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.

Diagnosing a learning practice: the validity and reliability of a learning practice inventory.

BACKGROUND: There is an increasing literature on learning organisations as a way of fostering communication, teamwork, collaboration and collective learning, thereby promoting quality improvement and enhancing patient safety. An increasing number of instruments are being developed in an attempt to measure learning organisation characteristics. However, the majority of these tools are created for a business setting, have not been scientifically tested and have not been applied in healthcare. OBJECTIVE: To evaluate elements of the validity and reliability of an instrument (ie, learning practice inventory (LPI)) for diagnosing learning practice characteristics in primary healthcare. METHOD: Content validity was evaluated using a modified nominal group technique and a content validity rating scale. Construct validity and reliability evaluation was undertaken with 10 staff members from 10 general practices in the west of Scotland. Staff completed the inventory twice, 4-6 weeks apart. Applying generalisability theory, a variance component analysis was performed. RESULTS: The main findings present evidence that the inventory has acceptable reliability and content validity. The results also demonstrate that the inventory can reflect the consistent and uniquely different perspectives of particular designations of staff within a practice. It is possible to compare practices' overall learning environments and to identify specific areas of practice strength as well as areas for development. CONCLUSION: This study demonstrates the psychometric properties of a learning practice diagnostic inventory. It highlights the consistently different perspectives that individual staff groups have on the function of their practice, suggesting that the success of quality improvement initiatives may be compromised without the involvement and true engagement of each staff group.

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.

Challenge of improving postoperative pain management: case studies of three acute pain services in the UK National Health Service.

BACKGROUND: Previous national survey research has shown significant deficits in routine postoperative pain management in the UK. This study used an organizational change perspective to explore in detail the organizational challenges faced by three acute pain services in improving postoperative pain management. METHODS: Case studies were conducted comprising documentary review and semi-structured interviews (71) with anaesthetists, surgeons, nurses, other health professionals, and managers working in and around three broadly typical acute pain services. RESULTS: Although the precise details differed to some degree, the three acute pain services all faced the same broad range of inter-related challenges identified in the organizational change literature (i.e. structural, political, cultural, educational, emotional, and physical/technological challenges). The services were largely isolated from wider organizational objectives and activities and struggled to engage other health professionals in improving postoperative pain management against a background of limited resources, turbulent organizational change, and inter- and intra-professional politics. Despite considerable efforts they struggled to address these challenges effectively. CONCLUSIONS: The literature on organizational change and quality improvement in health care suggests that it is only by addressing the multiple challenges in a comprehensive way across all levels of the organization and health-care system that sustained improvements in patient care can be secured. This helps to explain why the hard work and commitment of acute pain services over the years have not always resulted in significant improvements in routine postoperative pain management for all surgical patients. Using this literature and adopting a whole-organization quality improvement approach tailored to local circumstances may produce a step-change in the quality of routine postoperative pain management.

Understanding the challenges of service change - learning from acute pain services in the UK.

OBJECTIVES: To explore organizational difficulties faced when implementing national policy recommendations in local contexts. DESIGN: Qualitative case study involving semi-structured interviews with health professionals and managers working in and around acute pain services. SETTING: Three UK acute hospital organizations. MAIN OUTCOME MEASURES: Identification of the content, context and process factors impacting on the implementation of the national policy recommendations on acute pain services; insights into and deeper understanding of the generic obstacles to change facing service improvements. RESULTS: The process of implementing policy recommendations and improving services in each of the three organizations was undermined by multiple factors relating to: doubts and disagreements about the nature of the change; challenging local organizational contexts; and the beliefs, attitudes and responses of health professionals and managers. The impact of these factors was compounded by the interaction between them. CONCLUSIONS: Local implementation of national policies aimed at service improvement can be undermined by multiple interacting factors. Particularly important are the pre-existing local organizational contexts and histories, and the deeply-ingrained attitudes, beliefs and assumptions of diverse staff groups. Without close attention to all of these underlying issues and how they interact in individual organizations against the background of local and national contexts, more resources or further structural change are unlikely to deliver the intended improvements in patient care.

A randomized comparative crossover study to assess the affect on circuit life of varying pre-dilution volume associated with CVVH and CVVHDF.

OBJECTIVE: To determine if circuit life is influenced by a higher pre-dilution volume used in CVVH when compared with a lower pre-dilution volume approach in CVVHDF. DESIGN: A comparative crossover study. Cases were randomized to receive either CVVH or CVVHDF followed by the alternative treatment. SUBJECTS: All patients >or= 18 yrs of age who required CRRT while in ICU were eligible to participate, but excluded if coagulopathic, thrombocytopenic or unable to receive heparin. Based on an intention-to-treat, 45 patients were randomized to receive either CVVH or CVVHDF followed by the alternative treatment. SETTING: A 24-bed, tertiary, medical and surgical adult intensive care unit (ICU). INTERVENTION: Blood flow rate, vascular access device and insertion site, hemofilter, anticoagulation and machine hardware were standardized. An ultrafiltrate dose of 35 ml/ kg/h delivered pre-filter was used for CVVH. A fixed pre-dilution volume of 600 mls/h with a dialysate dose of 1 L was used for CVVHDF. RESULTS: Thirty-one patients received CVVH or CVVHDF out of 45 participants followed by the alternative technique. There was a significant increase in circuit life in favor of CVVHDF (median=16 h 5 min, range=40 h 23 min) compared with CVVH (median=6 h 35 min, range=30 h 45 min). A Mann-Whitney U test was performed to compare circuit life between the two different CRRT modes (Z=-3.478, p<0.001). Measurements of circuit life on the 93 circuits which survived to clotting (50 CVVH and 43 CVVHDF) were log transformed prior to under taking a standard multiple regression analysis. None of the independent variables - activated prothrombin time (aPTT), platelet count, heparin dose, patient hematocrit or urea - had a coefficient partial correlation >0.09 (coefficient of the determination=0.117) or a linear relationship which could be associated with circuit life (p=0.228). CONCLUSION: Pre-diluted CVVHDF appeared to have a longer circuit life when compared to high volume pre-diluted CVVH. The choice of CRRT mode may be an important independent determinant of circuit life.

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.

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.

Unlearning in health care.

Learning in health care is essential if healthcare organisations are to tackle a challenging quality of care agenda. Yet while we know a reasonable amount about the nature of learning, how learning occurs, the forms it can take, and the routines that encourage it to happen within organisations, we know very little about the nature and processes of unlearning. We review the literature addressing issues pivotal to unlearning (what it is, why it is important, and why it is often neglected), and go further to explore the conditions under which unlearning is likely to be encouraged. There is a difference between routine unlearning (and subsequent re-learning) and deep unlearning--unlearning that requires a substantive break with previous modes of understanding, doing, and being. We argue that routine unlearning merely requires the establishment of new habits, whereas deep unlearning is a sudden, potentially painful, confrontation of the inadequacy in our substantive view of the world and our capacity to cope with that world competently.

Rhetoric and reality on acute pain services in the UK: a national postal questionnaire survey.

BACKGROUND: The study aimed to explore the extent to which NHS acute pain services (APSs) have been established in accordance with national guidance, and to assess the degree to which clinicians in acute pain management believe that these services are fulfilling their role. METHODS: A postal questionnaire survey addressed to the head of the acute pain service was sent to 403 National Health Service hospitals each carrying out more than 1000 operative procedures a year. RESULTS: Completed questionnaires were received from 81% (325) of the hospitals, of which 83% (270) had an established acute pain service. Most of these (86%) described their service as Monday-Friday with a reduced service at other times; only 5% described their service as covering 24 hours, 7 days a week. In the majority of hospitals (68%), the on-call anaesthetist was the sole provider of out of hours services. Services were categorized by respondents as thriving (30%), struggling to manage (52%) or non-existent (17%). There was widespread agreement (> or =85%) on the principles that should underpin acute pain services, and similar agreement on the need for better organizational approaches (95%) rather than new treatments and delivery techniques (19%). CONCLUSIONS: More than a decade since the 1990 report Pain after Surgery, national coverage of comprehensive acute pain services is still far from being achieved. Despite wide consensus about the problems, concrete solutions are proving hard to implement. There is strong support for a two-fold response: securing greater political commitment to pain services and using organizational approaches to address current deficits.

Using routine comparative data to assess the quality of health care: understanding and avoiding common pitfalls.

Measuring the quality of health care has become a major concern for funders and providers of health services in recent decades. One of the ways in which quality of care is currently assessed is by taking routinely collected data and analysing them quantitatively. The use of routine data has many advantages but there are also some important pitfalls. Collating numerical data in this way means that comparisons can be made--whether over time, with benchmarks, or with other healthcare providers (at individual or institutional levels of aggregation). Inevitably, such comparisons reveal variations. The natural inclination is then to assume that such variations imply rankings: that the measures reflect quality and that variations in the measures reflect variations in quality. This paper identifies reasons why these assumptions need to be applied with care, and illustrates the pitfalls with examples from recent empirical work. It is intended to guide not only those who wish to interpret comparative quality data, but also those who wish to develop systems for such analyses themselves.

How to present the findings of research.

Providing an account of research involves telling a story during which four key questions are answered: why did you start, what did you do, what did you find out and what does it mean? It is the third of these--what did you find out--that is at the heart of any research paper. Ensuring that the key messages emerge from the data is the duty of the author and requires considerable skill and craft.

A rapidly expanding lesion in the neck: unusual presentation of Castleman's disease.

We report a painless but rapidly enlarging 9 cm x 4 cm lobulated hard neck mass. CT scanning suggested lymphoid tissue that was not confirmed by cytopathology. Histopathological analysis of the excision specimen detected Castleman's disease, extending to the resection margin. Postoperative radiotherapy was administered. The patient remains disease-free after 44 months.

Exploring the pathology of quality failings: measuring quality is not the problem--changing it is.

The USA can boast a long history of investigation into quality failings in health care. From Ernest Codman and Abraham Flexner in the opening decades of this century through to the intense activity of the 1980s and 1990s, much careful study has exposed extraordinary and at times scandalous deficiencies in the quality of care (Millenson 1997; Chassin & Galvin 1998; Schuster et al. 1998). Yet we are still far from developing 'industrial strength' quality in health care: in all but a few isolated areas, such as general anaesthesia, 'six sigma quality' (i.e. a handful of errors per million) seems wishful thinking (Chassin 1998). Pockets of excellence and innovation notwithstanding, the dominant experience of the past two decades has been an increasing ability to document quality failings and a seeming inability to mobilize effective action (Coye & Detmer 1998). The rich literature on health-care quality that has sprung up over the past few decades has largely failed to provide a clear direction for quality improvement activity. This paper analyses some of the reasons why this might be so. Contrasting the relative absence of progress on health-care quality with the relative success of disease epidemiology provides some illuminating parallels. In essence, study of the quality of care has focused largely on providing a 'descriptive epidemiology'. Much more work is needed yet to unravel the underlying pathology of quality failings, in order to empower development of an 'aetiological epidemiology' of quality in health care. Such understanding is essential as a precursor to targeted and effective preventative and remedial action.

Reading and assessing qualitative research.

What makes doctors burn out? What is it like to have epilepsy? Why do smokers not give up? Qualitative research makes it possible to look behind the statistics and to study health and health care from the inside: to find out what it is really like for the health professionals who provide the care and for the patients on the receiving end.

Public release of performance data and quality improvement: internal responses to external data by US health care providers.

Health policy in many countries emphasises the public release of comparative data on clinical performance as one way of improving the quality of health care. Evidence to date is that it is health care providers (hospitals and the staff within them) that are most likely to respond to such data, yet little is known about how health care providers view and use these data. Case studies of six US hospitals were studied (two academic medical centres, two private not-for-profit medical centres, a group model health maintenance organisation hospital, and an inner city public provider "safety net" hospital) using semi-structured interviews followed by a broad thematic analysis located within an interpretive paradigm. Within these settings, 35 interviews were held with 31 individuals (chief executive officer, chief of staff, chief of cardiology, senior nurse, senior quality managers, and front line staff). The results showed that key stakeholders in these providers were often (but not always) antipathetic towards publicly released comparative data. Such data were seen as lacking in legitimacy and their meanings were disputed. Nonetheless, the public nature of these data did lead to some actions in response, more so when the data showed that local performance was poor. There was little integration between internal and external data systems. These findings suggest that the public release of comparative data may help to ensure that greater attention is paid to the quality agenda within health care providers, but greater efforts are needed both to develop internal systems of quality improvement and to integrate these more effectively with external data systems.