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Governance and management in healthcare
- 1. Healthcare Management & Governance in Africa Richard Jones Chief Director, Department of Health Northern Cape, South Africa Healthcare Management Conference - September 2010 1
- 2. “The exercise of political authority and the use of institutional resources to manage society’s problems and affairs” (The World Bank 1991) “The effective management of social and economic resources in a manner that is open, transparent, accountable and equitable”(Bilney, G. 1994) What is Governance? 2
- 3. “An internal system encompassing policies, processes and people, which serves the needs of shareholders and other stakeholders, by directing and controlling management activities with good business savvy, objectivity, accountability and integrity.”(Gabrielle O'Donovan) Corporate governance 3
- 4. “A framework through which health care organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.”(G Scally and L M Donaldson, 1998) Clinical governance 4
- 6. “Systems, processes and behaviours by which health care organisations lead, direct and control their functions in order to achieve organisational objectives, safety and quality of service and in which they relate to patients and carers, the wider community and partner organisations”(M. Deighan and J. Bullivant 2004) Integrated governance 6
- 7. Organisation's clarity of purpose Strategic annual business cycle Integrated assurance systems Decision-taking using intelligent information Streamlined committee structure Strengthened audit committee Effective top management support roles Top management’s fitness for purpose Top management etiquette Corporacy – consistency of approach Integrated Governance:10 Improvement Activities 7
- 8. Clinical Governance: Key Components 8
- 9. Use tried & tested strategies Standards Risk management Measureable & time-bound objectives Process mapping & redesign Model for Improvement/PDSA Lean Balanced scorecard Leadership development 9
- 10. Policies and strategies covering: Quality Assurance Infection Control Complaints Management Etc Internationally many countries have introduced standards as a means of establishing minimum quality required across a health care system Quality improvement 10
- 11. The basis for providing quality care Expected level of performance Anticipated best practice in a given context South Africa: “National Standards for Health Establishments” Independent watchdog Standards 11
- 12. South Africa’s National Standards are grouped into 7 domains Patient rights 2. Patient Safety, clinical governance & care 3. Clinical support services. 4. Public health 5. Leadership & corporate governance 6. Operational management 7. Facilities & infrastructure 12
- 13. Example from Patient Safety 13
- 14. Neither standards nor monitoring of performance are ends in themselves. The key test is whether they are leading to sustained improvements in the quality of patient care. The aim must be for clinical governance to have the same profile and "bite" as financial governance. Not an end in themselves 14
- 15. The risk associated with each Standard is assessed by establishing: The likelihood of the risk in terms of its expected frequency of occurrence The impact of the risk on the patients, processes, finances, staff or reputation of a health establishment Tackle extreme & high risks first 15
- 16. Risk managementLikelihood versus Impact Likelihood Impact Insignificant Minor Moderate Major Catastrophic Rare Unlikely Possible Likely Certain 16
- 17. Risk Matrix 17
- 18. Objectives & Performance Management Specific Measureable Achievable Relevant Time-bound 18
- 19. In truly SMART objectives, two characteristics far outweigh the others:Measurable and Time-bound You will know that you have achieved your objective because there will be measurable evidence that it is reached within a specified timescale. A Truly SMART Objective 19
- 20. Measurable & Time-bound 20
- 21. Process Mapping & Redesign http://www.institute.nhs.uk/images/documents/ILG/general/1_2PM_Nov05.pdf 21
- 22. Model for Improvement Ask 3 questions… Set aims Establish measures Select changes Then… Test changes using PDSA cycle www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/ 22
- 23. FORMING THE TEAM Including the right people on a process improvement team is critical to a successful improvement effort Teams vary in size and composition Each organisation builds teams to suit its needs 23
- 24. SETTING THE AIM Improvement requires setting aims The aim should be time-specific and measurable The aim should define the specific population of patients that will be affected. 24
- 25. ESTABLISHING MEASURES Measurement is a critical part of testing and implementing changes Measures tell a team whether the changes they are making actually lead to improvement Measurement for improvement should not be confused with measurement for research 25
- 26. SELECTING CHANGES All improvement requires making changes, but not all changes result in improvement Organisations therefore must identify the changes that are most likely to result in improvement 26
- 27. The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change It is a scientific method for action-oriented learning Step 1: Plan Step 2: Do Step 3: Study Step 4: Act TESTING CHANGES with PDSA 27
- 28. Test a change on a small scale 28
- 29. Changes to Focus On 29
- 30. Lean:Core principles in healthcare www.leanuk.org/downloads/health/lean_thinking_for_the_nhs.pdf www.nhsconfed.org/Publications/Documents/Lean%20thinking%20for%20the%20NHS.pdf 30
- 31. “The balanced scorecard translates an organisation’s mission and strategy into a comprehensive set of performance measures that provide the framework for a strategic measurement and management system. The balanced scorecard retains an emphasis on achieving financial objectives, but also includes the performance drivers of those financial objectives. The scorecard measures organisational performance across four balanced perspectives: financial, customers, internal business processes and learning and growth.” (Kaplan & Norton) Balanced Scorecard 31
- 34. I would never require a follower to do something that I wouldn't do myself. My followers would say that they know what I stand for. Inspiring others has always come easy to me. My followers have told me that my enthusiasm and positive energy are infectious. My followers would say that I am very attentive to their needs and concerns. Even though I could easily do a task myself, I delegate it to expand my followers' skills. Team creativity and innovation are the keys to success. I encourage my followers to question their most basic way of thinking. (Items 1 & 2 = II; 3 & 4 = IM; 5 & 6 = IC; 7 & 8 = IS) Test your own transformational leadership qualities 34
- 35. Financial governance Corporate governance Clinical governance Human resource governance Research governance Environmental governance Integrated Governance Health & Safety Patient safety Safety culture Organisational structure Management structure Committee structures Adverse events reporting What is Governance? Accountability Audit: Clinical, Financial, Non-financial Morbidity & mortality Training Development, CPD Complaints Risk management, Risk register Quality assurance Quality improvement Monitoring & evaluation Statement of internal control Infection prevention & control Leadership 35
- 36. In Conclusion 36
- 37. Leadership and management – it comes from the top Systems and process that are known and understood Defined management structures, reporting lines, individual accountability and committees Goals and objectives and a performance management framework. Good governance requires... (1) 37
- 38. Information: on resources, outcomes, value for money. Comparative information is very helpful: between different parts of the organisation & between organisations. A culture of reporting and learning – learn from complaints, from adverse events. Patient and community involvement. Good governance requires... (2) 38
- 39. Process mapping and redesign, Lean Benchmarking Standards Regulation, inspection and audit Leadership development Patient participation forums Complaints procedures Adverse event reporting procedures Risk management procedures Performance management frameworks Checklists Use tried and tested strategies 39
- 40. Bringing everyone up to best practice Doing more with less Meeting increasing expectations and demands from public and government Providing what is now possible at an affordable price Ageing populations and the burden of disease Key challenges... 40
- 41. Thank you and have an enjoyable two days 41
Hinweis der Redaktion
- Good morning colleagues.In this opening presentation I shall explain what we mean by Governance in healthcare,Provide you with an overview of some tried and tested strategies to improve healthcare management,And, indicate some of the key challenges facing us in healthcare service delivery
- The term “Governance” is usually applied to governments. – Here are two definitions:“The exercise of political authority and the use of institutional resources to manage society’s problems and affairs” “The effective management of social and economic resources in a manner that is open, transparent, accountable and equitable”Let is spend a couple of minutes trying to understand what we each mean or understand by Governance in relation to our organisations.What I’d like you to do is to team up with the person next to you and discuss what subject areas you think would be covered by the term GovernanceJot down as many as you can(about 1-2 minutes)
- Corporate Governance:If you ask any ten business leaders what `corporate governance' is, they are likely to give ten different answers.This is one of the better definitions...“An internal system encompassing policies, processes and people, which serves the needs of shareholders and other stakeholders, by directing and controlling management activities with good business savvy, objectivity, accountability and integrity.”
- The concept Clinical Governance has some parallels with the more widely known Corporate Governance, in that it addresses those structures, systems and processes that assure quality, accountability and proper management of service delivery. However, clinical governance applies only to those aspects that relate to the delivery of care to patients; it is not concerned with the other business processes of the organisation. Here is perhaps the earliest and best formal definition of Clinical Governance published in 1998 :“A framework through which health care organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.”This definition embodies 3 key attributes: Recognisably high standards of care, Transparent responsibility and accountability for those standards, and Aconstant dynamic of improvement.Just for fun, watch how many times the word Improvement occurs in this presentation – it is critical to good governance in healthcare.
- More recently the concept of “Integrated Governance" has emerged to refer jointly to the corporate governance, staff governance and clinical governance duties of healthcare organisations. Staff governance is the system of accountability for the fair and effective management of all staff, including recruitment, training and well-being. You will be touching of staff wellbeing in the workshop later today.Corporate governanceis, as we have said, the internal accountability systems.And Clinical governance is about Improving the quality of patient services as the main business of healthcare organisations.
- Here is a definition of Integrated Governance for healthcare organisations:It is the “systems, processes and behaviours by which health care organisations lead, direct and control their functions in order to achieve organisational objectives, safety and quality of service and in which they relate to patients and carers, the wider community and partner organisations”
- Integrated Governance consists of a series of 10 improvement activities which are designed to rationalise and sharpen the way healthcare organisations are run. These improvement activities are:Clarity of purpose An Annual business cycle Integrated assurance systemsUse of Management informationFunctional committee structuresA Strong audit functionEffective top management team, which isFit for purpose, and which demonstrates anEtiquette of mutual trust, respect and honesty, andCorporacy
- Clinical governance applies to all treatments and services. The three most recognisable components of clinical governance are:Clinical effectiveness: How do we know we are doing the right things? What evidence do we have for what we do? It includes activities such as clinical audit & service redesign 2. Risk management:How can we minimise the chances of things going wrong?How do we learn from adverse events and near-misses? It includes activities such as risk assessment & reporting systems3. Patient focus:What is the patient experience of this service? Is the service safe and effective?It includes all forms of public and patient involvementAn awareness of local and national influences can help you understand how to use clinical governance systems and structures to make improvement happen in your organisation.
- The simplest and most obvious way to improve Governance andhealthcare management in your organisation is to usetried and tested strategiesI’m going to introduce you to one or two of these...
- In our definition of Clinical Governance we said that it was about: “continually improving the quality of services...”Many countries in Africa will have a number of Quality-related policies and strategies covering such topics as Quality Assurance, Infection Control, Complaints Management, risk management and the like.The definition of Clinical Governance went on to say: “continually improving the quality of services...... and safeguarding high Standardsof care...”Again, many countries have introduced Standards as a means of establishing expected minimum quality required across a health care system
- So, Whatis a Standard? In essence a Standard is a statement of an expected level of performanceStandards form the basis for providing quality care, as they set out the anticipated best practice in a given contextIn 2009 the South African Government announced that an independent health watchdog will be introduced to ensure clinics and hospitals adhere to a new set of “National Standards for Health Establishments”This will apply across the private and public sector, and is seenas a critical step in the introduction of the National Health Insuranceor NHI to start being rolled out from 2012You first session tomorrow afternoon is on the NHI.
- The South African National Standards are structured into seven domains which reflect the most critical cross-cutting areas of high risk in relation to quality & safety. 1. Patient Rights specifies responsibilities of health facilities in ensuring that the rights of patients are respected and upheld, as seen from the patient's perspective2. Patient Safetycovers management and processes of effective quality clinical care and ethical practice, the reduction unintended harm to health care users or patients. This includes the minimisation of healthcare associated infections, which will be discussed at your workshop on Thursday morning.3. Clinical Support Services includes management and support to clinical care through the timely and efficient provision of medicines, diagnostics and other clinical support services, and with suitable healthcare technology.4. Public Health covers active collaboration between healthcare facilities,other relevant organisations,and with local communities to ensure an integrated and effective health care system5. Leadership & Governance covers strategic direction provided by senior management, through proactive leadership, planning and risk management, supported by the structures of corporate governance and oversight6. Operational Management covers responsibilities required on a day-to-day basis to support and ensure the delivery of safe and effective patient care, such as HR, finance, supply chain &information.7. And finally, Facilities & Infrastructure covers the requirement for clean, safe and secure physical infrastructure and non-clinical support services that are functional and well-managed
- This is an example from the Patient Safety domain.One of the Standards is:“Universal precautions are applied to prevent health care associated infections.”In the hand washing criteria, one of the measures states:“A programme indicates that a hand washing drive or campaign is held at least annually in the establishment”
- Standards can be a valuable tool in developing and implementing population-based health care.Caring for populations and for individuals is complementary not contradictory.Starting with the population, once a clinical care guideline or standard is established for a certain condition, the health care worker can apply that guideline or standard to all patients who present with the same condition.Since the guideline or standard is determined and monitored by assessing its effectiveness on a population of similar patients, the health care worker should have confidence that it does indeed reflect best practice.That is precisely how Standards were used to improve population-based health care in the UK. Under the generic heading of National Service Frameworks or NSFs, the NHS set clear quality requirementsfor care, based on the best available evidence of what treatments and services work most effectively for patients.NSFs have been set for a range of disease conditions and patient groups, including Cancer, Children, Coronary Heart Disease, Diabetes, COPD, long-term chronic conditions, Mental Health, Older People, Renal services, and Stroke
- When you monitor your organisation’s performance against agreed Standards, some areas and activities will emerge as high risk, and others as low risk, with the full spectrum in between.But how can you assess, objectively, what is high risk and what is low risk,and which should you tackle first?
- Risk ManagementIn order to score or rank a risk you need to assess theLikelihood of the event occurring, and theImpact it will have if it does occur.The likelihood of the something occurring is scored on a scale of 1-5, from Rare to Certain. Rare could be something like, every one or two years the emergency generator fails to start up.Certain could be something like every morning at 7am the mains electricity supply goes off for 30 minutes. The Impact if it did occur is then scored, againon a scale of 1-5, from Insignificant to CatastrophicInsignificant could be something like the laundry washing machine fails to start on time.Catastrophic could be something like the ventilator machine in intensive care stops working leading to potential loss of life.
- Once you have the Likelihood score and the Impact score, you can apply it to the Risk Matrix.This methodology prioritises healthcare risks according to four levels of risk:Extreme riskHigh riskMedium riskLow riskFor example, If the Likelihood is almost certain, a score of 5, and the Impact is Catastrophic, a score of 5, the Risk is Extreme with a score of 25 (from 5 x 5)Or,If the Likelihood is unlikely, a score of 2, and the Impact is minor, a score of 2, the Risk is Low with a score of 4 (from 2 x 2)You should tackle Extreme and High risks first!
- Objectives & Performance ManagementLets have a brief look at setting objectives. We have all heard the acronym SMART – just a couple of slides on this.In all aspects of good governance it is critical to have goals, aims or objectives – to know what you are trying to achieve, and to then manage your performance against those goals, aims or objectives.SMART objectives are as relevant to personal objectives as they are to organisational goals.S is for Specific: This is about the detail. The objective is concrete, focused and defined. M is for Measurable: This means that you will know when you have achieved your objective because there is evidence.A is for Achievable: This is about keepingyou motivated. If the objective is too far in the future, you will find it difficult to keep motivated. R is for Realistic: This is about resources:human, equipment, funding, and opportunity.T is for Time-bound: This means setting a deadline for achievement of the objective.Deadlines create the necessary urgency for action.
- Which charatersitics in a SMART objective are the most critical?Its unlikely that anyone will set an objective that is not specific, is not achievable and is not relevant.But you go back to your organisation, or even to you own personal objectives, and see how many times they are not measurable and their is no timeframe for delivery! Recall our definition of Clinical Governance... “health care organisations are accountable for continually improving...”Measurable and Time-bound are THE most important characteristics when setting objectives.It is those two characteristics that hold you and the organisation to account.
- Here are a few examples of poor objectives and truly SMART objectives.A poor objective might read:“Reduce follow-up outpatient appointments”But a truly SMART objective will read:“” Reduce follow-up outpatient rate from X% to Y% by qtr3.”I will leave you to review the remaining examples in your own time.
- Process Mapping & RedesignA process has the following characteristics:• A starting point and an end point. This is the scope• A purpose or aim for the outcome• Rules governing the standard or quality of inputs• It is usually linked to other processes• It can be simple and short, or complex and longPatient processes have often evolved over years as changes have been grafted on to established working practices. There can be many different layers in addition to the patient journey. These include communication processes and administration processes, and often cross departments. It’s no wonder that patient processes are not always as effective as they should be.Process mapping and redesign is the way to revisit and streamline patient pathways and other processes. The web reference I have given should allow you to download a useful handbook on this topic.
- lean production was developed by the Toyota car company and the term ‘Lean” was adopted in the 1990s. Lean has since been developed and adapted to meet the needs of a wide range of private and public sector industries, including health care. You will be having a session on Lean first thing tomorrow morning.The whole focus of Lean is on the elimination of waste whilst maintaining quality.Under Lean, value is defined solely from the customer’s perspective – in our case, the patient. Anything that helps treat the patient is value-adding. Everything else is seen as waste.Delivering services in line with demand means all work, materials and information should be pulled towards the task as and when needed. Not before. Not after. All time waiting or queuing is seen as waste.Pull leads to flow, where each patient is worked with, one at a time, and passed on for the next step of the process without any delay. A preoccupation of Lean is to identify wasteful blockages and obstacles and remove them.As value is specified, value streams are identified, wasted steps are removed, and flow and pull are introduced. Then begin the process again and continue it until a state is reached in which Perfection is created and all waste has been removed.
- The balanced scorecard approach can be quite an undertaking for any organisation.However the benefits of aligning all activities, individual and departmental, to the overall strategy and goals of the organisation, as well as balancing performance across four balanced perspectives: financial, customers, internal business processes and learning & growth, can have significant rewards for strategic management.
- Here is the Balanced Scorecard approach in more detail.The balanced scorecard retains traditional financial measures,But adds three more performance domainsCustomers - Patients and the community in our case – “How should we appear to our customers?”Learning and growth – “How will we sustain our ability to change and improve?”And Internal processes – “What internal processes must we excel at?”The balance brought to performance management by using all four domains improves overall strategic management
- Perhaps the most popular theory of leadership today is Transformational LeadershipIt originally focused on leaders who "transform" groups or organisationsThere are Four components of Transformational Leadership, most people will excel or be stromger in one or two of these:Idealized Influence – someone who walks the talk.Inspirational Motivation – someone who inspires & motivatesIndividualized Consideration - someone who shows genuine concern for othersIntellectual Stimulation – someone who is a innovative and creative.Evidence shows us that groups led by transformational leaders have higher levels of performance and satisfaction than groups led by other types of leaders. Why? Because transformational leaders hold positive expectations for followers, believing that they can do their best. As a result, they inspire, empower, and stimulate followers to exceed normal levels of performance.
- You can use this slide to test your own transformational leadership qualities during the coffee break.(Pause)
- OK, lest go back to the beginning.When we started I asked you to jot down your own lists of what Governance means to you.Here’s my listHow many of these did you include? What different ones did you come up with?(Pause)
- In conclusion,Good governance requires Leadership and management – it comes from the topIt requires Systems and process that are known and understoodIt requires Defined management structures, reporting lines, individual accountability and committees It requires Goals and objectives and a performance management framework.
- Good governance requires Information on resources, on outcomes, on value for money. It requires Comparative information between different parts of the organisation & between organisations.It requires A culture of reporting and learning – learn from complaints, from adverse events. and it requires Patient and community involvement.
- When improving Governance and healthcare management in your organisation,Use tried and tested strategies and tools.We explored a few of these...Process mapping and redesignLean to eliminate wasteStandard settingRisk managementBalance scorecardand the Model for Improvement
- The key challenges we face in healthcare are the same ones you will face when to get back to your office, your hospital or your clinic.These challenges include:Spreading best practice so as to bring everyone up to the best.Doing more with less – there are always constraints on money, perhaps you will also have less staff.Meeting increasing expectations and demands – as users of healthcare we always expect more, so we can understand this to some extent.Reducing costs – healthcare inflation is notoriously higher than retail price inflationAnd of course, the pressures brought about by HIV, TB, Malaria, chronic illness, diseases of old age, trauma, etc, etc, etc.
- I hope you will Remember one phrase from this presentation:All Improvement Require ChangeThank you and enjoy your conference.