Professional leadership and organisational change: progress towards developing a quality culture in New Zealand's health system By Pauline Barnett, Laurence Malcolm, Lyn Wright, Christine Hendry Journal of the New Zealand Medical Association, 23-July-2004, Vol 117 No 1198 Summary by Malcolm Macpherson for Brilliant New Zealand Ltd, Friday, February 22, 2008 Background Professional clinical leadership and organisational systems are critical for quality in healthcare. In New Zealand professional leadership has emerged from both primary and secondary care organisations. In primary care, extensive quality systems have developed based on professional leadership in governance and management. In secondary care, progress has sometimes been impeded by the market experiment of the 1990s. The most recent reforms have led to quality progress in secondary care, associated with a convergence of managerial and clinical cultures. The role of the centre emerged only recently, providing support and resources to assist rather than exert leadership for quality. New Zealand appears to be adopting Freidson's preferred model of clinical organization, a new professionalism that recognises the importance of professional leadership and collective accountability for quality and cost. Introduction The last decade has seen intense international interest in the issue of quality in healthcare, fuelled partly by research on adverse events and medical error and by more spectacular system failures that exposed health services to public and media scrutiny. Responses have focused less on the problems of individual failure and more on the need to create safe, supportive systems of care - in the NHS, in the US, in Australia, and New Zealand. Two themes emerge: (1) engage clinicians in leadership for quality (2) provide a supportive environment for quality care. These ideas are embraced in the concept of clinical governance: the exercise of collective, or organisational accountability for the management of clinical performance; clinical governance gives emphasis to both professional leadership and organisational systems and legitimacy to both clinician and manager involvement. Commentators recognise the barriers to engaging clinicians - including the failure to reconcile clinician values and needs with appropriate incentives or to mobilise clinician leadership. Organisations characterised by poor quality and resistance to change often have mistrustful and unhappy environments with a defensive attitude towards outsiders and patients and systems that disregard international best practice. This paper's objectives are: (1) describe the policy and organisational context in New Zealand relevant to healthcare quality and the research framework for assessing approaches to quality (2) report on leadership and organisational initiatives significant in promoting quality in both primary and secondary care settings (3) provide examples of quality achievements (4) reflect on lessons of wider relevance. The context for research New Zealand faces difficult choices about health priorities. Market experimentation in healthcare during the 1990s undermined collaboration between clinicians and management. High levels of conflict impeded progress towards a quality culture. Conflict between clinicians and managers, from which recovery is still incomplete, had serious consequences for quality. District health boards (DHBs), established in 2002, provide a more collaborative environment, and are required (by contract) to achieve health goals set out in the New Zealand Health Strategy and the Primary Healthcare Strategy. The Government is required by the New Zealand Public Health and Disability Act (2000) to develop a quality strategy. The research below is from three projects funded by the Ministry of Health via the Clinical Leaders Association of New Zealand (CLANZ). (1) a review of documents relating to quality policy from 1997 to 2001 in New Zealand (2) interviews and analysis of documents from 12 primary care organisations (PCOs). Nine were GP-led, one was community-led, and two were associations of health professionals (midwives and physiotherapists). Interviews explored quality initiatives and achievements, resources for quality and the role of clinical leadership (3) an analysis of documents and key informant interviews with chief executives and selected senior staff in a sample of 10 DHBs, including the 6 major tertiary service providers and 4 smaller provincial boards. Document analysis and interviews explored the role of clinical and other leadership, organisational arrangements and resources for quality, and quality initiatives and achievements. Leadership for quality Leadership for quality emerged from disparate sources. (1) The first model came from primary care, where professional and community initiatives led to the formation of primary care organisations. The success of these ventures can be attributed to health professionals assuming both managerial and clinical leadership roles. (2) A second model emerged from the National Health Committee, a statutory committee that provides advice to the Minister of Health, with a membership of academic, clinical and lay people, noted for innovation, independence, and willingness to address contentious issues. The NHC embarked on a national programme of capacity building for quality, including clinical guidelines development, and training programme. A cadre of clinicians emerged with a commitment to quality, evidence-based practice, scrutiny, and accountability. The NHC promoted a broadly-based discussion on quality improvement. This culminated in the publication of Safe Systems Promoting Safe Care in 2002, and to Improving Quality (IQ): a Systems Approach for the New Zealand Health and Disability Sector, in 2003. (3) A third model, based on a community of clinical leaders with a shared commitment to improved services and population health came from CLANZ, whose founder, Dr Robin Youngson, believed that New Zealand had many people of outstanding talent and commitment working in relative isolation, which had disenfranchised clinicians from both management and governance roles (see http://www.clanz.org/). CLANZ undertook research into the learning needs of clinicians for leadership roles, and developed programmes to meet these needs. (4) The New Zealand Public Health and Disability Act 2000 provided the framework for a fourth model of quality, policy leadership. The Ministry of Health became more active in quality with work on credentialling proposals; an adverse event reporting system; and papers addressing technical issues of quality improvement in hospitals, clinical audit, and peer review. The MOH also underwrote the 3rd Asia Pacific Quality Forum in Auckland in 2003, an important occasion for fostering what has now become recognised as the quality movement. These initiatives were fostered by previous work on quality from Government and non-Government sources. Of special importance has been the Office of the Health and Disability Commissioner. Further commitment by Government to quality has come from the Health Practitioners Competence Assurance Act (2003). Another contribution has been from the no-fault (litigation-free) compensation for medical misadventure universally available from the Accident Compensation Corporation. The recent review of medical misadventure has proposed a move to a fully no-fault system (with the removal of medical error in compensation for patient injury). Beyond Government, national policy on quality improvement has also been encouraged by several national organisations (clinical colleges, the Medical and Nursing Councils, and Quality Health New Zealand, responsible for health services' accreditation). Mobilising organisations for quality Summary of the findings of the study of 10 DHBs and 12 PCOs on the organisation and management of clinical quality and reported achievements Clinical leadership DHBs Chief medical and nursing advisors at top executive level, clinical directors/heads at service level PCOs Clinical leaders at governance and executive level, the critical factor in driving the quality programme. High levels of practitioner involvement in professional issues Organisation and accountability for quality DHBs Clinical boards/groups, clinical improvement committees, quality managers/co-ordinators at executive and service level. At service level joint partnership between clinicians and managers for quality PCOs Most PCOs had a well organised quality infrastructure with quality committees, quality managers, quality facilitators for prescribing and other services, quality focused information systems Quality initiatives DHBs Accreditation, credentialling of senior medical staff, clinical audit, quality and risk management programmes, developing quality frameworks PCOs Screening programmes, better prescribing, disease management, sexual health, patient satisfaction, well organised recall systems, measuring quality in practices Quality achievements DHBs Greater openness and moves towards a culture of safety, growing partnership between clinical leaders and management, integration of previously disparate quality efforts into a coherent system, reporting of adverse events PCOs High levels of child and influenza immunisation coverage, better management of chronic disease (eg, diabetes), increasing screening rates for cervical and breast cancer, advanced information systems for managing and monitoring quality Facilitating factors DHBs Increasing commitment to accreditation, dedicated quality staff, integration of clinical and financial management, strategies to identify and address adverse events PCOs Clinical leadership, national primary care strategy, education programmes, information systems Limiting factors DHBs Resource constraints, pressures on time, shortage of leadership skills, past conflicts leading to mistrust between clinicians and management PCOs Lack of funding, poor quality data, low GP morale, lack of recognition of achievement by funders Clinical governance DHBs Formal in three DHBs but being practised widely, driven by clinical leadership and clinical values PCOs Widely discussed and largely practised, clinical leadership at governance level a key factor Notes PCOs have emphasised the development of infrastructure to support improved quality and clinical performance, including quality committees, facilitators, co-ordinators, and information systems, as well as encouraging the involvement of clinicians in governance and management. The upskilling of practitioners to participate in these roles has been an important task. For example, liaison arrangements with secondary care providers have promoted joint primary-secondary care decision-making and the development of protocols for effective community management. Increasing attention is also being paid to developing quality measures and rating practices via quality scores (using financial and other incentives to reward performance). The Pinnacle Quality Score provides a system of rating individual practices which has been agreed to by all Pinnacle members and which encourages improved performance in key areas of strategic health policy (such as screening, diabetes management and immunisation). The organisational development of PCOs has enabled the dramatic recent development of primary health organisations (PHOs) further supporting the broad-based promotion of quality in primary care. Examples of quality initiatives initiated by clinical leaders Pegasus Health and the acute admissions project Pegasus Health is a PCO based in Christchurch, with 230 GP members. In 2000, Pegasus leaders established an acute admissions project to provide community alternatives to hospital care, now widely accepted by patients. The result has been a significant fall-off in referrals to the Christchurch Hospital Emergency Department and a decline in acute admissions. The project has been so successful that it is being replicated in other DHBs. GP secondary care liaison In 1999 leaders from a number of PCOs (in collaboration with clinical leaders from DHBs, especially emergency departments) initiated the placement of GPs within several secondary care settings to promote joint primary/secondary care clinical decision-making. The outcomes have included better communications and relationships between primary and secondary care, the development of management protocols, and reduction of inappropriate attendances at emergency departments. The Pinnacle PCO Quality Score In 1996 clinical leaders in Pinnacle, a PCO based in Hamilton with a membership of 200 GPs, developed a scoring system to measure and improve quality. This included indicators such as immunisation and cervical screening levels, practice register improvements such as disease coding, and practice organisation. A small financial incentive was given to recognise improvements. Pinnacle report that the scoring and incentive system has been successful in improving performance levels on key indicators. The Midwifery and Maternity Provider Organisation In 1997 the New Zealand College of Midwives (NZCOM) established MMPO as a mechanism for promoting and monitoring the quality of care provided by its members. MMPO membership requires participation in a wide range of specific quality initiatives, including an open patient complaints resolution process. The MMPO has established a comprehensive midwifery care outcome database to monitor quality. There is evidence that MMPO members are achieving better quality outcomes. Pegasus Health and the acute admissions project Pegasus Health is a PCO based in Christchurch, with 230 GP members, which has established an acute admissions project to provide community alternatives to hospital care, now widely accepted by patients. The result has been a significant fall-off in referrals to the Christchurch Hospital The Waitakere Hospital theatre fire accident On the 17 August 2002, a patient undergoing caesarean section in Waitakere Hospital (Auckland) received 16% body burns from diathermy-ignited, alcohol-based disinfectant. Clinical leaders, together with management, initiated an immediate open and systems-based inquiry. This fully involved the patient and family, who were given an apology and full support, including assistance with compensation. The DHB accepted accountability. The widely available results of the investigation provided an important regional and national learning experience in building a safety culture. This much more open approach is now becoming normal practice in DHBs. Counties-Manukau DHB quality initiatives and achievements In 1993, clinical leaders (in partnership with management) established a broadly representative Clinical Board responsible for the organisation-wide planning and implementation of continuous quality improvement. Significant quality achievements have been: accreditation of all services; development a comprehensive set of clinical indicators for all services; credentialling of all senior medical, nursing, and allied health staff, well established handling of adverse events including openness, offering an immediate apology and working with patients and families; complaints handling and resolution; and developing a learning organisation. This DHB, in the forefront of promoting a quality culture, has provided a model being adopted elsewhere. Within DHBs, there have been the significant organisational changes necessary for building a quality culture. These include devolution of accountability to clinical services divisions for quality and financial management, a developing system of quality coordinators/managers, and mechanisms to support the emerging partnership between clinical leaders and management. An important innovation has been appointments of clinical and nursing leaders to DHB executive management positions, with responsibility for facilitating high-level professional advice and advancing quality issues with management. Entrepreneurial leadership and the role of the centre The most striking feature of quality development in New Zealand over the last decade has been the emergence of professional leadership at all levels, despite the personal and professional risk that sticking one's head above the parapet might entail (especially during the conflicts of the commercially-driven reforms). First were PCOs taking a collective professional approach to organising and managing their activities and providing examples of ways in which clinical leadership can be developed. Second were hospital clinicians spurred quality developments in secondary care in response to growing concerns about quality in hospital-based services and threats to it from commercially-driven reforms. Third were the NHC (despite its dependence on government resources) who undertook important, independent, professionally directed work on quality. This work led directly to the development and launch of the government's quality strategy. Fourth, in the late 1990s, were CLANZ who played a role as a collective of professionals, thus providing an independent forum for debates about quality. These entrepreneurial activities raise questions about the role of the government and central agencies. Unlike the NHS in the UK, the New Zealand Ministry of Health has only recently become involved in policy in quality areas. Assuming such a role in late 1990s would probably not have received endorsement from clinicians and other health professionals. Nationally, policy on quality has hence come from the plurality of organisations referred to above, with little overall coordination, leading to calls for the assemblage of the quality jigsaw. The Government support (provided via the NHC and CLANZ) suggests that national roles can be more varied than providing developed policy and direction, and that facilitation and resourcing behind the scenes can be equally effective. Flexible organizations The primary care sector was able to develop quality initiatives because of the presence of professional leadership, financial incentives, and high levels of autonomy. The creation of an environment for quality owed little to national policy, although this was influential in the choice of priority project areas. The hospital sector, however, appears to have required more time to recover from the market experience of the 1990s. Hospital-sector quality-management initiatives are being professionally driven, with the importance of clinical leadership recognised in new organisational and staffing arrangements. The pursuance of these strategies on the initiative of individual PCOs and DHBs is in contrast to the more centralised approach in the UK where national directives are more usual. In New Zealand, national policy has been influential in more subtle ways. Convergence of clinical and managerial cultures The well-documented gulf between governance/managerial and clinical cultures was exacerbated in New Zealand by the commercially-driven conflicts of the 1990s. Recent developments might be described as building a convergence of cultures. The convergence was evident early in PCOs, with clinicians often taking a dominant role in organisational governance. Primary care clinical leaders have enjoyed a new sense of clinical empowerment and autonomy, which many secondary care clinicians have yet to experience. Guidance for governance/management in DHBs is provided by the New Zealand Health Strategy, which encourages the shift from resource management to quality-focused health outcomes. Implicit in this is the acceptance by clinicians of their role in resource management and organisational goals. Although there are tensions related to budgetary shortages, clinical and managerial cultures are moving towards a more trusting and interdependent partnership. This partnership is seen as critical for quality improvement. Independent support for the progress in quality improvement comes from the 2001 Commonwealth Fund study of consumer perceptions of healthcare quality in five countries which showed that New Zealand had the highest consumer quality rating (67%) of the countries studied. The authors of the study attributed at least some of this improvement to the latest health reforms with its more open and collaborative climate. This includes engaging with communities and consultation. While the involvement of consumers has not progressed to the extent that it has in Australia, significant steps have been made with the development of PHOs, and public participation in the credentialling process. Related to convergence is the theme of professionalism. According to Freidson, in almost all health systems, professionalism is in conflict with managerialism and commercialism. Professionalism places a high value on complex knowledge and skills, on decentralised and discretionary decision-making, and on a commitment to public good, all critical to achieving a quality culture. Freidson has argued for keeping the professional model at the centre of healthcare while checking and correcting the vices of its practitioners by carefully chosen elements of the other models. These vices are those associated with an older form of professional autonomy, including an aversion to organisational accountability. Through clinical leadership, New Zealand may be implementing a new professionalism. In this model, clinicians (in partnership with management) become collectively and professionally accountable for both the quality and cost of their decisions. This may be a new and more successful form of clinical autonomy. Conclusion This paper presented evidence of several streams of leadership-endorsed quality; and the authors' support for the views of Moss et al that organisational change is the key to quality improvement. Improvements are being achieved by entrepreneurial clinical leadership (in partnership with management) within both primary and secondary organisations. This partnership has been assisted by the policy framework provided by the Government's health strategy, which encourages collaboration within an integrated district based health system. Within this policy framework, the role of the centre in relation to quality has tended to be more supportive and facilitatory than directive. Indeed, a partnership between political/bureaucratic and professional cultures may be the key to quality success in New Zealand, and perhaps elsewhere.