Involving doctors in improvement work can be……difficult.
Professor Michael West, an organisational psychologist, touched on this at a presentation at the 2013 Faculty of Medical Leadership and Management conference. West has worked with colleagues on an enormous survey of culture and behaviour in the National Health Service in England. The full text of a published summary paper in BMJ Quality and Safety is available at this link.
The report is worth reading. Several aspects touch on quality, and engagement in quality improvement. In improvement projects, it is common to encounter doctors who complain:
- I don’t have time for this – I’m too busy doing my day job
- Improvement isn’t part of my role
- This is all just another management fad
- Quality improvement has been about box ticking – no one cares about actual improvements, as long as it looks as if we’re doing something
- No one will support us to make changes in any case
The BMJ Quality and Safety Report confirms that these are understandable concerns. According to the paper (page 7),
‘Staff at the sharp end were very often aware of
systems problems but felt powerless to bring about
change. Changes within organisations, uncertainty
about priorities, poor systems, heavy workloads and
staff shortages were all blamed for staff feeling they
lacked support, further reducing their motivation and
morale. Given that many systems required significant
improvement, it was disappointing that we found a
clear trend of decreasing levels of board innovation,
especially in relation to quality and safety.’
Despite this, some organisations did work well, and delivered what the authors described as ‘bright spots’ of good quality care. Several speakers at the Faculty of Medical Leadership and Management conference talked of the importance of aligning policy, making goals clear, and working to produce agreement between clinicians and managers on problems, priorities and actions.
The authors of the BMJ Quality and Safety paper make the responsibilities at all levels of the organisation clear. People delivering care can fix some problems themselves, but organisational culture is important, and is affected by Boards, and by senior managers. Culture will affect whether staff feel they can engage in the first place, and whether they will be supported to make changes.
So how does this relate to doctors? Well, many will have experienced previous projects that did not result in change. In some cases, projects will have been designed with unrealistic expectations of the scale of possible improvements, leading to disappointment. In others, improvements will have been designed assuming that new resource is available, which is rarely the case in the current financial climate. In still others, there will have been no real structures to support change, and the work will have run in to interdepartmental disagreements, old rivalries or plain unwillingness to change.
These past experiences can contribute to cynicism and hopelessness. Overcoming these, and re-engaging doctors, depends on focusing on the reasons people came in to medicine in the first place. Generally, doctors care about their patients and want to make things better for them. When improvement projects are focused on improvements in care quality, and have aims that demonstrably relate to better patient care, then we have a much better chance of obtaining active involvement. The BMJ Quality and Safety Report strongly suggests that, in turn, this has the best chance of working when the organisation is clear on its aims, can demonstrate that it cares about service quality, and aligns its organisational resource with improvement activity.
Will all doctors then come on board with improvement work? Probably not – but many will, with others following on once they see evidence of benefit. Clarity, engagement and persistence seem to be key.
Photo by Michael Connors http://www.mconnors.com/