How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England

Jones, Linda; Pomeroy, Linda; Robert, Glenn; Burnett, Susan; Anderson, Janet; Fulop, Naomi

doi:10.1136/bmjqs-2016-006433

Cited by 75 publications

(122 citation statements)

References 27 publications

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“…This lack of confidence in clinical affairs may be part of the reason why many boards focus more on financial governance and meeting external targets than on issues like quality and safety. 17,18 Given the presence of a separate medical staff governance system, this "hands off" approach is likely to be even more pronounced when it comes to physician well-being. And this outlook naturally trickles down to nonclinical administrators at all levels, because it defines what they are accountable for.…”

Section: Barriersmentioning

confidence: 99%

Physician Burnout: Resilience Training is Only Part of the Solution

Card

2018

Ann Fam Med

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Physicians and physician trainees are among the highest-risk groups for burnout and suicide, and those in primary care are among the hardest hit. Many health systems have turned to resilience training as a solution, but there is an ongoing debate about whether that is the right approach. This article distinguishes between unavoidable occupational suffering (inherent in the physician's role) and avoidable occupational suffering (systems failures that can be prevented). Resilience training may be helpful in addressing unavoidable suffering, but it is the wrong treatment for the organizational pathologies that lead to avoidable suffering- and may even compound the harm doctors experience. To address avoidable suffering, health systems would be better served by engaging doctors in the co-design of work systems that promote better mental health outcomes.

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Section: Barriersmentioning

confidence: 99%

Physician Burnout: Resilience Training is Only Part of the Solution

Card

2018

Ann Fam Med

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“…Jones et al 59 have recently constructed a measure of 'QI governance maturity' from working with 15 hospital boards. Consistent with wider organisational literature, they conclude that boards with higher levels of QI maturity had the following characteristics, which were particularly enabled by board-level clinical leaders: l explicitly prioritising QI l balancing short-term external priorities with long-term internal investment in QI l using data for QI, not just for quality assurance l engaging staff and patients in QI l encouraging a culture of continuous improvement.…”

Section: Wider Literature On Quality Improvement Theory Methods and mentioning

confidence: 99%

Understanding how front-line staff use patient experience data for service improvement: an exploratory case study evaluation

Locock

Graham

King

et al. 2020

Health Serv Deliv Res

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Background and aim The NHS collects a large number of data on patient experience, but there are concerns that it does not use this information to improve care. This study explored whether or not and how front-line staff use patient experience data for service improvement. Methods Phase 1 – secondary analysis of existing national survey data, and a new survey of NHS trust patient experience leads. Phase 2 – case studies in six medical wards using ethnographic observations and interviews. A baseline and a follow-up patient experience survey were conducted on each ward, supplemented by in-depth interviews. Following an initial learning community to discuss approaches to learning from and improving patient experience, teams developed and implemented their own interventions. Emerging findings from the ethnographic research were shared formatively. Phase 3 – dissemination, including an online guide for NHS staff. Key findings Phase 1 – an analysis of staff and inpatient survey results for all 153 acute trusts in England was undertaken, and 57 completed surveys were obtained from patient experience leads. The most commonly cited barrier to using patient experience data was a lack of staff time to examine the data (75%), followed by cost (35%), lack of staff interest/support (21%) and too many data (21%). Trusts were grouped in a matrix of high, medium and low performance across several indices to inform case study selection. Phase 2 – in every site, staff undertook quality improvement projects using a range of data sources. The number and scale of these varied, as did the extent to which they drew directly on patient experience data, and the extent of involvement of patients. Before-and-after surveys of patient experience showed little statistically significant change. Making sense of patient experience ‘data’ Staff were engaged in a process of sense-making from a range of formal and informal sources of intelligence. Survey data remain the most commonly recognised and used form of data. ‘Soft’ intelligence, such as patient stories, informal comments and daily ward experiences of staff, patients and family, also fed into staff’s improvement plans, but they and the wider organisation may not recognise these as ‘data’. Staff may lack confidence in using them for improvement. Staff could not always point to a specific source of patient experience ‘data’ that led to a particular project, and sometimes reported acting on what they felt they already knew needed changing. Staff experience as a route to improving patient experience Some sites focused on staff motivation and experience on the assumption that this would improve patient experience through indirect cultural and attitudinal change, and by making staff feel empowered and supported. Staff participants identified several potential interlinked mechanisms: (1) motivated staff provide better care, (2) staff who feel taken seriously are more likely to be motivated, (3) involvement in quality improvement is itself motivating and (4) improving patient experience can directly improve staff experience. ‘Team-based capital’ in NHS settings We propose ‘team-based capital’ in NHS settings as a key mechanism between the contexts in our case studies and observed outcomes. ‘Capital’ is the extent to which staff command varied practical, organisational and social resources that enable them to set agendas, drive process and implement change. These include not just material or economic resources, but also status, time, space, relational networks and influence. Teams involving a range of clinical and non-clinical staff from multiple disciplines and levels of seniority could assemble a greater range of capital; progress was generally greater when the team included individuals from the patient experience office. Phase 3 – an online guide for NHS staff was produced in collaboration with The Point of Care Foundation. Limitations This was an ethnographic study of how and why NHS front-line staff do or do not use patient experience data for quality improvement. It was not designed to demonstrate whether particular types of patient experience data or quality improvement approaches are more effective than others. Future research Developing and testing interventions focused specifically on staff but with patient experience as the outcome, with a health economics component. Studies focusing on the effect of team composition and diversity on the impact and scope of patient-centred quality improvement. Research into using unstructured feedback and soft intelligence. Funding The National Institute for Health Research Health Services and Delivery Research programme.

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“…We will apply a board maturity framework developed in previous research, which found that boards with higher levels of maturity in relation to governing for quality improvement were able to effectively balance short-term (external) priorities against long-term (internal) investment in quality improvement and engage staff and patients in the process of change. 21 In order to understand processes of quality improvement beyond board level, especially amongst "clear improvers" that exit SMQ and sustain change, we will use the concepts of absorptive capacity and dynamic capabilities from the strategic management literature to identify any routines or processes that have helped staff -from senior leaders to frontline clinicians -to learn from external information about performance and quality to sustain performance objectives. 22 Absorptive capacity refers to the ability of organisations to acquire and exploit new information and knowledge and successfully transfer it internally -across organisational subunits -to support learning and performance.…”

Section: Conceptual Frameworkmentioning

confidence: 99%

“…or performance-focused meetings at divisional level, after securing prior permission, at the 4 'in-depth' sites and gaining individual consent from participants at the time of the meeting. We will use the board quality improvement maturity framework 21 in our observations of boards and other relevant meetings to support analysis of observational data. We will focus on critical quality incidents or service issues where progress in quality improvement appears 'transparently observable' or where improvements are proving especially challenging for the organisations.…”

mentioning

confidence: 99%

Special Measures for Quality and Challenged Providers: Study Protocol for Evaluating the Impact of Improvement Interventions in NHS Trusts

Fulop

Barbosa

Hill

et al. 2019

Int J Health Policy Manag

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Background: Healthcare organisations in England rated as inadequate in terms of leadership and one other domain enter the Special Measures for Quality (SMQ) regime to receive increased support and oversight. There is also a ‘watch list’ of challenged National Health Service (NHS) providers at risk of going into SMQ that receive support. There is limited knowledge about whether the interventions used to deliver this support drive improvements in quality, their costs, and whether they strike the right balance between support and scrutiny. The study will seek to determine how provider organisations respond to these interventions, and whether and how these interventions impact organisations’ capacity to achieve and sustain quality improvements over time. Methods: This is a multi-site, mixed methods study. We will carry out interviews at national level to understand the programme theory underpinning the interventions. We will conduct 8 NHS case studies to explore the impact and implementation of the interventions that form part of the SMQ and challenged providers programme. We will use a conceptual framework based on models of organisational readiness for change and draw on board maturity research for implementing quality improvement. We will also review the use of quantitative metrics and data for tracking the progress of improvements in quality of care and sustainability upon leaving SMQ, as well as the costs and benefits of the interventions through a cost-consequence analysis (CCA). Discussion: High-quality interventions that successfully support struggling healthcare organisations are essential and an issue that is an international concern. Our study will allow a greater understanding of the programme theory, impact, and staff views and experiences of the SMQ and challenged providers regime. Formative feedback will be reported to key stakeholders

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How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England

Cited by 75 publications

References 27 publications

Physician Burnout: Resilience Training is Only Part of the Solution

Physician Burnout: Resilience Training is Only Part of the Solution

Understanding how front-line staff use patient experience data for service improvement: an exploratory case study evaluation

Special Measures for Quality and Challenged Providers: Study Protocol for Evaluating the Impact of Improvement Interventions in NHS Trusts

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