There is no steady state in healthcare. Organizations are either continuing their never-ending improvement journey or declining. Mark Rochon and Govind Adaikappan discuss what ‘excellence’ looks like in healthcare, and how a healthcare institution can maintain a state of excellence over the long term without slipping into a spiral of organizational decline.
Attaining and then sustaining excellence in healthcare is hard because it requires a subtle mix of numerous tangible and intangible elements, such as values and beliefs, everyday behaviours such as how teams work together, and hard edged measurement, structure and systems to review, improve and optimise performance.
Leaders in excellent healthcare organizations instil a culture of innovation, collaboration and continuous learning to improve the quality of care, value and patients’ experiences. There is a strong sense of team members feeling responsible to one another as they work together to promote reliability and secure high quality.
Declining organizations gradually lose their quality or value. Many of them don’t even know their performance is sliding. There are lots of important lessons from studying declining healthcare organizations. There are four key symptoms that healthcare organizations on the decline share:
Some of the symptoms, such as declining care quality and the health of human resources can be measured easily, while others such as organizational malaise are more challenging to quantify. All of them can be spotted if you are looking for them, but they can also be lost among volumes of other data and information.
As weaknesses emerge, leaders often fall into the trap of talking up the positive signals while downplaying and explaining away the warning signs. It is vital to identify and address these signs quickly, because the technological, regulatory and competitive changes which can destabilise organizations are happening with ever greater speed.
Decline can happen across an organization or in one ward or team. Often looking at organization wide performance averages mask issues within a specific area. Several factors can make it difficult to spot problems:
Relying on poorly designed reporting tools and analysis
Many organizations rely on reporting mechanisms such as scorecards to indicate where there is high performance or trouble. But this approach has its limitations.
Leaders need to recognise that numbers will not tell them everything. It is important to complement data with anecdotal evidence from patients and staff given their first hand experiences with the organizational processes and issues. Triangulating data and information from various sources to create a comprehensive picture of performance is important. So too is augmenting data with leader experiences and what patients, staff and other stakeholders are saying is also key. When data is in conflict with experience, intuition and and additional analysis should be undertaken before conclusions are drawn. Senior leaders need to walk the corridors of their organizations with purpose to understand what the delivery of care looks like and what barriers their staff face in delivering quality care.
Not being able to sense a genuine threat among all the other noise
Warning signs are often ambiguous, allowing managers to either ignore or discount the risk and take a wait-and-see attitude, or overreact. Richard Bohmer of the Harvard Business School says organizations may be unable to deal with ambiguous threats effectively if:
Serious patient safety errors or disasters such as a train or plane crashes rarely if ever result from a single failure, but a series of occurrences along the system. If every error, close call, deviation from accepted practice or adverse event is examined to understand the root cause there is far less risk of smaller events coming together to form a major failure.
While most data tends to be retrospective, organizations need more focus and systems which look forward. As organizations navigate more complex and fast changing environments, there is a need to spend more time looking out the windshield versus the rear-view mirror. This increasingly means building predictive tools and simulation models to investigate ‘what-if’ scenarios.
The investigation into the Mid-Staffordshire scandal1 exposed how the causes of its decline included tolerance of poor standards by the leadership, poor governance and a focus on the wrong priorities. This is consistent with KPMG’s experience working with organizations it has seen in decline. The primary causes are:
Ineffective governance in setting expectations and holding leaders to account
Ineffective governance is usually a key contributor to an organization’s inability to meet its strategic objectives or be in control how care is delivered. Organizations that are in control measure care outcomes methodically, understand the key drivers of these outcomes, understand how to make these outcomes best of class, and systematically prevent avoidable harm to patients.
Effective governance requires a critical tension between different levels of the organization, starting with the board to the chief executive then cascading throughout the organizational structures and processes. The board and leaders throughout the organization must feel comfortable in asking difficult questions and drilling down to understand the drivers of performance.
A lack of critical reflection on performance, leading to complacency
It is essential that healthcare organizations embrace critical reflection of their performance, to avoid being lulled into complacency based on current or past success. Complacency leads to decline.
Complacent organizations become unwilling to talk openly about failure and learn lessons about how to improve quality and reliability. While it is important to acknowledge what isn’t working, organizations need to spend as much if not more time discussing the issues and how they will be solved. A healthcare organization will never perform highly unless it creates an environment in which it is safe to report, discuss and resolve mistakes. To encourage an open culture, leaders need to admit their own mistakes, so that others believe it is safe to admit theirs.
How should organizations think about sustaining and building upon excellence? The key is to cultivate that spirit of continuous improvement – a belief that as an organization you are never finished that there is always space to improve and as a leader you need to create a culture where learning and calling out an error can be done in a safe environment.
Sustained excellence is underpinned by leadership which puts critical reflection of performance at the heart of the organization, encourages a relentless focus on continuous improvement and supports staff in making and sustaining that improvement. Excellence is certainly not maintained by simply layering on more measurement, governance and assurance.
Organizations that have an innate desire to seek perfection see providing care and improving it as inseparable parts of the day-to-day work of every member of the team.
Ten attributes for sustaining and improving organizational excellence
Mark Rochon is an inspiring leader and former as the Chief Executive Officer with a proven record of success in transforming healthcare organizations and systems. In a 25 year career he has led a number of complex change initiatives in a broad range of healthcare organizations while working within tight financial constraints. In addition to leading successful healthcare organizations he has been appointed by regulatory authorities to lead the turnaround of hospitals and led the largest healthcare system change process in Canada. He is now using this experience to help both public and private healthcare providers around the world to deliver better patient care with KPMG in Canada.
Govind Adaikappan is a Director at KPMG Healthcare based in Toronto. He has over 15 years of experience working in the healthcare sector with clinicians, administrators and executive teams to improve and optimize organizational performance. Through his work with providers, he has led transformations that have engaged frontline staff, built organizational capability for on-going operations improvement and embedded a relentless focus on sustainability helping organizations improve quality, safety and access while reducing cost in a sustainable manner. He has supported organizations accelerate their improvement journey in Canada and globally.
1 Francis, Robert. (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Executive summary. London: The Stationery Office.