Culture, compassion and clinical neglect: probity in the NHS after Mid Staffordshire.

Speaking of the public response to the deaths of children at the Bristol Royal Infirmary before 2001, the BMJ commented that the NHS would be 'all changed, changed utterly'. Today, two inquiries into the Mid Staffordshire Foundation Trust suggest nothing changed at all. Many patients died as a result of their care and the stories of indifference and neglect there are harrowing. Yet Bristol and Mid Staffordshire are not isolated reports. In 2011, the Health Services Ombudsman reported on the care of elderly and frail patients in the NHS and found a failure to recognise their humanity and individuality and to respond to them with sensitivity, compassion and professionalism. Likewise, the Care Quality Commission and Healthcare Commission received complaints from patients and relatives about the quality of nursing care. These included patients not being fed, patients left in soiled bedding, poor hygiene practices, and general disregard for privacy and dignity. Why is there such tolerance of poor clinical standards? We need a better understanding of the circumstances that can lead to these outcomes and how best to respond to them. We discuss the findings of these and other reports and consider whether attention should be devoted to managing individual behaviour, or focus on the systemic influences which predispose hospital staff to behave in this way. Lastly, we consider whether we should look further afield to cognitive psychology to better understand how clinicians and managers make decisions?

Visualizing surgical quality data with treemaps.

BACKGROUND: Treemaps are space-constrained visualizations for displaying hierarchical data structures using nested rectangles. The visualization allows large amounts of data to be examined in one display. The objective of this research was to examine the effects of using treemap visualizations to help surgeons assess surgical quality data from the American College of Surgeons created the National Surgical Quality Improvement Program database in a quick and timely manner. STUDY DESIGN: A controlled human subjects experiment was conducted to assess the ability of individuals to make quick and accurate judgments on surgery data by visualizing a treemap, with data hierarchically displayed by surgeon group, surgeon, and patient. Participants were given 20 task questions to complete involving examining the treemap and comparing surgeons' patients based on outcomes (dead or alive) and length of stay days. The outcomes measured were error (incorrect or correct) and task completion time. RESULTS: 120 participants completed 20 task questions for a total of 2400 responses. The main effects of layout and node size were found to be significant for absolute error, P < 0.0505 and P < 0.0185, respectively. The average judgment time to complete a task was 24 s with an accuracy rate of approximately 68%. CONCLUSIONS: This study served as a proof of concept to determine if treemaps could be beneficial in assessing surgical data retrospectively by allowing surgeons and healthcare administrators to make quick visual judgments. The study found that factors about the layout design affect judgment performance. Future research is needed to examine whether implementing the treemap within a dashboard system will improve on judgment accuracy for surgical quality questions.

Healthcare managers in negative media focus: a qualitative study of personification processes and their personal consequences.

BACKGROUND: Over the last decade healthcare management and managers have increasingly been in focus in public debate. The purpose of the present study was to gain a deeper understanding of how prolonged, unfavorable media focus can influence both the individual as a person and his or her managerial practice in the healthcare organization. METHODS: In-depth interviews (n = 49) with 24 managers and their superiors, or subordinate human resources/information professionals, and partners were analyzed using a grounded theory approach. RESULTS: The conceptual model explains how perceived uncertainties related to the managerial role influence personification and its negative consequences. The role ambiguities comprised challenges regarding the separation of individual identity from the professional function, the interaction with intra-organizational support and political play, and the understanding and acceptance of roles in society. A higher degree of uncertainty in role ambiguity increased both personification and the personal reaction to intense media pressure. Three types of reactions were related to the feeling of being infringed: avoidance and narrow-mindedness; being hard on self, on subordinates, and/or family members; and resignation and dejection. The results are discussed so as to elucidate the importance of support from others within the organization when under media scrutiny. CONCLUSIONS: The degree of personification seems to determine the personal consequences as well as the consequences for their managerial practice. Organizational support for managers appearing in the media would probably be beneficial for both the manager and the organization.

The impact of the board's strategy-setting role on board-management relations and hospital performance.

BACKGROUND: The appropriate governance of hospitals largely depends on effective cooperation between governing boards and hospital management. Governing boards play an important role in strategy-setting as part of their support for hospital management. However, in certain situations, this active strategic role may also generate discord within this relationship. PURPOSE: The objective of this study is to investigate the impact of the roles, attributes, and processes of governing boards on hospital performance. We examine the impact of the governing board's strategy-setting role on board-management collaboration quality and on financial performance while also analyzing the interaction effects of board diversity and board activity level. METHODOLOGY: The data are derived from a survey that was sent simultaneously to German hospitals and their associated governing board, combined with objective performance information from annual financial statements and quality reports. We use a structural equation modeling approach to test the model. FINDINGS: The results indicate that different board characteristics have a significant impact on hospital performance (R = .37). The strategy-setting role and board-management collaboration quality have a positive effect on hospital performance, whereas the impact of strategy-setting on collaboration quality is negative. We find that the positive effect of strategy-setting on performance increases with decreasing board diversity. When board members have more homogeneous backgrounds and exhibit higher board activity levels, the negative effect of the strategy-setting on collaboration quality also increases. PRACTICE IMPLICATIONS: Active strategy-setting by a governing board may generally improve hospital performance. Diverse members of governing boards should be involved in strategy-setting for hospitals. However, high board-management collaboration quality may be compromised if managerial autonomy is too highly restricted. Consequently, hospitals should support board-management collaboration about empowered contrasting board roles.

Are healthcare middle management jobs extreme jobs?

PURPOSE: The purpose of this paper is to explore the incidence of "extreme jobs" among middle managers in acute hospitals, and to identify individual and organizational implications. DESIGN/METHODOLOGY/APPROACH: The paper is based on interviews and focus groups with managers at six hospitals, a "proof of concept" pilot with an operations management team, and a survey administered at five hospitals. FINDINGS: Six of the original dimensions of extreme jobs, identified in commercial settings, apply to hospital management: long hours, unpredictable work patterns, tight deadlines with fast pace, broad responsibility, "24/7 availability", mentoring and coaching. Six healthcare-specific dimensions were identified: making life or death decisions, conflicting priorities, being required to do more with fewer resources, responding to regulatory bodies, the need to involve many people before introducing improvements, fighting a negative climate. Around 75 per cent of hospital middle managers have extreme jobs. RESEARCH LIMITATIONS/IMPLICATIONS: This extreme healthcare management job model was derived inductively from a qualitative study involving a small number of respondents. While the evidence suggests that extreme jobs are common, further research is required to assess the antecedents, incidence, and implications of these working practices. PRACTICAL IMPLICATIONS: A varied, intense, fast-paced role with responsibility and long hours can be rewarding, for some. However, multi-tasking across complex roles can lead to fatigue, burnout, and mistakes, patient care may be compromised, and family life may be adversely affected. ORIGINALITY/VALUE: As far as the authors can ascertain, there are no other studies exploring acute sector management roles through an extreme jobs lens.

Engaging physicians in organisational improvement work.

PURPOSE: To improve health-care delivery from within, managers need to engage physicians in organisational development work. Physicians and managers have different mindsets/professional identities which hinder effective communication. The aim of this paper is to explore how managers can transform this situation. DESIGN/METHODOLOGY/APPROACH: The authors' interview study reveals physicians' own perspective on engagement for organisational improvement. They discuss identities from three theoretical perspectives and explore the mindsets of physicians and managers. They also explore the need to modify professional identities and how this can be achieved. FINDINGS: If managers want physicians to engage in improvements, they must learn to understand and appreciate physician identity. This might challenge managers' identity. The paper shows how managers - primarily in a Swedish context - could act to facilitate physician engagement. This in turn might challenge physician identity. RESEARCH LIMITATIONS/IMPLICATIONS: Studies from the western world show a coherent picture of professional identities, despite structural differences in national health-care systems. The paper argues, therefore, that the results can be relevant to many other health-care systems and settings. ORIGINALITY/VALUE: The paper provides an alternative to the prevailing managerial control perspective. The alternative is simple, yet complex and challenging, and as the authors understand it, necessary for health care to evolve, from within.

A road to better governance.

An elected board uses competency-based peer assessment to improve governance and outreach.

Competencies required by senior health executives in New South Wales, 1990-1999.

It is accepted that health care reforms and restructuring lead to the change of the tasks and competencies required by senior health care managers. This paper examined the major tasks that senior health executives performed and the most essential competencies required in the NSW public health sector in the 1990s following the introduction of major structural reforms. Diverse changes, restructuring and reforms introduced and implemented in different health care sectors led to changes in the tasks performed by health care managers, and consequently changes in the competencies required.

Ten questions for hospital leaders.

Although there are no litmus tests to evaluate hospital leadership, the answers to 10 critical questions can provide a useful assessment.

The skills gap in hospital management in the South African public health sector.

A lack of management capacity has been identified as the key stumbling block to the transformation and reconceptualization of the public sector in South Africa into a more effective, efficient, and responsive system of health delivery. As part of the overall management development process, this research aimed to identify the skills important for public sector health management and to evaluate managers' self-assessed proficiency in each of these skills. A cross-sectional survey using a self-administered questionnaire was conducted among hospital managers in the South African public health sector. Respondents were asked to rate the level of importance that each proposed competency had in their job and to indicate their proficiency in each skill. Self-assessment of levels of competency showed that managers felt most competent in strategic planning, people management, and self-management, and relatively less competent in the task-related skills and their ability to deliver healthcare. People management, self-management, and task-related skills were rated as being most important, followed by strategic management and health delivery skills, respectively. The largest differences between mean importance rating and mean skill rating were for people management skills, task-related and self-management skills. These findings reflect the reality of the local health service environment and the needs of health managers and will be useful in the conceptualization, design, and delivery of health management programs aimed at enhancing current and future management and leadership capacity in the public health sector in South Africa.

The changing role of the CMIO.

Chief medical information officer is a relatively new position at most hospitals, but the job is changing as rapidly as the technology they oversee. This foldout describes CMIOs' key responsibilities, desirable traits and barriers to effectiveness.