Cornell University International Healthcare Conference

11th - 12th May 2010

Staff involvement as a matter of life and death?

Participative governance and the Hospital of the Future project

Peter Totterdill

Joint Chief ExecutiveUK Work Organisation Network

Visiting ProfessorKingston University

peter.totterdill@ukwon.net

The UK Work Organisation Network A coalition committed to shared knowledge, collaborative action and policy advocacy• the future of work and organisations• closing the gap between leading-edge

practice and common practice

The UK Work Organisation Network Health Sector experience includes:• Action Research• European Hospital Network• NHS Improving Working Lives programme• Hospital of the Future project in Ireland

How can we create a system of governance that leads to sustainable quality improvement in hospitals?

Integrated governance

Corporate Governance

• cost effectiveness

• transparency

• accountability

Clinical Governance

• patient safety

• risk assessment

• learning from incidents

• patient satisfaction

Integrated governance

Regulation or innovation?

Quality assurance without quality improvement?

• compliance• distortion of management effort• authoritarian control

Innovation in hospital work organisation: an under-utilised resource?

• quality of patient care• mortality• risk and patient safety• cost effectiveness• quality of working life

“Organisations with mutually reinforcing . . . practices achieve superior performance as their collective impact is greater than the sum of individual measures.”

Teague, P., (2005) What is Enterprise Partnership? Organization 2005; 12; 567

South Maasland Hospital, The Netherlands

A conceptual model of partnership and governance in hospitals

PATIENT EXPERIENCEMacro Systems

A conceptual model of partnership and governance in hospitals

PATIENT EXPERIENCEMacro and Micro-

Systems

A conceptual model of partnership and governance in hospitals

Partnership & involvement

PATIENT EXPERIENCEMacro and Micro-

Systems

A conceptual model of partnership and governance in hospitals

PATIENT EXPERIENCEMacro and Micro-

Systems

A conceptual model of partnership and governance in hospitals

Knowledge distribution

PATIENT EXPERIENCEMacro and Micro-

Systems

A conceptual model of partnership and governance in hospitals

Partnership & involvement

Knowledge distribution

PATIENT EXPERIENCEMacro and Micro-

Systems

Hospital of the Future Project

What are the principal obstacles and dilemmas which hospitals face in securing effective governance and quality improvement?

And what can be done to overcome them?

Seven hospitals studied

• University Hospital Galway• Adelaide and Meath• Naas General Hospital• Waterford General Hospital• St Luke’s Kilkenny• National Maternity Hospital• Beaumont Hospital

We identified many participative initiatives which are improving patient

care and hospital performance.

But there is no systemic approach, either at hospital level or national

level, to implementing the practices that we know work.

A conceptual model of partnership and governance in hospitals

Partnership & involvement

Knowledge distribution

PATIENT EXPERIENCE

Partnership & involvement

· A better IR climate.· Some superb examples of high

involvement innovation.· Only a few hospitals spreading

partnership practices systematically, and with only partial success.

· Widespread medical indifference to the potential of other staff to make an enhanced contribution to governance and quality improvement.

· Trade union role often weak and unfocussed.

· A better IR climate.· Some superb examples of high

involvement innovation.· Only a few hospitals spreading

partnership practices systematically, and with only partial success.

· Widespread medical indifference to the potential of other staff to make an enhanced contribution to governance and quality improvement.

· Trade union role often weak and unfocussed.

A conceptual model of partnership and governance in hospitals

· International evidence and local examples demonstrate that teamworking increases staff engagement & enhances patient care.

· The dissemination of team-based practices depends on individual medical consultants, not on evidence of clinical effectiveness or patient safety.

· Effective teamworking needs sustained organisational support.

· Many managers fear staff empowerment.

· International evidence and local examples demonstrate that teamworking increases staff engagement & enhances patient care.

· The dissemination of team-based practices depends on individual medical consultants, not on evidence of clinical effectiveness or patient safety.

· Effective teamworking needs sustained organisational support.

· Many managers fear staff empowerment.

A conceptual model of partnership and governance in hospitals

· Staff engagement in governance is sporadic

· Widespread persistence of a climate of fear perpetrated by some managers & clinicians.

· Some excellent examples of continuous improvement and innovation at local level, but systemic approaches at hospital level hard to find.

· Staff and frontline unions are an underused resource in managing crisis.

· Staff engagement in governance is sporadic

· Widespread persistence of a climate of fear perpetrated by some managers & clinicians.

· Some excellent examples of continuous improvement and innovation at local level, but systemic approaches at hospital level hard to find.

· Staff and frontline unions are an underused resource in managing crisis.

A conceptual model of partnership and governance in hospitals

UNION

UNION

Risk Committee

Clinical Directorate

STAFF

QualityCommittee

Partnership Committee

UNION

EXECUTIVE TEAM

Local Forums

Local Forums

Multi-Disciplinary Clinical and Service Teams

The dis-integration of partnership and governance

Clinical Governance Committee

STAFF

EXECUTIVE TEAM

UNION

TRADE UNION ALLIANCE

UNION UNION

Beyond the fragments

Clinical Directorate

Partnership Committee

Local Forums

Local Forums

Local Forums

Local Forums

Multi-Disciplinary Clinical

& Service Teams

The Role of Partnership Committees

Strategic Policy

Industrial Relations

Improvement & Innovation

Proposition: a Partnership Committee working to its full potential is located at the centre of the triangle.

Challenges

• The problem of voluntarism

• Quality assurance without quality improvement?

• Regulation or animation?

Regulation or animation?

• External validation has been a valuable and valued tool for bringing people together around shared interests across occupational and functional divisions.

• There is a high risk of a narrow focus on compliance rather than on achieving sustainable improvement.

• There is a fear that the emerging system of central regulation will seek “one size fits all” compliance rather than resourcing local innovation.

Regulation alone does not bring about sustainable change but may only securecompliance with audit requirements. However given the right circumstances

regulation can create the conditions for sustainable and meaningful change.

What is to be done?

Formulating clear and actionable recommendations involving all stakeholders

A process of shared learning

www.ukwon.net