Is quality improvement sustainable long term?

29 Nov 2018

Professor Chris Baggoley shares his considerable experience and ideas on whether sustainable quality improvement is possible.

Chris Baggoley is the Chief Medical Advisor for Calvary Healthcare and previously was the Australian Government Chief Medical Officer and the Chief Executive of the Australian Commission on Safety and Quality.

Kevin caught up with Chris recently to talk about what will make quality improvement sustainable long term.

Chris’s view is that there are a multiplicity of factors that make safety and quality sustainable, and can be summarised as: 

  1. Organisational factors 
  2. Patient/family factors
  3. Staff factors
  4. Regulation

Chris: I must admit I don’t mind a bit of regulation, I think it helps make a difference. And people talk about the culture of an organisation but that might be if you’ve got a respectful organisation if you’ve got strong leadership, you celebrate success, so it’s a range of activities there.

But, if I was to think about what it is that moves staff, be that doctors, nurses, board members, whatever, they all have a focus on patients. The consumers of their healthcare and their families and they need to live that. They really need to be at the centre of what they do, that’s important.

The other thing that drives Commissions in particular, but also those others I mentioned, is the provision of data. Anything that can be measured is provided in a timely way that can make a difference. Everyone wants to do better and if they’ve got the data that is fresh, that can make a difference, that’s going to help sustain quality improvement.

Kevin: You’ve talked before about organisational turbulence, so that can be both, get in the way of quality of improvement but it could also be a disruptor to help advance the agenda, what are your thoughts about that?

Chris: What we know about organisations is that the setting for improvement is greatly enhanced by stability and leadership.

And what we also know in our health systems – and I do focus on now in South Australia, which is my home state – is that the continual change of Chief Executives of hospitals and networks who bring in fresh ideas when people are getting used to the fresh ideas of their predecessors so that in the end the doctors and nurses just get a sense that this change is constant, nothing is followed through and what is constant for them is their work with patients. That’s what they do. That’s what they are best at.

While they might want to be part of an organisation, the organisation is so turbulent. There may well be someone that comes along who really has got fantastic ideas great skills, but people have to decide how much of myself am I going to invest in this person, in this organisation. And of course, if they don’t invest, that leader may not be successful, and they may be moved.

So what executives are often judged by is the financial performance of their organisation. They know that improved quality care improves financial performance. But if they’re not given the time and they’re in a hurry to get things done then it’s going to be hard for the doctors and nurses to really enjoy themselves. And I’ve spoken to doctors and nurses at Flinders Medical Centre, who have been there for 30 years, brilliant people, great clinicians but what they’ve seen and the people they’ve seen come and go over the years is quite disruptive. Turbulent times of course can bring up great ideas and great solutions, so it can work both ways.

Kevin: Absolutely and you can understand why people respond the way they do because when you see a continual rollover of Chief Executives and you invest in one and they’re gone, well then it is like, well let’s start again.

Chris: Everyone wants the system to get better and they want the system to support them as they do that but if the system becomes preoccupied with organisational change seemingly for its own sake then you can lose people.

Kevin: You talked about finances, one of the spinoffs of good quality improvement also is improved financial performance quite often, but sometimes the quality improvement agenda is a three-year investment or a longer one, obviously longer whereas the financial imperatives are day by day, month by month, year by year so there is almost an inbuilt tension to leadership having courage. Did you have any thoughts about that?

Chris: Yes, I was just involved yesterday in a Hospital where the head of the health department, Chief Executive of the network, treasury officials and so on, they came to help to do something about the financial status of this hospital. They were ushered into the operations room and we have heard now how many hospitals and networks have similar places. 

The discussion was had about cost is made up of a range of components. They were measuring safety, by safety they are looking at safety of staff, they’re looking at quality and quality improvement, they’re looking at delivery of care those things that are actually happening, they are looking at people, people factors, turnover and so on. Put all those together and you have costs. It was understood, in fact the head of that health department understood that if quality was improved, patient turnover, fewer complications was a focus then cost will lower and improvements will come along with it. It was understood that these things take time. This organisation had been focusing on quality for a long time.

Part of the regulation side of things is bringing a sharp focus to this cause as they introduction of healthcare acquired complications or the hacks as people talk about it now, which the independent hospital pricing authority or IHPA has introduced as part of the financial mix. So, when money gets married with quality improvement then I think it can be a great incentive. It has to be handled carefully. It means then that everyone has a focus on quality and focusing on those issues that prolong patients stay or cause complications and from varying perspectives can only improve patient care I think.

“So, when money gets married with quality improvement then I think it can be a great incentive. It has to be handled carefully.”

Kevin: You’ve mentioned that the health system is like a bird. What do you mean by that? 

Chris: I don’t take credit for this but boy it stuck with me. I remember a presentation from Geoffrey Braithwaite and the slide he had which he has let me use. He talked about people’s attitudes towards the health system and effecting change.

Those who work in the health system, they know that making change, effecting change, isn’t easy, it’s complicated and it needs constant attention. Geoffrey, and I am sure he got it from others, likens it to holding a bird in your hands. The system is like a bird, birds must be nurtured, they must be cared for, but they’ve got minds of their own. You throw a bird in the air and you watch where it goes, make sure it’s fed, but you can’t be sure where it’s going to land, it may come straight back home to roost, it might be one of those sort of birds and you may not get far at all but you’ve got to persist. Change and effecting change is not as predictable as people would like think.

Kevin: You’ve talked before about health literacy, would you like to share a little more about that?

Chris: Yes, I think that the understanding that the patients and the consumers of healthcare may not understand what it is that health professionals are saying to them or advising them hasn’t been well understood.

What really made a difference for me in this was a study, I think a brilliant study conducted by the Australian Bureau of Statistics, published back in 2008 where they looked at 27,000 people. They spoke to them, they gave 5 pieces of information and asked them to interpret it. It could have been directions for their next appointment, it could be an article written in a popular magazine – those sorts of things. What they found was that two thirds of patients did not have the basic health literacy that was needed to even deal with those matters. Worse, it was the older the people were, and probably for a variety of reasons, the less they understood. Also, the sicker people were, the less they understood. So, it skewed in all the wrong ways, which is why the health system needs to accept that, try to do something about it but work with it so that they know that the patient or their carers, both, when they are given information, given advice, it is given in a way that they understand.

Check that they do understand it and constantly focus on that because what we also know is that patient centred healthcare is the best way to get the best results, but you can’t have patient centred care if the patient doesn’t get it.