Deficiencies in Clinical Governance
In 2015, the Consultative Council reported to the Department of Health and Human Services that the number of perinatal deaths has increased at Djerriwarrh Health Services in the year 2013 and 2014. The Australian Commission on Safety and Quality Health Care(ACSQHC) was requested to conduct a review on Djerriwarrh Health Services’ actions in detecting, responding and managing the perinatal deaths and their capacity to respond to current critical health concerns in the public health system(Duckett, Cuddily, & Newnham, 2016). Regarding the perinatal deaths and obstetric emergencies, ACSQHC found that Djerriwarrh had significant deficiencies in conducting appropriate clinical governance, undertaking routing surveillance when it comes to adverse clinical situations and the health service was unable to respond to adverse incidents. Furthermore, Professor Euan Wallace conducted a further review where he identified seven perinatal deaths that were potentially avoidable. He concluded that there was inadequate clinical governance in the region which lead to poor responding and monitoring of adverse clinical outcomes(Duckett et al., 2016). Due to these facts, the Minister for Health requested the review of the department’s current methods of governance and assurance of safety and quality care in hospitals and recommend where there was a deficiency. This study seeks to give some of the deficiency found relating them to the National Safety and Quality Health Standards of the nation.
The current health care system is complex due change in technology, increase in chronic and complicated diseases, enhancement of treatment methods and the rise of new medicines(Australian Commission on Safety and Quality in Health Care, 2016). This has lead to difficulties in decision making for healthcare workers which often lead to errors during care delivery. Patients are usually subjected to these errors and adverse effects during care delivery(Twigg, Duffield, & Evans, 2013). However, some of these adverse effects and errors are avoidable and health care workers should always have a comprehensive system that makes sure patients are not subjected to such harms(Schrauf, 2014). In addition, the health care team in a hospital and its department should always be ready to respond to such errors when they arise(Nathan, 2012). Avoidable patient harm means individuals suffered while receiving care but not because of their illness or lack of knowledge in medication or treatment.
There may have been poor quality and safety problems related to obstetric services in Djerriwarrh. Some of the indicators for poor quality and safety in the region include failure of various health systems, culture and processes(Livingston, 2017). In 2013, the Djerriwarrh was under investigation by the Ministry of Health concerning the issues of maternal services in the West of Melbourne(Duckett et al., 2016). In addition, the nursing and midwifery union had initialized the investigation claiming the hospital had no met allowed accreditation standards. In both cases, the hospital promised to change but after the review in 2015, there was little or no change in terms of quality and safety standards.
Importance of Board Governance
The staff in both instances directed the blame on hospital management. There were, however, some issues arising from the operations in the hospital but the management failed to follow up for proper implementation thus resulting in inappropriate accountability. A review carried out by the concerned department at Djerriwarrh found that the Health Service Performance and Programs were aware of the cluster of deaths but acted little(Duckett et al., 2016). There would be improvement had they had put a more robust oversight system at place.
The concerned department at Djerriwarrh demonstrated to lack responsibility in terms of oversight of the systems, monitoring, and board governance(Duckett et al., 2016). Board governance is crucial in all healthcare systems as it oversees and regulates hospital leadership and management(Moran & Brightman, 2013). A board that lacks an understanding of contemporary and health service challenges become very dependent on the CEO thus it does not execute the right functions(Duckett et al., 2016). This, in turn, leads to a poor balance of responsibilities between the CEO and the board thus leading to negative outcomes. Good board governance always leads to avoidance of negative organization culture, inadequate financial management and promote clinical care.
Djerriwarrh health services have demonstrated to have significant failures across all the departments in terms of clinical governance. The review by Department of Health found that the board of Djeriiwarrh was the only one out of 86 in Victoria that was unable to address problems in a timely manner(Duckett et al., 2016). This is due to the poor appointment of board members who lack enough skills. For instance, at the Djerriwarrh, out of nine board members, only four proved they have skills in clinical governance(Duckett et al., 2016). In addition, the board was likely to have anomalies in terms of selection of the members. The board’s members could have been selected from areas that have greater potential problems(Duckett et al., 2016). Other than that, almost all of the board members did not understand or lack clinical expertise in terms of medical administration skills thus they could not understand most of the .clinical issues.
Knowledge and skills are the key elements to be considered when choosing a board member(South Australia Health, 2014). Recent academic research has found that Victoria lack board members who have sufficient knowledge. A research published by the ministry between the year 2013 and 2014 showed that one out of five of the boards did not offer formal training of the board members and still lack enough quality performance(Duckett et al., 2016). Although most of the boards believed they deliver quality performance, about half of them did not benchmark their work against the external boards(Duckett et al., 2016). The Mistry of Health acknowledges that it is difficult to appoint the board members but also recommend they should be highly screened in order to choose those who have interest in quality and safety but not for business purposes.
Appointment of Board Members
Djerriwarrh case has proved inadequate as the systems put in place have not been able to function as expected(Duckett et al., 2016). This well explains why when there are differences in both the responsible board and the department, failures are likely to happen thus hindering or halting proper service delivery in any organization. It is therefore of great importance to ensure proper ways are followed to ensure there is harmonious cooperation between them(Victorian Council of Social Service, 2013). Catastrophic failures in all levels occurred at Djerrwarrh health facilities in clinical governance with no exception including the board. The review found that majority of boards were having difficulties in noting and finding solutions to problems arising in a timely manner(Duckett et al., 2016). Another problem that stood out was the appointment of board members in the vast region of Victoria. There was no proper assessments and instead applicants were told to carry out self-analysis on their competence in various areas. The answer was shallow as there was no in-depth explanation and therefore not being able to identify underlying issues. Another great issue that stood out Djerriwarrh board is the health services being moderate in size which was located in urban regions with high population and from where the majority of board members came from(Duckett et al., 2016). This meant that small public hospitals had a lower hand in terms of expertise of the board members as theirs didn’t come from privileged areas.
The issue of term limits for members of the board played a key role in their independence and also continuous internal renewal. While having a quality committee on a board does not necessarily mean good governance in clinical matters, it helps create better performance in quality(Cifalinò & Villa, 2016). There are differences in the appointment of board members between small and big public hospitals. Smaller public hospitals have a greater role in interviews carried out than bigger health facilities. The procedure followed in public sector yields more liberty on local interests in terms of merit of those appointed in boards(Australian Commission on Safety and Quality in Healthcare, 2011). This independence brings diversity in the boards and prevents them from having a clique of special members. It was, therefore, suggested an amendment to the various broad areas in order to improve service delivery. A proposal was tabled for the introduction of a rigorous process in board appointment(Duckett et al., 2016). This was to make sure that there was a variety of skills in those boards especially on clinical, financial as well as legal expertise. This enables the hospital to have an abundance of skills which will enable better service delivery.
Consumer Representation
Consumer representation is a matter which needed to put into consideration as they are the recipients of services those hospitals offer(Royal College of Paediatrics and Child Health, 2015). A patient concerns are well taken care of if he/she is given representation and the board thus concentrates on quality of the healthcare(Australian Commission on Safety and Quality in Healthcare, 2016). This will be possible if the person is able to bring the expertise necessary to get the views of the patients. The main advantage of this model is that the board got firsthand information on patients concern(Health Services Council, 2016). This information helps in policy formulation and assessment of its performance. Clinicians also played a greater role when appointed in those boards. This was not only important on matters of clinical governance but also a great experience in health(Health Services Council, 2016). Having such proposals ensured great scope on skills and expertise among board members which enabled proper decision making
What happened at Djerriwarrh put the test to the trust that the community had on the Victorian health facilities. The trust depended on the health department to improve on system performance geared towards better service delivery to their patients(Duckett et al., 2016). Lack of transparency also played a major key in the problem of mistrust from the patients. Accountability among workers and other stakeholders prayed another major role to this problem. New changes were proposed in order to improve on the quality of services offered.
Meaningful transparency is one of the major solutions. Health department need to have an obligation to evaluate how public hospitals systems help healthcare recipients make sound decisions(Australian Commision on Safety and Quality in Health Care, 2012). This can be brought about by the kind of feeling one gets after treatment. When one gets the positive feeling that was not there before the treatment, he/she is inspired to come another time. The opposite is also true since one may not want to come back if there was no improvement after seeking those services(U.S. Department of Health & Human Services: Agency for Healthcare Research and Quality, 2016). Patients need to be informed about the various risks associated with certain treatments(Umachandran, 2016). One is able to decide whether they stand a chance to get better after treatment. There was, however, little to be shown on Victorian health facilities on transparency. This was due to;
Too little access to the information by the public on safety-the Victorian hospitals website had limited on their safety(Ibrahim et al., 2014). It left the public unable to make the required decisions based on the kind of information they got. There was no annual performance report which would have helped in an assessment to determine whether positive or negative strides are made(Duckett et al., 2016). Hospital website should, therefore, be used as the basic source of information to the public. Patients are able to make the right decisions right before seeking treatment from the hospital.
Conclusion
Lack of transparency in case of an occurrence of any harm- health workers might not be willing to share information to the patients or other concerned parties when harm occurs to the patient(Reidenberg, 2013). Sharing information with the patient helps the patient come to terms with what happened and what to do to prevent further damage(Horne & Karnick, 2012). Transparency plays a major function on the relationship between the patient and the hospital. This should be well fostered to bring positive perception about the hospital by the public. Legislation alone cannot solve this and therefore collective responsibility among key players is required.
The major standards related to the deficiencies in the review were the first and second standards. These include the clinical governance and partnering with the consumer’s standards. Djerriwarrh health care system lack mangers who takes responsibilities for continuous improvement of quality and safety in their services since they had an increase in perinatal deaths(Australian Commission on Safety and Quality in Healthcare, 2011). A healthcare organization that has good leaders and managers have good quality and safety standards, positive culture systems, increase clinical performance and effectiveness and provide a safe environment for the delivery of care(Twigg et al., 2013). Other than that, the health care system in the region had a poor partnership with the consumers. The departmental managers did not have a properly developed, implemented and maintained a system that supports consumers involvement. The department had received several reviews regarding accreditations but in all cases, they fail to implement their plans.
Conclusion:
Djeriiwarrh health service was just one out many in Victoria that set a good example of the incompetencies that many health services have which usually lead to poor quality and safety standards. Clinical governance and proper partnering with consumers have been found to be the major critical issues affecting most hospitals. At Djerriwarrh, there was a problem in clinical governance. The former board members did not have enough competencies, knowledge, and skills or medical expertise to execute the major clinical issues. Health services should be keen when appointing the board members to prevent catastrophic events. Other than that, Djerriwarr Health Service did not produce enough quality and safety standards as required. They had been reviewed several times but still, they fail to implement the issues presented. In addition, they lacked accountability and transparent to patients. It is important to portray trust to consumers in order to build a positive partnership. All the above deficiencies at Djerriwarrh Health Service go hand in hand with two major National Safety and Quality Health Standards developed in 2012 which include clinical governance and partnering with consumers.
The organization culture includes individuals’ perceptions, attitudes, values, behaviors, and competencies that determines commitments to safety management and institution health(El-Tohamy et al., 2015). Positive safety culture in an organization has individuals who understand what is needed to be done, when it is needed, when to consult and everything that goes around in a given time(Martin, Sutton, Willars, & Dixon-Woods, 2013). In addition, Unlike in a negative organizational culture, healthcare workers in a positive organizational culture are highly committed, make collaborated and individual decision, and are capable of responding to adverse conditions when they occur(Institute for Healthcare Improvement, 2014). Leadership and management qualities are the key elements that enhance positive culture in a hospital. To encourage a positive culture in a healthcare organization, leaders and managers always apply change management principles and models. Leaders have critical roles in change management which include having a sense of urgency and passion, encouraging commitments, acting as an example to others, embracing personality change, communication and listening and encouraging other healthcare workers to adhere with quality and safety standards(Sereika, Zheng, Hu, & Burke, 2017). This study seeks to demonstrate how managers in the hospital can apply change management principles and theories of power to the culture in a ward around reporting safety concerns.
A desired organizational culture should be all-inclusive. It should describe what is expected of the individual caregiver in respect to quality care and safety of the patient and operational efficiency. These changes can be effected using the following principles of change management:
A manager should first understand the health facility’s culture and as this will enable him/her plan for the future(Mani?, 2013). Before implementing any change pertaining culture, a manager should take into consideration its impact on the groups which are likely to be affected(Sereika et al., 2017). There are many players in a health facility. These players can either join the change initiative or decline. By so doing, planners of a change initiative will be able to cluster various views and come up with a concrete conclusion. In addition, a leader in a healthcare delivery set up should incorporate other people who have influence in the organization’s operations(Eaton, 2014). They should be involved, in different ways, as participants and guides. These additional participants are referred to as informal as they do not directly impact on the organization’s functionality. They act as culture and change ambassadors.
The leadership hierarchy should act as a collaborative team in implementing changes(Parkin, 2009). These changes will affect all areas in the healthcare facility and should thus be cascaded from the topmost administrative hierarchy to the bottom in the right way(Khalil, 2015). Other groups and levels should also be equally involved in the implementation of these changes. Caution should be taken to ensure that the right information is conveyed to the right level and what is expected of them clearly defined(South Australia Health, 2014). This will ensure that the various levels do what is expected of them leading to the success of the change implementation. Furthermore, Leaders in a health care set up should become clear communicators of what is expected of other personnel under him in the hierarchy(Chreim, Williams, & Coller, 2012). He or she should define the critical areas that will be changed and clearly outline those who are likely to be affected. This is critical as employees will believe in the changes only when they see it happening at the top of the company(Ionescu, Dragomiroiu, Hurloiu, & Rosca, 2014). A leader should ensure that the decisions concerning changes in culture engage the people’s minds and hearts. They should feel that they are part of these changes and that it will benefit them positively.
People involved should be persuaded through formal ways to cope up with the changes to be implemented(National Institute for Health and Clinical Excellence, 2012). This persuasion can be achieved through training and reward systems. For instance, the top authorities can put out a call for volunteers willing to undergo training on the changes to be affected. This will enable the trainees to feel like part of the organization. Creating informal solutions at every level of the administrative hierarchy will also produce positive results in the implementation process(Fritzenschaft, 2014). For instance, a leader can make impromptu visits to various departments and conduct informal teachings on the teachings on the changes to be put in place. This will give employees at various levels air their views freely and get direct feedback from their leaders. Other than that, change management involves assessment and adaption(Morrison, 2014). A manager should first measure the possibility of success or failure of implementing changes in a healthcare facility. He or she should identify what is workable and what is not in order to come up with the next strategy. For instance, realizing that implementation of s certain culture is unfavorable to persons of certain religion, a manager will be able to come up with the next course of action.
Problem analysis is one of the basic principles of change management that can trigger the proper evaluation of circumstances(Masrom & Rahimli, 2015). One major primary tool that is used in evaluating the internal and external concerns necessary for change is the SWOT analysis tool which stands for strengths, weaknesses, opportunities, and threats(Arshad & Noordin, 2017). Strengths and weaknesses are within the internal organizations while opportunities and threats are the external forces. SWOT analysis focuses on what an organization intends to offer and what its customers needs(Shahmoradi, Darrudi, Arji, & Nejad, 2017). In doing so, it helps the health care workers to see their healthcare organization or individual department from a different cultural perspective. SWOT analysis results to the listing of the related factors, general description of the situation, setting of priorities and set the possible interventions that may be used to rectify the situation(Shahmoradi et al., 2017). SWOT analysis can also help to change the organizational negative norms, beliefs attitudes and values.
In addition, Total Quality Management (TQM) tools are often used to change the organizational culture for better care. TQM focuses on the processes of work that enhance better quality and safety standards(El-Tohamy et al., 2015). TQM uses the processes of risk assessment through the process of data collection, analysis, formulation of hypothesis and changes processes that can be applied to introduce a smooth flow of quality care(Maher Altayeb & Bashir Alhasanat, 2014). TQM helps health care workers to develop skills that enhances effective team collaboration, understanding of work as a process, analyzing the existing and needed conditions for a change, designing the desired work processes, and encouraging patient involvement.
The field theory presents an approach that involves analyzing the context in which a group of behaviors occurs, for instance in a hospital ward. The theory debits that, a manager should view the current situation as maintained by certain conditions or culture(Roman, 2014). The components of these behaviors and patterns should be portrayed as symbolic interactions that affect certain outcomes and individuals behaviors (Fritzenschaft, 2014). Therefore personal behaviors and actions are dependent on group dynamics and group environment presented as a ‘field’. The theory acknowledges that the organization environment is dynamic and undergoes a continuous change due to both internal and external forces(Roman, 2014). Therefore if a manager is able to plot, identify and determine these forces, he or she will be able to comprehend health workers behaviors and take a necessary change to this behaviors to bring a positive culture. For instance, if a ward manager will be able to understand why nurses fail to report incidents as they happen in a ward, he or she will be able to know where to put inputs and strategies that encourage reporting of such incidents.
The 3-steps model was developed by Lewin which provide a general explanation of how an organization’s behaviors and culture can be changed for better care. The model consists of three processes of change which include unfreezing, moving and refreezing(Morrison, 2014). The first step of unfreezing involve establishing the status quo by creating a plan for change and ensuring all health care workers appreciate the need for change(Bibby et al., 2012). To be more specific, establishing the status quo include disconfirming its validity and inducing guilt. Disconfirming the status quo involves presenting an argument and the reasons behind them. Inducing guilt consist of cultivating a common belief in those involves in the change process showing them the necessity of the change(Bibby et al., 2012). In addition, this stage involves creating a psychological safety for health care workers involved. A psychological safety ensures that individuals anxiety and fear of the unknown is catered to allow mitigation. The theory suggests that, only after unfreezing the old behaviors, the new ways can be successfully adopted.
The second step on moving to involve identifying what needs to be changed and the establishing an implementation strategy that will bring the desired outcomes(Morrison, 2014). For instance, what needs to be done to nurses who fail to report the incidents as they happen in the wards is to encourage positive culture, commitments and nurses autonomy(Morrison, 2014). Managers need to take accounts of all forces that make nurses have this problem and analyze their complexity, influencing factors and available options. This is done better by conducting an action research.
Once a realistic state has been established through the change process, refreezing have to be done to stabilize all healthcare workers with the new conditions. New behaviors adopted from the change process have to be congruent with the environment and all personality behaviors (Fritzenschaft, 2014). Therefore, change has to be initiated as a group activity to ensure all group values and norms accommodate new personal behaviors (Bibby et al., 2012). The process of refreezing ensures that workers do not regress to old behaviors. This planned change theory emphasizes an understanding of how social groups are formed, motivated and maintained.
This is among the most useful emergent change models that consist of a complex interaction of both internal and external organizational processes. Change management in this model involves unfolding a series of actions and circumstances from a moving context and unanticipated consequences(Hinings, Greenwood, Reay, & Suddaby, 2004). The theory suggests that change occurs through an interplay of five major factors which include interest, situational constraints, dependence power, interpretive schemes, and organizational capacity. Each of the factors is subjected to change and leaders must recognise all and take the appropriate responses to each(Cantat et al., 2013). The situational constraints include the institution broader industry, the nature of service and processes involve and side-related factors that might induce necessities for change or enhance the successfulness of the organizational change. Interpretive schemes are values, beliefs, and ideas that underpin the operation of a given institution. Interest factors represent the motivation and orientations of the members of an organization that enhance and maintain their departmental claims(Fritzenschaft, 2014). This theory represents organizational political system where leaders exercise power to maintain orders in an organization.
The dependencies of power involve the relation of power use and organisation capability. These power relations determine who in an organization has the ability to influence decisions for better change(Fritzenschaft, 2014). Power can be spread across the organization and give other people opportunity and autonomy to make their own decisions where applicable(Hinings et al., 2004). For instance, a nurse has the power to report adverse effects in a ward without necessarily involving other or waiting to be told to report(Fritzenschaft, 2014). Lastly, the ability of an organization depends on leadership and management skills the leaders have. This is influenced by excitement over a change and commitment of the managers to influence it. This theory suggests that, in order for an organization to change its culture toward the positive direction, leaders must understand the constraints presented and evaluate them in terms of organizational context.
Lucas organizational Model for Transformational Change in Healthcare System suggests that a stable organization have for basic components that determine how the organization reported. The first component includes organization mission, strategies, and vision that set priorities and direction of the organization(Fritzenschaft, 2014). The second component involves the healthcare organization culture which determines the attitudes, norms, and values of the individuals. The other one is the operational processes and functions that determine how patients are taken care of and finally is the infrastructure which includes all human resources, fiscal services, technology, and facility management. A positive change in any of the component is what contributes to change in health care system(Fritzenschaft, 2014). In order to facilitate change, five essential elements must be considered. These include leadership commitment to quality, impetus to change, establishment of initiatives that involve all stakeholders, alignment to achieve consistency of broader goals and integration of older traditional behaviors with new ones. The impetus to transform involves the internal and external pressures that make the organization to change. Leadership commitments to quality refers to acknowledgement of mangers to the necessity for a change since they are highly involved in promoting a change (Fritzenschaft, 2014). Improvements initiatives are strategies that sustain, undertake and have potential for improvements. They bring an excellent opportunity for staff engagement and incorporates all insights necessary for the change process. In addition, the initiatives along with staff may give the management some insights of the resources and time that is required to enforce and implement the new changes. lastly, the integration across the hospital is necessary to break down boundaries between personal components and hospital’s functions and processes.
Conclusion:
The phrase presented shows that nurses at Djerriwah had a poor reporting culture of incidents as they happen in the wards. This is due to poor leadership and managerial problems. Change management is always applied when the necessity for a change arises. In such circumstances the principles of change management and change models are always used to help the leaders and managers execute the changes while making all stakeholders feel contented.There are various change management principles that can be used which include leading with the culture and involve every player, starting at the top, considering emotional impact of the changes, Looking for formal and informal solutions and analyzing the problem for a better change. In terms of analysis, there are various tools that are involved. This includes the SWOT analysis and TQM tools. SWOT analysis enables the organization to check both internal and external problems and execute the most appropriate intervention. TQM is a comprehensive way of delivering quality management practices. Other than the principles of management, there are some theories that have been used by many leaders and managers in hospitals to planned and apply cultural and managerial changes. These include the 3-step model, field theory, Henning and Greenwood’s model of change dynamics and Lucas’ Organisational Model for Transformational Change in Healthcare Systems.
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