Middle manager responses to hospital co-workers' unprofessional behaviours within the context of a professional accountability culture change program: a qualitative analysis.

BACKGROUND: The critical role that middle managers play in enacting organisational culture change designed to address unprofessional co-worker behaviours has gone largely unexplored. We aimed to explore middle managers' perspectives on i) whether they speak up when they or their team members experience unprofessional behaviours (UBs); ii) how concerns are handled; iii) the outcomes; and iv) the role of a professional accountability culture change program (known as Ethos) in driving change. METHODS: Qualitative, constructivist approach. Five metropolitan hospitals in Australia which had implemented Ethos. Purposive sampling was used to invite middle-level managers from medicine, nursing, and non-clinical support services. Semi-structured interviews conducted remotely. Inductive, reflexive thematic and descriptive thematic analyses undertaken using NVivo. RESULTS: Thirty interviews (approximately 60 min; August 2020 to May 2021): Nursing (n = 12), Support Services (n = 10), and Medical (n = 8) staff, working in public (n = 18) and private (n = 12) hospitals. One-third (n = 10) had a formal role in Ethos. All middle managers (hearers) had experienced the raising of UBs by their team (speakers). Themes representing reasons for ongoing UBs were: staying silent but active; history and hierarchy; and double-edged swords. The Ethos program was valued as a confidential, informal, non-punitive system but required improvements in profile and effectiveness. Participants described four response stages: i) determining if reports were genuine; ii) taking action depending on the speaker's preference, behaviour factors (type, frequency, impact), if the person was known/unknown; iii) exploring for additional information; and iv) addressing either indirectly (e.g., change rosters) or directly (e.g., become a speaker). CONCLUSIONS: Addressing UBs requires an organisational-level approach beyond supporting staff to speak up, to include those hearing and addressing UBs. We propose a new hearer's model that details middle managers' processes after a concern is raised, identifying where action can be taken to minimise avoidant behaviours to improve hospital culture, staff and patient safety.

Novel imaging techniques in refractory pituitary adenomas.

Accurate localization of the site(s) of active disease is key to informing decision-making in the management of refractory pituitary adenomas when autonomous hormone secretion and/or continued tumor growth challenge conventional therapeutic approaches. In this context, the use of non-standard MR sequences, alternative post-acquisition image processing, or molecular (functional) imaging may provide valuable additional information to inform patient management.

Modern imaging in Cushing's disease.

Management of Cushing's disease is informed by dedicated imaging of the sella and parasellar regions. Although magnetic resonance imaging (MRI) remains the investigation of choice, a significant proportion (30-50%) of corticotroph tumours are so small as to render MRI indeterminate or negative when using standard clinical sequences. In this context, alternative MR protocols [e.g. 3D gradient (recalled) echo, with acquisition of volumetric data] may allow detection of tumors that have not been previously visualized. The use of hybrid molecular imaging (e.g. 11C-methionine positron emission tomography coregistered with volumetric MRI) has also been proposed as an additional modality for localizing microadenomas.

11C-methionine PET aids localization of microprolactinomas in patients with intolerance or resistance to dopamine agonist therapy.

PURPOSE: To assess the potential for 11C-methionine PET (Met-PET) coregistered with volumetric magnetic resonance imaging (Met-PET/MRCR) to inform clinical decision making in patients with poorly visualized or occult microprolactinomas and dopamine agonist intolerance or resistance. PATIENTS AND METHODS: Thirteen patients with pituitary microprolactinomas, and who were intolerant (n = 11) or resistant (n = 2) to dopamine agonist therapy, were referred to our specialist pituitary centre for Met-PET/MRCR between 2016 and 2020. All patients had persistent hyperprolactinemia and were being considered for surgical intervention, but standard clinical MRI had shown either no visible adenoma or equivocal appearances. RESULTS: In all 13 patients Met-PET/MRCR demonstrated a single focus of avid tracer uptake. This was localized either to the right or left side of the sella in 12 subjects. In one patient, who had previously undergone surgery for a left-sided adenoma, recurrent tumor was unexpectedly identified in the left cavernous sinus. Five patients underwent endoscopic transsphenoidal selective adenomectomy, with subsequent complete remission of hyperprolactinaemia and normalization of other pituitary function; three patients are awaiting surgery. In the patient with inoperable cavernous sinus disease PET-guided stereotactic radiosurgery (SRS) was performed with subsequent near-normalization of serum prolactin. Two patients elected for a further trial of medical therapy, while two declined surgery or radiotherapy and chose to remain off medical treatment. CONCLUSIONS: In patients with dopamine agonist intolerance or resistance, and indeterminate pituitary MRI, molecular (functional) imaging with Met-PET/MRCR can allow precise localization of a microprolactinoma to facilitate selective surgical adenomectomy or SRS.

Spinal navigation for minimally invasive thoracic and lumbosacral spine fixation: implications for radiation exposure, operative time, and accuracy of pedicle screw placement.

PURPOSE: Navigation is emerging as a useful adjunct in percutaneous, minimally invasive spinal surgery (MIS). The aim of this study was to compare C-Arm navigated, O-Arm navigated and conventional 2D-fluoroscopy assisted MIS thoracic and lumbosacral spine fixation techniques in terms of operating time, radiation exposure and accuracy of pedicle screw (PS) placement. METHODS: Retrospective observational study of 152 consecutive adults who underwent MIS fixations for spinal instability: 96 2D-fluoroscopy assisted, 39 3D-C-Arm navigated and 27 using O-Arm navigated. RESULTS: O-Arm navigation significantly reduced PS misplacement (1.23%, p) compared to 3D-C-Arm navigation (7.29%, p = 0.0082) and 2D-fluoro guided placement (5.16%, p = 0379). 3D-C-Arm navigation was associated with lower procedural radiation exposure of the patient (0.4 mSv) than O-Arm navigation (3.24 mSv) or 2D-fluoro guidance (1.5 mSv). Operative time was comparable between three modalities. CONCLUSIONS: O-Arm navigation provides greater accuracy of percutaneous instrumentation placement with an acceptable procedural radiation dose delivered to the patients and comparable operative times. These slides can be retrieved under Electronic Supplementary material.

Do Hospital Boards matter for better, safer, patient care?

Manifest failings in healthcare quality and safety in many countries have focused attention on the role of hospital Boards. While a growing literature has drawn attention to the potential impacts of Board composition and Board processes, little work has yet been carried out to examine the influence of Board competencies. In this work, we first validate the structure of an established 'Board competencies' self-assessment instrument in the English NHS (the Board Self-Assessment Questionnaire, or BSAQ). This tool is then used to explore in English acute hospitals the relationships between (a) Board competencies and staff perceptions about how well their organisation deals with quality and safety issues; and (b) Board competencies and a raft of patient safety and quality measures at organisation level. National survey data from 95 hospitals (334 Board members) confirmed the factor structure of the BSAQ, validating it for use in the English NHS. Moreover, better Board competencies were correlated in consistent ways with beneficial staff attitudes to the reporting and handling of quality and safety issues (using routinely collected data from the NHS National Staff Survey). However, relationships between Board competencies and aggregate outcomes for a variety of quality and safety measures showed largely inconsistent and non-significant relationships. Overall, these data suggest that Boards may be able to impact on important staff perceptions. Further work is required to unpack the impact of Board attributes on organisational aggregate outcomes.

A pilot study on the feasibility of European harmonized human biomonitoring: Strategies towards a common approach, challenges and opportunities.

In 2004 the European Commission and Member States initiated activities towards a harmonized approach for Human Biomonitoring surveys throughout Europe. The main objective was to sustain environmental health policy by building a coherent and sustainable framework and by increasing the comparability of data across countries. A pilot study to test common guidelines for setting up surveys was considered a key step in this process. Through a bottom-up approach that included all stakeholders, a joint study protocol was elaborated. From September 2011 till February 2012, 17 European countries collected data from 1844 mother-child pairs in the frame of DEMOnstration of a study to COordinate and Perform Human Biomonitoring on a European Scale (DEMOCOPHES).(1) Mercury in hair and urinary cadmium and cotinine were selected as biomarkers of exposure covered by sufficient analytical experience. Phthalate metabolites and Bisphenol A in urine were added to take into account increasing public and political awareness for emerging types of contaminants and to test less advanced markers/markers covered by less analytical experience. Extensive efforts towards chemo-analytical comparability were included. The pilot study showed that common approaches can be found in a context of considerable differences with respect to experience and expertize, socio-cultural background, economic situation and national priorities. It also evidenced that comparable Human Biomonitoring results can be obtained in such context. A European network was built, exchanging information, expertize and experiences, and providing training on all aspects of a survey. A key challenge was finding the right balance between a rigid structure allowing maximal comparability and a flexible approach increasing feasibility and capacity building. Next steps in European harmonization in Human Biomonitoring surveys include the establishment of a joint process for prioritization of substances to cover and biomarkers to develop, linking biomonitoring surveys with health examination surveys and with research, and coping with the diverse implementations of EU regulations and international guidelines with respect to ethics and privacy.

The associations between organizational culture, organizational structure and quality management in European hospitals.

OBJECTIVE: To better understand associations between organizational culture (OC), organizational management structure (OS) and quality management in hospitals. DESIGN: A multi-method, multi-level, cross-sectional observational study. SETTING AND PARTICIPANTS: As part of the DUQuE project (Deepening our Understanding of Quality improvement in Europe), a random sample of 188 hospitals in 7 countries (France, Poland, Turkey, Portugal, Spain, Germany and Czech Republic) participated in a comprehensive questionnaire survey and a one-day on-site surveyor audit. Respondents for this study (n = 158) included professional quality managers and hospital trustees. MAIN OUTCOME MEASURES: Extent of implementation of quality management systems, extent of compliance with existing management procedures and implementation of clinical quality activities. RESULTS: Among participating hospitals, 33% had a clan culture as their dominant culture type, 26% an open and developmental culture type, 16% a hierarchical culture type and 25% a rational culture type. The culture type had no statistically significant association with the outcome measures. Some structural characteristics were associated with the development of quality management systems. CONCLUSION: The type of OC was not associated with the development of quality management in hospitals. Other factors (not culture type) are associated with the development of quality management. An OS that uses fewer protocols is associated with a less developed quality management system, whereas an OS which supports innovation in care is associated with a more developed quality management system.

Is having quality as an item on the executive board agenda associated with the implementation of quality management systems in European hospitals: a quantitative analysis.

OBJECTIVE: To assess whether there is a relationship between having quality as an item on the board's agenda, perceived external pressure (PEP) and the implementation of quality management in European hospitals. DESIGN: A quantitative, mixed method, cross-sectional study in seven European countries in 2011 surveying CEOs and quality managers and data from onsite audits. PARTICIPANTS: One hundred and fifty-five CEOs and 155 quality managers. SETTING: One hundred and fifty-five randomly selected acute care hospitals in seven European countries (Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey). Main outcome measure(s) Three constructs reflecting quality management based on questionnaire and audit data: (i) Quality Management System Index, (ii) Quality Management Compliance Index and (iii) Clinical Quality Implementation Index. The main predictor was whether quality performance was on the executive board's agenda. RESULTS: Discussing quality performance at executive board meetings more often was associated with a higher quality management system score (regression coefficient b = 2.53; SE = 1.16; P = 0.030). We found a trend in the associations of discussing quality performance with quality compliance and clinical quality implementation. PEP did not modify these relationships. CONCLUSIONS: Having quality as an item on the executive board's agenda allows them to review and discuss quality performance more often in order to improve their hospital's quality management. Generally, and as this study found, having quality on the executive board's agenda matters.

Outcome of translabyrinthine surgery for vestibular schwannoma in neurofibromatosis type 2.

OBJECTIVES: To analyse the long-term outcome of translabyrinthine surgery for vestibular schwannoma (VS) in neurofibromatosis type 2 (NF2). RESEARCH TYPE: Retrospective cohort study. SETTING: Two tertiary referral NF2 units. PATIENTS: One hundred and forty eight translabyrinthine operations for patients with VS were performed. Preoperative stereotactic radiotherapy had been performed on 12(9.4%) patients. RESULTS: Mean tumour size was 3.1 cm. Total tumour excision was achieved in 66% of cases, capsular remnants were left in 24% of cases, and subtotal excision was achieved in 5% and partial removal was achieved in 5%. The radiological residual/recurrence rate was 13.9%. The perioperative mortality was 1.6%. At 2 years postoperatively, facial function was expressed in terms of House-Brackmann score (HB): HB 1 in 53.4%, HB 1/2 in 61.3%, HB 1-3 in 83.2% and HB 4-6 in 16.8%. All nine patients who underwent surgery following failed stereotactic radiotherapy had HB 3 function or better. Among 9.5% of the cases, 14 facial nerves were lost during surgery and repaired using direct anastomosis or grafting. There was no tinnitus present preoperatively in 27% of the cases, and 22% of patients developed tinnitus postoperatively. In patients with preoperative tinnitus, 61% remained the same, 17% got it resolved and only in 21% it worsened. The preoperative hydrocephalus rate was 26%, and among 15% of the cases five ventriculo-peritoneal (VP) shunts were performed. The cerebrospinal fluid leak rate was 2.5%. Fifty-six patients underwent auditory brainstem implantation (ABI) and two patients had cochlear implant (CI) sleepers inserted. CONCLUSIONS: The management of patients with NF2 presents the clinician with a formidable challenge with many patients still presenting themselves late with the neurological compromise and a large tumour load. There is still an argument for the management by observation until the neurological compromise dictates interventional treatment particularly with the option of hearing rehabilitation with ABI or CI. The translabyrinthine approach provides a very satisfactory means of reducing the overall tumour volume.

Unintended consequences of performance measurement in healthcare: 20 salutary lessons from the English National Health Service.

The objective of the study is to review the evidence on the consequences associated with the introduction of national performance measurement systems in the National Health Service (NHS), with the aim of informing the development of similar national performance measurement programmes proposed for Australia. Narrative review of the published evidence on the unintended and adverse consequences of performance measurement systems in the NHS is the data source. We identified 20 different dysfunctional consequences of national performance measurement systems in the NHS in four headings. These are poor measurement (measurement fixation, tunnel vision, myopia, ossification, anachronism and quantification privileging), misplaced incentives and sanctions (complacency, silo-creation, overcompensation, undercompensation, insensitivity and increased inequality), breach of trust (misrepresentation, gaming, misinterpretation, bullying, erosion of trust and reduced staff morale), and politicisation of performance systems (political grandstanding and creating a diversion). Performance measurement programmes can contribute to systems improvement, delivering benefits to health services and patients, as evidenced by the dramatic reduction in waiting times in the NHS following the incorporation of targets and indicators for waiting times. Nevertheless, experience from the NHS shows that in addition to generating desired improvements, performance measures can induce a range of unintended and dysfunctional consequences. We recommend Australia to heed the lessons of the NHS, and strive to balance effective performance measurement and management against the potential drawbacks and adverse consequences. Any national performance measures need to be piloted and carefully evaluated to assess potential benefits and pitfalls.

Assessing organisational culture for quality and safety improvement: a national survey of tools and tool use.

BACKGROUND: There is growing international interest in managing organisational culture as a lever for healthcare improvement. This has prompted a practical need to understand what instruments and tools exist for assessing cultures in healthcare contexts. The present study was undertaken to determine the culture assessment tools being used in the English NHS and assess their fitness for purpose. METHODS: Postal questionnaire survey of clinical governance leads in 275 English NHS organisations, with a response rate of 77%. RESULTS: A third of the organisations were currently using a culture assessment instrument to support their clinical governance activity. Although we found a high degree of satisfaction with existing instruments, in terms of ease of use and relevance, there is an immediate practical need to develop new and better bespoke culture assessment tools to bridge the gap between the cultural domains covered by extant instruments and the broader range of concerns of clinical governance managers. CONCLUSION: There is growing interest in understanding and shaping local cultures in healthcare, which is not yet matched by widespread use of available instruments. Even though extant tools cover many of the most important cultural attributes identified by clinical governance managers, the over-riding focus of tools in use is on safety rather than a holistic assessment of the dimensions of healthcare quality and performance.

The surgical management of metastatic spinal disease: prospective assessment and long-term follow-up.

The last decade has witnessed a resurgence of interest in the surgical treatment of metastatic spinal disease to compliment radiotherapy. A recent randomized controlled trial looking directly at this issue concluded strongly in favour of a combination of surgical decompression and radiotherapy, and there is now growing enthusiasm for surgery to play a role in the management of these patients. We present a prospective cohort study of 62 patients who presented with metastatic cord or cauda equina compression, and were treated with surgical decompression and fixation where necessary. Patients were treated by one surgeon working in a single unit. They were followed-up long term and were assessed objectively, by clinical assessment and prospective questionnaires that included SF36, visual analogue pain scores and Roland Morris back pain scores. Sixty-two patients with a median age of 62 (22-79 years, 27 male) were included in the study. The commonest primary tumours were breast (26%) and lymphoma (13%). The majority of patients had involvement of thoracic vertebrae (58%). 56% of patients were alive at 1 year and 28% at 3 years, with significant improvements observed in both walking and continence. Similarly, significant improvements were seen in SF36 quality of life scores as well as pain. With careful patient selection, long-term survival and good quality of life can be achieved. However, not every patient is suitable or appropriate for surgery, and the discussion focuses on where the surgical threshold should be set.

Exploring the relationship between senior management team culture and hospital performance.

The purpose of this study was to explore relationships between senior management team culture and organizational performance in English hospital organizations (NHS trusts [National Health Service]). We used an established culture-rating instrument, the Competing Values Framework, to assess senior management team culture. Organizational performance was assessed using a wide variety of routinely collected measures. Data were gathered from all English NHS acute hospital trusts, a total of 197 organizations. Multivariate econometric analyses were used to explore the associations between measures of culture and measures of performance using regressions, ANOVA, multinomial logit, and ordered probit. Organizational culture varied across hospital organizations, and at least some of this variation was associated in consistent and predictable ways with a variety of organizational characteristics and measures of performance. The findings provide particular support for a contingent relationship between culture and performance.

Conceptualisations of trust in the organisational literature: some indicators from a complementary perspective.

PURPOSE: This paper evaluates the non-healthcare organisational literature on conceptualisations of trust. The aim of the paper is to review this diverse literature, and to reflect on the potential insights it might offer healthcare researchers, policy makers and managers. DESIGN/METHODOLOGY/APPROACH: A number of the key concepts that contribute to contrasting definitions of trust in the organisational literature are identified. FINDINGS: The paper highlights the heterogeneity of trust as an organisational concept. Aspects of trust that relate more specifically to non-healthcare settings are shown to have some potential relevance for healthcare. Five aspects of trust, considered to have particular significance to the changing face of the NHS, appear to offer scope for further exploration in healthcare settings. PRACTICAL IMPLICATIONS: The NHS continues to face changes to its organisational structures, both planned and unplanned. Healthcare providers will need to be alert to intra- and inter-organisational relationships, of which trust issues will form an inevitable part. Whilst it might be argued that the lessons offered by conceptualisations of trust within wider organisational settings have limitations, the paper demonstrates sufficient areas of overlap to encourage cross-fertilisation of ideas. ORIGINALITY/VALUE: The paper draws together previous research on a topic of increasing relevance to healthcare researchers, which has exercised management researchers for at least three decades. The paper acts as a guide to future research and practice.

Cultural characteristics of "high" and "low" performing hospitals.

PURPOSE: To compare and contrast the cultural characteristics of "high" and "low" performing hospitals in the UK National Health Service (NHS). DESIGN/METHODOLOGY/APPROACH: A multiple case study design incorporating a purposeful sample of "low" and "high" performing acute hospital Trusts, as assessed by the star performance rating system. FINDINGS: These case studies suggest that "high" and "low" performing acute hospital organisations may be very different environments in which to work. Although each case possessed its own unique character, significant patternings were observed within cases grouped by performance to suggest considerable cultural divergence. The key points of divergence can be grouped under four main headings: leadership and management orientation; accountability and information systems; human resources policies; and relationships within the local health economy. PRACTICAL IMPLICATIONS: As with any study, interpretation of findings should be tempered with a degree of caution because of methodological considerations. First, there are the limitations of case study which proceeds on the basis of theoretical rather than quantitative generalisation. Second, organisational culture was assessed by exploring the views of middle and senior managers. While one should in no way suggest that such an approach can capture all important cultural characteristics of organisations, it is believed that it may be at least partially justified, given the agenda-setting powers and influence of the senior management team. Finally "star" performance measures are far from a perfect measure of organisational performance. Despite such reservations, the findings indicate that organisational culture is associated in a variety of non-trivial ways with the measured performance of hospital organisations. ORIGINALITY/VALUE: Highlights considerable cultural divergence within UK NHS hospitals.

Accident and emergency and general practitioner plain radiograph reporting by radiographers and radiologists: a quasi-randomized controlled trial.

Two specially trained radiographers at York District Hospital have been reporting appendicular plain radiograph X-ray examinations for Accident and Emergency (A&E) patients since February 1995. This study explores the potential for further expanding their reporting role. This was achieved by assessing the two radiographers' and a group of consultant radiologists' ability to report on a retrospectively selected random stratified sample of 400 A&E and General Practitioner (GP) plain radiograph X-ray examinations for all body areas. Using receiver operating characteristic (ROC) curve analyses there was no statistically significant difference at the 5% level between the area under the ROC curves for the radiographers and consultant radiologists when reporting A&E or GP plain radiographs. It may be feasible to expand the reporting role of suitably trained radiographers to include plain radiograph X-ray examinations for all A&E patients and for GP patients, with no detriment to the quality of reports.

Impact of published clinical outcomes data: case study in NHS hospital trusts.

OBJECTIVE: To examine the impact of the publication of clinical outcomes data on NHS Trusts in Scotland to inform the development of similar schemes elsewhere. DESIGN: Case studies including semistructured interviews and a review of background statistics. SETTING: Eight Scottish NHS acute trusts. PARTICIPANTS: 48 trust staff comprising chief executives, medical directors, stroke consultants, breast cancer consultants, nurse managers, and junior doctors. MAIN OUTCOME MEASURES: Staff views on the benefits and drawbacks of clinical outcome indicators provided by the clinical resource and audit group (CRAG) and perceptions of the impact of these data on clinical practice and continuous improvement of quality. RESULTS: The CRAG indicators had a low profile in the trusts and were rarely cited as informing internal quality improvement or used externally to identify best practice. The indicators were mainly used to support applications for further funding and service development. The poor effect was attributable to a lack of professional belief in the indicators, arising from perceived problems around quality of data and time lag between collection and presentation of data; limited dissemination; weak incentives to take action; a predilection for process rather than outcome indicators; and a belief that informal information is often more useful than quantitative data in the assessment of clinical performance. CONCLUSIONS: Those responsible for developing clinical indicator programmes should develop robust datasets. They should also encourage a working environment and incentives such that these data are used to improve continuously.