Discussion paper:
A framework for quality improvement
and patient safety capability
and leadership-building for
the New Zealand health system
July 2015
Contents
Executive summary
Introduction
Background
Defining quality and safety
Benefits of developing health quality and safety capability and leadership
Developing a New Zealand capability framework
The framework
1Capabilities of consumers
2Capabilities of everyone engaged in the health and disability workforce
3Capabilities of operational, clinical and team leaders, and other change agents
4Capabilities of senior organisational leaders
5Capabilities of quality and safety experts
6Capabilities of governance/boards
Executive summary
The Health Quality Safety Commission (the Commission) has a national mandate to develop and support capability and leadership in quality improvement and patient safety to ensure that the delivery of health care is consistent with its overarching framework, the Triple Aim.Building capability is identified as one of the Commission’s strategic priorities to assist the sector to effect change.
This document describes a high level framework to guide the development of quality and safety capability across all levels in the health care sector, including consumers. It has been developed at the request of the sector and informed by an expert advisory group.
The framework is intended to provide the basis for a common understanding of the expected knowledge, skills and underpinning values required to achieve better quality and safer patient centred health care.
Articulating this for each of the broad roles within health care provides a benchmark against which organisations and individuals can gauge their current knowledge and identify future requirements for learning and development.It also serves to clarify and deepen understanding of the responsibilities associated with each role to enable more effective and consistent delivery of quality and safety expectations for patient care.
Currently, the quality improvement capability of the health sector in New Zealand is reflected in uneven system performance, with a few centres of excellence and islands of good practice as well as an over-reliance on the commitment and expertise of individuals to drive the quality and safety agenda. There is a compliance orientation towards quality and a lack of confidence in the sustainability of gains.
The serious failures in the Mid-Staffordshire National Health Services Foundation Trust demonstrate the consequences of not having quality and safety as a central consideration within the systems of their organisation. One of Berwick’s nine groups of recommendations in response focused on education, training and capacity building(National Advisory Group on the Safety of Patients in England 2013)which has also been recognised by many other international health systems.
To date the Commission’s focus on building capacity has been on quality improvement advisor scholarships, sponsored course attendances, supporting visits by international speakers, and building capability and leadership as part of all campaigns and collaboratives. The Commission believes there now needs to be a broader and more integrated approach to address the complex change challenge involved in achieving and enhancing system wide quality and safety.
Such a strategy needs to include addressing existing workforce needs, sustainably building the quality improvement capability of the future workforce; developing specialist roles in quality improvement science; supporting consumer participation; ensuring decision-making based on data and evidence; and supporting boards to provide leadership that encourages a quality improvement and patient safety focus throughout the sector.
This capability and leadership framework will provide the basis for a common understanding of the knowledge, skills and underpinning values required to achieve better quality and safer patient centred health care, and providesoverall direction to the health sector. For each of the groups identified in the framework, we define who typically belongs within these broad categories, and outline the quality and safety knowledge and actions that could reasonably be expected within the roles in each group.
The framework also recognises that most health care is delivered within the context of teams and within services. Quality and safety capability and leadership within and between multidisciplinary teams and networks is required for the seamless and safe care of patients, as part of the systems of care within an organisation.
Ultimately, embedding quality improvement and safety within all roles will result in organisations demonstrating a more mature quality and safety culture, and having in place the requisite systems and structures to enhance the delivery of better patient outcomes. Making explicit the expected knowledge, skills and behaviours required across broad roles within healthcare will enhance system capability.
Introduction
Safer and better quality care occurs when those in governance and management, health practitioners,non-clinical staff andconsumers all work together at all levels of the health system with a common purpose. This common purpose been expressed through the New Zealand Triple Aim.
The Triple Aim identifies three dimensions that together mean:
- providing effective, evidence-based treatments that meet the values and needs of individuals
- ensuring there is improved health and equity for all populations in New Zealand
- avoiding harm and waste by doing the right thing first time.
Achieving the Triple Aim requires more than technical knowledge and skills. It requires a capable workforce that can adapt to meet the changing needs of the complex health care environment(Bodenheimer and Sinsky 2014).This can only occur in a system where consumer[1] safety and their experience of care is a top priority. Compassionate care, underpinned by openness and transparency, to engendermutual trust and respect is fundamental to enable consumers and the health care workforce to work effectively together to co-design a more resilient health care system.
The Health Quality Safety Commission (the Commission) has a national mandate to develop and support capability and leadership in quality improvement and patient safety to ensure that the delivery of health care is consistent with its overarching framework, the Triple Aim (Health Quality & Safety Commission 2014). The Commission clearly identifies building sector capability as one of its strategic priorities to assist the sector to effect change(Health Quality & Safety Commission 2014).
This document describes a high level framework to guide the development of quality and safety capability across all levels in the health care sector, including consumers. It has been developed at the request of the sector and informed by an expert advisory group.
Background
Currently, the quality improvement capability of the health sector in New Zealand is reflected in uneven system performance, with a few centres of excellence and islands of good practice as well as an over-reliance on the commitment and expertise of individuals to drive the quality and safety agenda. There is a compliance orientation towards quality and a lack of confidence in the sustainability of gains.
The serious failures in the MidStaffordshire National Health Services Foundation Trust in 2005–08 demonstrate the consequences of not having quality and safety as central to the systems of an organisation.One of Berwick’s nine groups of recommendations in response to the Francis Report(Robert Francis 2013)focused on education, training and capacity building (National Advisory Group on the Safety of Patients in England 2013), which has also has been recognised by many international jurisdictions (Lachman 2013, Went 2013, Wales 2014).
The Commission has embarked on building capability as a key strategy for improving health care quality and safety. To date the focus has been on quality improvement advisor scholarships, sponsored course attendances, supporting visits by international speakers, and building capability and leadership as part of all campaigns and collaboratives. The Commission believes there now needs to be a broader and more integrated approach to address the complex change challenge involved in achieving system wide quality and safety.
Such a strategy needs to include addressing existing workforce needs, sustainably building the quality improvement capability of the future workforce, developing specialist roles in quality improvement science, supporting consumer participation, ensuring decision-making based on data and evidence, and supporting boards to provide leadership that encourages a quality improvement and patient safety focus throughout the sector.
Defining quality and safety
In 2003 in ‘Improving Quality: A systems approach for the New Zealand Health and Disability Sector’ (Minister of Health 2003)quality was defined as follows:
‘Within a systems approach, quality can be defined as the degree to which the services for individuals or populations increase the likelihood of desired health outcomes, and/or increase the participation and independence of people with a disability, and are consistent with current professional knowledge (adapted from Lohr (1990)). Quality is the cumulative result of the interactions of people, individuals, teams, organisations and systems.’
The key dimensions of quality include the following:
- Safe: avoiding harm to patients from the care that is intended to help them.
- Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.
- Patient-centred: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
- Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.
- Accessible and equitable: providing care that does not vary in quality because of personal characteristics such as gender, age, ethnicity, geographic location, and socioeconomic status.
In this paper we do not specify timeliness as a separate dimension as we see this as a component of other dimensions of effectiveness, accessibility and efficiency. The dimensions above are underpinned by the foundations of the partnership, participation and protection principles of the Treaty of Waitangi (Te Tiriti).
While safety is considered a dimension of quality, the inherently hazardous nature of health care and the high numbers of reported adverse events means safety demands additional consideration.
As defined above, safety is essentially about avoiding harm caused by the process of health care. To date there has been a strong emphasis on improving safety by learning from past harm. The causes of patient harm from health care however are seldom simple.In an increasingly complex health care system, safety needs to be addressed as a system property:
‘Safety does not reside in a person; device or department. Improving safety depends on learning how safety emerges from the interaction of components’(Cooper, Gaba et al. 2000).
Improving safety requires a focus on what goes right as much as what goes wrong.This strengthens our understanding of how the system works and how to build system resilience by ensuring that things go in the right direction(Hollnagel 2014).
Benefits of developing health quality and safety capability and leadership
Developing workforce capability and leadership offers an important platform for better health carequality and safety outcomes, and a more systematic and predictable quality and safety response across the health and disability sector, with the following envisaged medium- and long-term benefits(Rimmer 2012).
Envisagedmedium-term benefits include:
- a transparent quality and safety agenda in whicheveryone has an opportunity to participate
- a critical mass of the (technical and leadership) skills and knowledge in quality and safety to facilitate system-wide spread and change
- more consistent application nationally of quality and safety knowledge, tools and techniques, demonstrated by active projects and improved performance on key quality and safety priorities
- wider engagement and participation by patients/communities in their health and disability services.
Envisaged long-term benefits include:
- a health culture where ‘quality and safety is inherent in everything we do’
- a health system that is responsive to patient needs and preferences through effective partnerships across all levels of healthcare
- reduced harm, waste and unwarranted variation across the system with quality and safety outcomes matching or better than comparable health systems.
Developing a New Zealand capability framework
Developing a New Zealand capability framework is important for a number of reasons:
- It will provide the basis for a common understanding of the knowledge, skills and underpinning values required to achieve better quality and safer patient-centred healthcare.
- It provides overall direction to planning and development for capability building across all levels of the health sector, including consumers.
- It is intended to articulate clearly specific leadership expectations for quality and safety at each level of the health system from all frontline clinical and non-clinical staff to senior executive teams and Board members.
- It will also inform the development of a range of training and education programmes to meet the needs of the sector, so that there is a coherent approach to building quality and safety capability in New Zealand.
Ongoing lifelong learning in quality and safety should be supported by a range of education delivery strategies that are easily accessible to all health care workers throughout their careers, to advance knowledge and skills, including:
- postgraduate pathways in quality and safety that will support a New Zealand evidence base for quality and safety
- a coordinated education programme, using a variety of delivery models and providers with recognised levels of attainment through New Zealand Qualifications Authoritycertification, that will support ongoing education and training for health care workers
- the development of a New Zealand College/Association that will support specialist roles in quality and safety, and provide the necessary leadership to support and sustain excellence in quality and safety in the New Zealand health care system.
Sustaining a knowledgeable and skilled workforce in quality and safety can only occur in the context of:
- a culture across all levels within the health and disability sector where quality and patient safety are the central foci
- consumer partnership across all levels in the health and disability sector to inform quality and safety improvement initiatives
- effective governance and leadership, both clinical and managerial, across all levels within the health and disability sector to improve quality and safety
- an infrastructure being in place to support and sustain capability in quality and safety across the sector.
The framework
- The New Zealand framework builds on other frameworks previously described by leading health care organisations, including NHS Scotland, Kaiser Permanente, (NHS Scotland , Scrimshaw and Parisi 2013).Appendix 1:
The New Zealand framework has been chosen to describe capabilities rather than competencies. While both competence and capability are required for the ongoing improvement of the quality and safety of health care, capability reflects a perspective that builds on competence, to include the ability to adapt to change and generate new ideas and knowledge. It is about staying curious and open-minded, attributes that are essential for a 21st century workforce (Fraser and Greenhalgh 2001).
The New Zealand Framework takes a whole of system approach as described in the following definition (Batalden and Davidoff 2007):
‘the combined unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning).’
It is unique in describing consumer capabilities. Consumers have an important role to play not only with respect to managing their own health, but also by being actively engaged in the planning and design of care to improve quality and safety.
The framework also recognises that most healthcare is delivered within the context of teams and within services. Quality and safety capability and leadership within and between multidisciplinary teams and networks is required for the seamless and safe care of patients, as part of the systems of care within an organisation.
Organisations express capability not only through their systems and structures, but more importantly through their culture, values and behaviours. Exemplary organisations are those where quality and safety practices and values are embedded as part of routine practice, resulting in measurable improvements in the patient experience of care and patient outcomes.
Ultimately, embedding quality and safety within all roles will result in organisations demonstrating a more mature quality and safety culture, and having in place the requisite systems and structures to enhance the delivery of better patient outcomes. Making explicit the expected knowledge, skills and behaviours required across broad roles within health care will enhance system capability.
For our quality and safety framework nine domains have been identified and defined as follows:
Domain / Description- Partnerships with patients/consumers and their whānau/families
- Quality and safety culture
- Leadership
- Systems thinking
- Teamwork and communication
- Improvement is evidence-based and data-driven
- Quality improvement knowledge and skills
- Patient safety knowledge and skills
- Managing change
- In developing domains and grouping knowledge and actions within these domains, we have taken account of the literature that describes generic capabilities as well as drawing on a number of sources of information specifically related to competencies in quality and safety. Appendix 2:
The New Zealandframework has chosen to identifycapabilitiesby health caregroups. These apply equally across the primary, secondary and aged care sectors. Healthcare groups have been broadly classified as follows: