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There is evidence that patient safety has not improved commensurate with the global attention and resources dedicated to achieving it. The authors explored the perspectives of hospital leaders on the challenges of leading safe care.

This paper reports the findings of a three-year longitudinal study of eight Australian hospitals. A representative sample of hospital leaders, comprising board members, senior and middle managers and clinical leaders, participated in focus groups twice a year from 2015 to 2017.

Although the participating hospitals had safety I systems, the leaders consistently reported that they relied predominantly on their competent well-meaning staff to ensure patient safety, more of a safety II perspective. This trust was based on perceptions of the patient safety actions of staff, rather than actual knowledge about staff abilities or behaviours. The findings of this study suggest this hegemonic relational trust was a defence mechanism for leaders in complex adaptive systems (CASs) unable to influence care delivery at the front line and explores potential contributing factors to these perceptions.

In CASs, leaders have limited control over the bedside care processes and so have little alternative but to trust in “good staff providing good care” as a strategy for safe care. However, trust, coupled with a predominantly safety 1 approach is not achieving harm reduction. The findings of the study suggest that the beliefs the leaders held about the role their staff play in assuring safe care contribute to the lack of progress in patient safety. The authors recommend three evidence-based leadership activities to transition to the proactive safety II approach to pursuing safe care.

This is the first longitudinal study to provide the perspectives of leaders on the provision of quality and safety in their hospitals. A large sample of board members, managers and clinical leaders provides extensive data on their perspectives on quality and safety.

Hospitals have used process redesign to increase the efficiency of the emergency department (ED) to cope with increasing demand. While there are published studies suggesting a positive outcome, recent reviews have reported that it is difficult to conclude that these approaches are effective as a result of substandard research methodology. The purpose of this paper is to explore the perceptions of hospital staff on the impact of a process redesign initiative on quality of care.

A retrospective qualitative case study examining a Lean Six Sigma (LSS) initiative in a large metropolitan hospital from 2009 to 2010. Non-probability sampling identified interview subjects who, through their participation in the redesign initiative, had a detailed understanding of the implementation and outcomes of the initiative. Between April 2012 and January 2013 26 in-depth semi-structured interviews were conducted and analysed with thematic content analysis.

There were four important findings. First, when asked to comment on the impact of the LSS implementation, without prompting the staff spoke of quality of care. Second, there was little agreement among the participants as to whether the project had been successful. Third, despite the recognition of the need for a coordinated effort across the hospital to improve ED access, the redesign process was not successful in reducing existing divides among clinicians and among managers and clinicians. Finally, staff expressed tension between production processes to move patients more quickly and their duty of care to their patients as individuals.

One of the first studies to explore the impact of process redesign through in-depth interviews with participating staff, this study adds further evidence that organisations implementing process redesign must ensure the supporting management practices are in place.

To investigate the association between implementation of clinical governance and patient safety.

A pre-post study was conducted in an Australian health service following the implementation of clinical governance systems (CGS) in the inpatient wards in 2016. Health service audit data from 2017 on CGS implementation and the rate of adverse patient safety events (PSE) for 2015 (pre-implementation) and 2017 (post-implementation), across 45 wards in six hospitals were collected. CGS examined compliance with 108 variables, based on the Australian National Safety and Quality Health Service standards. Patient safety was measured as PSE per 100 bed days. Data were analysed using odds ratios to explore the association between patient safety and CGS percentage compliance score.

There was no change in PSE between 2015 and 2017 (MD 0.04 events/100 bed days, 95% CI -0.11 to 0.21). There were higher odds that wards with a CGS score >90% reported reduced PSE, compared to wards with lower compliance. The domains of leadership and culture, risk management and clinical practice had the strongest association with the reduction in PSE.

Given that wards with a CGS score >90% showed increased odds of reduced PSE health service boards need to put in place strategies that engage frontline managers and staff to facilitate full implementation of clinical governance systems for patient safety.

The findings provide evidence that implementation of all facets of CGS in a large public health service is associated with improved patient safety.

The authors explored clinical staff perceptions of their interactions with middle management and their experiences of the uncongeniality of their working environment.

Semi-structured interviews of clinical staff from an Australian public health service's Emergency, Surgery and Psychiatry departments. Volunteer interview transcripts were inductively coded using a reflexive thematic content analysis.

Of 73 interviews, 66 participants discussed their interactions with management. Most clinicians considered their interactions with middle management to be negative based on a violation of their expectations of support in the workplace. Collectively, these interactions formed the basis of clinical staff perceptions of management's lack of capacity and fit for the needs of staff to perform their roles.

Strategies to improve management's fit with clinicians' needs may be beneficial for reducing uncongenial workplaces for healthcare staff and enhanced patient care.

This article is among the few papers that discuss interactions with management from the perspective of clinical staff in healthcare. How these perspectives inform the perception of workplace uncongeniality for clinicians contributes greater understanding of the factors contributing to adversarial relationships between clinicians and managers.

The purpose of this paper is to review the implementation of seven components of quality systems (QSs) linked with quality improvement in a sample of Australian hospitals.

The authors completed a systematic review to identify QS components associated with measureable quality improvement. Using mixed methods, the authors then reviewed the current state of these QS components in a sample of eight Australian hospitals.

The literature review identified seven essential QS components. Both the self-evaluation and focus group data suggested that none of the hospitals had all of these seven components in place, and that there were some implementation issues with those components that were in use. Although board and senior executives could point to a large number of quality and safety documents that they felt were supporting a vision and framework for safe, high-quality care, middle managers and clinical staff described the QSs as compliance driven and largely irrelevant to their daily pursuit of safe, high-quality care. The authors also found little specific training in quality improvement for staff, lack of useful data for clinicians on the quality of care they provide and confusion about how organisational QSs work.

This study provides a clearer picture of why QSs are not yet achieving the results that boards and executives want to achieve, and that patients require.

This is the first study to explore the implementation of QSs in hospitals in-depth from the perspective of hospital staff, linking the findings to the implementation of QS component identified in the literature.

Studies of high‐performing organisations have consistently reported a positive relationship between high performance work systems (HPWS) and performance outcomes. Although many of these studies have been conducted in manufacturing, similar findings of a positive correlation between aspects of HPWS and improved care delivery and patient outcomes have been reported in international health care studies. The purpose of this paper is to bring together the results from a series of studies conducted within Australian health care organisations. First, the authors seek to demonstrate the link found between high performance work systems and organisational performance, including the perceived quality of patient care. Second, the paper aims to show that the hospitals studied do not have the necessary aspects of HPWS in place and that there has been little consideration of HPWS in health system reform.

The paper draws on a series of correlation studies using survey data from hospitals in Australia, supplemented by qualitative data collection and analysis. To demonstrate the link between HPWS and perceived quality of care delivery the authors conducted regression analysis with tests of mediation and moderation to analyse survey responses of 201 nurses in a large regional Australian health service and explored HRM and HPWS in detail in three case study organisations. To achieve the second aim, the authors surveyed human resource and other senior managers in all Victorian health sector organisations and reviewed policy documents related to health system reform planned for Australia.

The findings suggest that there is a relationship between HPWS and the perceived quality of care that is mediated by human resource management (HRM) outcomes, such as psychological empowerment. It is also found that health care organisations in Australia generally do not have the necessary aspects of HPWS in place, creating a policy and practice gap. Although the chief executive officers of health service organisations reported high levels of strategic HRM, the human resource and other managers reported a distinct lack of HPWS from their perspectives. The authors discuss why health care organisations may have difficulty in achieving HPWS.

Leaders in health care organisations should focus on ensuring human resource management systems, structures and processes that support HPWS. Policy makers need to consider HPWS as a necessary component of health system reform. There is a strong need to reorient organisational human resource management policies and procedures in public health care organisations towards high performing work systems.

While there has been substantial discussion about the potential for clinical leadership in improving quality and safety in healthcare, there has been little robust study. The purpose of this paper is to present the results of a qualitative study with clinicians and clinician managers to gather opinions on the appropriate content of an educational initiative being planned to improve clinical leadership in quality and safety among medical, nursing and allied health professionals working in primary, community and secondary care.

In total, 28 clinicians and clinician managers throughout the state of Victoria, Australia, participated in focus groups to provide advice on the development of a clinical leadership program in quality and safety. An inductive, thematic analysis was completed to enable the themes to emerge from the data.

Overwhelmingly the participants conceptualised clinical leadership in relation to organisational factors. Only four individual factors, comprising emotional intelligence, resilience, self‐awareness and understanding of other clinical disciplines, were identified as being important for clinical leaders. Conversely seven organisational factors, comprising role clarity and accountability, security and sustainability for clinical leaders, selective recruitment into clinical leadership positions, teamwork and decentralised decision making, training, information sharing, and transformational leadership, were seen as essential, but the participants indicated they were rarely addressed. The human resource management literature includes these seven components, with contingent reward, reduced status distinctions and measurement of management practices, as the essential organisational underpinnings of high performance work systems.

The results of this study propose that clinical leadership is an organisational property, suggesting that capability frameworks and educational programs for clinical leadership need a broader organisation focus.

The paper makes clear that clinical leadership was not perceived to be about vesting leadership skills in individuals, but about ensuring health care organisations were equipped to conceptualise and support a model of distributive leadership.

This paper aims to explore the attitudes of managers and employees to high performance work practices (HPWS) in a medium sized rural Australian hospital.

The study consists of two stages. Stage one involved a qualitative investigation consisting of interviews and focus group sessions with senior, middle and line management at the hospital. Bowen and Ostroff's framework was used to examine how strategic HRM was understood, interpreted and operationalised across the management hierarchy. Stage one investigates the views of managers concerning the implementation of strategic HRM/ HPWS. Stage two consisted of a questionnaire administered to all hospital employees. The mediation effects of social identification on the relationship between high performance work systems and affective commitment and job satisfaction are examined. The purpose of stage two was to investigate the views and effects of SHRM/HPWS on employees. It should be noted that HPWS and strategic HRM are used inter‐changeably in this paper.

At the management level the importance of distinctiveness, consistency and consensus in the interpretation of strategic HRM/HPWS practices across the organization was discovered. Findings indicate that social identification mediates the relationship between HPWS and affective commitment and also mediates the relationship between HPWS and job satisfaction.

High performance work systems may play a crucial role facilitating social identification at the unit level. Such practices and management support is likely to provide benefits in terms of high performing committed employees.

The paper argues that team leaders and managers play a key role in building social identification within the team and that organizations need to understand this role and provide recognition, reward, education and support to their middle and lower managers.

The purpose of this paper is to evaluate the current evidence regarding the content of clinical supervision for nursing and allied health professionals.

The authors searched CINAHL, Medline, PsychINFO and Cochrane Database. Studies were included if the participants involved were nursing, medical or allied health practitioners, but not students, and if the studies contained discussion regarding the content of clinical supervision. Critical analysis of the articles was carried out by two independent researchers to ensure consistency and thematic analysis was applied.

Twenty included articles were in three main categories: cross‐sectional studies (n=9), including interview, survey and focus group methods of data collection; literature reviews (n=2); and nine published opinion pieces. Themes related to the content of clinical supervision that were identified were reflective practice; task oriented content; diversity of content; and stress management. The results indicated that current research into the content of clinical supervision for nursing and allied health practitioners is limited and of low quality and that further research is needed to determine what content in clinical supervision is associated with better quality and safety, particularly for health professions other than nursing and psychology.

This is the first review of the current evidence for what constitutes the most appropriate content of clinical supervision for health professionals. Clinical supervision is an important component of quality assurance and clinical governance frameworks and it is essential that health care organizations are assured that effective clinical supervision is in place.

The importance of managerial competencies in monitoring and improving the performance of organisational leaders and managers is well accepted. Different processes have been used to identify and develop competency frameworks or models for healthcare managers around the world to meet different contextual needs. The purpose of the paper is to introduce a validated process in management competency identification and development applied in Australia – a process leading to a management competency framework with associated behavioural items that can be used to measure core management competencies of health service managers.

The management competency framework development study incorporated both qualitative and quantitative methods, implemented in four stages, including job description analysis, focus group discussions and online surveys.

The study confirmed that the four-stage process could identify management competencies and the framework developed is considered reliable and valid for developing a management competency assessment tool that can measure management competence amongst managers in health organisations. In addition, supervisors of health service managers could use the framework to distinguish perceived superior and average performers among managers in health organisations.

Developing the core competencies of health service managers is important for management performance improvement and talent management. The six core management competencies identified can be used to guide the design professional development activities for health service managers.

The validated management competency identification and development process can be applied in other countries and different industrial contexts to identify core management competency requirements.