A strategic approach for managing conflict in hospitals: responding to the Joint Commission leadership standard, Part 2

BACKGROUND: A well-designed conflict management process for hospital leaders should both retain the positive benefits of constructive conflict engagement and minimize the adverse consequences that unmanaged conflict can have on patient care. Dispute system design (DSD) experts recommend processes that emphasize the identification of the disputing parties' interests and that avoid reliance on exertions of power or resort to rights. In an emerging trend in designing conflict management systems, focus is placed on the relational dynamics among those involved in the conflict, in recognition of the reciprocal impact that each participant in a conflict has on the other. The aim is then to restore trust and heal damaged relationships as a component of resolution. COMPONENTS OF THE CONFLICT MANAGEMENT PROCESS: The intent of Standard LD.02.04.01 is to prevent escalation to formal legal disputes and encourage leaders to overcome their conflict-avoidance tendencies through the use of well-designed approaches that support engagement with conflict. The sequence of collaborative options consists of individual coaching and counseling; informal face-to-face meetings; informal, internally facilitated meetings; informal, externally facilitated meetings; formal mediation; and postdispute analysis and feedback. CONCLUSIONS: Every hospital has unique needs, and every conflict management process must be tailored to individual circumstances. The recommendations in this two-part article can be adapted and incorporated in other, more comprehensive conflict management processes throughout the hospital. Expanding the conflict competence of leaders to enable them to effectively engage in and model constructive conflict-handling behaviors will further support the strategic goal of providing safe and effective patient care.     

The ethical leadership challenge: creating a culture of patient- and family-centered care in the hospital setting

The growing number of medical errors and resulting preventable deaths in hospitals presents an ethical dilemma that must be addressed by health care leaders and managers. These medical errors and deaths raise questions about safety and quality issues resulting in rising public mistrust and patient dissatisfaction. Many of these medical errors and deaths could have been avoided by including the patient and family in the care. The ethical challenge for leadership is creating a culture of patient- and family-centered care as a means to improve quality, safety, patient satisfaction, and public trust. This article addresses ways to improve safety, quality, patient satisfaction, and cost and thereby reduce medical errors and deaths by implementing a patient- and family-centered care culture. The first critical step for improvement is for hospital leaders and managers to answer the ethical call to create a culture centered on patient- and family-centered care in the hospital setting.     

Promoting clinical involvement in hospital quality improvement efforts: the effects of top management, board, and physician leadership.

STUDY QUESTION: An examination of the effects of top management, board, and physician leadership for quality on the extent of clinical involvement in hospital CQI/TQM efforts. DATA SOURCES: A sample of 2,193 acute care community hospitals, created by merging data from a 1989 national survey on hospital governance and a 1993 national survey on hospital quality improvement efforts. STUDY DESIGN: Hypotheses were tested using Heckman's two-stage modeling approach. Four dimensions of clinical involvement in CQI/TQM were examined: physician participation in formal QI training, physician participation in QI teams, clinical departments with formally organized QA/QI project teams, and clinical conditions and procedures for which quality of care data are used by formally organized QA/QI project teams. Leadership measures included CEO involvement in CQI/TQM, board quality monitoring, board activity in quality improvement, active-staff physician involvement in governance, and physician-at-large involvement in governance. Relevant control variables were included in the analysis. PRINCIPAL FINDINGS: Measures of top management leadership for quality and board leadership for quality showed significant, positive relationships with measures of clinical involvement in CQI/TQM. Active-staff physician involvement in governance showed positive, significant relationships with clinical involvement measures, while physician-at-large involvement in governance showed significant, negative relationships. CONCLUSIONS: Study results suggest that leadership from the top promotes clinical involvement in CQI/TQM. Further, results indicate that leadership for quality in healthcare settings may issue from several sources, including managers, boards, and physician leaders.     

Toward a healthy work environment

Patient safety and the quality of patient care have become important topics in U.S. hospitals in recent years. Nearly all hospitals have made mechanical and procedural changes to improve safety. But a truly healthy hospital is one in which caregivers, especially nurses, are treated with respect. The American Association of Critical-Care Nurses argues that a genuinely healthy work environment has six qualities: skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition of staff members' contributions, and authentic leadership. Although training is often needed to create a respectful and healthy workplace, some leaders are reluctant to allocate dollars on what they see as "soft" relationship issues. However, hospital leaders dedicated to improving safety and quality of care will see that they cannot afford to neglect such issues.     

The WAMI Rural Hospital Project. Part 3: Building health care leadership in rural communities.

The WAMI Rural Hospital Project (RHP) intervention combined aspects of community development, strategic planning and organizational development to address the leadership issues in six Northwest rural hospitals. Hospitals and physicians, other community health care providers and local townspeople were involved in this intervention, which was accomplished in three phases. In the first phase, extensive information about organizational effectiveness was collected at each site. Phase two consisted of 30 hours of education for the physician, board, and hospital administrator community representatives covering management, hospital board governance, and scope of service planning. In the third phase, each community worked with a facilitator to complete a strategic plan and to resolve conflicts addressed in the management analyses. The results of the evaluation demonstrated that the greatest change noted among RHP hospitals was improvement in the effectiveness of their governing boards. All boards adopted some or all of the project's model governance plan and had successfully completed considerable portions of their strategic plans by 1989. Teamwork among the management triad (hospital, board, and medical staff) was also substantially improved. Other improvements included the development of marketing plans for the three hospitals that did not initially have them and more effective use of outside consultants. The project had less impact on improving the functioning of the medical chief of staff, although this was not a primary target of the intervention. There was also relatively less community interest in joining regional health care associations. The authors conclude that an intervention program tailored to address specific community needs and clearly identified leadership deficiencies can have a positive effect on rural health care systems.     

Scotland's successful national approach to improving patient safety in acute care

What does it take to transform the safety of health care across a nation, even a small one? The Scottish Patient Safety Programme, mandated by the government, began in January 2008 with the aim of reducing mortality in Scotland's hospitals by 15 percent in five years. With the collaboration of political leaders, senior health care managers, clinicians, and patients, the program has improved the quality and safety of hospital care. At the halfway point, in-hospital mortality rates have declined by 5 percent, and infection rates for certain hospital-associated infections have been cut by more than half. The Scottish Patient Safety Programme continues to prove that a national strategic approach can lead to unprecedented improvements in patient safety.     

The pharmacy leadership competency gap: diagnosis and prescription

The purpose of this paper is to inform the health administration community and its educators about the importance of pharmacy leadership, the competencies associated with the role, and a suggested path to achieve a greater number of pharmacy leaders. The role of the pharmacy leader is often unrecognized or undervalued, yet it has significant implications for many facets of the healthcare delivery organization, including the cost of care, patient safety and quality, the influence and potential involvement of the pharmacist in the hospital or health system. Hospitals and health systems should recognize the power of an effective pharmacy leader, and strive to fill those positions. Unfortunately, should care leaders demand high performing pharmacy leaders, they will find that such individuals are in short supply, and will become more rare with time because of an aging pharmacy workforce. The health administration education community must respond to the demand by marrying pharmacy management education with the Master's in Health Administration degree (MHA). This article proposes the creation of a PharmD/MHA dual degree program, giving clinically trained pharmacists the skills they need to be effective managers and leaders in hospitals and health systems.     

Providers link health with human service

This issue's cover story looks at a handful of hospital leaders who appear to be radically redefining their hospital's role, but who are really just returning to the basics of hospital management and the basic hospital mission of community service. These CEOs of innercity hospitals are taking a leadership role in community development programs, ranging from literacy to housing. They bring together community groups to solve problems, work to find funding for projects, and attract new business to the hospital's service area. They also provide community residents with a sense of hope and a sense of stability. But their actions have ramifications that extend beyond their communities. These leaders may also be providing other health care executives with an approach to strategic planning that will add new meaning to the term "community hospital" in the 1990s.     

Creating a culture for health care quality and safety

Approximately 67% of hospital quality indicators require some type of laboratory testing to monitor compliance. Unfortunately, in many hospitals, laboratory data information systems remain an untapped resource in eliminating medical errors and improving patient safety. Using case scenarios, this article demonstrates potential consequences for patient safety and quality of care when information sharing between medical technologists and nurses is not a part of a hospital's culture. The outcome for this patient could have been avoided if a more inclusive health care quality and safety culture existed. Creating a culture for health care quality and safety requires consensus building by clinical and administrative leaders. Consensus building occurs by managing relationships among and between a team of independent, autonomous physicians, nurses, allied health professionals, and health care administrators. These relationships are built on mutual respect and effective communication. Creating a quality culture is a challenging but necessary prerequisite for eliminating medical errors and ensuring patient safety. Physician leaders promoting and advancing cultural change in clinical care from one of exclusive decision making authority to a culture that is based on shared decision making are a necessary first step. Shared decision making requires mutual respect, trust, confidentiality, responsiveness, empathy, effective listening, and communication among all clinical team members. Physician and administrative leaders with a focus on patient safety and a willingness to change will ensure a culture of health care quality and safety.     

Creating and sustaining a collaborative model of care

For the past 3 years, Toronto East General Hospital staff and leadership have been involved in the design, implementation, and evaluation of a transformational change to the model of patient care. The purpose of the new model is to enhance quality, safety, and patient satisfaction through a redefinition of our approach to the patient experience. The evaluation framework for the coordinated care team (CCT) model of care addressed safety and quality outcomes, patient satisfaction, staff and physician satisfaction, and resource impact. Results of the evaluation suggest that the introduction of the CCT model using the patient care bundle can have a significant impact on the patient experience through enhanced access to bedside care as well as improved quality and safety outcomes. This article is a follow-up to the article on the development of the model published in Forum (Fall 2009). It extends upon the previous article through an overview of the model as it evolved, a discussion of the first-year evaluation for three pilot units, and lessons learned regarding the change process.     

Quality management in Malaysian public health care

PURPOSE: The main aim of the study is to provide an empirical analysis of quality management practice among Malaysian Ministry of Health hospital employees, ranging from medical specialists to health attendants. DESIGN/METHODOLOGY/APPROACH: Self-administered questionnaires collected data and cluster sampling used to select hospitals, while stratified random sampling selected employee respondents. The research was limited to peninsular Malaysian public health care. FINDINGS: A total of 23 public hospitals participated in the survey, including the National Referral Centre, which is based in Hospital Kuala Lumpur. Eight quality management practices were identified in Malaysian public hospitals: continuous improvement, strategic planning, quality assurance, teamwork, leadership and management commitment, employee involvement and training, management by fact, and supplier partnership. Support for quality management was found to be lowest among the physicians. ORIGINALITY/VALUE: The article fills a lacuna in the health care quality management empirical research literature. The main recommendation is for the Malaysian Ministry of Health to gamer physicians' support in its quality endeavours.     

Clinical microsystems, Part 3. Transformation of two hospitals using microsystem, mesosystem, and macrosystem strategies

BACKGROUND: Two hospitals-a large, urban academic medical center and a rural, community hospital-have each chosen a similar microsystem-based approach to improvement, customizing the engagement of the micro-, meso-, and macrosystems and the improvement targets on the basis of an understanding of the local context. CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER (CCHMC): Since 2004, strategic changes have been developed to support microsystems and their leaders through (1) ongoing improvement training for all macro-, meso-, and microsystem leaders; (2) financial support for physicians who are serving as co-leaders of clinical microsystems; (3) increased emphasis on aligning academic pursuits with improvement work at the clinical front lines; (4) microsystem leaders' continuous access to unit-level data through the organization's intranet; and (5) encouragement of unit leaders to share outcomes data with families. COOLEY DICKINSON HOSPITAL (CDH): CDH has moved from near closure to a survival-turnaround focus, significant engagement in quality and finally, a complete reframing of a quality focus in 2004. Since then, it has deployed the clinical microsystems approach in one pilot care unit (West 2, a medical surgery unit), broadened it to two, then six more, and is now spreading it organizationwide. In "2+2 Charters," interdisciplinary teams address two strategic goals set by senior leadership and two goals set by frontline microsystem leaders and staff DISCUSSION: CCHMC and CDH have had a clear focus on developing alignment, capability, and accountability to fuse together the work at all levels of the hospital, unifying the macrosystem with the mesosystem and microsystem. Their improvement experience suggests tips and actions at all levels of the organization that could be adapted with specific context knowledge by others.     

Pay for performance in hospitals: implications for nurses and nursing care

As pay-for-performance programs gain momentum, hospital administrators and clinical leaders will need to consider the organization's infrastructure and measures that promote quality management initiatives. Many hospital performance measures by the Centers for Medicare & Medicaid Services involve chronic diseases that may be best managed by an interdisciplinary team-based approach, of which nurses are significant members. While the primary focus of pay-for-performance has been concentrated on physicians, comparatively less attention has been given to the potential impact on nurses and nursing care. Moreover, the impact of the pay-for-performance measures on nursing labor and processes has not been well studied. Within acute care settings, increasing attention has focused on the structure of nursing, such as number and skill mix of nursing personnel, processes of care, and influence on patient outcomes. As pay-for-performance standards evolve and encompass patient outcomes, attention to nursing's contribution will follow. Nursing leadership will need to address a number of strategies to (a) address the impact of pay-for-performance on nursing performance measures as well as (b) on staff nurses' ability to contribute to the organization's efforts in achieving pay-for-performance standards, including education, documentation, team collaboration, and patterns of care.     

Challenges of leadership in an era of health care reform

Health care leadership has never been more difficult than in the past decade--and the next ten years promise to be even more demanding. As a new era for health care emerges, organizational leaders will be required to manage increased levels of risk, uncertainty, and rapid change. Successful chief executives will be those who recognize and nurture intangible leadership qualities including knowledge of self, commitment to service, and depth and breadth of vision. With the continued shift away from hospital inpatient care, health care leaders will be called on to develop multipurpose delivery systems that move from a market-based to a community-based focus and deliver high quality services in a cost-effective manner. Several leadership themes will unfold in the midst of health care reform, including: exploiting change for the good of the organization and community; serving as educator, communicator, and comforter to divergent constituencies; and reestablishing a balance between short-term goals and long-term vision.     

Paying the piper: investing in infrastructure for patient safety

BACKGROUND: Although the best allocation of resources is unknown, there is general agreement that improvements in safety require an organization-level safety culture, in which leadership humbly acknowledges safety shortcomings and allocates resources at the patient care and unit levels to identify and mitigate risks. Since 2001, the Johns Hopkins Hospital has increased its investment in human capital at the patient care, unit/team, and organization levels to improve patient safety. PATIENT CARE LEVEL: An inadequate infrastructure, both technical and human, has prompted health care organizations to rely on nurses to help implement new safety programs and to enforce new policies because hospital leaders often have limited ability to disseminate or enforce such changes with the medical staff. UNIT OR TEAM LEVEL: At the team or nursing unit level, there is little or no infrastructure to develop, implement, and monitor safety projects. There is limited unit-level support for safety projects, and the resources that are allocated come from overtaxed department budgets. ORGANIZATION LEVEL: HOSPITAL LEVEL AND HEALTH SYSTEM: Infrastructure is needed to design, implement, and evaluate the following domains of work-measuring progress in patient safety, translating evidence into practice, identifying and mitigating hazards, improving culture and communication, and identifying an infrastructure in the organization for patient safety efforts. REFLECTIONS: Fulfilling a commitment to safe and high-quality care will not be possible without significant investment in patient safety infrastructure. Health care organizations will need to determine the cost-benefit ratio of various investments in patient safety. Yet, predicating safety efforts on the mistaken belief in a short-term return on investments will stall patient safety efforts.     

Conflict management in a hospital: designing processing structures and intervention methods

This article presents a case study describing the development, structure and operation of a comprehensive system for managing conflicts in a Norwegian city hospital. This was done in an effort to further develop the dispute mechanisms available in the hospital and to strengthen the management skills of clinical leaders and managers in general. By changing the ways managers and professionals handle their disputes, the hospital hopes to reduce the cost of conflicts and realize its benefits. The new conflict management system includes new procedures for managers and professionals to process disputes. The design process of the new system was framed according to an action research approach characterized by creating change through dialogue and the use of local expertise.     

现代医院管理制度背景下公立医院领导力探索

现代医院管理制度对我国公立医院的发展方向、治理机制、管理控制和过程等几个方面提出了全新的要求,为了实现这些新要求,公立医院领导能力至关重要。本研究提出公立医院领导的职责与定位和领导者需要满足的五项通用胜任能力要求,具体包括公共服务意识、战略规划能力、影响力、创新能力和变革能力。建议打破传统的"医而优则仕"的选拔方法,以本研究提出的公立医院院长胜任能力模型作为选拔的标准,采用科学的测评方法选拔与岗位要求匹配的医院高层领导者。本研究为公立医院领导力开发的理论研究贡献了评价标准和培养目标,也为公立医院高层领导班子选拔、配置和培养等管理实践提供了理论支撑。     

Revealing and resolving patient safety defects: the impact of leadership WalkRounds on frontline caregiver assessments of patient safety

Objective. To evaluate the impact of rigorous WalkRounds on frontline caregiver assessments of safety climate, and to clarify the steps and implementation of rigorous WalkRounds. Data Sources/Study Setting. Primary outcome variables were baseline and post WalkRounds safety climate scores from the Safety Attitudes Questionnaire (SAQ). Secondary outcomes were safety issues elicited through WalkRounds. Study period was August 2002 to April 2005; seven hospitals in Massachusetts agreed to participate; and the project was implemented in all patient care areas. Study Design. Prospective study of the impact of rigorously applied WalkRounds on frontline caregivers assessments of safety climate in their patient care area. WalkRounds were conducted weekly and according to the seven‐step WalkRounds Guide. The SAQ was administered at baseline and approximately 18 months post‐WalkRounds implementation to all caregivers in patient care areas. Results. Two of seven hospitals complied with the rigorous WalkRounds approach; hospital A was an academic teaching center and hospital B a community teaching hospital. Of 21 patient care areas, SAQ surveys were received from 62 percent of respondents at baseline and 60 percent post WalkRounds. At baseline, 10 of 21 care areas (48 percent) had safety climate scores below 60 percent, whereas post‐WalkRounds three care areas (14 percent) had safety climate scores below 60 percent without improving by 10 points or more. Safety climate scale scores in hospital A were 62 percent at baseline and 77 percent post‐WalkRounds (t=2.67, p=.03), and in hospital B were 46 percent at baseline and 56 percent post WalkRounds (t=2.06, p=.06). Main safety issues by category were equipment/facility (A [26 percent] and B [33 percent]) and communication (A [24 percent] and B [18 percent]). Conclusions. WalkRounds implementation requires significant organizational will; sustainability requires outstanding project management and leadership engagement. In the patient care areas that rigorously implemented WalkRounds, frontline caregiver assessments of patient safety increased. SAQ results such as safety climate scores facilitate the triage of quality improvement efforts, and provide consensus assessments of frontline caregivers that identify themes for improvement.     

Hospital patient safety: characteristics of best-performing hospitals

Hospitals have made slow progress in meeting the Institute of Medicine's patient safety goals, and implementation of safety systems has been inconsistent. The next logical question is this: What organizational characteristics predict greater implementation of patient safety systems, in terms of both extent of systems and progress over time? To answer this question, a survey was administered to 107 hospitals at two points in time. Data were consolidated into seven latent variables measuring progress in specific areas. Using the overall measure, Joint Commission-accredited hospitals showed statistically significant improvement, as reflected in the sum score (p = .01); nonaccredited hospitals did not show statistically significant improvement (p = .21). Joint Commission accreditation was the key predictor of patient safety system implementation. Management type and urban/rural status were secondary predictors. Several factors may account for the strong association between accreditation and patient safety system implementation. In 2003, the Joint Commission began tying accreditation to patient safety goals. Also, Joint Commission data are now widely available to the public and may stimulate hospitals to address safety issues. Healthcare executives, hospital trustees, regulators, and policymakers should encourage Joint Commission accreditation and reward hospital efforts toward meeting Joint Commission standards. The Joint Commission should continually strive to maintain evidence-based and state-of-the-art standards that advance the aim of providing the best possible care for hospitalized patients.