Stifling enthusiasm

Citation

Jackson, S. (2003), "Stifling enthusiasm", International Journal of Health Care Quality Assurance, Vol. 16 No. 4. https://doi.org/10.1108/ijhcqa.2003.06216daa.001

Stifling enthusiasm

Stifling enthusiasm

A "can do" attitude has often been quoted as being one of the main ingredients for ensuring improvements in the quality of health care. However, in today's healthcare environments enthusiasm is put to the test when teams feel exhausted with the workload, exasperated with the bureaucracy and too under-resourced to make any significant changes. It is for these reasons that I was so disappointed when I observed an interaction that totally stifled the enthusiasm of individuals attending a workshop I was facilitating.

To explain, the workshop was focusing on applying the principles of the RADAR logic from the European Foundation for Quality Management Excellence Model. The team in question had already worked on applying the RADAR logic to all their other long-term objectives and were now making a start with clinical governance. Each work group (five in total) were tasked with identifying results areas for an aspect of clinical care within their area of practice. Bearing in mind that this team were no different to other health-care professionals in that they were excellent at putting new initiatives into place, but not as good at measuring the impact of those initiatives, it was quite clear that the task before them was challenging and radical, particularly as this team were asked to think about the clinical results affected by any changes they had or were intending to make in the way healthcare was provided. Furthermore, this team would be expected to continuously self-assess against those results areas, something that had not happened robustly in the past. An example would be designing or improving a care pathway with the intention of raising the level of customer (patient) satisfaction. Often teams move straight into making the changes in the pathway before obtaining a baseline assessment. When this occurs improvement teams have no way of knowing the difference (if any) their pathway changes incurred to the level of customer satisfaction.

Having successfully transmitted this concept and provided some practical support during the 40-minute group work, the first team began to feedback. The first presenter was a dietician who had expressed that some changes had taken place (without any baseline assessment) in the way that constipation in children was being managed. To be specific there had been an increase in the use of laxatives, which the dietician had some concerns about. Hence the dietician informed the whole group of what it would look like should the RADAR logic be applied to this area of practice:

• •

  Results. There would be two: the total use of laxatives, and the total cost of using those laxatives. Once known targets would be set for achieving reductions in both results areas.

• •

  Approach. The children would be encouraged to adopt a high fibre diet.

• •

  Deployment. When each child attended the outpatient clinic they (or their parents) would be informed of the types of food that were high in fibre. The high fibre diet would be made to sound exciting and the benefits of this approach rather than using laxatives explained.

• •

  Assessment. At each clinic visit the take-up of a high fibre diet would be assessed along with the amount of laxatives used.

• •

  Review. Corrective action (if required) would be taken to change the approach, improve deployment and/or ensure a reduction in the use and cost of laxatives.

The second team then fed back with a suggestion for looking at the number of children who had attained the goals they had been set within the timescales identified. Examples would be speech and language goals and/or level of independence goals. Again this was an area of practice whereby the inputs (speech and language therapy and/or physiotherapy) were numerous but the outcomes of those inputs not measured. Given that both groups had grasped the concept, and were keen to make a start towards working in this way, I was really pleased with their progress.

The audience to which the teams fed back consisted of approximately 24 colleagues including the director and the assistant director of the department. Once the second person had completed their feedback, the director stood up to announce that the work groups had not chosen areas that were of corporate significance (record keeping and referral patterns) and so the next steps would be that the top team would go away and determine the results areas for the department. Once done these results areas would be shared with the whole team and the assessment and review process embedded.

What I then observed was a total eradication of enthusiasm for this new and more rigorous way of working. As a consequence I began to question, in my own mind, whether the director had acted strategically or operationally. To explain, I understand working strategically as influencing the culture of an organisation. This being the case it would be irrelevant which area of practice was chosen initially for applying the RADAR logic to because ultimately it would influence the way clinicians think and work in the future. Hence by suggesting that the RADAR logic should be applied to specific areas of practice in the first instance implied that the director was thinking and acting operationally. What was even worse was that the enthusiasm of the whole group was stifled by the suggestion that the top team determine the exact results areas before any further progress could be made.

As a consequence no one left the workshop "fired up" to put their new thinking into practice. Furthermore, I was left wondering how quickly the top team would identify the relevant corporate clinical governance results and whether they would be quick enough to capitalise on any momentum gained from the workshop. Having observed this type of scenario before, I am concerned that securing further improvements in health care will now be even harder for this team because the leaders want total control over the detail. For me a preferred way forward would have been to welcome the areas chosen by the clinicians and give encouragement for them to make a start, in addition to determining the relevant corporate clinical governance results. This two-pronged approach would then have enabled the clinicians to grasp the concept by applying it to an area of practice they understood and could relate to before they embarked upon other areas determined by the top team. However, the opportunity was lost and I fear may not be recaptured. I hope I am wrong.

I welcome your thoughts on my observations and views and would be really pleased to receive a piece of work that contradicts or supports my interpretations of the events described above. I would also be happy to receive suggestions on how I may have retrieved the situation, something that I am currently reflecting on for the next time I am faced with a similar situation.

Sue Jackson