LECTURE 8: Leadership for improving quality of care

What is clinical quality?
the degree of excellence in healthcare

Quality improvement is about achieving better patient experience and outcomes by changing provider behaviour and organisation through use of systematic change methods and strategies. Do you lead people and/or manage processes? Develop the infrastructure (B James) that supports the delivery of the right care (EBM) to the right person at the right place/time (EBM) (S Altschuler).

Dimensions of Quality Care

Safe: do no harm; avoiding injuries from care aimed at helping patients.

Timely: without undue delay both for those who receive and those who give care.

Effective: produces desired results; services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit; disease prevention and early detection.

Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy; resourced appropriately and done competently.

Equitable: providing care that does not vary because of gender, ethnicity, disabilities etc. in the patient; or at population level because of geographic location, and socio-economic state.

Patient-centred: providing care that is respectful of and responsive to individual patient preferences, needs, and values; seamless; provided with respect and compassion.

Useful QI Steps

  1. Understand the problem (emphasis on data).

  2. Understand the processes and systems within the organisation (particularly patient pathways).

  3. Analyse the demand, capacity, capability and reliability of the service.

  4. Choose the tools to bring about change; including leadership and clinical engagement, skills development, and staff/patient participation.

  5. Evaluate and measure the impact of a change.

What Are We Trying To Accomplish? (Aim)

This is the question on selecting the aim – specific, to time and population, and measurable. It is a statement that clearly sets the goal and needs to be agreed with the providers and the team of stakeholders.

How Will We Know That A Change Is An Improvement? (Measure)

This is the question that makes us consider processes and outcomes that will help us understand the direction of the change. This is typically complex, but it is important to appreciate that measures need to be tied to the intervention and include a mix of intended (outcomes) and unintended consequences (balancing outcomes).

The outcomes may be primary (a direct consequence of the change) or secondary (an indirect consequence).

What Change Can We Make That Will Result In An Improvement? (Change)

Once the aim and measurements are finalised with the project team, it is time to act. This needs to be rapid, short learning cycles that sequentially change and expand over time. This is also the time to use rapid Plan-Do-Study-Act (PDSA) cycles to test a change or group of changes on a small scale.

Small scale testing is rapid, minimally disruptive and easier to evaluate to see if they result in improvement. They should not take more than a few hours or days.

What are the Challenges?

Technical Adaptive
  • Problem is well defined
  • Solution is known and can be found
  • Implementation is clear
  • Challenge is complex
  • To solve requires transforming long-standing habits and deeply held assumptions and values
  • Involves feelings of loss, sacrifice (sometimes betrayal to values)
  • Solution requires learning and a new way of thinking, new relationships

CAS Leadership

  1. Systematic practice of a change method that influences behaviour.

  2. Effective leadership in health systems leads to sustained improvement in quality outcomes for patients.

  3. Leadership is a systems phenomena and is about the interactions between the individuals that leads to sustained change in behaviour.

  4. Leadership behaviours include making the first move, creating urgency around change, communicating a vision, inviting followers.

Leadership Types 1 & 2

Directive [1] Visionary [2]
The leader's modus operandi Demands immediate compliance Mobilises people toward a vision
The style in a phrase 'Do what I tell you' 'Come with me'
Underlying emotional intelligence competencies Drive to achieve, initiative, self control self confidence, empathy, change catalyst
When the style works best In a crises, to kick start a turnaround, or with problem employees When changes require a new vision, or when a clear direction is needed
Overall impact on climate Negative Most strongly positive

Leadership TYPES 3, 4, 5 & 6

Affiliative [3] Participative [4] Pacesetting [5] Coaching [6]
The leader's modus operandi Creates harmony and builds emotional bonds Forges consensus through participation Sets high standards for performance Develops people for the future
The style in a phrase 'People come first' 'What do you think?' 'Do as I do, now' 'Try this'
Underlying emotional intelligence competencies Empathy, building relationships, communication Collaboration, team leadership, communication Conscientious, drive to achieve, initiative Developing others, empathy, self awareness
When the style works best To heal rifts in a team or to motivate people during stressful circumstances To build buy-in or consensus, or to get input from valuable employees To get quick results from a highly motivated and competent team To help an employee improve performance or develop long-term strengths
Overall impact on climate Positive Positive Negative Positive

Leadership Style and Impact

Directive Visionary Affiliative Participative Pacesetting Coaching
Flexibility -0.28 0.32 0.27 0.28 -0.07 0.17
Responsibility -0.37 0.21 0.16 0.23 0.04 0.08
Standards 0.02 0.38 0.31 0.22 -0.27 0.39
Rewards -0.18 0.54 0.48 0.42 -0.29 0.43
Clarity -0.11 0.44 0.37 0.35 -0.28 0.38
Commitment -0.13 0.35 0.34 0.26 -0.20 0.27
Overall impact on climate -0.26 0.54 0.46 0.43 -0.25 0.42

Patient-centred Culture

Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported.

(Dixon-Wood et al. Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Qual Saf doi:10.1136/bmjqs-2013-001947)

High Impact Leadership

  • Person-centredness: be consistently person-centered in word and deed.

  • Front Line Engagement: be a regular, authentic presence at the front line and a visible champion of improvement.

  • Relentless Focus: remain focused on the vision and strategy.

  • Transparency: require transparency about results, progress, aims, and defects.

  • Boundarylessness: encourage and practice systems thinking and collaboration across boundaries.

(Swensen et al. IHI High Impact Leadership White Paper)

How do you lead when improving the quality of care for older people?

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