easily measured and improved.
Although quality improvement and performance improvement both take a systems view, performance improvement has a much greater emphasis on human capacity development and worker performance improvement as the keys to improving organisational performance. According to Bornstein (2001, n.p.) if performance is to improve at organisational level the following conditions are necessary for individual capacity development:
⦁ Clear job and performance expectations
⦁ Clear and immediate feedback on performance
⦁ A supportive environment, including adequate and proper tools, supplies, and work space
⦁ Motivation to perform to expectations (intrinsic motivation to do the job)
⦁ Organized support in terms of strategic direction, leadership and management communication, organizational structure, and well-conceived job roles and responsibilities
⦁ Knowledge and skills to do the job (technical competencies that match the requirements of the job)
Other differences between performance improvement and quality improvement are pointed out by Baars, Silvia, Evers, Arntz and van Merode (2009) who suggest that:
Performance management is proactive and concerns the capability to reach objectives in which data from the past are used for decision making, whereas quality improvement is reactive and focuses on deficiencies in quality and their improvement. Furthermore, quality improvement is mostly a one-time effort while performance management is an ongoing process. (n.p.).
Calls for performance improvement in health care often come out of major inquiries into system failures such as those related to the Campbelltown and Camden Hospitals in New South Wales, the Royal Melbourne Hospital, the King Edward Memorial Hospital in Perth (Hindle, Braithwaite, Travaglia & Iedema, 2006) and the Bundaberg inquiry in Queensland. Other areas where performance is of significant concern in Australia include those where there is a significant burden of disease that is not being adequately treated(e.g.diabetes, renal & obesity); clinical practice where evidence-based best practice is known but there are significant gaps between best and current practice and where there is significant variations in practice between places (Ward, 2008). In 2008 the Australian Government commenced the development of a set of national indicators to improve the performance of the Australian Health Care system in relation to safety and quality of care. The following slide shows the initial list of recommended indicators, grouped under the dimensions of quality and safety.
Measures for the Australian Health Care System (Hargraves, 2008)
In 2009 The Australian Government, through the Australian Institute of Health and Welfare (AIHW) produced a list of recommended indicators for the Australian health and aged care sector. This set of 55 indicators covers areas such as primary and community care, hospitals, specialised health services, residential aged care, and a number of indicators that cover multiple service categories. Some of the indicators are structural indicators, some are process indicators but the majority are indicators related to improving health outcomes or the outcomes of care. See the Table (Recommended list of Indicators) inserted at the end of this section.
Of course there are many barriers to undertaking process improvement, measurement and using the information to bring about change and improvement. Some of those barriers include:
⦁ a lack of knowledge, skill and motivation from leaders and managers in relation to using data to driving change
⦁ a lack of organisational development and capacity building to enable health care professionals to adopt best practice and lead change and improvement (skills in accessing and interpreting data, knowledge of process improvement techniques, time and resources away from the bedside, knowledge of organisational goals and objectives, change leadership and support),
⦁ A lack of vision and incentives to change practice and underdeveloped organisational systems and support processes that enable clinical staff to see quality as the cornerstone of patient-centred care. (Berwick, et al. 2003).
The following is an excellent reading with a number of Figures/models that really conceptualise performance measurement in health care. While the paper is related directly to performance measurement in mental health services the concepts can be universally applied across clinical services.
Reading 3.1
Baars, I.J., Evers, S.M., Arntz, A. & van Merode, G.G. (2010). Performance measurement in mental health care: present situation and future possibilities. International Journal of Health Planning Management, 25, (3), 198-214
Note - Figure 1 - The linking of performance measurement to accountability, quality improvement and performance management with a focus on structures, processes and outcomes provides a very clear overview of the main concepts.
Note - 2 - Provides a great deal of detail about the manner in which these authors have conceptualised and classified the domains of performance and the performance indicators.
Note - 3 - provides a model for using the information gained from performance measurement to compare with objectives, feedback into the system for performance management, improvement and organisational learning.
Activity 3.1
Please go to Figure 2 in Reading 3.1
In relation to your own sphere of practice think about:
The types of structural indicators that would be applicable to your service (What context do you work in? What are the characteristics of the staff? What are the characteristics of the population that accesses your services? What type of organisational structure do you work in?)
⦁ The types of process indicators that would be applicable to your service.
⦁ What type of outcomes indicators would be applicable to your service?
According to Baars et al. (2009) this conceptual framework can help professionals choose indicators that will be useful in performance measurement, management and improvement in mental health care, although the domains and many of the indicators they have conceptualised would be useful across most service types. They are of the belief that ‘performance management implies that the planning and control is based on information in order to be proactive and learn’. They also believe that ‘comparing the performances with objectives and taking appropriate actions to overcome shortfalls are essential in performance management’ (Baars et al., 2009, n.p.).
Reading 3.2
Isouard, G., Messum, D., Briggs, D., McAlpin, S. & Hanson, S. Improving organisational performance. In M.G Harris. & Associates. (2006). Managing health services: Concepts and practices. Sydney: Mosby Elsevier. pp. 349 – 380.
This reading provides a comprehensive review of theories and concepts underpinning organisational performance improvement from both an international and local (Australian) perspective. Figure 15.1 provides another diagramatic view of a systems approach to organisational performance analysis and improvement (Isouard et al., 2006b, p. 351). These authors also address approaches to improving performance (including best practice, benchmarking, performance indicators); they provide an overview of a process for reviewing organisational performance; an overview of a number of international frameworks for improving performance of health care systems and they discuss the challenges and opportunities in the development of appropriate performance indicators.
Activity 3.2
The case study on page 360 of Reading 3.2 asks you to think about the appropriateness of the use of financial and other indicators of efficiency related to the provision of dining and meal services in an aged care facility.
⦁ What other outcome indicators (other than financial and operational efficiency indicators) might be considered for this type of service?
⦁ How do organisations get a balance between accountability for efficiency (financial performance) and accountability for effectiveness (including quality of life and consumer satisfaction)?
⦁ How might the vision and mission of an organisation help in aligning the balance between the need for efficiency and effectiveness?
Of course accountability for sound financial management is very important from an organisational viewpoint but so is quality of life and satisfaction with care from a consumer’s perspective. In this case study the focus is on a residential aged care facility. While food and meal services in the acute public hospital setting are generally not seen to be a great source of consumer satisfaction, the quality of meals and dining experience for residents of aged care facilities contributes greatly to quality of life and health status and also provides opportunity for social interaction. The quality and performance of particular services need to be assessed from the point of view of all stakeholders when performance improvement is considered.
Including the patients/clients in performance improvement initiative is extremely important and the literature now contains many tools and methods for facilitating that involvement. There are many methods for involving patients and carers in quality and performance improvement including:
⦁ mapping the patient journey
⦁ listening to patient stories
⦁ observations of care
⦁ the use of carer champions and patient shadowing
⦁ focus groups
⦁ patients as teachers
⦁ patient diaries
⦁ discovery interviews
⦁ patient and carer surveys and questionnaires
See the NHS Improvement Leader Guide Involving Patients and Carers (2005.)
Walburg et al. 2006 make a distinction between performance improvement and outcomes management. They state that they prefer the term ‘outcomes management’ and they base this on two important principles – using a systematic and ‘integrated application of quality of care principles’, and ‘a strong and consistent orientation towards the improvement of actual care results’ (Walburg, 2006, p. 4). Outcomes management according to these authors is ‘the continual improvement of outcomes for the best possible care processes’ (p.4). Relating performance management (financial and operations management) to the outcomes of care in ways that lead to continuous improvement in outcomes for patients is equivalent to ‘performance improvement’ – according to these authors (Walburg at al., 2006).
According to Walburg et al. (2006) the important building blocks in outcomes management (or performance improvement) include:
⦁ effective teamwork
⦁ focusing on processes and systems
⦁ defining ‘outcomes of treatment’ in broad terms
⦁ recognition of the importance of patient variables in the outcomes of care
⦁ benchmarking and comparison of results
⦁ mechanisms for feedback of data for continuing improvement
⦁ developing a holistic approach to disease management
⦁ issues related to accountability mechanisms such as public disclosure of performance outcomes
⦁ strengthening the scientific value of outcomes measures for evaluation purposes
Key to all of this is learning by individuals, teams and organisations in order to continuously improve performance and strengthen patient outcomes (Walburg, et al. 2006). As you saw above, the concept of the ‘learning organisation’ and ‘organisational learning’ is particularly important in health care where data are numerous, information is plentiful and the knowledge required to provide effective, efficient, safe and timely care changes almost daily.
Successful change management and continuous performance improvement is conditional upon people being able to continuously learn and on organisations supporting that learning and changing in response to it. Grol, Bosch, Hulscher, Eccles and Wensing (2007) argue that the complexity and difficulty of achieving sustained and effective change in the health care system may be influenced by many interacting factors, other than individual health professionals (who often get the blame and are targeted for development when the quality of care is deficient). They suggest that a more integrated and systematic use of theories in the planning and evaluation of quality improvement interventions in health care can lead to the use of different strategies and more effective and sustained change.
Reading 3.3
Finkelman, A.W. (2016). Developing interprofessional and intraprofessional teams. In Leadership and management for nurses. Boston: Pearson pp.298-314
This reading emphasises the importance of the leader in the capacity building within the team by motivating the team to work together to achieve their goals. This is the basis of ensuring that the workplace is flexible and is better able to identify the need for change and embrace the strategies which lead to improved outcomes. Think about how you as a leader, would team build in order to develop a flexible workplace.
Reflection
As a manager or clinical leader, how useful do you find theory as a basis for your leadership/management practice? Many clinical leaders are promoted to management positions and then may undertake formal management training. Management training often offers techniques to deal with issues such as change management but, according to Andrews, Cameron and Harris (2008), when those techniques fail it is difficult for the leader to move forward because ‘they lack the necessary concepts for thinking creatively or adapting theories for their particular work context’ (p.302).
Additional Reading
Andrews, J., Cameron, H. & Harris, M. (2008). All change? Managers’ experience of organizational change in theory and practice. Journal of Organizational Change Management, 21, (3), 300-314
This reading reports on a study which examined how managers used organisational change theory and its relevance in their work. Many of them said that the broad explanatory theories helped them understand the context of their practice and the factors driving change. Having an understanding of the theory, the context and factors driving change gave them confidence in planning and implementing change. The managers valued having access to a broad range of ‘theories, concepts and models’ that could be used in different circumstances, substituted when one didn’t work, or used in combination to assist with critical analysis and problem solving.
⦁ Measuring Organisational Performance and Effectiveness
Many of our early leaders in nursing and medicine set out the principles of using indicators to measure outcomes in order to continuously improve patient care. Florence Nightingale is well known for her studies of mortality, for comparisons of outcomes of groups receiving different types of treatment and for documenting the impact of effective nursing care on the mortality of wounded soldiers (Walburg, 2006). One of the famous quotes from Florence Nightingale is:
In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of comparison. If they could be obtained ... they would show subscribers how their money was being spent, what amount of good was really being done with it, or whether the money was not doing mischief rather than good ... (Nightingale, 1863 cited in Barnett, Jenders and Chueh, 1993)
Nightingale developed the Model Hospital Statistical Form in order to collect and report consistent data and statistics which she then used to improve the environment, the treatment and nursing care the patients received (Barnett, et al., 1993).
Dr Ernest Codman (a surgeon in the USA in the early 1900’s) examined the mortality rates of hospital patients in order to detect errors and improve care. He differentiated between unavoidable and avoidable deaths and advocated for reform of the hospital system and improved quality of care. In many sources he is acknowledge as the founder of what is now called ‘outcomes management’. He believed that all doctors should follow up their patients, assess the outcomes of treatment and make those results available to the public. He is quoted as saying:
I am called eccentric for saying in public that hospitals, if they wish to be sure of improvement, must find out what their results are, must analyze their results to find their strong and weak points, must compare their results with those of other hospitals… Such opinions will not be eccentric a few years hence.
(Codman, 1917. as cited in Mainz, n.d.)
In some ways health care has progressed a great deal since Florence Nightingale and Ernest Codman, but in other ways – it has not. In Australia at the current time debate continues about the limitations and benefits of publishing the outcomes of hospital care to the public. As we know when outcomes are measured there are many factors which can have an impact on patient outcomes other than the treatment or care process itself (Walburg, 2006). Since outcomes cannot be treated strictly as ‘cause and effect’ (Walburg, 2006) and they are often difficult to measure, there was a period when structure and process indicators were the main measures used to try to assess and improve quality of care. According to Walburg (2006) in the 1980’s in the USA attention again turned to outcomes measures when differences in mortality rates for different hospitals began to be published and when Donabedian clearly defined the differences between the three aspects care: structure, process and outcomes. Since that time, the drive for quality and performance improvement has basically taken on an outcomes focus and has been driven largely by external stakeholders such as governments, insurers and the public (Walburg, 2006). The focus now is on organisational performance improvement using indicators that can track processes and outcomes over time. To repeat the quote from Isouard et al. (2006b) above organisation performance improvement is defined as:
...a continuing (and evolving process) - based in a context of shared responsibility and accountability for health improvement – for (1) selecting and using a limited number of indicators that can track critical processes and outcomes over time and among accountable stakeholders: (2) collecting and analysing data on those indicators; and (3) making the results available to inform assessments of effectiveness of the intervention and the contribution of accountable entities (IOM, 1997, cited in Isouard, et al. 2006, p.351).
The Baars et al (2009) model for performance measurement (Figures 1& 2 in Reading 3.1) includes the purpose of measurement and the types of indicators used.
⦁ The purpose of measurement is said to be:
⦁ Accountability – Measurement for presentation, benchmarking and comparison. Empowers consumers in choice of providers, for external audit, stimulates political debate. Examples include publications or presentation of comparisons of outcomes of coronary artery bypass surgery, wound infections rates between providers and or facilities, waiting times for elective surgery, triage category performance, etc.
⦁ Quality Improvement – measurements used to facilitate improvement activities. Examples could include QI activities to improve compliance with wound dressing techniques and reduce infection rates, hand washing campaigns to reduce nosocomial infections, etc.
⦁ Performance management – measure to monitor and manage organisational performance, predict effect of management interventions. Proactive and concerned with organisational capacity to meet strategic goals and objectives. Uses information for forecasting, planning and control.
⦁ Performance indicators are classified as:
⦁ Structure (or input) indicators relate to the context of care and the environment in which it is provided. Can include characteristics of the population served by the health service; the characteristics of the staff ,the context of care including the health system, legal parameters, funding, etc. plus the organisational structures and resources.
⦁ Process indicators relate the actual care processes (how care is provided) and the interactions between the health care providers, clients and carers and include access, appropriateness, continuity and coordination of care, prevention and safety.
⦁ Outcomes indicators relate to the consequences of care and are classified under effectiveness (including health status, quality of life, functional status and satisfaction with care), and efficiency and optimal use of resources (including length of stay, consultations, throughput, utilisation, cost containment, financial measures. (Compiled from Baars et al. 2009).
Of course the Baars et al. (2009) model for performance measurement is only one way of looking at a system wide organisational performance measurement and improvement framework. Isouard et al. (2006b) provide a diagram that captures a whole of system approach to organisational performance analysis and improvement – see page 351 of Reading 3.2.
⦁ Levels of performance measurement - global, national, state and local
Isouard et al. (2006) discuss levels of performance measurement from four perspectives including global, nation, State/Territory and local organisation service delivery (see p.353). These levels include:
⦁ Global - The World Health Organisation in 2000 published its framework for performance as it relates to global health improvement goals and health system performance (Isouard et al. 2006).
⦁ National - At the national or state health system level performance management and improvement is usually tied to government policy through performance agreements between the health department and each statutory health service (state/area/regional health service and hospital). In Australia, the Federal Government uses its Australian Health Care Agreements which are negotiated every five years, to fund health care at state and territory level, to bring about reform in specific areas. The funding is tied to certain performance indicators over the period of the agreement. This is the same in most developed countries with funding being tied to major health priorities and the actions required to improve the health of the populations and health care services.
⦁ State or Territory - At state or territory level the health department will negotiate funding with the health services based on the requirements of the Federal Government and their own health priorities and goals.
⦁ Local - The Chief Executive of the health service will be responsible for the performance of the health system in relation to strategic goals and objectives of the government and the health service. These can include indicators related to equity and access to care, improving the quality and safety of care, development of organisational, team and individual capacity, improving the health of the population and many other goals and objectives related to improving the health of the population. Again, the performance of the system is generally tied to funding using a broad set of indicators that can be compared and published across systems.
The following slide is the same as the one seen previously (Hargraves, 2008) however it has now been coloured to show the different levels of accountability for performance improvement across the different levels of government.
Hargraves (2008). Measures for the Australian Health Care System.
⦁ Setting standards for performance
In order to improve the quality and safety of care, performance needs to be assessed against sets of standards and indicators. According to the Australian Council on Safety and Quality in Healthcare (2006) there are two main reasons for setting standards and they are to:
⦁ protect the public from harm, and
⦁ improve the safety and quality of service provision.
Standards generally relate not just to health care service provision, but also to such things as the regulation of health care providers, the environment in which care is provided, safety of consumers and staff (fire safety, occupational health and safety, drug manufacture and safety, etc.), technology assessment and many other issues related to the quality and safety of care in all areas of practice (Australian Commission on Safety and Quality in Healthcare, 2006). Many of these areas are underpinned by legislation and regulations promulgated by governments. The standards and their accompanying indicators form the basis for measurement, benchmarking or comparison and continuous improvement. Organisations and facilities are formally assessed and accredited against appropriate standards and that accreditation status is used to show the key stakeholders (government, funders, consumers, health professionals) that the organisation has been assessed as having met a particular set of standards (Australian Commission on Safety and Quality in Healthcare 2006).
In Australia there are many different sets of standards related to health and social care and that in itself is often very confusing to both the providers and consumers of health care services. The Australian Commission on Safety and Quality was set up in 2006 to report publically on the safety and quality of care within the Australian health care system against as set of national standards. The publication of these results demonstrates public accountability for the safety and quality of care provided by publically funded institutions, in particular. Hospital and health service accreditation is seen as an important step in improving quality and safety in health care however there are now standards for many other aspects of care provision including home and community, aged care, general practice – in fact any ‘point of care where there is a patient interaction’ (Australian Commission on Safety and Quality in Healthcare, 2008). In Australia the national accreditation system has been under review with a view to adopting an alternative model for safety and quality accreditation for health care (Australian Commission on Safety and Quality in Healthcare, 2008). At the end of 2008 the Hong Kong Hospital Authority produced a discussion paper on a three year pilot scheme for accreditation of public hospitals (Hong Kong Health Authority).
Two of the major sets of standards that are used for the assessment of quality and safety in Australian health and aged care settings are:
⦁ Australian Council on Health Care Standards EQuIP standards, and
⦁ Aged Care Standards and Accreditation Agency, Standards for Residential Aged Care
Activity 3.3
⦁ What standards are used in your sphere of practice?
⦁ Is your organisation / facility accredited?
⦁ When you visit a hospital or health care facility, do you look to see if they display a notice to say that they are accredited with the relevant authority?
⦁ What does that notice mean to you?
Reading 3.4
Marquis, B.L. & Huston, C.J. (2015). Socializing and educating staff for team building in a learning organization. Leadership roles and management functions in nursing. Theory and application (8th ed.) Philadelphia: Lippincott, Williams & Wilkins. Pages 363-380
This reading examines the strategies for developing an organisation which is able to learn as a team and how this enables the organisation to be better able to identify the need for change and develop capacity to optimise outcomes. The leader in such an organisation must be able to facilitate the appropriate training and support for individuals and the group in order to achieve the desired changes. The needs of adults as learners and strategies which support their learning requirements, is applied to health care staff. While this has a focus on nurses, the principles are the same for any discipline within the health care sector (or any organisation where there are adults).
⦁ Improvement methods
There are many ways of planning for improvement in performance in the health care setting. The Institute of Healthcare Improvement (USA) recommends a model for healthcare improvement which includes:
⦁ three fundamental questions which have to be part of any performance improvement planning, and
⦁ the use of the Plan-Do-Study-Act (PDSA) cycle (which will be familiar to many of you from your quality improvement experience) to pilot test and evaluate changes in the health care setting.
The following table (Table 3.1) shows the questions and actions for performance improvement. It is compiled from the Institute of Healthcare Improvement and the NHS Improvement Network, East Midlands websites.
Table 3.1 Questions and Actions for Performance Improvement.
Question Actions
What are we trying to accomplish? Set aims and objectives for improvement (refer to strategic goals and objectives).
Aims and objectives should be SMART – Specific (clear and well defined), Measurable, Achievable, Relevant (to the population, process, etc)/Realistic and Time-specific.
How will we know that a change is an improvement? Establish measures - choose indicators that are evidence-based, valid and reliable and will measure whether a specific change results in improved performance. Data need to be able to be accessed or collected within the timeframe and within available resources.
What changes can we make which will result in improvement? Select change – identify changes that are most likely to result in improvement and can be implemented using available resources. Plan change process using change principles
PLAN - DO - STUDY - ACT Test changes - pilot test changes in an actual care setting, observe results and use information gathered to make further change, re-test, observe, etc.
Implement changes – after going through the PLAN-DO-STUDY-ACT cycle as many times as necessary, implement the change on a larger scale (at wards, department or facility level) and evaluate. Report performance improvement against SMART aims and objectives.
Spread changes – Disseminate report on outcomes of change and the improvements achieved to help spread the successful change throughout the system.
⦁ Choosing Performance Improvement Indicators.
It is not possible to cover performance and quality improvement indicators in great depth in this Unit however a broad outline of the subject will be provided along with extra resources for those who are interested in pursuing this topic area.
According to the Australian Government Department of Health and Ageing, quality indicators are one of the tools that can be used to encourage performance improvement, along with standards, guidelines, audits, surveys and many other methods of measuring and monitoring performance. Indicators are said to provide an assessment of:
⦁ The extent to which a standard or desired practice is being implemented (the process), and
⦁ The impact of that practice (the outcome).
Indicators are not direct measures themselves but they are ‘flags’ or pointers that something needs investigation and / or improvement.
(Australian Government, Department of Health and Ageing, n.d.)
Definitions – The following definitions are provided from Mainz (1999)
Indicators provide a quantitative basis for clinicians, providers, organisations and planners aiming to achieve improvement in care and the processes by which patient care is provided. (ISQua, Melbourne 1999, cited in Mainz, 1999.)
Indicators are quantitative measures that can be used to monitor and evaluate the quality of important governance, management, clinical, and support functions that affect patient outcomes. (Joint Commission, 1990 cited in Mainz, 1999)
According to the Rand Corporation (1998, cited in Mainz, 1999.):
⦁ Indicators should be explicit statements of desirable (or undesirable) structural, process or outcome dimensions.
⦁ Indicators should be supported by either research that establishes the efficacy or effectiveness of the indicators by a formal process of obtaining experts consensus.
⦁ The tools for measurement should be tested and evaluated for reliability, validity and feasibility.
⦁ Results should be repeated in a format that maximizes the likelihood that the information can be interpreted and used in appropriate decision contexts.
Indicators are used for many purposes including;
⦁ to measure and document quality of care;
⦁ to be used for benchmarking and comparison over time and between providers;
⦁ to demonstrate accountability for performance to key stakeholders;
⦁ for transparency to assist consumers to make judgements about providers, facilities and other aspects of care;
⦁ to drive priorities for health care agreements, funding arrangements and incentives for health care performance improvement. (Mainz, n.d.).
Supplementary Reading
NHS Institute for Innovation and Improvement.(n.d.) The Good Indicators Guide: Understanding how to use and choose indicators. NHS Institute for Innovation and Improvement.
This is an easy to read and understand guide on choosing and using clinical indicators. The guide focuses on the key principles behind developing, understanding and using indicators. It is easy to read and understand and provides an introduction to indicators and it helps understand variation in practice and provides many good examples of indicators in use.
If you think that indicators are just about collecting data for measurement – there is a very good quote from Don Berwick (p.18) from the Institute of Health Care Improvement in the US (The Good Indicator Guide n.d. p.18). He is quoted as saying:
‘I am not interested in measurement per se. I am obsessed by improvement and the role measurement has in that process.’
In your own practice you will be using various standards and indicators to measure, monitor and improve the quality of the service that you provide. Even if you work in ‘Head Office’, there are now corporate standards to assess the quality, effectiveness and efficiency of the administrative services provided within health care.
See over for the AIHW (2009) List of Recommended Indicators.
Activity 3.4
Review the list of recommended indicators (see over) and consider the following:
⦁ Is your sphere of practice covered by this list of indicators (primary health care or general practice, acute care, residential aged care)?
⦁ Are you familiar with the indicators presented in this list?
⦁ Do you regularly report on any of these indicators in your practice?
⦁ Can you see the relevance of these indicators to improvements in practice and the quality and safety of health care delivery?
It is beyond the brief of this Unit to discuss all the different types of indicators that are available for quality improvement in health care and other associated social services. There are a number of very good practical resources and toolkits related to quality indicators and methods for improvement, as well as information on different sets of standards and indicators. A number of resources in this area can be found at the end of the module in Additional Readings for Module 3.
List of Recommended Indicators.
Adapted from
Australian Institute of Health and Welfare. (2009).Towards National Indicators for Quality & Safety.
Primary care and community health services
⦁ Enhanced primary care services in general practice
⦁ General practices with a register and recall system for patients with chronic disease
⦁ People with moderate to severe asthma who have a written asthma action plan
⦁ Management of hypertension in general practice
⦁ Management of arthritis and musculoskeletal conditions
⦁ Mental health care plans in general practice
⦁ Annual cycle of care for people with diabetes mellitus
⦁ Cervical cancer screening rates
⦁ Immunisation rates for vaccines in the national schedule
⦁ Eye testing for target groups
⦁ Quality of community pharmacy services
⦁ Developmental health checks in children
⦁ People receiving a medication review
Hospitals
⦁ Assessment for risk of venous thromboembolism in hospitals
⦁ Pain assessment in the emergency department
⦁ Reperfusion for acute myocardial infarction in hospitals
⦁ Stroke patients treated in a stroke unit
⦁ Complications of transfusion
⦁ Health care associated infections acquired in hospital
⦁ Staphylococcus aureus (including MRSA) bacteraemia in hospitals
⦁ Adverse drug events in hospitals
⦁ Intentional self-harm in hospitals
⦁ Malnutrition in hospitals and residential aged care facilities
⦁ Pressure ulcers in hospitals and residential aged care facilities
⦁ Falls resulting in patient harm in hospitals and residential aged care facilities
⦁ Complications of anaesthesia
⦁ Accidental puncture/laceration in hospitals
⦁ Obstetric trauma - third and fourth degree tears
⦁ Birth trauma – injury to neonate
⦁ Postoperative haemorrhage
⦁ Postoperative venous thromboembolism
⦁ Unplanned return to operating theatre
⦁ Unplanned re-admission to an intensive care unit
⦁ Hospital standardised mortality ratio (HSMR)
⦁ Death in low mortality DRGs
⦁ Independent peer review of surgical deaths
⦁ Discharge medication management for acute myocardial infarction
⦁ Timely transmission of discharge summaries
Specialised health services
⦁ Mental health admitted patients having seclusion
⦁ Post-discharge community care for mental health patients
⦁ Quality of palliative care
⦁ Functional gain achieved in rehabilitation
43. Multi-disciplinary care plans in sub-acute care
(5). Management of arthritis and musculoskeletal conditions
Residential aged care
44. Oral health in residential aged care
(13). People receiving a medication review
(23). Malnutrition in hospitals and residential aged care facilities
(24). Pressure ulcers in hospitals and residential aged care facilities
(25). Falls resulting in patient harm in hospitals and residential aged care facilities
Multiple service categories
45. Unplanned hospital re-admissions
46. Inappropriate co-prescribing of medicines
47. Selected potentially preventable hospitalisations
48. End stage kidney disease in people with diabetes
49. Lower-extremity amputation in people with diabetes
50. Cancer Survival
51. Failure to diagnose
52. Potentially avoidable deaths
All service categories
53. Patient experience
54. Presence of appropriate incident monitoring arrangements
55. Accreditation of health care services
⦁ Leadership in Capacity Building and Performance Improvement
As we saw above in Module 2 for organisations to succeed and prosper in the current environment they need leaders who can influence and guide people through the transformation process while taking on the challenge of building a learning organisation (McLaughlin and Kaluzny, 2006). According to McLaughlin and Kaluzny (2006) health care has to transition from a ‘professional’ model (individual clinicians responsible for the care of individual clients with little accountability for system level improve) to a ‘transformational’ model which is ‘characterised by shared responsibility, and collaborative decision-making, continuous innovation and learning’ (p. 199). This transformational model has a number of important features that distinguish it as a model for leadership, learning and continuous improvement. These features include:
⦁ Leaders and employees share overall responsibility, as well as take individual responsibility
⦁ People at multiple levels assume leadership
⦁ Outcome driven
⦁ Share decision making
⦁ Continuous planning
⦁ Futures orientation
⦁ Performance enhancement appraisals
⦁ Continuous innovation
(McLaughlin& Kaluzny, 2006, pp. 199-202).
A great deal of literature has been devoted to the links between transformational leadership, capacity development and improvements in the quality and safety of patient care. An influential research report from the US Institute of Medicine (IOM) that addresses this issue is called Keeping Patients Safe: Transforming the Work environment of Nurses (2004). This report focused on how transforming the work environment of nurses contributes to patient safety. It identified four major threats to patient safety and four safety defences that health care leaders, particularly nurse leaders, need to address in order to improve the safety and quality of health care. Whilst this IOM report acknowledges the critical role that nurses have in relation to patient safety it also concludes that the working environment of nurses poses many serious threats to patient safety (De Groot, 2005). The key to improving the safety of patient care, according to this report is ‘’leadership capable of transforming not just a physical environment for nursing, but also the beliefs and practices of nurses and other health care workers providing care…’ (IOM, 2004, p.7). Having a focus on safety and quality improvement will not be enough to bring about change. There needs to be a focus on leadership and the development of a workplace culture that values learning and innovation, change management and team development. The people who deliver the care need to be actively involved in the decision-making about improving systems, processes and performance. The leader focuses attention on the needs of the patient as the central tenant of safety and quality of care (Ferguson, Calvert, Davie, Fallon, Fred, Gersbach & Sinclair, 2007).
Chapter four of this report talks about the need for ‘transformational leadership and evidence-based management’ practices that can create environments that are conducive to patient safety (IOM, 2004, p.108). The evidence-based management practices that are identified include:
⦁ balancing the tension between production efficiency and reliability (safety),
⦁ creating and sustaining trust throughout the organization,
⦁ actively managing the process of change,
⦁ involving workers in decision making pertaining to work design and work flow, and
⦁ using knowledge management practices to establish the organization as a “learning organization.”
Much of this report can be accessed through the National Academies Press website. Retrieved on 28/01/17 at: http://www.nap.edu/openbook.php?record_id=10851&page=R1
Reading 3.5
Greenfield, D. (2007). The enactment of dynamic leadership. Leadership in Health Services, 20, (3), 159-168
This reading reports on a study which clearly demonstrates how effective clinical team leadership, using different leadership styles at different times and in different situations, can develop a collaborative team within a child and family health service and, in doing so, drive change and improvement in that service. The article uses Goleman’s leadership typology which is based in emotional intelligence and consists of six styles of leadership including coercive, authoritative, affiliative, democratic, pacesetting and coaching. The article provides an excellent exposé of how teams react to different styles of leadership that are participative and supportive but can also be authoritative and coercive if required, compared to a primary style of authoritarian management where participation and team decision making is not invited nor welcomed.
Activity 3.5
Framework for Leadership Improvement.
Please go to Figure 2 on page 3 of the above reading.
As a manager or clinical leader, how will you:
⦁ Make the status quo (what is happening in your service or organisation now) seem uncomfortable for your team, as a way of moving them towards change and improvement?
⦁ What is your vision for the future (of your service or organisation) and how will you present it as an attractive alternative to the status quo?
⦁ What is your plan for establishing the foundation for the change, building the will and generating ideas for change and then executing that change?
See additional resources for leading change and improvement at the Additional Readings for Module 3 below.
Reading 3.6
Son, C., Chuck, T., Childers, T., Usiak, S. Dowling, M., Andiel, C., Backer, R., Eagan, J. & Sepkowitz, K. (2011). Practically speaking: Rethinking hand hygiene improvement programs in health care settings. American journal of infection control, 39:716-724.
This reading examines an approach to the introduction of a hand hygiene compliance program. You may wish to use this or develop you own performance improvement strategy for assignment 2. You are encouraged to consider the way in which the program was introduced and to think about how the leaders managed and supported this change process.
⦁ Summary
While it is not possible to cover all aspects of improving organisational performance in health care, this module has covered a range of issues related to the topic. It covered a number of theories and concepts underpinning organisational performance improvement in health care; issues related to measuring organisational performance and effectiveness and the need for leadership at all levels of the organisation to build capacity for change and performance improvement. Measuring health care performance provides a number of challenges and the section covered the levels of measurement, the purposes of measurement, standards for measurement, choosing appropriate indicators and methods for measurement including questions to ask when using the familiar Plan-Do-Study-Act method for performance improvement.
The Framework for Leadership Improvement from the Institute of Healthcare Improvement provides an excellent starting point for managers and clinical leaders, who wish to build a foundation for organisational transformation and performance improvement. The Framework brings together most of the issues covered in this Study Guide – setting the mission, vision and strategic directions, establishing a foundation for change, engaging stakeholders and building the will for change, generating ideas and executing change.
The Module finished with a case study on building organisational capacity using the SARS crisis as an example of leadership learning and capacity building.
A large number of leadership resources for improving organisational performance are provided at the Additional Readings for Module 3. (See over page)
⦁ Additional Readings for Module 3
AHRQ Agency for Health Care Quality and Research. The OECD Health Care Quality Indicators Project. Supplement. Retrieved on 24/01/17 from https://www.ahrq.gov/research/publications/index.html
American Nurses Association. The National Database of Nursing Quality Indicators (NDNQI). Retrieved on 24/01/17 from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingQualityIndicators.aspx
ASQ American Society for Quality, Seven Basic Quality Tools. Retrieved on 24/01/17from
http://asq.org/learn-about-quality/seven-basic-quality-tools/overview/overview.html
Auditor-General’s Report to Parliament (2009) Volume 1: Health Overview. (Overview of performance NSW Health System – all Area Health Services). Retrieved on 26/03/09 from http://www.audit.nsw.gov.au/publications/reports/financial/2009/vol1/pdfs/13_health_overview.pdf
Australian Council on Healthcare Standards (2015). Australasian Clinical Indicator Report: 2008-2015. Determining the potential to improve quality of care ( 17th ed.) Retrieved on 24/01/17 from
http://www.achs.org.au/publications-resources/australasian-clinical-indicator-report/
Australian Government Department of Health and Ageing Annual Report 2016-16. Retrieved on 24/01/17from
http://www.health.gov.au/internet/main/publishing.nsf/Content/annual-report2015-16
Bell, J.A.H., Hyland, S., DePellegrini, T., Upshuri, R., Bernstein, M. & Martin, D.K. (2006) SARS and hospital priority setting: a qualitative case study and evaluation. BMC Health Services Research 2004, 4:36
Institute for Healthcare Improvement. Plan do study act worksheet. Retrieved on 24/01/17 from http://www.ihi.org/resources/pages/tools/plandostudyactworksheet.aspx
Institute for Healthcare Improvement. How to improve. Retrieved on 03/03/09 from http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/
Janamian, T., Upham, S.J., Crossland, L. & Jackson, C.L. (2016). Quality tools and resources to support organisational improvementintegral to high quality primary care: a systematic review of published and grey literature. Medical Journal of Australia. 204(7) 22-28 Retrieved on 27/01/17 from https://www.mja.com.au/sites/default/files/issues/204_07/10.5694mja16.00113_Appendix%204.pdf
Mainz, J. (2003) Defining and classifying clinical indicators for quality improvement. International Journal of Quality Health Care. 15 (6). 523-530. Retrieved on 27/01/17 from https://www.ncbi.nlm.nih.gov/pubmed/14660535
Montalvo, I. (2007). The National Database of Nursing Quality Indicators (NDNQI). Online Journal of Issues in Nursing, 12, (3). Retrieved on 27/01/17 from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingQualityIndicators.aspx
National Health Performance Committee. (2001). National Health Performance Framework Report . A report to Australian Health Ministers Conference, August 2001. Queensland Health. Retrieved on 27/01/17 from http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129550571
Janamian, T., Upham, S.J., Crossland, L. & Jackson, C.L. (2016). Quality tools and resources to support organisational improvement integral to high quality primary care: a systematic review of published and grey literature. Medical Journal of Australia. 204(7) 22-28 Retrieved on 27/01/17 from https://www.mja.com.au/sites/default/files/issues/204_07/10.5694mja16.00113_Appendix%204.pdf
NHS Institute for Innovation and Improvement (n.d.) The Good Indicators Guide: Understanding how to use and choose indicators. Retrieved on 27/01/17 from http://www.apho.org.uk/resource/item.aspx?RID=44584
ISD Scotland. Quality indicators. Retrieved on 27/01/17 from
http://www.isdscotland.org/Health-Topics/Quality-indicators/
OECD Health Care Quality Indicators Project (HCQI). Retrieved on 27/01/17 from
http://www.oecd.org/els/health-systems/health-care-quality-indicators.htm
Road Map for Quality Improvement: A Guide for Doctors. Retrieved on 27/01/17 from http://www.physiciansinstitute.org/wp-content/uploads/2012/10/roadmapforqiguidefordoctorsjune06.pdf
ACI: NSW Agency for clinical innovation. Redesign resources: Focusing on patient journeys, redesign improves health system performance. Retrieved 27/01/17 from https://www.aci.health.nsw.gov.au/resources/redesign
⦁ References for Module 3
Andrews, J., Cameron, H. & Harris, M. (2008). All change? Managers’ experience of organizational change in theory and practice. Journal of Organizational Change Management, 21, (3), 300-314
Australian Commission on Safety and Quality in Health Care. National safety and quality health service standards (2012). Retrieved on 24/02/17 from
https://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-Sept-2012.pdf
Australian Institute of Health and Welfare. (2009).Towards National Indicators for Quality & Safety. Retrieved on 22/6/15 from http://www.aihw.gov.au/publications/index.cfm/title/10792
Barnett, G.O., Jenders, R.A. & Chueh, H.C. (1993). The Computer-based clinical record – Where do we stand? Annals of Internal Medicine, 119, (10), 1046-1048. Retrieved on 20/01/17 from http://www.annals.org/cgi/content/full/119/10/1046
Berwick, D.M., James, B, & Coye, M.J. (2003). Connections between Quality Measurement and Improvement. Medical Care, 41, (1), Supplement, pp I–30–I–38
Brand, C.A., Ibrahim, J.E., Cameron, P.A. & Scott, I.A. (2008). Standards for health care: a necessary but unknown quantity. Medical Journal of Australia, 189, (5), 257-260
Daly, J., Hill, M.N. & Jackson, D. (Eds.). (2014). Leadership & nursing (2nd ed.). Sydney: Elsevier
De Groot, H.A. (2005). Evidence-based leadership: Nursing new mandate. Nurse Leader, 3,(2), 37–41.
Ferguson, L. Calvert, J., Davie, M. Fred, N. Gersbach, V. & Sinclair, L. (2007) Clinical leadership: Using observations of care to focus risk management and quality improvement activities in the clinical setting. Contemporary Nurse, (2) 212-214.
Forbes, I., Day, G.E., Rotem, A., & Jochelson, T. Case studies in health services management. In M.G Harris. & Associates. (2006). Managing health services: Concepts and practices. Sydney: Mosby Elsevier
Grol, R., Bosch, M.C., Hulscher, M.E., Eccles. M.P. & Wensing, M. (2007). Planning and studying improvement in patient care: The use of theoretical perspectives. The Milbank Quarterly, 85, (1), 93–138
Hargraves, J. (2008). Measures for the Australian health care system. Presentation at clinical excellence commission workshop on hospital performance indicator workshop, Sydney, 13 November, 2008
Hindle, D., Braithwaite, J., Travaglia, J. & Iedema, R. (2006). Patient safety: a comparative analysis of eight inquiries in six countries. Sydney: University of New South Wales.
Institute of Medicine. (1999). To Err is Human: Building a Safer Health Care System. Washington DC: National Academy Press
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington DC: National Academy Press
Institute of Medicine (2004). Keeping patients safe: Transforming the work environment of nurses. Washington DC: National Academy Press
Isouard, G., Stanton, P., Bartram, T., Thiessen, V. & Hanson, S. Managing people in the health care industry. In M.G.Harris & Associates. (2006). Managing health services: Concepts and practices. Sydney: Mosby Elsevier.
Isouard, G., Messum, D., Briggs, D., McAplin, S. &Hanson, S. Improving organisational performance in health care. In M.G. Harris & Associates. (2006). Managing health services: Concepts and practices. Sydney: Mosby Elsevier cited in-text as (Isouard et al. 2006b)
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Mainz, J. (2003a). Developing Evidence-based clinical indicators: a state of the art methods primer. International Journal for Quality in Health Care, 15, (1), i5-i11.
Mainz, J. (2003b). Defining and classifying clinical indicators for quality improvement. International Journal for Quality in Health Care, 15, (6), 523-530.
Mainz, J., Kjaergaard, J. & Knudsen, J.L. (1999). Monitoring the quality of care using clinical indicators. Public Medicine 161, 40, 5536-5542
Retrieved on 24/01/17 from https://www.ncbi.nlm.nih.gov/pubmed/10553364
McLaughlin, C.P. & Kaluzny, A.D. (2006). Continuous quality improvement in health care. Boston: Jones and Bartlett Publishers
Senge, P. (2006). The fifth discipline: The art and practice of the learning organization. New York: Doubleday.
Siriwardena, A. N. (2006). Releasing the potential of health services: translating clinical leadership into healthcare quality improvement. Quality in Primary Care, 14(3), 125-128.
Speedy, S., & Jackson, D. Power, politics and gender. In J. Daly, S. Speedy & D. Jackson (Eds.) (2015). Leadership and nursing (2nd ed.). Sydney: Elsevier.
Walburg, J., Bevan, H., Wilderspin, J. & Lemmens, K. (2006). Performance management in health care. Improving patient outcomes: an integrated approach. London: Routledge Taylor and Francis Group.
Ward, M. (2008). Public Reporting of Healthcare Quality & Safety in Queensland. Presentation at Clinical Excellence Commission Workshop on Hospital Performance Indicator Workshop, Sydney, 13 November 2000